Orange County Citizens’ Review Panel(CRP)

Funding Proposal

FY: 2018-2019

AUTHORIZATION PAGE

Legal Name of Agency:
Registered Fictitious Name:
Registered on Florida Department of State Division of Corporations (
Mailing Address:
Chief Professional Officer: / Title:
Telephone/Fax: / Email:
Proposal Contact Person: / Title:
Telephone: / Email:
Agency Fiscal Year: (mm– mm) / Website:
Funding Panel:
Request for Proposal:

Authorization Signatures

Our signatures certify that to the best of our knowledge, the information contained in this proposal is accurate, complete and consistent with our organization’s Mission, Articles of Incorporation and Bylaws and that we have the legal authority to sign below.

Chief Volunteer Officer (type or print)

/ Chief Professional Officer (type or print)
Chief Volunteer Officer (sign in blue ink) / Chief Professional Officer (sign in blue ink)
Date / Date
Florida has a very broad public records law. As a result, upon request, unless otherwise exempt, any written communication created or received by Orange County officials and employees will be made available to the public and media. Furthermore, under Florida law, email addresses are public records.

INDEX

Section / Page #
Index
Supporting Documents Checklist
Summary of Funding Request
Agency Overview
Board Governance And Structure
Employee Structure And Compensation
Agency Revenue Comparison
Agency Expenditure Comparison
Agency Budget Explanation
Program/RFP Overview – Program/RFP 1 –
Program/RFP Specific Information
RFP - Proposed Outcomes
Program Deliverables andOutcomes Report
Program/RFP Revenue Comparison
Program/RFP Expenditure Comparison
Program/RFP Expenditure Detail
Program/RFP Budget Explanation
Program/RFP Overview – Program/RFP 2 –
Program/RFP Specific Information
Program Demographics
RFP - Proposed Outcomes
Program Deliverablesand OutcomesReport
Program/RFP Revenue Comparison
Program/RFP Expenditure Comparison
Program/RFP Expenditure Detail
Program/RFP Budget Explanation
Program/RFP Overview – Program/RFP 3 –
Program/RFP Specific Information
Program Demographics
RFP - Proposed Outcomes
Program Deliverables and Outcomes Report
Program/RFP Revenue Comparison
Program/RFP Expenditure Comparison
Program/RFP Expenditure Detail
Program/RFP Budget Explanation

SUPPORTING DOCUMENTS CHECKLIST

Instructions: In the order listed below, attach the following itemsto the original and each copy of the proposal. Place an X in all boxes indicating included or not included. Place NA for items not applicable.

Included

/

Not

Included

  1. 501(C)(3) Determination Letter from the IRS

  1. Fictitious Name Registration or Renewal from the Florida Department of State Division of Corporations (

  1. Current Bylaws

  1. Audited Financial Statement with Management Letter (most recent)

  1. Agency Audited Management Letter for Audit Submitted or Letter from the Auditor stating no Management Letter was issued

  1. Agency’s Response to the Audited Management Letter (if applicable)

  1. IRS Form 990 (most recent)

  1. Any correspondence received from the Internal Revenue Service since January 1, 2016

  1. Annual Report(produced by organization)

  1. Discrimination/EEO Policy

  1. Insurance Certificate and Endorsements*

  1. Strategic Plan/Planning Document and Updates

  1. Americans With Disabilities Act (ADA) Policy

  1. Letters of Partnerships & Collaborations or Memorandums of Understanding (MOU) from agency partners listed in the Agency Overview Section of the funding proposal

Please answer the questions below and provide a detailed explanation where necessary.

  1. Provide an explanation for any requested documents not attached.
  1. Is your agency registered in the System for Award Management (SAMS)?

Yes / No

(If yes, please provide your Data Universal Number System [DUNS] number) (If more instructions are needed please refer to the instructions manual)

Yes / No
  1. Is your agency (local chapter) involved in any pending litigation?

(If yes, please explain) (Please use additional sheets of paper

if needed)

*Insurance carriersfurnishing coverage must be authorized to do business in the State of Florida, and must possess a minimum, current rating of A- Class VIII in the most recent edition of “Best Key Rating Guide”.Insurance Certificates must have all applicable endorsements required by funder.

SUMMARY OF FUNDING REQUEST

REQUEST FOR PROPOSAL (RFP) AGENCIES

REQUEST FOR PROPOSAL (RFP) ALLOCATION SUMMARY

For any agency applying for funding through the Orange County RFP Process please list if applicable, current and proposed funding amounts in Orange County’s fiscal year (October – September).

Note:Table is an embedded spreadsheet with formulas.Double click to activate, and then enter information. Calculations are automated. When completed, click outside the spreadsheet to deactivate.

AGENCY OVERVIEW

  1. Agency’s History and Mission Statement: Provide a brief agency history and mission statement that includes agency’s goals and objectives. (Not to exceed 1 page)
  1. Agency Affiliation:Is your agency a part of a larger organization? If yes, please explain your affiliation. Include information regarding operational oversight, dues, etc.
  1. Major Agency Activities and Accomplishments during the Past Year: Provide information on major activities such as special events and agency/program achievements. (Not to exceed ½ page)
  1. Major Changes during the Past Year:Provide information regarding any major changes that your agency has experienced during the past year (e.g., Board, Staff, Mergers, Location,and Policy).(Not to exceed ½ page)
  1. Agency Partnerships and/or Collaborations: List any organizations with which your agency has partnerships and/or collaborations.Place an asterisk (*) next to the partners pertaining to this funding proposal. Attach letters of partnership on partner’s letterhead and/or memorandum of understanding(MOU) from each partner associated with this proposal as listed on the SupportingDocuments Checklist.

BOARD GOVERNANCE AND STRUCTURE

Please answer the following questions for your last completed fiscal year (12 months) according to your agency’s bylaws.If your organization has a local advisory board responsible for local issues, provide the following information for the local presiding board.

Check if your organization is a local chapter with an advisory board that presides over local issues.
  1. Board Structure:

a)How many available Board slots does your agency have?
b)How many currently seated Board Members does your agency have?
c)How many Board meetings were held during the past year?
d)What is the percentage of Board attendance for the past year?
  1. Board Governance Structure:

a)Describe the attendance guidelines and requirements for Board and committee meetings.

b)List your Board’s subcommittees, including the responsibilities of each committee and how many times each committee meets per year.

c)Describe your diversity goals for the agency’s Board.

d)Discuss any changes/resignation of Board members during the last year that were not related to term expiration.

  1. Board’s Role & Responsibilities: Please describe the Board’s role in supervising fiscal matters of the agency.

1

BOARD INFORMATION FORM

  1. Provide a breakdown of the membership of your organization’s current Board of Directors.

EXECUTIVE COMMITTEE
Name / Board Position / Business Affiliation
& Title / Mailing Address, Phone & Email / Areas of
Expertiseor Relevant Experience / Gender / # of Continuous Years on Board / Current Term
Expiration
MEMBERS AT-LARGE
Name / Business Affiliation
& Title / Areas of
Expertise or
Relevant Experience / Gender / # of Continuous Years on Board / Current Term
Expiration
  1. Describe efforts made to recruit new board members.Please include anticipated start date of upcoming board term and expertise.

1

EMPLOYEE STRUCTURE AND COMPENSATION

  1. Using the chart below, provide a breakdown of employee compensation for all current agency employees. Salary information should NOT reflect benefits, taxes, or other employee related expenditures.Note:Table is an embedded spreadsheet with formulas.Double click to activate, and then enter information. Calculations are automated. When completed, click outside the spreadsheet to deactivate.

Definition of Employee Groups:

  • Upper Management – CEO, President, Executive Director, Vice President, Director
  • Middle Management – Senior Manager, Manager, Other
  • Support Staff – Administrative Assistant, Clerical
  • Direct Service – Counselors, Childcare Providers, any staff working directly with clients/customers
  • Other Employee group not listed above (please define): ______

  1. Does your agency currently have leased employees? If yes, please provide information about your leased employees. Include the name of the leasing company, positions, and total salaries of the group employees(Do not exceed ½ page).

Agency Budget

Review

Page Left Blank Intentionally

Insert

Agency Revenue Comparison

Budget Spreadsheet

Here

Page Left Blank Intentionally

Insert

Agency Expenditure Comparison

Budget Spreadsheet

Here

AGENCY BUDGET EXPLANATION

Using the submitted Agency budget spreadsheets as a reference, please answer the questions below. Budgets should only reflect the organization’s operating budget. Below-the-line resources such as in-kind goods and/or services should not be included in the budget.

Note:Table is an embedded spreadsheet with formulas.Double click to activate, and then enter information. Calculations are automated. When completed, click outside the spreadsheet to deactivate.

  1. Total Agency Budget:In agency’s fiscal year, complete the table below.

*Percentage of administrative costs as reported in most recent IRS Form 990*.

  1. Percentage of Administrative Costs more than 25%:If the percentage of administrative costs is more than 25% of your agency’s budget for the Current and/or Proposed fiscal years, provide a breakdown of all included expenses and your plan to lower costs in the future for each year. (Do not exceed ½ page)
  1. Agency Fundraising Activities: List and describe fundraising efforts for Past,Current,and Proposedfiscal years. Include actual costs compared to the net funds raised for each activity. (Not to exceed 1 page)
  1. Agency Reserves: Answer the following questions about your agency’s funding reserve.

a)Does your agency currently have a funding reserve?
If Yes, answer b-d. If No, proceed to e.
b)What is the balance of your agency’s funding reserve?
c)How is the agency’s reserve funded?
d)Provide your agency’s guidelines for utilizing funds in the funding reserve.
e)If your agency does not have a funding reserve, what is your agency’s contingency plan in the event there is a shortfall in operational funding?
  1. Leveraging: Provide a breakdown of all matching dollars received for all agency revenue.

Funder & Amount of Funding / Match Source / Amount of Match per Dollar / Total Amount of Matched Dollars / Terms & Time Period of Match

Program/RFP Information

Complete for eachprogram/RFP.

Name of Program/RFP 1:

PROGRAM/RFP OVERVIEW

1. Program/RFPDetailed Description and Design:Please provide a detailed description of how the agency plans to execute the proposed RFP, including types of services to be provided, agency’s history and experience providing these services, geographic area to be served, targeted groups to be served, current or proposed partnerships with other agencies to provide services, proposed participant goals and objectives, staffing or volunteer plan, and community support. Please include any data you are using to support that the requested need exists in Orange County. (e.g., agency data, survey information, needs assessment data, other secondary data sources, etc.) (Not to exceed 2 pages)

2. Success Story:If the agency has provided program services or similar services as prescribed by the proposed RFP, provide a short success story from last fiscal year.(Not to exceed ½ page)

PROGRAM/RFP SPECIFIC INFORMATION

1.Outreach Plan: Describe the outreach plan for the program/RFP and strategies used to engage target population. Include how participants are identified, engaged, and retained. (Not to exceed ½ page)

2.ProgramChanges:If your agency has previously received funding for this program/RFP, list any significant changes to the programduring the past year. Include demographics, staffing, locations, hours, etc.(Do not exceed ½ page)

3. Volunteer Utilization:

a)Will volunteers be utilized in programming under this RFP? (Yes or No)
If yes, complete the table below.
Volunteer Position / Number of Proposed Persons for this Position / Number of Proposed Hours per Volunteer per month

PROGRAM DEMOGRAPHICS

Demographic Information

  1. Provide the following information about all unduplicated clients served by this program from October 1, 2016toSeptember 30, 2017. Only include information for clients funded by Orange County.

Total Number of Unduplicated Clients Served:
NA – My agency was not funded during this timeframe.
AGE / RACE/ETHNICITY / HOUSEHOLD INCOME
MALE / FEMALE / MALE / FEMALE / Less than $25,000
0-4 / Black / $25,000 - $50,000
5-9 / White / $50,001 - $100,000
10-14 / Hispanic/Latino / $100,000+
15-19 / Asian/Pacific Islander / Unknown
20-34 / Native American / TOTAL
35-54 / Mixed/Biracial
55-64 / Other
65+ / Unknown
Unknown / TOTAL
TOTAL
HOUSEHOLD TYPE / EMPLOYMENT STATUS / RESIDENCE
With Children / Without Children / MALE / FEMALE / MALE / FEMALE
Married/ Couple / Employed / Orange County
Single Female / Unemployed / Other
Single Male / Retired / Unknown
Extended/
Multi-Family / *N/A / TOTAL
Other / Unknown
Unknown / TOTAL
TOTAL / *not expected to work, i.e., children
  1. If you are unable to provide any of the above information, please explain.

RFPPROPOSED OUTCOMES(New Agencies Only)

Provide at least two (2) proposed outcomes and plan for measuring success for this RFP.

Outcome 1:
a)Proposed Indicator:
b)Proposed Measurement Tool:
c)Proposed Frequency of Data Collection:
Outcome 2:
a)Proposed Indicator:
b)Proposed Measurement Tool:
c)Proposed Frequency of Data Collection:

PROGRAM DELIVERABLESAND OUTCOMES REPORT

Complete this section if your organization received funding for fiscal year 2016-2017from Orange County– CRP. This information should be based on data collected from October 1, 2016toSeptember 30, 2017.

PROGRAM DELIVERABLES
Total number of contracted units:
Total number of units provided:
Provide explanation for units not met:
PROGRAM OUTCOMES
Outcome 1:
Total number of clients counted towards this outcome: / Total number of clients meeting this outcome:
Percentage of outcome achieved:
(# of clients meeting this outcome ÷
# of clients counted towards this outcome)
Was Outcome Achieved? / Yes / No
If no, provide an explanation and plan for program adjustments.
Outcome 2:
Total number of clients counted towards this outcome: / Total number of clients meeting this outcome:
Percentage of outcome achieved:
(# of clients meeting this outcome ÷
# of clients counted towards this outcome)
Was Outcome Achieved?
If no, provide an explanation and plan for program adjustments. / Yes / No

Program/RFP

Budget Review

Page Left Blank Intentionally

Insert

Program/RFP Revenue Comparison BudgetSpreadsheet

Here

Note: Be Sure To Insert Page Numbers on Each Spreadsheet

Page Left Blank Intentionally

Insert

Program/RFP Expenditure Comparison

BudgetSpreadsheet

Here

Note: Be Sure To Insert Page Numbers on Each Spreadsheet

Page Left Blank Intentionally

Insert

Program/RFP Expenditure Detail

BudgetSpreadsheet

Here

Note: Be Sure To Insert Page Numbers on Each Spreadsheet

PROGRAM/RFP BUDGET EXPLANATION

Using the submitted Program/RFP budgetas a reference, please answer the following questions.Below-the-line resources such as in-kind goods and/or services should not be included in the budget.

  1. Explanation of Funding: Using the Program/RFP Expenditure Detail budget spreadsheet as a reference, please provide, for each year, a breakdown of what funding from Orange County – CRP will specifically fund.
  1. Units of Service: Provide the unit of service (e.g., shelter nights, hours, etc.) and the cost per unit ($ per unit). Then, in the space provided, calculate the total cost of a service year based on the defined unit of service.(# of units in a service year x $ - unit cost = total cost per service year.)

Note:Proposed unit cost is not guaranteed. If the agency is recommended for funding, the final unit cost will be negotiated and must be approved by contract execution.

Description of Unit of Service
(e.g., Shelter night including
Use of a bed with 1 meal and hot shower) / ProposedTotal NumberofUnits of Service
(e.g., 50 units) / Proposed Cost per Unit of Service
(e.g., $10 per night) / Total Cost per Service Year
(e.g., $10 X 50 nights = $500)

Program/RFP Information

Complete for eachprogram/RFP.

Name of Program/RFP 2:

PROGRAM/RFP OVERVIEW

1. Program/RFP Detailed Description and Design:Please provide a detailed description of how the agency plans to execute the proposed RFP, including types of services to be provided, agency’s history and experience providing these services, geographic area to be served, targeted groups to be served, current or proposed partnerships with other agencies to provide services, proposed participant goals and objectives, staffing or volunteer plan, and community support. Please include any data you are using to support that the requested need exists in Orange County. (e.g., agency data, survey information, needs assessment data, other secondary data sources, etc.) (Not to exceed 2 pages)

2. Success Story:If the agency has provided program services or similar services as prescribed by the proposed RFP, provide a short success story from last fiscal year. (Not to exceed ½ page)

PROGRAM/RFP SPECIFIC INFORMATION

1.Outreach Plan: Describe the outreach plan for the program/RFP and strategies used to engage target population. Include how participants are identified, engaged, and retained. (Not to exceed ½ page)

2.Program Changes: If your agency has previously received funding for this program/RFP, list any significant changes to the program during the past year. Include demographics, staffing, locations, hours, etc. (Do not exceed ½ page)

3.Volunteer Utilization:

b)Will volunteers be utilized in programming under this RFP? (Yes or No)
If yes, complete the table below.
Volunteer Position / Number of Proposed Persons for this Position / Number of Proposed Hours per Volunteer per month

PROGRAM DEMOGRAPHICS