15-060AAppendix B-1 – VMTN Program Grant Application

RTC of Southern Nevada

FOR RTC Date Received: / Time Received: / Received By:
USE ONLY / /

APPLICATION:VETERANS MEDICAL TRANSPORTATION NETWORK

(VMTN) PROGRAM REQUESTS ONLY

APPLICANT INFORMATION

Applicant Information
Date
Legal Name of Applicant
Contact Person
Street Address
City/State/Zip Code
Email
Phone Number
Fax Number
Project Title (question #1)
Organizations Type
State or Local Government Authority
Private Non-Profit Organization (please attach documentation certifying non-profit status)
* For-Profit firms cannot be subrecipients of 5307 or 5310 grant funds.
Partnering Organizations and Contact Information
Partnering Organization
Contact Person
Title / Position
Street Address
City/State/Zip Code
Email
Phone Number
Fax Number
Project Request Information
Project Cost: * (Refer to Total Program Expense line from Appendix B-2)
Grant Portion Requested: ** (Refer to Total Federal Share from Appendix B-2)
Funding Source Requested(A separate application needs to be submitted for each category of funding being requested)
FTA 5310 Formula Grant Funds- Enhanced Mobility of Seniors and Individuals with Disabilities (New Freedom Type Projects)
Call Center: Mobility Management– 80%Federal Funds/20% Local Match (Use Appendix B-2, Budget Form B)
Transportation: Contracted Services–50%Federal Funds/50%Local Match(Use Appendix B-2,Budget Form C)
Letters of Support
Number of letters of support
Application Instructions
a.The font is Times New Roman 12 point. Please limit the number of typed pages submitted in the application to 20 single spaced pages maximum answered in the format provided.
b.The Word document form is provided for your input. Please adjust the spacing to fit the response, leaving two (2) spaces at the end of each question’s response.
c.Please use full justification and no indentation of new paragraphs.
d.Please check the document for spelling, typing, or grammar errors, and contact RTC with any questions regarding the format prior to submitting it for consideration.
f.Attachments required do not count as pages for the 20 page maximum.
g.Please be concise when formulating your responses. Specific information that describes your project, its relevance to the community, its goals and costs will be well received by the evaluators. Vague or broad generalized statements may detract from understanding the project.
Checklist of Application Attachments (in order of placement):
Appendix B-1 Application Form
Appendix B-2 Budget Form (Excel spreadsheet)
Non-Profit Status Documentation (501(3)(c), if applicable)
Appendix C - Form for Certification of Ability to Provide Local Match
Appendix D - Federal Requirements:
Certification Regarding Lobbying
Certificate Regarding Debarment, Suspension, Ineligibility & Voluntary Exclusions
Verification Regarding Disadvantaged Business Enterprises
Certificate of Insurance
Map of Service Area
Letters of Support
Overview of the Veterans Medical Transportation Network (VMTN) Program
The Veterans Medical Transportation Network (VMTN) is intended to provide effective and efficient transportation to Veterans throughout Southern Nevada. This service gives a viable option to Veterans who are in need of medical related transportation, including but not limited to VA clinics, primary care physicians and the Veterans Medical Center. This program provides a one-call option, using the VMTN call-centerfor Veterans needing transportation to and from medical appointments. The goal of the VMTN is to provide transportation to veterans. This is a first come first serve program intended to serve as a much needed transportation and is constantly looking for ways to provide a more efficient and reliable service to those who gave so much in defending our nation.
Vehicle Fleet: The RTC will provide a fleet of approximately 8 paratransit vehiclesThe Contractor will be required to have the expertise to operate and maintain all of the vehicles allocated to the scope of services.
Facilities and Equipment: TheVMTNService will be operated and maintained using portions of the RTC’s Sunset Maintenance Facility (SMF).
Project Information - This section should provide an explanation of the Proposer’s experience in operating a call center and providing transportation services.
  1. Please provide a description of your organizations experience operating a call center and providing customer service. Please include any scheduling and dispatching software.

Answer here:
  1. Please provide a description of your organizations experience operating a transportation service including ADA paratransit transportation, public transportation, private transportation, etc.

Answer here:
  1. Please provide a description of your organizations experience providing service to veterans and individuals with disabilities.

Answer here:
Responsiveness to Evaluation Criteria
  1. Explain how this project partners with existing public and private agencies, non-transit entities, and/or private non-profit or for-profit transportationproviders.

Answer here:
  1. Provide an operational plan to support the implementation and operation of the project, including activities to be conducted to accomplish the program’s goals/objectives. Describe the project deliverables and expected outcomes along with the methods to be used in implementing the project.

Answer here:
  1. Describe how the data outlined in Appendix J Eligible Projects – Reporting will be collected to ensure compliance with FTA requirements for reporting enhancements to service, impact of vehicles added to the service and number of one-way trips provided.

Answer here:
  1. Would your organization be ready to commence service on July 1, 2015? Please note that the grant period is a maximum of 12 months from the commencement date.

Answer here:
Budget Experience and Implementation
  1. Describe your organization’s experience in administering federal grants?

Answer here:
  1. Provide a narrative budget justification that describes how the categorical costs outlined in Budget Form Exhibit 1 are derived. Include the necessity, reasonableness, and allocation of the proposed costs related to proposed capacity building activities.

Answer here:
  1. Indicate the source of Local Match funds. If the funds are coming from In-Kind or Soft Match contributions, explain the contribution including naming the contributor and listing the portion contributed (Information may be listed on –Appendix B-2, Tab(s) A – CBudget Form or further explained in Question 22.)

Answer here:
  1. Please list below potential funding sources for sustaining the project beyond the grant period. Environmental sustainability.

Answer here:
  1. Could the project be implemented on a more limited scope with less funding?

YES (Proceed to Question 13)
NO (Continuing Projects refer to Question 14)
  1. If the project could be offered on a more limited scope, please describe.

Answer here:
  1. Describe any steps subrecipient has taken to identify other sources of funds to sustain programs if the 5310 funding is no longer available.

Answer here:
Miscellaneous
  1. Identify and list such current or former RTC employees involved in the preparation of this Application or the anticipated performance of work or services if selected. (Note requirements in Section 22 (c)(2) of Solicitation No. 15-060A)

Answer here:
  1. Does your organization employ 50 or more employees?

YES NO
If answered YES, does your organization have an EEOC policy?
YES NO

Name of official who can on behalf of Applicant affirm that Applicant is authorized to submit a Proposal and execute the Subrecipient Agreement if selected.

Name:

Title:

______

SignatureDate

Solicitation No. 15-060A

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