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HomeMy WebLinkAboutCOM 0628.001 2012-2014 J�<V OF N''•'7 Nancy E. Crawford William P. Kenoi Mayor Director y +: :• Deanna S. Sako if•:; ,.o±�'r.` Deputy Director �rE os•M�u► County of Hawaii Finance Department 25 Aupuni Street, Room 2103 • Hilo,Hawaii 96720 (808)961-8234 • Fax(808)961-8569 February 11, 2014 ' J Yoshimoto, Council Chair and Members of the Hawaii County Council N Hawaii County Council = 25 Aupuni Street Hilo, Hawaii 96720 Re: Nonprofit Grant Applications In compliance with Chapter 2, Article 25 of the Hawaii County Code, I am submitting the applications from eligible nonprofit organizations for your review and appropriation of funds for the FY2014-15 nonprofit grant program. Also enclosed is a list of these eligible organizations with the name of their program and the amount they are requesting from the County. Should you have any questions, please feel free to call Ted Schrey at 961-8489. 44'� 'Z�+ Nancy Crawford Director of Finance Enc. Applications for Nonprofit Grant Funds List of Nonprofit Grant Applicants Comm.No,�O °��• Ref. o SQ Ref.Date FEB 1 P. 2 n...`._.. Hawaii County is an Equal Opportunity Provider and Employer NONPROFIT GRANT APPLICANTS FOR FY2014-15 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants retain their sort number resulting in those numbers being skipped in the main table. Numerical Sort Order Order ORGANIZATION NAME PROGRAM NAME REQUESTED 1 1 Ala KuoIa Coaching Boys into Men 55,071.00 2 2 American National Red Crass,The Disaster Preparedness and Response in Hawaii County 50,000.00 3 3 Are of Hilo,The Em loymenl Training Services Program Expansion(ETS) 35,000.00 4 4 Arts and Science Center(ASC) ASC Community Facility 51,700.00 5 5 Big Brothers Big Sisters Hawaii School Based Program 25,000.00 6 6 Big Island Mediation inc dba West Hawaii Mediation Center Mediation Services 15,000.00 7 7 Big Island Resource Conservation&Development Council Hawaii Homegrown Food Network(HHFN) 13,900.00 8 8 Big Island Resource Conservation&Development Council Ho'oulu Lehua(www.hooululehua.or ) 21,827.00 9 9 Boys&Girls Club of the Big Island Hamakua STEM Revolution 40,000.00 10 10 Boys&Girls Club of the Big Island Hilo STEM Revolution 40,000.00 11 11 Boys&Girls Club of the Big Island Keaau STEM Revolution 40,000.00 12 12 Boys&Girls Club of the Big Island Ocean View-Walehu STEM Revolution 40,000.00 13 13 Boys&Girls Club of the Big Island Pahala STEM Revolution 40,000.00 14 14 Boys&Girls Club of the Big Island Pahoa STEM Revolution 40,000,00 15 15 Bridge House,Inc. Vocational Skills 130ding Program 27,000.00 16 16 Child and Famifly Service East Hawaii Domestic Abuse Shelter 50,000.00 17 17 Child and Familiy Service Hale Kahua Pa'a Transitional Apartment Program 45,000.00 18 18 Child and Farnilly Service Hawaii Island Alternatives to Violence 50,000.00 19 19 Child and Familiy Service The Child and Family Center Program 50,000.00 20 20 Child and Farniliy Service West Hawaii Domestic Abuse Shelter 50,000.00 21 21 COVO Foundation 2nd Annual Phill's ine Cultural Festival 6.000.00 22 22 East Hawaii Cultural Council Aloha Aina;Big Island Memories-Plantation Style 5,000.00 23 23 Estria Foundation,The Mole Murals 20,970.00 24 24 Family Support Hawaii Next Steps 10,000.00 25 25 Family Support Hawaii Street Outreach-Homeless and At-Risk Youth 30,000.00 26 26 Family Support Hawaii West Hawaii Fatherhood Initiative 30,000.00 27 27 Food Basket,The Improving Food Access While Building Farming Infrastructure 48.000.00 28 28 Friends of the Children of West Hawaii Enhancement and Basic Needs 15,000.00 29 29 Friends of the Children's Justice Center of East Hawaii Special Needs&Enhancement,Ctr Support Education!Training 25,000.00 30 30 Friends of the Palace Theater Marketing Capacity Building 15,000.00 31 31 Full Life Adult Day Health Trans artation Support 24,600.00 32 32 Goodwill Industries of hawaii,Inc. Job Connections 30,000.00 33 33 Goodwill Industries of hawaii,Inc. Work Experience Pror ram 45,000.00 34 34 Grassroots Community Development Group I Hawaii Youth Business Center 35,000.00 35 35 Green Will Conservancy Inc.,The Hui Mana'o"Thinking Together&Sharing Knowledge' 90,000.00 36 36 Habitat for Humanity West Hawaii "Set the Foundation,Raise the Roof,and Let in the Light" 60,000.00 37 37 Hale Aloha O Hilo Habitat for Humanity ReStore-Donation Pick Ups 14,616.00 38 38 Hate Kipa,INC. Kal Like Program 5,000.00 39 39 Hamakua Youth Foundation,Inc. Hamakua Youth Center 32,500.00 40 40 Hawaii County Economic Opportunity Council Drop Out Prevention Program 254,465.00 41 41 Hawaii Island Adult Care,Inc. Adult Day Care Centers 30,000.00 42 42 Hawaii Island Home for Recovery.Inc(HIHR) HIHR Supportive Housing Program 59,000,00 43 43 Hawaii Island Home for Recovery,Inc(HIHR) HIHR Transitional Housing Program 64,000.00 44 44 Hawaii Montessori Schools Financial Aid Program 15,000.00 NONPROFIT GRANT APPLICANTS FOR FY2014-15 Numerical Sort Order Order ORGANIZATION NAME PROGRAM NAME REQUESTED 45 45 Hawaii Volcano Circus HICCUP Youth Circus 19,200.00 46 46 Hawaii Volcano Circus SPACE Farmers Market 15,100.00 47 48 Hilo Community Players 2014-2015 Theatrical Season 29,675.00 48 49 Holualoa Foundation for Arts&Culture Art Creates Change 17,000.00 49 50 HOPE Services Hawaii,Inc. Care-A-Van Homeless Outreach Program 15,000,00 50 51 HOPE Services Hawaii,Inc. Hawaii County's Going Home Consortium 17,400.00 51 52 Hope Services Hawaii,Inc. HOPE Resource Center(HRC) 20,000.00 52 53 HOPE Services Hawaii,Inc. Kthei Pua Emergency Shelter 20,000.00 53 54 HOPE Services Hawaii,Inc. Shelter+Care:Kukui and New Direction 20,000.00 54 55 HOPE Services Hawaii,Inc. West Hawaii Emergency Shelter WHEP) 20,000.00 55 56 Hospice of Hilo(HOH) Hawaii Palliative Care Center-Home of the Transitions Program 65,600.00 56 57 Hui Malama Ola Na"Oiwi 14th Annual Ladies Night Out Event 5,000.00 57 58 Hui Malama Ola Na"Oiwi Kokua Hall-Health Transportation Program 50,000.00 58 60 Hui Pono Holoholona Subsidized Low Cost Spay/Neuter Clinics 25.000.00 59 61 Innovations Public Charter School Foundation Nurturing the Body,Mind and Spirit through Responsible Choices 10,000.00 60 62 Ka Hale 0 Na Keiki,Inc. Families-At-Risk 10.000.00 61 63 Kahua Pa'a Mua,Inc. Palili'O Kahala 50,000.00 62 64 Kaita a Community Association Ka Pike(Community Center/Park Project) 500,000.00 63 65 Kanu o ka'Aina Learning Ohana Halau Hcoki a Community Recreation Center 1,700,000.00 64 65 Kohala Animal Relocation and Education Service(KARES) Canine Spay and Neuter 20,000.00 65 67 Kohanaiki'Ohana Environmental and Cultural Stewardship Program 30,000.00 66 68 Kona Adult Day Center,INC Adult Day Care 20,000.00 67 69 Kona Association Association for Retarded Citizens(Arc of Kona) maximizing independence 24,500.00 68 70 Kona Historical Society Living History Programs 26,000.00 69 71 Ku'ikahi Mediation Center Community Conflict Resolution Services 12,000.00 70 72 Laupaticehce Train Museum Best of Hamakua 14,985.00 71 73 Lau ahoehoe Train Museum Pa'auilo Mauka Community Emergency Response Team CERT 24,150.00 72 74 Legal Aid Society of Hawaii Removing Barriers for Hawaii County's Vulnerable Population 40,000.00 73 75 Malama 0 Puna Pahoa Community Certified Kitchen 24,250.00 74 76 Malama O Puna(MOP) Restoring Priority Area of Keau'ohana Native Lowland Wet Forest 20,000.00 75 77 Malamalama Waldorf School Diabetes Reversal Research Program DRRP) 15,000.00 76 78 Malamalama Waldorf School Natural Pla sca e:Community&School 60.000.00 77 79 Malamalama Waldorf School Puna Arts in the Park Intersession&Summer Program 15,000.00 78 81 Mental Health Kokua Residential Rehabilitation Services 5,000.00 79 82 Neighborhood Place of Puna Family and Community Streathening 30,000.00 80 83 Neighborhood Place of Puna Ready to Loam 5,000,00 81 84 North Kahala Community Resource Center Kohala Welcome Center Phase II 10,190.00 82 85 P.A.R.E.N.T.S.,Inc. Confident Parenting 5,000.00 83 86 Pacific Tsunami Museum Pacific Tsunami Museum-Essential Upgrades and Updates 43,500.00 84 87 Palekana Kai Ocean Safety LLC Ocean Safety Education-Island Wide 30,000.00 85 88 Palekana Kai Ocean Safety LLC Wilderness and Remote First Aid Training 25,000.00 86 89 Positive Coaching Alliance-Big island Keeping Kids in the Game 15,550.00 87 90 Project Vision hawaii Increasing Vision&Health Screening Services for Hawaii Island 48,500.00 88 91 Puna Community Medical Center Sustaining Access to Care 97,727.00 89 [--92 Read Aloud America RAP Programs for the Island of Hawaii 94,925.00 NONPROFIT GRANT APPLICANTS FOR FY2014-15 Numerical Sort Order Order ORGANIZATION NAME PROGRAM NAME REQUESTED 90 93 Salvation Army-Family Intervention Services,The Independent Livin Skills Program-West Hawaii 35,000.00 91 94 Salvation Army-Family Intervention Services,The Positive Youth Development Prevention Program-Kea'au 35,000.00 92 95 Salvation Army-Family Intervention Services,The Substance Abuse Prevention Program-Pahoa 35,000.00 93 96 Special Olympics Hawaii Special Olympics Hawaii-East Hawaii Area 25,000.00 94 97 Special Olympics West Hawaii SOWH General Fund 15,000.00 95 98 Sure Foundation,Inc. Yeshua Outreach Center 67,500.00 96 100 'Peach for America,INC. Teach for America Hawaii 100,000.00 97 101 Volunteer Legal Services Hawaii Hawaii County Community Law Project 38,768.89 98 903 West Hawaii Communit Health Center Dental Van for Adult Services 20,000.00 99 104 West Hawaii County Band Friends Music and Equipment Fund 8,100.00 100 105 West Hawaii County Band Friends Volunteer Musicians Fund 18,000.00 101 106 YWCA of Hawaii Island Sexual Assault Support Services 60,000.00 102 107 YWCA of Hawaii Island YWCA Development Preschool 16,500.00 103 108 YWCA of Hawaii Island YWCA Healthy Start-Positive Moms-Happy Babies PMHB) 40,000,00 Total 5,619,789.89 Note: The following applicants did not meet one or more application requirements(disqualified) 1 47 Hiilei Aloha,LLC Sustaining a Health Services Coordinator for Kau,Keeau,Pahoa,Complex Area 70,000.00 2 59 Hui Okinawa 2014 Haari Boat Festival 18,800.00 3 80 Mana'olana Hope Inc Independence Day Surf Day with Aloha 20,000.00 4 99 Sustainable Hawaii Youth Leadership Initiative SITYLI Fellows an Hawaii Island 20,200.00 5 102 Waiakea Nakoa(Nakoa Nation) Pop Warner Football(Flag&Tackle)(Cheerleadin ) 60,000.00 Total 189,000.00 1 Ala Kuola Coaching Boys into Men Agency Name: Ala Kuala Program Name: COACHING BOYS INTO MEN Agency Director: Edwin K. Flores Phone No.:(808) 545-1880 Contact Person: Edwin K. Flores Phone No.: Mailing Address: Address: 550 Halekauwila St. #207 Address: city,sT,zIP Honolulu, Hawaii 96813 Facility Address: Address: 550 Halekauwila St. #207 Address: cty,sT,zIp Honolulu, Hawaii 96813 Email Address: Fax No.: Accountant/CP Phone No.:(808) 523-7588 Firm (if applicable): Tomishima & Fukuhara Mailing Address: Address: 1520 Liiliha Street#705 Address: ctty,sT,zip Honolulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENTAND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $55, 071 . 00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: To assist victims of domestic abuse in attaining safety,peace and healinQ through a contanuum of services throwh at partners and collaborators in the community. To provide a youth violence prevention program that promotes healft relatinngh1p and respectful h�havinr- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Ala Kuola Program Name: COACHING BOYS INTO MEN 3. Program Description: See attached. 4.Total Budget& Position Count: Total Program Budget: 1$55,071.00 Total Program Position Count: 2 Total Agency Budget: 1$355,000.00 Total Agency Position Count: 5 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Friends of Hawaii Charities $8,000.00 TOTAL: $8,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: See attached. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 3. Program Description Ala Kuola is a Honolulu-based non-profit organization that assists victims of domestic abuse with the preparation and filing of temporary restraining orders with the Family Court. Since opening its doors in 2007, Ala Kuola has assisted several thousand individuals and families. Throughout the years, domestic abuse and its consequent problems have become more prevalent. This has led Ala Kuola to seek a more proactive role by delivering to youth a gender intervention program based on an existing model known as "Coaching Boys Into Men" (CBIM). CBIM was originally created as a high school athletic-based program that seeks to reduce dating violence by engaging athletic coaches and training them to be positive role models capable of delivering evidenced base curriculum to young male athletes. CBIM provides coaches with resources, strategies, and scenarios needed to create behaviors and attitudes that prevent relationship abuse, sexual assault and harassment. CBIM core values center towards male high school athletes. Conversely, CBIM can be tailored and made adaptable for community athletic programs or by others where a person who may be of influence can be identified to deliver the curriculum. Led by the Executive Director Edwin K. Flores, who has been trained by Futures Without Violence the creator of CBIM based in San Francisco, and along with a program assistant, athletic directors and coaches will be trained in the use and strategies of delivering the CBIM program. In implementing CBIM,the objective is to train athletic directors and coaches as they play an influential role in the lives of young men, often serving as life-long mentors to the boys they coach. A series of training cards are used to share strategies for opening the conversations about dating violence, as well as techniques for helping their athletes develop appropriate and healthy attitudes towards women and girls. Subjects addressed in the training cards include: (1) Personal Responsibility; (2)Use of Insulting Languages; (3) Disrespectful Behavior Towards Women and Girls; (4)Digital Disrespect; (5) Understanding Consent; (6) Bragging About Sexual Reputation; (7)Responsibility of Physical Strength; (8) When Aggression Crosses The Line; (9) There's No Excuse For Relationship Abuse; and (10) Modeling Respectful Behaviors Towards Women And Girls. Once trained, athletic directors and coaches are encouraged to hold meetings during or after practices, or when appropriate. Coaches can set aside at least 10-15 minutes per week to lead their youths through the "Training Card" series that covers one individual aspect as mentioned above and open dialogue on each subject matter. Each of the trainings is designed to encourage youths to discuss and practice respect and non-violence for themselves,women, girls and others. Although each of the trainings is intended to be brief, it is the consistency of the message and repeated weekly lessons that will make the greatest impact. The"Training Card" series provides the"talking points"to be addressed, and coaches are encouraged to deliver these talking points using life experiences, personal examples, and/or current events as strategies in the delivery of the message to the youths. Ala Kuola will be available to continually provide any technical assistance including but not limited to questions concerning use of the curriculum. Program participants will not be charged any fees for program materials. Participating athletic directors, coaches or others to be trained will either receive training on a one to one basis or in a group setting. Since many coaches are not part of the school's faculty or staff at the school's campus, Ala Kuola will provide training at their convenience after practices, after their work hours, or when convenient. In order to evaluate CBIM's effectiveness in creating attitudes and behaviors that prevent relationship abuse, sexual assault and harassment, end of season surveys will be administered to coaches and pre-season and post-season surveys will be administered to participating athletes. The end of season survey will assess to what extent the coaches used CBIM with their athletes. The pre-season and post-season surveys will assess the changes in the athletes' attitudes and beliefs about treating women with respect, what constitutes abusive behaviors in an interpersonal relationship,the likeliness to report disrespectful behaviors and the likeliness to try to stop a male peer from exhibiting disrespectful behaviors toward girls and women. Due to this program's current use in high school athletics, the data from the administered surveys are considered, by policy, the"property"of the Department of Education. Ala Kuola has submitted the entire CBIM curriculum to the State of Hawaii Department of Education Superintendent's Office for review. Following their review,the Superintendent's Office has requested Ala Kuola prepare a work plan in conjunction with Raymond Fuj io, the head of the HIDOE Athletics Office, to allow access to the data collected from the surveys. The work plan will result in a three-year Memorandum of Understanding (MOU). Currently, the surveys are administered and data is collected by and for athletic directors and coaches review only. When the data becomes available to Ala Kuola, Ala Kuola will analyze the results of the surveys to insure the learning objectives of CBIM have been met. The results of these surveys will prove to be crucial in the delivery and further development of CBIM. Delivering the CBIM model to the young men and high school athletes will educate and reinforce how to treat girls and women with respect, and will foster their ability to build and maintain healthy and positive relationships as adults. According to a study conducted by UC Davis (Miller et.al, 2012), young men exposed to CBIM were significantly more likely to report actually taking action to stop harmful and disrespectful behaviors amongst their peers. The CBIM.model has the ability to facilitate positive change in our present day and future social environment. By teaching the young men of today through the implementation of this program, we nurture healthy attitudes towards girls and women in their future relationships as adults. Approximately one in three adolescent girls in the U.S. is a victims of physical, verbal, or emotional abuse from a dating partner(Davis, 2008). Interpersonal violence, also known as relationship violence and intimate partner violence, is a public health threat that must be taken seriously. A youth risk behavior surveillance study conducted by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention(2012), found that 9% of female high school students in Hawaii that were surveyed, had experienced dating violence and 9.8%reported having been forced to have sexual intercourse. Female teen victims of interpersonal violence are more at-risk to developing many negative outcomes, such as substance abuse, risky sexual behavior and attempted suicide. By using CBIM as an intervention to reduce interpersonal violence,we may reduce the incidence of the maladaptive behaviors that related to its experience. The study by Miller et al (2012), noted that previous violence-prevention efforts have not utilized coaches as partners. CBIM is an innovative program, in that it utilizes a coach's special relationship with their male athletes and taps into their ability to serve as positive role models. A study by Dobosz and Beaty (1999) found that high school athletes demonstrated significantly greater leadership ability than did non-athletes, which implies that athletes may serve as role models to their peers. Simply put, the benefits of the CBIM program can extend beyond high school athletes to the general population of Hawaii's high school students as a whole. Using this program with the target population of male high school athletes is also important because prior research has shown that male college athletes who had participated in aggressive high school sports (e.g., football, basketball, wrestling) reported using more physical and psychological aggression and sexual coercion in their dating relationships than did those who did not participate in aggressive sports (Forbes, Adams-Curtis, Pakalka& White, (2006). With the assistance of Ala Kuola, Waiakea High School, Hilo High School and Ka'u High School have implement CBIM along with the Hilo Football Club a youth football organization. In the October 2013,the Hawaii State Legislature recognized Waikea High School, Hilo High School, Ka'u High School and the Hilo Football Club with Certificates honoring them with the implementation of Coaching Boys Into Men. References Davis,A. (2008).Interpersonal and physical dating violence among teens.The National Council on Crime and Delinquency Focus. Available at hgp://www.nccd ' crc.or nccd/ ubslDatin %20Violence%24Amon °/a20Teens. d£ Dobosz,R P. &Beaty,L. A. (1999). The relationship between athletic participation and high school student's leadership ability.Adolescence, 34. Forbes,G.B.,Adams-Curtis,L.E.,Pakalka,A.H., &White, K. B. (2006)Dating aggression,sexual coercion,and aggression- Supporting attitudes among college men as a function of participation in aggressive high school sports. Violence Against Women, 12(5),441-455. Miller,E.,Tancredi,D. J.,McCauley,H.L.,Decker,M.R.,Virata,Maria Catrina D., Anderson,H.A., Stetkevich,N.,Brown,E. W.,Moideen,F., Silverman,J. G. (2012). "Coaching boys into men":A cluster-randomized controlled trial of a dating violence prevention program.Journal ofAdolescent Health. U.S.Department of Health and Human.Services Centers for Disease Control and Prevention. (2412). Youth risk behavior surveillance—United States,2011. 6. Explain what plans you agency or program has to increase revenues to support this program: Ala Kuola has been successful with obtaining funding sources for this program. Currently Ala Kuola is submitting an application for funding through the Friends Of Hawaii Charities. Futures Without Violence the creator of the curriculum Coaching Boys Into Men solicits grant applications. Also Ala Kuola is seeking A Grant In Aid Subsidy in this current legislative year to provide funding to extend the reach of Coaching Boys In to Men Statewide. Ala Kuola look forward to submitting a grant proposal to the Office of Violence Against Women under the solicitation of Engaging Men and Boys as Allies prospectively offered for the fiscal year 2014. 7. Program Objectives Using County Nonprofit Program Funds: The implementation of Coaching Boys Into Men, will train athletic directors, coaches, community sports program leaders, to be mentors and role models and equip them with strategies, scenarios, and resources needed to build attitudes and behaviors among young male athletes that prevent relationship abuse, harassment, and sexual assault. Also, through delivery of the program curriculum youths will gain knowledge of healthy relationship and respect for women and girls. 8. Table I: What are the intended measurable outputs or outcomes that would be achieved with this funding: Program Performance Measures: 20-30 Athletic Directors/Coaches/Community members will be trained with the use of the Coaching Boys In to Men Curriculum. Approximate amount of hours for training: 1.0 per participant Volunteer time to deliver the curriculum to youths: 10-15 minuets per session {average 12.5 minuets} Total number of curriculum to be delivered: 12 Average number of volunteer hours to deliver curriculum 2.5 hours Youth/Athletes to receive curriculum: 250-300 Applicant Projected Results: Athletic Directors/Coaches/Community members following a comprehensive training will effectively deliver the Coaching Boys Into Men curriculum. Through data collected as a result of pre season,post season and end of season surveys administered will reaffirm the value and effectiveness of the Coaching Boys Into Men curriculum. Agency Name: Program Name: 7. Program Objectives Using County Nonprofit Grant Program Funds: SEE ATTACHED 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (l.e.:Number of clients served workshops or events held,volunteerhours,etc.Describe,be speck.) SEE ATTACHED Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req SEE ATTACHED BUDGET Salary and Wages BUDGET REQUEST A Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $0.00 501071 $55 ,071 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 BUDGET (Period to ) Applicant/Provider: Hawaii Family Law Clinic-dba Ala Kuola Hilo Contract Period: 711114-6130115 Contract No. (As Applicable): BUDGET Budget Hawaii State CATEGORIES Request Judiciary Foundations Private Donations (a) (b) (c) (d) A. PERSONNEL COST 1. Salaries 22,300 245,884 2. Payroll Taxes&Assessments 3,936 27,413 3. Fringe Benefits 8,304 12,831 TOTAL PERSONNEL COST 34,540 286,128 B_ OTHER CURRENT EXPENSES 1. Airfare,Inter-Island 2. Airfare,Out-of-State 5,000 3. Audit Services 2,100 6,725 4. Contractual Services-Administrative - 5. Contractual Services-Subcontracts 5,000 1,000 2,500 6. Insurance 840 4,600 325 7. Lease/Rental of Equipment 252 2,000 500 8. Lease/Rental of Motor Vehicle - 9. Lease/Rental of Space 5,083 28,000 10. Mileage - 347 150. 11. Postage,Freight&Delivery 225 12. Publication&Printing 650 500 500 79 13. Repair&Maintenance - 14. Staff Training 350 400 15. Substance/Per Diem - 175 16. Supplies 275 1,500 1,500 17. Telecommunication 756 4,400 18. Transportation - 19. Advertisement 8,400 20 Professional Fees 12,000 21 22. 23. TOTAL OTHER CURRENT EXPENSES 20,531 68,872 3,500 3,229 C_ EQUIPMENT PURCHASES D. MOTOR VEHICLE PURCHASES TOTAL A+B+C+D 55,071 355,000 3,6001 3,229 Bridget Prepared Ely: SOURCES OF FUNDING a) Budget Request Name(Please type or print) Phone b) C Signature of Authorized Official Date (d) Name and Title(Please type or print) For State Agency Use Only TOTAL REVENUE Signature of Reviewer Date Agency Name: Ala Kuola Program Name:COACHING BOYS INTO MEN lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless o f whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. IL _�Y_ Signa7ure of Authorized Person (specify ti le) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Program Name: 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'l County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'l, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to htt vendors.ehawaii. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i I we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual yea r for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided,.wi!! impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http.//www.hawalicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Program Name: 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $0.00 Additional Council directives regardin>; award: EXH I BIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 2 American National Red Cross, The Disaster Preparedness and Response in Hawaii County Agency Name: The American National Red Cross Program Name; Disaster Preparedness and Response in Hawaii County Agency Director: Coralie Matayoshi Phone No.:(808) 739-8103 Contact Person: Barney Sheffield Phone No.:(808) 935-8305 Mailing Address: Address: 4155 Diamond Head Road Address: city,sT,zip Honolulu, Hl 96816 Facility Address: Address: 55 Ululani Street Address: City,ST,zip Hilo, HI 96720 Email Address: Barney.Sheffield@redeross.org Fax No.: (808) 735-8626 Accountant/CP KPMG LLP Phone No.:(703) 286-8000 Firm (if applicable): KPMG LLP Mailing Address: Address: 1676 International Drive Address: City,ST,zip McLean, VA 22012 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000.00 $14,750.00 $20,000.00 2.Agency Mission Statement: The Red Cross mission is to prevent and alleviate human suffering in n the face of emeMencies by mQbflJz'ng the power of voluoteers and q.Pne[os' y of donors. We do this by„commina to the aid of disgster Victims teaching people how to save lives and .proy dine emergency -commUnicatinn between deployed-m-ifitary service Members-and their EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:The American National Red Cross Program Name: Disaster Preparedness and Response in Hawaii County 3. Program Description: Our Disaster Preparedness and Response Program in Hawaii Count helps people before, during and after disasters. It includes disaster relief assistance to help victims of single family and major disasters overcome the physical and emotional distress of a disaster and meet their immediate emergency needs as they begin to rebuild their lives after a tragedy. (please see additional_pa,gp.)_, ..,..__ 4.Total Budget& Position Count: Total Program Budget: $196,833.00 Total Program Position Count: 1.00 Total Agency Budget: $3,187,378.00 Total Agency Position Count; 21.00 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii $20,000.00 Hawaii Island United Way $40,000.00 Other contributions (direct mail & grants) $66,750.00 Subsidy by American Red Cross to meet deficit $70,083.00 TOTAL: $196,833.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Red Cross is not a government agency and relieg n_ the generosity, of the public_to provide our critical services. We continue., Q'increase Red Cross visibility and salicit dnnations fram_individuals ;and_„ corporations. and win contim ie to seek grant fi indin -Q from foundabons EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:The American National Red Cross Program Name: Disaster Preparedness and Response in Hawaii County 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide for the immediate emer enc needs of Big Island disaster victims (food, clothing, shelter & crisis counselina)o,, train yDJ-uoJeer disaster responders to serve them[ communities;disseminate disaster..__ pr_eparedness information to Bia Island residents andbt1si11essPs- S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific) Number of disasters responded to 15 Number of individuals assisted after disasters 40 Number of mass shelters opened & individuals sheltered 1110 Number of individuals reached thru community presentations 1,000 Number of certificates issued for free disaster training 200 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual` Total Budget Grant Rey Salary and Wages $54,000 $55,620.00 $30,000. Professional Fees Operations $72,200 $72,200.00 Supplies $5,850. $5,850.00 $3,000.0 Equipment Other:disaster relief(unpredictable) $20,00q$20,000.00 $15,000. other:travel, postage, gas, program related expense $43,163 $43,163.00 $2,000.0 Other: Other: Other: TOTAL 1$195,211$196,833.0 $50,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: The American National Red Cross Program Name: Disaster Preparedness and Response in Hawaii County so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. A!1 disclosure arms must be signed,regardiess of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by on individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 412'�11� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:The American National Red Cross Program Name: Disaster Preparedness and Response in Hawaii County i1. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. i (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. 1 (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register,go to http:llvendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii;i (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, using the template Provided, will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301h shall result in loss of all grant funds received during the grant Period must be refunded to Count and exclusion from future grant p-articil2ation for a minimum of one year or until a written report is submitted to and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nongrofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation of our agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name;The American National Red Cross Program Name: Disaster Preparedness and Response in Hawaii County 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of disasters responded to 15 Number of individuals assisted after disasters 40 Number of mass shelters opened & individuals sheltered 1110 Number of individuals reached thru community presentations 1,000 Number of certificates issued for free disaster training 200 TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $30,000.00 Professional Fees Operations Supplies $3,000.00 Equipment other: disaster relief(unpredictable) $15,000.00 Other: travel, osta e, gas, program related expense $2,000.00 Other: Other: Other: TOTAL $50,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 The American National Red Cross Disaster Preparedness and Response in Hawaii County Additional Page for#3 Program Description This assistance includes: food, clothing, shelter, mental health counseling and financial assistance to help families recover more quickly from a disaster. In a larger disaster or tragic event, crisis counseling, mass care, family reunification, emergency first aid and other support services as appropriate are also provided to victims. The Red Cross is unlike any other organization. Working side by side local police, fire, and civil defense, we are the only nonprofit organization that responds to disasters big and small, 2417, 365 days a year. Our services are essential, irreplaceable, and assist county, state, and federal government in their responsibility to provide for the welfare of those who reside in their jurisdictions. Response is only the tip of the spear. It takes preparation, resources, and infrastructure to be able to respond everyday throughout the year. We accomplish this with a small staff and hundreds of volunteers who work 12-hour shifts, morning, noon, and night. Having volunteers play such a vital role in carrying out our mission makes the Red Cross unique. Whereas other organizations might pay for drug counselors or child care workers to provide services, we leverage the free services of Red Cross volunteers to fulfill our mission. Just as the County would fund contracts/salaries of drug counselors or child care workers as a program expense, the salary of our Red Cross staff person, who enables us to use volunteers to provide services, is a program expense. The fact that we don't have to pay our volunteers to do the work demonstrates that Red Cross is indeed, a very wise investment. Most funders want to donate money to buy tangible items like cots and blankets, but don't think about the cost to rent space to store the cots, or how the cots and blankets will get transported to shelters when needed. Hawaii County funding would help support the basic infrastructure of our disaster response and preparedness program so that our Big Island Red Cross is able to respond and prepare the community beforehand to mitigate the loss of life and property. Hawaii County funding would be used to support the partial salary and benefits of our only paid staff person on the Big Island who recruits and trains volunteers, works with volunteers to secure, inventory, and preposition disaster supplies, ensures that volunteers are mobilized to help disaster victims anytime and anywhere on the Big Island, organizes volunteers to do community disaster education outreach, engages the community in disaster preparedness planning, and works with government agencies and other non-profit organizations to plan and exercise for disasters. All of these duties entail direct program (not administrative) expenses. Whether a disaster happens or not, the Red Cross must still constantly recruit and train volunteers to be ready to respond and educate the community about disaster preparedness. Without support of these fixed costs, we couldn't operate and would not able to respond when needed. Our volunteers are ready to respond to disasters 24 hours a day, 7 days a week, 365 days a year. All disaster training and response are provided free of charge. Another component is community education, which empowers families and individuals to prepare for and respond to disasters before they strike. The geographic remoteness of the Hawaiian Islands makes community preparedness and resiliency crucial. Following a major disaster like a tsunami, hurricane or earthquake, our logistics bridge would likely be compromised and critical resupply of items such as fuel, food and medical supplies could be delayed. Educating families and businesses to take responsibility for their own preparedness can mitigate the loss of life and property. When people have a disaster plan and kit, the effects of a disaster are lessened and recovery is quicker. Since 1917, the people of Hawaii have depended on us to respond not only to everyday fires and floods, but also every major natural and man-made disaster that has struck our islands, including the bombing of Pearl Harbor, Hurricanes Iniki and Iwa, Big Isle earthquake, multiple tsunami, Sacred Falls landslide, New Years and Manoa floods, Kaloko Dam burst, airplane and helicopter crashes, explosions, and hostage situations. The Red Cross is not a government agency and relies on the aloha spirit and generosity of Hawaii's people to provide critical services to the community. All disaster training, services, and financial assistance to victims is free. In Fiscal Year 2013 (July 1, 2012- June 30, 2013), the Red Cross in Hawaii County responded to 22 disasters on Big Island enabling 67 individuals to recover from their losses and begin rebuilding their lives; reached 1,320 people with disaster preparedness information through community presentations; recruited 21 new volunteers; and provided training certificates for 149 individuals in free disaster training courses. According to a 2011 Census Bureau report, 12% of Hawaii's population lives below the poverty level. This "poor and needy" demographic is particularly vulnerable to disasters and is dependent on Red Cross services when affected by a disaster. Based on family size and income levels, our records show that in FY13, over 57% of the disaster families we served on the Big Island were below the Poverty Guidelines set by the U.S. Department of Housing & Urban Development. Of the families, 57% did not own their home and 83% did not have structure insurance. Since over half of them do not own their homes and have no property insurance, they are truly destitute after a fire destroys everything they own or claims the life of a loved one. The Red Cross is truly a safety net for victims of"every day" disasters who have nowhere else to turn. Beyond the "every day" disasters, the Red Cross is preparing for and will respond to major disasters like Hurricane Katrina, which may affect the entire population of Hawaii, especially those with special needs like the elderly, frail, handicapped, and poor. 3 Are of Hilo, The Employment Training Services Program Expansion (ETS) Agency Name: The Arc of Hilo Program Name: Employment Training Services Program Expansion (ETS) Agency Director: Michael E. Gleason Phone No.:(808) 938-8535 Contact Person: Debbie Perkins Phone No.: (808) 935-8535 Mailing Address: Address: 1099 Waianuenue Ave. Address: City,ST,ZIP Hilo, HI 96720, Facility Address: Address: same Address: City,ST,Zip Email Address: debbieperkins @hiloarc.org Fax No.: (808) 965-8468 Accountant/CP Ms. Ann Fukuhara, CPA,MBA Phone No.: (808) 961-5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: Suite #102 City,ST,Zip Hilo, HI 96720 - YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000.00 $25,125.00 $2,770.00 2. Agency Mission Statement: The Arc of Hilo`s mission statement is to improve the quality of life for people wilh developmental and other disabilities on Hawai'i through ent and EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 page 1 of 7 Agency Name: The Arc of Hilo Program Name: Employment Training Services Program Expansion (ETS) 3. Program Description: The ETS team conducts job development activities for individuals with _physical and/or mental disabilities which includes employment training, supported employment,_job placement, and employment retention., The staff assists individuals to gain hands-on work experience & 'I on 1 job ma-chmnq. Support seryRces are provided once they-are employed 4. Total Budget & Position Count: Total Program Budget: $152,106.00 Total Program Position Count: 1 Total Agency Budget: $3,700,000.00 Total Agency Position Count: 104 5. Program Funding Sources(identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate DVR Contracts: Job Placement and Retention Services (JPRS) $43,700.00 Supported Employment $18,000.00 United Way (Stipends for Participants only) $10,000.00 Program Service Fees $45,000.00 TOTAL: $116,700.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: By increasing th-e-ETS part time position to full time, the Arc of Hilo will increase the number of d[ent L)artmempants, and the potential revenue obligations but provide the ability to qinink EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: The Arc of Hilo Program Name: Employment Training Services Program Expansion (ETS) 7. Program Objectives Using County Nonprofit Grant Program Funds: To achieve maximum employment success, & increase the number of clients served, we impose an hourly increase for one staff persona from 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Potential number of clients to be served 12 Assessment & Evaluation (hours) 24 Additional workshops to be held (hogs) 120 Community outreach to current and new employers (hours) 48 Placement, Training and Job Coaching (hours) 214 Staff Training $8 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $78,435.00 $29,600. Professional Fees Operations $600.00 $150.oo Supplies $560.00 $190.00 Equipment Other: Travel and Millage $1,500.00 $350.00 Other: Staff training $1,061.00 $350.00 Other: Printing brochures $1,500.00 $1,500.0 Other: Administrative costs $12,450,00 $2,860.0 Other: program Activities $56,000.00 $Q.Qa TOTAL $0.00 $152,106.0 $35,000.q *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of Agency Name: The Arc of Hilo Program Name: Employment Training Services (ETS) Program Expansion so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be sinned, regardless of whether a conflict exists. NAM E: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. h� Signature,of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: The Arc of Hilo Program Name: Employment Training Services (ETS) Program Expansion 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, i (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely. complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301h shall result in loss of all grant funds received during the grant period (must,be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report,is submitted to and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http1/w ww.hawaiicounty.gov/fn-non-profit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will Impact the evaluation of Your aaencv's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. 'y T f Signature of Authorized Person (specify title) pate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: The Arc of Hilo Program Name: Employment Training Services Program Expansion (ETS) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Potential number of clients to be served 12 Assessment & Evaluation (hours) 24 Additional workshops to be held (hours) 120 Community outreach to current and new employers (hours) 48 Placement, Training and Job Coaching (hours) 214 Staff Training 88 TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $29,600.00 Professional Fees Operations $150.00 Supplies $190.00 Equipment Other: Travel and Millage $350.00 Other: Staff training $350.00 Other: Printing brochures $1,500.00 Other: Administrative costs $2,700.00 Other: Program Activities $0.00 TOTAL. $34,840.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 4 Arts and Science Center (ASC) ASC Community Facility CJ Agency Name:Arts and Sciences Center(ASC) .. .. . .-_ Program Name:ASC Community Facility Agency Director: Gail Clarke Phone No.:965-3730 Contact Person: Gail Clarke Phone No.:938-2933 Mailing Address: Address: PO Box 2091 Address: city,sT,zip pahoa, HI 96778 Facility Address: Address: no uses Address: 15-1397 Homestead Rd MY,ST,zip pahoa Email Address: ascpuna @gmail.com Fax No.: 965-3733 Accountant/CP Rozanne Connell Phone No.:966-1002 Firm (if applicable): Carbonaro CPA and Assoc Mailing Address: Address: PO Box 4372 Address: city,sT,zip Hllo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT ND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $51,700.00 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $30,000.00 $25,000.00 $0.00 2.Agency Mission Statement: ASC formed as a 501 c3 in 2043.to„provide support and infrastructure and sharing opportunities to empower narticinants to thrive.,_ .Q -rate_,- , stewardship of EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Arts and Sciences Center(ASC) Program Name:ASC Community Facility lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board.member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the"No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All discfasure forms must be signed regardless of„whether a conaba exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as apposed to benefits accruing.in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: m If no conflicts exist, check here. MALL CLL&2- Alle'�duv Signature of Authorized Person (speci title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:Arts and Sciences Center (ASC) Program Name:ASC Community Facility 7.Program Objectives Using County Nonprofit Grant Program Funds: 1 . Provide access to post high school classes in Pahoa 2. 2EQV!de asafe place fQr commu itV events, meetings and programs for grant or othp-r funding for communit�t and non-profil ments- 8.TABLE is What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results ft.e.:Numberof cllents served workshops orevents held,volunteer hours,etc.Describe,be specific.) 1. Host 1-3 public post high school classes per semester(credlnc) 12-25 individuals will complete 2. Host 10-12 community meetings and activities (CAN, PPA, Spooktacular—800+ attended in 2013) 800-1000 individuals will acces 3. Host 6-12 public work sessions focused on proposal developmen grants for economic and community projects 12-25 individuals will access Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $7,200.1 $31,200.00 $31,200. Professional Fees $0.00 $6,000.00 $3,200.0 Operations $6,000. $6,000.00 $6,000.0 Supplies $200.00 $1,800.00 $1,800.0 Equipment $6,000A $9,000.00 $9,000.0 Other:Facilities Development; consultation re safety and security $0.00 $500.00 $500.00 Other: Other: Other: Other: TOTAL $19,400 $54,500.00 $51,700. *if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:Arts and Sciences Center(ASC) Program Name;ASC Community Facility so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board.member, officer, director, or administrator of your organization may have with the County of Nawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: m If no conflicts exist, check here. Signature of Authorized Person (speci title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 20142015 Page 4 of 7 Agency Name.Arts and Sciences Center (ASC) Program Name.ASC Community Facility 11.Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to htt : vendors.ehawa'i. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I {wel understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grantfunds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report, using the template provided, will impact the evaluation of our ro ram's or a enc 's future funding re nests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss f all erant funds r c ived during the grant Period (must be rmfmnded to oun and exclusion fr m future rant particivation for a minimum of one year or until a written report is submitted to and accented by,_th-e cyuncil. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.goy/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your_awncy's future funding request and may result in actions taken to recover these.Lun_ds. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify titih Date f EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:Arts and Sciences Center(ASC) Program Name:ASC Community Facility 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1. Host 1-3 public post high school classes per semester(cred/nc) 12-25 individLd 2. Host 10-12 community meetings and activities (CAN, PPA, Spooktacular---800+ attended in 2013) 800-1000 ind' ' 3. Host 6-12 public work sessions focused on proposal developmen grants for economic and community projects 12-25 individ TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $31,200.00 Professional Fees $3,200.00 Operations $6,000.00 Supplies $1,800.00 Equipment $9,000.00 Other: Facilities Development; consultation re safety and security $500.00 Other: Other: Other: Other: TOTAL $51,700.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 5 Big Brothers Big Sisters Hawaii School Based Program Agency Name: Big Brothers Big Sisters Hawaii Program Name: School Based Program Agency Director: Dennis Brown Phone No.:(808) 695-4570 Contact Person: Jill Matro Phone No.:(808) 695-4564 Mailing Address: Address: 418 Kuwili St. #106 Address: City,ST,zip Honolulu, Hawaii 96817 Facility Address: Address: 106 Makalea Pl. Address: city,sT,zip Hilo, Hawaii 96720 Email Address: Jmatro @bbbshawaii.org Fax No.: (808) 356-3536 Accountant/CP Rebekah Remchuk Phone No.:(808) 695-4561 Firm (if applicable): Mailing Address: Address: 418 Kuwili St. #106 Address: City,ST,zip Honolulu, Hawaii 96817 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $5,000.00 $20,000.00 2. Agency Mission Statement: Big Brothers Big Sisters Hawaii is a prevention oriented non-profit agency that with the belief thatinherent in every child is the desire to succeed and thrive On 10fe. Qu JsAo-provmde choldren farina adversity with strong and enduring_ professionally sc an aded one-tn-nntm- rplaflonships that change the8r lives for the bettpr, forever We qpr-vL= at-risk, es 6-18 in mmmunities throughout the state EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Big Brothers Big Sisters Hawaii Program Name: School Based Program 3. Program Description: Our School Based Program matches in-need elementary students with high school mentors. A professionally trained case manager facilitates weekly activities designed to strengthen match relationships and increase positive outcomes for at-risk youth. Your support will help our continued aro�wth and success at the Waiakea Elementary mentorina site in Hilo- 4. Total Budget & Position Count: Total Program Budget: $42,848.00 Total Program Position Count: 1 Total Agency Budget: $1,550,000.00 Total Agency Position Count: 22 5. Program Funding Sources (identify ail sources of funding applied to this proL_ram): FY14-15 Revenue Source Estimate Kamehameha Schools $17,000.00 TOTAL: $17,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: .The Hawaii Island Regional Board is actively organizing a golf tournament and a 2nd Annual Bowl for Kids' Sake fundraiser in 2014_ Add0fianal funds are anfic'pated throuqh partnerships with Hawaii Arts & .Crafts and (;avprs, Inn , as well as continued comi .1 1twnrkqng EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Big Brothers Big Sisters Hawaii Program Name: School Based Program 7. Program Objectives Using County Nonprofit Grant Program Funds: Our initial year at Waiakea Elementary School required extensive effort in recruiting children and mentors. Funding will be used to continue .efforts On community awareness and recruRmentin or-der to approach .capacitV enrollment in the 2014-2015 schad year- 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Recruitment of childrenlmentors, process 24 inquiries enroll 16-20 participants Minimum of four partnership meetings or presentations/month community supportlawarenes Pair compatible children/mentors, create 8-10 "matches" 80% capacity enrollment Strengthen "match" success and longevity, min 3 mentor trainings 70% participant completion Administer Youth Outcome Survey to 80% of participants positive youth outcomes Address DOE general learning outcomes 1, 2, 3 & 5 help schools meet standard Facilitate weekly sessions from Oct 2014 - May 2015 conduct min 20 sessions Attach additional pages as necessary. 9. TABLE II: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $40,000 $37,000.00 $25,000. Professional Fees $264.00 $0.00 $0.00 Operations $2,700.( $3,190.00 $0.00 Supplies $384.00 $460.00 $0.00 Equipment $0.00 $58.00 $0.00 Other: Program Activities $2,000.( $2,140.00 $0.00 Other: Other: Other: Other: TOTAL $45,348 $42,848.00 $25,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Big Brothers Big Sisters Hawaii Program Name: School Based Program 1o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether_a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Sign ure eAuthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Big Brothers Big Sisters Hawaii Program Name: School Based Program ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future unding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted bv,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.goy/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Flawai'i with the final report. Failure to return these funds in a timely manner will impact the evoluation of our a enc 's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. C "20 c Signature of Authorized Person (specify titlef V Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 1 Agency Name: Big Brothers Big Sisters Hawaii Program Name: School Based Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Recruitment of children/mentors, process 24 inquiries enroll 16-20 pa Minimum of four partnership meetings or presentations/month community sl0 Pair compatible children/mentors, create 8-10 "matches" 80% capacity e Strengthen "match" success and longevity, min 3 mentor trainings 70% participan Administer Youth Outcome Survey to 80% of participants positive youthd Address DOE general learning outcomes 1, 2, 3 & 5 help schools Facilitate weekly sessions from Oct 2014 - May 2015 conduct min 2f, TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $25,000.00 Professional Fees $0.00 Operations $0.00 Supplies $0.00 Equipment $0.00 Other: Program Activities $0.00 Other: Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 6 Big Island Mediation ine dba West Hawaii Mediation Center Mediation Services Agency Name: Big Island Mediation inc dba West Hawaii Mediation Center Program Name:Mediation Services Agency Director: Janie Chandler-Edmondson Phone No.:(808) 885-5525 Contact Person: Janie Chandler-Edmondson Phone No.:(808) 885-5525 Mailing Address: Address: PO Box 7020 Address: City,ST,zip Kamuela, HI 96743 Facility Address: Address: Address: City,ST,Zip Email Address: ED @whmediation.org Fax No.: (808) 887-0525 Accountant/CP John Carbonaro Phone No.:(808) 242-5002 Firm (if applicable): Carbonaro CPA Mailing Address: Address: 1885 Main Street, Suite 408 Address: city,ST,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 1213 FY 13-14 $5,000.00 $12,240.00 $8,000.00 2.Agency Mission Statement: West Hawaii Mediation Center em owers individuals organizations and EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page I of 7 Agency Name: Big Island Mediation inc dba West Hawaii Mediation Center Program Name:Mediation Services 3. Program Description: See attached 4.Total Budget& Position Count: Total Program Budget: $158,500.00 Total Program Position Count: 3 Total Agency Budget: 1$200,000.00 Total Agency Position Count: 5 S. Program Funding Sources(identify ail sources of funding applied to this program): FY14-1S Revenue Source Estimate Hawaii Justice Foundation $6,000.00 Hawaii island united Way $14,000.00 Private foundations and Grants $53,000.00 County of Hawaii $15,000.00 State of Hawaii $39,138.00 Donations and Fundraising $12,000.00 Program fees and private client fees $20,000.00 TOTAL: $159,138.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: See aftarbed. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Big Island Mediation ine dba West Hawaii Mediation Center Program Name: Mediation Services 7. Program Objectives Using County Nonprofit Grant Program Funds; See a ached. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.:Number of clients served workshops or events held,volunteerhours,etc.Describe,be spetifc.) Applicant Projected Results Case Management Hours 2080 Mediation Cases Served 450 Mediation Sessions Conducted 300 Agreements reached in mediation (presented as percentage) 62% Affordable or free service to low income clients-% low income clien 50% Conflict Resolution Education training for youth 5 schools served Volunteer trainings and skills enhancement trainings see attached 8 * See attached Attach additional pages as necessary, 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 14-13 FY 14.15 Actual* Total Budget Grant Req Sala ry and Wages $112,0 $90,000.00 $10,000. Professional Fees E$45,00 000. $3,000.00 Operations $40,000.00 $3,000.0 Supplies $6,000. $5,000.00 $1,000.0 Equipment $3,000. $500.00 Other: $20,OOC $20,000.00 Other:Training $1,000.0 Other: Other: Other: TOTAL $191,00 $158,500.0 $15,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Big Island Mediation inc dba West Hawaii Mediation Center Program Name.Mediation Services so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. A ou rued Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Big Island Mediation inc dba West Hawaii Mediation Center Program Name:Mediation Services i1. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records,reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135--2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Com I'i_ance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawail.gov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i I we understand and will comply with the requirement to submit a ear-end re ort to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawal`i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timey&com lete and accurate ear-end re ort using the template provided, will impact the evaluation of your proaram's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 (we) understand that failure to submit the final report within 60 days of June NO shall result in loss of all grant funds received during the kyrant period must be refunded to Coup and exclusion from future grant Participation for a minimum of one year or until a written report is submitted to and accepted by,the council.' I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.govZfn-nonprofit-grant-formsl on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30,2075 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation o f your aaencv's Luture funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. S' nature o uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Big Island Mediation inc dba West Hawaii Mediation Center Program Name: Mediation Services 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Case Management Hours 2080 Mediation Cases Served 450 Mediation Sessions Conducted 300 Agreements reached in mediation (presented as percentage) 62% Affordable or free service to low income clients-% low income clien 50% Conflict Resolution Education training for youth 5 schools se Volunteer trainings and skills enhancement trainings *see attached 8 * See attach TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $10,000.00 Professional Fees Operations $3,000.00 Supplies $1,000.00 Equipment Other: Other: Training $1,000.00 Other: Other: Other: TOTAL $15,000.00 Additional Council directives reaardine award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014.2015 Page 7 of 7 3. Program Description The funds are requested to support West Hawaii Mediation Center(WHMC)which serves the districts of Hamakua, North&South Kohala, North &South Kona,and Ka'u. WHMC provides community-based mediation for both self-referred and court/legal system referred clients.These services are provided in an accessible and affordable manner to ensure any and all disputes in West Hawaii can be resolved in a safe,fair and appropriate way without the expense (time and money)of litigation. WHMC also provides conflict resolution education and training to adults, and to youth through peer mediation. WHMC utilizes trained community volunteers to deliver this vital service to their fellow community members. 6. Agency plans to increase revenues to support this program: West Hawaii Mediation Center continues to hold fundraisers to support its programs. We have completed two successful online auctions.The Center recently held its "Ho'olauna is Pu'u Wa'awa'a Tour" fundraiser. In addition to this year's fundraisers we will continue with our annual Sponsors and Supporters Campaign. This year's Sponsors and Supporters Campaign will be completed in June 2014. The Center receives ongoing support in fundraising from its Board of Directors. West Hawaii Mediation Center continues to receive and seek support from the United Way and other private agencies.The Center is also exploring increasing fee based social enterprise services. 7. Program Objectives using County Nonprofit Grant Program Funds: 1. Provide mediation services in an affordable and accessible manner for disputes arising both in and out of the court/legal system for a wide array of dispute issues including: divorce, custody,foreclosure, landlord-tenant,temporary restraining order,small claims,civil rights etc. 2. Recruit,train and retain high quality volunteer community mediators. 3. Provide case management and intake services to adequately serve all referred cases. 4. Educate youth in peaceful conflict resolution skills and peer mediation. 8. Table 1 Continued Program performance measures: Clients willing to recommend services to 95% others (percentage) Clients satisfied with services(presented as 95% percentage) 12. Council award worksheet Table l: Clients willing to recommend services to 95% others(percentage) Clients satisfied with services(presented as 95% percentage) Big Island Resource Conservation & Development Council Hawaii Homegrown Food Network (HHFN) Agency Name: Big Island Resource Conservation & Development Council Program Name: Hawai'i Homegrown Food Network (HHFN) Agency Director: Larry M, Komata Phone No.:(808) 935-8426 Contact Person: Craig Elevitch Phone No.: 808) 324-4427 Mailing Address: Address: 200 Kanoelehua Ave Address: PMB 285 city,sT,zip Hilo, HI 96720 Facility Address: Address: 202 B Chong St(home ofc Address: City,ST,zip Hilo, HI 96720 Email Address: brcd @hawaii.rr.com Fax No.: (808) 934-0616 Accountant/CP Elizabeth De Roche Phone No.:(406) 741-5843 Firm (if applicable): Mailing Address: Address: P.O. 843 Address: City,ST,zip Hot Springs, MT 59845 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $13,900.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $4,580.00 2.Agency Mission Statement: BIRCD: "To assist geogle in achieving sustainable development while caring fQr and appredaU their natural envir-Qnments; to ensure hrnadened economic aportunifies,_ enriched communifies_and_better EXHIBIT NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Big Island Resource Conservation & Development Council Program Name:Hawai'i Homegrown Food Network (HHFN) 3. Program Description: HHFN will use its well-established programs newsletterlwebsite social media Ho'oulu ka 'Ulu breadfruit festivals worksho ps, ublications to SUDDort traditional agriculture groups workin to revive native Hawaiian foods or m k a ' i nt populations, foods (e.-g- can rogram 4.Total Budget&Position Count: Total Program Budget: $27,600.00 Total Program Position Count: 4 Total Agency Budget: $32,939.00 Total Agency Position Count: 1 S. Program Funding Sources(identify all sources of funding applied to this gro ram FY14-15 Revenue Source Estimate Admin fees from HHFN special program grants $4,000.00 Website donation initiative $2,500.00 In-kind from volunteer staff $7,200.00 County Nonprofit Grant $13,900.00 TOTAL: $27,600.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: nitiative, grant P posals, and a new traditional crops grower EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name:Hawal'I Homegrown Food Network (HHFN) 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 . S ecial report series and medi a cam ai non reviving canoe !ants FxPand Hdoulu ka 'Ulu to include 10 natove, Hawaiian fo-Qd crops 8.TABLE 1: What are the intended measurable outputs or Outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc.Describe,bespec>flc.) Number of reports on groups reviving canoe plants 6 Number of native crops for Ho'oulu ka 'Ulu - Forest Island Program 10 Number of workshops on native foods and commercial production 2 Number of staff members added to publishing team one Number of volunteer hours 240 Attach additional pages as necessary. 9.TABLE 11: FY 33-14 FY 1425 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Reci Salary and Wages $10,800. $14,400.00 $7,900.00 Professional Fees $4,800.0 $3,600.00 $3,600.00 Operations $860.00 $2,400.00 $2,400.00 Supplies Equipment Other: In-kind from volunteer staff $8,585.0 $7,200.00 Other: $2,553.0 Other: Other: Other: TOTAL $27,598.1 $27,600.00 $13,900.0 *If applicable EXHIBIT A !NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name: Hawaii Homegrown Foot! Network(HHFN) 1o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed re ardless o whether a con lict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor [] The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 5 Signature o Aut o izeS Persar (spec fey it W Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name: Hawai'i Homegrown Food Network (HHFN) ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records, reporting„ and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that 1 (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. 1 (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process,and pay the annual registration fee online using a credit card. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawal`i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, using the template PLovided. will impact,the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30t'shall result in loss of all grant funds received during the grant period must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted hy,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http-//www.hawalicaunty.gov- /fn-nonprofit:grant-forms on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these f ands in a time!y manner will impact the evaluation of aura enc 's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 r Agency Name: Big Island Resource Conservation & Development Council Program Name:Hawaii Homegrown Food Network (HHFN) 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of reports on groups reviving canoe plants 6 Number of native crops for Ho'oulu ka 'Ulu - Forest Island Program 10 Number of workshops on native foods and commercial production 2 Number of staff members added to publishing team one Number of volunteer hours i240 TABLE II: IY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $7,900.00 Professional Fees $3,600.00 Operations $2,400.00 Supplies Equipment Other: In-kind from volunteer staff Other: Other: Other: Other: TOTAL $13,900-00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 _ Page 7 of 7 S Big Island Resource Conservation & Development Council Hdoulu Lehua (www.hooululehua.org) Agency Name: Big Island Resource Conservation & Development Council Program Name:Ho'oulu Lehua (www.hooululehua.org) Agency Director: Larry Komata Phone No.:(808) 935-8426 Contact Person: Jennifer Johansen Phone No.:(808) 345-8544 Mailing Address: Address: 200 Kanoelehua Ave Address: PMB 285 City,ST,zip Hilo, Hawaii 96720 Facility Address: Address: 202B Chong St (home ofc) Address: city,sT,zip Hilo, Hawaii 96720 Email Address: brcd @hawaii.rr.com Fax No.: (808) 934-0616 Accountant/CP Elizabeth De Roche Phone No.:(406) 741-5843 Firm (if applicable): Mailing Address: Address: P.O Box 843 Address: city,sT,zip Hot Springs MT 59845 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $21,827.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: BIRM "To assist people in achieving sustainable development while caring for and appreciating their natural environments; to ensure broadened economic ononrtunities, eoldched communities and better loves" EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name:Ho`oulu Lehua (www.hooululehua.org) 3. Program Description: Ho'oulu Lehua provides hands-on forest restoration/education for youth. We aim to implement an educational and fun after-school program in Pahoa. This low-cost (5,20/student per semester program will serve ten grade 7-12 students per sernester through th 2 - r• 4.Total Budget&Position Count: Total Program Budget: $43,077.00 Total Program Position Count: 2 Total Agency Budget: $32,939.00 Total Agency Position Count: I 5. Program Funding sources(identify all sources of funding applied to this Rro ram FY14-15 Revenue Source Estimate NSF CAREER Grant (Pi:Elizabeth Stacy). Salary donation for J. Johansen $3,900.00 Polestar Education Inc. (contingent on obtaining full funding for van) $1,200.00 Jennifer Johansen (Gen. Liability Insurance Policy) $650.00 TOTAL: $5,750.00 Attach additional pages,if needed. C. Explain what plans your agency or program has to increase revenues to support this program: Additional fundmou W11 hp. Qught fronlAximate foundations, Plans are 4) ant-support m business owners w a are inter-ested in supporting yoi ith and the enviminment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Big island Resource Conservation & Development Council Program Name: Ho'oulu Lehua (www.hooululehua.org) 7. Program Objectives Using County Nonprofit Grant Program Funds: Our main objective is to start-up an after-school_program_in Pahoa that will prayide a_safe environment ,foryouuth to learn about and engaa ins =tectinq Hawaim's native forests. We will also ronnect students with 8.TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results Ji.e.:Numberofclientssmed workshops orevents held.volunteerhours,etc.Describe,be specific.) 10 students served per semester for 8 after-school hours/week 20 students served 1 parent volunteer day to educate families on native forests 2 annual Ho'ike Days Two hectares of forest will be cleared of invasive species 4 hectares cleared of invasives 25 native seedlings will be prepared for out-planting 50 natives seedling prepared 2 community service events per semester for students 4 community service events Continued interest in our program for the 2015-2016 school year 20 students enrolled for 15-16 Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 24.15 FY 1415 Actual* Total Budget Grant Req Salary and Wages $3,900.1 $9,660.00 $5,760.0 Professional Fees $1,700.00 $1,700.0 Operations $500.00 $0.00 Supplies $430.0 $2,500.00 $2,500.0 Equipment $4,883.00 $4,883.0 Other: 12 Passenger Van $20,000.00 $5,000.0 Other:General Liability Insurance $650.00 $650.00 $0.00 Other:Insurance for van $1,200.00 $0.00 Other:Administrative $1,984.00 $1,984.0 Other: TOTAL. $4,980.q $43,077.00 $21,827. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name: Ho-oulu I_ehua (www.hooululehua.org) lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be si ned regardless of whether a con lict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 9 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name: Ho'oulu Lehua (www.hooululehua.org) is.Certification of Understanding (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135--2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expend ing/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property, or records pertinent to the grant,contract, or program for which funds were used. (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to htt vendors.ehawaii. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i I we understand and will comp..Iv with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual y ear for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report using the template grovided, will impact the evaluation of our program's or agency's uture funding requests EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted-by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.h awa Hco u nty.gov/fn-non prof it-grant-fo rmsj on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2015 must be returned to the County of Hawal'i with the final report.Failure to return these Lunds in a timelZ manner will impact the evaluation of our a enc s future f unding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. ' 44 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name:Ho'oulu Lehua (www.hooululehua.org) n. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 10 students served per semester for 8 after-school hours/week 20 students sel 1 parent volunteer day to educate families on native forests 2 annual Ho'ikE Two hectares of forest will be cleared of invasive species 4 hectares clew 25 native seedlings will be prepared for out-planting 50 natives see( 2 community service events per semester for students 4 community s( Continued interest in our program for the 2015-2016 school year 20 students eni TABLE I!: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $5,760.00 Professional Fees $1,700.00 Operations $0.00 Supplies $2,500.00 Equipment $4,883.00 other: 12 Passenger Van $5,000.00 Other: General Liability Insurance $0.00 Other: Insurance for van $0.00 Other: Administrative $1,984.00 Other: TOTAL $21,827.00 Additional Council directives re ardin award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 9 Boys & Girls Club of the Big Island Hamakua STEM Revolution Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua STEM Revolution Agency Director: Zavi Brees-Saunders Phone No.:(808) 961-5536 Contact Person: Zavi Brees-Saunders Phone No.:(808) 961-5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,5T,zip Hilo, HI 96720 Facility Address: Address: 43-1477 Hauolo Road Address: city,sT,zip Paauilo, HI 96776 Email Address: zavi @becbi.org Fax No.: (808) 9615534 Accountant/CP Ann Fukuhara, CPA MBA Phone No.:(808) 961 .5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street Address: Suite 102 MY,sr,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds. $40,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000.00 $10,000.00 $25,000.00 2. Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and responsible citizens, through quality programs, in a safe and caring environment." Girls Club for nvp s--currently serving over 400 YOUth per day- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua STEM Revolution 3. Program Description: Hamakua STEM Revolution is a youth led project based initiative focused on the creation of a thoughtful and moductive community of youth and adults from the Big Island who work together to build and _promote youth garden programs that focus on sustainable food systems and STEM. (Science, Technology. Engineering and Math) with odmarr for;us on. vouth ciardenina in the Boys & ((-anf inued on attached-panQ�,� 4. Total Budget& Position Count: Total Program Budget: $50,000.00 Total Program Position Count: 2 Total Agency Budget: 1$1,358,300.00 Total Agency Position Count: 34 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate State of Hawaii, Office of Youth Services $10,000.00 County of Hawaii Community Grants $40,000.00 TOTAL: $50,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Hamakua STEM Revolution" as,_a-biahly relevant youth led food production, SIEM and leadership proqram for Biq Island EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua STEM Revolution 7. Program Objectives Using County Nonprofit Grant Program Funds: Improved Leadership Skills among youth participants Improved Communication Skills anamayouth participants Increased knowledge and understanding of the science of qardeninq lmproyed community access to fresh nrerli ce 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results fi.e.:Numberof clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 90% of participating youth take a leadership role in the project 90% of 30 youth 90% of participating youth exhibit an increase in leadership skills as 90% of 30 youth observed by program staff 90% of participants show an increase in communication skills 90% of 30 youth including team building and collaboration as determined by staff observation (Continued of attachment) Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $75,000.00 $26,000. Professional Fees Operations $20,000.00 $5,000.0 Supplies $5,000.00 $4,000.0 Equipment Other:Liability Insurance $2,000,0 Other:Administrative support $3,000.0 Other: Other: Other: TOTAL $0.00 $100,000.0 $40,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua STEM Revolution zo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: None If no conflicts exist, check here. r I e eci ti ate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua STEM Revolution 11. Certification of Understanding (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 1 (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii revised Statutes. (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance.Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov., complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we)understand and will comply with the requirement„ to submit ayear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing an specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30;"shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:Hwww.hawalicounty.gov/fn-nonl)rofit-grant-form.s/`on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future Lunding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. ig t e-o t ers f tl~ �`i?Q/�J bate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name:Hamakua STEM Revolution 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 90% of participating youth take a leadership role in the project 90% of 30 yout 90% of participating youth exhibit an increase in leadership skills as 90% of 30 yout observed by program staff 90% of participants show an increase in communication skills 90% of 30 yout including team building and collaboration as determined by staff observation (Continued of attachment) TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $26,000.00 Professional Fees Operations $5,000.00 Supplies $4,000.00 Equipment Other: Liability Insurance $2,000.00 Other: Administrative support $3,000.00 Other: Other: Other: TOTAL $40,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 /4p/ MFssfon: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." BUYS&GILLS CLUB OF THE BIG ISLAND AGENCY NAME: Boys & Girls Club of the Big Island PROGRAM NAME: Hamakua STEM Revolution Extended answers continued from application form 3. Program Description (continued): "Hamakua STEM Revolution'' is a youth led,project based, initiative focused on the creation of a thoughtful and productive community of youth and adults from the Big Island who work together to build and promote youth garden programs that focus on sustainable food systems and STEM (Science, Technology, Engineering and Math) with primary focus on youth gardening in the Boys & Girls Club and extending to equitable access to healthy foods for the communities around the Boys & Girls Club site. This program will provide an on-going, sustainable leadership program for youth to learn about growing food, business and community service. This program provides a community that produces healthy food,provides youth leadership opportunities, and inspires and supports others to create change in their own communities. The success of the 2013 County of Hawaii STEM Garden initiative has led to the formation of the Hamakua STEM Revolution. This was a highly successful initiative that has expanded to include other youth garden groups including neighboring school gardens, 4-H's Junior Master Gardener Program, the University of Hawaii and other local farms and garden groups. The Junior Master Gardener curriculum was used for learning about gardening and the various Science, Technology, Engineering and Math components of gardening and food production as well as a large variety of age appropriate garden activities and lessons to include all ages of youth in the program. The Hamakua STEM Revolution will involve multiple levels of food production and distribution. Youth will lead projects and working groups including defining goals, designing and revising their garden, preparing, planting, maintaining and harvesting food from the garden, and exploring varying option for growing plants and evaluating environmental inputs and outputs. The Hamakua STEM Revolution participants will also build collaborative partnerships with other youth garden initiatives including school gardens,particularly with Paauilo School and other Paauilo and Hamakua community organizations and programs. The youth will also explore options to provide community access to fresh produce. As the Big Island community seeks to become more sustainable in energy and food production, the BGCBI is committed to providing youth opportunities to help build healthier communities. Hamakua STEM Revolution Mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs In a safe and caring environment." BOYS&GIRLS CLUB OF THE sl(i tSMD 6.Explain what plans your agency or program has to increase revenues to support this program (continued): BGCBI views Hamakua STEM Revolution as a highly relevant and timely youth led food production, STEM and leadership program for Big Island youth. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and is seeking community contributions. 8.TABLE I:What are the intended measurable outputs or outcomes that would be achieved with this funding? (Continued): PROGRAM PERFORMANCE MEASURES fte.:Numberofclientsserved Applicant Projected workshops or events held,volunteer hours,etc.Describe,be specific.) 90%of participating youth take a leadership role in the 90%of 30 youth project 90% of participating youth exhibit an increase in leadership 90%of 30 youth skills as observed by program staff 90%of participants show an increase in communication skills including team building and collaboration as determined by 90%of 30 youth staff observation 90%of participating youth will show an increased knowledge of the science of gardening including soil and plant growth, 90%of 30 youth as measured by pre and post tests 90%of participants will contribute to the growing, harvesting 90%of 30 youth and distribution of produce to the community 20 community volunteers will contribute an average of 20 400 Volunteer hours hours each to the project contributed Hamakua STEM Revolution 10 Boys & Girls Club of the Big Island Hilo STEM Revolution Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo STEM Revolution Agency Director: Zavi Brees-Saunders Phone No.:(808) 961-5536 Contact Person: Zavi Brees-Saunders Phone No.:(808) 969-5536 Mailing Address: Address: 100 Kamakahonu Street Address: city,ST,zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: city,ST,zip Hilo, HI 96720 Email Address: zavj@bgcbi.org Fax No.: (808) 961-5534 Accountant/CP Ann Fukuhara, CPA MBA Phone No,:(808) 961-5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street Address: Suite 102 City,sr,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $20,000.00 $10,000.00 $95,000.00 2. Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and _responsible citizens_, through quality pro rams., in a safe and caring_.__ -environment." -Girl,q Club for over 60 yearscurrently serving over 400 YOUth ppr day EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: goys & Girls Club of the Big Island Program Name: Hilo STEM Revolution 3. Program Description: "Hilo STEM Revolution" is a youth led ro'ect based initiative focused on the creation of a thoughtful and productive community of youth and adults from the Big Island who work together to build and promote youth _garden programs that focus on sustainable food systems and STEM �Sdence, TechInolQw., En_' . _� and Math) with Primary focus on i in the Boy, 4. Total Budget& Position Count: Total Program Budget: $100,000.00 Total Program Position Count: 6 Total Agency Budget: $1,36$,300.00 Total Agency Position Count: 34 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-1.5 Revenue Source Estimate Verizon Foundation $4,500.00 Walmart Foundation $13,000.00 Office of Juvenile Justice Programs $32,500.00 Atherton Foundation $10,000.00 County of Hawaii Community Grants $40,000.00 TOTAL: $100,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Hilo STEM Revolution" as a hi_qhly relevant and-tim v y-Quth led food production, STEM and leadership , roaram for Big Bland EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo STEM Revolution 7. Program Objectives Using County Nonprofit Grant Program Funds: Improved Leadership Skills.among outh participants Improved mmu i n SkRls am c�youth articipants Improved commu-nityaccess to fresh r)rndHc-P 8.TABLE l: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (l.e-Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 90% of participating youth take a leadership role in the project 90% of 30 youth 90% of participating youth exhibit an increase in leadership skills as 90% of 30 youth observed by program staff 90% of participants show an increase in communication skills 90% of 30 youth including team building and collaboration as determined by staff observation (Continued of attachment) Attach additional pages as necessary. 9. TABLE I!: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $75,000.00 $26,000. Professional Fees Operations $20,000.00 $5,000.0 Supplies $5,000,00 $4,000.0 Equipment Other: Liability Insurance $2,000.0 other:Administrative support $3,000.0 Other: Other: Other: TOTAL $0.00 $900,000.0( $40,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo STEM Revolution la. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be si ned regardless of whether a conflict exists. NAME: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:asubstantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: None if no conflicts exist, check here. Si n u e s i Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo STEM Revolution 11. Certification of Understanding (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. 1 (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, l (we) understand and will comp[y with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i E we understand and will comply with the requirement to submit a near-end report to the County Council within 60 days after June 30 of the contractual,year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report, using the template 2rovided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grantparticip ation for a minimum of one year or until a written report is submitted to and accepted bv, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawalicounty.ROV/fn-nonprofit-grant-forms/­on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. failure to return these Lunds in a time!y manner will impact the evaluation of our a enc 's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. CUo 3/ o244 Sig t e-of r� o f ti I pate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo STEM Revolution 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 90% of participating youth take a leadership role in the project 90% of 30 yout 90% of participating youth exhibit an increase in leadership skills as 90% of 30 yout observed by program staff 90% of participants show an increase in communication skills 90% of 30 yout including team building and collaboration as determined by staff observation (Continued of attachment) TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $26,000.00 Professional Fees Operations $5,000.00 Supplies $4,000.00 Equipment Other: Liability Insurance $2,000.00 other: Administrative support $3,000.00 Other: Other: Other: TOTAL $40,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Mission: "To Inspire and enable Big Island youth to be productive and responsible citlzens,through quality programs in a safe and caring environment." BOYS&GHU S CLUB OF THE BIG ISLAND AGENCY NAME: Boys & Girls Club of the Big Island PROGRAM NAME: Hilo STEM Revolution Extended answers continued from application form 3.Program Description (continued): "Hilo STEM Revolution"is a youth led, project based, initiative focused on the creation of a thoughtful and productive community of youth and adults from the Big Island who work together to build and promote youth garden programs that focus on sustainable food systems and STEM (Science, Technology, Engineering and Math) with primary focus on youth gardening in the Boys& Girls Club and extending to equitable access to healthy foods for the communities around the Boys& Girls Club site. This program will provide an on-going, sustainable leadership program for youth to learn about growing food,business and community service. This program provides a community that produces healthy food,provides youth leadership opportunities, and inspires and supports others to create change in their own communities. The success of the 2013 County of Hawaii STEM Garden initiative has led to the formation of the Hilo STEM Revolution. This was a highly successful initiative that has expanded to include other youth garden groups including neighboring school gardens, 4-H's Junior Master Gardener Program,the University of Hawaii and other local farms and garden groups. The Junior Master Gardener curriculum was used for learning about gardening and the various Science, Technology,Engineering and Math components of gardening and food production as well as a large variety of age appropriate garden activities and lessons to include all ages of youth in the program. The Hilo STEM Revolution will involve multiple levels of food production and distribution. Youth will lead projects and working groups including defining goals, designing and revising their garden,preparing,planting, maintaining and harvesting food from the garden, and exploring varying option for growing plants and evaluating environmental inputs and outputs. The Hilo STEM Revolution participants will also build collaborative partnerships with other youth garden initiatives including school gardens, particularly with Hilo Union School and with Kua O Ka La PCS. The youth will also explore options to provide community access to fresh produce including piloting a Youth Garden Market. As the Big Island community seeks to become more sustainable in energy and food production, the BGCBI is committed to providing youth opportunities to help build healthier communities. Mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." BOYS&GILLS CLUB OF THE W I5LANO 6.Explain what plans your agency or program has to increase revenues to support this program (continued): BGCBI views Hilo STEM Revolution as a highly relevant and timely youth led food production, STEM and leadership program for Big Island youth. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and is seeking community contributions. S.TABLE I:What are the intended measurable outputs or outcomes that would be achieved with this funding? (Continued): PROGRAM PERFORMANCE MEASURES ae.:Numberofchentsserved Applicant Projected workshops or events held,volunteer hours,etc.Describe,be specific.) 90%of participating youth take a leadership role in the 90%of 30 youth project 90%of participating youth exhibit an increase in leadership 90%of 30 youth skills as observed by program staff 90%of participants show an increase in communication skills including team building and collaboration as determined by 90%of 30 youth staff observation 90%of participating youth will show an increased knowledge of the science of gardening including soil and plant growth, 90%of 30 youth as measured by pre and posttests 90%of participants will contribute to the growing, harvesting 90%of 30 youth and distribution of produce to the community 20 community volunteers will contribute an average of 20 400 Volunteer hours hours each to the project contributed Mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs In a safe and caring environment." 11 Boys & Girls Club of the Big Island Keaau STEM Revolution Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau STEM Revolution Agency Director: Zavi Brees-Saunders Phone No.:(808) 961-5536 Contact Person: Zavi Brees-Saunders Phone No.:(808) 961-5536 Mailing Address: Address: 100 Kamakahonu Street Address: city,sT,zip Hilo, HI 96720 Facility Address: Address: Holy Rosary Catholic Church Address: Shipman Gym Road city,sr,zip Keaau, HI 96749 Email Address: zavi @becbi.org Fax No.: (808) 961-5534 Accountant/CP Ann Fukuhara, CPA MBA Phone No.:(808) 961-5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street Address: Suite 102 city,ST,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds., FY 11-12 FY 12-13 FY 13-14 $15,000.00 $10,000.00 $15,000.00 2. Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and responsible citize s throu h quality programs, in a safe- and caring EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau STEM Revolution 3. Program Description: Keaau STEM Revolution is a youth led project based initiative focused on the creation of a thoughtful and productive community of youth and adults from the Big Island who work together to build and promote youth garden programs that focus on sustainable foods stems and STEM -vo.uth ciardenho in the Boys & Gods Club (continued on atta 4.Total Budget & Position Count: Total Program Budget: $100,000.00 Total Program Position Count: g Total Agency Budget: $1,358,300.00 Total Agency Position Count: 34 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-1S Revenue Source Estimate Atherton Foundation $10,000.00 Walmart Foundation $5,004.00 Office of Juvenile Justice Programs $32,500.00 State of Hawaii, Office of Youth Services $12,500.00 County of Hawaii Community Grants $40,000.00 TOTAL: $100,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Keaau STEM Revolution" as a highly relevant and timely— Vnijth—RG ;BI has already fnrj_ed many rommi�nitv�na tnershins to EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau STEM Revolution 7. Program Objectives Using County Nonprofit Grant Program Funds: Improved Leadership Skills among youth participants Improved Communication Skills among youth participants Im-mnyed-community access to fresh nror uop. S. TABLE t: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.;Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 90% of participating youth take a leadership role in the project 90% of 30 youth 90% of participating youth exhibit an increase in leadership skills as 90% of 30 youth observed by program staff 90% of participants show an increase in communication skills 90% of 30 youth including team building and collaboration as determined by staff observation (Continued of attachment) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $75,000.00,$26,000.( Professional Fees Operations $20,000.00 $5,000.0 Supplies $5,000.00 $4,000.0 Equipment Other: Liability Insurance $2,00p,0 Other:Administrative support $3,000.0 Other: Other: Other: TOTAL $Q.00 $100,000.0 $40,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau STEM Revolution io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Flawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: None If no conflicts exist, check here. J,� �. -) i t e` er c' Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name; Keaau STEM Revolution 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 1.35—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 1 (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. 1 (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai r, I (we) understand and will comply with the requirement to enrol[with Hawai'i Compliance Express, and be compliant prior to final payment. To register,go to htt vendors.ehawail. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a..grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 da s after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of our program—'s or agency's uture undin re uests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawalicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by-lune 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. ityf e-of r' P son (specify t' I bate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau STEM Revolution 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 90% of participating youth take a leadership role in the project 90% of 30 yout 90% of participating youth exhibit an increase in leadership skills as 90% of 30 yout observed by program staff 90% of participants show an increase in communication skills 90% of 30 yout including team building and collaboration as determined by staff observation (Continued of attachment) TABLE fl: PROGRAM EXPENDITURES FY 14-15 Counci[ Grant Request Award Salary and Wages $26,000,00 Professional Fees Operations $5,000.00 Supplies $4,000.00 Equipment other: Liability Insurance $2,000.00 Other: Administrative support $3,000.00 Other: Other: Other: TOTAL $40,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 /4p/ MISS[= "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." BOYS&GHU S CLUB OF THE MG ISLAND AGENCY NAME: Boys & Girls Club of the Big Island PROGRAM NAME: Keaau STEM Revolution Extended answers continued from application form 3. Program Description (continued): "Keaau STEM Revolution" is a youth led,project based, initiative focused on the creation of a thoughtful and productive community of youth and adults from the Big Island who work together to build and promote youth garden programs that focus on sustainable food systems and STEM (Science, Technology, Engineering and Math) with primary focus on youth gardening in the Boys & Girls Club and extending to equitable access to healthy foods for the communities around the Boys & Girls Club site. This program will provide an on-going, sustainable leadership program for youth to learn about growing food, business and community service. This program provides a community that produces healthy food,provides youth leadership opportunities, and inspires and supports others to create change in their own communities. The success of the 2013 County of Hawaii STEM Garden initiative has led to the formation of the Keaau STEM Revolution. This was a highly successful initiative that has expanded to include other youth garden groups including neighboring school gardens, 4-H's Junior Master Gardener Program, the University of Hawaii and other local farms and garden groups. The Junior Master Gardener curriculum was used for learning about gardening and the various Science, Technology, Engineering and Math components of gardening and food production as well as a large variety of age appropriate garden activities and lessons to include all ages of youth in the program. The Keaau STEM Revolution will involve multiple levels of food production and distribution. Youth will lead projects and working groups including defining goals, designing and revising their garden, preparing,planting, maintaining and harvesting food from the garden, and exploring varying option for growing plants and evaluating environmental inputs and outputs. The Keaau STEM Revolution participants will also build collaborative partnerships with other youth garden initiatives including school gardens, particularly with Keaau area schools and other Keaau community organizations and programs. The youth will also explore options to provide community access to fresh produce. As the Big Island community seeks to become more sustainable in energy and food production, the BGCBI is committed to providing youth opportunities to help build healthier communities. Keaau STEM Revolution Mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." BUYS&GILLS CLUB Of THE 810 ISLAND 6. Explain what plans your agency or program has to increase revenues to support this program(continued): BGCBI views Keaau STEM Revolution as a highly relevant and timely youth led food production, STEM and leadership program for Big Island youth. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and is seeking community contributions. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? (Continued): PROGRAM PERFORMANCE MEASURES(i.e.:Numberof clients served Applicant Projected workshops or events held,volunteer hours,etc.Describe,be specific.) 90%of participating youth take a leadership role in the 90%of 30 youth project 90%of participating youth exhibit an increase in leadership 90% of 30 youth skills as observed by program staff 90%of participants show an increase in communication skills including team building and collaboration as determined by 90%of 30 youth staff observation 90%of participating youth will show an increased knowledge of the science of gardening including soil and plant growth, 90%of 30 youth as measured by pre and post tests 90%of participants will contribute to the growing, harvesting 90%of 30 youth and distribution of produce to the community 20 community volunteers will contribute an average of 20 400 Volunteer hours hours each to the project contributed Keaau STEM Revolution 12 Boys & Girls Club of the Big Island Ocean View - Na'alehu STEM Revolution Agency Name: goys & Girls Club of the Big Island Program Name:Ocean View- Na'alehu STEM Revolution Agency Director: Zavi Brees-Saunders Phone No.:(808) 961-5536 Contact Person: Zavi Brees-Saunders Phone No.:(808) 961-5536 Mailing Address: Address: 100 Kamakahonu Street Address: city,sT,zip Hilo, Hl.96720 Facility Address: Address: 95-5635 Mamalahoa Hwy, Address: city,sT,zip Naalehu, HI 96772 Email Address: zavi @becbi.org Fax No.: (808) 961-5534 Accountant/CP Ann Fukuhara, CPA MBA Phone No.:(808) 961-5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street Address: Suite 102 . city,ST,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $20,000.00 $10,000.00 $10,000.00 2.Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and responsible citizens through qualltV proqrams, in a safe and caring Gris Club for over 60 yea�q u irrpntly serving over 400 youth per day EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name:Ocean View- Na'alehu STEM Revolution 3. Program Description: Ocean View - Naalehu STEM Revolution is a youth led project based initiative focused on the creation of a thoughtful and productive community of youth and adults from the Big Island who work together to build and promote youth garden programs that focus on sustainable foosLsystems and STEM (Sci 'Tech_nQlogy, Engineering and Matb) with primary focus on outh aardeninc ,eanfi_nued an attached I32aP 4. Total Budget & Position Count: Total Program Budget: $50,000.00 Total Program Position Count: 2 Total Agency Budget: $1,358,300.00 Total Agency Position Count: 34 S. Program Funding Sources (identify all sources of funding applied to this program): FY1,4-15 Revenue Source Estimate State of Hawaii, Office of Youth Services $10,000.00 County of Hawaii Community Grants $40,000.00 TOTAL: $50,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BG BI views n View - Naalehu STEM Revolution" as relevant Vouth led ad production, STEM and leadetship progra for r)artnp-rships to leverage resources, is (continuBd on page.) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name:Ocean View- Na'alehu STEM Revolution 7. Program Objectives Using County Nonprofit Grant Program Funds: Improved Leadership Skills among - outh..participants Improved Communication Skills among youth �didpants Increased knowledge and understanding of the science of aardeninc lmpr_oyed c;ommunitV access to fresh nrodunp. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results fi.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,bespecifrc.) 90% of participating youth take a leadership role in the project 90% of 30 youth 90% of participating youth exhibit an increase in leadership skills as 90% of 30 youth observed by program staff 90% of participants show an increase in communication skills 90% of 30 youth including team building and collaboration as determined by staff observation (Continued of attachment) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Reg Salary and Wages $75,000.00 $20,000. Professional Fees Operations $20,000.00 $5,000.0 Supplies $5,000.00 $4,000.0 Equipment Other:Liability Insurance $2,000.0 Other:Administrative support $3,000.0 Other: Other: Other: TOTAL 1 $0.00 1$100,000.0d$40,000.( *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Ocean View- Na'alehu STEM Revolution lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑. The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: None If no conflicts exist, check here. 5 gn au e-of ri ed Pe n (sp )' Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Ocean View- Na'alehu STEM Revolution ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, 1 (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to htt vendors.ehawaii. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded_a from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of-your program's or agency's uture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 3eh shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted bv,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawailcounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will imgact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. gna re of�,iytor' ed P son (sp le) ' Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Ocean View- Na`alehu STEM Revolution 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 90% of participating youth take a leadership role in the project 90% of 30 yout 90% of participating youth exhibit an increase in leadership skills as 90% of 30 yout observed by program staff 90% of participants show an increase in communication skills 90% of 30 yout including team building and collaboration as determined by staff observation (Continued of attachment) TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $25,000.00 Professional Fees Operations $5,000.00 Supplies $4,000.00 Equipment Other: Liability Insurance $2,000.00 Other: Administrative support $3,000.00 Other: Other: Other: TOTAL $40,000.00 Additional Council directives regarding award: ward: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 /4p/ Mission: "To Inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." BOYS&.GHU S CLUB OF THE BIO ISLAND AGENCY NAME: Boys & Girls Club of the Big Island PROGRAM NAME: Ocean View-Naalehu STEM Revolution Extended answers continued from application form 3.Program Description(continued): "Ocean View-Naalehu STEM Revolution" is a youth led,project based, initiative focused on the creation of a thoughtful and productive community of youth and adults from the Big Island who work together to build and promote youth garden programs that focus on sustainable food systems and STEM (Science,Technology, Engineering and Math) with primary focus on youth gardening in the Boys & Girls Club and extending to equitable access to healthy foods for the communities around the Boys & Girls Club site. This program will provide an on-going, sustainable leadership program for youth to learn about growing food,business and community service. This program provides a community that produces healthy food,provides youth leadership opportunities, and inspires and supports others to create change in their own communities. The success of the 2013 County of Hawaii STEM Garden initiative has led to the formation of the Ocean View-Naalehu STEM Revolution. This was a highly successful initiative that has expanded to include other youth garden groups including neighboring school gardens,4-H's Junior Master Gardener Program,the University of Hawaii and other local farms and garden groups. The Junior Master Gardener curriculum was used for learning about gardening and the various Science, Technology,Engineering and Math components of gardening and food production as well as a large variety of age appropriate garden activities and lessons to include all ages of youth in the program. The Ocean View-Naalehu STEM Revolution will involve multiple levels of food production and distribution. Youth will lead projects and working groups including defining goals, designing and revising their garden,preparing,planting, maintaining and harvesting food from the garden, and exploring varying option for growing plants and evaluating environmental inputs and outputs. The Ocean View-Naalehu STEM Revolution participants will also build collaborative partnerships with other youth garden initiatives including school gardens,particularly with Naalehu School and other Ka'u area community organizations and programs. The youth will also explore options to provide community access to fresh produce. As the Big Island community seeks to become more sustainable in energy and food production, the BGCBI is committed to providing youth opportunities to help build healthier communities. Ocean View- Naalehu STEM Revolution Mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." BOYS&GERLS CLUB OF THE 810ISLMD 6. Explain what plans your agency or program has to increase revenues to support this program(continued): BGCBI views Ocean View-Naalehu STEM Revolution as a highly relevant and-timely youth led food production, STEM and leadership program for Big Island youth. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and is seeking community contributions. 8.TABLE I:What are the intended measurable outputs or outcomes that would be achieved with this funding? (Continued): PROGRAM PERFORMANCE MEASURES(i.e.:Number of clients served Applicant Projected workshops or events held,volunteer hours,etc.Describe,be specific.) 90%of participating youth take a leadership role in the 90/of 30 youth project 90%of participating youth exhibit an increase in leadership 90%of 30 youth skills as observed by program staff 90%of participants show an increase in communication skills including team building and collaboration as determined by 90% of 30 youth staff observation 90%of participating youth will show an increased knowledge of the science of gardening including soil and plant growth, 90%of 30 youth as measured by pre and post tests 90%of participants will contribute to the growing, harvesting 90% of 30 youth and distribution of produce to the community 20 community volunteers will contribute an average of 20 400 Volunteer hours hours each to the project contributed Ocean View-Naalehu STEM Revolution 13 Boys & Girls Club of the Big Island Pahala STEM Revolution Agency Name: goys & Girls Club of the Big Island Program Name: Pahala STEM Revolution Agency Director: Zavi Brees-Saunders Phone No.:(808) 961-5536 Contact Person: Zavi Brees-Saunders Phone No.:(808) 961-5536 Mailing Address: Address: 100 Kamakahonu Street Address: city,sT,zip Hilo, HI 96720 Facility Address: Address: 96-1134 Kamani St. Address: city,sT zip Paha[a, H1 96777 Email Address: zavi @becbi.org Fax No.: (808) 961-5534 Accountant/CP Ann Fukuhara, CPA MBA Phone No.:(808) 961-5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street Address: Suite 102 City,ST,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $20,000.00 $10,000.00 $10,000.00 2.Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and responsible citizens., through quality programs, in a safe and ca i environment." _ This_mission_has bopn imr)IPmPnted with Ria Island youth by thQ Roy.,;-& EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala STEM Revolution 3. Program Description: Pahala STEM Revolution is a youth led, project-based initiative focused on the creation of a thoughtful and productive community of youth and adults from the Big Island who work together to build and 'promote youth garden den programs that focus on sustainable food systems and—STEM (Science, TechnQlQu, Enpineerinq and Math) wit 4.Total Budget& Position Count: Total Program Budget: $50,000.00 Total Program Position Count: 2 Total Agency Budget: $1,358,300.00 Total Agency Position Count: 34 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate State of Hawaii, Office of Youth Services $10,000.00 County of Hawaii Community Grants $40,000.00 TOTAL: 1 $50,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Pahala STEM Revolution"-as..a_.highlyrele_v_ant youth led fo production, STEM and leadership n_roaram,for Pzi.g Island youth. BGCBI has already forcled many community..Dar_tnershins to leverage EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala STEM Revolution 7. Program Objectives Using County Nonprofit Grant Program Funds: Improved Leadership Skills among youth participants -ImprQved QQmmunicafion Skills amanq h i i pants Increased knowledge and understanding of the science of aardenina Imr)myed community access to fresh produce. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 90% of participating youth take a leadership role in the project 90% of 30 youth 90% of participating youth exhibit an increase in leadership skills as 90% of 30 youth observed by program staff 90% of participants show an increase in communication skills 90% of 30 youth including team building and collaboration as determined by staff observation (Continued of attachment) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $75,000.00 $26,000. Professional Fees Operations $20,000.00 $5,000.0 Supplies $5,000.00 $4,000.0 Equipment Other: Liability Insurance $2,000.0 Other:Administrative support $3,000.0 Other: Other: Other: TOTAL 1 $0.00 1$100,000.0 $40,000.( *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala STEM Revolution lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including anyfamilial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: None If no conflicts exist, check here. ie r e t Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala STEM Revolution ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that 1 (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawaii,goy, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of Your program's or agency's future undinp requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the rant eriod must be refunded to Count and exclusion from future grant participation for a minimum of one year or Until a written report is submitted to, and accepted by, the council. 1 (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawalicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. igneA bate EXHIBIT A NONPROFIT G RANT APP L I CATI 0 N FY 2014-2015 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala STEM Revolution 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 90% of participating youth take a leadership role in the project 90% of 30 yout 90% of participating youth exhibit an increase in leadership skills as 90% of 30 yout observed by program staff 90% of participants show an increase in communication skills 90% of 30 yout including team building and collaboration as determined by staff observation (Continued of attachment) TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $26,000.00 Professional Fees Operations $5,000.00 Supplies $4,000.00 Equipment other: Liability Insurance $2,000.00 Other: Administrative support $3,000.00 Other: Other: Other: TOTAL $40,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." BOYS&GILLS C= OF THE BIG ISLAND AGENCY NAME: Boys & Girls Club of the Big Island PROGRAM NAME: Pahala STEM Revolution Extended answers continued from application form 3. Program Description (continued): "Pahala STEM Revolution"is a youth led,project based, initiative focused on the creation of a -thoughtful and productive community of youth and adults from the Big Island who work together to build and promote youth garden programs that focus on sustainable food systems and STEM (Science, Technology, Engineering and Math) with primary focus on youth gardening in the Boys & Girls Club and extending to equitable access to healthy foods for the communities around the Boys & Girls Club site. This program will provide an on-going, sustainable leadership program for youth to learn about growing food, business and community service. This program provides a community that produces healthy food,provides youth leadership opportunities, and inspires and supports others to create change in their own communities. The success of the 2013 County of Hawaii STEM Garden initiative has led to the formation of the Pahala STEM Revolution. This was a highly successful initiative that has expanded to include other youth garden groups including neighboring school gardens, 4-H's Junior Master Gardener Program, the University of Hawaii and other local farms and garden groups. The Junior Master Gardener curriculum was used for learning about gardening and the various Science, Technology, Engineering and Math components of gardening and food production as well as a large variety of age appropriate garden activities and lessons to include all ages of youth in the program. The Pahala STEM Revolution will involve multiple levels of food production and distribution. Youth will lead projects and working groups including defining goals, designing and revising their garden,preparing,planting,maintaining and harvesting food from the garden, and exploring varying option for growing plants and evaluating environmental inputs and outputs. The Pahala STEM Revolution participants will also build collaborative partnerships with other youth garden initiatives including school gardens, particularly with Pahala area schools and other Ka'u area community organizations and programs. The youth will also explore options to provide community access to fresh produce. As the Big Island community seeks to become more sustainable in energy and food production, the BGCBI is committed to providing youth opportunities to help build healthier communities. Pahala STEM Revolution Mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." BUYS&GIIUS CLUB OF THE BIG ISLAND 6.Explain what plans your agency or program has to increase revenues to support this program(continued): BGCBI views Pahala STEM Revolution as a highly relevant and timely youth led food production, STEM and leadership program for Big Island youth. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and is seeking community contributions. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? (Continued): PROGRAM PERFORMANCE MEASURES(i.e.:Numberof clientsserved Applicant Projected workshops or events held,volunteer hours,etc.Describe,be specific.) 90%of participating youth take a leadership role in the 90%of 30 youth project 90%of participating youth exhibit an increase in leadership 90%of 30 youth skills as observed by program staff 90%of participants show an increase in communication skills including team building and collaboration as determined by 90%of 30 youth staff observation 90%of participating youth will show an increased knowledge of the science of gardening including soil and plant growth, 90%of 30 youth as measured by pre and post tests 90%of participants will contribute to the growing, harvesting 90%of 30 youth and distribution of produce to the community 20 community volunteers will contribute an average of 20 400 Volunteer hours hours each to the project contributed Pahala STEM Revolution 14 Boys & Girls Club of the Big Island Pahoa STEM Revolution Agency Name: Boys & Girls Club of the Big Island Program Name:Pahoa STEM Revolution Agency Director: Zavi Brees-Saunders Phone No.:(808) 961-5536 Contact Person: Zavi Brees-Saunders Phone No.:(808) 961-5536 Mailing Address: Address: 100 Kamakahonu Street Address: MY,sT,ziP Hilo, HI 96720 Facility Address: Address: 15-3001 Kauhala Street Address: CitY,ST,ziP Pahoa, H[ 96778 Email Address: zavi @becbi.org Fax No.: (808) 961-5534 Accountant/CP Ann Fukuhara, CPA MBA Phone No.:(808) 961-5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street Address: Suite 102 OtY,sT,z1P Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000.00 $10,000.00 $25,000.00 2.Agency Mission Statement: "To inspire and enable Big- Island Youth to be productive and res onsible citizens through-quality pro ra s in a safe and caring This miss'on has been with Rlq Island Vol Ith by the-B.n-vs ('-jiri-q Ch.ib for over 60 years, a irrently serving over 400 YOUth per day EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa STEM Revolution 3. Program Description: Pahoa STEM Revolution is a youth led, project based, initiative focused_ on the creation of a thoughtful and productive community of youth and adults from the Q[q Island who work together to build and promote youth garden programs that focus on sustainable foods stems and STEM vauth ciarden'nq in thp. Bn s-..& Girls Club nfinued on attached pa 4.Total Budget& Position Count: Total Program Budget: $100,000.00 Total Program Position Count: g Total Agency Budget: $1,358,300.00 Total Agency Position Count: 34 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Atherton Foundation $10,000.00 Walmart Foundation $7,000.00 Office of Juvenile Justice Programs $20,500.00 State of Hawaii, Office of Youth Services $22,500.00 County of Hawaii Community Grants $40,000.00 TOTAL: $100,000.00 Attach additional pages, if needed. G. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Pahoa STEM Revolution" as a highly relevant and timety yczuth led food productions STEM and leadership program-for Bia Island vauth. BGCBI has alrPadV forded marry cc) partnerships fin EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: goys & Girls Club of the Big Island Program Name: Pahoa STEM Revolution 7. Program Objectives Using County Nonprofit Grant Program Funds: Improved Leadership Skills among youth partidipants Improved Comm Lion S kills among youth participants Increased knowled derstandina of the science of_cla_rdenina 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 90% of participating youth take a leadership role in the project 90% of 30 youth 90% of participating youth exhibit an increase in leadership skills as 90% of 30 youth observed by program staff 90% of participants show an increase in communication skills 90% of 30 youth including team building and collaboration as determined by staff observation (Continued of attachment) Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $75,000.00 $26,000. Professional Fees Operations $20,000.00 $5,000.0 Supplies $5,000.00 $4,000.0 Equipment Other:Liability Insurance $2,000.0 other:Administrative support $3,000.0 Other: Other: Other: TOTAL 1 $0.00 1$100,000.0 $40,000. *if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 20142015 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa STEM Revolution io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. if no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether o conflict exists. NAM h: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: None [� if no conflicts exist, check here. igl r i i Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa STEM Revolution ii. Certification of Understanding 1 (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'l, I (we) understand and will comply with the requirement to enroll with Hawaii Com liance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the re uirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, usinq the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:llwww.hawailcounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%) for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of our agency's future funding request and moV result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. gn e-o s 1 t' a Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa STEM Revolution 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 90% of participating youth take a leadership role in the project 90% of 30 yout 90% of participating youth exhibit an increase in leadership skills as 90% of 30 yout observed by program staff 90% of participants show an increase in communication skills 90% of 30 yout including team building and collaboration as determined by staff observation (Continued of attachment) TABLE I1: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $26,000.00 Professional Fees Operations $5,000.00 Supplies $4,000.00 Equipment other: Liability Insurance $2,000.00 Other: Administrative support $3,000.00 Other: Other: Other: TOTAL $40,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of Mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and oaring environment." BOYS&GRU S CLUB OF THE Bia isi.alao AGENCY NAME: Boys & Girls Club of the Big Island PROGRAM NAME: Pahoa STEM Revolution Extended answers continued from application form 3. Program Description (continued): "Pahoa STEM Revolution"is a youth led,project based, initiative focused on the creation of a thoughtful and productive community of youth and adults from the Big Island who work together to build and promote youth garden programs that focus on sustainable food systems and STEM (Science, Technology, Engineering and Math) with primary focus on youth gardening in the Boys & Girls Club and extending to equitable access to healthy foods for the communities around the Boys & Girls Club site. This program will provide an on-going, sustainable leadership program for youth to learn about growing food, business and community service. This program provides a community that produces healthy food,provides youth leadership opportunities, and inspires and supports others to create change in their own communities. The success of the 2013 County of Hawaii STEM Garden initiative has led to the formation of the Pahoa STEM Revolution. This was a highly successful initiative that has expanded to include other youth garden groups including neighboring school gardens, 4-H's Junior Master Gardener Program,the University of Hawaii and other local farms and garden groups. The Junior Master Gardener curriculum was used for learning about gardening and the various Science, Technology, Engineering and Math components of gardening and food production as well as a large variety of age appropriate garden activities and lessons to include all ages of youth in the program. The Pahoa STEM Revolution will involve multiple levels of food production and distribution. Youth will lead projects and working groups including defining goals, designing and revising their garden,preparing,planting, maintaining and harvesting food from the garden, and exploring varying option for growing plants and evaluating environmental inputs and outputs. The Pahoa STEM Revolution participants will also build collaborative partnerships with other youth garden initiatives including school gardens,particularly with Pahoa area schools and other Pahoa community organizations and programs. The youth will also explore options to provide community access to fresh produce. As the Big Island community seeks to become more sustainable in energy and food production, the BGCBI is committed to providing youth opportunities to help build healthier communities. Mission: "To Inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." BOYS&GINS CLUB OF THE SIG M M 6. Explain what plans your agency or program has to increase revenues to support this program (continued): BGCBI views Pahoa STEM Revolution as a highly relevant and timely youth led food production, STEM and leadership program for Big Island youth. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and is seeking community contributions. 8.TABLE I:What are the intended measurable outputs or outcomes that would be achieved with this funding?(Continued): PROGRAM PERFORMANCE MEASURES(i.e.:Numberofclientsserved Applicant Projected workshops or events held,volunteer hours,etc.Describe,be specific.) 90%of participating youth take a leadership role in the 90%of 30 youth project 90%of participating youth exhibit an increase in leadership skills as observed by program staff 90%of 30 youth 90% of participants show an increase in communication skills including team building and collaboration as determined by 90%of 30 youth staff observation 90% of participating youth will show an increased knowledge of the science of gardening including soil and plant growth, 90%of 30 youth as measured by pre and post tests 90% of participants will contribute to the growing, harvesting 90%of 30 youth and distribution of produce to the community 20 community volunteers will contribute an average of 20 400 Volunteer hours hours each to the project contributed 15 Bridge House, Inc. Vocational Skills Building Program C �1 SPY Agency.Name°-sm ge House-, Inc. Program NaMe:"Vwational•Skills Building Prrngrarrro Agency Director: Mark Schuster Phone No.:($08) 322-3305 Cant-act Person: Mark Schuster Phone No,:f§2.8).=- S Mailing Address: Address: P_0. Sox 24$9 Address: Facility,Address: Address: 7 a7-8 Mamlahoa l- j Address: City:ST,rig Kojualoa"Ht` 96725 Email.Addr-e : mark-- bddgehouse. ar-thlink net. Fax-No:: M }.322-d3M, Accountant/CP $renda=Srnkh- Phone No,.-L808 9 -5143 Firm(if applicable): Smart Solutions Mailing Address: Address: P.O. Box1254 Address: Cf,5T VP- Kaifua,Kona, i-H. 95745 KQ ARE RESP 1N51 U TaKEEP MEASOVENWRMATIONAM&EP T PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COLMCIL OF ANY CHANGES Arncyarfraf Request for-Ceun ty,NunprofirGrantPrugremFurrds- $27,G00.09. I. Ptior bear Award-of Couay Noepoit-6mut PnDgram-F sz FY 11-12 FY 12-13 FY 13-14 $15,000.00 $0.00 $25,000.00 2.Agency-MWm5tatamein: The Bridge douse miss QL1 is to assList adults who g-ein recavM front • amen €WA NONPROFIT GRANT APPLICATION FY 2014-2013 rage 3 of 7 Agency Name SnWge Hain, Inc. Frogram Name:'Voca ionaf•SiciiisBuildingProgram" 3.Program Description: All - - �' ' ed t�3 zj new,admits t� House� history_questionnaire. Results of this eveluabon, elan€..with pprsonal—� obselvat gn by staff, then helps IdentiN skills-attitudes and behaviors pre aration. engages in mark intermiews. ,proyidelfq instrudian in (cwt) 4.Total Budget&Position Count: Total Program Budget: 1$69,515.00 Total Program Position Count 1,Z21S 'rotai'Kgency Budget: `$376,002.88 TotaTAgency Position Count: 14 S. Program-fundingSoufEes-(ident#fgsources-4 funding appk4to,tw� FY14-15 Revenue Source Estimate County of Hawaii $27,000.00 Hawag Island.mod•Way Client Program Fees $5,400.01 Contributions $815.00 Mate•, DeMftmeft afAicuW-&Drug Abuse $1,200:00- TOTAL;'$69,51'5.60 Attach addf nal pages,if needed. 6.EM,93in what plans Your agency crr.prog_rarn has to increase revenues to support this gym: y EHIBM A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name;S House,Inc. Program dame:'Vocatiorral-stdusBuiePragraw 7. Program Objectives Using County Nonprofit Grant Program Funds: To prepare our rastrcte lts toa erterfre-er-t-ert#ie work farce._,.Hhot2rfc� 0 result of fallina into tha dniq sub-culture, Most have d' d from >3,-TABLE k- What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES - (ir htumbera cliem�rser�rdwarksfugsareuerrfs°irpid;tWv&mrfrauM etc D-a x &-sp�ecpa). I� tit Projected Results ,Agp =matefy 45.aduk indir �Lia la!effemate).will.pw=pate. 8 °f°.of gr adU�Wit be in the program. employed or attending school or a training program. At six months post-discharge, graduates will have no new arrests, 85% of our graduates will have been incarcerated, and be employed, or attending attain these benchmarks. schoolf#raining program. Attach addkianal pages as necessary. 9.TABLE 3I: PROGRAM EXPENOtTURES FY 13-14 FY 14-15 FY 1435 • AClls ila�y ��I< � ��M r�. ,. Salary and Wages .$Z,7. 8 ..$�- Professional Fees $5,480. $5,500.00 $2,200. Operations '$1,2001 $t200.00 $600.00 - Supplies- $2, 2,4QQ:i 1,2flB: Equipment $2,600.q $2,000.00 $9,000. Other:Payroll Taxes and Fringe Benefits $7,576.4 $7,6'15.00 $2,800. OtheMOccu an $15, I $fib;5@O:aO $6�65t9:: Other:lasuran-ce $9,2004 $1,400.00 ,$700.00 ,. Other: Other: TOTAL *If applicable HMT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 A-gerrcy Nmne &-idge X30 ; .lnc. pro graM Na "Vocational Skills Building Program" lo. ORGANUA'TtON CON FUCT WSCLOS[TRE FORM Please disclose any conflicts or potential conflicts orinterest that any board'member,officer,director, or administrator of your organization may have with the County of Hawaii. Only these listed below need to be disclosed. One form per person with a conflict is needed. if no conflicts exist,one form for the or-gae iz-ation,with.tbe'No-conflic. .exisr-option:checked.needs•fo..be submitted> Pease dupficate. as needed to fully disclose. All disclosure furms must be signed, regardless o whether a can /ict exists. NAME: POSITION: May have a•confliet or•potential-comic#-4i Merest-,including any.farnjhafrelation ,with-any-oft-he following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance The CorporatiorrC uns-e4,the Assistant or a•i3eputyC-orpar~ati1DW Counsel Coact of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as apposed'to benefits accruing in generalto an industry. Po ease-specify+an and-all.mitigatian,measures-to•-avoid}tn•fact or-appearance,any-cGn-f#icts--Gr pGtlentW- conflicts of interest if no conflicts exist,,check here. Signature of Authorized Person(specify title) Date �M-RIT A NONPROFIT GRANT APPl.1CATION iY 20142015 Page 4 of 7 Agency Name--.Bridge House, Inc. Program Dame:"VocatiomfSkift°Building Program" ii.Certification of Understanding I (we)have read and understood all of the eligibility requirements,grant conditions, award procedures; and.recrds,.reporting,,and fiscaf.ac=ntabi it regwr--ements.as.rna Rda d in,A Icte-Z ,. ctltuts.2- 135—2-142.1, Hawaii County Code,relating to Appropriation of Funds to Nonprofit Organizations. i(we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to exammeandirtspect-any ,facility,ecquipment,property,or recar&pertinent-tothe•grarrtt contracts rnr program for which funds were used. i.(ure)_hereby certify that information supplied herein,,including.ali supporting documents„is correct and that I (we)have the authority and ability to fully administer the program(s)pursuant to taw. I(we)understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I•(we).understand.that appticatlons-wifl•not be r-eulewed•by County personnel•r-ece-ncirig-our-C-ounty Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I4we).understand-that ail-documents regt&inga-c-urre-ntsignatw,--m- t*tbe_the-t)I1IGINAl,SIGNED- document. Unsigned documents will be disqualified.Faxed or copied documents will not be accepted as original documents. if awarded a grant,from•the E-ourp-of-Hawaii;J-fWe)'uradars and•an 6 W4cGm*with-tierequirement, to•enroll-witKi 4awai`i._Comphan€e-Exm'ess, andbe-campliant.prior.to-f Fial-payment. To-register,go= to http://vendors.�hawaii.eov,complete the.easy-step-by-st-ep-process,and.pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawa!, I(wet understand and will comply with the reguiremen_t to submit a year-endreoort to the County Coundl-within Gad'ays after June Wof the contractual War for which the grant was awarded.The report,using.the template provided,shall include an explanation of the public benefits derived from the awarding of the grant ifocusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grantfunds,.and.alegof otdec%ndirkg.s=ces.and.amounts inedduringthe-awan .perm w- Failure to submit a timely,complete d ccurate ear-end Mort, tern late will im act the evaluation of your Program's or a en suture funding.Leguests. -EXWBITA NONPROFIT GRANT APPLICATION FY 20142015 page 5 of 7 I('aYmuterst-anitthatfaihrre-trrsubmit-ttie-li rairiportwittrirr6-0-daWof` aw3d'sharWreM*1whm of all grant funds received during the Bran#period(must be refunded„to,Coup )and exclusion from future-grant participation for a minimum of one year or until a written report s submitted#o,and — —accepted-by,the council; i understood t#e is oo s c:sion # er no at to-submft tlefimL pee lnfomiati n, and instructions are•available•at htt www.hawaiicount ov fn-Ron rofit- rant-forms on%or about May 30 of the year the final report is due. As-pan of this-application,you acknowledge-that any,#ids awarded,vAl-ber-e-st-ricted•fcar•the-purposes* stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2015 must be returned to the County of Hawaii with the final report.F€dare-to•r-ety-m these ftm&m%q tog manner wiffim ct the evakjatioapLym o enE - future funding renuest and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) pate EXHIB4T A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency. rme:-B A ige-MoUSP-,-Inc. Program N "ilocational S4cills Sail ng Program" v-COUNGLAWARD WORKSKEEr TABLE{: PROGIRMt v ANCE.MEASUM& Applikant I:OunCH pmt Projected Results � Projected Rew t Approximately 45 adult individuats(maleffemali?y wilt participate 'WA of gradUel in.tom.pry • -e€nopyed.-or or a training pp At six months post-discharge, graduates will have no new arrests: 85% of our are havk---beerr irrcar-ceratad' and--be-employed;or attending attain�ese schoolftrainirq prNram. TAKE-W:- PROGIRWEE"ENMUfES FY 1415 Council Grant Request Award Salary and'Wages �y{yRw ey�,lyy' • ��1 3./MMYL Professional Fees Operations $600.00 Supplies $1,200.00 Equipment $1, 3fl fl0 Other: Payroll Takes and Fringe Benefds $2,800.00 Other. Occupancy $6,650.00 Mari Insurance other: Other: TOTAL $27,000.00 Additional€oundt#WeC 'tve award: EXHIBIT$ NONPROFIT GRANT APPUCATION FY 2014-2015 Page 7 of 7 3. (Program Description,cont'd.), ...the use of basic office egpipment and computers,facil m itates linkages to ether comunity resources, and provides guidance to jobs appropriate for ability_ Transportation necessary to obtaih job applications, attend'interviews and'arrive at then'worksite is provided, as weft: 7. (Program Objectives,cont'd.) ...beliefs/ideals that are found within our community. Employment has clearly been demonstrated to correlate with increased sense of self-esteem, responsible behaviors and the dbiW to'giire back"to one's community. 16 Child and Familiy Service East Hawaii Domestic Abuse Shelter Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter Agency Director: Howard Garval Phone No.:(808) 681-3500 Contact Person: Heidemarie Koop Phone No.:(808) 959-8864 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,ziP Ewa Beach, HI 96706 Facility Address: Address: 1045 Kilauea Ave. Address: Suite A City,ST,ziP Hilo, HI 96720 Email Address: hkoop @cfs-hawaii.org Fax No.: (808) 961-2073 Accountant/CP N & K CPA's, Inc. Phone No.:(808) 524-2255 Firm (if applicable): N & K CPA's Inc. Mailing Address: Address: 1001 Bishop Street Address: Suite #1700 City,ST,ziP Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $8,500.00 $8,750.00 $40,000.00 2. Agency Mission Statement: "Strengthening families and fostering the healthy development of children". EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 3. Program Description: Child & Family Service has been providing emergency shelter for domestic violence victims in the Big Island community for 24 years. The West Hawaii Domestic Abuse Shelter opened in 1988 followed by the East Hawaii Domestic Abuse Shelter in 1995. Continued on attachment. 4.Total Budget& Position Count: Total Program Budget: 1$492,879.00 Total Program Position Count: 8 Total Agency Budget: $4,230,173.00 Total Agency Position Count: 48 5. Program Funding Sources (identify all sources of funding applied to this proeram): FY14-15 Revenue Source Estimate Department of Human Services $340,000.00 County of Hawaii (Pending) $50,000.00 Department of Human Services Emergency Shelter Grant $14,728.00 EBT Food Stamps $10,000.00 Private Foundation $2,000.00 Program Fees $1,000.00 TOTAL: $417,728.00 "Please note funding sources ($417,728) do not meet projected budgeted expenses ($492,879). 6. Explain what plans your agency or program has to increase revenues to support this program: Child & Service (CFS) relies on other funding sources to fund its Fmp-Wencv Shelter Grant (F� and the Victims of Crime Act fmm the PMSeclutnr's Offir:P [.nntb pd nn attachment _ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 7. Program Objectives Using County Nonprofit Grant Program Funds: The East Hawaii Domestic Abuse Shelter's ob'ective is to provide a safe and healthy envimm—ant in Qr-der to_a sist vjjQfim--of_domestic violence to aain self-esteem and_overall self determination. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Percent of clients gain knowledge of community resources available to them. 85% Percent of clients will complete a safety plan for themselves and their children. 90% Percent of clients will complete an assessment upon admission. 80% Percent of clients will complete a service plan. 80% Percent of clients will complete the service plan successfully and move into a 60% non-abusive home environment. Number of bed days. 5500 Attach additional pages as necessary. *See attachment. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $307,107 $313,249 $38,695 Professional Fees $400 $425 $0 Operations $175,692 $179,205 $11,230 Supplies $0 $0 $75 Equipment $0 $0 $0 Other: $0 $0 $0 Other: $0 $0 $0 Other: $0 $0 $0 Other: $0 $0 $0 Other: $0 $0 $0 TOTAL $483,199 $492,879 $50,000 **Please note operations includes leaselrental of space, repair and maintenance, mileage, staff training, client assistance, provisions, and administrative support. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 3.o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:o substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. Ck a -7 Signature of Authorized Person (specify title) Date Executive Vice President&Chief Operating Officer EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Child & Family Service Program Name; East Hawaii Domestic Abuse Shelter il. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certifythat information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http:Zlvendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report; using the template provided, will impact the evaluation o f your rogram's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountV.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact,the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. 711'q f!J Signature of Authorized Person (specify title) Date Executive Vice President& Chief Operating Officer EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Percent of clients gain knowledge of community resources available to them. S5% Percent of clients will complete a safety plan for themselves and their children. 90% Percent of clients will complete an assessment upon admission. 80% Percent of clients will complete a service plan. 80% Percent of clients will complete the service plan successfully and move into a 60% non-abusive home environment. Number of bed days. 5500 TABLE II: FY 14-1S Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $38,695 Professional Fees $0 Operations $11,230 Supplies $75 Equipment $0 Other: $0 Other: $0 Other: $0 Other: $0 Other: $0 TOTAL $50,000 Additional Council directives re ardin award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter 2. Agency Mission Statement: Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of"Strengthening families and fostering the healthy development of children." CFS has 37 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need of support and services. The broad spectrum of services provided by CFS include domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, immigrants, older adults, individuals, and families in need benefit from these services.To broaden the continuum of the services, The Institute for Family Enrichment(TIFFS) became a subsidiary of CFS on August 1, 2012, as a means of strengthening the infrastructure and sustainability for continuing quality programs.TIFFE's programs and staff have blended with those of CFS to provide a mix of evidence-based, outcome driven programs that make the most impact on lives while building an unduplicated continuum of services. CFS's programs are responsive, flexible, family centered and focused on positive outcomes. CFS's value of offering continuing higher quality programs, can be seen by CFS Leadership implementing Risking Connection®, a Trauma-Informed Care Model, the Results Based Accountability(outcomes and impact measuring) program, piloted on the island of Hawaii, evidence-based programs such as the"SAFE" curriculum for the Domestic Violence Intervention program and the TF-CBT(Trauma-Focused Cognitive Behavioral Health)for Trauma victims and their families and an Electronic Record Keeping system to meet the clients in their homes and communities and complete documentation on the spot with mobile electronic devices. Services are provided in homes, schools and in the community as well as at CFS's offices. CFS provides services through 42 sites throughout the State on the islands of Hawaii, Kauai, Maui, Molokai, and Oahu. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the islands and communities it serves. Despite a 40% negative fluctuation of funding for some critical DV programs in the County of Hawaii, CFS has successfully continued domestic violence services on the island of Hawaii by consolidating operations and optimizing resources. As the community continues to face a multitude of difficult problems during the continuing challenging times for many residents of the County of Hawaii, CFS continues to demonstrate our commitment to the community of the Big Island by supporting populations that are faced with complex problems and situations by providing high quality services in a respectful, informational, communicative and hopeful environment. CFS continues to be at the forefront of developing these skills, knowledge, and service models to address the needs of each community they serve. 3. Program Description: CFS's East Hawaii Domestic Abuse Shelter(EHDAS) and West Hawaii Domestic Abuse Shelter (WHDAS)are the only shelters on the Big Island to serve the immediate needs of residents seeking safety due to domestic violence. Funds are requested to provide partial funding for a Domestic Violence Specialist Il (DVSII)at the East Hawaii Domestic Abuse Shelter(Hale `Ohana), that provides support, advocacy, counseling and referrals to residents. As resources allow the DVSII transports and accompanies the residents to provide assistance in obtaining needed services and achieving their service plan goals. Within the first few days of entering the shelter, the domestic violence victim (resident) meets with the DVSII who assesses the resident's needs and assists him/her in developing service plan goals. Safety issues are discussed further and a personalized safety plan is developed to address the resident's and, if applicable, his/her 1 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter children's safety while at the Shelter as well as in the community. Weekly meetings are held to review the progress the resident is making in meeting his/her service plan, whether goals need to be adjusted and/or whether additional steps have to be taken to reach the identified goals. Throughout the resident's stay at the shelter, the DVSIi discusses-how to transition the resident safely back into the community and in addition, develops an aftercare plan to ensure that needed services are in place. Hale `Ohara provides emergency shelter to single women/men and women/men with children who are victims of domestic violence(for a maximum of 90 days). The victims flee from the geographic areas from Volcano to Puna, from Puna to Hilo, and from Hilo to Hamakua. Victims from West Hawaii often access Hale 'Ohana in East Hawaii for safety reasons. There are no restrictions to enter the shelter as long as the circumstances of need are identified within 48 hours as a domestic violence issue. Hale `Ohara operates 24 hours a day/365 days a year including holidays. Staff members monitor and oversee the safety and needs of the residents. The victims are from all walks of life and all socioeconomic backgrounds. The main goal of the program is to provide a safe environment. An experienced DVSII and Shelter Workers help families identify their needs, their barriers and develop plans to overcome these barriers and meet these needs. The EHDAS program offers education on the dynamics of domestic violence, safe residence, emergency food, transportation, referrals as needed, case management, individual counseling, advocacy, outreach services, safety planning, Temporary Restraining Order assistance, support groups, and personal planning to all residents. The DVSII also works with the mothers/fathers and children to build healthy relationships and to strengthen their role as effective parents without using physical and/or verbal violence towards their children. We are committed to raising the consciousness of our society by: educating our families on a violence free lifestyle; promoting family coping and stability; and, providing a place of refuge. In addition, Hale 'Ohara operates a 24-hour domestic violence hotline which provides crisis intervention, information, and referral services. During the last 4 years, the hotline utilization by victims of domestic violence has increased due to the added economic stressors in the communities of the Big Island. The staff provides a safety assessment, makes recommendations and provides referral and resource information for the callers. It is expected that the hotline will continue to see a high volume of calls due to the violence resulting from increased poverty and homelessness. Hale 'Ohana is located in a two-story home on approximately three acres in an agricultural/residential area of East Hawaii and is set off from the roadway. It has three full bathrooms, four bedrooms and has a 20-person capacity. The downstairs of the Shelter facility has a laundry room that is accessed through the covered double car garage entrance. A comfortable-sized living room with an adjoining bathroom is accessible via the laundry room and a short walkway connects into the spacious kitchen area. There is an adjoining dining room and pantry which is also accessible via an entrance off the side of the kitchen that exits into the side yard of the property. The Shelter facility is ADA compliant; it has an ADA ramp which leads to the lower floor where an ADA bedroom is located. 4. Total Budget & Position Count: Total Program Position count: 8.25 (application will only accept whole numbers. Actual count is 8.25). 2 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter 6. Explain what plans your agency or program has to increase revenues to support this program: The shelter charges a modest fee to those clients with an ability to pay. A well run Domestic Abuse Shelter is essential to the integrity of a community. A community must be able to provide for those who need help; providing the necessary resources the community expects for victims of domestic violence. CFS received a generous grant from the Mclnerny.Foundation in Fiscal Year 2013. We don't anticipate having this funding source in Fiscal Year 2014. We humbly ask for your support. 8. Table 1: Continued What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected (i.e. Number of clients served workshops or events held,volunteer hours, etc. Results Describe,be specific) Number of hotline calls 550 Number of single womenlmen served 100 Number of women/men wlchildren served 70 Number of children served 150 Number of requests for information and referral only 200 Number of group session 120 Number of individual session hours provided 3000 Number of meals provided 16,500 Number of transportation hours provided 330 ** Estimates are based on historical data. 12. COUNCIL AWARD WORKSHEET: Table I Continued PROGRAM PERFORMANCE MEASURES Applicant Projected Council Proposed Results Projected Result Number of hotline calls 550 Number of single women/men served 100 Number of women/men wlchildren served 70 Number of children served 150 Number of requests for information and referral only 200 Number of group session 120 Number of individual session hours provided 3000 Number of meals provided 16,500 Number of transportation hours provided 330 3 17 Child and Familiy Service Hale Kahua Pa'a Transitional Apartment Program Agency Name: Child & Family Service Program Name: Hale Kahua Pa'a Transitional Apartment Program Agency Director: Howard Garval Phone No.:(808) 681-3500 Contact Person: Heidemarie Koop Phone No.:(808) 935-2188 Mailing Address: Address: 91-1841 Fort Weaver Road Address: city,sT,zip Ewa Beach, HI 96706 Facility Address: Address: 1 045 Kilauea Ave. Address: Suite A city,sT,zip Hilo, HI 96720 Email Address: hkoop @cfs-hawaii.org Fax No.: (808) 961-2073 Accountant/CP N & K CPA's, Inc. Phone No.:(808) 524-2255 Firm (if applicable): N & K CPA's, Inc. Mailing Address: Address: 1001 Bishop Street Address: Suite #1700 city,sT,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $17,000.00 $13,750.00 $10,000.00 2. Agency Mission Statement: "Strengthening families and fostering the healthy development of children" Continued on attachment_ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Child & Family Service Program Name: Hale Kahua Pa`a Transitional Apartment Program 3. Program Description: Funds are requested to support the operation of the East Hawaii Transitional Housing_Program. The County of Hawaii funding will be used to support a portion of the Domestic Violence Specialist position. Continued on attachment. 4.Total Budget& Position Count: Total Program Budget: $141,800.00 Total Program Position Count: 2 Total Agency Budget: $4,230,173.00 Total Agency Position Count: 148 S. Program Funding Sources (identify all sources of funding applied to this aroeram): FY14-15 Revenue Source Estimate U.S. Department of Justice $100,000.00 County of Hawaii (pending) $45,000.00 Program Fees $1,800.00 TOTAL: $146,800.00 6. Explain what plans your agency or program has to increase revenues to support this program: The Hale Kahua Pa'a Transitional Apartment Program has been primarily funded by the Department of Justice,,.Office, of Violence Against Women (QVW)- Additinnal_fundina notinns have been explored includina charging program fees_ C:ontinu d on attachment_. _ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Child & Family Service Program Name: Hale Kahua Pa`a Transitional Apartment Program 7. Program Objectives Using County Nonprofit Grant Program Funds: The program's is to transition clients and their children to a stable, non-violent independent lifestyle, 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected. Results (Le.:Numberofclients served workshops or events held,volunteer hours,etc.Describe,be specific.) Clients will gain knowledge of additional community resources, such as housing, 80% employment programs and financing. Clients will maintain a Safety Plan for themselves and their children while 90% participating in the program. Clients will maintain a safe and violence free lifestyle while participating in the 80% program. Clients will transition within 24 months to safe non-violent permanent living 80% quarters. *Additional program measures 9. TABLE II: are attached PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $23,014 $56,472 $23,442 Professional Fees $200 $200 $0 Operations $82,949 $83,808 $18,929 Supplies $1,295 1 $1,320 $200 Equipment $0 $0 $0 Other:Client assistance $0 $0 $2,429 Other: $0 $0 $0 Other: $0 $0 $0 Other: $0 $0 $0 Other: $0 $0 $0 TOTAL $107,4581 $141,800 $45,000 **Operations includes leasetrental of equipment, leaseirental of residential If applicable apartments for clients ($10,500), repair and maintenance, and administrative support($4,500). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Child & Family Service Program Name: Hale Kahua Pa`a Transitional Apartment Program 1o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: NIA If no conflicts exist, check here. &�-�- ait� //X-7 N Signature of Authorized Person (specify title) Date Executive Vice President& Chief Operating Officer EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Child & Family Service Program Name: Hale Kahua Pa`a Transitional Apartment Program il. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to Countyl and exclusion from future grant particiRation for a minimum of one year or until a written report is submitted to and accepted bv,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt www.hawaiicount . ov fn-non rofit- rant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused byJune 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) f Date Executive Vice President& Chief Operating Officer EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:Child & Family Service Program Name: Hale Kahua Pa`a Transitional Apartment Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Clients will gain knowledge of additional community resources, such as housing, 80% employment programs and financing. Clients will maintain a Safety Plan for themselves and their children while 90% participating in the program. Clients will maintain a safe and violence free lifestyle while participating in the 80% program. Clients will transition within 24 months to safe non-violent permanent living 80% quarters. *See attachment continued. TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $23,442 Professional fees $0 Operations $18,929 Supplies $200 Equipment $0 Other: Client assistance $2,429 Other: $0 Other: $0 Other: $0 Other: $0 TOTAL $45,000 Additional Council directives_regarding_award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Attachment Applicant: Child & Family Service Program: The Hale Kahua Pa'a Transitional Apartment Program 2. Agency Mission Statement Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of"Strengthening families and fostering the healthy development of children." CFS has 37 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need of support and services. The broad spectrum of services provided by CFS include domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, immigrants, older adults, individuals, and families in need benefit from these services. To broaden the continuum of the services, The Institute for Family Enrichment(TIFFE) became a subsidiary of CFS on August 1, 2012, as a means of strengthening the infrastructure and sustainability for continuing quality programs.TIFFE's programs and staff have blended with those of CFS to provide a mix of evidence-based, outcome driven programs that make the most impact on lives while building an unduplicated continuum of services. CFS's programs are responsive,flexible, family centered and focused on positive outcomes. CFS's value of offering continuing higher quality programs, can be seen by CFS Leadership implementing Risking Connection®, a Trauma-Informed Care Model, the Results Based Accountability(outcomes and impact measuring) program, piloted on the island of Hawaii, evidence-based programs such as the"SAFE" curriculum for the Domestic Violence Intervention program and the TF-CBT(Trauma-Focused Cognitive Behavioral Health)for Trauma victims and their families and an Electronic Record Keeping system to meet the clients in their homes and communities and complete documentation on the spot with mobile electronic devices. Services are provided in homes, schools and in the community as well as at CFS's offices. CFS provides services through 42 sites throughout the State on the islands of Hawaii, Kauai, Maui, Molokai, and Oahu. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the islands and communities it serves. Despite a 40% negative fluctuation of funding for some critical DV programs in the County of Hawaii, CFS has successfully continued domestic violence services on the island of Hawaii by consolidating operations and optimizing resources. As the community continues to face a multitude of difficult problems during the continuing challenging times for many residents of the County of Hawaii, CFS continues to demonstrate our commitment to the community of the Big Island by supporting populations that are faced with complex problems and situations by providing high quality services in a respectful, informational, communicative and hopeful environment. CFS continues to be at the forefront of developing these skills, knowledge, and service models to address the needs of each community they serve. 3. Program Description: Victims of Domestic Violence are faced with many challenges when making the courageous decision to finally leave their batterers. Both women and men are provided services in our Domestic Abuse programs, but it is mostly women who are confronted with financial challenges. When leaving the batterer, the victim embarks upon a path that is as fearful for her and her children as it is to stay with an 1 Attachment Applicant: Child & Family Service Program: The Hale Kahua Pa`a Transitional Apartment Program abusive partner. Many of these women leave with just the clothes that they are wearing, seeking shelter, safety and, most of all, assurances that they made the right choice. Many lack the skills, tools and resources needed to sustain themselves and their children away from their batterer. Many women are faced with the reality of no financial resources, and inability to access resources due to marital assets retained by the abusers which disqualifies them from eligibility for public assistance or subsidized housing. Many victims turn to the East or West Hawaii Domestic Abuse Shelters initially where they can recover and start planning a new life. The Domestic Abuse Shelters provide safety, basic needs, counseling and support for up to 90 days. Securing a safe home for themselves and their children is one of the serious challenges that the victims are facing in the County of Hawaii due to an expensive rental market and the current economic situation. At the end of the 90 days in a Domestic Abuse Shelter, the victim must make a decision not only for herself but for her children as well. Unfortunately that decision is often to return to the abuser she sought refuge from or to become homeless since resources of financial and housing support are limited. The Hale Kahua Pa`a Transitional Apartment Program is a 24 month program that assists victims of domestic violence and their children to rebuild their fives. The program goal is to assist victims and their children to gain stability and independence while transitioning into a violence-free lifestyle. Victims who qualify for services transition from the Domestic Abuse Shelters located in West and East Hawaii and can be placed in one of four apartments/houses. During their 24 month stay, victims and their families receive intensive support services that guide the victims and their families towards independence: to move to a regular home in the community, to secure income and to be able to care for the children. By providing weekly home visits, case management, individual family service plans, and information and referrals to community resources, the program allows both the victims and their children the time to heal, and to live safely. The program is in need of a full-time Domestic Violence Specialist to provide case management, counseling, and support to victims.The Specialist also works with the participants on developing employment and education opportunities. The County of Hawaii funding, matched by other funding, will allow for a full-time Domestic Violence Specialist to be hired. Without a full-time Domestic Violence Specialist, positive outcomes for clients are greatly impacted since the time spent with victims to provide support and resources is reduced. The Domestic Violence Specialist gives the clients weekly opportunities to learn about and to enhance their life skills, including budgeting, money management and job training, nutrition, increasing self- esteem, emotional and physical health. Support groups are also provided by the Domestic Violence Specialist to educate participants on the effects violence can have on victims as well as their children. Groups are beneficial in building a much needed support system for those in the program. In doing so, the Domestic Violence Specialist addresses many of the barriers to establishing income, housing and independence. 4. Total Budget & Position count: Total Program Position Count: 1.5 (application will only accept whole numbers. Actual Count is 1.5). 2 Attachment Applicant: Child & Family Service Program: The Hale Kahua Pa`a Transitional Apartment Program 6. Explain what plans your agency or program has to increase revenues to support this program: Clients are not turned away if they cannot pay. Child & Family Service has a strong history of fundraising and is committed to growing our private donations and grants. We continue to apply for alternative funding sources for our programs and have expanded our efforts to receive funding from private foundation sources dedicated to the belief that everyone deserves a violence free life. Program fees are collected at 30% of the participants income except for food stamps. Depending on the financial situation of the participant,fees may not be collected if the client has to pay debts or does not have income. B. Table 1: Continued What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected (i.e. Number of clients served workshops or events held, volunteer hours, Results etc. Describe, be specific) Number of families provided housing 8 Number of service plans developed 8 Number of provided case management 8 Number of safety plans developed 8 Number provided with aftercare services 8 Number with secured income 4 Number enrolled in education program 3 Number with secure employment 4 Number obtained permanent housing 3 12. COUNCIL AWARD WORKSHEET: Table 1 Continued PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of families provided housing 8 Number of service plans developed 8 Number of provided case management 8 Number of safety plans developed 8 Number provided with aftercare services 8 Number with secured income 4 Number enrolled in education program 3 Number with secure employment 4 Number obtained permanent housing 3 3 18 Child and Familiy Service Hawaii Island Alternatives to Violence Agency Name:Child & Family Service Program Name: Hawaii Island Alternatives to Violence Agency Director: Howard Garval Phone No.:(808) 681-3500 Contact Person: Heidemarie Koop Phone No.:(808) 323-2664 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,sT,Zip Ewa Beach, HI 96706 Facility Address: Address: 81-6587 Mamaloahoa Hwy Address: Pualani Terrace, Building C city,sT,Zip Kealakekua, HI 96750 Email Address: hkoop @cfs-hawaii.org Fax No.: (808) 323-2999 Accountant/CP N & K CPA's, Inc. Phone No.:(808) 524-2255 Firm (if applicable): N & K CPA's, Inc. Mailing Address: Address: 1001 Bishop Street Address: Sulte#1700 city,sT,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $17,000.00 $22,500.00 $40,000.00 2.Agency Mission Statement: "Strengthening families and fostering the healthy development of children". Continued reattachment. EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Child & Family Service Program Name: Hawaii Island Alternatives to Violence 3. Program Description: Funds are requested to support the operation of the Alternatives to Violence_(ATV) Program in the County of Hawaii, more specifically the victim support component of our program. Continued on attachment. 4. Total Budget& Position Count: Total Program Budget: $696,613.00 Total Program Position Count: 12 Total Agency Budget: $4,230,173.00 Total Agency Position Count: 4g S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Judiciary $535,799.00 County of Hawaii (pending) $50,000.00 Hawaii Island United Way $10,000.00 Victims of Crime Act $17,500.00 Program Fees $57,341.00 TOTAL: $670,640.00 *Please note there is a gap between budgeted expenses (696,613) and expected revenue(670,640). 6. Explain what plans your agency or program has to increase revenues to support this program: CFS was a recipient of a Violence Aqaiost Women Act (VAWA)_StQP grant wl isI Mrte-d the delivery of victims services. The funding ran tom July 2013 to NnvemhPr 2013 and na nthPr VAWA Stop rant reins_ from December 2013 to ,hine .10, 9014 Cnotwnijed an attachment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Child & Family Service Program Name: Hawaii Island Alternatives to Violence 7. Program Objectives Using County Nonprofit Grant Program Funds: The Hawaii Island Alternatives to Violence Program's objective is to reduce the impact that domestic violence has on families and the community to break the intergenerational cycle of violence. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (le.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Clients participating in Support Services will be able to identify and implement at 80% least three personal safety skills. Children & adolescents will gain insight into their feelings of anger, sadness, 80% confusion associated with witnessing domestic violence. Clients completing the Domestic Violence Intervention services will significantly 100% increase their knowledge of the effects domestic violence has on children and adolescents. Clients completing Domestic Violence Intervention Services will be able to 85% demonstrate the knowledge, resources, skills and attitudes necessary for maintaining a non-abusive relationship. Attach additional pages as necessary. 9.TABLE II: See attached. PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $469,493.00 $470,523.00 $37,807.00 Professional Fees $400.00 $400.00 $0.00 Operations $292,442.00 $216,690.00 $11,793.00 Supplies $8,935.00 $9,000.00 $400.00 Equipment $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $10.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 TOTAL $683,280.00 $696,613.00 $50,000.00 **Please note operations includes leaseirental of space, repair and maintenance pplicable mileage, staff training, and administrative support. EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Child & Family Service Program Name: Hawaii Island Alternatives to Violence lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure dorms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council 7 ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. Signature of Authorized Person (specify title) Date Executive Vice President and Chief Operating Officer EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Child & Family Service Program Name: Hawaii Island Alternatives to Violence 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time complete, and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County_) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted_by,_the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http;lwww.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in-a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. -2--7 h Signature of Authorized Person (specify title) Date Executive Vice President and Chief Operating Officer EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Child & Family Service Program Name: Hawaii Island Alternatives to Violence 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Clients participating in Support Services will be able to identify and implement at 80% least three personal safety skills. Children &adolescents will gain insight into their feelings of anger, sadness, 80% confusion associated with witnessing domestic violence. Clients completing the Domestic Violence Intervention services will significantly increase their knowledge of the effects domestic violence has on children and 100% adolescents. Clients completing Domestic Violence Intervention Services will be able to 85% demonstrate the knowledge, resources, skills and attitudes necessary for maintaining a non-abusive relationship. See attachment continued TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $37,807.00 Professional Fees $0.00 Operations $11,793.00 Supplies $400.00 Equipment $0.00 Other: $0.00 Other: $0.00 Other: $0.00 Other: $0.00 Other: $0.00 TOTAL $50,000.00 Additional Council directives regarding, award: EXH I BIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Attachment Applicant: Child & Family Service Program: Hawaii Island Alternatives to Violence 1. Mission Statement: Since 1599, Child & Family Service(CFS) has dedicated its efforts to its mission of"Strengthening families and fostering the healthy development of children." CFS has 37 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need of support and services. The broad spectrum of services provided by CFS include domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, immigrants, older adults, individuals, and families in need benefit from these services.To broaden the continuum of the services, The Institute for Family Enrichment(TIFFE) became a subsidiary of CFS on August 1, 2012, as a means of strengthening the infrastructure and sustainability for continuing Quality programs.TIFFE's programs and staff have blended with those of CFS to provide a mix of evidence-based, outcome driven programs that make the most impact on lives while building an unduplicated continuum of services. CFS's programs are responsive, flexible, family centered and focused on positive outcomes. CFS's value of offering continuing higher quality programs, can be seen by CFS Leadership implementing Risking Connection®, a Trauma-Informed Care Model, the Results Based Accountability(outcomes and impact measuring) program, piloted on the island of Hawaii, evidence-based programs such as the"SAFE" curriculum for the Domestic Violence Intervention program and the TF-CBT(Trauma-Focused Cognitive Behavioral Health)for Trauma victims and their families and an Electronic Record Keeping system to meet the clients in their homes and communities and complete documentation on the spot with mobile electronic devices. Services are provided in homes, schools and in the community as well as at CFS's offices. CFS provides services through 42 sites throughout the State on the islands of Hawaii, Kauai, Maui, Molokai, and Oahu. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the islands and communities it serves. Despite a 40% negative fluctuation of funding for some critical DV programs in the County of Hawaii, CFS has successfully continued domestic violence services on the island of Hawaii by consolidating operations and optimizing resources. As the community continues to face a multitude of difficult problems during the continuing challenging times for many residents of the County of Hawaii, CFS continues to demonstrate our commitment to the community of the Big Island by supporting populations that are faced with complex problems and situations by providing high quality services in a respectful, informational, communicative and hopeful environment. CFS continues to be at the forefront of developing these skills, knowledge, and service models to address the needs of each community they serve. 3. Program Description: The victim support component of the Alternatives to Violence Program consists of assisting clients seeking a temporary restraining order(TRO)with their application to the Family Court, providing court advocacy for the client during TRO hearings in the Family Court, and providing case management and facilitation for the survivors of domestic abuse with the Support and Pattern Changing groups. The Domestic Violence Specialist works with the survivors of domestic violence with the goal of ensuring future safety for every member of the family. Safety Plans are developed with each survivor at intake that is tailored to their unique situation. The ATV Program provides an array of Domestic Violence Intervention (DVI)services to men,women and youth. In fiscal year 2014 CFS implemented the Stop Abuse for Everyone (SAFE) curriculum for the men's Domestic Violence Intervention Program. This is a curriculum that incorportates evidence-based 1 Attachment Applicant: Child & Family Service Program: Hawaii Island Alternatives to Violence components including motiviational interviewing, congnitive behavioral therapy and the change theory into our work with domestic violence offenders.The services to male and female batterers include psycho- educational groups that teach skills of non-violence and accountability for their behavior. The services to victims include providing assistance to completing and filing TROs, providing Court Advocacy during TRO hearings in Family Court, individualized safety planning, psycho-educational and pattern changing groups, victim support groups and case management. This proposal seeks funding to support victim services by funding two part-time Domestic Violence Specialist positions, one part-time for East Hawaii and one part-time for West Hawaii. Adult victims of both genders, including same sex partners, are offered support services, group and/or brief individual services. Victim support groups provide education and support to those individuals who are in, or have been in, abusive intimate relationships. The purpose of the group is to provide information about how to be safe, and to develop a safety plan and understanding what has happened. Our primary goal is to educate survivors about the dynamics of domestic violence; assist participants to understand their anger, improve problem solving and social support, identify and remove barriers to safety, and decrease isolation. We assist clients by helping them regain their identity in order to build a foundation which is essential to the success of developing a healthy sense of self-worth. The support group opens up greater awareness of resources and pathways to empower individuals and to teach the necessary tools of self sustainment. The goal is for clients to understand how violence is used as power in intimate relationships and violence causes disrespect and harm that is inconsistent with the values, beliefs and conduct of every culture. 4. Total Budget &Position Count: Total Program Position count: 11.75 (application will only accept whole numbers. Actual count is 11.75). 6. Explain what plans your agency or program has to increase revenues to support this program: CFS is always searching for possible funding sources. As the leader of Domestic Violence services, CFS was recently awarded the contract from the Department of Human Services to provide domestic violence services for families in the child welfare system impacted by domestic violence. These services are provided to victims, child witnesses and offenders. The contract runs from June 15, 2013 to June 30, 2014 and we will be pursuing a one year extension to this contract. Referrals for this DHS contract are made by Child Welfare Services, Voluntary Case Management, and Family Strengthening Services. All Domestic Violence programs work very closely together and collaborate for the best interest of the client. We have received funding from the Hawaii Island United Way for our Youth Services program. We have received monies from the yearly Visitor Industry Charity Walk, in which our employees actively participate. We actively explore national funding sources. CFS does collect a group fee for our Domestic Violence Intervention program of$18 per group session. This fee can be waived and replaced by work exchange for indigent clients as well as those who are unemployed. Despite the financial challenges, CFS has continued to be committed to quality services. CFS has trained and will train all new staff in Trauma-Informed Care, through our 24-hour Risking Connection©training. Over a 3 day period, staff are educated about the impact of trauma, how to work with the clients we serve and how staff needs to have support addressing vicarious trauma, reflecting best practices, and always being mindful of the impact trauma has had on people. Additionally, CFS has interviewed all program staff to begin to implement a Results Based Accountability across the organization, with the goal of more accurately providing grantors, as well as state and federal agencies, a clearer picture of how our programs and 2 Attachment Applicant: Child & Family Service Program: Hawaii Island Alternatives to Violence services have positively impacted the individuals we serve. We have advocated for additional funding from the Third Circuit Court with the result of receiving the additional funding from the 1st Circuit Court which provided CFS in this fiscal year additional funding of$65,000. This still does not bring the funding to its original contract amount. The Probation Officers were advised to refer Batterers also to private providers. Since CFS believes that the new evidence SAFE program will continue the tradition of our known excellent DVI services in the County of Hawaii, we will continue to seek funding to provide these services. CFS is committed to remaining a leader in the domestic violence field, staying focused on implementing evidence-based programs and outcomes that attract additional funding resources. B. Table 1: Continued What are the intended measurable outputs or outcomes that would be achieved with this funding? Program Performance Measures (i.e. Number of clients served workshops or events held, volunteer Applicant Projected Results hours, etc. Describe, be specific. Unduplicated individuals served 2180 Individuals served through TRO assistance 1285 Family Court TRO hearings-Court Advocacy provided to petitioners 1800 Group sessions held for victims of domestic violence 175 Individuals that completed Pattern Changing group 65 Number of men who completed the Domestic Violence Intervention 110 Program Number of women who completed the Domestic Violence 30 Intervention Program ** Projected results are based on historical data. 12.Council Award Worksheet: Continued Program Performance Measures Applicant Council (i.e. Number of clients served workshops or events held, Projected Proposed volunteer hours, etc. Describe, be specific.) Results Projected Result Unduplicated individuals served 2180 Individuals served through TRO assistance 1285 Family Court TRO hearings-Court Advocacy provided to 1800 petitioners Group sessions held for victims of domestic violence 175 Individuals that completed Pattern Changing rou 65 Number of men who completed the Domestic Violence 110 Intervention Program Number of women who completed the Domestic Violence 30 Intervention Program 3 19 Child and Familiy Service The Child and Family Center Program Agency Name: Child & Family Service Program Name:The Child and Family Center Program Agency Director: Howard Garval Phone No.:(808) 681-3500 Contact Person: Heidemarie Koop Phone No.:(808) 935-2188 Mailing Address: Address: 91-1841 Fort Weaver Road Address: MY, sT,zlP Ewa Beach, HI 96706 Facility Address: Address: 1045 Kilauea Ave. Address: Suite A cty,sT,zlP Hilo, HI 96720 Email Address: hkoop @cfs-hawaii.org Fax No.: (808) 961-2073 Accountant/CP N & K CPA's Inc. Phone No.:(808) 852-4225 Firm (if applicable): N & K CPA's, Inc. Mailing Address: Address: 1001 Bishop Street Address: Suite #1700 city,sT,z!P Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND 'COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: "Strengthening families and fostering the healthy development of _ children' See attached. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Child & Family Service Program Name:The Child and Family Center Program 3. Program Description: The Child and Family Center Program offers a Family Resource Center model as a prevention strategy for addressing the many challenges that face individuals and families in Hilo and East Hawaii. Continued on attachment. 4. Total Budget& Position Count: Total Program Budget: $50,000.00 Total Program Position Count: 1 Total Agency Budget: $4,230,173.00 Total Agency Position Count: 48 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii (pending) $50,000.00 See attached. TOTAL: $50,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: See attachment. _ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Child & Family Service Program Name:The Child and Family Center Program 7. Program Objectives Using County Nonprofit Grant Program Funds: The Child and Family Center Program's objective Is to promote healthy communities by bringing toget er services and activities that e ucate and develop skills for building strong relationships with other community resources. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of people accessing the Child and Family Center. 25,000 per yr Number of people receiving information and referrals. 15,000 per yr Number of child renladolescent groups offered (50 x 2 hr sessions). 100 hrs Number of adult groups offered (50 x 2 hr sessions). 100 hrs Number of community outreach (Information booths)(2 per month). 24 per year Provide information to visitors and participants about CFS and 95% other community resources. Attach additional pages as necessary. * Performance measures are continued on attachment. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 1415 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $26,074 $26,074 Professional Fees $10,000 $10,000 Operations $3,175 $3,175 Supplies $2,400 $2,400 Equipment (Lease) $151 $151 Other:Client Assistance $3,200 $3,200 Other:Administrative Support $5,000 $5,000 Other: $0 $0 Other: $0 $0 Other: $0 $0 TOTAL $0.00 $50,000 J $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:Child & Family Service Program Name:The Child and Family Center Program zo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Q] If no conflicts exist, check here. A Signature of Authozized Person {specify Title} Date Executive Vice President and Chief Operating Officer EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:Child & Family Service Program Name:The Child and Family Center Program 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii. I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained puring the award period. Failure to submit o time!y, complete, and accurate ear-end rel2ort, using the tem late 2rovided, will impact the evaluation of your program's or agency's future funding requests. EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:llwww.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. h Signature of Authorized person (specify title) Date Executive Vice President and Chief Operating Officer EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Child & Family Service Program Name:The Child and Family Center Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of people accessing the Child and Family Center. 25,000 per yr Number of people receiving information and referrals. 15,000 per yr Number of children/adolescent groups offered (50 x 2 hr sessions). 100 hr5 Number of adult groups offered (50 x 2 hr sessions). 100 hrs Number of community outreach (Information booths)(2 per month). 24 per year Provide information to visitors and participants about CFS and 95% other community resources. * Performance measures are continued on attachment. TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $26,074 Professional Fees $10,000 Operations $3,175 Supplies $2,400 Equipment (Lease) $151 Other: Client Assistance $3,200 Other: Administrative Support $5,000 Other: $0 Other: $0 Other: $0 TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Attachment Applicant: Child & Family Service Program: Child and Family Center Program 1. Prior Year Award of County Nonprofit Grant Program Funds: Not applicable. This is a new program. 2. Agency Mission Statement Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children." CFS has 37 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need of support and services. The broad spectrum of services provided by CFS include domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, immigrants, older adults, individuals, and families in need benefit from these services. To broaden the continuum of the services, The Institute for Family Enrichment (TIFFS) became a subsidiary of CFS on August 1, 2012, as a means of strengthening the infrastructure and sustainability for continuing quality programs. TIFFE's programs and staff have blended with those of CFS to provide a mix of evidence-based, outcome driven programs that make the most impact on lives while building an unduplicated continuum of services. CFS's programs are responsive, flexible, family centered and focused on positive outcomes. CFS's value of offering continuing higher quality programs, can be seen by CFS Leadership implementing Risking Connection®, a Trauma-Informed Care Model, the Results Based Accountability(outcomes and impact measuring) program, piloted on the island of Hawaii, evidence-based programs such as the "SAFE" curriculum for the Domestic Violence Intervention program and the TF-CBT (Trauma-Focused Cognitive Behavioral Health)for Trauma victims and their families and an Electronic Record Keeping system to meet the clients in their homes and communities and complete documentation on the spot with mobile electronic devices. Services are provided in homes, schools and in the community as we][ as at CFS's offices. CFS provides services through 42 sites throughout the State on the islands of Hawaii, Kauai, Maui, Molokai, and Oahu. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the islands and communities it serves. Child and Family Service has experience with Family Centers on Kauai and with the Neighborhood Place of Wailuku. The concept of combining service offices with the Family 1 Attachment Applicant: Child & Family Service Program: Child and Family Center Program Center framework derives from the CFS Strategic Planning process. One of the strategic goals is to develop "welcoming, informative, and supportive environments" at all CFS sites. Despite decreases in funding of some critical programs in the County of Hawaii, CFS has successfully continued high quality services on the island of Hawaii by consolidating operations and optimizing resources. As the community continues to face a multitude of difficult problems during the continuing challenging times for many residents of the County of Hawaii, CFS continues to demonstrate our commitment to the community of the Big Island by supporting populations that are faced with complex problems and situations by providing high quality services in a respectful, informational, communicative and hopeful environment. CFS continues to be at the forefront of developing these skills, knowledge, and service models to address the needs of each community they serve. 3. Program Description: To improve outcomes for both families and communities, the Child and Family Center will bring together services and activities that educate, develop skills and promote healthy families and healthy communities. The Child and Family Center will promote the well- being of the CFS program participants and the community at-large. One of the primary goals is to build strong relationships with other community resources and services. During the last five years, CFS has grown substantially in East Hawaii. In 2008, Turning Point For Families (TPFF) merged with Child and Family Service and CFS is now offering the community two high-quality one-stop shops for Domestic Violence service, Child Welfare and Youth Services in the County of Hawaii. The Institute for Family Enrichment (TIFFS)joined CFS as a subsidiary in 2012 and became a non-profit organization in 2013 and is scheduled to merge with CFS in fiscal year 2015. This has already strengthened CFS's youth services in the community. In June of 2013, both CFS and TIFFE moved to the new location on 1045A Kilauea Avenue and the new office has become the home of 18 programs of which many offer a variety of components. CFS/TPFFITIFFE is known for working with the whole family offering services to adults, youth and children supporting family members on their path to a better future. The Child and Family Center will rely on the key principles of: • Family support, • East Hawaii resident involvement, • Public/private partnership within the County of Hawaii and State, • Community building and shared accountability for the health of the community. 2 Attachment Applicant: Child & Family Service Program: Child and Family Center Program The vicinity to state and county agencies, the schools and other partners in the community gives the Child and Family Center the opportunity to assist the community in a family- centered, trauma-informed, community-based and welcoming environment with the vision of E Komo mai, Nou Ka Hale- "Come Inside, the House is Yours." CFS already offers comprehensive and integrated services that serve the unique needs and strengths of individuals, families and the surrounding community in Hilo and East Hawaii. The CFS office provides a safe environment for growing, learning and connecting. As a community gathering-place, the center will provide a safe place for play and for confidential conversations. The Child and Family Center will be the one-stop shop of community services designed to improve family life by working collaboratively with all community partners to bring together resources and activities into a service system that is accessible and responsive. East Hawaii residents, families and volunteers will be actively recruited and nurtured for their involvement in all aspects of the Child and Family Center. The Hilo office will be permeated by visual cues, design and delivery of programs and services that affirm the rich ethnic and cultural diversity that characterizes the community of East Hawaii. The Child and Family Center will also sponsor activities and community events to promote healthy families, arts, culture and history of Hawaii. Services will be provided based on trauma-informed principles to ensure that families receive the support and connections they need without intrusion. The Child and Family Center will offer an array of services and activities that are integrated, comprehensive, flexible and responsive to the community's identified needs. Included are: 1. Parent Education (classes, support groups, peer-to-peer) 2. Child Development Activities (play time) 3. Resource and Referral (links to community resources and services) 4. Drop-in Availability(a comfortable place for confidential conversations, neighbor-to- neighbor meetings) 5. Peer-to-Peer Supports (such as support groups, mentoring) 6. Life Skills Advocacy (such as Pattern Changing, Domestic Violence Intervention, Anger Management classes, communication, budgeting, fiscal management, employment readiness skill building). These activities will be interwoven in the comprehensive services of the current 18 programs taking the role of welcoming our families and other visitors in an environment that brings families hope that there is a better future and that the community is here to support them. CFS is committed to strengthening the protective factors of parents, by advocating on all levels through prevention and intervention programs for non-violent living in East Hawaii and by supporting the community in working together to meet their goals as people who respect each other's culture. 3 Attachment Applicant: Child & Family Service Program: Child and Family Center Program Fallowing the model of a family resource center, the Child and Family Center will increase Protective Factors by supporting parents to develop community connections, improve access to resources, reduce social isolation, improve social skills and empower families. On an average, we see 100 clients and receive 300 phone calls a day. This gives CFS the importunity to connect with many people in the community. The new location has allowed CFS already to provide a Child and Family Center culture that allows our clients, guests and visitors to feel comfortable and access resources. Cultural activities and educational groups have been made available to the whole community. CFS sees the opportunity to build on our strengths, expertise and knowledge in Hilo to offer structured family and support group activities for all ages to learn to work with each other as a family and community member. The goals are the following: • Strengthen the resource center • Provide weekly activities for children and adolescents • Provide weekly activities to adults (Parenting groups, Domestic Violence Intervention Support Groups and Survivor Support Groups, other support groups as identified) • Develop a stronger presence in the community to support stronger partnerships in the community • Provide a drop-in center • Provide a welcoming atmosphere at the CFS office in Hilo that emphasizes meeting the needs of so many clients that have experienced trauma and are in need of a supportive and trauma-informed environment • Provide free Notary Services The Child and Family Center in Hilo is open Mondays to Fridays from 8:OOam to 4:30pm except for state holidays. In addition, activities and educational groups will be scheduled during evening and Saturday hours. To support this plan, the county funds will be used to invest in assets such as guest computers, laptops to allow flexible usage of space at the office, tablets that provide educational and informational software products, printing supplies for the brochures, flyers and supplies. To support the activities, facilitators and supplies will be secured through contracting with a culturally diverse faculty that represents the community and the clients CFS serves in East Hawaii. The coordination of this project is overseen by the Director of Hawaii Island Programs with the assistance of a Child and Family Center Coordinator. This Child and Family Center Coordinator will coordinate the activities, organize support groups, oversee the resource center, coordinate with the community and handle other logistics of the project. In addition, the Child and Family Center Coordinator will also be responsible for representing the project during community events and fairs. 4 Attachment Applicant: Child & Family Service Program: Child and Family Center Program The vicinity of the courts gave CFS the idea to provide free Notary services to allow not only our clients but also any other guests or visitors to receive a much needed notarized document and learn about CFS and the resources in the community. Having become a Trauma-Informed organization and focusing on outcomes and the impact of our services on the community, the importance of engaging our clients and community members in a respectful and welcoming atmosphere and treating our clients as respected customers opens the doors for more honest and effective communication that supports the clients in their goals of becoming stronger families. The Director of Hawaii Island Programs is co-facilitating a CFS statewide project that focuses on Welcoming Families in an environment that provides a comfortable surrounding and allows our guests to feel safe and supported. Project coordination and communication and the knowledge of the community is vital for the success of the program. Although the Director of Hawaii Island Programs will oversee the implementation of the Child and Family Center Program, a CFS/TIFFE Big Island Leadership Team will monitor the implementation as a Guiding Coalition. The members of the Guiding Coalition represent all CFS programs offered by the Hilo office which allows the project be nurtured by a variety of aspects, cultures and connections to the community. 5. Program Funding Sources (identify all sources of funding applied to this program): This is a new program and we have no other funding at this time. 6. Explain what plans your agency or program has to increase revenues to support this program: The Child and Family Center Program is a new concept to connect CFS programs internally and reach out to our partner organizations and agencies to improve services in the f=ast Hawaii community and build a partnership with the people we serve to allow them to make the best choices for themselves. This project will be accompanied by data collection to measure outcomes and the impact on the community. Future and additional funding is being pursued through private and other public donations and grants. 5 Attachment Applicant: Child & Family Service Program: Child and Family Center Program 8. Table 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? Program Performance Measures Applicant Projected (i.e. Number of clients served workshops or events held, volunteer hours, Results etc. Describe, be specific.) Provide the" 5 Protective Factor"test to 20% of the visitors and 20% participants. Provide services to those visitors who request it. 90% Demonstrate a 80% attendance rate of the adult participants in the groups. 80% Demonstrate a 80% of attendance rate of the child and adolescent 80% participant in the groups. Increase of Protective Factors of Parents measured by pre-and post- 80% of parent participants tests. in groups Improved Social Support and Self Sufficiency of Parents measured by 80% of parent participants parent's self report and documentation in groups Increased Parent Employment measured by measured by participant's 50% of participants self-report and documentation. Increase of knowledge of available resources in the community after 90% of visitors visiting the Child and Family Center brief surveys that are offered to visitors. 12. Council Award Worksheet: Table I Continued Program Performance Measures Council (i.e. Number of clients served workshops or events held, Applicant Proposed volunteer hours, etc. Describe, be specific.) Projected Results projected Result Provide the" 5 Protective Factor"test to 20% of the visitors 20% and participants. Provide services to those visitors who request it. 90% Demonstrate a 80% attendance rate of the adult participants 80% in the groups. Demonstrate a 80% of attendance rate of the child and 80% adolescent participant in the groups. Increase of Protective Factors of Parents measured by pre- 80% of parent and post-tests. participants in rou s Improved Social Support and Self Sufficiency of Parents 80% of parent measured by parent's self report and documentation. participants in groups Increased Parent Employment measured by measured by 50% of participants participant's self-report and documentation. Increase of knowledge of available resources in the 90% of visitors community after visiting the Child and Family Center brief surveys that are offered to visitors. 6 20 Child and Familiy Service West Hawaii Domestic Abuse Shelter Agency Name: Child & Family Service Program Name:West Hawaii Domestic Abuse Shelter Agency Director: Howard Garval Phone No.:(808) 681-3500 Contact Person: Heidemarie Koop Phone No.:(808) '123-2664 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,zip Ewa Beach, H1 96706 Facility Address: Address: PO Box 1808 Address: city,ST,zip Kealakekua, HI 96750 Email Address: hkoop @cfs-hawaii.org Fax No.: (808) 323-2999 Accountant/CP N & K CPA's, Inc. Phone No.:(808) 524-2255 Firm (if applicable): N & K CPA's, Inc. Mailing Address: Address: 1001 Bishop Street Address: Suite #1700 city,sT,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $8,500.00 $8,750.00 $40,000.00 2.Agency Mission Statement: "Strengthening families and fostering the healthy development of T_ children". Continued on attachment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Child & Family Service Program Name:West Hawaii Domestic Abuse Shelter 3. Program Description: CFS has been providing emergency shelter for domestic violence victims in the Big Island community for 25 years. The West Hawaii Domestic Abuse Shelter WHDAS opened in 1988 followed by the East Hawaii Domestic Abuse Shelter in 1995. Continued on attachment 4.Total Budget& Position Count: Total Program Budget: $536,586.00 Total Program Position Count: 19 Total Agency Budget: $4,230,173.00 Total Agency Position Count: 148 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-1S Revenue Source Estimate Department of Human Services $340,000.00 County of Hawaii (pending) $50,000.00 DHS Emergency Shelter Grant $13,177.00 Hawaii Island United Way $25,000.00 EBT Food Stamps $10,000.00 Private Foundation $3,000.00 Program Fees $650.00 TOTAL: $441,827.00 *Please note funding sources($441,827) do not meet projected budget expenses ($336,586).This is primarily due to the ending of two funding sources (VAWA&Mclnerny)that totaled$84,505. 6. Explain what plans your agency or program has to increase revenues to support this program: Clients are not turned away if they cannot pay.. Child & Family Service _ has a strong history of fundraising and is committed to arowina our private donations and nrant,S._ hnntinued on attachment EXHIBIT A NONPROFIT GRANT APPLICATION PY 2014-2015 Page 2 of 7 Agency Name: Child & Family Service Program Name:West Hawaii Domestic Abuse Shelter 7. Program Objectives Using County Nonprofit Grant Program Funds: The West Hawaii Domestic Abuse Shelter's ob'ective is to provide a safe and v' in order to assist victims of domestic violence to qain self--esteem and overall self-determMation. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results ft.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Percent of clients will gain knowledge of community resources available to them. 80% Percent of clients will complete a safety plan for themselves and their children. 80% Percent of clients will comple an assessment on admission. 80% Percent of clients will complete a service plan. 80% Percent of clients will complete the service plan successfully and move into a 60% non-abusive environment. **See attachment continued Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $353,476 $360,545 $38,893 Professional Fees $200 $200 $0 Operations $170,124 $173,526 $11,032 Supplies $2,270 $2,315 $75 Equipment $0 $0 $0 Other: $0 $0 $0 Other: $0 $0 $0 Other: $0 $0 $0 Other: $0 $0 $0 Other: $0 $0 $0 TOTAL $526,0701 $536,586 $50,000 **Please note operations includes leaselrental of space, repair and maintenan �,PPI'cable mileage,staff training, client assistance provisions, and administrative support. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Child & Family Service Program Name:West Hawaii Domestic Abuse Shelter 1o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forrrrs must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: NIA © If no conflicts exist, check here. r /9-7 IN 1 Signature of Authorized Person (specify title) Date Executive Vice President&Chief Operating Officer EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Child & Family Service Program Name:West Hawaii Domestic Abuse Shelter 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135--2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express,and be compliant prior to final payment. To register,go to htt vendo_rs.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I welunderstand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, using the tem Tote provided, will impact the evaluation of our proarams or agency's uture funding re uests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt www.hawaiicount . ov fn-nonprofit-grant-formsZ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of Your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. P, r Signature of Authorized Person (specify title) Date Executive Vice President&Chief Operating Officer EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:Child & Family Service Program Name:West Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Percent of clients will gain knowledge of community resources available to them. 80% Percent of clients will complete a safety plan for themselves and their children. 80% Percent of clients will comple an assessment on admission. 80% Percent of clients will complete a service plan. 80% Percent of clients will complete the service plan successfully and move into a 60% non-abusive environment. **See attachment continued TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $38,893 Professional Fees $0 Operations $11,032 Supplies $75 Equipment $0 Other: $0 Other: $0 Other: $0 Other: $0 Other: $0 TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter 2. Agency Mission Statement: Since 1899, Child & Family Service(CFS) has dedicated its efforts to its mission of"Strengthening families and fostering the healthy development of children." CFS has 37 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need of support and services. The broad spectrum of services provided by CFS include domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, immigrants, older adults, individuals, and families in need benefit from these services. To broaden the continuum of the services, The Institute for Family Enrichment (TIFFE) became a subsidiary of CFS on August 1, 2012, as a means of strengthening the infrastructure and sustainability for continuing quality programs.TIFFE's programs and staff have blended with those of CFS to provide a mix of evidence-based, outcome driven programs that make the most impact on lives while building an unduplicated continuum of services. CFS's programs are responsive,flexible, family centered and focused on positive outcomes. CFS's value of offering continuing higher quality programs, can be seen by CFS Leadership implementing Risking ConnectionO, a Trauma-Informed Care Model, the Results Based Accountability(outcomes and impact measuring) program, piloted on the island of Hawaii, evidence-based programs such as the"SAFE" curriculum for the Domestic Violence Intervention program and the TF-CBT(Trauma-Focused Cognitive Behavioral Health)for Trauma victims and their families and an Electronic Record Keeping system to meet the clients in their homes and communities and complete documentation on the spot with mobile electronic devices. Services are provided in homes, schools and in the community as well as at CFS's offices. CFS provides services through 42 sites throughout the State on the islands of Hawaii, Kauai, Maui, Molokai, and Oahu. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the islands and communities it serves. Despite a 40% negative fluctuation of funding for some critical DV programs in the County of Hawaii, CFS has successfully continued domestic violence services on the island of Hawaii by consolidating operations and optimizing resources. As the community continues to face a multitude of difficult problems during the continuing challenging times for many residents of the County of Hawaii, CFS continues to demonstrate our commitment to the community of the Big Island by supporting populations that are faced with complex problems and situations by providing high quality services in a respectful, informational, communicative and hopeful environment. CFS continues to be at the forefront of developing these skills, knowledge, and service models to address the needs of each community they serve. 3. Program Description: CFS's West Hawaii Domestic Abuse Shelter(WHDAS) and East Hawaii Domestic Abuse Shelter (EHDAS)are the only shelters on the Big Island to serve the immediate needs of residents seeking safety due to domestic violence. Funds are requested to provide partial funding for a Domestic Violence Specialist 11 (DVS 11) at the WHDAS that provides support, advocacy, counseling and referrals to residents. As resources allow, the DVS I[transports and accompanies the residents to provide assistance in obtaining needed services and achieving their service plan goals.Within the first few days of entering the shelter, the domestic violence victim (resident) meets with the DVS II who assesses the resident's needs and assists him/her in 1 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter developing service plan goals. Safety issues are discussed further and a personalized safety plan is developed to address the resident's and, if applicable, his/her children's safety while at the Shelter as well as in the community. Weekly meetings are held to review the progress the resident is making in meeting his/her service plan, whether goals need to be adjusted and/or whether additional steps have to be taken to reach the identified goals. Throughout the resident's stay at the shelter, the DVS 11 discusses how to transition the resident safely back into the community and in addition, develops an aftercare plan to ensure that needed services are in place. The WHDAS provides emergency shelter to single women/men and women/men with children who are victims of domestic violence (for a maximum of 90 days). The victims flee from the geographic areas of Ka'u to Kona, and from Kona to the greater Koha[a area. Victims from East Hawaii often access the WHDAS in West Hawaii for safety reasons. There are no restrictions to enter the WHDAS as long as the circumstances of need are identified within 48 hours as a domestic violence issue. The shelter operates 24 hours a day/365 days a year including holidays. Staff members monitor and oversee the safety and needs of the residents. The victims are from all walks of life and all socioeconomic backgrounds. The main goal of the program is to provide a safe environment. An experienced DVS 11 and Shelter Workers help families identify their needs, their barriers and develop plans to meet these needs. The WHDAS program offers emergency food, transportation, referrals as needed, case management, individual counseling, advocacy, outreach services, safety planning, Temporary Restraining Order assistance, support groups, and personal planning to all residents. The DVS II also works with the mothers/fathers and children to build healthy relationships and to strengthen their role as effective parents without using physical and/or verbal violence towards their children.We are committed to raising the consciousness of our society by: educating our families on a violence free lifestyle; promoting family coping and stability; and, providing a place of refuge. In addition, the WHDAS operates a 24-hour domestic violence hotline which provides crisis intervention, information, and referral services. During the last 4 years, the hotline utilization by victims of domestic violence has increased due to the added economic stressors in the communities of the Big Island. The staff provides a safety assessment, makes recommendations and provides referral and resource information for the callers. It is expected that the hotline will continue to see a high volume of calls due to the violence resulting from increased poverty and homelessness. The WHDAS provides three bedrooms with a total of 21 beds for families who enter into the program. In addition to the three bedrooms each room has a full bathroom to accommodate the residents who share the bedroom space. One bedroom is specifically geared towards housing single women and women with disabilities. This room is ADA compliant. The facility also has an ADA ramp for easy access in/out of the Shelter. In addition to the client areas, the WHDAS has two offices, a playground and a children's room. These offices are used for intake and exit interviews to provide client confidentiality, case management, and individual counseling. The Shelter also provides the residents with a laundry facility, full kitchen, a 2 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter large living room and a dining area. A large Matson container on the WHDAS site holds furniture items, clothing and household miscellaneous items. These items are donated throughout the year from the West Hawaii community. 4. Total Budget &Position count: Total Program Position Count: 8.75 (application will only accept whole numbers. Actual Count is 8.75). 6. Explain what plans your agency or program has to increase revenues to support this program: The shelter charges a modest fee to those clients with an ability to pay. We continue to apply for alternative funding sources for our programs and have expanded our efforts to receive funding from private foundation sources dedicated to the belief that everyone deserves a violence free life. We have received VOCA funding from the County through the Prosecuting Attorney's Office. CFS received a generous grant from the Mclnerny Foundation and funding from VAWA in Fiscal Year 2013. We don't anticipate having these funding sources in Fiscal Year 2014, which totals approximately $84,505. 8. Table 1: Continued What are the intended measurable outputs or outcomes that would be achieved with this funding? Program Performance Measures Applicant Projected (i.e. Number of clients served workshops or events held, volunteer hours, Results etc. Describe, be specific.) Number of beds days. 5400 Number of hotline calls. 250 Number of single women/men served. 75 Number of womenlmen with children served. 65 Number of children served. 100 Number of requests for information and referral only. 250 Number of group session. 1,500 Number of individual session hours provided. 3,000 Number of meals provided. 18,305 Number of transportation hours provided. 750 ** Estimates are rased on historical data. 3 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter 12. Council Award Worksheet: Table I Continued Program Performance Measures Applicant Council (i.e. Number of clients served workshops or events held, Projected Proposed volunteer hours, etc. Describe, be specific.) Results Projected Result Number of beds days. 5400 Number of hotline calls. 250 Number of single women/men served. 75 Number of women/men with children served. 65 Number of children served. 100 Number of requests for information and referral only. 250 Number of group session. 1,500 Number of individual session hours provided. 3,000 Number of meals provided. 18,305 Number of transportation hours provided. 750 4 21 COVO Foundation 2nd Annual Phillipine Cultural Festival Agency Name:COVO Foundation Program Name:2nd Annual Philippine Cultural Festival Agency Director: Jane Clement Phone No.:(808)7583103 Contact Person: ,lane Clement Phone No.: 808 756-3103 Mailing Address: Address: 77-6517 Kuakini Hwy Address: City,5T,Zip Kailua-Kona, HI 96740 Facility Address: Address: 77_6617 Kuakini Hwy Address: city,sT,zip Kailua-Kona, HI 96740 Email Address: janeclement @hawaii.rr.com Fax No.: Accountant/CP Phone No.: Firm (if applicable): Mailing Address: Address: Address: City,5T,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENTAND COUNCIL MANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 1. prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $5,000.00 2.Agency Mission Statement: 1 . To preserve and promote the culture, language and traditions of _.. _. Filipinos of Visa yan-anQestry in Hawaii;- 9_ To assist in the aducafi nsl and sonio_er.onomir, develonment_of Hipinas of Visayan ancestry in Hawaii _ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2415 Page 1 of 7 Agency Name:COVO Foundation Program Name'2nd Annual Philippine Cultural Festival I Program description: This ro ram is organized by the Kona Visa n Club to promote the Philippines rich cultural heritage. This ear's theme " Festivals of the Philippines" will celebrate and features the many different colorful festivals of the Philippines through son s aim dances and -rewactments. 4.Total Budget&Position Count: Total Program Budget: 1$8,000.00 Total Program Position Count: Total Agency Budget: 1$8,000.00 Total Agency Position Count: 5.Program Funding Sources(identify all sources of funding applied to this RLqgram FY14-15 Revenue Source Estimate County of Hawaii $6,000.00 Business and individual Sponsorships $2,000.00 TOTAL: $8,000.00 Attach additional pages,if needed 6. Explain what plans your agency or program has to increase revenues to support this program: The Foundation will seek community partners in a form qf.s„pQnsorshin tobeln-fund the-program. In-kind donations and sunnnr#-from-other apply for grants ftom different tot indat"ons and government agencies- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:COVO Foundation Program Name'2nd Annual Philippine Cultural Festival 7.Program Objectives Using County Nonprofit Grant Program Funds: Prese eL�,Qr_om_ote & perpetuate the Fil%nino_herilage aflnongoar members & the general public thraugh Gultural & educational -activat a es, 2.. Promote an understanding of our Eilipina heritage and_create aware.ne�s. of_Phiiindne ailture among other ethnic arouns in Hawaii 8.TABLE It What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc describe,be specific.) Cultural Event Completion Attendance 300 people or more Volunteer hours (including dance and production rehearsais0 50 hours or more Other participating Filipino groups 5 or more Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-34 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $3,000. $1,000.00 $1,000.0 Equipment $1,000. $1,000.00 $1,000.0 Other:Venue, Advertising &Promotion (event will be held a@ hotel) $1,000. $3,000.00 $3,000.0 Other:Habi at Baro Exhibit $0.00 $500.00 $0.00 Other:Set Design $1,000.00 $500.00 Other:Entertainment $1,500.00 $500.00 Other: TOTAL $5,004. $8,000.00 $6,000.0 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:COVO Foundation Program Name:2nd Annual Philippine Cultural Festival zo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any beard member,officer, director, or administrator of your organization may have with the County of Hawai`l. Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure Lorms must be signed, regardless of whether a conflict exists. NAME: Jane Clement POSITION: Legislative Assistant to Councilman Dru Kanuha & President of COVO Foundation May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council 91 Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of Interest: Neither Jane Clement nor Councilman Dru Kanuha will sit on the Ad Hoc Committee where they can influence decisions on the awarding ofi this grant. ❑ If no conflicts exist,check here. r,&�LU4j - RrCls I'd 14 S' natu a of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name'COVO Foundation Program Name:2nd Annual Philippine Cultural Festival ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1,Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. i (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawal`i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Comp ance Express,and be compliant prior to final payment. To register,go to hap://vepdors.ehaw_aii.eoy, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the CounV of Hawal`i I we understand and will comply with the re uirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawal`i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time! com lete and accurate ear-end re-o-t, usin the template Provided, will im act the evaluation of our ro ram's or a enc s Luture Lunding.-Mg nests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301h shall result in loss of all Brant funds received durine the grant period (must be refunded to County)and exclusion from futureerant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2015 must be returned to the County of Hawaii with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. i 30 Sig Lure of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:COVO Foundation Program Name:2nd Annual Philippine Cultural Festival 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Cultural Event Completion Attendance 300 people old Volunteer hours (including dance and production rehearsals0 50 hours or Mg Other particlpating Filipino groups 5 or more TABLE 11: FY 1415 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies $1,000.00 Equipment $1,000.00 Other: Venue, Advertising &Promotion (event will be held @ hotel) $3,000.00 Other: Habi at Baro Exhibit $0.00 Other: get Design $500.00 Other: Entertainment $500.00 Other: TOTAL $6,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 22 East Hawaii Cultural Council Aloha Aina: Big Island Memories - Plantation Style Agency Name: East Hawaii Cultural Council Program Name: Aloha Aina: Big Island Memories - Plantation Style Agency Director: Lourdan Kimbrell Phone No.:(808) 961-5791 Contact Person: Lourdan Kimbrell Phone No.:(808)_961-5711 Mailing Address: Address: P.O. Box 1312 Address: city,sT,zip Hilo, HI 96721 Facility Address: Address: 141 Kalakaua St Address: City,sT,zip Hilo HI 96721 Email Address: exec @ehce.org Fax No.: Accountant/CP Amy Paikuli Phone No.:(808) 961-5711 Firm (if applicable): Mailing Address: Address: P.O. Box Address: city,sT,zip Hilo Hl 96721 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENTAND COUNCIL MANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $5,000.00 ti 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: The East Hawaii Cultural Council/Hawaii Museum of Contemporary Art was established in 1967 as a non-profitafts and cultural_ ti-on with a mission to preserve, Dramate and perpetuate the arts and cultures of our diverse c y can the Bia_ Island_ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: East Hawaii Cultural Council Program Name: Aloha Aina: Big Island Memories - Plantation Style 3. Program Description: Folks on the Big Island love to 'talk story'. This second edition of the book Aloha Aina: Big Island Memories puts down on paper the stories of the Plantation era, passed down from one generation_to the next.__ Very f w resour-ces tell the f what i5 was-like was-like to i r n the plantations. In_contrast to our stressful times, it's comforfina t�o kick back-and let thpse memodes 'talk story to us of a simpler time and dar-p- 4.Total Budget&Position Count: Total Program Budget: $29,000.00 Total Program Position Count: 15 Total Agency Budget: $135,000.00 Total Agency Position Count: 60 5. Program Funding Sources(identify all sources of funding applied to this rp ram): FY14-15 Revenue Source Estimate County of Hawaii $5,000.00 Hawaii State foundation on Culture and the Arts $2,000.00 In-kind Nolunteer Hours (200 @ $15.00 per hour) $3,000.00 East Hawaii Cultural Council $3,000.00 Private Donations $1,000.00 Book Sales $15,000.00 TOTAL: $29,000.04 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: Qur first book, Aloha Aina•Big Island,Memories, old almost 1 ,000 c:�ni?s yithaut_.an- inq. After the Initial production_costs_have hp-en met_ the cnntini�i� sales of AlohaAina7 ROCI Jsland Memories Plantation-StWa will generate the revenue to suppInd future printings EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: East Hawaii Cultural Council Program Name: Aloha Aina: Big Island Memories - Plantation Style 7. Program Objectives Using County Nonprofit Grant Program Funds: The Grant funds will be used to coyer the expense of a Graphic Artist, _illustrator, a pQ#ion of_the-advertising and production costs S,TABLE E: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number ofclientsserved workshops orevents held,volunteer hours,etc.Describe,be specific.) Our intent is to interview 50 customers post sale. These customers To provide a way for later will be of different backgrounds and cultures and will be asked if generations to better under- the content was meaningful to their understanding of the plantation stand the traditions and history culture and how or if it's effects are still felt. of their ancestors. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 1415 FY 14-15 Actual' Total Budget Grant Req Salary and Wages $5,000. $2,500.00 $2,000.0 Professional Fees $2,000. $2,000.00 $1,500.0 Operations $500.0 $1,000.00 $300.00 Supplies $2,500. $2,500.00 $200.00 Equipment $500.Oq $2,500.00 $500.00 Other:Advertising $500.00 $500.00 Other: Other: Other: Other: TOTAL $10,50 $11,000.00 $5,000.0 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: East Hawaii Cultural Council Program Name: Aloha Aina: Big Island Memories- Plantation Style lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of iiawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be sinned regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: East Hawaii Cultural Council Program Name: Aloha Aina: Big Island Memories- Plantation Style u. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. 1 (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawaii, 1 (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register,go to http://vendors_.ehawiYi.gov_, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council.within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawal'i grant Binds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete,and accurate year-end report, using the template provided wi!! impact the evaluation of our ro ram's or a enc 's uture undin re nests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2415 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by.the council. I (we) understand there is no provision for further notification to submit the final report.Information and instructions are available at http://www.hawaiicounty.goy/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: East Hawaii Cultural Council Program Name: Aloha Aina: Big Island Memories - Plantation Style 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Our intent is to interview 50 customers post sale. These customers To provide a will be of different backgrounds and cultures and will be asked if generations tea the content was meaningful to their understanding of the plantation 1 stand the tra culture and how or if it's effects are still felt, of their ancesil TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,000.00 Professional Fees $1,500.00 Operations $300.00 Supplies $200.00 Equipment $500.00 Other: Advertising $500.00 Other: Other: Other: Other: TOTAL $5,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 23 Estria Foundation, The Mele Murals Agency Name: The Estria Foundation . Program Name: Mele Murals Agency Director: Erin Yoshioka Phone No.:(610) 698-6640 Contact Person: Estria Miyashiro Phone No.:(808) 638-4005 Mailing Address: Address: 4694-1 Kilauea Avenue Address: City,ST,zip Honolulu, Hl 96816 Facility Address: Address: Address: City,ST,zip Email Address: estria@estria.org Fax No.: (510) 868-0262 Accountant/CP Stephanie Daniels Phone No.:(510) 698-6640 Firm (if applicable): Mailing Address: Address: 4210 Holden Street Address: city,ST,ZIP Oakland, CA 94608 YOU ARE RESPONSIBLE TO KEEP THEABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,970.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2. Agency Mission Statement: Founded in 2010 by world-renowned Hawaiian artist and educator Estria iyashiro,_The Estria Foundation's mission.,_is-AQ create art in Public snares locallV and globally. We collahQrate with communities on �e�ative projects that raise awareness and artinn in moypmPnts EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: The Estria Foundation Program Name: Mele Murals 3. Program Description: Mele Murals is a statewide multi-year, youth cultural arts project creating 20 murals rooted in important stories of place and developed using traditional Hawaiian meditative and cultural practices with youth artists on the maior islands. Murala,are p,la.nned for several Bia Island sites Me seek support for a mural and workshop series,i,ncollaboration with Donke.V Mill-Arts Center and Ke Kula 0 Ehuntinkaimalmno- 4. Total Budget&Position Count: Total Program Budget: 1$259,900.00 Total Program Position Count: 12 Total Agency Budget: 1$771,175.00 Total Agency Position Count: 15 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Ddnkey Mill Arts Center Contribution $2,500.00 Estria Foundation Budget Contribution $2,500.00 Ehunuikaimalino School Contribution-Kona Brewers Festival/Healy Fdn. $4,000.00 TOTAL: $9,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Mole Murals (MM ) entered it's first full year of mining on January qrants 2nd mosancl funds for mrals-on each Wand, Partner sehools nnd organizations,also raise fi inds A new fi indraising staff starts March 1 . EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:The Estria Foundation Program Name: Mele Murals 7. Program Objectives Using County Nonprofit Grant Program Funds: -Create_aBigJsland. mural using traditional practices reflecting Hawaii's history and culture. --Develop arts-interested youth from m our paadners into visual storytellers through traditional lessons and creative skills... building_ -Transform nllhlic srnar:P into rnlar P-S of r Itwal nridP_ 8.TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results ft.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific,) Creation of a Mural Club with students from partner organizations 45 youth Holding a mele and Hawaiian practices workshop with the Club 45 youth Holding visioning/sketching workshop rooted in traditional practices 45 youth Paint the Mele Mural and teaching paint skills. 45 youth Offer a public mural unveiling and dedication with cultural leaders 180 people Sharing the mural and process via OiWi-TV, social media, and film 20,000+ Implement a docent plan for ongoing stewardship of the mural site 15,000+ Attach Additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $65,754 $105,500.0 $3,950.0 Professional Fees $2,954. $27,500.00 $5,470,0 Operations $1,930. $36,500.00 $2,000.0 Supplies $830-00 $34,400.00 $3,550.0 Equipment $0.00 $5,500.00 $500.00 Other:Travel/Housing/Per Diems $700.00 $22,500.00 $3,000.0 Other: Documentation $500.00 $28,000.00 $2,500.0 Other:*2nd column (in the 1st table) presents a full year of MM Other:**3rd column is the request for County grant funds Other:***Full cost for this Mele Mural and process is $29,970 TOTAL 1$72,136 $259,900.0 $20,970. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: The Estria Foundation Program Name: Mele Murals so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a con,Llict exists. NAM E: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. exE&tp 1`/e D I ZC-CTo(7— 'TA IJXA 2-1, 2t a Sig luv of Aut rized Person (specify title) D to EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2415 Page 4 of 7 Agency Name:The Estria Foundation Program Name: Mele Murals 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year--end report using the template provided, will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one ear or until a written re Dort is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htWi./www.hawaiicounty.gov/fn-nongrofit-grant-forms/­on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation of auragency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Da e EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:The Pstria Foundation Program Name: Mele Murals 12. COUNCIL AWARD WORKSHEET FABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Creation of a Mural Club with students from partner organizations 45 youth Holding a mele and Hawaiian practices workshop with the Club 45 youth Holding visioning/sketching workshop rooted in traditional practices 45 youth Paint the Mele Mural and teaching paint skills. 45 youth Offer a public mural unveiling and dedication with cultural leaders 180 people Sharing the mural and process via OiWi-TV, social media, and film 20,000+ Implement a docent plan for ongoing stewardship of the mural site 15,000+ TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $3,950.00 Professional Fees $5,470.00 Operations $2,000.00 Supplies $3,550.00 Equipment $500.00 other: Travel/Housing/Per Diems $3,000.00 Other: Documentation $2,500.00 Other: *2nd column in the 1st table resents a full year of MM Other: **3rd column is the request for County grant funds Other: ***Full cost for this Mele Mural and process is $29,970 TOTAL $20,970.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 24 Family Support Hawaii Next Steps Agency Name: Family Support Hawaii Program Name: Next Steps Agency Director: Ray Wofford Phone No.:(808) 334-4115 Contact Person: Rebecca Transue Phone No.:(808) 334-4160 Mailing Address: Address: 75_127 Lunapuie Road, St. 11 Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 75-127 Lunapule Road, St. 11 Address: City,ST,Zip Kailua-Kona, HI 96740 Email Address: rwofford @fsswh.org Fax No.: (808) 326-4063 Accountant/CP Rozanne Connel, Manager Phone No.:(808) 930-6850 Firm (if applicable): Carbonaro CPA &Associates, Inc. Mailing Address: Address: P. 0. Box 4372 Address: City,sT,Zip Hilo, Hl 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: Family Support Hawaii (FSH) was founded in 1979 as a grassroots organization providing family support in communities throughout es Hawaii. FSH incorporated in 1981 as a private non-profit organization whose mission is o Support Families. and Gommunities in Providing Love and Care for Our Children." EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Family Support Hawaii Program Name: Next Steps 3. Program Description: Since its inception 35 years ago, FSH has been a leader in community development o benefit the families of await. Next steps is a community organization that Is a program of no one agency but is a paftnership of agencies and community members. FSH, in Keeping with Is history and mission, has provided e primary leadership, coordination, and other kinds of support or Next Steps, though it has received no funding to do so. (See attached or continuation) 4.Total Budget& Position count: Total Program Budget: $10,000.00 Total Program Position Count: 10 Total Agency Budget: $3,067,769.00 Total Agency Position Count: 154 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii grant $10,000.00 TOTAL: $10,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: One of our primary goals for FY14-15 is the establishment of the Big Island Marshallese Communities Association as a 501 (C)(3), which will then be able to apply for County, State, and Federal grants and POS contracts. In addition, the Marshallese communites raise funds through food and craft saes, and sports activities registration fees. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Family Support Hawaii Next Steps 3. Program Description: (Continued) Examples of the leadership and support Family Support Hawaii has provided Next Steps in 2013 beyond regular committee participation are: • Writing proposals for funding and writing reports to grantors • Serving as financial umbrella for grant funds received and disbursed • Convening meetings;providing documentation of meetings; keeping,updating and expanding a mailing list; providing reminders of meetings coming up and sending out minutes of meetings held; providing and/or arranging for meeting locations • Serving as communication liaison, forwarding information and requests to and from individuals and organizations Next Steps was organized in December of 2012 in an effort to close cultural gaps between the West Hawaii Marshallese communities and service providers that had faced significant challenges in serving this population. The group began as a collection primarily of service providers whose first goal was to recruit representatives of the Marshallese communities. Fortunately, at the same time, a concurrent organizational effort was being made in the Marshallese community itself with the formation of the Kona Marshallese Constitution Day Committee (KMCDC). The KMCDC was formed by Marshallese leaders in Kona to organize a community-wide observance of the Marshallese Constitution Day (May 1), which is the most important holiday for the Marshallese people, the day the Republic of the Marshall Islands won its independence. The KMCDC saw this celebration as an opportunity to bring together members of the various Marshallese communities of West Hawaii. The Next Steps members saw the event as an opportunity to acquaint many service providers with Marshallese culture and expand their comfort and familiarity with this population and, at the same time, give the Marshallese people an opportunity to meet providers in a non-threatening role. They also saw the celebration as a venue for distribution of outreach and educational materials. The KMCDC joined forces with Next Steps, and together the group planned and carried out a very successful three-day celebration for 2013 that included an opening day ceremony that involved many service providers as well as representatives of County and State government, as well as from the Republic of the Marshall Islands. Next Steps achievements in 2013 included, in addition to the Constitution Day Celebration, three projects at Kahalu'u Public Housing, where the majority of tenants are Marshallese. Projects there include establishment of a community garden, initiation of a tutoring program for children, and of an athletic league for youth. The tutoring program is partnering with the University of the Nations, and the athletic program is partnering with the Hawaii Police Athletic League and Family Support Hawaii's Youth Development Program. (Page 1 of 2) Family Support Hawaii Next Steps 3. Program Description: Next Steps has been providing ongoing support for the KMCDC's evolution into a larger effort, one that seeks to unite the Marshallese people beyond a celebration of Constitution Day. The vision is an organization that will: • Unite Marshallese people across the different communities • Promote the advancement of Marshallese people educationally, economically, and socially; • Serve as a cultural liaison between the Marshallese communities and the larger host community of Hawaii County. The KMCDC is therefore evolving into the Big Island Marshallese Communities Association (BIMCA). Currently Next Steps is assisting to develop by-laws and a charter of incorporation for BIMCA, with a year-end goal of registration as a 501(C)(3) nonprofit organization. Next Steps has formed an Executive Committee of long-term committed members to enable decision-making pending formalization of the Big Island Marshallese Communities Association. The Executive Committee is comprised of I l members; the voting quorum is 7 members, with majority vote prevailing. Members include officers of the original Kona Marshallese Constitution Day Committee: President Embi Jude; Vice-President Tommy Bohanny; Secretary Walter Lanwi; and Treasurer, Clady Bohanny; and also community member Lilo Keju. The Executive Committee also includes service providers: John Powell with the Department of the Attorney General; Jasmin Kiernan with the West Hawaii Community Health Center; Paul Strauss with the Department of Health/Chronic Disease Prevention and Management: Rebecca Transue with Family Support Hawaii; Paul Sopoaga with Hawaii Public Housing; and Cris Lindborg, community member who lived and worked in the Marshall Islands for many years. (Page 2 of 2) Agency Name: Family Support Hawaii Program Name: Next Steps 7. Program Objectives Using County Nonprofit Grant Program Funds: Next Steps seeks $10,000 to fund pertinent projects that arise during the year. Proposals will e reviewed by the Executive Committee of members at regular monthly meetings, and grants will a made with a quorum of , with a majority vote prevat ing. (See attached) S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Next Steps Executive Committee will review min of 20 requests EC to fund min of 10 projects All materials, fees, etc. needed to register BIMCA will be submitted BIMCA established as 501C3 Education materials/activities provided to 2 public housing projects 25% fewer govt interventions Educational outreach about Marshallese provided to host commun. Outreach to min 3 communities Promotion of Marshallese cultural events Min of 3 events Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $0,00 Professional Fees $0.00 $500.00 $500.00 Operations $0,00 $1,000.00 $1,000.00 Supplies $0.00 $3,000.00 $3,000.00 Equipment $0.00 $3,000.00 $3,000.00 Other: Filing Fees, registration fees, etc. $0.00 $500.00 $500.00 other: Publication, copying $0.00 $1,000.00 $1,000.00 Other: Transportation $0.00 $1,000.00 $1,000.00 Other: Other: TOTAL $0,00 $10,000.00 ;10,OOOA! *If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Family Support Hawaii Next Steps 7. Program Objectives Using County Nonprofit Grant Program Funds: Examples of requests that are foreseen include: • Filing and other fees related to establishment of the Big Island Marshallese Communities Association as a 501(Q) 3)nonprofit organization • Fees to provide replacement I-93 Forms for people who have misplaced their copy and therefore are not able to obtain driver's licenses or employment • Equipment and supplies for a tutoring program already in progress through the Education-Outreach Committee of Next Steps, held at Kahalu'u Housing. • Equipment and supplies for a youth athletic program already in progress through the same Next Steps Committee. • Expenses related to community outreach activities such as providing entries into local parades, festivals, and the like. • Expenses related to Marshallese cultural events such as Constitution Day Celebration, a Marshalese Women's Conference, etc. Page 1 of 1 Agency Name: Family Support Hawaii Program Name: Next Steps so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Ray Wofford POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑, If no conflicts exist, check here. xao�- &Wd��L ) — e23 - / 5� Signatu a of Authorize lR son (specify title) Date &,GG��ve EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: f=amily Support Hawaii Program Name: Next Steps 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135--2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http:,//vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report, using the template provided, wil! impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawalicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these finds in a timely manner will impact the evaluation of your agency's future tunding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. SigriatLVe of Authori ed drson (specify title) Date aecu+'o bire4or EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Family Support Hawaii Program Name: Next Steps 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Next Steps Executive Committee will review at least 20 requests EC to fund min. All materials, fees provided to register BIMCA BIMCA establis Education mate rialslactivities provided to 2 public housing projects 25% fewer govt Educational outreach about Marshallese provided to host common. Outreach to mil Promotion of Marshallese cultural events Min. of 3 event. TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees $500.00 Operations $1,000.00 Supplies $3,000.00 Equipment $3,000.00 Other: Filing fees, registration fees, $500.00 Other: Publication, copying $1,000.00 Other: Transportation $1,000.00 Other: Other: TOTAL $10,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 25 Family Support Hawaii Street Outreach - Homeless and At-Risk Youth Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At-Risk Youth Agency Director: Ray Wofford Phone No.: (808) 334-4115 Contact Person: Taren Klingler Phone No.: (808) 334-4159 Mailing Address: Address: 75-127 Lunapule Rd. Ste 11 Address: City,sT,zip Kailua-Kona, HI 96740 Facility Address: Address: 75-127 Lunapule Rd. Ste 11 Address: City,ST,zip Kailua-Kona, Hl 96740 Email Address: rwofford @fsswh.org Fax No.: (808) 3264063 Accountant/CP Rozanne Connell, Manager Phone No.:(808) 930-6850 Firm (if applicable): Carbonaro CPA &Associate, Inc. Mailing Address: Address: P.O. Box 4372 Address: City,sT,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program' Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 0.00 $0.00 $0.00 2. Agency Mission Statement: Family Support Hawaii FSH was founded in 1979 as a grassroots orqanization providing famil)l mm ni i r West whose mission is "to Support FamMes and-Communities in Providincl EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At-Risk Youth 3. Program Description: Since its inception 35 years ago, FSH has been a leader in the field of rovidin,"gality intervention and prevention services in the State of Hawaii. The mission of this program is for every homeless youth in the Kona area to have needed support, assistance and referrals to services. In accordance with--the purpose OfAhe Runaway an-d-Homeless Youth Act, our Street Outreach procirani(SOP) seek s to:-See attached - 4. Total Budget& Position Count: Total Program Budget: $10,000.00 Total Program Position Count: 1 Total Agency Budget: $3,067,769.00 Total Agency Position Count: 54 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Hawaii Youth Services Network $10,000.00 TOTAL: $10,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: -The Street Outreach program is-the_pri�prograim,.that serves at-risk and homeless youth,Qn the Bi __Island The nrincipa_I c1rant e, Hawaii -- Youth Services Network, (we_are a sut�r-antee) was not awa -ded a fedp-ral street outreach grant this year See attached - EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Family Support Hawaii Street Outreach—Homeless and At-Risk Youth 3. Program Description: In accordance with the purpose of the Runaway and Homeless Youth Act, our Street Outreach program (SOP) seeks to: (1) Encourage runaway, homeless and street youth to leave the streets and to make other healthy personal choices regarding where they live and how they behave; and (2) provide street based services to runaway, homeless, and street youth who have been subjected to or are at risk of being subjected to sexual abuse, prostitution, or sexual exploitation. FSH is seeking funding from the County of Hawai'i to continue and to expand the work of the Street Outreach program. The SOP increases the immediate safety of Runaway and Homeless Youth (RHY) through the provision of street outreach and crisis intervention. Through our outreach program we increase the well-being of RHY so that they will be better able to resolve trauma and conflict, have improved communication, and will be less likely to deal with problems in unhealthy ways through access to case management, increased access to health and social services. The program increases the self-sufficiency and independence of RHY through the provision of opportunities for education, employment, community service, and leadership. By increasing their permanent connections with our outreach staff, RHY develop healthy, positive, trusting and sustainable relationships. Hawaii has the third highest rate of homelessness per capita in the United States with an increase of 11% between 2010 and 2011. Of these homeless individuals, 45% are children. In 2012, the homeless population increased by 4.7%, and the number of unsheltered homeless rose by 11%. In fiscal year 2012, 13,980 persons received shelter and/or outreach services from programs for homeless funded by the state's Homeless Programs Branch of Hawaii Public Housing Authority. Minors comprised 3,370 or 25% of those served. The island of Hawaii has the state's highest rates of unemployment (9.8%), confirmed child and dependent adult abuse cases, temporary restraining orders against domestic violence perpetrators, alcohol and drug abuse, suicide rate, and 3 times as many violent deaths among its teens than any other island. Our staff members collaborate with other agencies and homeless service providers to identify and provide services at new outreach sites. Outreach staff maintain a regular presence at all free hungry and homeless feeding locations including The Friendly Place, a drop-in center for homeless adults. We are active members of several committees to assist the homeless, including Mayor Billy Kenoi's special committee to help the homeless in Kona, the Chronic Homelessness Intervention and Rehabilitation Project. We also monitor legislation, law enforcement initiatives, and special events that impact homeless persons (e.g.,the intense security during the Ironman World Championship that drove many youth from their usual hangouts on Alii Drive). We collaborate with the police and business owners in Kona to help keep the streets safe for tourists, businesses and the RHY. The youth themselves, as well as homeless adults, help us to identify new RHY on the streets and link them with our services. In general, RHY are most likely to be found in tourist centers, where they are less noticeable and have more opportunities to obtain resources to meet their survival needs. Street outreach primarily occurs on foot on Alii Drive and other street youth hangouts in Kona. Our youth do not feel comfortable attending feedings with the adult homeless population and often go without food or services because of the negative interaction between the adults and youth. If this application is fully funded, the program will expand outreach to additional sites in more rural areas including Kealakekua. in addition to outreach, there is a great need for a drop in place for our at risk youth. There is nothing in Kona that offers that type of service and it is much needed. In the coming year we intend to find a place for youth to drop in, even if it is just a few hours a week, to receive assistance — food, restroom, computer, clothes closet, independent living skills training, employment referrals and case management - an opportunity to sit and talk with a case worker in a safe and non-hurried environment. Our youth need to feel cared for, to feel special to someone, our program supplies that to the youth on the street in Kona. Family Support Hawaii is focused on investing in the promotion of the positive assets of our at-risk and homeless youth. In the long term, providing support to these individuals is a societal investment in the creation of happy, healthy, productive citizens. Page 1 Family Support Hawaii Street Outreach—Homeless and At-Risk Youth 6. Explain what plans your agency or program has to increase revenues to support this program: The principal grantee, Hawaii Youth Services Network, (we are a sub-grantee) was not awarded a federal street outreach grant this year, they previously had been awarded the grant for 15 consecutive years. The loss of this grant has resulted a shortage of street outreach programs for homeless youth in Hawaii. This situation has caused our agency to think creatively in order to continue to serve these youth. We are supplementing our Street Outreach program with two small grants that serve homeless/at-risk youth, the result is a much downsized program. We used to serve most of West Hawaii but due to the loss of funding for salaries and transportation, we now concentrate our time to the homeless youth on Alii Drive. We are currently seeking new sources of funding from such entities as state, federal, and foundations, as well as solicitations and in-kind donations from businesses and the community. We are also expanding our grant searches to focus on specific groups of RHY such as Foster youth and Gay, Lesbian, Bisexual, Transsexual and Questioning youth. The community has been generous in providing our homeless youth with clothing, shoes and beach towels (used for blankets). We developed a "Pass the Plate" initiative whereby people can donate via the Family Support Hawaii website to our homeless youth program. We use 100% of this funding to purchase healthy non-perishable food/snacks and drinks for our clients. There are many days that youth knock on our office door saying they are hungry and would like some food; these Bass the Plate donations allow us to give the youth food they would not otherwise have or would have to get in an illegal manner. The continued support and donations from the Hawaii community are vital to the continuation of much needed services provided by the Street Outreach program how=ever we need and are seeking grant funding to ensure the depth and breadth of a vital all encompassing program to assist our at risk and homeless youth. Page 1 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At-Risk Youth 7. Program Objectives Using County Nonprofit Grant Program Funds: 'i To heighten the youth's ability to transition off the streets. -) To ensure safety, youth will have access to emergency, transitional and permanent shelter w0th the confinued-support from the outreach Case Worker_ See attarhad - 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc,Describe,be specific.J Street Outreach Case Worker will be accessible to youth for service Case Worker will be on the delivery and case management. street at least 8 hrs per-wk Youth will have access to information concerning emergency, 15% of clients will accept safe transitional and permanent shelter. and stable sheltering Youth will have access to information to promote good health, All clients will get information prevent illness, unplanned pregnancy and victimization. promoting good health Youth will have access to nutrition and hygiene resources. All will get informationlgoods Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $10,000 $40,000.00 $26,000.( Professional Fees Operations $3,000.00 $3,000.0( Supplies $2,000.00 $1,000.0( Equipment Other: Other: Other: Other: Other: TOTAL $10,000 $45,000.00 $30,000.( *If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Family Support Hawaii Street Outreach—Homeless and At-Risk Youth 7. Program Objectives Using County Nonprofit Grant Program Funds: 3) To prevent illness, unplanned pregnancy and to promote good health by the distribution of health care information. 4) To prevent victimization or re-victimization, clients will receive information about prevention of and/or resources concerning sexual abuse and exploitation. 5) To ensure adequate nutrition and hygiene, clients will receive referrals for access to food resources and will be provided hygiene products. Page 1 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At-Risk Youth so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,. regardless of whether a conflict exists. NAM E: Ray Wofford POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ® If no conflicts exist, check here. Signat e of Aut 'zed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At-Risk Youth 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 --2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance_Express, and be compliant prior to final payment. To register, go to htt vendors.ehawaii. ov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 da s after June 30 of the contractual ear for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using_the-template provided, evil! impact the evaluation of our program's or a enc 's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301" shall result in loss of all grant funds received during the-grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written-report is submitted to and accepted bv,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt : / ww.hawaHcounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation ot your-ggency-s future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signatur of Authorize P son (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At-Risk Youth 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Street Outreach Case Worker will be accessible to youth for service Case worker)h delivery and case management. street at leasta Youth will have access to information concerning emergency, 15% of clientsd transitional and permanent shelter. and stable shli Youth will have access to information to promote good health, All clients will Ig prevent illness, unplanned pregnancy and victimization. goqm Youth will have access to nutrition and hygiene resources. All will get infcd TABLE fl: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $26,000.00 Professional Fees Operations $3,000.00 Supplies $1,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $30,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 26 Family Support Hawaii West Hawaii Fatherhood Initiative Agency Name: Family Support Hawaii Program Name:West Hawaii Fatherhood Initiative Agency Director: Ray Woff`ord Phone No.:(808) 334-4115 Contact Person: Taren Klingler Phone No.:(808) 334-4159 Mailing Address: Address: 75-127 Lunapule Rd. Ste. 11 Address: city,sT,zip Kailua-Kona, HI 96740 Facility Address: Address: 75-127 Lunapule Rd. Ste. 11 Address: city,sT,zip Kailua-Kona, Hl 96740 Email Address: rwofford @fsswh.org Fax No.: (808) 326-4063 Accountant/CP Rozanne Connell, Manager Phone No.: (808) 930-6850 Firm (if applicable): Carbonaro CPA &Associate, Inc. Mailing Address: Address: P.O. Box 4372 Address: city,sT,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENTAND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 10.00 $0.00 $0.00 2. Agency Mission Statement: Family Support Hawaii FSH was founded in 1979 as a grassroots omanizaWon providing family u commu i 'es throughout West Hawaii_ FSH incorporated in 1981 as a orivate, non-profit oraanization EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page Z of 7 r Family Support Hawaii West Hawaii Fatherhood Initiative 2. Agency Mission Statement: Family Support Hawaii (FSH) was founded in 1979 as a grassroots organization providing family support in communities throughout West Hawai'i. FSH incorporated in 1981 as a private, non-profit organization whose mission is "to Support Families and Communities in Providing Love and Care for our Children." As are all mission statements, this one is carefully chosen. It embodies two key elements: support for families and support for communities. The first guides us in the direct work of supporting families, which we do through our counseling, home visiting, school based and parent education and support programs. The second is assisting communities to develop the capacity to provide a supportive environment for families and individuals. These are achieved through our community development activities, economic development projects, collaboration building and advocacy work for a better quality of life for the people of Hawaii. Rage 1 Agency Name: Family Support Hawaii Program Name: West Hawaii Fatherhood Initiative 3. Program Description: Since its inception 35 years a o FSH has been a leader in the field of -providing quality intervention and prevention services in the State of Hawaii. Research states involved fathers bring positive benefits to their children such as The mission of this program is for every father on the B'Qlsland to have a productive-and positive Ealations NP with hgs choldren-because FATHERS MATTER. See attached - 4. Total Budget & Position Count: Total Program Budget: $45,000.00 Total Program Position Count: 1 Total Agency Budget: $3,067,769.00 Total Agency Position Count: 54 5. Program Funding Sources (identify ail sources of funding applied to this program): FY14-15 Revenue Source Estimate Hawaii Island United Way $15,000.00 Private Donations $2,000.00 TOTAL: $17,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The FatherhQod program-is impor ta h work of idin .Island_ It is exneded fhat FSH will confinue to,..e . services to EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Family Support Hawaii West Hawaii Fatherhood Initiative 3. Program Description: The West Hawai'i Fatherhood Initiative (WHFI) seeks to strengthen families in our community by _�-errouragiri `aft,d•preparing fathers to play a more active role in nurturing and raising their children. This -`-;program was started because our community has experienced a change in family structure; more and more children are living in fatherless homes. We saw our fathers willingly or unwillingly separate themselves from their families and have seen the negative effects this has had in our schools and community. Our organization has many programs designed to enhance the well being of families yet none were specifically designed to assist fathers in being better parents, instead focusing on strengthening the relationship between the mothers and their children. When we reviewed our programs and saw there was a need to bring the fathers back into focus, we began the Fatherhood program to meet those needs. Fathers embraced the program because by participating in our support groups they could tell their own stories and learn how to be a better parent without being blamed or shamed. The WHFI responds to escalating social concerns regarding "father absence" by providing our fathers with knowledge and skills designed to prepare them to better meet the emotional, psychological, and financial needs of their children. The WHFI also seeks to increase community awareness of the importance of father involvement. In 2012 the State of Hawai'i was ranked the 7th highest in U.S. poverty, due in part to being near the top in both father absent households and out-of-wedlock births. Research has consistently shown a direct correlation between father absence and poverty. WHFI is committed to contributing to a future where every child in Hawai'i County can grow up with an involved father or father figure who is loving, nurturing, and who helps to provide the basic needs of his child. Our support groups_% use the evidence based curriculum "A Nurturing Father" and the accompanying workbook, "A Nurturing Father's Journal and Workbook"to systematically address some of the underlying issues fathers deal with daily. The fathers who attend our classes are encouraged to see fatherhood as an honor as well as a responsibility. We teach fathers to recognize they have the potential to be the strongest advocates for their children and for them to identify and value the importance of their influence in the lives of their children. Our family support program offers a whole new philosophy of service to the community -- one that builds on strengths, focuses on the father within their culture and community, and one that gives the group a role in the planning, design and delivery of implemented services. These father supports are designed to empower the fathers, build communities and help prevent such problems as spousal and child abuse and neglect, increase in public assistance dependence, teen pregnancy, poor scholastic performance and youth dropping out of school. In the last few years, with the sharp decline in the nation's economic condition, Hawaii County has taken a particularly hard strike. Families are feeling the financial burdens of simply keeping a roof over their family's heads and food in their children's stomachs. Dealing with this type of stress can lead to substance abuse, crime, and family violence. Our fatherhood program is essential in our communities in providing fathers with linkages and referrals and, thus, preventing these issues from escalating. By increasing awareness and education about the importance of fathers as male role models, their influence on child development and the stability of their families, we can improve the quality of lives in our community and long term, minimize the need for public services. FSH is seeking funding from the County of Hawai`l to continue and to expand the work of the Fatherhood program. As of today, these groups meet in three of our Hawaii Island communities both rural and urban - being community based is a fundamental principle for FSH even if it means our Father Coach drives hundreds of miles weekly to deliver our services. Fathers are able to access our services without having to travel long distances because we go to them, this alleviates some of the transportation and financial concerns many community residents face. Just this month, we were asked to offer classes in another community however, at this time, our funding does not allow more sites to be added and the fathers cannot travel out of their communities. Page 1 Family Support Hawaii West Hawaii Fatherhood Initiative 3. Program Description (cont.): We have plans to increase the community impact of our program by offering much needed Fatherhood classes at the two high schools in the Kona area. There are teen Mom support classes and day care centers at the high schools but no teen Dad support programs. This collaboration will allow us to expand our reach and partner with the schools to interact with the teen Dads so we may teach these young men how to be good fathers for a lifetime. The Fatherhood meetings are welcoming, culturally sensitive, unpretentious and something that is important to the fathers --we provide a light meal. This program meets the critical needs of the fathers by providing open and honest discussions and also the program provides linkages for health care, mental health needs, career opportunities, and educational and financial assistance. In summary, we have an existing program, fathers who want to attend the classes, an evidence based curriculum, and an experienced Father Coach ready to assist additional community members with fathering issues - we just need additional funding to be able to reach more of those in need. Our father-coach is a trusted and respected person in the community; one that fathers know they can go to in order to receive the help they need--be it referrals, linkages or direct services. If the funding requested is awarded in full, the program would be staffed at one full time position benefitting both existing and additional communities with services to include, but not limited to, facilitating classes in parenting education/family planning, career development, financial counseling and cultural exploration. The Fatherhood program has established its value to the community by being a consistent point of reference to those who need the services. Our hope for the future is that this program will meet the needs of the community and help provide a better quality of life for all. This Family Support Hawaii program is focused on investing in the promotion of the positive assets of fathers to create happy, healthy, productive citizens and communities. Page 2 Family Support Hawaii West Hawaii Fatherhood Initiative G. (Explain what plans your agency or program has to increase revenues to support this program; These areas include a substantial number of families from the Marshall Islands and Mexico who are having severe challenges with finances, health, social service and educational systems. The Fatherhood program was launched 11 years ago, it reaches over 100 men but it needs to be expanded to help more fathers on Hawaii Island. We intend to expand the basic program area and to add additional services by creating an enterprise activity to increase revenue to support the program. An example of how we are going to do this is to offer our Fatherhood program as a fee for service to the Court system to serve as a parenting class for those men who are court ordered to get parent education training. Currently fathers. needing such training as a court-mandated stipulation of release from jail, complete only a web based class. By charging these fathers a fee for our classes we would be able to increase revenues to support the program. Our WHFI classes offer real time support from other men who are also working to become the best parent possible. Family Support Hawaii is planning a father/child activity for every weekend in June. June is Fatherhood month, and to celebrate and educate, we will have fun activities (for a nominal charge) to promote attachment between the fathers and their children. Family Support Hawaii also sponsors a Fatherhood Celebration close to Father's Day every year. At this event we offer food, shave ice, inflatable waterslides, bouncers, climbing walls and photo booths — all at no charge to the fatherhood program participants and a nominal charge to other attendees. Men from the community attend with their children to spend the day playing, and having fun. To ensure this is an annua.#.:event,1we solicit corporate sponsorships as well as private foundation support. These events arelwili be self supporting and will not draw from program funding. Another fundraising event we are planning is to have a breakfast just for Dads and their children. There would be food; a speaker, fun activities for the attendees and recognition of a father in the community. We have many events planned for the coming year, with sponsorships we can make these fun and educational activities happen. The continued support from the Hawai'i Island United Way, potential county, state and federal funding along with donations from the community, will provide funding for much needed services offered by our Fatherhood program. Our mission must live-on: "for every father on the Big Island to have a productive and positive relationship with his children because FATHERS MATTER". Page 1 Agency Name: Family Support Hawaii Program Name: West Hawaii Fatherhood Initiative 7. Program Objectives Using County Nonprofit Grant Program Funds: I . To reduce criminal activities. 2. To increase positive attachment between father nd child. 3. To decrease the child's behavioral disorders- 4- To .increase employment and economic stabMV. 5. To ncrease cooperation between-Ahe mother and fathpz-r-e- child-rearing- 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specifrc.) Fathers completing the program will reduce alcohol/substance use 50% will reduce within 1 year Fathers will have a greater presence in their child's life 75% will increase presence Fathers will reduce their domestic/child abuse behavior 80% will reduce behavior Fathers will retain/share custody of their children 50% will retain/share custody Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $8,996.( $35,000.00 $25,000.( Professional Fees Operations $1,266.{ $5,000.00 $3,000.0( Supplies $447.00 $5,000.00 $2,000.0{ Equipment Other: Other: Other: Other: Other: TOTAL $10,709 $45,000.00 $30,000.{ *if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Family Support Hawaii Program Name: West Hawaii Fatherhood Initiative so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed, if no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Ray WofFord POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council., ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. /o" Signatur f Authoriz erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Family Support Hawaii Program Name: (Nest Hawaii Fatherhood Initiative 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administerthe program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F; Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Haw ai'l Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii,g v, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a ear-end report to the Count Council within 60 days after June 30 of the contractual Vea r for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timel y, complete, and accurate ear-end re ort using the template provided will impact the evaluation of our program's or agency's uture funding re guests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant particil2ation for a minimum of one year or until a written report is submitted to and accented bv,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http Z www.hawaiicounty.goy/fn-nonprofit-grant-formsZ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation of our a enc 's future funding re nest and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature Authorized erVbn (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Family Support Hawaii Program Name: West Hawaii Fatherhood Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Fathers completing the program will reduce alcohol/substance use 50% will reduti Fathers will have a greater presence in their child's life 75% will increil Fathers will reduce their domestic/child abuse behavior 80% will reduU Fathers will retain/share custody of their children 50% will retaigi TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $25,000.00 Professional Fees Operations $3,000.00 Supplies $2,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $30,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 27 Food Basket, The Improving Food Access While Building Farming Infrastructure Agency Name:The Food Basket, Inc. Program Name; Improving Food Access while Building Farming Infrastructure Agency Director: En Young Phone No.:(808) 430-2554 Contact Person: Ryan Wenzel Phone No.:(808) 933-6030 Mailing Address: Address: 40 Holomua Street Address: City,sr,zip Hilo, Hawaii 96720 Facility Address: Address: 40 Holomua Street u Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: En.Young.Foodbaskethi@gmail.com Fax No.: (808) 934-0701 Accountant/CP Chris Nakano Phone No.:(808) 933-6030 Firm (if applicable): Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $48,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $30,000.00 2. Agency Mission Statement: The mission of The Food Basket, Inc is to feed the hungry in Hawaii County while attending to the root causes of this critical social problem. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name.' The Food Basket, Inc. Program Name: Improving Food Access while Building Farming Infrastructure 3. Program Description: The Food Basket proposes to use its distribution and storage capabilities to linK low-income individuals with res locally source produce. y uti lzing Supplemental Nutrition Assistance Program SNAP) dollars, The Food Basket will ameliorate two major challenges in Hawaii County: food equity and self-sufficiency. (Please see attached Program Description) 4. Total Budget & Position Count: Total Program Budget: $183,332.00 Total Program Position Count: g Total Agency Budget: $924,181.00 Total Agency Position Count: 13 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Restricted Food Funds (Various Sources) $15,000.00 Supplemental Nutrition Assistance Program $120,000.00 TOTAL: $135,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Food Basket, Inc. projects this program will be self-sustaining after the initial capitalization. (Please see attached supplemental Program Description) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name;The Food Basket, Inc. Program Name: Improving Food Access while Building Farming Infrastructure 7. Program Objectives Using County Nonprofit Grant Program Funds: The Food Basket intends to responsibly plan as well as begin implementation during FY2015. Objectives include farmer solicitation and client education as well as direct service. (See Attached) 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 2 Farmer Meetings Fifteen (15) farmers recruited Produce Purchased $135,000 locally purchased Produce Provided 100,000 Ibs delivered Clients Served 1000 Individuals served Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $41,032.00 $41,032.( Professional Fees Operations Supplies $1,000.00 $868.00 Equipment Other:Venue costs/Other meeting expenses $1,000.00 $1,000.0( Other:Publication of flyers/promotional materials $500.00 $300.00 Other: Food $135,000.0( Other:Administrative Cost-Accounting/Reporting/Overhead(10%) $4,800.00 $4,800.0( Other: TOTAL $0.00 $183,332.0( $48,000.( *if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name;The Food Basket, Inc. Program Name: Improving Food Access while Building Farming Infrastructure io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: En Young POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. Signature o orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: The Food Basket, Inc. Program Name: Improving Food Access while Building Farming Infrastructure 11. Certification of Understanding (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 1.35–2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. — If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to htt vendors.ehawaii. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i I we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual vLar for which the grant was awarded. The report, using the template provided, small include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, com lete and accurate re ort usin the tem Late rovided will im act the evaluation o our ro ram's or a enc 's uture undin re uests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30t''shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http_://www.hawaiicounty.gov/fn-nonprofit-grant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature o Authorized Person (specify title) pate EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:The Food Basket, Inc. Program Name: Improving Food Access while Building Farming Infrastructure 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 2 Farmer Meetings Fifteen (15) far Produce Purchased $135,000 local] Produce Provided 100,000 lbs de Clients Served 1000 individual TABLE li: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $41,032.00 Professional Fees Operations Supplies $868.00 Equipment other: Venue costs/Other meeting expenses $1,000.00 Other: Publication of flyers/promotional materials $300.00 Other: Food other: Administrative Cost-Accountin /Re ortin /Overhead(10%) $4,800.00 Other: TOTAL $48,000.00 Additional Council directives re ardin award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 I. mprovinL-Farm Access While Building Farming Infrastructure Program Description: The Food Basket, Inc is proposing the following program to alleviate a number of challenges in Hawaii County. These are hunger, food access and equity, nutrition and health, food self-sufficiency, and economic opportunity. Experience and Capacity: The Food Basket will utilize existing resources and maximize their economic impact through its business practices. The fundamental advantage of The Food Basket over any private or other not for profit agency in the State is our ability to leverage and grow existing programs to save costs. An initial capitalization of a similar program, even for another food bank, would be extremely difficult. The Food Basket is unique in the State as it implements the only publicly funded Community Supported Agriculture (CSA) program. This program, the Senior Farmer's Market Nutrition Program (SFMNP) distributes over$200,000 worth of local produce to needy Seniors island-wide at no charge. This is accomplished through a United States Department of Agriculture(USDA)grant received by the State. In our implementation, it is necessary for us to process Federal funds and purchase and procure up to standards set by OMB Circular A-133. Furthermore, we use our refrigerated truck infrastructure to store produce and deliver to satellite sites from Kapa'au in Kohala to Pahala in Ka'u. The proposed program would expand upon the tasks and responsibilities already being accomplished by The Food Basket. Prograin Activities: The Food Basket, Inc. will enroll Supplemental Nutrition Assistance Program (SNAP) eligible clients into a program similar to the SFMNP. SNAP clients,with an emphasis on rural areas,would then be able to get a box of fresh, locally-grown produce delivered to their town through our distribution network. Other individuals will also be solicited for participation in the program. The Food Basket, will expand its existing Farmer network with County funds by holding no less than two (2) educational sessions designed to recruit farmers into the program as suppliers. As the funds are collected up front, farmers can be given a share of their profit to assist in the Iarge up-front costs of starting a crop. Once items have been identified for distribution, The Food Basket will maintain farmer contracts and receive produce once the target season has been reached. After receiving, The Food Basket will pack boxes of produce for distribution and deliver. Funding: The Food Basket intends to serve the entire community of the Big Island with this program. For SNAP individuals,they will be allowed to pay with SNAP funds and will get The Food Basket's wholesale price due to the prohibition by the USDA on marking-up items for SNAP clients. By using this funding source, The Food Basket will turn Federal tax dollars into an economic driver for farming communities. By serving 6,000 individuals, or less than 3% of the population of Hawaii County, The Food Basket will create over$1,000,000 in commerce by buying local. Additionally, because the money is delivered up front, this will stabilize the small farmer by creating cash flow, rather than intermittent income which is regularly experienced among farmers. For non-SNAP residents, The Food Basket intends to charge a delivery fee. This fee will subsidize the costs of delivering to SNAP clients and to Seniors in the produce program, as well as cover The Food Basket's overhead. Food prices will still be comparable or less than major supermarkets as our leverage allows us to take a smaller margin. LO N N Q7 [d N O cn o 1 0 0 0 a � ° N O O d O N U7 t— N O O ti O ca G N O 00 '� O L() L(7 r C O z w x qT w `o 0 Ef3 64 64 64 63 H9 64 64 64 69 69 64 U�, U Q a a N o 0 0 0 0 o Q w '-' W O O O 0 O O w CY N N O N 6 F= t- w U 0 Z J Q Ur O O O O O O o d o 0 0 0 fJ! O ti O O 00p0 Co V � N N La (D M a Q E9 64 E9 63 69 ug, Z o z O N Q ~ a ° a �q `e) UYJ r LO r r r w r ° ° w cn a Q L N w W W � Z o m Z m O N EY. W c O Y Z a � o L U (D E E C C c N to a a) g ca F is l 1 s °c z m c r L`a m z o - - L ur m aa) w 2 .> > z a ti Q O 0 ❑ ❑ LLI 0 u z o a � � O U U_ LL Q H p., co Q 28 Friends of the Children of West Hawaii Enhancement and Basic Needs Agency Name: Friends of the Children of West Hawaii Program Name:Enhancement and Basic Needs Agency Director: Beverly Fraser Phone No.:(808) 331-2425 Contact Person: Beverly Fraser Phone No.: 808)331-2425 Mailing Address: Address: P.O. Box 9041 Address: City,sT,zip Kailua Kona, H196745 Facility Address: Address: 75_5617 Pawai Street Address: Suite 205 CRY,ST,Zip Kailua Kona, HI 96740 Email Address: friendschw @gmail.com Fax No.: (808) 315-8473 Accountant/CP Steve Fassbender-Treasurer Phone No.:(808) 930-7773 Firm (if applicable): Mailing Address: Address: P.O. Box 9041 Address: city,sT,zp Kailua Kona, HI 96745 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000.00 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000.00 $15,000.00 $0.00 2.Agency Mission Statement: The Friends of the Children of West Hawai'i mission statement is to i i'' who have,been the awareness and wy-ention of child abuse EXHIBIT A NONPROFIT GRANT APPLICATION FY 20142015 Page 1 of 7 t Agency Name.. Friends of the Children of West Hawaii Program Name,Enhancement and Basic Needs 3.Program Description: The Enhancement and Basic Needs Program strives to proVi de financial assistaance to het and support the heal in rocess for children who have been victims of abuse or ne lect or who have witnessed violent crime, n i submita quest fQr assistance to be e needs of the nhw1d that jendes- 4.Total Budget&Position Count: Total Program Budget: $53,900.00 Total Program Position Count: 1 Total Agency Budget: 1$90,125.00 Total Agency Position Count: 1 5. Program Funding Sources(identify all sources of funding applied to this progLam FY14-15 Revenue Source Estimate County of Hawaii Non Profit Grant $15,000.00 Private Foundations and Grants $25,000.00 Donations $10,900.00 In Kind Donations $3,000.00 TOTAL-- $53,900.00 Attach additional pages,if needed. 5.Explain what plans your agency or program has to increase revenues to support this program: ilant on tunitles as _ell as 1j)cal fund commi EXHiBIT a NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:mends of the Children of West Hawai'i Program Name'Enhancement and Basic Needs 7.Program Objectives Using County Nonprofit Grant Program Funds: The obiective is to assess and process at least 75 requests -t9 benefit 300 indoydi ial children, it as also to work with 1 1 Drivate tberapaSL%-and-others to identify and address the ntntzd-c; for-- 8.TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results al e.:Number of dienftserwdwodshops or events held,volunteer hours,etc Describe,be specific) Number of Individual Children Serried 300 Number of Needs Requests Funded 750 Attach additional pages as necessary. 9.TABLE ll: FY 13-14 FY 14-15 FY 1415 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $0.00 $0.00 $0.00 Professional Fees $13,288 $13,260.00 $0.00 Operations $0.00 $0.00 $0.00 Supplies $0.00 $0.00 $0.00 Equipment $0.00 $0.00 $0.00 Other:Enhancement and Basic Needs calendar year 2013 $11,551 other:Enhancement and Basic Needs $40,640.00 $15,000. Other: Other: Other. TOTAL $24,83 $53,900.00 $15,000. *If applicable ETCH l B!T A Page 3 of 7 NONPROFIT GRANT APPLICATION FY 2014-2015 Agency Name:Friends of the Children of West Hawai'i Program Name:Enhancement and Basic Needs so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted, Please duplicate as needed to fully disclose. All disclosure orms must be signed re ardless of whether a con list exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: All Board Members are asked to sign a conflict of interest statement, and current b -taws include a conflict of interest poligy. Q] if no conflicts exist,check here. Signature f Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 203.4-2035 Page 4 0€7 Agency Name:Friends of the Children of West Hawai'i Program Name'Enhancement and Basic Needs 11.Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions,award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment,property,or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents,is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawaii, I(we)understand and will comply with the requirement to enroll with Hawaii Compliance Ex ress and be compliant prior to final payment. To register,go to htt vendors.ehawaii. ov complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a rant from the Coug_W of Hawaii I we understand and will comply with the rectuiremen.t to submit a y ear end report to the Counly Council within 60 days after June 30 of the contractual ear for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time com lete and accurate ear-end report. us in a the template Provided, will imp act the evaluation of our programs or a en s ty tore funding re uests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-201S Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received durinst the grant period must be refunded to Count3d and exclusion from future grant partici2atjon for a minimum of one ear or until a written re ort is submitted to and acts ted by,the council. I (we)understand there is no provision for further notification to submit the final report.Information and instructions are available at htto://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of auragency's uture funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. QI -15. 1 'A Signatu I-V of Authorized Person (specify title) Date EXHIBIT A Page 6 of 7 NONPROFIT GRANT APPLICATION FY 2014-2015 Agency Name:Friends of the Children of West Hawaii Program Name:Enhancement and Basic Needs 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of Individual Children Served 300 Number of Needs Requests Funded 750 TABLE II: FY 1415 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $0.00 Professional Fees $0.00 Operations $0.00 Supplies $0.00 Equipment $0.00 Other: Enhancement and Basic Needs calendar year 2013 Other: Enhancement and Basic Needs $15,000.00 Other. Other: Other: TOTAL $15,000.00 Additional Council directiles regarding award: EXH I BIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 29 Friends of the Children's Justice Center of East Hawaii Special Needs & Enhancement, Ctr Support Education / Training Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs & Enhancement, Ctr Support Education / Training Agency Director: Robin Benedict Phone No.: (808) 935-8755 Contact Person: Robin Benedict Phone No.: (808) 935-8755 Mailing Address: Address: P.O. BOX 6908 Address: City,5T,zip Hilo, Hawaii 96720 Facility Address: Address: 1290 Kinoole St. Address: City, ST,zip Hilo, Hawaii 96720 Email Address: fcjceh @hawaii.rr.com Fax No.: (808) 961-7511 Accountant/CP Jennifer L. Gossert Phone No.: (808) 969-3115 Firm (if applicable): Jennifer L. Gossert Mailing Address: Address: 688 Kinoole St, Suite 201 Address: City, ST,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000.00 $20,000.00 $20,000.00 2. Agency Mission Statement: The mission of the Friends of the Children's Justice Center of East Hawaii is to help sexually. h sicall and emotionally abused and lected chddren, and children who are witnesses to crime, in _p;;r_tnPrqh.4D_with the Children's Justice Center of Fast Hawaii, with a n� rima1y goal of enhancing and protecting their physical and psych lr)giral well--being EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs & Enhancement, Ctr Support Education 1 Training 3. Program Description: The Program serves children between the ages of 0-18, who are documented victims of abuse or are witnesses to crime residing in East Hawaii filling requests forspecial needs and enhancements i.e. clothing, hygiene items transportation, school supplies, sports, dance arts, and musoc), The Proqram also provides Center suppaft - romotes child abuse a areness and training sponsorships of_professionals. 4. Total Budget & Position Count: Total Program Budget: $171,700.00 Total Program Position Count: 1 Total Agency Budget: $198,000.00 Total Agency Position Count: 1 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate COH $25,000.00 H I UW $5,000.00 Foundation & Corporate Grants $101,000.00 Charity Walk $4,500.00 Special Events & Fundraisers $28,000.00 Donations $2,000.00 Other $6,100.00 TOTAL: $171,600.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Friends--do not oollect f-ees for any of our services. We are increa m non-event fundraisPr, and -cloJf tournament fundrai(-;Pr EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs & Enhancement, Ctr Support Education 1 Training 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide funds for emergency needs (i.e. clothing, hygiene items, and drama, music art, school supplies; intercession, rr rom, and qraduaflonl_.Cienfier_ _sur)Pcrf (ice s, snacks), child abuse awareness, training snon rso ship=. 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events hefd,volunteer hours,etc.Describe,be speclfie.) Serve Emergency & Enhancement Requests thru the SNR process 1200 Serve child victims of abuse and 1 or neglect, & witnesses to crime 600 Maintain Holiday Gift Program 200 Volunteer Hours 900 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $43,075 $45,000.00 $5,000.0( Professional Fees $9,800.( $9,800.00 Operations $7,250.( $7,400.00 Supplies $3,000.{ $3,200.00 Equipment $300.00 $300.00 Other: Special Needs Requests $97,500 $98,500.00 $20,000.( Other:Center Support $2,510.( $3,000.00 Other: CJC Facility Maintenance $300.00 $300.00 Other: Education & Prevention $3,300.( $3,300.00 Other:Training $750.00 $800.00 TOTAL $167,781$171 ,600.0 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs & Enhancement, Ctr Support Education 1 Training lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure Lorms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as: a substantial probability that action token by oo individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Y Sign Lure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs & Enhancement, Ctr Support Education /Training io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, re ordless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action token by on individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: [� If no conflicts exist, check here. NaS Signature f Aut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs & Enhancement, Ctr Support Education /Training ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http_/Zve_ndors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the CountV Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your progc om's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30«' shall result in loss Of all grant funds received during the Rrant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt : www.hawaiicount ov fn-non prof it rant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of our a enc 's future fundinQ4equest and may result in actions taken to recover these unds. By signing below, you are acknowledging that you have read and understood these requirements. Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs & Enhancement, Ctr Support Education 1 Training 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Serve Emergency & Enhancement Requests thru the SNR process 1200 Serve child victims of abuse and 1 or neglect, & witnesses to crime 600 Maintain Holiday Gift Program 200 Volunteer Hours 900 TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $45,000.00 Professional Fees $9,800.00 Operations $7,400.00 Supplies $3,200.00 Equipment $300.00 Other: Special Needs Requests $98,500.00 Other: Center Support $3,000.00 Other: CJC Facility Maintenance $300.00 Other: Education & Prevention $3,300.00 Other: Training $800.00 TOTAL $171,600.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 30 Friends of the Palace Theater Marketing Capacity Building Agency Name: Friends of the Palace Theater Program Name: Marketing Capacity Building Agency Director: Marta Birchard Phone No.:(808) 934-7010 Contact Person: Marta Birchard Phone No.:(808) 557-8022 Mailing Address: Address: 38 Haili Street Address: City,ST,zip Hilo, HI 96720 Facility Address: Address: Same Address: City,ST,Zip Email Address: marta_b @hotmail.com Fax No.: (808) 969-9912 Accountant/CP Phone No.:(808) 930-6850 Firm (if applicable): Carbonaro CPA & Associates Mailing Address: Address: P.O. Box 4372 Address: City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES A t of Request for County Nonprofit Grant Program Funds: $15,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2. Agency Mission Statement: The mission statement of The Friends of the Palace Theater is to revotalnZe, realore,and Sustain Hilo's historic theater, as,a venue that will educate, entertain,_and inspire our diverse community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Friends of the Palace Theater Program Name: Marketing Capacity Building 3. Program Description: A new, self-manageable web presence is needed to offer online ticket sales, online donations & potentially merchandise sales. The new website would reduce cost of weekly content updates a enerate new ~ inQomg 51ource i r v it etimefor staff o focus ri s�o 4. Total Budget & Position Count: Total Program Budget: $27,300.00 Total Program Position Count: 1 Total Agency Budget: $368,967.00 Total Agency Position Count: 3 5. (Program Funding Sources (identify all sources of funding applied to this ro ram): FY14-15 Revenue Source Estimate Atherton Family Foundation $10,000.00 Palace Theater $2,000.00 Attach additional pages, if needed. TOTAL: $12,000.00 6. Explain what plans your agency or program has to increase revenues to support this program: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Friends of the Palace Theater Program Name: Marketing Capacity Building 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 . To build a consistent unified public-facing identity that comes a .�trona 5ens� of sQ.lf $� 'SSion � Acl _ 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Increased donations from both local and distant supporters +20% Increased revenue from higher ticket sales +20% More available time for staff to focus on programming +15% Higher website visitor metrics as tracked in Google Analytics +25% - 35% Drive local awareness of Palace engagements +20% Attach additional pages as necessary, 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees $12,000 Operations Supplies Equipment Other: Marketing Consultant/logo development, collateral branding $5,000.0 Other:Convert existing site to HTML, e-mail & hosting set-up- $2,500.0 Other: Interim tech staff for solicitation of RFP/review/consult $2,000.0 Other: Part-time tech/staff—web mana2ement/support for one year $5,000.0 Other:Ticket barcode scanner $800.00 TOTAL $0.00 t $0.00 $27,300. if applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Friends of the Palace Theater Program Name: Marketing Capacity Building io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed ,regardless o whether a con lict exists. TAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: if no conflicts exist, check here. Signature of Au horized Person (specify title) ate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Friends of the Palace Theater Program Name: Marketing Capacity Building ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawaii County Code, relating to Appropriation of Funds to nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. if awarded a grant from the,County_ of Hawaii, I (we) understand and will comply with the reouirement to submit a ear-end report to the County Council within 50 days after June 30 of the contractual vear for which the grant was awarded, The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and occurate ear-end report usinq the template yrovided, will impact the evaluation of sour program's or ogencv's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to County) and exclusion from future grant participation for a minimum of one_year,or until. a written report is submitted to, and accepted by.the council. I (titre) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonr)rofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a time!y manner will impact the evaluation of auragency's future funding request and may result in actions taken to recover thesefunds. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Aut orized Person (specify title) ate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Friends of the Palace Theater Program Name: Marketing Capacity Building �z. COUNCIL AWARD WORKSHEET TABLE I: - PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increased donations from both local and distant supporters +20% Increased revenue from higher ticket sales +20% More available time for staff to focus on programming +15% Higher website visitor metrics as tracked in Google Analytics +25% - 35% Drive local awareness of Palace engagements +20% TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees $12,000.00 Operations Supplies Equipment Other: Marketing Consultant/logo development, collateral branding $5,000`00 Other: Convert existing site to HTML, e-mail & hostin set-up $2,500.00 Other: Interim tech staff for solicitation of RFP/review/consult $2,000.00 Other: Part-time tech/staff--web management/support for one year $5,000.00 Other: Ticket barcode scanner $800.00 TOTAL $27,300.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 31 Full Life Adult Day Health Transportation Support Agency Name: Full Life Program Name:Adult Day Health Transportation Support Agency Director: Stone Wolfsong Phone No.:(808) 322-9333 Contact Person: Stone Wolfsong Phone No.:(808) 322-9333 Mailing Address: Address: 75-5995 Kuakini Highway Address: Suite 432 City,ST,zip Kallua-Kona, HI 96740 Facility Address: Address: 79-7460 Mamalahoa Highwa Address: Suite 112 and 114 City,sT,zip Kealakekua, HI 96750 Email Address: admindir @fulllifehawail.org Fax No.: (808) 322-9334 Accountant/CP Ann Fukahara, CPA Phone No.:(808) 961-5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: Suite 102 City,ST,zip Hilo, Hl 9720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $24,600.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: Full Life assists in the empowerment of individuals.with developmental _of life. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Full Life Program Name:Adult Day Health Transportation Support I Program Description: Located in Mango Court in Kainaliu, the Learning Center is a daytime program for adults with developmental disabilities where social skills, recreational pursuits, and independent living skills are encouraged, „developed and shared. Individuals who reflect various levels of „ intellectual, social and physical abilities are given the environment,. 4.Total Budget& Position Count: Total Program Budget: $166,104.00 Total Program Position Count: $15.00 Total Agency Budget: $2,902,887.00 Total Agency Position Count: 1$110.00 5. Program Funding Sources(identify all sources of funding applied to this p r oeram): FY14-15 Revenue Source Estimate State of Hawaii Developmental Disabilities Division/Medicaid Waiver $141,485.00 TOTAL: 1 $141,485.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Increasono enrollment! Full Life recently doubled The pro aram space so enrollment could increase. State funds do not cover the costs of transporting individuals the Iong dostances required On Kona ML incrPaged enrollment transpIndatim costs would be mRfiaMpri EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Full Life Program Name:Adult Day Health Transportation Support 7. Program Objectives Using County Nonprofit Grant Program Funds: Our obiective is to maintain a quality adult day health program in Kona r supparl transoartation of those individuals from nodh of Palisades and as farsnift as Honaunau to and from, the cen S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number ofcilentsserved workshops or events held,volunteer hours,etc.Describe,be specific.) Up to 22 individuals will be transported to and from the Learning Increase enrollment and Center daily. maintain the adult day health program. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* "total Budget Grant Req Salary and Wages $96,57 $102,$36.0 $16,723. Professional Fees $1,240. $60.00 Operations $327.0 $163.00 Supplies $5,8$3. $7,740.00 Equipment Other:Transportation (fuel) $19,352 $13,890.00 $8,000.0 other: Rent, Utilities $16,455 $28,292.00 Other: Other: Other: TOTAL $139,83 $152,981.0 $24,723. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Full Life Program Name:Adult Day Health Transportation Support so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council [❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature of Authorized Perso specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Full Life Program Name:Adult Day Health Transportation Support zs. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility,.equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the programs) pursuant to law. 1 (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Ex ress and be compliant prior to final payment. To register, go to htt vendors.ehawaii. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, wi11 q irn�, act.the.evaluation of your program's or a ency s future fundin,_.g requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301h shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation-o}your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. VO�Ar- '?'(7W&Vr4 Ab� Signature of Authorized son (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Full Life Program Name:Adult Day Health Transportation Support 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Up to 22 individuals will be transported to and from the Learning Increase enrolh Center daily. maintain the ac program. TABLE !r: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $16,723.00 Professional Fees Operations Supplies Equipment Other: Transportation (fuel) $8,000.00 Other: Rent, Utilities Other: Other: Other: TOTAL $24,723.00 Additional Council directives regardina award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 32 Goodwill Industries of hawaii, Inc. Job Connections Agency Name: Goodwill Industries of Hawaii Program Name:Job Connections Agency Director: Laura Smith - President & CEO Phone No.:(808) 836-0313 Contact Person: Katherine Keir-VP Mission Adv. Phone No.:(808) 836-0313 Mailing Address: Address: 2610 Kilihau St Address: City,ST,zip Honolulu, HI 96819 Facility Address: Address: 200 Kanoelehua ave Address: Suite 102 City,sT,zip Hilo, HI 96720 Email Address: KKeir @higoodwill.org Fax No.: (808) 833-4943 Accountant/CP N&K CPAs, Inc. Phone No.:(808) 524-2255 Firm (if applicable): Mailing Address: Address: 1001 Bishop St. Address: Suite 1700 city,sT,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $10,000.00 $0.00 $20,000.00 2. Agency Mission Statement: The mission of Goodwill Industries of Hawaii, Inc. (01H) is to "help people with employment barriers to reach their full potential and C has served Hawaii as a reputable non-profit nrgan,1zation for 55 Tears;n.rnvidieducational- wnrkforceslevelcn,mP it, and social EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Goodwill Industries of Hawaii Program Name:Job Connections 3. Program Description: GIH's Job Connections Program provides employment services to low-income and re-integrating individuals. GIH has a strong relationship with HCCC's Hale Nani, serving over 140 referrals over the past two __years. We conduct a thorough intake & assessment, provide Job Readiness Traininq, perform job development, place individuals into.__ lobs, and provide job retentjon servjces for E months after plat am-ent, 4.Total Budget& Position Count: Total Program Budget: $30,000.00 Total Program Position Count: Total Agency Budget: $3,000,000.00 Total Agency Position Count: 176 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii $30,000.00 Office of Hawaiian Affairs $50,000.00 TOTAL: $$0,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: ,The requested funding E I r in ' resources (, icjljties, ad m anr�Mnt from OHA that provides EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Goodwill Industries of Hawaii Program Name:Job Connections 7. Program Objectives Using County Nonprofit Grant Program Funds: The overall goal of this program is to continue to provide employment services -i in individuals, A minimum of 0 .wall comolete training of these, 0 ced 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Intake/Assessment 50 Job Readiness Training 45 Job Placement 36 90-Day Job Retention 29 6-Month Job Retention (as of grant end) 22 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $30,000.00 $30,000. Professional Fees Operations Supplies Equipment Other:Tuition Support $20,000 Other: Other: Other: Other: TOTAL 1$20,000 $30,000.00 $30,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Goodwill Industries of Hawaii Program Name:Job Connections lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAM E: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Goodwill Industries of Hawaii Program Name:Job Connections 11. Certification of Understanding (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 T 2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawa_i`i Compliance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation of our ro ram's or agency's uture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30"' shall result in loss of all grant funds received during the Brant period-(must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. 1 (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http1/www.hawaiicounty.goy/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except fora maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of Your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Goodwill Industries of Hawaii Program Name:Job Connections 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Intake/Assessment 50 Job Readiness Training 45 Job Placement 36 90-Day Job Retention 29 6-Month Job Retention (as of grant end) 22 TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $30,000.00 Professional Fees Operations Supplies Equipment Other: Tuition Support Other: Other: Other: Other: TOTAL $30,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 33 Goodwill Industries of hawaii, Inc. Work Experience Prorgram Agency Name: Goodwill Industries of Hawaii, Inc. Program Name:Work Experience Program Agency Director: Laura Smith Phone No.:(808) 836-0313 Contact Person: Tracy Young Phone No.:(808) 961--0307 Mailing Address: Address: 500 Kalanianaole Avenue Address: Suite 3 City,5T,Zip Hilo, HI 96720 Facility Address: Address: 500 Kalanianaole Avenue Address: Suite 3 City,ST,zip Hilo, HI Email Address: Fax No.: (808) 969-3861 Accountant/CP N&K CPAs, Inc. Phone No.:(808) 524-2255 Firm (if applicable): Mailing Address: Address: 1001 Bishop Street Address: Suite 1700 City,5T,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $10,000.00 $27,500.00 $20,000.00 2.Agency Mission Statement: The mission of Goodwill Industries of Hawaii Inc. GIH is to "help -people with employment barriers to reach heir full potential and become self-sufficient." A nationally accredited human service oroyir„ier,_ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name:Work Experience Program 3. Program Description: The Work Experience Program provides support and opportunities for individuals with developmental disabilities to receive training through Goodwill's Janitorial Program and Hawaii Design and Art program. The Work Experience Program offers participants choice in potential career hs witibotb hands-on and computer-bane-d-A raining. The Janitorial Psocram provides skills training with the inv nf_.receivina a paycherk. 4. Total Budget& Position Count: Total Program Budget: $45,000.00 Total Program Position Count: 7 Total Agency Budget: $3,000,000.00 Total Agency Position Count: 76 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate State of Hawaii $280,000.00 County of Hawaii nonprofit grant $45,000.00 TOTAL: $325,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: -The requested funding wil Lbe-us-ed to broaden the scope of Goodwill's -Work Experience Proqrani.-Th4s pr part of GoodMI's-laraer � elo rn_ental-DisabiIities (Waiverl program-which movirip-s servic:Ps and supports to persons with disabilitie-&-to become independent EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name:Work Experience Program 7. Program Objectives Using County Nonprofit Grant Program Funds: The overall goal of this program is to provide wage subsidy, training and 3uppod for individuals with developmental disabilities. Three important cnmpQnQnts include: Janitorial Work Training, Hawaii Design & Art �roc�r��exnansion_ and sustainable. la t food production S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of participants trained in Janitorial Program Minimum of 15 Number of participants trained in Design & Art Program Minimum of 10 Number of participants trained in Gardening & Healthy Food Minimum of 10 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $15,000 $17,000.00 $17,000. Professional Fees $2,000.00 $2,000.0 Operations Supplies $5,000. $1,000.00 $1,000.0 Equipment $25,000.00 $25,000. Other: Other: Other: Other: Other: TOTAL $20,00q $45,000.00 $451000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name:Work Experience Program so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAM E: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. 0&'- 6. 97 � /-d-1-/ �z Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name:Work Experience Program 11. Certification of Understanding 1 (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. if awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 da s after June 30 of the contractual Vea r for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant artici ation for a minimum of one year or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/`on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and moy result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name:Work Experience Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of participants trained in Janitorial Program Minimum of 15 Number of participants trained in Design &Art Program Minimum of 10 Number of participants trained in Gardening & Healthy Food Minimum of 10 TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $17,000.00 Professional Fees $2,000.00 Operations Supplies $1,000.00 Equipment $25,000.00 Other: Other: Other: Other: Other: TOTAL $45,000.00 Additional Council directives re&rdina award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 34 Grassroots Community Development Group Hawaii Youth Business Center Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center Agency Director: Trina Nahm-Mijo Phone No.:(808) 640-5109 Contact Person: same as above Phone No.:(808) 640-5109 Mailing Address: Address: PO Box 1772 Address: city,sT,ziP Keaau, HI 96749 Facility Address: Address: 16-1450 Kahakai Blvd. Address: city,sT,zip Pahoa, HI 96778 Email Address: nahmmijo @hawaii.edu Fax No.: (808) 974-7757 Accountant/CP John Carbonaro Phone No.:(808) 968-1002 Firm (if applicable): Carbonaro CPA&Assocs. Mailing Address: Address: PO Box 4372 Address: City,sT,ziP Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $35,000.00 $25,000.00 $30,000.00 2.Agency Mission Statement: To strengthen our communities through. the cooperative development of programs and servicea f-Qr all of East Hawa". To ProVide quality prOars_for_Vauth- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 3. Program Description: The target population is youth, 12-24 yrs. old, from the Puna and Hilo area. The program provides After-School entrepreneurial, digital media arts, culinary, and workforce training at the site located in Pahoa as well as collaborating with h r youth manizations I vi 4.Total Budget& Position Count: Total Program Budget: $75,000.00 Total Program Position Count: 1 Total Agency Budget: $75,000.00 Total Agency Position Count: 1 5. Program Funding Sources(identify all sources of funding applied to this 2t2 gram): FY14-15 Revenue Source Estimate County of Hawai'i $35,000.00 Program Income $20,000.00 Other Grants $5,000.00 Contributions $5,000.00 Fundraising $10,000.00 TOTAL: $75,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We have found this a challengffing economic tome, so ou[ jalans are to collaborate and Ee�sn"roe_share with other yout.h,aManizations like T Youth GhaJlenae,_Neiahbrwhood Place of Pena and nhartpr sch.00.ls EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center now 7. Program Objectives Using County Nonprofit Grant Program Funds: Support youth efforts for employment, health life choices c mm.dev 2) Provide w-o[kface development in diq'tal madia arts, culinary arts, business entrppreneurshius, _ 3) Pmvide_Youth Leaders I pI V rtiinitieg thrnuclh community ennac 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 50 youth will receive training in Digital Media Arts 90% will increase skills 20 youth will receive training in Culinary arts and Healthy cooking 90% will increase skills 10 youth will receive entrepreneurial training 90% will increase skills 50 youth will engage in community service projects 100% will contribute Attach additional pages as necessary. 9.TABLE II; PROGRAM EXPENDITURES FY 13-14 FY 1415 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $10,000 $10,000.00 $5,000.0 Professional Fees $5,000. $5,000.00 $4,000.0 Operations $30,000 $29,200.00 $10,000. Supplies $2,000.00 $1,000.0 Equipment $2,000.00 Other:Rent $36,000 $24,000.00 other:Insurances $2,800. $2,800.00 Other: $15,000. Other: Other: TOTAL. $83,800,$75,000.00 f$35,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless o f whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. E kan "L Signature of Auth t rized P rson (s ec4 title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 1i. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Corte, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.,g_o_v, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,Shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely. comp_Iete, and accurate year-end report; using the temolote.provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301h shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future arant ParticiRation for a minimum of one year or until a written report is submitted to and accented by,the„council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%) for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. 1 d l Signature of Auth rized P rson (sp cify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 50 youth will receive training in Digital Media Arts 90% will increa 20 youth will receive training in Culinary arts and Healthy cooking 90% will increa 10 youth will receive entrepreneurial training 90% will increa 50 youth will engage in community service projects 100% will contr TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $5,000.00 Professional Fees $4,000.00 Operations $10,000.00 Supplies $1,000.00 Equipment Other: Rent Other: Insurances Other: $15,000.00 Other: Other: TOTAL $35,000.00 Additional Council directives reeardine award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 20142015 Page 7 of 7 35 Green Will Conservancy Inc., The Hui Mana'o "Thinking Together & Sharing Knowledge" Agency Name:The Green Will Conservancy Inc Program Name: Hui Mana'o: "Thinking Together & Sharing Knowledge" Agency Director: Frank Capatch, LCSW Phone No.: (808) 965-5349 Contact Person: Frank Capatch, LCSW Phone No.: (SOS) 955-5349 Mailing Address: Address: PO Box 1341 Address: City,ST,Zip Pahoa, H 1 96778 Facility Address: Address: 14-803B Seaview Rd. Address: City,ST,Zip Email Address: green.will.conservancy @gmail.com Fax No.: (808) 965-5036 Accountant/CP Nancy Jean Kramer, CPA Phone No.: (808) 965-2729 Firm (if applicable): Mailing Address: Address: 15-2984 Pahoa village RD Address: PO Box 1519 City,sT,Zip Pahoa, H 1 96778 YOU ARE RESPONSIBLE TO KEEP THEABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $90,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $500.00 $5,500.00 $0.00 2.Agency Mission Statement: "Empower our island youth with life skills and sustainable practices to future enruch their lives and th-e- lives of " Our vision _fists maintain and restore bio_psycbo-social ecoloav in Q.jr__ island c mmunities_ Poverty is accompanied by a host of sodal 1 oroblemg that impact every aspect of an adolescent�ddendllrn A) EXHI BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: The Green Will Conservancy Inc Program Name: Hui Mana`o: "Thinking Together & Sharing Knowledge" 3. Program Description: In the Puna district, where child poverty ranks second highest in the state, the Hui Manab (Thinking Together & Sharing Knowledge) project _provides services for 12 to 18 year-old youth and their ohanas. Over time, social services have decreased and according to the State of Social Services in Hawai" (2009) the County of Hawaii has the least mil _able casel oci of all the islands-(see Addendum A) 4.Total Budget& Position Count: Total Program Budget: 1$90,000.00 Total Program Position Count: 1 Total Agency Budget: 1$146,500.00 Total Agency Position Count: 17 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Program Service Revenue $38,000.00 Public Contributions: Hawaii Nonprofit Grant $90,000.00 Public Contributions: Cash Contributions $4,000.00 Fund Raising $4,000.00 Atherton Foundation $7,500.00 Hawaii Community Foundation $3,000.00 TOTAL: $145,500.00 Attach additional Pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hui Manab will continue to offer professional mental health services on a sliding scale and billable fitment to Health Insurance agencies. In NPw Century Public Charter School (NCPCS)(see Addendum ) - - EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: The Green Will Conservancy Inc Program Name: Hui Mana'o: "Thinking Together & Sharing Knowledge" 7. Program Objectives Using County Nonprofit Grant Program Funds: From a financial perspective, one of our ke oNectives is to purchase a vehicle to transport our program participants. ManV families are Without czars and/or the gasoline to transport their (see Addendum A) 8.TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of youth served (% increase) 25% increase Goal to engage 25 youth and their families in project(s) 100% Increase in paid professional mental health services provided 15% increase Recruit 30 Volunteer Hours per week 100% Fundraising Events, Workshops for Caregivers, First Responders $5,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $10,000.( Professional Fees $3,000.0( Operations $10,000.( Supplies $1,000.0( Equipment $17,000.( Other: Ford Passenger Van E-150XL (seats 8) Incl. tax $35,000.( Other:Web Site Development, technical support, web tools $14,000.( Other: Other: Other: TOTAL $0.00 1 $0.00 $90,000.( *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:The Green Will Conservancy Inc Program Name: Hui Mana'o: "Thinking Together & Sharing Knowledge" io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a con lict_exsts. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by on individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: The Green Will Conservancy Board Meeting of 12/12/2012 reviewed and unanimously__approved FY2013-14 Nonprofit Grants Program, Cou,OV of Hawaii specific definitions of "Nepotism" and "Conflict of Interest" and are included in Green Will's Ethics Policy's published rules If no conflicts exist, check here. aL - 19/) Signature of Authoriz Person (specify t e Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: The Green Will Conservancy Inc Program Name: Hui Mana'o: "Thinking Together & Sharing Knowledge" iz. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administerthe program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to_County)_and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. 1 (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:l/www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in atimely manner will impact the evaluation of our a enc 's future funding request and My result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. LQ5"j Ij Signature Authori ed Pe on (spe ' itle) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:The Green Will Conservancy Inc Program Name: Hui Manab: "Thinking Together & Sharing Knowledge" 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of youth served (% increase) 25% increase Goal to engage 25 youth and their families in project(s) 100% Increase in paid professional mental health services provided 15% increase Recruit 30 Volunteer Hours per week 100% Fundraising Events, Workshops for Caregivers, First Responders $5,000 TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $10,000.00 Professional Fees $3,000.00 Operations $10,000.00 Supplies $1,000.00 Equipment $17,000.00 Other: Ford Passenger Van E-150XL. (seats 8) Incl. tax $35,000.00 Other: Web Site Development, technical support, web tools $14,000.00 Other: Other: Other: TOTAL $90,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Addendum —The Green Will Conservancy Hui Mana'o (Thinking Together & Sharing Knowledge) January 2014 2. Agency Mission Statement "Empower our island youth with life skills and sustainable practices to enrich their lives and the lives of future generations." Our vision is to maintain and restore bio-psycho-social ecology in our island communities for youth and their families. Poverty is accompanied by a host of social problems that impact every aspect of an adolescent's life. Our community, the Pahoa area, has the third highest unemployment rate in the state and 55% of our families rely on food stamps to survive. The decline of the family and lack of essential life skills demonstrates an erosion of self-sustainability. We need small scale, replicable social support'models of community' and education towards increased efficacy, balanced community living and planning for future generations. It is our goal to remove barriers and replace them with the skills to learn, unlearn and re-learn from past wisdom as well as embrace current 21 s'Century technologies. 3. Program Description In the Puna district, where child poverty ranks second highest in the state, the Hui Mana'o (Thinking Together& Sharing Knowledge) project provides services for 12 to 18 year-old youth and their ohanas. Over time, social services have decreased and according to the State of Social Services in Hawaii (2009)the County of Hawai'i has the least manageable caseload of all the islands. Poor youth typically have little or no access to mental health support or life skills counseling. Hui Mana'o offers work opportunities and life skills training as well as professional mental health services to address adolescent issues and behaviors. Many of our participants are victims of domestic violence; deep poverty, low self-esteem and exposure to substance abuse. Our participants can choose pre-vocational skills, green technology, construction arts or a combination of interests. Individualized options include incentives such as earned stipends and cottage industry start-up costs. In addition, volunteers and Kupunas offer cultural and emotional support as well as opportunities for community integration. In line with our commitment to community outreach we plan to liaise with Kua o ka La (KOKL) New Century Public Charter School (NCPCS) to offer individualized and group counseling, psychoeducation as well as symbiotic projects such as green house cultivation. Psycho-education is key for poor minorities while affirming diversity, their cultural values and beliefs. As Leong (1995) points out, group career counseling may be a better approach for such populations so that the therapist and participants can explore their common beliefs and values in a supportive, safe environment. Opportunities for socialization in groups and teams offer structure and a venue to observe and practice positive behaviors. 6. Explain what plans your agency or program has to increase revenues to support this program: Hui Mana'o will continue to offer professional mental health services on a sliding scale and billable treatment to Health Insurance agencies. In addition, we intend to pilot an outreach program to Kua o ka La (KOKL) New Century Public Charter School (NCPCS)with the goal of offering group and individual counseling as well as public workshops within our community. The United Way may offer opportunities for raising public awareness and interest in our program. We continue to communicate with and provide services to the Department of Education, Department of Health, Alternative schools, Teen Court, Family Court, the Judiciary and Child Protection Services. We will continue to make public presentations to multicultural designated agencies and broad-spectrum community organizations. We will also create fundraising activities with our Hui Mana'o participants, KOKL and local business proprietors in East Hawaii. In addition, we actively seek out and welcome liaisons with community organizations that offer support groups and activities that reinforce positive interaction among youth and their families. EXHIBIT A - ADDENDUM NONPROFIT GRANT APPLICATION FY2014-2015 1 Addendum —The Green Will Conservancy Hui Manab (Thinking Together & Sharing Knowledge) January 2014 7. Project objectives using County Non-Profit Grant Program Funds: From a financial perspective, one of our key objectives is to purchase a vehicle to transport our program participants. Many families are without cars and/or the gasoline to transport their adolescents to our facility. It is our intention to create a practical, dynamic web site that will allow our youth to access online projects, services and courses of interest. Our program participants will actively contribute to the creation of our proposed web site that will link us locally and globally. Online course material will teach youth everything from how to complete a resume to managing finances. Interactive forums about teenage challenges such as stress, anxiety and depression will give them a safe and private space to learn and help to clarify their feelings with the option of seeking professional help from our staff of mental health professionals. On a larger scale, our objectives are three-fold: 1. To leave a legacy for the community and environment by learning and practicing `green' gardening, mental wellness, exercise, enhancing leadership abilities and ecological skills that offer a 'pay for work' opportunity and additional complementary skills 2. Teach asset building by reducing psycho-social barriers and increasing access to both individual and community resources 3. Establish a liaison with our neighboring charter school, KOKL, to offer psycho-education, individual and group counseling as well as opportunities for interaction with Hui Mana'o programs and special projects. EXHIBIT A - ADDENDUM NONPROFIT GRANT APPLICATION FY2014-2015 2 36 Habitat for Humanity West Hawaii "Set the Foundation, Raise the Roof, and Let in the Light" Agency Name: Habitat for Humanity West Hawaii Program Name: "Set the Foundation, Raise the Roof, and Let in the Light!" Agency Director: Patrick F. Hurney Phone No.:(808) 331-8090 Contact Person: Isobel Donovan Phone No.:(808) 339-8090 Mailing Address: Address: P.O. Box 4619 Address: City,sr,zip Kailua-Kona, Hl, 96745 Facility Address: Address: 73-5576 Kauhola Street#4 Address: City,ST,zip Kailua-Kona, Hl, 96740 Email Address: do @habitatwesthawaii.org Fax No.: (808) 331-8020 Accountant/CP Julie Horrell Phone No.:(808) 331-8010 Firm (if applicable): Mailing Address: Address: P.O. Box 4619 Address: City,ST,zip Kailua-Kona, HI, 96745 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $60,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $20,000.00 $24,250.00 $9,000.00 2. Agency Mission Statement: Habitat West Hawaii's mission is to empower families and build community and ner through home ownership opportunities for families earninq -betwean 4-0-80% AMI. Habitat works to build homes for lnw-Mr ome families and is alsn the Only affordble home-builder-in the area that builds hnmPS on a no-interest, no-profit basis, ijtllizlnn EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 .. w Agency Name: Habitat for Humanity West Hawaii Program Name:"set the Foundation, Raise the Roof, and Let in the Light!" 3. Program Description: In 2014 Habitat West Hawaii will be building three new homes in Ocean View, HI. Each of these homes will provide a low-income family with a new home, breaking the cycle of poverty that accompanies sub--standard housing conditions, a stated focus of the County. The funds awarded would be specifically used..to p-_y_f-Qr the ,cost and installation of each home's foundation, roof, and doors/windows. 4.Total Budget&Position Count: Total Program Budget: 1$60,000.00 Total Program Position Count: 12 Total Agency Budget: $2,223,281.00 Total Agency Position Count: 18 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii $60,000.00 Habitat for Humanity ReStore $20,000.00 TOTAL: $80,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Furthar fund'nq will be secured through individual donors, private grant awards, and corporate donations. County fug ism aspect of th-e-- nT ram_as a-mmQnetary commitment wi11 help lay the framework and Pnnni irage other private dnnnrs to gi mnnirt this important project. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Habitat for Humanity West Hawaii Program Name:"Set the Foundation, Raise the Roof, and Let in the Light!" 7. Program Objectives Using County Nonprofit Grant Program Funds: This program will seek to Drovide safe and affordable housing for three _Low-income families. By funding the installation of three roofs, doors, windows and foundations, this prociram-will achieve a priority coal of the C launtV Consolidated Plan by imnrnvinq the lives of three Inral families- S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.oescribe,be specific.) Number of volunteer participants 45 Volunteer work hours donated 32,000 Number of families served 3 Number of individuals served 15 Number of female-headed households served 1 Attach additional pages as necessary. 9.TABLE [I: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees $10,000.00 Operations Supplies $55,000.00 $55,000. Equipment Other:Supplies (ReStore funded) $10,000.00 other:Contracted site supervisors $5,000.00 $5,000.0 Other: other:All labor is performed by volunteers with the exception of our Other:two contracted site supervisors. TOTAL $0.00 $80,000.00,$60,000.( *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Habitat for Humanity West Hawaii Program Name:"Set the f=oundation, Raise the Roof, and Let in the Light!" io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: FO If no conflicts exist, check here. Signature of Authorized Person (specify title) Date �Y�e uri✓� �i rc�cTO� EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 r. Agency Name: Habitat for Humanity West Hawaii Program Name:"Set the Foundation, Raise the Roof, and Let in the Light!" a.a.. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including ali supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'l, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, 1 (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate near-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 c I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant-period-(must be refunded to County) and exclusion from future grant participation for a minimum-of one year or until_a written report is submitted to,and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%) for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation of our a enc 's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. 1Z Signature of Authorized Person (specify title Date GArc r/Ti de T;>1 f`C>'a>Z-- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Habitat for Humanity West Hawaii Program Name: "Set the Foundation, Raise the Roof, and Let in the Light!" 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of volunteer participants 45 Volunteer work hours donated 32,000 Number of families served 3 Number of individuals served 15 Number of female-headed households served 1 TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies $55,000.00 Equipment Other: Supplies (ReStore funded) other: Contracted site supervisors $5,000.00 Other: other: All labor is performed.by volunteers with the exception of our Other: two contracted site supervisors. TOTAL $60,000.00 Additional Council directives regardiniz award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 37 Hale Aloha O Hilo Habitat for Humanity Restore - Donation Pick Ups Agency Name:Hale Aloha O Hilo Habitat for Humanity Program Name:ReStore - Donation Pick Ups Agency Director: Rex Lauer, ReStore Manager Phone No.:(808) 935-6677 Contact Person: Julie Hugo, Board President Phone No.:(808) 990-0426 Mailing Address: Address: 700 Manono Street, Ste. 102 Address: city,sT,zip Hilo HI 96720 Facility Address: Address: 700 Manono Street, Ste. 102 Address: City,ST,zip Hilo, HI 96720 Email Address: rex @hilohabitat.org; JulieHugo @realtor.com Fax No.: Accountant/CP Alex Smith, CPA Phone No.008) 927-1725 Firm (if applicable): Mailing Address: Address: 1403 Frank Street Address: city,sT,zip Honolulu, H1 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 4 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $98,000.00 $0.00 $0.00 2. Agency Mission Statement: Seeking to put Gods love into action, Habitat for Humanity brings people together to build homes, communities and hope. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Hale Aloha O Hilo Habitat for Humanity Program Name:Restore - Donation Pick Ups 3. Program Description: Restores are nonprofit home improvement stores and donation centers that sell new and gently used furniture, home accessories, 15uilding materials, and appliances to the public at a fraction of e retail price. Re Stores diveft waste stream by re-purposing. Rebtore profits fund building of omes with paftner families at o 0 of median Income !eve!. 4. Total Budget&Position Count: Total Program Budget: $150,100.00 Total Program Position Count: 1 Total Agency Budget: $222,750.00 Total Agency Position Count: S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Restore sales $10,755.00 TOTAL: $10,755.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: ReStore Hilo opened at Manono Street in Nov., 2009. Each year of its operation, ReStore has increased sales by at least 10°0. By expanding its donation pick up program beyond Hilo and establishing weekly pick ups in Puna and Waimea, ReStore sales will increase, to cover further expansion of the donation pick up program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:Hale Aloha O Hilo Habitat for Humanity Program Name:Restore - Donation Pick Ups 7. Program Objectives Using County Nonprofit Grant Program Funds: ReStore will expand its donation pick up program beyond South Hilo (strict and establish a weekly pick-up program for Puna an ama ua Districts. ReStore sales will Increase, to raise tunds or ome ul Ing. 8.TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results Number of clients served workshops or events held,volunteer hours,etc.describe,be specific.) Increase donation pickups from 42 in Hilo area only to 100 in Hilo, diversion from landfill Puna and Hamakua Increase sales beyond 10% budgeted growth 5% sales growth Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages ;6,300.0( $15,000.00 $8,700.00 Professional Fees Operations Supplies Equipment 3,052.01 $7,518.00 $4,466.00 Other:insurance ;1,050.0( $2,500.00 $1,450.00 other:overhead 1,075.01 $2,350.00 Other: Other: Other: TOTAL 11,477.0 $27,368.00 ;14,616.0( *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:Hale Aloha O Hilo Habitat for Humanity Program Name:ReStore - Donation Pick Ups io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. Sign t r of Au horized Perso (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:Hale Aloha O Hilo Habitat for Humanity Program Name:Restore - Donation Pick Ups ii. Certification of Understanding i (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 1 (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. 1 (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarde_d_a grant from the County of Hawai'l, I (we) understand and will„comply with the requirement to submit a year-end report to the County Council within 50 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301h shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant varticipation for a minimum of one year or Until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a time!y manner will impact the evaluation of auragency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of u horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:Hale Aloha O Hilo Habitat for Humanity Program Name:ReStore - Donation Pick Ups 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase donation pick ups from 42 in Hilo area only to 100 in Hilo, diversion from I Puna and Hamakua Increase sales beyond 10% budgeted growth 5% sales growt TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $8,700.00 Professional Fees Operations Supplies Equipment $4,466.00 Other: $1,450.00 Other: Other: Other: Other: TOTAL $14,616.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 38 Hale Kipa, INC. Kal Like Program Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program Agency Director: Ernest Pietan-Cross Phone No.:(808) 589-1829 Contact Person: Jaclue Kelley-Uyeoka Phone No.: (808) 589-1829 Mailing Address: Address: 615 Piikoi Street Address: Suite 203 city,sT,zip Honolulu, Hawaii 96814 Facility Address: Address: 622 Hinano Street Address: City, ST,zip Hilo, Hawaii 96720 Email Address: jaq @halekipa.org Fax No.: (808) 589-2610 Accountant/CP Lucino Diaz Phone No.:(808) 589-1829 Firm (if applicable): Mailing Address: Address: 615 Piikoi Street Address: Suite 203 City, ST,zip Honolulu, Hawaii 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $5,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000.00 $3,000.00 2. Agency Mission Statement: Hale Ki a provides opportunities and environments that strengthen and encourawe youththleir families an ni i actualize it potential and social responsibility. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program 3. Program Description: Island-wide intensive supervision & support services for Family Court youth, ages 12-17 to hold them accountable for behaviors comply with probation rules improve academic & social behavior and strengthen families. Staff executes an Implementation Plan provides ed-voc 4.Total Budget& Position Count: Total Program Budget: $264,000.00 Total Program Position Count: 14 Total Agency Budget: $5,752,000.00 Total Agency Position Count: 1145 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate DHS (end date 06130114) $200,000.00 County of Hawaii (end date 04130114) $61,000.00 County of Hawaii Grant (end date 06130113) $3,000.00 TOTAL: $264,000.00 Attach additional pages, if needed. 5. Explain what plans your agency or program has to increase revenues to support this program: receiving Hale K*pa has been will expire in April 2014. HnIP Kipa daps amply for nrants from other sniirces in arldition to h jinn EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program 7. Program Objectives Using County Nonprofit Grant Program Funds: 90% KLP participants will be 1 ) in compliance.with their probation terms Aconditions and be ositively discharged from the program; 2) engaged illa.n educational/vocational oroaram and/or become emnloved; 3) *n __ stable living situation and remain arrest-free 3 months nngt-discharge 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Youth Serviced 75 Number of Contacts with youth, family and collaterals 9500+ Number of linkages to community resources 250 Participants who became involved in HK's ed-voc initiative 10 % of participants who will not become pregnant while in program 90% Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $150,45 $155,000.0[ Professional Fees $3,412.( $3,400.00 $750.00 Operations $32,578 $33,000.00 $650.00 Supplies $1,676. $1,700.00 $500.00 Equipment $7,389. $7,200.00 $500.00 Other:Payroll Taxes, Assessments, Fringe Benefits $39,760 $40,000.00 other:Staff Training $1,000.( $9,100.00 $100.00 Other: Mileage $16,062 $16,900.00 $750.00 Other: Program Activities $3,000. $3,750.00 $750.00 Other:Travel, Telecommunication, Publishing/Printing $8,664. $8,700.00 $1,000.0 TOTAL $264,001$270,750A $5,000.0 *If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program j.o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "Na conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: NA POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to on industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © if no conflicts exist, check here. W/ ', L- Signature of Authorized Person (specify title) Date EXH f B[T A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will .impact the evaluation of our program's or agency's uture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June.30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until, a written report is submitted to,and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-non prof,it-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agencv's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. .WA-,L C-1 1 -Z z - 2 0t Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Youth Serviced 75 Number of Contacts with youth, family and collaterals 9500+ Number of linkages to community resources 250 Participants who became involved in HK's ed-voc initiative 10 % of participants who will not become pregnant while in program 90% TABLE II: PROGRAM EXPENDITURES FY 1415 Council Grant Request Award Salary and Wages Professional Fees $750.00 Operations $650.00 Supplies $500.00 Equipment $500.00 other: Payroll Taxes, Assessments, Fringe Benefits Other: Staff Training $100.00 Other: Mileage $750.00 Other: Program Activities $750.00 Other: Travel, Telecommunication, Publishing/Printing $1,000.00 TOTAL $5,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 39 Hamakua Youth Foundation, Inc. Hamakua Youth Center Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center Agency Director: T. Mahealani Maiku'i Phone No.:(808) 775-0976 Contact Person: T. Mahealani Maiku'i Phone No.:(808)443-1249 Mailing Address: Address: 45-3396 Mamane St. or Address: POB 381 city,sT,zip Honokaa, HI 96727 Facility Address: Address: 45-3396 Mamane St. Address: city,ST,zip Honokaa, HI 96727 Email Address: HamakuaYouthCenter @gmail.com Fax No.: Accountant/CP Phone No.:(808) 392-9220- Firm (if applicable): Aloha Business Services - Mailing Address: Address: 74-5596 Pawai Pl. #3E Address: city,sT,zip Kailua-Kona, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENTAND COUNCIL MANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $32,500.00 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $10,000.00 $1 1,250.00 $17,500.00 2.Agency Mission Statement: The Hamakua Youth Foundation, Inc. _(HYF) is a community, bagged.... or_Ogram__during._Dan-SChooJ_hours. enaaginq Wuth in environmental fam.i.l.ies_Wth social_se.rvice agencies. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 3. Program Description: Hamakua Youth Center is a free drop-in youth program open daily after school inter sessions and summer breaks. Our services include Hawaiian culture, arts and _crafts,_healthy foods and drinks, emergency preparedness and gardening. We recently adopted Huinawai which will develop youth leaders- in-the communities are gur Hawaii Island and serve as a-Youth Advisory Council to the Hawaii County Council, 4.Total Budget&Position Count: Total Program Budget: $32,500.00 Total Program Position Count: $4.00 Total Agency Budget: 1$129,500.00 Total Agency Position Count: $4.00 S. Program Funding Sources(identify pil sources of funding applied to this program : FY14-15 Revenue Source Estimate Hawaii Community Foundation $15,000.00 County of Hawaii Non-Profit $32,500.00 Service Clubs/Local Businesses (Le: lions/Rotary, Hotel Industry) $7,000.00 State of Hawaii $10,000.00 Hawaii Island Untied Way $20,000.00 Fundraisers/Community Donations $25,000.00 4HA $20,000.00 TOTAL: $129,500.00 Attach additionsl pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: HYF_will work to schedule community fundraising events throughout the year_ The Huinawai component will,fundraiise with island wide youth at acitia, Kona G1= 5-0, Imn Man nnd other ements that the wijth leaders dedde to affempt EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 ) Prov de_Hawaiia Culture immersion programs,, 2) Provide leadership- �gnvernment isslies_ 4) Strengthen lifelieadershin skills to Qn,SI I:r hpalth� .choices- 5) Deyelc� accountabildy ca. for Wtith- 8.TABLE is What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results ft.e.:lVumber of clientsserved workshops or events held,volunteer hours,etc.Describe,be specific.) Maintain and increase youth participation 60+ (unduplicated) Continual evaluation and improvement of existing programs 60+ (unduplicated) Survey youth participants through council and interview process at random (5 1month) Feedback from peers, youth and family members at random (51month) Youth Council and County Sponsored Youth Forums increased numbers Youth Advisory Council to Hawaii Island County Council at least 51 district Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 1415 FY 1415 Actual* Total Budget Grant Req Salary and Wages $53,160 $55,160.00 $8,500.0 Professional Fees $16,64q$16,954.00 $8,500.0 Operations $18,916 $18,916.00 $1,500.0 Supplies $7,500. $8,000.00 $7,000.0 Equipment $2,000. $2,500.00 $0.00 Other:Admin Costs (BOD Ins. Audit, Fundraising Exp) $5,090. $5,090.00 $0.00 Other' Food and Beverages $3,500. $3,500.00 $2,000.0 other:Mileage/Transportation $3,000. $3,000.00 $5,000.0 Other:Emp. Benefits I Health Ins/GL Ins 1 Emp. Training $16,380 $16,380.00 $0.00 Other: TOTAL $126,18 $129,500.0 $32,500. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 page 3 of 7 Agency Name: Hamakua Youth Foundation, Inc. Program Name:Hamakua Youth center so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form per person with a conflict is needed. if no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms mast be signed regordless„of whether a„con�li„ „ct exi ts. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Caakt of Interast is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an Industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: m if no conflicts exist,check here. 1 Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions;award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express,and be compliant priorto final payment. To register,go to http://vendors.ehawaii.goy, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I_(we) understand and will comply with the requirement to submit a ear-end rej3ort to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'l grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end regent using the template provided, will impact the evaluation of vour program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we)understand that failure to submit the final report within 60 days of June 3e shall rum in loss hiturne.greal participatigg for a mj9IMM gf go Moor written r Is I(we)understand there is no provision for further notification to submit the final report.information and instructions are available at htt : www.hawaiicount . ov fn-non rofit- rant farms on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except fora maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2015 must be returned to the County of Hawaii with the final report.W16- th a d i a ner wi! i ct-the evaluation of r e s .LuLure.f_�nd g neauest and may result in actions taken to recover these signing below,you are acknowledging that you have read and understood these requirements. . � ' ✓�` � Signature of Authorized Person(specifytitle) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Maintain and increase youth participation 60f (unduplica- Continual evaluation and improvement of existing programs 60f (unduplica Survey youth participants through council and interview process at random (51m Feedback from peers, youth and family members at random 51m Youth Council and County Sponsored Youth Forums increased numl Youth Advisory Council to Hawaii Island County Council at least 5/distr TABLE 11: PROGRAM EXPENDITURES FY 1415 Council Grant Request Award Salary and Wages $8,500,00 Professional Fees $8,500.00 Operations $1,500.00 Supplies $7,000.00 Equipment $0.00 other: Admin Costs (BOD Ins. Audit, Fundraising Exp) $0.00 Other: Food and Beverages $2,000.00 Other: Mileage/Transportation $5,000.00 Other: Emp. Benefits 1 Health Ins/GL Ins 1 Emp. Training $0.00 Other: TOTAL $32,500.00 Additlonai Council directives reearding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 40 Hawaii County Economic Opportunity Council Drop Out Prevention Program Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL Program Name: DROP OUT PREVENTION PROGRAM Agency Director: Jay Kimura Phone No.:961-2681 Contact Person: George Yokoyama Phone No.:961-2681 Mailing Address: Address: 47 Rainbow Drive Address: 47 Rainbow Drive city,sT,zip Hilo, Hawaii 96720 Facility Address: Address: 47 Rainbow Drive Address: 47 Rainbow Drive City,ST,zip Hilo, Hawaii 96720 Email Address: hceocgy @hawaii.rr.com Fax No.: 935-9213 Accountant/CP Tessie Padamada Phone No.:961-2681 Firm (if applicable): Mailing Address: Address: 47 Rainbow Drive Address: City,sr,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $254,465.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $50,000.00 $45,000.00 $5,000.00 2. Agency Mission Statement: HCEOC's mission is to prevent, alleviate, and eliminate poverty in the County of Hawaii. EXHIBIT NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL Program Name: DROP OUT PREVENTION PROGRAM I Program Description: The Drop Out Prevention Program (DOPP) is aimed at helping at-risk and low-income school and court referred high school students at Hilo, Waiakea, Pahoa, Honokaa, and Kau high schools to improve in academics attendance and behavio.r-.by.workin-q-mllaboratively with the students, staff.. paw, and available resources in the community to prevent students from dropping out_ 4.Total Budget& Position Count: Total Program Budget: $254,465.00 Total Program Position Count: 10 Total Agency Budget: $2,572,867.00 Total Agency Position Count: 53 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate STATE OF HAWAII GRANTS-IN-AID $200,000.00 TOTAL: $200,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The plans are to apply for grants with the Department of Education to fijnds will also he souQhttbraigh the state via grants-in-aid fundinn_ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL Program Name: DROP OUT PREVENTION PROGRAM 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives are to have 95% of all senior clients graduate.75% of referred students will attend school 85% of school days.75%Q r_Pferred students will not have suspensions exceedinq three days, 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held volunteer hours,etc.Describe,be specific.) 26 CLIENTS ENROLLED AT EACH SCHOOL BY DEC 31, 2014 90% ACHIEVED 50 REFERRALS ASSISTED AT EACH SCHOOL BY MAY 1, 2015 100% ACHIEVED THE GPA AVG OF DOPP WILL BE 2.0 BY END OF 4TH QTR 80% OF CENTERS THE AVG ATTENDANCE WILL BE 85% OR HIGHER BY 4TH QT 75% OF PARTICIPANTS BY YEAR END 75% WILL NOT HAVE 3+ DAYS SUSPENSIONS 75% OF PARTICIPANTS Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $226,040.0 $226,040 Professional Fees $0.00 $0.00 Operations $4,300.00 $4,300.0 Supplies $10,750.00 $10,750. Equipment $0.00 $0.00 Other:Mileage $12,000.00 $12,000. Other:Physical/Drug Physical/Drug Screen $375.00 $375.00 other:Criminal Background Checks $500.00 $500.00 Other:Advertising $500.00 $500.00 Other: TOTAL $0.00 $254,465.0 $254,465 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL Program Name: DROP OUT PREVENTION PROGRAM io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL. Program Name: DROP OUT PREVENTION PROGRAM 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135--2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. 1 (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, 1 (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual_year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted,to, and accepter[ bv,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www,hawaiicounty.Pov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of Vour agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. L�x (/vim 41 Signat re of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL Program Name: DROP OUT PREVENTION PROGRAM 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 26 CLIENTS ENROLLED AT EACH SCHOOL BY DEC 31, 2014 90% ACHIEVE 50 REFERRALS ASSISTED AT EACH SCHOOL BY MAY 1, 2015 100% ACHIE)6 THE GPA AVG OF DOPP WILL BE 2.0 BY END OF 4TH QTR 80% OF CEN THE AVG ATTENDANCE WILL BE 85% OR HIGHER BY 4TH QT 75% OF PARJi BY YEAR END 75% WILL NOT HAVE 3+ DAYS SUSPENSIONS 75% OF PARJi TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $226,040.00 Professional Fees $0.00 Operations $4,300.00 Supplies $10,750.00 Equipment $0.00 Other: Mileage $12,000.00 Other: Physical/Drug Physical/Drug Screen $375.00 Other: Criminal Background Checks $500.00 Other: Advertising $500.00 Other: TOTAL $254,465.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 41 Hawaii Island Adult Care, Inc. Adult Day Care Centers Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers Agency Director: Paula Uusitalo Phone No.:(808) 961-3747 Contact Person: same as above. Phone No.: Mailing Address: Address: 34 Rainbow Drive Address: city,sT,zip Hilo, HI 96720 Facility Address: Address: same as above Address: 2nd location in Honomu at city,sT,zip the Hilo Coast UCC Email Address: Puusitalo @hawaiiislandadultcare.org Fax No.: (808) 961-3740 Accountant/CP Jennifer Gossert Phone No.:(808) 969-3115 Firm (if applicable): Jennifer L. Gossert, CPA Mailing Address: Address: 688 Kinoole St., Address: City,ST,zip Hila, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000.00 $20,000.00 $30,000.00 2.Agency Mission Statement: To provide quality community based care for elders and challenged adults an support for their families on the island of await. .EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 3. Program Description: Adult Day care centers in Hilo and Honomu, provide a safe, socially active daytime program for aging e-Iders and disa5led adults. e programs provide a structured dal y schedule which includes exercise, ac Ive ies for mental stimulation, soda iza Ion and fun. I he goals are to keep our upuna Iving at ome as long as possible, with igni y an independence and to provide suppoft fbor the aml ies caregivers o e a e to continue employment and/or have respi e. 4.Total Budget &Position Count: Total Program Budget: $1,333,500.00 Total Program Position Count: 36 Total Agency Budget: $1,354,700.00 Total Agency Position Count: 36 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Tuition/Fees $895,000.00 State/Federal (Medicaid) $204,750.00 County of Hawaii $30,000.00 Templeton Hooper Fund $71,250.00 Hawaii Island Adult Way $20,000.00 Other Tuition Assist Grants: Friends of HI Charities, Charity Walk, MA Cargill + $38,750.00 Other, please see Attachment A $131,000.00 TOTAL: $9,390,750.00 Attach additional pages,,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The tuition assistance program supports those who are above medicaid income levels, needing daytime supervision and socialization. At this time we write many grants for this gap group, The best move would be if e scare started paying for low Income for adult ay care, the alternative, institutionalization Is very costly for e scare e ical EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 7. Program Objectives Using County Nonprofit Grant Program Funds: This object of this funding .is to assist low income to attend adult day care; they need to attend yet areabove Medicaid Income eve s thus o not ave enoug un ing to pay u costs. ese un s e p I t e gap it is a cost share, we review each applicant income, expenses, savings. S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le.:!Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Participants able to attend adult day care over the course of the yr 12 - 24 Total Units( Months) of funding assistance, estimated over the yr 85 -120 Elders who maintained/improved self care/alleviate depression 12 - 24 Families who receive respite 12 - 24 Families who are able to continue employment 10 - 15 Caregiver satisfaction - deterring burnout 12 - 24 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $927, 501 .00 I81-;!$932,000.00 Professional Fees $8,250.00 . [ $8,500.00 Operations _$j90, 550.00 99,669 $193,000.00 Supplies t92, 725.00 3e-,7-2� $93,250.00 Equipment $4 , 000. 00 1' I $4,000.00 Other: Direct Client Expense $145,270.00 46 .I$160,000.00;30,000.01 Other: Other: Other: Other: - Total $1-1-368, 296.00r, TOTAL 4&&,496 1,390,750.0 ;30,000.01 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 1.a. ORGANIZATION CONFLICT DISCLOSURE FORM .Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be sinned, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ if no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 11. Certification of Understanding (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 1 (we) hereby certify that information supplied herein, including all supporting documents, is correct and that 1 (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment, To register, go to http://endors.ehawaii.poy, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. if awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a ear-end report to the County Council within 50 da s after June 30 of the contractual yea r for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, using the template provided will impact the evaluation of our program's or agency's uture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at.http://www.hawa'ricounty.gov/fn-nonprofit-grant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation of auragency-'s future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) bate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 12. COUNCIL AWARD WORKSHEET TABLE l: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participants able to attend adult day care over the course of the yr 12 - 24 Total Units( Months) of funding assistance, estimated over the yr 85 -120 Elders who maintained/improved self care/alleviate depression 12 - 24 Families who receive respite 12 - 24 Families who are able to continue employment 10 - 15 Caregiver satisfaction - deterring burnout 12 - 24 TABLE 11: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Direct Client Expense $30,000.00 Other: Other: Other: Other: TOTAL $30,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Hawaii Island Adult Care, Inc. Hawaii County Human Services Grant for Fiscal Year 2015 For Page 2, Attachment A Additional Program Funding Sources USDA Lunch Reimbursement $ 70,000.00 Donations, lunch, Christmas, etc. 16,000.00 Donations, Tuition Assistance - Friends of HIAC drive 5,000.00 Fundraising 35,000.00 PIN Management Fees/misc 5,000.00 Total: 131,000.00 Please note: We disburse Persons-In-Need (PIN) grants for the community at large (through referrals), and thus the fee is allowed by the grantor. 42 Hawaii. Island Home for Recovery, Inc (HIHR) illiM Supportive Housing Program Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Supportive Housing Program Agency Director: Rita Sandi Palma Phone No.:(808) 934-7852 Contact Person: Rita Sandi Palma Phone No.:(808) 640-9442 Mailing Address: Address. 440 Kaplolani St. Address: City,sT,zip Hilo, Hl. 96720 Facility Address: Address: 440 Kapiolani St. Ad d ress: City,sT,zip Hilo, HI. 96720 Email Address: hihr @hawaii.rr.com Fax No.: (808) 935-7894 Accountant/CP Alex J. Smith Phone No.:(808) 257-6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: MY,sT,zip Honolulu, HL 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $59,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: HIHR provides alcohol and drug_free_independent healthier living residenu for chronically homeless. HIHR supportive living environment restores individuals to a sound mind, body and spirit. HIHR emphasis is an serving adults with serious mental illnesses,substance_ahuse broadpr servicps to -address the significant unmet need in Hilo— EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Supportive Housing Program 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR will achieve the overall program goals, as stated above in the mission statement and_ogram descri to ion, _ Prarnatnq and strenathenina the abilitvof fbe chrcnieally homeless_.yvith d'ssh' ' es_to live in balance. andiin[le�pndently_ 8.TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteerhours,etc.Describe,be specific.) Comprehensive assessmenVindividual service plan/case manager 100% Linked to health/mental health/substance abuse treatment services 100% Life skills training in program/other community providers 90% At exit to obtain/maintain permanent housing six month or longer 80% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 1415 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $64,842 $64,842.00 $24,000. Professional Fees $7,000.1 $7,000.00 Operations $84,58E $84,586.00 Supplies $12,16 $12,160.00 Equipment Other:Purchase 15 Passenger van $35,000. Other: Other: Other: Other: TOTAL 1$168,58 $168,588.0 $59,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Supportive Housing Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure Lorms must be si ned regardless of whether a con lict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. L�- Ta4zd /'30 Signat re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Supportive Housing Program ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register,go to http://yendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant-was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accented by the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30,2015 must be returned to the County of Hawal`i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency-'s future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Hawaii Island Home for Recovery, Inc. (HJHR) Program Name: HIHR Supportive Housing Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Comprehensive assessment/individual service plan/case manager 100% Linked to health/mental health/substance abuse treatment services 100% Life skills training in program/other community providers 90% At exit to obtain/maintain permanent housing six month or longer 80% TABLE Ik PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $24,000.00 Professional Fees Operations Supplies Equipment Other: Purchase 15 Passenger van $35,000.00 Other: Other: Other: Other: TOTAL $59,000.00 Additional Council directives reizardinl=award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 43 Hawaii Island Home for Recovery, Inc (HIHR) WHIZ Transitional Housing Program V Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Program Agency Director: Rita Sandi Palma Phone No.:(808) 934-7852 Contact Person: Rita Sandi Palma Phone No.:(808) 640-9442 Mailing Address: Address: 440 Kapiolani St. Address: city,sT zip Hilo, HI. 96720 Facility Address: Address: 440 Kapiolani St. Address: city,sT,zip Hilo, HI. 96720 Email Address: hihr @hawaii.rr.com Fax No.: (808) 935-7894 Accountant/CP Alex J. Smith Phone No.:(808) 257-6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: city,sT,zip Honolulu, Hl. 96816 YOU ARE RESPONSIBLE TO KEEP THEABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $64,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: HIHR_ provides_alcohol and drug-free independent healthier living _ residency for chronically homeless. HIHR supportive,.li,yi.n.g_.environment � restores individuals to a sound mind, body.and spirit_ HIHR emphasis is on serving adults with serious mental illnesses, substance abuse hma.der erv'ces to address the significant i inmet need in Hilo EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Program 3. Program Description: HIHR program activities, also coordinate with other community services._ Assessing and creating an individualized service plan including case management, job training/placement, substance abuse/mental health treatmenfi,bealthcare, living skills/financial training,_edu!afiQn,_housing _ resources, entitlements pare ntinq/d omestic: violence ser_vices_,__ recreatinnal activities, holistic spirituality and other social services_ 4. Total Budget& Position Count: Total Program Budget: $228,$98.00 Total Program Position Count: 4 Total Agency Budget: $397,786.00 Total Agency Position Count: 14 5. Program Funding Sources(identify all sources of funding applied to this Rro ram FY14-15 Revenue Source Estimate Federal Contract DHS-13-HPO-777 $115,128.00 State Contract DHS-12-HPO-564 SA01 $129,960.00 Hawaii United Way $17,000.00 HIHR Supportive Housing Program Fees $47,760.00 HIHR Transitional Housing Program Fees $84,938.00 Charity/Donations $3,000.00 TOTAL: $397,786.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Actively research all other possoble grant optaQos amailable, EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program-Name-: HIHR Transitional Housing Program 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR will achieve the overall program goals, as stated above in the mission statement and program descriotiQn- _ _Promoting and strenathe�the, abimy-of the chronicaliv .barneless with 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific) Comprehensive assessmenVindividual service plan/case manager 100% Linked to health/mental health/substance abuse treatment services 100% Life skills training in program/other community providers 90% At exit to obtain/maintain permanent housing six month or longer 80% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $75,600 $64,842.00 $24,000. Professional Fees $6,000. $7,000.00 Operations $145,29 $84,586.00 Supplies $2,000. $12,160.00 $5,000.0 Equipment Other:Purchase 15 Passenger van $35,000. Other: Other: Other: Other: TOTAL 1$228,89$16 8,588.0 $64,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Program lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance , ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIM Transitional Housing Program ii. Certification of Understanding (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express,and be compliant prior to final payment. To register,go to http://yendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 3CP shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future arant participation for a minimum of one year or until a written report is submitted to,and acre ted bv,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely_manner will impact the evaluation of Your agency's future funding request and moy result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. r Z-77 Signature of Authorized person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Hawaii island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Comprehensive assessment/individual service plan/case manager 100% Linked to health/mental health/substance abuse treatment services 100% Life skills training in programlother community providers 90% At exit to obtain/maintain permanent housing six month or longer 80% TABLE il: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $24,000.00 Professional Fees Operations Supplies $5,000.00 Equipment Other: Purchase 15 Passenger van $35,000.00 Other: Other: Other: Other: TOTAL $64,000.00 Additional Council directives re-eardine award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 44 Hawaii Montessori. Schools Financial Aid Program Agency Name: Hawaii Montessori Schools Program Name: Financial Aid Program Agency Director: Angeline Geldhof Phone No.:(808) 329-0700 Contact Person: Angeline Geldhof Phone No.:(808) 936-1857 Mailing Address: Address: 74-978 Manawale'a Street Address: city,sT,zip Kailua-Kona, HI 96740 Facility Address: Address: 74-978 Manawale'a Street Address: City,ST,zip Kailua-Kona, HI 96740 Email Address: angeline@hawaiimontessori.org Fax No.: (808) 334-0327 Accountant/CP Rozanne Connell Phone No.:930-6850 Firm (if applicable): Carbonaro CPA &Associates, Inc Mailing Address: Address: PO Box 4372 Address: city,sT,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $12,500.00 $7,500.00 2.Agency Mission Statement: Our Mission at Hawaii Montessori Schools is educating.children for life by providing a nurturing prepa[ed en-vironment where children, parents, and staff iovfully develop their esteem, inner discipline,_i.ndPpenr3enr.P,_ EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 3. Program Description: We believe that Early Childhood Montessori Education should be available to all children, regardless of their families' income. Currently, for the 2013-2014 school year, we have students enrolled of which 31 are receiving some kind of financial aid from us. To date, we have provided a total of $42,24-1-in financial and for the 2013-14 SY and we will continue to give financial aid to qualified new families as the)/ enroll_ 4.Total Budget& Position Count: Total Program Budget: $40,000.00 Total Program Position Count: 40 Total Agency Budget: $815,333.00 Total Agency Position Count: 126 S. Program Funding Sources (identify all sources of funding applied to this rp ogram): FY14-15 Revenue Source Estimate Bill Healy Foundation $5,000.00 County of Hawaii Non-Profit Grant in Aid $15,000.00 G. N. Wilcox Trust $5,000.00 Samuel N. and Mary Castle Foundation $15,000.00 TOTAL: $40,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our-Board, Staff-and Parents are comm'tted to maintanning hmqh quality programs for Hawai`i's children. Our„f=d[ai_ers have been successful because of the tremendous commitment of our staff, fames and.tne EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Hawaii Montessori Schools Program Name: Financial Aid Program 7. Program Objectives Using County Nonprofit Grant Program Funds: The Financial Aid Grants allows us to assist needy families who are seeking to enroll their children in a aual_ity Preschool program, thereby increasing their chance for success in their future educational,,c mer, We hone to nive tuition assistance to 40 Students in the 2014-15 vear 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Students who will receive financial aid so they may attend a high- quality early learning center. 40 Amount of Financial Aid disbursed to 35 students for 2014-15 SY $40,000 Attach additional pages as necessary. 9.TABLE Ill: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other:Financial Aid Program $42,241 $40,000.00 $15,000. Other: Other: Other: Other: TOTAL 1$42,2411 $40,000.00 $15,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hawaii Montessori Schools Program Name; Financial Aid Program 1o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signatu a of Authorized Person ( pecify tit Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Flawai'i Montessori Schools Program Name: Financial Aid Program u.. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135--2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant priorto final payment. To register, go to htt�Yvendors.ehawaii.Rov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 da s after June 30 of the contractual yea r for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.govLfn-ngnprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. 1 • Ir� L a 5ignatur of Authorized Person ( ecify titl Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 12. COUNCIL, AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Students who will receive financial aid so they may attend a high- quality early learning center. 40 Amount of Financial Aid disbursed to 35 students for 2014-15 SY $40,000 TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment other: Financial Aid Program $15,000.00 Other: Other: Other: Other: TOTAL 1 $15,000.00 Additional Council directives regarding; award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 45 Hawaii Volcano Circus HICCUP Youth Circus Agency Name: Hawaii's Volcano Circus Program Name: HICCUP Youth Circus Agency Director: Jenna Way Phone No_ 808-965-8756 Contact Person: _Jenna Way _ Phone No_: 808-965-8756 Mailing Address: Address: Address: City, ST zip Pahoa, HI 96778 Facility Address Address: 12-427 West Pohakupele Address: Loop Road City, sT,zip Pahoa, HI 96778 Email Address: infoghawaiispace.com ._ Fax No. 808-965-8756 A,c tantl�' Ph.: (808)937-5542 I-irm i applicable Mailing Address: PO Box 167 Kurtistown, HI 96760 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: _ $19,200 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 1213 FY 13-14 $7,000 2. Agency Mission Statement: Hawaii's Volcano Circus (HVC)was founded in 1984 to provide quality culture and arts enrichment programs in Puna Makai. Our mission is to creatively promote a sustainable local community at Seaview Performing Arts Center for Education (SPACE). Through outreach programs and services,HVC helps to improve conditions in the broader community by engaging and connecting youth and adults in educational, agricultural, artistic, cultural, environmental and sustainability activities. We host a public elementary charter school,various classes and camps in performing arts for youth and adults, and a regular weekly Artists/Farmers Market. HICCUP Circus Mission Statement: HICCUP(Hawaii Island Community Circus Unity Project) Circus is HVC's innovative and highly successful ongoing education program. The Mission of the Hiccup Circus is "to promote the healthy development of children and the community through the time honored skills of the circus." We offer educational services to the public at large with emphasis on elementary and intermediate school age children and teenagers, especially in under-served isolated rural communities. Our methodology for developing and implementing programs is through partnerships with other educational, civic, and charitable organizations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hawaii's Volcano Circus Program Name: HICCUP Youth Circus 3. Program Description: HVC hosts weekly classes at S.P.A.CE. in the circus and performing arts to support the healthy development of youth and adults and to fill the need for local, affordable recreational activities in Puna Makai. Through nominal class fees and scholarships,HVC creates access to educational opportunities for low-income,underserved communities. HICCUP students are school-aged children and teenagers. The HICCUP Circus creates desperately needed access for low-income youth to valuable learning experiences and alternatives to drugs and alcohol. Our classes enhance the mental and physical health of students as they learn juggling, improvisation, aerial,unicycling, dance and performance skills from experienced instructors. The children and families of the Puna district and Hawaii County are challenged by poverty, lack of transportation, and the highest rates of social dysfunction in the State. In Hawaii County nearly 25% of children under 18 years old live in poverty compared to 13.9% for the State (American Community Survey, 2010). 84.5% of K-12 students enrolled in rural Lower Puna schools receive free or reduced-cost lunch compared to 65.5% of K-12 students in all of Hawaii County(Hawaii DOE, 2012). 85% of Hawaii County's Section 8 Low-Income Rental Certificate holders reside in the Puna district,which means many families cannot afford the transportation and enrollment costs associated with extracurricular activities (American Community Survey, 20 10) 4, Total Budget & Position Count: Total Program Budget: $24,000 Total Program Position 5 Count: Total Agency Budget: $150,000 Total Agency Position 12 Count- 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Program Revenues $13,000.00 Hawaii County Non-Profit Grant (FY 13-14) $3,500.00 Recycle Hawaii Community Education $7,500.00 TOTAL: $24,000.00 Attach additional pages, if needed. fi. Explain what plans your agency or program has to increase revenues to support this program: In the past year,HICCUP Circus has partnered with Recycle Hawaii to offer community educational performances. The message of these performances are to encourage recycling and sustainability and to educate the audience about related issues. We believe that the partnership is successful and will continue into 2015. We also plan to raise money to support this program by charging nominal class fees for students(and families)who are able to afford it. Additionally, we plan to sell tickets to performances we stage for the public, sell handmade circus props and HVC merchandise. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Provide children and adolescents living in a low-income community access to performing arts activities 2) Create paid instructor and volunteer opportunities for adults and adolescents in the community. 3.)Improve EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Hawaii's Volcano Circus Program Name: HICCUP Youth Circus students' social, mental and physical skills, including enhanced creativity and confidence, concentration, communication, spontaneity and coordination. 4.)Increase community appreciation and support for the arts We plan to accomplish these objectives by offering scholarships for after school classes and camps to those students in need, of which we have many, and by purchasing a new laptop computer for program administration. One of our two computers is malfunctioning and it is integral for an organization of this size to have more than one reliable computer in support of our diverse programs. 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.:Number of clients served workshops or events held, volunteer hours, Applicant Projected Results etc.Describe,be speck.) Number of classes held during the school year 72 Number of camps held 4 Number of children served 160 Number of instructor positions provided 3 Number of volunteer positions provided 7 to 10 Audience at shows 500 - 750 Building of self-esteem and confidence of kids Priceless! Of benefit for the rest of their lives! Attach additional pages as necessary. 9. TABLE 11: PROGRAM FY 13-14 FY 14-15 FY 14-15 Grant EXPENDITURES Actual* Total Budget Req Salary and Wages: $6,500.00 $9,000.00 $1,000.00 Professional Fees $2,000.00 Operations $5,100.00 $7,000.00 Supplies $1,000.00 $2,000.00 Equipment: $1,600.00 $4,000.00 Other: Laptop Computer, warranty, accessories $2,200.00 Other: Scholarships $16,000.00 TOTAL $14,200.00 1 $24,000.00 $19,200.00 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hawaii's Volcano Circus Program Name: HICCUP Youth Circus 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed conflict exists. regardless of whether a NAME: tj POSITION: � � �� May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The ❑ Mayor The ❑ Managing Director The ❑ Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. -UJ Si ature of Authorized Per on (specify title) Date t�x -D r EXHIBIT NONPROFIT GRANT APPLICATION FY 2014-2045 Page 4 of 7 Agency Name: Hawaii's Volcano Circus Program Name: HICCUP Youth Circus ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2135 --2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. . I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including ail supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Com liance Express, and be compliant prior to final payment. To register, go to ht_tp://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii. I (we) understand and will comply with the requirement to submit a year-end report to the County.,-Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timelv. complete, and accurate , ear-end report, using the template provided, will impact the evaluation of your program's or agency's uture funding requests. I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future rant artici ation for a minimum of one vear or until a written report is submitted to, and accepted bv, the council. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 page 5 of 7 Agency Name: Hawaii's Volcano Circus Program Name: HICCUP Youth Circus I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant- forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by .tune 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a time!y manner will jM act the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signat re of Authorized Person ( pecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Hawaii's Volcano Circus Program Name: HICCUP Youth Circus COUNCIL AWARD WORKSHEET TABLE I: Council PROGRAM PERFORMANCE MEASURES Applicant Projected Proposed Results Projected Result Number of classes held during the school year 72 Number of camps held 4 Number of children served 160 Number of instructor positions provided 3 Number of volunteer positions provided 7 to 10 Audience at shows 500 - 750 Building of self-esteem and confidence of kids Priceless! Of benefit for the rest of their lives! TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Award Request Salary and Wages $1,000.00 Professional Fees Operations Supplies Equipment Other: Laptop Computer, warranty, accessories $2,200.00 Other: Scholarships $16,000.00 Other: TOTAL $19,200.00 Additional Council directives regarding award: NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 46 Hawaii Volcano Circus SPACE Farmers Market Agency Name: Hawaii's Volcano Circus Program Name: SPACE Farmers Market Agency Director: Jenna Way Phone No.: 808-965-8756 Contact Person: _ Jenna Way Phone No.: 808-965-8756 Mailing Address: Address: RR2 Box 4524 Address: City,ST,zip Pahoa. Hl 96778 Facility Address: Address: 12-427 West Pohakupele Loop Address: City,sT,zip Pahoa, HI 96778 Email Address: info@ hawaiispace.com Fax No.: 808-965-8756_ Accountant/CP: Laurie SaarinenPhone: 808-937-5442 Firm: LKS Services Mailing Address: P.O. Box 163 Kurtistown, HI 96760 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,100.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $7,000 (HICCUP Camps) 2. Agency Mission Statement: Hawaii's Volcano Circus (HVC) was founded in 1984 to provide quality culture and arts enrichment programs in Puna Makai. Our mission is to creatively promote a sustainable local community at Seaview Performing Arts Center for Education (SPACE). Through outreach programs and services, HVC helps to improve conditions in the broader community by engaging and connecting youth and adults in educational, agricultural, artistic, cultural, environmental and sustainability activities. We host a public elementary charter school, various classes and camps in performing arts for youth and adults, and a regular weekly Artists/Farmers Market. Farmers Market Mission Statement: To promote sustainability and be a vital part of the local economy by providing a safe, village-based marketplace for the community to buy and sell goods and services produced on the Big Island. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hawaii's Volcano Circus Program Name: SPACE Farmers Market 3. Program Description: Started in 2007, SPACE Farmers Market is a weekly community marketplace of EXCLUSIVELY Hawaii Island grown and produced products including agricultural products, one of a kind artisan goods, and local services. In a region that otherwise sees little economic opportunity, SPACE Market has become a cornerstone in creating a vibrant local economy in the rural community of Puna Makai, from Kalapana to Kapoho. The market has proven successful as a business incubator for local entrepreneurs in the first 6 years of operation; many past vendors now operate successful businesses in the greater community. SPACE market provides opportunity as our low-income, rural community purchase goods and services without having to travel over 30 miles round trip to the nearest facilities in Pahoa. With limited public transportation, the bus passes our neighborhood only 3 times a day, this saves local residents a significant gas expense and the hassle of having to hitch-hike for others. Our market accepts EBT as a form of payment to provide the opportunity for low-income, elderly, and disabled residents to purchase food items with their federal benefits. It is estimated that over 50% of food sales at SPACE Market are purchased through the EBT program, demonstrating the importance of our market in addressing the needs of our underprivileged community. 4. Total Budget & Position Count: Total Program Budget: $53,760.00 Total Program Position 7 Count: Total Agency Budget: $150,000.00 Total Agency Position 12 Count: 5. Program Funding Sources (identify all sources of funding applied to this ro ram FYI 4-15 Revenue Source Estimate Program Revenues $34,800.00 USDA— Farmers Market Promotion Program $18,960.00 TOTAL $53,760.00 Attach additional pages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: To increase revenues in support of this program, SPACE Market increased vendor booth fees on January 4, 2014 and is introducing a certified kitchen to further incubate small businesses while generating revenues for the Farmers Market program. The Farmers Market program generally supports itself. However, two integral pieces of equipment that provide for efficient administration and public safety need to be replaced: laptop computer, a golf cart. As with most non-profit organizations, our biggest challenge is replacing run down equipment. The purchase of a laptop will enable the Farmers Market Manager and Executive Director to administer the program more efficiently and effectively, network with donors, and submit funding requests to further support this program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Hawaii's Volcano Circus Program Name: SPACE Farmers Market 7. Program Objectives Using County Nonprofit Grant Program Funds: The golf cart used to facilitate parking, security, community safety, and transportation for signage, refuse, etc. has been deemed unrepairable by its mechanic. 1 of our 2 computers is malfunctioning and it is integral for an organization of this size to have more than one reliable computer in support of our diverse programs. The objective of this funding request is to maintain the continued success of the SPACE Farmers Market program by replacing the equipment necessary to ensure public safety and proper administration. 8. TABLE l: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.:Number of clients served workshops or events held, volunteer hours,etc.Describe, Applicant Projected Results be specific.) Maintain required equipment for administration to remain 2 reliable computers will be active effective and efficient within the organization Maintain PatronNendor safety in parking lots (golf cart) # of unfavorable incidences in parking lots will be <31 ear Maintain resident safety in community (golf cart) # of unfavorable incidences in community will maintain at 01 ear Maintain efficient operation of market set-up and breakdown Market set up and breakdown will (golf cart be performed in <1/hour Attach additional pages as necessary. 9. TABLE ll: PROGRAM FY 13-14 Actual* FY 14-15 FY 14-15 EXPENDITURES Total Budget Grant Req Salary and Wages: $30,000.00 $32,500.00 $600.00 Professional Fees Operations Supplies $2,000.00 $2,500.00 Equipment: Golf cart, batteries, charger 0 0 $12,300.00 Other: Laptop Computer, warranty, accessories 0 0 $2,200.00 Other: Mobile Commercial Kitchen $45,000.00 $18,760.00 TOTAL $77,000,00 $53,760.00 $15,100.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hawaii's Volcano Circus Program Name: SPACE Farmers Market 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Vl�- WOL41 POSITION: ��t, -> , �T-C�Y- May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council Staff apWointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Si nature of Authorized Oerson (Specify Title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Hawaii's Volcano Circus Program Name: SPACE Farmers Market 11. Certification of Understanding (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2135 —2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov" complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year--end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the -grant period (must be refunded to County) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 Agency Name: Hawaii's Volcano Circus Program Name: SPACE Farmers Market and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at httg://www.hawaiicounty.gov/fn-nonprofit-prant- forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. LJC41 'D(,raio-r- hc;� -1q Sign _ure of Authorized P rson (specify tle); Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 20142015 Page 6 of 7 Agency Name: Hawaii's Volcano Circus Program Name: SPACE Farmers Market 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE Applicant Projected Results Council Proposed Projected Result MEASURES Maintain required equipment 2 reliable computers will be for administration to remain active within the organization effective and efficient Maintain PatronNendor # of unfavorable incidences in safety in parking lots (golf parking lots will be <3/year cart Maintain resident safety in # of unfavorable incidences in community (golf cart community will maintain 0/ ear Maintain efficient operation Market set up and breakdown of market set-up and will be performed in <1/hour breakdown (golf cart TABLE II: EXPENDITURES FY 14-15 Council PROGRAM Grant Award Request Salary and Wages $600.00 Professional Fees Operations Supplies Equipment: Golf cart, batteries, charger $12,300.00 Other: Laptop Computer, warranty, accessories $2,200.00 Other: Mobile Commercial Kitchen TOTAL $15,100.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 48 Hilo Community Players 2014-2015 Theatrical Season Agency Name:Hilo Community Players Program Name:2014-2015 Theatrical season Agency Director: Catherine McPherson Phone NO.:(808) 934-7248 Contact Person: Theresa Ten Eyck Phone No.:(808)443-7074 Mailing Address: Address: P.O. Box 46 Address: City,sT,Zip Hilo, Hl 96721 Facility Address: Address: P.O. Box 46 Address: city,sr,zip Hilo, HI 96721 Email Address: hilocommunityplayers@gmail.com Fax No.: Accountant/CP Theresa Ten Eyck Phone No.:(808)443-7074 Firm (if applicable): Theresa Ten Eyck CPA, LLC Mailing Address: Address: 614 Kilauea Ave., 102D Address: City,ST,zip Hilo, H[ 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $29,675.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-1+4 $0.00 $0.00 $5,000.00 2.Agency Mission Statement: The vision of the Hilo Community Players is to stimulate, celebrate, and enhance un ers an Ingo nurse ves an o ers t roug t e s are experience of ea re. The mission of e Hilo Community Players is to educate, &-n-rich, an entertain the Big Island Community through quality th ea rica productions, workshops, and activities tor children, you , and adults. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Hilo Community Players Program Name:2014-2015 Theatrical Season 3. Program Description: Through theatre, the Players educate and entertain the Big Island commune y. For 2014-1 b, we will -offer our a espeare, our first Kids' Shakes a show about a espeare aimed at ren and youth)—, a kid's show a show with at eas o casting of children an youth), and a women s show a cast -of all women). Our aim for is an enhanced ea reca experience through a major captial equipment investment o replace aging equipment. 4.Total Budget& Position Count: Total Program Budget: $42,150.00 Total Program Position Count: 15 Total Agency Budget: $42,150.00 Total Agency Position Count: 0 S. Program Funding Sources(identify all sources of funding applied to this pro ram FY14-15 Revenue Source Estimate Donations $4,500.00 Merchandise Sales $700.00 Ticket Sales $8,000.00 Grants $29,675.00 Advertsing $1,000.00 In-kind Donations TOTAL: $43,875.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Players are renovating our website to facilitate donations and ease of merchandise and ticket sales. We have formed committees for fund raising and advertising to allow for greater outreach. Our grant writing committee successfully pursue in other grants In 2013-14 an will pursue more Fff-ZG1-4-15. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:Hilo Community Players Program Name-2014-2015 Theatrical Season 7. Program Objectives Using County Nonprofit Grant Program Funds: The P ayers will purchase capital equipment in the form of all-weather lighting instruments. We will engage underrepresented populations (children, you , and women by staging pro auctions educating an encouraging their pa icipa ion on and oTT stage. S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Increase attendance to 5000 attendees Increase membership to 50 Increase donations by $1500 In-kind donation hours of 4250 hours Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $0.00 $0.00 $0.00 Professional Fees ;2,100.01 $2,000.00 $0.00 Operations 1,500.01 $2,200.00 $0.00 Supplies 1,200.01 $1,250.00 $0.00 Equipment $260.00 $27,000.00 ;27,000.01 Other:Printing $600.00 $1,350.00 $0.00 Other.1ights and Sound $800.00 $4,300.00 $650.00 other:Props and Sets $570.00 $2,500.00 $1,250.00 Other:Rent 3,400.01 $3,000.00 $0.00 Other:Costumes $25.00 $1,550.00 $775.00 TOTAL 110,455.Cl$42,150.00 >29,675.01 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:Hilo Community Players Program Name:2014-2015 Theatrical Season lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless-of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council (] Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict o€Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. 6�?r PC tD 1'27Lj� Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:Hilo Community Players Program Name:2014-2015 Theatrical Season u. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment,property,or records pertinent to the grant,contract,or program for which funds were used. f (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not he accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register,go to httpJ/vendors.ehawaii.eov, complete the easy step-by-.step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii,I (we)understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawal"i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report using the template provided, will impact the evaluation of your program's or agency"s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant padhdoation for a minimum of one year or until a written re ort is submitted to and accepted bL the council. I (we)understand there is no provision for further notification to submit the final report.Information and instructions are available at http:/Iwww.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawai`l with the final report.Failure to return these funds in a timely manner will impact the evacuation at your agency's future Lunding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name'Hilo Community Players Program Name:2014-2015 Theatrical Season 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase attendance to 5000 attendeeE Increase membership to 150 Increase donations by $1500 In-kind donation hours of 4250 hours TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $0.00 Professional Fees $0.00 Operations $0.00 Supplies $0.00 Equipment $27,000.00 Other: Printing $0.00 Other: Lights and Sound $650.00 Other: Props and Sets $1,250.00 Other: Rent $0.00 Other: Costumes $775.00 TOTAL $29,675.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2054-2015 Page 7 of 7 49 Holualoa Foundation for Arts & Culture Art Creates Change Agency Name: Holualoa Foundation for Arts & Culture Program Name: Art Creates Change Agency Director: Thalia Davis Phone No: 808-322-3362 Contact Person: Tomoe Nimori Phone No. 808-329-3058 Mailing Address: 78-6670 Mamalahoa Highway Holualoa,Hl 96725 Facility Address: 78-6670 Mamalahoa Highway Holualoa,HI 96725 Email Address: donkeymill@gmail.com CPA: Squire Lemkin, Phone No. 301-424-6800 111 Rockville Pike Suite 47 Rockville,MD 20850 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Non-Profit Grant Program Funds: -* rT,o0o 1.Prior Years of County Non-Profit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 0 0 $10,000 2. Agency Mission Statement The mission of the Holualoa Foundation for Arts and Culture is to enrich the lives of persons of all ages and abilities through arts and cultural education. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014.2015 Page 1 of 7 Agency Name: Holualoa Foundation for Arts & Culture Program Name: Art Creates Change 3. Program Description Art Creates Change focuses on presenting exhibits that display art work created in workshops and classes at the Donkey Mill Art Center. The exhibits will feature local and visiting artists' work. Exhibits are very important to our rural community because they provide an inspiring experience and learning moment for the viewer. Perhaps the viewer will become curious and pursue independent study of the medium or artists. The viewer will be inspired to take classes and move into the field of art as a vocation, or arts management. They will be challenged to choose a path that will lead to jobs that are beyond minimum pay levels. Exhibits impact businesses and generate revenue because visitors will patronize neighboring restaurants, other galleries, and shops. 4. Total Budget&Position Count Total Pro ram Budget $117,250 Total Program Position Count: 4 Total A ency Budget $288,200 1 Total Agency Position Count: 7 5.Program Funding Sources (identify all sources of funding applied to this program) Revenue Source FY14-15 Estimate Hawaii County $17,000 Holualoa Foundation for Arts& Culture Annual Fund $5,000 Workshop fees $10,000 TOTAL 1 $32,000 6.Explain what plans your agency or program has to increase revenues to support this program: The Development Director has developed strategies for Fundraising such as the Annual Fund, Membership Campaign and strategies for grant applications. Grant applications currently being developed include: National Endowment for the Arts to extend the reach of the arts to underserved populations. Elizabeth Firestone Graham Foundation to cover direct costs of publications associated with contemporary art exhibitions. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Holualoa Foundation for Arts & Culture Program Name: Art Creates Change 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide high quality arts and cultural exhibitions based on workshops and classes offered at the Donkey Mill Art Center. 2. Create opportunities for people of all ages and abilities to share knowledge and ideas. 3. Educate the public about the importance of innovation and creative thinking in their lives to move beyond minimum pay jobs. 8. Table I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.Number of clients served workshops or events held, volunteer, etc. Describe,be specific Number of people who view Exhibitions 2000 Number of out- of-county visitors who attend events related 500 to exhibitions Number of evaluation sheets completed with positive 1000 remarks Number of people participatipS in corresponding workshops 350 Number of exhibitions 8 9. TABLE H: PROGRAM EXPENDITURES FY 13- FY 14-15 FY 14-15 14 Total Grant Actual Budget Request Salary and Wages : : Exhibition Team: Curator, Program, $8,000 $2,000 $10,000 Coordinate,Install, Obtain and Record Viewer comments. Professional Fees: Artist instructors whose works are $52,920 $40,000 $5,000 reflected in Exhibits Operations Supplies : Art Exhibition materials,paint, signage, $2,000 $18,627 $2,000 brochures Equipment Other: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: of u-c'[ GU Frat ndq+lon 4r Ar�5 4 Cj&lrQ Program Name: Y'-l' torp q+- o-n io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Mawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed r, eaardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: If no conflicts exist, check here. r EvwLl- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: �c)[UOjreo F0 u ndaj f liar) 7�or 44-5 cp e' lire' Program Name: il. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawail.goy, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until,a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at httg://www.hawaiicountv.gov/fn-nonproLit-grant-formsl on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawal'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of our a enc 's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. - 1"7v` Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: uAl oa) �FmJa�i Ott -Poo Arlb 4 8t6r6 Program Name: Arf aregfeS 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 1415 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $0.00 Additional Council directives reeardin award: EXH I BIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 so HOPE Services Hawaii, Inc, Care - A - Van Homeless Outreach Program Agency Name: HOPE Services Hawaii, Inc. Program Name: Care-A-Van Homeless Outreach Program Agency Director-, Grandee Menino Phone.No.:(808)933-6013 Contact Person: Carol Matayoshi Phone No.:(808) 936-3995 Mailing Address: Address: 296 Kilauea Ave. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1) 116 Kapiolani St., Hilo Address: 2) 74-5593 Pawai Place City,ST,Zip Kailua-Kona, HI 96740 Email Address: bmenino @hopeserviceshawaii.org Fax No.: (808) 935-3794 Accountant/CP Shelly Toledo Phone No.:(808) 933-6008 Firm (if applicable): Mailing Address: Address: 296 Kilauea Avenue Address: City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Bequest for County Nonprofit Grant Program Funds: $15,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $1 0,000.00 $15,000.00 $15,000.00 2. Agency Mission Statement: Our mission is to bring to life the gospel values of justice, love, compassion, and honer through service, empowerment, and advocacy. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Care-A-Van Homeless Outreach Program 3.P=Wam Description. Mobile Outreach Specialists travel to areas where unsheltered homeless people congregate to help them to get into healthier and more stable living conditions. They provide emergency supplies, including food clothing, blankets, and hygiene items. The prime goal is to connect homeless individuals and families to mainstream community resourees, and ultimately, to obtain Iousonq and staff-sufficiency. 4. Total Budget& Position Count: Total Program Budget: $727,500.00 Total Program Position Count: 10 Total Agency Budget: $3,722,535.05 Total Agency Position Count: 38 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-1S Revenue Source Estimate State/Dept of Human Services, Homeless Programs Office $612,500.00 State/Dept of Health, Adult Menta[ Health Division $100,000.00 Hawaii County $15,000.00 TOTAL: $727,500.00 Attach additional pages,if needed. 5. Explain what plans your agency or program has to increase revenues to support this program: HOPE will continue to search-and apply for government grants and private nrants throunh foundations and other charitable organizations to heir) suj�tain our homeless outreach program We are also lookwna fi nr _raicin_ nn, sb ldtia,; and dPye1nning a dnnor base EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Care-A-Van Homeless Outreach Program 7.Program Objectives Using County Nonprofit Grant Program funds: The ob'ective is to help fund a full-time outreach specialist, whose -primary focus iq to-work with the chronically homeless population. This L _a population as theV are set'jo-their S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results fl.e.:Numberofclients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of chronically homeless persons(CHP) contacted/engaged 100 Number of intakes/assessments conducted for CHP 70 Number of CHP provided with emergency food/supplies 70 Number of CHP provided with medical/dental health referrals 60 Number of CHP linked to mental health service provider 40 Number of CHP placed in emergency or transitional housing 25 Number of CHP placed in permanent housing 20 Attach additional pages as necessary. 9.TABLE fl: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Totaf Budget Grant Req Salary and Wages $490,59 $490,591.0 $15,000. Professional Fees $1,407A $1,407.00 Operations $212,00 $212,002.0 Supplies $16,000 $16,000.00 Equipment $7,500A $7,500.00 Other: Other: Other: Other: Other: TOTAL $727,50 $727,500.0d$15,000.( *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Care-A Van Homeless Outreach Program u). ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. (" f 3 c Signa re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Care-A-Van Homeless Outreach Program ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Exoress, and be compliant prior to final payment. To register,go to htt vendors.ehawaii. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a_grant from the County of Hawai'i, I(we) understand and will comply-with the requirement to submit a year-end report to the County Council within 60 days after.Tune 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a fisting of other funding sources and amounts obtained during the award period. Failure to submit a timely complete, and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a,written report is submitted to,and accepted by._the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at littp-:://www.hawaiicounty.gov/fn-nonprofit-grant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these fynds in a timelk manner will impact the evaluation of our a enc 's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. j�� A 13 f d-0-I Sig ature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Care-A-Van Homeless Outreach Program 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of chronically homeless persons(CHP) contacted/engaged 100 Number of intakes/assessments conducted for CHP 70 Number of CHP provided with emergency food/supplies 70 Number of CHP provided with medical/dental health referrals 60 Number of CHP linked to mental health service provider 40 Number of CHP placed in emergency or transitional housing 25 Number of CHP placed in permanent housing 20 TABLE II; PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $15,000.00 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $15,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 51 HOPE Services Hawaii, Inc. Hawaii County's Going Home Consortium Agency Name: HOPE Services Hawaii, Inc. Program Name: Hawaii County's Going Home Consortium Agency Director: grandee Menino Phone No.:(808) 935-3050 Contact Person: Brandee Menino Phone No.:(808) 935-3050 Mailing Address: Address: 296 Kilauea Avenue Address: city, sT,zip Hilo, HI 96720 Facility Address: Address: same Address: City,ST,Zip Email Address: bmenino @hopeserviceshawaii.org Fax No.: (808) 935-3794 Accountant/CP Shelly Toledo Phone No.: (808) 933-6008 Firm (if applicable): Mailing Address: Address: 296 Kilauea Avenue Address: City,5T,zip Hilo, H 196720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTI FY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: .$17,400.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2. Agency Mission Statement: Our mission is to assist Hawaii Island men and women released from correctional institutions with re-integration into community life. The consortium's mission is consistent with the agency's mission to "Bring to life_cosi el_values of iustice_ love, COmnassion andj.ope through „ EKHI BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Hawaii County's Going Home Consortium 3. Program Description: The Going Home Consortium was established to be involved in organizing coordinating. facilitating and developing services for persons going home after bein released from incarceration. It accomplishes these tasks by bein a central point of communication among more than sixty volunteer organ groups, and stakeholders. It has operated fQ[ over ten Vears on priyatecQntrbutwons and volunteer efforts_ 4,Total Budget& Position Count: Total Program Budget: $23,400,00 Total Program Position Count: 0 Total Agency Budget: $3,722,636.06 Total Agency Position Count: 38 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Annual Fundraising Dinner $4,000.00 Voluntary contributions $2,000.00 TOTAL: $6,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We-will-c-Qnfinue to search for additional fundang opportunaties as well as hosting our Annual Fundraising Dinner and sol 0 citation of voluntarV EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Hawaii County's Going Home Consortium 7.Program Objectives Using County Nonprofit Grant Program Funds. In light of an anticipated increase in persons going home from incarceratian. the Consortium has identified two key Qbjectives -1 . Improve administrative manaiqlament of the Consoftlum-_ 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops orevents held,volunteer hours,etc.Describe,be specifre.) 1. All general meeting minutes accurately recorded and promptly Minutes from all twelve sent to members. meetings seat and received 2. All Executive Committee meeting minutes accurately recorded Minutes from all EC meetings and promptly sent to Executive Committee members. sent and received 3. At least six training events conducted during the year. 6 - 8 training events held Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14--15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees $19,200.00 $15,600. Operations $3,000.00 $1,200.0 Supplies $1,200.00 $600.00 Equipment Other: Other: Other: Other: Other: TOTAL $O.QQ $23,400.00 $17,400. *If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Hawaii County's Going Home Consortium so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be si ned re ardless o whether a con list exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ef If no conflicts exist, check here. Ivi&Yt t,- r131I�� _ Signature of Authorized Person (specify title) ! Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Hawaii County's Going Home Consortium u. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135— 2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the progra,m(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://yendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 50 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your pragram's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all Grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted try,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely,manner will Impact the evaluation of your agency's lure funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. -6±,� ti--- / C ev 113111 ignature of Authorized Person (specify title) Date EXHI BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Hawaii County's Going Home Consortium 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURE'S Applicant Council Proposed Projected Results Projected Result 1. All general meeting minutes accurately recorded and promptly Minutes from a sent to members. meetings sent ; 2. All Executive Committee meeting minutes accurately recorded Minutes from a and promptly sent to Executive Committee members. seat and receiv 3. At least six training events conducted during the year. 6 - 8 training eN TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees $15,600.00 Operations $1,200.00 Supplies $600.00 Equipment Other: Other: Other: Other: Other: TOTAL $17,400.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 52 Hope Services Hawaii, Inc. HOPE Resource Center (HRC) Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource Center (HRC) Agency Director: Brandee Menino, CEO Phone No.:(808)936-3050 Contact Person: Kate Nawahine Phone No.:(808) 933-6017 Mailing Address: Address: 296 Kilauea Avenue Address: city,sT,zip Hilo, HI 96720 Facility Address: Address: 116 Kapiolani St. Address: City,sT,zip Hilo, HI 96720 Email Address: bmenino @hopeserviceshawaii.org Fax No.: (808) 935-3794 Accountant/CP Shelly Toledo Phone No.:(808) 933-6008 Firm (if applicable): Mailing Address: Address: 296 Kilauea Avenue Address: MY,sT,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTL Y NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000.00 I. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $10,000.00 $16,000.00 $15,000.00 2.Agency Mission Statement: HOPE Services Hawaii Inc. mission is to: "Bring to life gospel values of and services lncl g_olztre advncar V, representative ayee EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2025 Page 1 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource Center (HRC) 111 �MNWI MM��� 3.Program Description: _HRC is a service-enriched transitional shelter for public safety involved men. With a targeted stay of twelve months, HRC provides lessons in _budgeting, cleanliness, and tenant readiness. Our on-site coordinator provides one-on-one goal setting and linkages to essential services, in uding,housinq, mental health, ,medic , dental, substance abuse tr-eatment, community voluntarism and housing -ement 4. Total Budget& Position Count: Total Program Budget: $285,943.00 Total Program Position Count; 5 Total Agency Budget: $3,722,535.05 Total Agency Position Count: 38 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii $20,000.00 State of Hawaii $202,480.00 Program Fees $43,463.00 Hawaii Island United Way $20,000.00 TOTAL: $285,943.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to search for additional funding opportunities to enrich service, reduce aperatina costs and increase hours of operation and staffing _ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource Center (HRC) 7. Program Objectives Using County Nonprofit Grant Program ends: Funding from the County of Hawaii will cover personnel cost to maintain .the inteqritLand stability oLthe Program. S.TABLE L What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results #.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of persons placed in transitional shelter 20 Number of persons placed in permanent housing 25 Number of persons participating in eduljob training assistance 15 Number of persons obtained employment 25 Number of persons participating in substance abuse treatement 15 Number of persons accessing mental health services 24 Number of persons participating in community activities 50 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Rey Salary and Wages $159,53 $159,530.0 $18,000. Professional Fees $0.00 $0.00 $0.00 Operations $122,41 $122,413.0 $0.00 Supplies $4,000.f $4,000.00 $0.00 Equipment $0.00 $0.00 $2,000.0 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 TOTAL $285,91$285,943.0 $20,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource Center (HRC) io, ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be sinned, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © if no conflicts exist, check here. Sign ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name. HOPE Resource Center (HRC) 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawal'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. t=axed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express,and be compliant prior to final payment. To register,go to http://vendors.ehawaii.eov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the re uirement to submit a year-end report to the County Council within 60_days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a_timely, complete, and accurate year-end report, using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30'h shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.govZLn-nonprofit-prant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation of aura enc 's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signa re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource Center (HRC) 12.COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of persons placed in transitional shelter 20 Number of persons placed in permanent housing 25 Number of persons participating in eduljob training assistance 15 Number of persons obtained employment 25 Number of persons participating in substance abuse treatement 15 Number of persons accessing mental health services 24 Number of persons participating in community activities 50 TABLE ll: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $18,000.00 Professional Fees $0.00 Operations $0.00 Supplies $0.00 Equipment $2,000.00 Other: $0.00 Other: $0.00 Other: $0.00 Other: $0.00 Other: $0.00 TOTAL $20,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 53 HOPE Services Hawaii, Inc. Kihei Pua Emergency Shelter Agency Name. HOPE Services Hawaii, Inc. Program Name: Kihei Pua Emergency Shelter Agency Director, Bmdee Menine,CEO Phone No.:(808)935-3050 Contact Person: Kate Nawahine Phone No.:(808) 933-6017 Mailing Address: Address: 296 Kilauea Avenue Address: City,sT,zip Hilo, HI 96720 Facility Address: Address: 115 Ka iolani Street Address: city,sT,zip Hilo, HI 96720 Email Address: bmenino @hopeserviceshawaii.org Fax No.: (808) 935-3794 Accountant/CP Shelly Toledo Phone No.:(808) 933-6008 Firm (if applicable): Mailing Address: Address: 296 Kilauea Avenue Address: City,sT,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTL Y NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $13,750.00 $15,000.00 $15,000.00 2.Agency Mission Statement: HOPE Services Hawaii, Inc, mission is to: "Bring to life gospel._values of- justice, love, compassion„and hope throuqh-s-eryice, empowerment and advocacy.” We carry Ou,f_this mission throuah,_a continuum of_proorams�_ y and services_including nutreach,_advoc,acy, sentafi na e servines, emergency and transitional Shelter, service enric6eri h---- community reintegration and financial em. nt- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Kihei Pua Emergency Shelter B. Program Description; Kihei Pua is a service-enriched emergence shelter for homelessness individuals and families. With a targeted stag of six weeks, Kihei Pua provides lessons in budgeting, cleanliness, and tenant readiness. Our on-site coordinator provides one-on-one goal setting and linkages to child care, essential services includina.housing, mental health, madical, dental, substance abuse treatment, and housing placement. 4. Total Budget & Position Count: Total Program Budget: 1$575,144.00 Total Program Position Count: 8 Total Agency Budget: $3,722,535,05 Total Agency Position Count: 38 5. Program Funding Sources (identify all sources of funding applied to this grogram): FY14-15 Revenue Source Estimate County of Hawaii $20,000.00 State of Hawaii $513,061.00 Program l=ees $17,280.00 ESG $24,503.00 TOTAL: $575,144.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to search for additional funding opportunities to enrich service_ reduce operating costs and increase staffing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Kihei Pua Emergency Shelter 7. Program Objectives Using County Nonprofit Grant Program Funds: -Funding from the County of Hawaii will cover ersonnel cost to maintain the integrity and stabilitV Qf the prQaam.- S.TABLE l: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Numberaf clients served workshops orevents held,volunteer hours,etc.Describe,be specific.) Number of persons placed in emergency shelter 300 Number of persons placed in permanent housing 120 Number of persons placed in transitional housing 20 Number of persons participating in eduljob training assistance 50 Number of persons who obtained employment 25 Number of persons participating in substance abuse treatement 10 Number of persons accessing mental health services 40 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $334,55 $334,559.0 $20,000. Professional Fees $7,740.1 $7,740.00 $0.00 Operations $198,44 $198,440.0 $0.00 Supplies $32,405 $32,405.00 $0.00 Equipment $2,000. $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 TOTAL $575,14 $573,144.0 $20,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Kihei Paa Emergency Shelter if}. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawal`i. Only those listed below need to be disclosed, One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a con lict exists. NAM E: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. Signa ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Kihei Pua Emergency Shelter ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations, (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'!, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii ! we understand and will comply with the re uirement to submit a ear-end report to the County Council within 60 da s after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate-year-end report, using the tem late provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received durine the Brant period (must be refunded to County)and exclusion from future rant participation for a minimum of one year or until a written report is submitted to and acce ted by,the council. I(we) understand there is no provision for further notification to submit the final report. Information and instructions are available at ht_tp://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will im act the evaluation of our agency's future funding request and may result in actions taken to recover these,Lunds. By signing below, you are acknowledging that you have read and understood these requirements. 'All Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: HOPE Services Hawaii, Inc, Program Name: Kihei Pua Emergency Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of persons placed in emergency shelter 300 Number of persons placed in permanent housing 120 Number of persons placed in transitional housing 20 Number of persons participating in eduljob training assistance 50 Number of persons who obtained employment 25 Number of persons participating in substance abuse treatement 10 Number of persons accessing mental health services 40 TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $20,000.00 Professional Fees $0.00 Operations $0.00 Supplies $0.00 Equipment $0.00 Other: $0.00 Other: $0.00 Other: $0.00 Other: $0.00 Other: $0.00 TOTAL $20,000.00 Additional Council_directives rewarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 20142015 Page 7 of 7 54 HOPE Services Hawaii, Inc. Shelter+ Care: Kukui and New Direction Agency Name: HOPE Services Hawaii, Inc. Program Name:Shelter+ Care: Kukui and New Direction Agency Director: Brandee Menino Phone No..(808) 933-6013 Contact Person: Jeremy McComber Phone No.:(808) 933-6005 Mailing Address: Address: 296 Kilauea Avenue Address: City,sT,zip Hilo, HI 96720 Facility Address: Address: 116 Kapiolani Street Address: - ^ city,sT,zip Hilo, HI 96720 Ismail Address: bmenino @hopeserviceshawaii.org Fax No.: (808) 935-3794 Accountant/CP Shelly Toledo Phone No.: 808) 933-6008 Firm (if applicable): Mailing Address: Address: 296 Kilauea Avenue Address: City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $15,000.00 2.Agency Mission Statement: HOPE Services Hawaii Inc. mission is to: "Bring to life gospel values of iustice, love, compaSSbo-and hope through-seuice, empowerment and _admay-asw." This mission is carried out through_a continuum of nr_oarams that include. homeless and mental health nutrPach, rernresPntative payee services, emergency and transitional Pnt EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name'Shelter+ Care: Kukui and New Direction 3,Progmm Description, The Shelter + Care (S+Q programs provide permanent supportive housing for persons experiencing homelessness with a targeted disability, primarily those with a severe and persistent mental illness. Preference is given to those that meet HUD's definition of chronically hom-el-ess—C-mmunity indners lamide supportive services that allow our clients to live by lying independently in their own home. 4. Total Budget& Position Count: Total Program Budget: $498,063.00 Total Program Position Count: Total Agency Budget: $3,722,535.05 Total Agency Position Count: 38 5. Program Funding Sources (identify ail sources of funding applied to this grogram): FY14-15 Revenue Source Estimate Kukui: State of Hawaii, Department of Human Services (BESSD) $387,275.00 New Direction: State of Hawaii, Department of Human Services (BESSD) $52,387.00 Hawaii Island United way $6,930.00 TOTAL: $445,792.00 Attach additional pages,if needed 6. Explain what plans your agency or program: has to increase revenues to support this program: S+C revenue is restrmdome with Z% allowed for personnel. Due to a decrease in state.funding. 1.00% of state funding will be used for rent assistance to avoid terminating services to clients, also seeking rp-veni ip throi iah other state ft inding, private grants and foi ind�t'ions_ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name:Shelter+ Care: Kukui and New Direction 7,Program Objectves llsjng County Nonprofit Grant Program Funds: Funding from the County will cover a portion of one 1 full-time staff and operational costs needed to maanta'n the 'nteqrity of the proqran-- With the-fundina for-staff, we will be able to maantain housiog stability and avoid dis'placement of 50 hotisebaLd-s. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteerhours,etc.Describe,be specific) Number of households proposed to serve 50 Number of persons proposed to serve 80 Number of households that will increase their income 25 Number of persons that will enroll in education/job training 5 Number of households that will receive supportive services 50 Number of households that will maintain permanent housing 50 Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Rey Salary and Wages $43,840 $56,901.00 $13,061. Professional Fees $0.00 $0.00 $0.00 Operations $1,900.1 $1,500.00 $1,500.0 Supplies $0.00 $0.00 $0.00 Equipment $0.00 $0.00 $0.00 Other:Rent Assistance (Subsidies & Deposits) $468,67 $439,662.0 $5,439.0 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 TOTAL 1$514,411$498,063.0( $20,000. *if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name:Shelter+ Care: Kukui and New Direction io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. Ile'Ad/ Si ature of Authorized Person (specify title) 7Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014.2015 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name:Shelter+ Care: Kukui and New Direction e rrirrrwrrri ju. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of f=unds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, 1 (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.Rov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii. I (we)-understand and will comply with the requirement, to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation_of your program's or aac ency's future funding,requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant eriod must be refunded to Count and exclusion from future grant Participation for a minimum of one year or until a written report is submitted to and accepted bv,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.s—ovLfn--nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of NawaVi with the final report. Failure to return these funds in a time!y manner will impact the evaluation of our agency's, uture funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signa ure of Authorized Person (specify title) Date EXH I BIT A NONPROFIT GRANT APPLICATION FY 2074-2015 Page 6 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name:Shelter+ Care: Kukui and New Direction 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of households proposed to serve 50 Number of persons proposed to serve 80 Number of households that will increase their income 25 Number of persons that will enroll in education/Job training 5 Number of households that will receive supportive services 50 Number of households that will maintain permanent housing 50 TABLE II; FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $13,051.00 Professional Fees $0.00 Operations $1,500.00 Supplies $0.00 Equipment $0.00 Other: Rent Assistance (Subsidies & Deposits) $5,439.00 Other, $0.00 Other: $0.00 Other: $0.00 Other: $0.00 TOTAL $20,000.00 Additional Council directives re ardin award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 55 HOPE Services Hawaii, Inc. West Hawaii Emergency Shelter (WISP) Agency Name. HOPE Services Hawaii, Inc. Program Name:West Hawaii Emergency Shelter (WHEP) wirrw r�wrwru�wi rw�ri Agency Director-* Brandee Menino, CEO Phone No.:(808)935-3050 Contact Person: Kate Nawahine Phone No.:(808) 933-6017 Mailing Address: Address: 296 Kilauea Avenue Address: City,ST,zip Hilo, Hi 96720 Facility Address: Address: 74-5593 Pawai Place Address: City,sr,zip Kailua, Kona 96740 Email Address: bmenino @hopeserviceshawaii.org Fax No.: (808) 935-3794 Accountant/CP Shelly Toledo Phone No.:-(SOP) 933-6008 Firm (if applicable): Mailing Address: Address: 296 Kilauea Avenue Address: City,ST,zip Hilo, Hl 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $10,000.00 $15,000.00 $15,000.00 2.Agency Mission Statement: HOPE Services Hawaii Inc. mission is to: "Bring to life gospel values of advocam" Wp- c,-a[ry QLA this mission throuqh a continuum of programs and servi-ces indudina nutreach, advocacy reorPsen ive navee -sen4ces, emergency and transitional shelter, service enriched housing, -community reintegration and fi.nanrlal Pmpnvverment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name:west Hawaii Emergency Shelter (WHEP) 3.Program Description; WHEHP is a service-enriched emergency shelter for homelessness single men and women. With a targeted stay of three months WHEHP provides lessons in budgeting, cleanliness and tenant readiness. Our on-site coordinator provides one-on-one gQ,al setting and linkages to essential services includinq.rhousinq, mental he. , medical, dental, substance abuse treatment, and houSina nta_mment 4.Total Budget& Position Count: Total Program Budget: $198,863.00 Total Program Position Count: 3 Total Agency Budget: $3,722,535.05 Total Agency Position Count: 38 5. Program Funding Sources (identify all sources of funding applied to this graeram): FY14-15 Revenue Source Estimate County of Hawaii $20,000.00 State of Hawaii $109,420.00 Program Fees $44,640.00 ESG $24,803.00 TOTAL: $198,863.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to search for ,additional fundinq,QU.portunities to enrich service, reduce operatinc tncrP.;;se_hours of operation and 1 costs and EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name:West Hawaii Emergency Shelter (WHEP) 7. Program Objectives Using County Nonprofit Grant Program Funds. -Funding from the County of Hawaii will cover ersonnel cost and one -0 ) new computer to mainta'n the 'nteqrity and stability of the program, 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.,Number of clients served workshops or events held,volunteerhaurs,etc.Describe,be specific.) Number of persons placed in emergency shelter 50 Number of persons placed in permanent housing 25 Number of persons participating in edu/jab training assistance 15 Number of persons obtained employment 20 Number of persons participating in substance abuse treatement 15 Number of persons accessing mental health services 40 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $117,41 $117,417.0 $18,000. Professional Fees $2,500A $2,500.00 $0.00 Operations $70,246 $70,246.00 $0.00 Supplies $8,700. $8,700.00 $0.00 Equipment $0.00 $0.00 $2,000.0 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 TOTAL $198,86 $198,863.0( $20,0 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name:West Hawaii Emergency Shelter (WHEP) lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. if no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be si gned, regardless of whether a con lict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. A"Ji Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name:West Hawaii Emergency Shelter(WHEP) 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 1.35 —2-142.1, Hawaii County Code, relating to Appropriation of f=unds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register,go to http:Z vendors.ehawaii.goy, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai`I grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end re ort usin the tem late rovided will impact the evaluation of your program's or agency's future Lunding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301h shall result in loss of all Prant funds received Burin the grant period must be refunded to Count and exclusion from future,grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.g vifn-nonprofit-,grant-formsl on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Alv�'4 t co --likik 5ign4re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name:West Hawaii Emergency Shelter (WHEP) 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of persons placed in emergency shelter 50 Number of persons placed in permanent housing 25 Number of persons participating in edu/job training assistance 15 Number of persons obtained employment 20 Number of persons participating in substance abuse treatement 15 Number of persons accessing mental health services 40 TABLE If: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $18,000.00 Professional Fees $0.00 Operations $0.00 Supplies $0.00 Equipment $2,000.00 Other: $0.00 Other: $0.00 Other: $0.00 Other: $0.00 Other: $0.00 TOTAL $20,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 56 Hospice of Hilo (HOH) Hawaii Palliative Care Center - Home of the Transitions Program Agency Name: Hospice of Hilo (HOH) Program Name:Hawai`l Palliative Care Center--Home of the Transitions Program Agency Director: Brenda S. Ho, MS, RN Phone No.:($08) 969-1733 Contact Person: An Umamoto Phone No.:(808) 961-7308 Mailing Address: Address: 1011 Waianuenue Ave. Address: city,sT,zip Hilo, HI 96720 Facility Address: Address: 590 Kapi`olani Street Address: city,sT,zip Hilo, H 196720 Email Address: anthuynC@hospiceofhilo.org Fax No.: (808) 969-4863 Accountant/CP Ioana Agasa, CPA Phone No.:(808) 981-2405 Firm (if applicable): Mailing Address: Address: 230 Kapualani Street Address: MY,sT,Zip Hilo, H196720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $65,600.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12.13 FY 13-14 $0.00 $62,250.00 $45,000.00 2.Agency Mission Statement: To improve the lives of those we touch by offerino.support, g� u�ce and compassionate care of body, m'nd and spirit. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hospice of Hilo (HOH) Program Name: Hawaii Palliative Care Center--Home of the Transitions Program 3. Program Description: The Transitions Program, a component of the Hawaii Palliative Care Center HPCC improves the continuily of care for serious!y ill patients on Hawaii Island through care coordination at no cost to the client, A Transitions' coordinator and team of volunteers help to address the co -pl_ex_needs that often overwheim patients and families 4.Total Budget&Position Count: Total Program Budget: $413,132.00 Total Program Position Count: i 3 Total Agency Budget: $6,286,255.00 Total Agency Position Count: 1$79.00 5. Program Funding Sources(identify all sources of funding applied to this pro ram FY14-15 Revenue Source Estimate State &County $100,000.00 Fee for Service--HPCC Physician/APRN Billable visits $140,000.00 Grants $150,000.00.- Donations $25,000.00 TOTAL: $415,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HPCC bas beaun partnering with local health care oroyiders, allowing fee for_service to begin. As HPCC CIEDWS, HOH anticinatPS.the Iransitions program to be sustained by fee fa 3nd r1rivate donors Cont'nued County support willengure the pro. EXHIBIT A -. NONPROFIT GRANT APPLICATION FY 20142015 Page 2 of 7 Agency Name: Hospice of Hilo (HOH) Program Name:Hawaii Palliative Care Center--Home of the Transitions Program 7.Program Objectives Using County Nonprofit Grant Program Funds: Funding will pay for the vital Full Time Transitions Coordinator who builds program awareness, assmsis in-client health care & resource nammoatban, and volurdeer coordination, Fundinq will also be USed to wild nrnnram nwarPnP�.,q thrnlinh outreach P. material production- S.TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le:Number of clients served workshops or events held,volunteer hours,etc Describe,be specific.) *See attached performance measures document Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual" Total Budget Grant Req Salary and Wages $73,193 $363,647.0 $61,400. Professional Fees $0.00 $6,200.00 $0.00 Operations $6,086. $29,585.00 $0.00 Supplies $638-47 $6,500.00 $0.00 Equipment $0.00 $3,000.00 $0.00 Other: $3,168. $4,200.0L$4,200,0 Other: Other: Other: Other: o TOTAL $83,08 $413,132. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hospice of Hilo (HOH) Program Name: Hawaii Palliative Care Center--Home of the Transitions Program lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. if no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure firms must be signed regardless of whether a conflict exists. NAME: Brenda S. Ho, MS RN POSITION: CEO--Sits on Mayor's Healthcare SestainabilityTask Force May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual os opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: If no conflicts exist, check here. )�P& I ew I-Aq- lq Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Hospice of Hilo (HOH) Program Name: Hawaii Palliative Care Center--Home of the Transitions Program 1f. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135--2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to'Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. 1 (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai`l, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance.Express,and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 50 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by._the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicount.y.goy/fn-nonprofit-grant-forms on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of our agency's Luture funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. , Su, -9, , (?,P, /-c�4-/q Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the rant Period must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted b the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt : www.hawaiicount . ov fn-non rofit- rant-forms on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30,2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a„timely manner will Impact the evaluation of Your agency's future.funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. 'M&O, �' , (?"C' Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2011-2015 Page 6 of 7 Agency Name: Hospice of Hilo (HOH) Program Name:Hawaii Palliative Care Center--Home of the Transitions Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result *See attached performance measures document TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $61,400.00 Professional Fees $0.00 Operations -- $0.00 Supplies $o.ao Equipment $0.00 Other: $4,200.00 Other: Other: Other: Other: TOTAL $65,600,00 Additional Council directives reeardiine award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Hospice of Hilo 8.Table 1: Attachment; What are the intended measurable outputs or outcomes that would be achieved with this funding? County Funding will be used to support the Transitions program component of Hospice of Hilo's Hawaii Palliative Care center. Pro ram Performance Measures Applicant Projected Results Provided education on Advance Health Care *Increased number of presentations delivered,a minimum of Directives(AHCD)&Physicians Orders for Life twelve(12)for grant year Sustaining Treatment(POLST),as well as general *Increased awareness/understanding evident by post presentation education about options for improved end-of-life surveys to determine knowledge gained care *Track number AHCD distributed to interested community members Education of Community&Providers *Have appropriate education materials produced *Design&implement a survey tool to assess availability of resources Collaboration and Increase in Referrals from *Data from 2010-2013 shows a dramatic increase in referrals to Community Partners such as: the Transitions program,showing that outreach and awareness building efforts are succeeding, Private Practice NEvercare;ealth *The program will continue to show strong growth in grant year Ph sicians 2014-2015,by a minimum of 25%. Public Health Nurse vices American Lun Assoc. iors 2010=28 referrals HIV Foundation 201144 referrals Kaiser Ohana Health 201280 refe rrals Queens Medical Ctr Hui Malama 2013=135 referrals HPOC Libe Dial sis United Healthcare 68%increase from 2012 to 2013 382%increase from 2010 to 2013 Patient Navigation&Support Servlces *Data from 2010-2013 shows a marked increase in clients accessing Transitions services,showing that client desire for and utilization of the program continues to increase. *Increased number and utilization of navigation&support services,minimum 25%anticipated. 2010=22 patients served 2011=39 patients served 2012=57 patients served 2013=77 patients served 250%increase from 2010 to 2013 Expanded Transitions/Palliative Care *Increased number and utilization of volunteers and student volunteer/student intern training program interns specially trained in Transitions/Palliative Care *Track number of volunteers and student interns to demonstrate increase numbers,as well as increased skills shown by pre/post training tests *Will offer at least two(2)volunteer/student intern trainings in ant ear Cultivated and Implemented Volunteer care giving *The program will continue to show strop growth in support network 2014-2015,by a minimum of 25%. g grant year 2011=199 volunteer hours 2012298.35 volunteer hours 2013=490.25 volunteer hours 92.25%increase hours served from 2011 to 2013 57 Hui Malama Ola Na "Oiwi 14th Annual Ladies Night Out Event PED Agency Name: Hui Malama Ola WOW Program Name: 14th Annual ladies Night Out Event Agency Director: Michelle M. Hiraishi Phone No.:(808) 969-9220 Contact Person: Kelsey Hiraishi Phone No.:(808) 969-9220 Mailing Address: Address: 69 Railroad Avenue STE A-3 Address: City,ST,zip Hilo, Hawaii 96720 Facility Address: Address: 69 Railroad Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: kelsey @huimalamahawaii.com Fax No.: (808) 961-4794 Accountant/CP Phone No.:(808) 861-1174 Firm (if applicable): CW Associates Mailing Address: Address: Topa Financial Center Address: 700 Bishop St. STE 1040 City,ST,zip Honolulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $5,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: Our mission is: Ho`oulu ola o ka lahui Hawaii - To uplift the health of the Hawaiian nation. We will M51ama is Moku o Keawe -Take care of Hawaii Island, .M_51ama i na kua`aina -Take care of country and rural areas_ Malama I kou nlakinn -Take rare of Your ohm sical, soi� ritual, and men n,5 I body Malama I n mea Hawaii - Take c'arP of Haw'attar cti(tllre and-prartaces We envision a. strong and healthy Hawaiian nation EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: 14th Annual Ladies Night Out Event 3. Program Description: Ladies Ni ht Out is an evening of " am erin " activities haircut manicure, pedicu re,massage,etc) for women identified with health issues and hardship in their life. The objective is to provide women with an opportunity t relieve some tress and allow h mselves to focus on Carina for self and taking advantage of the may pampering services frPPly provided. Please refer o Addendum #1- Program Description 4.Total Budget& Position Count: Total Program Budget. $28,054.00 Total Program Position Count: 39 Total Agency Budget: $2,770,177.00 Total Agency Position Count: 139 S. Program Funding Sources (identify all sources of funding applied to this grogram): FY14-15 Revenue Source Estimate Health Resources Services Administration (HRSA) $23,361.00 County of Hawaii $5,000.00 TOTAL: $28,361.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HRSA cont2nues to be the maior funding source f-Qr this event, Increase sere ' reased over the past two years and will help to cover the nuerall r_nct of the event It is hop di 11 this will continue EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: 14th Annual Ladies Night Out Event 7. Program Objectives Using County Nonprofit Grant Program Funds: County funds will be solely used for professional fees sounds stem and police security) and event supplies such as table and chair rentals, food, paper products, decorations, and overall event sunr) ,s_needed. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 1. Identify and provide health and wellness activities for women with health issues and hardship in their lives. 500 2. Participating women will report a reduction in stress at the event. 375 3. Participating women will report that"if not for the event" they would not be able to get a specific pampering service. 300 4. Community service providers will volunteer pampering services. 150 Attach additional pages as necessary. 9.TABLE fl: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $21,434 $21,434.00 $0.00 Professional Fees $206.00 $1,206.00 $1,206.0 Operations $721.00 $721.00 $0.00 Supplies $5,405. $5,000.00 $3,794.0 Equipment Other: Other: Other: Other: Other: TOTAL $27,766 $28,361.00 $5,000.0 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hui Mslarna Ola NV OW Program Name: 14th Annual Ladies Night Out Event lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 6 ! � Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Hui Malama Ola WOW Program Name: 14th Annual Ladies Night Out Event u. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided will impact the evaluations your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30tH shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.govLfn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NON PROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Hui Malama Ola WOW Program Name: 14th Annual Ladies Night Out Event 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1. Identify and provide health and wellness activities for women . with health issues and hardship in their lives. 50 2. Participating women will report a reduction in stress at the event. 37 3. Participating women will report that "if not for the event" they would not be able to get a specific pampering service. 30 4. Community service providers will volunteer pampering services. 15 TABLE 11: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $0.00 Professional Fees $1,206.00 Operations $0.00 Supplies $3,794.00 Equipment Other: Other: Other: Other: Other: TOTAL $5,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 58 Hui Malama Ola Na "Oiwi Kokua Hali - Health Transportation Program Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Kokua Hali - Health Transportation Program Agency Director: Michelle Hiraishi Phone No.:(808) 969-9220 Contact Person: Kelsey Hiraishi Phone No.:(808) 969-9220 Mailing Address Address: 69 Railroad Avenue STE A-3 Address: City,ST,zip Hilo, Hawaii 96720 Facility Address: Address: 69 Railroad Avenue STE A-3 Address: City,ST,zip Hilo, Hawaii 96720 Email Address: kelsey @huimalamahawaii.com Fax No.: (808) 961-4794 Accountant/CP Phone No.:(808) 861-1174 Firm (if applicable): CW Associates Mailing Address: Address: Topa Financial Center Address: 700 Bishop St. STE 1040 City,ST,zip Honolulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $20,000.00 $12,500.00 $30,000.00 2.Agency Mission Statement: Our mission is: Hdoulu ola o ka lahui Hawaii - To uplift the health of the Hawaiian nation. We will: Malama is Moku o Keawe -Take care of Hawaii Island, M51ama i na kuaAina -Take care of-s_'ountry no d rural areas, Mama I kou olakino -Take care of your physical, sdritual, and and practices VITA envision a strong and healthy Hawaiian nation EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hali - Health Transportation Program 3. Program Description: The Kokua Hali" Health Transportation program to provides access to essential health care on the island. HMQN`4 provides transportation for clients living in all districts on the island to health related appointments. 8 vehicles are used to service Ka'u, Kona, Hilo, Puna, Kohala,Waimea _and Hamakua. Please refer to Addendum #1 - Program Q- s_cription 4.Total Budget& Position Count: Total Program Budget: $253,419.00 Total Program Position Count: 6 Total Agency Budget: $2,770,177.00 Total Agency Position Count: 39 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate HRSA $283,419.00 County of Hawaii $50,000.00 TOTAL: $333,419.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Continue to explore billed revenue options. Develop a fee for service nroaram model. Ne otiate possible f-e-or_service contr_adS-With_the 3 C ommunitV Health Centers fortransnnrtation services-_C'antinl`ie to leverage HRSA fiindonn fnr program needs EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Kokua Haii - Health Transportation Program 7. Program Objectives Using County Nonprofit Grant Program Funds: County funds will be used to support the overall implementation cost of the "K6kua Haii" Health Transportation Program.-_Allocati-mQf funds will be towards fuel & oil, repairs,&-maintenance & insurance cost, It is ntende . to leverage untVsunnart with HRSA for fleet urnarade_ 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results ft.e.:Number of clients served workshops or events held,volunteer hours,etc.Oescribe,be specific.) Hilo residents will be transported to medical related visits. 200 unduplicated passengers Ka'u residents will be transported to medical related visits. 120 unduplicated passengers Kona residents will be transported to medical related visits. 120 unduplicated passengers Puna residents will be transported to medical related visits. 150 unduplicated passengers North Hawaii residents will be transported to medical related visits. 110 unduplicated passengers Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $79,310 $192,750.0 Professional Fees Operations $2,009. $2,749.00 Supplies $221.00 $351.00 Equipment Other:Gas & Fuel $14,197 $31,270.00 $30,000. Other: Repair & Maintenance $7,824. $14,739.00 $15,000. Other:Auto Insurance $5,001. $11,560.00 $5,000.0 Other: Fixed Asset- 2 new vehicles $80,000.00 Other:Note: * Denotes actual expenditures for 8113 thru 12113 TOTAL $108,56 $333,419.0 $50,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Kokua Hali - Health Transportation Program so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as apposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. i 0 Signature of Authorized Person (specify title) Date EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Hui Malama Ola Na 'Oiwi Program Name; Kokua Hali - Health Transportation Program 13.. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. f (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. L 61 " V /01-H - Signature of Authorized Person (specify title) Date I XHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Kokua Hali - Health Transportation Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Hilo residents will be transported to medical related visits. 200 unduplicati Ka'u residents will be transported to medical related visits. 120 unduplicati Kona residents will be transported to medical related visits. 120 unduplicati Puna residents will be transported to medical related visits. 150 unduplicati North Hawaii residents will be transported to medical related visits. 110 unduplicati TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Gas & Fuel $30,000.00 Other; Re air& Maintenance $15,000.00 Other: Auto Insurance $5,000.00 Other: Fixed Asset - 2 new vehicles Other: Note: * Denotes actual expenditures for 8113 thru 12113 TOTAL $50,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-20155 Page 7 of 7 Agency Name: Hui Malama 01a Na `Oiwi Program Name: Kokua Hali - Health Transportation Program Addendum #1 — Program Description Program Description continued from Application Exhibit A Section 3. HMON'O's transportation service operates Monday through Friday with scheduling flexibility to accommodate client needs. Transportation outside of the normal operating hours is approved on a case by case basis. The need on Hawaii Island for transportation continues to be an issue of need. As pointed out in the State Transportation Plan document, Hawaii Island faces a failing infrastructure that supports mobility for much of the population. Socio-economic barriers and the added "baby boomer" population reaching the age where there are limitations available for effective health related transportation for the older aged population. The challenges remain in our island communities for access to health care with a large number of our transportation clientele dependent on our provided transportation services island wide. Highlights from our program for 2013 demonstrate the effectiveness of our ability to support the needs of our island residents. A total of 136,820 miles were recorded on odometer reading from all vehicles used to provide direct service transports of island residents. Mileage distribution varied across the island with the Puna vehicles reporting a total of 31,140 miles of travel with Kona at 26,600, Kau at 28,916, Hilo at 28,353 and Waimea at 21,811 miles of travel. There were 693 unduplicated clients that used our transportation services at least 1 time though-out the year compared to 535 in 2012. The distribution of community residents showed that 210 individual clients used our Hilo transportation service, 146 in Puna, 125 in Kona, 115 in Ka'u and 97 in Waimea. This continues to play a major role in HMON'O recognizing the importance of maintaining this program. Data reports demonstrate some of the significant details of transport destinations that reflect the on- going need for our Hawaii Island population's access to health care: 2,864 transports were completed to island Physicians and Primary Care providers 682 transports were to pharmacies for medication 362 transports were to island laboratories as referred by client PCP for lab work. 213 transports were to our 3 Community Health Centers. 806 transports were to Chronic Disease Management& Health Education classes. 139 transports were to dentist. 15 transports were for mental health services. 344 transports were to other related needs such as social services, mental health, housing, DHS etc... 4,775 passengers were picked up and dropped off at their home residence. Please note that most transports begin and end at each passenger's home residence. It is our belief that our program supports the effort the County of Hawaii to build our transit infrastructure and is in alignment with other transportation programs in helping those with the need to have a mode that allows them to better care for their health. Year after year HMON'O continues to see the need for acquiring support for this program as there have been limiting funding for such as robust service. Our current vehicles are registering high numbers of Agency Name: Hui Wlama Ola Na `Oiwi Program Name: Kokua Hali - Health Transportation Program Addendum #1— Program Description miles and pose some financial challenges from year to year. High mileage means constant maintenance, increased fuel cost and insurance cost. It is our hope that the County of Hawaii supports this program and see's the viability of transportation services that services our entire island community. It is our vision to use all funding appropriated via the County of Hawaii to articulate and seek approval from the Health Resources Services Administration (HRSA)to update our current fleet of vehicles with two new vans. County funding would be allocated only towards fuel, repair/maintenance and insurance costs for our transportation fleet. 60 Hui Pono Holoholona Subsidized Low Cost Spay/Neuter Clinics Agency Name: Hui Pono Holoholona Program Name:Subsidized Low Cost Spay/Neuter Clinics Agency Director: Frances P. Pueo Phone No.:(808) 968-8279 Contact Person: Frances P. Pueo Phone No.:(808) 769-1128 Mailing Address: Address: PO Box 943 Address: City,ST,zip Mt. View, Hi 96771 Facility Address: Address: 11-3436 Hibiscus Street Address: City,ST,Zip Mt. View, Hi 96771 Email Address: webmistress @hphhawaii.org Fax No.: Accountant/CP Vivian S. Toellner Phone No.:(808) 345-2753 Firm (if applicable): Mailing Address: Address: PO Box 6,894 Address: City,ST,rA Hilo, Hi 96720 YOU ARE RESPONSIBLE TO KEEP THEABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds; $25,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: I=Y 11-12 FY 12-13 FY 13-14 $11,000.00 $10,000.00 $10,000.00 2.Agency Mission Statement: HPH is an all volunteer, non profit 50 c 3 animal organization, dedicated to providing Low Cost Spay/Neuter for Cats/Dogs in the communities of East Hawaii_ We also trap. Spa-WNeuter,_Examine, Vacdnntp, Release & Manage (INRM) feral & abandoned catlk'ttens in EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Hui Pono Holoholona Program Name:Subsidized Low Cost Spay/Neuter Clinics 3. Program Description: HPH advertises periodic Spay/Neuter clinics & works directly with the community to provide traps, transportation & assess individuals with rapping when necessary, We also have daily p o ne contact maintain lists of people in need of our assistance. From 2007 until end- o end— of 2013 we spayedineutered over 260U Dogs & Cats. rhese gran funds we are requesting will a used to maintain & increase our e o s as our operation is outgrowing our donations. 4.Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 12 Total Agency Budget: $14,984.71 Total Agency Position Count. 3 S. Program Funding Sources(identify all sources of funding applied to this program : FY14-15 Revenue Source Estimate General/Donation Box/Clinic Donations $12,398.77 HSUS Photo Contest & Pet Food Grant $682.18 Give Aloha & Program Matching Donations $1,312.69 Yard Sale $141.00 Mauna Lani Charity Tree $159.07 Volcano Parade/Hi-5 Recycle/Mission Fish-ebay & Others $154.00 County Fair Sales and Donations $137.00 TOTAL: $14,984.71 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Continuation of donations & fundraising as we have been doing since our inception. Spay Day Rally to be held in April 2014 at Mo oheau Bandstand, potential annual undraiser and community education event. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:Hui Porto Holoholona Program Name:Subsidized Low Cost Spay/Neuter Clinics 7. Program Objectives Using County Nonprofit Grant Program Funds: -Sponsor low cost pay/Neuter clinics for the public. 2-Transport Animals mweeKly to and from Spay/Neuter clinics. - ranspo traps ait food-to-and from homes of individuals. 4-Purchase me Ica supplies for the Spay/Neuter clinic. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.;Number of clients served workshops or events held,volunteer hours,etc.Describe,be speck.) Dr. Lyle Brooksby 166 Dr. Seeske/Kilauea Vet Services 35 Aloha Veterinary Center 38 Dr. Yoko Haneda 79 Dr. Castro /Hilo Vet Clinic 21 Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 14-15 FY 14-i5 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $0.00 $0.00 $0.00 Professional Fees $0.00 $0.00 $0.00 Operations $30,000.00 18,000.01 Supplies $6,000.00 $4,000.00 Equipment $4,000.00 $3,000.013 Other: Other: Other: Other: Other: TOTAL 1 $0.00 l $40,000.00 ;25,000.0/ *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Hui Pono Holoholona Program Name:Subsidized Low Cost Spay/Netter Clinics ;o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawal'i. Only those listed below need to be disclosed. One form per person with a conflict is needed, if no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: if no conflicts exist,check here. Si nature of Authorized Person (specify title) Date EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Hui Pono Holoholona Program Name:Subsidized Low Cost Spay/Neuter Clinics 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant, contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express,and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of_Hawai'i, I (we) understand and will-comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shalt include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by county of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation_of your progrraes or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the Brant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicount_y.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report.Failure to return these Lunds in a timely manner will impact the evaluation of our agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:Hui Pono Holoholona Program Name:Subsidized Low Cost Spay/Neuter Clinics 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Dr. Lyle Brooksby 166 Dr. Seeske /Kilauea Vet Services 35 Aloha Veterinary Center 38 Dr. Yoko Haneda 79 Dr. Castro/Hilo Vet Clinic 21 TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $0.00 Professional Fees $0.00 Operations $18,000.00 Supplies $4,000.00 Equipment $3,000.00 Other: Other: Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 61 Innovations Public Charter School Foundation Nurturing the Body, Mind and Spirit through Responsible Choices Agency Name: Innovations Public Charter School Foundation Program Name: Nurturing the Body, Mind and Spirit through Responsible Choices Agency Director: Jennifer Hiro Phone No.:(808) 327-6205 Contact Person: Julie "Lee" Nelson Phone No.:(808) 756-5492 Mailing Address: Address: 75-5815 Queen Ka'ahumanu Address: Hwy. city,ST,zip Kailua Kona, HI 96740 Facility Address: Address: 75-5815 Queen Ka'ahumanu Address: Hwy. City,ST,zip Kailua Kona, HI 96740 Email Address: ieenelson.ipcs @konaimage.com Fax No.: (808) 327-6209 Accountant/CP Gretchen Kremeyer, CPA Phone No.:(808) 968-1002 Firm (if applicable): Carbonaro CPA & Associates Mailing Address: Address: P.O. Box 4372 Address: City,5T,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: - $10,000.00 gc-..vm .,m mmy�_._.r..... ..., ... 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $5,000.00 $10,000.00 2. Agency Mission Statement: To provide support for Innovations Public Charter School and the community by heloina to aurtu.re the bady_ mind and spirit of the choldren-of West Hawaim Innovations Enundation makes every Pffort to- stFoves to teaGh students te make respensible Gh9iC;eS that will lead to EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Innovations Public Charter School Foundation Program Name: Nurturing the Body, Mind and Spirit through Responsible Choices 3. Program Description: In "Nurturing the Body, Mind and Spirit through Responsible Choices" students will work hands on with Garden Instructor Krista Donaldson and Phiv-sical Educator, Jennv Crusat to promote. health food and ;� urnrrl -ins 4.Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 0 Total Agency Budget: $360,000.00 Total Agency Position Count: 0 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Healy Foundation $10,000.00 Hawaii Community Foundation $5,000.00 County of Hawaii GIA $10,000.00 TOTAL: $25,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our fQuodatim is continuing its middle school expansion. Funds will be used to -.suppod additional droijaht tolerant 'ndigenous plants and fni't and veget�b'le local plants SUPPlieS tO protect garden areas from pigs— Funds to provide irrigation SUpplies for- the nnW-fitne EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: innovations Public Charter School Foundation Program Name: Nurturing the Body, Mind and Spirit through Responsible Choices 7. Program Objectives Using County Nonprofit Grant Program Funds: Lesson will be taught in solar energy, reclaiming waterg.rowing local and responsihIrn, food choices aq well-as the i -e of nurturinq the, body through daily exercise- lsemntn iq rl Ir large, level p1ayf'P--Ic-J. K-g-oki will 1Q2rn to move 2nd enjoy fitnes-s- 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Numberofciients served workshops or events held,volunteer hours,etc.Describe,be specific.) 240 Students and 240 parents will attend community workshops 400 in attendance 3 Community Breakfasts highlighting IPCS sustainable practices 250 in attendance 4 Volunteer days to plant indigenous plants for landscaping 100 in attendance Community volunteers to talk to students about health and fitness 240 students Tours of school campus highlighting sustainable pracitices 100 visitors Vermiculture, recycling and composting tours led by students 100 visitors Volunteer Garden Hours from local community college 200 hours Attach additional pages as necessary. 9.TABLE I1: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $6,750. $10,000.00 $0.00 Professional Fees Operations Supplies $10,000 $10,000.00 $5,000.0 Equipment $5,679. Other: Irrigation system for playfield $5,000.00 $5,000.0 Other: Other: Other: Other: TOTAL $24,429 $25,000.00 $10,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Innovations Public Charter School Foundation Program Name: Nurturing the Body, Mind and Spirit through Responsible Choices Zo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. if no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. ZPGS t=ouvicActi,ov, i)2`Ilzr'1�l SignaturA fAuth rized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Innovations Public Charter School Foundation Program Name: Nurturing the Body, Mind and Spirit through Responsible Choices . 1Z. Certification of Understanding 1 (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one ear or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:Z/www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these Lunds in a time!y manner will impact the evaluation of our a enc 's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. ' q 'C5 1=o u.-.cl0jLQ h 1)�-9 1-2-0) d y Signa re of thorized Person (specify tit e) Date EXHIBIT A NONPROFIT"GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Innovations Public Charter School Foundation Program Name: Nurturing the Body, Mind and Spirit through Responsible Choices 12. COUNCIL. AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Resuits Projected Result 240 Students and 240 parents will attend community workshops 400 in attendqj 3 Community Breakfasts highlighting IPCS sustainable practices 250 in attend 4 Volunteer days to plant indigenous plants for landscaping 100 in attendaA Community volunteers to talk to students about health and fitness 240 students Tours of school campus highlighting sustainable pracitices 100 visitors Vermiculture, recycling and composting tours led by students 100 visitors Volunteer Garden Hours from local community college 200 hours TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $0.00 Professional Fees Operations Supplies $5,000.00 Equipment Other: Irrigation system for playfield $5,000.00 Other: Other: Other: Other: TOTAL $10,000.00 Additional Council directives re ardin award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 62 Ka Hale O Na Keild, Inc. Families - At- Risk Agency Name: Ka Hale O Na Keiki, Inc. Program Name: Families-At-Risk Agency Director: Kathy Oshiro Phone No.:(808)-775-9870 Contact Person: Paula Seguerre Phone No.:(808)775-9870 Mailing Address: Address: 45-3668 Honokaa-Waipio Rd. Address: City,5T,Zip Honokaa HI 96727 Facility Address: Address: SAME Address: City,ST,Zip Email Address: 808paulaj @gmail.com Fax No.: (808)-775-9055 Accountant/CP Stacy Chun Phone No.:(808)-885-8589 Firm (if applicable): Stacy's Bookkeeping Mailing Address: Address: P.O Box 7096 Address: City,5T,Zip Kamuela, Hi 96743 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 10,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 8,000.00 7,750.00 10,000.00 2.Agency Mission Statement: r See additional sheets#2y� r� G'-C' EXHIBIT A NONPROFIT GRANT APPLICATION F Pagel of 7 Agency Name: Ka Hale O Na Keiki, Inc. Program Name: Families-At-Risk 3. Program Description: See additional sheets#3 4.Total Budget& Position Count: Total Program Budget: $95,031.00 Total Program Position Count: 7 Total Agency Budget: $356,565.00 Total Agency Position Count: 7 5. Program Funding Sources(identify all sources of funding applied to this program). FY14-15 Revenue Source Estimate See attachment#1 TOTAL: $0.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: see additional sheets#6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Ka Hale Q Na Keiki, Inc. Program Name: Families-At-Risk 7. Program Objectives Using County Nonprofit Grant Program Funds: see additional sheets#7 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Enrollment 39 Children enrolled 2:00 - 5:30 pm Families-At-Risk Program 32 Families receiving Financial assistance from Ka Hale O Na Keiki (coat) 32 for Families-At-Risk Program Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages 46,000 56,850 4200 Professional Fees 2,000 1,825 500 Operations 28,200 26,500 2500 Supplies 3,000 5,525 1900 Equipment 1,900 2,700 900 Other: Other: Other: Other: Other: TOTAL 81,100 95,031 10,000 *If applicable EXHIBITA ]NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Ka Hale O Na Keiki, Inc. Program Name: Families-At-Risk so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts.of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, req&dless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor 0 The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to on industry. Please specify any and all mitigation measures to.avoid, in fact or appearance, any conflicts or potential conflicts of interest: [J� If no conflicts 7xist, check here. r Signatur gf Authorized Person (specify title) Date. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Ka Hale 0 Na ON, Inc. Program Name: Families-At-Risk 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. 1 (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawai'i, l (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express,. and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, 1 (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete adcounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation of our program's or agency's uture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.sov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawal'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. 0-cf 44g 1 q Signatur of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Ka Hale O Na Keiki, Inc. Program Name: Families-At-Risk 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Enrollment 39 Children enrolled 2:00 - 5:30 pm Families-At-Risk Program 32 Families receiving Financial assistance from Ka Hale O Na Keiki (col 32 for Families-At-Risk Program TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages 4200 Professional Fees 500 Operations 2500 Supplies 1900 Equipment 900 Other: Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 #2. Agency Mission Statement At Ka Hale O Na Keiki it is our mission to help children develop a lifelong love of learning through a program that encourages freedom, individualism, and creativity. Our carefully prepared environment provides children with an opportunity to explore their surroundings, challenge their thoughts, and enjoy and love the people and world around them. Through a positive interaction among the children's developmental characteristics, their school,practices, family, and community, children will be ready to have successful learning experiences that will - last throughout their lifetime. Above all, our children come first. #3. Program Description The Families-At-Risk Project allows our school to remain open between 2:30 and 5:30 pm daily, year round (including Summers and holidays),providing a safe, stimulating, and caring environment for children ages 24 months to 6 years. This frees parents to work at their jobs, and allows the unemployed to seek work and pursue training and educational opportunities, particularly working parents transitioning from welfare assistance. We serve the working poor. These families are likely to be cut off from the mainstream community because of poverty, racism, lack of education, unemployment, and/or the inability to timely access community and human services. They are therefore at risk of being unable to take care of their basic needs and those of their nuclear family. It is important to understand that our school's positive stimulation of children's brains during these critical first years lays the foundation for the child's future ability to learn, develop language skills, and interact with others. While under our trained, caring, and gentle care, childreni at risk learn self confidence, initiative, self-worth, and independent thinking. Our teachers, all trained in Early Childhood Education (ECE), understand child development and excite our children about learning, as well as provide them., and their families,with basic health and nutritional information and referrals. We promote positive social behavior and conflict resolution, as well as actively engage parents in their children's care and education. Rising drug abuse continues to be our worst nightmare here on the Hamakua Coast. We are the anti-drug. Numerous studies have shown that participation in a quality ECE program can actually prevent illegal drug usage in the future, because we teach these children, at a very early age,how to appropriately handle conflict resolution as well as help them attain good self esteem. If we are to break the cycle of drug abuse in our community, we must begin taking preventative action now, and intervene at the preschool-age level. Our community, our island, and our state also benefit, as it is estimated that for every $1 invested in high-quality ECE programs the public will save $7 in costs like remedial education,welfare, and incarceration. Children who attend high quality ECE programs are more successful in later life and more productive than their peers who did not attend. Studies are showing that children with access to quality programs demonstrate higher I.Q.'s, High School graduation rates, and success than their peers. Most preschools are not open more than eight hours per day because a second qualified teaching staff is'required; and, such a service is just not economically feasible. Ka Hale O Na keiki is not "just another preschool", but a community organization that serves and meets multiple needs for the people of the entire area. With literally no other preschool, besides special needs preschool at the Honokaa Elementary School available in our isolated area,parents would have no where to place their child, except perhaps, in front of a neighbor's TV, if our Families-At-Risk Project was not available. And, obviously, our Families-At-Risk Project benefits our parents, as well as our children. Our low-income parents, leaving welfare rolls and entering the workforce, become more economically self-sufficient because they have been given access to reliable, quality care for their children. .It is imperative, therefore,that we remain open at least 10 hours a day, and operate year round; otherwise,parents would have no where to send their young children for quality care and education. We agree that private funds are a key to our success,but those funds are very limited. Therefore, we also, additional public support in order to help these young children and their families towards a successful,productive future. We need the County's continuing financial support until financial stability is realized. Our community understands and acknowledges the scarcity of County funds to non-prof tg, and we sympathize with the Council's difficult budgetary task. We are very grateful to the financial support we have received in the past from our County and truly believe that the County's continuing investment now in the Families-At-Risk Project will save the County ten-fold in future rehabilitation costs. In this time of Recession, the focus for all of us must be helping our keiki, for they are our future. No time has this belief been more critical for now. #b. Explain what plans your agency or program has to increase revenues to support this program Our absolute goal is to be financially independent of annual grants. With optimism, along with our State government's hopefully renewed interest in providing funds for Early Childhood Education and President Obama's ARRA monies for assistance-to needy famllies,we hope to be financially solvent, and without need for continued County grant funds,within a few years to come. Recent drastic cuts in State funding for ECE supplements to families have made it impossible that our parents pay additional fees for our Families-At-Risk Project. Therefore we need the County funds assistance because it is so critical for the survival of our Project. It must be remembered that our program is one that we were told "could not be done". We were told that our isolated community did not have the economic base to afford an early childhood center, and that our area could not provide the qualified teaching staff to run such a program. We are simply asking the County for their continued support for a few more years to help these children who are in desperate need while we continue to strive for the best! We have increased parent involvement as well as the number of fundraisers per year. Although the economy continues to be down, our small community always supports our efforts; be it buying crispy creme dougnuts or volunteering to build and repair our facility. Within the past few years we have grown. We have completed the additional hale in order to house more children, and indeed we have put that hale to use to continue to serve more children and families of the Hamakua Coast.Now, we are currently working towards adding a toddler room to our facility, as there are no toddler facilities in the community, and the need for toddler care is on the rise. Continuing to increase our capacity potential is expected to generate increased tuition income for our Project. With the rising need for preschool education and care, our budget has increased because the needs have increased; thefore we need more funding, and we are counting on the County and again, our community and teacher fundraisers. In this time of recession, the focus for all of us must be helping our keiki, now, for they are our future. #7. Program objective using county nonprofit grant program funds. 1) Make care and educational services available to at-risk families and their children between the hours of 2:30 and 5:30 pm daily. 2) Provide high-quality care and educational services to children of at-risk families of the under-serviced Hamakua Coast. 3) Provide monthly scholarship/tuition assistance to at-risk families. 4) Pursue other funding sources for the Families-At-Risk Project, to insure that the Project, and the school, will prevail. 5) Maintain a developmentally appropriate learning environment among all students, ensuring progress in social, emotional, cognitive,language, and physical development. •6) Increase the parenting skills, and the understanding of the developmental and educational needs of children of the at-risk parents we serve. 7) Recognize the need for, and provide referral services for children of at-risk families who may need treatment for known or suspected health, psychological or developmental problems. 8) Have the Families-At-Risk Program become financially self-sufficient, no longer a financial drain on the Day Program. L, o o a o 0 0 0 0 0 0 0 o 0 o a o 0 0 0 0 0 0 E cl 0 0 0 0 0 0 0 0 m o 0 0 0 0 0 Ll Ln Ln o Lr a a O O O m M O Ln N N Ln N r� W) 0. [V a 3 LU 4 C 43 R � � Q U. > � a L = R C : U O V off E oa LL ru 3 ' Y E a O 1 O + L.L 4-o :2 �" L- O w +' C 6 C N a], aj c i U IJ Li 2 J U d 0. O i]D C C �c- E R tu0 O CL LM 63 Kahua Pala Mua, Inc. Palili 'O Kohala Agency Name: Kahua Pa'a Mua, Inc. Program Name: Palili 'O Kohala Agency Director: David Fuertes Phone No.:(808) 889-5391 Contact Person: Andrea Dean Phone No.:(808) 960-3727 Mailing Address: Address: P.O. Box 896 Address: MY,ST,Zip Kapaau, HI 96755 Facility Address: Address. 55-370 Ho'ea Road Address: MY,ST,Zip Hawi, Hi 96719 Email Address: Fax No.: Accountant/CP Brian lwata, CPA Phone No.:935-5404 Firm (if applicable): Taketa, lwada, Hara and Associates, LLC Mailing Address: Address: 101 Aupuni Street, Suite 139 Address: city,sT,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $50,000.00 2. Agency Mission Statement: Kahua Pa`a Mua, _Inc. is a North Kohala based 501-c-3 with a mission to: "Enhance communities through economic, conservatoon/preservation.socffiaI and educational programs-fdr youth and adults_" EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of7 Agency Name: Kahua Pa'a Mua, Inc. Program Name: Palili 'O Kohala 3. Program Description: Palili `O Kohala is a project of Kahua Pa`a Mug, Inc. The Palili `O Kohala ro'ect is a ten family taro growing cooperative that addresses food self-sufficiency, food security and economic development in North _Kohala. The project provides training, as well as resources for the processing and distrubutmon of taro and value addejcLproducts from taro, ig chickens and ye eiables. 4.Total Budget& Position Count: Total Program Budget: $183,725.00 Total Program Position Count: 3 Total Agency Budget: $7,000.00 Total Agency Position Count: 0 5. Program Funding Sources (identify all sources of funding applied to this proeram): FY14-15 Revenue Source Estimate County of Hawai'i (pending) $50,000.00 Dorrance Family Foundation (secured) $5,000.00 PIDF Ka Hana No'eau (secured $22,000 mentor salary 1$24,300 labor in-kind) $46,300.00 Palili 'O Kohala (secured labor in-kind) $27,700.00 Land and Water (secured in-kind) $4,725.00 Palili 'O Kohala (secured facilities and equipment in-kind) $50,000.00 TOTAL: $183,725.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This is an economic development Droiect based on-growing taro and animal husbandry with .Mural Farming. TheBUsiness Plan for the n, roe t.forecasts income by year three= In FY 2014-20.1-5, pmject knts wHI be processing and selling taro prodlicts- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Kahua Pa`a Mua, Inc. Program Name: Palili 'O Kohala 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 . Development & management of Agricultural Cooperative 2.Provide tr_aionno and mentoring support for taro farming families ..,,._.._.- _3. Maintain and crow Natural Farming Demonstration EarM Market and sell taro products_ 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific_) Formation of agricultural cooperative 5 families minimum Number of pounds taro processed in Kohala HS Ag Kitchen 3,000 Ibs Students trained on Natural Farming Demonstration Farm 30 Adults on Natural Farming Demonstration Farm 10 Number of pounds taro products sold in the market 3,000 Ibs Visitors to Natural Farming Demonstration Farm 100 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual` Total Budget Grant Req Salary and Wages $6,532. $68,300.00 $22,000. Professional Fees $4,550. $8,000.00 $3,000.0 Operations $1,387.2 $47,425.00 $15,000. Supplies $13,169 $60,000.00 $10,000. Equipment $5,459. Other:Program Liability Ins. $885.1 Other:Administrative : Business License/fees $1,910. other:Travel / Meetings $3,696. Other: Other: TOTAL $37,59q$183,725.0 $50,000. *If applicable EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Kahua Pa`a Mua, Inc. Program Name: Palili `O Kohala j.o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Fj Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A Nf1NPRf1FIT(;RANT APPI ICATinN Fv 7n14^7n1 S Paaa A of 7 Agency Name: Kahua Pa`a Mua, Inc. Program Name; PaR `O Kohala 11. Certification of Understanding 1 (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report; using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A Mr)NPROFIT GRANT APPI IrATIMI ry 7olA-?ni q Paaa r%of 7 (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accented by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:,(Jwww.hawaiicountV.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. 1-8/U 1 Signature of Authorized Person (specify title) Date EXHIBIT A NCIRIPRnP1T GRANT APPI If ATInN FY )nlA-*)nl Paves A of 7 Agency Name: Kahua Pa`a Mua, Inc. Program Name: Palili 'O Kohala 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Formation of agricultural cooperative 5 families minir Number of pounds taro processed in Kohala HS Ag Kitchen 3,000 lbs Students trained on Natural Farming Demonstration Farm 30 Adults on Natural Farming Demonstration Farm 10 Number of pounds taro products sold in the market 3,000 lbs Visitors to Natural Farming Demonstration Farm 100 TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $22,000.00 Professional Fees $3,000.00 Operations $15,000.00 Supplies $10,000.00 Equipment Other: Program Liability Ins. Other: Administrative : Business License/fees Other: Travel I Meetin s Other: Other: TOTAL $50,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 64 Kailapa Community Association Ka Piko (Community Center/Park Project) Agency Name: Kaifapa Community Association Program Name: Ka Piko ( Community center/park project) r, Agency Director: Diane Kanealii Phone No.: (808) 640-3195 Contact Person: Diane Kanealii Phone No.: (808) 880-9798 Mailing Address: Address: 61-4011 Kaifapa St. Address: city,s-r,zip Kamuela, H1 96743 Facility Address: Address: 61-4016 Kai `Opae PI Address: city,ST,zip Kamuela, Hi 96743 Email Address: dkanealii02 @gmail.com Fax No.: (808) 880-9798 Accountant/CP Kaliko Grace Phone No.: (808) 938-2664 Firm (if applicable):.Volunteer Bookkeeper Mailing Address: Address: P.O.Box 44695 Address: City,ST,zip Kamuela, HI 96743 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $500,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2. Agency Mission Statement: Vision: Ehuehu i ka po.no Thri ing in balance Missim To empower Nadve Hawaiian livinq in Kohala, specifically the Kailapa and well-heing EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Kailapa Community Association Program Name: Ka Piko ( Community center/park project) 3. Program Description: Complete community center and park "Ka Piko" (plans for phase I done Obtain all building supplies and materials to build 3000 so ft open pavilion that includes one large offices ace storage space and 2 restrooms. Park- in udes a fenced children's playground.- playground 4. Total Budget & Position Count: Total Program Budget: $$00,000.00 Total Program Position Count: Total Agency Budget: $500,000.00 Total Agency Position Count: 2 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Dept of Hawaiian Homelands $50,000.00 Habitat for Humanity (labor of volunteers to build center, park) value estimate $250,000.00 County of Hawaii community grant $500,000.00 TOTAL: $800,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Planning support is provicLed by DHHL Over $200,000 of in-kind developm nt projects Wall hi EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Kailapa Community Association Program Name: Ka Piko ( Community center/park project) FOR 7. Program Objectives Using County Nonprofit Grant Program Funds: County funds will be used to fund the su pplies. a ui ment and mmmunity center building-and padK-landscaping- There are no athel: 3-within IS i1ps 8.TABLE l: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (Le.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Applicant Projected Results 140 Properties of 191 currently developed and in use 80% Community use Approximately 4 members per household —Average 560 persons 532 projected users/volunteers Quarterly classes in cultural/environmentallsafety/erosion control Educate Community Monthly board meetings, Annual community meetings Board members/Community South Kohala meetings/gatherings of other organizations 20% Kohala district use Private parties , gatherings 10 % Public use Office for community administration 80% Community use Attach additional pages as necessary. 9. TABLE fl: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $28,10 $85,000.00 $36,660. Professional Fees $6,000. $156,000.0 $100,000 Operations $0.00 $0.00 $0.00 Supplies $1,500. $302,000.0 $300,500 Equipment $2,200. $32,000.00 $30,000. Other: Planning $50,00 $50,000.00 $0.00 Other: Landscaping $5,000. $17,840.00 $12,840. Other:Administration $0.00 $0.00 $20;000. Other: Other: TOTAL $92,80 $642,840.0 $500,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Kailapa Community Association Program Name: Ka Piko ( Community center/park project) io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Kailapa Community Association Program Name: Ka Piko ( Community center/park project) 1t. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. 1 (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. To register, go to htt vendors.ehawaii, ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. if awarded a grant from the County of Hawaii I we understand and will com I t with the re uirement to submit a ear-end re iioort to the County Council within 60 d ts after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, com Iete and accurate ear-end report, using the template orovided. will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all rant funds received durin g the grant eriod must be refunded to Count and exclusion from future grant participation for a minimum of on rear or until a written report is submitted to and accepted b the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation oLyour agency's uture fun din request and mail result in actions taken to recover these unds. By signing below, you are acknowledging that you have read and understood these requirements. l Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Kailapa Community Association Program Name: Ka Piko ( Community center/park project) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 140 Properties of 191 currently developed and in use 80% Communil Approximately 4 members per household —Average 560 persons 532 projected L Quarterly classes in cultural/environmental/safety/erosion control Educate Coma Monthly board meetings, Annual community meetings Board member South Kohala meetings/gatherings of other organizations 20% Kohala di Private parties , gatherings 10 / Public us Office for community administration 80% Communil TABLE Ih PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $36,660.00 Professional Fees $100,000.00 Operations $0.00 Supplies $300,500.00 Equipment 00 $30,0 .00 Other: Planning $0.00 Other: Landscaping $12,840.00 Other: Administration $20,000.00 Other: Other: TOTAL $500,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 65 Kanu o ka 'Aina Learning Ohana Halau Hookipa Community Recreation Center 1 Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Hookipa Community Recreation Center Agency director: Taffl Wise Phone No.:($08) 887-1117 Contact Person: Katie Benioni Phone No.:(808) 887-1 117 Mailing Address: Address: PO Box 6511 Address: city,ST,ZIP Kamuela, HI 96743 Facility Address: Address: Address: City,ST,ZIP Kamuela, HI 96743 Email Address: grants @kalo.org Fax No.: (808) 887-0030 Accountant/CP Carl Williams Phone No.:(808) 531-1040 Firm (if applicable): CW Associates Mailing Address: Address: Topa Financial Center Address: 700 Bishop Street#1040 city,sT,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $1,700,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $5,000.00 2.Agency Mission Statement: Serving and perpetuating sustainable Hawaiian communities through Education yvithAloha. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Hookipa Community Recreation Center 3. Program Description: Kanu o ka Aina Learning Ohana KALO has a shovel read construction ro'ect for a 19,264 s .ft. Community Recreation Center housina a cafeteria athletics ace and performance hall to be built on a ear leased pancel of Dept. of Hawaiian Homeland-s.-The facilit will serve 300 Kanu Charter School students daily and residents...of all ages from the-Waimea/South Kohalq commijont4- 4.Total Budget& Position Count: Total Program Budget: $3,780,000.00 Total Program Position Count: Total Agency Budget: $1,700,000.00 Total Agency Position Count: S. Program Funding Sources (identify awl sources of funding applied to this rn oeram): FY14-15 Revenue Source Estimate U.S. Department of Agriculture Loan $2,000,000.00 Atherton Foundation $75,000.00 County of Hawaii Grant $5,000,00 GIA County Nonprofit grant $1,700,000.00 TOTAL: $3,780,000.00 Attach additional pages,if needed 6. Explain what plans your agency or program has to increase revenues to support this program: The secured US Dept of Agriculture Loan of $2.,.000, along yvith the other securpd arant fundinq wall he sufficient to complete this-=iect and no fijrthPr fErnds will bp._r.Qauirerl_ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Hookipa Community Recreation Center 7. Program Objectives Using County Nonprofit Grant Program Funds: The project meets the High priority of Public Facilities: childcare youth, purpose-far-ififies Improving quality of life for low income.'residents- 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops prevents held,volunteer hours,etc.Describe,be specific.) Construction begins and is monitored Completed on time Quality Control All inspections passed Cost Management Completed on or under budget Construction completed Space available to community Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees $700,472.0 Operations Supplies $375,000.0 Equipment $218,000.0 Other:Construction $2,486,528. $1,700,0 Other: Other: Other: Other: TOTAL $0.00 $3,780,000. $1,700,0 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Hookipa Community Recreation Center so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: [� If no conflicts exist, check here. Signatureyf Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name; Kanu o ka Aina Learning Ohana Program Name: Halau Hookipa Community Recreation Center 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135--2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNET] document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of HawaN, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register,go to htt _vendors.ehawaii.gov. complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant Period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted bv,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt : www.hawaiicount . ov fn-non rofrt- rant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawal`i with the final report. Failure to return these funds in a time1v manner will impact the evaluation of our a enc 's uture funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. XpcufrtlP dlpee" � /'� /f� Signature. f Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Hookipa Community Recreation Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Construction begins and is monitored Completed ord Quality Control All inspectionb Cost Management Completed orU Construction completed Space availatli TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Construction $1,700,000.00 Other: Other: Other: Other: TOTAL $1,700,000.00 Additional Council directives reEardinst award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 66 Kohala Animal Relocation and Education Service (KARES) Canine Spay and Neuter Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter Agency Director: Deborah Cravatta Phone No.:(808) 333-6299 Contact Person: Deborah Cravatta Phone No.:(808) 333-6299 Mailing Address: Address: KARES Address: P.O. Box 44670 City,ST,zip Kamuela, Hawaii 96743 Facility Address: Address: KARES Address: 59-241 Kipa Mai Place city,sT,zip Kamuela, Hawaii 96743 Email Address: pets @kohalaanimal.org Fax No.: (808) 880-1925 Accountant/CP Randall Macaluso Phone No.:(808) 881-1040 Firm (if applicable): Kamuela TAXPROS Mailing Address: Address: 65-1190 Mamalahoa Way Address: city,sT,zip Kamuela, Hawaii 96743 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $12,500.00 $0.00 2.Agency Mission Statement: To rescue and relocate abused abandoned/stray domestic animals to provide tempos housing,fQr them through our f-Aster care network and facilitate adoptions into Der�i3f homes. KARES focuses c)n cornmunitv education to promote responsible net ownershir) and .f�o prevent animal a rontrol inrli ding cnav/n EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name:Canine Spay and Neuter 3. Program Description: Provide free spay/neuter (SIN) surgeries in clinics hosted by KARES for 200 companion dogs that are owned b low income or economical) troubled residents who cannot afford these services. In 2012-13 KARES was responsible for sterilization of 1 ,250 dogs. In FY 2014-15 KARES plans to assist pets of low income residents with SIN of 700 dogs, depeT ndina on available funding. 4.Total Budget& Position Count:: Total Program Budget: $78,000.00 Total Program Position Count: j Total Agency Budget: 1$130,000.00 Total Agency Position Count: 3U S. Program Funding Sources (identify all sources of funding applied to this pr_ogram): FY14-15 Revenue Source Estimate (1) Applications to be submitted in 2014 or (2)Anticipated revenue sources Corporate Foundations (e.g. Petco Foundation, PetSmart Charities) $38,000.00 Private Foundations and Individual Donors $12,000.00 Community Foundations and/or County of Hawai'i Grant $25,000.00 Fund raising events (garage sales, dog washes) $3,000.00 TOTAL: $78,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Please see attached page for Item 6. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name:Canine Spay and Neuter 7. Program Objectives Using County Nonprofit Grant Program Funds: Please see attached page for Item 7. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops ore vents held,volunteer hours,etc.Describe,be specific.) Please see attached page for Item 8 Attach additional pages as necessary. 9.TABLE Il: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: Please see attached page for Item 9 Other: Other: Other: Other: TOTAL $0.00 $0.00 $0.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter Additional Pages 6. Explain what plans your agency or program has to increase revenues to support this program: KARES will apply for community, corporatelprivate foundation grants. In past years most grants have been awarded by Mainland USA organizations to support the Hawaii Canine SIN Program. Each year since 2009 KARES has exceeded performance expectations (number of S/Ns) and thus hopes to sequester renewed and increased funding. in 2012 we obtained our first grant from the County of Hawai'i that supported sterilization of 162 dogs. We feel it is imperative obtain financial support from our own Hawai'i Island community to help with this important work. With increased awareness of the Canine SIN Program throughout the Island we anticipate gaining further support from our local residents to achieve the humane control of the dog population with SIN. This work is essential for the well-being of our island communities. 7. Program Objectives using County Funds The KARES Canine SIN Program objectives are intended to benefit the people of Hawai'i by ....... 1) making available free SIN surgeries for their pets, an expense that most cannot afford 2) allowing families to keep the pets that they have without the additional economic burden of unwanted puppy litters for which they cannot cover the costs of food and veterinary care, and 3) reducing the number of free-roaming (stray) dogs which cause damage to property and livestock and could cause potential health risks due to bites and the spread of disease. 10. Conflict of Interest Statement KARES has no intent or plans to involve any of the above specified County of Hawai'i administrative staff in our organizational operations. KARES has only one volunteer that is also an employee of the County of Hawai'i. This KARES volunteer is Daylynn Kyles, Clerk ill, Puna District (dkyles @co.hawaii.hi.us). She volunteers with KARES for animal rescue, fostering of dogs, adoption events and participation in spay/neuter clinics. We do not perceive her volunteer activities to have any substantial probability of having a direct benefit with regard to grants awarded by the county. Therefore we report- no conflicts exist. o O _0 _0 V) � C o C o z rp N L N -F- CD CL �,Z 2) a) U a) O O C O rOn (D O ++ a) to 0 O a) L E O U U U CA p N C CO � E O (� O En W ) U (1) ) O U U O 21 L C CO j) U Cn Q Z3 @ fl L C a- 0 C) a te° C O ni L •L L � (D cE N r Q7 O N a} U U C U) w (D L O O C m W (n ^ Z CO Q C , o a) - ' C �. -r- :r- U CO C N U O :� a tD C .0 ,� C N C a) Q) W +' U CO 0 'Ul O r d tt— +'� U O O � .L U O O C > � o O _� a) 5 � = � 7 C O N ��� O x O O CL 0 a)�. O - U E CO O C L O Y C O) O _ a) C + C to =_ O U CO C1 O O a) O Z O U o � cll o O p co (n N N (D ' 0- 0 Q. 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Op � Za) vi ONtn ro � 0) w o �'c a} sr U t}j 7+ � :r�- � � tOj Nom _ CL a) m •N O di O H p c .� � o -2 .U) � � � -0 o � � � Cc o 0) a� 0) 'o 36.Q oC DL _ LO � � Z O a C;) o co 22 E g 2 �_ 73 CL% % a � \ % § / � CL § �_ k � e v � � CO 2 E k § CL d : 0 & CL CL E 0 7 k 3 E k § 0 o b o f bD U \ \ @ @ LU (D a 00) < C � V) § a u 7 2 u § 2 5 ' n E .2 o @ 2 § S & g Cl) 2 � 2 2 E o a- W @c - /§ 0 :E CL � E % n � 9 = k o \ : LLI co ƒ -0 q ( % & CL 0 u o 0 O CD E � g $ c R S a) Ek If � , u 0 -- a . E to 2 7d 2 2 $ 02 E � 2 ° § . , o \ 2 0 7 cn § 0 k cm $ Q P E 7 : -0 _0 E m C � � 7 ) g / E -Ef 2 @ ) ® 0 o :3 ƒ E � 2 o E7 e CD E k LU co � \ 0 � ° 0- 0 E 9 ° § < m 2 2 7 ) M u P � o \ 2 \ �EL (D2 227 2 � ECL Q k § 3 m t2CL * Ln = a CC o C } ° o o 0 o o o � 0 LL c CD 4+ () OA Q O Q o o Q O e-I m 0 C O O � CD C:) p 0 0 LL Lo rri cv r+ m OC p tr7- P% LLI 4 M Q Q O 00 o koo O 00 °o lOD p LO Q [. o m O LL ¢ t.0 � CY; m � U) �^ C Q 76 O m Q O A5 s EA F- v aj a) CD °-' tw v WE °' .� �- N L L Ln oC] LO 0 3 > O L cn vi CU bb N co to L *' >- tP C pip `M n Q Co XO C hE4 IA m° Q u L 'c C —° Q y w L a 0 _ m v cis '� C � ii E Q O VS �_ �_ L Q v0- a O ai CU O ? a, aj a Q 3 as a C m a c6 O +^ vn L a1 v V) Z Q t4 N w 0 7 > Y 1 E = L I N O v O 41 in N Z U S � 4 d0 r- C QJ O Q U- o CL +� +� Q D. of a cn a cn M }' w O a O 0 0 �' L O O L tko N O O — �j U E c0 O V) O' -0 O O O p cu � U � � L E O m O U 4— v1 V1 CD w C o E m �. ° ea E o � L v O o a� ° ° o Q n V3 Ln QJ CD Ln vii N ,Q? yr V O O a> ?- O a� N U z 'p •V}. O a� ci o W 4-• - 'aa Tf 3 au 0 O 0 p a) p N m o 4-. N D O O p p m a- C (v o = L O z iii O N U) cy +�+ 4-Ln to .,�.,e �..r � � Oi � O •L m V Q1 O '� O Z3 O z U m o 3 m E cD LL. w zs z °m o o E `� (� O m .v cn + r a, — O b m ` .ate t � m Q •aN coo ° o L. CV 0 cc cn coo O '� G = ca 00 -� O O N Q E o ,� u 0 r_{.} O � � '} N O 4- = m O s3 4- Ln a) O c6 O tn m d' � O 4-� to� Q a, > m u Gi z ui z m do .f.+ ay U W a E bA O ate-+ — C �l Y m O L m a) CJ O m w O fv L m w E as E a; �, aj Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name:Canine Spay and Neuter a.o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be si ned reclardless of whether a con lict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Please see attcached statement for Item 14 If no conflicts exist,check here. Signature of Authorized Person specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name:Canine Spay and Neuter ii.. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Ex ress and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation of our program's or agency's uture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30'h shall result in loss of all grant funds received during the grant period must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation of our agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) pate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Please See Attached Pages TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Please See Attached Pages Other: Other: Other: Other: TOTAL Additional Council directives regarding award: ao) o Dv EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 � O O Q. W O a � 4-0 V C � Q ^ v a W L L 0 W 0 0 o u) (D 0 G to U3 O °o °a " m o o o o cn CL CD -s o 0_- — LSf N Lo cn u) (13 -0 --• (D Ll- 0 CO, �- a) 0 M cu _ z m CZ cu C � �co c o � � o 0 U) s �3w- s O co o ins � _ 0 0 � N (1) o c� a? o c = os ° cn � � ass o � � C1. A s C U sy U Q �_ C IU W *' CL m 0 0 O O E � � � cn ° c ai ccu m a) 0 � s 'a 0 aa) ZcnC0 a) (n L _r � E 0 cn a� �. ova0 (D �' EL ms c� L a . 0 2 ❑ a) Z O �L. U cow � � ti... ,r � .� �. � EL [� o tti � U d N O Z 0) 0 4 o (a 0 CD W •Q 7+ Z C)- m uj a• CO cc o 0 3 C a) � L -0 Q � _0 � � � � � ao 0"°s o Cl) o) cSi N o 0 LO U 0 (o a) N Q) � � (S3 .0 N U n U a3 Q) O V Q C Z o cu a- Q oZ0a) � L 22 � a� 0 0 a) � 0 E i' � o E � 0 -0 >, ..1 N Z o Cc) 0 z V a) � �, o N E U 0 L C N �+ .0 > r . . Uj U3 O p ��' a) N N 0 0 0 4J ice. U fu (D•0 o O a) W C O � a O Cm .� 'j C 0- -32 2) 0)(D a) m s. nj co 0 0 o a0i a) 0 U CU L Q s r-I F- IL a) z). 2 in Q Lo o a d cA to 'T3 O Q• O a a ^ U tJ) W aj [L a •� L o cu c ++ V cn N `o o o ?' co o • CA t0) Q c Q (1) d a) E = �Ln (D _ Q) N O 0 "a v- C to c O' (D 0:Y 0} cc +. � La3Q ° 0) V 0 r Q "Q c Q O) V �, � U � a � 0 a coo 0 � cN � 3 a) � o cu W d c� � ANC Ec C m •c O �' E U N C 0 CL� v O U 0 E O CO :3 � �' O O it E [iS c CD CL C)a ° C c 0)+, — _0 c o c 0 !� 0 .E c 0 a) in ° m 0 � >' a) Urn -IM 0 � � � a- ._ O c EQ Q SA ° (� � o acOa N 0 o ,-O a�_ c gip °• o aa)� cB m TEc O Co u ^O O c0] n CL 0 ° a0 ° % � Eu, O d3 E o ;� co E m co rn ca c ca _ Z Z a 0 E 0 0 � � 0 E � 00 0 a) _ L (a a) E 0 4 U CO .r N U L O — N O O Cr OL 0 t0 N �p Q 0 0 0 � [`4 O 0- m �CL . � U U LU 'V cr = - = LL- o Q 0 0 0 0 0 0 2 r*4 @ U) \ � \ � O . u aj / 2 % m + E E § V @ EI W ' > _ ai V � 2 \ = � CL k 0 mw � ' e CL k ) / m t 2 @ O z E E u 0 � u o C m x a W) txo § , © m x \ 2 ° § LLI co m 2 / \ K � Z u LA u 4 � @ U 4T � k � C m \ @ / to k C aj 2 - E \ t t o E _ m t c / R § m 2 � e k § % 9 $ � U J § � » Ln § k § m 7 ,. / g ® k § 2 ma 2 c G g , u o a m « b ) � _ 2 ) § § m = 0 2 a c 0 m � a. � � m 2 Lu O ƒ 0 g q Q 67 Kohanaiki 'Ohana Environmental and Cultural Stewardship Program Agency Name: Kohanaiki `Ohana Program Name: Environmental and Cultural Stewardship Program Agency Director: Rebecca Villegas Phone No.:(808) 960-2805 Contact Person: Kaleo Pilago Phone No.:(808) 936-7507 Mailing Address: Address: P.O. Box 4753 Address: City,ST,zip Kailua-Kona, HI 96745 Facility Address: Address: 73-1224 Ka`iminani Drive Address: City,ST,zip Kailua-Kona, HI 96740 Email Address: pilago @hawaii.edu Fax No.: (808) 932-7421 Accountant/CP Jeff Turner, CPA Phone No.:(808) 329-9220 Firm (if applicable): Mailing Address: Address: 74-5596 Pawai PL Ste E Address: City,5T,zip Kailua-Kona, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 2. Agency Mission Statement: The mission of our organization is to remain active in the care and preservation of the cultural and natural resources at the Kohanaiki Beach Park. To accompfisb this, our orqan*zat0on fosters conumn'tv af_i_n_n__ovative_ste_warci.�h;noprograms that are Specific-to the Knha_a.i_ki F F EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Kohanaiki `Ohana Program Name; Environmental and Cultural Stewardship Program 3. Program Description: This program will_gpply an integrated and innovative approach to monitorin the near-shore reef ecology at the Kohanaiki and `O`oma areas. Included within the Hawaii Island Marine Managed Areas there are safeguards from commercial activities in these areas. To support this our program will provide consistent monitoring and maintain / -provide '1 health 4. Total Budget& Position Count: Total Program Budget: $30,000.00 Total Program Position Count: Total Agency Budget: Total Agency Position Count: S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii Nonprofit Grants Program $30,000.00 TOTAL: $30,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: level and qeneratasdunds through nonprofit rant support and our annual Keiki Surf for thQ_Earth surf contest_ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Kohanaiki `Ohana Program Name: Environmental and Cultural Stewardship Program 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective is to engage-in consistent monitoring of the coastal _resources impacted by commercial harvesting and St-ate regulations. -The primar-V soecies to bje-monotored are those most imoacted, these 8.TABLE l: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of monitoring 1 data collection activities 12 Number of volunteers per monitoring 1 data collection activity 10 Number of hours per monitoring /data collection activity 8 Total number of volunteers FY 14-15 120 Total number of monitoring / data collection hours FY 14-15 960 Number of monitoring 1 data collection reports for FY 14-15 4 Number of community informational 1 findings presentations 2 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Rey Salary and Wages Professional Fees $4,000.00 $4,000.0 Operations $6,000.00 $6,000.0 Supplies $6,000.00 $6,000.0 Equipment $14,000.00 $14,000. Other: Other: Other: Other: Other: TOTAL $0.00 $30,000.00 $30,000. *If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Kohanaiki `Ohana Program Name: Environmental and Cultural Stewardship Program 3.o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure_forms must be sinned, regardless of whether a conflict exists. NAME: Gary Eoff POSITION: Director and 2nd Chair May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): © Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Council Member Karen Eoff will refrain from making a recommendation on this application. ❑ If no conflicts exist, check here. z6e r&6 ;L JL. 14 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Kohanaiki `Ghana Program Name: Environmental and Cultural Stewardship Program 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your program's or agency_'s future funding requests. EXHIBITA NONPROFET GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-formsl on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of our agency-'s future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Kohanaiki 'Ghana Program Name: Environmental and Cultural Stewardship Program 12-. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of monitoring 1 data collection activities 12 Number of volunteers per monitoring 1 data collection activity 10 Number of hours per monitoring 1 data collection activity 8 Total number of volunteers FY 14-15 120 Total number of monitoring 1 data collection hours FY 14-15 960 Number of monitoring 1 data collection reports for FY 14-15 4 Number of community informational I findings presentations 2 TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees $4,000.00 Operations $6,000.00 Supplies $6,000.00 Equipment $14,000.00 Other: Other: Other: Other: Other: TOTAL $30,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 68 Kona Adult Day Center, INC Adult Day Care Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE Agency Director: ROWENA L TIQUI Phone No.:(S08) 322-7977 Contact Person: ROWENA L TIQUI Phone No.:(808) 322-7977 Mailing Address: Address: p O BOX 1360 Address: KEALAKEKUA CO,ST,zip H196750 Facility Address: Address: 81-989 HALEKII STREE Address: city,ST,zip KEALAKEKUA Hl 96750 Email Address: kadcrowena @hawaii.rr.com Fax No.: (808)_322-0614 Accountant/CP RONALD G HAWKES, CPA Phone No.:(808) 939-7392 Firm (if applicable): Mailing Address: Address: P O BOX 2030 Address: city,ST,zip KEALAKEKUA HI 96750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000.00 , 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000.00 $15,000.00 $15,000.00 2.Agency Mission Statement: "Our mission is to provide social, and recreational proamms and activatmes that enable 'mpaured adults to experience feefi= of belonoonq, friendshlip, acceptance, accomplishment and EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: KONA ADULT DAY CENTER, INC Program Name-: ADULT DAY CARE 3. Program Description: See Attached 4.Total Budget& Position Count: Total Program Budget: $20,000.00 Total Program Position Count: 5 Total Agency Budget: 1$20,000.00 Total Agency Position Count: 5 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate DHS - $25,234.00 SFS - KUPUNA CARE $85,880.00 OTHER GRANTS $20,865.00 PRIVATE TUITION $103,340.00 SERVICE FEES $16,010.00 MEMBERSHIPIFUNDRAISERS/DONATIONS $32,953.00 OTHER(Sale of Assests/In-Kind Revenue/Food Program $15,837.00 TOTAL: $300,119.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: See Aftached EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE 7. Program Objectives Using County Nonprofit Grant Program Funds: See Attached S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (1.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Maintain or improve hygiene and self-care 95% Maintain or improve interaction skills 95% Maintain participants at home for 6 months minimum 95% Survey of Caregivers satisfaction 95% Have intergenerational interaction with community groups 2X mo. 95% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $113,625.0( $15,000.( Professional Fees $4,605.00 Operations $56,088.00 $5,000.0 Supplies $7,060.00 Equipment $0.00 Other:Employee Benefits $24,000.00 Other: Payroll taxes $14,771.00 Other: Utilities $13,920.00 Other:Rent-In-Kind $10,176.00 Other:Insurance $8,616.00 TOTAL $0.00 $252,861.0 $201000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be si ned regardless of whether a conflict exists. NAME: ROWENA L TIQUI POSITION: EXECUTIVE DIRECTOR May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability thatoction taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. r Signature of Authoriz Perso (sp ify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE u. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. 1 (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to htt : vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County„Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete,_and_accurate year-end report, using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301h shall result in loss of all grant funds received durin g the grant period imust be refunded to Count and exclusion from future erant_participation for a minimum of one vear_or until a written report is submitted to,and acce Led by,the council. 1 (we) understand there is no provision for further notification to submit the final report. information and instructions are available at http:J1www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of our a enc 's future funding request and may result in actions taken to recover these fun ds. By signing below, you are acknowledging that you have read and understood these requirements. G r— ey-G -%A 0 C �c-rae— 1 I l Signature of Autho ized er n (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agee Names: KONA ADULT DAY CENTER: INN Program Name: ADULT DAY CARE 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Maintain or improve hygiene and self-care 95% Maintain or improve interaction skills 95% Maintain participants at home for 6 months minimum 95% Survey of Caregivers satisfaction 95% Have intergenerational interaction with community groups 2X mo. 95% TABLE II: PROGRAM EXPENDITURES FY 14-15 Council ° Grant Request Award Salary and Wages $15,000.00 Professional Fees Operations $5,000.00 Supplies Equipment Other: Employee Benefits Other: Pa roll`taxes other: Utilities Other: Rent-In-Kind Other: insurance TOTAL. $20,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRAFT APPLICATION FY 2014-2075 Page 7 of 7 PVT— v t-W u-r- Exhibit A Page 2,#3 3. Program Description Kona Adult Day Center is the only non-profit adult day care in West Hawaii. KADC is a community non-profit 501 C 3 organization providing impaired adults, their families and other caregivers with an alternative to premature institutionalization. Since opening in December 1987, service has been provided to approximately 600 families in our community. A comprehensive program provides a variety of social and related support service groups of adult clients in a protective and less restrictive setting during any part of the day, for Iess than 24 hours. Day Care allows caregivers to continue working. Day Care also provides a more cost effective program than home care or institutionalization. Exhibit A Page 2,#6 6. Explain what plans your agency or program has to increase revenues to support this program: We will continue to seek grants. We will plan our Fundraiser to attract more people. Increase our census especially those who pay privately. Seek donations through a membership drive. Increase awareness of the services we have to offer. Exhibit A Page 3, #7 7. Program Objectives Using County Nonprofit Grant Program Funds: For Individuals: a) Mentally and physically impaired adults are maintained at their highest level of fiuictioning, thus preventing or delaying further deterioration. b) Maximum level of independence is assessed and maintained through an individual care plan. c) Client is able to associate with place and time. d) Caregivers have access to elderly services. e) Defer premature or inappropriate institutionalization. f) Isolation is reduced. For Caregivers: a) Respite. b) Continue working. c) Safe and secure environment. For Community: Long term continuum. 69 Kona Association Association for Retarded Citizens (Arc of Kona) Maximizing Independence Agency Name: Kona Association Association for Retarded Citizens (Arc of Kona) Program Name: Maximizing Independence Agency Director: Gretchen Lawson Phone No.:(808) 323-2626 Contact Person: Jeani Navarro Phone No.:(808) 938-7512 Mailing Address: Address: PO Box 127 Address: city,sT,zip Kealakekua HI 96750 Facility Address: Address: 81-1065 Address: Konawaena School Road city,sT,zip Kealakekua, HI 96750 Email Address: gretchen @arcofkona.org Fax No.: (808) 323-9444 Accountant/CP Ann N. Fukuhara, CPA,MBA Phone No.:(808) 961-5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: PO Box 6691 Address: City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $24,500.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $10,000.00 $11,250.00 $10,000.00 2.Agency Mission Statement: The Arc of Kona is committed to helping people with disabilities achieve the fullest_possible independence and ,p.adicipation in society consistent wmth_thei-wishes. _ ... EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Kona Association Association for Retarded Citizens (Arc of Kona) Program Name: Maximizing Independence 3. Program Description: The Arc of Kona will provide critical independent livin g and life skills to 110 Youth and adult participants in our island wide program. All participants have been identified as Developmentally or Intellectual) Disabled by the State of Hawaii Department of Health and have cognitive limitations that 12revent them from living as independently as Possible-Athout extensove supports. See-attachment 1A. 4.Total Budget & Position Count: Total Program Budget: $2,677,010.00 Total Program Position Count: 76 Total Agency Budget: 1$3,263,511.00 Total Agency Position Count: 105 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Medicaid H&CBS $329,829.00 Hawaii Island United Way $30,000.00 County of Hawaii $24,500.00 TOTAL: $384,329.09 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: -F-Q[--the past 17 years the Arc has held an annual bazaar_and craft sale that is our signature event and for the past ears weti lcl-a Blue Grass Benefit Concert qt-the Aloha Theater We artiyely__and_ -successfuliv develop and cultivate donors for additinn� Support EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Kona Association Association for Retarded Citizens (Arc of Kona) Program Name: Maximizing Independence 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 Provide 110 participants safe healthy, and supportive environment independent for daily year- See attachment 2A S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of cfients served workshops or events held,volunteer hours,etc.Describe,be specific.) Please see attachment 3A, TABLE I. Attach additional pages as necessary. 9. TABLE fl: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other:SEE ATTACHMENT - PROGRAM EXPENDITURES Other: (COLUMN FIELDS DO NOT ALLOW Other:ENOUGH ROOM NEEDED FOR OUR BUDGET) Other: Other: TOTAL $0,00 $0,00 $0.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Kona Association Association for Retarded Citizens (Arc of Kona) Program Name: Maximizing independence so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure Lorms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. u January 23, 2014 Signluure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Kona Association Association for Retarded Citizens (Arc of Kona) Program Name: Maximizing Independence MEMN 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, 1 (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant priorto final payment. To register, go to http:f lvendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant Participation for a minimum of one year or until a written report is submitted to and accepted bv,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http_//www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of our a enc 's future fundina request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. January 23, 2014 Sign ure of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Kona Association Association for Retarded Citizens (Arc of Kona) Program Name: Maximizing Independence 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Please see attachment 3A, TABLE I. TABLE I1: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: SEE ATTACHMENT - PROGRAM EXPENDITURES Other: COLUMN FIELDS DO NOT ALLOW Other: ENOUGH ROOM NEEDED FOR OUR BUDGET Other: Other: TOTAL $0.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Arc of Kona 2014-2015 County Grant Application Program Expenditures Question 9 Table II PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual Total Budget Grant Req Salary and Wages $2,162,463 $2,270,586 $21,315 Professional Fees Operations $335,467 $352,240 $3,185 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $2,497,930 1 $2,622,826 $24,500 Arc of Kona 2014-2015 County Grant Application ATTACHMENT 1 A Question 3 Pro-gram Description: For over fifty years, the Arc of Kona has passionately and successfully operated an Adult Day Health (ADH) standard classroom program that currently serves 25-30 participants and a Personal Assistance/Habilitation program island-wide that serves 110 plus participants on a daily basis in their community setting. In addition we provide, through a special contract with the Deparment of Health, an Employment Services program, which includes pre vocational skills training, assessment and job placement services. These three programs are combined as Home and Community Based Services for individuals with an Intellectual or Developmental Disability and act as the platform for which we provide independent living and life skills training. The Arc of Kona is committed to serving this population especially those residing in the most rural areas which include Puna, Hamakua, and Kohala that lack adequate access to services and opportunities that lead to independence. All of the participants in the Home and Community Based Services programs have cognitive delays that limit their ability to make good judgments and prevent them from living as independently as possible without extensive life skills training and other urgently needed supports. The individuals need to be in a caregivers' line of vision at all times and require assistance gaining access to community services and activities that will allow them to utilize their abilities and skills to integrate into the communities where they reside and achieve goals designed to deliver life skill sets in order to live more independently. The Arc of Kona serves a diverse population of Native Hawaiian, Asian/Pacific Islander, Filipino and Caucasian youth and adults ranging from 8 to 60+ years of age with a core group of young adults in their late teens and mid 20's. The Developmentally Disabled population has several risk and protective factors that we consider when designing individual independent living and life skills training. First, this population is at risk of abuse, both sexual and physical, and need to be taught the skills for saying "NO" and reporting abuse. They are known to be at risk for chronic disease and have a high incidence of diabetes and heart problems related to weight and diet. Finally, they are all at risk for homelessness and/or being unprepared to prove they can live independently both with daily living skills and finances. Protective factors we consider urgent include: a) training in social development, b) appropriate sexual behaviors, c) protection from abuse including family members, employers and strangers, d) proper nutrition, e) preparation to find their own housing accommodations and live as independently as possible, with or without assistance and other agency supports, and f) preparation for work either supported or unsupported at the work site, non-traditional employment and entrepreneurial start ups. Each of these concentration areas when written into an Individual Plan are meaningful and measureable so that data can be accurately reported and progress evaluated quarterly. The "community as a classroom" where participants can practice these skill sets becomes essential to strengthening the protective factors around this vulnerable population. When provided with community access our participants not only learn those life sustaining independent living skills but also have the opportunity for each to share his or her own gifts that benefit the larger island community. This integration allows the transfer of independent adult life skills to multiple real life settings. Arc of Kona 2014-2015 ATTACHMENT 2A County Grant Application Question 7 Program Objectives: 1) Provide a safe, healthy, and supportive environment for independent living skills in the community setting for 365 days per year from July 1, 2014 to June 30, 2015 for 110 participants receiving Home and Community Based Services. This island-wide independent living through life skills will focus on the rural underserved areas of the island thus relieving families of the stress of daily care giving and allowing them the opportunity to work if they desire and make a living and/or care for other children. 2) Provide individualized independent living through life skills training programs with measurable goals and objectives that allow each participant to develop at his or her own pace in order to live as independently as possible. 3) Insure access to community events and resources that will be a learning laboratory for independent living and reinforce skills taught throughout the program year, including those for supported employment. 4) Provide needed materials to assess, instruct and support life skills specific training in health and safety areas relating to abuse and appropriate sexual behavior as well as hygiene, money management, household safety issues and nutrition. 5) Provide needed supports for interacting appropriately with each other and the public within the community setting throughout the program year that supports the independent living skills/and or work setting required to function on a daily basis. 6) Provide supports for seeking and receiving employment. 7) Contribute to creating healthy families for healthy communities. Are of Kona 2014-2015 County Grant Application ATTACHMENT 3 A Question 8 Table I MAXIMIZING INDEPENDENCE THROUGH LIFE SKILLS PROGRAM Performance Measures: Applicant Projected Results: Maximizing Independence All Home and Community Based Programs 1.a) Provide a safe, secure classroom 1. a)260 days of ADH standard classroom activities with environment with sufficient staff a one staff to four participant ratio for 25-30 participants. supervision, 5 days a week, 52 weeks a year, for current 25 DD/ID participants. b) Deliver ongoing independence through b)365 days of one on one service for approximately life skills training in the classroom and the 110 participants (number can grow larger with new rural areas as per each individual's plan referrals during the fiscal year). which is developed by the Department of Health, the family and the Arc of Kona. 2. Provide access to the community for 1. 144 ADH classroom transports into the community hands-on independent living through life per year to achieve individual goals for independent skills training experiences leading to living through life skills. independent living including budgeting for food and clothing, shopping, fire safety, 2. 3,500 individual transports to achieve individual ordering and eating in public, handling independent living through life skills plans in the money, making appointments, nutrition and community setting, exercise, and appropriate behaviors in public(including sexual behavior). 3. Provide on-going Independent Living 365 days of instruction provided with assessment, base Life Skills assessments and data collection line, and data collection for results reporting. Tools used for each individual. This includes areas are the Brigance Life Skills Assessment, and such as fine and gross motor skills, Individualized Service Plans (ISPs) developed by the receptive and expressive language, Participant, the family, and the Department of Health volunteering, recognizing and reporting Case Managers. abuse, health, hygiene, safety, This result in extensive progress reports written socialization, basic cooking skills, quarterly for the Department of Health and the family to behaviors, consumerism, basic literacy and determine success and any changes needed for the job skills training. current year to better achieve the individual goals. 80% of the total enrolled will meet at least one goal during the year. 70 Kona Historical Society Living History Programs Agency Name: Kona Historical Society Program Name: Living History Programs Agency Director: Joy Holland Phone No.:(808) 323-3222 Contact Person: Joy Holland Phone No.:(808) 323-3222 Mailing Address: Address: P.O. Box 398 Address: city,ST,zip Captain Cook, HI 96704 Facility Address: Address: 81-6551 Mamalahoa Hwy Address: city,sT,zip Kealakekua, HI 96750 Email Address: jopgkonahistorical.org Fax No.: (808) 323-2398 Accountant/CP Renee Gronwall Phone No.:(808) 323-3222 Firm (if applicable): Mailing Address: Address: P.O. Box 398 Address: city,sr,zip Captain Cook, HI 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $26,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $8,000.00 $9,250.00 $8,000.00 2.Agency Mission Statement: The Kona Historical Society_will_ores rve.the history of Kona to enrich our community and inform our visitors by ourfunna an_understaoding of, and insnirina an aonreciation for,_Kona_s_untoue island sense-of_olace_ EXH I BIT A Agency Name: Kona Historical Society Program Name: Living History Programs 3. Program Description: KHS offers three living history programs: the 1930's era Kona Coffee Living History Farm, Portuguese stone oven bread baking, and the 1890 H.N. Greenwell Store. In each program, one of our most important goals provide is to I aroups a place to experience n ' historV thro Uh hands-on actim6fies. Besearch on school excurswons has show an 1-skills-and ethnic toleranceafter stich visits. 4.Total Budget&Position Count: Total Program Budget: $268,964.00 Total Program Position Count: 21 Total Agency Budget: $476,598.00 Total Agency Position Count: 25 S. Program Funding Sources(identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Earned Income $293,500.00 Fund Raising $60,000.00 Donations $3,000.00 Grant Income $62,500.00 TOTAL: $419,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Visitor__numbers are expected to continue to increase in .2.014,.an we have received more large tour croup reservations than in 201.3 With i—creased visitors, coffee and c Oft sales ahotlld..imnrnve_ Mnre markPtinn EXHIBIT A Agency Name: Kona Historical Society Program Name: Living History Programs 7. Program Objectives Using County Nonprofit Grant Program Funds_ 1 Teach sludents about K n ' hi # n ul# r in vva #h # i f n hands-on, and interac jve to facilitate learning and retentim.. 2) Provide authentic and enaaairt�a_draarams at historic sites- 31 Demonstrate the themes-of susfainability, family values, and independence to Visitors- S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant projected Results (i.e.:Number of clients served workshops or events held,volunteerhours,etc.Describe,be specift-) School Groups (number of students) 1400 Group Tours 90 large groups (number of visitors) 3660 Free and Independent Tourists (number) 3795 Bread Sales (number of loaves) 429D Volunteer support for history program sites (annual hours) 1360 Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 1415 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $.126,98 $129,292.0( $16,120.( Professional Fees $25,01 q$33,990.00 Operations $17,069 $19,229.00 $2,730. Supplies $7,967.1 $6,710.00 $1,000. Equipment $0.00 $0.00 Other:Cost of Goods Sold $56,19q$51,729.00 $6,150_ other:Employee Benefits $17,39 $20,614.00 Other:General Liability Insurance $7,196.1 $7,400.00 Other: Other: TOTAL 1$257,82 $268,964.0d$26,000.( *If applicable EXHIBIT A Agency Name: Kona Historical Society Program Name: Living History Programs so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawaii. only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure fortes must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry_ Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ® If no conflicts exist, check here. )/kW0V'-/ Signs r Autharize Person (specify title) Date EXHIBIT A Agency Name; Kona Historical Society Program Name: Living History Programs 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the Counly Council within 60 days afterJune 30 of the contractual Vear for which the jzrant was awarded.The report, using the template provided,shall,include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding_requests. EXHIBIT A i (we) understand that failure to submit the final report within 60 days of June 30'h shall result in loss of all grant funds received during,the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htto://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused byJune 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future, funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. 1 Signs r o Authorized Oerson (specify title) bate EXHIBIT A Agency Name: Kona Historical Society Program Name: Living History Programs 12. COUNCIL AWARD WORKSHEET TABLE f: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result School Groups (number of students) 1400 Group Tours: 90 large groups (number of visitors) 3660 Free and Independent Tourists (number) 3795 Bread Sales (number of loaves) 4290 Volunteer support for history program sites annual hours 1360 TABLE 11I.- PROGRAM EXPENDITURES FY 14'15 Council Grant Request Award Salary and Wages $16,120.00 Professional Fees Operations $2,730.00 Supplies $1,000.00 Equipment other: Cost of Goods Sold $6,150.00 other: Employee Benefits other: General Liabili Insurance Other: Other: TOTAL $26,000.00 Additional Council directives regarding award: EXHIBIT B AGENCY NAME: _Kona Historical Society PROGRAM NAME: Livine History Programs 3. Program Description Additional Information KHS has two living history sites and offers three programs: 1) Kona Coffee Living History Farm is a 6-acre 1920's era coffee farm in Captain Cook, homesteaded by Japanese immigrants from 1913 to 1994. The Farm tells the story of Kona's coffee pioneers, emphasizing their family values, independence and resourcefulness. 2)H.N. Greenwell Store, an 1890's general store in Kealakekua, was founded by Henry N. Greenwell, an English immigrant. The store presents typical 19`h century shopping experiences using real multi-ethnic customers from the period. 3)The authentic Portuguese community-size stone oven is used to bake traditional bread each Thursday, which is sold that same day to customers, some of whom assist in the baking process. In each of our programs, one of our most important goals is to provide school groups from Hawai'i and beyond a place to experience Kona's history through hands-on and age appropriate activities. When children arrive at the Greenwell Store,they are divided into small groups and rotate through several interpretive stations where trained and costumed interpreters discuss subjects including ranching, dairying, land use, ethnic groups, and trade with the outside world. Included is a walk through the native forest area, where they learn about sustainability, preservation, and plants that Polynesians brought to the Islands and their use in Hawaiian culture. At the Farm, costumed interpreters demonstrate Japanese cooking using customary utensils and a wood-burning stove, demonstrate how coffee is picked and the role of the donkey in coffee farming, teach students to play traditional games, and let them experience hands-on how clothes were washed using a tub,washboard and clothesline. Students leave the site with an appreciation of the critical role of children in the success of the coffee farm, and the contrast between their own modern life and the family of 1920's Kona mauka. School groups that visit on Thursdays participate in rolling the dough as part of the authentic bread-baking program. Children are excited about helping to make bread, watching as the loaves are placed in the stone oven, and tasting the warm bread when it's done. An important learning outcome is a better understanding of Portuguese traditions, dairying, and how sweetbread became part of Hawai'is culture. In support of these activities, KHS offers deep discounts to school groups. Many children from Hawai'i Island are from low-income families, and may have few opportunities for exposure to museums and historical sites. School-sponsored excursions are often the only occasion for these students get a physical sense of Kona's history. Research on school excursions has shown that rural students, who live in towns with fewer than 10,000 people, and students from high-poverty schools, experience an increase in critical-thinking skills after visits to museums. The KHS sites provide knowledge about virtually all of Kona's different ethnic groups, so students get a sense of their own place—where they belong—in Kona. Often students leave KHS with a new understanding of their own family history. We believe that exposing our children to Kona's history benefits Hawai'i Island by inspiring in students an appreciation for its history and culture. EXHIBIT A 1130114 dss 71 Ku'ikahi Mediation Center Community Conflict Resolution Services Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services Agency Director: Julie Mitchell Phone No.:(808) 935-7844 Contact Person: Julie Mitchell Phone No.:(808) 935-7844 Mailing Address: Address: 101 Aupuni Street Address: Suite PH 1014 B-2 City,ST,Zip Hilo, HI 96720 Facility Address: Address: 101 Aupuni Street Address: Suite PH 1014 B-2 City,ST,Zip Hilo, HI 96720 Email Address: info @hawaiimediation.org Fax No.: (808) 961-9727 Accountant/CP Gretchen Kremeyer, CPA Phone No.:(808) 9681002 Firm (if applicable): Carbonaro CPA & Associates Mailing Address: Address: 136 Kinoole Street Address: Mailing: P.O. Box 4372 City,sT,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THEABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENTAND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $11,000.00 $11,250.00 $5,000.00 2. Agency Mission Statement: We empower people to come together -- to talk and to listen, to explore_._ ODs, and to find their,own best solutions. To ac 'eve this mi inn, we offer me intion, fndiitation, and firainincl to strengthen the ability of diverse ind'viduals and Qr0I1DS tO resolve EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services 3. Program Description: We are the sole non-profit community mediation center serving East Hawaii and 1 of only _5 in the state. Our services are provided on an affordable sliding scale, with no one turned away for lack of funds. Over 50% of our clients have annual household incomes of under $20,000. Qur aaencv helps individuals, families, organizations, businesses, schnols, and others to fond creative solutions to cballenqinq situations- 4. Total Budget & Position Count: Total Program Budget: $299,215.00 Total Program Position Count: Total Agency Budget: $299,215.00 Total Agency Position Count: 5 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Direct contributions $10,000.00 Foundation/trust grants $16,000.00 United Way contributions $10,000.00 County of Hawaii nonprofit grant $12,000.00 Hawaii state contracts (judiciary & attorney general--foreclosure.assistance) $177,762.00 Program fees (mediation, facilitation & trainings) $43,000.00 Special events $30,453.00 TOTAL: $299,215.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1 ) HokLmore communitv workshops/trainino that are tuition-based. 2) Hold our second annual fund dr've to Solicit dirent contributions. 3) Market otir services to local businesses and community aroups- 4) Research and apply for new and cant" ants frnm foun-riations EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 Provide low- or no-cost mediation and facilitation services to self-, community-, and court-referr-ed dients, 2) Offer a critical alternative to litiqation, 3) [?rovide conflict respluflon education to mediators and 1rommlinitv members, ;qnd 4) Promote penreful sduflons On Fast Hawai'_ 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (l.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of mediation cases opened 400 Number of mediation clients served(in cases closed) 800 Number of mediation session held 250 Number of mediator volunteer hours donated 800 Number of non-mediator volunteer hours donated 800 • of clients who are satisfied with the mediation process 90% • of clients who would consider recommending mediation to others 90% Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* 'total Budget Grant Req Salary and Wages $198,21 $198,215.0( $7,000.0( Professional Fees $12,OOC $12,000.00 $1,000.0 Operations $70,00 $70,000.00 $3,000.0 Supplies $7,000.1 $7,000.00 $1,000.0 Equipment $4,500. $4,500.00 $0.00 Other:Special events $7,500. $7,500.00 $0.00 Other: Other: Other: PLEASE NOTE: FY 13-14 figures are estimates (not actual Other:since we are only 7 months into the FY ending 6-30-14 TOTAL J$299,21 $299,215.0 $12,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services 1o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be sr ned regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council 0 Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing10 the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. D 4-'2:7cn�m n— 22-2-�f 1. Sign ure of�k thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Ku`ikahi Mediation Center Program Name: Community Conflict Resolution Services 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawal'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express) and be compliant prior to final payment. To register, go to http-.1/yend6rs.ehawaii.gov complete the easy step-by-step process,-and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report, using the tem late provided, will impact the evaluation of our program's or agency's uture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301h shall result in loss of all grant funds received during the grant period (must be refunded to County} and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. 1 (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty:gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that'any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of hlawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of Your aa_encV"s future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Sign at re of Au orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of mediation cases opened 400 Number of mediation clients served (in cases closed) 800 Number of mediation session held 250 Number of mediator volunteer hours donated 800 Number of non-mediator volunteer hours donated 800 • of clients who are satisfied with the mediation process 90% • of clients who would consider recommending mediation to others 90% TABLE IN FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $7,000.00 Professional Fees $1,000.00 Operations $3,000.00 Supplies $1,000.00 Equipment $0.00 Other: Special events $0.00 Other: Other: Other: PLEASE NOTE: FY 13-14 figures are estimates not actual other: since we are only 7 months into the FY ending 6--30-14 r— TOTAL $12,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 72 Laupahoehoe Train Museum Best of Hamakua Agency Name:Laupahoehoe Train Museum Program Name:Best of Hamakua Agency Director: Doug Connors Phone No.--962-630.0 Contact Person: Phone No.: Mailing Address: Address: PO Box 358 Address: city,5T,zip Laupahoehoe, H 96764 Facility Address: Address: 36-2377 Mamalahoa Hwy Address: city,sT,zip Laupahoehoe, HI 96764 Email Address: Fax No.: 962-6967 Accountant/CP Phone No.: Firm (if applicable): Mailing Address: Address: Address: City,5T,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANG S Amount of Request for County Nonprofit Grant Program Funds $14,985.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: LTM mis i n is to emphasize The his-t-Qry of his-t- railroads in Hi and EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Laupahoehoe Train Museum Program Name: Best of Hamakua 3.Program Description: To promote and establish Hamakua as a tourist destination. Best of Hamakua will highlight the Lau ahoehoe Train Museum Hamakua Mushrooms & Hawaiian Vanilla Company as tourist destinations that offer local Hawaiian products al3d ties the agricultural istor to cument_ venues that are tourist ready. We provide free & independent tourist a venue to learn about the c1p�gln�nment Of Hamakua andriculture_ 4.Total Budget&Position Count: Total Program Budget: $63,195.00 Total Program Position Count: 3 Total Agency Budget: $220,000.00 Total Agency Position Count: 7 S. Program f=unding Sources[identify all sources of funding applied to this program : FY14-15 Revenue Source Estimate LTM volunteer hours 40 hours x 20 days x 6 months @ $9.00/hr $43,200.00 Hamakua Mushroom & Hawaii Vanilla Farm $5,010.00 COH nonprofit grant $14,985.00 TOTAL: $63,195.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Once started, marketing will be continued with increased contributions from Hamakua Mushmoms_& Hawaiian Vanilla Farms___As other venues become tourist ready, then we will include them_ Increased revenue from admissions ip will st ipply increased ft itt ire marketong EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name' Laupahoehoe Train Museum Program Name:Best of Hamakua 7. Program Objectives Using County Nonprofit Grant Program Funds: This program is to-kick off branding of Hamakua as a tourist destination. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (l.e.:Number ofclientsserved workshops or events held,volunteer hours,etc.Describe,be specific.] 20% increase in visitor count at LTM 600 additional visitors in 6 mo. Develop group destinations to support destination marketing shared referrals between stops Shared marketing between three destinations shared brochure cost Increased social marketing with paid staff expert advise to non-technical sta Greater appeal to visitors to get to know local style&people ag related exposure to tourist 80% better exposure through internet&social media marketing multichannel marketing advantag development of tours along Hamakua Coast at least weekly tour bus visits Attach additional pages as necessary. 9.TABLE III: PROGRAM EXPENDITURES FY 13-14 FY 34-15 FY 1415 Actual* Total Budget Grant Req Salary and Wages $10,500.00 $8,100.0 Professional Fees Operations $43,200.00 Supplies Equipment Other:12,000 brochure design, printing & distribution $3,690.00 $3,690.0 other:6 month advertising campaign $3,555.00 $2,445.0 Other:6 month social media, website & sales campaign $2,250.00 $750.00 Other: Other: TOTAL $0.00 $63,195.00 $14,985. *If applicable EXHIBIT NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:Laupahoehoe Train Museum Program Name: Best of Hamakua io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawai`l.Only those listed below need to be disclosed.One form per person with a conflict is needed. if no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance, any conflicts or potential conflicts of interest: m if no conflicts exist,check here. a., L?9�uP E� / SignatuW of Authorized Person (specify title) Date EXHIBIT A WnKIPAORT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Laupahoehoe Train Museum Program Name:Best of Hamakua sa.. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'l County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that Information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express,and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process,and pay the annual registration fee online using a credit card. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely.complete, and accurate year-end report, using the template provided, wil! impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all Grant funds received during the Brant Period (must be refunded to Cou0n)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. 1(we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http-//www.hawaiicounty.gov/fn-nonprofit-grant-forms/­on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2015 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of our agency's future funding request and may result in actions taken to recover these LELnds. By signing below,you are acknowledging that you have read and understood these requirements. /- - r //3 C,//'t - - Signatur of Authorized Person (specify title) Date EXHIBIT A K1nNPRnr1T r.RANT APPI I(ATION FY 2014-2015 Page 6 of 7 Agency Name: Laupahoehoe Train Museum Program Name:Best of Hamakua 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 20% increase in visitor count at LTM 600 additional vi Develop group destinations to support destination marketing shared referrals Shared marketing between three destinations shared brochure Increased social marketing with paid staff expert advise to Greater appeal to visitors to get to know local style& people ag related expoE 80% better exposure through internet&social media marketing multichannel ma development of tours along Hamakua Coast at least weekly t TABLE II: PROGRAM EXPENDITURES FY 1415 Council Grant Request Award Salary and Wages $8,100.00 Professional Fees Operations Supplies Equipment other: 12,000 brochure design, printing & distribution $3,690.00 Other: 6 month advertising campaign $2,445.00 Other: 6 month social media, website &sales campaign $750.00 Other: Other: TOTAL $14,985.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 73 Laupahoehoe Train Museum Pa'auilo Mauka Community Emergency Response Team (CERT) Agency Name:Laupahoehoe Train Museum Program Name: Pa'auilo Mauka Community Emergency Response Team (CERT) Agency Director: Doug Connors Phone No.:(808)962-6300 Contact Person: Carl Pinhas/Jami Sales Phone No.:(808) 640-2924 Mailing Address: Address: PO Box 358 Address: city,sT,zip Laupahoehoe, Hl 96764 Facility Address: Address: 36-2377 Mamalahoa Hwy Address: city,sT,zip Laupahoehoe, Hl 96764 Email Address: JamiAloha @gmail.com Fax No.: 962-6957 Accountant/CP Phone No.: Firm (if applicable): Mailing Address: Address: Address: city,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE 1NFORMATION_CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $24,150.00 1. Prior Year Award of County Nonprofit.Grant Program Funds: FY 11.12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: M mission i5 to em hasi histo ry gf railroads in M and to -Dreserve. Dromote. & protect community interests. CERT mission Is ton -memhers to provide rapid and safe care-for residents until emergency respond - - r_an r'ear1 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Laupahoehoe Train Museum Program Name:Pa'auilo Mauka Community Emergency Response Team (CERT) 3. Program Description: We seek funding_ to secure materials and resources to fully implement the team functions specified in the CERT plan. This includes emergency generators, bottled water, medical supplies, FRS/GMRS handhelds . freeze-dried rations. and newsletter supplies. The December 2013 rains/ bridge loss] our area demonstrate our group's effectiveness , and we wishtohp- prenared_to assist our residents in a future disaster_ 4.Total Budget& Position Count: Total Program Budget: $80,'150,00 Total Program Position Count: 12 Total Agency Budget. 1$220,000.00 Total Agency Position Count: 116 S. Program Funding Sources(identify all sources of funding applied to this pLogram FY14-15 Revenue Source Estimate 12 CERT members volunteering 6,000 hours @ $9.00/hr(in-kind) $54,000.00 4 day CERT training and 1 day FEMA training $2,000.00 COH nonprofit grant $24,150.00 TOTAL: $80,150.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our volunteer aroup of 12 has been buying their own supplies_to date: X1200 in_ oc rn_munications handheld radios,$500 in meeting and traininn EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:Laupahoehoe Train Museum Program Name:Pa'auilo Mauka Community Emergency Response Team (CERT) 7.Program Objectives Using County Nonprofit Grant Program Funds: Purchase emer__aenc_y supplies and a trailer to hold-Aransport them. Needed: Trailer, generators, medical supplies, FRS/ MRS radios freeze-dried rations. We also wish to purchase newsletter sul)plies. to better educate the com muni y o AnPss and nur mle _. 8.TABLE 1: What are the intended measurable outputs.or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc Describe,be specific.) Volunteer hours per year 6,000 Number of residents served per year 2,462 Group training meetings held yearly 10 Public education meetings held yearly, minimum 2 One well supplied CERT response trailer 1 12 volunteers equipped with FRSIGMRS hand held radios 12 Community support&well-being during emergency 100% Attach additional pages as necessary. 9.TABLE fl: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $0.00 $54,000.00 $0.00 Professional Fees $0.00 $0.00 $0.00 Operations $2,000. $2,500.00 $500.00 Supplies $750.0 $6,800.00 $6,800.0 Equipment $500.0 $7,200.00 $7,200.0 Other:Community education: newsletters $0.00 $2,100.00 $2,100.0 Other:emergency medical supplies $0.00 $4,000.00 $4,000.0 Other:inter-team communication:G12 FRSIGMRS handheld radios $1,200. $1,200.00 $1,200.0 Other:Cribbing blocks, ry bars, lighting, tarps supplies: trai a tent $1,800. $350.00 $350.00 Other:emergency food supplies $0.00 $2,000.00 $2,000.0 TOTAL 1$6,250.q$80,150.00 $24,150. *If applicable EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:Laupahoehoe Train Museum Program Name:Pa'auilo Mauka Community Emergency Response Team (CERT) io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawai`l. Only those fisted below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure orms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ staff appointed by a member of the Council ❑ The Mayor [❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signatur of Authorized Person (specify title) Date EXH I BIT A NnNPRCIFIT GRANT APPI Ir'ATION FY 2014-2015 Page 4 of 7 Agency Name: Laupahoehoe Train Museum Program Name:Pa'auilo Mauka Community Emergency Response Team (CERT) 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135--2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expend!ng/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein,including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express,and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process,and pay the annual registration fee oniine using a credit card. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall Include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 i (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received cluding the grant period must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted tot and accepted bv,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawailcounty.goy/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A FJnNPRnr-1T rRANT APPI ICATION FY 2014-2015 Page 6 of 7 Agency Name:Laupahoehoe Train Museum Program Name: Pa'auilo Mauka Community Emergency Response Team (CERT) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Volunteer hours per year 6,000 Number of residents served per year 2,462 Group training meetings held yearly 10 Public education meetings held yearly, minimum 2 One well supplied CERT response trailer 1 12 volunteers equipped with FRS/GMRS hand held radios 12 Community support&well-being during emergency 100% TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $0.00 Professional Fees $0.00 Operations $500.00 Supplies $6,800.00 Equipment $7,200.00 Other: Community education: newsletters $2,100.00 Other: ernergency emergency medical supplies $4,000.00 Other: inter-team communication:G12 FRSIGMRS handheld radios $1,200.00 Other: Cribbing blocks,pry Fars, lighting, tarps supplies: trai a tent $350.00 Other: emergency food supplies $2,000.00 TOTAL $24,150.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 74 Legal Aid Society of Hawaii Removing Barriers for Hawaii County's Vulnerable Population Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for Hawaii County's Vulnerable Population Ilulll���� lilul Ilill Illll�llri Agency Director: M. Nalani Fujimori Kaina Phone No.:(808) 527-8014 Contact Person: Joanna Sokolow Phone No.:(808) 329-3910 Mailing Address: Address: 924 Bethel Street Address: MY,ST,zip Honolulu, Hawaii 96813 Facility Address: Address: 75-5656 Kuakini Hwy Address: Ste. 202 MY,ST,zip Kailua-Kona, Hawaii 96740 Email Address: josokol @lashaw.org Fax No.: (808) 334-9650 Accountant/CP Wayne Keawe Phone No.:(808) 527-8060 Firm (if applicable): Mailing Address: Address: 924 Bethel Street Address: City,ST,zip Honolulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $30,000.00 $15,000.00 2.Agency Mission Statement: The Legal Aid Society of Hawaii's mission.is to address critical legal needs through high quality advocacy, outreach and educatLim, in the n�.lmuififfairoess and Justice_ As the only community-based, nonproR law firm with offices in Kona and Hilo, we have emnowe[ed_ Inw-incnmQ.and d.is vantaned people for ov Ir_s EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for Hawaii County's Vulnerable Population AAllll IIIA Ii1�Ip9AAAAA�lp1� 3. Program Description: Legal Aid requests $40,000 to provide critical civil legal services in Hilo and Kona ($20.000 for each office). These services include assistance with family, housing,public benefits consumer, and senior le al issues. legal Aid will provide free i I - 'ndimi uabs with b usehold incomes less than 0 of the poverty lemel. See 4.Total Budget& Position Count: Total Program Budget: $40,000.00 Total Program Position Count: 7 Total Agency Budget: $6,982,657.00 Total Agency Position Count: 99 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Hawaii Island United Way $5,000.00 Hawaii County Office of Aging $72,450.00 State of Hawaii Judiciary - Guardian ad Litem/Parent Counsel Services $48,000.00 Fee for Service $11,000.00 Federal Funding $289,890.00 Hawaii County Nonprofit Grant Program $40,000.00 See Continuation Pages TOTAL: $486,340.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Legal Aid continues to apply fQr federal, state, and otbar grants to provide services to low-incoMe individuals-and fammas On ne d- WP M11 also seek donations fmixi-those who receive servaces fMM this program- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for Hawaii County's Vulnerable Population NNEWEEEMMMN� ;; -._. 7. Program Objectives Using County Nonprofit Grant Program Funds: Legal Aid will provide legal services to those below 200° of FPL in 75 cases to support for famialies; keep-Qh'idrell-safe and serve fetV- stability and health- See Confinuation PqC 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Numberoftlients served workshops or events held,volunteer hours,etc.Describe,be specific.) Support for Families 26 cases Keeping Children Safe and Secure 3 cases Preserving the Home 5 cases Maintaining Economic Stability 26 cases Protecting Consumers 3 cases Promoting Safety, Stability, and Health 12 cases Attach additional pages as necessary. 9.TABLE fl: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual` Total Budget Grant Req Salary and Wages $13,500 $465,090.0 $36,500. Professional Fees $1,800.00 Operations $1,500.( $155,800.0( $3,500.0 Supplies $10,700.00 Equipment $6,200.00 Other: Other: Other: Other: Other: TOTAL $15,000 $639,590.0 $40,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for Hawaii County's Vulnerable Population io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Legal Aid Society of Hawaii POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The corporation Counsel, the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substontial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: FO If no conflicts exist, check here. tr�cc�v-r�,rc vtmc,-cast— _ oil-LawA Signature of Author? rson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for Hawaii County's Vulnerable Population 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors_ehawaii.eov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 (we) understand that failure to submit the final report within 60 days of June 30h shall result in loss of all rant funds received during the rant Period must be refunded to Count and exclusion from future erant Participation for a minimum of one year or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:Hwww.hawailcounty.gov/fn-nongrofit-grant-forms/`on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will iml2act the evaluation of y,our agency's uture funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Lit-lac.vTI,ra v a.(rC.TOa— OWL 114 Signature o Auth zed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for Hawaii County's Vulnerable Population 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Support for Families 26 cases Keeping Children Safe and Secure 3 cases Preserving the Home 5 cases Maintaining Economic Stability 26 cases Protecting Consumers 3 cases Promoting Safety, Stability, and Health 12 cases TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $36,500.00 Professional Fees Operations $3,500.00 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $40,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Agency Name: Legal Aid Socie of Hawaii Program Name: Removing Barriers for Hawaii Coun 's Vulnerable Population Program Description: According to the 2010 American Community Survey, more than 13.92% of our state's population lives below 125% of the federal poverty guidelines and is eligible for Legal Aid's services based on their income. The Census Bureau's Small Area Income and Poverty Estimates (SAIPE) Program estimates the number of people living in poverty in Hawaii County as 33,285, or 17.98% of Hawaii County's total population. These statistics confirm that there is an even greater need for free civil legal services for Hawai'i County's low-income individuals and families. The Preamble of the United States Constitution states, "We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do, ordain and establish this Constitution for the United States of America." The Constitution establishes Justice as a citizen's fundamental right to secure prosperity, however low income and working poor citizens are often unable to access the legal system. Author Deborah L. Rhode says, "No issue presents a more dispiriting distance between America's core principles and actual practices than access to justice. We embrace equal justice as a social ideal, but fail to make even minimal access a social priority."' The effects of increased poverty are widespread throughout Hawaii: more people are losing their homes to foreclosure with Hawaii ranking 10th in the nation for foreclosures2, there is an increase in homelessness with 14,000 people utilizing shelter services or accessing homeless outreach programs3, and in 2010 more than 133,043 people in the state of Hawai'i received supplemental nutritional assistance program (food stamp) benefits4. In a 2007 report, Achieving Access_ to Justice for HawaiTs People: The 2007 Assessment of Civil Legal Needs and Barriers of Low and Moderate-Income People in Hawai'i,' key findings discovered that: • Only 1 in 5 low and moderate-income Hawai'i residents have their legal needs met. Legal service providers are able to help only 1 in 3 of those who contact them for assistance. 1 Rhode,Deborah,L.Access to Justice. New York;Oxford University Press,2004.Print. 2 August 2010 RealtyTrac figures:hM2://www.biAoumals.com/Dacific/stories/2010/09/13/daily32.html 3 Homeless Survey Utilization Report 2010), 4 http://hawaii.gov/dhs/self-sufficienoLLbenefit/FNS S http_//www.le2alaidhawaii.orgMI Access to Justice.pdf. NONPROFIT GRANT APPLICATION FISCAL YEAR 2014-15 Continuation Page 1 of 4 Agency Name: Legal Aid Socig of Hawaii Program Name: Removing Barriers for Hawaii County's Vulnerable Population • The areas with the greatest unmet civil legal needs are housing (24%), family (23%), domestic violence (8%), and consumer (7%). • Significant barriers to obtaining legal assistance in addition to inability to afford an attorney includes language and cultural barriers, lack of knowledge of one's legal rights, lack of knowledge of available legal services, and difficulty in accessing legal services programs. • There is one legal service attorney for every 2,291 persons living below 125% of the federal poverty guideline. • There is one legal service attorney for every 4,402 persons living below 200% of the federal poverty guideline. • There is one private attorney for every 361 persons in the general population. Since this report, the total number of people living below 200% of the federal poverty guidelines has increased by 8.52%. In 2013, responding to the demand for services, Legal Aid's attorneys and paralegals in Hawaii County closed 1,499 cases. This program will assist us in continuing to provide these critical legal services. Through this grant Legal Aid will provide critically needed legal services to Hawai'i County's residents to: • Maintain or secure affordable housing • Help families become safe and stable with family law services, including protection from domestic violence, child custody and support • Protect families and individuals from consumer problems such as mortgage "rescue" scams or illegal debt collection practices • Obtain public benefits such as disability benefits from the Social Security Administration or Medicaid • Eliminate illegal barriers to housing • Secure appropriate placement and services for abused and neglected children • Provide critical legal services to assist immigrants who are the victims of violence or trafficking • Ensure language access for non-English speakers. Our intent is to provide the widest breadth of civil legal services possible to meet the needs of Hawaii County. By assisting residents with their critical civil legal issues, Legal Aid can help them resolve their problems to meet their basic necessities like maintaining housing, stabilizing their families, avoid unfair acts and deceptive consumer practices, gain access to public assistance when they are unable to work, secure placement for abused and neglected children, and provide assistance to immigrants and those who are vulnerable because English is their second language. NONPROFIT GRANT APPLICATION FISCAL YEAR 2014-15 Continuation Page 2 of 4 Agency Name: Legal Aid Societ y of Hawaii Program Name: Removing Barriers for Hawaii County's Vulnerable Population So far, under our current Hawaii County Nonprofit Grant for this fiscal year, we have provided legal assistance in over 28 cases expending the full amount of the grant provided. Some of our services have included: • Assisting widowed client to create will and nominate successor guardian to ensure her children are cared for should something happen to her. • Negotiating a settlement between a client and her landlord to avoid litigation and retrieve her personal property. • Drafting Powers of Attorney and Advance Health Care Directives for an elderly couple. • Assisting an Air Force Veteran with an uncontested divorce • Preventing homelessness by negotiating to avoid eviction of a disabled client. By removing these barriers, Legal Aid's services can greatly assist individuals and families in Hawaii County to thrive and improve their lives. This grant would enable Legal Aid to provide a wide array of legal services not funded by any other specific grants, to ensure assistance to Hawaii County residents especially in times of decreased funding from federal and state resources. We will also be working closely with Volunteer Legal Services Hawaii, to ensure that services are complimentary. 6. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY14-15 Estimate State of Hawaii Attorney General Foreclosure Settlement Grant $20,000.00 Other State Funds $193,250.00 Total 1 $639,590.00 Program Objectives: The following services will be provided free to low-income individuals and families whose incomes are less than 200% of the poverty level. 1. Provide support for families (26 cases): Assist clients with child custody, child support, domestic violence, visitation, paternity and divorce. A domestic violence victim may require assistance in obtaining a temporary restraining order or establishing temporary custody, visitation, and support. Paternity cases are accepted to determine custody, visitation, and child support rights and obligations. NONPROFIT GRANT APPLICATION FISCAL YEAR 2014-15 Continuation Page 3 of 4 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for Hawaii Coun 's Vulnerable Po ulation 2. Keeping children safe and secure (3 cases): Assist with guardianships and adoptions; and advise family members and others about their rights and responsibilities in caring for abused and neglected children. 3. Preserving the home (5 cases): Assist clients with private landlord eviction defense or negotiation; foreclosure assistance; mortgage predatory lending practices, public housing applications, evictions, grievances, rent issues, security deposits; and, habitability, repairs, illegal lockouts, or illegal utility shutoff. 4. Maintaining economic stability (16): Provide assistance with denials, appeals and terminations of General Assistance, Temporary Assistance for Needy Families (TANF), SNAP (fka Food Stamps) and other public benefit programs. Unemployment and Veteran's benefits are also areas in which assistance is provided. Public benefits may be the only source of income for an individual or family. 5. Protecting consumers (3): Assist clients with consumer issues including predatory lending, debt collection, bankruptcy, consumer credit matters, repossession, and unfair or deceptive practices. 6. Promoting safety, stability and health (12): Provide assistance with program denials of services or eligibility as well as terminations from the health insurance programs, district court restraining orders, individual rights, immigration, powers of attorney and advance health care directives. Legal Aid intends to provide critically-needed legal services to 75 individuals and families in Hawaii County. The proposed objectives reflect an average cost of $533 per case which can involve hours of assistance in a contested custody case, foreclosure defense, help in getting access to public assistance, assisting a victim to get a temporary restraining order, or getting a temporary power of attorney to care for a relative's child. Assistance will be provided by either an attorney or paralegal, depending on the nature of assistance needed. NONPROFIT GRANT APPLICATION FISCAL YEAR 2014-15 Continuation Page 4 of 4 75 Malama Q Puna Pahoa Community Certified Kitchen Agency Name: MALAMA O PUNA Program Narre: Pahoa Community Certified Kitchen Agency Director: Rene Siracusa Phone No.:965-2000 Contact Person: Re4Siracusa Phone No.: Mailing Address: Address: POB 1520 ° Address: CO,ST,Zip Pahoa, H! 96778 Facility Address: Address:. 15-2754 Pahoa Village Rd. Address: City,ST,Zip Pahoa, HI 96778 Email Address: malamaopuna @yahoo.com Fax No.: Accountant/CP Phone No.: Firm (if appiicabie): Mailing Address: Address: Address: City,ST,Zip YOU AN RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT A14j) TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $24,250.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $20,000.00 $20,000.00 2. Agency Mossioa Statement: To assurn.unlical habitat for nativespecies and open scace for future generations througbe nvironmental educatkm, hands-on Qjects and - . EXHI BIT A nii-twiai+r=+i=ir i•i+ i wir it iti ii-•nri rtwi i`ti IA4 A •i A%F Agency Name: MALAMA O PUNA Program Name: Pahoa Community Certified Kitchen 3. Program Description: We propose to convert an existing building into a community certified kitchen. It will create value-added products to make farming more viable, aid entrepreneurs as a business incubator, allow families & nonprofits tO Drepare large quantities of food for special events, provide food service during emergencies/evacuations, and in general aid the —mr PunaecQnov and protect farmland from yielding to development. 4.Total Budget& Position Count: Total Program Budget: 1$98,500.00 LTotal Program Position Count: $2.00 Total Agency Budget: #$eC ho Total Agency Position count: $9,Q0 S. Program Funding Sources(identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Hi.-.man Services & Economic Development grant- County----.-- $24,250.00 HQHQ, Inc. dba Pahoa Feed & Fertilizer _ $57,500.00 Maiama O Puna W $16,750.00 $98,500.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: USDA awarded us a $46,000 grant for kitchen equipment but won't release the funds-until_the renovation/construction is completed.The Nam for n.l_u.mbing, alactrical_ ventilation and architectural are already self--supporting ,......_� EXHIBIT w h1llf1i 1311 4PIQ fil 71&M A..j-1i i^A Tiliwi w Ali n iitili i7 Ti Agency Name: MAL.AMA O PUNA Program Name: Pahoa Community Certified Kitchen 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide opportunity for residents & farmers to increase income, save as land from development; create.ad.isa.n_alv_a.lue—ar value-added orodu�t,a to promote Bl, give families & nonprofits a place to produce food f-Qr events rovHe a venue for emer-gency, evacuation m.eaf.s_.�....,..Y. 8.TABLE I: What are the littended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) to comply with DOH cert. kitchen regs:renovate structure's electric we will get DOH approval of ditto: renovate structure's plumbing &ventilation certified kitchen permit & be ditto: install septic system able to start serving the Puna ditto: install large propane tank corrnitinity. All renovation ditto: remove carpet & re-floor structure work will be completed within 1 year of receipt of funding. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 3415 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $25,000.00 $0.00 Professions! Fels $10,000.00 $10,000. Operations $8,000.00 $1,250.0 Supplies -- - $530.00 $0.00 Equipment --- - Other:septic tank & installation $7,000.00 $7,000.0( Other:propane tank & installation $3,000.00 $3,000.0 Other:ripping out carpet & installing washable flooring $3,000.00 $3,000.0 Other:one year A/S on property $42,OOC $42,000.00 $0.00 Other: TOTAL $42,00C $98,500.00 $24,250. *if applicable EXHIBIT A r"!is wiY ni.ii iP°RR'iR i1i r,r Srl�i. .T T 2' is«..... ..iS Agency Name: MALAMA O PUNA Program Name: Pahoa Community Certified Kitchen io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be suUmitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Rene Siracusa POSITION: MOP president, project consultant May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor he Managing Director The Director of Finance ❑ rae Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual wit!resvit in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry, Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: �] If no conflicts exist, check here. A�C2 Signature of Authorized Person (specify title) Date EXHIBIT A Flf�iii7Si)rSi iT J`i'.nki1 Agency Name: MALAMA O PUNA Program Name: Pahoa Community Certified Kitchen ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135--2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (wit ) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) under.-tarid that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will-be disqualified. Faxed or copied documents will not be accepted as original. documents. if awarded a grant from the County of Hawaii, I (we) understand and will corn oly with the requirement to enroll wilt, Flawai'i Compliance Express, and be compliant prior to final pa*;rne,,-r,. To register, go to http://ver:dors.ehawaii.gov, complete the easy step-by-step process, and pa'V tl-e awival registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement y n contractual year to submit a ear-end report to the County Council within 64 days after lone 30 of the for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely,complete, and accurate year-end report, using the template arovided, will impact the evaluation of our program's or agency's uture funding requests. EXHIBIT /- niriniSis��i4 i i n&M aAr.i ie A1M^Ki r—ir 5A-i A 5A-i c ii...... 2 ..r 9 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all_grant funds received durine the Brant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at.ltiLo:!/www.hawaiicount,, F-oyii,3-no;,Q alit-grant-for'71s on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these Lunds in a time!y manner will-impact the evaluation of our agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A w BAR;I!)A FiT'%'i)AR 'F A I)I)11/^A Tfrinl FUf; 4A 71A4 �lww.. 4' w+7 Agency Name: MALAMA O PUNA Program Name: Pahoa Community Certified Kitchen 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result to comply with DOH cert. kitchen regs:renovate structure's electric we will get DCJ ditto: renovate structure's plumbing & ventilation certified kitchqj ditto: install septic system able to start sel ditto: install large propane tank communi ditto: remove carpet & re-floor structure work will be go 1 Vear of rec TABLE I" Council PROGRAM EXPENDITURES FY 14-15 Grant Request Award Salary anu *zges $01.00 Professicm-.41 Fees $10,000.00 Operation.!; . � $1,250.00 Supplies � $0.00 Equipment Other: septic tank & installation $7,000.00 other: ro ane tank & instalIation $3,000.00 Other: ripping out carpet & installing washable flooring $3,000.00 Other: one year AIS on property $0.00 Other: TOTAL $24,250.00 Additional Council directives regarding award: EXHIBIT B AiFI A[il i]Fl1T F'1]A MTF A 1111I [F'A TiI"y T1 Fk;5r\R A 9Wvi C ..F { MALAMA O PUNA P. O. Box 1520 Pahoa, Hawai`*5 96778 (808) 965-2000 y^yw.ma1amao una.or maiamaopuna@yahoo.com Preserving Hawaii `s precious natural heritage Additional explanations and clarifications to grant agplication Page 1, MOP does not have an accountant, because our general operating budget is too small to require it. Our board approves the Treasurer's Report at its monthly meetings. Page 1, #1: The funds received in FY 2012-13 and 2013-14 were not for this project. They were for the Puna Panthers. We are in compliance with all County funds we have ever received. Page 2, #3: We are in partnership with HQHQ Inc., a Hawaiian family for-profit, which owns the property, and Hawaii TechWorks, a Hawaii-based nonprofit which will provide various services and with whom we have an MOU. Page 2,#4: MOP's fiscal year is the calendar year. It's 2014 budget is approved at its Janu,wy board meeting. Therefore, at this point,the Total Agency Budget has not been de',�nrnined. The form program insisted on putting dollar signs on the Position Counts, which are a simple 2 and 9 positions (9 board members- all unpaid). Page 2,#b: The plans referred to were paid with a grant from County Research & Deve!aprnent (except the drainage study which was paid by HQHQ Inc), grid are on file in that office. We have a Feasibility Study and a Business Plan for the project,which are available upon request. Page 3,#S: The Hawaii County Planning Commission granted us a Spe,.ial Permit for this project and made certain conditions, and the Dept. of Health also has conditions in its guidelines for certified kitchens.Th-e renovations we are seeking funding for are so that we can comply with those conditions. 76 Malama O Puna (MOP) Restoring Priority Area of Keau'ohana Native Lowland Wet Forest Agency Name: Malama O Puna (MOP), a 501(c)(3) nonprofit Program Name: Restoring Priority Area of Keau`ohana Native Lowland Wet Forest Agency Director: Rene Siracusa Phone No.:965-2000 Contact Person: Cindy J. Dupuis Phone No.:937-8867 Mailing Address: Address: RR2 Box 3331 Address: City,sT,Zip Pahoa, Hl. 96778 Facility Address: Address: 15-2754 Pahoa Village Rd. Address: P.O. Box 1520 City,ST,zip Pahoa, HI. 96778 Email Address: malamaopuna @yahoo.com. Fax No.: Accountant/CP None Phone No.: Firm (if applicable): Mailing Address: Address: Address: City,5T,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $20,000.00 $20,000.00 2. Agency Mission Statement: To assure_critical habitat for native species and open space far future gen-er-ationa-thmuah-emir-QnmentaI ti EXHIBIT A hinhilnnr%r1T nl7Axm Ann]li-AT!nAl rv!' ni A 7f19 r Agency Name: Malama O Puna (MOP), a 501(c)(3) nonprofit Program Name: Restoring Priority Area of Keau`ohana Native Lowland Wet Forest 3. Program Description: Keauohana forest reserve is the largest and most intact native lowland wet forest remaining Statewide and critical habitat for the endangered C rtandra Nanawalensis. One field biologist assisted by two field L technicians will oversee weekly chemical/mechanical control of invasive species beginning in most intact core area, as well as monthly volunteer efforts x tr area near 'l wr 4,Total Budget & Position Count: Total Program Budget: $137,672.00 Total Program Position Count: $2,00 Total-Agency Budget: $8,995.00 Total Agency Position Count:. $.9.00. S. Program Funding Sources(identify all sources of funding applied to this pMgram FY14-15 Revenue Source Estimate County Grant $20,000.00 Quarterly community volunteer work days $2,000.00 Council contingency fund (submitted) $5,000.00 State G-I-A (suUmitted) $107,672.00 TOTAL: $134,672.00 Attach additional pages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: Continued gran proposals and volunteer efforts will su poyt ongoing efforts of Keau'ohana restoration_ Community outreach contributes ate,, wPll,_as this area is very accessihle to the nuhlic- a, nd isbejn utilized Ap EXHIBMA M fi P.jrsnrtirrT a-nASIT AFIM 1#'4A+3An1 nr-iri4 A -1611r 6- Agency Name: Malama O Puna (MOP), a 501(c)(3) nonprofit Program Name:Restoring Priority Area of Keau`ohana Native Lowland Wet Forest 7: Program Objectives:Using County Nonprofit Grant Program Funds: Expand current restoration area (app.3 acres) of the total 160 acres. of priority area identified in Keau`ohana Forest Reserve, at an average of three acres per month and striyi,na toward an estimated 6.acros,In..thP fiscal- year. S.TABLE !: What are the intended measurable+outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEM61ktS Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 98°/a control of invasive species currently degrading the part of the forest selected for restoration 36 acres controlled Attach additional#arges as necessary. 9.TABLE li: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget . Grant Req Salary and Wages Professional Fees $.10,435.00 :$1 8;436. Operations Supplies Su . . pp. . .. _ .. .. . . . . .. - $5,000.40.. . .. Equipment Other:Field technician assistant Other:Vgluriteer Labor non-cash cost.share $6,000.00 Other:Administration, indirect_costs, insurance... $1,500.00 .$1,500.0 Other: Other: TOTAL 1 $0.00J$31,000.00 $20,000. *If applicable EXHIBITA ennririririr ^rr��irAnniIl A'rI^NI ry-inia nnic Agency Name: Malama O Puna.(MOP), a 501(c)(3).nonprofit Program Name. Restoring Priority Area of Keau`ohana Native Lowland Wet Forest lo. ORGANIZATION CONFLICT DISCLOSURE FORM IN Please disclose any conflicts or potential conflicts of interest that any board member;officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One forin per person with a conflict is needed. If no conflicts exist,one form for tine organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure Lorms must be signed, regardless of whether a conflict exists. NAME:,. Rene Siracusa POSITION: President May have a conflict or potential conflict of interest, including any fairiilial relationship,with ally of the following(check all th8t apply): [] Member or members of the Council �] Staff appointed by a member of the Council Q The Mayor [] The Managing Director ❑ The Director of Finance ❑' The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interes#is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation nieasures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. r 3,9 �� l Signature of Authorized Person (specify title) Date EXHIBIT A Agency Name: Malama O Puna (MOP),.a,501(c)(3) nonprofit Restorin P�riorit Area of Keau ohana Native Lowland Wet Forest Program-Name: ._ � � y ` u. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135�2-142.1. Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I'(we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expend ng/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant, contract,or program for which funds were used. I (we) hereby certify that information supplied herein,including all supporting documents;is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I ewe) understand that information supplied herein shall-be made public according to Chapter 92F, Hawa'i'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature most be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents: If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express,and be compliant prior to final payment. To register,go tohttp://vendors.ehawaii.gov, complete the easy step-by:step process, and pay the annual registration fee online using a credit card. if awarded a grant from the County of Howai`i, F_(we) understand and will_comnl�with the requirement to submit a,.year-end_report to:.the. County.Council within 60 days.after June.30 of the contractual year for which_the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding:sources and amounts obtained during the award period. Failure to submit a timely, complete;and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A �+rnnrririnrrra^ririRir nnn�ir+R�r�nni r+��nrn in�r ri...... a ..�� I (we) understand that failure to submit the final report within 60 days of June Wh shall result in loss of all grant funds received during theArant period (must be refunded to Countyl and exclusion from future grant Participation for a minimum of one vear or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available athttp://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application;you acknowledge that any funds awarded will be restricted for the purposes: stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final ,. report. Failure_to return_these funds m_d ttrriely rriariner Will impacf the evaluation of your ardency s future funding request and may result in actl6m taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. zel�re S^ fil a�Gl Signature of Authorized Person (specify title) Date EXH I BIT A �ir+��r�nnrir�n A R" hnnl ii rinm rV,)n's n 'Ina a Agency Name: .. Malama O Puna (MOP), a 501(c)(3) nonprofit Program Name: Restoring Priority Area of Keau`ohana Native Lowland Wet Forest 12.COUNCIL AWARD WORKSHEET TABLE Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 98% control of invasive species currently degrading the part of the forest selected for restoration 36 acres controlled TABLE lt: PROGRAM EXPENDITURES FY 14-15 cduhcil Grant Request Award Salary and Wages Professional Fees $10,438.00 Operations Supplies Equipment Other: Field techniciari assistant $8064.00 Other: Volunteer Labor- non-cash cost share Other: Administration, indirect costs, insurance..... $1,500.00 Other: Other: TOTAL $20,000.00 Additional Council'directives regarding award: EXHIBIT B AFf Sion 6 it!-n Ahre Anrii If ATfhAt ry jni/{ h111.i 6rew..'7 nC- Additional explanations and clarifications to grant application ' Page 1: MOP does not have an accountant because our general operating budget is too small to require it. Our board approves the Treasurer's Report at its monthly meetings. Page 1,#1: ine funds received in FY 2012-13 and 2013-14 were not for this project, but were for the Puna Panthers. We are in compliance with all County funds we have ever received. Page 2,#3: Project Description: As the Hawaiian island ecosystems continue to be lost to development, agriculture and invasive species,there is an urgent need for'native forest conservation planning and implementation. Lowland wet forest studies conducted by University of Hawaii and USDA Forest Service researchers have contributed much to our awareness and interest in preserving these native forests(Hughes and Denslow, 2005; Hughes and Uowolo,2005;Zimmerman, et al. 2008; Cordell et al., 2009; Ostertag et al.,2009). Despite heavy invasion levels,there are significant remnant areas that are native-dominated in the canopy as well as understory layers, and these make up important priority areas for restoration and conservation(Dupuis, et al. 2013). Keau'ohana Forest Reserve in the Puna district of Hawaii Island is the largest and most intact lowland wet forest remaining below 1,000 feet in elevation in the State of Hawai'i. The proposed restoration area down-slope of Highway 19 includes up to one quarter of the 200 acres identified as-priority-area within-Keau'ohana Forest Reserve.This project will use-a'variety of control strategies to manage and/or eradicate all invasive species, including strawberry guava (Psidium cattleianum), albizia(Falcataria moluccana, Clidemia hirta,Melanoma septemnervium, Cecropia obtusifolia,Melochia umbellata, Paederia foetida. It will incorporate a rapid response capacity for any and all newly established pests or potential future pests. A front line defense and control of invasive species will receive priority along Hwy 19 where volunteer restoration efforts will continue east and south of currently restored-area, leaving a 50 meter strawberry guava buffer along the roadside. Field biologist and assistants will oversee weekly chemical/mechanical control of invasive species in most intact core area. Control strategies will prioritize certain weed species when appropriate,based on timing of seed maturation and persistence.-Con rol methods will include hand-pulling individuals that can be pulled with ease and creating large compost piles as needed; hand sawing individuals that are< 1.5 inches in diameter at base and applying Garlon-4, or applying Garlon-4 to basal bark; machete notching individuals> 1.5 inches in diameter at base and applying Garlon-4; spraying larger patches of understory species such as clidemia by foiiar application. We will selectively pull understory species,primarily Nephrolepis multiflora and Oplismenus hirtellus, to remove competition with existing native plants and to create space for native recruits and outplants. More than a dozen of the endangered Cyrtandra nanawalensis colonies have been located in this area and will receive priority attention through the removal of surrounding weeds and debris to foster their growth and success. Remaining lowland wetforests-of-Hawai`i are today reservoirs of rare native species,and their surviving biota is of great biological significance. Protection of this native ecotype will provide habitat for the endangered Hawaiian hawk(`io, or Buteo solitarius), and other native birds such as the `amakihi (Hemignathus virens) and `apapane (Himatione sanguine), that are making a comeback in the low elevation forests. This project will secure the most optimal critical habitat for the endangered ha`iwale (Cyrtandra nanawalensis), whose habitat is entirely restricted to lower Puna forest fragments. Page 3, 0: Program Objectives The goal of the project is to reconstitute the native forest composition and integrity to the extent possible.'We'do not propose-to recover 140%native forest as-some*of the less aggressive non-native species may need to be tolerated in some cases, and a selective process may determine exceptions to certain control measures if it may cause too much disturbance to a largely native canopy and understory. We will strive toward>90%native composition. This particular forest is likely to respond well to control and planting measures;native seedling recruitment is occurring naturally on approximately a half dozen acres in the Keau`ohana reserve that have undergone restoration thus far, likely due to the high degree of shade being provided by native trees. Base maps with systematically established transects and plots have already been created for recent study using the Geographic Information System(Dupuis,2013). A total of 23 ten meter square-plots have been assessed in the proposed area in terms of-their vegetation cover, and provide a basis for future monitoring if needed. With the use of existing maps, GPS units and compasses,we can effectively define accomplished restoration efforts.A record of daily ..progress will be kept indicating the area covered and approximate number of plants of each species treated and/or planted. By the end of the project's term,most invasive species will likely be absent firom the area,however there will be some alien plant recruitment and recovery in areas. where beginning efforts were made. In order to minimise this,a final sweep will be made one to two months before the project completion date. 77 Malamalama Waldorf School Diabetes Reversal Research Program (DRRP) Agency Name: Malamalama Waldorf School Program Name: Diabetes Reversal Research Program (DRRP) Agency Director: Kelley Lacks Phone No.:(808) 982-7701 Contact Person: Kelley Lacks Phone No.:(808) 982-7701 Mailing Address: Address: HC 3 Box 13068 Address: City,ST,zip Keaau, HI 96749 Facility Address: Address: HC 3 Box 13068 Address: City,ST,zip Keaau, HI 96749 ' Email Address: kelley @hawaiiwaldorf.org Fax No.: (808) 982-7806 Accountant/CP Ron Dolan Phone No.:(808) 935-5433 Firm (if applicable): CPA & Associates Mailing Address: Address: 16 Railroad Ave Address: City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $7,500.00 $5,200.00 2. Agency Mission Statement: The mission of Malamalama Waldorf School is to improve the quality of the educational experience by rovidin Waldorf Education in East Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Malamalama Waldorf School Program Name: Diabetes Reversal Research Program (DRRP) 3. Program Description: An educational pro-gram for those diagnosed with diabetes or as re--diabetic to control their diabetes and possibly, in conjunction with their health care provider, reduce or eliminate the need for medication -through tailored nutrition and healthy activity, 4. Total Budget& Position Count: Total Program Budget: $36,000.00 Total Program Position Count: 3 Total Agency Budget. $666,668.00 Total Agency Position Count: 23 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Nutritional Research Foundation $16,000.00 Hawaii County Grant $15,000.00 Other Grants (Private Foundation & Corporations) $5,000.00 TOTAL: $36,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We All be applying for additional grants and lo-kind support EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Malamalama Waldorf School Program Name: Diabetes Reversal Research Program (DRRP) 7. Program Objectives Using County Nonprofit Grant Program Funds: -1 ) To support those enrolled in the program to eliminate or reduce use of pharmaceuticals in dealing with diabetes. 2) To demonstrate that diabetes and its complicationssan be reduced through Proper nutritional protocols and healthy 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number ofclientsserved workshops or events held,volunteer hours,etc.Describe,be specific.) 9 workshops, one per month September 2014 - May 2015 Publication of results 25-30 per session (approximately 250 participants) Reduction of reliance on drugs Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $9,500.00 $4,500.0 Professional Fees $12,500.00 $5,500.0( Operations $4,000.00 $4,000,0( Supplies $5,000.00 $1,000.0( Equipment Other: Recruitment $5,000.00 Other: Other: Other: Other: TOTAL $0.00 $36,000.00 $15,000.( *If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Mency Name: 'Vafamala,ma Waldorf School -- Program Name: Diabetes Reversal Researc'r, Program (DRRP) lo. ORGANIZATION CONFLICT DISCLOSURE FORM TWA 600A a^1J COnflicti or poter)'4 Corihcts of l 1ternsi Way: any board member, o`hcw dkeaw or adnwatator of your organwa_on may have :'1 ch the Cou,ng of Hawk Only thoa? Wed WavIv veed to be dk,> ,,Sed- On. oer oemo' Wth a con 9m is needed. I(no corl"kty 2Y'3t one fc)-m {O" We orgatllzwon, .':Itr. the 11'o [c,nh b eWs C op&on checwW needs to be �.jbrl tted Please duolicaw as needed to `.Ji 'i u:5d ose ---audoswe 'ms n7r5: be Vaned. Ty QQfdr?55 GI n'Cr e'G �O n* _ °xsry 11A1 i Ida; hagn a confn:t or poten a ?W"; of a. oam 4 re 31.0,", . a' ', o T. FvIe"!' er o r-w�r,c) r o :hi; Co,,r1_i• Re Mens of Pnowe j- T,a I.or on '..__ ov the As i-.mni rOr;,,,`a' an ICouni_. Co..r5 P'laaye fir;nN Ir 3 nd aq rt ;?` J a a j f: a syd I^. Mr t or appear.., 1-1 - a - V Ll EXHiBJ A. �ax _ Agency Name: Malamalama Waldorf School Program Name: Diabetes Reversal Research Program (DRRP) 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine-and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. i (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. if awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a__year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301"shall result in loss of all grant funds received during the Brant period(must be refunded to Countyl and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accented by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-formes on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds,awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions token to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Malamalama Waldorf School Program Name: Diabetes Reversal Research Program (DRRP) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 9 workshops, one per month September 2014 - May 2015 Publication ofd 25-30 per session (approximately 250 participants) Reduction of 0 TABLE 11: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $4,500.00 Professional Fees $5,500.00 Operations $4,000.00 Supplies $1,000.00 Equipment Other: Recruitment Other: Other: Other: Other: TOTAL $15,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 High Nutrient Density (HND) Diabetes Study Outline Duration: one year Number of subjects desired: 100 (out of 250 possible) Inclusion Criteria: Diagnosis of type 2 diabetes; HbA lc>7 or HbA I C>6 with use of medication for at least 6 months. Total cholesterol below 250 without medications, willingness to stop cholesterol lowering drugs for the study duration. Cholesterol lowering medications must be stopped 2 months prior to study commencement. Hawaii County residents. Permission from physician. Exclusion Criteria: HbA ICc6.5 or>10.5 Use of insulin >I 0 years Current smoking, alcohol or drug abuse, pregnancy, unstable medical status Over the age of 75 years Unmediated cholesterol greater than 250 Inability to ambulate Dietary interventions: hiterventron Group —» High nutrient density diet, plus supplemental Vitamin D') (20001U), when blood test determined need, EPA/DHA (200 mg), iodine (I50mcg), B 12 (30mcg). Exercise and current medications: Advise participants on exercise:' All participants to do at least 5 minutes of activity, more vigorous than walking before each meal. Could be fast walking,jogging in place,jumping jacks, or walking stairs. This is additional to general exercise/activity at current level that was maintained. Medication adjustment and blood work follow up: Existing medications reduced with protocol to attempt to maintain fasting glucose in 100-120 range. Any onetime reading below 100 justifies a medication reduction. Adjustments made by physician, with protocol to reduce and eliminate insulin and oral medications associated with weight gain first. Monthly review with physician to review medications and review blood work ordered prior to physician visit. All participants should have access to health professional via phone, to get instant medication adjustment advice if needed. Blood pressure medication reduced when systolic falls bellow 120 one time goal, of systolic between 120 and 140. Fingerstick glucose and blood pressure readings done during 5 days of intial diet, and then evdry other day for 2 weeks and then twice weekly thereafter for 12 weeks self-monitor need for medication adjustment. Method of dietary instruction: One day instructional presentation, two hours in morning and two hours in afternoon required of all participants and entry point. One-half hour meeting with a study trained dietician to establish review, rnotiv ate and docrrrnent the nutritarian diet plan. Weekly one-hour meetings with their assigned group for further nutrition and cooking instruction; conducted by physician and RD or cooking instructor. Definition of dietary protocol High nutrient density diet — based on analysis of diet diary. adherence defined as all calories from vegetables, fruit, beans, nuts, and seeds, intact whole grains, all low glycenuc whole plant foods meeting the guidelines below. To include 3 meals daily with no snacking. No calorie counting though portion size controlled for seeds and nuts and for intact grains (one-cup) Guidelines: 1. At least one larue salad daily, with ray,, shredded cruciferous vegetables, tomatoes. raw% onion, and dressing made of nuts/seed allotment according to recipes given. 2. At least one serving of cooked (lightly steamed) Green non-starchy veuetables daily, along with cooked mushrooms and onions, mushrooms. 3. One howl of ve,etable bean or vegetable lentil soup or stew daily (with lunch). -l. At least one additional serving of beans or other legumes daily (with dinner). 5. One-two ounces ol' nuts/seeds daily (one ounce for women and two ounces for men, made into salad dressinas). Half of nut intake to be mix of seeds and walnuts, other half variahle. 0, One, one tap serving of intact ,train or starchy veaetahle daily, squash. Black wild rice. steel cut oats, cauhtlower, or green peas (no white potato permitted). Only urains require one cup limit. Peas, cauliflower, squash not limited to one Cup, but only serving a day of variable (self-adjusted) sire. 7. No refined carhohydratc, oils, or- foods derived from flour~ or- animal products 8. Three whole fre,h fruits dally. one with each meal. preferably berries. sour cherry, g*reen apple. kiwi. or kumquat,. Evaluation of adherence: Monthly meeting with RD for a 24-h0ur diet recall to check for poor adherence and provide additional counseling if needed. Three-day diet diary completed by participants at weeks 0, 11. 22. 36 weeks - consistina of 2 weekdays and one weekend day, using a food scale. Outcomes— glycemic control, cardiovascular risk factors: Blood tests. initial (0)_ 6 weeks. 12 weeks. 24 weeks. 36 weeks. 48 weeks. Height Body weiaht Wait circumference, waist-to-hip ratio Flip circurference Blood pressure HbAIC Fasting glucose Chole,Sterof (Total. LDL. VLDL. HDL) Triglycerides Urinary albumin hsCRP fasting insulin and c-peptide vitamin D 25 hydroxy medications with dosages reduction in medications (diabetes, lipids, BP, total meds) number of reported hypoglycemic and hyperglycemic episodes hospitalizations or unscheduled doctor visits for any illness analysis of diet diaries: calorie intake fat, carbohydrate, protein intake cholesterol intake fiber intake dietary glycemic load intake of certain micronutrients —>>folate, lutein, lycopene, Vitamin C Statistical analysis: t-tests to determine whether change from baseline was significant. Regression analysis to show correlation between weight loss and HbA 1 C. 78 Malamalama Waldorf School Natural Playscape: Community & School f t Agency Name: Malamalama Waldorf School Program Name: Natural Playscape: Community & School Agency Director: Kelley Lacks Phone No.:(808) 982-7701 Contact Person: Kelley Lacks Phone No.:(808) 982-7701 Mailing Address: Address: HC 3 Box 13068 Address: City,ST,zip Keaau, H[ 96749 Facility Address: Address: HC 3 Box 13068 Address: City,ST,ziP Keaau, HI 96749 Email Address: kelley @hawaiiwaldorf.org Fax No.: (808) 982-7806 Accountant/CP Ron Dolan Phone No.:(808) 935-5433 Firm (if applicable): CPA &Associates Mailing Address: Address: 16 Railroad Ave Address: City,ST,zlp Hilo, HI 96720 YOUARE RESPONSIBLE TO KEEP THEABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $60,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $7,500.00 $5,200.00 2.Agency Mission Statement: The mission_of Malamalama Waldorf School is to improve the quality of the educational experience by providing Waldorf Education in East Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Malamalama Waldorf School Program Name: Natural Playscape: Community & School I Program Description: There are currently no public play structures in Hawaiian Paradise Park, estimated 27% of the development community is under the age of 18: MWS will create natural playscapes to enrich learning for students -grades 1-8. In addition, MWS encourages the community to use these structures to connect their children to nature outside school hours. These structures encourage social enaaae�, reT, & compassion 4.Total Budget& Position Count: Total Program Budget: $90,000.0() Total Program Position Count: 8 Total Agency Budget: $666,668.00 Total Agency Position Count: 123 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate MWS In Kind $12,800.00 Hawaii County Grant $60,000.00 Other Grants (Private Foundation & Corporations) $17,200.00 TOTAL: $90,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: MWS intends to increase enrollment in the school, as well as after care, .intemessmon, and summer proq[ams-The PQ01 of potential applicants All he expanded xpasure to the school and its offerings in the r_.reation of these natural structures and avallabillty to the community EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Malamalama Waldorf School Program Name: Natural Playscape: Community & School 7. Program Objectives Using County Nonprofit Grant Program Funds: -1 ) Provide natural play structures to foster imagination. 2) Connect kids to nature. 3) Increase physical Activity. 4) Encourage social engagement, reT, and compassion_ 5) Improve social condit'Qos for HPP and East Hawaii. 6) Create a relaxed meeting area for aarents 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number ofcl ients served workshops or events held,volunteer hours,etc.Describe,be specific.) Percentage of participants engaging in a new play experience 100% Percentage of participants active in daily exercise 100% Percentage of participants interacting with nature 100% Percentage of participants developing respect & compassion 100% Percentage parent satisfaction for safe & nurturing environment 100% New and continued enrollment in school increase of 10-20% per year New/continued enrollment in after care and intersession programs increase of 10-20% per year Attach additional pages as necessary. 9. TABLE fl: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $22,800.00 $10,000.( Professional Fees $15,000.00 $5,000.0( Operations $5,000.00 $3,000.0( Supplies $4,200.00 $2,000.0( Equipment $43,000.00 $40,000.( Other: Other: Other: Other: Other: TOTAL 1 $0.00 $90,000.00 $60,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Malamalama Waldorf School Program Name: Natural Playscape: Community & School io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be_slgned: regardless of_whether a comet exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. � 'CC (b(S 3( Y Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2035 Page 4 of 7 Agency Name: Malamalama Waldorf School Program Name: Natural Playscape: Community & School 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawail.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawal`i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of Your program's or agency's future funding requests. EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30`"shall result in loss of all grant funds received during the grant period {must be refunded to Countyl and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt www.hawaiicount . ov fn-non rofit- rant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report, Failure to return these funds in a timely manner will impact the evoluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. ?�'6 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Malamalama Waldorf School Program Name: Natural Playscape: Community & School 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Percentage of participants engaging in new play experience 100% Percentage of participants active in daily exercise 100% Percentage of participants interacting with nature 100% Percentage of participants developing respect & compassion 100% Percentage parent satisfaction for safe & nurturing environment 100% New and continued enrollment in school increase of 1 New/continued enrollment in after care and interssesion programs increase of 10a TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $4,800.00 Professional Fees $1,000.00 Operations $4,000.00 Supplies $4,200.00 Equipment $1,000.00 Other: Other: Other: Other: Other: TOTAL $15,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 79 Malamalama Waldorf School. Puna Arts in the Park Zntersession & Summer Program Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Intersession & Summer Program Agency Director: Kelley Lacks Phone No.:(808) 982-7701 Contact Person: Kelley Lacks Phone No.:(808) 982-7701 Mailing Address: Address: HC 3 Box 13068 Address: Oty,ST,zip Keaau, HI 96749 Facility Address: Address: HC 3 Box 13068 Address: City,sr,zip Keaau, HI 96749 Email Address: kelley @hawaiiwaldorf.org Fax No.: (808) 982-7806 Accountant/CP Ron Dolan Phone No.:(808) 935-5433 Firm (if applicable): CPA &Associates Mailing Address: Address: 16 Railroad Ave Address: city,sT,zip Hilo, Hl 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $7,500.00 $5,200.00 2. Agency Mission Statement: The mission of Malamalama Waldorf School is to improve the quality of the educational experience by providing Wald-Qrf Education in East Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Intersession & Summer Program 3. Program Description: MWS seeks to provide Intersession & Summer Enrichment Programs in East Hawaii to students in Grade 1-6. The school will offer these enrichment programs coinciding with the State's DOE Calendar for Fall Intersession Winter Recess and Spring Break in order to extend Abeses sexLcm_to the greater community. In addition'#ti-e school will sffei g 6 Week SUMMer Arts_ 4.Total Budget& Position Count: Total Program Budget: $48,000.00 Total Program Position Count: 8 Total Agency Budget: $666,668.00 Total Agency Position Count: 23 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Tuition ($50/student/week x 10 weeks) 50 students $25,000.00 Hawaii County Grant $15,000.00 Other Grants (Private Foundation & Corporations) $8,000.00 TOTAL: $48,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Malamalama Waldorf School plans to continue increasing revenue through increased enrollment tuition to full capacity of 60 students; and EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Intersession & Summer Program 7. Program Objectives Using County Nonprofit Grant Program Funds: -1 ) MWS to enroll an ayerade of 50 students for intersession, winter recess, spring break, and summer. 2) Approximately 50 studeents per day will participate in art instruction with local artists_ 3) MWS ,wall employ two local artists per week to provide art ins#rilction _ 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Percentage of enrolled students participating in new art experience 100% Percentage of enrolled students participating in daily exercise 100% Percentage of enrolled students interacting with local artists 100% Percentage of enrolled students meeting a new friend 100% Percentage parent satisfaction for safe & nurturing environment 100% Percentage of students re-enrolling for future programs 100% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $32,000.00 $4,800.0{ Professional Fees $4,000.00 $1,000.0 Operations $4,000.00 $4,000.0 Supplies $4,200.00 $4,200.0 Equipment $3,800.00 $1,000.0 Other: Other: Other: Other: Other: TOTAL 1 $0.00 1 $48,000.00 $15,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Intersession & Summer Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether_a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by on individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ® If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFITGRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park lntersession & Summer Program 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. i (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to Countyl and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accented by,the council. I (we) understand there is no provision for further notification to submit the final report. information and instructions are available at http://www.hawaiicounty.govLn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions token to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements, O Signature of Authorized Person (specify title) bate EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Intersession & Summer Program 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Percentage of enrolled students participating in new art experience 100% Percentage of enrolled students participating in daily exercise 100% Percentage of enrolled students interacting with local artists 100% Percentage of enrolled students meeting a new friend 100% Percentage parent satisfaction for safe & nurturing environment 100% Percentage of students re-enrolling for future programs 100% TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $4,800.00 Professional Fees $1,000.00 Operations $4,000.00 Supplies $4,200.00 Equipment $1,000.00 Other: Other: Other: Other: Other: TOTAL $15,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 81 Mental Health Kokua Residential Rehabilitation Services Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services Agency Director: Greg Payton Phone No.:(808) 737-2523 Contact Person: Gary Michell Phone No.:(808) 331-1468 Mailing Address: Address: Mental Health Kokua Address: 1221 Kapiolani Blvd.,Ste 345 city,sT,ZIP Honolulu, HI 96814 Facility Address: Address: Mental Health Kokua Address: 75-166 Kaiani St., Ste 103 City,ST,zP Kailua-Kona, HI, 96740 Email Address: gmichell @mhkhawaii.org Fax No.: (808) 331-1468 Accountant/CP Summer B. Such, CPA Phone No.:(808) 737-2523 Firm (if applicable): N/A Mailing Address: Address: Mental Health Kokua Address: 1221 Kapiolani B1vd.,Ste 345 City,ST,Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $5,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $5,000.00 $5,000.00 $5,000.00 2. Agency Mission Statement: The Mission of Mental Health Kokua (MHK) is to assist people with ojental heallb and related challe1 ges to achieve optimum recovery and functioning in the commu.aiLy. MHK provides hQusin% case EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 3. Program Description: Our Residential Rehabilitation Services prograrn provides community based housing to adults recoverin from severe mental illness. The goal is to enable the consumer to move on to more independent living. Staff _provide daily living skills training while facilitating educational, social,_ and recreational activities as well as linkage to community resources 4.Total Budget& Position Count: Total Program Budget: $1,067,026.00 Total Program Position Count: 40 Total Agency Budget: $8,202,195.00 Total Agency Position Count: 215 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii $5,000.00 State of Hawaii — DOH $1,214,276.00 United Way $20,371.00 Program Service Fees $163,826.00 Donation/Other $33,247.00 MHK Support $204,881.00 TOTAL: $1,641,601.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Onwi.r a.,am ncv wide e o—cls are being made, and will..,continue to be made to pursue additional grant fun�l_ina from trusts and foun -dations EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 Provide residential services to 110 unduplicated consumers. 2 Limit psycbiatric hospitatizahm tQ less than ° I ° f n m r served are satisfied with services received-Mi n.rayement in daily Iivirll- S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of unduplicated consumers served 110 % of consumers served requiring psychiatic hospitalization Less than 3% % of consumers discharged to more independent living settings 75% % of consumer satisfied with services 95% Attach additional pages as necessary. 9.TABLE il: PROGRAM EXPENDITURES FYI -14 FY 1415 FY 14-15 Actual* Total Budget Grant Req Salary and Wages 51,015,768 $1,232,425. Professional Fees $24,429 $27,801.00 Operations $368,469 $3$1,375.0 $5,000.0 Supplies Equipment Other: Other: Other: Other: Other: TOTAL$1,408,666 $1,641,601. $5,000.0 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conf lict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council [] The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here.(iu P - I �I-�j I A _ Q"'- -Signature of Authorized 4rson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Com fiance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.goy, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure_to submit a timely, complete, and accurate year-end report, using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt Www.hawaiicount . ov fn-non rofit- rant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum tent percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these Lunds in a time!v manner will impact the evaluation of our agency's future funding request and may result in actions taken to recover these LundS. By signing below, you are acknowledging that you have read and understood these requirements. '. '3 Signature of Authorized person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of unduplicated consumers served 110 % of consumers served requiring psychiatic hospitalization Less than 3% % of consumers discharged to more independent living settings 75% % of consumer satisfied with services 95% TABLE fl: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees Operations $5,000.00 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $5,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 82 Neighborhood Place of Puna Family and Community Strenthening y COPY Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strenthening Agency Director: Paul Normann Phone No.:(808) 965-5550 Contact Person: Paul Normann Phone No.:(808) 965-5550 Mailing Address: Address: PO Box 2020 Address: City,ST,zip pahoa, HI 96778 Facility Address: Address: 15-3039 Pahoa Village Rd. Address: City,sT,zips pahoa, HI 96778 Email Address: paul @neighborhoodplace.org Fax No.: (808) 965-5109 Accountant/CP Alex Smith Phone No.:(877) 257-6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: roc C-Ak (-w" r. r3rw.��Cec��. ' FY 11-12 FY 12-13 FY 13-14 $21,000.00 $25,000.00 $25,000.00 2.Agency Mission Statement: The goal of the Neighborhood Place of Puna is to prevent child abuse.__ and neTgled-bueosuring�that families have access to the resources and skills they need to raise safe and healthy children. NPP's mission, "Emr)owerinn families and communities in Puna hV bididina strong foundations thrni iclh healf relationsbi s_thet Mall e Pach r " rr EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strenthening 3. Program Description: NPP is a child abuse and neglect prevention program serving Puna & Hilo. NPP provides on-going' weekly, free & voluntary, in-home sevices for families with some risk of Child Abuse & Ne lect even if the risk is simply poverty. NPP connects families to resources, provides support & advocacy, teaches life skills & developmentally a,nproproate parenting._ 4.Total Budget&Position Count: ( Fyi-k --15) Total Program Budget: 1$185,000.00 1 Total Program Position Count: 3 5 Total Agency Budget: $439,114.00 Total Agency Position Count: 7 S. Program Funding Sources (identify all sources of funding applied to this rxoeram): FY14-15 Revenue Source Estimate Blue Print for Change $130,000.00 County of Hawaii $25,000.00 Hawaii Island United Way $30,000.00 TOTAL: $185,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program. NPP continues to develop its fund-raising ogram, and seek grants to towards families at .risk for Child Ah1jgP &NPalPCt &often living in DnvPrtw_, are never nnina to he self sustaining EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strenthening 7. Program Objectives Using County Nonprofit Grant Program Funds: Help East Hawaii families raise healthy keiki by oroyiding_intensive, weekly, on igs�na_in.-home visitation Aodam.Hies Help familiess access resources that might otherwise be difficult to obtain, due to a lack of transportation, internet connecti�, cell phone service, or isnlatinn_ 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.;Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Weekly home visits to Families at risk for Child Abuse or Neglect 70 Families Family Safely Assesment 70 Families Develop Family Success Plan 70 Families Successful Completion of Family Success Plan 80% of Families Ages & Stages Assessment of above fam. wl Children =< 5 years 100% Families free of Child Abuse & Neglect 85% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages iS(. a6S $156,26 $133,555.0($28,060.( O Professional Fees 3 00� $3,000.( $3,000.00 Operations c4 c 3 a3 $46,323 $46,324.00 $1,070,0 Supplies a W) $2,000. $2,121.00 $870.00 Equipment Other: Other: Other: Other: Other: ao� a$gTOTAL $207,5 $185,000.0 $30,000. O *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: �e� !�- �,� ?l-c��-c of � �•� Program Name: t .. ��� c..,� .,,,,`, _"...;:T�, arc •: io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Flawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. ignature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Neighborhood Place of Puna Program Name: f=amily and Community Strenthening io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, re ordless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest:. If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A ' NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strenthening u. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135-2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 02 F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to htti2://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30_of_the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of our ro ram's or a enc 's future funding re ue.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to,Counly)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return theseuunds in a timely manner will impact the evaluation of Your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. 1�3�Zi Signat re of Authors Person (s y title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strenthening 12. COUNCIL AWARD WORKSHEET errune puiefere irtunneeee�er —— �euinenRee� TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Weekly home visits to Families at risk for Child Abuse or Neglect 70 Families Family Safely Assesment 70 Families Develop Family Success Plan 70 Families Successful Completion of Family Success Plan 80% of Famili Ages & Stages Assessment of above fam. wl Children =< 5 years 100% Families free of Child Abuse & Neglect 85% TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $28,060.00 Professional Fees Operations $1,070.00 Supplies $870.00 Equipment Other: Other: Other: Other: Other: TOTAL $30,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 83 Neighborhood Place of Puna Ready to Learn Agency Name: Neighborhood Place of Puna Program Name: Ready to Learn Agency Director: Paul Normann Phone No.:(808) 965-5550 Contact Person: Paul Normann Phone No.:(808) 965-5550 Mailing Address: Address: PO Box 2020 Address: City,ST,zip Pahoa, HI 96778 Facility Address: Address: 15-3039 Pahoa Village Rd. Address: city,ST,Zip Pahoa, HI 96778 Email Address: Paul @neighborhoodplace.org Fax No.: (808) 965-5109 Accountant/CP Alex Smith Phone No.:(877) 257-6484 Firm (if applicable): , Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $5,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $21,000.00 $25,000.00 $25,000.00 2.Agency Mission Statement: The goal of the Neighborhood Place of Puna is to prevent child abuse and neglect b ensuring that families have access to the resources and skills they need to ramse safe and bealft-ch'Idren. NPP's mission: "Ernpowe_.___r naffamilies and r:ommunitiPs in Puna by bididinc Ill , Aach person'c i inf "Emalama norm kakoi i " EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Neighborhood Place of Puna Program Name: Ready to Learn 3. Program Description: Since 2004 NPP in collaboration with community police officers community associations, service clubs, government agencies, churches, foundations, businesses, & individuals have worked together to purchase & distribute free basic school supplies to school aged children in East Hawaii. 4.Total Budget& Position Count: C=-/i y -- [S Total Program Budget: $15,000.00 Total Program Position Count: 0 Total Agency Budget: $439,114.00 Total Agency Position Count: 7 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii $5,000.00 Young Brothers $1,000.00 Donations $2,100.00 InKind Doantions $6,900.00 TOTAL: $15,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: .Every year the "Ready Learn" Comm ittea-raises funds and seeks support for the free school supplies distribution. This year over 60% of the nrniect is funded through donatinns_ NPP donates all sans-staf.time .as well as affice resources to the project EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 1 ' Agency Name: Neighborhood Place of Puna Program Name: Ready to Learn 7. Program Objectives Using County Nonprofit Grant Program Funds: Poverty & lack should not be a barrier to education. it is the goal of this -proaram to ensure that every child stars school, "Ready to Learn", with basic school supplies. We will distribute free SChool-Supplies to , nraximatPly 1800 school aclPd children in E_ Hawaii_ 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Distribute Free School Supplies to school aged children, June 2015 1800 children Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages Professional Fees + Operations Supplies $15,000.00 $5,000.0 Equipment Other: Other: other: Other: Other: TOTAL .$0.00 $15,000.00 $5,000.0 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:: Program Name: lo. ORGANIZATION CONFLICT DISCLOSURE FORM Pleased isclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be si ned regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: If no conflicts exist, check here. A b t Si ature of Aut rson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Neighborhood Place of Puna Program Name: Ready to learn i.o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. if no conflicts exist, one form for the organization,with the "No conflicts exist".option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be sr ned regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in meosurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name; Neighborhood Place of Puna Program Name: Ready to Learn 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. 1 (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express,and be compliant prior to final payment. To register, go to http-//vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i I we understand and will comply with the requirement to submit a ear-end report to the County Council within 50 da s after June 30 of the contractual yea r for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end re,nort using the template provided, wii! impact the evaluation of your program's or agency's future fundinq_requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 301h shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms!on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum.ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawai`I with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. j Lwzf� Signat re of Author specify title) Date EXHIBIT A NONPROFIT GRAN'APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Neighborhood Place of Puna Program Name: Ready to Learn 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Distribute Free School Supplies to school aged children, June 2015 1800 children TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies $5,0.00.00 Equipment Other: Other: Other: Other: Other: TOTAL $5,000.00 Additional Council directives regarding award: , EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 84 North Kohala Community Resource Center Kohala Welcome Center Phase 11 Agency Name: North Kohala Community Resource Center Program Name: Kohala Welcome Center Phase II Agency Director: Christine Richardson Phone No.:(808) 889-5523 Contact Person: Megan Solis Phone No.:(808) 889-5523 Mailing Address: Address: PO Box 519 Address: city,sT,zIP Hawi, Hl 96719 Facility Address: Address: 55-3393 Akoni Pule Hwy. Address: City,ST,ziP Hawi, Hl 96719 Email Address: megan@northkohala.org Fax No.: (808) $89-5527 Accountant/CP Alida Adamek Phone No.:(808) 938-2200 Firm (if applicable): NKCRC Director &Treasurer Mailing Address: Address: PO Box 540 Address: City,ST,zip Hawi, HI 96719 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFAIIIY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,190.00 1. Prior Ye_ar Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: North Kohala Community Resource Center is a 12-year-old, 501 (c)(3) nQnprofit seNinq North Kahala. Our mission increase h number sponsor 84 diverse nrassrnnt,;nroiprt-,; EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: North Kohala Community Resource Center Program Name: Kohala Welcome Center Phase 11 3. Program Description: (see attachment - #3 Program Description) 4.Total Budget& Position Count: Total Program Budget: $26,490.00 Total Program Position Count: .y Total Agency Budget: $194,837.00 Total Agency Position Count: 3 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Projected Welcome Center Donations 2014 budgeted $20,000.00 Projected Welcome Center Product Sales 2014 budgeted $6,000.00 TOTAL: $26,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: attachment - Revenue Plans EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: North Kohala Community Resource Center Program Name: Kohala Welcome Center Phase II 7. Program Objectives Using County Nonprofit Grant Program Funds: See attached - 7 - Program Objectives 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 1. Kohala Welcome Center sales/donations FY 2014-15 $30,000 2. Number of visitors 18,000 3. Online sales $3,000 Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $12,800 $12,800.00 Professional Fees $0.00 $4,500.00 $4,500.0 Operations Supplies $3,388. $3,500.00 Equipment Other:rack cards 8,000 @.33 $0.00 $2,640.00 $2,640.0 Other:fruit stand - carpenter and materials $0.00 $1,250.00 $1,250.0 Other:display board - project photos $0.00 $1,800.00 $1,800.0 Other: other.See attached - 9 - Budget Narrative TOTAL $16,18 $26,490.00 $10,190. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: North Kohala Community Resource Center Program Name: Kohala Welcome Center Phase 11 io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: Christine Richardson POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance [❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a�ubstantiol probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: North Kohala Community Resource Center Program Name: Kohala Welcome Center Phase It 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135--2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, 1 (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to final payment. To register, go to http://Vendors.ehawaii.gov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii l we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report using the template provided, wiI! impact the evaluation of Your program's or agency's Luture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%) for administrative and overhead costs. Any funds unused byJune 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in o timely manner will impact the evaluation of our a enc 's Luture funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: North Kohala Community Resource Center Program Name: Kohala Welcome Center Phase It 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1. Kohala Welcome Center sales/donations FY 2014-15 $30,000 2. Number of visitors 18,000 3. Online sales $3,000 TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees $4,500.00 Operations Supplies Equipment Other: rack cards 8,000 @.33 $2,640.00 Other: fruit stand - carpenter and materials $1,250,00 Other: display board - graphic artist and photos $1,800.00 Other: other: See attached - 9 - Budget Narrative TOTAL $10,190.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 North Kohala Community Resource Center Kohala Welcome Center Phase II 3. Program Description 3. Program Description The North Kohala Community Resource Center (NKCRC) opened in 2002 and served as the sponsor for six community projects. A decade later that number is 84 and growing. In the past 12 years we have trained over 187 volunteers to plan, organize, and coordinate their projects and have brought in over $9 million to fund these projects. This growth represents a notable accomplishment: we have been successful in our mission and proved that our unique program model works. It also represents many challenges—most notably a near exponential increase in the workload of the Center—an increase that clearly necessitated hiring additional staff,which we did in 2013. Until recently our income was dependent on individual and business donations (about 40% of the 1,800 households and almost all of the businesses in the community donate to NKCRC), annual fund development activities (special events and online auctions), sponsorship fees from grants and donations secured for our projects, as well as mission-related business sales of books and CDs related to the community. Though successful,these income streams were insufficient to support additional staff and so we turned our attention to the development of a mission-related business—the program for which we are seeking funds -the Kohala Welcome Center. Based on a careful analysis and the support of the community, we concluded that opening a welcome center for visitors to North Kohala had the largest potential to provide the growth in income we needed to meet the increasing demand for our services. After three years of planning, fund raising, and construction, we opened the Kohala Welcome Center on January 2, 2012. Our office and the Kohala Welcome Center reside in a beautiful and historic gateway building on the main highway as you enter the towns of Hawi and Kapa'au. The Welcome Center provides much needed clean public restrooms and offers the visitor an informative, museum-quality interpretive corridor that conveys the history of our community. The Welcome Center also maintains and sells an inventory of T-shirts, hats, books and CDs related to North Kohala, many of which were self-published. These first two years, the Welcome Center has exceeded our business plan projections. We now have a much deeper understanding of visitor needs and have concluded that the Welcome Center has the potential to become a key income stream. In its second year,the Welcome Center greeted 13,689 visitors and generated$21,854 in operating support income. These numbers reflect a nearly$6,000 revenue increase from 2012, despite a modest increase of just 130 visitors. Some of this growth was due to the expansion of our product line to include high quality t-shirts and caps. Marketing the Kohala Welcome Center has been limited to a sandwich board across the street and signage on the front of the building. Likewise, our online presence for product sales has been just a link on NKCRC's website. Because our small retail space precludes North Kohala Community Resource Center Kohala Welcome Center Phase II 3. Program Description much expansion of our product line, our best opportunity for growth is by increasing the number of visitors in the Welcome Center as well as those who visit our website. We are therefore devoting full attention to its growth and are using the knowledge and experience we have acquired to develop Phase II of the improvement of the Welcome Center. This proposal is to provide funding over the next County fiscal year to increase the capacity of the Welcome Center, and in turn, enhance the capacity of the Resource Center to serve our community. This endeavor will also provide an increased economic benefit for all of the businesses in the district, especially the eco-tourism adventures, shops, galleries and restaurants our guides are able to direct visitors to. Capacity building, or Phase II of the Welcome Center, is comprised of three key elements: 1. Advertise the Kohala Welcome Center in resort areas across the island to generate more visitor traffic. 2. Enhance the Kohala Welcome Center's web presence to generate more online product sales. 3. Enhance the retail area of the Welcome Center to showcase the work of the NKCRC with pictorial storyboards so the visitor can better understand the work of the Resource Center and be more likely to donate to our organization. North Kohala Community Resource Center Kohala Welcome Center Phase I1 6—Revenue Plans 6. Agency Plans to increase revenue Our first effort will be to increase foot traffic at the Welcome Center by direct advertising in resort areas and through an editorial campaign in island journals.North Kohala is considered "off the beaten track" and many tourists don't know what our area has to offer. Most small communities like North Kohala don't have visitor centers, so knowing that this resource is. available will attract more visitors to our area. We will hire a graphic artist to design rack cards, which we will distribute to the resorts on the west side of the island, where most tourists stay. We will also provide information cards for resort and hotel concierges so they can direct visitors here. We will work with a public relations specialist who will provide an editorial campaign for feature coverage of the Welcome Center and determine the feasibility of current advertising opportunities such as drive guides and island-wide magazines. Our current online store on the NKCRC website generates some transactions but is not immediately noticeable and needs to be easier to access. We will design and create a separate webpage for the Kohala Welcome Center that will provide visitors with an overview of what the Welcome Center offers and also provide a more visible and easily accessed online product store. To help attract visitors who are driving by, we are planning to build a small produce stand in front of the building,which we will make available to our sponsored agricultural projects to sell their fresh produce. Inside the Welcome Center, we will enhance the retail area with pictorial storyboards to showcase the work of the community projects sponsored by NKCRC, so the visitor can better understand the work of the Resource Center and be more likely to donate to our organization. We currently do not have the funding for the advertising,web development, public relations specialist or retail enhancements. These additions to this effort will effectively increase visitor traffic and sales which will directly increase the capacity at the Resource Center to serve our community. North Kohala Community Resource Center Kohala Welcome Center Phase II 7- Program Objectives 7—Programs Objectives 1. Increase sales and donations at the Kohala Welcome Center and online by 50% in FY2014-15. 2. Increase the number of visitors by 30% in FY2014-15. 3. Increase our capacity to effectively market the Kohala Welcome Center and our online store as measured by the number of visitors and the amount of sales and donations. North Kohala Community Resource Center Kohala Welcome Center Phase Il 9—Budget Narrative 9 -Budget Narrative Our total budget for FY2014-15 for Kohala Welcome Center is $26,490,which includes $16,188 for operations and$10,190 for capacity building projects. We are requesting 510,190 from the County of Hawaii to be used for these capacity building efforts.Note that the $12,800 budgeted for salary is for the portion of employee salary(.4 time) devoted to managing the Welcome Center. Professional fees are budgeted at $4,500, which includes a graphic designer for the rack cards and other promotional materials; public relations specialist; and web designer. Supplies ($3,500) reflect our product inventory of t-shirts,hats,books and music CDs. Rack cards for the resorts and concierges are budgeted for 8,000 cards ($2,640.) The fruit stand includes carpenter labor and materials ($1,250), and the display board about sponsored projects includes the work of a graphic designer and costs of storyboard printing ($1,800). Kohala Welcome Center Income and Visitors 2013 January a rua arc Musicians $250 Musicians $270 Musicians $210 Contributions $608 Contributions $400 Contributions $411 Kind $80 Kind $120 Kind $45 Kohala Aina $123 Kohala Aina $0 Kohala Aina $120 Kohala Keia $20 Kohala Keia $0 Kohala Keia $0 Link $23D Link $240 Link $135 Maps $653 Maps $512 Maps $520 Painted King_ $50 Painted Kin $25 Painted Kin $50 Water $41 Water $23 Water $30 Total Income $2,055 Total Income $1,590 Total income $1,521 Visitors 1,537 Visitors 1,442 Visitors 1,547 $/Visitor $1.34 ;Visitor $1.10 $/Visitor $0.98 n a n Day 466.25 $/Open a April May une Musicians $85 Musicians $150 Musicians $75 Contributions $258 Contributions $261 Contributions $314 Kind $160 Kind $315 Kind $100 Kohala Aina $180 Kohala Aina $180 Kohala Aina $60 Kohala Keia $0 Kohala Keia $100 Kohala Keia $80 Link $160 Link $60 Link $245 Maps $432 Maps $408 Maps $352 Painted Kin $0 Painted Kin $50 Painted Kin $0 Water $32 Water $33 Water $39 Ca p$ $250 Caps $300 Caps $225 T Shirts $475 T Shirts $600 T Shirts $675 Total Income $2,032 Total Income $2,457 Total Income $2,165 Visitors 1,219 Visitors 1,036 Visitors 1,001 $/Visitor $1.67 $Nisitor $2.37 $/Visitor $2.16 n Day (28) !$72.57 n a n Da July u u st Septemoer Musicians $90 Musicians $120 Musicians $30 Contributions $283 Contributions $253 Contributions $197 Kind $90 Kind $20 Kind $80 Kohala Aina $180 Kohala Aina $120 Kohala Aina $0 Kohala Keia $20 Kohala Keia $80 Kohala Keia $0 Link $45 Link $133 Lan $15 aps Maps Maps Painted King Painted King King Year over Year comparison Water $41 Water $44 r $39 2012 2013 Caps $50 Caps $50 $75 Jan S $1,317 $2,055 I s i s s a n , ,Totallncome $1,321 Totallncome $1,656 lncome $1,008 eb 1,75Q 1,590 isitors is ors ors e 1 777 ,$/Visitor $1.43 $/Visitor 51.47 itor $1.36 Mar 1,650 $1,521 n Day(27) $/Open Da n Va-r-W 1496 1,547 October ovem r v scam r A r $1'410 TT63= usicians Musicians Musicians pr , Contributions $353 Contributions $299 Contributions $398 a 1,416 2,45 my my my May , Kohala Aina $60 [K.hala Aina $60 Kohala Aina $120 Jun 1,394 -32716'T- Kohala x eia Kohala Keia Kohala un , Link $55 k $265 Link $175 Jul 1,257 1,3 1 Maps Maps Maps u , Painted Kin $50 inted Kin $50 Painted Kin $25 Au 1,106 1, 6 ater a er 1 Water ug , Caps $250 s $175 Ca s $200 Se 1, 1, 0 is is is ep 785 --74U- Total Si,954 tallncome $1807 Totallncome $2,288 ct 1, 8 1,954 is ors si ors isitors$/Visitor $1.84 isitor $2.04 118qEitor $1.95 Nov 930 1,8 n Day(27) $iOpen DgX 9M N-ov T 787 84 Summary ear To Date I hrough December ec 1, 1 2, 88 Total ncome l $21,8541 lVisitors 1 13 689 ec , 2013 Bud et 19,001 1$/Visitor $1.60 Cum 15, 75 21,854 Percent o » e n a um , 85 P.A.R.E.N.T.S., Inc. Confident Parenting Agency Name: P.A•R.E.N.T.S., Inc. Program Name: Confident Parenting Agency Director: Lisa Grouix Phone No.:($08) 235-0256 Contact Person: Danielle Spain Phone No.:(808) 934.9552 Mailing Address: Address: 45-955 Kameharneha Hwy. Address: Suite 403 city,sT,zip Kaneohe, Hl 96744 Facility Address: Address: 120 Pauahi Street Address: Suite 201 city,sT,zip Hilo, Hl 96720 Email Address: info @hawaiiparents.org Fax No.: (808) 2470447 Accountant/CP Phone No.: Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: 4 P.A.R.E.N.T.S., Inc. (Prodding Awareness, Referrals, Education, urturing, erapy an upport isslon: artnering wit aml les to empower t em t roug parenting e uca Ion an suppo services In t e preen Ion an red men o c I a use an neg ec . Islon: a every child sou grow up in a nu wring family. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: P.A.R.E.N.T.S., Inc. Program Name: Confident Parenting 3. Program Description: Confident Parenting is a comprehensive group-based parenting education support program ope he public. I he program consists o nine, two our, sessions. participants are eva ua a through pre pos es Ing, an receive a ce I Ica e o comp e Ion. ur currlcu um Is cu ura y approprla e an covers e o owing oplcs: I eve opmen , osl Ive Isclp Ine, a e y ec no ogy, ress nger, ommunlca Ion, emperamen a - seem, xcerlse u rl Ion 4.Total Budget& Position Count: Total Program Budget: $10,000.00 Total Program Position Count: 2 Total Agency Budget: $1,711,028.00 Total Agency Position Count: 3 S. Program Funding Sources(identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Hawaii County Grant $5,000.00 Central Pacific Bank $2,000.00 PARENTS, Inc. Fundralsing (Kickball Tournament) $3,000.00 TOTAL: $10,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Promotion of the program to build community partnerships and seek other funding streams through community collaborations. Seek additional grant monies to bring the program to other communities In or er to fill the gap In prevention services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: P.A.R.E.N.T.S., Inc. Program Name: Confident Parenting 7. Program Objectives Using County Nonprofit Grant Program Funds: To provide the community at-large with parenting education and support services to strengthen families in an elfort to prevent child abuse and neglect through skill ul Iding and the Imp ementlon of functional eve opmentally appropriate positive parenting techniques. S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Provide weekly Confident Parenting classes (5) 9 week sessions Educate & Support 50 adult participants through the curriculum 10 adults per session Administer Pre & Post testing every week to assess knowledge 80% increase in knowledge Attach additional pages as necessary. 9.TABLE il: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $2,600.00 $2,600.00 Professional Fees $2,550.00 $0.00 Operations $3,000.00 $1,600.00 Supplies $750.00 $500.00 Equipment $1,100.00 $300.00 Other: Other: Other: Other: Other: TOTAL 1 $0.Q0 $10,000.00 $5,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: P.A.R.E.N.T.S., Inc. Program Name: Confident Parenting zo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization;with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be sinned, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 if no conflicts exist, check here. C- L-Aia 44�� t'2� 611-, V, .2-() 1 q Signature of Authorized Person (specify title) Date ��C�C,v►�-t✓V EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: P.A.R.E.N.T.S., Inc. Program Name: Confident Parenting 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 1.35—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, l (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. To register, go to htt vendors.ehawaii. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the re uirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely,. complete, and accurate ear-end report, using the template rovided will impact the evaluation of our program's or agency's uture funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these Lunds in a time!y manner will impact the evaluation of our agency-'s future funding request and may result in actions taken to recover these fun ds. By signing below,you are acknowledging that you have read and understood these requirements. 26 I� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: P.A.R.E.N.T.S., Inc. Program Name: Confident Parenting 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Provide weekly Confident Parenting classes (5) 9 week ses: Educate & Support 50 adult participants through the curriculum 10 adults per sE Administer Pre & Post testing every week to assess knowledge 80% increase it TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,600.00 Professional Fees $0.00 Operations $1,600.00 Supplies $500.00 Equipment $300.00 Other: Other: Other: Other: Other: TOTAL $5,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 86 Pacific Tsunami Museum Pacific Tsunami Museum - Essential Upgrades and Updates ti Agency Name: Pacific Tsunami Museum Program Name: Pacific Tsunami Museum - Essential Upgrades and Updates Agency Director: Marlene Murray Phone No.:(808) 935-0926 Contact Person: Marlene Murray Phone No.:(808) 935-0926 Mailing Address: Address: P.O. Box 806 Address: City,ST,zip Hilo, HI 96721 Facility Address: Address: 130 Kamehameha Avenue Address: city,sT,zip Hilo, HI 96720 Email Address: hitec @tsunami.org Fax No.: (808) 935-0842 Accountant/CP Jill Jacunski Phone No.:(808) 640-7424 Firm (if applicable): Mailing Address: Address: P.O. Box 4564 Address: city,sT,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $43,500.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: We believe that through education and awareness no one should ever again die due to a tsunami. Tsunamis have killed more people in Hawaii than all other natural disasters combined. Since the last major tsunami over 50 years ago,an entire generation has grown up without experiencing a major tsunami and therefore has no experience with the devastating and deadly tsunami hazards. Our exhibits features powerful stories of tsunami survivors and the cultural and socio-economic impact on Hawaii. Through educational presentations to dozens of schools, educators, civic and cruise ship groups,the Pacific Tsunami Museum promotes tsunami education to our extremely vulnerable island community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 5 Agency Name: Pacific Tsunami Museum Program Name: Pacific Tsunami Museum - Essential Upgrades and Updates 3. Program Description: BACKGROUND: Since opening its doors over 20 years ago,the Pacific Tsunami Museum has never been in a financial position to allow for the refurbishing of old,outdated museum exhibits, replace torn and soiled carpeting; replace the old projector, and other equipment. Additionally, new scientific discoveries have been made in recent years that should be reflected in museum exhibits. DESCRIPTION: "The Story of Hilo" and "Tsunamis of the 1950's" Exhibits will be refabricated; newly acquired photos will be featured and content will be rewritten with updated scientific information. A new projector, laptop, and chairs will be purchased to improve the quality of educational presentations. Our popular interactive wave machine will be repaired and carpet will be replaced in the theater. 4. Total Budget&Position Count: Total Program Budget: $43,500.00 Total Program Position Count: 3 Total Agency Budget: $222,500.04 Total Agency Position Count: 5 S. Program Funding Sources(identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Unfortunately, at this time, we do not have revenue sources to support the upgrades and updates. TOTAL: $0.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Since admissions, membership dues and donations only cover our year to expenses, we continue to pu st_... e grants and other funding -opportunities. - - --- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Pacific Tsunami Museum Program Name: Pacific Tsunami Museum - Essential Upgrades and Updates 7. Program Objectives Using County Nonprofit Grant Program Funds: Through upgrades and improvements,the Pacific Tsunami Museum will provide an enriched educational experience to each visitor with enhanced exhibits,the latest scientific information, and a more meaningful understanding of tsunamis. Time and again, knowledge and awareness has proven to be one of the most critical elements in saving lives during a tsunami emergency. Our goal is that every visitor to the museum leaves with a basic understanding of tsunamis, recognize nature's warning signs, and know how to take action when the next tsunami comes—because the next one is inevitable. 8.TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Replace pieces in the "Story of Hilo" & "1950's" exhibit replace 66 exhibit pieces Purchase Video Kiosk for Story of Hilo Exhibit purchase 1 video kiosk Replace carpet in the theater (which people sit on) replace carpet Purchase laptop computer and projector for presentations purchase 1 laptop & 1 projector Purchase chairs for educational presentations purchase 60 chairs Purchase HD Digital Tape Player purchase 1 digital tape player Repair Wave Machine repair Wave Machine Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $13,500A Professional Fees $4,350.0 Operations Supplies $3,000.0 Equipment $18,650A Other: Repair Wave Machine $1,000.0 other:Signage for Exhibits $3,000.0 Other: Other: Other: TOTAL $0.00 $0.00 $43,500. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Pacific Tsunami Museum Program Name: Pacific Tsunami Museum - Essential Upgrades and Updates lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure orms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ , The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. ,� r �> �y Signat re f Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Pacific Tsunami Museum Program Name: Pacific Tsunami Museum - Essential Upgrades and Updates 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, l (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include are explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your program's or agency's future.funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all,grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http.,Hwww.hawailcounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return-these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. V -A 4 r; Sign atur o Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Pacific Tsunami Museum Program Name: Pacific Tsunami Museum - Essential Upgrades and Updates 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Replace pieces in the "Story of Hilo" & "1950's" exhibit replace 66 exh Purchase Video Kiosk for Story of Hilo Exhibit purchase 1 vid Replace carpet in the theater (which people sit on) replace carpet Purchase laptop computer and projector for presentations purchase 1 laps Purchase chairs for educational presentations purchase 60 ch Purchase HD Digital Tape Player purchase 1 dig Repair Wave Machine repair Wave M TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $13,500.00 Professional Fees $4,350.00 Operations Supplies $3,000.00 Equipment $18,650.00 Other: Repair Wave Machine $1,000.00 Other: Signa a for Exhibits $3,000.00 Other: Other: Other: TOTAL $43,500.00 Additional Council directives re ardin award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 87 Palekana Kai. Ocean Safety LLC Ocean Safety Education - Island Wide i t Agency Name: Palekana Kai Ocean Safety LLC Program Name: Ocean Safety Education - Island Wide Agency Director: Harlen Fragas Phone No.:937-9805 Contact Person: Haden Fragas Phone No.:937-9805 Mailing Address: Address: 980 Railroad Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 980 Railroad Avenue Address: city,sT,Zip Hilo, Hawaii 96720 Email Address: palekanakai @yahoo.com Fax No.: Accountant/CP Phone No.: Firm (if applicable): Mailing Address: Address: Address: City,5T,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 20,000.00 25,000.00 18,535.00 2. Agency Mission Statement: Palekana Kai Ocean Safety's mission is.to...educate community youth about ocean water-safety while proV d ding onnortunities,a0d alternative act'v't'es that buitcLib-ese younq adults confidence, self-esteem, 1 respect for the ar-ean and the skill, enjoy the ocean-safely EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Palekana Kai Ocean Safety LLC Program Name: Ocean Safety Education - Island Wide 3. Program Description: Palekana Kai is a non-profit organization that provides wafter safety programs such as ocean safety/awareness, ocean rescue and lifeguard training. First aid/CPRIAED training for community and at-risk youth between the ages of 11-18. Youth receive certifications, upon completion.,The Team's experienced lifeguards voluntarily conduct ocean safety classes at varioils schools_ proarams,agenries island-wide 4.Total Budget& Position Count: Total Program Budget: 25,000.00 Total Program Position Count: 17 Total Agency Budget: 159,570.00 Total Agency Position Count: 17 S. Program Funding Sources (identify all sources of funding applied to this p 2gram): FY14-15 Revenue Source Estimate County of Hawai'i Non-profit grant 25,000.00 Service/Program Fees 10,000.00 TOTAL: 1 $35,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: At this time our irogram is looking into fundraising activities. We are consi scan charaina yario�encies and programs a minimal fee for traininns in order to increase revenues to stionart our programs- We W ill rnJlabnrate `Wrath varini is anenries as well EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Palekana Kai Ocean Safety LLC Program Name: Ocean Safety Education - Island Wide 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 )Obtain equipment: expand training program and activities for youth 2)Conduct classes on Ocean Awa[enseas/Safety, F' A' Lifequard Skills, Oxvaen Admin, bloodborne nathoaens for community 31inecrease number of iniuries,drownina and death after an emergency S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Water awareness/safety classes for youth 70+ youth First Aid/CPR1AED Training for youth 50+ youth Lifeguard/Oxygen Admin/Spinal Management Training for youth 30+ youth First Aid/CPR/AED Spinal Management for Adults 40+ Lifeguard Training/Oxygen Admin/Bloodborne Pathogens for Adult 50+ Youth able to find employment due to program participation 20+ Provide Rescue services for community, school events, regattas 2500+ Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 808. 2,000.00 2,000.00 Operations 4,000.00 4,000.00 Supplies 5046. 12,000 12,000 Equipment 4432. 12,000 12,000 Other: Other: Other: Other: Other: TOTAL 1 10,286 1 30,000 30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Palekana Kai Ocean Safety LLC Program Name: Ocean Safety Education - Island Wide lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure Lorms must be si ned regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ . The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: if no conflicts exist, check here. nil) Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Paleltana Kai Ocean Safety LLC Program Name: Ocean Safety Education - Island Wide 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and-records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that 1 (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to htt vendors.ehawaii. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from-the County of Hawai'i, I (we) understand and will comply with the requirement to submit_a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end reportusing the template provided, will impact the evaluation of our Program—'s or a enc 's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of-all_grant funds received during the Brant period (must be refunded to County)and exclusion from future,grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council - I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:Lwww.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of tiawai`i with the final report. Failure to return these funds in a_timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Palekana Kai Ocean Safety LLC Program Name: Ocean Safety Education - Island Wide 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Water awareness/safety classes for youth 70+ youth First Aid/CPR/AED Training for youth 50+ youth Lifeguard/Oxygen Admin/Spinal Management Training for youth 30+ youth First Aid/CPR/AED Spinal Management for Adults 40+ Lifeguard Training/Oxygen Admin/Bloodborne Pathogens for Adult 50+ Youth able to find employment due to program participation 20+ Provide Rescue services for community, school events, regattas 2500+ TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages 0 Professional Fees 2,000.00 Operations 4,000.00 Supplies 12,000 Equipment 12,000 Other: Other: Other: Other: Other: TOTAL 30,000 Additional Council directives re ardin award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Bud et Details E ui ment Project Title: Ocean Awareness Education Legal Nam of Entity: Palekana Kai Ocean Safety,LLC Non-profit 50103 Address: 980 Railroad Avenue City: Hilo State: Hawaii Zip:96720 A. Training Equipment for FY 2014 - 2015 Items Unit Price Quantity Price Rescue Boards $ 1,200.00 2 $ 2,400.00 Infant Manikins $ 350.00 (set of 4) 2 $ 700.00 Adult Water Rescue $ 1,000.00 2 $ 2,000.00 Manikin Adolescent Water Rescue $ 1,000.00 2 $ 2,000.00 Manikin Ambu for Adult $ 30.00 1 $ 30.00 Ambu for Child $ 30.00 1 $ 30.00 Ambu for Infant $ 30.00 1 $ 30.00 Ambu Military $ 260.00 1 $ 260.00 Airway Pro Bag $ 190.00 2 $ 380.00 VHF Radios $ 250.00 6 $ 1500.00 UHF Radios $ 350.00 6 $ 2100.00 Total Training Equip $ 11,430.00 B. Vehicle and Equipment Re airs/Maintenance/Fael Items Unit Price Quantity Price Vehicles 2,000.00 1 2,000.00 Wave Runners $ 1,500.00 2 $ 3,000.00 Maintenance/Fuel $ 2,000.00 $ 2,000.00 Totalllaintenance $ 7,000.00 C. Office Equipment Items Unit Price Quantity Price Desk Top Computer $ 1,000.00 2 $ 2,000.00 Printers $ 200.00 2 $ 400.00 Hard Drive $ 200.00 1 $ 200.00 Ink Cartridges $ 50.00 10 $ 500.00 Misc.Paper/Memory cards $ 310.00 $ 310.00 Total Office Equipment $ 3,410.00 D. Educational and Training Materials/Manuals Items Unit Price Quantity Price First Aid/AED Part.Man $ 8.50 50 $ 425.00 Adult FA Ref Card $ 5.00 80 $ 400.00 CPR/AED for the $ 80.00 1 $ 80.00 Professional Rescuer First Aid Certifications $ 35.00 15 $ 525.00 Lifeguard Manuals $ 40.00 10 $ 400.00 Pocket Masks $ 25.00 30 $ 750.00 Total $ 2,580.00 E. Insurance Sterns Unit Price Quantity Price General Liability Insurance $ 2,700.00 1 $ 2,700.00 Total insurance $ 2,700.00 F. Training Items Unit Price Quantity Total Price Training Course $ 500.00 2 $ 1,000.00 Travel $ 500.00 2 $ 1,000.00 Total Training Course $ 2,000.00 Q Professional Fees Items Unit Price Quantity T=;Price Bookkeeping $ 880.00 1 $ 880.00 Total $ 880.00 TOTAL $ 30,400.00 SS Palekana Kai Ocean Safety LLC Wilderness and Remote First Aid Training Agency Name: Palekana Kai Ocean Safety, LLC Program Name:Wilderness and Remote First Aid Training Agency Director: Harlen Fragas Phone No.:937-9805 Contact Person: Harlen Fragas Phone No.:937-9805 Mailing Address: Address: 980 Railroad Avenue Address: City,ST,ZIP Hilo, Hawaii 96720 Facility Address: Address: 980 Railroad Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: Palekanakai @yahoo.com Fax No.: Accountant/CP Phone No.: Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12.13 FY 13-14 0 0 22,500.00 2. Agency Mission Statement: Palekana Kai's mission is to educate and empower youth, at-risk youth and individuals of our community to be confident and able to utilize their skills to_Eeq=d to an emergency situation safely in a Wilderness andlor Remoteenvironment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: Palekana Kai Ocean Safety LLC Program Name:Wilderness and Remote First Aid Training 3. Program Description: Palekana Kai provides Wilderness and Remote First Aid Training to those of our community. The program consists of practical exercises, classroom lecture skill practice and realistic scenarios to teach assessment and advanced first aid techniques, extended care transports and evacuations while dealing with emotional ind'Aduals. Rereive ARC VVRFA cedifiration upon completion of training. 4.Total Budget& Position Count: Total Program Budget: 25,000.00 Total Program Position Count: 7 Total Agency Budget: 159,570.00 Total Agency Position Count: 7 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawai'i Non-profit grant 25,000.00 TOTAL: $25,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: At this time our program is looking into fundraising activities. We are _1rams a minimal fee for trannonc n part our programs- We. Is i order to increase revenues to SUP will collaborate with various agenries as well EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Palekana Kai Ocean Safety, LLC Program Name:Wilderness and Remote First Aid Training 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 }Obtain equipment and educational materials to expand training program and activities to educate indivi-dualaJ4 years of age and above 2) Train those of our commun tv s are able to respond to an emPraPnc:v situation, help decreasPlnrPVPnt iniur, and death 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Provide classes for youth 14-17 years of age 20+ Provide classes for adults of our community 35+ Provide training for community and at-risk youth 14-17 years of age 25+ Provide training for individuals, various programs and agencies 45+ Empower individuals to respond to an emergency situation 75% Prevent injuries and death 80% Attach additional pages as necessary. 9.TABLE ll: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 2,001 2,000 2,000 Operations 1,062 3,000 3,000 Supplies 3,856 10,000 10,000 Equipment 3,652 10,000 10,000 Other: Other: Other: Other: Other: TOTAL 10,571 1 $25,000 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Palekana Kai Ocean Safety, LLC Program Name:Wilderness and Remote First Aid Training io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any hoard member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be si ned regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: [] If no conflicts exist, check here. C)M, T2 Signature of Authorized Person (specify title) I/ .Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2035 Page 4 of 7 Agency Name: Palekana Kai Ocean Safety, L LC Program Name:Wilderness and Remote First Aid Training 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http:/wendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end re ort using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Palekana Kai Ocean Safety, L.L.0 Program Name:Wilderness and Remote First Aid Training 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide classes for youth 14-17 years of age 20+ Provide classes for adults of our community 35+ Provide training for community and at-risk youth 14-17 years of age 25+ Provide training for individuals, various programs and agencies 45+ Empower individuals to respond to an emergency situation 75% Prevent injuries and death 80% TABLE il: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 2,000 Operations 3,000 Supplies 10,000 Equipment 10,000 Other: Other: Other: Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Bud eg t Details (Equipment) Project Title: Wilderness and Remote First Aid Training Legal Name of Entity: Palekana Kai Ocean Safety,LLC Non-profit 50103 Address: 980 Railroad Avenue City: Hilo State: Hawaii Zip:96720 A. Training Equil iment for FY 2014-2015 Items Unit Price Quantity Price True North Firefly $ 200.00 10 $ 2,000.00 Backpack Garmin GPS $ 300.00 5 $ 1,500.00 Compass $ 30.00 10 $ 300.00 Northern Day Hip Pack $ 130.00 10 $ 1,300.00 Waterproof supply $ 90.00 4 $ 360.00 carrying pack CPR Rescue Mask $ 10.00 50 $ 500.00 B-V-M Adult/Child $ 20.00 2 $ 40.00 0-V-M Infant $ 20.00 2 $ 40.00 Orange Safety Vest -$ 20.00 10 $ 200.00 Responder Kit $ 45.00 10 $ 450.00 Trauma Medical Bag $ 200.00 1 $ 200.00 Conterra Airway Kit $ 180.00 1 $ 180.00 02 Cylinder $ 90.00 2 $ 180.00 Meret PPE Kit $ 30.00 10 $ 300.00 Emergency Holster $ 15.00 10 $ 150.00 02 Wrench $ 40.00 2 $ 80.00 02 Regulator $ 40.00 2 $ 80.00 Pulse Oximeter Fingertip $ 85.00 2 $ 170.00 Total $ 0,030.00 S. Vehicle and Equipment Re airs/Maintenance/Fue1/Re istration Items Unit Price Quantity Price Vehicles 1,500.00 2 3,000.00 Trailer $ 2,000.00 1 $ 2,000.00 Maintenance/Fuel $ 2,000.00 $ 2,500.00 Toi;, $ 7,500.00 C. Educational and Training Materials/Manuals Items Unit Price Quantibi Price Wilderness Remote First $ 300.00 1 $ 300.00 Aid Instructor Class Wilderness Remote First $ 20.00 40 $ 800.00 Aid Participant Manual Certifications for $ 20.00 20 $ 400.00 Participants Total $ 1,500.00 A Office Equipment Items Unit Price Quantity Price Lap Tops $ 800.00 2 $ 1,600.00 Ink Cartridges $ 50.00 10 $ 500.00 Misc.Paper/Pens $ 300.00 $ 300.00 Cameras $ 1,000.00 2 $ 2,000.00 Total Office Equipment $ 4,400.00 E. Insurance Items Unit Price Quantity Price General Liability Insurance $ 2,570.00 1 $ 2,570.00 Totallnsurance $ 2,570.00 F. Miscellaneous Items Unit Price Quantity Total Price Professional Fees $ 1,000.00 $ 1.000.00 TOTAL $ 1,004.00 TOTAL $ 25,000.00 89 Positive Coaching Alliance - Big Island Keeping Kids in the Game Agency Name: Positive Coaching Alliance - Big Island Program Name: Keeping Kids in the Game Agency Director: Keith Morioka Phone No.:(808) 292-5520 Contact Person: Jeanne Yagi — Phone No.:(808) 959-8154 Mailing Address: Address: DH-Hilo Athletic Dept Address: 200 W. Kawili Street City,ST,cap Hilo, Hawaii 96720 Facility Address: Address: Same Address- City,ST,Zip Email Address: PCABigisland @hawaiiantel.net Fax No.: (808) 969-1988 Accountant/CP N/A Phone No.: Firm (if applicable):Y Mailing Address: Address: Address; City,ST,Zip ------ YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,550,00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 1344 $0.00 $0.00 $0.00 2.Agency Mission Statement: To.replace the "win-at-all cost" attitude and embrace the.-philosoph hat winning is impatant but m p-cdantly be a_nns fire ex .riQnce fQr o1av ;parents and_ DacheS and Where_..__. teachAna life-Less-ons_-are.h dd-in bighP ard- an itjqt wiftnjng�-_-- ____ EXHIBIT A NONPROFIT GRANT"APPLICATION FY 2014-2015 Page I of 7 Agency Name: Positive Coaching Alliance - Big Island Program Na Me:.Keeping Kids in the Game 3.Program Description: T© rovide Ip ayer, parent and coaches workshops the rough the Positive Coaching_Alliance program. Workshops will be made available i throughout Hawaii County in coordination and support of the Parks and_ Remrea�ion DivisjQn.._Wdoing soLt wi.lI Qrrd u the—o rtunity to _rea-cbAh-Qs-ejn-WL=-ners.Qf-comm-unity wb-o-p-articipate-in-P_ ,- .A YS.0 BlIF c n.ame._a..Iewr_._ _-- _ 4.Total Budget& Position Count: Total Program Budget: $20,000.00 Total Program Position Count: Q �---- Total Agency Budget: $20,000,00 Total Agency Position Count: 0 ' ---_ - .—_.--__--___._._.- _ ! 5. Program Funding Sources(identify ail sources of funding applied to this V ro ram Revenue Source Estimate I Board Member Donations $1,000.00 Sheraton Hawaii Bowl Foundation - ___—_.------_-.–.--------_ – $2,000.00 Corporate Sponsors $2,000.00 TOTAL, $5,000.00 Attach additional pages,if needed_ 6. Explain what plans your agency or program has to increase revenues to support this program: W-e-are plannirtg-onmlid ing corporations_ai2d_iad viduals with a Comm unity drive. This will entail a Ie tter seeking finsLit srjnnort _ end will be fQlI_ewed -up—it-a._persanal3ti-,:�t or phnne. cal.l__ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Positive Coaching Alliance - Big Island Program Name: Keeping Kids in the Game 7. Program Objectives Using County Nonprofit Grant Program Funds: To affect current youth coaches to adop - Lpositive cogchinr� techniques. To in octrin iae.W-Y hes into tWsuaul. Je-oLpsitiVen ,c,__ T PDA li.and-_ _- -supported i.n_a...p-ositiar whiie..teacWng life lessQ ts- --- S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results(Le..Number of dientx srvverl workshops or events held,volunteer hours.etc.ovscrihe,fir Npeiefic.J Three (3) East Hawaii Clinics (Coaches, Players and Parents) 150 attendees, 5 vol hours Three (3) West Hawaii Clinics (Coaches, Players and Parents) 150 attendees, 10 vol hours_ Three (3) North Hawaii Clinics (Coaches, Players and Parents) 100 attendees, 7 vol hours _ Three (3) South Hawaii Clinics (Coaches, Payers and Parents) 50 attendees, 7 vol hours - AItoch additional pages as necessory. 9.TABLE I1: PROGRAM EXPENDITURES Fr 33 14 FY 14-15 FY 14-15 Actual' Total Budget Grant Req Salary and wages Professional Fees--.� .�-...__.� $6.300.00 Operations 1,000.00 Supplies $� 500.00 T Equipment ..�— -- Other:Screen -- $500.00 other:Projector ----_---------.__...-----_-------------- ----- .�— $1,500.00 - Other:Laptop ... ---- -------------_--.._�_ $750.00 Other:Sound System ---- �� $750.00 -----. Other:Software $250.00 — � -- TOTAL $0.00 $15,550.00 $0.00-^ "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 rage 3 of 7 Agency Name: Positive Coaching Alliance- Big Island Program Name: Keeping Kids in the Game zo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. if no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Mason Souza POSITION: Director _-- May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): Z Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substormal probability that action takers bV an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruinq it?general to as industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Director has abstained from participating in reg�ilar board meetings ❑ If no conflicts exist, check here. t-#-- Signature of Authorized Person(specify title) Elate ExNiaiT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Positive Coaching Alliance - Big Island Program Name: Keeping Kids in the Game ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 1.35--2-142.1, Hawaii County Code, relating to/appropriation of Funds to Nonprofit Organizations. 1 (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative,or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Flawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to htt vendors.eliawaii. ov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to subunit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit o timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your proaram s or aaency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30`r'shall result in loss of all grant funds received during the grant period must be refunded to County and exclusion from future grant participation for a minimum of one ear or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at h,t www.tliiwiiicotirily.gov/fii-noiiprofit-graiit-forms on or about May 30 of the year the Final report is due. As part of this application, you acknowledge that any Funds awarded will be restricted for the purposes stated in the application, except For a maximum ten percent (100) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to tine County of Nawai'i with the final report. f=ailure to return these funds in a tiniely rnanner will impact the evaluation of aura enc 's future fygding request and moy result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Positive Coaching Alliance- Big Island Program Name: Keeping Kids in the Game 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Three (3) East Hawaii Clinics (Coaches, Players and Parents) 150 attendee Three (3) West Hawaii Clinics (Coaches, Players and Parents) 150 attendeeb Three (3) North Hawaii Clinics (Coaches, Players and Parents} 100 attendees — —__ W Three (3) South Hawaii Clinics (Coaches, Payers and Parents) 50 attendees, - TABLE H: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees ____- --- --- – 41 I c V -- -- Operations Supplies �# 51� c 0 Equipment Other: Screen _�_. ----.-----_—_ ____......___...----.....�_-------_.------- Other: Pro•ector Other: Laptop _ T 'I Other. Sound System t Other: Software 5 2,5-0,V� TOTAL -gyp — Additional Council directives regarding award: -- 1 ,sTa io EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 90 Project Vision hawaii Increasing Vision & Health Screening Services for Hawaii Island Agency Name: Project Vision Hawaii Program Name: Increasing Vision & Health Screening Services for Hawaii Island Agency Director: Elizabeth "Annie" Hiller Phone No.:808-282-2265 Contact Person: Maryellen Markley Phone No.:808-561-8096 Mailing Address: Address: P.O. Box 23212 Address: city,sT,z1P Honolulu Hl 96823 Facility Address: Address: 525 Wyllie Street Address: city,sT,4 Honolulu, Hl 96817 Email Address: annie@projectvisionhawaii.org Fax No.: Accountant/CP John Kojima Phone No.:808-223-1943 Firm (if applicable): Mailing Address: Address: P.O. Box 23212 Address: city,sT,zip Honolulu, Hl 96823 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $ 48,500 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 0.00 0.00 0.00 2.Agency Mission Statement: PROJECT VISION HAWAII is a non-profit 507 (c)(3) with a mission to restorative A EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2025 Page 1 of 7 Agency Name: Project Vision Hawaii Program Name: Increasing Vision & Health Screening Services for Hawaii island 3. Program Description: Although Pro'ect Vision Hawaii Staff provide services for several weeks each year on the Big Island island residents` needs for the services we provide far exceed what we currently are able to provide. We are -Seeking retrofit a new screening bus dedilaated the island -of Hawa'i, to remain-On 'sland year round,-and to provide siclofficantIV expanded fr &-far the people Invona on the- Ric -1 Island- 4.Total Budget&Position Count: Total Program Budget: $ 147,433 Total Program Position Count: 4 Total Agency Budget: $ 388,433 Total Agency Position Count: 8 5. Program Funding Sources(identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate State of Hawaii Grant in Aid 79,114 Kaiser Permanente Foundation 19,819 Hawaii County Grant in Aid 48,500 Attach additional pages,if needed. TOTAL: $147,433 6. Explain what plans your agency or program has to increase revenues to support this program: used by P[p2ert Vision H it Will be leased hV phVsi *ans at-North EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Project Vision Hawaii Program Name: Increasing Vision & Health Screening Services for Hawaii Island 7. Program Objectives Using County Nonprofit Grant Program Funds: The medical screenino bus is located at North Hawaii Community ,Hospital, but Must be retr-ofitted with visbri-screenin"nd evaluation 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Retrofit will be completed and installed within 90 days of funding Project Vision Services will be increased by more than 400%/yr 400% increased BI services Hawaii Island residents receiving screening services per year 3,500 residents minimum Local volunteers(including medical professionals) supporting project 175 annually Medical costs saved by early free screening and intervention $5 million/annually estimated Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages 58,000 15,000 Professional Fees 33,800 Operations 15,800 Supplies Equipment 28,500 22,500 Other: Bus upgrades to allow retrofit 10,333 10,000 Other:Staff Travel costs to oversee retrofit and a ui ment install 1,000 1,000 Other: Other: Other: TOTAL 147,433 48,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Project Vision Hawaii Program Name: Increasing Vision & Health Screening Services for Hawaii Island io. ORGANIZATION CONFLICT DISCLOSURE FORM rM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed— re ardless of whether a conflict exists. NAME: None known POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by on individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: None known 0 If no conflicts exist, check here. Lly Sign , ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Project Vision Hawaii Program Name: Increasing Vision & Health Screening Services for Hawaii Island is. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. To register,go to htt vendors.ehawaii. ov complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, complete, and accurate ear-end report, using the tem late provided, will impact the evaluation of our ro ram's or agency's uture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all jzrant funds received during the grant Period must be refunded to Count and exclusion from future grant Participation for a minimum of one ear or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at fitti)://www.hawaiicounty,govLfn-nonprofit-&Eant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30,2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of our agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. t I&k /�Lal, rte/ Signatur of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Project Vision Hawaii Program Name: Increasing Vision & Health Screening Services for Hawaii Island 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Retrofit will be completed and installed within 90 days of funding Project Vision Services will be increased by more than 400%/yr 400% increase Hawaii Island residents receiving screening services per year 3,500 residerd Local volunteers(including medical professionals) supportin pro'ect 175 annuall Medical costs saved by early free screening and intervention $5 million/an TABLE!l: PROGRAM EXPENDITURES FY 1415 Council Grant Request Award Salary and Wages 15,000 Professional Fees Operations Supplies Equipment Other: Bus upgrades to allow retrofit 22,500 10,000 Other: Staff Travel Other: costs to oversee retrofit and a ui ment install 1,000 Other: Other: TOTAL 48,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 91 Puna Community Medical Center Sustaining Access to Cage Agency Name: Puna Community Medical Center Program Name: Sustaining Access to Care Agency Director: Dan Domizio Phone No.:930-6001 Contact Person: Dan Domizio Phone No.:930-6001 Mailing Address: Address: 15-2662Pahoa Village Rd Address: PMB 8741 city,ST,zIP Pahoa, Hl, 96778 Facility Address: Address: 15-2662 Pahoa Village Rd Address: Suite 303 City,ST,ZIP Pahoa Hawaii, 9.6778 Email Address: land @punahealth.org Fax No.: 930-6007 Accountant/CP Nancy Kramer CPA Phone No.:965-2729 Firm (if applicable): Mailing Address: Address: PO Box 1519 Address: city,sT,ziP Pahoa, Hi, 96778 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for-County-Nonprofit Grant Program Funds: 4 27. 00 1. Prior Year Award of County Nonprofit Grant Program Funds:, FY 11-12 FY 12-13.. FY 13-14 $115,500.00 -$64,000.00 $20,000.00 2.Agency Mission-Statement: To provide readily accessible health care to residents of and visitors to,- Puna District, walk-on hasffis, wi ut rpgard to insumnce. coverage or the ability to pay Since me have opened almiast 5 years ago, vvp. have managed more EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name, Puna Community Medical Center Program Name. Sustaining Access to Care 3. Program Description: Puna Community Medical Center (PCMQ provides Urgent Care services to the community surrounding Pahoa and Puna district -including all who ask for services regardless of their ability to pay. We re walk-in we care for infants the frail elderly and everyone in -between. We need outsffide—financial support (qrants, qifts, donations) ff- -we are to continue keeping nur pm ise to the community we servex- 4.Total Budget& Position Count: Total Program Budget: $, _71-12-71 00 Total Program Position Count: g Total Agency Budget: $510,000.00 Total Agency Position Count: g 5. Program Funding Sources(identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate All revenue sources from services; Insurance, patient payments $426,000.00 Shippers Wharf(uncertain after 6130114) HSEDC (County Nonprofit) (This grant is uncertain after 613012014) Contributions (average /year) $14,000,00 TOTAL: $440,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We bave ap-Wied for and expect to receive a federal Rural Health Clinffc will receive Increased ,imbursPment_for services-We orovide,._.to EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 HSEDC NON PROFIT GRANT, FY-2014-15 PUNA COMMUNITY MEDICAL CENTER(PCMC) "SUSTAINING ACCESS TO CARE" #3 Program Description, (addendum); PCMC provides clinical services to anyone asking for care; we help manage acute and chronic medical problems such as asthma and colds, Obstructive Pulmonary disease, hypertension and diabetes. We often refill medications when people run out. We also help manage surgical problems; cuts and abrasions, skin infections; strains, sprains and broken bones, and dental infections. What we cannot manage in-house is triaged, stabilized and referred on to Hilo Medical Center either by private vehicle or, if warranted by circumstances, by ambulance. PCMC referred 99 people to the emergency room in 2013. We also avoided hundreds of ER visits by providing services in Pahoa. PCMC has managed more than 26,000 visits through the end of 2013; many of those visits were made by people with no insurance and little or no money. Many clients did not even have our minimum $30 sliding fee payment.The HSEDC grant for this past year was only$20,000; The Shippers' Wharf grant of$44,000 supplemented this for a total of$64,000. However,the Uninsured Program costs approximately$120,000 annually and we have had to go to our meager cash reserves to continue to provide services. We have requested $60,000 for the Uninsured Fund in this HSEDC- non-profit application for the next fiscal year. All uninsured services are priced out and tracked for reporting as part of our normal operating procedure. In the meantime, PCMC is approaching five years of operation and our computer equipment is becoming troublesome and unreliable as it has reached the predicted end of it expected life. We need to replace hardware and upgrade our software both because it is failing and because of new HIPPA compliance standards.This replacement alone is$15,000 of the $25,975 being requested. Premiums for liability, malpractice and insurance for our Board of Directors have increased or are new additions to our costs of operations. Any support for these vital cost centers would go a long way to assure we are able to continue the high standards of operations that have prevailed the past five years.All such expenditures will be invoiced, recorded and tracked for reporting. We need financial assistance. We simply cannot afford to make these changes, and without them, our IT problems will escalate in the year immediately before us. There are no administrative costs included in this request. 't Agency Name: Puna Community Medical Center Program Name: Sustaining Access to Care 7. Program Objectives Using County Nonprofit Grant Program Funds: We will be open 365 days per year, we will manage roughly 500 visits per month, including about 15%- 20% uninsured v"sits, we will employ 8 full ed-part time employees, any our bills. We would We to or-ganize-another Health Fair for Pahoa, 8.TABLE t: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e..Number of clients served workshops or events held,volunteerhours,etc.Describe,be specific.) To see approximately 500+ visits per month. 500 visits To see between 75 and 100 Uninsured clients per month 80 visits To be open 365 days (except for unpredictable circumstances) 365 days open To employ 8 full and part time staff(perhaps one more) 8 To conduct a Health Fair in Pahoa 1 Health Fair To pay for IT upgrades as required by the Affordable Care Act Upgraded IT systems To 'pay for insurance required to operate (detailed below) Paid Insurance bills. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other:Medical Malpractise Insurance $7,824. $8,000.00 $8,000.0 Other:General Liability Ins. $875.00 $875.00 $875.00 Other:Board of Directors Insurance $0.00 $; 287'7 of} $A $77. Other:IT/Computer System maintenance and upgrades $9,776. $25,975.00 $25,975. Other: Uninsured-Underinsured Fund $20,000 $120,000.0 $60,000. TOTAL $38,475 $157,72-1.09$�t7,121aD *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Puna Community Medical Center Program Name:Sustaining Access to Care so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be si ned regardless of whether a Conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 91 If no conflicts exist, check here. Signa ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Puna Community Medical Center Program Name:Sustaining Access to Care 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http:/Ivendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of„Hawai`i. I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, wit! impact the evaluation of vour program's or aaenc_y„'s future funding requests. EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. 1 (we) understand there is no provision for further notification to submit the final report. information and instructions are available at http://www.hawailcounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in_a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. Si ature Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Puna Community Medical Center Program Name: Sustaining Access to Care 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result To see approximately 500- visits per month. 500 visits To see between 75 and 100 Uninsured clients per month 80 visits To be open 365 days (except for unpredictable circumstances) 365 days open To employ 8 full and part time staff(perhaps one more) 8 To conduct a Health Fair in Pahoa 1 Health Fair To pay for IT upgrades as required by the Affordable Care Act Upgraded IT To pay for insurance required to operate (detailed below) Paid Insurance TABLE II: PROGRAM EXPENDITURES FY 1415 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Medical Malpractise Insurance $8,000.00 Other: General Liability Ins. $875.00 Other: Board of Directors Insurance $4,665.00 Other: IT/Computer System maintenance and upgrades $25,975.00 Other: Uninsured-Underinsured Fund $60,000.00 TOTAL $99,515.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 92 Read Aloud America RAP Programs for the Island of Hawaii Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii Agency Director: Jed Gaines, President Phone No.:(808) 593-1 984 Contact Person: Beverly Heikes Phone No.:(808) 938-3215 Mailing Address: Address: 1314 S. King Street Address: Suite G4 city,sT,zip Honolulu, H1 96814 Facility Address: Address: 99 Aupuni Street, Suite 101 Address: City,ST,zip Hilo, Hawaii 96720 Email Address: bgheikesQyahoo.com Fax No.: (808) 593-1984 AccountantJCP Allen Arakaki, CPA Phone No.:(808) 591-8480 Firm (if applicable): Allen M. Arakaki CPA LLC Mailing Address: Address: 1314 S. King Street Address: Suite 710 city,sT,ziP Honolulu, Hawaii 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENTAND COUNCIL OFANY CHANGES �..._....... . ......_.,..w._�,..:.::.......:,....._�....... ,R,.._ ...._._.... _....... .... , Amount of Request for County Nonprofit Grant Program Funds: $94,925.00 1. Prior Year Award of Co-unty Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 2.Agency Mission Statement: Throughthe fun of reading and being read to, Read Aloud America promQjes literacy, teac-bes stronger familV communication skills-and BAA provides evening Parents and-sti idpnts for si)c-sp-ssbns-oveLJ2-waeksteaChong them to zon=uaa' ( EXHIBIT A \._. NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 ......_._......�._.,.... __....�.. ..___....._........-__......._--.,..,._.,._._._._.�.__..._�.�.-.ter_°..-_...__.--.._..._..._....__.«..�-_..._.___�___...,.u.---_._..,_....._.__..__.�_.. ..� Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii 3. Program Description: Read Aloud America's target population is low income schools and students facing challenges such as homelessness, single parent households foster care language barriers, special needs and poverty. _ RAA prQposes to provide four k in the Fall and 2 in the Spr'nq) at such schools onlha Biq Island to serve a deeplv underseryp.d r)nI)tj1afion of schooh; That have been requesting programs- 4.Total Budget&Position Count: Total Program Budget: 1$207,938.00 Total Program Position Count: 7 Total Agency Budget: 1$896,695.00 1 Total Agency Position Count: 114 S.Program Funding Sources(identify all sources of funding applied to this rp ogram): FY14-15 L Revenue Source Estimate l State of Hawaii Grant in Aid Funding - 2014-2015 $94,925.00 Funds From private grants, foundations and donations $18,088.00 County of Hawaii Nan-Profit Grant $94,925.00 TOTAL: $207,938.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Read Aloud America wishes IQ partner with Hawaii QouMLjo provide programs, in order to more swiftlV f0fill-lbe outsfandinq need and EXHI BIT A �__. NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2of7 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii 7. Program Objectives Using County Nonprofit Grant Program Funds: Provides family activity that promotes closeheas and communication literary level in adults & children, which reducas chances of 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 24 evening programs with average of 350 participants per evening 8400 participants Participating families will build a Family Reading Handbook 100% Parents will commit to reading to children at least 3/week 50% Teachers report clearly improved home-to-school relationships 50% Parents report student's increased interest in voluntary reading 50% Students decrease electronic media time in favor of reading 60% `- Students increase use of school and local library resources 75% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $20,065 $80,262.00 $40,131. Professional Fees $0,00 $0,00 $0,40 Operations $4,000. $9,000.00 $2,000.0 Supplies $1,000. $15,000.00 $2,000.0 Equipment $2,000. $2,088.00 $0.00 Other: Travel (Parent Presenter from Oahu) - 24 sessions $3,545. $14,380.00 $7,190.0 Other: Local supply and storage space for materials/staff $2,502, $10,008.00 $5,004.0 Other:Postage 2 first class mailings per dome x 4 schools) $700.00, $2,800.00 $1,400.0 Other:Printing/publications (Family binders, references for parents) $1,500. $6,000.00 $3,000.0 Other:program Materials (free books, giveaways, refreshments) $17,100 $68,400.00 $34,200. TOTAL $52,412 $207,938.0 $94,925. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii 1o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawal'i.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure formwust be si ned regardless of whether a conflict exists. NAME: No Conflict Exists -�Ehl - '/A/ POSITION: Ff)f5 (( 15AI7 MI N �� May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to on industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: NIA [� If no co licts xi , check here. ti x Sign at a of Authorized ers (specify title) Ate EXHIBIT A �- NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: Head Aloud America Program Name: RAP Programs for the Island of Hawaii Niiiiiiiiiam- 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s)'pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the.ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to final payment. To register,go to htti)://vendors.ehawaii.gov, complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i 1 we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual ear for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, cam fete and accurate ear-end report, using the template provided, will imi2act the evaluation-of our program's or agency's uture funding re guests. EXHIBIT A t NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30`x'shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://"www.hawaiicounty.goy/fn-nonprofit-grant-formsL on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2015 must be returned to the County of Hawai'i with the final report. Failure to return these fund5 in a timely manner will impact the evaluation oL your agency's future funding re guest and may result in actions taken to recover these funds- By signing below,you are acknowledging that you have read and understood these requirements. 5igna re of Authoriz d Person(-SIJecify title) date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii 12, COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 24 evening programs with average of 350 participants per evening 8400 participc-d Participating families will build a Family Reading Handbook 100% Parents will commit to reading to children at least 3/week 50% Teachers report clearly improved home-to-school relationships 50% Parents report student's increased interest in voluntary reading 50% Students decrease electronic media time in favor of reading 60% Students increase use of school and local library resources 75% TABLE ll: FY 1415 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $40,131.00 Professional Fees 1 $0.00 Operations $2,000.00 Supplies $2,000.00 Equipment $0.00 Other: Travel (Parent Presenter from Oahu) - 24 sessions $7,190.00 other: Local supply and storage space for materials/staff $5,004.00 Other: Postage 2 first class mailings per Home x 4 schools)_ $1,400.00 other: Printin / ublications (Family binders, references for parents)-_ $3,000.00 Other: Program Materials (free books, giveaways, refreshments) $34,200.00 TOTAL $94,925.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 93 Salvation Army-Family Intervention Services, The Independent Living Skills Program - West Hawaii ti Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii Agency Director: Pauline Pavao Phone No.:(808) 959-5855 Contact Person: Denise Pacheco Phone No.:(808) 959-5855 Mailing Address: Address: P.O. Box 5085 Address: City,sT,zip Hilo, HI 96720 Facility Address: Address: 1786 Kinooie St. Address: City,ST,zip Hilo, HI 96720 Email Address: Pauline.Pavao @usw.salvationarmy.org Fax No.: (808) 959-2301 Accountant/CP Cary Ebesugawa Phone No.:(808) 959-5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 1112 FY 12-13 FY 13-14 $15,000.00 $1 8,750.00 $10,000.00 2. Agency Mission Statement: The Salvation Army-Family Intervention Services mission statement reflects o at-risk youth and-their i [s the_auidina principle in delivering outreach, prevention and residential �Prvir.P�� "TO PROVIDE YOUTH WITH SKILLS FOR A HEALTHY LIFE AND INSTILL PURPOSE, HOPE, AND VISION TO YOUTH AND THEIR FAM11 00,11 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii 3. Program Description: The Salvation Army-Family Intervention Services - Independent Living Skills Program is designed to help foster youth and emancipated foster youth apes 12-21 prepare for and manage the transition to productive, self sufficient adulthood with base of independent living skills. 4. Total Budget& Position Count: Total Program Budget: $126,038.00 Total Program Position Count: 10 Total Agency Budget: $3,000,000,00 Total Agency Position Count: 50 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii $35,000.00 Department of Human Services $91,038.00 TOTAL: $126,038.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continuQuBly-explore avenues of funding to continue these nroarams. However, in view of the nature of our mission in develooina� hPalthv lifestyles for youth and their families, we do rely hP_ayIIV on f indba at all levels of anvPrnmP-nt EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 30 foster youth, ages 12-21 participating in the program, 75% will successfully complete their IL rroogram and attain_atJeast a "fair prognosis" of achieving gals of indQp :ndence upon exiting I e- prora m_ 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Completion of ILSP 30 Participates in IL activities 30 Participates in IL plan 30 Cultural Awareness and Identity 10 Follow up and Monitoring 30 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $19,292 $90,298.68 $25,105. Professional Fees $825.00 $1,080.00 $240.00 Operations $11,343 $32,859.32 $9,054.5 Supplies $498.00 $1,800.00 $600.00 Equipment Other: Other; Other: Other: Other: TOTAL $31,958 $126,038.0 $35,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure Lorms must be signed, regardless of whether a conflict exists. NAM E: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑ If no conflicts exist, check here. Y- :��a Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. 1 (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://Yendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i I we understand and will comply with the requirement to submit_a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely- com lete and accurate ear-end report, using the template provided, will impact the evaluation o_your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all erant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawailcounty.eov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these Lunds in a time!y manner will impact the evaluation of our agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. 4 —��� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name:-]ndepend ent Living Skills Program - West Hawaii 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of ILSP 30 Participates in IL activities 30 Participates in IL plan 30 Cultural Awareness and Identity 10 Follow up and Monitoring 30 TABLE I[: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $25,105.42 Professional Fees $240.00 Operations $9,054.58 Supplies $600.00 Equipment Other: Other: Other: Other: Other: TOTAL $35,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Attachment 1: Independent Living Skills Program —West Hawaii Program Description: The curriculum emphasizes career, education and job-skills development, utilizing a school- based skills format as a framework for implementing an array of independent living/transition curriculums that can be tailored to fit the respective participants relative to age, level of education and psychosocial developmental levels. The focus of this training is to draw a connection between academic success, jobs skills and positive social skills development in order to attain a higher quality of life in the high need areas of Health, Housing, and Economic Self-Sufficiency. The curriculum is divided by components or themes that highlight sessions connected to self- sufficiency. In following with the school year, each component represents a month. These components include: • Orientation/Personal Development (Sept) • Educational Success & Planning (Oct) • Social and Community Awareness (Nov) • VocationallJob Skills Training (Dec) • Post-High Options/ Financial Aide (Jan) • Career Preparation &Work-Based Learning Experiences(Feb) • Life Planning & Money Management (Mar) • Self-Care & Positive Relationship Building (Apr) • Daily Living & Community Involvement (May) • Evaluation, Youth Recognition (June) • Community Service Learning Projects/Team Building Activities- Leadership (July, August) Group sessions are held at Kealakehe Middle School on Wednesdays, Kealakehe High School on Fridays and Konawaena Middle and High School on Thursdays. Each foster youth is required to attend one 2-hour session per week as well as individual sessions. In addition, we stress a youth driven approach when developing their transition plan. Community service projects, family strengthening and extra- curricular activities are designed to further expand their knowledge of their community and the abundance of resources available to them. This includes: College Fairs, Job Fairs, Housing Fairs, World of Work Tours sponsored by the Hawaii Community College, West Hawaii Community College, University of Hawaii at Hilo, Hawaii National Park Service, National Energy Laboratory Hawaii Authority, Sheraton Keauhou Beach Resort and Spa, Work Force Development Division-West Hawaii and many others. We strongly encourage our participants to engage in civic connectedness and giving back to one's community. In addition we also stress the importance of cultural awareness and learning ones identity. The Department of Human Services currently funds our Independent Living Skills Program. Our area of coverage is West Hawaii which includes: Kohala, Waimea, Waikoloa, Kealakehe, Konawaena and the Kau District. This contract supports only a 1.00 FTE Youth Development Specialist IV, which is not enough to cover this vast district. Funding received through the County would help support .50 FTE Youth Development Specialist IV position to increase staff coverage and services to the West Hawaii District. 94 Salvation Army-Family Intervention Services, The Positive Youth Development Prevention Program - Kea`au Agency Name:The Salvation Army-Family Intervention Services Program Name: Positive Youth Development Prevention Program - Keaau Agency Director: Pauline Pavao Phone No.:(808) 959-5855 Contact Person: Denise Pacheco Phone No.:(808) 959-5855 Mailing Address: Address: P.O. Box 5085 Address: city,sT,zip Hilo, HI 96720 Facility Address: Address: 1786 Kinoole St. Address: city,sT,zip Hilo, Hl 96720 Email Address: Pauline.Pavao @usw.salvationarmy.org Fax No.: (808) 959-2301 Accountant/CP Cary Ebesugawa Phone No.:(808) 959-5855 Firm (if applicable): Mailing Address: Address: P.O. BOX 5085 Address: city,sT,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $31,750.00 $10,000.00 Z.Agency Mission Statement: The Salvation Army-Family Intervention Services mission statement w reflects our approach in assisting at-risk youth and their families, and is the qu'd'oo odocuple on delivednq outreach, prevention and residential services: "TO PROVIDE YOUTH WITH SKILLS FOR A HEALTHY LIFE AND INSTII I PURPQSE_ HOPE AND VISION To YOUTH AND IHEIR EAMII IES" EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:The Salvation Army-Family Intervention Services Program Name: Positive Youth Development Prevention Program - Keaau 3. Program Description: The Salvation Army-Family Intervention Services -Positive Youth Development Prevention Program provides a safe and nurturing .environment along with access to opportunities, experiences, and services to support youth development for youth 7-21 residing in the Keaau communities. We utilize a prevention approach to decrease the fuse and abuse of alcohol, tobacco and other illicit drugs_ 4. Total Budget& Position Count: Total Program Budget: $107,750.00 Total Program Position Count: 10 Total Agency Budget: $3,500,000.00 Total Agency Position Count: 50 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii $35,000.00 State of Hawaii- Office of Youth Services $72,750,00 TOTAL: $107,750.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continuously explore avenues of funding to continue these programs. However, in view of the nature of our mission in developing healft lifestyles for youth and their fames, we do rely heavily on fI�Inci_i_n__c, at_all_levels of_government__,___.___ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:The Salvation Army-Family Intervention Services Program Name: Positive Youth Development Prevention Program - Keaau 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 40 youth targeted to participate in the Prevention Program, at least 85% will demonstrate an increase in competencies through the Botvin Life Skills Training Curriculum, 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Completion of L.E.A.D. 40 Participation in Positive Alternative Activities 40 Completion of Botvin Life Skills Training Curriculum 40 Cultural Awareness and Identity 20. Follow up and Monitoring 40 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $21,647 $79,599.06 $27,191.rl Professional Fees $827.00 $1,080.00 $240.00 Operations $8,334.( $24,670.94 $6,968.4 Supplies $1,428. $2,400.00 $600.00 Equipment Other: Other: Other; Other: Other: TOTAL $32,236 $107,750.0 $35,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Positive Youth Development Prevention Program - Keaau lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAM E: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the - following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. � , F (A, 16 114 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:The Salvation Army-Family Intervention Services Program Name: Positive Youth Development Prevention Program - Keaau 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to.examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (vote) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, l (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawail.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the_template provided, wil! impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,_and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http./Iwww.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. — (f) QL F 1311j+ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:The Salvation Army-Family Intervention Services Program Name: Positive Youth Development Prevention Program - Keaau 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of L.E.A.D. 40 Participation in Positive Alternative Activities 40 Completion of Botvin Life Skills Training Curriculum 40 Cultural Awareness and Identity 20 Follow up and Monitoring 40 TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $27,191.51 Professional Fees $240.00 Operations $6,968.49 Supplies $600.00 Equipment Other: Other: Other: Other: Other: TOTAL $35,000.00 Additional Council directives reearding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Attachment 1- Positive Youth Development Prevention Program - Keaau Program Description: Additional services consist of: • The Botvin Life Skills Training Curriculum is an evidence based program designed to strengthen student skills in: Personal Self-Management, General Social Skills and Drug Resistant Skills. Curriculum consists of 10 sessions—45 minutes each session. • Leadership Development Program- The L.E.A.D (Learning Experience in Assisting and Directing)provides development of leadership skills and training in areas of personal and social skills, teamwork, decision making, goal setting, and action planning to conduct community service and learning projects. • TSA-FIS has developed a cultural component that emphasizes cultural awareness and identity through a number of different strategies acid/or approaches that promote the beauty of all cultures and traditions in our community • Positive Alternative Activities consist of: Recreational, Educational, Cultural and Youth Leadership activities. Other prevention activities consist of community service and learning projects, drug-free dances, ohana fun days, and field trips. Program services will be provided at Keaau school districts, Neighborhood Place of Puna- Mountain View and Charter schools in outlying Keaau areas. We propose to implement program services during in-school, afterschool and occasionally weekend hours. The proposed funding would support a 0.5 FTE Youth Development Specialist IV. Supplemental funding from the Office of Youth Services- Positive Youth Development Program will help support and establish a LOOFTE Youth Development Specialist IV to provide prevention/outreach to the Puna community. 95 Salvation Army-Family Intervention Services, The Substance Abuse Prevention Program - Pahoa Agency Name:The Salvation Army - Family Intervention Services Program Name:Substance Abuse Prevention Program - Pahoa Agency Director: Pauline Pavao Phone No.:(808) 959-5855 Contact Person: Denise Pacheco Phone No.:(808) 959-5855 Mailing Address: Address: P.O. Box 5085 Address: city,sT,zip Hilo, HI 96720 Facility Address: Address: 1786 Kinoole St. Address: city,sT,zip Hilo, HI 96720 Email Address: Pauline.Pavao @usw.salvationarmy.org Fax No.: (808) 9592301 Accountant/CP Cary Ebesugawa Phone No.:(808) 959-5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: city,sT,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000.00 $14,000.00 $10,000.00 2.Agency Mission Statement: The Salvation Army-Family Intervention Services mission statement reflects ur approach in assisting at-r' outh and their families, d is the Quidinq p6ndple in delivering outreach Dreven,f.iQn._and majdential services: "TO PROVIDE YOUTH WITH THE SKILLS I S FOR A HEALTHY I IFE AND INST11 I PURPOSE, HOPE AND VISION TO YOUTH AND THEIR EAMILIES EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:The Salvation Army - Family Intervention Services Program Name: Substance Abuse Prevention Program - Pahoa 3. Program Description: TSA-FIS Substance Abuse Prevention Program - Pahoa provides a safe and nurturing environment along with access to opportunities, experiences, and services to support the prevention of alcohol, tobacco and other drug use among youth ages 7 - 17 residing in the Pahoa communities. We Utilize a prevention approach to decrease the used and abuse of alcohol, tobacco and other illicit drugs. 4. Total Budget& Position Count: Total Program Budget: $120,000.00 Total Program Position Count: g Total Agency Budget: $3,500,000.00 Total Agency Position Count: 50 S. Program Funding Sources (identify all sources of funding,applied to this program): FY14-15 Revenue Source Estimate County of Hawaii $35,000.00 Department fo Health, Substance Abuse Prevention $85,000.00 TOTAL: 1 $120,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continuously explore avenues of funding to continue these healthy lifestyles for your youth and their families, we do rely heavilyy on fundino at all levels of anvernment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:The Salvation Army - Family Intervention Services Program Name: Substance Abuse Prevention Program - Pahoa 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 40 youth targeted to participate in the Prevention Program, at least 85% will demonstrate an increase in competencies through the Botvin Life Skills Training Curriculum, 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (l.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Completion of L.E.A.D. 40 Participation in Positive Alternative Activities 40 Completion of Botvin Life Skills Training Curriculum 40 Cultural Awareness and Identity 20 Follow up and Monitoring 40 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* 'total Budget Grant Req Salary and Wages $30,925 $79,625.00 $24,506. Professional Fees $651.00 $1,320.00 $300.00 Operations $9,917. $35,454.00 $8,993.0 Supplies $1,517.( $3,600.00 $1,200.0 Equipment Other: Other: Other: Other: Other: TOTAL $43,010 $119,999.0 $34,999. *If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:The Salvation Army- Family Intervention Services Program Name:Substance Abuse Prevention Program - Pahoa so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑ If no conflicts exist, check here. �-- i 1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:The Salvation Army - Family Intervention Services Program Name:Substance Abuse Prevention Program -, Pahoa . 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors,ehawaii.gov_, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual Vear for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided, will impact the evaluation of our program's or agency's uture funding re nests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for min_mum_of one year or until a written report is submitted to, and accepted_by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agencv's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. - � �Q;L 1 1151 114 Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:The Salvation Army - Family Intervention Services Program Name: Substance Abuse Prevention Program - Pahoa 12. COUNCIL AWARD WORKSHEET TABLE l: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of L.E.A.D. 40 Participation in Positive Alternative Activities 40 Completion of Botvin Life Skills Training Curriculum 40 Cultural Awareness and Identity 20 Follow up and Monitoring 40 TABLE II: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $24,506.35 Professional Fees $300.00 Operations $8,993,65 Supplies $1,200.00 Equipment Other: Other: Other: Other: Other: TOTAL $35,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Attachment 1- Substance Abuse Prevention Program- Pahoa Program Description: Additional services consist of: • The Botvin Life Skills Training Curriculum is an evidence based program designed to strengthen student skills in: Personal Self-Management, General Social Skills and Drug Resistant Skills. Curriculum consists of 10 sessions—45 minutes each session. • Leadership Development Program- The L.E.A.D {Learning Experience in Assisting and Directing}provides development of leadership skills and training in areas of personal and social skills, teamwork, decision making, goal setting, and action planning to conduct community service and learning projects. • TSA-FIS has developed a cultural component that emphasizes cultural awareness and identity through a number of different strategies and/or approaches that promote the beauty of all cultures and traditions in our community • Positive Alternative Activities consist of: Recreational, Educational, Cultural and Youth Leadership activities. Other prevention activities consist of community service and learning projects, drug-free dances, ohana fun days, and field trips Program services will be provided at Pahoa school districts, Neighborhood Place of Puna located in Pahoa and Charter schools in outlying Pahoa areas. We propose to implement program services during in-school, afterschool and occasionally weekend hours. The proposed funding would support a 0.5 FTE Youth Development Specialist IV. Supplemental funding from the Department of Health—Substance Abuse Prevention Program will help support and establish a 1.00FTE Youth Development Specialist IV to provide prevention/outreach to the Pahoa communities. 96 Special Olympics Hawaii Special Olympics Hawaii - East Hawaii Area Agency Name: Special Olympics Hawai'i Program Name: Special Olympics Hawai'i-East Hawaii Area Agency Director: Nancy Bottelo Phone No.:808 695-3522 Contact Person: Lisa Pana Phone No.:808 443-4032 Mailing Address: Address: PO BOX 7265 Address: City,ST,zip Hilo, Hawai'i 96720 Facility Address: Address: None Address: City,ST,Zip Email Address: soeasthi @gmail.com Fax No.: 808-943-8814 Accountant/CP Akamine, Oyadomari, Kosaki Phone No,:808 941-0500 Firm (if applicable): Akamine, Oyadomari, Kosaki Mailing Address: Address: 1440 Kapiolani Street#900 Address: City,sT,zip Honolulu, Hawai'i 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $15,000 $15,000 $25,000 2. Agency Mission Statement: See attached EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Special Olympics Hawaii Program Name:Special Olympics Hawai'i-East Hawaii Area 3. Program Description: See attached 4.Total Budget& Position Count: Total Program Budget: $139,000 Total Program Position Count: 1 Total Agency Budget: $1,600,000 Total Agency Position Count: 18 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii Grant $25,000 Foundations & Service Clubs $12,100 Individual Contributions $14,000 Corporation Contributions $6,000 Special Events $44,000 SOHI Co-op Funds $2,500 Merchandise Sales $35,400 TOTAL: $139,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: See attached EXH I BIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawai'i-East Hawai'i Area 7. Program Objectives Using County Nonprofit Grant Program Funds: See attached 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results #.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of athletes served 239 Number of unified partners and families served 200 Number of community volunteers serving our program 563 Number of professional dev & leadership training opportunities 11 Number of coaching staff 40 Number of delegations within our Area 12 Number of competitions (Area & State) 10 Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $6,200 $6,900 Professional Fees 0 0 0 Operations $47,600 $46,600 0 Supplies 0 0 0 Equipment $6,000 $2,500 $2,000 Other:Airfare for After School All Stars Program $10,400 $10,000 $10,000 Other:Airfare for athletes to attend competitions $59,000 $69,500 $10,000 Other:Profession Development & Leadership Training $1,800 $3,000 $3,000 Other: Other: TOTAL $131 K $139,000 $25,000 *[f applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: Special Olympics Hawaii Program Name:Special Olympics Hawaii-East Hawaii Area 1o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be si ned regardless of whether a con lict exists. NAME: NIA POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. ev Sig tore of thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:Special Olympics Hawaii Program Name:Special Olympics Hawai'i-East Hawaii Area sa.. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. i (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register,go to htt vendor_s.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a_grant from the County_of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end re ort to the County Council within 60-days after June 30 of the contractual yea r for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timer complete,_and accurate year-end report; using the template provided, wil! impact the evaluation of our program's or agency's uture funding re nests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all rant funds received during the erant Period must be refunded to Count and exclusion from future grant Participation for a minimum of one year or until a written report is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:ILWww.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a time!y manner will impact the evaluation of our agency 's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. .WKI,17,6, ^Q HY �. C d Z/s-- Sign ture of horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:Special Olympics Hawaii Program Name:Special Olympics Hawaii-East Hawaii Area 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of athletes served 239 Number of unified partners and families served 200 Number of community volunteers serving our program 563 Number of professional dev & leadership training opportunities 11 Number of coaching staff 40 Number of delegations within our Area 112 Number of competitions (Area & State) 10 TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees 0 Operations 0 Supplies 0 Equipment $2,000 Other: Airfare for After School All Stars Program $10,000 Other: Airfare for athletes to attend competitions $10,000 Other: Profession Development & Leadership Training— $3,000 Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Agency Name: Special Olympics Hawai'i Program Name: Special Olympics Hawai'i-East Hawai`I Area 2.Agency Mission Statement The mission of Special Olympics is to provide year round sports training and athletic competition in a variety of Olympic-type sports for children and adults with intellectual disabilities,giving them continuing opportunities to develop physical fitness, demonstrate courage, experience joy and participate in the sharing of gifts, skills and friendship with their families, other Special Olympics athletes and the community. 3. Program Description Special Olympics is a national award-winning nonprofit organization created by Eunice Kennedy Shriver in 1968 to address the neglect and disregard of individuals with intellectual disabilities. Our Special Olympics program is open to everyone with intellectual disabilities in Hawaii,regardless of the extent of their disability. People who are isolated from life experiences by a disability have little chance for the developmental growth and acquisition of important skills that they will need to gain employment, maintain relationships and function within the community. Special Olympics believe that all people, regardless of their disability deserve to lead full, active lives, enriched with social and recreational opportunities that most of us take for granted. Unfortunately, appropriate physical education programs in the public schools and social service programs that realistically address the special needs of their population are virtually non-existent and/or very limited. The benefits for our athletes continue to be: improved physical fitness and motor skills, greater self-confidence,a more positive self-image, friendships and increased family support. We encounter these benefits in their daily lives at home, in the classroom, on the job and in the community. Our program could not happen without the help from our community volunteers. Through our program over 560 community volunteers interact with individuals with special needs. Our program is free of cost to all our athletes,special partners,and coaches. All of the money raised for the East Hawaii program stays here to support our program's area budget of$139,000. Those funds will pay for all aspects of the Special Olympics program,which includes, equipment, uniforms,transportation costs, family activities, our Athlete Leadership Program (ALPS) and training and professional development for our volunteers,unified partners and coaching staff. All coaches are required to attend a sport specific training on Oahu prior to coaching athletes. Airfare of$1000 will be needed to be able to send five coaches to the certification clinic for each team in our program in this upcoming year. A professional development opportunity and leadership conference will be held for coaches,volunteers,unified partners and coaching staff in which an additional $2000 will help to fund this travel. Knowledge gained at this leadership conference will be implemented into our area program and attendees will be held accountable for sharing their learning outcomes with others in our program. This portion of the County of Hawaii grant will allows us to continue to provide our area support 1 Agency Name: Special Olympics Hawai'i Program Name: Special Olympics Hawai'i-East Hawai'I Area people the opportunity to be better for the athletes they serve by attending these training and professional development opportunities. Special Olympics East Hawaii is only one of 2 area programs in the State to offer a Young Athlete Program (YAP). The YAP program is for preschool-aged (2 Y2 to 5 years old) students with intellectual disabilities. The program has its own curriculum,which introduces the preschoolers to basic eye hand coordination activities that help to strengthen their fine and gross motor skills.As the curriculum progresses, it prepares the preschoolers for future training in Special Olympics' program called Future Stars as they reach 6-7 years old. Keaau Elementary, Mt. View Elementary, Kaumana Elementary and E.B. DeSiIva Elementary preschool classes continue to grow in the YAP program. One of our goals for the upcoming year is to develop, establish and implement a Future Stars program to ensure that our"graduating"YAP preschoolers will have a program in which to feed into and more importantly, to increase the likelihood that our young athletes will have a consistent, on-going and fluent experience in our program. We are asking for$2000 to help us kick-start our Future Stars Program with the necessary curriculum, supplies and equipment. As always, Special Olympics East Hawai'i's largest expense for 2014-2015 will be transportation. It is an essential part of our program that Special Olympics athletes are provided an opportunity to interact and compete against people of similar athletic ability. Unfortunately, our area program is too small to be able to provide quality competition; therefore our athletes must travel to other islands to achieve that goal. The state competitions that are held on Oahu three times per year provide many activities that our athletes never have a chance to experience. They include dances, Opening and Closing ceremonies, entertainment and games, and exposure to a Healthy Athlete Program. The Healthy Athlete Program provides free dental, vision, hearing,nutrition and podiatric screening, as well as, a Fun Fitness (flexibility and strength) screening for all athletes. These services,which sometimes are not available to individuals with disabilities for a multitude of reasons, continue to be an essential and notably popular service provided at the state games. As we continue to recover and push through these economic difficulties, our area program will remain staunch in utilizing our quota system,where a delegation will need to select a season to opt out of traveling off island. However,we would like to still provide this opportunity to as many athletes as we possibly can and with $10,000 from the County of Hawaii for transportation to state competitions,we will be able to make this happen. Our East Hawaii After School All Star program,which targets schools that are not meeting the No Child Left Behind mandates continues to grow. Kea'au Intermediate and Pahoa Intermediate Schools places an equal number of special needs athletes within the school in partnerships with mainstream students athletes.Together, they train and compete in unified softball and unified basketball. The transportation costs to get these teams to our state competitions during the school year is $10,000. 2 Agency Name: Special OIympics Hawaii Program Name: Special Olympics Hawaii-East Hawai`l Area The County of Hawaii grant will assist in providing these travel opportunities for our After School All Star program athletes. Special Olympics Hawaii-East Hawaii Area is requesting$25,000 from the County of Hawaii to help fund our Special OIympics East Hawaii program activities and events for FY 2014-2015. 6. Explain what plans your agency or program has to increase revenues to support this program As a new area director for our East Hawaii program, I am committed to the following: 1. Continue to research and apply for various community grants available for programs such as ours 2. Implement new fundraisers with the potential to generate funds of$6000- $7000 or more 3. Seek and solicit funding assistance and contributions from community and business partners, as well as, from civic,governmental, social and sports- oriented constituents within our area Our program continues to operate in a very diverse manner in which we raise monies to support our athletes, coaches, families and volunteers. As our program grows, so do our expenses; therefore, our commitment to providing our athletes with opportunities to compete on the field and in life are that much more important and requires us to be steadfast and focused on our plans to increase revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds 1. To provide quality sports training&Olympic type competitions in our area for 239 athletes and 100 unified partners by June 2015 2. To provide sport-specific coaches training and recertification opportunities for five coaches by June 2015 3. To provide professional development and leadership training opportunities for our program athletes, coaches,families, unified partners and volunteers by June 2015 4. To develop, establish and implement a Future Stars Program for special needs athletes ages 6-7 by June 2015 5. To provide airfare transportation to 160 athletes, coaches and unified partners three times a year, so that they may compete at each state competition by June 2015 6. To provide an opportunity for 560 community volunteers to interact with our program athletes throughout June 2015 7. To continue our outreach initiatives to individuals with special needs in our East Hawaii area and provide them with unique experiences to grow and function within our community 3 97 Special. Olympics West Hawaii SOWH General Fund Agency Name:SPECIAL OLYMPICS WEST HAWAII Program Name:SOWN GENERAL FUND Agency Director: NANCY BOTTELO Phone No.:(808) 943-8808 Contact Person: DENISE LINDSEY Phone No.:(808)345-0433 Mailing Address: Address: P.O. BOX 390358 Address: City,sT,zip KEAUHOU-KONA, HI 96739 Facility Address: Address: 81-6636 MULI STREET Address: City,sT,zip KEALAKEKUA, HI 96750 Email Address: denise @bigislandtv.com Fax No.: (808) 322-3498 Accountant/CP Ronelle Matsunami Phone No.:(808) 833-1183 Firm (if applicable): Akamine, Oyadomari, & Kosaki CPA's, Ins Mailing Address: Address: 440 Kapiolani Blvd., Suite 90 Address: city,sT,zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $12,000.00 $12,000.00 $15,000.00 2.Agency Mission Statement: The mission of Special Olympics is to ,prQvide year-round sports training and athletic competition on a yariety of Olympic-type sports for all children and adults_Wth intellectual disabilities�giv ngAhem continuing nonor-tunities tc__develon rftsical fitness demonstrate courage.,,...._ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:SPECIAL OLYMPICS WEST HAWAII Program Name:SOWN GENERAL FUND 3. Program Description: Special Olympics goal is to dispel ne ative stereo es about people with intellectual disabilities to build athlete and o'hana involvement through sports, and to promote the extraordinary gifts of geople with intellectual di very individual With jotellectual disabilities [ages 2 and up] regardless of skill level or IgCCor ; n —P ,cr p- �e� o ALT-- Uer C-/11+C- G-- 4.Total Budget& Position Count: Total Program Budget: $84,060,00 Total Program Position Count: 1 Total Agency Budget: $1,600,000.00 Total Agency Position Count: 118 S. Program Funding Sources(identify ail sources of funding applied to this Rrogram FY14-15 Revenue Source Estimate See attached Revenue Source $84,050.00 TOTAL: $84,050.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 2. IncreasQ_.pnnpatary soonsorshio level of HQ1e On_Bus Pull EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:SPECIAL OLYMPICS WEST HAWAII Program.Name: SOWH GENERAL FUND 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 Non profit grant_funds to be used toward,s,..Quter island air fare for atbletes_ -3- Add Unified Soccer to our '-;uMmPr ,-qPaqnn- 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (1e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Round trip air fare for Summer Games for Athletes and Coaches 30 athletes, 7 coaches Air fare for Global Messenger training 5 athletes, 1 mentor Develop a Unified Soccer team 5 athletes 5 partners 2 coach Train new and existing coaches 10 coaches trained, 20 total Rount trip air fare for Aukake Classic for Athletes and Coaches 30 athletes, 7 coaches Round trip air fare for Winter Games for Athletes and Coaches 130 athletes, 7 coaches Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $15,000 $15,000.00 Professional Fees $0.00 $0.00 $0.00 Operations $19,OOC $19,000.00 $2,500.0 Supplies $13,17E $12,250.00 $2,500.0 Equipment Other: $37,775 $37,800.00 $10,000. Other: Other: Other: Other: TOTAL 1$84,953 $84,050.00 $15,0001 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name. 'ciLl l e Program Name: ZD ra �xrx ,._ so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization, with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be sianed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an Individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: �If no conflicts exist, check here. Sign ture Futhorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: SPECIAL OLYMPICS WEST HAWAII Program Name:SOWH GENERAL FUND :1. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. To register, go to httpj/yendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Ha_wai'i, I_(we)understand and will comply with the requirement to submit a ear-end report to the County Council within-60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, com lete and accurate ear-end repart-usina the tem late provided, will impact the evaluation ofYQ r rxroaram's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30'h shall result in loss of all grant funds received during the grant period Imust be refunded to County)and exclusion from future arant_participation for aminimum of one year or until a,written report is submitted to.and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt www.hawaiicoun . ov fn-non rofit- rant-forms on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawai"r with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's utureLunding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Sign ture of uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APP€.ICATI0N FY 2014-2015 Page 6 of 7 Agency Name:SPECIAL OLYMPICS WEST HAWAII Program Name:SOWN GENERAL FUND 12t. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Round trip air fare for Summer Games for Athletes and Coaches 30 athletes, 7d Air fare for Global Messenger training 5 athletes, 1 ra Develop a Unified Soccer team 5 athletes 5 Train new and existing coaches 10 coaches tr ' Rount trip air fare for Aukake Classic for Athletes and Coaches 30 athletes, 7 Roland trip air fare for Winter Games for Athletes and Coaches 30 athletes,7ji TABLE II: PROGRAM EXPENDITURES FY 1415 Council Grant Request Award Salary and Wages Professional Fees $0.00 Operations $2,500.00 Supplies $2,500.00 Equipment Other: $10,000.00 Other: Other: Other: Other: TOTAL $15,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Agency Name: SPECIAL OLYMPICS WEST HAWAII Program Name: SOWH GENERAL FUND 3. Program Description (can't): Special Olympics helps bring all persons with intellectual disabilities into a larger society under conditions whereby they are accepted, respected, and given a chance to become productive citizens. Physical fitness training and competition is crucial for children with intellectual disabilities; and being part of a team" is essential to all athletes. Special Olympics is often the only option available to the intellectually challenged population for sports training and competition. Certainly Special Olympics is the only program that welcomes involvement by the entire family. Our program is designed to increase inclusion by every member of the family and the community; we believe we help them to overcome the barriers that have historically caused children and adults with intellectual disabilities and their 'ohana to live in a world of isolation. Benefits that our athletes receive from their participation in Special Olympics include: improved physical fitness and motor skills, greater self-confidence, a more positive self- image, friendships, and increased family support. Special Olympics athletes carry these benefits with them into their daily lives at home, in the classroom, on the job, and in the community. Families who participate become stronger as they learn a greater appreciation for their child's talents. We have found that many of our strongest supporters and best volunteers are the family members of our Special Olympics athletes. We provide a "safe haven" for families where they know that their child is not judged and is accepted for who they are and for what they can do. Community volunteers make long lasting bonds that continue off of the sports field into their daily lives. Everyone learns more about the capabilities of people with intellectual disabilities, and a huge majority of our volunteers continue with the program year after year. These active volunteers are often a source of recruiting new volunteers to the program as they share their stories with friends, neighbors and co-workers. Special Olympics West Hawaii Unified Sports Program is a vital program where these special needs individuals interact with their non-handicapped peers on a weekly basis. Unified Sports is a program that combines equal numbers of athletes with intellectual disabilities and special partners without disabilities. All participants are of similar age and athletic ability. This program dramatically increases inclusion of our athletes into the community by helping break down barriers that have historically kept people with and without disabilities apart. Special Olympics West Hawaii will have unified softball, track relays, bocce and bowling teams and will expand and have our first unified soccer team in FY 2014-15. The need for the Special Olympics West Hawaii program to continue here on this island is extremely high. There is no other program in our Area to provide these services to our athletes. Special training is provided for our athletes and the coaching staff throughout the year. The training is essential due to the unique services that we Agency Name: SPECIAL. OLYMPICS WEST HAWAII Program Name: . SOWH GENERAL FUND provide. We not only touch the lives of our Special Olympics athletes, but also their families and the hundreds of volunteers from our community. Our program is free of cost to all of our athletes and their families,special partners, and coaches. Due to this aspect of our program, a volunteer committee under the leadership of our Area Director must raise all the funds needed for our West Hawaii area program. Those funds will pay for all aspects of the Special Olympics program. Our largest needs for 2014-2015 are 1. Develop our new After School All Stars Program in Ka'u complete with staff, coaches, uniforms, and equipment. 2. Host a neighbor island softball 1 t-ball tournament. 3. Host a neighbor island Power lifting Tournament. 4. Host a neighbor island Soccer and Bocce Bali tournament. Our largest cost, as always is airfare to get our athletes to their competitions where they compete against their peers from around the state of Hawaii. Hosting these three major competitions here on the West side of the Island, as well as a local bowling competition helps us out financially by not having to buy as many flights to off island competitions, however that aspect of our budget is extremely large. It is an essential part of our program that Special Olympics athletes are provided an opportunity to interact and compete against people of similar athletic ability. We find as many teams in the community as we can to practice and play against, but we still must travel to Oahu three times a year to compete against similar Special Olympics teams/athletes. The state competitions that are held on Oahu three times per year provide many activities that our athletes never have a chance to experience. They include: dances, Opening and Closing Ceremonies, entertainment, games, and free health exams through the Healthy Athlete Program. This Healthy Athlete program provides free dental, vision, hearing, podiatry, flexibility & nutrition screening and education for our athletes. As you know, these services are sometimes not available to individuals with disabilities due to financial difficulty or lack of professionals who are trained to treat people with disabilities. Special Olympics West Hawaii wishes to continue to provide these opportunities to all the athletes that are currently involved and to be able to reach out to new special needs individuals throughout our communities. In order to do this, we will need funds to maintain our services and to purchase new uniforms and equipment, host local competitions as well as provide transportation for athletes to get to competitions. Special Olympics Hawaii-West Hawaii Area is asking for$15,000.00 from the County of Hawaii to help fund our Special Olympics West Hawaii program activities. 5. Revenue Source: ANTICIPATED REVENUE SOURCES AMOUNT Kona Crossfit Fund Raiser $2,000 Copty Grant $15,000 Ironman Grant $6,000 Charity Walk $10,000 Fueling Dreams $5,000 Fishin g Tournament $11,550 Hele-On Bus Pull $3,500 Cop On To $25,000 Cosmic Bowling Fund Raiser $4,000 Co orate and Individual Donations $2,000 Total Revenue . . . . . $849050 7. Program Objectives Using county Nonprofit Grant Program Funds: 4) Establish our new Ka'u After School All Star Program. 5) Train more coaches and volunteers to continue to provide the highest skilled training to our athletes. 6) Provide athletes with additional opportunities: to learn, more work opportunities, and to move towards self-sufficiency through our partnerships with.The ARC of Kona and Full Life. 7) Continue to add community service events to give back to our Kona community that is so supportive of SOWH. 8) Expand our management team to have additional input from the local community members and businesses. 9) Strengthen our financial contacts and expand our local fundraising opportunities. 10) Expand our outreach to younger athletes in the community to enhance the development of our keiki. 98 Sure Foundation, Inc. Yeshua Outreach Center s"1 r Agency Name:Sure Foundation, Inc. Program Name:Yeshua Outreach Center Agency Director: Pastor Lorin Carmichael Phone No.:(808)966-6489 Contact Person: Andrea Miday Phone No.:(808)966°6489 Mailing Address: Address: P.O. Box 1598 Address: City,ST,zip Keaau, HI 96749 Facility Address: Address: 16-1592 Pohaku Circle Address: city,sT,zip Keaau, H1 96749 Email Address: andreamiday @yahoo.com Fax No.: {808 966-6712 Accountant/CP Carolee Fernandez Phone No.:(808) 982-3900 Firm (if applicable): Strategy By Numbers Mailing Address: Address: P.O. Box 4130 Address: City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 67,500 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 50,000 0 67,500 2.Agency Mission Statement: To build bridges and connect people to Christ and committed to turn Wes around through qualfty Christ-centered mentoring, fitness and support programs. Tb impaet lives, families and our eemmunity through Ind body and spirit by building character-, teaching racnar_t anrd developing champions V�1 11n A0 app - V il%V) EXHIBIT A � ' NONPROFIT GRANT APPLICATION FY 2014-2015 ge 1 of 7 Agency Name:sure Foundation, Inc. Program Name:Yeshua Outreach Center Prop am De :cry flow. r0'1 ac?iVities Including, kempo karate, boxing, fitness equipment, and 6 12 week support elasses. I.A.I.P. p,revide a nurturing environment that give farnifles a pos4h.iQ- Q-nivironrnent in lAthir.-h too rd&vip�lop. On Friday, for YOUth- We offer counseling, guid Onrporatp community outreach and continue to.oartner with ouhiic and private organizations. 4.Total Budget & Position Count: Total Program Budget: 141,600 Total Program Position Count:. 2.0 Total Agency Budget: 1,286,000 Total Agency Position Count: 8.5 S. Program Funding Sources {identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii Grant Request 67,500 Tuition from membership/registration 4,600 Special EventsNouth boxing events 5,000 Cash Donations 4,000 Sale of Goods 1,000 Admission Fees 4,500 Sure Foundation Facility (in-kind) 60,000 TOTAL: 146,600 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Expanding outreach efforts aim to increase registration tees and mernbershilp U-Jues. Four (41) USA boxing-ocinctioned events that includes EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:Sure Foundation, Inc. Program Name:Yeshua Outreach Center . Pro ram Objectiv $ Using C unty Nonprofit Grant Program Funds- participants. Plan and conduct community outreach. DissemMate materials, publdeize and delover elasses and event(s). Expand partFlerships with leGal and private organ m.Z—At.m.c9n S. S.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Increase number of participants enrolled in Weightlifting by 50% 60 Increase attendance at 4 sanctioned-boxing events by 10% 550 Outreach program to 500 individuals 500 Deliver USA Boxing-sanctioned amateur events 3 Increase number of participants enrolled in Boxing by 30% 60 Increase number of participants enrolled in YOC Youth by 20% 255 increase number of participants enrolled in Kempo by 20% 55 Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 41,000 43,000 1,700 Professional Fees 11,833 13,000 2,000 Operations 64,186 65,000 2,500 Supplies 2,572 3,000 8,500 Equipment 11,451 15,000 45,000 Other:Travel 373 1,500 7,000 Other:Sanctioned Fees x 3 Boxing Events 1,020 1,100 800 Other: Other: Other: TOTAL 1132,4351 141,600 67,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:sure Foundation, Inc. Program Name:Yeshua outreach Center io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure farms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 if no conflicts exist, check here. Signature of Authorized Person (specify title) Date Wei Pira;0emk 1 m'[,i V EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:Sure Foundation, Inc. Program Name:Yeshua Outreach Center ii. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 1 (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://Vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual vear for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end re�a. ort using the template provided will im act the evaluation of our program's or a enc 's Luture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant.participation for a minimum of one year or until a written report is submitted to, and aceeuted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov.,/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date bad 41646A 16�A'W' EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:Sure Foundation, Inc. Program Name:Yeshua Outreach Center 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase number of participants enrolled in Weightlifting by 50% 60 Increase attendance at 4 sanctioned-boxing events by 10% 550 Outreach program to 500 individuals 500 Deliver USA Boxing-sanctioned amateur events 3 Increase number of participants enrolled in Boxing by 30% 60 Increase number of participants enrolled in YOC Youth by 20% 1255 Increase number of participants enrolled in Kempo by 20% 155 TABLE p: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 1,700 Professional Fees 2,000 Operations 2,500 Supplies 8,500 Equipment 45,000 Other: Travel 7,000 Other: Sanctioned Fees x 3 Boxing Events 800 Other: Other: Other: TOTAL 67,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT"GRANT APPLICATION FY 2014-2015 Page 7 of 7 100 Teach for America, INC. Teach for America Hawaii Agency Name:Teach For America, Inc. Program Name:Teach For America Hawai'i Agency Director: Jill Murakami Baldemor Phone No.:(808) 521-1371 Contact Person: Jacob Karasik Phone No.:(808) 521-1371 Mailing Address: Address: 500 Ala Moana Blvd. Address: Suite 3-400 City,ST,zip Honolulu, HI 96813 Facility Address: Address: 75-170 Hualalai Road Address: Suite 0209 City,ST,zip Kailua-Kona, HI 96740 Email Address: Jill.baldemor @teachforamerica.org Fax No.: (808) 538-3793 Accountant/CP Grant Thornton LLP Phone No.:(212) 599-0100 Firm (if applicable): Mailing Address: Address: 666 Third Avenue Address: 13th floor city,sT,zip New York, NY 10017-4011 YOU ARE RESPONSIBLE TO KEEP THEABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $100,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $0.00 $0.00 $0.00 2.Agency Mission Statement: Teach For America Hawai`i's mission is growing a movement of leaders who n r that i r w`nu -up-in-povedy get an excellent educatoon- We enlist promisinq future leaders-tQ help cieate a system that delivers an excellent education for all children in_Hawai`i.by becominn teachers in our highest need schools EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Teach For America, Inc. Program Name:Teach For America Hawai'i 3. Program Description: Teach For America recruits and selects a highly diverse corps of college graduates who complete our intensive teacher education pro-gram over their first two years of workin in Hawaii ublic schools that serve low-income communities. Our program was the largest trainer of new corps are known for leadeiship and high-achievement- 4.Total Budget&Position Count: Total Program Budget: $932,881.00 Total Program Position Count: 5 Total Agency Budget: $5,200,000.00 Total Agency Position Count: 20 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate See attached Committed and Pending Funding for Teach For America Hawai'i note that the attached is for both Oahu and Hawai'i Island TOTAL: $Q.00 Attach additional pages,if needed 6. Explain what plans your agency or program has to increase revenues to support this program: Over the Past ei ght Years, we have cultivated relationships with many local foundations. As our program has grown, we have attempted to huild new relationships in our new communifies_ We are currently planning new d nts an Hawaii Island as well as Q'ahu EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:Teach For America, Inc. Program Name:Teach For America Hawai'i 7. Program Objectives Using County Nonprofit Grant Program Funds: Our program's objective is to train a high quality corps of instructional _leaders to serve in Hawaii Island public schools which serve low-income communities. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results ft.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Recruitment 30 Teachers for SY14-15 Above average content mastery or student growth 80% TFA demonstrate Tripod Surrey Score TFA avg. above state avg. Mean Student Growth Percentile (MSGP) MSGP higher than state avg. `See attached for details and specifics on these measures Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $103,799 $722,905.00 $50,000.00 Professional Fees Operations Supplies $279.75 $500.00 Equipment Other:Travel $6,851.0 $22,800.00 Other:Food& Lodging $2,378.17 $18,818.00 Other:Rent&Utilities $16,399.E $27,490.00 Other:pre-Service Training $140,368.00 $50,000.00 Other: TOTALt$129,7071 $932,881.00 $100,000.0 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:Teach For America, Inc. Program Name:Teach For America Hawai'i j.o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jill Murakami Baldemor POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: © If no conflicts exist, check here. /J�Y/2or Signs ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:Teach For America, Inc. Program Name:Teach For America Hawai'i u. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a_grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual yea r for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timelycomplete,_and accurate year-end report, using the template provided, will impact the evaluation of our program's or agency's uture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.goy/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a time!y manner will impact the evaluation of our agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. /a-/ /20 Signa ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:Teach For America, Inc. Program Name:Teach For America Hawaii 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Recruitment 30 Teachers fil Above average content mastery or student growth 80% TFA denig Tripod Survey Score TFA avg. abolg Mean Student Growth Percentile (MSGP) MSGP hi her *See attached for details and specifics on these measures TABLE II: FY 1415 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $50,000.00 Professional Fees Operations Supplies Equipment Other: Travel Other: Food & Lodging Other: Rent & Utilities other: Pre-Service Training $50,000.00 Other: TOTAL $100,000.00 Additional Council directives_regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 Teach For America Hawai'i I FY14 Sources of Secured &Anticipated Support COMMITTED . PENDING TOTAL 5,375,200 COMMITTED • Hacvai`i Department of Education Committed 435,000 Public McInerny Foundation Committed 200,000 Foundation Harold KL.Castle Foundation Committed 250,000 Foundation AmeriCorps Hawaii Committed 153,600 Public Kamehameha Schools Committed 100,000 Foundation Hawaii Community Foundation Committed 75,000 Foundation James and Abigail Campbell Foundation Committed 50,000 Foundation Aloha United Way Committed 47,296 Public Wollenberg Foundation Committed 30,000 Foundation :Atherton Family Foundation Committed 25,000 Foundation Kzmaile Academy Committed 20,000 Charter G.N.Wilcox Trust Committed 15,000 Foundation Schuler Family Foundation Committed 10,000 Foundation Ritchie\Mudd,Board Member Committed 10,000 Individual First Insurance Company of Hawaii Committed 10,000 Corporation Cades Foundation Committed 10,000 Foundation Nanea Foundation Committed 10,000 Foundation Kua D Ka La Charter School Committed 10,000 Charter Sub-$1,000 Gifts Committed 8,600 'Mixed First Hawaiian Bank Kokua Mai Committed 5,350 Corporation Dr.Mike Sayama Committed 5,000 Individual Jim&Marilyn Pappas Committed 5,000 Individual AC Kobayashi Family Foundation Committed 5,000 Foundation Ron&Janet Stern Committed 5,000 Corporation Honolulu Star-Advertiser Committed 5,000 Corporation Richard Parry Committed 5,000 Individual Friends of Hawaii Charities Committed 5,000 Foundation Outrigger Enterprises Group Committed 5,000 Corporation David&Becky Pietsch Committed 5,000 Individual H.Mitchell D'©lier,Board Chair Committed 5,000 Individual Donald Horner Committed 5,000 Individual Connections PCS Committed 5,000 Charter Jill Higa,Board'Member Committed 4,952 Individual Hung Wo and Elizabeth Lau Ching Foundation Committed 3,500 Foundation Karen Chang,Board Member Committed 3,000 Individual Jodee Burris Committed 3,000 Individual Matson Foundation Committed 2,500 Corporation Stanvood Hotels Hawaii Committed 2,500 Corporation Dee Jay hailer Committed 1,000 Individual David Simons Committed 1,000 Individual Sharon McPhee Committed 1,000 Individual Robert&Paulette Wo Committed 1,000 Individual Brian Sen Committed 1,000 Individual PENDING TOTAL i Upgrades,New Sources of Support,and TFA National Funding Pending New 2,334,552 Dlixed I Iawei Department of Education Pending Upgrade 435,000 Public Chamberlin Family Foundation Pending Renewal 450,000 Foundation Charles and Helen Schwab Foundation Pending Renewal 150,000 Foundation Kosasa Family Fund at the Hawaii Community Foundation Pending Upgrade 50,000 Individual First Hawaiian Bank Pending Upgrade 50,000 Corporation Bank of Hawaii Foundation Pending Renewal 50,000 Foundation K.Taniguchi Ltd. Pending Renewal 25,000 Individual Corine Watanabe Pending Renewal 20,000 Individual R.E.Wilhelm Fund of the Ayco Charitable Foundation Pending Renewal 20,000 Foundation Alexander&Baldwin,Inc. Pending Upgrade 15,000 Corporation Bill Healy Foundation Pending Renewal 12,500 Foundation JCPenney Company,Inc. Pending RenewaI 12,000 Corporation Jay Shidler Pending Renewal 10,000 Individual Island Insurance Foundation Pending Renewal 10,000 Foundation James McIntosh Pending Renewal 10,000 Individual Dwayne and tvlarti Steele Fund at Hawai`i Community Foundation Pending Renewal 10,000 Individual The MacNaughton Group Pending Renewal 10,000 Corporation Hawaii Pacific Health Pending Renewal 5,000 Corporation Grace Pacific Corporation Pending Renewal 5,000 Corporation Royal Contracting Co.,Ltd. Pending Renewal 5,000 Corporation J.Crew Pending Renewal 5,000 Corporation Jean Rolles Pending Renewal 5,000 Individual David Carey Pending Renewal 5,000 Individual Time Warner Inc_ Pending Renewal 51000 Corporation JD Waturnull Pending Renewal 5,000 Individual Jhamandas Watumull Fund Pending Renewal 5,000 Foundation Lewis Williamson Pending Renewal 5,000 Individual Scott Bradley Pending Renewal 5,000 Individual Jeffrey.'rce,Board Member fending Renewal 5,000 Individual Hawaiian Airlines Pending Renewal 5,000 Corporation Colbert Matsumoto Pending Renewal 5,000 Individual Nordic PCL Construction Pending Renewal 5,000 Corporation Robert Fujiolm Pending Renewal 5,000 Individual Benjamin Godsey Pending Renewal 5,000 Individual Dr.Arthur&Bonnie Ennis Foundation Pending Renewal 5,000 Foundation Goodsill,Anderson,Quinn And Stifel LLP Pending Renewal 5,000 Corporation James Wei Pending Renewal 5,000 Individual Steven Loui Pending Renewal 5,000 Individual Jane&Jerry Mount Fending Renewal 5,000 Individual Ken&Shaunagh Robbins Pending Renewal 5,000 Individual Duncan 1facNaughton Pending Renewal 5,000 Individual Growney Family Fund at the Hawaii Community Foundation Pending Renewal. 5,000 Fotmdation Queen's Health Systems Pending Renewal 3,000 Corporation Michael J.Anderson\Memorial Fund Pending Renewal 3,000 Foundation Central Pacific Bank Pending Renewal 2,5001 Corporation Castle'Medical Center Pending Renewal 1,000 Corporation Julia Ing Pending Renewal 1,000 Individual Dacia Silvestro Pending Renewal 1,000 Individual XvImam Scott Pending Renewal 1,000 Individual Cox Fricke LLP Pending Renewal 1,000 Corporation Franklin Kudo Pending Renewal 1,000 Individual Miles Baidack Pending Renewal 1,000 Individual Stanford Carr Pending Renewal 1,000 Individual Trever Asam,Board Member Pending Renewal 1 350 Individual COMMITTED &PENDING TOTAL II Attachment 2: Program Performance Measures Measure and Explanation Projected Results Impact Measure 30 corps members beginning Number of 2015 corps members on Hawaii Island Fall semester of the 2014-2015 school year on Hawaii Island. Student Performance Measure 1 Mean Student Growth Mean Student Growth Percentile(MSGP) Percentile(MSGP)for Teach For America Hawaii teachers will Note:In 2012-2013, HIDO,Ebegan tracking the growth of individual be above state average in both students from year to year and correlating those results to teacher mathematics and reading and education programs across Hawaii. We propose to use this measure will rank within the top 3 of all as metric to demonstrate the effective of Teach For America Hawaii Hawaii teacher education as compared to our peers. program results. Student Performance Measure 2 80% Percent of Teach For Percent of Teach For America teachers on Hawaii Island America teachers on Hawai'i demonstrating above average classroom results. Island will demonstrate above average classroom results. Note:Teach For America collects classroom data based either on content standards or growth assessments. Wherever passible, these assessments are nation-wide assessments(ex:Gates-McGinitie Reading Assessment or the ACT)or statewide exams(ex.Hawaii State Assessment). In subjects where national and statewide do not exist, we align our assessments with other rigorous tools. We propose this metric to demonstrate the effectiveness of our teachers in all subjects, not just state tested subjects. Teacher Performance Measure Average Tripod Survey scores Average Tripod Survey scores above state average for Teach For America Hawaii Island teachers will be above Note:HIDOE administers the Tripod Survey to all public school the state average. students in order to gauge the classroom environment High scores indicate classrooms where students feel safe, cared for, and supported in their learning. We propose this metric because we believe that it helps measure the culture of the classroom and ensures that we are preparing teachers who faster a supportive environment for children to grow. 101 Volunteer Legal Services Hawaii Hawaii County Community Law Project Agency Name:Volunteer Legal Services Hawaii Program Name: Hawaii County Community Law Project Agency Director: Michelle Acosta Phone No.:(808) 522-0678 Contact Person: Michelle Acosta Phone No.:(808) 522-0678 Mailing Address: Address: 545 Queen Street Address: Suite 100 city,sT,zip Honolulu, HI 96813 Facility Address: Address: Same Address: City,ST,zip Email Address: michelle@vlsh.org Fax No.: (808) 524-2147 Accountant/CP Jeffrey E. J. Lee Phone No.: (808) 734-1921 Firm (if applicable): Choo Osada & Lee, CPAs, Inc. Mailing Address: Address: 1136 12th Avenue Address: Suite 240 city,sT,zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $38,768.89 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $35,000.00 $0.00 $5,000.00 2.Agency Mission Statement: Volunteer Legal Services Hawaii(Volunteer legal)is the only organization in' the State whose sole mission is to serve Hawaii's low-income community through volunteer attorneys. Our pool of pro bono attorneys serve Hawaii's low-income population through in-person advice and counsel sessions,phone consultations,self-help workshops,document preparation and full representation. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:Volunteer Legal Services Hawaii Program Name: Hawaii County Community Law Project 3. Program Description: The Community Law Project(CLP)is designed to provide unrepresented(pro se)litigants legal advice,brief services and,in some cases,full representation on a wide range of civil legal issues including,but not limited to,family law, landlord tenant law and collections. The CLP will conduct outreach to Hawaii County service providers to inform them of the project and ensure consumers are aware of the services available through Volunteer Legal. Hawaii county residents will be provided phone consultations by volunteer attorneys to initially address their legal issue and provide basic legal advice. If this service does not meet the client's needs,Volunteer Legal Staff will attempt to place the client with a pro bono attorney for further help and/or assist the client directly through Volunteer Legal Staff. Staff will coordinate,recruit volunteers and attend monthly workshops,alternating between Hilo and Kona,where Volunteer Legal staff and/or volunteer attorneys will prepare the necessary forms for pro se litigants filing for divorce. 4.Total Budget& Position Count: Total Program Budget: $74232,38 Total Program Position Count: 1 .05 Total Agency Budget: 1$850,000.00 Total Agency Position Count: 8 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Hawaii County Nonprofit Grants Program $38,768.89 State of Hawaii GIA FY 2015 $35,463.49 TOTAL: $74,232.38 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Volunteer Legal will also be seeking FY 2015 funding from the State of Hawaii GIA to expand our services to Maui County,Kauai County and increase services in Hawaii County as outlined in this application, Our staff is working closely with the Judiciary and Hawaii State Bar Association(HSBA)to assess the legal needs on the neighbor islands so that we can design and implement a system to deliver legal services effectively and efficiently. We have opened a dialogue with the Legal Aid Society of Hawaii offices in Hawaii County to determine how we can best complement their services and to best address the unmet legal needs due to their funding restrictions and/or limited resources. We are actively working to implement a cross-referral mechanism between our organizations. Volunteer Legal will be approaching the Court's Self- Help Centers to determine how we can best assist the clients who leave the center still in need of legal services. We are hopeful these discussions and collaborations will lead to a more efficient system of legal services in Hawaii County and potentially allow the partners to apply for any joint funding opportunities that may become available,locally or nationally. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:Volunteer Legal Services Hawaii Program Name: Hawaii County Community Law Project 7. Program Objectives Using County Nonprofit Grant Program Funds: Volunteer Legal will continue to take calls directly from Hawaii County applicants for services and arrange phone consultations for those in need of immediate legal advice. We will also conduct education and outreach about our program in Hawaii County to increase the calls for services,including the development of new outreach materials that are specific to Hawaii County. We also plan to use the funds to integrate our services with the Hilo and Kona courthouse Self-Help Centers and the services already being provided by the Legal Aid Society of Hawaii. Our objective is to increase services on the Big Island by complementing those services already being provided by the self- hel'p centers and Legal Aid, 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results ft.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Number of intakes completed (eligible applicants) 450 Number of services provided (e.g. advice, brief services, full rep) 350 Number of workshops held in Hawaii County 12 Number of attorney volunteer hours 400 Value of attorney volunteer hours (at the market rate of$240/hour) $96,000.00 Client Satisfaction Surveys Attach additional pages as necessary. 9. TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual` Total Budget Grant Req Salary and Wages *For FYI 3-14: Program funds spent as of 1/24/2014 $2,672. $66,287.78 $33,289. Professional Fees $0.00 $0.00 Operations $3,249.60 $1,612.0 Supplies $120.00 $60.00 Equipment $0.00 $0.00 Other:Postage & Delivery $20.00 $10.00 Other:Travel between Oahu and Hawaii Count 12 roundtrip $3,600.00 $2,880.0 Other:Informational Materials and Brochures $200.00 $200.00 Other:Volunteer Development $75.00 $37.50 Other:Monthly Workshop Expenses $680.00 $680.00 TOTAL $2,672. $74,232.38 $38,768. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 t Agency Name:Volunteer Legal Services Hawaii Program Name: Hawaii County Community Law Project 1o, ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lincoln S.T. Ashida POSITION: Officer, Board of Directors for Volunteer Legal Services Hawaii May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance [� The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: The members of the Board and Volunteer Legal Staff will be instructed in writing to refrain from discussing the details of this application with Mr. Ashida or others in his office until the Council makes its cirantmaking decision. ❑ If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:Volunteer Legal Services Hawaii Program Name: Hawaii County Community Law Project ii.. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. i (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to htt vendors.ehawaii. ov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end re ort using the temp late rovided will impact the evaluation of our program's or agency's uture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant-participation for a minimum of one ear or until a written rel2ort is submitted to and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nongrofit-grant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation of our agency's future funding reguest and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. 41e'.ff1x11e Si ature of Authorized Pers (specify title) Date EXHIBITA NONPRONT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency,Name:Volunteer Legal Services Hawaii Program Name: Hawaii County Community Law Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of intakes completed (eligible applicants) 450 Number of services provided (e.g. advice, brief services, full rep) 350 Number of workshops held in Hawaii County 12 Number of attorney volunteer hours 400 Value of attorney volunteer hours (at the market rate of$240/hour) $96,000.00 Client Satisfaction Surveys TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages $33,289.31 Professional Fees $0.00 Operations $1,612.08 Supplies $60.00 Equipment $0.00 other: Postage & Delivery $10.00 Other: Travel between Oahu and Hawaii County 12 roundtri $2,880.00 Other: Informational Materials and Brochures $200.00 Other: Volunteer Development $37.50 Other: Monthly Workshop Expenses $680.00 TOTAL $38,768.89 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 103 West Hawaii Community Health Center Dental Van for Adult Services Agency Name:West Hawaii Community Health Center Program Name:Dental Van for Adult Services Agency Director: Richard Taaffe Phone No.:326-3878 Contact Person: Lauren Avery Phone No.:331-6472 Mailing Address: Address: 75-5751 Kuakini Hwy. Address: City,ST,zip Kailua-Kona, HI 96740 Facility Address: Address: 74-5599 Alapa St. Address: city,sT,zip Kailua-Kona, HI 96740 Email Address: Fax No.: (808) 327-1939 Accountant/CP Phone No.:(808) 524-2255 Firm (if applicable): Nishihana & Kishida, CPAs, INC. Mailing Address: Address: American Savings Bank Address: 1001 Bishop St. City,ST,zip Honolulu, H 19813-3696 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $10,000.00 $10,000.00 $10,000.00 2.Agency Mission Statement: The mission of the West Hawaii Community Health Center WHCHC is to make uali�ty- comprehensive s integrated health services _.,.,. accessibl-e_to_all_reaardless of income. These services will he culturally EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 COPY Agency Name:West Hawaii Community Health Center Program Name: Dental Van for Adult Services 3. Program Description: The WHCHC Dental Van offers emeMengy dental care to the uninsured, low-income and Medicaid adult (21 yrs & older) patients. In addition we are seeing our WHCHC patients, age 18-20 that aged out Qf our_Keiki Clinic for continuing care. We are ]oQking at expanding serynces to our WHCHC preqnant42afients and those with Uncontmiled _diabetes for basic care_ In 2013 we served .663 patents. 4.Total Budget&Position Count: Total Program Budget: 1$171,700.00 Total Program Position Count: 1 Total Agency Budget: $9,600,000.00 Total Agency Position Count: 93 S. Program Funding Sources(identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate County of Hawaii -grant $20,000.00 Billable Revenue $100,000.00 DOH state Purchase of Service Agreement $9,000.00 Soliciting change in Adult Support at State level for Medicaid $20,700.00 Possible grant support- ie. HPCA support as in 2012 grant $22,000.00 TOTAL: 1 $171,700.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: WHCHC is working with the State Medicaid program to assist in.,._,__, exparndii es-to the adult population, inclLa.ri,i,n, pregnant women_ qs-; stena state to -ant On support of adult health- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name:West Hawaii Community Health Center Program Name:Dental Van for Adult Services 7. Program Objectives Using County Nonprofit Grant Program Funds: The main obje iye for use of the County grant proceeds is funding for the salary of our dentist and supDort staff to keep the doors open-two sly oe�ek _... - 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.,Number of clients served workshops or events held,volunteerhours,etc.Describe,be specific.) 8 clients served per day (open 2 days/week) 9 290 toothbrushes &toothpaste given out to patients- 500 Educational materials 300 Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages $133,58 $133,000.0 $20,000. Professional Fees Operations $16,877 $17,000.00 supplies $11,556 $12,000.00 Equipment $4,617. $5,000.00 Other:Travel, training $510-00 $500.00 Other:Facility expense $4,212. $4,200.00 Other: Other: Other: TOTAL $171,3 $171,700.0 $20,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:West Hawaii Community Health Center Program Name: Dental Van for Adult Services io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by on individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and ail mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:WeSt Hawaii Community Health Center Program Name:Dental Van for Adult Services 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'l County Cade, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 42F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a Brant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time! complete, and accurate ear-end report, usin the template provided, wi!! impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period must be refunded to Count and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted bv,the council. 1 (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. -4 Signature of 4uthorid Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:West Hawaii Community Health Center Program Name:Dental Van for Adult Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 8 clients served per day (open 2 days/week) 9 290 toothbrushes &toothpaste given out to patients - 500 Educational materials 300 TABLE IL• PROGRAM EXPENDITURES FY 1415 Council Grant Request Award Salary and wages $20,000.00 Professional Fees Operations Supplies Equipment Other: Travel, training other: Facility expense Other: Other: Other: TOTAL $20,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 104 West Hawaii County Band Friends Music and Equipment Fund Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund Agency Director: Larry Boucher Phone No.: Contact Person: Larry Boucher Phone No.: Mailing Address: Address: WHCB Friends Address: P.O. Box 5058 city,sT,Zip Kailua-Kona, HI 96745 Facility Address: Address: Address: City,ST,Zip Email Address: maestrolisa @yahoo.com Fax No.: 929-8004 Accountant/CP Meleana Smith Phone No.:929-8000 Firm (if applicable): Kau Business Services Mailing Address: Address: P.O. BOX Address: city,sT,Zip Ocean View, H 1 96737 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $8,100.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $8,100.00 2. Agency Mission Statement: The primary and specific purpose for the West Hawaii County Band Fr8ends shall be to support morally and financially, promote, assmst and enchance the County Band in V�Lest Hawa'i. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2414-2015 Page 1 of 7 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 3. Program Description: The program will help to purchase sheet music sets with instrument arts and conductor score to assist the Band in its compliance of Parks and Recreation goal of sight-reading 20 new compositions a year. The -purchase f unifiam pants and percussion instruments will create more j)rofessional appearance and parade sound. 4. Total Budget& Position Count: Total Program Budget: $8,100.00 Total Program Position Count: 0 Total Agency Budget: $23,000.00 Total Agency Position Count: 8 S. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Private individuals $100.00 TOTAL: $100.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our organ to apply for morespecific grants to promote outre_achh and _educational performances in the West yawaii community EXHIBIT A NONPROFIT GRANT APPLICATION FY 2414-2015 Page 2 of 7 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 7. Program Objectives Using County Nonprofit Grant Program Funds: The program will provide the ability for compliance with the partment's qoal Qf 20 new compositions a yea[-and will gave the-Rand a more professional aplDearance and sound with addiflonal m2rch 0 no- 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results ft.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Band will be able to sight read at least 20 new compositions Diverse audiences. Compliance with County goals Improve sound and encourage additional percussion volunteers Have 6 drummers available Larger sound at parades Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees $250.00 $500.00 $500.00 Operations Supplies $400.00 $400.00 $400.00 Equipment Other: Insurance $675-00 $675.00 $675.00 Other:Sheet Music $4,000A $2,000.00 $2,000.0 Other: Folders and Lights $2,775A $0.00 $0.00 Other:Marching percussion instruments $2,525.00 $2,525.0 Other: Uniform pants $25000.00 $2,000.0 TOTAL $8,100.q $8,100.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name: west Hawaii County Band Friends Program Name: Music and Equipment Fund so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature of uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I we understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of our program's or a enc 's future Lun din requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and acce ted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htt www,hawaiicounty.gov/fn-no n prof it- rant-forms on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will imp-act the evaluation of our a enc 's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of AWhorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Band will be able to sight read at least 20 new compositions Diverse audied Compliance vd improve sound and encourage additional percussion volunteers Have 6 drum Larger sound il TABLE II: PROGRAM EXPENDITURES FY 14-15 Council Grant Request Award Salary and Wages Professional Fees $500.00 Operations Supplies $400.00 Equipment Other: Insurance $675.00 Other: Sheet Music $2,000.00 Other: Folders and Lights $0.00 Other: Marching percussion instruments $2,525.00 Other: Uniform pants $2,000.00 TOTAL $8,100.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 105 West Hawaii County Band Friends Volunteer Musicians Fund Agency Name: West Hawaii County Band Friends Program Name:Volunteer Musicians Fund Agency Director. Larry Boucher Phone No.: Contact Person: Larry Boucher Phone No.: Mailing Address: Address: WHCB Friends Address: P.O. Box 5058 City,ST,zip Kailua-Kona, HI 96745 Facility Address: Address: Address: City,ST,Zip Email Address: maestrolisa @yahoo.com Fax No.: 929-8004 Accountant/CP Meleana Smith Phone No..929-8000 Firm (if applicable): Kau Business Services Mailing Address: Address: P.O. Box Address: City,ST,Zip Ocean View, HI 96737 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $13,250.00 $15,000.00 2. Agency Mission Statement: The primary and specific purpose for the West Hawaii County Band Friends shall be to support morally and financially, promote, assist and enchance the County Band in West Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name: West Hawaii County Band Friends Program Name:Volunteer Musicians Fund 3. Program Description: The Volunteer Musicians Fund helps the Volunteer musicians by _providing them with an honorarium to defray the cost of gas to travel to a rehearsal or performance._ These musicians donate their time and _ talent to augmen-t the_ ten member County-aid group and sometimes -ask fszr financial assistance for travel. 4. Total Budget & Position Count: Total Program Budget: $15,000.00 Total Program Position Count: 17 Total Agency Budget: $23,000.00 Total Agency Position Count: 20 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Hawaii international Billfish Tournament $700.00 Ironman Corporation $300.00 TOTAL: $1,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our organization glans to apply for more specific grants to promote outreach and educational performances in the West Hawaii comm ni�- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: West Hawaii County Band Friends Program Name: Volunteer Musicians Fund 7. Program Objectives Using County Nonprofit Grant Program Funds: .The proLram will provide the ten member County paid musicians an .=Qrtunifv for_more-complete coverage of music parts and a b2gger _ more_nr )fessional sound. The Volunteer Musicians Fund will encourage more musicians to volunteer when their travel needs are met 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results ft e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) To perform every month at WHCB monthly concert series Perform 12 concerts for series To increase number of parades per year Perform 3 additional parades . To increase total number of musicians available to volunteer Have 20 musicians available Attach additional pages as necessary. 9.TABLE ll: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: Honorarium $15,00 $15,000.00 $15,000. Other: Other: Other: Other: TOTAL 1$15,000 $15,000.001$15,000.( *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 Agency Name:West Hawaii County Band Friends Program Name:Volunteer Musicians Fund lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: FO If no conflicts exist, check here. Signature of uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name: West Hawaii County Band Friends Program Name:Volunteer Musicians Fund si. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii;.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii. I (we) understand and will comply with the requirement to submit a year-end report to the County,Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report, usina the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 Agency Name: West Hawaii County Band Friends Program Name: Volunteer Musicians Fund 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result To perform every month at WHCB monthly concert series Perform 12 cqj To increase number of parades per year Perform 3 adcfi To increase total number of musicians available to volunteer Have 20 mus' TABLE II: PROGRAM EXPENDITURES FY 1415 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Honorarium $15,000.00 Other: Other: Other: Other: TOTAL $15,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 106 YWCA of Hawaii Island Sexual Assault Support Services Agency Name:YWCA of Hawaii Island Program Name:Sexual Assault Support Services Agency Director: Kathleen McGilvray Phone No.:(808) 961-3877 Contact Person: Lorraine Davis Phone No.:(808) 961-3877 Mailing Address: Address: 1382 Kilauea Ave. Address: City,ST,ziP Hilo, Hl 96720 Facility Address: Address: 1382 Kilauea Ave. Address: City,ST,zip Hilo, HI 96720 Email Address: Idavis @ywcahawaiiisland.org Fax No.: (808) 961-9140 Accountant/CP Phone No.:(808) 935-5404 Firm (if applicable): Taketa, Iwata & Hara, Inc. Mailing Address: Address: 101 Aupuni Street, Ste. 139 Address: city,sT,zip Hilo, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $60,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $20,000.00 $36,250.00 $60,000.00 2.Agency Mission Statement: YWCA of Hawaii Island is dedicated to eliminating racism, empowering_ women and promoting peace, ustice, freedom and dignity for all. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:YWCA of Hawaii Island Program Name: Sexual Assault Support Services B. Program Description: The program's mission is to provide services for victims of sexual assault. Services include the only 2417 sexual assault crisis line on the island which includes crisis response and stabilization for the victim' Other services include: face-to-face services, support during forensic Interviews and evidence collections, therapy._ vocacv and com_munitV 4.Total Budget& Position Count: Total Program Budget: $576,898.00 Total Program Position Count: 11 Total Agency Budget: $3,682,591.00 Total Agency Position Count: 56 5. Program Funding Sources (identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Attorney General, through Sex Abuse Treatment Center, (master contract) $285,510.00 VOCA, through the Office of the Prosecuting Attorney $42,000.00 Unrestricted (Fundraising, donations) $12,000.00 West Hawaii Fund $2,500.00 Hawaii County $60,000.00 HPD pass through for SANE Program (VAWA, John Burn) $161,068.00 TOTAL: $563,078.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Walk a Mole fund raiser slated for Oct_ 2014 which benefits SASS. The PDa plies for funds through granters, foundatinns_ and rornorations. T Lb- hey also reduces exppnditures by m resnarps collabnrat've P-ffortq and co-locating other services and4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 3. Program Description The Sexual Assault Support Services program's mission is to provide services for the healing and prevention of sexual-violence. Sexual violence is a hard topicto talk about and it happens everywhere, even on our island. Our victims have been as young as 6 months old and as old as 95 years old. Sexual violence is an equal opportunity crime that crosses the boundaries of age, race, religion and gender equally. Sexual violence is pervasive. Sexual violence is crippling to the victim. Victims of sexual violence want to keep their experience a secret. Public outreach and talking to victims and potential victims is our best way to increase disclosure, help victims heal and increase chances for successful prosecution of the offender. To let you know how pervasive this crime is, imagine yourself seated in a crowded movie theater here on the island. Based on national and local statistics, at least 2 people in every row has either been or will be a victim of sexual violence. If you attend a high school graduation in Hilo, Kona, Honolulu or somewhere on the mainland, chances are J. in 4 girls and 2 in 6 boys will have been a victim of sexual violence already. The impact of sexual violence to a person manifests itself in many different ways and during various times in a victim's life. Studies show that sexual violence left untreated will cost more to the public then the treatment of chronic diseases like diabetes or life threatening diseases like cancer,with respect to lost wages, mental and emotional issues, and alcohol and substance abuse. In the economic depression that the county of Hawaii has been experiencing, with an increase in financial stress and unemployment, alcohol and substance abuse increases as does sexual and domestic violence. The SASS program works to reduce the incidences of sexual assault and disability to those who have been victimized. Services includes the only 24/7 sexual assault crisis line on the island which includes crisis response and stabilization and opportunities to enter into the SASS program for a variety of services. The advocates who answer the crisis line also accompany a victim to the hospital for a forensic exam and, in the case of a-m inor, will meet the family at the Children's Justice Center to stay with the family during a forensic interview. The SASS program also offers clinical services which includes counseling for the victim and immediate family. The clinician will also accompany the victim and family to court to help prevent re-traumatizing the victim and family during court proceedings. The SASS program provides professional training to adults on how to look for signs of sexual assault,what to do when a child discloses and the effect of sexual violence on a person. All services are provided at no charge to the victim or family. The YWCA is in our fourth decade of helping sexual assault survivor, who are men, women, girls and boys. This year the funding requested from the County of Hawaii will help to support the core services provided by the program, allow for additional training for advocates in topics that are related to sex assault that will enable them to provide more comprehensive services to our Island's victims, and to provide some outreach to our community (adults and children alike) regarding good touch/bad touch, healthy relationships for'tweens and teens and how to recognize signs of sexual assault for parents,teachers and community members. Agency Name:YWCA of Hawaii Island Program Name:Sexual Assault Support Services 7. Program Objectives Using County Nonprofit Grant Program Funds: Continue to operate the 2417 crisis hot line island wide. Provide face to face support for victims undergsza a forensic interview or forensic examination, support in ohtainina other se vices, and providing .psychofhPranv to victims and their families_ S.TABLE l: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results ft.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) 1. Crisis phone calls are answered 2417, 365 days by trained staff. 100% of the calls answered 2. Victims receive appropriate support and care face-to-face. 150 victims will receive service 3. Victims will receive psychotherapy from MANFT therapists. 100 victims will receive service Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $7,241.( $314,347.0( $17,023. Professional Fees $5,125. $63,435.00 $2,734.0 Operations $1,166. $9,326.00 $4,094.0 Supplies $8,780. $30,528.00 $8,432.0 Equipment Other:Occupancy $19,889 $56,667.00 $4,069.0 other:Mileage, Per Diem, Travel Costs $10,799 $24,997.00 $16,648. other:Training $1,000. $2,000.00 $1,000.0 Other: Indirect $6,000. $75,598.00 $6,000.0 Other: TOTAL $60,00 $576,898.0 $60,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2415 Page 3 of 7 Attachment C. Program Expenditures: (Continued) 9.TABLE II: PROGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual * Total Budget Grant Request Salary and Wages 7,241.00 314,347.00 17,023.00 Professional Fees 5,125.00 63,435.00 2,734.00 Operations 1,166.00 9,326.00 4,094.00 Supplies 8,780.00 30,528.00 8,432.00 Equipment Other: Occupancy 19,889.00 56,667.00 4,069.00 Other: Mileage, Per Diem,Travel Costs 10,799.00 24,997.00 16,648.00 Other:Training 1,000.00 2,000.00 1,000.00 Other: Indirect 6,000.00 75,598.00 6,000.00 TOTAL 60,000.00 576,898.00 60,000.00 Agency Name:YWCA of Hawaii Island Program Name: Sexual Assault Support Services so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, re ordless ot whether a conflict exists. NAME: Karen Teshima POSITION: Board Member May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council © The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Abstains from any voting required by the Board of Directors when County of Hawaii is involved. ❑ If no conflicts exist, check here. Aji Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:YWCA of Hawaii Island Program Name:Sexual Assault Support Services is. Certification of Understanding I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135-2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that 1 (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http:/Zvendors.ehawaii.gov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i 1 we understand and will comply with the requirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate ear-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant lgeriod must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted bv,the council_. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawailcounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused byJune 30, 2015 must be returned to the County of Hawaii with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:YWCA of Hawaii Island Program Name:Sexual Assault Support Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1. Crisis phone calls are answered 2417, 365 days by trained staff. 100% of the ca 2. Victims receive appropriate support and care face-to-face. 150 victims will 3. Victims will receive psychotherapy from MAIMFT therapists. 100 victims will TABLE 11: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $17,023.00 Professional Fees $2,734.00 Operations $4,094.00 Supplies $8,432.00 Equipment Other: Occupancy $4,069.00 Other: Mileage, Per Diem, Travel Costs $16,648.00 other: Training $1,000.00 other: Indirect $6,000.00 Other: TOTAL. $60,000.00 Additional Council directives reeardiniz award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 107 YWCA of Hawaii Island YWCA Development Preschool Agency Name:YWCA Hawaii Island Program Name:YWCA Developmental Preschool Agency Director: Kathleen McGilvray Phone No.:935-6067 Contact Person: Lissa Van Kralingen Phone No.:935-7141 Mailing Address: Address: YWCA Hawaii Island Address: 145 Ululani Street City,ST,zip Hilo, Hawaii 96720 Facility Address: Address: YWCA Hawaii Island Address: 145 Ululani Street City,ST,z;p Hilo, Hawaii 96720 Email Address: Ivankralingen @ywcahawailisland.org Fax No.: 935-5150 Accountant/CP Phone No.:935-5404 Firm (if applicable): Taketa, Iwata, Hara & Associates LLC Mailing Address: Address: 101 Aupuni Suite 139 Address: City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $16,500.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $13,750.00 $10,000.00 2.Agency Mission Statement: The YWCA is dedicated to eliminating racism, empowering women and prom_oflnQ peace, 'ustice, freedom and dignity for all. _. EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:YWCA Hawaii Island Program Name:YWCA Developmental Preschool 3. Program Description: The YWCA Developmental Preschool focuses on the social/emotional physical, cognitive, and language development of our children. Our program is licensed by the State of Hawaii Department of Human Services QHS)and accredited by the National Association for the Education of Young Children (NAYEC). We provide children with 4.Total Budget&Position Count: Total Program Budget: $837,164.00 Total Program Position Count: 16 Total Agency Budget: Total Agency Position Count: 5. Program Funding Sources(identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Program service fees $716,860.00 HIM Castle Foundation, Hawaii County non-profit grant $45,000.00 Activity fees $11,900.00 USDA Child and Adult Care Food Program reimbursement $66,404.00 TOTAL: $840,164.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We oantinue to actively apply for r ants that will support our curricul „and prnaram that we provide for children. we hold an annual Family Fun Fair to heir) meet ' s rtas es in nur revenue; and we. assist EXHIBITA NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of 7 Agency Name: YWCA Hawaii Island Program Name:YWCA Developmental Preschool 7. Program Objectives Using County Nonprofit Grant Program Funds: We are requesting County Nonprofit Grant Funds to be used for tuition assistance assistance. The will -in m fam'lies w'th multiple children enrolled, and children who rnav be 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Children at risk of losing their tuition assistance will be able to 50% of children at risk for loss remain enrolled while parent seek other assistance opportunities of tuition assistance will remain Children will be able to begin attending school while family waits on 50% of all applicants waiting assistance determination. on subsidy determination will be able to attend school Families with multiple children of preschool age will be able to All enrolled siblings will receive receive tuition assistance tuition assistance if needed. Attach additional pages as necessary. 9.TABLE Il: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $504,14 $503,375.0 Professional Fees $17,459 $17,542.00 Operations $22,356 $30,834.00 Supplies $104,17 $105,948.0 Equipment $1,774. $0.00 Other; indirect costlpostagelother expenses $165,19 $161,947.0 $1,500.0 other;Travel/training/registration fees/printing/advertising $9,694. $17,520.00 Other:Tuition assistance -$22,06 -$22,500.00 $15,000. Other: Other: TOTAL $802,73 $814,666.0 $16,500. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 20142015 Page 3 of 7 YWCA of Hawaii Island YWCA Developmental Preschool County of Hawaii Nonprofit Grants Program (FY 2014-15) Application Proposal Attachment C: 9, Program Expenditures: (Continued) Ln � a } *' o oo oo oo o 00 0 LL 1-- 0 0 0 6 0 O 0 L 0 0 0 r-I LO to °o 00 00 00 Co 00, °o °o 0 Lf] Lrj N d' 00 0 I� 0 O O c�1 Ln 00 a) 0) tl1 Ln CLD m 0 rn-] Om 0 to c�-I N L4a Ill 00 F, V)- IA V). V)- IVl- 1/� V} C7 0 0 0 O q O 0 0 w al w Ill r- l' 06 m ,Zt Ill In r` rn rn �o m r-I d' m r 1 r-I lfl C] o rn-� N o W °1 N a 3>n ri N 00 U La 0 U -V� in- t/)- V)• -V} try N }+ x :a °' Arr L � W L O X LL! to E bA LLI a o uo '� 0 x L N o. aj a v -� tn as U Li U — o N m aj `�° � a� a ai ai Q Q cn a o crr) w o o o o I- Agency Name:YWCA of Hawaii Island Program Name:YWCA Developmental Preschool so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Teshima POSITION: Board Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council © The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Abstains from any voting required by the Board of Directors when County of Hawaii is involved. ❑ If no conflicts exist, check here. Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 20142015 Page 4 of 7 Agency Name:YWCA Hawaii Island Program Name;YWCA Developmental Preschool 11. Certification of Understanding I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135--2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template,provided, will impact the evaluation of our programs or a enc 's Luture funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the_grant_period (must be refunded to County).and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. 1 (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.goy/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of aura enc 's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. vtc/ 0 L,3 D Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 6 of 7 Agency Name:YWCA Hawaii Island Program Name:YWCA Developmental Preschool 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Children at risk of losing their tuition assistance will be able to 50% of childred remain enrolled while parent seek other assistance opportunities of tuition assiFa Children will be able to begin attending school while family waits on 50% of all apVA assistance determination. on subsidy dEfi be able to aftEd Families with multiple children of preschool age will be able to All enrolled si receive tuition assistance tuition assistad TABLE 1111: FY 14-15 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: indirect cost/postage/other expenses $1,500.00 other: Travel/training/registration fees/printing/advertising other: Tuition assistance $15,000.00 Other: Other: TOTAL $16,500.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7 108 YWCA of Hawaii Island YWCA Healthy Start - Positive Moms - Happy Babies (PN4HB) Agency Name:YWCA of Hawaii Island Program Name:YWCA Healthy Start- Positive Morns-Happy Babies (PMHB) Agency Director: Kathleen McGilvray, CEO Phone No.:(808) 930-5702 Contact Person: Andrew Kahili, CREO and PD Phone No.:(808) 930-5727 Mailing Address: Address: 1382 Kilauea Avenue Address: 145 Ululani Street City,ST,zip Hilo, Hawaii 96720 Facility Address: Address: 1382 Kilauea Avenue Address: City,ST,zip Hilo, Hawaii 96720 Email Address: akahili @ywcahawaiiisland.org Fax No.: (808) 961-9140 Accountant/CP Jeffrey S. Girdner, CPA Phone No..(808) 935-5404 Firm (if applicable): Taketa, Iwata, Hara & Associates, LLC Mailing Address: Address: 101 Aupuni Street, Suite 139 Address: city,ST,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENTAND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 12-13 FY 13-14 $75,000.00 $42,500.00 $30,000.00 2.Agency Mission Statement: Our mission the YWCA of Hawaii Island is dedicated to eliminating racism, empowering women, and promoting apace, -fie, freedom, and dianwtvfa all. Thp. YWCA of Hawain Island, was first ofganizPA r r ' EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 1 of 7 Agency Name:YWCA of Hawaii island Program Name:YWCA Healthy Start- Positive Moms-Happy Babies (PMHB) 3. Program Description: The Positive Moms-Happy Babies is an 8-week course that focuses on — preventing stress and depression through home visiting. The course teaches moms ways to better manage their moods. We do this by -having them learn to modify thinking and their behavior. The course is Jntended for use w0th hiqh-rlsk preqnaiii women and those with infants up to 12 months old. (Spe Attachment A - 3- Proqram Description.) 4.Total Budget& Position Count: Total Program Budget: $40,000.00 Total Program Position count: 14 Total Agency Budget: $100,000.00 Total Agency Position Count: 112 S. Program Funding Sources(identify all sources of funding applied to this program): FY14-15 Revenue Source Estimate Hawaii State Department of Health, Maternal Child Health Branch $90,000.00 O'Neill Foundation - Positive Moms Initiative Grant $10,000.00 TOTAL: $100,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We anticipate continued collaboration and Hawain State Department of Health with funds from the fedpral r........dation's Pnsitive Moms Initiative grant EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 2 of YWCA of Hawaii Island YWCA Healthy Start - Positive Moms-Happy Babies (PMHB) County of Hawaii Nonprofit Grants Program (FY 2014-15) Application Proposal Attachment A: 3. Program Description (Continued) Agency Name: YWCA of Hawaii island Program Name: YWCA Healthy Start- Positive Moms-Happy Babies (PMHB) Attachment A. Program_Description: (Continued) The Positive Moms-Happy Babies group is an 8-week course that focuses on preventing stress and depression through home visiting. The course teaches moms ways to better manage their moods. We do this by having them learn to modify thinking and their behavior. The course is intended for use with high-risk pregnant women and those with infants up to 12 months old. Prevalence of Depression Major depression is the most common mental health disorder in the United States and young women of childbearing age are at the highest risk. Overall, the lifetime prevalence rate for major depression is 17% and the female to male ratio is estimated to be approximately 2:1 (Kessler, et al., 1994). Approximately 10 to 15% of women develop postpartum depression (PPD). Research has shown that poor, young minority women are at the highest risk for developing PPD. Studies suggest that PPD remains undetected and undertreated during pregnancy and at birth, further demonstrating the importance of attending and intervening during the pregnancy period and the postpartum period. Consequences of Postpartum Depression It is well documented that depression during the postnatal period is a serious mental health problem for women, and its consequences have negative implications for infants' development and the mother-infant relationship (e.g., Field, 1997). In addition, postpartum depression is associated with birth complications and more difficult infant temperament(Hopkins, Campbell, & Marcus 1987). Compared to children of non-depressed mothers, children of depressed mothers have more difficulty with emotional regulation, and show delays in cognitive and language development. Purpose of this Course and Materials Given the negative consequences associated with postpartum depression, this course is designed to reduce the number of new cases of major depressive episode in pregnant women and postpartum women, who are at high risk for PPD. The primary aim of this course is to promote healthy mood management by teaching participants how their thoughts, behaviors and support systems influence their mood. The overall goal of the Positive Moms and Happy Babies project is to prevent depression in mothers, with the long-term goal of enhancing mother and child mental and physical health and strengthening their relationship. Organization of Course The course includes an Instructor's manual with class-by-class instructions on ways to convey the information presented to the participants, a Participant manual, includes outlines for each class, with several exercises in each class, from which the instructor can select for each class session, and Home Visitor Reinforcement, which includes keys points for home visitors to reinforce from each class. All material is copyrighted and purchased though Johns Hopkins University. Childcare (Professional services) is provided for each class to allow moms the ability to fully participant in each class session. Project Budget The total annual budget is $140,000. We are seeking $40,000 in County grant funding for this project. We expect to enroll 100 women throughout fiscal year 2014-15. NONPROFIT GRANT APLLICATION FY 2013-2014 Page 1 of 1 Agency Name:YWCA of Hawaii Island Program Name:YWCA Healthy Start- Positive Moms-Happy Babies (PMHB) 7. Program Objectives Using County Nonprofit Grant Program Funds: See Attachment B. Program Ob`ectives. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE~ MEASURES Applicant Projected Results (i.e.:Numberof clients served workshops or events held,volunteer hours,etc.Describe,be specific.) Enroll 100 women into the PMHB project 90% Provide ten 8-week PMHB course sessions 90% Provide 200 hours of PMHB course class sessions 90% Provide 240 hours of childcare for mothers attending PMHB course 90% Provide 1,000 hours of Home Visitor reinforcement in the home 90% Conduct pre/post screening with all enrolled PMHB participants 100% Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 14-15 FY 14-15 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $39,090 $42,540.00 Professional Fees $34,500 $32,730.00 $27,270. Operations $2,475. $2,250.00 $2,250.0 Supplies $7,935. $6,480.00 $6,480.0 Equipment Other: Indirect Cost $16,000 $16,000.00 $4,000.0 Other: Other: other:please see Attachment C. Program Expenditures Other:The attachment is"Table I1: Program Expenditures" TOTAL $100,0q$100,000.0 $40,000. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of 7 YWCA of Hawaii Island YWCA Healthy Start - Positive Moms-Happy Babies (PMHB) County of Hawaii Nonprofit Grants Program (FY 2014-15) Application Proposal Attachment B.: 7. Program Objectives Using County Grant Program Funds: (Continued) Agency Name: YWCA of Hawaii Island Program Name: YWCA Healthy Start- Positive Moms-Happy Babies (PMHB) Attachment B. Program Objectives: (Continued) The Positive Moms-Happy Babies (PMHB) curriculum was selected because: a) it has been successful in reducing distress and depression in at-risk pregnant and postpartum women: b) it is a short term intervention that can be integrated with home visiting services; and c)the curriculum can be implemented by bachelors and masters trained facilitators. PMHB is a cognitive-behavioral group intervention developed for low-income and minority pregnant and postpartum populations faced with multiple stressors. The curriculum integrates proven cognitive-behavioral methods for managing stress and reducing psychosocial symptoms. Women in the course receive six 2.5-hour intervention sessions delivered weekly and two 2.5-hour booster session at 3-month intervals in a group format. Each session contains didactic instruction on course content, as well as activities and group discussion. The 8-week course is divided into three 2-session modules: pleasant activities, thoughts, and contacts with others. These modules map onto core cognitive-behavioral approaches for the treatment and prevention of depression and stress reduction. Between each session, home visiting staff provides a one-hour 1-on-1 reinforcement session on the key content covered during the last session. The PMHB curriculum has been in use for several years on the mainland by the Johns Hopkins University and in Hawaii the past 2 years. The course is intended for use with populations of at- risk pregnant women with infants up to 12 months postpartum. The primary aim is to promote healthy mood management by teaching participants how their thoughts and behaviors influence their mood. We attempt to increase the frequency of thoughts and behaviors that lead to healthy mood states, including thoughts and behaviors related to assertive communication. All concepts are applied to both mental (subjective, inner) reality, and physical (objective, outer) reality. The overall goal of the PMHB course is to prevent depression in mothers, with the long- term goal of enhancing mother and child mental and physical health and strengthening their relationship. This curriculum combines the cognitive-behavioral approach and the attach mentldeveIopment model to provide coping strategies in the prevention of antenatal and postpartum depression. This is the key to "reality management", a concept based on how a person's management of their inner and outer reality shapes their experience of world. Throughout the curriculum, moms are encouraged to apply these concepts not only to themselves, but also with their children. Finally, the course is preventive in nature, and therefore consists largely of psycho-education, that is, education about psychological processes. Facilitators are there to provide class members with information about mood and depression and ways to decrease the likelihood of becoming depressed in the future. NONPROFIT GRANT APLLICATION FY 2013-2014 Page 1 of 1 YWCA of Hawaii Island YWCA Healthy Start - Positive Moms-Happy Babies (PMHB) County of Hawaii Nonprofit Grants Program (FY 2014-15) Application Proposal Attachment C: 9. Program Expenditures: (Continued) Attachment C. Program Expenditures: (Continued) 9.TABLE II: PRGRAM EXPENDITURES FY 13-14 FY 14-15 FY 14-15 Actual * Total Budget Grant Request Salary and Wages $ 39,090.00 $ 42,540.00 $ 0.00 Professional Fees $ 34,500.00 $ 32,730.00 $ 27,270.00 Operations $ 2,475.00 $ 2,250.00 $ 2,250.00 Supplies $ 7,935.00 $ 6,480.00 $ 6,480.00 Equipment Other: Indirect Cost $ 16,000.00 $ 16,000.00 $ 4,000.00 Other: Other: Other: TOTAL $ 100,000 $ 100,000.00 $ 40,000.00 Agency Name:YWCA of Hawaii Island Program Name:YWCA Healthy Start - Positive Moms - Happy Babies (PMHB) so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Teshima POSITION: Board Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Abstains from any voting required by the Board of Directors when County of Hawaii is involved. _..._. ❑ If no conflicts exist, check here. f� /5ory Signa ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 4 of 7 Agency Name:YWCA of Hawaii Island Program Name:YWCA Healthy Start- Positive Moms-Happy Babies (PMHB) ii. Certification of Understanding 1 (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135--2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. 1 (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express,and be compliant prior to final payment. To register,go to http://vendors.ehawaii.gQv, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i [ we understand and will comply with the reg uirement to submit a ear-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time!y, comi2lete, and accurate ear-end re Port, u5inq the temjQlate Provided will impact the evaluation of our program's or a enc 's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2014-2015 Page 5 of 7 I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to Coun and exclusion from future rant participation for a minimum of one year or until a written report is submitted to and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/­on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a time!y manner will impact the evaluation of our agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understood these requirements. Ecl) Za f Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2024-2015 Page 6 of 7 Agency Name:YWCA of Hawaii Island Program Name:YWCA Healthy Start- Positive Moms-Happy Babies (PMHB) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Enroll 100 women into the PMHB project 90% Provide ten 8-week PMHB course sessions 90% Provide 200 hours of PMHB course class sessions 90% Provide 240 hours of childcare for mothers attending PMHB course 90% Provide 1,000 hours of Home Visitor reinforcement in the home 90% Conduct prelpost screening with all enrolled PMHB participants 100% TABLE 11: FY 1435 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees $27,270.00 Operations $2,250.00 Supplies $6,480.00 Equipment other: Indirect Cost $4,000.00 Other: other: Other: Other: TOTAL $40,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 7 of 7