APPLICATION – FY 2018 TITLE III FUNDING

SECTION I. COVER PAGE One page only.

  1. Project Name

  1. Amount of SWCAA Grant Request
/ $
  1. Proposed Total Project Budget
/ $ which is % of Organization Budget
  1. Organization Annual Operating Budget
/ $
  1. Title of the Older American Act under which funding is requested

Title III B / Title III D / Title III E
  1. Project Contact Name & Title

  1. Project Address

  1. Project Phone

  1. Project ContactEmail

  1. Organization Mission Statement and Capacity to Implement Proposed Project

  1. Organization Name

  1. OrganizationAddress

  1. Organization Phone

  1. Organization Website

  1. Head of Organization

  1. Title

  1. Email

  1. Signature

  1. Title

  1. Date

SECTION II. PROJECT DESCRIPTION & WORK PLAN

References to “project” relate to theproposed projectfor which you are requesting FY 2018funding. The term “project” does notrefer to your entire organization or your current program or project.

  1. PROJECT NAME

  1. MIS SERVICE NAME(S) (Maximum of 5. Choose from the appropriateTitle III MIS Service Definitionslist at

  1. PROJECT SUMMARY Briefly describe the proposed project in one paragraph (no more than 100 words).
  1. NEED Identify the community need your project proposes to address. How does this need address a SWCAA funding priority as defined in the Area Plan on Aging for Fiscal Years 2014-2017?(full plan and plan summary available at
  1. GOALS Identify a maximum of three goals that describe what you expect your proposed PROJECT to accomplish during the grant period to address the identified need. For each goal, explain (1) the overall goal, (2) whom you will serve, and (3) how you will measure project outcomes.

The following language format is preferred:

Goal #1 – (1) PROJECT GOAL. (2) Of the (number) older adults served, (number or percentage) will _____ (3) as evidenced (or demonstrated) by ______.

Examples:

To improve the health of seniors. Of the 100 seniors served at the Senior Center, 75 will participate in exercises classes at least four times per month as evidenced by attendance sheets.

To increase financial stability. Of the 50 seniors served by the outreach workers, 35 will receive application assistance as evidenced by completed applications.

Goal #1
Goal #2
Goal #3
  1. WORK PLAN Describe in detail how you will address the identified needand achieve your proposed project goals. If you apply to provideSenior Center Use, attach both a sample proposed center activity calendar for Fiscal Year 2018 and an actual center activity calendar for the current year.
  1. PERSONNEL In the chart below, list the positions and qualifications of all of the key individuals, including program staff, supervisory staff, volunteers, and/or contract positions, who will be responsible for achieving the anticipated project results. Specify the role each will play in the proposed project. All positions must also be included in the project budget.

Job Title / Qualifications / S/V/ C1 / F/P2 / Y/N3 / Role

1Staff (S), Volunteer (V), Contract Position (C)

2Full Time (F), Part Time (P)

3 Yes (Y) or No (N):is/will there be a background check on record for each employee?

  1. PROPOSED NUMBER OF PROJECT CLIENTS & SERVICES Complete one section below for each MIS service proposed for the project. If you intend to provide more than one MIS service, complete one section per service and include client numbers specific to each serviceand to the goals detailed above. If your application includes more than three services, you may copy and paste one or two additional sections. MIS Service Definitions listsand poverty guidelines are available at Complete all non-shaded areas for each service.

Estimated number to be provided
FY 2018project / Actual number fromFY 2016final MIS report / Explanation of Difference
MIS SERVICE NAME:
Units of service
Clients (unduplicated count)
Clients at or below 100% of poverty level (“poor”)
Minority clients
MIS SERVICE NAME:
Units of service
Clients (unduplicated count)
Clients at or below 100% of poverty level (“poor”)
Minority clients
MIS SERVICE NAME:
Units of service
Clients (unduplicated count)
Clients at or below 100% of poverty level (“poor”)
Minority clients
  1. GEOGRAPHY Indicate the estimated percentage of Fiscal Year 2018project participants living in each of the following:

Bridgeport / Darien / Easton / Fairfield / Greenwich
Monroe / New Canaan / Norwalk / Stamford / Stratford
Trumbull / Weston / Westport / Wilton
  1. VOLUNTARY CONTRIBUTION PLAN Grantees may not charge fees for services provided with Title III funding. However, grantees are required to offer clients an opportunity to donate to the project. Donations must be confidential and no person may be denied involvement if s/he chooses not to contribute. All contributions received are to be used to expand the services of the project being funded under the grant. Describe HOW you will meet these requirements.
  1. PLAN TO REACH TARGET POPULATIONS Title III grantees are required to implement a plan to reach out to prospective clients in the populations listed below. Complete all non-shaded areas in the chartin describing your plans.

Clients 60 years of age or older and: / How will you make prospective clients aware of your project and maintain contact with current clients in each listed population group? How will you track and measure results?
At or below 100% of poverty level (“poor”)
Minority
101% - 150% of poverty level (“near poor”)
With limited English proficiency
With severe disabilities
At-risk of institutionalization
With Alzheimer’s or related disorders
  1. REFERRALS Title III grantees are required to help participantsgain access to additional assistance. Describe how you will:
  1. assess unmet needs of your clients for assistance beyond what your project will provide
  1. and make referrals that will help clients access needed services.
  1. COMMUNITY COORDINATION Title III grantees are required to coordinate with other appropriate community services and to avoid duplication of services.
  1. Describe how you will coordinate services with other programs/services for elders in your service area.
  1. Applications for new projects may include a maximum of three (3) letters of support from related community agencies and groups.

SECTION III. PROJECT MANAGEMENT

  1. GOVERNANCE
  2. Specify what governing body or staff position has responsibility for oversight of your project
  1. and explain how your Board of Directors or other governing body will exercise fiduciary responsibility, policy guidance, and/orassist with fundraising/financing.
  1. FINANCIAL SUPPORT
  2. Describe your organization’s financial position, including trends, challenges, or unusual developments over the last three years.
  1. Foundation, Corporate and Government Grant Details: Title III grantees are required to initiate efforts to obtain additional support from private sources and other public organizations for grant-funded projects. List other funding sources for the project described in this applicationand the amount provided by each (a) during FY 2017 and (b) as anticipated for the project in FY 2018. If there are additional funding sources shared with the organization as a whole, or with a department within the organization, list on the second chart the FY 2017 and anticipated FY 2018shared funding sources.

Project Funding
Foundation, Corporation, Government Funding Source / FY 17 Status* / FY 17 Amount / FY 18 Status* / FY 18 Projected Amount
Organizationor Department Shared Funding
Foundation, Corporation, Government Funding Source / FY 17 Status* / FY 17 Amount / FY 18 Status* / FY 18 Projected Amount

*Status – Awarded, Applied, Plan to Apply

SECTION IV. EXECUTIVE SUMMARY

One page only. A summary of responses inSections I & II.

  1. Project Name

  1. Amount of SWCAA Grant Request
/ $
  1. Proposed Total Project Budget
/ $
  1. Organization Name

  1. PROJECT SUMMARY (Section II.3 – Bullet points may be used to summarize.)
  1. PROJECT GOALS (Maximum of three. Section II.5.)

GOAL #1
GOAL #2
GOAL #3
  1. PROPOSED NUMBER OF PROJECT CLIENTS (Summary of Section II.8) How many clients do you expect to serve with the proposedproject during Fiscal Year 2018?

CLIENTS TO BE SERVED FY 2018
Clients 60 Years or Older (unduplicated count)
Clients at or below 100% of Poverty Level
Minority Clients
  1. GEOGRAPHY (Check towns to be served by proposed project. Section II.9)

Bridgeport / Darien / Easton / Fairfield / Greenwich
Monroe / New Canaan / Norwalk / Stamford / Stratford
Trumbull / Weston / Westport / Wilton

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