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DeKalb County, Georgia
Burrell Ellis, CEO
BOARD OF COMMISSIONERS
Elaine Boyer, District (1); Jeff Rader, District (2); Larry Johnson, District (3);
Sharon Barnes Sutton, District (4); Lee May, District (5);
Kathie Gannon, Super District (6); Stan Watson, Super District (7)
2012 Human Services Grant
(DeKalb County General Fund)
APPLICATION
DUE DATE
July 29, 2011
5:00 P.M.
Absolutely No Applications Will Be Accepted After The Deadline
DeKalb County Human Development Department
Dale Phillips, Director
2538 Panola Poad, Lithonia, GA 30058
Main: (770) 322-2900
www.dekalbcountyga.gov
Page ii
2012 DeKalb County
HUMAN SERVICES GRANT APPLICATION
TABLE OF CONTENTS
ATTENTION! Before completing this Application, please read the 2012 Human Services Grant
Application Guidelines carefully. For copies of this Application, Guidelines and other grant
documents go to the DeKalb County Human Development website,
http://www.dekalbcountyga.gov/humanserv/hs-grants-apps.html.
Page
Minimum Threshold Review Sheet…………………………………………………………. iii
Attachment Checklists……..……………………..…...….……………......................... iv
I. General Information……..……………………..…...….……………............................. 1
II. Locations of Current Operations and Current and Proposed Staffing……… 4
III. Proposed Program Information………………………………………………………………. 5
IV. Proposed Program Budget……………………………………………………………………… 9
V. Financial Information For Total Agency...…………….....……………………………… 10
VI. Proposed DeKalb County Contract…………………………………………………………. 12
VII. Certification……...…………………………..…….....………..…....…………………………… 12
Supplemental Documents
1) 2012 DeKalb County Human Services Grant Guidelines
2) Sample DeKalb County Contract (HD Standard Form Number 5 - Revised 12/1/10)
APPLICATION COVER PAGE
DeKalb County
Page iii
2012 Human Services Grant Application
MINIMUM THRESHOLD REQUIREMENT REVIEW SHEET
Agency Name
Program(s) Name
Please use this page as the top sheet or first page when submitting this application. All applications
must be complete. Applications failing to meet all of the minimum threshold requirements stated below in
Areas I, II, and III will be disqualified, and will not be considered for funding.
For
AREA I. ELIGIBILITY REQUIREMENTS Office
Use ONLY
A. A complete, thorough, typewritten application must be submitted by the deadline. Yes No
B. Service(s) proposed for 2012 funding must be for DeKalb County, Georgia. Yes No
C. Applicant has a prevention or early intervention focus and meets an urgent community
need serving economically disadvantaged individuals, families, children, youth, or senior
adults, and underserved or difficult-to-serve populations. Yes No
D. Applicant must currently provide services in DeKalb and have at least two (2) years proven
track record of acceptable performance in providing services in DeKalb County. Yes No
E. Applicant must be a Georgia Nonprofit Corporation registered to do business in Georgia at
the time of application. Yes No
F. Applicant must have 501 (c) (3) tax exempt status. Yes No
G. Agency has an active, governing board that meets at least quarterly. Yes No
H. Agency must submit most recent independent audit and management letter (within past
two years) conducted by a certified public accountant. Eligible audits must be for 2009
OR 2010, and preferably 2010. Yes No
The 2012 funding request must not exceed 50% of the proposed budget for the
I.
overall Agency. Yes No
J. Applicant applying for Victim Assistance Funds must have a current program eligibility
certification from the State of Georgia Criminal Justice Coordinating Council. Yes No
AREA II. SUBMISSION REQUIREMENTS
Submit one (1) original and four (4) hardcopies, including Attachments. The original and each
hardcopy must include attachments. In addition, submit on CD or flash drive the completed
application form in Excel and the Program Description in Microsoft Word.
Mail or Deliver to:
DeKalb County Human Development Department
Grants Section
William T. White Resource Center
39 Rogers Street, NE
Atlanta, GA 30317
MINIMUM REQUIREMENT REVIEW SHEET (Continued) Page iv
ATTACHMENT CHECKLISTS
All Attachments must be placed at the back of the application. Use these checklists to ensure that all
Attachments (Appendices) for the application are included. The Appendix that are Applicable must be numbered
with the assigned number below and in the order listed. If an Appendix is not applicable, mark the NA box next
to the number.
Separate each Appendix by inserting dividers, tabs or colored paper between each one and with Appendix
number on each attachment.
AREA III. REQUIRED ATTACHMENTS FOR MINIMUM THRESHOLD REVIEW
Assigned For
Submit Required Attachments (Appendices) in the following
*NA Appendix
order:
Office
Number Use ONLY
c c 1 By-Laws (New Applicants & Current Grantees if bylaws were changed) Yes No
c c 2 Articles of Incorporation (New Applicants Only) Yes No
c c 3 501(c) 3 Certification from IRS (New Applicants Only) Yes No
c 4 Certificate of Corporation from Georgia Secretary of State's Office Yes No
Organizational Chart that shows how the proposed program and its staff fit
c 5
into the organization Yes No
6 Most recent independent Audit and management letter for 2009 OR 2010
c
(prepared within past 2 years) conducted by a certified public accountant Yes No
c 7 Mission Statement & Agency Overview, including brief history Yes No
8 Current List of Board Members (including name, address, phone numbers,
c current office held, term of office, and business and community affiliation of
each member) Yes No
c 9 Current Agency Budget as approved by the Board of Directors Yes No
c 10 Two (2) sets of the most recent and consecutive Board Minutes Yes No
11 Current Victim Assistance Fund Certification (if applicable) from the Georgia
c c
Criminal Justice Coordinating Council Yes No
*NA Not Applicable
AREA IV. ADDITIONAL ATTACHMENTS
Assigned
NA
Appendix
Submit Additional Attachments (Appendices) in the following order:
c 12 Long Range Operating Plan (3 years), including Financial Aspects of the plan
c 13 Fundraising Efforts and Plans to Sustain the Program, if not in Long Range Plan
c c 14 Applicable Licenses or Permits required by Federal, State or Local government to
operate the program, if applicable
c 15 Evaluation findings performed by a government or private agency within the past three (3)
c
years, if applicable
c 16 Program Description in Microsoft Word (5 page limit)
17 Job Descriptions for positions involved in the proposed program, at a minimum a
c description of the roles responsible for implementing the program. Indicate if roles are
staff or volunteers.
c 18 Resumes or List of Person's Qualifications, if a person has been identified for the Program
c 19 Proof of two(2) current funding sources for the proposed program, i.e., copies of award
letters, letters of commitment, etc.
c c 20 For Collaborations Only: Attach a description of the collaboration. Also attach Letter(s) of
Commitment from the collaborating agency(s) detailing the roles in implementing the
proposed program.
c 21 Tool(s)/Instrument(s) used to measure Outcome Indicators
5d1398dd-07c6-439e-b0f7-a807218e5c73.xls
Page 1
SECTION I - GENERAL INFORMATION
Please complete each item in as much detail as possible.
If needed, attach additional pages, include the question number being addressed.
1. AGENCY NAME TAX ID (EIN)#
(This should be the proper and legal name as stated on Agency's seal or charter.)
2. (Check One) NEW AGENCY *RETURNING AGENCY
(*Funded in 2011 by DeKalb County Human Services Grant)
*For RETURNING Agency: Funds requested are for: New Program Existing Program
(Check One) (Program is funded for 2011 with HS funds)
3. DATE OF AGENCY INCORPORATION
4. PREVIOUS AGENCY NAME (if changed since last fiscal year):
5. ADDRESS**:
Street, City, State
& Zip Code
**Domestic Violence Agencies DO NOT put Street Address
6. MAILING ADDRESS:
(If different from
street address)
7. AGENCY PHONE: FAX: WEBSITE:
8. AGENCY DIRECTOR'S NAME: TITLE:
DIRECTOR'S PHONE: EMAIL:
9. ***CONTACT PERSON'S NAME: TITLE:
CONTACT'S PHONE: EMAIL:
***Person responsible for Program Coordination or Program Management
10. A. TOTAL FUNDS REQUESTED from DeKalb County Human Services Grant for 2012: $
B. TOTAL PROGRAM BUDGET for which funds are being requested: $
C. PERCENT of Proposed Program Budget (to be) supported with DeKalb County Human Services Funds
with this Request: %
11. TIME PERIOD Covered for this Request: (DeKalb County HS Contract Year is 3/1 to 2/28)
12. Provide a brief Description of the Proposed Program. This may be used for publication. (Limit to 30 words or less)
13. Describe how the requested DeKalb County Human Services Funds will be used. What type of expenditures?
2012 DeKalb County Human Services Grant
Page 2
SECTION I - GENERAL INFORMATION
(continued)
Please complete each item in as much detail as possible.
If needed, attach additional pages, on the page include the question number being addressed.
14. How many years has the Agency operated in DeKalb County? Years
15. Agency's FISCAL YEAR: From To
16. A. Is your Agency CURRENTLY Certified to receive VICTIM ASSISTANCE (VA) Funds? YES NO
B. If Yes, Is the program for which you are requesting funds eligible for VA funds? YES NO
C. If Yes, Attach current VA Fund Certification provided by the Georgia Criminal Justice Coordinating Council. Appendix 11
D. If Yes, and if VA Funds are available, do you want your Application considered for Victim Assistance Funds,
as well as, DeKalb County General Funds? YES NO
17. Attach your Agency's Mission Statement and an Overview of the Organization, including a Brief History,
and the Agency's Major Accomplishments. Appendix 7
18. Attach an Organizational Chart showing how the Proposed Program and staff fit into the Organization. Appendix 5
19. A. Name of Governing Authority of Agency (Attach complete listing of CURRENT Membership of the Board
of Directors. All Board Members and Officers must be identified and the listing must include Name,
Address, Phone Number, Office held, Term of Office and Business/Community Affiliation.) Appendix 8
B. Attach two (2) sets of the most recent and consecutive Board Minutes. Appendix 10
C. Briefly describe how the Board of Directors participate in FUNDRAISING Activities and the Percentage of the Board
that gives financially to the Agency.
20. Attach Current Agency Budget approved by the Board of Directors. Appendix 9
21. Attach your Agency's most recent independent Audit and Management Letter. Appendix 6
22. Attach your Agency's Long-Range Operating Plan (3 YEARS) including the FINANCIAL Aspects of the Plan. Appendix 12
23. Attach your FUNDRAISING EFFORTS, including your Agency's Sustainability Plan for the program? Appendix 13
If your Fundraising or Sustainability Plan is in you LONG RANGE PLAN, please cite the page numbers
where this information may be found.
24. If DeKalb County funds are not available, what are your plans to continue the Proposed Program?
25. What OTHER Counties are represented in the Client Population of your Agency?
26. Which of the Counties listed above provide FUNDING to your Agency?
2012 DeKalb County Human Services Grant
ew of the Organization, including a Brief History,
Appendix 7
sed Program and staff fit into the Organization. Appendix 5
plete listing of CURRENT Membership of the Board
be identified and the listing must include Name,
e and Business/Community Affiliation.) Appendix 8
ecutive Board Minutes. Appendix 10
of Directors. Appendix 9
nd Management Letter. Appendix 6
EARS) including the FINANCIAL Aspects of the Plan. Appendix 12
gency's Sustainability Plan for the program? Appendix 13
2012 DeKalb County Human Services Grant
Page 3
SECTION I - GENERAL INFORMATION
(continued)
Please complete each item in as much detail as possible.
If needed, attach additional pages, include the question number being addressed.
27. TOTAL CLIENTS SERVED BY AGENCY
A. Annually, how many Total Clients does your Agency currently serve in your entire Service Area?
B. Annually, how many Clients does your Agency currently serve in DeKalb County?
C. Indicate Percentage of Total Clients served by your Agency who are DeKalb County residents?
D. *What Percentage (%) of the DeKalb County Clients served by your Agency are Low to Moderate
income (Below 80% of County Median Income for Individuals)? %
*See HUD Income Limits in Application Guidelines
28. A. Are there any Federal, State, or Local Government LICENSING Requirements or Operating Permits
(Georgia Department of Human Resources, Etc.) that the Agency must adhere to OR any Inspections
that the Agency must Pass to Operate?
YES NO
If Yes, please describe these Requirements? Attach License/Permit. Appendix 14
B. Has your Agency been evaluated by a Government or Private Agency within the Last Three (3) Years?
YES NO
If Yes, Attach findings. Appendix 15
29. In the table below, please list any services your Agency is currently performing under contract or grant
award for a DeKalb County Department, include the funding amount and purpose.
Contract or
Funding
Name of DeKalb County Department Purpose Award
Amount
Received?
$ -
$ -
$ -
$ -
$ -
$ -
TOTAL $ -
30. List other Agencies that provide the same or similar services as your Agency AND describe how your
proposed services enhances or differs from the other Agencies' services.
Page 4
SECTION II - LOCATIONS OF CURRENT OPERATIONS
AND CURRENT AND PROPOSED STAFFING
1. On the Table below, Complete Information for the Agency's Main Office and any Satellite Operations and/or
Locations where Services are Provided.
Cost of Operations
Is Site
*DeKalb Co. Non-
Located in No. of Staff Personnel
Name of Operation Address Commission Personnel Total
DeKalb Persons Cost
Districts Cost
County?
$ - $ - $ -
$ - $ - $ -
$ - $ - $ -
$ - $ - $ -
*If site is located in DeKalb go to http://web.co.dekalb.ga.us/street.asp and follow
TOTAL $ - $ - $ -
the steps to find the Commission Districts for your Agency's site(s).
2. Are there any branches, affiliates, or subsidiary activities? YES NO If yes, please explain:
3. Do you expect an increase in the number of employees or an expansion in the services provided during the coming year.
YES NO If yes, please explain.
4. Have there been any losses as a result of fraudulent activities on the part of personnel? YES NO
If yes, please explain (including any changes in procedures as a result).
5. Complete the Actual and Projected Staffing Chart below.
TOTAL TOTAL
Number of Number of
Employees EMPLOYEES Volunteers VOLUNTEERS
Admin. Direct Board of Direct
Admin.
Staff Services Directors Services
Actual 2010:
Projected 2011:
Projected 2012:
6. How are Staff and Volunteers Oriented, Trained and Supervised?
2012 DeKalb County Human Services Grant
Page 5
SECTION III - PROPOSED PROGRAM INFORMATION
Copy and Complete SECTION III (pages 5, 6, 7, 8 and 9) for Each Proposed Major Program funded in whole or in part with
DeKalb County funds.
NAME OF PROPOSED PROGRAM:
1. Is the program: Continuation of existing program
Expansion of existing program
Mark (X) One
Existing program with modifications
New program
2. If this is a continuation of an existing program, describe any Changes and Accomplishments in 2011.
4. Indicate below the Type of Services you will Provide (check all that apply):
PREVENTION SERVICES EARLY INTERVENTION TREATMENT SERVICES
5. Indicate your Agency's Target Population for the Proposed Program. Mark all that apply.
GENDER *INCOME AGE
Male Low Children Youth Adults Seniors
Female Moderate 0 - 5 years 12 - 17 yrs 18 -25 yrs 55-59 yrs
High 5 - 11 yrs 26 -36 yrs 60-79 yrs
37-54 yrs 80+ yrs
*See HUD Income Limits
6. Select up to Two (2) Primary CATEGORY(S) that Best describes the Proposed Program's Services & applicable Subcategories
A. ADVOCACY E. DISABILITY SERVICES I. HEALTH SERVICES
Development Disabilities Education/Prevention
B. AGING SERVICES Physical Disabilities Meal Program
C. CHILDREN & YOUTH F. DOMESTIC VIOLENCE J. JUDICIAL SYSTEM
Before and/or After-School Victim Assistance SUPPORT SERVICES
Child Abuse & Neglect Violence Prevention
Child Care Services K. MENTAL HEALTH
Early Childhood Education G. EMERGENCY SERVICES
Teen Pregnancy Prevention Homelessness Prevention L. VOLUNTEER
Tutoring/Mentoring PROGRAM
Youth Leadership H. FAMILY SERVICES
Family Involvement M. OTHER, Specify
D. CRISIS INTERVENTION SERVICES Parenting Skills & Support
7. What is your Program Service Area? All of DeKalb County Partial Service Area, please specify:
8. CLIENTS SERVED BY PROPOSED PROGRAM
Indicate Total number of DeKalb County Clients (to be) served Annually by the Proposed Program.
2010 2011 2012
A. Explain below significant increases or decreases for Previous Years:
B. How many unduplicated Clients does your Agency estimate you will serve with the DeKalb County
Human Services Grant?
C. Please estimate your Program Costs for each DeKalb County Client.
D. Maximum Number of unduplicated DeKalb Clients you are able to serve in the Proposed Program.
2012 DeKalb County Human Services Grant
SECTION III - PROPOSED PROGRAM INFORMATION
Copy and Complete SECTION III (pages 5, 6, 7, 8 and 9) for Each Proposed Major Program funded in whole or in
part with DeKalb County funds.
9. PROGRAM DESCRIPTION: Describe your program in detail. State WHAT you plan to do, WHEN you plan
to do it, WHERE the activities will take place, HOW the program will be implemented or services delivered
(example, how many sessions for how long with how many participants), HOW many months during the
year do you serve clients, WHOM will be served and WHO are the program staff. Identify your eligibility
criteria for participants. And, how and if family members are involved. The development of the contract will
be determined from this description. RETURNING Agencies: Give justification when requesting an increase
in funds. (Limit to 5 pages) Appendix 16
10. What months, days, hours will the program operate?
11. Attach Job Descriptions for any positions involved in implementing the Proposed Program, at a minimum a
description explaining their roles and responsibilities. Indicate if roles are staff or volunteers. Appendix 17
12. Attach resumes or qualifications of persons in the above positions that play key roles in the implementation of the
program and/or are funded in whole or in part by the HS Grant. Appendix 18
13. Is there a Waiting List for the Program? YES NO How long is the waiting list?
Will DeKalb County funds help eliminate the Waiting List for the Proposed Program?
YES NO
14. COORDINATION/PARTNERSHIPS
List any Agencies (including other DeKalb County Departments) in which your Agency coordinates services and
partnerships for the Proposed Program. This should also include Human Services Planning Groups or Initiatives,
(i.e., DeKalb Initiative for Children & Families, DeKalb Prevention Alliance, etc.) Briefly identify the type of
meaningful coordination/partnerships.
Agency and/or DeKalb Co.
Type of Coordination/Partnerships
Department(s)
15. COLLABORATIONS are two or more organizations working together on the Proposed Program through a
Memorandum of Understanding (MOU) or a Memorandum of Agreement (MOA).
Is your Proposed Program a Collaboration?
Yes No
If yes, list the Agencies you are collaborating with?
If yes, Attach a description of the activities of the Collaboration. Appendix 20
16. For COLLABORATIONS Only: Attach Letters of Commitment from the Collaborating Agencies detailing the
roles in implementing the Proposed Program. Appendix 20
2012 DeKalb County Human Services Grant
Page 6
ORMATION
ram funded in whole or in
an to do, WHEN you plan
ed or services delivered
any months during the
dentify your eligibility
ment of the contract will
en requesting an increase
am, at a minimum a
eers. Appendix 17
the implementation of the
Appendix 18
coordinates services and
ning Groups or Initiatives,
dentify the type of
erships
rogram through a
Appendix 20
Agencies detailing the
Appendix 20
2012 DeKalb County Human Services Grant
Page 7
SECTION III - PROPOSED PROGRAM INFORMATION
(continued)
Copy and Complete SECTION III (pages 5, 6, 7, 8 and 9) for Each Proposed Major Program funded in whole or in part with
DeKalb County funds.
17. Identify how the agency will facilitate access to services for culturally and ethnically diverse populations? (i.e., translators,
bilingual literature, etc.)
18. Is the program site American Disability Act (ADA) accessible? YES NO
If no, what are your plans for ADA accessibility?
19. Is your Agency or Service Location(s) accessible to Public Transportation? YES NO
If no, how will clients gain access to your Proposed Program?
21. A. Please list ALL Funding Sources for Proposed Program, Enter Dollar Amounts and indicate if funds are Anticipated
or Committed, insert (A) or (C), also indicate Dates for which funds are anticipated or committed.
Anticipated (A) or
FUNDING SOURCE AMOUNT Month/Year
Committed* (C)
$ -
$ -
$ -
$ -
$ -
$ -
B. *Attach proof of two (2) current funding sources (i.e., copies of award letters, commitments, etc.) Appendix 19
22. IN-KIND CONTRIBUTIONS/VOLUNTEERS for Proposed Program
List and describe, in broad categories, unpaid Volunteers & In-Kind Contributions received in 2011 and anticipated in 2012.
Type of Volunteers/
YEAR DESCRIPTION VALUE
Source of Contribution
$ -
$ -
$ -
$ -
$ -
$ -
IN-KIND TOTAL $ -
23. Is there a fee charged to Clients who participate in the Proposed Program? YES NO
If Yes, How much is the fee?
24. Has the fee increased in the past 6 months? How much has the fee increased? How is the fee determined?
25. Does your Agency use a sliding fee scale for the Proposed Program? YES NO
2012 DeKalb County Human Services Grant
Page 8
SECTION III - PROPOSED PROGRAM INFORMATION
Copy and Complete SECTION III (pages 5, 6, 7, 8 and 9) for Each Proposed Major Program funded in whole or in part with DeKalb County funds. If needed, attach
additional pages.
26. PROGRAM LOGIC MODEL (Activities, Outcomes and Outputs)
Agency Name: Program:
A. MAJOR PROGRAM ACTIVITIES B.* C. *OUTPUTS D. OUTCOMES E. OUTCOME INDICATOR F. DATA SOURCE/ HOW
(What you will do) Insert # of DeKalb Clients (how you expect people to benefit # and % of clients/units to achieve MEASURED What tool/instrument
EB/ Served or # of Units from your program, what difference each outcome used, how and how often
BP/ Provided (i.e., persons, will the program make?) The indicators are measured, who is
CB/ families, children, activity will lead to the following responsible for data, who is
O/ NA volunteers, counseling anticipated results: evaluated/surveyed
sessions, meals, etc.) (participants/stakeholders, etc)
* Evidence Based (EB), Best Practice (BP), Consensus Based (CB), Other (O), Not Applicable (NA)
27. Is the proposed program's activities based on a research model, best practices, consensus, other, or NA? YES NO Please explain in more detail:
28. Identify the source of tool(s)/Instrument(s) referred to in Column F above. Who created or developed the tool?
29. Attach copy of tool(s)/instrument(s) used to measure Outcome Indicators. Appendix 21
2012 DeKalb County Human Services Grant
Page 9
Section IV - PROPOSED DEKALB COUNTY PROGRAM BUDGET
Copy and Complete SECTION III (pages 5, 6, 7, 8 and 9) for Each Proposed Major Program funded in whole or in part with DeKalb County funds.
1. PROPOSED LINE ITEM BUDGET FOR DEKALB COUNTY FUNDS
Please list all proposed line items and provide sufficient information in Explanation Column. List line items that DeKalb County Funds will pay for wholly or in part, to justify use of the
funds requested. DeKalb County funds may not be used to fund Capital Projects, Consultants, Fundraising Campaigns, Endowment Funds, Debt Reductions or Feasibility Studies,
Furniture, Fixtures, Equipment (FFE), Out-of-State travel, Cell Phones, 100% of Salary and Benefits for any position (County will pay only partial salaries and benefits), or any other
activities/items determined to be ineligible.
PROGRAM NAME:
B. DEKALB C. OTHER
A. LINE ITEM Budget Request FUNDS
D. PROGRAM BUDGET JUSTIFICATION
Salary and benefits of one part-time (50% PTE) Early Intervention Counselor (Salary - $8,662, Group
EXAMPLE: Salaries & $ 3,000.00 $ 8,187.00 Insurance - $1,039, FICA - $663, Pension - $823) = $11,187 total salary and benefits for one Part-time
Benefits Early Intervention Counselor for the operation of the XYZ Program.
Program Materials $ 100.00 $ 300.00 Training materials for parenting classes @ 4 sets of materials x $100 = $400
Office Supplies $ 300.00 $ 900.00 Office Depot ($100/ mo x 12 mo) = $1,200
Salaries & Benefits $ - $ -
Rent/Lease $ - $ -
Local Mileage $ - $ -
Utilities
$ - $ -
Program Materials
$ - $ -
Office Supplies $ - $ -
Other: (Please specify/itemize) $ - $ -
TOTAL BUDGET
$ - $ -
REQUEST
2012 DeKalb County Human Services Grant
Page 10
SECTION V - FINANCIAL INFORMATION FOR TOTAL AGENCY
NOTE: Include funding sources for all programs operated by the agency not just County-funded programs. Do not include in-kind
contributions. (See Page 7 for in-kind contributions.)
1
Source of Funds:
ACTUAL FY 2009 ACTUAL FY 2010 PROJECTED FY 2011 PROPOSED FY 2012
GOVERNMENT REVENUE
A. Federal: (specify amount received from
each agency.)
1) $ - % $ - % $ - % $ - %
2) $ - % $ - % $ - % $ - %
3) $ - % $ - % $ - % $ - %
SUBTOTAL $ - 0% $ - 0% $ - 0% $ - 0%
B. State: (specify amount received from
each agency.)
1) $ - % % $ - % $ - %
2) $ - % $ - % $ - % $ - %
SUBTOTAL $ - 0% $ - 0% $ - 0% $ - 0%
C. DeKalb County:
1) Human Services General Fund $ - % $ - % $ - % $ - %
2) Human Services Victim Assistance
Fund $ - % $ - % $ - % $ - %
3) DeKalb Workforce Dev. $ - % $ - % $ - % $ - %
4) Community Development $ - % $ - % $ - % $ - %
5) Other, specify: $ - % $ - % $ - % $ - %
SUBTOTAL $ - 0% $ - 0% $ - 0% $ - 0%
D. Other Government Agencies
(City/County)
1) $ - % $ - % $ - % $ - %
2) $ - % $ - % $ - % $ - %
SUBTOTAL $ - 0% $ - 0% $ - 0% $ - 0%
TOTAL GOVERNMENT FUNDING
E.
(A. thru D.) $ - 0% $ - 0% $ - 0% $ - 0%
Source of Funds:
ACTUAL FY 2009 ACTUAL FY 2010 PROJECTED FY 2011 PROPOSED FY 2012
NON-GOVERNMENT REVENUE
F. Foundations:
1) $ - % $ - % $ - % $ - %
2) $ - % $ - % $ - % $ - %
3) $ - % $ - % $ - % $ - %
SUBTOTAL $ - 0% $ - 0% $ - 0% $ - 0%
G. Cash/Private Contributions:
1) Board of Directors $ - % $ - % $ - % $ - %
2) $ - % $ - % $ - % $ - %
3) $ - % $ - % $ - % $ - %
SUBTOTAL $ - 0% $ - 0% $ - 0% $ - 0%
Other Non-Gov.: (List other funding
H.
sources not stated elsewhere.)
1) United Way $ - % $ - % $ - % $ - %
2) Fees $ - % $ - % $ - % $ - %
3) $ - % $ - % $ - % $ - %
SUBTOTAL $ - 0% $ - 0% $ - 0% $ - 0%
I. TOTAL NON -GOVERNMENT FUNDING $ - 0% $ - 0% $ - 0% $ - 0%
(F. thru H.)
TOTAL REVENUE: (E. + I.) $ - $ - $ - $ -
J.
K. FUND BALANCE/CARRYOVER
FROM PRIOR YEAR
(Total Prior Year's Funds Available
Less Total Prior Year's Expenditures) $ - $ - $ - $ -
L. TOTAL FUNDS AVAILABLE (J. + K.) $ - $ - $ - $ -
2012 DeKalb County Human Services Grant
Page 11
SECTION V - FINANCIAL INFORMATION FOR TOTAL AGENCY
(continued)
NOTE: Include expenditures for all programs operated by the Agency, not just DeKalb County
funded programs. (The categories are a guide, you can revise categories as needed.)
2.
Use of Funds: ACTUAL ACTUAL PROJECTED PROPOSED
EXPENDITURES FY 2009 FY 2010 FY 2011 FY 2012
Salaries $ - $ - $ - $ -
Employer F.I.C.A. $ - $ - $ - $ -
Unemployment Comp. $ - $ - $ - $ -
Worker Comp. $ - $ - $ - $ -
Insurance (Employee) $ - $ - $ - $ -
Other Employee Benefits $ - $ - $ - $ -
Subtotal $ - $ - $ - $ -
Rent/Lease $ - $ - $ - $ -
Utilities $ - $ - $ - $ -
Supplies $ - $ - $ - $ -
Insurance $ - $ - $ - $ -
$ - $ - $ - $ -
Subtotal $ - $ - $ - $ -
Audit $ - $ - $ - $ -
Other Professional Services $ - $ - $ - $ -
$ - $ - $ - $ -
Subtotal $ - $ - $ - $ -
Program Materials $ - $ - $ - $ -
$ - $ - $ - $ -
$ - $ - $ - $ -
Subtotal $ - $ - $ - $ -
Other (list) $ - $ - $ - $ -
$ - $ - $ - $ -
Subtotal
TOTAL EXPENDITURES $ - $ - $ - $ -
Carryover to Next Year (Total
Funds Available Less Total
Expenditures) $ - $ - $ - $ -
3. Please state approximately what Percentage of the 2011 Agency Expenditures was for Programs and
what Percentage was for Overhead.
Programs % Overhead %
Please explain how these percentages were determined. What does the overhead include?
4. Has the Agency had an Operating Budget Surplus or Deficit during the last year? If so, please explain
the impact. YES NO
5. Have there been any Cash Management issues in the past SIX Months? If so, please explain the reasons
and the impact. YES NO
2012 DeKalb County Human Services Grant
Page 12
SECTION VI - PROPOSED DEKALB COUNTY CONTRACT
PROPOSED CONTRACT REQUIREMENTS
1 DeKalb County requires that a human service agency which receives DeKalb County funds must enter into a
contract agreement, a copy of which is attached.
Please review the Sample DeKalb County Contract in detail. Describe below any problems your Agency
would have in fulfilling the requirements.
2 As referenced in Section IV of the contract, fidelity bond coverage equal to the funding award is required.
Your agency's blanket fidelity coverage is acceptable as long as it provides the required amount of coverage.
Does your agency either currently have Fidelity Bond coverage in effect, or would your agency be able to
obtain a Fidelity Bond for this Contract?
Yes No
If No, Please explain:
NOTE: If your agency is selected for funding, additional documentation may be required. It is
the responsibility of the Agency to insure that all Federal, State, and Local requirements are met.
SECTION VII - CERTIFICATION
I certify to the best of my knowledge that all of the information stated in this funding application is true and correct.
Signature of Authorized Official Date
(Agency Executive Director or Board President)
Typed Name and Title
5d1398dd-07c6-439e-b0f7-a807218e5c73.xls
