SENIOR CENTERS
APPLICATION FOR SENIOR CITIZEN MILLAGE FUNDS FOR CALENDAR YEAR 2007 DATE OF APPLICATION________________ NAME OF SERVICE PROVIDER__________________________________________________ NAME OF PROGRAM___________________________________________________________ MAILING ADDRESS____________________________________________________________ PHONE NUMBER_____________________________ PERSON IN CHARGE__________________________________TITLE______________________________ DAYS AND HOURS OF SERVICE_____________________________________________________________________ HOW MANY PAID MEMBERS DO YOU HAVE AS OF THIS DATE? ___________________ INDICATE THE NUMBER OF UNDUPLICATED CLIENTS SERVED IN THE LAST TWELVE MONTHS: ASH_________ ERIE_________ BEDFORD_________ BERLIN_________ EXETER_________ FRENCHTOWN_________ LUNA PIER_________ DUNDEE____ IDA_________ MAYBEE____ OTHER______
LASALLE_________ LONDON_________ MILAN________
MONROE TWP_____ MONROE CITY________ S. ROCKWOOD_____ WHITEFORD_______
PETERSBURG______ RAISINVILLE_____ SUMMERFIELD______
TOTAL______
HOW MANY OF THESE CLIENTS ARE 60+________________ IS YOUR ORGANIZATION REGISTERED WITH THE STATE OF MICHIGAN? _________ OFFICIAL NAME__________________________________________________________ NAME, TITLE AND RESIDENCE OF OFFICERS: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (ATTACH SHEETS AS NEEDED)
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DO YOU CHARGE, OR REQUEST A DONATION FROM THE SENIORS FOR ANY SERVICES OR ACTIVITIES? YES____ NO____ IF YES, PLEASE LIST SERVICES: _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ WHAT PROGRAMS OR ACTIVITIES DO YOU PROVIDE WEEKLY? NARRATE BELOW AND ADD ADDITIONAL SHEETS IF NECESSARY. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
ON THE AVERAGE, HOW MANY HOURS DO VOLUNTEERS CONTRIBUTE TO THE PROGRAM EACH WEEK? OF THESE, HOW MANY HOURS ARE NOT COUNTED BY RSVP? ______________________________________________________________________ HOW MANY HOURS OF OPERATION DO YOU PLAN TO PROVIDE IN 2007? _____________________ WHAT IS YOUR TOTAL UNIT COST (COUNTY DOLLARS REQUESTED DIVIDED BY # OF PAID MEMBERS DIVIDED BY WEEKLY HOURS OF OPERATION)? ____________________________________________
EXPLANATION OF EMPLOYEE BENEFITS
THIS WILL EXPLAIN HOW THE BENEFITS ON THE SALARY PAGE HAVE BEEN DETERMINED. DOES YOUR ORGANIZATION PROVIDE: INSURANCE AGENCY PROVIDE: YES/NO COST PER EMPLOYEE
Hospitalization Dental Life Vision
NUMBER OF EMPLOYEES__________________________ DOES YOUR ORGANIZATION HAVE ANY TYPE OF 401K OR RETIREMENT PROGRAM__________ IF YES, PLEASE EXPLAIN THE AMOUNT YOUR ORGANIZATION CONTRIBUTES INTO THE PROGRAM ON BEHALF OF THE EMPLOYEE. (PERCENT OFSALARY)_____________________________________________ WHAT IS THE VESTING PERIOD________________________________________________ DO EMPLOYEES IN YOUR ORGANIZATION RECEIVE PAID LUNCH TIME? __________ IF YES, HOW LONG___________________________
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EXPLANATION OF REQUEST FOR FUNDING INCREASE
SALARY INCREASES OF _____% OR $_____ PER HOUR FOR THE FOLLOWING POSITIONS: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ***(THESE SENIOR GROUPS DO NOT NEED TO COMPLETE THE REST OF THIS SHEET: PETERSBURG, ASH, MILAN, AND BERLIN.
FRINGE BENEFIT INCREASES WORKER’S COMP. __________________ HEALTH INSURANCE_______________ OTHER (SPECIFY)___________________ OPERATIONS INCREASES FOR THE FOLLOWING LINE ITEMS: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
ADDITIONAL STAFF/ADDITIONAL TIME FOR EXISTING PART TIME STAFF POSITION TITLE 1. 2. 3. 4. 5. WAGE PER HOUR FRINGE BENEFITS HOURS PER WEEK
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BUDGET SUMMARY 2006
County Dollars requested for salaries County Dollars received for salaries County Dollars requested for operations County Dollars received for operations Total County Dollars requested for calendar year Total County Dollars received for calendar year Total additional County Dollars received throughout budget year Total cost of program Percent of Total Program cost required from County Dollars
2007
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I ASSURE THE MONROE COUNTY COMMISSION ON AGING THAT ALL THE INFORMATION PROVIDED HEREIN IS CURRENT AND ACCURATE, AND THAT ANY COUNTY FUNDS GRANTED WILL BE USED EXPRESSLY FOR THE PURPOSES REQUESTED, AND THAT ALL SERVICES AND ACTIVITIES WILL BE OPERATED IN ACCORDANCE WITH STATE AND FEDERAL LAWS, REGULATIONS, POLICIES AND PROCEDURES.
SIGNATURE________________________________ TITLE____________________________ PROGRAM__________________________________ DATE____________________________
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