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2012GrantApplication.. - DeKalb County_ Georgia

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2012GrantApplication.. - DeKalb County_ Georgia Powered By Docstoc
					                       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

				
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