HomeMy WebLinkAboutExhibit 12a11112 %,1111UI II ti 1 IU,t
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):❑
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
1.11
11)
Amount of Coverage Expiration Date
Phone:
Phone:
Phone:
Phone:
Fax:
Zip Code:
Agency does not carry
0
0
"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
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 1 of 24
Grant Application Forms
l•over rage c
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 113 YES
0 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
Grant Application Forms
Cover Page 3
D. Proposed Number to be Served
Total Number of Unduplicated
Participants lo be Served:
From age
(in years):
Up to age
(in years):
Estimated Numbers to be Served b A e Range (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 Ty a (total should equal total number listed above):
Children with Disabilities
At -Risk Participants
General Population
E. Service Delivery Categories and Descriptions
$ ategic Funding Categories (select one, and complete requested information):
' Out -of -School Programs (refer to RFP for definitions of enhancement and expansion)
CHECK ONE: 0 Summer Only ❑ After -school Only ❑ Year -Round Programs
CHECK ALL THAT APPLY: 0 Program Enhancement 0 Program Expansion
❑ Promotion & Prevention (refer to RFP for definitions of approaches)
CHECK ALL THAT APPLY: 0 Universal El Selected 0 Outreach/Advocacy
❑ Resource Network (CHECK ONE program focus area below)
0 Maternal/Infant/Child Health & Development 0 SafetyNiolence Prevention
0 . Children with Disabilities 0 Adolescent Risk Reduction
❑ Other (briefly specify):
❑ Service Partnership (describe specific population/neighborhood on Primary Population Worksheet)
CHECK ONE: ❑ Population -based ❑ Neighborhood -based
0 Other (specify RFP/ITN): I
Will any fees be charged/collected for the proposed services?
YES -Briefly explain: N O 1 wifl charge parents in based on income eligibility and othercriterias 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?
❑ YES -transportation is available to/from all standard services
0 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:
Expected number of volunteer hours to be contributed:
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 3 of 24
IIV Vi111MIV.. V .I MVL
Grant Application Forms
Program Summaries
>MenerafFormatting- 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
1 1113 101111414 G11 V 1111.0I
Grant Application Forms
Organizational Capability
A. Agency 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 (i.e., 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 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
jrogrammatic 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 !S 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 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
aelow:
Enter Applicant Agency Name in Footer Section
12/30/2005
Page 7 of 24
. 1.•..... .......�
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, 10/1104-9130/07, 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
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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,
including responsibilities for specific activities and deliverables (Le., 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 to the professional team. These should
be summarized in the narrative response above. Include docurnent(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
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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
broposed 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
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Grant Application Forms
Primary Workshee
Multiple Site Instructions: If different service delivery sites serve different primary populations, fist each participant group on a separate fine 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
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 :neighborhood, school performance, and :into the program 'a particular school, residence in a
community members) ;other risk factors that will be used to ;particular neighborhood, income
guide recruitment efforts. If serving below poverty level). If program is
-.'children with disabilities,. specify_types
.. ..... .:.'open to.anyone, put "N/A" hare,
EnterAgency Name in footer
12/30/200.
Page 12 of 2.
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:
locations, specify within each section this variation by
specific sites throughout the worksheet narratives.
If any information within the remaining sections of the Application Forms varies across site
noting the applicable sites. If all details are identical across sites, there is no need to reference
'Site #1
Site Name:
Site Contact Person:
Contact Person E-mail:
Is this a school -based site?
• Summer Only
Street Address:
City:
Zip Code:
' Phone Number:
• Fax Number:
Hours of Operation:
LI YES Li
0 After -school
NO Days of Operation:
Only • Year -Round Program
_
Start Date:
From age
(in years):
above):
End Date:
Up to age
(in years):
Population
Total Number of Unduplicated
Participants to be Served:
rstimated Numbers to be Served
Children with Disabilities'
(total should equal total number listed
At -Risk Participants
by Population Type
General
'Site #2
Site Name:
Site Contact Person:
Contact Person E-mail:
Is this a school -based site?
• Summer Only
-
Street Address:
City:
Zip Code:I
• 1 Phone Number:
Fax Number:
Hours of Operation:
Li YES Li
❑ After -school
NO Days of Operation:
Only ❑ Year -Round Program
(total should equal total number listed
1 At -Risk Participants
Start Date:
From age
(in years):
above):
End Date:
Up to age
(in years):
Population
Total Number of Unduplicated
Participants to be Served:
stimated Numbers to be Served
Children with Disabilities'
by Population Type
General
iS ite #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:
stimated Numbers to be Served
Children with Disabilities
Street Address:
City:
Zip Coder
I Phone Number:
Fax Number:
Hours of Operation:
■ YES ❑
NO Days of Operation:
Only ❑ Year -Round Program
(total should equal total number listed
At -Risk Participants
0 After -school
Start Date:
From age
{in years}:,
above}:
End Date:
Up to age
(in years):
Population
by Population Type
General
-
Enter Agency Name in Footer
12/30/20(
Page 11 of :
Grant Application Forms
Goals Worksh
Multiple Site Instructions: If different service delivery sites have varying
sites to which each applies. If all sites follow the same goals, outcomes and activiiti sl, thereomes is no need toorrt riesefe, list each one on a searate line rence specific sites on th s h works r
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
12/30/20
Page 13 of
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Grant Application Forms
Outcomes WorkshE
Multiple Site Instructions: If different service delivery sites have varying outcome measures, list each one on a separate fine 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, INDICATOR MEASUREMENTS are
measurable expected changes and the tools, tests and measures that will
benefits for the people served as a be used to specify the evidence to be
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
DATA SOURCES & METHODS
indicate where and how information
will be collected (e.g., observations
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
STAFF
position
responsible
for the
collection of
each indicator
measure (e.g., parent, child, teacher, measure
staff, etc.)
12/30/20
Page 14 of
e IIG 4uIuHsecee b I J A t
Grant Application Forms
Activities Descriptior
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 :NUMBER ACTIVITY DESCRIPTION includes the details for each program activity, including the approach or model being
actually do for, to or with participants (e.g., expected used (referencing evidence-based/best practices when applicable), how the activity will be provided in an engaging
providing events, interventions, etc.) to °to receive manner, the materials to be used, how materials will be selected, and how participants will be assessed to ensure
achieve each outcome for program each activities are tailored to the appropriate ability levels. Activities should include all required components stated
participants (this column will be automatically .activity within the bid solicitation.
filled with the activities listed on the Goals Rows will expand with text to allow sufficient space to describe all activities.
Worksheet) ATTACH a Schedule of Daily Activities (and Field Trips if applicable) that details when activities will be conducted.
Include document(s) in the Supporting Documents section, in order indicated by Table of Contents.
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
12/30/200
Page 15 of
The Children's Trust
Grant Application Forms
Process Workshc
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
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
(i.e_, # participants,
attendance, # classes offered,
# brochures distributed, etc.)
12/30/2C
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 Budgl
Areas in Blue to be completed by the Agency
0
0
0
Agency Fiscal Ycar Begins: 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
Miami -Dade County Grants(Local)
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 (Spec' Source)
. .
0.00
0.00
Dept of Education
0.00
0-00
Foundations/Charitable Funds (Speeq5., Source)
0_00
0-00
0.00
0.00
0.00
0.00
0.00
0.00
Cash/Fees/Other Revenue (Spec0.. Source) .
0.00
0.00
0.00
0.00
0-00
0.00
In -Kind Contributions
o.OD
.
0.00
0.00
0.0ti
0.00
0.00
TOTAL BUDGET
S0.00
SOAO
C) BUDGET SUMMARY FOR PROPOSED PROJECT/PROGRAM
CATEGORY
REQUESTED AMOUNT
DESCRIPTION
Personnel
0A0
Salaries
Fringe Benefits
0-00
Fringes .
Operating
0-00,All
Other Costs
Indirect/Administrative Costs
0.00
TOTAL REQUESTED
S0.00
. ,
Enter Agency Name in Footer
12/30/20
Page 17 of
The Children's Trust
Grant Application Forms
Budget Summary for Proposed Progra
Period:
s/***/20's to ../..R0r.
NAME OF FUNDING SOURCE:
0 months
Areas in Blue to be completed by the Agency
Requested Funding Other Funding Requested or Received -
Childress Trust
Matching Funds
Total
SALARIES:
List Full -Time Employees
Position Name
Annual Salary
Full -Time Total 0.00
Last Part -Time Employees
Part -Time Total 0.00
TOTAL FTEsiSAL.ARIES
FRINGE BENEFITS
Fica/Mica Rate: 7.65%
W-Comp's Rate:
Unemploy Rate:
Health Ins. Cost per Staff
Life Inc. Cost per Staff
Retirement Rate:
Other Specify do provide calculations
Rate:
Efate:
Rate:
Rate:
TOTAL FRINGE BENEFITS
0.00
Amount
0.00
0.00
0.00
o.00
0.00
0.00
0.00
0.00
0.00
0.0ft
0.00
0.00
0.00
0_00, 0:00
.o0 50.00
Amount % Amount
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. 0.00 0.00 0.00
.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.o0 0.00 0.00
0.00 - 0.00 0.00 0.00 0.00
50.00 .00 50.00 _00 50.00
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 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
50.00 50.00 50.00 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
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
50.00
Amount
0% 0.00
0% 0.00
0% 0.00
0% 0.00
0'/. 0.00
0.00 .0.00
.00 50.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
S0.00
Enter Agency Name in Footer
12/30/20(
Page 18 of
The Children's Trust
Grant Application Forms
Budget Summary for Proposed Prograi
Areas in Blue to be completed by the A
Requested Fundm
Totai
NAME OF FUNDING SOURCE:
Children's Trust-
- - --
_ ------a---,
____`-__
.-._-.....6....w
%
Amount
%
Amount
%
Amount
%
Amount
%
Arnotmt
%
Amount
OPERATING EXPENSES: Annual Cost
-
Travel (other than clients')
Local mileage, tolls, parking
0.00
:00
0.00
0.00
0.00
0'/s
0.00
Out-of-town -
- 0.00
- - - . ' .00
. 0.00
0.00
- 0.00
0%
0.004
Travel (clients)
-
Bus pus/tokens
0.00
'0.00
0.00
0.00
0.00
0!
0.00
Field trips/Bu_sesNans
. 0.00
0.00
0.00
0.00
0.00
0%
0.00
Meals (clients)
Snacks (after 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
Spy
Lease/Rent
0.00
0.00
0.00
0.00
O.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
Slnppmg/Postage
0.00
--0.00
0.00
0,00
0.00
0%
0.00
Non -Capital Equipment (.3750) (List
each)
0.00
: 0.00
0.00
- 0.00
0.00
0%
0.00
0.0D
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 (>S750) (List
each)
0.00
- 0.00
0.00
0.00
0.00
0%
0.00
0.00
. U.00
0.00
. 0.00
0.00
0%
0.0D
0.00
0.00
-
- 0.00
-
0.00
0.00
.0%
0.00
Professional Services (Lint acb)
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
01
0.00
Other (Lint each)
0.00
-
' 0.00
-
0.00
0.00
0.00
0%
0.00
0.00'
000
: 0.00
0,00
0.00
0% :_
0.00
_
TOTAL OPERATING EXPENSES:
- S0.00
S0.00
S0.00
S0.00
S0.00
50.00
Administrative/Indirect Costs
iCan not exceed 10%)
0.00
0.00
-
0.00
0.00
-
0.00
TOTAL BUDGET
S0.00
S0.00
S0.00
S0.00
S0.00
SO.1
Enter Agency Name in Footer
12/30/201
Page 19 of
The Children's 1 rust
Grant Application Forms
Budget Justificatic
..r...n0.. to ,y..no..
SALARIES:
Position
List Pall -Time Employees
Amount
Areas in Blue to be completed by the Agency
Credentials -describe staff education
0
0
0
0%
o
0
0
0%
o
0
0
0%
o
0 -
0
0%.
0
0
0
0%
0
0
0
0%
0
0
0
0%
Full-limeTotal
0.00, 0.00
. .
Lest Part -Time Employes -
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
.
OPERATING EXPENSES
Travel (other than dimes)
Local mileage, tolls: parking
0-00
Out -of -tow
0-00
Travel (demts)
&a pass/rolcens
0.00
Field trips/Buses/Vans
0.00
Meals (dimes) •
Snacks (after school)
0.00
Meals (Full days)
0.00
Space
Lease/Rent
0.00
Maintenance
0 or
Electricity
0.00
Coaauarications
0.00
Supplies
k
Office Supplies
0.00
Program Supplies
0.00
Printingjreprodu tian -
0.00-
Shipping/Postage
0.00
Non -Capital Equipment 0750) (List each)
0
0.00
0
0.00
0
0.00
Capital Equipment (>5750) (Lest eadt
0
0.00
0
0.00
0
0.00
Profinsimud Services (List ach)
0
0.00
0
0.00
0
0.00
Other (List each)
0
0.00
0
0.00
TOTAL OPERATING EXPENSES:
S0.00
Administrative/Indirect Coats
(Can not exceed 1.0%) F
0.00
TOTAL BUDGET S0.00 l
Enter Agency Name in Footer
12/30120(
Page 20 of
Grant Application Forms
Budget By Site Locatic
°r/° °,rz0s° to ' */° °/20`° 0 months
Site Location
NAME OF SITE LOCATION:
Site Location 2
Site Location 3
Areas in Blue to be completed by the Agency
Site Location 4
Site Location 5
Total
SALAFJ S:
List Full -Tune Employees
Position Name Annual Salary
O 0 0
O 0 0
O 0 0
O 0 0
O 0 0
O 0 0
O 0 0
Full -Time Total
List Part -Time Employees ..
0.00
O a
O 0 0
0 0 0
0 0 0
O D 0
Part -Tame Total . , ' 0.00
TOTAL FTEs/SALARIES
FRINGE BENEFITS
Flea/Mica 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
Amount
0.00
0.00
0.00
0.00,
0.00
0.00
0:00
0.00 - 0.00
.00
0.00
0.00
0.00
0.00
0.00
0.00
So_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
X Amount
.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
0.00
0.00
0.00
0.00 0.00
00 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
"h Amount
.00
50.00
Amount
0% 0.00
0% 0.00
0% • 0.00
0% 0.00
0% 0.00
0% .0.00
0Y 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 50 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 Rate: 0 0.00 0.00 0.00 0.00 0.00 . 0.00
0 Rate: 0 0.00 0.00 0.00 .0.00 0.00 0.00
O Rate: 0 0.00 - 0.00 . 0.00 0.00 0.00 0.00
0 Rate: 0 0.00 0.00 0.00 0.00 0.00 0.00
TOTAL FRINGE BENEFITS S0.00 50.00 50.00 50.00 50.00 50.00
Enter Agency Name in Footer
12/30/200
Page 21 of 2
E ne c:n1idren-s i rust
Grant Application Forms
Budget By Site Locatit
Areas in Blue to be completed by the agency.
NAME OF SITE LOCATION:
OPERATING EXPENSES Annual Cost
Travel (other than clients)
Local, tolls, parking 0.00
Out-of-town 0.00
Travel (clients)
Bus pass/tokens 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 Q.00
Supplies
Office 0.00
Prograrn Supplies 0.00
Printing/reproduction 0.00
Sbipping/Postage 0.00
Non -Capital Equipment (<5750) (List
each)
O 0.00
O 0.00
O 0.00
Capital Equipment (>5750) (List each)
0 0.00
0 0.00
0 0.00
Professional Services (List each)
Other (List each)
Admitwtrative/Indirect Costs
Can not exceed 10%)
O 0.00
O 0.00
0 0.00
O 0.00
0
TOTAL BUDGET
Site Location I
Amount
S0.00
30.00
Site Location 2
%. Amount
0.00
0.00
50.00
0.00
Site Location 3
Amount
$0,00
50.00 S0.00
Site Location 4
% Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Site Location 5
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
0.60
0.00
0.00
0.00
- 0.00
0.00
0.00
0.00
0.00
0.00
•0.00
S0.00 50.00
0.00
0.00
S0.00 S0.00
Total
%
Amount
0% 0.00
0°/ 0.00
0% 0.00
0% 0.00
0%. 0.00
0% . 0.00
0% . 0.00
0%r 0.00
0% 0.00
0% -•'. - 0.00j
0% 0.00
0% 0.00
0% 0.00
0°A '' 0.00
0% . 0.00
0%` 0.00
0% 0.00
0% - 0.00
0% 0.00
0% 0.00
0% 0.00
0% 0.00
0%. ' -0.00
04.4
0%
0.00
0.00
S0.00
0.00
Enter Agency Name in Footer
12/30/20i
Page 22 of
Iuu t..rinureii s 1 rust
Grant Application Forms
Daily Unit Cot
Overall Program
Unit Cost (per youth) - General Population
# of
students
# of days
Total hours
Unit Cost
- Total
Service Name
Summer Camp
-:- $0.00
Stemmer After -School
50.00
Legal Holiday
$0.00
Teacher Planning
„
50:04
Thanksgiving/Winter/Spring Breaks
- 50"00
After School Days
0.D0
Saturdays
$
$0.00
s0.
Site Location 1
Unit Cost (per youth) - General Population
Service Name
# of
students
if of days
Total hours
Unit Cast
Total
Sumner Camp
50:00
Summer After -School
SO.OD
Legal Holiday
S0.00
Teacher Planning
50.00
Thanksgiving/Winter/Spring Breaks
S0.00
After School Days
50.00
Saturdays
Site Location 2
Unit Cost (per youth) - General Population
Service Name
Sumner Camp
Summer After -School
Legal Holiday
Teacher Planning
Thanksgiving/Winter/Spring Breaks
After School Days
Saturdays
# of
students
#ofdays
Total hours
Unit Cost
Total
: 0.00
50.00
$0.00
S0.00
$9.00
50.00
Site Location 3
Total
50.00
Areas in Blue to be completed by the agency.
Unit Cost (peer youth)--. Children with disabilities -
Service Name
students
# or days
Total hove
Unit Cost
Total
Summer Cupp
50.00
Summer After -School
SO 00
Legal Holidays
$0.00
Teacher Planning
50.00
Thanksgiving/Winter/Spring Breaks
50.00
After School Days
00
Saturdays
50 00
S0.00
S0.00
Unit Cost. (per. youth)- Children With disabilities
Service Name
:#.of
students
# of days
Total hours
Unit Cost
.. Total
.Summer Camp
$0.00
Summer After -School
50.00
Legal Holidays
50.00
Teacher Pluming
a0.00
ThanksgromeWuatenSprmg Breaks
50.00
After School Days
S0_00
Saturdays
$0.00
Unit Cost (per youth) -- Children with disabilities
Service Name'
Sum Camp
Sumner After -School
Legal Holidays
# of
students
# of days
50.
Total bouts
Unit Cost
Total
$0.00
50.00
Teacher Planning
. $0-00
Thanksgiving/Winter/Spring Breaks
After School Days
Saturdays
Unit Cost (per youth) - General Population
Service Name
#of
students
# of days
Total hours
Unit Cost
Total.
Summer Camp
$0.00
Summer After -School
KW
Legal Holiday
50.00
Teacher Plarming
50.00
Thanksgiving/Winter/Spring Breaks
50.00
After School Days
50.00
Saturdays
50.00
50.00
Enter Agency Name in Footer
Total
50.00
S0.00
$0 00
50.00
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
Sununu Camp
$0.00
Summer After -School
50.00
Legal Holidays
50.00
Teacher Planning
$0.00
Thanksgiving/Winter/Spring Bra
50.00
After School Days
S0.00
Saturdays
S0.00
0
S0.00
S0.00
50.00
50.001 S0.00.
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 tb 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