AUDITED FINANCIAL STATEMENTS - United Way Broward
Request for ApplicationsFor Fiscal Year 2020-21 ServicesCOMMUNITY IMPACT AREA: HEALTHAvailable January 17th 2020Closes February 20th 2020 UNITED WAY OF BROWARD COUNTYREQUEST FOR APPLICATION: HEALTHPart I: APPLICANT AGENCY INFORMATIONGeneral Agency Information Applicant Agency Legal Name:Main Administrative Address:City & State:Zip Code:Telephone Number:Website:CEO/Executive Director:Office Phone Number:E-mail Address:Federal Identification Number: Applicant Agency Fiscal Year: Beginning (mm/dd): Ending (mm/dd): Certification of Accuracy and ComplianceI do hereby certify that all facts, figures, and representations made in the application are true and correct. Furthermore, all applicable statutes, terms, conditions, regulations and procedures for program compliance and fiscal control will be implemented to ensure proper accountability. I certify that the funds requested in this application will not supplant funds that would otherwise be used for the purposes set forth in this program and are a true estimate of the amount needed to operate the proposed program. The filing of this application has been authorized by the contracting entity and I have been duly authorized to act as the representative of the agency in connection with this application. I also agree to follow all Terms, Conditions, and applicable federal and state statutes.__________________________ __________________________ Print Authorized Official’s NameAuthorized Official’s Title__________________________ ___________________________ Authorized Official’s Signature (Blue Ink)DateOrganization Background Provide a concise description of the Applicant Agency, including its history, years of operation, general mission statement and primary services provided. (Up to 2 points)How does the Applicant Agency support United Way of Broward County? (Up to 2 points)? Workplace fundraising campaign? Facility tours? Speakers’ bureau members? Event Support? Other (Please describe) _______________________________________ Has the Applicant Agency been a defendant in any litigation or regulatory action in the last three (3) years? If yes, provide a brief explanation of each instance. (Up to 2 points) Is the Applicant Agency accredited? If yes, please include the name of the accrediting body, the level of accreditation, and the time period, if applicable. (Up to 2 points)Part II PROGRAM INFORMATIONProgram Information: Program Name: Funding Category: ? Health & Wellness In or Out of Home Care? Health and Wellness Care Coordination? Combination Funding Request: $Is this program currently funded by UWBC? Yes ?No ?Application/Program Contact Information: Name: Title: Phone Number: E-mail Address: Program Location(s): (Please attach additional addresses if needed)Name of Location (School/Organization): Address: City & State: Zip Code: Name of Location (School/Organization):Address: City & State: Zip Code: Name of Location (School/Organization):Address: City & State: Zip Code: Program Summary Please summarize the proposed program in 300 words or less, including in the project title and requested funding amount. Please provide an overview of the program’s key components, target population, numbers to be served, geographic area, and proposed outcomes. (Up to 2 points)Statement of NeedProvide a narrative detailing the geographic area proposed, the target population to be served, and the service location. Provide a detailed overview of the condition/problem/ gap in services that your proposal will address and why the funding is needed. The statement should include city, school, and/or neighborhood statistics regarding the identified issue. (Up to 18 points)Evidence Based Model and Program PlanPlease provide a detailed description of the proposed model with supporting evidence. Describe client eligibility and how the population will be recruited and retained. Describe the proposed service schedule (days, hours, etc.) and dosage (frequency and duration). Please provide a detailed staffing plan that includes: positions, education requirements, experience level, duties of the position, and the percentage of time devoted to your proposed program model. (Up to 18 points)Evaluation PlanDescribe your proposed evaluation processes. Please provide an overview of your proposed outcomes using a “Results Based Accountability” framework and your target goals for each. Describe the measurement tools you intend to employ. Describe the proposed data collection methodology and data collection points. (Up to 15 points)Organizational CapacityDescribe the agency’s experience with providing the proposed service. Describe the agency’s experience in working with the targeted population. Please provide an overview of key staffs’ experience with providing the proposed service to the target population. Address how and why the agency is uniquely qualified to provide services in the geographic area proposed. Please provide a detailed overview of the agency’s cultural and linguistic competencies. Please address whether the program or agency has been monitored by UWBC or other funder within the last 12 months and the results. (Up to 15 points)Collaboration and CoordinationDescribe the agency’s existing programmatic and any other relevant collaborations, partnerships, or coordination of services. Explain the agency’s capacity to leverage other services, funding, and/or resources. (Up to 6 points)PART III: ORGANIZATIONAL ATTACHMENTS (No Point Values)Attachment A:Audited Financial Statement(s): Must be included with Application as Organizational Attachment “A”. Applicant Agencies are required to submit their audited financial statements for the most recently completed fiscal year or the previous fiscal year if the most recent one ended within 180 days of the due date of this Application. Smaller agencies (those agencies with annual revenues less than $300,000) must submit unaudited compiled financial statements prepared by a CPA. Attachment B:Applicant Agency Verification: Complete and attach the two (2) page form provided as Organizational Attachment “B” to the Application. Requires original signature duly verifying the authority of the signatory to act on behalf of the Applicant Agency for this Application and certifies that all representations made in the Application are true and correct. Attachment C: Certificate of Corporation: Must be submitted as Organizational Attachment “C”. The Applicant Agency is required to attach a printout of the Public Inquiry page from Corporations Online, (), dated within twelve (12) months of the due date of this RFA, stating that Applicant Agency is active. In the alternative the Applicant Agency may submit a copy of its Certificate of Corporation from the Secretary of State, State of Florida certified and dated by the Secretary of State within twelve (12) months of the due date of this RFA. This Certificate must state on its face that the Applicant Agency is active. Please note that a copy of the Articles of Incorporation, acknowledgement of Annual Reports, or any similar document does not meet the requirements of this section. Attachment D: Current Drug Free Work Place Certification: Complete and attach the two (2) page form provided as Organizational Attachment “D”. This certifies that the Applicant Agency will provide a drug-free workplace. Notarized original signature required.Attachment E: IRS determination of 501 (c) (3) nonprofit status, if applicable. Include as Organizational Attachment “E”.Attachment F: Client Non-Discrimination Policy: A sample policy is provided. Include the Applicant Agency’s current policy as Organizational Attachment “F”. The Applicant Agency will not engage in or commit any discriminatory practice in violation of the Broward County Human Rights Act. Original signature required.Attachment G: Current Equal Employment Opportunity Policy: A sample policy is provided. Include the Applicant Agency’s current policy as Organizational Attachment “G”.Attachment H: Current Americans with Disabilities Act Policy: A sample policy is provided. Include the Applicant Agency’s current policy as Organizational Attachment “H”.Attachment I: Include a direct line Organizational Chart showing where this program would function within the Applicant Agency if the requested funds are awarded. The Organizational Chart should be attached to this Application as Organizational Attachment “I”.Attachment J: Not-for-Profit organizations must include a list of the Applicant Agency’s Board of Directors, and/or Advisory Board, including their addresses and offices held within the Board as Organizational Attachment “J”.Attachment K: The second page of the Organizational Profile for Providers, which has been submitted to 211-Broward First Call for Help, must be attached to this Application as Organizational Attachment “K”. Directions for obtaining the appropriate form can be accessed by calling the Information Manager at 211-Broward First Call for Help at (954) 390-0493 or by emailing at info@211-Organizational Attachment “A”AUDITED FINANCIAL STATEMENTSOrganizational Attachment “B”AGENCY VERIFICATIONNAME OF Applicant Agency: ______________________ I hereby certify that:I am duly authorized to sign this Application.I have participated in and/or read the information provided in this Application and agree to the terms and conditions in the Application.Quotations and all other responses in this Application are, to the best of my knowledge, accurate and true.I recognize that failure to be truthful in this Application may result in the canceling of a contract award.I understand that United Way of Broward County will award the contract that is most advantageous to Broward County, taking all other factors into consideration.I certify that all persons, companies or parties interested in the Application, made it without collusion with any other person, persons, company or parties submitting an Application and that it is in all respects made in good faith.I certify that NO litigation is threatened or pending which could impair this Applicant Agency’s ability to fulfill the provisions of this Application.I certify that NO adverse action is pending or threatening by any regulatory, licensing, or oversight Applicant Agency which could impair the Applicant Agency’s ability to fulfill the provisions of this Application.All Applicant Agency decisions regarding recruitment, hiring, promotions, releases, and conditions of employment will be made without regard to consideration of race, creed, religion, gender, country of national origin, age, physical or mental handicap, marital status or any other factor which cannot lawfully be used as a basis for an employment decision.The budget included in this Application is a reasonable estimate of the anticipated revenues and expenditures for the activities anizational Attachment “B”, Agency Verification, page 2Any of the following documents are available upon request by the United Way of Broward County and will be produced by the Applicant Agency within five (5) work days and may not need to be submitted with this Application:a.Agency By-lawsb.Personnel Policies and Proceduresc.Job Descriptionsd.Licenses to Operate Agency/ProgramIf any of these statements cannot be made, please explain on a separate 8 ? x 11 sheet of paper and attach to this form.OFFICIAL AUTHORIZED TO SIGN AND BIND Applicant Agency TO APPLICATION:WITNESS SIGNATURES:SignatureSignatureName (Print or Type)Name (Print or Type)Title (Print or Type)DateDateSignatureName (Print or Type)DateOrganizational Attachment “C”CERTIFICATE OF CORPORATIONOrganizational Attachment “D”DRUG FREE WORKPLACE CERTIFICATIONThe undersigned Applicant Agency hereby certifies that it will provide a drug-free workplace program by:(1)Publishing a statement notifying its employees that unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace, and specifying the actions that will be taken against employees for violations of such prohibition;(2)Establish a continuing drug-free awareness program to inform its employees about:(I)The danger of drug abuse in the workplace;(ii)The policy of maintaining a drug-free workplace;(iii)Any available drug counseling, rehabilitation, and employee assistance programs; and (iv)The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;(3)Giving all employees engaged in performance of a contract a copy of a statement required by subparagraph (1);(4)Notifying all employees, in writing, of the statement required by subparagraph (1), that as a condition of employment on a covered contract, the employee shall;(I)Abide by the terms of the statement; and(ii)Notify the employer in writing of the employee’s conviction under criminal drug statute for a violation occurring in the workplace no later than 5 calendar days after such conviction;(5)Notifying United Way of Broward County in writing within 10 calendar days after receiving under subdivision (4) (ii) above, from an employee or otherwise receiving actual notice of such conviction. The notice shall include the position title of the employee;(6)Within 30 calendar days after receiving notice under subparagraph (4) of a conviction, taking one of the following actions with respect to an employee who is convicted of a drug abuse violation occurring in the workplace:(I)Taking appropriate personnel action against such employee, up to and including termination;(ii)Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purpose by federal, state, or local health, law enforcement, or other appropriate agency; andOrganizational Attachment “D”, Drug Free Workplace Certification, page 2(7)Making a good faith effort to maintain a drug-free workplace program through implementation of subparagraphs (1) through (6). ________________________________ (Applicant Agency Signature) ________________________________ (Print Applicant Agency Name)STATE OF COUNTY OF The foregoing instrument was acknowledged before me this day of , 20 , by _____________________________________________________________ (Name of individual signing)As of (Title) (Name of Applicant Agency/entity)Known to me to be the person described herein, or who produced as identification, and who did/did not take an oath. NOTARY PUBLICMy commission expires:Organizational Attachment “E”IRS Form 501(c) (3)Organizational Attachment “F”CLIENT NON-DISCRIMINATION POLICYIn accordance with Title VII of the Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, and the Broward County Human Rights Act (Broward County Code, Chapter 16?), the Applicant Agency’s decisions regarding the delivery of services under any Agreement with Broward County will be made without regard to, or consideration of race, age, religion, color, gender, sexual orientation, national origin, marital status, physical or mental disability, political affiliation, or any other factor which cannot be lawfully used as a basis for service delivery.The Applicant Agency will not engage in or commit any discriminatory practice in violation of the Broward County Human Rights Act (Broward County Code, Chapter 16?) in performing any services under any Agreement with United Way of Broward County.Applicant Agency: ________________________________________ Executive Director: ________________________________________ (Signature)(Date)Organizational Attachment “G”EQUAL EMPLOYMENT OPPORTUNITY POLICYPOLICY:The progress of our organization requires that we utilize all available staff to the fullest, regardless of race, color, religion, age, gender, sexual orientation, disability, political affiliation or belief, national origin, veteran status or marital status. Unlawful discrimination must be eliminated and individuals with demonstrated talent recognized and encouraged through fair and equitable personnel practices. It is the policy of this Agency to grant equal employment opportunities to all qualifies persons without regard to the factors listed above.This Agency’s policy of nondiscrimination includes, but is not limited to, employment advertising, recruiting, employment, placement, promotion, transfer, and selection for training, rates of pay, and layoff or termination. All employees are informed of the emphasis on nondiscrimination.This Agency will comply with all provisions of applicable federal, state, and local equal opportunity laws, orders, rules, and regulations and will cooperate with all agencies established under such laws in guaranteeing compliance.PROCEDURES:All applications for employment will be printed with the term “Equal Opportunity Employer”.All advertisements for recruiting purposes will contain the statement “An Equal Opportunity Employer” at the bottom of the ad. Agency: __________________________________________________________ Executive Director: _____________________________________________ (Signature)(Date)Organizational Attachment “H”AMERICANS WITH DISABILITIES ACT POLICYThis Agency and its employees support through policy, procedure, and action the right of disabled persons, prospective staff and persons served, to equal access to services and employment.APPLICANTS:This Agency shall make efforts in good faith to arrange “reasonable accommodations” for qualified applicants, providing these accommodations do not create “undue hardship” for the agency.The process of “reasonable accommodations” will include the following steps: 1) Consultation with the individual by the supervisor or operations director; 2) Identifying barriers in question; 3) Identifying possible accommodations (including assistance from outside authorities or agencies); 4) Assessing reasonableness of accommodations with the final decision from the Executive Director or designee; and 5) Implementing the accommodation or determining that the accommodation would be an “undue hardship”.Should the accommodation create an “undue hardship” for the Agency, the prospective employee will be offered the opportunity to implement the accommodation on their own.In the event that accommodations: 1) Create “undue hardship” on the agency or the fellow employees; 2) Cannot be accessed through assistance from other authorities or agencies; and, 3) Cannot be arranged with the prospective employee, the decision not to hire shall be documented along with records of all efforts made.Applications for employment shall be completed in wheelchair accessible locations. All relevant compliance posters shall be readily visible in areas with public access. If an individual should need assistance in completing the application, staff shall be available to help with the application process, and any other necessary pre-employment materials.EMPLOYEES:In the event an employee develops a disability during the course of employment, modifications to the employee’s original position shall be assessed, as well as, a possible job change, or restructuring, providing this does not cause “undue hardship” to the Agency.In the event that an employee is found to have a substance abuse problem that is affecting their work performance, that employee shall be offered the opportunity to go on a leave of absence until the problem is corrected through immediate and appropriate intervention and therapy, provided the employee seeks such opportunity early in the disciplinary action, and does not commit an offense that is punishable by termination on the first offense.If an employee requires a leave of absence due to a disability, not associated with work, they may request such leave through procedures outlined in the Agency’s leave of absence policies.If an employee requires leave due to a work related injury, the rules governing workers compensation shall be followed.The Agency shall comply with the provisions of the Family and Medical Leave Act of 1993.Agency: ______________________________________________________________ Executive Director: ______________________________________________________ (Signature)(Date)Organizational Attachment “I”Organizational ChartOrganizational Attachment “J” SEQ CHAPTER \h \r 1List of Board of Directors(Include affiliation, phone number and email address)Organizational Attachment “K”Organizational Profile (second page)Part IV: PROGRAM ATTACHMENTSAttachment A: Staff Information: Must be included with Application as Program Attachment “A”. List all positions and the number of each, that will be providing direct and support services. Include the job title (which should match your budget narratives), minimum education, training and experience requirements, primary duties, and the percent of each position’s time that will be devoted to this program & funded by UWBC. (Up to 3 points)Attachment B: Budget Detail and Summary: Complete and attach the budget form provided as Program Attachment “B” to the Application. Complete the Budget Cover Sheet (tab1). Provide detail of the annual expenses related to the proposed program on the Budget Detail Document (tab 2) and a summary on the Budget Summary Document (tab 3). (Up to 6 points)Attachment C: Performance Measures Matrix: Complete and attach form provided as Program Attachment “C”. (Up to 3 points)Program Attachment D:Monitoring Reports: Attach as Program Attachment “D”. All monitoring reports for this Program Model. (Up to 2 points)Program Attachment “A”Staff Information Staff Qualifications: Complete the chart below. List all positions and the number of each, that will be providing direct and support services. Include the job title (which should match your budget narratives), minimum education, training and experience requirements, primary duties, and the percent of each position’s time that will be devoted to this program & funded by UWBC. Position/Job Title# of positionsEducationTraining and ExperienceDuties% of time devoted to the programProgram Attachment “B”Budget Detail and Summary (Downloadable as separate Excel File on the Website)Program Attachment “C”Performance Measures MatrixThe Provider shall be responsible for submitting mid-year and end of year narrative reports to UWBC. Provider success stories may be requested, as needed. Providers shall comply with all requests in a timely manner. Exact due dates and reporting format shall be provided by UWBC within the first 90 days of the contract term. ??The Provider shall also report any barriers experienced in performance measure achievement, as required. The report should also include any noteworthy activities that have occurred during the term of this Agreement, as requested. The Provider will use the UWBC Data Quality Assurance Report to ensure administration (data) points are completed and service components are attached. DESIRED RESULT: Individuals and Families residing in Broward County have Access to Quality Healthcare and ServicesResults based accountability utilizes data to improve performance outcome measures to achieve the desired customer result. When applied, performance measurement answers the following key questions:Key QuestionPerformanceTarget GoalSampleEvaluation ToolAdmin ScheduleHow Much Did We Do?#How Well Did We Do It?%Is Anybody Better Off?%Program Attachment “D”Monitoring Reports (if applicable) ................
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