NC COUNCIL FOR WOMEN & DOMESTIC VIOLENCE COMMISSION DISPLACED HOMEMAKER/DIVORCE FILING FEE
2010-2011 Grant Application
NOTE: A separate application must be completed for each county
DEADLINE: Completed applications must be received by 5:00pm May 3, 2010
Applications are available on our website:
http://www.doa.state.nc.us/cfw/grantinfo.htm
US Mail Only: Federal Express/UPS/Hand Delivery:
Grants Section Grants Section
NC CFW/DVC NC CFW/DVC
1320 Mail Service Center 422 N. Blount Street
Raleigh NC 27699-1320 Raleigh NC 27601
Applicants should read and refer to the Application Guidelines on the website when completing this application. http://www.doa.state.nc.us/cfw/grantinfo.htm
· DH Program’s County Location:(list ALL of the counties to be served by the one allocation)
§ DH Program’s Full Name:
§ DH Program’s Federal Tax Identification Number:
(Aka Contract Number)
§ DH Executive Director:
§ Email Address:
§ DH Program Director:
§ Email Address:
§ DH Program Status: r Government Operated r Private, Non-Profit
§ DH Program’s Fiscal Year: Month of through Month of
§ Year DH program started: Year DH program was incorporated:
§ Date your DH program received non-profit status:
§ Is DH program a subsidiary of another organization? Yes ____ No___
§ DH Administrative Office Address:
(Street, city, zip code)
§ DH Mailing Address:
(If a PO Box or different from address provided above)
§ DH Office Phone: ( ) Fax: ( )
§ Provide the number of DH Employees to be funded with NC CFW/DVC funds:
__ Full-time DH staff ____Part-time DH staff ______Total
§ DH Program’s website address:
§ Does your Program receive DV/MLF funds from NC CFW/DVC? Yes___ No____
§ Does your Program receive SA funds from NC CFW/DVC? Yes___ No_____
Program Narrative Criteria
(Based on 100 accumulative points)
DH Program’s History=15 pts
DH Program’s Project Need=40pts
DH Program’s Objectives=18pts
DH Program’s Board participation and Community Support=12pts
DH Program’s Quality of Personnel=5pts
DH Program’s Budget Effectiveness=10pts
· The Grant Applications must be complete at the time of submission and cannot be modified in any manner once submitted
· Be sure to address ALL items of application
· If an item is not applicable…please indicate N/A and briefly explain why item does not apply
· All responses should refer to the DH program only
· For clarity in your response, please provide the title of the bullet/section with each response.
Example:
o Provide your Board’s sustainability plan for the program-
o Our Board’s sustainability plan consists of…..
· Limit your response to one page, double space, using 12pt Times New Roman Font
DO NOT ALTER ANY OF THE CONTENT PRINTED ON THE FORMS
“BLUE” INK STRONGLY RECOMMMENDED FOR SIGNATURES
Applicants should read and refer to the Application Guidelines when on the website completing this application. http://www.doa.state.nc.us/cfw/grantinfo.htm
Possible Resources for data requested
https://www.ncesc.com/default.aspx
http://www.ncjustice.org/
www.ncruralcenter.org
Glossary of Terms:
Ø Co-mingling of Funds: Funds from personal, business or church sources mingled together with grant funds. The IRS discourages this practice. The NC CFW/DVC prohibits co-mingling of funds.
Ø Conflict of Interest: Any personal, financial and/or professional interest that might create a conflict with the ability to fairly and objectivity carry out one’s responsibilities. This term also refers to a situation in which a person has vested interest in the outcome of a decision and tries to influence the decision making process as they did not.
Ø Evaluate: To ascertain or fix the value or worth of something or to examine and judge carefully; appraise
Ø In Kind: refers to payment for goods or services with a medium other than legal tender (anything can be used as money, but legal tender is what the State accepts for all debts).
Ø Objective: A specific, measurable accomplishment within a specified time frame.
Example: By December 2010, tobacco use will decrease to 10% of patients seen as reported on a prevalence survey.
Ø Goal: A broad statement of the ultimate aims of a program.
Ø Example:
Ø Goal: To improve production quality.
Ø Objective 1: Recruit advanced production talent.
Ø Objective 2: Train mid-level producers.
Ø Objective 3: Upgrade production equipment
Ø Matching Funds: An element of some grant programs that requires the grantee (the organization receiving the grant) to provide part of the funding for the program either in cash or by contributing facilities or other resources of value. These funds or resources are sometimes referred to as “matching funds”. They usually must be raised from other than state or federal sources. Matching funds are funds applied to a specific grant and cannot be utilized as a match for other grants.
Ø Mission: A description of an entity’s purpose
Ø Monitor: To keep close watch over; supervise
Ø Qualitative: Investigates the why and how of decision making, as compared to what, where, and when of quantitative research.
Ø Quantitative: A quantitative property is one that exists in a range of magnitudes, and can therefore be measured.
History– (15 pts total)
Each bulleted item must be addressed
· What is your program’s mission and if you are a multi-service agency how does the DH program fit into the mission of your organization? -5pts
· Describe outreach and any significant or unique accomplishments of the DH program during the past year and describe evidence of success -5pts
· List and describe whether or not DH program met projected goals during previous year, if projected goals were no met, please explain why they were not met-5pts
You can utilize this area to type your responsesEach line is expandable
You can type over this message
Project Need (purpose/justification of request for funds)-(40pts total)
Each bulleted item must be addressed
· Describe the need for the DH program within your community -5pts
· List and describe any barriers that affect current service delivery and training -5pts
¬ Provide data on the probable number of displaced homemakers in the area (in accordance to G.S. 143B-394.5A) -5pts
¬ Provide data on the availability of resources for training and education in the area (in accordance to G.S. 143B-394.5A) –5pts
¬ Provide data on viable living wage job opportunities in the area (in accordance to G.S. 143B-394.5A) –5pts
You can utilize this area to type your responsesEach line is expandable
You can type over this message
· Utilize charts to describe how the program will provide the services & numbers served -15pts
Statutory Services / Agency/Group providing service / ComponentsOutreach, Intake & Orientation:
Referral, Follow-up (5pts)
Job Counseling
(2pts)
Job Training/Job Placement
(2pts)
Health Education
(2pts)
Financial Services
(2pts)
Educational Services
(2pts)
Provide the total numbers served or numbers to be served in each category.
If applicant serves more than one county, specify the county served beside the number)
Actual Service ResultsDuring present grant cycle
FY09-10
(July 1st thru December 31, 2009)
(6 months) / Projected/Anticipated Service Goals
For
FY10-11
(July 1,2010 --September 30, 2011)
(15 months)
Overall Number of DH Clients Served
Type of Service:
Job counseling
Job training
Health education
Financial Management
Educational Services
Number of Stipends Provided
Childcare:
Education:
Books:
Transportation: / Childcare:
Education:
Books:
Transportation: / Childcare:
Education:
Books:
Transportation:
Number of Clients Placed in Jobs:
Full Time
Part Time
Disabled
Number Placed in Education Placements:
4- Year College
Community College
Trades
Other
Objectives-(18pts total)
Each bulleted item must be addressed
· List three (3) measurable objectives and describe the projected outcome for each objective
listed-12pts
· Describe the method(s) utilized to measure and evaluate the program’s effectiveness-6 pts
You can utilize this area to type your responsesEach line is expandable
You can type over this message
Board participation and Community Support-(12pts total)
Each bulleted item must be addressed
***If any item below is not applicable…state and provide explanation
· Describe the Governing Board’s role and participation with the program including the
monitoring and evaluation process (Refer to 501 C3) –5pts
· List and describe partnerships, community supporters, and collaborations -2pts
· Provide your Board’s sustainability plan for the program-3pts
· Provide details on the Board’s diversity (including gender, race/ethnicity, geographic)-2pts
You can utilize this area to type your responsesEach line is expandable
You can type over this message
Quality of Personnel – (5pts total)
· Explain your efforts to address staff diversity-3pts
· Provide a job description of each DH position(s) that will be funded by NC CFW/DVC-2pts
· (SPECIFY WHICH GRANT FUND WILL BE UTILIZED TO FUND POSITION-DH OR DFF)
You can list the positions and provide job descriptions in the area below
OR
Attach each job description that addresses each bulleted item listed above
o Position/Title
o Duties of Position
o Knowledge, skills & abilities
o Trainings/credentials required)
You can utilize this area to type your responseEach line is expandable
You can type over this message
Budget Effectiveness – (10pts total)
Each bulleted item must be addressed
· Describe how your DH program will provide the 20% match -3pts
· Describe the basis of accounting to be utilized and how will accounting records will be maintained to ensure consistency and accountability of the state issued grant funds-7pts
(example: Cash, Modified Cash, Accrual)
You can utilize this area to type your responseEach line is expandable
You can type over this message
Please provide a list of ALL funding sources for the past 2 years for this program
List Funding Source / List Amount Provided / Year Funds Provided$
$
$
$
$
$
$
$
$
$
$
$
$
List Funding Source / List Amount Provided / Year Funds Provided
$
$
$
$
$
$
$
$
$
$
$
$
$
Verification of Policy Implementation
Government Agencies are exempt from completing this page
Complete this page ONLY if your program submitted the policies listed below during Fiscal Year 2006-2007
Program’s Full Name: County:
Print Board Chair’s Name: Date: 20____
Board Chair’s Signature: ______
Print Executive Director’s Name: Date: 20____
Executive Director’s Signature: ______
q Confidentiality Policy (submitted during FY06-07)
Approval Date______
Effective Date______
Amendment Date (attach amended section) ______
q Non-discrimination Policy (submitted during FY06-07)
Approval Date______
Effective Date______
Amendment Date______
q Organizational Code of Conduct Policy (submitted during FY06-07)
Approval Date______
Effective Date______
Amendment Date (attach amended section) ______
q Internal Controls Policy (submitted during FY06-07)
Approval Date______
Effective Date______
Amendment Date (attach amended section) ______
q Recordkeeping Policy (submitted during FY06-07)
Approval Date______
Effective Date______
Amendment Date (attach amended section) ______
q Whistleblower Policy (submitted during FY06-07)
Approval Date______
Effective Date______
Amendment Date (attach amended section) ______
Certification Page
Program’s Full Name: County:
NC COUNCIL FOR WOMEN & DOMESTIC VIOLENCE COMMISSION
CERTIFICATION PAGE
2010-2011
Certification of Matching Funds
This is to certify that this agency has received funds and/or services in an amount necessary to provide the required match, or that the agency has been pledged funds and/or services for the required match for the 2010-2011 year and has supporting documentation on file.
Certification of Non-Lobbying
This is to certify that this agency will not use any funds received from this grant for lobbying to influence legislators to support or vote for or against legislation or appropriations.
Certification of Bonding/Insurance
This is to certify that all employees, volunteers and board members who handle funds are properly bonded to insure that all monies are safeguarded.
______
Date Board Treasurer/Equivalent (Printed Name)
Date Board Treasurer/Equivalent (Signature)
Signatures certify that all information subscribed to above is true and accurate
Verification of Applicant’s Review of Grant Application
The persons whose signatures appear below, certify that they have reviewed the information within this grant application and verify that all items are true and accurate
Signature Section: (Use of Blue Ink suggested for Signature)
_____
Board Chair/Equivalent (Printed Name) Executive Director/Equivalent (Printed Name)
Board Chair/Equivalent (Signature) Executive Director/Equivalent (Signature)
Date Date
TO REQUEST RECEIPT OF THE GRANT APPLICATION…COMPLETE ITEMS BELOW AND ATTACH THIS DOCUMENT AT THE VERY FRONT OF YOUR GRANT APPLICATION.
PROVIDE PROGRAM’S NAME:
PROVIDE PROGRAM’S COUNTY LOCATION:
PROVIDE CONTACT PERSON’S NAME:
PROVIDE CONTACT PERSON’S PHONE #:
PROVIDE CONTACT PERSON’S EMAIL ADDRESS:
GRANT APPLICATION CHECKLIST:
(1)Original and (6) Copies to be submitted:
q Grant Application Cover Sheet
q Program Narrative
q Verification of Policy Implementation(Signatures required)
q Certification Section(Signatures required)
q Verification of Grant Application Page(Signatures required)
q Projected Income Statement(Excel Attachment)
q Budget Proposals(Excel Attachments)
(State Funds, 20 % Match, Divorce Filing Fees)
q List of current members of the Board of Directors, including the Finance Committee- New applicants must submit one (1) copy of items listed below
q Copy of agency’s 501c(3)
q Articles of Incorporation
q Agency bylaws
New Applicants will have to submit all of the policies listed below
Existing applicants will only need to complete the verification section provided.
(If the policy was submitted during FY06-07 grant cycle to NC CFW/DVC)
q Confidentiality Policy
q Non-discrimination Policy
q Organizational Code of Conduct Policy
q Internal Controls Policy
q Recordkeeping Policy
q Whistleblower Policy
BE SURE TO INCLUDE THE EXCEL ATTACHMENTS LISTED BELOW
· DH State funds excel budget page worksheet
· Divorce Filing Fee excel budget page worksheet
· 20% Matching Funds excel budget page worksheet
The match must be generated locally and represent a minimum of 20% of the total award
Ø Projected Income Statement-separate excel page
Ø Any of the policies listed on the “Policy Implementation” page that have been amended must be submitted with grant application
2