FY23 SRC ARPA AAAAmerican Rescue Plan Act of 2021 (ARPA)
Agreement for the Provision of County -Based Aging Services
July 181, 2022 thru June 30m, 2024
This AGREEMENT, entered into as of this day of A45 2022 by and between NEW
HANOVER COUNTY (SENIOR RESOURCE CENTER), 230 OdvernAnt Drive, Wilmington, NC 28403,
(hereinafter referred to as the "Grantee") and the CAPE FEAR COUNCIL OF GOVERNMENTS, Lead Regional
Organization for the Area Agency on Aging, 1480 Harbour Drive, Wilmington, NC 28401, (hereinafter referred
to as the "Area Agency').
WITNESSETH That:
WHEREAS, Congress continues to support the safety and independence of older adults in the recovery from the
COVID-19 pandemic by providing recovery funds for Supportive Services, Home -Delivered Meals and
Congregate Nutrition, Health Promotion, Ombudsman and Family Caregiver Support Services included in the
American Rescue Plan Act of 2021 (ABPA), and
WHEREAS, funding expended from the ABPA, must be used to provide recovery services to the COVID-19
Pandemic by providing Older Americans Act services related to the response, and
WHEREAS, funds must be expended on allowable Older Americans Act activities as defined by the Older
Americans Act, state and local policy, and as defined in Attachment A, Approved ARPA Proposal and Budget,,
and
WHEREAS, the Area Agency and the Grantee agree to the terms and conditions for provision of aging services
in connection with activities financed in part by the ARPA and authorized under Titles III and VII of the Older
Americans Act, provided to the Area Agency from the United States Department of Health and Human Services
through the North Carolina Division of Aging and Adult Services (DAAS), as set forth in a) this document, b)
related administrative letters on the federal disaster grants issued by DAAS to convey the flexibilities,
requirements for allowable expenditures and documentation of service delivery, and other applicable flexibilities
and waivers permitted under the ARPA and Major Disaster Declaration, c) the DAAS Home and Community
Care Block Grant Procedures Manual for Community Service Providers, d) DAAS Service Standards and, e) the
DAAS Community Service Providers Monitoring Guidelines.
NOW THEREFORE, in consideration of these premises,, and mutual covenants and agreements hereinafter
contained, the parties hereto agree as follows:
The Grantee shall be the same as those specified on Attachment A, Approved ARPA Proposal and Budget,
for the period stated above as deemed necessary for a prompt and efficient response both under the Major
Disaster Declaration and when the Major Disaster Declaration is rescinded.
Availabilitv of Funds. The terms set forth in this Agreement for payment are contingent upon the receipt
of ARPA funding by the Area Agency.
3. Grant Administration. The grant administrator for the Area Agency shall be Holly Pilson, Area Agency
on Aging Director. The grant administrator for the Grantee shall be Amber Smith, New Hanover
County Senior Resource Center Director.
It is understood and agreed that the grant administrator for the Grantee shall represent
the Grantee in the performance of this Agreement. The Grantee shall notify the Area Agency in writing
if the administrator changes during the grant period. Specific responsibilities of the grant administrator
for the Grantee are provided in paragraph eight (8) of this Agreement.
4. Services authorized under this agreement or those identified as necessary to provide timely and necessary
response to the COVID-19 pandemic, provided they are among those services allowable under Titles III
B, Ill -C. III -D, III -E and VII of the Oldar.Americans Act, as specified in Attachment A, Approved ARPA
Proposal and Budget (732-ARPA), are to commence no later than July 1, 2022 and shall be undertaken
and pursued in such sequence as to assure their expeditious completion. All services required hereunder
shall be completed on or before the end of the Agreement period stated above.,
5. Assignability and Contraetine. The Grantee shall not assign a" or any portion of its interest in this
Agreement. Any purchase of services with ARPA funding shall be carried out in accordance with the
procurement and contracting policy of the Grantee or, where applicable, the Area gency, which does not
oonfiict with procurement and contracting requirements contained in 45 CPR Part 75. Subpart D -Post
Federal Award Requirements, Proourement Standards, except for those services purchased in response to,
and during the active period of the Major Disaster Declaration far North Carolina due to the COVID-19
pandemic, as declared by the President of the Unitcd tateson March 25202 ,
52020, effective January 20, 2020
and continuing. Federal funds shall be awarded to any subrecipients who have been suspended or
debarred by the Federal government. In addition, Federal funds may not be used to purchase goods or
services costing over $100,000 from a vendor that has been suspended or debarred from Federal grant
programs.
6. Compensation and Payments to the Grantee. The Grantee shall be, compensated for the work and services
actually performed under this Agreement by payments to be made monthly by the Area Agency. Total
reimbursement to the Grantee under this Agreement may not exceed $754,626, the grand total of
applicable ARPA funding, as specified in Attachment A.
A detailed breakdown of services and their respective cost can be located in Attachment A, Approved
ARPA Proposal and Budget.
(a) Reimbursement of Service Costs
Grantees must have a method of projecting service costs based on estimated revenues and
expenses, in order to receive adequate reimbursement as well as show reasonable and justifiable
costs. Reimbursement of service costs will be based on the DAAS-732-A-ARPA Service Cost
Computation Worksheet and the DAAS 732-A-1-ARPA Labor Distribution Form or comparable
formats to develop unit and non -unit costs.
(b) Aging Resource Management System (ARMS) Requirements: All program performance and
financial reports must conform to the requirements of DAAS' ARMS. The Grantee will be required
to participate in the automated ARMS by supplying the necessary and required input data. The
Grantee will also be required to participate in appropriate workshops by DAAS and/or Area
Agency. Failure to comply with the reporting requirements may results in either withholding of
funds or possible suspension/termination of funding. Grantees are required to participate in the
ARMS user's fee. The fee shall apply to each of the categories as the reimbursements are requested
through ARMS. It shall be based on the following formula:
4 of records X $.17 maintenance cost per service record in ARMS
7. Collection of Non -Federal Matching Resources. There is no match requirement for the Grantee for direct
services delivered through the ARPA funding.
8. Reallocation of Funds and Budget Revisions. Any reallocation of ARPA funding between counties shall
be voluntary on the part of the Grantee and shall be effective only for the period of the Agreement. The
reallocation of ABPA funds between counties will not affect the allocation of future funding to the
Grantee. If during the performance period of the Agreement, the Area Agency determines that a portion
of the ARPA funding will not be expended, the grant administrator for the Grantee shall be notified in
writing by the Area Agency and given the opportunity to make funds available for reallocation to other
counties in the Planning and Service Area or elsewhere in the state.
Transfers are authorized up to 30% of funds between Title 111-13 and 111-C congregate or home -delivered
nutrition programs, but transfers must occur within the same ARPA grant grouping. If a Grantee wishes
to exceed the 30% transfer within a grant, approval must be obtained through the Area Agency from
DAAS.
Unless Grantees have been given the capacity to enter data into the ARMS, the Area Agency is responsible
for entering amended service data into ARMS.
9, Monitoring. This Agreement will be monitored to assure that services are being provided as stated. in this
agreement and as outlined in administrative letters on the ARPA federal disaster grants issued by DAAS
to convey the requirements for allowable expenditures and documentation of service delivery to eligible
older adults.
The Grantees will receive a written report of monitoring findings in accordance with procedures
established in, Section 308 of the AAA Policies and Procedures Manual
(iju www.nedhhs, Dov/auinL/monitor/mnolict.htm). Any areas of non-compliance will be addressed in
a written corrective action plan with the Grantee.
Consumer Contributions. Grantees must allow for "consumer contributions" (client must be given
opportunity to contribute to defray the cost of the service but may not be denied service should he/she fail
to or choose not to contribute). DAAS Home and Community Care Block Grant Service Standards for
Consumer Contributions will be followed, and a signed/dated provider assurance form must be present in
each client file. Please review the Consumer Contributions Policy and Procedures at:
http.//rvww.nedhhs.eov/document/consumer-contributions-nohow -and-irorocedures
10. Disputes and Appeals. Any dispute concerning a question of fact arising under this Agreement shall be
identified to the designated grants administrator for the Area Agency, In accordance with Lead Regional
Organization (LRO) policy, a written decision shalt be promptly furnished to the designated grants
administrator for the Grantee.
The decision of the LRO is final unless within twenty (20) days of receipt of such decision the grant
administrator for the Grantee furnishes a written request for appeal to the Director of DAAS, with a copy
sent to the Area Agency. The request for appeal shall state the exact nature of the complaint. DAAS will
inform the grant administrator for the Grantee of its appeal procedures and will inform the Area Agency
that an appeal has been filed. Procedures thereafter will be determined by the appeals process of DAAS.
The state agency address is as follows:
Director
North Carolina Division of Aging and Adult Services
693 Palmer Drive
2101 Mail Service Center
Raleigh, North Carolina 27699-2101
11. Termination for Cause. If through any cause, the Grantee shall fail to fulfill in a timely and proper manner
its obligations under this Agreement, or the Grantee has or shall violate any of the covenants, agreements,
representations or stipulations of this Agreement, the Area Agency shall have the right to terminate this
Agreement by giving the Grantee's Executive Officer written notice of such termination no fewer than
fifteen (15) days prior to the effective date of termination. In such event, all finished documents and other
materials collected or produced under this Agreement shall at the option of the Area Agency, become its
property. The Grantee shall be entitled to receive just and equitable compensation for any work
satisfactorily performed under this Agreement.
12. Audit. The Grantee agrees to have an annual independent audit in accordance with North Carolina General
Statutes. North Carolina Local Government Commission requirements, DAAS Program Audit Guide for
Aging Services, and Federal Office of Budget and Management (OMB) Uniform Guidance 2 CFR Part
200.
Grantees, as specified in paragraph one (1), who are not units of local government or otherwise subject to
the audit and other reporting requirements of the Local Government Commission are subject to audit and
fiscal reporting requirements, as stated in NC General Statute 143C-6-22 and 23 and OMB Uniform
Guidance CFR 2 Part 200, where applicable. Applicable Grantees must send a copy of their year-end
financial statements, and any required audit, to the Area Agency. Grantees are not required to submit
Activities and Accomplishments Reports. For-profit corporations are not subject to the requirements of
OMB Uniform Guidance 2 GFR Part 200 but are subject to NC General Statute 1430-6-22 and 23 and
Yellow Book audit requirements, where applicable. Federal funds may not be used to pay for a Single
or Yellow Book audit unless it is a federal requirement. State funds will not be used to pay for a Single
or Yellow Book audit if the Grantee receives less than $500,000 in state funds. The Department of Health
and Human Services will provide continuation of federal and state expenditures at the close of the state
fiscal year. Information on audit and fiscal reporting requirements can be found at
ht!M.//www.osbm.nc.Lov/manavenient/erants.
The following provides a summary of reporting requirements under NCGS 143C-6-22 and 23 and OMB
Uniform Guidance 2 CFR Part 200 based upon funding received and expended during the Grantees fiscal
year.
Expenditures
Report Required to AAA
Ile cos
Allowable
re
`Annual
Less than $25,000 in
_
Certification form and State Grants Compliance
P
N.A.
slate or federal funds
Reporting <$25,000
(Item #11, Activities and Accomplishments)
does not have to be completed)
OR
Audited Financial Statements in compliance with
GAO/GAS (i.e.. Yellow Book).
+ Greater than $25,000
Certification form and Schedule of Grantee
N.A.
and less than $500,000
Receipts x$25,000 and Schedule of Receipts and
in state fiords or
Expenditures
$750,000 in federal
OR
funds.
Audited Financial Statements in compliance with
GAO/GAS O.e. Yellow Book)
Audited Financial Statement in compliance with
May use state
_
® $500,000+ in state
funds but federal pass
GAO/GAS (i.e., Yellow Book)
funds, but not
federal funds.
13. AudiUAssessment Resolutions and Disallowed Cost. It is further understood that the Grantees are
responsible to the Area Agency for clarifying any audit exceptions that may arise from any Area Agency
assessment, Grantee single or financial audit, or audits conducted by the State or Federal Governments.
In the event that the Area Agency or the Department of Health and Human Services disallows any
expenditure made by the Grantee for any reason, the Grantee shall promptly repay such funds to the Area
Agency once any final appeal is exhausted in accordance with paragraph ten (10). The only exception is
if the Area Agency is approved to provide direct services under the ARPA and expenditures are disallowed
by DAAS. In this case, the Area Agency is responsible for any. disallowed costs. The Area Agency can
recoup any required payback from the Grantee in the event that payback is due to a Grantee's failure to
meet OMB Uniform Guidance CFR 2 Part 200; 45 CFR Part 1321 or state eligibility requirements as
specified in policy.
14. Indemnity The Grantee agrees to indemnify and save harmless the Area Agency, its agents, and
employees from and against any and all loss, cost. damages, expenses, and liability arising out of
performance under this Agreement to the extent of errors or omissions of the Grantee.
15. Attendance at Region 0 Area Acencv on Aeint Meetings. The Grantee, upon request of the Area Agency
Administrator, will make efforts to attend any committee or special meeting relating to the project. The
Grantee will attend any scheduled ARPA meetings.
16. Eetuai Etnnlotment Ootzorlunity and Americans With Disabilities Act Compliance. The Grantee shall
comply with all federal and state laws relating to equal employment opportunity and accommodation for
disability.
17 Data to be Furnished to the Grantee. Al] information which is existing. readily available to the Area
Agency without cost and reasonably necessary, as determined by the Area Agency's staff, for the
performance of this Agreement by the Grantee shall be furnished to the Grantee with charge by the
Area Agency. The Area Agency, its agents and employees. shall fully cooperate, with the Grantee in the
performance of the Grantee's duties under this Agreement.
18. Ri hts in Documents. Materials and Data Produced. The Grantee agrees that at the discretion of the Area
Agency"a ll reports and other data prepared by or for it under the terms ofthis Agreement shall be delivered
to, become and remain, the property of the Area Agency upon termination or completion of the work.
Both the Area Agency and the Grantee haIIhave
the right to use same without restriction or limitation
and without compensation to the other. For the purposes of this Agreement, "data" includes writings,
sound recordings, or other graphic representations, and works of similar nature. No reports or other
documents produced in whole or in part under this Agreement shall be the subject ol'an application for
copyright by or on behalf of the Grantee.
19. Interest of the Governin t Board. The Governing Board covenants that neither the Governing Board nor
its agents or employees presently has an interest, nor shall acquire an interest, direct or indirect, which
conflicts in any manner or degree with the performance of its service hereunder, or which would prevent,
or tend to prevent, the satisfactory performance of the service hereunder in an impartial and unbiased
manner.
20, Interest -of Members of the Area Agency, Lead Regional Organization. and Others. No officer; member
or employee of the Area Agency or Lead Regional Organization, and no public official of any local
government which is affected in anyway by the Project, who exercises any function or responsibilities in
the review or approval of the Project or any component part thereof, shall participate in any decisions
relating to this Agreement which affects his personal interest or the interest of ally corporation, partnership
or association in which he is, directly or indirectly, interested; nor shall any such persons have any interest,
direct or indirect, in this Agreement or the proceeds arising there from.
21. Officials not to Benefit. No member of or delegate to the Congress of the United States of America,
resident Commissioner or employee of the United States Government, shall be entitled to any share or
part of this Agreement or any benefits to arise here from.
22, Prohibition A+sainst Use of Funds to Influence Le6slation. No part of any funds under this Agreement
shall be used to pay the salary or expenses of any employee or agent acting on behalf of the Grantee to
engage in any activity designed to influence legislation or appropriations pending before Congress.
23. Additional Provisions.
a. The Grantee and any subrecipients are required to follow policies and procedures for procurement that
are at least as stringent as those of the State. For federal funds this requirement pertains to verifying
that federal funds are not used to award funds to any subrecipients who have been suspended or
debarred by the federal government. In addition, federal funds may not be used to purchase goods or
services costing over $100,000 for a vendor that has been suspended or disbarred from Federal grant
programs. Contractors and subcontractors of Older Americans Act funds are prohibited from
discharging, demoting, or otherwise discriminating against and employee for whistle blowing as
codified in 48 CFR Ch. 13.908.
b. Any capital purchases of $5,000 or more must be pre -approved by the Area Agency and DAAS
c. If any copyrightable material is developed in the course of or under this agreement and any subaward,
a copy will be furnished to the Department of Health and Human Services and the Department shall
have a royalty fee, non-exclusive, and irrevocable right to reproduce, publish or otherwise use the
work for Department purposes.
d. In accepting this award, the Grantee agrees not to replace local program support with Total
Federal/State Reimbursement and will contract for any aging services as identified through the county
funding plan in accordance with policies and procedures established in the DAAS Manual of Policies
and Procedures. blIlLs /nolicies.nedhhs Lov/div ssionaUaLin+ -and-adult
e. The Grantee and any subrecipients shall comply with the Federal Funding Accountability and
Transparency Act (FFATA) by enrolling as a subrecipient in System for Award Management (SAM)
Registration on an annual basis and providing required award information in the FFATA Subaward
Reporting System per 2 CFR part 170.
f. In accepting this award, the Grantee and any subrecipients agree to maintain compliance with Section
306(a), (13), (14), and (15), of the Older Americans Act, as amended in 2006 with regards to
contractual and commercial relationships.
g. By signatures on Attachment B, Federal Certifications, the Grantee certifies its compliance and
compliance of any subrecipients with federal requirements regarding nondiscrimination; drug-free
workplace; environmental tobacco smoke; debarment, suspension, ineligibility, and voluntary
exclusion lower tier covered transactions; and Iobbying.
h. E -Verify Comrlianee. Pursuant to Session Law 2013418; Contractor shall fully comply with the U.S.
Department of Homeland Security employee legal status E -Verify requirements for itself and all its
subcontractors, if applicable. requires an affidavit attesting to Contractor's compliance. Violation. of
the provision,, unless timely cured, shall constitute a breach of contract:
24. Conflict of Interest. The Grantee shall comply with all applicable federal and state conflict of interest
laws. The Grantee expressly states that presently they have no interest and shall not acquire any interest,
direct or indirect, which would conflict in any manner or degree with the performance of services required
to be performed under this contract. The Grantee shalt employ any person having such interest during the
performance of this contract. The Grantee further agrees to notify the Area Agency in writing of any
instance that might have the appearance of a conflict of interest.
25. Confidentiality and Security. Any client information received in connection with the performance of any
function of a Grantee or its subcontractors under this Agreement shall be kept confidential. The Grantee
acknowledges that in receiving, storing, processing, or otherwise handling any confidential information,
the Area Agency and any subcontractors will safeguard and not further disclose the information except as
provided in this Agreement and accompanying documents.
26. Record Retention and Disrosition. All state and local government agencies, nongovernmental, entities,
and their subrecipients, including applicable vendors, that administer programs funded by federal sources
passed through the NC DHHS and its divisions and offices are expected to maintain compliance with the
NC DHHS record retention and disposition schedule and any agency -specific program schedules
developed jointly with the NC Department of Cultural Resources, Division of Archives and Records.
Retention requirements apply to the Grantees funded under this Agreement to provide Home and
Community Care Block Grant and other services necessary to provide emergency response funded through
the FFCRA and CARES Act funding. Information on retention requirements is posted at
haps:/Mvww.ncdhhs nov/about!administrative-offices/olite e-controller/records-retention and updated
semi-annually by the NC DHHS Controller's Office. By funding source and state fiscal year, this schedule
lists the earliest date that grant records in any format may be destroyed. The Division of Archives and
Records provides information about destroying confidential data and authorized methods of record
destruction (paper and electronic} at httns:llarchives.neder.cov/covetnment(retention-schedules.
The NC DHHS record retention schedule is based on federal and state regulations and pertains to the
retention of al] financial and programmatic records, supporting documents, statistical records, and all other
records supporting the expenditure of a federal grant award. Records legally required for ongoing official
proceedings, such as outstanding litigation, claims, audits, or other official actions, must be maintained
for the duration of that action, notwithstanding the instructions of the NC DHHS record retention and
disposition schedule.
In addition to record retention requirements for records in any format. the long-term and/or permanent
preservation of electronic records require additional commitment and active management by agencies.
The Grantee will comply with all policies, standards, and best practices published by DAAS regarding the
creation and management of electronic records.
27. Federal Award Identification.. This agreement constitutes a subaward of federal funds, the details of which
are provided below pursuant to 2 CPR 200.332(a)(I ):
Subrecipient name:
New Hanover County Senior Resource Center
Subrecipienf_'s unique entity identifier:
F7TLT2GMEJEI
TITLE III-B-ITLE
III -Cl
ITLE III -C2 TITLE lIl-D
ITLE III -E
Federal Award Identification Number
(FAIN):
210INCSSC6-
00
'IOINCCMC6-
)0
IOINCHDC6- IOiNCOliC6-
i0 i0
'IOINCFCC6-
'0
Federal Award Date:
07-01-2022
Subaward and Budget Period of
Performance Start Date:
07-01-2022
Subaward and Budget Perioaof
Performance End Date:.
06-30-2024
TITLE I1I-11
TITLE III -CI
TITLE III -C2
TITLE 1II-D
TITLE Ill -E
Amount of Federal Funds Obligated to
the Subrecipient by this action:
$340,404
138,674
744,31$
30,082
Ifl1,088
Total Amount of Federal Funds
Obligated to the subrecipient by
CFCOG:
$754,566
Total Amount of the Federal Award
Committed to the subrecipient by
CFCOG:
$2,123,386
TITLE M-
B
TITLE III-C1TITLE
III C2
TITLE III=D
TITi E III -E
Federal award project description:
Supportive
Services
congregate
utrition
-tome Delivered
leafs
lealth
romotion
CSP
Federal awarding agency:
Administration on Community Living
Federal rcci Tient:
North Carolina Division of AginE and Adult Services
Subawarding agency:
Cape Fear Council of Governments
Subawarding agency contact
information:
Holly Pilson, Director Area Agency on Aging
TITLE III-
Ii
TITLE 11I -CI
ITLE III -C2 TITLE III -D
TITLE III -E
Assistance listings number:
93.044 )3.045
'3.045 3.043
3.052
Research and development:
No
28. Applicable Law. This Agreement is executed and is to be perfonned in the State of North Carolina, and
all questions of interpretation and construction shall be construed by the laws of such State.
20. Compliance Documents. Cape Fear Council of Governments Area Agency on Aging requires each
Grantee to complete the following documents:
Attachment B — Federal Certifications
In witness whereof, the Area Agency and the Grantee have executed this Agreement as of the day first written
above.
Grantee
Arrest: L r�jy�/l Vil.vri'C D�9��
By: Date:— �d
Auth r¢ed ci- ufanna Bra. y
Title: Asst nt County Manager
Cain Council of Governments Area encyon Agin&Council of Governments Area Agin
By:
ly Mlson, a Agency on Aging Director Allen Ser.AExecut'iveirector
This instnim t has be audited in the manner required by the Local Government Budget and Fiscal Control Act.
By:
Dawn Tucker, Finance Director
Attachment k Title III -B Scope of Work
Title 11-B Allocation: $ 346,464.00
Title 111-B TOTAL: $ 340,464.00
CODE CODE
ARPA-LTSS Outreach to
Underserved Targeted
Populations -This non -unit
service code defines outreach
as interventions for the
purpose of identifying
potential clients and
encouraging their use of
existing services and benefits
across funding sources.
Outreach is a count of one-on-
one contacts between an
agency and individual older
adults or persons acting on
their behalf, An activity that
involves contact with multiple
U current or ootentiai clients or
7.72
-ations - Costs normally
cable for providers under
III -B can be used for
ider's continuation and
nsion of senior center
client and unit reporting
rquirement): ARPA-Housing
Home Improvement - Non-
iit service for Housing/Home
norovement services such as
and
PROPOSAL
ling will support a new
tion, Community Engagement
Jalist, that will focus on
each, trust and service
Nledge building, identifying,
ice gaps, and developing
:ram Implementation in
:rserved, hard to reach areas,
special populations such as
9rity and L.BGTQ+. Funds will
u salary,fringe, benefits,
Nare license, supplies,
each material, computer/cell
ne, etc. Funding will also
)ort cost to develop and
stain an online resource
;will be used to increase a
of classes, actvities, and
ns at the SRC and offsite
)s. Expenses will include
instructor fees and program
Fundingwill support expenses
(contractor and supplies) for
housing and home repairs and/or
modifications to allow clients to
live in a safe and secure
environment and prevent
47
259
iml
Attachment A: Title III -B Scope of Work
047 (This is non -unit code with
a client and unit reporting
requirement): Chore Services -
Assistane sub as heavy
housework (inloding
decluttering and taking trash
to the dmp), yardwork, or
sidewalk maintenance.
Examples include scrubbing
floors, washing walls, washing
windows indoors, and moving
furniture. One unit=one hour.
client and unit reporting
!quirement): Chore Enhanced
arvices - Assistance suh as
eaning carpets, washing
indows outside, and
ousehoid maintenance that
ARPA-Transportation -
Provides transportation to
medical care facilities and
general transportation to
community resources or other
locations to access services or
:EPTthat one unit=one one
I trip AND provider will
ort number of trips/month
each client by state-
ined S/R/W) (This is non
-
t code with a client and
t reporting requirement) -
vides a transportation
icher to an elis ible older
Legal, MH Counseling,
ling, Social Isolation,
ARPA-Non-Unit III -B In-
& Support Services -
able expenditures
Funding will support expenses for
level I chore services , and other
chore services that goes beyone
level 1 such as yard maintenance.
These services will allow clients
who do hot have other assistance
to live in a safe and clean
environment.
Funding will support expenses for
enhanced chores services that
requires detailed cleaning,
decluttering, heavy yard work,
and pest control. Providing these
services will help allow clients live
in a safe and clean envioriment.
will support the cost of
:ed and SRC van trips to
medical and general
rtation. Transportation is
ry for clients to
ate in health and social
Funding will support the cost of
transportation vouchers to
provide additional trips beyond
traditional contracted services.
Vouchers will be provided to
elegible clients to support their
needs for on demand vendor
transportation services and/or
Funding will support consumable
supplies for emergency
preparedness kits to including
COVID supplies, safety supplies,
technology supplies, and
Title III -C1 Allocation: $ 138,674.00
Title 11I -Ci TOTAL: $ 138,674,00
CODE
CODE DESCRIPTION
PROJECT PROPOSAL
BUDGET
062: ARRA-Congregate Meals -
Congregate Nutrition Meals (Ill -C1)
Support unit cost for
Meals to congregate nutrition
drive up meals, in
program clients that may or may not
person, and carry
meet one-third ofthe recommended
out coggreagate
daily allowance dietary reference
meals at the main
intake (RDA -DRI) requirements. Not
SRC and offsite
62
eligible for NSIP. One unit --one meal.
locations.
$ 130,000M
ongregate utriton on -
Unit - Congregate Nutrition Meal
expenses for participants such as
Congregate supplies
groceries, produce boxes, PPE, food
for nutrition .
service equipment.and other costs
programs, food
associated with providing a
service equipment
congregate meal eaten in
(less than $5,000),
person/virtually where people dine
and expenses for
together. Costs associated with start-
client grocery/food
907
up of new sites, staff hiring and new
boxes.
$ 8,674.00
Title III -C2 Allocation: $ 144,318.00
Title 111-C2 TOTAL: $ 144,318.00
CODE
CODE DESCRIPTION
PROJECTPROPOSAI BUDGET
Support unit cost for
HpNI meals to
continue providing
061: ARPA-Home Delivered Meals - Home Delivered
services for
Meals (III -C2) Meals to home -delivered meal clients
homebound seniors
that may or may not meet one-third of the
In an effort to
recommended daily allowance dietary reference
improvetheir
intake (RDA -DRI) requirements. Not eligible for NSIP.
nutrition and social
61
One unit=one meal.
health. $80,318.00
HDM supplies
(delivery bags, hot
packs, labels, etc.),
equipment
maintenance &
repair, shed
replacement (more
than $5,000) to store
906: ARPA-HDM Non -Unit - Home Delivered Meal
HDM supplies and
expenses for participants such as produce boxes, PPE,
commodity boxes,
food service equipment and other costs associated
and purchase
with providing service. One unit=one item purchased
grocery/food boxes
906
or one expense.
for clients in need. $64,000.00
Title III -D Allocation: $ 30,082.00
Title III -D TOTAL: $ 30,082.00
402
Funding will support
12 (mirror BG code 401): ARPA-III-D Evidence-
instuctor cost,
ised Health Promotion -ACL approved
supplies, training
,idence-based health promotion/disease
and license fees to
evention program expenses such as training
increase evidenced
aterials, program licenses, and other unique
based health
ems that allow providers to continue and
promotion/disease
pand service. One unit=one item purchased.
prevention program
ay include training for both seniors and staff
approved by the ACL
these programs. This code will be captured
to expand services at
ARMS - do not report on tracking
the SRC and offsite
402
Title ill -E Allocation:
Title III -E TOTAL:
101,088.00
101,088.00
CODE
CODE DESCRIPTION
PROJECT PROPOSAL
BUDGET
Funding will support
expenses to hire a
causal part time (19
hours/wk) FCSP
program coordinator to
help administer
caregiver support
programs and increase
caregiver education and
program awareness
through events and
marketing. The position
will also help provide
FCSP client follow up
and navigation of
support services to help
ease the stress of
878: FC -ABPA Program Planning $
caregiving. Expenses
Administration -Administrative program
include salary, FICA,
costs, such as bulk purchases and public
equipment; supplies,
information materials related to pandemic
servtracker license, cell
recovery and outreach to caregivers. One
phone fees, and mileage'
878
unit=one expense.
reimbursement.
$51,388.00
879: FC-ARPA Information -
Outreach/program promotion and social
Funding will support
media activities specific to building new
expenses related to
partnerships on behalf of caregivers and
caregiver education
reaching new caregivers who have not been
events, promotion fees
served by FCSP in the past. One event/post
and supplies, materials
associated with audience size is recorded for
for outreach, and lunch
879
tracking purposes.
and learn events.
$5,000.00
Funding will support
882: FC-ARPA Respite - Respite care provided
respite expenses for
to caregivers during the pandemic recovery,
home health
All respite types paid for through ARPA
care/companion
funding should be coded under this category.
services, adult day care,
The type of respite should be identified.
and respite care
Number of hours or respite is recorded for
vouchers for consumer
882
tracking (ex:4 hours=4 units).
directed care.
$41,700.00
that allow a caregiver to continue safely care
for the care recipient during a pandemic
Expenses will support
recovery phase. This category includes
caregivers with
consumable supplies, assistive technologies,
supplemental support
safety/DME equipment, emergency response
to provide assisted
systems, and other items as approved to
technology, safety
further a caregiver's ability to continue to
equipment, emergency
provide tare. Track the number of items
response systems, and
883 provided (ex:1 case of cleaning.supplies and
consumable supplies. _ $3,000.00
Division of Aging and Adult
Provider: Senior Resource Center
county: New Hanover
Project Start Date: July 1, 2022
Project End Date: lune 30, 2024
Revision H: Date: 7/8/2022
1. Projected Revenues
Grand
Total
COVID-19 DISASTER GRANTFUNDING from DAAS and AAA
I I I I I { { {
ARPAFunding
$
754,56E I.IIIIIIII
$
IIIIIIIII
A. Subtotal COVID-19DisasterGrant .Funding
$
491,396
B.'naai -, NOT Required
0 I{jII{III'
C. Subtotal, ARPA Funding
$
491,396 ) { I I (({ I I
D NS'n NO1 allowed
0
E. OAA Title V Worker Wages, Fringe Benefits and Costs
Local Cash, Non -Match
$
I I Lf
I { I I (III I
I I I A I (l i {III I
1)
$
- 111911111
z)
$
IIIIIIfII
4)
F. Subtotal, Local Cash, Non -Match
Other Revenues, Non -Match
1)
$
111111111
$
1II{II{II
2)
$
IIIIIIIII
3)
S
VIIIIIII
G. Subtotal, Other Revenues, Non -Match
$
Local In -Kind Resources (Includes Volunteer Resources)
{ I I
1 I I I I{ 1 1 1 1 1 1{ I I
il_
2)
S
S
- 11{111111
IIII{1111
3)
$
- IIIIIIIII
H. Subtotal, Local In-kind Resources, Non -Match
T--
-1.
1. consumer Contributions
$
- I I { I {III I
J. Total Projected Revenues (Sum of C, 0, E, F, G, H, & 1)
$
491,396
SERVICE COST COMPUTATION
Grand Admin.
11. Line Item Expense
Total
Cost
Staff Salary From Labor Distribution Schedule
I I
I111111
I i I I l i I f i
1) Full-time Staff -
$
86,176
2) Park-time staff (do not include Title V workers)
A, Subtotal, Staff Salary
$
$
-
86,176
Fringe Benefits
1) FICA @ %
$
'. 6,592
2) Health ins. @
3) Retirement (local govt and 401k)
$
$
20,968
11,978
4) Unemployment insurance
$
146
5) Worker's Compensation
$
-
6) Other
B. Subtotal, Fringe benefits
$
$
39,684
$
Localln-Kind Resources, Non-Match
iillilill.
Illilllii
1) County
$
2)
$
3)
$
C. Subtotal, Local In-i0nd Resources Non-Match
$
-
$
D. OAA Title V Worker Wages, Fringe Benefits and Costs
$.
Travel
1) Per Diem
is
-
2) Mileage Reimbursement
$
-
3) other Travel Cost:
E. Subtotal, Travel
-$
$
¢
General Operating Expenses
J I l
I l 111 i
f l I (I I I I I
1) Supplies, food boxes, equipment, M&R, contracted services
$
324,992
2):Computer equipment '
$
5,898
3) Software fee
$
12,566
4)'Cell phone :
$
1,080
5). Mileage Reimbursement
$
2,000
6) Printing
$
1,800
7) Outreach cost (materials, event dues, etc.)
$
3,200
8) Captiai Cost
$
14,000
Subtotal, General Operating Expenses
$
365,536
$ -
G. Subtotal, Other Administrative Cost Not Allocated
) I 1111
I I(
I f I I I (III
rF.
in tines ILA through F
H. Total Proj: Expenses Prior to Admin. Distribution
$
491,396.
$ -
1. Distribution of Admininistrative Cost
$
J. Total Proj. Expenses After Admin. Distribution
is
491,396
I LI I I I I I I
SERVICE COST COMPUTATION
Grand
IR. Computation of Rates - - -
Total
A.
Computation of Unit Cost Rate: III 11)
1. Total Expenses (equals line 11.1) $
2. Total Projected Units U I I I
I I I
491,396
I I I I
I I I I I I I i l
I I I I I I I I I
111111111
Line 1.6
I Total Unit Cost Rate
IIIIIIIII
11 I I I I 1 I I
B:.Computation
of Reimbursement Rate: I I I I I!
1. Tota) Revenues (equals line IJ) $
I I I
491,396
I l I I l I l l l
11 I I I I I I J
Total Funding
2 6;i, N.A. (nolallowed-see Line I.D)
0
ProjectedARPAReimbursed Units
Line III.0
Title V (equals line LE less 11.0) $
Total Reimbursement Rate
Line 111 .8.9
Col G
Non Match In -Kind (equals fine LH less ILC) $
-
I LI I I I I I
I
3. Revenues Subject to Unit Reimbursement $
491,396
4 Total Projected Units (equals line III.A.2) I
I I I I I LI I
I I I I I I I -I I
5. Total Reimbursement Rate I
I l l l l l l l
I I I I I I I I I
C.
Units Reimbursed through ARPA Funding
D.
Units Reimbursed through Consumer Contributions* I
I PI I I I f I
I I I I I I I I
E.
Units Reimbursed through Remaining Revenues
F.
Total Units Relmbursed/Total Projected Units IIIII-)III
.IIIIIIIII
ARMS deducts reported consumer contributions from
reimbursmet paid to providers. Line III -D indicates the
number of units allowed that will have to be produced in
addition to those stated on line III.0 in orderto earn the
net revenues stated on line I.C.
on this form (DAAS-732-A COVID) corresponds with
stated on the Provider Services Summary (DAAS-732 ARPA)
follows:
ARPA Funding
Line LA
ARPA
Col. A
Local Match (NOT REQUIRED for ARPA grants)
Line 1.6
Col.B
ARPA Net Service Cost
Line LC
Coi. C
NSIP(NOT ALLOWED for ARPA services)
Line 1.13
COLD
Total Funding
Line LC
Col. E
ProjectedARPAReimbursed Units
Line III.0
Col: F
Total Reimbursement Rate
Line 111 .8.9
Col G
COVID-19 EMERGENCY RESPONSE AND RECOVERY:.
AMERICAN RESCUE PIAN ACT
Service Cost Computation Worksheet
DAAS-732-A-ARPA
IIIC2 IIIC2 III0 IIIC1 [IIB
IIIB
1118
IIIB
BIB
Service
Service
. Service Service
Service
Service
Service
Service
Service
ARPA-HDM
(061)
ARPA-HDM
(906) Non-
Unit
ARPA- ARPA-
CONG (062) CONG (907)
Non•Unit
ARPAATSS ARPA-
Outreach Senior
(201) Center Ops
(172)
ARPA- ARPA-Chore
'Housing & (047)
Home
Repair
942 ,
ARPA-Chore
Enhanced
(048)
II1F111)I
16lilllll
Iliilllll IIIIIIIII
IIIIIIIII
Ililllfli
IIIIIIIII
'IIIIIIIII
111111111
$ 80;318
$ 64,0001
$ 130,000. $ 8,674
$ .158,404.
;$ 20,000:
:$ 24,000
$ 6,OD0;
$ 12,000
$ 80,318
$ 64,000
$ 130,000 $ 8,674,1
$ 158,404
$ 20,000
$ 24,000
$ 6,OD0
$ 12,000
0
0
0 01
0 0'
0 0
$ 80,318
$ .64,000
$ 130,000 $ 8,674
$ 1s8,404
$ 20,000
T 24,000
$ 6,000
$ 12,006
0
0
0 0
0 01
0 0
;:: 0
Illlilill
111111111
11111lI1f IIIIIIIII
Illilllll
IIIIIIIII
11111111!
IIIIIlIiI
Ifllliil!
.IIIIIIIII
IIIIIIIII
Illlllllf IIIIIIIII
Illilliil
IIIIIIIII
IIIIIIIII
111111111
Llllllll(
-
IIIiIIIIi
IIIIIIIII
llillllil IIIIIIIII
IIIIIIIII
IIIIIIIII
IIIIIIIII
IIIIII111
Illlillll
64,000
$ 13Q000 $ 8,674
$ 158,404
-$ 20,000
$ 24,000.
$ 6,000
$ 12,000
Service
Service
service
Service
.Service
service
Service
ServiceService
ARPA-HDM
ARPA-HDM
ARPA-
ARPA-
ARPAATSS
ARPA-
ARPA-
ARPA-Chore
ARPA-Chore
(061)
(906) Non-
Unit
CONG (062) CONG (907)l Outreach
Nan -Unit (201)
Senior
Center Ops
(172)
Housing &
Home
Repair
(047)
-
Enhanced
(048)
11111111L
IIIIIIIII
tllllllll
Ii111ll11
IIIIIlIlI
IIIlllll(
IIIIII111
IIIIIIIII
llHlllil
----
$ 86,176
86,176-
IIIIIIIJI
IIIIIIIII
IfIllllli.
IIIIIIIII
IIIIIIIII
111111111
111111 -III
IIIIIIII)
IIIIIIIII
$ 6,592-
-
$ 20,968
$ 11,978
-
$ 146
$
$
$
$ 30,684
$
$
$
$
IIIIIIIII
111111111
IIIIIIII
illllllll
IIIIIIIII
Illlllllf
11111J111
IIIIIIJII
Illlillll
lilllllll
IIIIIIIII
11(1111.11-
Illllilll
IIIII111(
_111IU111
Ililllfll
liJiillll
11111
-Illi
111111111
Illllflll
IUIIIIII
IIIIIIIII
IIIIIIIII
111illlll
IIIIIIIII
lllllliil
Illlillll
$
80,318
$ 50,000
$ 130,000:
$ 8,674.
I$ 6,000
$ 20,000,$
24,000
$
:6,000
$
=12,000
$ 5,898
I$ 12,566
$ 1,080
'$ 21000
'.
---
,$ 1,800
$ 3,200
-
$ 14,000
$
80,318
$ 64,000
$ 130,000
$ 8,674
S 32,544
$ 20,000
$ 24,000-
$
- 6,000
$
12,000
IIIIIIIII
lililflll
.IIIIIIIfI
IIIIIIIII
111111111.
111111111
111111111
Illflllll
IIIIIIIII.
i111111I1
IIIIIIIII
Illlllfll
((1111111
IIIIIIILI
IIIIIIII
IIIIIfIII
IIIIJIII1
II1111111
IIIIIIIII
IIIIIIIII
iI1111111
IIIIIIIII
Aimmi
Mimi
IIIIIIIII
IIIIIIIII
II1111111
$
80,318
$ 64,000
$ 130,000
$ 8,674
$ 158,404
$ 20,000
$ 24,000
$
61000
$
121000
$-
$
$ -
$
$
$- -
$.
$
-
$
-
$
80,318
$ 64,000 -
$ 130,000 1
$ 8,6741$
158,404
$ 20,0001$
24,000
$
6,000
$
12,000
Service
Service
Service
service
I Service
Service
Service
Service
Service
ARPA-HDM ARPA-HOM
(051) (906) Non-
ARPA- ARPA-
LONG (062) LONG (907)
ARPA-CESS
Outreach
-ARPA-
Senior
ARPA-
Housing &
ARPA-Chore
(047)
ARPAChore
Enhanced
Ililiflll
Illi
llil
Illlllifl
IIIIIIIII
IIIIIIIII
ICIIII(II
lIIIiIIII
IIIII1111
IIIIIIIII
$
80,318
11,804
$
64,000
$
130,000
18,988
$
8,674
$
158,404
$
20,000
$
24,000$
-6,000
--
$
12,000:
$---6.8043
$-
6.8464
--
111111(11
IIIIIUf(
111111111
Iillillll
Ifllillll
IIIfIIIII
IIIIIIIII
Ifllillll
IIIIIIIII
-$
80,318
$
64,00D
$
_130,000
$
:8,674
$
158,404
$
20,000
$
24,000
$
6,000
$
12,000
0
0
0
0'
0
0
0
0
0
$
-
$.
-
$
$
-
$
-
$
-
$
-.
$
80,318
$
64,000
$
,130,000'
$
8,674
$.
158,404
$
20,000
$
24,000.
$
6,000
$
12,000
$.11,804
$
-
$
18,988
$
-
$
-
$.
-
$-
$
6.8043
$
-
$.
6.8464
$
-
$
-
$
-
$
-
$
-
$
0
0
0
0
0
0
0
.0
0
0
ol
0
0.....
0
R.-..
_. 0:0
0
0-
0-
0
0
0'0
-0
0
0
0
0
0
0-
0
-0
0
0
--0
IIIB IIIB
1118
IIIE
111E
IIIE
111E It ID
Service Service
Service
service
service
service
Service Service
ARPA-Trans ABPA-Trans
(259) Vouchers
(248)
ARPA-in Home
Support
Services (960)
Non-unit
ARPA-FCSP
(876) Program
& Planning
Admin
ARPA-FCSP
(879)
Information
ARPA-FCSP
(882) Respite
ARPA-FCSP:ARPA-111-0
(883) (402)
Supplemental EBHP
IM11111 111111111
1111111!1
111111111
111111111
1 IIIIIIIII
11111/111 Ulllllll
$ 70,000. $ 30,600
$ 20,000
$ 51,388
$ 5,000
$ 41,700
$ 3,000 S-3 0,082
$ 70,000 $ 30,000
0 0
$ 20,000
0
$ 51,388
D
$ 5,000
0
$ 41,700
0
$ 31000 $ 30,082
0 0
$ 70,000 $ 30,000
0 0
$ 20,000.
0
$ 51,388
0
$ 5,000
0
$ .41,700
0
$ 3,000 $ 30,082
0 d
111111111 111111111
illlllill
11(111111
1,548.
IIIIIIIII
,..
illlll.l!!
IIIIIHlI .IIIIIIIII
3,548
$
$
S
III111111 1/1111111
111111111
1111 l 1111
111 1111!1
Illlillll
111111111 111!11111
11111.1111 111111111
I Ii1.11111
111111111
Ili l 1!111
IIIIIIIII
I Il l 11 111 111111111
$ 70,000 $ 36,000
$ 20,000
$ 52,936
$ 5,000
$ 41,700
$ 3,000 $ 30,062
Service Service
Service
Service
service
service
service Service
ARPA-Trans ARPA-Trans
ARPA-In Home
ARPA-FCSP I
ARPA-FCSP I
ARPA-FCSP I
ARPA-FCSP ARPA-III-D
(259)
Vouchers
(248)
Support 1(878) Program (879) (882) Respite {883)
Services (960) & Planning Information Supplemental
Non-unit Admin
..........
(402)
EBHP
1.11111111
(Illlflll
Illlllllf
IIIIIIIII
Illilllll
IIIIIIIII
IillIII11
IIIIIIIII
$ 41,496
41,496
IIIIIIIII
lfilillPl
IIIII1111
11111111!
$ 3,174
IliliJli!
IIIIIIIII
1CIIIJ111
IIIIIIIII
S
$
$
S 3,174
.$
$
IIIIIIIII
Illllilil
711IIIJ11
Iflllllfl
Ifiilllll
Timm
IIIIIIIII
111111111
IIIIIIIII
lIIfIIfII
illllllll
Illfillll
Illlillll
111111111
111111111
IIIIIIIII
Illllllli
IIIIIIIII
111111111
II11U1lI
IIIIIIIII
11 111111
IIIII1111
Ilil1l11i
$ 70,000
$ .30,000
$ 20,000
$ ._..,3,200
S 2,566
is _._ _ 1,080
00
00
$ 1,000
=20,000
0
$ 4,000
;
$ 70,000
$6
$ 5,000
$ 41,700
$ 3,006
$ 30,082
fiflll
llillflJlll
IIIII1111
1)1111111
IIIllllll
IIIIRIII
Illllflll
llilllLl!
Illllitll
111111(11
Illllllll
IIIIIIIII
IIIllllli
IIIII1111
Illliilll
11I1llili
Tiiii-ii i
Iiiiiilif
II [fill
111111111
1II11UJl
$ 70,000
$ 30,000
$ 20,000
$ 52,936
$ 5,000
$ 41,700
$ 3,000
$ 30,082
$
$
$
$ -
$ -
$
$ - -
.$
$ 70,000
$ 30,000
$ 20,000
$ 52,936
$ 5,000
$ 41,700
$ 3,000
$ 30,082
Service
Service
Service
Service
Service
Service
Service
Service
ARPA-Trans
(259)
ARPA-Trans
Vouchers
ARPA-!n Home
Support
ARPA-FCSP
(878) Program
ARPA-FCSP
(879)
ARPA-FCSP
(882) Respite
ARPA-FCSP
(883)
ARPA-111-D
(402)
111111111
$
70,000
111111111
$
30,000
111111111
$_
20,000
111111111
$
52,936
111111111.
$ 5,000
111111111-
$
41,700
111111111
$
3,000..
111111111
$
30,082.
3,740
11.1111111
18.7166
111111111
1111111II
111111111
IlUlllli
1!1111111.
111111111
Iilllllll.
$
70,000
$
30,000
$
20,000
$
52,936
$ 5,000
$
41,700
$
3,000
$
30,082
0}
Di
0
ol
ol
0
0
$
$
$
70,000
3,740
18.7166
$
$ .
$.
30,000
$
$
$
20,000
$.
$
$
52,936.
-
$ 5,000
$. -
$
$
$
$
41,700
-
$
$
$
3,000
-
$
$
$
30,082
-
0
0
0
0
0
0
0
'0
0
0
0
0
0
0
0
0
'0
0
0
-0
0
0
0
0
0
0
0
0
0
-0
0
0
Division of
C
8,
COVID-19 EMERGENCY RESPON:
AMERICAN RESCUE P
Labor Distribution 5(
FULLTIME
STAFFNAME POSITION PARTTIME
TOTAL
SALARY
ADMIN.
SALARY
878
201
- SERVICE
TBA OUTREACH FULLiIME
TBA CASUAL PART TIME FCSP-CPT PARTTIME.
$
$
125,800
44,7$0
$
44,780
$
125,860
SUBTOTAL FT:
$
125,860
$ -
$
-
$
12S,860
SUBTOTAL PT:
$
44,780
$ -
$
44,780
$
-
$-
TOTAL
$
170,640
$ -
$
44,780
$
125,860
$ -
PERCENT FT:
73.76%
O.00%jl
100.00%
PERCENTPT:
26.24%
100.00%
O.00%
ATTACHMENT B - FEDERAL CERTIFICATIONS
The undersigned states that:
1, He or she is the duly authorized representative of the Provider named below;
2. floor she is authorized to make, and does hereby make; the following certifications on behalf of
the Provider, asset out herein.-
a.
erein:a. The Certification Regarding Nondiscrimination;
b. The Certification Regarding Drug -Free Workplace Requirements;.
c. The Certification Regarding Environmental Tobacco Smoke;
d. The Certifleatfon Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion
Lower Tier Covered Transactions; and
e. The Certification Regarding Lobbying;
3. }Ie or she bas completed the Certification Regarding Drug -Free Workplace Requirements by
providing the addresses at which the contract work will be performed;
4. [Check the applieabie statement]
[ ] He or she has completed the attached Disclosure of Lobbying Activities because the Provider has
made, or has an agreement to make, a payment to a lobbying entity for influencing or attempting to
influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with a covered Federal action;
OR
[ X ] He or she has not completed the attached Disclosure Of Lobbying Activities because the Provider has
not made, and has no agreement to make, any payment to any lobbying entity for influencing or
attempting to influence any ofiicer or employee of any agency, any Member of Congress, any officer or
employee of Congress, or any employee of a Member of Congress in connection with a covered Federal
action.
5. The Provider shall require its subcontractors, if any, to make the same certifications and
disclosure.
New Hanover County,,___—_ UJ" ' Com ---
Provider f j Date
Manager
I. Certification Regarding Nondiscrimination
The Provider certifies that it will comply with all Federal statutes relating to nondiscrimination. These include
but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P,L. 88-352) which prohibits discrimination
on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended
(20 U.S.C. §§7681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of
10
the Rehabilitation Act of 1973, as amended (29 U.S.C, §794), which prohibits discrimination on the basis of
handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107), which prohibits
discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as
amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to
nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Title Vlll of the Civil Rights Act of 1968 (42
U.S.C. §§3601 et seq.), as amended, relating to nondiscrimination in the sale, recital or financing of housing; (h)
the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political
beliefs; and (i) the requirements of any other nondiscrimination statutes which may apply to this Agreement.
II. Certification Regarding Drug -Free Workplace Requirement
1. The Provider certifies that it will provide a drug-free workplace by:
a. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession or use of a controlled substance is prohibited in the Provider's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
b; Establishing a drug-free awareness program to inform employees about:,
i. The dangers of drug abuse in the workplace;
ii. The Provider's policy of maintaining a drug-free workplace;
iii, Any available drug counseling, rehabilitation, and employee assistance programs; and
iv. The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
c. Making it a requirement that each employee be engaged in the performance of the agreement be given a
copy of the statement required by paragraph (a);
d. Notifying the employee in the statement required by paragraph (a) that, as a condition of employment
under the agreement, the employee will:
i. Abide by the terms of the statement; and
ii. Notify the employer of any criminal drug statute conviction for a violation occurring in the
workplace no later than five days;afteir such conviction;
e. Notifying the Department within ten days after receiving notice under subparagraph (d)(H) from an
employee or otherwise receiving actual notice of such conviction;
f. Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(ii), with
respect to any employee who is so convicted:
i. Taking appropriate personnel action against such an employee, up to and including termination; or
ii. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State, or local health, law enforcement, or other
appropriate agency; and
g. Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and (f).
2. The sites for the performance of work done in connection with the specific agreement are listed below (list
all sites; add additional pages if necessary):
Street Address, City, State, Zip Code
Street Address, City, State, Zip Code
3. Provider will inform the Department of any additional sites for performance of work under this agreement.
4. False certification or violation of the certification may be grounds for suspension of payment, suspension or
termination of grants, or. government -wide Federal suspension or debarment. 45 C.F.R. 82.510.
III, Certification Regarding Environmental Tobacco Smoke
Public Law 103-227, Part C -Environmental Tobacco Smoke, also known as the Pro -Children Act of 1994 (Act),
requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by
an entity and used routinely or regularly for the provision of health, day care, education, or library services to
children under the age of IS, if the services are funded by Federal programs either directly or through State or
local governments, by Federal grant, contract, loan, or loan guarantee. The law does not apply to children's
services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of
facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may
result in the imposition of a civil monetary penalty of up to $1,000.00 per day and/or the imposition of an
administrative compliance order on the responsible entity.
The Provider certifies that it will comply with the requirements of the Act. The Provider further agrees that it
will require the language of this certification be included in any subawards that contain provisions for children's
services and that all
subgramees shall certify accordingly.
IV. Certification Regarding Debarment, • Suspension, Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions
Instructions
[The phrase "prospective lower tier participant" means the Provider,]
1. By signing and submitting this document, the prospective. lower tier participant is providing the certification
set out below.
2. The certification in this clause is a material representation of the fact upon which reliance was placed when
this transaction was entered into. If it is later determined that the prospective lower tier participant
knowingly rendered an erroneous certification, in addition to other remedies available to the Federal
Government, the department or agency with which this transaction originate may pursue available remedies,
including suspension and/or debarment.
3. The prospective lower tier participant will provide immediate written notice to the person to whom this
proposal is submitted if at any time the prospective lower tier participant learns that its certification was
erroneous when submitted or has become erroneous by reason of changed circumstances.
4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction,"
"participant," "person," "primary covered transaction," "principal,` "proposal," and "voluntarily excluded,"
as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules
12
implementing Executive Order 12549, 45 CFR Part 76. You may contact the person to whom this proposal
is submitted for assistance in obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered
transaction be entered into, it shall not knowingly enter any lower tier covered transaction with a person
who is debarred, suspended, determined ineligible or voluntarily excluded from participation in this covered
transaction unless authorized by the department or agency with which this transaction originated:
6. The prospective lower tier participant further agrees by submitting this document that it will include the
clause titled "Certification Regarding Debarment, Suspension; Ineligibility and Voluntary Exclusion --Lower
Tier Covered Transaction," without modification, in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower
tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from covered
transaction, unless it knows that the certification is erroneous. A participant may decide the method and
frequency by which it determines the eligibility of its principals: Each participant may, but is not required
to, check the Nonprocurement List.
8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in
order to render in good faith the certification required by this clause. The knowledge and information of a
participant is not required to exceed that which is normally possessed by a prudent person in the ordinary
course of business dealings.
4. Except for transactions authorized in paragraph 5 of these instructions, if a participant in a covered
transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred,
ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies
available to the Federal Government, the department or agency with which this transaction originated may
pursue available remedies, including suspension, and/or debarment.
Certification
L The prospective lower tier participant certifies, by submission of this document, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any Federal department or agency.
2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this proposal.
V. Certification Regarding Lobbying
The Provider certifies, to the best of his or her knowledge and belief, that:
1, No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any .
person for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with
the awarding of any Federal contract, continuation, renewal, amendment; or modification of any Federal
contract, grant, loan, or cooperative agreement.
2. if any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing of attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with this Federally
funded contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard
Form SF -LLL, "Disclosure of Lobbying Activities," in accordance with its instructions.
3. The undersigned shall require that the language of this certification be included in the award document for
subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative
agreements) who receive federal funds of $100,000.00 or more and that all subrecipients shall certify and
disclose accordingly.
13
4. This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required .
certification shall be subject to a civil penalty of not less than $10,000.00 and not more than $100,000.00 for
each such failure.
VI. Disclosure of Lobbying Activities
Instructions
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient,
at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title
31 U.S,C. section 1352. The filing of a form is required for each payment or agreement to make payment to any
lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress: an officer or employee of Congress, or an employee of a Member of Congress in connection with a
covered Federal action. Use the SF -LLL -A Continuation Sheet for additional information if the space on the
form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to
the implementing guidance published by the Office of Management and Budget for additional information.
1: Identify, the type of covered Federal action for which lobbying activity is andlor has been secured to
influence the outcome of a covered Federal action.
2. identify the status of the covered Federal action.
3.1 Identify the appropriate classification of this report. If this is a follow-up report caused by a material change
to the information previously reported, enter the year and quarter in which the change occurred. Enter the
date of the last previously submitted report by this reporting entity for this covered Federal action.
4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District,
if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be,
a prime or subaward recipient. Identify the tier of the subawardee, e.g:; the first subawardee of the prime is
the 1st tier. Subawardsinclude but are not limited to subcontracts, subgmnts and contract awards under .
grants.
5; if the organization filing the report in Item 4 checks "Subawardee", then enter the full name, address, city,
state and zip code of the prime Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one
organizational level below agency name, if known. For example, Department of Transportation, United
States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the
full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and
loan commitments.
S. Enter the most appropriate Federal Identifying number available for the Federal action identified in Item I
(e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number, grant announcement number,
the contract grant, or loan award number, the application/proposal control number assigned by the Federal
agency). Include prefixes, e.g., 'RFP-DE790-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency,
enter the Federal amount of the award/loan commitment for the prime entity identified in Item 4 or 5.
10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting
entity identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services and include full address if different from 10(a).
Enter Last Name, First Name and Middle Initial (MI).
11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to
the lobbying entity (Item 10). Indicate whether the payment has been made (actual) or will be made
(planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of
payment made or planned to be made.
14
12. Check the appropriate boxes. Check all boxes that apply. If payment is made through an in-kind
contribution, specify the nature and value of the in-kind payment.
13. Check the appropriate boxes. Check all boxes that apply. If other, specify nature..
14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be
expected to perform, and the date(s) of any services rendered. Include all preparatory and related activity,
not just time spent in actual contact with Federal officials. Identify the. Federal official(s) or employee(s)
contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted.
15. Check whether or not a SF -LLL -A Continuation Sheets) is attached.
16, The certifying official shall sign and date the form, print his/her name, title, and telephone number.
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering acid maintaining the data heeded, and
completing and reviewing the collection of information. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management
and Budget, Paperwork Reduction Project(0348-0046), Washington, D. C. 20503
IS
FORM CD -511 U.S. DEPARTMENT OF COMMERCE
(REV 05/17) CERTIFICATION REGARDING LOBBYING
rots should also review the instructions for certification included in the regulations before completing this form. Signature on this form provides for
ance with certification requirements under 15 CFR Part 28,'New Restrictions on Lobbying: The certifications shall be treated as a material representat
upon which reliance will be placed when the Department of Commerce determines to award the covered transaction, grant, or cooperative agreement.
LOBBYING
As required by Section 1352, Title 31 of the U.S. Code, and implemented
at 15 CFR Part 28, for persons entering into a grant, cooperative
agreement or contract over $100,000 or a loan or loan guarantee over
$150,000 as defined at 15 CFR Part 28, Sections 28.105 and 28.110, the
applicant certifies that to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on
behalf of the undersigned, to any person for influencing or attempting to
influence an officer or employee of any, agency, a Member of Congress in
connection with the awarding of any Federal contract, the making of any
Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of any Federal contract, grant, loan, or
cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will
be paid to any person for Influencing or attempting to influence an officer or
employee of any agency, a Memberof Congress, an officer or employee of
Congress, or an employee of a member of Congress in connection with
this Federal contract, grant, loan. or cooperative agreement, the
undersigned shall complete and submit Standard Form-LLL,'Disclosure
Form to Report Lobbying.' In accordance with its instructions.
(3) The undersigned shall require that the language of this certification be
included in the award documents for all subawards at all tiers (including
subcontracts,-subgrants, and contracts under grants, loans, and
cooperative agreements) and that all subrecipients shall certify and
disclose accordingly.
This certification is a material representation of fact upon which reliance
was placed when this transaction was made or entered into. Submission of
this certification is a prerequisite for making or entering into this
transaction imposed by section 1352, title 31, U.S. Code. Any person who
fails to file the required certification shall be subject to a elvit penalty of not
less than $10,000 and not more than $100,000 for each such failure
occurring on or before October 23-, 1996, and of not less than $11,000 and
not more than $110,000 for each such failure occurring after October 23,
1996,
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief,
that:
In any funds have been paid or will be paid to any person for influencing or
attempting to Influence an officer or employee of any agency,. a Member of
Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with this commitment providing for the
United States to insure or guarantee a loan, the undersigned shall
complete and submit Standard Form,LLL,'Disclosure Form to Report
Lobbying: in accordance with its.instmclions.
Submission of this statement is a prerequisite for making or entering into
this transaction imposed by section 1352, fills 31, U.S. Code. Any person
who fails to file the required statement shall be subject to a civil penalty of
not less than $10,000 and not more than $100.000 for each such failure.
occurring on or before October 23, 1996, and of not less than $11,000 -and
not more than $110,000 for each such failure occurring after October 23,
1996. -
As the duty authorized representative of the applicant, I hereby certify that the applicant will comply with the above applicable certification.
NAME
AWARD NUMBER - % ' PPROJECT NAME
1
Middle Name:
• Last Name: Suffix:
SPAA
Title:151U lotrsc4sr
'SIGNATURE: DATE:
Completed by Grants.gov upon submission. `Completed by Gran .gov upon submission.