COUNTY OF ROCKLAND

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					                                    COUNTY OF ROCKLAND
                       Rockland County Office of Health and Human Services Policy
                         2 New Hempstead Road, Suite 224, New City, NY 10956

               REQUEST FOR PROPOSALS                                           RFP- RC-09-004
                        Rockland Community Capacity Building Initiative

Date Issued:                        January 22, 2009

Due date for Application:           March 6, 2009 – 5:00 PM

Range of Awards:                    $2,000 – $20,000

Project Timeframe:                  Project must be operational within sixty (60) days following the
                                    notification of the funding award and completed by December 31,
                                    2009.

Eligible Applicants:                Not-for-profit organizations (community-based and/or faith-based)
                                    incorporated in Rockland County and which provide social services in
                                    Rockland County.

Application and Submission          Prior to submitting an application, each applicant is
Information:                        expected to attend a 1-hour pre-submission orientation workshop:

                                     Friday, January 23, 2009, 10:00 a.m. at Cornell Cooperative Extension
                                                               OR
                                      Wednesday, January 28, 2009, 7:00 p.m. at New City Library
                                                              OR
                                    Tuesday, February 10, 2009, 3:00 p.m. at Cornell Cooperative Extension
                                    10 Patriot Hills Drive, Stony Point, NY 10980 – 845-429-7085 ext. 117 –
                                    Registration

                                    Application must be typed, double-spaced, printed on only one side, with 1
                                    inch margins, using standard 12-Point font (Arial or Times New Roman) on
                                    White 8 ½ X 11 paper.
                                    All pages must be numbered. Do NOT email or fax.

                                    Submit:
                                        One (1) original copy with cover letter and all attachments. Use one
                                            clip to bind the original complete application. Do not use binders or
                                            staples.
                                        Two (2) additional stapled copies.

                                   Submit all required copies of application by mail or hand-deliver to:
                                            Office of the County Executive
                                            11 New Hempstead Road, 1st Floor
                                            New City, NY 10956

                                    Contact:         Ronaldo L. Figueroa
                                                     Health & Human Service Unit
                                                     TEL: 845-638-5865
                                                     FigueroR@co.rockland.ny.us
                                                       1
Background
As a demonstration program of the Administration for Children and Families of the U.S. Department of Health and
Human Services Compassion Capital Fund, the County of Rockland is offering capacity building services to faith-
based, community-based and grassroots organizations throughout Rockland County.
To this end, the County of Rockland is accepting applications from eligible organizations to receive sub-awards
through the Rockland Community Capacity Building Initiative (RCCBI) for that purpose. Capacity building refers
to activities that improve an organization’s ability to achieve its mission effectively and to sustain itself over the long
term.
RCCBI is a county-wide initiative to assist Rockland’s grassroots, faith-based and community organizations in
building organizational strength, capacity and sustainability. RCCBI provides training, technical assistance and sub-
awards for capacity building activities that produce measurable effects resulting in more sustainable non-profit
organizations. After addressing areas that are vital to long term sustainability, Rockland’s organizations will be better
equipped to understand and meet the needs of the communities they serve.
Through RCCBI, the County of Rockland along with Cornell Cooperative Extension works with faith- and
community-based organizations (F&CBO) to help increase organizational capacity in the areas of leadership and
organizational development, improve and increase “back office skills and abilities” in order to meet service mission,
build community partnerships, and become more successful in efforts to obtain funding and expand programs and
services.
In addition to financial assistance provided through sub-awards, recipients work with RCCBI educators from Cornell
Cooperative Extension for the 12-month period of the sub-award to guide and support capacity-building efforts.
Organizations receiving sub-awards are expected to collaborate with the RCCBI educators in developing an
organizational capacity-building plan, fulfill duties assigned in the capacity building plan, participate in cohort meetings
and submit relative narrative progress and fiscal reports according to a calendar determined at the commencement of the
grant period.

Purpose: Program Goals and Anticipated Outcomes

The purpose of the RCCBI sub-award program is to provide financial assistance to faith- and community-based
organizations for the purposes of building capacity and maximizing the social impact of these organizations.
1. Goals: Sub-award funding should be dedicated to sustainable organizational capacity building projects in at least one
   of the five critical areas of development:

    - Leadership development         - Organizational development         - Program development
                - Revenue development strategies          - Community Engagement
2. Outcomes: RCCBI will provide training, technical assistance and sub-awards for capacity building activities that
   produce measurable effects resulting in more sustainable non-profit organizations. The projects supported through
   these activities should provide, enhance, improve or increase knowledge, skills, abilities and resources to address
   specific organizational deficits that impede the organization’s ability to provide services to the community of
   Rockland.




                                                            2
Eligibility and Expectations
Organizations applying for a RCCBI sub-award must demonstrate at least one (1) year of continuous past service in
Rockland County, and future intention to serve at least one (1) of the six Priority Populations, which are listed below.
Applications that do not propose to use the funding to increase capacity in serving a minimum of one of the Priority
Populations will be disqualified.
        1. Homeless individuals
        2. Prisoners re-entering the community
        3. Children of prisoners
        4. At-risk youth
        5. Elders in need
        6. Families in transition from welfare to work

RCCBI Sub-awards are for capacity building projects only. Sub-awards cannot be used for direct social services and
activities; for organized fundraising or solicitation; for medical equipment or supplies; for medically-oriented trainings
and/or certification; for religious instruction, worship or proselytization; for purchase, development or distribution of
religious materials, publications or media; for purchase of real property, building construction, repairs and/or
maintenance.
All faith-based sub-award recipient organizations must abide by the Title 45 CFR 87.1 (c), which clearly delineates the
separation of all religious activity. More specifically, faith-based organizations cannot use any funds received through
the RCCBI, which serves as an intermediary for the federal CCF program, for programs or services which include
inherently religious activities. If a sub-award recipient does provide programs and services that include inherently
religious activities, then such activities must be separate in time and location from the programs or services that the
organization is seeking to improve through its association with the RCCBI and its use of federal CCF funds.
The RCCBI’s sub-award program is available to organizations with total annual operating budgets not exceeding
$500,000. Faith-based organizations with annual budgets exceeding $500,000, may be eligible if the total human
service portion of the overall annual budget is less than $350,000.
Eligible organizations must be incorporated in Rockland County, New York. 501 (c) (3) status is not a requirement.
Consideration is given to eligible groups who may not previously have been recipients of Federal government funds.
Eligible organizations should have comprehensive general liability insurance in a minimal amount of one million
dollars, combined single limit (CSL), prior to receiving an RCCBI sub-award.
Eligible organizations for the RCCBI sub-awards may have services offered by both paid staff and/or volunteers.
F&CBO which are applying for sub-awards should be small to moderate in size, with no more than ten (10) “full time
equivalents”(FTE) reflected in their current annual budget.
RCCBI sub-awards ranging from $2,000 to $20,000 for a twelve-month period are granted to eligible F&CBO based
on levels and types of needs. Sub-awards are granted in amounts that are manageable for the size and current capacity
of each sub-recipient. Sub-awards require no financial match from the sub-recipient F&CBO, although sub-recipient
F&CBO may choose to seek and invest additional resources in attaining a stated project outcome.
RCCBI sub-awards are non-renewable-- each capacity-building project is funded one time only. However, this does
not preclude sub-recipient F&CBO from applying for subsequent sub-awards in other years for new capacity-building
projects not previously funded through the RCCBI sub-awards program.
In some cases, sub-awards may be made for only a portion of the request. Applicant organizations will be asked if
they will accept the reduced amount and proceed with the funded portion of the proposed project. Applicant
organizations will have the option to either refuse the modified sub-award or accept the modified sub-award and
proceed with a respectively modified project.



                                                            3
Sub-awards must be used for the specific purpose and in the precise manner for which they were requested. All sub-
recipient organizations will need to supply documentation to this effect. Any modifications that may need to be
considered must be presented and approved by the RCCBI staff in writing.

Program Funding
The funding source for sub-awards under RCCBI comes from the federal Administration for Children and Families
Compassion Capital Fund (CCF) Demonstration Program. The County of Rockland serves as an intermediary between
the federal government and local F&CBOs.

Program Scope
Organizations receiving sub-awards will identify specific activities which will lead to improvement in one or more of
the critical organizational areas. Examples of the kinds of allowable activities relating to each critical area are listed
below. These examples are intended to be illustrations of possible activities; they are not the only activities F&CBO
may propose under any of the areas.
 1. Leadership Development       * Training on Board Composition, Function, and Policy Manual
                                 * Staff Professional and Career Development
                                 * Succession Planning
                                 * Strategic Planning
 2. Organizational Development   * Written Policies and Procedures on Employee Management and Employer Guidelines


                                 * Board Governance
                                 * Systems: Management, Human Resources
                                 * Training and Development of Volunteers
                                 * System Technology (hardware, software, IT support, and IT maintenance)

                                 * Fiscal Controls and Financial Management
                                 * Comprehensive Communications Strategy to build community awareness about organization
                                 and to market services
                                 * Attainment of 501(c)(3) status
 3. Program Development          * Curriculum Development
                                 * Program Monitoring
                                 * Evaluating Program Outcomes
 4. Revenue Development          * Designing a Funding/Donor Development Plan
 Strategies
                                 * Donor Development Training
                                 * Donor Tracking Software
                                 * Consultant to develop grant templates and to coach on grants research and preparation

 5. Community Engagement         * Community Asset Mapping
                                 * Community Needs Assessment
                                 * Establishing Collaborative Relationships




                                                                    4
Administrative and Management Requirements
By submitting a proposal for this grant, an applicant certifies that it is a duly incorporated legal entity with the ability to
meet the administrative and reporting requirements of this grant program. In addition, the applicant certifies that neither it
nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this transaction by any State or Federal department or agency. The applicant organization accepts
responsibility for keeping all records on file for the purpose of audit.

Support/Coordination of Services
Applicants must complete and submit a RCCBI Organizational Assessment along with their proposal. By submitting a
proposal, applicants agree to participate in the collaborative processes included in the RCCBI.
Grant recipients must be willing to cooperate fully with a RCCBI educator, coordinate for ongoing assistance and on-
site interviews, and participate in available training experience to the fullest extent possible.
Grant recipients are responsible for maintaining and being able to provide receipts and other related documentation on
file for the purpose of accurate reporting and audit.
F&CBOs participating in the sub-award program are expected, at minimum, to:
    -   Attend one pre-submission orientation session;
    -   Participate in RCCBI-approved cohort/affinity groups (based on shared developmental issues and needs);
    -   Attend one half-day training on outcomes and evaluation;
    -   Participate in at least six (6) additional RCCBI-approved workshops or classes within 12 months;
    -   Coordinate with RCCBI representatives for ongoing monitoring of progress, including on-site visits and
        interviews as needed.

Evaluation of Proposals:
All written proposals are screened for completeness by project staff, and are then submitted to a Review Panel selected
by the County Executive. The Review Panel reviews and assigns numerical ratings to all proposals submitted to them.
Sub-award applications are evaluated according to the following criteria:

    A. Organization Background Information (20%)
       Does the organization have a solid commitment to this project and the people residing in Rockland County?
       Does the organization’s administration support this request? Does the organization have an experienced and
       capable project leader and staff that will be assigned to the project? Has the organization collaborated with
       other community groups?

    B. Purpose of Request (55%)
       Does the project identify a thoughtful and clear strategy for building the capacity and sustainability of the
       organization? Does the organization serve a high-needs population and how? Does the Organizational Self-
       Assessment correlate with the identified need? Does the project make sense? Is the project consistent with the
       purpose of the RCCBI? Does the project appear to be well thought out?

    C. Project Budget (15%)
       Does the budget align with the project? Are the projected costs allowable and reasonable? Is there sufficient
       explanation of proposed expenditures?

    D. Attachments (10%)
       Are all the requested documents included with the application submitted?

IMPORTANT REMINDER: Funds are to used ONLY for capacity building projects that are vital to long-term
sustainability, and must be used for the specific purpose for which they are requested. Funds CANNOT be used for
                                                             5
direct services to needy individuals or families, nor to replace/supplant existing funding available for similar activities.
Funds CANNOT be used to support “inherently religious” activities and/or practices such as religious instruction,
worship, prayer, or any form of proselytizing, nor can they be used to purchase any religious or scriptural materials.

                          Submit all required copies of application by mail or hand-deliver to:

                                        Office of the County Executive
                                        11 New Hempstead Road, 1st Floor
                                        New City, NY 10956
                                 Applications must be received no later than
                          5:00 p.m. on March 6, 2009. NO EXCEPTIONS.




                                                             6
                                         RCCBI PROJECT PROPOSAL

General Application Requirements: Application must be typed, double-spaced, printed on only one side, with 1-
inch margins, using standard 12-Point font (Arial or Times New Roman) on White 8 ½ X 11 paper. All pages must be
numbered.

Cover Letter: The application must include a cover letter on official stationery signed by the official signatory of the
organization. The letter should summarize the purpose of the request, and clearly state that the organization agrees to
participate in training and receive technical assistance from RCCBI and Cornell Cooperative Extension if selected as a
sub-award recipient.

Narrative: Following the cover letter, the narrative should closely follow the format below. Please answer the
questions in the corresponding order.

A. Organizational Background Information (no more than 3 pages)
    1. What is the official name of your organization (as it appears in the Articles of Incorporation), and any other
       name or acronym by which your organization or program is known?
    2. What is the primary mission or purpose of the your organization?
    3. What is the official mailing address of the organization?
    4. What is the central telephone number for the organization?
    5. What is the fax number for the organization?
    6. What is the main e-mail address for the organization?
    7. Who is (are) the primary contact person(s) for the organization?
    8. Who is the official signatory (duly designated to sign agreements) and what is her/title?
    9. What year was your organization incorporated and how many years of continuous operation?
    10. What is the Employer Identification Number (EIN) or federal identification number of the organization?
    11. Are you receiving or have you received any Federal, State or Local government funding? If so, please explain
        (e.g. how much, for how long, for what purpose).
    12. What programs and services do you provide in Rockland County? (Please include statistical information for all
        programs for the most recent 12-month period).
    13. What community or audiences do you mainly serve (geographic or demographic)?
    14. Which of the “Priority Populations” do you currently serve or hope to serve?

    1. How many full-time and/or part-time staff do you have? What is the total “full-time equivalents” (including
       full-time, part-time and per diem workers). How many volunteers, if any?
    2. How many Board members currently serve on your Board? (Kindly supply a list of members and officers with
       your application.)

    3. Who would be principally responsible for coordinating, monitoring, and reporting regarding this project on
       behalf of your organization?



B. Purpose of Request (no more than 5 pages)
                                                           7
    1. What particular needs or challenges do you want to address through this capacity building project? Please
       refer to the five critical areas of development.
    2. What specific activities or strategies do you propose?
    3. What do you generally hope to accomplish? What key changes do you foresee? What milestones do you
       expect to reach during the year?
    4. What are your expected program outcomes? How will you measure increased service capacity or improved
       service to “Priority Populations?”
    5. What is your timeline for this project?
    6. What particular strengths, assets, resources do you already have or expect to have to support or enhance this
       particular project, or your services in general?
    7. If you were a previous RCCBI sub-award recipient, what were the key activities and accomplishments
       achieved with this support during the past year?
    8. If you are a previous RCCBI sub-award recipient, how many RCCBI-approved capacity-building activities
       (e.g. conferences, seminars, technical assistance sessions, networking sessions) did you participate in during
       the past 12 months?

IMPORTANT: PLAN OF ACTION (Attachment) – Your application must include a detailed plan as an
attachment. The format below will guide you in presenting your plan in a clear manner.
   Capacity-Building Area         Outcome                     Activities                  Outcome Indicator
 Identify Area:              Describe the           Describe the specific tasks   Describe how you will measure
                             desired capacity       that your organization will   progress towards your desired
 Revenue Dev’t               building result you    perform.                      outcome, e.g. what way(s) has
 Leadership Dev’t            want for your                                        change occurred and how do you
 Program Dev’t               organization                                         know.
 Organizational Dev’t
                                                                                  Describe the specific measurable
 Community Engagement
                                                                                  change that will occur when the
                                                                                  outcome is achieved
 Example 1                   Increase the           Staff/Board will create a     Organization has created a written
 Revenue Development         capacity of the        written development plan      revenue development plan and
                             organization to                                      initiated plan in March 2009
                             raise funds            2 staff/board members will
                                                    attend a grant writing        Organization has submitted two
                                                    training                      grants to new potential funding
                                                                                  sources in June 2009
                                                    Identify 3 new potential      Organization has increased revenue
                                                    funding sources               from private foundations by $30,000
                                                    Write and submit 2 grants     in 2009
 Example 2                   Increase the           Board will create/update      Organization developed and
 Leadership Development      capacity of the        board packet                  distributed a packet to all board
                             organization to                                      members by March 2009
                             create and sustain     Assess effectiveness of
                                                    board meetings and current    Organization developed a written
                             the vision, inspire,
                                                    structure                     board action plan and initiated plan
                             inspire, model,
                                                                                  in February 2009
                             make decisions,
                             and provide            Develop and implement a       Organization has recruited three new
                             direction              board action plan             board members to the board by
                                                                                  March 2009
C. Project Budget: Your narrative must included a detailed budget that includes a summary followed by a budget
narrative. The following is a suggested format for presenting your budget narrative in a simple and clear manner.

                                                             8
                                            BUDGET SUMMARY
            ITEM                             COST                          DESCRIPTION
                                                     Support from
                                Requested from      Other Sources
                                   RCCBI            (If Applicable)

Personnel

In-State Travel

Supplies and Materials

Services

Equipment

Contracted Services

Training Costs

           Subtotal :

      TOTAL COST
      OF PROJECT:



Budget Narrative: You must provide a narrative (not to exceed 3 pages) to accompany this Project Budget
Summary. For each line item requested in the Project Budget Summary above, please give a more detailed description
and explain how the resources will be used. Refer to the category definitions on the next page for budget category
descriptions and allowable expenditures. All funding requests in the project budget must have a designated purpose
explained in the budget narrative.


Budget Categories: Following are some definitions of the allowable categories for which your organization may
seek funding from the RCCBI:

        Personnel: Full-time and part-time salaried employees, including FICA, Retirement, Group Insurance,
        Workers Compensation, FICA Medicare, State Unemployment, Other Employee Benefits

        Travel: In-State Travel, In-State Lodging

        Supplies and Materials: Training supplies, Photocopy, Photo and Reproduction Supplies, Shop Supplies,
        Software up to $999 per unit, Office and Computer Supplies, Postage and Mailing

        Services: Long Distance Telephone, Internet Service, Office Equipment Rent, Other Equipment Rent, Leased
        Items

        Equipment: Telephone Equipment Charges, Equipment (non-computer), Computer Hardware/Equipment,
        Software costing $1000 per unit and above

        Contracted Services: Consultant and Professional Services, Computer Processing Services, General
        Contracted Services
                                                          9
        Training Costs: Dues, Subscriptions, Registration Fees, Scholarships and Fellowships, Educational Expenses,
        Honorariums and Speakers


D.      OTHER REQUIRED INFORMATION – Please remember to include the following as attachments


● List of Board of Directors and Officers

● Latest Annual Financial Report and last filed 990 (federal report)

● Completed RCCBI Organizational Self Assessment

● Copy of Incorporation Letter

● Copy of General Liability Insurance certificate

● Plan of Action

● Checklist




                         Submit all required copies of application by mail or hand-deliver to:

                                         Office of the County Executive
                                         11 New Hempstead Road, 1st Floor
                                         New City, NY 10956

                                Applications must be received no later than
                         5:00 p.m. on March 6, 2009. NO EXCEPTIONS.




                                                          10
APPENDIX A

                    Rockland Community Capacity Building Initiative (RCCBI)
                                   Request for Proposal
                                               Checklist

Organization:_______________________________________________________________

Executive Director:____________________________________

Telephone:________________

E-Mail: ___________________________________________________________________

Address: __________________________________________________________________


_______      Sub-Award Proposal and Cover Letter

_______      List of Board of Directors and Officers

_______      Copy of Incorporation Letter

_______      Last filed 990
             Please Indicate Year __________________

_______      Latest Annual Financial Report
             Please indicate Year __________________

_______      General Liability Insurance Statement

_______      Checklist

_______      Completed RCCBI Organizational Self Assessment

_______      Plan of Action

_______      Organization Service Statistics




                                                     11
APPENDIX B              Rockland Community Capacity Building Initiative (RCCBI)
                               Organization Annual Summary of Service Statistics

Organization Name: _______________________________________________________________

Total Number of Persons (unduplicated) Receiving Service in 2008: __________________________
Please complete information for unduplicated services to individuals in 2008:

Residence                                               Gender
Clarkstown              _______                         Male                    _______
Haverstraw              _______                         Female                  _______
Orangetown              _______
Ramapo                  _______                         Household Income
Stony Point             _______                         Below $9,999            _
Out of County           _______                         $10,000 - $24,000       _
                                                        $25,000 - $34,999       _
                                                        $35,000 - $49,999       ______
                                                        $50,000 +               ______

Background                                              Target Population
African American                                        Homeless                _______
Asian                                                   Youth                   _______
Caribbean/W. Indian                                     Veterans                _______
Caucasian                                               Parents                 _______
Hispanic/Latino                                         Seniors                 _______
Other                                                   Mentally Ill            _______
                                                        Physically Disabled     _______
                                                        Immigrant               _______
Age                                                     Dev’tally Disabled      _______
0 – 4 years                                             Incarcerated            _______
5 – 12 years                                            Families in Transition _______
13 – 19 years                                           General Public          _______
20 – 34 years           _______                         Other                   _______
35 – 49 years           _______
50 – 64 years           _______                         Education
65 – 74 years           _______                         Less than High School _______
75 years +              _______                         High School Graduate ______
                                                        College Courses         _
                                                        Advanced Degree
                                                         12
APPENDIX      C

COUNTY OF ROCKLAND - Health and Human Services Unit, Office of the County
Executive, 11 New Hempstead Road, 1st Floor, New City, NY 10956
TITLE: ROCKLAND COMMUNITY CAPACITY                          RFP NUMBER:
BUILDING INITIATIVE                                         RFP-RC-09-004

RFP QUESTION FORM

ALL QUESTIONS PERTAINING TO THIS RFP MUST BE SUBMITTED IN WRITING
USING THIS FORM; WE WILL RESPOND AS SOON AS POSSIBLE.

FAX TO: _ _845-708-7250
ATTENTION: Ron Figueroa

   Date: _____________

Applicant: ___________________ Contact Name: ___________________
Fax No.: ___________________ Telephone No.: ___________________
E-mail address: _______________________________________________

Question(s): please reference RFP section or page number for each question:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________



                                        13
APPENDIX D
AFFIDAVIT OF DISCLOSURE OF POLITICAL CONTRIBUTIONS PURSUANT TO CHAPTER 323
OF THE ROCKLAND COUNTY CODE (STATE OF NEW YORK, COUNTY OF ROCKLAND)

NAME                            OF                          REPORTING                                               ENTITY:
______________________________________________________________________________________

ADDRESS: ___________________________________________________________________________

TELEPHONE NO.: _____________________EXT:_____               FAX NO.: __________________________

THE REPORTING ENTITY IS (Check one of the following):

__________ AN INDIVIDUAL           ___________ A PARTNERSHIP           __________ A CORPORATION

THE REPORTING ENTITY: (Check One)
_____________ Will enter into a contract with the County of Rockland which did/did not result from public bidding in excess of
              Ten Thousand Dollars ($10,000.00) this calendar year.

_____________ Is currently under a contract with the County of Rockland in excess of Ten Thousand Dollars ($10,000.00).

THE REPORTING ENTITY, ITS MEMBERS, DIRECTORS, POLICY MAKING OFFICERS, OR MAJORITY
SHAREHOLDERS, HAVE DIRECTLY OR INDIRECTLY MADE THE FOLLOWING CONTRIBUTIONS TO THE PERSONS
OR ORGANIZATIONS LISTED BELOW. (PLEASE LIST ALL CONTRIBUTIONS HAVING A VALUE IN EXCESS OF
TWO HUNDRED DOLLARS ($200.00) PER YEAR MADE TO ANY POLITICAL PARTY OR ANY INDIVIDUAL OR ANY
COMMITTEE FOR AN INDIVIDUAL RUNNING FOR PUBLIC OFFICE IN ROCKLAND COUNTY OR IN A DISTRICT IN
WHICH ROCKLAND COUNTY IS LOCATED, FOR A PERIOD OF THREE (3) YEARS PRIOR TO THE DATE OF THIS
AFFIDAVIT.).:

NOTE: PLEASE ANSWER “NONE” OR LIST EACH CONTRIBUTION SEPARATELY.
(Use additional sheets if necessary)
 NAME OF                  RELATIONSHIP TO CONTRIBUTION DATE         OF                                VALUE        &
 CONTRIBUTOR              REPORTING       MADE TO      CONTRIBUTION OF                                NATURE     OF
                          ENTITY                                                                      CONTRIBUTION




I am the __________________________________________________________ (Title or Office) of the reporting entity listed
above.

I make this affirmation based upon my personal review of the books and records of the reporting entity. All of the foregoing
information is true to the best of my knowledge, after inquiry. I make these statements under penalty or perjury.

SIGNATURE: ____________________________________________

PRINT NAME & TITLE: ____________________________________

SWORN to before me this ______________ day of _____________________, 2008


_____________________________________________
Notary Public




                                                             14
APPENDIX E
CERTIFICATION REGARDING AFFIRMATIVE ACTION PLAN
AND
BUSINESS DEALINGS IN NORTHERN IRELAND
(State of New York)

                  :SS

County of Rockland

AFFIRMATIVE ACTION PLAN

I, _______________________________________ being duly sworn, deposes and says that he/she is the

_________________________ of the ___________________________________ Corporation. I and/or the

corporation (DO) (DO NOT) employ fifteen (15) employees and I (TRANSACT) (DO NOT TRANSACT)
              (Circle One)                                            (circle one)
a minimum of $50,000 per annum business with the County of Rockland.

Based on the above information, If either the Corporation or I is transacting business greater than $50,000 annually, a copy of the
corporations Affirmative Action Plan is attached to this RFP submittal

BUSINESS DEALINGS IN NORTHERN IRELAND – MACBRIDE PRINCIPLES

In accordance with Article 5 of the County of Rockland Procurement Policy, the proposer, by submission of this proposal certifies
that it or any individual or legal entity in which the proposer holds a 10% or greater ownership interest, or any individual or legal
entity that holds a 10% or greater ownership in the proposer, either: (answer yes or no to one or both of the following, as
applicable).

         (1) has business operations in Northern Ireland:   Yes_______       No________ if yes;

         (2) shall take lawful steps in good faith to conduct any business operations in Northern Ireland in accordance with the
              MacBride Fair Employment Principles relating to the nondiscrimination in employment and freedom of workplace
              opportunity regarding such operations in Northern Ireland, and shall permit independent monitoring of their
              companies with such Principles.

                                                               Yes________      No__________

                                                               ________________________________________
                                                                      SIGNED
SWORN to before me this

____________ day of ________________ 20__________


Notary Public: __________________________




                                                                 15
APPENDIX F
COUNTY OF ROCKLAND Health and Human Services Unit, Office of the County Executive,
11 New Hempstead Road, 1st Floor, New City, NY 10956
TITLE:                                               RFP NUMBER:
 ROCKLAND COMMUNITY CAPACITY                         RFP-RC-09-004
BUILDING INITIATIVE

INSURANCE: THE RFP NUMBER IS TO APPEAR ON ALL INSURANCE CERTIFICATES

INDEPENDENT CONTRACTOR: The CORPORATION / CONTRACTOR/ AGENCY / CONSULTANT, is an independent
contractor and covenants and agrees that it, its agents, servants and/or employees, will neither hold itself/themselves out as, nor
claim to be an employee, servant or agent of the COUNTY, and that it, its agents and employees will not make claim, demand or
application to or for any right or privilege applicable to an officer or employee of the COUNTY including, but not limited to,
Worker’s Compensation coverage, unemployment insurance benefits, Social Security Coverage or retirement membership or
credit.

INSURANCE REQUIREMENTS:

GENERAL LIABILITY: The CONTRACTOR shall, at its/his/her own cost and expense, procure and maintain insurance to cover
his/her/its work, services, employees, agents and servants under the terms of this agreement which shall include, but not be limited
to:

A.       XX       Comprehensive general liability insurance in a minimal amount of one million dollars, combined single limit
                  (CSL).
Or

B.                Comprehensive general liability insurance in a minimal amount of one million dollars, combined single limit
                  (CSL); with two million dollars excess of one million dollars.

WORKERS COMPENSATION: The CONTRACTOR shall procure, pay for, and maintain during the entire term of the contract
such insurance as will protect both the owner and the contractor from claims under worker’s compensation acts and amendments
thereto and from any other claims for property damage and for personal injury including death, which may arise from operations
under this contract, whether such operations by contractor or by any other party directly or indirectly employed by the Contractor.
Copy of Certificates to be provided to the County of Rockland.

COMPREHENSIVE AUTOMOBILE INSURANCE: The CONTRACTOR procure, pay for, and maintain during the entire term
of the contract in an amount no less than $300,000/$500,000 for each occurrence for bodily injury, and $100,000 for each
occurrence of property damage.

DISABILITY INSURANCE & UNEMPLOYMENT INSURANCE: The Contractor shall procure, pay for, and maintain during
the entire term of the contract any disability benefits and unemployment insurance as required by law. Copy of Certificates to be
provided to the County of Rockland.

MALPRACTICE INSURANCE:               (I.E. professional liability) in the amount of no less than one million and 00/100th
($1,000,000.00) dollars.

                  If this box IS CHECKED, malpractice insurance IS REQUIRED.

CONTRACTOR TO HAVE ALL OTHER INSURANCE REQUIRED BY LAW.

When the CONTRACTOR signs and returns this agreement, contractor shall provide the County (Department of Purchasing) with
a policy endorsement showing the above required insurance. The County of Rockland shall be named as additional insured on all
insurance policies and policy endorsements, and the policies and policy endorsements shall provide that the insurance shall not be
canceled or terminated without thirty (30) days prior written notice to the County of Rockland. Unless and until CONTRACTOR
obtains such insurance and provides a policy endorsement to the County, this agreement shall not be effective and no moneys shall
be paid or given to the CONTRACTOR.



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