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HomeMy WebLinkAboutFY18 Soil and Water Stream Debris Removal Granta NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES Steven W. Troxler, Commissioner NCDA &CS Division of Soil & Water Conservation CONTRACT "CHECK OFF LIST" for Grantee INSTRUCTIONS: CHECK THE "YES" BOXES IN LEFT COLUMN FOR THE DOCUMENT TITLES THAT ARE BEING RETURNED WITH THE TWO SIGNED. DATED and WITNESSED COPIES OF THE CONTRACT, WITH SIGNATURES IN BLUE INK. BE SURE TO INCLUDE ALL THE OTHER DOCUMENTS SPECIFIED IN YOUR CONTRACT PACKAGE. IF "® NO" HAS BEEN CHECKED OFF FOR YOU, THAT DOCUMENT IS NOT REOURED FOR THIS GRANT PROGRAM OR PROJECT. GRANTEE ORGANIZATION NAME: New Hanover Soil & Water Conservation District PROJECT TITLE /NAME: Stream Debris Removal Project CONTRACT #: 17- 175 -4023 GOVERNMENTAL ENTITIES ONLY Check one Box DOCUMENT TITLE ALL SIGNATURES MUST BE IN BLUE INK DEPARTMENTAL USE- DOCUMENTS ATTACHED OR ON FILE GRANTS & CONTRACTS USE - DOCUMENTS ATTACHED ❑ Yes ❑ No Contract "Check Off List" for Grantee ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Contract Cover To be signed, dated & witnessed ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ATTACHMENT A - Scope of Work Description of Services ❑ Yes El No ❑ Yes ❑ No ❑ Yes ❑ No ATTACHMENT B - General Terms & Conditions ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ATTACHMENT C - Certifications and Assurances Section ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ATTACHMENT D - NCO enBook Supplemental Information ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ATTACHMENT E - Signature Card ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ATTACHMENT F - W -9 Tax Information ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No I ATTACHMENT G - Vendor Electronic Payment Form ❑ Yes ❑ No ❑ Yes ❑ No Effective 7/14 cci �kc t'G STATE OF NORTH CAROLINA 3'gr v Departmental Use Only =+ CENTER: 2975 =4786 COUNTY OF WAKE z ACCOUNT: 536502 b AMOUNT: $152,000.00 North Carolina Department of Agriculture and Consumer Services Division of Soil & Water Conservation Stream Debris Removal Project - Government Contract # 17 -175 -4023 This Contract is hereby entered into by and between the North Carolina Department of Agriculture and Consumer Services, Division of Soil & Water Conservation (the "Agency ") and New Hanover Soil & Water Conservation District (the "Grantee "), and referred to collectively as the "Parties ". The Grantee's federal tax identification number is 56- 6000324 and is physically located in New Hanover County, and is further located at 230 Government Center Drive, Suite 100 Wilmington, NC 28403. The purpose of this Contract is to remove from streams debris resulting from past and recent hurricanes, ice storms and tornadoes. The Grantee's project title is Stream Debris Removal Project. This Contract is funded by state appropriations from the Disaster Recovery Act of 2016. Funds awarded under this Contract must be used for the purposes for which they are intended. The Grantee's fiscal year ends June 30. Contract Documents: This Contract consists of the Grant Contract and its attachments, all of which are identified by name as follows: 1. This Contract 2. Scope of Work (Attachment A) 3. General Terms and Conditions (Attachment B) 4. Certifications and Assurances Section (Attachment C) 5. NC Openbook Supplemental Information (Attachment D) 6. Signature Card (Attachment E) 7. W -9 Tax Information (Attachment F) 8. Electronic Payment Request Forth (Attachment G) These documents constitute the entire agreement between the Parties and supersede all prior oral or written statements or agreements. I. 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 I, above, with the first- listed document having the highest precedence and the last- listed document having the lowest precedence. If there are multiple NCDA &CS (Gov't Contract Cover - Soil & Water) Rev. 7/14; 12/14 Page 1 of 6 Contract Amendments, the most recent amendment shall have the highest precedence and the oldest amendment shall have the lowest precedence. II. Effective Period: This Contract shall be effective on January 1. 2017 and shall terminate on December 31. 2018 with the option to extend, if mutually agreed upon, through a written amendment as provided for in the General Terms and Conditions as described in Attachment B. III. Grantee's Duties: The Grantee shall provide the services as described in the Attachment A: Scope of Work. IV. Agency's Duties: 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 $152,000.00. This amount consists of: $152,000.00 in State funds. [ ] a. There are no matching requirements from the Grantee. [ ] b. There are no matching requirements from the Grantee; however, the Grantee has committed the following match to this project: [X] c. The Grantee's matching requirement is $66,000.00, which consists of: In Kind $ Cash $ Cash and In -kind $ Cash and /or In -kind $ Other /S eci : $ [X] c. The Grantee's matching requirement is $66,000.00, which consists of: The contributions from the Grantee shall be sourced from non - federal funds. The total contract amount with matching funds is $218,000.00. V. Conflict of Interest Policy: The Agency has determined that the Grantee is a governmental agency and is not subject to N.C.G.S. § 143C- 6- 23(b). Therefore, the Grantee is not required to file a Conflict of Interest Policy with the Agency prior to disbursement of funds. VI. Statement of No Overdue Tax Debts: The Agency has determined that Grantee is a governmental agency and is not subject to N.C.G.S. § 143C- 6- 23(c). Therefore, the Grantee is not required to file a Statement of No Overdue Tax Debts with the Agency prior to disbursement of funds. NCDA &CS (Gov't Contract Cover - Soil & Water) Rev. 7/14; 12114 Page 2 of 6 In Kind $ Cash $ Cash and In -kind $ Cash and/or In -kind $66,000.00 Other/Specify: $ The contributions from the Grantee shall be sourced from non - federal funds. The total contract amount with matching funds is $218,000.00. V. Conflict of Interest Policy: The Agency has determined that the Grantee is a governmental agency and is not subject to N.C.G.S. § 143C- 6- 23(b). Therefore, the Grantee is not required to file a Conflict of Interest Policy with the Agency prior to disbursement of funds. VI. Statement of No Overdue Tax Debts: The Agency has determined that Grantee is a governmental agency and is not subject to N.C.G.S. § 143C- 6- 23(c). Therefore, the Grantee is not required to file a Statement of No Overdue Tax Debts with the Agency prior to disbursement of funds. NCDA &CS (Gov't Contract Cover - Soil & Water) Rev. 7/14; 12114 Page 2 of 6 VII. Reversion of Unexpended Funds: Any unexpended grant funds shall revert to the Agency within 60 days of the termination of this Contract. VIII. Reporting Requirements: (1) State fN.C.G.S. 143C -6 -231: The Agency has determined that the Grantee is a governmental entity and is not subject to the State reporting requirements mandated by N.C.G.S. § 143C -6 -23. Therefore, the Grantee does not have to file annual electronic reports with the NC Office of State Budget & Management. (2) Agency Reporting Requirements: a) The Grantee shall submit quarterly progress reports, with each report due on or before the last day of April, July, October, and January, continuing until the project is complete and final project report is approved. The quarterly progress report is required even if no activity has occurred for the quarter and no reimbursement is requested for the quarter. b) The quarterly and final report shall include a narrative summary of the work completed each quarter and for the project to date and a summary of cash and in -kind expenditures for the quarter and total project. c) Grantee shall submit a Final Financial report and Final Invoice not later than 60 days after the expiration or termination of this Contract. IX. Payment Provisions: Upon execution of this Contract the Grantee shall submit to the Agency Contract Administrator a completed Request for Payment forth, to be provided by the Agency. All Request for Payment forms should be received no more than monthly, an invoice showing expenditures and matching funds, if applicable, for the current period and cumulatively for the entire project and, upon approval by the Agency, shall receive payment within 30 days. Twenty percent (20 %) of the total funds awarded under this Contract shall be retained by the Agency until both the final performance and financial reports are submitted by the Grantee and approved by the Agency. Up to 12 percent (12 %) of the funds awarded to the Grantee may be used to reimburse actual documented administrative expenses for the project, excluding any expenses pledged by the Grantee as match for this project and salary, benefits, and operating expenses that would normally have been paid by the Grantee. If this Contract is terminated prior to the original end date, the Grantee may submit a final Request for Payment form. All unexpended funds shall be returned by the Grantee to the Agency within 60 days of the Contract termination date with a complete final financial report, accompanied by either a final invoice or a refund of any funds received but not expended. The Agency shall have no obligation to honor requests for payment based on expenditure reports submitted later than 60 days after termination or expiration of the contract period. Reimbursement requests shall be completed on a "Request for Reimbursement" form furnished to the Grantee by the Agency. All reimbursement forms must include support documentation, including but not limited to; copies of invoices, individual time sheets and travel logs that have been signed by the employee and supervisor; salary registers or payrolls that include fringe benefits, hourly rates of pay, and signature of the Grantee's responsible financial person, cancelled checks and lease agreements. Eligible expenditures for payment must be within the effective period noted in the Contract. Reimbursement may not be considered prior to the submission and final execution of the Contract. NCDA &CS (Gov't Contract Cover - Soil & Water) Rev. 7/14; 12114 Page 3 of 6 All travel reimbursement shall be made in accordance with the current State rates, at the time of the expenditure, and shall be made in accordance with the "State Budget Manual ". Staff from the Division of Soil and Water Conservation or its designated agent will conduct a site visit and approve the work completed and submitted for reimbursement prior to releasing any payment to the Grantee. The Agency must determine that all work has been completed satisfactorily in accordance with the Best Management Practices for Selective Clearing and Snagging. All matching funds, including in -kind and cash, must be spent concurrently with funds provided by the Contract. Both types of matching funds expended shall be accounted for on the monthly invoices. Indirect costs are not allowable expenditures under this Contract, except as described in paragraph two of this section. X. 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, post office address, street address, telephone number, fax number, and email address of the Parties' respective initial Contract Administrator are set out below. Either Party may change the name, post office address, street address, telephone number, fax number, or email address of its Contract Administrator by giving timely written notice to the other Party. For the Agency: IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS David B. Williams David B. Williams Division of Soil & Water Conservation Division of Soil & Water Conservation 1614 Mail Service Center 512 N. Salisbury Street, Room 417D Raleigh, NC 27699 -1614 Raleigh, NC 27604 -1170 Telephone: 919- 715 -6103 Email: David. B.Williams @ncagr.gov For the Grantee: Grantee Contract Administrator Grantee Principal Investigator or Key Personnel Dru Harrison Same New Hanover Soil & Water Conservation District 230 Government Center Drive, Suite 100 Wilmington, NC 28403 Telephone: 910- 798 -7135 Fax: 910 - 798 -6049 Email: drharrison@nhcgov.com XI. Supplementation of Expenditure of Public Funds: The Grantee assures that funds received pursuant to this Contract shall be used only to supplement, not to supplant, the total amount of federal, state and local public funds that the Grantee otherwise normally expends for salary and benefits for activities involved with specialty services and related programs. Funds received under this Contract shall be used to provide additional public funding for NCDA &CS (Gov't Contract Cover -Soil & Water) Rev. 7/14; 12/14 Page 4 of 6 such services. The funds shall not be used to reduce the Grantee's total expenditure of other public funds for such services. XII. Disbursements: As a condition of this Contract, the Grantee acknowledges and agrees to make disbursements in accordance with the following requirements: Will implement or already have implemented adequate internal controls over disbursements Pre -audit all invoices presented for payment to determine: • Validity and accuracy of payment • Payment due date • Adequacy of documentation supporting payment • Legality of disbursement Assure adequate control of signature stamps /plates Assure adequate control of negotiable instruments; and Have procedures in place to ensure that account balance is solvent and to reconcile the account monthly. X111. 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 prior notice to the Agency. XIV. N.C.G.S. § 133 -32 and Executive Order 24: N.C.G.S. § 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 or Contract, 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 employee of your organization. [This contract is continued on the next page.] NCDABCS (Gov't Contract Cover - Soil & Water) Re, 7/14; 12/14 Page 5 of 6 XV. Signature Warranty: The undersigned represent and warrant that they are authorized to bind their principals to the terms of this Contract. IN WITNESS WHEREOF, the Grantee and the Agency execute this contract in two (2) originals, one (1) of which is retained by the Grantee and one (1) which are retained by the Agency, the day and year first above written. Witness: nature (( Date 11ln '14,(1 �Si1bfGLL ¢ cGt°lal�i3t Printed Name tale l s1` f o North Carolina Department of Agriculture and Consumer Services 3 Signature of Authorized Representative Date N. David Smith, Chief Deputy Commissioner NCDA&CS (Gov't Contract Cover- Soil & Water) Re, 7/14; 12/14 Page 6 of 6 ATTACHMENT A SCOPE OF WORK STREAM DEBRIS REMOVAL PROJECT New Hanover Soil & Water Conservation District (the "GRANTEE ") will complete stream debris removal activities including cutting and removing downed trees, broken tops, and woody /vegetative debris that impede or potentially impede water flow in the streams and tributaries included in Table Al below (taken from the application submitted by the GRANTEE). The GRANTEE must use its best judgment to only remove debris resulting from Hurricane Matthew or Tropical Storms Hermine and Julia. TABLE A 1 _ Stream /Ditch Sesments to he Renaired Name/Description of Stream or Channel Description of Damage and Planned Repair Approximate Length of Channel ft Number of Known Beaver Dams to Remove Smith Creek Urban Vegetation removal 25,000 3 Motts Creek Urban Vegetation removal 9,700 4 Prince George Creek Urban Vegetation removal 3,300 5 Reserve at West Bay Urban Vegetation removal 1,800 Tribuatary to Prince George Creek Urban Vegetation removal 1,800 3 The GRANTEE will ensure that all required permits are secured for each site before any work proceeds for that site. The GRANTEE will ensure that it follows the Best Management Practices for Selective Clearing and Snagging to manage all woody debris removed from streams. These guidelines can be downloaded at hhtt • / /www ncaa gov/ SWC/ disasterresponse/ documents/ BestManagementPracticesforSelectiveClearin gandSnagging,pdf NCDA &CS (Govt Contract Cover - Soil & Water) Rev. 7114; 12114 Page 1 of 1 PUBLIC SECTOR CONTRACTS (Including Local Governments) General Terms and Conditions DEFINITIONS 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 individuals for Medicare and Medicaid patient 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 G.S. 143C -6- 23(ax2): 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 N.C.G.S. 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 N.C.G.S. 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 NCDA &CS - General Terms and Conditions — Public - Local Govemmental Entities Eff. 07/14;4/15;1117 Page 1 of 4 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 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 N.C.G.S. 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 G.S. 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 G.S. 143C- 1- 1(d)(29): A municipal corporation that has the power to levy taxes, including a consolidated city- county as defined by G.S. 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, including any of its Divisions, and any of its officers, agents and employees, from liability of any kind, and from any claims of third parties arising out of any act or omission of the Contractor in connection with the performance of this Contract to the extent permitted by law. 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 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 NCDA &CS - General Terms and Conditions — Public - Local Governmental Entities Eff. 07114;4115;7117 Page 2 of 4 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. The filing of a petition for bankruptcy by the Grantee shall be an act of default under this Contract. 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. 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. Equal Employment Opportunity: The Grantee shall take affirmative action in complying with all federal and State statutes and all applicable requirements concerning fair employment of people with disabilities, and concerning the treatment of all employees without regard to discrimination by reason of race, color, religion, sex, national origin or disability. For additional information see Title VI of the Civil Rights Act of 1964 (42 U.S.C., 2000d, 2000e- 16), Title XI of the Education amendments of 1972, as amended (20 U.S.C. 1681 -1683 and 1685- 1686), and section 504 of the Rehabilitation Act of 1973 as amended (29 U.S.C. 794). Executive Order 24: In accordance with Executive Order 24, issued by Governor Perdue, and N.C.G.S.§ 133 -32, a vendor or contractor (i.e. architect, bidder, contractor, construction manager, design professional, engineer, landlord, offeror, seller, subcontractor, supplier, vendor, or grantee), is prohibited from making gifts or giving favors to any employee of the Agency of Agriculture and Consumer Services. This prohibition covers those vendors, contractors, and /or grantees who: (a) have a Contract with a governmental Agency; or (b) have performed under such a Contract within the past year; or (c) anticipate bidding on such a Contract in the future. For additional information regarding the specific requirements and exemptions, vendors, contractors, and /or grantees are encouraged to review Executive Order 24 and N.C.G.S. § 133 -32. 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. NCDA &CS - General Terms and Conditions — Public - Local Governmental Entities Eff. 07/14;4115;1/17 Page 3 of 4 Oversight Access to Persons and Records: The State Auditor and the using agency's internal auditors 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 General Statute 147 -64.7 and Session Law 2010 -194, Section 21 (i.e., the State Auditors and internal auditors may audit the records of the contractor during the term of the Contract to verify accounts and data affecting fees or performance). 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. 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. 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. 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. 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 shall be used. International travel shall not be reimbursed under this Contract. 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 G.S. 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. Indirect Costs Policy: The Agency has adopted a "Zero" policy that indirect costs are unallowable expenditures in all State funded grant applications and /or grant guidance, informational or directional documents. Allowable Uses of State Funds: Expenditures of State funds by any grantee shall be in accordance with the Cost Principles outlined in the Office of Management and Budget (OMB) CFR Title 2, Part 200 Uniform Administrative Requirements, as applicable. If the grant funding includes federal sources, the grantee shall ensure adherence to the cost principles established by the Federal Office of Management and Budget. [09 NCAC 03M.0201 NCDA &CS - General Tems and Conditions — Public - Local Governmental Entities Eff. 07/14;4/15;1117 Page 4 of Certifications and Assurances CERTIFICATIONS REGARDING LOBBYING, NONPROCUREMENT, DEBARMENT, SUSPENSION AND DRUG -FREE WORKPLACE Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Signature of this form provides for compliance with certification requirements under 2 CFR, Subtitle B, Chapter IV, Part 417, "Nonprocurement Debarment and Suspension," Part 418, "New Restrictions on Lobbying," and Part 421, "Requirements for Drug -Free Workplace (Financial Assistance)," and 2 CFR Part 180. The certifications shall be treated as a material representation of fact upon which reliance will be placed when the Department of Agriculture & Consumer Services determines to award the covered transaction, grant, or cooperative agreement. 1. LOBBYING As required by authority: 31 U.S.C. 1352 and U.S.C. 301 and implemented at 2 CFR Part 180, for persons entering into a grant or cooperative agreement over $100,000, as defined at 2 CFR Section 418.110, the applicant certifies that to the best of their knowledge and belief, that: 1) 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 an agency, a Member of Congress, an 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 contract, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. 2) 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 Form to Report Lobbying" in accordance with its instructions. 3) 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, 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. 2. NONPROCUREMENT DEBARMENT AND SUSPENSION As required by Executive Order 12549, Debarment and Suspension, and implemented at 2 CFR Part 180 and 2CFR Part 417, for prospective participants in primary covered transactions, as defined at 2 CFR 180.435 and Subpart C, 417.332, the applicant certifies that it and its principals: a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; b) Have not within a three -year period preceding this application 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; NCDA &CS Certifications & Assurances Page 1 of 3 Rev 9/12, 10/12, 11/13;1/17 c) 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 2. (a) (b) of this certification. d) Have not within a three -year period preceding this application had one or more public transaction (Federal, State, or local) terminated for cause or default. e) Agree to include a term or condition in lower tier covered transactions requiring lower tier participants to comply with subpart C of the OMB guidance in 2 CFR part 180, as supplemented by subpart C of Part 417. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this certification. 3. DRUG -FREE WORKPLACE (GRANTEES OTHER THAN INDIVIDUALS) As required by the Drug -Free Workplace Act of 1988, and implemented at 2 CFR Part 182, Subparts B, and C, for grantees: The applicant certifies that it will: a) Make a good faith effort, on a continuing basis, to maintain a drug -free workplace. You must agree to do so as a condition for receiving any award covered by this part. b) Publish a drug -free workplace statement and establish a drug -free awareness program for your employees (see Sections 182.205 through 182.220); and c) Take actions concerning employees who are convicted of violating drug statutes in the workplace (see Section 182.225), including notification to any Federal agency on whose award the convicted employee was working and within 30 days take appropriate personnel action against the employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973 (29 U.S.C. 794), as amended; or require the employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for these purposes by a Federal, State or local health, law enforcement, or other appropriate agency. d) You must identify all known workplaces under your Federal awards (see Section 182.230). The grantee must provide the location site(s) for the performance of work done in connection with the specific grant. Place(s) of Performance (Street address, city, county, state, zip code) �f ox; tus 1 ej.'.) Al"4 r DRUG -FREE WORKPLACE (GRANTEES WHO ARE INDIVIDUALS) As required by the Drug -Free Workplace Act of 1988, and implemented at 2 CFR Part 182: A. As a condition of the grant, I certify that I will comply with drug -free workplace requirements in Subpart B (or Subpart C, if the recipient is an individual) of part 421, which adopts the Government - wide implementation (2 CFR part 182) of sec. 5152 -5158 of the Drug Free Workplace Act of 1988 (Pub.L100 -690, Title V, Subtitle D; 41 U.S.C. 701 -707). NCDA &CS Certificafions & Assurances Page 2 of 3 Rev 7/14 B. I agree to notify the agency as required by 2 CFR 182.300(b) of any conviction for a criminal drug offense within ten days. Notice shall include the identification number(s) of each affected grant. As the duly authorized representative of the Grantee, I hereby certify and state to the best of my knowledge and belief, that the Grantee will comply with the above certifications. Printed Name of Au horized Repres tative Titl NCDA &CS Certifications & Assurances page Rev 9/12, 10/12, 11/13;1/17 NC OpenBook Supplemental Information Instructions: Complete the information below and return it to the Contract Administrator identified in your original contract. This information must be submitted as part of your contract. If you have questions, please contact the Contract Administrator or the Alternate Contact as reflected in your contract. DUNS Number: Contract Number: Grantee Name: TAX ID Number: Fiscal Year Ends: 1. Brief Description and Background /History of your Organization. • • . Lois uL • • .i �� ► . _ 2. Current project timeline: Begin ❑ End bA. 'q 3. Expected outcomes and specific deliverables. (Example: Expected Outcome: Aquaculture operation will remain in business. Deliverable: Healthy food made available for human consumption.) 4. The Grantee's WEB URL: LOW 5. ' Grantee County of Residence: -k 6. "County of Benefit: Single County. Statewide: Regional: iy 1 ,C_ f\�\c!P,OQ QOM Congressional District #: (CONGRESSIONAL DISTRICT #AA��MUST BE IDENTIFIED) Yes ❑ No County Name: Iv Q tai YiUy ei� ❑ Yes ❑ No ❑ Yes ❑ No 7. If the answer to question number 6 is "Regional ", list the counties receiving benefit. 'Grantee County of Residence: County in which grantee is located. **County of Benefit: Identified county or counties in which funding will be spent and /or food commodities will be received. NCDA &CS INC OpenBook Supplemental Information Page 1 of 1 Rev 07/14 Card pl.0 L7'l1Npt4 CONTRACT & FINANCIAL DOCUMENTS INSTRUCTIONS: Please read and fill in the required information to the right of each field where applicable. Provide the requested printed and written signatures (in Blue Ink) of agency representatives in the designated areas. In the event the affixed signature(s) are no longer valid, a revised form must be submitted prior to processing any contractual documents or submitting "Request for Payments" or any other financial documents. SECTION I. Date: q Legal Applicant Organization /Agency Name: Federal Tax Identification Number: _ uwn p4 SECTION II. Certification: By affixing my signature below, I certify that person(s) identified are designated having legal authorization to sign on behalf of the organization named in Section I., above, for purposes of executing contractual documents and preparing, approving and executing all financial documents; including "Requests for Payments." I understand the legal implications of any and all misrepresentation, which include but are not limited to defrauding the State of North Carolina, and certify that the person signing below has full authority to execute this Agreement on behalf of the named organization. GOVERNMENTAL ENTITIES Authorized Governmental Official Chief Fiscal Officer Print Name &Title: Print Name & Title: M S I r Signatu e: r�0.o� ! t' Si nature: NCDA&CS - Signature Card — NGO & Govemmental Page 1 of 1 Rev 7/11, 2/12, 5/12, 7/12, 8/12, 10/12, 5/13, 1/14 Form W -9 Request for Taxpayer Give Form tot he (Rev. Janusry2011) Iden tifi cation Number and Certification requester. Do not Depart mentoltheireesury send to the IRS. Internal Revenue Service Name ( s shown on your' come tax mtum) u N v rn Business name /disregarded entity name, 'd different from above n Check appropriate box for federal tax 0 classification (required): ❑ Individual sole proprietor ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate � ❑ Limited liability company. Eller the lax classification (C =C corporation, 5 =S corporation, P= paMership) e ❑ Exempt payee z c o. @ O er (see instructions) v ress n ee , an apt. or suite no P Requesters name and address (optional) n m I / Ci , slaIs all ZIP code N ' I List account number(s) h (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line I Social security number to avoid backup withholding. For individuals, this is your social Part I i security number n page However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Under penalties of perjury, I certity Mat: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. lam not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. 1 am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on Dace 4. Sign Signature of Here us. person a General Instructions CA Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W -9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income. Date � —11 Lt. I 1 ote. If a requester gives you a form other than Form W -9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W -9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701 -7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding lax on any foreign partners' share of income from such business. Further, in certain cases where a Form W -9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W -9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat No 10231X Form W -9 (Rev. 1 -2011) Form W -9 (Rev. 1 -2011) Page 2 The person who gives Form W -9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases: • The U.S. owner of a disregarded entity and not the entity, • The U.S. grantor or other owner of a grantor trust and not the trust, and • The U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person, do not use Form W -9. Instead, use the appropriate Form W -8 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W -9 that specifies the following five hems: 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S. -China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W -9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completed Form W -8. What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS a percentage of such payments. This is called "backup withholding." Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, 2. You do not certify your TIN when required (see the Part II instructions on page 3 for details), 3. The IRS tells the requester that you furnished an incorrect TIN, 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Instructions for the Requester of Form W -9. Also see Special rules for partnerships on page 1. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W -9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and /or imprisonment. Misuse of TINS. If the requester discloses or uses TINS in violation of federal law, the requester may be subject to civil and criminal penalties. Specific Instructions Name If you are an individual, you must generally enter the name shown on your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name. If the account is in joint names, list first, and then circle, the name of the person or entity whose number you entered in Part I of the form. Sole proprietor. Enter your individual name as shown on your income lax return on the "Name" line. You may enter your business, trade, or "doing business as (DBA)" name on the "Business name /disregarded entity name" line. Partnership, C Corporation, or S Corporation. Enter the entity's name on the "Name" line and any business, trade, or "doing business as (DBA) name" on the "Business name /disregarded entity name" line. Disregarded entity. Enter the owner's name on the "Name" line. The name of the entity entered on the "Name" line should never be a disregarded entity. The name on the "Name" line must be the name shown on the income tax return on which the income will be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a domestic owner, the domestic owners name is required to be provided on the "Name" line. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on the "Business name /disregarded entity name" line. If the owner of the disregarded entity is a foreign person, you must complete an appropriate Form W -8. Note. Check the appropriate box for the federal tax classification of the person whose name is entered on the "Name" line (Individual /sole proprietor, Partnership, C Corporation, S Corporation, Tmstlestate). Limited Liability Company (LLC). If the person identified on the "Name" line is an LLC, check the "Limited liability company" box only and enter the appropriate code for the tax dassification in the space provided. If you are an LLC that is treated as a partnership for federal tax purposes, enter "P" for partnership. If you are an LLC that has filed a Form 8832 or a Form 2553 to be taxed as a corporation, enter "C" for C corporation or "S" for S corporation. If you are an LLC that is disregarded as an entity separate from its owner under Regulation section 301.7701 -3 (except for employment and excise tax), do not check the LLC box unless the owner of the LLC (required to be identified on the "Name" line) is another LLC that is not disregarded for federal tax purposes. If the LLC is disregarded as an entity separate from its owner, enter the appropriate tax classification of the owner identified on the "Name" line. Form W -9 (Rev. 1 -2011) Other entities. Enter your business name as shown on required federal tax documents on the "Name" line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the "Business name/ disregarded entity name" line. Exempt Payee If you are exempt from backup withholding, enter your name as described above and check the appropriate box for your status, then check the "Exempt payee" box in the line following the "Business name/ disregarded entity name," sign and date the form. Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. The following payees are exempt from backup withholding: 1. An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2), 2. The United States or any of its agencies or instrumentalities, 3. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities, 4. A foreign government or any of its political subdivisions, agencies, or instrumentalities, or 5. An international organization or any of its agencies or instrumentalities. Other payees that may be exempt from backup withholding include: 6. A corporation, 7. A foreign central bank of issue, 8. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States, 9. A futures commission merchant registered with the Commodity Futures Trading Commission, 10. A real estate investment trust, 11. An entity registered at all times during the tax year under the Investment Company Act of 1940, 12. A common trust fund operated by a bank under section 584(a), 13. A financial institution, 14. A middleman known in the investment community as a nominee or custodian, or 15. A trust exempt from tax under section 664 or described in section 4947. The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 15. IF the payment is for ... THEN the payment is exempt for... Interest and dividend payments All exempt payees except for 9 Broker transactions Exempt payees 1 through 5 and 7 through 13. Also, C corporations. Barter exchange transactions and Exempt payees 1 through 5 patronage dividends Payments over $600 required to be Generally, exempt payees reported and direct sales over 1 through 7' $5,000, See Form 1099 -MISC, Miscellaneous Income, and its instructions. ' However, the following payments made to a corporation and reportable on Form 1099 -MISC am not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency. Part I. Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN. If you are a single- member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on page 2), enter the owner's SSN (or EIN, if the owner has one). Do not enter the disregarded entity's EIN. If the LLC is classified as a corporation or partnership, enter the entitys EIN. Note. See the chart on page 4 for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS -5, Application for a Social Security Card, from your local Social Security Administration office or get this form online at www.ssa.gov. You may also get this forth by calling 1 -800- 772 -1213. Use Form W -7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS -4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at wwwirs.govlbusinesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W -7 and SS4 from the IRS by visiting IRS.gov or by calling 1- 800 -TAX -FORM (1- 800 - 829 - 3676). If you are asked to complete Form W -9 but do not have a TIN, write "Applied For" in the space for the TIN, sign and date the forth, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60 -day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. Note. Entering "Applied For" means that you have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W -8. Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W -9. You may be requested to sign by the withholding agent even if item 1, below, and items 4 and 5 on page 4 indicate otherwise. For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on the "Name" line must sign. Exempt payees, see Exempt Payee on page 3. Signature requirements. Complete the certification as indicated in items 1 through 3, below, and items 4 and 5 on page 4. 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. Forth W -9 (Rev. 1 -2011) 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" include payments made in the course of the requesters trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations). 5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. What Name and Number To Give the Requester For this type of account: Give name and SSN of: 1. Individual The individual 2. Two or more individuals (joint The actual owner of the account or account) if combined funds, the first individual on the account 3. Custodian account of a minor The minor' (Uniform Gift to Minors Act) 4. a. The usual revocable savings The grantor - trustee trust (grantor is also trustee) b. So- called trust account that is The actual owner' not a legal or valid trust under state I- 5. Sole proprietorship or disregarded The owner entity owned by an individual 6. Grantor trust filing under Optional The grantor' Form 1099 Filing Method 1 (see Regulation section 1.6714(b)(2)(i)(A)) For this type of account: Give name and EIN of: 7. Disregarded entity not owned by an The owner individual 8. A valid trust, estate, or pension trust Legal entity 9. Corporation or LLC electing The corporation corporate status on Form 8832 or Form 2553 10. Association, club, religious, The organization charitable, educational, or other tax- exempt organization 11. Partnership or multi - member LLC The partnership 12. A broker or registered nominee The broker or nominee 13. Account with the Department of The public entity Agriculture in the name of a public entity (such as a state or local govemment, school district, or prison) that receives agricultural program payments 14. Grantor trust fling under the Form The trust 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulation section 1.6714(b)(2)(i)(13)) List first and circle the name of the person whose number you famish. a only one person on a joint account has an SSN. Uat person's number must be fumisted. Ci tl the minors name a. furnish the minors SSN. You must show your individual name and you may also enter your business m -DBA' name on the -Business nam dhregarded entity' name lire. You may use elver your SSN or EIN (y you have one), but the IRS encourages you io use your SSN. List first and circle the name of the Vust, estate, or pension Wst. (Do not fumish the TIN of the personal representative a t—tee unless the legal entity ifself is not designated in the account Otle.) Also sea Spa 1 rules W parbersh'ps on page 1. 'Note. Grantor also must provide a Form W -9 to trustee of trust. Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed. Secure Your Tax Records from Identity Theft Identity theft occurs when someone uses your personal information such as your name, social security number (SSN), or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund. To reduce your risk: • Protect your SSN, • Ensure your employer is protecting your SSN, and • Be careful when choosing a tax preparer. If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter. If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1- 800 - 908 -4490 or submit Form 14039. For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance . Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll -free case intake line at 1- 877 - 777 -4778 or TTYfTDD 1 -800- 829 -4059. Protect yourself from suspicious smalls or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business smalls and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft. The IRS does not initiate contacts with taxpayers via entails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts. If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing&rs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration at 1- 800 -366 -4484. You can forward suspicious smalls to the Federal Trade Commission at: spam @uce.gov or contact them at www.ftagowidfheft or 1- 877 - IDTHEFT (1- 877 - 4384338). Visit IRS.gov to learn more about identity theft and how to reduce your risk. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to fie information retums with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cites, states, the District of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat termnsm. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Office of the State Controller Vendor Electronic Payment Form Return to: OSC Support Services Center -, " Address: 1410 Mail Service Center i . 11 New Add Request Raleigh, NC 27699 -1410 �•. � , � ❑ Change/Update Existing Account Email: osc.su000rt.servicesaaosc.nc.eov i� �F Telephone: 919 - 707 -0795 ❑ Inactivate Existing Account Fax: 919 - 981 -5561 The State of North Carolina offers payees the opportunity to receive payments electronically through U.S. based banks, rather than by check. In addition to having the money deposited electronically, you also will be notified of the deposit either by fax or by e-mail. The fax or e-mail will provide you with all the information that would normally be on your check stub. We require you to submit a copy of a voided check, bank statement, or a letter from your bank for account verification. TAX ID # or SSN PAYEE NAME ADDRESS (AS PRINTED ON YOUR INVOICE) CONTACT 5�o ag NEW FINANCIAL INFORMATION FINANCIAL INSTITUTION NAME: Kl NAME ON ACCOUNT: NEW ROUTING NUMBER: NEW ACCOUNT NUMBER: ACCOUNT NUMBER: I ci IS I I 11-75 D ACCT TYPE: heckina ❑ Savines ACCT TYPE: REMIT E -MAIL ADDRESS e,\z PRIOR FINANCIAL INFORMATION (only required for updates) FINANCIAL INSTITUTION NAME: NAME ON ACCOUNT: ROUTING NUMBER: ACCOUNT NUMBER: ACCT TYPE: ❑ Checkino ❑ Savin s REMIT ADDRESS ALL BOXES BELOW MUST BE REVIEWED AND CHECKED I acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, as well as the requirements of the Office of Foreign Assets Control (OFAC). By signing form, you are affirming that, regarding electronic payments the State of North Carolina may remit to the financial institution for credit to the account that I have designated, the entire payment amount is not subject to bein transfened to a forei n bank account. ErI authorize the Office of the State Controller to initiate direct deposit entries each pay period, and if necessary, adjustments for any direct deposit entries in error, to the financial institution and account identified on the attached certificafion document. I understand and accept the conditions of participation in the direct deposit program. This authority will remain in effect until I cancel it in writing. I have attached a copy of a current voided check, current bank statement or included a bank letter on bank letterhead signed by a bank re resentative. SIGNATURE, a a �I-��� DATE: z-L t ,+„- •- Pagel of 37 08/31/17 t.�. NC 0005108171326 212- 05 -01 -00 02505 2273 C 001 19 T 62 002 NEW HANOVER COUNTY GENERAL ACCT ATTN BEVERLY THOMAS 230 GOVERNMENT CENTER DR STE 165 WILMINGTON NC 28403 -1732 Your account statement For 08/31/2017 ■ PUBLIC FUND ANALYZE CHECKING 0005108171326 Account summary Your previous balance as of 07/31/2017 $7,666,398.76 Checks - 7,278,769.79 Other withdrawals, debits and service charges - 43,616,133.83 Deposits, credits and interest + 49,581,581.68 Your new balance as of 08/31/2017 = $6,353,076.82 Checks DATE 08/18 08/15 CHECK # 181732 *365456 AMOUNT($) 23.74 124.74 08/08 *373634 85.86 08/02 *374104 23.54 08/25 *374418 135.00 08/25 *375451 138.89 08/08 *375523 13.72 08/14 *376166 26.99 08/21 *376219 1,805.62 08/22 * 376631 322.72 08/23 *376853 145.95 08/28 376854 148.19 08/28 *376856 51.39 08/31 *376859 85.15 08/31 *376867 243.27 08/25 376868 78.11 08/28 *376872 46.00 08/03 *376895 51.52 08/23 *377409 108.27 08/14 * 377413 175.78 08/28 *377424 103.91 08/28 *377433 2.94 08/07 *377462 24.39 08/04 *377623 3,021.68 08/16 *377644 300.00 08/28 *377824 10.00 08/01 *378940 20.00 Contact us 13 BBT.com e (800) BANK -BBT or (800) 226 -5228 DATE CHECK # AMOUNT($) 08/03 *377829 15.00 08/03 377830 15.00 08/08 *377896 62.84 08/22 *377933 41,231.36 08/28 * 378016 94.09 08/25 *378045 36.39 08/03 378046 389.56 08/03 378047 309.21 08/01 *378322 60.63 08/03 *378326 89.00 08/04 *378359 1,670.00 08/21 *378453 22.50 08/07 *378477 4.50 08/07 378478 4.96 08/04 *378483 9.05 08/17 *378541 1,000.00 08/30 *378555 100.00 08/09 *378788 51.85 08/09 *378790 13.25 08/15 * 378818 13.18 08/14 *378920 10.00 08/23 *378924 5.00 08/02 *378932 15.00 08/07 *378938 10.00 08/01 *378940 20.00 08/29 *378972 1,000.00 DATE CHECK # AMOUNT($) 08/01 *379079 5.83 08/02 *379100 1,800.00 08/14 * 379116 500.00 08/04 * 379162 48.70 08/07 *379279 45.00 08/17 *379283 15.00 08/10 *379385 141.79 08/03 *379463 10.00 08/14 *379466 15.00 08/28 *379486 160.54 08/04 *379597 210.00 08/09 *379600 8.87 08/04 *379670 600.00 08/17 *379739 1,666.00 08/17 *379827 328.15 08/02 *379844 50.02 08/04 *379863 13.73 08/03 *37986R 1,372.23 08/08 *379882 92.34 08/02 *379887 8.00 08/01 *379904 50.50 08/23 * 379915 48.00 08/23 379916 48.00 08/01 *379927 48.00 08/01 379928 48.00 08/22 * 379931 48.00 continued 0001073 ■ PAGE 1 Of 37