HomeMy WebLinkAbout2004-229T 1
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Indian River County Grant Contract
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 Children ' s Home Society ( Recipient) , of:
Children ' s Home Society
415 Avenue A , Suite 10
Fort Pierce , Florida 34950
Independent Living Program
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 .
— 1 —
4 . Grant Funds and Payment The approved Grant for the Grant Period is Fifteen
Thousand dollars ($ 15 , 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 , 20041
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 :
2 —
( 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 .
3 —
IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date
first above written .
INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS
By : P'tt"(: ot JJLA,
Chairman : Arthur Neuber e
BCC Approved :
Attest: J . K. Barton , Clerk
diCJL�- 'rte
BY � M
Deputy Clptk - TN
w .
Approved :
Jose h A . B ird
County Administrator
t �
Ap s to form and legal sufficiency :
arian . Fell , Assi nt rney
RECIPIENT :
By :
Jhildren ' s Home Society
4 -
EXHIBIT A
[Copy of complete proposal/application ]
- 1 -
'CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
PROGRAM COVER PAGE
Organization Name CHILDREN' S 14(O1VI SOCIETV , .
Executive Director: John Bruhn E-mail : i ohn.bruhnPchsfl . org
Address : 415 Avenue A Telephone : (772)489-5601
Fort Pierce, Florida 34950 Fax (772) 489-0243
Program Director: Sandy Pietrewicz, Ph . D . E-mail : sandy.pietrewicz@chsfl . org
Address : 415 Avenue A Telephone : (772)489- 5601 ext 289
Fort Pierce, Florida 34950 Fax . (772) 489 - 0243
Program Tit ` vipn'"r
Priority Need Area Addressed: Mental Wellness Issues : Ages 1345 , Promoting life skills training,
emotional-social skills ; Ages 16- 18 , Promoting independent living skills
Brief Description of the Program : Taxonomy Statement: Emancipation Preparation Programs- PH
620 . 190 : Programs that offer training which focuses on the knowledge and skills an individual may
need to make a successful transition to independent living. In order to be eligible for Independent
Living Program services a child must be between the ages of 13 and 18 . Children 13 - 15 years of age
are provided pre-independent living services, such as life skills training , educational support,
employment training, counseling, relationship building, academic tutoring, and educational outings .
Intensive services are offered to children ages 15 % to 18 . These services include banking and
budgeting, obtaining employment, parenting, academic support, interview skills, counseling, and
relationship building_ At the age of 18 , the young adult may receive case management and other
assistance through Aftercare, Transitional Support, or Road to Independence Scholarship ,
SUMMARY REPORT — (Enter Information In The Black Cells Only)
Percent of Total Program Budget : 10 . 0 %
Current Program Funding ( 2003 / 04 ) : $ 209000
Dollar increase / ( decrease ) in request : $ -
Percent increase / ( decrease ) in request * * 0 . 0 %
Unduplicated Number of Children to be served Individually : 23
Unduplicated Number of Adults to be served Individually : 1
Unduplicated Number to be served via Group settings : -
Total Program Cost per Client : 8333 . 33
* * If request increased 5 % or more, briefly explain why:
If these funds are being used to match another source, name the source and the $ amount :
3
CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
The Organ ' io 's Board of Directors has approved this application on (date). 5/24/04
of �'.J V
Name ([TP ident/Chair of the Board SignaAure.
hn � , esu
Name of Executive Director/CEO Si ture
I
,
CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
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 %" 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 .
The mission of Children ' s Home Society is : Embracing Children , Inspiring Lives .
We envision Children ' s Home Society as a state and national leader in providing
responsive, relevant, high quality community-based solutions to meet the needs of
individuals, families , and communities .
2 . Provide a brief summary of your organization including areas of expertise,
accomplishments , and population served.
Children ' s Home Society has a long and rich legacy as Florida ' s oldest non-profit provider
of services to children and families. In 2002 , Children ' s . Home Society marked 100 years of
service. Established in 1902 as an orphanage, Children ' s Home Society has dramatically
expanded its mission as a statewide, multi-service agency. Today, Children ' s Home Society
provides Florida ' s families with a unique spectrum of social services responding to the
needs of various communities , including foster care , adoptions , child abuse prevention ,
emergency shelters , group homes , case management and treatment for developmentally
disabled children . The Treasure Coast Division was established in 1991 and currently
operates 11 programs for children and families , including Adoptions , Independent Living,
Targeted Case Management, Teen Life Choices , Children in Need of Services/ Families in
Need of Services (CINS/FINS), Wave CREST Shelter, Safe Place, Child Protection Team ,
Intensive Crisis Counseling (ICCP) , Protective Services , and the Residential Girls ' Group
Home.
Children ' s Home Society is one of the founding members of the Child Welfare League of
America and is accredited by the Council in Accreditation . In 2001 , Children ' s Home
Society was granted the first large privatization contract, for adoption services , from
District 15 of the Department of Children and Families .
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' CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
B . 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 .
Florida is experiencing a surge of teenagers and young adults . Between the years 2000 and
2015, the number of teens and young adults in Florida (ages 14 -24) will increase some 23 % .
Florida has never experienced this volume increase of teenagers , and our state ' s service
infrastructure- educational, health , social service, therapeutic, or youth justice systems- is
simply unprepared for this surge of young Floridians
(http : //www.floridakids . org/trends . htm) . The Independent Living Program is designed to
provide services to children in foster care and young adults formally in foster care who are
ages 13 to 23 . The largest group of children in foster care is between the ages of 12 and 18
(http : //www. chilescenter. org/index. htm) . The Independent Living Program provides the
skills necessary for these children without a loving family to grow into productive, self-
sufficient adults. At this time there are 140 children between the ages of 13 and 18 in foster
care in District 15. In addition, there are 19 young adults who are receiving transitional
support services . This program is currently serving 22 Indian River County youth and
young adults .
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.
This program is the only one of this nature serving the targeted population of youth and
young adults ages 13 -23 , in the foster care system .
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CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
C . PROGRAM DESCRIPTION (Entire Section C, 1 — 6, not to exceed two pages)
1 . List Priority Needs area addressed .
FOCUS AREA I : Mental Wellness Issues
GOAL : Improve the capacity of children in Indian River County to succeed to adulthood
in a safe, healthy, and productive manner.
2 . Briefly describe program activities including location of services .
The Independent Living Program provides foster teens and young adults with the skills
necessary to have a quality of life appropriate for their age and to assume personal
responsibility for becoming self-sufficient adults . The emphasis is on obtaining life skills
through education , skills training, and case management to obtain employment. ILP
assists young adults formerly in foster care to become productive members of their
community. Aftercare Services , Transitional Support Services , and Road to Independence
Scholarships are available to young adults who remain in school.
ILP staff complete an assessment of individual functioning, values , behavior, family
functioning, educational readiness and career readiness. Within 10 days of assessment,
A student profile is developed that identifies the specific skills the child already has, as well
as those skills needed to prepare for independence. These scores are measured and an
individual case plan is developed . ILP staff conduct monthly home visits with the youth to
assess progress and assist with any identified needs. Medical, dental, and support system
needs are identified and reviewed . In addition to case management, monthly training
programs are developed and presented to the youth . Topics for these workshops include
developing and strengthening social skills , and accessing community resources . A training
program is also offered to promote lifestyle choices and to provide an overview of the
emotional and physical aspects of parenting. A monthly newsletter is circulated to inform
youth , their families , and other interested parties of local, regional, and stewide events ,
upcoming training, and other relevant information . ILP hosts the Youth Advisory Board ,
comprised of teen boys and girls in foster care, as well as young adults formerly in foster
care. The Board meets monthly, discusses issues in care, and is effective in making
recommendations for changes in legislation .
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 .
By identifying and working with youth who are at risk early in their teenage years and
targeting their skill deficits , we can significantly reduce the barriers they face when
transitioning into adulthood . Our foster care system by its very nature encourages
dependency as opposed to independence. Because we know that more than 20 ,000
American foster youth turn 18 and step out into the world alone, most without resources , a
primary focus of ILP is to ensure self-sufficiency. We strive to teach foster care teenagers
the basic living skills necessary to lead prosperous , independent lives . ILP considers
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CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
completion of education , continued skills training, and development of the personal
support system as essential tools needed for self-sufficiency . Consistent skill training is
needed for preparation of the life experience. Teaching job skills , interviewing techniques ,
budgeting, apartment hunting, placing a value on self and personal safety in regard to
high-risk behavior, and monitoring youth in part time jobs are important tools to address
the barriers of unemployment, homelessness , and access to health care and self-sufficiency .
According to the Survey of Local Homeless Coalitions for 2001 -2003 (January, 2003 ,
Treasure Coast Services Council) , there were 1 ,405 homeless youth and children in the
Treasure Coast area during the reporting reporting period . This represents almost one
half of the homeless population in the area . Learning the skills necessary to gain
independence improves self- esteem . We know that positive self-image helps youth make
positive choices , accept personal responsibility, have a greater tolerance for others , and
hold greater concern for the needs of others .
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).
Program Director. minimum of Master' s degree in social work or related field with a
minimum of 5 years supervisory experience in social welfare or health care agency. 10 % (4
hours per week) of this position is dedicated to supervision , of the Independent Living
Program .
Independent Support Coordinator . minimum of Bachelor ' s degree in social, behavioral , or
health science with 2 years experience working with children . 100 % ( 40 hours per week)
of this position is dedicated to the Independent Living Program .
Life Skills Specialist : minimum of Bachelor ' s degree in social, behavioral, or health science
with a minimum of 1 year experience working with troubled children/youth . One full time
specialist (100 % , 40 hours per week) and 1 half-time specialist (100 % , 20 hours per week)
are dedicated to this program .
5 . How will the target population be made aware of the program .
The ILP staff work closely with the Department of Children and Families (DCF) and United
for Families (UFF) to identify youth eligible for services . Children in foster care are
referred by their legal case manager at their 13th birthday. ILP can now access a report
from DCF ' s client tracking computer database (HomeSafeNet) , which lists all children
eligible for ILP services . An ILP representative also attends monthly staff meetings with
DCF and UFF staff to educate them about the program and obtain referrals . In addition ,
ILP staff attend Guardian Ad Litem meetings , foster parent association meetings , and foster
parent training (MAPP) to provide information about the program . Newsletters and
brochures are sent out monthly to interested parties .
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CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
6 . How will the program be accessible to target population (i. e. , location , transportation ,
hours of operation) ?
The Independent Living Program ensures that the program is accessible to the target
population by providing services in the client' s home and by providing transportation to
activities and workshops as needed . Monthly case management visits occur in the client' s
home. Workshops are scheduled in the clients ' county of residence and transportation is
offered to ensure clients can attend. Visits and events are often scheduled in the evenings
and on weekends when the youth are not in school in order to make these services easily
accessible.
9
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CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
D. MEASURABLE OUTCOMES (Entire Section D not to exceed two pages)
OUTCOMES ACTIVITIES
Add all o the elements or the Measurable Outcomes Add the tasks to accomplish the Outcome(s)
1 . Develop and implement individual case
1 . To increase to 95 % the percentage of plans following assessment of current level of
program participants who successfully meet functioning ,
one or more of their educational, vocational, or 2 . Review individual case plans every 6
basic living objectives within 6 months of months .
enrollment in the program as measured by 3 . Provide educational workshops .
documentation in their case plan . Baseline : 4 . Provide case management services .
2002-2003 FY in Independent Living Program . 5 . Monitor school attendance and grades .
2 . To increase to 95 % the percentage of 1 . Monitor progress through attendance
program participants who are successfully reports, report cards , or other performance
enrolled in an appropriate educational or reports ,
vocational placement as measured by 2 . Maintain monthly face-to-face contact with
attendance reports , GPA, and performance school counselor or other appropriate
appraisals . Baseline : 2002 -2003 FY in personnel to coordinate services .
Independent Living Program . 3 . Maintain contact with school counselor or
other appropriate personnel to coordinate
services .
4 . Attend school conferences and/or staffings to
advocate for ILP participant.
3 . To maintain at 6 the number of
vocational/educational outings that program 1 . Plan/schedule monthly
participants are exposed to as measured by vocational/educational outings .
attendance at outings . Baseline : vocational/ 2 . Inform participants of upcoming outings
educational outings 2002 -2003 FY . through monthly newsletter, home visits , and
phone calls .
3 . Maintain attendance records at all outings .
4 . Maintain evaluation records of participation
at all outings .
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CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
E . COLLABORATION (Entire Section E not to exceed one page)
1 . List your program ' s collaborative partners and the resources thata 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
Agency for Workforce Development Provides vocational exploration for program
participants .
Works cooperatively with Children ' s Home Society to
Homeless Coalition for the Treasure prevent emancipated youth from becoming homeless .
Coast
Provides education on domestic violence and teen dating
Safes ace, Inc. violence
Provides instruction on health and nutrition.
Indian River County Health
Department
Collaborates with Homeless Coalition to address issues
Indian River County Sheriff' s of emancipated youth and homelessness .
Department
D .A.T.A. Works cooperatively with Children ' s Home Society to
deliver drug abuse assessments and treatment.
Accepts referrals for counseling and assessment services
Suncoast Mental Health Center, Inc.
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CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
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
All youth in foster care between the ages of 13 and 18 are eligible for Independent Living
Services , and are referred to the program by their legal case manager. Young adults
between the ages of 18 and 23 are eligible for Aftercare, Transitional Support Services ,
and/or Road to Independence Scholarships if they were in foster care at their 18th birthday.
Eligibility criteria are verified through DCF staff; however, the young adult can request
services independently.
Demographics , including age, gender, and ethnicity, are gathered on each client upon
admission to the Independent Living Program and entered into client records .
Each month , reports are generated with the active client caseload , listing each client' s
name and current age. We track the number of admissions to the program, the number of
discharges , and the number of youth receiving follow-up services such as Aftercare,
Transitional Support Services , and/or the Road to Independence Scholarships.
Sign-in sheets are used at each educational/vocational function so that participation in
monthly workshops and outings can be evaluated .
2 . MEASURES : What data elements will you need to collect to show that you have
achieved (or made progress toward) your Neasurable 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 are collected during quarterly chart reviews as part of our internal Quality Assurance
Program . During these reviews , the chart is assessed for timeliness of services as,well as
quality of service and achievement of treatment goals . Case plans are reviewed with the
youth every month for progress toward goals . Case plans are updated as per target date of
each objective.
School and/or vocational program attendance and progress are monitored through reports
cards , pay stubs , and contact with school personnel . Attendance at program
vocational/educational workshops is also monitored .
Satisfaction surveys are used to ascertain whether program participants feel that their
needs are being met or if other services would be more beneficial.
12
CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
The program is monitored by the Indian River County CSAC , the Department of Children
and Families , and United for Families to assess compliance with contracted and
legislatively mandated goals .
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 ?
Data are compiled into monthly reports for programmatic purposes , and each report is
reviewed by agency administration . These reports are also assessed by our regional
Quality Assurance team to identify areas for improvement within the program.
Quarterly and annual reports will be prepared and provided to all funding sources .
Information is shared with the Statewide Coordinator for Independent Living Programs .
Program staff attend statewide workshops and coordinators ' meetings to share information
and ideas with other agencies that provide Independent Living services .
13
CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
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
10/04 to 9/05 Monthly educational/vocational workshops wi ; ; be presented to
program participants .
Case management services will be provided to all program participants
Educational presentations regarding the Independent Living Program
will be presented to DCF, CHS , and community agencies .
Program staff will attend staffings at the DCF service center to identify
eligible youth for referral to Independent Living .
Program staff will attend quarterly statewide Independent Living
Coordinators meetings .
Within 30 days of
referral Program staff will complete an assessment and develop an individual
case plan for each program participant .
This program is staffed and fully operational at the present time ;
therefore, a start up timetable is not necessary .
14
CHILDREN ' S HOME SOCIETY INDEPENDENT LIVING PROGRAM
Indian River County Children ' s Services Advisory Committee
15
Number 1 Unduplicated 1 1 1
Current
F a, <;m.- �, + . s �i any r,&
Budget 2003/04
Ka
OEM.RIMMUMM
S . In(lian River County
Indian River Co. TotalI ■
/ 1
/ . . . �■ o ■tea
TotalPort Saint Lucie
St Lucie Co.
Other Locations
Number • d Clients by Age
Current Fiscal Year
W
4y iY+ ° rtR & iz T3 KJ$
-VIM
0 to 4 (Pre-school)
16vivulwimm •
to • /
169MIMUMS SIM 11
Total / •
/ + (Seniors)
Total
Edit this Header. Type the organization and program name and the funder for whom it is being completed . The page # is already set at
the bottom right
of every page.
I. BUDGET FORMS - To open the Budget Forms , please double-click on the icon below.
" Core Budget Forms "
17
The Children's Home Society of Florida/ Treasure Coast Division
Independent Living Program
UNIFhOeRM GR�A�IT Committee of
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 :
FUNDER :
I CAUTION : Do not enter any figures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should
j
:be used for calculations and to write information only.
I C
E t s r rcv?ua +ocY f� pu05@t ;`o "% gaw
IN
�r "� �rs�rotvoernE _
mat cuunoivsr , � , ° m` g k e
1 Children's Services Council-St Lucie = Mme;', 1401000.00
2 Children's Services Council-Martin x . 38,077,00
3 Advisory Committee-Indian River € 20,000.00 209000.00 209000.00
4 United Way-St Lucie County1 '1119,922.00
5 United Way-Martin County 91 _ 99,922,00
6 United Way-Indian River County 49MINIM 1138,684.0
7 Department of Children & Families
8 County Funds IN 49,440.00
9 Contributions-Cash 157,617.50
10 Program Fees „ - k 30,900.00
11 Fund Raising Events-Net � ;, . 99,775.50
12 Sales to Public • NetI INer
13 Membership Dues
14 Investment Income ..
15 Miscellaneous
11 ' N I
16 Legacies & Bequests
17 Funds from Other Sources 200,000. 00 4,724 ,912 . 82
18 Reserve Funds Used for Operating k " y „:"'_
19 In -Kind Donations (Not included in total) ' 111 MUNI ;" 50,807.84
20 TOTAL REVENUES E ”
(doesn't include line 19) , „ ` ` $220 ,000.00 $20,000. 00 $586199250.82
a ' � a.�: .
' ? .•€' Ay ,w'c" 3 '. � as e . xls : ` ` £�'x : a w '
PENDITURfoay ¢ken�o ' aposetlr d 0 Fu de 5pc � W prat
wkS h. ac . r t a t- AOEN�'P'�lt:p K-5 Fm w
i i I � tlge Butl of 6iitl of A r .
�� � .-. .,. .rte - ,m�.x.,.g
21 Salaries - (must complete chart on next page) 121 ,835. 00 1697.75. 00 3 , 348,435.00
�� f kF 3b a d %Aa C4 kid F: a atx � a f4YPWA 'T wi i
NOW
° xrr
n;nls 'd utwk $ ¢ v „x�
S _ s..F. . m , . "dal . �
22 FICA - Total salaries x 0. 0765NIA EER* ° 0 9,320. 38 11283 .29 256 , 155.28
Retirement - Annual pension for qualified Wi
23 staff . „88°% 4,727.20 650 .87 129 ,919.28
Life/Health - e Ica enta 0 -termIN
�
24 Disab . k_. RON 7,894 . 91 1 ,087 .02 216 ,978 .59
Workers Compensation - # employees x �
25 rate �r� % 3 ,655.05 503 .251 100,453.05
Florida unemployment - # pro)ec a r„ t2 ar
26 employees x $7, 000 x UCT-6 rate 5, 0.25'Io 304.59 41 . 94 81371 . 09
I IN
IN
S
"sIN IGfOSs Aifrillal a :xa�rrs � - Cyt , a SS na ` E!'
OSIS STING z a Tan ofs�la o"n a Pos
W
Sa ifl
o tion . e Total HrsMrlx , 4�3 fRg
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� k
n7obobgo �� a;*o,�� i _ ~ ;oa`t�:oo � w ... 4
5/25/2004 8-1
The Children's Home Society of Florida/ Treasure Coast Division
Independent Living Program
Director of Program Operations 1 FTE 6, 19i
0. 00%
Program Director 1 FTE 46 , 000.00 18 ,400 0.00°
Pro ram Supervisor 1FTE 30, 500. 00 30,50016 ,775 . 00 55.000
Life Skills Specialist 1FTE 25, 000. 00 25,000 0 .00%
Life Skills Specialist 1FTE 25 , 000 .00 25 ,000. 0 .000
Life Skills Specialist .5FTE 12, 500. 00 12,500.00 0.00%
Adminsitraive Secratry 1 FTE 23 , 000 . 00 2 , 300.00 0. 00%
Adminsitraive Secratry 1FTE 21 , 500 . 00 1 ,935.00 0.000
#DIV/01
Postions in Other Programs 3, 102 , 935.00 0.00 0.00°
#DIV/0 !
#DIV/0 !
#DIV/01
#DIV/0 !
#DIV/01
#DIV/01
#DIV/01
#DIV/O1
#DIV/o !
#DIV/01
Remaining positions throughout the agent
Tota/ Salaries 1 $3 , 348,435.00 $ 121 ,835.00 $ 16,775.00 0 .500
^ �
Director of Program Operations 1 FTE 0 .00 0.00 0.0
Program Director 1 FTE 0 .00 0.00 0.00 0.00 0. 00 0.00 0.0
Program Supervisor 1 FTE 16 , 775.00 1 , 283 . 29 650. 87 1 ,087.02 503.25 41 .94 3,566.3
Life Skills Specialist 1 FTE 0 . 00 0. 00 0. 0
Life Skills Specialist 1 FTE 0 . 00 0.00 0.0
Life Skills Specialist . 5FTE 0 .00 0 . 00 0.0
Adminsitraive Secratry 1FTE 0 . 00 000 0.0
Adminsitraive Secratry 1FTE 0 .00 0.00 0.0
0 0. 00 0. 00 0.0
Postions in Other Programs 0 . 00 0.00 0.0
0 0 .00 0.00 1 0.0
0 0 .00 0. 00 0.0
0 0 .00 0 . 00 0.0
0 0. 00 0.00 0. 0
0 0. 00 0. 00 0.0
0 0 . 00 0. 00 0.001
0 0.00 0 . 00 0. 0
0 0 .00 0. 00 0 .0
0 0. 00 0.00 0.0
0 0 .00 0 . 00 0. 0
Total Funder Request Fringe Benefits $ 16 ,775 . 00 $ 1 ,283 . 29 $650. 87 $ 1 ,087.02 $5036251 $41 . 94 $3 , 566. 37
Rmllm�nlmxa,
$ ' %:�;_ 9ft�Pro oY M� tbrs, YS.. „,�,� „ _mow„ .. .27 Travel-Daily � . .,_ CIA
R t 5 400 00 0.00 1300783 .22
# of Staff x average # of miles/wk x 50 wks x
$ = Estimated Daily TraveVMileage Reimb dntif s= $„4800 t „ „ ;<. ." u � r . ,.. .. . }
28 Travel/Conferencesrrraining �G"onfr$50pi 9,926. 00 0.00 21 ,933 . 85
AAA ° =
5/252004 B-1
The Children's Home Society of Florida/ Treasure Coast Division
Independent Living Program
• National Conference (cost per staff)
Other(Lodging
• Training/Seminar (cost per staff) ' ' F ? �
Meals, Airfare, �
Other Trainings (cost of travel, lodging , other a1 M � � x a ,� �ri��
registration , food) $1482x4—"$,7826 , �g �IerII
29 Office Supplies 1 , 200.00 0. 00 41 ,244.2
Office supplies (monthly average x 12 s t �s ask
$ 100 monthly k � �° tIr
> . s •Ip t s • ��
months = estimated cost of office supplies average � XXV,.IiI'A Z10�11 3A
based onhisto resent 8� � w • � ,, , r `� _�'
p history.
30 Telephone $1,06 x12`,Z� # 2 884 00 0.00 76j408.49
m._$� 2rgg
7 ,! � x
# Phone lines x average cost per month x
OCtg disthC �zi *� , s k wa A
$55x12 ,Rr I
12 months = local phone cost mtfls-$657 t � b
• Average long distance calls x 12 months Ce(ttIyr .II$80 x12 _ ; �� : s r ,• x
g ItltftS $966 ,az zX
= Estimated cost of Ion distance
11
31 Postage/Shipping
650.001 0.00 8,704.53
• Postage Special events Postage + rr
' r '- "
t$ Ir" r �& G
etc. shipping 55X
Bulk mailings - appealX 11
rr
s >' ' fit '
9 PP 12 ;mths ',� , . . . z 1-
32 Utilities _ <° 2 , 178 .00 0.00 369529.98
• Electricity ($ x 12 months)
• Water/Sewer ($ x 12 months) CltliGUes
• Garbage ($ x 12 months) 1=2mths8 , : . . Vie
33 Occupancy (Building & Grounds) �.
5,765 .00 0.00 183tl83,44
• Mortgage/Rent ($ x 12 months) �. .. VV
• Janitorial ($ x 12 months)
nd It $ �.
• Grounds Maint. ($ x 12 months)
It Real Estate Taxes ,
34 Printing & Publications 1 ,200.00 0.00 50,596.6
• Quarterly Newsletter ($ x 4) Allr t
• Letterheads, Envelopes, etc. ;
s k NnvW4 rV
• Fundraising materials• Other r �r � �� � ,�$ 200 a 5
.R ay °53 :
35 Subscription/Dues/Memberships 200 . 001 0.00 17,638.75
• Membership to National Organization xkIP
,
AIR H
• Dues
Ig �r £„3
� "p `"b5 , z�r � x s 3 say w
• Subscriptions to Newspapers/magazines , =` r Y , r #,;IQ=
P
etc. > { as s . .
��.
36 Insurance 2 , 847.00 0.00 24,331 .69
Directors/Officers Llab.
• Commercial/General InsurancePropoe
• Bond Ins. z x s � r�
047 �C1I0� 11Crty
at
• Auto Insurance 5 �ggyp
$ 1800 „
37 Equipment: Rental & Maintenance 31213 . 000. 00 301739.32
• Copier lease ($ x 12 months) �qutp Renta
• Meter lease ($ x 12 months)
$ (fi05, Edi '
• Copier Maintenance ($ x 12 months) la!n , {195 .:
• Computer Maintenance ( $ x 12 months) tt x
Is Other % t13, . .._N : .
38 Advertising �� 800 . 00 0 .00 12,752.43
tt
Itt IIt
W Y tl%fre 9 .S R MINIMUM
8 `,.
• Newspaper ads1 - a "
• Fundraising ads/promotionsRecrutfine�tW '
• Other (Vacancies) $,$�0 = » 4a _ _?�` ,�Z,.€x«E5�-•r"' S <x .. a ' .`;'� ^°c. 'fit€. ; ` .d-. ' ^ . : .,
'� .."�`S" gs+- r" 's`r" .eEr �. . e
39 Equipment Purchases : Capital Expense 0 . 00 0. 00 0. 00
• Computer/monitor (# x $) f `a
zIV' le
• Laser Printer ���
.. ., , ? . , . . I '. -^ R , wy, .. $e ..aa T... ate . " , .r15`� ..
40 Professional Fees ( Legal, Consulting ) 0 . 00 0.00 33,261 .79
Legal advice ( estimated #hrs x $) M z s=� d
Consultant fees �Other
41 Books/Educational Materials 0001 0.00 1 ,447. 15
&2&2W4 B-1
The Children's Home Society of Florida/ Treasure Coast Division
Independent Living Program
Books/videos s
Materials ($ x staff)
• ;' ?;` E .�k�Y: m w :M1°. 5. .. Yom. _ } Y �rC. ,r� A.� f , v. - „ P . N w
a0..3' „
42 Food & Nutrition 0. 00 0.00 30,601 .30
• Meals ( # meals x clients x 5days x 50 wks) � .. ;
• SnacksNt , z 2 .
..`T.: r
43 Administrative Costs 279869. 16 0.00 687t352 .9
• Admin. Cost (% of total budget) IndlreGf
:rci.2�skr,",
44 Audit Expense ' , 472 .00 0.00 91461 .58
• Independent Audit Review ProgratrrShae . � ? W �. . , .. 1 . ., . .
� .
45 Specific Assistance to Individuals 4 , 884.00 91 ,217.8i
t'•s
• Medical assistance < �
• Meals/Foods ,
Y.M�G {iQ � �•• b4 � � .
3
• Rent Assistance ax
S5t3;0, x ,�
• Other $ 5,84, '
46 Other/Miscellaneousgro 29845. 00 µ 50.00 64 587. 18
• Background check/drug test 6 mnw �
• Other
47 Other/Contract ENRON= 0.00 0.00 0.00
• Sub-contract for program services '
48 TOTAL EXPENSES $220 ,070.28 $20, 391 . 37 $5,613 ,088.78
i
5/25/ZM B-1
TM CM&wi s Hb Sa ey of Fhidd Tnsan Coal Dwsbn
wepwoe L"V Ao7s'n
LwIF0 �V AR rAW01 ICAf10N
TOTAL AGENCY BUDGET
AGENCY/PROGRAM NAME :
FY 02/01 FY 01/04 FY 04105 % INCREASE
FYE FYE FYE CURRENTVS.
NEXT FY BUDGET
A B C D
ACTUAL TOTAL PROPOSED (col. Caol. BycoL B
REVENUES BUDGETED BUDGETED
1 Children's Services Council-St Lucie 104t658.00 140t000,00 140 000.00 0.00%
2 Children's Services Council-Martin 38 077.00 #DIV/01
3 Advisory Committee-Indian River 20 000.00 20 000.00 0.00%
4 United Way-St. Lucie County 40 000.00 4000,00 119t922.00 199.81 °/1,
5 United Way-Martin County 30 000.00 30 000.00 99 922.00 233.07eA
6 United Way-Indian River County 73 000.00 73 000.00 138t684.00 89.98%
7 Department of Children & Families 21384, 269.00 237782200 0.00 -100.00%
a County Funds 47 444.00 48 000.00 49 440.00 3.00%
9 Contributions-Cash 909t113.00 262 250.00 157 617.50 -39.90%
10 Program Fees 27t283.00 30 000.00 30 900.00 3.00%
11 Fund Raising Events-Net 91j682.00 130 850.00 99 775.50 -23.75%
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 25 188.00 0.00 #DIV/01
16 Legacies & Bequests 0.00 #DIV/01
17 Funds from Other Sources 197859985.00 2 209 472.00 4 724 912.82 113.85%
to Reserve Funds Used for Operating 0.00 #DIV/01
19 In-Kind Donations (Not included Intotel) 21 ,220,00 49 328.00 50 807.84 3.00%
2oTOTAL 5518622,00 536139400 5 619 250.82 4.81 %
EXPENDITURES
21 Salaries 2p552,097.00 3 100 015.00 31348,435,00 8.01 %
22 FICA 189 492.00 237151 .00 256155.28 8.01 %
23 Retirement 90 633.00 123 280.00 129 919.28 5.39%
24 Life/Health 145 568.00 200 881 .00 216t978.59 8.01 %
25 Workers Compensation 48J94,00 93 000.00 100 453.05 8.01 %
26 Florida Unemployment 51901 .00 79750.00 8f371 .09 8.01 %
27 Travel-Daily 109 434.00 126 974.00 130 783.22 3.00%
28 Travel/Conferences/Training 24 272.00 21 295.00 21 933. 85 3.00%
29 Office Supplies 47 994.00 40 043.00 41t244. 29 3.00%
30 Telephone 88 845.00 74 183.00 76,408.49 3.00%
31 Postage/Shipping 71353.00 8451 ,00 8704.53 3.00%
32 Utilities 37 831 . 00 35 466.00 36 529.98 3.00%
33 Occupancy (Building & Grounds 167 261 .00 177 848.00 183 183.44 3.00%
34 Printing & Publications 24 777.00 49 123.00 5059669 3.00%
35 Subscription/Dues/Memberships 81127.00 17 125.00 17t638.75 3.00%
36 Insurance 26 468 .00 23 623.00 24331 69 3.00%
37 Equipment: Rental & Maintenance 32 077.00 29t844.00 30 739.32 3.00%
38 Advertisinq 28 003.00 12 381 .00 12 752.43 3.00%
39 Equipment Purchases : Ca ital Expense 0.00 0.00 0. 00 #DIV/01
40 Professional Fees (Legal, Consulting) 22t455.00 32 293.00 33 261 .79 3.00%
41 Books/Educational Materials 37 064.00 1A05,00 11447, 15 3.00%
42 Food & Nutrition 26 431 .00 29 710.00 30P601 .30 3.00%
43 Administrative Costs 563t010.00 667 333.00 687 352.99 3.00%
44 Audit Expense 7, 564.00 91186.00 9t461 .58 3.00%
45 Specific Assistance to Individuals 133 938 .00 88 561 .00 91 217.83 3.00%
46 Other/Miscellaneous 21 117.00 62P706.00 64 587. 18 3.00%
47 Other/Contract 0.00 0.00 #DIV/01
48 TOTAL4 445 906. 00 5269627,00 5,613 088.78 6.52%
t?• �.. w r-.x . .q:ax $._ x. . . ..;. . � . . . < .rs.. k 'a�. . , d= _ _ aa.@�? 3` g. _ . _ �' ' " . Y 3m`�-. �.
. . .. 5 &' . _ . . „. . „ . �' �: t � .. ...-$*:_p�' . s �' .: - W
491REVENUES OVER/ UNDER EXPENDITURES 1 072 716.00 91 767.00 61162.04 -93 .29%
E
WS200/
n. Cw *@ � xwryaF�rTr...,r. Co C�
Mm."« wny mm"
Tti Clie.rl S« A° " Ca+nr°r of w Mvw Courcy
UNIFORM GRANT APPLICATION
TOTAL PROGRAM BUDGET
AGENCY/PROGRAM NAME:
FY 02103 FY 03/04 FY 04/05 % INCREASE
FYE FYE FYE CURRENT VS.
NEXT FY BUDGET
A B C D
ACTUAL TOTAL PROPOSED Icol. C-col. B)led. B
REVENUES BUDGETED BUDGETED
1 Children's Services CouncilSt, Lucie 0. 00 #DIV/01
2 Children's Services Council-Martin 0. 00 #DIV/01
3 Advisory Committee-Indlan River 20 000. 00 20, 000. 00 0.00%
4 United Way-St Lucie County 0. 00 #DIV/01
5 United Way-Martin County 0.00 #DIV/01
6 United Wa 4ndlan River County 0.00 #DIV/01
7 Department of Children & Families 221 031 .00 0. 00 #DIV/01
8 CountyFunds 0. 00 #DIV/01
9 Contributions-Cash 180.00 0. 00 #DIV/01
to 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 26.00 0.00 #DIV/01
16 Legacies & Bequests 0.00 #DIV/01
17 Funds from Other Sources 219 998.00 200,000. 00 -9.09%
1a Reserve Funds Used for Operating 0.00 #DIV/01
19 In-Kind Donations (Not Included In total) 0.00 #DIV/01
20 TOTAL 221 237.00 239 998.00 220 000.00 -8.33%
EXPENDITURES
21 Salaries 87j532.00 97t446,00 121 835.00 25.03%
22 FICA 62511 ,00 7115. 00 91320.38 31 .00%
23 Retirement 1 533.00 11620,00 472720 191 .80%
24 Life/Health 49286,00 3109.00 71894.91 153.94%
25 Workers Compensation 21254, 00 21962.00 3$ 655. 05 23.40%
26 Florida Unemployment 103.00 136.00 304. 59 123.96%
27 Travel-Daily 81334. 00 91127,00 5,400.00 -40.83%
28 Travel/Conferencesrrrainin 2,229.00 41736. 00 9t926. 00 109. 59%
29 Office Supplies 21349.00 11948,00 19200. 00 -38.40%
30 Telephone 5 660. 00 21990.00 2P884. 00 -3. 55%
31 Postage/Shipping 479. 00 644. 00 650. 00 0.93%
32 Utilities 1 110.00 19245.00 2, 178 . 00 74.94%
33 Occupancy (Building & Grounds 5j138.00 59338.00 57650mmmwwmww� 0 8.00%
34 Printing & Publications 256. 00 293.00 M 1t200. 001 309.56%
35 Subscription/Dues/Memberships 60. 00 242.00 200. 00 -17.36%
36 Insurance 564.00 607.00 21847. 00 369.03%
37 Equipment: Rental & Maintenance 21496. 00 31848,00 3,213. 00 -16.50%
38 Advertising 19366.00 868. 00 800.00 -7.83%
39 Equipment Purchases: Capital Expense 0. 00 #DI,V/01
40 Professional Fees (Legal, Consulting) 333. 00 513.00 0. 00 -100. 00%
41 Books/Educational Materials 0. 00 #DIV/01
42 Food & Nutrition 0. 00 #DIV/01
43 Administrative Costs 26 079. 00 26 772.00 27 869. 16 4. 10%
44 Audit Expense 255.00 414.00 472. 00 14.01 %
45 Specific Assistance to Individuals 45 765.00 71087.00 4,884. 00 -31 . 09%
46 Other/Miscellaneous 11524, 00 2,644.00 21845. 00 7. 60%
47 Other/Contract 0. 00 0. 00 0. 00 #DIV/01
48 TOTAL 206216.00 181 704. 00 220, 070. 28 21 . 11 %
49 REVENUES OVER/ UNDER EXPENDITURES 15 021 .00 589294, 00i -70. 28 -100. 12%
6QYlf101 N
The Children's Home Society of Florida/ Treasure Coast Division
Independent Living Program
The Children's Services Advisory Committee of Indian River County
UNIFORM GRANT APPLICATION
FUNDER SPECIFIC BUDGET
PROGRAM EXPENSES
AGENCY/PROGRAM NAME :
FUNDER : 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 121 , 835 . 00 169775.00 13 .77%
22 FICA 91320 . 38 1 , 283. 29 13 . 77%
23 Retirement 4, 727. 20 650.87 13.77%
24 Life/Health 79894.91 11087. 02 13 .77%
25 Workers Compensation 31655. 05 503. 25 13 .77%
26 Florida Unemployment 304.59 41 .94 13 .77%
27 TravelwDaily 59400.00 0.00 0000%
28 Travel/Conferences/Training 91926 .00 0.00 0.00%
29 Office Supplies 1 , 200 .00 0200 0 .00%
3o Telephone 21884. 00 0. 00 0 .00%
31 Posta a/Shi in 650 . 00 0.00 0 . 00%
32 Utilities 25178 . 00 0 . 00 0 .00%
33 Occupancy Building & Grounds 59765 . 00 0 . 00 0 . 00 %
34 Printing & Publications 19200 . 00 0 . 00 0 . 00%
35 Subscription/Dues/Memberships 200 . 00 0 . 00 0 .00%
36 Insurance 21847 . 00 0 . 00 0 . 00%
37 Equipment: Rental & Maintenance 39213 . 00 0 .00 0 .00 %
38 Advertising 800 . 00 0 .00 0 . 00%
39 Equipment Purchases : Ca ital Expense 0 . 00 0 . 00 #DIV/01
40 Professional Fees (Legal , Consulting ) 0 . 00 0 . 00 #DIV/01
41 Books/Educational Materials 0 . 00 0 . 00 #DIV/01
42 Food & Nutrition 0 . 00 0 . 00 #DIV/01
43 Administrative Costs 27 , 869 . 16 0 .00 0 . 00%
44 Audit Expense 472 . 00 0 .00 0 . 00%
45 Specific Assistance to Individuals 41884 . 00 0 .00 0 . 00%
46 Other/Miscellaneous 2 , 845 . 00 50 . 00 1 . 76%
47 Other/Contract 0 . 00 0 . 00 #DIV/01
48 TOTAL $ 220 , 070 . 28 1 $ 20 , 391 . 37 9 . 27%
512erz004 B-4
UNIFORM •
EXPLANATION • • VARIANCES OF OR MORE
FUNDER SPECIFIC BUDGET
AGENCYIPROGRAM
FUNDER:
.TSi __i,v•^µit•'R`I.-'(['^�S�: x-t /, ��.r. _;4•�'fY:Km�iw
� g/l• � � _ _ •
merit salary Y / Increased staff
Merit salary increases and increased staff
Increased staff • benefitcost
ge�afthlnsuran • ' Increases
nsation Increased costs toemployer
Increased FfCA
etirement
atio
Unemolovment
costs to employer
Attendance • nationalY /Ni
nference for 2 staff
Utilities
Projectedrate increases
IncreasedPrIntina and Publications trainingrnaterialsprintedand professional style newsletter
SEP-23 - 2003 10 : 10 CHS REGION THREE P . 02 /02
Internal Revenue Service Department of the Treasury
District Delaware -Maryland District 31 Hopkins Plaza , Baltimore , MD 21201
Director
Date : August 26 , 1997 P • O • Box 13163
C> Baltimore , MD 21203
Employer Identification Number :
59-0192430
CHILDREN ' S HOME SOCIETY OF FLORIDA Person
EP / EOLTaxoExaminer
P . O . BOX 10097
JACKSONVILLE , FL 32247 -0097 Telephone Number :
( 410 ) 962 - 6058
I,
Dear Sir /Madam :
This is in response to your inquiry requesting a copy of the letter which
granted tax exempt status to the above named organization .
Our records show that the organization was granted exemption from Federal income
tax under section 501 ( a ) of the Internal Revenue Code as an organizatior
described in section 501 ( c ) ( 3 ) effective NOVEMER , 1941 . We have also
determined that the organization is not a private foundation because it is
described in sections 509 ( a ) ( 1 ) and 170 ( b ) ( 1 ) ( A ) ( vi ) .
Donors may deduct contributions to you under section 170 of the Code . '
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 each of your employees during a calendar year . You are not liable for
the tax imposed under the Federal Unemployment Tax Act ( FUTA ) .
You are required to file Form 990 , Return of Organization Exempt From Income
Tax , only if your gross receipts each year are normally more than $ 25 , 000 .
However , if you receive a Form 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 $ 25 , 000 or less , and
sign the return .
A copy of our letter certifying the status of the organization is not
available , however , this letter may be used to verify your tax—exempt status .
Because this letter could help resolve any questions about your exempt status ,
it should be kept in your permanent records .
Sincerely yours ,
Paul M . Harring on
District Director
TOTAL P . 02
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
184025 th Street
Vero Beach , Florida 32960-3365
Recipient: Children ' s Home Society
415 Avenue A , Suite 10
Fort Pierce , Florida 34950
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 —
c iienro: urol vrlsoCT
A " ORD-w CERTIFICATE OF LIABILITY INSURANCE DATE
(M 40
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
BROWN & BROWN OF LV, INC . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P O BOX 25001 HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Lehigh Valley , PA 18002-5001
800 634=8237 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A. NONPROFITS ' INSURANCE COMPANY 36684
CHILDREN ' S HOME SOCIETY OF FLORIDA
INSURER B :
OF FLORIDA
INSURER C:
Jacksonville, FL 32247
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR
MAY PERTAIN , THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
DATE MM/DD DATE MMIOD/YY
A GENERAL LIABILITY NIAIS10389 01 /01 /04 01 /01 /05 EACH OCCURRENCE 3110009000
X COMMERCIAL GEN�RAL LIABILITY DAMAGE TO RENTED
R MI as e e x100 low00
CLAIMS MADE 51OCCUR MED EXP (Any one person) $59000
PERSONAL & ADV INJURY $190009000
GENERAL AGGREGATE 010001000
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $1 ,000 , 000
POLICYF�j PROJECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Peraccident) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTOOTHER THAN EA ACC $
AUTO ONLY: AGG $
A EXCESS/UMBRELLALIABILITY NEL1803569 01 /01 /04 01 /01 /05 EACH OCCURRENCE $520009000
X OCCUR O CLAIMS MADE AGGREGATE $S 000 000
$
DEDUCTIBLE $
RETENTION S $
jIhWORKERS COMPENSATION AND TWO
STATU- OTHFR-
EMPLOYERS' LIABILITY E.L. EACH ACCIDENT S
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED? E.L DISEASE - EA EMPLOYEE $
Udescribetnder
SIAL PROVISIONS below E.L DISEASE - POLICY LIMIT $
A mHER PROFESSIONAL NIAIB10389 01 /01 /04 01 /01105 1 ,000,000 OCCURRENCE
LIABILITY 3,000,000 AGGREGATE
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Certificate holder is additional insured as respects general liability in
regards operations of named insured as respects landord.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Indian River County DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1n DAYS WRITTEN
1840 25th Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Vero Beach , FL 32960 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
19.016.E cr y°-
ACORD 25 ( 2001 /08) 1 of 2 #S146150/ M145998 MOC o ACORD CORPORATION 1988
STATE FL INSURANCE IDENTIFICATION CARD OP ID TL
COMPANY NUMBER COMPANY
40231THIS CARD MUST BE KEPT IN THE INSURED
Old Dominion Insurance VEHICLE AND PRESENTED UPON DEMAND
POLICY NUMBER EFFECTIVE DATE
EXPIRATION DATE
B1G10866
# 1 10 / 15 / 04 10 / 15 / 05
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER
2000 Ford RLT Van 1FBSS31L8YHB71884
IN CASE -0F ACCIDENT ; Report all accidents
AGENCY/COM@ANY ISSUING CARD to your Agent/Company as soon as
possible .
Greene - Hazel & Associates , Inc , Obtain the following information :
R . Hardaker - - - -
904 - 398 - 1234 1 . Name and address of each driver ,
•
INSURED passenger and witness ..
2 . Name of Insurance Company and policy
Children ' s HOm@ Society of FL
number for each vehicle involved .
1485 South Semoran Blvd # 1448
Winter Park FL 32792
COVERAGE MEETS MINIMUM LIABILITY INSURANCE PRESCRIBED BY LAW
ACORD 50 idi ( 2 / 95 )
w
This certificate is executed by Liberty Mutual Insurance Group as respects such insurance as is afforded by thou companies.
BMnt0
Certificate of Insurance
This certificate is issued as a matter of information only and confers no rights upon you the certificate holder. This certificate is not an insurance
policy and d(ws nix amend. extend, or alter the coverage
Fafforded by the policies listed below.
This is to certify that (Name and address of Insured )
CHILDREN'S HOME SOCIETY OF FLORIDA
1485 S . SEMORAN BLVD. wbEarty
SUITE 1448
WINTER PARK, FL 32792 ' . .
is, at the issue date of this certificate. insured by the Company under the policy( ics ) listed below . The insurance afforded by the listed policytits
t is subJect to all their terms . exclusions and conditions and
is no: altered by anv requirement, term or condition of anv contras or other document with respect to which this certificate may be issued.
Expiration T Ex iration Date(s ) Policy Number(s)' Limits of Liability
Continuous * 07/01 /2005 WA6- 15D-280851 -014 Coverage afforded under WC law of Employers Liability
Extended the following states: Bodily Injury By Accident
X Policy Term FL $500.000 Each Accident
Bodily Injury By Disease
5500.000 Policy Limit
Workers Compensation Bodily Injury By Disease
$500.000 Each Person
General Liability General Aggregate-Other than Prod/ICompleted Operations
Products/Completed Operations Aggregate
Claims Made
Occurrence Bodily Injury and Property Damage Liability Per
Occurrence
Retro Date� Personal and 4dNertising Injur} Per Person /
l
Organization
Other Liability Other Liability .
Each Accident - Single Limit - B. 1 . and P. D . Combined
Automobile Liability
Each Person
Owned
Non-0wnedEach Accident or Occurrence
Hired
00� Each Accident or Occurrence
. . . . .
C
O _
M
M
E
N
T
S
*If the oettificate expiration date is continuous or extended term, you will be notified if coverage is terminated or reduced before the certificate
expiration date. However, you will not be notified annually of
the continuation of coverage .
Special Notice - Ohio: Any person who, with intent to defraud or knowing that he / she is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or
deceptive statement is guilty of insurance fraud.
Important information to Florida policyholders and certificate holders: in the event you have any questions or need information about this certificate for
any reason. please contact your local sales producer,
whose name and telephone number appears in the lower left corner of this certificate. The appropriate local sales office mailing address may also be
obtained by calling this number.
Notice of cancellation: (not applicable unless a number of days is entered below ) . Before the stated expiration date the company will not canal
or reduce the insurance afforded under the above
policies until at least 30 days notice of such cancellation has been mailed to:
Office : Orlando. FL Phone: 407-829-7951
Certificate Holder, Tereasa Myers
DAN HOOD Authorized Representative
CHILDREN ' S HOME SOCIETY
TREASURE COAST DIVISION
415 AVENUE A
SUITE 101
FT . PIERCE , FL 34950 Date Issued: 07/06/2004 Prepared By : TH