Docstoc

100171 - 3 CDBG PS

Document Sample
100171 - 3 CDBG PS Powered By Docstoc
					Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services
                                         Application Checklist
  Applicant:                                       Project:

  Review the following list of documentation requirements. Five hard copies and one electronic copy on
  disc are required for submittal. ALL copies submitted must include the following attachments in the
  stated order. Applications that do not contain all of the required information will be considered
  ineligible.

  Tab 1                  Harris County Request for Proposal Cover Sheet* (Offerors Note)
                         Application Checklist

  Tab 2                  Exhibit A: Applicant Information
                              Attachment A-1: Project Service Area Map

  Tab 3                  Exhibit B: Organizational Information
                              Attachment B-1: Articles of Incorporation
                              Attachment B-2: 501 (c) (3) documentation from IRS
                              Attachment B-3: Agency organization charts
                              Attachment B-4: Project organization charts
                              Attachment B-5: Job descriptions
                              Attachment B-6: Résumés of key personnel
                              Attachment B-7: Letters of funding commitment
                              Attachment B-8: 90- day working capital documentation

  Tab 4                  Exhibit C: Project Information

  Tab 5                  Exhibit D: Statement of Work/Scope of Services
                              Attachment D-1: Policy and Procedures Manual

  Tab 6                  Exhibit E: Logic Model

  Tab 7                  Exhibit F: Project Budget Information
                              Personnel Detail (one per Service Activity)
                              Non-Personnel Detail (one per Service Activity)
                              Combined Activity Budget (one per Service Activity)
                              Budget Summary
                              Attachment F-1: Audit/Financial Statements and IRS Form 990
                              Attachment F-2: Single Audit (if applicable)
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services
                  Community Development Block Grant Program
                                 Application
     Original                     PRIORITY 1           PRIORITY 2             PRIORITY 3
     Copy              (If submitting more than one proposal, indicate the priority of this proposal.)

Exhibit A – Applicant Information (4 Points)
Part 1- General Information
 1. Type of Organization:              Please select entity type:
                                       Other (Specify):
 2. Organization Legal Name:
 3. Project Name:
 4. Mailing Address:
    City, State, and Zip Code:
 5. Physical Address of Project:
    City, State, and Zip Code:
 6. Telephone:                                                      7. Fax:
 8. What are your program's hours of operation?
 9. What Harris County Precinct is your project located within?
 10. DUNS Number:                                                     11.     Tax ID:
Provide the following information:
 Program Contact              Name:                       Phone:              Email:

 Person managing the          Title:
 project on a daily basis
 Finance Contact              Name:                       Phone:              Email:

 Person able to provide       Title:
 budget information.
 Application Contact          Name:                       Phone:              Email:

 Person writing this          Title:
 application.
 Authorized Contact           Name:                       Phone:              Email:

 Person authorized to sign Title:
 contracts.
 I CERTIFY THAT I AM AUTHORIZED TO REPRESENT THE ABOVE NOTED ORGANIZATION AND THAT THE
 INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT AND THAT IT CONTAINS NO
 FALSIFICATIONS, MISREPRESENTATIONS, INTENTIONAL OMISSIONS OR CONCEALMENT OF MATERIAL
 FACTS. I FURTHER CERTIFY THAT NO CONTRACTS HAVE BEEN AWARDED, FUNDS COMMITTED OR
 CONSTRUCTION BEGUN ON THE PROPOSED PROJECT AND THAT NONE WILL BE DONE PRIOR TO
 ISSUANCE OF A RELEASE OF FUNDS BY HARRIS COUNTY.


     Signature of Authorized Person Listed Above                                        DATE



     Print Name




                                                                                                         A2
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services
Part 2 - Application Technical Assistance
 Did the applicant or its principals attend the HCCSD applicant workshop that was
 offered?               Yes              No
 In completing this application, has the applicant received technical assistance from HCCSD
 staff?               Yes               No
Part 3 - Program Funding
 1) Requested Amount
 2) Other Funding                                                                                                 -
 3) Total Project Cost                                                                                            -
 4) Percentage of HCCSD funds **                                                    #DIV/0!

         ** HCCSD will not consider applications for projects requesting 100% of total project funding **

Part 4 - RENEWAL OPTION
 HCCSD has the option of renewing contracts on an annual basis without the need to submit a
 complete application. This opportunity will be available next year, based on project performance.
 The applicant must agree to the same terms (i.e., unit cost and service definition must remain the
 same) while the total value of the contract may increase or decrease depending on funding
 availability.
 Do you agree to a renewal for the period of 3/01/12 through 2/28/13?                              Yes       No
Part 5 - Project Description
 A. Please describe the project for proposed funding. Do not include general information about the
 organization, but be specific about the types of services that will be provided, the population
 served, the anticipated number served and how this project will fulfill one of the CDBG objectives.

 Example: ABC Agency will provide case management and job training skills to 40 unduplicated persons .




 B. Describe the service area. Please be specific. (i.e. streets, zip codes, key maps). Include a
 copy of your project service area map as Attachment A-1. Do not submit HCCSD Service Area
 maps as your project map.
 Example: The eight hundred block of Lantern Point Drive (Murworth Drive and Westridge are cross streets).




                                                                                                                      A3
A4
A5
A6
A7
A8
A9
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services

Exhibit B: Organizational Information (26 Points)
Part 1 - Organizational Experience
  Provide an organizational overview of your agency, including:
     A. A description of the history and purpose of the organization




     B. Is the organization applying for funding incorporated?           Yes           No
        If so, what year was the organization incorporated?
        As a requirement of this application, please submit copies of your Articles of
        Incorporation as a requirement of Attachment B-1.
          Please attach 501 (c )(3) documentation from the IRS as Attachment B-2.
     C. Provide the agency's organizational chart as Attachment B-3.
     D. Provide the project organizational chart as Attachment B-4.
     E. Please list staff members who will be working directly or indirectly with the project. This
          information should match the information included on both the agency organizational
          and project organizational charts. Provide job descriptions as Attachment B-5 and
          resumes as Attachment B-6 for the persons listed below.
        Name and Title             Years and Type of Relevant        Years and Type of Relevant
                                      Program Experience                Federal Experience




                                                                                                      B10
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services
Part 2 – Similar Services
  A. Are you aware of services or activities similar to your project provided by other
     organizations in Harris County?                       Yes              No
  If yes , briefly explain how your proposed project is different or unique from other similar projects?




Part 3 – Financial Capacity
  A. Indicate the funding for this project from other sources in the following table. For each
     secured funding source listed, attach a letter of funding commitment (dated no more than 6
     months prior to the application) as Attachment B-7.
                                                             Status - Approved,
           Funding Source                     Amount                                   Award Date
                                                             Pending or Denied
  Example: XYZ Foundation                          $30,000                 Pending                  6/1/10




                                     Total           $0

  B. All organizations must have 90-days working capital to ensure operational liquidity while
     awaiting reimbursement. Select one of the eligible sources of working capital listed below
     and attach supporting documentation as Attachment B-8. If necessary, provide detailed
     explanation below.
          Cash in Bank (provide 3 most recent bank statements or audited financial statements)
          Line of Credit (provide a letter on financial institution letterhead stating line of credit amount)
          Acct. Recv. Collection (provide recent audit, current balance sheet and evidence of validity)
          Liquidation of Securities, CD or Investments (provide copy of recent brokerage or CD statements)
          Thrift shop proceeds (provide IRS 990 or 990-T forms)
          Other- Please explain below and provide appropriate supporting documentation




                                                                                                                B11
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services
Part 4 – Board of Directors

  Complete the table below for each current member of the applicant's Board of Directors and
  attach additional pages if necessary. (Not applicable for local governments)
                                             Board of Directors
                                                                  Occupation/Area of
      Board Member                Company Affiliation                                  Term*
                                                                      Expertise




  *Beginning and ending years




                                                                                               B12
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services
Part 5 – Conflict of Interest Disclosure
  All Applicants
  The standards in OMB Circular A-110, Subpart C, provide that no employee, officer, or agent shall participate in the
  selection, award, or administration of a contract supported by Federal funds if a real or apparent conflict of interest
  would be involved. Such a conflict would arise when an employee, officer, or agent, any member of his or her
  immediate family, his or her partner, or an organization which employs or is about to employ any of the parties
  indicated herein, has a financial or other interest in the firm selected for an award.

  CDBG and HOME Applicants Only
  The CDBG regulations at 24 CFR 570.611 and HOME regulations at 24 CFR 92.356 provide that no person who is
  an employee, agent, consultant, officer, or elected official or appointed official of the recipient or subrecipient that
  are receiving CDBG or HOME funds and (1) who exercises or has exercised any functions or responsibilities with
  respect to activities assisted with CDBG funds; or (2) who is in a position to participate in a decision-making
  process or gain inside information with regard to these activities, may obtain a financial interest from a CDBG-
  assisted or HOME-assisted activity, or have any interest in any contract, subcontract, or agreement with respect
  thereto, or the proceeds there under, either for themselves or those with whom they have family or business ties,
  during their tenure or for one (1) year thereafter.

  A disclosure of the nature of any perceived or actual conflict must be made prior to the execution of agreements
  utilizing CDBG or HOME.
  IF NO CONFLICT EXISTS, COMPLETE THE FOLLOWING:
      I certify that no conflict of interest exists between Harris County and (name of
      organization)
      I certify that no conflict of interest exists between the subcontractors of and (name of
      organization)
  IF A CONFLICT EXISTS, COMPLETE THE FOLLOWING:
      I certify that a conflict of interest does exist between Harris County and name of
      organization)
      I certify that a conflict of interest does exist between (name of subcontractor)
                                 and (name of organization)
  Describe the nature of the conflict of interest below. Identify the individual, employment and the
  conflict or potential conflict, and their affiliation with your organization.




  Signature of Authorized Agency Official                                                            Date

  Typed Name and Title




                                                                                                                             B13
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services

  CONFLICT OF INTEREST QUESTIONNAIRE                                                                         FORM CIQ
  For vendor or other person doing business with local governmental entity                          OFFICE USE ONLY

  This questionnaire is being filed in accordance with chapter 176 of the Local                     Date Received
  Government Code by a person doing business with the governmental entity.

  By Law this questionnaire must be filed with the records administrator of the
   local government not later than the 7th business day after the date the person
  becomes aware of facts that require the statement to be filed. See Section
  176.006, Local Government Code.

  A person commits an offense if the person violates Section 176.006, Local
  Government Code. An offense under this section is a Class C misdemeanor.

  1. Name of person doing business with local governmental entity.

  2.
       Check this box if you are filing an update to a previously filed questionnaire.
  (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than
  September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending
  and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or
  inaccurate.)

  3. Describe each affiliation or business relationship with an employee or contractor of the local
     governmental entity who makes recommendations to a local government officer of the local
     governmental entity with respect to expenditure of money.




  4. Describe each affiliation or business relationship with a person who is a local government
     officer and who appoints or employs a local government officer of the local governmental
     entity that is the subject of this questionnaire.




                                                                                                                            B14
Harris County PY2010 Request for Proposals
Community Development Block Grant (CDBG) – Public Services

  CONFLICT OF INTEREST QUESTIONNAIRE                                                                           FORM CIQ
  For vendor or other person doing business with local governmental entity                                       Page 2
  5. Name of local government officer with whom filer has affiliation or business relationship.
     (Complete this section only if the answer to A, B, or C is YES.)

       This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has
       affiliation or business relationship. Attach additional pages to this Form CIQ as necessary.

       A.   Is the local government officer named in this section receiving or likely to receive taxable income from the
            filer of the questionnaire?        Yes          No
       B.   Is the filer of the questionnaire receiving or likely to receive taxable income from or at the
            direction of the local government officer named in this section AND the taxable income is not
            from the local governmental entity?                Yes          No
       C.   Is the filer of this questionnaire affiliated with a corporation or other business entity that
             the local government officer serves as an officer or director, or holds an ownership of
            10 percent or more?                      Yes         No
       D.   Describe each affiliation or business relationship.




  6. Describe any other affiliation or business relationship that might cause a conflict of interest.




  7.


       Signature of person doing business with the governmental entity                                  Date




                                                                                                                           B15
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services

  LOCAL GOVERNMENT OFFICER                                                                                                        FORM CIS
  CONFLICTS DISCLOSURE STATEMENT
  This is the notice to the appropriate local governmental entity that the                                            OFFICE USE ONLY
  following local government officer has become aware of facts that require the
  officer to file this statement in accordance with chapter 176, Local Government                                     Date Received
  Code.
  1. Name of Local Governmental Officer



  2. Office Held



  3. Name of person described by Sections 176.002(a) and 176.003(a), Local Government Code



  4. Description of the nature and extent of employment or business relationship with person named in Item 3




  5. List gifts if aggregate value of the gifts received from person named in item 3 exceeds $250

  Date Gift Received                                      Description of Gift                                         Did Not Accept Gift
  Date Gift Received                                      Description of Gift                                         Did Not Accept Gift
  Date Gift Received                                      Description of Gift                                         Did Not Accept Gift

  6. AFFIDAVIT
                                                          I swear under penalty of perjury that the above statement is true and correct. I
                                                          acknowledge that the disclosure applies to a family member (as defined by
                                                          Section 176.001(2), Local Government Code) of a government officer. I also
                                                          acknowledge the statement covers the 12-month period described by Section
                                                          176.003(a)(2)(b), Local Government Code.


                                                                                       Signature of Local Government Officer

  AFFIX NOTARY STAMP/SEAL ABOVE
  Sworn to and subscribed before me, by the said                                       , this the                     day of
            ,20                  , to certify which, witness my hand and seal of office.




  Signature of officer administering oath                 Printed name of officer administering oath      Title of officer administering oath




                                                                                                                                                B16
B17
B18
B19
B20
B21
B22
B23
B24
B25
B26
B27
B28
B29
B30
B31
B32
B33
B34
B35
B36
B37
B38
B39
B40
B41
B42
B43
B44
B45
B46
B47
B48
B49
B50
B51
B52
B53
B54
B55
B56
B57
B58
B59
B60
B61
B62
B63
B64
B65
B66
B67
B68
B69
B70
B71
B72
B73
B74
B75
B76
B77
B78
B79
B80
B81
B82
B83
B84
B85
B86
B87
B88
B89
B90
B91
B92
B93
B94
B95
B96
B97
B98
B99
B100
B101
B102
B103
B104
B105
B106
B107
B108
B109
B110
B111
B112
B113
B114
B115
B116
B117
B118
B119
B120
B121
B122
B123
B124
B125
B126
B127
B128
B129
B130
B131
B132
B133
B134
B135
B136
B137
B138
B139
B140
B141
B142
B143
B144
B145
B146
B147
B148
B149
B150
B151
B152
B153
B154
B155
B156
B157
B158
B159
B160
B161
B162
B163
B164
B165
B166
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services

Exhibit C – Project Information ( 8 Points)
Part 1 – Measurable Objectives
  A. Which PY2008-2012 Consolidated Plan Objective will the proposed project address? Refer
     to descriptions of the Consolidated Plan Measurable Objectives in the Guidebook.
                                     Objectives                                          Priority Level
               Objective 1: General Services                                                 High
               Objective 2: Senior Services                                                 Medium
               Objective 3: Youth Services/Child Care                                        High
               Objective 4 : Health Services                                                Medium
               Objective 5: Services to Persons w/Disabilities and
                             Persons with HIV/AIDS                                           Medium
               Objective 6: Transportation Services                                          Medium
               Objective 7: Abused/Neglected Children                                         Low
  ** Please note, Harris County Community Services Department reserves the right to change the priority levels of the
  above objectives.

  B. Service Area: Includes unincorporated Harris County and 15 cooperative cities.
      1. Does the project serve residents in a HC target area?                         Yes      No
         If yes, name of target area being served:
      2. If the facility housing your project is located in Houston (or other HUD Entitlement
         Jurisdiction), how will your organization ensure service to Harris County service area
         residents for the portion of the project funded by Harris County?




Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services
                                                                                                               C167
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services
Part 2 - Project Need and Beneficiaries
 A. Please identify the primary beneficiaries this project will serve. Be cognizant of the target
     population you name in the narrative portion of this proposal. Please check the appropriate
     categories below:
     Project Beneficiary Population (Please check only one, “1.” or “2.”)
          1. Low-income population based on income eligibility
                          or
          2. Presumed low-income population (Please check one below)
             Illiterate adults                   Migrant farm worker
             Battered spouses                    Homeless individuals
             Elderly individuals                 Abused children
             Persons living with AIDS            Adults with disabilities
  B. Who are the project beneficiaries (target group) to be served? Please check all that apply.
          Male                                     Special Needs
          Female                                   Elderly, Frail Elderly
          Substance Abusers                        Veterans
          At-risk of Becoming Homeless             Youth* Ages (                               to                   )
                                                  *Please include youth age range, not to exceed 19 years of age.

  C. Number of unduplicated persons from the Harris County Service Area to be served.

                     Column A                   Column B                                 Column C
                 Total number of         Number of unduplicated                 *Percentage of low-
               unduplicated persons      low-income persons to                income persons served,
                      served                   be served                        must be at least 51%
                         500                        350                                      70%
                                                                                            #DIV/0!




                                                                                                                        C168
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services

Exhibit D – Statement of Work/Scope of Services (20 Points)
Part 1 – Program Development and Delivery (Use only the space provided.)
  A. Work Plan
      ● Please give an overview of your operational capacity including hours of operation,
        intake and eligibility procedures, and which staff will be responsible for incorporating
        Harris County reporting requirements, such as the Individual Eligibility form for each
        client served.




      ● Please describe how you identify and recruit clients including referral services you
        have in place with other agencies.




      ● What partnerships or collaborations for services are in place for this program?
        If none, please explain how you plan to engage other agencies that serve your
        population.




                                                                                               D169
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services

      ● Please explain the evaluation plan for this program, including baseline data,
        measurable goals, how the data is collected and how the evaluation data will inform
        program changes and needs.




   ● Please attach a copy of your program policy and procedures manual, including program
     specific details, relevant grievance procedures, confidentiality and termination policies, as
     Attachment D-1 . If you do not have one, please indicate when it will be available.




                                                                                                D170
D171
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG)- Public Services

Exhibit E: Logic Model (14 points)


                                                              Logic Model Instructions
Overview
Please complete the logic model for the proposed project for HCCSD funding. The logic model requests general information about the
project, as well as the specific information about activities for which you are requesting funding. By completing the activities and objectives
section for Activity 1 and Activity 2, you are requesting funding for those two activities. All other activities in the logic model are part of the
program, but are not part of this funding request. If the application is only requesting funding for one activity, please put n/a for the second
activity. Please refer to the example for additional guidance.

Technical Instructions
To enter information into any section, click on the desired cell and type the appropriate content in the function window. To add an
additional line press Alt then Enter key. Please separate outcomes with two spaces (hit Alt Enter two times) and number the list to indicate
separate outcomes as reflected in the sample. When completing the outputs section, put the number/measure for an output in the amount
column and the description in the output section. The data input into the blue cells of the logic model will automatically fill sections of the
budget form.




                                                                                                                                               E172
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG)- Public Services
                                                                  Output
      Inputs                                Activities            Number             Outputs                             Outcomes                               Impact
                                                                                                            Short-term               Long-term
Instructors                          For activities requesting HCCSD funding only                    1. Families have safe     1. Student achievement Cycle of low-income
Volunteers                           Provide after-school       9,000          Day of after-         place for children        scores increase by       students scoring poorly


                       Activity #1
Counselor                            services to residents of                  school services       normally home alone                                on standardized tests is
Students                             East Harris County.                                                                       2. Children engage in    broken
Food                                                                                                 2. After-school curriculm healthy social
Curriculum                                                                                           will follow local school  relationships with other
Phones                               For activities requesting HCCSD funding only                    district, maintaining     students
Campus Coordinator                   n/a                        n/a            n/a                   consistency in learning
                       Activity #2
                       Activity #3
                       Activity #4




Inputs are resources                  Activities are what the                    Outputs are the      Short term outcomes       Long term outcomes       Impact describes the
   dedicated to or                    program does to fulfill                   direct products of    are the Initial benefits are typically changes in overall goal or change
  consumed by the                            its mission                        the program and      experienced, usually in behavior because of the desired by the program
      program                                                                    are measurable        the form of skills or   new knowledge or skills
                                                                                                            knowledge




                                                                                                                                                                            E173
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG)- Public Services
                                                               Output
      Inputs                              Activities           Number       Outputs   Outcomes                 Impact
                                                                                      Short-term   Long-term
                                   Activity requesting HCCSD funding only




                     Activity #1

                                   Activity requesting HCCSD funding only
                     Activity #2
                     Activity #3
                     Activity #4
                     Activity #5




                                                                                                                        E174
E175
E176
E177
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services
Exhibit F: Project Budget Information ( 28 Points)
Part 1- Entity-wide Financial Management & Systems Questionnaire
  A. Please describe your organization’s fiscal management practices & systems related to
  financial reporting, accounting systems, financial capacity, budgetary and internal controls and
  audit requirements by completing the Financial Management questionnaire below.

                                                FINANCIAL MANAGEMENT
                                                   (QUESTIONNAIRE)
                                                   YES      NO            COMMENT
  ACCOUNTING SYSTEM:
  1. Does your organization have and
  maintain a standard chart of accounts?
  2. Does your accounting system include a
  project cost ledger that can be used for
  recording expenditures for “each” program
  by required budget cost categories?
  3. How do employees account for their
  time and effort? Please explain.
  FINANCIAL CAPABILITY:
  1. Does your organization prepare annual
  financial statements?
  2. Are those financial statements reviewed
  formally and approved/accepted by your
  Board or Officers.
  3. Are the financial statements subject to
  an annual Audit?
  4. Describe which basis of accounting
  your organization uses, e.g. (accrual,
  cash, or other) and what authoritative
  guidance your organization relies for
  accounting for general and grant funded
  activities.
  5. Has the organization established line(s)
  of credit? If so, identify source and
  amount.
  BUDGETARY CONTROLS:
  1. Are there budgetary controls in effect
  (e.g. comparison of budget with actual
  expenditures on a monthly basis) to
  preclude exceeding budgetary limitations?

  2. Are all purchases made by PO whereby
  that encumbers/earmarks funds available
  for use.
  3. Does someone in your organization
  periodically perform analysis and
  recommends/makes adjustments to
  budgetary spending levels due to
  identification of unforeseen or potential
  cash flow problems resulting from the
  analysis? If so, name the
  person(s)/position(s) responsible for these
  activities.
                                                                                                     F178
 Harris County PY2011 Request for Proposals
 Community Development Block Grant (CDBG)- Public Services
 Community Development Block Grant (CDBG) – Public Services
 1. Are there written procedures for the
 following?
   a.Accounting entries are supported by
   appropriate documentation; e.g.
   purchase orders and vouchers.
   b.Separation of responsibility in the
   receipt, payment, and recording of cash.

   c.Procedures for procurement and
   practices are consistent with applicable
   governing regulations.
   d.Travel is reviewed and approved and
   consistent with program guidelines and
   applicable to job functions.
   e.Timekeeping and payroll functions
   having segregation, proper review,
   approval, and support documentation of
   hours worked by activity and program.
   f.Disclosures of Board, Officers or
    employees for related party
    transactions.
 2. Describe the safeguards your entity has
 instituted to ensure adequate internal
 controls in the company (e.g. Officially
 adopted policies and procedures, all
 expenses approved by board,
 documented and required annual review of
 policies).

Part 2 – Financial Statements (Not Applicable to Harris County Departments)
 A. Does organization have revenues in excess of $300,000?              Yes            No
     If yes, you MUST attach an audit performed by a Certified Public Accountant, along with the
     organization’s most recently filed IRS Form 990 as Attachment E-1.
 B. Does organization have revenues less than $300,000?                 Yes            No
     If yes, you MUST attach the organization’s most recently filed IRS Form 990, along
     with the items from either (a) or (b) as Attachment E-1:
         a) A set of Basic Financial Statements, which MUST include the industry equivalent of
            a Balance Sheet, Statement of Cash Flows, Income Statement and the Notes to the
            Financial Statements. These must have been certified as official financials and
            evidenced by a copy of the board minutes showing that they were presented and
            accepted as official financial statements by the entity’s board or governing body.
                                                  OR
         b) A compiled set of Basic Financial Statements, along with a letter that the
            compilation was performed in accordance with American Institute of Certified Public
            Accountants’ industry standards. The compilation must include the industry’s
            equivalent of the Balance Sheet, Statement of Cash Flows, Income Statement and
            the Notes to the Financial Statements.

                                                                                               F179
Harris County PY2011 Request for Proposals
Community Development Block Grant (CDBG) – Public Services
  C. Did organization receive more than $500,000 in Federal funding in the preceding year?
                            Yes          No
     If yes, please attach as Attachment E-2, a copy of your required “single audit”. If your audit
     has not been completed, please note when this audit is to be completed.
     Date:
  D. Financial Statement & Single Audits Findings
     If there were findings noted in either your most recent Financial Statement audit or Single
     Audit, please describe the nature of the findings and what steps your organization has taken
     to resolve the finding.




                                                                                                  F180
F181
F182
                                CDBG
                       Budget Forms Instructions

                                          START:
                                         Form: Tab 4




                     Complete a Personnel Form for each activity

    If staff salaries will be used as match, detail the amount and source of match in
                   columns G and H. Please do not exceed 100% match.

   If the project is not requesting funding for personnel or using personnel as match,
                             move to the Non-Personnel Form



                     Complete a Non-Personnel form for each activity.

      Use this form to detail any match other than salaries for the program, including
                                      volunteer time.



         Complete a Personnel and Non-Personnel form for each activity. The
           Budget Summary will auto populate once the forms are complete.



Review the Budget Summary Form. All information should automatically calculate, and
  will pull information from other budget forms, Exhibit B (Logic Model) and Exhibit A
(Organizational Information). If there are errors in these forms, the budget summary will
                                    reflect these errors.

Detail the planned monthly expenditures for PY 2011 in the Monthly Expenditure Plan.

      Use the Budget Narrative Space to explain the Expenditure Plan, detail any
information not captured in the budget forms or explain any costs that may not appear
                             directly related to the program.




                                     Save your work.
                                      Print the entire
                                        workbook.




                                                         Harris County Community Services Department
                                                                        PY2011 Request for Proposals
                                                                Personnel Detail
                                                                                                                                                       2011
Service Activity #              1
Activity:                                                                                               -

                                         Monthly         No. of           Harris County         Leverage       Leverage Funds Source
Position                  FTE            Salary          Months           Grant Funds            Funds              Description                 TOTAL
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                Salary Subtotal $                     -     $           -                                   $           -
Fringe Benefits
FICA (7.65%)                                                                           -                                                                -
Fringe Benefits                                                                                                                                         -
Worker's Compensation (not to exceed 5%)                                                                                                                -
Insurance                                                                                                                                               -
Retirement                                                                                                                                              -
                                  Fringe Benefits Subtotal $                          -     $           -                                   $           -
                                Operations Personnel Total $                          -     $           -                                   $           -



                                                                                                                                                       2011
Service Activity #              2
Activity:                                                                                               -



                                         Monthly         No. of           Harris County         Leverage       Leverage Funds Source
Position                  FTE            Salary          Months           Grant Funds            Funds              Description                 TOTAL
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                                                      -                                                                 -
                                                Salary Subtotal $                     -     $           -                                   $           -
Fringe Benefits
FICA (7.65%)                                                                           -                                                                -
Fringe Benefits                                                                                                                                         -
Worker's Compensation (not to exceed 5%)                                                                                                                -
Insurance                                                                                                                                               -
Retirement                                                                                                                                              -
                                  Fringe Benefits Subtotal $                          -     $           -                                   $           -
                                Operations Personnel Total $                          -     $           -                                   $           -


                                                                             HCCSD              OTHER                                       TOTAL FTE(S)
SAL ALL ACTIVITIES:                                                   $          -          $           -                                   $        -
BENEFITS ALL ACTIVITIES                                               $          -          $           -                                   $        -
SAL & PAY EXP & BEN FOR ALL ACTIVITIES:                               $          -          $           -                                   $        -
FTE'S ALL ACTIVITIES                                                             -                      -                                        0
                                                                   IMPORTANT NOTES:
1) FTE stands for Full Time Equivalent and is based on a 40-hour work week. Forty hours per week is 1 FTE, 20 hours per week is 0.5 FTE, ten hours
per week is .25 FTE, etc. For the "Monthly Salary" column, insert the monthly salary that would be paid for a Full Time Equivalent. For example, for a
year-round, part-time employee working 20 hours per week who is paid $500 per month, enter 0.5 in the "FTE" column, $1000 in the "Monthly Salary"
column, and 12 in the "No. of Months" column. The form then calculates the salary at $6,000 for the year.

2) You should include only those personnel, or portion of FTE that contributes directly to the production of an activity's unit cost. Personnel, such as a
counselor, food preparer or individual that directly supports another individual that is "direct"ly responsible for counseling or serving a program
participant is an example of Direct personnel costs that should be considered in arriving at unit costs.




                                                                                                             Harris County Community Services Department
                                                                                                                            PY2011 Request for Proposals
                                                       Non-Personnel Detail
Costs for Activity No.                             Service Activity #             1
Activity :                                                              #VALUE!


                                                 Harris County                            Leverage Funds Source
                 Description                      Grant Funds      Leverage Funds              Description                TOTAL
Professional Fees/Contract Services (including volunteer time for match)
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                          Subtotal $              -     $             -                             $               -
Travel & Training (ineligible shelter cost)
Type of Training
                                                                                                                    $               -
                                                                                                                    $               -
Type of Travel (non-mileage)                                                                                        $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
Mileage:

___ mi./mo. x ___ mos. x 50.5 cents/mi.                                                                             $               -
                                          Subtotal $              -     $             -                             $               -
Building leases/rent/utility expenses
Space Costs (provide location):
Location:                                                                                                           $               -
Rent: ___ sq. ft. @ $___ /ft./year                                                                                  $               -
                                                                                                                    $               -
                                                                                                                    $               -
Utilities:                                                                                                          $               -
Electricity                                                                                                         $               -
Water                                                                                                               $               -
Telephone                                                                                                           $               -
Other Utilities:                                                                                                    $               -
                                          Subtotal $              -     $             -                             $               -
Consumable Supplies (describe)
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                          Subtotal $              -     $             -                             $               -
Rent, Lease of Equipment and Furniture
                                                                                                                    $               -
                                                                                                                    $               -
                   Rent, Lease Furniture Subtotal $               -     $             -                             $               -
Other Costs
Direct Audit Costs                                                                                                  $               -
Postage                                                                                                             $               -
Direct payments / benefits to clients                                                                               $               -
Program specific insurance                                                                                          $               -
Financial Assistance                                                                                                $               -
Other (specify)                                                                                                     $               -
Other (specify)                                                                                                     $               -
                            Other Costs Subtotal $                -     $             -                             $               -
                    Non-Personnel Detail Total $                  -     $             -                             $               -




                                                                                                            Harris County Community Services Department
                                                                                                                           PY2011 Request for Proposals
                                                       Non-Personnel Detail
Direct Costs for Activity No.                      Service Activity #             2                                             2011
Activity :                                                              #VALUE!


                                                   Harris County                              Leverage Funds Source
Expense                                            Grant Funds          Leverage Funds             Description                TOTAL
Professional Fees/Contract Services
                                                                                                                          $             -
                                                                                                                          $             -
                                                                                                                          $             -
                                          Subtotal $              -     $             -                                   $             -
Travel & Training (Ineligible shelter cost)
Type of Training
                                                                                                                          $             -
                                                                                                                          $             -
Type of Travel (non-mileage)                                                                                              $             -
                                                                                                                          $             -
                                                                                                                          $             -
                                                                                                                          $             -
Mileage:

___ mi./mo. x ___ mos. x 50.5 cents/mi.                                                                                   $             -
                                          Subtotal $              -     $             -                                   $             -
Space Costs (provide location)
Location:                                                                                                                 $             -
Rent: ___ sq. ft. x $___ /ft./year                                                                                        $             -
Utilities: $__ / month x __ months                                                                                        $             -
                                                                                                                          $             -
Utilities:                                                                                                                $             -
Electricity                                                                                                               $             -
Water                                                                                                                     $             -
Telephone                                                                                                                 $             -
Other Utilities                                                                                                           $             -
                                          Subtotal $              -     $             -                                   $             -
Consumable Supplies
                                                                                                                          $             -
                                                                                                                          $             -
                                                                                                                          $             -
                                                                                                                          $             -
                                                                                                                          $             -
                                          Subtotal $              -     $             -                                   $             -
Rent, Lease of Equipment and Furniture
                                                                                                                          $             -
                                                                                                                          $             -
                   Rent, Lease Furniture Subtotal $               -     $             -                                   $             -
Other Costs
Direct Audit Costs                                                                                                        $             -
Postage                                                                                                                   $             -
Direct payments / benefits to clients                                                                                     $             -
Program specific insurance                                                                                                $             -
Rental Assistance                                                                                                         $             -
Other (specify)                                                                                                           $             -
Other (specify)                                                                                                           $             -
                            Other Costs Subtotal $                -     $             -                                   $             -
                    Non-Personnel Detail Total $                  -     $             -                                   $             -

Total Non-Personnel - All Activities:             $               -     $             -   $                           -




                                                                                                                Harris County Community Services Department
                                                                                                                               PY2011 Request for Proposals
                                 Combined Activity Budget
                                      This form will auto populate.

Service Activity #                                         1

Activity:                                        #VALUE!



Number of Units to be Provided:                      #VALUE!

                                                  Harris County         Leverage
              Expense Category                    Grant Funds            Funds          TOTAL BUDGET

Personnel                                        $             -    $          -    $                  -
Professional Fees/Contract Services                            -               -    $                  -
Travel                                                         -               -    $                  -
Lease Space                                                    -               -    $                  -
Consumables and Supplies                                       -               -    $                  -
Rent, Lease Equipment                                          -               -    $                  -
Other (audit, insurance, office content, etc.)                 -               -    $                  -
Total Activity Cost:                             $             -    $          -    $                  -
Unit Cost:                                       $             -



Service Activity #                                         2

Activity:                                        #VALUE!


Number of Units to be Provided:                      #VALUE!

                                                  Harris County         Leverage
              Expense Category                    Grant Funds            Funds          TOTAL BUDGET

Personnel                                        $             -    $          -    $                  -
Professional Fees/Contract Services                            -               -    $                  -
Travel                                                         -               -    $                  -
Lease Space                                                    -               -    $                  -
Consumables and Supplies                                       -               -    $                  -
Rent, Lease Equipment                                          -               -    $                  -
Other (audit, insurance, office content, etc.)                 -               -    $                  -
Total Activity Cost:                             $             -    $          -    $                  -
Unit Cost:                                       $             -




                                                                   Harris County Community Services Department
                                                                                  PY2011 Request for Proposals
                                            CDBG Budget Summary
                           Program Year:               2011

                         Name of Project: #REF!
                                               Activity   No. of        HCCSD            LEVERAGE        TOTAL    HCCSD
                                                                         Award                       PRGM/ACT
1. Grant Funds Requested by Activity             No.       Units        (Share)                       COSTS      Unit / Price

                  #VALUE!                         1       #VALUE! $             -                -   $       -    #VALUE!

                  #VALUE!                         2       #VALUE! $             -                -           -    #VALUE!
                                  Subtotals:                        $               -    $       -   $       -
2. Summary of Funds from other sources                                                                                                $
(Entity name and type) of funding              Activity    No. of                                                               Contribution /
(Leveraging):                                   No.        Units                                                                    Unit

                                                  1       #VALUE!               -                                                 #VALUE!

                                                  2       #VALUE!               -                                                 #VALUE!
                                   Subtotal:                        $           -


                Summary of Project Funding

Harris County - Direct                                                  #REF!

Total Other Sources of Funding (Leveraging)                         $           -

Project Budget Total:                                                   #REF!
Harris County Percentage of Total Funding
(Harris County Grant Funds / Total Revenues of Activities)                  0.00%




                                                                                        Harris County Community Services Department
                                                                                                       PY2011 Request for Proposals
                              Monthly Expenditure Plan and Narrative

                        MONTH                                             CDBG PROGRAM
MARCH                       2011                                              $0.00
APRIL                                                                         $0.00
MAY                                                                           $0.00
JUNE                                                                          $0.00
JULY                                                                          $0.00
AUGUST                                                                        $0.00
SEPTEMBER                                                                     $0.00
OCTOBER                                                                       $0.00
NOVEMBER                                                                      $0.00
DECEMBER                                                                      $0.00
JANUARY                          2012                                         $0.00
FEBRUARY                                                                      $0.00
                         TOTAL                                                $0.00

                                          Budget Narrative
Please use this space to explain the estimated monthly expenditure plan as well as any details not captured in the
forms




                                                                          Harris County Community Services Department
                                                                                         PY2011 Request for Proposals

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:3
posted:12/11/2011
language:
pages:189