ࡱ> /1*+,-. 8bjbj rrv^cpp!!b"b"b"4"""h"$"()))),^X-,-/111111$t&Ub"'8,^,'8'8U!!))j:::'8j!l)b")/:'8/::z 6",̀)j84|<0 }̩8̩x̀̀B̩b" "-$0>:24]---UUg:^---'8'8'8'8̩---------p : STATE OF NEVADA   DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF CHILD AND FAMILY SERVICES Request for Proposals Chafee Foster Care Independence Program (CFCIP) and Transition from Foster Care / Fund to Assist Former Foster Youth (FAFFY) Release date: April 5, 2010 ALL PROPOSALS MUST BE RECEIVED NO LATER THAN 5:00PM ON MONDAY, MAY 17, 2010 Postmarks will not be used to determine eligibility. NO FAXES OR E-MAILS WILL BE ACCEPTED. Applications may be mailed or hand-delivered to: Cindy Routh Division of Child and Family Services 4126 Technology Way, 3rd Floor Carson City, NV 89706 (775) 684-7944 State of Nevada Department of Health and Human Services Division of Child and Family Services GRANTS MANAGEMENT UNIT REQUEST FOR PROPOSALS July 1, 2010 through June 30, 2013 Table of Contents Page Mandatory Pre-Application Conference3Introduction 4Source and Purpose of Funds4Information, Requirements and Restrictions on Chafee and FAFFY Funds4Referral Process6Awarding and Funding Process6Proposal Narrative, Sequence and Scoring7Chafee Budget Request and Justification8FAFFY Budget Request and Justification10Budget Forms: Program Revenues11Budget Forms: Personnel Funding Table12Additional Attachments12Scope of Work Form13Technical Assistance14Submission Requirements14Proposal Review Process/Decision Letter and Awards15Site Reviews/Reporting Requirements16Proposal Cover Page17Proposal Checklist18Sample Fiscal Reporting Form 19Additional Requirements / Assurances and Agreements22Certification of Application26Certifications 1-527 FUNDING PERIOD: Grants may be awarded for a 36 month period: July 1, 2010 through June 30, 2013. Please Note: Awards for funding will be evaluated annually with special emphasis given to regional needs. Based upon changes in such needs, awards may be increased or reduced with 30 day notice to sub grantees on an annual basis. All awards are contingent upon available funding. PROPOSAL DEADLINE: MONDAY, May 17, 2010, no later than 5:00 p.m. Proposals with postmarks dated May 17, 2010 that arrive late (after 5:00 p.m.) will NOT be accepted. COPY REQUIREMENTS: One (1) original, three (3) clear copies. Only hard copies will be accepted. Faxed or emailed documents will not be accepted. Unrequested attachments will not be accepted. Do not use binders, paperclips or staples. Rubber bands are acceptable. ELIGIBILITY: Any 501(c)(3) rural nonprofit organizations, school district, or tribal government is eligible to receive federal money for Chafee and FAFFY State funds. RFP AVAILABILITY: Beginning Monday, April 5, 2010, Request for Proposal (RFP) packets may be obtained on the Division of Child and Family Services webpage  HYPERLINK "http://www.dcfs.state.nv.us/" http://www.dcfs.state.nv.us/ or by contacting Cindy Routh at  HYPERLINK "mailto:crouth@dcfs.nv.gov" crouth@dcfs.nv.gov in Las Vegas, Nevada, at (702) 364- MANDATORY PRE-APPLICATION BIDDERS CONFERENCE will be conducted as noted below. Attendance by a representative of the applicant agency is required at the pre-application bidders conference. It is highly recommended that conference attendees are the Executive Director, fiscal agent or the Grant Manager from each program submitting an application. Wednesday, April 28, 2010 from 10:00am-11:00am To connect with the webinar, please go to  HYPERLINK "http://www.odesinc.org" www.odesinc.org. Login information will include how to connect to the webinar, ask questions and participate in the audio portion of the conference through a teleconference number being provided specifically for the pre-application conference. REQUEST FOR PROPOSALS July 1, 2010 through June 30, 2013 Introduction The Division of Child and Family Services (DCFS) is requesting proposals from rural providers of Independent Living services to be awarded through Chafee and FAFFY (also known as AB-94 and Transitioning from Foster Care) funding for the period of July 1, 2010 through June 30, 2013. Source and Purpose of Funds The purpose of the Chafee grant is to assist youth in goal setting and planning for their transition out of foster care and attaining self-sufficiency. The target population is youth ages 15 up to 18 years of age. However, a portion of these federal funds must be used to serve eligible young people ages 18 up to 21 who left foster care, because they reached age 18. Youth age 18 to 21 who aged out of foster care in other states but are now residing in Nevada are also eligible for this funding. The Fostering Connections to Success and Increasing Adoptions Act of 2008 allows youth who leave foster care after age 16 for kinship guardianship or adoption to be eligible for independent living services. The purpose of the Fund to Assist Former Foster Youth (FAFFY) is to assist former foster youth from Nevada ages 18 up to 21 in attaining economic self-sufficiency (youth who are 17.5 years of age and will be leaving foster care at age 18 are eligible for services to assist with transitioning into adulthood upon leaving foster care.) This state-funded program is available to youth who have aged out of Nevadas child welfare system, including recognized Nevada tribal entities. Description Funds will be granted to community-based organizations or local governments throughout Rural Nevada to ensure that Chafee and FAFFY funds are provided to eligible youth. Agencies who receive funding will be required to use a standardized Ansell Casey Life Skills Assessment and complete the required Division of Child and Family Services Youth Independent Living planning documentation. The Chafee / FAFFY Youth Plan for Independent Living can be administered by a Service Coordinator employed or contracted with your agency. Service Coordination is the identification and arrangement of services which will assist youth in gaining access to needed medical, social, educational, vocational, and other services that will help youth achieve or maintain a quality of life and community participation. Proposals must address the following requirements and restrictions, and describe how your agency will track and / or document these requirements and restrictions (this should be done in the evaluation section, as well as on the scope of work form). CHAFEE: Eligible youth: Those youth who are likely to remain in foster care until age 18 and youth aging out of foster care. Youth currently in foster care ages 15 up to 21. The target population is youth ages 15 up to 18. However, a portion of the funds must be used to serve eligible young people ages 18 up to 21 who left foster care, because they reached age 18. Youth age 18 to 21 who aged out of care in another state but are currently residing in Nevada Youth 16 and older who are adopted from foster care or who exit foster care to live with a relative guardian (per ACYF-CB-PI-09-06) Funds can be used for the purpose of: Assistance in obtaining a high school diploma Career exploration, vocational training, job placement and retention Training in daily living skills, training in budgeting and financial management skills Substance abuse prevention Preventive health activities (including smoking avoidance, nutritional education, and pregnancy prevention) Education Leadership development Training and employment services Preparation for postsecondary training and education Mentors and interactions with adults Financial, housing, counseling, employment, education, and other appropriate supports and services for young people ages 18 up to 21 formerly in foster care. Funds cannot be used in the following manner: No more than 30 percent of the funds may be used for room and board. These funds may only be used by youth ages 18 up to 21. In order to maximize funding for these youth, the funds cannot be used to substitute for or to supplant any other funds already being used for the same general purpose in the state. FAFFY: Not less than 90 percent of the money disbursed to an agency which provides child welfare services pursuant to NAC 432.280 must be used for services provided by the agency or by a nonprofit community organization pursuant to a contract or other agreement entered into the agency. Eligible youth: Youth ages 18 up to 21 who are former foster youth from the State of Nevada Former foster youth is defined as, a person who attained the age of 18 years while in the custody of an agency which provides child welfare services or in foster care provided by an Indian tribe as defined in NRS 383.150 and who has not attained the age of 21 years. Youth who are 17 years of age and will be leaving foster care at age 18 are eligible for services to assist with transitioning into adulthood upon leaving foster care. Funds can be used for the purpose of: The money disbursed pursuant to NAC 423.120 must be used for the purpose required by NRS 423.137 which may include obtaining goods and services for former foster youth, including, without limitation: Room and board Housing assistance Job training Vocational services, including, without limitation, job placement assistance Educational assistance Medical insurance Services to reduce high-risk behaviors in the former foster youth Mental health services Referral Process Youth referrals must come from the Division of Child and Family Services (DCFS) Rural Region Child Welfare office(s). Applicants will be asked to document their plan for ensuring ongoing collaboration and discussion with local child welfare office(s) such as regular meetings with office staff to discuss client flow or other referral issues. Awarding and Funding Process The total amount of funding available for rural Chafee providers is approximately $123,000 for each year of the award. The amount of funding available for rural FAFFY is approximately $129,000 for each year of the award. It is expected that providers who apply for Chafee will also apply for FAFFY funding. Future awards may be based upon sub grantee/applicants past performance in maximizing funds and client utilization while maintaining a reasonable unit cost. All awards are contingent upon availability of funds. The Division reserves the right to modify or reject any or all proposals. Proposals must conform to the conditions or guidelines contained in this Request for Proposal (RFP). GRANT APPLICATION PROCESS AND INSTRUCTIONS PROPOSAL NARRATIVE, SEQUENCE AND SCORING Complete all items as outlined below. All forms and documentation listed should be attached to the narrative. Note: Items 1-4 are not to exceed 7 typed pages (this is the narrative portion of the proposal). 1) Proposal Cover Page (1 page maximum) 2) Organizational Summary (1 page maximum) - 10 points possible a) Describe the organization - history, mission, and total budget, showing all funding sources; b) Provide a list of programs and services currently offered and frequency; c) Describe key staff and their qualifications 3) Proposed Services to be funded (3 page maximum) - 50 points possible Describe day-to-day services and activities to be funded; Describe how your agency will implement a Self-Sufficiency Program to support these services and activities (if your agency is requesting funding for a Service Coordinator, please state that clearly); Provide a program implementation timeline that shows when each program component will be initiated; Describe how proposed services will be staffed and staff qualifications to provide services; Describe collaboration with referral sources, the referral process, and how these referrals will be documented; Describe in detail your current collaboration with your local child welfare agency and document your plan to enhance your existing collaborative activities for this project. Describe targeted foster care youth and former foster care youth to be served; include the number of foster care youth and former foster care youth that will be served during a one year period; include how your agency will inform statewide foster care youth and former foster care youths of the services your agency provides and the funds available; Describe the targeted service area (geographic); Develop and provide a fair hearing / grievance procedure within your agency for youth who want to contest funding decisions; Include a statement of agreement to participate in the state and federally required Chafee / FAFFY program evaluation component. This includes participation in the National Youth in Transition Database (NYTD) process for youth both currently in care and youth who have aged out of care. Include a statement of agreement to participate in activities (telephonically or in person, as needed) required by the Division such as: statewide IL workgroup meetings, child and family team meetings or other youth focused meetings, youth advisory board meetings, and statewide youth conferences. Note: Funding priority will be given to agencies that have developed a comprehensive, deliberate, and reliable Self-Sufficiency Program related to the services to be provided by the applying agency. The Self-Sufficiency Program will then be directly related to the standardized Chafee / FAFFY Youth Plan for Independent Living. 4) Outcome Measures (2 page maximum - 27 points possible) Describe the method (i.e., analyses based on services provided, pre- and post- youth questionnaires, anonymous evaluation forms, outside evaluators, etc.) you will use to evaluate your agencys success at assisting youth with moving towards self-sufficiency. For programs already receiving Chafee/FAFFY funding: Provide an analysis of year to year outcomes achieved for youth as a result of previous Chafee/FAFFY funding. If there has been a decrease in outcomes achieved, describe how the proposed scope of work will address this decrease. Please summarize any data obtained to evaluate services provided via Chafee/FAFFY funding during this time frame and attach any evaluation instruments used. Performance Report Sub-grantees who receive FAFFY and Chafee grant awards will be required to participate in all data collection and tracking as required by DCFS. Each recipient will be provided instructions and reporting form(s). Successful applicants must comply with all federal and DCFS reporting requirements as a condition of receiving funding. 5) Budget Request, Budget Justification, Program Revenues and Personnel Funding Table - 10 points possible. Please use the form provided in a separate attachment entitled Chafee/FAFFY Supplemental Packet. CHAFEE BUDGET REQUEST AND JUSTIFICATION Chafee/FAFFY RFP Supplemental Packet The Detailed Budget Report for each of the three years of the funding cycle (which will also provide a total program cost), the Program Revenue Report and the Personnel Funding Table templates are all included in the Chafee/FAFFY RFP Supplemental Packet. On the Detailed Budget for Year 1 tab, enter personnel and staffs full annual salary. In the next column, enter the percentage of effort that the staff member will be working on the activities in the proposed grant. This will automatically calculate the salary that is being requested from the grant. In the next column include fringe benefits. If there are no fringe benefits being applied to this grant, enter $0. In the match column enter the dollar amount that will be applied towards the match requirement. If no match is applied, enter $0. MATCH: The Chafee grant requires a 20% match. MATCH is calculated by dividing the amount requested by .80 then multiplying the result by .20. Example: requested amount $100,000 divided by .80 = $125,000 times by .20 = MATCH of $25,000. MATCH resources may include in-kind contributions and cash contributions. Each recipient is responsible for providing MATCH tracking and documentation for Chafee. If applicants are awarded both Chafee and FAFFY, FAFFY funds will be used as MATCH for Chafee and the awarded agency would not need to provide the 20% MATCH. FAFFY funds will be identified as MATCH on the Chafee Notice of Sub-grant Award. Below the Personnel Section of the budget form, list the expenses and show calculations (how you arrived at the dollar amount). Under Grant Funds Requested, show the amount of funds being requested to support the proposed project. In the next column, show the amount of all other funds to be used for the project (match, in-kind, cash). The Total Program Budget column will automatically calculate with the total funds being requested for each service category. Match is 20% of Total Program Costs and is required and will calculate separately on the bottom of the spreadsheet entitled Total Match. Please do this for year 1, year 2 and year 3, all included in the Chafee/FAFFY RFP Supplemental Packet. The Total Budget Form will automatically calculate 3 years of funding requested and required match. Please include a separate narrative justification for all expenses. A. PERSONNEL: Positions to be funded, total annual salaries of each, percentage of time the person will work on the project and the total fringe. Payroll Taxes and Fringe Benefits: Rate for each position multiplied by each salaried person. Subtotal for personnel costs will calculate automatically in the last column of the spreadsheet entitled Total Program Budget. B. CONTRACTUAL SERVICES: List all independent contractors and consultants. Organizations who utilize independent contractors / consultants are responsible to ensure that they too, abide by the assurances, agreements and requirements of this RFP. Describe each consultant's scope of work, list rate, hours, and cost. DCFS approval is required prior to the use of subcontractors. Subtotal all contractual service costs. C. EQUIPMENT PURCHASE: This includes all equipment purchased by the grant (all non-consumable items.) Equipment under $1,000 should be included under Operating Costs, Supplies. All equipment costing $1,000 and over must be listed separately and itemized. An inventory must be kept for all equipment purchased and must be provided to DCFS. All equipment purchased with Chafee funds must be marked as Chafee property and remains the property of the Division of Child and Family Services (DCFS). A clear audit trail must be maintained through accounting records that show the source of funds. Subtotal all equipment costs. D. OPERATING COSTS: Occupancy: This details all costs associated with maintaining a facility including rent, utilities, basic maintenance, repairs, etc. Example: Chafee funds may be used to buy paint if your organization provides the labor. Construction, remodeling, and repairs to current structures are not allowed. Communications: This includes the costs of telephones, fax, postage, etc. Supplies: This includes the cost of all consumable items needed for the project such as office supplies, client supplies, etc. Other (operating costs): This could include insurance, dues, conference fees, subscriptions, awards, program costs, and costs not covered in the other categories. Only consumer/service delivery activities are reimbursable. E. TRAVEL: Detail all costs showing rates or allowances for transportation, lodging, per diem and any other allowable travel associated costs. Travel costs should include travel for a chaperone and a youth to attend the statewide youth conference and youth advisory board meetings. All travel costs will be in accordance to Federal travel guidelines available on the GSA website ( HYPERLINK "http://www.gsa.gov" http://www.gsa.gov). F. DIRECT SERVICES: Expenses incurred from direct services such as job training, housing assistance, youth development, service coordination and medical insurance can be applied to this category. Service coordination is the identification and arrangement of services which will assist youth in gaining access to needed medical, social, educational and other services that will help youth achieve or maintain a quality of life and community participation. DIRECT SERVICES A: Expenses incurred from direct services which are listed under Chafee. NO funds may be used to pay for housing, room, and board for youth in the agencys custody. DIRECT SERVICES B: Housing/room and board. Direct Services B costs cannot exceed 30% of the total award for youth people ages 18-21 who have aged out of foster care. G. OTHER EXPENSES: This category includes everything not covered by the above. Note: Federal law prohibits the provision of food as a reimbursable item. H. MATCH: The Chafee grant requires a 20% match. MATCH is calculated by dividing the amount requested by .80 then multiplying the result by .20. Example: requested amount $100,000 divided by .80 = $125,000 times by .20 = MATCH of $25,000. MATCH resources may include in-kind contributions and cash contributions. Each recipient is responsible for providing MATCH tracking and documentation for Chafee. If applicants are awarded both Chafee and FAFFY, FAFFY funds will be used as MATCH for Chafee and the awarded agency would not need to provide the 20% MATCH. FAFFY funds will be identified as MATCH on the Chafee Notice of Sub-grant Award. FAFFY BUDGET REQUEST AND JUSTIFICATION Chafee/FAFFY RFP Supplemental Packet A. PERSONNEL: Positions to be funded, total annual salaries of each, percentage of time the person will work on the project and the total of the annual salary multiplied by the percentage of time to be spent. A.1. Payroll Taxes and Fringe Benefits: Rate for each position multiplied by each salaried person. Subtotal all personnel costs. B. CONTRACTUAL SERVICES: List all independent contractors and consultants. Describe each consultant's scope of work, list rate, hours, and cost. DCFS approval is required prior to the use of subcontractors. Subtotal all contractual service costs. C. DIRECT SERVICES: Expenses incurred from direct services, listed under FAFFY can be applied to this category. Expenditures in Direct Services cannot be less than 90% of the total award. D. EQUIPMENT PURCHASE: This includes all equipment purchased by the grant (all non-consumable items.) Equipment under $1,000 should be included under Operating Costs, Supplies. All equipment costing $1,000 and over must be listed separately and itemized. An inventory must be kept for all equipment purchased and must be provided to DCFS. All equipment purchased with FAFFY funds must be marked as FAFFY property and remains the property of the Division of Child and Family Services (DCFS). A clear audit trail must be maintained through accounting records that show the source of funds. Subtotal all equipment costs. E. OPERATING COSTS: 1. Occupancy: This details all costs associated with maintaining a facility including rent, utilities, basic maintenance, repairs, etc. Example: FAFFY funds may be used to buy paint if your organization provides the labor. Construction, remodeling, and repairs to current structures are not allowed. 2. Communications: This includes the costs of telephones, fax, postage, etc. 3. Supplies: This includes the cost of all consumable items needed for the project such as office supplies, client supplies, etc. 4. Other (operating costs): This could include insurance, dues, conference fees, subscriptions, awards, program costs, and costs not covered in the other categories. Only consumer/service delivery activities are reimbursable. F. TRAVEL: Detail all costs showing rates or allowances for transportation, lodging, per diem and any other allowable travel associated costs. Travel costs should include travel for a chaperone and a youth to attend the statewide youth conference and youth advisory board meetings. All travel costs will be in accordance to Federal travel guidelines available on the GSA website ( HYPERLINK "http://www.gsa.gov" http://www.gsa.gov). G. OTHER EXPENSES: This category includes everything not covered by the above. Note: Federal law prohibits the provision of food as a reimbursable item. Add all subtotals to show the grand total for the proposed project. H. MATCH: No MATCH Required BUDGET FORM: PROGRAM REVENUES In the Chafee/FAFFY RFP Supplemental Packet under the Program Revenues tab, please explain any revenue that is secure as well as revenue that is pending. Pending means that you have applied for funding from another source but have not yet received a Notice of Grant Award. BUDGET FORM: PROGRAM REVENUES EXAMPLE All revenue for the agency/organization must be listed on this form. Funding Source Pending or Secured Time Period Amount Title IV-B/21Pending7/01/07-06/30/10$80,000Childrens Trust FundSecured10/01/06-9/30/07$40,000WICSecured10/01/06-9/30/07$20,000March of Dimes2Pending01/01/07-12/31/07$20,000United WaySecured07/01/06-06/30/07$15,000Nevada State WelfareSecured07/01/06-06/30/07$10,000Funds for Healthy NevadaSecured07/01/06-06/30/07$10,000 Total Revenue: ______$195,000_______ BUDGET FORM: PERSONNEL FUNDING TABLE Included in the Chafee/FAFFY RFP Supplemental Packet, includes a template to breakdown all secured and pending funding sources for personnel costs. List all personnel that will be funded through this RFP. Include name or position, the funding agency, and the percentage of salary they are being funded. ADDITIONAL ATTACHMENTS A copy of an organizational chart with current and proposed staff specific to this project. Clearly delineate positions proposed for funding through Chafee/FAFFY; List of Board or Governing Body with Officers', Affiliations and Terms; Copy of current IRS designation 501(c)(3). This applies only to private, nonprofit organizations and does not apply to local government agencies; List of services currently provided by the applicant organization; Scope of Work completed as per form attached Balance Sheet and income/expense statement from most recent organization audit; Management letter/s from most recent Audit and Schedule of Questionable Costs; Copies of Insurance Coverage (not applicable to local government agencies): Commercial General Liability; Professional Liability; Business Auto; Worker's Compensation; Other Insurance Policies SCOPE OF WORK DEVELOPMENT AND REVISION FORM AGENCY NAME: _______________________________________ GRANT NAME: _________________________________________ Goal: Global problem statement Objective and Time FrameEvaluation, how measuredHow DocumentedTarget PopulationProjected services #Actual services #EXAMPLE Increase public awareness of domestic violence in Northern NV ________ Agency will provide 10 presentations and 20 public service announcements in Northern NVPublic service presentations and announcements will be completed annuallyCalendar, sign in sheets media records, spreadsheets etc.Northern NV citizens10 presentations 20 public service announcementsComplete if requesting a revision to the approved Scope of Work    Technical Assistance Cindy Routh, Grants and Projects Analyst, is available to help applicants requiring clarification or technical assistance in preparing the proposal. Please contact her by email  HYPERLINK "mailto:crouth@dcfs.nv.gov" crouth@dcfs.nv.gov or by phone at 775-684-7944. Submission Requirements The proposal must be typed single spaced on white paper in Times New Roman, size 12, black font, kept within specified page limits. (Do not use binders or covers). Illegible material will be returned without consideration. Check for spelling mistakes, redundancies, factual omissions and unsupported assumptions. The name of the agency and page numbers must be included in the footer of every page. The original (clearly labeled) and three (3) copies of all materials must be submitted. Do not use binders, paper clips or staples. Rubber bands are acceptable. Any materials previously submitted are not valid for consideration as part of this application for funds. All material submitted by an applicant becomes property of the Division of Child and Family Services. Additional application materials not requested by the Division are not necessary and will not be considered as part of the grant application. All required information must be submitted with the application in order to be considered. The Division reserves the right to make or deny an award without requesting further clarification of the proposal received. Therefore applicants are encouraged to submit proposals that are technically correct and self-explanatory. All applications should be prepared simply and economically and should provide a straightforward and concise description of the proposed services and the applicants ability to meet the program requirements. Late or incomplete applications will not be considered for funding. The Department of Health and Human Services, Division of Child and Family Services is not responsible for any costs incurred by applicants responding to the RFP. Proposals submitted become the property of the Division. Awards for funding will be a three (3) year provisional award. All awards for funding will be evaluated annually with consideration given to regional service array needs. Based upon the annual service array assessment and changes in service needs, awards may be increased or reduced with 30 day notice to sub grantees. Proposal Review Process Applicants will be required to complete an application, based on requirements specified in this document. All new and current Chafee and FAFFY grant programs will be required to submit a complete application for funding. Each application will undergo technical review of their proposal that will be conducted by Division grants management staff. The purpose of the review will be to determine if an applicant meets the minimum eligibility requirements, has adhered to the application procedures outlined in this document and has submitted all required materials. Applications that do not technically comply with the minimum requirements of the application procedures will not be considered. Under no circumstances will late or incomplete applications be considered for review or funding. Postmarks will not be used to determine eligibility. All eligible applications must arrive by mail or be hand delivered before 5:00pm on the deadline date of May 17, 2010. All applications, which have met minimum eligibility and technical requirements, will be evaluated. Various factors will be considered in the merit review of applications. The considerations addressed in this document will be included. While the organizational / administrative and budget / fiscal sections will be carefully reviewed, the primary factor in the analysis of applications will be the description of the proposed service program. Decision Letter and Awards Applicants will be notified in writing of the decision by the Division regarding their application. Applicants are cautioned to make no assumptions about funding for their program until they receive written notification from the Division. Those who are preliminarily selected for funding will be given the opportunity to revise their budget or clarify programmatic issues. A Notice of Sub-Grant Award must be executed and approved by all required parties prior to start-up date of the project, July 1, 2010. As the best interest of the Division may require, the Division reserves the right to reject any and all proposals or waive any minor irregularity or technicality in proposals received. Upon Approval of Funding Upon approval of funding, the Division will provide each grantee or sub-grantee with the following documents and information: A Notice of Sub-grant Award for Chafee and a Notice of Grant Award for will be mailed to the sub-grantee / grantee. Two copies must be returned with original signatures to the: Division of Child and Family Services 4126 Technology Way, 3rd Floor Carson City, NV 89706 Attn: Cindy Routh Monthly Financial Status and Request for Funds Report Filing SITE REVIEWS AND MONITORING: DCFS will conduct a minimum of one on-site review annually. By signing a sub grant award, the sub grantee agrees to collaborate during the site visit process. These site reviews will evaluate the following areas: Program evaluation/outcome measures; Human resources/policies and procedures; Trustee or advisory board activities; Fiscal policies and procedures; Verification of expenditures A formal site visit will result in a written report of findings. If additional information is required, sub-grantee agrees to provide the requested documentation. Should site review results highlight fiscal vulnerabilities, an independent audit may be required. REPORTING REQUIREMENTS: There are two (2) types of required reports. The first is a financial report entitled Monthly Financial Status and Request for Funds Report which requires submission on a monthly basis by the fifteenth of each month for the previous month. These Requests will be emailed to DCFS and an original Request submitted to DCFS. In 1999, Congress established the John H. Chafee Foster Care Independence Program (CFCIP). This program gives States flexible funding to assist youth in transitioning out of foster care. The law also requires the Administration for Children and Families (ACF) to develop a data collection system to track the independent living services provided to youth and to develop outcomes that measure states' success in preparing youth for their transition from foster care to independent living. To meet this requirement, the National Youth in Transition Database, or NYTD, was created. NYTD requires all states to survey each youth that receives any independent living service on their 17th birthday and then again on their 19th birthday and their 21st birthday. Grantees will be required to assist DCFS in the NYTD process of contacting identified 19 and 21 year old and facilitating their completion of the survey. Sub-grantee Non-Compliance: DCFS will maintain close scrutiny over the following: Reporting deadlines (both financial and program reports); Compliance with Scope of Service (see attachments); Cooperation with program evaluation initiatives; Site visit responses; Fiscal audit responses; DCFS may require corrective action plan implementation to overcome barriers to outcomes noted through evaluation processes DCFS reserves the right to terminate any funding if there is a pattern of non-compliance or if there are questions of fiscal mismanagement. PROPOSAL COVER PAGE CHAFEE / FAFFY PROPOSALS Submit this cover page with the completed proposal, no later than May 17, 2010 5:00 p.m. Do not leave any line blank. Grant Period: ________________________ Total Amount Requested: ____________________ Chafee: Amount year 1: _____________ Amount year 2: _____________ Amount year 3 ____________ Chafee Total Amount Requested must equal sum of year 1, year 2 and year 3. FAFFY: Amount year 1: _____________ Amount year 2: _____________ Amount year 3 ____________ FAFFY Total Amount Requested must equal sum of year 1, year 2 and year 3. Applicant Organization: _________________________________________________________ Project Name: _________________________________________________________________ Mailing Address: ______________________________________________________________ Physical Address: _______________________________________________________________ Contact Person: ________________________________________________________________ Phone: Fax: E-Mail Address: ______________________ Fiscal Agent (if different from Applicant Organization):__________________________________ Fiscal Agent Address: ___________________________________________________________ Date of the most recent audit completed: ____________________________________________ Administrator/Director (typewritten): ______________________________________________ Administrator/Director (signature): ________________________________________________ Brief description of proposed services: ______________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Projected number of individuals to be served Funding SourceFunds RequestedRural ChafeeFAFFYTotal PROPOSAL CHECKLIST (Please attach to application in this order) _____ Completed Cover Page _____ Proposal Checklist _____ Proposal Narrative _____ Statement of agreement to participate in the state Chafee/FAFFY program evaluation _____ Budget Form: Chafee Proposed Program Budgets _____ Budget Narrative/Justification for Chafee _____ Budget Form: FAFFY Proposed Program Budgets _____ Budget Narrative/Justification for FAFFY _____ Budget Form: Program Revenue _____ Budget Form: Personnel Funding Table _____ Organizational Chart _____ List of Board or Governing Body with Officers Affiliations and Terms _____ If applicable, attach a copy of IRS designation 501(c)(3) _____ List of Current Organization Services _____ Completed Scope of Work Form for Chafee _____ Completed Scope of Work Form for FAFFY _____ Balance Sheet and income/expense statement from most recent organization audit _____ Management letter(s) from most recent Audit and Schedule of Questionable Costs _____ Copies of Insurance Coverage (not applicable to local government agencies): _____ Professional Liability _____ Commercial General Liability _____ Business Automobile Liability _____ Workers Compensation _____ Fire Insurance _____ Other Insurance Policies _____ Three (3) copies, plus one (1) original, of the application with the original clearly marked, for a total of four (4) documents _____ Additional Requirements/Assurances _____ Certification of Application _____ Certifications 1-5 NOTE: Please do not submit the monthly reporting forms with your proposal. A sample has been attached to this RFP for your reference only. SAMPLE FISCAL REPORTING FORM INSTRUCTIONS Monthly Financial Status and Request for Funds Report All Monthly Financial Status and Request for Funds Reports must be submitted in the Excel file format provided by the Division of Child and Family Services (DCFS) by the 15th of the month for the previous month. The file contains a worksheet for each month of the current budget period. You must go to a new worksheet each month DO NOT write over a previous worksheet. Upon receiving the file, you should save it to your desktop. The workbook and individual worksheets have been protected to ensure that formulas are not altered and to minimize the required input each month. You will not be able to access any protected cells. If information needs to be corrected and you do not have access to the cell, please contact Cindy Routh at 775-684-7944 at DCFS. Please note that all cells in the first five sections other than the highlighted cells should already contain information or formulas. Certain information has been entered and automatically carries forward, so it doesnt have to be retyped. However, if you need to change the address, phone number, or contact information or you receive a budget modification, make those changes in the current months worksheet. Following are instructions, which correspond to the numbers indicated on the attached sample worksheet, for the lines that require input: Indicate whether this a final report for the grant by marking an X next to Yes or No. Indicate whether this is an amended report for the period by marking an X next to Yes or No. Enter your name as the preparer of the report even if you are not signing the report. Enter the current months expenses for each of the budgeted categories. Please note that reimbursement may only be requested for expenditures within approved budget categories. Key in WHOLE dollar amounts only, DO NOT enter cents. If the total for a category is $100.50 round up to $101, otherwise round down to the next whole dollar amount. Enter the amount of advance funds you are currently requesting. Please remember that any advance of funds requires prior approval. Enter the amount of the current months expenses that are to be applied to a previous advance, if any. For example, if you had received a $5,000 advance and your current months expenses are $10,000, you can enter 0 here, thereby requesting reimbursement for the full $10,000 or enter an amount to be applied to the advance, which would reduce the current months draw request by that amount. Please remember that all advanced funds must be expended in accordance with your grant agreement prior to the end of the budget period. The form should be printed, signed and dated by an authorized person. The signed hardcopy must be mailed to DCFS, postmarked by the 15th of the month for the previous month to: Division of Child and Family Services 4126 Technology Way, 3rd Floor Carson City, NV 89706 Attn: Cindy Routh The electronic version of the request must be emailed back to DCFS at  HYPERLINK "mailto:FundsRequest@dcfs.state.nv.us" FundsRequest@dcfs.state.nv.us by the 15th of the month for the previous month. If you receive a payment from DCFS in excess of your reported expenses or you receive a duplicate payment, please notify Cindy Routh at 775-684-7944 at DCFS. The bottom section is for the states use. Do not complete this section. DCFS staff will review the forms. If any corrections are required, DCFS staff will contact you to make the necessary changes and ask you to resubmit the form. Due to DCFS Internal Control policies, reimbursements cannot be processed until an identical electronic form and signed original is received and verified. Typically, advanced funding is available to new sub-grantees. Prior approval is required in all instances and may not exceed 2/12ths of the annual award.  ADDITIONAL REQUIREMENTS AGREED TO BY SUB-GRANTEE IN RECEIVING FUNDS PURSUANT TO THIS AWARD OR IN APPLICATION FOR SAME The sub-grantee agrees to abide by all appropriate provisions and procedures of the Division of Child and Family Services (DCFS). The sub-grantee agrees to comply with arrangements for review of accounting procedures, back-up documentation and programmatic information, as initiated by DCFS. The sub-grantee agrees to facilitate and participate in annual on-site reviews, where fiscal and programmatic documents will be reviewed and discussed. The sub-grantee agrees to comply with the Basic Accounting Requirements. The sub-grantee agrees to provide the agreed upon Scope of Service(s). The sub-grantee agrees to comply with general financial requirements and submit the Monthly Financial Status and Request for Funds Report form (Reimbursement form) as prescribed by DCFS Grants Management Unit (GMU). Payment for services rendered under this grant will only be made after the complete and correct financial request has been approved by the GMU. The sub-grantee agrees to submit quarterly program performance reports utilizing the Odes, Inc. (formerly University of Nevada, Reno, Human Development and Family Studies) online reporting system. The sub-grantee certifies that the proposal upon which these grant funds are based was authorized by the governing body of the applicant. The sub-grantee has provided DCFS GMU with the following signed and dated certifications regarding: Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions; Lobbying and Drug Free Work Place. The sub-grantee agrees to comply with Public Law 103-227, Part C, Environmental Tobacco Smoke (Pro Children Act of 1994) requiring that smoking not be permitted in any portion of any indoor area routinely owned or leased or contracted for by any entity and used routinely or regularly for provision of health, day care, education or library services to children under the age of 18, if the services are funded by federal programs either directly of through state or local governments, by federal grant, contract, loan or loan guarantee. The law does not apply to childrens services provided in private residences, facilities funded solely by Medicare or Medicaid funds and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 per day and/or imposition of an administrative compliance order on the responsible entity. By signing and submitting this application the applicant certifies that the agency/organization will comply with this Act (Public Law 103-227). The sub-grantee acknowledges that this sub-grant award may be terminated with 30 days written notice by either party. The sub-grantee has provided DCFS GMU with verification that the following insurance coverage meets State of Nevada insurance requirements: Workers Compensation Insurance, Commercial General Liability Insurance, Business Automobile Insurance (for agency owned vehicles) and Professional Liability Insurance (as applicable). The sub-grantee will cooperate with DCFS GMU and any contractor hired by the GMU in establishing a professional program evaluation system to include outcome measures and the measurement of consumer impact. Require its employees, board members and volunteers to maintain the confidentiality of any information, which would identify persons receiving services. Agrees to mark equipment purchased with grant funds with the grant name, track equipment by the acquisition date, cost, percentage of grant funds used and disposition information. Equipment must be returned to the Division of Child and Family Services (DCFS) if the sub-grant is terminated or if the sub-grantee is no longer funded by the particular grant source in the following grant cycle. The sub-grantee acknowledges that this sub-grant award is contingent upon available funding and may be reduced within the sub-grant period. The sub-grantee agrees to have a 5-year record retention schedule for the Chafee and FAFFY sub-grant documentation. All documents, certifications and Public Laws addressed in this document are considered part of the conditions under which this sub-grant is offered and must be adhered to by the sub-grantee. Additional requirements of the sub-grantee may also apply. _________________________________ ________________________ Signature Date _________________________________ _________________________ Printed or typed name Title _____________________________________________________________ Sub-grantee legal/corporate name _____________________________________________________________ Legal/corporate address Division of Child and Family Services Grants Management Unit ASSURANCES AND AGREEMENTS FEDERAL GRANTS As the duly authorized representatives of the applicant organization, we certify that by submitting this proposal, the applicant: Will establish safeguards to prohibit employees or board members from using his/her positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest or personal gain. Has a copy of its official organizational by laws and amendments available for review. (Required of Community Based Organizations only) Has resumes for key personnel on file. Will initiate and complete the Scope of Work within the applicable time frame after receipt of approval from the Division of Child and Family Services (DCFS). Will inform the awarding agency within 30 days of any substantial material situations affecting the successful completion of this project. Will comply with all federal and state statutes relating to nondiscrimination, including, but not limited to Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975. Will comply with the provisions of the Hatch Act which limits the political activities of employees whose principal employment activities are funded in whole or in part with federal funds. Will comply with P.L. 93-34B regarding the protection of human subjects involved in research, development and related activities supported by this award. Will comply with all applicable requirements of all other state and federal laws, executive orders, regulations and policies governing the program. Will abide by all appropriate provisions and procedures of the Division of Child and Family Services (DCFS). Will comply with the Division of Child and Family Services (DCFS) Business Associate Addendum (effective 4-20-05). Will comply with the minimum wage and maximum hours of the federal Fair Labor Standards Act. Agrees to provide reports as required by the awarding agency as well as additional information requested by the awarding agency. Agrees to provide the awarding agency with a copy of each outside audit conducted for the organization, whether that audit is a formal audit or a report from a qualified, independent source which provides an opinion regarding the financial practices and solvency of the applicant organization. (Formal audits are required for organizations that received $500,000.00 or more in federal funds during a Federal Fiscal Year.) _____________________________________ ____________________________ Printed Name Title _____________________________________ ____________________________ Signature Date _____________________________________ ____________________________ President/Chairperson of Governing Body, Date Tribal Authority or Director of Public Agency Division of Child and Family Services Grants Management Unit CERTIFICATION OF APPLICATION The applicant certifies the following: To the best of our knowledge and belief, the information in this application is true and correct and all documents requiring signature and date have been appropriately signed and dated. The application for funds has been authorized by the governing body of the applicant. The applicant will comply with the Assurances and Agreements if the application is funded. ________________________________ ______________________________ Printed Name Title ________________________________ ______________________________ Signature Date __________________________________ ______________________________ President/Chairperson of Governing Body, Date Tribal Authority or Director of Public Agency CERTIFICATION # 1 Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions Instructions for Certification By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. The prospective lower tier participant shall provide immediate written notice to the person to whom this proposal is submitted if at any time the prospective lower tier participant learns that certification was erroneous when submitted or has become erroneous by reason of changed circumstances. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549: 45 CFR Part 76. You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those regulations or the definitions. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, the prospective lower tier participant shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. The prospective lower tier participant further agrees by submitting this proposal that the clause titled Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions will be included, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. A participant in a covered transaction may rely upon the certification of a prospective participant in a lower tier covered transaction that the prospective participant is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless the participant in a covered transaction knows that the certification is erroneous. A participant may decide the method and frequency of determining the eligibility of the principals. Each participant may, but is not required to, check the Non-procurement List (of excluded parties). Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. Except for transactions authorized under Paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is debarred, suspended, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including debarment and/or suspension. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions (1) The prospective lower tier participant certifies, by submission of this proposal, that neither the prospective participant or the prospective participants principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in any transaction by any Federal department or agency. (2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Suspension. An action taken by a suspending official in accordance with these regulations that immediately excludes a person from participating in a covered transaction for a temporary period, pending completion of an investigation and such legal, debarment, or Program Fraud Civil Remedies Act proceedings as may ensue. A person so excluded is suspended. Voluntary Exclusion or Voluntarily Excluded. A status of nonparticipation or limited participation in covered transactions assumed by a person pursuant to the terms of a settlement. SignatureTitleGrantee Legal/Corporate NameDate CERTIFICATION # 2 Certification Regarding Drug-Free Workplace Requirements Instructions for Certification By signing and/or submitting this application or grant agreement, the grantee is providing the certification set out below. The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grantee knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act. For grantees other than individuals, Alternate I applies. For grantees who are individuals, Alternate II applies. Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If known, they may be identified in the grant application. If grantee does not identify the workplace at the time of the application, or upon award, if there is no application, the grantee must keep the identity of the workplace(s) on file in the office and make the information available for Federal inspection. Failure to identify all known workplaces constitutes a violation of the grantees drug-free workplace requirements. Workplace identifications must include the actual address of buildings (or parts of buildings) or other areas where work under the grant take place. Categorical descriptions may be used (e.g. all vehicles of a mass authority of State highway department while in operation, State employees in each local unemployment office, performance in concert halls or radio studios). If the workplace identified to the agency changes during the performance of the grant, the grantee shall inform the agency of the change(s) if it previously identified the workplaces in question (see paragraph five). Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to the certification. Grantees attention is called, in particular, to the following definitions from these rules: Controlled substances means a controlled substance in Schedules I through V of the Controlled Substance Act (21 U.S.C. #12) and as further defined by regulations (21 CFR 1308.11 through 1308.15); Conviction means a finding of guilt (including a plea of Nolo Contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statues; Employee means the employee of a grantee directly engaged in the performance of work under a grant, including: (I) All direct charge employees; (II) All indirect charge employees under their impact or involvement is insignificant to the performance of the grant; and (III) Temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the payroll of the grantee (e.g., volunteers, even if used to meet a matching requirements consultants or independent contractors not on the grantees payroll; or employees of sub-recipients or subcontractors in covered workplaces). Alternate I - Grantees Other Than Individuals The grantee certifies that it will continue to provide a drug-free workplace by: Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grantees workplace and specifying the actions that will be taken against employees for violation of such prohibition; Establishing an ongoing drug-free awareness program to inform employees about: The dangers of drug abuse in the workplace; The grantees policy of maintaining a drug-free workplace; Any available drug counseling, rehabilitation, and employee assistance programs; The penalties that may be imposed upon employees or drug abuse violations occurring in the workplace; Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a); Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will: (1) Abide by the terms of the statement; and (2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction. Notifying the agency in writing, within ten calendar days after receiving notice under paragraph (d) (2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant; Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d) (2), with respect to any employee who is convicted: Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by Federal, State, or local health, law enforcement, or other appropriate agency; Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f). The grantee may insert the space provided below the site(s) for the performance of work done in connection with the specific grant: Place of Performance:Street addresscitycountystatezip codeAre there workplaces on file that are not identified here? FORMCHECKBOX YES FORMCHECKBOX NO Alternate II - Grantees Who Are Individuals The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of controlled substance in conducting any activity with the grant; If the convicted of a criminal drug offense resulting form a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include identification number(s) of each affected grant. [55 FR 2160, 21702, May 25, 1990] SignatureTitleGrantee Legal/Corporate NameDate CERTIFICATION # 3 CERTIFICATION REGARDING LOBBYING (1) No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loam or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form 111, Disclosure Form to Report Lobbying, in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. SignatureTitleGrantee Legal/Corporate NameDate CERTIFICATION #4 Certification Regarding Environmental Tobacco Smoke Public Law 103-227, Part C Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (ACT), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision or health, day care, education, or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law does not apply to childrens services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 per day and/or the imposition of an administrative compliance order on the responsible entity. By signing and submitting this application, the applicant/grantee certifies compliance with the requirements of the Act. The applicant/grantee further agrees that the language of this certification will be included in any sub-awards which contain provisions for childrens services and that all sub-grantees shall certify accordingly. SignatureTitleGrantee Legal/Corporate NameDate CERTIFICATION # 5 Certification Regarding Equal Treatment for Faith-Based Organizations A final rule of the Department of Health and Human Services (DHHS) went into effect on August 16, 2004, which created, among other things, a new Part 87 Equal Treatment for Faith-Based Organizations, and revised the Departments uniform administrative requirements at 45 CFR Parts 74, 92 and 96 to incorporate the requirements of Part 87. The Administration of Children and Families (ACF) is committed to providing State Administrators, State Grant Managers and subsequently sub-grantees with the most accurate and concise information to help guide program activities. This regulation addresses several key Equal Treatment issues that require full compliance by Federally-funded State Programs, sub-grantees, grantees and contractors. Issues include: Nondiscrimination against religions organizations; Ability of religious organizations to maintain their religious character, including the use of space in their facilities, without removing religious art, icons, scriptures, or other religious symbols; Prohibition against the use of Federal funds to finance inherently religious activities, except where Federal funds are provided to religious organizations as a result of a genuine and independent private choice of a beneficiary or though other indirect funding mechanisms, such as certificates or vouchers; and Application of State or local government laws to religious organizations. NOTE: Neither the Department (DHHS) nor any State or local government and other intermediate organizations receiving funds under any Department (DHHS) program shall, in the selection of service providers, discriminate for or against an organization on the basis of the organizations religious character or affiliation. It is imperative that State sub-grantees, grantees and contractors policies reflect the Equal Treatment Regulations. The full text of the final rule may be accessed via the Internet at  HYPERLINK "http://www.hhs.gov/fbci/regs.html" http://www.hhs.gov/fbci/regs.html This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 45 CFR Part 87, Equal Treatment for Faith-Based Organizations as revised in the Departments uniform Administrative requirements identified above. Any organization that fails to file the required certification shall be subject to disqualification of their application. SignatureTitleGrantee Legal/Corporate NameDate     DIVISION OF CHILD AND FAMILY SERVICES GRANTS MANAGEMENT UNIT Page  PAGE 1 JIM GIBBONS Governor MICHAEL J. 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