ARKANSAS DEPARTMENT OF FINANCE AND ADMINISTRATION
OFFICE OF INTERGOVERNMENTAL SERVICES
SEXUAL ASSAULT SERVICES PROGRAM
2010-2011 APPLICATION
1. Applicant Organization2. Mailing Address (Street/P.O. Box)
3. City/State / 4. Zip Code
5. Type of Applicant / Select OneNon-profit OrganizationHospital/Emergency Medical FacilityInstitution of Higher LearningFaith-based OrganizationRape Crisis CenterOther (Specify) / 6. Federal Identification Number / 7. DUNS Number
8. Is the applicant delinquent on any federal debt? / Select OneYesNo
8a. If yes to item 8, explain
9. Would the federal funds being requested replace prior local or state support for this project? / Select OneYesNo
9a. If yes to item 9, explain
10. Authorized Official (Name/Title)
11. Amount of funds requested / 12. Purpose of Request:
Indicate the counties, judicial districts and congressional districts to be served by the project and whether or not the subgrant organization currently provides services to the indicated areas.
County (ies) / Judicial District(s) / Congressional District (s) / Currently Providing Services / Number Served in last 12 months
Select OneYesNo
Select OneYesNo
Select OneYesNo
Select OneYesNo
Select OneYesNo
Select OneYesNo
Please provide contact information for matters involving this application
First Name / Middle Initial / Last Name
Phone Number / Alternate Contact Phone Number
E-mail address
Applicant Organization
(90 character maximum)
A. AGENCY CAPACITY
(50 Points)
SERVICES: (check all that apply)
(Indicate sexual assault services currently provided by the applicant organization, as well as the approximate number of victims served in each category within the past 12 month period. / Yes / No / Unsure / Number Served
1. 24-hour Hotline providing rape crisis intervention services and referral
2. Medical accompaniment
3. Crisis intervention
4. Criminal justice advocacy
5. Individual support services
6. Group support services
7. Information and referral (in person) to assist victim and family
8. Community-based linguistically and culturally specific services
9. Outreach activities for underserved communities
10. Develop and/or distribute materials on issues related to sexual assault
11. List any other services currently provided by the applicant.
12. What is your current service area(s)?
STAFFING: / Yes / No / Unsure
13. Does the applicant have dedicated sexual assault staff?
If no, skip to question 15
Please list the job title(s) and funding source(s) for each sexual assault position:
Job Title / Funding Source
14. Please attach job descriptions for all staff currently providing sexual assault services: (ATTACHMENT IV)
If yes, please state the funding source(s):
15. Number of staff members certified as sexual assault victim advocates? / 16. Number of volunteers certified as sexual assault victim advocates?
17. State the source of the certification:
18. Please attach a copy of the applicant’s organizational chart: (ATTACHMENT V)
Applicant Organization
(90 character maximum)
A. AGENCY CAPACITY (cont’d)
(50 Points)
FINANCIAL: / Yes / No / Unsure
19. Does the applicant utilize computerized double entry accounting system in accounting for funds?
20. Do the applicant’s accounting records identify receipt and expenditure of program funds separately for each grant/ funding source?
21. Does the applicant maintain timesheets, signed by the employee and supervisor for all employees?
22. Does the applicant maintain backup documentation to substantiate payments for withholding tax, purchases and to verify other claimed expenditures?
23. Does the applicant expend more than $500,000 annually in federal funds? If yes, when was the agency's most recent A-133 audit completed.
If yes, when was the agency's most recent A-133 audit completed.
26. Please summarize the applicant organization’s mission statement (450 character maximum)
Applicant Organization
(90 character maximum)
B. PROJECT NEED
(20 Points)
27. List all sexual assault services within a 50 mile radius of the proposed project location. If none, so indicate.
PROGRAM NAME
(72 character maximum) / LOCATION (City/County)
(50 character maximum)
Indicate the service(s) to be provided with funding, check all that apply / Yes / No / Unsure
29. 24-hour Hotline providing rape crisis intervention services and referral
30. Medical accompaniment
31. Crisis intervention
32. Criminal justice advocacy
33. Individual support services
34. Group support services
35. Information and referral (in person) to assist victim and family
36. Community-based linguistically and culturally specific services
37. Outreach activities for underserved communities
38. Develop and/or distribute materials on issues related to sexual assault
39. Other (specify)
(150 character maximum)
40. Will the funding increase the current service area?
If yes, indicate additional area(s) to be served:
41. Please identify the specific need for funding, the benefits to be achieved, as well as the measurement to be used to determine success (450 characters maximum):
Applicant Organization
(90 character maximum)
C. GOALS and OBJECTIVES (10 Points)
Please state the overall goals to be accomplished by the funding. Be sure to include the measurement(s) to be used to determine the desired long-term impact of the project, as well as the date of completion for each objective. DO NOT list more than three (3) goals.
GOAL
(195 character maximum) / OBJECTIVE
(72 character maximum) / COMPLETION DATE / MEASUREMENT
(85 character maximum)
Applicant Organization
(90 character maximum)
ADDITIONAL INFORMATION
(Use this space to provide any additional information you feel is relevant to this application)
1,000 character maximum
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