HomeMy WebLinkAboutExhibit 12The Chilctren's Trust Grant Application Forms `ior RFP# 2006-01
NEW Prevention Services for Childr>n Birch to Five
OMNAL
Cover Page
Proposed Project Titic: City of Miami Faniitie:: First - Parent Academy
Proposed Start Date: March 1, 2006 Proposed End Date: July 31, 200'7
A. Agency Information
Agency Name: City of Miami, Office of the Mayor
Federal Identification #: 59-6000375 Licensed to do business in FL?
Street Address: 3500 Pan American Drive
City: Miami State:
Phone Number: 305-250-5323
CEO/Executive Officer:
Chief Financial Officer:
Public Relations Contact:
Application Contact Person:
Contact Person E-mail:
Type of Entity
(mark one)
Joe Arriola
Linda Haskins
Alejandro Miyar
Robert Ruano
Rruano@ci.miami.fl.us
Florida
Fax Number:
X Yes
Zip Code: 33133
305-854-4001
Phone:
Phone:
Phone:
Phone:
Fax:
Private -for -profit Private -not -for -Profit X Governmental
8, Population and Activity Descriptions
Total Number of Unduplicated Participants to be served: 840
Children/youth (birth-18 years): 320
Adults (over 18 years):
305-250-5400
305-416-1009
305-250-5311
305-416-1532
305-416-2151
No
Other (specify)
From age (in years): 0 Up to age (in years): 5
Adult types: 320 ParentslCaregivers • 200 General Public
(note subtotal # for
each type served)
Professionals, specify:
Estimated Numbers to be Served by Age Range (total must equal total number of children/youth listed
above) 320
Infants Early Elementary Children
(prenatal - 2 yrs): 160 (5 - 8 years / grades K - 2):
Late Elementary Children
160 (8 - 11 years / grades 3 - 5):
Preschoolers
(3 - 5 years):
Number of (unpaid) volunteers program will utilize: 8
Of these, how many will be ages 16-24 years?
Middle Schoolers
(11 - 14 years I grades 6 - 8):
High Schoolers
(14 - 18 years I grades 9 - 12):
Expected # of total annual direct
service volunteer hours: 100
Does the proposed program include participant transportation services? .X Yes No
Will any participant fees be charged/collected for the proposed services? Yes X No -
If YES to fees, briefly explain
The Children's Trust Grant Application Forms for RFPfi 2006-01 Document Certification Page
Prevention Services for Children Birth to Five
Agency Name: City of Miami. Office of the Mayor
List any current contract numbe,r(s) with The Trust: Miami's Learning Miai i Youth
Zone 506-193 Council 509-
193
Tr,e following adn-ministrative ano fiscal Documents are req'u!red in order to do business with The Children's Trust
Only the a uditr'financi?al statement must be submitted w;th this application, unless the current version has teen
p{evIously submitted as a current contractor with The Trust if documents on file are valid and time periods
current or this application, items do not need to be resubmitted. just check YES below and enter audit period
Remaining !terns must either be submitted after funding award prior to signing a contract or kept on file at the
Agency and made available for review during contract monitoring: as.noted below
Required with
application
unless up -to- Required : Must be
date documents prior to in place
on file at The signing on file at
Documents Trust contract Agency
Financial audit OR Un-audited financial statement (the tatter is
accepted only for Agencies in business less than 18 months or with
a total budget less than 5300,000)
Check here if previously sucmitted X Yes
If YES, for what audit/fiscal period?, Year ended 9/30104
Administrative Internal Control Questionnaire
X
Documentation. of General Liability Insurance (minimum amount
required is 5500,000f' .
Documentation of Workers' Compensation Insurance (minimum
amount required tis $500,000)' .
Documentation of Automobile Insurance, if applicable (minimum
amount required is $1,000,000 if providing transportation services/"
Evidence of Board Authorization to submit application X
X
Internal Revenue Service (IRS) Tax Determination Letter
Current Corporate Status Certificate/Letter of Good Standing X
from State of Florida .
IRS Tax Form (990 or other appropriate form) for the past 2 years
X
IRS Form 941 and Proof of Payment if Tax Liability Existed X
X
- Directors List
Board of ,
Current Board of Directors' Meeting. Schedule X
X
Americans with Disabilities Act policy X
Non-discrimination policy, including client non-discrimination X
Drug -free Workplace Certification
Equal Employment Opportunity/.Affirmative Action policy XX
Policy on participant fees to be. charged. if applicable
'Note: If current insurance coverage amounts are less than the required minimums noted above. Agency agrees
1o, purchase the minimum amounts prior to contract execution
I do hereby certify that each of the documents listed above will be provided as noted above, as a condition
of aoolvinq for and/or receiving funding from The Children's Trust.
i he Children's Trust Grant Application Forms for RFP# 200.E=01'
NEW Prevention Services for Children Birth to Five •'Document Certification Page
P.DbEr1 f;;r,anc,.DIrc-clor (rn15 AJmir,ir,tralhcn . '• '
Print Name/Title Signature Date
The Children's Trust Grant Application Forms for RFP# 200t;-01 Citficial Certificatier�s Page
NEW Prevention Servic.es for Children Birth to Five
Agency Name: Cit\ of Miami Office rit the f,9aybr
has the Agency been sanctioned for non-compliance with any contract. government law or regulation relaters to the
oi?eralionai program proposed 'Nit. this 35piiCation within tree past three Jars. or has your agency had any vic',ations
under the public enIhty crimes statrite f (check one below)
YES —Include copy in Supper -ling Documents section, in order Indicated in Table of Contents
x NO
Please deseiI17i' In zr separate attachment Its 11(1?;atlnn Or regulator' action tiled aI`'annst the in the last
three \'errs related to the Operatianal oroz:am proposed with :his appricaliOn, 111CIudinLg c;ts.. name, court name,
and current ~idols Include docurnent(s) it' the Supporting Documents section, in order indicated in the 'Fable of
Contents. ]f none has been tiled- acknowledge (his by checking ��elo�•
:X NOT APPLICABLE
I do hereby certify that all faces, 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
o1,.erwise be used for the purposes set forth in this orolect(s) and are a true estimate of the amount needed to operate the
proposed programs)
The filing of this application(s) has been authcrized by the contracting entity and l have been d.ily authorized to act as the
representative of the agency in connection with this applicationls, i also agree to follow ail terms, conditions, and
applicable federal and state statutes Further, I understand that it is the responsibiily cf the agency head to obtain from
its governing body the authorization for the submission of this application Evidence cf this authorization must be
p:ovided 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 ) t further
state that to the best of my Knowledge, submission of this proposal is in compliance with the stale and county conflict of
interest laws
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
List below the dates of Issue of each Addendum received in connection with the bid solicitation for the current proposal, or
acknowledge that none were received Note, there may be fewer than 5 addenda, list only those that were published on
The Trust's official website.
• - - Check all that apply:.. Date of Issue
I No Addendum was received in connection with the bid solicitation 12/15i05
X Addendum #1
Addendum #2
Addendum #3
Addendum #4
Addendum #5
Robert Ruano/Director, Grants Administration
Print Authorized Official's Name/Title
Authorized btficial s Signature in BLUE INK
Date