SECTION I:



dOMESTICE VIOLENCE interim hOUSING

Application and instructions

1. Proposal Deadline and Pre-Submittal Conference

A. Proposal Deadline and Submittal Procedures

Please send one original and one copy by 4:30 p.m. on

March 20, 2012 to:

Jennifer Welch

Deputy Commissioner

Department of Family and Support Services

1615 West Chicago Avenue, 5th Fl.

Chicago, Illinois 60622

The outside of the envelope or package must clearly indicate the title of this RFP “2013 Domestic Violence Interim Housing Program Expansion”, the name and address of the Applicant and the date and time the proposal is submitted.

Proposals will be accepted prior to the due date, from 9:00 a.m. to 4:00 p.m. Monday – Friday at the same location. All proposals must be complete. Incomplete proposals may not be reviewed. In-person or bonded messenger delivery of proposals is encouraged. Time-stamped receipts will be issued as proof of timely submittal.

No proposal will be considered complete and therefore reviewed unless the original copy is delivered and received at DFSS offices.

Proposals received after the due date and time may be deemed NON-RESPONSIVE and, therefore, subject to rejection.

B. Questions

Respondent are strongly encouraged to submit all questions and comments related to the RFP via e-mail. For answers to program-related questions please contact:

Jennifer Welch: Jennifer.welch@, 312-746-7448

All other questions regarding the administrative aspects of this RFP may be directed to: Julia Talbot: jtalbot@

C. Pre-Proposal Conference

A pre-proposal conference will be held on Friday, February 15, 2013 from 3:00 to 5:00 p.m. at the Department of Family and Support Services, 1615 W. Chicago Ave., Room 249A (second floor large conference room). Attendance at this conference is not mandatory but is highly advised.

To request reasonable accommodation for the pre-submittal conference, please contact, Monica Rafac, monica.rafac@ . Requests for accommodations will be accepted up to 48 hours prior to the event.

D. Timeline

This is the anticipated timeline for the funded programming:

|Proposal Release Date: |February 1, 2013 |

|Bidders Conference: |February 15, 2013 |

|Proposal Due: |March 20, 2013 |

|Anticipated Contract Start Date: |May 1, 2013 |

2. Application Requirements

A. Formatting

Submitted proposals must adhere to all of the following requirements:

• One original and one copy will be submitted for each proposal

• One complete set of the proposal containing original signatures in blue ink signed by an authorized representative of the Respondent will be marked “Original” by March 20, 2013, 4:30 p.m.

• Recycled paper

• 8 1/2 x 11 letter size

• Double-sided printing

• One inch margins

• At least 1.5 -spaced

• At least 11-point font

In addition to the requested information stated in accompanying application and budget files (constituting the narrative and budget portions of the proposal), Respondent must supply the following additional information in their response to this RFP identified in the list below in items 4-10). The proposal should consist of the following items, in this order:

1. A proposal cover sheet signed by an authorized representative of the Respondent’s agency (found in the accompanying application packet).

2. Written response, supporting documentation and required attachments (if any) to questions (found in the accompanying application packet).

3. An itemized budget request developed using the guidelines and budget forms (found in the accompanying application packet/files).

4. A System for Award Management (SAM) number. For information on how to obtain a SAM number for your agency, please refer to the following website:

5. Proof of 501(c) (3) Good Standing from the IRS (for non-profits only). This can be accomplished by filling out the following form and printing the result for inclusion in your application packet.

6. Copy of Official Articles of Incorporation.

7. A copy of the Respondent’s most recent fiscal audit report.

8. Certificate of Insurance

9. A Certificate of Good Standing from the Illinois Secretary of State’s Office.

10. A Certificate of Economic Disclosure will be required for all awarded contracts but is not required at the time of submission.

The Narrative portion of the proposals should be no longer than 20 pages in length.

Failure to submit a complete proposal and/or to respond fully to all requirements may cause the proposal to be deemed unresponsive and, therefore, subject to rejection.

Receipt of a final proposal does not commit the department to award a grant to pay any costs incurred in the preparation of an application.

3. Evaluation and Selection Procedures

A. Evaluation Process

An evaluation committee selected by DFSS will evaluate and rate all proposals based on the evaluation criteria outlined below. Each proposal will be evaluated on the strengths of the proposal and the responsiveness to the selection criteria outlined below. DFSS reserves the right to consult with other city departments or public or private funders during the evaluation process. Selected Applicant must be ready to proceed with proposed facility development at the time of contracting.

The Commissioner, upon review of recommended agencies, may reject, deny or recommend agencies that have applied for grants based on previous performance and/or area need.

Selections will not be final until the City and the Applicant have fully negotiated and executed a contract. The City assumes no liability for costs incurred in responding to this RFP or for costs incurred by the Applicant in anticipation of a fully executed contract.

Failure to submit a complete proposal and/or to responds fully to all requirements may cause the proposal to be deemed unresponsive and, therefore, subject to rejection.

B. General Selection Criteria

The Proposals will be evaluated on the Respondent’s ability to provide services as defined in this RFP. The following criteria will be used in evaluating all proposals:

1. Previous Programmatic Experience

• Respondent should demonstrate knowledge of serving victims of domestic violence as evidenced by previous or current operation of a successful program of a similar nature.

• In the case of programs providing services to individuals (direct benefit), the individuals serviced must meet low/moderate income criteria. Delegate agencies must be willing to maintain records regarding income eligibility of each client served.

• Provide evidence of financial, physical, and human resources leverage in the community. Also provide any collaborations or partnerships with other public and private agencies related to your program design and objectives (Examples: referral system, linkage agreements, neighborhood coalitions or partnerships with Chicago Public Schools).

• Prior experience serving domestic violence victims and their families.

2. Administrative/Fiscal Capacity and Experience

• Respondent will demonstrate the resources and expertise to assume and meet all administrative and fiscal requirements. This includes the Respondent’s fiscal (including financial management systems), technological, management, administrative and staff capabilities.

• Respondent will demonstrate the capability to undertake a facility development project, preferably including prior facility development and capital campaign fundraising experience.

• Overall fiscal soundness, as evidenced by the financial history and record of the organization, as well as audited financial statements (or the equivalent) from the most recent program year. All Respondents must be current on all prior financial or contractual obligations with the City. All Respondents must be able to prove that there are no outstanding liens or taxes owed to City, State or IRS.

• Evidence of other (non-City) financial support and/or fundraising accomplishments for the organization.

3. Program Design and Administration

• Respondent will demonstrate program and administrative plans specifically tailored to the goals of the program.

• Proposals will be rated based on the criteria and considerations listed in this RFP for the Interim Housing program model. System level considerations (such as geographic location, need to target underserved populations, etc.) may be taken into account in final ratings and funding decisions. The selection process will also consider how all programs fit together to achieve a comprehensive, citywide system of care that supports Plan 2.0 (Plan to End Homelessness) and aligns with HEARTH Act standards.

C. Additional Evaluation Criteria

In addition to general selection criteria, proposals will be evaluated on the following criteria:

• Agency’s program experience and capacity, including experience serving victims of domestic violence.

• Agency’s cost per client served. Proposals will be evaluated based on their proposed budget request and the number of clients to be served and their estimated cost per client for subsequent year.

• Agency’s demonstrated fiscal and administrative capacity. For current DFSS providers, DFSS will consider all DFSS program and fiscal monitoring reports, as well as expenditure reports indicating agency’s ability to expend funds in a timely manner.

• Substantially leverage other non-DFSS public and private funding sources by providing a cash or in-kind match of 25% or more for operations (only). After the facility is developed, the intent of this application is to fund a portion of a program’s total annual budget, and not to be a program’s sole funding source. Therefore, Respondents that provide for leverage in their proposed budget will be considered more responsive.

• Agency’s program implementation, scope, and outcomes. The Respondent’s program design must be consistent with the Interim Housing Program Model described in this RFP. Proposals will be evaluated on the expertise and ability of the agency to address the required key elements of the proposed program model and fulfill the required program outcomes. The agency must demonstrate an evaluation strategy that is feasible and can reasonably measure program impact. Proposals will be evaluated based on the Respondent’s prior performance for the Interim Housing Program Model being implemented. Prior performance be evaluated based on the Respondents’ narrative response to this Application as well as review of programs’ prior performance (based on DFSS quarterly reports).

• Agency’s proposed staffing. Proposals will be evaluated on the extent to which the Respondent demonstrates staffing patterns necessary to operate the program in accordance with the Interim Housing Program Model design and outcomes.

• Service coordination and integration. Respondents must demonstrate their capacity to locate and leverage partners on an on-going basis. Proposals will be evaluated on the extent to which the Respondent has linkage agreements and partnerships with providers of the following services: Case Management; Employment Training, Placement, and Retention; Health Care; Housing Placement; Substance Use and Recovery Treatment; Mental Health Assessment and Treatment (for adults and children); Child Care and After-school Programs (for family programs); Legal Assistance and Advocacy; Credit Counseling; Life Skills Training. Proposals will be evaluated on the extent to which clients will have the ability to access these services either on-site or at a nearby location.

• Facility Assessment. Agencies must meet ADA and local code regulations to operate a shelter, where applicable. Failure to respond or meet the criteria in the Facility Assessment will be taken into consideration.

The following priorities may be taken into consideration when making final funding decisions. Priority may be given to programs that:

• Enable DFSS to expand domestic violence shelter bed capacity.

• Consider the geographic locations of existing housing programs for families impacted by domestic violence.

• Align with the goals of Plan 2.0 and anticipated HEARTH standards by focusing on rapid re-housing and supportive services needed to keep individuals and families housed.

• Target underserved populations and exhibit flexible admissions criteria, to assure that there are sufficient programs available to respond to system needs.

o Best represent outcome-based programming. This is programming that can be measured by meaningful outcomes, rather than solely by the reporting of activities.

o Consider all DFSS program and fiscal monitoring reports for the Respondent agency.

o Consider prior performance, as indicated in quarterly reports submitted to DFSS.

o Consider complaints and unresolved complaints pertaining to the service provider.

DFSS reserves the right to seek clarification of information submitted in response to this Application and/or to request additional information during the evaluation process and make site visits and/or require Respondents to make an oral presentation or be interviewed by the review subcommittee, if necessary.

DEPARTMENT OF FAMILY AND SUPPORT SERVICES

Domestic Violence Interim Housing

Agency Application Information Form

|Legal Name of Applicant Agency | FEIN Number |

| | |

|Administrative/Mailing Address |DUNS Number |

|Executive Director |Executive Director’s Phone Number |

| | |

|Executive Director’s Fax Number |Executive Director’s Email Address |

| | |

|Contact Person for Proposal |Contact Person’s Phone Number |

|Contact Person’s Fax Number |Contact Person’s Email Address |

Type of Agency (check one)

| |Not-for-Profit Agency | | For-Profit Agency | |Faith-Based Agency |

| |Other, if yes Description: | |

Amount Requested: $ Aldermanic Ward

Proposed Geographic Region:

Agency Statement of Certification

This proposal has been duly authorized by the governing body of the proposed. The proposed activities, dates, availability of resources, staff, cost, and all statements made are true and correct. The applicant will comply with all rules and regulations of the funding agency and will revise this proposal if necessary.

| | |

|Authorized Signer’s Name |Authorized Signature |

| | |

|Authorized Signer’s Title |Date Signed |

Application

Executive Summary

Please attach an Executive Summary, which briefly describes your agency’s qualifications and proposed program under this RFP. The Executive Summary may be no more than two pages. The Executive Summary must include:

• The total amount requested for each proposed program.

• A commitment to provide the requested services.

• An overview of the qualifications of the Applicant and any other organization(s) that will provide or will significantly contribute to the requested services.

• If applicable list multiple service address locations, ward numbers and dollar allocations.

• The name and telephone number of the lead contact person for the proposal.

• Signature of Executive Director or President in blue ink.

Program Narrative

Please write a narrative that provides information and description about your agency’s capacity, vision and plans on the following areas in respect to operating an interim housing program for families impacted by domestic violence in the geographic area. The narrative should be no more than 20 pages.

1. Facility Development and Rehabilitation

• Do you have a site in mind for this project? If not, what strategies will you employ to identify a site?

• Describe the Respondent’s experience in facility acquisition.

• Provide an overview of your agency’s plan for acquiring and rehabilitating a shelter facility.

• Describe the Respondent’s experience with facility development including both rehabilitation and construction projects.

• Describe the applicant’s plan to involve a facility development consultant.

• Describe the Respondent’s experience with capital campaign fundraising.

• Describe the Respondent’s resources including, staff or volunteers, for facility acquisition, construction, rehabilitation or financing.

• Provide an overview of how your agency will comply with prevailing wage and other construction requirements.

• Please provide a timeline outlining your anticipated acquisition, construction and/or rehabilitation phases in detail. Please include in this timeline the amount of time anticipated to find the necessary site, people and resources to complete the proposed work and list any vendors you anticipate using if known at this time.

2. Agency Capacity

• Provide a brief overview of your agency. The overview should minimally address the following items: brief history of your agency; agency’s philosophy and mission; current services provided and demographics including population served and geographic service delivery area, etc.

• Describe the applicant’s history in operating a domestic violence program or shelter program.

• Describe the applicant’s programmatic, fiscal and administrative capacity for operating the program and managing the grant, if funded.

• Describe your agency’s participation in the Chicago Metropolitan Battered Women’s Network and/or the Illinois Coalition Against Domestic Violence.

• Describe your agency’s interactions with the Domestic Violence Help Line.

• If applying as collaborative, please address the following:

o Name of all partner agencies.

o Describe role of each partner/services provided by each partner.

o Prior experience of agencies in working together and coordinating similar services.

o Lead agency’s procedures for ensuring fiscal and programmatic outcomes of subcontracted partners.

o A letter of commitment from each participating provider must be included as a supplement to this application. The letters should specify the nature of the participation in the collaborative, and the specific services to be provided.

3. Staffing

• Please describe the proposed staffing pattern for this program, including job description and qualifications of key staff.

• Include discussion of whether positions are currently filled or will have to be hired, and describe plan for hiring within the established grant time frame.

• Describe participating agencies’ processes for hiring, training and retaining qualified staff, and the agencies’ process for ensuring continuous training and supervision for staff.

• Describe where and when staff will acquire 40 hour domestic violence training.

• Describe the strategies the agency employs to promote cultural diversity and cultural competency among staff.

• Demonstrate that staff is trained on gender/sexual orientation, HIV/AIDS issues, trauma informed care and harm reduction approaches, and positive youth development.

• Include an Organizational Chart of your agency, clearly showing the relationship of this proposed domestic violence shelter to other programs at your agency.

4. Program Overview and Population Served

Briefly describe the following:

• The applicant’s ability to serve the geographic focus area.

• Describe the program’s target population and the need for services.

• Describe the applicant’s experience and strategies for serving special populations, such as LGBTQQI, clients involved in human trafficking, and clients with disabilities.

• Include an unduplicated count of those to be served during the course of the grant, including the methodology used to determine this count.

• Describe eligibility requirements for clients coming into the shelter as well as any client issues or characteristics that would exclude a client from your shelter.

• If clients are not accepted into the shelter, describe whether or not your agency provides these individuals support in finding other services.

• Describe how the program will address client diversity, including the cultural, ethnic and other needs and differences (i.e., disability, sexual orientation) within the client population, as well as how services will be provided in a linguistically and culturally appropriate setting.

• Describe the agency’s grievance procedures and client voluntary discharge procedures, and involuntary client termination procedures.

5. Program Implementation and Service Coordination

• Describe the process for conducting initial intake

• Describe your agency’s plan to provide housing services, including initial assessment upon intake, and appropriate placement within a 120-day goal.

• Describe how your agency will utilize the Housing Options Screening Tool and rapid-re-housing assistance as well as other permanent housing placement options.

• Describe services to be provided, including case management, development of case plan, victim safety planning, and explanation of Illinois Domestic Violence Act, how to obtain an Order of Protection, and how to utilize the legal system to address domestic violence.

• Describe how the program will ensure that the following service needs are addressed, as appropriate, for clients while they are enrolled in your program as well as once clients are placed in appropriate housing: employment training, placement, and retention; housing placement; substance abuse detox services; mental health assessment and treatment; child care; financial literacy; health care and life skills training (including parenting training).

• Specifically describe which services are provided directly by your program, and which are provided through linkage agreements with service providers. State whether each linkage agreement is formal (written) or informal.

• Describe process for screening clients for, and helping them obtain, public benefits.

• Describe plans for leadership development opportunities and ways in which the program will create opportunities for youth to be involved in program decision making.

• List proposed outcomes for the program (including the outcomes noted in the RFP), and describe prior success in achieving outcomes such as placement in appropriate housing, housing retention, increase in income, increase in skill level, etc. Describe process for tracking outcomes.

• Please attach a flow chart of program service provision.

6. Financial, physical, and human resources being leveraged

• Describe the financial, physical, and human resources that are being leveraged for the program.

• Clearly indicate the amount and sources of other funding for the program (should align with budget submission “Other Share”)

• State whether the agency has a line of credit or an operating reserve to cover one month of payroll, OR can document having met payroll obligations for the past 12 months.

• Describe your agency’s capacity to locate and leverage additional resources on an on-going basis.

• Is your proposed facility ADA compliant? If not, please describe how reasonable accommodations can and will be made.

• Please describe your proposed start-up timeline.

7. Monitoring & Evaluation

Describe the methods your agency will employ to evaluate the project’s progress and record project accomplishments.

• Describe how client progress and outcomes will be assessed and tracked, and how the agency will determine if the program is achieving its intended outcomes. Some outcomes have provided a minimum performance measure that is the standard. Respondent must, in the description of deliverables and performance measures, describe the program’s strategies for achieving the outcomes noted in the RFP. Respondent must also describe any potential barriers in achieving these outcome levels as well as specific strategies for overcoming these barriers.

• Describe the process for conducting follow-up with clients who have exited the program. State the percentage of clients that receive follow-up, and when.

• Describe the procedure(s) which will be in place to provide program reports as may be required by DFSS in regard to client information and program performance.

• Please describe how your agency assures the confidentiality of all client information and records.

8. Administrative and Financial Procedures

Describe how your agency will monitor program expenditures and ensure that appropriate fiscal controls and records are in place.

• Describe the agency’s fiscal and administrative procedures for operating the program and managing the grant, if funded.

• Proposed plan for fundraising for the program (not the acquisition phase) and details of the agency’s fundraising history. The fundraising plan should include annual financial targets for the next two years.

• If the agency has received DFSS homeless or domestic violence services grants in the past, describe previous expenditure rates (for a minimum of the past 3 years: 2010, 2011, and 2012) and explain any difficulties in expending funds.

• If you are a current DFSS grantee, please provide the outcome of your agency’s last program or fiscal audit. If you received findings or were not in compliance, please explain.

• Please attach a minimum of three (3) verifiable references regarding your agency’s performance (references can be from a variety of sources, i.e., funding sources, social service agencies or other professional agencies or community groups.) on that agencies’ letterhead.

9. Charts

• Please attach a table outlining all of your current grants:

|Name of program |Source of funding (please be as |Grant Amount |Grant start/end |Data tracking software used|

| |specific as possible) | |dates |(if any) |

| | | | | |

| | | | | |

| | | | | |

Please expand this table as necessary to include all current grants

• Provide the number of meals provided in one year, if applicable: __________

| |Breakfast | |

|Check meals provided | | |

| |Lunch | |

| |Dinner | |

|Number of meals to be provided | |

|(Average daily attendance X number of meals served X operating days) | |

| | |

|For example, a 30 bed program that provides breakfast, lunch, and dinner, and operates 365 days a year would have | |

|32,850 Meals (30 X 3 X 365) | |

• Please list what languages and ethnic populations your agency currently works with. Please outline your agency’s plan to provide assistance for non-English speaking clients. When appropriate identify specific agencies, community groups and ethnic associations that you plan to coordinate with and any that you currently have a working relationship with.

| | |

|Ethnic/non-English Speaking Population |Language Speaking |

| |Staff Member currently on staff? |

| | |

| | |

____ My agency only works with English speaking clients.

Budget Instructions

Respondent should provide two budgets with its application. The first budget should demonstrate the anticipated expenses to acquire rehab and furnish the proposed shelter. The second budget should consist of a 12-month operations budget demonstrating at least a 25% match.

Budget Forms - Instructions

BUDGET SUMMARY- Form 1

The purpose of this form is: 1) to summarize, by item of expenditure, the total budget of a program or project to be funded in whole or in part by the City of Chicago, Department of Family and Support Services and identify any additional funds that will be leveraged for this program either cash or in-kind; and 2) to specify the share of total cost charged to the awarded grant program and the share of total cost charged to other matching or supplemental funding sources.

Please show both the expenses that will be paid for with awarded funds and those that will be paid for with other share. Numbers should be rounded to the nearest dollar.

A. Applicant- Name of Applicant Agency.

B. Department Program - Filled out by City Department.

C. Project Name - Name of project.

D. Department - Filled out by City Department.

E. Contract Term - Indicate beginning (month/day/year) and ending (month/day/year) of contract period.

F. Allocation – Indicate the amount of awarded funds allocated for this project.

G. Vendor Code Number - Filled out by City Department.

H. Service Contract Number - Filled out by City Department.

I. Fund/Dept./Organization #: Filled out by City Department.

J. Project Budget - Columns (1) and (2): Item of expenditure and account number - The required information has already been provided in these two columns. Applicant budgets are limited to the accounts listed on the Budget Summary. In exceptional cases, City Departments may obtain approval to use "other" accounts by contacting their budget analyst at the Office of Budget and Management.

Personnel Costs (Account 0005) - salaries, stipends, overtime, salary adjustments.

Fringe Benefits (Account 0044) - term life insurance, worker’s compensation, health insurance, unemployment insurance, dental plan, Medicare.

Operating/Technical Costs (Account 100) - accounting, auditing (if anticipating expending $500,000 or more in federal funds), legal, publications, rental of property, rental of equipment/services, repair/maintenance of property, repair/maintenance of equipment, utilities, telephone, local transportation, postage, advertising, technical meeting costs, general liability insurance, reproduction, dues, promotions, memberships, messenger service.

Professional and Technical Services (Account 0140) - consultants/subcontractors.

Materials and Supplies (Account 0300) - stationery and office supplies, tools, materials and supplies, books and related material.

Equipment Costs (Account 0400) - office machinery, furniture and furnishings, equipment, and communication devices. If purchases are $5,000 or greater a property inventory must be maintained.

Other Program Costs (Account 0900) - All other expenses that do not fit in the other account categories.

Insurance - The City Comptroller’s Office has established minimum insurance requirements for Respondent awarded City of Chicago, state and federal funds. If all insurance requirements have not been met, the City Comptroller will withhold reimbursement from an applicant until such requirements are met. The types of insurance required include worker’s compensation; general liability; a fidelity bond (if applicable); automobile liability; and professional liability. The City Comptroller reserves the right to require additional types of insurance, if deemed necessary. City Departments should contact the City Comptroller’s Insurance Division, Maria Santiago at (312) 744-7923 with questions regarding your agencies’ insurance requirements.

Local Transportation - The automobile allowance for applicant staff is the same as the allowance for City employees - .505 cents per mile. The per-person reimbursement cannot exceed $250 per month.

Column (3): Provider Share of Cost - Summarize by budget line item the of the awarded budget allocation for this program or project.

Column (4): Other Share - Summarize by budget line item the share of the project’s cost which will be funded with matching or supplemental public or private funds. If funding is supporting the agency's general operations then "Other Share" should represent all non-funded awarded operating support.

Column (5): Total Cost - Add columns (3) and (4) to derive the amount of the total budget for the program or project.

K. Percentage of Total Project Costs Paid by Other Share - Column 4 divided (÷) by Column 5. Please indicate any leveraged or matching funds allocated to this program.

Personnel Budget - Form 2

The purpose of this form is to estimate the total personnel costs the sub-recipient expects to incur in operating its funded project, and to provide a brief summary of job responsibilities for each budgeted position.

A. Name of Applicant: Self-explanatory.

B. Department: Filled out by Department.

C. Project Name: Self-explanatory.

D. Federal Employer Identification Number - The Internal Revenue Service (IRS) assigns a 9-digit Federal identification number to every organization employing one or more individuals. Indicate the sub-recipient's number in the space provided. Should an agency have questions concerning its identification number, call the IRS at (800) 829-1040.

E. Personnel Budget Allocation

Column (1): Position Title - List all positions (even those for which the salary will be paid exclusively with an "other share" funding source) that will be funded under this project.

Columns (2) and (3): Number and Rate - For each position listed in Column (1) indicate the number of employees to be funded and the corresponding salary rates (either annually or hourly). If there are different rates for the same position, list the rates one under another.

Column (4): % of Time Spent on Project - Often an employee spends only a fraction of his or her time on the funded project because they are engaged in other sub-recipient projects. Please indicate for each employee to be funded, percentage (%) of time that will be spent on this project. If the employee is part time, please show the percentage (%) of the hours they work on this project out of the total hours they work.

Column (5): Grant Award Share of Total Cost - For each position listed, please indicate the amount of total salary cost to be paid with grant funds.

Column (6): Total Cost - To determine the total salary cost for each position; multiply Column (3) by Column (2) for each position/rate. Then multiply this amount by the percentage of time to be spent on the project Column (4) and put the final amount in Column (6).

Column (7): Brief Summary of Job Responsibilities - Describe briefly the duties and responsibilities associated with each position listed in Column (1).

Line (8): Positions/Salaries Subtotals - Add the number of positions to be funded for this project and indicate the number at the bottom of Column (2). Also, subtotal Columns (5) and (6) to derive respectively the funded share of total cost and the total salary cost.

F. Fringe Benefits and Total Personnel Costs: Both the federal and state governments require employers to pay various employee taxes and contributions. These taxes and contributions, along with certain fringe benefits that a sub-recipient may wish to offer its employees, are funded eligible expenses. The share of fringe costs to be borne by funded amount must be reasonably proportional to the share of the salary costs borne by funded amount. Please estimate these various costs on the form where indicated. You must have written organizational policies to support those costs.

Line (9): F.I.C.A. and Medicare - Federal Insurance Contribution Act tax otherwise known as the Social Security Tax and Medicare.

Line (9a): The Social Security Tax is computed every payroll period 6.2% of total payroll, up to $ 106,800 per employee year.

Line (9b): The Medicare Tax is computed every payroll period as 2.9% of total payroll per employee year.

For further information regarding the F.I.C.A., contact the Internal Revenue Service at 800-829-1040 or refer to Publication 15 - Circular E. Calculate the funded share of the total F.I.C.A. cost for the annual value of the contract in columns (5) and (6) respectively.

Line (10): State Unemployment Insurance - It is likely that your organization is liable for Unemployment Insurance. For further information contact the Illinois Department of Employment Security hotline at (312) 793-1905. In Columns (5) and (6) show respectively the share of this total to be borne by funded share and the total State Unemployment Insurance Cost.

Line (11): State Worker's Compensation Insurance - This insurance is computed at a rate determined by the employee's type of business or organization. How often an employer must pay worker's compensation is based on the size of its insurance premium. All Respondent are encouraged to call the National Council of Compensation Insurance (NCCI) at 800-622-4123 for technical assistance in this matter. In Columns (5) and (6) show respectively the share of this total to be borne by funded share and the total State Worker's Compensation Insurance cost.

Lines (12-13): Other - Please list any other employer expenses or benefits the agency will offer its employees. Most non-profit agencies do not have to pay the Federal Unemployment Tax, which is computed every payroll period as .008 of total payroll up to $7,000 per employee per year. This rate is subject to change and will be determined by the Internal Revenue Service. Check with the IRS at (800) 829-1040 to determine if your agency is exempt. An agency should also check with the lead City department to determine whether additional benefit(s) it wishes to offer are grant awarded eligible expenses. In Columns (5) and (6) show the GRANT AWARD share and the total cost for each benefit listed.

Line (14): Subtotal Fringe Benefits - Add lines (9) through (13) to obtain the total fringe benefits (account number 0044).

Line (15): Total Personnel Costs - Add lines (8) and (14) in both Column (5) and (6), to obtain both the Grant award Share of the total costs and the Total Personnel Costs for the project.

Non-Personnel Budget - Form 3

The purpose of this form is to estimate and justify the non-personnel line item amounts shown on the Budget Summary (Form 1).

A. Name of Applicant.

B. Self-explanatory.

C. Self-explanatory.

D. Federal Employer Identification Number - The Internal Revenue Service (IRS) assigns a 9-digit Federal identification number to every organization employing one or more individuals. Indicate the sub-recipient's number in the space provided. Should an agency have questions concerning its identification number, call the IRS at (800) 829-1040.

E. Detailed Schedule of Non-Personnel Allocations

Columns (1) and (2): Item of Expenditure and Account Number - List the account descriptions and the corresponding account numbers specified on the Budget Summary (Form 1) which are applicable to this project. Do not include the personnel account.

Column (3): Grant Award Share of Cost - Indicate the share of the total cost listed in Column (3) that will be paid from awarded Grant.

Column (4): Total Cost - Indicate the total amount of funds budgeted for each item of expenditure specified in Column (1).

Column (5): Line Item Description and Justification - Each amount of budgeted funds listed in Column (4) must be justified. Please show all calculations. Include quantities and unit costs wherever possible (add additional sheets if necessary).

Column (6): Total - Indicate the totals for Columns (3) and (4).

Each Applicant must submit a complete line-item budget and budget narrative.

Checklist for Submission of the Proposal

Use the following list as a guide before submitting your application.

|YES |N/A |Original application plus one copy consisting of: |

| | |IRS statement of tax exempt status/Proof of Good Standing |

| | |Federal Employer Identification Number (FEIN) |

| | |A System for Award Management (SAM) number |

| | |Copy of Official Articles of Incorporation |

| | |Most Recent Fiscal Audit Report |

| | |List of Board of Directors |

| | |Certificate of Insurance (found in Attachment A) |

| | |A Certificate of Good Standing from the Illinois Secretary of State’s Office |

| | |Agency Application Cover Form (signed) |

| | |Executive Summary |

| | |Application Narrative |

| | |ATTACHMENTS – not counted as part of the 20 pg. narrative limit. |

| | |Staff resumes, proof of a minimum of 40 hours of qualified domestic violence training for all direct |

| | |service staff serving program clients , |

| | |Job descriptions and organizational chart |

| | |Staffing Plan and flow chart of program service provision |

| | |Three (3) references regarding your agency’s performance. |

| | |Charts: Hours of operation, meals, grants, language |

| | |Agency grievance and confidentiality policies |

| | |Complete Budget Packet (two budgets- one for Phase 1 and one for Phase 2 of the proposed project) |

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