Committee is chaired by the Treasurer. Two (2) copies of Governing Board’s strategic plan and sustainability plan. Submit by to : *Include county and program type in subject line. Include all attachments in a single email. One (1) Grant Application including signatures and a clear attachment title (e.g. Wake DV Grant Application). One (1) of each policy: conflict of interest, confidentiality, organizational code of conduct, internal controls, recordkeeping (for electronic and manual files), and whistleblower. Identify each policy clearly in attachment titles. Please note: The NCCFW/YI does not accept responsibility for the sufficiency or the legality of the policies submitted. Sample policy templates are available in the Grants section of the NCCFW/YI website. GRANT APPLICANT INFORMATION Organization type: Nonprofit Corporation Local Governmental Entity DUNS # if applicable (Data Universal Numbering System): Organization’s fiscal year: January - December July - June October – September Year the organization was incorporated: Year the organization obtained nonprofit status: Month and year DV or SA program began operations: Is program a subsidiary of another organization? Yes No Current Executive Director: As of Name: E-mail Address: Telephone Number: Current Program Director (if applicable): As of Name: E-mail Address: Telephone Number: Administrative Office Physical Address: Mailing Address (if different from above): Days and Hours of Operation: Administrative/Business Line Phone: Fax: DV or SA Shelter/Program Physical Address (optional): Mailing Address (if different from Days and Hours of Operation: Program Office/Facility Phone: Fax: Crisis Line: Organizational Website Address: Please indicate if the agency providing program services funded by the NCCFW/YI: Owns the property where services will be provided: Yes No Leases space where services will be provided: Yes No Utilizes donated space where services will be provided: Yes No Does your program multi-lingual services? Yes No If so, please indicate language(s):
Provide information about the composition of your entire staff: Number of Full-Time Part-Time Contract: Gender: Male Female Race/Ethnicity: Black/African American American Indian Asian Hispanic/Latinx Other Provide information about volunteers serving the DV or SA program that is the subject of this application: Number of active volunteers: Estimated financial value of volunteer support to your program: Explain method used to calculate estimated value of volunteer support: Provide information about the composition of your Board of Directors: Number of people currently serving on the Board: Gender: Male Female Age: < 35 35-50 51-65 > 65 Race/Ethnicity: American American Indian Asian Hispanic/Latinx Other 1) List current written memorandums of understanding or agreement (MOUs or MOAs) that your organization has in place, such as those with hospitals or neighboring DV or SA programs. 2) List and describe how your organization coordinates and collaborates with community partners, task forces, committees, councils, response teams, and/or other entities to carry out the DV or SA program. 3) Describe your organization’s process for making interagency referrals. The comment box below has a 1000-character limit including spacing and punctuation. PERSONNEL List all NCCFW/YI funded positions. For each position listed, indicate the entire salary/wage amount (not just the amount funded by NCCFW/YI, but the entire annual salary/wage amount) and the percentage of the entire salary/wage to be funded by each type of NCCFW/YI fund during fiscal year 2017-2018. If a position performs both DV and SA services and will be a proposed line item on both your DV and SA budgets, then that position should be listed in this section both on your DV grant application and also on your SA grant