FUNDING APPLICANT

ORGANIZATION INFORMATION OVERVIEW

 

  1. name of organization:      
  2. Address:      
  3. How many years has your organization been in existence?         Years
  4. Does your organization have a governing board?   Yes         No
  5. If yes, how are board members chosen? 

     

  1.  

a. Total Persons Served

b. Total Jasper County Residents with a MR/DD

c. Percent Eligible

     

     

0.00%
  1. What is the organizations total budgeted Income?                  
  2. What is the organizations total budgeted Expense?         
  3. What is the organizations administrative percentage?      
  4. Do you have personnel, fiscal and organizational policies and procedures in place?  Yes      No
  5. if yes, do these policies and procedures ensure the stability of the organization, and safety and equitable treatment of staff and persons that your organization serves?  Yes      No

 

  1. how many full time equivalents does your organization employ?       
  2. what percent of staff have less than 1 year of tenure with your organization?       
  3. What percent of staff members have more than 5 years of tenure with your organization?       
  4. is there a specific area in which your organization excels or is noted for?

     
ASSURANCES - NON-CONSTRUCTION

Funding Applications

 

As the duly authorized representative of the applicant I certify that the applicant:

 

  1. Has the legal authority to apply for JCSFB assistance, and the managerial and financial capability to ensure proper planning, management and completion of the project described in this application.
  2. Will give JCSFB access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standard or agency directives.
  3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain.
  4. Will initiate and complete the work within the applicable time frame after receipt of approval of the JCSFB.

 

 

 

 

Name of Organization:      

 

 

 

_____________________________                          _______________________

  (Agency's Representative)                                     Date

 

 

ASSURANCES - CONSTRUCTION/PROPERTY

Funding Applications

 

 

As the duly authorized representative of the applicant I certify that the applicant:

 

  1. Has the legal authority to apply for JCSFB assistance, and the managerial and financial capability to ensure proper planning, management and completion of the project described in this application.
  2. Will give JCSFB access to and the right to examine all records, books, papers, or documents related to the assistance; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives.
  3. Will not dispose of, modify the use of, or change the terms of the real property title, or other interest in the site and facilities without permission and instructions from JCSFB.  Will record interest in the title of real property in accordance with JCSFB directives and will include a covenant in the title of real property required in whole or in part with assistance funds to assure non-discrimination during the useful life of the project.
  4. Will comply with the requirements of the JCSFB with regard to the drafting, review and approval of construction plans and specifications.
  5. Will provide and maintain competent and adequate engineering supervision at the construction site to ensure that the complete work conforms with the approved plans and specifications and will furnish progress reports and such other information as may be required by the JCSFB or State.
  6. Will initiate and complete the work within the applicable time frame after receipt of approval of the JCSFB.
  7. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or represents the appearance of personal or organizational conflict of interest, or personal gain.
  8. Will comply with the Lead-Based Paint poisoning Prevention Act (42 U.S.C. §§ which prohibits the use of lead based paint in construction or rehabilitation of residence structures.

 

 

 

 

Name of Organization:      

 

 

 

_____________________________                          _______________________

  (Agency's Representative)                                     Date