APPLICATION – FY 2014 TITLE III FUNDING

SECTION I.COVER PAGE. One page only.

  1. Legal Name of Organization

  1. Address

  1. Phone Number

  1. Organization Website

  1. Head of Organization

  1. Title

  1. Email

  1. Contact Name

  1. Title

  1. Phone

  1. Email

  1. Organization Mission Statement and Capacity to Implement Proposed Project

  1. Organization Annual Operating Budget
/ $
  1. Project Name

  1. Annual Project Budget
/ $ which is % of Organization Budget
  1. Amount of SWCAA Grant Request
/ $
  1. Title of the Older American Act under which funding is requested

Title III B / Title III D / Title III E
  1. Signature

  1. Title

  1. Date

SECTION II. EXECUTIVE SUMMARY.

One page only. Complete this section after completing Section III.

  1. ORGANIZATION NAME

  1. PROJECT NAME

  1. ANNUAL PROJECT BUDGET
/ $
  1. AMOUNT OF SWCAA GRANT REQUEST
/ $
  1. PROJECT SUMMARY (Use of bullet points is encouraged.)
  1. TARGETED SWCAA COMMUNITIES SERVED BY PROGRAM (Check all that apply.)

Bridgeport / Darien / Easton / Fairfield / Greenwich
Monroe / New Canaan / Norwalk / Stamford / Stratford
Trumbull / Weston / Westport / Wilton
  1. TARGET POPULATION. How many clients do you expect to serve in the followingareas:

TOTAL CLIENTS FY 2014
Unduplicated Clients 60 Years or Older
100% of Poverty or below
Minority
At risk of institutionalization
  1. PROJECT GOALS (Maximum of three. Please refer to Section III, Question 5.)

Top of Form

  1. Bottom of Form
  1. Top of Form
  2. Bottom of Form

GOAL #1
GOAL #2
GOAL #3

SECTION III.PROJECT DESCRIPTION & WORK PLAN

  1. PROJECT NAME

  1. MIS SERVICE NAME(S)
(For MIS Service Name, look at Title II Service Definition List on
  1. PROJECT SUMMARY. Briefly describe the proposed project in one paragraph (no more than 100 words).
  1. PROJECT DESCRIPTION.Any question that refers to “the project” in the following refers to the project or program for which you are requesting funding – not your wholeorganization.
  1. Identify the community need your project proposes to address. How does this need address a SWCAA funding priority as defined in the area plan on aging (plan summary available at
  1. Describe the services you will provide, including all major components of the project. Applicants for Senior Center Use must attach a sample center activity calendar.
  1. Describe how you will assess the needs of clients for additional assistance and how referrals will be managed.
  1. Describe how you will coordinate services with other programs/services for elders in your service area. (Only for new applicants - Attach letters of support for your project from no more than three related community agencies and groups.)
  1. PROJECT GOALS. For each goal, explain (1) what is the overall goal, (2) whom you will serve, and (3) how you will measure project impact. Identify up to three goals.

The following language format is preferred:

Goal #1 –(1)OVERALL GOAL. (2)Of the (number) of older adults served, (number/percentage) will _____ (3)as evidenced (or demonstrated) by ______.

Examples:

To improve the health of seniors. Of the 100 seniors served at the Senior Center, 75 will participate in exercises classes at least two times per month as evidenced by attendance sheets.

To increase financial stability. Of the 50 seniors served by the outreach workers, 35 will receive application assistance as evidenced by completed applications.

Goal #1.
Goal #2.
Goal #3.
  1. GEOGRAPHY. The percentage of estimated project participants living in each of the following localities:

Bridgeport / Darien / Easton / Fairfield
Greenwich / Monroe / New Canaan / Norwalk
Stamford / Stratford / Trumbull / Weston
Westport / Wilton
  1. TARGET SERVICES. Complete one chart (below) for each service proposed,including the name of the service, the estimated number of units of services to be provided and unduplicated count of clients for the funded project over the grant year. Use one chart per service and include client numbers only for that service. You can find the Title III service definition list at

COMPLETE ALL SHADED AREAS IN THE CHART:

  1. MIS SERVICE NAME:

Estimated numbers to be provided under FY 2014 grant: / Last year’s actuals (use MIS report numbers):
a)Units of service
b)Unduplicated count of clients
c)Minority clients
d)Clients at 100% of poverty level or below
  1. MIS SERVICE NAME:

Estimated numbers to be provided under FY 2014 grant: / Last year’s actuals (use MIS report numbers):
a)Units of service
b)Unduplicated count of clients
c)Minority clients
d)Clients at 100% of poverty level or below
  1. MIS SERVICE NAME:

Estimated numbers to be provided under FY 2014 grant: / Last year’s actuals (use MIS report numbers):
a)Units of service
b)Unduplicated count of clients
c)Minority clients
d)Clients at 100% of poverty level or below
  1. MIS SERVICE NAME:

Estimated numbers to be provided under FY 2014 grant: / Last year’s actuals (use MIS report numbers):
a)Units of service
b)Unduplicated count of clients
c)Minority clients
d)Clients at 100% of poverty level or below
  1. MIS SERVICE NAME:

Estimated numbers to be provided under FY 2014 grant: / Last year’s actuals (use MIS report numbers):
a)Units of service
b)Unduplicated count of clients
c)Minority clients
d)Clients at 100% of poverty level or below
  1. POPULATIONS SERVED AND OUTREACH PLAN:

Population / Estimated
# to be served / Explain your outreach plan. How will you attract new clients and maintain contact with current clients? Who will be responsible for outreach?
Unduplicated clients 60 years of age or older
Clients 60 years of age or older who:
Are low-income (150% of poverty level)
Are 100% of poverty level or below
Are minority
Have limited English proficiency
Have severe disabilities
Are at-risk of institutionalization
Have Alzheimer’s & related disorders
  1. VOLUNTARY CONTRIBUTION PLAN. How will you offer participants the opportunity to voluntarily contribute to the cost of activities? The charging of a fee is prohibited. Contributions must remain confidential. However, no person may be denied involvement if s/he chooses not to contribute. All contributions received are to be used to expand the services of the program being funded under this grant.

SECTION IV.PROJECT MANAGEMENT.

  1. GOVERNANCE. How does the Board of Directors or other governing body exercise its fiduciary responsibility, assist with fundraising or financing, and evaluate the organization’s ability to achieve its mission?
  1. KEY STAFF. Please specify the names and qualifications of the key staff and/or volunteers responsible for achieving the anticipated results in your proposedproject. Specify the role each playsin the proposed program. Please indicate if background checks are completed for direct-service staff.

Name / Professional Qualifications / S/V* / Role

*Staff (S) or Volunteer (V)

Background Check Information:

  1. FINANCIAL SUPPORT. Please describe your organization’s financial position, including trends, challenges, or unusual developments, over the last three years. In addition, please complete the chart (on the next page) with your top five (5) largest income sources and amounts for the full yearFY 12 and FY 13 to date.

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FUNDING SOURCES

FY 2012-13 Actuals
Funding Source / Amount
FY 2013-14 Expected
Funding Source / Amount / Status* / Explanation

*Request Status – Application Submitted (AS), Application to be Submitted (ATS), Pledged (P),

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