Application for Economic Development Grants

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Domenic Nash
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1 Application for Economic Development Grants DUE November 1, 2013 by 4:00 pm to: AWARD DATE: December 1, 2013 Funds Available: July 1, 2014 Coos County Board of Commissioners Office Attn: Grant Applications 250 N. Baxter, Coquille, OR Or Applicant/Organization Mailing Address Contact Name Contact Contact Phone No Contact Name #2 Contact Contact Phone No Federal Tax ID IRS Class (Exemption) Total Grant Request Page 1

2 PLEASE ANSWER THE FOLLOWING QUESTIONS COMPLETELY. ADDITIONAL SUBMITTAL REQUIREMENTS ARE DETAILED AT THE END OF THE QUESTIONS SECTION 1. Describe the purpose and objectives of your organization and mission statement (from bylaws, articles of incorporation or board adopted mission statements). 2. Provide a short history of your organization. 3. Describe the purpose and objectives of this grant request and summarize the programs/events utilized to meet the purpose/objectives (Include descriptions for each funding category of your request) If your grant request is for date specific events, programs or activities, please complete the following table: (If completing electronically, double click the table to enter data) Anticipated Dates Program/Event Title of Event Funding Request 4. Describe how your grant proposal meets and accomplishes the desired outcomes for Economic Development, specifically to improve and advance the economic growth and prosperity of Coos County. 5. If you do not receive the full amount of your request, describe how your organization would use a smaller amount of funds. 6. Describe what, if any, actions your organization takes in developing and securing other revenue sources beyond the Coos County Economic Development grant funds. 7. What percentage of your total annual revenue would come from this grant? 8. What percentage of your organization s total annual expenditures will go toward the grant activity/program/event proposed in this application? Page 2

3 9. Describe your organization s strategies and efforts to minimize administrative overhead costs for your organization in general and for the specific programs, activities or events being applied for in this application, including collaboration and/or leveraging of other partner organizations. What is your administrative overhead cost rate? 10. Describe data collection and reporting systems that will be utilized for gathering the data for the outcomes on the use of the grant funds. ADDITIONAL SUBMITTAL REQUIREMENTS If applicable, please include: 1) List of all Board members, their occupations, and years on the board. 2) Organizational Client Demographic Profile 3) Grant Program Budget (for activities/programs/events that are a part of this grant application) 4) 1 copy of your organization s 501(c) letter verifying your non-profit status 5) 1 copy of your organization s corporate bylaws 6) 1 copy of your organization s most recent Form 990 IRS filing (summary page only) 7) 1 copy of your organization s previous year financial statement summarizing expenses and revenues 8) Acknowledgement of ability and intent to provide the County with Certificate of General Liability Insurance in the amount of 1,000,000 or more naming Coos County, its officers and employees as additional insured. See Insurance Requirements, Attachment A. I understand and commit that, if awarded grant funding, our organization is able and willing to provide the insurance certificate described above. I also understand that a final grant report will be required, and if not provided, my organization will not be eligible for any future grant funding from Coos County. Name (print) Name (signature) Title Incomplete Applications May Be Rejected Page 3

4 Applicant Organization Board Member Information Reporting Sheet Name Address Phone Occupation Title Years on Board Page 4

5 COOS COUNTY GRANT PROGRAM BUDGET Please use this page to identify the program within your organization that you are requesting funds for. APPLICANT/ORGANIZATION: PROJECT NO.: PROGRAM/EVENT TITLE: PROJECT PERIOD: to. If not completed by proposed date, funding may be terminated. REVENUE Coos County Funds/Identify: Other State or Federal Funds/Identify: Other Funds/Identify: TOTAL REVENUE EXPENDITURES A. PERSONAL SERVICES (List Employees by Position Title) Total Salaries % of time to project 1. % 2. % 3. % 4. % Total Benefits TOTAL PERSONAL SERVICES B. MATERIALS & SERVICES: TOTAL MATERIALS & SERVICES C. CAPITAL OUTLAY (must constitute part or all of funded public service activity to be eligible expense) Equipment Furnishings Other capital expenses /Identify: TOTAL CAPITAL OUTLAY TOTAL EXPENDITURES (Sum of A, B & C) Page 5

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7 Attachment A: Insurance Requirements A. CONTRACTOR shall not commence work under this Contract until it has furnished COUNTY with satisfactory proof of the coverage of insurance as specified below: 1. Workers compensation coverage as required by law with a Waiver of Subrogation in favor of Coos County and to include employer s liability with limits of not less than 1,000,000 per occurrence; or, alternatively, CONTRACTOR shall provide documentation establishing that CONTRACTOR is exempt from workers compensation coverage pursuant to ORS Chapter General commercial liability coverage for damages as a result of death or bodily injury (including personal injury) to any person s destruction or damage to any property with limits of not less than 1,000,000 each occurrence, 2,000,000 policy aggregate. Such coverage shall include, but is not limited to, the following: commercial general liability coverage, products liability including completed operations, premises operations including X (explosion), C (collapse), U (underground), broad form property damage including fire fighting expense which is also known as loggers broad form, personal injury. All coverage shall be on an occurrence basis and not on a claim made basis. 3. Automobile liability insurance as a result of death or bodily injury to any persons, or destruction of or damage to any property arising out of the ownership, maintenance, or use of any owned, non-owned, or hired motor vehicle with limits of not less than 1,000,000 per occurrence. All coverage shall be on an occurrence basis and not on a claim made basis. 4. Excess/Umbrella Liability coverage as follows: a. If this is a contract for a public improvements, or personal services contracts with architects, engineers, and land surveyors, then CONTRACTOR shall maintain an excess/umbrella liability policy of not less than 1,000,000 each occurrence and aggregate that will provide excess limits of liability over the commercial general liability, automobile liability, employer s liability, and professional liability. b. For contracts other than public improvements or personal services contracts with architects, engineers, and land surveyors, an excess/umbrella liability policy is not required, but may be used in conjunction with a general commercial liability policy to satisfy the primary insurance limit requirements. c. All excess/umbrella liability coverage shall be on an occurrence basis and not on a claim made basis. 5. For personal services contracts, professional liability insurance, including errors and omissions, with limits of not less than 2,000,000 per occurrence and 4,000,000 policy aggregate. B. The following inclusions to CONTRACTOR S certificate of insurance shall be made: 1. Waiver of transfer of rights of recovery against others to Coos County. The preferred form is CG / It is agreed that this insurance is primary to and non-contributory with any insurance maintained by Coos County. 3. The general liability coverage and automobile liability, if required, shall include endorsements for additional insured, naming Coos County, its elected officials, employees, agents, and volunteers as an additional insured. The additional insured endorsement shall be attached to the certificate of insurance. 4. The additional insured shall contain a severability of interest provision in favor of Coos County and a Waiver of Subrogation in favor of Coos County. 5. All required coverage shall be written with companies that have at least an AmBest rating of B+ VII. 6. The insurance shall provide a 30 day notice of cancellation or material change. 7. For public improvement contracts or architectural, land surveying, or engineering personal services contracts, CONTRACTOR shall carry the required insurance for at least three years after acceptance of completed project. Page 7

8 BOARD OF COMMISSIONERS 250 N. Baxter Street, Coquille, Oregon (541) FAX (541) / TDD (800) bbrooks@co.coos.or.us John Sweet Robert Bob Main Melissa Cribbins LETTER OF UNDERSTANDING Contribution to [RECIPIENT] [INSERT RECIPIENT ADDRESS] Dear [RECIPIENT]: This letter shall serve as confirmation of the Coos County Board of Commissioners commitment, on behalf of Coos County, to contribute from the County s Economic Development Fund to [RECIPIENT], and of [RECIPIENT] s acknowledgment and agreement to the terms and conditions of the disbursement as set forth herein. This contribution is to be used solely and exclusively for the purpose of. The County will provide the funds. [RECIPIENT] will. The County reserves the right to audit or request additional documentation from [RECIPIENT] evidencing how funds were expended. Additionally, the County may require the return of funds upon [RECIPIENT] s refusal to permit an audit or provide such documentation, or upon a determination in the County s sole discretion that the funds were not used in a manner consistent with this agreement. COOS COUNTY John Sweet, Chair Robert Bob Main, Commissioner Melissa Cribbins, Commissioner Date [RECIPIENT] Signature Name Title Date Page 8

EXHIBIT B. Insurance Requirements for Environmental Contractors and/or Consultants

EXHIBIT B. Insurance Requirements for Environmental Contractors and/or Consultants EXHIBIT B Insurance Requirements for Environmental Contractors and/or Consultants Contractor shall procure and maintain for the duration of the contract insurance against claims for injuries to persons