HomeMy WebLinkAboutCOM 0140.029 2002-2004 tr w
harry Kim r1~'%~'`' RED: ~ - ,
f-1 ' ~ ~1 Alan R. Parker
.1/or°r . - lirecu(me on Agin,(
'03 AUG 29 R(~ 10 39
COUf,. C:._..~•:
Lounty o~ Hawaii COUNTS u= r~,';>°~~,111
OFFICE OF AGING
Ililu I agoun Can VC, 101 Aupuni Strcch Sui1c 342. Hilo. Hae'ai'1 96 7 2 0--7 2 62
P6onc (808) 961-R600 • Pay (ROS) 961-8603
Manama 19ace_ 7~-706 6uakini HighwHy. Suiic 10G. I~ailua-ICnnu, Iluo url 96740-1711
Phone (808)727-7597 • rae (ROR)327-3 X99
DATE: August 2$ 2003
TO: James Y Arakaki Council Chair and
Council Members
VIA: Dean a S~ko, controller ~ LM+ ~ ~~,utu
FROM: Alan Parked' Executive on Aging
RE NOTIFICATION OF GRANT AWARD
Compliance with Ordinance No. Q~r~$, Section 7(1)
Mr
Name of Grant Program: Senior Employment Program
Grantor: SOH, Dept. of Labor 8 Ind. Relations, Workforce Dev. Div.
County Grantee Department or Agency: Hawaii County Office of Aging
Grant No. (IF KNOWN): PY03-SCSEP-H-HCOA
Amount of Grant: $281,828.00
Amount of County Match: $ 87,792.00
County Revenue Account Numbers. #3301.20
County Expenditure Account Numbers: #010-481-5481.01 to 5481.02 8 5484.02 to 5484.03
Grant Period (Commence. & Completion): July 1, 2003 to June 30, 2004
Purpose of Grant: To provide the subsidized part-time employment opportunities to
individuals fifty-five years of age or older
Is final report required by grantor? [X] Yes No
Notification attached: ~C] Yes No
cc Parks & Recreation
Comm. No.
att. ::ate ~P 4 7(103
irr.b~r~i -Igenrl'„n .Iging
LINDA LINGLE tc w NELSON B. BEFITEL
GOVERNOR 4Y.1gsg % DIRECTOR
9 / '
1
COLLEEN V. LaCLAIR
~ ~ DEPUTY DIRECTOR
d ELAINE YOUNG
~~Og~e vA~n~~ ADMINISTRATOR
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
W ORKFORCE DEVELOPMENT DIVISION
830 Punchbowl Street, Room 329
Honolulu, Hawaii 96813 DATE RECEIVED -7
I~
o~._~
s~IRi~ULATE TO ~ t
June 30, 2003 ~.~)PY iG
~~C iIJN BY
GA i E UUE Tp
FILE C__ n~t`E vzt< ~ ~ [
TO: Alan R. Parker, Executive on Aging
Hawaii County Office of Aging
~j~L~ I~;
FROM: Elaine Young, Administrator r_ ~
Workforce Development Division ~
SUBJECT: Agreement for Health and Human Services: Transactions Exempt from
Chapter 103F, HRS [dumber: PY 03-SCSEP-H-HCOA
Enclosed for your appropriate action is an executed copy of the Agreement for Health and
Human Services referenced above. This Agreement is for the administration and operation of a
Senior Community Service Employment Program for the period from July 1, 2003 through
June 30, 2004 on the County of Hawaii.
Should there be any questions or concerns, please call Ms. Yvonne Chong at 586-9262. We look
forward to working with you.
Enclosure
PY03-SCSEP-H-HCOA
STATE OF HAWAII
AGREEMENT FOR HEALTH AND HUMAN SERVICES:
TRANSACTIONS EXEMPT FROM CHAPTER 103F, HRS
This Agreement, executed on the respective dates of the signatures of the
parties shown hereafter, is effective as of (date) July 1 2003
between the (agency) Department of Labor and Industrial Relations
State of Hawaii (the "STATE"), by its Director
(the "DIRECTOR"), whose address IS 830 Punchbowl Street, Room 321, Honolulu, HI 96813
and Hawaii County Office ~f AginQ
(the "PROVIDER"), a (government entity/corporation/partnership/sole proprietorship/other
business form) a county governmental entity ,
whose business address and taxpayer identification number are:
101 Aupuni Street Suite 342 Hilo, Hawaii 96720 Federal ID~k: 99-6000567
RECITALS State IDlk: 30016002
A. This Agreement is for a purchase of health and human services that is exempt
from the requiremenu of Chapter 103F, HRS, because:
? this Agreement is between or among government agencies as provided
in Section 103F-101(a)(2), HRS;
? this Agreement is to award grams or subsidies of state funds
appropriated by the legislature to a specific organization as provided
in Section 103F-101(a)(1), HRS, and Section 3-141-503(a)(2), HAR,
or to award subawards and subgranu to specific organizations directed
by the funding source as provided in Section 3-141-503(a)(1);
? this Agreement is wholly or partly funded from federal sources that
conflict with the procedures and requirements established by Chapter
103F, HRS, and its implementing regulations;
? this Agreement is wholly or partly funded from federal sources that (1)
identifies a target class of beneficiaries, (2) defines We requiremenu
for a provider to be qualified to participate in the federal program, and
(3) has the price of the provided health and human services dictated
by federal law;
EXEMPT TRANSACTIONS
Page 1 Focw a,GS-F~omta/99)
? this Agreement is for an affiliation agreement with hospitals and other
health care providers required for University of Hawaii clinical
programs;
? this Agreement is for the services of psychiatrist, or psychologists in
criminal or civil proceedings as required by a court order or by the
rules of the court;
? this Agreement is for a transaction covered by a written exemption
from the Chief Procurement Officer for the STATE dated
The STATE is in need of the health and human services described in this
Agreement and its exhibits (the "Required Services"). The PROVIDER is agreeable to
providing the Required Services.
C. Money has been appropriated for the purchase of the Required Services by:
(1) (identify state sources) , or
(2) (identify federal sources) Public Law 108-7 , or both,
in the following amounts:
State: E
Federal: S 2sl 828
D. Pursuant to (legal authority for Agreement) Chapters 103-F and 26-20, xxs
the STATE is authorized to enter into this Agreement.
E. The undersigned representative of the PROVIDER represents, and the
STATE relies upon such representation, that be or she has authority to sign this Agreement
by virtue of (check any or all that apply):
? corporate resolutions of the PROVIDER or other authorizing
documents such as partnership resolutions;
? corporate by-laws of the PROVIDER, or other similar operating
documents of the PROVIDER, such as a partnership agreement, or an
limited liability company operating agreement;
EXEMPT TRANSACTIONS
Page 2 Focm AG3-Exem(4/99)
? the PROVIDER is a sole proprietor and as such does not require any
authorizing documents to sign this Agreement;
? the PROVIDER is a government entity, and fhe undersigned
representative of the PROVIDER is duly-authorized to execute
contracts on behalf such government entity;
? other evidence of signing authority:
F. The PROVIDER has produced, and the STATE has inspected, a certificate
of insurance in the amount of DOLLARS
for bodily injury and property damage liability arising in connection with
the PROVIDER's performance under this Agreement. N/A
G. The PROVIDER has produced, and the STATE has inspected, a tax clearance
certificate with approval from the State of Hawaii, Department of Taxation, dated
N/A
NOW, THEREFORE, in consideration of the promises contained in this Agreement,
the STATE and the PROVIDER agree as follows:
1. Scope of Services. The PROVIDER shall, in a proper and satisfactory manner
as determined by the STATE, provide the Required Services as set forth in Exhibit "A" to
this Agreement, which is attached, and made a part of this Agreement.
2. Term of Agreement. The PROVIDER shall provide the Required Services
f7om (date) July 1 2003 , to (date) June 30,
2004 ,unless this Agreement is sooner terminated.
3. Compensation. The PROVIDER shall be compensated
? in a total amount for all required services not to exceed
Two Hundred Eighty One Thousand Eight Hundred Twenty Eight DOLLARS 2$1.828.00
including taxes, at the time and in the manner set forth in Exhibit "B"
to this Agreement, which is ariached, and made a part of this
Agreement.
? based upon referrals to the PROVIDER from the STATE, payment
EXEMPT TRANSACTIONS
Page 3 Form AG3-Exem(4/99)
for each such referral shall be made according to Exhibit "B" to this
Agreement, which is attached, and made a pari of this Agreement.
The STATE shall provide a minimum of referrals to
the PROVIDER.
4. Reporting Requirements. In addition to whatever other reports may be
required elsewhere in this Agreement, the PROVIDER shall also submit a Final Project
Report, by (date) August 31 Anna No amendment to the
PROVIDER'S Final Project Report shall be considered after (date) September 30
2004
5. Standards of Conduct Declaration. The Standards of Conduct Declaration of
the PROVIDER is attached as Exhibit "C", and is made a part of this Agreement.
6. Other Terms and Conditions. The General Conditions for Health and Human
Services Contracts (the "General Conditions") are attached as Exhibit "D," and are made a
part of this Agreement. If applicable, any Special Conditions are attached as Exhibit "E,"
and are made a pari of this Agreement. In the event of a conflict between the General
Conditions and the Special Conditions, the Special Conditions shall control.
7. Notices. Any notice, communication, or information required to be given by
any party to this Agreement shall be made in writing ,and shall be (a) delivered personally,
or (b) sent by United States 5rst class mail, postage prepaid. Notice required to be given
to the DIRECTOR shall be sent to the DIRECTOR's office in Honolulu, Hawaii. Notice
to the Agency Procurement Officer shall be sent to:
830 Punchbowl Street Room 309 Honnl,l HT o~Rt7 NOtice t0 the
PROVIDER shall be sent to the PROVIDER at the PROVIDER'S address as indicated in
this Agreement. Notice to the STATE'S Chief Procurement Officer shall be sent to _
1151 Punchbowl Street, Ii230A, Honolulu, Hl A notice shall be deemed to have been received
96813
three (3) days after mailing or at the lime of actual receipt, whichever is earlier. The
PROVIDER is responsible for notifying the STATE in writing of any change of address.
EXEMPT TRANSACTIONS
Page 4 Form AG3-Ezcm(4/99)
IN VIEW OF THE ABOVE, the parties execute this Agreement by their signatures,
on the dates below, to be effective as of the date 5rst above w/ritten.
yA~~ic.~,V
Print Name Nelson B. Befitel
Title Director
?~6,,1 `
~ !f}i
Date
PROV~
...__._.-_f, '~C~_._`.~ [ Print Name DIXIE KAEtSY
j ~ :.c:> : ~ Title Manogtng OMrAat•
t;~ , JUN 2 D 2U03.
a___.._._.._.__....____ Date
APPROVED AS TO FORM:
- APPROVED AS TO
.DLe~pu-lty.At o ey General FORM AND LEGALITY:
DEP CORPORATION COUNSEL
CO OF HAWAII
Date JUN 13 ZC03
EXEMPT TRANSACTIONS
Page 5 Form AG3-Exem(a/99)
STATE OF HAWAII )
SS.
COUNTY OF HAWAII )
On this 20~h day of June, 2003, before me personally appeared DIXIE
KAETSU, to me personally known, who, being by me duly sworn, did say that she is
the Managing Director of the County of Hawaii, a municipal corporation of the State
of Hawaii; that the seal affixed to the foregoing instrument is the corporate seal of
said County of Hawaii; that the foregoing instrument was signed and sealed in behalf
of the County of Hawaii by authority given to said Mayor of the County of Hawaii by
Section 5-1.3(g) of the County Charter, County of Hawaii (1991), as amended, and
assigned by the Mayor to the Managing Director pursuant to Section 6-1.3(h) of the
County Charter; and said DIXIE KAETSU acknowledged said instrument to be the
free act and deed of said County of Hawaii.
cfr ~ T q Q Yq CATHY . CORREIA
Notary Public, State of Hawaii
`~•~r~
a ~p ~C My commission expires: 10/13/06
U BL
~p N11`
PROVIDER'S ACKNOWLEDGMENT
State of )
SS.
County of
On this day of ,before me personally
appeared , to me personally known, who being by me
duly sworn, did say that he/she is the of
.the PROVI R named in the foregoing instrument, and that
he/she is authorized to sign said instrument n behalf of the PROVIDER, as provided in
Recital E of the foregoing Agreement, and acknowledges that he/she executed said
instrument as the free act and deed of the PRO DER.
Notary Public,
My commission a 'res:
EXEMPT TRANSACTIONS
Page 6 Form AG3-Exem(4/99)
JM1Y^Oi y,w
O 7~
4. ~~l'
Ham' Kim
Dixie Kaetsu
M:pror
Managing llirwmr
~T:
w ,T
+>F 6i•p+• Yctcr T. Young
Deputy 61anagmg Diredo~
Cl,uuntp of ~abnai`i
2S Aupuni Street, Room ? 15 Hilq nawx~5 96720-4252 • (ROft) 961-8211 • Fax (SOS) 961-6553
KOKiA 7S570C hunkini IIfghway, Suite 103 . Kailux-Kona, Hawat~ 9G7d0
(808) 329-5226 • Fax (SOS) 326-5663
Apri I ] 6, 2001
Dixie Kaetsu
Managing Director
County of Hawaii
Hilo, Hawaii 96720
Re Authorization to Sign County Documents
Dear Ms Kaetsu:
As authorized by section 6-L3(~ of the Charter of the County of Hawaii, I hereby assign to
you the authorization to sign instruments requiring execution by the County on my behalf,
whether I am in the County or not.
~
J~
Harry Kim
MAYOR
cc Lincoln Ashida, Corporation Counsel
William Takaba, Director ofFinance
N/A
CERTIFICATION OF EXEMPTION FROM CIVIL SERVICE
1. By Heads of State Departments or Agencies Pursuant to Delegation of the Director
of Human Resources Development'
Pursuant to the delegation of the authority by the Director of Human Resources
Development, I certify that the services provided under this Agreement, and the person(s)
providing the services under this Agreement are exempt fiom the civil service, pursuant to
Hawaii Revised Statutes §76-16.
(signature) (date)
Print Name
Print Title
2. By the Director of Human Resources Development, State of Hawaii=
I certify that the services provided under this Agreement, and the person(s) providing
the services under this Agreement are exempt fiom the civil service, pursuant to Hawaii
Revised Statutes §76-16(x.
(signature) (date)
Print Name
Print Title, if designee of Director
of Human Resources Development
iThis part of the form may be used by all department heads and others to whom the Director o[
Human Resources Development has delegated authority to certify Hawati Revised Statutes section 76-16
civil service exceptions. The spec paragraph(s) o[ section 76-16 upon which an exemption is based
should be noted in the contras fle. N07'E: Authority to certify exceptions under Hawau Revised Statutes
sections 76-16(2) and 76-16(3) has not been delegated; only the Duector of Human Resources
Development may certify sections 76-16(2) and 76-16(3) exceptions.
'Ibis part of the form may be used only by the Director of Human Resources Development or the
D'irector's designee. See N07'E at footnote 1.
EXEMPT TRANSACTIONS
Page 7 Form AG3F.xem(4/99)
SCOPE OF SERVICES
The purpose of this Agreement is to foster and promote useful part-time opportunities in
community service activities for unemployed, low income "older individuals" (individuals over
55 yeazs of age) who have poor employment prospects; to foster individual economic self-
sufficiency; to increase the number of persons who may enjoy the benefits of unsubsidized
employment. (See Section 2, Service Specifications of the Request for Proposals-Identification
Number LBR ] 11-02-1(SCSEP), which is attached hereto as Attachment "1 In order to
achieve these goals, the PROVIDER shall, in a satisfactory and proper manner as determined by
the STATE and in strict accordance with the terms and conditions of this Agreement, provide
employment and training services to the older individuals which aze designed to initially place
the individuals in part-time community service jobs which will be subsidized as set forth in this
Agreement, with the ultimate goal of helping the older individuals transition into unsubsidized
employment. The PROVIDER shall, to the maximum extent feasible, cooperate with other
agencies, including, but not limited to Workforce Investment Act partner agencies, in providing
the services to the older individuals.
The scope of services is set forth in detail in the Detailed Program Objectives which is the
PROVIDER'S proposal attached hereto as Attachment " 2" and the PROVIDER's Detailed
Program Budget, attached hereto as Attachment " 3" (Attachments " 2" and " 3" supersede
previous documents regazding program objectives and budget), but, in general, the requirements
of this Agreement aze set forth below as follows:
1. Statutory and Regulatory Requirements: The PROVIDER shall comply with
the Cost Principles for Pwchases of Health and Human Services set forth in HRS
Chapter 103F, and applicable federal cost principles listed in OMB Circulars A-
87, A-21, A-1 10 and A-122, and the Senior Community Service Employment
Program Financial Management Manual which aze hereby incorporated and made
a part of this Agreement. The PROVIDER shall enswe that such services shall be
in accordance with Title V of the Older Americans Act promulgated thereunder;
and applicable Federal and State laws, regulations, policies and instructions.
2. Recruitment, Selection, and Assessment of Eligible Enrollees: In accordance
with Title V of the Older Americans Act and applicable laws, regulations, policies
and instructions issued by the STATE, the PROVIDER should recruit, select, and
assess eligible enrollees to fill all available community service assignment slots.
The PROVIDER shall strive to provide services to 40% more enrollees than the
established slot level for the project. Priority for enrollment shall be given to
individuals who aze at least 60 yeazs old and a veteran or a qualified spouse of a
veteran. Within these priority groups, special consideration shall also be given, to
the extent feasible, to eligible individuals who aze minority, limited English
Exhibit "A"
Page l
speaking, Indian, have incomes below the poverty level, or who have the greatest
social and economic need.
3. Case Management and Service Planning: The PROVIDER shall provide case
management services and prepaze individualized service plans which reflects each
enrollee's employment goal(s), appropriate achievement objectives, supportive
service needs, sequence and timetable.
4. Placement into Subsidized and Unsubsidized Employment: The PROVIDER
shall develop appropriate subsidized and unsubsidized employment opportunities
for the enrollees participating in the program. The PROVIDER shall provide
sufficient counseling, assessment, supportive services and training that will enable
the transition into unsubsidized employment for the number of enrollees that
equals at least 20 percent of the project's annual slot level.
5. Monitoring and Evaluation: The PROVIDER shall implement sufficient
procedures for monitoring this awazd to insure the proper and effective
expenditwe of funds and the achievement of program goals.
6. Reporting Requirements: In order that the STATE may monitor the
PROVIDER'S compliance with this Agreement, the PROVIDER shall submit
written monthly fiscal and quarterly program progress reports to the STATE.
A. Fiscal Reports: The fiscal reports shall detail the uses made by the
PROVIDER of compensation paid to it pursuant to this Agreement,
outline the expenditures incurred, and be certified as to accuracy by the
PROVIDER. SCSEP Expenditure Register and Subcontractor's Invoice
reports are due no later than twenty (20) days after each month ends. In
addition, the PROVIDER shall submit a completed close-out package
within sixty (60) days after the termination of the Agreement containing
the documents identified in the Service Specifications for the Request for
Proposals.
B. Program Reports: The program progress report shall consist of
statements by the PROVIDER relating to the work accomplished during
the reporting period and shall include a statement of the nature of the work
performed, including actual performance measures, activity levels, and
target group indicators, identification of persons served by the PROVIDER
during the reporting period, and any recommendations deemed pertinent
by the PROVIDER. Quarterly Progress Reports and Summary of
Terminations aze due within ten (10) calendaz days after the end of each
quarter and Quarterly Review Reports aze due twenty-five (25) calendaz
Eabibit "A"
Page 2
days after the end of each quarter.
C. Additional Reports: In addition to the quarterly written reports, the
PROVIDER, upon request, shall be required to submit additional reports
that the STATE from time to time may request and to meet with
representatives of the STATE to discuss the progress of the work required
hereunder.
D. Reporting Penalty: Should the PROVIDER fail to file the written fiscal
and program progress reports with the STATE on or before the required
date, the STATE is authorized to withhold funds owed to the PROVIDER
until such time as the reports are acceptable and placed in file with the
STATE.
1. Audit Requirement: Any PROVIDER agency that expends $300,000.00 or more
a yeaz in federal awazds shall have a single orprogram-specific audit conducted
for that year. Such PROVIDER shall have an audit conducted by an independent
Certified Public Accountant to verify that its financial management system and
internal control procedwes aze effective in meeting the terms and conditions of
the Agreement. The audit shall be in accordance with generally accepted auditing
standazds, the requirements of OMB Circulaz A-133, and the Government
Auditing Standazds issued by the U.S. General Accounting Office. The audit
report shall be famished to the STATE within twelve (12) months after the
completion of the Agreement. A pro rata shaze of the audit costs may be chazged
to the Agreement only if an audit is required as stated above. Should the actual
federal expenditwe be less than $300,000.00, no portion of the cost of the audit, if
conducted, may be chazged to this award.
2. Personnel: The PROVIDER represents that it has, or will secwe at its own
expense, all personnel required in performing the services under this Agreement.
Such personnel shall not be employees of, or have any contractual relationship
with the STATE. All of the services required hereunder will be performed by the
PROVIDER or under its supervision, and all personnel engaged in the work shall
be fully qualified and shall be authorized under federal, state and local laws to
perform such services.
9. Participation in the One-Stop Delivery System: The PROVIDER shall make
available information regazding their program to participants of the One-Stop
Delivery System. The PROVIDER shall participate with the operation of the
Workforce Investment Act One-Stop Delivery Centers in their area. Such
participation shall be described in a Memorandum of Understanding between the
PROVIDER and the Local Workforce Investment Board.
Exhibit "A"
Page 3
10. Performance Standards: The PROVIDER shall meet the required levels of
performance annually set by the Secretazy of the U.S. Department of Labor for
each of the following performance indicators:
A. The number of persons served, with particular consideration given to
veterans or the qualified spouse of a veteran, individuals with the greatest
economic need, greatest social need, or poor employment history or
prospects, and individuals over the age of 60. The PROVIDER should
strive to provide services to 40% more enrollees than their established slot
level;
B. Identification of community services provided;
C. The number of enrollees placed into unsubsidized employment. The
minimum rate of placement into unsubsidized employment shall be no less
than 20% of the PROVIDER'S allocated slot level;
D. The number of individuals who aze still employed in an unsubsidized
position six months after placement;
E. Customer Satisfaction of enrollees, employers, and host agencies that
provide community service jobs; and
F. Any other indicators of performance that the Secretary of Labor
determines to be appropriate to evaluate services and performance.
11. Consequences for Poor Performance: if the PROVIDER fails to achieve the
established level of performance, the PROVIDER shall no later than 90 days after
the end of the program yeaz, submit to the STATE their corrective action plan to
resolve such poor performance. If the PROVIDER continues to fail to achieve the
established level of performance for a second yeaz, even with the provision of
technical assistance and training from the STATE and/or the U.S. Department of
Labor, the STATE may select another entity to operate the subproject.
12. Contingency Plan: The PROVIDER shall provide to the STATE a Contingency
Plan which they agree to implement to ensure a minimal disruption of services to
the PROVIDER'S enrollees should the PROVIDER lose some or all of their
SCSEP slots. Such plan shall be submitted no later than 45 days after the start of
this Agreement. The PROVIDER'S plan should include the following
information:
Eabibit "A"
Page 4
A. How and when the participants will be notified;
B. If appropriate, what records will be turned over to the new operator,
C. What efforts will be made to place program participants into other
employment and training opportunities;
D. What other services will be provided to ease the transition; and
E. How will final payroll payments be made.
13. Assurances and Certifications: The PROVIDER shall assure and certify that it
will fully comply with the following regulations:
29 CFR Part 97 (Uniform Administrative Requirements for Grants and
Cooperative Agreements to State and Local Governments);
29 CFR Part 95 (Uniform Administrative Requirements for Grants and
Agreements with Institutions of Higher Education, Hospitals, and Other Non-
Profit Organizations)
29 CFR Part 96 (Single Audit Requirements);
29 CFR Pari 98 (Debarment and Suspension, Drug Free Workplace);
29 CFR Part 93 (Lobbying Certification);
29 CFR Parts 33 and 34 (Nondiscrimination and Equal Opportunity); and
20 CFR Part 641 (Senior Community Service Employment Program, Proposed
Rule).
The PROVIDER must also sign the following certification forms:
Debarment and Suspension Certification
Certification Regarding Lobbying
Drug Free Workplace Certification and
Certification ofNon-Delinquency.
Eabibit "A"
Page 5
BUDGET REQUEST SUMMARY
(Perrod July 1, 2003 To June 30, 2004 )
ApplicanUProvider. Hawaii County Office of Aging
RFP NO.: LBR 111-02-1(SCSEP) Date Prepared: '6/13/03
CODtraCt No. (As Applicable): PY03-SCSEP-H-HCOA
BUbGET Budget Program Program
CATEGORIES Request Admin EWFB Other Costs
(a) (b) 1~1 Id)
A. PERSONNEL COST
1. Salaries 19,989 17,990 y,ggg
2. Pa roll Taxes 8 Assessments 2,455 2,210 245
3. Frin a Benefts 2,342 2,108 234
TOTAL PERSONNEL COST 24,786 22,308 2 478
B. OTHER CURRENT EXPENSES
1. Airfare, Inter-Island 420 420
2. Subsistence I Per Diem 540 60 480
3. Trans ortation 45 45
4. Lease/Rental of E ui ment 7fi5 765
5. Lease/Rental of Motor Vehicle 0 0
6. Lease/Rental of Space 0 0
7. Mileage 1,657 200 1,457
8. Postage Freight 8 Delivery 300 50 250
9. Publication 8 Printing 236 0 236
10. R~air 8 Maintenance 300 300
11. Supplies 1,500 1,500
12. Telecommunication 0
13. Utilities 0
14. Contractual Services - Suhcontracts 0
15. Contractual Services -Administrative 0
16. Independent Audit 300 300
17. Information Systems Development 750 750
18.
19.
20.
21.
22.
23.
PROGRAM ACTIVITIES
24. Enrollee Wa es 218,400 216,400
25. Fringe Benefts 26,820 26.820
26. Supportive Services 1,744 1,744
27. Classroom Training 250 250
28.
TOTAL OTHER CURRENT EXPENSES 254,027 3,640 245,220 5.167
C. EQUIPMENT PURCHASES 3,015 1,015 2,000
D. MOTOR V HICLE PURCHASES
i i 4 Q ,
Butlget Prepared By
Marcus Ka a 961-8750
SOURCES OF FUNDING Name (Pl se type or print) - Phone
a Bud et Re uest 281,828 / / ~ O
(b) Nonfederal Match 87,792 Signature of Authorized Official Date
(c) Alan Parker, Executive on A in
(d) Name and Title (Please type or print)
Far Slate Agency Use Only
TOTAL REVENUE 369,620
Signature of Reviewer Dale
Form SPO-H-205 (Effective 10101198) App B-5
l