REQUEST FOR PROPOSAL
                 RELEASED BY
               COUNTY OF SUMMIT

                 47 NORTH MAIN STREET
                    AKRON, OH 44308

           Proposals Due by 12:00 P.M. E.S.T.
                  Friday, July 6, 2007
                       Contract Period
                       7/1/07 to 6/30/08
                    Renewal Option Period
                       7/1/08 to 6/30/09

James B. McCarthy
Summit County Executive

Sarah L. Kisner, JD
Director, Department of Job and Family Services


CSDJFS Vision & Mission                               Page 3

Introduction & Background                             Page 3

Scope of Work                                         Page 4

Proposal Information                                  Page 5

Proposal Format                                       Page 6

Proposal Procedure                                    Page 7

Budget Considerations                                 Page 8

     A.    Proposal Signature Sheet                   Page 9
     B.    Organization Description                   Page 10
     C.    Organization Capacity                      Page 10
     D.     Requested Service Delivery Description    Page 10
     E.    Position Description Information           Page 11
     F.    Appendix:
           •    Required Documentation                Page 12
     G.        Attachments & Supportive Information   Page 15
     H.        Budget Instructions Budget Forms       Page 16

The County of Summit Department of Job and Family Services is committed to
providing high quality services in order to promote self-determination and positive
outcomes for residents of County of Summit

County of Summit Department of Job and Family Services will assure that the
residents of County of Summit have access to resources and services necessary
to obtain and sustain quality of life, self-determination and self-sufficiency in
order to build stronger families and a better community.

The CSDJFS announces the availability of Child Care Quality Grant funds for the
purpose of entering into a Purchase of Service Agreement. The contract will be
awarded to a state licensed Child Care Center. The County seeks a Child Care
Center provider willing and able to operate a “drop-in” child care services at the
County’s newly created Job Center.

CSDJFS is committed to providing quality services to Summit County residents in
order to promote self-determination, self-sufficiency, and positive outcomes for
those seeking assistance. A wide range of services are available to qualifying
residents including but not limited to, cash assistance, food stamps, and social
services. Services are provided to residents of all ages, races, religious
denominations and abilities.

In 1996 the Federal Personal Responsibility and Work Opportunity Reconciliation
Act (PRWORA) authorized the Temporary Assistance to Needy Families (TANF)
program created to reduce the cyclical dependence on the welfare system. TANF
encourages self-sufficiency for families through employment while meeting their
basic needs through temporary cash assistance. Since the implementation of
TANF a direct result of persons seeking employment, becoming employed and
retaining employment has been the very real need for an increased availability of
quality child care.

One of the methods to assist unemployed persons find employment has been
met through some of the objectives of the Workforce Investment Act (WIA) of
1998. WIA was created to provide a framework for a national workforce
preparation and employment system. WIA was authorized by Title I and designed
to meet the needs of the nation’s employers, job seekers, and those who want to
further their careers. A key component of the WIA employment system is the
mandate of a career facility. This mandate is often applied through a delivery
system of employment services physically located within “one-stop” facility. In
Summit County, this mandated career facility opened in September of 2006 and

is known as “The Job Center”. The Job Center is centrally located for all Summit
County residents at: 1040 East Tallmadge Avenue, Akron, Ohio.

Persons utilizing the Job Center as a resource to seek employment opportunities,
may have a need to bring their child(ren) with them while visiting the center. This
action may be prohibitive to their ability to fully concentrate on the various
employment seeking methods available through the Job Center. Further,
Participants of CSDJFS’ services/programs may have to meet with Case
Managers for long interviews that can be difficult and inappropriate for children.
Therefore, to eliminate this barrier and address the needs of all the Summit
County residents utilizing the Job Center, one of the services CSDJFS desires to
make available is the accessibility of a “drop-in” child care service. To this end,
CSDJFS is currently seeking proposals for the delivery of a drop-in child care

Problem Statement
On average 250 Summit County residents per day seek the services of the Job
Center, many with multiple visits throughout the month. The majority of programs
operating in the Job Center, require Participants to be physically present to meet
staff personnel when determining program eligibility. Some of these meetings
require personal interviews and information gathering sessions in order to
complete the processing of perspective applicants. In order to have the
Participants’ fullest attention while at their appointment, a Child Care Drop-In
services needs to be provided for the Participants’ children. Based upon other
County’s experiences with drop-in services, it is estimated the length of care
averages from thirty (30) minutes to two (2) hours depending on the purpose of
the appointment.

Drop-in child care services will be contracted for the County’s Job Center facility
located at 1040 East Tallmadge Avenue, Akron.

Hours of Operation
The Job Center is open Monday, Wednesday and Friday from 8:00 a.m. to 4:30
p.m. with Tuesday and Thursday operations extended until 7:00 p.m. The Drop-
in child care services should mirror these operating hours.

The space designated for the drop-in facility has a City of Akron occupancy
permit based upon square footage authorizing a capacity of 32 children
regardless of the age combinations, and eight (8) adults. No state child care site
license will be required to provide these services. However, all the local
ordinances for health and safety standards typically expected of any public
facility must be met including adhering to the occupancy permit. Further, the
County expects Parents must remain at the Job Center, sign their child in, and be

accessible. Any parent found in violation of this rule would not be permitted to
use the service.

The County requests the operator adhere to the state’s adult to child ratios for
child care services. The National Association for the Education of Young Children
Accreditation (NAEYC) recommends the following Adult/Child Ratios:
               Infants              1 adult to 4 children
               Toddlers             1 adult to 5 children
               Preschoolers         1 adult to 10 children
               School-age           1 adult to 12 children
The County will give preference to a potential operator who can demonstrate
their staff are credentialed professionals, experienced with all age groups and
able to work with children with special needs. To receive this preference,
potential operators must demonstrate 4 out 5 of the following:
     they have met the NAEYC qualification standards;
    capable of rendering first-aid,
    screening for communicable diseases,
    if needed, providing proper child feeding,
    and maintaining high standards of child hygiene and child care.

The goal of the Drop-in Center Project is to create a warm, family friendly child
care center atmosphere that is not simply a “babysitting service”. The County
desires a high quality child care service that serves the needs of the children
while modeling high quality services for the parents. The Drop-in service is
supporting the County and Job Center partner staff enabling them to attend to
the parents’ employment needs.

                                Proposals due:
                                  July 6, 2007
                                 12:00 PM EST
The contract awarded under this RFP will utilize State of Ohio funding available
to the CSDJFS through an allocation of Child Care Quality Grant (CCQG) funds.
The CCQG fund is identified by the Catalog of Federal Domestic Assistance
(CFDA) by number 93.575. CSDJFS has estimated the annual funds available
for the operator of the drop-in center is approximately $70,000 per year.
Once the center is in operation, depending upon actual costs, this figure might
be adjusted. This funding shall cover salaries, general costs (i.e. sealed snacks,
beverages, art and office supplies, etc.) and phone bills.
       Lease CSDJFS will pay the Job Center owner for the lease/utilities of the
       Insurance The selected operator is expected to maintain all relevant
       insurance costs associated with this type of business.

       Furnishings CSDJFS is currently in the process of purchasing many
       items for the site (e.g. furniture, rugs, cribs, cots, TV, changing table, DVD,

There is one (1) contract renewal option associated with this RFP. The Renewal
is contingent upon CSDJFS receiving adequate allocation from the State,
Summit County Council approval and Provider’s demonstrated performance.

Conflict of Interest
Should the proposal receive funding, all providers will be required to sign a
Statement of Ethical Behavior, as well as a Statement of Conflict of Interest.

Technical Assistance
Questions/technical assistance while developing responses to the packet, the
following CSDJFS staff members will be available to answer questions pertaining
to guidelines contained herein:

   •   Ralph Sinistro: 330-633-3055 for questions relating to the space the
       Drop-in Child Care site will occupy
   •   Jennifer Daubenspeck: 330-643-7926 for questions related to proposal

The following material contains instructions for completion of each of the above
listed proposal components. Any requested specific information should be
supplied in a manner that complies with the standardized format or as directed.
Any additional relevant supportive information that meets the purpose of any
component should be in narrative form and submitted as an attachment.

Submit one (1) original and four (4) copies for a total of five (5) sets of your
TYPEWRITTEN proposal in the prescribed format to:
                          Christine Gardner Marshall
                                Deputy Director
                            Contract Administration
                              County of Summit
                    Department of Job and Family Services
                             47 North Main Street
                              Building 1, Floor 2
                              Akron, Ohio 44308

Proposals are to be mailed or hand-delivered to the County Department and
office shown above. Proposals that are not typewritten will not be reviewed for
funding consideration.

The County reserves the right to reproduce the submitted proposal during the
internal review process. DO NOT PUT THE PROPOSALS IN ANY TYPE OF
PERMANENT BINDER. Anything used to fasten the proposal together in a
permanent manner such as three-ring binders, spiral binders, staples, or report
covers are considered a binder. Rubber bands, paper clips and binder clips may
be used to fasten proposals together, as these are easily removed. Also,
proposal sections may not be separated using tab systems. Proposals received
in a binder will not be reviewed for funding consideration. This requirement
will be strictly enforced.

Please note this is not a sealed bid process. Only proposals received by
12:00 P.M. EST, Friday, July 6, 2007 will be reviewed and considered for
funding. All proposals will be time and date stamped as received.
Proposals received after this time, or that are received incomplete, will not
be considered or accepted. Any late proposals will be returned unopened
to sender. This requirement will be strictly enforced.

Upon receipt of proposal, an acknowledgement letter will be sent to the
respondent. Please note that this acknowledgement may contain requests for
revisions or additional information. Such requests may occur anytime during the
review process.

If your proposal is accepted for funding, you may receive notice regarding a
deadline for submitting a final and or revised budget. If your proposal is rejected
for funding, you will receive written notice from the County.

                Proposal and Budget due by 12:00 P.M. E.S.T.
                               July 6, 2007

Keep the following for reference when completing the Budget Packet of this
   • The respondent’s pricing quotation is to be itemized and include all costs
      associated with the operation of a drop-in facility.
   • All prices quoted are on a not to exceed basis.
   • Provider’s billing will be structured on a cost reimbursement basis.
   • Upon award of a contract, only items identified in the contract and
      approved budget will be eligible for reimbursement.
   • Any changes to items identified in the contract will be subject to CSDJFS
      approval before consideration for payment can be made.
   • Provider is expected to maintain copies of all receipts for purchases of
      equipment, activities or materials paid through Child Care Quality Grant

                                                                           FOR CSDJFS USE ONLY
                                                                           By: ___________________


                            REQUEST FOR PROPOSALS
                         CHILD CARE QUALITY GRANT FUNDING
                          Job Center Child Care Drop-in Services
                                   FISCAL YEAR 2008

Name of Proposing Organization/Firm (legal name and dba’s)          Federal I.D. #

Address of Proposing Organization/Firm                              City/Zip Code

Name of Person Preparing Proposal                                    Phone Number #

Organization Web Site Address                    Preparer’s Email Address

Workers’ Compensation and Unemployment Insurance Account #’s

Proposed Service Provision:

Total Amount of this Proposal Request: $__________________________

I hereby attest that I have reviewed this proposal, and I am in full agreement with its
content and cost. I further attest that the cost and price information submitted is accurate
and complete and is based on current available data. I further assure that I have the
authority to commit the organization/firm to submit this proposal and will abide by all of
the conditions and assurances implied or required herein. Should this proposal be
accepted, this organization is willing to comply with all provisions of this RFP and the
County’s general contract terms and conditions.


Name & Title

___________________________________________________ __________________
Printed Name & Title                                 Date

This section of the proposal is a description of the proposing organization. Be
very specific and detailed in addressing required information.
   1. Briefly and concisely, state the organization’s purpose as defined in its
       Articles of Incorporation, including its classification such as public, private,
       corporation, partnership, not for profit, etc. include a copy of the current
       state license as an attachment to the proposal. Very important: if the
       organization is incorporated under one name, but does business under
       another, clearly state both names and describe this relationship.
   2. Describe the organization’s governing structure, years in operation and
       years of experience in providing child care services and any experience
       with the requested drop-in services.

     1. Describe for the review team:
           o that the organization has sufficient credentialed staff to support the
               operation of a drop-in center.
           o that the organization has suitable administrative, accounting, and
               management information systems in place.
           o that the adequate policies and procedures in place to verify staff
               reference checks and criminal background history?
           o that the organization has an educational/training plan to maintain staff

This section of the proposal is a description of the service provision (i.e. the
operation of the drop-in center) and how you propose it will be designed and
implemented. The responses should be very specific and detailed in
addressing required information. Consider pages 3-5 (Introduction, Background
and Scope of Work) when developing responses to this section.

The Drop-in Center should be designed with a variety of age-appropriate
educational equipment and materials that will address the presenting needs of
children ages 6 weeks to12. Children should have the opportunity to take part in
a variety of creative activities while under care.
    1. Describe your proposed drop-in child care service delivery model to highlights
       planned achievements and the desired results to meet the County’s
       presented needs described herein.
           • This description should include an overview of the approach that will
               be used to operate the Drop-in Child Care service, including the
               envisioned daily routine.
           • This description should include how a quality service as well as age-
               appropriate activities for the children will be provided.

   2. Provide your envisioned/proposed rule structure, including policy and
      procedure for the general operation of this site.
         • This description should include how you plan to implement parental
             rights and responsibilities.
         • This description should include how you plan to maintain an organized
             course of business with the large volume of Job Center visitors who
             may utilize this Drop-in Center on a first come first serve basis.

   1. Does/or has your organization partnered with any other public agencies
      and/or other organizations to deliver the type of desired services. If so,
   2. Please provide a description that the organizational entity has the resources
      (time, staff, etc.) and capability to carry out the overall plan for an intensive
      and dynamic drop-in service?

Describe all position descriptions which are included in the budget. Description
should include minimum qualifications, specific job duties and salary ranges. If
the particular discipline requires licensure or certification (e.g. CPR) of individuals
providing the service, this must be part of the minimum qualifications, and the
provider must be able to insure that staff meets these requirements. If applicable,
include as an attachment resumes of staff currently providing services.

The following items must be included in this section in the following order. If a
form is included in this packet it is noted next to the item. If the request is not
applicable please indicate such in your response and state the reason.
   1. Copy of the certificate or receipt for the Articles of Incorporation from the
       State in which the organization operates.
   2. Provider shall provide a Certificate of Insurance naming the County of
       Summit as an Additionally Insured with regard to General Liability
       upon execution of this Agreement. Provider agrees to provide and
       maintain throughout the term of this Agreement the following with regard
       to insurance:
           (a) General Liability insurance with limits of One Million Dollars
               ($1,000,000) per occurrence;
           (b) Certificates of Insurance: include accident, auto, general liability
               and property;
           (c) Worker’s Compensation insurance in such limits as prescribed by
           (d) 30 days of advance written notice of policy cancellation, non-
               renewal, reduction of limits, or other material modification.
   3. Sign and notarize a Non-collusion affidavit - form included.
   4. Complete a Declaration of Property Tax Delinquency – form included.

    5. Sign and notarize an EEO Statement – form included

NON-COLLUSION AFFIDAVIT______________________________

State of Ohio
County of Summit

________________________________ being first duly sworn and deposed says that he or she is
______________________________________________ (hereafter referred to as “the Company”) the
party making the foregoing Proposal, that such Proposal is genuine and not collusive or a sham and is made
in good faith and without fraud; that the Company is not functionally interested in, or otherwise affiliated in
any business way with any other bidder on the contract; that the Company has not colluded, conspired,
connived, or agreed, directly or indirectly, with any bidder or person to put in a sham proposal or to refrain
from bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion or
communication of conference with any person, to fix the price of the Company’s proposal or of any bidder,
or to secure any advantage against County of Summit or any person or persons interested in the proposed
contract; and that all statements contained in said proposal are true.

                                                        Official Signature                           Date

    Sworn to and subscribed before me this ____ day of _____________, 20___

    Notary Public in and for The State of Ohio


ORC 5719.042 I, ________________________________, hereby affirm that the Proposing organization
herein, ______________________________________, is ____ / is not ____ (check one) charged at the
time of submitting this proposal, with any delinquent property taxes on the general tax list of personal
property of the County of Summit.

If the Proposing Organization is delinquent in the payment of property tax, the amount of such due and
unpaid delinquent tax and any due and unpaid interest is $____________________.

State of Ohio
County of Summit

Before me, a notary public in and for said County, personally appeared ____________________________,
authorized signatory for the Proposing Organization, who acknowledges that he/she has read the foregoing
and that the information provided therein is true to the best of his knowledge and belief.

                                                       Official Signature                      Date

Sworn to and subscribed before me this ____ day of _____________, 20___

Notary Public in and for The State of Ohio

 A. The CONTRACTOR agrees that in the hiring of qualified employees for the performance of work
    under this contract or any subcontract, no contractor, subcontractor, or any person acting on their
    behalf, shall discriminate on the basis of race, creed, gender, disability, national origin or ancestry,
    or for any other reason against any citizen of this state who is qualified and available to perform
    the work related to the employment.

 B. The CONTRACTOR agrees that no contractor, subcontractor or any person on his behalf shall, in
    any manner, discriminate against or intimidate or retaliate against any employee hired for the
    performance of work under this contract on account of race, creed, gender, age, handicap, national
    origin or ancestry.

 C. Any provision of a hiring hall contract or agreement which obligates a contractor to hire, if
    available, only such employees as are referred to him by a labor organization, shall be void as
    against public policy and is unenforceable with respect to employment under any public works
    contract unless at the date of execution of such hiring hall contract or agreement, or within thirty
    (30) days thereafter, such labor organization has in effect procedures for referring qualified
    employees for hire without regard to race, creed, national origin or ancestry and unless such labor
    organization includes in its apprentice and journeyman membership, or otherwise has available for
    job referral potential employees without discrimination of any kind.

 D. The CONTRACTOR states that it has a written affirmative action program for the employment
    and effective utilization of economically disadvantaged persons, as defined in Division (E)(1) of
    Section 122.71 of the Ohio Revised Code and that annually the CONTRACTOR shall file a
    description of the affirmative action program and a progress report on its implementation with the
    Equal Employment Opportunity Office of the Department of Administrative Services.

                                                    Official Signature                            Date

 Sworn to and subscribed before me this ____ day of _____________, 20___

 Notary Public in and for The State of Ohio

For the RFP include, with the submitted proposal packet, one (1) set of any
requested and supportive information the organization believes will enhance the

   Requested Attachments:
    • State License to operate a Child Care Center
    • Resumes, individual licenses & certifications (if applicable)

                        COUNTY OF SUMMIT


Salaries - Includes all renumeration, paid currently or accrued, for services
rendered during the period of the contract. Salaries are allowable to the extent
that the costs are reasonable for the services rendered, and are supported by
documented payroll vouchers or a generally accepted method of documentation.
Payroll must be further supported by time and attendance or equivalent records
for individual employees. Salaries of employees chargeable to more than one
program or cost center will be supported by appropriate time distribution records.
The method used should produce an equitable distribution of time and effort.
Compensation for owners is allowable provided the service performed is a
necessary function.

Payroll Related Expenses - Employee benefits in the form of employer
contributions to social security, state and municipal retirement systems, life and
health insurance plans, unemployment insurance coverage, worker’s
compensation insurance and pension plans are allowable if equitably distributed.
Severance pay is allowable when payment is consistent with standard or
approved policy.

Incentive Compensation - Such payments to employees based on cost
reduction, or efficient performance, suggestion awards, etc., are allowable to the
extent that overall compensation is determined to be reasonable and such costs
are paid or accrued pursuant to an established plan followed by the institution so
consistently as to imply, in effect, an agreement to make such payment.

Deferred Compensation - Such cost is allowable to the extent that except for
past service pension and retirement costs: (1) it is for services rendered during
the period of the projected budget; (2) it is, together with all other compensation

paid to the employee, reasonable in amount; (3) it is paid pursuant to an
agreement entered into in good faith between the institution and its employees
before the services are rendered, or pursuant to an established plan followed by
the institution so consistently as to imply, in effect, an agreement to make such
payments; (4) the benefits of the plan are vested in the employees or their
designated beneficiaries and no part of the deferred compensation reverts to the
employer institution; (5) for a plan which is subject to approval by the Internal
Revenue Service, and falls within the criteria and standards of the Internal
Revenue Service Code and the regulations of the Internal Revenue Service.

Severance Pay - Also commonly referred to as dismissal wages, it is payment in
addition to regular salaries and wages, by institutions to workers whose
employment is being terminated. Costs of severance pay are allowable only to
the extent that, in each case, it is required by law; employer/employee
agreement; or established policy that constitutes, in effect, an implied agreement
on the institution’s part. Only severance benefits that accrue during the period of
the contract are allowable.

Consultation Fees - The cost of consultation fees, charges for the use of
personal services of outside agencies or persons not on the payroll; or functions
related to contract services, i.e., audit service, legal counseling, and specialized


Travel - Includes the costs of operation, maintenance, and repairs of agency
vehicles when relevant to the delivery of contract services; expenses for
transportation, lodging, subsistence, and related items incurred by employees
who are on a travel status on official business incident to delivery of contract
services either on an actual basis or a per diem and mileage basis; expenses for
meetings and conferences, if the primary purpose is the dissemination of
technical information relating to contract services. Purchased transportation is
allowable if required for the delivery of contract services. Reimbursement for
travel shall not exceed maximum state reimbursement rates. Out of State Travel
Is Not Reimbursable.

Consumable Supplies - The costs of materials and supplies are allowable.
Direct charges to services should be based upon the actual price less cash
discounts, trade discounts, rebates, and allowances. Consumable supplies are
those items which will be used up within one year.

Occupancy Costs/Rental Costs – This cost does not apply to this grant and
should not be included in the budget.

Indirect Costs - Indirect costs are those costs incurred for a common or joint
purpose benefiting more than one service area or cost center. The allocation of

indirect costs may be determined by any method, assuring that the distribution is
equitable. A suggested method of allocating indirect cost is to divide the direct
delivery staff costs of the specific service area by the total direct delivery staff
costs of the entire agency. This percentage is then applied to the indirect cost
pool. Allowable indirect costs for the indirect cost pool include, but are not limited
to, the accounting and budgeting functions, disbursing services, personnel
administration and payroll preparation, procurement services and general
administrator’s office.

Miscellaneous - Allowable miscellaneous costs include memberships and
subscriptions, reference materials, printing and reproduction, proposal
preparation, mailing and postage and any other costs incidental to the delivery of


Bad Debt - Losses arising from UNCOLLECTIBLE accounts and other claims
and related costs are unallowable.

Contingencies - Contributions to a contingency reserve or any similar provision
for unforeseen events are unallowable.

Contributions and Donations - Outlays of cash with no prospective benefit to
the contracting agency or program are unallowable.

Entertainment - Costs of amusements, social activities, and related cost are

Advertising - Costs of advertising with the exception of contract related
recruitment needs, procurement of scarce items, disposal of scrap and surplus is

Fines and Penalties - Costs resulting from violations of, or failure to comply
with, laws and regulations are unallowable.

Interest and Other Financial Costs - Interest on borrowings, bond discounts, or
any cost of financing or refinancing operations are unallowable.

Costs Borne by Other Federal or State Programs - Any costs specifically
subsidized by other state or federal dollars are unallowable and must be
deducted from the applicable line items prior to unit rate computation.

Clothing - Clothing for eligible individuals or employees is unallowable.

Cash Payments - Cash payments to eligible individuals such as a cash
allowance to children in residential treatment are unallowable.

Sabbatical Leave - Payment of any sabbatical leave is unallowable.

Fundraising - Cost of activities to raise monies to support the provider program
is unallowable.

Education - Cost activities provided by the public schools that are free of charge
to the general public is unallowable.

The budget for the services offered must reflect efficient administration and good
management practices. Anticipated expenditures shown on the budget must be
reasonably in line with those of similar service providers providing comparable
services. The budget is to be completed for a period of one year. The budget
is to be a clear reflection of the costs associated with operating the proposed

Before preparing the service costs of the budget, some providers will find it
necessary to prepare a total budget, including both the purchased services and
other services which are offered by the provider. This will ensure proper
allocation of indirect cost, such as overhead and administrative expenses, to the
specific program of purchased services. Only providers offering services
other than those to be purchased or responsible to a parent agency or
organization which operates other programs will incur indirect costs.

1.  Budget Form A - This is the total requested budget for the project
2.  Budget Form B - List all staff positions subject to reimbursement. Indicate
    whether filled (F) or vacant (V). If the position is vacant, the annual salary
    must be prorated to reflect the date the position is expected to be filled. If
    and individual functions in more than one capacity, segregate the position
    titles, and properly allocate the salary to the specific functions. The
    number of hours per week the individual works to earn the listed salary.
    This should correspond to the position descriptions mentioned in Budget
    Form A.
3.  Budget Form C - Indicate the employer share of fringe benefits relevant to
    the salary of listed staff. These costs are to reflect actual established
    rates less any cost subsidy by state or federal monies.
 4. Budget Form D - List all operating, equipment, supplies and miscellaneous
    expenses requested to provide direct services. Under “type of acquisition”
    list of item is to be leased or purchased.
5.  Budget Form E – List all support services expenses needed to help
    participant be come employable.
 6. Budget Form F – Show programs indirect cost that apply to program.

                                  COUNTY OF SUMMIT
                                             BUDGET FORM A

Agency Name________________________________ Contact Person ___________________

Program name________________________________

                      COST CATEGORIES                                               BUDGET

 Fringe Benefits

 Follow-up Supporting Schedule

    Total Salaries and Fringe Benefits

 Operating, Supplies, Insurance and Miscellaneous Cost – Detailed

 Supportive Services Costs - Detailed List

 Indirect Costs

 Total Operating Expenses

            **Administrative costs not to exceed 15% of total budget (See page 54 for worksheet)

            Total Budget Request                          ________________________________
            Direct Service Costs                          ________________________________
            Administrative Costs                          ___________________________________

                                        BUDGET FORM B
                                        STAFF SALARIES
       Agency Name______________________________________________

       Detailed staff listing - enter data for each person charged to this contract

                   Position Filled or
Position                                   Rate of Pay per        Hours per           Number of   Total
                   Vacant F/ V
Title                                      Hour                   Week                Weeks

                                                 BUDGET FORM C
                                                FRINGE BENEFITS
      Agency Name
    Detailed benefit listing - enter data for all person charged to this contract

           Categories                      Rate of              Expenses Non         Direct   Total
                                           Benefits             Direct Service      Service

State Unemployment

Federal Unemployment


Health Insurance


Worker’s Compensation

Other (specify)

                                           BUDGET FORM D
               Operation Expenses/Insurance/Supplies/Miscellaneous

Agency Name    ______________________________________________

Detailed listing of Operating Expenses/Supplies/Miscellaneous items to this contract

     Description                Quantity                   Price                  Total    Type of
      of Item                                                                             Acquisition

                                     BUDGET FORM E
                                 SUPPORT SERVICES COSTS

Agency Name      ______________________________________________

Detailed listing of Support Services Costs to this contract

   Description                 Quantity                       Price   Total    Type of
    of Item                                                                   Acquisition

                                    BUDGET FORM F
              (any costs not related to direct care)

Agency Name
Indirect Cost Instructions

Direct staff program costs - Enter the annual direct delivery staff costs for contract services
provided by the contracting agency.
Direct staff total costs - Enter the annual direct delivery staff costs for all services provided by the
contracting agency.
Indirect cost pool - Enter the total indirect cost, as defined in the Budget Guidelines, excluding
any direct service cost. Records substantiating development of the indirect cost pool must be
maintained by the provider agency.
Percent of indirect costs applicable to contract - Divide direct staff program costs by agency total
direct staff costs to arrive at the percentage of costs applicable to contract service(s).
Indirect cost for contracted services - Multiply indirect cost pool by percent of indirect costs
applicable to contract service(s).
Note: Indirect cost rates may be developed by any method which produces an equitable
distribution. The above is a suggested method of arriving at an indirect costs rate for the
contract. If another method is used, describe the computation for arriving at the indicated indirect
cost rate in a separate attachment.

 PROGRAM                 AGENCY                PERCENT INDIRECT          INDIRECT COST         INDIRECT COST
 DIRECT STAFF            DIRECT STAFF          COST APPLICABLE                POOL             FOR
 COST                    TOTAL COSTS           TO CONTRACT                                     CONTRACTED

 $                       $                     %                         $                     $


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