FY16 SRC SHIIP RSVP GRANT G0186STATE OF NORTH CAROLINA
COUNTY OF WAKE
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 County/Senior Resource Center /RSVP located in New
Hanover county, hereinafter referred to as the "Grantee ", referred to collectively as the "Parties ".
I. 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 listed 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 7/1/2015 and terminates on 6/3012016.
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, 2016;
C) A final comprehensive report within sixty (60) days of the project end date; due on or before August
31, 2016.
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 tennis of this Contract; and shall specify all reports and other
deliverables required from the Grantee.
6.
M
8.
9.
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 $_ M. This
amount consists of $5.52I,; 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 $5,521.
Conflict of Interest Policy: The Agency has determined that this Contract is not subject to NCGS 14 -C -6-
22 & 23.
Reversion of Unexpended Funds: Any unexpended grant funds shall revert to the Agency upon
termination of this Contract.
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.
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
11 South Boylan Avenue
919- 807 -6900
919- 807 -6901
For the Grantee:
Tracy Ash
t- Vv+wy, Smith Vr4 de r i e-
2222 S, College Rd
Wilmington, NC 28403
910- 798 -6410
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
• Legality of disbursement;
Page 2 of 16
C. Assure adequate control of signature stanipslplates;
d. Assure adequate control of negotiable instruments, and
c. 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 anv. Grantee further agrees that it will not outsource any such
jobs during the teem 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 frorn 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: ''i"he Grantee agrees to execute the following federal certifications that are attached
to this agreement (applicable when receiving fedcral 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:t`
Printed Name
�;y't�u�,� l�tei
P
DATE: I ( i C
Division of SHIM
C
R. Van Braxton
Deputy Commissioner
DATE:
BY:
Louis Belo
Chief Deputy Commissioner
DATE:
C
Witness
Carla Obiol
Senior Deputy Commissioner
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.
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
L
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'
0overnment 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 * C
I ied (is one of the parties hereto.
(2) "Audit" means an examination of records or
financial accounts to verify their accuracy.
(3) "Certification of Compliance" mean,,, 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 perforniance of the
grant.
(10) "Grantee" has the meaning in NCGS 1430 -6-
23(a)(2): a non-State entity that receives a
grant of State funds frorn 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 n 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
1430-1-1 (d)(l 8): Any of the following that is
not a Slate 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 AuthoHty" has the meaning in NCGS
1430-1-1(d)(212): 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
award,,;.
(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
1430- 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 16013 -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 subgrantecs
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 deerned 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 y
law.
Termination 'Without Cause: The Agency may
terminate this contract without cause by giving 60 days
written notice to the Contractor. In that event, all
finished 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 untif 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 tenms 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 Rands 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 perfortning 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 Gad.
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 (``I- IIPAA "), or its implementing regulations,
it will comply with the HIPAA requirements and will
execute such agr °eemerlts and practices as the Agency
may require to ensure compliance.
Executive Order # 24: "lay Executive Order 24, issued
by Governor Perdue, and I CGS 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 lesources, health and human
Services, Juvenile Justice and Delinquency Prevention,
Revenue. Transportation, and file Office of the
Governor). This prohibition covers those vendors and
contractors who have a contract with a governmental
agt ncy; or have performed under such a contract within
the past year, or anticipate bidding on such a contract in
the future.
I or additional information regarding the specific
requirements and exemptions, vendors and contractors
arc 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 detennine 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 laws, 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.
Page 7 of 16
Equal Employment Opportunity: The Grantee shall
comply with all federal and state laws relating to equal
employment opportunity.
Confidentiality
Confidentiality: Any infornation, 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 tenns 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 detennined.
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 bolds 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 docurnentation. Stage rates
should be used as guidelines. International travel shall
not be reimbursed under this Contract.
Page 8 of 16
Sales /use "fax 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
there 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 then- 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 B
For the period 7/1/2015 — 6/30/2016
Statement of Work
Grantee: New Hanover Count' /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
SFY2015. The uses of these funds are not limited to but MUST include the following activities:
1) Conduct a minimum of seven (7) dedicated enrollment events (counseling clinics) - -one (1) must be dedicated to
the disability population -- during the period 10/15/2015 through 12/7/2015 and conduct two or more counseling
clinics during the period 1/1/2016 through 2/14/2016;
2) Coordinate a county volunteer recognition event during the grant period;
3) Submit Client Counseling (CC) Contact and Public & Media (PAM) Outreach (NPR) forms by the 15'x' of the month
following the counseling session or event through the SHIPtalk website or mail completed paper forms to the SHIIP
office in Raleigh;
4) Each SHIIP coordinating site must reach out to 50% of the county's total population for activity events (PAM) and
report in SHIPtalk;
5) Each SHIIP coordinating site must counsel 5% of their county's Medicare population (CC) and report in SHIPtalk;
6) Represent SHIIP at a minimum of 2 health fair /senior fair /special events utilizing local certified SHIIP counselors;
7) Conduct a minimum of two (2) presentations - at least one (1) New to Medicare or Medicare 101 presentation to the
general public and one (1) Medicare Education presentation to a disability group or potential LIS group in your
county; and
8) Participate in 75% of the monthly coordinator conference calls conducted from August 2015 through June 2016.
SCOPE OF WORK:
(Maximum 2 pages)
1) TheNew Hanover County RSVP /SHIIP Program will hold counseling clinics weekly on Tuesday and Thursdays from
11 a.m. -1 p.m.. Except during Open Enrollment for Part D October 15, 2015 - December 7, 2015 we will be taking
appointments.
2) The New Hanover County RSVP /SHIIP will have a recogntion event for the RSVP /SHIIP volunteers during the grant
period.
3) Client Counseling Contact forms (CC) and Public and Media forms (PAM) will be entered into the SHIPtalk website
by the 15 °i of the month.
4) The New Hanover County will reach out to 50% of the county's total population through health fairs, senior housing
complexes, flyers, NHC Senior Resource Center website.
5) The New Hanover County RSVP /SHIIP Program will counsel 5% of the counties total population and report in
SHIPtalk. Counseling will be done through the Walk -In Clinic and appointments.
Page 10 of 16
6) The New Hanover County RSVP/Shill' will be represented at 21 health fairs/senior fair/ special events using SHLIP
certified volunteers, Including "Taking Control of You health" and the "Health and Safety Expo".
7) The New Hanove r RSVP/SIIIIP Program will conduct a minimum of-two (2) presentations to those who are new to
Medicare and one Medicare presentation to a disability group or potential Low-income Subsidy group in New Hanover
County.
8) The SHUP coordiantor will participate in 75% of the irionthly, conference calls from August 2015 - June 2016.
Page 11 of'16
SCOPE OF WORK: cont.
Page 12 of 1 6
Attachment C
For the period 7/1/2015 — 6/30115
Line Item Budget and Budget Narrative
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: New Hanover Count /Senior Resource Center/RSVP'
Budget
Amount
Contractual
2,470.00
Construction
0.00
Supplies
1,550.00
Equipment
0.00
Other
1,001.00
Travel
500.00
Personnel
Fringe
Total
$5,521.00
Narrative:
Contractual: Pharmancy Bags with RX Marketing for 4 different pharmacies in New Hanover County.
Supplies: Paper, Ink, Postage, printing and copier costs.
Other: Volunteer recognition and meals during Open Enrollment, refreshments for outreach activities
Page 13 of 16
Attachment D
Certifications Regarding, Drug -Free Work- Place; Lobbying; and
Debarment, Suspension and Other Responsibility Matters
1. Drug -Free Wort: -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 iii 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) Tlie 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 lave calendar days alter 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 4 -rant, it will not engage in the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance in conducting any activity with the grant.
Page 14 of 16
2. Lobbying
Title 3 1 of the United States Code, Section 1352, entitled "Limitation on use of appropriated funds Loinfluence
certain Federal z and Onmzuio) io»oomoduox,- 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 o SPECIFIC gnmu( ar 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 (aoo-apprupriu<ud)funds. These requirements apply to grants and cooperative agreements EXCEEDING
$ 10O,000io total costs (45CFBPmn93).
The undersigned (ouUhorzedotQciul) cerifies,&odzcbes ufhis*r her knowledge and belief" that:
(a) No Federal appropriated funds have been paid or will be paid, hvmoo behalf o[ the u to any
person for influencing or attempting to influence un officer mr employee oy any agency, a member of
Congress, any officer or employee of Congress, ormo employee ofu Member of Congress in connection with
the awarding of any Federal contract, the mmukiugm[any Federal grant, the making of any [u]eru| loan, the
entering io\uwf any cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any Federal grant, loan or cooperative agreement;
(b) lfooy funds other than Federal appropriated funds have been paid or will bc paid M tiny person for
influencing orattempting to influence un officer or employee of any agency, u Member of Congress, au
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 Forill -
LLL.1 "Disclosure of Lobbying Activities," in accordance with its instructions,
(c) The undersigned ebn|rcguircthaN1bc)mogon�cof this ccoi�oatiunbc included im the award docunzcota
for all xo6uwuodu at all tiers (including subcontracts, subgrants, oertruc1m and contracts under grants, lmouu
and cooperative agreements) and that all subrecipients shall ccrtl�v and disclose accordingly.
'rbncertifiutimuimo material representation of fact upon which reliance was placed when this transaction was made
or entered into. Submission of this mertibomiimm is upreregmiuitu for making or entering into this \oauyacdoo imposed
hy section i352, title 31,[J.8.Code. Any person who fails 1a file the required certification shall bc subject xma civil
penalty of not less than S 10,000 and not more than S 100,000 for each Such fal I UrC,
3, Debarment, Suspension and Other Responsibility Matters
NO/n: [u accordance with 45CF}l Part 76, amended June 20`l995,any debarment, suupnombao, proposed debarment
ur other government wide exclusion initiated under the Federal Acquisition Regulation (F/\R)onor after August 25,
1995, shall be recognized by and effective for Executive Branch agencies and participants as an exclusion under 45
CFR Part 76.
(u) Primary Covered Transactions
The undersigned (authorized official) certifies to the best of his orher knowledge and belief, that the
applicant, defined asthe primary participant im accordance with 45CFQ Part 7b, and its principals:
(l) are not presently debarred, suspended, proposed for debarment, declared ineligible, urvolmntah|y
excluded 6v any Federal department oragouc�
(2) have not within a3-yomr 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 u public (Federal, Stutmor local) transaction nr contract under a public 1ruuyaobou� violation of
[udcru1 or State antitrust statutes orcommission of embezzlement, theft, forgery, bribery, tb|aifioatiom or
destruction of records, making false statements, or receiving stolen property,
Page 15 of 16
(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
(I ) 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
Title
Grantee Name
Date Submitted
New Hanover County/
Senior Resource Center /RSVP
Page 16 of 16
Grant Document Routing
,
Start date: 8/11/2015
From: Teresa Hewett, Finance Department (7408)
Signatures required:
Avril Pinder, Deputy County Manager
VWitness of Avril's signature
Return to Teresa Hewett, Finance Department (7408)
Type(s) of documents attached:
1 original — SRC SHIIP (Senior Health Insurance Information Program)
Explanation of document(s):
Attached is the FYI award contract for the SRC SHIIP /RSVP program. The grant was included
in the FY16 adopted budget in the amount of $4,329. I will prepare a BA for the September
consent agenda to increase the amount to the award of $5,521. Please let me know if you have
any questions. Thank you, Teresa
--------- - - - - -- ---------- - - - - -- for finance department use --------------------------------------------------
DATE ADDED TO LASERFICHE
PICKED UP BY:
Print Name & Date
Signature
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