HomeMy WebLinkAbout2004-229Y � 0101e0 �
Indian River County Grant Contract py ZZ9r
This Grant Contract ("Contract") entered into effective this 1st day of October 2004 by and between
Indian River County, a political subdivision of the State of Florida , 1840 25th Street, Vero Beach FL ,
32960 ("County") and St. Peters Human Services , Inc. , (" Recipient") , of:
IV
4250 38th Avenue
G ' Florida 32967
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Background Recitals
A. The County has determined that it is in the public interest to promote healthy children in
a
healthy community.
B . The County adopted Ordinance 99- 1 on January 19 , 1999 ("Ordinance" ) and established the
Children 's Services Advisory Committee to promote healthy children in a healthy community
and to provide a unified system of planning and delivery within which children 's needs can be
identified , targeted , evaluated and addressed .
C . The Children 's Services Advisory Committee has issued a request for proposals from
individuals and entities that will assist the Children 's Services Advisory Committee in fulfilling
its purpose .
D . The proposals submitted to the Children 's Services Advisory Committee and the
recommendation of the Children 's Services Advisory Committee have been reviewed by the
County .
E . The Recipient, by submitting a proposal to the Children 's Services Advisory Committee , has
applied for a grant of money ("Grant") for the Grant Period (as such term is hereinafter
defined ) on the terms and conditions set forth herein .
F . The County has agreed to provide such Grant funds to the Recipient for the Grant Period (as
such term is hereinafter defined ) on the terms and conditions set forth herein .
NOW THEREFORE , in consideration of the mutual covenants and promises herein contained , and
other good and valuable consideration , the receipt and adequacy of which are hereby acknowledged ,
the parties agree as follows :
1 . Background Recitals The background recitals are true and correct and form a material
part of this Contract .
2 . Purpose of Grant The Grant shall be used only for the purposes set forth in the
complete proposal submitted by the Recipient attached hereto as Exhibit "A" and
incorporated herein by this reference (such purposes hereinafter referenced as "Grant
Purposes" ) .
3 . Term The Recipient acknowledges and agrees that the Grant is limited to the fiscal
year 2004/2005 ("Grant Period") . The Grant Period commences on October 1 , 2004
and ends on September 30 , 2005 .
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4 . Grant Funds and Payment The approved Grant for the Grant Period is Thirty
Thousand Dollars ($30 , 000 ) . The County agrees to reimburse the Recipient from
such Grant funds for actual documented costs incurred for Grant Purposes provided in
accordance with this Contract . Reimbursement requests may be made no more
frequently than monthly. Each reimbursement request shall contain the information , at
a minimum , that is set forth in Exhibit "B" attached hereto and incorporated herein by
this reference . All reimbursement requests are subject to audit by the County . In
addition , the County may require additional documentation of expenditures , as it
deems appropriate .
5 . Additional Obligations of Recipient.
5 . 1 Records . The Recipient shall maintain adequate internal controls in order to
safeguard the Grant. In addition , the Recipient shall maintain adequate records fully
to document the use of the Grant funds for at least three (3 ) years after the expiration
of the Grant Period . The County shall have access to all books , records , and
documents as required in this Section for the purpose of inspection or audit during
normal business hours at the County's expense , upon five (5) days prior written
notice .
5 . 2 Compliance with Laws . The Recipient shall comply at all times with all applicable
federal , state , and local laws , rules , and regulations .
5 . 3 Quarterly Performance Reports . The Recipient shall submit Quarterly Performance
Reports to the Human Services Department of the County within fifteen ( 15 ) business
days following : December 31 , March 31 , June 30 , and September 30 .
5 .4 Audit Requirements . If Recipient receives $25 , 000 or more in the aggregate from
all Indian River County government funding sources , the Recipient is required to have
an audit completed by an independent certified public accountant at the end of the
Recipient's fiscal year. Within 120 days of the end of the Recipient's fiscal year, the
Recipient shall submit the audit to the Indian River County Office of Management and
Budget. The fiscal year will be as reported on the application for funding , and the
Recipient agrees to notify the County prior to any change in the fiscal period of
Recipient . The Recipient acknowledges that the County may deny funding to any
Recipient if an audit required by this Contract for a prior fiscal year is past due and has
not been submitted by May 1 .
5 .4 . 1 The Recipient further acknowledges that, promptly upon receipt of a
qualified opinion from it's independent auditor, such qualified opinion shall
immediately be provided to the Indian River County Office of Management and
Budget. The qualified opinion shall thereupon be reported to the Board of
Commissioners and funding under this Contract will cease immediately. The
foregoing termination right is in addition to any other right of the County to
terminate this Contract .
5 .4 . 2 The Indian River County Office of Management and Budget reserves the
right at any time to send a letter to the Recipient requesting clarification if there
are any questions regarding a part of the financial statements , audit comments , or
notes .
5 . 5 Insurance Requirements . Recipient shall , no later than September 21 , 2004 ,
provide to the Indian River County Risk Management Division a certificate or
certificates issued by an insurer or insurers authorized to conduct business in Florida
that is rated not less than category A- : VII by A. M . Best, subject to approval by Indian
River County's risk manager, of the following types and amounts of insurance :
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( i ) Commercial General Liability Insurance in an amount not less than
$ 1 , 000 , 000 combined single limit for bodily injury and property damage ,
including coverage for premises/operations , products/completed operations ,
contractual liability, and independent contractors ;
(ii ) Business Auto Liability Insurance in an amount not less than $ 1 , 000 , 000
per occurrence combined single limit for bodily injury and property damage ,
including coverage for owned autos and other vehicles , hired autos and other
vehicles , non-owned autos and other vehicles ; and
(iii ) Workers ' Compensation and Employer's Liability (current Florida statutory
limit)
5 . 6 Insurance Administration . The insurance certificates , evidencing all required
insurance coverages shall be fully acceptable to County in both form and content ,
and shall provide and specify that the related insurance coverage shall not be
cancelled without at least thirty (30 ) calendar days prior written notice having been
given to the County. In addition , the County may request such other proofs and
assurances as it may reasonably require that the insurance is and at all times
remains in full force and effect. Recipient agrees that it is the Recipient's sole
responsibility to coordinate activities among itself, the County, and the Recipient's
insurer(s ) so that the insurance certificates are acceptable to and accepted by
County within the time limits set forth in this Contract . The County shall be listed as
an additional insured on all insurance coverage required by this Contract, except
Workers ' Compensation insurance . The Recipient shall , upon ten ( 10) days' prior
written request from the County, deliver copies to the County, or make copies
available for the County's inspection at Recipient's place of business , of any and all
insurance policies that are required in this Contract. If the Recipient fails to deliver or
make copies of the policies available to the County; fails to obtain replacement
insurance or have previous insurance policies reinstated or renewed upon
termination or cancellation of existing required coverages ; or fails in any other regard
to obtain coverages sufficient to meet the terms and conditions of this Contract , then
the County may, at its sole option , terminate this Contract .
5 . 7 Indemnification , The Recipient shall indemnify and save harmless the County, its
agents , officials , and employees from and against any and all claims , liabilities ,
losses , damage , or causes of action which may arise from any misconduct, negligent
act , or omissions of the Recipient, its agents , officers , or employees in connection
with the performance of this Contract.
5 . 8 Public Records . The Recipient agrees to comply with the provisions of Chapter
119 , Florida Statutes ( Public Records Law) in connection with this Contract.
6 . Termination . This Contract may be terminated by either party, without cause , upon
thirty (30 ) days prior written notice to the other party. In addition , the County may
terminate this Contract for convenience upon ten ( 10 ) days prior written notice to the
Recipient if the County determines that such termination is in the public interest .
7 . Availability of Funds . The obligations of the County under this Contract are subject
to the availability of funds lawfully appropriated for its purpose by the Board of
County Commissioners of Indian River County.
8 . Standard Terms . This Contract is subject to the standard terms attached hereto as
Exhibit C and incorporated herein in its entirety by this reference .
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IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date
first above written .
INDIAN RIVER COUNTY BOARD OF NTY COMMISSIONERS
By : Ikkl kAwg�
Arthur R . Neub er , Cha ' an
BCC Approved : 10 / 12 / 0 4 _ , IrI
est : J . rton , C rk
r
B
Deputy Clerk' ? .
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Approved :
Jos ph A. Baird
County Administrator
Ap OV d as orm and Val sufficiency:
r rian E . Fell , AssistantgvOorney
RECIPIENT :
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By :
St Peters man Services , Inc .
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EXHIBIT A
[Copy of complete proposal/application]
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St. Peter's Human Services, Inc . Village of Excellence Training Institute for Girls . Children 's Services Council
PROGRAM COVER PAGE
�.Y ..v A?l�bt Id'.#i v�{i1tY l �SVd i1�'.r :: to-gS.t •i[i •:
Organization Name : Village of xcelle ce�' ai ung Jhstitute for_Girls�
Executive Director : Pastor Andrew Jefferson E-mail : StPetersAcademy(iDaol . com
Address : 4250 38th Avenue Telephone : 772 - 562 - 1963
Vero Beach, FL 32967 Fax : 772 -562 - 8920
Program Director: Myra Ferguson E-mail : Same as above
Address : Same as above Telephone : Same as above
Fax : Same as above
Program 'title : Village of Excellence Training Institute for Girls
Priority Need Area Addressed: To reduce juvenile delinquency and crime
Brief Description of the Program : The program seeks to provide for school age children and teens
( 7- 16 years old) access to a weekend training program that offers recreation academic supportself
esteem, character building and community services experience The program also provides positive
role models through Investors to equip the girls with knowledge about substance abuse violence
pregnancy, abuse, hygiene and gang activity.
SUMMARY REPORT — (Enter Information In The Black Cells Only)
Amount Requested from Funder for 2004 / 05 : $ 50 , 349 . 11
Total Proposed Program Budget for 2004 / 05 : $ 50 , 349 . 11
Percent of Total Program Budget : 100 . 0 %
Current Program Funding ( 2003 / 04 ) : $ 20 , 000
Dollar increase / ( decrease ) in request : $ 305349
Percent increase / ( decrease ) in request * * : 151 . 7 %
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Unduplicated Number of Adults to be served Individually :
Unduplicated Number to be served via Group settings : 30
Total Program Cost per Client : 839 . 15
* * If request increased 5 % or more, briefly explain why: The program is requesting an additional
$ 9 , 640 . for food as indicated in variance section of the application.
If these funds are being used to match another source, name the source and the $ amount :
The Organization 's Board of Directors has approved this application on d o� L
ANDREW JEFFERSON
Name of President/Chair of the Board Si e
LARRY TAYLOR _
Name of Executive Director/CEO ignature
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St. Peter's Human Services, Inc. Village of Excellence Training Institute for Girls. Children 's Services Council
PROPOSAL NARRATIVE
Please respond to each question in the allotted space for each section. In responding to each section of
the proposal narrative, please retain the section- label and/or question that you are addressing . Type
using 12 pt . font on 8 %i" X 11 " paper and number each page . These directions and the graphic boxes
may be deleted if space is needed .
A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page)
1 . Provide the mission statement and vision of your organization .
Mission Statement : St . Peter ' s Human Services , Inc . mission is to increase the success rate of
high risk students by providing educational support, drug awareness , and character education
through operation of a public school of choice. The Academy works cooperatively with
established social programs and assist the targeted population of Indian River County to become
self sufficient members of society.
Vision : The St. Peter' s Human Services , Inc . is a non denominational organization since
December 1996 . The Agency' s vision is to address social problems and needs in targeted areas
of Indian River County, Florida. The agency is designed to provide short and long term services
in the areas of affordable quality child/day care services , before and after school childcare, public
school of choice for children with special needs and children who are not successful in the
regular system, youth intervention programs and assisted living care for certain targeted groups .
2 . Provide a brief summary of your organization including areas of expertise,
accomplishments, and population served.
Since its incorporation, the agency has provided quality daycare services for families with
children ages zero to five years of age. The center also serves children who are Title 20 and
ALPI Certified. The agency has a chartered public school of choice, serving 90 to 100 students
of Indian River County. The Agency has also successfully implemented a Boy' s Development
and Training Program from the targeted population, ages 7 to 14 . The program ' s highlights
include organized drills , academic support, self esteem/character building, exploration and
exposure to educational and recreational activities through field trips and workshops . The
Program is the only one of its kind in Indian River County.
With the successful program for boys , the transition is a natural one to assist in providing a
program for the at risk girls in the community.
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St. Peter's Human Services, Inc. Village of Excellence Training Institute for Girls. Children 's Services Council
Be PROGRAM NEED STATEMENT (Entire Section B not to exceed one page)
1 . a) What is the unacceptable condition requiring change? b ) Who has the need ?
c) Where do they live ? d) Provide local, state, or national trend data, with reference
source, that corroborates that this is an area of need .
a . The unacceptable condition is juvenile delinquency that leads to further lives of crime,
truancy, dropping out of school , pregnancy, sexual abuse , low self esteem, etc . because
the approach has been only to lock up the offenders without changing the behaviors .
b . The children in need are at risk females between the ages of 6 and 16 who have exhibited
problem behaviors , such as school disciplinary referrals , chronic school truancy,
repeated school suspensions , poor academic performance, a history of alcohol, tobacco
and other drugs , rebellion, running away, mental and emotional health issues and those
with a history of delinquent behavior.
c. In Indian River County, 90% of the at risk females involved in the program are from the
surrounding community.
d . DJJ ' s fact sheet on female juvenile offenders quoted Bill Bankhead, "We have a growing
problem with serious delinquency among girls . . . Girls need specialized attention and
direction on dealing with issues like peer pressure, self image and goal setting . " There
has been a 44 % increase in the number of girls arrested annually for committing crimes
during the past 10 years . (Percentage of boys only rose 12 . 5 %) The number of girls
arrested for violent felony offenses doubled over the past ten years — and it is expected to
continue to climb . In the DJJ report, The Girls Initiative, it stated that girls have unique
needs and problems , such as sexual and/or physical abuse , teen pregnancy, poor
academic performance and mental health needs . The fact sheet on female offenders
states , "The need for appropriate new programs for girls continues . What happens to girls
in the system is critical not only because of their large numbers . Girls ' circumstances are
different than boys . The relevant issues to girls include avoiding teen pregnancy, getting
a good education, learning about health and hygiene, dealing with all kinds of abuse,
acquiring parenting skills , developing self esteem and being mentored by a female adult . "
(www. d state . fl. us/statsnresearch/factsheets/femaleoffenders .html)
2 . a) Identify similar programs that are currently serving the needs of your targeted
population ; b) Explain how these existing programs are under-serving the targeted
population of your program.
There are two programs that serve the targeted population, neither of which serve the whole
child :
la. Gifford Youth Activity Center provides a day program for all youth, not just females . lb . The
program does not provide many of the services rendered by our program, i . e . mentoring, meals ,
overnight stay at the site, one-on-one parent and children discussions , mentoring, tracking the
girls for six months after successful completion through DJJ, etc .
2a. Hope Academy provides an alternative program for suspended students from public schools ,
while the Girl ' s Institute serves the total child, making sure that no child will be left behind . 2b .
Hope Academy is not designed to meet the needs of the total child.
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St. Peter's Human Services, Inc. Village of Excellence Training Institute for Girls. Children 's Services Council
PROGRAM DESCRIPTION (Entire Section C, 1 — 6, not to exceed two pages)
1 . List Priority Needs area addressed.
To reduce juvenile delinquency and crimes .
2 . Briefly describe program activities including location of services .
Activities , Results and Program Requirements : The following services will be provided/required
by the program ; tutoring and academic instruction, counseling (rehabilitative, social , mental and
emotional) , drills for discipline training, character and self esteem building classes , conflict
resolution and life skills and parenting classes , rap sessions to develop communication skills ,
recreational activities , field trips , mentoring, guest speakers , etc . Overall results : reduced
juvenile delinquency and increased self esteem and responsibility. Process and Intended
Outcomes — Client involvement from start to finish : Referrals are made by local churches ,
parents of enrolled girls and from other partnering agencies . The girl is accepted into the
program and must participate on every level while attending. The girl ' s school attendance ,
records, etc . , are closely monitored and discussed during the duration of the program. Above is a
list of those areas in which the girl will participate . Expected Outcomes and Changes : The
outcomes generally include increased academic performance, decreased negative behavior,
improved relationships among peers , increased community awareness and increased awareness
of substance abuse addiction, pregnancy and HIV risk factors . The outcomes that would benefit
the community include reduced juvenile delinquency, reduced crimes , increased responsibility as
a citizen of the community, etc . Follow-up : After successful completion, the Girls are followed
up on a monthly basis through DJJ for a total of six months . In addition, a concerned
parent/school official is encouraged to contact the program director if there are any situations
that arise that might be handled by the program director or counselors . The services are provided
at St. Peter' s Church, 4250 38th Avenue, Gifford/Vero Beach, FL 32967 . The hours of operation
are from Friday, 4 : 30 p .m. through 5 : 00 p .m.
3 . Briefly describe how your program addresses the stated need/problem. Describe how
your program follows a recognized "best practice" (see definition on page 12 of the
Instructions) and provide evidence that indicates proposed strategies are effective with
target population .
The Village of Excellence Training Institute addresses the need to reduce juvenile delinquency
by providing a program for at risk females who are affected by chemical addictions , violence,
poor family environment, and lack of social and academic skills , poor self esteem and other areas
in need of improvement in a female youth ' s life. The focus of this program centers on addressing
these young female issues along the same line as DJJ, as indicated in the editorial written by the
Secretary of DJJ, Bill Bankhead, where he stated (concerning the DJJ programs) , "Individualized
resources that meet the needs of the particular juvenile and his or her family are provided . These
can include mental health counseling, substance abuse treatment and tutoring . . . to get everyone
working together positively on issues and to give the kids a way up and out of failure . " When
looking at the Girl ' s Institute, these areas have been addressed through a variety of mediums ;
mentors discipline training, academic accountability, tutoring, parental involvement, community
Involvement (which increases ties to the community) , mental health assessment and counseling,
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St. Peter's Human Services, Inc. Village of Excellence Training Institute for Girls. Children 's Services Council
substance abuse awareness and referral (if necessary) , etc . The DJJ report on Community
involvement indicated that evidence shows that communities can deter juvenile crime by
targeting the key risk factors of truancy, school failure, access to weapons , not enough positive
activities to keep kids busy. It indicated that " . . . some of the same strategies that can prevent
delinquency from ever happening in a child ' s life also can stop a juvenile offender from re-
offending and recycling back into the delinquency system . " The articles closes with this
statement : "No matter how good an individual juvenile justice program strives to be, a young
person sooner or later returns to his home community. " St . Peter ' s Girl ' s Program assists in
diverting the girls ' lives away from crimes in their communities . It is a community program that
develops community attachments for the youth while addressing the needs that placed the child
at risk in the first place . According to DJJ Secretary, Bill Bankhead, " . . . outreach must be done in
the neighborhoods where juvenile crime is high. " Governor Bush said of the successful
outreaches, " . . . they focus on preserving the unity and integrity of the family and emphasizing
parental responsibility in dealing with troubled youth. "
(www. dii . state . fl . us/features/runaways .html . ) Delinquency prevention is paramount to DJJ ' s
plan, which includes three elements : targeting the most at risk, cooperation between community-
based programs working with the government to approach families , and accountability through
data collection and measurement of program success . The Girl ' s Institute does all three and goes
beyond in preventing or reversing the patterns and risk factors associated with delinquency while
addressing specific female needs .
4 . List staffing needed for your program, including required experience and estimated
hours per week in program for each staff member and/or volunteers (this section
should conform with the information in the Position Listing on the Budget Narrative
Worksheet) .
1 — Program Director (PT, BA degree preferred, 2 yrs . ' experience working with at risk kids . )
Oversees the operation of the program, including data collection, quarterly reporting and
financial management of the program. Will supervise and oversee all staff.
1 -Programs Operation Manager (PT. Minimum HS diploma/equivalency, training in child
development at least 2 years of experience in working with at risk children. ) Responsible for
overall operation of program. Will assist institute trainers in development of appropriate
materials addressing social and educational needs of the enrollees, ensuring a safe, nurturing
environment conducive to learning, house parenting for the weekend, and assisting with data
collection from schools and coordination with teachers . Responsible for planning all activities ,
working with institute staff, mentors and volunteers .
2 — Institute Trainers/Teachers (Part time . Must have experience in working with at risk
children. ) Will provide appropriate educational and recreational activities during program hours
including computer instruction and reading clinic ; will conduct parent meetings and assure that
the data is collected in a timely manner.
1 — Institute Prevention Coordinator (BA degree in related field and /or 2 years of experience
in social setting working with youth. Knowledge of children and teaching basic skills .)
Recruitment and new referrals , handle data, planning, parent training, discipline, counseling and
assist with data collection from schools including school visits on- site monitoring and
coordination with teachers .
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• St. Peter's Human Services, Inc . Village of Excellence Training Institute for Girls. Children 's Services Council
5 . How will the target population be made aware of the program?
The program continues to provide awareness through word-of-mouth, local churches , parents of
enrolled girls and through our collaboration with our partnering agencies .
6. How will the program be accessible to target population (i. e. , location , transportation ,
hours of operation) ?
The St . Peter ' s Village of Excellence Training Institute for Girls is located in the heart of 90 % of
the targeted population . The address is St. Peter' s Missionary Baptist Church, 4250 38th Avenue,
Vero Beach, FL. Transportation is provided by the parents . The program is open from Friday,
4 : 30 p . m. to Saturday, 5 : 00 p . m .
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St. Peter's Human Services, Inc . Village of Excellence Training Institute for Girls . Children 's Services Council
D . MEASURABLE OUTCOMES (Entire Section D not to exceed two pages)
OUTCOMES ACTIVITIES
Add all of the elements or the Measurable Outcome(s) Add the tasks to accomplish the Outcome(s)
1 . To increase the academic performance of 1 . Provide tutoring each week to enrolled girls ,
enrolled girls by 75 % as reported by the IRC including a designated study hour each week .
progress notes/report cards .
2 . To decrease negative/disruptive behavior of 2 . Provide rap sessions to enrolled girls weekly.
enrolled girls by 50% as reported by parents Provide mentoring with positive role models
and IRC schools ' Conduct Code . on a weekly basis ; provide character/self
esteem building through weekly class sessions .
Improve relationships among Girls as reported Weekly — Demonstrate and role play positive
by the girl ' s program Staff-baseline and friendly behaviors towards adults and
2003 /2004 — staff and parents . peers .
Increase community awareness — baseline : Monthly — recreational activities that are
2003 /2004 — staff and parents . service oriented.
3 . Raise awareness level of chemical 3 . Invite and schedule guest speakers from
addictions , STD , teen pregnancy, abuse and Substance. Abuse Council to discuss chemical
HIV for enrolled girls by 90% as reported by addiction, etc .
pre and post tests .
Invite guess speakers from the IRC Health
Department to discuss STD , pregnancy,
hygiene and HIV at least once during the
program year.
Participate and attend seminars sponsored by
community agencies pertaining to alcohol and
drug abuse and abstinence, domestic violence,
sexual abuse, etc .
4 . To increase mental health services 4 . Contact Indian River Mental Health Center
accessibility for enrolled girls with mental to have speakers address the enrolled girls .
health issues by 80% as reported by schedules
appointments attended and as reported by Connect appropriate girls with mental health
mental health workers . services in the community.
Follow up with mental health professionals
concerning girls ' progress .
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St. Peter's Human Services, Inc. Village of Excellence Training Institute for Girls. Children 's Services Council
E . COLLABORATION (Entire Section E not to exceed one page)
1 . List your program ' s collaborative partners and the resources that they are providing to
the program beyond referrals and support. (See individual funder requirements for
inclusion of collaborative agreement letters .
Collaborative Agency Resources provided to the program
Substance Abuse Council Drug Awareness
Sheriff' s Department Scared Straight Jail Tour
IRC Health Department Sexually Transmitted Diseases
Gifford Youth Activity Center Seminar, "Raising Them Chaste"
Black Faith-Based Organization, Inc . Basketball Tournament
IRC Mental Health Center Seminars
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St. Peter's Human Services, Inc . Village of Excellence Training Institute for Girls. Children 's Services Council
F. PROGRAM EVALUATION (Entire Section F not to exceed two pages)
1 . DEMOGRAPHICS : What information (data elements) will you need to collect in order
to accurately describe your target population including demographics (age, gender, and
ethnic background) required by the funder in Section H ? What are the pieces of
information that qualify them for your target population ? How do you document their
need for services or their "unacceptable condition requiring change" from Section B19
The information to be collected includes : name, age, ethnic background, birth date and grade . To
qualify for the target population, a prospective enrollee will be at risk for at least two of the
following conditions : At risk females between the ages of 6 and 16 who have exhibited at least
two problem behaviors , such as school disciplinary referrals , chronic school truancy, repeated
school suspensions , poor academic performance, a history of alcohol, tobacco and other drugs ,
rebellion, running away, mental and emotional health issues and those with a history of
delinquent behavior. The unacceptable condition is juvenile delinquency and is documented
through DJJ reports , school reports , parent reports , etc . This shall be documented and maintained
through a database and spreadsheet programs .
2 . MEASURES : What data elements will you need to collect to show that you have
achieved (or made progress toward) your Measurable Outcomes in Section D ? What
tools or items are you using as measures (grades , survey scores, attendance, absences ,
skill levels) for your program? Are you getting baseline information from a source on
your Collaboration List in Section E ? Are there results from your Activities in Section
D that need to be documented? How often do you need to collect or follow-up on this
data?
Data will be collected from participants via progress reports/report cards on a nine week basis .
Copies of schedules of activities listing the study hour, rap sessions and dates and times of guest
speakers will be maintained on location . An entrance description of behaviors will be maintained
and reviewed quarterly for improvement. Upon exiting a program, a summary of progress made
while attending the program will be documented. Measurement items include grades , attendance
sheets , progress reports , school conduct codes report, pre and post test reports , counselor reports,
prevention activity attendance sheets, etc . The progress report/report cards will be collected
every nine weeks and at the end of each semester. The schedule of activities will be collected on
an ongoing basis . The entrance and exit behavior description will be collected upon entering and
exiting the program . Progress notes on behavior improvement will be documented quarterly or as
needed . After successful completion, there will be a monthly follow-up for six months via
parents , school and DJJ .
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St. Peter's Human Services, Inc . Village of Excellence Training Institute for Girls . Children 's Services Council
3 . REPORTING : What will you do with this information to show that change has
occurred ? How will you use or present these results to the consumer, the funder, the
program, and the community ? How will you use this information to improve your
program?
The data will be compiled in a notebook under each activity and also copies of the
progress/report cards will be placed in each enrollee ' s file . The information will be provided
upon request to any requesting agency, collaborative partners and the Human Service Board of
Directors .
In areas where the increase in a positive attributer is low or minimal, the program director and
board will determine and research new ways to implement a more substantial increase in the
positive attribute . It will also be utilized to determine what is working so that it can be continued .
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St. Peter's Human Services, Inc. Village of Excellence Training Institute for Girls. Children 's Services Council
G. TIMETABLE (Section G not to exceed one page)
1 . List the major action steps, activities , or cycles of events that will occur within the
program year. New programs should include any start- up planning that may occur
outside the funding year. In completing the timetable, review information detailed in
prior sections.
Month/Period Activities
Weekly Tutoring — study hour
Weekly Character/self esteem building sessions ; community activities ; conflict
resolution.
As needed - ongoing Life Skills sessions ; rap sessions
Each nine weeks Academic improvement (progress reports and report cards)
Weekly — ongoing Reducing negative behaviors — through rap sessions, field trips ,
seminars
Weekly Recreational activities and drills
Weekly Institute counseling, including mental health
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y 1 . vx ro Yi its v
1 to (Pre-school)
to 10
ChildrenTotal MA
160 + (Seniors)
AdultsTotal
TOTALSERVED ,
Type the Organization and Program Name
UNIFORM GRANT APPLICATION
BUDGET NARRATIVE WORKSHEET
IMPORTANT: The Budget Narrative should provide details to justify the amount requested in each line item of the budget for your
program. From this worksheet, your figures will be linked to the Total Agency Budget, Total Program Budget and Funder Specific
Budget Forms.
AGENCY/ PROGRAM NAME : St . Peter's Human Services , Inc . Village of Exc . Girls ' Trng Institute
FUNDER : Children 's Services Council
j
CAUTION : Do not enter any figures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should
I
Abe used for calculations and to write information only,
- - - - - - - - - - - - - - - - - - - - - - -
�. fr *t} ' ORAY'MFAS FOR ' a +s <� , < r,
�� REV UES A� �m � °E"1011EON11r �roposed Total Program FuntlerSpecrfic TotalAgency
a ` ° "" `� P Budget " � Budget Budget
t
,. °CACCt1G1T10N91% Y �aj4 �� A m � re - .k , � g
. . ,. +r . <. + -- ,.�.. -
1 Children 's Services CouncilmSt. Lucie
2 Children's Services Council-Martin 4 ` � '
3 Advisory Committee-Indian River 500349. 11 50 , 349. 11 50 ,349. 11
4 United Way-St. Lucie County ,1 s
5 United Way-Martin County
6 United Way-Indian River County °°
7 Department of Children & Families
8 County Funds � E �
9 Contributions -Cash
10 Program Fees
11 Fund Raising Events-Net
12 Sales to Public - Net 3 �
13 Membership Dues ' ,
14 Investment Income
15 Miscellaneous
16 Legacies & Bequests i
17 Funds from Other Sources , ; ,
18 Reserve Funds Used for Operating
19 In-Kind Donations (Not included In total)
20 TOTAL REVENUES
(doesn't Include line 19) $50,349. 11 $ 50,349. 111 $50 , 349. 11
„ �FXPE! 711RES v P o ° osedT i �' d ra Fyn"der ecltiT
Sp �, ��Tofal �4 ei�cy
sriow$c+�iand%ipl P `B dge , ., g � Bii
A Ls: Bu �.
21 Salaries - (mustf complete chart on next page) 361872.00 36,872.00 369872 .00
dfr; 0 wo
^#, '§
FMS U11
3 l "9atpt"'.w fte&` ." 3' € . ..�ir S' . a a•.l ^ si„. dam . x . `',�R 'K° F.-i ,�a ' i `', # x
, E d�
22 FICA - Total salaries x 0.0765 7:65 21820. 71 2 ,820. 71 29820 . 71
Retirement - Annual pensionT6'rqu57M'eff
23 staff 0.00
Life/Health - e ica en a o eerm
24 Disab. „ z= 4 0 . 00
Workers Compensation - # employees x 1
y
25
rate �, "� ,� '. 0 . 00
Honda Unemployment - # projected }
26 employees x $7 ,000 x UCT-6 rate , _ 0 .00
-Y'<. de.i , .cc •- rs �� r ,
SALARIES 1 r k A y cc w ra v � D
POSITION LISTING b si Gross Annual I. � C % of Gross Annual
Portlort of Salary on Proposed t
4 F Funder Speclffc 8udget �= Salary
i"�+ SA�ary „mac z,; s " PfOgraln ��'' rs sn m a. sf P� e �.
Position Title / Total Hrs/wk (Agency) _ _ y rRequested(C/A)
.. .
5/2912004 8 -1
Type the Organization and Program Name
Program Director 10 hrs 7, 800 .00 79800. 00 79800. 00 100 . 00%
Program Operations Manager . 25 hrs 15, 500 . 00 15 , 500 .00 151500 . 00 100 .00 %
Institute Trainers/Teachers - 6 hrs 41212 . 00 4 ,212. 00 4 ,212.00 100 . 00%
Institute Prevention Coordinator - 12 hrs 91360 . 00 99360 .00 99360 . 00 100 . 00%
#DIV/0 !
#DIV/0 !
#DIV/0 !
#DIV/0 !
#DIV/0 !
#DIV/0 !
#DIV/0 !
#DIV/0 !
#DIV/0 !
#DIV/0 !
#DIV/0 !
#DIV/0 !
#DIV/0 !
r #DIV/0 !
#DIV/0 !
#DIV/0 !
Remaining positions throughout the agency
Total Salaries $36,872. 00 $36 ,872 .00 $36 , 872 .00 100 . 000/0
FRINGE BEiVEFITS DETk L, . � l x ;a " '�� k 3� � el
we
xx �
f/� i ' � .Sl f new nt' Y, t�, i :b f Y h
(Funder Speci><c Btitlget Ao yF wnaer s . z s «we
elk' G` �n k F,
Pension Workers Unemployme .Total.Fringes Funder
Column C onl fromalme 22 to 27) �Speclflc FICA 7 65/ f r 0/ Health Ins P
Y, IIN s Q x /o x Com ens of Compens.' Specific
Position Title / Total Hak `,lIN, °"Budget �� s f
M
wlwN
�a u
.k � F z 4
we
.w N , k. ar > ,aa r, r . `n' .b ,y F , '. .' � , . �x�Cq, i week
- d
Program Director 10 hrs 700 . 00 596 . 70 596 . 70
Program Operations Manager - 25 hrs 15,500 . 00 11185 . 75 1 , 185 . 7
Institute Trainers/Teachers - 6 hrs 49212 .00 322 .22 322. 22
Institute Prevention Coordinator - 12 hrs 9,360. 00 716 . 04 716 . 04
0 0 .00 0. 00 0 . 00
0 0 . 00 0 .00 0 . 00
0 0.00 0.00 0. 00
0 0.00 0.00 0. 00-
0 0 . 00 0.00 0 . 00
0 0 .00 0.00 0 .00
0 0.00 0 .00 0 .00
0 0.00 0.00 0. 00
0 0 . 00 0. 00 0 . 00
0 0 .00 0 . 00 0 . 00
0 0 .00 0.001 0 .00
0 0.00 0.00 0 . 00
0 0. 00 0.00 0 . 00
0 0 . 00 0. 00 0. 06
0 0 .00 0.00 0. 00
0 0 .001 0. 00 0 . 00
Total Funder Request Fringe Benefits $36 , 872 .001 $ 2 , 820 . 711 $0.001 $0 .001 $0.00 $0 . 00 $ 21820 . 71
ys
A "11 ' k , B c D11 we I `
EXPENDITURES ORAYAREA9 Eoa ; Proposed Total Program Funder Specific, Total Agency
AOENCYUSEOMYTO - + . '
SHOWDETAIL ° " 'Budget - Budget Budget . -
27 Travel -Daily '�
# of Staff x average # of miles/wk x 50 wks x
$ = Estimated Daily Travel/Mileage Reimb .
28 Travel/Conferences/Training
5n5/200a
e-i
' M �
Type the Organization and Program Name
• National Conference (cost per staff)
• Training/Seminar (cost per staff)
• Other Trainings (cost of travel , lodging ,
registration , food )
29 Office Supplies
i
• Office supplies ( monthly average x 12
months = estimated cost of office supplies
based on present history.
30 Telephone
• # Phone lines x average cost per month x
12 months = local phone cost
• Average long distance calls x 12 months =
Estimated cost of long distance
31 Postage/Shipping
• Quarterly Mailing of Newsletter
• Special events, etc. ;
Bulk mailings - appeals `IV. ; :` IV
32 Utilities ,
• Electricity ($ x 12 months)
• Water/Sewer ($ x 12 months) '
• Garbage ($ x 12 months )
33 Occupancy (Building & Grounds) 4 ;' ?
• Mortgage/Rent ($ x 12 months)
• Janitorial ($ x 12 months )
• Grounds Maint. ($ x 12 months) � _ � � '„ � �rVVV
'AM'F 3 x ' "
• Real Estate Taxes `
r
34 Printing & Publicationsz „
J
• Quarterly Newsletter ($ x 4) ,
• Letterheads , Envelopes , etc. _ R
Fundraising materials111 A6 1 16 "
Other � sVI
� n
Ir I ' r
35 Subscription/Dues/Memberships V Mqq % �V"�
RX
• Membership to National Organization �' � W
• Dues
'S 3 j v , I IV
r 1 v
i i :. l` s � .¢� J i n g 4 3
• Subscriptions to Newspapers/magazines , yx � F ,
IV VI
etc. �x >
361nsurance
• Directors/Officers Liab .
r � - ,
• Commercial/General Insurancex t i,� r _
Bond Ins .
Auto Insurance `
37 Equipment : Rental & Maintenance
• Copier lease ($ x 12 months ) a _ �y + s ,
w3' `b $ �3 cy l iYs a s, , zire t'y a
• Meter lease ($ x 12 months) s
• Copier Maintenance ($ x 12 months ) x V-' I
• Computer Maintenance ( $ x 12 months) "� � � ���� r '
I VI c
• Other ..
38 Advertisin9 500 . 00 500 .00 500 . 00
g ,T. , ._ .,
• Newspaper ads
• Fundraising ads/promotions .gib
• Other (vacancies ) y
39 Equipment Purchases : Capital Expense
• Computer/monitor (# xI IV
• Laser Printer
40 Professional Fees ( Legal , Consulting ) V I w
• Legal advice ( estimated #hrs x $)
• Consultant fees
• Other
VV
41 Books/Educational Materials 500 . 00 500 .00 500 . 00
Books/videos
Materials ($ x staff)
42 Food & Nutrition 91656 . 40 91656 .40 99656 . 40
5/252004 g. �
Type the Organization and Program Name
Meals (60 meals 30 clients x 2 days x 52 ;" ` Zrtd
wks ) Snacks � ,� ,
43 Administrative Costs
• Admin . Cost ( % of total budget) , " ; ,
44 Audit Expense
a
Independent Audit Review
45 Specific Assistance to Individuals .;
• Medical assistance � z , _ , {
• Meals/Food
x a
• Rent Assistance f.
A �
Other ,
46 Other/Miscellaneous
• Background check/drug test N�
• Other _
47 Other/Contract
Sub-contract for program services r , a
481 TOTAL EXPENSES' ' *'',, $50,349. 11 $ 50 , 349 . 11 $50, 349. 11
5/25/2004 B-I
T" h QgWiMbn ..e PWM N.
UNIFORM GRANT APPLICATION
TOTAL AGENCY BUDGET
AGENCY/PROGRAM NAME :
FY 02/03 FY 03/04 FY 04/05 % INCREASE
FYE FYE FYE CURRENT VS.
NEXT FY BUDGET
A B C D
ACTUAL TOTAL PROPOSED (col. Ccol. B)lcol. B
REVENUES BUDGETED BUDGETED
1 Children 's Services Council-St. Lucie 0.00 #DIV/01
2 Children's Services Council-Martin 0. 00 #DIV/Ol
3 Advisory Committee-Indian River 50 349. 11 #DIV/01
4 United Way-St. Lucie County 0.00 #DIV/01
5 United Way-Martin County 0.00 #DIV/01
6 United Way-Indian River County 0. 00 #DIV/01
7 Department of Children & Families 0.00 #DIV/01
a County Funds 0.00 #DIV/01
9 Contributions-Cash 0.00 #DIV/01
10 Program Fees 0. 00 #DIV/01
11 Fund Raising Events-Net 0.00 #DIV/01
12 Salessto Public-Net 0. 00 #DIV/01
13 Membership Dues 0.00 #DIW01
14 Investment Income 0.00 #DIV/01
15 Miscellaneous 0. 00 #DIV/01
16 Legacies & Bequests 0. 00 #DIV/01
17 Funds from Other Sources 0.00 #DIV/01
19 Reserve Funds Used for Operating 0. 00 #DIV/01
19 In-Kind Donations (Not Included In total 0.00 #DIV/01
20 TOTAL 0.00 0.00 50 349. 11 #DIV/01
, 'e4' a:;i�C<,^' ""§Re. , ..ice##szv„ka .,�*z'v--,z , ,. e 'vdM.,r'mta . .v.:w�Met,-, . •�ti+i^A .'�'sd�eye ,
EXPENDITURES
21 Salaries A0. 00
#DIV/01
22 FICA #DIV/01
23 Retirement #DIV/01
24 Life/Health #DIV/01
25 Workers Compensation #DIV/01
26 Florida Unemployment #DIW01
27 Travel-Dail 0.00 #DIV/Ol
28 Travel/Conferences/Trainin 0.00 #DIV/01
29 Office Supplies 0.00 #DIV/01
30 Telephone 0. 00 #DIV/01
31 Postage/Shipping 0.00 #DIV/01
32 Utilities 0.00 #DIV/01
33 Occupancy (Building & Grounds 0.00 #DIV/01
34 Printing & Publications 0.00 #DIV/01
35 Subscri tion/Dues/Membershi s 0.00 #DIV/01
36 Insurance 0.00 #DIV/01
37 E ui ment:Rental & Maintenance 0.00 #DIV/01
39 Advertisin 500.00 #DIWOI
39 Equipment Purchases :Ca ital Expense 0.00 #DIW0l
40 Professional Fees (Legal, Consultin 0.00 #DIV/01
41 Books/Educational Materials 500.00 #DIV/01
42 Food & Nutrition 91656.40 #DIV/01
43 Administrative Costs 0.00 #DIV/01
44 Audit Expense 0.00 #DIV/01
45 Specific Assistance to Individuals 0.00 #DIV/01
46 Other/Miscellaneous 0.00 #DIV/01
47 Other/Contract 0.00 #DIV/01
4a TOTAL 0.00 0.00 50 349.11 #DIV/01
t S hr Nb�i ,n.°yA ^
49 REVENUES OVER/ UNDER EXPENDITURES 0.00 0.00 0. 00EMI I
WW001 g_2
TYW MOrg�Y � PWm N�
UNIFORM GRANT APPLICATION
TOTAL PROGRAM BUDGET
AGENCY/PROGRAM NAME :
FY 02/03 FY 03/04 FY 04/05 % INCREASE
FYE FYE FYE CURRENT VS.
NEXT FY BUDGET
A B C D
ACTUAL TOTAL PROPOSED (col. C.col. e)/col. B
REVENUES BUDGETED BUDGETED
1 Children 's Services Council-St. Lucie 0.00 #DIV/01
2 Children 's Services Council-Martin 0.00 #DIV/01
3 Advisory Committee-Indian River 50 349. 11 #DIV/01
4 United Way-St. Lucie County 0.00 #DIV/01
5 United Way-Martin County 0. 00 #DIV/01
6 United Way-Indian River County 0.00 #DIV/0I
7 Department of Children & Families 0.00 #DIV/01
6 County Funds 0.00 #DIV/01
9 Contributions-Cash 0. 00 #DIV/01
10 Program Fees 0.00 #DIV/01
11 Fund Raising Events-Net 0.00 #DIV/01
12 Sales to Public-Net 0.00 #DIV/01
13 Membership Dues 0.00 #DIV/01
14 Investment Income 0.00 #DIV/01
15 Miscellaneous 0.00 #DIV/01
16 Legacies & Bequests 0.00 #DIV/01
17 Funds from Other Sources 0.00 #DIV/01
18 Reserve Funds Used for O eratin 0.00 #DIV/01
19 In-Kind Donations (Not Included In total) 0.00 #DIV/01
20 TOTAL 0.00 0.00 50p349. 111 #DIV/01
EXPENDITURES
21 Salaries 36 872.00 #DIV/01
22 FICA 2p820. 711 #DIV/01
23 Retirement 0.00 #DIV/01
24 Life/Health 0.00 #DIV/01
25 Workers Compensation 0.00 #DIV/01
26 Florida Unemployment 0. 00 #DIV/01
27 Travel-Dail 0.00 #DIV/01
28 Travel/Conferences/Train Ing 0.00 #DIV/01
29 Office Supplies 0. 00 #DIWOI
30 Telephone 0.00 #DIV/Ol
31 Postage/Shipping 0.00 #DIV/01
32 Utilities 0.00 #DIV/Ot
33 Occupancy (Building & Grounds 0.00 #DIV/01
34 Printing & Publications 0.00 #DIV/01
35 SubscriUon/Dues/Membershi s 0.00 #DIV/01
36 Insurance 0.00 #DIV/OI
37 Equipment: Rental & Maintenance 0.00 #DIV/Ol
3B Advertising 500.00 #DIV/01
39 Equipment Purchases:Ca ital Expense 0.00 #DIV/01
40 Professional Fees (Legal, Consultin 0.00 #DIV/01
41 Books/Educatlonal Materials 500.00 #DIV/01
42 Food & Nutrition 99656.40 #DIV/01
43 Administrative Costs 0.00 #DIV/01
44 Audit Expense 0.00 #DIV/01
45 Specific Assistance to Individuals 0.00 #DIV/Ol
46 Other/Miscellaneous 0.00 #DIV/Ol
47 Other/Contract 0.00 #DIV/01
48 TOTAL 0.001 0.001150 349.11 #DIV/OI
49 REVENUES OVER/ UNDER EXPENDITURES 0.001 O. oOj 0.00 #DIV/01
nvzaa ea
Type the Organization and Program Name
UNIFORM GRANT APPLICATION
FUNDER SPECIFIC BUDGET
PROGRAM EXPENSES
AGENCY/PROGRAM NAME : St. Peter's Human Svcs , Inc . Village of Excellence Training Institi
FUNDER : Children 's Services Council A B C
FY 04/05 FY 04/05 % OF
TOTAL FUNDER TOTAL VS ,
PROGRAM SPECIFIC FUNDER REQUEST
BUDGET BUDGET (col . B/col . A)
EXPENDITURES
21 Salaries 36 , 872 . 00 36 , 872 . 00 100 .00 %
22 FICA 2 , 820 .71 29820 . 71 100 . 00 %
23 Retirement 0 . 00 0 . 00 #DIV/01
24 Life/Health 0 . 00 0 . 00 #DIV/0 !
25 Workers Compensation 0 .00 0 . 00 #DIV/0 !
26 Florida Unemployment 0 . 00 0 . 00 #DIV/01
27 Travel -Dail 0 .00 0 . 00 #DIV/0 !
28 Travel/Conferences/Training 0 . 00 0 . 00 # DIV/01
29 Office Supplies 0 . 00 0 . 00 # DIV/01
30 Telephone 0 . 00 0 . 00 #DIV/0 !
31 Postage/Shipping 0 . 00 0 . 00 # DIV/O !
32 Utilities 0 . 00 0 . 00 #DIV/01
33 Occupancy ( Building & Grounds 0 . 00 0 . 00 #DIV/0 !
34 Printing & Publications 0 . 00 0 . 00 #DIV/01
35 Subscription/Dues/Memberships 0 . 00 0 . 00 #DIV/0 !
36 Insurance 0 .00 0 .00 #DIV/0 !
37 Equipment: Rental & Maintenance 0200 0 . 00 #DIV/0 !
38 Advertising 500 . 00 500 . 00 100 . 00 %
39 Equipment Purchases : Capital Expense 0 .00 0 .00 #DIV/01
40 Professional Fees ( Legal , Consulting ) 0 .00 0 . 00 #DIV/01
41 Books/Educational Materials 500 . 00 500 . 00 100 . 00 %
42 Food & Nutrition 99656 . 40 99656 . 40 100 . 00 %
43 Administrative Costs 0 .00 0 .00 #DIV/01
44 Audit Expense 0 . 00 0 .00 #DIV/01
45 Specific Assistance to Individuals 0 . 00 0 . 00 #DIV/01
46 Other/Miscellaneous 0 . 00 0 . 00 #DIV/O !
47 Other/Contract 0 . 00 0 . 00 #DIV/01
48 TOTAL $ 50 , 349 . 11 $ 50 , 349 . 11 100 . 00 %
525/2004
84
- a •
Type IM OMam albn wW Program Name
Village of Excellence Girls Training Institute
EXPLANATION FOR VARIANCES OF 15% OR MORE
TOTAL PROGRAM BUDGET
AGENCY/PROGRAM NAME: St. Peter's Human Services, Inc . Village of Exc . Girls' Trng Institute
Children's Services Countil
EXQ.L Itii 'TlO,N, FQ.R VA�2/AN,C
#DIV/0 ! Grant request exceeds 15% increase in budget due to Food and Nutrition line Rem. The request is for an additional $9 ,656.40
for
#DIV/O ! food . This calculates to $6. 19 per child per weekend. The program will utilize any extra food which may be left over from
the
#DIV/01 School Lunch Program. However, all meals for weekend program participants cannot be applied to the regular School Lunch
#DIV/01 Program. Therefore, the program will need assistance in providing meals for the youth each weekend.
#DIV/01
#DIV/01
#DIV/01
#DIV/01
#DIV/0 !
#DIVI01
#DIV/01
#DIV/01
#DIV/01 i
#DIV/01
#DIV/01
#DIV/01
#DIV/Ol
#DIVl01
#DIVl01
#DIV/OI
#DIV/01
#DIV/Ol
#DIV/01
#DIV/O !
#DIV/0 !
#DIV/0 !
#DIV/0!
#DIV/01
#DIV/01
#DIV/0 !
#DIV/01
#DIV/Ol
#DIV/Ol
#DIV/01
#DIV/01
#DIV/01
#DIV/0!
#DIV/Ol
#DIV/01
#DIV/01
#DIV/01
#DIV/01
#DIV/01
#DIV/01
#DIV/01
#DIV/01
5/25/2004 8-5
. e
NOT FOR PROFIT AGENCY CERTIFICATION
The County of Indian River requires , as a matter of policy , that any Consultant or
firm receiving a contract or award resulting from the Request for Qualifications
issued by the County of Indian River, Florida , shall make certification as below .
Receipt of such certification , under oath , shall be a prerequisite to the award of
contract and payment thereof.
I (we ) hereby certify that if the contract is awarded to me , our firm , partnership , or
corporation , that no members of the elected governing body of Indian River
County , nor any professional management , administrative official or employee of
the County, nor members of his or her immediate family, including spouse ,
parents , or children , nor any person representing or purporting to represent any
member or members of the elected governing body or other official , has solicited ,
has received or has been promised , directly or indirectly , any financial benefit ,
including but not limited to a fee , commission , finder's fee , political contribution ,
goods or services in return for favorable review of any Proposal submitted in
response to the Request for Qualifications or in return for execution of a contract
for performance or provision of services for which Proposals are herein sought .
The undersigned certifies that he/she is a principal or officer of the firm applying
for consideration and is authorized to make the above acknowledgments and
certifications for and on behalf of the applicant .
The undersigned certifies that the Applicant has not been convicted of a public
entity crime within the past 36 months , as set forth in Section 287 . 133 , Florida
Statutes .
Failure to si n this form will result in discivalificatiod '
Handwritten Signature of Authorized Principal (s ) : DATE : J
NAME : Andrew Jefferson
TITLE : President
NAME OF FIRM/PARTNERSHIP/CORPORATION : St. Peter's Human Services , Inc .
FOR AND ON BEHALF OF THE APPLICANT:
Sworn to and sulpscribed to
! Notalry licthis
y 0 gY
RUTH L JEFFERSON f
a r MY COMMIS$ION I DD 19M CXo lV
0 F IFiES: May 6, 2007 TYPE NAME & TITLE
Notary Pitgc
Commissioners
1840 25t' Street
Vero Beach , FL 32960
X
AUTHORIZATION FOR RELEASE OF INFORMATION
Indian River County and St . Peter' s Human Services , Inc . (Agency/ Individual are
in the process of negotiation of a contract for St. Peter' s Village of Excellence
Institute for Girls Indian River County is authorized to make an investigation of
the Agency/ Individual regarding its experience and qualifications . The
Agency/Individual authorized the release of all relevant information concerning
prior services furnished , contracts and background information of the
Agency/ Individual . The Agency/Individual authorizes any individual or
organization that is in possession of relevant factual contract and background
information , to release such data to Indian River County in response of the
County' s request .
When an individual employee of the Agency signs Authorization for Release of
Information , such individual authorizes the County to obtain relevant background
information concerning such employee ' s criminal record , if any, and such other
information that may be relevant to employee ' s good character and work
experience .
Authorization is given here by the Agency/Individual and such employees who
execute this authorization with the understanding and limitation that Indian River
County will utilize the information obtained for the purposes set forth herein and
that such information shall not be disclosed to third parties except as provided by
law.
Name Agency/Individual St , Peter' s Human Services , Inc .
Print name
Name Employee Providing authorizatio Andrew Jefferson
Print name
Signature ( in blue ink
Date D
XI
SWORN STATEMENT UNDER SECTION 105 . 08 ,
INDIAN RIVER COUNTY CODE , ON DISCLOSURE OF RELATIONSHIPS
THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS ,
1 . This sworn statement is submitted with RFP No . 6067 for
St . Peter' s Village of Excellence Institute for Girls
2 . This sworn statement is submitted by: St . Peter' s Human Services , Inc .
(Name of entity submitting Statement )
whose business address is :
425. 0 . 38' Avenue , Vero Beach , FL 32967 and
( if applicable )
its Federal Employer Identification Number ( FEIN ) is 31 - 1480633 .
( If the entity has no FEIN , include the Social Security Number of the individual
signing this sworn statement
3 . My name is Andrew Jefferson
( Please print name of individual signing )
and my relationship to the entity named above is President .
4 . 1 understand that an "affiliate " as defined in Section 105 . 08 , Indian River
County Code , means :
The term "affiliate " includes those officers , directors , executives , partners ,
shareholders , employees , members , and agents who are active in the
management of the entity .
5 . 1 understand that the relationship with a County Commissioner or County
employee that must be disclosed as follows :
Father, mother , son , daughter, brother, sister, uncle , aunt , first cousin ,
nephew, niece , husband , wife , father-in -law, mother- in -law , daughter-
in - law , son - in - law , brother-in - law , sister- in -law, stepfather, stepmother,
stepson , stepdaughter, stepbrother, stepsister, half brother, half sister,
grandparent , or grandchild .
XII
6 . Based on information and belief, the statement , which I have marked below is
true in relation to the entity submitting this sworn statement . [Please indicate
which statement applies . ]
Neither the entity submitting this sworn statement , nor any officers ,
directors , executives , partners , shareholders , employees , members , or
agents who are active in management of the entity, have any relationships
as defined in section 105 . 08 , Indian River County Code , with any County
Commissioner or County employee .
X The entity submitting this sworn statement , or one or more of the officers ,
'directors , executives , partners , shareholders , employees , members , or
agents , who are active in management of the entity have the following
relationships with a County Commissioner or County employee :
Name of Affiliate Name of County Commissioner Relationship
or entity or employee
St. Peter's Human Rose Teague Sister-in -law
Services , Inc. ( County Employee )
XIII
s
o
(signature )
re )
STATE OF Florida
COUNTY OF Indian River County
The foregoing instrurneIrqtt was ackn wled ed before me this day of
2004 , by � r✓ <� E7 who is personally
known tA me or who has produced as
identification,
1
NOT PU LIC /
SIGN : L6Vti
PRINT : jLan L. f
2L
State of Florida at Large
My Commission Expires :
(Seal )
RUTH L JEFFERSON
MY
COMMISSION # DO 199000
EXPIRES; May 6, 2007
Bonded Ttn NOq Public Undenvrbm
XIV
SUPPORTING DOCUMENTS CHECKLIST
RFP 6067
Cover Page
Application
List of current officers and directors
Latest Financial Audit Report & Management Letter that conforms with the
, AICPA Audit Guide
Most recent IRS Form 990 , including all schedules
Most recent Internal Financial Statement (i . e . : Balance Sheet and Operating
Budget
Staff Organizational Chart
Most Recent Annual Report (if available)
501 (C) (3 ) IRS Exemption Letter
Articles of Incorporation
Agency' s Bylaws
Agency' s written policy regarding Affirmative Action
Nepotism Statement
XV
NEPOTISM STATEMENT
The St . Peter ' s Human Services Agency, in the interest of good
practices and sound Jud�'�men_t, refrains from hiring family members as
listed in the Indian River- County ' s Nepotism Policy ,
The Agency ' s Administrator and / or Board of Directors however- will ,
as does the Indian. River County Personnel Director, and as indicated, in
the Indian River County ' s Nepotists Policy; at its discretion hire fatuity
members if it . is determined_ in the best, interest of the Agency ,
i
thor '_ .ed Pri.n,cipal.
N tart' RUTH L JEFFERSON
W COMMISSION a DD 1WW
EXPIRES: May 6, 2007
Dat
Ref. RFP #6067
FY2004/05
1 •
ST . PETER ' S HUMAN SERVICES , INC .
ORGANIZATIONAL LAYOUT
GIRL ' S VILLAGE OF EXCELLENCE TRAINING
INSTITUTE
BOARD OF DIRECTORS
ADMINISTRATOR/PROGRAM DIRECTOR
PROGRAM OPERATIONS MANAGER
INSTITUTE PREVENTION INSTITUTE TRAINERS
COORDINATOR & TEACHERS
VOLUNTEERS
MENTORS
EXHIBIT B
[ From policy adopted by Indian River County Board Of County Commissioners on February 19 ,
2002]
" D . Nonprofit Agency Responsibilities After Award of Funding
Indian River County provides funding to all nonprofit agencies on a reimbursement basis
only .
All reimbursable expenses must be documented by an invoice and/or a copy of the canceled
check . Any expense not documented properly to the satisfaction of the Office of Management &
Budget and/or the County Administrator may not be reimbursed .
If an agency repeatedly fails to provide adequate documentation , this may be reported to the
Board of Commissioners . In the event an agency provides inadequate documentation on a
consistent basis , funding may be discontinued immediately . Additionally , this may adversely
affect future funding requests .
Expenditures may only be reimbursed from the fiscal year for which funding was awarded . For
example , no expenditures prior to October 1St may be reimbursed with funds from the following
year . Additionally, if any funds are unexpended at the end of a fiscal year, these funds are not
carried over to the next year unless expressly authorized by the Board of Commissioners .
All requests for reimbursement at fiscal year end (September 30th) must be submitted on a timely
basis . Each year, the Office of Management & Budget will send a letter to all nonprofit agencies
advising of the deadline for reimbursement requests for the fiscal year. This deadline is typically early
to mid October, since the Finance Department does not process checks for the prior fiscal year
beyond that point .
Each reimbursement request must include a summary of expenses by type . These summaries
should be broken down into salaries , benefits , supplies , contractual services , etc . If Indian River
County is reimbursing an agency for only a portion of an expense (e .g . salary of an employee ) , then
the method for this portion should be disclosed on the summary. The Office of Management &
Budget has summary forms available .
Indian River County will not reimburse certain types of expenditures . These expenditure types are
listed below .
a . Travel expenses for travel outside the County including but not limited to ; mileage reimbursement ,
hotel rooms , meals , meal allowances , per Diem , and tolls . Mileage reimbursement for local travel
(within Indian River County) is allowable .
b . Sick or Vacation payments for employees . Since agencies may have various sick and vacation
pay policies , these must be provided from other sources .
c . Any expenses not associated with the provision of the program for which the County has awarded
funding .
d . Any expense not outlined in the agency's funding application .
The County reserves the right to decline reimbursement for any expense as deemed necessary. "
- 1 -
EXHIBIT C
STANDARD TERMS FOR GRANT CONTRACT
1 . Notices : Any notice , request, demand , consent, approval or other communication required or
permitted by this Contract shall be given or made in writing , by any of the following methods
:
facsimile transmission ; hand delivery to the other party; delivery by commercial overnight courier
service ; or mailed by registered or certified mail (postage prepaid ) , return receipt requested at the
addresses of the parties shown below:
County : Joyce Johnston-Carlson , Director
Indian River County Human Services
1840 25th Street
Vero Beach , Florida 32960-3365
Recipient : St . Peters Human Services , Inc.
4250 38th Avenue
Gifford , Florida 32967
Attention : Pastor Andrew Jefferson , Executive Director
2 . Venue : Choice of Law: The validity, interpretation , construction , and effect of this Contract shall
be in accordance with and governed by the laws of the State of Florida , only. The location for
settlement of any and all claims , controversies , or disputes , arising out of or relating to any part of
this Contract, or any breach hereof, as well as any litigation between the parties , shall be Indian
River County, Florida for claims brought in state court , and the Southern District of Florida for
those claims justifiable in federal court .
3 . Entirety of Agreement : This Contract incorporates and includes all prior and contemporaneous
negotiations , correspondence , conversations , agreements , and understandings applicable to the
matters contained herein and the parties agree that there are no commitments , agreements , or
understandings concerning the subject matter of this Contract that are not contained herein .
Accordingly, it is agreed that no deviation from the terms hereof shall be predicated upon any prior
representations or agreements , whether oral or written . It is further agreed that no modification ,
amendment or alteration in the terms and conditions contained herein shall be effective unless
contained in a written document signed by both parties .
4 . Severability : In the event any provision of this Contract is determined to be unenforceable or
invalid , such unenforceability or invalidity shall not affect the remaining provisions of this Contract,
and every other term and provision of this Contract shall be deemed valid and enforceable to the
extent permitted by law. To that extent , this Contract is deemed severable .
5 . Captions and Interpretations : Captions in this Contract are included for convenience only and are
not to be considered in any construction or interpretation of this Contract or any of its provisions .
Unless the context indicates otherwise , words importing the singular number include the plural
number, and vice versa . Words of any gender include the correlative words of the other genders ,
unless the sense indicates otherwise .
6 . Independent Contractor. The Recipient is and shall be an independent contractor for all purposes
under this Contract. The Recipient is not an agent or employee of the County, and any and all
persons engaged in any of the services or activities funded in whole or in part performed pursuant
to this Contract shall at all times and in all places be subject to the Recipient's sole direction
,
supervision , and control .
7 . Assignment , This Contract may not be assigned by the Recipient without the prior written consent
of the County.
— 1 —
may_ RE1JV-4UE SERV LL-: -
DjICT DIRECTOR
P BOX 2 : 08
J ? " TI , ON 45201
Eomaloyer Identification .Numoer :
Date : 3I - 14806 � �
0LN :
17052042275008
ST PETERS HUMAN SERVICES Contact Person :
INCORPORATED D . A . DONNING
C/ fl REV ANDREU JEFFERSON Contact Telephone Number :
4250 38TH AVE ' ( 513 ) 241 - 5199
• GiFFORD , FL 32967
Accounting Period Ending :
Auqus t 31
Fora 990 Required :
Yes
Addendum Applies :
Yes
mmmmk
Dear Applicant :
Based on information supplied , and assuminq your operations will be as
stated in your application for recognition of exemption , we have determined
you are exempt from federal income tax under section 501 ( a ) of the Internal
Revenue Code as an organization described in section 501 ( c ) ( 3 ) .
We have further determined that you are not a private foundation within
the meaninq of section 509 ( a ) of the Code , because you are an organization
described in sections 509 ( a ) ( 1 ) and 170 ( b ) ( 1 ) ( A ) ( ii ) .
Lf your sources of support , or your purposes , cnaractar , or method of
operation change , please Let us know so we can consider the effect of the
change an your exempt status and foundation status . Ia the case of an amend -
ment to your organizational document or bylaws , please send us. A. COPY of the
amended document or bylaws . Also , you should inform us of all changes in your
name or address .
As of January 1 , 1984 , you are Liable for taxes under the Federal
Insurance Contributions Act ( social security taxes ) on - remuneration of $ 100
or more you pay to eacri of your employees during a calendar year . You are
not liable for the tax imposed under the Federal Unemployment Tax Act ( FUTA ) .
Since you are not a private foundation , you are not subject to the excise
taxes under Chapter 42. of the Code . However , if you are involved in an excess
benefit transaction , that transaction might be subject to the excise taxes of
section 4918 . Additionally , you are not automatically exempt from other
federal excise taxes . If you have any questions about excise , employment , or
other federal taxes , please contact your key district office .
Grantors and contributors may rely an this determination unless the
Internal Revenue Service publishes notice to the contrary . However , if you
lose your section 509 ( a ) ( 1 ) status , a grantor or contributor may not rely
an this determination if he or she was in part responsible for , ar was aware
on the
of , the act or failure to act , or the substantial or material change•
foss of
part of the argani : ation that resulted in your such status , or che or
e
she acquired knowledge that the Internal Revenue Service had given no ticthat
Letter 947 ( DO / C3 )
• � ..
HUMAN HRVICE5
'ST PETERS
you would no longer be classified as a section 509 ( a ) ( 1 ) organisation .
Donors may deduct contributions to you as provided in section 170 of the _
Cade . Bequests , legacies , devises , transfers , or gifts to you or for your use
are deductible for federal estate and gift tax purposes if they meet the
applicable provisions of Code sections 2055 , 2106 , and 252"_' . I
r
Contributicn deauctions are allowable to donors only to the extent that F
their contributions are gifts , with no consideration received . Ticket pur -
chases and similar payments in conjunction with fundraisinq events may not i
necessarily qualify as deductible contributions , depending on the circum -
stances . See Revenue Ruling 67 - 246 , published in Cumulative Bulletin 1967 - 2 ,
an page 104 , which sets forth guidelines regarding the deductibility , as chari -
table contributions , of payments made by taxpayers for admission to or other
participation in fundraisinq activities for charity .
In the heading of this letter we have indicated whether you must file Fora
990 , Return of Organization Exespt From Income Tax . If Yes is indicated , you
A " required to file Farm 990 only if your gross receipts each year are
normally more than $25 , 000 . However , if you receive a Fora 990 package in the
mail , please file the return even if you do not exceed -the gross receipts test .
If you are not required to file , simply attach the label provided , check the
box in the heading to indicate that your annual gross receipts are normally
S25 , 000 or less , and sign the return .
If a return is required , it - must be filed by the 15th day of the fifth
month after the end of your annual accounting period . A penalty of $ 20 a day
is charged when a return is filed late , unless there is reasonable cause for
the delay . However , the maximum penalty charged cannot exceed s10 , 000 ar
5 percent of your gross receipts for the year , whichever is less . For
organizations with gross receipts exceeding $ 1 , 000 , 000 in any yraar , the penalty
is 5100 per day per return , unless there is reasonable cause fc. r the delay .
The maximum penalty for an organization with gross receipts exceeding
si , 000 , 000 shall not exceed 250 , 000 . This penalty may also be charged if a
• return is not complete , sa be sure your return is complete before you file it .
You are required to make your annual return available for public /
inspection for three years after the return is due . You are also required
to make available a copy of your exeeptien application , any supporting
documents , and this exemption letter . Failure to make these documents
available for public inspection may subject you to a penalty of - S20 per day
for each day there is a failure to COOP17 ( up to a maximum of s101000 in the
case of an annual return ) .
You are not required to file federal income tax returns unless you are
subject to the tax an unrelated business income under section 511 of the Cade .
If you are subject to this tax , you must file an income tax return on Fora
990 - T , Exempt Organization Business Income Tax Return . In this letter we are
not determininq wnether any of your present or proposed activities are unre-
lated trade or business as defined in section 513 of the Code .
Letter 947 ( 00 / CG )
S; PEicRS HUMAN SERVICES
You need an employer identification number even it you have no a % clCyees .
If an employer identificaticn number was not entered on your aopl. ication , a
number will be assigned to you and you will be advised of it - Please use that
number on all returns you file and in all correspondence with the Interval
Revenue Service -
This determination is based on evidence that your funds are dedicated
to the purposes listed in section 50L ( c ) ( 3 ) of the Code . To assure your
continued exemption , you should keep records to show that funds are expended
only for those purposes . If you distribute funds to other organizations , your
records should show whether they are exempt under section In cases
where the recipient organization is not exempt under section there
should be evidence that the funds will remain dedicated to the required
purposes and that they will be used for those purposes by the recipient .
If distributions are made to individuals , case histories regarding the
recipients should be kept showing names , addresses , purposes of awards , manner
of selection , relationship ( if any ) to members , officers , trusters or donors of
funds to you , so that any and all distributions made to individuals can be
substantiated upon request by the Internal Revenue Service . ( Revenue Ruling
SS - 304 , C - 300 1956 - 2 , page 306 . 3
If we have indicated in the heading of this letter that An addendum
applies , the enclosed addendum is an integral part of this letter .
Because this letter could help resolve any questions about your exempt
status and foundation status , you should keep ,it in your permanent records .
If you have any questions , please contact the person whose name and
telephone number are shown in the heading of this letter .
Sinczre' ly yours ,
� �
District Director
Enclosure s )
Addendum
Letter 947 ( DO / CG )
A �Q63.0 . CERTIFICATE OF LIABILITY INSURANCE GP ID > � OAE (M:AI7D/YV yI
0 10 / 10 / 03 1
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF I "JFORMATIO
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Hatcher Insurance , Inc . I HOLDER , THIS CERTIFICATE DOES NOT AMEND , EXTEND OR
P . Q . Son.. 540689 I ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
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Phone : 407 - 841 - 2606 Fax : 407 - 341 - 2695 INSURERS AFFORDING COVERAGE ' NAIC #
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4250 38th Avenue 1NSU.=_ R D•
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CERTIFICATE HOLDER CANCELLATION
SCHODIS SHOULD ANY OF THE ABOVE DESCRIOED POLICIES BE CANCELLED BE►ORC TME EXPIRATION
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1990 25th Street REPRESENTATYft: 5.
Vero Beach FL 32960 AUTHQRIZ5e1 LSGNTA
VAGORD
ACORD 25 ( 2001 /08 ) CORPORATION 1