START-UP and EXPANSION GRANT APPLICATION SUMMER MEALS and AFTERSCHOOL MEALS
& SNACKS PROGRAM 2013-2015 /
Organization Information
Organization Name: / Address:
Doing Business As: / City/State/Zip:
Contact Name: / Contact Title:
Contact Phone: / Extension: / DUNS® Number:
Email:
Staffing Information
This information is used to set up account in E-Grant Management System (EGMS)
Project Director
Name / Title
Phone Number / Email
Authorized Representative
Name / Title
Phone Number / Email
Financial Office Contact
Name / Title
Phone Number / Email
Operation Plan
1)  Select the best description of your organization’s status:
Current approved Oregon Department of Education Child Nutrition Programs (ODE CNP) Sponsor
·  ODE CNP Agreement Number:
(check all that apply):
Child and Adult Care Food Program
Summer Food Service Program
National School Lunch Program
ODE CNP applicant (with an application pending with ODE CNP)
·  ODE CNP Agreement Number:
ODE CNP applicant (without an application pending with ODE CNP)
2)  Check here if the applicant has previously received Start-up and Expansion grant funds.
3)  Which Programs will you increase participation in with the grant funds?
Summer Meals—Summer Food Service Program/Seamless Summer Option (Complete number 5 below)
Afterschool Meals & Snacks Program (Complete number 6 below)
4)  Total amount of funds requested (not to exceed $20,000) from Budget on page 4: $

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5)  Summer Meals: Summer Food Service Program/Seamless Summer Option: Select strategies the program plan to use to increase program participation
Yes No Add new site(s)
Yes No Add new meal type(s)
Yes No Add days of operation
Yes No Conduct Outreach
Yes No Other:
Use additional sheets if you are adding or modifying more than four sites.
Name of Site
If a new site,
provide address / Add
New Site / Add
New Meal Type(s) / Current Meal Types Served
(check none if new site) / New or Additional Meal Types to be served: / Other Strategies for Increasing Participation / Average Daily Participation
Increase
Add Days of Operation
Describe Plan / Outreach
Describe Plan / Other
Describe / Current
ADP / Target/Goal ADP
Site 1: / Yes No / Yes
No / Breakfast
Lunch
Supper
One Snack
Two snacks
None / Breakfast
Lunch
Supper
One Snack
Two snacks
None
Site 2: / Yes No / Yes
No / Breakfast
Lunch
Supper
One Snack
Two snacks
None / Breakfast
Lunch
Supper
One Snack
Two snacks
None
Site 3: / Yes No / Yes
No / Breakfast
Lunch
Supper
One Snack
Two snacks
None / Breakfast
Lunch
Supper
One Snack
Two snacks
None
Site 4: / Yes No / Yes
No / Breakfast
Lunch
Supper
One Snack
Two snacks
None / Breakfast
Lunch
Supper
One Snack
Two snacks
None
6)  Afterschool Meals & Snacks Program: Select strategies the program plan to use to increase program participation
Yes No Add new sites
Yes No Add new meal type(s)
Yes No Add days of operation
Yes No Conduct Outreach
Yes No Other:
Use additional sheets if you are adding or modifying more than four sites.
Name of Site
If a new site,
provide address / Add
New Site / Add
New Meal Type(s) / Current Meal Types Served
(check none if new site) / New or Additional Meal Types to be served: / Other Strategies for Increasing Participation / Average Daily Participation
Increase
Add Days of Operation
Describe Plan / Outreach
Describe Plan / Other
Describe / Current
ADP / Target/Goal ADP
Site 1: / Yes No / Yes
No / Breakfast
Lunch
Supper
One Snack
Two snacks
None / Breakfast
Lunch
Supper
One Snack
Two snacks
None
Site 2: / Yes No / Yes
No / Breakfast
Lunch
Supper
One Snack
Two snacks
None / Breakfast
Lunch
Supper
One Snack
Two snacks
None
Site 3: / Yes No / Yes
No / Breakfast
Lunch
Supper
One Snack
Two snacks
None / Breakfast
Lunch
Supper
One Snack
Two snacks
None
Site 4: / Yes No / Yes
No / Breakfast
Lunch
Supper
One Snack
Two snacks
None / Breakfast
Lunch
Supper
One Snack
Two snacks
None

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Budget

Complete the Budget chart. Refer to the grant instructions for eligible cost descriptions. If your organization is requesting Staff Expenses, also complete the Staff Expenses Worksheet and include the total staff expenses on the Budget.

Line Item: Describe item to be purchased, services to be rendered or description of tasks staff will accomplish with requested grant funds. Include site name where equipment/services/staffing will be utilized, if appropriate. Staff costs require a sustainability plan in the Budget Narrative.

Other Sources of Funding: If you will receive additional monetary support for a specific line item, list the dollar amount and the source of funding. (i.e. Meyer Memorial Trust Grant, local Target store, etc.). If none, write none.

Budget Chart (Attach additional sheet if needed):

Approved Category / Line Item / Describe How Line Item will Contribute to Increased participation / Quantity
(enter N/A
if not applicable) / Total Cost / Grant Amount Requested / Other Funding Sources & Amount)
(If none, write none)
Example: Outreach Activities / Advertising in 3 local newspapers / Increased awareness of program / 3 / $900 / $900 / none
Foodservice Equipment Purchases / $ / $
Sanitation Inspection Fees/related repairs / $ / $
Outreach Materials/Activities / $ / $
Enrichment or Education activities equipment/supplies / $ / $
Transportation related purchases / $ / $
Vehicle gas/mileage reimbursement / $ / $
Staff costs:
·  support implementation of enrichment or educational activities (max. of $1,000 per each new or current site.) *
·  outreach activities *
·  additional foodservice labor for first two months of operation *
·  training on curriculum implementation* / $ / $
$ / $
$ / $
$ / $
Other activities to meet grant goal(s) / $ / $
Total Requested Funds (with staff expenses) à / $

* Staff Expenses Worksheet

(Complete if requesting Staffing Expenses. Include total labor expenses in budget above. Add additional pages, as needed.)

Position / New or current employee? / Hours per month spent on grant activities / Number of Months / Total
Wages / Total Payroll Benefits / Total
Labor
Example: Outreach Coordinator / New / 40 / 2 / $800
($10 hr. x 40 x 2) / $200 / $1,000
Total Requested Staff Expenses à / $

Budget Narrative: Describe how the requested costs will support the sponsor to achieve the goals selected in Sections 5 and 6. Refer to the Grant Instructions for eligible cost descriptions. List amount of funds requested in whole dollars (Example: $4,000). Staff costs require a sustainability plan.

Check all that apply, with a description of specific grant activities:

Foodservice Equipment Purchases $Amount; Detailed Description

Sanitation Inspection Fees/related repairs/equipment $Amount; Brief Description

Outreach Materials/Activities $Amount; Brief Description

Enrichment or Educational Activities Equipment & Supplies $Amount; Brief Description

Transportation related purchases $Amount; Detailed Description including purpose and cost

Vehicle gas/mileage reimbursement $Amount; Brief Description

Staff Costs to support implementation of enrichment or education activities $Amount; Detailed Description including purpose, cost, and sustainability plan

Staff Costs for outreach activities for first two months of operation $Amount; Detailed Description including purpose, cost, and sustainability plan

Staff Costs for food service labor for first two months of operation $Amount; Detailed Description including purpose, cost, and sustainability plan

Staff Costs for training on curriculum implementation $Amount; Detailed Description including purpose, cost, and sustainability plan

Other (describe): $Amount; Detailed Description

Comments regarding Budget, if any:

The information provided in this grant application is true and correct, to the best of my knowledge. If my organization is awarded grant funds, I agree to follow all grant requirements, submit funding requests and itemized cost records to show the funds awarded were spent as approved, and submit a report at the end of the grant round. I understand funding will be issued by the Oregon Department of Education and I will adhere with their guidelines for submission of information and claims for grant funds. The funds will only be used for awarded purposes.

Signature of person completing this application Title Printed Name Date

If current, approved CNP Sponsor or a potential CNP Sponsor with an applicant submitted to ODE:

Signature of CNPweb Authorized Representative Title Printed Name Date

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complain form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.

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