HomeMy WebLinkAboutExhibit 12 aThe Children's Trust
Grant Application Forms
Cover Page 1
The Trust RFP/ITN Number:
The Trust RFP/ITN Title:
Proposed Project Title:
A. Agency Information
Applicant Agency Legal Name:
Federal Identification Number:
Contact Street Address:
City: State:
Telephone Number: Fax Number:
CEO/Executive Officer:
Chief Financial Officer:
Public Relations Contact:
Application Contact Person:
Contact Person E-mail:
Type of Entity (click one box):❑
10
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/ 0
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
Amount of Coverage Expiration Date
Phone:
Phone:
Phone:
Phone:
Fax:
Zip Code:
Agency does not carry
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 1 of 24
The Children's Trust
Grant Application Forms
Cover Page 2
C. Relationship with The Children's Trust
Has Agency ever held a contract with The Children's Trust?
❑ YES ❑ NO
If YES, List most recent contract number(s) (up to 3):
(
o to Cover Page 3)
If YES, has Agency previously submitted the current version of each of the following documents?*
Financial audit ❑ YES -Period of Audit: I
❑ 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 by Age Range (total should equal total number listed above):
11-13 years
14-18 years
Adult Parents/Caregivers
Birth to 2 years
3-5 years
6-10 years
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
§gafegic Funding Categories (select one, and complete requested information):
X Out -of -School Programs (refer to RFP for definitions of enhancement and expansion)
CHECK ONE: ❑ Summer Only 0 After -school Only ❑ Year -Round Programs
CHECK ALL THAT APPLY: ❑ Program Enhancement ❑ Program Expansion
❑ 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 ❑ SafetyNiolence Prevention
❑ . Children with Disabilities 0 Adolescent Risk Reduction
❑ Other (briefly specify): 1
❑ Service Partnership (describe specific population/neighborhood on Primary Population Worksheet)
CHECK ONE: ❑ Population -based 0 Neighborhood -based
❑ Other (specify RFP/ITN): f
Will any fees be charged/collected for the proposed services
❑ YES -Briefly explain:
❑ NO
I will charge parents In based an income eligibility and other criterias thathave been developed by our borad
of directores.
Does the proposed program include a health component?
0 YES -please identify and fully describe this on the Activities Description Worksheet
❑ NO
Does program include participant transportation?
0 YES -transportation is available to/from all standard services
❑ YES -transportation is provided for special services only (e.g., field trips)
0 NO -transportation is not provided
Number of youth workers (age 16-22) proposed program will utilize:
Number of volunteers proposed program will utilize:
Expected number of volunteer hours to be contributed:
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 3 of 24
The Children's Trust
Grant Application Forms
Certifications Page
Official Certif cations
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 in
he 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.
❑ 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 funds
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
to 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 forthe
submission of this application. Evidence of this authorization must be provided within 21 days of notice
of award. I 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 Jroduct.
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
1 1 It3 41111 U I t711 5 1 I Ub l.
Grant Application Forms
Table of Contents
AADOcATibN FORM$
(submit original plus 6 copies, bound with Supporting Documents) Page #'s
Cover Pages
1-3,
Certifications Page
4
Table of Contents
5-6
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 Continued
(submit original plus 6 copies, bound with Application Form..) Page #'s
Sanctions, Violations, and/or Litigation Documentation, if applicable
Organizational Chart(sI
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 New
(submit a total of 3 separately bound sets) Page #'s
Cover Pages (from Application Forms) -write "FISCAL/POLICY MATERIALS" on top
1-3
Certifications Page
4
Table of Contents
5-6
Financial Audit/Unaudited Financial Statements
Certification Form
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 5 of 24
The Children's Trust
Grant Application Forms
Program Summaries
eneral Formatting Notes:
ow height should automatically expand with text. If that does not occur, select Format-Row-Autofit and/or go to
r _
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
s 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
urgarnzauundi 44}ia14ii11u.y
A. Description (2 pages maximum, not including attachments)
Provide a clear description of the Agency, including its mission, history, and particular qualifications as
related to the current bid solicitation. Include a listing and description of agency accreditations and
licensure relevant to the field, if applicable (Le., accrediting or licensing body, level and period of
accreditation/licensure, etc,),
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 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 TRUST ARE 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 1S REQUIRED WITH THIS APPLICATION.
If explanation is needed, include a narrative description of the organizational charts) 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 Tess 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
1 iue ismiurtm I I UbL
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, 7/1/03-6/30/04, 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 funderl
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
The Children's Trust
Grant Application Forms
Organizational capaanity •
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,
including 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
efforts,worksheets
nd (hots that
since the Budget Justification includes all staff titles, names, salaries, percent
ials,
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
ute the specific duties and response above.ions of each
I Include document(s) professional the Supporting hese should
Documents
be summarized in the narrativep
section, in the order indicated in the Table of Contents.
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 9 of 24
t ne Lnnoren•s t rust
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 Detail:
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
noting 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 Code:
❑ YES LI NO
❑ After -school Only
Phone Number:
Days of Operation:
0 Year -Round Program
Fax Number:
Hours of Operation:
Start Date:
Total Number of Unduplicated From age
Participants to be Served: (in years):
Estimated Numbers to be Served by Population Type (total should equal total number listed above):
Children with Disabilities At -Risk Participants
End Date:
Up to age
(in years):
General Population
bite #2
Site Name:
Site Contact Person:
Contact Person E-mail:
Is this a school -based site?
❑ Summer Only
Total Number of Unduplicated
Participants to be Served:
Estimated Numbers to be Served by Population Type (total should equal total number listed above):
Children with Disabilities At -Risk Participants
Street Address:
City:
Zip Code:
1 Phone Number:
❑ YES Ll NO
❑ After -school Only
Days of Operation:
0 Year -Round Program
Fax Number:
Hours of Operation:
Start Date:
From age
(in years):
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?
❑ Summer Only
Total Number of Unduplicated
Participants to be Served: (in years):
Estimated Numbers to be Served by Population Type (total should equal total number listed above):
Children with Disabilities At -Risk Participants
Street Address:
City:
Zip Code:
❑ YES ❑ No
❑ After -school Only
Fax Number:
Hours of Operation:
Phone Number:
Days of Operation:
❑ Year -Round Program
Start Date:
From age
End Date:
Up to age
(in years):
General Population
Enter Agency Name in Footer
12/30/200
Page 11 of ';
The Children's Trust
Grant Application Forms
Primary Worksheet
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
expected to participate in the :are expected
.program (e.g., children, parents, i,to participate
families, teachers, other
community members)
Enter Agency Name in footer
CHARACTERISTICS of expected
participants, including age, gender,
:race, ethnicity, income level,
`neighborhood, school performance, and
:other risk factors that will be used to
guide recruitment efforts. If serving
:children with disabilities, sepecify types:
RECRUITMENT strategies and iSELECTION CRITERIA are factors
'activities that will be used to inform used to screen participant eligibility
and engage the described participants ;for participation (e.g., attendance at
Into the program is particular school, residence in a
particular neighborhood, income
;below poverty level). if program is
:open to anyone, put "N/A" here_ . .
12/30/200
Page 12 of 2
ne Lnhuaren s i rust
Grant Application Forms
Goals Workshee.
Multiple Site Instructions: If different service delivery sites have varying program goals, outcomes or activities, list each one on a separate line al
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
12/30/200
Page 13 of 2,
The Chiidren's Trust
Grant Application Forms
Outcomes Worksheet
Multiple Site Instructions: If different service delivery sites have varying outcome measures, list 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,
measurable expected changes and
benefits for the people served as a
result of program participation and
should be related to the described
population characteristics and risks
(this column will be automatically
filled with the outcomes listed on the
Goals Worksheet)
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 wilt be collected (e.g., observations
collected to measure how well a by staff, school system data, self -
program is achieving its outcomes report surveys, etc.), managed,
(Attach copies of the proposed stored and analyzed
measures in the Supporting
Documents section, in the order
indicated in Table of Contents)
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, measure
staff, etc.)
:STAFF
:position
:responsible
•for the
:collection of
each indicator
Enter Agency Name in Footer
12/301200`
Page 14 of 2,
The Children's Trust
Grant Application Forms
Activities Descriptions
Multiple Site instructions: If different service delivery :•:ites 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
Enter Agency Name in Footer
NUMBER ACTIVITY DESCRIPTION includes the details for each program activity, including the approach or model being
:expected used (referencing evidence-based/best practices when applicable), how the activity will be provided in an engaging
to receive manner, the materials to be used, how materials will be selected, and how participants will be assessed to ensure
each activities are tailored to the appropriate ability levels. Activities should include all required components stated
activity :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.
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
12130/20Df.
Page 15 of 2‘
The Children's Trust
Grant Application Forms
Process Workshe
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 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
a
0
0
0
0
a
a
0
0
0
0
0
0
0
0
a
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
how often the
activity will be
:delivered (e.g.,
;daily, once a
week, 3 times a
year, etc.)
:PLANNED PLANNED PLANNED OUTPUTS are the direct
:FREQUENCY of INTENSITY of DURATION products and evidence of
how long each includes the total
activity session time frame within
will last (e.g., 15 which
minute check -in, participants will
2 hour class, be involved in
.etc.) the activity
:(e.g.,1-time only,
6 weeks, all
school year)
service delivery and the work
of the program, including the
volume of work accomplished
(Le., # participants,
attendance, # classes offered,
# brochures distributed, etc.)
12/30/20
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 Budget
Areas in Blue to be completed by the Agency
0
0
0
Agency Fiscal Year Begins: 0
Fax: 0
E-mail: 0
Agency Source of Funding
FundiuglGraut Period
Program Budget
Agency Budget
The Children's Trust Requested Grant Amount for Program
0.00
-'. 0.00
Child Development Services Funds
0.00
0.00
Miami Dade County GrantsfLoca!)
Homan Services Coalition
0.00
0.00
0.00
0.00
0.00
0.00
Federal Grants (SpecV 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
Foundation/Charitable Funds (Specify Source) - -
0.00
0.00
0.00
0.00
0.00
0.40
0.00
0.00
Cash/Fees/Other Revenue (Specify Source)
0.00
0.00
0.00
- - 0.00
0.00
0.00
Iln-Kind Contributions
- 0.00
0.00
0.00
0.00
0.00
0.00
TOTAL BUDGET
S0.00
S0.00
BUDGET SUMMARY FOR PROPOSED PROJECT/PROGRAM
CATEGORY
REQUESTED AMOUNT
DESCRIPTION
Personnel
0.00
Salaries
Fringe Benefits
0.00
Fringes
Operating
0.00
All Other Costs
Indirect/Administrative Costs
0.00 .
TOTAL REQUESTED
50.00�- -.
Enter Agency Name in Footer
12/30/200!
Page 17 of 24
The Children's Trust
Grant Application Forms
Budget Summary for Proposed Program
Period:
0 mot:ths
L nndm
Areas in Blue to be completed by the Agency
Other Funding Requested or Received
Matching Funds 1 1
Total
NAME OF FUNDING SOURCE:
Chtidre'sTrust
SALARIES:
List Fun -Time Employees
Position Name Annual_Salary
%
Amount
°
Amount
%
Amount
%
Amount
%
Amount
%
Amount
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%
-.'.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%
0.00
0.00
. 0.00
0.00
0.00
0.00
0%
, 0.0o
0.00
0.00
0.00
0.0d
0.00
0°
0.00
Full Time Total ODD
0 00
0 00
0 00
0 00
0.00
0.00
0.00
0.00
0.00 :
0.00
0.00
0.00
List Past -Time Employees
. 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%
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%
0.00
Part -Time Total 0.00
0.00. -
0 00
0.00. .
0.00
0 00
0.00
0.00 ._
•. 0.00
. , o_oo -
. 0.00
0.00
.o.00
TOTAL FTEsISALARIES
.00
S0.00
.00
S0.00
.00
S0.00
.00
50.00
.00
S0.00
.00
50.00
FRINGE BENEFITS
FicafMica Rate: 7.65%
0.00
. 0.00
0.00
. 0.00
0.00
0.00
W-Comps Rau: -
0.00
0.00
0.00
,
0.00
0.00
0.001
Hnernploy Rale:
0.00
. . 0.00
0.00
0.00
0.00
0.00
Health Ins. Cost per Stab'
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
Retirement Rate:
0.00
0-00
0.00
0.00
0.00
0.00
Other Specify & provide calculations Rate:
0.00
0.00
. 0.00
. 0.00
0.00
0.00
Rate:
0.00
0.00
0.00
0.00
0.00
0.00
Rate:
0.00
0.00
0.00
0.00
0.00
0.00
Rate:
0.00
0.00
0.00
0,00
0.00
0.00
TOTAL FRINGE BENEFITS
S0.00
S0.00
S0.00
S0.00
50.00
50.00
Enter Agency Narne in Footer
121301200E
Page 18 of 2,
The Children's Trust
Grant Application Forms
Budget Summary for Proposed Program
Areas in Blue to be competed by the Agency
Regnrve Funding
Other Funding Requested or Received
Matching Funds
Total
'NAME OF FUNDING SOURCE:
Cbildren's Trust
°%. Amount
°%
Amount
°%
- Amount
s %.
Amount
%
Amount
%
Amount
OPERATING EXPENSES: Annual Cost
Travel (other than clients)
.
Local mileage, tolls. parking
0.00
- .00
0.00
_
0.00
0.00
0%
0.00
Out-of-town
.0.00
.00
. 0.00
0.00
0.00
0%
0.00
Travel (clients)
Bus pass/tokens
0.00
0.00
0.00
0.00
0.00
0%
0.00
Fieidirips/Buses/Vans
000
0.00
0.00
0.0q
0.00
0%
0.00
Meals (clients)
Snacks (Mier school)
0.00
0.00
0.00
0.00
0.00
0%
0.00
Meals (full days)
0.00
0.00
. 0.00
0.00
0.00
. 0°%
0.00
Space
Lease/Rent
0.00
0.00
0.00
0.00
0.00
0%
0.00
Maintenance
0.00
.0.00
0.00
,0.00
0.00
0°%
0.00
Electricity
0.00
::;- 0.00
0.00
0.00
.- 0.00
0%
0.00
Communications
_
0.00
0.00
.0.00
0.00
0.00
0%
0.00
Supplies
Office Supplies
0.00
0,00
0.00
0.00
• .0.00
0%
0.00
Program Supplies
0.00
. -0.00
_. 0.00
0.00
. 0.00
0%
0.00
Printing/reproduction
0.00
0.00
0.00
0.00
0.00
0%.
0.00
Shipping!Postage
. 0,00
-0.00
0.00
0.00
000
096
0.00
Noe -Capital Equipment (<5750) (List
each)
_
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%
0.00
Capital Equipment (>5750) (List
midi)
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%
0.00
Professional Services (List each)
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°%
o.00
Other (List each)
. 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
TOTAL OPERATING EXPENSES: S0.00
S0.00
S0.00
S0.00
S0.00
S0.00
Administrativrllndirett Costs
Can not exceed 10%)
0.00
0.00
0.00
0.00
0.00
TOTAL BUDGET S0.00
■r
50-00
S0.00
S0.00
S0.00
$0.00
Enter Agency Name in Footer
12/30/200!
Page 19 of 2-
I 11IU L111IUr C11 , 1 I U5L
Grant Application Forms
Budget Justificatior
..y...120.. to •4/..a0..
SALARIES:
Position
List Fall -Time Employees
Name
Amount
Areas in Blue to be completed by the Agency
Detailed Jnstifiestion for Each Line It®
Credentials -describe staff t cation
o
0
0
0%
o
0
0
0%
0
0
0
0%
o
0
0.
0%
0
0
0
0%
0
0
0
0%
0
D
0
0%
EMI -Time Total
0.00
0.00
• :
List Pirt-Time Employees -.
..
•
0
0
0
0%
0
0
0
0%
0
0
0
0%
0
0
0
0%
0
0
0
0%
.:
Part -Time Total
0.00
0.00
TOTAL
S0.00
0.00
TOTAL FRINGE BENEFITS
S0.00
OPERATINGEXPENSES
Travel (other than clients)
Local mileage, tolls. parking
- 0,00
Out-of-tomn
0.00
Travel (clients)
Bus pan/tokens
0.00
.. .
FieEd 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 Supplies -
0.00
Program.�Supplies
0.00
PnnttngFreproduction
0.00
ShtppmpfPoslage
0-00
Non -Capital Equipment (< 750) (List each)
-
-
... ... ...
i
0
0.00
0
0.00
0
0.00
Capital Equipment (>S750) (List each)
I
0
0.00
0
0.00
0
0.00
Professional Services (List each)
- -
- f
0
0,00
0
0.00
0
0.00
Other (list each)
i
0
0.00-
0
0.00
TOTAL OPERATING EXPENSES:
S0.00
Administrative/Indirect Costs
(Can not exceed 10%) 1
0.00
TOTAL BUDGET
S0.00 -
l
Enter Agency Name in Footer
12/30/200!
Page 20 of 2.
The Chiidren's Trust
Grant Application Forms
Budget By Site Location
../.../20.. to s.1../20:.
0 montas
Site Location 1
Site Location 2
Site Location 3
Areas in Blue to be completed by the Agency
Site ltration 4
Site Location S
Total
NAME OF SITE LOCATION:
SALARIES:
List Full -Tune Employees
Position Name Annual Salary
O 0 0
0 0 0
0 0 0
0 0 0
O 0 0
0 0 0
0 0
Full -Time Total
List Part -Time Employees
0
0
0
0
0
Part -Time Total
FRINGE BENEFITS
0.00
O 0
O 0
0
O 0
O 0
0.00
TOTAL FTEs&SALARIE.S
FicafMica Rate: 7.65%
W-Comp's Rate: .00%
Unemploy Rate:.00%
Health Ins. Cost per Staff 300.00
Life Inc. Cost per Staff 0.00
Retirement Rate: 0,00
Other Specify & provide calculations
°l. Amount
0.00
0.00
000
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
.00
50.00
0.00
0.00
0.00
0.00
0.00
0.00
% Amount
.00
50.00
0.00
0.00
0.00
0.00
O Rate: 0 0.00 0.00
O Rate: 0 0.00 0.00
O Rate: 0 0.00 0.00
O Rate: 0 0.00 '- 0.00
TOTAL FRINGE BENEFITS 50.00 50.00
% Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
a.t00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
_oo 50.00
Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
.00
50.00
•/. - Amount
0.00
0.00
0.00
000
0.00
0.00
0.00
0.00 0.00
0.00
0.00
0.00
0.000
o.00,
0.00 . - 0.00
.00 50.004
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
50.00
0.00
0.00
0.00
0.00
50.00
0.00
o.00
0.00
0.00
50.00
Amount
0•/. ;.0.00
0% 0.00
0% 0.00
0°/. 0.00
0% 0.00
0°i 0.00
0% 0.00
0.00 0.00
0% 0.00
0°4 - 0.00
0%. . 0.00
0% . 0.00
0•4. .0.o0
o.00 . . o_oo
_on 5000
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
50.00-
Enter Agency Name in Footer
12/30/200:
Page 21 of 2
The Children's Trust
Grant Application Forms
Budget By Site Location
Areas in Slue 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
Amount
OPERATING EXPENSES: Annual Cost
Travel (other than clients)
Local, tolls, parlrm& 0.00
Out-of-town 0-00
Travel (clients)
Bus pass/tokens 0.00
field trips/Buses/Vans 0.00
Me■b (clients)
Snacks (after school) 0.00
Meals (full days) 0.00
Space
Lease/Rent 0.00
Maurtenance O.Oq
Electricity 0-00
Communications 0.00
Supplies
Office 0.00
Program Supplies 0.00
Printing/reproduction 0.00
Shipping/Postage 0.0D
Non -Capital Equipment (<S750) (List
each)
0 0.00
D 0.00
0 0.00,
Capital Equipment (>$750) (List each)
0 0.00
0 0.00
0 0.00
Professional Services (List each)
0
0
a
Other (List each)
0
0
0.00
0.00
0.00
0.00
50.00
Administrativerindk et Cots
Can not exceed 10Y
Enter Agency Name in Footer
Amount
$0.00
Amount
0.00
0.00
Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
°A° Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.0D
0.00
0.00
- 0.40
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%s 0.00
0%a 0.00
0% 0.00
0.00
0%
$0.00
S0.00
$0.00
$0.00
0.00
12/30/200
Page 22 of 2
The Children's Trust
Grant Application Forms
Daily Unit Cost
Overall Program
Unit Cost (per youth) --General Population
Service Name
# of
students
# of days
Total hoots
-Unit Cost.
. Total
Summer Camp
$0.00
Summer After -School
Legal Holiday
$0.00I
Teacher Planning
_$0.00
Thanksgiving/Winter/Spring Breaks
$0.00
After School Days
S0.00
Saturdays
: S0.00
Total
Site Location X
50.
Unit Cost (per youth) - General Population
Service Name
#of
students
1 of days
Total boon
. Unit Cost
: Total ::'
Sunnier Camp
. 50.00
Summer After -School
' 50.00
Legal Holiday
50.00
reacher Maiming
SO-00
Thanksgiving/Winter/Spring Breaks
- 313.00
After School Days
. 50.00
Saturdays
S0.00
Total
Site Location 2
Unit Cost (per youth) - General Population
Service Name
# of
students
# of days
Tout hours
^ .Uoit Cost
Total
Summer Camp
.. - 50.00
Sumner After -School
.. - S0.00
Legal Holiday
: $0.00
Teacher Planning
S0.00
Thanksgiving/Winter/Spring Breaks
$0.00
After School Days
= S0.00
Saturdays
50.00
Torn,
Site Location 3
SO.
Unit Cost (per youth) - General Population .
Service Name
#of
students
.
# of Jaya
Total hoots; Unit Chat .
Total
Summer Camp
$0.00
Summer After -School
ij
. S000
Legal Holiday
$0.00
Teacher Planning
-S0.00
`fhardsgivi nglWinter/Spring Breaks
$0.00
Aber School Days
50.00
Saturdays
$0.00
Total
Enter Agency Name in Footer
so.
Areas m Bluc to be tompIeled by the agency.
Unit Cost (per youth) - Children with disabilities
Service Name
#of
stndeats
# of days
Total hours
Unit Cost
Total
Summer Camp
. S0.00
Summer After -School
50.00
Legal Holidays
50.00
Teacher Planning
$0.00
Thanksgiving/Winter/Spring Breaks
50.00
After School Days
$0.00
Saturdays
S0.00
Total
S0.00
Unit Cost (per.youth) -- Children with disabilities
Service Name- - -
of
- student!
# of days
Total bolus
Unit Cost
. - Total .
Summer Camp
. 50.00
Sumner After -School
50.00
Legal Holidays
50.00
Teacher Planning
$0.00
Thanksgiving/Winter/Spring Breaks
S0.00
After School Days
50.00
Saturdays
50.00
Total
Unit Cost((per youth) = Children with disabilities
.
Service Name'
#of
stodenla
# of days
.
Total hoofs
Unit Cost
Total
Summer Camp
50.00
Simmer After -School
50.00
Legal Holidays
. $•00
Teacher Maiming
S0.00
thanksgiving/Winter/Spring Breaks
S0.00
After School Days
SO.00
Saturdays
S0.00
Total
$0.00
50.00
.00 S0.00
Areas in Blue to be completed by the agency.
Unit Cost (per youth) Children.with disabilities
Service Name
if of
students
# of days
Total hours
Unit Cost
Total
Summer Camp
SO 00
Summer After -School
50.00
Legal Holidays
50.00
Teacher Planning
S0.00
Thanksgiving/Winter/Spring Breaks
S0.00
.After School Days
$0.00
Saturdays
50.00
Total
SO-00
12/30/200
Page 23 of 2
The Children's Trust
Grant Application Forms
Acknowledgement of Addendum
instructions: Complete Part I or Part 11, 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 11: 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