HomeMy WebLinkAboutNonprofit Grant Application for FY14 (2)Facility Address:
Email Address:
Accountant /CPA:
Firm (if applicable):
Address:
City, ST, Zip
Address:
Address:
City, ST, Zip
Fax No.: ( ) —
Phone No.:
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. Agency Mission Statement:
EXHIBIT A
NONPROFIT GRANT APPLICATION
FY 2013 -2014
Page 1 of 7
Agency Name:
Program Name:
3. Program Description:
4. Total Budget & Position Count:
Total Program Budget: Total Program Position Count:
Total Agency Budget: Total Agency Position Count:
S. Program Funding Sources (identify all sources of funding applied to this program):
FY13 -14
Revenue Source Estimate
TOTAL:
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:
Program Name:
7. Program Objectives Using County Nonprofit Grant Program Funds:
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.)
Attach additional pages as necessary.
9. TABLE II:
PROGRAM EXPENDITURES
FY 12 -13
Actual*
FY 13 -14
Total Budget
FY 13 -14
Grant Re q
Salary and Wages
Professional Fees
Operations
Supplies
Equipment
Other:
Other:
Other:
Other:
Other:
TOTAL
EXHIBIT A
NONPROFIT GRANT APPLICATION
FY 2013 -2014
*If applicable
Page 3 of 7
Agency Name:
Program Name:
lo. ORGANIZATION CONFLICT DISCLOSURE FORM
Please disclose any conflicts or potential conflicts of interest that any board member, officer, director,
or administrator of your organization may have with the County of Hawai'i. Only those listed below
need to be disclosed. One form per 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):
F] No conflicts exist (No further information required. Please sign form at the bottom.)
F] 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)
EXHIBIT A
NONPROFIT GRANT APPLICATION
FY 2013 -2014
Date
Page 4 of 7
Agency Name:
Program Name:
11. Certification of Understanding
I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures;
and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2-
135 — 2- 142.1, Hawai'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 httpe / /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
Lure fundina reauest 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:
Program Name:
12. COUNCIL AWARD WORKSHEET
TABLE I:
PROGRAM PERFORMANCE MEASURES Applicant Council Proposed
Projected Results I Projected Result
TABLE II:
PROGRAM EXPENDITURES
FY 13 -14
Grant Request
Council
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