AgeOptions

Application for Provision of Services

Under Title III of the Older Americans Act andState of Illinois General Revenue Funds

Title III-B Supportive Services, Senior Health Assistance Program/MIPPA

Title III-D Health Promotion,

Title III-E Caregiver Resource Center

Fiscal Year 2018 with potential extensions for FY 19, 20)

October 1, 2017—September 30, 2018

1. Applicant Organization Information / 2. Program Name Information (If Different)
Name: / Name:
Street Address: / Street Address:
City, State, Zip / City, State, Zip
Phone: / Phone:
Email: / Email:
Organization Director: / Program Director:
Website:

3. Proposed ServicesCheck all that apply. Please submit one narrative for each separate Title (3b/SHAP/MIPPA, 3d, 3e).

Designations:

 Aging and Disability Resource Network (Title III-B and SHAP/MIPPA)

 Caregiver Resource Center (Title III-E)

Title III-B Services:

 Chore Friendly Visiting Home Repair

 Housing Assistance  Legal Assistance (III-B) Multi-Purpose Senior Center

 Respite Care Senior Opportunities and Services Telephone Reassurance

 Transportation Targeting to Culturally and Linguistically Isolated Older Persons

Title III-D Services:

 Countywide Health Promotion Coordinator

Title III-E Services:

 Caregiver Legal Assistance for Non-Parent Relatives Raising Children (Countywide Provider)

4. Proposed Service Areas(Check all townships that will be served by the site named above)

Northern Townships / Western Townships / Southern Townships
Barrington / Berwyn / Bloom
Elk Grove / Cicero / Bremen
Evanston / Leyden / Calumet
Hanover / Lyons / Lemont
Maine / NorwoodPark / Orland
New Trier / Oak Park / Palos
Niles / North Proviso / Rich
Northfield / South Proviso / Stickney
Palatine / RiverForest / Thornton
Schaumburg / Riverside / Worth
Wheeling

5. Acknowledgement

I acknowledge that I have received all of the following documents from AgeOptions related to the Request for Proposal. Further, I have read these documents and agree to abide by the requirements and policies set forth.

 FY 2018 Conditions of Award

 Requirements for Recipients of Title III Older Americans Act Funds

 FY 18-20 Request for Proposal for Supportive Services, SHAP/MIPPA, Health Promotion, Caregiver Resource Center

 FY 18-20 Definitions and Standards

 Signature Page for Application

6. Application Agreement

By signing this application I certify that I am an authorized representative to sign for this Agency. I

certify that I will adhere to all AgeOptions requirements and policies for funding and provision of services, including Definitions and Standards, FY 18-20 Request for Proposals, FY 18 Conditions of Awards, and Requirements for Recipients of Title III Older Americans Act Funds. I certify that the specifications

outlined in this application represent the Applicant’s Agency’s commitments for Fiscal Year 2018 and any subsequent extensions. All costs for the preparation of this application shall be the responsibility of the Applicant Agency and not the responsibility of AgeOptions. I hereby certify that all of the information and answers provided in this application are true and accurate to the best of my knowledge.

Typed Name: / Signature:
Title: / Date:

Program Narrative and Budget

Each applicant should answer the following questions for each service AND be specific for all areas proposed. AgeOptions will review the application based on information presented as well as the applicant’s past history.

1.Needs Statement and Target Group

Briefly describe the target population to be served, and the needs of that population, by service proposed and township to be served. Provide demographic, needs assessment, service data and/or other data to establish the need for the service.(See Appendix 3, 4, 5, 6, and 7 for detailed demographic information).

2.Program Plan and Design (Quality)

Briefly describe the proposed programincluding: how the applicant maintains a physical presence in the community; staffing and staff qualifications; how consumer input is collected and used; how you will attract and retain volunteers; how the cultural and language needs of the identified target population will be incorporated into the program design; and how your program will evolve over the next three to five (3-5) years to meet the needs of your target population.

3.Outreach and Community support (Access)

Provide a clear, logicaland concise outreach planto attract the target population and new participants that is specific to the community, creates visibility and uses a variety of methods such as social media and technology. The plan should be specific in how the applicant will satisfy the service needs of low-income minority and Limited English Proficient older adults in the same or higher proportions as the service area. Describe the applicant’s involvement in the community including how they will collaborate with existing community agencies to provide referrals to additional services and conduct outreach to older adults.

4.Performance Experience and Capacity

AgeOptions will evaluate current and past performance of applicants, including the degree of experience the provider has in the proposed area, the organization’s capacity to provide oversight of the project and the organization’s capability to submit and maintain fiscal and program reporting.

Applicants who have current funding from AgeOptionsfor the proposed service do not need to submit a response to this question.AgeOptions will review internal data to evaluate current and past performance in meeting standards over time as defined by AgeOptions. This evaluation will include timeliness and accuracy of their current data, fiscal reports and program reports; past productivity (clients and units) for the proposed service in the proposed service area; and performance findings related to financial audits and AgeOptions monitoring reviews.

Applicants who do not have current funding from AgeOptions for the proposed service should submit letters of recommendation/reference showing that the applicant organization has met grant or contract requirements from another funding source. The letters must specifically address timeliness and accuracy of fiscal reports and program reports; timeliness and performance findings related to financial audits; whether applicant has a history of providing the proposed service in the proposed service area; whether applicant met or exceeded projections for units and clients; whether applicant met or exceeded grant or contract requirements related to compliance; and overall performance in meeting standards of the grant or contract.AgeOptions also will look at the applicant’s experience fulfilling other Title III grants through AgeOptions,

5.Budget

  1. Submit a program budget. Applicants must submit a hard copy of the budget AND submit it electronically in a format compatible with Excel 2007 via email to .

At a minimum, AgeOptions will look to see that the program is cost effective and feasible. The proposed AgeOptions unit rate is logical, reasonable, and within a range appropriate to available funding and network history. Client and unit projections are achievable given the proposed outreach activities and the applicant’s past performance. The level of match is at least 15% and the percent of local cash. Proposed project income and in-kind income that are logical, reasonable and consistent with previous years.

  1. Submit a budget justification that is clear, logical and specifically describes the program and cost allocation as well as how project income will be solicited. A separate budget and justification must be submitted for each Title application. An effective budget justification explains how the budget would be spent, why the item is needed, and why it is cost effective.
  2. Personnel: Include all personnel. List the position, all responsibilities, hours spent per week on the project proposed by service using an allocation formula. Specify fringe by category (e.g. FICA, Worker’s Compensation, Health, Dental, etc.) Where volunteers are used, specify their hours and an hourly rate and enter the cost under in-kind.
  3. Travel:Enter all travel expenses. Specify reason for travel and amount allocated to each position for each service. Specify per mile reimbursement rate for all travel.
  4. Supplies: All suppliesnecessary to implement the program. Specify by item and unit cost. Include allocation formulas where appropriate.
  5. Food:Not applicable.
  6. Delivery:Not applicable.
  7. Other: This section is where operational costs are entered. These costs include rent, utilities, postage, telephone, insurance and other similar administrative expenses.An allocation formula must be provided for the above costs. The proportion of space used by the program relative to other uses is a common method, i.e., if the program uses 50% of the space it may be charged with 50% of the rent and utilities. A reasonable accounting of each cost must be provided in this category.
  8. Match Details: The amount and source of all Local Cash and In-Kind must be specified.

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