15-060C Appendix B-1 –Current/Existing Program Application

RTC of Southern Nevada – Section 5307 and 5310 Grant Funds

FOR RTC Date Received: / Time Received: / Received By:
USE ONLY / /

APPLICATION: CURRENT/EXISTING PROGRAMS ONLY

APPLICANT INFORMATION

Applicant Information
Date
Legal Name of Applicant
Contact Person
Street Address
City/State/Zip Code
Email
Phone Number
Fax Number
Current Project Title
Current RTC Project #
Organizations Type
State or Local Government Authority
Private Non-Profit Organization (please attach documentation certifying non-profit status)
* For-Profit firms cannot be subrecipients of 5307 or 5310 grant funds.
Partnering Organizations and Contact Information
Partnering Organization
Contact Person
Title / Position
Street Address
City/State/Zip Code
Email
Phone Number
Fax Number
Project Request Information
Previously Requested Amount: Previous Project#
Previous Amount Awarded:
New Project Cost: *(Refer to
Total Program Expense line from Appendix B-2)
Funding Source Requested (A separate application needs to be submitted for each category of funding being requested)
FTA 5307 Formula Grant Funds –Job Access Reverse Commute
FTA 5310 Formula Grant Funds- Enhanced Mobility of Seniors and Individuals with
Disabilities (New Freedom Type Projects)
Operating - 50 percent Federal Funds / 50 percent Local Match
(Use Budget Form A)
Planning - 80 percent Federal Funds / 20 percent Local Match
(Use Budget Form B)
Capital - 80 percent Federal Funds / 20 percent Local Match
(Use Budget Form C)
Application Instructions
a. The font is Times New Roman 12 point. Please limit the number of typed pages submitted in the application to 10 single spaced pages maximum answered in the format provided.
b. The Word document form is provided for your input. Please adjust the spacing to fit the response, leaving two (2) spaces at the end of each question’s response.
c. Please use full justification and no indentation of new paragraphs.
d. Please check the document for spelling, typing, or grammar errors, and contact RTC with any questions regarding the format prior to submitting it for consideration.
f. Attachments required do not count as pages for the 10 page maximum.
g. Please be concise when formulating your responses. Specific information that describes your project, its relevance to the community, its goals and costs will be well received by the evaluators. Vague or broad generalized statements may detract from understanding the project.
Checklist of Application Attachments (in order of placement):
Appendix B- Application Form
Appendix B-2 -Budget Form (Excel spreadsheet)
Non-Profit Status Documentation (501(3)(c), if applicable)
Appendix C - Form for Certification of Ability to Provide Local Match
Appendix D - Federal Requirements:
Certification Regarding Lobbying
Certificate Regarding Debarment, Suspension, Ineligibility & Voluntary Exclusions
Verification Regarding Disadvantaged Business Enterprises
Certificate of Insurance
Service Area Map
Project Information
1.  Provide a brief description of the project and focus on any differences the project will have moving forward into the new grant cycle.
Answer here:
2.  Please indicate the type of clients that your program will serve, check all that apply. If multiple client types please indicate percentage of clients being served.
Senior 60+ 1-25% 26-50% 51-75% 76-100%
Individuals with Disabilities 1-25% 26-50% 51-75% 76-100%
Veterans 1-25% 26-50% 51-75% 76-100%
3.  Please include the number of clients that will be served using the grant funding, the estimated number of trips that will be provided and the number of clients served that are certified for RTC ADA Paratransit services.
Clients Per Month:
Trips Per Month:
RTC ADA Certified Clients:
4.  Project Timeline and Milestones: (Add or delete rows to the Table as required)
Step / Milestone / Start Date / Complete
5.  Describe some of the successes of your current program.
Answer here:
6.  Describe some of the challenges you face in your current program.
Answer here:
Responsiveness and Implementation
7.  Would your project be ready to commence on July 1, 2015? Please note that the grant period is a maximum of 12 months from commencement.
YES NO please explain
Budget Information
8.  Please list below potential funding sources for sustaining the project beyond the grant period. Environmental sustainability.
Answer here:
9.  Could the project be implemented on a more limited scope with less funding?
YES (Proceed to Question 10) NO (Refer to Question 11)
10.  If the project could be offered on a more limited scope, please describe.
Answer here:
11.  Describe any steps subrecipient has taken to identify other sources of funds to sustain programs if the FTA 5307 and 5310 grant funding is no longer available.
Answer here:
Miscellaneous
12.  Identify and list such current or former RTC employees involved in the preparation of this Application or the anticipated performance of work or services if selected. (Note requirements in Section 22 (c)(2) of Solicitation No. 15-060)
Answer here:
13.  If awarded continued grant funding, indicate below if your program is able to participate in the RTC Coordinated Network of Providers.
Note: All recipients of FTA 5307 and 5310 Formula Grant Funds, funding may be required to participate in the RTC Coordinated Transportation Network. As part of the coordinated network your organization may be required to assist in the transportation of clients beyond the initial scope described in the agreement, but remaining in conformity with the mission and guidelines of your organization.
YES NO
If answered NO, please explain.
If answered YES, please explain to what extent applicant can participate, and what restrictions may apply to participation.
Explain here:
14.  Does your organization employ 50 or more employees?
YES NO
If answered YES, does your organization have an EEOC policy?
YES NO

Name of official who can on behalf of Applicant affirm that Applicant is authorized to submit a Proposal and execute the Subrecipient Agreement if selected.

Name:

Title:

______

Signature Date

Solicitation No. 15-060C