Respond to All of the Questions in the Expandable Space Provided

APPLICATION FOR 2019 FUNDING PURSUANT TO COUNTY LAW §224/225
This opportunity for a one-year contract is a consideration from the County
(January 1, 2019 – December 31, 2019) and is subject to availability of funds.
A contract in one year does not guarantee a contract in future years.
PROPOSAL DUE DATE: 5:00PM on FRIDAY, June 29, 2018.
PROPOSALS WILL NOT BE ACCEPTED AFTER THIS TIME.
PROPOSAL MUST BE COMPLETED USING THIS MICROSOFT WORD APPLICATION FORM. ENTER RESPONSES UNDER EACH SECTION. SECTIONS ARE EXPANDABLE.
PROPOSAL MUST BE TYPED - HANDWRITTEN PROPOSALS WILL NOT BE ACCEPTED.
INCOMPLETE PROPOSALS WILL NOT BE EVALUATED AND WILL BE RETURNED TO THE APPLICANT - EACH APPLICATION MUST BE ACCOMPANIED BY IRS DETERMINATION LETTER, FILED IRS FORM 990, MOST RECENT AUDITED FINANCIAL STATEMENTS, AND LIST OF BOARD OF DIRECTORS.
COMPLETED PROPOSAL MUST BE SUBMITTED TO THE FOLLOWING EMAIL ADDRESS ONLY:

QUESTIONS RELATING TO THIS DOCUMENT SHOULD BE SUBMITTED BY EMAIL ONLY TO:

Organizations submitting a proposal must meet the following requirements:
Be a 501(c)3
Be governed by a Board of Directors
Be up-to-date with all IRS filings
Be up-to-date with all NYS filings
Have a 2016 budget with Board approval
Be fiscally sound
Have a Non-discrimination Policy
Have a Conflict of Interest Policy
Maintain program records for the purpose of an audit and provide to the County all program-related information including proprietary materials, upon request
Be available for on-site visits, announced and unannounced
______
Organization/Provider Name:
Organization/Provider Main Administrative Office Address: (must include street location):
Federal ID #: ______
Days and Hours of Proposed Program Operation: / Title of Your Proposed Service/Program:
Requested Funding Amount for Proposed Service/Program:
Name of Individual Submitting Proposal:
Title:
Phone: Fax:
E-mail:
Name of Proposed Program Contact Person:
Title:
Phone: Fax:
E-mail:
Name of Proposed Contract Signator:
Title:
Phone: Fax:
E-mail:

Respond to all of the questions in the expandable space provided.

Furnish appropriate attachments where indicated.

The focus of this document is on the proposed program (not on your organization).

PROPOSAL: PART I:

SERVICE/PROGRAM DESCRIPTION: Please provide detailed and specific information for each section. Use as much space as necessary.

SERVICE/PROGRAM SUMMARY

1.BRIEF SERVICES/PROGRAM DESCRIPTION OF NEED/OPPORTUNITY: Describe the need for the service/program - be specific. If data and/or a needs assessment exists that identifies/supports the need, it should be provided as an attachment(s) that includes the source and date of the information. NOTE: A needs assessment will be required as an attachment(s) for future County of Rockland Funding Opportunities.

RESPONSE:

2.TARGET POPULATION: Describe:

• unduplicated number to be served in 2019
• duplicated number to be served in 2019
• demographic breakdown (age, gender, and location)
• recruitment process

RESPONSE:

3.ELIGIBILITY REQUIREMENTS: Does your proposed program have any eligibility requirements? If yes, please describe and explain how eligibility will be verified.

RESPONSE:

4.SERVICE(S) DELIVERY: Describe your program and how services will be delivered. Indicate why you chose this approach to address the need. How is this program different from the services already provided by the County? What are the program’s services delivery model/modality and activities (reference best practice or evidence-based model being replicated).

RESPONSE:

5.If program services will be provided at any other location other than the address listed on the cover page, please identify:

Name & Address of Site / Day(s) / Time (from____ to____)
Use this space to explain possible ad hoc sites that may be used for this program, e.g. libraries, schools, etc.

6.PROGRAM GOALS: Briefly summarize the specific goals and anticipated outcomes for this program.

RESPONSE:

7.QUALIFICATIONS:

1. What makes your organization uniquely qualified to provide this type of program/services?

1. Are there any barriers to working with the target population that your organization is uniquely appropriate/prepared to address?

RESPONSE:

8.VOLUNTEERS: Do you intend to use volunteer staff to provide direct care/services and/or non-direct care/services for this proposed program? If yes, please specify. Describe your organization’s screening process for volunteers.

RESPONSE:

9.WORK PLAN: Attach a chart showing the schedule for how this program will be executed. Include each goal with a target date for implementation that will assure program implementation as scheduled. (Refer to PROPOSAL: PART I

Section 10)

RESPONSE:

10.DIRECTIONS FOR PERFORMANCE OUTCOMES, INDICATORS AND TARGETS: What will you measure and monitor to know if consumers have achieved the desired outcome(s)?

• Performance Outcomes are benefits or changes for participants during or after participating in service/program activities. Outcomes are based on service/program goals.

• Outcome Indicators are the specific items of data that you will measure and monitor to track how well the service/program is succeeding on reaching identified outcomes. The data should tell you if participants have achieved the desired outcomes.

• Outcome Targets are either of the following:

• percentage, rate or number of participants expected to achieve the desired outcomes, or
• the amount of change participants are expected to experience.

NOTE: THE FOLLOWING IS AN EXAMPLE ONLY. APPLICANT SHOULD USE ITS OWN JUDGEMENT

IN DEVELOPING PROPOSAL-RELATED PERFORMANCE OUTCOMES, OUTCOME INDICATORS, TARGETS, ETC.

PERFORMANCE OUTCOME: EXAMPLE ONLY

Sample
Performance Outcome:
Benefit or change for participants during or after participating in service/program activities. Should be based on service/program goals. / Recipient will comply with the conditions of apartment’s lease and maintain permanent, independent housing.
Outcome Indicator & Target*
The Outcome Indicator is the specific item of data to be measured and monitored to track how well the program is succeeding on this outcome. The data should tell you if participants have achieved the desired outcome within the specified timeframe (at least semiannually).Outcome Target
The Target is the percentage, rate or number of participantsexpected toachieve this outcome, or the amount of change participants are expected toexperiencequarterly. / 90% of leases will be renewed upon expiration
Data Collection Method
How will data be collected to measure and monitor the outcome indicator.
Attach data collection instrument(s). / Data will be collected based on the individual terms of the leases (i.e. month to month, semiannual or annual) and charted as leases expire.
Brief description of why the Outcome is important: / When individuals comply with the conditions of the lease landlords are likely to renew leases upon expiration, thereby facilitating stable, permanent housing.

NOTE: IF AWARDED A GRANT, A NOTARIZED AFFIDAVIT DETAILING SERVICES AND/OR PROGRAMS PROVIDED WILL BE REQUIRED WITH SUBMISSION OF VOUCHERS

PERFORMANCE OUTCOME

COMPLETE A SEPARATE PAGE FOR EACH PERFORMANCE OUTCOME.

Performance Outcome:
Benefit or change for participants during or after participating in service/program activities. Should be based on service/program goals.
Outcome Indicator & Target*
The Outcome Indicator is the specific item of data to be measured and monitored to track how well the program is succeeding on this outcome. The data should tell you if participants have achieved the desired outcome within the specified timeframe (at least semiannually).Outcome Target
The Target is the percentage, rate or number of participantsexpected toachieve this outcome, or the amount of change participants are expected toexperiencequarterly.
Data Collection Method:
How will data be collected to measure and monitor the outcome indicator.
Attach data collection instrument(s).
Brief description of why the Outcome is important:

NOTE: ADDITIONAL PERFORMANCE OUTCOMES MAY BE SUBMITTED; COPY AND PASTE THE ABOVE FORM

FOR EACH ADDITIONAL PERFORMANCE OUTCOME.

PROPOSAL: PART II

BUDGET FORM AND NARRATIVE FOR PROPOSED PROGRAM:

PROGRAM BUDGET SUMMARY
Expense / Amount
Personnel
Fringe Benefits
Travel
Equipment
Supplies
Contractual/Consultants
Other
Administrative
TOTAL

1. Will this proposed program be funded from different/additional sources?

1. What other sources will provide funding for this proposed program? Do not include in-kind donations/services, use of facilities, etc.. (Please underline all that apply).

1. fundraising proceeds
2. donor’s choice
3. school district
4. local, state or Federal funds or grants
5. municipality
6. other (please explain)

1. What does your organization do to secure additional funds for this program(s)?

NOTE: Payments for the work to be performed as described in the corresponding Service/Program Proposal shall not duplicate payments for the same work performed or to be performed under other agreements between the Organization and other funding sources including Rockland County.

1. Describe any cost saving or program-enhancing collaborations that are part of this program. Do not list agencies with which you only have a referral relationship.

1. Please attach your most recent year-end auditor/accountant-prepared financial report including Balance Sheet and Income Statement.

DIRECT CARE/SERVICES PERSONNEL and FRINGE COSTS
Instructions: List only direct care/services staff positions (individuals who work directly with program participants) to be included in this program. Indicate the base (annual) salary of each staff position and the % of time that will be spent on the program. List total fringe cost for all personnel. Give brief description of program-related responsibilities for each position below under “Explanation/Justification”.
Indicate with a (*) next to each title listed that has regular, substantial contact with children/youth, senior citizens, and people with disabilities/different abilities or potential for regular, substantial contact with one or more of these populations. Please include volunteer positions and indicate $0 base salary.
List vacant position(s) that will be needed for this program on a separate line(s). If vacant, indicate if it is a new position that will be filled if funding is approved and anticipated hire date. Specify if it is an existing position that was vacated and indicate the anticipated hire date.
Position Title / Annual Base Salary / % of time Devoted to Project / Amount Budgeted
Personnel Total
Fringe Benefit / ____%
Total Personal Services Costs

Explanation/Justification:

Fringe Cost Breakdown as a % of Salary:

Health Insurance
Dental Insurance
Vision Insurance
Retirement
FICA
Unemployment Ins.
Disability
Workers' Compensation
Other
Total

NON-DIRECT CARE/SERVICES PROGRAM STAFF & ORGANIZATION ADMINISTRATIVE STAFF

Instructions: List only non-direct care staff positions to be included in this program. Indicate the base (annual) salary of each staff position and the % of time that will be spent on the program. List total fringe cost for all personnel. Give brief description of program-related responsibilities for each position below under “Explanation/Justification”.
Indicate with a (*) next to each person listed who has regular, substantial contact with children/youth, senior citizens, and people with disabilities/different abilities or potential for regular, substantial contact with one or more of these populations. Please include volunteer positions and indicate $0 base salary.
Position Title / Annual Base Salary / % of Time That Will Be Spent on Project / Amount Budgeted
Personnel Total
Fringe Benefit / ____%
Total Personal Services Costs

Explanation/Justification:

TRAVEL
Instructions: Include paid staff travel only. Consultant travel should be shown under the Contractual/Consultant category. Client travel should be shown under the Other Expenses category. Travel costs include the following: air travel, train, personal auto mileage, bus, taxi, parking fees, tolls, lodging and meals. Explain which staff will be traveling and the destination, purpose and frequency of travel. For each trip to program-related training, conferences, meetings, etc., list: destination, length of stay, purpose, number of travelers, mode of transportation and cost (with mileage rate if applicable), meals and lodging costs. Any proposed conference and training must be an integral and essential part of this proposed program and necessary in connection with the program/project. Receipts must be provided. Provide information below under “Explanation/Justification”.
Item / Amount
Total

Explanation/Justification:

EQUIPMENT
Instructions: Equipment is tangible property having an acquisition value of $1,000 or more per unit. Budget requests for equipment purchases using contract funds must be fully explained and justified by program need. Itemize any equipment to be purchased by type and cost. Equipment purchased with County funds remain the property of Rockland County upon completion of the program. Rental/leased equipment should be shown under Contractual/Consultants.
Item / Amount
Total

Explanation/Justification:

SUPPLIES
Instructions: Supplies are those items consumed during the term of this contract. List major supply items (office, program, janitorial, etc.) and provide details showing how estimated costs were developed.
Item / Amount
Total

Explanation/Justification:

CONTRACTUAL/CONSULTANTS
Instructions: This category includes costs for institutions, individuals or organizations external to the organization. Justify the need and/or purpose of the contractual services. Specify the services to be provided and indicate how the cost was determined. Indicate whether the consultant’s rate includes travel and lodging. If the contractor/consultant is reimbursed at an hourly rate, include the hourly rate and the number of hours to be worked. Provide information below under “Explanation/Justification”.
The use of subcontractors or consultants may require additional insurance coverage.
Item / Amount
Total

Explanation/Justification:

OTHER EXPENSES
Instructions: Includes items that are not applicable under any other category and that are directly related to the services to be provided, including: postage, telephone, insurance, reproduction, books, computer time, Internet usage, conference fees, staff training fees other than travel, and direct client expenses. Delineate between program and administrative items. Food/refreshments for staff and/or volunteers are not an allowable expense. Food/refreshments for clients participating in the program for a meeting directly rated to the program will be considered. Indicate how cost was determined.
If any listed expenses are charged to more than one program, indicate what % is attributed to this program and how the % is determined.
Item / Amount
Total

Explanation/Justification:

ADMINISTRATIVE
Instructions: Includes general administrative costs, such as accounting and legal services, and overhead costs, such as office rent and utilities for this specific program only.
NOTE: Total administrative costs may not exceed 15% of the contract total, unless there are extenuating circumstances that are fully explained.
NOTE: If any listed expenses are charged to more than one program, indicate what % is attributed to this program and how the % is determined.
Item / Amount
Total

Explanation/Justification:

PART III: APPLICANT INFORMATION

1. Has your organization obtained tax-exempt status from the IRS?

If yes, attach a copy of your organization’s IRS determination letter.

1. Is your organization current on all payments for real property taxes and payroll taxes?

1. Is your organization current on all payments for rent, if applicable?

1. Is your organization current with the filing of IRS-990 – Return of Organization?

Attach a copy of your organization’s IRS 990 – Return of Organization.

1. Is your organization exempt from Income Tax and NYS Non-profit annual returns?

1. Is there any actual, pending, or threatened litigation or judgments within the past five (5) years against your organization or any individual in your organization?

If yes, please explain and provide specific information.

BOARD OF DIRECTORS

1. How many positions are there on your organization’s Board of Directors and how many positions are currently filled?

1. Do any Board members receive compensation? If yes, please explain.

1. Are any Board members employed by the County of Rockland? If so, please list name(s) and capacity.

1. How many Board meetings held YTD?

1. How many Board meetings held in prior year?

Attach a list of Board of Directors’ names on a separate page.

1. CEO or Executive Director's total salary and compensation from the organization submitting the proposal:

1. CEO or Executive Director's total salary and compensation from all other non-profit organizations:

1. Percentage of your organization's total budget spent on general and management expenses/administration. (For calculation of percentage, please use figure for Total Functional Expenses from most recently filed IRS Form 990, Part IX, Line 25,Column C)

If greater than 15%, an explanation must be provided on a separate page.

1. What percentage of your organization’s total budget is received from fundraising activities? (Fundraising does not include fees for programs/services)

1. What is your organization’s overall fundraising plan? Please be specific.

1. What is the role of your Board of Directors in meeting your fundraising goals? Please be specific.

FUNDING REQUEST INFORMATION

1. What is the annual budget of your organization?

1. Requested County funding as a percentage of your organization's total estimated income for FY 2019:

1. If your organization received County funding in 2016 for this program, please attach a report detailing how that specific funding was spent and what was accomplished to date.

1. In addition to your 2016 grant(s), did your organization have a contract with one or more County departments:

If yes, please provide details on a separate page.

1. Identify, in measurable terms, the economic impact of your organization on Rockland County (i.e. local employment, expenditures, related/auxiliary spending). Please be specific:

1. What would be the impact on the program and/or service you are requesting a grant for if the County’s funding ceased to exist today? Please be specific:

ORGANIZATION CERTIFICATIONS*

I hereby certify and represent to the Rockland County Legislature as follows:

1)That I am fully familiar with all of the information contained in this document and attachments;