CAP-HC RFP Cover Sheet 1

Form 1. Cover Sheet

Agency Name:

Director Name:

Director Title: (Executive Director, President, CEO, etc.)

Director Phone:

Director Email:

Agency Administrative Office Address Street Address:

City:

Zip:

Agency Administrative Office Phone:

Agency Website:

Agency Facebook: (if applicable)

Agency Twitter: (if applicable)

Application Contact Name (if different than Director):

Contact Telephone (if different than Director):

Contact Fax Number (if different than Director):

Contact Email Address (if different than Director):

Contact Address (if different than the Agency address):

Federal Tax ID Number (required):

Minnesota Tax ID Number (required):

DUNS Number:

SWIFT Vendor ID Number (if known):

Project Name:

Primary Geographic Area Served (Minneapolis or Suburban Hennepin County)

How Many People Does the Organization Support Each Year (All Programs)

Amount of Funding Requested (All Grant Expenditures Must Be Made Between March 1, 2019 – December 31, 2019)

REQUIRED ATTACHMENTS

CAP-HC RFP Cover Sheet 2

I certify that the information contained herein is true and accurate to the best of my knowledge and that I am

authorized to submit this application on behalf of the applicant.

Authorized Signature: Date:

Title: Executive Director

Form 2: Work Plan

Enter Program Name:

Service Provided (Brief description of how the program addresses the need)

Population(s ) Served

Targeted number of

unduplicated families served

Measurable Outcomes Data collection & analysis methods

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text.

Form 3: Budget

Agency Name:

All grant funds must be expended between March 1, 2019 and December 31st 2019

CAP-HC Sub-Grant

Cost Category # March 1, 2019 - December 31, 2019PROVIDE NARRATIVE FOR EACH BUDGET LINE ITEM

under COLORED Budget Detail SHEET

1

2

3

4

5

6

7

8

TOTALS

Submitter's Signature Date Signed

CAP-HC Approval Signature Date Approved

Community Action Partnership of Hennepin County

Direct Client Services

Personnel

Travel

Supplies

2019 PROPOSED FUNDING BUDGETMarch 1, 2019 to December 31, 2019

Category Description

Consultant & Professional Services

Space and Rentals

Other

The CAP-HC signature below indicates that the above Budget has been accepted and approved and will be attached to the executed grant contract.

Outreach

The signature below indicates that the above Budget has been submitted for approval and if approved will be attached to the executed grant contract.

Agency Name:

CAP-HC Sub-Grant

March 1, 2019 - December 31, 2019

Cost Category # Direct Client Services Description Amounts

18 1

19 1

20 1

21 1

22 1

23 1

Direct Client Services Total:

Narrative- Provide detailed budget calculations (e.g.

amt. of rent X # of clients, mos. etc)

2019 PROPOSED FUNDING BUDGETMarch 1, 2019 to December 31, 2019

Cost Category 1 - Direct Client Services

Agency Name:

Salary Amount Fringe Benefit Amount Total of Salary & Fringe

1 2

2 2

3 2

4 2

5 2

6 2

7 2

8 2

9 2

10 2

11 2

12 2

13 2

14 2

15 2

16 2

17 2

TOTAL PERSONNEL COSTS

Cost Category # Title or Position (Paid Personnel)

CAP-HC Sub-Grant

March 1, 2019 - December 31, 2019 Narrative- Provide detailed budget calculations (e.g. # of

FTEs, wage/fringe, # of weeks/mos., etc)

2019 PROPOSED FUNDING BUDGETMarch 1, 2019 to December 31, 2019

Cost Category 2 - Personnel (Salaries & Fringe)

Agency Name:

CAP-HC Sub-Grant

COST CAT. NO. March 1, 2019 - December 31, 2019

3

Cost Category 3 - Instate Travel

Na

rrat

ive:

Inst

ate

Trav

el

DESCRIPTION

Instate Travel Total:

2019 PROPOSED FUNDING BUDGETMarch 1, 2019 to December 31, 2019

Agency Name:

CAP-HC Sub-Grant

COST

CAT.

NO.

March 1, 2019 - December 31, 2019

4

2019 PROPOSED FUNDING BUDGETMarch 1, 2019 to December 31, 2019

Cost Categories 4 - Supplies

DESCRIPTION

Supplies: Total:

Nar

rati

ve:

Su

pp

lies

Agency Name:

CAP-HC Sub-Grant

COST CAT.

NO.March 1, 2019 - December 31, 2019

5

6

7

Nar

rati

ve:

Co

nsu

ltan

ts &

Pro

fess

ial S

erv

ices

Nar

rati

ve:

Ou

trea

ch

2019 PROPOSED FUNDING BUDGETMarch 1, 2019 to December 31, 2019

Nar

rati

ve:

Spac

e C

ost

s an

d

Re

nta

ls

Consultant & Prof. Services TOTAL:

DESCRIPTION

Cost Categories 5 - Consultant & Professional Services, 6 - Space and Rentals, & 7 - Outreach

Outreach

Space and Rentals TOTAL:

Agency Name:

CAP-HC Sub-Grant

March 1, 2019 - December 31, 2019

Cost Category # Description of Other Costs AmountsNarrative - Please provide information to support

expense

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

8

TOTAL OTHER

2019 PROPOSED FUNDING BUDGETMarch 1, 2019 to December 31, 2019

Cost Category 8 - Other

FORM 5: Planned Activities Performance Goals

Organization:

NPI PLANNED ACTIVITIES

PLANNED NUMBER OF

PEOPLE SERVED

(Unduplicated) 3/1/19-

12/31/19

PLANNED NUMBER OF

HOUSEHOLDS SERVED

(Unduplicated) 3/1/19-

12/31/19

PLANNED TIMES

SERVICE IS

PROVIDED

3/1/19-12/31/19

Employment

SRV

1a Vocational Training

SRV

1f Job Readiness Training

SRV

1c Youth Summer Work Placements

SRV

1d Apprenticeships/Internships

SRV

1o Job Coaching

SRV

1j Resume Development

SRV

1q Purchase of Employment Supplies

Income and Asset-Building Services

SRV

3a/

b Financial Coaching/Counseling/Skills Training

SRV

3f

Small Business Start-Up and Development Counseling

Sessions/Classes

SRV

3g Child Support Payments

SRV

3h Health Insurance

SRV

3i Social Security/SSI Payments

SRV

3j/k

/l Veterans/TANF/SNAP Benefits

SRV

3o VITA, EITC, or Other Tax Preparation/Assistance Programs

SRV

3p/

q Micro Loans/Business Development Loans

Housing Services

SRV

4a-e Housing Payment Assistance

SRV

cde

Rent Payments/Emergency Rent Payment/Deposit

Payment/Mortgage Payment

SRV

4f Eviction Counseling

SRV

4g Landlord/Tenant Mediation

Date:

FORM 5: Planned Activities Performance Goals

SRV

4i-l Utility Payment Assistance

SRV

4m-

p Housing Placement/Rapid Re-Housing

SRV

4q Housing Maintenance and Improvements

Health and Social/Behavioral Development Services

SRV

5a-j

Health Services, Screening and Assessments

SRV

5e/f

Prescription Payments/Doctor Visit Payments

SRV

5g Maternal/Child Health

SRV

5k-o

Reproductive Health Services

SRV

5n

STI/HIV Screenings/Prevention Counseling Services

SRV

5r-x

Mental Behavioral Health

SRV

5tSubstance Abuse Counseling

SRV

5bb-

ee

Dental Services, Screening and Exams

SRV

5nn-

oo

Emergency Hygiene Assistance

Education and Cognitive Development

SRV

a-j

Child/Young Adult Education Programs

SRV

2b

Head Start

SRV

2d

K-12 Education

SRV

2h

College-Readiness Prep/Support

SRV

2k School Supplies

SRV

2l-q

Extra-Curricular Programs

SRV

2m

Summer Youth Recreational Opportunities

FORM 5: Planned Activities Performance Goals

SRV

2r-z

Adult Education Programs

SRV

2yPost-Secondary Education Supports

FORM 5: Planned Activities Performance Goals

Performance Indicators

PLANNED # of Program

Participants

(3/1/19-12/31/19)

PLANNED # of Participants Achieving Outcome

(3/1/19-12/31/19)

Employment

The number of unemployed adults who obtained employment

The number of unemployed adults who obtained and

maintained employment for at least 90 days

The number of youth who obtained employment to gain skills or

income

The number of employed participants in a career-advancement

related program who entered or transitioned into a position

that provided increased income or benefits

Income and Asset Building Services

The number of individuals who achieved and maintained

capacity to meet basic needs for 90 days

The number of individuals who opened a savings account or IDA

The number of individuals who increased their savings

The number of individuals who used their savings to purchase

an asset

The number of individuals who improved their credit scores

Housing Services

The number of households experiencing homelessness who

obtained safe temporary shelter

The number of households who obtained safe and affordable

housing

The number of households who avoided eviction

The number of households who avoided foreclosure

FORM 5: PLANNED Performance Goals

FORM 5: Planned Activities Performance Goals

The number of households who experienced improved health

and safety due to improvements within their home (e.g.

reduction or elimination of lead, radon, carbon dioxide and/or

fire hazards or electrical issues, etc.)

Health and Social/Behavioral Development Services

The number of individuals who demonstrated improved physical

health and well-being

The number of individuals who demonstrated improved mental

and behavioral health and well-being

The number of individuals with chronic illness who maintained

an independent living situation

The number of individuals who improved skills related to the

adult role of parents/ caregivers

Education and Cognitive Development Services

The number of children (0 to 5) who demonstrated skills for

school readiness

The number of children and youth who are achieving at basic

grade level (academic, social, and other school success skills)

The number of adults who demonstrated improved basic

education

The number of individuals who obtained a high school diploma

and/or obtained an equivalency certificate or diploma

The number of individuals who obtained a recognized

credential, certificate, or degree relating to the achievement of

educational or vocational skills.