FY22 JCPC COASTAL HORIZONS STEP PROGRAM AGREEMENTDocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
W OVA—
North Carolina Department of Public Safety
JCPC Program - Program Agreement
SECTION I A
SPONSORING AGENCY AND PROGRAM INFORMATION
FUNDING PERIOD:
FY 21-22
DPS/JCPC FUNDING # (cont only)
965-XXXX
COUNTY:
New Hanover
AREA:
Eastern Area
Multi -County:
No
Multi -Components
No
NAME OF PROGRAM:
Systematic Training for Effective Parenting
SPONSORING AGENCY:
Coastal Horizons Center, Inc.
SPONSORING AGENCY
615 Shipyard Blvd.
PHYSICAL ADDRESS:
Wilmington NC 28412
SPONSORING AGENCY
615 Shipyard Blvd.
MAILING ADDRESS:
Wilmington NC 28412
TYPE:
Non -Profit
(910) 202-0840 Fax: 1 (910) 202-0843 E-mail: deeanna@coastalhorizons.org
FEDERAL ID #156-0950370
Program Manager Name & Address (same person on signature page)
Name:
TOTAL COST OF
COMPONENT ID # NAME OF PROGRAM COMPONENT
PROGRAM TYPE
Mailing
Address:
EACH COMPONENT
31617 Systematic Training for Effective Parenting (STEP)
Parent/Family Skill Building $ 47,536
Zip:
Total cost of components: $ 47,536
Program Manager Name & Address (same person on signature page)
Name:
Deeanna Hale -Holland
Title:
Prevention Director
Mailing
Address:
615 Shipyard Blvd.
City:
Wilmington
Zip:
28412
Phone:
(910) 202-0840 Fax: 1 (910) 202-0843 E-mail: deeanna@coastalhorizons.org
Contact Person (if different from program manager)
Name:
Erin Ditta
Title:
Prevention Coordinator
Mailing
Address:
615 Shipyard Blvd.
City:
Wilmington
Zip:
28412
Phone:
(910) 202-0840 Fax: 1 (910) 202-0843
E-mail: editta@coastalhorizons.org
Program Fiscal Officer (cannot be program manager)
Name:
Jenifer Burns
Title:
Controller
Mailing
Address:
615 Shipyard Blvd.
City:
Wilmington
Zip:
28412
Phone:
(910) 343-0145 Fax:
E-mail: jburns@coastalhorizons.org
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION I B
PROGRAM COMPONENT DESCRIPTION
COMPONENT ID #
COMPONENT INFORMATION
31617
NAME OF COMPONENT: Systematic Training for Effective Parenting (STEP)
BRIEF DESCRIPTION: Systematic Training for Effective Parenting (STEP) is an evidence -
based skills training for parents on how to handle misbehavior, discouragement, discipline, and
the problems that face every parent -teen relationship.
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION II
COMPONENT STATISTICAL INFORMATION
Multi -Components No
Component Service Statistics
PROGRAM COMPONENT INFORMATION - APPLICATION YEAR
Component Name: Systematic Training for Effective Parenting (STEP)
Component ID #
31617
What is this component's maximum client capacity at any given time?
14
Frequency of client contact per month:
4
Anticipated Average Length of
Stay:
56
Days
y
Total Component Cost:
$47,536
- by
Estimated # to be served during funding period:
36
Estimated Average Cost Per Youth:
$1,320
Actual number of youth admitted FY 19-20:
32
Applies to
10
Number of admissions Juvenile Justice Referred
31.25% of total admissions
continuation
programs only.
0
Number of admissions Law Enforcement Referred
0% of total admissions
0
eferred
Number of admissions District Court REEL:
0% of total admissions
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 01/09/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION III I COMPONENT SUMMARY
NAME OF COMPONENT: I Systematic Training for Effective Parenting (STEP)
1. Statement of the Problem: In concise terminology, describe how the program will address continuum need(s) in
the county.
The New Hanover County Juvenile Crime Prevention Council (JCPC) has listed the following as priorities to address:
Youth association with other delinquent peers or peers involved with gangs; Peer relationship problems & conflict;
Moderate to serious behavioral problems at school; Prior assaultive behavior; Involvement in alcohol and substance
use; Prior referrals to juvenile court; Referral to juvenile court prior to age 12; Inadequate supervision by parents/
guardians.
The Department of Juvenile Justice Court Counselors and Department of Social Services listed priorities of services for
parents/guardians and non-custodial parents of youth 12-17 years of age. There are no current services in the area
that meet this reach.
Systematic Training for Effective Parenting (STEP) is an evidence -based program which provides skills training for
parents dealing with frequently encountered challenges with their children. STEP emphasizes how to handle
misbehavior, discouragement, discipline, and the problems that face every parent -teen relationship. It also confronts
today's more complex issues of drug use, sex, gangs, and depression. STEP promotes a more participatory family
structure by fostering responsibility, independence, and competence in children; improving communication between
parents and children; and helping children learn from the natural and logical consequences of their own choices. The
lessons focus on how to understand child behavior and misbehavior, practice positive listening, give encouragement
(rather than praise), explore alternative parenting behaviors and express ideas and feelings, develop their child's
responsibilities, apply natural and logical consequences, convene family meetings, and develop their child's
confidence. Parents engage in role-plays, exercises, discussions of hypothetical parenting situations, and the sharing
of personal experiences.
Following the completion of the STEP program, the families (youth & parent) will participate in a four (4) hour challenge
course filled with experiential activities designed to increase the cooperation of all family members through
communication and problem solving activities. These programs help parents and youth empathize with each other and
have fun together. A family meal will also be provided with discussion on the importance of eating together as a family.
Per the National Center on Addiction and Substance Abuse at Columbia University, surveys have consistently found
that the more often children have dinners with their parents, the less likely they are to smoke, drink or use drugs, and
that parental engagement fostered around the dinner table is one of the most potent tools to help parents raise healthy,
drug-free children.
Families needing additional services will be referred to appropriate programs.
2. Target Population: Describe the target population, including age, and the steps taken to insure that the target
population is served.
Systematic Training for Effective Parenting (STEP) targets the parents of youth 12-17 years of age. Families will be
referred by:
New Hanover County Department of Juvenile Justice and Delinquency Prevention
Juvenile Attendance Counsel
Wilmington Police Department
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION III
COMPONENT SUMMARY
NAME OF COMPONENT:
Systematic Training for Effective Parenting (STEP)
School Resource Officer/ In School Suspension
Department of Social Services
Any additional community partner with troubled youth
Parent's self -referral
The referral sources get priority to the STEP program in the order stated above.
3. Program Goal(s): Provide a brief statement to describe the overall purpose of the program.
STEP is rooted in Adlerian psychology and promotes a more participatory family structure by fostering responsibility,
independence, and competence in children; improving communication between parents and children; and helping
children learn from the natural and logical consequences of their own choices. STEP teaches lessons on how to
understand child behavior and misbehavior, practice positive listening, give encouragement (rather than praise),
explore alternative parenting behaviors and express ideas and feelings, develop their child's responsibilities, apply
natural and logical consequences, convene family meetings, and develop their child's confidence. Parents engage in
role-plays, exercises, discussions of hypothetical parenting situations, and the sharing of personal experiences.
The goals of Systematic Training for Effective Parenting (STEP) are:
-Increased encouragement skills
-increased skill in communication
-Increased skill in cooperation (parental and child)
-Increased skill in discipline
-Increased skill in choosing parenting approach
-Increase child self-esteem and confidence
-Decreased inappropriate parental behaviors in disciplining children and teens
4. Measurable Objective(s): State in measurable terms (%) the intended effect of the program on specific
undisciplined and/or delinquent behaviors. Example: anticipated reductions in court referrals, runaway behavior,
disruptive behavior at school, anticipated improved school attendance and academic achievement. These objectives
must include impact on participants.
70% Clients will have no new adjudications for a complaint with an offense date after the admission date.
70% Parents and/or families will actively participate in skill building activities as intended by the program design/
service plan.
70% Clients will reduce specific problem behaviors presented at referral and targeted in the individual service plan.
70% Clients successfully/satisfactorily completing the program will have no new complaints in the 12 months following
completion.
70% Clients will successfully or satisfactorily complete services as intended by the program design/service plan.
70% Clients will demonstrate improvement in targeted skills identified in the individual service plan.
70% Clients successfully/satisfactorily completing the program will have no new adjudications in the 12 months
following completion.
70% Clients and families will demonstrate enhanced family functioning as a result of program services.
70% Clients will have no new complaints with an offense date after the admission date.
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION III
COMPONENT SUMMARY
NAME OF COMPONENT: I Systematic Training for Effective Parenting (STEP)
5. Elevated Risks and Needs: Describe how you will address one or more of the Elevated Risk and Needs of
adjudicated juveniles listed in the local JCPC Request for Proposal.
Per the New Hanover County Juvenile Crime Prevention Council (JCPC) has listed the following as priorities to
address: Youth association with other delinquent peers or peers involved with gangs; Peer relationship problems &
conflict; Moderate to serious behavioral problems at school; Prior assaultive behavior; Involvement in alcohol and
substance use; Prior referrals to juvenile court; Referral to juvenile court prior to age 12; Inadequate supervision by
parents/guardians.
The Department of Juvenile Justice Court Counselors and Department of Social Services listed priorities of services for
parents/guardians and non-custodial parents of youth 12-17 years of age. There are no current services in the area
that meet this reach.
Systematic Training for Effective Parenting (STEP) is an evidence -based program for parents of teens, which provides
skills training for parents dealing with frequently encountered challenges with their children. STEP emphasizes how to
handle misbehavior, discouragement, discipline, and the problems that face every parent -teen relationship. It also
confronts today's more complex issues of drug use, sex, gangs, and depression.
STEP is presented in a group format, with optimal group sizes ranging from 6 to 14 parents. The parents will meet the
first night to complete paperwork and receive any additional logistical information. The parents will then be guided
through seven interactive lessons, each 1.5 hour in length. These lessons include information on understanding child
behavior, parent behavior, positive listening, giving encouragement, development of a child's responsibilities and
confidence, consequences, and family meetings. Parents engage in discussions, role-plays, and share personal
experiences.
The Challenge Course experience will provide experiential activities for the family to take initiative, make decisions,
and be accountable for the results. The families will have the opportunity to engage intellectually, creatively,
emotionally, socially or physically. This learning experience will provide the opportunity to learn from natural
consequences, mistakes, and successes. Parents and youth will have the opportunity to reflect on the experiences
through a positive environment to increase knowledge, develop skills, and clarify values.
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION IV
COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Systematic Training for Effective Parenting (STEP)
1. Location: List physical address(es) and describe where program services are delivered.
Office:
Coastal Horizons
Prevention Services
330 Shipyard Blvd., Ste B
Wilmington, NC 28412
Program:
Wilmington Health Access for Teens of Coastal Horizons
4005 Oleander Dr
Wilmington, NC 28403
Challenge Course:
Coastal Horizons
Adventure Learning Center
3837 Juvenile Center Dr
Castle Hayne, NC
2. Operation: Describe the daily/weekly schedule of program operation.
STEP will be conducted once a week for eight consecutive weeks, during the duration of the program. Duration of the
STEP program does not match the SPEP parameters. To increase client contact hours, the hours for each session will
increase to 2 hours. This will allow for a total of 19.5 hours. (1) 1.5 hour introduction day, (7) 2 hour program sessions,
(1) 4 hour family day. If the family is not meeting the minimum of 15 hours during the scheduled session time, program
staff will meet with them to help fulfill the required 15 hours.
Programs will be held at the location listed previously. The facilities will include audio equipment, meeting rooms and
tables and chairs. Drinks and dinner will be provided to the parents.
Following the completion of the STEP program, the families (youth & parent) will participate in a four (4) hour challenge
course filled with experiential activities designed to increase the cooperation of all family members through
communication and problem solving activities. These programs help parents and youth empathize with each other and
have fun together. A family meal will also be provided with discussion on the importance of eating together as a family.
3. Staff Positions: Describe paid or volunteer position qualifications, (certifications, degrees, work experience) and
position(s) responsibilities relative to this component.
Erin Ditta, CSAPC, Prevention Coordinator has worked with Coastal Horizons Center for 17 years. Erin is a Certified
Substance Abuse Prevention Consultant through the NC Substance Abuse Professional Practice Board. Erin is trained
and has facilitated multiple evidence -based programs. Erin will be responsible for supervising and assisting in the
organization of the program, assist with coordination and implementation of the program and overseeing the grant
requirements.
Deeanna Hale -Holland, MA, CSAPC, Prevention Director has worked with Coastal Horizons Center for over 30 years.
Deeanna is a Certified Substance Abuse Prevention Consultant through the NC Substance Abuse Professional
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION IV
COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Systematic Training for Effective Parenting (STEP)
Practice Board. Deeanna is trained and has facilitated multiple evidence -based programs. Deeanna will assist with the
supervision of the program and overseeing the grant requirements.
Meredith Ross, CSAPC< Prevention Coordinator has worked with Coastal Horizons for 19 years. Meredith is a
Certified Substance Abuse Prevention Consultant through the NC Substance Abuse Professional Practice Board.
Meredith is trained in the STEP curriculum and has facilitated multiple evidence -based programs. Meredith will assist
with the supervision of the facilitation staff, John Dail.
John Dail has worked with Coastal Horizons Center for more than 35 years. John is a Certified Substance Abuse
Counselor. His role with the program will be to facilitate the STEP program.
Part-time prevention specialist to assist with program logistics and paperwork.
Child Care professional to provide onsite child care.
4. Service Type SPEP: Describe implementation to include:
Primary Service: Social Skills Training; Secondary Service: None
Evidence -Based Program Name: Systematic Training for Effective Parenting (STEP)
Target Weeks: 8; Target Hours: 15
5. Admission Process: Describe the specific referral, screening, admission process (including timeline), the staff
responsible for making decisions about admissions and reasons why a referral may not be accepted.
Court counselors, case managers and school personnel will complete the Universal JCPC Referral form and
fax it to the STEP staff member, John Dail. John Dail will follow-up with referring agency to obtain any necessary
information or additional questions regarding family needs. John Dail will contact families upon receipt of their referral
to address any questions participants may have regarding the program, and provide date, time, and location of the
program. Parents/guardians sign a consent form; release of confidential information and HIPAA; parents complete
participant information/medical form. Client tracking forms are completed on the family entering the STEP Program and
upon completion of the program; a monthly progress report is completed for all participants and submitted to the
referring court counselor, case manager or school personnel until program completion.
6. Termination Process: Describe the termination process to include the staff responsible for making decisions and
the criteria for a successful termination, satisfactory termination, unsuccessful completion and non-compliant
termination.
Termination occurs in two ways: when the participant completes all sessions of the STEP program and Challenge
Course Day or if the participant misses more than two sessions. Participants will be successfully terminated once the
post survey is completed or upon referral to other services by their court counselor, school personnel or referral
source. Participants will receive a certificate of accomplishment at graduation. Within one month of completion, a
phone call will be made to the parent and referral agent to follow up. Participants who do not complete 70% or more
sessions due to non-compliance with their probation, diversion or school contract will result in a less than successful or
unsatisfactory termination. Referring agencies will be notified of client compliance or non-compliance throughout the
program and receive a letter of termination at the completion of the program.
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION IV
COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Systematic Training for Effective Parenting (STEP)
How is the referring agency involved with the termination process?
The Prevention Specialist contacts the referring agency to notify them of their client's termination status. Referring
agency will provide any additional progress notes needed.
7. Referring Agency Interaction: Describe the interaction with juvenile court counselors and/or other referring
agencies including how client progress will be communicated.
The STEP staff will regularly inform the referring agencies and community partners of upcoming sessions through
emails, flyers, community meetings, etc.
The STEP staff will regularly inform the referring agency of the participant's attendance, progress, and completion of
the program. Referral agents will receive a letter of client acceptance to the program and a letter of client termination.
Prevention staff will maintain regular contact with court counselors, case managers or school personnel. Parents are
encouraged to contact the program for follow-up discussions as needed. Referrals come through the Juvenile Court
Counselors, DSS case managers, School Principals/Counselors and other community partners and parent self -referral.
8. Intervention/Treatment: Describe specifically what the component will do to redirect inappropriate youth behavior
or how the component will address the identified needs of the youth and family. What interventions will typically be
utilized in this component and how will parents/guardians be involved?
Systematic Training for Effective Parenting (STEP) provides skills training for parents dealing with frequently
encountered challenges with their children that often result from autocratic parenting styles. STEP is rooted in Adlerian
psychology and promotes a more participatory family structure by fostering responsibility, independence, and
competence in children; improving communication between parents and children; and helping children learn from the
natural and logical consequences of their own choices.
STEP is presented in a group format, with optimal group sizes ranging from 6 to 14 parents. The program is typically
taught in 7 weekly, 1.5 -hour study groups facilitated by a counselor, social worker, or individual who has participated in
a STEP workshop. Using the STEP multimedia kit (including the Leader's Resource Guide, Parent's Handbook, DVDs,
and an 11 -point drug prevention educational component), the leader teaches lessons to parents on how to understand
child behavior and misbehavior, practice positive listening, give encouragement (rather than praise), explore alternative
parenting behaviors and express ideas and feelings, develop their child's responsibilities, apply natural and logical
consequences, convene family meetings, and develop their child's confidence. Parents engage in role-plays,
exercises, discussions of hypothetical parenting situations, and the sharing of personal experiences. Videos
demonstrate the concepts covered each week with examples of ineffective and effective parent-child interactions.
From the NREPP/SAMHSA website (http://legacy.nreppadmin.net/Viewlntervention.aspx?id=132#divContacts)
Sessions address the important issues of: Understanding Yourself and Your Teenager
Changing Your Response to Your Teen
Communicating Respect and Encouragement
Encouraging Cooperation and Solving Problems
Using Consequences to Build Responsibility
Deciding What to Do -Part I & II
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION IV
COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Systematic Training for Effective Parenting (STEP)
STEP/Teen not only helps parents with everyday problems such as messy rooms, moods, and meals, it also confronts
today's more complex issues -drug use, sex, gangs and depression.
From the STEP Publishers website (http://www.steppublishers.com/products/stepteen-kit)
STEP is not intended for therapy or treatment services, the program is appropriate for families who could benefit from
an educational program.
9. Best Practice Model: Describe what model or evidence-supported/best practice the program is based upon.
Systematic Training for Effective Parenting (STEP) provides skills training for parents dealing with frequently
encountered challenges with their children that often result from autocratic parenting styles. STEP is rooted in Adlerian
psychology and promotes a more participatory family structure by fostering responsibility, independence, and
competence in children; improving communication between parents and children; and helping children learn from the
natural and logical consequences of their own choices. Although STEP was designed for use with parents facing
typical parenting challenges, all the studies reviewed for this summary targeted families with an abusive parent,
families at risk for parenting problems and child maltreatment, or families with a child receiving mental health treatment.
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION V Terms of Agreement
This Agreement is entered into by and between Department of Public Safety (hereinafter referred to as DPS), and New
Hanover County, (hereinafter referred to as the County), the County's Juvenile Crime Prevention Council (hereinafter
referred to as the JCPC) and Coastal Horizons Center, Inc. (hereinafter referred to as the Sponsoring Agency).
DPS, the County, the JCPC and the Sponsoring Agency do mutually agree as follows:
Term of Agreement
This Agreement shall become effective Jul 1, 2021 and shall terminate Jun 30, 2022.
Payment to Sponsoring Agency
All parties agree that services will be delivered as described in the approved Program Agreement and that funds will be
disbursed in an amount not to exceed the amount $39180 for the term of this agreement, unless amended by an
approved Program Agreement Revision.
Availability of Funds:
All parties to this Agreement agree and understand that the payment of the sums specified in this Program Agreement
budget, or most recently approved Program Agreement Revision, is dependent and contingent upon and subject to the
appropriation, allocation, and availability of funds for this purpose to DPS.
Responsibilities of the Parties
DPS shall:
1. Disburse funds monthly to County Governments, for payment to the Sponsoring Agency, from the fund
appropriation by the General Assembly;
2. Reserve the right to suspend payment to the County for any non-compliance by the Sponsoring Agency with any
reporting requirements set forth in DPS JCPC Policy and Procedures;
3. Notify in writing the County and Sponsoring Agency immediately if payments are suspended and again once
payments resume;
4. Pay only for work as described in the Program Agreement, or most recently approved Program Agreement
Revision, provided by the Sponsoring Agency and approved subcontractors;
5. Provide technical assistance, orientation and training to the Sponsoring Agency, the County and the JCPC;
6. Monitor Sponsoring Agency's funded program(s) in accordance with DPS JCPC Policy 3. Operations: Program
Oversight and Monitoring; and
7. Notify parties entering into this Agreement of all due dates in a timely manner in order for reports to be submitted
by the established due date.
The Sponsoring Agency shall:
1. 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;
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
2. Comply with all Federal and State laws relating to equal employment opportunity;
3. Keep as confidential and not divulge or make available to any individual or organization without the prior written
approval of DPS any information, data, instruments, documents, studies or reports given to or prepared or
assembled by the Sponsoring Agency under this Agreement;
4. Acknowledge 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 Agreement;
5. Comply with DPS JCPC Policy and Procedures and the North Carolina Administrative Procedures;
6. Secure local match as required, if applicable, pursuant to 14B NCAC 11 B.0105, for approved JCPC funds;
7. Create and adopt individualized guidelines specific to the funded program, while also adhering to DPS JCPC
Policy and Procedures for all funded programs and for the specific program type for which they receive funding;
8. Ensure that state funds received are spent in accordance with the approved Program Agreement, or most recently
approved Program Agreement Revision, and be accountable for the legal and appropriate expenditure of those
state funds;
9. Maintain reports, records, and other information to properly document services rendered and outcomes; also
maintain an ability to send and receive electronic communication;
10. Have the capacity to use DPS electronic, internet-based system for tracking clients served;
11. Use generally accepted accounting procedures that guarantee the integrity of the expenditure of funds, maintain
reports, records, and other information to properly account for the expenditure of all State funds provided to the
Sponsoring Agency;
12. When refunds are requested from the North Carolina Department of Revenue for sales and/or use taxes paid by
the agency in the performance of the Program Agreement, or most recently approved Program Agreement
Revision, as allowed by NCGS §105-164.14(c), the agency shall exclude all refundable sales and use taxes from
reportable expenditures submitted to the County and DPS;
13. Submit Program Agreement Revisions, Third Quarter Accounting, Final Accounting and annual detailed
expenditures through NCALLIES. These reports must be in accordance with the submission process as outlined in
DPS JCPC Policy and Procedures and with the due dates established by DPS;
14. Make personnel, reports, records and other information available to DPS, the County, the JCPC, and/or the State
Auditor for oversight, monitoring and evaluation purposes;
15. Submit any other information requested by the JCPC, County or DPS;
16. Be responsible for the performance of all subcontractors as described in the JCPC Program Agreement, or most
recently approved Program Agreement Revision;
17. Indemnify and hold harmless DPS, the State of North Carolina, the County and any of their officers, agents and
employees, from any claims of third parties arising out of any act or omission of the Sponsoring Agency in
connection with the performance of the Program Agreement or most recently approved Program Agreement
Revision;
18. Receive permission and budgetary approval from DPS prior to using the Program Agreement, or most recently
approved Program Agreement Revision, as a part of any news release or commercial advertising and
acknowledge DPS funding in partnership with the County;
19. Comply with DPS trainings and requirements regarding the United States Department of Justice national
standards to prevent, detect, and respond to prison rape under the Prison Rape Elimination Act (PREA);
Reference: 14B NCAC 118, and in compliance with DPS JCPC Policy 2: Operations: Program Operational
Requirements
20. Be deemed an independent contractor in the performance of services described in the Program Agreement, or
most recently approved Program Agreement Revision, and as such shall be wholly responsible for the services to
be performed and for the supervision of its employees;
21. Represent that it has, or shall secure at its own expense, all personnel required in performing the services as
described in the Program Agreement. Such personnel shall not be employees of, or have any individual
contractual relationship with, DPS;
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
Sponsoring Agency and Use of Contractor(s)/Subcontractors
The Sponsoring Agency may engage with independent contractors as needed to perform services or support services
described in the Program Agreement. When independent contractors (funds are included in line item 190 of the
budget) are providing services as described in the Program Agreement, the sponsoring agency must:
22. Upload a signed Contract for Professional Services into NCALLIES once the Program Agreement (or
Program Agreement Revision) is approved by DPS;
23. Be responsible for the performance of all contractors or subcontractors as described in the Program
Agreement, or most recently approved Program Agreement Revision;
24. Hold any contractor or subcontractor to which the Sponsoring Agency provides State funds accountable for
the legal and appropriate expenditure of State funds, and to all applicable laws and DPS JCPC Policies and
Procedures; and
25. Ensure that all contractors or subcontractors provide all information necessary to comply with the standards
set forth in the Program Agreement or most recently approved Program Agreement Revision.
The JCPC shall:
1. Ensure the Sponsoring Agency uses JCPC funds for only the purposes DPS has approved in the JCPC Program
Agreement or most recently approved JCPC Program Agreement Revision;
2. Comply with DPS JCPC Policy and Procedures and the North Carolina Administrative Code; N.C.G.S. §1436-801
(a);143B-602;143B-851
3. Review and locally approve Program Agreement Revision(s) received from the Sponsoring Agency and submit to
the County in a timely manner;
4. Review and locally approve Third Quarter Accounting forms and submit to the County in order to meet the due
date established by DPS (applicable only to JCPC funded agencies);
5. Submit any other information requested by the County or DPS; and
6. Monitor the Sponsoring Agency's currently funded JCPC program(s) in accordance with DPS JCPC Policy 3.
Operations: Program Oversight and Monitoring
Reference: 14B NCAC 118.0202 and DPS JCPC Policy 1, 7, 8, 9, 10, and 11.
The County shall:
1. Ensure the Sponsoring Agency is appropriately licensed, and either local public agencies, 501(c) (3) non-profit
corporations or local housing authorities (applicable only to JCPC funded agencies);
2. Use funds only for the purposes DPS has approved in the Program Agreement or most recently approved
Program Agreement Revision;
3. Disburse funds monthly and oversee funds to the Sponsoring Agency in accordance with 14B NCAC 11 B.0108
4. Comply with DPS JCPC Policies and Procedures and the North Carolina Administrative Procedures;
5. Review and locally approve Program Agreement Revisions received from the Sponsoring Agency for final
approval from DPS; and
6. Review and locally approve Third Quarter and jointly submit Final Accounting forms for the JCPC and all funded
programs according to the procedures and due dates established by DPS.
Reference: 14B NCAC 11 B; DPS JCPC Policy 3, 7, 8, 9, 10, and 11
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.
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
Choice of Law: The validity of this Program Agreement and any of its terms or provisions, as well as the rights and
duties of the parties to this Program Agreement, are governed by the laws of North Carolina. The parties, by signing
this Program Agreement, agree and submit, solely for matters concerning this Program Agreement, to the exclusive
jurisdiction of the courts of North Carolina and agree, solely for such purpose, that the exclusive venue for any legal
proceedings shall be Wake County, North Carolina. The place of this Program Agreement 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 Program Agreement or tort, relating to the validity, construction, interpretation, and enforcement shall be
determined.
Assignment: No assignment of the Sponsoring Agency's obligations or the Sponsoring Agency's right to receive
payment hereunder shall be permitted. However, upon written request approved by the issuing purchasing authority,
DPS may:
(a) Forward the Sponsoring Agency's payment check(s) directly to any person or entity designated by the
Program Manager, or
(b) Include any person or entity designated by Sponsoring Agency as a joint payee on the Sponsoring Agency's
payment check(s).
In no event shall such approval and action obligate DPS or County Government to anyone other than the Sponsoring
Agency, and the Sponsoring Agency shall remain responsible for fulfillment of all Program Agreement obligations.
Beneficiaries: Except as herein specifically provided otherwise, this Program Agreement 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 Program Agreement, and all rights of action relating to such
enforcement, shall be strictly reserved to DPS, the County Government, and the Sponsoring Agency. 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 DPS and County Government that any such person or entity, other than DPS or the County
Government, or the Sponsoring Agency receiving services or benefits under this Program Agreement shall be deemed
an incidental beneficiary only.
Property Rights
Intellectual Property: All deliverable items produced pursuant to this Program Agreement are the exclusive property of
DPS. The Sponsoring Agency shall not assert a claim of copyright or other property interest in such deliverables.
Physical Property: the Sponsoring Agency agrees that it shall be responsible for the proper custody and care of any
property purchased for or furnished to it for use in connection with the performance of this Program Agreement and will
reimburse DPS for loss of, or damage to, such property. At the termination of this Program Agreement, the Sponsoring
Agency, County Government, and JCPC shall follow the guidelines for disposition of property set forth in Administrative
Code and JCPC policy.
Reference: 14B NCAC 11B.01 10; DPS JCPC Policy 9. Fiscal Accounting and Budgeting: Final Accounting Process
Disbursements and Internal Controls
Reversion of Unexpended Funds
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
Any remaining unexpended funds DPS disbursed to the County for the Sponsoring Agency must be refunded/reverted
back to DPS at the close of fiscal year or upon termination of this Agreement.
Accountability for Funds
Audit Requirement - Local Government or Public Authority Requirements
Local Government or Public Authorities in accordance with N.C.G.S. §159-34 must have an audit performed in
conformity with generally accepted auditing standards. The audit shall evaluate the performance of a unit of local
government or public authority with regard to compliance with all applicable Federal and State agency regulations. This
audit, combined with the audit of financial accounts, shall be deemed to be the single audit described by the, "Federal
Single Audit Act of 1984".
Audit Requirement — Non -Governmental Entities: An audit, when required by law, or requested by the County or
DPS shall be performed in conformity with generally accepted auditing standards and audits of non-governmental
entities, both for-profit and not-for-profit, and must meet the requirements of OMB Circular A-133. At a minimum, the
required report shall include the financial statements prepared in accordance with generally accepted accounting
principles, all disclosures in the public interest required by law, and the auditor's opinion and comments relating to
financial statements. The audit report must be submitted to the State Auditor's office as required by law, to the County
and DPS, and to other recipients as appropriate within nine (9) months after the end of the program's fiscal year.
Oversight
Access to Persons and Records: The State Auditor shall have access to persons and records as a result of all
Program Agreements entered into by State agencies or political subdivisions in accordance with N.C.G.S. §147-64.7.
Additionally, as the State funding authority, DPS shall have access to persons and records as a result of all Program
Agreements 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
DPS. State basic records retention policy requires all records to be retained for a minimum of five years or until all
audit exceptions have been resolved, whichever is longer. If the Program Agreement 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 Program Agreement 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.
No Overdue Tax Debt — Not for profit organizations ONLY must comply with this section. This form must be
uploaded in NCALLIES when submitting a Program Agreement. The Sponsoring Agency shall be responsible for
the payment of all State, local, and Federal taxes. Consistent with N.C.G.S. § 143C-6-23 (c), not for profit
organizations shall file with DPS and the County a written statement completed by that Sponsoring Agency's board of
directors or other governing body, stating whether or not the Sponsoring Agency has any overdue tax debts, as
defined by N.C.G.S. 105-243.1, at the Federal, State, or local level. This written statement, Certification of No
Overdue Tax Debts, shall be completed by the Sponsoring Agency to certify when there are no overdue taxes. If the
agency has overdue taxes, the Sponsoring Agency must notify DPS at the time of Program Agreement submission.
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
Conflict of Interest — Not for profit organizations ONLY must comply with this section. This form must be
uploaded in NCALLIES when submitting a Program Agreement. Consistent with the N.C.G.S. §143C-6-23 (b), not
for profit organizations shall file with DPS and the County a copy of that Sponsoring Agency's policy addressing
conflicts of interest that may arise involving the Sponsoring Agency's management employees and the members of its
board of directors or other governing body. The policy shall address situations in which any of these individuals may
directly or indirectly benefit, except as the Sponsoring Agency's employees or members of its board or other
governing body, from the Sponsoring Agency's disbursing of State funds and shall include actions to be taken by the
Sponsoring Agency or the individual, or both to avoid conflicts of interest and the appearance of impropriety. The
policy shall be filed before the County or DPS may disburse any funds. The Sponsoring Agency shall also complete
the DPS Conflict of Interest Policy Statement (Form DPS 13 001) and upload the statement and the Sponsoring
Agency's policy addressing conflicts of interest to the JCPC Program Agreement upon submission.
Proof of 501(c) (3) — Not for profit organizations ONLY must comply with this section. This document must be
uploaded in NCALLIES when submitting a Program Agreement. Not for profit organizations must upload proof of
the Sponsoring Agency's 501 (c) (3) status.
Amendment: This Agreement may not be amended orally or by performance. Any amendment must be requested in
writing by the Sponsoring Agency through submission of a Program Agreement Revision and executed by duly
authorized representatives of DPS, the County Government, JCPC and Sponsoring Agency.
Severability: In the event that a court of competent jurisdiction holds that a provision or requirement of this Program
Agreement 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 Program
Agreement shall remain in full force and effect.
Termination for Cause: If, through any cause, the Sponsoring Agency shall fail to fulfill its obligations under this
Program Agreement in a timely and proper manner, DPS shall have the right to terminate this Program Agreement by
giving written notice to the Sponsoring Agency and specifying the effective date thereof. In that event, all finished or
unfinished deliverable items prepared by the Sponsoring Agency under this Program Agreement shall, at the option of
DPS, become its property and the Sponsoring Agency 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 Sponsoring Agency shall not be relieved of liability to DPS for damages
sustained by DPS by virtue of the Sponsoring Agency's breach of this agreement, and DPS may withhold any
payment due the Sponsoring Agency for the purpose of setoff until such time as the exact amount of damages due
DPS from such breach can be determined. The filing of a petition for bankruptcy by the Sponsoring Agency shall be
an act of default under this Program Agreement.
Termination without Cause: DPS, the County Government, or the Sponsoring Agency may terminate this
Agreement at any time and without cause by giving at least thirty (30) days advance written notice to the other. If this
Program Agreement is terminated by DPS as provided herein, the Sponsoring Agency shall be reimbursed on a pro
rata basis for services satisfactorily provided to DPS under this Program Agreement prior to Program Agreement
termination.
Waiver of Default: Waiver by DPS of any default or breach in compliance with the terms of this Program Agreement
by the Sponsoring Agency 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 Program Agreement unless stated to be such in writing, signed by an
authorized representative of DPS, County Government, the JCPC and the Sponsoring Agency.
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
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, pandemic, or act of God.
Survival of Promises: All promises, requirements, terms, conditions, provisions, representations, guarantees, and
warranties contained herein shall survive the Program Agreement expiration or termination date unless specifically
provided otherwise herein, or unless superseded by applicable Federal or State statutes of limitation.
END OF SECTION V — Terms of Agreement
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION VI: BUDGET NARRATIVE
Systematic Training for Effective Parenting
Fiscal Year
FY 21-22
Wages
Wages
Item #
Justification
Expense
In Kind Expense
120
(Deeanna - $34.33/per hr x 24 hours= $823.92) + (Meredith-
$22.18/per hr x 36 hours = $798.48
$1,622
120
(part time prevention specialist - $13.77 x 200 hours)
$2,754
120
(John- $27.41/per hr x 290 hours = $7948.90) + (Erin - $23.24/
per hr x 275 hours = $6391)
$14,340
180
Total Benefits (FICA, Group Insurance, Retirement,
Unemployment, Workers Comp, Vacation) --- Full time Salary
($14340 Erin, John x 27.9%) + Part time Salary($2754 x 15%)
$4,414
180
Total Benefits (FICA, Group Insurance, Retirement,
Unemployment, Workers Comp, Vacation) ---Salary ($823.92
Deeanna x 27.9%) + ($798.48 Meredith x 15%)
$350
220
Meal and refreshments ($74/session x 8 sessions x 6 cycles)
$3,552
230
($23 x 36 participants for individual family participation bags)
$828
260
Service Maintenance Contracts for office supplies (programs
assigned cost)
$125
310
Taxi cab and/or bus passes to assist with client travel as
needed
$300
320
5740 -Telephone Fair share portion (programs assigned costs)
$184
370
5120 -Advertising Expense Fair share portion (programs
assigned costs)
$6
390
5320 -Contracted Services Other- ($1050/ per OA Challenge
Course x 6 Days)
$6,300
390
5100 -Administration charges Fair share portion (programs
assigned costs)
$2,329
390
5320 -Contracted Services Other- Onsite Childcare professional
($13/per hr x 8 sessions x 6 cycles x 2.5 hours)
$1,560
390
5160 -Audit Expense Fair share portion (programs assigned
costs)
$53
390
Contracted Services Cleaning
$210
410
In-kind meeting location for program ($14/per sq ft x 256 sq ft)
+ location for onsite childcare ($14/per sq ft x 200 sq ft)
$6,384
410
5680 -Rent Fair share portion (programs assigned costs)
$1,620
450
5500 -Insurance Prop/Liab 5510 -Insurance -Vehicle Fair share
portion (programs assigned costs)
$605
TOTAL
$39,180
$8,356
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
Annual Expense
Annual In Kind
Job Title
Wages
Wages
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
John Dail, Prevention Specialist, Facilitate STEP Program
$7,949
Meredith Ross, Prevention Coordinator, Supervise STEP Facilitator
$798
Deeanna Hale -Holland, Prevention Director, Manage and Supervise Program
$824
part time prevention specialist/program administration support
$2,754
Erin Ditta, Prevention Coordinator, Coordinate and Supervise STEP Program
$6,391
TOTAL
$17,094
$1,622
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA150A1DA06C
SECTION VII Program: Systematic Training for Effective Parenting
Fiscal Year: FY 21-22
Number of Months: 12
Cash
In Kind
Total
I. Personnel Services
$21,508
$1,972
$23,480
120 Salaries & Wages
$17,094
$1,622
$18,716
180 Fringe Benefits
$4,414
$350
$4,764
190 Professional Services"
$0
*Contracts MUST be attached
II. Supplies & Materials
$4,505
$4,505
210 Household & Cleaning
$0
220 Food & Provisions
$3,552
$3,552
230 Education & Medical
$828
$828
240 Construction & Repair
$0
250 Vehicle Supplies & Materials
$0
260 Office Supplies and Materials
$125
$125
280 Heating & Utility Supplies
$0
290 Other Supplies and Materials
$0
III. Current Obligations & Services
$10,942
$10,942
310 Travel & Transportation
$300
$300
320 Communications
$184
$184
330 Utilities
$0
340 Printing & Binding
$0
350 Repairs & Maintenance
$0
370 Advertising
$6
$6
380 Data Processing
$0
390 Other Services
$10,452
$10,452
IV. Fixed Charges & Other Expenses
$2,225
$6,384
$8,609
410 Rental or Real Property
$1,620
$6,384
$8,004
430 Equipment Rental
$0
440 Service and Maint. Contracts
$0
450 Insurance & Bonding
$605
$605
490 Other Fixed Charges
$0
V. Capital Outlay
$0
[This Section Requires Cash Match]
510 Office Furniture & Equipment
$0
530 Educational Equipment
$0
540 Motor Vehicle
$0
550 Other Equipment
$0
580 Buildings, Structure & Improv.
$0
Total
$39,180
$8,356
$47,536
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: 05ED4668-D714-4F7A-9795-DA1 50A1 DA06C
SECTION VIII SOURCES OF PROGRAM REVENUE (ALL SOURCES)
FY 21-22 New Hanover County Funding ID: 965-XXXX
Sponsoring Agency: Coastal Horizons Center, Inc. Program: Systematic Training for Effective Parenting
$39,180
20%
$8,356
$47,536
DPS/JCPC Funds
Local Match Rate
County Cash
Local Cash
Local Cash
Local In -Kind
Other
Other
Other
Other
TOTAL
" This is the amount approved in your application
Is the Local Match Rate 10%, 20% or 30%?
(Specify Source)
Staff management and supervision & program
meeting location
$7,836
(Specify Source)
(Specify Source)
(Specify Source)
(Specify Source)
(Specify Source)
(Specify Source)
(Specify Source)
$8,356
Required Local Match Match Provided
E791'11
ouSigned by:E7A4BD9F419... 6/9/2021
Authorizing Official, Department of Public Safety Date
The following signature certifies that this program agreement has been locally approved by the Board of County Commissioners.
DocuSigned by:
E�`.�.u, �un��Uu,�ne�
741AAC4C4DDE460...
6/9/2021
Chair, County Board of Commissioners or County Finance Director Date
The following signature certifies that this program agreement has been locally approved by the Juvenile Crime Prevention
Council.
—DocuSigned by:
9 R (hvpuu" l f
—3DD8E15D4A2540C... 6/2/2021
Chair, Juvenile Crime Prevention Council
DocuSigned by:
�eeaai.wa �a�-�o�Ccwcl
Program Manager
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
Date
6/2/2021
Date
03212e
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C0v2,Ivr HOM0142 CE141EH' IMC'
Certificate Of Completion
Envelope Id: 05ED4668D7144F7A9795DA150A1DA06C
Subject: DPS eSignature Request for New Hanover 965-22597 Systematic Training for Effective Parentinc
Source Envelope:
Document Pages: 28 Signatures: 4
Certificate Pages: 5 Initials: 0
AutoNav: Enabled
Envelopeld Stamping: Enabled
Time Zone: (UTC -05:00) Eastern Time (US & Canada)
Record Tracking
Status: Original
6/2/2021 1:59:14 PM
Signer Events
Deeanna Hale -Holland
deeanna@coastalhorizons.org
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 6/2/2021 4:25:39 PM
ID:8319df6b-2f7f-4b22-b425-fade22b654ee
J H Corpening II
julius.h.corpening@nccourts.org
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 6/2/2021 4:43:45 PM
ID:la90bcl9-4dc9-49e2-8612-lb9ldec58099
Lisa Wurtzbacher
Iwurtzbacher@nhcgov.com
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 6/9/2021 1:17:06 PM
ID:5242f1fb-51b6-4ffe-a80e-ad1b2dc865f8
Cindy Porterfield
cindy.porterfield@ncdps.gov
Director of Juvenile Community Programs
NC Dept of Public Safety
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Holder: DPS-DJJ Community Programs
djjdp.applicationsupport@ncdps.gov
Signature
D S'g d by:
eea�wwa Wia W.#. a�
E
247969E19614FE...
Signature Adoption: Pre -selected Style
Using IP Address: 173.93.17.14
DocuSigned by:
f - (rpuu," N
3DD8E15D4A2540C...
Signature Adoption: Pre -selected Style
Using IP Address: 204.152.2.230
CDocuSigned by:
74 1`� C4DDE46
Signature Adoption: Pre -selected Style
Using IP Address: 70.63.86.17
CD sg a by:
798FUMBDU419...
Signature Adoption: Pre -selected Style
Using IP Address: 199.90.60.4
DocuSign
Status: Completed
Envelope Originator:
DPS-DJJ Community Programs
3040 Hammond Business PI
Raleigh, NC 27603
djjdp.applicationsupport@ncdps.gov
IP Address: 207.4.107.21
Location: DocuSign
Timestamp
Sent: 6/2/2021 1:59:16 PM
Viewed: 6/2/2021 4:25:39 PM
Signed: 6/2/2021 4:28:45 PM
Sent: 6/2/2021 4:28:47 PM
Viewed: 6/2/2021 4:43:45 PM
Signed: 6/2/2021 4:43:54 PM
Sent: 6/2/2021 4:43:56 PM
Viewed: 6/2/2021 4:58:07 PM
Signed: 6/9/2021 1:17:47 PM
Sent: 6/9/2021 1:17:49 PM
Viewed: 6/9/2021 2:03:38 PM
Signed: 6/9/2021 2:03:43 PM
In Person Signer Events
Signature
Timestamp
Editor Delivery Events
Status
Timestamp
Agent Delivery Events
Status
Timestamp
Intermediary Delivery Events
Status
Timestamp
Certified Delivery Events
Status
Timestamp
Carbon Copy Events
Status
Timestamp
Witness Events
Signature
Timestamp
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted
6/2/2021 1:59:16 PM
Certified Delivered
Security Checked
6/9/2021 2:03:38 PM
Signing Complete
Security Checked
6/9/2021 2:03:43 PM
Completed
Security Checked
6/9/2021 2:03:43 PM
Payment Events
Status
Timestamps
Electronic Record and Signature Disclosure
Electronic Record and Signature Disclosure created on: 4/3/2018 2:57:43 PM
Parties agreed to: Deeanna Hale -Holland, J H Corpening II, Lisa Wurtzbacher
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How to contact NC Dept of Public Safety:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: david.pozun@ncdps.gov
To advise NC Dept of Public Safety of your new e-mail address
To let us know of a change in your e-mail address where we should send notices and disclosures
electronically to you, you must send an email message to us at david.pozun@ncdps.gov and in
the body of such request you must state: your previous e-mail address, your new e-mail address.
We do not require any other information from you to change your email address..
In addition, you must notify DocuSign, Inc. to arrange for your new email address to be reflected
in your DocuSign account by following the process for changing e-mail in the DocuSign system.
To request paper copies from NC Dept of Public Safety
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an e-mail to david.pozun@ncdps.gov and in the
body of such request you must state your e-mail address, full name, US Postal address, and
telephone number. We will bill you for any fees at that time, if any.
To withdraw your consent with NC Dept of Public Safety
To inform us that you no longer want to receive future notices and disclosures in electronic
format you may:
i. decline to sign a document from within your DocuSign session, and on the subsequent
page, select the check -box indicating you wish to withdraw your consent, or you may;
ii. send us an e-mail to david.pozun@ncdps.gov and in the body of such request you must
state your e-mail, full name, US Postal Address, and telephone number. We do not need
any other information from you to withdraw consent.. The consequences of your
withdrawing consent for online documents will be that transactions may take a longer time
to process..
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To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please verify that you were
able to read this electronic disclosure and that you also were able to print on paper or
electronically save this page for your future reference and access or that you were able to e-mail
this disclosure and consent to an address where you will be able to print on paper or save it for
your future reference and access. Further, if you consent to receiving notices and disclosures
exclusively in electronic format on the terms and conditions described above, please let us know
by clicking the a€ -I agreea€TM button below.
By checking the a€ -I agreea€TM box, I confirm that:
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ELECTRONIC CONSUMER DISCLOSURES document; and
• I can print on paper the disclosure or save or send the disclosure to a place where I can
print it, for future reference and access; and
• Until or unless I notify NC Dept of Public Safety as described above, I consent to receive
from exclusively through electronic means all notices, disclosures, authorizations,
acknowledgements, and other documents that are required to be provided or made
available to me by NC Dept of Public Safety during the course of my relationship with
you.