Section I: Contact Information
In the section below, provide the primary contact information for the individual in yourorganization who is completing the NCIDC RFQ application. Include contact information for your organization’s Executive Director, President, and/or CEO.
Primary Contact Information
1. Name of primary contact
(First name, Last name)
2. Title of primary contact
3. Phone number of primary contact
(10-digit phone number, including area code: ###-###-####)
4. Email of primary contact
(Your e-mail address should be in the form „‟)
5. Fax number of primary contact
(10-digit phone number, including area code: ###-###-####)
Executive Director Information
1. Name of Executive Director
(First name, Last name)
2. Phone number of Executive Director
(10-digit phone number, including area code: ###-###-####)
3. Email of Executive Director
(Your e-mail address should be in the form “‟)
Organization Contact Information
1. Organization (Headquarters) physical address
(Street, City, State, and Zip)
2. Organization (Headquarters) phone number
10-digit phone number, including area code: (###-###-####)
3. Organization (Headquarters) email
(Your e-mail address should be in the form )
4. Organization website
(Your website should be in the form mydomain.com)
5. Field Office Location(s)
(List the address & phone number of other field offices from which you provide services in San Diego County. If you have a physical presence in Imperial County, please list that as well.)
Section II: Organization Information
The purpose of this section is for NCIDC to learn more about your organization’s capacity,
operating geography, staff, and partners.
Please note that at the end of this section you will be asked to provide information on your Board
of Directors, senior leadership, and organizational structure. All of these documents are
required.
Applicant
1. Organization name
2. Is your organization a current 501(c)(3) nonprofit in good standing?
3. Employer Identification Number (Tax ID)
(Employer Identification Number (Tax ID) is 9-digits in the form 12-3456789)
4. Does your organization primarily provide services to Native Americans? (Specify type and percentage of services to non-natives)
5. Can your organization demonstrate Native American governance on the Board, and is this documented in the bylaws?
6. Does your organization provide Indian Preference in hiring of staff?
7. What year was your organization established?
8. Number of full-time employees in your organization
(Use only numbers; do not include volunteers)
9. Number of part-time employees in your organization
(Use only numbers; do not include volunteers)
10. Average number of volunteers utilized on an annual basis, and average total volunteer hours donated to your organization.
11. In which California counties do you operate?
(List all that apply.)
12. Do you provide any services outside of the State of California?
13. Listany agency membership (or affiliation) in state, regional or national organization(s) or consortiums.
Organizational Documents To Include
Please provide the most recent version of the documents requested. All documents are required for a complete application.
1. Attach a list of your Board of Directors, including brief biographies.
2. Attach a list of your senior leadership or management teammembers, including
contact information (email address and phone number) and brief biographies or resumes.
3. Attach your most current organizational chart.
4. Attach your current bylaws.
5. Attach approved board minutes for the prior 12 month period.
Section III: Financial Information
The purpose of this section is for NCIDC to learn more about your organization’s finances,
experience with government funding, and independent auditing history over your last three fiscal
years. Before you begin, please carefully read the directions and guidance listed below.
Required materials
Questions in this section require data from six documents, which also need to be attached as part of your submission including IRS Form 990 (last three years), Audited financial statements (last three years), and your organization’s annual reports if available.
What if we do not have our 2015 Form 990 and/or 2015 audited financial statements
finalized or available?
If your organization’s 2015 financial documents (Form 990 and/or audited financial
statements) are not yet available, please use information from the three most
recent fiscal years, and indicate when the latest audit and 990 will be available.
Fiscal Year
What is your organization’s fiscal year-end date?
Revenue
1. What was your organization’s annual revenue in each of your past three fiscal years?
ENTER YEARContributions and grants
Program service revenue
Investment income
Other revenue
Total Revenue
2. What were your two largest funding sources in each of your past three fiscal years?
(Specify the exact source (e.g., US Department of Labor WIOA funding)
ENTER YEARLargest funding source
Amount
Second largest funding source
Amount
Liabilities
What were your organization’s accounts payable and accrued expenses, long-term
debt, and other liabilities in each each of your past three fiscal years?
ENTER YEARAccounts payable and accrued expenses
Long-term debt
All other liabilities
Total Liabilities
Auditing History
1. Has your organization received a qualified opinion from your independent auditor on your financial statements within the last three fiscal years?
(Please explain)
2. As a result of any external or funder audit, review, or site visit over your past three fiscal years, which of the following, if any, were identified (please be specific, attach copy of monitoring report, audit, or review findings, and your reply(s)):
Significant deficiencies or material weaknesses in internal controls
Non-compliance with funding requirements
Questioned costs
None of the above
Optional Statement
3. If there are any extraordinary circumstances that your organization has experienced
during your past three fiscal years, which you believe have had a material impact on
your organization’s financial position, please feel free to provide details below.
Financial Documents to Attach
Please attach the most recent version of the documents requested below.
Your organization’s IRS Form 990 and audited financial statements are required.
1. Attach your organization’s filed IRS Form 990 for each of your past 3 fiscal
years.
2. Attach your organization’s Audited Financial Statements for each of your past
3 fiscal years.
3. Attach a copy of your organization’s current year to date financial statements.
4. If available, Attach your organization’s Annual Report for each of your past 3
fiscal years.
Section IV: Mission, Strategy, and Target Population
The purpose of this section is for NCIDC to learn more about your organization’s mission,
primary activities, strategic vision, and the target population that you serve. Since many of the
questions are free response, please be succinct while describing your organization.
Mission and Strategy
1. Describe your organization’s mission.
(Provide board-approved agency mission/vision statement)
2. What are your organization’s primary activities?
3. Summarize the initiatives or programs for which you hope to gain NCIDC support through the CSBG funding. (you are provided the opportunity to discuss this in greater detail below).
4. Summarize your organization’s most recent strategic plan and risk assessment, including details on specific goals you aim to achieve, and over what time period, as well as risks and barriers related to achieving your goals.
5. If available, please attach your organization’s most recent strategic plan and risk assessent.
Target Population
1. How does your organization define your target population?
2. What percentage of the people your organization serves can be characterized by each
of the following? (Note: The collective total of the percentages below does NOT have to add up to 100%
as NCIDC understands that the individuals your organization serves may fall into multiple categories. If you do
not track this information please enter “N/A‟ for Not Available).
% Low income?
% Unemployed and seeking work
% At-risk youth and young adults?
%Elders
% Disabled (include partially disabled)
% Having a history of incarceration and/or is on parole or probation?
% Having a history of mental health issues or mental health disabilities?
% Having a history of homelessness?
% Having a history of substance abuse?
% Veterans
% TANF recipients
3. List the name of each significant program/service your agency currently provides, identify the funding source and annual funding amount, and include a brief description of the services offered, and the number served on an annual basis. Address if you anticipate expanding services or providing new services within each program based on the availability of CSBG funding.
4. List any new significant programs or services your agency would provide if awarded a CSBG sub-contract, including listing proposed matching funds from other sources, and the number you anticipate serving on an annual basis.
5. List and briefly describe any active partnerships you maintain with other non-profit service providers, governmental entities, faith-based entities, for profit businesses, or other similar entities.
6. Attach any letters of support you deem relevant.
CSBGRFQCertification
The ______(name of organization)
is submitting this application for CSBG program funding, provided in the form of a Community Service Block Grant (CSBG) sub-contract with the NCIDC.
As the authorized officer of ______
my signature below certifies that to the best of my knowledge all of the information provided in this application is accurate, and if funded, we agree to comply with the requirements of the NCIDC CSBG program as described in the announcement and contract, and to meet the reporting and financial requirements of this award:
I certify that proposed activities and fundingwouldnot be used for physical construction or renovation of a facility or space within a building. I further certify that our agency can function within the administrative/indirect cost limitation of twelve percent (12%) of total sub-contract funds.
The effort proposed will be consistent with all Federal and State requirements. Additionally, the project provides assurances it will NOT use these grant funds to supplant or replace existing funding for current projects.
______
Signature
______
Printed name
______
Title
______
Date
1
NCIDC RFQ1