FY23 JCPC STEP PROGRAM AGREEMENT EXECUTEDDocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
WOFFAP"-
North Carolina Department of Public Safety
JCPC Program - Program Agreement
SECTION I A
SPONSORING AGENCY AND PROGRAM INFORMATION
FUNDING PERIOD:
FY 22-23
DPS/JCPC FUNDING # (cont only)
965-XXXX
COUNTY:
New Hanover
AREA:
Eastern Area
Multi -County:
No
Multi -Components
No
NAME OF PROGRAM:
Systematic Training for Effective Parenting
SPONSORING AGENCY:
Coastal Horizons Center, Inc.
SPONSORING AGENCY
615 Shipyard Blvd.
PHYSICAL ADDRESS:
Wilmington NC 28412
SPONSORING AGENCY
615 Shipyard Blvd.
MAILING ADDRESS:
Wilmington NC 28412
TYPE:
Non -Profit
(910) 202-0840 Fax: 1 (910) 202-0843 E-mail: deeanna@coastalhorizons.org
FEDERAL ID #156-0950370
Program Manager Name & Address (same person on signature page)
Name:
TOTAL COST OF
COMPONENT ID # NAME OF PROGRAM COMPONENT
PROGRAM TYPE
Mailing
Address:
EACH COMPONENT
35328 Systematic Training for Effective Parenting (STEP)
Parent/Family Skill Building $ 47,536
Zip:
Total cost of components: $ 47,536
Program Manager Name & Address (same person on signature page)
Name:
Deeanna Hale -Holland
Title:
Prevention Director
Mailing
Address:
615 Shipyard Blvd.
City:
Wilmington
Zip:
28412
Phone:
(910) 202-0840 Fax: 1 (910) 202-0843 E-mail: deeanna@coastalhorizons.org
Contact Person (if different from program manager)
Name:
Erin Ditta
Title:
Prevention Coordinator
Mailing
Address:
615 Shipyard Blvd.
City:
Wilmington
Zip:
28412
Phone:
(910) 202-0840 Fax: 1 (910) 202-0843
E-mail: editta@coastalhorizons.org
Program Fiscal Officer (cannot be program manager)
Name:
Jenifer Burns
Title:
Controller
Mailing
Address:
615 Shipyard Blvd.
City:
Wilmington
Zip:
28412
Phone:
(910) 343-0145 Fax:
E-mail: jburns@coastalhorizons.org
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION I B
PROGRAM COMPONENT DESCRIPTION
COMPONENT ID #
COMPONENT INFORMATION
35328
NAME OF COMPONENT: Systematic Training for Effective Parenting (STEP)
BRIEF DESCRIPTION: Systematic Training for Effective Parenting (STEP) is an evidence -
based skills training for parents on how to handle misbehavior, discouragement, discipline, and
the problems that face every parent -teen relationship.
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION II
COMPONENT STATISTICAL INFORMATION
Multi -Components No
Component Service Statistics
PROGRAM COMPONENT INFORMATION - APPLICATION YEAR
Component Name: Systematic Training for Effective Parenting (STEP)
Component ID #
35328
What is this component's maximum client capacity at any given time?
14
Frequency of client contact per month:
4
Anticipated Average Length of
Stay:
56
Days
y
Total Component Cost:
$47,536
- by
Estimated # to be served during funding period:
36
Estimated Average Cost Per Youth:
$1,320
Actual number of youth admitted FY 20-21:
22
Applies to
9
Number of admissions Juvenile Justice Referred
40.91 % of total admissions
continuation
0
Number of admissions Law Enforcement Referred
0% of total admissions
programs only.
0
Number of admissions District Court Referred
0% of total admissions
Actual number served FY 20-21:
24
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 01/09/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION III I COMPONENT SUMMARY
NAME OF COMPONENT: I Systematic Training for Effective Parenting (STEP)
1. Statement of the Problem: In concise terminology, describe how the program will address continuum need(s) in
the county.
The New Hanover County Juvenile Crime Prevention Council (JCPC) has listed the following as priorities to address:
Youth association with other delinquent peers or peers involved with gangs; Peer relationship problems & conflict;
Moderate to serious behavioral problems at school; Prior assaultive behavior; Involvement in alcohol and substance
use; Prior referrals to juvenile court; Referral to juvenile court prior to age 12; Inadequate supervision by parents/
guardians.
The Department of Juvenile Justice Court Counselors and Department of Social Services listed priorities of services for
parents/guardians and non-custodial parents of youth 12-17 years of age. There are no current services in the area
that meet this reach.
Systematic Training for Effective Parenting (STEP) is an evidence -based program which provides skills training for
parents dealing with frequently encountered challenges with their children. STEP emphasizes how to handle
misbehavior, discouragement, discipline, and the problems that face every parent -teen relationship. It also confronts
today's more complex issues of drug use, sex, gangs, and depression. STEP promotes a more participatory family
structure by fostering responsibility, independence, and competence in children; improving communication between
parents and children; and helping children learn from the natural and logical consequences of their own choices. The
lessons focus on how to understand child behavior and misbehavior, practice positive listening, give encouragement
(rather than praise), explore alternative parenting behaviors and express ideas and feelings, develop their child's
responsibilities, apply natural and logical consequences, convene family meetings, and develop their child's
confidence. Parents engage in role-plays, exercises, discussions of hypothetical parenting situations, and the sharing
of personal experiences.
Following the completion of the STEP program, the families (youth & parent) will participate in a four (4) hour challenge
course filled with experiential activities designed to increase the cooperation of all family members through
communication and problem solving activities. These programs help parents and youth empathize with each other and
have fun together. A family meal will also be provided with discussion on the importance of eating together as a family.
Per the National Center on Addiction and Substance Abuse at Columbia University, surveys have consistently found
that the more often children have dinners with their parents, the less likely they are to smoke, drink or use drugs, and
that parental engagement fostered around the dinner table is one of the most potent tools to help parents raise healthy,
drug-free children.
Families needing additional services will be referred to appropriate programs.
2. Target Population: Describe the target population, including age, and the steps taken to insure that the target
population is served.
Systematic Training for Effective Parenting (STEP) targets the parents of youth 12-17 years of age. Families will be
referred by:
New Hanover County Department of Juvenile Justice and Delinquency Prevention
Juvenile Attendance Counsel
Wilmington Police Department
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION III
COMPONENT SUMMARY
NAME OF COMPONENT:
Systematic Training for Effective Parenting (STEP)
School Resource Officer/ In School Suspension
Department of Social Services
Any additional community partner with troubled youth
Parent's self -referral
The referral sources get priority to the STEP program in the order stated above.
3. Program Goal(s): Provide a brief statement to describe the overall purpose of the program.
STEP is rooted in Adlerian psychology and promotes a more participatory family structure by fostering responsibility,
independence, and competence in children; improving communication between parents and children; and helping
children learn from the natural and logical consequences of their own choices. STEP teaches lessons on how to
understand child behavior and misbehavior, practice positive listening, give encouragement (rather than praise),
explore alternative parenting behaviors and express ideas and feelings, develop their child's responsibilities, apply
natural and logical consequences, convene family meetings, and develop their child's confidence. Parents engage in
role-plays, exercises, discussions of hypothetical parenting situations, and the sharing of personal experiences.
The goals of Systematic Training for Effective Parenting (STEP) are:
-Increased encouragement skills
-increased skill in communication
-Increased skill in cooperation (parental and child)
-Increased skill in discipline
-Increased skill in choosing parenting approach
-Increase child self-esteem and confidence
-Decreased inappropriate parental behaviors in disciplining children and teens
4. Measurable Objective(s): State in measurable terms (%) the intended effect of the program on specific
undisciplined and/or delinquent behaviors. Example: anticipated reductions in court referrals, runaway behavior,
disruptive behavior at school, anticipated improved school attendance and academic achievement. These objectives
must include impact on participants.
70% Clients will successfully or satisfactorily complete services as intended by the program design/service plan.
70% Clients will have no new adjudications for a complaint with an offense date after the admission date.
70% Clients will have no new complaints with an offense date after the admission date.
70% Clients successfully/satisfactorily completing the program will have no new complaints in the 12 months following
completion.
70% Parents and/or families will actively participate in skill building activities as intended by the program design/
service plan.
70% Clients will demonstrate improvement in targeted skills identified in the individual service plan.
70% Clients and families will demonstrate enhanced family functioning as a result of program services.
70% Clients successfully/satisfactorily completing the program will have no new adjudications in the 12 months
following completion.
70% Clients will reduce specific problem behaviors presented at referral and targeted in the individual service plan.
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION III
COMPONENT SUMMARY
NAME OF COMPONENT: I Systematic Training for Effective Parenting (STEP)
5. Elevated Risks and Needs: Describe how program services will address one or more of the elevated risk and
needs listed in the most recent JCPC Request for Proposal.
Per the New Hanover County Juvenile Crime Prevention Council (JCPC) has listed the following as priorities to
address: Youth association with other delinquent peers or peers involved with gangs; Peer relationship problems &
conflict; Moderate to serious behavioral problems at school; Prior assaultive behavior; Involvement in alcohol and
substance use; Prior referrals to juvenile court; Referral to juvenile court prior to age 12; Inadequate supervision by
parents/guardians.
The Department of Juvenile Justice Court Counselors and Department of Social Services listed priorities of services for
parents/guardians and non-custodial parents of youth 12-17 years of age. There are no current services in the area
that meet this reach.
Systematic Training for Effective Parenting (STEP) is an evidence -based program for parents of teens, which provides
skills training for parents dealing with frequently encountered challenges with their children. STEP emphasizes how to
handle misbehavior, discouragement, discipline, and the problems that face every parent -teen relationship. It also
confronts today's more complex issues of drug use, sex, gangs, and depression.
STEP is presented in a group format, with optimal group sizes ranging from 6 to 14 parents. The parents will meet the
first night to complete paperwork and receive any additional logistical information. The parents will then be guided
through seven interactive lessons, each 1.5 hour in length. These lessons include information on understanding child
behavior, parent behavior, positive listening, giving encouragement, development of a child's responsibilities and
confidence, consequences, and family meetings. Parents engage in discussions, role-plays, and share personal
experiences.
The Challenge Course experience will provide experiential activities for the family to take initiative, make decisions,
and be accountable for the results. The families will have the opportunity to engage intellectually, creatively,
emotionally, socially or physically. This learning experience will provide the opportunity to learn from natural
consequences, mistakes, and successes. Parents and youth will have the opportunity to reflect on the experiences
through a positive environment to increase knowledge, develop skills, and clarify values.
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION IV
COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Systematic Training for Effective Parenting (STEP)
1. Location: List physical address(es) and describe where program services are delivered.
Office:
Coastal Horizons
Prevention Services
330 Shipyard Blvd., Ste B
Wilmington, NC 28412
Program:
Wilmington Health Access for Teens of Coastal Horizons
4005 Oleander Dr
Wilmington, NC 28403
Challenge Course:
Coastal Horizons
Adventure Learning Center
3837 Juvenile Center Dr
Castle Hayne, NC
2. Operation: Describe the daily/weekly schedule of program operation.
STEP will be conducted once a week for eight consecutive weeks, during the duration of the program. Duration of the
STEP program does not match the SPEP parameters. To increase client contact hours, the hours for each session will
increase to 2 hours. This will allow for a total of 19.5 hours. (1) 1.5 hour introduction day, (7) 2 hour program sessions,
(1) 4 hour family day. If the family is not meeting the minimum of 15 hours during the scheduled session time, program
staff will meet with them to help fulfill the required 15 hours.
Programs will be held at the location listed previously. The facilities will include audio equipment, meeting rooms and
tables and chairs. Drinks and dinner will be provided to the parents.
Following the completion of the STEP program, the families (youth & parent) will participate in a four (4) hour challenge
course filled with experiential activities designed to increase the cooperation of all family members through
communication and problem solving activities. These programs help parents and youth empathize with each other and
have fun together. A family meal will also be provided with discussion on the importance of eating together as a family.
3. Staff Positions: Describe paid or volunteer position qualifications, (certifications, degrees, work experience) and
position(s) responsibilities relative to this component.
Erin Ditta, CSAPC, Prevention Coordinator has worked with Coastal Horizons Center for 18 years. Erin is a Certified
Substance Abuse Prevention Consultant through the NC Substance Abuse Professional Practice Board. Erin is trained
and has facilitated multiple evidence -based programs. Erin will be responsible for supervising and assisting in the
organization of the program, assist with coordination and implementation of the program and overseeing the grant
requirements.
Deeanna Hale -Holland, MA, CSAPC, Prevention Director has worked with Coastal Horizons Center for over 30 years.
Deeanna is a Certified Substance Abuse Prevention Consultant through the NC Substance Abuse Professional
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION IV
COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Systematic Training for Effective Parenting (STEP)
Practice Board. Deeanna is trained and has facilitated multiple evidence -based programs. Deeanna will assist with the
supervision of the program and overseeing the grant requirements.
Meredith Ross, CSAPC< Prevention Coordinator has worked with Coastal Horizons for 20 years. Meredith is a
Certified Substance Abuse Prevention Consultant through the NC Substance Abuse Professional Practice Board.
Meredith is trained in the STEP curriculum and has facilitated multiple evidence -based programs. Meredith will assist
with the supervision of the facilitation staff, John Dail.
John Dail has worked with Coastal Horizons Center for more than 36 years. John is a Certified Substance Abuse
Counselor. His role with the program will be to facilitate the STEP program.
Heather Boike prevention specialist to assist with program logistics and paperwork.
Child Care professional to provide onsite child care.
4. Service Type SPEP: Describe implementation to include:
Primary Service: Social Skills Training; Secondary Service: None
Evidence -Based Program Name: Systematic Training for Effective Parenting (STEP)
Target Weeks: 8; Target Hours: 15
5. Admission Process: Describe the specific referral, screening, admission process (including timeline), the staff
responsible for making decisions about admissions and reasons why a referral may not be accepted.
Court counselors, case managers and school personnel will complete the Universal JCPC Referral form and
fax it to the STEP staff member, John Dail. John Dail will follow-up with referring agency to obtain any necessary
information or additional questions regarding family needs. John Dail will contact families upon receipt of their referral
to address any questions participants may have regarding the program, and provide date, time, and location of the
program. Parents/guardians sign a consent form; release of confidential information and HIPAA; parents complete
participant information/medical form. Client tracking forms are completed on the family entering the STEP Program and
upon completion of the program; a monthly progress report is completed for all participants and submitted to the
referring court counselor, case manager or school personnel until program completion.
6. Termination Process: Describe the termination process to include the staff responsible for making decisions and
the criteria for a successful termination, satisfactory termination, unsuccessful completion and non-compliant
termination.
Termination occurs in two ways: when the participant completes all sessions of the STEP program and Challenge
Course Day or if the participant misses more than two sessions. Participants will be successfully terminated once the
post survey is completed or upon referral to other services by their court counselor, school personnel or referral
source. Participants will receive a certificate of accomplishment at graduation. Within one month of completion, a
phone call will be made to the parent and referral agent to follow up. Participants who do not complete 70% or more
sessions due to non-compliance with their probation, diversion or school contract will result in a less than successful or
unsatisfactory termination. Referring agencies will be notified of client compliance or non-compliance throughout the
program and receive a letter of termination at the completion of the program.
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION IV
COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Systematic Training for Effective Parenting (STEP)
How is the referring agency involved with the termination process?
The Prevention Specialist contacts the referring agency to notify them of their client's termination status. Referring
agency will provide any additional progress notes needed.
7. Referring Agency Interaction: Describe the interaction with juvenile court counselors and/or other referring
agencies including how client progress will be communicated.
The STEP staff will regularly inform the referring agencies and community partners of upcoming sessions through
emails, flyers, community meetings, etc.
The STEP staff will regularly inform the referring agency of the participant's attendance, progress, and completion of
the program. Referral agents will receive a letter of client acceptance to the program and a letter of client termination.
Prevention staff will maintain regular contact with court counselors, case managers or school personnel. Parents are
encouraged to contact the program for follow-up discussions as needed. Referrals come through the Juvenile Court
Counselors, DSS case managers, School Principals/Counselors and other community partners and parent self -referral.
8. Intervention/Treatment: Describe specifically what the component will do to redirect inappropriate youth behavior
or how the component will address the identified needs of the youth and family. What interventions will typically be
utilized in this component and how will parents/guardians be involved?
Systematic Training for Effective Parenting (STEP) provides skills training for parents dealing with frequently
encountered challenges with their children that often result from autocratic parenting styles. STEP is rooted in Adlerian
psychology and promotes a more participatory family structure by fostering responsibility, independence, and
competence in children; improving communication between parents and children; and helping children learn from the
natural and logical consequences of their own choices.
STEP is presented in a group format, with optimal group sizes ranging from 6 to 14 parents. The program is typically
taught in 7 weekly, 1.5 -hour study groups facilitated by a counselor, social worker, or individual who has participated in
a STEP workshop. Using the STEP multimedia kit (including the Leader's Resource Guide, Parent's Handbook, DVDs,
and an 11 -point drug prevention educational component), the leader teaches lessons to parents on how to understand
child behavior and misbehavior, practice positive listening, give encouragement (rather than praise), explore alternative
parenting behaviors and express ideas and feelings, develop their child's responsibilities, apply natural and logical
consequences, convene family meetings, and develop their child's confidence. Parents engage in role-plays,
exercises, discussions of hypothetical parenting situations, and the sharing of personal experiences. Videos
demonstrate the concepts covered each week with examples of ineffective and effective parent-child interactions.
From the NREPP/SAMHSA website (http://legacy.nreppadmin.net/Viewlntervention.aspx?id=132#divContacts)
Sessions address the important issues of: Understanding Yourself and Your Teenager
Changing Your Response to Your Teen
Communicating Respect and Encouragement
Encouraging Cooperation and Solving Problems
Using Consequences to Build Responsibility
Deciding What to Do -Part I & II
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION IV
COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Systematic Training for Effective Parenting (STEP)
STEP/Teen not only helps parents with everyday problems such as messy rooms, moods, and meals, it also confronts
today's more complex issues -drug use, sex, gangs and depression.
From the STEP Publishers website (http://www.steppublishers.com/products/stepteen-kit)
STEP is not intended for therapy or treatment services, the program is appropriate for families who could benefit from
an educational program.
9. Best Practice Model: Describe what model or evidence-supported/best practice the program is based upon.
Systematic Training for Effective Parenting (STEP) provides skills training for parents dealing with frequently
encountered challenges with their children that often result from autocratic parenting styles. STEP is rooted in Adlerian
psychology and promotes a more participatory family structure by fostering responsibility, independence, and
competence in children; improving communication between parents and children; and helping children learn from the
natural and logical consequences of their own choices. Although STEP was designed for use with parents facing
typical parenting challenges, all the studies reviewed for this summary targeted families with an abusive parent,
families at risk for parenting problems and child maltreatment, or families with a child receiving mental health treatment.
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION V Terms of Agreement
This Agreement is entered into by and between Department of Public Safety (hereinafter referred to as DPS), and New
Hanover County, (hereinafter referred to as the County), the County's Juvenile Crime Prevention Council (hereinafter
referred to as the JCPC) and Coastal Horizons Center, Inc. (hereinafter referred to as the Sponsoring Agency).
DPS, the County, the JCPC and the Sponsoring Agency do mutually agree as follows:
Term of Agreement
This Agreement shall become effective Jul 1, 2022 and shall terminate Jun 30, 2023.
Payment to Sponsoring Agency
All parties agree that services will be delivered as described in the approved Program Agreement and that funds will be
disbursed in an amount not to exceed the amount $39180 for the term of this agreement, unless amended by an
approved Program Agreement Revision.
Availability of Funds:
All parties to this Agreement agree and understand that the payment of the sums specified in this Program Agreement
budget, or most recently approved Program Agreement Revision, is dependent and contingent upon and subject to the
appropriation, allocation, and availability of funds for this purpose to DPS.
Responsibilities of the Parties
DPS shall:
1. Disburse funds monthly to County Governments, for payment to the Sponsoring Agency, from funds appropriated
by the General Assembly;
2. Reserve the right to suspend payment to the County for any non-compliance of reporting requirements by the
Sponsoring Agency set forth in the DPS JCPC Policy;
3. Immediately notify, in writing, the JCPC, County, and Sponsoring Agency (including the Board of Directors, if
applicable), if payments are suspended and again once payments resume;
4. Pay only for work as described in the Program Agreement, or most recently approved Program Agreement
Revision, provided by the Sponsoring Agency and approved subcontractors;
5. Provide technical assistance, orientation, and training to the Sponsoring Agency, the County and the JCPC;
6. Monitor the Sponsoring Agency's funded program(s) in accordance with DPS JCPC Policy 3. Operations: Program
Oversight and Monitoring; and
7. Notify parties entering into this Agreement of all due dates in a timely manner in order for reports to be submitted by
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371 C
the established due dates.
The Sponsoring Agency shall:
1. Comply with all laws, ordinances, codes, rules, regulations, and licensing requirements that are applicable to the
conduct of its business, including those of Federal, State, and local agencies having jurisdiction and/or authority;
2. Comply with all Federal and State laws relating to equal employment opportunity;
3. Keep as confidential and not divulge or make available to any individual or organization without the prior written
approval of DPS any information, data, instruments, documents, studies or reports given to or prepared or assembled
by the Sponsoring Agency under this Agreement;
4. Acknowledge that in receiving, storing, processing or otherwise dealing with any confidential information, it will
safeguard and not redisclose the information, except as otherwise provided in this Agreement;
5. Comply with the DPS JCPC Policy and North Carolina Administrative Code procedures;
6. Secure local match, if applicable, pursuant to 14B NCAC 11 B.0105, for the approved DPS funds;
7. Create and adopt individualized written agency guidelines specific to the funded program, while also adhering to
DPS JCPC Policy for the specific funded program type;
8. Ensure that state funds received are spent in accordance with the approved Program Agreement, or most recently
approved Program Agreement Revision, and be accountable for the legal and appropriate expenditure of those state
funds;
9. Maintain reports, records, and other information to properly document services rendered and outcomes; also
maintain an ability to send and receive electronic communication;
10. Have the capacity to use the DPS electronic, internet-based system for tracking clients served; also maintain an
ability to electronically sign required DPS documents;
11. Use generally accepted accounting procedures that guarantee the integrity of the expenditure of funds, and
maintain reports, records, and other information to properly account for the expenditure of all State funds provided to
the Sponsoring Agency;
12. When refunds are requested from the North Carolina Department of Revenue for sales and/or use taxes paid by
the agency in the performance of the Program Agreement, or most recently approved Program Agreement Revision,
as allowed by NCGS § 105-164.14(c), the agency shall exclude all refundable sales and use taxes from reportable
expenditures submitted to the County and DPS;
13. Submit Program Agreement Revisions, Third Quarter Accounting, Final Accounting, and annual detailed
expenditures through NCALLIES. These reports must be in accordance with the submission process as outlined in the
DPS JCPC Policy and with the due dates established by DPS;
14. Make personnel, reports, records and other information available to DPS, the County, the JCPC, and/or the State
Auditor for oversight, monitoring and evaluation purposes;
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
15. Submit any other information requested by DPS, the County, the JCPC, and/or the State Auditor;
16. Be responsible for the performance of all subcontractors as described in the Program Agreement or most recently
approved Program Agreement Revision;
17. Indemnify, defend, and hold harmless DPS, the State of North Carolina, the County, the JCPC and any of their
officers, agents and employees, from any claims of third parties arising out of any act or omission of the Sponsoring
Agency in connection with the performance of the Program Agreement or most recently approved Program Agreement
Revision;
18. Receive written permission and budgetary approval from DPS prior to using the Program Agreement, or most
recently approved Program Agreement Revision, as a part of any news release or commercial advertising, and
acknowledge DPS funding in partnership with the County;
19. Comply with DPS JCPC Policy 6: Operations: Program Eligibility for Funding regarding any trainings and
requirements for the United States Department of Justice national standards to prevent, detect, and respond to prison
rape under the Prison Rape Elimination Act (PREA) and any additional requirements in 14B NCAC 11 C
20. Be deemed an independent contractor in the performance of services described in the Program Agreement, or
most recently approved Program Agreement Revision, and as such shall be wholly responsible for the services to be
performed and for the supervision of its employees, interns, volunteers and subcontractors; and
21. Represent that it has, or shall secure at its own expense, all personnel required in performing the services as
described in the Program Agreement, or most recently approved Program Agreement Revision. Such personnel shall
not be employees of or have any individual contractual relationship with DPS.
Sponsoring Agency and Use of Contractor(s)/Subcontractors
The Sponsoring Agency may engage with independent contractors as needed to perform services or support services
described in line item 190 the Program Agreement, or most recently approved Program Agreement Revision. When
independent contractors are providing services the Sponsoring Agency must:
22. Upload a signed Contract for Professional Services (Form JCPC/PO 001 Contract for Professional Services
Template) into NCALLIES once the Program Agreement or Program Agreement Revision is approved by DPS;
23. Be responsible for the performance of all contractors or subcontractors as described in the Program
Agreement, or most recently approved Program Agreement Revision;
24. Hold any contractor or subcontractor to which the Sponsoring Agency provides State funds accountable for
the legal and appropriate expenditure of State funds and require compliance with all applicable laws and DPS
JCPC Policy; and
25. Ensure that all contractors or subcontractors provide all information necessary to comply with the standards
set forth in the Program Agreement, or most recently approved Program Agreement Revision.
The JCPC shall:
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
1. Ensure the Sponsoring Agency uses JCPC funds only for the purposes approved by DPS in the JCPC Program
Agreement or most recently approved JCPC Program Agreement Revision;
2. Comply with the DPS JCPC Policy, the North Carolina Administrative Code procedures (14B NCAC 11 B), and N.C.
G.S. §§ 14313-845 to 851;
3. Review and locally approve Program Agreements, Program Agreement Revision(s), and Third Quarter Accounting
and submit information to the County in a timely manner to meet due dates established by DPS;
4. Submit any other information requested by the County or DPS; and
5. Monitor the Sponsoring Agency's currently funded JCPC program(s) in accordance with DPS JCPC Policy 3.
Operations: Program Oversight and Monitoring.
Reference: 14B NCAC 118.0202 and DPS JCPC Policy (policies 1, 3, 7, 8, 9, 10 and 11).
The County shall:
1. Ensure the Sponsoring Agency is appropriately licensed when applicable, and either a local public agency, a 501(c)
3 nonprofit corporation or local housing authority (applicable only to the JCPC funding process);
2. Use funds only for the purposes approved by DPS in the Program Agreement, or most recently approved Program
Agreement Revision;
3. Disburse funds monthly and oversee funds to the Sponsoring Agency in accordance with 14B NCAC 11 B.0108;
4. Comply with the DPS JCPC Policy and North Carolina Administrative Code procedures (14B NCAC 11 B);
5. Review and locally approve Program Agreement Revisions received from the Sponsoring Agency for final approval
from DPS; and
6. Review and locally approve Third Quarter and Final Accounting forms for the JCPC and all funded programs
according to the procedures and due dates established by DPS.
Reference: 14B NCAC 11 B.0108; DPS JCPC Policy (policies 8 and 9).
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.
Choice of Law: The validity of this Program Agreement and any of its terms or provisions, as well as the rights and
duties of the parties to this Program Agreement, are governed by the laws of North Carolina, including the relevant
provisions of G.S. Chapter 143B, Article 13, Part 3, Subpart F, and the Rules of 14B NCAC Chapter 11. The parties,
by signing this Program Agreement, agree and submit, solely for matters concerning this Program Agreement, to the
exclusive jurisdiction of the courts of North Carolina and agree, solely for such purpose, that the exclusive venue for
any legal proceedings shall be Wake County, North Carolina. The place of this Program Agreement and all
transactions and agreements relating to it, and their situs and forum, shall be Wake County, North Carolina, where all
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371 C
matters, whether sounding in Program Agreement or tort, relating to the validity, construction, interpretation, and
enforcement shall be determined.
Assignment: No assignment of the Sponsoring Agency's obligations or the Sponsoring Agency's right to receive
payment hereunder shall be permitted. However, upon written request approved by the issuing purchasing authority,
DPS may:
(a) Forward the Sponsoring Agency's payment check(s) directly to any person or entity designated by the
Program Manager, or
(b) Include any person or entity designated by the Sponsoring Agency as a joint payee on the Sponsoring
Agency's payment check(s).
In no event shall such approval and action obligate DPS or County Government to anyone other than the Sponsoring
Agency, and the Sponsoring Agency shall remain responsible for fulfillment of all Program Agreement, or the most
recently approved Program Agreement Revision, obligations.
Beneficiaries: Except as herein specifically provided otherwise, this Program Agreement shall inure to the benefit of
and be binding upon the parties hereto and their respective successors. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Program Agreement, and all rights of action relating to such
enforcement, shall be strictly reserved to DPS, the County Government, and the Sponsoring Agency. Nothing
contained in this document shall give or allow any claim or right of action whatsoever by any third person. It is the
express intention of DPS and County Government that any such person or entity, other than DPS or the County
Government or the Sponsoring Agency receiving services or benefits under this Program Agreement shall be deemed
an incidental beneficiary only.
Property Rights
Intellectual Property: All deliverable items produced pursuant to this Program Agreement are the exclusive property
of DPS. The Sponsoring Agency shall not assert a claim of copyright or other property interest in such deliverables.
Physical Property The Sponsoring Agency agrees that it shall be responsible for the proper custody and care of any
property purchased for or furnished to it for use in connection with the performance of this Program Agreement, or the
most recently approved Program Agreement Revision, and will reimburse DPS for loss of, or damage to, such
property. At the termination of this Program Agreement, the Sponsoring Agency, County Government, and JCPC shall
follow the guidelines for disposition of property set forth in the North Carolina Administrative Code and DPS JCPC
Policy 1. Operations: JCPC Operations.
Reference: 14B NCAC 118.0110.
Disbursements and Internal Controls
Reversion of Unexpended Funds
Any remaining unexpended funds disbursed by DPS to the County for the Sponsoring Agency must be refunded/
reverted back to DPS at the close of the fiscal year or upon termination of this Agreement.
Accountability for Funds
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
Audit Requirement - Local Government or Public Authority Requirements
Local Government or Public Authorities in accordance with N.C.G.S. § 159-34 must have an audit performed in
conformity with generally accepted auditing standards. The audit shall evaluate the performance of a unit of local
government or public authority regarding compliance with all applicable Federal and State agency regulations. This
audit, combined with the audit of financial accounts, shall be deemed to be the single audit described by the "Federal
Single Audit Act of 1984".
Oversight
Access to Persons and Records
The State Auditor shall have access to persons and records related to all Program Agreements entered into by State
agencies or political subdivisions in accordance with N.C.G.S. § 147-64.7. Additionally, as the State funding authority,
DPS shall have access to persons and records related to all Program Agreements entered into by State agencies or
political subdivisions.
Record Retention
Records shall not be destroyed, purged, or disposed of without the express written consent of DPS. State basic
records retention policy requires all records to be retained for a minimum of five (5) years or until all audit exceptions
have been resolved, whichever is longer. If the Program Agreement is subject to Federal policy and regulations,
record retention may be longer than five (5) years since records must be retained for a period of three (3) years
following submission of the final Federal Financial Status Report, if applicable, or three (3) years following the
submission of a revised final Federal Financial Status Report. Also, if any litigation, claim, negotiation, audit,
disallowance action, or other action involving this Program Agreement has been started before expiration of the five-
year retention period described above, the records must be retained until completion of the action and resolution of all
issues which arise from it, or until the end of the regular five-year period described above, whichever is later.
No Overdue Tax Debt Not for profit organizations ONLY must comply with this section. This form must be
uploaded in NCALLIES when submitting a Program Agreement.
The Sponsoring Agency shall be responsible for the payment of all State, local, and Federal taxes. Consistent with N.
C.G.S. § 143C -6-23(c), not for profit organizations shall file with DPS and the County a written statement completed
by that Sponsoring Agency's Board of Directors or other governing body, stating whether or not the Sponsoring
Agency has any overdue tax debts, as defined by N.C.G.S. § 105-243.1, at the Federal, State, or local level. This
written statement, No Overdue Tax Debts, shall be completed by the Sponsoring Agency to certify when there are no
overdue taxes. If the agency has overdue taxes, the Sponsoring Agency must notify DPS at the time a Program
Agreement is submitted.
Conflict of Interest Not for profit organizations ONLY must comply with this section. This form must be
uploaded in NCALLIES when submitting a Program Agreement.
Consistent with the N.C.G.S. § 143C -6-23(b), not for profit organizations shall file with DPS and the County, a copy of
that Sponsoring Agency's policy addressing conflicts of interest that may arise involving the Sponsoring Agency's
management employees and the members of its Board of Directors or other governing body. The policy shall address
situations in which any of these individuals may directly or indirectly benefit, except as the Sponsoring Agency's
employees or members of its Board or other governing body, from the Sponsoring Agency's disbursing of State funds
and shall include actions to be taken by the Sponsoring Agency or the individual, or both to avoid conflicts of interest
and the appearance of impropriety. The policy shall be filed before the County or DPS will disburse any funds. The
Sponsoring Agency shall also complete the DPS Conflict of Interest Policy Statement (Form DPS 13 001) and upload
the statement in NCALLIES along with and the Sponsoring Agency's policy addressing conflicts of interests.
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371 C
Proof of 501(c)(3) Not for profit organizations ONLY must comply with this section. This form must be
uploaded in NCALLIES when submitting a Program Agreement.
Not for profit organizations must upload proof of the agency's 501(c)(3) status when submitting a program agreement
in NCALLIES.
Amendment: This Agreement may not be amended orally or by performance. Any amendment must be requested by
the Sponsoring Agency through submission of a Program Agreement Revision and executed by duly authorized
representatives of DPS, the County Government, JCPC, and Sponsoring Agency.
Severability: In the event that a court of competent jurisdiction holds that a provision or requirement of this Program
Agreement violates any applicable law, each such provision or requirement shall continue to be enforced to the extent
it is not in violation of law or is not otherwise unenforceable and all other provisions and requirements of this Program
Agreement shall remain in full force and effect.
Termination for Cause: If, through any cause, the Sponsoring Agency shall fail to fulfill its obligations under this
Program Agreement in a timely and proper manner, DPS shall have the right to terminate this Program Agreement by
giving written notice to the Sponsoring Agency and specifying the effective date thereof. In that event, all finished or
unfinished deliverable items prepared by the Sponsoring Agency under this Program Agreement shall, at the option of
DPS, become its property and the Sponsoring Agency shall be entitled to receive just and equitable compensation for
any satisfactory work completed on such materials, minus any payment or compensation previously made.
Notwithstanding the foregoing provision, the Sponsoring Agency shall not be relieved of liability to DPS for damages
sustained by DPS by virtue of the Sponsoring Agency's breach of this agreement, and DPS may withhold any
payment due the Sponsoring Agency for the purpose of setoff until such time as the exact amount of damages due
DPS from such breach can be determined. The filing of a petition for bankruptcy by the Sponsoring Agency shall be
an act of default under this Program Agreement.
Termination without Cause: DPS, the County Government, or the Sponsoring Agency may terminate this
Agreement at any time and without cause by giving at least thirty (30) days advance written notice to the other parties.
If this Program Agreement is terminated by DPS as provided herein, the Sponsoring Agency shall be reimbursed on a
pro rata basis for services satisfactorily provided to DPS under this Program Agreement, or the most recently
approved Program Agreement Revision, prior to Program Agreement termination.
Waiver of Default: Waiver by DPS of any default or breach in compliance with the terms of this Program Agreement,
or the most recently approved Program Agreement Revision, by the Sponsoring Agency shall not be deemed a waiver
of any subsequent default or breach and shall not be construed to be modification of the terms of this Program
Agreement unless stated to be such in writing, signed by an authorized representative of DPS, County Government,
the JCPC, and the Sponsoring Agency.
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 as a result of events beyond its reasonable control, including, without
limitation, fire, power failures, any act of war, hostile foreign action, nuclear explosion, riot, strikes, civil insurrection,
earthquake, hurricane, tornado, or other catastrophic natural event, pandemic, or act of God.
Survival of Promises: All promises, requirements, terms, conditions, provisions, representations, guarantees, and
warranties contained herein shall survive the Program Agreement expiration or termination date unless specifically
provided otherwise herein, or unless superseded by applicable Federal or State statutes of limitation.
Entire Agreement: This Program Agreement (including any documents mutually incorporated specifically herein)
represents the entire agreement between the parties and supersedes all prior oral or written statements or
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
agreements.
END OF SECTION V — Terms of Agreement
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION VI: BUDGET NARRATIVE
Systematic Training for Effective Parenting
Fiscal Year
FY 22-23
Wages
Wages
Item #
Justification
Expense
In Kind Expense
120
(Deeanna - $34.33/per hr x 24 hours= $823.92) + (Meredith-
$22.18/per hr x 36 hours = $798.48
$1,622
120
(John- $27.41/per hr x 290 hours = $7948.90) + (Erin - $23.24/
per hr x 275 hours = $6391)
$14,340
120
(part time prevention specialist - $13.77 x 200 hours)
$2,754
180
Total Benefits (FICA, Group Insurance, Retirement,
Unemployment, Workers Comp, Vacation) --- Full time Salary
($14340 Erin, John x 27.9%) + Part time Salary($2754 x 15%)
$4,414
180
Total Benefits (FICA, Group Insurance, Retirement,
Unemployment, Workers Comp, Vacation) ---Salary ($823.92
Deeanna x 27.9%) + ($798.48 Meredith x 15%)
$350
220
Meal and refreshments ($74/session x 8 sessions x 6 cycles)
$3,552
230
($23 x 36 participants for individual family participation bags)
$828
260
Service Maintenance Contracts for office supplies (programs
assigned cost)
$125
310
Taxi cab and/or bus passes to assist with client travel as
needed
$300
320
5740 -Telephone Fair share portion (programs assigned costs)
$184
370
5120 -Advertising Expense Fair share portion (programs
assigned costs)
$6
390
5320 -Challenge Services Other- ($1050/ per OA Challenge
Course x 6 Days)
$6,300
390
5100 -Administration charges Fair share portion (programs
assigned costs)
$2,329
390
Services Cleaning
$210
390
5320- Other- Onsite Childcare professional ($13/per hr x 8
sessions x 6 cycles x 2.5 hours)
$1,560
390
5160 -Audit Expense Fair share portion (programs assigned
costs)
$53
410
5680 -Rent Fair share portion (programs assigned costs)
$1,620
410
In-kind meeting location for program ($14/per sq ft x 256 sq ft)
+ location for onsite childcare ($14/per sq ft x 200 sq ft)
$6,384
450
5500 -Insurance Prop/Liab 5510 -Insurance -Vehicle Fair share
portion (programs assigned costs)
$605
TOTAL
$39,180
$8,356
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
Annual Expense
Annual In Kind
Job Title
Wages
Wages
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
Meredith Ross, Prevention Coordinator, Supervise STEP Facilitator
$798
part time prevention specialist/program administration support
$2,754
Deeanna Hale -Holland, Prevention Director, Manage and Supervise Program
$824
John Dail, Prevention Specialist, Facilitate STEP Program
$7,949
Erin Ditta, Prevention Coordinator, Coordinate and Supervise STEP Program
$6,391
TOTAL
$17,094
$1,622
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION VII Program: Systematic Training for Effective Parenting
Fiscal Year: FY 22-23
Number of Months: 12
Cash
In Kind
Total
I. Personnel Services
$21,508
$1,972
$23,480
120 Salaries & Wages
$17,094
$1,622
$18,716
180 Fringe Benefits
$4,414
$350
$4,764
190 Professional Services"
$0
*Contracts MUST be attached
II. Supplies & Materials
$4,505
$4,505
210 Household & Cleaning
$0
220 Food & Provisions
$3,552
$3,552
230 Education & Medical
$828
$828
240 Construction & Repair
$0
250 Vehicle Supplies & Materials
$0
260 Office Supplies and Materials
$125
$125
280 Heating & Utility Supplies
$0
290 Other Supplies and Materials
$0
III. Current Obligations & Services
$10,942
$10,942
310 Travel & Transportation
$300
$300
320 Communications
$184
$184
330 Utilities
$0
340 Printing & Binding
$0
350 Repairs & Maintenance
$0
370 Advertising
$6
$6
380 Data Processing
$0
390 Other Services
$10,452
$10,452
IV. Fixed Charges & Other Expenses
$2,225
$6,384
$8,609
410 Rental or Real Property
$1,620
$6,384
$8,004
430 Equipment Rental
$0
440 Service and Maint. Contracts
$0
450 Insurance & Bonding
$605
$605
490 Other Fixed Charges
$0
V. Capital Outlay
$0
[This Section Requires Cash Match]
510 Office Furniture & Equipment
$0
530 Educational Equipment
$0
540 Motor Vehicle
$0
550 Other Equipment
$0
580 Buildings, Structure & Improv.
$0
Total
$39,180
$8,356
$47,536
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
SECTION VIII SOURCES OF PROGRAM REVENUE (ALL SOURCES)
FY 22-23 New Hanover County Funding ID: 965-XXXX
Sponsoring Agency: Coastal Horizons Center, Inc. Program: Systematic Training for Effective Parenting
$39,180
20%
$8,356
$47,536
DPS/JCPC Funds
Local Match Rate
County Cash
Local Cash
Local Cash
Local In -Kind
Other
Other
Other
Other
TOTAL
" This is the amount approved in your application
Is the Local Match Rate 10%, 20% or 30%?
(Specify Source)
Staff management and supervision & program
meeting location
$7,836
(Specify Source)
(Specify Source)
(Specify Source)
(Specify Source)
(Specify Source)
(Specify Source)
(Specify Source)
$8,356
Required Local Match Match Provided
Ei
ocuSigned by:
798FE7A4BD9F419... 5/19/2022
Authorizing Official, Department of Public Safety Date
The following signature certifies that this program agreement has been locally approved by the Board of County Commissioners.
EDocuSigned by:
' wau vx, 1vuLWYR ('FOL 517/2022
9507FA3F06164E9... /
Chair, County Board of Commissioners or County Finance Director Date
The following signature certifies that this program agreement has been locally approved by the Juvenile Crime Prevention
Council.
—DocuSigned by:
9 R (hvpuu" l f
—3DD8E15D4A2540C... 5/10/2022
Chair, Juvenile Crime Prevention Council
—DocuSigned by:
�eeariria �a�- �o �n.cl
Program Manager
Form JCPC/PA 001 JCPC Program Agreement
Form structure last revised 12/31/2012
Department of Public Safety
Date
5/10/2022
Date
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
B-1
035455
IRS i'4 pa an[ R of the Tri�Emury
vice
F7 hitolusi Navomio Srrvlcc
CINCINNATI OH 45999-0038
COASTAL HORIZONS CENTER INC
615 SHIPYARD BLVD
WILMINGTON NC 28412
Employer ID number: 56-0950370
Form 990 required: Yes
Dear Taxpayer:
In reply refer to: 0248288031
Feb. 06, 2019 LTR 41(i8C 0
56--0950370 000000 00
00008433
BODC: TF
We're responding to your request dated Jan. 28, 2019, about Your
tax-exempt status.
We issued you a determination letter in March 1971, recognizing
you as tax-exempt under Internal Revenue Code CIRC) Section 501(c)
(3).
We also show you're nut a private foundation as defined under IRC
Section 509(x) because you're described in IRC Sections 509(a)(1) and
170(b)(1)(A)(vi).
Donors can deduct contributions they make to you as provided in IRC
Section 170. You're also qualified to receive tax deductible bequests,
legacies, devises, transfers, or gifts under IRC Sections 2055, 2106,
and 2522.
In the reading of this letter, we indicated whether you must file an
annual information return. If you're required to file a return, you
must file one of the following by the 15th day of the 5th month after
the end of your annual accounting period:
Form 990, Return of Organization Exempt From Income Tax
Farm 990EZ, Short Form Return of Organization Exempt From Income
Tax
- Form 990-N, Electronic Notice (e -Postcard) for Tax -Exempt
Organizations Not Required to File Form 990 or Form 990 -EZ
Form 990 -PF, Return of Private Foundation or Section 4947(a)(1)
Trust Treated as Private Foundation
According to IRC Section 6033Cj), if you don't file a required annual
information return or notice for 3 consecutive years, we'll revoke
your tax-exempt status on the due date of the 3rd required return or
notice.
You can get IRS forms or publications you need from our website at
www.irs.gov/forms-pubs or by calling 800 -TAX -FORM (800-829-3676).
if you have questions, call 877-829-5500 between 8 a.m. and 5 p.m.,
0
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
°P MWPAP—
NC DEPARTMENT OF PUBLIC SAFETY
NOT FOR PROFIT
DPS CONFLICT OF INTEREST POLICY STATEMENT
This document is only required from not for profit organizations ONLY: In accordance i0th
the N..C.G.S. 143C-6-23 (b), every Grantee shall file with the State agencylGrantor a copy of the
Grantee's agency policy addressing conflicts of interest that may arise involving the Grantee's
management employees and the members of its board of directors or other governing body. The
policy shall address situations in which any of these individuals may directly or indirectly benefit,
except as the Grantee's employees or nrernbers of its board or other governing body, from the
Grantee's disbursing of State finrds and shall include actions to be taken by the Grantee or the
individual, or both to m,oid conflicts of interest and the appearance of impropriety. Agency conflict
of interest policy shall be submitted to the Department of Public Safety (DPS) to avoid any delay
with the disbursement of DPS JCPC finds.
The Grantee shall submit this form (Not for Profit DPS Conflict of Interest Policy Statenrerat Form
DPS 13 001) along Smith the agency's conflict of interest policy ivhen applying far f riding.
Accordingly, no member or board member of the private, nonprofit entity may receive
directly or indirectly, any funds received from the State of North Carolina, except for duly,
authorized staff compensation and benefits, and reimbursement for expenses actually
incurred in connection with the private, nonprofit entity's business and in accordance with
final approved grant agreements.
WHEREAS, (Name of entity) Coastal Horizons desires to require its Board of
Directors and managing employees to avoid conflicts of interest or the appearance of
impropriety in the disbursement of State funds;
THEREFORE, no member of the Board of Directors or staff members of said private,
nonprofit entity shall participate in the solicitation, negotiation, formation, award,
arbitration, modification, or settlement of any contract or grant fielded in whole or in part
by State funds or of any dispute arising under such contract or grant when the director or
staff members stands to benefit, either directly or indirectly, from such grant or contract;
PROVIDED, no member of the Board of Directors or staff members shall be deemed to
benefit directly or indirectly fiom any contract or grant funded in whole or in part by State
fiends if he/she receives only the salary or stipend due to him/her in the normal course of
employment with, or service to, said private, nonprofit entity.
FURTHERMORE, said private, nonprofit entity has written conflict of interest policies
and reporting procedures applicable to board members, staff members and volunteers who
have any interest or any authority regarding the resources of the private, nonprofit entity.
These policies have been communicated to board members, staff members and volunteers
and full disclosure has been provided for any possible appearance of conflict of interest
that may exist.
Foram DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement
Form structure last revised July 2014
NC Department of Public Safety Page 1 of 3
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
NC DEPARTMENT OF PUBLIC SAFETY
NOT FOR PROFIT Mj
DPS CONFLICT OF INTEREST POLICY STATEMENT
The folloiving serves to identify and document any personal interest staff members,
officers, rind members of the Board of Directors nary have. This document is also to be
used to disclose any transactions that may result in personal, financial, professional
mrd/or political gain at the expense of DPS. The statement requires that all personal
relationships that may inappropriately influence (bias) actions be disclosed.
Relationships, be it personal, financial, professional mrd/or political are required to be
discloser) to DPS. Conflict means a conflict or the appearance of a co►rflict between the
private interests and official responsibilities of a person in a position of trust. Persons
in a position of trust include staff members or the Board of Directors.
Private, nonprofit entities shall make full disclosure by notice in writing to the full
Governing Board/Council all conflicts of interest, if "yes" is answered to any of the
following: (Check all that apply)
Form DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement
Form structure last revised duly 20I4
NC Department of Public Safety
Page 2 of 3
YES
NO
1.
A Board member is related to a staff member.
❑
2.
A staff member in a supervisory capacity is related to another staff
❑
member whom he/she supervises.
3.
A staff member is related to another staff member.
❑
4.
A board member or staff member has or may have personal,
❑
financial, professional, and/or political gain at the expense or
benefit of the private, nonprofit entity.
5.
There is a business entity in which a staff, board, or family member
❑
participates that may be viewed as having direct or indirect
influence over the private, nonprofit entity's business.
6.
A staff, board, or family member may be viewed as having direct
❑
or indirect financial gain from personal or business
investments/interest in real property held by that staff, board, or
family member.
7.
A staff or board member received honorarium or other
❑
compensation outside of the scope of employment/operations with
the private, nonprofit entity that creates ora ears to create bias.
S.
A staff or board member secured employment with a competitor or
❑
other similar private, nonprofit entity.
9.
Ongoing, paid consulting work outside of the staff member's
❑
current employment or board member's with your private,
nonprofit entity exists.
Form DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement
Form structure last revised duly 20I4
NC Department of Public Safety
Page 2 of 3
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
NC DEPARTMENT OF PUBLIC SAFETY
NOT FOR PROFIT
DPS CONFLICT OF INTEREST POLICY STATEMENT
1. If "yes" is checked to any of the aforementioned items, the JCPC Program Manager
and Board Chair must ensure details for any transaction that exists are described
and attached to this form.
2. If this statement fails to list a transaction that may exist that is non-financial in
nature, please attach details.
3. Details must include at least the name, and, address, or persons involved, and a
description of the relationship and the transaction.
Note: Failure to disclose any conflict of interest transaction that exists or is
potential within your private, nonprofit entity may result in the cessation
of any further DPS JCPC State funds.
County: New Hanover
Agency's Name:
(Legal Applicant)
Federal Tax ID #: 56-0950370
Private, Nonprofit
Entity Name: Coastal Horizons
Executive Director's Print Margaret Weller• -Star ell
(Date of signature)
Name: Sign A, ,
Board Chair's Print d Hods
(Date f Si nature)
Name: Sign
I �-
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3 .1.
Sworn to and subscribed before me on the
ay of.the date of said certification
.� N
(Notary Public)
0 — — — — — — — — — — — -
CHRISTINA M CARTER
NOTARY PUBLIC
NEW HANOVER COUNTY
STATE OF NORTH CAROLINA .
MY COMMISSION EXPIRES O4-12-20.
Form DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement
Form structure last revised July 2014
NC Department of Public Safety Page 3 of 3
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
Coastal
oa%,
Horizons
Margaret Weller Stargell, January 19, 2022
President and CEO
To: State Agency Head and Chief Fiscal Officer
Corporate Headquarters
Willie Stargell Office Park
615 Shipyard Blvd.
Wilmington, NC 28412
Administration
910-790.0187
910.790.0189 Fax
Open House Youth Shelter
(920)39Z 6916
Rape Crisis Center
(910)392-7185 New Hanover
(910) 754.7949 Brunswick
Om patient Treatment
(Boo) 672-2903
(910) 343 014 5 New Hanover
(910) 754-4515 Brunswick
(9ro) 259-o668 PenJer
Community Based
FamilyScrvices
(910) 202 3155
Horizons Health
Primary Care
{910) 202-3860
WHAT
(910)790 9949
Colltinatim ofCare
(9to) 216.6080
Prevention Services
(910) ZOL-0840
Outdoor Adventure
(910)392.7306
TASC
(910) 762-5333 New Hanover
TASC RCE,
(2sz) 638-3909 Region 1
(910) 321 6793 Region z
NC TASC Training
Institute.
(910) ].02-SSOo
Our Children's Place
(919) 904-4286
Recidivists Reduction Services
(910) 202.5125
RESET
(910) 762-5333
Certification:
We certify that Coastal Horizons Center, Inc. does not have any overdue tax debts, as defined by
N. C. G. S. 105-243.1, at the federal, State, or local level. We further understand that any person
who makes a false statement in violation of N. C. G. S. 143C -6-23(c) is guilty of a criminal offense
punishable as provided by N.C.G.S.) 143C -10-1b.
Sworn Statement:
Brad Hudson and Margaret Weller-Stargell being duly sworn, say that we are the Board Chair and
President and CEO respectively, of Coastal Horizons Center of Wilmington in the State of North
Carolina; and that the foregoing certification is true, accurate and complete to the best of our
knowledge and was made and subscribed by us. We also acknowledge and understand that any
misuse of State funds will be reported to the appropriate authorities for further action.
Board Chair + R}
W
President and CEO
Sworn to and subscribed before me on the day of the date of said certification.
(Notary Signature and Seal)
My Commission Expires: A�-3
' G.S. 105-243.1 defines: Overdue tax debt. — Any part of a tax debt that remains unpaid 90 days or more
after the notice of final assessment was mailed to the taxpayer. The term does not include a tax debt,
however, if the taxpayer entered into an installment agreement for the tax debt under G.S. 105-237 within 90
days after the notice of final assessment was mailed and has not failed to make any payments due under the
installment agreement."
to rice/,
C
ar " e CARF - Internationai Accreditation for Quality wi1nv,Coastalhorizons.Org
* CABHA -Critical Access Behavioral Health Agency
—
DocuSign Envelope ID: AD132EF9-AFC2-44D6-8CE7-54C13BEA371C
COASTAL HORIZONS CENTER, INC.
Pr-omotiogcLoiceslorltealduerGres aidsafer•conunuruties"
Board of Trustees
Conflict of Interest Policy
A. Statement of Policy
No board member shall use his or her position, or the knowledge gained there from, in such a manner that a
conflict between the interest of Coastal Horizons Center, Inc. or any of its affiliates and the board member
may arise. Each board member has a duty to place the interest of Coastal Horizons Center, Inc. foremost in
any dealings pertaining to Coastal Horizons Center, Inc. and has a continuing responsibility to comply with
the requirements of this policy.
Board or committee members may not obtain for themselves, their relatives, or their friends a material
interest of any kind from their association with Coastal Horizons Center, Inc.. If a board member has an
interest in a proposed transaction with Coastal Horizons Center, Inc, in the form of a significant personal
financial interest or in any organization involved in the transaction, or holds a position as trustee, director, or
officer in any involved organization, he or she must make full disclosure of such interest before any
discussion or negotiation of such transaction.
Any board or committee member who is aware of a potential conflict of interest with respect to any matter
coming before the board or committee shall not be present for any discussion of or vote in connection with
the matter.
B. Disclosure
To ensure that the decision making process of the Board of Trustees of Coastal Horizons Center, Inc. is free
from conflict of interest and appearances of conflict, the following procedures will be followed:
1) All Board members will file with the Administrative Office of the Corporation a statement(s) listing any
person, firm, or organization by which they are employed or associated and through which a conflict of
interest might reasonably be expected as a possibility. Such statements will be filed no later than 60
days after the board member takes office and will be reviewed annually by the Executive Committee of
the board.
2) Any board member who perceives a potential conflict of interest, or the appearance of a conflict of
interest regarding any issue before the board of Coastal Horizons Center, Inc., shall declare a conflict of
interest and disqualify themselves from participation in discussion or voting of the issue in question.
These reports will be reviewed by the Executive Committee, which will attempt to resolve any actual or
potential conflict(s) and, in the absence of resolution, refer the matter to the Board of Trustees.
C. Potential Conflict of Interest Statement
I have read the statement of policy regarding conflicts of interest. To the best of my knowledge and belief,
except as disclosed herewith, neither I nor any person with whom I have or had a personal or business
relationship is engaged in any transaction or activity or has any relationship that may represent a potential
competing or conflicting interest, as defined in the statement of policy.
Further, to the best of my knowledge and belief, except as disclosed herewith, neither I nor any person with
whom I have or had a personal, business, or compensated professional relationship intends to engage in
any transaction, to acquire any interest in any organization or entity, or to become the recipient of any
substantial gifts or favors that might be covered by the statement of policy regarding conflicts of interest.
L,,w
Pria e
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Sig aVlv tDate
Board of Trustees Conflict of Interest Policy. doc//2/20/18
Certificate Of Completion
Envelope Id: AD132EF9AFC244D68CE754C13BEA371C
Subject: DPS eSignature Request for New Hanover 965-22597 Systematic Training for Effective Parentinc
Source Envelope:
Document Pages: 29 Signatures: 4
Certificate Pages: 5 Initials: 0
AutoNav: Enabled
Envelopeld Stamping: Enabled
Time Zone: (UTC -05:00) Eastern Time (US & Canada)
Record Tracking
Status: Original
5/10/2022 11:49:44 AM
Signer Events
Deeanna Hale -Holland
deeanna@coastalhorizons.org
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 5/10/2022 12:11:48 PM
ID:c87fa668-ad2a-4110-bc4b-345a79f97a00
J H Corpening II
julius.h.corpening@nccourts.org
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 5/10/2022 4:54:24 PM
ID:dd9e8391-7598-463e-9380-b50941f3349d
Martha Wayne, Interim CFO
mwayne@nhcgov.com
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 5/17/2022 3:07:20 PM
ID:67e9bfed-b4a6-4dc6-8475-644261c8a172
Holder: DPS-DJJ Community Programs
djjdp.applicationsupport@ncdps.gov
Signature
CDocuSigned by:
`Deeccwwa �a��o�ean.ci
424706OE19614FE...
Signature Adoption: Pre -selected Style
Signed by link sent to deeanna@coastalhorizons.org
Using IP Address: 173.93.10.16
[DSiby:
,n1d R (vrtw"
3DD8E15D4A2540C...
Signature Adoption: Pre -selected Style
Signed by link sent to
julius.h.corpening@nccourts.org
Using IP Address: 204.152.2.230
CDocuSignetl by:
%� IA , W�� c �
9507FA3F06164E9...
Signature Adoption: Pre -selected Style
Signed by link sent to mwayne@nhcgov.com
Using IP Address: 70.63.86.17
DocuSign
Status: Completed
Envelope Originator:
DPS-DJJ Community Programs
3040 Hammond Business PI
Raleigh, NC 27603
djjdp.applicationsupport@ncdps.gov
IP Address: 207.4.107.7
Location: DocuSign
Timestamp
Sent: 5/10/2022 11:49:46 AM
Viewed: 5/10/2022 12:11:48 PM
Signed: 5/10/2022 12:19:28 PM
Sent: 5/10/2022 12:19:30 PM
Viewed: 5/10/2022 4:54:24 PM
Signed: 5/10/2022 4:54:32 PM
Sent: 5/10/2022 4:54:34 PM
Viewed: 5/17/2022 8:00:02 AM
Signed: 5/17/2022 3:11:07 PM
Signer Events Signature Timestamp
Cindy Porterfield Sig -d by: Sent: 5/17/2022 3:11:09 PM
cindy.porterfield@ncdps.gov �O
CCD ""'� �'' Viewed: 5/19/2022 9:37:23 AM
Director of Juvenile Community Programs 798FE7A4BD9F419.. Signed: 5/19/2022 9:37:25 AM
NC Dept of Public Safety
Signature Adoption: Pre -selected Style
Security Level: Email, Account Authentication
(None) Signed by link sent to cindy.porterfield@ncdps.gov
Using IP Address: 199.90.60.4
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events
Signature
Timestamp
Editor Delivery Events
Status
Timestamp
Agent Delivery Events
Status
Timestamp
Intermediary Delivery Events
Status
Timestamp
Certified Delivery Events
Status
Timestamp
Carbon Copy Events
Status
Timestamp
Witness Events
Signature
Timestamp
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted
5/10/2022 11:49:46 AM
Certified Delivered
Security Checked
5/19/2022 9:37:23 AM
Signing Complete
Security Checked
5/19/2022 9:37:25 AM
Completed
Security Checked
5/19/2022 9:37:25 AM
Payment Events
Status
Timestamps
Electronic Record and Signature Disclosure
Electronic Record and Signature Disclosure created on: 4/3/2018 2:57:43 PM
Parties agreed to: Deeanna Hale -Holland, J H Corpening II, Martha Wayne, Interim CFO
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