REQUEST FOR PROPOSALS

REQUEST FOR PROPOSALS TANF SUMMER YOUTH EMPLOYMENT PROGRAM For Service Provision May 1, 2015- October 31, 2015 Contracts may be extended when the state approves and funds are available. Offered by Mercer County Commissioners 220 W. Livingston Street Suite 201 Celina, Ohio 45801 on behalf of Mercer County Job & Family Services 419-586-5106 Deadline for Proposal Submission is March 31, 2015 10:00 a.m. Programmatic questions in Mercer County regarding this RFP may be directed to Elizabeth Rinderle, Mercer County Department of Job & Family Services, E.R.S. Administrator 419-586-5106 x 524 (voice) ~ Elizabeth.Rinderle@jfs.ohio.gov (e-mail) Fiscal questions may be directed to Anita Kremer Fiscal Administrator or Cindy Bittinger, Fiscal Specialist, Mercer County Department of Job & Family Services 419-586-5106 x 528 (voice) ~ Anita.Kremer@jfs.ohio.gov (e-mail) 419-586-5106 x 540 (voice) ~ Cindy.Bittinger@jfs.ohio.gov (e-mail) All Questions and Answers will be posted on: http://www.mercercountyohio.org/jfs 1

Table of Contents I General Information A. Purpose 3 B. Proposal 3 C. Performance and Outcomes 3 D. Partners 3 E. Renewal/Amendment Clause 4 F. RFP Time lines & Information 4 G. General Requirements for grants 5 II Technical Assistance 5 III Proposal Guidelines A. Cover Letter 5 B. Project and Fiscal Narrative 6 C. Attachments 6 D. Project Budget 7 IV V Minimum Standards & Evaluation Criteria A. Minimum Standards 7 B. Evaluation Criteria 7 C. Contract Award 8 Attachments A. Assurances Form 8 & 10 B. Americans with Disabilities Act and Compliance Statement 8 & 11 C. Certification Regarding with Debarment 9 & 12 D. Affidavit in Compliance 9 & 13 E. Equal Opportunity Certification 9 & 14 F. Budget 9 & 17-26 G. Proposal Checklist Form 9 & 15 H. Audit 9 VI Appendix A. Family Assistance Letter # 143 B. Budget Instructions 2

I. General Information A. Purpose The Mercer County Board of Commissioners have authorized the Mercer County Department of Job & Family Services (MCJFS) to release this Request for Proposals (RFP) to solicit Summer Youth Employment program to assist low income youth by providing job readiness training and summer employment work experience made available with Temporary Assistance for Needy Families (TANF) Funds. This Request for Proposal is not in itself an offer of work nor does it commit Mercer County Department of Job & Family Services (MCJFS) to fund any proposals submitted, nor will they be liable for any costs incurred in the preparation or research of proposals. B. Proposal The intent of this proposal is to offer services to low income youth, specifically up to 4 months of Paid Work Experience, with minimal Supportive Services. Providers are also required to offer low income youth Job Readiness training to assist them in being successful in the work experience and to better prepare them to join the workforce. C. Performance and Outcomes: MCJFS would like to have at a minimum, 40 participating Youth in the TANF Summer Youth Employment Program. The only performance outcome for those youth in the summer program will be the Work Evaluation by Employers and Youth Participants. D. Partners: MCJFS and local OhioMeanJobs encourage partnering and collaboration to deliver the most effective services to have the greatest possible community impact. If the proposal involves a partnership, a letter of agreement generally outlining the partnership and the activities or services of each of the partners must be provided. Before funding, partnerships will have to be firmly established by means of a Memorandum of Understanding (MOU). The MOU, whether developed as an umbrella agreement with a variety of agencies, or independently with a particular partner must contain, at a minimum, the following information: A description of the services that will be provided by each partner. How the costs of services and operating costs of the partnership will be funded. Method of referral between partners. Duration of the Memorandum and procedures for amending the Memorandum. Other provisions as agreed upon by the parties to the MOU. 3

E. Renewal/Amendment Clause Renewals and/or amendments are based on availability of funding and could involve extension of time or either increase or reduction of funds. F. RFP Time Lines & Information Request for Proposals Issued: March 6, 2015 Bidder s Conference: March 18, 2015 2 p.m. at Mercer County Job and Family Services 220 W. Livingston St Suite 10 Celina, Ohio 45822. RFP Submission Deadline: March 31 st at 10:00 a.m. Proposals will be available at the following locations and hours: Mercer County Department of Job & Family Services 220 W. Livingston St. Suite 10 Celina Ohio 45822 Monday 7 a.m. 5:00 p.m. Tuesday-Thursday 8 a.m 4:30 p.m Friday 8 a.m-3 pm Proposals may be requested by phone during the above listed hours at 419-586-5106. Mercer County Commissioners 220 W. Livingston Street Suite 201 Celina, Ohio 45801 Monday Friday 8:30 a.m. 4:00 p.m. Proposals may be requested by phone during the above listed hours at 419-586-3178. In order to be considered, three (3) copies of the proposal must be submitted with original signatures. In addition, proposer must meet the minimum standards listed in section IV (Page7). Proposals are to be sealed, and should bear the name and address of the proposer, and be plainly marked TANF Summer Youth Employment Proposal. Timely submission of the proposals is the sole responsibility of the proposer. The Mercer County Boards of Commissioners reserve the right to reject any and/or all of the proposals and waive any irregularities in favor of the county, and to award a contract in whole or in part if it is deemed to be in the best interest of MCJFS. The MCJFS reserves the right to approve a proposal in part or whole. MCJFS reserves the right to negotiate with any Proposer after proposals are reviewed, if such action is deemed to be in the best interest of MCJFS. Proposals must be hand delivered or delivered via U. S. Postal Service or other mail delivery service, and must be received no later than 10:00 a.m. to the following address: Mercer County Commissioners 220 W. Livingston Suite 201 Celina, Ohio 45822 4

G. General Requirements for TANF Summer Youth Grants: All guidelines to this program are outlined in the Ohio Department of Job and Family Assistance Letter #143 and included in this packet as Appendix A. II Technical Assistance A bidder s conference has been scheduled for March 18, 2015 at 2 p.m. at the Mercer County Department of Job & Family Services, 220 W. Livingston St, Suite 10 Celina, Ohio. MCJFS staff will respond to questions regarding the requirements of the RFP. All prospective proposers should plan to attend this conference. Please bring your copy of the RFP. Please prepare as many questions as possible prior to the conference so that staff can prepare responses. These questions can be submitted by fax to Anita Kremer, Elizabeth Rinderle and Cindy Bittinger (Mercer County) at 419-586-5643 (fax) or Anita.kremer@jfs.ohio.gov, Elizabeth.Rinderle@jfs.ohio.gov, or Cindy.Bittinger@jfs.ohio.gov. II Proposal Guidelines Proposers must submit a proposal to this RFP that meets the minimum requirements included in Section IV of this RFP. All Proposers are required to respond to this RFP exactly as outlined in order for the MCJFS to evaluate all proposals on an equal and timely basis. Proposals must be submitted in the following order: Section A: Cover letter Section B: Project and Fiscal Narratives Section C: Attachments A-G A. Cover Letter A Cover Letter must be enclosed (as the first page) with your proposal and should not exceed one (1) typed page and must state the following: 1. The organization s name. 2. Organization s mailing address and e-mail address (if available). 3. Organization s telephone number and fax number. 4. A statement of the intent to provide said services utilizing TANF funding. 5. Federal I.D. number 6. Type of organization (i.e., private, non-profit, governmental) 7. Name, title, and original signature of the person submitting the proposal for the organization. 8. Title of project or program (if applicable) 9. Contact persons for application 10. Total number of participants to be served 11. Cost per participant 12. Total amount requested 13. Brief description of organization 5

B. Project and Fiscal Narrative Please number and address each point. 1. Describe the organization s outreach and recruitment process, and how it will ensure success. 2. Provide a detailed description of how the proposer intends to provide the services requested within Section I., of this RFP. Include how collaboration between all agencies providing services will be accomplished, and the role each agency will play. 3. Describe the organization s plan for training, include at a minimum a training outline and the number of training contact hours. 4. How will the organization implement the proposal? 5. What methods will be used to evaluate the proposal s effectiveness? 6. How will the proposer obtain its proposed goals and objectives? 7. Describe the organization s staff and management structure for the proposal. If using current staff, include resumes or qualifications. If not using current staff, include position descriptions and qualifications for hire. 8. Describe how the organization intends to coordinate support services with other community organizations, which includes introduction and use of the local Ohio Means Jobs Center. 9. A youth under the age of 18 is required to have a parent/guardian sign their application. Parental cooperation has been a problem in the past, how will the organization secure parental involvement throughout the process for youth under age 18? 10. How will the organization select work sites, and will occupations utilized for work experience be in demand occupations in our area? 11. Describe the organizations past participation as the lead partner and/or other partner in collaborative efforts for youth. 12. Briefly describe the organization s previous youth services and the outcome and/or performance of these services. C. Attachments Review and sign all attachments found in Section V. Attachment A- Assurance Form Attachment B- Americans with Disabilities Act and Compliance Statement Attachment C- Certification Regarding Debarment 6

Attachment D- Affidavit in Compliance with Section 3517.13 of the Ohio Revised Code Attachment E- Equal Opportunity Certification Attachment F- Budget Work sheets Attachment G- Proposal Checklist Form D. Project Budget 1. Provide a narrative to explain and support the budget for the proposal. Provide a copy of the most recent audit of the organization. 2. Complete the budget forms, found in Section V., Attachment F IV. Minimum Standards & Evaluation Criteria A. Minimum Standards These minimum standards must be met if the proposal is to be further evaluated: 1. The proposal was submitted before the closing time and date. 2. The proposing organization is not on a Federal or State Debarment List. 3. The proposing organization is fiscally solvent. 4. The person signing the proposal as the submitting officer has the authority to do so. 5. The proposing organization agrees to meet all Federal, State, and local compliance requirements. B. Evaluation Criteria The MCJFS will review all proposals for completeness and compliance with the terms and conditions of the RFP. Proposals inconsistent with the RFP requirements will be eliminated from consideration. Proposals received after the proposal due date and time shall be rejected. Each proposal will be reviewed according to the rating system below. A total of 30 points may be awarded to each proposal. A scoring team of impartial parties will rate the proposals. The scoring team will forward the scores and their comments to the MCJFS Director and Fiscal Administrator who will make the final determination. 7

POINTS APPLICANT RESPONSE SCORE COMMENTS Max=3 The proposal gives a detailed profile of the target. Max=3 Proposal demonstrates ability to recruit and enroll eligible participants Max=3 Program description addresses HOW, WHEN, WHERE services will be provided. Max=3 Proposal demonstrates previous experience in delivering proposed services to the target population and demonstrates staff and volunteer qualifications Max=3 Proposal has identified specific goals and corresponding evaluation/ monitoring strategies which are appropriate and sound Max=3 Outcomes are realistic and clearly specified Max=3 Budget: Detailed individual cost sections and narrative complete and accurate Max=3 Program/service costs are deemed appropriate & reasonable Max=3 Proposal leverages funds and/or expands existing, successful programs Max=3 Proposal describes appropriate plan for training and includes outline. Max 30 TOTAL POINTS C. Contract Award Once the selection has been approved, the MCJFS will notify the Proposer(s) with the winning proposal. A contract negotiation process will immediately follow the verbal notification. The Proposer(s) that are not selected will be notified in writing. V. Attachments A. Assurances Form Review each of the assurances listed within the Assurances Form (Attachment A). Then sign and date the form and include it with your proposal. B. Americans with Disabilities Act and Compliance Statement Review then sign and date the form and include it with your proposal. 8

C. Certification Regarding Debarment, Suspension, ineligibility, and voluntary exclusion lower tier covered transactions Review then sign and date the form and include it with your proposal. D. Affidavit in Compliance with Section 3517.13 of the Ohio Revised Code Review then sign and date the form and include it with your proposal. E. Equal Opportunity Certification Review then sign and date the form and include it with your proposal. F. Budget Review the Youth Budget Form Instructions (Appendix B). Complete the Youth Budget form attachment F, which must correspond to the budget narrative. Include form with the proposal G. Proposal Checklist Form Review then sign and date the form and include it with your proposal. H. Audit Include a copy of your most recent audit 9

ATTACHMENT A. ASSURANCES FORM I recognize that I must give assurances for each item below. If I cannot, this proposal will be automatically rejected. The assurances are: 1. I am authorized by my Board of Directors, Trustees, other legally qualified officer, or as the owner of this agency or business to submit this proposal. 2. We are not currently on any Federal, State of Ohio, or local Debarment List. 3. We will provide records to show that we are fiscally solvent. 4. We have, or will have; all of the fiscal control and accounting procedures needed to ensure that TANF funds will be used as required by law and contract. 6. We will meet all applicable Federal, State and Local compliance requirements. These include, but are not limited to: * Records accurately reflect actual performance. * Maintaining record confidentiality, as required. * Reporting financial, participant, and performance data, as required. * Complying with Federal and State non-discrimination provisions. * Meeting all applicable labor laws, including Child Labor Law standards. * Drug Free Workplace We will not: * Place a youth in a position that will displace a current employee. * Use TANF money to assist, promote or deter union organizing. * Use funds for youth in the construction, operation or maintenance of any part of a facility to be used for sectarian instruction or religious worship. I hereby assure that all of the above are true. Signature Name (printed) Date Title 10

ATTACHMENT B Americans with Disabilities Act and Compliance Statement The Americans with Disabilities Act (ADA), Public Law 101-336, was signed into law on July 26, 1990 to provide a national mandate for the elimination of discrimination against individuals with disabilities. If selected to be a contractor through Mercer County Job & Family Services, I hereby will abide by all mandates of the ADA, Public Law 101-336 as it applies to the activities provided by the contract. Name of Organization Signature of agency s responsible representative: Date: 11

Attachment C Certification Regarding debarment, suspension, ineligibility, And voluntary exclusion lower tier covered transactions This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 20 CFR Part 98, Section 98.510, participants Responsibilities. The regulations were published as Part VII of the May 26, 1988 Federal Register (pages 19160-19211). The prospective lower tier participant certifies, by submission of the proposal, that neither it nor its principals is Debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in this transaction by any Federal department or agency. 1. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Name of Organization Signature of agency s responsible representative Date 12

Attachment D AFFIDAVIT IN COMPLIANCE WITH SECTION 3517.13 OF THE OHIO REVISED CODE STATE OF OHIO COUNTY OF MERCER SS: Personally appeared before me the undersigned, as an individual or as a representative of for a contract for (Name of Entity) (Type of Product or Service) to be let by the County of Mercer, who, being duly cautioned and sworn, makes the following statement with respect to prohibited activities constituting a conflict of interest or other violations under Ohio Revised Code Section 3517.13, and further states that the undersigned has the authority to make the following representation on behalf of himself or herself or of the business entity: 1. That none of the following has individually made within the two previous calendar years and that, if awarded a contract for the purchase of goods or services in excess of $500, none of the following individually will make, beginning on the date the contract is awarded and extending until one year following the conclusion of the contract, as an individual, one or more campaign contributions totaling in excess of $1,000, to any member of the Mercer County Board of Commissioners or their individual campaign committees: a. myself; b. any partner or owner or shareholder of the partnership (if applicable); c. any owner of more than 20% of the corporation or business trust (if applicable); d. each spouse of any person identified in (a) through (c) of this section; e. each child seven years of age to seventeen years of age of any person identified in divisions (a) through (c) of this section (only applicable to contributions made on or after January 1, 2007). 2. That none of the following have collectively made since January 1, 2007, and that, if awarded a contract for the purchase of goods or services in excess of $500, none of the following collectively will make, beginning on the date the contract is awarded and extending until one year following the conclusion of the contract, one or more campaign contributions totaling in excess of $1,000, to any member of the Mercer County Board of Commissioners or their individual campaign committees: a. myself; b. any partner or owner or shareholder of the partnership (if applicable); c. any owner of more than 20% of the corporation or business trust (if applicable); d. each spouse of any person identified in (a) through (c) of this section; e. each child seven years of age to seventeen years of age of any person identified in divisions (a) through (c) of this section. Signature Title: Sworn to before me and subscribed in my presence this day of,, 20. Notary Public My Commission Expires: 13

ATTACHMENT E EQUAL OPPORTUNITY CERTIFICATION Prior to contract award, potential contractors must assure that they are in compliance with nondiscrimination and equal opportunity requirements. The following statements must be in all proposals submitted and will be included in any contract with Mercer County Job & Family Services (MCJFS). As a condition to the award of a contract the contractor assures, with respect to the operation of MCJFS activities, that it will fully comply with the nondiscrimination and equal opportunity provisions. These will include: Title IV of the Civil Rights Act of 1964, as amended Section 504 of the Rehabilitation Act of 1975, as amended Age Discrimination Act of 1975, as amended Nontraditional employment for Women Act of 1991 Title IX of Education Amendments of 1972, as amended Name of organization: Signature of Agency s responsible representative 14

ATTACHMENT G PROPOSAL CHECKLIST FORM Format Narrative Three originals of proposal included Completed Cover Letter serving as the first page of proposal Project Narrative Budget Narrative Attachments Evaluation Criteria Understand and Agree to All Evaluation Criteria (pages 8) Contract Award Understand and Agree to Contract Award Information (page 8) Forms Assurances Form completed & attached (Attachment A, page10) Budget Forms completed & attached (Attachment D 12-40) Proposal Checklist Form completed & attached (Attachment C, page 11) Prosposer s Signature Date 15

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BUDGET FACE SHEET Enter below the total cost for each program from the Budget Recap Sheet, units to be served, and unit cost. Note: Subcontractors of the service provider must complete a separate budget to be submitted along with the service provider s budget. PROVIDER: CONTACT PERSON: ADDRESS: TELEPHONE: FAX: BUDGET PERIOD: CONTRACT PERIOD: PROGRAMS TOTAL COST TOTAL UNITS UNIT COST PROGRAM A Name PROGRAM B Name PROGRAM C Name PROGRAM D Name CONTRACT UNITS COMPLETED BY ACDJFS CONTRACT AMOUNT COMPLETED BY ACDJFS UNIT DEFINITION - Please give clear definition of each unit of service for each program being proposed. A unit can be per hour, per class, per participant, etc. Describe the specific activities that will be provided to comprise each unit. PROGRAM A - PROGRAM B - PROGRAM C - PROGRAM D - ATTACHMENT F 17

SALARY PAGE Budget Item Number I A. PROGRAM A PROGRAM B PROGRAM C PROGRAM D Name Name Name Name POSITION F SALARY HRS LENGT % SALARY % SALARY % SALARY % SALARY H OR or PER PER OF TO THE CHGD TO THE TO THE CHGD TO THE TO THE CHGD TO THE TO THE CHGD TO THE TITLE V HOUR WEEK BUDGET PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM TOTALS 18

PAYROLL RELATED EXPENSES Budget Item Number I B. ATTACH WORK SHEET IF RELATED EXPENSES ARE NOT UNIFORM, OR ACROSS THE BOARD, FOR ALL STAFF PROGRAM A PROGRAM B PROGRAM C PROGRAM D Name Name Name Name INSERT IN EACH PROGRAM THE AMOUNT FROM SALARY PAGE Amt. Amt. Amt. Amt. TOTAL SOCIAL SECURITY 6.2%,PERS 14%,SERS % MEDICARE 1.45% WORKERS COMP % RETIREMENT % HOSPITALIZATION % UNEMPLOYMENT % OTHER (IDENTIFY TOTAL PAYROLL RELATED EXPENSES ATTACH SERVICE AGREEMENT OR FEE SCHEDULE CONSULTATION FEES Budget Item Number I C. PROGRAM A PROGRAM B PROGRAM C PROGRAM D TYPE: e.g. accountant, etc. RATE HOURS/DAYS Name Name Name Name TOTAL TOTAL CONSULTATION FEES 19

TRAVEL Budget Item Number II A. AGENCY/EMPLOYEES ACTUAL VEHICLE EXPENSE GAS & OIL REPAIRS AND OTHER MAINTENANCE LICENSE INSURANCE OTHER MILEAGE REIMBURSEMENT @ 50 CENTS/MILE FOR MILES CONFERENCE, MEETINGS, ETC. CLIENTS PURCHASED TRANSPORTATION: Please see note below. PROGRAM A PROGRAM B PROGRAM C PROGRAM D Name Name Name Name TOTAL TOTAL TRAVEL NOTE: If the service being provided requires transportation for clients and if the transportation is being provided by a vendor, other than the vendor this contract is with, that ACDJFS already contracts with, the transportation rates can not exceed ACDJ CONSUMABLE SUPPLIES Budget Item Number II B. PROGRAM A PROGRAM B PROGRAM C PROGRAM D Consumable Supplies related directly to the program(s). Name Name Name Name TOTAL OFFICE TRAINING PROGRAM OTHER (SPECIFY) TOTAL CONSUMABLE SUPPLIES NOTE: Attach an itemized list so that ACDJFS is aware of the consumable supplies being budgeted for. 20

OCCUPANCY COSTS Budget Item Number II C. A. RENT (Office Space) 1. Total # of 2. Cost per Sq. Square Feet Ft. per Month 3. Total Cost per Month B. UTILITIES (If Not Included In Rent) 1. HEAT 2. ELECTRICITY 3. TELEPHONE 4. WATER 5. JANITORIAL & MAINTENANCE 6. INTERNET SERVICE 7. TOTAL PER MONTH C. DEPRECIATION OR USAGE ALLOWANCE 1. DEPRECIATION a. Item b. Acquisition Cost c. Acquisition Date e. Useful Life Years f. Straight-line Annual Dep. 2. USAGE ALLOWANCE (Limited to 2% for buildings per year) a. Item b. Acquisition Cost c. Acquisition Date e. Useful Life Years f. Usage Allowance Amt 3. DEPRECIATION (C.1.f.) OR USAGE ALLOWANCE ( C.2.f.) DIVIDED BY 12 EQUALS D. MISCELLANEOUS BUILDING EXPENSES 1. Item 2. Cost 3. TOTAL COST PER MONTH E. TOTAL MONTHLY OCCUPANCY COSTS (A.3.+B.7.+C.3.+D.3.) X LENGTH OF THE BUDGET EQUALS TOTAL OCCUPANCY COSTS FOR BUDGET PERIOD. Please see note below. NOTE: USE THE FULL-TIME EQUIVELANCY RATE, SQUARE FOOTAGE RATE, OR OTHER MEANS OF ALLOCATING TO DETERMINE THE ALLOWABLE AMOUNT TO CHARGE AND THE AMOUNT TO SPREAD TO EACH PROGRAM. PROGRAM A PROGRAM B PROGRAM C PROGRAM D Name Name Name Name % AMT CHGD % AMT CHGD % AMT CHGD % AMT CHGD UNRELATED TO THE TO THE TO THE TO THE TO THE TO THE TO THE TO THE TO THE PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAMS 21

INSURANCE COSTS Budget Item Number II D. NOTE: USE THE FULL-TIME EQUIVELANCY RATE OR OTHER MEANS OF ALLOCATING TO DETERMINE THE ALLOWABLE AMOUNT TO CHARGE AND TH EACH PROGRAM. PROGRAM A PROGRAM B PROGRAM C PROG Name Name Name Name % AMT CHGD % AMT CHGD % AMT CHGD % LENGTH OF TO THE TO THE TO THE TO THE TO THE TO THE TO THE INSURANCE BUDGET PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM LIABILITY See note below. AGENCY EMPLOYEE BONDING # OF EMPLOYEES COVERED OTHER TOTAL INSURANCE NOTE: Liability Insurance covers damage done to other persons or to property other than that of contractor. INDIRECT COSTS Budget Item Number II E. ENTER BELOW OTHER INDIRECT COSTS NOT ALREADY CAPTURED (e.g. GENERAL OFFICE SUPPLIES, ETC.) PROGRAM A PROGRAM B PROGRAM C PROG Name Name Name Name % AMT CHGD % AMT CHGD % AMT CHGD % LENGTH OF TO THE TO THE TO THE TO THE TO THE TO THE TO THE ITEM BUDGET PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM TOTAL INDIRECT NOTE: Attach an itemized list so that ACDJFS is aware of the indirect costs being budgeted for. 22

EQUIPMENT SUBJECT TO DEPRECIATION OR USAGE ALLOWANCE Budget Item Number III A. A. DEPRECIATION OR USAGE ALLOWANCE 1. DEPRECIATION List below the items costing $5,000.00 or more. a. Item b. Acquisition Cost c. Acquisition Date e. Useful Life Years f. Straight-line Annual Dep. TOTAL PER YEAR 2. USAGE ALLOWANCE (Limited to 6 2/3% for equipment per year) List below items already owned and depreciation by contractor. a. Item b. Acquisition Cost c. Acquisition Date e. Useful Life Years f. Usage Allowance Amt (b. X.0667) TOTAL PER YEAR 3. DEPRECIATION (A.1.f.) + USAGE ALLOWANCE ( A.2.f.) EQUALS ANNUAL DEPRECIATION AND USAGE ALLOWANCE, DIVIDED BY 12 EQUALS PER MONTH, X LENGTH OF PROGRAM EQUALS TOTAL EQUIPMENT DEPRECIATION AND USAGE ALLOWANC NOTE: USE THE FULL-TIME EQUIVELANCY RATE OR OTHER MEANS OF ALLOCATING TO DETERMINE THE ALLOWABLE AMOUNT TO CHARGE AND THE AMOUNT TO SPREAD TO EACH PROGRAM. PROGRAM A PROGRAM B PROGRAM C PROGRAM D Name Name Name Name % AMT CHGD % AMT CHGD % AMT CHGD % AMT CHGD UNRELATED TO THE TO THE TO THE TO THE TO THE TO THE TO THE TO THE TO THE PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAM PROGRAMS 23

SMALL EQUIPMENT ( Equipment Costing Under $5,000.00) Budget Item Number III B. ITEM PROGRAM A PROGRAM B PROGRAM C PROGRAM D ITEM QUANTITY COST Name Name Name Name TOTAL COST TOTAL SMALL EQUIPMENT PURCHASES LEASED AND RENTED EQUIPMENT Budget Item Number III C. NOTE: ONLY WHEN FEASIBLE AND WHEN THE LEASE OR RENT AMOUNT DOES NOT EXCEED THE COST TO PURCHASE THE ITEM(S). RENTAL PROGRAM A PROGRAM B PROGRAM C PROGRAM D ITEM QUANTITY COST Name Name Name Name TOTAL COST TOTAL LEASED AND RENTED EQUIPMENT MISCELLANEOUS COSTS Budget Item Number IV ITEM PROGRAM A PROGRAM B PROGRAM C PROGRAM D ITEM QUANTITY COST Name Name Name 24 Name TOTAL COST

I STAFF COSTS RECAP OF BUDGET ITEMS Enter below the totals for the various categories which are detailed on the attached sheets of this EXHIBIT. TOTAL PROGRAM A PROGRAM B PROGRAM C PROGRAM D BUDGET Name Name Name Name AMOUNT A. SALARIES B. PAYROLL RELATED EXPENSES C. CONSULTATION FEES TOTAL STAFF COSTS II OPERATIONAL COSTS A. TRAVEL B. CONSUMABLE SUPPLIES C. OCCUPANCY D. INSURANCE E. INDIRECT COSTS TOTAL OPERATIONAL COSTS III EQUIPMENT COSTS A. DEPRECIATION AND USAGE ALLOWANCE B. SMALL EQUIPMENT PURCHASES C. LEASED AND RENTED EQUIPMENT TOTAL EQUIPMENT COSTS IV MISCELLANEOUS TOTAL PROGRAM BUDGET FOR PROGRAM(S) UNDER CONTRACT 25

TOTAL INCOME FOR BUDGET PERIOD A. INCOME FOR PROGRAM(S) UNDER THIS CONTRACT: 1. FEES FROM PRIVATE CONSUMERS 2. FEES GENERATED BY CONTRACT FOR RECIPIENTS 3. OTHER FEDERAL SUPPORT OF CONTRACTED PROGRAM(S) PROGRAM A PROGRAM B PROGRAM C PROGRAM D Name Name Name Name TOTAL 4. STATE, COUNTY OR MUNICIPAL ALLOCATIONS 5. CONTRIBUTIONS 6. OTHER CONTRACTS 7. MISCELLANEOUS TOTAL INCOME FOR PROGRAM(S) UNDER CONTRACT B. INCOME FOR OTHER SERVICES PROVIDED BY AGENCY NOT UNDER THIS CONTRACT TOTAL 1. FROM PRIVATE CONSUMERS 2. FEDERAL MONIES (GRANTS OR CONTRACTS) 3. STATE, COUNTY OR MUNICIPAL ALLOCATIONS 4. CONTRIBUTIONS 5. MISCELLANEOUS TOTAL OTHER PROGRAM SERVICE(S) INCOME TOTAL AGENCY INCOME (SECTION A TOTAL + SECTION B TOTAL) 26

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