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HomeMy WebLinkAboutFY17 SRC SHIIP AWARD CONTRACTDocuSign Envelope ID: 92AE1148- C41374060- 92137ADDA48B810CC STATE OF NORTH CAROLINA COUNTY OF WAKE Grant Name: CDAP - StateHealthinsurance Assistance Program Federal Awarding Agency: u5 Department of Health & Human services, Administration for Community Living CFDA # 93.324 Grant Award # 90sa0090 -01 -00 Cost Center: 16001636g6 Account # 536405 Contract Between Recipient: State of North Carolina Department of Insurance SHIIP Division Fiscal Year: 2016 -2017 Performance Period: 07/01/16- 06/30/17 Award Amount S 6790.00 Federal Award Date: 03/24/16 Subreceipient: Name: New Hanover County County: New Hanover Tax ID /FIN# 56- 6000324 DUNS # 40029563 This Contract and its attachments shall be completed and returned to the Recipient within 45 days of receiving the electronic document in order for the Recipient to process the award and provide funds to the Subrecipient. The Subrecipient shall provide the Recipient with progress reports and a final report detailing the Subrecipient's use of State funds. 1. 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) (6) Certification of Eligibility Under the han Divestment Act (Attachment E) 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. Subrecipient's Duties: The Subrecipient 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 Subrecipient 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 Recipient, the North Carolina State Auditor, or applicable federal agencies. Upon termination of contract as a SHIIP Coordinating Site, any equipment or property less than five (5) years old purchased by Subrecipient with grant funds to perform SHIIP functions shall be returned to the Recipient in good working order. The DocuSign Envelope ID: 92AE1148- C4D7- 4060- 92D7- 4DDA486810CC Subrecipient shall submit to the Recipient all plans, reports, documents or other products that the Recipient may require, in the form specified by the Recipient, 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 Subrecipient due by January 31; C) A final comprehensive report within sixty (60) days of the project end date; due on or before August 31. 4. Recipient's Duties: The Recipient shall reimburse the Subrecipient for the costs of services and activities described in Attachment B and in accordance with the approved budget in Attachment C. The Recipient shall monitor the Subrecipient for compliance with the terms of this Contract; and shall specify all reports and other deliverables required from the Subrecipient. The Recipient shall pay the Subrecipient in the manner and in the amounts specified in the Contract Documents. [ X ] a. There are no matching requirements from the Subrecipient. [ ] b. The Subrecipient's matching requirement is $n/a, which shall consist of: [ ] In -kind [ ] Cash [ ] Cash and In -kind [ ] Cash and/or In -kind The contributions from the Subrecipient shall be source from non - federal funds. 5. Conflict of Interest Policy: The Recipient has determined that this Contract is not subject to NCGS 14 -C- 6-22 & 23. 6. Reversion of Unexpended Funds: Any unexpended grant funds shall revert to the Recipient upon termination of this Contract. 7. Grants: The Subrecipient has the responsibility to ensure that all sub - grantees, if any, provide all information necessary to permit the Subrecipient to comply with the terms and conditions set forth in this Contract. The grant award for the contract is not to be used for Research & Development (R &D). 8. 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. 9. 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 Receipient: R. Van Braxton, Deputy commissioner SHIIP Division 11 South Boylan Avenue Raleigh, NC 27603 Telephone: 919 - 807 -6900 For the Subreceipient: Valerie Smith Senior Resource Ctr /RSVP 2222 S. College Road Wilmington, NC 28403 Telephone: 910- 798 -6410 10. Supplementation of Expenditures of Public Funds: The Subrecipient 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 Subrecipient 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 Subrecipient's total expenditure of other public funds for such services. Page 2 of 16 DocuSign Envelope ID: 92AE1148 -C4D7- 4060- 92D7- 4DDA48B810CC 11. Disbursements: As a condition of this Contract, the Subrecipient 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; 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. 12. Outsourcing: The Subrecipient certifies that it has identified to the Recipient all jobs related to the Contract that have been outsourced to other countries, if any. Subrecipient further agrees that it will not outsource any such jobs during the term of this Contract without providing notice to the Recipient. 13. 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. 14. Audit: The Recipient reserves the right to conduct an audit through the NCSMP Program Director. The Subrecipient must permit access to records and financial statements by the audit staff of Recipient as necessary. 15. Federal Certifications: The Subrecipient 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. Page 3 of 16 DocuSign Envelope ID: 92AE1146- C4D7-4060- 92D7- 4DDA48B810CC 16. Signature Warranty: The undersigned represent and warrant that they are authorized to bind their principals to the terms of this agreement. Subrecipient: BY: DATE: QLALP are\ M• Division of SIIIIP, DocuSig -d Cy: /au, �v'apfeti. BY: �6sec,Fgs «_ DATE: BY BY: Contract is not executed until last signature is obtained. aeviewed by: Pi controller's office Review: DATE: DATE: 08/19/2016 Page 4 of 16 DocuSign Envelope ID: 92AE1148- C4D7- 4060- 92D7- 4DDA48B810CC Attachment A General Terms and Conditions DEFINITIONS individuals for Medicare and Medicaid patient Unless indicated otherwise from the context, the services. following terms shall have the following meanings in (8) "Financial Statement" means a report this Contract. All definitions are from 9 NCAC providing financial statistics relative to a given 3M.0102 unless otherwise noted. If the rule or statute part of an organization's operations or status. that is the source of the definition is changed by the (9) "Grant" means financial assistance provided adopting authority, the change shall be incorporated by an Recipient, Subrecipient, or subgrantee to herein. carry out activities whereby the grantor (1) "Recipient" (as used in the context of the anticipates no programmatic involvement with definitions below) shall mean and include the Subrecipient or subgrantee during the every public office, public officer or official performance of the grant. (State or local, elected or appointed), (10) "Subrecipient" has the meaning in NCGS institution, board, commission, bureau, 143C- 6- 23(a)(2): a non -State entity that council, department, authority or other unit of receives a grant of State funds from a State government of the State or of any county, unit, agency, department, or institution but does not special district or other political subagency of include any non -State entity subject to the government. For other purposes in this audit and other reporting requirements of the Contract, "Recipient" shall mean the entity Local Government Commission. For other identified as one of the parties hereto. purposes in this Contract, "Subrecipient" shall (2) "Audit" means an examination of records or mean the entity identified as one of the parties financial accounts to verify their accuracy. hereto. (3) "Certification of Compliance" means a report (11) "Grantor" means an entity that provides provided by the Recipient to the Office of the resources, generally financial, to another entity State Auditor that states that the Subrecipient in order to achieve a specified goal or has met the reporting requirements established objective. by this Subchapter and included a statement of (12) "Non -State Entity" has the meaning in NCGS certification by the Recipient and copies of the 143C- 1- 1(d)(18): Any of the following that is submitted Subrecipient reporting package. not a State agency: An individual, a fum, a (4) "Compliance Supplement" refers to the North partnership, an association, a county, a Carolina State Compliance Supplement, corporation, or any other organization acting maintained by the State and Local as a unit. The term includes a unit of local Government Finance Agency within the North government and public authority. Carolina Department of State Treasurer that (13) "Public Authority" has the meaning in NCGS has been developed in cooperation with 143C- 1- 1(d)(22): A municipal corporation agencies to assist the local auditor in that is not a unit of local government or a local identifying program compliance requirements governmental authority, board, commission, and audit procedures for testing those council, or agency that (i) is not a municipal requirements. corporation and (ii) operates on an area, (5) "Contract" means a legal instrument that is regional, or multiunit basis, and the budgeting used to reflect a relationship between the and accounting systems of which are not fully Recipient, Subrecipient, and subgrantee. a part of the budgeting and accounting systems (6) "Fiscal Year" means the annual operating year of a unit of local government. of the non -State entity. (14) "Single Audit" means an audit that includes an (7) "Financial Assistance" means assistance that examination of an organization's financial non -State entities receive or administer in the statements, internal controls, and compliance form of grants, loans, loan guarantees, with the requirements of Federal or State property (including donated surplus property), awards. cooperative agreements, interest subsidies, (15) "Special Appropriation" means a legislative act insurance, food commodities, direct authorizing the expenditure of a designated appropriations, and other assistance. Financial amount of public funds for a specific purpose. assistance does not include amounts received (16) "State Funds" means any funds appropriated as reimbursement for services rendered to by the North Carolina General Assembly or Page 5 of 16 DocuSign Envelope ID: 92AE1148 -C4D7- 4060- 92D7- 4DDA48B810CC collected by the State of North Carolina. State 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 Subrecipient 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 Subrecipient 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 Subrecipient 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 Recipient. Subcontracting: The Subrecipient shall not subcontract any of the work contemplated under this Contract without prior written approval from the Recipient. 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 Recipient shall not be obligated to pay for any work performed by any unapproved subcontractor or subgrantee. The Subrecipient 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 Subrecipient has the responsibility to ensure that all subgrantees, if any, provide all information necessary to permit the Subrecipient to comply with the standards set forth in this Contract. Assignment: No assignment of the Subrecipient's obligations or the Subrecipient'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 Subrecipient's payment check(s) directly to any person or entity designated by the Subrecipient, or (b) Include any person or entity designated by Subrecipient as a joint payee on the Subrecipient's payment check(s). In no event shall such approval and action obligate the State to anyone other than the Subrecipient and the Subrecipient 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 Recipient and the named Subrecipient. 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 Recipient and Subrecipient that any such person or entity, other than the Recipient or the Subrecipient, receiving services or benefits under this Contract shall be deemed an incidental beneficiary only. Indemnity Indemnification: The Subrecipient agrees to indemnify and hold harmless the Recipient, 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 Subrecipient 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 law. Termination Without Cause: The Recipient may terminate this contract without cause by giving 60 days Page 6 of 16 DocuSign Envelope ID: 92AE1148 -C4D7- 4060- 92D7 -4DDA48B810CC 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 Recipient, become its property and the Contractor shall be 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 Subrecipient shall fail to fulfill its obligations under this Contract in a timely and proper manner, the Recipient shall have the right to terminate this Contract by giving written notice to the Subrecipient and specifying the effective date thereof In that event, all finished or unfinished deliverable items prepared by the Subrecipient under this Contract shall, at the option of the Recipient, become its property and the Subrecipient 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 Subrecipient shall not be relieved of liability to the Recipient for damages sustained by the Recipient by virtue of the Subrecipient's breach of this agreement, and the Recipient may withhold any payment due the Subrecipient for the purpose of setoff until such time as the exact amount of damages due the Recipient from such breach can be determined. Waiver of Default: Waiver by the Recipient of any default or breach in compliance with the terms of this Contract by the Subrecipient 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 Recipient and the Subrecipient 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 Recipient. 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 Recipient 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 ( "HIPAA "), or its implementing regulations, it will comply with the HIPAA requirements and will execute such agreements and practices as the Recipient 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 Recipient. The Subrecipient shall not assert a claim of copyright or other property interest in such deliverables. Page 7 of 16 DocuSign Envelope ID: 92AE1148 -C4D7- 4060- 92D7- 4DDA48B810CC Compliance with Applicable Laws Compliance with Laws: The Subrecipient 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. Equal Employment Opportunity: The Subrecipient 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 Subrecipient 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 Recipient. The Subrecipient 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 Recipient 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 Recipient. 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 Subrecipient, 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 Recipient and the Subrecipient. 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 Recipient. 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 Subrecipient 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 Page 8 of 16 DocuSign Envelope ID: 92AE1148 -C4D7- 4060- 92D7- 4DDA48B810CC Recipient for loss of, or damage to, such property. At the termination of this Contract, the Subrecipient shall contact the Recipient for instructions as to the disposition of such property and shall comply with these instructions. Travel Expenses: Reimbursement to the Subrecipient 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. Sales/Use Tax Refunds: If eligible, the Subrecipient 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 Subrecipient shall not use the award of this Contract as a part of any news release or commercial advertising, except as allowed in Attachment B. Page 9 of 16 DocuSign Envelope ID: 92AE1148 -C4D7- 4060- 92D7- 4DDA48B810CC Attachment B For the period 07/01/16- 06/30/17 Statement of Work Subrecipient: New Hanover County This statement should be a short summary describing what the Subrecipient does and how the Subrecipient will use these funds. The terms of the contract between the SHIM office and the agencies require local programs meet these goals for the contract period. 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 10/15/16 through 12/7/16 and conduct two (2) or more counseling clinics during the period 1/1/17 through 2/14/17; 2. Initiate and develop a relationship with local Community Health Centers that support Medicare beneficiaries in your county; 3. Submit Client Counseling (CC) Contact and Public and Media (PAM) Outreach (NPR) forms by the 15th of the month following the counseling session or event through the SHIPtalk website; 4. Attend the Annual SHIIP Coordinators' Training Conference August 2 & 3, 2016; this is mandatory for all coordinators; all new coordinators are required to attend a special training beginning at 12:30 pm on August 1, 2016. 5. 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 Extra Help group in your county; and represent SHIIP at a minimum of two (2) health fair /senior fair /special event utilizing local certified SHIIP counselors; 6. Reach out to 50 percent of the county's total population for activity events (PAM) and report in SHIPtalk; 7. Counsel 5 percent of the county's Medicare population (CC) and report in SHIPtalk; 8. Coordinate a county volunteer recognition event during the grant period; and 9. Participate in 75 percent of the monthly coordinator conference calls from July 2016 through June 2017. Page 10 of 16 DocuSign Envelope ID: 92AE1148 -C4D7 -0060- 92D74DDA48B810CC subrecipient Response to scope of work 1) The New Hanover County RSVP /SHIIP Program will conduct counseling clinics weekly on Tuesday and Thursdays from 11 am -1 pm. Except during Open Enrollment for Part D October 15, 2016 - December 7, 2016 appointments will be taken for counseling sessions. 2) The NHC RSVP /SHIIP will have a recognition event for the RSVP /SHIIP volunteers during the grant period and provide counselors with necessary supplies to effective conduct SHIIP counseling. 3) Client Counseling Contact forms (CC) and Public and Media forms (PAM) will be entered into the SHIPtalk website by the 15th of the month. 4) The New Hanover County RSVP /SHIIP will reach out to 50% of the county's Medicare eligible population through health fairs, senior housing complexes, flyers, additional county departments, NHC SRC website, NHC SRC newsletter. 5) The NHC RSVP /SHIIP Program will counsel a minimum of 5% of the counties total Medicare eligible population and report in SHIPtalk. Counseling will done through appointments and walk -in clinics. 6) The NHC RSVP /SHIIP Program will maintain client confidentially by providing volunteer training, providing counseling workstations, and securing files. Page 11 of 16 DocuSign Envelope ID: 92AE1148 -C4D7- 4060- 92D7- 4DDA48B810CC Attachment C For the period 07/01/16- 06/30/17 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. Upon termination of contract as a SHIIP Coordinating Site, any equipment or property less than five (5) years old purchased by Subrecipient with grant funds to perform SHIIP functions shall be returned to the Recipient in good working order. All budgets must be approved by the Recipient. Subrecipient Name: New Hanover County All fields must be completed. zero is an acceptable answer. Must agree to the award HOKIN required by your local government? This instrument has been pre- audited in the manner required by the Local Government Budget and Fiscal Control Act. Yes Award Amount: $ 6790.00 Budget Amount Contractual 100 Construction Supplies 3170 Equipment 1400 Other 1720 Travel 400 Personnel Fringe Total 6,790.00 Written description of planned expenditures: Purchase of a study workspace to conduct additional SHIIP counseling while maintain participant confidentiality. Purchase of general supplies (paper, pens, ink, printer, laptop) for SHIIP counseling and outreach. SHIIP outreach expenses (printing and SHIIP promotion). SHIIP volunteer recognition and expenses related to quarterly SHIIP training. Expense for providing interpreter to SHIIP clients in needs of service. Training and travel expenses to and from SHIIP training. Page 12 of 16 DocuSign Envelope ID: 92AE1148- C4D7- 4060- 92D74DDA48B810CC 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 Subrecipient 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 Subrecipient'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 Subrecipient'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 Recipient, 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 Recipient 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 Subrecipient 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. Page 13 of 16 DocuSign Envelope ID: 92AE1148 -C4D7- 4060- 92D7- 4DDA48B810CC 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; Page 14 of 16 DocuSign Envelope ID: 92AE1148- C4D74060- 92D74DDA48B810CC (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 Title Subrecipient Name Date Submitted New Hanover County (ql^ ` I I Page 15 of 16 DocuSign Envelope ID: 92AE1148 -C4D7- 4060- 92D7- 4DDA48B810CC Attachment E CERTIFICATION OF ELIGIBILITY Under the Iran Divestment Act Pursuant to G.S. 147- 86.59, any person identified as engaging in investment activities in Iran, determined by appearing on the Final Divestment List created by the State Treasurer pursuant to G.S. 147- 86.58, is ineligible to contract with the State of North Carolina or any political subdivision of the State. The Iran Divestment Act of 2015, G.S. 147 -86.55 et seq.* requires that each vendor, prior to contracting with the State certify, and the undersigned on behalf of the Vendor does hereby certify, to the following: 1. that the vendor is not identified on the Final Divestment List of entities that the State Treasurer has determined engages in investment activities in Iran; 2. that the vendor shall not utilize on any contract with the State agency any subcontractor that is identified on the Final Divestment List; and 3. that the undersigned is authorized by the Vendor to make this Certification. Vendor: New Hanover County By: �� �D Signa re Date Printed Name Title The State Treasurer's Final Divestment List can be found on the State Treasurer's website at the address: https: / /www.nctreasurer.com/ inside - the - department /OpenGoveniment/Pages/ Iran- Divestment- Act - Resources.aspx and will be updated every 180 days. For questions about the Department of State Treasurer's Iran Divestment Policy, please contact Meryl Murtagh at Meryl.Murtagh @nctreasurer.com or (919) 814 -3852. * Note: Enacted by Session Law 2015 -118 as G.S. 143C -55 et seq., but has been renumbered for codification at the direction of the Revisor of Statutes. Page 16 of 16 DocuSign Envelope ID: 92AE1148- C4D74060- 92D7- 4DDA48B810CC All participants: Enter any necessary notes throughout the process in the comments box below. Comments are not part of the contract.