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Home My WebLink AboutFY21 EWP State executed 19-091-4050 New Hanover County 2020.AWARDSteve Troxler North Carolina Department of Agriculture Commissioner and Consumer Services April 27, 2020 Ms. Dru Harrison New Hanover County 230 Government Center Dr, Suite 100 Wilmington, NC 28403 ACCEPTANCE OF AWARD NOTIFICATION Dear Ms. Harrison: N. David Smith Chief Deputy Commissioner On behalf of Commissioner Steve Troxler and the North Carolina Department of Agriculture and Consumer Services, we are pleased that you have accepted the Department's offer of $1,099,124.00 for Hurricane Florence Watershed Restoration. By accepting our offer of financial assistance, you have agreed to the specific stipulations, terms and conditions, and reporting requirements contained in the contract that you signed. Enclosed is a fully executed contract for your records. If you have any questions regarding the contract, please feel free to contact Heather Reichert at (919) 707- 3768, or by email to Heather.Reichert@ncagr.gov. Invoices or matters regarding work to be performed should also be directed to Ms. Reichert. would like to take this time to wish you succe on your w tershed restoration project. nce N. David Smith Chief Deputy Commissioner Enclosure Email: David,Smith@ncagr.gov 1001 Mail Service Center, Raleigh, North Carolina, 27699-1001 (919) 707-3033 0 Fax (919) 715-0026 An Equal Opportunity Affirmative Action Employer . �MUNA l+ 61P 1 o. M DrD Steve Troxler North Carolina Department of Agriculture Commissioner and Consumer Services March 25, 2020 Ms.Dru Harrison New Hanover County 230 Government Center Dr, Suite 100 Wilmington, NC 28403 NOTIFICATION OF FUNDING OFFER Dear Ms. Harrison, N. David Smith Chief Deputy Commissioner On behalf of Commissioner Steve Troxler and the North Carolina Department of Agriculture and Consumer Services -- Division of Soil & Water Conservation, I am pleased to inform you that $1,099,124.00 for your project, Watershed Restoration Project, was approved under the Hurricane Florence Emergency Response Act. Two original contract packets must be completed and returned to the NCDA&CS, making sure that the contracts and certain forms have been signed, dated, and witnessed, as applicable, before they are returned to the address provided below. By completing these documents, you are agreeing to the specific stipulations, the general terms and conditions and specific reporting requirements. Please return the two completed packets to: Heather Reichert NC Department of Agriculture & Consumer Services, Division of Soil & Water Conservation 1614 Mail Service Center Raleigh, NC 27699-1614 All authorized re resentative signatures must be blue ink. Use the Contract Check Off List to ensure all attachments are included and are in the correct order for each contract packet. One fully executed, original contract will be returned to you for your records. If you have any questions about your contract or any of the forms contained in your offer packet, please call Heather Reichert at 919- 707-3768, or feel free to send an email to Heather. Reichert@ncagr.gov. I would like to take this opportunity to thank you for participating in the Watershed Restoration Project for restoring drainage and securing streambanks fo ing regent storms. C cer N. David Smith' Enclosures Chief Deputy Commissioner cc: Tara Tyson, Grants Administrator Email; David.Smith@ncagr.gov 1001 Mail Service Center, Raleigh, North Carolina, 27698-1001 (919) 707.3033 0 Fax (919) 715-0026 An Equal Opportunity Affirmative Action Employer 0 NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES Steven W. Troxler, Commissioner Contract Check Off List for Grantee (Government/University) INSTRUCTIONS: Check the "Yes" boxes in the 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 required for this grant program or project. GRANTEE ORGANIZATION NAME: New Hanover Co PROJECT TITLEINAME: Watershed Restoration Prole CONTRACT #: 19-091-4050 GO Entities Only Check One Box Document Title Department Use— Documents Attached or On File Grants and Contracts - Documents Attached or On File Yes No Contractual "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 — General Terms and Conditions — Government/University Yes No Yes No Yes No Attachment B — Scope of Work includes Timeline and Line Item Budget) Yes No / Yes No Yes No Attachment C — Certifications and Assurances Section Yes No / Yes No Yes No Attachment D — NCO enBook Supplemental Information es No / Yes No Yes No Attachment E — Signature Card Yes No i Yes No Yes No Attachment F — W-9 Tax Information Yes No / Yes No Yes No Attachment G — Vendor Electronic Payment Form Yes No / Yes No Yes No Attachment H — FFATA Data Reporting Requirements if applicable) Yes No N Yes No Yes No Attachment I — Federal Regulations if applicable) Yes No W Yes No Rev. 6117 f1 STATE OF NORTH CAROLINA COUNTY OF WAKE nm Departmental Use Only CENTER: 2985-1803 ACCOUNT: 536502 AMOUNT: 11,099,124.00 CENTER: ACCOUNT: 536502 AMOUNT: CENTER: ACCOUNT: 536502 AMOUNT. CENTER: ACCOUNT: 536,502 AMOUNT: .00 North Carolina Department of Agriculture and Consumer Services Division of Soil & Water Conservation Watershed Restoration Project - Governmental CONTRACT # 19-091-4050 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 County ("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 Dr, Suite 100 Wilmington, NC 28403. The purpose of this Contract is to implement needed repairs to streams and drainage ways resulting from hurricanes and subsequent flooding. The Grantee's project title is Watershed Restoration Project. This Contract is funded by state appropriations. 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. General Terms and Conditions (Attachment A) 3. Scope of Work, including Timeline, Line Item Budget and Budget Narrative (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. Vendor Electronic Payment Form (Attachment G) These documents constitute the entire agreement between the Parties and supersede all prior oral or written statements or agreements. Precedence Among Contract Documents: In the event of a conflict between or among the terms of the Contract Documents, the terms in the Contract Document with the highest relative precedence shall prevail. The order of precedence shall be the order of documents as listed in Paragraph 1, above, with the first -listed document having the highest precedence and the last -listed document having the lowest precedence. If there are multiple NCAA&CS (Govt Contract Cover) Rev. 7114;12114; 8117 Page 1 of 6 Contract Amendments, the most recent amendment shall have the highest precedence and the oldest amendment shall have the lowest precedence. Effective Period: This Contract shall be effective on January 1. 2020 and shall terminate on December 31. 2022 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 A. III. Grantee's Duties: The Grantee shall provide the services as described in the Attachment B: Scope of Work. The Grantee shall be responsible to obtaining necessary landowner authorization Tor site access and all permits needed to complete the planned 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 $1,099,124.00. This amount consists of: $1,099,124.00 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 $3,627,109.20, which consists of: [ a d. The Grantee has committed to an additional $ to complete the project as described in Attachment B. The total contract amount with matching funds is $4,726,233.20. 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&C5 (Govt Contract Cover) Rev. 7114;12114; 8117 Page 2 of 6 VII. Reversion of Unexpended Funds: Any unexpended grant funds shall revert to the Agency upon termination of this Contract. VIII. Reporting Requirements: (1) State [N.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 January, April, July, and October, 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 form, to be provided by the Agency. All Request for Payment forms should be received no more than monthly, with an invoice showing expenditures and matching funds, if applicable, for the current period and cumulatively for the entire project. Upon approval by the Agency, payment shall be made 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. For sites for which this contract is supplementing USDA Emergency Watershed Protection Program (EWPP) funding, completed work must also satisfy EWPP requirements prior to payment being authorized. Up to 16 percent (16%) of the funds awarded to the Grantee may be used to reimburse actual documented engineering, technical assistance, and 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. The Grantee shall expend funds in accordance with G.S. 143C-6-23 (f1)(f2)0). The Grantee shall account for any income earned, which may result from any funds awarded under this Contract, on the Agency "Request for Reimbursement" form, Eligible uses of income earned are: a) Expanding the project or program; b) Continuing the project or program after grant ends; or c) Supporting other projects or programs that further the broad objectives of the grant program. 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 NCDA&CS (Govt Contract Cover) Rev. 7!14;12114; 8117 Page 3 of 6 X. XI 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. 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. 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 David B. Williams, Deputy Director Division of Soil & Water Conservation 1614 Mail Service Center Raleigh, NC 27699-1614 Telephone: 919-715-6103 Email: David. B.Williams(&ncaar.00v IF DELIVERED BY ANY OTHER MEANS David B. Williams, Deputy Director Division of Soil & Water Conservation 216 West Jones Street Raleigh, NC 27603 For the Grantee: Grantee Contract Administrator Grantee Dru Harrison Same New Hanover County 230 Government Center Dr, Suite 100 Wilmington, NC 28403 Telephone: 910-798-7135 Fax: 910-798-6049 Email: drharrison@nhcgov.com Supplementation of Expenditure of Public Funds: or Key Personnel 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 (Govt Contract Cover) Rev. 7114;12114; 8117 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: a. Will implement or already have implemented adequate internal controls over disbursements b. 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 c. Assure adequate control of signature stamps/plates d. Assure adequate control of negotiable instruments; and e. Have procedures in place to ensure that account balance is solvent and to reconcile the account monthly. f. XIII. 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. § 433-32 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] NCDA&CS (Govt Contract Cover) Rev. 7!14;12114; 8117 Page 5 of 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. Grantee: New Hanov County Sig a of Authorized entative Date ✓`' S Printed ame Title Witness: V �1 / Si nature Date c 1"k -- Printed Name ` Title ! North Carolina Department of Agriculture and Consumer Services aignaiure of Authorized Represenfative N. David Smith, Chief Deputy Commissioner NCDA&C5 (Govt Contract Cover) Rev. 7114;12114; 8/17 Date Page 6 of 6 ATTACHMENT B SCOPE OF WORK WATERSHED RESTORATION PROJECT New Hanover County (the "GRANTEE") will complete watershed restoration activities including cutting and removing downed trees, broken tops, woody/vegetative debris and sediment that impede or potentially impede water flow in the streams and tributaries included in Table B1 below (taken from the application submitted by the GRANTEE). For sites for which this contract is supplementing USDA Emergency Watershed Protection Program (EWPP) funding, completed work must also satisfy EWPP requirements prior to payment being authorized. TABLE B1: Stream/Ditch Seents to be repaired ID Segment Name Planned Treatment EWP Project Linear Feet Planned A Bernards Creek Removal of storm debris and 37-07-18-5038-200 9088 Water shed (Whiskey sediment Creek 1) B Dock Creek Removal of storm debris and 37-07-018-5038- 2637 sediment 203 C Everette Creek Water Removal of storm debris and 37-07-18-5038-204 8260 Shed sediment D Futch Creek Removal of storm debris and 37-07-18-5038-205 5079 sediment E we Creek Removal of storm debris and 37-07-18-5038-206 8148 sediment F Motts Creek Removal of storm debris, grade 37-07-18-5038-210 14 447 and realign channel, reshape 2 drains and install rip rap under eotextile G Ness Creek Removal of storm debris and 37-07-18-5038-211 21221 sediment H Page Creek Removal of storm debris and 37-07-18-5038-212 33511 Watershed sediment I Prince George Creek Removal of storm debris and 37-07-18-5038-213 48452 sediment J Cape Fear River Removal of storm debris 37-07-18-5038-215 300 (Shipwatch Drive) K Smith Creek Removal of storm debris and 37-07-18-5038-216 60462 Watershed sediment L Whiskey Creek lI Removal of storm debris and 37-07-18-5038-219 30153 sediment M Sneeden Drive -Pipe Removal of storm debris and 37-07-18-5038-217 1 sediment NCDA&CS (Gov't Contract Cover - SO & Water) Rev. 7114; 12114 Page 1 of 2 The GRANTEE will ensure that all required permits are secured for each site and landowner permission is granted before any work proceeds for that site. The GRANTEE will ensure that it and its contractors follow the Division of Water Resources' Hurricane Matthew Stream and Wetland Cleanup/Restoration Guideline dated October 2016. The GRANTEE shall also follow Best Management Practices for Selective Clearing and Snagging to manage all woody debris removed from streams. These guidelines can be downloaded at: htt s://www.nca r. ov/SWC/disasterres onse/WatershedRecove Efforts.html In the event the Grantee completes the work specified in the Scope of Work without exhausting the funds in the Contract, the Agency Contract Administrator may issue a Work Authorization to approve stream debris removal work for additional stream segments requested by the Grantee, not to exceed the funds available in the Contract. NCDA&CS (Gov't Contract Cover - Soil & Water) Rev. 7114; 12/14 Page 2 of 2 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. Attachment A (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(a)(2): a non -State entity that receives a grant of State funds from a State agency, department, or institution but does not include any non -State entity subject to the audit and other reporting requirements of the Local Government Commission. For other purposes in this Contract, "Grantee" shall mean the entity identified as one of the parties hereto. (11) "Grantor" means an entity that provides resources, generally financial, to another entity in order to achieve a specified goal or objective. (12) "Non -State Entity" has the meaning in 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 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 NCDA&CS - General Terms and Conditions — Public - Local Governmental Entities Eff, 07114;4115;1117 Page 1 of 4 PUBLIC SECTOR CONTRACTS (Including Local Governments) 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. 16013-2(1), and all boards, agencies, commissions, authorities, and institutions thereof that are not municipal corporations. Relationships of the Parties Independent Contractor: The Grantee is and shall be deemed to be an independent Contractor in the performance of this Contract and as such shall be wholly responsible for the work to be performed and for the supervision of its employees. The Grantee represents that it has, or shall secure at its own expense, all personnel required in performing the services under this agreement. Such employees shall not be employees of, or have any individual contractual relationship with, the Agency. Subcontracting: The Grantee shall not subcontract any of the work contemplated under this Contract without prior written approval from the Agency. Any approved subcontract shall be subject to all conditions of this Contract. Only the subcontractors or 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 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 NCDA&C5 - General Terms and Conditions — Public - Local Governmental Entities Eff. 07114;4115;1117 Page 2 of 4 PUBLIC SECTOR CONTRACTS (including Local Governments) 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. Oversight Access to Persons and Records: The State Auditor and the using agency's internal auditors shall have NCDA&CS - General Terms and Conditions — Public - Local Governmental Entities Eff. 07/14:4115;1/17 Page 3 of 4 PUBLIC SECTOR CONTRACTS (Including Local Governments) 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.020] NCDA&CS - General Terms and Conditions — Public - Local Governmental Entities Eff. 07114;4115;1117 Page 4 of 4 Attachment C 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 9112, 10112, 11113;1117 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) various county water sheds as listed in project scope 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.1-100-690, Title V, Subtitle D; 41 U.S.C. 701-707). NCDA&CS Certifications & Assurances Page 2 of 3 Rev 9112, 10112, 11!13;1117 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. New Hanover Coynty ,-i r rganizatio e Signature of Authorized Representative Date Chris Coudriet County Manager Printed Name of Authorized Representative Title NCDA8CS Certifications & Assurances Page 3 of 3 Rev 9/12, 10112, 11113;1117 Attachment D 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: 0400029563 Contract Number: 19-091-4050 Amendment Number: Grantee Name: New Hanover Countv TAX ID Number: 56-6000324 Fiscal Year Ends: June 30th 1. Brief Description and Background/History of your Organization. Be sure to include the number of years In existence, number of employees, mission and goals of your organization. soun 2. Current project timeline: Begin 04/07/2020 End 11/13/2020 3. Expected outcomes and specific deliverables. 4. The Grantee's WEB URL: nhcgov.com 5. * Grantee County of Residence: New Hanover Congressional District#: 7 (CONGRESSIONAL DISTRICT # MUST BE IDENTIFIED) 6. "County of Benefit: Single County: 0 Yes ❑ No County Name: New Hanover Statewide: ❑ Yes ❑■ No Regional: ❑ Yes ❑ No 7. If the answer to question number 6 is more than one county or "Regional", list the counties receiving benefit. New Hanover *Grantee County of Residence: County in which grantee is located. **County of Benefit: List only county or counties in which funding will be spent and/or food commodities will be received. NCDAWS NC OpenBook Supplemental Information Page 1 of 1 Rev 07114; 4117 r%LLC1%A 11 1 FGI FL L Signature Card CONTRACT & FINANCIAL DOCUMENTS INSTRUCTIONS: Please read and fill in the required information to the right of each field where applicable. Signatures must match the Contract signatures. 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. If more than two people will sign for the organization, this form may be duplicated. SECTION I. Date: jApril 7, 2024 Legal Applicant Organization/Agency Name: I New Hanover County Federal Tax Identification Number: 56-6000324 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. NUN -GOVERNMENTAL ORGANIZATIONS ONLY Must match Contract signature) Board Chair, Executive Director, etc. Financial Representative, Treasurer, etc. Print Name & Title: I Print Name & Title: Signature: Signature: GOVERNMENTAL ENTITIES Must match Contract signature Authorized Governmental Official Chief Fiscal Officer -Print Name &Title: Print Name &Title: Chris Coudriet, qty Manag r Lisa Wurtzbacher, Chief Financial Officer Sig NCAA&CS - Signature Card — NGO & Governmental Rev 7114; 1117;11117 re: Page 1 of 1 Form W 9 Request for Taxpayer Attachment F {Rev. November 2017} Identification Number and Certification sotsrm Do not Department of the Treasury etqu Internal Revenue Service ► Go to www.irs.gov/FormW9 for instructions and the latest information. send to the IRS. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. New Hanover County 2 Business name/disregarded entity name, ii different Irom above `-15 3 Check appropriate ppro riate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes. 4 Exemptions (codes apply only to Cr C o Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate certain entities, not individuals; see instructions on page 3): ti e single -member LLC a o rr '� `o ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P -Partnership) ► Exempt payee code (if any) C N Note; Check the appropriate box in the tine above for the tax classification of the single -member owner. De not check LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the Exemption from FATCA reporting d o owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that is disregarded from the owner should check the appropriate box for coda (it any) the tax classification of its owner. ✓ Other m (see instructions)1 GfMpi+e 5 Address (number, street, and epi. or suite no.) See instructions. ra eeeounh ma,nr•ii.ad oursitl• Ih• U S.) 230 Government Center Drive Requester's name and address (optional) c8 B City, state, and ZIP code —.Wilmington, NC 28403 7 List account number(s) here (optional) Number Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid s backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other C entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later, or Note: if the account is in more than one name, see the instructions for line 1. Also see What Name and F Number To Give the Requester for guidelines on whose number to enter. 7 Under penalties of perjury, I certify that: 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. 1 am 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); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. 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 for Part 11, later. Cinn bignature of i ' Here U.S. person ► L 7r - General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.im.gov/FormWg. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (FIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. ■ Form 1099 -INT (interest earned or paid) Date ► April 7, 2020 • Form 1099 -DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-5 (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding, See What is backup withholding. later. Cat. No. 10231X Farm W-9 (Rev. 11-2017) Form W-9 (Rev. 11-2017) By signing the filled-out form, you: Page 2 1. Certify that the TIN you are giving is correct (or you are waiting for a Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese number to be issued), student temporarily present in the United States. Under U.S. law, this 2. Certify that you are not subject to backup withholding, or student the United lSlates exceeds 5 calendar years. Hl become a resident alien for tax oweveroses in ara graph 2 3. Claim exemption from backu withhold'in If ou are a U.S. exempt p g y , paragraph of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows 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 the provisions of Article 20 to continue is apply even after the Chinese student becomes a resident alien of the United States. A Chinese or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and Protocol) and isalifies relying on this exception toder clapm anararaxemptionhfrofim tax 4, Certify that FATCA code(s) entered on this form (if any) indicating on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to that you are exempt from the FATCA reporting, is correct. See What is support that exemption. FATCA reporting, later, for further information. If you are a nonresident alien or a foreign entity, give the requester the Note: If you are a U.S. parson and a requester gives you a form other appropriate completed Form W-8 or Form 8233. than Form W-9 to request your TIN, you must use the requester's form it it is substantially similar to this Form W-9. Backup Withholding Definition of a U.S. person. For federal tax purposes, you are y What is backup withholding? Persons making certain payments to you considered a U.S. person if you are: must under certain conditions withhold and pay to the IRS 28% of such • An individual who is a U.S. citizen or U.S. resident alien; payments. This is called "backup withholding." Payments that may be subject to backup withholding include interest, tax-exempt • A partnership, corporation, company, or association created or interest, dividends, broker and barter exchange transactions, rents, royalties, organized in the United States or under the laws of the United States; nonemployee pay, payments made in settlement of payment card and • An estate (other than a foreign estate); or third party network transactions, and certain payments from fishing boat • A domestic trust (as defined in Regulations section 301.7701-7). withholdingeat estate transactions are not subject to backup Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to You will not be subject to backup withholding on payments you receive if pay a withholding tax under section 1446 on any foreign partners' share of effectively you give the requester your correct TIN, make the proper certifications, and report all your taxable interest dividends connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules and on your tax return. under section 1446 require a partnership to presume that a partner is a foreign person, and Payments you receive will be subject backup withholding it: pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade business 1 You do not furnish your TIN to the requester, a 2, You or in the United States, provide Form W-9 to the partnership to establish your do not certify your TIN when required (see the instructions for Part II for details), U.S. status and avoid section 1446 withholding on your share of partnership income. 3. The IRS tells the requester that you furnished an incorrect TIN, In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing Its U.S. status 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on tax and avoiding withholding on its allocable share of net income from the partnership your return (for reportable interest and dividends only), or conducting a trade or business in the United States. 5. You do not certify to the requester that you are not subject to • In the case of a disregarded entity with a U.S. owner, the U.S. owner backup withholding under 4 above (for reportable interest and dividend of the disregarded entity and not the entity; accounts opened after 1983 only). • In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner the Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the of grantor trust and not the trust; and not of Form W-9 for more Information. • In the case of a U.S. trust (other than a grantor trust), the U.S. trust Also see Special rules for partnerships, earlier. (other than a grantor trust) and not the beneficiaries of the: trust. Foreign What is FATCA Reporting? person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use The Foreign Account Tax Compliance Act (FATCA) requires a Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Participating foreign financial institution report all United States Pub, 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). account holders that are specified United States persons. Certain d payees are from Nonresident alien who becomes a resident alien. Generally, exempt FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form only a nonresident alien individual may use the terms of a tax treaty to reduce W-9 for more information. or eliminate U.S. tax on certain types of income. However, most tax treaties Updating Your Information contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to You must provide updated information to any person to wham you continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. claimed to at an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future If you are a U.S. resident alien who is relying on an exception from this person. For example, you may need to provide updated information if contained in the saving clause of a tax treaty to claim an exemption from U.S. tax certain types of income, you must attach a statement 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 to Form W-9 that specifies the following five items. the name or TIN changes for the account; for example, if the grantor of a 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a grantor trust dies. nonresident alien. 2. The treaty article addressing the income. Penalties 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 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 4. The type and amount of income that qualifies for the exemption from tax. unless your failure is due to reasonable cause and not to willful neglect. 5. Sufficient facts to justify the exemption from tax under the terms of Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no the treaty article. backup withholding, you are subject to a $500 penalty. Form W-9 (Rev. 11-2017) 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 Line 1 You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return. If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9. a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name. Note: ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1 a. This should also be the same as the name you entered on the Form 104011040A/1040EZ you filed with your application. b. Sole proprietor or single -member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or "doing business as" (DBA) name on line 2. c. Partnership, LLC that is not a single -member LLC, C corporation, or S corporation, Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2. d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. 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 line 2. e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a "disregarded entity." See Regulations section 301.7701-2(c)(2)(iff). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the Income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. 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 line 2, "Business name/disregarded entity name." If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN, Line 2 If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2. Line 3 Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3, Page 3 IF the entity/person on line 1 is THEN check the box for a(n) .. , ... Corporation Corporation • Individual Individual/sole proprietor or single - Sole proprietorship, or member LLC - Single -member limited liability company (LLC) owned by an individual and disregarded for U.S. federal tax purposes. ■ LLC treated as a partnership for Limited liability company and enter U.S, federal tax purposes, the appropriate tax classification, • LLC that has filed Form B832 or (P= Partnership; C= C corporation; 2553 to be taxed as a corporation, or S= S corporation) or • LLC that is disregarded as an entity separate from its owner but the owner is another LLC that is not disregarded for U.S, federal tax purposes. • Partnership Partnership • Trust/estate Trust/estate Line 4, Exemptions If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on tine 4 any code(s) that may apply to yo u. Exempt payee code. • Generally, individuals (including sole proprietors) are not exempt from backup withholding. • Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends. a Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions. ■ Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 10$9-MISC. The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4. 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(%2) 2—The United States or any of its agencies or instrumentalities 3--A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities 4—A foreign government or any of its political subdivisions, agencies, or instrumentalities 5—A corporation 6—A dealer In securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession 7—A futures commission merchant registered with the Commodity Futures Trading Commission B—Areal estate investment trust 9—An entity registered at all times during the tax year under the Investment Company Act of 1940 10—A Common trust fund operated by a bank under section 584(a) 11—A financial institution 12—A middleman known in the investment community as a nominee or custodian 13—A trust exempt from tax under section 664 or described in section 4947 Form W-9 (Rev. 11-2017) Page 4 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 13. IF the payment is for ... THEN the payment is exempt for... Interest and dividend payments All exempt payees except for 7 Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012. Barter exchange transactions and Exempt payees 1 through 4 Patronage dividends Payments over $600 required to be Generally, exempt payees reported and direct sales over 1 through 5? $5,000' Payments made in settlement of Exempt payees 1 through 4 Payment card or third party network transactions See Form 1099-MISC, Miscellaneous Income, and its instructions. However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding; medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency. Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with "Not Applicable" (or any similar indication) written or printed on the line for a FATCA exemption code. A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37) B—The United States or any of its agencies or instrumentalities C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulattons section 1.1472-1(c)(1){i) E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i) F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state G—A real estate investment trust H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940 I—A common trust fund as defined in section 584(a) J --A bank as defined in section 581 K—A broker L—A trust exempt from tax under section 664 or described in section 4947(a)(1) M—A tax exempt trust under a section 403(b) plan or section 457(8) plan Note. You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed. Line 5 Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. It this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payer changes your address in their records. Line 6 Enter your city, state, and ZIP code. 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 (fTIN). 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. If you are a single -member LLC that is disregarded as an entity separate from its owner, 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 entity's EIN. Note: See What Name and Number To Give the Requester, later, 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 SSA office or get this form online at www,SSA.gov. You may also get this form by calling 1-500-772-1213. 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 www.ir;.gov/Businesses and clicking on Employer Identification Number (EIN) under Starting a Business. Go to www.irs.govlFbrms to view, download, or print Form W-7 and/or Form SS -4. Or, you can go to wwwJrs.gcvlOrderForms to place an order and have Form W-7 and/or SS -4 mailed to you within 10 business days, If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write "Applied For" in the space for the TIN, sign and date the form, 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 U.S. 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, 4, or 5 below indicates 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 line 1 must sign. Exempt payees, see Exempt payee code, earlier. Signature requirements. Complete the certification as indicated in items 1 through 5 below. Form W-9 (Rev. 11-2017) 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. It 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, 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 requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (ncluding payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, 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), ABLE accounts (under section 529A), 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; I Clive name and SSN of: ' """•""'a' the individual 2. Two or more individuals 6oint The actual owner of the account or, if account) other than an account combined funds, the first individual on maintained by an FFI the account' 3. Two or more U.S. persons Each holder of the account Qoint account maintained by an FFI) 4, Custodial account of a minor The minor' (Uniform Gift to Minors Act) 5. a. The usual revocable savings trust The grantor -trustee' (grantor is also trustee) b. So-called trust account that is not The actual owner' a legal or valid trust under state law 6. Soto proprielorship or disregarded The owner' entity owned by an individual 7. Grantor trust filing under Optional The grantor' Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i) (A)) For this type of account: Give name and EIN of. - 8. Disregarded entity not owned by an The owner individual 9. A valid trust, estate, or pension trust Legal entity 10. Corporation or LLC electing Tho corporation corporate status on Form 8832 or Form 2553 11. Association, club, religious, The organization charitable, educational, or other tax- exempt organization 12. Partnership or multi member LLC The pannership 13. A broker or registered nominee I I The broker or nominee Page 5 For this type of account: Gyve name and EIN of: 14. Account with the Department of The public entity Agriculture In the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments 15. Grantor trust filing under the Form The trust 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B)) ' List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person's number must be furnished, ' Circle the minor's name and furnish the minor's SSN. 3 You must show your individual name and you may also enter your business or DBA name on the "Business name/disregarded entity" name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN. List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special ales for partnerships, earlier, 'Note: The 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, 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 t -800-908-4490 or submit Form 14039, For more information, see Pub. 5027, Identity Theft Information for Taxpayers. Victims of identity theft who are experiencing economic harm or a systemic 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 TTY/TDD 1-800-829-4059. Protect yourself from suspicious emalis or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails 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. Form W-9 (Rey. 11-2017) Page 6 Th IRS d eoes not initiate contacts with taxpayers via emaits. 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�irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emaits to the Federal Trade Commission at spam@uce.gov or report them at www. ffc.gov/complaint. You can contact the FTC at www.ftc.goWidtheft or 877-IDTHEFT (877-438-4338). If you have been the victim of identity theft, see www.identilyTheft.gov and Pub. 5027. Visit www.irs.gov/ldentityThefi 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 EISA. The person collecting this form uses the Information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving 11 to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and 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 terrorism. 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 Return to: OSC Support Services Center Address: 1410 Mail Service Center Raleigh, NC 27699-1410 Email: osc,support, servicesciiosc.nc. ov Telephone: 919-707-0795 HlldUl III SCI II l7 Vendor Electronic Payment Form Jr '` ❑ New Add Request " . ''_ ❑ Change/Update Existing Account �� ❑ Inactivate Existing Account - *Denotes a required field The State of North Carolina offers payees the opportunity to receive payments electronically through U.S. based banks. In addition to having the funds deposited electronically, you will also receive remittance information by e-mail. 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 5 1 6 1 6 1 0 1 0 0 3 2 4 -PAYEE NAME New Hanover County *REMITTANCE ADDRESS 230 Government Center Drive Ee 165 (AS PRINTED ON STREET SUITE/ROOM # YOUR INVOICE) Wilmington NC 28403 CITY STATE ZIP CODE CONTACT Teresa Hewett, Grants & Project Analyst 910-798-7408 NAME & TITLE PHONE NUMBER NEW FINANCIAL INFORMATION *FINANCIAL INSTITUTION NAME: *NAME ON ACCOUNT: *NEW ROUTING NUMBER: *NEW ACCOUNT NUMBER: *ACCT TYPE: *REMIT E-MAIL ADDRESS Branch Banking & Trust New Hanover County 0 1 5 1 3 1 11 0 1 1 .11 2 1 01 "1 01 51 11 01 81 11 71 11 31 21 6 ■ Savi thewett@nhcgov.com New add requests MUST include contact information for the state agency with which you are doing business. *Agency Name: Division of SOII & Water *Agency Contact Name: David Williams *Agency Contact Email Address: *Agency Contact Phone Number: David.B.WiIIiams@ncagr.gov 919-715-6103 PRIOR FINANCIAL INFORMATION (only required for updates) FINANCIAL INSTITUTION NAME: NAME ON ACCOUNT: ROUTING NUMBER: ACCOUNT NUMBER: ACCT TYPE: Savinqs REMIT E-MAIL 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, and the requirements of the Office of Foreign Assets Control (OFAC). I affirm the entire amount of the payment will not be transferred to a foreign bank account. ❑I authorize the Office of the State Controller to initiate ACH payments, and if necessary, adjustments for any ACH payments in error, to the financial institution and account identified on the attached certification document. This authority will remain in effect until i, the vendor, cancel it in writing or the authority is terminated by the NC Office of the State Controller. I have attached a copy of a current voided check, current bank statement or included a bank letter on bank letterhead. *PRINT NAME: Lisa Wurtzbacher, Chief Financial Officer *DATE: t. *SIGNATURE: *PHONE NUMBER: 910-798-7187 Revised May 2018 Instructions * Denotes a required field on the form 1. `Check the appropriate box at the top of the form: ■ New Add Request — Vendor would like to begin receiving payments via ACH. • Change/Update Existing Account — Vendor's account number, routing number, or remittance email address has changed. ■ Inactivate Existing Account — Vendor no longer wants to receive payments via ACH. 2. Enter the vendor's Tax Identification Number or Social Security Number. 3. *Enter the Payee Name —The name of the person or business receiving payment. 4. "Enter the vendor's remittance address. The remittance address is the address printed on your invoice where payments should be sent. 5. 'Enter the vendor's contact name, title, and phone number. 6. `Enter the vendor's financial information: ■ Financial Institution Name — Name of the financial institution. ■ Name on Account — The account owner's name. • Routing Number — Nine -digit number identifying the financial institution. ■ Account Number — The bank account number where the funds should be deposited. ■ Account Type — Is this a checking or savings account? Check the appropriate box. ■ Remit E-mail address - Enter the email address to which the remittance advices should be sent. 7. 'For a new add request only, provide the following: ■ Agency Name — The state agency the vendor is doing business with. { Agency Contact Name — The vendor's contact person name at the state agency. • Agency Contact Email Address — The contact person's email address at the state agency. Agency Contact Phone Number -- The contact person's phone number at the state agency. NOTE: New add requests MUST include contact information for the state agency with which you are doing business. 8. Prior Financial Information —this is required if the vendor's bank account, routing number, or remittance email address has changed. • Financial Institution Name — Name of the financial institution. ■ Name on Account — The account owner's name. • Routing Number — Nine -digit number identifying the financial institution. ■ Account Number — The bank account number where the funds should be deposited. ■ Account Type — Is this a checking or savings account? Check the appropriate box. ■ Remit E-mail address - Enter the email address to which the remittance advices should be sent. *Review all the information in the 3 attestation boxes located above the signature area. All 3 boxes must be checked — otherwise the form will not be processed. 10. *Print Name —Print the name of the authorized signee on the form. "Date — Date of signature. 'Signature — The authorized signee's signature. *Phone Number—The authorized signee's phone number. Return to: OSC Support Services Center Address: 1410 Mail Service Center Raleigh, NC 27699-1410 Email: osc.su ort.services osc.nc. ov Please allow up to 30 days for processing. Revised May 2018