Date Completed SECTION NAME & ORDER PAGE LIMITS Grant Applicant Information Pages as provided Budget Summary 1 page as provided Budget Sheets and Narratives as needed. Agency Budget & Funding Sources Chart as provided Activities/Timetables 2 pages Continuation Narratives 3 Goals, Objectives & Performance Measures Pages as needed (format provided) Signed & Dated Certified Assurances Form provided Signed & Dated Lobbying, Debarment, Drug-Free Workplace Form Form provided Applicant Disclosure of Pending Applications Form provided ATTACHMENTS Volunteer & Employee Job Descriptions Required for all employee and volunteer positions(separate PDF) Surveys Copy of Survey and established Policies and Procedures (separate PDF) Indirect Cost Rate Verification, if applicable Copy of federally approved indirect cost rate agreement (separate PDF) Non-profit Verification, if applicable Copy of 501(c)(3) designation letter or other verification (separate PDF) Match/Volunteer Waiver Request – if applicable Attach applicant’s letter on agency letterhead (separate PDF) Applicant Information Provide all requested information. The applicant must be the agency that will receive and disburse the grant funds. The Federal Identification Number and the DUNS number must be that of the applicant. Project must provide separate individuals for each project position (Director, Coordinator, Fiscal Officer, and the Authorized Official). Project Summary is a concise statement, of 150 words or less, highlighting the major aspects of the proposed project. Budget Summary All costs must be necessary, reasonable, allowable, allocable and substantiated. Provide budget figures rounding to the nearest dollar. Do not include cents. Please ensure figures calculate correctly. The Budget Summary page must be signed by the Authorized Official. Please explain why, if a non-profit Vice Chair is signing as the Authorized Official. Applicant must provide a according to the following guidelines or submit with the grant application a Waiver of Match request. Match:
Example for calculating 10% De Minimis Rate for Indirect Costs: Direct The amount listed here must match the Budget Summary. Please note that the Budget Summary amounts must match the corresponding budget sheets and budget narratives. Budget Category Amount Requested Comments Personnel $244,000 200,000 Advocate Salaries, $44,000 Advocate Fringe Benefits Consultants/Contracts (including subawards) $100,000 3 Partner Agency’s: #1 receives $30,000; #2 receives $28,000 and #3 receives $42,000 Travel $10,000 Training and Outreach Supplies/Operating $4,000 Office Supplies Equipment Other Total Direct Costs $358,000 Modified Total Direct Costs (MTDC): Calculations Total Direct Costs $358,000 Subtract the amounts over $25,000 for each consultant are the 3 Partner Agencies under Consultants/Contracts) $358,000 – $25,000 = $333,000 #1: $30,000 – 25,000 = 5,000 #2: $28,000 – 25,000 = 3,000 #3: $42,000 – 25,000 = 17,000 Total = $25,000 10% of $333,000 $33,300 Modified Indirect Cost Rate Requested Direct Amount $358,000 Requested Indirect Amount $33,300 Total Federal Request $391,300 Project Description Community Description Provide a description of the community which includes aspects that impact victims of crime. Examples include availability of hospitals, police departments and shelters and other victim services. The community description must match the applicant’s response on the applicant information page which identifies the area served by the project. The identified community must also fit with the census information provided and, if feasible, the statistics provided in the Problem Statement section. Problem Statement Identity the problem that requires a solution. Describe the social and economic factors contributing to the problem and explain the effects or impact of the problem on the community. (Note: the problem cannot be stated solely as an applicant’s lack of funding.) Complete the statistical documentation of the chart. The table should be completed however, if statistics are not available or they are not relevant to the project indicate “NA” for not applicable.