Department of Social and Health Services

Domestic Violence Program

ANNUAL REPORT OF DOMESTIC VIOLENCE PROGRAM EXPENDITURES

NAME OF CONTRACTOR:

REPORTING PERIOD:

Note: Click anywhere inside the box below to activate the Excel Spreadsheet. When you are finished, click outside the box.

WHAT IS THE PURPOSE OF THIS FORM? As a condition of receiving the federal Family Violence Prevention and Services Act (FVPSA) grant from the U.S. Department of Health and Human Services (HHS), beginning in December 2009 DSHS must collect and report certain information from subrecipients (contractors) of FVPSA grant funds. Emergency domestic violence shelter programs that contract with DSHS receive FVPSA funding in their annual contracts. This form is intended to collect the total fiscal year expenditures for your domestic violence program, which is one of the FVPSA grant conditions. DSHS will aggregate the total fiscal year expenditures for all the domestic violence shelter contractors and report this as a statewide total in its annual grant report to HHS.

WHEN IS THIS INFORMATION DUE TO DSHS? This form must be completed and submitted to the DSHS Program Manager for your contract by August 31stfollowing the end of the contract period.

WHO DO I SEND THE FORM TO? The form should be sent to the DSHS Program Manager who is listed on page 1 of your contract face sheet. It can be sent in hard copy by mail, by fax, or as an email attachment.

WHAT EXPENDITURES DO I INCLUDE AND EXCLUDE IN COMPLETING THIS FORM? Read all the definitions before you complete the form so you know what funding/expenses are to be included and excluded for each category. Complete this form based on the retrospective annual expenses– cash only – for your domestic violence victim services program. This includes emergency domestic violence shelter and non-residential services for domestic violence victims. Include expenses from all revenue sources for the indicated fiscal year. Complete only those categories that apply to your organization. If you operate a transitional housing facility/services or some other separate program, or are part of a larger multi-service/purpose agency (such as the YWCA), do not include revenue sources on this form for those programs/activities. Also, do not include expenses from contracts for sexual assault or general crime victim services. Do not include in-kind, match, or other non-cash revenue/expenses.

WHO DO I CONTACT IF I HAVE QUESTIONS? If you have questions about this form, contact the DSHS Program Manager who is listed on page 1 of your contract face sheet.

HOW IS EACH EXPENSE CATEGORY DEFINED?

1. DSHS:

(a)Include the total expenditures from your emergency shelter contract, both state and federal funds.

(b)Include the total expenditures from your contract for DVPA intervention services to culturally specific populations.

(c)Include the total expenditures from your contract for DVPA prevention activities.

(d)Include the total expenditures from your contract for VOCA – enhancement/expansion services.

(e)Include the total expenditures from your contract for VOCA – culturally specific services.

(f)Include the total expenditures from your contract for VOCA – specific services for victims and survivors.

(g)Include the total expenditures from your contract for advocacy services in the DSHS Community Service Office (CSO).

2. Commerce:

(a)OCVA -- Include the total expenditures fromgrants you have with the Office of Crime Victims Advocacy (OCVA) for domestic violence services – e.g. Domestic Violence Legal Advocacy (DVLA), and STOP grant victim services funds, if funds are received by grant from OCVA – otherwise see “Other Federal”, or “Local Government” below. Do not include expenditures from grants for sexual assault or general crime victim services.

(b)OTHER -- Include the total expenditures fromgrants/contracts you have with Commerce for emergency housing services such as Consolidated Homeless Grant (CHG), Housing Trust Fund (HTF) operating (not capital) funds for emergency shelter, and total expenditures from any other grants/contracts for emergency domestic violence services you have with Commerce.

3. UNITED WAY: Include expenditures from contracts with local United Way agencies.

4. OTHER FEDERAL GRANTS: Include the total expenditures from funding received directly as a grant or contract from federal agencies such as the Office on Violence Against Women (OVW), FEMA, HUD, Department of Justice, etc.

5. OTHER STATE GRANTS: Include the total expenditures from funding (state, federal, other) received from any other state department or agency (not DSHS or Commerce).

6. LOCAL GOVERNMENT: Include the total expenditures from funding received (local, state, federal, other) received from an agency of local government (city, county) such as federal STOP, GTE funds, “2060” housing funds, DV Prevention Account (DVPA) funds, local government grants/contracts, HUD pass through funding, CDBG funds, etc.

7. OTHER PRIVATE: Include the total expenditures from grants, awards, and cash donations from private individuals, foundations, fundraising efforts, and other donations which are expended on the domestic violence program. An example is funding from WSCADV for DV Housing First. Do not include in-kind, match, or other non-cash revenue.

8. OTHER – NOT SPECIFIED ABOVE: Include the total expenditures from allother sources not described above, including sub-contracts with tribal and non-governmental entities for services, self-generated revenue such as thrift stores and sales of items, etc.

ANNUAL REPORT OF DOMESTIC VIOLENCE PROGRAM EXPENDITURES FORM.DOC

Updated 11/17