2006 Minnesota Tax Form

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					                            REQUEST FOR PROPOSALS




  Minnesota WIC Peer Breastfeeding Support Program
            Intent to Apply and Application


              Intent to apply Due Monday, April 24, 2006
(The intent to apply is a very brief form included in this application packet. Submitting
           this form does not obligate you to complete the application.)


              Proposals Due Wednesday, June 21, 2006




                        Minnesota Department of Health
                           Minnesota WIC Program
                                  April 2006
                     Intent to Apply: Minnesota WIC Peer Breastfeeding Support Program

By April 24, 2006 please let us know your plans and interest. Completing this form does not
obligate you to submit a grant application. It will help us in planning.

____ We plan to submit an application for Minnesota WIC peer breastfeeding support funding.

____ We don’t plan on submitting an application at this time, but may be interested in the future if
     funds are available. Optional: comments on why you are not applying at this time:

____ We are not interested in developing a peer support program.

____ We request a conference call about peer breastfeeding support. We are available on the
following dates / times (please indicate all dates and times you are available):
__Wednesday, May 3, 2006,10:00 am                        __Tuesday, May 9, 2006,10:00 am
__Wednesday, May 3, 2006, 2:00 pm                        __Tuesday, May 9, 2006, 2:00 pm
__Thursday, May 4, 2006,10:00 a.m.                       __Wednesday, May 10, 2006,10:00 am
__Thursday, May 4, 2006, 2:00 pm                         __Wednesday, May 10, 2006, 2:00 pm

People in our agency that would like to be notified of the conference call:
Name           Email address


Intent to apply completed by (name):

Position:          ____ WIC Coordinator,
                   ____ WIC Breastfeeding Coordinator,
                   ____ Other _______________

Agency name and address:



Phone:                                     Fax:                  E-mail:

__ Please mail us the application and guidance. (We will mail to the name & address above.)
__ We will obtain the application and guidance from the MN WIC website.

By April 24, 2006 please submit this form
    By fax (651-215-8951) or
    E-mail pamela.anderson@health.state.mn.us with “Peer BF Support Program” in the subject
       line.
   If you email or fax the intent to apply please contact us by phone to verify receipt. You can call
   Pamela Anderson at 651-281-9911 or Mary B. Johnson 1t 651-281-9906).

        You can also submit the form electronically via the MN WIC website.

If you have questions please contact Mary B. Johnson at 651-281-9906 or
mary.b.johnson@health.state.mn.us.

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                                   Application

   Minnesota WIC Program Peer Breastfeeding
               Support Program

          Applications due Wednesday, June 21, 2006

Applicant: ___________________________________________

Current MN WIC Program Grantee?
___ Yes,      __ No (If no, not eligible to apply as lead agency)

Check one:
___ We are a current MN WIC Peer Breastfeeding Support Program Site (Pilot Site)
___ We do not currently have a MN WIC Peer Breastfeeding Support Program
                          Minnesota Department of Health Grant Application Face Sheet

    Grant Application for:
     Minnesota Department of Health, Minnesota WIC Program, Peer Breastfeeding Support
                                          Program
    1. Applicant Agency With Which Grant Contract is to be Executed
    Legal Name:                                            Street Address:                                               Telephone Number:
                                                                                                                         (      )

                                                                                                                         FAX Number:
                                                           E-Mail Address:                                               (     )

    2. Director of Applicant Agency
    Name and Title:                                        Street Address:                                               Telephone Number:
                                                                                                                         (      )

                                                                                                                         FAX Number:
                                                           E-Mail Address:                                               (     )

    3. Fiscal Management Officer of Applicant Agency
    Name and Title:                                        Street Address:                                               Telephone Number:
                                                                                                                         (      )

                                                                                                                         FAX Number:
                                                           E-Mail Address:                                               (     )

    4. Operating Agency (if different from number 1 above)
    Name and Title:                                        Street Address:                                               Telephone Number:
                                                                                                                         (      )

                                                                                                                         FAX Number:
                                                           E-Mail Address:                                               (     )

    5. Contact Person for Operating Agency (if different from number 2 above)
    Name and Title:                                        Address:                                                      Telephone Number:
                                                                                                                         (      )

                                                                                                                         FAX Number:
                                                           E-Mail Address:                                               (     )

    6. Contact Person for Further Information on Application (if different from number 5 above)
    Name and Title:                                        Street Address:                                               Telephone Number:
                                                                                                                         (      )

                                                                                                                         FAX Number:
                                                           E- Mail Address:                                              (     )

    7. Certification
    I certify that the information contained herein is true and accurate to the best of my knowledge and that I submit this application on behalf of the
    applicant agency.


    __________________________                                  _________________________
    __________________
    Signature of Director of Applicant Agency                            Title                                                  Date
HE-01274-05 (4/01) - PART A

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                                                                                                                                                           2
                                      Minnesota Department of Health (MDH)

                          Information Sheet for Minnesota WIC Program,
                      Peer Breastfeeding Support Program Grant Applications

      1. Applicant Information
      Applicant Agency Name
      Minnesota Tax I.D.                   Federal Tax I.D.
                                                              Social Security Number
      Number                               Number
                                                              N/A
      Non-profit Status – 501.C3 form attached?

      ___ Yes          ___ Not Applicable

      2. Proposal Information
      Project Funds Requested Per Year

      $

      Proposed Service Area



      Proposed Funding Category

           Minnesota WIC Peer Breastfeeding Support Program


HE-01274-05 (3/01) - PART B




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Need for peer breastfeeding support /plan for addressing highest priority needs.

1. Need for peer support staff. Please briefly describe any special needs in your WIC population
that you believe could effectively be addressed through peer breastfeeding support (PBS). Needs
might include language, culture, age, isolation / lack of support, characteristics of your community or
service area that create challenges to breastfeeding support, length of breastfeeding duration, etc.
Please be as specific as possible.




Please include numbers of participants in your proposed service area(s). (Summary statistics
participation report February 2006.)Total number of pregnant participants & total number of
postpartum breastfeeding participants



2. Plan for addressing needs. Please briefly describe your plan and how it will address your
higher priority needs for breastfeeding support. If you plan to have peers available for all of your WIC
clients please describe your plan and how you will assign peers to the highest priority needs if there is
not enough peer time available to serve all of your participants.




3. Days, times, locations peer services will be available. As many breastfeeding problems do not
occur during regular clinic hours, FNS requires that peers are available outside of regular clinic hours
and clinic settings. Ideally peer support with WIC backup would be available 24/7, however, this may
not be feasible for some programs. Please identify the hours and locations that you plan to have peer
services available and your plan for providing back-up for breastfeeding issues beyond the role of the
peer.
                    Mon       Tues     Wed       Thu       Fri       Sat        Sun        Comments
    Days and
    hours peers
    available
    Plan for backup
    WIC staff
    available for
    backup
    (hours)
    Peer to refer
    to health
    provider /
    clinic (hours)
   Insert additional grids if needed for different clinic or county locations .

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Brief comments that will help us understand your plans, including your plan for back-up when key
staff are on vacation or otherwise unavailable. (In the training section indicate how the staff who are
available for back-up have been or will be trained.)




Peer service areas
    Specific WIC clinics: ________________________________________________
    The entire local WIC program.
    Other: ______________________________________________________________
Peer work locations: (Check all that apply)
    WIC clinics
    Calls to / from home
    Hospital Visits
    Home visits
    Classes / Groups @ WIC
    Accompany participant to first breastfeeding support group meeting (such as La Leche
         League)
    Other:         ______________________________________________________________
    Other:         ______________________________________________________________

Staffing
4. How many peer support staff do you plan to use? (see Instructions/Guidance )
_____ We (WIC) plan to contract with peer support staff.
_____ We (WIC) plan to hire peer support staff.
_____ We plan to use staff from another (non-WIC) program for peer breastfeeding support. Please
describe their current role and how they meet the FNS peer support definition:__________________
_____ We plan to use current WIC staff who meet the FNS definition of a breastfeeding peer support
staff person. Please describe their current role and how they meet the FNS peer support definition:


How many hours a week do you anticipate a peer will work? (A range of hours is fine. Some may
work more than others)




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For current MN WIC peer pilot programs:
___ We currently employ have peers (list as peer A, peer B, etc or use first name and last initial
only) and they have knowledge of culture or language, and / or have other characteristics /
breastfeeding experiences as described below: (Cultural experience, languages spoken, teen,
breastfed multiples, breastfed a baby with special needs, single parent, familiarity with WIC, or other
background which will help them relate to the clients they serve.)

___ We plan to hire / add additional peers to meet these needs:



5. International Board Certified Lactation Consultant (IBCLC) involvement. (An IBCLC must
   be available on staff or by contract.) See guidance.
        We have an IBCLC (or IBCLCs) on staff who will be involved in developing and
         implementing the peer support program.
        We have an IBCLC on staff who will be involved in developing the peer support program
         and we plan to hire / contract with an IBCLC to help with (check all that apply):
         o Initial training of peer support staff.
         o Ongoing training of peer support staff.
         o Providing peers and/or CPAs an opportunity to “shadow” the IBCLC as part of their
             training.
         o Providing back – up for peer support staff when problems are beyond their scope of
             practice.
         o Supervising or helping with supervision of peer support staff.
         o Other: ________________________________________________________________
    Notes, if you feel they will help us understand your plan. For large service areas please comment
    on how the IBCLC will be available for issues beyond the scope of the on-site WIC clinic staff.




             Our breastfeeding coordinator or ( ________________________ ) will be involved in
              developing the peer support program and we plan to hire an IBCLC to help with:
              o Initial training of peer support staff.
              o Ongoing training of peer support staff.
              o Providing peers and/or CPAs an opportunity to “shadow” the IBCLC as part of their
                 training.
              o Providing back – up for peer support staff when problems are beyond their scope of
                 practice.
              o Supervising or helping with supervision of peer support staff.
              o Other: __________________________________________




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6. If you plan to obtain services from an IBCLC who is not currently employed by WIC please
   check the applicable statement:
         Not applicable, we have an IBCLC or IBCLCs on staff.
         IBCLC is currently employed by our agency, but not by WIC and we will contract for a
          portion of her time.
         IBCLC is currently employed by another WIC agency and we will contract for a portion of
          her time.
         We plan to contract with an IBCLC but have not yet identified this person. We will look for
          the following background, skills and abilities when hiring (brief).



7. IBCLC and Other Staff, if any, involved in training, backup & supervision
   A. IBCLC
          We have a full time IBCLC on staff. We estimate about ____ % of her time or ____ FTE
           will be spent on the peer support Program.
          We have an IBCLC on the WIC staff who is not full time or has responsibilities beyond WIC.
           We estimate about ___ hours per week or ____ FTE of her time will be spent on the peer
           support Program.
          We plan to contract or have contracted with an IBCLC to provide about ___ hours per week
           or ____ FTE.
   Briefly describe why you feel this amount of time will meet the needs for the program
   responsibilities she is assigned.


    B. Other Staff
    Identify any other staff who will be involved in training, back-up, and supervision of peer support
    staff and their credentials, as well as lactation training completed (name and date of training
    program) or plans to send any of these staff to a breastfeeding management course or other
    training, if needed.
    Name (if known)/position          Background/Training in Breastfeeding or plan for training.




Essential Peer Breastfeeding Support Functions Plan
8. Overview of plan for Essential Peer Breastfeeding Support Program Functions.
   8A. Please complete the grid on next page.

    8B. WIC agencies that will provide some essential functions through arrangements with another
    organization must include a letter from that organization agreeing to fulfill the designated
    required functions if the grant is awarded, outlining roles, and defining who has decision-making
    authority for the peer functions in the organization. Include as Attachment A.


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8A. Essential functions. (Check the appropriate column or columns). Please identify who will:
 If known, please enter the name of the staffperson in the         IBCLC. WIC? Other        Other:                                       Other:             Comments / Including
 column header. If abbreviations are used to describe roles please Other?                                                                                   explanation for any
    define the abbreviations used in the comments section.                                                                                                  abbreviations used.
    Manage or coordinate the peer support program (see attached
    sample job description)
    Be responsible for development of local agency peer support policies
    consistent with FNS model and Minnesota WIC Program policies
    Develop peer support staff position description (see attached sample)
    Recruit peer support staff
    Hire peer support staff
    Reassign participants to another peer if a peer resigns or is unable to
    follow the participant.
                                            1
    Be trained on FNS peer management .
                                          2
    Be trained on FNS peer curriculum
    Attend the 2 required meetings for Minnesota Peer Programs.
                                                   2
    Provide initial training for peer support staff .
    Provide ongoing training for peer support staff.
    Ensure that peer support staff have the opportunity to meet regularly
    with other peer support staff
    Ensure that all peer staff have the opportunity to meet with WIC CPA
    staff at least twice a year (such as at a WIC staff meeting or clinic
    with opportunity to talk w CPA staff or CPA staff attend peer
    meeting.)
    Supervise peer support staff, including periodic review of peer
    documentation.
    Peer mgmt staff maintain regular contact with peer support staff. (At
    minimum every other week. Note that if peers provided through
    another program WIC peer mgmt staff must have individual contact
    with each peer at least monthly.)
    Provide and document random calls to participants the peer support
    staff is working with, to assess their perspective on peer support (this
    also serves to verify that services are being provided.). Note that if
    peers provided through another program WIC peer mgmt staff must
    call 1 – 2 participants for each peer at least twice a year, in addition
    to any other calls made by staff from the contracted agency.
    Provide back-up after hours if the peer support staff person gets a
    call she can’t handle after hours.
    Identify referral resources & protocols in the event that the peer
    support person receives a call beyond her scope of practice when a
    WIC backup staffperson is not available.
    Outreach to enhance the effectiveness of the WIC PBSP

1
    If this person has already completed FNS training on peer management and peer curriculum please note “attended”
2
    Training must include “Loving Support through Peer Support” training curriculum, available from the State WIC office. Supplemental training may also be provided.
                                                                                                                                                                                   8
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Training / Integrating Peer Program with other WIC services
9. Plan for participation in required meetings and training. (Must be IBCLC or CPA who will
     be involved in implementing the peer program and planning training.)

              Our peer managers / supervisors have been trained on the FNS Peer Management
               and FNS Peer Training Curriculum.
               o Staff were trained: (check all that apply)
                      MN WIC Videoconference on Peer Management
                      FNS training on Peer Curriculum in Chicago, Spring 2005
                      Reviewed Peer Management Curriculum
                      Reviewed Peer Training Curriculum
                      Other: ____________________________
               Our plan for providing this training if these key staff leave is: _____________________

              One or more of our peer managers / supervisors will need / needs to be trained on the
               FNS Peer Management and FNS Peer Training Curriculum.
               o We are a new applicant for peer funding.
               o We have replaced key staff and they have not been trained on: _________________

          The staff is/are:
     _________________________________________________________

              We anticipate having ____ staff participate in the two Minnesota WIC Program peer
               management meetings with staff from other Minnesota PBS Programs. The staff is/are:
               ___________________________________________________

10. Plan for training of WIC Peer support staff and other WIC staff.
   A. Plan for initial training of new peer support staff:
           We prefer to do our own initial peer support staff training.
           If possible, we would prefer to coordinate with other peer breastfeeding support
            programs to provide the initial peer breastfeeding support staff training.
 Comments:



   B. Our plan for ongoing training for existing peer support staff. Check all that apply:
          Monthly meetings with other peers to provide short training (by IBCLC, other WIC staff
           or guest) and discuss their questions/successes.
          Opportunity to shadow IBCLC or other WIC staff trained in lactation management.
          As peers become more experienced, opportunity for newer peer staff to shadow other
           peers.
          Other: ________________________________________________________________




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                                                                                                     9
      C. Our plan for orienting current WIC staff to peer support functions and how CPAs will refer
         a participant for peer support. (Consider having WIC CPA staff attend the peer training or
         provide the WIC CPA staff with a shorter version of the training or an overview of peer
         services.)




      D. Our plan for training WIC CPAs more extensively in lactation to help provide back-up for
         peer support staff if needed.
             We feel we have enough staff already trained.
             We plan to train additional staff. Number of CPAs you plan to train or send to training:
              ___ .
          Planned method for training3: _______________________________________________
          ________________________________________________________________________

        E Our plan for providing ongoing training in lactation management for staff who provide
          supervision and back-up (check all that apply)
            WIC conference breastfeeding sessions
            Workshops
            Self study
            We would like periodic conference calls with other area peer program
             managers/supervisors and the opportunity to learn from each other or those with more
             experience in managing/supervising peer programs, such as staff form extension or
             other states with longer experience working with peer support.
            Other



    11. Plans for integrating all peer staff into the WIC program to help them feel a part of the
       program and to encourage referrals from WIC staff to peers. (check all that apply)
             Peers have an opportunity to observe WIC clinics as a part of their orientation.
             Peers are introduced to WIC staff as a part of their orientation
             Peers are present in WIC clinics to: ________________________________
             Peers attend WIC staff meetings or WIC CPA staff ,in addition to peer management
              staff, attend some peer meetings. Frequency/ other comments: _________________
              ____________________________________________________________________
             Other: ______________________________________________________________
              ____________________________________________________________________
             Additional comments on how peer staff will be integrated into existing WIC services
              initially and on an ongoing basis:



3
  See the MN WIC website for information on sources of lactation education. http://www.health.state.mn.us/divs/fh/wic/index.html
(local agency, then breastfeeding) or http://www.health.state.mn.us/divs/fh/wic/localagency/bf/index.html
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Collaboration / Outreach
12. Plan for collaboration with others to deliver peer services. Check all that apply:

             We plan to provide peer services within our WIC program and do not plan to contract
              or collaborate with other agencies or counties to provide essential peer services.

             We plan to collaborate with neighboring WIC programs to provide peer support
              services. (Note that MOU, contract or similar agreement is required after the grant is
              awarded.)
               Please briefly describe your plan. Include any specific activities such as
                 collaborating to share peer management or IBCLC services:




                   A letter, agreeing to fulfill the designated required functions if the grant is awarded,
                   outlining roles, and defining who has decision-making authority for the peer functions
                   in the organization, is attached from all agencies or organizations we will collaborate
                   or contract with to deliver peer services. REQUIRED if you will use other
                   organizations to provide essential peer services. Attach as Attachment A. If you
                   contract with more than one entity, list all of those you will contract with on the cover
                   page and attach letters in that order.

             We plan to collaborate with a non-WIC agency, and to provide peer support services
              through their staff who meet the FNS peer definition. (Note that MOU, contract or
              similar agreement will be required after the grant is awarded.)

                  Please briefly describe your plan:



                  How will you assure the FNS requirements are met?




                  How will you integrate all peer breastfeeding support staff with your WIC program ?




                  How will you coordinate peer services with WIC services?



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                  A letter, agreeing to fulfill the designated required functions if the grant is awarded,
                   outlining roles, and defining who has decision-making authority for the peer functions
                   in the organization, is attached from all agencies or organizations we will collaborate
                   or contract with to deliver peer services. REQUIRED if you will use other
                   organizations to provide essential peer services. Attach as Attachment A. If you
                   contract with more than one entity, list all of those you will contract with on the cover
                   page and attach letters in that order.

13. Plan for outreach / coordination with others to inform them of peer services and
   address any barriers. (Check all that apply.)
        We have existing networks for coordination / informing others of peer support activities.
         Please describe any existing breastfeeding coalitions, task forces, or other established
         methods of communicating about breastfeeding and how you will use these existing
         relationships to disseminate information about peer support and build a supportive
         breastfeeding environment:



             Describe your plans for informing and involving others in your community, such as
              meeting with representatives from area hospitals, clinics and other organizations to
              inform them about your peer program.




             We plan to implement the following additional outreach activities related to the peer
              program (for example displays, media, newsletters, etc).




Evaluation / Agency Capacity
14. Evaluation and progress report. You will be asked to provide a brief written evaluation and
    progress report periodically (see timeline). See page 14 of the guidance for information on
    this report.

             We plan to use the State reporting and evaluation requirements only.
             In addition to the State reporting and evaluation requirements we plan to:




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15. Agency Capacity
   Other comments about the peer Program and reasons you believe your program can:
        successfully implement peer services




             implement peer services without compromising the required basic WIC services.




    (Consider funding, progress toward meeting unmet standards for basic WIC services identified
    during your management evaluation (if any), strengths of your agency and community, etc.)


Contact for phone call with grant review team.
  16. On June 28, 2006 the grant review team, as a part of the review process, will initiate
  a call each applicant for PSBP funding. We will have more information on timing of the calls
  when we know how many applications we receive.

    Name of person we should call: ________________________________

    Phone number, with area code: ________________________________




Budget
  17. Other funding sources, if any. (Other funding sources encouraged, but not required.)

     In addition to the designated peer funds we will use the following funding sources to
    supplement the peer program funding:

    We receive the following in-kind services:

    We plan to seek outside funding from:

    18. See budget information on next page.




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18A Budget: Minnesota WIC Peer Breastfeeding Support Program Grant Application

Please fill out this form completely. For any item that is not applicable, draw a line through the
space.
 Name of Applicant Lead Agency:

 Name of Contact Person for Budget:

 Phone:                         Fax:         E-mail:



 Item                                          Amount through September 2007
 Salary and Fringe Benefits for                $
 employees

 Contracted staff                              $

 Training                                      $

 Travel                                        $

 Supplies/Reference materials/Training         $
 materials

 Other                                         $

 Indirect                                      $

 Total                                         $




Attach a brief description of your budget describing how you arrived at the amounts in your
budget, including number of staff and rate of pay.

There is a form on the next page to use for the budget narrative. See the guidance – page
15 - for instructions and additional information to help in planning your budget.




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                                                                                                     14
18B. Include a narrative description explaining the details of your budget through September
30, 2007 in two pages or less. -

1. Salary and Fringe Benefits
         a. Employees




              b. Contracted staff


For peers: Please describe how you determined hourly rate of pay, any plans for salary increases
in future years, and benefits, if any.



2. Training




3. Travel




4. Supplies Reference materials/Training materials




5. Other costs




6. Indirect




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Attachment A. Letters from collaborating organizations for providing essential peer
functions

WIC agencies that will provide some essential functions through arrangements with
another organization must include a letter of support from that organization agreeing to
fulfill the designated required functions if the grant is awarded, outlining roles, and defining
who has decision-making authority for the peer functions in the organization.

Letters are attached from the following organizations:

    1.




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Attachment B. Abbreviations used in our application, if any
(Attach only if you have used abbreviations in your application.)




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                                                                    17
Submitting your application.
   To be considered for funding, your proposal must be mailed or delivered to:

Mailing Address                                            Delivery Address
Pamela Anderson                                            Pamela Anderson
Minnesota WIC Program                                      Minnesota WIC Program
Minnesota Department of Health                             Minnesota Department of Health
Post Office Box 64882                                      85 East Seventh Place, Room 220
St. Paul, Minnesota 55164-0882                             St. Paul, Minnesota 55101
pamela.anderson@health.state.mn.us                         If no one is available in room 220 to accept the
                                                           application do not leave the application - call and
                                                           make sure a WIC staff person accepts the delivery.
                                                           There is a phone in room 220 you can use.

To meet the deadline, your proposal must:
    Have a legible postmark from the U.S. Post Office or a private carrier dated on or
     before June 21, 2006. We will not accept a postmark from a private, in-office metering
     machine as proof that you mailed your proposal on time, or

        Be hand delivered to the address listed above and date-stamped upon delivery before
         4:30 p.m. on June 21, 2006.
            o If no one is in the room to accept the proposal call 651-281-9911 or 651-281-9906 to
               have a WIC staff person accept and date-stamp the proposal.

        We will accept emailed proposals if received before 4:30 pm on June 21, 2006.
         Proposals must be attached as a Microsoft Word document. It is the responsibility of the
         applicant agency to verify that the emailed proposal was received. This verification
         must be made before the deadline. Occasionally email delivery systems are slow. Email
         with viruses or files that are too large is not delivered. The State email system does not
         inform you if a document was not delivered.
             o If you submit a proposal by email you must also mail in pages that require
                 signatures, with an original signature.
             o E-mail the proposal to pamela.anderson@health.state.mn.us with “WIC PBSP” in
                 the subject line. Copy mary.b.Johnson@health.state.mn.us on the email.

        We will not accept FAXED proposals.

                                           We will not accept or consider late proposals

If an organization plans to provide some essential peer services through collaboration with
     another WIC program or organization a signed letter from that organization must be
                      included for the peer proposal to be considered.

  Proposals will not be considered if they are not from a current MN WIC Program Grantee


                                           WIC is an equal opportunity provider



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Description: 2006 Minnesota Tax Form document sample