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WEATHERIZATION ASSISTANCE PROGRAMPermanent Designations for Person, Pitt

and Rowan Counties

Solicitation No. 2018PPR

ISSUE DATE: Tuesday, January 16, 2018

INFORMATION SESSION: Tuesday, January 30, 2018

QUESTIONS DUE DATE: 5:00 pm Tuesday, February 6, 2018

PROPOSAL DUE DATE: 2:00 pm Friday, February 16, 2018

Notice of Funding Opportunity and Invitation to Submit Proposals

Announcement Type This Funding Opportunity under the Weatherization Assistance Program for Low Income Persons is issued by the North Carolina Department of Environmental Quality (DEQ).

DEQ’s Weatherization Assistance Program is made available through the federal Weatherization Assistance Program Formula Grants. DEQ grants these funds to local organizations which receive and process weatherization applications and dispatch subcontractors to perform weatherization work in their designated service territory.

With this Funding Opportunity, DEQ will evaluate each Proposal and award annual formula funds to entity selected as designee for each area.

Eligible ApplicantsLocal units of government and 501(c)(3) not-for-profit entities in the State of North Carolina that are able to provide the weatherization services described herein are eligible to apply for this Funding Opportunity. For more information on Eligibility Requirements, please see page 5.

Statutes, Regulations, Agreements and Guidelines

This Funding Opportunity is through the US Department of Energy’s (DOE) Weatherization Assistance Program Formula Grants and North Carolina Department of Health and Human Services (NCDHHS) Low Income Home

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Energy Assistance Program (LIHEAP) Formula Grants. The Weatherization Assistance Program Guidelines (10 CFR 440) are incorporated into this Funding Opportunity by reference as though set forth in their entirety herein. Capitalized terms in this Funding Opportunity have meanings ascribed to them in the Guidelines. This Funding Opportunity is governed by the agreement between the DEQ and NCDHHS, identified as 17B1NCLIEA/18B1NCLIEA, the agreement between the DEQ and DOE, identified as EE0007939, 10 CFR 440, 10 CFR 600, all subsequent guidance contained in DOE Weatherization Program Notices, and Federal and State guidelines issued thereunder.

Solicitation Period January 16, 2018 – February 16, 2018

Period of Performance All projects funded through this Funding Opportunity must be completed between April 1, 2018 (estimated date), and June 30, 2018 (Program Year 2017). Any allowed renewal or extension thereof is subject to federal funding availability and is issued at the discretion of the DOE and DHHS.

Closing Date(s) Proposals must be received by 2:00pm on Friday, February 16, 2018.DEQ must receive ALL electronic Proposal materials by 2:00 pm on the closing date, to be opened and evaluated in the period following the closing date. No Proposals will be accepted after 2:00 pm on February 16, 2018.

Funding Available Through This Funding Opportunity

The DEQ will evaluate Proposals to determine each Applicant’s experience and capacity to deliver and manage a successful weatherization program. Funds are granted annually and vary based on North Carolina’s federally-determined state funding allocation, as described on page 4. The award of a contract and any allowed renewal or extension thereof is subject to federal funding availability and is issued at the discretion of the DEQ.

Information Session and Questions About This Funding Opportunity

The Information Session is scheduled for 10:00am – 12:00 pm Tuesday, January 30, 2018 at: DEQ Office: 217 W. Jones Street, Raleigh NC. Applicants can come and ask questions in person regarding the solicitation. All applications are at DEQ website below.

To ensure fairness, additional questions relating to the intent and/or content of this Funding Opportunity must be submitted by email to: [email protected] by 5:00 pm Tuesday, February 6, 2018. Answers will be returned by email.

https://deq.nc.gov/about/divisions/energy-mineral-land-resources/weatherization-assistance-program

No questions will be answered regarding Proposal status. Information about all Proposals will not be available until the Public Hearing. Notice of Public Hearing will be posted on DEQ website after Proposals have been evaluated.

Notice of Receipt Acknowledgement of a Proposal’s receipt will be sent by reply email. The DEQ will endeavor to notify Applicants of award or rejection within 60-days of the closing date. The notification letter will be sent via email to the address located on Application Information Form.




mailto:[email protected]

TABLE OF CONTENTS

Introduction....................................................................................................................................4

Eligibility Requirements.................................................................................................................5

Scope of Work...............................................................................................................................5

Cancellation.............................................................................................................................12

Proposal Requirements...............................................................................................................13

Proposal Format Specifications...................................................................................................13

Virus Check..............................................................................................................................14

Confidential Information...........................................................................................................14

Evaluation Criteria.......................................................................................................................15

Submission Process....................................................................................................................16

Submission Checklist...............................................................................................................16

Review Process...........................................................................................................................16

Appendix A – Training Requirements for Auditors and Contractors............................................17

Appendix B – Subrecipient Terms and Conditions......................................................................18


INTRODUCTIONThe mission of the North Carolina Weatherization Assistance Program is to improve energy efficiency, household safety, and to educate the public about maintaining energy efficiency. Families with income below 200% of the Federal Poverty Level or those receiving cash assistance payments under Supplemental Security Income are eligible for weatherization services. Priority is placed on providing assistance to the elderly, individuals with disabilities, and families with children. The goal of the Weatherization Assistance Program is to keep North Carolina citizens warm in the winter, cool in the summer, and safe all year long.

The Weatherization Assistance Program is administered through the DEQ. The program receives annual Weatherization Assistance Program (WAP) funds from the Office of Energy Efficiency and Renewable Energy (DOE) and Low-Income Home Energy Assistance Program (LIHEAP) and Heating Appliance Repair/Replacement Program (HARRP) funds from the NCDHHS DEQ grants funds to local 501(c)(3) non-profit organizations and local units of government to receive and process weatherization applications and dispatch subcontractors to perform weatherization work in designated service areas. Successful Applicants will be awarded funds in the form of grants by the North Carolina Department of Environmental Quality and henceforth be known as Subrecipients or Subgrantees in this document.

The purpose of this solicitation is to designate administrators of weatherization services for Person, Pitt and Rowan counties (see Figure 1).

Figure 1 | Service Areas Needing Permanent Weatherization Provider

The DEQ uses a federally-approved formula to allocate funds to Subrecipients; the formula is revised every 10-years based on US Census information. Currently, 51% of the allocation will be based on the number of households in poverty in a Subrecipient’s service area and 49% of the allocation will be based on the number of houses weatherized in the most recent state fiscal year. Table 1 below lists the estimated amount of funds and the number of households scheduled to be weatherized within each area between April 1, 2018 and June 30, 2018. Applicants may apply for one or more service areas. Applicants are not required to apply for all three service areas. This estimated funding excludes Training and Technical Assistance (T&TA) funds that will be awarded. Applicants may apply for more than one area; however, DEQ reserves the right to further delineate counties between Subrecipients and/or limit the amount of service areas to any Subrecipient to build the capacity of the delivery network.

Table 1 | Funding and Estimated Production

Area

WAP Approximate

Funding

WAPApproximate No.

of Units

HARRP Approximate

Funding

HARRPApproximate No.

of Units

Person County $12,947/$51,788* 2/6* $4,849/$19,397* 1/3*Pitt CountyRowan County*FY18 ONLY! --funding/production to be reduced to 25% for last quarter of 2018 fiscal year

$66,711/$266,847*$68,396/$273,584*

7/28* 7/28*

$31,454/$125,819*$27,418/$109,674*

5/19*4/16*


ELIGIBILITY REQUIREMENTSThe DEQ is interested in receiving responses from units of local government and 501(c)(3) non-profit entities that: 1) have been incorporated for at least 5 years; 2) are able to provide the services described in the Scope of Work; 3) have or will establish an operational office within the service area being applied for; and 4) meet all of the requirements in 10 CFR 440.15. Specifically, a successful Applicant must

Be a Public Entity, or Community Action Agency (CAA), or other Non-Profit;

Have experience and performance in weatherization or housing renovation activities;

Have experience assisting low-income persons; and

Have the capacity to undertake a timely and effective weatherization program.

Federal rules require that DEQ give preference to any CAA or other public or nonprofit entity which has, or is currently administering, an effective program through the Weatherization Assistance Program or under Title II of the Economic Opportunity Act of 1964, where program effectiveness is evaluated by consideration of factors including, but not limited to, the following:

The extent to which the past or current program achieved or is achieving weatherization goals in a timely fashion;

The quality of work performed by the Subrecipient;

The number, qualifications, and experience of the staff members of the Subrecipient.

The DEQ may only select Subrecipients after a public hearing and comment. See page 16Error: Reference source not found.

SCOPE OF WORK The primary responsibility of the Subrecipient is to provide an efficient and effective weatherization program that complies with the Weatherization Assistance Program’s state and federal rules and regulations.

PROJECT METHODS:

The Subgrantee shall weatherize «DOE_WAP_UNITS» units using DOE Funds, «LIHEAP_WAP_UNITS» units using DHHS Funds and inspect, repair, replace heating or air conditioning systems in «HARRP_UNITS» units, in accordance with this Grant Agreement and the Program Guidance. The units must be occupied by individuals and families who meet the prescribed eligibility requirements in designated service area as described in the Program Guidance and applicable regulations. The Subgrantee shall base the scope of work for at least «DOE_WA» unit(s) using DOE Funds and «LH_WAP_WA» unit(s) using DHHS funds on properly conducted computerized Weatherization Assistant energy modeling.

The Department may at any time during this Contract Agreement, assume any of the duties if it is determined that they can be performed more efficiently or at a lower cost through a state-wide approach. If the Department absorbs any of the workload that otherwise would be performed by the Subgrantee, the Department may lower the amount of Administrative funds made available to the Subgrantee. Unless notified otherwise, the Subgrantee will perform the following activities:

1. Promote and market the WAP and HARRP Programs to recruit priority populations;2. Conduct intake/receive applications for services from potentially eligible individuals;3. Establish prioritized waiting list using the State rating tool;4. Perform initial inspection/audit and share energy education info;5. Identify measures to be installed;6. Complete health and safety improvements;7. Install identified energy reduction measures;8. Evaluate effectiveness of service provided;9. Conduct final inspection;10. Maintain customer logs and receive client evaluation survey;11. Maintain files, complete and submit program and financial reports;12. Provide continuous training for staff and contractors; and


13. Evaluate program effectiveness.

PROJECT EVALUATION:The above activities will be monitored for compliance as follows:

1. The weatherization coordinator will review the home energy audits and work orders for all homes weatherized

2. The energy auditor will conduct post inspections of all work performed on the homes.3. Monthly, quarterly, semi-annual and end-of-year performance reports will be reviewed by the weatherization

coordinator, the executive director, the program analyst and the program manager.

Outcome measures will be evaluated by the following:1. Comparing pre- and post-energy consumption bills to determine energy savings;2. Percentage of air infiltration reduced; and3. Number of energy efficiency measures installed.

Service quality measures will be evaluated by the following:1. Number of client applications received quarterly;2. Number of defects identified during the final inspection;3. Client satisfaction evaluation survey; and4. Number of defects found during the onsite Assessment.

Efficiency measures will be evaluated by following the average cost per home weatherized and the average cost per heating and air system repaired or replaced. Per DOE guidelines, the average cost per home excludes costs associated with administration, the single audit, liability insurance, and health and safety. The average cost per home weatherized, based on budgeted program operations shall not exceed $«DOE_Cost_Per_Unit_» for DOE units and $«LIHEAP_Cost_Per_Unit_» for LIHEAP units. The average cost per heating and air system shall not exceed $«HARRP_Cost_Per_Unit_».

Subrecipients will be monitored on a yearly basis. Failure to comply with established program policies and procedures, regulations, reporting requirements, production goals or allowable expenditures etc., could result in the re-distribution of funds or the termination of the grant award. Subrecipients will need to ensure their staff and/or their Contractors have sufficient training to perform the following types of activities:

KEY PERSONNEL:

Subrecipient shall notify DEQ within 5 business days when any key personnel identified in the grant agreement are no longer associated with the Subrecipient or the weatherization program. The term “key personnel” includes: Board Chairperson (or equivalent), Executive Director (or equivalent), Fiscal Director (or equivalent), and the Weatherization Coordinator (or equivalent).


Weatherization Coordinator Subrecipient shall engage a Weatherization Coordinator who has the following competencies:Possess Competencies, including:- Ability to read and write legibly; - Moderate verbal and written communication skills; - Basic construction knowledge; - Moderate math skills; and- Moderate computer skills.Understand building science principles, including:- Types of insulation materials;- Hazards of knob and tube wiring;- Use of safe work practices;- Air and heat movement principles;- Typical air leakage problems;- Air Barrier and Proper alignment;- Different types of duct leakage;- Carbon Monoxide action levels;- Factors that affect heat loss in buildings;- Know air-sealing techniques and appropriate materials;- Causes and remedies of moisture problems;- Causes and remedies of Indoor Air Quality problems;- ASHRAE 62.2 2016;- Electric base-load usage;- How to measure building dimensions and compute areas;- Compute volume of conditioned space; and- Define thermal envelope of a building;Materials allowed by 10 CFR 440 Appendix A; - Regulation and policy affecting measure selection; and- Understand the interaction between measures. Understanding program policy, including:- Enabling legislation of Weatherization Program;- DOE program regulations 2 CFR 200 and 10 CFR 440;- DOE program guidance and policy;- Federal, state, and local budget processes;- DOE financial regulations 10 CFR 600;- Applicable state procurement regulations; - State approach to monitoring & T&TA; and- Procurement and Conflict of Interest Policy.Understand Program Management, including:- Applicable databases & tracking systems;- Submit accurate financial and production reports;- Provide T&TA for staff & contractors;- Coordinate resources;- Develop and implement leveraging strategies;- Prepare and track budgets;- Help maintain a purchase order system; - Maintain inventory tracking system;- Comply with federal limits on administrative expenses;- Manage a small construction-focused operation; and- Ensure rigorous final inspection of all weatherized units.

Fiscal Year 2017-2018 Salary Range for NC Weatherization CoordinatorsNetwork Average Salary Highest Salary Lowest Salary

$51,701 $74,584 $30,445


Energy Auditor/Quality Control Inspector Subrecipient shall engage an Energy Auditor/Quality Control Inspector with the following competences:Basic Competencies, including:- Ability to read and write legibly; - Basic verbal and written communication skills; - Basic construction knowledge; - Basic math skills; and- Basic computer skills. Safe Work Practices, including:- Possess a working knowledge of: DOE program regulations/policy and Environmental Protection Agency

(EPA) guidelines for asbestos, lead, mold, and other health hazards;- Material Safety Data Sheets; and- Occupational Safety and Health Act (OSHA) standards:

o Ladder safety;o Fall protection;o Personal protective equipment;o Respiratory protection;o Motor vehicles;o Power-operated hand tools;o Fire prevention; ando Confined spaces.

Demonstrate the ability to:- Select, fit, and use the appropriate Personal Protection Equipment for a particular task;- Safely use basic hand and power tools;- Use a basic first aid kit to treat common job-site injuries;- Use lead safe weatherization;- Identify serious mold conditions; and- Assess work area safety hazards.Inspection and Measurement / Possess a working knowledge of: - Air and heat flow in buildings; - Factors that affect building heat loss; - Construction features and critical junction points of common housing types; - Insulation R-values; - Different insulation materials and installation techniques; - Various air-sealing techniques and appropriate materials; - Causes of and remedies for existing and potential moisture problems; - Causes of and remedies for other existing and potential indoor air quality problems;- Residential mechanical ventilation systems; - Minimum ventilation rates/building tightness limits based on the appropriate ASHRAE 62.2-2016

standard; and - Electric base-load usage. Demonstrate the ability to: - Measure the dimensions of floors, walls, ceilings, windows, and doors, and compute surface areas; - Compute the volume of conditioned space of a building; - Define the thermal envelope of a building; - Assess the effectiveness of existing insulation and the effective R-values; and - Analyze utility bills including breaking out base-load usage from heating and cooling usage. Diagnostic Testing: - Blower door:

o Possess a working knowledge of: Principles of air movement and how they relate to building heat loss; Typical air leakage problems in common housing types; and Minimum ventilation rates.

o Demonstrate the ability to: Set up a blower door; Prepare a building for a blower door test; and Take blower door readings and interpret results.

- Zone pressure diagnostics:


o Possess a working knowledge of: o The air barrier of a building and the importance of aligning it with the thermal barrier; ando Primary and intermediate zones of a house.

- Demonstrate the ability to: o Conduct zone pressure diagnostics and interpret results; o Determine the location and effectiveness of the air barrier of a house; and

- Duct testing / Possess a working knowledge of Duct Leakage problems:o Demonstrate the ability to:

Determine dominant duct leakage; and Conduct pressure tests. Potential tests include Pressure Pan and Ductblaster Seal duct leaks with appropriate materials and good workmanship. Measure room pressure imbalances in houses with forced-air systems.

o Steam and hot water distribution system testing / Possess a working knowledge of: The components of typical steam and hot water distribution systems and the

characteristics of their proper operation. Demonstrate the ability to test air vents, steam traps, thermostatic radiator valves, and

hot water zone valves; and estimate the energy impacts of existing overheating problems.

o Base-load systems: Demonstrate the ability to meter electrical devices to determine annual energy

consumption. - Combustion Appliance Safety / Possess a working knowledge of:

o CO action levels; o Common code requirements related to: o Vent system sizing, materials, clearances, and installation; o Safety shut-off devices; o Gas line sizing; and o Combustion air; o Causes of and remedies to common vent system problems.

- Demonstrate the ability to: o Measure the CO level in ambient air; o Measure the CO level of vented and unvented combustion appliances; o Measure the CO levels of gas- or propane-fired cook stoves (oven and

burners); o Understand the difference between as-measured and air-free CO readings; o Detect any natural gas, propane, and fuel oil leaks; o Conduct a worst-case draft test of a combustion appliance zone (CAZ); o Measure the CAZ to assure sufficient volume for combustion air; o Clock a gas meter to determine the actual input of a gas-fired combustion appliance; o Conduct basic temperature-rise and static-pressure-drop tests on forced-air

furnaces;o Measure the steady-state efficiency of a vented combustion appliance; and o Assess the potential inadequacy of supply and return plenum and duct sizes for forced-air

systems. - Measure Selection / Possess a working knowledge of:

o What materials are allowed to be installed based on 10 CFR 440 Appendix A; o The regulatory and policy requirements for selecting weatherization measures using the

Weatherization Assistant or priority lists; and o The interaction between typical weatherization measures (e.g., the impact of air-sealing and

insulation measures on the potential savings of heating efficiency improvements). o Demonstrate the ability to:

Use a DOE-approved energy audit to input accurate building data and recommend appropriate, cost-effective weatherization measures; and

If required, use a DOE-approved priority list to select appropriate, cost-effective weatherization measures.

o Prioritize air-sealing efforts;


o Estimate the heating and/or cooling load of a dwelling to ensure proper equipment sizing if the heating or cooling system is to be replaced;

o Select the proper CFL or LED to replace an incandescent lamp while maintaining or improving lighting levels; and

o Meter an existing refrigerator or locate its DOE tested usage in a database to estimate annual energy consumption.

- Work Scope Development: o Demonstrate the ability to: o Accurately estimate the type and quantity of materials required to cost-effectively weatherize an

eligible dwelling unit; and o Prepare clearly written work orders for work crews or contractors.

Fiscal Year 2017-2018 Salary Range for NC Energy Auditor/Quality Control InspectorsNetwork Average Salary Highest Salary Lowest Salary

$35,541 $50,854 $35,227

Special Note Regarding Quality Control Inspectors

DOE established that Subrecipients must ensure that all DOE funded weatherization homes must receive a final inspection from a certified Quality Control Inspector (QCI) starting July 1, 2015. These QCI inspections may be contracted out to a third party.

Conduct client outreach and education Subrecipients will be required to conduct outreach within targeted areas and/or to eligible households. Also, Subrecipients shall inform clients of observed hazards and risks on-site and discuss and provide information (hand-outs) regarding the appropriate use and maintenance of all equipment to protect the weatherization investment. Subrecipients will also be responsible for educating clients on a range of health and safety issues, including but not limited to asbestos, unsanitary living conditions, code compliance issues, fire hazards, lead-based paints, air pollutants, carbon monoxide, mold and moisture issues, knob-and-tube wiring, and unvented space heaters.

Determine client eligibilityClients are eligible for DOE WAP or LIHEAP WAP/HARRP when the household’s annual gross income is at or below 200% of the federal poverty level, adjusted for the appropriate household size. Subrecipients will be responsible for ensuring and documenting annual household income. A household is categorically eligible for WAP if, in the prior twelve months, any member of that household has received the benefits listed below:

o Supplemental Security Income (SSI)o Temporary Assistance for Needy Families (TANF)o Low-Income Energy Assistance Program (LIEAP)o Crisis Intervention Program (CIP)o Energy Neighboro Share the Warmtho Wake Electric Round-Up Program (WERU)o Helping Each Member Cope (HEMC)

Prioritize client assistanceSubrecipients must review and approve all applications for client assistance. Assistance is available to individuals residing in single and multi-family dwellings as well as mobile homes, which can be rented, owned, subsidized, or non-subsidized. Priority assistance must be given to households which are single family, high-energy users, or those occupied by individuals who are elderly (60 yrs of age or more), disabled, or have children under the age of six. The owners of rental units are required to sign a form stating the rent will not be increased nor will the tenant be evicted for a period of one year, as a result of receiving weatherization assistance.

Conduct energy assessments10 of 63

Solicitation No. 2018PPR

Subrecipients must secure the services of at least one energy auditor and subsequent contractors who meet the criteria set forth in Appendix A (Training Requirements for Auditors and Contractors). An audit will be required prior to any work beginning on every unit and after completion of work of the unit. The auditor will be required to produce a written audit report that meets the criteria set forth by the North Carolina Weatherization Assistance Program as well as written work orders for any subcontractors used and all other applicable documentation.

Install allowable weatherization measuresSubrecipients must ensure that proper weatherization is accomplished on the greatest number of dwelling units as possible during the contract term. Subrecipients must further ensure that proper procedures are followed, that each dwelling unit receives the most comprehensive weatherization necessary to achieve the greatest level of energy efficiency, and that services are performed in the most cost-effective manner. All energy efficiency measures will be required to comply with DOE’s definition of cost effectiveness. The costs of the measures are deemed to be the installed costs and are therefore inclusive of the labor costs of Contractors and any Subcontractor costs associated with installing a particular measure. Measures installed through the North Carolina Weatherization Assistance Program may include, but are not limited to the following:

Single Family Measures (Not Applicable to Multifamily Buildings)

1. Inspect heating/cooling equipment and repair as necessary, including duct diagnostics and sealing (return and supply systems);

2. Seal major air leaks and bypasses;

3. Insulate and vent attic;

4. Insulate sidewalls;

5. Insulate floor;

6. Insulate ducts and heating pipes;

7. Install compact fluorescent lamps (CFLs) or Light Emitting Diodes (LEDs);

8. Refrigerator evaluation and replacement, if needed;

9. General heat waste measures (weatherstripping, caulking, glass patching, water heater insulation, etc.).

10. Energy-related Health & Safety

Perform on-site inspectionsSubrecipients must ensure units are inspected after mechanical work has been completed to ensure proper installation of materials and appropriate operation of mechanical systems. Subrecipients also must ensure that a quality control inspection is completed verifying that all work has been completed according to the audit, vendor invoices match the work performed, the unit has achieved appropriate air sealing, and the mechanical systems are working properly before final payment is made.

Ensure client satisfaction (i.e. resolve client or contractor issues or disputes)The Subrecipient must recognize the special needs and concerns of low-income, elderly, and handicapped clients and must ensure that clients are at all times treated respectfully and professionally. The Subrecipient’s staff must conduct themselves in a professional manner at all times. This includes providing prompt responses and service, adhering to scheduled appointments, resolving client or contractor complaints or disputes, and monitoring customer satisfaction through quality assurance visits, phone surveys, and written surveys.

Special Note Regarding Call-Backs

DOE established that Subrecipients may not charge their grant for additional work on homes that have already been reported to DOE as a completed unit. This places a greater responsibility on the Energy Auditors and Quality Control Inspectors to ensure that all appropriate measures have been called for and that those measures have been installed properly. This guidance must not be seen as alleviating Subrecipients’ responsibility to serve clients responsibly. If errors or oversights do occur,


Subrecipients are required to find solutions to deal with these occurrences while complying with DOE regulations.


Enter client information for each household weatherized into the statewide databaseSubrecipients must ensure that each job has all costs, activities, energy-saving measures, household information, notes, vendor information, and product information entered via the Accountable Results for Community Action (AR4CA) Program software to facilitate monthly reporting.

Responsibly managing award fundsSubrecipients must exhaust all grant funds during the one-year grant period, from July 1 of each year to June 30 of the following year. Up to 10% of grants funds may be used for administrative costs associated with managing the Weatherization Assistance Program for Subrecipients that receive $350,000 or less in DOE WAP funds. Subrecipients that receive more than $350,000 in DOE WAP funds are limited to 5% of the grant for administrative costs. All LIHEAP WAP/HARRP administrative costs are limited to 5% of grant funds. In addition, Health and Safety expenses may not exceed 20% of program operations. Funds will also be made available for training and technical assistance, liability insurance, equipment purchases, contract services, and operational costs. Moreover, the average cost per unit for all homes weatherized with this grant must not exceed $6,700 DOE and $7,100 LIHEAP.

Meeting all reporting requirementsProject costs will be reimbursed on a monthly basis and Subrecipients may request an advance at the beginning of the program year for DOE. Subrecipients will be required to report program expenditures and production information on a monthly basis. A Financial Status Report must be submitted monthly and a financial and/or compliance audit must be submitted on an annual basis. Failure to provide accurate and timely monthly reports may result in delayed processing of the reimbursement of program expenditures and/or termination of the grant. The DEQ reserves the right to review and verify an Applicant’s financial statement(s) on a monthly basis.

Complying with all quality assurance and evaluation proceduresAll Subrecipients will be subject to program and technical monitoring for up to one year following the expiration of the grant cycle. All findings in program and technical monitoring reports must be remedied within 30 days of receipt of monitoring report. Subrecipients are expected to include Quality Control inspections as a part of the audit process to ensure safety and prevent fraud. As a requirement of federal funding, all Subrecipients who expend in excess of $750,000 (from all program areas) will be required to conduct an annual, third party audit in compliance with the standards set forth in 2 CFR 200.

CANCELLATIONAny of the following will result in an investigation and, if found to be accurate, the Subrecipient’s contract will be terminated. The Subrecipient may be reported to the Office of the State Auditor and the appropriate federal Office of the Inspector General for suspension or debarment:

Reports of sub-standard workmanship or unprofessional behavior;

Discrimination against or denial of employment to any individual in the performance of any weatherization contract in violation of Equal Opportunity Employment Laws;

Failure to maintain appropriate working relationships with the client and representatives of the NC Weatherization Assistance Program;

Failure to adhere to established time schedules for work completion;

Failure to honor the contract documents;

Failure to meet reporting and invoicing requirements in a timely manner; or

Failure to maintain insurance coverage, as stated.


PROPOSAL REQUIREMENTSThe response to this Funding Opportunity shall consist of one completed and signed electronic Application Information Form, all supporting documentation as requested in the Application Information Form, and a sample one-year weatherization Sample Work Plan. The Application Information Form and Sample Work Plan documents are available in MS Word 2016 and MS Excel 2016 at the DEQ website:


Proposals submitted without using the supplied forms will not be considered.

PROPOSAL FORMAT SPECIFICATIONS1. Electronic copies of Proposals must be generated in PDF format from a text-based file (such as a Microsoft

Word document) so that Proposals are searchable. The Proposal file MUST BE SUBMITTED AS A SINGLE PDF file. Other file formats will NOT be accepted.

2. All pages/sections must be numbered for easy reference.

3. All page margins must be 1.0 inch (2.5 cm).

4. Proposals may be single spaced (1.0).

5. No type size smaller than 12 point is to be used for text or tables, except as legends on reduced drawings.

6. Proposals should be focused, concise, and organized in accordance with the Funding Opportunity requirements.

7. Samples, videotapes, slides, DVDs or other ancillary items will NOT be accepted.

8. Applicants are encouraged, but not required, for reasons of space conservation and simplicity, to embed graphics within Proposals. For graphics submitted as separate files, the acceptable file formats (and the respective extensions) are Graphics Interchange Format (.gif), JPEG (.jpg), and Tagged-Image Format (.tif). Note: Each graphic submitted as a separate file will count as one page in the Proposal page count, regardless of size.

9. No files larger than 20 MB in size will be accepted.



VIRUS CHECKThe Applicant is responsible for performing a virus check on the electronic Proposal prior to submission. As a standard part of entering the Proposal into its processing system, the DEQ will scan each electronic Proposal for viruses. A Proposal may be rejected if a virus is detected.

CONFIDENTIAL INFORMATIONAll documents submitted to the DEQ, including all Proposal materials, are public records governed by Chapter 132 of the General Statutes and applicable provisions of the General Statutes protecting confidential information. When specific information in a Proposal is regarded by the Applicant and by law as confidential and not subject to disclosure under the North Carolina Public Records Act (e.g., trade secrets and/or privileged and confidential information), the Applicant should specifically and clearly designate it as such in writing on that portion of the Proposal in which the information appears with the following notice:

Notice of Restriction on Disclosure and Use of DataThe data contained in pages __, __, __, and __ of this Proposal have been submitted in confidence and contain trade secrets or proprietary information, and such data shall be used or disclosed only for evaluation purposes, provided that if this Applicant receives an Award as a result of or in connection with the submission of this Proposal, the DEQ and DOE shall have the right to use or disclose the data here to the extent provided in the Award. This restriction does not limit the government’s right to use or disclose data obtained without restriction from any source, including the Applicant.

An Applicant should provide an explanation for why particular information is regarded as confidential. Indiscriminate designations of information as “confidential,” such as form language automatically inserted into e-mails or into the margins of documents, will not be regarded as sufficient designations. On pages with mixed confidential and non-confidential information, the Applicant shall add the tag [BEGIN CONFIDENTIAL] on the line before confidential information starts and the tag [END CONFIDENTIAL] on the line after the confidential information ends. Only information between these two tags will be redacted before being provided as part of a Public Records request.


EVALUATION CRITERIATo be accepted as a Subrecipient, a Proposal must receive at least 70-points. Grading for each criterion will occur on a sliding scale up to the listed maximum score unless otherwise noted. Each Proposal may receive a maximum score of 100-points, weighted as follows:

Evaluation Criteria Max PointsExperience administering projects of a similar nature, including but not limited to development, new construction, rehabilitation, energy efficiency upgrades, and other housing-related federal or State grant projects. Efficacy will be judged according to historical expenditure rate, on-time reporting, timely and accurate payment processes, timely claims submission, appropriate contractor management, and, if applicable, energy savings.

30

Quality of proposed plan and budget to provide Weatherization and HARRP services. The Sample Work Plan (including budget) will be judged based on the feasibility of the timeline for expending funds, the number of households receiving energy conservation measures, the degree of energy efficiency achieved and the ability to ensure the quality of work completed.

30

Capacity to provide transparent and accountable administration of funds. Responses and supporting documentation will be judged based on demonstrated conformance with stated bylaws and policies and rigor of systems in place to ensure the quality of work performed and to prevent waste, abuse or fraud.

30

Thoroughness of responses in providing the requested information and conformance with Solicitation requirements.

10

TOTAL 100

The DEQ reserves the right to deny approval to any Applicant who does not meet the minimum acceptable score after an evaluation pursuant to the criteria above. In the event of a tie, preference will be given first to the Applicant that is currently administering an effective weatherization program; if no Applicant is currently administering an effective weatherization program, preference will be given to the Applicant that is based in the area within which it is applying to provide service.


SUBMISSION PROCESSAn electronic copy of the complete Proposal should be emailed in PDF format by 2:00 pm on the closing date Friday, February 16, 2018 to: [email protected]. The subject line should include only the solicitation number and the Applicant’s name.

SUBMISSION CHECKLISTPLEASE SUBMIT PROPOSAL DOCUMENTS IN THE FOLLOWING ORDER:

Application Information Form Sample Work Plan Supporting Documentation:

Organization Bylaws Directory of Board of Directors members References from 3 largest funders References from 3 trade or vendor businesses Résumés and position descriptions of all key members Organizational Chart Cost Allocation Plan Recent Monitoring/Assessment/Evaluation Reports from Funders and Federal/State Auditors Copy of Applicant’s Conflict of Interest Policy Audited Financial Statement with Financial Management Letter Most Recent Trial Balance and P&L Statement or Revenue and Expense Report Most Recent IRS Form 990 or Comprehensive Annual Financial Report Indirect Rate Proposal and Approval Letter Insurance Certificates or a letter of insurability (see Application Information Form for information on coverage types and levels)

REVIEW PROCESSAt 2:00 pm on the closing date, Friday, February 16, 2018, all emails will be opened and recorded. The review process will proceed in four stages:

1. Eligibility Review: Proposals will be checked for completeness; incomplete responses will be withheld from further review.

2. Recommendation by Committee: Complete responses will be sent to a review committee to be scored per the evaluation criteria listed on page 15. The review committee will consist of at least three members. The committee may be comprised of DEQ staff and non-DEQ experts from the private sector, academia, or other governmental agencies who are qualified to determine the merits of the Proposal.

3. DEQ Review: The third stage of review will be completed by DEQ staff who will determine which Proposals shall be selected based on recommendations of the review committee and feedback from the references provided.

4. Public Hearing: After DEQ has completed its review, it will hold a Public Hearing to discuss the Proposals received and solicit public comment on the top scoring Applicant(s). Notice of Public Hearing will be posted to DEQ website after Proposals have been evaluated. After the Public Hearing, a formal award will be made.


mailto:[email protected]

APPENDIX A – TRAINING REQUIREMENTS FOR AUDITORS AND CONTRACTORSThe following table lists all the Required training and which individuals need to attend the training.

REQUIRED TRAININGSubject Approximate

DurationWho Should Attend

Renovate Right 8 Hours Coordinators, Auditors, Crew Leaders/Contractor Leaders

Lead Safe Work Practice 8 Hours Coordinators, Auditors, Crew Leaders/Contractor Leader, Installers

Asbestos (Class 3 O&M with Specifications)

40/Hr. Supervisors16 Hours Coordinators

Coordinators, Auditors, Crew Leaders, Contractor Leaders, Installers

Mold 4 Hours Coordinators, Auditors, Crew Leaders, Contractor Leaders, Installers

Monthly Safety Meeting 1 Hour ALLWx Basics/Fundamentals 3 Days Coordinators, Auditors, Crew Leaders,

Contractor LeadersHVAC Fundamentals 3 Days Auditors, Quality Control Inspectors,

Crew Leaders, Contractor Leaders, HVAC Contractors

Auditor Training (Classroom) 5 Days Auditors, Quality Control Inspectors, Crew Leaders

Auditor Training (Field) 4 days Auditors, Crew Leaders/Contractor Leaders

Mobile Home 4 days Auditors, Crew Leaders, Contractor Leaders, Installers

NEAT/MHEA 3 Days Auditors


APPENDIX B – SUBRECIPIENT TERMS AND CONDITIONS

The following is provided as a SAMPLE ONLY of the contract executed between the DEQ and each non-profit Subrecipient. Applicants should review and be willing to agree to the attached document with no changes. Attachments E, G, and H are not included in Contracts with units of government. An executed document does not need to be submitted with a Proposal.


SAMPLE

STATE OF NORTH CAROLINACOUNTY OF WAKE

SUBGRANTEE’S FEDERALIDENTIFICATION NO.: **-***####

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITYFINANCIAL ASSISTANCE AGREEMENT

This financial assistance agreement is hereby made and entered into this «BeginDate», by and between the NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY (the "Department") and [CAA ENTITY NAME] (the “Subgrantee”, DUNS XXXXXXXXX)1.

1. Purpose of Agreement. The purpose of this agreement is to provide the Subgrantee with funds (the “Subaward Funds”) to operate (1) a Weatherization Assistance Program to provide weatherization services for low income families to help reduce household energy costs pursuant to 10 CFR Part 440 (“Weatherization Services”) and (2) a Heating and Air Repair and Replacement Program to provide for the inspection, repair and replacement of heating and air systems for low income residents pursuant to 45 CFR Part 96, Subpart H (“HARRP Services”) in accordance with the most recent versions of the North Carolina Weatherization Assistance Program & Heating and Air Repair and Replacement Program Budget and Program Guidance, North Carolina DOE State Plan and North Carolina Standard Work Specifications issued by the Department, as may be amended from time to time, WPN 15-4, and this Grant Award Contract. Each Subgrantee must also comply with the applicable sections of 2 CFR 200. By signing this contract, the Subgrantee acknowledges reading and abiding by the aforementioned documents.

2. Contract Documents. The subaward agreement consists of this document (the “Subaward Contract”) and its attachments, when applicable, are incorporated herein by reference and identified by name as follows:

Attachments

A. State’s General Terms and Conditions B. Notice of Certain Reporting and Audit Requirements C. Approved BudgetD. Subgrantee Proposal E. Certification of No Overdue Tax Debts F. Certification Regarding Lobbying, Debarment, Drug-Free Workplace, Environmental Tobacco Smoke G. Subgrantee’s Conflict of Interest Policy H. IRS Federal Tax Exempt Letter or 501 C verification form

Together, these documents (the “Contract Documents”) constitute the entire agreement between the parties and supersede all prior oral or written statements or agreements. Modifications to this Subaward Contract or to any other Contract Document may only be made through written amendments duly executed by authorized representatives of the parties.

3. Precedence Among Contract Documents. In the event of a conflict or inconsistency between or among the Contract Documents, the document with the highest relative precedence prevails. The order of precedence is established by the order of documents in Section 2 above, with the first-listed document having the highest precedence and the last-listed document having the lowest precedence. If there are multiple contract amendments, the most recent amendment has the highest precedence and the oldest amendment has the lowest precedence.

4. Subgrantee Proposal. All representations and commitments made in the Subgrantee Proposal (Attachment D), including all representations regarding sources and amounts of public funding, are incorporated herein by reference and deemed material to this agreement.

5. Contract Period. This agreement shall be effective starting «BeginDate» and shall expire on «EndDate» (the “Expiration Date”).

6. Subgrantee’s Duties. As a condition of the subaward, the Subgrantee agrees to: 1The contract documents attached hereto may at times use alternative terms to describe the Subgrantee. Such terms might include, but are not necessarily limited to, “subrecipient” and/or “applicant.”


A. Perform the Weatherization and HARRP Services as described in the Subgrantee Proposal (Attachment D) and in accordance with the Approved Budget (Attachment C).

B. Ensure that all Subaward Funds are expended in a manner consistent with the goals and objectives of the Federal Grant Awards as herein described.

C. Comply with all Federal financial assistance regulations applicable to the Subgrantee as a recipient of USDOE and USDHHS funding, including, but not limited to:

i. 2 CFR Parts 200 and 910 and 45 CFR Part 75 concerning uniform administrative requirements, cost principles, and audit requirements for awards of financial assistance by USDOE and USDHHS;

ii. 10 CFR Part 440 concerning financial assistance under USDOE’s Weatherization Assistance Program;

iii. 45 CFR Part 96, Subpart H concerning financial assistance under USDHHS’ Low-Income Home Energy Assistance Program;

iv. 2 CFR Parts 376 and 901 (“Nonprocurement Debarment and Suspension”);

v. 2 CFR Parts 382 and 902 (“Requirements for Drug-Free Workplace (Financial Assistance)”); and

vi. 10 CFR Part 601 and 45 CFR Part 93 (“New Restrictions on Lobbying”).

D. Comply with the requirements of 09 NCAC 03M .0101, et seq. (“Uniform Administration of State Awards of Financial Assistance”), including, but not limited to, those provisions relating to audit oversight, access to records, and availability of audit work papers in the possession of any auditor of any recipient of State or Federal funding.

E. Comply with the applicable provisions of Attachment B, Notice of Certain Reporting and Audit Requirements.

F. Maintain all records related to this Subaward Contract (i) for a period of six (6) years, (ii) for the period of time required by the Federal Grant Awards, or (iii) until all audit exceptions have been resolved, whichever is longest.

G. Comply with all other laws, ordinances, codes, rules, regulations, and licensing requirements applicable to its performance under this agreement and/or the conduct of its business generally, including those of Federal, State, and local agencies having jurisdiction and/or authority.

7. Department’s Duties. The Department shall pay the Subgrantee in the manner and in the amounts specified in this Subaward Contract and in accordance with the Approved Budget set forth in Attachment C.

8. Contract Amount. The total amount paid by the Department to the Subgrantee under this agreement shall not exceed [dollar amount] (the “Total Contract Amount”). Program-specific payment totals shall not exceed the dollar figures set out in the following table:


CFDA No. FAIN Funding Source Amount

Total Funding

~ Federal Award Identifications ~DOE:Federal Award No.Effective DateCFDA NumberTotal PY17 DOE Funds to DEQContract is R&D

DHHS LIHEAP:Federal Award Identification Number (FAIN)Federal Award DateCFDA Number and NameLIHEAP Federal Award Indirect Cost RateTotal FY18 LIHEAP Funds to DEQ Contract is R&D

9. Budget and Budget Modification. The Subgrantee’s expenditures shall not exceed the line-item amounts set forth in

the Approved Budget (Attachment C) without prior written consent from a duly authorized representative of the Department. Requests by the Subgrantee to modify or amend the Approved Budget shall be submitted to the Department in writing.

10. Payment Provisions. Payments to the Subgrantee shall be made in accordance with the following provisions:

A. Requests for payment shall be submitted to the Department in the prescribed format of Form 286. All such requests must be supported with, and accompanied by, documentation showing that expenditures are consistent with the Subgrantee Proposal, the Approved Budget and the provisions of this Subaward Contract.

B. The completed Form 286 and its accompanying documentation must be submitted monthly no later than the tenth (10th) business day of each month, or as otherwise requested by the Department.

C. Payments shall be calculated based on allowable costs less funds advanced in excess of cash need, disallowed costs or other setoff items as the Department deems necessary. In any event, the Subgrantee may not be reimbursed more than 60% of the Total Contract Amount until such time as the Department provides written notification to the Subgrantee that the remaining funds have become available.

D. Payments to the Subgrantee may be withheld if reporting obligations are not met at the time payment is requested. Moreover, the Department may, in its sole discretion, de-obligate or redistribute any portion of the Subaward Funds if the Subgrantee fails to meet any of its duties or responsibilities under this agreement.

E. Upon written request by the Department, the Subgrantee shall return any Subaward Funds it receives for costs that are determined to be “disallowed costs” as defined in 2 CFR Part 200.


F. All costs must be incurred on or before the Expiration Date of this Subaward Contract. The final Form 286 and all other reimbursement requests must be submitted to the Department on or before the forty-fifth (45th) calendar day following such date.

G. If the Subaward Contract is terminated before the Expiration Date (the “Termination Date”), the Subgrantee shall complete a final reimbursement report and return any unspent funds to the Department no later than thirty (30) calendar days after the Termination Date.

H. If the amount reimbursed to the Subgrantee exceeds the expenditures reported on the final Form 286, a check made payable to the Department representing the difference between those amounts must accompany the final Form 286.

I. Payments by the Department that are delayed, withheld, or denied shall not be subject to penalty or interest.

11. Advances. At the request of the Subgrantee, the Department may, in its sole discretion, provide an operating advance for allowable costs. Any such advance shall be subject to the following provisions:

A. The Subgrantee shall repay advances, or certain portions of advances, no later than ten (10) business days following a request for such repayment by the Department.

B. The Subgrantee may repay all or any portion of an outstanding advance at any time.

C. Funds advanced to the Subgrantee under this section shall be exhausted in full or repaid to the Department no later than June 15 of the contract year. Where the advanced funds are not exhausted in full, repayment shall be accomplished by offsetting the amount due back to the Department against reimbursements requested by the Subgrantee, or by some other method suitable to the circumstances as agreed upon by the parties. Notwithstanding any other provision in this section, the Department shall have ultimate discretion with respect to determining the Subgrantee’s the timing andmanner of repayment.

12. Availability of Funds. The Subgrantee understands and agrees that payment of the sums specified herein shall be subject to, and contingent upon, the allocation and appropriation of funds to the Department for the purposes set forth in this agreement.

13. Reversion of Unexpended Funds. The Subgrantee understands and agrees that any unexpended grant funds shall revert to the Department upon termination or expiration of this Subaward Contract.

14. Supplantation of Expenditure of Public Funds. The Subgrantee understands and agrees that funds received pursuant to this Subaward Contract may be used only to supplement, not to supplant, the total amount of Federal, State, and local public funds that the Subgrantee otherwise expends for Weatherization and HARRP services.

15. Contract Administrators. Each party shall submit notices, questions, and correspondence related to this agreement to the other party’s Contract Administrator. The contact information for each party’s Contract Administrator is set out below. Either party may change its Contract Administrator and/or the associated contact information by giving timely written notice to the other party.


Subgrantee Contract Administrator: Department’s Contract AdministratorName and Title Name and Title

City, State and Zip City, State and ZipTelephone: Telephone:Fax: Fax:Email: Email:

16. Subgrantee’s Key Personnel. The Subgrantee shall not substitute its key personnel (“Key Personnel”) assigned to the performance of this agreement without prior written approval from the Department’s Contract Administrator. The Subgrantee has assigned its Key Personnel as follows:

Name Position Email

17. Historic Preservation. Throughout the course of its performance hereunder, the Subgrantee shall comply with applicable requirements of Section 106 of the National Historic Preservation Act, as amended, taking care to avoid any conduct or activity that could adversely impact historic property.

18. Procurement. The Subgrantee understands and agrees that all procurement activities undertaken in connection with this Subaward Contract must conform to the procurement standards set forth in 2 CFR Part 200. Any such procurement activities shall also be subject to the following provisions:

A. None of the work to be performed under this agreement involving the specialized skill or expertise of the Subgrantee shall be contracted without prior written approval from the Department’s Contract Administrator.

B. In the event the Subgrantee contracts for any of the work to be performed hereunder, the Subgrantee shall not be relieved of any duties or responsibilities herein set forth.

C. The Subgrantee shall not contract with any vendor who is restricted from contracting with the State of North Carolina under N.C. Gen. Stat. §§ 143-133.3, 143-59.1, 143-59.2, or 147-86.60.

19. Privacy Protections. The Subgrantee understands and acknowledges that applicants and recipients of Weatherization and HARRP services will be required to provide the Subgrantee with personal information of a private and sensitive nature, such as name, address, age, income, and disability status (“Personal Information”). Accordingly, the Subgrantee agrees to keep and maintain all Personal Information in strict confidence, using such degree of care as is appropriate to avoid unauthorized access, use, or disclosure. In particular, the Subgrantee shall restrict access to client data in the AR4CA database to those of its staff having a legitimate need for such access. Upon learning that an employee’s legitimate need for access no longer exists (e.g., by reason of dismissal, resignation, or a change in the individual’s job duties), the Subgrantee shall take immediate action to remove that person’s AR4CA accessibility. In addition, the Subgrantee shall maintain a log of all active AR4CA users and keep detailed records of any changes in user access status.

20. Title VI and Other Nondiscrimination Requirements. Throughout the course of its performance hereunder, the Subgrantee agrees to comply with all applicable laws, regulations, executive orders, and policies relating to nondiscrimination, including, but not limited to:

A. Title VI of the Civil Rights Act of 1964, as amended;

B. Section 504 of the Rehabilitation Act of 1973, as amended;


C. Title IX of the Education Amendments of 1972;

D. The Age Discrimination Act of 1975, as amended; and

E. Part III of Executive Order No. 11246 (September 24, 1965), as amended, concerning equal employment opportunity in Federally-assisted construction activities.

In accordance with the above laws and their implementing regulations, the Subgrantee agrees to assure that no person in the United States shall, on the ground of race, color, national origin, sex, age, or disability, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Subgrantee receives Federal assistance.

21. E-Verify. To the extent applicable, the Subgrantee represents that it and each of its contractors and subcontractors performing work pursuant to, or in association with, this Subaward Contract are in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes, including, in particular, the requirement that certain employers verify the work authorization of newly hired employees using the Federal E-Verify system.

22. Survival. Any provision contained in this or any other Contract Document that contemplates performance or observance subsequent to the termination or expiration of this agreement shall survive the termination or expiration thereof and continue in full force and effect.

23. Signature Warranty. The undersigned represent and warrant that they are authorized to bind their principals to the terms of this Subaward Contract, which includes all terms incorporated by reference to other documents and/or applicable law.

IN WITNESS WHEREOF, the Subgrantee and the Department execute this Subaward Contract in two (2) originals, one (1) of which is retained by the Subgrantee and one (1) of which is retained by the Department, the day and year first above written.

SUBGRANTEE NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY

By____________________________________ By_____________________________________________Subgrantee Signature Signature of Department Head or Authorized Agent

______________________________________ _____________________________________________ Printed Name and Title Printed Name and Title

Financial Services Division, Purchasing and Contracts SectionOrganization Division/Section


Attachment AGeneral Terms and

Conditions

Definitions

Unless indicated otherwise from the context, or as specifically defined in the Grant Agreement (including its Attachments), the following capitalized terms have the meanings ascribed to them below.

Application means any application submitted by the Subgrantee to the Department for funding for Weatherization Services and HARRP Services.

Award means the grant of funds made by the Department to the Subgrantee for Weatherization Services and HARRP Services, the terms of which are governed by this Grant Agreement.

Eligible Costs are those for which Award disbursements may be made pursuant to 10 CFR Part 440 and 45 CFR Part 96, Subpart H, and the applicable cost principles of 0MB Circulars A-87, A-21, and A-121.

State means the State of North Carolina.

State Actor means any employee, contractor, or agent of the Office of State Budget and Management, the State Auditor, and other State auditors, and the Department.

Relationships of the Parties

Independent Contractor: The Subgrantee is and shall be deemed to be an independent contractor in the performance of this Grant Agreement and as such shall be wholly responsible for the work to be performed and for the supervision of its employees. The Subgrantee represents that it has, or shall secure at its own expense, all personnel required in performing the services under this agreement. Such employees shall not be employees of, or have any individual contractual relationship with, the Department.

Assignment: No assignment of the Subgrantee's obligations or the Subgrantee's right to receive payment hereunder shall be permitted. However, upon written request approved by the issuing purchasing authority, the State may:

{a) Forward the Subgrantee's payment check(s) directly to any person or entity designated by the Subgrantee, or

(b) Include any person or entity designated by Subgrantee as a joint payee on the Subgrantee's payment check(s).

In no event shall such approval and action obligate the State to anyone other than the Subgrantee and the Subgrantee shall remain responsible for fulfillment of all Grant Agreement obligations.

Beneficiaries: Except as herein specifically provided otherwise, this Grant 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 Grant Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the Department and the named Subgrantee. Nothing contained in this document shall give or allow any claim or right of action whatsoever by any other third person. It is the express intention of the Department and Subgrantee that any such person or entity, other than the Department or the Subgrantee, receiving services or benefits under this Grant Agreement shall be deemed an incidental beneficiary only.

Indemnity and Insurance

Indemnification: The Subgrantee agrees to indemnify and hold harmless the Department, the State of North Carolina; and any of their officers, agents and employees, from any claims of third parties arising out of any act or omission of the Subgrantee in connection with the performance of this Grant Agreement. The State shall not provide such indemnification to the Subgrantee.

(a) Insurance: During the term of the Grant Agreement, the Subgrantee shall provide, at its sole cost and expense, commercial insurance of such types and with such terms and limits as may be reasonably associated with the Grant Agreement. At a minimum, the Subgrantee shall provide and maintain the following coverage and limits:

(1) Worker's Compensation Insurance: The Subgrantee shall provide and maintain worker's compensation insurance, as required by the laws of the states in which its employees work, covering all of the Subgrantee's employees who are engaged in any work under the Grant Agreement.

(2) Employer's Liability Insurance: The Subgrantee shall provide employer's liability insurance, with minimum limits of$500,000.00, covering all of the Subgrantee's employees who are engaged in any work under the Grant Agreement.

(3) Commercial General Liability Insurance: The Subgrantee shall provide commercial general liability , insurance on a


comprehensive broad form on an occurrence


basis with a minimum combined single limit of $1,000,000.00 for each occurrence.

(4) Pollution Occurrence Insurance Liability insurance to protect against incidental disturbances of environmental pollutants like lead-based paint dust. The policy must provide three basic limits -$500,000 per occurrence; $500,000 aggregate for the policy term; and $2,500 deductible per occurrence.

(5) Automobile Liability Insurance: The Subgrantee shall provide automobile liability insurance with a combined single limit of $500,000.00 for bodily injury and property damage; a limit of $500,000.00 for uninsured/under insured motorist coverage; and a limit of $2,000.00 for medical payment coverage. The Subgrantee shall provide this insurance for all automobiles that are:

(A) owned by the Subgrantee and used in the performance of this Grant Agreement;

(B) hired by the Subgrantee and used in the performance of this Grant Agreement; and

(C) owned by Subgrantee's employees and used in performance of this Grant Agreement ("non-owned vehicle insurance"). Non-owned vehicle insurance protects employers when employees use their personal vehicles for work purposes. Non-owned vehicle insurance supplements, but does not replace, the car-owner's liability insurance.

The Subgrantee is not required to provide and maintain automobile liability insurance on any vehicle - owned, hired, or non owned -- unless the vehicle is used in the performance of this Grant Agreement.

(b) The insurance coverage minimums specified in subparagraph (a) are exclusive of defense costs.

(c) The Subgrantee understands and agrees that the insurance coverage minimums specified in subparagraph (a) are not limits, or caps, on the Subgrantee's liability or obligations under this Grant Agreement.

(d) The Subgrantee may obtain a waiver of any one or more of the requirements in subparagraph (a)

by demonstrating that it has insurance that provides protection that is equal to or greater than the coverage and limits specified in subparagraph (a). The Department shall be the sole judge of whether such a waiver should be granted.

(e) The Subgrantee may obtain a waiver of any one or more of the requirements in paragraph (a) by demonstrating that it is self-insured and that its self-insurance provides protection that is equal to or greater than the coverage and limits specified in subparagraph (a). The Department shall be the sole judge of whether such a waiver should be granted.

(f) Providing and maintaining the types and amounts of insurance or self-insurance specified in this paragraph is a material obligation of the Subgrantee and is of the essence of this Grant Agreement.

(g) The Subgrantee shall only obtain insurance from companies that are authorized to provide such coverage and that are authorized by the Commissioner of Insurance to do business in the State of North Carolina. All such insurance shall meet all laws of the State of North Carolina.

(h) The Subgrantee shall comply at all times with all lawful terms and conditions of its insurance policies and all lawful requirements of its insurer.

(i) The Subgrantee shall require its subcontractors to comply with the requirements of this paragraph.

(j) The Subgrantee shall demonstrate its compliance with the requirements of this paragraph by submitting certificates of insurance to the Department before the Subgrantee begins work under this Grant Agreement.

Default and Termination

Termination Without Cause: The Department may terminate this Grant Agreement without cause by giving 30 days written notice to the Subgrantee.

Termination for Cause: In the event that the Subgrantee breaches any covenants, agreement, or certifications in this Grant Agreement, including the expenditure of Award Funds for any other use than for the purposes set forth in this Grant Agreement or the Program Guidance or in any other unauthorized manner, the Department shall have the right to terminate this Grant Agreement by giving written notice to the Subgrantee and specifying the effective date thereof. In that event, all finished or unfinished deliverable items


prepared by the Subgrantee under this Grant Agreement shall, at the option of the Department, become its property and the Subgrantee shall be entitled to receive just and equitable compensation for any satisfactory work completed on such materials, minus any disallowed costs outstanding or currently under investigation, and payment or compensation previously made. Notwithstanding the foregoing provision, the Subgrantee shall not be relieved of liability to the Department for damages sustained by the Department by virtue of the Subgrantee's breach of this agreement.

Termination by Mutual Consent: The Parties may terminate the Grant Agreement by mutual consent with60 days' notice to the other Party, or as otherwise provided by law.

Remedies: All rights and remedies existing under this Grant Agreement shall be cumulative and in addition to those rights allowed and provided by law. The Department may demand repayment from the Subgrantee of any amounts that the Department determines were not expended in accordance with this Agreement. The Department may demand repayment of all Award funds distributed to the Subgrantee which were not utilized in accordance with this Agreement. The Department may at any time proceed to protect and enforce all rights available to the Department by suit in equity, action at law, or by any other appropriate proceedings, all of which rights and remedies shall survive the termination of this Agreement. Department may withhold any payment due the Subgrantee for the purpose of setoff until such time as the exact amount of damages due the Department from such breach can be determined. In case of default by the Subgrantee, without limiting any other remedies for breach available to it, the Department may procure the Grant Agreement services from other sources and hold the Subgrantee responsible for any excess cost occasioned thereby. The filing of a petition for bankruptcy by the Subgrantee shall be an act of default under this Grant Agreement.

Waiver of Default: Waiver by the Department of any default or breach in compliance with the terms of this Grant Agreement by the Subgrantee 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 Grant Agreement unless stated to be such in writing, signed by an authorized representative of the Department and the Subgrantee and attached to the Grant Agreement.

Availability of Funds: The parties to this Grant Agreement agree and understand that the payment of the sums specified in this Grant Agreement is dependent and contingent upon and subject to the appropriation,

allocation, and availability of funds for this purpose to the Department.

Force Majeure: Neither party shall be deemed to be in default of its obligations liereunder if and so long as it is prevented from performing such obligations by any act of war, hostile foreign action, nuclear explosion, riot, strikes, civil insurrection, earthquake, hurricane, tornado, or other catastrophic natural event or act of God.

Survival of Promises: All promises, requirements, terms, conditions, provisions, representations, guarantees, and warranties contained herein shall survive the Grant Agreement expiration or Termination Date unless specifically provided otherwise herein, or unless superseded by applicable Federal or State statutes of limitation.

Intellectual Property Rights

Copyrights and Ownership of Deliverables: All deliverable items produced pursuant to this Grant Agreement are the exclusive property of the Department. The Subgrantee shall not assert a claim of copyright or other property interest in such deliverables.

Federal Intellectual Property Bankruptcy Protection Act: The Parties agree that the Department shall be entitled to all rights and benefits of the Federal Intellectual Property Bankruptcy Protection Act, Public Law 100-506, codified at 11 U.S.C. 365 (n) and any amendments thereto.

Compliance with Applicable Laws

Compliance with Laws: The Subgrantee shall comply with all laws, ordinances, codes, rules, regulations, and licensing requirements that are applicable to the conduct of its business, including those of Federal, State, and local agencies having jurisdiction and/or authority.

Equal Employment Opportunity: The Subgrantee shall comply with all Federal and State laws relating to equal employment opportunity.

Title VI, Civil Rights Compliance: In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Commerce policy, the contractor is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs.

Health Insurance Portability and Accountability Act (HIPAA): The Subgrantee agrees that, if the Department determines that some or all of the activities within the scope of this Grant Agreement are subject to the Health Insurance Portability and Accountability Act of 1996,P.L. 104-91, as amended ("HIPAA"), or its


implementing regulations, it will comply with the HIPAA requirements and will execute such agreements and practices as the Department may require to ensure compliance.

Confidentiality

Confidentiality and Public Records: To the extent that any information or documents provided to the Department by, or on behalf of, the Subgrantee would be regarded as confidential or not subject to disclosure under Federal law or the North Carolina General Statutes (including, without limitation, N.C. Gen. Stat. §§ 132-1 et seq., commonly referred to as the "Public Records Act"), the Subgrantee shall clearly identify and mark it as such and that information will, to the extent allowed by law, be treated as confidential and not subject to disclosure by the Department. The Subgrantee has read and understands North Carolina's laws regarding the treatment of public records and confidential information. Anything that qualifies as a trade secret under North Carolina law must be designated as "confidential" or "trade secret" at the time of initial disclosure to the Department, or it is considered a public record under State law.

Oversight

Access to Persons and Records: All State Actors shall have access to persons and records of the Subgrantee, and the right to inspect, copy, audit, and examine all of the relevant books, records, and other documents relating to the Award and fulfillment of this Grant Agreement for the time period specified for retention in this Grant Agreement. Records shall also include those of other funding programs, should they be considered to potentially provide information relevant to this Grant Agreement. The Subgrantee shall make such records available upon demand of a duly authorized representative of a State Actor. In addition, any representative of the United States Inspector General or of the Comptroller General may examine any of the Subgrantee's or contractor's records or records of other firms working on the Project. The foregoing Federal entities and State Actors may also interview any of the Subgrantee's (and Subgrantee's and contractor's or other firm's) employees or officers working on the Project. Nothing in this section shall be interpreted to limit or restrict in any way any existing authority of an Inspector General or the Comptroller General.

Record Retention: Records shall not be destroyed, purged or disposed of without the express written consent of the Department. State basic records retention policy requires all grant records to be retained for a minimum of five years or until all audit exceptions have been resolved, whichever is longer. Under applicable

Federal regulations, record retention may be longer than five years since records must be retained for a period of three years following submission of the final Federal Financial Status Report, if applicable, or three years following the submission of a revised final Federal Financial Status Report. Also, if any litigation, claim, negotiation, audit, disallowance action, or other action involving this Contract has been started before expiration of the five-year retention period described above, the records must be retained until completion of the action and resolution of all issues which arise from it, or until the end of the regular five-year period described above, whichever is later.

Warranties and Certifications

Date and Time Warranty: The Subgrantee warrants that the product(s) and service(s) furnished pursuant to this Grant Agreement ("product" includes, without limitation, any piece of equipment, hardware, firmware, middleware, custom or commercial software, or internal components, subroutines, and interfaces therein) that perform any date, time or GIS data recognition function, calculation, or sequencing will support a four digit year format and will provide accurate date, time and GIS data and leap year calculations. This warranty shall survive the termination or expiration of this Grant Agreement.

Certification Regarding Collection of Taxes: G.S. 143-59.1 bars the Secretary of Administration from entering into contracts with vendors that meet one of the conditions of G.S. 105-164.8(b) and yet refuse to collect use taxes on sales of tangible personal property to purchasers in North Carolina. The conditions include:(a) maintenance of a retail establishment or office; (b) presence of representatives in the State that solicit sales or transact business on behalf of the vendor; and (c) systematic exploitation of the market by media-assisted, media-facilitated, or media-solicited means. The Subgrantee certifies that it and all of its affiliates (if any) collect all required taxes.

Miscellaneous

Choice of Law: The validity of this Grant Agreement and any of its terms or provisions, as well as the rights and duties of the parties to this Grant Agreement, are governed by the laws of North Carolina. The Subgrantee, by signing this Grant Agreement, agrees and submits, solely for matters concerning this Contract, to the exclusive jurisdiction of the courts of North Carolina and agrees, solely for such purpose, that the exclusive venue for any legal proceedings shall be Wake County, North Carolina. The place of this Grant 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 contract or tort,


relating to the validity, construction, interpretation, and enforcement shall be determined.

Amendment: This Grant Agreement may not be amended orally or by performance. Any amendment must be made in written form and executed by duly authorized representatives of the Department and the Subgrantee.

Severability: In the event that a court of competent jurisdiction holds that a provision or requirement of this Grant 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 Grant Agreement shall remain in full force and effect.

Headings: The Section and Paragraph headings in these General Terms and Conditions are not material parts of the agreement and should not be used to construe the meaning thereof.

Time of the Essence: Time is of the essence in the performance of this Grant Agreement.

Key Personnel: The Subgrantee shall not replace any of the key personnel assigned to the performance of this Grant Agreement without the prior written approval of the Department . The term "key personnel" includes any and all persons identified as such in the Contract Documents and any other persons subsequently identified as key personnel by the written agreement of the parties.

Care of Property: The Subgrantee agrees that it shall be responsible for the proper custody and care of any property furnished to it for use in connection with the performance of this Grant Agreement and will reimburse the Department for loss of, or damage to, such property. At the termination of this Grant Agreement, the Subgrantee shall contact the Department for instructions as to the disposition of such property and shall comply with these instructions.

Travel Expenses: Reimbursement to the Subgrantee for travel mileage, meals, lodging and other travel expenses incurred in the performance of this Grant Agreement shall not exceed the rates published in the applicable State rules. International travel shall not be reimbursed under this Grant Agreement.

Advertising: The Subgrantee shall not use the award of this Grant Agreement as a part of any news release or commercial advertising

Conflicting Provisions: To the extent that any provision of this Grant Agreement is determined to be in contradiction of, or in conflict with any Federal or State law or regulation, the Federal or State law or regulation,

shall control. All applicable Federal and State laws and regulations are incorporated herein by reference. Otherwise, any conflict · between the provisions, requirements, duties or obligations of this Grant Agreement and any other documentation for this Award shall be resolved in favor of this Grant Agreement.

Sales/Use Tax Refunds: The Contractor and all subcontractors shall: (a) ask the North Carolina Department of Revenue for a refund of all sales and use taxes paid by them in the performance of this contract, pursuant to G.S. 105-164.14; and (b) exclude all refundable sales and use taxes from all reportable expenditures before the expenses are entered in their reimbursement reports.

Entire Agreement: This Grant Agreement constitutes the entire agreement between the Parties and supersedes all prior oral or written statements or agreements.


Attachment BNotice of Certain Reporting and Audit Requirements

Subgrantees, local governments, and public authorities shall comply with all rules and reporting requirements established by statute or administrative rules. All reports must be submitted to the addresses below.

Subgrantees

The applicable prescribed requirements are found in the Office of the State Auditor's Audit Advisory #ADV-2005-001, North Carolina General Statute 143C-6-22 & 23 and Implementation of Required Rules, 09 NCAC 03M .0102 -0802, North Carolina Administrative Code. The Office of State Auditor's Audit Advisory #ADV-2005-001, additional policy statements, access to the Grants Information Center and forms are available on the State Auditor's Internet web site at www.ncauditor.net. From the home page select "Grants". Select the "Regulations" tab for the standards and the "Fonns" tab to download forms as needed.

N.C.G.S. §143C-6-23 requires every nongovernmental entity that receives State or Federal pass-through grant funds directly from a State agency to file annual reports on how those grant funds were used. There are 3 reporting levels which are determined by the total direct grant receipts from all State agencies in your fiscal year:

• Level I : Less than $25,000• Level 2: At least $25,000 but less than $500,000• Level 3: $500,000 or more

A Subgrantee's reporting date is determined by its fiscal year end and the total funding received directly from all State agencies. For those Subgrantees receiving less than $500,000, the due date is 6 months from its fiscal year end. For those receiving $500,000 or more, the due date is 9 months from its fiscal year end. In addition to the reports, Subgrantees receiving $500,000 or more must submit a yellow book audit in electronic or hard copy to the Office of the State Auditor and to all funding State agencies at the addresses below.

All annual Subgrantee reports required by GS 143C-6-23 must be completed online at www.NCGrants.gov. The online reporting system will automatically place your organization on the Noncompliance list if your reports have not been completed in www.NCGrants.gov by your required due date.

To access the online grants reporting system go to www.NCGrants.gov and click on the LOGIN tab at the top of the page. You must have a NCID to access the online reporting system. To obtain a user manual or request assistance with the system please go to htt_ps://www.ncgrants.gov/NCGrants/Help . jsp . You can also email requests for assistance directly to NCGrants @ osbm.nc.gov .

Once you have logged in you will see your "Grantee Summary / Data Entry Screen".

• Your summary screen will identify your correct level of reporting, i.e., Level 1, 2 or 3, based on the State grant funds paid to your organization during your fiscal year.

• The summary will show all the grants contained in the www.NCGrants.gov system that have been awarded to your organization. The program will automatically provide links to the reports that correspond to your reporting level, and only those reports, for each grant. Check to make sure that the grant(s) shown in the system correspond with what you show as having received from each agency for your fiscal year.

• If you have questions, need help in resolving any differences between your records and online reporting system or need corrections to be made to the data you enter, send an e-mail to NCGrants @ osbm . nc.gov to request help.


IMPORTANT NOTE FOR AUDITS

If the Subgrantee expends more than $750,000 in Federal grant funds from all sources, then it must have a 2 CFR 200 Subpart F audit performed. If you are at this level for Federal reporting, the Subgrantee may use the 2 CFR 200 audit to comply with State statutes under N.C.G.S. §143C-6-23.

If you are required to have an 2 CFR 200 audit performed and you receive any Federal grant funds passed through the Department, you are required to file the 2 CFR 200 audit with the Department.

If you expend more than $750,000 and you are required to file a yellow book audit with the State Auditor under G.S. 143C-6-23, then you are also required to file the yellow book audit with the Department.

All audits must be completed within 9 months of the Subgrantee's fiscal year.

Fiscal Year for Action Pathways, Inc.: January I to December 31

Please send the required audit to the following address:

Mail to: Weatherization Assistance Program Attention: Audit Resolution4345 Mail Service Center Raleigh, NC 27699-4345

Or direct delivery to: 217 West Jones StreetRaleigh, NC 27603


Attachment C

LINE ITEM BUDGET AND NARRATIVE


Attachment D

FY 2017 APPLICATION FOR FUNDING

(July 1, 2017 - June 30, 2018)

Weatherization Assistance Program

Heating and Air Repair and Replacement Program

[AGENCY NAME]

North Carolina Department of Environmental Quality

Division of Energy, Mineral, and Land Resources

4345 Mail Service Center

Raleigh, North Carolina 27699-4345

Telephone: (919) 707-8113

Fax: (919) 707-715-1117


________________________________ SECTION I. IDENTIFICATION ________________________________________

Agency Name:

Mailing Address:

Street Address (if different from above):

Agency Website:

Telephone Number:

Fax Number:

Board Chairperson:

Board Chairperson Email Address:

Executive Director:

Finance Director:

Finance Director Email Address:

Contact Person for Program Narrative:

Contact Person for Budget:

In addition to a signed hard copy of the application, please submit an electronic version of the Application, Budget, and the One-Year Work Programs to your agency’s program analyst.

SECTION II. CERTIFICATION

THIS IS TO CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT AND RECEIVED APPROVAL FOR SUBMISSION BY THE BOARD OF DIRECTORS OR DULY AUTHORIZED BODY.

Typed Name of Board Chairperson

Signature of Board Chairperson

Date of Certification


SECTION III. PROGRAM NARRATIVE __ _______

Needs Assessment, Resource Analysis and Service Plan

1. Describe how your agency will identify and recruit applicants for the program from the following demographic groups:

a. Elderlyb. Disabledc. Households with young childrend. Households with a high energy burdene. Households that are considered high energy users


PROGRAM NARRATIVE (Cont.)

2. Identify all staff members that are currently paid directly, in whole or in part, with weatherization funds in the table below. Attach a current resume and job description for each individual and position listed (certifications, licenses, etc.).

Name Position Title # Yrs. in WAP

3. Attach a current agency-wide organizational chart that includes all positions that are to be paid, directly or indirectly, in whole or in part, with Weatherization or HARRP funds.

4. Does your agency plan to subcontract weatherization work (including shell work, insulation placement, and duct sealing) during FY 2017-2018?


5. Identify all firms and individuals that your agency currently contracts with and intends to contract with to perform standard weatherization services including insulation installation and HVAC.

Business Name Owner’s NameHUB

(Y/N)Type Work Performed

6. Can your agency commit to having a different Auditor and Quality Control Inspector (QCI) on every weatherization job?

a. List the name, BPI number and expiration date of your agency’s certified QCI.Employee Name BPI # Expiration Date

b. If no one on staff is QCI certified, fill out the information below.Employee Name BPI Approval Target Date for Exam

7. Attach a copy the agency’s most recent cognizant approved indirect cost rate and full proposal (with supporting calculations) submitted to the cognizant. NA -- (already received)

8. Attach a copy of the agency’s Entity Record from the System of Award Management Site that reflects an expiration date of February 1, 2018, or later.


9. Describe the local training and technical assistance activities that your agency plans to provide to staff and to subcontractors using Weatherization Training and Technical Assistance funds received during FY 2018 (identify tentative dates, topics, trainers and costs). Training sponsored directly by the State Weatherization Office should not be listed here.

Topic Date Trainers Cost

Total

10. Describe what type of State Weatherization Office sponsored training and technical assistance activities that your

agency would like to see planned for the FY 2018 (Please reference the NC Training Plan for topics).

Topic Number of Projected Participants


Attachment E

CERTIFICATION OF NO OVERDUE TAX DEBT

Instructions:

The attached document must be completed by all non-governmental entities receiving state funds.

1. Copy the attached document on your agency’s letterhead

2. Fill in agency’s information

3. Print, notarized, and return with original contract


Instructions: Subgrantee should complete this certification for all State funds received. Entity should enter appropriate data in the shaded areas. The completed and signed form should be provided to the State agency funding the grant to be attached to the contract for the grant funds. A copy of this form, along with the completed contract, should be kept by the funding agency and available for review by the Office of the State Auditor.

Note: If you have a contract that extends more than one State fiscal year, you will need to obtain an updated certification for each year of the contract.

Entity’s Letterhead

[Date of Certification (mmddyyyy)]

To: State Agency Head and Chief Fiscal Officer

Certification:

We certify the [insert organization’s name] 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-10-1-1b.

Sworn Statement:

[Name of Board Chair] and [Name of Second Authorizing Official] being duly sworn, say that we are the Board Chair and [Title of the Second Authorizing Official], respectively, of [insert name of organization] of [City] in the State of [Name of State]; and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action.

______________________________

Board Chair

______________________________

[Title of Second Authorizing Official]


Sworn to and subscribed before me on the day of the date of said certification.

_______________________________ My Commission Expires: __________

(Notary Signature and Seal)

If there are any questions, please contact the North Carolina Office of the State Auditor.

1 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. 105237 within 90 days after the notice of final assessment was mailed and has not failed to make any payments due under the installment agreement.”


EXAMPLEDate

To: State Agency Head and Chief Fiscal Officer

Certification:

We certify that the ______________________________ (agency’s name) 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. §143-6.2(b2) is guilty of a criminal offense punishable as provided by N.C.G.S. §143-34(b).

Sworn Statement:

____________________________________ (Board Chair) and ______________________________ (Board Treasurer) being duly sworn, say that we are the Board Chair and Board Treasurer, respectively, of ____________________________________ (Agency’s name) of __________________________ (City) in the State of North Carolina; and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action.

______________________________

Board Chair

______________________________

Board Treasurer

Sworn to and subscribed before me on the day of the date of said certification.

________________________ My Commission Expires: __________

(Notary Signature and Seal)


Attachment FFEDERAL CERTIFICATIONS

THE UNDERSIGNED STATES THAT:

1. HE OR SHE IS THE DULY AUTHORIZED REPRESENTATIVE OF THE CONTRACTOR NAMED BELOW;

2. HE OR SHE IS AUTHORIZED TO MAKE, AND DOES HEREBY MAKE, THE FOLLOWING CERTIFICATIONS ON BEHALF OF THE CONTRACTOR, AS SET OUT HEREIN:

A. THE CERTIFICATION REGARDING NONDISCRIMINATION;B. THE CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS;C. THE CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE;D. THE CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY

EXCLUSION LOWER TIER COVERED TRANSACTIONS; ANDE. THE CERTIFICATION REGARDING LOBBYING;

3. HE OR SHE HAS COMPLETED THE CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS BY PROVIDING THE ADDRESSES AT WHICH THE CONTRACT WORK WILL BE PERFORMED;

4. [Check the applicable statement]

[ ] He or she has completed the attached Disclosure Of Lobbying Activities because the Contractor 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

[ ] He or she has not completed the attached Disclosure Of Lobbying Activities because the Contractor has not made, and has no agreement to make, any payment to any lobbying entity for influencing or attempting to influence any officer 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 Contractor shall require its subcontractors, if any, to make the same certifications and disclosure.

_______________________________________________________________________Signature Title_______________________________________________________________________Contractor NameDate

[This Certification Must be Signed by the Same Individual Who Signed the Proposal Execution Page]


I. Certification Regarding Nondiscrimination

The Contractor 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. §§1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of 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 VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended, relating to nondiscrimination in the sale, rental 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 Requirements

1. THE CONTRACTOR 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 Contractor’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 Contractor’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 after such conviction;

e. Notifying the Department within ten days after receiving notice under subparagraph (d)(ii) 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):

Address

Street

______________________________________________________________________

City, State, Zip Code _____________________________________________________________________

Street

______________________________________________________________________

City, State, Zip Code _____________________________________________________________________


3. Contractor 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 18, 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 Contractor certifies that it will comply with the requirements of the Act. The Contractor 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 subgrantees 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 Contractor.]


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 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.

9. 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

1. 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 Contractor 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 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 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.

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 and/or has been secured to influence the outcome of a covered Federal action.

2. Identify the status of the covered Federal action.

3. 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 sub-award recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants 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.

8. Enter the most appropriate Federal Identifying number available for the Federal action identified in Item 1 (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-DE-90-001."

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.

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 Sheet(s) 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 and maintaining the data needed, 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


Disclosure Of Lobbying Activities(Approved by OMB 0344-0046)

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352

1. Type of Federal Action:

a. contract

b. grant

c. cooperative agreement

d. loan

e. loan guarantee

f. loan insurance

2. Status of Federal Action:

a. Bid/offer/application

b. Initial Award

c. Post-Award

3. Report Type:

a. initial filing

b. material change

For Material Change Only:

Year___________ Quarter____________

Date Of Last Report:_________________

4. Name and Address of Reporting Entity:

Prime

Subawardee Tier (if known) ________________________

Congressional District (if known) _________________________

5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime:

Congressional District (if known) ________________________

6. Federal Department/Agency: 7. Federal Program Name/Description:

CFDA Number (if applicable) ________________________

8. Federal Action Number (if known) 9. Award Amount (if known) $


10. a. Name and Address of Lobbying Entity

(if individual, last name, first name, MI):

(attach Continuation Sheet(s) SF-LLL-A, if necessary)

b. Individuals Performing Services (including address if different from No. 10a.) (last name, first name, MI):

(attach Continuation Sheet(s) SF-LLL-A, if necessary)

11. Amount of Payment (check all that apply):

$ actual planned

13. Type of Payment (check all that apply):

a. retainer

b. one-time fee

c. commission

d. contingent fee

e. deferred

f. other; specify: _____________________________

12. Form of Payment (check all that apply):

a. cash

b. In Nature -kind; specify:specify: Nature

Value

14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11(attach Continuation Sheet(s) SF-LLL-A, if necessary):

15. Continuation Sheet(s) SF-LLL-A attached: Yes No

16. Information requested through this form is authorized by title 31 U. S. C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U. S. C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Signature:

Print Name:

Title: ______________________________________________

Telephone No: Date:

Federal Use Only Authorized for Local Reproduction

Standard Form - LLL


Attachment G

NOTARIZED CONFLICT OF INTEREST POLICY

State of North Carolina

County of __________________________________

I, ____________________________________________________, Notary Public for said County and State, certify that

_______________________________________________ personally appeared before me this day and acknowledged

that he/she is ________________________________________ of _________________________________________ [enter name of entity]

and by that authority duly given and as the act of the Organization, affirmed that the foregoing Conflict of Interest Policy

was adopted by the Board of Directors/Trustees or other governing body in a meeting held on the __________ day of ___________, _________.

Sworn to and subscribed before me this _________ day of ______________________, ____.

___________________________________(Official Seal) Notary Public

My Commission expires ______________________________, 20 ___

Instruction for Organization: Sign and attach the following pages after adopted by the Board of Directors/Trustees or other governing body OR replace the following with the current adopted conflict of interest policy.

___________________________________________Name of Organization

___________________________________________Signature of Organization Official

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EXAMPLEConflict of Interest Policy

Instructions: This document is intended as an aid to assist non-State entities in establishing a conflict of interest policy. It is not intended to be used verbatim, but rather to serve as a template for nongovernmental organizations as they craft their individual conflict of interest policy. This example includes definitions of what is considered unacceptable, and the consequences of any breaches thereof. Each organization that chooses to use this template should take care to make changes that reflect the individual organization.

The Board of Directors/Trustees or other governing persons, officers, employees or agents are to avoid any conflict of interest, even the appearance of a conflict of interest. The Organization‘s Board of Directors/Trustees or other governing body, officers, staff and agents are obligated to always act in the best interest of the organization. This obligation requires that any Board member or other governing person, officer, employee or agent, in the performance of Organization duties, seek only the furtherance of the Organization mission. At all times, Board members or other governing persons, officers, employees or agents, are prohibited from using their job title, the Organization's name or property, for private profit or benefit. A. The Board members or other governing persons, officers, employees, or agents of the Organization should neither solicit nor accept gratuities, favors, or anything of monetary value from current or potential contractors/vendors, persons receiving benefits from the Organization or persons who may benefit from the actions of any Board member or other governing person, officer, employee or agent. This is not intended to preclude bona-fide Organization fund raising-activities. B. A Board or other governing body member may, with the approval of Board or other governing body, receive honoraria for lectures and other such activities while not acting in any official capacity for the Organization. Officers may, with the approval of the Board or other governing body, receive honoraria for lectures and other such activities while on personal days, compensatory time, annual leave, or leave without pay. Employees may, with the prior written approval of their supervisor, receive honoraria for lectures and other such activities while on personal days, compensatory time, annual leave, or leave without pay. If a Board or other governing body member, officer, employee or agent is acting in any official capacity, honoraria received in connection with activities relating to the Organization are to be paid to the Organization.C. No Board member or other governing person, officer, employee, or agent of the Organization shall participate in the selection, award, or administration of a purchase or contract with a vendor where, to his knowledge, any of the following has a financial interest in that purchase or contract:

1. The Board member or other governing person, officer, employee, or agent;2. Any member of their family by whole or half blood, step or personal relationship or relative-in-law;3. An organization in which any of the above is an officer, director, or employee;4. A person or organization with whom any of the above individuals is negotiating or has any

arrangement concerning prospective employment or contracts.

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EXAMPLED. Duty to Disclosure -- Any conflict of interest, potential conflict of interest, or the appearance

of a conflict of interest is to be reported to the Board or other governing body or one’s supervisor immediately.

E. Board Action -- When a conflict of interest is relevant to a matter requiring action by the Board of Directors/Trustees or other governing body, the Board member or other governing person, officer, employee, or agent (person(s)) must disclose the existence of the conflict of interest and be given the opportunity to disclose all material facts to the Board and members of committees with governing board delegated powers considering the possible conflict of interest. After disclosure of all material facts, and after any discussion with the person, he/she shall leave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon. The remaining board or committee members shall decide if a conflict of interest exists. In addition, the person(s) shall not participate in the final deliberation or decision regarding the matter under consideration and shall leave the meeting during the discussion of and vote of the Board of Directors/Trustees or other governing body.F. Violations of the Conflicts of Interest Policy -- If the Board of Directors/Trustees or other governing body has reasonable cause to believe a member, officer, employee or agent has failed to disclose actual or possible conflicts of interest, it shall inform the person of the basis for such belief and afford the person an opportunity to explain the alleged failure to disclose. If, after hearing the person's response and after making further investigation as warranted by the circumstances, the Board of Directors/Trustees or other governing body determines the member, officer, employee or agent has failed to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective action.G. Record of Conflict -- The minutes of the governing board and all committees with board delegated powers shall contain:

1. The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing boards or committee's decision as to whether a conflict of interest in fact existed.

2. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings.

Approved by:

___ Name of Organization

_______________________________________Signature of Organization Official:

_______________________________________Date

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Attachment H

IRS Tax Exempt Letter

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