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center-35560Orange County Citizens’ Review Panel (CRP)Small Scale Funding Proposal FY: 2016-2017AUTHORIZATION PAGE Legal Name of Agency:Registered Fictitious Name:Registered on Florida Department of State Division of Corporations ()Mailing Address:Chief Professional Officer:Title:Telephone/Fax:Email:Proposal Contact Person:Title:Telephone:Email:Agency Fiscal Year: (mm – mm)Website:Funding Panel: Request for Proposal: Authorization SignaturesOur signatures certify that to the best of our knowledge, the information contained in this proposal is accurate, complete and consistent with our organization’s Mission, Articles of Incorporation and Bylaws and that we have the legal authority to sign below. Chief Volunteer Officer (type or print)Chief Professional Officer (type or print)Chief Volunteer Officer (sign in blue ink)Chief Professional Officer (sign in blue ink)DateDateFlorida has a very broad public records law. As a result, upon request, unless otherwise exempt, any written communication created or received by Orange County officials and employees will be made available to the public and media. Furthermore, under Florida law, email addresses are public records.INDEXSectionPage # Supporting Documents ChecklistSummary of Funding RequestAgency OverviewBoard Governance and StructureEmployee Structure and CompensationAgency Revenue ComparisonAgency Expenditure ComparisonAgency Budget ExplanationRequest for Proposal Section Overview Proposed OutcomesRevenue ComparisonExpenditure ComparisonExpenditure DetailBudget ExplanationSUPPORTING DOCUMENTS CHECKLIST Instructions: In the order listed below, attach the following items to the original and each copy of the proposal. Place an X in all boxes indicating included or not included. Place NA for items not applicable. IncludedNotIncluded501(C)(3) Determination Letter from the IRS Fictitious Name Registration or Renewal from the Florida Department of State Division of Corporations () Current BylawsIRS Form 990 (most recent)Any correspondence received from the Internal Revenue Service since January 1, 2015Annual Report (produced by organization)Discrimination/EEO PolicyInsurance Certificate and Endorsements*Strategic Plan/Planning Document and UpdatesAmericans With Disabilities Act (ADA) PolicyLetters of Partnerships & Collaborations or Memorandums of Understanding (MOU) from agency partners listed in the Agency Overview Section of the funding proposal. Please answer the questions below and provide a detailed explanation where necessary.Provide an explanation for any documents not attached. YesNoIs your agency (local chapter) involved in any pending litigation? (If yes, please explain) (Please use additional sheets of paper if needed)* Insurance carriers furnishing coverage must be authorized to do business in the State of Florida, and must possess a minimum, current rating of A- Class VIII in the most recent edition of “Best Key Rating Guide”. Insurance Certificates must have all applicable endorsements required by funder.SUMMARY OF FUNDING REQUEST For any agency applying for funding through the Orange County RFP Process please list if applicable, current and proposed funding amounts in Orange County’s fiscal year (October – September). Request for Proposal Proposed Funding (FYE 2017)AGENCY OVERVIEWAgency’s History and Mission Statement: Provide a brief agency history and mission statement that includes agency’s goals and objectives. (Not to exceed 1 page)Agency Affiliation: Is your agency a part of a larger organization? If yes, please explain your affiliation. Include information regarding operational oversight, dues, etc.Major Agency Activities and Accomplishments during the Past Year: Provide information on major activities such as special events and agency/program achievements. (Not to exceed ? page)Major Changes during the Past Year: Provide information regarding any major changes that your agency has experienced during the past year (e.g., Board, Staff, Mergers, Location, and Policy). (Not to exceed ? page)Agency Partnerships and/or Collaborations: List any organizations with which your agency has partnerships and/or collaborations. Place an asterisk (*) next to the partners pertaining to this funding proposal. Attach letters of partnership on partner’s letterhead and/or memorandum of understanding (MOU) from each partner associated with this proposal as listed on the Supporting Documents Checklist. BOARD GOVERNANCE AND STRUCTURE Please answer the following questions for your last completed fiscal year (12 months) according to your agency’s bylaws. If your organization has a local board advisory board responsible for local issues, provide the following information for the local presiding board. Check if your organization is a local chapter with an advisory board that presides over local issues.Board Structure: How many available Board slots does your agency have?How many currently seated Board Members does your agency have?How many Board meetings were held during the past year?What is the percentage of Board attendance for the past year?Board Governance Structure: Describe the attendance guidelines and requirements for Board and committee meetings.List your Board’s subcommittees, including the responsibilities of each committee and how many times each committee meets per year. Describe your diversity goals for the agency’s Board? Discuss any changes/resignation of Board members during the last year that were not related to term expiration. Board’s Role & Responsibilities: Please describe the Board’s role in supervising fiscal matters of the agency.BOARD INFORMATION FORMProvide a breakdown of the membership of your organization’s current Board of Directors.EXECUTIVE COMMITTEENameBoard PositionBusiness Affiliation & TitleMailing Address, Phone & EmailAreas of Expertise or Relevant ExperienceGender# of Continuous Years on BoardCurrent TermExpirationMEMBERS AT-LARGENameBusiness Affiliation & TitleAreas of ExpertiseGender# of Continuous Years on BoardCurrent TermExpirationDescribe efforts made to recruit new board members. Please include anticipated start date of upcoming board term and expertise.EMPLOYEE STRUCTURE AND COMPENSATION Using the chart below, provide a breakdown of employee compensation for all current agency employees. Salary information should NOT reflect benefits, taxes, or other employee related expenditures. Note: Table is an embedded spreadsheet with formulas, double click to activate, and then enter information. Calculations are automated. When completed, click outside the spreadsheet to deactivate.Definition of Employee Groups: Upper Management – CEO, President, Executive Director, Vice President, DirectorMiddle Management – Senior Manager, Manager, OtherSupport Staff – Administrative Assistant, ClericalDirect Service – Counselors, Childcare Providers, any staff working directly with clients/customersOther Employee group not listed above (please define): ______________________________________Does your agency currently have leased employees? If yes, please provide information about your leased employees. Include the name of the leasing company, positions, and total salaries of the group employees (Do not exceed ? page). Agency Budget Review Page Left Blank IntentionallyInsertAgency Revenue Comparison Budget Spreadsheet HerePage Left Blank IntentionallyInsertAgency Expenditure Comparison Budget Spreadsheet HereAGENCY BUDGET EXPLANATIONUsing the submitted Agency budget spreadsheets as a reference, please answer the questions below. Budgets should only reflect the organization’s operating budget. Below-the-line resources such as in-kind goods and/or services should not be included in the budget. Note: Table is an embedded spreadsheet with formulas, double click to activate, and then enter information. Calculations are automated. When completed, click outside the spreadsheet to deactivate.Total Agency Budget: In agency’s fiscal year, complete the table below. *Percentage of administrative costs as reported in most recent IRS Form 990.Percentage of Administrative Costs more than 25%: If the percentage of administrative costs is more than 25% of your agency’s budget for the Current and/or Proposed fiscal years, provide a breakdown of all included expenses and your plan to lower costs in the future for each year. (Do not exceed ? page) Agency Fundraising Activities: List and describe fundraising efforts for Current and Proposed fiscal years. Include actual costs compared to the net funds raised for each activity. (Not to exceed 1 page)Agency Reserves: Answer the following questions about your agency’s funding reserve. Does your agency currently have a funding reserve? If Yes, answer b-d. If No, proceed to e.What is the balance of your agency’s funding reserve?How is the agency’s reserve funded?Provide your agency’s guidelines for utilizing funds in the funding reserve. If your agency does not have a funding reserve, what is your agency’s contingency plan in the event there is a shortfall in operational funding?Leveraging: Provide a breakdown of all matching dollars received for all agency revenue. Funder & Amount of FundingMatch SourceAmount of Match per DollarTotal Amount of Matched DollarsTerms & Time Period of MatchRequest for Proposal Section Complete for the Request for Proposal (RFP) for which you are applying. Name of RFP: OVERVIEW RFP Detailed Description and Design: Please provide a detailed description of how the agency plans to execute the proposed RFP, including types of services to be provided, agency’s history and experience providing these services, geographic area to be served, outreach plan with targeted groups to be served, current or proposed partnerships with other agencies to provide services, proposed participant goals and objectives, staffing or volunteer plan, and community support. Please include any data you are using to support that the requested need exists in Orange County. (e.g., agency data, survey information, needs assessment data, other secondary data sources, etc.) (Not to exceed 2 pages)Success Story: If the agency has provided services as prescribed by the proposed RFP, pprovide a short success story from last fiscal year. (Not to exceed 1/2 page)Volunteer Utilization: Will volunteers be utilized in programming under this RFP? (Yes or No)If yes, complete the table below. Volunteer PositionNumber of Proposed Persons for this PositionNumber of Proposed Hours per Volunteer per monthPROPOSED OUTCOMES Provide at least two (2) proposed outcomes and plan for measuring success for this RFP.Outcome 1:Proposed Indicator:Proposed Measurement Tool:Proposed Frequency of Data Collection:Outcome 2:Proposed Indicator:Proposed Measurement Tool:Proposed Frequency of Data Collection:Request for ProposalBudget Review Page Left Blank IntentionallyInsert Request for Proposal Revenue Comparison Budget Spreadsheet Here Note: Be Sure To Insert Page Numbers on Each SpreadsheetPage Left Blank IntentionallyInsert Request for Proposal Expenditure ComparisonBudget Spreadsheet Here Note: Be Sure To Insert Page Numbers on Each SpreadsheetPage Left Blank IntentionallyInsert Request for Proposal Expenditure DetailBudget Spreadsheet Here Note: Be Sure To Insert Page Numbers on Each SpreadsheetBUDGET EXPLANATIONUsing the submitted Program/RFP budget as a reference, please answer the following questions. Below-the-line resources such as in-kind goods and/or services should not be included in the budget. Explanation of Funding: Using the Expenditure Detail budget spreadsheet as a reference, please provide, for each year, a breakdown of what funding from Orange County – CRP will specifically fund.Units of Service: Provide the unit of service (e.g., shelter nights, hours, etc.) and the cost per unit ($ per unit). Then, in the space provided, calculate the total cost of a service year based on the defined unit of service. (# of units in a service year x $ - unit cost = total cost per service year) Be specific to each funder. Note: Proposed unit cost is not guaranteed. If the agency is recommended for funding, the final unit cost will be negotiated and must be approved by each funded before contract execution. X=Description of Unit of Service (e.g., 45 units, Shelter Night – Use of a bed with 1 meal and hot shower)Proposed Cost per Unit of Service(e.g., $10 per night)Total Cost per Service Year(e.g., $10 X 50 nights = $500) ................
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