HomeMy WebLinkAboutFY24 JCPC ATC Family Preservation agreementDocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
North Carolina Department of Public Safe
Juvenile Justice and Delinquency Prevention
Intensive Intervention - Program Agreement
SECTION I A: SPONSORING AGENCY AND PROGRAM INFORMATION
FUNDING PERIOD:
FY 23-24
DPS/JCPC FUNDING # (cont only)
865-XXXX
COUNTY:
New Hanover
AREA:
Eastern Area
Multi -County:
Yes
Multi -Components:
No
NAME OF PROGRAM:
Alternatives to Committment: Family Preservation Program
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) 525-6630 Fax: 1 (910) 202-5772 E-mail:Ijmain@coastalhorizons.org
FEDERAL ID #156-0950370
COMPONENT ID # NAME OF PROGRAM COMPONENT PROGRAM TYPE TOTAL COST OF
EACH COMPONENT
38199 Homebuilder's Family Preservation Home Based Family Counseling $ 100,00C
Total cost of components: $ 100,00C
Program Manager Name & Address (same person on signature page)
Name:
Joshua Main
Title:
IFPS Consultant
Mailing
Address:
615 Shipyard Blvd.
City:
Wilmington
Zip:
28412
Phone:
(910) 525-6630 Fax: 1 (910) 202-5772 E-mail:Ijmain@coastalhorizons.org
Contact Person (if different from program manager)
Name:
Joshua Main
Title:
IFPS State Consultant
Mailing
Address:
615 Shipyard Blvd.
City:
Wilmington
Zip:
28412
Phone:
(910) 524-6630 Fax: 1 (910) 202-5772 E-mail: jmain@coastalhorizons.org
Program Fiscal Officer (cannot be program manager)
Name:
Jennifer Burns
Title:
Controller
Mailing
Address:
615 Shipyard Blvd.
City:
Wilmington
Zip:
28412
Phone:
(910) 343-0145 Fax: E-mail: jburns@coastalhorizons.org
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION I B: PROGRAM COMPONENT DESCRIPTION
COMPONENT ID #
COMPONENT INFORMATION
38199
NAME OF COMPONENT: Homebuilder's Family Preservation
BRIEF DESCRIPTION: Coastal Horizons provides intensive family preservation modeled off
the Homebuilders Program that is highly successful at reducing out of home placement and
providing support in times of crisis. This program eliminates existing service gaps in the
continuum of care, while diversifying family centered treatment. The model requires caseloads
to remain on average 3 families with ten hours of treatment per week completed by one
professional. Services are rendered in the home for 4-6 weeks.
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION II: COMPONENT STATISTICAL INFORMATION
Multi -Components No
Component Service Statistics
PROGRAM COMPONENT INFORMATION - APPLICATION YEAR
Component Name: Homebuilder's Family Preservation
Component ID #
38199
What is this component's maximum client capacity at any given time?
3
Frequency of client contact per month:
12
Anticipated Average Length of
Stay:
32
Days
y
Total Component Cost:
$100,000
- by
Estimated # to be served during funding period:
18
Estimated Average Cost Per Youth:
$5,556
Applies to
Actual number of youth admitted FY 21-22:
12
12
Number of admissions Juvenile Justice Referred
100% 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 21-22:
16
Form structure last revised 01/09/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION III: COMPONENT SUMMARY
NAME OF COMPONENT:
Homebuilder's Family Preservation
1. Statement of the Problem: In concise terminology, describe how the program will address continuum need(s) in
the county.
What are the Intensive Intervention needs the program intends to address?
How will the program effectively serve juveniles at different levels of involvement with juvenile justice?
Describe the gap in continuum of services for the population you will serve.
Currently, in New Hanover and Pender County there are minimal evidence -based family counseling programs that are
able to meet the network needs. New Hanover and Pender County's continuum of care for youth has gaps that keep
youth and families from being safeguarded in their home communities. These gaps cause many Juvenile Justice
involved families to be underserved or have behaviors that escalate until higher levels of care become needed. Many
of these youth are disqualified from other enhanced levels of care for a myriad of reasons. The existing array of
services is insufficient to meet the community-based family service needs of youth that do not qualify for mental
services because they have not engaged in lower levels of care despite current high-risk behaviors or do not qualify
based on sub -clinical mental health needs. Other gaps are families that need shorter periods of treatment. Most
models of community-based services last for three to six months and employ models not supported by the Office of
Juvenile Justice. A third, and critically impacted portion, are privately insured families. These families find themselves
in a vulnerable position because their insurance companies do not cover the needed care or have deductibles that are
too high for families to financially support their child's care. This leaves families being unable to comply with legal
requirements because they are unable to meet their child's legal, behavioral, and mental health needs. This program
has been able to meet youth on Post -Release and start engaging with the family prior to discharge.
2. Target Population: Describe the target population, including age, and the steps taken to insure that the target
population is served.
This program will serve youth from six to seventeen years old. The service will be open to male and female clients.
The following clients will be appropriate for services:
1.Juvenile court referred youth, between the ages of 10 and 17, or older youth remaining under juvenile court
jurisdiction, who have received a Level II disposition or Level III disposition,
2.Juvenile court referred youth that are high risk Level I adjudicated juveniles, with a Medium Risk or Medium/High
Needs Score;
3.Juvenile court referred Level III youth re-entering the community on community placement or Post Release
Supervision (PRS);
4.Juvenile court referred Level II youth who are most at -risk of a commitment to a YDC;
5. Juvenile court referred Level III or Level II youth re-entering the community from a residential or out of home
placement.
3. Program Goal(s): Provide a brief statement to describe the overall purpose and effect of the program.
The overarching goal of the program is to form an enhanced network of services to decrease delinquent and criminal
behaviors, reduce unnecessary out -of -home placements, and offer concrete supports to families during time of needs.
Coastal Horizons Center's mission is to promote choices for healthier lives and safer communities. This program will
advance the mission of our organization by helping to ensure that some of the most marginalized juveniles have their
mental health and behavioral health needs met.
The developers of this model describe the goals as followed: HOMEBUILDERS® provides intensive, in-home crisis
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION III: COMPONENT SUMMARY
NAME OF COMPONENT:
Homebuilder's Family Preservation
intervention, counseling, and life -skills education for families who have children at imminent risk of placement in state -
funded care. It is the oldest and best -documented Intensive Family Preservation Services (IFPS) program in the United
States. Our goal is to prevent the unnecessary out -of -home placement of children through intensive, on-site
intervention, and to teach families new problem -solving skills to prevent future crises.
(Institute for Family Development, http://www.institutefamily.org/programs_lFPS.asp, 2015).
4. Measurable Objective(s): State in measurable terms (Yo) 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.
80% Clients will comply with the permanency plan as described in the individual service plan.
80% Clients successfully/satisfactorily completing the program will have no new complaints in the 12 months following
completion.
80% Clients and families will demonstrate enhanced family functioning as a result of program services.
80% Clients successfully/satisfactorily completing the program will have no new adjudications in the 12 months
following completion.
80% Clients will have no new adjudications for a complaint with an offense date after the admission date.
80% Clients will successfully or satisfactorily complete services as intended by the program design/service plan.
80% Clients will demonstrate improvement in replacement behaviors targeted in the individual service plan.
80% Clients will have no new complaints with an offense date after the admission date.
80% Clients will reduce specific problem behaviors presented at referral and targeted in the individual service plan.
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 Intensive Intervention services Request for Proposals.
Be sure to identify the specific risk and/or needs item(s) you will address.
Per 2022 YASI Pre-screen:
The most current Risk Comparison Data produced by the Division of Juvenile Justice shows New Hanover County
trending higher than the state in many instances. For overall risk level, New Hanover County is 8% higher than the
state. Additionally, New Hanover County very high needs level is double the 6% reported overall by the state. In
regards to aggression, New Hanover County rates 13% with display of a weapon and 12% using a weapon, the state's
rates are 9% and 7% respectively. Gang association is 15% for New Hanover County while the statewide rate is 9%.
Alcohol/Drug Use overall in the state has increased by 1.2% in 2022 ,whereas Alcohol/Drug Use in New Hanover
County has increased by 10% from 49.6% last year to 59% in 2022.
Per 2021 YASI Pre-screen:
The most current Risk Comparison Data produced by the Division of Juvenile Justice shows New Hanover County
trending higher than the state in many instances. For overall risk, New Hanover County is at 42.2% for moderate risk
and 20.0% high risk in comparison to 38.9% and 16.7% respectively statewide. In reference to aggression, New
Hanover County rates 12.6% with display of a weapon and 11.9% using a weapon, the state's rates are 9.1 % and
8.1 % respectively. Gang association is 13.3% for New Hanover County while the statewide rate is 8.5%. Alcohol/Drug
Use in New Hanover County is almost 15% higher at 49.6% vs. 35.8% for the state. Family Mental Health and Juvenile
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION III: COMPONENT SUMMARY
NAME OF COMPONENT: I Homebuilder's Family Preservation
Mental health rate 2-6% higher in New Hanover County with incidences of neglect, a youth being kicked out of their
home, or running away ranging 5-6% higher than the state's rate.
These elevated risks can be addressed through the funding of the Homebuilder's model for this county. Programming
will address risk and needs though Protective Factors such as concrete support in times of need, children's social and
emotional competence, knowledge of parenting and child development, social connections and parent resiliency. The
program focuses on stabilizing the crisis which put the family at risk. With a focus on making small but significant
changes the ATC / Intensive Intervention Specialist uses the NCFAS assessment to address needs in the
environment, parental capabilities, family interactions, family safety, child well-being, social/community life, and
trauma. These factors affect risk related behaviors such as gang membership, alcohol and drug use, anger
management and aggression. Specific strategies/intervention used are assessments, intensive family/individual
counseling, client advocacy, case management, development/enhancement of parenting skills, referrals to other
services and concrete services. This program will allow Court Counselors to have greater access to evidence -based
treatment, with proven supports. Additionally, this program will give Court Counselors more access to an organization
that they have an established partnership, and that has a wealth of resources housed in one agency.
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION IV: COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Homebuilder's Family Preservation
1. Location: List physical address(es) and describe where program services are delivered.
The program is a community based program, and will primarily be delivered in the juvenile's home. Other acceptable
service delivery places would include services delivered to meet the holistic needs of the child and/or family such as
school, mental health facility, court, Division of Juvenile Justice facility, detention center, and other relevant
collaborative services. The corporations physical address is 615 Shipyard Blvd, Wilmington, NC 28412.
2. Operation: Describe the daily/weekly schedule of program operation.
The ATC / Intensive Intervention worker and their supervisor will adhere to the fidelity of the Homebuilders Model while
providing routine and crisis care available twenty-four hours a day, seven days a week, 365 days per year. Each family
will always receive minimally forty hours of face-to-face contact and have no less than on average three visits per
week. The family will develop a service plan with their Child and Family team. The service plan will serve as the
guiding mechanism for how their services will be tailored. Scheduled hours will be flexible to meet the needs of youth
and families, and this will include night and weekend hours. For this reason, the worker will only carry two cases at a
time per the fidelity of the model.
3. Staff Positions: Describe paid or volunteer position qualifications, (certifications, degrees, work experience) and
position(s) responsibilities relative to this component.
This time-limited service ultimately strives to help parents to have the skills to maintain their child in the home, and to
develop the necessary skills to keep all parties safe. Our professionals are trained in ten hours of trauma focused
Cognitive Behavioral Therapy, thirteen initial hours of North Carolina's System of Care Model, Motivational
Interviewing, eleven hour of crisis intervention including eight hours of NCI, twelve hours of Person Centered Thinking,
and multiple other related trainings for behavioral healthcare specialists. These trainings are intended to be the starting
point of investment in the youth and families that we serve. The staff will attend training in the Homebuilder's model
provided by Homebuilder's State Consultant. The funding will pay for 1 FTE time, dedicated ATC / Intensive
Intervention Specialist and another .25 FTE for the ATC / Intensive Intervention Program Manager in order to maintain
the current number of clients being served in the community. These staff members will have a Bachelors, and
preferably a Master's degree in a social services field and at least one year of relevant work or internship experience.
The program will receive oversight by the Homebuilder's State Consultant that is also trained in the model. The
Homebuilder's State Consultant will also have a minimally a Bachelors degree, preferably a Master's degree along with
three years experience working in the social service field. This position will not be fully funded through this funding
stream. The responsibilities will be to assist the ATC / Intensive Intervention Program Manager and Specialist with on-
call crisis situations, training needs, and supervision related to services, progress, issues, updates, and expectations
of the program. Additionally, the department has a medical records and data collection administrative position that is
connected to the program. This position is a High School Graduate with two years clerical experience or equivalent
combination of education and experience along with experience with third party billing and the ability to work a flexible
schedule. Responsibilities of this position include review of paperwork, filing of paperwork, and whenever needed other
duties assigned.
4. Service Type SPEP: Describe implementation to include:
Primary Service: Family Counseling; Secondary Service: None
Evidence -Based Program Name: Homebuilder's Intensive Family Preservation Services
Target Weeks: 4; Target Hours: 40
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION IV: COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT: Homebuilder's Family Preservation
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.
Please describe:
a) The specific referral, screening, and admission process, including at a minimum, the staff involved with the decision
process.
b) Interaction with Juvenile Court Counselors, other juvenile justice staff, and youth development centers, if applicable,
including frequency, ongoing meetings, and other means of communication.
Coastal Horizons Center values a collaborative process with referring youth that stresses the importance of timely
admission, and to the correct level of care. Based on the Homebuilder's model, youth must be accepted into services
and have their first appointment with a staff member within forty-eight hours of referral. If the program does not have
any available positions then the referring Court Counselor will learn immediately that there are no available spaces,
and when the next projected opening will occur. If a youth is being referred from Youth Development Center then the
Specialist will attend the meeting and these youth will receive priority with spaces on the Specialist's caseload.
Referrals are are given to the ATC/ Intensive Intervention Program Manager. The referral will consist of the NCDPS
Juvenile Justice/JCPC Universal Referral Form, Family Data Sheet, YASI, and any assessments available that have
been completed in the last 12 months. The screening process will ensure that the client is a level 2 or level 3
disposition and are within the ages of 12 to 18. ATC/ Intensive Intervention Program Manager will review referrals with
Homebuilder's State Consultant as received. Reasoning for why a referral is not accepted is if the youth in question is
a level 1 or diversion contract, or under the age of 12 or over the age of 18.
Coastal Horizons Center has been an active participant in local JJSAMHP committees as well as Juvenile Crime
Prevention Councils. These meeting serve as a vehicle to continue communication with vested stakeholders, and
understand the perception of services being offered. Our program intends to follow the expectations generally held by
most JJSAMHP partnerships such as notifying the referring Court Counselor at time of referral, communication once
an intake has been scheduled, providing any assessments or screens completed at intake within five days of intake, a
pre -closure meeting is held one week from discharge, and termination and aftercare paperwork is shared within one
week of discharge.
6. Termination Process: Describe the termination process, to include:
a) The staff responsible for making decisions.
b) The process for making the decision to terminate.
c)The criteria for a successful termination, satisfactory termination, unsuccessful completion, and non-compliant
termination.
The Homebuilder's model requires a pre -closure meeting to occur on the week of the twenty-first day of service. This is
the time when a determination to extend to six weeks typically occurs. At this time, the service plan will be updated to
reflect progress made and aftercare recommendations. A discharge summary will be made available one week from
the discharge date or sooner as requested.
The specialist will maintain open communication with the court counselor regarding the family's progress with the
service. During the Pre -Closure meeting, open conversation will be had with all parties involved regarding
termination.
Successful termination requires the minimum number of hours have been completed (40), progress has been made
towards all goals developed at the start of services, and no new complaints have been received.
Satisfactory termination will be considered when the minimum of hours have been completed (40), progress has been
made in only one goal of multiple goals developed at the start of services, and there are no new complaints have been
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION IV: COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Homebuilder's Family Preservation
received.
Unsuccessful termination will be considered when the minimum number of hours have not been completed (40), no
progress made towards goals that were developed at the start of services, or if there are new complaints that require
additional adjudication.
Non-compliant termination will be considered when client absconds from home, or refuses to meet with specialist after
at least 2 interventions to address attendance/engagement concerns.
How are the Juvenile Court Counselor and/or other juvenile justice staff involved in the termination process?
The court counselor is actively involved in the termination process. The court counselor is invited to the termination
meeting with the juvenile and their family. The court counselor is provided with a copy of the closing letter, case
closure form (indicates goals and contact information for referrals) and weekly progress form (indicates weekly contact
hours and areas addressed), and a discharge summary within seven days of discharge.
7. Referring Agency Interaction: Describe the interaction with Juvenile Court Counselors and/or other juvenile
justice staff, including how client progress will be communicated.
During the duration of service, the Court Counselor will receive at least weekly phone communication, all crisis or
behaviors that impact probationary status will be communicated in a period not to exceed twenty-four hours, and face-
to-face meetings will be accommodated as requested or as needed to coordinate care. Court Services staff will also
receive written correspondence at a minimum of once every 30 days.
8. Intervention/Treatment: Describe specifically:
What will the component do to address intensive intervention continuum needs and/or redirect inappropriate youth
behavior?
How will the component address the identified needs of the youth and family?
What interventions will typically be utilized in this component?
How will parents/guardians be involved?
What is the therapeutic element within the service?
The Institute for Family Development states "HOMEBUILDERSO also works with youth and their families to correct
problems that contribute to delinquency, while allowing the youths to remain in the community. Staff help clients find
the right school setting, attend classes regularly, adhere to curfews, comply with the court, participate in constructive
activities with peers, and learn to manage anger and conflict without getting into trouble. Therapists also help parents
learn to deal with the stress of raising a difficult adolescent (http://www.institutefamily.org/programs_lFPS.asp, 2015)."
The model provides family and individual supportive counseling as appropriate to the education and licensure status of
the staff. The model allows flexibility where to place emphasis between the child or caregiver, however, at least one
caregiver must be actively involved in the services.
The model's key elements are:
Intervention at the crisis point: Services start when the families are in crisis. Client families are seen within 24-48 hours
of referral.
Treatment in the natural setting: Services take place in the client's home or the community where the problems are
occurring and, ultimately, where they need to be resolved.
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION IV: COMPONENT NARRATIVE (attach for each component)
NAME OF COMPONENT:
Homebuilder's Family Preservation
Accessibility and responsiveness: Specialists are on call to their clients 24 hours a day, 7 days a week. Families are
given as much time as they need, when they need it. This accessibility also allows close monitoring of any dangerous
situations.
Intensity: Services are time-limited and concentrated in a period targeted at 4 weeks. The service is designed to
resolve the immediate crisis, and teach the skills necessary for the family to remain together. Each family receives an
average of 40 to 50 hours of direct service.
Low caseloads: Maximum client capacity is 3 cases. This enables specialists to be accessible and provide intensive
services. Low caseloads also allow therapists the time to work on specific psycho -educational interventions, as well as
the basic hard service needs of the family. The services are concentrated to take advantage of the time when families
are experiencing the most pain, and have the most motivation to change.
Research -based interventions: Specialist utilize a range of research -based interventions, including crisis intervention,
motivational interviewing, parent education, skill building, and cognitive/behavioral therapy.
Flexibility: Services are provided when and where the clients wish. Specialists provide a wide range of services, from
helping clients meet the basic needs of food, clothing, and shelter, to the most sophisticated therapeutic techniques.
Specialists teach families basic skills such as using public transportation systems, budgeting, and where necessary,
dealing with the social services system. They also educate families in areas commonly associated with counseling,
such as child development, parenting skills, anger management, mood management skills, communications, and
assertiveness.
9. Best Practice Model: Describe what evidence based/support model(s) or practice the program will use.
North Carolina Child Welfare worked in partnership with Institute of Family Development to employ a state Intensive
Family Preservation model based on the Homebuilders program. Our team works with Child Welfare to implement this
program, and receive fidelity review with the child welfare state consultant. The Homebuilders model has stringent
requirements that staff work with two families on average with the ability to only take a third family during the discharge
week of an existing family. This heightened level of commitment to a small caseload ensures that families are creating
strong therapeutic alliance, greater accessibility to their worker, and allow for progress at a much faster rate. The
model is based on working with families for four weeks with the ability to extend to a maximum period of six weeks at
the request of the referring agency in consultation with the worker. National Research has shown that this model is one
of the most effective models to deliver home based family preservation services (Kirk, Raymond S., and Diane P.
Griffith. 2003. "Intensive Family Preservation Services: Demonstrating Placement Prevention Using Event History
Analysis." Social Work Research 28:5-18) and it is endorsed by the OJJDP website.
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
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, 2023 and shall terminate Jun 30, 2024.
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 $100000 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: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
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: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
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 11C
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:
1. Ensure the Sponsoring Agency uses JCPC funds only for the purposes approved by DPS in the JCPC Program
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Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
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: 148 NCAC 118.0202 and DPS JCPC Policy (policies 1, 3, 7, 8, 9, 10 and 11).
The Countv 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
matters, whether sounding in Program Agreement or tort, relating to the validity, construction, interpretation, and
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Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
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
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Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
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".
Audit Requirement — Non -Governmental Entities
An audit, when required by law, or requested by the County or DPS shall be performed in conformity with generally
accepted auditing standards and audits of non-governmental entities, both for-profit and not-for-profit, and must meet
the requirements of OMB Circular A-133. At a minimum, the required report shall include the financial statements
prepared in accordance with generally accepted accounting principles, all disclosures in the public interest required by
law, and the auditor's opinion and comments relating to financial statements. The audit report must be submitted to the
State Auditor's office as required by law, to the County, and DPS, and to other recipients as appropriate within nine (9)
months after the end of the program's fiscal year.
Oversight
Access to Persons and Records
The State Auditor shall have access to persons and records 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
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
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.
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
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Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
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
agreements.
END OF SECTION V — Terms of Agreement
Form structure last revised 12/20/2013
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION VI: BUDGET NARRATIVE
Alternatives to Committment: Family Preservation Program
Fiscal Year
FY 23-24
Item #
Justification
Expense
In Kind Expense
120
ATC/Intensive Intervention Specialist ($24.05 per hour, 40
hours per week)
$50,024
120
ATC/Intensive Intervention Program Manager ($26.60 per hour,
10 hours per week)
$13,832
180
ATC/Intensive Intervention Specialist fringe benefits (100% of
benefits package)
$11,500
180
ATC/Intensive Intervention Program Manager fringe benefits
(25% of benefits package)
$3,180
220
Flex funding spending averaging $500 per family as indicated
by Homebuilder's model
$9,000
260
Work supplies
$1,200
310
Mileage reimbursement ($0.565 for Specialist's personal
vehicle)
$2,600
320
Cell phone and WiFi expenses for staff specialist
$3,175
390
Initial and on-going professional development training
$1,250
390
5100 Administration Cost, Fair Share Portion, Program
Assigned Cost (ATC/II portion)
$4,239
TOTAL
$100,000
$0
Job Title
Annual Expense
Wages
Annual In Kind
Wages
ATC/Intensive Intervention Specialist
$50,024
ATC/Intensive Intervention Program Manager
$13,832
TOTAL
$63,856
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION VII: BUDGET NARRATIVE LINE ITEM SUMMARY
Program: Alternatives to Committment: Family Preservation Program
Fiscal Year: FY 23-24 Number of Months: 12
Form structure last revised 12/31/2012
Department of Public Safety
Cash In Kind
Total
I. Personnel Services
$78,536
$78,536
120 Salaries & Wages
$63,856
$63,856
180 Fringe Benefits
$14,680
$14,680
190 Professional Services*
$0
*Contracts MUST be attached
II. Supplies & Materials
$10,200
$10,200
210 Household & Cleaning
$0
220 Food & Provisions
$9,000
$9,000
230 Education & Medical
$0
240 Construction & Repair
$0
250 Vehicle Supplies & Materials
$0
260 Office Supplies and Materials
$1,200
$1,200
280 Heating & Utility Supplies
$0
290 Other Supplies and Materials
$0
III. Current Obligations & Services
$11,264
$11,264
310 Travel & Transportation
$2,600
$2,600
320 Communications
$3,175
$3,175
330 Utilities
$0
340 Printing & Binding
$0
350 Repairs & Maintenance
$0
370 Advertising
$0
380 Data Processing
$0
390 Other Services
$5,489
$5,489
IV. Fixed Charges & Other Expenses
$0
410 Rental or Real Property
$0
430 Equipment Rental
$0
440 Service and Maint. Contracts
$0
450 Insurance & Bonding
$0
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
$100,000 $0
$100,000
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
SECTION VIII: SOURCES OF PROGRAM REVENUE (ALL SOURCES)
FY 23-24 New Hanover County Funding ID: 865-XXXX
Sponsoring Agency:
Coastal Horizons Center, Inc.
Program:
Alternatives to Committment: Family Preservation Program
$100,000 DPS/JCPC Funds
' This is the amount approved in your application
0% Local Match Rate
Is the Local Match Rate 10%, 20% or 30%?
County Cash
(Specify Source)
Local Cash
(Specify Source)
Local Cash
(Specify Source)
Local In -Kind
(Specify Source)
Other
(Specify Source)
Other
(Specify Source)
Other
(Specify Source)
Other
(Specify Source)
$100,000 TOTAL
$0 $0
Prevention Council.
Required Local Match Match Provided
e—DocuSigned by:
�--798FF7A4Rn9F419
6/15/2023
Authorizing Official, Department of Public Safety
Date
The following signature certifies that this program agreement has been locally approved by the Board of County
Commissioners.
,—DocuSigned by:
�' I
t`L (A,&
�C6B88cFc5D1A485...
6/15/2023
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.
e—DocuSiignned by:
J R '� '" uu 11
`-3f)nAF15f)4A2540C
6/14/2023
Chair, Juvenile Crime Prevention Council
Date
e— DocuSigned by:
�OSU IAA nil AAlit
�QARF�RF�QR7Ad('F
6/14/2023
Program Manager
Date
Form structure last revised 12/31/2012
Department of Public Safety
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
Department of the Treasury
Internal Revenue Service
In reply refer to: 0248288031
CINCINNATI OH 45999-0038 Feb. 06, 2019 LTR 4168C 0
56-0950370 000000 00
00008433
in BODC: TE
035456
COASTAL HORIZONS CENTER INC
615 SHIPYARD BLVD
WILMINGTON NC 28412
Employer ID number: 56-0950370
Form 990 required: Yes
Dear Taxpayer:
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 (IRC) Section 501(c)
(3).
We also show you're not a private foundation as defined under IRC
Section 509(a) 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 heading 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
- Form 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 6033(j), 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.,
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
0248288031
Feb. 06, 2019 LTR 4168C 0
56-0950370 000000 00
00008434
COASTAL HORIZONS CENTER INC
615 SHIPYARD BLVD
WILMINGTON NC 28412
local time, Monday through.Friday (Alaska and Hawaii follow Pacific
time).
Thank you for your cooperation.
Sincerely yours,
Kim A. Billups, Operations Manager
Accounts Management Operations 1
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
PENDER COUNTY
JUVENILE CRIME PREVENTION COUNCIL
February 17, 2023
Ms. Pamela Stokes
Eastern Area Lead Consultant
Department of Public Safety
2241 Dickinson Avenue
Greenville, NC 27834
Dear Ms. Stokes:
The Pender County Juvenile Crime Prevention Council is pleased to commit to the
Homebuilders Grant, submitted by Coastal Horizons Center, Inc. Coastal Horizons is a leader in
providing family counseling services. The agency offers a variety of mental health and wellness
supports in the community. They are and have been a vital partner of the Division of Juvenile
Justice. Historically the partnership between Coastal Horizons and the Pender County Juvenile
Crime Prevention Council (JCPC) has been significant and productive. The agency has
demonstrated the ability to initiate new programs through good leadership and collaborative
partnerships with various agencies.
The Alternatives to Commitment program provides Intensive Family Preservation Services that
align with the mission of the JCPC. The mission of this service is to deliver immediate
interventions for at -risk, adjudicated youth upon their return to the community in an effort to
prevent their return to a Youth Development Center or another out -of -home placement.
Involving and supporting the family is a crucial component of the program. Connections to
community resources, goal setting, problem solving, skill building, and teaching replacement
behaviors are a few of the strategies implemented.
Coastal Horizons' Homebuilders Alternatives to Commitment program meets all the
qualification as outlined in the county Plan of Action. Without programs such as Homebuilders,
many of the youth and their families would not have the opportunity or skills to successfully
remain in the community and become productive citizens.
Res ectfully submitted,
Dee Turner
Chairman, Pender lCounJCPC
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
NEW HANOVER COUNTY
JUVENILE CRIME PREVENTION COUNCIL
230 Government Center Drive
New Hanover County
Suite 195
N O RTH OC.A R P LINA Wilmington, North Carolina 28403
February 17, 2023
Ms. Pamela Stokes
Lead Area Consultant
Department of Public Safety
2241 Dickinson Avenue
Greenville, NC 27834
Dear Ms. Stokes:
The New Hanover County Juvenile Crime Prevention Council is pleased to commit to
the Homebuilders Grant, submitted by Coastal Horizons Center, Inc., for an eighth year. Coastal
Horizons is a leader in providing family counseling services. The agency offers a variety of
mental health and wellness supports in the community. They are and have been a vital
partner of the Division of Juvenile Justice. Historically the partnership between Coastal Horizons
and the New Hanover County Juvenile Crime Prevention Council (JCPC) has been significant
and productive. The agency has demonstrated the ability to initiate new programs through
good leadership and collaborative partnerships with various agencies.
The Alternatives to Commitment program provides Intensive Family Preservation Services that
align with the mission of the JCPC. The mission of this service is to deliver immediate
interventions for at- risk, adjudicated youth upon their return to the community in an effort to
prevent their return to a Youth Development Center or another out -of -home placement.
Involving and supporting the family is a crucial component of the program. Connections to
community resources, goal setting, problem solving, skill building, and teaching replacement
behaviors are a few of the strategies implemented.
Coastal Horizons' Homebuilders Alternatives to Commitment program meets all the
qualifications as outlined in the county Plan of Action. Without programs such as Homebuilders,
many of the youth and their families would not have the opportunity or skills to successfully
remain in the community and become productive citizens.
Sin r
Honora H. orpening II
Chief District Court Judge
Chairman, New Hanover County Juvenile Crime Prevention Council
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
COASTAL HORIZONS CENTER, INC.
1'iomoling choiccs lorlic;dthicr lives and salcr comnuuiidcs'
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.
Colin Hackman
Print Name
Signature
9122/2021
Date
Board of Trustees Conflict of Interest Policy.doc//2120/18
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
tiCoastal
Horizons
Margaret Weller-Stargell, February 6, 2023
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
910.790.0t89 Fax
Open House Youth Shelter
(910)392-6926
Rape Crisis Center
(910) 292-7185 New Hanover
(910) 754-7949 Brunswick
Outpatient Treatment
(800167L 2903
(910)343-0145 New Hanover
(910)754-4515 Brunswick
(910) 259 0663 Pender
Community Based
Family Services
(910) 202-3155
Horizons Health
Primary Care
(910) 202-3860
WHAT
(910) 7909949
Continuum ofcare
(910)Z166080
Prevention Services
(910) ,o2 0840 - _
O 7400rAdventure
t110)492-7306-
T=C
.(9:0)7621 23 NewHaxuver
'i.f'�S%
tcyD) 038-3909 Region 1
(910} 221-6793 Rgion 2
NC TASC Training
Institute
(910) 202-5500
Our Children's Place
(919) 904-4286
Recidivism Reduction Services
(910)L02-5125
RESET
(910) 7625333
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 -lb.
Sworn Statement:
Colin Hackman 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.
DUMWAO—WAMM—WRA
Chair
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: Aq,%% 11� 102.3
' 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."
Ego txcp,/P
y r
*car * CAR - International Accreditation for Quality WWW.COaSidIl10T1ZOI15.Org
CABHA - Critical Access Behavioral Health Agency
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
a y o
n. 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 with
the N.CG.S. 143C-6-23 (b), every Grantee shall file with the State agency/Grantor 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 members of its board or other governing body, from the
Grantee's disbursing of State funds and shall include actions to be taken by the Grantee or the
individual, or both to avoid 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 funds.
The Grantee shall submit this form (Not for Profit DPS Conflict of Interest Policy Statement Form
DPS 13 001) along with the agency's conflict of interest policy when applying for funding.
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 funded 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 from any contract or grant funded in whole or in part by State
funds 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.
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 1 of 3
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
NC DEPARTMENT OF PUBLIC SAFETY 10 WA
NOT FOR PROFIT
DPS CONFLICT OF INTEREST POLICY STATEMENT
The following serves to identify and document any personal interest staff members,
officers, and members of the Board of Directors may have. This document is also to be
used to disclose any transactions that may result in personal, financial, professional
and/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 and/or political are required to be
disclosed to DPS. Conflict means a conflict or the appearance of a conflict 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 July 2014
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 or appears to create bias.
8.
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 July 2014
NC Department of Public Safety
Page 2 of 3
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
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 �
Agency's Name:
(Legal Applicant)
Federal Tax ID #: 56-0950370
Private, Nonprofit
Entity Name:
Executive Director's Print
Name: Sign
Board Chair's
Name:
Coastal Horizons
Print Colin Hackman (Date of Signature)
Sign . ew_- ,�?- V6 /Z.3
Sworn to and subscribed before me on the
Day of the date of said certification
• (`
(Notary Public)
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: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
d ST�Fu
.."n NC DEPARTMENT OF PUBLIC SAFETY
� IDIPS
NOT FOR PROFIT
DPS CONFLICT OF INTEREST POLICY STATEMENT
This document is only required from not for profit organizations ONLY: In accordance with
the N.C.G.S. 143C-6-23 (b), every Grantee shall file with the State agency/Grantor 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 members of its board or other governing body, from the
Grantee's disbursing of State finds and shall include actions to be taken by the Grantee or the
individual, or both to avoid 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 funds.
The Grantee shall submit this form (Not for Profit DPS Conflict of Interest Policy Statement Form
DPS 13 001) along with the agency's conflict of interest policy when applying for funding.
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 funded 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 from any contract or grant funded in whole or in part by State
funds 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.
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] of 3
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
n MW WA
NC DEPARTMENT OF PUBLIC SAFETY
NOT FOR PROFIT
wv
DPS CONFLICT OF INTEREST POLICY STATEMENT
The following serves to identify and document any personal interest staff members,
officers, and members of the Board of Directors may have. This document is also to be
used to disclose any transactions that may result in personal, financial, professional
andlor 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 andlor political are required to be
disclosed to DPS. Conflict means a conflict or the appearance of a conflict 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 July 2014
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 or appears to create bias.
8.
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 July 2014
NC Department of Public Safety
Page 2 of 3
DocuSign Envelope ID: AEDAAFF4-B8C4-418A-AC8A-7E933704F7E1
A �57NF o
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: Pender_
Agency's Name:
(Legal Applicant)
Federal Tax ID #: 56-0950370
Private, Nonprofit
Entity Name:
Executive Director's Print
Name: Sign
Coastal Horizons
Board Chair's Print Colin Hackman (Date of Signature)
Name: Sign
Sworn to and subscribed before me on the
of the date of said certification
H rt j
(Notary Public)
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
Certificate Of Completion
Envelope Id: AEDAAFF4B8C4418AAC8A7E933704F7E1
Status: Completed
Subject: DPS eSignature Request for New Hanover 865-12425 Alternatives to Committment: Family Preservation Pr
Source Envelope:
Document Pages: 33 Signatures: 4
Envelope Originator:
Certificate Pages: 5 Initials: 0
DPS-DJJ Community Programs
AutoNav: Enabled
3040 Hammond Business PI
Envelopeld Stamping: Enabled
Raleigh, NC 27603
Time Zone: (UTC -05:00) Eastern Time (US & Canada)
djjdp.applicationsupport@ncdps.gov
IP Address: 207.4.107.7
Record Tracking
Status: Original Holder: DPS-DJJ Community Programs Location: DocuSign
6/14/2023 12:13:49 PM djjdp.applicationsupport@ncdps.gov
Signer Events Signature Timestamp
Joshua Main EDII"Sil"Idby: Sent: 6/14/2023 12:13:52 PM
jmain@coastalhorizons.org 6SL& Ata,Un, Viewed: 6/14/2023 2:47:15 PM
Security Level: Email, Account Authentication 9A5F38F30E7A4CE... Signed: 6/14/2023 2:48:08 PM
(None)
Signature Adoption: Pre -selected Style
Using IP Address: 172.59.217.214
Electronic Record and Signature Disclosure:
Accepted: 6/14/2023 2:47:15 PM
ID:9b5c359c-f712-4356-ab80-3ac42d7d778b
J H Corpening II sg dbY Sent: 6/14/2023 2:48:09 PM
julius.h.corpening@nccourts.org � (,oVr ln.'" N Viewed: 6/14/2023 4:48:29 PM
Securit Level: Email Account Authentication ED
3DD8E15D4A2540C... Signed: 6/14/2023 4:48:36 PM
Y 9
(None)
Signature Adoption: Pre -selected Style
Using IP Address: 204.152.2.231
Electronic Record and Signature Disclosure:
Accepted: 6/14/2023 4:48:29 PM
ID: 3e977078-ee7a-4b5f-9d c8-f68287a58e02
Eric Credle /'byy: I' Sent: 6/14/2023 4:48:38 PM
ecredle@nhcgov.com EDOCUSigned
VIG t rLD�u Viewed: 6/15/2023 8:07:30 AM
Security Level: Email, Account Authentication C8B88CFC5D1A485 Signed: 6/15/2023 8:43:28 AM
(None)
Signature Adoption: Pre -selected Style
Using IP Address: 152.31.193.130
Electronic Record and Signature Disclosure:
Accepted: 6/15/2023 8:07:30 AM
ID:e318998e-Oc8c-41ae-8b23-Of81666d9795
by:Cindy Porterfield ED—Sign1d Sent: 6/15/2023 8:43:30 AM
cindy.porterfield@ncdps.gov ""' C �0'` Viewed: 6/15/2023 11:22:39 AM
Director of Juvenile Community Programs 7g8FE7A4ED0F410. Signed: 6/15/2023 11:22:47 AM
NC Dept of Public Safety
Signature Adoption: Pre -selected Style
Security Level: Email, Account Authentication
(None) 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
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Witness Events
Signature
Timestamp
Notary Events
Signature
Timestamp
Envelope Summary Events
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Envelope Sent
Hashed/Encrypted
6/14/2023 12:13:53 PM
Certified Delivered
Security Checked
6/15/2023 11:22:39 AM
Signing Complete
Security Checked
6/15/2023 11:22:47 AM
Completed
Security Checked
6/15/2023 11:22:47 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: Joshua Main, J H Corpening II, Eric Credle
CONSUMER DISCLOSURE
From time to time, NC Dept of Public Safety (we, us or Company) may be required by law to
provide to you certain written notices or disclosures. Described below are the terms and
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send you paper copies of any such documents from our office to you, you will be charged a
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If you decide to receive notices and disclosures from us electronically, you may at any time
change your mind and tell us that thereafter you want to receive required notices and disclosures
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If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
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All notices and disclosures will be sent to you electronically
Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or
made available to you during the course of our relationship with you. To reduce the chance of
you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
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described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
electronically from us.
How to contact NC Dept of Public Safety:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: david.pozun@ncdps.gov
To advise NC Dept of Public Safety of your new e-mail address
To let us know of a change in your e-mail address where we should send notices and disclosures
electronically to you, you must send an email message to us at david.pozun@ncdps.gov and in
the body of such request you must state: your previous e-mail address, your new e-mail address.
We do not require any other information from you to change your email address..
In addition, you must notify DocuSign, Inc. to arrange for your new email address to be reflected
in your DocuSign account by following the process for changing e-mail in the DocuSign system.
To request paper copies from NC Dept of Public Safety
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an e-mail to david.pozun@ncdps.gov and in the
body of such request you must state your e-mail address, full name, US Postal address, and
telephone number. We will bill you for any fees at that time, if any.
To withdraw your consent with NC Dept of Public Safety
To inform us that you no longer want to receive future notices and disclosures in electronic
format you may:
i. decline to sign a document from within your DocuSign session, and on the subsequent
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To confirm to us that you can access this information electronically, which will be similar to
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