FY22 DSS NCPRO ERA1 contractDocuSign Envelope ID: 7449AA08-3D32-4BOD-B46F-ED52923AEF63
New Hanover County Contract #22-0091
EMERGENCY RENTAL ASSISTANCE PROGRAM
Agreement # ERAl-2021-0009
THIS Agreement is hereby entered into by and between the North Carolina Pandemic Recovery Office (NCPRO), under the
auspices of Office of State Budget and Management, OSBM, (the "AGENCY'), and New Hanover County, NC, (the
"RECIPIENT' ). The parties mutually agree to the terms and conditions set forth herein.
WHEREAS, NCPRO, an agency of the Office of State Budget and Management ("OSBM'), was designated by OSBM to
accept and administer funds from the federal COVID-19 pandemic relief funds under Section 501 of Division N of the
Consolidated Appropriations Act, 2021, Pub. L. No. 116-260 (Dec. 27, 2020) (referred to herein as "Section 501'); and
WHEREAS, North Carolina Session Law 2021-25, Senate Bill 172 An Act To Establish The State Fiscal Recovery Reserve And
Fund, Coronavirus Capital Projects Reserve And Fund, And Local Fiscal Recovery Reserve And Fund To Maintain Funds Paid To
The State From The Coronavirus State Fiscal Recovery Fund, Coronavirus Capital Projects Fund, And Coronavirus Local Fiscal
Recovery Fund; To Appropriate Funds From The Local Fiscal Recovery Fund For Distribution To Non -Entitlement Units Of
Local Government; To Appropriate Certain Federal Grant Funds Provided To The State Under The American Rescue Plan Act;
And To Make 'Technical And Other Changes reserves or allots a maximum amount of Emergency Rental Assistance to the
RECIPIENT and shall manage those funds in accordance with local priorities and federal requirements; and
WHEREAS, the parties enter into this Agreement to memorialize their understanding of the mutual advantages of this
cooperative relationship;
NOW, THEREFORE, the parties agree to the terms and conditions set forth below:
1. EFFECTIVE TERM
This Agreement shall be effective starting July 1, 2021 and shall terminate on December 31, 2022.
2. RECIPIENT'S DUTIES
The RECIPIENT understands and agrees that the funds disbursed under this award may only be used for the purposes set
forth in Section 501 of Division N of the Consolidated Appropriations Act, 2021, Pub. L. No. 116-260 (Dec. 27, 2020)
(referred to herein as "Section 501'1 and any revisions made, and guidance issued thereto.
The RECIPIENT shall provide the activities as authorized and referenced in the North Carolina Session Law 2021-25, Senate
Bill 172 An Act To Establish The State Fiscal Recovery Reserve And Fund, Coronavirus Capital Projects Reserve And Fund, And
Local Fiscal Recovery Reserve And Fund To Maintain Funds Paid To The State From The Coronavirus State Fiscal Recovery
Fund, Coronavirus Capital Projects Fund, And Coronavirus Local Fiscal Recovery Fund; To Appropriate Funds From The Local
Fiscal Recovery Fund For Distribution To Non -Entitlement Units Of Local Government; To Appropriate Certain Federal Grant
Funds Provided To The State Under The American Rescue Plan Act; And To Make Technical And Other Changes to administer
the Emergency Rental Assistance Program. Funds will be used to provide rental and/or utility assistance payments, housing
stability services to families in New Hanover County, North Carolina adversely affected by the pandemic, thereby placing them
at risk of eviction from rental housing.
The RECIPIENT is responsible for completing ERA Grant Scope of Work (Form A-1) and NC PRO ERA Budget (Form A-
2) found in Appendix I and II of this Agreement and the Federal Funding Accountability and Transparency Act (FFATA)
Certification found in Appendix Til and submitting these Forms to NCPRO within 14 days of signing this Agreement.
The RECIPTENT agrees to use the funds in the amounts allocated for the budget cost items set forth in the RECIPIINI''s
budget. See Appendix II,
ORIGINAL
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The RECIPIENT understands and acknowledges that these are federal funds and the total funding level available under this
Agreement will not exceed 1;8-607365.20. Appendix I and Appendix II provides scope of work and budgeted amounts to be
paid to RECIPIENT.
The RECIPIENT understands that 65% of these federal funds must be obligated by September 30, 2021 to prevent
reallocation by the U.S. Treasury.
The RECIPIENT understands and acknowledges required compliance with all statutory provisions outlined in:
a. The Consolidated Appropriations Act, 2021, P.L. 116-260 (December 27, 2020) referred herein as "the Act".
b. Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform
Guidance) promulgated by the United States Office of Management and Budget sections: 2 C.F.R. 200.303 regarding
internal controls, 2 C.F.R. 200.330 through 200.332 regarding subrecipient monitoring and management, and subpart F
regarding audit requirements; and
C. Guidance issued by the United States Department of Treasury during the term of this Agreement; and
d. The RECIPIENT agrees to establish data privacy and security requirements as required by Section501 (g) (4) of the Act;
and
e. Pursuant to Executive Order 13043, 62 FR 19217 (April 8, 1997), the RECIPIENT is encouraged to adopt and enforce
on-the-job seat belt policies and programs for their employees when operating company-owned, rented or personally
owned vehicles; and
f. Pursuant to Executive Order 13513, the RECIPIENT should encourage its employees, subrecipicnts, and contractors to
adopt and enforce policies that ban text -messaging while driving, and Recipient should establish workplace safety
policies to decrease accidents caused by distracted drivers; and
g. Statutes and regulations prohibiting discrimination including the following.
• Title VI of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d et seq.) and Treasury's implementing regulations at 31
C.F.R. Part 22, which prohibit discrimination on the grounds of race, color, or national origin under programs or
activities receiving federalfinancial assistance.
• The Fair Housing Act, Tide VIII -IX of the Civil Rights Act of 1968 (42 U.S.C. § 3601 et seq.), which prohibits
discrimination in housing on the basis of race, color, national origin,sex, familial status, or disability.
• Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. § 794), which prohibits discrimination on the
basis of handicap under any program or activity receivingor benefitting from federal assistance.
• The Age Discrimination Act of 1975, as amended (42 U.S.C. §§ 6101 et seq.) and Treasury's implementing
regulations at 31 C.F.R_ Part 23, which prohibit discriminationon the basis of age in programs or activities receiving
federal financial assistance; and
• The Americans with Disabilities Act of 1990, as amended (42 U.S.C. §§ 12101 et seq.), which prohibits
discrimination on the basis of disability- under programs, activities, and services provided or made available by state
and local governments or instrumentalities oragencies thereto.
The RECIPIENT agrees that it will maintain in effect a Conflict of Interest policy. The RECIPIENT and subrecipients shall
disclose in writing to NCPRO, as appropriate, any potential conflict of interest affecting the awarded funds in accordance with
2 C.F.R § 200.112_ The RECIPIENT agrees to submit'the RECIPIENTS policy surrounding conflict of interest within 14
calendar days of execution of this Agreement.
The RECIPIENT understands that if the funds have been allocated to a nonprofit corporation or a contractor, and the use of
funds by the nonprofit corporation or contractor is disallowed by federal law, the nonprofit corporation or contractor shall
return the amount of funds allocated to nonprofit corporation to OSBM.
'T'he RECIPIENT agrees to provide any necessary information as required by the Federal Funding Accountability and
Transparency Act. See Appendix III.
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The RECIPIENT understands that any publications produced with funds from this award must display the following
language: "This project [is being] [was] supported, in whole or in part, by federal award number F..RA0019 awarded to the
State of North Carolina by the U.S. Department of the Treasury."
3. AGENCY'S DUTIES & STATUS REPORTING
The AGENCY shall ensure that funds allocated and disbursed pursuant to Session Law 2021-25, comply with the intent
and guidance found in this Law and ensure compliance with related federal and state statutes and financial management
standards. Additionally, the RECIPIENT agrees to allow NCPRO to work with the RECIPIENT database
administrator to collect detail transaction information supporting the expenditures from these funds.
i. Invoice and Payment. The AGENCY shall advance one-fourth of the grant amount, 1 $2.151.841.30, within ten
business days after execution of this Agreement After the initial payment is provided to the RECIPIENT, the
RECIPIENT shall submit disbursement requests every month.
ii. The RECIPIENT shall submit the final disbursement request to be received by the AGENCY by September 15,
2022.
iii- On or before October 31, 2022 the RECIPIENT will submit the final outcome and accomplishment reports (see
Appendix VI).
iv. The AGENCY reserves the right to withhold, reduce, or delay disbursement of the payments noted above, if the
disbursement requests are not submitted, are not complete or do not include adequate attached documentation that
can verify disbursement. The AGENCY must provide the RECIPIENT with a written explanation of the business
reasons to delay, alter, or reject disbursement payments that have been invoiced to the AGENCY. The RECIPIENT
has three (3) business days after such AGENCY communication to respond to address the item(s) of concern. The
AGENCY is to communicate a final review within three (3) business days of such RECIPIENT response.
Administrative Costs
a. The RECIPIENT may use funds provided to the RECIPIENTto cover both direct and indirect costs.
b. The total of all administrative costs, whether director indirect costs, may not exceed 10 percent of the total amount
of the total award or $860,736.52.
c. SB 172 stipulates that 10% of the total award may be used for a program hotline, housing stability services and
administrative costs with no more than 5% of these funds used for administrative costs.
4. FUNDS MANAGEMENT
The RECIPIENT also agrees to operate all transactions from these funds x ithin a special revenue account that is not
commingled with other funds to prevent the accidental inclusion of transactions not related to the Emergency Rental
Assistance grant.
5. POST -GRANT AWARD DOCUMENTATION REQUIREMENTS
RECIPIENT shall comply with all rules and reporting requirements established by the requirements of 9
N.C.A.C. Subchapter 3M.0205. The RECIPIENT agrees to submit the ERA Grant Project Status Report (Appendix
IV) to the AGENCY every Friday during the tern of this Agreement The RECIPIENT further agrees to submit the
Outcomes and Accomplishments Final Report (APPENDIX VI) to the AGENCY no later than October 31, 2022 or
within forty-five (45) days of fuial expenditure date, whichever is earlier.
The above noted reports shall include RF,CIPIENI' reporting information related to the above noted quantitative results
and accomplishments. RECIPIENT agrees that all program activity results information reported shall be subject to
review and authentication as described in Section 7 and RECIPIENT will provide access to work papers, receipts,
invoices, and reporting records, if requested by the .AGENCY, as the AGENCY executes any internal audit
responsibilities.
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6. AGREEMENT ADMINISTRATORS
All notices permitted or required to be given by one Party to the other and all questions about the Agreement from one
Parry to the other shall be addressed and delivered to the other Party's Agreement Administrator.
The name, post office address, street address, telephone number, fax number, and email address of the Parties'
respective initial Agreement Administrators are set out below. Either Party may change the name, post office address,
street address, telephone number, fax number, or email address of its Agreement Administrator by giving timely written
notice to the other Party.
For the AGENCY
IF DELIVERED BY US POSTAL SERVICE
IF DELIVERED BY ANY OTHER MEANS
Stephanie McGarrah
Stephanie McGarrah
North Carolina Pandemic Recovery Office
North Carolina Pandemic Recovery Office
MSC 20320
430 N. Salisbury Street
Raleigh, NC 27699-0320
Raleigh, NC 27603
Direcr. 98_4-202-4267
Direct: 984-202-4267
Email: Ste phanie..mc,,arrah(@/osbm.nc.l:ov
Email: Stephanie.mcr,,rrahr,tiosbm.nc._*ov
For the RECIPIENT
IF DELIVERED BY US POSTAL Sl:sRVICE
IF DELIVERED BY ANY OTHER MEANS
tiame: Chris Coudtiet
.Tame: Chris Coudriet
Title: New Hanover County Manager
Title: New Hanover County Manager
Address: 230 Government Center Drive, Suite 195
address: 230 Goverment Center Drive, Suite 195
11'Inington, NC 28403
''iltnington, NC 28403
Direct: 910-798-7184
ii-)irect: 910-798-7184
Email: ccoudriet@nhcgov.com
�F_rnail: ccoudriet@nhcgov.com
7. MONITORING AND AUDITING
The RECIPIENTacknowledges and agrees that, from and after the date of execution of this Agreement and for five (5)
years following its termination, the books, records, documents, and facilities of the RECIPIENT arc subject to being
audited, inspected, and monitored at any time by the AGENCY upon its request (whether in writing or otherwise). The
RECIPIENT further agrees to provide AGENCY staff and staff of the Office of State Auditor and any federal monitor
or auditor with access to financial and accounting records and audit work papers in the possession of any auditor of any
recipient of State funding to support internal audit, financial reporting, and related requirements.
Per 9 N.C.A.C. Subchapter 3M.0205A, a recipient or subrecipient that receives, holds, uses, or expends State financial
assistance in an amount equal to or greater than five hundred thousand dollars ($500,000) within its fiscal year shall have
a single or program -specific audit prepared and completed in accordance with Generally Accepted Government Auditing
Standards, also known as the Yellow Book. Audits must be provided to the AGENCY no later than nine months after the
end of the RECIPIENT's fiscal year.
8. SITUS
This Agreement shall begoverned by the laws of North Carolina and any claim for breach or enforcement of this
Agreement shall be filed in State court in Wake County, North Carolina.
DocuSign Envelope ID: 7449AA08-3D32-4BOD-B46F-ED52923AEF63
9. SUBCONTRACTING AND ASSIGNMENT
The RECIPIENT agrees that the assigning or subcontracting of any work related to the contract to a subcontractor
requires the advance written permission of the AGENCY. The AGENCY agrees to provide a response within three (3)
days of the request. If such permission is granted, such entities shall comply with the following.
(a) The RECIPIENT is not relieved of any of the duties and responsibilities of the original Agreement; and
(b) The RECIPIENT agrees and is responsible for managing and monitoring each project, program, or activity
supported by giant funds.
(c) Any SUBCONTRACTOR agrees not to have any overdue tax debts, as defined by N.C.G.S. 105-243.1, at the
federal, state, or local level. The SUBCONTRACTOR agrees to complete the State Grant Certification found in
APPENDIX III and submit to the Agency within 30 calendar days of execution of this Agreement, as required by
North Carolina General Statute 143C-6- 23(c).
10. COMPLIANCE WITH LAW
The RECIPIENT' agrees to comply with all applicable federal and state laws, rules, and regulations in its performance of
this Agreement.
11. TERMINATION OF AGREEMENT
This agreement may be terminated by mutual consent upon sixty (60) days written notice to the other party, or as
otherwise provided by law. As soon as reasonably possible following termination of this agreement, the amount of any
residual unexpended funds shall be transferred to the AGENCY.
12. AMENDMENTS
This Agreement may be amended in writing which documents approval of changes by both the AGFNCY and the
RECIPIENT.
13. AGREEMENT CLOSE-OUT PROCESS
The RECIPIENT agrees to submit to the AGENCY a complete performance and expenditure status report (final report)
no later than October 31, 2022 or within forty-five (45) days of final incurred date, whichever is earlier. All funds not
incurred as of September 1, 2022 will be returned to the AGENCY by September 30, 2022.
The above noted reports shallinclude RECTPIRNT reporting information related to the above noted quantitative results
and accomplishments. RECIPIENT agrees that all program activity results information reported shall be subject to review
and authentication as described in Section 7 and RECIPIENT will provide access to work papers, receipts, invoices, and
reporting records, if requested by the AGENCY, as the AGENCY executes any audit internal audit responsibilities.
RECIPIENT will be deemed noncompliant if its final report is not submitted within the timeframe mentioned earlier in
Section 13 of this AGREEMENT. Once the complete final project status report package has been received and evaluated
by the AGENCY, the RECIPIENT will receive official notification of agreement close-out. The letter will inform the
RF,CIPIENT that the AGENCY is officially closing the agreement and retaining all agreement files and related material
for a period of five (5) years or until all audit exceptions have been resolved, whichever is longer.
14. AUTHORIZED SIGNATURE WARRANTY
The undersigned represent and warrant that they are authorized to bind their principals to the terms of this
agreement.
DocuSign Envelope ID: 7449AA08-3D32-4BOD-B46F-ED52923AEF63
In Witness Whereof, the RE, CIPIE and the AGENCY have executed this Agreement in duplicate originals, with one
original being retained by each party.
NEW HANOVER COUNTY, NC
OONTY.
� � f
S' e Date
JJulia Olson-Boseman ��
Chair New Hanover County- Board of Commission
Printed NaYelar- 46
Title 7 • v# •t' S.
SrANCISH£V
Chris Coudriet New Hanover County Manager
NORTH CAROLINA OFFICE OF BUDGET AND MANAGEMENT
NORTH CAROLINA PANDEMIC RECOVERY OFFICE
DocuSigned by:
r,Lvb,S 8/5/2021
Signa re Date
Charles Perusse State Budget Director
Printed Name Title
Approved as to fomVCo my Attomey
'i
1
Os13M/NCPR0 - Agreement
orbs ('�'3 16-
Co
DocuSign Envelope ID: 7449AA08-3D32-4BOD-B46F-ED52923AEF63
Appendix I
ERA Grant Scope of Work (Form A-1)
Before it will be possible to finalize this award and make any disbursement, you are required to provide to the Agency a
description for how the organization will spend the amount of funding allocated for the specific purpose as stated in the
Agreement. This will include completing the following:
1. Organization Section of this Document
2. Scope of Work Section of this Document
3. The Budget for Recipient in Appendix A-2
1. Organization:
Organization Name: New Hanover County, NC
Organization Fiscal Year End: June 30
2. Scope of Work:
Recipient shall detail below how the organization will spend the amount of funding allocated for the specific purpose as
stated in the Agreement. The description should include activities to be provided, objectives to be achieved, and
expected results. The description should also include anticipated timing of those activities, objectives and expected
results. Contractor's budgeted amounts and description of work with the activities, objectives, and expected results
are to be provided within fifteen (15) days of contract approval. The following documents must also be provided -
Emergency Rental Assistance Program Policies and Procedures, Outreach/Communication Plan and Program
Compliance Plan.
As required by Treasury, the program policies should include the collection of the following information.
• Address of the rental unit.
• Amount and percentage of monthly rent covered by ERA assistance.
• Amount and percentage of separately stated utility and home energy costs covered by ERA assistance.
• Total amount of each type of assistance provided to each household (i.e., rent, rental arrears, utilities and
home energy costs, utilities and home energy costs arrears, and other expenses related to housing
incurred due directly or indirectly to the COVID-19 outbreak).
• Amount of outstanding rental arrears for each household.
• Number of months of rental payments and number of months of utility or home energy cost payments
for which ERA assistance is provided.
• Household income and number of individuals in the household; and
• Gender, race, and ethnicity of the primary applicant for assistance.
• For landlords and utility providers, the name, address, and Social Security number, tax identification and DUNS
number.
OSBM NCPRO —Form A-1
Effective: 4/1/2021
DocuSign Envelope ID: 7449AA08-3D32-4BOD-B46F-ED52923AEF63
Appendix II: NCPRO ERA Grant
Grant Recipient's Budget (Form A-2)
Below are general expenditure descriptions that can serve as a guide for preparing the organization's budget related to the grant award. Please add rows in the budget section as needed. This form must be certified bythe signature of an authorizing
official. The certification is for both Attachment A-1 and A-2. If subcontractors' detail is not available upon contract execution, include the expenses in the "Subcontract Expenses" column.
1. General Information
2. Budget Section
Recipient Name or Employee Expenses (e.g.,
Subcontractor Name Payroll and benefits cost for
employee that are
dedicated to COVID-19)
Other Administrative
Expenses (e.g., utilities,
Contracted Labor Expenses telephone, data, lease
related expenses)
Other Expenses
(e.g., related
Rent Awards Utility Awards charges not
Housing Stability Services assigned above and
described by
recipient)
TOTAL
Expenditures Notes
Will you subgrant or
$0.00
$0.00
Contract Agreement
Total Funding Authorized by
$0.00
pass down funds to
Organization Tax ID
$0.00
Point of Contact
Point of Contact
Point of Contact
Point of Contact
NAME OF RECIPIENT ORGANIZATION:
Number
SB 172
CDFA
Term of Grant
other
Number
DUNS Number
Name:
Title:
Email
Phone Number
$0.00
organizations?
$0.00
$0.00
New Hanover County, NC
ERA -1-2021-0009
$8,607,365.20
21.023
July 1, 2021 to December 31, 2022
$0.00
$0.00
2. Budget Section
Recipient Name or Employee Expenses (e.g.,
Subcontractor Name Payroll and benefits cost for
employee that are
dedicated to COVID-19)
Other Administrative
Expenses (e.g., utilities,
Contracted Labor Expenses telephone, data, lease
related expenses)
Other Expenses
(e.g., related
Rent Awards Utility Awards charges not
Housing Stability Services assigned above and
described by
recipient)
TOTAL
Expenditures Notes
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.001
$0.001 $0.001
$0.001 $0.001 $0.001 $0.001
$0.00
DocuSign Envelope ID: 7449AA08-3D32-4BOD-B46F-ED52923AEF63
Appendix III: Federal Funding Accountability and Transparency Act (FFATA)
The State of North Carolina must report into the FFATA Subaward Reporting System which
captures and report subawards and executive compensation data regarding their first tier subawards
to meet the FFATA reporting requirements.
New Hanover County, North Carolina
Enter your DUNS Number:
Enter your 9 Digit Zip Code:
Question 1: In your business or organization's preceding completed fiscal year, did your business or
organization (the legal entity to which this specific CCR record, represented by a DUNS number,
belongs) receive (1) 80 percent or more of your annual gross revenues in U.S. federal contracts,
subcontracts, loans, grants, subgrants, and/or cooperative agreements; and (2) $25,000,000 or more
in annual gross revenues from U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or
cooperative agreements?
Question 2: Does the public have access to information about the compensation of the executives
in your business or organization (the legal entity to which this specific CCR record, represented by a
DUNS number, belongs) through periodic reports filed under section 13(a) or 15(d) of the Securities
Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of
1986?
DocuSign Envelope ID: 7449AA08-3D32-4BOD-B46F-ED52923AEF63
Appendix IV
Emergency Rental Assistance Grant Project Status Report (Form R-1)
On the first day of each month during the term of this Agreement, and before it will be possible to make any disbursement,
you are required to provide to the Agency the status towards the specific purpose as stated in the ERA Grant Scope of
Work (A-1) (Attachment 1). This report is to be completed by the grant recipient and uploaded to the link below.
https://ncosbm.sharefile.com/r-rebabb700a228473I b3cOe5cdef837398
1. Organization
Organization Name New Hanover County, North Carolina
Contract Agreement Number ERA1-2021-0009
Date
2. Financial Summary
3. Performance: The Recipient shall detail below how the organization has spent the amount of funding allocated for the
specific purpose as stated in the Agreement. The description should include all activities and progress.
Descriptive summary of how the funds were used, including specific deliverables achieved to include the
following performance information.
ance Indicators
- Number of applications received
- Number of applications approved
- Number of applications determined ineligible
- Number of rent awards
- Number of utility awards
- Number of applicants below 80%, 50% and 30% of area median income
- Number of households qualified for unemployment benefits
- Number of households demonstrating a risk of homelessness or housing instability
icant Characteristics
• Head of Household (HH) Race
• HH Ethnicity
• HH Age
• HH Gender
• HH Zip Code
• Household Size
• Traditionally undeserved groups (underserved, non-English speaking population)
OSBM NCPRO —Form R-1
Effective: 4/1/21
Page 1 of 2
Total Funding
Total Funding Authorized
Received to
Balance
Date
$8,607,365.20
3. Performance: The Recipient shall detail below how the organization has spent the amount of funding allocated for the
specific purpose as stated in the Agreement. The description should include all activities and progress.
Descriptive summary of how the funds were used, including specific deliverables achieved to include the
following performance information.
ance Indicators
- Number of applications received
- Number of applications approved
- Number of applications determined ineligible
- Number of rent awards
- Number of utility awards
- Number of applicants below 80%, 50% and 30% of area median income
- Number of households qualified for unemployment benefits
- Number of households demonstrating a risk of homelessness or housing instability
icant Characteristics
• Head of Household (HH) Race
• HH Ethnicity
• HH Age
• HH Gender
• HH Zip Code
• Household Size
• Traditionally undeserved groups (underserved, non-English speaking population)
OSBM NCPRO —Form R-1
Effective: 4/1/21
Page 1 of 2
DocuSign Envelope ID: 7449AA08-3D32-4BOD-B46F-ED52923AEF63
I certify that funds mentioned in this document were used in
accordance with Appendix I and II in the contract between the
State of North Carolina and my organization.
OSBM NCPRO —Form R-1
Effective: 4/1/21
Name:
Signature:
Title:
Phone:
Email:
Page 2 of 2
DocuSign Envelope ID: 7449AA08-3D32-4BOD-B46F-ED52923AEF63
APPENDIX V: NCPRO Emergency Rental Assistance Grant
Monthly Disbursement Request (Form R-2)
Form R-1 must accompany this form to receive funds disbursement from NCPRO.
RECIPIENT COMPLETION INFORMATION: Upload complete form to: httys:Hncosbm.sharefile.com/r.rebabb700a228473lb3cOe5cdef837398
PART A: Summary of Funding Received and Spent ■
Contract Total Funding
NAME OF RECIPIENT Agreement Authorized by HB
ORGANIZATION: Number 196 Advance
W
Disbursement Disbursement
Request #1 Request #2
Disbursement Disbursement Disbursement Disbursement Disbursement
Request #2 Request #3 Request #4 Request #5 Request #5 Total Received Point of Contact Point of Point of Contact
�- .., to Date Name Point of Contact Title: Contact Email Phone Number
Employee Expenses (e.g., Other Administrative
Other Expenses (e.g.,
Notes
Recipient Name Payroll and benefits cost for Expenses (e.g., utilities,
Utility Awards
related charges not
or Contracted Labor
employee that are dedicated telephone, data, lease
Housing Stability
assigned in herein and
TOTAL
Subcontractor Name Expenses
to COVI D-19) related expenses)
Rent Awards
Services
described by recipient)
Expenditures
Ex. eRecipientName, vendor
Ex.,RecipientName.
emto ee
Ex. «RecipientName»
5
Recipient
Ex. «RecipientName»
$ -
Subcontractor
S -
S -
S -
DocuSign Envelope ID: 7449AA08-3D32-4BOD-B46F-ED52923AEF63
Appendix VI
Emergency Rental Assistance Program Grant (Form F)
Outcomes and Accomplishments Final Report
To finalize this award, you are required to provide to the Agency with a narrative of the outcomes and accomplishments related
to the funds spent for the specific purpose as stated in the grant contract. You can use the secure link that is provided by NCPRO
to upload images, brochures, and other information to illustrate your outcomes and accomplishments. _
1. Organization:
Organization Name: INew Hanover County, North Carolina
2. Outcomes and Accomplishments:
Signed by_
Printed Name
Title
Date
OSBM NCPRO — Form F Effective: 4/1/2021