NC 4:13 Batch

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Notarization of Conflict of Interest Policy

State of North Carolina, County of _FOKSiAto.
4_Monique S Shields Notary Public for said County and State

betta FMeer (Nane of Bord Cie

cr Auterize Ofc] personally appeared before me this day and acknowledged that heshe
is_State Duector frie} of
lanchinos Pregnancy Cases Hl Shao [Organization's fll

‘egal name] and by that authority duly given and as the act of the Organization, affirmed that

iors Trustees oF

the foregoing Conli oflterest Policy was adopted by the Board of i
other governing body ina meeting held on the _3“4tay of December _, 200%,

‘Swom to and subscribed before me this!" day of NOVEM ber _.201 3.

Laren ization Ocal

INES Apt 207, DP 110410
Employees and board members have an obligation to conduct business within guidelines
that prohibit actual or potential conflicts of interest. This policy establishes only the
framework within which the Carolina Pregnancy Care Fellowship wishes its business 0
‘operate. The purpose of these guidelines is to provide general direction so that board
_members and employees can seek further clarification on issues related to the subject of
acceptable standards of operation.

‘An actual or potential conflict of interest occurs when a board member or an employee is
ina position to influence a decision that may result in personal ean organ fra relative
asa result of the Carolina Pregnancy Care Fellowship ‘s business dealings. For the
purpose ofthis policy relative is any person who is related by blood or marrage, or
‘whose relationship with the board member or employee is similar to that of persons who
ae related by blood or marrage.

No presumption ofa conflict is ereated by the mere existence of a relationship with
outside firms. However, ifa board member or an employee has any influence on any
‘material business transactions, iis imperative that he or she discloses to an officer of the
‘organization as soon as possible the existence of any actual or potential conflict of
Interest so that safeguards can be established to protect all parties.

Personal gain may result not only in cases where a board member, an employee, or a
relative has a significant ownership in a firm with which the Carolina Pregnancy Care
Fellowship does business, but also when a board member, an employee, or a relative
receives any kickback, bribe, substantial gift or special consideration as a result of any
transaction or business dealings involving the Carolina Pregnancy Care Fellowship.

Carolina Pregnancy Care Fellowship

“Swe
‘Approved 12/08
N.C. Department of Health and Human Services
Division of Pubic Health
Women & Children’s Heath WHE.
‘Section/Branch
Contract Expenditure Report

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Purpose
Contractor match ls REQUIRED by this contract:
27 ne aspera Don) No.

Them Deseapion Tia Numer —| Contactor Ancunt]| ORS Anant
a 35578 53
[Sta Development $839.00]
[Supples & Materais- Offer $1461.83
[Eaupment (i)
[Eauipment(orcey
TI $1913.79
Inve = aaveriang,
Inve Prometone! Rem
=Websles & sie $37.0]

ues & Subssripions
[Qperatonal Other insurance & Bonding

[Scosontract and Grants
des - Telephone $208.79
Intent $96.9]
$21,801.55
[Suber Ear) GED)
THIS SECTION FOR DPH USE ONLY:
\Company 2604
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‘sche exc ero dois ol he contacgoprizatn, herby ct ale us ldo DHHS on i pbc
fyrantecter have been dvd in acatance wh be condos of he contact ra oe best ny roe and
Bolt wo have ciple wh live, ola rl coral reson hat a aeons pyen unde scone
‘Asche carer son oft ecirt eparzatin, hare crt bcs r wit tier imbue en
‘ne dane Reutty Rembursenert were hero rt avd sexo wha provost askance aerate
cary ht any cuted ming expercure hve been ncured, an athe bet of my knowl ard bel we have compet
tallow, oles al contac povsins Pa conosco pamer under Bs car.

State. bire —— isis
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(01s 241 Avan 00) (0FH Rove 01008) Page tots
MONTHLY FINANCIAL REPORT

‘CONTRACTOR: Caraina Praga Gare Foto Crack,
‘CONTRACT PERIOD: Deser ATT Hay 2076
CONTRACT: ies
REPORTING PERIOD: Decora OT
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s1a61.63

sum a [on "p00
[Equant OnE $000.

[rst $iaooss| Sa
[odiaConmunicton -aerig "30.00

[ModixConmunicaton= Wobstee & Nails 00 ESAT
{MediaConmunicaton- Reams "0.00

{use Susecpions 05.

Operational tor Inuranen Bonding ‘0.00

IReotomner 0.00

itis. TetoharS F1378.00 sat Esa}

lute =Iemet $475.00 $187.10 538.60 $2007
Opera Oto: enives and Paribas 74,120.00 soo Sicea0
[Bubeosracte and Gree ‘3400 00| S202 251 S187
SubcrnracingGrants (NC Pegrancy Cana) Siwsi200| ——oeyurssl —Sryanege | wer evzst
[TOTAL $00,500.00 | sana | SRE | OTOL
MONTHLY FINANCIAL REPORT
‘Sub-Contractors.

CONTRACTOR: ‘Cave Pregnancy Gore Fallshio Sul
CONTRACT PERIOD: ‘DeaeraOTy yatta
CONTRACT sats
REPORTING PERIOD: Dezember AT
isoreg Sages] ——_—_ sh ao] saga
apa aie — 5.800 Sinig0| ganas —"talezeos
[seneniosred Biasfis00 9500“ sottan | — state.
Exermrenrererea sh77500 | ——STe.006 0 $49,206.25
(ugow a Mena rue 51621800 S16 29 S1a.a85 78
ean 7 315.7400 $2200 Sesto
aun ENA) Sf S160 0551 51778]
2865.00 Haars | _ sidaceoe
= #2318007 00 32.65.00,
Ce MT TETTY ser 0m g.ia7.00f
eseconrusetncoaee $1,586.00 $c. OE
hae one ast Tigi 9. Wazb
eaeconmsinon alive 3e,7780 s2s0007 —Sitarao | 38.3400
[est rs Crone Bi.ea00 sreagt{ ——siowan]” $1027.10
Eset revere 8 ss S12s7700 Si ‘seo7.00 |“ $10870.50
fusteternneser Pun Set Announcer $5750 Ea ‘ooo! es7s.00
fae seen ssa, Snot 30.00) Sige
losing eae roan a aiaeas ~~ ~Sin 915.00 Sagres | —waago.at| —Gei saa
fs $2,008.00 EERE Bist stawo72
eee $500.00 $0.00 soe.
io 3510.atz00| __,_eaepursa| —gataeaas] ~Bieterast
ATTACHMENT A
SPECIAL APPROPRIATIONS AGREEMENT COVER
Non-Profit Organiga tions

THIS AGREEMENT i: buxeby ade he-ween the Sale of North Caroling, Departament af Cleaith and
Tuan Services, Division of PubLe Healtl and Carolina Vcgnuney Cars Ze lvaslp itt at addi ut 3320
(OME Phamaiow Opole, WevstnneSalamn C2221.

¢ incarpomnted enc hy rolerence

his agreement consists of Le Flowing decutrents which

Atvaclunent 4 ~ Special Appiopristions Agreement Cav

1
2. Atuichaent Ty - General ‘Taeray andl Comitions

3. Altuelinent C - Payauent Regret Form

4. Actaclinect 1 ~ Retipient Hlectranie Pasinent Fore

5. Attachment E Wy (Recipient to Aceh!

G ‘AUigchment F - State Grant No Overdue “Tax Debts

2. Aaelment Ge - Contlet af feraest Poy

Attache 1! - IRS Tus Pscanptine. Leer (Retain eo Attach Tappa

9, Anachment |= Hg-lases (Recipient Achy
1g. Amachment J - List of Board Meutbers (Recipient te Asch
HT” Anaxtrwnt K - Seape of Work

12, Auuchisen!T,- Reporing Require-ncrs

Leflective Dates July 1.2917

ermine Pes Jane 8, 2019

State Fingmesal Agsiromecs Award Amount: $2 BHH.000 Stars Appropratians

Tena 86-89, the

Scopes work: As provided in the Conferonce Corrmittze Report fog SL. 86. 201
shall se

tesipicnt herehy inten to aeide Funding ts Cursing Preynancy Care Vellawshin iPCF} CPCI
SS8CO.000 en purchase durable medical equipment for clinies thar apps tone Eel-cwshipy For such
Ips thiny chousand dollars (B3U.UDU1 ia 6xch year may be used hy CPE tor adnuunlstraive pmspascs, Lp
{517.000 may be used exeh seor fe provide ym fo s.inies Yor taining ov the use of amrable recal

ete The venusniags $1004 is provided lve the Tuma Ceiion to level and inherent a iceyoar
(Consiauuen ot Care pilot progzam st its Raleigh Uline. The pil yrogsum shall povide care eeddiaation and
medisal support to werner experiencing crisis peegnare.cs

spe

Reporting, Requinerrents: The Division has skreraine tht thie i subsavard for Ananeial acastonce. Vinal
Assistance Coetracts we subject tothe Unione Aurinisiraion of Sate Awards, Oxersig’. amd. Repsirting
oguirements for esipiont and subvecipients deseribed int, caceog, aa > ES Seri

siieg who rsvcivex a combined SUk,U2 mare Tims trom al stats Apencies
runt nui Usubmitasing'eer pegrar-spexiie abr prepare aa cmp n ascondance
Geral: Aooeptal Giverias Alitng Saands alt hres as 2 Yelle Book to Risk
Wirigarion ad dit Monitoring x within 9 moaiths of the rantee’s
Fiscal year en.

1p DILIT§ gnconurages all of its non-geweramerral grantees that weveive Fonds From eae see agencies oF
DOU IS Mivisians wo coutact their assipped eantrael momiler( to detenunine 7 year-end reports rms
submnited for those particule prantsawards,
(©) North Carolina State agencies are exempt from the reporting requirements of this section. Local
‘governments that have reporting requirements for the Local Government Commission are exempt. All
others are not exempt and must adhere to the reporting requirements of this section,
|. Quarterly Reporting Requirements:

Report | - Quarterly Status Report
2. Bnd of Year Reporting (Final Quarterly Report) Requirements:
Report 2 State Grant Compliance Reporting,
Report 3 - Schedule of Receipts and Expenditures
Report 4 - Program Activities and Accomplishment
3. Reporting Timeframes and Due Dates.

Report Title Reporting Period ‘Due Date ]
‘Quarterly Report |__| July 3017 - September 2017 | November 13, 2017
“Quarterly Report2 | October 2017 - December 2017 | February 16,2018
Quarterly Report 3 | January 2018 - March 2018 | May 18, 2018,
‘Quarterly Report 4 | April 2018 - June 2018 ‘August 17, 2018
End of Year Report | July 2017 - June 2018 “August 17, 2018
ATTACHMEMT B
GENERAL TERMS AND CONDITIONS,

A. Ube feiss of thor paety to ins im any eae or rons iotanewe pe See periarmunes: ob amy of
the lenny ar pans isians of this Asteemenl, ot he overtise any eplion or election here, shall w0¢ bs
consinied sa waiver WU ach tevin. pun isms, afin se Skeet itv the Hamme, No seskver ay any
ally 0: shte ne reeneice andr Unis Apyoemest shsdl ae deer st BE
this Agweraent as cunua

any prion or sulbesquer? rigs nr reed Bureuamder ara law. I seine alse i

sul ation es ie wexivs remedioe available in lat us i cai

1B. Choice al Lax. “Fhe validity of thie Agseenaunt cud any of a terms ¢!
lights and dues ut the partes t this Agroement, sre yoverned by the Lows of Nexth Carling, The
Rectpiont. ky signitg this Agecement, agrees amd scbmits, salely fr mamers relied tar his
Agreetnent, #8 Ihe exch ares, snisly fer sash

peovisions, as well sh

ieriaFction af The cowss uf Nomth Coral! w and saree
fe tor aay Fewal proovedings sal be Wake County, North Carolina

pparpase, thatthe eactiive

Al: notieoe permitod oF roguined te be given fy va Pury the afar un ull questo bow! te
fsonfragtfrony cone Pary’ Uo the other shall he adresse uid delivered ws die other Party's Contra
Adhininisi or

upaiyene ! india
den Bove Bidgcl Angst | Robers“Dablie” Magen, 3
i serve Con | Plretor

1, N.C. 27H09.2iN0L 5320 OM Plantation Cielo
Telesnone: B19 885 185 Winsm-Salem, NO TIN
Desa: Sigh hugelonichbsm. 30528} A091

1D, Availsiligy 0” Pemds The ponies his eoalvect sense nel undershane hia the pagament a Uhe sms
spwei iad in dhis contract is eamngent spor aul subject w the availability ef andl for this purpase.

E, Payment Provisions, pes: cccontion of this contact. the Recipient may request ara, upon anaroval
by the Ageney, reesive a singe payment lier arsaunle up io ane Frssred Mewsere. dallas
(E1GR008%, Por yrane-in-aid of more doun oe hundred thousand dollars (S£UG,C00} payments il
the pail in quarterly isitallnunns, consistent sth G, 8. ASC 6 2

E. Hiretave Mesias ‘This comtnnct sfuill he effective om July 1. 2017 an shall serine we Loe 3,
ane,

44. The Recipient shall comply with al lass, omdinauoes, codes, rules rogulullons. ame licensing
eguigeanems that ate appl cate 10 the veneer oF is business. inetudiny aoe of dora, ats sre
oval agonetos haiing jurisiction unde auheriy

Tl. The Revipient shafl maintain fis accounting records reating to the peetormanee af
this Agreemens ia accordance with goncral’y sceopicd accoaating nroccdurss, Lipen rersonimbls
atior notice to Recipict, ths Offiee ot State Budget und Mimayernent wary, dling, Uhe term 0 This
Aggoemary aml li a periondof up tn six pers fallswving the expirtsivn oe fevinedion Kar ay reuso
of fis Aprosmment aust au copy such seconds
M

ral AnEaust

AwEtust F2e9, Tals Agreomen is oaeered fimo in goungtinace with all Sue and Fes

fous

Record Recentivw, Ve Reeipient sha | muinain all pertinent recurs for 2 peviod of Bve years or
tuna al ankdic exceptions hats heen rowed whichever is tomger,

Ung Situs Suaditor and Usiee a State Budget sré Manager shall Have aueoss (@ persons. a
Fecunls ay result nf a'T conics or Stake Francial ausisance entebed iene by State agencies ot
politi sutadivindinss in acewdance ich Cners) Statute 147-64.7, Adsitiubally, as the Stare
owing aiuhysits. the Deyurtnsant of Health and Ilunan Servless shal have acwess Re poses tnd
recurds 4 4 resuh nl a1 eootaets or State Enancaal asiseance enterd tne by Skate agencies of
politial subsivisious,

figneal ar wransternu’ Py ths

Assignment, This Agtrenent or any imterast thercic, shal) mt he
Contractor

The tom af dhis Asaocenent shall hewn on the effective date described in Anicle | and sell
Foreainate upon ite earlier of (1) somplecion 02 all roquizesl serviges. ar (21 an eacie: lermtnaton a8

reviled fo in paragrap B below:

Lither #2: ma: apn sisty ¢6th) ays pear serieer notice fo the ater party. fominale ll or any
pociow ofthis Aptoctnent cr the services require 1 be perfoned Ierein sth ese

Mor

ss wniy, hy wttten tive, mnedintely teri

Ute Departrnent sf Health and Auman Servis
amy porlon ai Unis Agrecmenr ar the Services Far case in any of che Falls ing, circumstances

(1) Recipient breaches uny abligation hereund:. ot fails to mak> piogiess saffisuent co assure
performance oF this Agnosment o* any athe Services

sent in the beni

(2) Rocipent is adjudged insolvent o¢ bankrupt: Contractor taken an a
of ereditas: of the appointovent of a revel er, liguidlur ve ier of any nf Cantractor’s pape

er owsals

Neither pay sball be liable, or dcomed to he an derkult. for any delay. intermption oe failure in
Trerfowrance imo: cis Agrecmert rosulting ditcctly ar indiestly from acts of God, aets of civ ar
rmiE lary anthorty: fires. Joods: wcidenis, explasio w, cartbyuakes. stikes ar labor disputes. Tas 3
interrupting of elzelrieal power ar other public ubility, ov avass in temsputtation or sy cause
ey oid reasons ec

scat and warrant thal they ace authorizes bind the

Signveme Warranty: the undersigned wep
prieipais the tern a this

Per $1,201
sel implesnont a nspeyesr pik prugrarn a is Raleigh cline be pravide a voalir Lucu eeare ere
“lp esis women experiontiny crisis pregnancies ta cuntinue their pregnancies lo Tull enn
These funds chall he used lar nansestariany purposes oy

Th pulot acaguam sathorial sha, ocesis wal least ull wf che follewing eamporents

(TThe use of eate coordinators to pectin the tallowing functions

a. Assess the immediate challenges causing & 2-ogzam partivipant to seek sbertion al eliminate
ofullenyes by assisting ube pengzam potieipaa: in eonnevting ia appropri wesunnces, The

Sectier HIT-[3, Funds allpested tthe uma Casifon shall he use 10 deselop

4
‘ore onoofinator shall oevonslly sista programs sudicipanl in conneeting to uppenpriate eseurzes,
velien azaropriate,

by, Iearalace wei gaagran: sarlicipant to a Irsned ener whe will gon
pattielpene testd pasntize fires le elanes

+ Toe use 9. leased aursing staf'm the Haran Coalition's Kaleigh elaie we pravice medical
Support prin patespens,

ue be ystde te prs

18} Close callsutior helo eare eins ond Tivensead rersiry std during iba canes
soouon in-oide. to acenieplish te lla

> Apprapwiately jrsradnee continuuns af care servioey wwailale tage hh the pilot progeam,

b. Create anitédng! enty plas for progeam par leipseta and their Zraiies to nalp ail a able

Ltunily “ie for she deration al ihe pregnancy. Care pliss should ilowifs and adiss any further
ctalleages identified by care eoordinadars ith enessursgennans aad sllitensl aseuries

Slanatures follow on the nest page