NC Dept of Insurance SHIIP RSVP grant contract FY14STATE OF NORTH CAROLINA
COUNTY OF WAKE
RQ 16998401
This Contract and its attachments shall be completed and returned to the Agency within 45 days of receiving the
electronic document in order for the Agency to process the award and provide funds to the Grantee. The Grantee
shall provide the agency with progress reports and a final report detailing the Grantee's use of State funds.
This Contract is entered into by and between the North Carolina Department of Insurance, Division of SHIIP,
hereinafter referred to as the "Agency", and New Hanover Coun 1 Senior Resource Center RSVP located in
New Hanover county, hereinafter referred to as the "Grantee ", referred to collectively as the "Parties ".
. Contract Documents: This Contract shall consist of the following documents, incorporated herein by
reference:
(1) This Contract;
(2) General Terms and Conditions for Public Sector Contracts (Attachment A)
(3) Statement of Work (Attachment B)
(4) Line Item Budget and Budget Narrative (Attachment C)
(5) Certifications Regarding, Drug -Free Work - Place; Lobbying; and Debarment, Suspension and Other
Responsibility Matters (Attachment D)
These documents constitute the entire agreement between the Parties and supersede all prior statements or
agreements.
2. Precedence Among Contract Documents: In the event of a conflict between or among the terms of the
Contract Documents, the terms in the Contract Document with the highest relative precedence shall prevail.
The order of precedence shall be the order of documents as Iisted in Paragraph 1, above, with the first- listed
document having the highest precedence and the last - listed document having the lowest precedence. If
there are multiple Contract Amendments, the most recent amendment shall have the highest precedence and
the oldest amendment shall have the lowest precedence.
3. Effective Period: This Contract is effective 7/1/2013 and terminates on 6/30/2014.
4. Grantee's Duties: The Grantee shall provide the services as described in Attachment B with the terms of
this Contract and in accordance with the approved budget in Attachment C. The Grantee shall maintain and
make available all records, papers, vouchers, books, correspondence or other documentation or evidence at
reasonable times for review, inspection or audit by duly authorized officials of the Agency, the North
Carolina State Auditor, or applicable federal agencies. The Grantee shall submit to the Agency all plans,
reports, documents or other products that the Agency may require, in the form specified by the Agency,
including at the least following:
A) A final budget report of expenses incurred during the contract period date;
B) A mid -year report of the contracted activities of the Grantee due by January 31, 2014;
C) A final comprehensive report within sixty (60) days of the project end date; due on or before August
31, 2014.
5. Agency's Duties: The Agency shall reimburse the Grantee for the costs of services and activities described
in Attachment B and in accordance with the approved budget in Attachment C. The Agency shall monitor
the Grantee for compliance with the terms of this Contract; and shall specify all reports and other
deliverables required from the Grantee.
The Agency shall pay the Grantee in the manner and in the amounts specified in the Contract Documents.
The total amount paid by the Agency to the Grantee under this Contract shall not exceed $3,532.00. This
amount consists of $3,532.00; CFDA # 93.779.
[ X ] a. There are no matching requirements from the Grantee.
] b. The Grantee's matching requirement is $ , which shall consist of:
] In -kind [ ] Cash
Cash and In -kind [ ] Cash and/or In -kind
The contributions from the Grantee shall be source from non - federal funds.
The total contract amount is $3,532.0.
6. Conflict of Interest Policy: The Agency has determined that this Contract is not subject to NCGS 14 -C -6-
22 & 23.
7. Reversion of Unexpended Funds: Any unexpended grant funds shall revert to the Agency upon
termination of this Contract.
8. Grants: The Grantee has the responsibility to ensure that all sub - grantees, if any, provide all information
necessary to permit the Grantee to comply with the terms and conditions set forth in this Contract.
9. Payment Provisions: As provided in NCGS 143C -21 this Contract is an annual appropriation of $100,000
or less to or for the use of a non -profit corporation and payment shall be made in a single annual payment.
10. Contract Administrators: All notices permitted or required to be given by one Party to the other and all
questions about the contract from one Party to the other shall be addressed and delivered to the other Party's
Contract Administrator. The name, address, telephone number and fax number of the Parties' respective
initial Contract Administrators are set out below. Either Party may change the name, address, telephone
number and fax number of its Contract Administrator by giving timely written notice to the other Party.
For the Agency:
R. Van Braxton, Deputy Commissioner
SHIIP Division
1 I South Boylan Avenue
Raleigh, NC 27603
919 -807 -6900
919 -807 -6901
For the Grantee:
Avril Pinder
2222 S. College Road
Wilmington,NC 28403
Phone 910- 798 -6400 / 910 - 798 -6410
Fax 910- 798 -6411
11. Supplementation of Expenditures of Public Funds: The Grantee assures that funds received under this
Contract shall be used only to supplement, not to supplant, the total amount of federal, state and local public
funds the Grantee otherwise expends for SHIIP services and related programs. Funds received under this
Contract shall be used to provide additional public funding for such services; the funds shall not be used to
reduce the Grantee's total expenditure of other public funds for such services.
12. Disbursements: As a condition of this Contract, the Grantee acknowledges and agrees to make
disbursements in accordance with the following requirements:
a. Implement adequate internal controls over disbursements;
b. Pre -audit all vouchers presented for payment to determine:
• Validity and accuracy of payment;
Payment due date;
• Adequacy- of documentation supporting payment; and
Page 2 of 16
• Legality of disbursement;
C. Assure adequate control of signature stamps /plates;
d. Assure adequate control of negotiable instruments; and
e. Implement procedures to ensure that the account balance is solvent and reconcile the account
monthly.
13. Outsourcing: The Grantee certifies that it has identified to the Agency all jobs related to the Contract that
have been outsourced to other countries, if any. Grantee further agrees that it will not outsource any such
jobs during the term of this Contract without providing notice to the Agency.
14. Executive Order # 24: NCGS 133 -32 and Executive Order 24 prohibit the offer to, or acceptance by, any
State Employee of any gift from anyone with a contract with the State, or from any person seeking to do
business with the State. By execution of any response in this procurement, you attest, for your entire
organization and its employees or agents, that you are not aware that any such gift has been offered,
accepted, or promised by any employees of your organization.
15. Audit: The Agency reserves the right to conduct an audit through the NCSMP Program Director.
16. Federal Certifications: The Grantee agrees to execute the following federal certifications that are attached
to this agreement (applicable when receiving federal funds).
A. Certification Regarding Lobbying.
B. Certification Regarding Department.
C. Certification Regarding Drug -Free Workplace Requirements.
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17. Signature Warranty: The undersigned represent and warrant that they are authorized to bind their
principals to the terms of this agreement.
In witness whereof, the Grantee and the Agency have executed this Agreement with one original, which is
retained by Agency.
New Hanover County / Senior
Resource Center RSVP
BY:�
1i to - s.. A
:Printed Name
DATE:
Division of SHIM
DATE:
Witness
-TD L-t_
Printed Nance
BY: r [ Y� r
arla 0 iol
Senior Deputy Commissioner
DATE: S—f 0
VV
Contract is not executed until last signature is obtained.
The Agency and the Grantee agree and understand that this contract is considered executed on the latest date of either
the last signature on this agreement or the date of Department of Insurance's procurement electronic approval.
[ TBi 7 -23 -2013 ] Format reviewed & approved by Controller's Office
Page 4 of 16
Attachment A
General Terms and Conditions
DEFINITIONS individuals for Medicare and Medicaid patient
Unless indicated otherwise from the context, the
following terms shall have the following meanings in
this Contract. All definitions are from 9 NCAC
3M.0102 unless otherwise noted. If the rule or statute
that is the source of the definition is changed by the
adopting authority, the change shall be incorporated
herein.
(1) "Agency" (as used in the context of the
definitions below) shall mean and include
every public office, public officer or official
(State or local, elected or appointed),
institution, board, commission, bureau,
council, department, authority or other unit of
government of the State or of any county, unit,
special district or other political subagency of
government. For other purposes in this
Contract, "Agency" shall mean the entity
identified as one of the parties hereto.
(2) "Audit" means an examination of records or
financial accounts to verify their accuracy.
(3) "Certification of Compliance" means a report
provided by the Agency to the Office of the
State Auditor that states that the Grantee has
met the reporting requirements established by
this Subchapter and included a statement of
certification by the Agency and copies of the
submitted grantee reporting package.
(4) "Compliance Supplement" refers to the North
Carolina State Compliance Supplement,
maintained by the State and Local
Government Finance Agency within the North
Carolina Department of State Treasurer that
has been developed in cooperation with
agencies to assist the local auditor in
identifying program compliance requirements
and audit procedures for testing those
requirements.
(5) "Contract" means a legal instrument that is
used to reflect a relationship between the
agency, grantee, and subgrantee.
(6) "Fiscal Year' means the annual operating year
of the non -State entity.
(7) "Financial Assistance" means assistance that
non -State entities receive or administer in the
form of grants, loans, loan guarantees,
property (including donated surplus property),
cooperative agreements, interest subsidies,
insurance, food commodities, direct
appropriations, and other assistance. Financial
assistance does not include amounts received
as reimbursement for services rendered to
services.
(8) "Financial Statement" means a report
providing financial statistics relative to a given
part of an organization's operations or status.
(9) "Grant" means financial assistance provided
by an agency, grantee, or subgrantee to carry
out activities whereby the grantor anticipates
no programmatic involvement with the grantee
or subgrantee during the performance of the
grant.
(10) "Grantee" has the meaning in NCGS 143C -6-
23(a)(2): a non -State entity that receives a
grant of State funds from a State agency,
department, or institution but does not include
any non -State entity subject to the audit and
other reporting requirements of the Local
Government Commission. For other purposes
in this Contract, "Grantee" shall mean the
entity identified as one of the parties hereto.
(11) "Grantor" means an entity that provides
resources, generally financial, to another entity
in order to achieve a specified goal or
objective.
(12) "Non -State Entity" has the meaning in NCGS
143C- 1- 1(d)(18): Any of the following that is
not a State agency: An individual, a firm, a
partnership, an association, a county, a
corporation, or any other organization acting
as a unit. The term includes a unit of local
government and public authority.
(13) "Public Authority" has the meaning in NCGS
143C- 1- 1(d)(22): A municipal corporation
that is not a unit of local government or a local
governmental authority, board, commission,
council, or agency that (i) is not a municipal
corporation and (ii) operates on an area,
regional, or multiunit basis, and the budgeting
and accounting systems of which are not fully
a part of the budgeting and accounting systems
of a unit of local government.
(14) "Single Audit" means an audit that includes an
examination of an organization's financial
statements, internal controls, and compliance
with the requirements of Federal or State
awards.
(15) "Special Appropriation" means a legislative act
authorizing the expenditure of a designated
amount of public funds for a specific purpose.
(16) "State Funds" means any funds appropriated
by the North Carolina General Assembly or
collected by the State of North Carolina. State
Page 5 of 16
funds include federal financial assistance
received by the State and transferred or
disbursed to non -State entities. Both Federal
and State funds maintain their identity as they
are subgranted to other organizations.
Pursuant to NCGS 143C- 6- 23(a)(1), the terms
"State grant funds" and "State grants" do not
include any payment made by the Medicaid
program, the Teachers' and State Employees'
Comprehensive Major Medical Plan, or other
similar medical programs.
(17) "Subgrantee" has the meaning in NCGS
143C- 6- 23(a)(3): a non -State entity that
receives a grant of State funds from a grantee
or from another subgrantee but does not
include any non -State entity subject to the
audit and other reporting requirements of the
Local Government Commission.
(18) "Unit of Local Government" has the meaning
in NCGS 143C- 1- 1(d)(29): A municipal
corporation that has the power to levy taxes,
including a consolidated city - county as
defined by NCGS 160B -2(1), and all boards,
agencies, commissions, authorities, and
institutions thereof that are not municipal
corporations.
Relationships of the Parties
Independent Contractor: The Grantee is and shall be
deemed to be an independent contractor in the
performance of this Contract and as such shall be wholly
responsible for the work to be performed and for the
supervision of its employees. The Grantee represents
that it has, or shall secure at its own expense, all
personnel required in performing the services under this
agreement. Such employees shall not be employees of,
or have any individual contractual relationship with, the
Agency.
Subcontracting: The Grantee shall not subcontract any
of the work contemplated under this Contract without
prior written approval from the Agency. Any approved
subcontract shall be subject to all conditions of this
Contract. Only the subcontractors or subgrantees
specified in the contract documents are to be considered
approved upon award of the contract. The Agency shall
not be obligated to pay for any work performed by any
unapproved subcontractor or subgrantee. The Grantee
shall be responsible for the performance of all of its
subgrantees and shall not be relieved of any of the duties
and responsibilities of this Contract.
Subgrantees: The Grantee has the responsibility to
ensure that all subgrantees, if any, provide all
information necessary to permit the Grantee to comply
with the standards set forth in this Contract.
Assignment: No assignment of the Grantee's
obligations or the Grantee's right to receive payment
hereunder shall be permitted. However, upon written
request approved by the issuing purchasing authority, the
State may:
(a) Forward the Grantee's payment check(s) directly
to any person or entity designated by the
Grantee, or
(b) Include any person or entity designated by
Grantee as a joint payee on the Grantee's
payment check(s).
In no event shall such approval and action obligate the
State to anyone other than the Grantee and the Grantee
shall remain responsible for fulfillment of all contract
obligations.
Beneficiaries: Except as herein specifically provided
otherwise, this Contract shall inure to the benefit of and
be binding upon the parties hereto and their respective
successors. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Contract,
and all rights of action relating to such enforcement,
shall be strictly reserved to the Agency and the named
Grantee. Nothing contained in this document shall give
or allow any claim or right of action whatsoever by any
other third person. It is the express intention of the
Agency and Grantee that any such person or entity, other
than the Agency or the Grantee, receiving services or
benefits under this Contract shall be deemed an
incidental beneficiary only.
Indemnity
Indemnification: The Grantee agrees to indemnify and
hold harmless the Agency, the State of North Carolina,
and any of their officers, agents and employees, from
any claims of third parties arising out of any act or
omission of the Grantee in connection with the
performance of this Contract.
Default and Termination
Termination by Mutual Consent: The Parties may
terminate this Contract by mutual consent with 60 days
notice to the other party, or as otherwise provided by
lave .
Termination Without Cause: The Agency may
terminate this contract without cause by giving 60 days
written notice to the Contractor. In that event, all
fmished or unfinished deliverable items prepared by the
Contractor under this contract shall, at the option of the
Agency, become its property and the Contractor shall be
Page 6 of 16
entitled to receive just and equitable compensation for
any satisfactory- work completed on such materials,
minus any payment or compensation previously made.
Termination for Cause: If, through any cause, the
Grantee shall fail to fulfill its obligations under this
Contract in a timely and proper manner, the Agency
shall have the right to terminate this Contract by giving
written notice to the Grantee and specifying the effective
date thereof In that event, all finished or unfinished
deliverable items prepared by the Grantee under this
Contract shall, at the option of the Agency, become its
property and the Grantee shall be entitled to receive just
and equitable compensation for any satisfactory work
completed on such materials, minus any payment or
compensation previously made. Notwithstanding the
foregoing provision, the Grantee shall not be relieved of
liability to the Agency for damages sustained by the
Agency by virtue of the Grantee's breach of this
agreement, and the Agency may withhold any payment
due the Grantee for the purpose of setoff until such time
as the exact amount of damages due the Agency from
such breach can be determined.
Waiver of Default: Waiver by the Agency of any
default or breach in compliance with the terms of this
Contract by the Grantee shall not be deemed a waiver of
any subsequent default or breach and shall not be
construed to be modification of the terms of this
Contract unless stated to be such in writing, signed by an
authorized representative of the Agency and the Grantee
and attached to the contract.
Availability of Funds: The parties to this Contract
agree and understand that the payment of the sums
specified in this Contract is dependent and contingent
upon and subject to the appropriation, allocation, and
availability of funds for this purpose to the Agency.
Force Majeure: Neither party shall be deemed to be in
default of its obligations hereunder if and so long as it is
prevented from performing such obligations by any act
of war, hostile foreign action, nuclear explosion, riot,
strikes, civil insurrection, earthquake, hurricane, tornado,
or other catastrophic natural event or act of God.
Survival of Promises: All promises, requirements,
terms, conditions, provisions, representations,
guarantees, and warranties contained herein shall survive
the contract expiration or termination date unless
specifically provided otherwise herein, or unless
superseded by applicable federal or state statutes of
limitation.
Health Insurance Portability and Accountability Act
(HIPAA): The Contractor agrees that, if the Agency
determines that some or all of the activities within the
scope of this contract are subject to the Health Insurance
Portability and Accountability Act of 1996, P.L. 104 -91,
as amended ( "HIPAX ), or its implementing regulations,
it will comply with the HIPAA requirements and will
execute such agreements and practices as the Agency
may require to ensure compliance.
Executive Order # 24: `By Executive Order 24, issued
by Governor Perdue, and NCGS 133 -32, it is unlawful
for any vendor or contractor ( i.e. architect, bidder,
contractor, construction manager, design professional,
engineer, landlord, offeror, seller, subcontractor,
supplier, or vendor), to make gifts or to give favors to
any State employee of the Governor's Cabinet Agencies
(i.e., Administration, Commerce, Correction, Crime
Control and Public Safety, Cultural Resources,
Environment and Natural Resources, Health and Human
Services, Juvenile Justice and Delinquency Prevention,
Revenue, Transportation, and the Office of the
Governor). This prohibition covers those vendors and
contractors who have a contract with a governmental
agency; or have performed under such a contract within
the past year; or anticipate bidding on such a contract in
the future.
For additional information regarding the specific
requirements and exemptions, vendors and contractors
are encouraged to review Executive Order 24 and NCGS
Sec. 133 -32.
Executive Order 24 also encouraged and invited other
State Agencies to implement the requirements and
prohibitions of the Executive Order to their agencies.
Vendors and contractors should contact other State
Agencies to determine if those agencies have adopted
Executive Order 24."
Intellectual Property Rights
Copyrights and Ownership of Deliverables: All
deliverable items produced pursuant to this Contract are
the exclusive property of the Agency. The Grantee shall
not assert a claim of copyright or other property, interest
in such deliverables.
Compliance with Applicable Laws
Compliance with Laws: The Grantee shall comply
with all Iaws, ordinances, codes, rules, regulations, and
licensing requirements that are applicable to the conduct
of its business, including those of federal, state, and local
agencies having jurisdiction and/or authority.
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Equal Employment Opportunity: The Grantee shall
comply with all federal and state laws relating to equal
employment opportunity.
Confidentiality
Confidentiality: Any information, data, instruments,
documents, studies or reports given to or prepared or
assembled by the Grantee under this agreement shall be
kept as confidential and not divulged or made available
to any individual or organization without the prior
written approval of the Agency. The Grantee
acknowledges that in receiving, storing, processing or
otherwise dealing with any confidential information it
will safeguard and not further disclose the information
except as otherwise provided in this Contract.
Oversight
Access to Persons and Records: The State Auditor
shall have access to persons and records as a result of all
contracts or grants entered into by State agencies or
political subdivisions in accordance with NCGS 147-
64.7. Additionally, as the State funding authority, the
Agency and all applicable federal agencies or their
agents shall have access to persons and records as a
result of all contracts or grants entered into by State
agencies or political subdivisions.
Record Retention: Records shall not be destroyed,
purged or disposed of without the express written
consent of the Agency. State basic records retention
policy requires all grant records to be retained for a
minimum of five years or until all audit exceptions have
been resolved, whichever is longer. If the contract is
subject to federal policy and regulations, record retention
may be longer than five years since records must be
retained for a period of three years following submission
of the final Federal Financial Status Report, if
applicable, or three years following the submission of a
revised final Federal Financial Status Report. Also, if
any litigation, claim, negotiation, audit, disallowance
action, or other action involving this Contract has been
started before expiration of the five -year retention period
described above, the records must be retained until
completion of the action and resolution of all issues
which arise from it or until the end of the regular five -
year period described above, whichever is later.
Miscellaneous
Choice of Law: The validity of this Contract and any of
its terms or provisions, as well as the rights and duties of
the parties to this Contract, are governed by the laws of
North Carolina. The Grantee, by signing this Contract,
agrees and submits, solely for matters concerning this
Contract, to the exclusive jurisdiction of the courts of
North Carolina and agrees, solely for such purpose, that
the exclusive venue for any legal proceedings shall be
Wake County, North Carolina. The place of this
Contract and all transactions and agreements relating to
it, and their situs and forum, shall be Wake County,
North Carolina, where all matters, whether sounding in
contract or tort, relating to the validity, construction,
interpretation, and enforcement shall be determined.
Amendment: This Contract may not be amended orally
or by performance. Any amendment must be made in
written form and executed by duly authorized
representatives of the Agency and the Grantee.
Severability: In the event that a court of competent
jurisdiction holds that a provision or requirement of this
Contract violates any applicable law, each such
provision or requirement shall continue to be enforced to
the extent it is not in violation of law or is not otherwise
unenforceable and all other provisions and requirements
of this Contract shall remain in full force and effect.
Headings: The Section and Paragraph headings in these
General Terms and Conditions are not material parts of
the agreement and should not be used to construe the
meaning thereof.
Time of the Essence: Time is of the essence in the
performance of this Contract.
Key Personnel: The Contractor shall not replace any of
the key personnel assigned to the performance of this
contract without the prior written approval of the
Agency. The term "key personnel' includes any and all
persons identified as such in the contract documents and
any other persons subsequently identified as key
personnel by the written agreement of the parties.
Care of Property: The Grantee agrees that it shall be
responsible for the proper custody and care of any
property furnished to it for use in connection with the
performance of this Contract and will reimburse the
Agency for loss of, or damage to, such property. At the
termination of this Contract, the Grantee shall contact
the Agency for instructions as to the disposition of such
property and shall comply with these instructions.
Travel Expenses: Reimbursement to the Grantee for
travel mileage, meals, lodging and other travel expenses
incurred in the performance of this Contract shall be
reasonable and supported by documentation. State rates
should be used as guidelines. International travel shall
not be reimbursed under this Contract.
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Sales/Use Tax Refunds: If eligible, the Grantee and all
subgrantees shall: (a) ask the North Carolina Department
of Revenue for a refund of all sales and use taxes paid by
them in the performance of this Contract, pursuant to
NCGS 105 - 164.14; and (b) exclude all refundable sales
and use taxes from all reportable expenditures before the
expenses are entered in their reimbursement reports.
Advertising: The Grantee shall not use the award of
this Contract as a part of any news release or commercial
advertising.
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Attachment
For the period 7/112013 — 6/30/2014
Statement of or
Grantee: New Hanover County / Senior Resource Center RSVP
This statement should be a short summary describing what the Grantee does and how the Grantee will use these funds.
The terms of the contract between the SHIIP office and the agencies require local programs meet these goals for
SFY2014. The uses of these funds are not limited to but MUST include the following activities:
1) Hold regular (weekly) counseling clinics during the period 10/2013 through 3/2014. The Senior Resource Center
has a total of 17 trained volunteers who staff a SHIIP weekly walk -in clinic on Tuesdays and Thursdays from
11AM to IPM. Volunteers also increase their availability during open - enrollment;
2) Coordinate a county volunteer recognition event during the period 3/1/2014 through 5/31/2014;
3) Attend the SHIIP Coordinators' Training Conference on July 16 and 17, 2013 this is mandatory for all coordinators;
This has already been accomplised as Tracy Ash, Program Manager and Valerie Smith, Coordinator attended the
Conference in July 2013.
4) Submit Client Counseling Contact and Public & Media Outreach (NPR) forms in a timely manner to the SHIIP office
in Raleigh or through the SHIPTalk website;
5) Each SHIIP coordinating site must reach out to 50% of the county population for activity events; coordinating sites
not reaching their goals may incur reduced future funding; According to the 2010 census, New Hanover County has
approximately 2,497 senior residents aged 65 and above. Half (50 %) would be 1,249. This will be accomplished
through outreach educationa presentation at area churches, senior housing, and the Senior Resource Center.
6) Each SHIIP coordinating site must counsel 1.5% of their county's Medicare population; coordinating sites not
reaching their goals may incur reduced future funding; Walk -in clinic access and scheduled appointments will address
this need of approximately 37 individuals and has exceeded this number in the past.
7) Represent SHIIP at health fair events by utilizing local certified SHIIP counselors; The volunteers have been very
active in participating in health and community service events.
8) Conduct at least one (1) Medicare education class for new to Medicare beneficiaries in your local county. Medicare
101 classes are offered twice an year and are well attended.
SCOPE OF WORK:
(Maximum 2 pages)
The New Hanover County- Senior's Health Insurance Information Program is sponsored by the New Hanover County
Senior Resource Center's Retired & Senior Volunteer Program. RSVP will continue to recruit and retain volunteers for
the SHIIP Program. RSVP will provide an office, supplies and necessary computers for the volunteers. RSVP will
provide quarterly training for the volunteers and invite other community professionals to join the training sessions.
Our goal is to keep Medicare recipients of all ages up to date on changes and/or services that are available. We will
achieve the goal by:
Page 10 of 16
1) The Senior Resources Center/RSVP SHIIP Program will continue to hold Tuesday and Thursday SHIIP walk -in
counseling clinics from 11:OOam until 1:OOpm. We will also provide individual scheduled appointments for Medicare
recipients on Monday, Wednesday and Friday from 9:OOam until 4:00pm throughout the grant period.
2) The Senior Resources Center/RSVP SHIIP Program will coordinate a county volunteer recognition event during
the period of 3/1/2014 - 5/31/2014. A New Hanover County SHIIP volunteer recognition event will be scheduled in this
time period, an exact date is yet to be determined.
3) In order to expand Low Income Subsidy outreach and enrollment in New Hanover County, the Senior Resources
Center/RSVP SHUP Program will participate in at least two outreach programs targeting the LIS Medicare population.
Outreach events will be planned in conjunction with expanding the LIS enrollment as well as educating Medicare
recipients and the general population.
In addition to the outreach events listed above, we will also attempt to expand enrollment in the LIS program through
direct mailings, community special events, media announcements, social media, and all other available opportunities.
Presentations and distribution of SHIIP and Low Income Subsidy Assistance materials will be made available at assisted
income housing facilities, Senior Housing facilities, Assisted Living Facilities, Home Health Agencies, Independent
Living Facilities, Health Fairs, Hurricane Expos, business organizations, New Hanover County Nutrition Site, the
National Association of Social Workers Conference, New Hanover County Foster Grandparent Program, New Hanover
County Special Needs Registry, New Hanover County Senior Resource Center, and the Retired and Senior Volunteer
Program Volunteer Stations.
4) The New Hanover County RSVP /Senior Resource Center SHIIP Coordinator and RSVP Program Manager will
attend the mandatory SHHP Coordinators' Training Conference on July 16 and 17, 2013 in Greensboro, NC.
5) The New Hanover County RSVP/Senior Resource Center SHIM program will submit Client Counseling (NPR)
forms in a timely manner to the SHIM office in Raleigh or through the SHIIP Talk website.
6) The NHC Senior Resources Center/RSVP SHIIP Program will reach out to 50% of the population of New
Hanover County for activity events through radio, television, print media, newsletters, websites, social media, outreach
events, New Hanover County RSVP /Senior Resource Center events and programming and mailings.
7) The NHC Senior Resources Center/RSVP SHED program will counsel at least 1.5% of the county's Medicare
population through the weekly walk -in clinics as well as individual scheduled appointments and referrals made through
the numerous outreach activities planned for the reporting period.
8) The NHC Senior Resources Center/RSVP SH1IP Program will be represented at health fair events and other
outreach events utilizing local certified SHIIP counselors.
9) The NHC Senior Resources Center/RSVP SHEP Program will host at least one (1) Medicare education class for
"new to Medicare" beneficiaries in our county. The educational event will be entitled Medicare 101.
10) Participate in 75% of the monthly coordinator conference calls conducted from August 1, 2013 through June 30,
2014.
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SCOPE OF WORK: cant.
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Attachment C
For the period 7/1/2013 — 6/30/2014
U 11 Jill I Ill, III I
Provide a budget and short narrative on the use of the funding amount reflected on the contract. Please provide details of
all expenses including routine charges. These expenditures may include telephone, postage, salary, equipment purchases,
internet services etc.
All budgets must be approved by the Agency.
Grantee Name: New Hanover County / Senior Resource Center RSVP
Grantee Name: Ne,,r Hanover Count • / Senior Resource Center RSVP
Bud et
Contractual
Amount
Construction
Supplies
1,000.00
Equipment
Other
1,982.00
Travel
550.00
Personnel
Fringe
Total
3,532.00
Narrative:
2013 -2014 SHUP Grant Award: $3,532
Budget:
Supplies /Equipment: $1,000
Office Supplies, Postage, Shredder
Other: (See attached detail) $1,982
Outreach Activities and Events: $742
Advertising: $500
Volunteer Training/Recognition: $740
Travel: $ 550.00
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Attachment D
Certifications Regarding, Drug -Free Work - Place; Lobbying; and
Debarment, Suspension and Other Responsibility Matters
1. Drug -Free Work -Place
The undersigned (authorized official) certifies that it will provide a drug -free workplace in accordance with the Drug -
Free Work -Place Act of 1988, 45 CFR Part 76, subpart F. The certification set out below is a material representation
of fact upon which reliance will be placed when awarding the grant. False certification or violation of the certification
shall be grounds for suspension of payments, suspensions or termination of grants or government wide suspension or
debarment.
The grantee certifies that it will or will continue to provide a drug -free workplace by:
(a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the grantee's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
(b) Establishing an on -going drug -free awareness program to inform employees about —
(1) The dangers of drug abuse in the workplace;
(2) The grantee's policy of maintaining a drug -free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
(c) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy
of the statement required by paragraph (a); above;
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment
under the grant, the employee will —
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute
occurring in the workplace no later than five calendar days after such conviction;
(e) Notifying the agency, in writing, within 10 calendar days after receiving notice under subparagraph (d)(2),
above, from an employee or otherwise receiving actual notice of such conviction. Employers of convicted
employees must provide notice, including position title, to Agency on whose grant activity the convicted
employee was working.
Notices shall include the identification number(s) of each affected grant;
(f) Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), above,
with respect to any employee who is so convicted —
(1) Taking appropriate personnel action against such an employee, up to and including termination,
consistent with the requirements of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State, or local health, law enforcement, or other
appropriate agency;
(g) Making a good faith effort to continue to maintain a drug -free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and (f).
The grantee certifies that, as a condition of the grant, it will not engage in the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance in conducting any activity with the grant.
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2. Lobbying
Title 31 of the United States Code, Section 1352, entitled "Limitation on use of appropriated funds to influence
certain Federal contracting and financial transactions," generally prohibits recipients of Federal grants and cooperative
agreements from using Federal (appropriated) funds for lobbying the Executive or Legislative Branches of the Federal
Government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each
person who request or received a Federal grants or cooperative agreement must disclose lobbying undertaking with
non - Federal (non- appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING
$100,000 in total costs (45 CFR Part93).
The undersigned (authorized official) certifies, to the best of his or her knowledge and belief, that:
(a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any
person for influencing or attempting to influence an officer or employee of any agency, a member of
Congress, any officer or employee of Congress, or an employee of a Member of Congress in connection with
the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the
entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any Federal grant, loan or cooperative agreement;
(b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal
contract, grant, loan or cooperative agreement, the undersigned shall complete and submit Standard Form -
LLL, "Disclosure of Lobbying Activities," in accordance with its instructions;
(c) The undersigned shall require that the language of this certification be included in the award documents
for all subawards at all tiers (including subcontracts, subgrants, contracts and contracts under grants, loans
and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was made
or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed
by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil
penalty of not less than $10,000 and not more than $100,000 for each such failure.
3. Debarment, Suspension and Other Responsibility Matters
NOTE: In accordance with 45 CFR Part 76, amended June 26, 1995, any debarment, suspension, proposed debarment
or other government wide exclusion initiated under the Federal Acquisition Regulation (FAR) on or after August 25,
1995, shall be recognized by and effective for Executive Branch agencies and participants as an exclusion under 45
CFR Part 76.
(a) Primary Covered Transactions
The undersigned (authorized official) certifies to the best of his or her knowledge and belief, that the
applicant, defined as the primary participant in accordance with 45 CFR Part 76, and its principals:
(1) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded by any Federal department or agency;
(2) have not within a 3 -year period preceding this proposal been convicted of or had a civil judgment rendered
against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,
or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
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(3) are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal,
State, or local) with commission of any of the offenses enumerated in paragraph (a)(2) of this certification; and
(4) have not within a 3 -year period preceding this application /proposal had one or more public transactions
(Federal, State, or local) terminated for cause or default.
Should the applicant not be able to provide this certification, an explanation as to why should be placed under
the assurances page in the application package.
(b) Lower Tier Covered Transactions
The applicant agrees by submitting this proposal that it will include, without modification, the following clause titled
"Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion -- Lower Tier
Covered Transaction" (Appendix B to 45 CFR Part 76) in all lower tier covered transactions (i.e., transactions with
subgrantees and/or contractors) and in all solicitations for lower tier covered transactions:
Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion -- Lower Tier
Covered Transactions
(1) The prospective lower tier participant certifies by submission of this proposal, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any Federal department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in this
certification, such prospective participant shall attach an explanation to this proposal.
Signature of Authorized Certifying Official I Title
NHC Assistant County Manager
Name I Date Submitted
New Hanover County I Senior Resource Center
RSVP
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