CITY OF LAKEWOOD HUMAN SERVICES FUNDING APPLICATION

Transcription

1 AGENCY NAME: PROGRAM/PROJECT NAME: NEW OR EXISTING PROGRAM?: NEW PROGRAM COMPONENTS (CHOOSE ONE): EXISTING USE OF FUNDS (CHOOSE ALL THAT APPLY): ACCESS TO HEALTH & BEHAVIORAL HEALTH EMERGENCY FOOD EMOTIONAL SUPPORT FOR HEALTHY RELATIONSHIPS HOUSING ASSISTANCE DIRECT CLIENT BENEFIT UNIT COST FOR SERVICES PROGRAM OPERATIONS (STAFFING) ADMINISTRATION (INDIRECT) STABILIZATION SERVICES TOTAL NUMBER OF CLIENTS SERVED BY THIS PROGRAM IN 2017: NUMBER OF LAKEWOOD CLIENTS TO BE SERVED IN 2019: PROGRAM DESCRIPTION (LIMIT TO ONE - THREE SENTENCES): BUDGET AT A GLANCE: City of Lakewood Funds Requested: $ Other Program Funds: $ Total Program Budget: $ Past City of Lakewood funding received in the past five years, year and amount (n/a if not applicable). The 2018 annual agency budget? $ Percentage of the Lakewood funding request to total program budget (from section 2c). %

2 AUTHORIZED SIGNATURE OF APPLICANT: To the best of my knowledge and belief, all information in this application is true and correct. The applicant s governing body has duly authorized this document and if funded will comply with all contractual obligations. Signature of Authorized Representative: Typed Name and Title: Date Signed: Applicants must answer the following questions and provide the requested information in response to this funding application. Please be sure to complete the entire application, including the required budget forms and attachments. A. Organizational Information 1) Provide the organization name, mailing address, physical office address, phone number (include area code) and address. If the applicant s organization also has a separate office location within Lakewood, please provide information for both the primary and Lakewood office locations. Organization Legal Name: Mailing Address (include City and Zip Code): Physical Street Address (include City and Zip Code): Main Business Phone Number (include area code): Website Address: 2) Provide the name(s) and title(s) of the person(s) authorized to execute a contract on behalf of the organization. Executive Officer Name and Title: Address: Phone Number (include area code): 3) Provide the name(s) and title(s) of the person(s) who serves as the organization s primary point of contact (if different). Contact Name and Title: Address: Phone Number (include area code): 4) Provide the names and number of years the agency has been in business under current or previous names or additional assumed business names. 5) Provide the federal tax identification number for the applicant s organization.

3 SUMMARY OF SERVICES 1) PROGRAM DESIGN 1a) Provide a detailed description of the program services to be provided. Be sure to include an overview of the main program activities, identify the service intervention type, how many Lakewood residents will be served.

4 1b) Describe which City of Lakewood s Human Services funding strategy best fits this program design (Access to Health, Emergency Food, Emotional Supports, Housing Assistance, or Stabilization Services) and why. 1c) In what ways will the program ensure that Lakewood residents will have access to these services?

5 2) SERVICE COORDINATION & PARTNERSHIPS 2a) Does this program link clients to other resources in the community, such as health and behavioral health services, employment services, veterans services, benefits advocacy and others? If so, how is this achieved and to what services? 2b) List the organizations that the program will collaborate with most often, and why?

6 3) EFFECTIVE PRACTICES 3a) Describe the community need that will be addressed with this program. Provide research, statistics or other information to validate the need. 3b) Describe the program s measurable outcomes. What social condition, behaviors or situations will improve because of this service?

7 3c) Describe your program evaluation process. How often does it occur? 3d) Describe the required qualifications for the staff providing this service. Does the organization require specific training certification and licenses? Does the organization provide training or staff development opportunities for its staff?

8 4) ACCESSIBILITY & OUTREACH 4a) What criteria is used to determine eligibility for program participation? How do people learn about your program? 4b) How is this program tailored or adapted to reach diverse populations through language, other communications, or physical accommodations? 4c) Describe specific program outreach activities to increase services to Lakewood residents?

9 B. CONTRACTING/ PERFORMANCE EVALUATION 1a) Describe the agency s fiscal management (i.e. financial reporting, record keeping, accounting systems, payment procedures and audit requirements). Explain the internal processes and procedures that ensure timeliness and accuracy in meeting contract requirements. 1b) How does the program collect and track client data?

10 C. PROGRAM BUDGET 1a) Budget Priorities In the event that full funding is not possible, how will the program be modified or what will change due to reduced funding? 1b) Provide comments on the Program Budget listed under Other or provide more details that is relevant for the reviewer to better understand the program budget:

11 PROGRAM BUDGET DETAIL 2a) Personnel List ALL staff positions associated with this program. Include all payroll costs (salaries, taxes, benefits). List Amount Requested for this application. Program Position FTE Amount Requested this Application ($) Other Funds ($) TOTAL Total 2b) Other Program Operating Costs (see instructions for eligible costs) Category Amt. Requested ($) Other Funds ($) Total Program Facility Costs Communication Supplies Travel Training Consultants Direct Services (not staff) Other (explain in narrative) Total Other Operating Costs 2c) Total Program Budget Category Amt. Requested Other Funds Total Program $ % $ % $ % Total Personnel (2a) 100 % Total Other Operating (2b) 100 % Total Program 100 %

12 2d) Sources of Program Revenue: List all confirmed (C) and proposed but unconfirmed (P) funding sources for this program in the coming year, including revenues from fees and fundraising. (Jan through Dec. 2019) Source of Revenue C/P $ Amount % of Budget Supports What Program Aspect Total 100% 2e) Current Program Revenue List all current funding sources for the existing program year including revenues from fees and fundraising. (Jan through Dec. 2018) Source of Revenue $ Amount % of Budget Start/End dates of Funding Cycle Total Current Funds 100%

13 CITY OF LAKEWOOD HUMAN SERVICES FUNDING APPLICATION D. ATTACHMENTS (Provide the following documents, attach to the applications, and complete the attachment check list below) A list of Board of Directors which includes the member s full name, occupation or affiliation, as well as identifying the principle officers of the board. A copy of the Board of Directors meeting minutes from June or July 2018 Internal Revenue Service (IRS) tax-exempt determination letter for applicant organizations with a 50l (c) 3 tax status A copy of the organization s last I-990 tax filing or end of year financial statement. A copy of the agency s 2018 operating budget (income and expense)