HomeMy WebLinkAboutExhibit 12 aGrant Application Forms
cover rage .i
The Trust RFP/ITN Number:
The Trust RFPIITN Title:
Proposed Project Title:
A. Agency Information
Applicant Agency Legal Name:
Federal Identification Number:
Contact Street Address:
City:
Telephone Number:
CEO/Executive Officer:
Chief Financial Officer:
Public Relations Contact:
Application Contact Person:
Contact Person E-mail:
Type of Entity (click one box):❑
Corporation
Private -for -profit
Private -not -for -profit
Federal government
State government
County government
City government
Other (specify):
Licensed to do business in
Florida? (click one box)❑ YES
❑ NO
B. Finances and Insurance
Agency Fiscal Year Begins:
Amount Requested (fills
automatically from budget):
Other/Matching Funds (fills
automatically from budget):
Total Program Value (fills
automatically from budget):
Insurance Coverages:
*Comprehensive Coverage/
General Liability ❑
Workers' Compensation ❑
Automobile ❑
`Note: If General Liability coverage amount is less than $500,000, Agency must agree to purchase
A minimum of $500,000 Comprehensive General Liability insurance prior to contract execution
State:
Fax Number:
Amount of Coverage Expiration Date
Zip Code:
Phone:
Phone:
Phone:
Phone:
Fax:
Agency does not carry
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 1 of 24
urant Application rorms
C. Relationship with The Children's Trust
Has Agency ever held a contract with The Children's Trust?
❑ YES ❑ NO (go to Cover Page 3)
If YES, List most recent contract number(s) (up to 3):
If YES, has Agency previously submitted the current version of each of the following documents?*
Financial audit ❑ YES -Period of Audit;
❑ NO
Unaudited financial
statement YES -Fiscal Period:
❑ NO
Current board of directors ❑ YES
❑ NO
*If previously submitted documents are valid and time periods current for this application,
items do not need to be resubmitted; just check YES above for each item currently on file
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 2 of 24
The Children's Trust
Grant Application Forms
Cover Page 3
D. Proposed Number to be Served
Total Number of Unduplicated
Participants to be Served:
From age
(in years):
Up to age
(in years):
Estimated Numbers to be Served b Age Ran a (total should equal total number listed above):
Birth to 2 years 11-13 years
3-5 years 14-18 years ,
6-10 years Adult Parents/Caregivers
Estimated Numbers to be Served by Population Type (total should equal total number listed above):
Children with Disabilities
At -Risk Participants
General Population
E. Service Delivery Categories and Descriptions
Strategic Funding Categories (select one, and complete requested information):
�14 Out -of -School Programs (refer to RFP for definitions of enhancement and expansion)
CHECK ONE: 0 Summer Only 0 After -school Only 0 Year -Round Programs
CHECK ALL THAT APPLY: 0 Program Enhancement 0 Program Expansion
O Promotion & Prevention (refer to RFP for definitions of approaches)
CHECK ALL THAT APPLY: 0 Universal 0 Selected 0 Outreach/Advocacy
❑ Resource Network (CHECK ONE program focus area below)
❑ Maternal/Infant/Child Health & Development 0 SafetyNiolence Prevention
❑ Children with Disabilities 0 Adolescent Risk Reduction
0 Other (briefly specify): I
0 Service Partnership (describe specific population/neighborhood on Primary Population Worksheet)
CHECK ONE: 0 Population -based 0 Neighborhood -based
0 Other (specify RFP/ITN): I
Will any fees be charged/collected for the proposed services?
❑ YES -Briefly explain: I will charge parents in based on income eligibility and other criterias thathave been developed by our bored
❑ NO of direclores.
Does the proposed program include a health component?
❑ YES -please identify and fully describe this on the Activities Description Worksheet
❑ NO
Does program include participant transportation?
❑ YES -transportation is available to/from all standard services
O YES -transportation is provided for special services only (e.g., field trips)
❑ NO -transportation is not provided
Number of youth workers (age 16-22) proposed program will utilize:
Number of volunteers proposed program will utilize:
Fxpected number of volunteer hours to be contributed:
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 3 of 24
Grant Application Forms
Certifications Page
Official Grertifiications
Has the Agency been sanctioned for non-compliance with any contract, government law or regulation
related to the operational program proposed with this application within the past three years, or has your
agency had any violations under the public entity crimes statute? (click one box)
■ YES -include copy in Supporting Documents section, in order indicated in Table of Contents
❑ NO
Please describe in a separate attachment any litigation or regulatory action filed against the Agency ir\
the last three years related to the operational program proposed with this application, including case'
name, court name, and current status. Include document(s) in the Supporting Documents section, in
order indicated in the Table of Contents. If none has been filed, acknowledge this by checking below.
0 NOT APPLICABLE
I do hereby certify that all facts, figures, and representations made in the application(s) are true and
correct. Furthermore, all applicable statutes, terms, conditions, regulations and procedures for program
compliance and fiscal control, including but not limited to, those contained in the Bid Solicitation and
Core Contract, will be implemented to ensure proper accountability of contracts. I certify that the fund;
requested in this application(s) will not supplant funds that would otherwise be used for the purposes set'
forth in this project(s) and are a true estimate of the amount needed to operate the proposed program(s).
The filing of this application(s) has been authorized by the contracting entity and I have been duly
authorized to act as the representative of the agency in connection with this application(s). I also agree
Ito follow all terms, conditions, and applicable federal and state statutes. Further, I understand that it is
the responsibility of the agency head to obtain from its governing body the authorization for the
submission of this application. Evidence of this authorization must be provided within 21 days of notice
of award. 1 further understand that such contract award may be rescinded for failure to provide such
documentation. •
This bid process is subject to a "Cone of Silence" and the state conflict of interest laws (S. 112.311,
et.seg. F.S,). I further state that to the best of my knowledge, submission of this proposal is in
compliance with the state and county conflict of interest laws.
Lastly, I hereby attest that all work contained within this proposal is the unique and original product of
the agency I represent, and has not been plagiarized or duplicated in any way from another agency's
work product.
Print Authorized Official's Name:
Authorized Official's Title:
Date of Signature:
Authorized Official's Signature in BLUE INK:
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 4 of 24
Grant Application Forms
I able of GOntents
✓APPLICATION FORMS
(submit original plus 6 copies, bound with Supporting Documents) Page #' -
Cover Pages
1-
Certifications Page
'
Table of Contents
5-=
Program Summaries
Organizational Capability
Primary Population
Collaborations
Site Locations Details
Goals Worksheet
Outcomes Worksheet
Activities Descriptions
Process Worksheet
Agency and Program Budget
_
Budget Summary for Proposed Program
•
Budget Justification
Budget by Site Location
Daily Unit Cost
Acknowledgment of Addendum
SUPPORTING DOCUMENTS Continue
(submit original plus 6 copies, bound with Application Forms) Page #' -
Sanctions, Violations, and/or Litigation Documentation, if applicable
_
Organizational Chart(s)
Evidence of Past Success, if applicable (monitoring reports, letters of support, etc.)
Staff Resumes _
Job Descriptions
Collaborative Letters of Agreement, Memoranda of Understanding, if applicable
Outcome Tests and Measures
Schedule of Daily Activities and Field Trips, if applicable
Documentation of Cash or In -kind Matching Funds
Consultant Agreement Letters
Verification of Agency's Indirect Cost Rate
FISCAL/POLICY MATERIALS Start Ne
(submit a total of 3 separately bound sets) Page #'-
Cover Pages (from Application Forms) -write "FISCAL/POLICY MATERIALS" on top
1-
Certifications Page
Table of Contents
5-:
Financial Audit/Unaudited Financial Statements
Certification Form
12/30/2005
Page 5 of 24
Enter Applicant Agency Name in Footer Section
• ••W .+r•••r+•vrr.• SI MYL
Grant Application Forms
Program Summaries
eneral Formatting Notes:
Row height should automatically expand with text. If that does not occur, select Format-Row-Autofit and/or go to
- the Alignment tab under Format Cells to make sure the Wrap Text option is checked.
To start a new line in the same cell (i.e., a space between paragraphs), press ALT + ENTER. It may also be useful
to break apart text, with individual paragraphs in separate cells.
25-Word Publicity Description: If funded, this description will be posted on The Children's Trust
website to publicize available programs to parents/caregivers, youth and the community regarding
services offered. Write this description in present tense, as if the program was funded.
50-Word Program Description: This description will be used in the documents submitted to The
Children's Trust Board of Directors when funding recommendations are released. This should be a brief
version of the full Program Summary.
PROGRAM SUMMARY (1-2 pages maximum): This description is used by reviewers. Include a
summary of the proposal that clearly describes the organizational capability; proposed participants;
collaborative partnerships; and overall program goals, activities, and expected outcomes and benefits. it'
is typically more effective to write this section after completing the other narrative portions of the grant
application forms.
•
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 6 of 24
Grant Application Forms
&. Agency Description (2 pages maximum, not including attachments)
Provide a clear description of the Agency, including its mission, history, and particular qualifications as-
-elated to the current bid solicitation. Include a listing and description of agency accreditations and
icensure relevant to the field, if applicable (i.e., accrediting or licensing body, level and period of
accreditation/licensure, etc.).
CURRENT OR PAST PROVIDERS OF THE CHILDREN'S TRUSTARE NOT REQUIRED TO COMPLETE
THIS SECTION, UNLESS THEY WISH TO PROVIDE UPDATED OR CHANGED INFORMATION.
Describe Agency's overall approach to ensuring cultural competence in its current organization, as well
as the plan to ensure cultural competence in implementing the proposed project.
CURRENT OR PAST PROVIDERS OF THE CHILDREN'S TRUSTARE NOT REQUIRED TO COMPLETE
THIS SECTION, UNLESS THEY WISH TO PROVIDE UPDATED OR CHANGED INFORMATION.
Attach the Agency's organizational chart(s) that clearly indicate the current fiscal, administrative, and
programmatic reporting structures, as well as how the proposed program will fit within the larger
organization. Include document(s) in the Supporting Documents section, in the order indicated in the
Table of Contents.
CURRENT OR PAST PROVIDERS OF THE CHILDREN'S TRUST ARE NOT REQUIRED TO RESUBMIT THE
ORGANIZATIONAL CHART IF THE MOST CURRENT VERSION IS ALREADY ON FILE AND NOTED AS
SUCH ON THE COVER PAGE 2. ONLY THE ORGANIZATIONAL CHART FOR THE PROPOSED
PROGRAM IS REQUIRED WITH THIS APPLICATION.
If explanation is needed, include a narrative description of the organizational chart(s) below:
Attach the Agency's 2004 financial audit and related management letter. If the Agency's fiscal year
ends after June 30, 2004 and the audit of 2004 financial statements has not been completed, the
Agency may provide the audited financial statements for its 2003 fiscal year. If in business for less
than 18 months, or if Agency total budget is less than $300,000, attach a copy of the most recent un-
audited financial statements. Either must be completed by a registered CPA and conducted in
accordance with generally accepted accounting principles. Include documents in the Fiscal/Policy
Materials section, in the order indicated in the Table of Contents.
CURRENT OR PAST PROVIDERS OF THE CHILDREN'S TRUST ARE NOT REQUIRED TO RESUBMIT
AUDITS/FINANCIAL STATEMENTS IF THE 2004 VERSION IS ALREADY ON FILE AND NOTED AS SUCH
ON THE COVER PAGE 2.
If explanation is needed, include a narrative description of the audit/financial statements and findings
below:
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 7 of 24
ne unuaren's i rust
Grant Application Forms
Organizational Capability
b. Experience (2 pages maximum, .not including attachments)
Did the proposed program operate prior to current funding request?
• YES
❑ NO
If YES, list funding source(s), dollar amount(s), time period(s), and current status of each, for the past
three (3) years, as shown in these examples:
Alliance for Human Services, $45, 000, 7/1/03-6/30/04i project completed/not renewed
Center for Substance Abuse Prevention, $200,000, 10/1/04-9/30/07, project currently ongoing
CURRENT OR PAST PROVIDERS OF THE CHILDREN'S TRUST ARE NOT REQUIRED TO COMPLETE
THIS SECTION, UNLESS THEY WISH TO PROVIDE UPDATED OR CHANGED INFORMATION.
Describe the Agency's relevant experiences and successes in conducting services related to the
current bid solicitation and proposal. Summarize organizational qualifications and accomplishments,
including the scope of work conducted, a description of related funded work conducted within the past
three years, and performance measures achieved.
CURRENT OR PAST PROVIDERS OF THE CHILDREN'S TRUST ARE NOT REQUIRED TO COMPLETE
THIS SECTION, UNLESS THEY WISH TO PROVIDE UPDATED OR CHANGED INFORMATION.
Attach any relevant documentation or evidence of past successes achieved, such as funder
monitoring reports, program evaluation summaries, general letters of support or endorsement,
publications, work samples, etc. These should be described in the narrative response above. Include
document(s) in the Supporting Documents section, in the order indicated in the Table of Contents.
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 8 of 24
II VIRUu117lS b I lust
Grant Application Forms
Organizational Capability
C. Staffing (1 page maximum, not including attachments)
Describe how the project will be appropriately staffed, including employees, subcontractors,
consultants, and volunteers. Explain the staffing plan for how primary activities will be conducted,
ncluding responsibilities for specific activities and deliverables (i.e., a brief summary of the detailed job,
descriptions). Provide a narrative description of the number and types of positions and the staff
experiences and credentials required, using the same title labels as in budget worksheets (note that)
since the Budget Justification includes all staff titles, names, salaries, percent efforts, and credentials,
such a detailed breakdown is NOT required in this section). Out -of -school programs are strongly
encouraged to employ at least one licensed or certified education professional.
Also, briefly describe the Agency's approach to staff training and orientation required for working within,
the proposed program.
Based on the proposed staffing plan and number of participants to be served, what is the maximum\
ratio of participants -to -staff?
Maximum of children/youth for every one adult.
Attach Staff Resumes for the project director and other key personnel (including consultants) to
Indicate relevant experience of each person to the professional team. These should be summarized in
the narrative response above. Include document(s) in the Supporting Documents section, in the order
indicated in the Table of Contents.
Attach Job Descriptions for the project director and other key personnel (including consultants) to
indicate the specific duties and contributions of each person 10 the professional team. These should
be summarized in the narrative response above. Include document(s) in the Supporting Documents
section, in the order indicated in the Table of Contents.
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 9 of 24
a air r •aa •ra V •a V .,MVr
Grant Application Forms
Collaborations
Collaborative Partnerships (2 pages maximum, not including attachments)
Describe any collaborative partnerships with other organizations in the community that are directly
related to the proposed program. Include for each partner a brief description of the agency, the role
that partner is expected to play, as well as the specific resources and commitments they will bring to
the proposed program. For applicants using multi -site collaboratives for service delivery, individual
agency sites may be briefly described within this section if desired (in addition to the completion of the
Site Location Details worksheet).
Attach collaborative Letters of Agreement and/or formal Memorandum of Understanding affirming
commitments. These should be described in the narrative response below. For any sites based in a
school, applicants must submit a Letter of Agreement from the current school principal at each of the
proposed schools. Include document(s) in the Supporting Documents section, in the order indicated in
the Table of Contents.
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 10 of 24
The Children's Trust
Grant Application Forms
Site Locations Detai'
Service Delivery Site Locations:
Instructions for applicants with more than one service delivery site location:
If any information within the remaining sections of the Application Forms varies across site locations, specify within each section this variation by
rioting the applicable sites. If all details are identical across sites, there is no need to reference specific sites throughout the worksheet narratives.
'Site #1
Site Name:
Site Contact Person:
Contact Person E-mail:
Is this a school -based site?
❑ Summer Only
Street Address:
City:
Zip Coder
OYES LINO
❑ After -school Only
Phone Number:
Days of Operation:
❑ Year -Round Program Start Date:
• Fax Number:
Hours of Operation:
Total Number of Unduplicated From age
Participants to be Served: (in years):
stimated Numbers to be Served by Population Type (total should equal total number listed above):
Children with Disabilities { At -Risk Participants
i
End Date:
Up to age
(in years):
General Population
Site #2
Site Name:
Site Contact Person:
Contact Person E-mail:
Is this a school -based site?
❑ Summer Only
Street Address:
City:
Zip Coder
❑ YES U NO
❑ After -school Only
Phone Number:
Days of Operation:
❑ Year -Round Program Start Date:
Total Number of Unduplicated From age
Participants to be Served: (in years):
Estimated Numbers to be Served by Population Tyr (total should equal total number listed above):
Children with Disabilities! At -Risk Participants
Fax Number:
Hours of Operation:
End Date:
Up to age
(in years):
General Population
'Site #3
Site Name:
Site Contact Person:
Contact Person E-mail:
Is this a school -based site? 0 YES ❑ NO
0 Summer Only_ ❑ After -school Only 0 Year -Round Program Start Date:
Total Number of Unduplicated From age
Participants to be Served: (in years):
Estimated Numbers to be Served by Population Tyr (total should equal total number listed above):
Children with Disabilities! - At -Risk Participants !
I
Street Address:
City:
Fax Number:
Hours of Operation:
Zip Code:I
Phone Number:
Days of Operation:
End Date:
Up to age
(in years):
General Population
Enter Agency Name in Footer
12/30/20i
Page 11 of
The Chddren's Trust
Grant Application Forms
Primary Workshec
Multiple Site Instructions: If different service delivery sites serve different primary populations, list each participant group on a separate line and note
which sites serve each group in the Selection Criteria column. If all sites serve the same primary population, there is no need to reference specific
sites on this worksheet.
PRIMARY POPULATION ':-HOW MANY 'CHARACTERISTICS of expected RECRUITMENT strategies and ;SELECTION CRITERIA are factors 3
expected to participate in the •are expected ;participants, including age, gender, =activities that will be used to inform `used to screen participant eligibility
:program (e.g., children, parents, to participate :race, ethnicity, income level, and engage the described participants for participation (e.g., attendance at
:families, teachers, other
community members)
Enter Agency Name in footer
neighborhood, school performance, and into the program
:other risk factors that will be used to
guide recruitment efforts. If serving
:children with disabilities, specify_types..
a particular school, residence in a
;particular neighborhood, income
:below poverty level). If program is
_ _open to anyone, put "NIA" here.
12/30/20(
Page 12 of
The Children's Trust
Grant Application Forms
Goals Workshe
Multiple Site Instructions: If different service delivery sites have varying program goals, outcomes or activities, list each one on a separate line at
sites to which each applies_ if all sites follow the same goals, outcomes and activities, there is no need to reference specific sites on this worksh•
GOALS are statements of purpose or specific
aims, outlining what the program expects to
accomplish in broad terms
Enter Agency Name in Footer
OUTCOMES are the realistic, measurable expected ACTIVITIES are what the staff will actually do for,
changes and benefits for the people served as a result of to or with participants to achieve the outcomes.
program participation List/name activities briefly in this column, as they
will be described in more detail in a later section.
Required Program Components are noted below.
List Literacy Component
List Physical Activity/Fitness Component
List Social Skills Development Component
List Family Involvement/Outreach Component
List Nutrition Services Component
List Additional Optional Progam Components
12130/20C
Page 13 of 2
The Children's Trust
Grant Application Forms
Outcomes Workshee
Multiple Site Instructions: If different service delivery sites have varying outcome measures, fist each one on a separate line and note the sites to which each applies.
If all sites collect the same outcome measures, there is no need to reference specific sites on this worksheet.
OUTCOMES are the realistic,
rneasurable expected changes and
benefits for the people served as a
INDICATOR MEASUREMENTS are ;DATA SOURCES & METHODS
the tools, tests and measures that will indicate where and how information
be used to specify the evidence to be will be collected (e.g., observations
result of program participation and collected to measure how well a
should be related to the described program is achieving its outcomes
population characteristics and risks (Attach copies of the proposed
(this column will be automatically measures in the Supporting
filled with the outcomes listed on the Documents section, in the order
Goals Worksheet) indicated in Table of Contents)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Enter Agency Name in Footer
by staff, school system data, self -
report surveys, etc.), managed,
stored and analyzed
TIME OF MEASUREMENTS
indicates when measures will be
obtained (e.g., every 3 months, at
program completion, 6 weeks after
the program, etc.) & WITH WHOM
indicates who will complete each
measure (e.g., parent, child, teacher,
staff, etc.)
STAFF
:position
responsible
for the
collection of
each indicator
'measure
12/30/20C
Page 14 of 2
I he Children's Trust
Grant Application Forms
Activities Descriptioi
Multiple Site Instructions: If different service delivery sites have varying activity components this should be noted within the Goals worksheet, and will
automatically show up in the Activities column below.
ACTIVITIES are what the program staff will
actually do for, to or with participants (e.g.,
providing events, interventions, etc.) to
achieve each outcome for program
participants (this column will be automatically
filled with the activities listed on the Goals
Worksheet)
List Literacy Component
List Physical Activity/Fitness Component
List Social Skills Development Component -
List Family Involvement/Outreach Component
List Nutrition Services Component
List Additional Optional Progam Components
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Enter Agency Name in Footer
NUMBER
expected
to receive
each
activity
ACTIVITY DESCRIPTION includes the details for each program activity, including the approach or model being
used (referencing evidence-based/best practices when applicable), how the activity will be provided in an engaginc
manner, the materials to be used, how materials will be selected, and how participants will be assessed to ensure
activities are tailored to the appropriate ability levels. Activities should include all required components stated
within the bid solicitation.
Rows will expand with text to allow sufficient space to describe all activities.
ATTACH a Schedule of Daily Activities (and Field Trips if applicable) that details when activities will be conducted.
Include documents) in the Supporting Documents section, in order indicated by Table of Contents.
12/30/200:
Page 15 of 2
The Children's Trust
Grant Application Forms
Process Worksh
Multiole Site Instructions: If different service delivery sites have varying activity components this should be noted within the Goals worksheet, and will
automatically show up in the Activities column below.
ACTIVITIES are what the program
staff will actually do for, to or with
participants (e.g., providing events,
interventions, etc.) to achieve each
outcome for program participants
(this column will automatically be
filled by the activities listed on the
Goals Worksheet)
List Literacy Component
List Physical Activity/Fitness
Component
List Social Skills Development
Component
List Family Involvement/Outreach
Component
List Nutrition Services Component
List Additional Optional Progam
Components
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Enter Agency Name in Footer
INPUTS & RESOURCES required to
:fully accomplish activities and
outcomes, including staffing (i.e.,
responsible parties) and other financial,
organizational, and community
resources (e.g., training, space,
equipment, etc.), as should be reflected
within the program budget
PLANNED PLANNED
,*FREQUENCY of INTENSITY of
how often the how long each
activity will be activity session
delivered (e.g., will last (e.g., 15
daily, once a minute check -in,
week, 3 times a 2 hour class,
year, etc.) etc.)
:PLANNED
DURATION
,includes the total
time frame within
:which
participants will
be involved in
'the activity
(e.g.,1-time only,
6 weeks, all
_school year)
OUTPUTS are the direct
products and evidence of
service delivery and the work
of the program, including the
volume of work accomplished
(Le., # participants,
attendance, # classes offered,
# brochures distributed, etc.)
12!3012C
Page 16 of
The Children's Trust
Grant Application Forms
A) GENERAL
Organization Name.
Address:
Contact Person:
Telephone:
B) AGENCY BUDGET
0
Agency and Program Budge
Areas in Blue to be completed by the Agency
0
0
0
Agency Fiscal Year Begun: 0
Fax: 0
E-mail: 0
Agency Source of Funding
Funding/Grant Period
Program Budget
Agency Budget
The Children's Trust Requested Grant Amount for Program
0.00
0.00
Child Development Services Finds
0.00
0.00
Maini-Dade County Grants(Loeal)
Human Services Coalition
0.00
0.00
0.00
0.00
0.00
0.00
Federal Grants (Specify Source) _
Dept of Education
0.00
0.00
0.00
0.00
0.00
0.00
State Grants (Specify Source) :
0.00
0.00
Dept of Education
0.00
0.00
,,Foundations/Charitable Funds (Specify+ Source
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Cash/Feer/Oiher Revenue (Specify Source
0.00
0.00
0.00
0.00
0.00
0.00
In -Kind Contributions
0.00
0.00
0.00
0.00
0.00
0.00
TOTAL BUDGET
50.00
s0.00
T SUMMARY FOR PROPOSED PROJECT/PROGRAM
CATEGORY
REQUESTED AMOUNT
DESCRIPTION
Personnel
0.00
Salaries
Fringe Benefits
0.00Trmges
OPerating
0.00.AIi Other Costs
Indirect/Administrative Costs
0.00
TOTAL REQUESTED
S0.80 -
Enter Agency Name in Footer
12130120C
Page 17 of
The Children's Trust
Grant Application Forms
Budget Summary for Proposed Prograr
Period:
**1***j20** to **t**/20**
0 months
Areas in Blue to be completed by the Agency
!NAME OF FUNDING SOURCE:
Cht0dretis Trust
% ,
Amount
%
Amount
%
Amount
%
Amount
%
Amount
%
Amount
SALARIES: _
List Pall -Time Employees
Position Name Amoral Salary
0.00
0.00
0.00
0.00
0.00
0%
0.00
. 0.00,
o.00
o.00
0.00
0.00
0%
. "0.00
0.00
0.00
0.00
0.00
- 0,0D
0%
0.00
. 0.00
.0.00
0.00
' 0.00
0°%
0.00
0.00
0.00
0.00
0.00
0.00
0%
0.00
0.00
0.00
0.00
0.00'
0.00
0%
- too
0.00
-
0.00
0.00
0.00
0.00
0%
0.00
Foli-Tome Total 0.00
0.00
' 0.00
..= 0.00
0.00
0.00,
coo"
0.00
Q00
0.00 .
0.00
0.00
.0.00
List Part -Time Employees
.
0.00
0.00
0.00
- 0.00
0.00
0%
0.00
0.00
.. 0.00
0.00
0.0D
- 0.00
0%
0.00
0.00
0.00
' 0.00
0.00
0.00
0%
-, 0.00
0.00
_._ 0.00
- 0.00
0.00
0.00
0%
0A0
o_00
_' 0.00
o.00
.0.00
0.00
0%
0.00
Putt -Time Total 0.00
0.00
0.00
Om
2.. 0.00 -
0.00
0.00
0.00..
0.00
0.00 -
0a10
0.00
.0.00
TOTAL FTEstSALARIES
.00 -
S0.00
.00
S0.00
.00
50.00
.00
50.00
.00
50.00
.00
50.00
FRINGE BENEPJ TS
FicalMica Rate: 7.65%
0.00
- 0.00
0.00
0.00
0.00
0.00
W-Camp's Rate: .
0.00 -
- 0.00
0:00
0.00
0.00
0.00
Unenploy Rate:
0.00
- . 0.00
0.00
0.00
0.00
0.00
Health Its. Cost per Staff
0.00 -
0.00
0.00
0.00 -
0.00
0.00
Life Inc. Cost per Staff
0.00
- 0.00
- . - 0.00
0.00
- 0.00
0.00
- 0.00
0.00
0.00
0.00
0.00
0.00
RU ...,cnt Rate:
Other Specify & provide calculations
'
' Rate:
0.00 - -
. " 0.00
0.00
0.00
0.00
0.0D
Rate:
0.00
0.00
0.00
0.00
0.00
o:oo
Rate:
0.00
0.00
-
0.00
0.00
0.00
0.00
Rate:
0.00
0.00
0.00
0.00
0.00
0.0D
TOTAL FRINGE BENEFITS -
50.00
S0.00
50.00
50.00
50.00
50.00
Enter Agency Name in Footer
12/30/2005
Page 18 of 24
The Children's Trust
Grant Application Forms
Budget Summary tor rroposeu rruyreai
Areas in Bhie to be completed by the A
NAME OF FUNDING SOURCE:
OPERATING EXPENSES:
Travel (other than clients)
Local mcicage, tolls, parking
Out-of-town
Travel clients)
Bus pass/tokens
Field trips/Buses/Vans
Meals (dients)
Snacks (alter school)
Meals (full days)
Space
Lease/Rent
Maintenance
Electricity
Communications
Supplies
Office Supplies
Program Supplies
Printing/reproduction
Shipping/Postage
Non -Capital Equipment (6750) (Usk
each).
Capital Equipment (>S750) (list
each)
Professional Services (List each)
Other (List each)
TOTAL OPERATING EXPENSES:
Administrative/Indirect Costs
Can not exceed 10%)
Enter Agency Name in Footer
Annual Cost
Requested Funding
Chsldrai s Trust
Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00j
0.00
Other Fundmg Requested or Received
% Amount % Amount %. Amocmt
0.00
0.00
0.00
0.00
0.00 0.00 0.00
0.00 0.00 a.0o
OE00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00 0.00
0.00 0.00 0.00
olio 0.00 0.00
• 0.00 0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00 0.00
0.00 0.00 0 00
'0.00 0.00 0.00
0.00 .0.00
0.00 0.00
0.00 0.00
0.00
0.00
0.00
0.00
Mani neg Funds Total
%. Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00.
0.00
0.00
0.00
0.00
% Amount
0%. 0.00
0% • 0.00
0%
0%.
0.00
0.00
0.00
0.00
0% 0.00
0% 0.00
0`A 0.00
0%. 0.000
0% 0.00
0% 0.00
0% 0.00
0.00
0% 0.00
0% 0.00
A%. 0.00
0y. 0.00
0.00
0% 0.00
0%. 0.00
0%s 0.00
0%. 0.00
0% 0.00
0% 0.00
0.00 0.00
0.00 0.00
S0.00 S0.00 50.00 50.00 50.00 50.00
0.00
0.00
0.00
0.00
0.00 0.00
TOTAL BUDGET 50.00 S0.00 S0.00
0.00
0.00
S0.00 50.00
0.00
sal
12130/20C
Page 19 of
I ne t.niiaren's I rust
Grant Application Forms
Budget Justificatioi
.. f."/20.. to f.. fy0..
SALARIES:
Position
List Fall -tuner Efloyna
0
0
0
0
0
0
0
List Part -Time Employees
0
0
0
0
0
0
0
Nome Amount
0
0%
Atcas in Blue to be completed by the Agency
Defied 7mti5ea6on Iot Each Line Item
•
Crtdentials•dtscRibe staff education
staining and key. experience
0
0
0-
0%
0%
0
Fu1FTimeTotal
0
0
0.00
0%
0%
0.00
0
0
0
0
0
0
0
0
0
0%
0
0
0%
0
0
0%
TOTAL
TOTAL FRINGE BENEFITS
OPERATING EXPENSES
Trovd (ethrr thou clients)
Local =leage. toils parktog
Opt -of -town
Travel,(cheob)
Bus passhokens
Part -Time Total
0
0
0%
0.00
S0.00
0.00
0.00
0.00
0.0D
field tripe/Buses/Vass
Meals (gents)
0.00
0.00
Snacks (after school)
Meals (fon days)
Space
0.00
0.00
LeatalRe a
M mteotace
Elechicrty
0.00
0_D0
Common atoms
Supplies
0.00
0.00
(ISce Supplies
Program Supplies
0.00
PruningireproductIon
Sit/map/Pottage
0.00
0.00
0.00
Noa-Corpitrl Equipment (d750) (Lint eadt)
0
0.00
0
0.00
0
0.00
Capital Equipment (>S750) (List each)
0
0.00
0
0.00
0
0.00
Professional Services (Lest each)
0
0.00
t
0
0.00
0
0.00
Other (LSsteach)
0
0.00
0
0.00
TOTAL OPERATING EXPENSES:
S0.00
Adtuinistrativellndirect Costs
(Can not exceed 10%)
0.00
TOTAL BUDGET S0.00
Enter Agency Name in Footer
12/30/200!
Page 20 of 2.
The Children's Trust
Grant Application Forms
Budget By Site Locatioi
0 months
Sile Location 1
NAME OF SITE LOCATION:
Areas in Blue to be completed by the Agency
Site Location 2 Site Location 3 Site Location 4 She Location 5
Total
SALARIES:
List Fall -Time Employee
Position Name Annual Salary
0 0 0
O 0 0
D 0 0
O 0 0
0 0 0
0 0 0
0' 0 0
Fall -Time Total -.0.00
Lint Part -Time Employers -
a 0 0
0 0 0
O 0 0
O 0 0
O 0 0
Part Time Total 0.00,
TOTAL FTFa1SALARIES
.00
Amount
50.00
%. Amount
.00
S0.0a
%. Amound
0.00
0.00
0.00
0.00
0-00
0.00
0.00
0.00 0.00
0.00
.0-00
0.00
0.00
0.00
0.00 C00
.0o S0.00
% Amount
0.00
0.00
0:00
0.00
0.004
0-00
0.00 0.00
o.00
.00
0.00
0.00
0.00
0.00
S0.00
Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 _ 0.00
•
0.00
0.00
0:0o
0.00
0.00
0_00
0.00
_00 S0.00i
% . Amount
0%. 0.00
0%/. .0.00
0% :. 0.00
0°/s 0.00
Ct°4 0.00
0%. ' • -0.0D
0.00
0.00 0.00
0%. 0.00
0%. 0.00
0% . 0.00
0%. 0.00
0"/. 0.00
0.00 0.00
.00 S0,00
FRINGE BENFPITS
Fic arMic a Rate: 7.65%
W-Comp's Rate:.00%.
Unemploy Rate: .00 4
Health Ins. Cost per Staff 300.00
Life Inc. Cost per Staff 0.00
R/..lu .iuci.t Rate: 0.00
Other Specify & provide calculations
O Rate: 0
O Rate: 0
O Rate: 0
O Rate: 0
TOTAL FRINGE BENEFITS
0.00 0.00 - 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00
0.00
0.00
0.00
S0..00
0.00
0.00
0.00
0.00
S0.00
0.00
0.00
0.00
0.00
S0.00
0.00 . 0.00 0.00
0.00 . 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 .0.00 0.00
0.00 0.00 • • 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
S0.00 S0.00 50.00
Enter Agency Name in Footer
12/30/200t.
Page 21 of 2.
The Children's Trust
Grant Application Forms
Budget By Site Locatioi
Areas m Blue to be completed by the agency
NAME OF SITE LOCATION:
Site Location 1
Site Location 2
Site Location 3 Site Location 4
Site Location 5
Total
OPERATING EXPENSES: Annual Cost
Tnr lel (other than clients)
Local, tolls, parking 0.00
Out--of-town 0.00
Travel (clients)
Bus passhokens 0.00
Field trips/Buses/Vans 0.00
Meals (clients)
Snacks (after school) 0.00
Meals (full days) 0.00
Space
Lease/Rent 0.00
Maintenance 0.00
Electricity 0.00
Communications 0.00
Supplies
Office 0.00
Pavgwu Supplies 0.00
Printing/reproduction 0.00
Shipping/Postage 0.00t
Non -Capital Equipment (4750) (List
each)
O 0,00
0 0.00
O 0.00(
Capital Equipment (>S750) (Litt each)
0 0.00\
O 0.00
0 0.001
Professional Services (Lot each)
Other (List each)
O 0.00
O 0.00
✓ 0.00
✓ 0.00
0
.ti
Amount
% Amount
0.00
0.00
0.00
0.00
0.00
Amoum
% Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.0D
Ain01mt
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
- 0.00
o.0o
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.0D
0:00
0.00
°/. Amotmt
50.00
S0.00 S0.00 S0.00 S0.00
$0.00
Administrative/Indirect Costs
(Can not exceed 10%)
TOTAL BUDGET
$0.00
0.00
S0.00
r
50.00
r
0.00
0.00
S0.00 30.00
0.00
Enter Agency Name in Footer
12/30/200t
Page 22 of 2i
The Children's Trust
Grant Application Forms
Daily Unit Cos
Areas in Blue to be completed by the agency.
Overall Program
Unit Cost (per youth) - General Population
Unit Cost (per.youth) - Chiidre ni with disabilities -
Service Name
#of
students
# of drys
Total boars
flak Cost.
Total ,
Semite Name '
it of ..
students .
._
fl of days
Total hoar
Unit Cost
Total
S0.00
Summer Camp
S0.00
Summer After -School-
50.00
Summer After -School
$0.00
Legal Holiday
S0.00
Legal Holidays
50.00
Teacher Planning
: -$0.00
Teacher Planning
$0.00
Thanksgiving/Winter/Spring Break
. g.00
Tbanlcsgivring/Wncer/Sprmg Breaks
$0.00
After School Days
.' so.00
Alter School Days
$0 00
Saturdays
- S0.00
Saturdays
S0.00
Site Location 1
Unit Cost (per youth) - General Population
Service Name
#of
students
# of days
Total hours
Unit Cost
Total
Summer Camp
. $0.00
Sumner After -School
S0.00
Legal Holiday
. $0,00
Teacher Planning
50.00
Thanksgivmg/Wmter/Spnng Bra
$0.00
,50.00
After School Days
Saturdays
S0.00
of
Site Location 2
SO.
Unit Cost (per youth) - General Population .
Service Name
#of
students
* of days
Total boars
. ..
Unit Cost
Total
Summer Camp
:50.00
Summer After -School
. $0,00
Legal Holiday
, ,;S0.00
Teacher Planning
50.00
Thanksgiving/Winter/Spring Breaks
$0.00
After School Days
> S0.00
Saturdays
.,S0.00
bra
Site Location 3
S0.
Unit Cost (per youth) - General Population
Service Name
#of
students
# of days
Total hours
Unit Cost
.. Total:
Sumner Camp_
:::S0.00
Summer After -School
. 50.00
Legal Holiday
- .
.50.00
Teacher Planning
.50.00
Thanksgiving/Winter/Spring Breaks
$0.00
After School Days
50.00
Saturdays
- $0.00
50.
Enter Agency Name in Footer
$0.00
Unit Cost (per. youth) - Children ildren with disabilities
Service Name
#of
students
# of days
Total hour
Unit Cost
.
Total
Summer Camp
. S0.00
Sunnmtr After -School
50.00
Legal Holidays
$0.00
Teacher Planing
50.00
Thanlzcgrving'WmierSpring Breaks
_
$0 00
After School Days
S0.00
Saturdays
$0.00
oral
50.00
50.001 S0.00
Unit Cost (per youth)=Children with disabilities
Service Name `. ,
• #of
students
# of days
Total boars
.
trait Coat
Total
Sumter Camp -
. $0.00
Sumner After -School
S0.00
Legal Holidays
. 50.00
Team Planning
$0.00
TbanksgivinglWinter/Spr'ing Breaks
_
S0.00
After School Days
S0.00
Saturdays
50.00
Total
S0.001 50.00
Areas in Blue to be completed by the agency.
Unit Cost (per youth) - Children with disabilities . -
Service Name
#of
students
# of days
Total hours
Unit Cost
Total
Summer Camp
S0.00
Summer After -School
50.00
Legal Holidays
S0.00
Teacher Planning
50.00
Thaukseving/Winter/Spting Breaks
50.00
After School Days
S0.00
Saturdays
S0.00
Total
S0.00 50.00
12/30/200
Page 23 of 2
The Children's Trust
Grant Application Forms
Acknowledgement of Addendum
instructions: Complete Part I or Part II, whichever is applicable.
PART I: Listed below are the dates of issue for each Addendum received in connection with the
bid solicitation for the current proposal. Note, there may be fewer than 5 addenda; list only
those that were published on The Trust's website.
Addendum #1, Dated:
Addendum #2, Dated:
Addendum #3, Dated:
Addendum #4, Dated:
Addendum #5, Dated:
PART II: Check here if no Addendum was received in connection with the bid solicitation. ❑
Sign below to acknowledge receipt of the Addenda listed above,
or to certify that no Addenda were received.
Authorized Signature:
Print Name:
Title:
Organization Name:
Federal Identification Number:
Street Address:
City: State: Zip Code:
Date:I
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 24 of 24
Attachment F: Provider's Response to the Request
for Proposals
rjj:Document Final Approved contract.12.20.05.sxw