ࡱ>  _bjbj 7]W_6 8884lllhdlU,4##^P$P$h$J&6( B)>U@U@U@U@U@U@U$WZdU8+(&"J&++dUP$h$yUg/g/g/+R8P$8h$>Ug/+>Ug/g/nL PP$05~<+rN *UU0UNo[,Zo[@PPo[8P)Z$*@g/d*4*)))dUdU=.*)))U++++o[))))))))) : Legal Services Advisory Committee (LSAC) 130 Minnesota Judicial Center 25 Rev. Dr. Martin Luther King Jr. Blvd. St. Paul, MN 55155 651-284-4379  HYPERLINK "http://www.mncourts.gov/lsac" www.mncourts.gov/lsac Application Cover Sheet Name of Organization: Address: Telephone: Web Site: Name of Director: Telephone: Name and Title of Contact Person: Telephone: Email: Proposals Submitted for Consideration (check all that apply): LSAC grants are for a two year period with the same amount being awarded for each year (e.g., $50,000 award for July 1, 2015 June 30, 2016 and $50,000 award for July 1, 2016 June 30, 2017). Enter the amount requested for each year of the grant cycle.  FORMCHECKBOX  General Operating Grant for Staff Services Annual Grant Request: $  FORMCHECKBOX  General Operating Grant for PAI Services Annual Grant Request: $  FORMCHECKBOX  Project Grant Annual Grant Request: $ Please respond to the following statements: 1. The Organization is a 501(c) (3) tax-exempt organization:  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. The Organization has an equal opportunity statement and conducts its employment practices in accord with the policy:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Not Applicable I certify that all information in this grant application is true and correct to the best of my knowledge and that I have the authority to commit the Organization to the work proposed. This application is valid for a minimum of ninety days from the date of submission. Signature of Director: Date: Application Definitions Organization: Refers to your corporate entity, including all Programs as defined below and other parts of your entity, if any. Private Attorney Involvement (PAI): Refers to Legal Services provided by private attorneys, rather than staff attorneys, and includes both pro bono and judicare. Program: Refers to that part of your Organization that provides law-related services, including but not limited to, services eligible for LSAC funding. Program services may include Legal Representation and/or Other Eligible Services. Proposal: Refers to LSACs Request for Proposals in three areas: general operating grant for staff services, general operating grant for private attorney involvement (PAI) services, and project grants. Organizations can submit Proposals in more than one category. Legal Representation: Refers to those services through which lawyers and other legal advocates provide legal representation to clients, in an attorney/client relationship, whether using a staff, volunteer, judicare, or some other model. Other Eligible Services: Refers to law-related services (other than Legal Representation) eligible for LSAC funding. Examples include community legal education; advocacy on issues affecting eligible clients at the legislature, before other elected bodies, in administrative rulemaking, or the like; support to Programs that provide Legal Representation; mediation and/or other dispute resolution services, administration of justice; and other eligible law-related services not defined as Legal Representation. Application Instructions General Application Guidelines Please type your answer to each question in a 12-point font. You must answer the application questions in format provided. You can delete sections if you are not applying for that Proposal type (e.g., you can delete the Project Grant Proposal questions if that is not part of your application). Each grant application must include: Cover Sheet (limit one page) Organizational Capacity Information (limit seven pages) Proposal (an Organization may submit more than one Proposal; each Proposal is limited to seven pages) Required Appendices (see Application Appendices Guide below for details; no page limit for required appendices). If your Organization provides Legal Representation to clients, then you must complete the case data spreadsheet available at  HYPERLINK "http://www.mncourts.gov/lsac" www.mncourts.gov/lsac. You should be providing case data for cases closed in calendar year 2014. There is also a Data Handbook on the website that provides detailed definitions for the spreadsheet categories. Email the completed spreadsheet to  HYPERLINK "mailto:bridget.gernander@courts.state.mn.us" bridget.gernander@courts.state.mn.us by the application deadline. This spreadsheet is a required part of the application for all Proposals including Legal Representation. Application Appendices Guide (Append only the following supporting materials to the application form, in the order specified. Do not provide any letters of recommendation or other materials not requested.) 1. Appendix 1 Revenue and Expense Forms: Please use the charts provided and do not modify the format. If only a portion of your Organization provides law-related services, please provide the requested budget data only for your law-related Program. If your entire Organization focus on law-related services, provide the budget data for the Organization as a whole. 2. Appendix 2 Board of Directors: Provide a list indicating the name and affiliation of each member of the Organizations Board of Directors and indicate the required attorney member(s) and eligible client(s) on the Board. (An eligible client is a person who could meet the LSAC income guidelines of 200% of the federal poverty guidelines at the time of Board appointment. Minn. Stat. 480.242 has been interpreted by LSAC as requiring that the Board include an eligible client member to qualify to receive a grant from LSAC. Eligible client participation on a supervisory or advisory committee is not sufficient to meet this statutory requirement.) 3. Appendix 3 Audit: Each applicant must provide an audit of the Organizations immediate past fiscal year (see below for quantity). If you are unable to provide the required audit with your application, you must indicate when the audit will be available or provide an explanation of why your Organization has not sought an audit. Grant awards will be withheld pending receipt of the audit. Organizations with annual revenue of less than $750,000 can provide copies of their most recent Form 990 and annual financial statements with year to date and previous year comparison in lieu of an audit. Application Submission Please submit six (6) copies of the application Cover Sheet, Organizational Capacity Information, Proposal(s), and Appendices 1 and 2, along with and one (1) copy of Appendix 3. The case data spreadsheet, if required, is to be submitted via email as directed above. All required materials must be received by the application deadline. PLEASE NOTE: All copies of application materials should be stapled or secured with a binder clip. Applications should not be bound, include a plastic cover, etc. to prevent difficulty scanning the materials. Organizational Capacity Information A1. Please describe your Organization and its major services and activities, including the counties currently served. A2. Complete the following table for each office used by your Program, adding and deleting rows as necessary: LocationFTE* Program AttorneysFTE* Program Support Staff and ParalegalsFTE* Administrative, Fundraising, etc.TOTAL FTE* *Full-time equivalent (FTE) should be calculated on a 40 hour work week. For example, if you have an executive director who spends an average of 20 hours per week (.5 FTE) on management and fundraising and 20 hours per week (.5 FTE) on program services, then you should allocate those FTE accordingly in the categories above. A3. Describe the financial guidelines you use for determining who receives service from your Program. Note that LSAC defines eligible client as having household income at or below 200% of the federal poverty guidelines. A4. Describe the processes you have in place to ensure and evaluate the quality, effectiveness, and/or outcomes of your Program. Please provide at least one example of a change that was instituted as a result of this evaluation. A5. Describe how your Program leverages community resources through local partnerships with other nonprofit or government agencies. A6. Describe how often your Board of Directors meets, the process for setting your annual budget and the process that is in place for Board review of financial information. A7. Would you describe your Organization as growing, sustaining or reorganizing? Provide information about any new ideas or efficiencies have been implemented in the last two years or are under discussion to improve your Organizations financial stability, including administrative savings. A8. Please complete the following table describing the all funding sources to which applications for the Program have been submitted and/or funding is being received in the past year, adding or deleting rows as necessary. This table will not count against the seven page limit for this section. Funding SourceAmount RequestedAmount Granted (enter $0 if request was denied or n/a if pending )Grant Term (if applicable)  B1. Which region(s) does this Proposal cover (see region description in LSAC Cover Memo)? If your Proposal covers a portion rather than a full region, please list the specific communities, counties or Indian reservations within the region to be served. B2. Describe the range of client service that will be provided by staff if this Proposal is funded. Does your Program provide a full range of Legal Representation (advice, brief service, and extended representation)? If not, why not? If your Program undertakes impact litigation, including class action cases, as part of the extended representation cases please describe that work as well. B3. What is your Programs intake process? Does your Program follow specific case priorities in deciding what clients to serve? Does your Program undertake a formal client needs assessment and/or strategic planning process? If so, how often? If you have had a change in client service in the last two years due to a client needs assessment, strategic plan, or for another reason, please describe the change that was made and why. B4. The Minnesota Supreme Court has charged LSAC with funding projects to ensure a base level of access to civil legal services in all Minnesota counties. Please describe how the services provided in this Proposal contribute to the provision of a base level of civil legal services in the region(s) to be served. How will your Program work to reach underserved areas or populations? Is the type of service to be provided available in all regions? If not, why should LSAC fund services that are available only in a limited geographic area? B5. What case management system does your Program currently use? If your Program has discussed changing case management systems, what are you considering and what is your timeframe? Does your Program currently use or refer clients to any of the following: projusticemn.org, lawhelpmn.org, mnlegaladvice.org and online intake? If so, please detail how these statewide resources are used. If not, what are your plans for future implementation? B6. How does your Program collaborate with other civil legal services providers in the region(s) to be served? If the region to be served includes a staffed law library or court self-help center, please describe any plan for how your staffed legal services will coordinate with their services. List the organization, contact name and email address of two persons collaborating with your Program. These persons should be able to speak to the quality of and the need for the services your Program provides. B7. If your Program provides Legal Representation, your case closed numbers and outcome measures should be provided in the case spreadsheet available at  HYPERLINK "http://www.mncourts.gov/lsac" www.mncourts.gov/lsac. If your Program provides Other Eligible Services, please provide any available statistics in the applicable sections below. Please include the counties in which you have provided the services, relevant statistics (e.g., number of people attending trainings or community legal education presentations, number of times a fact sheet was downloaded, etc.) and major accomplishments. Community Legal Education: Legislative and Administrative Rulemaking Advocacy: Other (describe): General Operating Grant for PAI Services Proposal C1. Which region(s) does your Proposal cover (see region description in LSAC Cover Memo)? If your Proposal covers a portion rather than a full region, please list the specific communities, counties or Indian reservations within the region to be served. C2. Describe the range of client service that will be provided by private attorneys if this Proposal is funded. Does your Program provide a full range of Legal Representation (advice, brief service, and extended representation)? If not, why not? Will your Program be providing both pro bono and judicare services in the region? If not, why not? C3. What is your Programs intake process? Does your Program follow specific case priorities in deciding what clients to serve? If so, please describe. Does your Program undertake a formal client needs assessment and/or strategic planning process? If so, how often? If you have had a change in client service in the last two years due to a client needs assessment, strategic plan, or for another reason, please describe the change that was made and why. C4. The Minnesota Supreme Court has charged LSAC with funding projects to ensure a base level of access to civil legal services in all Minnesota counties. Please describe how the services provided in this Proposal contribute to the provision of a base level of civil legal services in the region(s) to be served. How will your Program work to reach underserved areas or populations? Is the type of service to be provided available in all regions? If not, why should LSAC fund services that are available only in a limited geographic area? C5. What case management system does your Program currently use? If your Program has discussed changing case management systems, what are you considering and what is your timeframe? Does your Program currently use or refer clients to any of the following: projusticemn.org, lawhelpmn.org, mnlegaladvice.org and online intake? If so, please detail how these statewide resources are used. If not, what are your plans for future implementation? C6. How does your Program collaborate with other civil legal services providers in the region(s) to be served? If the region to be served includes a staffed law library or court self-help center, please describe any plan for how your staffed legal services will coordinate with their services. List the organization, contact name and email address of two persons collaborating with your Program. These persons should be able to speak to the quality of and the need for the services your Program provides. C7. If your Program provides Legal Representation, your case closed numbers and outcome measures should be provided in the case spreadsheet available at  HYPERLINK "http://www.mncourts.gov/lsac" www.mncourts.gov/lsac. If your Program provides Other Eligible Services, please provide any available statistics in the applicable sections below. Please include the counties in which you have provided the services, relevant statistics (e.g., number of people attending trainings or community legal education presentations, number of times a fact sheet was downloaded, etc.) and major accomplishments. Community Legal Education: Legislative and Administrative Rulemaking Advocacy: Other (describe): Project Grant Proposal D1. Describe the project for which funding is requested, including the implementation plan and timeline. Please make sure to include enough detail that LSAC members can analyze whether the project should be a priority for funding. D2. Does this project support an integrated service delivery infrastructure? Stated another way, if this project is funded, does it create efficiency or improve client service in a way that benefits the statewide delivery system? D3. What will be the community impact of this project? What is the anticipated geographic reach? Will the project reach a wide range of programs or client groups? D4. Has your Program researched whether this project is duplicative of existing services? Is your Program collaborating with other providers to ensure the project results in an effective and efficient use of funds? List the organization, contact name, phone number and email address of two persons collaborating with your Program on this or other projects. These persons should be able to speak to the quality of and the need for the services your Program provides. If you are completing the Project Grant Proposal, please make sure to complete the Project Revenue Source Reporting and Project Expense Reporting forms in Appendix 1. Appendix 1 Program Revenue Source Reporting (2013-2017) When does your fiscal year begin and end? ______________________________ Use the end date of your fiscal year to complete the columns on this form. Revenue SourceActual Revenue for 2013Actual Revenue for 2014Budgeted Revenue for 2015Anticipated Revenue for 2016Anticipated Revenue for 2017Foundations; CorporationsUnited Way LSAC (Use consolidated LSAC/LTAB figures for past and current fiscal years; anticipated revenue is just from LSAC)Individuals; Firms; EventsOther State GovernmentCounty GovernmentOther Local GovernmentLSC Older AmericansViolence Against WomenOther Federal (please specify)Other GovernmentAttorney FeesClient Fees; Administrative FeesOther (specify)TOTAL  Appendix 1 Staff Program Expense Reporting 2013-2017 When does your fiscal year begin and end? ____________________________________ Use the end date of your fiscal year to complete the columns on this form. ExpensesActual Expenses for 2013Actual Expenses for 2014Budgeted Expenses for 2015Anticipated Expenses for 2016Anticipated Expenses for 20172015 FTE Support Staff Attorneys ParalegalsAdministrative & Fundraising OtherFringes for Above: Health Insurance Retirement Other Total FringesTOTAL PersonnelRent/BuildingUtilitiesPhoneEquipment Rental/Leasing PurchaseSuppliesTravelProfessional Development & TrainingAuditClient Service Contracts, e.g. InterpretersAdministrative Contracts, e.g. Maintenance, AccountingLitigationTechnology Costs, e.g. IT Support, Software LicensesInsuranceOther (specify)TOTAL Non-PersonnelTOTAL EXPENSES For Staff Representation: _____ % of Expenses for Civil Representation _____ % of Expenses for Criminal Representation Appendix 1 Private Attorney Involvement (PAI) Program Expense Reporting 2013-2017 When does your fiscal year begin and end? ____________________________________ Use the end date of your fiscal year to complete the columns on this form. ExpensesActual Expenses for 2013Actual Expenses for 2014Budgeted Expenses for 2015Anticipated Expenses for 2016Anticipated Expenses for 20172015 FTE Support Staff Attorneys ParalegalsAdministrative & Fundraising OtherFringes for Above: Health Insurance Retirement Other Total FringesTOTAL PersonnelRent/BuildingUtilitiesPhoneEquipment Rental/Leasing PurchaseSuppliesTravelProfessional Development & TrainingAuditClient Service Contracts, e.g. InterpretersAdministrative Contracts, e.g. Maintenance, AccountingLitigationTechnology Costs, e.g. IT Support, Software LicensesInsuranceJudicare ContractsOther (specify)TOTAL Non-Personnel TOTAL EXPENSES For Pro Bono and Judicare Representation: _____ % of Expenses for Civil Representation _____ % of Expenses for Criminal Representation Appendix 1 Project Revenue Source Reporting- 2013-2017 (if requesting a project grant) When does your fiscal year begin and end? ______________________________________ Use the end date of your fiscal year to complete the columns on this form. Revenue SourceActual Revenue for 2013Actual Revenue for 2014Budgeted Revenue for 2015Anticipated Revenue for 2016Anticipated Revenue for 2017Foundations; CorporationsUnited Way LSAC (Use consolidated LSAC/LTAB figures for past and current fiscal years; anticipated revenue is just from LSAC)Individuals; Firms; EventsOther State GovernmentCounty GovernmentOther Local GovernmentLSC Older AmericansViolence Against WomenOther Federal (please specify)Other GovernmentAttorney FeesClient Fees; Administrative FeesOther (specify)TOTAL  Appendix 1 Project Expense Reporting (if requesting a project grant) When does your fiscal year begin and end? ______________________________________ Use the end date of your fiscal year to complete the columns on this form. ExpensesAnticipated Exp for Grant YearLSAC Amount Requested2015201620152016 2015 FTE  Support Staff Attorneys Paralegals Administrative and Fundraising OtherFringes for Above: Health Insurance Retirement Other Total FringesTOTAL PersonnelRent/BuildingUtilitiesPhoneEquipment Rental/Leasing PurchaseSuppliesTravelProfessional Development and TrainingAuditClient Service Contracts, e.g. InterpretersAdministrative Contracts, e.g. Maintenance, AccountingLitigationLibraryInsuranceOther (specify)TOTAL Non-PersonnelTOTAL EXPENSES     PAGE 26 PAGE 4 PAGE 26  PAGE 1  PAGE 5 8 General Operating Grant for Staff Services Proposal  ()+-      ( ) ; < I J y z  ˵yrnjnhchc hBhc h$ahmnhJhBhmn>*hBhmn5CJ\aJ&hBhmn5CJOJQJ\^JaJ hBhmnh<h<0J"56h<h<56jh<h<56UhJUhF56hmn hrThKxh< hrThQD hrThmn(    vtnnnn $ikd$$Ifl$h%  04 lap $$Ifa$$a$$a$gd<$a$gdF  ) * J K n o   t u K  $0^`0a$gdc$a$gdcgdc H$ $ $ $        - . / 5 P \ c h p q s t u v աЙա}yuhch< hu-5hFjh Uhqh<5hqhmn5hu-hq5h3cjh Uhqhc5hqhq5hqhJ5 hq5hu-hu-5jh Uh jh UhchJhj-    * + , 5 6 D E F H    / I 67?BО{s{shBhmn>* hBhmnhJU h7_6] h-u6]hBhmn6]jhJhcUjYhcUjhcUjqhJhcU hJhcjhJhcUjhcUjhcUhc hBhc,  ABD\]^lzqllgd3!gd3!nkdA$$Ifl$h%  04 lap $If 4$$a$gd[ BCD\]^kl ~nķ||mdķZMhBhmn0J6>*]hQD56\]hBhmnCJhBh_[o56CJ\]hBh_[o56\]hBh_[o0J5>*\] hBh_[oh_[oh_[o56\]hmn56\]hBhmn56\]hBhmn0J5>*\] hBhmnhmnhBhmn5CJ\aJhBhmnCJh< h<5\oyxe~def  $ & Fa$gd.Mh $ & Fa$gd > $ & Fa$gd.Mh$a$gd3!gd3!gd_[ogd_[onowxy7:;Twx'Gde~ƿڃyj]PhBhmn0J6>*]hBhmn0J5>*\hBhmn56CJ\]hu-56\]hBhmn56\]hd1hmn\]hBhmn]h3!hmn56CJh3!h3!56 hc56 hG 56h3!56\]hc56\]hBhmn0J5>*\] hBhmnh3!hBhmn6CJ]Jbcde =h/NOY[o)ȿ}hl5Dh.Mh0J"jh.MhUhxhOfhmnh=h.Mhhu-hchchBhmn6] hBhmnhBhmnCJhBhmn6CJ]hBhmn0J6>*]hc0J6>*]h0J6>*]hP0J6>*]1 Etuxy #3#4#gd_[o$0^`0a$gd( 0^`0gd > 0^`0gdh% gd > $ & F a$gd.Mh $ & Fa$gd.Mh)X0:"Opqtuxʿʸʱʝ~t~j~`hh% 56\]hc56\]hO+56\]h^4056\]hd1hX06\]hX056\]hBhmn56\] hu-5\ hc5\ hO+5\hBhmn5>*\hBhmn5\ hBhmnhchqhl5Dhx0J"jhxUhxhOfh.Mh"#$BI\hp>LR^aw./78yz|ŻxnxxnnnnŻh(i56\]hO+56\]hBh^V56\]h^V56\]h1s56\]hBh56\]hd1hX06\]hX056\]hBhmn56\]hh% 56\]hh% hh% 56\]hh% hh% 56hBhh% 56\](|  6 9 o ȺՁwmcwcw\RhP56\] hBhmnhob56\]hvQ56\]hfZ56\]hBh1@56\]hG 56\]hBhwIN5\hBhwIN56\]hG 56>*\]hBhwIN56>*\]hBhmn56\]h1@56\]hX056\]hd1hX06\]hd1hmn6\] !!)!N!Y!\!_!q!r!}!!!!!!!!!"="J"U"n""""ӽӲ|qi^Sih_[oh_[o56]h_[ohX056]h_[o56]h_[ohP56]h_[oh1@56]h_[o56\]hq56\]hc56\]hBhmn56\]h3ch 56\]h3chc6\]h3chmn6\]h3chq6\]h3ch(i6\]h3ch 6\]h3ch=6\]""" ###2#4#5#6#8#?#Q#u##############$$"$#$$$%$1$2$H$I$R$Z$_$n$r$s$t$ºϲϮϢϞϮϮώ~r~r~r~r~r~h=h%zi5CJaJh=h?)5CJaJh?)hmnhqh<h hOfhBhmn]h=h%zih3chj/hBh)P\hBhmn\ hOf\ hBhmnhc h3ch!;h_[ohG856]h_[o56]h_[oh(i56]+4###$$%$.$E$o$$$ $IfgdR `^``gdwH 0^`0gd%zigdwH$ \0^`0a$gd%zi t$$$$$$$$8%Z%`%a%%%%%%%%%%%%&&& &b&t&{&&&&&&&&&&&A'R'^'a'|'''''h8mh7hyGh$ hBhmn hobhmnhdh9N=h hOfh-] hBhwhOfhmn6hOfh?)6hOfh%zi6 hBh?)h?)h=h%zi5CJaJh=h?)5CJaJh=hX5CJaJ0$$$$.!! $IfgdRkd$$Iflrbj"\(b2 ~ B t0644 lalp2yt=$$$$ $IfgdR$$$$.!! $IfgdRkd$$Iflrbj"\(b2 ~ B t0644 lalp2yt=$$$$ $IfgdR$$$$.!! $IfgdRkd$$Iflrbj"\(b2 ~ B t0644 lalp2yt=$$$$ $IfgdR$$$. `^``gdwHkd$$Iflrbj"\(b2 ~ B t0644 lalp2yt=$%%&&''J(K(((**nnnn07$8$H$^`0gd^[q 7$8$H$gd 07$8$H$^`0gdqGd #07$8$H$`0gdwH$ 0^`0a$gdwH 0^`0gdwH$ 0`0a$gdd ^`gd%zi ^gd?) 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