NC Council for Womenfy 2011-2012 Displaced Homemaker/Divorce Filing Fee

NC Council for WomenFY 2011-2012 Displaced Homemaker/Divorce Filing Fee

GRANT APPLICATION

INSRUCTIONS

DEADLINE: All applications must be received by 5:00pm April 15th 2011

** All required information in this document is highlighted in RED

1.  Complete the following sections of this document:

·  GRANT APPLICATION COVER SHEET

·  DETERMINATION OF LEVEL OF FUNDING

·  PROGRAM NARRATIVE CRITERIA

·  GRANT APPLICATION

§  Request for Program Policy

§  Certification Section

§  Verification of Review of Grant Application

2.  Complete the required Proposed Budget Worksheets and Projected Income Statement:

·  Projected Income Statement (Excel file)

·  Budget Proposals (Excel file)

3.  E-mail to CFW

§  E-mail Address:

§  Subject of Email: Domestic Violence/Marriage License Fee Grant Application

·  A completed copy of this form

·  Completed copies of the Projected Income Statement and Budget Proposals Excel files.

4.  Mail to CFW:

·  Copies of GRANT APPLICATION Sections (The items below that require a signature – BLUE INK require for signature) Provide (1) Original in BLUE INK and (2) Copies of each of the items that require a signature listed in the order below.

§  Request for Program Policy

§  Certification Section

§  Verification of Review of Grant Application

·  Items below must be provided by Applicant

·  List of current members of the Board, including the Finance Committee

·  Copy of agency’s 501c(3)

·  Articles of Incorporation

·  Agency bylaws

For Government operated programs only (Community Colleges are exempt)-The Governmental Tax Exempt Form

·  Conflict of Interest Policy

·  Confidentiality Policy

·  Non-discrimination Policy

·  Organizational Code of Conduct Policy

·  Internal Controls Policy

·  Recordkeeping Policy

·  Whistleblower Policy

All these items must be mailed to CFW via:

US Mail: / Or / Physical (Fedex / UPS):
Grants Staff
NC Council for Women
1320 Mail Service Center
Raleigh, NC 27699-1320 / Grants Staff
NC Council for Women
422 N. Blount St.
Raleigh, NC 27601

NC Council for Women
FY 2011-2012 Displaced Homemaker/Divorce Filing Fee

GRANT APPLICATION COVER SHEET

Note: A Separate application must be completed for each county.

*All Required information is highlighted in RED.

County:

(If more than one county will be served by the one grant award, please list the counties above)

New Applicant this fiscal year: Yes No

Full Legal Name of Displaced Homemaker Program:

Also Known As:

Federal Tax Identification Number: (Contract Number)

Executive Director: Email Address:

Program Director: Email Address:

Program Status: Government Operated Private, Non-Profit

Displaced Homemaker Program’s Fiscal Year: thru

Year Displaced Homemaker Program started:

Year Displaced Homemaker Program was incorporated:

Date the Displaced Homemaker Program received non-profit status:

Is Displaced Homemaker Program a subsidiary of another organization? Yes No

Displaced Homemaker Administrative Office Address:
(include City State and Zip Code)

Displaced Homemaker Administrative Office Hours:

Displaced Homemaker Mailing Address:
(if PO Box or different than above)

Displaced Homemaker Office Phone: () Fax: ( ) Crisis Line: ()

Number of Displaced Homemaker staff to be funded by NC CFW DH/DFF funds:

Full-time DH Staff Part-time DH Staff

Does your Displaced Homemaker Program receive DV/MLF funds from NC CFW? Yes No

Does your Displaced Homemaker Program receive SA funds from NC CFW? Yes No

Displaced Homemaker Program’s website address:

NC Council for WomenFY 2011-2012 Displaced Homemaker/Divorce Filing Fee

DETERMINATION OF LEVEL OF FUNDING

Full Legal Name of Displaced Homemaker Program:

Also Known As:

Federal Tax Identification Number:

Please indicate only one (1) level of funding

Does your Displaced Homemaker Program meet Level 1 Reporting? Yes No
Receiving less than $25,000 in total state issued grant funds
Does your Displaced Homemaker Program meet Level 2 Reporting? Yes No
Receiving at least $25,000 but less than $500,000 in total state issued grant funds
Does your Displaced Homemaker Program meet Level 3 Reporting? Yes No
Receiving $500,000 or more in total state issued grant funds
12 / NCCFW- DH DFF Grant Application, Rev. 01/2011

NC Council for WomenFY 2011-2012 Displaced Homemaker/Divorce Filing Fee

Program Narrative Criteria

DH Program’s History=15 pts DH Program’s Project Need=40pts

DH Program’s Objectives=18pts DH Program’s Board participation and Community Support=12pts

DH Program’s Quality of Personnel=5pts DH Program’s Budget Effectiveness=10pts

·  Please be sure to provide the title of the section that you are responding to in order to allow grant reviewer the ability to verify that all items received a response

Example:

o  Provide your Board’s sustainability plan for the program-

o  Our Board’s sustainability plan consists of…..

·  No more than 1000 characters per response to each bulleted item allowed

·  12 pt, Times New Roman Font must be utilized. Double-space all text

·  Be sure to address ALL items of the application

·  If an item is not applicable…please indicate “N/A” and briefly explain why item does not apply

Glossary of Terms:

Ø  Co-mingling of Funds: Funds from personal, business or church sources mingled together with grant funds. The IRS discourages this practice. The NC CFW prohibits co-mingling of funds.

Ø  Conflict of Interest: Any personal, financial and/or professional interest that might create a conflict with the ability to fairly and objectivity carry out one’s responsibilities. This term also refers to a situation in which a person has vested interest in the outcome of a decision but tries to influence the decision making process as if they did not.

Ø  Matching Funds: An element of some grant programs that requires the grantee (the organization receiving the grant) to provide part of the funding for the program either in cash or by contributing facilities or other resources of value. These funds or resources are sometimes referred to as “matching funds”. They usually must be raised from other than state or federal sources. Matching funds are funds applied to a specific grant and cannot be utilized as a match for other grants.

Ø  In Kind: refers to payment for goods or services with a medium other than legal tender (anything can be used as money, but legal tender is what the State accepts for all debts).

Ø  Objective: A specific, measurable accomplishment within a specified time frame.

Ø  Goal: A broad statement of the ultimate aims of a program.

Ø  Mission: A description of an entity’s purpose to exist.

Ø  Qualitative: Investigates the why and how of decision making, as compared to what, where, and when of quantitative research.

Ø  Quantitative: A quantitative property is one that exists in a range of magnitudes, and can therefore be measured.

Ø  Evaluate: To ascertain or fix the value or worth of or to examine and judge carefully; appraise

Ø  Monitor: To keep close watch over; supervise

12 / NCCFW- DH DFF Grant Application, Rev. 01/2011

History of the Displaced Homemaker program: (15 pts total)

Each bulleted item must be addressed: All response should refer to the DH program only

·  What is your Program’s mission and if you are a multi-service agency how does the Displaced Homemaker Program fit into the mission of your organization? -5pts

·  Describe outreach and any significant or unique accomplishments of the Displaced Homemaker Program during the past year and provide evidence of success.-5pts

·  List and describe whether or not the Displaced Homemaker Program met projected goals during the previous year, if projected goals were not met, please explain why they were not met-5pts

Please type your complete answer in the box. (It is expandable)

Program Need (purpose/justification of request for funds): (40 pts total)

Each bulleted item must be addressed: All response should refer to the DH program only

Explain why there is a need for the Displaced Homemaker Program within your community- 15pts

(Please include content that will provide success stories of your program)

Describe barriers that affect current service delivery and training-10pts

Provide data on the probable number of displaced homemakers in the area (accordance to G.S. 143B-394.5A)-5pts

Provide data on the availability of resources for training & education in the area(accordance to G.S. 143B-394.5A)-5pts

Provide data on viable living wage job opportunities in the area (accordance to G.S. 143B-394.5A)-5pts

Possible Resources for data requested

https://www.ncesc.com/default.aspx

http://www.ncjustice.org/

www.ncruralcenter.org

Please type your complete answer in the box. (It is expandable)

Objectives of the Displaced Homemaker Program: (18 pts total)

·  List three(3) measurable objectives and describe the projected outcome for ach objective listed-12pts

·  Explain why the objectives were essential to the Displaced Homemaker Program and describe the method(s) utilized to evaluate the program’s effectiveness- 6pts

Each bulleted item must be addressed: All response should refer to the DH program only

Please type your complete answer in the box. (It is expandable)

Board participation and Community Support: (12pts total)

Each bulleted item must be addressed: All response should refer to the DH program only

·  Describe the Governing Board’s role and participation with the program including the monitoring & evaluation process- 5pts

·  List and describe partnerships, community supporters, and collaborations-2pts

·  Provide details of your Board’s sustainability plan for the Displaced Homemaker Program-3pts

·  Provide details on the Board’s diversity including gender, race/ethnicity, geographic make up-2pts

Please type your complete answer in the box. (It is expandable)

Personnel: (5pts)

Each bulleted item must be addressed: All response should refer to the DH program only

·  Provide details of your efforts to address staff diversity-3pts

·  Provide a job description of each DV position(s) that will be funded by NC CFW that will include-2pts

o  You can list the positions and provide job descriptions in the area below

o  OR…Attach each job description that addresses each position listed

§  Position/Title & Duties of Position

§  Knowledge, skills & abilities & Trainings/credentials required

Please type your complete answer in the box. (It is expandable)

Budget Effectiveness: (10pts)

Each bulleted item must be addressed: All response should refer to the DH program only

·  Describe how the Displaced Homemaker Program will provide the 20% match-2pts

·  Please provide the DH & DFF amount that your program received during the most current complete grant cycle Specify FY: thru DH amount=$ Total DFF amount received=$ 3pts

·  Did your program have to return any DH and/or DFF funds during the most current complete cycle? If so, specify which grant and how much was reimbursed and why-3pts

DH funds returned DFF funds returned .

·  Describe the basis of accounting that the Displaced Homemaker Program will utilize and how the accounting records will be maintained to ensure consistency and accountability of the state issued grant funds-2pts

Please type your complete answer in the box. (It is expandable)

NC Council for Women

FY2011-2012 Displaced Homemaker/Divorce Filing Fee

GRANT APPLICATION
Please provide a list of ALL funding sources for the past 2 years for this program

List Funding Source
This applies to the most recent year. Please state year / List Amount Provided / Year Funds Provided
$
$
$
$
$
$
$
$
$
$
$
$
$
List Funding Source
This applies to the year prior to the year listed above. Please state year / List Amount Provided / Year Funds Provided
$
$
$
$
$
$
$
$
$
$
$
$
$
12 / NCCFW- DH DFF Grant Application, Rev. 01/2011

NC Council for WomenFY 2011-2012 Displaced Homemaker/Divorce Filing Fee

GRANT APPLICATION

Utilize charts to describe how the program will provide the services & numbers served-15pts

Statutory Services / Plan for Provision of Service / Additional comments
Outreach, Intake & Orientation
Referral, Follow-up
(5pts)
Job Counseling
(2pts)
Job Training/Job Placement
(2pts)
Health Education
(2pts)
Financial Services
(2pts)
Educational Services
(2pts)
Provide the total numbers served or numbers to be served in each category. If applicant serves more than one county, specify / Actual Service Results
During present grant cycle
FY10-11
(July 1st thru December 31, 2010)
(6 months) / Projected/Anticipated Service Goals
For
FY11-12
(July 1,2011 --September 30, 2012)
(15 months)
Overall Number of DH Clients Served
Type of Service:
Job counseling
Job training
Health education
Financial Management
Educational Services
Number of Stipends Provided
Childcare:
Education:
Books:
Transportation: / Childcare:
Education:
Books:
Transportation: / Childcare:
Education:
Books:
Transportation:
Number of Clients Placed in Jobs:
Full Time
Part Time
Disabled
Number Placed in Education Placements:
4- Year College
Community College
Trades
Other

NC Council for Women

FY 2011-2012 Displaced Homemaker/Divorce Filing Fee

GRANT APPLICATION

Request for Program Policy (Attach this form at the beginning of the series of Policies requested below)

ALL Agencies must submit the policies listed below (Government & Nongovernment)

Program’s Full Legal Name: County: Tax ID:

Also Known As:

Board Chair’s Signature______Date______

Print Board Chair’s Name:

Executive Director’s Signature ______Date______

Print Executive Director’s Name:

Please only provide the Conflict of Interest Policy (submitted during FY11-12)

Approval Date:

Effective Date:

Please only provide the Confidentiality Policy (submitted during FY11-12)

Approval Date:

Effective Date:

Please only provide the Non-discrimination Policy (submitted during FY11-12)

Approval Date:

Effective Date:

Please only provide the Organizational Code of Conduct Policy (submitted during FY11-12)

Approval Date:

Effective Date:

Please only provide the Internal Controls Policy (submitted during FY11-12)

Approval Date:

Effective Date:

Please only provide the Recordkeeping Policy (submitted during FY11-12)

Approval Date:

Effective Date:

Please only provide the Whistleblower Policy (submitted during FY11-12)