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COM 0092.002 2012-2014
JMt/'GS M''Y . William P.Kenoi � y{,;•' ' Nancy OE eCrrawford Mayor Deanna S. Sako �r•S•=.............#0.• Deputy Director • Os County of Hawaii Finance Department 25 Aupuni Street, Room 2103 • Hilo,Hawaii 96720 (808)961-8234 • Fax(808)961-8569 February 12, 2013 J Yoshimoto, Council Chair and Members of the Hawai`i County Council Hawai`i County Council 25 Aupuni Street Hilo, Hawai`i 96720 Re: Nonprofit Grant Applications In compliance with Chapter 2, Article 25 of the Hawai`i County Code, I am submitting the applications from eligible nonprofit organizations for your review and appropriation of funds for the FY2013-14 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. 6\10%, Nancy Cr wford Director of Finance Enc. Applications for Nonprofit Grant Funds List of Nonprofit Grant Applicants (Note: The attached application packet, due to its size, is not made a part of the duplicate copies, but is available for viewing at the Office of the County Clerk. ) Comm. No. a •el- Ref.To: Ref. Date .ht3 15 zu13 Hawaii County is an Equal Opportunity Provider and Employer r NONPROFIT GRANT APPLICANTS FOR FY14 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 REQUESTS PROGRAM NAME O 1 1 Aha Punana Leo,Inc Ho'oulu'Ghana $52,766 2 2 Alahou Clean&Sober Clean and Sober Housing $32,000 3 4 American Red Cross,Hawaii State Chapter P Disaster Preparedness and Response in Hawaii County $20,000 4 5 Arc of Kona Home and Community Based Services Life Skills Program $10,000 5 6 Big Brothers Big Sisters Hawaii big[mar meuianuri me.,uua vvesi hewer I mearanun School Based Program $25,000 6 7 Center Mediation Services $15,000 7 8 Big Island Resource Conservation&Development(BIRCD) Hawaii Homegrown Food Network(HHFN) 8 9 Big Island Resource Conservation&Development Council Military Family Gathering $14,500 9 10 Boys&Girls Club of the Big Island $5,000 Hamakua-Healthy STEMS $30,000 10 11 Boys&Girls Club of the Big Island Hilo-Healthy STEMS $31,000 11 12 Boys&Girls Club of the Big Island Kea'au-Healthy STEMS $31,000 12 13 Boys&Girls Club of the Big Island Ocean View-Healthy STEMS $30,000 13 14 Boys&Girls Club of the Big Island Pahala-Healthy STEMS $30,000 14 15 Boys&Girls Club of the Big Island Pahoa-Healthy STEMS $30,000 15 16 Brantley Center,Inc Employment Rehabilitation $40,000 16 17 Bridge House,Inc Vocational Skills Building Program(VSB) $25,000 17 18 Child and Family Service Alternatives to Violence $50,000 18 19 Child and Family Service East Hawaii Domestic Abuse Shelter $40,000 19 20 Child and Family Service East Hawaii Transitional Housing $40,000 20 21 Child and Family Service Transitional Family Homes $30,000 21 22 Child and Family Service West Hawaii Domestic Abuse Shelter $40,000 22 23 Cooper Center Volcano Friends Feeding Friends(VFFF) 23 $35,900 24 COVO Foundation Pamana ng Kulturang Pilipino(Heritage of the Filipino Cultr) $10,000 24 25 East Hawaii Community Development Corporation Hawaii Food Hub 25 $74,480 26 Family Support Hawai'i Hawaii Island Fatherhood Initiative 26 27 Friends of Big Island Drug Court $ Assistance to Drug Court Clients&Programs $10,000 0,000 27 28 Friends of Kona Community Aquatic Center Heated Pool for Kona Community Aquatic Center $70,000 28 29 Friends of Kona Community Aquatic Center Warm Water for Kona Community Aquatic Center $13,000 29 30 Friends of the Children's Justice Center-East Hawaii Special Needs&Ehancement,Ctr support,Edu/Training $25,000 30 31 Friends of the Children's Justice Center of West Hawaii Enhancement and Basic Needs 31 32 Global Ecology Foundation $15,000 Hawaiian Agroecology $30,520 32 33 Goodwill Industries of Hawaii,Inc Employment Core Services-Tuition Support $30,000 33 34 Goodwill Industries of Hawaii,Inc Work Experience Program $45,000 34 35 Grassroots Community Development Group Hawaii Youth Business Center(HYBC)-Puna 35 36 Habitat for Humanity-West Hawaii $50,000 Partnering for Progress $43,100 36 37 Hale Kipa,Inc Ka'i Like Program $20,000 37 38 Hamakua Health Center,Inc Healthy Moms Mean Healthy Babies $51,000 38 39 Hamakua Health Center,Inc Underserved Child Dental Access Grant $12,500 39 40 Hamakua Youth Foundation,Inc Hamakua Youth Center $17,500 40 41 Hawaii County Economic Opportunity Council After School STEM Program $76,479.54 41 42 Hawaii County Economic Opportunity Council Language Arts Multicultural Program $98,239.06 42 43 Hawaii County Economic Opportunity Council Youth Mentoring and Drop-out Prevention $90,009.53 43 44 Hawai'i Island Adult Care,Inc Adult Day Care Centers $30,000 44 45 Hawaii Island Cardiovascular,Inc Remote Cardiovascular Screening Program 45 46 Hawaii Island Health Information Exchange-HIHIE $38,000 9 HIHIE Consortium $50,192 46 47 Hawaii Island HIV/AIDS Foundation HIV Transmission Prevention for Women(SISTA)-Kona $15,000 47 48 Hawai'i Island HIV/AIDS Foundation Multi-Disciplinary HIV&Hepatitis C Case Management-Hilo $15,000 48 49 Hawai'i Island Humane Society(HIHS) Humane Education Classes for At-Risk Children and Youth $10,000 NONPROFIT GRANT APPLICANTS FOR FY14 , 1 Numerical Sort REQUESTE Order '' order ORGANIZATION NAME PROGRAM NAME D 49 50 Hawaii Montessori Schools Financial Aid Program $40,000 50 52 Hawaii's Volcano Circus Hiccup Youth Circus Camps $24,000 51 53 Hawai'i's Volcano Circus Truth Speaks Hawaii by Truth 2 Youth $4,564 52 54 Hawaiian Community Assets Hawaiian Island Financial Capability Inititative $31,579 53 55 Hilo Community Players 2013 Cultural and Educational Theatre Productions $18,715.79 54 56 Holualoa Foundation for Arts&Culture Art Matters $28,718 55 57 Ho'oulu Lahui Inc Food Security for Hawaii Island $25,000 56 58 HOPE Services Hawaii,Inc Care-A-Van Homeless Outreach Program $20,000 57 59 HOPE Services Hawaii,Inc HOPE Resource Center $20,000 58 60 HOPE Services Hawaii,Inc Kihei Pua Emergency Shelter $20,000 59 61 HOPE Services Hawaii,Inc Shelter Plus Care:Kukui and New Direction $20,000 60 62 HOPE Services Hawaii,Inc West Hawaii Emergency Housing Program $20,000 61 63 Hospice of Hilo(HOH) Transitions Program Evansion&Transformation $298,405 62 64 Hui Malama Ola Na'Oiwi Cancer Program $20,000 63 65 Hui Malama Ola Na'Oiwi Kokua Hali Health Transportation $30,000 64 66 Hui Malama Ola Na'Oiwi Mai Ka Mala'Al Program $20,000 65 67 Hui Pono Holoholona Subsidized Low Cost Spay/Neuter Clinics $25,000 66 68 Innovations Public Charter School Foundation Teaching our Keiki Aloha Toward the Aina $10,000 67 69 Ka Hale 0 Na Keiki,Inc Familes-At-Risk Project $10,000 68 70 Ka'Ohana 0 Honu'apo Honu'apo Park Program $22,782 69 71 Kahua Pa'a Mua Palili'0 Kohala $50,000 70 72 Kalani Honua Community Arts Program $19,965 71 74 Kanu o ka Aina Learning Ohana Halau Ho'okipa $1,700,000 72 77 Keaukaha One Youth Development(KOYD) RISE 21st Century After School Program $10,000 73 78 Keaukaha One Youth Development(KOYD) Youth Paddling Program $10,000 74 79 Keep Hawaii Beautiful Let's Grow Hilo Sustainability Plan $15,000 75 80 Kohala Animal Relocation and Education Service(KARES) Canine Spay and Neuter Program $40,800 76 81 Kona Adult Day Caner,Inc Adult Day Care $25,000 77 82 Kona Historical Society Living History Program Operations $15,000 78 83 Kona Literacy Council Kailua Learning Center $2,500 79 84 Ku'ikahi Mediation Center Community Mediation Services $15,000 80 85 Legal Aid Society of Hawaii Removing Barriers for HI Countys Vulnerable Population $40,000 81 86 Lyman Museum Education and Public Programs $12,000 82 87 Malama 0 Puna Puna Panthers $25,000 83 88 Malamalama Waldorf School Puna Arts in the Park Intersession&Summer Program $20,000 84 89 Mental Health Kokua Residential Rehabilitation Services $5,000 85 90 Miloli'i Emergency Response Team,Inc. Miloli'i Resiliency Project $11,500 86 91 Neighborhood Place of Puna Family and Community Strenghening $30,000 87 92 Neighborhood Place of Puna Ready to Learn $5,000 88 93 North Kohala Community Resource Center Growing a Local Food System-N.Kohala Eat Locally Grown $30,000 89 94 North Kohala Community Resource Center Kohala Welcome Center,Phase II $17,280 90 95 0 Ka'u Kakou Ka'u Family Fun Fest $7,000 91 96 0 Ka'u Kakou Ka'u Sanitation Program $8,500 92 97 0 Ka'u Kakou Punalu'u Annual Fishing Tournament $9,000 93 98 Palekana Kai Ocean Safety,Ilc Ocean Safety Education-East Hawaii $35,000 94 99 Palekana Kai Ocean Safety,Ilc Ocean Safety Education-West Hawaii $35,000 95 100 Palekana Kai Ocean Safety,Ilc Wilderness and Remote First Aid Training $25,000 96 101 Paradise Ponies,Inc Carousel of Aloha-Sourcing Local Woods $10,000 97 103 Puna Community Medical Center Uninsured/Underinsured Fund $120,000 98 104 Society for Kona's Education&Art(SKEA) Art Camps for Children&Teens $5,000 NONPROFIT GRANT APPLICANTS FOR FY14 ' e Numerical Sort Order order ORGANIZATION NAME REQUESTE PROGRAM NAME O 99 105 Special Olympics Hawaii Special Olympics-East Hawaii Area $25,000 100 108 The Arc of Hilo Advocacy Program $35,000 101 109 The Exploration Foundation Malama Honua 102 110 The Food Basket,Inc $110,000 Enabling Safe and Cost Effective Food Distribution-East HI $30,000 103 111 The Food Basket,Inc Enabling Safe and Cost Effective Food Distribution-West HI 104 112 The Greenwill Conservancy Inc $30,000 Hui Mana'o:"Thinking Together&Sharing Knowledge" $70,000 105 113 The Island of Hawaii YMCA Child&Youth Assets 2013-2014 $40,000 106 114 The Salvation Army-Family Intervention Services Independent Living Skills Program-West Hawaii 107 115 The Salvation Army-Family Intervention Services Positive $35,000 e Youth Development Prevention Program-Kea'au 108 116 The Salvation Army-Family Intervention Services $35,000 Prevention Program-Hilo $35,000 109 117 The Salvation Army-Family Intervention Services Substance Abuse Prevention Program-Pahoa $35,000 110 118 Volunteer Legal Services Hawaii County of Hawaii Pro Bono Legal Services $46,756 111 119 Waimea Outdoor Circle Ulu La'au,Waimea Nature Park 112 120 West Hawaii Community Health Center $4,000 Adult Emergeny Dental Services $20,000 113 121 West Hawaii County Band Friends Music and Equipment Fund $8,100 114 122 West Hawaii County Band Friends Volunteer Musicians fund 115 123 YWCA of Hawaii Island $21,825 Healthy Start Plus 116 124 YWCA of Hawaii Island $100,000 Sexual Assault Support Services $60,000 117 125 YWCA of Hawaii Island YWCA Developmental Preschool $25,000 TOTAL $5,500,175 Note: The following applicants did not meet one or more application requirements(disqualified). Hawaii Independent Living Services 2 1 51 3 Hawaii Nat dependent onal Guard Living Youth Challenge Academy Fdn HINGYCA Hawaii Community Fair $10,000 3 73 Kamuela Philharmonic Orchestra $12,000 In-School Concerts for West Hawaii Schools 4 75 Ka'u Lions $10,000 POP Warner Football Association 5 76 Kau Rural Health Community Association,Inc(KRHCAI) Ka'0 Rural Health Academy Demonstration Program $25,000 6 102 Puko'a Kani'Aina $30,940 Ho'oulu Lehua Special $19,113 7 106 5 P Olympics West Hawaii SOWN General Fund 8 107 Sure Foundation,Inc $15,000 Yeshua Outreach Center $70,000 TOTAL $192,053 1 Aha Punana Leo, Inc Ho'oulu 'Ohana Agency Name: Aha Punana Leo, Inc. Program Name: Ho`oulu `Ghana Agency Director: M. 'Ekekela Aiona Phone No.: (808) 935 — 4304 Contact Person: Janice Bueltmann Phone No.: (808) 936 — 2268 Mailing Address: Address: 96 Pu'uhonu Place Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 96 Pu'uhonu Place Address: City,ST,Zip Hilo, HI 96720 Email Address:janice @ahapunanaleo.org Fax No.: (808) 969 — 7512 Accountant/CPA: Wikoff Combs & Co LLC Phone No.: (808) 791 — 1414 Firm (if applicable): Mailing Address: Address: 1001 Bishop St., Suite 2760 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $52,766 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 116,655 2.Agency Mission Statement: E Ola Ka `Olelo Hawaii. The Hawaiian Language Shall Live. The Punana Leo Movement grew out of a dream that there be reestablished throughout Hawaii the mana of a living Hawaiian language from the depth of our origins.The Punana Leo initiates, provides for and nurtures various Hawaiian Language environments, and we find our strength in our spirituality, love of our language, love of our people, love of our land, and love of knowledge. The core of our program are our Punana Leo, family based preschools. Three out of 11 preschools administered throughout the State are located in Hawaii County, in Puna, Waimea and Kona. The Punana Leo is the only early education option for families who choose to educate their children in the official State language of Hawaiian. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: `Aha Punana Leo, Inc. Program Name: Ho'oulu `Ghana 3. Program Description: Over 230 families and community members in Hawaii County benefit each year from 80+ direct instructional hours through the Ho'oulu `Ghana initiative. A minimum of 26 weekly classes are held on the Punana Leo school site each year. In addition to providing curriculum that focuses on Hawaiian language fluency and Hawaiian medium education advocacy and awareness in an environment that encourages intergenerational interaction, partnerships with community cultural practitioners further enhance this initiative. Extension curriculum developed specifically for home use empowers caregivers to realize their role as the primary educators of their children while simultaneouly advancing their own progress in Hawaiian language acquisition and fluency. 4.Total Budget&Position Count: Total Program Budget: $220,689 Total Program Position Count: 30 Total Agency Budget: 2.5MM Total Agency Position Count: 100 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate The Kamehameha Schools $11,042 WK Kellogg Foundation $155,683 The Office of Hawaiian Affairs $4,080 TOTAL: $170,805.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Beginning in SY 2013-2014, the `Aha Punana Leo (`APL) will begin to adjust its tuition model while remaining committed to the 72% of our families that fall at or below the recognized federal poverty guidelines for the USDA Free and Reduced Lunch Program. In 2013-2014, the portion of overall costs covered by tuition revenue is expected to increase from 39% to 44%. The `APL is currently in negotiations with Ka Haka `Ula o Ke`elikolani College of Hawaiian Language under the University of Hawaii to offer online Hawaiian language tutorial modules to their students for a fee. The revenue generated from these tutorial modules would offset the cost of providing the online resources to `APL parents and families. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: `Aha Punana Leo, Inc. Program Name: Ho`oulu `Ohana 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of the Ho`oulu `Ohana program is to engage the immediate and extended family caregivers, as well as community stakeholders to participate in both school and home based activities that will ultimately impact both the healthy physical and cognitive growth of Hawaii County children by applying traditional practices and knowledge in contemporary environments - giving these children the best start in thier journey of lifelong learning through the medium of Hawaiian language. 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 Hawaii County community members served 230 Number of direct instructional hours provided to participants 80 Volunteer hours at school site from participants 3500 Attendance rate of Punana Leo families 90% Number of hours in online extension learning 780 Number of family reading hours 2000 Satisfaction rate from participants 100% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Reg Salary and Wages 188,809 188,809 24,966 Professional Fees 4,080 4,080 0 Operations Supplies 21,000 27,800 27,800 Equipment Other: Other: Other: Other: Other: TOTAL 213,889 220,689 52,766 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: 'Ana Punana Leo, Inc. Program Name: Ho`oulu `Ghana 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) nMember 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: Oof 1/UrYtt- , ))(teff,4,-cteiZadli- 306 ifyiEl A3 Si; of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: 'Ana Punana Leo, Inc. Program Name: Ho`oulu `Ghana 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. 'Aa LE 6313 Signa - . Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: `Aha Punana Leo, Inc. Program Name: Ho`oulu `Ghana 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County community members served 230 Number of direct instructional hours provided to participants 80 Volunteer hours at school site from participants 3500 Attendance rate of Punana Leo families 90% Number of hours in online extension learning 780 Number of family reading hours 2000 Satisfaction rate from participants 100% TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 24,966 Professional Fees Operations Supplies 27,800 Equipment Other: Other: Other: Other: Other: TOTAL 52,766 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 2 Alahou Clean & Sober Clean and Sober Housing Agency Name: Alahou Clean & Sober Program Name: Clean and sober housing Agency Director: Sandra McCoy Phone No.: (808) 327 — 5397 Contact Person: Sandra McCoy Phone No.: (808) 327 — 5397 Mailing Address: Address: 75-5708 Alahou Street Address: City,sr,zip Kailua-Kona, HI 96740 Facility Address: Address: Same as Mailing Address Address: City,ST,Zip Email Address: alahoucleanandsober @hawaii.rr.com Fax No.: (808) 327 — 1654 Accountant/CPA: Sharon Davis CPA PC Phone No.: (808) 883 — 2748 Firm (if applicable): Mailing Address: Address: P. O. Box 383190 Address: City,sr,Zip Waikoloa, HI 96738 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 So So So 2.Agency Mission Statement: Provide a clean, safe, low-cost and mutually supportive living environment for at-risk individuals who are in active recovery from alcohol or drugs and who are committed to maintaining a clean and sober lifestyle. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Alahou Clean & Sober Program Name: Clean and sober housing 3. Program Description: Alahou provides up to 55 chronically homeless and dual-diagnosed individuals with a clean, safe and affordable supported-living and recovery program in a peer-enforced drug- and alcohol-free environment. On-site ANNA meetings are conducted several times each week and each participant must attend a minimum of two. Life-skills discussion groups are also conducted several times each week to assist participants in the development of effective coping and interpersonal skills, and to facilitate their evenual reentry into the community as a stable and productive citizen. 4.Total Budget& Position Count: Total Program Budget: $364,000 Total Program Position Count: 2 Total Agency Budget: $364,000 Total Agency Position Count: 2 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Participant Fees (Rent) $187,000 Hawaii Island United Way $25,000 Shippers' Wharf Committee Trust $50,000 Hawaii State Grant-In-Aid $70,000 Hawaii County Grant-In-Aid $32,000 TOTAL: $364,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Alahou has applied for a Hawaii Department of Public Safety Grant for the provision of Reentry Housing and Referral Services for up to 50 adult male and female inmates per year. This program will require increasing Alahou staff to provide 24/7 on-site supervision and would enhance Alahou's sustainability through expansion of its funding base. Given nature of our program and our participant pool, however, it is unlikely that Alahou Clean & Sober will ever become completely self-sustaining based only on fees-for-service. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Alahou Clean & Sober Program Name: Clean and sober housing 7. Program Objectives Using County Nonprofit Grant Program Funds: Alahou currently spends approximately $64,000 per year in electrical, water, cable and trash removal utilities. We are asking Hawaii County to fund half of this amount, thereby freeing up program fee dollars to be used elsewhere. The result will be Alahou's delivery of over 18,000 bed-nights to some of Hawaii's most at-risk citizens. In addition to protecting the health and well-being of our participants, their absence from the streets also improves overall public safety and the attractiveness of the Kailua-Kona community. 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.) Average Occupancy per month 80% Number of bed-nights delivered each month >1,500 Number of Unduplicated Participants per year >180 Weekly On-Site ANNA Meetings held 4 Weekly On-Site ANNA attended by each participant 2 Weekly On-Site Community Meetings held 1 Percentage of participants attending Community Meetings 80% Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $9.9K $81,750 - Professional Fees $3.0K $23,000 - Operations $224.5K $250,250 $32,000 Supplies $7.1K $8,000 - Equipment $1.0K $1,000 - Other: Other: Other: Other: Other: TOTAL $245.5 $364,000 $32,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Alahou Clean & Sober Program Name: Clean and sober housing 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 conflict is needed. Please duplicate as needed to fully disclose.AN 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): IN No conflicts exist (No further information required. Please sign form at the bottom.) 0 Member or members of the Council _ Staff appointed by a member of the Council The Mayor n 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: V4 .42s 1,3t' % .1 28 ( ( 3 Signature of i orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Alahou Clean & Sober Program Name: Clean and sober housing 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. lJ (?' Signature of •uthori -d Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Alahou Clean & Sober Program Name: Clean and sober housing 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 \ \° \° \° \o \ \p \o \ \p \o 0 0 0 0 0 0 0 0 0 o to • MMNY- o y- C) - Q Cn • N O ti W r N O o r W — cc cn h CO X CO-0 u) U) • W W > 0 0 T Z tT'V CD 0. 0 00 M W 0 N = tll N 0 T �+ C y m JCf V MCA /� Q a 0 Q Cn C L_ N f6 •— 75 U xxxx N 0 E — W W W W _ O H W c - 0 HH Q (/) O LO V' a, LCD CO CD as CV CO CV r •�- N N N. N O 0 +r N } Co r�n� z ol 0 m >. 0 vJ a. L. H m-0 w CO 4--• d V N w @ O 000 -gyp m N tT 0 0 0 T 0 Z z Z co al 0 O o0 0 o ° ODO °)a � z M as 'V t• om- QQ Q v ca) n CO -C) ▪ C'7 C9 "5-5-5—E � 2 ltf 1,. 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I--- - Q P.= C) 00 I- 4 American Red Cross, Hawaii State Chapter Disaster Preparedness and Response in Hawai`I County Agency Name: American Red Cross, Hawaii State Chapter 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, HI 96816 Facility Address: Address: 55 Ululani Street Address: city,ST,zip Hilo, HI 96720 Email Address: Barney.Sheffield @redcross.org Fax No.: ( ) — Accountant/CPA: 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 Amount of Request for County Nonprofit Grant Program Funds: $20,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000 $15,000 $15,000 2.Agency Mission Statement: The Red Cross mission is to prevent and alleviate human suffering by mobilizing the power of volunteers and the generosity of donors. We do this by helping people prevent, prepare for and respond to emergencies and by providing disaster relief to the people of Hawaii 24 hours a day, 7 days a week and 365 days a year. We teach people how to save lives and provide emergency communication between deployed military service members and their families in times of crisis. Although established by Congressional Charter in 1905, the American Red Cross is NOT a government agency and must rely on the generosity of Hawaii's people to provide critical services to the community. All disaster training, services, and financial assistance to victims is free. Therefore, fundraising is critical to ensure that services can continue. Because we are an island community and considering the time it takes for assistance from other neighbor islands and the mainland, having the response capacity on island immediately after a disaster is essential. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: American Red Cross, Hawaii State Chapter Program Name: Disaster Preparedness and Response in Hawaii County 3. Program Description: The Hawaii County Red Cross Disaster Response and Preparedness Program 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. This assistance includes food, clothing, shelter, crisis counseling, and financial assistance to help families recover more quickly from a disaster. Our volunteers are ready to respond to disasters 24 hours a day, 7 days a week, 365 days a year. Recruiting, training and mobilizing volunteers is an ongoing process. We leverage the resources of our volunteers to provide this critical service. Community education, which empowers families and individuals to prepare for disasters, is also critical. (see additional page) 4.Total Budget& Position Count: Total Program Budget: 162,475 Total Program Position Count: 1 Total Agency Budget: 162,475 Total Agency Position Count: 1 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii County 20,000 Hawaii Island United Way 40,000 Special Events (Hats Off) 12,000 Other Contributions 71,000 Subsidy by American Red Cross to meet deficit 19,475 TOTAL: 162,475 Attach additional pages, if needed. 6. Explain what plans your agency or program Mas to increase revenues to support this program: We continue to work on increasing Red Cross visibility in the community in order to increase private individual and corporate donations from Big Island residents and businesses. We look for Big Island grant funders (private foundations, etc) and promote our annual Hats Off to the public to increase donations. The Red Cross is not a government agency and relies on the generosity of the public to provide our critical services. We emphasize to all that because a disaster can strike at any time without notice, advance preparation makes a significant difference in the well-being of a family or the resiliency of a business. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: American Red Cross, Hawaii State Chapter Program Name: Disaster Preparedness and Response in Hawaii County 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide for the immediate emergency needs of Big Island disaster victims (food, clothing, shelter, crisis counseling). Train volunteer disaster responders to serve their local communities during times of disaster. Provide essential disaster preparedness information to Big Island families, businesses, and communities so that they will be prepared before disasters strike. Hawaii County Funding is critical to build resiliency and capacity for the communities of Hawaii County. 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,voluntee-hours,etc.Describe,be specific.) Number of disasters responded to 15 Number of individuals assisted after disasters 40 Number of mass shelters opened and individuals sheltered 2/20 Number reached through community disaster presentations 1,000 Number of certificates issued for free disaster training 200 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 50,673 53,000 2,000 Professional Fees 0 Operations 72,000 72,000 Supplies 5,850 6,000 3,000 Equipment 0 Other: Disaster relief "(unpredictable) 22,788 20,000 15,000 Other: tvl/postage/gas/program related expenses 11,475 11,475 Other: Other: Other: TOTAL 162,786 162,475 20,000 *we are in midst of FY12-13, figures are budget *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FT 2013-2014 Page 3 of 7 Agency Name: American Red Cross, Hawaii State Chapter Program Name: Disaster Preparedness and Response in Hawaii County 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 conflict is needed. 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): 0 No conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council _ Staff appointed by a member of the Council _ The Mayor n 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: LL- Coralie Matayoshi, CEO January 29, 2013 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Red Cross Disaster Preparedness and Response in Hawaii County Additional Page for# 3 Program Description The Hawaii State Chapter was founded in 1917 and has assisted victims of every major disaster in the islands' history, including the bombing of Pearl Harbor, Hilo tsunami, volcanic eruptions, Kiholo Bay earthquake, Hurricanes Iwa and Iniki, New Years & Manoa floods, Kaloko Dam burst, Sacred Falls landslide, Xerox shooting, air transportation crashes, and hostage situations. The Hawaii County Red Cross Disaster Response and Preparedness Program 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. This assistance includes food, clothing, shelter, mental health counseling, and financial assistance to help families recover more quickly from a disaster. Our volunteers are ready to respond to disasters 24 hours a day, 7 days a week, 365 days a year. At the end of FY12, we had 124 active disaster volunteers on the Big Island and leverage the resources of our volunteers to provide this critical service. We also have more partner volunteers who are trained to help in a major disaster. Recruiting, training and mobilizing all of these volunteers is an ongoing job. Because a disaster can strike at any time without notice, advance preparation makes a significant difference in the well-being of a family or the resiliency of a business. As an island community and considering the time it takes for assistance from other neighbor islands and the mainland, having the response capacity on island immediately after a disaster is essential. All disaster training and response are provided free of charge. The Hawaii State Chapter continually trains volunteers to become disaster responders to serve during time of disasters (all disaster training is free). In the last fiscal year, the Red Cross conducted courses for volunteers in different communities statewide to achieve our objective of providing a seamless response when disaster strikes. We train volunteers to be able to conduct disaster assessment in neighborhoods, serve as shelter managers, conduct crisis counseling and emergency first aid and provide financial assistance to those whose homes have been affected by disaster. Our volunteers actively exercise with state agencies in preparation for natural disasters, pandemics and acts of terrorism. Through trained and capable disaster responders, communities will be better prepared prior to, during and after disasters. In light of lessons learned from the recent flooding, Superstorm Sandy and in the past from Hurricane Iniki, it is critical to have trained and capable volunteers ready and prepared to respond if a large disaster struck our islands. 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. These services are offered to anyone whose loved ones were directly affected by the event. Crisis counseling services may also be extended to the community for secondary victims. Another component of this program is community education, which empowers families and individuals to prepare for and respond to disasters before they strike. This will result in more aware and prepared communities. Red Cross volunteers and staff continually go out into the community to speak to the public about the importance of being prepared before a disaster strikes: get a disaster supplies kit, make a plan for your family and workers, and be informed. Because a disaster can strike at any time without notice, it is essential for communities to be prepared. Advance preparation can make a significant difference in the well-being of a family or the resiliency of a business. With the threat of pandemic influenza, bio-terrorist attacks, and major natural disasters, the American Red Cross is more relevant and necessary than ever before. With global warming and changing weather patterns, it is not"if," but "when" a major disaster in Hawaii will occur. Hawaii is especially vulnerable to hurricanes, tsunami, earthquakes, and other natural disasters. When a disaster strikes, we will have to be able to survive longer on our own due to our isolation. It is critical for the Red Cross to be prepared for and respond to everyday disasters and major disasters. Overall Goal: To provide 24/7 emergency disaster response and relief to those in need on the Big Island after a disaster (man-made or natural), train volunteer responders and share critical preparedness information to the communities on the Big Island. Who We Serve: The Big Island has had more than its share of disasters over the years, including devastating tsunami, lava flows, flooding, heavy rains, high surf, earthquakes, brush fires, air crashes, explosions and hazardous material incidents. Whatever the incident, the Red Cross has always been there, ready to help those in need. The Hawaii Red Cross provides compassionate aid to people in Hawaii who fall victim to natural and man-made disasters that occur every 3 to 4 days in Hawaii. Disaster victims served by the Hawaii Red Cross are the poorest of the poor. All disaster training and response are provided free of charge, due to the generosity of our donors. According to a U.S. Census Bureau Report, 15.8% of the Big Island population lives below the poverty level. This "poor and needy" population is particularly vulnerable to disasters and is dependent on Red Cross services when affected by a disaster. In FY 12, the Red Cross responded to 13 disasters on Big Island enabling 37 individuals to recover from their losses and begin rebuilding their lives Based on family size and income levels, at least 56% of disaster families we served in FY12 on the Big Island were below the poverty level. Of the disaster families, 39% owned their home and only 22% had 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. In addition, we reached 885 persons in Hawaii County with disaster preparedness information through community presentations. This will help them be prepared before disasters strike. For new and existing volunteers, we issued 194 certificates in free disaster training courses This training is essential to build capacity on island. The Red Cross is truly a safety net for victims of"every day" disasters who have nowhere else to turn. The Red Cross not only offers food, clothing, and shelter to those who may have lost everything they own, but also volunteer caseworkers provide crisis counseling and emotional support to help these victims get back on their feet. Beyond the "every day" disasters, the Red Cross is preparing for and will respond to major disasters, which may affect the entire population of Hawaii, especially those with special needs like the elderly, frail, handicapped, and poor. Agency Name: American Red Cross, Hawaii State Chapter Program Name: Disaster Preparedness and Response in Hawaii County 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. s(C - Coralie Matayoshi, Chief Executive Officer January 29, 2013 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: American Red Cross, Hawaii State Chapter Program Name: Disaster Preparedness and Response in Hawaii County 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of disasters responded to 15 Number of individuals assisted after disasters 40 Number of mass shelters opened and individuals sheltered 2/20 Number reached through community disaster presentations 1,000 Number of certificates issued for free disaster training 200 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 2,000 Professional Fees Operations Supplies 3,000 Equipment Other: Disaster relief 15,000 Other: Other: Other: Other: TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 5 Arc of Kona Home and Community Based Services Life Skills Program Agency Name: Arc of Kona (Kona Association of Retarded Citizens) Program Name: Home and Community Based Services Life Skills Programs Agency Director: Gretchen Lawson, President, CEO Phone No.: (808) 323 — 2626 Contact Person: Gretchen Lawson Phone No.: (808) 323 — 2626 Mailing Address: Address: PO Box 127 Address: City,ST,Zip Kealakekua, HI 96750 Facility Address: Address: 81-1065 Konawaena School Road Address: City,ST,Zip Kealakekua, HI 96750 Email Address: gretchen @arcofkona.org Fax No.: (808) 323 — 9444 Accountant/CPA: 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 Amount of Request for County Nonprofit Grant Program Funds: $10,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $15,000 $10,000 $10,000 2.Agency Mission Statement: The Big Island Association to Help Retarded Citizens began in 1962, incorporated in 1966 as Kona Association for Retarded Citizens/Kona Krafts and is now dba The Arc of Kona. The names have changed and the type of programs and services have also changed but the mission has remained consistant: "to aid people with disabilities, their advocates and families; to help persons with disabilties achieve the fullest possible independence and participation in society consistent with their wishes." Today the array of services includes employment programs (Arc of Kona became a certified 'Employment Network with the Social Security Administration in April 2012), housing: both independent living and assisted living, therapeutic and life skills training and personal care. The Arc of Kona began 51 years ago in West Hawaii but now supports individuals and families in all districts across Hawaii Island. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Arc of Kona (Kona Association of Retarded Citizens) Program Name: Home and Community Based Services Life Skills Programs 3. Program Description: Arc of Kona will provide critical Life Skills training to 107 persons in the community and 25 adults in a classroom setting diagnosed with an Intellectual/Developmental disability.Arc of Kona reaches to the most rural settings (Puna/Hamakua/Kohala)that lack adequate access to needed services.Individualized measurable goals are designed for each participant in the areas of health,hygiene,safety, behavior,communication,independent living or employment with needs determined by the individual,the family and the Department of Health.These skill sets allow the individual to better integrate into their community sharing their own unique skills and when possible, gaining employment and earning an income of their own.As individuals gain greater independence,they can contribute to society and release their families so they are able to become employed and pursue other endeavors that enhance the county of Hawaii. 4.Total Budget&Position Count: Total Program Budget: $2,771,762 Total Program Position Count: 75 Total Agency Budget: $3,303,110 Total Agency Position Count: 104 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Medicaid H&CBS $2,615,000 HIUW $30,000 County of Hawaii $10,000 TOTAL: $2,655,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Arc of Kona has two signature events each year that raise program funds. For 16 years we have held an Annual Bazaar and Car Show the weekend before Thanksgiving. Our 14th Annual Bluegrass Concert with Grammy Award winning artists Laurie Lewis and Tom Rozum is scheduled at the Aloha Theater January 26, 2013. We have been actively and successfully working with our island-wide donors for additional program support for this critical life sustaining program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Arc of Kona (Kona Association of Retarded Citizens) Program Name: Home and Community Based Services Life Skills Programs 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide safe, healthy and supportive environment for measureable Life Skills training in the community setting 365 days a year for 107 participants receivng Home and Community Based Services island-wide with the focus on the rural underserved areas of the island. 2. Provide safe secure classroom environment for 25 adults that allow each participant to develop measureable Life Skills at his or her own pace. 3. Foster independence and less use of any Government funding for support. 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. 260 days of Adult Day Health Classroom activities for 25 adults 1.Safe secure classroom 2. 365 days one on one Life Skills training to 107 in the community 2.On going skills training 3. 365+ transports into the community for services 3.Access to services 4.Quarterly pre/post testing in Life Skills areas to measure progress 4.Baseline and measurable using best practice materials. outcomes for each goal with 80% showing improvement See additional page in at least one goal area Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Req Actual* Total Budget Salary and Wages 1,986,334 2,000,000 9,000 Professional Fees Operations 324,640 325,000 1,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 2,310,974 2,325,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 ARC OF KONA HOME AND COMMUNITY BASED SERVICES LIFE SKILLS PROGRAM COUNTY GRANT PROPOSAL 2013-2014 Performance Measures Additional Information: Home and Community Based FY 2013-2014 Services Life Skills Program 1. a. Provide a safe, secure classroom 260 days of ADH standard classroom activities with a environment with sufficient staff one staff to four ratio for 25-30 participants and 365 supervision, 5 days a week, 52 weeks a days of one on one services for 107 participants. year, for current 25 DD/ID participants. b. Deliver ongoing Life Skills training in the classroom and the rural areas as per each individual's plan which is developed by the Department of Health, the family and the Arc of Kona. 2. Provide access to the community for 144 ADH classroom transports proposed and 365+ hands-on life skills training experiences individual transports proposed to achieve Life Skills plan including food and clothing, shopping, fire in the community. safety, ordering and eating in public, handling money, making appointments, nutrition and exercise, and appropriate behaviors in public (including sexual behavior). 3. Provide on-going Life Skills 365 days of instruction proposed with assessment, base assessments and data collection for each line, and data collection for results reporting four times a individual. This includes areas such as year to measure progress growth and the need to make recognizing and reporting abuse, health, any changes or corrections to the goals. hygiene, safety, socialization, basic cooking skills, behaviors, consumerism, basic literacy and job skills training. • Agency Name: Arc of Kona (Kona Association of Retarded Citizens) Program Name: Home and Community Based Services Life Skills Programs 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) 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: am4,7(.44. President/CEO January 23 , 2013 Si ' ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Arc of Kona (Kona Association of Retarded Citizens) Program Name: Home and Community Based Services Life Skills 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, 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. i� r%" ,�y✓ President/CEO January 23 , 2013 Si ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Arc of Kona (Kona Association of Retarded Citizens) Program Name: Home and Community Based Services Life Skills Programs 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1.260 days of Adult Day Health Classroom activities for 25 adults Safety 2.365 days of Life Skills training to 107 people in the community On going skills 3.365+transports to various locations in community for services Access 4.Quarterly pre/post testing in Life Skills to measure progress Baseline and using best practices materials. outcomes 80% attain at least one goal area TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 9,000 Professional Fees Operations 1,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 10 , 000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 6 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 Mato Phone No.: (808) 695 — 4564 Mailing Address: Address: 418 Kuwili St #106 Address: City,ST,Zip Honolulu, HI 96817 Facility Address: Address: 6 Kamehameha Avenue #6 Address: City,ST,Zip Hilo, HI 96720 Email Address: jmatro @bbbshawaii.org Fax No.: (808) 356 — 3536 Accountant/CPA: Rebekah Remchuk Phone No.: (808) 695 — 4561 Firm (if applicable): Mailing Address: Address: 418 Kuwili St #106 Address: City,ST,zip Honolulu, HI 96817 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $5000 2.Agency Mission Statement: Big Brothers Big Sisters Hawaii is a prevention oriented non-profit agency which operates under the belief that inherent in every child is the desire to succeed and thrive in life. Our mission to is create meaningful, carefully monitored "matches" between qualified volunteers ("Bigs") and children ("Littles"), ages 6 through 18, in communities across the state. Mentorship provides support and stability, helping children reach their fullest potential. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Big Brothers Big Sisters Hawaii Program Name: School Based Program 3. Program Description: Our School Based Program offers elementary school students the opportunity to meet with a high school mentor at their school for an hour a week alongside other "Bigs" and "Littles". A professionally trained case manager facilitates each mentoring session which begins with homework and ends with an activity specially designed to foster a deeper relationship between the pair. By working closely with our case managers, high school mentors are supported in their educational goals through guidance, letters of recommendation, and most importantly, the chance to see first-hand that one person can be the difference for a child. The focus of this specific grant will be to open our third after-school site in Hilo, located at Waiakea Elementary. 4. Total Budget& Position Count: Total Program Budget: $71,888 Total Program Position Count: 1 Total Agency Budget: $1.63M Total Agency Position Count: 25 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii Community Foundation - East Hawaii Fund $1,950 Kamehameha Schools 47,900 TOTAL: $49,850 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The signature fundraising event for Big Brothers Big Sisters (BBBS) nationally is Bowl for Kids' Sake (BFKS). The BFKS event in Honolulu raised $365,000 for BBBS Hawaii in Sept 2012. The Hilo advisory committee is in the process of planning its first Bowl for Kids' Sake event for June 15, 2013 at the Hilo Lanes. In addition, Savers Inc., a partner of BBBS Hawaii Foundation is seeking to begin operations in Kona. BBBS Hawaii is currently doing the leg work to establish three donation sites in Kona that will help to bring in revenue for programs on Hawaii Island. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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: Presently, BBBS of Hawaii Island has one full-time case manager. Through the efforts of this staff member, two after-school sites are currently at 90% capacity in their first year of operation. The administration of Waiakea Elementary has asked our agency to consider opening our school based program on their campus. The use of these funds will be focused on hiring a part time case manager to launch the Waiakea site in the fall of 2013 and build the number of children served in our Community Based 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,volunteer hours,etc.Describe,be specific.) Recruitment of children/mentors, process 24 inquiries enroll 16-20 participants Build community support/awareness, min of 4 agency presentations (2) two partnership MOUs Pair compatible children/mentors, create 8-10 "matches" 80% capacity enrollment Facilitate wkly sessions Oct 2012 - May 2013, min 20 sessions administer BBBSH curriculum Administer Youth Outcome survey to 80% of participants research based results 70% of participants will complete program global learning for participants Address DOE general learning outcomes 1, 2, 3 & 5 Assist schools to meet stndard Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages 23,536 59,345 19,782 Professional Fees 83 1,855 619 Operations 6,827 7,813 3,641 Supplies 419 423 141 Equipment 384 85 28 Other: 250 2,367 789 Other: Other: Other: Other: TOTAL 31,499 71,888 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Big Brothers Big Sisters Hawaii Program Name: School Based Program 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 conflict is needed. 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): ✓ No conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council nThe Mayor nThe 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: f'`e /C.e_.6 Zy-,-A1A-4-tr 2-S) 13 Sign ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Big Brothers Big Sisters Hawaii Program Name: School Based 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. ! ('� dcsr C) zS 2t5'( ?� Sig re "thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 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 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 7 Big Island Mediation Inc., 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,sr,zip Kamuela, HI 96743 Facility Address: Address: 65-1291 Kawaihae Rd Address: City,ST,Zip Kamuela, HI 96743 Email Address: ED©whmediation.org Fax No.: (808) 885 — 5525 Accountant/CPA: 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 Amount of Request for County Nonprofit Grant Program Funds: 15,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 10,000 8,000 12,240 2.Agency Mission Statement: West Hawaii Mediation Center exists to improve the way people deal with conflict by providing mediation, facilitation, conflict resolution education and training services. Our purpose is to help people find peaceful, participatory solutions to the inevitable conflicts that arise in any community. We do this in three ways: 1) providing mediation and facilitation services to community members; 2) providing conflict resolution education to youth; and 3)training residents to act as volunteer mediators in their community. WHMC has worked with the State Judiciary, United Way, and other local organizations to create the only non-profit mediation service serving West Hawaii. Mediation provides an alternative, peaceful method to resolve disputes; it is also a viable alternative to the judicial system for individuals with limited access to legal resources. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Big Island Mediation inc dba West Hawaii Mediation Center Program Name: Mediation Services 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 disp utes 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 volunteers to deliver this vital service to their fellow community members. 4.Total Budget&Position Count: Total Program Budget: 134,744 Total Program Position Count: 2.8 Total Agency Budget: 134,744 Total Agency Position Count: 2.8 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii Justice Foundation 4,000 State of Hawaii 39,138 County of Hawaii 15,000 Hawaii Island United Way 12,000 Private Foundations/Grants 20,000 Donations and Fundraising 12,606 New Grants 17,000 TOTAL: See attached Attach additional pages,if needed. 6. Explain what plans your agency or program has 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 has also partnered with Kona-Kohala Chamber of commerce for a "Green Homes 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 2012. 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Big Island Mediation inc dba West Hawaii Mediation Center Program Name: Mediation 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 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) 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 client 50% Conflict Resolution Education training for youth 5 Volunteer trainings and skills enhancement trainings 8 Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Reg Salary and Wages 109,528 85,244 10,000 Professional Fees 5,000 500 0.0 Operations 43,940 30,000 3,000 Supplies 4,000 2,000 0.0 Equipment 2,300 0.00 0.0 Other: 20,000 14,000 300 Other: 4,500 3,000 1,700 Other: Other: Other: TOTAL 189,268 134,744.00 15,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Big Island Mediation inc dba West Hawaii Mediation Center Program Name: Mediation Services 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) 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: Alt _..it lig0-3 Si:- .ture o ' rson (specify -) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Big Island Mediation inc dba West Hawaii Mediation Center Program Name: Mediation 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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/fin-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, 2014 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. !C `iv 1- " -ct ) 1 3 arature of Authorized Person (specify title) Date L xec 1, e -15Irec---c C EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Big Island Mediation inc dba West Hawaii Mediation Center Program Name: Mediation Services 12.COUNCIL AWARD WORKSHEET TABLE I: 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 client 50% Conflict Resolution Education training for youth 5 Volunteer trainings and skills enhancement trainings 8 G82 0■6\ - OY 15 \ ''Da3e TABLE H: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 10,000 Professional Fees Operations 3,000 Supplies Equipment Other: 300 Other: 1700 Other: Other: Other: TOTAL 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 5. Program funding Sources continued Revenue Source FY 2012-2013 Service/Program fees 2,000.00 Client Private fees 13,000 Total 134,744 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 1: Clients willing to recommend services to 95% others(percentage) Clients satisfied with services(presented as 95% percentage) 8 Big Island Resource Conservation & Development (BIRCD) Hawaii Homegrown Food Network (HHFN) Agency Name: Big Island Resource Conservation & Development (BIRCD) Program Name: Hawai'i Homegrown Food Network (HHFN) Agency Director: David "Kawika" Marquez Phone No.: (808) 935 — 8426 Contact Person: Carol Sampaia Phone No.: (808) 935 — 8426 Mailing Address: Address: 200 Kanoelehua Ave, PMB 285 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 202 B Chong Street (this is a home office) Address: City,ST,Zip Hilo, HI 96720 Email Address: brcd @hawaii.rr.com Fax No.: ( ) — Accountant/CPA: Elizabeth De Roche Phone No.: (406) 741 — 5843 Firm (if applicable): Mailing Address: Address: PO Box 483 Address: City,ST,Zip Hot Springs, MT 59845 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $14,500 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $10,000 2.Agency Mission Statement: BIRCD (fiscal sponsor): "To assist people in achieving sustainable development while caring for and appreciating their natural environments; to ensure broadened economic opportunities, enriched communities and better lives" HHFN: "To build and support a new food paradigm based on a thriving community network of sustainable food system stakeholders through education, research, information, partnership, facilitation, and training." EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Big Island Resource Conservation & Development (BIRCD) Program Name: Hawai'i Homegrown Food Network (HHFN) 3. Program Description: HHFN's core outreach via a monthly e-mail newsletter and frequently updated website (www.hawaiihomegrown.net) currently have 1500 subscribers and 200 daily website visitors, respectively. HHFN resources include the island's most complete and accurate farmers market directory with 30 detailed market profiles featuring 90 local vendors; the most up-to-date and comprehensive calendar of educational and skill-building local food events in the county; and an ever-expanding library of local agricultural resources and websites from Hawaii universities, public and private sectors. HHFN also is principal organizer of Ho'oulu ka 'Ulu, a major project to revitalize breadfruit and other traditional crops. HHFN's outreach activities constitute a significant capacity-building resource to increase production of our county's locally grown food. 4.Total Budget& Position Count: Total Program Budget: $28,085 Total Program Position Count: 4 Total Agency Budget: $46,289 Total Agency Position Count: 1 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Admin fees from special projects (Ho'oulu ka 'Ulu) 5,000 In-kind from volunteer staff 8,585 County Nonprofit Grant 14,500 TOTAL: 28,085 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HHFN will develop a fundraising plan in consultation with a fundraising planner who works with nonprofits such as ours. Revenue development plans include a Board initiative to individual donors, grant proposals to new funding sources, a public donation campaign, an annual supporting membership fee, and sales of products that promote locally and sustainably grown food. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Big Island Resource Conservation & Development (BIRCD) Program Name: Hawai'i Homegrown Food Network (HHFN) 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Expand and continue to publish monthly newsletter with two additional reporters 2. Increase newsletter subscription base and website social network members 3. Upgrade Farmers Market Page with more complete information and directional maps 4. Increase marketing of two Breadfruit Festivals (one each in Kona and Puna) &tree sales 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. Number of newsletters & feature articles 12 with four articles each 2. Number of new sub-contracted professional writers 2 3. Number of new newsletter subscribers increase from 1500 to 1800 4. Number of new website social network members increase from 430 to 500 5. Number of on-line maps to island farmers markets 25 6. Number of Breadfruit Festival attendees Min. 1000 each, Kona & Puna 7. Number of Breadfruit tree sales 100 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 F'13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 6,214 11,287 9,936 Professional Fees 600 4,800 2,400 Operations 860 860 860 Supplies Equipment Other: 8,585 8,585 Other: 1,625 2,553 1,320 Other: Other: Other: TOTAL 17,884 28,085 14,516 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: BIRCD Program Name: Hawaii Homegrown Food Network 14. 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 conflict is needed. 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): IN No conflicts exist(No further information required. Please sign form at the bottom.) 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: z--------------S"-- Wis'i)‘' 1/10 i 1 3 Signature of A thori -d Perso (speci title) Date EXHIBIT A NONPROFIT GRANT APPLICATION. FY 2013-2014 Page 4 of 7 Agency Name: Big Island Resource Conservation & Development (BIRCD) 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, 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.govffn-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, 2014 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 / e4/13 Signat re of A thorized P- .n (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Big Island Resource Conservation & Development (BIRCD) Program Name: Hawai'i Homegrown Food Network (HHFN) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1. Number of newsletters &feature articles 12 w/4 arts 2. Number of new sub-contracted professional writers 2 3. Number of new newsletter subscribers 300 4. Number of new website social network members 70 5. Number of on-line maps to county farmers markets 25 6. Number of Breadfruit Festival attendees 1000 7. Number of Breadfruit tree sales 100 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 9,936 Professional Fees 2,400 Operations 860 Supplies Equipment Other: 1,320 Other: Other: Other: Other: TOTAL 14,516 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 9 Big Island Resource Conservation & Development Council Military Family Gathering Agency Name: Big Island Resource Conservation & Development Council Program Name: Military Family Gathering Agency Director: David "Kawika" Marquez Phone No.: (808) 935 — 8426 Contact Person: Carol Sampaia Phone No.: (808) 935 — 8426 Mailing Address: Address: 200 Kanoelehua Ave Address: PMB 285 city,s-r,zip Hilo, Hawaii 96720 Facility Address: Address: 202 B Chong Street (this is a home office) Address: City,s-r,Zip Hilo, Hawaii 96720 Email Address: brcd @hawaii.rr.com Fax No.: (808) 935 — 8426 Accountant/CPA: Elizabeth De Roche Phone No.: (406) 741 — 5843 Firm (if applicable): Mailing Address: Address: P.O. Box 483 Address: City,s-r,zip Hot Springs, MT 59845 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $5,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $10,000.00 - - 2.Agency Mission Statement: " To assist people in achieving sustainable development while caring for and appreciating their natural environments; to ensure broadened economic opportunities, enriched communities and better lives". The Big Island Resource Conservation and Development Council is a 501(c)(3) non-profit corporation consisting of an all volunteer board of directors and one paid part-time employee. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name: Military Family Gathering 3. Program Description: A private Luau lunch on Sunday, May 19, 2013 at Aunty Sally's Luau House, honoring veterans who are/have returned from the war. These soldiers are still active duty and have served in Iraq and Afghanistan conflicts and will include their immediate families. This will be a one-time program to replace the Veterans' Day Parade 2013, which will be cancelled due to road repairs on Kamehameha Avenue. 4.Total Budget& Position Count: Total Program Budget: $5,000.00 Total Program Position Count: Volunteers Total Agency Budget: $46,289.00 Total Agency Position Count: 01 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Acct w/Fiscal Sponsor (Big Island RC&D Council) for Vet Day Parade $1000.00 Private Donations (requesting) $1000.00 Donations from Unions (State) and Local Businesses (requesting) $3000.00 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: Letters have been sent to private individuals, businesses, and state Unions requesting monetary donations. There is a carry over balance from the 2012 veterans'day parade that if need be, can be used towards this Program but will be used as a "last resort". EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name: Military Family Gathering 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective is to honor our veterans returning from Iraq and Afghanistan and their immediate families with an invitational luau. 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.) Clients Served 400 people Volunteer hours by Event Planner (Dan Kama) 800 hours Volunteer set-up/serves/clean-up (10 people) 80 hours Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages - - - Professional Fees - 500.00 Operations - - - Supplies - 4425.00 4425.00 Equipment - 350.00 350.00 Other: - 225.00 225.00 Other: Other: Other: Other: TOTAL - 5,500.00 5,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: BIRCD Program Name: Hawaii Homegrown Food Network 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 conflict is needed. Please duplicate as deeded to ful y 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): 0 No conflicts exist(No further information required. Please sign form at the bottom.) rTiMember 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 defiieed 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: ‘ \ T VIPI 6,)A-7 1 ke) / 1 Signature of Authorized Person( cify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name: Military Family Gathering 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 5 of 7 I(we)understand that failure to submit the final report within 60 days of June 30th shag ntEult in loss I _{l:nt 1. 1:_r 1;"_-1l A.-1 •_l.:l,'1.: !ai. "4r_LU _.-L'.' 1L_^1 _. 1-i1'LL ' " .2..:111 .1 11.' 1..L:.i1= '4r. 11 ' 1. 1'1-13.2.4. 1J _11. _ " 11'1 } lli�= 1 '.1.1 i `i l•u�•_ i* -n• acoeoted bv.tlrags acit 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 30,2014 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. A-V 41111•. E2 ..utc.) 25 22l natu of hori d Person(specify title) Date EXHIBIT A NONPRORT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Big Island Resource Conservation & Development Council Program Name: Military Family Gathering 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Clients Served 400 Volunteer Hours by Event Planner(Dan Kama) 800 hours Volunteer Set-up/Servers/Clean-Up 10 People TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages - Professional Fees - Operations - Supplies 4425.00 Equipment 350.00 Other: 225.00 Other: Other: Other: Other: TOTAL 5000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 • 4� -�,� r �tea; Adminpr L1�i t `�t of )t)" ( i01 t`' )ti ' '4' x[ )10 14 ` 1 + CORPORATE RESOLUTION I, David Marquez, President of Big Island Resource Conservation& Development Council, Inc., do hereby certify that the following is a full, true and correct copy of a resolution duly adopted by the Board of Directors of said Corporation, at it's meeting duly called at Hilo, Hawaii on the 24th Day of February 2012, at which a quorum was present and acting throughout; and that said resolution has not been modified, amended or rescinded and continues in full force and effect; RESOLVED that the persons holding the positions of President, David Marquez; Vice- President, Christopher Manfredi; Secretary, Larry Komata; and/or Treasurer, Leslie Takayama, are hereby authorized to execute on behalf of the Corporation any bid, proposal or contract for the sale or rental of the products of the Corporation or for services performed by the Corporation, and to execute any bond required by any such bid, proposal or contract with the United States Government, or the State of Hawaii or the City and County of Honolulu or County of Hawaii or County of Kauai or county of Maui or any department or subdivision of any of them. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the corporation seal of said Big Island Resource Conservation an d Development Council, Inc., this 24th day of February 2012. Davis qez, Pr rent 10 Boys & Girls Club of the Big Island Hamakua - Healthy STEMS Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua - Healthy STEMS 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 St. Address: City,sr,zip Hilo, HI 96720 Facility Address: Address: Paauilo Hongwanji Address: 43-1477 Haulolo Rd. City,ST,Zip Paauilo, HI 96776 Email Address: zavi@bgcbi.com Fax No.: (808) 961 — 5534 Accountant/CPA: Ann Fukuhara MBA CPA Phone No.: (808) 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku St., Suite 102 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000.00 $15,000.00 $15,000.00 2.Agency Mission Statement: Throughout its 60 year history, the Boys & Girls Club of the Big Island (BGCBI) has strived to fullfill its mission, "To inspire and enable Big Island youth to be productive and responsible citizens through quality programs in a safe and caring environment." Island wide, the Boys & Girls Club serves 400 youth per day. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua - Healthy STEMS 3. Program Description: The BGCBI is seeking County funds to implement "Healthy STEMS" (Science, Technology, Engineering and Math), a project based program of STEM Gardening for our community's youth ages 6 thru 17. "Healthy STEMS" will provide youth a unique, hands-on, inquiry-based experience via gardening. Gardens are living laboratories providing exposure to, and exploration of, a wide variety of topics in the STEM fields. "Healthy STEMS"falls within the larger evidence-based program currently being implemented at the BGC called "Triple Play for the Mind, Body and Soul"which stresses the importance of health, nutrition and healthy lifestyles for optimum growth physically, academically and socially. (See attached page for additional program information.) 4.Total Budget& Position Count: Total Program Budget: $65,737.00 Total Program Position Count: 4 Total Agency Budget: $1,463,750.00 Total Agency Position Count: 29 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate State of Hawaii, Grant in Aid (pending) $33,333.00 U.S. Dept. of Justice - OJJP (secured) $2404.00 County of Hawaii (pending) $30,000.00 TOTAL: $65,737.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Healthy STEMS" as a highly relevant and timely pilot gardening program for our youth. BGCBI has already initiated a community partnership to leverage University resources via the Pacific Island Programs for Exploring Science (PIPES) program to assist with in-kind expertise via science demonstrations and program advice. A successful pilot program will allow BGCBI to approach a variety of funders including, Hawaii Island United Way, Hawaii Community Foundation, the Wallace Foundation, Time Warner, and Boys & Girls Club of America. Additionally, BGCBI has been successful in capacity building, and has created a position dedicated to resource development. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua - Healthy STEMS 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives of the "Healthy STEMS" program are multi-dimensional, and encompass four main areas: 1.) Improved outcomes for youth in Health and Nutrition, 2.) Exposure of youth to Science, Technology, Engineering and Math via the context of a Garden, 3.) Introduction of youth to project-based Learning, and project life cycles. 4.) Allow youth to participate in a group goal, and to deliver the fruits of their efforts back to the community as an example of community giving. 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.) 20 Youth will participate twice weekly in Healthy STEMS 20 participating youth 2.) 80% of participating youth will increase understanding of the 80% of 20 youth importance of fresh produce to positive health outcomes as measured by pre and post tests. 3.) 100% of participating youth will increase the number of hours 100% of 20 youth per week in the garden, as measured by attendance logs. 4.) (see attached page) Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Req Actual* Total Budget Salary and Wages $39270.00 $17922.65 Professional Fees $3505.00 $1,600.00 Operations $3462.00 $1,580.00 Supplies $4006.00 $1,828.05 Equipment $4601.00 $2,100.00 Other: $4387.00 $2,000.00 Other: $6506.00 $2,969.30 Other: Other: Other: TOTAL 0 $65,737 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua - Healthy STEMS 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 conflict is needed. 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): 171 No conflicts exist (No further information required. Please sign form at the bottom.) 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: ----A ..4i ' t ,f t3 G✓o Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua - Healthy STEMS 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. 7)) gff e _ -.7)C 1/4T/i3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua - Healthy STEMS 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME: Hamakua- Healthy STEMS 1. Prior Year Award of County Nonprofit Grant Program Funds(continued): FY 12—13,$10,000.00 3. Program Description(continued) "Healthy STEMS" is a project-based gardening program for youth ages 6 thru 17 years. The creation of an after school garden will enable youth to be successful hands on learners who will be able to gain skills necessary to succeed in their future lives. Through this project will also learn connections between healthy food, nutrition and long term health benefits. Engaging in age appropriate projects and working in groups,youth will define goals,design their garden, prepare, plant, maintain and harvest food from the garden, and explore the environmental inputs and outputs.At the end of each semester, each gardening group will arrange to "give back"to their community with a donation of harvested produce to a local food basket. The youth will also learn teamwork and build positive relationships through the process of gardening in groups with positive adult leadership. The program will also foster a variety of life skills while teaching relevant topics in Science,Technology, Engineering and Math (STEM). Specific STEM topics from the garden will be expanded to underscore the relevance to STEM related careers. For example a discussion of the importance of the carbon cycle in plants will tie naturally to measurements of carbon in the atmosphere, and hence to a discussion of atmospheric science, meteorology,and climate science (esp. on Mauna Loa).Once these areas of STEM are introduced,youth will learn about related science careers(meteorologists, climate modelers, computer scientists, scientific instrument builders,data analysts etc.). BGCBI is partnering with U.H. Hilo's Pacific Island Programs for Exploring Science (PIPES).The PIPES group has volunteered to present a traveling science enrichment program to the club twice a year. As the Big Island community seeks to become more sustainable in energy and food production,the BGCBI is poised to contribute by delivering this important program,which will foster values and skills clearly aligned with the personal needs of our youth and the long term goals of the community. 8.See Table I continued below. AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME: Hamakua- Healthy STEMS 8.TABLE I (continued): Program Performance Measures Applicant Projected Results 4.) 80%of participating youth will show increased knowledge of the 80%of 20 youth science of gardening including soil and plant growth, as measured by pre and post tests. 5.) 80%of participating youth will show increased basic knowledge of the 80%of 20 youth careers available to scientists and others who support food production, as measured by pre and post tests. 6.)80%of participating youth will increase skills of planning, prioritizing 80%of 20 youth and managing for results, as determined by pre and post tests. 7.) 80%of participating youth will exhibit an increase in communication 80%of 20 youth skills including team-building, and collaboration, as determined by pre and post tests. 8.) 95%of participating youth will assist with harvest and donation of 95%of 20 youth food to a local food bank, as verified by a receipt from the Hawaii Island Food Bank. 9.) 95%of participating youth will help plan and deliver a community 95% of 20 youth "feast"from produce grown in the garden, as verified by sign-in sheet for the event. 9.Table II Explanation. Other 1:Liability Insurance Other 2:Administrative SECRETARY'S CERTIFICATE OF BOARD RESOLUTIONS I,the undersigned, do hereby certify: 1. That I am the duly elected and acting Secretary of the Boys and Girls Club of the Big Island, a Hawaii non-profit corporation. 2. That the following resolution was adopted by the Directors of the corporation at a duly called and held meeting of the Board of Directors on January 10,2013 and such resolution is still in effect as the date of this document, in addition, Toby Taniguchi was, and still is the Chief Volunteer Officer: "Resolved that the Chief Volunteer Officer of this corporation is authorized to enter into contracts and sign as signatory on any document in the name of the corporation as required from time to time. This resolution shall be valid until revoked by a vote of the board at a meeting duly noticed and held and where a quorum is present." IN WITNESS WHEREOF, I have hereunto subscribed my name this 10th day of January, 2013. Ne 'en J. Ch Secretary, Board of Directors `` 100 Kamakahonu Street Hilo,Hawaii 96720 `` Ph:808-961-5536 Fax: 808-961-5534 BOYS &GIRLS CLUB OF THE BIG ISLAND Visit the Club's Website at www.bgcbi.com SECRETARY'S CERTIFICATE OF BOARD RESOLUTIONS Chief Professional Officer Zavi Brees-Saunders Chief Volunteer Officer Toby Taniguchi I, the undersigned, do hereby certify: Chief Volunteer Officer Elect Donn Mende 1. That I am the duly elected and acting secretary of the Boys & Girls Club of the Big Island. Pice-President Mitch Roth 2. That the following resolution was adopted by the Directors of the corporation at a duly called and held meeting of the Board of Directors on June 21, 2011 Treasure, Ivan Nakano and such resolution is still in effect as of the date of this document, in addition Toby Taniguchi was and still is the Chief Volunteer Officer until June 30, Secretary 2013. Newton Chu 3. That as of July 1, 2013 Donn Mende will be Chief Volunteer Officer until Bill Past Walter Chief Volunteer Officer June 30,2015. "Resolved that the Chief Volunteer Officer of this corporation is authorized to Directors enter into contracts and sign as signatory on any document in the name of the Ann Kikuta corporation as required from time to time.This resolution shall be valid until Bonnie Geiger Burt Tsuchiya revoked by a vote of the board at a meeting duly noticed and held where a Corinne Akatsuka quorum is present," Cyrus Wilson Gregg Hirata Harry Yada an Nakano IN WITNESS WHEREOF, I have hereunto subscribed my name this 10th day of Jerry Watanabe January 2013. Julia Neal Kiyoko Ota Mike Tulang Randy Kurohara if/ Rhea Lee Russell Chin 7 Russell Hayashi Newto Chu / Ryan Kadota Secret.i ,Board of Directors Tom Brown Warren Lee Wayne Yamauchi United fY 1f. Way f : ... Hawaii Island Member Agency 11 Boys & Girls Club of the Big Island Hilo - Healthy STEMS Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo - Healthy STEMS 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 St. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu St. Address: City,ST,Zip Hilo, HI 96720 Email Address:zavi@bgcbi.com Fax No.: (808) 961 — 5534 Accountant/CPA: Ann Fukuhara MBA CPA Phone No.: (808) 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku St., Suite 102 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $31 ,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $30,000.00 $20,000.00 $20,000.00 2.Agency Mission Statement: Throughout its 60 year history, the Boys & Girls Club of the Big Island (BGCBI) has strived to fullfill its mission, "To inspire and enable Big Island youth to be productive and responsible citizens through quality programs in a safe and caring environment." Island wide the Boys & Girls Club serves 400 youth per day. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo - Healthy STEMS 3. Program Description: The BGCBI is seeking County funds to implement "Healthy STEMS" (Science, Technology, Engineering and Math), a project based program of STEM Gardening for our community's youth ages 6 thru 17. "Healthy STEMS"will provide youth a unique, hands-on, inquiry-based experience via gardening. Gardens are living laboratories providing exposure to, and exploration of, a wide variety of topics in the STEM fields. "Healthy STEMS"falls within the larger evidence-based program currently being implemented at the BGC called "Triple Play for the Mind, Body and Soul"which stresses the importance of health, nutrition and healthy lifestyles for optimum growth physically, academically and socially. (See attached page for further program details.) 4.Total Budget& Position Count: Total Program Budget: $75,551.00 Total Program Position Count: 5 Total Agency Budget: $1,463,750.00 Total Agency Position Count: 29 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate State of Hawaii, Grant in Aid (pending) $33,333.00 U.S. Dept. of Justice - OJJP (secured) $11,218.00 County of Hawaii (pending) $31,000.00 TOTAL: $75,551.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Healthy STEMS" as a highly relevant and timely pilot gardening program for our youth. BGCBI has already initiated a community partnership to leverage University resources via the Pacific Island Programs for Exploring Science (PIPES) program to assist with in-kind expertise via science demonstrations and program advice. A successful pilot program will allow BGCBI to approach a variety of funders including, Hawaii Island United Way, Hawaii Community Foundation, the Wallace Foundation, Time Warner, and Boys & Girls Club of America. Additionally, BGCBI has been successful in capacity building, and has created a position dedicated to resource development. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo - Healthy STEMS 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives of the Healthy STEMS program are multi-dimensional, and encompass four main areas: 1.) Improved outcomes for youth in Health and Nutrition, 2.) Exposure of youth to Science, Technology, Engineering and Math via the context of a garden.3.) Introduction of youth to Project-Based Learning, and project life cycles. 4.)Allow youth to participate in a group goal, and to deliver the fruits of their efforts back to the community as an example of community giving. 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.) 20 Youth will participate twice weekly in Healthy STEMS 20 youth participating youth 2.) 80% of participating youth will increase understanding of the 80% of 20 youth importance of fresh produce to positive health outcomes as measured by pre and post tests. 3.) 100% of participating youth will increase the number of hours 100% of 20 youth per week in the garden, as measured by attendance logs 4.) (see attached page) Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages $45,775 $18420.26 Professional Fees $4,176 $1,600.00 Operations $4,673 $1,800.00 Supplies $4,202 $1,610.43 Equipment $4,176 $1,600.00 Other: $5,170 $2,000.00 Other: $7,379 $2,969.30 Other: $0 $1,000.00 Other: Other: TOTAL 0 $75,551 $31,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo - Healthy STEMS 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 conflict is needed. 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): Q No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: ■14 I ig 943 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo - Healthy STEMS 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. . (,) - C V D % 21113 Signature of Authoriz.. Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo - Healthy STEMS 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME: Hilo- Healthy STEMS 1. Prior Year Award of County Nonprofit Grant Program Funds(continued): FY 12—13,$10,000.00 3. Program Description (continued) "Healthy STEMS" is a project-based gardening program for youth ages 6 thru 17 years. The creation of an after school garden will enable youth to be successful hands on learners who will be able to gain skills necessary to succeed in their future lives. Through this project youth will also learn connections between healthy food, nutrition and long term health benefits. Engaging in age appropriate projects and working in groups,youth will define goals, design their garden, prepare, plant, maintain and harvest food from the garden, and explore the environmental inputs and outputs.At the end of each semester,each gardening group will arrange to"give back"to their community with a donation of harvested produce to a local food basket. The youth will also learn teamwork and build positive relationships through the process of gardening in groups with positive adult leadership. The program will also foster a variety of life skills while teaching relevant topics in Science,Technology, Engineering and Math (STEM). Specific STEM topics from the garden will be expanded to underscore the relevance to STEM related careers. For example a discussion of the importance of the carbon cycle in plants will tie naturally to measurements of carbon in the atmosphere,and hence to a discussion of atmospheric science, meteorology,and climate science (esp. on Mauna Loa).Once these areas of STEM are introduced,youth will learn about related science careers(meteorologists,climate modelers, computer scientists, scientific instrument builders,data analysts etc.). BGCBI is partnering with U.H. Hilo's Pacific Island Programs for Exploring Science (PIPES).The PIPES group has volunteered to present a traveling science enrichment program to the club twice a year. Additionally,the PIPES group has offered to coordinate and facilitate the placement of a university student scholar to assist with science explorations in the garden. As the Big Island community seeks to become more sustainable in energy and food production,the BGCBI is poised to contribute by delivering this important program,which will foster values and skills clearly aligned with the personal needs of our youth and the long term goals of the community. 8.See Table I continued below. AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME: Hilo- Healthy STEMS 8.TABLE I (continued): Program Performance Measures Applicant Projected Results 4.) 80%of participating youth will show increased knowledge of the 80%of 20 youth science of gardening including soil and plant growth, as measured by pre and post tests. 5.) 80%of participating youth will show increased basic knowledge of the 80%of 20 youth careers available to scientists and others who support food production, as measured by pre and post tests. 6.) 80%of participating youth will increase skills of planning, prioritizing 80%of 20 youth and managing for results, as determined by pre and post tests. 7.) 80%of participating youth will exhibit an increase in communication 80%of 20 youth skills including team-building, and collaboration, as determined by pre and post tests. 8.) 95%of participating youth will assist with harvest and donation of 95%of 20 youth food to a local food bank, as verified by a receipt from the Hawaii Island Food Bank. 9.) 95%of participating youth will help plan and deliver a community 95%of 20 youth "feast"from produce grown in the garden, as verified by sign-in sheet for the event. 9.Table II Explanation. Other 1: Liability Insurance Other 2:Administrative Other 3:Student Stipends($500/semester x 2 semesters) SECRETARY'S CERTIFICATE OF BOARD RESOLUTIONS I,the undersigned, do hereby certify: 1. That I am the duly elected and acting Secretary of the Boys and Girls Club of the Big Island, a Hawaii non-profit corporation. 2. That the following resolution was adopted by the Directors of the corporation at a duly called and held meeting of the Board of Directors on January 10, 2013 and such resolution is still in effect as the date of this document, in addition, Toby Taniguchi was, and still is the Chief Volunteer Officer: "Resolved that the Chief Volunteer Officer of this corporation is authorized to enter into contracts and sign as signatory on any document in the name of the corporation as required from time to time. This resolution shall be valid until revoked by a vote of the board at a meeting duly noticed and held and where a quorum is present." IN WITNESS WHEREOF, I have hereunto subscribed my name this 10th day of January, 2013. Ne .on J. Ch Secretary,Board of Directors 100 Kamakahonu Street Hilo,Hawaii 96720 Ph: 808-961-5536 Fax: 808-961-5534 BOYS &GIRLS CLUB OF THE BIG ISLAND Visit the Club's Website at www.bgcbi.com SECRETARY'S CERTIFICATE OF BOARD RESOLUTIONS Chief Professional Officer Zavi Brees-Saunders Chief Volunteer Officer Toby Taniguchi I, the undersigned,do hereby certify: Chief Volunteer Officer Elect 1. That I am the duly elected and acting secretary of the Boys & Girls Club of Donn Mende the Big Island. Lice-President Mitch Roth 2. That the following resolution was adopted by the Directors of the corporation at a duly called and held meeting of the Board of Directors on June 21, 2011 Treasurer Ivan Nakano and such resolution is still in effect as of the date of this document, in addition Toby Taniguchi was and still is the Chief Volunteer Officer until June 30, Secretory 2013. Newton Chu 3. That as of July 1, 2013 Donn Mende will be Chief Volunteer Officer until Past Chief Volunteer Officer Bill Walter June 30,2015. "Resolved that the Chief Volunteer Officer of this corporation is authorized to Directors enter into contracts and sign as signatory on any document in the name of the Ann Kikuta corporation as required from time to time.This resolution shall be valid until Bonnie Geiger Burt Tsuchiya revoked by a vote of the board at a meeting duly noticed and held where a Corinne Akatsuka quorum is present," Cyrus Wilson Gregg Hirata Harry Yada van Nakano IN WITNESS WHEREOF, I have hereunto subscribed my name this 10th day of Jerry Watanabe January 2013. Julia Neal Kiyoko Ota Mike Tulang Randy Kurohara air) Rhea Lee Russell Chin Russell Hayashi Newto Chu / Ryan Kadota Secret. ,Board of Directors Tom Brown Warren Lee Wayne Yamauchi United Y ' Way fir'.: Hawaii Island Member Agency 12 Boys & Girls Club of the Big Island Kea'au - Healthy STEMS Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau - Healthy STEMS 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 St. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 16-565 Keaau-Pahoa Rd. Address: City,ST,Zip Keaau, HI 96749 Email Address:zavi@bgcbi.com Fax No.: (808) 961 — 5534 Accountant/CPA: Ann Fukuhara MBA CPA Phone No.: (808) 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku St., Suite 102 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $31 ,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000.00 $15,000.00 $15,000.00 2.Agency Mission Statement: Throughout its 60 year history, the Boys & Girls Club of the Big Island (BGCBI) has strived to fullfill its mission, "To inspire and enable Big Island youth to be productive and responsible citizens through quality programs in a safe and caring environment." Island wide the Boys & Girls Club serves 400 youth per day. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau - Healthy STEMS 3. Program Description: The BGCBI is seeking County funds to implement "Healthy STEMS" (Science, Technology, Engineering and Math), a project based program of STEM Gardening for our community's youth ages 6 thru 17. "Healthy STEMS"will provide youth a unique, hands-on, inquiry-based experience via gardening. Gardens are living laboratories providing exposure to, and exploration of, a wide variety of topics in the STEM fields. "Healthy STEMS"falls within the larger evidence-based program currently being implemented at the BGC called "Triple Play for the Mind, Body and Soul"which stresses the importance of health, nutrition and healthy lifestyles for optimum growth physically, academically and socially. (See attached page for further program details.) 4.Total Budget& Position Count: Total Program Budget: $71,545.00 Total Program Position Count: 5 Total Agency Budget: $1,463,750.00 Total Agency Position Count: 29 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate State of Hawaii, Grant in Aid (pending) $33,333.00 U.S. Dept. of Justice - OJJP (secured) $7212.00 County of Hawaii (pending) $30,000.00 TOTAL: $71,545.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Healthy STEMS" as a highly relevant and timely pilot gardening program for our youth. BGCBI has already initiated a community partnership to leverage University resources via the Pacific Island Programs for Exploring (PIPES) program to assist with in-kind expertise via science demonstrations and program advice. A successful pilot program will allow BGCBI to approach a variety of funders including, Hawaii Island United Way, Hawaii Community Foundation, the Wallace Foundation, Time Warner, and Boys & Girls Club of America. Additionally, BGCBI has been successful in capacity building, and has created a position dedicated to resource development. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau - Healthy STEMS 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives of the "Healthy STEMS" program are multi-dimensional, and encompass four main areas: 1.) Improved outcomes for youth in Health and Nutrition. 2.) Exposure of youth to Science, Technology, Engineering and Math via the context of a garden. 3.) Introduction of youth to Project-Based Learning, and project life cycles. 4.)Allow youth to participate in a group goal, and to deliver the fruits of their efforts back to the community as an example of community giving. 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.) 20 Youth will participate twice weekly in Healthy STEMS 20 participating youth 2.) 80% of participating youth will increase understanding of the 80% of 20 youth importance of fresh produce to positive health outcomes as measured by pre and post tests. 3.) 100% of participating youth will increase the number of hours 100% of 20 youth per week in the garden, as measured by attendance logs 4.) (see attached page) Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $43,315 $18420.26 Professional Fees $3,962 $1600.00 Operations $3,421 $1370.00 Supplies $4,528 $1840.44 Equipment $4,433 $1800.00 Other: $4,904 $2000.00 Other: $6,982 $2969.30 Other: 0 $1000.00 Other: Other: TOTAL 0 $71,545 $31,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau - Healthy STEMS 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: PqC‘t) %r b 1 Is I ( Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau - Healthy STEMS 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. .77) ' I q,‘i 1? G'^ Signature of Autho -d Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Keaau - Healthy STEMS 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME: Keaau- Healthy STEMS 1.Prior Year Award of County Nonprofit Grant Program Funds(continued): FY 12—13,$10,000.00 3. Program Description (continued) "Healthy STEMS" is a project-based gardening program for youth ages 6 thru 17 years. The creation of an after school garden will enable youth to be successful hands on learners who will be able to gain skills necessary to succeed in their future lives. Through this project youth will also learn connections between healthy food, nutrition and long term health benefits. Engaging in age appropriate projects and working in groups,youth will define goals, design their garden, prepare, plant, maintain and harvest food from the garden, and explore the environmental inputs and outputs.At the end of each semester, each gardening group will arrange to "give back"to their community with a donation of harvested produce to a local food basket. The youth will also learn teamwork and build positive relationships through the process of gardening in groups with positive adult leadership. The program will also foster a variety of life skills while teaching relevant topics in Science,Technology, Engineering and Math (STEM). Specific STEM topics from the garden will be expanded to underscore the relevance to STEM related careers. For example a discussion of the importance of the carbon cycle in plants will tie naturally to measurements of carbon in the atmosphere,and hence to a discussion of atmospheric science, meteorology, and climate science (esp. on Mauna Loa). Once these areas of STEM are introduced,youth will learn about related science careers(meteorologists, climate modelers, computer scientists,scientific instrument builders, data analysts etc.). BGCBI is partnering with U.H. Hilo's Pacific Island Programs for Exploring Science (PIPES).The PIPES group has volunteered to present a traveling science enrichment program to the club twice a year. Additionally,the PIPES group has offered to coordinate and facilitate the placement of a university student scholar to assist with science explorations in the garden. As the Big Island community seeks to become more sustainable in energy and food production,the BGCBI is poised to contribute by delivering this important program,which will foster values and skills clearly aligned with the personal needs of our youth and the long term goals of the community. See Table I continued below. AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME: Keaau- Healthy STEMS 8.TABLE I (continued): Program Performance Measures Applicant Projected Results 4.) 80%of participating youth will show increased knowledge of the 80%of 20 youth science of gardening including soil and plant growth,as measured by pre and post tests. 5.) 80%of participating youth will show increased basic knowledge of the 80%of 20 youth careers available to scientists and others who support food production, as measured by pre and post tests. 6.) 80%of participating youth will increase skills of planning, prioritizing 80%of 20 youth and managing for results, as determined by pre and post tests. 7.) 80%of participating youth will exhibit an increase in communication 80%of 20 youth skills including team-building, and collaboration,as determined by pre and post tests. 8.) 95%of participating youth will assist with harvest and donation of 95%of 20 youth food to a local food bank, as verified by a receipt from the Hawaii Island Food Bank. 9.) 95%of participating youth will help plan and deliver a community 95%of 20 youth "feast"from produce grown in the garden, as verified by sign-in sheet for the event. 9.Table II Explanation. Other 1: Liability Insurance Other 2:Administrative Other 3:Student Stipend ($500/semester x 2 semesters) 13 Boys & Girls Club of the Big Island Ocean View - Healthy STEMS Agency Name: Boys & Girls Club of the Big Island Program Name: OceanView - Healthy STEMS 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 St. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 95-5635 Mamalahoa Hwy. Address: City,ST,Zip Naalehu, HI 96772 Email Address: zavi @becbi.com Fax No.: (808) 961 — 5534 Accountant/CPA: Ann Fukuhara MBA CPA Phone No.: (808) 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku St., Suite 102 Address: City,sr,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000.00 $15,000.00 $25,000.00 2.Agency Mission Statement: Throughout its 60 year history, the Boys & Girls Club of the Big Island (BGCBI) has strived to fullfill its mission, "To inspire and enable Big Island youth to be productive and responsible citizens through quality programs in a safe and caring environment." • Island wide the Boys & Girls Club serves 400 youth per day. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: OceanView- Healthy STEMS 3. Program Description: The BGCBI is seeking County funds to implement "Healthy STEMS" (Science, Technology, Engineering and Math), a project based program of STEM Gardening for our community's youth ages 6 thru 17. "Healthy STEMS" will provide youth a unique, hands-on, inquiry-based experience via gardening. Gardens are living laboratories providing exposure to, and exploration of, a wide variety of topics in the STEM fields. "Healthy STEMS" falls within the larger evidence-based program currently being implemented at the BGC called "Triple Play for the Mind, Body and Soul" which stresses the importance of health, nutrition and healthy lifestyles for optimum growth physically, academically and socially. (See attached page for further program details.) 4.Total Budget& Position Count: Total Program Budget: $65,737.00 Total Program Position Count: 4 Total Agency Budget: $1,463,750.00 Total Agency Position Count: 29 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate State of Hawaii, Grant in Aid (pending) $33,333.00 U.S. Dept. of Justice - OJJP (secured) $2404.00 County of Hawaii (pending) $30,000.00 TOTAL: $65,737.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Healthy STEMS" as a highly relevant and timely pilot gardening program for our youth. BGCBI has already initiated a community partnership to leverage University resources via the Pacific Island Programs for Exploring Science (PIPES) program to assist with in-kind expertise via science demonstrations and program advice. A successful pilot program will allow BGCBI to approach a variety of funders including, Hawaii Island United Way, Hawaii Community Foundation, the Wallace Foundation, Time Warner, and Boys & Girls Club of America. Additionally, BGCBI has been successful in capacity building, and has created a position dedicated to resource development. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: OceanView - Healthy STEMS 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives of the "Healthy STEMS" program are multi-dimensional, and encompass four main areas: 1.) Improved outcomes for youth in Health and Nutrition. 2.) Exposure of youth to Science, Technology, Engineering and Math via the context of a garden. 3.) Introduction of youth to Project-Based Learning, and project life cycles. 4.)Allow youth to participate in a group goal, and to deliver the fruits of their efforts back to the community as an example of community giving. 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.) 20 Youth will participate twice weekly in Healthy STEMS 20 participating youth 2.) 80% of participating youth will increase understanding of the 80% of 20 youth importance of fresh produce to positive health outcomes as measured by pre and post tests. 3.) 100% of participating youth will increase the number of hours 100% of 20 youth per week in the garden, as measured by attendance logs. 4.) (see attached page) Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Re q Salary and Wages $38,325 $17490.07 Professional Fees $3,506 $1600.00 Operations $3,900 $1780.00 Supplies $4,515 $2060.63 Equipment $4603 $2100.00 Other: $4382 $2000.00 Other: $6,506 $2969.30 Other: Other: Other: TOTAL 0 $65,737 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: OceanView- Healthy STEMS 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 conflict is needed. 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): [ I No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor n 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: —77)t / C.-41) 13 Signature of Autholl ed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: OceanView - Healthy STEMS 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. r y?,,c1R, Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: OceanView - Healthy STEMS 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME:OceanView-Healthy STEMS 1. Prior Year Award of County Nonprofit Grant Program Funds(continued): FY 12—13,$10,000.00 3. Program Description (continued) "Healthy STEMS" is a project-based gardening program for youth ages 6 thru 17 years. The creation of an after school garden will enable youth to be successful hands on learners who will be able to gain skills necessary to succeed in their future lives. Through this project youth will also learn connections between healthy food, nutrition and long term health benefits. Engaging in age appropriate projects and working in groups,youth will define goals,design their garden, prepare, plant, maintain and harvest food from their garden, and explore the environmental inputs and outputs.At the end of each semester, each gardening group will arrange to"give back"to their community with a donation of harvested produce to a local food basket. The youth will also learn teamwork and build positive relationships through the process of gardening in groups with positive adult leadership. The program will also foster a variety of life skills while teaching relevant topics in Science,Technology, Engineering and Math (STEM). Specific STEM topics from the garden will be expanded to underscore the relevance to STEM related careers. For example a discussion of the importance of the carbon cycle in plants will tie naturally to measurements of carbon in the atmosphere,and hence to a discussion of atmospheric science, meteorology,and climate science (esp. on Mauna Loa).Once these areas of STEM are introduced,youth will learn about related science careers(meteorologists,climate modelers, computer scientists,scientific instrument builders,data analysts etc.). BGCBI is partnering with U.H. Hilo's Pacific Island Programs for Exploring Science (PIPES).The PIPES group has volunteered to present a traveling science enrichment program to the club twice a year. The federally funded After School All Stars(ASAS) program,which operates out of Ka'u High School, has offered to share their on-site garden space, and professional resources with BGCBI youth from Ka'u for this project. BGCBI will work closely with ASAS to make this shared partnership a reality. As the Big Island community seeks to become more sustainable in energy and food production,the BGCBI is poised to contribute by delivering this important program,which will foster values and skills clearly aligned with the personal needs of our youth and the long term goals of the community. 8.See Table I continued below. AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME:OceanView- Healthy STEMS 8.TABLE I (continued): Program Performance Measures Applicant Projected Results 4.) 80%of participating youth will show increased knowledge of the 80%of 20 youth science of gardening including soil and plant growth, as measured by pre and post tests. 5.) 80%of participating youth will show increased basic knowledge of the 80%of 20 youth careers available to scientists and others who support food production, as measured by pre and post tests. 6.)80%of participating youth will increase skills of planning, prioritizing 80%of 20 youth and managing for results, as determined by pre and post tests. 7.)80%of participating youth will exhibit an increase in communication 80%of 20 youth skills including team-building, and collaboration, as determined by pre and post tests. 8.)95%of participating youth will assist with harvest and donation of 95%of 20 youth food to a local food bank, as verified by a receipt from the Hawaii Island Food Bank. 9.) 95%of participating youth will help plan and deliver a community 95%of 20 youth "feast"from produce grown in the garden, as verified by sign-in sheet for the event. 9.Table II Explanation. Other 1:Liability Insurance Other 2:Administrative 14 Boys & Girls Club of the Big Island Pahala - Healthy STEMS Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala - Healthy STEMS 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 St. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 96-1149 Kamani St. Address: City,ST,Zip Pahala, HI 96777 Email Address: zavi @becbi.com Fax No.: (808) 961 — 5534 Accountant/CPA: Ann Fukuhara MBA CPA Phone No.: (808) 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku St., Suite 102 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000.00 $15,000.00 $20,000.00 2.Agency Mission Statement: Throughout its 60 year history, the Boys & Girls Club of the Big Island (BGCBI) has strived to fullfill its mission, "To inspire and enable Big Island youth to be productive and responsible citizens through quality programs in a safe and caring environment." Island wide the Boys & Girls Club serves 400 youth per day. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala - Healthy STEMS 3. Program Description: The BGCBI is seeking County funds to implement "Healthy STEMS" (Science, Technology, Engineering and Math), a project based program of STEM Gardening for our community's youth ages 6 thru 17. "Healthy STEMS" will provide youth a unique, hands-on, inquiry-based experience via gardening. Gardens are living laboratories providing exposure to, and exploration of, a wide variety of topics in the STEM fields. "Healthy STEMS" falls within the larger evidence-based program currently being implemented at the BGC called "Triple Play for the Mind, Body and Soul"which stresses the importance of health, nutrition and healthy lifestyles for optimum growth physically, academically and socially. (See attached page for further program details.) 4.Total Budget& Position Count: Total Program Budget: $65,737.00 Total Program Position Count: 4 Total Agency Budget: $1,463,750.00 Total Agency Position Count: 29 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate State of Hawaii, Grant in Aid (pending) $33,333.00 U.S. Dept. of Justice - OJJP (secured) $2404.00 County of Hawaii (pending) $30,000.00 TOTAL: $65,737.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Healthy STEMS" as a highly relevant and timely pilot gardening program for our youth. BGCBI has already initiated a community partnership to leverage University resources via the Pacific Island Programs for Exploring (PIPES) program to assist with in-kind expertise via science demonstrations and program advice. A successful pilot program will allow BGCBI to approach a variety of funders including, Hawaii Island United Way, Hawaii Community Foundation, the Wallace Foundation, Time Warner, and Boys & Girls Club of America. Additionally, BGCBI has been successful in capacity building, and has created a position dedicated to resource development. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala - Healthy STEMS 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives of the "Healthy STEMS" program are multi-dimensional, and encompass four main areas: 1.) Improved outcomes for youth in Health and Nutrition. 2.) Exposure of youth to Science, Technology, Engineering and Math via the context of a garden. 3.) Introduction of youth to Project-Based Learning, and project life cycles. 4.)Allow youth to participate in a group goal, and to deliver the fruits of their efforts back to the community as an example of community giving. 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.) 20 Youth will participate twice weekly in Healthy STEMS 20 participating youth 2.) 80% of participating youth will increase understanding of the 80% of 20 youth importance of fresh produce to positive health outcomes as measured by pre and post tests. 3.) 100% of participating youth will increase the number of hours 100% of 20 youth per week in the garden, as measured by attendance logs. 4.) (see attached page) Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages $38,325 $17490.07 Professional Fees $3,506 $1600.00 Operations $4,120 $1880.00 Supplies $4,296 $1960.63 Equipment $4,602 $2100.00 Other: $4,382 $2000.00 Other: $6,506 $2969.30 Other: Other: Other: TOTAL 0 $65,737 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala - Healthy STEMS 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 conflict is needed. 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): WINo conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: Fe4-5- C /?i/12 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala - Healthy STEMS 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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 tz Gibs F.1C Signature of Authorize erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala - Healthy STEMS 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME: Pahala -Healthy STEMS 1. Prior Year Award of County Nonprofit Grant Program Funds(continued): FY 12—13,$10,000.00 3. Program Description (continued) "Healthy STEMS" is a project-based gardening program for youth ages 6 thru 17 years. The creation of an after school garden will enable youth to be successful hands on learners who will be able to gain skills necessary to succeed in their future lives. Through this project youth will also learn connections between healthy food, nutrition and long term health benefits. Engaging in age appropriate projects and working in groups,youth will define goals, design their garden, prepare, plant, maintain and harvest food from the garden, and explore the environmental inputs and outputs.At the end of each semester, each gardening group will arrange to"give back" to their community with a donation of harvested produce to a local food basket. The youth will also learn teamwork and build positive relationships through the process of gardening in groups with positive adult leadership. The program will also foster a variety of life skills while teaching relevant topics in Science,Technology, Engineering and Math (STEM). Specific STEM topics from the garden will be expanded to underscore the relevance to STEM related careers. For example a discussion of the importance of the carbon cycle in plants will tie naturally to measurements of carbon in the atmosphere, and hence to a discussion of atmospheric science, meteorology,and climate science (esp. on Mauna Loa). Once these areas of STEM are introduced,youth will learn about related science careers(meteorologists,climate modelers, computer scientists, scientific instrument builders,data analysts etc.). BGCBI is partnering with U.H. Hilo's Pacific Island Programs for Exploring Science (PIPES).The PIPES group has volunteered to present a traveling science enrichment program to the club twice a year. The federally funded After School All Stars(ASAS) program,which operates out of Ka'u High School, has offered to share their on-site garden space, and professional resources with BGCBI youth from Ka'u for this project. BGCBI will work closely with ASAS to make this shared partnership a reality. As the Big Island community seeks to become more sustainable in energy and food production,the BGCBI is poised to contribute by delivering this important program, which will foster values and skills clearly aligned with the personal needs of our youth and the long term goals of the community. 8. See Table I continued below. AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME: Pahala- Healthy STEMS 8.TABLE I (continued): Program Performance Measures Applicant Projected Results 4.) 80%of participating youth will show increased knowledge of the 80%of 20 youth science of gardening including soil and plant growth, as measured by pre and post tests. 5.) 80%of participating youth will show increased basic knowledge of the 80%of 20 youth careers available to scientists and others who support food production, as measured by pre and post tests. 6.) 80%of participating youth will increase skills of planning, prioritizing 80%of 20 youth and managing for results, as determined by pre and post tests. 7.)80%of participating youth will exhibit an increase in communication 80%of 20 youth skills including team-building, and collaboration, as determined by pre and post tests. 8.) 95%of participating youth will assist with harvest and donation of 95%of 20 youth food to a local food bank, as verified by a receipt from the Hawaii Island Food Bank. 9.)95%of participating youth will help plan and deliver a community 95%of 20 youth "feast"from produce grown in the garden, as verified by sign-in sheet for the event. 9.Table II Explanation. Other 1: Liability Insurance Other 2:Administrative SECRETARY'S CERTIFICATE OF BOARD RESOLUTIONS I,the undersigned,do hereby certify: 1. That I am the duly elected and acting Secretary of the Boys and Girls Club of the Big Island, a Hawaii non-profit corporation. 2. That the following resolution was adopted by the Directors of the corporation at a duly called and held meeting of the Board of Directors on January 10, 2013 and such resolution is still in effect as the date of this document, in addition, Toby Taniguchi was, and still is the Chief Volunteer Officer: "Resolved that the Chief Volunteer Officer of this corporation is authorized to enter into contracts and sign as signatory on any document in the name of the corporation as required from time to time. This resolution shall be valid until revoked by a vote of the board at a meeting duly noticed and held and where a quorum is present." IN WITNESS WHEREOF, I have hereunto subscribed my name this 10th day of January, 2013. X_I Ne 'In J. Ch , Secretary, Board of Directors `` 100 Kainakahonu Street Hilo,Hawaii 96720 Ph: 808-961-5536 Fax: 808-961-5534 BOYS &GIRLS CLUB OF THE BIG ISLAND Visit the Club's Website at www.bgcbi.com SECRETARY'S CERTIFICATE OF BOARD RESOLUTIONS Chi fPwfes.cioiutl Officer Zavi Brees-Saunders Chief Volunteer Officer Toby Taniguchi I, the undersigned, do hereby certify: Chief Volunteer Officer Elect Donn Mende 1. That I am the duly elected and acting secretary of the Boys & Girls Club of the Big Island. !-ice-President Mitch Roth 2. That the following resolution was adopted by the Directors of the corporation at a duly called and held meeting of the Board of Directors on June 21, 2011 Ivan Nakano and such resolution is still in effect as of the date of this document, in addition Toby Taniguchi was and still is the Chief Volunteer Officer until June 30, Secretary 2013. Newton Chu 3. That as of July 1, 2013 Donn Mende will be Chief Volunteer Officer until Past Chief Volunteer Officer Bill Walter June 30,2015. "Resolved that the Chief Volunteer Officer of this corporation is authorized to Directors enter into contracts and sign as signatory on any document in the name of the Ann Kikuta corporation as required from time to time.This resolution shall be valid until Bonnie Geiger Burt Tsuchiya revoked by a vote of the board at a meeting duly noticed and held where a Corinne Akatsuka quorum is present," Cyrus Wilson Gregg Hirata Harry Yada an Nakano IN WITNESS WHEREOF, I have hereunto subscribed my name this 10th day of Jerry Watanabe January 2013. Julia Neal Kiyoko Ota Mike Tulang Randy Kurohara Rhea Lee Russell Chin Russell Hayashi Newto Chu / Ryan Kadota Secret.1 ,Board of Directors Tom Brown Warren Lee Wayne Yamauchi UnitedY Ir Way; Hawaii Island Member Agency 15 Boys & Girls Club of the Big Island Pahoa - Healthy STEMS Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa - Healthy STEMS 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 St. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 15-3003 Kauhale St. Address: City,ST,Zip Pahoa, HI 96778 Email Address: zavi@bgcbi.com Fax No.: (808) 961 — 5534 Accountant/CPA: Ann Fukuhara MBA CPA Phone No.: (808) 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku St., Suite 102 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000.00 $15,000.00 $15,000.00 2.Agency Mission Statement: Throughout its 60 year history, the Boys & Girls Club of the Big Island (BGCBI) has strived to fullfill its mission, "To inspire and enable Big Island youth to be productive and responsible citizens through quality programs in a safe and caring environment." Island wide the Boys & Girls Club serves 400 youth per day. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa - Healthy STEMS 3. Program Description: The BGCBI is seeking County funds to implement "Healthy STEMS" (Science, Technology, Engineering and Math), a project based program of STEM Gardening for our community's youth ages 6 thru 17. "Healthy STEMS" will provide youth a unique, hands-on, inquiry-based experience via gardening. Gardens are living laboratories providing exposure to, and exploration of, a wide variety of topics in the STEM fields. "Healthy STEMS"falls within the larger evidence-based program currently being implemented at the BGC called "Triple Play for the Mind, Body and Soul"which stresses the importance of health, nutrition and healthy lifestyles for optimum growth physically, academically and socially. (See attached page for further program details.) 4.Total Budget& Position Count: Total Program Budget: $30,000.00 Total Program Position Count: 5 Total Agency Budget: $1,463,750.00 Total Agency Position Count: 29 S. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate State of Hawaii, Grant in Aid (pending) $33,333.00 U.S. Dept. of Justice - OJJP (secured) $5609.00 County of Hawaii (pending) $30,000.00 TOTAL: $68,942.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views "Healthy STEMS" as a highly relevant and timely pilot gardening program for our youth. BGCBI has already initiated a community partnership to leverage University resources via the Pacific Island Programs for Exploring Science (PIPES) program to assist with in-kind expertise via science demonstrations and program advice. A successful pilot program will allow BGCBI to approach a variety of funders including, Hawaii Island United Way, Hawaii Community Foundation, the Wallace Foundation, Time Warner, and Boys & Girls Club of America. Additionally, BGCBI has been successful in capacity building, and has created a position dedicated to resource development. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa - Healthy STEMS 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives of the "Healthy STEMS" program are multi-dimensional, and encompass four main areas: 1.) Improved outcomes for youth in Health and Nutrition. 2.) Exposure of youth to Science, Technology, Engineering and Math via the context of a garden. 3.) Introduction of youth to Project-Based Learning, and project life cycles. 4.) Allow youth to participate in a group goal, and to deliver the fruits of their efforts back to the community as an example of community giving. 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.) 20 Youth will participate twice weekly in Healthy STEMS 20 participating youth 2.) 80% of participating youth will increase understanding of the 80% of 20 youth importance of fresh produce to positive health outcomes as measured by pre and post tests. 3.) 100% of participating youth will increase the number of hours 100% of 20 youth per week in the garden, as measured by attendance logs. 4.) (see attached page) Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Reg Actual* Total Budget Salary and Wages $42,331 $18420.27 Professional Fees $3,677 $1600.00 Operations $3,493 $1520.00 Supplies $4,344 $1890.43 Equipment $3,677 $1600.00 Other: $4,596 $2000 Other: $6,824 $2969.30 Other: Other: Other: TOTAL 0 $68,942 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa - Healthy STEMS 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 conflict is needed. 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): 0 No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: -7)) �l l G� Signature of Author -: Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa - Healthy STEMS 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. __7hgT‘LD-----2J0 w/ ?Iite Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa - Healthy STEMS 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME: Pahoa-Healthy STEMS 1. Prior Year Award of County Nonprofit Grant Program Funds(continued): FY 12—13,$10,000.00 3. Program Description(continued) "Healthy STEMS" is a project-based gardening program for youth ages 6 thru 17 years. The creation of an after school garden will enable youth to be successful hands on learners who will be able to gain skills necessary to succeed in their future lives. Through this project youth will also learn connections between healthy food, nutrition and long term health benefits. Engaging in age appropriate projects and working in groups,youth will define goals,design their garden, prepare, plant, maintain and harvest food from the garden, and explore the environmental inputs and outputs. At the end of each semester,each gardening group will arrange to"give back"to their community with a donation of harvested produce to a local food basket.The youth will also learn teamwork and build positive relationships through the process of gardening in groups with positive adult leadership. The program will also foster a variety of life skills while teaching relevant topics in Science,Technology, Engineering and Math (STEM). Specific STEM topics from the garden will be expanded to underscore the relevance to STEM related careers. For example a discussion of the importance of the carbon cycle in plants will tie naturally to measurements of carbon in the atmosphere,and hence to a discussion of atmospheric science, meteorology,and climate science (esp. on Mauna Loa).Once these areas of STEM are introduced,youth will learn about related science careers(meteorologists, climate modelers, computer scientists,scientific instrument builders,data analysts etc.). BGCBI is partnering with U.H. Hilo's Pacific Island Programs for Exploring Science (PIPES).The PIPES group has volunteered to present a traveling science enrichment program to the club twice a year. As the Big Island community seeks to become more sustainable in energy and food production,the BGCBI is poised to contribute by delivering this important program,which will foster values and skills clearly aligned with the personal needs of our youth and the long term goals of the community. 8.See Table I continued below. AGENCY NAME: Boys&Girls Club of the Big Island PROGRAM NAME: Pahoa-Healthy STEMS 8.TABLE I (continued): Program Performance Measures Applicant Projected Results 4.)80%of participating youth will show increased knowledge of the 80%of 20 youth science of gardening including soil and plant growth, as measured by pre and post tests. 5.) 80%of participating youth will show increased basic knowledge of the 80%of 20 youth careers available to scientists and others who support food production, as measured by pre and post tests. 6.)80%of participating youth will increase skills of planning, prioritizing 80%of 20 youth and managing for results, as determined by pre and post tests. 7.)80%of participating youth will exhibit an increase in communication 80%of 20 youth skills including team-building, and collaboration, as determined by pre and post tests. 8.) 95%of participating youth will assist with harvest and donation of 95%of 20 youth food to a local food bank, as verified by a receipt from the Hawaii Island Food Bank. 9.)95%of participating youth will help plan and deliver a community 95%of 20 youth "feast"from produce grown in the garden, as verified by sign-in sheet for the event. 9.Table II Explanation. Other 1: Liability Insurance Other 2:Administrative 16 Brantley Center, Inc Employment Rehabilitation Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation Agency Director: Steven Pavao Phone No.: (808) 775 — 7245 Contact Person: Steven Pavao Phone No.: (808) 775 — 7245 Mailing Address: Address: P.O. Box 1407 Address: City,sr,Zip Honoka'a, HI 96727 Facility Address: Address: 45-370 Ohelo Street Address: City,sr,Zip Honoka'a, HI 96727 Email Address: bcenter2 @hawaiiantel.net Fax No.: (808) 775 — 0211 Accountant/CPA: Jennifer L. Gossert, CPA Phone No.: (808) 969 — 3115 Firm (if applicable): Same Mailing Address: Address: 688 Kino'ole Street Suite 201 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $40,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000 $15,000 $13,750 2.Agency Mission Statement: To provide quality rehabilitative services to people with disabilities that empower them to participate independently in their community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation 3. Program Description: The Employment Rehabilitation Program provides participants with a variety of services that develop and support the accomplishment of goals leading to meaningful employment . These services include;job-readiness classes, competitive employment placement services, and on-the-job follow-up services. Participants receive quality vocational training and at the same time are paid for the work performed. Program staff work closely with the community to provide community-based vocational training, and at the same time provide the public with an additional workforce. Also included in this program are the work transition services for high school students with disabilities. 4.Total Budget& Position Count: Total Program Budget: $234,665 Total Program Position Count: 4 Total Agency Budget: $346,394 Total Agency Position Count: 8 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii Non-Profit Grant $40,000 State of Hawaii DHS Vocational Rehabilitation Grant $30,000 Hawaii Island United Way $10,000 County of Hawaii Mass Transit $21,000 Program Sales and Services $127,200 Fundraising $6,465 TOTAL: $234,665 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Brantley Center, Inc. started an annual campaign in 2010 and it continues to grow every year. Our annual Golf Tournament has been our major fundraiser for over thirty (30) years. We kicked off the Honoka'a Half-Marathon and Waipi'o 30K Challenge Runs in 2012 and raised over$3,700.00. The event will again occur in 2013, and we anticipate a significant growth this year. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation 7. Program Objectives Using County Nonprofit Grant Program Funds: To provide vocational evaluations, individualized employment planning services, work adjustment training, occupational skills training,job-readiness classes, competitive job placement and work transition services with the goal of having clients placed in long-term employment situations in the competitive job market. 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 clients who received employment rehabilitation services. 24 Number of consumers with improved scores on the vocational eval 12 Number of consumers with improved productivity percentages 14 Number of client who successfully completed the job-readiness pro. 11 Number of clients placed in competitive employment for 90 days 10 Number of students who received work transition services 14 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 93,990 104,295 25,000 Professional Fees 9,866 12,755 Operations 72,446 97,615 15,000 Supplies 6,778 11,800 Equipment 3,990 8,200 Other: Other: Other: Other: Other: TOTAL 187,070 234,665 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Valerie Poindexter 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): CNo conflicts exist(No further information required. Please sign form at the bottom.) 0 Member or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: Board member Poindexter has not been involved with any of the application process of our County of Hawaii Non-Profit Grant application. 1 4c12)O•-Y:s I — 9-jk — 13 Signatu - of Authorized Person (specify title) Date EXHIBI A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. a a- ` Signature • uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation 12.COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of clients who received employment rehabilitation services. 24 Number of clients with improved scores on the vocational Eval 12 Number of clients with improved productivity percentages 14 Number of clients who successfully completed the job-readines pro. 11 Number of clients placed in competitive employment for 90 days 10 Number of students who received work transition services 14 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 25,000 Professional Fees Operations 15,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 17 Bridge House, Inc Vocational Skills Building Program (VSB) } S0PY Agency Name: Bridge House, Inc. a • - Program Name: Vocational Skills Building Program (VSB) Agency Director: Mark Schuster Phone No.: (808) 322 — 3305 Contact Person: Mark Schuster Phone No.: (808) 322 — 3306 Mailing Address: Address: P.O. Box 2489 Address: City,ST,Zip Kailua Kona, HI 96745 Facility Address: Address: 78-6687-B Mamalahoa Hwy. Address: City,ST,Zip Holualoa, HI 96725 Email Address:mark_bridgehouse @earthIink.net Fax No.: (808) 322 — 0809 Accountant/CPA: Brenda Smith Phone No.: (808) 960 — 5041 Firm(if applicable): Smart Solutions Mailing Address: Address: P.O. Box 1164 Address: City,sr,Zip Captain Cook, HI 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $15,000. $10,000. $15,000. 2.Agency Mission Statement: The Bridge House mission is to assist adults who are in recovery from drug/alcohol addiction, to develop successful living skills through residential and vocational experiences in our safe, structured and supportive environment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program (VSB) 3.Program Description: All new admits to Bridge House are required to complete a vocational history questionnaire. Results of this evaluation, along with personal observation by staff, then helps identify skills, attitudes and behaviors that require remediation. The program also provides actual job training, evaluates performance at on-site job assignments, assists with resume preparation, engages residents in mock interviews, provides instruction in the use of basic office equipment, facilitates linkages to other community resources and offers guidance to jobs appropriate for ability. Transportation necessary to obtain job applications, attend interviews and arrive at their work site is provided to our residents, as well. 4.Total Budget&Position Count: Total Program Budget: 67,635.00 Total Program Position Count: 1.25 Total Agency Budget: 34,3922.75 Total Agency Position Count: 4 5.Program Funding Sources(identify a sources of funding applied to this program): FY13-14 Revenue Source Estimate County 25,000.00 HIUW 35,000.00 Client Program Funds 5,000.00 Contributions 835.00 ADAD 1,800.00 TOTAL: 67,635.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Over this past year we have expanded our organic garden areas, and are now selling our produce to a local, established distributor. Due to the success of this activity, we are currently planning further expansion of our growing grounds. Also, our seasonal crop of lychee (2 acres) continues to be in big demand and is marketed to both private individuals, and via local health food stores. Although these endeavors contribute income to the VSB program, they remain generally insufficient to completely support the program. Thus, we vigilantly continue to seek out other grants, and apply for those which appear appropriate. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program (VSB) 7. Program Objectives Using County Nonprofit Grant Program Funds: The VSB program's primary objective is to prepare our residents to enter/re-enter the work force. Historically, approximately 90% of our residents are unemployed or unemployable at time of admission. Further, as a result of falling into the drug culture, most have disengaged from mainstream society and no longer share many of the healthy 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 ability to 'give back'to one's community. 8.TABLE!: 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.) Approximately 55 individuals will participate in the program. 80% of graduates will be employed or attending school! training program. At six months post-discharge, graduates will have remained clean 85% of graduates will attain and sober, and have no arrests or incarcerations, be employed these benchmarks. or attending school/training program. Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual'* Total Budget Grant Req Salary and Wages 32,995.0 32,250.00 11,600.00 Professional Fees 6,024.75 6,225.75 2,200.00 Operations 1,050.00 1,200.00 600.00 Supplies 2,008.00 2,400.25 1,200.00 Equipment 4Er{jv•errn.QO-gym •"*• 1,008.00 1,200.00 600.00 Other: -02 rottoces t{ Y�,,e� a be�.eF', (�s 6,914.00 6,798.75 2,200.00 Other: Oo�„f',`c,� 15,980.0 16,360.25 6,000.00 Other: 1 v,S v o..r+ 1,000.00 1,200.00 600.00 Other: Other: TOTAL 66,979.7 67,635.00 25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program (VSB) 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 conflict is needed. 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): 0 No conflicts exist(No further information required. Please sign form at the bottom.) 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 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: ,/`L� 76;7t Pre.a t-1 �'" �% S ature of Author zed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program (VSB) 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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. he 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.gpv/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, 201 '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. 4t_r 3ot,� «<, ��' /4=2 V—4S Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program (VSB) 12.COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Approximately 55 individuals will participate in the program. 80% At six months post-discharge, graduates will have remained clean 85% and sober, and have no arrests or incarcerations, be employed or attending school/training program. TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 11,600.00 Professional Fees 2,200.00 Operations 600.00 Supplies 1,200.00 Equipment t ,v P . 600.00 Other: 1:33o..* t e. k(1.12.-vs or_c- 4s 2,200.00 Other: o 6,000.00 Other: k s ,-�,,,« 600.00 Other: Other: TOTAL 25,000.00 Additional Council directives reeardinft award: EXHIBIT B AIf1NDDfICIT r.DAKIT ADDI IrATIf1M CV )Al2_7(11 A Dmnn 7 of 7 18 Child and Family Service Alternatives to Violence Agency Name: Child and Family Service Program Name: Alternatives to Violence Agency Director: Howard S Garval Phone No.: (808) 681 — 3500 Contact Person: Heidi Koop, Director of Hawaii Island Programs Phone No.: (808) 935 — 8229 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 1266 Kamehameha Avenue, Suite A Address: City,ST,Zip Hilo, HI 96720 Email Address: hkoop @cfs-hawaii.org Fax No.: (808) 961 — 2073 Accountant/CPA: N&K CPAs, Inc Phone No.: (808) 524 — 2255 Firm (if applicable): Mailing Address: Address: American Savings Bank Tower Address: 1001 Bishop Street, Suite 1700 city, sr,zip Honolulu, HI 96813-3696 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 50000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 15,000 20,000 17,000 2.Agency Mission Statement: "Strengthening families and fostering the healthy development of children" 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. 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, older adults, individuals, and families in need benefit from these services. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as CFS's offices. Continued on attached page. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Child and Family Service Program Name: 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. The victim support component consists of assisting clients seeking a Temporary Restraining Order (TRO) with their application to the Family Court, and providing Court Advocacy for the client during TRO hearings in the Family Court, 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. Continued on attached page. 4. Total Budget&Position Count: Total Program Budget: 672,001 Total Program Position Count: 11.85 Total Agency Budget: 3,650,378 Total Agency Position Count: 52 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Judiciary 470,499 County of Hawaii 50,000 Program Fees 68,325 HIUW 10,000 TOTAL: 598,824 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: CFS was a recipient of a Violence Against Women Act Stop grant which supported delivery of victims services this program. This funding ran from July 2011 to May 2012. reflected in the revenues above. CFS is actively working with legislators and the Judicidiary to strategize on how to address the gaps in funding for victims of Domestic Violence. CFS has actively increased its fundraising pursuits and has achieved some successful milestones which benefit all CFS programs. CFS also actively pursues other sources of funding from the Hawaii Island United Way, the Visitor Industry Charity Walk and private foundations with a focus on Hawaii County. Continued on attached page. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Child and Family Service Program Name: Alternatives to Violence 7. Program Objectives Using County Nonprofit Grant Program Funds: The county grant funds are to support two Domestic Violence positions in Hilo and Kona (12 hrs per position from County funds) for the victim support component of ATV with the following measurable objectives: Continued on attached page 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 individuals served (unduplicated) 2,075 Number of individuals served through TRO assistance 1,275 Number of provided Court Advocacy 2,050 Number of Victim Support and Pattern Changing Classes held 70 Number of women's offenders classes held 154 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 460,077 469,279 40,748 Professional Fees Operations 198,747 202,722 9,252 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 658,824 672,001 50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Child and Family Service Program Name: Alternatives to Violence 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 conflict is needed. 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): W1No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: tiC1(1§V t Executive Vice President and F �� Chief Operating Officer 0/ 9L I~ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Child and Family Service Program Name: 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, 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. ecutivee Vice President and Chief O•eratl • Officer Of 13 0 Signature of Authorized Person (specify title) D 113 to EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Child and Family Service Program Name: Alternatives to Violence 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of individuals served (unduplicated) 2,075 Number of individuals served through TRO assistance 1,275 Number of provided Court Advocacy 2,050 Number of Victim Support and Pattern Changing Classes held 70 Number of women's offenders classes held 154 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 40,748 Professional Fees Operations 9,252 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: Child and Family Service Program Name: Alternatives to Violence Question #2:Agency Mission Statement CFS provides services through 35 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 island and communities it serves. Despite significant changes in funding, CFS 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 continuing challenging economic times, CFS will demonstrate our commitment to the community of the Big Island by supporting populations that present with increasingly complex problems and situations. CFS continues to be at the forefront of developing the skills, knowledge, and service models to address these needs. Agency Name: Child and Family Service Program Name: Alternatives to Violence Question #3: Program Description The ATV Program provides an array of Domestic Violence Intervention (DVI) services to men, women and youth. 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 assistance to complete and file Temporary Restraining Orders, Court Advocacy, 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, developing 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; and 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 causes disrespect and harm that is inconsistent with the values, beliefs and conduct of every culture. Program Highlights: (from Fiscal Year 2011-12) The ATV Program clients who have been affected by domestic violence (offenders, victims, child witnesses) were offered individual and group sessions that emphasize how to overcome the trauma of domestic violence and to live a violence free lifestyle. The objective of our work is to remind the men and women we serve of the importance of mutual respect that can be found in every culture. In Fiscal Year 2011-2012, the program achieved the following: 1) 2,001 unduplicated individuals were served. 2) 1,269 individuals received Temporary Restraining Order Services. 3) 1,917 Court Advocacy services were provided. 4) 55 classes were held for victims of domestic violence. 5) 12 women graduated from the women's support and pattern changing group. 6) 94% of victims participating in Support Services identified at least 3 personal safety skills. 7) 107 men completing batterer intervention services demonstrated the knowledge, skill and attitudes necessary for maintenance of non-abuisve behavior which includes learning non-violent conflict resolution and non-aggressive communication. Agency Name: Child and Family Service Program Name: Alternatives to Violence Question #6: Explain what plans your agency or program has to increase revenues to support this program: CFS also explores national funding sources. For the Domestic Violence Intervention groups, CFS collects an $18 fee per individual per group session. This fee can be waived and replaced by work exchange for indigent clients as well as those who are unemployed. Agency Name: Child and Family Service Program Name: Alternatives to Violence Question #7: Program Objectives Using County Nonprofit Grant Program Funds: 1. Assist in TRO preparation for 10 clients per week. 2. Provide weekly Court Advocacy for 10 clients per week. 3. Establish an Individualized Safety Plan with 90% of TRO petitioners at the time of the TRO assistance services. 4. Ensure that 80% of victims participating in Victim Support Services are able to identify at least 3 personal safety skills. 5. Ensure that 100% of TRO clients are provided with community resources. 19 Child and Family Service East Hawaii Domestic Abuse Shelter Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter Agency Director: Howard S Garval Phone No.: (808) 681 — 3500 Contact Person: Heidi Koop, Director of Hawaii Island Programs Phone No.: (808) 935 — 8229 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 1266 Kamehameha Avenue, Suite A Address: City,ST,Zip Hilo, HI 96720 Email Address: hkoop @cfs-hawaii.org Fax No.: (808) 961 — 2073 Accountant/CPA: N&K CPAs, Inc Phone No.: (808) 524 — 2255 Firm (if applicable): Mailing Address: Address: American Savings Bank Tower Address: 1001 Bishop Street, Suite 1700 City,ST,Zip Honolulu, HI 96813-3696 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 40,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 7,500 10,000 8,500 2.Agency Mission Statement: "Strengthening families and fostering the healthy development of children" 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. 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, older adults, individuals, and families in need benefit from these services. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as CFS's offices. Continued on attached page. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter 3. Program Description: CFS 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. These two shelters 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 Client Advocate at the East Hawaii Domestic Abuse Shelter (Hale `Ghana), that provides support, advocacy, counseling and referrals to residents. Continued on attached page. 4.Total Budget& Position Count: Total Program Budget: 443,188 Total Program Position Count: 7.85 Total Agency Budget: 3,650,378 Total Agency Position Count: 52 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Department of Human Services 340,000 County of Hawaii 40,000 DHS Emergency Shelter Grant 14,535 Prosecutors VOCA 10,000 Department of Attorney General VAWA 25,000 EBT Food Stamps 9,000 Private Foundation 500 TOTAL: See Attached Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: CFS is committed to supporting critical services in the community despite tight budgetary limitations. Since the Rainy Day funds ended in June 2012, decreased funding continues to have a tremendous impact on the program. New avenues for funding are continuously explored through our Development and Grant offices. CFS relies on other funding sources to fund its Domestic Abuse Shelters, such as Hawaii Island United Way (HIUW), Emergency Shelter Grant (ESG) and the Victims of Crime Act from the Prosecutor's Office. The shelter charges a modest fee to those clients with an ability to pay. Continued on attached page. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter 7. Program Objectives Using County Nonprofit Grant Program Funds: The county grant fund are to support the Client Advocate position in Hilo for 32 hours a week with the following measurable objectives : Continued on attached page. 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.) # of Bed Days 5,509 # of Hotline Calls 542 # of Single Women 95 # of Women w/children 66 # of Children Served 131 # of requests for information and referral only 338 Continued on attached page Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages 282,215 308,818 33,577 Professional Fees Operations 131,735 134,370 6,423 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 413,950 443,188 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter 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 conflict is needed. 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): QNo conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: Executive Vice President and EYä:' " Chief Operating Officer 0 c) 13 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Child and Family Service Program Name: East 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, 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. Executive Vice President and Chief operating Officer <' ( 3 O 13 Signature of Authorized Person (specify title) Dat EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Child and 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 # of Bed Days 5,509 # of Hotline Calls 542 # of Single Women 95 # of Women w/children 66 # of Children Served _ 131 # of requests for information and referral only 338 Continued on attached page. TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 33,577 Professional Fees Operations 6,423 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter Question #2:Agency Mission Statement CFS provides services through 35 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 island and communities it serves. Despite significant changes in funding, CFS 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 continuing challenging economic times, CFS will demonstrate our commitment to the community of the Big Island by supporting populations that present with increasingly complex problems and situations. CFS continues to be at the forefront of developing the skills, knowledge, and service models to address these needs. • Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter Question #3: Program Description As resources allow, the Client Advocate 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 Client Advocate 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 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 on 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 Client Advocate 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 `Ohana 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 `Ohana 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 Client Advocate and Shelter Workers help families identify their needs, their barriers and develop a plan to overcome these barriers and meet these needs. Hale `Ohana 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 Client Advocate 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 `Ohana 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 Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter 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. Program Highlights: (from Fiscal Year 2011-12) 1) During the fiscal year of 2011-2012, Hale `Ohana served 112 children and 151 adults, and provided 4,755 bed days. Hale `Ghana received 1,109 hotline calls that involved a crisis due to domestic violence. Hale `Ohana handled 469 requests for information and referral. Hale `Ghana experienced an increase of victims and their children served compared to fiscal year 2010-2011. 2) As anticipated, an increase of domestic violence occurred during the last fiscal year due to economic stressful times which historically effects domestic violence between domestic partners. CFS continues to be committed to support the community to ensure that families are protected. 3) Hale 'Ohana achieved 100% of its outcomes during the fiscal year of 2011-2012. Despite the economic challenges, 74% of adults were able to secure a safe home after discharge in East Hawaii. 4) Other services include: assisting the residents with personalized safety planning, increasing awareness among parents and caregivers of the effects on children who witness domestic violence, increasing awareness of community resources, and providing education on healthy relationships. 5) During the past year, CFS staff has been trained in a new, evidence-based methodology called Trauma Informed Care. This approach greatly assists the staff in helping clients through understanding the complex ways that exposure to trauma can affect their behavior. Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter Question #5: Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY 13-14 Estimate Program Fees 1,500 Total: 440,535 Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter Question #6: Explain what plans your agency or program has to increase revenues to support this program: We are asking for additional funding from the County of Hawaii to help offset the funding shortages we are experiencing. 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. We humbly ask for your support. Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter Question #7: Program Objectives Using County Nonprofit Grant Program Funds: 1. Increase client knowledge of community resources by 85%. 2. Complete Safety Plan with 90% of shelter clients for themselves and their children. 3. Complete Assessment with 80% of shelter clients. 4. Complete Service Plan with 80% of shelter clients. 5. Moving from the shelter to a non-abusive home environment will occur among 60% of clients (victims). Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter Question #8: TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? Program Performance Measures Projected Results # of group session hours 123 #of individual session hours provided 3,026 #of meals provided 16,526 # of transportation hours provided 331 Agency Name: Child and Family Service Program Name: East Hawaii Domestic Abuse Shelter Question #12: Council Award Worksheet Program Performance Measures Projected Results Council Proposed Projected Results # of group session hours 123 # of individual session hours provided 3,026 # of meals provided 16,526 # of transportation hours provided 331 20 Child and Family Service East Hawaii Transitional Housing Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing Agency Director: Howard S Garval Phone No.: (808) 681 — 3500 Contact Person: Heidi Koop, Director of Hawaii Island Programs Phone No.: (808) 935 — 8229 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 1266 Kamehameha Avenue, Suite A Address: City,ST,Zip Hilo, HI 96720 Email Address: hkoop @cfs-hawaii.org Fax No.: (808) 961 — 2073 Accountant/CPA: N&K CPAs, Inc Phone No.: (808) 524 — 2255 Firm (if applicable): Mailing Address: Address: American Savings Bank Tower Address: 1001 Bishop Street, Suite 1700 City,ST,zip Honolulu, HI 96813-3696 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 40000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 15,000 10,000 17,000 2.Agency Mission Statement: "Strengthening families and fostering the healthy development of children" 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. 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, older adults, individuals, and families in need benefit from these services. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as CFS's offices. Continued on attached page. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing 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. 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 abusive partner. Continued on attached page. 4.Total Budget& Position Count: Total Program Budget: _133,158 Total Program Position Count: 1.25 Total Agency Budget: 3,650,378 Total Agency Position Count: 52 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate U.S. Department of Justice 85,427 County of Hawaii 40,000 Program Fees 3,000 TOTAL: 130,427 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The East Hawaii Transitional Housing Program has been primarily funded by the Department of Justice, Office of Violence Against Women (OVW). Additional funding options have been explored including charging program fees. Clients are not turned away if they cannot pay. CFS 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing 7. Program Objectives Using County Nonprofit Grant Program Funds: The county grant funds are to support a 16-hours Domestic Violence Specialist and a 6-hours Program Supervisor position with the following measurable objectives : Continued on attached page. 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.) # of families provided housing 7 # of service plans developed 7 # provided case management 7 # of safety plans developed 7 # provided aftercare services 1 #w/secured income 5 Continued on attached page Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 27,723 47,702 32,774 Professional Fees Operations 78,454 85,456 7,226 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 106,177 133,158 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing 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 conflict is needed. 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): QNo conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: Executive Vice President and Chief Operating Officer 01/ C--)/( Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing 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 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 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 will impact the evaluation of yourproqram's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. Executive Vice President and pAtkr Chief Operating Officer 0! S Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result # of families provided housing 7 # of service plans developed 7 # provided case management 7 # of safety plans developed 7 # provided aftercare services 1 # w/secured income 5 Continued on attached page TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 32,774 Professional Fees Operations 7,226 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 • Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing Question #2:Agency Mission Statement CFS provides services through 35 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 island and communities it serves. Despite significant changes in funding, CFS 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 continuing challenging economic times, CFS will demonstrate our commitment to the community of the Big Island by supporting populations that present with increasingly complex problems and situations. CFS continues to be at the forefront of developing the skills, knowledge, and service models to address these needs. Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing Question #3: Program Description 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 East Hawaii Transitional Housing Program is a 24 month program that assists victims of domestic violence and their children to rebuild their lives. 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 victims 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. Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing Program Highlights: (from Fiscal Year 2011-12) 1. The program is fulfilling a high need for providing the only transitional housing for victims of domestic abuse and their families in Hawaii County. 2. Eight families were provided with transitional housing from July 2011 to June 2012. 3. The staff has developed a strong program that focuses on reintegrating victims of domestic abuse into the community and gaining their independence and self-sufficiency. 4. Five families successfully transitioned into permanent housing between July 2011 and June 2012. 5. Four participants obtained part-time employment. 6. Two participants decided to further their education, one enrolled at the University of Hawaii, working on a degree in marine biology, the other did an online course and received a Veterinarian assistant certificate. 7. Of the 35 participants who have transitioned out of program since its beginning in 2006, 87% of participants have made the decision not to re-involve themselves with their abusers and have established a violent free home for themselves and their children. Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing Question #7: Program Objectives Using County Nonprofit Grant Program Funds: 1. Increase the knowledge of community resources, including housing, employment and finances, among 80% of participants in program. 2. Maintain a safe and violence free lifestyle during participation in the program among 80% of clients in the program. 3. Support safety by having 90% of the clients maintain a Safety Plan for themselves and their children at intake and for the duration of their participation in program. 4. Secure independent housing after 24 months of safe transitional housing among 80% of the clients seeking permanent safe living quarters. . Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing Question #8: TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? Program Performance Measures Projected Results # enrolled in education program 2 # w/secure employment 4 # obtained permanent housing 2 Agency Name: Child and Family Service Program Name: East Hawaii Transitional Housing Question #12: Council Award Worksheet Program Performance Measures Projected Results Council Proposed Projected Result # enrolled in education program 2 # w/secure employment 4 # obtained permanent housing 2 SUPPORTING DOCUMENTATION 21 Child and Family Service Transitional Family Homes Agency Name: Child and Family Service Program Name: Transitional Family Homes Agency Director: Howard S Garval Phone No.: (808) 681 — 3500 Contact Person: Heidi Koop, Director of Hawaii Island Programs Phone No.: (808) 935 — 8229 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 1266 Kamehameha Avenue, Suite A Address: city,ST,Zip Hilo, HI 96720 Email Address: hkoop @cfs-hawaii.org Fax No.: (808) 961 — 2073 Accountant/CPA: N&K CPAs, Inc Phone No.: (808) 524 — 2255 Firm (if applicable): Mailing Address: Address: American Savings Bank Tower Address: 1001 Bishop Street, Suite 1700 City,ST,zip Honolulu, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 30,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 20,000 18,000 17,000 2.Agency Mission Statement: "Strengthening families and fostering the healthy development of children" 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. 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, older adults, individuals, and families in need benefit from these services. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as CFS's offices. Continued on attached page. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Child and Family Service Program Name: Transitional Family Homes 3. Program Description: Funds are requested to support the Transitional Family Homes (TFH) Program in its work with children and adolescents who present with severe behavioral challenges including self-injuries, property damage, physical assaults, elopements, truancy, substance abuse and stealing. These youths are in high need of professional Life Skills Specialists and highly trained therapeutic foster parents who are able to give them one-on-one attention. CFS is requesting funding for a part-time Life Skills Specialist and monies to continue supporting therapeutic activities in the foster homes and the community. Continued on attached page. 4.Total Budget& Position Count: Total Program Budget: 406,676 Total Program Position Count: 3.25 Total Agency Budget: 3,650,378 Total Agency Position Count: 52 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Department of Health (Child Adolescent Mental Health Div) 370,000 County of Hawaii 30,000 TOTAL: 400,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: CFS continues to be committed to providing critical services for a high-risk population on the Big Island. Pursuing new treatment modalities such as Trauma Informed Care (Risking Connection) and focusing on what it takes to improve outcomes, CFS was able to hire a Hawaii trained staff that is very familiar with the local needs and their families on the Big Island. As the program continues to grow and shows strong outcomes, CFS will continue to collaborate with the State Child and Adolescent Mental Health Division and other funding sources to continue the Trauma Informed Care TFH project to reunify youths and families in their homes with skills that allow the whole family to be successful in their respective community. Continued on attached page. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Child and Family Service Program Name: Transitional Family Homes 7. Program Objectives Using County Nonprofit Grant Program Funds: The intermediate goal of the TFH Program is to provide a safe and stable living environment to youths who experience emotional and/or behavioral problems. This stable environment is needed while the youths engage in therapy to address their individualized mental health and behavioral issues. Continued on attached page. 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.) # of clients served 16 # of bed days utilized 3,650 # of licensed foster homes 16 # of individual therapy, therapeutic activities and/or skill building 1,000 #family therapy sessions 380 # of discharges to a lateral or lower level of care 8 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 157,470 160,619 24,816 Professional Fees Operations 241,232 246,057 5,184 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 398,702 406,676 30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Child and Family Service Program Name: Transitional Family Homes 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 conflict is needed. 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): QNo conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: '7p Executive Vice President and � ' Chief Operating Officer C( 36 _3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Child and Family Service Program Name: Transitional Family Homes 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. a _ � Executive Vice President and Chief Operating Officer (7 //3 o /3 Signature of Authorized Person (specify title) ate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Child and Family Service Program Name: Transitional Family Homes 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result # of clients served 16 # of bed days utilized 3,650 # of licensed foster homes 16 # of individual therapy, therapeutic activities and/or skill building 1,000 #family therapy sessions 380 # of discharges to a lateral or lower level of care 8 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 24,816 Professional Fees Operations 5,184 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: Child and Family Service Program Name: Transitional Family Homes Question #2:Agency Mission Statement CFS provides services through 35 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 island and communities it serves. As the community continues to face a multitude of difficult problems during continuing challenging economic times, CFS will demonstrate our commitment to the community of the Big Island by supporting populations that present with increasingly complex problems and situations. CFS continues to be at the forefront of developing the skills, knowledge, and service models to address these needs. Agency Name: Child and Family Service Program Name: Transitional Family Homes Question #3: Program Description The TFH Program provides foster placement and clinical services for youth who have been identified as needing out-of-home placement. Additional resources are provided to accommodate their emotional, behavioral, and mental health issues. The TFH Program offers a system of support, counseling and skill building to youth as well as training and support to the caregivers/family members and foster parents. The TFH Program provides services countywide on the island of Hawaii. The goal of the program is to teach the youth and his/her family how to build trusting relationships that support the youth in achieving his or her highest potential. The behavioral health and residential programs at CFS continue to see an increase in the number of youth who are in need of"line of sight" supervision, life skills development and therapeutic activities throughout the day, including weekends and holidays. Often, these children are neuro-behaviorally challenged due to multiple causes. Exposure to substances, child abuse and neglect, poverty, homelessness and crime are typical circumstances that require the youth to be placed in a highly therapeutic environment. Most of these youth have experienced multiple traumas, unsuccessful placements and/or the 'ohana are unable to support that youth in their homes due to the severity of the behavior and/or other family and work commitments. Many of these youth are so desperate that their behaviors place them in acute units of hospitals. It is well known that the Big Island has been seriously affected by the use of methamphetamine ("ice"). As children who are born to "ice" parents are getting older, it is anticipated that over time, the number of youth referred for behavioral health services, including Transitional Family Homes, will increase as Hawaii's "ice babies" grow up. Of the 3,153 Big Island women screened between December 2007 and September 2012 by the Children's Research Triangle on the Biq Island , 49% of the pregnant women had a positive screen for substance abuse (30% smoking cigarettes, 33% drinking alcohol, 9 % smoking marijuana, 1% cocaine/methamphetamine/opiates). Native Hawaiian women were most likely to have a positive screen (61%), followed by Caucasian women (59%). In addition, it was reported in 2010 after the screening of 1,000 pregnant women that 42.2% of the women who were drinking in early pregnancy continued drinking after learning of their pregnancy which can put their children at risk for significant neurological impairments. Youth with neurological impairments may have learning impairments, behavioral deficits, increased motor activity, and enhanced conditioned avoidance responses. Parents and foster parents become frustrated and cannot cope with the demands, resulting in multiple placements for these youth. Often times, multiple placements reinforce problem behaviors and erode the self-esteem of the youth. It is cost-beneficial to provide interventions as early as possible to prevent further problems from developing. The current staffing on the Big Island consists of a Director of Hawaii Island Programs and Clinical Supervisor who provide programmatic and clinical oversight of the Transitional Family Homes. A Master's level Clinical Specialist provides intensive clinical and case management services for the youths, the therapeutic foster parents and the biological family members. The proposed Life Skills Specialist will provide daily practical support to the youths to increase their independent living skills as appropriate for their age and development. In addition, the Life Skills Agency Name: Child and Family Service Program Name: Transitional Family Homes Specialist provides intensive one-on-one services to allow the youths to adjust to their new Transitional Foster Homes and to get along in the community within the school and with peers. During crisis situations, the Life Skill Specialist assists the Therapeutic Foster Parents and the clinical TFH team as appropriate for the situation. CFS has been innovative in exploring new modalities to achieve better outcomes for the youths and the families. CFS has trained staff on neurological impairments, Trauma Informed Care, Cognitive Behavioral Therapy modalities and family engagement. With this training, the TFH staff is able to focus on how the TFH placement addresses the trauma that families experience, and rebuilds connections between the youth and the family with the goal for reunification and a higher level of functioning for both the youth and family members. When these youths are placed into our TFH Program, there is a high need for providing one-on-one staffing to allow the youth to adjust to his/her new therapeutic foster home, learn independent living skills and get along in the community within the school and with peers. The youth is often adjusting to a new school environment and making connections with peers in the community which is a challenge. CFS staff have received extensive training including Trauma Informed Care that focuses on working with youths between the ages 3 and 17 years old with these difficulties. To further support this project, an experienced and well trained Life Skills Specialist is needed to provide the described intensive services at the beginning of the placement, during crisis situations and during transition when the youth is reunified with the family or transitioned to another permanent placement. The Life Skills Specialist would be working under the direct supervision of a Clinical Supervisor in coordination with the Clinical Specialist. The Life Skills Specialist would provide groups to teach life skills that allow the youths to learn to manage their neurobehavioral challenges in a healthy way. Program Highlights: (from Fiscal Year 2011-12) The TFH Program has been very successful in working with the youths and families. Focus has been on developing the program's ability to provide innovative and valuable therapeutic interventions to each youth. CFS continues to be a pioneer in offering services that are trauma informed and that cater to the unique needs of these special youths. One method currently implemented is through CFS's Risking Connection trainings for our foster parents which enables them to recognize and effectively address the youth's trauma history. This approach has helped to prevent referring youth to acute services in Honolulu. This evidence-based approach helps to assure that youth are provided supportive services on the Big Island for optimal success. Agency Name: Child and Family Service Program Name: Transitional Family Homes Question #6: Explain what plans your agency or program has to increase revenues to support this program: CFS is confident that the evidence-based methods of working with this challenging population will continue to strengthen the Program. CFS is committed to providing critical services for the Big Island community and pursues new treatment modalities such as Trauma Informed Care (Risking Connection), despite budgetary limitations. CFS is actively writing grants for supplemental funding to keep its critical programs operating. Agency Name: Child and Family Service Program Name: Transitional Family Homes Question #7: Program Objectives Using County Nonprofit Grant Program Funds: The long-term goal of the program is to provide the support and skill building necessary to empower youth to engage in socially appropriate and manageable behaviors, thereby facilitating their reunification (if appropriate) with their biological families or to a less restrictive environment. Measurable objectives for the TFH Program include: 1. Demonstrate the development of interpersonal relations and life skills 75% of the time as measured by the youth's participation in extracurricular, community or other pro-social activities. 2. Demonstrate being a positive and productive member of a family 75% of the times as measured by the youth's ability to follow daily scheduling and completion of household duties. 3. Achieve quarterly goals of an identified permanency plan by 100% of youth. 22 Child and Family Service West Hawai`i Domestic Abuse Shelter Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter Agency Director: Howard S Garval Phone No.: (808 ) 681 — 3500 Contact Person: Heidi Koop, Director of Hawaii Island Programs Phone No.: (808) 935 — 8229 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,zip Ewa Beach, HI 96706 Facility Address: Address: 1266 Kamehameha Avenue, Suite A Address: City,ST,Zip Hilo, HI 96720 Email Address: hkoop @cfs-hawaii.org Fax No.: (808) 961 — 2073 Accountant/CPA: N&K CPAs, Inc Phone No.: (808) 524 — 2255 Firm (if applicable): Mailing Address: Address: American Savings Bank Tower Address: 1001 Bishop Street, Suite 1700 City, ST,zip Honolulu, HI 96813-3696 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 40,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 7,500 10,000 8,500 2. Agency Mission Statement: "Strengthening families and fostering the healthy development of children" 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. 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, older adults, individuals, and families in need benefit from these services. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as CFS's offices. Continued on attached page. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Child and 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. These two shelters 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 Client Advocate at the WHDAS that provides support, advocacy, counseling and referrals to residents. Continued on attached page. 4.Total Budget & Position Count: Total Program Budget: 503,026 Total Program Position Count: 8.25 Total Agency Budget: 3,650,378 Total Agency Position Count: 52 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Department of Human Services 340,000 County of Hawaii 40,000 DHS Emergency Shelter Grant 14,535 HIUW 15,000 Prosecutors VOCA 10,000 Department of Attorney General VAWA 27,000 EBT Food Stamps 10,000 TOTAL: See Attached Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: CFS is committed to supporting critical services in the community despite tight budgetary limitations. Repeated funding reductions have had a tremendous impact on the program. New avenues for funding are being explored through our Development and Grant offices. CFS relies on other funding sources to fund its Domestic Abuse Shelters, such as Hawaii Island United Way (HIUW), Emergency Shelter Grant (ESG) and the Victims of Crime Act from the Prosecutor's Office. The shelter charges a modest fee to those clients with an ability to pay. Continued on attached page. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter 7. Program Objectives Using County Nonprofit Grant Program Funds: The county grant fund are to support the Client Advocate position in Kona for 32 hours a week with the following measurable objectives : Continued on attached page. 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.) # of Bed Days 5,500 # of Hotline Calls 260 #of Single Women/Men 70 # of Women/Men w/children 69 # of Children Served 100 # of requests for information and referral only 200 Continued on attached page. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages 304,093 337,699 33,576 Professional Fees Operations 162,085 163,706 6,424 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 466,178 501,405 40,000 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter 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 conflict is needed. 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): CNo conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: Executive Vice Presiders and 1 Chief Operating Officer 01 c/ (3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter it 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. fp Executive Vice President and PC;d6_ s Chief Operating Officer 0 Signature of Authorized Person (specify title) D o EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result # of Bed Days 5,500 # of Hotline Calls 260 # of Single Women/Men 70 # of Women/Men w/children 69 # of Children Served 100 # of requests for information and referral only 200 Continued on attached page TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 33,576 Professional Fees Operations 6,424 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter Question #2:Agency Mission Statement CFS provides services through 35 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 island and communities it serves. Despite significant changes in funding, CFS 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 continuing challenging economic times, CFS will demonstrate our commitment to the community of the Big Island by supporting populations that present with increasingly complex problems and situations. CFS continues to be at the forefront of developing the skills, knowledge, and service models to address these needs. • Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter Question #3: Program Description As resources allow, the Client Advocate 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 Client Advocate 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 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 on 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 Client Advocate 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 Kohala 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 Client Advocate and Shelter Workers help families identify their needs, their barriers and develop a plan 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 Client Advocate 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 Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter 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 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. Program Highlights: (from Fiscal Year 2011-12) 1) During the fiscal year of 2011 - 2012, the WHDAS served 100 children and 112 adults. The WHDAS provided 5,373 bed days. The WHDAS received 216 hotline calls that involved a crisis due to domestic violence. The WHDAS handled 149 requests for information and referral. WHDAS experienced an increase of victims and their children served compared to fiscal year 2010-2011. 2) As anticipated, an increase of domestic violence occurred during the last fiscal year due to economic stressful times which historically effects domestic violence between domestic partners. CFS continues to be committed to support the community to ensure that families are protected. 3) The WHDAS achieved 100% of its outcomes during the fiscal year except in the area of adults and families moving into a non-abusive environment. There were increasing challenges to obtaining affordable housing in West Hawaii under the current economic situation. The expected outcome for WHDAS was at 47% for this outcome. The staff of WHDAS will continue to support and advocate for the adults and families to establish a transition to safe housing. 4) Other services include: assisting the residents with personalized safety planning, increasing awareness among parents and caregivers of the effects on children who witness domestic violence, increasing awareness of community resources, and providing education on healthy relationships. 5) During the past year, CFS staff has been trained in a new, evidence-based methodology called Trauma Informed Care. This approach greatly assists the staff in helping clients through understanding the complex ways that exposure to trauma can affect their behavior. Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter Question #5: Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY 13-14 Estimate Private Foundation 15,000 Program Fees 500 Total 472,035 Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter Question #6: Explain what plans your agency or program has to increase revenues to support this program: CFS has utilized Community Development Block Grants for much needed repairs and improvement projects in West and East Hawaii that are now completed. We are asking for additional funding from the County of Hawaii to help offset the funding shortages we are experiencing. 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. We humbly ask for your support. Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter Question #7: Program Objectives Using County Nonprofit Grant Program Funds: 1. Increase client knowledge of community resources by 85%. 2. Complete Safety Plan with 90% of shelter clients for themselves and their children. 3. Complete Assessment with 80% of shelter clients. 4. Complete Service Plan with 80% of shelter clients. 5. Moving from the shelter to a non-abusive home environment will occur among 60% of clients (victims). - Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter Question #8: TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? Program Performance Measures Projected Results # of group session 1,200 # of individual session hours 3,000 provided # of meals provided 18,350 # of transportation hours provided 750 Agency Name: Child and Family Service Program Name: West Hawaii Domestic Abuse Shelter Question #12: Council Award Worksheet Program Performance Measures Projected Results Council Proposed Projected Results # of group session hours 1,200 # of individual session hours provided 3,000 # of meals provided 18,350 # of transportation hours provided 750 23 Cooper Center Volcano Friends Feeding Friends (VFFF) Agency Name: Cooper Center Program Name: Volcano Friends Feeding Friends (VFFF) Agency Director: BarbaraToles Phone No.: (808) 769 — 3903 Contact Person: Barbara Toles Phone No.: (808) 967 — 7800 Mailing Address: Address: POB 1000 Address: 11-4030 Wright Road City,sr,zip Volcano, HI 96785 Facility Address: Address: POB 1000 Address: 11-4030 Wright Road City,ST,Zip Volcano, HI 96785 Email Address:barbaratoles @ymail.com Fax No.: (n/a ) — Accountant/CPA: David Goodman Phone No.: (808) 937 — 8135 Firm(if applicable): Mailing Address: Address: POB 1000 Address: 114030 Wright Road City,ST,Zip Volcano, HI 96785 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $35,900 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 n/a n/a n/a 2.Agency Mission Statement: VFFF seeks to improve the health and welfare of our surrounding communities by providing healthy meals and nutritional education to families with children (35%), indigents (40%), and seniors (25%) in the districts of Kau and Puna. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Cooper Center Program Name: Volcano Friends Feeding Friends(VFFF) 3.Program Description: VFFF provides a weekly, warm meal to on average of 175 individuals (with take-out meals available also)and monthly food pantry also to approximately 175 individuals, is based at Cooper Center, a 501c3 community center. VFFF is strongly supported by volunteers (approximately 35 individuals/week, comprising 225 hours/week)who prepare meals in Cooper's certified kitchen, pick-up food from the Food Basket, procure other donated items, and clean-up upon meal completion. An increase in revenue will allow us to create more sustainability in a concerted, organized effort, food handling education (especially for our "off-grid" population), and extending the reach of our food program (which now serves 8000 meals per year). 4.Total Budget&Position Count: Total Program Budget: 14,300 Total Program Position Count: 8000/year Total Agency Budget: 14,300 Total Agency Position Count: 8000/year 5.Program Funding Sources(identify gl_i sources of funding applied to this program): FY13-14 Revenue Source Estimate Rotary Club of Volcano $1,500 Volcano Community Association 1,200 Personal cash donations from community members 6,000 fundraisers 5,600 TOTAL: $14,300 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: The current program desperately needs a designated staff person to monitor and supervise volunteers, solicate food vendors for a 50% increase in food product available and work with emergency workers should the need arise for Cooper to become an after-emergency shelter. Capital requirements, equipment and appliances are needed to expand kitchen and food service capabilities for increased service and security. Annual fundraisers can be increased by 50%. In-kind matching monies from the Rotary Club of Volcano($1,500)can be utilized in kitchen upgrades. Increased marketing will increase funding of personal sources as well. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Cooper Center Program Name: Volcano Friends Feeding Friends(VFFF) 7.Program Objectives Using County Nonprofit Grant Program Funds: Increase sustainability by 50%. Educate the public regarding home food preparation and storage. Create a laundry storage closet utilizing in-kind donation of a washer and dryer. Purchase generator to run program during after-emergency event. New shelving, windows, kitchen counters, and awning for increased kitchen usage, safety and security. Doors to separate the eating space will increase usage potential. 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) Contacting ten new potential donors per month increase sustainability by 50% Educating public re. food prep and storage via workshops&flyers decrease food waste by 25% Increase kitchen rental usage by 20% increase rental funding by 20% Manage volunteer hours increase volunteer outcome Laundry storage closet decrease laundry costs Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages yv' ,,k,c 2,600 2,600 20,300 d -0- -0- 3,000 Operations 5,500 5,500 500 Supplies 5,700 5,900 300 Equipment (fit 1 7�2„.„ GO I/440W5 at-Ott-CU j 200 1,500 5,700 Other: V1 ect 300 300 1,500 Other: -0- -0- 3,800 Other: Other: kj -e t ,kQ Iv �C Cc tc -0- -0- 800 Other: Q TOTAL 14,300 15,800 35,900 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 . Agency Name: ' / -0 Program Name: Ud et,(A-0 . {1` F-eQ(lj i� Fr i E (v F F � � w. ORGANIZATION CONFLICT DISCLO URE 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 conflict is needed.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): 0 No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council p ,� , /" The Mayor a/de l T `5- ��Qo cbi, /iv The Managing Director L 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 intere : 4ed I o ?2!i n5. c l 4�L.5 (Le /t/t a i ITV aY 6 tr rAit 11-e L4 1,0 ' a� Q t S@ f C w GC,(Gi CI tvu lV u PI i5 o i Crre, ( .,,,,,rd,y (IL A pe. , /,,4,,e,,, 0/(12iri:ej, I . 0 f . 13 Signature of Autho��riized Pier (specify title)f i j We4e, Date ( L■14dck EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Program Name: \J(6510f- awt.O fi `yt, Tri eVic ( v Fr I) ii.Certification of Unde tending 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 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 Hawaft 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 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 will impact the evaluation of your program's or aaency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 11'x_ L : C 11 _." t101 '..••L '1 L.A Li 1 _ll '1 ' L. 0 _lli Alit. C tom' 1 . 1 it.,._ ! _nd 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 30,2014 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. ter- 0 —5 I E 1 ignature of Authorized Person specify title) Date bcwc&- To 5) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Cooper Center Program Name: Volcano Friends Feeding Friends (VFFF) 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant GO11Cj Proposed Projected Results Projected Result contact new potential donors/month 50%+ product education 25%-waist kitchen rental increase 20%+funds manage volunteer hours 25%+ TABLE H: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 20,300 Professional Fees 3,000 Operations Supplies 500 300 Equipment 5,700 Other: Other: 1,500 Other: 3,800 Other: 800 Other: TOTAL 35,900 Additional Council directives reeardigg award: EXHIBIT B NONPROFIT GRANT APPUCATION FY 2013-2014 Page 7 of 7 • 24 COVO Foundation Pamana ng Kulturang Pilipino (Heritage of the Filipino Cultr) Agency Name: COVO Foundation Program Name: Pamana ng Kulturang Pilipino(Heritage of the Filipino Cultr) Agency Director: Dr. Serafin P. Colmenares, Jr. Phone No.: (510) 734 — 4491 Contact Person: Jane Clement Phone No.: (808) 756 — 3103 Mailing Address: Address: 99-1325 Aiea Heights Address: City,sr,zip Aiea, HI 96701 Facility Address: Address: 99-1325 Aiea Heights Address: City,sr,Zip Aiea, HI 96701 Email Address:janeclement @hawaii.rr.com Fax No.: (808) 443 — 0401 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 0 2.Agency Mission Statement: 1. To preserve and promote the culture, language and traditions of Filipinos of Visayan ancestry in Hawaii; 2. To assist in the educational and socio-economic development of Filipinos of Visayan ancestry in Hawaii; and EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: COVO Foundation Program Name: Pamana ng Kulturang Pilipino(Heritage of the Filipino Cultr) 3. Program Description: Pamana ng Kulturang Pilipino (Heritage of the Filipino Culture) is a Philippine Independence Day Celebration organized and presented by the Kona Visayan Club. The program will feature: * Cultural Entertainment * Habi at Baro - An exhibit of costumes and implements from the different regions of the Philippines * Cultural Booths * Food and Games 4.Total Budget& Position Count: Total Program Budget: 10,000 Total Program Position Count: 0 Total Agency Budget: 10,000 Total Agency Position Count: 0 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii Grant 10,000 TOTAL: 10,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This is the inaugural launching of this program and the Kona Visayan Club intends to turn it into an annual event. Organizing benefit events and other fundraising activities will be the primary sources of revenue to sustain this program. In-kind donations, support from other organizations and community donations will be solicited. We will also continue to apply for grants form different foundations and government agencies as it becomes available. Any reusable items, costumes and equipments will be ketp and reuse to reduce expenditure in future events. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: COVO Foundation Program Name: Pamana Ng Kulturang Pilipino(Heritage of the Filipino Cultr) 7. Program Objectives Using County Nonprofit Grant Program Funds: * Preserve, promote and perpetuate the Filipino heritage among our members and the general public through cultural, charitable and educational activities. * Provide Filipino-Americans, especially our youth, the opportunity to learn their cultural heritage through different activities, including participation in cultural dances and games. * Promote an understanding of our Filipino heritage and create awareness of Philippine culture among the other diverse ethnic groups in 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.) Cultural Event Completion Attendance 300 people or more Volunteer Hours (including dance practices) 50 hours or more Other participating Filipino Groups 5 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations •. Ucvl ue, �d✓Gr��S'h9.Pri h}''v1 , 0 nil\faA 1 1000 Supplies: Cos+VIN1e4 De,c.O✓vI f off ,TCvrEc , C o Ole 3000 Equipment : S pvied Qiiol Lid/1+ SYc+eA1115 1000 Other: if qoi pl.f bo,,v 1000 Other: l.;rrG✓c., kcc-owlooioi1i'oo , Mc4c rot' Eml-c TollhcY'S 2000 Other: A(rrcrC, lrccowlod0141'014, Mom IS roc- G405-1- s1- -o ker5 500 Other: food allot gPa/G t,. l 1500 Other: TOTAL 10000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: COVO Foundation Program Name: Pamana Ng Kulturang Pilipino(Heritage of the Filipino Cultr) 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jane Clement POSITION: Legislative Assistant to Councilman Dru Kanuha May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): CNo conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council 1 Staff appointed by a member of the Council The Mayor nThe 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 be on the Ad Hoc Committee where they can influence decisions on the awarding of this grant. //Zy/3 Signature of A thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: COVO Foundation Program Name: Pamana Ng Kulturang Pilipino(Heritage of the Filipino Cultr) 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. 7e0_6‘...7 • //2,7//3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: COVO Foundation Program Name: Pamana Ng Kulturang Pilipino(Heritage of the Filipino Cultr) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Cultural Event Completion Attendance 300 people Volunteer Hours (including dance practices) 50 hrs or more Other participating Filipino groups 5 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations: U6,14e, Advcr-hsivl , �v;►n�vl 'Owi;yc 1000 Supplies;COS vvtc.5 J�covoi.woo Tc 4s G awl GSJ 3000 Equipment: Sovv►,) avid c ysiewls 1000 Other: 14 ow 4 got,, 1000 Other: k Marc, AtzA)ww0001.1'0h Mc4 ror �vl�L✓kolivlCN 5 2000 Other: Airray-c., Auo wt0 cAq �'o� Mc Gi k ?we- gvcc 4'ccol kc,+-s 500 Other: toad ovi oi 8cvc✓cl9c 1500 Other: TOTAL 10000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 25 East Hawaii Community Development Corporation Hawaii Food Hub Agency Name: East Hawaii Community Development Corporation Program Name: Hawaii Food Hub Agency Director: Ernest F. Matsumura Phone No.: (808) 935 — 3381 Contact Person: Anthony M. Marzi Phone No.: (808) 557 — 9372 Mailing Address: Address: 113 Kuawa Street Address: City,ST,Zip Hilo, Hawaii, 96720 Facility Address: Address: 230 Kekuanaoa Street Address: City,sr,Zip Hilo, Hawaii, 96720 Email Address:anthonymarzi@easthawaii.org Fax No.: (808) 935 — 3381 Accountant/CPA: Sharyl Kasarskis Phone No.: (808) 933 — 0849 Firm(if applicable): Mailing Address: Address: 113 Kuawa Street Address: City,ST,Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $74,480 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0 $0 $0 2.Agency Mission Statement: EHCDC's mission is to promote community and economic development, and educational, research, and charitable activities in the east side of the County of Hawaii. EHCDC represents a diverse set of talents with a strong community focus: (1) EHCDC is interested in the application of 21st century technology as a way to help rural communities become globally competitive; (2) EHCDC is working to coordinate with existing economic development activities through strategic project planning and outreach to build a vibrant community with quality economic activity; (3) EHCDC has partnerships in place to provide training and mentoring, as well as to provide an expanded professional community; and, (4) EHCDC is facilitating strong community ties through informal networking and relationship-building, new job opportunities for local residents, and spurred community economic development. In support of these activities, EHCDC has a primary social enterprise initiative, which is to strengthen agribusiness and cultivate safe and regional food systems via our Hawaii Food Hub program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: East Hawaii Community Development Corporation Program Name: Hawaii Food Hub 3. Program Description: In order to foster increased food security, local consumption,food safety, and profitability associated with the Hawaii Island agribusiness industry, the Hawaii Food Hub will be a centralized facility designed to aggregate, certify the safety of, store, process, distribute, and market locally-produced food products, which will enable long-term regional economic development through increased employment opportunities on the farm and in food processing, manufacturing, and distribution, and increased value of agricultural production on Hawaii Island. The project responds to the calls of several Hawaii County plans to increase the capacity of the County's agricultural industry. The Hawaii Food Hub will serve both producers and food purchasers (including institutions, grocers, and small businesses) in Hawaii County. 4.Total Budget&Position Count: Total Program Budget: $1,423,514.27 Total Program Position Count: 3 Total Agency Budget: $2,510,962.31 Total Agency Position Count: 10 5.Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Private Funds $127,727.89 In-Kind Contributions $41,786.38 State of Hawaii Grant-In-Aid $1,100,000 Hawai'i Island Beacon Community Healthy Eating &Active Living (HEAL) $20,000 USDA Rural Business Opportunity Grant (RBOG) Grant $50,000 USDA Value-Added Producer Grants (VPAG) Grant $39,000 USDA Community Food Projects (CFP) Competitive Grant Program Grant $45,000 TOTAL: $1,423,514.27 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: Revenues will be self-sustaining and derived from wholesale and retail value-added products, food distribution, and user fees derived from Hawaii Food Hub users. Startup funding is needed to kickstart the project, which will supplement additional funds being sourced through local fundraising efforts targeted at program partners, state and local governments, community organizations, revolving loan fund programs, and private donors. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: East Hawaii Community Development Corporation Program Name: Hawaii Food Hub 7.Program Objectives Using County Nonprofit Grant Program Funds: (1) Upgrade 3,200 sq ft of certified cold prep facility to accommodate up to 15 local agribusiness'demand for food safety-certified food prep, blast freezing, and cold storage: (a) HVAC reinstall; (b) electrical update; (c) walk-in freezer purchase and reinstall; (d) 3-compartment sink reinstall; and, (2) technical assistance provided for(a) agribusiness, (b) value-added production, (c) startups, (d) food safety education and certification, and (e)farmer outreach will generate improved economic development, incomes, and employment. 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) All upgrades completed Facility is food safety certified (2)(a) Local agribusinesses served by (1) upgraded facilities 15 (2)(b) Facility utilization for value-added products 80% processing area utilitized (2)(c) Local startups assisted through partnerships 8 partnerships (2)(d) Food safety plans written (GAPs) 18 (2)(e) Outreach events to farmers 65 farmers reached Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages - 41,786 27,160 Professional Fees - 89,000 15,600 Operations 229,332 127,727 - Supplies - - - Equipment - 24,400 31,720 Other: - - - Other: - - - Other: - - - Other: _ - - Other: - - - TOTAL 229,332 282,916 74,480 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: East Hawaii Community Development Corporation Program Name: Hawaii Food Hub 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Ernest Matsumura POSITION: President May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): IN No conflicts exist(No further information required. Please sign form at the bottom.) ljMember 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: 07;0/A3 Signature of uthorized Person(specify title) Date .0.......4_.H--../' EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: East Hawaii Community Development Corporation Program Name: Hawaii Food Hub 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 he 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.govJfn-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 30,2014 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. '07 Alf 0/0/As Signature of Authorized Person (specify title) Date fa- Art et_ ■ EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: East Hawaii Community Development Corporation Program Name: Hawaii Food Hub 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result (1) All upgrades completed Facility cert (2)(a) Local agribusinesses served by (1) upgraded facilities 15 (2)(b) Facility utilization for value-added products 80% utilization (2)(c) Local startups assisted through partnerships 8 partnerships (2)(d) Food safety plans written (GAPs) 18 (2)(e) Outreach events to farmers 65 reached TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 27,160 Professional Fees 15,600 Operations - Supplies - Equipment 31,720 Other: - Other: - Other: - Other: - Other: - TOTAL 74,480 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 26 Family Support Hawaii Hawaii Island Fatherhood Initiative Agency Name: Family Support Hawaii Program Name: Hawaii Island Fatherhood Initiative Agency Director: Ray Wofford Phone No.: (808) 334 — 4115 Contact Person: Ray Wofford Phone No.: (808) 334 — 4115 Mailing Address: Address: 75-127 Lunapule Rd. Address: Suite 11 City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 75-127 Lunapule Rd. Address: Suite 11 City,s-r,Zip Kailua-Kona, HI 96740 Email Address: rwofford @fsswh.org Fax No.: (808) 326 — 4063 Accountant/CPA: Rozanne Connell, Manager Phone No.: (808) 968 — 1002 Firm (if applicable): Carbonaro CPA &Associates, Inc. Mailing Address: Address: P.O. Box 4372 Address: City,sr,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $75,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $40,000 $20,000 $55,000 2.Agency Mission Statement: Family Support Hawaii (FSH) was founded in 1979 as a grassroots organization providing family support in communities throughout West Hawaii. 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. These are achieved through our community development activities, economic development projects, collaboration building and advocacy work for a better quality of life for families in Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Family Support Hawaii Program Name: Hawaii Island Fatherhood Initiative 3. Program Description: Family Support Hawaii (FSH) is seeking funding from the County of Hawaii to continue the work of the Hawaii Island Fatherhood Initiative -- Na Makuakane Maika`i `0 Hawaii: Great Fathers of Hawaii. The Initiative originated in 2002 when FSH hired two male Family Support Workers (later referred to as "Father Coaches"), both part-Hawaiians who were themselves fathers, specifically to address the needs and interests of fathers. Staff had observed a pattern where men, without positive outlets for stress relief and habits of self-care, were using drugs, alcohol, and violence to manage problems, exacerbating the problems for themselves and their families. (Continued on attached pages) 4. Total Budget& Position Count: Total Program Budget: $105,000 Total Program Position Count: 2.0fte Total Agency Budget: $3,107,062 Total Agency Position Count: 67 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii Island United Way $20,000 Private Donations/Fundraising (FSH Campaign, John Cruz Concert, In-Kind) $10,000 TOTAL: $30,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Collaboration has been a key to the success of the Hawaii Island Fatherhood Initiative and is valued by FSH as top priority in the continued growth of the program. The Fatherhood Initiative relies on other agencies, the Departments of Health and Human Services, civic and religious organizations, local businesses and individuals to provide event locations, services, activities, in-kind donations and financial support. We are currently receiving funding through the Hawaii Island United Way (strong supporters of the Initiative) and have a continuation grant request pending their consideration. (Continued on attached pages) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Family Support Hawaii Program Name: Hawaii Island Fatherhood Initiative 7. Program Objectives Using County Nonprofit Grant Program Funds: • help men understand and be more comfortable in the role of a father; • increase knowledge about the best ways for babies and children to develop; • share and help fathers use the latest effective parenting techniques; • help reduce family stress and destructive behaviors such as violence and substance use in order to encourage a loving parent relationship; and • build a social support network of fathers. 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 fathers will attend 9 weekly classes quarterly 85% improve communication 50 fathers will receive and average of 6 visits annually 85% greater awareness needs 50 fathers will attend one monthly or weekend activity group 85% build positive relations 140 adults participants will attend Celebration of Fatherhood Event 90% attain greater knowledge Father Coaches will provide 2 agency trainings annually 90% attain greater knowledge (Continued-greater detail on attached pages) Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 53,872 83,250 57,250 Professional Fees 3,185 5,500 5,500 Operations 4,616 7,100 5,750 Supplies 2,731 4,415 3,000 Equipment Other: 1,000 1,000 Other: 411 735 500 Other: 1,695 3,000 2,000 Other: Other: TOTAL 66,510 105,000 75,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Family Support Hawaii Program Name: Hawaii Island Fatherhood Initiative 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 conflict is needed. 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): 7 No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: 4 , A 6)(4,7 , Signs re of Authori e. erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Family Support Hawaii Program Name: Hawaii Island 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 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.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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./Ajt 'jr r/Q g ye c ,i4jue red-ri I — Signature fi094 Pers.n s'ecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Family Support Hawaii Program Name: Hawaii Island Fatherhood Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 50 fathers will attend 9 weekly classes quarterly 85% improve 50 fathers will receive and average of 6 visits annually 85% greater 50 fathers will attend one monthly or weekend activity group 85% build 140 adults participants will attend Celebration of Fatherhood Event 90% greater Father Coaches will provide 2 agency trainings annually 90% greater (Continued-greater detail on attached pages) TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 57,250 Professional Fees 5,500 Operations 5,750 Supplies 3,000 Equipment Other: 1,000 Other: 500 Other: 2,000 Other: Other: TOTAL 75,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: Family Support Hawaii Program Name: Hawaii Island Fatherhood Initiative 1. Program Description (continued): Family Support Hawaii's Healthy Start Program completed local needs assessments in 2001 that supported the need for a father program. Fathers reported an interest in attending program-sponsored group activities to learn more about child development and also to benefit from the support of other fathers. Community members disclosed a priority on having a happy family, better housing, good jobs and financial security. All these priorities directly pertained to the role of fathers and supported the need to strengthen them in fulfilling their roles and responsibilities at the prevention or early intervention level. The wisdom of strengthening men's abilities to fulfill their roles as fathers is also supported by national data. According to 2011 U.S. Census Bureau data, over 24 million children (one out of three children) live apart from their biological fathers. Children who live in the absence of their biological or adoptive fathers are, on average, two to three times more likely to be poor, to use drugs, to experience educational, health, emotional and behavioral problems, to be victims of child abuse, and to engage in criminal behavior. Consequently, there is a "father factor" in nearly all of the social issues facing America today, (U.S. Census Bureau, 2011 Population Survey). Sadly, programming for fathers is still lagging far behind other areas of social capital development. While there are organizations that include fathers in their programming, the Hawaii Island Fatherhood Initiative is the only one that provides a particular focus on fathers' involvement in the lives of their children and family. Another distinction is that it is the only program with only one requirement for participation: the fact of being a father. One of our Father Coaches is funded partially through one of our Department of Human Services contracts and, in that role, he reaches out specifically to fathers involved in the Child Welfare Services differential response system to try to engage them in the Initiative's support groups and other services. The Initiative referrals from Family Court and Drug Court. In recent years, the program has become so well known on the island that it receives an ever-increasing number of requests to replicate the program in other parts of the island. Increasing numbers of individuals are being referred from fathers who have participated in the program, their family members, or other agencies. 8 Agency Name: Family Support Hawaii Program Name: Hawaii Island Fatherhood Initiative The Hawaii Island Fatherhood Initiative serves predominantly the districts of North and South Kona and Ka`u, although men from the entire island are welcome to attend groups and activities. Though there are only two sites for the weekly group sessions (Kailua-Kona and Ocean View), some of the individual services and community events extend island-wide. The Initiative is designed to increase fathers' involvement in the lives of their children and promote responsible fathering practices and healthy lifestyles in the context of cultural competency. The Initiative serves fathers primarily through group support, though it also provides individual support services and promotes community wellbeing through educational and public awareness activities. The mission of Hawaii Island Fatherhood Initiative is "to support fathers in understanding how babies develop, parenting with love, and creating strong and healthy families." The Initiatives objectives are to: • help men understand and be more comfortable in the role of a father; • increase knowledge about the best ways for babies and children to develop; • share and help fathers use the latest effective parenting techniques; • help reduce family stress and destructive behaviors such as violence and substance use in order to encourage a loving parent relationship; and • build a social support network of fathers. Fatherhood Support and Education Groups: The Fatherhood Coaches deliver a variety of modules through these groups, including lessons from an evidence-based curriculum, Nurturing Fathers: Developing Attitude and Skills for Male Nurturance, published by the Center for Growth and Development. The Initiative has also developed its own culturally sensitive fatherhood curriculum. The weekly education and support groups include topics such as strategies for developing personal power, honoring the range of male emotions, fathering without fear or violence, positive play and discipline, parental teamwork, and dealing with stress without substances. Within the groups, substance use is addressed as a way of coping with anger, which in turn masks the deeper emotions of sadness, loss, fear, anxiety, depression and failure. Through discussion, men in the Initiative are invited to explore their own emotions and to develop positive coping strategies independent of drugs and alcohol. The weekly support groups provide a healthy delicious meal and the Kailua-Kona group also offers child care. Food is an important part of local culture and serves not only to attract fathers, but also to nurture them. Child care removes barriers that might otherwise deter attendance. 9 Agency Name: Family Support Hawaii Program Name: Hawaii Island Fatherhood Initiative Individual Services: The Father Coaches also provide individualized support for fathers to address their specific needs. One of the tools used to determine needs is the Nurturing Parenting AAPI (Adult Adolescent Parenting Inventory). The Father Coaches review completed assessments and debrief with the men their priorities, values and beliefs, identify any need for and provide resources for counseling or other services, and promote a connection with a volunteer Father Mentor. These Father Mentors, who are themselves fathers trained through the program, are matched with a younger or less experienced father on an as-needed basis, providing support to fathers as they face daily challenges. Because these young fathers often lack social support, they experience emotional isolation and difficulties in handling family responsibilities such as employment, housing and child care. They value having someone to turn to who will act as "big brothers," talk story and just be there as a helping hand whenever necessary. Social and Community Activities: In addition to the group and individual support services, the Initiative features social activities such as father-child camping excursions, picnics, and an annual Fatherhood Celebration that is open to the community. These safe, casual events afford fathers the opportunity to build an extended support network amongst one another and other service providers, reduce stress, get help and develop confidence in their parenting ability -- all while having a good time in the natural surroundings of our beautiful island. In addition, the annual Fatherhood Celebration raises on a community-wide level the vision and ideal of fatherhood as "man's greatest calling." The event has enjoyed excellent media coverage in recent years, including front-page photographs in the local newspaper. Father Coaches have shared their unique vision and experience to provide training at the request of other providers who wish to improve their effectiveness with fathers. Recent recipients of the presentations have included the Hawaii Department of Human Services/Child Welfare Division, Home Instruction for Parents of Preschool Youngsters (HIPPY), and Early Head Start and Head Start locations across the state. In the past year, 112 fathers received direct support through the Fatherhood Initiative primarily as participants in individual and group activities, while another 208 fathers were served by the program indirectly. Additionally, Father Coaches provide consulting and trainings through the annual conference, appearances on the radio and television, workshops conducted and written information distributed to the general public. As a result, thousands of individuals learned about the status and needs of fathers, tips and techniques for effective parenting and how people can get involved in the Initiative. 10 Agency Name: Family Support Hawaii Program Name: Hawaii Island Fatherhood Initiative 6. Explain what plans your agency or program has to increase revenues to support this program (continued): In the past year, FSH has developed new strategies to sustain the Initiative. FSH has a very active Board of Directors that is committed to fundraising to support the Initiative. The Board has recently approved a Social Media Policy that will afford us the opportunity to not only take part in more lucrative fundraising ventures but also to increase the awareness of our mission, identify new networks and partners, and grow the lifelong value of our donors. The Board and staff are also looking at the possibility of entrepreneurial business ventures such as opening a thrift store and facilitation of community events. We are considering new approaches to solicit corporate sponsorship. In addition, we have established local donors that financially support our annual Celebration of Fatherhood. The requested support from the County of Hawaii, along with the powerful support and donations given by our partners in mission, is vital to our continuation of the much needed services provided by the Hawaii Island Fatherhood Initiative. 8. Table 1 (continued): Program Performance Measures Applicant Projected Results 50 fathers will attend 9 weekly 90-minute classes 85% of fathers will express improvement in their offered each quarter& learn: 3 conflict mgmt ability to communicate effectively with their partners strategies, 3 positive discipline techniques & 3 &children while developing responsibility & healthy stress reduction & substance abuse prevention lifestyle habits. skills. 50 fathers will receive an average of 6 visits per 85% of fathers will express greater awareness of year and learn 3 child development milestones, 3 their child's needs, greater satisfaction with their problem-solving and goal-setting strategies to role as a parent& resolution of at least one of the reduce life stressors. reasons for referral into the program 50 fathers will attend one monthly evening or 85% of fathers will build positive relationships with weekend activity group hosted by staff or partners one another for support, glean parenting wisdom where they will share cultural wisdom about from other men & reduce stress. fatherhood. 140 adult participants will attend the Celebration of 90% of all attendees will attain greater Fatherhood annual event. understanding of the status of fathers &the impact of the Initiative on improving intervention strategies. Father Coaches will provide 2 training 90% of the agency participants will attain greater presentations for other community agencies over understanding of the importance of father the year. involvement& of the elements needed for attracting participants & maintaining a father involvement program. 11 Agency Name: Family Support Hawaii Program Name: Hawaii Island Fatherhood Initiative 12. Council Award Worksheet Table 1 (continued): Program Performance Measures Applicant Projected Council Proposed Results Projected Result 50 fathers will attend 9 weekly 90-minute 85% of fathers will express classes offered each quarter& learn: 3 conflict improvement in their ability mgmt strategies, 3 positive discipline techniques to communicate effectively & 3 stress reduction & substance abuse with their partners & prevention skills. children while developing responsibility & healthy lifestyle habits. 50 fathers will receive an average of 6 visits per 85% of fathers will express year and learn 3 child development milestones, greater awareness of their 3 problem-solving and goal-setting strategies to child's needs, greater reduce life stressors. satisfaction with their role as a parent& resolution of at least one of the reasons for referral into the program 50 fathers will attend one monthly evening or 85% of fathers will build weekend activity group hosted by staff or positive relationships with partners where they will share cultural wisdom one another for support, about fatherhood. glean parenting wisdom from other men & reduce stress. 140 adult participants will attend the Celebration 90% of all attendees will of Fatherhood annual event. attain greater understanding of the status of fathers&the impact of the Initiative on improving intervention strategies. Father Coaches will provide 2 training 90% of the agency presentations for other community agencies participants will attain over the year. greater understanding of the importance of father involvement& of the elements needed for attracting participants & maintaining a father involvement program. 12 27 Friends of Big Island Drug Court Assistance to Drug Court Clients & Programs Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program Agency Director: None Phone No.: ( ) — Contact Person: Carol A. VanCamp, President Phone No.: (808) 938 — 0828 Mailing Address: Address: PO Box 6100 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: None - voluntary board only Address: City,ST,Zip Email Address: cvancamp3 @hawaii.rr.com Fax No.: (808) 982 — 9958 Accountant/CPA: Brian Iwata Phone No.: (808) 935 — 5404 Firm (if applicable): Taketa, Iwata, Hara & Associates, LLC Mailing Address: Address: 101 Aupuni St., Ste. 139 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $1 0,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $10,000 $8,000 $8,000 2.Agency Mission Statement: The Mission of the Big Island Drug Court is to help address societal problems related to substance abuse in order to minimize their societal and economic costs, and to protect the Big Island community by providing timely and effective treatment for drug offenders with appropriate sanctions and incentives. Simply stated, the "Friends of Big Island Drug Court" is a 501c3 organization created to provide financial and other support for Drug Court clients and the overall program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program 3. Program Description: The Friends of Big Island Drug Court provide funding and other support for the clients and programs of Big Island Drug. Court. This includes rewards and incentives to clients during their drug-free journey (such as gift certificates, movie tickets, etc.), loans or awards for tuition to further their education, and loans or awards for housing, travel or other such needs. The Friends also sponsor graduation activities fot Drug Court clients, and responds to requests for individual and group support and needs. The Friends also support alumni activities to ensure long-term success for the clients. All programs and activities of the Friends are conducted by volunteers from across the island, as there are no paid employees. The organizaiton is governed by a volunteer board of directors, representing a cross-section of individuals. 4.Total Budget& Position Count: Total Program Budget: $14,000 Total Program Position Count: 0 Total Agency Budget: $14,000 Total Agency Position Count: 0 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii Grant $10,000.00 Office of the Prosecuting Attorney - Drug Forfeiture Funds 2,500.00 Private Donations - Former Drug Court clients, others organizations, etc. 1,500.00 TOTAL: $14,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to network with community service organizations for donations and have received some Rotary support in the past. We are also networking with various public defenders to encourage their clients to make donations to the Friends as part of their restitution and/or community service programs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program 7. Program Objectives Using County Nonprofit Grant Program Funds: Our goal is to not only serve the clients currently in the Drug Court program, but to also offer more outreach to alumni from this program, as keeping graduates drug and alcohol-free on a long-term basis so that they can be contributing members of our community is very important. Also, for clients currently in the program, our ability to help with GED or college tuition or books, rent for housing, travel for necessary programs, incentives to get them through the program, etc., is critically to keeping them moving forward toward their goal of graduating from DC. 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.) At any given time, there are about 115 adults & 15 juveniles served. Provide financial support. Job fair for employers to consider hiring Drug Court clients Held in Hilo & Kona Alumni events island-wide for an estimated 175 graduates Keep clients substance-free Our organization is made up of all volunteers No administrative overhead Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Req Actual* Total Budget Salary and Wages 0 0 0 Professional Fees 0 0 0 Operations $14,000 $10,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program 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 conflict is needed. 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): Q No conflicts exist (No further information required. Please sign form at the bottom.) 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: % l3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. C� a �, %— -/3 j Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result At any given time, there are about 115 adults & 15 juveniles served. Help clients Job fair for employers to consider hiring Drug Court clients Find jobs Alumni events island-wide for an estimated 175 graduates Stay clean Our organization is made up of all volunteers No overhead TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 0 Operations $10,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 28 Friends of Kona Community Aquatic Center Heated Pool for Kona Community Aquatic Center Agency Name: Friends of Kona Community Aquatic Center Program Name: Heated pool for Kona Community Aquatic Center Agency Director: Janice Beeson Phone No.: (808) 325 — 7865 Contact Person: Janice Beeson Phone No.: (808) 325 — 7865 Mailing Address: Address: P.O. Box 1693 Address: City,ST,Zip Kailua Kona HI 96745 Facility Address: Address: None Address: City,ST,Zip Email Address:jdbeeson @hawaii.rr.com Fax No.: ( ) — Accountant/CPA: Ann Finney- Treasurer Phone No.: (808) 322 — 1460 Firm (if applicable): Mailing Address: Address: 77-158 Koa Koa St. Address: City,ST,Zip Kailua Kona HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 None None None 2.Agency Mission Statement: The mission of Friends of Kona Community Aquatic Center is to bring warm water to Kona Community Aquatic Center. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Friends of Kona Community Aquatic Center Program Name: Heated pool for Kona Community Aquatic Center 3. Program Description: Friends of Kona Community Aquatic Center is requesting funding for installation of two propane heaters to heat the pool during the winter months and a thermal blanket cover with storage reel. The current two electric heaters are both old and have been non functioning for several years. The pool water during the winter can dip as low as 75 degrees. This lack of hot water is a health consideration for many who use the pool. When funds would be made available we would hire a contractor to install two(2) new Pentair 1,500,000 BTU heaters, remove and dispose of old heaters, saw cut, remove and replace concrete and asphalt, remove and replace of current gas line with larger gas line. These heaters will bring the water temperture up to 82 degrees and the thermal blanket will keep the heat in and help reduce energy consumption. 4.Total Budget&Position Count: Total Program Budget: $500.00 Total Program Position Count: Total Agency Budget: Total Agency Position Count: 5.Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii County Grant $70,000.00 Public Donations $15,000.00 TOTAL: $85,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Once the propane heaters and thermal blanket with reel are installed at Kona Community Aquatic Center the system will become a part of Kona Community Aquatic Center which is under the management of Hawaii County Parks & Recreation. All warranty certificates will be issued to Hawaii County by the contractor and manufacturer. When warranty expires it will be the responsibility of the Hawaii County Parks & Recreation to provide any future maintenance to the propane pool heating system. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Friends of Kona Community Aquatic Center Program Name: Heated pool for Kona Community Aquatic Center 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Determine final budget and project plan by 27 September 2013. 2) Make any adjustments to project and secure final quote for project by 11 October 2013. 3) Install the propane heating system and thermal blanket with reel by 16 May 2014. 4)Attend a final inspection of the propane heating system by Hawaii County by 13 June 2014. 5) Conduct a ribbon-cutting ceremony and secure press coverage for project by 11 July 2014. 6) Keep a accurate accounting of grant funds spent and return unspent funds by 25 July 2014. 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.) Propane heated pool water 82 degrees Increase attendence during winter months 30% Thermal blanket reduces energy consumption 60-70% Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Ken Salary and Wages 0 Professional Fees o Operations 725 Supplies 200 Equipment $70,000 $70,000 Other: Other: Other: Other: Other: TOTAL $70,925 $70,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Friends of Kona Community Aquatic Center Program Name: Warm water for Kona Community Aquatic Center 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 conflict is needed. 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): o No conflicts exist(No further information required. Please sign form at the bottom.) nMember 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: ip , , ,, li j , ./ /ate t. ,. .,I_ .rte ' g 44,,,, 0/ Signa ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Friends of Kona Community Aquatic Center Program Name: Warm water for Kona Community Aquatic 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,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 httplvendors.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 ttp://,v,r.•t:..i- v;a i s nt o ,m -n.on .ofit ent-`arms! 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, 2013 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 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. O/3 Si: ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Friends of Kona Community Aquatic Center Program Name: Heated pool for Kona Community Aquatic Center 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Propane heated pool 82 degrees Increase attendence during winter months 30% Thermal blanket reduces energy consumption 60-70% TABLE II: FY PROGRAM EXPENDITURES 13-14 Council Grant Request Award Salary and Wages 0 Professional Fees 0 Operations 725 Supplies 200 Equipment $70,000 Other: Other: Other: Other: Other: TOTAL $70,925 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 29 Friends of Kona Community Aquatic Center Warm Water for Kona Community Aquatic Center Agency Name: Friends of Kona Community Aquatic Center Program Name: Warm water for Kona Community Aquatic Center Agency Director: Janice Beeson Phone No.: (808) 325 — 7865 Contact Person: Janice Beeson Phone No.: (808) 325 — 7865 Mailing Address: Address: P.O.Box 1693 Address: City,sr,zip Kailua Kona HI 96745 Facility Address: Address: None Address: City,ST,Zip Email Address:jdbeeson @hawaii.rr.com Fax No.: ( ) — Accountant/CPA: Ann Finney-Treasurer Phone No.: (808) 322 — 1460 Firm (if applicable): Mailing Address: Address: Address: 77-158 Koa Koa St. city,sr,zip Kailua Kona HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $00000 $00000 $00000 2.Agency Mission Statement: The mission of Friends of Kona Community Aquatic Center is to bring warm water to Kona Community Aquatic Center. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Friends of Kona Community Aquatic Center Program Name: Warm water for Kona Community Aquatic Center _ r 3.Program Description: Friends of Kona community Aquatic Center is requesting funding for installation of solar panels to provide hot water for showers year round. Solar is a clean renewable energy that will replace the currant system now in use. We have researched sources located on Hawaii Island and have had two courtesy bids to establish an estimate for our program. When funds would be made available our organization will hire a contractor to install 22 solar panels on the south facing roof of the mechanical building. The 22 solar panels will provide 1962 gallons of hot water per day based on an average of 600 users or 392 showers using a base of 5 gallons of hot water per user. Our program is a much needed upgrade that will benefit the swimming pool, gymnasium, tennis courts, basketball courts and sports fields that all use the shower facilities. 4.Total Budget&Position Count: Total Program Budget: $52,500 Total Program Position Count: Total Agency Budget: Total Agency Position Count 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii County Grant $13,000 Public Doanations 3,000 TOTAL: $16,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Once completed the solar hot water system will become a part of Kona Community Aquatic Center which is under the management of Hawaii County Parks& Recreation. All warranty certificates will be issued to Hawaii County by the contractor and manufacturer. When warranty expires it will be the responsibility of the Hawaii County Parks & Recreation to provide any future maintenance to the hot water solar system. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Friends of Kona Community Aquatic Center Program Name: Warm water for Kona Community Aquatic Center 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Secure final phase 2 funding for the solar hot water system by 28 June 2013. 2) Install final phase 2 solar hot water system by 25 April 2014. 3)Attend a final inspection of the solar installation by Hawaii County by 12 May 2014. 4)Conduct a ribbon-cutting ceremony and secure press coverage for the final phase 2 installation of the solar hot water project by 02 June 2014. 5) Maintain accurate accounting of funds expended and return unspent funds by 16 June 2014. 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 dientsseed,workshops or events held,volunteer hours,etc.Describe,be specific) Applicant t Projected Results Cost savings on propane per month $ 1660.00 Cost savings on propane per year $19,920.00 Return on investment 3.5 years Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Reg Salary and Wages 0 0 0 Professional Fees 0 0 0 Operations 725 725 0 Supplies 200 200 0 Equipment $52,500 $64,791 $13,000 Other: Other: Other: Other: Other: TOTAL $53,425 $65,716 $13,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Friends of Kona Community Aquatic Center Program Name: Warm water for Kona Community Aquatic Center 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 conflict is needed. 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): 0 No conflicts exist(No further information required. Please sign form at the bottom.) 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: ailitt-44) ,6 P ) JA, IJS . 1 1 1. Si nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Friends of Kona Community Aquatic Center Program Name: Warm water for Kona Community Aquatic 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, 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://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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 yntil 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 30,2013 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. 411P id," V •AO r Sig .ture of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Friends of Kona Community Aquatic Center Program Name: Warm water for Kona Community Aquatic Center 12.COUNCIL AWARD WORKSHEET TABLE 1: Appkant PROGRAM PERFORMANCE MEASURES Council Proposed Projected Results Projected Result Cost savings on propane per month $1,660.00 Cost savings on propane per year $19,920.00 Return on investment 3.5 years TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 0 Operations $725.00 Supplies $200.00 Equipment $13,000.00 Other: Other: Other: Other: Other: TOTAL $13,925.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 30 Friends of the Children's Justice Center - East Hawaii Special Needs & Ehancement, Ctr support, Edu/Training Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: SpecialNeeds&Enhancemnt,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, sr, 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/CPA: Jennifer L. Gossert Phone No.: (808) 969 — 3115 Firm (if applicable): Jennifer L. Gossert, CPA Accounting Corp. Mailing Address: Address: 688 Kinoole St, Suite 201 Address: City,ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $10,000.00 $10,000.00 $15,000.00 2. Agency Mission Statement: The mission of the Friends of the Children's Justice Center of East Hawaii is to help sexually, physically, and emotionally abused and neglected children, and children who are witnesses to crime, in partnership with the Children's Justice Center of East Hawaii, with a primary goal of enhancing and protecting their physical and psychological well being. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: SpecialNeeds&Enhancemnt,Ctr Support,Education/Training 3. Program Description: Founded in 1990, the Friends of the Children's Justice Center, serves children between the ages of 0-18, who are documented victims of abuse or are witnesses to crime, residing in East Hawaii.The Special Needs and Enhancement Program is designed to help child victims develop positive self-worth. Funds are used to provide basic essentials (i.e.clothing,toiletries), special needs(i.e.transportation, school supplies, correspondence courses) and enhancement support (i.e. sports, music lessons, and tutoring).The Friends maintain the Center's safe and child-friendly atmosphere with toys, games and snacks. The Prevention and Education Program promotes awareness and child abuse prevention. The Training Program sponsors professionals at seminars and conferences to update interviewing techniques & refine skills. 4.Total Budget& Position Count: Total Program Budget: 190,000 Total Program Position Count: 1 Total Agency Budget: 218,000 Total Agency Position Count: 1 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate COH 25,000 HIUW 5,000 Foundation & Corporate Grants 102,000 Charity Walk 3,000 Special Events & Fundraisers 35,000 Donations, Refunds, Interest 5,000 Carryover Funds 15,000 TOTAL: 190,000 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 collect fees for any of our services. We are continuously researching for additional grant funding, striving to increase donations for our Phantom non-event fundraiser, and expanding participation in our golf tournament fundraiser. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: SpecialNeeds&Enhancemnt,Ctr Support,Education/Training 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide funds for emergency needs such as clothing, hygiene items, bed/mattress, car seats etc., & necessities for children in emergency or relative foster placement. Provide funds for enhancements such as sports, registration fees, dance lessons, drama, art activities, music lessons, water sports, intersession fees, tuition, correspondence school, school supplies, ground & air transportation, graduation & prom expenses, birthday & christmas gift, photos, etc.,& funds for sponsor of professional training, community awareness & Center support. 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.) Fill Emergency & Enhancement requests thru the SNR process 1,300 Serve child victims of abuse and/or neglect, & witnesses to crime 600 Maintain Holiday Gift Program 200 Volunteer Hours 1,100 Attach additional pages as necessary. 9. TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Total Budget Grant Reg Salary and Wages 40,500 42,000 2,100 Professional Fees 10,800 12,000 Operations 6,700 7,000 2,900 Supplies 3,000 3,000 Equipment 0 0 Other: Special Needs Requests 113,500 118,000 20,000 Other: Center Support 2,400 3,000 Other: CJC Facility Maintenance 1,250 2,000 Other: Education & Prevention 1,000 2,000 Other: Training 500 1,000 TOTAL i 179,650 190,000 25,000 *if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: SpecialNeeds&Enhancemnt,Ctr Support,Education/Training 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 conflict is needed. 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): l ' I No conflicts exist (No further information required. Please sign form at the bottom.) 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: - l, VrCe rYcisc-6. (/3,7(3 Signatur of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: SpecialNeeds&Enhancemnt,Ctr Support,Education/Training 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 conflict is needed. 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): 71 No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: Tr � 1 - 30 —►3 SignatA of Au horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: SpecialNeeds&Enhancemnt,Ctr Support,Education/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, 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 I ttp://vendors.ehawaiiiov, 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 htj>; ,,ti 0A h d,v,iiii_)unt.z. p_1'f, 1),):Iproili Kr.Int__fn<<,i,, 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, 2014 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. r Li r � kid c P r�52e . I ,.,,. I-3 o- (3 Signa ure Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: SpecialNeeds&Enhancemnt,Ctr Support,Education/Training 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Fill Emergency & Enhancement requests thru the SNR process 1,300 Serve child victims of abuse and/or neglect, & witnesses to crime 600 Maintain Holiday Gift Program 200 Volunteer Support in Hours Worked 1,100 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 42,000 Professional Fees 12,000 Operations 7,000 Supplies 3,000 Equipment 0 Other: Special Needs Requests 118,000 Other: Center Support 3,000 Other: CJC Facility Maintenance 2,000 Other: Education and Prevention 2,000 Other: Training 1 ,000 TOTAL 190,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION P1 2013-2014 Page 7 of 7 31 Friends of the Children's Justice Center of West Hawai`i Enhancement and Basic Needs Agency Name: FRIENDS of the Children's Justice Center of West Hawaii Program Name: Enhancement and Basic Needs r Agency Director: Timothy Ashcraft, Board President Phone No.: (808) 331 — 2425 Contact Person: Michelle Ono, Executive Director Phone No.: (808) 331 — 2425 Mailing Address: Address: p0 Box 9041 Address: City,ST,Zip Kailua-Kona, HI 96745 Facility Address: Address: Address: City,ST,Zip Kailua-Kona, HI 96740 Email Address:fcjcwh @hawaii.rr.com Fax No.: (808) 328 — 8883 Accountant/CPA: Steve Fassbender Phone No.: (808) 331 — 2425 Firm (if applicable): Mailing Address: Address: P.O. Box 9041 Address: City,ST,Zip Kailua-Kona, HI 96745 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $15,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $15,000 $1 0,000 $15,000 2.Agency Mission Statement: The FRIENDS of the Children's Justice Center of West Hawaii mission statement is to provide assistance to the children of West Hawaii who have been traumatized by sexual assault, physical abuse and/or neglect, or who have been witnesses to violent crime such as domestic violence and to promote the awareness and prevention of child abuse. EXHIBIT A Page 1 of 7 NONPROFIT GRANT APPLICATION FY 2013-2014 Agency Name: FRIENDS of the Children's Justice Center of West Hawaii Program Name: Enhancement and Basic Needs 3. Program Description: The Enhancement and Basic Needs program strives to provide financial assistance to help improve and support the healing process for children who have experienced child abuse, negelct, and/or witnesses to violent crime, including domestic violence. The FCJC-WH work with numerous professionals from over 15 different social service agencies who submit Special Needs Requests to the FCJC-WH on behalf of the child victims that they are working with to help meet needs that cannot and/or have not been meet by their agencies. In 2011, the FCJC-WH funded over 1200 needs requests, providing direct and immediate support to child vicitms of abuse in West Hawai'i. Our goal is to "help a victim become a child again" by helping to support the entire healing process. 4.Total Budget&Position Count: Total Program Budget: $ 89,500 Total Program Position Count: 0.50 Total Agency Budget: $ 131,350 Total Agency Position Count: 0.50 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii NPO Grant Funds $15,000 Private Foundations $73,850 Donations $8,000 In Kind Donations $1,500 TOTAL: $98,350 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The FRIENDS of the Children's Justice Center of West Hawaii Board of Directors is committed this year to increasing fundraising efforts and exploring new grant opportunites. Several events such a Benefit Brunch, golf tournament, and Project Compassion are planned as well a mailing. These events are planned to not only increase revenue but to increase awareness of the FRIENDS, the services we provide, and the precious keiki we are honored to serve. EXHIBIT A Page 2 of 7 NONPROFIT GRANT APPLICATION FY 2013-2014 Agency Name: FRIENDS of the Children's Justice Center of West Hawaii Program Name: Enhancement and Basic Needs 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives: 1) Assess 1000 enhancement and/or basic needs requests benefiting 400 individual children by June 30, 2014. 2) Work with social service agencies, private therpists, and other professionals who serve our clientele to identify and address needs and areas of need. 3) Increase awareness of the FRIENDS,the services we provide, and our clientele. 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 Individual Children Served 400 Number of Special Needs Requests Funded 1000 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 0 0 Professional Fees $13,751 $15,000 0 Operations 0 0 0 Supplies 0 0 0 Equipment 0 0 0 Other: $49,630 $74,500 $15,000 Other: 0 Other: 0 Other: 0 Other: 0 TOTAL $63,381 $89,500 $15,000 *If applicable EXHIBIT A Page3of7 NONPROFIT GRANT APPLICATION FY 2013-2014 Agency Name: FRIENDS of the Children's Justice Center of West Hawaii Program Name: Enhancement and Basic Needs 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: None POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): Q No conflicts exist(No further information required. Please sign form at the bottom.) 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 prubability that action token by an individual will result in mensurable 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: / gY 4.0 Pc I l S gnature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: FRIENDS of the Children's Justice Center of West Hawaii 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, 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 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, 2014 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. / 1AAA rKelu re 1)1reCfaY- //18 ab13 Signature of Aut iced Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: FRIENDS of the Children's Justice Center of West Hawaii Program Name: Enhancement and Basic Needs 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Individual Children Served 400 Number of Special Needs Requests Funded 1000 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 0 Operations 0 Supplies 0 Equipment 0 Other: $15,000 Other: Other: Other: Other: TOTAL $15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 32 Global Ecology Foundation Hawaiian Agroecology Agency Name: Global Ecology Foundation Program Name: Hawaiian Agroecology Agency Director: Dr. William Moekahi Steiner, President Phone No.: (808) 294 — 0750 Contact Person: same Phone No.: (808) 326 — 5649 Mailing Address: Address: POB 4565 Address: City,ST,Zip Hilo Hawaii 96720 Facility Address: Address: 200 Address: Kanoelehua Avenue City,ST,Zip Hilo, Hawaii 96720 Email Address: wwmsteiner @gmail.com Fax No.: ( ) — Accountant/CPA: Holo Hoopai Phone No.: (808) 640 — 3825 Firm (if applicable): self employed Mailing Address: Address: POB 5751 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 none none none 2.Agency Mission Statement: Mission: Promote ecologically compatible living. Vision: Humanity in balance and harmony with natural systems. The Global Ecology Foundation has 4 programs of which funding is requested for one program, The GEF Agroecology Program (GEFAP), which has a mission stated as follows: "Mission: Create food production systems that are convenient and in balance with nature." The other 3 programs deal with a Program for Integrating Indigenous Cultures, the Program for Environmental and Natural Resource Conservation, and a Program for Online Library and Invormation Resources. EXHIBIT A Agency Name: Global Ecology Foundation Program Name: Hawaiian Agroecology 3. Program Description: Mission: "Create food production systems that are convenient and in balance with nature." GEFAP employs a systems approach to agriculture and food production based on traditional knowledge, alternative agricultural approaches, and local cultural food system experiences. Its projects seek approaches to agriculture that maintain soil health and richness, biodiversity at all levels, and reduced artificial inputs. Key controlling factors for this strategy include the five major system properties of biodiversity, stability, productivity, sustainability, and equitability. GEF sees these properties as interconnected and interdependent in a social network. This project fits County code requriements of Article 24 on education, community welfare and enviro 4.Total Budget& Position Count: Total Program Budget: $30,520 Total Program Position Count: 5 Total Agency Budget: $ 1,200 Total Agency Position Count: 3 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Fees, first year 1,200 Donations, first year (estimate) 10% of 5,000 web viewers x $5 average when 2,500 web site is finished in February, 2013. TOTAL: 3,700 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The GEF is establishing a website that will have donor buttons for each program including the Agroecology program. A donor can read about the program and its philosophy, then press the button to donate a dollar. Multiple presses enables donation of multiple dollars. Via the web, donations can result in potential numbers of donors in the thousands. GEF plans to continue these tests and hands on approaches and expand them to include other methods of growing including organic and permaculture. Thus, if 30 potential farmers/year take at least two of these courses at $25 each, at least $1,500 can be raised to offset courses. Sales of educational materials (videos, books) is also expected to bring additional funding. Finally, federal and alternative foundation grants will be sought. EXHIBIT A Agency Name: Global Ecology Foundation Program Name: Hawaiian Agroecology 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 conflict is needed. 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): ra No conflicts exist(No further information required. Please sign form at the bottom.) 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: ,�/,/1 r► VIV/3 SignatI e�thorized Perso' (specify title) Date EXHIBIT A Agency Name: Global Ecology Foundation Program Name: Hawaiian Agroecology 7. Program Objectives Using County Nonprofit Grant Program Funds: The Global Ecology Foundation of Hawaii located in Hilo, HI seeks funding to help build the farming community on the Big Island and provide examples of how to proceed in building a food secure Hawaii for the future. During this process the GEF intends to provide training to high school level students to help them establish a background for college level preparatory work, and to interested adults who wish to enter the field of growing food sustainably. Thus this project fits County Code requirements of Article 24 (see attached for more detail). 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.) Project 1: Establish an annual set of sustainable agriculture course based on Korean Natural Farming, Biodynamic farming, mycorem mycoremediation and beekeeping producing new farmers for HI 20 new farmers/year Project 2: test biochar as a soil remediation replacing expensive fertilizers and used to replenish sols depleted of nutrients by sugar 40% higher production Project 3: demonstrate multiple cropping techniques versus mono- culture methods showing how to produce 2x fruits and veg products 30-40% higher biomass prod. Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 0 11,250 11,250 Professional Fees 0 9,500 9,500 Operations 1,100 2,200 2,200 Supplies 100 4,570 4,570 Equipment 0 3,000 3,000 Other: Other: Other: Other: Other: TOTAL 1,200 30,520 30,520 *If applicable EXHIBIT A Agency Name: Global Ecology Foundation Program Name: Hawaiian Agroecology 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 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 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 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 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, 2013 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. ;00ply Q ///7)X5 Signature of Authorized Per on specify title) Date EXHIBIT A Agency Name: Global Ecology Foundation Program Name: Hawaiian Agroecology 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B GLOBAL ECOLOGY FOUNDATION AGROECOLOGICAL EDUCATION FOR FARMERS ON HAWAII ISLAND WHILE BUILDING ENVIRONMENTAL SUSTAINABILITY The Global Ecology Foundation of Hawaii located in Hilo,HI seeks funding to begin build up of the farming community on the Big Island and provide examples of how to proceed in building a food secure Hawaii for the future. Through this process the GEF will also provide training to high school level students to help them establish a background for college level preparatory work and excite them about the possibilities,and to interested adults who wish to enter the field of growing food sustainably. Thus this project fits County Code requirements of Article 24 which states"The service or activity to be provided by the nonprofit organization...shall address....educational concerns....and welfare of the people and the environment." To grow food sustainably on Hawaii Island,there is a need to establish and replenish nutritious soil on the shallow lava soils and/or the deep and depleted former sugar cane soils of the island. There is also a need to integrate and determine the best growing conditions for different elevations, soil profiles and climatic conditions on the islands. Sustainable agriculture information is not generally available from University investigations,nor is it taught in any venue with the type of research support we envision necessary for small farms on the Big Island. Here we begin the formal instructional process to build fresh,new farmers for the future that will be able to grow food on the Big Island in an environmentally stable and friendly way without costly inputs from offshore. We will demonstrate how this can be done,determine factors that can promote healthy,high production levels, and integrate this into the teaching program. This project helps promote the County's desire to develop small,sustainable, diversified farms on lands it owns. This project seeks to teach by demonstration and hands-on learning: (1) Strong resource conservation ethics for our youth and adults who desire to operate their own farms on County lands that are available for long term lease including demonstration of how to become accomplished professional farmers. (2) Soil supplementation utilizing a locally produced product without use of or with great reduction in use of expensive imported fertilizers;and (3) Methods of planting multiple crops in an integrated manner so that productivity is tripled over monocultured crops. We can do this by concentrating attention,funding and knowledge on three inter-related projects. Project 1; Teach 4 courses of ranging from 3-16 weeks each utilizing the resulting applications from projects 2 &3 below in hands-on and classroom approaches comparing the Korean Natural Farming (KNF)Method,farming via Biodynamics, and Myco-remediation/mushroom Farming as agroecological approaches to sustainable farming. Running simultaneously with the Korean Natural Farming method and the Biodynamics farming method,bee-keeping will be taught and will overlap these two farming methods such that hives created and raised by students will provide fertilization for the plots. Students will be incorporated into every aspect of the teaching projects. In these courses, the KNF and Biodynamics courses will run for 16 weeks for 2-8 hours/day depending on subject matter and time needed to set up growing regimes. Lecture portions will be taught at a charge of $25 donation/person/course will be administered to offset costs. High School students will be offered the courses free as long as they have approval of their agriculture teacher or their school officials and/or their parent(s)to take the course.These are teaching and hands on intensive and so each course will be taught by a team of people. We estimate 5 teachers in total with a bee specialist and a mushroom specialist participating from mainland programs. GLOBAL ECOLOGY FOUNDATION AGROECOLOGICAL EDUCATION FOR FARMERS ON HAWAII ISLAND WHILE BUILDING ENVIRONMENTAL SUSTAINABILITY The Global Ecology Foundation of Hawaii located in Hilo, HI seeks funding to begin build up of the farming community on the Big Island and provide examples of how to proceed in building a food secure Hawaii for the future. Through this process the GEF will also provide training to high school level students to help them establish a background for college level preparatory work and excite them about the possibilities,and to interested adults who wish to enter the field of growing food sustainably. Thus this project fits County Code requirements of Article 24 which states"The service or activity to be provided by the nonprofit organization...shall address....educational concerns....and welfare of the people and the environment." To grow food sustainably on Hawaii Island,there is a need to establish and replenish nutritious soil on the shallow lava soils and/or the deep and depleted former sugar cane soils of the island. There is also a need to integrate and determine the best growing conditions for different elevations,soil profiles and climatic conditions on the islands. Sustainable agriculture information is not generally available from University investigations,nor is it taught in any venue with the type of research support we envision necessary for small farms on the Big Island. Here we begin the formal instructional process to build fresh,new farmers for the future that will be able to grow food on the Big Island in an environmentally stable and friendly way without costly inputs from offshore. We will demonstrate how this can be done,determine factors that can promote healthy,high production levels, and integrate this into the teaching program. This project helps promote the County's desire to develop small, sustainable, diversified farms on lands it owns. This project seeks to teach by demonstration and hands-on learning: (1) Strong resource conservation ethics for our youth and adults who desire to operate their own farms on County lands that are available for long term lease including demonstration of how to become accomplished professional farmers. (2) Soil supplementation utilizing a locally produced product without use of or with great reduction in use of expensive imported fertilizers; and (3) Methods of planting multiple crops in an integrated manner so that productivity is tripled over monocultured crops. We can do this by concentrating attention, funding and knowledge on three inter-related projects. Project 1; Teach 4 courses of ranging 8 weeks each utilizing the resulting applications from projects 2 & 3 below in hands-on and classroom approaches comparing the Korean Natural Farming(KNF)Method, farming versus Biodynamics Farming as agroecological approaches to sustainable farming. Running simultaneously with the Korean Natural Farming method and the Biodynamics farming method, bee- keeping will be taught and will overlap these two farming methods such that hives created and raised by students will provide fertilization for the plots. Students will be incorporated into every aspect of the teaching projects. In these courses,the KNF and Biodynamics courses will run for 8 weeks each for 2-4 hours/day depending on subject matter and time needed to set up growing regimes. Lecture portions will be taught at a charge of$25 donation/person/course will be administered to offset costs. High School students will be offered the courses free as long as they have approval of their agriculture teacher or their school officials and/or their parent(s)to take the course. These are teaching and hands on intensive, and so each course will be taught by a team of people. We estimate 5 teachers in total with a bee specialist participating from mainland programs. An example of a timeline is show below. Beekeeping classes will necessarily overlap with Korean Natural Farming method and the biodynamic method of growing to give bee keepers and their hives a 1 GLOBAL ECOLOGY FOUNDATION choice of sources of pollen and honey. The first 2 weeks of each class will be focused on course preparation. Bee keeping is taught as an essential component of an integrated farming method. TIMELINE FOR PROJECTS: 2013 2014 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun KNF Biodynam KNF Biodynam data analysis----reporting Bee keeping Project 2; on teaching plots,test use of biochar as a soil supplement to support sustainable agriculture in different growing systems under different growing conditions. Biochar made from invasive alien trees is available in the community from a small producer for a price of $0.85/pound. GEF will incorporate biochar into the teaching plots above to conduct this test. Studies have shown that biochar, or crushed charcoal, improves soil quality by creating porous conditions that both absorb water to increase soil moisture, and provide surfaces to house microfilament fungi and good soil bacteria that provide nutrients for plants( Chan et al 2007; Warnock et al 2007). These studies also indicate that pest microbes, fungi and animals(nematodes)are reduced with the application of biochar through microchemistry and other means(Lehmann and Joseph 2009). We propose to test the idea that biochar will improve Hawaiian soil that has been depleted of micronutrients which includes most sugar cane land on the Big Island. At center is the idea we can reduce inputs of offshore, expensive fertilizers by substituting biochar. We will set up four, 10' x 10' test plots that are paired on ex-sugar cane land. By paired we mean one plot receiving biochar in one of 3 different densities,and one plot receiving no biochar(control plot). A 10' x 10' plot will contain 6 rows of plants about 10' long and 17"apart with 10" margins to the side of each plot. On each plot,two rows will be planted with green beans(vegetable crop),two with onion(root crop)and two with corn(a grass seed crop). This will be replicated on each of the four plots(see Figure 1). We will conduct the following tests which will give us an idea of what is happening relative to micronutrients, soil organisms, and climate: a. Test each plot for soil pH, soil moisture retention, microbiota density,pH,nitrogen levels (NO3),phosphate levels(PO4),potassium levels(K+)and calcium (Ca++)levels before planting or applying biochar. b. Plant seeds on each plot on the same day. c. Monitor stem thickness; monitor growth rates, height, flowering time, rate and quantity; measure number of fruiting bodies,quality and biomass from each plant on each plot. d. Using multivariate statistics,compare data from plants on each plot against(1) its control;(2)between the three different levels of biochar used,and (3)under different climate features. e. Determine relative amount of insect damage and numbers of different pests on each plant. Excavate the bean and onion roots at harvest and count the number of harmful nematodes for each plant on each plot. f. Test each plot for soil pH, soil moisture retention, microbiota density,pH, nitrogen levels(NO3), phosphate levels(PO4),potassium levels (K+)and calcium(Ca++) levels after crops are harvested. The expectation from the research, based on studies done in Australia and the continental USA, is that biochar will increase production regardless of crop tested here(a vegetable, a root and a seed). The hypotheses governing the research,then, can be stated as follows: 2 GLOBAL ECOLOGY FOUNDATION Hypothesis 1: There are no difference between plots with biochar and plots without biochar for sprout rate,growth rate, flowering rate, numbers of flowers, loss of fruit(no. of flowers minus no. of fruit), production rates,biomass of vegetable,root or seed produced and insect pests nor with respect to climate variable. The null hypothesis is that there will be significant differences at the 0.05 or less level thus disproving the fact that no differences exist in plant growth and production. Hypothesis 2 to be tested: There are no significant differences in soil characteristics such as moisture retention,pH, relative amounts of soil nutrients,amounts of microbiota present,and soil nematodes within and between plots. The null hypothesis is that there will be significant differences at the 0.05 or less level thus disproving the fact that biochar presence has no effect on soil microbiota. This experiment will begin in mid-July of 2013 and end in late March 2014 with data analysis and report preparation following. Funding is requested for seeds,tools,salaries and for publication of a County R&D manual that can be made available to all small farmers in the County and even the State of Hawaii. The manual will also be made available on the GEF website for downloading. Project 3; On the teaching plots(second go around),demonstrate integrated,triple level planting in order to show how small plots of land strengthened by biochar applications can grow plants stacked in a way to triple and quadruple production. Agriculture traditionally has grown crops in monoculture conditions,that is, one crop in one field or plot. Sometimes for pest control purposes or fertilization purposes the crop is rotated out every other year with a second crop such as soybean(nitrogen fixing plant)one year followed by corn the second year in the Midwestern USA. If crops could be grown so that a single field or acreage could produce 2,3 or more crops simultaneously instead of one,then fertile farm land could conceivable feed 3 x the number of people from the same land. This would lend considerably to food security on a small island. In this project, we propose to grow corn,green beans and pumpkins on the same plot replicated(similar to Figure 1 b)once without biochar(plot 6)and three times with 3 types of monocultured crop plots(plots 7,8 &; corn only, green beans only and pumpkins only with each plot having biochar on one half of plot) so that we can compare harvest on monocultured crops versus multiple cultured crops. The primary objective is to demonstrate that a triple-culture crop, via synergistic interactions, will produce more total biomass than a monocrop culture. This project will run on five plots from late November 2013 through March 2013. Biomass production will be measured in two ways: first that total plant material(stems, leaves, roots+fruits and seeds)as measured will be higher in total production than any individual plot, and second that total fruit and seed biomass will be higher taken together than any single plot and single fruit or seed. Two hypotheses are under test here: Hypothesis 1: there will be equivalent biomass production between plots with one crop and plots with two or more crops. The null hypothesis is that biomass will be higher on the triple cultured plot at the .05%or higher significance level. The reason is that biodiversity on the plot will increase the amount of production as has been shown for soil and aboveground biota and insects in certain farming systems (Hooper et al 2000, Bengtsson et al 2005). Hypothesis 2: there will be equivalent fruit and seed production on triple culture and mono culture plots. The null hypothesis is that total fruit and seed production on triple culture crops will be higher than on each fruit or seed on the individually planted plots. This is because ecological theory predicts that biodiversity of beneficial microfungi and insccts will be higher on mixed plots leading to increases in synergism(Loya-Rameriz et al 2003)and will produce more micronutrients to support higher productivity. Plant productivity is measured separate from total biomass because sometimes plants put more energy into fruit or seed production than into stems 3 GLOBAL ECOLOGY FOUNDATION OUTCOMES We anticipate that the proposed courses,besides readying at least 20 new farmers for production,will teach these the value of a scientific approach so that they will know how to ask questions of their growing systems,how to set up comparative studies to determine answers,how to set up testable hypotheses, and how to grow integrated crops. Simple and straightforward methods we teach have been proven in other growing systems throughout the world(Reddy 2011; Reagonold et al 1993; Paull 2011). BUDGET Salaries and Wages: $12,800 salaries for 4 teachers and five classes *Professional Fees: 10,500 includes soil and chemistry tests,professional bee keeper Operations: 2,200 includes ground preparation and rental Supplies: 4,570 includes grow pots,ground sheathing,biochar, etc Equipment: 3,000 includes hand tools,rental for roto-tiller $33,070 REFERENCES Bengtsson,J.,J. Ahnstro'm, and A.-C. Weibull. 2005. The effects of organic agriculture on biodiversity and abundance: a meta-analysis.Journal of Applied Ecology 42: 261-269. Chan, K.Y., L. Van Zwieten, I. Meszaros,A. Downie, S.Joseph. 2007. Agronomic values of Green-waste biochar as a soil amendment. Soil Research 45(8)629-634. Hooper, D.U., D.E. Bignell, V.K. Brown, L. Brussaard, J.M., Dangerfield, D.H. Wall, D.A. Wardle, D.C. Coleman, K.E. Giller, P. Lavelle, W.H. Van der Putten, P.C. De Ruiter,J. Rusek, W.L. Silver,J.M. Tiedje, and V. Wolters.2000. Interactions between aboveground and belowground biodiversity in terrestrial ecosystems: patterns, mechanisms, and feedbacks. BioScience 50(12): 1049-1061.County agroecol prop.doc Lehmann,Johannes and Stephen Joseph. 2009. Biochar for Environmental Management: Science and Technology. Earthscan publishers, London,UK.448 pp. Loya-Ramirez, J.G.,J.L. Garcia-Hernandez,J.J. Ellington,and D.V. Thompson. 2003. The impact of interplanting crops on the density predation of hemipteran predators. Interciencia 28(7):415-420. Paull,John. 2011. Attending the first organic agriculture course: Rudolf Steiner's Agriculture Course At Koberwitz, 1924. European J. of Soc Sciences.21: 64-70. Reddy, R. 2011. Cho's Global Natural Farming. Publ. S. Asia Rural Reconstr. Assoc. 92 pp. Reganold, J.P., A.S. Palmer,J.C. Lockhart and A.N. MacGregor. 1993. Soil quality and financial performance of biodynamic and conventional farms in New Zealand. Science 260: 344-349. Warnock, Daniel D., Johannes Lehmann, Thomas W. Kuyper, and Matthias C. Rillig. 2007. Plant and Soil Mycorrhizal responses to biochar in soil —concepts and mechanisms. Plant Sciences, Volume 300, Issue 1-2, pp 9-20 PREPARED BY: William W.M.Steiner,Ph.D.,President,Global Ecology Foundation ADDRESS: 200 Kanoelehua Ave,Hilo,HI 96720 CONTACT: wwmsteiner wnail.com;808-294-0750 4 FIGURE la. Field plots for testing and demonstrating use biochar on production. Plot 1: 50 gr/sq. ft. biochar Plot 2: control; no biochar corn corn corn corn onions onion onions onion green beans green beans green beans green beans Plot 3 Plot 2 Replicate 1, Biochar amnt:100 gr/sq. foot versus no biochar Plot 4 Plot 2 Replicate 1, Biochar amnt: 150 gr/sq. foot versus no biochar FIGURE lb. Field plots for demonstration and testing multi-culturing on production. Plots 5 and 6 showing interplanting of different crops between and within rows. Plot 5 is planted with biochar at 100 gr/sq. ft. while plot 6 has none. Plots 7,8 & 9 o =green beans(vegetable; between corn rows) control plots with x =pumpkin (fruit; within corn rows) single rows of corn, ---=corn row (grass with seed) green beans or pumpkin Half of each plot with biochar O 0 0 0 0 0 0 0 I biochar added --x--x--x--x--x--x--x-- O 0 0 0 0 0 0 0 I « GG --X--X--X -XXX--X-- O 0 0 0 0 0 0 0 I « « --X--X--X--X--X--X--X-- 0 0 0 0 0 0 0 0 O 0 0 0 0 0 0 0 I <( --X--X--X--X--X--X--x-- 0 0 0 0 0 0 0 0 O 0 0 0 0 0 0 0 I " --x--x--x--x--x--x--x-- x x x x x x x x I (f 44 O 0 0 0 0 0 0 0 x x x x x x x x --x--x--x--x--x--x--x--- I 46 66 33 Goodwill Industries of Hawaii, Inc Employment Core Services - Tuition Support Agency Name: Goodwill Industries of Hawaii Program Name: Employment Core Services- Tuition Support Agency Director: Laura Smith, President& C.E.O. Phone No.: (808) 836 — 0313 Contact Person: Katherine Keir, Senior Director- Human Services 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) 690 — 9783 Accountant/CPA: Wikoff Combs & Co., LLC Phone No.: (808) 791 — 1414 Firm (if applicable): Mailing Address: Address: 1001 Bishop Street Address: Suite 2760 City,ST,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $10,000 $7,500 $10,000 2. Agency Mission Statement: The mission of Goodwill Industries of Hawaii, Inc. (GIH) is to "help people with employment barriers to reach their full potential and become self-sufficient." A nationally accredited human service provider, GIH has served Hawaii as a reputable non-profit organization for 52 years, providing educational, workforce development, and social services to over 15,000 residents annually; in 2011, GIH helped over 1,500 people find jobs in our communities. Over 90% of the people we serve fall below the poverty level, with barriers to economic opportunity such as: Low incomes, immigrant populations, returning from incarceration, disabilities, lower skills or a lack of education, and limited or no work history. GIH is committed to serving the residents of Hawaii County: Its Employment Core Services programs, located in East and West Hawaii, serve un/under-employed individuals <_ 150% of the FPL; their goal is to improve the ability of low-income persons to obtain and maintain employment and increase self-sufficiency. In FY2011-12, these programs served 184 participants, placing 90 into employment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Goodwill Industries of Hawaii Program Name: Employment Core Services- Tuition Support 3. Program Description: Goodwill's Employment Core Services programs provide comprehensive services inclusive of outreach, assessment, plan development, pre-employment training, job development, job placement, and job retention. Due to the significant barriers our clients face, further education and training are vital to facilitate their achievement of employment at a livable wage. GIH respectfully request $30,000 to provide scholarships/tuition subsidies (up to $500/participant) to assist clients in attaining academic, technical and job skills (i.e. Hilo Community College- Continuing Education) necessary to obtain meaningful employment in industries with current job growth; this competitive advantage will help them achieve career advancement. This program will complement GIH's existing employment services to increase participants' success. 4. Total Budget& Position Count: Total Program Budget: $30,000 Total Program Position Count: 5 Total Agency Budget: $3 mil (HI Cty) Total Agency Position Count: 76 (HI County) 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii $30,000 Office of Community Services $100,000 Office of Hawaiian Affairs $50,000 TOTAL: $180,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The requested funding will be used to provide education/training subsidies to participants in GIH's Hawaii County employment servies programs. These programs have a significant presence and a strong record of success in Hawaii County. Goodwill will leverage their resources (i.e. personnel, facilities) to ensure the success of this program; this support network will allow 100% of the requested funding to be spent directly on helping individuals to attend a training program and receive a marketeable certification. Armed with the success of the proposed project, GIH will be able to support program expenses through multiple mechanisms: The accomplishments can be utilized to engage GIH's corporate partners, and capitalize on its proven track record of grant development, to continue providing the scholarship support. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Goodwill Industries of Hawaii Program Name: Employment Core Services- Tuition Support 7. Program Objectives Using County Nonprofit Grant Program Funds: The overall goal of this program is to give individuals the opportunity to attend vocational training and/or receive certifications to facilitate their attainment of meaningful employment, reflecting the training which was subsidized. A minimum of 60 participants will receive this opportunity; of these it is expected 80% will complete the training. Of these, it is expected —85% will be placed into employment, in a related job, as a result of the training received. Further, it is expected this program will also increase participants' self-efficacy to succeed. 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 participants who receive scholarship Minimum of 60 Number of participants who complete certificate/degree Minimum of 48 Number of participants with employment at a related job Minimum of 40 Percentage of participants with improved self-efficacy 100% Attach additional pages as necessary. 9. TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages Professional Fees Operations Supplies Equipment Other: $0 $30,000 $30,000 Other: Other: Other: Other: TOTAL *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Goodwill Industries of Hawaii Program Name: Employment Core Services- Tuition Support 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 conflict is needed. 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): No conflicts exist (No further information required. Please sign form at the bottom.) 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: (/tatli J /(Q. /-,23 -(3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Goodwill Industries of Hawaii Program Name: Employment Core Services- Tuition Support 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.govjfn•-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, 2013 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. dkuvuk, e3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Goodwill Industries of Hawaii Program Name: Employment Core Services- Tuition Support 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 34 Goodwill Industries of Hawaii, Inc Work Experience Program Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program Agency Director: Laura Smith Phone No.: (808 ) 836 — 0313 Contact Person: Mary Roblee Phone No.: (808) 961 — 0307 Mailing Address: Address: 500 Kalanianaole Avenue Address: Suite 3 city,ST,Zip Hilo, HI 96720 Facility Address: Address: 500 Kalanianaole Avenue Address: Suite 3 city,sr,Zip Hilo, HI 96720 Email Address: mroblee @higoodwill.org Fax No.: (808) 969 — 3861 Accountant/CPA: Catha Combs Phone No.: (808) 791 — 1420 Firm (if applicable): Wikoff Combs and Co., LLC Mailing Address: Address: 1001 Bishop Street Address: Suite 2760 City,sT,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $45,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $28,000 $25,000 $10,000 2.Agency Mission Statement: Our mission statement: Goodwill Industries of Hawaii, Inc. helps people with employment barriers to reach their full potential and become self-sufficient. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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. Each program offers dedicated training and support. The Work Experience Program offers participants choice in potential career paths with both hands on and computer based training. The Janitorial Program provides skills training with the joy of receiving a paycheck and the Hawaii Design and Art program encourages creative expression and self-sufficiency through establishing and operating a micro-enterprise. Computer based pre-employment training is provided for all levels of disability, including persons with more severe physical and learning limitations. 4.Total Budget& Position Count: Total Program Budget: $45,000 Total Program Position Count: 7 Total Agency Budget: $3,000,000 Total Agency Position Count: 76 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate State of Hawaii $280,000 County of hawaii nonprofit grant $45,000 TOTAL: $325,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The requested funding will be used to broaden the scope of Goodwill's Work Experience Program. This program is part of Goodwill's larger Developmental Disabilities (Waiver) program which provides services and supports to encourage persons with disabilities to become as independent as possible while being active and contributing members of the Hawaii Island community. Our Developmental Disabilities program maintains a positive reputation in our community through the success of this program, our accessible computer training program and volunteer involvement in the community. An increase in Waiver program participants will provide increased revenues to assist in supporting this program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 Work Experience Program provides wage subsidy and self-sufficiency training and support for individuals with developmental disabilities. Three components of the program include Janitorial Work training, Hawaii Design and Art program expansion, and development of a Sustainability and Self-sufficiency program through gardening and healthy food production. Equipment will include assistive technology devices, computers, software, art programs, and accessible design, art, gardening, food production and janitorial equipment. 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 participants trained in Janitorial Program Minimum of 15 Number of participants trained 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: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Re p Salary and Wages $15,000 $17,000 $17,000 Professional Fees $2,000 $2,000 $2,000 Operations Supplies $500 $1,000 $1,000 Equipment $10,000 $25,000 $25,000 Other: Other: Other: Other: Other: TOTAL $27,500 $45,000 $45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 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 conflict is needed. 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): QNo conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: CALUVL AO. ic:; l _..., /—/ - 23 -/3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. oecauli., A . 5rn k) / 2 3 -13 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $17,000 Professional Fees $2,000 Operations Supplies $1,000 Equipment $25,000 Other: Other: Other: Other: Other: TOTAL $45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Goodwill 9 Industries of Hawaii, Inc. 9 udo"" CERTIFICATE OF THE BOARD OF DIRECTORS OF GOODWILL INDUSTRIES OF HAWAII, INC. The undersigned Chairman of the Board of Goodwill Industries of Hawaii, Inc. (the "Corporation") hereby certifies that Laura D. Smith, President/CEO of the Corporation, has been authorized by the Board of Directors of the Corporation to sign proposals, contracts, and related documents on behalf of the Corporation. Accordingly, I hereby certify that: Laura D. Smith is duly authorized by the Corporation to execute proposals, contracts, and contract amendments on behalf of the Corporation, and further certify that Laura D. Smith is given the power and authority to do all things necessary to implement, maintain, amend, or renew such contracts. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seal of the Corporation, effective the first day of July 2012. Pat ong Chairman of he Board Goodwill Industries of Hawaii, Inc. STATE OF HAWAII CITY & COUNTY OF HONOLULU Oahu On this 15th day of May 2012, before me personally appeared Pat Wong, to me Administrative Office personally known, who, being by me duly sworn or affirmed, did say that she is the 2610 Kilihau Street P Y 9 Y Y Y Honolulu,HI 96819-2020 Chairman of the Board of Directors of Goodwill Industries of Hawaii, Inc., the person Business:(808)836-0313 Facsimile:(808)833-4943 executing the foregoing instrument, and that she executed said instrument as the www.higoodwill.org free act anstdetttiof4he Corpor tion. ����� HA Y ��ii� Beretania Office `�� QZ- ........-10 1085 South Beretania Street .. <4 • •, Si Honolulu,HI 96814-1603 �. • `. Merl a ashi Business:(808)524-6942 :�i ; 1dc = Y Facsimile:(808)521-1637 = * : 08-390 : = Notary Public, State of Hawaii •erupt, • My commission expires: 09-07-2012 East Hawaii Hilo Office 500 Kalanianaole Avenue,Suite 1 f77//1/Ill ItN►P� Hilo,HI 96720-4756 \`N�t1a Business:(808)961-0307 \��<(..,NA`/.r�•5,6, Facsimile:(808)969-3861 �� " • ' • Doc. Date: 5-15-12 # Pages: 1 Maui Name: Merle Hayashi First Circuit = : .0 ,fir Maui Office Doc. Description: Certificate of the Board r �vw• 250 Alamaha Street,Suite N16A irectors of Goodwill Industries of HI PiustN Kahului,HI 96732 %��' ••••... •• Business:(808)873-3972 5-15-12 ��i 4T �����` Facsimile:(808)873-3974 n ure Date 'fl/////iii title'\ NOTARY CERTIFICATION we see the good we see the will Goodwill works_ 35 Grassroots Community Development Group Hawaii Youth Business Center (HYBC) - Puna Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center (HYBC) - Puna Agency Director: Lily Chan-Harris Phone No.: (808 ) 966 —6354 Contact Person: Trina Nahm-Mijo Phone No.: (808 )640 —5109 Mailing Address: Address: PO Box 1772 Address: City,ST,Zip Kea'au, HI 96749 Facility Address: Address: 16-540 Kea'au-Pahoa Highway, Ste. 6 Address: City,ST,Zip Kea'au, HI 96749 Email Address:nahmmijo @hawaii.edu Fax No.: (808 )974 —7757 Accountant/CPA: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 Amount of Request for County Nonprofit Grant Program Funds: $ ,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $50,000 $45,000 $35,000 2. Agency Mission Statement: To strengthen our communities through the cooperative development of programs and services for all of Puna. To provide quality programs for youth. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center (HYBC) - Puna 3. Program Description: The target population is youth, 12-18 year olds, predominantly from the Puna area. The program will be held at a new location in Pahoa at Woodland Cntr. which will have an internet cafe and Mac lab as well as a fully equipped culinary kitchen (former KFC) and a certified mobile kitchen. The Board of GCDG has expanded its vision of training and education to creating a business arm to be called Hawaii Youth Business Center. HYBC will be collaborating with a professional Chef, Thomas Aiu, and Pooki's Bakery who will run their businesses out of the site. HYBC will place an emphasis on learning business, teaming and entrepreneurial skills to survive in a global economy of the 21st century. Besides training and education, HYBC will expand its goal of economic development for youth and the community 4.Total Budget & Position Count: Total Program Budget: $132,000 Total Program Position Count: 4 PT Total Agency Budget: $132,000 Total Agency Position Count: 4 PT 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii $45,000 Other Grants $35,000 Program Income $20,000 Contributions $20,000 Fundraising $12,000 TOTAL: $132,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As explained above in our program description, HYBC will be collaborating with two businesses to both develop an income generating arm to help sustain the training and education non-profit arm of the organization. Besides learning to cook, serve, and manage a business, youth will develop their own recipes, food products, digital products and projects which will be income generating. They will also be a center where community members needing assistance in marketing their services or products to the global community can come and hire Center youth. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center (HYBC) - Puna 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Prevent drug use and other anti-social behaviors in Puna area youth. 2) Provide workforce development in digital media arts, culinary arts, business, entrepreneurship through After-School training and business internships with site partners. 3) Cultivate the talents of area youth to increase the economic viability of the area. 4) Provide Youth Leadership opportunities through community engagement, entrepreneurial training, and product and talent development. 5) Support youth efforts for employment, island sustainability, healthy life choices, and rnmmi snit i rlammInnmont 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.) 60 youth will receive training in Digital Media Arts and Culinary 100% will increase skills 20 Interns will get job training in working in a restaurant 90% will increase job skills emp 10 Interns will get job training in running a business 90% will gain managerial skills 10 participants will plan, implement entrepreneurial project 90% will gain entrepreneurial Attach additional pages as necessary. 9. TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $30,000 $30,000 $20,000 Professional Fees $14,000 $14,000 Operations $20.000 $20,000 $5,000__ -------- Supplies _ $4,900 $4,900 Equipment $5,500 � $5,500 Other: `R Cr1.}- $43,700 $43,700 $25,000 Other: (A e 5 $8,400 $8,400 - -------- — ------ Other: 3u ra $5,500 $5,500 Other: Other: TOTAL $132,000 $132,000 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center (HYBC) - Puna 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 conflict is needed. 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): I� I No conflicts exist (No further information required. Please sign form at the bottom.) nMember 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: ( 2 i 3 Signature o,Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center (HYBC) - Puna 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 Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to , }J: ', s , _� _ 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 L ....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, 2014 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. (111/s- ere_c LA- ( p—c) Signature`of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center (HYBC) - Puna 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 36 Habitat for Humanity - West Hawaii Partnering for Progress Agency Name: Habitat for Humanity West Hawaii Program Name: Partnering for Progress Agency Director: Patrick F. Hurney Phone No.: (808) 331 — 8010 Contact Person: Patrick D. Hurney Phone No.: (808) 331 — 8010 Mailing Address: Address: PO Box 4619 Address: City,ST,Zip Kailua-Kona HI 86745 Facility Address: Address: 73-5576 Kauhola Street Address: City,ST,Zip Kailua-Kona HI 96740 Email Address:ed @habitatwesthawaii.org Fax No.: (808) 331 — 8020 Accountant/CPA: Alex J. Smith Phone No.: (877) 257 — 6484 Firm (if applicable): Alex J. Smith, Certified Public Accountant Mailing Address: Address: 1403 Frank Street, Address: City,ST,Zip Honolulu, Hawaii 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $43,100 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $30,000 $15,000 $20,000 2.Agency Mission Statement: Habitat for Humanity West Hawaii is a non-profit, faith-based organization whose mission is to "empower families and build community and hope through home ownership opportunities for low-income partner families". Our vision is that all residents of West Hawaii will achieve that through our affordable homebuilding efforts. We serve the entire west side of the Big Island of Hawaii, where the lack of low-income sustainable housing has been extensively detailed at both the County and State levels. Granted affiliation with Habitat International in 2002, we serve families earning between 40% and 80%of the County median income on a no-interest, no-profit basis. We address the lack of affordable housing in West Hawaii through new construction of safe, decent homes (19 completed homes to date). We are also about to implement a new program of critical repair and rehabilitation that allows families to remain in their existing homes and in their own neighborhoods. This will allow us to serve even more needy families. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Habitat for Humanity West Hawaii Program Name: Partnering for Progress 3.Program Description: We are seeking the sum of$43,100 to cover the living allowances for 4 AmeriCorps volunteers. In FY2012 our affiliate successfully partnered with the Corporation for National and Community Service to support our goal of providing an ever-increasing number of affordable home ownership opportunities for low-income families in West Hawaii. The 4 new positions will augment our current capacity to implement a program of critical home repairs and rehabilitations, as well as to escalate our new home construction program. The strategic use of these volunteers as the hearts, hands, and voices for the cause of affordable housing will align our affiliate and its work with the strategic direction of the County General Plan, creating and improving sustainable housing solutions and opening new doors for financial support. 4.Total Budget&Position Count: Total Program Budget: $52,100 Total Program Position Count: 4 Total Agency Budget: $869,772 Total Agency Position Count: 5 5. Program Funding Sources(identify g_II sources of funding applied to this program): FY13-14 Revenue Source Estimate Habitat for Humanity West Hawaii supplements the AmeriCorps living allowance through the provision of in-kind benefits such as office space and equipment, reduced housing, and transportation support. Housing supplement $1800 Office equipment $1200 Transportation support $6000 TOTAL: $9000 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: 1. Implementing a program of critical repairs (Neigborhood Revitalization Initiative) has proven to attract increased resources, both from individuals, because of the reduced scope of commitment compared to new home construction, and from government and private foundations that value initiatives that allow families to remain in their own homes. 2. Escalating our new construction program with multiple simultaneous builds increases the mortgage funds that go into our revolving Fund for Humanity, which is used to support our homebuilding efforts. Repayments from the repair program will also go into a revolving account. 3. A 5-year Strategic Plan and a Resource Development Plan specifically address fiscal solvency, with key strategic initiatives for increasing financial resources to support programs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Habitat for Humanity West Hawaii Program Name: Partnering for Progress 7.Program Objectives Using County Nonprofit Grant Program Funds: These volunteers,who care personally about housing as a critical issue, and who have the technical and leadership skills to build our organizational capacity, will be powerful ambassadors for the cause of affordable housing within their personal networks and the funder community. They will allow our affiliate to increase the number of new homes that are constructed simultaneously, implement a Neighborhood Revitalization program, recruit and train new volunteers, and develop sustainable systems for engaging more partner families. 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 sped ic.) Recruit 4 AmeriCorps volunteers in partnership with CNCS; 4 highly skilled members hired Implement Neighborhood Revitalization Initiative, including 6 -8 critical home repairs; 10 development of a system for engaging partner families exterior paint jobs;3 rehabs for new applicants; Recruit/train volunteers for repair program and simultaneous builds 15 trained core volunteers 5 simultaneous builds Research/advocate for new sources of funding to sustain programs 4 funding sources identified Attach additional pages as necessary. 9.TABLE H: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual Total Budget Grant Reg Salary and Wages ,U°6- Az 6)(_09/06 $21,700 $43,100 $43,100 Professional Fees Operations Supplies Equipment Other: of-rICr ./J6 `rk4Vs'ecrVT_ Tii.)„1/ SoPPe-er $4,500 $9,000 Other: Other: Other: Other: TOTAL $26,200 $52,100 $43,100 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Habitat for Humanity West Hawaii Program Name: Partnering for Progress 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 conflict is needed. 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): No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: 1/4q`/ 3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Habitat for Humanity West Hawaii Program Name: Partnering for Progress 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. 6e6C ei 7,VC b/R er7VR.. (07/02 ■ Signature of Authorized Pers specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Habitat for Humanity West Hawaii Program Name: Partnering for Progress 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Recruit 4 AmeriCorps volunteers in partnership with CNCS; 4 Implement Neighborhood Revitalization Initiative, including 6 -8 repairs, development of a system for engaging partner families 10 paints, 3 rehabs Recruit/train volunteers for repair program and simultaneous builds 15 volunteers 5 new builds Research/advocate for new sources of funding to sustain programs 4 new funders TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages,,:/V,Al i; L..L,�L// NC $43,100 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $43,100 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 37 Hale Kipa, Inc Ka'i Like Program Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program Agency Director: Ernest Pletan-Cross Phone No.: (808) 589 — 1829 Contact Person: Jaque Kelley-Uyeoka Phone No.: (808) 589 — 1829 Mailing Address: Address: 615 Piikoi Street Address: Suite 203 City,s-r,zip Honolulu, Hawaii 96814 Facility Address: Address: 622 Hinano Street Address: City,ST,Zip Hilo, Hawaii 96710 Email Address:jaq @halekipa.org Fax No.: (808) 945 — 9007 Accountant/CPA: Maria Gozzip 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 Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $10,000 $15,000 2. Agency Mission Statement: Hale Kipa provides opportunities and environments that strengthen and encourage youth, their families and communities to actualize their potential and social responsibility. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program 3. Program Description: KLP provides island-wide intensive supervision and support services for youth, ages 12-17, in Family Court to hold them accountable for behaviors, be in compliance with probation rules, improve academic and social behavior and strengthen families. Staff executes an individualized Implementation Plan, provide case management (assessment, educational/vocational support, advocacy, monitoring, coordination, connecting to community resources, transportation, etc.), support pro-social/life skill building and strengthen parenting skills and relationships. Youth are connected to activities that seek to decrease risk (unsupervised time, lack of positive adult-youth relationships, low academics, unprotected sex, and increase protective (connections to school, positive influences and activities) factors. 4.Total Budget&Position Count: Total Program Budget: $200,000.00 Total Program Position Count: 9 Total Agency Budget: $6,265,688.00 Total Agency Position Count: 138 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Office of Youth Services $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: Hale Kipa had been receving supplemental funds for this program from another source that will expire April 30, 2012. Hale Kipa is committed to applying for Grants from other sources; encouraging more OYS monies to be applied to program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. 90% of KLP participants will be in compliance with their probations terms and conditions and be positively discharged from the program. 2. 90% of KLP participants will be engaged in an educational/vocational program and/or become employed. 3. 90% of KLP participants will be in stable living situation and remain arrest-free 3 months post discharge. 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,etc.Describe,be specific.) Applicant Projected Results Number of youth served 75+ Number of contacts with youth, family, and collaterals 9500+ Number of linkages to community resources 250 Participants who become involved in HK's education/voc initiative 25 Participants will not become pregnant while in program 90% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages 162,574 164,000 8,000 Professional Fees Operations 5,000 5,000 1,500 Supplies 25,000 26,000 4,800 1,695 1,700 250 Equipment 7,400 7,000 1,500 Other:01-a f �1—�z u,,,_ Other: /9-144/t 500 500 0 3,918 4,000 500 Other: -,pay�� 1,500 1,500 200 Other: )(e,s J._.y r7e/ 37,280 37,800 2,500 Other: T' Ce_61,7 fie,y 2,000 2,000 750 TOTAL 246,867 249,500 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program 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 conflict is needed. 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): R-71 No conflicts exist (No further information required. Please sign form at the bottom.) I Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. c)laii(4„„,, L. �� ac.)I3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hale Kipa, Inc. Program Name: Ka'i Like Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 38 Hamakua Health Center, Inc Healthy Moms Mean Healthy Babies Agency Name: Hamakua Health Center, Inc. Program Name: Healthy Moms Mean Healthy Babies Agency Director: Ward Fansler Phone No.: (808) 930 — 2721 Contact Person: Ward Fansler Phone No.: (808) 930 — 2721 Mailing Address: Address: 45-549 Plumeria St. Address: City,sT,zip Honoka'a, HI 96727 Facility Address: Address: 45-549 Plumeria St. Address: City,ST,Zip Honoka'a, HI 96727 Email Address:wfansler @hamakua-health.org Fax No.: (808) 775 — 9404 Accountant/CPA: Sandra Silva Phone No.: (808) 930 — 2760 Firm (if applicable): Mailing Address: Address: 45-549 Plumeria St. Address: City,ST,Zip Honoka'a, HI 96727 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 51 ,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 12,500 2.Agency Mission Statement: To improve the health of our patients annd community through integrated medical, behavioral health, dental and health education services that are patient centered, accessible, affordable, coordinated, culturally competent and community directed for all.The Amazing Tooth Bus is a state of the art mobile dental office which is owned and operated by Hamakua Health Center, Inc. Dr. Ayer and her amazing staff can assist you with exams, digital x-rays, cleanings, fillings, extractions, root canals, crowns, dentures, partials, bridges, and referrals to specialists. Our schedule rotates between Honokaa and Kapa'au spending approximately 3 months at each location. Dental care is an integral part of a patient's overall health and well-being. Our mission is to educate and start prevention measures at an early age to encourage good oral hygiene habits, which will lead to healthy adult teeth. If you know someone who cannot afford dental care and they live in Hamakua, Waimea, Waikoloa or Kohala, we offer a Sliding Fee Discount Program to all patients who qualify. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 } Agency Name: Hamakua Health Center, Inc. Program Name: Healthy Moms Mean Healthy Babies 3. Program Description: Gum disease has been implicated as a factor in Preterm Birth (PTB). While the data is inconclusive, we believe that improving overall maternal health is a cost effective intervention in reducing the risk of PTB. This program will provide dental examinations and appropriate periodontal treatment. Priority will be given to women residing in the North Hawaii service area, but residents from other districts would also be accepted. Collaboration and referral of pregnant women eligible for this program would be provided primarily by the Malama Perinatal Program, (See attached for more information) 4.Total Budget&Position Count: Total Program Budget: 85,984 Total Program Position Count: 4.0 Total Agency Budget: 6,534,489 Total Agency Position Count: 63 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii 51,000 Third party billing (Med-Quest) 15,507 Minimum patient co-pay 4,290 In-kind Hamakua-Health Center 15,187 TOTAL: 85,984 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Beginning 1/3/13 the dental van added a new service site in Waimea increasing the service area to three sites: North Kohala, Waimea and Honokaa. In addition, we intend to add a hygienist two days a week by 4/1/2013. The increased availability to a broader community and increased serices from a hygienist are expected to increase our ability to subsidize the outreach to underserved pregnant women. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hamakua Health Center, Inc. Program Name: Healthy Moms Mean Healthy Babies 7. Program Objectives Using County Nonprofit Grant Program Funds: Improving one aspect of overall maternal health by reducing gum disease in pregnant women could reduce the risk of PTB. Our objective is to reduce the number of PTBs in the patient population in the HHC service area. Patients under 21 with MedQuest will be treated using MQD funds, not funds from this grant. Their data will be included in performance measures. (See attached for additional information) 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.) Reduce the percentage of Pre Term Births from 10% To less than 10% Pregnant women complete treatment program Exceed 80% success rate Attract 100 underserved pregnant women to program 100 pregnant women served Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Req Actual* Total Budget Salary and Wages 69,844 34,860 Professional Fees Operations 4,185 4,185 Supplies 11,955 11,955 Equipment Other: Other: Other: Other: Other: TOTAL 85,984 51,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hamakua Health Center, Inc. Program Name: Healthy Moms Mean Healthy Babies 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 conflict is needed. 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): nNo conflicts exist (No further information required. Please sign form at the bottom.) QMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: Valerie Poindexter, current council member, is a former employee of Hamakua Health Center. t .,_ £ViA2 -&€ P ►4 • • 30 l3 •ig :ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hamakua Health Center, Inc. Program Name: Healthy Moms Mean Healthy Babies 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. Woi,u-e,c‘')- 0) '.ignature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hamakua Health Center, Inc. Program Name: Healthy Moms Mean Healthy Babies 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Reduce the percentage of Pre Term Births from 10% Less than 10% Pregnant women complete treatment program 80% Attract 100 underserved pregnant women to program 100 participate TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Hamakua Health Center, Inc. Program: "Healthy Moms Mean Healthy Babies" Additional Program Information The primary objective of this project is to demonstrate improvement in the overall health of the mother will translate into a healthier child, measured as an expected reduction in preterm births (PTB) and Low Birth Weight (LBW). The secondary objective is to demonstrate that cost effective,quality oral health services can be delivered in an accessible manner to a greater number of underserved pregnant women through the dental services of a locally available community health center than is currently being realized. Finally,we will share the outcome data, experiences and lessons learned with a wider group of interested oral and primary health care agencies, organizations and providers in order to determine the extent of unmet needs in this target population, to test for effective modes of treatment and to inform those at the public policy level with the hope of expanding funding and services to this unique, under-served population in other communities. In theory and practice, effective access to oral health education and preventive services by underserved populations will reduce more acute and costly health care conditions that could develop in the future. A statement of need that this project will address Based on the most recent PRAMS report for Hawaii County, from the Hawaii Department of Health, in an average year approximately 2,350 babies are born on the island. The HHC service area accounts for about 18 % of the county's population, meaning about 423 childbirths will take place in this region. The report states that only about 30% of pregnant women see a dentist during their pregnancy, therefore we expect that about 125 women in the HHC service area will have need of dental care. In Hawaii Quest/Medicaid insured adults, including all pregnant adult women, receive only emergency dental services. Thus, preventive, dental hygiene and restorative services are not a covered benefit. This strongly suggests that the lack of coverage for these basic dental services could be a significant obstacle to care among lower income, pregnant women. In reviewing calendar year 2011 data from the Malama Perinatal Program,they saw 81 unduplicated prenatal women from the island (30 from the North Hawaii region) aged 21 and older. Of these only 20% self-reported having seen a dentist in the past year; a percentage even lower than that experienced island-wide. In Hawaii County there are currently 13.5 FTE dentists who report that they are available to serve the low-income, and from that group 6.5 report that they serve Medicaid patients. Recent research indicates that efforts to support oral health can begin even before birth; just as a pregnant woman's overall health can affect the health of her pregnancy and baby, her oral health can play a role in the occurrence of early childhood disease in her children. The condition of a woman's mouth can also contribute to pregnancy-related problems and influence birth outcomes. These relationships are complex and multidirectional (CDHP and NIHCM Foundation 2010) In the past few years, many professional organizations have released guidelines to support oral health care during pregnancy. One example is the California Dental Hamakua Health Center, Inc. Program: "Healthy Moms Mean Healthy Babies" Additional Program Information Association Foundation (CDA Foundation),which, in collaboration with the American College of Obstetricians and Gynecologists (ACOG), District IX, convened a panel of oral health professionals to review current research. Based on this work, and with support from foundations, including the California HealthCare Foundation, Sierra Health Foundation, and Anthem Blue Cross and Blue Shield Foundation, the panel released Oral Health During Pregnancy and Early Childhood: Evidence-Based Guidelines for Health Professionals (2010). The following consensus statement is included in the guidelines: Prevention, diagnosis, and treatment of oral diseases, including needed dental radiographs and use of local anesthesia, are highly beneficial and can be undertaken during pregnancy with no additional fetal or maternal risk when compared to the risk of not providing care. Good oral health and control of oral disease protect a woman's health and quality of life and have the potential to reduce the transmission of pathogenic bacteria from mothers to their children. Adult pregnant women have unique oral health and dental care needs that can affect their own health as well as the health of their children. But access to non-emergent dental care for these mothers is clearly a problem on the island, particularly for those women who lack insurance coverage or are enrolled in the Hawaii MedQuest program. This proposed pilot project is a serious collaborative attempt to address these issues in this underserved population. We sincerely hope that the outcomes demonstrated by this project can serve the larger policy agenda to expand needed dental services to this target population and reduce costly and more serious oral and general health problems later in life of both the mother and their children. Operational Plan Any low-income pregnant woman is eligible to participate. We expect most referrals to come from Hui Malama, but other referral sources (or none) are acceptable. If a person presents without any referral,we will make the appropriate referral for their obstetric care. Each patient will receive a dental examination and as few x-rays as possible. The ideal time for dental treatment and x-rays is during the second trimester of pregnancy, but early intervention (during first trimester) can be started without taking radiographs; this additional diagnostic information can be obtained when appropriate.After the diagnosis of gum disease is made, appropriate treatment and education will be commenced. Each patient will be given follow-up appointments to determine the effectiveness of treatment and home-care. Data (patient age, severity of disease, follow-up diagnosis) will be collected at each visit and reported at the end of the project. If the patient has MedQuest benefits and is under age 21,the fee for services will be billed directly to MQD. If the patient is over age 21,we will charge the grant fund the same fee that MQD is charged under the ESPDT program and the patient will pay only a minimum $10 co-pay. Hamakua Health Center, Inc. Program: "Healthy Moms Mean Healthy Babies" Additional Program Information Marketing and Publicity Plan The primary goal of the publicity plan is to notify the community of the availability of this program. Secondarily,we must present the information in a way that overcomes barriers to care (cost, transportation, fear of x-rays, etc).These goals will be accomplished by utilizing culturally sensitive messages that both inform and reassure prospective patients of the safety and benefit to the health of their child this program will offer. Messages will be in the form of printed announcements distributed to community service bulletin boards, churches, health care providers, DOH offices, schools and newspapers. We will also send press releases to local radio and TV stations. Expected Outcomes The project expects to provide screening and treatment of gum disease for 100 pregnant women during the course of the program. While the data is not conclusive, recent research shows there may be a causal link between untreated gum disease and PTB and LBW.We expect to see a reduction in these unfavorable events. It may be unrealistic to anticipate a specific percentage reduction, but it is our strong conviction that any adverse event that can be avoided will be of such significant cost savings over the lifetime of the child that the project's costs will be more than justified. The most recent PRAMS report for Hawaii County reports 235 PTB on approximately 2,350 births or about 10% births are PTB.We hope our treatment plans for 100 pregnant women will result in a PTB rate below 10% Hamakua Health Center will obtain permission from each participant to follow up on their pregnancy to determine if birth was normal PTB or LBW. Hamakua Health Center, Inc. —"Healthy Mom's Mean Healthy Babies" Hamakua Health Center, Inc. Program: "Healthy Moms Mean Healthy Babies" The primary objective of this project is to demonstrate improvement in the overall health of the mother will translate into a healthier child, measured as an expected reduction in preterm births (PTB) and Low Birth Weight (LBW). The secondary objective is to demonstrate that cost effective, quality oral health services can be delivered in an accessible manner to a greater number of underserved pregnant women through the dental services of a locally available community health center than is currently being realized. Finally,we will share the outcome data, experiences and lessons learned with a wider group of interested oral and primary health care agencies, organizations and providers in order to determine the extent of unmet needs in this target population, to test for effective modes of treatment and to inform those at the public policy level with the hope of expanding funding and services to this unique, under-served population in other communities. In theory and practice, effective access to oral health education and preventive services by underserved populations will reduce more acute and costly health care conditions that could develop in the future. A statement of need that this project will address Based on the most recent PRAMS report for Hawaii County, from the Hawaii Department of Health,in an average year approximately 2,350 babies are born on the island. The HHC service area accounts for about 18 % of the county's population, meaning about 423 childbirths will take place in this region. The report states that only about 30% of pregnant women see a dentist during their pregnancy, therefore we expect that about 125 women in the HHC service area will have need of dental care. In Hawaii Quest/Medicaid insured adults, including all pregnant adult women, receive only emergency dental services. Thus, preventive, dental hygiene and restorative services are not a covered benefit. This strongly suggests that the lack of coverage for these basic dental services could be a significant obstacle to care among lower income, pregnant women. In reviewing calendar year 2011 data from the Malama Perinatal Program,they saw 81 unduplicated prenatal women from the island (30 from the North Hawaii region) aged 21 and older. Of these only 20% self-reported having seen a dentist in the past year; a percentage even lower than that experienced island-wide. In Hawaii County there are currently 13.5 FTE dentists who report that they are available to serve the low-income, and from that group 6.5 report that they serve Medicaid patients. Recent research indicates that efforts to support oral health can begin even before birth; just as a pregnant woman's overall health can affect the health of her pregnancy and baby, her oral health can play a role in the occurrence of early childhood disease in her children. The condition of a woman's mouth can also contribute to pregnancy-related problems and influence birth outcomes. These relationships are complex and multidirectional (CDHP and NIHCM Foundation 2010) In the past few years, many professional organizations have released guidelines to support oral health care during pregnancy. One example is the California Dental Hamakua Health Center, Inc. —"Healthy Mom's Mean Healthy Babies" Hamakua Health Center, Inc. Program: "Healthy Moms Mean Healthy Babies" Association Foundation (CDA Foundation), which, in collaboration with the American College of Obstetricians and Gynecologists (ACOG), District IX, convened a panel of oral health professionals to review current research. Based on this work, and with support from foundations, including the California HealthCare Foundation, Sierra Health Foundation, and Anthem Blue Cross and Blue Shield Foundation,the panel released Oral Health During Pregnancy and Early Childhood: Evidence-Based Guidelines for Health Professionals (2010). The following consensus statement is included in the guidelines: Prevention, diagnosis, and treatment of oral diseases, including needed dental radiographs and use of local anesthesia, are highly beneficial and can be undertaken during pregnancy with no additional fetal or maternal risk when compared to the risk of not providing care. Good oral health and control of oral disease protect a woman's health and quality of life and have the potential to reduce the transmission of pathogenic bacteria from mothers to their children. Adult pregnant women have unique oral health and dental care needs that can affect their own health as well as the health of their children. But access to non-emergent dental care for these mothers is clearly a problem on the island, particularly for those women who lack insurance coverage or are enrolled in the Hawaii MedQuest program. This proposed pilot project is a serious collaborative attempt to address these issues in this underserved population. We sincerely hope that the outcomes demonstrated by this project can serve the larger policy agenda to expand needed dental services to this target population and reduce costly and more serious oral and general health problems later in life of both the mother and their children. Operational Plan Any low-income pregnant woman is eligible to participate.We expect most referrals to come from Hui Malama, but other referral sources (or none) are acceptable. If a person presents without any referral,we will make the appropriate referral for their obstetric care. Each patient will receive a dental examination and as few x-rays as possible. The ideal time for dental treatment and x-rays is during the second trimester of pregnancy, but early intervention (during first trimester) can be started without taking radiographs; this additional diagnostic information can be obtained when appropriate.After the diagnosis of gum disease is made, appropriate treatment and education will be commenced. Each patient will be given follow-up appointments to determine the effectiveness of treatment and home-care. Data (patient age, severity of disease, follow-up diagnosis) will be collected at each visit and reported at the end of the project. If the patient has MedQuest benefits and is under age 21, the fee for services will be billed directly to MQD. If the patient is over age 21,we will charge the grant fund the same fee that MQD is charged under the ESPDT program and the patient will pay only a minimum $10 co-pay. Hamakua Health Center, Inc. —"Healthy Mom's Mean Healthy Babies" Hamakua Health Center, Inc. Program: "Healthy Moms Mean Healthy Babies" Marketing and Publicity Plan The primary goal of the publicity plan is to notify the community of the availability of this program. Secondarily, we must present the information in a way that overcomes barriers to care (cost, transportation, fear of x-rays, etc). These goals will be accomplished by utilizing culturally sensitive messages that both inform and reassure prospective patients of the safety and benefit to the health of their child this program will offer. Messages will be in the form of printed announcements distributed to community service bulletin boards, churches, health care providers, DOH offices, schools and newspapers. We will also send press releases to local radio and TV stations. Expected Outcomes The project expects to provide screening and treatment of gum disease for 100 pregnant women during the course of the program.While the data is not conclusive, recent research shows there may be a causal link between untreated gum disease and PTB and LBW.We expect to see a reduction in these unfavorable events. It may be unrealistic to anticipate a specific percentage reduction, but it is our strong conviction that any adverse event that can be avoided will be of such significant cost savings over the lifetime of the child that the project's costs will be more than justified. The most recent PRAMS report for Hawaii County reports 235 PTB on approximately 2,350 births or about 10% births are PTB. We hope our treatment plans for 100 pregnant women will result in a PTB rate below 10% Hamakua Health Center will obtain permission from each participant to follow up on their pregnancy to determine if birth was normal PTB or LBW. 39 Hamakua Health Center, Inc Underserved Child Dental Access Grant Agency Name: Hamakua Health Center, Inc. Program Name: Underserved Children Dental Access Grant Agency Director: Ward Fansler Phone No.: (808) 930 — 2721 Contact Person: Ward Fansler Phone No.: (808) 930 — 2721 Mailing Address: Address: 45-549 Plumeria St. Address: City,ST,Zip Honoka'a, HI 96727 Facility Address: Address: 45-549 Plumeria St. Address: City,ST,Zip Honoka'a, HI 96727 Email Address:wfansler @ hamakua-health.org Fax No.: (808) 775 — 9404 Accountant/CPA: Sandra Silva Phone No.: (808) 930 — 2760 Firm (if applicable): Mailing Address: Address: 45-549 Plumeria St. Address: City,s-r,Zip Honoka'a, HI 96727 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 12 500 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 12,500 2.Agency Mission Statement: To improve the health of our patients and community through integrated medical, behavioral health, dental and health education services that are patient centered, accessible, affordable, coordinated, culturally competent and community directed.The Amazing Tooth Bus is a state of the art mobile dental office which is owned and operated by Hamakua Health Center, Inc. Dr. Ayer and her amazing staff can assist you with exams, digital x-rays, cleanings, fillings, extractions, root canals, crowns, dentures, partials, bridges, and referrals to specialists. Our schedule rotates between Honokaa and Kapa'au spending approximately 3 months at each location. Dental care is an integral part of a patient's overall health and well-being. Our mission is to educate and start prevention measures at an early age to encourage good oral hygiene habits, which will lead to healthy adult teeth. If you know someone who cannot afford dental care and they live in Hamakua, Waimea, Waikoloa or Kohala, we offer a Sliding Fee Discount Program to all patients who qualify. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hamakua Health Center, Inc. Program Name: Underserved Children Dental Access Grant 3. Program Description: Hawaii's children have one of the highest rates of dental cavities in the nation and the shortage of providers willing to treat these needy and vulnerable populations exists in all urban and rural areas of the Hawaiian Islands. Consistant with the two priorities of the Hawaiian Islands Oral Health Task Force 2-4-6-8 Action Plan, Hamakua Health Center will provide Assurance of Care, Education and Prevention to under-served children kindergarten through fifth grade. Hamakua Health Center, Inc. will use its 38 foot mobile dental van equipped with three operatories, digital x-ray equipment, computerized electronic dental record systems and disposable supplies and staff to provide dental screening, oral health education and comprehensive and emergency dental services at two elementary schools. 4.Total Budget& Position Count: Total Program Budget: 41,738 Total Program Position Count: 4.0 Total Agency Budget: 6,534,489 Total Agency Position Count: 63 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii 12,500 Third party billing (Med-Quest) 28,050 TOTAL: 41,738 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Beginning 1/3/13 the dental van added a new service site in Waimea increasing the service area to three sites: North Kohala, Waimea and Honokaa. In addition, we intend to add a hygienist two days a week by 4/1/2013. The increased availability to a broader community and increased services from a hygienist are expected to increase our ability to subsidize the outreach to underserved students in two elementary schools. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hamakua Health Center, Inc. Program Name: Underserved Children Dental Access Grant 7. Program Objectives Using County Nonprofit Grant Program Funds: Implement an effective system to provide oral health education, screening, comprehensive and emergency dental services to under-served children in two elementary schools. One school will be Waimea Elementary School where this will be our second annual visit and the second school site is yet to be determined, but will be located in North Kohala or Hamakua areas to target under-served children. Both areas have elementary schools with high percentage of students participating in the free and reduced lunch programs. 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.) Waimea Elementary School (WES)-Visual dental screenings 200 under-served children WES - Oral health education with free oral hygiene kits 200 under-served children WES - Provide comprehensive & emergency dental services 100 under-served children New Target Elementary School (NTES)-Visual dental screenings 200 under-served children NTES - Oral health education with free oral hygiene kits 200 under-served children NTES - Provide comprehensive & emergency dental services 100 under-served children Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 13,678 28,716 Professional Fees Operations 1,188 1,188 Supplies 5,919 11,834 11,312 Equipment 5,210 Other: Other: Other: Other: Other: TOTAL 24,807 41,738 12,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hamakua Health Center, Inc. Program Name: Underserved Children Dental Access Grant 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 conflict is needed. 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): nNo conflicts exist(No further information required. Please sign form at the bottom.) gi Member or members of the Council _ Staff appointed by a member of the Council The Mayor n 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: Valerie Poindexter, current council member, is a former employee of Hamakua Health Center. ( -e/J/K) al/atraa0 yJ(430A-dm- c)Nux.44, s )(4.6 CS Authorized Person Sl eci title) Date Sign t re of Author ( p f1/ ) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hamakua Health Center, Inc. Program Name: Underserved Children Dental Access Grant 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.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 fora maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2014 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. .._ ( AO bakd se405 J [3 is nature of Authorized Person (specify title) / +ate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hamakua Health Center, Inc. Program Name: Underserved Children Dental Access Grant 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Waimea Elementary School (WES)-Visual dental screenings 200 under-ser WES - Oral health education with free oral hygiene kits 200 under-ser WES - Provide comprehensive & emergency dental services 100 under-ser New Target Elementary School (NTES)-Visual dental screenings 200 under-ser NTES - Oral health education with free oral hygiene kits 200 under-ser NTES - Provide comprehensive & emergency dental services 100 under-ser TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 40 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: POB 381 or 45-3396 Mamane. St. Address: 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/CPA: Aloha Business Services Phone No.: (808) 329 — 9220 Firm (if applicable): Mailing Address: Address: 74-5596 Pawai Pl. #3E Address: City,ST,Zip Kailua-Kona, HI 96740-1688 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $1 7,500 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $15,000 $10,000 $11,250 2.Agency Mission Statement: The Hamakua Youth Foundation, Inc. (HYF) is a community based organization dedicated to creating no-fee, nuturing youth service programs for ages ten through eighteen during non-school hours, engaging youth in environmental sustainability and stewardship, providing Hawaiian culture and arts education, developing youth leadership and connecting youth and their families with local social services agencies. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 3.Program Description: The Hamakua Youth Center (HYC)is a free drop-in youth and community program open after school Monday through Friday until 5:30pm and10am to 4pm during school intersessions and summer breaks. Our no-fee services include the following programs 'Ai Pono, Wai Pono, Homework Help, Computer Lab, E Ola Pono, Gender Specific Boys'/Girls' Nights (discussions), Hawaiian Language, Gardening, Waipi'o Valley Ahupua'a Sustainbility, Arts/Crafts and Games/Sports. This request is for the County of Hawaii to continue essential programs to youth and families. We serve 250 annually with 50 (unduplicated) participants on a weekly basis. Our primary focus is on services for teenage youth. 4.Total Budget&Position Count: Total Program Budget: $145,429 Total Program Position Count: 4 Total Agency Budget: $145,429 Total Agency Position Count: 4 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii Community Foundation $15,000 County of Hawai'i - Non-Profit Grant $17,500 State of Hawai'i -Special Funds $20,000 "Service Clubs" /"Local Business" (i.e: Lions Club, Hotel Industry, etc.) $6,300 Shippers' Wharf Trust Fund $32,980 Hawaii Island United Way $20,000 Fundraisers/Community Donations $35,000 TOTAL: $146,780 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: The Hamakua Youth Foundation, Inc. will work with our community partners to schedule special community events, including 'Ohana Nights'and the Second Annual HYF Hula Festival in November 2013. We plan to increase individual donations through "Friends of the Hamakua Youth Center". The Hamakua Youth Foundation, Inc. will continue to explore additional private and public funding sources. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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) Provide a comprehensive after-school, summer and occasional weekends educational, cultural and recreational programs. 2) Build life skills such as: healthy cooking and drinks, personal hygiene. 3) Instill a sense of self-worth, confidence, accountability and cultural awareness. 4) Encourage envolvement and peer leadership. 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.) Maintain and increase youth participation 55-70 unduplicated youth /wk Continual evaluation and improvement of existing programs 55-70 unduplicated youth/wk Survey youth participants through council and interview process at random Feedback from peers, youth and family members at random Youth Council and County Sponsored Youth Forums increasing numbers Increase in the number of B.O.D, committees and volunteers increasing numbers Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $75,600 $97,269 $10,300 Professional Fees $12,080 $15,660 $2,000 Operations $14,484 $15,000 $2,500 Supplies $14,700 $15,000 $2,500 Equipment $6,400 $500 $100 Other: rwnaraisir Ex enSe. $750 $1,000 $0 Other: 53/4.4.C4*" Tra'rneiY1l ar 4"-VrI"e t $700 $1,000 $100 Other: Other: Other: TOTAL 123,964 $145,429 $17,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 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 conflict is needed.Please duplicate as needed to fully disclose.All disclosure forms must be signed,regardless of whether a conflict exists. NAME: Valerie Poindexter POSITION: County Council May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): nNo conflicts exist(No further information required. Please sign form at the bottom.) ✓i Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director HThe 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: CWaC!& Pres1M4 Signature of Authorized Person (specify title) "MP P) DD Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth 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,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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.hawailcounti.govith-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 30,2014 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. • OC /A: ecitee, • PreSiJenf II I 13 �jC Signature of Authorized Person (specify title) 1 T D'D•D Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 55-70/wk (ud) Continual evaluation and improvement of existing programs 55-70/wk (ud) Survey youth participants through council and interview process at random Feedback from peers, youth and family members at random Youth Council and County Sponsored Youth Forums increase in #'s Increase in the number of B.O.D, Committees and volunteers increase in #'s TABLE I1: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $10,300 Professional Fees $2,000 Operations $2,500 Supplies $2,500 Equipment $100 Other: FtRndta(S1 �.J Eacv eb1 $0 Other: Sta TrraiiJningi and Tc-ate1 $100 Other: J Other: Other: TOTAL $17,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 41 Hawaii County Economic Opportunity Council After School STEM Program Agency Name: Hawaii County Economic Opportunity Council Program Name: After School STEM Program Agency Director: Lester Seto Phone No.: (808) 961 — 2681 Contact Person: Bettie Wagstaff Phone No.: (808) 961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,zip Hilo, HI 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo, HI 96720 Email Address: bettie48wag @gmail.com Fax No.: (808) 935 — 9213 Accountant/CPA: John Carbonara Phone No.: '(808) 968 — 1002 Firm (if applicable): Carbonara & Associates Mailing Address: Address: P 0 Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 2.Agency Mission Statement: Agency Mission Statement: Applicant's mission is the alleviation, elimination and prevention of poverty in the County of Hawaii by: • Mobilizing and channeling private and public resources into antipoverty action; • Stimulating new and effective approaches to the alleviation of poverty; • Strengthening communication, mutual understanding with residents; • Planning the coordination and implementation of antipoverty program; • Educ2ting children and youth to become responsible contributing adults; • Assisting the poor to attain economic self-sufficiency. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: After School STEM Program 3. Program Description: The after school STEM program is an academic enhancement program which will provide students with age-appropriate learning opportunities, designed to increase their interest and knowledge of science technology, engineering and math. Program activities will be conducted 5 days per week . An IT specialist and an engineer will vist each school on a rotational basis. Robotic activites, math games and IT projects will be conducted. Transportation home will be provided to ensure equal access to the program. Afterschool and weekend activites will be offered. The program will ibe conducted at 4 school in Hilo, Puna and Kau. 4.Total Budget & Position Count: Total Program Budget: 152,959.08 Total Program Position Count: 9 Total Agency Budget: 2,420,896 Total Agency Position Count: 13 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Co HI non-profit grant program 76479.54 CSBG 76479.54 TOTAL: 152959.08 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HCEOC is actively applying for funding for this program. Applicants are being researched and written to various charitable foundations. The agency will hold several fund raising activities throughout the year to raise funds for this project. Current fund raising plans include 2 rummage sales and 3 car washes. These fund raising activities are in addition to the annual HCEOC Fund Raising Drive. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: After School STEM Program 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of the program is to increase the participation of low-income at-risk students pursuing careers in STEM-related professions. The objectives are: 1) increase youth confidence in science and math; 2) increase youth achievement on standardized achievement tests; provide yourth stress free, project-based and inquiry based which encourage independent thought; 3) increase opportunitties for youth to participate in supervised after-school activities as an alternative to drugs, and other at-risk behaviors; and 4) provide youth role models 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 who enroll in the program 60 youth will participate in prog Number of youth who improve their academic achievement 90 % of youth will improve their academic achievement Number of youth who express interest in a STEM-related career 75% will express interest in STEM-related career Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Re q Salary and Wages 76976.40 38488.20 Professional Fees Operations 11420 5710 Supplies 12000 6000.00 Equipment 0 0 Other: 14572 7286 Other: 15395 7697.5 Other: 22595.68 11297.84 Other: Other: TOTAL 152959.08 76479.54 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: After School STEM Program 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 conflict is needed. 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): No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: /A,IA r,\ Signature of Authorized Person (specify title) Date L. s f Sefc EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: After School STEM 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. % t .1(1 3 Signature of Authorized Person (specify title) Date L e I-ex- 5 i-C EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: After School STEM Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 42 Hawaii County Economic Opportunity Council Language Arts Multicultural Program Agency Name: Hawaii County Economic Opportunity Council Program Name: Language Arts Multicultural Program Agency Director: Lester Seto Phone No.: (sos ) 961 — 2681 Contact Person: Bettie Wagstaff Phone No.: (8os) 961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,zip Hilo, HI 96720 Email Address: bettie48wag @gmail.com Fax No.: (808) 935 — 9213 Accountant/CPA: John Carbonara Phone No.:, (80s) 968 — 1002 Firm (if applicable): Carbonara & Associates Mailing Address: Address: P 0 Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 75,000 58,000 2.Agency Mission Statement: Agency Mission Statement: Applicant's mission is the alleviation, elimination and prevention of poverty in the County of Hawaii by: • Mobilizing and channeling private and public resources into antipoverty action; • Stimulating new and effective approaches to the alleviation of poverty; • Strengthening communication, mutual understanding with residents; • Planning the coordination and implementation of antipoverty program; • Educating children and youth to become responsible contributing adults; • Assisting the poor to attain economic self-sufficiency. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: Language Arts Multicultural Program 3. Program Description: HCEOC (LAMP) is an inschool tutoring and mentoring program with after school tutoring of low-achieving youth. During the day, LAMP staff assist the classroom teachers by working with designated youth. After school the LAMP staff tutor syouth with their class work as well as provide additional material to enhance their academic achiement. The LAMP program focuses on language arts, math and social skills. Because parental participation is important in youth learning, LAMP staff make home visits and meet with the parents of the students periodically. Excursions are scheduled which provde the students a chance to explore their communities and learn about different cultures. Transportation is provided home so that all students have equal opportunity to participate. LAMP will be conducted at 2 schools in Puna and Kau. 4.Total Budget& Position Count: Total Program Budget: 196,478.13 Total Program Position Count: 5 Total Agency Budget: 2,420,896 Total Agency Position Count: 9 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Co HI non-profit grant program 98239.06 CSBG 98239.07 TOTAL: $196,478.13 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HCEOC is actively applying for funding for this program. Applicants are being researched and written to various charitable foundations. The agency will hold several fund raising activities throughout the year to raise funds for this project. Current fund raising plans include 2 rummage sales and 3 car washes. These fund raising activities are in addition to the annual HCEOC Fund Raising Drive. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: Language Arts Multicultural Program 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of the program is to increase the academic achievement of low-income at-risk students on standardized achievement tests; provide increased opportunitties for youth to participate in supervised after-school activities as an alternative to drugs, and other at-risk behaviors; and provide youth role models. The program focuses on working with English language learners and employs two Marshallese speaking staff. 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 who enroll in the program 40youth will participate in prog Number of youth who improve their academic achievement 90 % of youth will improve their academic achievement Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Req Actual* Total Budget Salary and Wages 95575 120160 60080 Professional Fees Operations 12600 11540 5770 Supplies 4500 2000 1000 Equipment Other: 12571 46778.13 23389.07 Other: 12768 16000 8000 Other: Other: Other: TOTAL $126700 $196478.13 98239.06 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: Language Arts Multicultural Program 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 conflict is needed. 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): No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council _ The Mayor nThe 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: 1j 2C I3 Signature of Authorized Person (specify title) Date s r c EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: Language Arts Multicultural 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.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, 2014 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. �-' 11/:-- / \ L t/L/l..4 t )-c,•4 l t e-4.-;o1 j 7 'X e.<:..t[ �l V P✓ -) 1-CC 1 G-- (/ '2 ` / .2 3 i i Signature of Authorized Person (specify title) Date L _5 - T r- j L c EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: Language Arts Multicultural Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 43 Hawaii County Economic Opportunity Council Youth Mentoring and Drop-out Prevention Agency Name: Hawaii County Economic Opportunity Council Program Name: Youth Mentoring and Drop -Out Prevention Agency Director: Lester Seto Phone No.: (808) 961 — 2681 Contact Person: Bettie Wagstaff Phone No.: (808) 961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: bettie48wag @gmail.com Fax No.: (808) 935 — 9213 Accountant/CPA: John Carbonnara Phone No.: (808) 968 — 1002 Firm (if applicable): Mailing Address: Address: P 0 Box 4372 Address: City,sr,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $45,000.00 2.Agency Mission Statement: The mission of HCEOC is to reduce and prevent poverty in the County of Hawaii through education, job training and advocacy. The objectives of HCEOC include the following: to mobilize and channel resources of private and public institutions into anti-poverty action; to stimulate new and more effective approaches to the solution of problems; to strengthen communication, mutual understanding, planning, coordination and implementation of anti-poverty programs in the community; and to educate children and youth to become responsible, contributing adults in society. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: Youth Mentoring and Drop -Out Prevention 3. Program Description: The Drop Out Prevention Program (DOPP) works with high school students,refered for chronic unexcused absenteeism and are at risk of dropping out of school before graduating. Program Facilitators work with school-referred students, parents, school counselors, teachers and administration, as well as family court and other public agencies, to establish rapport and open channels of communications among all involved parties. Activities are conducted to help students develop positive attitudes toward school, increase self esteem and explore career options. Regardless of the reasons for a student being referred to the program as at-risk, DOPP staff assess the student's interest and ability, his level of self esteem and his attitude toward his parents, students and the community and develop an agreed plan of action. 4.Total Budget&Position Count: Total Program Budget: $183,862 Total Program Position Count: 5 Total Agency Budget: 2,420,896 Total Agency Position Count: 9 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Co Hawaii Non-profit Grant Program 90,009.53 Community Services Block Grant 90,009.53 TOTAL: 180,019.06 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HCEOC is actively seeking additional funds for this program. These include applying for a Grant-in-aid, foundation grants and fundraising. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: Youth Mentoring and Drop -Out Prevention 7. Program Objectives Using County Nonprofit Grant Program Funds: By the end of the school year a) 90% of the seniors in the program will graduate. b) 70% of the students referred will pass all courses necessary for promotion. c) 75% of the referred students will have an attendance of 65% or better. d) 70% of the students referred will finish the school year without any suspensions exceeding 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.) 1. Program will serve 40 students 36 students will meet all progra objectives 2.15 seniors will participate in the program 13 seniors will graduate 3. 40 students will have course achievement evaluated 28 students will pass all course 4. 40 students will have attendance monitored 30 students will have an attendance better than 65% 5. 40 students will have monitoring of suspensions 28 stds will have no suspensi Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Req Actual* Total Budget Salary and Wages 0 120796 60398 Professional Fees 0 0 Operations 10725 5364 Supplies 600 300 Equipment 0 0 Other: 47895 23947.50 Other: Other: Other: Other: TOTAL 180019.06 90,009.53 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: Youth Mentoring and Drop -Out Prevention 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 conflict is needed. 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): I. No conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor I I 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: kit et .n, =x ,./ ;LC ' �2 1 :3 Signature of Authorized Person (specify title) Date *c y S - c EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: Youth Mentoring and Drop -Out Prevention it 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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 r< a f / 12C 3 Signature of Authorized Person (specify title) Date eSfty- Se-}o, EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaii County Economic Opportunity Council Program Name: Youth Mentoring and Drop -Out Prevention 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 44 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: Hilo - 34 Rainbow Drive, Hilo, HI 96720 and Address: Honomu - 28-1630 Old Mamalahoa Hwy, Honomu, HI 96728 City,ST,Zip Email Address: Puusitalo @hawaiiislandadultcare.org Fax No.: (808) 961 — 3740 Accountant/CPA: Jennifer Gossert Phone No.: (808) 969 — 3115 Firm (if applicable): Jennifer L. Gossert, CPA Mailing Address: Address: 688 Kinoole Street Address: City,s-r,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $30,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 20,000.00 20,000.00 15,000.00 2. Agency Mission Statement: To provide quality community based care for elders and challenged adults and support for their families on the island of Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 elders and disabled adults. Hilo is open six days per week, and current enrollment is 103, with daily attendance of 60 to 70. Honomu is new with six participants. Of the combined participants, 76% are over 80 years old, the majority are frail with some dementia, the remainder are stroke debilitated, have Alzheime's disease, or other conditions. The programs provide a structured daily schedule including exercise, activities for mental stimulation, socialization, and fun. The goals are to keep our kupuna living at home as long as possible, provide dignity, deter premature institutionalization into long term care facilities and support families/caregivers with respite time and the opportunity to continue being employed. 4.Total Budget& Position Count: Total Program Budget: 1,336,200 Total Program Position Count: 33 Total Agency Budget: 1,350,600 Total Agency Position Count: 33 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Tuition/Fees 780,000.00 State/Federal (Medicaid) 180,000.00 County of Hawaii 30,000.00 Templeton Hopper Fund 71,250.00 Hawaii Island United Way 20,000.00 Other Grants: Friends of Hawaii Charities, HHA-Charity Walk, Mclnerny, etc. 40,000.00 Please see Attachment A 120,500.00 TOTAL: 1,241,750.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The tuition assistance portion of our program is a hole that remains insatiable in the sense that the participant cannot afford the whole cost, and there is no-where except grant sources that cover this gap. For the day care program we raise our rates every year (or as needed) to cover increased costs, with this increase the tuition assistance requests increase also, so the request to other funding sources also increases. Our one large fundraiser, our golf tournament did much better this past summer, but this is unknown year for year. Unless the federal/state governments recognize the Medicaid tax savings of adult day care versus care homes or nursing homes (many would be in such if not for day care) the only choice for the supplement is grants. They could change the income requirements for Medicaid and also have Medicare start paying for at least some adult day care after hopitalizations. EXHIBIT A NONPROFIT GRANT APPLICATION 'FY 2013-2014 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: The objective of this request is to assist low income participants to attend adult day care. All our participants need to attend, either under doctors' orders for socialization and safety, or the families have concerns about their safety at home alone all day. The low income group is above the poverty level requirements, and thus ineligible for Medicaid, the QExA program, to help pay for their care. Yet they do not have enough resources themselves to pay for full costs. These funds and other grants help fill the gap, we review each financial request's income and expenses, and use tuition assistance as a cost share. 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.) Participants able to attend adult day care over the course of the yr 12 - 24 Total Units (months) of funding assistance, estimated over the year 85 - 110 Elders who maintained/improved self care/alleviate depression 12 - 24 Families who received respite 12 - 24 Families who are able to continue employment 10 - 15 . Caregiver Satisfaction - deterring burn-out 12 - 24 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 835,443 836,000.00 Professional Fees 8,290 8,300.00 Operations 170,401 172,450.00 Supplies 75,891 77,000.00 Equipment 3,750 3,750.00 Other: Di r.cf_ Gjic -i >✓><�Py 141,050 144,250.00 30,000.00 Other: Other: Other: Other: TOTAL 1,234,825 1,241,750.00 30,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 • Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 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 conflict is needed. 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): I� I No conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: 00,1) Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 • Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.govJfn-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, 2014 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. e s— /1e),A.1 Sign ture of Authorized Person (specify title) Date • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 12. COUNCIL AWARD WORKSHEET TABLE I: 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 full yr 85 - 110 Elders who maintained/improved self care/alleviate depression 12 - 24 Families who receive respite 12 - 24 Families who are able to continue employment 12 - 15 Caregiver satisfaction - deterring burnout 12 - 24 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: r7„-,.e f L bent PAN 30,000.00 Other: Other: Other: • Other: TOTAL 30,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION .FY 2013-2014 Page 7 of 7 Hawaii Island Adult Care, Inc. Hawaii County Human Services Grant for Fiscal Year 2014 Page 2, Attachment A Additional Program Funding Sources USDA Lunch Reimbursement $ 60,000.00 Donations, lunch, Christmas, etc. 13,000.00 Donations, Tuition Assistance 4,500.00 Fundraising 35,000.00 PIN Management Fees/misc 8,000.00 Total: 120,500.00 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. • 45 Hawaii Island Cardiovascular, Inc Remote Cardiovascular Screening Program Agency Name: Hawai'i Island Cardiovascular, Inc. Program Name: Remote Cardiovascular Screening Program Agency Director: Raphael Chaikin Phone No.: (808) 887 — 0040 Contact Person: Mary Stancill Phone No.: (808) 936 — 3632 Mailing Address: Address: 64-1067 Mamalahoa Hwy Address: Suite B4 city,sr,Zip Kamuela, HI 96743 Facility Address: Address: Address: City,ST,Zip Kamuela, HI 96743 Email Address:stancill @hawaiicardiovascular.org Fax No.: (808) 885 — 8511 Accountant/CPA: Stacy Chun Phone No.: (808) 885 — 8589 Firm(if applicable): Stacy's Bookkeeping Mailing Address: Address: P.O. Box 7096 Address: City,ST,Zip Kamuela, HI 96743 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 NA NA -0- 2.Agency Mission Statement: Hawai'i Island Cardiovascular(HIC) is dedicated to markedly improving the health of Hawai'i County Native Hawaiians, residents, and visitors by fulfilling unmet needs for screenings to identify heart and vascular disease and refer individuals for appropriate levels of treatment. Given the tremendous threat that undetected heart disease (#1 killer in USA) holds for the well-being of the island's population and its economic prosperity, HIC is unique as the island's only organization providing actual screenings on a consistent basis to people who may not otherwise receive them. To improve our ohana's heart health, HIC also plans 1) module in school garden program; 2) middle school science class module/demonstration of effects of heart disease; 3) public service ads on signs of heart attack and stroke;4) wellness classes teaching healthy choice grocery shopping and cooking (sign-ups offered at screenings); among others. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawaii Island Cardiovascular, Inc. Program Name: Remote Cardiovascular Screening Program 3. Program Description: HIC's Remote Screening Program will provide cardiovascular screenings in the County, particularly in the underserved southern part of the island. Held in churches, clinics, farmers markets, etc., sites will be convenient for participants. Volunteer doctors, nurses and lay assistants, will provide people with blood tests, a variety of blood pressure measurements, screening ultrasound, EKG and oxygen consumption measurements, which will identify those at risk of cardiovascular disease. When needed, referrals will be made to primary care physicians, hospital-based clinics, West Hawaii Community Health Center and Hamakua Health Center. Lives will be saved by identifying undetected disease; health resources will reduced by identifying disease early when treatment outcomes can be better and less costly. 4.Total Budget&Position Count: Total Program Budget: $225,000 Total Program Position Count: 2.5 Total Agency Budget: $375,000 Total Agency Position Count: 3.25 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate * As HIC is initiating its fundraising as of this date, the following are projected and in development Grants from individuals in memory of loved ones $15,000 Corporate grants $75,000 Grant to cover 1 RN/sonographer $50,000 TOTAL: $140,000 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: HIC's Remote Screening Program for the County's underserved population will be sustained by the organization's development of an expanded fee-for-service and/or donation based program that will include consultations with a cardiologist, cardiac nurse practitioner, nutritionist, and wellness practitioners, along with genetic testing. By leveraging the Island's economic diversification, HIC will thus be able to generate funds to provide robust screening services to uninsured and/or underserved Big Islanders. Additionally, HIC is in the initial stages of seeking grant funding from a variety of medical device and healthcare organizations, among others. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawai'i Island Cardiovascular, Inc. Program Name: Remote Cardiovascular Screening Program 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Conduct 2 days of screenings per month at locations convenient for underserved to access screenings; providing screenings to at least 50 people per month (more than 600 annually). 2) Conduct onsite screenings at West Hawaii Community Health Center, screening more than 120 people per month (more than 1440 annually). 3) Engage Big Islanders through screenings, public service advertising and health fair participation in understanding the risks of heart disease, a silent killer if left undetected. 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.) Screen more than 2,000 for cardiovascular disease annually Save lives with detection Save --- lives (*County's death rate of CVD disease =--- %) *Source: No Hawaii Outcomes Project 2012 data Identify more than --- poeple who may not otherwise know they Prevent increase in disease have America's#1 killer disease Engage volunteers in 2,650 hours of service to island's ohana Generate 2,650 volunteer hrs Raise awareness -crucial window to get to ER for stroke care Save lives with awareness Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages -NA-* $113,000 0 Professional Fees 2,000 0 Operations 19,000 0 Supplies 28,000 20,000 Equipment 63,000 18,000 Other: Other: Other: Other: Other: TOTAL $225,000 $38.000 if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hawai'i Island Cardiovascular, Inc. Program Name: Remote Cardiovascular Screening Program 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Raphael Chaikin POSITION: Director May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): IN No conflicts exist(No further information required. Please sign form at the bottom.) 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: I �.e) - ) 3 ce civY-" Signature of uthorized 1 ,son(specify I/Iiii.O Date r ,t � I -6v J 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawai'i Island Cardiovascular, Inc. Program Name: Remote Cardiovascular Screening 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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) DI Iec-.' Date i I l EA/A. __f 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaii Island Cardiovascular, Inc. Program Name: Remote Cardiovascular Screening Program 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 46 Hawaii Island Health Information Exchange - HIHIE HIHIE Consortium Agency Name: Hawaii Island Health Information Exchange - HIHIE Program Name: HIHIE Consortium Phone No.: (808) 933 — 8559 Agency Director: Susan B. Hunt Phone No.: (808) 933 — 8559 Contact Person: Susan B. Hunt Mailing Address: Address: 1437 Kilauea Ave., Ste. 105 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 1437 Kilauea Ave., Ste. 105 Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: susanbh @hawaii.edu Fax No.: (808) 933 — 8574 Accountant/CPA: Stephanie Ladwig Phone No.: (808) 933 — 8559 Firm (if applicable): n/a Mailing Address: Address: 1437 Kilauea Ave., Ste. 105 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $50,192 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 11-12 FY 09-10 FY 10-11 0 0 $50,192 2.Agency Mission Statement: Hawaii Island Health Information Exchange (HIHIE) dba Island tx Beacon xempt, corporation (HIBC) and hereafter referred to as HIBC) is a ( )( ) non-profit, established in2010 as part of a Beacon grant received aare and Hawaii at reduce The grant funded numerous initiatives to improve health and healthcare costs. HIBC is committed to continue the valuable work started under the grant, which includes convening and engaging the community and health care mission ss to address sly barriers improve ove to access to quality health care on Hawaii Island. HIBC's healthcare quality, cost-efficiency, and population health, known as "the Triple Aim." The result of these efforts will be improved care, improved outcomes es f for patients, l enable more o t savings for the system as a whole. HIBC will work to improve systems and accountable patient partners who are more actively involved in their own healthcare decisions. EXHIBIT A Page 1 of 7 NONPROFIT GRANT APPLICATION FY 2013-2014 Agency Name: Hawaii Island Health Information Exchange - HIHIE Program Name: HIHIE Consortium 3. Program Description: The HIBC Board of Directors is the core tc team the transformation and of providers, government officials, health insurance rep ntativesbusinesses, private physicians, and epresentativesfrom Independent Physicians. A key activity of Beacon and Consortium�oll borate to achieve the vision of a future where hospitals,the HIHIE Care Consortium.The HIBC Board ncy clinicians, patients ion h and the HIHIE together comprised of improvements in health staff, efficiency, and partners anon health. The HIH commuaw partnerd Fed stakeholders island-wide.I h Cliinics, Bay Clinic, Inc., Hamakua Health Center, Inc.,i anld West Hawaii three Hawaii Island Federal Qualified Health i anity Health Care Hawaii Island three Coordination Services d acute hospitals; public andupr vate community ty st keholders who Hawaiian Health Care System; all thr also provide culturally appropriate support and care coordination; and provider Associations (IPA's). 4.Total Budget&Position Count: ®,. Total Program Budget: 51:x,192 Total Program Position Count: Total Agency Budget: 90,192 Total Agency Position Count: 5. Program Funding Sources(identify all sources of funding applied to this pro gram): FY13-14 Estimate Revenue Source County of Hawaii Grant - Request 501,192 HMSA Foundation _■„ TOTAL: 90,192 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Several of the objectives require only one-time start-up funding bonito initiate, d will be nd sustained through the volunteer work of the HIBC Board and in-kind d Consortium organizations. HIBC will include the administrative and finance l eanagge aelnt support in its fund development work and continue to pursue grant support the island-wide leadership collaboration. If and when Account lledCare Organizations assumed by (AGO) are developed on Hawaii Island. many of these functions the ACOs or another island-wide health group, EXHIBIT A Page 2 ofd NONPROFIT GRANT APPLICATION FY 2013-2014 Agency Name: Hawaii Island Health Information Exchange - HIHIE Pro ram Name: HIHIE Consortium 7. Program Objectives Using County Nonprofit Grant Program Funds: (1) Program Operation and Oversight:Provide/hire staff to manage the project on a part-time basis,and oversee the development of Objectives 2-3 below,and a plan to sustain the efforts including writing additional grants. (2)Facilitate and grow the regional,island-wide approach community learning collaborative,and funding go costs;pcos'tspstobtained facilitate, litate Institute for Healthcare Improvement(IHI)Triple Aim Improvement Y coordinate and expand the Consortium network and effortsof care improve ort the act vi1 es of the comfmittleesepromote collaboration a individuals, e organizations and the community in improving the system support (3)Develop consensus on objective measures of success and performance measures for island-wide health,healthe ca (including graccess to care),and cost;collaborate to obtain,analyze,and feed back data on these performance measures by appropriately 9 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results fix.:number of clients served,workshops or events held,volunteer hours.,etc.Describe,be soeufic) Increase the number of organizations/agencies involved by 10% 30 organizations active support Sustain progress through mobilizing and growing resources 40 to attend: args & Payers Deliver half-day gathering to share the Triple Aim Data Facilitate 2 meetings to expand network and promote collaboration 30 people to attend: Orgs Develop requirements for Hawaii Island health services plan values, vision & framework Attach additional pages as necessary. 9.TABLE II: . FY 13 14 FY 12-13 FY 13-14 PROGRAM EXPENDITURES Grant Red Actual' Tcttai Buriget n!a 40,800 Salary and Wages �Ot'�0 Professional Fees !Va. 3,392 Operations nta nta Supplies n!a Equipment n!a Other: n!a Other: Na Other: ___ a Other: nia n!a Other. TOTAL $50,192 if applicable EXHIBIT A Page 3 of NONPROFIT GRANT APPLICATION FY 2013-2014 Agency Name: Hawaii Island Health Information Exchange - HIHIE Program Name: HIHIE Consortium 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Sharon Vitousek POSITION: Board President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ✓ No conflicts exist (No further information required. Please sign form at the bottom.) 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: ,,,,,P1 g:/611----4—L--- //'. /97,/3 Signatur of Authorize Jerson (sp cify)tle) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawaii Island Health Information Exchange - HIHIE Program Name: HIHIE Consortium 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. /3/A-0/3 Signature of Authorized Per n ecify title Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaii Island Health Information Exchange - HIHIE Program Name: HIHIE Consortium 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 47 Hawaii Island HIV/AIDS Foundation HIV Transmission Prevention for Women (SISTA) - Kona cis :.-ky Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: HIV Transmission Prevention for Women (SISTA)-Kona Agency Director: Tina Clothier Phone No.: (808 ) 331 — 8177 Contact Person: Tina Clothier Phone No.: (808) 331 — 8177 Mailing Address: Address: 75-240 Nani Kailua Drive Address: Suite 5 City,sT,Zip Kailua-Kona, HI 96740 Facility Address: Address: 75-240 Nani Kailua Drive Address: Suite 5 City,ST,Zip Kailua-Kona, HI 96740 Email Address: tina @hihaf.org Fax No.: (808) 331 — 0762 Accountant/CPA: Rozanne Connell Phone No.: (808) 968 — 1002 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 Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 15,000 15,000 8,000 2. Agency Mission Statement: The Hawaii Island HIV/AIDS Foundation (HIHAF)is a non-profit organization dedicated to assisting those affected by HIV/AIDS to maximize their qualilty of life, and to ending the spread of HIV. We also utilize the lessons learned in the HIV epidemic to care and advocate for others with related health issues such as Hepatitis and STDs. Our vision is to build a healthier, stronger and more sustainable community, supporting all its members as we focus on HIV and related health issues. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: HIV Transmission Prevention for Women (SISTA)-Kona 3. Program Description: The Hawai'i Island HIV/AIDS Foundation - Kona is proposing to continue funding for the HIV transmission prevention programs (SISTA) for a minimum of 100 at risk women in West Hawai'i , including individual and group protocols and counseling and testing of women at risk. This program is designed to STOP HIV and other STDs, at the source, with individuals who can transmit the disease to others. The program also provides access to early treatment for newly diagnosed HIV positive women, stablizing and maintaining long term health and well being for all HIV+ women in West Hawai'i County, and transmission prevention interactions. 4.Total Budget & Position Count: Total Program Budget: 44,679 Total Program Position Count: 2.5 Total Agency Budget: 1,016,294 Total Agency Position Count: 14 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii 15,000 Omidyar Ohana 20,000 Big Island AIDS Walk 2,500 Taste of Life fund raiser 2,500 donations 5,000 TOTAL: 45,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hawaii Island HIV/AIDS Foundation continues to collaborate with the other AID Service Organizations around the state (Malama Pono on Kauai, Life Foundation on Oahu and Maui AIDS Foundtion on Maui). We are in the midst of developing a proposal to Hawaii Community Foundation for a state-wide grant to conduct SISTA programs in each county. The HIHAF Board of Directors has also pledge that a portion of our annual fundraisers will be used to support the SISTA Program. In addition, we are working with the Asian Pacific Islander Health Forum to secure grants for this program. We hope to present our adaptation of the program at National Conference on AIDS in New Orleans, Sept 8-11, 2013. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: HIV Transmission Prevention for Women (SISTA)-Kona 7. Program Objectives Using County Nonprofit Grant Program Funds: The program will reduce HIV, STD and Hepatitis risk among low income women who are at the highest risk as many of them suffer from illegal drug use, domestic violence, sexual abuse, poverty, food and/or housing insecurity and lack adequate medical care. In addition, through testing, will identify those women who are HIV+ and link them to medical care, services and support, thereby reducing the spread of HIV within West 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.) 1. Conduct six (6) 5-week programs +1 follow up session each 6 programs + follow up 2. Enroll a minimum of 12 women per program 72 participants 3. Conduct 72 Rapid tests during program 72 tests 4. Locate 4 HIV+ women who were unaware fo the thier status 4 5. Link 4 newly diagnosed HIV+ women to care 4 6. Enroll 4 HIV+ women in HIHAF case management program 4 Attach additional pages as necessary. 9. TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 30,783 33,861 5,384 Professional Fees Operations 4,345 5,050 3,848 Supplies 3,268 3,268 Equipment 2,500 2,500 Other: Other: Other: Other: Other: TOTAL 35,128 44,679 15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: HIV Transmission Prevention for Women (SISTA)-Kona 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 conflict is needed. 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): IN No conflicts exist (No further information required. Please sign form at the bottom.) ElMember or members of the Council _ Staff appointed by a member of the Council _ The Mayor piThe 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 HIHAF staff and board members submit an annual COI form in which they are required to disclose any conflict of interest, including those relative to this grant. (\f\ C)\Q-C)6xQ1)ja-(21 (Ne VI /13 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: HIV Transmission Prevention for Women (SISTA)-Kona 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. Ins- �■ • 5C-`QJJDUiret.CfC, 141 l,5 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 , Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: HIV Transmission Prevention for Women (SISTA)-Kona 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 48 Hawaii Island HIV/AIDS Foundation Multi-Disciplinary HIV & Hepatitis C Case Management - Hilo t Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Multi-Disiplinary HIV & Hepatitis C Case Management- Hilo Agency Director: Tina Clothier Phone No.: (808 ) 331 — 8177 Contact Person: Tina Clothier Phone No.: (808) 331 — 8177 Mailing Address: Address: 75-240 Nani Kailua Drive Address: Suite 5 City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 16-204 Melekahiwa Place Address: Suite 1 City,ST,Zip Keaau, HI 96749 Email Address: tina @hihaf.org Fax No.: (808) 331 — 0762 Accountant/CPA: Rozanne Connell Phone No.: (808) 968 — 1002 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 Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 15,000 15,000 12,000 2. Agency Mission Statement: The Hawaii Island HIV/AIDS Foundation (HIHAF) is a non-profit organization dedicated to assisting those affected by HIV/AIDS to maximize their qualilty of life, and to ending the spread of HIV. We also utilize the lessons learned in the HIV epidemic to care and advocate for others with related health issues such as Hepatitis and STDs. Our vision is to build a healthier, stronger and more sustainable community, supporting all its members as we focus on HIV and related health issues. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Multi-Disiplinary HIV & Hepatitis C Case Management- Hilo 3. Program Description: HIHAF provides invaluable support to HIV-infected individuals to assist them in keeping their loved ones free of HIV and Hep C. HIVand Hep C transmission prevention is based upon a culturally appropriate harm reduction methodology. When a new client begins their relationship with HIHAF, we take care to assess their current relationships and activities they may participate in that might put others at risk for HIV and/or Hep C infection. A multidisciplinary team composed of two full-time (2.0 FTE) case managers,(a Treatment Advocate, RN; and a Benefits Specialist); one half-time (0.50 FTE) housing specialist and one half- time (0.50 FTE) client services facilitator provide direct care services for PLWHA and/or Hepatitis C residing in East Hawai'i. (The housing specialist also serves clients on the west side of the island). 4. Total Budget & Position Count: Total Program Budget: 379,035 Total Program Position Count: 2.5 Total Agency Budget: 1,016,294 Total Agency Position Count: 14 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii 15,000 Hawaii State Department of Health 359,595 Shipper's Wharf Committee 4,440 TOTAL: 379,035 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In addition to the DOH Care Management contract, Hawaii Island HIV/AIDS Foundation has recently been awarded $30,000 for Hepatitis C awareness, testing and development of a case management program based on HIHAF's HIV case managment experience. A portion of this grant will be used toward the salary of our case manager for East Hawaii. Once the case management program has been established HIHAF will be eligble for funding from two pharmacutical companies beginning in 2014. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Multi-Disiplinary HIV & Hepatitis C Case Management- Hilo 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Secure resources to pay health insurance premiums for no less than ninety percent (90%) of all PLWHA and/or Hep C. 2. Forestall homelessness by providing financial support and/or housing relocation assistance for no less than ninety percent (90%) of all eligible PLWHA requesting or demonstrating a need for emergency shelter, or either short-term or long-term shelter or housing assistance. 3.Assist eligible PLWHA or Hep C who request or demonstrate a need for substance misuse treatment,mental health counseling, medication, and food. 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. A mimimum of 250 clients and their families will receive services 250 case managed 2. 90% of PLWA or Hep C will be linked to an insurance program 225 will be helped to enroll 3. 90% of PLWA will be housing secure 198 will have housing 4. 100% PLWA will have access to food via our food pantry 250 will have access to food 5. 90% PLWA will be linked to medication 198 will have access to meds 6.90% of PLWA and/or Hep C will receive behavior assesment 225 will be assesed by nurse 7. 90% " " will receive transmission prevention education 225 will receive education Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages 298,235 304,199 9,361 Professional Fees 8,793 9,672 Operations 59,240 65,164 3,139 Supplies Equipment 0 2,500 2,500 Other: Other: Other: Other: Other: TOTAL 366,268 379,035 15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Multi-Disiplinary HIV & Hepatitis C Case Management- Hilo 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 conflict is needed. 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): 0 No conflicts exist (No further information required. Please sign form at the bottom.) ElMember or members of the Council _ Staff appointed by a member of the Council _ The Mayor I I 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 HIHAF staff and board members submit an annual COI form in which they are required to disclose any conflict of interest, including those relative to this grant. .xQC1) C Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Multi-Disiplinary HIV & Hepatitis C Case Management- Hilo 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.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 lwe) 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. 1012,N14AK-C P.X.Qt&-Q:DUre-Cf-C-k- t/l // Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Multi-Disiplinary HIV & Hepatitis C Case Management- Hilo 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 49 Hawaii Island Humane Society (HIHS) Humane Education Classes for At-Risk Children and Youth Agency Name: Hawaii Island Humane Society (HIHS) Program Name: Humane Education Classes for At-Risk Children and Youth Agency Director: Donna Whitaker Phone No.: (808) 329 — 8002 Contact Person: Donna Whitaker Phone No.: (808) 329 — 8002 Mailing Address: Address: 74-5225 Queen Kaahumanu Highway Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: Same as Above Address: City,ST,Zip Email Address: exec.dir @hihs.org Fax No.: (808) 329 — 7375 Accountant/CPA: Carbonaro CPA& Associates, Inc. Phone No.: (808) 968 — 1002 Firm (if applicable): Same as Above Mailing Address: Address: P.O. Box 4372 Address: City,sr,zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $1 0,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 N/A N/A N/A 2.Agency Mission Statement: The mission of Hawaii Island Humane Society is to prevent cruelty to animals, eliminate pet overpopulation, and enhance the bond between humans and animals. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawaii Island Humane Society (HIHS) Program Name: Humane Education Classes for At-Risk Children and Youth 3. Program Description: The Hawaii Island Humane Society offers age-appropriate educational classes designed to teach at risk youth and/or underprivileged children and teens responsibility, compassion, and respect for living things. Courses for young children focus on the proper treatment, care and feeding of animals, while classes for"tweens" and young adults are aimed at improving self-esteem and confidence through hands-on experiences with animals. HIHS plans to incorporate technology into these courses to increase student engagement, as well as give children and youth opportunities to experience the visual and tactile aspects of interactive technologies. Students will be able to access media, create apps, update blogs or websites, create presentations and become actively involved with the humane efforts in our community. 4.Total Budget&Position Count: Total Program Budget: $10,000 Total Program Position Count: 3 Total Agency Budget: $2,642,000 Total Agency Position Count: 38 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Private Funding $35,250 County of Hawaii Nonprofit Organization Grant Program $10,000 TOTAL: $45,250 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As the demand for our Humane Education courses grows, HIHS may charge participants a sliding-scale fee based on income to increase revenues to support this program. In addition, HIHS will continue to look for community partners to expand and enhance this program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawaii Island Humane Society (HIHS) Program Name: Humane Education Classes for At-Risk Children and Youth 7. Program Objectives Using County Nonprofit Grant Program Funds: Using interactive technology and hands-on experiences, at-risk children and teens will learn respect, responsibility, compassion and gain self-esteem through the following courses: Dog Safety - Weekly class for 6-9 year olds to learn about the proper treatment of animals; Junior Pals - Summer program for 9-14 year olds to learn about the proper care of animals; Manadoob - Year-long program where 9-12 year olds care for animals in the shelters; and New Leash on Life -4-6 month program where 13-17 year-olds care for and train a shelter dog. 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.) 25, 6-9 year-olds will participate in the "Dog Safety" course 25 students/week enrolled 25, 9-14 year olds will participate in the "Junior Pals" program 25 students/summer enrolled 25, 9-12 year-olds will participate in the "Manadoob" program 25 students/year enrolled 25, 13-17 year-old (referrals) will participate in "New Leash on Life" 50 students/year referred Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 1344 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages N/A $37,500 $2,250 Professional Fees 0 0 Operations 0 0 Supplies 0 0 Equipment $7,750 $7,750 Other: 0 0 Other: 0 0 Other: 0 0 Other: 0 0 Other: 0 0 TOTAL $45,250 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hawaii Island Humane Society (HIHS) Program Name: Humane Education Classes for At-Risk Children and Youth 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) 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 Hawaii Island Humane Society has a written Conflict of Interest Policy as part of its By-Laws, which is regularly and consistently monitored to ensure compliance. On an annual basis, all Board members are provided a copy of the Policy and are required to complete and sign an acknowledgement and disclosure form. All completed forms are reviewed by the HIHS Executive Committee, as well as all other conflict information provided by Board members. If a conflict arises, the associated Board member must recuse himself/herself from voting on related matters. U)ki&. Itiyi 3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION Fy 2013-2014 Page 4 of 7 Agency Name: Hawaii Island Humane Society (HIHS) Program Name: Humane Education Classes for At-Risk Children and 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. ik3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaii Island Humane Society (HIHS) Program Name: Humane Education Classes for At-Risk Children and Youth 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 25, 6-9 year-olds will participate in the "Dog Safety" course 25/week 25, 9-14 year olds will participate in the "Junior Pals" program 25/summer 25, 9-12 year-olds will participate in the "Manadoob" program 25/year 25, 13-17 year-old (referrals)will participate in "New Leash on Life" 50/year TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages $2,250 Professional Fees 0 Operations 0 Supplies 0 Equipment $7,750 Other: 0 Other: 0 Other: 0 Other: 0 Other: 0 TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 50 Hawaii Montessori Schools Financial Aid Program Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program Agency Director: Angeline Geldhof Phone No.: (808) 329 — 0700 Contact Person: Angeline Geldhf Phone No.: (808) 936 — 1857 Mailing Address: Address: 74-978 Manawale'a Street Address: City,ST,Zip Kailua-Kona, Hawai'i 96740 Facility Address: Address: 74-978 Manawale'a Street/64-1058 Mamalahoa Hwy Address: City,s-r,Zip Kailua-Kona, Hawai'i 96740 / Kamuela, Hawai'i 96743 Email Address:angeline @hawaiimontessori.org Fax No.: (808) 334 — 0327 Accountant/CPA: Dianna Lally, CPA LLC Phone No.: (808) 756 — 0788 Firm (if applicable): Mailing Address: Address: 73-1341 Oneone Place Address: City,ST,Zip Kailua-Kona, Hawai'i 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $40,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0.00 $0.00 $12,500.00 2.Agency Mission Statement: Our Mission at Hawai'i Montessori Schools is educating children for life by providing a nurturing prepared environment where children, parents, and staff joyfully develop their esteem, inner discipline, independence, motivation and sense of community involvement to their fullest potential. Hawai'i Montessori Schools offers carefully planned, stimulating environments for learning. The curriculum covers a broad range of topics, including social skills, social and natural sciences, language, math and the arts. The materials used are designed to provide specific learning experiences to meet the unique needs of children at each stage of their development. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 3. Program Description: Providing quality early childhood education is expensive, however we believe Early Childhood Montessori Education should be available to all children, regardless of their families' income. Currently, for the 2012-2013 school year, we have 95 students enrolled, of which 42 are receiving some kind of financial aid from us. To date, we have provided a total of$48,098 in financial aid for the 2012-13 SY and we will continue to give financial aid to qualified new families as theyenroll. We write grants to help supplement our Financial Aid Program as well as raise money through our own fund raising efforts, donations from individuals, and keeping our cost to essentials. 4.Total Budget& Position Count: Total Program Budget: 60,000 Total Program Position Count: 55 Total Agency Budget: $835,500 Total Agency Position Count: 112 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate G. N. Wilcox Trust $ 7,500 Mclnerny Foundation 13,750 Samuel N and Mary Castle Foundation 16,000 Hawai'i Montessori Schools PTO/PTA Fund Raising Efforts 5,000 Hawai'i Montessori Schools Operating Budget (if do not get Cty. Hawaii Grant) 17,750 TOTAL: $60,000 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 committed to maintaining high quality programs for Hawai'i's children. Our fundraisers have been successful because of the tremendous commitment of our staff, families and the overwhelming support of local merchants and countless members of our community. Financial aid is awarded on a basis of need without regard to gender, religion or ethnic background. We generate financial aid funds by soliciting donations, writing grants and conducting fund raisers each year. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 7. Program Objectives Using County Nonprofit Grant Program Funds: By obtaining Financial Aid Grants we will be able to provide Financial Aid to families in need who are seeking to enroll their children into a quality preschool program, thereby giving them an increased chance for success in their future educational career. We are looking to give partial tuition assistance to 55 children ranging from 5% - 20% of the full tuition cost during the 2013-14 School 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.) Students who will receive financial aid so they may attend a high- quality early learning center. 55 Amount of Financial Aid disbursed to 55 students for 2013-14 SY $60,000 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages Professional Fees Operations Supplies Equipment Other: $48,098 $60,000 $40,000 Other: Other: Other: Other: TOTAL $48,098 $60,000 $40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Angeline Geldhof 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): Q No conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: 36ca8 Signature of Authorized Person (speci title) D-t Date �4C�e C_Ck1A u EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid 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. 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.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. I - ■`1 4 i v'e A0/3 Signat re of Authorized Person (s■ecify title y,C.-kp Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 that they may attend a high quality early learning environment. 55 Amount of Financial aid disbursed in 2013-14 school year $60,000 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: $40,000 Other: Other: Other: Other: TOTAL $40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 52 Hawai`i's Volcano Circus Hiccup Youth Circus Camps • Agency Name: Hawaii's Volcano Circus Program Name: Hiccup Youth Circus Camps Agency Director: Jenna Way Phone No.: (8os) 965 — 8756 Contact Person: Jenna Way Phone No.: (808) 965 — 8756 Mailing Address: Address: RR 2 Box 4524 Address: City,ST,Zip Pahoa, HI 96778 Facility Address: Address: 12-247 West Pohakupele Loop Address: City,sr,zip Pahoa, HI 96778 Email Address: info @hawaiispace.com Fax No.: ( ) — Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 0 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. HVC provides free and subsidized performances, space, and equipment to other educational, civic, and charitable organizations to support their events and fundraising activities. HVC has over 20 years of experience in circus and performing arts education and continues to play an active role in the development of Puna's local community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawaii's Volcano Circus Program Name: Hiccup Youth Circus Camps 3. Program Description: HVC will hold four circus camps in 2013 and four in 2014. Two camps will be held during public school winter break (one beginners and one advanced) and two camps (beginner and advanced) summer break each year. Each camp will be open to 20 youth, ages 7 to 14, and will+be five days long, from 9am to 4pm, with a performance in the early evening of the final day. The camp will be held at the SPACE Performing Arts Center, which is owned and operated by Hawaii's Volcano Circus. Kids will learn circus skills such as juggling, acrobatics, stilt walking, unicycling, and aerial dance from professional circus instructors and performers. 4. Total Budget& Position Count: Total Program Budget: 50,680 Total Program Position Count: 0 Total Agency Budget: 120,000 Total Agency Position Count: 2 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Community contributions/student tuition 26,680 Hawaii County Non-profit grant 24,000 TOTAL: 50,680 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Few families in Puna Makai can afford the full camp tuition and with the current economy, we are finding an even greater need to be able to provide scholarships to campers. We have a four approachs to support our Hiccup Circus Camps. First, profit made during afterschool circus classes held throughout the school year is applied to camps. Second, the circus occasionally receives income from performing at community events. We hope to increase this type of funding in the coming years. Thirdly, we hold fundraisers to support the program and finally, we continue to write grants to obtain funds. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawaii's Volcano Circus Program Name: Hiccup Youth Circus Camps 7. Program Objectives Using County Nonprofit Grant Program Funds: We will hold a total of 8 camps in the two year period. We will have up to 20 kids attend each camp. There will be 3 main camp instructors and 2 teenaged assistant instructors who will be hired to teach. The kid's show will be supported by volunteers who will perform tasks such as costuming, stage lighting, stage management, prop preparation and managment, stage crew. We expect to entertain an audience of friends and family of the campers at the end-of-camp show. We anticipate an audience of 60 to 80 proud and happy people at each performance. 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 camps held 8 camps Number of children served 160 kids Number of instructor positions provided 3 main, 2 asst. instrs./camp Number of volunteer hours (7-10 people, 7 hours each per camp) 392 - 560 hours Audience at camp shows (60-80 each show) 480 - 640 people Building of self-esteem and confidence of campers Priceless! Of benefit for the rest of their lives. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages ar ' .. G n k.(-41-0 4 -feakk,-y‘s-kys , 4,480 Professional Fees pc, e,^Li 12,000 Operations Supplies 1,000 Equipment : �'e�,; (cam ,m aw 10,000 Other: 1 kk�L ,T� _r f i� * q 3,600 Other: AT "� ' 1' `�- 3,000 Other: ,r9 4.A:-z-J- (" r r-eC: 2,000 Other: ` _ rv. A. ` 5,.{ 0 trAe..44\ 700 scif\ rcrskfts &4( eta t .�n -fp . 14,000 150 b v." di .si{t, r\e' ) TOTAL 26,680 24,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hawaii's Volcano Circus Program Name: Hiccup Youth Circus Camps 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jenna Way 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): igi No conflicts exist(No further information required. Please sign form at the bottom.) riMember or members of the Council Staff appointed by a member of the Council _ The Mayor 0 The Managing Director 0 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: % . /kik.I.WIC../ tikiati I -)., - IS Signat re of Authorized Person (s)oecif Y title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawaii's Volcano Circus Program Name: Hiccup Youth Circus Camps 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.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. Sig ature of Authorized Per (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaii's Volcano Circus Program Name: Hiccup Youth Circus Camps 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of camps held 8 camps Number of children served 160 kids Number of instructor positions provided 3 main, 2 asst. Number of volunteer hours (7-10 people, 7 hours each per camp) 392 - 560 hrs Audience at camp shows (60-80 people per show) 480-640 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment 10,000 Other: 14,000 Other: Other: Other: • Other: TOTAL 24,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 • 53 Hawai`i's Volcano Circus Truth Speaks Hawai`i by Truth 2 Youth Agency Name: Hawaii Volcano Circus Program Name: "Truth Speaks Hawaii" by Truth 2 Youth Agency Director: Jenna Way Phone No.: (808) 965 — 8756 Contact Person: Catherine Kennedy Phone No.: (808) 985 — 9151 Mailing Address: Address: p0 Box 975 Address: City,sr,Zip Volcano HI 96785 Facility Address: Address: Hawaii's Volcano Circus Address: RR2 Box 4524 city,sr,zip Pahoa, HI 96778 Email Address: info @hawaiispace.com Fax No.: ( ) — Accountant/CPA: N/A Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 2.Agency Mission Statement: Truth 2 Youth's (T2Y) mission is to teach the youth of these rural districts the value of artistic expression as a force for personal growth and change, and to demonstrate options for richer alternative lifestyles outside the materialistic paths represented so strongly in the popular media. We hope to guide teens towards channel their life issues creatively rather than to become alienated or self-destructive. In the process we also hope to cultivate socially aware, engaged future citizens who understand each person's role in a healthy community, and thus become dynamic role models for their siblings and peers. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawaii Volcano Circus Program Name: "Truth Speaks Hawaii" by Truth 2 Youth 3. Program Description: "Truth Speaks Hawaii" is a creative writing & performing program for the youth of Kea'au High & Pahoa High school districts. It aims to provide them with some of the artistic exposure & opportunities they miss as rural schools with strained budgets. We propose to host 2 young national award-winning Youth Speaks Hawaii poets from Oahu to conduct a series of creative writing workshops in each high school that will culminate in a school-wide performance by a number of the students. The assembly format of the performance will involve roles for many of each student body, collaboration of community youth groups & nearby charter school students. Each will also include an information fair on serious youth issues. which should provide students with new perspectives & constructive tools to help deal with their complex problems. 4.Total Budget&Position Count: Total Program Budget: $4564 Total Program Position Count: 1 (myself) Total Agency Budget: project based Total Agency Position Count: 2 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii County Non-Profit Grant $4564 TOTAL: $4564 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: • We will apply for Hawaii People's Fund and Hawaii Community Foundation grants • Each school may have approx. $100 towards poet fees • Wal-Mart may contribute $50 towards journals • KTA may contribute $75 towards food for pupus • Volcano B&Bs will give us discounted lodging rates • "In-Kind" donations will be great, totalling at least 60 hours of work by 4 volunteers • The award-winning design could be silk-screened on canvas shopping bags to sell in the communitiy as a fundraiser; this would require an initial investment in blank bags and ink EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawaii Volcano Circus Program Name: "Truth Speaks Hawaii" by Truth 2 Youth 7. Program Objectives Using County Nonprofit Grant Program Funds: T2Y gets as many of the student body involved as possible: the performing students give the slam a title that art students compete to design a logo for. That logo is made into a poster & used on programs. Food science classes prepare healthy pupus, leadership classes make a program to hand out. If there is a good student band they play while students enter& leave. The perimeter of the venue is turned into an information fair with students joining members of MADD, Suicide Prevention, Peer Educators and Recycle Hawaii with literature. 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 minute creative writing poetry workshops 6 per school, 12 total 75 students attend each workshop 450 per school, 900 total 3 teachers attend each workshop 18 per school, 36 total students to perform in assembly 35 per school, 70 total educational stations at assembly 5 per school, 10 total programs designed by leadship students 250 per school, 500 total posters of winning logo 30 per school, 60 total Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES �7 Actual' Total Budget Grant Req Salary and Wages A ft.ei.�SQ- See 4:�(-'',kaerk 8�a 4,`•� N/A Professional Fees 707 1414 Operations 860 1720 Supplies 340 680 Equipment N/A Other: 25 50 Other: 200 400 Other: 150 300 Other: Other: TOTAL 2282 4564 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Truth 2 Youth Project Proposal Budget Narrative (A project of Hawaii Volcano Circus) Truth 2 Youth has a history of adhering to our prudent budgets. T2Y takes no salary. For past slams we solicited a small donation towards the journals from Wal-Mart and donations from KTA Grocery towards pupu ingredients. The following budget documents one event; there are to be two (one in each high school) Expenses Salary& wages: none (organization is all volunteer) Professional fees: $400 poet stipends $100 me fee $207 fiscal sponsor fee Operations: $450 airfares for visiting poets $200 lodging $50 gas $160 meals Supplies: $40 ink/paper for posters $175 photocopies for literature tables and programs $125 ingredients for pupus Equipment: none (school & organization will supply all audio-visual equip.) Other: $25 gift certificate for winning logo submission $200 journals for students who perform $150 buttons, stickers for attending students TOTAL: $2282 An award of$4564 would enable us to provide an event in each high school that resonates strongly with both the entire student body and the dedicated, over-worked teaching staff. Mahalo for your consideration, Catherine Kennedy Founder, Truth 2 Youth Agency Name: H G` t-cs Program Name: '`` rIJ. n Sperms " b-1- it a- `fo--h 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: ND Zvi✓ a Waii POSITION: (_ 0-1 U c+c)r May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): laNo conflicts exist (No further information required. Please sign form at the bottom.) 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: Y Si nature of Authorized Person (specify title) Date (1'- - Xecti-h `L .D,4--e c,-i-01 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawaii Volcano Circus Program Name: "Truth Speaks Hawaii" by Truth 2 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, 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 5 of 7 rkW pit\ LCA K/ C. I v '�(La_je.., -� ) { Y C L5 11U/A4),tL6l- (( ci l" ,.T lit. Z LiCl..a.A�. (1D iclr tti VlrcC..�--<L) .,.�Y�,�-i-tai P� � � ( �JI ll I (we) understand that failure to submit the final report within 60 days of June 30th;hall 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, 2014 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. '-'---- 611/1(1(-% tAA--ti E-\,zertri-Ai-u Sig 1 ture of Authorized Person (specify title) Date 1 a,:j V)/(u C1 t i EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaii Volcano Circus Program Name: "Truth Speaks Hawaii" by Truth 2 Youth 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 90 minute creative writing poetry workshops 12 total 75 students attend each workshop 900 total 3 teachers attend each workshop 36 total students to perform in assembly 70 total educational stations at assembly 10 total programs designed by leadship students 500 total posters of winning logo 60 total TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages N/A Professional Fees 1414 Operations 1720 Supplies 680 Equipment N/A Other: 50 Other: 400 Other: 300 Other: Other: TOTAL 4564 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 54 Hawaiian Community Assets Hawaiian Island Financial Capability Inititative Agency Name: Hawaiian Community Assets Program Name: Hawaii Island Financial Capability Initiative Agency Director: Jeff Gilbreath Phone No.: (808) 587 — 7653 Contact Person: Kelly Lincoln Phone No.: (808) 934 — 0801 Mailing Address: Address: 200 N Vineyard Boulevard Address: Suite A300 City,ST,Zip Honolulu, HI 96817 Facility Address: Address: 260 Kamehameha Avenue Address: Room 207 City,ST,Zip Hilo, HI 96720 Email Address: info @hawaiiancommunity.net Fax No.: (808) 587 — 7899 Accountant/CPA: Robert Kawahara Phone No.: (808) 244 — 5531 Firm (if applicable): Kawahara and Associates, Inc Mailing Address: Address: 840 Alua Street Address: Suite 203 City,sr,zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $31 ,579 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0 $0 $0 2.Agency Mission Statement: Hawaiian Community Assets (HCA) is a 501(c)(3) nonprofit HUD-approved housing counseling agency and Native Community Development Financial Institution that was founded in 2000 to build the capacity of low- and moderate-income communities to build and sustain economic self-sufficiency. HCA's philosophy - kahua waiwai (foundation of wealth) - supports permanent housing, place-based financial education, and asset building programs to achieve its mission. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hawaiian Community Assets Program Name: Hawaii Island Financial Capability Initiative 3. Program Description: The goal of the Hawaii County Financial Capability Initiative is to enhance the financial capabilities of 200 Hawaii County families by implementing the recommendations of President Obama's Advisory Council on Financial Capability. In-line with the Advisory Council's recommendations, HCA will partner with local businesses, public schools, and County agencies and departments to integrate financial education into (1) Schools, (2) Government, and (3) Businesses. A secondary goal of the Initiative will be to establish a career training program within HCA to certify individuals as Kahua Waiwai Trainers and HUD-approved housing/financial counselors. Career training participants will include individuals recruited through HCA's AmeriCorps VISTA program. 1.25 FTE VISTAs will serve this Initiative. 4.Total Budget& Position Count: Total Program Budget: 62,275 Total Program Position Count: 1.5 Total Agency Budget: 897,671 Total Agency Position Count: 15 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Corporation for National and Community Service $12,500 Fee-for-Service Contracts $13,196 Kahua Waiwai Curriculum Sales $5,000 Hawaii County Request $31,579 TOTAL: 62,275 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HCA will sustain activities beyond the Initiative period by enhancing the marketability of its placed Kahua Waiwai: Building a Foundation of Wealth(c) financial education curriculum and corresponding training and technical assistance program on Hawaii Island. HCA has seen its curriculum sales to certified Kahua Waiwai Trainers and the general public increase over previous years as follows - FY11: $5,600, FY12: $14,485, and FY13 (Oct 2012-Jan 2013): $29,625. Based on these projections, HCA has established a staffing plan that will effectively certify 1 AmeriCorps VISTA member as a HUD-approved housing/financial counselor able to serve with HCA's Hawaii Island office at the end of their year of service (February 2014). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hawaiian Community Assets Program Name: Hawaii Island Financial Capability Initiative 7. Program Objectives Using County Nonprofit Grant Program Funds: HCA will achieve the Initiative goal by: *Serving (100) Hawaii County employees and their families with financial education workshops *Providing training and technical assistance to certified Kahua Waiwai Trainers to deliver financial education workshops to (100) Hawaii County public school students. *Establishing a financial education employee training plan for (1) local business. *Training (1) individual as a Kahua Waiwai Trainer and HUD-approved financial counselor. 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.) # of Hawaii Island residents served with financial education 200 # of clients who report an increase in financial capabilities 150 # of businesses the implement a financial education employee training plan 1 # of individuals who secure certification as a Kahua Waiwai Trainer and HUD-approved financial/housing counselor 1 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages 13,000 51,720 25,500 Professional Fees 0 0 0 Operations 3,357 4,476 0 Supplies 1,500 3,000 3,000 Equipment 0 0 0 Other: NULD CownSe-6r Ce-c- - ` .n,I,n5 3,079 3,079 3,079 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 TOTAL 20,936 62,275 31,579 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hawaiian Community Assets Program Name: Hawaii Island Financial Capability Initiative 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jeff Gilbreath 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): No conflicts exist(No further information required. Please sign form at the bottom.) nMember 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: 11� /2-q) l Signat re of Authorized Person specify title) • e_iCj'r Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hawaiian Community Assets Program Name: Hawaii Island Financial Capability 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. to e of .f∎1114 Sign Authorized Person (speci/ eci,div title) _ n _ Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hawaiian Community Assets Program Name: Hawaii Island Financial Capability Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 55 Hilo Community Players 2013 Cultural and Educational Theatre Productions Agency Name: Hilo Community Players Program Name: 2013 Cultural and Educational Theatre Productions Agency Director: Kalani Spain, Ph.D., President Phone No.: (808) 987 — 1431 Contact Person: Kalani Spain Phone No.: (808) 987 — 1431 Mailing Address: Address: p0 Box 46 Address: City,ST,Zip Hilo, HI 96721 Facility Address: Address: Address: City,ST,Zip Email Address: hilocommunityplayers.org Fax No.: (808) 961 — 7099 Accountant/CPA: Terri Ten Eyck CPA Phone No.: (808) 443 — 7074 Firm (if applicable): Mailing Address: Address: 182 Liko Lehua Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $18,715.79 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0.00 $0.00 $0.00 2. Agency Mission Statement: The mission of the Hilo Community Players is to educate, enrich, and entertain the Big Island community through quality theatrical productions, workshops and activities for children, youth, and adults. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hilo Community Players Program Name: 2013 Cultural and Educational Theatre Productions 3. Program Description: The theatrical programming for the FY 2013-2014 year is particularly special for the HCP. As the oldest community theatre group in the State of Hawaii with the longest running Shakespeare Festival, HCP is celebrating 75 years of volunteer theatre on Hawaii Island. HCP plans an extensive outreach program to involve and entertain the broadest spectrum of Big Island residents as possible. The FY 2013-2014 includes Shakespeare in the Park (As You Like It), The Trial of Liliuokalani, The Spoon River Project, Rashomon, Tiki Awards and the Laura Andres Scholarship Fund. This is an outreach effort involving multi-cultural diversity representing Hawaii Island. HCP goal for programming during this 75th anniversary year will give the public an opportunity to participate in the cooperative effort and support local performing arts. The HCP programming was chosen to address growing diversity. 4.Total Budget& Position Count: Total Program Budget: $20,350.00 Total Program Position Count: 16 Total Agency Budget: $5,038.58 Total Agency Position Count: 4 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Campaign for donor participation $1,000.00 Donations- Shakespeare in the Park $3,000.00 HCP 75th Anniversary Fundraising Event $800.00 TOTAL: $4,800.00 _ Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1) HCP board members and volunteers have a collection of costumes that are being catalogued for potential resale prior to the 2013 Halloween season; possible revenue, $600.00. 2) Develop Direct Mailing Campaign to sell memberships; possible revenue, $1,000.00. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hilo Community Players Program Name: 2013 Cultural and Educational Theatre Productions 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Present works of the theatre to enhance the lives of Hawaii Island audiences. 2) Invlove residents in a co-operative enterprise that enriches heritage and cultural history. 3) Introduce youth and those withtout prior experience to the history and cultural literature of the Big Island; producing theatre and educational programs the make a difference. 4) To introduce and make available theatre to those without the financial means to access the more expensive commercial theatre. 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.) Email donor database currently 350 Increase to 1000 Offering internships to 3 high school students Increase to 10 Audience for two shows 3,800 Increase to 4 shows with 9,000 Volunteer hours 10,000 Increase to 20,000 Scholarship for performing arts $1,200.00 Increase to $2,000.00 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $500.00 $4,400.00 $3,900.00 Professional Fees $0.00 $250.00 $250.00 Operations $7,319.85 $9,273.10 $9,265.79 Supplies $0.00 $600.00 $600.00 Equipment $0.00 $2,500.00 $2,500.00 Other: $0.00 $200.00 $200.00 Other: $0.00 $500.00 $500.00 Other: $0.00 $1,000.00 $1,000.00 Other: $0.00 $500.00 $500.00 Other: TOTAL $7819.85 $19,223.10 $18,715.79 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hilo Community Players Program Name: 2013 Cultural and Educational Theatre Productions 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 conflict is needed. 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): IN No conflicts exist(No further information required. Please sign form at the bottom.) 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: Ir-6,Latevi 1,,,,,, iji"l!5 i Olt'-11 j i A— 7 , -,-:. Signature of Authorized'Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hilo Community Players Program Name: 2013 Cultural and Educational Theatre Productions 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. r -1 4 Art,` :, 4L11, 1~)(.9.11.6,'Y l 4 Signature of Authorized P rson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hilo Community Players Program Name: 2013 Cultural and Educational Theatre Productions 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Campaign for donor participation $1,000.00 Donations- Shakespeare in the Park $3,000.00 HCP 75th Anniversary Fundraising Event $800.00 $4,800.00 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages $3,900.00 Professional Fees $250.00 Operations $9,265.79 Supplies $600.00 _ Equipment $2,500.00 Other: $200.00 Other: $500.00 Other: $1,000.00 Other: $500.00 Other: TOTAL $18,715.79 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 56 Holualoa Foundation for Arts & Culture Art Matters Agency Name: Holualoa Foundation for Arts & Culture Program Name: Art Matters Agency Director: Erma F.K. MikeII-Jacobson Phone No.: (808) 322 — 3362 Contact Person: Erma F.K. MikeIl-Jacobson Phone No.: (808) 987 — 9196 Mailing Address: Address: 78-6670 Mamalahoa Highway Address: City,ST,Zip Holualoa, HI 96725 Facility Address: Address: 78-6670 Mamalahoa Hwy Address: City,ST,Zip Holualoa, HI 96725 Email Address: DonkeyMill @gmail.com Fax No.: ( ) — Accountant/CPA: Chris Mathews Phone No.: (301 ) 424 — 6800 Firm (if applicable): Squire Lemkin Mailing Address: Address: 111 Rockville Pike, Suite 475 Address: City,sr,zip Rockville, MD 20850 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 0 2.Agency Mission Statement: The mission of the Holualoa Foundation for Arts and Culture (HFAC) is to enrich the lives of persons of all ages and abilities through arts and cultural education. The Donkey Mill Art Center (DMAC), home of HFAC, is a gathering place for all to explore, expand and develop their artistic and cultural identities in a supportive community. Educational programs that support HFAC's mission include artist talks, exhibitions, workshops, on-going classes, films, school teacher/artist partnerships, open studios, demonstrations and poetry readings. Program goals are to help all persons refine their skills and raise their creativity to a higher level by continually exploring new media and new ideas. HFAC programs serve adults and youth of Hawaii as well as people from other islands and mainland visitors. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Holualoa Foundation for Arts & Culture Program Name: Art Matters 3. Program Description: Art is an essential element for a thriving and vibrant community. This proposal requests funding to provide arts &cultual exhibitions, lectures, films and concerts to the community at large. The Donkey Mill's goal is to become a destination arts center that provides inspirational experiences for both local residents and Hawaii visitors. The intention of Art Matters is to create opportunities for dialogue and thoughtful exchange of new ideas amongst diverse groups of people. At the same time, respect and wider appreciation is given to traditional practices and cultural awareness. Through these exhibitions and programs, the vitality and skill levels of resident artists are increased. Therefore, the quality of art available for viewing and purchase helps to maintain Hawaii's reputation for a strong sense of place and economic opportunity. 4.Total Budget& Position Count: Total Program Budget: $217,340 Total Program Position Count: .5 Total Agency Budget: $288,200 Total Agency Position Count: 2 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Fees from Contractural Services $107,512 Corporate and/or Foundation support $24,412 Private Donors $27,918 Membership Revenue $19, 152 Fundraisers $25,882 TOTAL: $204,876 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Holualoa Foundation for Arts & Culture is implementing a Long Term Strategic Plan that began in 2008. This plan calls for utilizing emerging technologies to increase memberships, increase enrollments in tuition-based programs, and better advertise events. The plan is being successfully implemented and it is anticipated that this program will be self-sustaining in two years. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Holualoa Foundation for Arts & Culture Program Name: Art Matters 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide high quality arts and cultural exhibitions, lectures, concerts and films 2. Create opportunities for people of all ages and abilities to share knowledge and ideas 3. Develop interdisciplinary networks for people to collaborate 4. Advertise Hawaii as a premier arts & cultural destination 5. Educate the public about the importance of innovation and creative thinking 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 who view exhibitions 5000 Number of out-of-county visitors who attend events 2000 Number of people who attend Artist Talks 640 Number of evaluation sheets completed with a positive experience 780 Number of exhibitions 8 Number of concerts/films or other exhibit corresponding events 20 Number of people attending corresponding workshops 360 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages hi\; „,.Cooc(Ufva-1Uf (.a*tAectic, C.aS} 124,000 122,000 14976 Professional Fees6,0eA �`SS_d6 O-vs1`t-d pit QX1•Su?.?ost 39985 39985 5400 Operations - 37991 37076 2500 Supplies NA- &■ ■ 116.0 r cL,\ -(yaahIcdiulr�)515,rka�� 18279 18279 2742 Equipment t U UU I Other: -V,�e--� \A ( a C.�c�1 GG1� O`v\� 1C � 1500 Other: 1``i1\V t"}S'} 1..\,l W oc w� 1��\9j 1 ) � 1600 Other: 0 Other: Other: TOTAL 220,225 217,340 28718 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Holualoa Foundation for Arts & Culture Program Name: Art Matters 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Erma F.K. Mikell-Jacobson 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) 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: sSignatu re of Au horized Pers n (specif ) Date e' C 4'.e.._ `c� C EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Holualoa Foundation for Arts & Culture Program Name: Art Matters , 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. EAsAKik . ) ,.R.!,,,,,,,\\._., ,______ ,/, q/„.,,, ,-5 Signature of Au horized Person (speci title) Date E)CeC J k Us- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Holualoa Foundation for Arts & Culture Program Name: Art Matters 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of people who view exhibitions 5000 Number of out-of-County visitors who attend events 2000 Number of people who attend Artist Talks 640 Number of evaluation sheets completed with a positive experience 780 Number of exhibitions 8 Number of concerts/films or other exhibit corresponding events 20 Number of people attending corresponding workshops 360 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $14,976 Professional Fees $5,400 Operations $2,500 Supplies $2,742 Equipment Other: $1,500 Other: $1600 Other: Other: Other: TOTAL $28,718 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 57 Ho'oulu Lahui Inc Food Security for Hawaii Island Agency Name: Ho'oulu Lahui Inc. Program Name: Food Security for Hawai'i Island i Agency Director: Auli'i Mitchell Phone No.: (808) 315 — 6021 Contact Person: Susie Osborne Phone No.: (808) 640 — 3439 Mailing Address: Address: 14-5322 Kaimu Kapoho Road Address: City,ST,Zip Pahoa, HI 96778 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: pualaa @ilhawaii.net Fax No.: (808) 965 — 9618 Accountant/CPA: Rozanne Connell Phone No.: (808) 968 — 1002 Firm (if applicable): Cabenero and Associates Mailing Address: Address: P.O. bxo 4372 Address: City,ST,Zip Hilo, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 20,000.00 17,000.00 2.Agency Mission Statement: Ho'oulu Lahui is a 501c3 organization, formed in 1995, with the purpose of awakening Hawaiian culture, beliefs and lifestyle in partnership with the community to achieve unity, harmomy and total well being (lokahi). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Ho'oulu Lahui Inc. Program Name: Food Security for Hawaii Island 3. Program Description: This grant addresses short and long term goals in addressing food security for our District. Fencing, soil and water systems will be put in place in order to grow vegetables. A 500 sq. foot garden will be developed and producing food by the end of the project period. 75 Breadfruit trees will be grown and planted for a long term crop in addressing food security. The produce in 3-5 years and are an abundant crop. An educational 'Ulu Festival will be held in March for the community with over 1200 persons expected to attend. Everything about breadfruit and sweet potatoe, two staple foods, will be shared, from cooking demonstrations, agricultural presentations, cultural activities, food, music and information. This community event will help to ensure the people have the understanding and motivation to help our island be food secure. 4.Total Budget&Position Count: Total Program Budget: 55,000.00 Total Program Position Count: 0 Total Agency Budget: 250,000.00 Total Agency Position Count: 2 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Kua o ka La Public Charter School 20,000.00 County of Hawaii request 25,000.00 In-kind donations 10,000.00 TOTAL: 55,00.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The organization will continue to seek in-kind contributions and sponsors for the program and Festival. We will also write some grants specifically for the Festival iin March 2014. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Ho'oulu Lahui Inc. Pro:ram Name: Food Security for Hawai'i Island 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) To build a fenced in garden (500 feet fencing) including water infrastructure in order to grow vegetables in support of the partnering school healthy lunch culinary program. 2) To grow and plant 75 'ulu trees in addressing long term food security for our District of Puna. 3)To educate the community on the importance of'ulu(breadfruit), and 'uala (sweet potatoe),for food security for our Hawaii Island by hosting an educational Festival. 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,etc.Describe,be specific.) r Applicant Projected Results Educational 'Ulu Festival held 1000 attendees Volunteer hours 500 hours 'Ulu trees grown 75 Vegetable Garden area developed 500 sq feet Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 1344 FY 1344 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 20,000.00 0 Professional Fees Operations Supplies 25,000.00 22,500.00 Equipment Other: 10,000.00 2,500.00 Other: _ . Other: Other: Other: TOTAL 25,000.00 L if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Ho'oulu Lahui Inc. Program Name: Food Security for Hawai'i Island 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Charles Aulii Mitchell POSITION: President, Ho'oulu Lahui May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): 0 No conflicts exist(No further information required. Please sign form at the bottom.) 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: ___' /-_ .,,_}_,--,-,--) (,) /11--4%/y_.,e/ //3 °/---3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Ho'oulu Lahui Inc. Program Name: Food Security for Hawai'i Island 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. / 0/3 Signature of Authorized Person (specify title) Date I'. EXHIBI1 NONPROFIT' Page 6 of 7 Agency Name: Ho'oulu Lahui Inc. Program Name: Food Security for Hawai'i Island 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 58 HOPE Services Hawai`i, Inc Care-A-Van Homeless Outreach Program Agency Name: HOPE Services Hawaii, Inc. Program Name: Care-A-Van Homeless Outreach Program Agency Director: Brandee Menino Phone No.: (808) 933 — 6013 Contact Person: Jeremy McComber Phone No.: (808) 933 — 6005 Mailing Address: Address: 1315 Kalanianaole Avenue Address: City,sr,zip Hilo, HI 96720 Facility Address: Address: 116 Kapiolani St. Address: 74-5593 Pawai Place city,sr,Zip Hilo, HI 96720 & Kailua-Kona, HI 96740 Email Address: bmenino @hopeserviceshawaii.org Fax No.: (808) 935 — 3794 Accountant/CPA: Gail Shioshita Phone No.: (808) 933 — 6048 Firm (if applicable): CW Associates Mailing Address: Address: 1315 Kalanianaole Avenue, Hilo, HI 96720 Address: 700 Bishop Street, Suite 1040 city,sr,zip Honolulu, HI 96813-4124 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: # a0 00O 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000 $20,000 $10,000 2.Agency Mission Statement: HOPE Services Hawaii, Inc. mission is to: "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." We carry out this mission through a continuum of programs and services including outreach, case management, information and referral services, advocacy, representative payee services, emergency shelter, transitional housing, community reintegration assistance, housing placement, emergency financial assistance, permanent supportive housing, financial empowerment initiatives and service-enriched housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Care-A-Van Homeless Outreach Program 3. Program Description: Care-A-Van is the only mobile homeless outreach program on Hawaii Island that specifically targets the unsheltered homeless population. The purpose of the program is to connect unsheltered homeless people to mainstream community programs, to help them get into healthier and more stable living conditions, and ultimately, to gain housing and self-sufficiency. With the support of our funders, community partners, HOPE staff members and volunteers, the Care-A-Van program serves nearly 1,500 unsheltered homeless persons throughout the county every year including The Friendly Place, a drop-in service site in Kailua-Kona. Services at this site include meals, the provision of emergency food/supplies, showers, laundry/mail services, life skills/renter's education classes, and linkages to other community resouces. 4.Total Budget&Position Count: Total Program Budget: 768,566 Total Program Position Count: 10 Total Agency Budget: 4,002,911 Total Agency Position Count: 46 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate State of Hawaii, Dept. of Human Services, BESSD 612,500 State of Hawaii, Dept. of Health, Adult Mental Health Division 100,000 Hawaii County 20,000 State of Hawaii, Dept. of Human Services, BESSD/SNAP 36,066 TOTAL: 768,566 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HOPE's management team continues to seek additional funding opportunities to enrich services, reduce operating expenses, and increase staffing. Currently, we are seeking additional funding through Veteran's Affairs, the Hawaii Island United Way and private foundations. We are also making a concerted effort to raise funds through individual and corporate asks and building our volunteer program base with the Hawaii Community College and University of Hawaii at Hilo and Manoa. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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: Due to an increased presence in Kailua-Kona, it is our intention to coordinate and faciliate housing and supportive services for the most vulnerable and chronically homeless persons. By targeting our outreach efforts and resources on the most vulnerable, this funded position will help decrease chronic homelessness and help the most vulnerable persons off the streets and into shelter, treatment and/or permanent housing. 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 chronic homeless persons served 20 Number of persons that will receive substance abuse treatment 10 Number of persons that will obtain mental health care 10 Number of persons that will obtain medical/dental health care 12 Number of persons provided with emergency food and/or supplies 20 Number of persons placed in emergency or transitional housing 10 Number of persons placed in permanent housing 6 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Reel Salary and Wages 505,658 530,185 20,000 Professional Fees 0 7,000 0 Operations 117,326 205,955 0 Supplies 17,576 23,826 0 Equipment 0 1600 0 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 TOTAL 726,250 768,566 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Care-A-Van Homeless Outreach Program 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 conflict is needed. 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): No conflicts exist(No further information required. Please sign form at the bottom.) II 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: AL-411"-k /4"1-fr aif EkecltAV& ceie- //3///3 f >" Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Care-A-Van Homeless Outreach 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. A-A-4"10 /14--e444—;.-4--/ C4,,i< EXe of Al✓L OfSc-eg- i/C 33 ///4 (Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 new homeless persons served 20 Number of persons that will receive substance abuse treatment 10 Number of persons that will obtain mental health care 10 Number of persons that will obtain medical/dental health care 12 Number of persons provided with emergency food and/or supplies 20 Number of persons placed in emergency or transitional housing 10 Number of persons placed in permanent housing 6 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 20,000 Professional Fees 0 Operations 0 Supplies 0 Equipment 0 Other: 0 Other: 0 Other: 0 Other: 0 Other: 0 TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 59 HOPE Services Hawaii, Inc HOPE Resource Center Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource Center Agency Director: Brandee Menino Phone No.: (808) 933 — 6013 Contact Person: Jeremy McComber Phone No.: (808) 933 — 6005 Mailing Address: Address: 1315 Kalanianaole Avenue Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 115 Kapiolani St. Address: City,sr,zip Hilo, HI 96720 Email Address: bmenino @hopeserviceshawaii.org Fax No.: (808) 935 — 3794 Accountant/CPA: Gail Shioshita Phone No.: (808) 933 — 6048 Firm (if applicable): CW Associates Mailing Address: Address: 1315 Kalanianaole Avenue, Hilo, HI 96720 Address: 700 Bishop Street, Suite 1040 city,s-r,zip Honolulu, HI 96813-4124 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: it 020 ,OU 0 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000 $15,000 $12,000 2.Agency Mission Statement: HOPE Services Hawaii, Inc. mission is to: "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." We carry out this mission through a continuum of programs and services including outreach, case management, information and referral services, advocacy, representative payee services, emergency shelter, transitional housing, community reintegration assistance, housing placement, emergency financial assistance, permanent supportive housing, financial empowerment initiatives and service-enriched housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource Center 3. Program Description: Hope Resource Center provides shelter services to homeless men with criminal convictions.The objective is to improve public safety and reduce recidivism by supporting program participants to overcome obstacles that include limited work history, minimal supports or lack of education/occupational skills. During the initial assessment special needs are addressed by linking participants to financial entitlements,medical,dental, mental health and substance treatment.After special needs are addressed the Care Coordinator works with the participant to link to life skill building services which include financial literacy,child support enforcement,mediation,vocational training,job placement,mentorship,prosocial activities and housing placement and after care. 4.Total Budget& Position Count: Total Program Budget: 285,943.00 Total Program Position Count: 5.25 Total Agency Budget: 4,002,911.00 Total Agency Position Count: 41'o 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawai 20,000.00 State of Hawaii- Homeless Programs Office 207,480 Hawaii Island United Way 15,000.00 Hope Resource Center- Program Fees and Private Grants 43,463.00 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: 1)Relocating to the program to the 116 Kapiolani Street property has reduced our rent and utility costs by aproximatly 40%. 2)Hope Resource Center is developing the second floor of the 116 Kapiolani Street property to include 14 individual units equipped with bed,chest of drawers,desk/table,chair, refrigerator and microwave_ Once construction is complete the monthly fees for the unit will increase to$300.00. 3)We continue to search for additional funding opportunities to enrich service,reduce operating costs,and increase staffing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource Center 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover operational cost to maintain the integrity and stability of the program. With the funding from the County,HOPE expects to meet the following program objectives:place 50 individuals into transitional shelter, place 25 individuals into permanent housing,place 10 individuals into transitional housing,assist 10 individuals with enrolling in education/job training, assist 20 individuals in obtaining employment,assist 24 individuals access mental health services and assist 30 individuals participate in community activities. 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 persons placed in transitional shelter 50 Number of persons placed in permanent housing 25 Number of persons who obtained employment 20 Number of persons who retained employment for three months 15 Number of persons who participated in community activities 30 Number of persons receiving education/job training assistance 10 Number of persons accessing mental health services 24 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 159,530. 159,530 0 Professional Fees 0 0 0 Operations 113,663.0 122,413.00 20,000 Supplies 4,000. 4,000 0 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 277,193.0 285,943.00 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource Center 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 conflict is needed. 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): No conflicts exist(No further information required. Please sign form at the bottom.) 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: A-44A-044.) /✓(mom //31/3 /Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource 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, 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. ik1144-44() AUM/P-Uts- eke, ere til-A Ve elfe-e e—Signature of Authorized Person (specify title) / Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: HOPE Resource Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of persons placed in transitional shelter 50 Number of persons placed in permanent housing 25 Number of persons who obtained employment 20 Number of persons who retained employment for three months 15 Number of persons participated in community activities 30 Number of persons receiving education/job training assistance 10 Number of persons accessing mental health services 24 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 0 Professional Fees 0 Operations 20,000 Supplies 0 Equipment 0 Other: 0 Other: 0 Other: 0 Other: 0 Other: 0 TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 60 HOPE Services Hawaii, Inc Kihei Pua Emergency Shelter Agency Name: HOPE Services Hawaii, Inc. Program Name: Kihei Pua Emergency Shelter Agency Director: Brandee Menino Phone No.: (808) 933 — 6013 Contact Person: Jeremy McComber Phone No.: (808) 933 — 6005 Mailing Address: Address: 1315 Kalanianaole Avenue Address: City,sr,zip Hilo, HI 96720 Facility Address: Address: 115 Kapiolani St. Address: City,sr,Zip Hilo, HI 96720 Email Address: bmenino @hopeserviceshawaii.org Fax No.: (808) 935 — 3794 Accountant/CPA: Gail Shioshita Phone No.: (808) 933 — 6048 Firm (if applicable): CW Associates Mailing Address: Address: 1315 Kalanianaole Avenue, Hilo, HI 96720 Address: 700 Bishop Street, Suite 1040 city,sr,Zip Honolulu, HI 96813-4124 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: a0 00 0 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000 $15,000 $10,000 2.Agency Mission Statement: HOPE Services Hawaii, Inc. mission is to: "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." We carry out this mission through a continuum of programs and services including outreach, case management, information and referral services, advocacy, representative payee services, emergency shelter, transitional housing, community reintegration assistance, housing placement, emergency financial assistance, permanent supportive housing, financial empowerment initiatives and service-enriched housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Kihei Pua Emergency Shelter 3. Program Description: Kihei Pua Emergency Shelter is the only 24/7 family shelter program on the island that is designed to support homeless families. It is a face-paced (6) six-week program. Our goal is to support homeless families' achieve a healthier, more stable lifestyle. Our program provides skill-building opportunities in budgeting, cleanliness and tenant responsibilities. We have an on-site care coordinator that provides one on one goals setting, counseling, referrals and linkages for case specific services including, mental health services, medical, dental & prescription services, substance abuse treatment programs, temporary employment agencies, educational and vocational training opportunities, elderly care services, public entitlements, social security benefits, and/or HOPE housing placement programs. 4.Total Budget&Position Count: Total Program Budget: 575,144 Total Program Position Count: 6.5 Total Agency Budget: 4,002,911 Total Agency Position Count: 46 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii 20,000 State of Hawaii, Dept. of Human Services, BESSD - State Homeless Shelter 493,050 Hawaii Island United Way 15,000 Program Fees 16,060 State of Hawaii, Dept. of Human Services, BESSD - Emer. Solutions Grant 31,034 TOTAL: 575,144 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HOPE's management team continues to seek additional funding opportunities to enrich services, reduce operating expenses, increase staffing, volunteers and partnerships. Currently, we are seeking additional funding through Veteran's Affairs, the Zonta Club and private foundations. We are also making a concerted effort to raise funds through individual and corporate asks and building our volunteer program base with the Hawaii Community College and University of Hawaii at Hilo and Manoa. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 personnel cost to maintain the integrity and stability of the program. With the funding from the County, HOPE expects to meet the following objectives: provide 300 participants with emergency shelter, maintain clean, safe, sanitary housing for of all participants. Assist 120 participants in obtaining permanent housing and 40 participants in obtaining transitional housing. Assist 25 participants with obtaining employment, 50 participants with placement in education/job training, 10 participants in obtainin 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 persons placed in emergency shelter 300 Number of persons placed in permanent housing 120 Number of persons placed in transitional housing 40 Number of persons participating in education/job training asst 50 Number of persons who obtained employment 25 Number of persons who participated in substance abuse services 10 Number of persons accessing mental health services 40 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages 334,559 334,559 20,000 Professional Fees 0 7,740 0 Operations 199,930 198,440 0 Supplies 32,405 32,405 0 Equipment 2,000 2,000 0 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 TOTAL 568,894 575,144 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Kihei Pua Emergency Shelter 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 conflict is needed. 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): Ir l No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor 11 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: Me41.1.4;—, 04.el /A3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Kihei Pua Emergency 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. /61.1( i,,`ti--- &€C !Ve. G ee• to/ 31//3 fgnature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 40 Number of persons participating in education/job training assistance 50 Number of persons who obtained employment 25 Number of persons who participated in substance abuse counseling 10 Number of persons accessing mental health services 40 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 0 Professional Fees 0 Operations 20,000 Supplies 0 Equipment 0 Other: 0 Other: 0 Other: 0 Other: 0 Other: 0 TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 61 HOPE Services Hawai`i, Inc Shelter Plus Care: Kukui and New Direction Agency Name: HOPE Services Hawaii, Inc. Program Name: Shelter Plus Care: Kukui and New Direction Agency Director: Brandee Menino, MA Phone No.: (808) 933 — 6013 Contact Person: Jeremy McComber Phone No.: (808) 933 — 6005 Mailing Address: Address: 1315 Kalanianaole Avenue Address: city,sr,zip Hilo, HI 96720 Facility Address: Address: 1315 Kalanianaole Avenue Address: City,sr,Zip Hilo, HI 96720 Email Address: bmenino @hopeserviceshawaii.org Fax No.: (808) 935 — 3794 Accountant/CPA: Gail Shioshita Phone No.: (808) 933 — 6048 Firm (if applicable): CW Associates Mailing Address: Address: 1315 Kalanianaole Avenue, Hilo HI 96720 Address: 700 Bishop Street, Suite 1040 City,ST,zip Honolulu, HI 96813-4124 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 4 °ID, d.° 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 0 2.Agency Mission Statement: HOPE Services Hawaii, Inc. mission is to: "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." We carry out this mission through a continuum of programs and services including outreach, case management, information and referral services, advocacy, representative payee services, emergency shelter, transitional housing, community reintegration assistance, housing placement, emergency financial assistance, permanent supportive housing, financial empowerment initiatives and service-enriched housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 • Agency Name: HOPE Services Hawaii, Inc. Program Name: Shelter Plus Care: Kukui and New Direction 3. Program Description: The Shelter Plus Care (S+C) programs are supportive housing programs for persons experiencing homelessness with targeted disabilities such as severe and persistent mental illness (SPMI), chronic substance abuse disorders, co-occuring disorders, HIV/AIDS, and/or developmental disabilities. The S+C Housing Coordinator secures affordable rental units by negotiating with landlords and property managers for eligible participants to move directly from the streets to permanent supportive housing. Our staff partners with case management providers to offer supportive services to newly-housed persons while HOPE pays a rental subsidy directly to the landlord in their behalf. These partnerships allow persons to live with dignity in the least restrictive means by living independently in their own homes. 4.Total Budget&Position Count: Total Program Budget: 585,132 Total Program Position Count: 1 Total Agency Budget: 4,002,911 Total Agency Position Count: 46 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Kukui: State of Hawaii, Dept. of Human Services (BESSD) 528,172 New Direction: State of Hawaii, Dept. of Human Services (BESSD) 36,960 County of Hawaii 20,000 TOTAL: 585,132 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program is federally-funded by the U.S. Department of Housing and Urban Development (HUD) on an annual basis through which HOPE must apply for every year through a SuperNOFA competitive process among "neighbor island" counties. No more than 8% of the grant can be used for operational expenses, which equates to only $42,080.64. This does not fund the cost of operating this program effectively, or even fund for the cost of one full-time employee. Hence, it is critical for HOPE to seek matching funds in other ways in order to maximize the S+C grant funds for tenant-based rental assistance. HOPE plans to seek additional revenues from private grants and foundations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Shelter Plus Care: Kukui and New Direction 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County will cover the entire cost of one (1) full-time staff and necessary operational costs to maintain the integrity of the program and housing stability for program participants. With the funding from the County, HOPE expects to meet the following program objectives: 75% of all households will maintain housing stability, 50% of all households will increase their total income, and 10% of households will increase their income through employment. 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 households proposed to serve 50 Number of persons proposed to serve 80 Number of persons that will increase their income 25 Number of persons that will enroll in education/job training 5 Number of persons that will receive supportive services 40 Number of households that will maintain permanent housing 38 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 38,263 57,662 15,800 Professional Fees 0 0 0 Operations 487,745 527,470 4,200 Supplies 0 0 0 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 526,008 585,132 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Shelter Plus Care: Kukui and New Direction 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 conflict is needed. 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): No conflicts exist(No further information required. Please sign form at the bottom.) _ Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: iviii,- a;ef fxe_tu>Syet-e-re, ol�c�0//3 Si/LAI°gnature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Shelter Plus Care: Kukui and New Direction 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. /�ittu !/' Ch; &.-Liave etic 0 /h3-/ /3 r Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: Shelter Plus Care: Kukui and New Direction 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of households served 50 Number of persons served 80 Number of persons that will increase their income 25 Number of persons that will enroll in education/job training 5 Number of persons that will receive supportive services 40 Number of households that will maintain permanent housing 38 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 15,800 Professional Fees 0 Operations 4,200 Supplies 0 Equipment 0 Other: 0 Other: 0 Other: 0 Other: 0 Other: 0 TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 62 HOPE Services Hawaii, Inc West Hawaii Emergency Housing Program Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program Agency Director: Brandee Menino MA Phone No.: (808 ) 935 — 3050 Contact Person: Kate Nawahine Phone No.: (808 ) 935 — 2830 Mailing Address: Address: 1315 Kalanianaole Avenue Address: City,ST,Zip Facility Address: Address: 74-5593 Pawai Place Address: City,sr,zip Kailua-Kona, HI 96745 Email Address:bmenino@hopeserviceshawaii.org Fax No.: (808) 935 — 3794 Accountant/CPA: CW Associates Phone No.: (808 ) 695 —4014 Firm (if applicable): Mailing Address: Address: 700 Bishop Street Address: Suite 1040 city,s-r,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: ` 2-0, j 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0 10,000 10,000 2.Agency Mission Statement: HOPE Services Hawaii,Inc.mission is to:"Bring to life gospel values of justice,love,compassion and hope through service, empowerment and advocacy." We carry out this mission through a continuum of programs and services including outreach, case management,information and referral services,advocacy,representative payee services,emergency shelter,transitional housing,community reintegration assistance,housing placement,emergency financial assistance,permanent supportive housing,financial empowerment initiatives and service-enriched housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 3. Program Description: The County of Hawaii completed the construction of the West Hawaii Emergency Housing Facility(WHEHP)in October 2010. WHEHP is a service-enriched emergency shelter for single individuals experiencing homelessness,with a target stay of no more than 3 months. WHEHP provides skill-building opportunities in budgeting,cleanliness and tenant responsibilities.We have an on-site care coordinator that provides one-on-one goals setting,counseling,referrals i linkages for services including, mental health,medical,dental&prescription services,substance abuse treatment,temporary employment,educational and vocational training,elderly care,entitlements,social security,and housing placement programs.The emergency shelter is open 365 days a year for 15 hours a day, 7 days a week. 4.Total Budget&Position Count: Total Program Budget: 198,863 Total Program Position Count: 3 Total Agency Budget: 4,002,911 Total Agency Position Count: 46 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii 20,000 State of Hawaii- Homeless Programs Office 114,608 Hawaii Island United Way 5,000 Program Fees 22,487 ESG 36,768 0 0 TOTAL: 198,863 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 2013-2014 Page 2 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover personnel cost to maintain the integrity and stability of the program. With the funding from the County,HOPE expects to meet the following program objectives:place 50 individuals into emergency shelter, place 25 individuals into permanent housing,place 10 individuals into transitional housing,assist 15 individuals with enrolling in education/job training and assist 40 individuals access mental health services. 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 persons placed in emergency shelter 50 Number of persons placed in permanent housing 25 Number of persons placed in transitional housing 10 Number of persons participating in education/job training assistance 15 Number of persons who obtained employment 20 Number of persons who participated in substance abuse counseling 15 Number of persons accessing mental health services 40 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages 114,917 117,417 20,000 Professional Fees 2,500 2,500 0 Operations 70,746 70,246 0 Supplies 8,700 8,700 0 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 196,363 198,863 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be shined, 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): Iv No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: #"\-eit.) -P-44-GL C / eta— %3///3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency 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://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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. ;of e�cc lSv zA, X_?I/43 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 CAN Hospice of Hilo (HOH) Transitions Program Expansion & Transformation Agency Name: Hospice of Hilo (HOH) Program Name: Transitions Program Expansion & Transformation Agency Director: Brenda S. Ho, MS, RN Phone No.: (808 ) 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,sr,zip Hilo, HI 96720 Email Address: anthuyn @hospiceofhilo.org Fax No.: (808) 969 — 4863 Accountant/CPA: loana Agasa, CPA Phone No.: (808) 981 — 2405 Firm (if applicable): Mailing Address: Address: 230 Kapualani Street Address: City,Si,Zip Hilo, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $298,405. 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 0* 2.Agency Mission Statement: To be an integral part of the community, providing compassionate, quality end-of-life care through support, counseling and education. *FY 12/13 Prior year funding: $62,250.00 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hospice of Hilo (HOH) Program Name: Transitions Program Expansion & Transformation 3. Program Description: The 2012 County grant made sustaining and expanding Transitions possible. In 2013, HOH hopes to continue the successful care and support of patients in Transitions, as well as develop and initiate the Hawaii Palliative Care Center, incorporating the Transitions program into palliative care, with an overall goal of identifying the physical,psychological, spiritual and practical burdens of illness, involving the right specialists and organizations, and working together with community partners to promote the best possible quality of life for patients and their families facing serious, life-threatening illness. Transforming Transitions into the Hawaii Palliative Care Center, allows the Transitions program to become a self-sustaining program through billable physicians' visits under the Palliative Care Business Model. 4.Total Budget& Position Count: Total Program Budget: $463,223.00 Total Program Position Count: 2 Full / 2 Part Total Agency Budget: $3,426,102.00 Total Agency Position Count: 70 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate AlohaCare Grant (Awarded) $5000.00 Hawaii County Non-Profit Grant $298,405.00 Fee for Service, Frances Spector, MD, Hospice & Palliative Care Physician * * Hilo Medical Center HMSA Local Healthcare Providers * HOH reserve fund, grants and donations * TOTAL: $303,405.00* Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: *Because of the County's support of the Transitions Program, FY12-13, the viability of Transitions has been ensured through 2012. For 2013 Increased revenue will come via: 1. Planned opening of Hawaii Palliative Care Center, allowing physician billing for services. 2. HOH has begun discussions with Hilo Medical Center, HMSA and local healthcare providers to build collaborations that will result in further insurance reimbursements. 3. In addition to medical billing revenue, the Hospice of Hilo Development Team will continue applying for grants and seeking donor support. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hospice of Hilo (HOH) Program Name: Transitions Program Expansion & Transformation 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding will continue to support the work of Hospice of Hilo's Transitions Program as Hospice of Hilo develops the Hawaii Palliative Care Center, which incorporates the Transitions' scope of work. Funding will support the planning and establishement of the Hawaii Palliative Care Center and will also support the planning, expansion and transformation of Transitions into one streamlined, self-sustaining Palliative Care 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,volunteer hours,etc.Describe,be specific.) *Please see attached page Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $49,896. $350,628.00 $250,833. Professional Fees $3,000. $17,000.00 $8,500. Operations $12,466. $59,213.00 $5,921. Supplies -- -- -- Equipment -- $13,600.00 $13,600. Other: $2,980. $4,460.00 $4,460. Other: $3,500. $6,600.00 $6,600. Other: -- $2,640.00 $2,640. Other: -- $9082.00 $5851. Other: -- -- -- TOTAL $71,842. $463,223.00 $298,405. *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hospice of Hilo (HOH) Program Name: Transitions Program Expansion & Transformation 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Brenda S. Ho, MS, RN POSITION: CEO--Sits on Mayor's Healthcare Sustainabiliy Taskforce May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Iv ' No conflicts exist (No further information required. Please sign form at the bottom.) LIMember 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: gliAteLt- S . ((3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hospice of Hilo (HOH) Program Name: Transitions Program Expansion & Transformation 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. SUittd)C- s- ) I a 1 "3f-13 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hospice of Hilo (HOH) Program Name: Transitions Program Expansion & Transformation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result *Please see attached page TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $250,833.00 Professional Fees $8,500.00 Operations $5,921.00 Supplies -- _ Equipment $13,600.00 Other: $4,460.00 Other: $6,600.00 Other: $2,640.00 Other: $5,851.00 Other: -- TOTAL $298,405.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 8. Table 1: Attachment What are the intended measurable outputs or outcomes that would be achieved with this funding? Program Performance Measures Applicant Projected Results Develop a Strategic Plan and Budget *Develop policies and procedures for Palliative Care including services,staffing and metrics to Program document program value *Develop tools to collect program data and measure value added components Begin Palliative Care Pilot Program with *Establish Palliative Care Physician and other team outpatient Oncology Patients and phase in members expansion to acute and long-term care *Establish billing and documentation processes facilities *Use these measures to create a replicable program of care for future expansion of program Implementation of capacity to have *Research and acquire Medicare approved EMR Electronic Medical Records(EMR) system with appropriate hardware *Install system and train personnel Education of Community and Providers *Have appropriate education materials produced *Design&implement a survey tool to assess availability of resources *At least six(6) palliative care outreach&palliative care presentations in grant year Skills Development of Program Staff *Support at least one(1),hopefully two(2) staff to attend national conference on Palliative Care *On-going participation in available webinars *On-going training modules offered&provided by the palliative care physician,Dr. Frances Spector *Purchase necessary print resources *Increase staff understanding of Palliative Care best practices and program policies and procedures Design&Pilot Transitions/Palliative Care *Increased number and utilization of volunteers and volunteer/student intern training program student 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 grant year Provided education on Advance Health Care *Increased number of presentations delivered,a Directives(AHCD) &Physicians Orders for minimum of twelve(12) for grant year Life Sustaining Treatment(POLST),as well *Increased awareness/understanding evident by as general education about options for post presentation surveys to determine knowledge improved end-of-life care gained *Track number AHCD distributed to interested community members Palliative Care Physician fosters professional *Increased awareness/understanding demonstrated &collegial relationships within the by increased appropriate referrals shown in patients healthcare system&community inquiring about palliative care *Will track data on admissions for monitoring expected increases 12. Council Award Worksheet—Table 1: Attachment Program Performance Applicant Projected Results Council Proposed Measures Projected Result Develop a Strategic Plan *Develop policies and procedures for Palliative and Budget including Care Program services,staffing and *Develop tools to collect program data and metrics to document measure value added components program value Begin Palliative Care Pilot *Establish Palliative Care Physician and other Program with outpatient team members Oncology Patients and *Establish billing and documentation processes phase in expansion to acute *Use these measures to create a replicable and long-term care facilities program of care for future expansion of program Implementation of capacity *Research and acquire Medicare approved EMR to have Electronic Medical system with appropriate hardware Records(EMR) *Install system and train personnel Education of Community *Have appropriate education materials and Providers produced *Design&implement a survey tool to assess availability of resources *At least six(6) palliative care outreach& palliative care presentations in grant year Skills Development of *Support at least one(1),hopefully two(2) staff Program Staff to attend national conference on Palliative Care *On-going participation in available webinars *On-going training modules offered&provided by the palliative care physician,Dr. Frances Spector *Purchase necessary print resources *Increase staff understanding of Palliative Care best practices and program policies and procedures Design&Pilot *Increased number and utilization of volunteers Transitions/Palliative Care and student interns specially trained in volunteer/student intern Transitions/Palliative Care training program *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 grant year Provided education on *Increased number of presentations delivered, Advance Health Care a minimum of twelve(12) for grant year Directives(AHCD) & *Increased awareness/understanding evident Physicians Orders for Life by post presentation surveys to determine Sustaining Treatment knowledge gained (POLST),as well as general *Track number AHCD distributed to interested education about options for community members improved end-of-life care Palliative Care Physician *Increased awareness/understanding fosters professional& demonstrated by increased appropriate collegial relationships referrals shown in patients inquiring about within the healthcare palliative care system&community *Will track data on admissions for monitoring expected increases LIMA Hui Malama Ola Na'Oiwi Cancer Program c 3 py Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program Agency Director: Michelle M. Hiraishi Phone No.: (808 ) 969 — 9220 Contact Person: Kelsey K. Hiraishi Phone No.: (808) 969 — 9220 Mailing Address: Address: 69 Railroad Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 69 Railroad Avenue Address: City,sr,zip Hilo, Hawaii 96720 Email Address: Kelsey @huimalamahawaii.com Fax No.: (808) 961 — 4794 Accountant/CPA: Phone No.: (808) 861 — 1174 Firm (if applicable): CW Associates Mailing Address: Address: Topa Financial Center 700 Bishop St, STE 1040 Address: City,ST,zip Honolulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $20,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0 $0 $15,000 2.Agency Mission Statement: FY 2012-2013 Funding $0 '0 Hui Malama Ola Na `Oiwi makou - We are the group that takes care of the health of Hawaiian people. Eia ke kuleana:Our mission is: Ho`oulu ola o ka lahui Hawaii - To uplift the health of the Hawaiian nation 0 keia ka mana`o: We will: Malama is moku o Keawe -Take care of Hawaii Island Malama i na kua`aina -Take care of country and rural areas Malama I kou olakino -Take care of your physical, spiritual, and mental body Malama I na mea Hawaii -Take care of Hawaiian culture and practices E ho'oikaika a ola ka lahui Hawaii. - We envision a strong and healthy Hawaiian nation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hui Mama Ola Na 'Oiwi Program Name: Cancer Program 3. Program Description: HMON`O is requesting funding from the County of Hawaii for fiscal year 2013-2014 to support the Cancer Program. The Cancer Program is under the direction of our one (1) full-time Cancer Program Manager (CPM). Annual island-wide program deliverables include planned tobacco cessation education classes, cancer patient navigation, facilitation of the Mai Ka Pili Pa'a - Cancer Support group and an array of community based outreach presentations. The Cancer Program also provides financial assistance via a Susan G. Komen for the Cure grant fund for mammography and other breast health screening cost for those registered members having financial hardship and without help would not complete annual screening as a prevention. Please refer to Addendum #1 for additional program description narrative. 4.Total Budget& Position Count: Total Program Budget: $74,399 Total Program Position Count: 2 Total Agency Budget: $2,738,441 Total Agency Position Count: 45 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii 20,000 Susan G. Komen 25,000 APPEAL - ECHOES 9,323 Health Resources Services Administration 20,076 Imi Hale/POL - Discontinued 0 TOTAL: $74,399 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HMON'O plans to continue seeking grant funding from Susan G. Komen Foundation as well as other appropriate cancer related funding sources. We continue to work closely with Papa Ola Lokahi on state-wide initiatives and possible collaboration with Queens Medical Center/Imi Hale. Planning our Cancer Program's annual E Ola Kakou canoe regatta has opened the door for mainstreaming a fundraising drive component as part of the event itself. Community based fundraising drives are being planned for the FY 2013-2014 and it is anticipated that funds raised can support our program needs. Billing revenue is on our radar and the process has been a difficult one to certify tobacco cessation as a billable education revenue stream. We continue to work on approval from insurances for this delivered service. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide those diagnosed with cancer a venue that supports cancer education/navigation and provide an opportunity for those diagnosed to be part of a support group structure. The program will provide registered clients with prevention venues such as our Ho'ola Hou Tobacco Cessation education classes to decrease tobacco use as a risk factor associated with Cancer. The program will increase cessation opportunities by providing services to organizations and the workforce within our island comunities. 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.) Clients diagnosed with cancer will register for navigation services 20 clients Clients will participate in cancer support groups in the funding year 40 clients Clients will register and complete the tobacco cessation program 30 clients Clients will quit smoking 9 clients Clients will reduce tobacco use 18 clients Community agencies will complete cessation curriculum 5 agencies Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 22,331 51,846 20,000 Professional Fees _ Screening & Mammograms 2,519 5,000 Operations Supplies - Program Supplies & Events 5,523 7,861 Equipment Other: _ Travel 1,575 1,371 Other: - Mileage 943 2,000 Other: - Occupancy (Rent & Electric) 2,550 6,321 Other: Other: *Note: FY12-13 Actual for Period 1AUG12-31DEC12 TOTAL 35,441 74,399 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hall Health Transportation 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 conflict is needed. 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): CNo conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: N/A Executive Director C1f 3/ 1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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.v Executive Director f�' Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hui Mama Ola Na `Oiwi Program Name: Cancer Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Hilo clients will be transported to medical related visits. 175 Ka'u clients will be transported to medical related visits. 100 Kona residents will be transported to medical related visits. 110 Puna residents will be transported to medical related visits. 125 North Hawaii residents be transported to medical related visits. 90 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 20,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Cancer Program Addendum # 1 Program Description continued from Application Exhibit A Section 3. The program addresses the needs of those diagnosed with cancer and their 'ohana. Much of the Cancer Program Manager (CPM) time has been spent on direct one to one cancer patient navigation services with diagnosed patients. The level of the encounters can vary from a patient wanting to understand cancer more in detail to a patient being overwhelmed with many barriers such as cost for screening and treatment, lack of insurance, family based issues of support, understanding how cancer evolves and much more. The role of the CPM becomes a valuable support structure for these patients and the 3 year old support group that has been formed at HMON'O is an example of the power of building and strengthening a patient facing such a scary diagnosis. The CPM works in providing day in and day out support for each patient who request assistance. The latest complete report of data related to program deliverables is for the period August 1, 2011 thru April of 2012. Current report for entire 2012 calendar year is being extrapolated once all visit records are completed and inputted for December 2012. In the 2011-2012 reporting period we have reported to the Health Resources Services Administration (HRSA) the following highlighted data sets: • Cancer Awareness and Prevention Program-Community Screening and Education • 45 patients have registered in the Ho'okele I Ke Ola Cancer Navigation Program • 100% patients diagnosed with cancer have been linked to in-house or community agencies. • 54 women completed an annual mammography exam. • 67 women completed breast care exams • 22 women remain as members of the Cancer Survivor Support Group. • 5 HMON'O sponsored event with Cancer focus was completed in the reporting period. • There have been 20 community presentations with cancer education consults, navigation and referrals completed. • 1751 patient encounters have been completed by the Cancer Program staff by presentations, community events and consultations in Cancer Education and Prevention information. • Tobacco Cessation • 14 clients completed Tobacco Cessation Classes in the reporting period. • 28% of Tobacco Cessation Class participants have been tobacco free for at least 3 months. • 50% of the class participants reduced the number of cigarettes smoked. Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Cancer Program Addendum # 1 • Tobacco prevention and awareness education provided at 14 community health events. The funding request to the County of Hawaii is focused on allocation of funding to the CPM position. Use of county funds will help leverage the use of federal funding in possibly expanding to another CPM position that would service the West Hawaii communities and service delivered would be a team of two staff available for program implementation and our effort to reach more of our island population. IIrJ Hui Malama Ola Na'Oiwi Kokua Hali Health Transportation ©0 py Agency Name: Hui Malama Ola Na `Oiwi Program Name: KOkua Hali Health Transportation Agency Director: Michelle M. Hiraishi Phone No.: (808 ) 969 — 9220 Contact Person: Kelsey K. Hiraishi Phone No.: (808) 969 — 9220 Mailing Address: Address: 69 Railroad Avenue 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/CPA: Phone No.: (808) 861 — 1174 Firm (if applicable): CW Associates Mailing Address: Address: Topa Financial Center 700 Bishop St, STE 1040 Address: City,s-r,zip Honolulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $30,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0 $20,000 $20,000 2.Agency Mission Statement: FY 12/13 Funding = $12,500 'O Hui Malama Ola Na `Oiwi makou - We are the group that takes care of the health of Hawaiian people. Eia ke kuleana:Our mission is: Ho`oulu ola o ka lahui Hawaii - To uplift the health of the Hawaiian nation 0 keia ka mana`o: We will: Malama is moku o Keawe -Take care of Hawaii Island Malama i na kua`aina -Take care of country and rural areas Malama I kou olakino -Take care of your physical, spiritual, and mental body Malama I na mea Hawaii -Take care of Hawaiian culture and practices E ho'oikaika a ola ka lahui Hawaii. - We envision a strong and healthy Hawaiian nation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hali Health Transportation 3. Program Description: HMON`O is requesting funding from the County of Hawaii for fiscal year 2013-2014 to continue "Kokua Hali" Health Transportation program to provide access to essential health care on the island. HMON`O provides transportation for clients living in all districts on the island and to an array of health related appointments. 9 vehicles are used to service Ka'u, Kona, Hilo, Puna and Kohala/Hamakua. The primary focus of the program is to provide door-to-door transportation for registered clients to get them to and from physician, diagnostic labs, pharmacy, dialysis, and other health-related appointments. HMON'O's transportation service operates Monday through Friday with scheduling flexibility to accommodate client needs. Those that require Please refer to Addendum # 1 for continuing program description narrative. 4.Total Budget& Position Count: Total Program Budget: $303,381 Total Program Position Count: 7 Total Agency Budget: $2,738,441 Total Agency Position Count: 45 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County Of Hawaii $30,000 HRSA $273,381 TOTAL: $303,381 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HMON'O continues to explore the health insurance billing/revenue aspect of transportation services. It remains our hope that insurance payors will provide reimbursement for transportation of those clients under their insurance coverage. Billed revenue via our Primary Care provider services supports agency functions including the rising transportation cost. Administrative staff continue to explore funding streams to support this program. Grants and sources of private funding is scarce for this program but remains an avenue for applied financial support. Fee for services has been assesed as a non-feasible method due to the high percentage of clients who are poverty stricken. Agency fundraising efforts will seek community based support for this and all HMON'O programs. HRSA remains our main revenue source. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hali Health Transportation 7. Program Objectives Using County Nonprofit Grant Program Funds: County funds will be used to support the overall implementation cost of the "Kokua Hali" Health Transportation Program. The primary objective is to support transportation of our Hawaii island population with another means to get to health related appointments and activities. County funds will support the state and county efforts to build the transit infrastructure as reported in the State of Hawaii, Coordinated Transit Plan - Human Services Transportation Plan of May 2011. 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.) Hilo residents will be transported to medical related visits. 175 Ka'u residents will be transported to medical related visits. 100 Kona residents will be transported to medical related visits. 110 Puna residents will be transported to medical related visits. 125 North Hawaii residents will be transported to medical related visits. 90 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages 104,433 220,058 Professional Fees Operations Supplies Equipment Other: Fuel 20,164 47,774 20,000 Other: Repairs & Maintenance 4,689 20,779 10,000 Other: Insurance 5,479 14,770 Other: Other: Note: FY 12-13 Actual for 5-mos.- 01AUG12-31DEC12 TOTAL 134,775 303,381 30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hali Health Transportation 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 conflict is needed. 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): VINo conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: N/A LA//1 /1 Executive Director O! 3l 13 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Kokua Hall Health Transportation 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. c 4 Executive Director 01 /3/ /LS Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hui Mama Ola Na `Oiwi Program Name: Kokua Hali Health Transportation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Hilo clients will be transported to medical related visits. 175 Ka'u clients will be transported to medical related visits. 100 Kona residents will be transported to medical related visits. 110 Puna residents will be transported to medical related visits. 125 North Hawaii residents be transported to medical related visits. 90 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Fuel 20,000 Other: Repairs & Maintenance 10,000 Other: Other: Other: TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Kokua Hali - Health Transportation Program Addendum #1 Program Description continued from Application Exhibit A Section 3. 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. In reviewing our demographic data of those clients we have transported in 2012, reports show that 79%of those using our transportation services are 55 years and older. This remains a challenge for our community at large with dependence on transportation has moved away from family support to community based support such as our program. Highlights from our program for 2012 demonstrate the effectiveness of our ability to support the needs of our island residents. A total of 161,267 miles were recorded on odometer reading from all vehicles. An estimated 159,534 miles was attributed to direct service transports of island residents. Mileage distribution varied across the island with the Puna vehicles reporting a total of 41,719 miles of travel with Kona at 36,720, Ka'u at 34,354, Hilo at 28,831 and Waimea at 19,643 miles of travel. There were 535 unduplicated clients that used our transportation services at least 1 time though-out the year. The distribution of community residents showed that 172 individual clients used our Hilo transportation service, 103 in Puna, 100 in Kona, 98 in Ka'u and 62 in Waimea. This continues to play a major role in HMON'O recognizing the importance of maintaining this program. We are currently generating the breakdown of where transportation destination was reported for the period August to December of 2012. As reported to the county in August of 2012 for the period July 1, 2011 thru June 30, 2012, the Kokua Hali transports has some significant transportation numbers with most noted: 4,438 transports were completed to island Physicians and Primary Care providers 1230 transports were to pharmacies for medication 638 transports were to island laboratories as referred by client PCP for lab work. 376 transports were to our 3 Community Health Centers. 1722 transports were to Chronic Disease Management& Health Education classes. 30 transports were to or from hospitals. 110 transports were to dentist. 604 transports were to other related needs such as social services, mental health, housing, DHS etc... A total of 9148 transports were completed and 242 "new" clients registered for this service as first timers. Our 4 wheel drive handicap/wheel lift capable van transported 36 mobility challenged individuals with 1170 transports. 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. Agency Name: Hui Malama Ola Na `Oiwi Program Name: KOkua Hall - Health Transportation Program Addendum #1 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. Fleet maintenance of our vehicles which put on such a high number of miles has affected our budget in caring for our wear and tear issues. 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. MR, Hui Malama Ola Na'Oiwi Mai Ka Mala 'Ai Program Agency Name: Hui Malama Ola Na `Oiwi Program Name: Mai Ka Mala 'Ai Program Agency Director: Michelle M. Hiraishi Phone No.: (808) 969 — 9220 Contact Person: Kelsey K. Hiraishi Phone No.: (808) 969 — 9220 Mailing Address: Address: 69 Railroad Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 69 Railroad Avenue Address: City,sr,Zip Hilo, Hawaii 96720 Email Address: Kelsey @huimalamahawaii.com Fax No.: (808) 961 — 4794 Accountant/CPA: Phone No.: (808) 861 — 1174 Firm (if applicable): CW Associates Mailing Address: Address: Topa Financial Center 700 Bishop St, STE 1040 Address: City,sr,Zip Honolulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $20,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0 $0 $5,000 2. Agency Mission Statement: FY 2012-2013 Funding $16,000 '0 Hui Malama Ola Na `Oiwi makou - We are the group that takes care of the health of Hawaiian people. Eia ke kuleana:Our mission is: Ho`oulu ola o ka lahui Hawaii - To uplift the health of the Hawaiian nation O keia ka mana`o: We will: Malama is moku o Keawe -Take care of Hawaii Island Malama i na kua`aina -Take care of country and rural areas Malama I kou olakino -Take care of your physical, spiritual, and mental body Malama I na mea Hawaii -Take care of Hawaiian culture and practices E ho'oikaika a ola ka lahui Hawaii. - We envision a strong and healthy Hawaiian nation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Mai Ka Mala 'Ai Program 3. Program Description: HMON`O is requesting funding from the County of Hawaii for fiscal year 2013-2014 to support the Mai ka Mala 'Ai Diabetes Program. This 10 week health education class fosters self management skills of patients diagnosed with diabetes as well as those patients at risk for diabetes. Clinical screening assessments are conducted at pre/post class and 3, 6 and 12 month intervals to support each patient's effort to monitor their blood sugar (HbA1 c), blood pressure, cholesterol, triglyceride, body mass index, fruit and vegetable intake and physical activity level. Facilitated by our Registered Nurse(s) Community Health Educators and with help from county funding, HMON'O will roll out classes in Hilo, Kona, North Hawaii, Puna and for the first time in Ka'u. Please refer to Addendum #1 for additional program description. 4.Total Budget& Position Count: Total Program Budget: 289,839 Total Program Position Count: 15 Total Agency Budget: 2,738,441 Total Agency Position Count: 45 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Health Resources Services Administration (HRSA) 262,839 County of Hawaii 27,000 TOTAL: 289,839 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HMON'O is in the final process of collecting billed revenue for the clinical screening component of our Mai Ka Mala'Ai program. All our sites are certified to perform clinical screening and our Primary Care Provider has been working with our staff on meeting all the compliance requirements to establish billed revenue. Securing other private foundation and grant funds continues to be a task for the agencies administration. On the federal level, our administrative staff continues to advocate for increased funding to support all programs including the proposed Mai Ka Mala'Ai Program. HRSA continues to be the main funding stream that supports this program delivery. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Mai Ka Mala 'Ai Program 7. Program Objectives Using County Nonprofit Grant Program Funds: HMON'O's Mai Ka Mala'Ai Program objective is to assist individuals to self-manage their diabetes and to promote healthy eating and physical activity in efforts to increase the protective factors associated with diabetes. Knowledge and awareness of clinical screening numbers and what they mean to a diabetic is of utmost importance. The program also fosters assistance to individuals who are faced with multiple barriers to care. Need for transportation to regular PCP visits, needing understanding of the changes in insurance coverage and much more. 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.) Clients will register and complete the Mai Ka Mala'Ai Program 155 Clients will reduce and/or maintain a HbA1 c level of<9% 124 or 80% Clients will reduce and/or maintain a blood pressure level <140/90 108 or 70% Clients will reduce and/or maintain a LDL level <100 mg/dl 100 or 65% Clients will reduce and/or maintain triglyceride level of<100 85 or 55% Clients will increase Fruit and Vegetable intake on a daily basis 116 or 75% Clients will increase physical activity level to 30min/day-7 days /wk 116 or 75% Attach additional pages as necessary. 9.TABLE II: * FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages& Fringe 98,176 215,401 Professional Fees Operations Supplies 4,531 16,672 16,000 Equipment Other: Clinical Supplies 8,287 11,279 11,000 Other: Occupancy Allocation 19,452 46,487 Other: Other: Other: * FY12-13 Actuals Based on period O1AUG12-31DEC12 TOTAL 130,446 289,839 27,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Kokua Hali Health Transportation 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 conflict is needed. 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): No conflicts exist (No further information required. Please sign form at the bottom.) nMember 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: N/A (--41/1 Executive Director °I 131 43 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Mai Ka Mala 'Ai 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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-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 for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2014 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. (44/1 W\Ca". Executive Director 0 I3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Mai Ka Mala 'Ai Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Hilo clients will be transported to medical related visits. 175 Ka'u clients will be transported to medical related visits. 100 Kona residents will be transported to medical related visits. 110 Puna residents will be transported to medical related visits. 125 North Hawaii residents be transported to medical related visits. 90 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies - Program Supplies 16,000 Equipment Other: _ Clinical Supplies 11,000 Other: Other: Other: Other: TOTAL 27,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Mai Ka Mala'Ai Diabetes Education Program Addendum # 1 Program Description continued from Application Exhibit A Section 3. The course was developed by clinical staff from HMON'O and the John A. Burns School of Medicine, Department of Native Hawaiian Health. The course is a critical component of HMON'O's overall Diabetes Management Program, and has been successful in East Hawai'i for the past 61/2 years and over the past year these classes have been completed in West Hawaii and North Hawaii. In 2012 a total of 63 individual classes were implemented with 148 class participants. Over 500 clinical screening assessments were completed. Significant clinical assessment results showed that 89% of the 148 patient's improved and maintained their HbA1c blood sugar level below the 9% national standard. 59%of the patient's lowered and maintained their blood pressure level to <140/90 and 57% of the patients lowered their Low-density lipoprotein (LDL) cholesterol level to <100 mg/dl. 67% lowered their saturated fat (triglyceride) levels to <100 and 78% of patients increased their fruit and vegetable intake and 74% maintained a physical activity level of 30 min/day for 7 days a week. The improvement in patient clinical numbers for 2012 depicts the effectiveness of our program delivery and patient investment in their health. The course itself assist clients in establishing personal goals as they work with staff to design a plan to achieve those goals; goals are revisited at each screening interval, and new goals established as necessary. The course incorporates: • Pre-screen (baseline) of clinical measurements at the start of the class • Post-screen at the completion of the class (10 weeks from baseline) • Follow-up clinical screens at 3-mo, 6-mo, and 1 year from post-screen; coaching with client • Customary diabetes clinical information: Via weekly "Diabetes 101" sessions presented by the CDE equivalent/RN, clients are educated about the basic facts of diabetes (types, symptoms, blood sugar levels, basic management, etc.) • Local community Specialists: Each week a different Specialist from the community provides information in the management of diabetes within their area of expertise, followed by a question and answer session. These Specialists provide this service for free. These Specialists and their topic discussions include: Exercise Specialist: Fitness , Podiatrist: Foot Care, Optometrist: Eye Care, Pharmacist: Medication Management, Medical Doctor: Kidney Health, Dentist: Oral Health, Psychologist: Coping Skills, 1 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Mai Ka Mala'Ai Diabetes Education Program Addendum # 1 Registered Dietician: Well Balanced Meals; Recipe Modification, Agricultural Specialist: Planting Seeds-Growing Healthy Plants; Fertilizers; Maintaining and Refreshing Your Mala (Other specialists may be recruited as clients' needs warrant) • Mala (Garden) Construction: Each client is provided with a mala built at their home, and numerous vegetable seedlings for planting. Over the course of the class, an Agricultural Specialist provides information for growing vegetables, utilizing fertilizers (both store- bought and homemade), maintaining and sustaining a mala, and harvesting. Native Hawaiians have a very strong respect for and spiritual connection with the 'aina, the land; it is a value that is ingrained in all aspects of Hawaiian culture. The mala provides clients the opportunity to connect with the land, supplement their food supply, and exercise. (Graduates of the class have credited their mala as giving them "purpose": one client cited his mala as part of his substance abuse sobriety plan, another cited her mala as the reason she progressed out of a wheel chair and into a walker, "I needed to be able to get to my mala.") • Meal: As a "topic" of each class, clients are served (by HMON'O staff) a healthy meal. This is an opportunity for clients to "see it all in action": healthy food choices, including vegetables they bring in from their mala, and appropriate portion size. The evening's presenting Specialist joins in the meal, providing an opportunity for clients to ask further questions, talk-story, and get to know the Specialist they may visit in their disease management. The value-added byproducts of the meal include building of the client's self-esteem (feeling pampered by being served), and increasing their support network by enjoying a meal and talking story with other clients. Friendships are formed. Support group: Upon completion of the Mai Ka Mala'Ai class, clients are offered the opportunity to join the on-going Diabetes Support Group. The group meets bi-monthly (daytime and evening groups are offered), and again shares a meal together. As the barriers and gaps in health care continue to plague our island community, it has become apparent that our MKM program is needed and wanted to increase the opportunity for our population to have a meaningful and personal means of managing their health. To address the need in management of diabetes for the growing diabetic population in Hawaii County, HMONO will organize and implement the Mai Ka Mala°Ai Program in Pahoa, Hilo, Ka'u, Kona and Waimea. HMON'O is projecting to implement a total of 11 groups throughout the funding year with 110 individual classes and a projected 1280 individual clinical screens. Diagnosed diabetics will afford the opportunity to deal with the everyday health issues surrounding their chronic disease by increasing protective factors through established routines such as exercise, nutrition and diet intake, recognition of possible 2 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Mai Ka Mala'Ai Diabetes Education Program Addendum # 1 symptoms of diabetics in eye care, foot care and kidney care. We will address mental health issues of participants with possible mind-set and life skill tools to deal with emotions and stressors of disease in themselves, their families and friends. To address the risk factors related to the socio-economic crisis where many of our residents are unemployed, some homeless and little or no means to provide healthy meals, we will assist to implement cost effective garden areas using recycled pallets, maintaining healthy compose and using natural products to create fertilizers as a means of self-sustainable food produce for their families. In more detail, the 10 week curriculum consist of 2 sessions on sustainable gardening, 2 classes titled Diabetes 101 where the basic understanding of diabetes and other contributing health factors are shared by a diabetes specialist, 1 session on physical exercise, 1 session on foot care, 1 session on eye care, 1 session on mental health, 1 session on healthy diet practices & nutrition, 1 session on modifying recipes and 1 session on the various pharmaceutical medicines. Based on the dynamics and needs of each group HMONO has been very flexible in retaining local professionals who provide in-kind hours as presenters in the program. Each of our 5 island satellite sites can provide transportation on a limited basis for class participants. In support of patient self-care process HMON'O conducts activities to support patients/ families in self-management by: • Directly provides educational resources in diabetes, hypertension, and nutrition via group and one-on-one sessions • Utilizes the Indian Health Services Resource Patient Management System electronic health record system as a basis for tracking and monitoring clinical and non-clinical care provided • Conducts an Intake Assessment and establishes a Plan of Action for all enrolled clients; the plan is reviewed at established intervals and all client contacts and goal progressions are entered into the agency's EHR • Provides each client with a copy of their HMON'O Care Plan with areas for daily and weekly client input of self-care results • All classes include information on healthy behaviors and life choices; individual coaching provided at all follow-up screenings; all clients offered the opportunity for one-on-one counseling 3 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Mai Ka Mala'Ai Diabetes Education Program Addendum # 1 The program supports patients/families that need access to community resources by: • Offering referrals to community agencies, including health related entities, life- management services, mental health services, and substance abuse treatment services • Maintaining a comprehensive resource lists of community services, including traditional healers and practitioners • Tracking all client activity via EHR, including referrals • Arranges for and refers to mental health providers • Directly provides health education via group and one-on-one sessions; provides day and night support groups. County funding requested will be used strictly for the program supply cost which include class supplies and clinical supplies for screening assessments. 4 67 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) 968 — 8279 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.: (808) 968 — 8279 Accountant/CPA: Vivian S. Toellner Phone No.: (808) 345 — 2753 Firm (if applicable): Mailing Address: Address: PO Box 6894 Address: City,sr,Zip Hilo, Hi 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 Fy 12—13 11 ,000.00 10,000.00 2.Agency Mission Statement: HPH is an all volunteer, non-profit 501 © (3) animal organization, dedicated to providing Low Cost Spay/Neuter for Cats/Dogs in the communities of East Hawaii. We also trap, Spay/Neuter, Examine, Vaccinate, Release & Manage (TNRM)feral & abandonned cat/kittens in various locations, including the waste &transfer station in Keaau to prevent uncontrolled breeding and overpopulation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 & assists individuals with trapping when necessary. We also have daily phone contact& maintain lists of people in need of our assistance. From 2007 until end of 2012 we spayed/neutered over 2400 dogs and cats. These grant funds we are requesting will be used to maintain & increase our efforts as our operation is outgrowing our donations. Approximately another 700 dogs and cats could be assisted this year with this grant. 4.Total Budget&Position Count: Total Program Budget: 25,000.00 Total Program Position Count: 12 Total Agency Budget: 15,300.00 Total Agency Position Count: 4 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Spay Day Photo Contest 1,000.00 Volcano Parade Sales 50.00 County Fair Sales 100.00 Give Aloha Program 1,000.00 Yard Sale 350.00 Donation Boxes 800.00 Donations 12,000.00 TOTAL: 15,300.00 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 Saturday, February 23, 2013 at Mo'oheau Brandstand, potential annual fundraiser and community education event. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay/Neuter Clinics 7. Program Objectives Using County Nonprofit Grant Program Funds: 1- Sponsor low cost Spay/Neuter clinics for the public (individuals who meet low income financial criteria). 2-Transport Animals biweekly to and from Spay/Neuter clinics. 3-Transport traps & bait food to and from homes of individuals of low income & elderly. 4- Purchase medical supplies for the Spay/Neuter clinic, additional traps, pet carriers, kennels. 5- Seek homes for adoptable animals. 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.) Dr. Lyle Brooksby 150 Dr. Seeske/Kilauea Vet Services 50 Aloha Veterinary Ctr 50 Dr. Kim Kozuma 20 Dr. Hatt 200 Dr. Yoko Haneda 500 Dr. Castro /Hilo Vet Clinic 50 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages -0- -0- -0- Professional Fees -0- -0- -0- Operations 30,000.00 18,000.00 Supplies 6,300.00 4,000.00 Equipment 4,000.00 3,000.00 Other: Other: Other: Other: Other: TOTAL 40,300.00 25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay/Neuter Clinics 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 conflict is needed. 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): CNo conflicts exist(No further information required. Please sign form at the bottom.) 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: c, S :nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 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.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. Sign ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay/Neuter Clinics 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Dr. Lyle Brooksby 150 Dr. Seeske/Kilauea Vet Services 50 Aloha Veterinary Ctr 50 Dr. Kim kozuma 20 Dr. Hatt 200 Dr. Yoko Haneda 500 Dr. Castro/Hilo Vet Clinic 50 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages -0- Professional Fees -0- 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 2013-2014 Page 7 of 7 F5" 16 Innovations Public Charter School Foundation Teaching our Keiki Aloha Toward the Aina Agency Name: Innovations Public Charter School Foundation Program Name: Teaching our Keiki Aloha Toward the Aina 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 Hwy Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 75-5815 Queen Ka'ahumanu Hwy Address: City,ST,Zip 75-5815 Queen Ka'ahumanu Hwy Email Address: Ieenelson.ipcs @konaimage.com Fax No.: (808) 327 — 6209 Accountant/CPA: Gretchen Kremeyer, CPA Phone No.: (808) 930 — 6871 Firm (if applicable): Carbonaro CPA & Associaties Inc. Mailing Address: Address: PO Box 4372 Address: City,sr,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $10,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $5,000 2.Agency Mission Statement: Innovations Public Charter School Foundation's mission is to provide facilities, raise funds for capital campaigns, seek contributions and preserve the ednowment for Innovations Public Charter School. Innovations Foundation makes every effort to provide facilities and exist in a sustainable way. Innovations Foundation refers to sustainability as the human ability to maintain, support and endure life on our Island and planet Earth. Sustainability is physical development and general education that meets the needs of the present without compromising the ability of future generations to meet their own needs. As a Foundation supporting a public school, we strive to make choices that acknowledge the present generation's responsibility to improve future generation's life by restoring previous ecosystem damage and resisting to contribute to future ecosystem damage. While not perfect, we are striving to make a difference. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Innovations Public Charter School Foundation Program Name: Teaching our Keiki Aloha Toward the Aina 3.Program Description: Our program is designed to teach Innovations' students and community members to show "Aloha toward the Aina" though sustainable practices. In this program, students will work "Hands On" with local architect, contractors and teachers to promote a green Innovations' campus. During fiscal year 2013-2014, Innovations will be adding a 15,000 sq.ft. middle school campus on its upper 4 acres. Ground breaking is scheduled i May 2013. Keiki will track that "Aloha is shown to the Aina" during all phases of construction by calculating LEEDS points. The architect will mentor middles school students to build responsibly; teaching students that preserving existing trees, strategically aligning buildings for natural air ventilation and rainwater management helps offset the carbon footprint of the school, saves energy and water resources. 4.Total Budget& Position Count: Total Program Budget: 40000 Total Program Position Count: 0 Total Agency Budget: 200000 Total Agency Position Count: 0 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Bill Healy Foundation 10000 County of Hawaii GIA 10000 USDA (Funded) 10000 Foundation Donors 10000 TOTAL: 40000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our Foundation will be running a school and community wide campaign advertising "Teaching our Keiki Aloha toward the Aina." The program will be highlighted on our special construction site website. On the website, we will detail the components of our program and have a LEEDS point tracker which will calculate our students' progress in identifying and contributing to green building practices. There will be a "donate now" button and the option for individuals to pledge support to our program by providing a dollar per LEEDS point matching system. Additionally, Krista Donaldson, Innovations' Garden and Sustainability Director, will be meeting with Healy Foundation, Kona Brewer's Festival and community members to promote our program. Student presentations highlighting the program will be given at curriculum shares and outreach events. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Innovations Public Charter School Foundation Program Name: Teaching our Keiki Aloha Toward the Aina 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective is to teach the Keiki to exist in a sustainable way while meeting the needs of a changing environment. Funds will be used to purchase specific items that show "Aloha toward the Aina" such as solar water, solar panels, wind turbines, drought tolerant indigenous plants, bike racks so that students and the community can be exposed to all types of sustainable systems. Also, there will be a schooi & community LEEDS tracking point system on-line so students and the community can check their progress toward our school LEEDS designation. 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.) 224 students and 400 parents /community will attend workshops 624 in attendance Sustainable pancake breakfast highlighting progress and recycling 300 in attendance LEEDS volunteer day to plant indigenous plants for landscaping 100 in attendance Recycling centers designed and implemented by students 224 students 40 staff Community volunteers talk to students about sustainable practices 224 students 20 volunteers Vermiculture system shared by students w/parents & community 224 students 200 parent/comm Obtain LEEDS designation and provide a model for sustainability Ongoing to Community Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies 10000 Equipment 30000 10000 Other: Other: Other: Other: Other: TOTAL 40000 10000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Innovations Public Charter School Foundation Program Name: Teaching our Keiki Aloha Toward the Aina 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 conflict is needed. 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): No conflicts exist(No further information required. Please sign form at the bottom.) nMember 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 genet-al to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: il 030)13 Signature dAuth ized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Innovations Public Charter School Foundation Program Name: Teaching our Keiki Aloha Toward the Aina 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 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 .ring 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. n f� 1 130/i3 Signatur of Au orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Innovations Public Charter School Foundation Program Name: Teaching our Keiki Aloha Toward the Aina 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 224 students and 400 parents/community will attend workshops 624 in attend Sustainable pancake breakfast highlighting progress and recycling 300 in attend LEEDS volunteer day to plant indigenous plants for landscaping 100 in attend Designated recycling centers designed and implemented 224 stud 40 stf Community volunteers to talk about sustainable practices 224stud 20 vol Vermiculture system shared by students w/parents & community 224stud 200p/ Obtain LEEDS designation and provide a model for sustainability Ongoing TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment 10000 Other: Other: Other: Other: Other: TOTAL 10000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 11 Ka Hale O Na Keiki, Inc Familes -At -Risk Project Agency Name: Ka Hale 0 Na Keiki, Inc Program Name: Families-At-Risk Project Agency Director: Kathy Oghiro Phone No.: (808) 775 — 9870 Contact Person: Paula Seguerre Phone No.: (808) 775 — 9870 • Mailing Address: Address: 45-3668 Honokaa-Waipio Road Address: City,ST,Zip Honokaa HI 96727 Facility Address: Address: SAME • Address: City,ST,Zip Email Address: 808paulaj @gmail.com Fax No.: (808) 775 — 9055 Accountant/CPA: Ho'olae'a Phone No.: (808) 775 — 1319 Firm (if applicable): Andrade Accounting Services • Mailing Address: Address: 46-1068 Kinimaka Rd. Address: City,ST,Zip Honokaa, HI 96727 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1 0,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 6,000.00 10,000.00 . 8,000,00 2.Agency Mission Statement: At Ka Hale 0 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Ka Hale 0 Na Keiki, Inc • Program Name: Families-At-Risk Project • 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. 4.Total Budget& Position Count: Total Program Budget: 81,100.00 Total Program Position Count: 6 Total Agency Budget: $311,617.00 Total Agency Position Count: 7 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Payment from Families-At-Risk (family pmt) 11,520.00 Fundraisers 3,000.00 County of Hawaii Grant 10,000.00 Friends of Hawaii Charities 3,000.00 Wilcox Trust $7000 + Mclnerny Foundation $14,000 21,000.00 Donations In-Kind and Cash 20,580.00 Castle Foundation Grant 12,000.00 TOTAL: 81,100.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: SEE ATTACHED PAGES (#6) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 6. Explain what plans your program and agency 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 famliies, we hope to be financially solvent, and without need for continued County grant funds, within the next four years. 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, a temporary, one year increase in County funds assistance is 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. We have increased parent involvement as well as the number of fundraisers per year. Although the economy is down, our small community always supports our • efforts; be it buying cinnamon bread or volunteering to build and repair our facility. We have recently completed constructing an additional hale in order to house more children and are currently working towards adding a toddler room to our facility. Increasing our capacity potential is expected to generate increased tuition income for our Project. 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 then now. • Agency Name: Ka Hale 0 Na Keiki, Inc Program Name: Families-At-Risk Project 7. Program Objectives Using County Nonprofit Grant Program Funds: • To provide a develomentally appropriate and qualified care and education while remaining open for the at-risk families until 5:30 pm daily, including monthly holidays, and Summer. To provide monthly scholarship/tuition assistance to at-risk families.lncrease the parenting skills, • and to recognize the need for refferal if needed. Also to pursue other funding sources for the Families-At-Risk Project, to insure that the Project, and the school, will prevail. 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 37 Children enrolled 2:00 to 5:30. Families-At-Risk Program 32 Families receiving financial assistance from Families-At-Risk Prog. 32 Attach additional pages as necessary. 9. TABLE II: • FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg • Salary and Wages 42,857 46,000 4200 Professional Fees 1,771 2,000 500 Operations • 35,729 28,200 2500 Supplies 0 3,000 • 1900 Equipment 600 1,900 900 ---Other;.__^ �.---_ Other: Other: Other: . Other: TOTAL 80',957 81,100 10,000 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 • Agency Name: Ka Hale 0 Na Keiki, Inc Program Name: Families-At-Risk Project 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Kathy Oshiro POSITION: School Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist (No further information required, Please sign form at the bottom.) 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 • SG' lvv, Signature of Authorized Person (specify title) Date • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Ka Hale 0 Na Keiki, Inc Program Name: Families-At-Risk Project 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 Compliahce 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 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 will impact the evaluation of your program's or agency's future funding requests. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. Cf 'r _�./ a ` . > S G Lt7:•'/ GG!J t C j;, l/07 rd/Z.] Signature of Authorized Person (specify title) Date • • EXHIBIT A . NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 • Agency Name: Ka Hale 0 Na Keiki, Inc Program Name: Families-At-Risk Project 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Enrollment 37 Children enrolled 2:00 - 5:30 Families At Risk Program 32 Families receiving financial assistance from Ka Hale 0 Na Keiki 37 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES 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 2013-2014 Page 7 of 7 70 Ka 'Ohana O Honu'apo Honu'apo Park Program Agency Name: Ka 'Ohana 0 Honu'apo Program Name: Honu'apo Park Program Agency Director: LEHUA LOPEZ-MAU Phone No.: (808 ) 929 — 9891 Contact Person: LEHUA LOPEZ-MAU Phone No.: (808 ) 929 — 9891 Mailing Address: Address: PO BOX 903 Address: City,ST,Zip Na'alehu, HI 96772 Facility Address: Address: Honu'apo Park, Na'alehu, Ka'u Address: City,ST,Zip Na'alehu, HI 96772 Email Address:lehualz©yahoo.com Fax No.: ( ) — NONE Accountant/CPA: Chris Reid Phone No.: (808 ) 936 —2653 Firm (if applicable): Mailing Address: Address: PO BOX 903 Address: City,ST,Zip Na'alehu, HI 96772 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0.00 0.00 18,000.00 2.Agency Mission Statement: Ka 'Ohana 0 Honu'apo's mission is to"care for, restore, and protect the natural and cultural resources of the Honu'apo area, utilizing the values of malama 'aina (care of the land), kupono (honesty, integrity) and kuleana (responsibility), we will work in community partnerships to preserve this area for future generations." EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Ka 'Ohana 0 Honu'apo Program Name: Honu'apo Park Program 3.Program Description: Ka 'Ohana 0 Honaupo's Park Program is a year-long series of events at Honu'apo Park. From July, 2013 to June, 2014 we will host 4 "Sunday in the Park" events on Sundays at the Park: August 25, 2013, "Science Sunday," (science demostrations by volunteer scientists),October 13, 2013, "Kanikapila 3," (Ka'u musicians playing on stage), March 2, 2014, "Makahiki Games" (Hawaiian games demonstrations and contests),June 15, 2014, "Pork in the Park BBQ Recipe Contest." We anticipate up to 500 visitors at each event. Keiki Workshops will be held with students from Na'alehu Elementary and Ka'u Middle and High Schools, to be scheduled for fall and spring semesters. Workshops include sessions in Hawaiian culture, Honu'apo history, and marine science information. Workshops run from 9:00 am to 1:00 pm in the Park. 4.Total Budget&Position Count: Total Program Budget: 46,724 Total Program Position Count: 1 Total Agency Budget: 55,000 Total Agency Position Count: 2 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate None 0 TOTAL: 0 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Ka 'Ohana 0 Honu'apo intends to charge booth fees and other event fees in the coming years to finance events at the Park. KOOH also has an on-going relationship with the Queen Lili'u'okalani Children's Center that provides some of the refreshments and equipment for events at the Park. We also sell t-shirts, food items, water bottles, and other items at our events to help pay for expenses. KOOH now qualifies for the newly-passed Open Space Maintenance Fund, however, with the extremely tight restricions of that fund we may NOT be able to receive any of those funds for park programs. We continue to seek grants from local foundations to help pay for program expenses but have been unsuccessful to date. We also send direct mail appeals and continue to receive small donations from our supporters. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Ka 'Ohana 0 Honu'apo Pro:ram Name: Honu'apo Park Program 7.Program Objectives Using County Nonprofit Grant Program Funds: 1) Educate at least 200 Ka'u and other students from Hawaii Island elementary, middle, and high schools about the cultural, historical, and evironmental resources and values of the Honu'apo area in age-appropriate workshops at Honu'apo Park, and involve at least 30 parents and volunteers. 2) Provide educational and recreactional events at Honu'apo Park for local families and visitors by implementing at least 4 "Sunday in the Park" events, for up to 500 people per event. 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.) Anticipated park visitors for 2013-2014 Approx. 93,000 Total attendance for"Sundays in the Park" events Approx. 2,000 Total attendance for all Keiki and 'Opio Workshops Approx. 230 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees $16,848 $26,832 14,000 Operations $8,358 $10,000 $2,200 Supplies $1,540 $3,500 $1,750 Equipment (g.oe, sou Nt p genent-fors, -ft, j c,L-l-s_.) $1,750 $2,000 $1,000 Other: US tra/1S portodt'or g�n M i 1,p0,1�-f-vrs+vd fill G $400 $1,360 $800 Other: &add;4-y"Ns txrct!'4Ct- -pitrk, ve4A:11 $1,032 $1,032 $1,032 Other: P►A,Gr4St►,39 ac eve(t4-S $800 $2,000 $2,000 Other: Other: TOTAL $29,728 $46,724 $22,782 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Ka 'Ohana 0 Honu'apo Program Name: Honu'apo Park Program 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) 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: dif6- 1 3 6)//3 Signature of iI1'F r ie IPer••n(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Ka 'Ohana 0 Honu'apo Program Name: Honu'apo Park 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.I/ww■A h 3waiir:OUnty oyjfn nonprofit ;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, 2014 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. / -e— ( !� /3v//3 Signature of • iz: Perso (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Ka 'Ohana 0 Honu'apo Program Name: Honu'apo Park Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 71 Kahua Pa'a Mua Palili 'O Kohala CC;PY 2- Agency Name: Kahua Pa'a Mua Program Name: Palili `O Kohala Agency Director: David Fuertes Phone No.: (808 ) 889 — 5391 Contact Person: Carol Fuertes Phone No.: (808 ) 345 — 4610 Mailing Address: Address: P.O. Box 896 Address: City,ST,Zip Kapaau, HI 96755 Facility Address: Address: 53-4240 Akoni Pule Hwy Address: City,ST,Zip Kapaau, HI 96755 Email Address:kpminc808 @aol.com Fax No.: (808 ) 884 — 5531 Accountant/CPA: Brian Iwata, CPA Phone No.: (808 ) 935 — 5404 Firm (if-applicable): Taketa Iwata Nara & Associates Mailing Address: Address: 101 Aupuni Street, Suite 139 Address: City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 0 2. Agency Mission Statement: Kahua Pa'a Mua is a new North Kohala based 501-c-3 formed in order to assume and expand upon the work of the Palili `O Kohala project, which was previously under the fiscal umbrella of the Hawaii FFA Foundation. The mission of Kahua Pa'a Mua is to enhance communities through Hawaiian cultural land-based social, economic and educational programs for youth and adults. Kahua Pa'a Mua believes it can help distressed, unemployed, and underemployed individuals and families meet their socio-economic needs through agricultural projects related to conservation and preservation of our land. Palili `O Kohala Founder and Land Manager David Fuertes brings over 30 years of agricultural, economic development and youth mentorship knowledge to the project. David is currently the Program Director for the Ka Hana No`eau, a youth mentoring program for Native Hawaiians that melds traditional knowledge with contemporary methodologies. EXHIBIT A Agency Name: Kahua Pa'a Mua Program Name: Palili '0 Kohala 3. Program Description: The Palili `O Kohala project serves unemployed and underemployed families and at-risk youth in North Kohala by creating an economically viable cooperative agricultural business model through the cultivation of taro and animal husbandry. The project will work with ten families on taro cultivation and ten students on animal husbandry, combining traditional Hawaiian knowledge with Natural Farming methodologies to: -Continue the 5 acre Natural Farming Demonstration Farm at Ho'ea -Revitalize 49 acres of land at Kokoiki to grow healthy, chemical free, high quality food that meets the current market demand. Producing 10,000 pounds of poi in year 1 . -Student produced video of oral history of the connection of Kohala families with the land. 4.Total Budget & Position Count: Total Program Budget: 247,925 Total Program Position Count: 3 Total Agency Budget: 7,000 Total Agency Position Count: 0 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Office of Hawaiian Affairs (pending) 100,000 Kahua Pa'a Mua- (secured $5,000 in kind/$2,000 cash) 7,000 County of Hawaii- County Council (pending) 50,000 Ka Hana No`eau (secured-$22,000 mentor salary cash /$24,300 labor in-kind) 46,300 Palili `O Kohala (secured $4,200 cash on hand/$27,700 labor in-kind) 31,900 Kamoe/Kinoshita Lands (secured in-kind) 4,725 Hawaiian Community Assets (in-kind) 8,000 TOTAL: 247,925 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1. This is an economic development project based on growing taro and animal husbandry with Natural Farming. It is estimated that this project will generate significant revenue, and create a long-term agricultural economic base for participants. 2. In order for the project to reach its goal of producing 10,000 pounds of taro per month, it requires approximately three years of planning, planting and implementation. As the project is still in its start-up phase, it is not yet generating revenue, but is pursuing grants for start-up and infrastructure from a number of sources including County of Hawaii, OHA and ANA (Administration for Native Americans). EXHIBIT A Agency Name: Kahua Pa'a Mua Program Name: Palili '0 Kohala 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Natural Farming Demonstration Farm at Ho'ea continued activities 2. New Development of 49 acres at Kokoiki, 5 for taro cultivation and 44 acres for animal husbandry. 2. Provide training and support for 10 families to start taro cultivation buisness ventures. 3. Provide training and support for 10 students in animal husbandy and business mgmt. 4. Student produced video of oral history of the connection of Kohala families with the land. 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 visitors to Natural Farming Demonstration Farm 100 No. families trained in taro farming, financial literacy & biz mgmt. 10 No. students trained in animal husbandy & business management 10 Number of hull planted 10,000 Pounds of poi produced for sale or trade 3,000 Economic impact over 2 year start up phase- gross revenue $80,000 Viewers-Video of oral history of Kohala families with the land 10,000 viewers Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 102,500 22,000 Professional Fees 23,200 4,000 Operations 76,550 11,250 Supplies 32,175 8,250 Equipment Other: 13,500 4,500 Other: Other: Other: Other: TOTAL 247,925 50,000 *If applicable EXHIBIT A Agency Name: Kahua Pa'a Mua Program Name: Pauli `O Kohala 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: David Fuertes POSITION: President, Board of Directors May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): INNo conflicts exist (No further information required. Please sign form at the bottom.) 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: (12111.41)k Of) Signature of Authorized Person (specify title) Date EXHIBIT A Agency Name: Kahua Pa'a Mua Program Name: Pauli `O Kohala 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 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 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 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 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 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, 2014 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. 4reskeICPA-1 Signature of Authorized Person (specify title) Date EXHIBIT A Agency Name: Kahua Pa`a Mua Program Name: Palili '0 Kohala 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of visitors to Natural Farming Demonstration Farm 100 No. families trained in taro farming, financial literacy & biz mgmt. 10 No. students trained in animal husbandy & business management 10 Number of hull planted 10,000 Pounds of poi produced for sale or trade 3,000 Economic impact over 2 year start up phase- gross revenue $80,000 Viewers-Video of oral history of Kohala families with the land 10,000 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 22,000 Professional Fees 4,000 Operations 11,250 Supplies 8,250 Equipment Other: 4,500 Other: Other: Other: Other: TOTAL 50,000 Additional Council directives regarding award: EXHIBIT B 72 Kalani Honua Community Arts Program Agency Name: Kalani Honua Program Name: Community Arts Program Agency Director: L.J. Bates Phone No.: (8os) 965 — 7828 Contact Person: L.J. Bates Phone No.: (808) 965 — 7828 Mailing Address: Address: RR2 Box 4500 Address: City,ST,Zip Pahoa, HI 96778 Facility Address: Address: 12-6860 Kalapana-Kapoho Rd. Address: City,ST,Zip Pahoa, HI 96778 Email Address: Ij @kalani.com Fax No.: (808) 965 — 0527 Accountant/CPA: Nancy Kramer, CPA Phone No.: (808) 965 — 2729 Firm (if applicable): Mailing Address: Address: 15-2984 Pahoa Village Rd Address: City,sr,zip Pahoa, HI 96778 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 N/A N/A N/A • 2.Agency Mission Statement: Kalani, located on Kalapana-Kapoho Road in lower Puna, is a 501(c)(3) educational nonprofit with a 37-year track record of service, and currently the largest non-governmental organization (NGO) serving Puna, the poorest district in Hawai'i. Kalani hosts workshops, stewards several festivals, preserves three archaeological sites, and is a major economic driver for the district of Puna. Our weekly Community Arts Program provides over 50 classes and events each week, free or by donation to our community, ranging from Hawaiian culture classes, to multiple styles of yoga, volleyball, dance and visual arts. Kalani's mission is to present nature, culture and wellness in sustainable, educational programs that honor Hawaii's native and diverse heritage. As pioneers in nonprofit social enterprise, Kalani incorporates practices that positively affect Hawaii's "triple bottom line" —the economy, the community and the environment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Kalani Honua Program Name: Community Arts Program 3. Program Description: Kalani's vibrant Community Arts Program is hosted in our community facility, EMAX. 50 classes and events each week are available free or by donation to our local kama'aina. Classes range from Hawaiian culture classes, to multiple styles of yoga, wellness, volleyball, and performing/visual arts. Our capacity to host larger numbers of participants for our community classes is excellent, particularly due to the spaciousness of our multi-use facility, EMAX. Knowing that our program has the capacity to be further utilized by our community, we have undertaken to identify opportunities to grow and adjust programming to best serve Lower Puna. ** Please see attached sheet marked Exhibit C with the full answer to this question. 4.Total Budget&Position Count: Total Program Budget: 183970 Total Program Position Count: 42 Total Agency Budget: 3060760 Total Agency Position Count: 128 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Participant Donations 9360 Class Fees -Visiting Guests 28600 Kalani Honua Operating Fund 126045 County of Hawai'i Nonprofit Grant Fund 19965 TOTAL: 183970 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We make continual adjustments to our programming to ensure that we have sufficient revenue to sustain programming and to malama our community center, EMAX. Introducing new programming, such as the proposed programs outlined above, requires startup funding to properly market and support community offerings until they reach full sustainability. As our proposed programs develop, participant donations and guest pass income will help sustain their continuance. We appreciate the County of Hawaii's support to expand our offerings, so that we may fulfill these identified needs in Lower Puna. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Kalani Honua Program Name: Community Arts Program 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective 1: Launch no-cost programming specifically for seniors/kupuna, and promote existing programs which are suitable for seniors. - Objective 2: Launch a no-cost weekly keiki care program, and explore adding recreational opportunjties for our area's youth. Objective 3: Introduce programming well suited for native Hawaiian residents, including a no-cost ho'okipa program to increase employment opportunities in the island's visitor industry. 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.) Increase number of participants from 23,244 to 25,500. 25,500 participants. Provide community arts programming to underserved populations: 1,250 participants. Senior/kupuna 600 participants. Youth/keiki 400 participants. Native Hawaiians 250 participants. Grow our weekly community class offerings by 10% to 55. 55 classes. Engage volunteers with the delivery of these new programs. 625 volunteer hours. Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 30160 31126 1815 Professional Fees 124850 143000 18150 Operations 4380 4564 Supplies 1800 1980 Equipment 3000 3300 Other: Other: Other: Other: Other: TOTAL 164190 183970 19965 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Kalani Honua Program Name: Community Arts Program 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: r May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): Q ' No conflicts exist(No further information required. Please sign form at the bottom.) I I Member or members of the Council Staff appointed by a member of the Council _ The Mayor EiThe 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: There are no conflicts of potential conflicts of interest that any board member, officer, director, or administrator of Kalani Honua Inc. has with the County of Hawaii. A notice has been sent to all staff and board members to ensure any potential future conflicts are brought to immediate attention. �� _ ._.11 10- ink -64-eta4- 1 24l/3 :nature of Auth• :d Person (specify title) /Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Kalani Honua Program Name: Community Arts 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. Irr-411111111 �( 1 'bat c7 1/2—///3 Si:-ature of Authoriz:. Per (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Kalani Honua Program Name: Community Arts Program 12. COUNCIL AWARD WORKSHEET TABLE I: • PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase number of participants from 23,244 to 25,500. 25,500 Provide community arts programming to underserved populations: 1,250 Senior/kupuna f 600 Youth/keiki 400 Native Hawaiians 250 Grow our weekly community class offerings by 10% to 55. 55 Engage volunteers with the delivery of these new programs. 625 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 1,815 Professional Fees 18,150 Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL 19,965 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: Kalani Honua Pro•ram Name: Community Arts Program Full Response to Question 3 - Program Description: Kalani's vibrant Community Arts Program is hosted in our community facility, EMAX. More than 50 classes and events each week are available free or by donation to our local kama'aina. Classes range from Hawaiian culture classes,to multiple styles of yoga,wellness,volleyball, and performing/visual arts. Our capacity to host larger numbers of participants for our community classes is excellent, particularly due to the spaciousness of our multi-use facility, EMAX. Knowing that our program has the capacity to be further utilized by our community,we have researched opportunities to grow and adjust programming to best serve Lower Puna. In doing so,we have identified three key areas of opportunity: Programming for Seniors. Recent surveying done by KAPONO (the Kalapana to Pohoiki Neighborhood Organization) indicates a strong need and desire for services for the kupuna of this area. We have several classes on our schedule which are suitable for seniors in a multi-generational environment, and wish to highlight these; and we have plans to launch additional programs specifically the kupuna of this area, including quilting, kupuna hula, and a monthly lunch/talk story series. Programming for Youth. We wish to begin our expansion into providing complimentary services for youth by launching a weekly keiki care program, and exploring recreational opportunities for our area's youth. Programming for Native Hawaiians. Under the direction of our Hawaiian culture practitioners, both resident and local,we wish to expand and adapt our programming to serve the evolving needs of our local Native Hawaiian population.We have identified an opportunity to host an ongoing ho'okipa (Hawaiian Hospitality) program, and we are exploring other offerings which would provide valuable skills to our local kama'aina. While Kalani has a bus stop at its front gate,we would like to invite council to collaborate and discuss increasing transportation options, so that residents without transportation are better able to access our extensive community programming. We hope that with this modest expansion of our services in FY2013-2014,we will continue to be a catalyst for education, growth, and transformation in Lower Puna. EXHIBIT C NONPROFIT GRANT APPLICATION FY2013-2014 Page 8 of 8 74 Kanu o ka Aina Learning Ohana Halau Ho'okipa Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Ho'okipa Agency Director: Taffi Wise Phone No.: (808) 890 — 2500 Contact Person: Nancy Levenson Phone No.: (808) 890 — 2513 Mailing Address: Address: PO Box 6511 Address: City,ST,Zip Kamuela, Hawaii 96743 Facility Address: Address: 64-1043 Hiiaka Street Address: City,ST,Zip Kamuela, Hawaii 96743 Email Address: nancy @kalo.org Fax No.: (sos) 887 — 0030 Accountant/CPA: 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, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $1 ,700,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 0 2.Agency Mission Statement: Serving and perpetuating sustainable Hawaiian communities through Education with Aloha. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Ho'okipa 1 3. Program Description: Kanu o ka 'Aina Learning 'Ghana (KALO) has a shovel ready construction project for a 19,264 square foot community multipurpose building, that will contain a cafeteria, athletic space, and performance hall. The facility will be available as an emergency shelter. The land is owned by the Department of Hawaiian Homelands and has been leased to KALO. The project is a community-based, community-driven effort. The building will support a variety of services to the community. The County General Plan states that the County will "coordinate recreational programs and facilities with governmental and private agencies and organizations". Supporting KALO's goal of strengthening the community through improved facilities and subsequent activities, with GIA funding is a solid mechanism for leveraging County funds. 4.Total Budget&Position Count: Total Program Budget: 3,700,000.00 Total Program Position Count: Total Agency Budget: 1,700,000.00 Total Agency Position Count: 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate USDA Loan 2,000,000.00 GIA County Nonprofit grant 1,700,000.00 TOTAL: 3,700,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The secured USDA loan of$2,000,000 will be suficient to complete this project and no further funds will be required. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Ho`okipa 7. Program Objectives Using County Nonprofit Grant Program Funds: Project goals meet the High priority of Public Facilities: Childcare, youth; neighborhood facilities; and parks & recreation facilities, and medium Economic Development priority. The goal of the project is to strengthen/empower the community by providing high quality, multi-purpose facilities designed to improve quality of life for low to moderate income community members. Objectives: 1)to complete the construction of the recreation center on time and within budget and 2) to make the space available to the community. 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.) Construction begins and is monitored Completed on time Quality Control Construction meets all specs Cost Management Completed on or under budget Construction completed Space available to community Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages Professional Fees 700,472 Operations Supplies 375,000 Equipment 218,000 Other: 2,406,278 1,700,000 Other: Other: Other: Other: TOTAL 3,700,000 1,700,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Ho`okipa 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 conflict is needed. 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): © No conflicts exist(No further information required. Please sign form at the bottom.) 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: • eY,a-ter v, /Jam ; ,)s 0 Signa e of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Ho'okipa 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. Si: eva,hre Areaw //70,3 attire of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Kanu o ka Aina Learning Ohana Program Name: Halau Hobkipa 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completed construction of the recreation center on time Building is avaiable for community use TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 700,472.00 Operations Supplies Equipment 375,000.00 Other: 218,250.00 Other: 2,406,278.00 Other: Other: Other: TOTAL 3,700,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 77 Keaukaha One Youth Development (KOYD) RISE 21st Century After School Program Agency Name: Keaukaha One Youth Development (KOYD) Program Name: RISE 21st Century After School Program Agency Director: Shadd Keahi Warfield Phone No.: (808) 895 — 8666 Contact Person: Naomi Ahu Phone No.: (808) 756 — 5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, Hawaii, 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: nahu @hawaii.edu Fax No.: ( ) — Accountant/CPA: Valerie Peralto Phone No.: (808) 961 — 3462 Firm (if applicable): Peralto & Co., CPAs, Inc. Mailing Address: Address: 180 Kinoole Street Address: Suite 302 City,ST,Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $10,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0.00 $0.00 $0.00 2.Agency Mission Statement: The mission of Keaukaha One Youth Development (KOYD) is to contribute toward developing the future leaders of Hawaii County through offering programs that help youth ages 8-18 recognize their strengths and passions and the importance of team work, goal setting, physical, mental, and spiritual well-being, and cultural identity. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Keaukaha One Youth Development (KOYD) Program Name: RISE 21st Century After School Program 3. Program Description: See attached 4.Total Budget& Position Count: Total Program Budget: $52,776.00 Total Program Position Count: 0 Total Agency Budget: $62,776.00 Total Agency Position Count: 0 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Kamehameha Schools - Aina Based Learning Department Grant $42,776.00 County of Hawaii Grant (reflects our current request) $10,000.00 TOTAL: $52,776.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The RISE 21st Century After School Program continues to rely on contributions and grants from the public and private sector. We continually strive for community support in these sectors to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Keaukaha One Youth Development (KOYD) Program Name: RISE 21st Century After School Program 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 (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Hawaii County youth served (see attached) Approximately 30 youth Volunteer hours of twelve people (see attached #2 ) Approximately 1800 hours Individual Student Success Plans (see attached) Beginning development stages Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages 0 0 0 Professional Fees 7,766 8,766 1,000 Operations 10,000 10,000 0 Supplies 0 0 0 Equipment 15,000 24,000 9,000 Other: 10,000 10,000 0 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 TOTAL 42,776 52,776 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Keaukaha One Youth Development (KOYD) Program Name: RISE 21st Century After School Program 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 conflict is needed. 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): No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: See By-Laws attached, page 14 & Exhibit A /C • • Pre Elde ,f- /EAT cal) ik_s/20/ 3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Keaukaha One Youth Development (KOYD) Program Name: RISE 21st Century After School 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. 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.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. I Pre g7 /1 ri/Ex-ecapv-e Coked- /2 she/3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Keaukaha One Youth Development (KOYD) Program Name: RISE 21st Century After School Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County youth served (see attached) 30 youth Volunteer hours of twelve people (see attached #2 & #3) 1,800 hours Individual Student Success Plans (see attached) Development TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 1,000 Operations 0 Supplies 0 Equipment 9,000 Other: 0 Other: 0 Other: 0 Other: 0 Other: 0 TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 County of Hawaii Non-Profit Grants Program — Attachment Keaukaha One Youth Development (KOYD) Revealing Individual Strengths for Excellence (R.I.S.E.) Reference to Page 2, Question 3: Program Description RISE, an acronym for Revealing Individual Strengths for Excellence, is a 21st Century After School Program that was created in 2011 to serve as a community resource bank for underprivileged, Native Hawaiian youth ages 12-17 in the Hilo district to aid in revealing their individual strengths and passions for future career and academic success. A variety of mediums will be used to help youth build Individual Student Success Plans (ISSP) such as but not limited to: apprenticeships, Hawaiian cultural practice, internships, multimedia, performing arts, project exhibitions, student exchange, and work study initiatives. Once youth discover their potential strengths and passions, RISE will help connect them with voluntary mentors once a month from the immediate community and abroad who share similar strengths and passions to share knowledge, foster and develop self-esteem, and to bridge the generational gap between adults and youth. RISE will also provide opportunities to support physical well-being, cultural identity, and leadership. By implementing this mission, RISE envisions that when the youth participants graduate from high school, they will have a clear and strong idea of what their future career and academic pursuits will be and the relationships they have gained through our program will help motivate and encourage them to become valuable contributors to the well-being and sustainability of the Hilo community. Reference to Page 3, Question 7: Program Objectives Using County Non-Profit Grant Program Funds Our key objectives for the RISE 21st Century After School Program are the following: 1) To reveal the strengths and passions of youth participants to contribute toward overall student engagement and confidence. 2) To help youth participants develop Individual Student Success Plans (ISSP) to track monthly goals and expectations and to contribute toward building responsible, respectful, and reliable students. 3) To provide individual mentoring for encouragement, motivation, self-esteem, and to increase knowledge of future career and academic paths. 4) To implement Hawaiian cultural practices such as the art of lua (balance discipline) and hoe waa (canoe paddling) to teach values and encourage discipline, balance, and leadership for physical, mental, and spiritual well-being. 1 Reference to Page 3, Question 8: Table I —What are the intended measurable outputs or outcomes that would be achieved with this funding? Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served _ Approximately 30 youth _ 2) Volunteer hours of two people: Executive Approximately 1440 hours (see breakdown Director and Administrative Assistant below): * 60 hours per month x 12 months = 720 hours per person x 2 people = 1440 hours 3) Number of volunteer mentors and hours 10 volunteers, 360 hours (see breakdown served below): 10 volunteers x 3 hours = 30 hours per month x 12 months = 360 hours 4) Development of Individual Student Success Evidence of beginning stages of development Plans (ISSP) for youth participants such as goal setting and recorded support from mentors and parents Reference to Page 3, Question 9: Table II —Program Expenditures for County Grant Request Program Expenditures Additional Details Budget Professional Fees: CPA — Year End Financial $800.00 Statement Generation Contracted Grant Writer— $200.00 Application and Final Report Generation Equipment: Laptops for student use $6,500.00 Interior and exterior $2,000.00 furnishing for facility Other office & ISSP supplies $500.00 2 Reference to Page 7, Question 12: Council Award Worksheet, Table I— Program Performance Measures Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 30 youth 2) Volunteer hours of two people: Executive Approximately 1440 hours (see breakdown Director and Administrative Assistant below): * 60 hours per month x 12 months = 720 hours per person x 2 people = 1440 hours 3) Number of volunteer mentors and hours 10 volunteers, 360 hours (see breakdown served below): 10 volunteers x 3 hours = 30 hours per month x 12 months = 360 hours 4) Development of Individual Student Success Evidence of beginning stages of development Plans (ISSP) for youth participants such as goal setting and recorded support from mentors and parents Reference to Page 7, Question 12: Council Award Worksheet, Table II— Program Expenditures for County Grant Request Program Expenditures Additional Details Budget Professional Fees: CPA — Year End Financial $800.00 Statement Generation Contracted Grant Writer— $200.00 Application and Final Report Generation Equipment: Laptops for student use $6,500.00 Interior and exterior $2,000.00 furnishing for facility Other office & ISSP supplies $500.00 3 IL6q] Keaukaha One Youth Development (KOYD) Youth Paddling Program Agency Name: Keaukaha One Youth Development (KOYD) Program Name: Youth Paddling Program Agency Director: Shadd Keahi Warfield Phone No.: (808) 895 — 8666 Contact Person: Naomi Ahu Phone No.: (808) 756 — 5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, Hawaii, 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: nahu @hawaii.edu Fax No.: ( ) — Accountant/CPA: Valerie Peralto Phone No.: (808) 961 — 3462 Firm (if applicable): Peralto & Co., CPAs, Inc. Mailing Address: Address: 180 Kinoole Street Address: Suite 302 City,ST,Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $10,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $10,000.00 $10,000.00 $8,000.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development (KOYD) is to contribute toward developing the future leaders of Hawaii County through offering programs that help youth ages 8-18 recognize their strengths and passions and the importance of team work, goal setting, physical, mental, and spiritual well-being, and cultural identity. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Keaukaha One Youth Development (KOYD) Program Name: Youth Paddling Program 3. Program Description: The Youth Paddling Program was established in 2006 to offer Hawaii County youth ages 8-18 Native Hawaiian cultural opportunities that reconnect them to historic ocean experiences, particularly the Hawaiian Canoe. 4.Total Budget& Position Count: Total Program Budget: $10,000.00 Total Program Position Count: 0 Total Agency Budget: $62,776.00 Total Agency Position Count: 0 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii Non-Profit Grant (reflects our current request) $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 Youth Paddling Program continues to rely on contributions and grants from the public and private sector. We strive for community support to expose the great accompllishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Keaukaha One Youth Development (KOYD) Program Name: Youth Paddling Program 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 (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Hawaii County youth served (see attached) Approximately 120 youth Volunteer hours of four people (see attached) Approximately 850 hours Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 1,000 1,000 1,000 Operations 0 0 0 Supplies 0 0 0 Equipment 2,000 3,000 3,000 Other: 5,000 6,000 6,000 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 Other: 0 0 0 TOTAL 8,000 10,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Keaukaha One Youth Development (KOYD) Program Name: Youth Paddling Program 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) nMember 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: See By-Laws attached, page 14 & Exhibit A Z"r" Pr-etc/e,i /5recKaSve N'eefW !f x/20/3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Keaukaha One Youth Development (KOYD) Program Name: Youth Paddling 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. 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. t. W2 "' Preg Clonf/ xecublue D, ctev I/28 2-D/3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Keaukaha One Youth Development (KOYD) Program Name: Youth Paddling Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County youth served (see attached) 120 youth Volunteer hours of four people (see attached) 850 hours TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 1,000 Operations 0 Supplies 0 Equipment 3,000 Other: 6,000 Other: 0 Other: 0 Other: 0 Other: 0 TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 • County of Hawaii Non-Profit Grants Program — Attachment Keaukaha One Youth Development (KOYD) Youth Paddling Program Reference to Page 3, Question 7: Program Objectives Using County Non-Profit Grant Program Funds The Youth Paddling Program will strive to reach the following objectives: 1) Teach the values of team work, goal setting, commitment, physical, mental, and spiritual well-being, and cultural identity through the use of the Hawaiian Canoe. 2) Utilize the Hawaiian Canoe to present the metaphoric message of ones journey through life: you steer your own waa (life), but not without the help of others (KOYD and our extended communities)." 3) Help offset the high risks of drug and alcohol exposure/abuse among our Hawaii County youth through fostering after school canoe paddling practices and weekend regatta races, a healthier alternative for the utilization of their time. 4) Teach the values and processes necessary for the maintenance of Keaukaha Canoe Club's historic koa canoes and other equipment for current and future generations. 1 Reference to Page 3, Question 8: Table I—What are the intended measurable outputs or outcomes that would be achieved with this funding? Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 120 youth 2) Volunteer hours of four people: Youth Approximately 850 hours (see breakdown Division Head Coach, two Youth Division below): Assistant Coaches, and one Youth Division * 16 two hour practices per month x 5 months Program Assistant (March-July) = 160 hours x 3 coaches =480 hours * 9 ten hour Saturday regattas x 3 coaches = 270 hours * 20 hours per month for Program Assistant x 5 months = 100 hours Reference to Page 3, Question 9: Table II—Program Expenditures Program Expenditures Additional Details Budget Professional Fees: CPA — Year End Financial $800.00 Statement Generation Contracted Grant Writer— $200.00 Application and Final Report Generation _ Equipment: Paddle and canoe repair $1,000.00 Various paddling equipment $1,000.00 and supplies Escort boat repair and $1,000.00 maintenance Other: Travel Costs (bus rentals, $6,000.00 gasoline expenses, airfare, etc.) 2 Reference to Page 7, Question 12: Council Award Worksheet, Table I —Program Performance Measures Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 120 youth 2) Volunteer hours of four people: Youth Approximately 850 hours (see breakdown Division Head Coach, two Youth Division below): Assistant Coaches, and one Youth Division * 16 two hour practices per month x 5 months Program Assistant (March-July) = 160 hours x 3 coaches = 480 hours * 9 ten hour Saturday regattas x 3 coaches = 270 hours * 20 hours per month for Program Assistant x 5 months = 100 hours Reference to Page 7, Question 12: Council Award Worksheet, Table II —Program Expenditures Program Expenditures Additional Details Budget Professional Fees: CPA — Year End Financial $800.00 Statement Generation Contracted Grant Writer— $200.00 Application and Final Report Generation Equipment: Paddle and canoe repair $1,000.00 Various paddling equipment $1,000.00 and supplies Escort boat repair and $1,000.00 maintenance Other: Travel Costs (bus rentals, $6,000.00 gasoline expenses, airfare, etc.) 3 79 Keep Hawaii Beautiful Let's Grow Hilo Sustainability Plan Agency Name: Keep Hawaii Beautiful Program Name: Let's Grow Hilo Sustainability Plan Agency Director: Sam Robinson(Coordinator) Phone No.: (808) 747 — 2737 Contact Person: Kristine Kubat Phone No.: (808) 747 — 4246 Mailing Address: Address: P.O. Box 6906 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: N/A Address: City,ST,Zip Email Address: let'sgrowhilo.com Fax No.: (808) 969 — 2014 Accountant/CPA: Julie Cozad Phone No.: (808) 965 — 7858 Firm (if applicable): Emerald Bookeeping Mailing Address: Address: P.O. Box 1487 Address: City,ST,Zip Pahoa, Hawaii 96778 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $1 5,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 N/A N/A N/A 2.Agency Mission Statement: Keep Hawaii Beautiful promotes civic engagement by educating individuals and groups involved with businesses, government agencies and community organizations about the benefits of maintaining and beautifying public places. To support this mission, we forge partnerships among these stakeholders to organize activities that enhance Hawaii Island's natural beauty. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Keep Hawaii Beautiful Program Name: Let's Grow Hilo Sustainability Plan 3. Program Description: Let's Grow Hilo is a Downtown Improvement Association edible landscaping and beautification project that serves as a living classroom for the local community and visitors. It uses the commonly accessible urban landscape to educate people about safe and healthy ways to produce more food while inspiring them to plant gardens at home. This project also builds community by involving local schools, organizations and government agencies in volunteer activities. Let's Grow Hilo began as a guerrilla gardening project three years ago when Sam Robinson (then-student/now graduate of the UH-Hilo College of Agriculture)convinced the DIA to share her dream of creating community gardens. In 2013, LGH will work closely with KHB to implement a sustainability plan so the organization can operate independent of grant funding. 4.Total Budget&Position Count: Total Program Budget: $24,050 Total Program Position Count: 1 Total Agency Budget: Total Agency Position Count: 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii County GIA $15,000 Kristine Kubat(in-kind art and editing services) $3,000 Keana Okuda (in-kind layout services) $500 Petroglyph Press (in-kind printing services) $750 Sam Robinson (in-kind project management services) $4,800 Let's Grow Hilo $400 TOTAL: $23,450 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This request provides seed money for the LGH Sustainability Plan, which includes staging the Hilo Harvest Fest as well as the publication and printing of materials that will be sold to provide income. At the festival, food harvested from the gardens will be served to the community as a means to educate the public and recruit volunteers. Throughout the year, cookbooks featuring recipes with plants grown in the gardens and items that can be purchased with vouchers from the WIC program will be printed and sold. Walking maps for self-guided tours of the gardens will be printed and given away, but a packet which includes the map and postcards featuring garden vignettes will be offered for sale. The postcards will also be sold separately. Downtown businesses will be recruited to support the festival and help market the products. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Keep Hawaii Beautiful Program Name: Let's Grow Hilo Sustainability Plan 7. Program Objectives Using County Nonprofit Grant Program Funds: The program objective is to implement the LGH sustainability plan so that by the end of the grant period, the organization is self-sufficient and it can continue to serve Downtown Hilo businesses along with clients of Tutu & Me, Catholic Youth Charities, the Girl/Boy Scouts, the Boys & Girls Club, First-2-Work, Under His Wings and the WIC, Second Chance and STEP programs. During the year, a paid coordinator will oversee the development of marketable products; she will also work to establish the Hilo Harvest Fest as a self-sustaining event. 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) Publication/distribution of self-guided tour maps 1000 produced/distributed Publication/sale of cookbooks 300 produced/distributed Printing/sale of postcards 4000 printed/distributed Production of Hilo Harvest Fest 800 attendees Increased volunteer participation +40 volunteer hours/month Increased food production +500Ibs/year Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $14,400 $9,600 Professional Fees Operations $1,000 Supplies $800 $400 Equipment Other: prin+in cr $8,250 $4,000 Other: Other: Other: Other: TOTAL $23,450 $15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Keep Hawaii Beautiful Program Name: Let's Grow Hilo Sustainability Plan 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: V,e.v.1"-ch,`l M NS POSITION: ylµ(Z� ..ak4 ..IF.:a-1;>,c� c t_ 1si(--\-12 p�S„tL=S< May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): 0 No conflicts exist(No further information required. Please sign form at the bottom.) 0 Member or members of the Council ElviStaff appointed by a member of the Council The Mayors 'E-T�c-. mss. 1 1 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: 111111111W411 z Signatur= • -Authoriz- •erso (specify Date EXHIBIT A -- NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Keep Hawaii Beautiful Program Name: Let's Grow Hilo Sustainability Plan 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 Hawai'i Compliance Express, and be compliant prior to final payment. To register,go to l :Tta://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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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:/jwww.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 30,2014 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. aKe91 Signature of u -°o 'r zed Person` Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Keep Hawaii Beautiful Program Name: Let's Grow Hilo Sustainability Plan 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Publication/distribution of self-guided tour maps 1000 Publication/sale of cookbooks 300 Printing/sale of postcards 4000 Production of Hilo Harvest Fest 800 attendees Increased volunteer participation +40vh/mo Increased food production +500lbs/yr TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages $9,600 Professional Fees Operations $1,000 Supplies $400 Equipment Other: 'pr n-Fc.rl $4,000 Other: Other: Other: Other: TOTAL $15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 :i Kohala Animal Relocation and Education Service (KARE S) Canine Spay and Neuter Program Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter Program - w. Agency Director: Deborah Cravatta, President and Founder Phone No.: (808) 333 — 6299 Contact Person: Phone No.: (808) 333 — 6299 Mailing Address: Address: Kohala Animal Relocation and Education Service (KARES) Address: P.O. Box 44670 City,s-r,Zip Kamuela, Hawaii 96743 Facility Address: Address: Kohala Animal Relocation and Education Address: 59-241 Kipa Mai Place City,ST,Zip Kamuela, Hawaii 96743 Email Address: pets @kohalaanimal.org Fax No.: (808) 880 — 1925 Accountant/CPA: Randall Macaluso Phone No.: (808) 881 — 1040 Firm (if applicable): Kamuela Taxpros (EN 45-2888877) Mailing Address: Address: 65-1190 Mamalahoa Highway Address: City,ST,Zip Kamuela, Hawaii 96743 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 $12,500 2.Agency Mission Statement: The interest to establish a "no kill" philosophy organization led to the creation of KARES. KARES' primary focuses are community education and relocation of healthy, adoptable animals throughout the entire island of Hawaii. KARES believes that by bringing knowledge and awareness of the causes of overpopulation and providing humane alternative solutions are the keys to changing the attitudes towards dealing with the animal overpopulation problem. KARES provides cat and dog food to low income families and to homeless people who might otherwise surrender their companion animals to shelters because they cannot afford to feed them. KARES works with veterinarians to offer low cost or no cost spay/neuter for pets of low income residents, establishes trap/neuter/release and maintain programs with feeding stations for feral cats, and maintains a network of volunteers to foster cats & dogs until they are safely adopted. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter Program 3. Program Description: Provide free or affordable (low cost) spay and neuter(S/N) surgeries for 330 companion dogs that are owned by low income or economically troubled families who cannot afford these services, however, we never will turn anyone away because the goal is to humanely control the overpopulation of dogs. S/N surgeries will primarily be performed in clinics that KARES hosts in order to make these services readily available within various communities throughout the island. In 2010 we supported S/N of 100 dogs, a total of 356 in 2011, a total of 670 in 2012 and plan to assist pets of low income residents with S/N of 850 dogs in 2013, depending on available funding. 4.Total Budget& Position Count: Total Program Budget: $123,000 Total Program Position Count: 10 volunteers Total Agency Budget: $175,000 Total Agency Position Count: 30 volunteers 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate (1) applications will be submitted in 2013 or (2) anticipated revenue sources Corporate Foundations (e.g. Petco Foundation) - restricted for canine S/N 25,000 Private Foundations (e.g. DJ&T Foundation) - restricted to companion dog S/N 35,000 Community Foundations and/or County of Hawaii Grant 35,000 Private Donors 25,000 Fund raisering events (dog washes, garage sales) 3,000 TOTAL: 123,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: KARES will continue to apply for community, corporate/private foundation grants. In past years most of our grants have been awarded by Mainland USA organizations to support our Hawaii Canine S/N Program. As we have exceeded performance expectations for this program we will request renewed and increased funding. In 2012 we obtained our first grant from the County of Hawai'i. We feel it is imperative to gain even greater financial support from our own Hawai'i Island community to help with this important work. Furthermore, each year since 2009 KARES has realized almost a 100% increase in private donations as people become aware of our service contributions to the people and animals of Hawai'i. These KARES' Programs also include animal rescue, foster care/adoptions and the Pet Food Bank. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter Program 7. Program Objectives Using County Nonprofit Grant Program Funds: The KARES Canine S/N Program objectives are intended to benefit the people of Hawai'i by 1) making available free or low cost S/N surgeries for their pets, an expense that many 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) to reduce the number of feral dogs which cause damage to property and livestock and could cause potential health risks to humans due to bites and the spread of disease. 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.) Please see attached page for Performance Measures & Results Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees Please see attached Operations pages for Table 11 Supplies Equipment Other: Other: Other: - Other: Other: TOTAL *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 a' V) o o 2 C a0 L .0 -0 C CU a)U 00 O C > a) 4- O O 2 c a1 O Y °� `^ 3 L t M ri L a) 9- o • M O L V1 C r+ "' N p !6 ++ E U a•, 'O O , CO Q 7 c �' a) a'' vt 4- ,� C ate) 0 O C O E a) a) N C O U O to > _O a) L M L O. t10 ate-, C .co C C N — L 1O ,'•'� Y ri O v N ,,,° O -Q C O co (n _) = •L L C ° a) C O C E I�i1 L o0 0 O a) C v1 V1 4-, L N W L C O L 4- 4a 0 a) a) Q > f(0 .� A U •C coo s0+ •L Q (-6 (0 N a) L p °' y,, of co U) Q of a) c U a) 00 > — ca O 4O N M O 4- O. 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Q - M o 0 O c .Q N +� O n a1 Ol M co c Q co �+- v- L o E p N .0 .0 0 C9 Co` OA ++ p I a) z C U *' C av o 0 O O )a) a — v1 a) >" WD m c U D C1 Q. _ _ � c > v1 X p p '3 4-- O c > c z t0 Z W Z o O •L 0 - 4-' a) N z w c c O a) N 00 N 0 = v• u fB - cr a°�p O 4-' QJ Cl) F-- c ?� O = to —°7 Y � v L Ca > V) '5 a a c E • s_ m .0 p O cv i o > < C. F F— 4-- as E— O u- ,e 0 u. a (D Z 713 al Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter Program 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: No conflicts exist POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): j No conflicts exist(No further information required. Please sign form at the bottom.) I I Member or members of the Council Staff appointed by a member of the Council The Mayor 17 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: 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 riot 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 exits. /- 22 —/3 Signature of Authorized Person (specify title) Date EXHIBIT A A l/1 A 1111111 r 1T f"1-3A All" A n f l tr.A7-1/1/1/41 r V'1/1'1'1 '1111 A fl...... ,l -s Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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 Pers. (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES I FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 CZ Kona Adult Day Cener, Inc Adult Day Care Agency Name: KONA ADULT DAY CENTER, INC. Program Name: ADULT DAY CARE Agency Director: ROWENA L.TIQUI Phone No.: (808) 322 — 7977 Contact Person: ROWENA L. TIQUI Phone No.: (808) 322 — 7977 Mailing Address: Address: p. 0. BOX 1360 Address: City,ST,Zip KEALAKEKUA HI 96750 Facility Address: Address: 81-989 HALEKII STREET Address: City,ST,Zip KEALAKEKUA HI 96750 Email Address: KADCROWENA @HAWAII.RR.COM Fax No.: (808) 322 — 0614 Accountant/CPA: RONALD G. HAWKES Phone No.: (808) 939 — 7392 Firm (if applicable): CERTIFIED PUBLIC ACCOUNTANT Mailing Address: Address: P. 0. BOX 2030 Address: City,ST,Zip KEALAKEKUA HI 96750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $15,000.00 $15,000.00 $15,000.00 2.Agency Mission Statement: "Our mission is to provide social and recreational programs and activities that enable impaired adults to experience feelings of belonging, friendship, acceptance, accomplishment and independence in a caring and secure social environment". EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: KONA ADULT DAY CENTER, INC. Program Name: ADULT DAY CARE 3. Program Description: Kona is the only non-profit adult day care in West Hawaii. Kona Adult Day Center, Inc. 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 525 families in our community. Kona Adult Day Center is a community based group that is designed to meet the needs of functionally impaired adults through an individual plan of care. 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 less than 24 hours. Day Care allows caregiver's to continue working. Day Care provides a more cost effective program than home care or institutionalization. 4.Total Budget&Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 5 Total Agency Budget: $25,000.00 Total Agency Position Count: 5 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Fundraising/Membership Drive/Fees for Services $20,000.00 Hawaii Island United Way $15,000.00 Kupuna Grant- Office of Aging / OHS $57,000.00 Charity Walk - Hotel Industry $5,000.00 Ironman Grant $ 3,000.00 Donations/Private Pay $95,000.00 Teresa Hughes -Administrative Fees $3,000.00 TOTAL: $198,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will continue to apply for grants where ever we can find them. We will plan our fundraiser to attract more people. Increase our census especially those who can pay privately. Seek donations through a membership drive. Increase awareness of the services we have to offer. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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: For Individuals: a) Mentally and physically impaired adults are maintained at their highest level of functioning, thus preventing or delaying futher deteriation. b) Maximum level of independence is assessed and maintained through individual care plan. c) Client is able to associate with a place and a group. d) Caregivers have access to elderly services. e) Defer premature or inapropriate institutionalization. f) Isolation is reduced. For Caregivers: a) Respite. b) Continue working. c) Safe and secure environment. For Community: Long term continuum 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.) Maintain participants at home for 6 month minimum 95%Maintain Maintain or improve interaction skills 95%Maintain Maintain or improve hygiene and self care 95%Maintain Survey of caregivers satisfaction 95%Satisfaction Have intergeneralization interaction w/community groups 2x month 95%Satisfaction Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Re q Salary and Wages 127693 130000 Professional Fees 4451 4500 4500 Operations 52280 53000 12500 Supplies 6235 6300 6250 Equipment 3025 4000 Other: -�`p ,5 !. 44812 44900 Other: ` � , � � 15922 16000 Other: ks.k-t-n�- �s 17464 18000 1750 Other: Other: TOTAL 271882 272700 1250 25000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: KONA ADULT DAY CENTER, INC. Program Name: ADULT DAY CARE 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 conflict is needed. 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): 0 No conflicts exist(No further information required. Please sign form at the bottom.) 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: wow- .. V 1 Signature o Authorized P= son -•ecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: KONA ADULT DAY CENTER, INC. Program Name: ADULT DAY 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, 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://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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. + 4 ►--` v _I Signature of Authori ed IP (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: KONA ADULT DAY CENTER, INC. Program Name: ADULT DAY CARE 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Maintain participants at home for 6 month minimum 95%Maintain 95%Maintain Maintain or improve interaction skills 95%Maintain 95%Maintain Maintain or improve hygiene and self care 95%Maintain 95%Maintain Survey of caregiver's satisfaction 95%Satisfactio 95%Satisfactio Have intergeneralization interaction w/community groups 2x month 95%Satisfactio 95%Satisfactio TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 4500 Operations 12500 Supplies 6250 Equipment Other: Other: Other: (.k..c.\ ES .4- , c. cL..-�--� 1750 Other: Other: TOTAL 25000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 gON Kona Historical Society Living History Program Operations Agency Name: Kona Historical Society Program Name: Living History Program Operations Agency Director: Jill R.Olson Phone No.: (808) 323 — 3222 Contact Person: Ku'ulani Auld Phone No.: (808) 323 — 3222 Mailing Address: Address: Kona Historical Society Address: P.O. Box 398 city,sr,Zip Captain Cook, HI 96704 Facility Address: Address: Kona Historical Society Address: 81-6881 Mamalahnha Hwy City,ST,Zip Kealakekua, HI 96704 Email Address: khs @konahistorical.org Fax No.: (808) 323 — 2398 Accountant/CPA: Renee Gronwall, Finance Manager Phone No.: (808) 323 — 3222 Firm (if applicable): Mailing Address: Address: Kona Historical Society Address: P.O. Box 398 City,ST,Zip Captain Cook, HI 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 $10,000 $8,000 Fy 0- -l3 q 2-50 2.Agency Mission Statement: The Kona Historical Society will preserve the history of Kona to enrich, inspire, and inform our community and visitors. We will do this through collecting, preserving, researching, interpreting, and disseminating the history of Kona, emphasizing the period from 1779 to the present. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Kona Historical Society Program Name: Living History Program Operations 3. Program Description: KHS has two unique sites and three great Living History programs: 1. Kona Coffee Living History Farm (D. Uchida Farm), is a 6-acre 1920's era coffee farm in Captain Cook, which was homesteaded by Japanese immigrants from 1913-1994. The farm interprets the history of Kona's Coffee Pioneers and their family values, independence, and resourcefulness. 2. H.N. Greenwell Store, an 1890's general store in Kealakekua, was founded by H.N. Greenwell, an English immigrant. The Store presents typical 19th century shopping experiences using actual multi-cultural customers from the period. 3. The authentic community-size Portuguese stone oven, is used to bake traditional bread. Each Thursday, visitors and residents gather to help with the bread making, which is sold to customers that day. 4.Total Budget&Position Count: Total Program Budget: 251,404 Total Program Position Count: 18 Total Agency Budget: 462,930 Total Agency Position Count: 22 S.Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Site Tours and Admission Fees 74,380 Gift Shop Sales 17,491 Coffee Sales 41,338 Coffee Crop Income 25,000 Bread Sales 30,000 Farm Special Event 1,900 Donations 16,800 TOTAL: Cont Next Page Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Visitor numbers continued to increase in 2012, and the first month of 2013 has again been a good month in terms of program participation. We expect a corresponding increase in coffee and gift sales, which our 2013 budget reflects. Coffee sales are still not projected to be at the 2009 level, but they are improving. Our updated website has seen increasing traffic in terms of online gift shop and coffee sales, and we are continuing to regularly publicize special programs. In 2013, we intend to increase marketing efforts with the support of a new Executive Director, who will come on board in February 2013. Her expertise in marketing and public relations are expected to make a difference in our visitor participation and sales. The 2013 revenue projections are ambitious, but we're optimistic that we'll reach our targets this year. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Kona Historical Society Living History Program Operations Page 2, Item #5 Continued Revenue Source FY13-14 Estimate State Grants 19,500 County of Hawaii Grants 15,000 Other Grants 5,000 Investment Income 4,995 TOTAL: 251,404 NONPROFIT GRANT APPLICATION FISCAL YEAR 2013-14 PAGE 2-A Agency Name: Kona Historical Society Program Name: Living History Program Operations 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Provide authentic, thoroughly researched and engaging programs at historic sites. 2) Demonstrate how coffee was grown, picked and processed during the 1930's with the participation of all family members. 3) Convey the history of 1890's multi-cultural Kona ranching and mercantile community. 4) Educate visitors to create an understanding of and appreciation for Kona's diverse history. 5) Demonstrate the themes of sustainability, family values, and indepence at KHS sites. 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) Number of adult visitors at historic sites 6200 Number of School Children at historic sites 1000 Attach additional pages as necessary. 9.TABLE II: I cv i 2-43 I cY 13-111 FY 13-14 I PROGRAM EXPENDITURES Actual' Total Budget Grant Reg Salary and Wages 107,250 110,449 6,000 Professional Fees 31,503 38,500 Operations 29,204 35,055 7,000 Supplies 26,254 26,718 2,000 Equipment o o Other: 17,558 21,800 Other: Other: Other: Other: TOTAL 211,769 232,522 15,000 if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Kona Historical Society —Agency Name Living History Program Operations — Program Name Explanation of Program Expenditures on Page 3, Item 9. Table II FY 12-13 FY 13-14 Other: Employee Benefits 17,558 21,800 This expense includes employee Medical Insurance, FICA taxes, and Worker's Compensation Insurance NOTE: Kona Historical Society's fiscal year runs from January through December. Therefore Program Expenditures shown on Page 3 are: FY 2012 (Actual) FY 2013 (Total Budget) NONPROFIT GRANT APPLICATION FISCAL YEAR 2013-14 Page 3-A Agency Name: Kona Historical Society Program Name: Living History Program Operations 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 conflict is needed. 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): 7/1 No conflicts exist(No further information required. Please sign form nt the hottom.) _ Member or members of the Council _ Staff appointed by a member of the Council _ The Mayor The i I`ie i RviPdi(aging 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: , President, Board of Directors /) 29 — I3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Kona Historical Society Program Name: Living History Program Operations 11. Certification of Understanding (we) have read and understood all of the- cii5hiuii.y 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 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 (wet understand and will comply with the reouirement 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.govith-nomarofit-grant-forms/on or about May 30 of the year the final report is due. of i i__ funds awarded � r the 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, 2014 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. ate President, Board of Directors 2q- 13 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Kona Historical Society Program Name: Living History Program Operations 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of adult visitors at historic sites 6200 Numbr of School Children at historic sites 1000 TABLE II: PROGRAM EXPENDITURES FY 13-14 Coundl III Grant Request I Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 M Kona Literacy Council Kailua Learning Center Agency Name: Kona Literacy Council Program Name: Kailua Learning Center Agency Director: Brenda Natina Phone No.: (808 ) 329 — 1180 Contact Person: Brenda Natina Phone No.: (808) 329 — 1180 Mailing Address: Address: Kailua Learning Center Address: 75-5766 Kuakini Hwy. 106A city,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: Same Address: City, ST,Zip Email Address: konalit @msn.com Fax No.: ( ) — Accountant/CPA: None Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $2,000 $2,000 $3,125 2. Agency Mission Statement: The Kona Literacy Council's trained volunteer tutors help any adult increase their basic reading, writing, math and communication skills to enable the learners to become better family members, workers, community members and lifelong learners. EXHIBIT A ninnuDa(1GITc PAMT ADP ICtTIfnI GV 7f1q_7r11d Paai 1 of 7 Agency Name: Kona Literacy Council Program Name: Kailua Learning Center 3. Program Description: Kona Literacy Council's trained volunteer tutors provide free, one-to-one, small group, and computer-assisted literacy services at the Kailua Learning Center to any adult who wants to improve their basic reading, writing, and computation skills. Special programs designed to meet the specific needs of the learners are offered, such as: English as a Second Language, preparation for passing the GED or Competency Based High School Diploma, Citizenship preparation, and keyboarding. All tutoring is at no cost to the student. Some of the 600 students, who have had lessons at the Kailua Learning Center since it opened in September 1992, have made progress in their basic skills; some have learned English, gained their High School Equivalency Diploma, passed the Citizenship exam, and have gotten better jobs. 4. Total Budget& Position Count: Total Program Budget:g g $5,250 Total Program Position Count: 0 Total Agency Budget: $5,250 Total Agency Position Count: o 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County Grant $2,500 Young Brothers Tug & Barge $1,500 lronman $1,000 Federal Pacific Campaign $500 TOTAL: $5,500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Kona Literacy Council plans to participate in more fundraising and grant proposal writing to keep the doors of the Kailua Learning Center open. Since we do not charge our clients for our literacy services, we will have to continue to rely on the generosity of our community Supporters. EXHIBIT A M(lr\IDRnGIT( PMT 1DDI ICdTifni cv 2_7(11d DnaA ) of 7 Agency Name: Kona Literacy Council Program Name: Kailua Learning Center 7. Program Objectives Using County Nonprofit Grant Program Funds: Continue to provide free one-to-one and small group literacy services at the Kailua Learning Center to any adult who wants to improve their basic reading, writing, and computation skills. Continue recruiting and training new tutors. Continue networking with community agencies to provide free literacy assistance to their clients, such as: Dept.of Human Services, First to Work, Kona Corn. School for Adults, Alternatives to Violence, the public libraries, and court ordered participants. Offer pre-employment skills, pre-GED, driver's license and Citizenship preparation. 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results 1 (I.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific) ESL (2 Japanese - small group), 1 Russian, 2 Thai 1 hr per week Increase English proficiency TESL (3 Japanese- small group) 2 hr per week Increase English proficiency Spelling & Writing (2 students) 1 hr each per week Write & spell better Citizenship preparation (1 Thai & 1 Mexican) 1 hr each per week Become Citizens Competency Based HS program (1 woman) help with homework get High School Diploma Help illiterate man with homework for Alternative to Violence pro. keep out of jail Job readiness (2 men, 1 woman) 1 hr each per week get job Attach additional pages as necessary. 9. TABLE H: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages 0 0 0 Professional Fees 0 0 0 Operations 4,150 4,150 2,200 Supplies 400 400 100 Equipment 0 200 0 Other: 500 500 200 Other: --- — — ---- Other: Other: Other: . TOTAL 5,050 5,250 2,500 *If applicable EXHIBIT A NIniVPPnrIT(:RAMIT ADP! I("1TI(INI pr 7n1 z_7n1a Pawn 2 of 7 CONTINUATION OF PAGE 3 TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results • 3 Volunteer Tutors approx. 450 hrs. Keep tutoring 5 Volunteer Auxiliary personnel approx. 350 hrs. Continue 1 Provided court ordered community service Continue 3 Board and General Membership meetings per yr. Continue 3 Newsletters per year Continue Agency Name: Kona Literacy Council Program Name: Kailua Learning Center 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 conflict is needed. 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): I No conflicts exist (No further information required. Please sign form at the bottom.) 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 'At. . . -' Ti't l Signature of A uthorized Person (specify title) Date EXHIBIT A Nr11\11:MCWIT(,RANT APP! Ir'ATIMI ry- n1 Q_7nh a Pnao, of 7 Agency Name: Kona Literacy Council Program Name: Kailua Learning 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, 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 '; :.: ://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 shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of ail 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A MIMIPR(IGIT f,RArIT ADP! ICATIMI PV 7(112.)1114. 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 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 1� �, `� � ,I�; ���I, �� E,�rl , :� c �.� ' 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, 2014 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. / ‘'//t- //;;_ //7:4,(GL 'Signature of Authorized Person (specify title) Date EXHIBIT A NInKIPPC IT(:1ThhIT 1 PPI IrdTlnJ{ PV 7n1 2_7(11A PaaP F;of 7 M Ku'ikahi Mediation Center Community Mediation Services Agency Name: Ku'ikahi Mediation Center Program Name: Community Mediation Services Agency Director: Julie Mitchell, Executive Director � Y Phone No.: (808) 935 — 7844 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: 101 Aupuni Street, Suite PH 1014 B-2 Address: City,sr,Zip Hilo, HI 96720 Facility Address: Address: Same Address: City,ST,Zip Email Address:julie@hawaiimediation.org Fax No.: (808) 961 — 9727 Accountant/CPA: Rozanne Connell Phone No.: (808) 968 — 1002 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 Amount of Request for County Nonprofit Grant Program Funds: $15,000 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $1 $,000 $15,000 $11 ,000 2.Agency Mission Statement: Our mission is to provide a safe environment, an impartial process, and skilled, trained personnel for the delivery of affordable dispute prevention and resolution services to the East Hawai'i community. Ku'ikahi Mediation Center is the sole non-profit mediation center serving East Hawaii and one of only five in the state. We provide mediations for a wide variety of cases, including domestic cases (e.g., divorce/property and child custody/visitation); civil cases (e.g., neighbor-to-neighbor and business); small claims cases (e.g., consumer/merchant and landlord/tenant); and specialized cases (e.g.,foreclosures referred by the Third Circuit Court, discrimination referred by the Hawaii Civil Rights Commission, and special education referred by the Department of Education). Our agency helps individuals, families, organizations, businesses, schools, and others to find creative solutions to challenging situations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Ku'ikahi Mediation Center Program Name: Community Mediation Services 3.Program Description: Mediation is a self-empowering, flexible process that allows people to arrive at enduring resolutions to conflicts. The parties themselves control the outcome, so solutions come from within rather than without. Mediation agreements tend to be more durable than court orders since there is greater buy-in by the participants. These mutual resolutions tend to be long lasting and help to improve relationships, promote understanding, and ultimately strengthen our community. Our community mediation services are provided on a sliding scale fee schedule, and no one is turned away for lack of funds. Over 50% of our clients have annual household incomes of under$20,000. Our community mediation services are often the only option for those with low or no incomes to resolve conflicts and move on with their lives. 4.Total Budget&Position Count: Total Program Budget: 154,000 Total Program Position Count: 3 Total Agency Budget: 154,000 Total Agency Position Count: 3 5.Program Funding Sources(identify All sources of funding applied to this oroeram): FY13-14 Revenue Source Estimate Direct contributions 7,000 United Way contributions 10,000 Hawai'i Justice Foundation grant (4K) & Omidyar'Ohana Fund grant (25K) 29,000 County of Hawaii Nonprofit grant 15,000 Hawai'i State Judiciary contract 43,000 Mediaton fees & training revenue 25,000 Fundraising & special events revenue 25,000 TOTAL: 154,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1) Hold regular community workshops to raise revenue via tuition. 2) Launch an annual fund drive to raise revenue via direct contributions. 3) Market our services to local businesses, schools, associations, and other community organizations to raise revenue via mediation, facilitation, and training fees. 4) Research and apply for new grants to increase revenue from foundations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Ku'ikahi Mediation Center Program Name: Community Mediation Services 7.Program Objectives Using County Nonprofit Grant Program Funds: 1) Provide low-or no-cost mediation services to self-, community-, and court-referred clients. 2) Provide a critical alternative to litigation, especially for those who cannot afford legal counsel and/or have a hard time navigating the legal system as pro se litigants. 3) Offer continuing education to our volunteer mediators in the form of trainings and workshops. 4) Promote peaceful solutions in the East Hawai'i community. 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 mediation cases served 300 Number of mediation clients served (unduplicated) 600 Number of mediation sessions held 250 Number of mediator volunteer hours donated 600 Number of non-mediator volunteer hours donated 400 % 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 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES lkotont* Total Budget Grant Reg Salary and Wages-' 113,000 83,000 9,000 Professional Fees 17,000 10,000 1,000 Operations 45,000 30,000 4,500 Supplies 7,000 5,000 500 Equipment 15,000 20,000 0 Other: .fir ogAtSt1JCi— 6,000 6,000 0 Other: Other: Other: Other: 11.3GWO - c€3 pte.ktril Q!1 -- TOTAL 203,00r 154,000 15,000 1213 egPeN o IT-V 3 A,u 1-1 tCrYC DOE-1-0 f} *lf applicable * — yt W r f M y &- p (s 0&ce 71-4-C1/2- Assr ,-nWCx pizoGaltuvk EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Ku'ikahi Mediation Center Program Name: Community Mediation Services 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 conflict is needed. 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): IN No conflicts exist(No further information required. Please sign form at the bottom.) 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: /6.1„,(---- ?l (3 Signat uthor' ed Person (specify title) Date a A-t pv ,Di EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Ku`ikahi Mediation Center Program Name: Community Mediation Services 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 Countvl and exclusion from future grant oarticipption for a minimum of one year or until a written report is submitted to.qnd 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, 2014 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 .3(/(3 Signs re of Auth• 'zed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Ku'ikahi Mediation Center Program Name: Community Mediation Services 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of mediation cases served 300 Number of mediation clients served (unduplicated) 600 Number of mediation sessions held 250 Number of mediator volunteer hours donated 600 Number of non-mediator volunteer hours donated 400 % of clients who are satisfied with the mediation process 90% % of clients who would consider recommending mediation to others 90% TABLE II: FY 13 PROGRAM EXPENDITURES -14 Council Grant Request Award Salary and Wages 9,000 Professional Fees 1,000 Operations 4,500 Supplies 500 Equipment 0 Other: p 2.Prt.S k".3 0 Other: Other: Other: Other: TOTAL 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 C �� Legal Aid Society of Hawaii Removing Barriers for HI County's Vulnerable Population Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for HI County's Vulnerable Population Agency Director: M. Nalani Fujimori Kaina, Executive Director Phone No.: (808) 527 — 8014 Contact Person: Joanna E. Sokolow, Managing Attorney, Kona Office Phone No.: (808) 329 — 3910 Mailing Address: Address: 924 Bethel Street. Address: City,ST,Zip Honolulu, HI 96813 Facility Address: Address: 75-5656 Kuakini Hwy, Suite 202, Kailua Kona, HI 96740 Address: 305 Wailuku Dr., Hilo, Hawaii 96720 City,ST,Zip Email Address:josokol @lashaw.org Fax No.: (808) 334 — 9650 Accountant/CPA: Wayne Keawe, Comptroller Phone No.: (808) 527 — 8060 Firm (if applicable): Mailing Address: Address: Legal Aid Society of Hawaii Address: 924 Bethel Street City,sr,zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $40,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0 $0 $0 2. Agency Mission Statement: The Legal Aid Society of Hawai'i (Legal Aid), a community-based, nonprofit law firm has empowered low-income and disadvantaged people throughout our state for over 60 years. It is the only legal service provider in the state, and one of the few non-profits, with statewide coverage through ten offices on each of the islands, from Lanai to urban Honolulu. Legal Aid Society of Hawaii has two offices on the island of Hawaii. The Hilo Office was original estabilished in the 1950's by the County of Hawaii as a legal aid/public defender program. Legal Aid assumed operation and is now a vital part of the Hilo community providing free legal assistance to low-income individuals and families on the East side of Hawaii. Legal Aid opened its Kona Office in 1979 with one paralegal. The Kona office has since grown and similarly to the Hilo Office provides assistance in the areas of consumer, family, public benefits, housing, and senior law cases. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for HI County's Vulnerable Population 3. Program Description: Legal Aid requests $40,000 in funding to provide critical civil legal services in the Hilo and Kona Offices ($20,000 allocated to each office). As the demand for Legal Aid's services increases, the organization faced a dramatic reduction in funds from major funding sources, including Legal Services Corportation, Legal Aid's largest funder. Now, more than ever, Legal Aid needs support to continue to provide access to justice for Hawaii's low to moderate income individuals and families. In most areas, Legal Aid is the only provider of legal services to these populations in all of Hawaii County. See attached continuation page 1. 4.Total Budget& Position Count: Total Program Budget: 40,000 Total Program Position Count: 10 Total Agency Budget: 6,304,499.00 Total Agency Position Count: 88.5 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii Island United Way 18,000 Hawaii County Office of Aging-Title III-E 72,296 Judicial - Guardian Ad Litem 48,000 Fee for Service 12,000 Federal Funding 12,500 TOTAL: 162,796 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 for federal, state, and other grants to provide services to low-income individuals and families in need. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for HI County's Vulnerable Population 7. Program Objectives Using County Nonprofit Grant Program Funds: Under this grant, in FY14, Legal Aid will provide screening, intake, counsel and advice, brief services and/or full representation in 75 cases. The services will be provided free to low-income individuals and families whose incomes are less than 125% of the poverty level. See attached continuation page 1 for breakdown of cases per individual subject area. 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.) 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 II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 35,500 Professional Fees Operations 4,500 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for HI County's Vulnerable Population 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 conflict is needed. 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): Q No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: 1/LS/i3 Signature o Ized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for HI County's Vulnerable Population 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. 025( 13 Signature of A Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Legal Aid Society of Hawaii Program Name: Removing Barriers for HI 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: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 35,500 Professional Fees Operations 4,500 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: Legal Aid Society of Hawaii Project Name: Removing Barriers for Hawaii County's Vulnerable Population 3.Program Description (Continued) According to the 2010 American Community Survey,more than 13.92% of Hawai'i's population lives below 125% of the federal poverty guidelines and is eligible for Legal Aid's services based on their income. Through this grant Legal Aid will provide critically needed legal services, community education and outreach services 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 a consumer problem 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 barriers to being homeless • Secure appropriate placement and services for abused and neglected children • Provide critical legal services to assist immigrants and those in need of language access. 7. Program Objectives (Continued) Breakdown of projected number of cases per subject area: 1. Provide support for families (100 cases): Assist clients with child custody, child support, domestic violence,visitation, divorce, property division and in some cases ex-military spouse issues. 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. 2. Keeping children safe and secure (5 cases): Provide guardians ad litem services for abused and neglected children; 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 (10 cases): Assist clients with private landlord eviction defense or negotiation; foreclosure assistance; mortgage predatory lending practices, housing discrimination;public housing applications, evictions, grievances, rent issues, and security deposits; and, habitability, repairs, illegal lockouts, or illegal utility shutoff. 4. Maintaining economic stability (100): Provide assistance with denials, appeals and terminations of SSI, General Assistance, Temporary Assistance for Needy Families (TANF), SNAP (fka Food Stamps) and other public benefit programs. 1 Agency Name: Legal Aid Society of Hawaii Project Name: Removing Barriers for Hawaii County's Vulnerable Population 5. 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. 6. Protecting consumers (5): Assist clients with consumer issues including predatory lending, debt collection,bankruptcy, consumer credit matters, repossession, and unfair or deceptive practices. 7. Promoting safety, stability and health (20): 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. Hilo Kona Total Support for Families 217 246 463 Keeping Children Safe and Secure 19 17 36 Preserving the Home 41 43 84 Foreclosure Prevention 0 2 2 Maintaining Economic Security 333 137 470 Protecting Consumers 35 15 50 Promoting Safety, Stability and Health 179 42 221 Program Highlights In FY2012, the Hilo and Kona offices assisted in more than 1,291 cases and families on the island of Hawaii with their civil legal needs. Hilo and Kona assisted over 294 people with the denials, appeals or terminations of their SSI benefits. Because of the lack of affordable legal services in Hawaii County, without the assistance of Legal Aid, many of these individuals' cases could result in homelessness, abuse of a child or domestic violence victim, or financial instability. In the most recently quarterly client satisfaction surveys, 100% of clients surveyed rated Kona Legal Aid's service as"excellent," and 80% of clients surveyed rated Hilo Legal Aid's service as "good" or"excellent."The impact of Legal Aid's services upon the community is best exemplified from client testimonies: - I am very happy! Mahalo nui loa. Awesome service &wonderful help. Charles is continuously helpful. - Great job. I am very happy with your work 100%. Thank you very much. - LASH treated me with respect and helped me understand all my paper work clearly. The results were more than I expected. Great people, great service. Mahalo! - Everything was perfect services, excellent and Donald Thomas was very compassionate and professional. Helpful always. - Joanna Sokolow and Charles McCreary are exceptional. 2 Lyman Museum Education and Public Programs Agency Name: LYMAN MUSEUM Program Name: EDUCATION AND PUBLIC PROGRAMS Agency Director: Barbara Moir Phone No.: (808) 935 — 5021 Contact Person: Barbara Moir Phone No.: (808) 935 — 5021 Mailing Address: Address: 276 Haili Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 276 Haili Street Address: City,ST,Zip Hilo, HI 96720 Email Address: bmoir @lymanmuseum.org Fax No.: (808) 969 — 7685 Accountant/CPA: Alex Smith, CPA Phone No.: (808) 737 — 7761 Firm (if applicable): Mailing Address: Address: 1403 Frank Street Address: City,ST,zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of . Nonprofit Grant Program F FY 99-10** (0 - i� FY 10 1 tl— IZ FY • $20,000 $10,000 $8,000 2.Agency Mission Statement: "To tell the story of Hawai'i, its islands and its people." The Museum exists to: Collect, preserve, and exhibit artifacts, artwork, and memorabilia relating to the culture, art, and historical heritage of Hawai'i; Educate and encourage awareness in these areas through visually exciting and interpretive exhibitions, informative tours, special programs, and activities; Serve as a learning resource center for those seeking information, entertainment, and knowledge; Fully extend itself to the public in order to instill community pride and support; Maintain a high standard of excellence and professionalism, seeking to improve, progress, and realize its full potential as a museum. (See also Appendix 1) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: LYMAN MUSEUM Program Name: EDUCATION AND PUBLIC PROGRAMS 3. Program Description: Education and Public Programs at the Lyman Museum both reaches out to the community and draws it into the Museum, to "tell the story of Hawai'i, its islands and its people" through programs, events, and activities that educate and encourage involvement by the public. Such efforts include focused educational tours and other learning activities for students; docent training for school and public tours;dissemination of information to teachers about Museum school-related programs, along with planning assistance; an annual agenda of lectures, demonstrations, performances, workshops, and other presentations for the community; and public programming specifically linked to traveling and special exhibits at the Museum. 4.Total Budget& Position Count: Total Program Budget: 88,403 Total Program Position Count: 7* Total Agency Budget: 532,301 Total Agency Position Count: 11 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Private donation for public programming 10,000 Friends of Hawaii Charities grant 5,000 County Nonprofit Grant 12,000 Lyman Museum Operations funds (earned income, donations, endowment 61,403 allotment) TOTAL: 88,403 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: By offering a regular calendar of highly regarded public programs, scheduled and prominently publicized in advance, the Museum anticipates being able to increase paid memberships which allow free or reduced-cost admission to such programs. Educational services to students, on the other hand, are never self-sustaining in that they are offered as a public service. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: LYMAN MUSEUM Program Name: EDUCATION AND PUBLIC PROGRAMS 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Conduct curriculum-appropriate school tours and other learning activities for student groups of any grade level 2) Provide Big Island teachers with information and one-on-one assistance 3) Train docents to lead school/public tours appropriate to different age groups 4) Provide semi-monthly public lectures,performances, workshops, and other presentations 5) Develop and present special public programming for each traveling and special exhibit 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.) Service students with school tours and workshops 2300 Train new docents for school tours 4 Provide public programs 35 Service community members with public programs 1300 Provide teachers with information and assistance 280 Conduct educational workshops for students/public 18 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Re q Salary and Wages 70,070 64,553 10,000 Professional Fees 4,225 0 0 Operations 22,000 23,000 1,150 Supplies 0 150 150 Equipment 0 700 700 Other: Other: Other: Other: Other: TOTAL 96,295 88,403 12,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: LYMAN MUSEUM Program Name: EDUCATION AND PUBLIC PROGRAMS 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 conflict is needed. 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): 0 No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: I --30 - 13 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Program Name: 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. I - 3o _ 9 Signature of Authorized Person (specify title) Date tSf e e EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: LYMAN MUSEUM Program Name: EDUCATION AND PUBLIC PROGRAMS 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Service students with school tours and workshops 2300 Train new docents for school tours 4 Provide public programs 35 Service community members with public programs 1300 Provide teachers with information and assistance 280 Conduct educational workshops for students/public 18 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 10,000 Professional Fees 0 Operations 1,150 Supplies 150 Equipment 700 Other: Other: Other: Other: Other: TOTAL 12,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: LYMAN MUSEUM Program Name: EDUCATION AND PUBLIC PROGRAMS APPENDIX 1 2. Agency Mission Statement (continued): The Museum's historical,cultural, contemporary, and environmental exhibits illuminate the following: a) Native Hawaiian life prior and subsequent to European discovery b) The Missionary period of 1840-1880 c) The traditional lifestyles of Hawai'i's major immigrant groups d) The natural history of Hawai'i, including its volcanoes,flora, and fauna e) Other aspects of ocean and earth science, such as shells and minerals 4. Total Budget& Position Count: *These 7 positions work part-time for Education and Public Programs. Only the portion of salaries/wages allocated to EDUCATION AND PUBLIC PROGRAMS has been included in the figure for Total Program Budget. Lbob Malama O Puna Puna Panthers Agency Name: Malama 0 Puna Program Name: Puna Panthers Phone No.: (sob) 965— 2000 Agency Director: Rene Siracusa 345 — 8428 Contact Person: R.Kaipo Like Phone No.: (808) Mailing Address: Address: P.O. Box 1520 Address: City,ST,rip Pahoa, Hawaii 96778 Facility Address: Address: 15-2754 Pahoa Village Rd. Unit 1 Address: city,ST,rp Pahoa, Hawaii 96778 Email Address:malamaopuna @yahoo.com, klike @hawaii.rr.co Fax No.: ( ) - Accountant/CPA: Firm(if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 20,000 2.Agency Mission Statement: The mission of the Puna Panthers is to enable youth to benefit from participation in team sports and physical activities in a safe and structured environment. EXHIBIT A Page 1 of 7 NONPROFIT GRANT APPLICATION FY 2013-2014 • Agency Name: Malama 0 Puna Program Name: Puna Panthers 3.Program Description: This program was first started through a Big Island Pop Warner Football Conference meeting on November 10, 2009 where a submitted letter of intent to all association presidents asking for permission to field a team in Pahoa for the upcoming 2010 football season. The following March of 2010 kicked off the inaugural flag season and we had 80 youth participants ages 5-13. In August we started the tackle season fielding a Mitey Mite and PeeWee division teams ages 7-9 and 9-12 respectively. In March 2011 the Puna Panthers kicked off the 2nd year flag, enrollment increased to 120 youth athletes fielding 6 teams total. In 2012 we expanded the organization to include a Midget division, ages 12-15 and for 2013 we are expanding to include cheerleaders. 4.Total Budget&Position Count: Total Program Budget: 50000 Total Program Position Count: 0 Total Agency Budget: 50000 Total Agency Position Count: 0 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Program Registration 25000 Fundraising 10000 County of Hawaii 25,000 TOTAL: 60000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The goal is to become self-sustaining by 2015. The program plans to increase revenue through 1) Fundraising 2) Soliciting community resources through collaborations. 3) Grant writing EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Malama 0 Puna Program Name: Puna Panthers 7.Program Objectives Using County Nonprofit Grant Program Funds: 1)To provide fun athletic learning opportunities for youths, while emphasizing the importance of academic success.. 2)To ensure a safe and positive playing environment for all participants. 3)To promote pro-social skill development and instill life-long values of teamwork and dedication. 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) 80 Youth develop prosocial skills and leadership 90% enhance skills 100 Youth to participate in a safe environment that promotes 95% participation dedication. 22 Adult Volunteer Coaches 12hrs/wkly&team moms 5hrs/weekly 95%/p�certification on 8 Adult Coaches 12hrs/wkly Attach additional pages as necessary. 9.TABLE II: FY 13-14 FY 12-13 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req 0 0 0 Salary and Wages - - Professional Fees 0 p 0 Operations 43000 43000 20,000 Supplies Equipment Other: 7-12A V 5000 5000 4000 Other: J/(fLy Rec.J COg7-. 1500 1500 1000 Other: Other: Other: TOTAL 49500 49500 25000 *If applicable EXHIBIT A Page 3 of NONPROFIT GRANT APPLICATION FY 2013-2014 Agency Name: Malama 0 Puna Program Name: Puna Panthers 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 conflict is needed.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): No conflicts exist(No further information required. Please sign form at the bottom.) CMember or members of the Council _ Staff appointed by a member of the Council _ The Mayor C 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: /, — -� 00 r3ai3 Signature of Authorized Person (specify title) Date EXHIBIT A Page 4 of 7 NONPROFIT GRANT APPLICATION FY 2013-2014 Agency Name: Malama 0 Puna Program Name: Puna Panthers 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.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 30,2013 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. cPygg/ ) gOdi• 3 oefp Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Malama 0 Puna Program Name: Puna Panthers 12.COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 o L C Malamalama Waldorf School Puna Arts in the Park Intersession & Summer Program Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Intersession & Summer Program Agency Director: Kehaulani Costa Phone No.: (808) 982 — 7701 Contact Person: Kehaulani Costa Phone No.: (808) 982 — 7701 Mailing Address: Address: HC 3 Box 13068 Address: City,ST,Zip Keaau, Hawaii 96749 Facility Address: Address: 15-1834 Makuu Drive Address: City,ST,Zip Keaau, Hawaii 96749 Email Address: admin @hawaiiwaldorf.com Fax No.: (808) 982 — 7806 Accountant/CPA: Chris Hannigan Phone No.: (808) 930 — 4024 Firm (if applicable): Midnight Oil,Inc. Mailing Address: Address: 1416 Kuulei Street Address: City,s-r,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $20,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $7,500 2. Agency Mission Statement: The mission of Malamalama Waldof School is to improve the quality of the educational experience by providing Waldorf Education in East Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Intersession & Summer Program 3. Program Description: Malamalama Waldorf School seeks to provide Intersession and Summer Enrichment Programs to students in Grades 1 - 6 at the school's 20-acre campus in Hawaiian Paradise Park. Malamalama Waldorf School is licensed by the Department of Human Services to provide After School, Intercession and Summer Programs to 60 children between the ages 6 - 12. The school currently provides an afterschool program on school days between the hours of 2:00 to 5:30pm. In the 2013/2014 school year, Malamalama Waldorf School has aligned it's school breaks to coincide with the State's DOE Calendar for the Fall Intersession, Winter Recess and Spring Break so that the school can expand its enrichment program offerings during these periods. In addition, the school proposes to offer a 4-week Summer Art Camp in June 2014. 4. Total Budget& Position Count: Total Program Budget: $44,000 Total Program Position Count: 8 part-time Total Agency Budget: $650,000 Total Agency Position Count: 26 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Tuition ($50/student/week x 8weeks) 40 students $16,000 Hawaii County Grant $20,000 Other Grants (Private Foundation & Corporations) $8,000 TOTAL: $44,000 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 increase revenue to this program beyond the pilot through increased enrollment tuition(full capacity of 60 students in the second year) and through other grant funding sources. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 . Malamalama Waldorf School will enroll an average of 40 students between the ages of 6 to 12 in its Puna Arts in the Park Day Camp during the following school breaks: Fall Intersession, Winter Recess, Spring Break, Summer. 2. Approximately 40 students per day will participate in art instruction with local artists. 3. MWS will employ two local artists per week to provide art instruction in various media. 4. MWS will offer 8 new employment opportunities per camp session to qualified applicants. 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 participting in daily exercise. 100% Percentage of enrolled students interacting with local artists. 100% Percentage of enrolled students meeting a new friend. 100% Percentage of parents indicating satisfaction for safe and nurturing environment. 100% Percentage of students re-enrolling for future programs. 100% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages 29,600 9,600 Professional Fees 4,000 2,000 Operations 4,000 2,000 Supplies 3200 3,200 Equipment 3200 3,200 Other: Other: Other: Other: Other: TOTAL 44,000 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Intersession & Summer Program 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 conflict is needed. 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): I I No conflicts exist (No further information required. Please sign form at the bottom.) 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: Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Intersession & 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. 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. OVIkt f 1\014 vU:S'nt of C, ACur ► ( 3 a 1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Percentage of enrolled students participating in new art experience. 100% Percentage of enrolled students participting in daily exercise. 100% Percentage of enrolled students interacting with local artists. 100% Percentage of enrolled students meeting a new friend. 100% Percentage of parents indicating satisfaction for safe and nurturing environment. 100% Percentage of students re-enrolling for future programs 100% TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 9,600 Professional Fees 2,000 Operations 2,000 Supplies 3,200 Equipment 3,200 Other: Other: Other: Other: Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 M 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 Kalani St., Ste 103 City,ST,Zip Kailua-Kona, HI, 96740 Email Address: gmichell @mhkhawaii.org Fax No.: (808) 331 — 1378 Accountant/CPA: Summer B. Such, CPA Phone No.: (808) 737 — 2523 Firm (if applicable): Mailing Address: Address: Mental Health Kokua Address: 75-166 Kalani St., Ste 103 City,ST,zip Honolulu, HI 96814 • YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $18,000 $10,000 $5,000 2. Agency Mission Statement: The Mission of Mental Health Kokua (MHK) is to assist people with mental health and related challenges, to achieve optimum recovery and functioning in the community. MHK provides housing, case management, and outpatient services on behalf of Hawaii citizens, and those with major mental illness and co-occurring conditions, since 1973. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 3. Program Description: Our Residential Rehabilitation Services program provides community based housing to adults recovering from severe mental illness, a more cost effective and humane alternative to institutional care and/or homelessness. The goal is to enable clients to move on to more independent living. While in placement, clients are assisted in acquiring personal and social survival skills necessary for sustained community living. Staff provide daily on-site training and support in daily living skills and medication management while facilitating social, educational and recreational activities in the community. Clients are also assisted in making connections to community resources including mental health centers, vocational training programs, and community housing agencies, as well as assistance with long-term community placement. 4.Total Budget& Position Count: Total Program Budget: 1,067,026 Total Program Position Count: 40 Total Agency Budget: 8,202,195 Total Agency Position Count: 214 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii 5,000 State of Hawaii — DOH 1,214,276 United Way 20,371 Program Service Fees 163,826 Donation/Other 33,247 MHK Support 204,881 TOTAL: 1,641,601 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Mental Health Kokua has been successful in building strong relationships with many foundations and trusts, which have become pivotal in providing funding for new properties and major renovations to existing properties. Grant funding to help support the general maintenance of our projects in Hilo and Kona has been received from G.N. Wilcox Trust, Bank of Hawaii Charitable Foundation, Hawaiian Tug & Barge/Young Brothers, Ltd., and Visitor Industry Charity Walk. Mental Health Kokua has demonstrated notable ability and success in obtaining funding from private sources such as trusts and foundations and special events and will continue to explore ways to become fully self-sustaining. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 and social rehabilitation services to 96 unduplicated persons with serious mental illness. 2) Reduce the number of consumers requiring psychiatric hospitalization to less than 10%. 3) Show evidence of satisfaction with services received at least 95% of consumers served. 4) Show improvement in daily living skill scores upon discharge. 5) Place at least 75% of consumers served in more independent living settings following planned 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 unduplicated consumers served 96 of consumers served requiring psychiatic hospitalization Less than 3% (< 3%) % of consumers discharged to more independent living settings 75% % of consumer satisfied with services 98% Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 1029305 1,232,425 0 Professional Fees 26,093 27,801 0 Operations 443,076 381,375 5,000 Supplies Equipment Other: 'Other: Other: Other: Other: TOTAL 1498474 1,641,601 5,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 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 conflict is needed. 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): CNo conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council _ Staff appointed by a member of the Council The Mayor CThe 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: ila� 1� 3 Signature of Authoriz d Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 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://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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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,-----..._ ___E")—ik--7- !l a�/1 j Signature of Authori%11 Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of unduplicated consumers served 96 % of consumers served requiring hospitalization Less than 3% % of consumers discharged to more independent living settings 75% % of consumer satisfied with services 98% TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 0 Operations $5,000 Supplies 0 Equipment 0 Other: Other: Other: Other: Other: TOTAL $5,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 U11 Miloli'i Emergency Response Team, Inc. Miloli'i Resiliency Project Agency Name: Miloli'i Emergency Response Team, Inc. Program Name: Miloli'i Resiliency Project Agency Director: Eric Edwards, President Phone No.: (808) 328 — 1403 Contact Person: Gail Garoutte, Treasurer Phone No.: (760) 267 — 5250 Mailing Address: Address: do William Houston Address: 88-1543 Elima Ave City,s-r,zip Captain Cook, HI 96704 Facility Address: Address: 88-1543 Elima Ave Address: City,5T,zip Captain Cook, HI 96704 Email Address: gail @garoutte.com Fax No.: ( ) — Accountant/CPA: Gail Garoutte Phone No.: (760) 267 — 5250 Firm (if applicable): Mailing Address: Address: 88-1509 Awapuhi Ave Address: City,sr,zip Captain Cook, HI 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $11 ,500 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0.00 0.00 0.00 2.Agency Mission Statement: Provide organized volunteer support to the community during disaster or emergency situations. This support consists of CERT members trained to secure their home and family; assess neighborhood situations; provide light search and rescue; provide first aid and triage; and communicate situation to first responders when they arrive at scene of a disaster. For more information on the Miloli'i Emergency Response Team can be found at https://sites.google.com/site/miloliicertsite/. Please see attachment A for more information on the CERT program and MERT. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Miloli'i Emergency Response Team, Inc. Program Name: Miloli'i Resiliency Project 3. Program Description: Our initial goal is to acquire the necessary equipment and supplies to support our community in the event of an emergency. We expect that in the case of a severe earthquake, tsunami, volcanic eruption, or hurricane we will need to support our area for days or weeks with little or no support from first responders due to our remote location. We need radio equipment to communicate with Honolulu regarding the severity of our situation; emergency food and water, medical supplies for injured community members; generators to provide emergency power; and, other supplies for basic search and rescue operations. With this grant we plan to purchase the storage container, food and water. 4.Total Budget&Position Count: Total Program Budget: 19,600 Total Program Position Count: 0 Total Agency Budget: 19,600 Total Agency Position Count: 13 volunteers 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii 11,500 Hawaii Community Foundation 3,000 Young Brothers 1,500 A&B Foundation 1,000 Civil Defense 1,200 Miloli'i Homeowners Association 1,400 TOTAL: 19,600 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: When Miloli'i Emergency Response Team (MERT)was first formed, our local homeowner's association dedicated some funds to allow us to purchase the initial first aid supplies. In addition, each member, upon completing the CERT training, received a backpack with basic safety gear from Civil Defense. In 2012 we applied for, and received, 3 grants so we could purchase additional first aid supplies, radios for communication, and search and rescue equipment. In ensuing years we will need additional funds to replace outdated medical supplies, expired food, and for routine maintenance of equipment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Miloli'i Emergency Response Team, Inc. Program Name: Miloli'i Resiliency Project 7. Program Objectives Using County Nonprofit Grant Program Funds: Our objective for these requested funds is to purchase the storage container, emergency food and water, and camp stoves. We would like to have enough supplies on hand to support 2000 people for 1 week. 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.) Miloli'i population 2,000 people 3 meals per day for 7 days 42,000 meals Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Req Actual* Total Budget Salary and Wages 0.00 0.00 0.00 Professional Fees 0.00 0.00 0.00 Operations 404.78 100.00 0.00 Supplies 798.38 1,000.00 1,000.00 Equipment 2083.91 4,500.00 4,500.00 Other: c 'o 0 0.00 5,000.00 5,000.00 Other: twl-2 0.00 1,000.00 1,000.00 Other: Other: Other: TOTAL 3,287.07 11,600.00 11,500.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Miloli'i Emergency Response Team, Inc. Program Name: Miloli'i Resiliency Project 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 conflict is needed. 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): No conflicts exist(No further information required. Please sign form at the bottom.) ❑ 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: \ - an r 13 SignaturefAuthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Miloli'i Emergency Response Team, Inc. Program Name: Miloli'i Resiliency 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, 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. P2es o,ElNT Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Miloli'i Emergency Response Team, Inc. Program Name: Miloli'i Resiliency Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Miloli'i population 2,000 3 meals per day for 7 days 42,000 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0.00 Professional Fees 0.00 Operations 0.00 Supplies G9rhP 3-1-0 VEs / v€L 1,000.00 Equipment co ,.v 7._A ` N 4C 4,500.00 Other: lam,o a 5,000.00 Other: ,-4 n - 1,000.00 Other: Other: Other: TOTAL 11,500.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Miloli'i Emergency Response Team,Inc. Miloli'i Resiliency Project Attachment A(page 1 of 2) Background on CERT The Community Emergency Response Team (CERT) Program was first developed by the Los Angeles Fire Department in 1985. Since then it has developed into a national program, supported by CitizenCorps, and classes are given in both rural and urban areas around the country. The Federal Emergency Management Agency (FEMA) recognizes the importance of preparing citizens to deal with disaster situations; therefore the Emergency Management Institute (EMI) and the National Fire Academy adopted and expanded the LAFD CERT materials, believing them applicable to all hazards. The goal of the CERT program is building resilient communities capable of responding in disaster situations until professional responders arrive. In Hawaii where many of our communities are in remote areas and we have limited first responder resources the CERT program is particularly important. In past disaster situations the CERT program has proven to save lives. CERT members are trained by the Fire Department under a program administered by Civil Defense and funded by FEMA. All CERT members are required to submit to a criminal background check before they are issued badges by Civil Defense and join a local team. About Our Team and Our Community The Miloli'i Emergency Response Team (MERT) consists of CERT trained graduates who reside in a remote area stretching from mile marker 98 south to mile marker 84, both above and below Mamalahoa Highway (Hwy 11), on the southern end of South Kona district, on the Big Island of Hawaii. The majority of this land is in USGS-designated lava zones 1 and 2, susceptible to volcanic outbreaks along the nearby Mauna Loa's Southwest Rift Zone. This is a remote area with a growing population (currently around 2,500), covering thousands of acres of rugged terrain, comprised of old lava flows and `dry forest'. Of note, Hawaii County is #1 out of the 3,140 counties in the US for the highest potential for different types of hazards. The CERT team arose as a response to Hawaii County Civil Defense statements indicating that we would be cut off from aid by any disaster which affected the only highway, which links us with the cities of Kailua-Kona (40 miles), and Hilo (90 miles). Miloli'i could easily be cut off on both sides during an eruptive event or flash flooding caused by severe storms or hurricanes. Our community has been informed by Civil Defense that it could be days, or in the case of an island-wide event, weeks or more, before help could arrive in any form other than by air drop. We are well aware that, in the case of an island-wide event, most available services would be focused on more densely populated areas. Miloli'i Emergency Response Team,Inc. Miloli'i Resiliency Project Attachment A(page 2 of 2) CERT Training was offered at no charge by the Hawai'i County Fire Department, in conjunction with the national CERT Program. After the first four members were trained and certified and passed the necessary background checks, we completed the necessary paperwork and were approved to be officially accepted by Hawaii Island Civil Defense as a viable emergency resource. Additional training sessions were completed last fall for 9 new members and we now have 13 certified team members. We are currently soliciting for more volunteers to grow our team further to support our goals of aiding our community in the event of a disaster. At the same time, other CERT teams are currently forming around the island. Our MERT team has monthly in-service/meetings, sends representatives to the monthly Miloli'i Volunteer Fire Dept. meetings, has monthly radio checks, and a yearly disaster drill to re- evaluate our preparedness. Last year we completed and received our own 501(c)3 status as a stand alone charitable corporation. MERT is dedicated to working with surrounding community organizations. The Miloli'i Beach Club Association II (MBCA II) has been extremely active in promoting Emergency Preparedness. The MBCA II actively supports the efforts of MERT and has been very generous in providing funds to assist with start-up emergency equipment and supplies, including our first four hand-held radios enabling the team to stay in contact with one another in the field. Neighborhood Place of Puna Family and Community Strenghening FY' Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strengthening 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,sr,zip Pahoa, HI 96778 Facility Address: Address: 15-3039 Pahoa Village Rd. Address: city,sr,Zip Pahoa, HI 96778 Email Address: paul @neighborhoodplaceofpuna.org Fax No.: (808) 965 — 5109 Accountant/CPA: 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 Amount of Request for County Nonprofit Grant Program Funds: $30,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $10,000 $20,000 $21 ,000 2.Agency Mission Statement: The goal of the Neighborhood Place of Pun is to prevent child abuse and neglect. The vision: "To Nurture, strenghten and Celebrate "ohana". The mission: "Empowering families and communities in Puna by building strong faoundations through healthy relationships that value each person's uniqueness. "E malama pono kakou". EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strengthening 3. Program Description: Neighborhood Place of Puna (NPP) is a child abuse and neglect prevention program that has been serving Puna families for 10 years, and the Hilo area since July of 2012. NPP provides on-going weekly, free and voluntary, in-home visitation for families with some risk of Child Abuse and Neglect, even if the risk is poverty and precarity. NPP outreach staff connects families to available resources, provide encouragement and advocacy, and helps parents understand their children's developmental stages. Most importantly, NPP helps parents gain the knowledge, skills, and tools they need to be a strong familiy that raises healthy safe children, and remains out of the Child Protective Services. 4.Total Budget& Position Count: Total Program Budget: $238,509 Total Program Position Count: 4 Total Agency Budget: $477,287 Total Agency Position Count: 8 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Blue Print for Change $159,000 County of Hawaii $30,000 Hawaii Island United Way $20,000 HCF $5,000 Foundation Grants $20,000 Casey Family Programs $4,509 TOTAL: $238,509 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Neighborhood Place of Puna is a successful child abuse and neglect prevention program. While we are aggressively developing our fundraising program and pursuing a variety of grants, the services NPP offers will never be completely self-sustaining. We serve the "least of these": families with underage children, usually single moms, often living in poverty in rural Hawaii, making due with extremely limited resources and minimal opportunities for employment. • It is not a "sexy" demographic, and their just aren't that many funders out their looking help struggling families at risk for child abuse and neglect. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strengthening 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives of Neighborhood Place of Puna's Family and Community Strengthening Program is to help east Hawaii families raise healthy safe children. NPP does this by providing intensive, regular, on-going home visitation to families. NPP also works extensively within the community, to help families, especially in Puna, get access to resources that might otherwise be difficult to obtain, due to a lack of transportation, internet connectivity, cell phone service, or due to isolation. 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 Familly Safety Assessment 70 Families Develop Family Success Plan 70 Families Successful Completion of Family Success Plan 80% of Families Safe Home Assessment of above 45 families w/ children =< 5 years 100% Ages & Stages Assement of above 45 fam. w/ children =< 5 years 100% Families free of Child Abuse and Neglect 85% Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Req Actual* Total Budget Salary and Wages 156,726 $176,286 $28,060 Professional Fees 6,000 $3,000 Operations 34,574 $57,223 $1,070 Supplies 1,700 $2,000 $870 Equipment Other: Other: Other: Other: Other: TOTAL 199,000 $238,509 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strengthening 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 conflict is needed. 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): No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strengthening 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A , NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. r rt \L c— 1 /if t S S':nature of Authors - (specify title) Date • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Neighborhood Place of Puna Program Name: Family and Community Strengthening 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 92 Neighborhood Place of Puna Ready to Learn 0 E7V 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,s-r,zip Pahoa, HI 967 Facility Address: Address: 15-3039 Pahoa Village Rd. Address: City,ST,Zip Pahoa, HI 96778 • Email Address: paul @neighborhoodplaceofpuna.org Fax No.: (808) 965 — 5109 Accountant/CPA: Alex Smith Phone No.: (808) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank Street Address: City,ST,zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $5,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $10,000 $20,000 $21 ,000 2.Agency Mission Statement: The goal of the Neighborhood Place of Pun is to prevent child abuse and neglect. The vision: "To Nurture, strenghten and Celebrate "ohana". The mission: "Empowering families and communities in Puna by building strong faoundations through healthy relationships that value each person's uniqueness. "E malama pono kakou". EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Neighborhood Place of Puna Program Name: Ready to Learn 3. Program Description: Since 2004 Neighborhood Place of Puna, in collaboration with, community police officers, community associations, service clubs, government agencies, churches, foundations, businesses, and individuals have worked together to purchase and distribute free basic school supplies to school aged children in East Hawaii. 4.Total Budget&Position Count: Total Program Budget: $16,500 Total Program Position Count: 0 Total Agency Budget: $477,287 Total Agency Position Count: 8 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii $5000 Friends of Hawaii Charaties $2,000 Donations $2,000 InKind Donations $6,000 Young Brothers $1,500 TOTAL: $16,500 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 to Learn" committee raises funds and seeks support for "Ready to Learn"free school supplies distribution. Close to 50% of the project is now funded through donations. Additionally, NPP donates all of its staff time, as well as office resources to make this rather large and wonderful project possible on what is a very thin budget. EXHIBIT A NONPROFIT GRANT APPLICATION P1 2013-2014 Page 2 of 7 Agency Name: Neighborhood Place of Puna Program Name: Ready to Learn 7. Program Objectives Using County Nonprofit Grant Program Funds: Poverty and lack should not be a barrier to education. It is the goal of this program is to ensure every child starts school, "Ready to Learn", with basic school supplies. Neighborhood Place of Puna and the "Ready to Learn" committee, with the help of community volunteers, will distribute free basic school supplies to approximately 1800 school aged children in East 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 2014 1800 children Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $16,500 $5,000 Equipment Other: Other: Other: Other: Other: TOTAL $16,000 $5,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Neighborhood Place of Puna Program Name: Ready to Learn 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 conflict is needed. 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): l� l No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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. 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 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 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 will impact the evaluation of yourprogram's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 :r.nt funds re eived durin: the :rant •eriod must be refunded to Coun 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, 2014 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. Eicecv��`..yC�lcec\o11- 4 /t 3 Signat a of Authorize (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 93 North Kohala Community Resource Center Growing a Local Food System -N. Kohala Eat Locally Grown Agency Name: North Kohala Community Resource Center Program Name: Growing a Local Food System-N. Kohala Eat Locally Grown Agency Director: Christine Richardson Phone No.: (808 ) 889 —5523 Contact Person: Andrea Dean Phone No.: (808) 960 — 3727 Mailing Address: Address: PO Box 519 Address: City,sT,zip Hawi, HI 96719 Facility Address: Address: 55-3393 Akoni Pule Highway Address: City,sT,zip Hawi, HI 96719 Email Address:andrea@andreadean.com Fax No.: ( ) — Accountant/CPA: Alida Adamek, treasure and CPA Phone No.: (808) 938 —2200 Firm (if applicable): Mailing Address: Address: P. 0. Box 540 Address: City,ST,Zip Hawi, HI 96719 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 30,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 $15,000 2.Agency Mission Statement: The North Kohala Community Resource Center (NKCRC) is the fiscal sponsor for the project. The mission of the NKCRC, a 501(c) 3 nonprofit, is to "Provide local support, bridges to funding and education for projects that benefit the community." NKCRC currently sponsors seventy-four projects, led by 105 organizers, and impacting over 6,000 children and adults in the community of North Kohala. The misison of the North Kohala Eat Locally Grown Campaign is to build community capapcity through planning and programs which grow a local, sustainable food sysem in North Kohala and meets the North Kohala CDP Goal to "Produce 50% of the food it consumes." EXHIBIT A Agency Name: North Kohala Community Resource Center Program Name: Growing a Local Food System-N. Kohala Eat Locally Grown 3. Program Description: The North Kohala Eat Locally Grown Campaign is playing a key role in addressing the North Kohala CDP Goal of 50% food self-sufficiency through community capacity building and initiatives which seek to educate consumers, drive demand for locally produced food, increase sales between local producers and buyers and increase access to locally grown food for Kohala residents. This proposal is for fulfilling some of the goals of our food self-sufficiency strategic plan: EBT/SNAP (formerly food stamps) at Hawi Farmers Market increase access to locally grown food for the low-income community, community workshops and events that increase growth and useage of locally grown foods and "eat local" public awareness outreach. (See attached.) 4.Total Budget&Position Count: Total Program Budget: $100,000 Total Program Position Count: 1.5 Total Agency Budget: $164,418 Total Agency Position Count: 2.4 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Kaiser Permanente 15,000 RSF Social Finance 25,000 Laura Jane Musser Fund 25,000 County of Hawaii- County Council 30,000 County of Hawaii- Office of Research and Development 5,000 TOTAL: 100,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The North Kohala Eat Locally Grown campaign is experimenting with social entrepreneurship projects in order to support key aspects of the initiative. Strategies are as follows: 1. Selling of smoked fish at the EBT Booth at the Hawi Farmers Market to support the booth. 2. Selling of North Kohala Eat Locally Grown branded t-shirts and hats to support programs. 3. Charging of fees for selected programs (such as the Kohala Farm-to-Fork Tours.) New grant funding sources have been developed this year and the organization will continue to pursure grants from multiple Hawaii-based and mainland-based sources. EXHIBIT A Agency Name: North Kohala Community Resource Center Program Name: Growing a Local Food System-N. Kohala Eat Locally Grown 7. Program Objectives Using County Nonprofit Grant Program Funds: Address objectives in the North Kohala CDP and Strategic Plan and COH Strategic Ag Plan: 1. Increase access to locally grown foods, especially to the low-income community (NK-SP) 2. Increase the local production of food consumed on Hawaii Island by growing and marketing commercial crops to substitute those being imported and encouraging island residents to grow some of their own produce. (COH Ag Plan) 3. Increase the profitability of Hawaii Island's agricultural businesses, etc... (COH Ag Plan) 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.) #of people that use EBT at Hawi Farmers Market 200 people/families per month Increase EBT at Hawi Farmers Markets expenditures to $35pp $7,000 per month Number of people that attend workshops and events 500 Number of workshops and events 4 Number of "Eat Local Plate" and "Eat Local Directory" dist. 500 Outreach impressions (media, blog, social media, newsletter) 5,000 impressions Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages Professional Fees 13,560 25,000 15,000 Operations 62,050 50,000 9,600 Supplies 4,400 Equipment 10,000 Other: 4,300 5,000 3,000 Other: 3,740 5,600 2,400 Other: Other: Other: TOTAL 83,650 100,000 30,000 *If applicable EXHIBIT A Agency Name: North Kohala Community Resource Center Program Name: Growing a Local Food System-N. Kohala Eat Locally Grown 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Christine Richardon POSITION: Executuve Director, NKCRC May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): P1No conflicts exist (No further information required. Please sign form at the bottom.) 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: Vil t 1 - Signature of Authorized Person (specify title) Date EXHIBIT A Agency Name: North Kohala Community Resource Center Program Name: Growing a Local Food System-N. Kohala Eat Locally Grown 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 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 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 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 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, 2014 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 Agency Name: North Kohala Community Resource Center Program Name: Growing a Local Food System-N. Kohala Eat Locally Grown 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of people that use EBT at Hawi Farmers Market 200 Increase EBT at Hawi Farmers Markets expenditures to $35pp $7,000 Number of people that attend workshops and events 500 Number of workshops and events 4 Number of "Eat Local Plate" and "Eat Local Directory" dist. 500 Outreach impressions (media, blog, social media, newsletter) 5,000 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 15,000 Operations 9,600 Supplies Equipment Other: 3,000 Other: 2,400 Other: Other: Other: TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B ,k GlOWING A LOCAL FOOD NORTH SIS�`E M I N KOHALA ash "°"T""°""`" The North Kohala Eat Locally Grown Campaign is a project of the \ ,'� North Kohala Community Resource Center www.foodhubkohala.org Andrea Dean, MBA, Project Coordinator 808-960-3727 andrea @andreadean.com Project Description This proposal is to fund strategies identified as important to the community during the strategic planning process for "Growing a Local Food System in North Kohala—Strategic Planning for Food Self-Sufficiency." Funds from the County of Hawaii will be leveraged with others sources to support the following activities. Goal: Increase access to locally grown food in the low-income community and grow the market for locally grown foods in the North Kohala community. 1. Objectives and Activities: • Increase access to fresh,locally grown food. o Set up program to accept EBT (SNAP- Supplemental Nutrition Assistance Program (formerly known as food stamps) at the Hawi Farmers Market. Projected Outcome: • Increase access to locally grow food for the low-income population. • Grow the market for locally grown foods. Evaluation: o Number of people served o Dollar value of EBT that runs through the market. o Vendor surveys. Goal: Grow the local food system in North Kohala by following up on priorities identified in the community-based"Growing a Local Food System in North Kohala- Strategic Planning for Food Self-Sufficiency." 1. Objectives and Activities: • Increase ability of the public—with a focus on the low-income population—to utilize fresh,local foods. o Three (3) community workshops and one (1) Ho'ike that focused on: Cooking, Eating, Planting Native Starches (Sweet Potato,Taro and'Ulu) and other locally grown food.Partnership with Ka liana No`eau. Projected Outcome: • Increased use, over time, of local foods and native starches in particular. Evaluation: o Public education and outreach materials. o Number of people and demographics of people in attendance. 3.Objectives and Activities: • Education and outreach to connect the community with knowledge and sources of locally grown food. o Distribution of"My Eat Local Hawai'i Plate"and"Kohala Eat Local Directory" o Continuing to build foodhubkohala.org as an online resource for the community. o Promote the"North Kohala Eat Local"message in the community. Projected Outcome: • Increased access to locally grown food. • Increase awareness about the health, environmental and economic benefits of eating locally grown food. Evaluation: o Media outreach/impressions o Number of posters and directories distributed/downloaded. Citizens in Kohala are interested in increased food self-sufficiency for the following reasons: • Reliable,Affordable and Safe Food Source o Hedge against changes in the global food system. o Protect against supply disruption. o Food security for all residents. • Healthier Population and a Healthier Community o Increase the affordability and availability of fresh, local,sustainably grown, nutrient rich,foods. o Educating youth about growing and eating healthy foods. • Reduce Transportation o Less expensive food due to less transportation costs. o Reduce greenhouse gasses from transportation of food and agricultural inputs. • Economic development o Support local farmers and local businesses. o Create new agricultural jobs and entrepreneurial opportunities for youth and adults. o Expanding the number of small, profitable agricultural ventures. • Preservation of Rural Community o Ensuring that agricultural land stays in agricultural production. • Community Building and Resilience o Creating deeper connections between growers and consumers, and business to business. o Build relationships among the diverse ethnic groups and age groups of Kohala around food production, preservation,harvesting, sharing and eating. M North Kohala Community Resource Center Kohala Welcome Center, Phase II 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: Christine Richardson Phone No.: ( ) — Mailing Address: Address: PO Box 519 Address: City,ST,Zip Hawi HI 96719 Facility Address: Address: 55-3393 Akoni Pule Address: City,ST,Zip Hawi HI 96719 Email Address: info @northkohala.org Fax No.: (808) 889 — 5527 Accountant/CPA: Alida Adamek,Director and Treasurer Phone No.: (808) 938 — 2200 Firm (if applicable): Mailing Address: Address: PO Box 540 Address: City,ST,zip Hawi HI 96719 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $1 7,280 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 N/A N/A $15,000 2.Agency Mission Statement: The North Kohala Community Resource Center (NKCRC) is a ten year old 501(c)3 nonprofit organization located in North Kohala, a small rural community (6,322 population) on the northern tip of the Big Island of Hawaii. The mission of NKCRC is to increase the number of successful community improvement projects in North Kohala. We meet this mission by providing training, coaching, and a 501(c)3 umbrella to a diverse group of volunteer community project organizers. Over 100 community projects have been realized due to the support provided by the NKCRC. These collective efforts have improved our community and the lives of our citizens and illustrate the power of volunteer grass roots efforts in community development. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: North Kohala Community Resource Center Program Name: Kohala Welcome Center Phase II 3. Program Description: See attachment#1. 4.Total Budget& Position Count: Total Program Budget: $21,088 Total Program Position Count: .4 Total Agency Budget: $164,418 Total Agency Position Count: 2.4 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Donations 2013 $2,000 Product sales 2013 $8,000 TOTAL: $10,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: See Attachment#2 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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: 1. Double sales and donations at the Kohala Welcome Center by 50%. 2. increase the number of visitors. 3. Increase our capacity to effectively manage the Kohala Welcome Center and its volunteer guide team as measured by the number of trained volunteers, the number of visitors and the number of sales. 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 income FY 2013-14 $30,000 2. Number of visitors 20,000 3. number of volunteers 25-30 4. number of volunteer hours 2,500 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $14,280 $14,280 Professional Fees $1,250 Operations Supplies Equipment Other: N1/E' '7 FL/ $2,558 $1,500 Other: RETAIL. -F/ k114✓)2/ ,5 $3,000 $1,500 Other: Other: Other: TOTAL $21,088 $17,280 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: North Kohala Community Resource Center Program Name: Kohala Welcome Center Phase II 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 conflict is needed. 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): QNo conflicts exist(No further information required. Please sign form at the bottom.) I I Member or members of the Council Staff appointed by a member of the Council The Mayor I I 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: • ilb I'• / 404 / c — /3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: North Kohala Community Resource Center Program Name: Kohala Welcome Center Phase II 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 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 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 will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. o Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: North Kohala Community Resource Center Program Name: Kohala Welcome Center Phase II 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1. Kohala Welcome Center income $30,000 2. Number of visitors 20,000 3. number of volunteers 25-30 4. number of volunteer hours 2,500 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $14,280 Professional Fees Operations Supplies Equipment Other: $1,500 Other: $1,500 Other: Other: Other: TOTAL $17,280 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 North Kohala Community Resource Center Kohala Welcome Center Phase II Attachment 1 —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 74 and growing. In the past ten years we have trained over 170 volunteers to plan, organize, and coordinate their projects and have brought in over$8 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. Up 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 the NKCRC), annual fund development activities (special events and on-line 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 hire 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 books and CDs related to North Kohala, many of which were self- published. The Welcome Center greeted 14,000 visitors and generated over $16,000 in operating support income in 2012. This exceeded our business plan projections and encouraged by this first year of success, our Board approved a 2013 budget which included two part time positions to support the programming and administrative aspects of the NKCRC. Also we concluded that the Welcome Center has the potential to become a key income stream and we are therefore devoting full attention to its growth and development. The first year of the KWC was a pilot project. Before we opened we only speculated about the needs of the visitor. After a full year, we now have a much deeper understanding of their needs and are using that knowledge and experience to develop Phase II of the development of the Welcome Center. This application is to provide funding over the next County fiscal year to North Kohala Community Resource Center Kohala Welcome Center Phase II Attachment 1 —Program Description increase the capacity of the Welcome Center, and in turn, increase and support the capacity of the Resource Center to serve our community. Capacity building, or Phase II of the Welcome Center, is comprised of two key elements: 1. Develop a part time Welcome Center part time manager position who will oversee its operations including training and scheduling the volunteer program and managing the inventory. 2. 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. North Kohala Community Resource Center Kohala Welcome Center Phase II Attachment 2—Revenue Plans 6. Agency Plans to increase revenue NKCRC has researched and developed a modest product line that will be on the shelves by late March. This will allow us to increase our sales at the Kohala Welcome Center. We are also working with a national marketing company owned by a local resident. Their in-kind donation of design concepts will help us to vision and create our point-of-sale area(s) so that we can effectively market and sell the product line; this company is working with us at no charge. We are working with a public relations specialist who will provide an editorial campaign for feature coverage on the Welcome Center, create and deliver trainings for our Guides, develop a civic tourism program that will integrate points of interest and local businesses and determine the feasibility of current advertising opportunities such as drive guides and island wide magazines. We currently do not have the funding for part time Welcome Center manager salary or retail enhancements. These two additions to this effort will effectively increase visitor traffic and sales which will directly increase capacity at the Resource Center to serve our community. Budget note: The two line items under "other" on the County funding request page 3 are for assistance with inventory ($1,500) and retail fixtures ($1,500). 95 O Ka'u Kakou Ka'u Family Fun Fest Agency Name: 0 Ka'u Kakou Program Name: Ka'u Family Fun Fest Agency Director: WS Kawachi Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 928 — 0027 Mailing Address: Address: PO Box 365 Address: • City,ST,zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: City,ST,Zip Pahala, HI 96777 Email Address: ebertn004 @hawaii.rr.com Fax No.: (808) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $7000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $00 $15,000 $8,000 2.Agency Mission Statement: To foster health and prosperity for all of Ka'u EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka'u Family Fun Fest 3. Program Description: The Ka'u Family Fun Fest is an annual event to offer fun, healthy activities while raising funds for different causes in Ka'u. 4.Total Budget&Position Count: Total Program Budget: $7,000 Total Program Position Count: $00 Total Agency Budget: $70,000 Total Agency Position Count: $00 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County grant $6,000 TOTAL: $6,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Any help we get from the County helps us give more of the proceeds to the community project for which we are trying to help raise money. In 2012 we did not have a specific project but had an adult bingo and lunch, and bouncy games,shave ice and hot dogs for the keiki on the 4th of July. We plan to use funds raised from shave ice, and hot dogs and our recycle program to supplement county funds received. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka'u Family Fun Fest 7. Program Objectives Using County Nonprofit Grant Program Funds: To have a 4th of July event where the family gather for games for the keiki and to have bingo and lunch for adults. 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.) Served 400 hot dogs to the keiki 500 hot dogs Served 600 shave ice to the keiki 800 shave ice Had 68 bingo participants 80 participants Served 107 adult lunches 125 lunches Had 39 volunteers 50 volunteers Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Req Actual* Total Budget Salary and Wages $00 $00 $00 Professional Fees $00 $00 $00 Operations $5067 $5600 $5600 Supplies $112 $380 $380 Equipment $840 $890 $890 Other: Other: Other: Other: Other: TOTAL $6019 $7000 $7000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka'u Family Fun Fest 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 conflict is needed. 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): 0 No conflicts exist(No further information required. Please sign form at the bottom.) 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: v),..0_11 J J J 9/Qil Signs ure of Authorized Person (specify title) , Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka'u Family Fun Fest 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 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 , 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 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, 2014 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. A/ ✓ _ /� � //,Z 9'420/5 Si. ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka`u Family Fun Fest 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 400 hot dogs served to the Keiki 500 hot dogs 600 shaved ice served to the Keiki 800 shave ice 68 bingo participants 80 participants 107 adult lunches served 125 lunches 39 volunteers 50 volunteers TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $00 Professional Fees $00 Operations $5600 Supplies $380 Equipment $890 Other: Other: Other: Other: Other: TOTAL $7000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 all O Ka' u Kakou Ka'u Sanitation Program Agency Name: 0 Ka'u Kakou Program Name: Ka'u Sanitation Program Agency Director: WS Kawachi Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 928 — 0027 Mailing Address: Address: PO Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: City,ST,Zip Pahala, HI 96777 Email Address: ebertn004 @hawaii.rr.com Fax No.: (808) 928 — 8981 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $8500 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $00 $6,755 $1000 2.Agency Mission Statement: To foster health and Prosperity for all of Ka'u EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka'u Sanitation Program 3. Program Description: To provide a means to keep those areas sanitary where there is no restroom facilities. 4.Total Budget& Position Count: Total Program Budget: $8500 Total Program Position Count: $00 Total Agency Budget: $70000 Total Agency Position Count: $00 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County grant $7000 Recycle Program $1300 TOTAL: $8300 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We have used some of our recycle money to pay for the portable toilets. We would like the County to continue helping with this program so that we might use other donations and money received from our recycling program to fund our Senior's program which we are not asking for funding. We continue to look for new venues for fund raising and community donations to become self-sustaining. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka'u Sanitation Program 7. Program Objectives Using County Nonprofit Grant Program Funds: To provide portable toilets at Punalu'u boat ramp, South Point visitor area, and for the Ka'u "at risk" youth 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,volunteer hours,etc.Describe,be specific.) Provide 2 portable toilets at Punalu'u boat ramp 2 portable toilets Provide 2 portable toilets at South Point fishing &visitor area 2 portable toilets Provide 1 portable toilet for the Ka'u at risk program 1 portable toilet Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Grant Req Actual* Total Budget Salary and Wages $00 $00 $00 Professional Fees $00 $00 $00 Operations $8300 $8500 $8500 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $8300 $8500 $8500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka'u Sanitation Program 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 conflict is needed. 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): Lr. No conflicts exist(No further information required. Please sign form at the bottom.) EllMember 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 genera!to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: • 1419 /.. Q/,3, Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka'u Sanitation 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. 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 , 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 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, 2014 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. IZ -, 81))-621 (74 JLi- / A9,q /o Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka'u Sanitation Program 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide 2 portable toilets for Punalu'u boat ramp 2 toilets Provide 2 portable toilets for the South Point fishing &visitor area 2 toilets Provide 1 portable toilet for the Ka'u "at risk" program 1 toilet TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $00 Professional Fees $00 Operations $8500 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $8500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 97 O Ka' u Kakou Punalu'u Annual Fishing Tournament Agency Name: 0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament Agency Director: WS Kawachi Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 928 — 0027 Mailing Address: Address: PO Box 365 Address: City,s-r,zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: City,ST,zip Pahala, HI Email Address: ebertn004 @hawaii,rr,com Fax No.: (808) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $9000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $00 $6000 $6000 2.Agency Mission Statement: To foster health and prosperity for all of Ka'u EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: 0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 3. Program Description: To have an annual fishing tournament for keiki ages 1 year to 14 years old. 4.Total Budget&Position Count: Total Program Budget: $9,000 Total Program Position Count: $00 Total Agency Budget: $70,000 Total Agency Position Count: $00 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County grant $7,000 Donations $700 TOTAL: $7,700 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We plan to reuse our equipment from previous years. We continue to seek donations and while the community continues to support the efforts of 0 Ka'u Kakou we have used non-specified donations to continue the programs for which we are not asking the county's help to maintain. We continue to look for new venues for fund raising and community donations to become self-sustaining. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: 0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 7. Program Objectives Using County Nonprofit Grant Program Funds: To promote a healthy love for the art of shore-line fishing, by providing an opportunity for family participation in a supervised fishing tournament. Each child up to the age of 14 must be accompnied by a parent or guardian in this catch and release tournament. 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.) 2012 - 307 2013 - 324 registered fishermen 2014 - 350 fishermen 2012 - 500 2013 - 750 lunches and mornings snacks 2014 - 900 lunches 2012 - 82 2013 - 90 volunteers 2014 - 95 volunteers 2012 - 595+ 2013 - 650+ volunteer hours 2014 - 700 volunteer hours Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $00 $00 $00 Professional Fees $00 $00 $00 Operations $8481 $9000 $9000 Supplies $177 $180 $00 Equipment $1079 $700 $00 Other: Other: Other: Other: Other: TOTAL $9737 $9880 $9000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: 0 Ka'u Kakou Program Name: Ka'u Family Fun Fest 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) 0 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: 4102Z, -4. ( J 1/0/9/aa>, Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: 0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 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 , 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 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, 2014 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. -,A,d 1 /:9 /act a Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: 0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 2012 - 307, 2013 - 324 registered fishermen 340 fishermen 2012 - 500, 2013 - 750 lunches and mornings snacks 900 lunches 2012 - 82, 2013 - 90 volunteers 95 volunteers 2012 - 595, 2013 - 750 volunteer hours 900 hours TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $00 Professional Fees $00 Operations $9,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $9000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 1 S Palekana Kai Ocean Safety, llc Ocean Safety Education - East Hawaii Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Education - East Hawai'i Agency Director: Marlen Fragas Phone No.: (808) 937 — 9805 Contact Person: Haden Fragas Phone No.: (808) 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/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $35,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 20,000 15,000 20,000 2.Agency Mission Statement: Palekana Kai Ocean Safety's mission is to educate community youth about ocean water safety while providing oppurtunities and alternative activities that build these young adults confidence, self-esteem, motivation and a life-long respect for the ocean and the skills needed to enjoy the ocean safely. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Program - East Hawaii 3. Program Description: Palekana Kai is a non-profit orginization that provides water safety programs such as ocean safety/awareness, ocean rescue and lifeguard training, First Aid/CPR and AED 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 various schools, programs and agencies island-wide. (see attachment) 4.Total Budget&Position Count: Total Program Budget: 35,000 Total Program Position Count: 7 Total Agency Budget: 53,000 Total Agency Position Count: 7 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate The County of Hawai'i non-profit grant 35,000 Service/Program Fees - Income 14,000 Donations 4,000 TOTAL: 53,000 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 various fundraising activities. Palekana Kai is currently charging various agencies and programs a fee for trainings in order to increase income and revenues to support our program. We have collaborated with Uncle David Fuentis in Kohala by assisting with youth affiliated with the Kahana No'eau Program as well. The County has generously awarded us with a 25,000 grant in July of 2012. These monies were used to purchase training equipment, office supplies/equipment, rental-fees, fuel, repairs, educational materials and certifications, also covered our General Liability Insurance and operation expenses. These were needed in order to provide a consistent level of delivery. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Program- East Hawaii 7.Program Objectives Using County Nonprofit Grant Program Funds: 1)Obtain equipment to expand training program and on-site activities to educate youth 2)Conduct informational classes on Ocean Awareness/Safety, First Aid/CPR/AED to enable youth to be prepared to respond to an emergency situation should one occur 3) Conduct informational classes in Lifeguarding Skills, Oxygen Administration,Bloodbome pathogens for community youth,various agencies, organizations, and residents Island-wide. 4)Decrease number of injuries, drowning and death following an emergency situation 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 diems served,workshops or events held,volunteer hours,etc Describe,be specific) Water Awareness/Safety Classes for youth 70-80 youth participants First Aid/CPR/AED Training for Youth 50-60 participants Lifeguard/Oxygen Admin/Spinal Management Training for Youth 30-40 participants First Aid/CPR/AED/Spinal Management for Adults 50-60 participants Lifeguard Training/Oxygen Admin/Bloodbome Pathogen for Adults 55-65 participants Youth able to find employment due to program certifications 10-15 youth Provide Rescue services for school events, regattas, swims, etc 2500+ participants Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages 0 0 0 Professional Fees 300 965 965 Operations 7,556 9,500 9,500 Supplies 4,095 6,545 6,545 Equipment 3,165 11,990 11,990 Other: 1,676 6,000 6,000 Other: Other: Other: Other: TOTAL 16,792 35,000 35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Palekana Kai Ocean Safety,LLC. Program Name: Ocean Safety Program-East Hawai'i 3. Program Description: Attachment Additionally the team conducts First Aid/CPR/AED,oxygen administration,spinal management,bloodborne pathogens and Lifeguard training for individuals of our community and staff of various organizations island-wide. Palekana Kai also provides rescue services at numerous ocean water sports events,such as The Business Man Race,Richardson Rough Water Swim,Long Distance Races for the Big Island Racing Association,Mayor Billy Kenoi's Health and Fitness Event,The Fire Department's Water Brigade, Paddle Board Races,High School Race,The Lili'uokalani Long Distance Race in Kailua Kona, one man races and so much more Palekana Kai's main objective is to strive to educate,strengthen and empower our youth,families and individuals of our Community to be confident and prepared to respond to an emergency situation should one occur at our beaches or recreational water sites.We have expanded our program island-wide and activities are scheduled throughout the year. We provide basic water awareness education and activities for our Pre-school and Kindergarten Keiki's.Youth between the ages of 11 and 15 complete basic skill courses and earn certificates of completion that recognize their readiness for the next levels of training.The next level includes First Aid/CPRAED, Ocean Awareness/Safety and Ocean Rescue. After completing the additional training levels youth ages 16- 18 will have the opportunity to complete a basic Lifeguard Training course and earn a Lifeguard Certification Card.This Certificate is recognized by the County of Hawai'i as evidence of meeting the primary requirements for an entry level Lifeguard 1 position.These certifications are approved by the American Red Cross. Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Program - East Hawaii 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 conflict is needed. 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): I7 I No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor ElThe 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: cm __I________ 41 7-5 13 Signature of Aut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Program - East 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, 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.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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 Au horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Program- East Hawaii 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Water Awareness/Safety Classes-Youth 70-80 First Aid/CPR/AED -Youth 50-60 Lifeguard/OxygenAdmin/Spinal Management Training for Youth 30-40 •First Aid/CPR/AED/Spinal Management for Adults 50-60 Lifeguard Training/Oxygen Admin/Bloodbome Pathogen for Adults 55-65 Youth able to find employment due to participation in program 10-15 Provide Rescue services for school events, regattas, swims, etc 2500+ TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 965 Operations 9,500 Supplies 6,545 Equipment 11,990 Other: 6,000 Other: Other: Other: Other: TOTAL 35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 �J Palekana Kai Ocean Safety, llc Ocean Safety Education - West Hawaii Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Education - West Hawai'i Agency Director: Harlen Fragas Phone No.: (808) 937 — 9805 Contact Person: Harlen Fragas Phone No.: (808) 937 — 9805 Mailing Address: Address: 980 Railroad Avenue Address: City,sr,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/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $35,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 20,000 15,000 20,000 2.Agency Mission Statement: Palekana Kai Ocean Safety's mission is to educate community youth about ocean water safety while providing oppurtunities and alternative activities that build these young adults confidence, self-esteem, motivation and a life-long respect for the ocean and the skills needed to enjoy the ocean safely. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Program -West Hawaii 3. Program Description: Palekana Kai is a non-profit orginization that provides water safety programs such as ocean safety/awareness, ocean rescue and lifeguard training, First Aid/CPR and AED 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 various schools, programs and agencies island-wide. (see attachment) 4.Total Budget&Position Count: Total Program Budget: 35,000 Total Program Position Count: 7 Total Agency Budget: 53,000 Total Agency Position Count: 7 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate The County of Hawai'i non-profit grant 35,000 Service/Program Fees - Income 14,000 Donations 4,000 TOTAL: 53,000 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 various fundraising activities. Palekana Kai is currently charging various agencies and programs a fee for trainings in order to increase income and revenues to support our program. We have collaborated with Uncle David Fuentis in Kohala by assisting with youth affiliated with the Kahana No'eau Program as well. The County has generously awarded us with a 25,000 grant in July of 2012. These monies were used to purchase training equipment, office supplies/equipment, rental-fees, fuel, repairs, educational materials and certifications, also covered our General Liability Insurance and operation expenses. These were needed in order to provide a consistent level of delivery. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Program -West Hawaii 7.Program Objectives Using County Nonprofit Grant Program Funds: 1) Obtain equipment to expand training program and on-site activities to educate youth 2)Conduct informational Basses on Ocean Awareness/Safety, First Aid/CPR/AED to enable youth to be prepared to respond to an emergency situation should one occur 3)Conduct informational classes in Lifeguarding Skills, Oxygen Administration,Bloodbome pathogens for community youth,various agencies, organizations, and residents Island-wide. 4)Decrease number of injuries, drowning and death following an emergency situation 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 dients served,workshops or events held,volunteer hours,etc Describe,be spedfic) Water Awareness/Safety Classes for youth 70-80 youth participants _First Aid/CPR/AED Training for Youth 50-60 participants Lifeguard/Oxygen Admin/Spinal Management Training for Youth 30-40 participants First Aid/CPR/AED/Spinal Management for Adults 50-60 participants Lifeguard Training/Oxygen Admin/Bloodbome Pathogen for Adults 55-65 participants Youth able to find employment due to program certifications 10-15 youth Provide Rescue services for school events, regattas, swims, etc 2500+ participants Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 300 965 965 Operations 7,556 9,500 9,500 Supplies 4,095 6,545 6,545 Equipment 3,165 11,990 11,990 Other: 1,676 6,000 6,000 Other: Other: Other: Other: TOTAL 16,792 35,000 35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Palekana Kai Ocean Safety,LLC. Program Name: Ocean Safety Program-West Hawai'i 3. Program Description: Attachment Additionally the team conducts First Aid/CPR/AED,oxygen administration,spinal management,bloodborne pathogens and Lifeguard training for individuals of our community and staff of various organizations island-wide. Palekana Kai also provides rescue services at numerous ocean water sports events,such as The Business Man Race,Richardson Rough Water Swim,Long Distance Races for the Big Island Racing Association,Mayor Billy Kenoi's Health and Fitness Event,The Fire Department's Water Brigade, Paddle Board Races, High School Race,The Lili'uokalani Long Distance Race in Kailua Kona, one man races and so much more Palekana Kai's main objective is to strive to educate,strengthen and empower our youth,families and individuals of our Community to be confident and prepared to respond to an emergency situation should one occur at our beaches or recreational water sites.We have expanded our program island-wide and activities are scheduled throughout the year. We provide basic water awareness education and activities for our Pre-school and Kindergarten Keiki's.Youth between the ages of 11 and 15 complete basic skill courses and earn certificates of completion that recognize their readiness for the next levels of training.The next level includes First Aid/CPRAED, Ocean Awareness/Safety and Ocean Rescue. After completing the additional training levels youth ages 16- 18 will have the opportunity to complete a basic Lifeguard Training course and earn a Lifeguard Certification Card.This Certificate is recognized by the County of Hawai'i as evidence of meeting the primary requirements for an entry level Lifeguard 1 position.These certifications are approved by the American Red Cross. Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Program - West Hawaii 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor I 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: I I � Signature of Aut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Program -West Hawaii 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.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, 2013 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. 0/W 1 .25 /23 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Program-West Hawaii 12.COUNCIL AWARD WORKSHEET TABLE I: Applicant PROGRAM PERFORMANCE MEASURES Cowl Proposed Projected Results Projected Result Water Awareness/Safety Classes-Youth 70-80 First Aid/CPR/AED-Youth 50-60 Lifeguard/OxygenAdmin/Spinal Management Training for Youth 30-40 First Aid/CPR/AED/Spinal Management for Adults 50-60 Lifeguard Training/Oxygen Admin/Bloodbome Pathogen for Adults 55-65 Youth able to find employment due to participation in program 10-15 Provide Rescue services for school events, regattas, swims, etc 2500+ TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 965 Operations 9,500 Supplies 6,545 Equipment 11,990 Other: 6,000 Other: Other: Other: Other: TOTAL 35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 100 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.: (808) 937 — 9805 Contact Person: Harlen Fragas Phone No.: (808) 937 — 9805 Mailing Address: Address: 980 Railroad Avenue Address: City,s-r,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/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $25,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 0 2.Agency Mission Statement: Palekana Kai's mission is to educate and empower youth and individuals of our community to be confident and able to utilize their skills to respond to an emergency situation safely in a Wilderness or Remote environment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Wilderness and Remote First Aid Program 3. Program Description: Palekana Kai provides Ocean Safety Education, but we have expanded to Wilderness and Remote First Aid training to those of our community. The program consists of practical exercises, classroom lecture, skills practice, and realistic scenarios to teach assessment, and advanced first aid techniques, extended care, transports and evacuations and dealing with emotionally upset individuals. Basic first aid skills are covered making this course appropriate for anyone regardless of experience level. Those who successfully complete this course will receive the "ARC" Wilderness and Remote First Aid certificate which is valid for 2 years. 4.Total Budget& Position Count: Total Program Budget: 25,000 Total Program Position Count: 7 Total Agency Budget: 0 Total Agency Position Count: 7 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate The County of Hawai'i non-profit grant 25,000 TOTAL: 25,000 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 various fundraising activities. Palekana Kai is currently charging various agencies and programs a fee for trainings in order to increase income and revenues to support our program. We have collaborated with Uncle David Fuentis in Kohala with the Kahana No'eau Program,Wildlife Foundation and Natural Conservency Group in Ka`u. Palekana Kai respectfully requests a 25,000 grant from the County of Hawai'i in order to purchase training equipment, office supplies and equipment, educational materials and certifications, General Liability Insurance and operation expenses. These are needed in order to provide a consistent level of delivery to our students. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Wilderness and Remote First Aid Program 7.Program Objectives Using County Nonprofit Grant Program Funds: 1)Obtain the proper equipment to expand training program and on-site activities to educate individuals 14 years of age and above 2) Conduct informational classes in Wilderness and Remote First Aid Training to those of our community so they are able to respond to an emergency situation should one occur 3) Obtain educational materials to provide a consistant level of delivery 4) Decrease and/or prevent number of injuries and death following an emergency situation 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 dients served,workshops or events held,volunteer bows,etc Describe,be specific) Provide informational lasses for youth 14-17years of age 20-30 participants Provide informational classes for adults of our community 40-50 participants Provide training for community and at-risk youth 14-17 years of age 20-30 participants Provide training for individuals and various programs, organizations 50-60 participants Empower individuals to respond to an emergency situation 80% Prevent injuries and death 90% Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages 0 0 0 Professional Fees 0 1,000 1,000 Operations 0 10,070 10,070 Supplies 0 1,500 1,500 Equipment 0 12,430 12,430 Other: Other: Other: Other: Other: TOTAL 0 25,000 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Wilderness and Remote First Aid Program 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 conflict is needed. 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): lr l No conflicts exist(No further information required. Please sign form at the bottom.) nMember 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: cf0 //i5g1/43 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Wilderness and Remote First Aid 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. (27q. //z //3 Signature of Authorized Person (specify title) e EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Wilderness and Remote First Aid Program 12.COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Provide informational classes for youth 14-17 years of age 20-30 Provide informational classes for adults of our community 40-50 Provide training for youth and at-risk youth 14-17 years of age 20-30 Provide training for individuals and various programs/organizations 50-60 Empower individuals to respond to an emergency situation 80% Prevent injuries and death 90% TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 1,000 Operations 10,070 Supplies 1,500 Equipment 12,430 Other: Other: Other: Other: Other: TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 101 Paradise Ponies, Inc Carousel of Aloha - Sourcing Local Woods Agency Name: Paradise Ponies, Inc. Pro:ram Name: Carousel of Aloha - Sourcing Local Woods Agency Director: Katherine Patton Phone No.: (808) 315 — 1093 Contact Person: Katherine Patton Phone No.: (808) 315 — 1093 Mailing Address: Address: PO Box 1030 Address: City,ST,Zip Kurtistown, HI 96760-1030 Facility Address: Address: 17-995 Volcano Rd (Temporary) Address: City,sr,Zip Mountain View, HI 96771 Email Address: CarouselOfAloha @gmail.com Fax No.: (808) 968 — 1733 Accountant/CPA: Nancy J. Kramer, CPA Phone No.: (808) 965 — 2729 Firm(if applicable): Mailing Address: Address: PO Box 1519 Address: City,sr,zip Pahoa, HI 96778 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $1 0,000.00 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0.00 $0.00 $0.00 2.Agency Mission Statement: Our mission is to create, develop and maintain the first permanent hand carved, Hawai'i themed carousel, pavilion and park on the Island of Hawai'i, providing a unique community recreational, educational, art and cultural center for people of all ages, while uniting each of our diverse island communities in a collective statewide art project. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Paradise Ponies, Inc. Program Name: Carousel of Aloha- Sourcing Local Woods 3.Program Description: This program will help fund the purchase of wood to carve carousel figures, train others to carve carousel figures using Albizia wood, and promote the Carousel of Aloha to a much wider audience including schools, seniors and other residents and visitors in Hawai'i. Background: Our original plan for carving carousel figures involved using traditional basswood which is procured from the mainland at a cost of$3/board feet. We have since discovered that Albizia wood, commonly considered to be useless or worse and found abundantly in Hawai'i can be successfully used at a cost of only$2/bf. Purchasing Albizia wood creates additional revenue to local businesses and develops a commercial viability for this otherwise junk wood. 4.Total Budget&Position Count: Total Program Budget: 16,000.00 Total Program Position Count: 0 Total Agency Budget: 4,000,000.00 Total Agency Position Count: 0 5.Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Individual Donations (Collection Boxes) 330.00 Rummage Sales 1,440.00 Event Proceeds 1,000.00 Volunteer Hours (current two-year total approximately 7255)(3500/2013-14) Charitable Contributions (Non-collection box donations) 1,880.00 Training Workshops (6 workshops - 8 participants - $30/ea) 1,440.00 TOTAL: 6,090.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1) grant submissions 2) training workshops charging participant fees 3) fundraising events (rummage sales, Hilo Orchid Society Show, Christmas in the Country Fair, etc.) 4) requesting individual charitable contributions through Have a Heart, internet donations, and informational displays at community events such as Hilo Coffee Mill Farmers' Market, Hilo Orchid Society Show, Girl Fest at UHH, and Lei Day at East Hawai'i Cultural Center. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Paradise Ponies, Inc. Program Name: Carousel of Aloha- Sourcing Local Woods 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) to develop a locally available source of wood from which we can carve our carousel figures 2) to demonstrate the commercial viability of lumber derived from trees commonly considered to be useless or worse 3) to train carver/teachers to produce carousel animals 4) to promote the Carousel of Aloha to a wider audience, especially among schools 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.) Teachers and/or Volunteers Trained 3 Carving Workshops Held 6 Local Wood Sourced (Albizia) 5000 board feet Carousel Figure Blanks Made and Carving Begun (using Albizia) 2 Presentations to Schools Regarding Carousel and Local Woods 4 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Re q Salary and Wages Professional Fees Operations 90.00 Supplies 16,000.00 10,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 16,090.00 10,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Paradise Ponies, Inc. Program Name: Carousel of Aloha- Sourcing Local Woods 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 conflict is needed. 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): © No conflicts exist(No further information required. Please sign form at the bottom.) 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: 44 '1 P sinrrUT /-3l- ,,2O/3 Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Paradise Ponies, Inc. Program Name: Carousel of Aloha - Sourcing Local Woods 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 Hawaii Compliance Express, and be compliant prior to final payment. To register,go to -tto:/fvendors.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.gav/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, 2014 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. .�/ •� 0 / Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Paradise Ponies, Inc. Program Name: Carousel of Aloha - Sourcing Local Woods 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Teachers and/or Volunteers Trained 3 Carving Workshops Held 6 Local Wood Sourced (Albizia) 5000/bd ft Carousel Figure Blanks Made and Carving Begun (using Albizia) 2 Presentations to Schools regarding Carousel and Local Woods 4 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies 10,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 10,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 103 Puna Community Medical Center Uninsured/Underinsured Fund Agency Name: PUNA COMMUNITY MEDICAL CENTER-Agency Name Program Name: UNINSURED/UNDERINSURED FUND- Program Name Agency Director: Daniel DiDomizio Phone No.: (808) 930 — 6001 Contact Person: Rene Siracusa Phone No.: (808) 965 — 2000 Mailing Address: Address: 15-2662 Pahoa Village Rd Address: Suite 306, PMB 8741 City,ST,Zip Pahoa, HI, 96778 Facility Address: Address: 15-2662 Pahoa Village Rd, Address: Suite 303 City,ST,Zip Pahoa, HI, 96778 Email Address:dand @punahealth.org Fax No.: (808) 930 — 6007 Accountant/CPA: Nancy Kramer CPA Phone No.: (808) 965 — 2729 Firm (if applicable): Mailing Address: Address: P.O. Box 1519 Address: City,ST,Zip Pahoa, HI, 96778 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $120,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $50,000 $59,500 $115,000 2.Agency Mission Statement: [From above: PREVIOUS NONPROFIT GRANT FY 12-13 =>$64,000] To provide readily accessible health care to the residents of, and visitors to, Puna District. We have promised the community we serve to strive to be open seven days a week, including half days on Sundays and all holidays. We have also promised too offer a broad spectrum of acute care services; including acute illness and minor injury, with the ability to stabalize patients with severe problems and get them transferred to the Hilo Medical Center's Emergency Department. PCMC offers all it services to all who seek care without descrimination, regardless of their ability to pay. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: PUNA COMMUNITY MEDICAL CENTER-Agency Name Program Name: UNINSURED/UNDERINSURED FUND- Program Name 3. Program Description: PCMC was established in 2009 by and for the community it serves to address the problem of access to health care services. Since the 2000 Census, the Puna District has grown 24%, from 31,335 to 45,000+. The District now comproses two County Council Districts. Despite the efforts of Hawai'i's health service community and other agencies across the Big Island to remedy provider shortages and unimployment, Puna still has federal designations as a Health Professional Shortage Area (HPSA) in Primary Care, Mental Health and Dental Health. It also carries a Medically Underserved Area (MUA) designation as well. Simply put, access to health care services has not kept up with population growth, and the problem is only getting worse. [cont. new sheet] 4.Total Budget&Position Count: Total Program Budget: $120,000 Total Program Position Count: 3 Total Agency Budget: $573,620 Total Agency Position Count: 9 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate HSEDC; FY2011-12 =$115 (ACTUAL), FY 2012-13 = $64,000 $120,000 OTHER GRANTS IF ELIGIBLE [Young Brothers FY 2012-13 = $1,000] Unknown BENEFITS AND FUNDRAISERS Unknown TOTAL: $120,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Unlike regular clinic operations for insured patients where insurance payments support the provision of care, this program, by definition, will bring in little or no income. Only those clients able to pay our minimum $25 fee will help sustain these services. The value of those services averages more that $150 per visit. If we have adaquate HSEDC funds ($120,000), we are able to collect about $100 per visit (-66%). If we have less than that, then services are provided without reimbursement. Uninsured visits have increased in every callendar year since we opened; 546/2009, 922/2010, 1018/2011, 1084/ 2012. We expect an increase of about 12% to 1214 this next year. => [continued on continuation sheet] EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: PUNA COMMUNITY MEDICAL CENTER-Agency Name Program Name: UNINSURED/UNDERINSURED FUND- Program Name 7. Program Objectives Using County Nonprofit Grant Program Funds: HSEDC funds will be used to afford PCMC the ability to provide services to the uninsured and to survive while doing that. We will continue to provide acute care for common medical problems including; infections of the Skin; the Respiratory System (flu, colds, bronchitis, asthma); of the digestive System (enteritis, diverticulitis); of the Genital-Urinary Tract (bladder infections, STDs); and so on. We will also manage cuts and abrasions, sprains and strains,contusions and fractures, etc.). These will be provided 365 days per 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.) 2011(actual) 2012 (actual) 2013-14 (estimated) Patient Visits /month 467 591 662 Pt's covered by this prog/mo 773 807 904 To be opened 365 days/yr 363 363 365 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: 115,000 135,382 120,000 Other: Other: Other: Other: TOTAL 115,000 135,000 120,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: PUNA COMMUNITY MEDICAL CENTER- Agency Name Program Name: UNINSURED/UNDERINSURED FUND- Program Name 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Rene Siracusa POSITION: President, PCMC Board of Directors May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): IN No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor n 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: Our current Board President, Rene Siracusa, has serves as vice-chair of the Hawaii County Planning Commission, and as chair of the Hawaii County Redistricting Commission. She is currently serving a 4-year term on the Puna Community Development Plan (PCDP) Action Committee. All these were and are voluntary positions, and she gains no financial benefit fro any of them. /i& - C6-4 fc� t Pr`oyr' s �,�: //7040/ Si ure df Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: PUNA COMMUNITY MEDICAL CENTER- Agency Name Program Name: UNINSURED/UNDERINSURED FUND- 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'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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. t,2 c/(14/C' ?/ 'aç tiu("/. /130 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 PUNA COMMUNITY MEDICAL CENTER —Agency Name Uninsured/Underinsured Fund — Program Name Continuations from basic application form; Item 3- Program Description; cont. =>Since opening, PCMC has managed 20,125 visits through December 2012. Approximately 20% of these were uninsured. In FY 2011-12 (7/1/2011- 6/30/2012) we saw 6,104 visits, approximately 1220 were uninsured or under insured. Although the State DOH Primary Care Needs Data Book lists Puna as having 15.9% of adults without health insurance, the figure of uninsured clients walking through our doors (including children) is actually much higher. However, in keeping our promise to the community, we turn no one away. Our 2012-13 HSEDC grant of$64,000 covered only 67% percent of the cost of providing those services; the balance had to be written off as unreimbursed care. Because we were not covering those costs, we also had to abandon our prescription supplement plan; we were no longer able to provide prescription vouchers to help cover the costs of medications. Although we have a sliding fee scale, and the minimum fee is only$25.00, many of our clients find even this unaffordable. If they do have the $25,they often have no money left to purchase prescription medications. We have no reason to believe these circumstances will change. Puna has some of the worse economic indicators in the state, and the fastest growing population. PCMC is averaging more than 500 clients per month and we are predicting an annual increase of about 12%this year. We wish to continue the uninsured program, including prescription vouchers, and continue to help meeting the needs of our community...and to survive financially. Item 6- Explain why the agency/program has to increase revenues to support Program. [cont.]; =>By its very nature,there is no way for this program to become completely self sustaining because it provides health services to clients without insurance, who have little or no money. These folks either come to us and get the care they need, or they defer treatment often making their problems worse and winding up in hospital. With contagious diseases, untreated clients would spread the contagion throughout the island community. We predict that the increase in the number of visits will be paralleled by a similar increase in the number of uninsured individuals seeking care: 405 in 2009; 660, in '10; 773 in '11; 807 in 2012. A twelve percent increase would bring us an additional 97, or about 904 uninsured individuals this next year. We have applied for a Rural Health Clinic (RHC) federal designation, and hopefully will have that before the end of 2013. An RHC designation will bring us higher reimbursements from Medicare, possibly from the various Medicaid programs (including MedQuest), and possibly from private insurers as well. However, this will not affect the income from clients without any insurance coverage. With the RHC designation, we may also be eligible for grants from the state and federal governments. [PCMC has never had support from either the state or Washington.] PUNA COMMUNITY MEDICAL CENTER —Agency Name Uninsured/Underinsured Fund — Program Name Item 6-continued; PCMC enjoys considerable community support, but our fundraising efforts do not bring in the amounts of money we need to sustain this program. The community we serve is the most economically depressed in the county and 2nd most depressed in the entire state. We cannot expect that our rummage sales, bottle and can collections, musical events, individual donations, and so on, will be able to support this program. We will continue to seek government grants, but the private sector has nearly dried up. The competition for private foundation and corporate grants is fierce, and frequently they are focused on their own geographic area. HSEDC funds, therefore, are more important than ever. Agency Name: PUNA COMMUNITY MEDICAL CENTER-Agency Name Program Name: UNINSURED/UNDERINSURED FUND- Program Name 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 IIM Society for Kona's Education & Art (SKEA) Art Camps for Children & Teens Agency Name: oc tC 1a'S Ec UcC1t o E Art- CS t FA) Program Name: -Afs pS ( i d;re.vl Cr e-e- IS Agency Director: SU i,C,y\ P .��C.� Phone No.: (gam 3R G15(Q I �, , Contact Person: '4 USt1e in NJ. P.t a e_ Phone No.: ($0$)32- 93 2 o f( Mailing Address: Address: P O BD X 25 Q [t i Address: City,ST,Zip —thY .A-. . Ct 10124 Facility Address: Address: $"1— S LQ I tied/vet-la-Loa . Address: (� / City,ST,Zip �tN\t►Lt t'O.LL , 't . "t(0 32k Email Address: 5ke& AaNA/Ca.; . rte. co An Fax No.: ( 32f-9 Si L Accountant/CPA: ?Ot,t.4.1 f b i t f"') -fret)SW-e- -' Phone No.: ( ) Firm (if applicable): 1+I' oul o�-1/100 .cam, Mailing Address: Address: tSf'C� y Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 119' eir 2.Agency Mission Statement: �p a- -P.0 S on Soo`'E"C- -Kowa, , ( +rte & - d- -ker tck� 8,0 CC + e-p- ,(1-r!-- S gyres -the-, 0e, k • •s toy. ,'►roV Lot r ct.,r�i-c c ri %e.cto cry a►,,.�,I o po►�-�nl �I.�s tttro� k v�.ms &pine u , C.b Inn Pr\ ni.1-17 EXHIBIT A NONPROFIT GRANT APPLICATION Pf 2013-2014 Page 1 of 7 SOC-te, kOVNO's -Pdt) ; ( tr (skis Agency Name: Program Name:'r1- yin s alltarelit ondi Tee.h5 3.Program Description: Local teaching artists offer a variety of activities such as painting, ukulele,magic, mixed media, mask- making, pottery,dance,theatre arts,and other diverse and enriching activities.High school students are hired and trained to act as counselors and teaching assistants;we hold a one-day training for the counselors before each camp that includes a seminar in job expectations and group management,and an art workshop designed just for them.The camps will be held during the school breaks,Mon.-Fri., 8:30AM—2:30 PM. The art camps provide a fun learning experience for out-of-school children, strengthen our sense of community,provide families a safe,affordable, and educational camp activities, and provide local teens with purposeful work and the opportunity to learn about art,teaching art,how to care for children,community service,and organizational skills. 4.Total Budget&Position Count: 2.0(3 — 2c I LI-- Total Program Budget: .45 goo, Total Program Position Count: 10 Total Agency Budget: 62,6,p0©. Total Agency Position Count: ((Q 5.Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Sk-c e., �10 crn U-u re 'tri►o t-s 5 oo. Ku D �VY+Vh U Ytii �y Utf,ci 5)boo 1". t k\ y cs V chit Vic 2,0 c . V$S,t s41 van. 5 000. QL� D� �-i''t 4c-� 5�. kPAc s n in �d �'o©_is -FLU on TOT! - Attach additional pages,if needed. �� 6.Explain what plans your agency or program has to increase revenues to support this program: We will continue to write grant proposals to local foundations for support for the Art Camp program. We will put on as many weeks of art camp that we have funding for,up to six weeks per year.The funding sources listed above are sources that are reliable,although the amounts may vary from year to year. We reduced the tuition in 2009 because of the economy,but raised the tuition to its prior level last year; raising tuition beyond its current level ($125 per week)would not be feasible in this economy and in this economically disadvantaged community. SKEA offers tuition discounts(for early sign-up and multiple children) and scholarships,when available.For the 2013-2014 FY, we are applying for the first time for a Grant-in-Aid from the state legislature and to this County non-profit program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 ; Page 2 of 7 �octe -K6ria's Ed u L -t— Art Camp Program Budget SY 2013-2014 6 weeks of camp Income: State Foundation on Culture&the Arts $3,500 the portion of award to be used for art camps Kukio Community Fund $5,000 projected-we get this every year. Charity Walk 500 the portion of award to be used for art comps 2014 Kona Brewers'Festival 5,000 projected Grant-inAid 7,200 projected-portion of award to be used for art camp County non-profit grant 5,000 projected Total projected income from grants $26,200 Tuitions 19,200 projected-6 fup weeks @$125/child x 28 children (3,500 per week less $1,800 in discounts.) SKEA scholarship fund 500 Total income: $45,900 Expenses-Per WEEK teaching artists — 2,000 " Teen Counselors 1,280 4 counselors x$8/hr.x 40 hrs. Program Director — 600— art supplies 750 Adult On-site supervisor 1,000 40 hrs.x$25/hr. SKEA facility use 750 Marketing 400 Administration&bookkeeping 750 Tshirts for counselors 120 TOTAL projected expenses 7,650 per week TbT'AL P 6)X W KS oFCAHP 45',(-im Ube,0.4( u¢s l+n 5;CD() . -Przym -- 0000 \2lP C--(3),(34 Uu ks o A-rh- camp t u--)-e2k. in gall , 13 1 - WeQJL S1 r i n5 20 t�- a.,Inct A 1uue. s irn utile_ 2,0 4 Agency Name: SC.�.Ie. ISa t - � ` �V C 5 � Program Name: Ay-k- �S atu, rein �tn5 7.Program Objectives Using County Nonprofit Grant Program Funds: 501. 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.) , n - 0-14' t ezIras 3a2 -a11 y�(?�'�ca�l� - vt avaluoL vn.s ae vi1-s -1-+ tri tea'1,%:s -s - !Mewl �t1a.�.ucxftn�e �r Gz -6 e_ pro roc.w�n cY��c r - t,r'ec - plea Se ,Vai can la boa v S --- - I,aUI✓t o.�- o -E-1�,� t---f)1�,� `'sue to wt, t A additio a/pa es as nece ary �►+y s t v S t V;c,M rah nS t 62 Loks . 9.TABLE II: p F•Ca r1 " 30 ArVi- - -YI(1 S— FY 12-13 A'13-14 FY 13-14 PROGRAM EXPENDITURES s _ Actual* Total Budget Grant Req Salary and Wages ` Professional Fees kr+M-5 a0 00,Se.�o-r� PY-,4r`eer "bt r. toi 9,15 2' ,280. 210 60• Operations � �h l s k DO _ 1 Ice '4 5-60 - - Supplies so , S� . �- PI° �► 9��c:, �� �7 -4,500 . `T5c Equipment - - Other:- mow DA-site- &Tier rinser 2 �1 (o)000. 6trt9 Other: Gl.y'V.e.±l.l,Nd.,/ex 1 �}UfJ, �� oo 00_ Other:-pi Qc) 1 �l 6�ex\A O cavytr p&�f YVY L ;.3©t .,t ( 00. Other: t t! U�2� 4 co. "I 5 OD. . Other: `�' „ D. j 0o• t_ TOTAL l�)! (o 4 ,-mo.5, oo s I�Lgs Q2C.' 2Yls�Wa S tow toe....cause. We. *If applicable v �pIP t 40,, our C-L rre--4- , gracI4eci 1'1 V°e.tn v C�y.Gt. ENE. G►eS N e�c Gi,��t v l}te_S 1,p e-.' EXHIBIT A 111"a-f u .�, 5v pp i ces . NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Society for Kona's Education&Art Proposal for FY 2013-2014 Page 3-addition 7.Program Objectives Art Camps and for Children and Teens and the Teen Counselors Program • Expose students ages 5-18 to the arts and to working artists and their materials, improving their artistic skills and knowledge,and stimulating creative thinking and communication. • Provide meaningful work experience to teens ages 14-18 in our community,giving our young people the opportunity to learn responsibility,cooperation,organization,as well as providing specific job skills and monetary compensation. • Increase the availability of culturally enriching activities for children and young people in our community. • Provide a safe venue for fun and educational activity during the school breaks. 8.Table 1: Program Performance Measures Attendance Records-we can accommodate up to 30 children at the camp. We expect to enroll between 25-30 each week (based on prior enrollments). Written evaluations by parents&teaching artists-we distribute a one page evaluation that we ask all parents to fill out. We make an effort to get them back and usually we receive about 10 back each week. Teaching artists are required to fill it out. Written evaluative report by the Program Director-describes the activities,participation, and observations on the children's level of engagement,their behaviors.Narrates the positive and negative aspects of the camp-what needs to be improved,etc. Direct observation by Board& Staff-several Board members act as teaching artists,and there is usually extra staff on the premises during camp. Level of creative output by students-projects completed-the students' level of engagement and focus, and whether they complete their project, is a good indicator of the quality of the project. Photographs-we will document the activities with photos. Agency Name: ge3C-Lia,1-9Ctsirt,11.015 Ed L$1 o� Ad-- Program Name:<}r}- C.rn p s - On 1 td, rev d ,r s 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 conflict is needed.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): XNo conflicts exist(No further information required. Please sign form at the bottom.) 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: eri,varrvezWe_4_ 7 --)c ec,u n VE b l kEc 1.1 i, Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: &Xt -Gr k� 'S Edo ca-ioll c 74r- Program t--- Name: Q. Lm p s - reo Teen 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 •1. . t: t in. r •Viz. • - ,l • r- LL • • u Z 1�1 '- • -' -.• _ 11% L' -__.- •_ _ • , l • u. 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 30,2014 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. Swpc.A..„ EtoTL VE At te.c.70.15 t •Q 24t c 3 Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION PI 2013-2014 Page 6 of 7 \ Agency Name: -(,� -k �0�- j Program Name: 4hCkvps � �� a revs t- n5 12.COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFQRMANCE MEASURES Applicant Council Proposed Projected Results Projected Result .A4eAAALX4040 c,�. z$ per w k. Wr i\ ..v e eA1 cauct i- s t 5 Q+.-YYN. Y k l yery 1- . I,reG� 60 S V�Y.i�,..1't e"-y% A CO net rn .. i-s,1 e4-rho °� ►. g 5 Per aiky f, TABLE 11: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages j� Professional Fees .per , 1 DINSQ.lor S, PIPO •D tr. 21000 . Operations Ackhnvl ,I. co ,5'oo . Supplies 7 56 . Equipment ,^ Other: Arlo tk- (IN% e e cJVP?.�I1CS(>r- I.) DDO • Other: t`.lcurkti4t,.. '� b0 Other: ,1,ccA_ A 1'7.1 ut..Q� 25D . Other:—1-44),1)..s C.0 U IA S2l oy s (Otn . Other: TOTAL 51 °on. Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 105 Special Olympics Hawaii Special Olympics - East Hawaii Area Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii-East Hawaii Area Agency Director: Nancy Bottelo Phone No.: (808) 695 — 3522 Contact Person: Carey Uchida Phone No.: (808) 990 — 5751 Mailing Address: Address: P.O. Box 7265 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: None Address: City,ST,Zip Email Address: careyuchida @gmail.com Fax No.: (808) 935 — 1968 Accountant/CPA: 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, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $15,000 $10,000 $15,000 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii-East Hawaii Area 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 Hawai'i, regardless of the extent of their disability. People who are isolated from life experience 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 believes 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. (Program Description is continued on the back of this gape....) 4.Total Budget&Position Count: Total Program Budget: $131,000 Total Program Position Count: 1 Total Agency Budget: $1,600,000 Total Agency Position Count: 18 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii Nonprofit Grant $25,000 Foundations & Service Clubs $10,500 Individual contributions $11,000 Corporation contributions $4,000 Special events $40,000 SOHI Co-op monies $2,500 Merchandise sales $38,000 TOTAL: $131,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1) We are planning to expand our Mile of Quarters fundraising campaign to more businesses. 2) We are planning to add a Zippy's fundraiser that will generate between $6,000-$7,000 more. 3)We will be researching for more grants to apply for. Special Olympics East Hawaii is very diverse in how we raise money to support the athletes, families & volunteers. However, as we continue to meet our mission of continuing to outreach to new athletes, family members and volunteers within our community, & with increased costs, our budget continues to grow, so even as we get better at raising money, it continues to be difficult to reach our budget without the support of the County of Hawaii. Because so much of our program is developed around outreaching to the intellectually disabled population in our community & airfare costs, which continue to increase each vear,our budget continues to grow. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Unfortunately, appropriate physical education programs in the public schools and social service programs that realistically address the special needs of this population are virtually non-existent. The benefits for our athletes continue to be: improved physical fitness and motor skills, greater self- confidence, a more postitive 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 425 community volunteers interact with individuals with special needs within our community. Our program is free of cost to all our athletes, special partners, and coaches. All of the money raised for the East Hawaii program must be raised in East Hawaii and stays here to support our program's area budget of$131,000. Those funds will pay for all aspects of the Special Olympics program, which includes, equipment, uniforms, transportation costs, training of the coaching staff, family activities and our Athlete Leadership Program (ALPS). All coaches are required to attend a sport specific training on Oahu prior to coaching athletes. Airfare of$1,800 will be needed to be able to have 10 coaches become certified coaches for each team in our program. The County of Hawaii grant will provide the funds to enable us to have these certified coaches. Special Olympics East Hawaii is only one of 2 area programs in the State to offer a new program called the Young Athlete Program(YAP). The YAP program is for preschoolders ages 2 1/2 to 5 years old with intellectual disabilities. The program has its own curriculum which introduces the preschoolers to basic eye hand coordination activities and as the curriculum continues, it prepares the preschoolers for further training in Special Olympics' program called Future Stars as they reach 6-7 years old. Thus far we have Keaau Elementary, Mt. View Elementary, Kaumana Elementary and E.B.DeSilva Elementary preschool classes in the YAP program.We are asking $2,800 to help us provide the necessary equipment for the YAP program to grow and continue to keep the prescholers physically fit. As always, Special Olympics East Hawaii's largest expense for 2013-2014 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 smiliar 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 3 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 being exposed to a Healthy Athlete Program. This program provides a free dental screening, vision screening, hearing screening, Fun Fitness (flexibility & strength) screening, nutrition screening and podiatric screening 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. Each athlete who participated in the vision screening at the 2012 Summer Games and who required glasses, were given free glasses that were mailed to each athlete. Because of the economic difficulty here in Hawaii and around the United States, Special Olympics East Hawaii has begun to utilize a quota system for athletes traveling off island. No longer will ALL athletes be able to travel to state games, but we would like to still provide that service to as many athletes as we possibly can and with $10,000 for transportation to State competitions from the County of Hawaii we will be able to continue to provide our athletes with meaningful competitions. Another new program for East Hawaii is called the After School All Star program. This program is targeting zone schools who are not meeting the No Child Left Behind mandates. In our area, Keaau Intermediate and Pahoa Intermediate are the 2 schools in our After School All Star(ASAS) program.We provide the physical fitness aspect of the ASAS program. The ASAS program participates in unified softball and unified basketball. The program places equal number of non-disabled students on the same team as disabled students where they train and compete together. The transportation cost to get the teams to our State competitions during the school year is$10,400, which is part of the amount of our requesting as part of the County of Hawaii Non-Profit grant. Special Olympics Hawaii-East Hawaii Area is asking for$25,000 from the County of Hawaii to help fund our Special Olympics East Hawaii program activities. (#7: Program objectives using County Nonprofit grant program funds continued from page 3) 3) To provide transportation to 130 athletes, coaches & special partners three times a year, so that they may compete at each State Competition with athletes of the same ability level by June 2014. 4) To increase business participation by 2 new businesses in our Mile of Quarters campaign in order to raise more funds to cover our annual budget by June 2014. 5) To develop and conduct 1 new fundraising Hawaii event with Zippy's to help raise additional funds to cover our annual budget by June 2014. 6) To provide an opportunity to 425 community volunteers to interact with our Special Olympic athletes throughout the year, providing them with the chance to make a difference in their community by June 2014. 7) To continue to reach out to any individual with special needs in our East Hawaii community to provide them these unique experiences. Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii-East Hawaii Area 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) To provide quality sports training & Olympic type competitions in our area program to 208 athletes and 90 unified partners by June 2014. 2) To provide sports specific coaches training or recertifications for 10 coaches in various Olympic type sports & various ability levels so that they may provide appropriate training to the athletes within their delegations by June 2014. (additional program objectives are continued on the back of this page...) 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.) Number of athletes served 225 Number of unified partners served 100 Number of volunteers from the community helping our program 435 Number of family members served 100 Number of coach staff 25 Number of delegations within our area program 13 Number of area and state competitions attended 10 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Reg Salary and Wages $6,200 $6,200 0 Professional Fees 0 0 0 Operations $50,150 $47,600 0 Supplies 0 0 0 Equipment $4,400 $6,000 $2,800 Other: Coaches training costs (airfare) $1,050 $1,800 $1,800 Other: Airfare for After School All Stars Program $5,250 $10,400 $10,400 Other: Airfare for athletes to attend State Competitions $48,600 $59,000 $10,000 Other: Other: TOTAL $115650 $131,000 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii-East Hawaii Area 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) To provide quality sports training & Olympic type competitions in our area program to 208 athletes and 90 unified partners by June 2014. 2) To provide sports specific coaches training or recertifications for 10 coaches in various Olympic type sports & various ability levels so that they may provide appropriate training to the athletes within their delegations by June 2014. (additional program objectives are continued on the back of this page...) 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 athletes served 225 Number of unified partners served 100 Number of volunteers from the community helping our program 435 Number of family members served 100 Number of coach staff 25 Number of delegations within our area program 13 Number of area and state competitions attended 10 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages $6,200 $6,200 0 Professional Fees 0 0 0 Operations $50,150 $47,600 0 Supplies 0 0 0 Equipment $4,400 $6,000 $2,800 Other: Coaches training costs (airfare) $1,050 $1,800 $1,800 Other: Airfare for After School All Stars Program $5,250 $10,400 $10,400 Other: Airfare for athletes to attend State Competitions $48,600 $59,000 $10,000 Other: Other: TOTAL $115650 $131,000 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii-East Hawaii Area 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) 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: 1)C, t,.?)/C.6' -1-1--dc) ceo 1 t5. 3 Sig ature of uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii-East Hawaii Area 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 th 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 30,2014 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. tne ,t(3,r7Lit rEc) 1- 15 Sig ature Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii-East Hawaii Area 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of Athletes in our program by June 30, 2014 225 Number of unified partners in our program by June 30, 2014 100 Number of community volunteers assisting us by June 30, 2014 435 Number of family members participating by June 30, 2014 100 Number of coaches in our area program by June 30, 2014 25 Number of Delegations within our area program by June 30, 2014 13 Number of area & state competitions we attend by June 30, 2014 10 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 0 Operations 0 Supplies 0 Equipment $2,800 Other: Coaches training costs (airfare) $1,800 Other: Airfare for After School All Stars Program $10,400 Other: Airfare for athletes to attend competitions $10,000 Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 MR, The Arc of Hilo Advocacy Program Agency Name: The Arc of Hilo Program Name: Advocacy Program Agency Director: Michael E. Gleason Phone No.: (808) 935 — 8534 Contact Person: Debbie Perkins Phone No.: (808) 935 — 8534 Mailing Address: Address: 1099 Waianuenue Ave. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: Aging and Disability Resource Center (ADRC) Address: 1055 Kinoole Street, Suite 104 City,ST,Zip Hilo, HI 96720 Email Address: dperkins @hiloarc.org Fax No.: (808) 961 — 0148 Accountant/CPA: Ms. Ann Fukuhara, CPA, MBA, Accountancy Phone No.: (808) 961 — 5582 Firm (if applicable): Mailing Address: Address: 714 Kanoelehua Ave. Address: Box 6691 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: -3-5e 000. 1. Prior Year Award of County Nonprofit Grant Program Funds: .204;243 c25 /as, O e. e FY 09-10 FY 10-11 FY 11-12 $20,000 $15,000 $15,000 2. Agency Mission Statement: The mission of The Arc of Hilo is to improve the quality of life for people with developmental and other disabilities, who reside on Hawaii, through educational, vocational, and skill training as well as employment and residential opportunities. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: The Arc of Hilo Program Name: Advocacy Program 3. Program Description: Now in our fith year of service, The Arc of Hilo continues partnership with the HI County Office of Aging and Disabilities (ADRC) to provide advocacy services to people with disabilities and their families in East Hawaii. The primary objective of this program is to advocate for people with disabilities to access services they need such as Social Security and disability benefits planning, medical insurance, housing, transportation, reasonable accommodation issues, and referrals to various community services. This program is the "disability component" of the ADRC. In addition to advocacy services, the advocate is a master trainer with the Chronic Disease Self Management Program (CDSMP), which provides educational skills development to lay leaders and consumers in managing chronic diseases and delaying disability and death. 4.Total Budget& Position Count: Total Program Budget: $45,130 Total Program Position Count: 1 Total Agency Budget: 3.9 M Total Agency Position Count: 93 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate The Arc of Hilo 5,130 _ United Way 5,000 County of Hawaii 35,000 TOTAL: 45,130 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Arc of Hilo is persuing foundation grants, such as United Way, and private donations for our Advocacy Program. We are advertising our CDSMP classes on the radio and in the Tribune Herald, which will increase exposure, and reach a larger population, informing individuals of all the services we provide. In the last 6 months, economic challenges have forced cutbacks in Mr. Tanigawa's salary and hours. We are looking to reinstate Mr. Tanigawa's position to full time in FY 2013-14. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: The Arc of Hilo Program Name: Advocacy Program 7. Program Objectives Using County Nonprofit Grant Program Funds: Continue as a primary resource on disability issues at the ADRC's one-stop shop. Advocate for people with disabilities to help them access benefits, resources, and services in the community. Provide outreach educational services to individuals and community groups about disability 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.) Information* 300 Referral* 270 Outreach* 300 Advocacy* 250 Education* 50 (*Number of contacts) Number of clients served 50 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 35,000 27,000 Professional Fees 110 110 Operations 2300 2300 Supplies *360 360 Equipment Other: *2060 2060 Other: 600 600 Other: 2300 570 Other: 2400 2000 Other: TOTAL 45,130 35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Operation expenses: Telephone & Internet (Direct cost) $2300 Office Supplies: paper, ink, envelopes 360 Mileage (Direct cost) 600 Professional fees: Accounting (Direct cost) 110 Professional development: Pac Rim Conference: 3 days @ $150 per night hotel lodging: $450 Air fare; 300 Per Diem: $100 per day 300 Ground Transportation: round trip: $80.00 80 Parking: $30 30 Disability Benefits Planning training: 2 days: 300 Air 300 Per Diem 200 Transportation 80 Parking 20 $2060 Overhead Cost (Allocated) $ 570 Salary&Wages (Allocated) $2000 Agency Name: The Arc of Hilo Program Name: Advocacy Program 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Mr. Wesley Tanigawa POSITION: The Arc of Hilo Disability Advocate May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: //2_ S Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: The Arc of Hilo Program Name: Advocacy 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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. C— /9/a Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: The Arc of Hilo Program Name: Advocacy Program 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 109 The Exploration Foundation Malama Honua Agency Name:The Exploration Foundation Agency Name: Program Name: Program Name: Malama Honua,to work with our hands to care for the world Agency Director: �.Q �l FOjz-1�VU114 Phone No.: ?✓Z? 4 !S 1 Contact Person:€ t rNerzil 0r6hei (e(1 _ ` Phone No.: 32? 471-f Mailing Address: Address: 7�j— ft(.60 QU- Address: city,Sr,MP i4•2U L t,l2l. Ko Na, H'1 '(Q'74O 2 Ce$(P Facility Address: Address: sOt.vVv2- ?As" Address: City,Sr,Zip Email Address: i✓j(?(,n)2,Pti 1&W, ® m{e-a .ner ,�FaxNo.: 0,0 - 3Z/-*4, ' D Accountant/CPA: CA R 7 3P 0 Oft A4 E C No.: (P.; - Firm(if applicable): 2 -t q(l2e 1002- Mailing Address: Address: T • D. 1? O ( 470�l 2- Address: City,si,zip Flo, 1-41 gCD720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 F Y 10-11 FY 11-12 1 2.Agency Mission Statement The Exploration Foundation is a non-profit organization whose mission is to promote educational innovation through outreach, technical assistance and advocacy. In ARTICLE VII, OBJECTS AND PURPOSES of the Articles of Incorporation for The Exploration Foundation states: The PURPOSE of the Corporation is to SUPPORT West Hawaii Explorations Academy. a public charter school, organized in accordance with the laws of the State of Hawaii,and its students and teachers in their school related endeavors. The State of Hawaii precludes public schools from building a school."WHEA is a public charter school. Public charter schools do NOT receive funding for buildings whereas public schools do receive facility money.The current critical goal of The Exploration Foundation is to raise the funds to relocate the campus.WHEA needs to relocate out of the tsunami impact zone, out of the direct path of jets and still be capable to take advantage of both deep sea water and sea water. EXHIBIT A NONPROFIT GRANT APPLICATION Pt 2013-2014 Page 1 of 7 Agency Name:The Exploration Foundation Agency Name: Program Name: Malama Honua,to work with our hands to care for the world Program. Name: 3. Program Description: "Seeing something once is better than hearing it a hundred times", a Japanese proverb, the essence of project based education offered by,WHEA,West Hawaii Explorations Academy, a public charter school. Malama Honua,to work with our hands to care for the world is WHEA. WHEA provides learning opportunities through integrative, hands on, self selected projects related to authentic real world problems for students grades 6 through 12. Every morning and every afternoon the high school and middle school begin and end their day in the bleachers.Tours of the campus begin and end in the bleachers,each year approximately 2,000 students tour WHEA. For the relocation of WHEA,the AMPHITHEATER facing the Pacific will be the pivotal meeting place serving WHEA students and visitors. 4.Total Budget&Position Count. - NigeveDTotal Program Budget: IS-Mit. e• Total Program Position Count: 2- Nert,e0Total Agency Budget: +25' Total Agency Position Count: 5.Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate CSR PXI \ Prro : _ �. 5iu l IAc Qv``► 1LeO F`D Mori c, F,owi Wes-6-1- ier - ovo CLAD C OftV1Wttrir nAe/1/69-002c7 IA l-MCam- imat)Pr 6} 2t,vtr TOTAL: ' d 6-4 r() OQ Attach additional pages,rneeded. J 6. Explain what plans your agency or program has to increase revenues to support this program: The Explorations Foundation has received$25,000 for relocation services rendered and will continue to receive$2,500 a month to oversee the relocation. The Explorations Foundation is in the process of being approved for a USDA loan. Upcoming plans for a fundraising concert in April, another fundraiser at Aloha Theatre of the Mark Twain, one man show. Finally, grant writing to various agencies such as ING, HONDA,the Lawrence Foundation, NOAA, Hawaii Community Foundation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 :-- Agency Name:The Exploration Foundation Pr gra Name; Program fame.Malama Manua,to work with our hands to care for the world - - �.i `.' .k....t� .-•.+Y�-'m�.€.w.aJ.y--_. a.---.s 7.Prom-rant O6.Ael e5 t#sirta C...eunty P Cn era .t program Funds: 1- To support the only project based, hands on learning public school in the state of Hawaii that serves students grade 6 through 1 2- To support the istand/peoples of Hawaii through the teaching of-sustainability,stewardship and environmental awareness via hands on projects off campus.,ie restoration of anchanline ponds damaged due to 2011 tsunami, reforestation of plants and trees at West Hawaii Veterans Cemetery. 3- To oversee the relocation of WHEA over a 2 year time period, February,2013 to May,2015. 8.TABLE1: , What are the intended measurable outputs or outcomes that would be achieved with this funding? 1?RMRAIUf PERFORMANCE MEASURES Aopi= n#Projected Resufts 1 The Malama Honua program serves the 220 students enrolled at WHEA grades 6 through 12 with a waiting list for each grade level, students come as far as Hilo, Hawi and Oceanview to attend WHEA in Kailua Kona. Over 25,000 students and adults have already toured WHEA and sat in the bleachers. The new amphitheater would serve the 1,500 plus yearly visitors, mainly students and adults from Hawaii Island, the other islands,the mainland and overseas. As part of Malama Honua, each student and staff member is required to perform 4 to 8 hours of community service a quarter, approximately 5,000 hours of community service, 208 days given back to the community. Once a year, a Community Fair is held, on the first Saturday in March on the campus of WHEA. The central meeting place is the bleachers the future plan is the amphitheater. D.TABLE II: FY 1243 0/3-14 FY 1344 PROGRAM l EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages- SALARY AND WAGES Administrative Assistant. $30,000 $15,000 Professional Fees' Operation. PROFESSIONAL FEES Grant Writer $30.000 $15,000 Supplies OFFICE SUPPLIES Paper, printer, laptop, paperclips files $10,000 $5,000 Other: COST OF BUILDING The amphitheater $355,000 $75,000 Other:: Other: The Explorations Foundation would be grateful for any amount to support the Malama Honua Progr Other: and the building of the amphitheater. —— Other: I Other: - _ AL $ -2�od t© oa . - . *If applicable I EXHIBIT A • NONPROFIT GRANT APPUCATION FY 2013-2014 - - - rage 3 of 7 Agency Name: Agency Name:The Exploration Foundation Program Name: Program Name: Malama Honua,to work with our hands to care for the world 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 conflict is needed. 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 heck all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe Managing Director H 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: fyie_e____ __, 40► / — 2A'--/ 3 Signature of a uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name:The Exploration Foundation Agency Name: Program Name: Malama Honua, to work with our hands to care for the world 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, 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 5 of 7 Agency Name:The Exploration Foundation Program Name: Malama Honua,to work with our hands to care for the world 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.hawaiicoun tv.g.ov/in-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, 2014 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 A horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Agency Name:The Exploration Foundation Program Name: Program Name: Malama Honua,to work with our hands to care for the world 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result TABLE 11: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 110 The Food Basket, Inc Enabling Safe and Cost Effective Food Distribution - East HI Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-East HI Agency Director: TBD Phone No.: (808) 933 — 6030 Contact Person: Betty Beck Phone No.: (808) 933 — 6030 Mailing Address: Address: 40 Holomua Street Address: city,sr,zip Hilo, HI 96720 Facility Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI 96720 Email Address: betty.foodbaskethi @gmail.com Fax No.: (808) 934 — 0701 Accountant/CPA: Ann Fukuhara Phone No.: (808) 961 — 5532 Firm (if applicable): Ann Fukuhara, CPA MBA, AAC Mailing Address: Address: P. O. Box 6691 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 —0— —0— —0- 2.Agency Mission Statement: To feed the hungry on the Island of Hawai'i while attending to the root cause of the social problem. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-East HI 3. Program Description: The Food Basket (TFB) serves as the distribution food hub to feed the hungry on the Island of Hawaii. On a daily basis, TFB collects, stores and distributes to our network of community partners, food that is donated from retail and community donors, USDA-TEFAP allocations and TFB purchases. TFB is unique in its ability to store and distribute food Island wide. In order to maximize our ability to store/distribute food, while operating in a cost effective manner, TFB is requesting assistance to purchase a narrow aisle reach truck (fork lift). This piece of equipment will enable warehouse employees to reach, place and store food stacked on pallets in the warehouse. Additionally, a narrow aisle stacker increases storage capacity in the warehouse as more warehouse racks can be used in the limited warehouse space. This piece 4.Total Budget& Position Count: Total Program Budget: 650,000 Total Program Position Count: 8 Total Agency Budget: 850,000 Total Agency Position Count: 14 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Contributed Income Donations, Goverment Contracts, Trusts & Foundations 700,000 Interest Income 1,400 Program Service Fees 76,000 Special Events 63,000 Other Income Cost of Goods Sold TOTAL: 840,400 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Food Basket conducts various fund-raising campaigns and food drives throughout the year and supports food drives/fundraisers conducted by various businesses and community groups. The Food Basket also continuously submits grant proposals to public and private funding sources for assistance. The Food Basket continues to work to increase the capacity of the community to support THE ONLY Food Bank on the Island of Hawai'i. To this end, the Board of Directors and staff will continue to work toward building coalitions amongst the businesses and corporations on the Island to support the Food Basket. The Food Basket fund-raising activities include or will include the following: 1. Mail solicitation — The Food Basket has used, and will continue to use, direct mail solicitation EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-East HI 7. Program Objectives Using County Nonprofit Grant Program Funds: (1) Increase TFB's ability to store perishable and nonperishable food donations and purchases for distribution at existing warehouse sites, thus increasing the ability to monitor First in First Out distribution of food Island wide (2) Maximize the ability of existing TFB employees by utilizing safe equipment for lifting and warehousing perishable and nonperishable food donations to maximize existing cubic warehouse footage to reduce/eliminate need to expand to offsite storage 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.) Increase the amount of core food distribution to food insecure -Food distribution will increase individuals and families on the Island by 15% by 15% in 2014 Decrease the amount of time that warehouse persons take to -Reduced time to move, store, intake and store food in the warehouse, thus allocating more and retrieve food for distribu- personnel to the distribution of food tion Increase TFB's ability to store perishable and nonperishable food -All donated food is accessible donations onsite for distribution Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Reg Salary and Wages 403,718 460,626 Professional Fees 27,542 36,300 Operations 307,269 320,000 Supplies 22,656 24,515 Equipment 12,695 30,000 30,000 Other: 44,322 25,000 Other: Other: Other: Other: TOTAL 818,202 896,441 30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-East HI 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) I I 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: Does not apply 2 eev3- 9 C 4140Z. / °/,-&.e.'4 Signature of Authorized Per on(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-East HI 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. /_ // &41/Zi) rte- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-East HI 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase the amount of core food distribution to food insecure -Food dist. will individuals and families on the Island by 15% inc. by 15% Decrease the amount of time that warehouse persons take to -Reduced time intake and store food in the warehouse, thus allocating more to move, store, personnel to the distribution of food & retrieve food Increase TFB's ability to store perishable and nonperishable food -All food donations accessible TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment 30,000.00 Other: Other: Other: Other: Other: TOTAL 30,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 cont` Question 3-Program Description warehouse. Additionally, a narrow aisle stacker increases storage capacity in the warehouse as more warehouse racks can be used. This piece of equipment will significantly improve the efficiency of TFB's operations by: 1. capitalizing every cubic inch of our warehouse by placing products higher and filling more rack space, 2. enabling a dramatic reduction of working aisle widths in our warehouse, 3. increasing better load visibility at higher levels while improving safety for our warehouse staff, 4. improving overall cube utilization to reduce the cost per pallet position, thus lowering overall operational expenditures tied to warehousing and material handling operations, and 5. providing food for ease of retrieving under a First In First Out Food Distribution protocol as required by Feeding America. cont` Question 6 -Explain what plans your agency or program has to increase revenues to support this program to raise funds. The Corporation plans to distribute five direct mail solicitations during the annual campaign year, the first will be mailed in the summer and the second will be mailed in the fall. The goals of the direct mail program is to (i) increase community awareness of the Corporation's name, mission and services; (ii) increase awareness and educate the community regarding hunger problems on the Island of Hawaii; and (iii) attract new donors, volunteers and other supporters of the Corporation. 1. Personal solicitations—The Food Basket utilizes personal solicitations for donations in excess of$1,000, which are classified as major gifts. Volunteers are trained to conduct face-to-face meetings to solicit mature donors and special prospects to the organization. Personal solicitations are not utilized as a means to contact the general public. 2. Foundation grant solicitations—The Food Basket currently applies for grants from private foundations that are located in the State of Hawaii. 3. Donations via website—The Food Basket's website is designed to receive contributions from donors. Contributions made through the website are processed as credit card transactions. 4. Government grant solicitations—The Food Basket currently applies for county, state, and federal grants on an annual basis and will continue to apply for government grants in the future. 5. Other • Fundraising events—in the past, The Food Basket has conducted food drives where both monetary and food donations were received. In addition, the Corporation has organized golf tournament fundraising dinners and donation events at supermarkets. • Gifts—The Food Basket receives unsolicited monetary donations from individuals, corporations and other organizations in the community on a regular basis. • Annual development plan—The Board of Directors is working on an Annual Development Plan for fundraising purposes. This is a comprehensive plan for developing the Corporation's major gift program, developing an in-kind giving program, establishing gift acceptance and donor recognition policies, recruiting staff for fund development and public relations functions, creating a gift tracking system and other fundraising plans. III The Food Basket, Inc Enabling Safe and Cost Effective Food Distribution - West HI Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-West HI Agency Director: To Be Announced Phone No.: (808) 322 — 1418 Contact Person: Betty Beck-Operations Manager Phone No.: (808) 322 — 1418 Mailing Address: Address: 40 Holomua Street Address: city,sr,Zip Hilo, HI 96720 Facility Address: Address: 79 E. Honalo Road Address: city,sr,Zip Kailua-Kona, HI 96740 Email Address: betty.foodbaskethi @gmail.com Fax No.: (808) 322 — 7373 Accountant/CPA: Ann Fukuhara Phone No.: (808) 961 — 5532 Firm (if applicable): Ann Fukuhara, CPA MBA, AAC Mailing Address: Address: P. O. Box 6691 Address: City,ST,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 —0— —0— —0- 2. Agency Mission Statement: To feed the hungry on the Island of Hawai'i while attending to the root cause of the social problem. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-West HI 3. Program Description: The Food Basket's (TFB) primary program is food distribution. TFB serves as the distribution food hub to feed the hungry on the Island of Hawai'i. On a daily basis, TFB collects, stores and distributes to our network of community partners, food that is donated from retail and community donors, USDA-TEFAP allocations and TFB purchases. TFB is unique in its ability to store and distribute food Island wide. In order to maximize our ability to store/distribute food, while operating in a cost effective manner, TFB is requesting assistance to purchase a narrow aisle reach truck (fork lift). This piece of equipment will enable warehouse employees to reach, place and store food stacked on pallets in the 4.Total Budget& Position Count: Total Program Budget: 250,000 Total Program Position Count: 3 (East HI) Total Agency Budget: 896,441 Total Agency Position Count: 14 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Contributed Income Donations, Goverment Contracts, Trusts & Foundations 700,000 Interest Income 1,400 Program Service Fees 76,000 Special Events 63,000 Other Income Cost of Goods Sold TOTAL: 840,400 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Food Basket conducts various fund-raising campaigns and food drives throughout the year and supports food drives/fundraisers conducted by various businesses and community groups. The Food Basket also continuously submits grant proposals to public and private funding sources for assistance. The Food Basket continues to work to increase the capacity of the community to support THE ONLY Food Bank on the Island of Hawai'i. To this end, the Board of Directors and staff will continue to work toward building coalitions amongst the businesses and corporations on the Island to support the Food Basket. The Food Basket fund-raising activities include or will include the following: 1. Mail solicitation —The Food Basket has used, and will continue to use, direct mail solicitation EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-West HI 7. Program Objectives Using County Nonprofit Grant Program Funds: (1) Increase TFB's ability to store perishable and nonperishable food donations and purchases for distribution at existing warehouse sites, thus increasing the ability to monitor First in First Out distribution of food Island wide (2) Maximize the ability of existing TFB employees by utilizing safe equipment for lifting and warehousing perishable and nonperishable food donations to maximize existing cubic warehouse footage to reduce/eliminate need to expand to offsite storage 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.) Increase the amount of core food distribution to food insecure -Food distribution will increase individuals and families on the Island by 15% by 15% in 2014 Decrease the amount of time that warehouse persons take to -Reduced time to move, store, intake and store food in the warehouse, thus allocating more and retrieve food for distribu- personnel to the distribution of food tion Increase TFB's ability to store perishable and nonperishable food -All donated food is accessible donations onsite for distribution Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 403,718 460,626 Professional Fees 27,542 36,300 Operations 307,269 320,000 Supplies 22,656 24,515 Equipment 12,695 30,000 30,000 Other: 44,322 25,000 Other: Other: Other: Other: TOTAL 818,202 896,441 30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-West HI 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 conflict is needed. 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): 0 No conflicts exist (No further information required. Please sign form at the bottom.) ❑ Member or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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: Does not apply X'74,e/-7) (14/7 //3 0/2,e/3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-West HI 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. 137,4/20 C' ,// i he)/ r_ Signature of Authorized rR� son (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: The Food Basket Inc., Hawaii Island's Food Bank Program Name: Enabling Safe and Cost Effective Food Distribution-West HI 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase the amount of core food distribution to food insecure -Food dist. will individuals and families on the Island by 15% inc. by 15% Decrease the amount of time that warehouse persons take to -Reduced time intake and store food in the warehouse, thus allocating more to move, store, personnel to the distribution of food & retrieve food Increase TFB's ability to store perishable and nonperishable food All food donations accessible TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment 30,00.00 Other: Other: Other: Other: Other: TOTAL 30,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 cont` Question 3-Program Description warehouse. Additionally, a narrow aisle stacker increases storage capacity in the warehouse as more warehouse racks can be used. This piece of equipment will significantly improve the efficiency of TFB's operations by: 1. capitalizing every cubic inch of our warehouse by placing products higher and filling more rack space, 2. enabling a dramatic reduction of working aisle widths in our warehouse, 3. increasing better load visibility at higher levels while improving safety for our warehouse staff, 4. improving overall cube utilization to reduce the cost per pallet position, thus lowering overall operational expenditures tied to warehousing and material handling operations, and 5. providing food for ease of retrieving under a First In First Out Food Distribution protocol as required by Feeding America. cont` Question 6 -Explain what plans your agency or program has to increase revenues to support this program to raise funds. The Corporation plans to distribute five direct mail solicitations during the annual campaign year, the first will be mailed in the summer and the second will be mailed in the fall. The goals of the direct mail program is to (i) increase community awareness of the Corporation's name, mission and services; (ii) increase awareness and educate the community regarding hunger problems on the Island of Hawaii; and (iii) attract new donors, volunteers and other supporters of the Corporation. 1. Personal solicitations—The Food Basket utilizes personal solicitations for donations in excess of$1,000, which are classified as major gifts. Volunteers are trained to conduct face-to-face meetings to solicit mature donors and special prospects to the organization. Personal solicitations are not utilized as a means to contact the general public. 2. Foundation grant solicitations —The Food Basket currently applies for grants from private foundations that are located in the State of Hawaii. 3. Donations via website—The Food Basket's website is designed to receive contributions from donors. Contributions made through the website are processed as credit card transactions. 4. Government grant solicitations—The Food Basket currently applies for county, state, and federal grants on an annual basis and will continue to apply for government grants in the future. 5. Other • Fundraising events—in the past,The Food Basket has conducted food drives where both monetary and food donations were received. In addition, the Corporation has organized golf tournament fundraising dinners and donation events at supermarkets. • Gifts—The Food Basket receives unsolicited monetary donations from individuals, corporations and other organizations in the community on a regular basis. • Annual development plan—The Board of Directors is working on an Annual Development Plan for fundraising purposes. This is a comprehensive plan for developing the Corporation's major gift program, developing an in-kind giving program, establishing gift acceptance and donor recognition policies, recruiting staff for fund development and public relations functions, creating a gift tracking system and other fundraising plans. 112 The Greenwill Conservancy Inc Hui Mana'o: "Thinking Together & Sharing Knowledge" • Agency Name: The Green Will Conservancy Inc r Nk-t y t e73*- Program Name: Hui Mana'o: "Thinking Together& Sharing nowledge Agency Director: Frank Capatch, LCSW Phone No.: (808) 965 — 5349 Contact Person: Frank Capatch, LCSW Phone No.: (808) 965 — 5349 Mailing Address: Address: PO Box 1341 Address: City,sr,zip Pahoa, HI 96778 Facility Address: Address: 14-803B Seaview Rd. Address: City,ST,zip Pahoa, HI 96778 Email Address:green.will.conservancy @gmail.com Fax No.: (808) 965 — 5036 Accountant/CPA: 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, HI 96778 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 70,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 00.00 00.00 500 2.Agency Mission Statement: il IA•, • s,'C. To empower the People with the Skills and Practical Methods to Persevere and Sustain: The effort to maintain and restore bio-psycho-social ecology is one of the most significant visions needed for human community and planetary self-sufficiency. Humans must mature into their destined role of a 'Steward Species'. Urgent efforts to increase the sustainability of bio-psycho-social ecology must emerge on the local Ievel.The current increase in poverty, physical and mental disease, the decline of family, the extended community and lack of basic skills appears to be examples of this erosion. We need small scale replicable social support models of community that preserve bio-psycho-social sustainability. The replicable models could increase efficacy towards increased fiscal skills among the regions impoversihed knowledge for basic earnings and savings, raising the likelihood for stable community living, and for planning for the next generations. It is habilitation of removal of barriers, replaced by the skills to learn, to unlearn and to re-learn from past wisdom and 21st century technologies. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: The Green Will Conservancy Inc Program Name: Hui Mana'o: "Thinking Together& Sharing Knowledge" 3. Program Description: The project services 12-17 year old youth and their ohanas in the Puna district, which ranks second highest in the state in child poverty. Students accepted into colleges in this community are among the lowest in the state and with economic downturn, services have decreased. Resources are declining; according to The State of Social Services in Hawaii 2009 Report the County of Hawaii has the least manageable caseload of all Islands. Hui Mana'o offers job skills, integrated with licensed clinical mental health prevention & treatment goals addressing low self esteem, depression, drug addiction & teen violence & can choose from pre-vocational skills or green technology, construction arts. Volunteers & Kupunas offer cultural support, & community integration. Four levels individualize options with earned stipends & cottage industry start-ups. 4.Total Budget&Position Count: Total Program Budget: 70,000 Total Program Position Count: .5 Total Agency Budget: 113,670 Total Agency Position Count: 6 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Program Service Revenue 38,000 Public Contributions: Hawai'i County Grant [$5,750 was received for 2012-13] 70,000 Public Contributions: Cash contributions 4,000 Fundraising 4,000 Atherton Foundation 7,500 Hawaii Community Foundation 3,000 TOTAL: 126,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will continue with professional services on a sliding scale as well as billable to the wide array of Health Insurances. Additionally, we will increase our public visibility among other non-profit ventures including United Way, with a goal of promoting co-op activities for fund-raising and increasing public awareness. Continued contact and service provision to the Department of Education, the Department of Health, alternative schools, Teen Court, Family Court, and the Judiciary and finally Child Protection Services. Public presentations to broad spectrum religious organizations and multi-culturally designated agencies. Advertisement through Credit Unions and local businesses. Teen activities for fundraising in various business areas in East Hawaii will be promoted. We hope to launch an Internet presence this year. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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: Our objectives are 3-fold: 1)teach asset building by using professional services as an antidote to psycho-social barriers & increasing access to both internal & external resources, 2)leave a legacy for community & environment by learning green gardening, ecological skills that bring pay for work and enhancing leadership skills, and 3) to establish financial security by learning about credit unions, the way to feed onself and one's ohana, to cooperate in complementary skills through co-op activities. Stipends attached to evidence-based learning increase success. 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.) 2012 served 28 individual youth and their families 35 youth and families _ 21 of 28 were engaged for an average of 20 1-2 days per week 27 of 35 youth and families Total sessions 425 500 sessions Total sessions 384 were billed on a sliding scale = 90% sustain 90% scale pay rate _ Total sessions given freely, no billing available = 10% sustain 10% donated service Volunteer hours = 1470 hours among volunteers, interns & Profesnl sustain 30 volunteer hours/wk 4 fundraisers = $1427 8 fundraisers for$4,000 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages 16,880 36,000 10,000 Professional Fees 749 749 Operations 6,906 6,906 Supplies 0 1,625 1,625 Equipment 1,625 55,475 55,475 Other: 3,755 5,755 2,000 Other: 1,498 1,498 Other: 3,492 3,492 Other: 6,317 6,317 Other: 344 344 1,800 TOTAL 41,556 118,161 70,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: The Green Will Conservancy Inc Program Name: Hui Mana'o: "Thinking Together& Sharing Knowledge" 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 conflict is needed. 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): Q No conflicts exist(No further information required. Please sign form at the bottom.) 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: /.3714. ki . -itil c ail- P/,4Pe/v1 /74/4-eV 3 nature of Authorize Person (scify tie) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: The Green Will Conservancy Inc Program Name: Hui Mana'o: "Thinking Together& Sharing Knowledge" 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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://wwvv.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, 2014 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 J /LI / :3 % "013 gnature of A horize• Person ( 'cify titre) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: The Green Will Conservancy Inc Program Name: Hui Mana'o: "Thinking Together& Sharing Knowledge" 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 35 youth and families = 25% increase in serviced clients >effectiveness 27 of 35 youth and families = sustain ratio of engaged clients >effectiveness 500 sessions compared to 425 program services= 67 more pd svcs 67 paid svcs sustain 90% sliding scale pay rate 450 sustain 10% scale pay rate = free public service 50 free svcs _ sustain 30 volunteer hours/wk-represents community investment appx 1400/yr 8 fundraisers for$4,000 $4,000 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 36,000 _ Professional Fees 749 Operations 6906 Supplies 1625 Equipment 55,475 _ Other: 5,755 Other: 1,498 Other: 3,492 Other: 6,317 Other: 344 _ TOTAL 118,161 Additional Council directives regarding award: $45,475 is for: tractor, leased car for program transports, 3 Apple computers & HP printers; & $10,000 for a metal cargo shipping container to be converted into an tool house. $10,000 is for .5 farm/garden worker to work routinely with clients & ohana during the 6 hour Sunday program and 4 hour Wed. and/or 4 hour Saturday in The Green Will Conservancy. $ 4,425 is for$2,000 additional client stipend earned incentives, $1,800 annual gas cost projection, and $ 625 for supplies. This program has shown stability, committment & growth from all spheres. It needs equipment to move programming forward. It will support food growth. EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 The Green Will Conservancy In / EIN: 26-4001666 page 9 12/12/2012 l( (6,„ Members Present: David Kazmierczak,President and Acting Secretary Frank Capatch,Executive Program Manager and Acting Treasurer \ Bryan Holston,Director At the meeting of the Board of Directors of of The Green Will Conservancy Inc.,a review of the Hawai'i County Non-Profit Grant Requirement was reviewed.The requirement in included in their Submission Format section and included in the application in section"11.Certification of Understanding a. Signature required.Proof of Authorization(as indicated in by-laws,resolution,etc.)to sign must be provided." NOTE: The 3 members of the Board of Directors agreed by unanimous vote to identify the President of the Board as the signature for the Proof of Authorization.At the current time that is David Kazmierczak who is President.Additionally, it was agreed that in his absence or in the absence of any President of The Green Will Conservancy Inc.,the Executive Program Director generally referred to as the Program Director can assume authority as legal representative as the signature for the Proof of Authorization. At this time,the Executive Program Director is Frank Capatch,LCSW. Additionally, it was noted that Ethics Policy for Directors and Officers that had been added to the original By-laws on 8/16/2009 under then President Frank Capatch,LCSW could have a yet further clarification in line with the FY2013-14 Nonprofit Grants Program of County of Hawai'i regarding specific definitions of "Nepotism"and"Conflict of interst". Quoted from their document: • "Nepotism"means appointing persons to positions on the basis of their blood or marital relationship to the appointing authority,rather than on merit or ability. • "Conflict of interest"means 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." These definitions were reviewed and voted on by unanimous approval of the current 3 Board of Directors to be included both along with Ethics Policy addition of clarification and to be included in the requirement that The Green Will Conservancy Inc. has these clauses within the organization's published rules. The meeting adjourned at 12:00 PM PST on 12/12/2012. The Green Will Conservancy Inc./7_,J1(% 4/4V7/4.-c Ethics Policy for Directors and Officers J /(17 Is the policy of the Green Will Conservancy Inc. to assure that the ethics clause included in the bylaws required by the Internal Revenue Service for review of our 501(cX3) status be further elaborated so as to prevent any confusion in day-to-day operations and administration. Procedures 1. No board member's family(biological, or through marriage) shall be employed by the Green Will Conservancy Inc. (This is commonly referred to as nepotism)Any special situation requiring reimbursement, such as loans or repayment of expenses needs to be explicitly reviewed and voted on by the Board of Directors in order to assure that was is(avoidance of conflict of interest or impropriety). 2. No board member of the Green Will Conservancy Inc. will use their position in the organization to influence, broker influence and any other organization, political institution, private profit or nonprofit organization for personal financial gain. 3. No board member of The Green Will Conservancy Inc. shall in any way present themselves and/or use their position, influence and reputation in the community in any way,which denigrates the credibility and ethical standards of The Green Will Conservancy Inc. Any such incident shall be reviewed by the ethics committee of the Board of Directors and can include censure, and/or dismissal from the board if any allegations are deemed credible, by a full quorum of the Board of Directors. 4. No board member of The Green Will Conservancy Inc. will present an appearance of impropriety in the community and will review any situation which they may have any concerns with the full Board of Directors for their consent to any involvement, which might present or appear as an impropriety in the community. Developed 08/16/09 FJC The Green Will Conservancy, Inc., Agency Document Page(s) containing nepostism & conflict of interest clauses. ( and provide a copy of the page on which the clause appears on it) NOTE: Please see attached pages 7 & 8 of the Articles of Incorporation, ARTICLE 4, STANDARDS OF CONDUCT FOR DIRECTORS AND OFFICERS, particularly SECTION 4.2. Standards of Conduct of Directors and SECTION 4.3. Director Conflict of Interest. Issues of nepotism and conflict of interest are addressed both directly and indirectly throughout ARTICLE 4, STANDARDS OF CONDUCT FOR DIRECTORS AND OFFICERS. Frank Capatch LCSW Signature Executive Director, President of The Green Will Conservancy Inc. 1,,,e.,,_fr � 2bi/ t3 1 113 The Island of Hawaii YMCA Child & Youth Assets 2013 -2014 Agency Name: The Island of Hawaii YMCA Program Name: Child & Youth Assets 2013-2014 Agency Director: Fred T.Yamashiro Phone No.: (808) 935 — 3721 Contact Person: Fred T. Yamashiro Phone No.: (808) 935 — 3721 Mailing Address: Address: 300 W. Lanikaula Street Address: City,sr,zip Hilo, Hawaii 96720 Facility Address: Address: 300 W. Lanikaula Street Address: City,ST,Zip Hilo, Hawaii 96720 Email Address:fred.yamashiro @gmail.com Fax No.: (808) 935 — 8414 Accountant/CPA: Carbonoaro CPA & Associates Phone No.: (808) 968 — 1002 Firm (if applicable): Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000 $20,000 $40,000 2.Agency Mission Statement: MISSION STATEMENT: Aloha Ke Akua-God is Love. "To bring God's Love to children, adults and families of all races and faiths by putting Christian principles into practice through programs that build healthy spirit, mind and body for all." YMCA CORE VALUES: We teach and demonstrate caring, respect, responsibility and honesty. YMCA THEME: We build strong kids, strong families, strong communities. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: The Island of Hawaii YMCA Program Name: Child & Youth Assets 2013-2014 3. Program Description: Our child and youth programs have continued to stretch beyond their typical activities, by exposing them to learning cultural practicies and lifeskills that other children may not be exposed to. These experiences are conducted within a supportive local environment where caring and patient adults are guding them in a respectful and encouraging manner. The YMCA is re-introducing its Youth in Government Program to the teens allowing them the opportunity to learn about the legislative process and governmental procedures. Teens will fly to Oahu to visit the Supreme Court, meet the Governor, write and pass bills that pertain to their community. Both childcare and youth program parents will benefit from the subsidies to offset the cost of tuition and fees. 4.Total Budget& Position Count: Total Program Budget: $696,200 Total Program Position Count: 11 Total Agency Budget: $934,975 Total Agency Position Count: 40 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Program Fees $560,450 County of Hawaii Grant $40,000 Hawaii Island United Way Grant $20,000 YMCA Subsidies (Fundraising & Gifts) $75,750 TOTAL: $696,200 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The YMCA has four major sources of revenues: membership/program fees, fundraising activities, gifts and grants. Ideally, membership/program fees (and member gifts) should be our main source of revenue. However, our membership list is very small for a YMCA of our size in this demographic area; so there has been an over-reliance on the other sources. A large, strong and supportive membership base is the fundamental goal to attain a self-sustaining statutimisticaliy p an to achieve a minimum sustainable membership size by the end of 2013. We will continue to fundraise, welcome gifts and apply for grants. Efforts will also be made to reduce expenses and increase productivity with out limited resources. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: The Island of Hawaii YMCA Program Name: Child & Youth Assets 2013-2014 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Collaborate activities during the program year with HIUW, Boys & Girls Club, QLCC and other non-profit agencies. 2) Receive evaluations by the end of the fiscal year with at least 80% of responding parents and children express being satisfied with the program. 3) Determine by the end of the fiscal year that at least 80% of children indicate they agree or strongly agree that the program has made a positive, significant growth to their academics. 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.) Total YMCA Members Served Islandwide 2300 Hilo YMCA Branch 1500 Kona YMCA Branch 800 Parent Workshops Participant Total (4 times within the year) 100 Staff Training (2 times within the year) 22 Total Parent Workshop Hours (25parents x 1 hour x 4workshops) 100 Total Staff Training Hours (11x8x2) 176 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages ^ ,q�7 $422,650 $40,000 Professional Fees $15,450 Operations $174,225 Supplies - OfF/CE $6,300 Equipment 0 Other: OF-/-7R -C1 A 77 OA/ $9,100 Other: /4/6-WRf}NCE $22,700 Other: /CHI/T $10,000 Other: REPI pi Rs RA, it l/4l T-rv,90-6 $7,600 Other: [,f r/L l Tl 6--T $28,175 TOTAL $696,200 $40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: The Island of Hawaii YMCA Program Name: Child & Youth Assets 2013-2014 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 conflict is needed. 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): 0 No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor in 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: Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: The Island of Hawaii YMCA Program Name: Child & Youth Assets 2013-2014 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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 2013-2014 Page 6 of 7 Agency Name: The Island of Hawaii YMCA Program Name: Child & Youth Assets 2013-2014 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Total YMCA Members Served Islandwide 2300 Hilo YMCA Branch 1500 Kona YMCA Branch 800 Parent Workshops Participant Total (4 times within the year) 100 Staff Training (2 times within the year) 22 Total Parent Workshop Hours (25 parents x 1 hour x 4 workshops) 100 Total Staff Training Hours (11x8x2) 176 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages - 2,��� $40,000 Professional Fees Operations Supplies - Equipment Other: Di PREG/R j/o4 Other: /71/67,i )t / e Other: REN7 Other: RePaRS F9A10 Mg1A/7t70-77/C� Other: U 77 t_In TOTAL $40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 _ 114 The Salvation Army - Family Intervention Services Independent Living Skills Program - West Hawaii 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 Kinoole St. Address: City,ST,Zip Hilo, HI 96720 Email Address: Pauline.Pavao @usw.salvationarmy.org Fax No.: (808) 959 — 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808) 959 — 5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,s-r,zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $35,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $15,000 $15,000 $15,000 2. Agency Mission Statement: The Salvation Army-Family Intervention Services mission statement reflects our approach in assisting at-risk youth and their families, and is the guiding principle in delivering outreach, prevention and residenial Services: "TO PROVIDE YOUTH WITH SKILLS FOR A HEALTHY LIFE AND INSTILL PURPOSE, HOPE AND VISION TO YOUTH AND THEIR FAMILIES". It is imperative that we recognize that all youth are "youth of promise," and have the potential to become self-directed, goal oriented and contributing members of our community. As such, our agency's goals are to provide youth with a safe, caring and nurturing environment; and provide opportunities for youth to challenge their life styles through development of appropriate social skills, academic success, and personal resiliency. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 ages 12-21 prepare for and manage the transition to productive, self sufficient adulthood with a base of independent living skills. The goal of ILSP is to: 1) provide a comprehensive life skills based curriculum 2) provide opportunities for foster youth to pursue higher education, vocational training, and/or employment, 3) provide linkages and resources to services in the community including: housing, health insurance, and other vital needs. Please refer to attachment 1 for a description of services in detail. 4.Total Budget& Position Count: Total Program Budget: $126,038.00 Total Program Position Count: 10 Total Agency Budget: $3,300,000 Total Agency Position Count: 55 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii $35,000 Department of Human Services $91,038 TOTAL: $126,038 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services, while part of the Salvation Army, is required to seek its own funding for program services. As such, TSA-FIS relies primarily on funding from government at the federal, State and County levels to continue our prevention and outreach programs that assist at-risk youth and their families. Such funding is primarily through the purchase of service system, which we are required to submit proposals through a competitive process. Very limited funding is available through grants from trusts and foundations. We continuously explore avenues of funding to continue these programs. However, in view of the nature of our mission in developing healthy lifestyles for youth and their families, we do rely heavily on funding at all levels of government. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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: 1). Of the 30 foster youth, ages 12-17 participating in the program, 75% will successfully complete their IL program and attain at least a "fair prognosis" of achieving goals of independence upon exiting the program. 2). Of the foster youth ages 18 plus participating in the program, 80% will participate in higher education, vocational training, employment and/or military 3). 75% of foster youth will avoid non-marital childbirth, incarceration and homelessness during program participation. 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: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 78,100 88,327.86 24,258.57 Professional Fees 1290 1080.00 240.00 Operations 28,427 33,030.14 9,301.43 Supplies 1970 3,600.00 1200.00 Equipment Other: Other: Other: Other: Other: TOTAL 109,788 126,038.00 35,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: indPgendent Living Skills Program-Wert Hawaii 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: John Chamness POSITION: Divisional Commander May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): © No conflicts exist(No further information required. Please sign form at the bottom.) F7Member 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: l (IQ vvwv-,4,41 Divisional Commander 1 1 a� 13 Sigil ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name:1Independent Living Skills Program- West Hawaii 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. Divisional Commander ti 1 as 13 '5i:nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent 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 II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 24,258.57 Professional Fees 240.00 Operations 9,301.43 Supplies 1200.00 Equipment Other: Other: Other: Other: Other: TOTAL 35,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 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) • Vocational/Job 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. 115 The Salvation Army - Family Intervention Services 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, HI 96720 Email Address: Pauline.Pavao @usw.salvationarmy.org Fax No.: (808) 959 — 2301 Accountant/CPA: 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 Amount of Request for County Nonprofit Grant Program Funds: $35,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 N/A N/A N/A 2. Agency Mission Statement: The Salvation Army-Family Intervention Services mission statement reflects our approach in assisting at-risk youth and their families, and is the guiding principle in delivering outreach, prevention and residenial Services: "TO PROVIDE YOUTH WITH SKILLS FOR A HEALTHY LIFE AND INSTILL PURPOSE, HOPE AND VISION TO YOUTH AND THEIR FAMILIES". It is imperative that we recognize that all youth are "youth of promise," and have the potential to become self-directed, goal oriented and contributing members of our community. As such, our agency's goals are to provide youth with a safe, caring and nurturing environment; and provide opportunities for youth to challenge their life styles through development of appropriate social skills, academic success, and personal resiliency. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 positive youth develoment for youth ages 7-21 residing in the Keaau communities. We utilize a prevention approach to decrease the use and abuse of alcohol, tobacco and other illicit drugs, involvement in gangs and violence, delinquent behaviors, early sexual behaviors, and to improve academic performance and school attendance. Please refer to attachment 1 for description of services in detail. 4.Total Budget& Position Count: Total Program Budget: $110,000 Total Program Position Count: 10 Total Agency Budget: $3,300,000 Total Agency Position Count: 55 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii $35,000 State of Hawaii-Office of Youth Services $75,000 TOTAL: $110,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services, while part of the Salvation Army, is required to seek its own funding for program services. As such, TSA-FIS relies primarily on funding from government at the federal, State and County levels to continue our prevention and outreach programs that assist at-risk youth and their families. Such funding is primarily through the purchase of service system, which we are required to submit proposals through a competitive process. Very limited funding is available through grants from trusts and foundations. We continuously explore avenues of funding to continue these programs. However, in view of the nature of our mission in developing healthy lifestyles for youth and their families, we do rely heavily on funding at all levels of government. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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: 1). 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 . (social well being, knowledge of alcohol/tobacco/drug prevention and social responsibility) 2). Of the 40 youth participating in the prevention activites throughout the year, at least 80% will participate in Positive Alternative Activities (community service learning projects, recreation, tutoring, community events and family 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.) Completion of L.E.A.D. 40 Participation in Positive Alternative Activities 40 Completion of Botvin Lifeskills Training Curriculum 40 Cultural Awareness and Identity 20 Follow up and Monitoring 40 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 78,011 80,592.32 27356.63 Professional Fees 1218 1080.00 600.00 Operations 24,471 25,927.68 6443.37 Supplies 3049 2400.00 600.00 Equipment Other: Other: Other: Other: Other: TOTAL 106,750 110,000.00 35,000.00 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Positive Youth Development Prevention Program - Keaau 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: John Chamness POSITION: Divisinnal Commander May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): © No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council `— Staff appointed by a member of the Council The Mayor nThe Managing Director EThe 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: • i � � T7ivisiont�l Corr-murder I1A�� 13 Sikh ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Positive Youth Development Prevention Program-Keaau 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, 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.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, 2014 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. e s Divisional Commander 1 Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 The Botvin Lifeskills Training Curriculum 40 Cultural Awareness and Identity 20 Follow up and Monitoring 40 TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages 27,356.63 Professional Fees 600.00 Operations 6443.37 Supplies 600.00 Equipment Other: Other: Other: Other: Other: TOTAL 35,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 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 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 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 1.00FTE Youth Development Specialist IV to provide prevention/outreach to the Puna community. 116 The Salvation Army - Family Intervention Services Prevention Program - Hilo Agency Name: The Salvation Army-Family Intervention Services Program Name: Prevention Program - Hilo 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) 959 — 2301 Accountant/CPA: 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 Amount of Request for County Nonprofit Grant Program Funds: $35,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 N/A N/A N/A 2.Agency Mission Statement: The Salvation Army-Family Intervention Services mission statement reflects our approach in assisting at-risk youth and their families, and is the guiding principle in delivering outreach, prevention and residenial Services: "TO PROVIDE YOUTH WITH SKILLS FOR A HEALTHY LIFE AND INSTILL PURPOSE, HOPE AND VISION TO YOUTH AND THEIR FAMILIES". It is imperative that we recognize that all youth are "youth of promise," and have the potential to become self-directed, goal oriented and contributing members of our community. As such, our agency's goals are to provide youth with a safe, caring and nurturing environment; and provide opportunities for youth to challenge their life styles through development of appropriate social skills, academic success, and personal resiliency. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Prevention Program - Hilo 3. Program Description: TSA-FIS Prevention Program-Hilo 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 Hilo communities, with priority given to areas of low economic status. We utilize a prevention approach to decrease the use and abuse of alcohol, tobacco and other illicit drugs, involvement in gangs and violence, delinquent behaviors, early sexual behaviors, family conflict and to improve academic performance and truancy. Please refer to attachment 1 for description of services in detail. 4.Total Budget& Position Count: Total Program Budget: $85,000 Total Program Position Count: 8 Total Agency Budget: $3,300,000 Total Agency Position Count: 55 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii $35,000 Department of Human Services- State of Hawaii $50,000 TOTAL: $85,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services, while part of the Salvation Army, is required to seek its own funding for program services. As such, TSA-FIS relies primarily on funding from government at the Federal, State and County levels to continue our prevention and outreach programs that assist at-risk youth and their families. Such funding is primarily through the purchase of service system, which we are required to submit proposals through a competitive process. Very limited funding is available through grants from trusts and foundations. We continuously explore avenues of funding to continue these programs. However, in view of the nature of our mission in developing healthy lifestyles for youth and their families, we do rely heavily on funding at all levels of government. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Prevention Program - Hilo 7. Program Objectives Using County Nonprofit Grant Program Funds: 1). 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 . (social well being, knowledge of alcohol/tobacco/drug prevention and social responsibility) 2). Of the 40 youth participating in the prevention activities throughout the year, at least 75% will participate in Positive Alternative Activities (community service learning projects, recreation, tutoring, community events and family 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.) Participation in Positive Alternative Activities 40 Completion of Botvin Lifeskills Training Curriculum 40 Cultural Awareness and Identity 10 Follow up and Monitoring 40 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 52,777.50 23,103.72 Professional Fees 1080.00 240.00 Operations 27,542.50 9,856.28 Supplies 3,600.00 1,800.00 Equipment Other: Other: Other: Other: Other: TOTAL 85,000.00 35,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: The Salvation Army-Family Tntervention Services Program Name: Prevention Programs Hilo 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 conflict is needed. Please duplicate as needed to fully disclose.AN disclosure forms must be signed, regardless of whether a conflict exists. NAME: tlohn Chamness POSITION: Divisional Commander May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ElNo conflicts exist (No further information required. Please sign form at the bottom.) 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: j u...vm{,vA_ Divisional Commander I / �a I�j \S' sf.'2 .--''' \ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 AgencyName: The Salvation Army-Family Intervention Services Program Name: Prevention Programs- Hilo 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 Countvl 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, 2014 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 ,� Divisional Commander L I a,a.� J3 Si ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Prevention Program - Hilo 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participation in Positive Alternative Activities 40 Completion of The Botvin Lifeskills Training Curriculum 40 Cultural Awareness and Identity 10 Follow up and Monitoring 40 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 23,103.72 Professional Fees 240.00 Operations 9856.28 Supplies 1800.00 Equipment Other: Other: Other: Other: Other: TOTAL 35,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Attachment 1- Prevention Program-Hilo 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 Keaukaha Elementary school and other school districts. We propose to implement program services during in-school and afterschool. The proposed funding would support a 0.5 FTE Youth Development Specialist IV. Supplemental funding from the Department of Human Services—Prevention Program will help support and establish a 1.00FTE Youth Development Specialist IV to provide prevention/outreach to the Hilo communities (Keaukaha). 117 The Salvation Army - Family Intervention Services 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,sr,Zip Hilo, HI 96720 Email Address: Pauline.Pavao @usw.salvationarmy.org Fax No.: (808) 959 — 2301 Accountant/CPA: 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 Amount of Request for County Nonprofit Grant Program Funds: $35,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $15,000 $15,000 $15,000 2. Agency Mission Statement: The Salvation Army-Family Intervention Services mission statement reflects our approach in assisting at-risk youth and their families, and is the guiding principle in delivering outreach, prevention and residenial Services: "TO PROVIDE YOUTH WITH SKILLS FOR A HEALTHY LIFE AND INSTILL PURPOSE, HOPE AND VISION TO YOUTH AND THEIR FAMILIES". It is imperative that we recognize that all youth are "youth of promise," and have the potential to become self-directed, goal oriented and contributing members of our community. As such, our agency's goals are to provide youth with a safe, caring and nurturing environment; and provide opportunities for youth to challenge their life styles through development of appropriate social skills, academic success, and personal resiliency. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 use and abuse of alcohol, tobacco and other illicit drugs, involvement in gangs and violence, delinquent behaviors, early sexual behaviors, family conflict and to improve academic performance and truancy. Please refer to attachment 1 for description of services in detail. 4.Total Budget& Position Count: Total Program Budget: $125,000 Total Program Position Count: 9 Total Agency Budget: $3,300,000 Total Agency Position Count: 55 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate County of Hawaii $35,000 Department of Health, Substance Abuse Prevention $90,000 TOTAL: $125,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services, while part of the Salvation Army, is required to seek its own funding for program services. As such, TSA-FIS relies primarily on funding from government at the Federal, State and County levels to continue our prevention and outreach programs that assist at-risk youth and their families. Such funding is primarily through the purchase of service system, which we are required to submit proposals through a competitive process. Very limited funding is available through grants from trusts and foundations. We continuously explore avenues of funding to continue these programs. However, in view of the nature of our mission in developing healthy lifestyles for youth and their families, we do rely heavily on funding at all levels of government. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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: 1). 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 . (social well being, knowledge of alcohol/tobacco/drug prevention and social responsibility) 2). Of the 40 youth participating in the prevention activities throughout the year, at least 80% will participate in Positive Alternative Activities (community service learning projects, recreation, tutoring, community events and family 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.) Completion of L.E.A.D. 40 Participation in Positive Alternative Activities 40 Completion of Botvin Lifeskills Training Curriculum 40 Cultural Awareness and Identity 20 Follow up and Monitoring 40 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 73,347 83,309.00 23,965.31 Professional Fees 892.00 1140.00 240.00 Operations 24,960 36,950.01 9,594.69 Supplies 4800.00 3,600.00 1200.00 Equipment Other: Other: Other: Other: Other: TOTAL 104,000 125,000.00 35,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Substance Abuse Prevention Program-Pahoa 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: John Chamness POSITION: Divisional Commander May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): © No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council _ The Mayor nThe 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: t Divisional Commander G 1 a�) i', Sin ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Suhstance Abuse Prevention Program- Pahoa 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 — 2442.1, 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. \\ I---' - Tn w-J"t/lA Divisional Commander I l AAI 13 i ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: The Salvation Army-Family Intervention Services Program Name: Substance Abuse Prevention Program- Pahoa 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 The Botvin Lifeskills Training Curriculum 40 Cultural Awareness and Identity 20 Follow up and Monitoring 40 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 23,965.31 Professional Fees 240.00 Operations 9594.69 Supplies 1200.00 Equipment Other: Other: Other: Other: Other: TOTAL 35,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 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. 118 Volunteer Legal Services Hawaii County of Hawaii Pro Bono Legal Services Agency Name: Volunteer Legal Services Hawaii Program Name: County of Hawaii Pro Bono Legal Services Agency Director: L. Dew Kaneshiro Phone No.: (808) 528 — 7059 Contact Person: L. Dew Kaneshiro Phone No.: (808) 528 — 7059 Mailing Address: Address: 545 Queen Street Address: Suite 100 city,sr,zip Honolulu, HI 96813 Facility Address: Address: Same Address: City,ST,Zip Email Address: dew @vlsh.org Fax No.: (808) 524 — 2147 Accountant/CPA: Jeffrey E. J. Lee Phone No.: (808) 734 — 1921 Firm (if applicable): Choo Osada & Lee, CPAs, Inc. Mailing Address: Address: 11.36_12th Avenue Address: Suite 240 City,ST,Zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $46,756 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 55,000 30,000 35,000 2.Agency Mission Statement: Volunteer Legal Services Hawaii (Volunteer Legal) provides volunteer attorneys to low-income individuals and families who need assistance with civil legal matters. Collectively, Volunteer Legal's pool of attorneys encompass many areas of legal expertise, thus allowing the organization to respond to the growing number of individuals in need through service options that include in-person advice and counsel, phone consultations, self help workshops, and full representation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: Volunteer Legal Services Hawaii Program Name: County of Hawaii Pro Bono Legal Services 3. Program Description: The Pro Bono Legal Services Program will provide County residents with services including: 1) Intake staff who will respond to calls from Hawaii County, determine an applicant's eligibility, schedule services, and/or make referrals to appropriate external agencies. 2) Neighborhood Legal Clinics in Hilo and Kona, where clients will meet one-on-one with an attorney who provides legal advice. Telephone consultations are arranged if the client has an urgent matter and/or an attorney on Hawaii Island is not available. 4) Volunteer attorneys will provide brief services, such as drafting uncomplicated documents. 5) In certain cases, Volunteer Legal will attempt to secure a pro bono attorney to provide full representation for the client's matter. 4.Total Budget&Position Count: Total Program Budget: 70,300 Total Program Position Count: 1.15 Total Agency Budget: 675,000 Total Agency Position Count: 7.5 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Grant-in-Aid 18,194 Hawaii State Bar Association 1,350 Bar Dues Renewal Contributions 1,250 Client fees 2,750 County of Hawaii 46,756 TOTAL: 70,300 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In 2012, a critical funding shortage forced Volunteer Legal to suspend clinics on the Neighbor Islands with the exception of Hilo, where clinics are now held just once a month. Volunteer Legal is seeking a FY2014 grant-in-aid to support its operations and expand its neighbor island programs. The organization is also pursuing statewide funding for groups it already serves, including immigrants and Native Hawaiians. Volunteer Legal anticipates that between 10 and15 percent of these statewide grants will be allocated to services for Hawaii County residents. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: Volunteer Legal Services Hawaii Program Name: County of Hawaii Pro Bono Legal Services 7. Program Objectives Using County Nonprofit Grant Program Funds: In addition to taking calls directly from Hawaii County applicants for services, Volunteer Legal plans to use the funds to integrate its services with the Hilo courthouse Self Help Center (SHC). Eligible court users referred by SHC attorneys will receive advice and counsel or brief services from a pro bono lawyer at a Neighborhood Legal Clinic in Hilo (held twice monthly) or in Kona (held monthly). Volunteer Legal staff will also schedule phone consultations and, in some cases, attempt to secure a volunteer attorney to provide full representation. 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.) No. of phone calls 400 No. of intakes completed (eligible applicants) 350 No. of services provided (excluding intake) 325 No..of Neighborhood Legal Clinics held 35 No. of attorney volunteer hours 435 Value of attorney volunteer hours $100,000 Client satisfaction surveys Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Re y Salary and Wages 56,708 42,526 Professional Fees 3,150 630 Operations 4,042 1,000 Supplies 500 400 Equipment 2,000 1,000 Other:postage & Delivery 300 150 Other:Travel (airfare, meals , ground transportation) 1,500 750 Other: Informational material, brochures 600 300 Other:Volunteer Development 1,500 0 Other: TOTAL 70,300 46,756 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: Volunteer Legal Services Hawaii Program Name: County of Hawaii Pro Bono Legal Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: L. Dew Kaneshiro (and all Volunteer Legal Board members) 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): No conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council _ Staff appointed by a member of the Council The Mayor nThe Managing Director The Director of Finance f 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: Corporation Counsel Lincoln Ashida is on the Executive Committee of the Volunteer Legal Board of Directors. The members of the Board of Directors 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 grantmaking decision. d ag/aoi 3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Volunteer Legal Services of Hawaii Program Name: County of Hawaii Pro Bono Services 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 conflict is needed. 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: Board of Director, Volunteer Legal Services of Hawaii May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): nNo conflicts exist(No further information required. Please sign form at the bottom.) nMember 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: I am a member of the Executive Committee of the Volunteer Legal Services of Hawaii, Board of Directors. I have not participated in any discussion with the Board of Directors and the Volunteer Legal Staff regarding details of their application. //,Q Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: Volunteer Legal Services Hawaii Program Name: County of Hawaii Pro Bono Legal 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'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.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. 0(1. 1.+--r(..//...A."-A- 4/I , CAe c.A.Aki4e, a-cedur 0 Agh...0,3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: Volunteer Legal Services Hawaii Program Name: County of Hawaii Pro Bono Legal Services 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result No. of phone calls 400 No. of intakes completed (eligible applicants) 350 No. of services provided (excluding intake) 325 No. of Neighborhood Legal Clinics held 35 No. of attorney volunteer hours 435 Value of attorney volunteer hours $100,000 Client satisfaction surveys TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 42,526 Professional Fees 630 Operations 1,000 Supplies 400 Equipment 1,000 Other: Postage & Delivery 150 Other: Travel (Airfare, meals , ground transportation) 750 Other: Informational material, brochures 300 Other: Volunteer Development 0 Other: TOTAL 46,756 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 119 Waimea Outdoor Circle Ulu La'au, Waimea Nature Park Agency Name: WAIMEA OUTDOOR CIRCLE Program Name: ULU LA'AU, WAIMEA NATURE PARK Agency Director: Cheryl Langton Phone No.: ( ) 885 —5702 Contact Person: Cheryl Langton Phone No.: ( ) 936 — 1468 Mailing Address: Address: P.O. Box 6144 Address: City,ST,Zip Kamuela, hawaii 96743 Facility Address: Address: Address:TMK 3-6-6-03-07 City,ST,Zip Email Address: Fax No.: ( ) — Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 M Coto*JcJaLM of UNbEk. zTAAM 1N • M*Yoit, I<itNOt 045-Oo.•✓ 4/24 l/& ^Sf3!f/2, 2.Agency Mission Statement: To keep Hawaii clean, green, and beautiful by preserving, protecting, and enhansing our environment for future generations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: WAIMEA OUTDOOR CIRCLE Program Name: ULU LA'AU, WAIMEA NATURE PARK 3. Program Description: SEE ATTACHMENT "A" 4.Total Budget&Position Count: ` 0 Total Program Budget: Total Program Position Count: Total Agency Budget: Total Agency Position Count: 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate DONATIONS 5;1 so GRANTS 4'1000 pl^irnrt Sft It t-go-'r 4ucr1 oeJ 4.0e, vJR�Pr1 ft CA-1455 Frog TOTAL: re 7 ra Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: A COOPERATIVE PROJECT WITH NATURAL RESOURCE CONSERVATION SERVICE, UNITED STATES DEPT. OF AGRICULTURE TO DEVELOPE A WATER CATCHMENT SYSTEM. SEE ATTACHMENT"B" EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 NEED FOR PROJECT (Describe the need(s) that this project is I aimed at addressing). 3 Ulu La'au, the Waimea Nature Park, is still the only Outdoor Circle project of its kind in the entire state of Hawaii. Created by Waimea Outdoor Circle and community volunteers over twelve years ago, this little gem in the heart of Waimea continues to be supported and maintained entirely by donations and volunteers. Many are surprised to learn that it is not a county park and that our largest expense is paying for the water that irrigates the park. Currently, about half of the ten acres is developed and our monthly water usage is approximately $415.00 to $500.00 per month, keep in mind that we do not water any grass, just the native plantings. Our water expense is what this project is aimed at addressing. Ulu La'au is not just a nature park, it is a living classroom filled with Native Hawaiian plants for everyone to see, enjoy and learn from. It is open to the public everyday free of charge and is children and pet friendly. Waimea Outdoor Circle is committed to protecting this valuable community resource and believes that exposure to our Native Hawaiian plants cannot be optional. The project will provide water service for the Park for approximately one year and until such time that Waimea Outdoor Circle finds a permanent solution for funding our water needs. The water in the Nature Park irrigates our native Hawaiian plants only, we do not water the grass and aside from a sink in the greenhouse, we have no other plumbing. We contract with Hawaii John's to meet our Lua requirement. Our native Hawaiian plants are drought resistant and require less water than non-natives. However they still need water, especially when they are first planted. 'N / . ?' To support this project we are doing a cooperative project with Natural Resource Conserevation Service, United States Dept. of Agriculture, developing a water catchment system. Page 1 of 3 Carol Hendricks From: <HOELIKE @aol.com> Date: Thursday,January 17,2013 1:00 PM To: <clangton @hawaii.rr.com>;<carolhe @hawaii.rr.com>;<blockk002a @hawaii.rr.com> Subject: Water subsidy Hi All, Yesterday, I submitted a water subsidy paper at the meeting. Today, I put more thought into it and also added the few things I remembered others brought up. This is done in hopes that we will be able to meet with Margaret and persuade her of its importance so she will make the effort to persuade the other council members. Leningrad JUSTIFICATION FOR WATER SUBSIDY FROM COUNTY 1. Approximately 20 years ago, The Waimea Outdoor Circle looked into what they could do to best benefit, and enhance the community. 2. Attention was brought to the fact that this community had only two community parks, The Waimea Ball Park and the Church Row Park. 3. Neither of these parks provided the open space or passive atmosphere where someone could just go to sit and relax or where parents could take their children to picnic or just to play with them. 4. The Waimea Outdoor Circle took upon itself to provide for this need. 5. With this intent in mind, the WOC searched and located a ten acre parcel of land in the very heart of Waimea belonging to the State of Hawaii that is basically split in half by the Waikoloa Stream. 6. After Seved years of negotiations, the WOC acquired this parcel through a lease agreement. 7. Volunteers under the supervision of the WOC came together to clear and develop the overgrown forested property. 8. Funds for equipment and maintenance were solicited by the WOC and after a couple years of sweat and dedication, the Waimea Nature Park became a functional part of the community. 1/18/2013 Page 2 of 3 9. Today, after 12 years of hard, dedicated volunteer efforts by numerous individuals and groups, approximately one half of the total acreage is under cultivation and accessible to the public. 10. The Park offers an open playground, picnic tables, safe access to the stream, trails that lead to endangered native plants and a number of endemic native plants of interest from the surrounding area. 11. School children utilize the park as a safe short cut to school that was not available prior to the parks development. 12. During the course of the day, people sit at the tables provided by the WOC and have meetings, sometimes over breakfast and sometimes just over their paper work. 13. Visitors, including tourists, drive into the park to tour the native plants that have been propagated and now thrive there. 14. The daily influx of visitors includes people who come to the park just to walk their dogs, or,just to enjoy the peaceful, quiet, atmosphere. 15. Teachers from the surrounding schools bring their science students to the park and do environmental studies on water quality and pollution utilizing the stream as their media 16. Occasionally, groups interested in native plants will schedule visits to the park to view the plants and the largest collection of diverse colors accumulated of Ohia Lehua blossoms publicly available in one place. 17. The park is available to the public for free but vehicular access is limited to the hours of 7:00 AM to 5:30 PM for security reasons. 18. A portable Lua is made available to the public in the park with the cost and maintenance paid for by the WOC. 19. The park has become the central parking area for those who walk the Ke Ala Kahawai 0 Waimea (The Stream Trail of Waimea) that passes through the Southern most segment of the Park. 20. The Trail is the property of the County of Hawaii, Dept. of Parks and Recreation but its maintenance is done by volunteers some of whom partner with the WOC to benefit the community. 1/18/2013 Page 3 of 3 21. The WOC makes the equipment they have accumulated through the years available to the trail volunteers on their scheduled work days. 22. Each year, the WOC spends thousands of dollars maintaining the Waimea Nature park that is not only utilized by locals but by others from throughout the island who passing through, seek a quiet refuge. 23. THE PROBLEM: The present drought has imposed an unexpected burden on the finances of the WOC in the form "irrigation needs." 24. The WOC hereby request assistance from the County of Hawaii in providing the irrigation funds, approximately $4,000 per year, to properly maintain the irrigation requirements for this very popular functional park. 1/18/2013 Agency Name: WAIMEA OUTDOOR CIRCLE Program Name: ULU LA'AU, WAIMEA NATURE PARK 7. Program Objectives Using County Nonprofit Grant Program Funds: SEE ATTACHMENT "C" 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.) SEE ATTACHMENT "D" Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: v,IkTER- d, +-1-5 4)000.00 Other: Other: Other: Other: TOTAL 4 eve.00 if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 \A■ I) Waimea Outdoor Circle MISSION AND OBJECTIVES Mission. The Waimea Outdoor Circle shall be a non-profit organization whose mission is to foster environmental preservation and the enhancement of nature through education and community involvement. We strive to create a healthy future for ourselves and our children. Obiectives. The aims of the organization shall include: A. To assist in planning the planting of streets, highways, parks, playgrounds, school grounds and other areas dedicated to public use. B. To recommend removal of all unsightly tree stumps. C. To recommend the clean-up of vacant lots. D. To rid the State completely of billboards and all other obstructive and unsightly outdoor advertising. E. To plant and preserve trees. F. To procure a park system that shall include: (a) public pleasure grounds, (b) scenic reservations, (c) ornamental squares, (d) playgrounds and (e) public gardens. G. To stimulate a love of nature and a sense of beauty. H. To conserve and develop the natural beauties of the landscape by encouraging the growth of native trees and shrubs, and the introduction of such new ones as belong to tropical life. • if # 8. 180,000 Island of Hawaii residents and especially 8,000 South Kohala residents, including students as well as visitors are able to enjoy this Public Park. Volunteer hours total in the thousands, including schools and armed services, and regularly every other Saturday from 9 to 12. (We have sign in sheets.) Plant sale fundraisers are held annually with workshops on plants, wreath making, lei making, kappa making, composting and worms. Agency Name: Program Name: 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Cheryl Langton POSITION: President May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): © No conflicts exist(No further information required. Please sign form at the bottom.) _ 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: • Signature it uthorized P T'on (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: WAIMEA OUTDOOR CIRCLE Program Name: ULU LA'AU, WAIMEA NATURE PARK 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 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.ehawai 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.xov/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, 2014 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 ?i.:L ; 7L /•e". I •c o/3 Signature of Aut rized Person (spe title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: WAIMEA OUTDOOR CIRCLE Program Name: ULU LA'AU, WAIMEA NATURE PARK 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Keeping the Ulu La©au, Waimea Nature Park native Hawaiian plant: alive during the drought while installing another water system. TABLE 11: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: 4,000.00 Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 120 West Hawaii Community Health Center Adult Emergeny Dental Services Agency Name: West Hawaii Community Health Center Program Name: Adult Emergency Dental Services Agency Director: Richard Taaffe, Executive Director Phone No.: (808) 326 — 3878 Contact Person: Donna Altshul, RDH Phone No.: (808) 323 — 8005 Mailing Address: Address: 75-5751 Kuakini Hwy., Suite 203 Address: City,ST,Zip Kailua-Kona, Hawaii 96740 Facility Address: Address: 74-5599 Alapa St. (Old Industrial Area) Address: City,ST,Zip Kailua-Kona, Hawaii 96740 Email Address: dalthsul @westhawaiichc.org Fax No.: (808) 327 — 1939 Accountant/CPA: Ryan lwawe Phone No.: (808) 524 — 2255 Firm (if applicable): Nishihama & Kishida, CPAs, INC. Mailing Address: Address: American Savings Bank Tower Address: 1001 Bishop Street, Suite 1700 City,sr,zip Honolulu, Hawaii 96813-3696 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $20,000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $10,000 $10,000 $10,000 2.Agency Mission Statement: The mission of West Hawaii Community Health Center (WHCHC) is to make quality, comprehensive and integrated health services acc4essible to all regardless of income. These services will be culturally sensitive and will promote community well-being through the practice of"malama pono". EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: West Hawaii Community Health Center Program Name: Adult Emergency Dental Services 3. Program Description: The Need for Emergency Adult Emergency Dental Services in West Hawaii is acute. A report prepared by the North Hawaii Outcomes Project - February 2012 states / see attachment A 4.Total Budget& Position Count: Total Program Budget: $ 139,542 Total Program Position Count: 1.4 FTE Total Agency Budget: $ 9,711,344 Total Agency Position Count: 91.1 FTE 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Medicaid, uninsured reimbursement $85,000 County of Hawaii $20,000 WHCHC Operating Funds $34,542 TOTAL: $139,542 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: West Hawaii Community Health Center will be asking for support in our 2013 Annual Campaign for the Dental Van and is planning on submitting a grant proposal to the West Hawaii Fund, sponsored by the Hawaii Community Foundation. As our public relations and marketing efforts continue to grow, we anticipate the West Hawaii community will become aware of what we do and how they can lend their support. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: West Hawaii Community Health Center Program Name: Adult Emergency Dental Services 7. Program Objectives Using County Nonprofit Grant Program Funds: Program objectives are to provide emergency dental care to approximately 884 adults who are uninsured or covered by Medicaid and to offer dental education through conversations and an education handout that educates patients on ways they can improve their oral hygiene. This number has decreased because we do not have the Hawaii Primary Care Association grant, and, thus our services only provides Adult Emergency Dental care. 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 uninsured or Medicaid adults seen for emergency dental services 884 An educational paper will be given to each patient 884 A survey will be taken to determine how else we can asssit them with their oral health needs - 1/4th of the patients 221 Attach additional pages as necessary. 9. TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $104,72 $108,889 $20,000 Professional Fees $800 $1,000 0 Operations $30,050 $18,150 0 Supplies $7,292 $11,173 0 Equipment 0 0 0 Other: $3,146 $330 0 Other: Other: Other: Other: TOTAL $146,00 $139,542 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: West Hawaii Community Health Center Program Name: Adult Emergency Dental Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: West Hawaii Community Health Center POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I� I No conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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: (//-;6/66/3 Signature of Authorized Person (s ec fy title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: West Hawaii Community Health Center Program Name: Adult Emergency Dental 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. 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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.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, 2014 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. /3 Signature of Authorized Person sp ify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 West Hawaii Community Health Center Adult Emergency Dental Services Attachment A PROGRAM DESCRIPTION The Need for Emergency Adult Emergency Dental Services in West Hawaii A report prepared by the North Hawaii Outcomes Project- February 2012, states that Hawaii County, like the other neighbor islands, has a lower ratio of dentists per population than the City& County of Honolulu.** These areas also have the highest rates of poverty, uninsured and Medicaid participation. Of the licensed dentists with a Hawaii primary address, Hawaii County has 56 dentists per 100,000 people which means that each of the 56 doctors would need to treat 1,785 patients - an unrealistic number. And, of those 56 Hawaii County dentists, many are unwilling to serve Medicaid and uninsured patients. For Hawaii County low-income adults, the problem of access to dental care is extreme because of the very limited number of private practice dentists that accept Medicaid and because the State Medicaid only pays for emergency care and limits payment to a $500 annual cap. The participation of our state's dentist in public insurance plans is so low that, according to a 2004 report, Hawaii "ranked almost last- 46th out of 47 states, with available data, for the proportion of dentists (30%) who offer services to publically-insured individuals." For example, on the Island of Hawaii, a 2012 survey of private dentists, none accepted new Medicaid patients. Dentists report that they do not accept Medicaid primarily because of low reimbursement rates. This leaves adults who have severe and immediate dental problems without options for even an extraction to alleviate infection and pain. The demand for services continues to grow with the residual effects of the economic crisis of 2009 and the State's elimination of adult dental benefits for Medicaid recipients in 2010. The Dental Van of West Hawaii Community Health Center is the only option for dental emergency services for adult patients when faced with an emergency dental situation. Although many of the Dental Van patients are Medicaid-eligible, Medical reimbursements, alone, do not support the operating expenses of the WHCHC Dental Van. West Hawaii Community Health Center's Solution The only solution for the uninsured and those on Medicaid is to visit the Dental Van,which operates only on Mondays and Tuesdays at the homeless shelter, Hope Services Hawaii located in Kailua-Kona. **Source: Department of Commerce and Consumer Affairs - July 27, 2011 and U.S. Census 2010 West Hawaii Community Health Center Adult Emergency Dental Services FY 2013 - 2014 - Operation Budget Detail Attachment B EXPENSES: Salaries and Wages Dentist (.40 FTE) $55,200 Dental Assistant/Van Ops Coordinator ( .50 FTE) $16,068 Receptionist/Assistant (.50 FTE) $16,546 Subtotal: $87,814 Fringe @ 24% $21,075 TOTAL - $108,889 Professional Fees $ 1,000 (Licensing& other associated fees) Operations Rent& Utilities $3,000 Telephone/Internet/Support ($800/mo) $9,600 Van fuel/repair/maintenance $3,750 Dental equipment repair / maintenance $1,300 Van insurance $ 500 TOTAL - $18,150 $ 18,150 Equipment&Supplies Dental supplies (based on $11.96 x 884 patient visits) $10,573 Office supplies $ 600 TOTAL - $11,173 $ 11,173 Other On-island mileage (600 miles x $.55) $ 330 TOTAL - $ 330 $ 330 BUDGET TOTAL - $139,542 Agency Name: West Hawaii Community Health Center Program Name: Adult Emergency Dental Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 121 West Hawaii County Band Friends Music and Equipment Fund Agency Name: West /414A414.4. est C° ` gam ct Program Name: Pitis etAi 7 r"e 71- Pvh d Agency Director: 1---) b / 5 00 - Phone No.: (10 ) 2 2—S3 S 3 2 Z Contact Person: Phone No.: (908 )939 Ss 65 Mailing Address: Address: 0. ,�oy 14 96c Address: City,ST,Zip - )44 A_ 1--- 1 LtS Facility Address: Address: Address: City,ST,Zip Email Address: hi a eS-h-b [i Su- @ c')�`h ° ° C'O Fax No.: ( ) — Accountant/CPA: N) I ea -a. Sh.t 4 Phone No.: (808)92-6/ — 000 Firm (if applicable): ic'a h(55 Spit v) Q(cS L L rP Mailing Address: Address: 9 a, 1,04145 B( o sS O117 L VI Address: lit City,ST,Zip N&c ehk 9 �"f l 2 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 0 `F)1 12-13 4 2.Agency Mission Statement: 7h e �n`m �-,�s 5 �ia-ll be f f w u�l Go l�Cc.�� d �`'� `Z/" 6 rwr7U1 c �� �-� a t y Oi J ? n , 55,' 71 041 c y _44 144 utiati Co EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: t1/esl- // w a l l Cep fj 95 6t" end flogran Name: l-1 u.�-r'C a-.1 d- wir�ru�u�urrouuuaurw���rr �r�urrurrrurs,riwuirr���r rut 3. Program Description: )7 ru✓1d II kelp s 1iee'f mcrSf c Cc c�a �'� a 5�' s �l a d i h ifs to rut op Z,' ,vi C C_ at e. sJ5/z - reek 11� � 9 bee u p k /e0 s t >e 4.Total Budget& Position Count: Total Program Budget: ' /p & Total Program Position Count: 0 Total Agency Budget: Total Agency Position Count: 8 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate 3r7)11J1/7 -� hC , 3DO . TOTAL: 3 0 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: P/PSf 1-1-4A-17 a-I /J d-" d Program Name: M c- izi d h-tieri t rt h d 7. Program Objectives Using County Nonprofit Grant Program Funds: l-.e 5 41,1 j `tom' // he Q h 2e. /5 /tea, 3 ,4 G I-61417 ti--,7/f. 2 p 9,)kr Fr-ic 'j' Ge �oS-7 a , dS 11,6 od c /7 LCc 25%� ,1-7)L d e,rs awl? cf fi 5/ ~"-1 "cam' 191'D{C ' 1-"M C� / �t��vfi�c Gam. e/f l. �f S f�a_/ d�1 d r� t x,$ 8.TABLE I: S'Ay 9 e d c -lam .-'l1 a v, Ic a u r dad 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) 77' e b Ai /1 0C a 6 l e -/t �I l t- & d er rer e•1 6/rc a>c o U_yr's K 11 i k f wry o f /et s f- i Si c- y reipaiie u24 / lnr�/� `T�'� l CM-I (fie -Ay riot oc4- c e /e (a £ 2 /^ d WPB H Itce.pce C Co-1, V a .V(444'S Gam,.,.,' . -(u(cLerS, rI'lls Q.K d ce Lt-e- C l i to(le pre preSS7.(Mct/ %a o z n c / i�r f z hZ 11_ Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies ', © ��C�r✓S jo o 11-00 t/DD Equipment old 5 C J lkt5 -- '9006 3700 Other: MU 51 6- -{ - /I - 2 0 pieces 1 1.Za0 - y p o a y 6 1, 6 Other: �J Other: Other: Other: TOTAL 60 � 110d 8 , 0v *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency, Name: the i > a'-'71^ -5 �'" � Program Name: i-1 u sri c- a,,7 d Et u'p »,erl•f i `,o1 d 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 conflict is needed. 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): No conflicts exist (No further information required. Please sign form at the bottom.) 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: / PRE.SthEtO 3 Si:nature a Aut • zed Pe ■ J n (specify title) to EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 A en Name: W�st _HO waft Cvv� �2n �,�, r g cY Program Name: Mu �c aM �� u-� rhier�-f- 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 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 shall include an explanation of the public benefits derived from thejawarding 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 will impact the evaluation of your program's or agency's future fundinq requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 Iby.the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htip://www. awaiicounty.,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, 2014 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 1 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. ature of; utho ed P r (specify title) Dat EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: live-s / Couvj 6'7 ci n/i`l S Program Name: /t/ v' kn Pt-2� 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result --014o t ii P /.<i// Ix it blc- � � t rd /^� ,j Li riv 7.3"71 5 et47 -& �f c /C-�T 7J ru2 cv Ct��T/��G D / tt�J /13 G40'I ce4- c c S a t �/ �klr S�%c p'teJ2 4 1/dbrsi 5f-*445-71 his aArd atier ,( lox q ? r se" -1t,17 01 n° h TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies O-['ec 5-u vpli eS o Equipmeht /./ S a,vcd d 3 10 v Other: IA/j S'I`e "Ivy �l '�y �„Z v pit'ccPS (a 1211 O y 0o 0 Other: Other: Other: Other: TOTAL 5 / 0 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 122 West Hawaii County Band Friends Volunteer Musicians fund e4-k cif Agency Name: 4Ve4't `",`` V Program Name: i/o/c+4,7 f e e-1 0145 ru/1d ke /Sic -j - � /chen t 3/2— 33.2 Agency Director: � � bhc Phone No.: (�+� Contact Person: L, /,/,‘.9 / I S`, 6'` I` `l Phone No.: vof} 238- F S 65 Mailing Address: Address: P. O. 8aX Address: �� Sys City,sr,Zip /C •/"a %7 Facility Address: Address: Address: City,ST,Zip Email Address: M G e Cs- (4 d "v" Fax No.: ( ) — Accountant/CPA: Me tea n a -S'1,l-' 11 Phone No.: (go ) 727- 3c2°o Firm (if applicable): K et Li L9��)7 C 5 S ,Z,)(es- LL p Mailing Address: Address: S 87,ss Address: tki-tA F- ( ' City,ST,Zip /Va a /e / Ct H/ q 67 7.2 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0 0 0 2.Agency Mission Statement: l ash , " cl u x Iv 'p l // '� 6 ds 5 �a a .s s t ez.od h ati,c 7117 � d �v� Wesf �a rva/ 1 . EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 �c -1-1J Agency Name: iv e 54" ' "411 � Program Name: V6 /k N fieer- ,€'ft iCi'a1.1 Fti d 3. Program Description: -7 I/ 1(4 X-14 51'cia 1i Fe-( h J he_ / s �e va lu rn/(,r 4r► c S b 77)-D v ! a-5 --f� e ±c ct r e ti e S cxj v,C These us-7 cia �is cIchc``T-e eir �► 3''-r ►v„ a -e L 1 ell f Amt c r'h-�� f 11 tYLe rn 12-�� CC, h , j �'v v r 5 111 ems �s Q 5 k I et Ste' S c e 4.Total Budget&Position Count: Total Program Budget: - I , 8 XS- Total Program Position Count: . . Total Agency Budget: 2., ), g a,5 Total Agency Position Count: 5. Program Funding Sources(identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate /-1'utivR_ti" l h J?ccf7bhea I/f7S1 /D i Hi a V►iein I, Ov 0 TOTAL: /� 0 6 0_ °rt) Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: -The F►'ie,pids rte// 9 yr-(7) ckv id 1,v A j 7 /11,0 1--e. dem 4--12'a-ri s S o-(- 11,4)(..() -/t) dah0.te - I ti � /s a I�1 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: W€sfizv a-i Program Name: V U e,, /' Si.0-4 - t"c✓ 7. Program Objectives Using County Nonprofit Grant Program Funds: ill C V 4 I t't vi -1- rw-( k)'ct cc 4-1 s fI y -D u)d e- �u2, J 0 me kn 6--e,- evvvi 5 ra9 d rvu 5-7 U 44-5- a'h 6 ap -1t t Li-; 5 40-e_ 4/0 re /.4---)-1.4.1, roe__ a,/`�� c< id) 5 v-r {�vi,a-�--2.. r-a"le s sl'o ri c` (--64 �`e_✓,,, . 7 V c /(-ty11 �e ei- 1-/ti.( 5-7'cat a v, S , �J is I ps -''2�- S o w�laf. vvit,f C-{a -5 w /2o pi (e a 5 s tir cc, -F75-,-- ,:-e l, 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 dients served,workshops or events held,volunteer hours,etc.Describe,be specific) L� 7U �-e140 rw► )11,17Y11-1-1 aX - lt,' Pc_g �er�rkvl /2- 6, -arJ ili,01 hi /9 uDicf-4-5 c,,Y-- 14,,te, 1-1-14_1-tiez. . pe4-- j6i,i a_Y- liqic. Hal cikin, I_a 1 n c-rfa-c- -71-1t, h.c-(Pk ‘ ✓ 6 f d 5 r-e - -9e' Zi.- )- 7 --/- cb f 2-e�'S' f 0''A-mot mo„"e. pa'` Lei q() r1i-est Q 6 b ct d in e4-- yew 1.,les1- 114 vc/214' C-Cw1 hl vv-117.f5 Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual' Total Budget Grant Req Salary and Wages Professional Fees /1---1 ,D t444 f i---1- 2 6b — 2 50 ^ 2-sO Operations / h o rQ ri u h S f0 0 0 0 _ 2. 1 C O O ,20000 Supplies Equipment SO u,S&�h-on e. /goo — Other: t i t J1/1 'f-I)Yrn 5I . i-1S l 0D Other: inn wr e ee.- 5/5 5-7 5 cis- Other: j_i brk ✓)avi 6c, ,,, ( ✓I-f' — / 000 /0o d Other: Other: TOTAL /3/L ZS '2 2 8 2 d V 2J)8.245 — *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: ��'``�`� Program Name: V 0/t1- - t(h C-i ni rl.t4,1 d 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 conflict is needed. 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): No conflicts exist (No further information required. Please sign form at the bottom.) ® 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: z o l 3 "1 Pkirth61;:ki2 / g ,ure of A thorized (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: ti/,-rf G° ` �S Program Name: G/o/crhI- e- It4u 3 �itd 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.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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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 particioation for a minimum of one year or until a written report is submitted to.and accepted Iby.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-forms1 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, 2014 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. pe/..o&v7 _ aeo ature Auth• • e• -'fr.on (specify title) (sate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: We Program Name: V /-t.f-eei k �7.4uo,J -P 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 10 Der err-, -04--r-A Ch r3 ii 1 (,zy- -th-e- w la 13 nl-c�i 1-tri764.4-S e- / la w" colt 4 h TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees - ' Z 5 0 Operations 6)-4 S D D 0 0 Supplies Equipment Other: f 5,t4,7or7ae. 57 5 Other: h i fr a i`7 cii (-517 5-1^-1 t I p t) O Other: Other: Other: TOTAL 2.1) 8 2 S Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 123 YWCA of Hawaii Island Healthy Start Plus Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus Agency Director: Lorraine Davis, Interim Chief Executive Officer Phone No.: (808) 961 — 3877 Contact Person: Andrew Kahili, CREO and Program Director Phone No.: (808) 961 — 3877 Mailing Address: Address: 1382 Kilauea Avenue Address: 145 Ululani Street city,s-r,zip Hilo, Hawaii 96720 Facility Address: Address: 1382 Kilauea Avenue Address: City,sr,zip Hilo, Hawaii 96720 Email Address: akahili @ywcahawaiiisland.org Fax No.: (808) 961 — 9140 Accountant/CPA: John Carbonaro Phone No.: (808) 242 — 5002 Firm (if applicable): Carbonaro CPAs & Management Group Mailing Address: Address: 1885 Main Street, Suite 408 Address: City,sr,zip Wailuku, Hawaii 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: $100,000 FY 13-14 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $0 $125,000 $75,000 2. Agency Mission Statement: Our mission, the YWCA of Hawaii Island is dedicated to eliminating racism, empowering women, and promoting peace, justice, freedom, and dignity for all. The YWCA of Hawaii Island, was first organized in 1990, and has been a nonprofit organization since 1965 and a partner agency of the Hawaii Island United Way since 1979. The YWCA is dedicated to providing services to meet our Hawaii island community needs, drawing together people with diverse experiences and relationships so that we may join together in implementing the YWCA's mission. We work to maintain the National YWCA's goals and objectives by fulfilling our local community's needs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 3. Program Description: Child abuse and neglect is a significant problem for Hawaii's children, seriously jeopardizing their immediate and long-range well-being and mental health. Current knowledge related to child abuse has made it possible to determine, at the time of birth, which families are at high risk. Thus prevention can be provided before the abuse occurs. The subject of this proposal will be the continuation of the Healthy Start Plus program throughout the duration of the fiscal year 2013 - 14. See attachment A- "3. Program Description:" 4.Total Budget& Position Count: Total Program Budget: $100,000 Total Program Position Count: 13 Total Agency Budget: $3,682,591 Total Agency Position Count: 75 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii State Department of Health $902,624.00 Hawaii State Department of Human Services 371,712.00 O'Neill Foundation - Positive Moms Initiative 75,000.00 TOTAL: $1,349,366.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The YWCA of Hawaii Island Healthy Start Plus program is a part of the Hawaii State Department of Health and Department of Human Services statewide Hawaii Home Visiting program. In January 2013, the Office of the Governor proposed legislation requesting for $2,800,000 of federal funding and $3,000,000 of state funding to support the continuation of the Hawaii Home Visiting Network ("HHVN") in fiscal years 2014 and 2015. The funding will be used to maintain/expand the operation/delivery of services of the existing HHVN programs. It is proposed that there will be on Oahu up to four (4) program sites, one (1) site on each of the islands and (2) sites on the island of Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 YWCA of Hawaii Island County of Hawaii Nonprofit Grants Program (FY 2013-14) Application Proposal Attachment: 3. Program Description (Continued) Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus Continued: 3. Program Description: The YWCA of Hawaii Island Healthy Start Plus proposes to provide comprehensive home visiting services to families at risk for poor child health outcomes, child development, and child maltreatment. Services include, but are not limited to maternal and child health, child maltreatment prevention, preschool readiness, domestic violence, family self sufficiency, and coordination and referral for other community resources and support. The program is voluntary and services are offered to eligible families with infants and children under the age of three (3) years of age. The program is part of the Hawaii Home Visiting Network, which provides culturally appropriate support services to families' to reduce the identified risk factors/stressors that may lead to child maltreatment. The service is provided in the family's home environment until the child reaches three (3) years of age. The Healthy Start Plus program offers all families structured parent-child group and home-based lessons that focus on developing early parent-child bonding/attachment, enhancing of positive self-worth in parents and children, creating a discipline plan that enhances the dignity of the parents and the children, learning strategies to empower children as well as adults, and emphasizing the importance for parents to nurture themselves as men and women. Families participating in the program will work together with a trained home visiting team consisting of professional and para-professional members, to create a parenting plan that immediately helps improve their lives, the lives of their children and the overall functioning of the family. The economic times that have hit Hawaii have added to the stressors of family functioning and requires additional safe havens that families can participate in for support and education. For over 25 years the program has been the model which provides parents, grandparents and other caregivers a place for healthy development of children and linkage to resources for Early Childhood care. NONPROFIT GRANT APLLICATION FY 2013-2014 Page 1 of 1 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 7. Program Objectives Using County Nonprofit Grant Program Funds: The program goals and objectives are to: 1) systematically reach out to families in the community to offer home visiting services; 2) cultivate the growth of nurturing, responsive parent child relationships; 3) promote healthy childhood growth and development; and 4) build foundations for strong family functioning. These goals are critical to the basic factors needed for changing the odds for our most vulnerable children. It is an approach that empowers parents to be effective role models for their children. See Attachment-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.) 100% of families enrolled shall not have a confirmed case of CAN 317 out of 317 families 100% of families enrolled shall have confirmed Medical Home 317 out of 317 families 90% of children enrolled shall not have a confirmed "dev. delay" 285 out of 317 children 100% of children shall be fully immunizied by 2 years of age 127 out of 127 children Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 12-13 FY 13-14 FY 13-14 Actual* Total Budget Grant Req Salary and Wages 922,752 886,187 69,964 Professional Fees 229,522 223,587 8,703 Operations 179,900 179,000 15,940 Supplies 56,861 56,861 5,393 Equipment 2,800 2,831 Other: Other: Other: Other: Other: TOTAL 1391835 1,349,366 100,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 YWCA of Hawaii Island County of Hawaii Nonprofit Grants Program (FY 2013-14) Application Proposal Attachment: 7. Program Objectives using County Nonprofit Grant Program Funds: (Continued) Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus Continued: 7. Program Objectives Using County Nonprofit Grant Program Funds: The YWCA of Hawaii Island Healthy Start Plus service is the only home visiting program of its kind in East Hawaii. It has the only program focused specifically on Hawaii's most vulnerable children and their families. Other home visiting programs do not offer the frequency of visits or the comprehensive and intensity of services that are necessary to address this important multifaceted issue. Research tells us that investing in young children has a higher rate of return than any other economic investment. The program's goals and objectives provide a prevention model to avert child abuse and neglect and promote healthy development among families. The program is effective and unique as it identifies and serves infants from birth, before abuse can occur. It truly is a preventive program. In-home services are necessary in the prevention of child abuse and neglect ("CAN"), families obtaining medical insurance/primary physician ("Medical Home"), identifying suspected developmental delays ("dev. delay") in children, and ensuring children are fully immunized by two (2) years of age. Our experience has shown that home visiting services can: address concrete survival needs of over-stressed, impoverished families; reduce risk factors and increase protective factors related to abuse; teach life coping skills to increase self sufficiency; promote healthy parent-child relationship as a protective factor against abuse; identify children with possible delays by conducting developmental screening and referring children to Early Intervention Service providers; make referrals to a medical home for infant/children checkups as well as prenatal care for subsequent pregnancies and other community resources; and utilizes a multidisciplinary team that provides treatment readiness services and referrals for domestic violence, substance abuse and mental health issues. Healthy Start Plus is not the cure all, but it has excellent outcomes in helping parents to overcome their challenges when caught in the cycle of trauma. Parents love their children, but many parents have experienced traumatic childhoods themselves: their parents were involved with drugs, alcohol, domestic violence, in addition to abuse and neglect. Without help, these problems become intergenerational. The cycle must be broken and that is where the YWCA of Hawaii Island Healthy Start Plus program services can and has made an impact on the families of Hawaii. NONPROFIT GRANT APLLICATION FY 2013-2014 Page 1 of 1 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Teshima POSITION: Board of Directors, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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 2013-2014 Page 6 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 100% of families enrolled shall not have a confirmed case of CAN 317 out of 317 100% of families enrolled shall have confirmed Medical Home 317 out of 317 90% of children enrolled shall not have a confirmed "dev. delay" 285 out of 317 100% of children shall be fully immunizied by 2 years of age 127 out of 127 TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $69,964.00 Professional Fees 8,703.00 Operations 15,940.00 Supplies 5,393.00 Equipment Other: Other: Other: Other: Other: TOTAL $100,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jennifer Tanouye POSITION: Board of Directors, President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Ir l No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Hayashida POSITION: Board of Directors, 1st Vice President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): { I No conflicts exist(No further information required. Please sign form at the bottom.) 1-7 Member or members of the Council Staff appointed by a member of the Council The Mayor I I 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. ,., ., , r Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jennifer Zelko POSITION: Board of Directors, 2nd Vice President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): v l No conflicts exist (No further information required. Please sign form at the bottom.) nMember 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lynn Nuniez POSITION: Board of Directors, Treasurer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I� I No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor EThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lorraine Godoy POSITION: Board of Directors, Secretary May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 171 No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. 7`',)'7 �t �y c.Z�b ,✓✓ � L Gr .vs`°'. �e Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Sandra Claveria POSITION: Board of Directors, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist (No further information required. Please sign form at the bottom.) CMember or members of the Council _ Staff appointed by a member of the Council The Mayor I 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. / °"6-' '«✓t=F i.4_.... J° G_e..a_9.^`°'mot :t, j t.J,d°f�r �_ la .'. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Teshima POSITION: Board of Directors, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): nNo conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council I 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Taylor Cockerham POSITION: Board of Directors, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Iv l No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lorraine Mendoza POSITION: Board of Directors, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Q No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council _ The Mayor CThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Beverly Heikes POSITION: Board of Directors, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): CNo conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council _ The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. ) . d r•=' Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Evelyn Lee POSITION: Board of Directors, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): { I No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor n 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Plus 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Darien Nagata POSITION: Board of Directors, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): I� I No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor n 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benefit(s) from the relationship bewteen the County of Hawaii and the YWCA of Hawaii Island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 124 YWCA of Hawaii Island Sexual Assault Support Services Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services Agency Director: Lorraine Davis, Interim Chief Executive Officer Phone No.: (808) 935 — 7141 Contact Person: Jeanette Clarke, Program Director Phone No.: (808) 334 — 1624 Mailing Address: Address: 145 Ululani Street Address: city,sr,Zip Hilo, HI 96720 Facility Address: Address: 1382 Kilauea Avenue, Hilo, HI 96720 Address: 75-5706 Hanama Place, #202, city,sr,Zip Kailua Kona, HI 96740 Email Address:jclarke @ywcahawaiiisland.org Fax No.: (808) 334 — 0406 Accountant/CPA: John Carbonaro Phone No.: (808) 968 — 1002 Firm (if applicable): Carbonaro CPAs & Management Group Mailing Address: Address: 1885 Main Street, Suite 408 Address: city,sr,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for Nonprofit Grant Program Funds: q County rofit p g I l9aJ000 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 $20,000 $15,000 $20,000 2.Agency Mission Statement: YWCA of Hawaii Island is dedicated to eliminating racism, empowering women, and promoting peace, justice, freedom and diginty for all. Please see attached page titled 2. Agency Mission Statement used to supplement this section. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services Program 2. Agency Mission Statement The YWCA of Hawaii Island, first organized in Hilo in 1919, has offered valuable programs and activities for the benefit of women, children and their families. The YWCA of Hawaii Island was established as a 501 (c)(3) non-profit organization in 1965 and has been a partner agency of the Hawaii Island United Way (HIUW) since 1979. It belongs to a national organization consisting of 300 YWCA Associations across the U.S. with 2.6 million members. Employing over 70 full-time and part-time staff, the YWCA offers a variety of services to people of all ages, from newborns to senior citizens in their 80's throughout the island of Hawaii. YWCA Hawaii Island programs include: • Healthy Start and Enhance Healthy Start, the only home visitation family support programs for all East Hawaii new mothers and babies who are at risk for child abuse and neglect; • Teen Court, available island-wide and the only way for teens and 'tweens to make up for their first-time offense, give back to the community and wipe their record clean; • Sexual Assault Support Services, the only 24/7 rape crisis center of its kind for all of Hawaii Island; • An aquatics center that offers the warmest, solar heated salt water and therapeutic pools in East Hawaii; and • A preschool that promotes kindergarten readiness by providing care at one of the only nationally accredited preschools on the island. Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 3. Program Description: The program's mission is to provide services for the healing and prevention of sexual violence. Please see attached page titled 3. Progam Description used to supplement this section. 4.Total Budget& Position Count: Total Program Budget: $397,360 Total Program Position Count: 12 Total Agency Budget: $3,682,591 Total Agency Position Count: 75 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate State of Hawaii Attorney through SATC 264,860 Office of the Prosecuting Attorney 46,000 State of Hawaii Attorney General SASP through SATC 17,500 Private Donations 9,000 County of Hawaii 60,000 TOTAL: 397,360 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program has a variety of funding streams because sexual assault is something that nobody wants to talk about much less fund. That being said, this agencvy is taking the following steps to keep this program funded: -Fundrasing. In the past four years, the YWCA has sponsored "Walk a Mile" and " YWalk" where the program was recipient of some of the funds raised. -Continuous grant writing to foundations, agencies and response to request for proposal that would support the efforts in alignment witht he program services. -Donations from the community, either in-kind or monetary to help victims of sexual assault. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services Program 3. Program Description The program's mission is to provide services for the healing and prevention of sexual violence. Sexual violence is a hard topic to talk about and it is 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. To let you know how pervasive this crime is, imagine yourself seated in a crowded movie theater her on the island. Based on national and local statistics, at least 2 people in every row either has 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 1 in 4 girls and 1 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. While our funding sources are reducing their assistance to support the services to victims, the demand for the same services has increased. In a comparison of the first 6 months of the last fiscal year against the first 6 months of this fiscal year is shown in Table 1. Table 1. Comparison of Number of Victims/Survivors Served Description July 1, 2011 to July 1, 2012 to December 31, 2011 December 31, 2012 Number of Initial Crisis Calls 265 238 Taken Number of Secondary 214 379 Phone Contacts Number of Initial Face to 82 54 Face Served Number of Victims 52 68 Receiving Crisis Outreach Victims receiving Clinical 189 169 Services *One employee out on maternity leave during this time frame. Had there been no break in services, it is estimated that 22-35 additional victims would have received services. In the coming fiscal year, due to Federal and State mandates, the SASS program funding will be reduced by an estimated. The program has made cuts in the infrastructure and now faces cuts in direct service to victims. As shown in Table 1, the demand has increased and the program is facing a reduction in direct services. The SASS program works to reduce the incidences of sexual assault and disability to those who have been victimized. Services include 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 minor, 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 assault on a person. All services are provided at no charge to the client or family. The SASS program functions as team members with the Hawaii County Sexual Assault Response Team (SART). Both advocates and therapists work with SART members in providing quality services to clients. SART members include police investigators, sex assault nurse examiners, prosecutors, Children's Justice Center and Child Welfare Services. The YWCA is in our third decade of helping sex assault survivors, who are men, women, girls and boys. Primary funding of the program is through the State of Hawaii, Office of the Attorney general through a subcontract with the Kapiolani Women's and Children's Medical Center Sex Abuse Treatment Center. As a result, quality assurance, program and fiscal monitoring of services are maintained at a statewide standard. Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Continue to operate the 24-hour, 7 day a week Sexual Assault Crisis Hotline receiving calls island-wide from persons seeking support, information, and referral that may lead to face to face support as described in the next objective. 2) Provide a SASS Advocate to support each sexual assault victim undergoing forensic and legal examination in the period July 1, 2012 to June 30, 2013. 3) Deliver professional counseling and/or case management service to at least 100 victims. 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. Fully trained personnel are available to assess and respond to 100% of calls responded to callers on the Sexual Assault Crisis Phone 24/7, 365 days a year. 2. Crisis counseling, legal systems advocacy, information and 150 victims will receive service referalls are provided to each sex assault victim undering medical- legals examinations on the island. 3. Survivors of sexual assault receive psychotherapy services from 100 victims will receive service masters prepared therapists. Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 361,332 272,231 Professional Fees 8,949 6,755 Operations 146,850 106,301 60,000 Supplies 9,342 7,073 Equipment 975 5,000 Other: Other: Other: Other: Other: TOTAL 527,448 397,360 60,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Teshima POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor n 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support 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'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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2013 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 2013-2014 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. Fully trained personnel are available to assess and respond to 100% of calls callers on the Sexual Assault Crisis Phone 24/7, 365 days a year. responded to 2. Crisis counseling, legal systems advocacy, information and 150 victims referalls are provided to each sex assault victim undering medical- served legals examinations on the island. 3. Survivors of sexual assault receive psychotherapy services from 100 victims masters prepared therapists. served TABLE II: PROGRAM EXPENDITURES FY 13-14 Council Grant Request Award Salary and Wages Professional Fees Operations $60,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jennifer Tanouye POSITION: Board of Director, President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s)from the relationship between the County of Hawaii and the YWCA of Hawaii island. • v<•17�]r . - ems w- r: �/.I Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Hayashida POSITION: Board of Director, 1st Vice President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s)from the relationship between the County of Hawaii and the YWCA of Hawaii island. l 0/x3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jennifer Zelko POSITION: Board of Director, 2nd Vice President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. /4'03 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lynn Nuniez POSITION: Board of Director, Treasurer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) nMember 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s)from the relationship between the County of Hawaii and the YWCA of Hawaii island. //5 645 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lorraine Godoy POSITION: Board of Director, Secretary May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ill No conflicts exist (No further information required. Please sign form at the bottom.) I I 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s)from the relationship between the County of Hawaii and the YWCA of Hawaii island. v / �✓ c� z�rs�,lsi-ry Z / //-3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Teshima POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): nNo conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council 1 The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s)from the relationship between the County of Hawaii and the YWCA of Hawaii island. //3.V/3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Sandra Claveria POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 0 No conflicts exist (No further information required. Please sign form at the bottom.) nMember 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. • Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Taylor Cockerham POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s)from the relationship between the County of Hawaii and the YWCA of Hawaii island. ofriA--tA----kt-e--i 620 A-0-u/ /46//, ' Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.A11 disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lorraine Mendoza POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s)from the relationship between the County of Hawaii and the YWCA of Hawaii island. add---7414 7 �/i%C iLLi v Dr /3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Beverly Heikes POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I� I No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor piThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. °ei4-/Avl — /30/4.3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Evelyn Lee POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I/ No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Darien Nagata POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor piThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. //3v/f3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 125 YWCA of Hawaii Island YWCA Developmental Preschool Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool Agency Director: Lorraine Davis, Interim Chief Executive Officer Phone No.: (808) 935 — 6067 Contact Person: Lissa Van Kralingen, Program Director Phone No.: (808) 935 — 7141 Mailing Address: Address: YWCA of Hawaii Island Address: 145 Ululani City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: YWCA of Hawaii Island Address: 145 Ululani City,ST,Zip Hilo, Hawaii 96720 Email Address: Ivankralingen @ywcahawaiiisland.org Fax No.: (808) 935 — 5051 Accountant/CPA: John Carbonaro Phone No.: (808) 242 — 5002 Firm (if applicable): Carbonaro CPAs & Management Group Mailing Address: Address: 1885 Main Street, Suite 408 Address: City,ST,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT Amount of Request for County Nonprofit Grant Program Funds: 25,000.00 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 09-10 FY 10-11 FY 11-12 0.00 0.00 0.00 2.Agency Mission Statement: YWCA Hawaii Island is dedicated to eliminating racism, empowering women and promoting peace, justice, freedom and dignity for all. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 1 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 3. Program Description: YWCA Developmental Preschool focuses on the whole child...socially, cognitively, emotionally and physically. Our program is Licensed by the State of Hawai'i Department of Human Serves (DHS) and accredited by the National Association for the Education of Young Children (NAEYC). YWCA Developmental Preschool is unique because we expose children to the academic world in a nurturing, safe and secure environment that is catered to each individual child. In our classrooms the children get a balance of a structured learning environment as well as time to learn through their own self-initiated discovery. Children are surrounded by things from which to learn. 4.Total Budget& Position Count: Total Program Budget: $839,440 Total Program Position Count: 23 Total Agency Budget: $3,682,591 Total Agency Position Count: 75 5. Program Funding Sources (identify all sources of funding applied to this program): FY13-14 Revenue Source Estimate Hawaii County Grant $25,000 Castle low-income tuition assistance $7,500 Program Fees $723,940 Hawaii Island United Way $20,000 USDA Child and Adult Care Food Program $60,000 Contribution / Special Events $3,000 TOTAL: $839,440 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our goal is to continue our "Family Fun Day" fundraiser and to seek specific grants and work with other agencies like the Food Basket to offset our program expenses and needs. In August 2012, we increased our tuition by 4% to raise the revenues to cover our expenses, the last tuition increase was in 2009. Our goal is to have 105 full time students enrolled to meet budget. We currently have 100 children enrolled and depending on available tuition assistance and the parents ability to pay tuition, each month enrollment numbers can change. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 2 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 7. Program Objectives Using County Nonprofit Grant Program Funds: The biggest line item in our budget is the meals; breakfast, lunch and the afternoon snack. For breakfast and snack we are planning to work more closely with the Food Basket to help bring our costs down. Our lunches are provided by a private vendor who works to be in compliance with USDA-CACFP providing a nutritious, well balanced, and portion controlled meal. Lunch cost $3.75 /day/ child. On the average, we order 90 lunches a day. Lunch expenses for one month is roughly $7087.50 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.) All enrolled children will receive a nutritious lunch 98% will receive a lunch All children will be introduced to different foods 95% will be served meals Children will learn to make healthier snack choices, nutrition ed. 90% will receive healthy snack To help end childhood obesity in our enrolled children 98% will be WNL of weight Staff receive annual training on food program & data collection 95% know CACFP procedures Annual application to USDA/CACFP full participation of agency Attach additional pages as necessary. 9.TABLE II: FY 12-13 FY 13-14 FY 13-14 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages 525,603 Professional Fees 8,809 Operations 206,753 Supplies 71,275 Equipment 2,000 Other: Tv` 64 pc c U. ���Yl 5 q 13,750 25,000 25,000 Other: Other: Other: Other: TOTAL 13,750 839,440 25,000 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 3 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Teshima POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist (No further information required. Please sign form at the bottom.) nMember 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 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 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 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 will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 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, 2014 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. 41/1t-&--6 ',--11-1:"-"Yij //3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 6 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result All enrolled children will receive a nutritious lunch 98% All children will be introduced to different foods 95% Children will learn to make healthier snack choices, nutrition ed. 90% To help end childhood obesity in our enrolled children 98% Staff receive annual training on food program & data collection 95% Annual application to USDA/CACFP full participatio TABLE II: FY 13-14 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: 25,000 Other: Other: Other: Other: TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2013-2014 Page 7 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jennifer Tanouye POSITION: Board of Director, President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 1-11 No conflicts exist (No further information required. Please sign form at the bottom.) nMember 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. ; . Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Hayashida POSITION: Board of Director, 1st Vice President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s)from the relationship between the County of Hawaii and the YWCA of Hawaii island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jennifer Zelko POSITION: Board of Director, 2nd Vice President May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 171 No conflicts exist (No further information required. Please sign form at the bottom.) F7Member or members of the Council Staff appointed by a member of the Council The Mayor I I 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s)from the relationship between the County of Hawaii and the YWCA of Hawaii island. t Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lynn Nuniez POSITION: Board of Director, Treasurer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 17,71 No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lorraine Godoy POSITION: Board of Director, Secretary May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 7 No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Sandra Claveria POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) nMember 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. . Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Karen Teshima POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council 1 The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. . . � � ° / of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Taylor Cockerham POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. °'° j „� p �-rJ ,..a.✓' g,y£,£...y a ,jyF+� 9 p�� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lorraine Mendoza POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) nMember 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. .:L I- L, iv-21/773 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Beverly Heikes POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor n 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Evelyn Lee POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist (No further information required. Please sign form at the bottom.) nMember or members of the Council _ Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 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 conflict is needed. Please duplicate as needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Darien Nagata POSITION: Board of Director, Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): No conflicts exist(No further information required. Please sign form at the bottom.) nMember or members of the Council Staff appointed by a member of the Council The Mayor nThe 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 Board of Directors of the YWCA of Hawaii Island are all volunteers and will not have any direct benifit(s) from the relationship between the County of Hawaii and the YWCA of Hawaii island. —A/4 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2013-2014 Page 4 of 7