HomeMy WebLinkAboutNonprofit Application - FY16
County of Hawai‘i Nonprofit Grant Application FY2015-16
Agency Name:
Program Name:
Agency Director:
Contact Person:
Mailing Address: Address:
Address:
City, ST, Zip
Phone No.:
Phone No.:
(
(
)
)
–
–
Facility Address: Address:
Address:
City, ST, Zip
Email Address: Fax No.: ( ) –
Accountant/CPA:
Firm (if applicable):
Phone No.: ( ) –
Mailing Address: Address:
Address:
City, ST, Zip
YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO
PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES
Amount of Request for County Nonprofit Grant Program Funds:
Geographical Areas To Be Served: (One or more can be checked)
Puna Hāmākua North Kona
South Hilo North Kohala South Kona
North Hilo South Kohala Ka‘ū
Educational concerns Youth Victims of Crimes
Culture and the arts Aged Victims of Health or Social Crises
Needs of the poor Physical/Emotional Disabilities
Public Health and Welfare of the People and the Environment
Services or Activities To Be Provided: (One or more can be checked)
EXHIBIT A
NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8
County of Hawai‘i Nonprofit Grant Application FY2015-16
Agency Name:
Program Name:
1. Prior Year Award of County Nonprofit Grant Program Funds:
FY 12-13 FY 13-14 FY 14-15
2. Agency Mission Statement:
3. Program Description:
4. Total Budget & Position Count:
Total Program Budget: Total Program Position Count:
Total Agency Budget: Total Agency Position Count:
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NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8
County of Hawai‘i Nonprofit Grant Application FY2015-16
Agency Name:
Program Name:
5. Program Funding Sources (identify all sources of funding applied to this program):
FY15-16
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:
7. Program Objectives Using County Nonprofit Grant Program Funds:
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NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8
County of Hawai‘i Nonprofit Grant Application FY2015-16
Agency Name:
Program Name:
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
Attach additional pages as necessary.
9. TABLE II:
PROGRAM EXPENDITURES FY 14-15
Actual*
FY 15-16
Total Budget
FY 15-16
Grant Req
Salary and Wages
Professional Fees
Operations
Supplies
Equipment
Other:
Other:
Other:
Other:
Other:
TOTAL
*If applicable
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County of Hawai‘i Nonprofit Grant Application FY2015-16
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 Hawai‘i. Only those listed below
need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for
the organization, with the “No conflicts exist” option checked needs to be submitted. Please duplicate
as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists.
NAME:
POSITION:
May have a conflict or potential conflict of interest, including any familial relationship, with any of the
following (check all that apply):
Member or members of the Council
Staff appointed by a member of the Council
The Mayor
The Managing Director
The Director of Finance
The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation
Counsel
Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct
benefits accruing to the individual as opposed to benefits accruing in general to an industry.
Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential
conflicts of interest:
If no conflicts exist, check here.
Signature of Authorized Person (specify title) Date
County of Hawai‘i Nonprofit Grant Application FY2015-16
Agency Name:
Program Name:
11. Certification of Understanding (Page 1 of 2)
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, using the template provided, shall include an
explanation of the public benefits derived from the awarding of the grant (focusing on specific,
measurable outcomes), a complete accounting of all expenditures supported by County of Hawai‘i
grant funds, and a listing of other funding sources and amounts obtained during the award period.
Failure to submit a timely, complete, and accurate year-end report, using the template provided, will
impact the evaluation of your program’s or agency’s future funding requests.
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NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8
County of Hawai‘i Nonprofit Grant Application FY2015-16
Agency Name:
Program Name:
11. Certification of Understanding (Page 2 of 2)
If awarded a grant from the County of Hawai‘i, I (we) understand that a current Certificate of Liability
($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai‘i
Finance Department, which specifically and explicitly indicates that the County of Hawai‘i is an
additional insured prior to receiving any payment(s).
I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss
of all grant funds received during the grant period (must be refunded to County) and exclusion from
future grant participation for a minimum of one year or until a written report is submitted to, and
accepted by, the council.
I (we) understand there is no provision for further notification to submit the final report. Information
and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about
May 30 of the year the final report is due.
As part of this application, you acknowledge that any funds awarded will be restricted for the purposes
stated in the application, except for a maximum ten percent (10%) for administrative and overhead
costs. Any funds unused by June 30, 2015 must be returned to the County of 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
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County of Hawai‘i Nonprofit Grant Application FY2015-16
Agency Name:
Program Name:
12. COUNCIL AWARD WORKSHEET
TABLE I:
PROGRAM PERFORMANCE MEASURES Applicant
Projected Results
Council Proposed
Projected Result
TABLE II:
PROGRAM EXPENDITURES FY 15-16
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 2014-2015 Page 8 of 8