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Please review and answer the following questions by Smjt2G


									                             Office of the Attorney General (OAG)
                         Bureau of Advocacy and Grants Management
                                  Victims of Crime Act (VOCA)
                                  Sub-grantee Self-evaluation

Sub-grantee Legal Name

Sub-grantee Doing Business As (DBA)

Sub-grantee Mailing Address

 Area Code/Phone Number             Area Code/Fax Number                  Email Address

Contract Period of Performance     October 2011 – September 2012

Sub-grantee Contact Name and Title


I (We) certify that the information contained in this Subgrantee Self-Evaluation is true and
accurate. I (We) acknowledge by obligation to notify the OAG Grant Manager for this contract of
any changes to statements made.

Signature of Agency Director                              Date Self-Evaluation Completed

________________________________________                  __________________________
Type or Print Name and Title

Signature of Board President (for Non-profits only)       Date Signed by Board President

_________________________________________                 ___________________________
                                      Sub-grantee Self-evaluation
Instructions: The Subgrantee Self-Evaluation is one of several documents that the OAG reviews to gauge
subgrantee compliance with applicable state and federal laws and rules, program guidelines, and the VOCA
agreement. Please review and answer the following questions. If you have any questions, please contact your
Grant Manager. Please attach explanations as needed.

1. Sub-grantee maintains documentation to substantiate its organization structure and tax status (i.e. Articles
   of Incorporation, Bylaws, State of Florida Business License).

    Yes                 No        If “No,” please explain:

2. Sub-grantee maintains all insurance necessary and appropriate for its agency’s operations.

    Yes                 No        If “No,” please explain:

3. Is the sub-grantee currently, or within the past year, involved in any litigation or administrative dispute
   resolution proceeding, including civil rights complaints, by current or past employees or service recipients?

    Yes                 No        If “Yes,” please explain:

4. In the past year, has the sub-grantee received any findings or a corrective action plan from any financial
   audit, license renewal, administrative proceeding, or contract monitoring review?

    Yes                 No        If “Yes,” please explain:

5. Has the sub-grantee’s VOCA program undergone any major restructuring within the past year?

    Yes                 No        If “Yes,” please explain:

6. Has there been turnover in the program’s management within the past year? Management includes the
   executive director, program director, accounting/fiscal managers, etc.

    Yes                 No        If “Yes,” please explain:

7. Has there been turnover of direct services program staff within the past year? Program staff includes
   advocates and other direct service staff.

    Yes                 No        If “Yes,” please explain:

8. If the sub-grantee is required to have and maintain a board of directors, what are the minimum and
   maximum number of board members required, in accordance with the agency’s bylaws?

9. How many board members are currently on the board of directors?

Sub-grantee Self-Evaluation
Page 2
10. In accordance with the agency’s bylaws, what constitutes a quorum?

11. Please list any and all family relationships that exist between the board of directors, the agency’s principal
    officers, the agency’s employees, and any independent contractors.

12. In the past 12 months, has the board taken any action without having the required quorum present?

    Yes                No          If “Yes,” please explain:

13. Does the board schedule and conduct meetings on a regular basis and in accordance with the agency’s

    Yes                No          If “No,” please explain:

14. Are there any amounts or reports due to the Internal Revenue Service and any other taxing agency that have
    not been paid or filed? Specify amounts, reports, and due dates.

15. Have any service-related grievances/complaints been filed against the agency? If yes, what were the
    grievance(s), date(s), and other pertinent information?

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