HomeMy WebLinkAboutNP Application FY19
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EXHIBIT A
Agency Name:
Program Name:
Agency Director: Phone No.:
Contact Person: Phone No.:
Mailing Address: Address:
Address:
City, ST, Zip
Facility Address: Address:
Address:
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 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
South Hilo
North Hilo
Hāmākua
North Kohala
South Kohala
North Kona
South Kona
Ka‘ū
Services or Activities To Be Provided: (One or more can be checked)
Educational concerns
Culture and the arts
Needs of the poor
Public Health and Welfare of the People and the Environment
Youth
Aged
Physical/Emotional Disabilities
Victims of Crimes
Victims of Health or Social Crises
NONPROFIT GRANT APPLICATION FY 201 -201 Page 1 of 8
Agency Name:
Program Name:
1. Prior Yr Award of County Nonprofit Grant Program F ds:
FY 1-1 FY 1-1 FY 1-1
2. Agency Mission Statement:
3. Program De scription:
4. Total Budget & Position Count:
Total Program Bud get: Total Program Posi tion Count:
Total Agency Budget: Total Agency Position Count:
EXHIBIT A
NONPROFIT GRANT APPLICATION FY 201-201 Page 2 of 8
Agency Name:
Program Name:
5. Program F unding Sources (identify all sources of funding applied to this program):
Revenue Source
FY1-1
Estimate
TOTAL:
Attach additional pages, if needed.
6. Explain what plans your agency or program h as to increase revenues to support this program:
7. Program Objectives Using County Nonprofit Grant Program Fu nds:
EXHIBIT A
NONPROFIT GRANT APPLICATION FY 201-20 Page 3 of 8
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 1-1
Actual*
*If applicable
FY 1-1
Total Budget
FY 1-1
Grant Req
Salary and Wages
Professional Fees
Operations
Supplies
Equipment
Other:
Other:
Other:
Other:
Other:
TOTAL
EXHIBIT A
NONPROFIT GRANT APPLICATION FY 201-201 Page 4 of 8
EXHIBIT A
NONPROFIT GRANT APPLICATION FY 201-201 Page 5 of 8
Please disclose 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:
Agency Name:
Program Name:
10. ORGANIZATION CONFLICT DISCLOSURE FORM
May have a conflict or potential conflict of interest, including any familial relationship, with any of the
following (check all that apply):
Member or members of the Council
Staff appointed by a member of the Council
The Mayor
The Managing Director
The Director of Finance
The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation
Counsel
Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct
benefits accruing to the individual as opposed to benefits accruing in general to an industry.
Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential
conflicts of interest:
If no conflicts exist, check here.
Signature of Authorized Person (specify title) Date
EXHIBIT A
NONPROFIT GRANT APPLICATION FY 201-201 Page 6 of 8
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 p rocedures;
and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2-
135 – 2-142.1, Hawai‘i County Code, relating to !ppropriation 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 ac cording 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 b e 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
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 w ith the requirement
to submit a year-end report to the County Council within 60 days a fter June 30 of the contractual year
for which the grant was awarded. The r eport, using the tem plate provided, shall include a n
explanation of the public benefits derived from the a warding of the g rant (focusing on specific,
measurable ou tcomes), 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 a ward period.
Failure to su bmit 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.
Signature of Authorized Person (s)
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 in dicates 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 o f June 30th shall result in loss
of all grant funds received during the g rant period (must be r efunded to County) a nd exclusion from
future g rant participation for a minimum o f one year or until a written report is submitted to, and
accepted by, the co uncil.
I (we) understand there is no provision for further notification to submit the f inal 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 f or the purposes
stated in the application, except for a maximum ten p ercent (10%) for administrative and overhead
costs. Any funds unused by June 30, 201 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.
Date
EXHIBIT A
NONPROFIT GRANT APPLICATION FY 201-201 Page 7 of 8
NONPROFIT GRANT APPLICATION FY 201-201 Page 8 of 8
Agency Name:
Program Name:
EXHIBIT B
12.COUNCIL AWARD WORKSHEET
TABLE I:
PROGRAM PERFORMANCE MEASURES Applicant
Projected Results
Council Proposed
Projected Result
TABLE II:
PROGRAM EXPENDITURES FY 1-Grant
Request
Council
Award
Salary and Wages
Professional Fees
Operations
Supplies
Equipment
Other:
Other:
Other:
Other:
Other:
TOTAL
Additional Council directives regarding award: