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Home My WebLink About2006-331Q. ods -33 l INDIAN RIVER COUNTY GRANT CONTRACT This Grant Contract ("Contract") entered into effective this y)jjD day of October 2006 , by and between Indian River County, a political subdivision of the State of Florida ; 1840 25" Street, Vero Beach, Florida , 32960-3365 ; and Exchange Club Castle ( Recipient), of: Exchange Club Castle P. O. Box 12908 Fort Pierce, Florida 34979 Valued Visits Program Background Recitals A. The County has determined that 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 proposal 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 (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 . Puroose of the 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 2006/2007 ("Grant Period" ) . The Grant Period commences on October 1 , 2006 and ends on September 30, 2007. - 1 - 4 . Grant Funds and Payment. The approved Grant for the Grant Period is: THIRTEEN THOUSAND , FIVE HUNDRED DOLLARS ($13,500 .). The County agrees to reimburse the Recipient from such Grant funds for actual documented costs incurred for the 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 Obligation 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 to written notice . 5 . 2 . Compliance with Laws . The Recipient shall comply at all times with all applicable federal , state , and local laws and regulations . 5 . 3 . Quarterly Performance Reports . The Recipient shall submit quarterly, cumulative, 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 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 the 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 its 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 the 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 October 21 2006 provide to 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 : (i) Commercial General Liability Insurance in an amount not less than $1 ,000,000 combined single limit for bodily injury and property - 2 - damage, including coverage for premises/operations, product/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) Worker's 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 the County. In addition , the County may request such other proofs and assurances as it may reasonable 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 Worker's 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 . IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date first above written . - 3 - INDIAN RIVER COUNTY BOARD OF COMMISSIONERS By ta , 3rye er- , Chairman BCC Approved: Attest: J . K. Bartbn; Clerk By: F'y a Deputy Clerk Approved : Jose h A. Baird County Administrator Appro ed as to form and legal sufficiency: Z� avian E. Fell , Assistant oun Att ey R CIPIENT : f Exchange Club Castle - 4 - EXHIBIT A (Copy of complete Request for Proposal) EXHIBIT - A - Qrganization: Exchange Club CASTLE Program: Valued Visits Funder: Children's Services Advisory Comm ttee RFP# 2006061 PROGRAM COVER PAGE Organization Name : Exchange Club CASTLE Executive Director: Theresa Garbarino-May Email : tgarbarino-mayaexchangecastle. org Address : P. O . Box 12908 Telephone : 772-465-6011 Fort Pierce, FL 34979 Fax : 772-465 -6013 Program Director: Jenene McFadden Email : imcfaddenaexchangecastle.org Address: _1275 Old Dixie Highway Telephone: 772-567-5700 Vero Beach, FL 32960 Fax : 772-567-7133 Program Title: Valued Visits Priority Need Area Addressed: Focus Area II : Parental Support and Education Brief Description of the Program : Taxonomy# PH-600 . 650 — Parental Visitation Monitoring. Valued Visits is a supervised visitation center that provides a safe and nurturing place for children to visit a parent who has hurt them when these visits are court ordered Court ordered supervision occurs when there is an ongoing risk of harm due to child abuse and/or domestic violence. Amount Requested from Funder for 2006/07 : $ 15 , 196 Total Proposed Program Budget for 2006/07 : $ 1759680 Percent of Total Program Budget : 8 . 6 % Current Funding (2005 /06 ) : $ 13 , 540 Dollar increase/(decrease) in request : $ 1 , 656 Percent increase /(decrease) in request : 12 . 2 % Unduplicated Number of Children to be served Individually : 95 Unduplicated Number of Adults to be served Individually : 131 Unduplicated Number to be served via Group settings : Total Program Cost per Client : 777 . 35 If request increased 5% or more, briefly explain why: 2006-2007 budget request is only 1 .3 % hider than last vear (prior to the 10% across the board cut from the county.) If these funds are being used to match another source, name the source and S amount: Junior League of Indian River County: $25 ,000; United Way of Indian River County: $23 ,315United for Families $7,649. The Organization' s Board of Directors has approved this application on 1/24/06 Michael Dillman Name of President/Chair of the Board5ig ature Theresa-Garbarino-May Q. Name of Executive Director/CEO Sig tune 3 Qrganization: Exchange Club CASTLE Program: Valued Visits Funder: Children's Services Advisory Committee RFP# 2006061 ORGANIZATION : Exchange Club CASTLE PROGRAM: Valued Visits TABLE OF CONTENTS Please X" the parts of the grant application to indicate they are included. Also, please put the page number where the information can be located. X I Section of the Proposal Page 4 X TABLE OF CONTENTS (Check list) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 X COVER PAGE (with signatures). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 A. ORGANIZATION CAPABILITY (one page maximum) X 1 . Mission and Vision of organization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 . . . . . . 4 X 2. Summary of expertise, accomplishments, and population served . . . . . . . . . . . 4 B, PROGRAM NEED STATEMENT (one page maximum) X 1 . Program Need Statement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 X 2. Programs that address need and gaps in service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 C. PROGRAM DESCRIPTION (two pages maximum) X1 . Funding priority. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . . . . . . . . . . . . . . 6 X 2. Description of program activities . . . . . . . . . . . . . . . . . . . . . . . 0 . . . . . . . . . . . . . . . . . . . . . . . . 6 X 3 . Evidence that program strategy will work . . . . . . . . . . 4 . . . . . . . . . . . . 0 . . . . . . . . . . 4 . . . . 6 X4. Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 . . . . . . . . . . . . . . . 7 X 5 . Awareness of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . . . . . . . . . . q . . . . . 0 . . . . . . . . . . . . . . . . 7 X 6 . Accessibility of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 . . . . . . . . . . . . . . . . . . . . 7 X D. MEASURABLE OUTCOMES (two pages maximum) . . . . . . 0 . . . d . . . . . . . . . . 8 X E. COLLABORATION (one page maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 F. PROGRAM EVALUATION (two pages maximum) X1 . Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 . . . . . . . . . . . . . . . . . . . . . 11 X2. Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 X3 . Reporting . . . . . . . 4 . . . . . . . . . . . . . . 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 . . . . . 0 . . . . . . . . . . . . . . . . 12 G. TIMETABLE. . . . . . . . 11 . 11 , 110 . . . . . . . go , * & * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 . . .. 13 H. UNDUPLICATED CLIENT COUNT X 1 . Projections by Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 . . . . . . . . . 14 X 2 . Projections by Age Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . . . . . 14 1 Organization: Exchanee Club CASTLE Program: Valued Visits Funder: Children's Services Advisory Committee RFP# 2006061 BUDGET1. FORMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 J. APPENDIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 24 2 Qrganization: Exchange Club CASTLE Program: Valued Visits Funder: Children's Services Advisory Committee - RFP42006061 PROPOSAL NARRATIVE A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page) 1 . Provide the mission statement and vision of your organization. The mission of the Exchange Club CASTLE is to improve the quality of family life while preventing child abuse and neglect, by providing community education, support and resources for families in need of assistance . The CASTLE envisions a community where each child is allowed to grow to his or her full potential, free from abuse and neglect, and families have access to the supports they need to create healthy living and learning environments for children. 2. Provide a brief summary of your organization including areas of expertise, accomplishments and population served. This year, the CASTLE is celebrating its 25th year of providing child abuse prevention services to families on the Treasure Coast, and Okeechobee. Starting in 1981 with one program and a staff of three, the CASTLE has grown, and now offers an array of prevention services which have been added as the needs of the community change and develop. The CASTLE ' s core program, Safe Families, remains an industry leader, and has set the benchmark for quality in-home services that produce results and keeps families together. More than 100 child abuse centers in 27 states utilize the Safe Families model that was implemented in Fort Pierce in 1981 , by those three CASTLE employees . CASTLE services are accredited by the national Council on Accreditation, and this year, the CASTLE will also be seeking accreditation from the National Exchange Club Foundation. All CASTLE services utilize a continuous quality improvement (CQI) model to monitor and improve the delivery of services . This model includes peer reviews, client satisfaction surveys, measurements of program effectiveness, and the use of this information to make improvements . CASTLE services are designed to prevent child abuse and build the capacity of families, through parenting education and family skills building. Our core program Safe Families, offers long term, home based, parenting education. Other programs offered include : Families First, a training seminar for divorcing parents ; High Hopes for Kids, offering support to children whose parents have divorced; Positive Parenting, a support group for parents facing difficulties raising their children; Valued Visits, a supervised visitation center; and Strengthening Families, a five agency collaborative that utilizes a group setting to build family skills . The population served is : families who are at risk for abusing or neglecting their children; families who have had a reported incident of abuse or neglect, but who, with support and education, can eliminate further episodes of abuse; families with children 0- 18 ; Families are served county wide, with no geographic restrictions. This year' s demographics indicate that 65 % of enrolled families are single parents, 51 % are White, 28 % are Hispanic, 17% are Black, and 4% are Haitian. Fifty-eight percent of families served (Safe Families only) are below the federal poverty level . 4 Organization: Exchange Club CASTLE Program: Valued Visits Funder: Children's Services Advisory Committee RFP# 2006061 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 . What: The unacceptable condition requiring change is contact between a parent and child that puts the child at risk. The child is at risk for abuse, at risk of witnessing domestic violence between parents, and at risk of being used in a manipulative manner by estranged parents. Following Florida law, visitation rights are often ordered between a parent and child, even if the parent poses a risk to that child, or has hurt that child in the past. It is unacceptable that these visits take place in the community, without supervision, placing the child, the ex-spouse, and the general community in jeopardy. Who : Children who are at risk of abuse, or are from homes where domestic violence is present. Where: Last year, parents were served in all parts of Indian River County Provide Data : In Indian River County, in 2004-2005 , there were 314 children in foster care; there were a total of 490 domestic violence crimes; there were 698 child abuse investigations. These children are eligible for Valued Visits, should visiting a parent pose a risk. (FDLE crime reports, DCF abuse hotline statistics). A recent study of children in foster care found that for children 0-6 years old, supervised visitation resulted in: more visits with biological parents, fewer behavioral problems, and a shorter stay in foster care, than for children who did not have supervised visitation, (Family Relations, April issue, 2004) . [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 targetedpopulation of your program. here are no other supervised visitation centers in Indian River County. Before Valued Visits pened, supervised visit occurred in the offices of Department of Children and Family caseworkers, the homes of relatives, at fast food restaurants, or in police station lobbies . Visits in these locations were often poorly supervised, and inadequately secure . Research shows that the majority of visits scheduled under these conditions were cancelled and did not occur as scheduled, which does not allow the parent/child relationship to mend. 5 Qreanization: Exchange Club CASTLE Program: Valued Visits Funder: Children's Services Advisory Committee RFP4 2006061 C. PROGRAM DESCRIPTION (Entire Section C, 1 — 6, not to exceed two pages) 1 . List Priority Needs area addressed. Focus Area II : Parental Support and Education 2. Briefly describe program activities including location of services. The purpose of Valued Visits is to provide a location for visiting parents to meet with their children in a safe, supervised manner. The participants in the program are referred by the courts due to contentious divorces or domestic violence, or by the Department of Children and Families because of the risk of child abuse or neglect. All referred families are screened for the appropriateness of Valued Visits, and given a date for a program orientation. Both parents and/or caretakers must complete orientation. Following successful completion of orientation, families are given a visitation schedule. The hour and date agreed upon for the family will be consistent on a weekly basis, until such time as visits are no longer needed. The visits occur in a recreation room type setting, to enhance the programs attractiveness to children, and to ensure a comfortable setting that encourages a positive, interactive visit. Age appropriate games and activities are provided for children from ages 0- 18 . Valued Visits is open for visits on Thursday evenings from 5 : 30pm to 8 : 30pm, Fridays from 2 : 30pm-8 : 30pm, Saturdays from 8 : 30am to 1 : 30pm, and Sundays from 2 : OOpm to 6 : 00pm . We are fortunate to have volunteers (Junior League members) to help monitor visits . The volunteers augment paid staff, and allow the program to increase its capacity. The services offered at Valued Visits include : Monitored Exchange — Supervised exchange of children between the residential and non- residential parent. Supervised Visitation — Supervised visits between a non-residential parent and a child. The visit is observed at all times by a monitor. The visit occurs on-site, at Valued Visits, and follows strict guidelines as to what can be said and done during the visit. Unless rules are violated, the monitor does not interact with the parent or child. Therapeutic Supervision — Supervised visits between the non-residential parent and a child. In this case, the visit monitor is a licensed mental health counselor, and takes an active role in the visit, working with the parent and child to improve the relationship. Parenting Classes — Non-residential parents are offered parent education classes before and after each visit. Services are provided at the CASTLE office at 1275 Old Dixie Highway, Vero Beach. 3 . Briefly describe how your program intends to address 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 stated need or problem is unsupervised visits or contact between a child and a parent that puts that child at risk. Valued Visits addresses this need by offering a safe, enriched setting in which to supervise this contact. Valued Visits also fosters boundary and limit setting, holds parents accountable for their behavior, and enrolls non-residential parents in a parenting education class . In some cases, therapeutic intervention is offered when ordered by the court. The policies and procedures of Valued Visits follow the guidelines recommended by the 6 Organization : Exchange Club CASTLE Program: Valued Visits Funder: Children's Services Advisory Committee RFPY. 2006061 Florida Clearinghouse on Supervised Visitation the Florida Supreme Court Standards for Supervised Visitation programs, and the "Recommendations from the National Council of Juvenile and Familv Court Judges. " ensuring that Valued Visits utilizes both state and national standards for best practices . Evidence that supervised visitation works comes from the following research: "Supervised Visitation Beneficial for Young Children," U. S . Dept. of Health and Human Services ; July, 2004) : • Only 17% of families using supervised visitation centers missed their appointments, compared with 71 % of families who use Department of Children and Families caseworkers to supervise visits . • Families using visitation centers were likely to have 10 or more visits, about 3 times more than if caseworkers supervised visits. • 50% of children who had regular family visits were in foster care for less than one year, while only 10% of children who had infrequent visits were in foster care for less than one year. • Children who use visitation centers have their court cases resolved sooner than children who use caseworkers to supervise family visits . 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 Manager 42% of time — 2 yrs . supervisory experience required. Program Supervisor 29% of time — 1 yr. relevant experience. Case Mgr. 20% of time — 1 yr. exp . Court Liaison 33 % of time — Bi-lingual required/ lyr. relevant experience required. 6 P/T visit monitors ( 100% of time) Required credentials/experience : High School/ 1 yr. Secretary (3) 7% of time — H. S . diploma 2yrs . exp. HR Spec . 7% of time — 2 yrs. HR exp. Development/Community Relations 8 % of time -2 yrs. exp required. Bookkeeper 8 % of time — 2 yrs. exp required. 10 Volunteers ( 100% of time) Required credentials/experience : High SchooUl yr. 5. How will the target population be made aware of the program ? All families using Valued Visits are court ordered to do so. Families are made aware of the program through the judge presiding at their court appearance, or in dependency cases, through their DCF caseworker. The program also has a bi-lingual court liaison to assist families and explain supervised visitation during and after court hearings . Program enrollment begins when a family provides a copy of the court order to the CASTLE. 6. How will the program be accessible to target population (i.e. location, transportation, hours of operation) ? Valued Visits is open in the evenings and on weekends, ensuring accessibility to working families. The program office is located on a major thoroughfare in South Vero Beach. Enrolled families provide their own transportation. 7 Organization: Exchange Club CASTLE Program: Valued Visits Funder: Children's services Advisory Committee RFP4 2006061 D . MEASURABLE OUTCOMES (Entire Section D not to exceed two pages) NEXT YEAR 10/06 — 9/07 OUTCOMES ACTIVITIES Add all the elements or the Measurable Outcomes) Add the tasks to accomplish the Outcome(s) 1 . Ensure that visits occurring at Valued Visits 1 . Provide each adult participant in the are successful, in that the visit will not be program with orientation training prior to the terminated for a rules violation (i. e. abuse, first visit, and monitor each adult participant at inappropriate touch, spousal alienation, etc.) all times during the scheduled visit. for 95 % of the visits occurring at the program, as measured by case notes, and significant event reports . 2004/05 Baseline : >99%. 2. Ensure the leaming of parenting skills in 2. Non-residential parents will be offered non-residential parents for 90% of enrolled parenting education classes while on site at parents, as measured by competency based Valued Visits . After each class, the parent questions (a post test) after each parenting will be given questions to answer that deal class session, during enrollment in Valued directly with that session' s topic. The Visits. 2004/05 Baseline : 100%. parenting instructor will review all questions answered incorrectly with the enrolled parents, until competency is achieved. 3 . 95 % of custodial parents will express 3 . Administer a satisfaction survey to satisfaction with the program services as custodial parents . The survey will emphasize measured by the results of a satisfaction survey enrollment procedures, safety, and changes in given prior to the end of services . 2004-05 their child' s behavior as a result of attending Baseline: 98% . Valued Visits. 4. Maintain at 20% the number of families 4 . Interviews, in person or by phone, will be who receive follow-up contact to ensure that conducted regarding the success of any any service linkages provided were successful, linkages with other services made by visitation as measured by a follow up survey delivered center staff. within 90 days of the service linkage. 80% of these linkages will be successful . Baseline to be established. 8 Qrcanization: Exchange Club CASTLE Program: Valued Visits Funder: Children's Services Advisory Committee RFPX 2006061 D. MEASURABLE OUTCOMES (Entire Section D not to exceed two pages) NEXT YEAR 10/06 — 9/07 ffthe UTCOMES ACTIVITIES nts for the Measurable Outcome(s) Add the tasks to accom lish the Outcomes) 83 % the number of scheduled 5 . Parents will be provided with the place (are not cancelled), as information needed to successfully meet their gn-in sheets/program records, court ordered obligation to have supervised or the 2006-2007 year. Baseline for 2004/05 : visits. Cancellations will be followed up with 80% . (new goal — recommended by UW panel phone calls by staff, to ensure that parents last year). understand their obligations. 6. Cases sent back to court for failure to 6 . Every effort will be made to work with comply with program rules will be limited to parents to ensure compliance with program 20% of all cases, for families enrolled in rules. The program will remain sensitive to the supervised visitation, for the 2006-2007 year, individual circumstances of each case, and all as measured by tracking of case closures. cases sent back to court will need supervisory Baseline to be determined. (New goal — review. recommended by UW panel last year) . 9 Organization: Exchange Club CASTLE Program: Valued Visits Funder: Children's Services Advisory Committee RFP# 2006061 E. COLLABORATION (Entire Section E not to exceed one page) 1 . List your program 's collaborative partners and the resources they are providing to the programbeyond referrals and support. (See individual funder requirements for inclusion of collaborative agree nt letters.) Collaborative Agency Resources provided to the program Junior League of Indian River Core funding for the program; assistance in securing foundation funding; volunteers for the program; serve on advisory board. Indian River County Sheriffs Provide security to Valued Visits during all operating Department hours. 50% of services will be donated. Department of Children and Families Cooperation on dependency cases; access to caseworkers; sharing of information. 19th Judicial Circuit Use of Valued Visits for court ordered supervised visitation; support of program; conduct quarterly program oversight meetings . Children' s Home Society Share information on client progress to help caseworkers determine compliance with case plans. Family Preservation Services Share information on client progress to help caseworkers determine compliance with case plans . Safe Space Provide training to Valued Visits staff on domestic violence; review program manual for safety issues; act as on-going consultant on domestic violence cases. 10 Organization: Exchanee Club CASTLE Program: Valued Visits Funder: Children's Services Advisory Committee RFP# 2006061 F. PROGRAM EVALUATION (Entire Section F not to exceed two pages) F MOGRAPHICS : What information (data elements) will you need to collect in order ccurately describe your target population including demographics (age, gender and nic background) required by the funder in Section H? What are the pieces of rmation that qualify them for your target population ? How do you document their d for services or their "unacceptable condition requiring change" from Section Bl ? Age, gender, ethnicity, marital status, and address are collected upon intake. Eligibility for the program requires that a judge has deemed that contact between a child and a non-residential parent poses a risk of harm to that child. Intake and eligibility are further assessed during the intake and orientation sessions required by Valued Visits . 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? Outcome I (successful visits) is measured by visit monitor notes and significant event reports which track the number of visits terminated for a rules violation. Visit monitor notes are reviewed weekly; significant events are reviewed immediately, and again quarterly at the Risk Management committee meeting. Outcome 2 (learning parenting skills) is measured with competency-based tests (post-tests) given after each parenting class . Participants must get all answers correct, or remediation is done by the group facilitator. Tests are collected after every parenting class. Outcome 3 (satisfaction survey) is measured with a survey that is administered prior to the case closing. Results are collated quarterly and reported to the Service Delivery committee. Outcome 4 (follow-un contact) is performed with families who have been given a service linkage contact. Contact is made by phone if the family is no longer enrolled in the program, and in person, if the family is still enrolled. Results are tabulated quarterly, and reported to the Service Delivery committee . Outcome 5 (visitation rate) Records are kept of visits scheduled, visits held, and visits cancelled. Case notes reflect the follow-up steps taken after a cancellation. Outcome 6 (cases returned to court) Case notes will reflect attempts by staff to help parents comply with the program rules. A supervisory review will be documented in the case notes prior to a case being sent back to court for non-compliance. 11 Organization: Exchange Club CASTLE Program: Valued Visits Funder: Children's Smices Adviso* Committee RFP# 2006061 FREPORTINIG: What will you do with this information to show that change has w will you use or present these results to the consumer, the funder, the the community? How will you use this information to improve your cted is reported to funders on a regular basis, through monthly, quarterly or semi-annual reports . Staff, board members, employees and other stakeholders are made aware of results through the CASTLE Continuous Quality Improvement process, and feedback at all-team and Board meetings . Recommendations for program improvement are developed through this CQI process. The community is made aware of results through an annual report. 12 Organization: Exchange Club CASTLE Program: Valued Visits Funder: Children's Services AdvisoryCommittee RFN 2006061 G. TIMETABLE (Section G not to exceed one page) 51 . 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 5r1 . sections. Mouth/Period Activities October 1 , 2006 Valued Visits is a continuing program and will be fully staffed and in full operation at the start of the contract year. Regarding the program operation: 1 . Families contact the program after receiving a court order for supervised visitation. 2 . Families are scheduled for a program orientation within seven days. 3 . Visits start as soon as both the non-residential and residential parent complete orientation. 4 . Supervised visits continue as scheduled on the court order. 5 . Visits are monitored for appropriateness of interactions and safety of the child. 6. Parents are offered parent education class as an adjunct to visits. 7. Visits are terminated when either party fails to comply with the rules of the program, or when the court deems that visits are no longer necessary. 13 Organization: Exchanee Club CASTLE Program: Valued Visits Funder: Children's Services Advisary Committee RFP#t 2006061 H. PROJECTIONS FOR UNDUPLICATED CLIENTS Number of Unduplicated Clients by Location ws� cdINM3est °' Current Fiscal Year erM!, Fta�cear Location ua 3UlI Budget 2005/06 Pil roectllons :21106/07 Unduplicated Clients Unduplicated Clients Unduplicated Clients N. Indian River County 31 60 60 S . Indian River County 133 166 166 Indian River Co. Total 164 226 226 Greater Stuart _ Hobe Sound Indiantown _ Jensen Beach Palm City _ Martin County Total Fort Pierce Port Saint Lucie St. Lucie Co. Total Other Locations _ TOTAL SERVED 164 226 A226 Number of Unduplicated Clients by Age Current Fiscal Year t, "�x is earMr Location ° ' 0472A11 �u Budget 2005/06rcrjel 060 ; 771 Individuals Grou ludiVidiimgP .. _ ,v —' i . :0 to 4 - (Pre-school) 33 - 33 5 to 10 - (Elementary) 35 - 35 1 I to 14 - (Middle) 17 - 17 MW 15 to 18 - (High School) 10 - 10 total children 95 95 19 to 59 - (Adults) 91 125 125 60 + (Seniors) 2 6 6 total adults 93 131 131 TOTAL SERVED 164 226 226 14 Exchange Club CASTLE Valued Visits 2006 - 2MT 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 : Exchange Club CASTLE / Valued Visits FUNDER: Children 's Services Advisory Committee - Indian River County - - - - - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - . . . . . . . . . . . . . . . . . . . . _ . . _ . . _ . . . . . . . CAUTION : Do not enter any figures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should be used for providing information and calculations only. REVENUES - Proposed Total Program Budget Funder Specific Budget Total Agency Budget 1rLEventsNat ldren's Services Council-St. Lucie 414, 226.00 2ldren's Services Council-Martin 170,358.00 3iso Committee-Indian River 15, 195.57 15, 195. 57 62,276.48 4ted Way-St Lucie Coun 65,330.00 5ted Way-Martin County 40,229. 00 6ed Way-Indian River County 23,315.28 132,839.00 7ed for Families 7,648.76 535,468.00 8County Funds 9tributions-Cash 17,818. 12 92,954.00 10ram Fees 8,000. 00 55,200.00 11 d Raisin Events-Net 11 ,500. 00 200,000. 0012 s to Public - Net13 bership Dues14 stment Income 10,000.0015 ellaneous 7,500.0016 acies & Bequests 17 Funds from Other Sources 92, 201 .91 396,719.30 18 Reserve Funds Used for Operating 19 In-Kind Donations (Not Included in bowl) 20 TOTAL REVENUES (doesn't include line 191 $175,679.64 $15, 195.57 $2, 183,099.78 5I2MOM 15 9-i Exchange Club CASTE Valued Visits A Proposed B C EXPENDITURES Total Program Budget Funder Specific Budget Total Agency Budget 21 Salaries - (must complete chart on next page 93,905.27 11 , 689. OD 1 , 146,814.00 22 FICA - Total salaries x 0.0765 7, 184. 00 894.21 87, 731 . 27 -- F uemen - nnua penswn or qua to 23 staff 2, 960.88 0. 00 40,000.00 Life/Health - Medicalmenta0 hort-term 24 Disab. 2,830.65 400.001 40,000.00 Workers Compensation - # #employees x 25 rate 31128.27 363. 00 41 , 300. 59 Florida Unemployment - projected 26 employees x $7,000 x UCT-6 rate 613. 89 0.00 5, 508. 00 SALARIES I Gross Iv POSITION LISTING Annual Salary g Portion l/I Funder % of Gross Annual (Agency) of Salary on Proposed Program Specific Budget Salary Position Title / Total Hrs/wk . Requested(CIA) Example:. Executive Director/ 40hrs 70,000.00 10,000.00 51000.00 7.14% Secretary, Madden 261996.00 558.02 0.00% Receptionist, Lewis 23, 968.00 11106.66 0. 00% Human Resources, ClevelandW131498.002P756. 57 . 00 2,563.69 Receptionist, Tober-Dunnington .00 3, 850.00 2, 5D0.00 10.42% Director Development .00 4,227. 36 0.00% Comm. Relations Coord. 00 3,039. 52 0.00°/ Comm. Relations Coord. .00 2,727 .52 0. 000 Bookkeeper . 00 2,285. 12 0.00% Program Manager, Hultman .00 14, 650.32 9, 189.00 28.72°/ Program Asst/Lead Monitor, Hooks00 8, 181 .72 0.00% Case Manager 00 2,756. 57 0. 00% Court Liason 19,469.00 6,424. 77 0. 000/0 Monitor 10,383. 00 10,383.00 0. 00% Monitor 10,383. 00 10,383.00 0.00% Monitor 57192.00 5, 192.00 0.000/0 Monitor 5, 192.00 5, 192. 00 0.00% Monitor 5, 192.00 5, 192. 00 0.00% Monitor5, 192. 00 5, 192.00 0.00% Remaining positions throughout the agency 755,421 .00 Total Salaries � $1 , 146, 814.001 $93,905.27 $11 ,689.00 1 . 02% 52212006 16 s-t Exchange Club CASTLE Valued Visits FRINGE BENEFITS DETAIL (Funder Specific Budget I Funder 11 la Pension Iv v m vil Specific Budget FICA 7.65% Worker's Unemployme Total Fringes Funder CO/I/R1l1 C only, from line 22 to 27 P g (A x %J Health ms. C Position Tide / Total Hrs/wk ompens. nt Compens. Specific Example: Case Manager/40 hrs 5, 000.00 382.50 200.00 500.00 300.00 200.00 1,582. 50 Secretary, Madden 0.00 0.00 0.00 Receptionist, Lewis 0.00 0.00 0.00 Human Resources, Cleveland 0.00 0 .00 0.00 Receptionist, Tober-Dunnin to 2, 500.00 191 .25 200.00 78. 00 469.25 Director Development 0. 00 0.00 0.00 Comm. Relations Coord. 0.00 0.00 0.0p Comm. Relations Coord. 0.00 0.00 0.00 Bookkeeper 0.00 0 .00 0.00 Program Manager, Huttman 9, 189.00 702.96 200.00 285.00 1 , 187.96 Program Asst/Lead Monitor, Hooks 0. 00 0.00 0. 00 Case Manager 0. 00 0.00 0.00 Court Liason 0.00 0.00 0.00 Monitor 0.00 0.00 0.00 Monitor 0.00 0.00 0.00 Monitor 0. 00 0.00 0.00 Monitor 0. 00 0.00 0.00 Monitor 0. 00 0.00 0.00 Monitor 0.00 0.00 0.00 Total Funder Request Fringe Benefits $ 11 ,689.00 894,21 $0.00 $400.00 $363.001 $0.001 $1 ,657.21 5i22noss 17 a-1 Exchange Club CASTLE Valued Visits EXPENDITURES A Proposed Total B C Program Budget Funder Specific Budget Total Agency 27 Travel-Daily Budget 2, 078.00 42,320. 00 # of Staff x average # of milesfwk x 50 wks x $ = Estimated Daily Travel/Mileage Reimb. 50 miles per week @ $.34 per mile 28 TravelfConferences/Training 4, 206.52 25, 044.00 • National Conference (cost per staff) • Training/Seminar (cost per staff) • Other Trainings (cost of travel, lodging, registration, food) Conferences & training for employees. Includes travel and meals 29 Office Supplies 1 ,668. 00 25,000. 00 Office supplies (monthly average x 12 months = estimated cost of office supplies based on present history. $204 per month, copy paper, pens, pencils, paper clips, etc. 30 Telephone 4, 056.00 46,800.00 . # 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 $214 per month, includes cell phone, land line, internet 31 Postage/Shipping 333.60 81460. 00 • Quarterly Mailing of Newsletter • Special events, etc. . Bulk mailings - appeals $60 per month for quarterly newsletter mailing, general mailing, and special events mailing, etc. 32 Utilities 21154. 60 34, 120.00 . Electricity ($ x 12 months) • Water/Sewer ($ x 12 months) - • Garbage ($ x 12 months) $85 per month for water and electricity 33 Occupancy (Building & Grounds) 15,769. 70 1 ,200.00 126,972.00 • Mortgage/Rent ($ x 12 months) • Janitorial ($ x 12 months) • Grounds Maint. ($ x 12 months) • Real Estate Taxes $1340. per month, rent, cleaning, pest control, security systems, ground mailntenance, ea. 34 Printing & Publications 1 ,450. 78 21 , 966. 00 • Quarterly Newsletter ($ x4) Letterheads, Envelopes, etc. Fundraising materials • Other Quarterly newsletters, letterhead, envelopes, special events materials, etc 35 Subscription/Dues/Memberships 154.321 2, 929.00 • Membership to National Organization • Dues • Subscriptions to Newspapers/magazines, etc. Memberships, dues, subscriptions to magazines and organitiaons, .etc, 36 Insurance 932.621 100. 00 19, 171 .00 • Directors/Officers Liab. • Commercial/General Insurance • Bond Ins. • Auto Insurance Directors insurance, general liability, auto, prof. liability, etc. 37 Equipment: Rental & Maintenance 11745.92 37,260.00 • Copier lease ($ x 12 months) • Meter lease S x 12 months) • Copier Maintenance ($ x 12 months) • Computer Maintenance ( $ x 12 months) • Other $83 per month, copier lease, meter lease, computer main[ race, copier maintenance, etc. 38 Advertising 921 .66 15, 312 . 00 • Newspaper ads • Fundraising ads/promotions • Other (vacancies) Help wanted ads, Fundraising and promotions ads, etc. 39 Equipment Purchases:Capital Expense 320.00 (# x $) 12,000. 00 Computer/monitor • Laser Printer 40 Professional Fees (Legal, Consulting) 3 , 940. 00 • Legal advice ( estimated #hrs x $) • Consultant fees • Other 33424 5/222006 B-1 18 Exchange Club CASTLE Valued Visits 41 Books/Educational Materials 555.44 200.00 25, 144. 00 • Books/videos • Materials ($ x staff) Update books and materials for staff and clients $83/month 42 Food & Nutrition • Meals ( # meals x clients x 5days x 50 wks) • Snacks 43 Administrative Costs 15, 917, 001 199,650. 92 • Admin. Cost (% of total budget) 44 Audit Expense 741 .701 349.36 5, 500.00 Independent Audit Review Annual independent audit 45 Specific Assistance to Individuals 172.501 8,518. 00 • Medical assistance • Meals/Food • Rent Assistance • Other Rent assistance, utility assistance, etc 48 Other/Miscellaneous 646.321 5,479. 00 • Background checkidrug test • Other Background/drug checks 47 Other/Contract 11 ,232.001156, 160. 00 Sub-contract for program services Development and marketing contracts, security guards, etc 48 TOTAL EXPENSES $175,679.64 $15, 195.57 $2, 183 ,099.78 5=006 1 913_1 r E Ielptaob Came VaYed vwB 2006-Mn UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME: Exchange Club CASTLE - Valueb Visits FY04/05 FY 05106 Z06107 % INCREASE FYE 9130/05 FYE 9130/06 FYE 9130107 CURRENTVS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (Col. C-col. B)IC01. B REVENUES Bu0c6re0 BUDGETED 1 Children's Services council-St. Lucie 0.001 #DIV/0! 2 Children's Services Council-Martin 0.001 #DIV/01 3 Advisory Committee-Indian River 13670.07 15000.00 15, 195.57 1 .30% 4 United Way-St. Lucie County 0.00 #DIV10! 5 United Wa -Martin County 0.00 #DIV/0! 6 United Way-Indian River County 30,000.00 2331528 -22.28% 7Department of Children & Families 5032.23 7648.76 52.00% 8 County Funds 0.00 #DIVlO! s Contributions-Cash 13.960.341 17818. 12 27.63% 10 Program Fees 2, 500.001 8 000.00 8,000.00 0.00% 11 Fund Raising Events-Net 11 ,500.00 11 500.00 0.00% 12 Sales to Public-Net 0.00 #DIV10I 13 Membership Dues 0.00 #DIV10! 14 Investment Income 0.00 #DIV701 15 Miscellaneous 0.00 #DIV/01 16 Legacies & Bequests 0.00 #DIVf0! 17 Funds from Other Sources 34 978.48 8687528 92 201 .91 6.13% IS Reserve Funds Used for 0 0peratinq 0.00 #DIVlO! 1s In-Kind Donations (Nor Included In bolo 0.00 #DIV10I 20 TOTAL 51148.55 170367.85 175679.64 3.12% EXPENDITURES 21 Salaries 33 510.43 89,930.87 93,905.27 4.427 22 FICA 2563.52 6879.71 7184.00 4.42% 23 Retirement 496.32 21960.88 2,960.88 0.00% 24 Life/Health 910.54 4076.83 2830.65 -30.57% zs Workers Compensation 338.89 1613.19 3, 128.27 93.92% 26 Florida Unemployment 573.25 613.89 7.09% 27 Travel-Daily 64.88 886.23 207800 134.48% 28 Tmvel/Conferences/Treinin 15.00 3p853.38 4,206.52 9. 16% 29 Office Supplies 206. 17 2456.13 1 668.00 -32.09% 30 Telephone 750.00 21567.16 4,056.00 58.00% 31 Postage/Shipping 27.27 721 .40 333.60 -53.767 32 Utilities 405.00 1 027.28 2.154.60 , 109.74% 33 Occupancy (Building & Grounds 7,273.96 16 170.46 15 769.70 -2.480/0 34 Printing & Publications 103.82 2,803.20 1 ,450.78 48.25% 35 Subscri tion/Dues/Membershi s 51 .25 228.00 154.32 .32.32% 36 Insurance 425.00 1092.32 932.62 -14.62% 37 E ui ment:Rental & Maintenance 250.00 996.72 1 745.92 75. 17% 38 Advertising 570.40 1 ,040.52 921 .66 -11 .42% 39 Equipment Purchases:Ca ital Expense 0.00 320.00 #DIV/01 40 Professional Fees (Legal, Consultin 0.00 1 0.00 #DIV/01 41 Books/Educational Materials 670.401 555.44 -17.15% 42 Food & Nutrition 1 0.001 #DIV10I 43 Administrative Costs 3.549.301 14 064.23 15 917.00 13.17% 44 Audit Expense 1 ,026-001 1 .342.25 741 .70 -44.74% 45 Specific Assistance to Individuals 47.31 950.14 172.50 -81 .840A 46 Other/Miscellaneous 381 .00 515.43 646.32 25.39% 47 Other[Contract 41019.21 12 947.87 11 232.00 -13.25% 48 TOTAL 56 985.27 170 367.85 175 679.64 3.12% 4s REVENUES OVERf UNDER EXPENDITURES -5,836.72 0.00 0.00 #D]V/01 20 Exchange Club CASTLE Valued Vsils 2006 - 2007 UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : Exchange Club CASTE - Valued Visits FUNDER : Children 's Services Advisory Cor A B C FY 06/07 FY 06/07 % OF TOTAL FUNDER TOTAL VS. PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET (col. B/col. A) EXPENDITURES 21 Salaries 939905.27 113689.00 12.45% 22 FICA 79184.00 894.21 12.45% 23 Retirement 21960.88 0.00 0.00% 24 Life/Health 21830.65 400.00 14. 13% 25 Workers Com ensation 3 , 128.27 363.00 11 .60% 26 Florida Unemployment 613.89 0.00 0.00% 27 Travel-Daily2,078.00 0.00 0 .00% 28 Travel/Conferences/Training 41206.52 0 .00 0.00% 29 Office Supplies 11668 .00 0. 00 0.00% 30 Telephone 4,056.00 0.00 0.00% 31 Postage/Shipping 333. 60 0.00 0.00% 32 Utilities 21154.60 0.00 0.00% 33 Occupancy (Building & Grounds 15,769. 70 13200.00 7 .61 % 34 Printing & Publications 1 ,450.78 0 .00 0. 00% 35 Subscription/Dues/Memberships 154.32 0.00 0.00% 36 Insurance 932.62 100 .00 10.72% 37 E ui ment: Rental & Maintenance 11745.92 0 .00 0.00% 38 Advertising921 .66 0.00 0.00% 39 E ui ment Purchases : Ca ital Expense 320.00 0. 00 0.00% 40 Professional Fees (Legal, Consulting) 0.00 0.00 #DIV/0 ! 41 Books/Educational Materials 555.44 200. 00 36.01 % 42 Food & Nutrition 0 .00 0.00 #DIV/0 ! 43 Administrative Costs 15, 917.00 0 .00 0.00% 44 Audit Expense 741 .70 349.36 47. 10% 45 Specific Assistance to Individuals 172.50 0.00ff 0 .00% 46 Other/Miscellaneous 646.32 0.00 0. 00% 47 Other/Contract 11 ,232. 00 0. 00 0.00% a8 TOTAL $175, 679 .64 $15, 195.57 8.65% 222006 21 B° r � , Exchange Club CASTLE • Valued Yana 2006 - 2007 UNIFORM GRANT APPLICATION FUNDER HISTORY PROGRAM EXPENSES AGENCY/PROGRAM NAME : ExchangecwbCASTLE - ValuedVsts FUNDER: Children 's Services Advisory Coi A B C FY 05106 FY 06/07 % INCREASE FUNDER FUNDER FY 05106 to SPECIFIC SPECIFIC FY 06107 BUDGET BUDGET (Col. Blcol. A EXPENDITURES 21 Salaries 11 ,689. 00 11 , 689.00 0.00% 22 FICA 894.21 894.21 0.00% 23 Retirement 0.00 0.00 #DIV10! 24 Life/Health 400. 00 400.00 0.00% 25 Workers Compensation 168.00 363.00 116.07% 26 Florida Unemployment 0.00 0. 00 #DMO ! 27 Travel-Daily0.00 0.00 #DIV/O ! 28 Travel/Conferences/Training0.00 0.00 #DMO! 29 Office Supplies 0.00 0.00 #DIV/01 30 Telephone 0 .00 0.00 #DIV/0! 31 Postage/Shipping0.00 0.00 #DIV/01 32 Utilities 0.001 0.00 #DIV/0 ! 33 Occupancy (Building & Grounds 19200.00 1 ,200.00 0.00% 34 Printing & Publications 0. 00 0.00 #DIVlO! 35 Subscription/Dues/Memberships 0.00 0.00 #DIV/0 ! 36 Insurance 100.00 100.00 0.00% 37 E ui ment:Rental & Maintenance 0. 00 0.00 #DIVIO ! 38 Advertising0.00 0.00 #DIV/0 ! 39 Equipment Purchases: Capita I Expense 0.00 0. 00 #DIV/O ! 40 Professional Fees (Legal , Consulting) 0.00 0.00 #DIV/01 41 Books/Educational Materials 200.00 200.00 0.00% 42 Food & Nutrition 0.00 0. 00 #DIV/0 ! 43 Administrative Costs 0. 00 0.00 #DIV/0! 44 Audit Expense 348.791 349.36 0. 16% 45 Specific Assistance to Individuals 0.00 0. 00 #DIV/O ! 46 Other/Miscellaneous 0.00 0.00 #DIV10 ! 47 Other/Contract 0.00 0.00 #DIV101 48 TOTAL $15,000.00 $15,195.57 1 .30% 5/22aao6 22 as MENNEN di .=Tre 2M 2M7 UNIFORM GRANT APPLICATION EXPLANATION FOR INCREASES OF 15% OR MORE TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME: Exchange Club CASTLE - Valued Visits FUNDER: Children's Services Advisory Committee - Indian River County s , GfilEk7EM iprW9TlON EOI;GVARfANC -�z..., - 4::,: , #OIVI01 #D1wol #DIV/01 De artmentof Children & Families Increase funding for program #01V101 contributionscashResults from new development staff efforts. 91 #DIV101 #D1Vlo1 #DIV101 #DIVI01 #DIVgh #DIV/01 Workers Com eirsation Increase In workers camp rate Travel-0aii Increased stag/reimbursement rate. Tele hone Increase in telephone usageldienrs using cell phones to schedule visits. Utilities Actual costs - last year were budaletlo lions. pr je Eautrurnent:Rental & Maintenance Increase in computer maintenance contract Ni #DIV/01 #DIV101 OtherlMiscellaneous Increase in background [estin UNIFORM GRANT APPLICATION EXPLANATION FOR INCREASES OF MORE THAN 5lo FUNDER HISTORY AGENCY/PROGRAM NAME: Exchange Club CASTLE - Valued Visits FUNDER: Children's Services Advisory Committee - Indian River County nisv a /!P, , t i!!q , Yn ! EICPIANAT/QNEFORiWi1$IAtVCE n _ � #DWA)l Workers compensation Increase in Workers Comp rate 91 NDIW01 #DIVI01 #DIV/01 #mv/ol #OIV101 #D1V101 #D1m01 #DIV/01 #DWRif #DIV101 #DIW01 #DIV/01 #DIV101 #D1V101 #DIV/01 #DIV101 #DIV/01 23 EXHIBIT B (From policy adopted by Indian River County Board of county Commissioners on February 19, 2002) "D. Nonprofit Agency Responsibilities After Award 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 and (September 30th) must be submitted on a timely basis. Each year, the Office of Management and 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 expense by type. These summaries should be broken down into salaries, benefit, 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." EXHIBIT - B - 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: Brad E. Bernauer, Director Indian River County Human Services 184025 1h Street Vero Beach , Florida 32960-3365 Recipient: Exchange Club Castle P .O . Box 12908 Fort Pierce, Florida 34979 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 provision and term 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 context indicates otherwise, words importing the singular number include the plural number, and vise 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. EXHIBIT - C - NO,)-02-2W6V15109 ' • • - - - -HRRB#" R INS FPu~ - •„•. ~y �.•N - -y 17724EC2315 vP . 01 OP ICI B " Iww r 14 A,C-QBQ CERTIFICATE F LIABILITY INSURANCE ExcaA-1 11/02M PROOOCPL THIS CERTIFICATE IS ISSUES AS A MATTER C-F INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE 4 ,ERMPtATE .ARBOR JVS7jRAC1Ci AGNACY HOLDER, THIS CERTIFICATE DOEs NOT AWRID, EXTEND OR 2222 , Colonial Road , Suits 100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Fort Pierce FL 3495D - 5309 Ph0n9L772 -461-6040 Fax ) 772 - 4604315 INSURERS AFFORDING COVEP'A" INAIC9 _ A: ._ �..._,_ ��_.... . REO , INSURER A: PAa1WAjNN;R ind.nn . ry ie. co The h712:5e C tEb center _ 9g t� PrAVP.ai ion O 'E WSUiiR is ••.• .. ... __ - CA 1d Abuse DBA WEURER C_ _ ftchangs Club C . A . S . T , L . B . . . - PO box 12908 IN.a1RER M IN Ft Pierce PL 34979 -I - SURER F: COVERAGES TNEROLIMES OF IA84.iMCEIW'TED BELOW -:-IMT BEEN ISS4E0 'O THE JJSVREO dPMRU ABOVE FOR -HEDOUCTPCRI0 , INOICATSF . NOT W17TlsTl ANY REQUIREMENT, TERM OR C06'CIYI014 OF ANY VQNTAaOT OR OTHER DOCUMEN' WITH RESPECT TO WHICH THI6 CERTIFICATE N'V Y BE IMES OR MAY PERTAIN, THE !N5L Rl APPPOROEO MYTNE POLICIES MCP.iOCO HUHN IS SU3J:-CT TO ALL TlIE 7ERNS, LtCLU3gN5 ANO C' >kEN'IDNS CF SUCH POLICIES ACONSWE LIMBS SHOWN my 'iP��E. BEEN REDUCED 6� PAIC CLAIMS. IOLIGITF pL EAP1mATw"- - LTR I _YPE CP INS-URANCE _ i ROUCY N{MpCA ATE IMMIOOM'1 bWYCIIIM1VDOIfI'1 - LIRRS GENERAL LAONITYocannBNcc 31 , 000 000 ;7A; fD AyX , XIeoMMErteIucFNFRatLwRl?r !! P8PR16] 969 03 / 26 / 06 03 /26 / 071_ PRkM!a.,'P16eRemleim«� _ 1100, ,. 000 Ty.•� '" CWM6 MADE ,' X OCCURi MEO UP (AM one PNax; S5 000 ) P RSONAL i ADV OW R-, f 1 , 00D , 000 � I� 1 GENERAL AGGRE 9 E a 3 000 000 � PRaG=7S . COFAPr PA.'G 33 , 000 , 000 . -GB4L AGGREGATE LIMB APPLIES PFR JM LOC A, .^. • �Al1tOMOE0.E W01llfY COMWN410 SINOLG 0VIS I s 0 PLAY AV, _. ! IP' ALL GAINED AUTCR I ! FOpLY1YJJRT S _ I � SCHEOULED AJTOE � I hx pgivnl -__ ., . -- HIRFIIAUTOS i DOOILY :ILURY g IPYIfLeiOq I nONOVJNlD AUTOS I __ !,.-•. - '. . I � PROPFRTVDAMAGE _.•. •. -, "WE WE LlARRfTY I I lUT00NLY - EA wC GDEN ! i 'S• ! 1 . ANYAJOO i OTHER THAN At ;G S ja r AUTO ONLY: -_ .P t ^ ERCE3SNIeaIReI.LALIAEILITY' EAON OCOURRENCF N I ,7 AGGREGATE . —_ f . . . .. _— 1 OCCUR ClAIN6 MADE ! � — y71. i 'TIL -. L a 1 .I _- yy. . Pre"T10N 9 1 OFFIDEPRIFNNFR FJLCLUOED° TORT ' MISS ', T,R, ,�`� V/OaNER3 COMPENSATION ANO � EMP4 OYIDu' LIAauTY E.L. EACH ACCIOEF7� -� N IPRGA%NR"NARTNERRiaFCVTIVE E.L. W6EAEFUiNP40 S , 'SPELW PfiOVn10N9 Del" 1 , E.L. OIEEASE - POL' CY LRaT a F. , .! OTHER A ProtL#aalomal Liab . ! PePi(163969 03 / 26 /06 ! 03 / 26 /071 voaurt'aac v� 1 . 000 , 000 A 1 333sakual / CI PRPK163969 I 03 /2606 03 / 26 / 07 bag l! ae ; 21000 , 000 CE: CRVIAcORO► hAuIGNIVENENPORWMENTISPECIAL PROVISIDJAl 04u -dRys uou-payment of promium , Certificane Holder is cased as an " ad'ffi'tianal 1XIOured . for General Liability coverage . CANCELLATION F.p:71FICATE HOLDER - 4iN0{ILEANT OP THE ARCH. DESCPoIIEO POIIGFS SE GVIGEALEtl EEFOCTNE EERR6TION .., 1rroxA - 2 DRTE TN[RtiOF, iHERISVUIC NSLIIIER WILL EROWVOR I',) MfIL 3DM GAYS WRITTtD: ludiaA River C013nEy NOTICETOTWICENTIFIGA174 KCA.MtN►MECTOTHE UIT, RUT FA:VRE TOOOSO SMALL Attn , Marion Na6tersou IMP06E NO ORLiCATLON OR 11AEkIT ' OP ANY KIND W014 ENE INSUINCry RUAOENTE OR LI 1 •; 1640 25th Street I Vero Beach FL 32960 REPRiiwrArnEa „_- 4 iS6 r!. AYTMOIVi£O RERRESENTAl1YE - .. 1 s _ Cindy MQQL1l ' � .A R1425 (2601/09) ACORO C URPORATICII 1966 HARBOR INSURANCE AGENCY MEMO Page 1 2222 Colonial Road, Suite 100 ma"Mmx Fort Pierce, FL 34950-5309 EXCI3A-1 LW 04/18/2006 Phone: 772-461-6040 Fax: 772-460-2315 m PBPK163969 m � . ,.sem �z� . �_ �•_� �1�s�,�"°`-=�„ PCKG 03/26/2006 03/26/2007 The Exchange Club Center Exchange C.A.S.T.L.E. PO Box 12908 Ft Pierce, FL 34979 Attached is a list of holders which were sent certificates on your renewal policy term . If you should need additional certificates in the coming year , please call our office with the complete name and address , fax number , if necessary . Thank you . Liane Walker C .. E, R T - I F I C A T E HOLDER LIST Date 04 / 18 / 06 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 1 CustOmer : EXCHA - 1 Range : All Dates : All re Exchange Club Center Code Name Street City ST Zip Code Iss Date Queued Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Copyco Inc . P . O . Box 3083 Cedar Rapids IA 52406-3083 04/18/06 No 10 Department of Children 337 North 4th Street Ste A Ft . Pierce FL 34950 04 /18/06 No 10 and Families Attn : Ann Birnes Junior League of P . O . Box 3008 Vero Beach FL 32964 04 /18 /06 No 10 Indian River Inc . North South Plaza, Inc . 686 3rd Place Vero Beach FL 34962 04/18/06 No 10 Publix-St . Lucie West 1333 NW St . Lucie Blvd . Pt . St . Lucie EL 34986 04/18 /06 No 10 Fax : 465-6013 Ted Glasurd Associates , Inc . 461 S . 7th St . , #2470 Minneapolis MN 55415 04/18 /06 No 10 Fax : 465-6013 Ken Dallman United for Families P . O . Box 2399 Fort Pierce FL 34954 04 /18/06 No 10 Fax #772-396-2925 CHILD-1 Childrens Service Council of 2030 BE Ocean Blvd . Stuart FL 34996 04 /18/06 No 10 Martin County Fax 772-288-5799 Attn : Frances Description of Operations Certificate Holder is an additional insured for general liability . CHILD- 1 Childrens Service Council of 250 NW Country Club Dr, Ste240 Pt St Lucie FL 34986 04/18/06 No 10 St Lucie County Fax : 464-2134 H&HLL-1 H & H, LLC 800 Virginia Avenue , 438 Fort Pierce FL 34982 04/18/06 No 10 Description of Operations H & H, LLC , as Landlord, and Additional Insured, is included as an Additional Insured as respects General Liability for location at 800 Virginia Avenue, Unit #34 & 35 , Fort Pierce, FL 34982 . HARBO- 1 Harbor Federal Savings Bank P o Box 249 Ft Pierce FL 34954 04/18/06 No 10 Its Successors and/or Assigns ATIMA Description of Cperations Re : Loan #52-24545650; Property Address : 3525 W . Midway Road , Fort Pierce . INDIA-2 Indian River Co Building Dept 1840 25th Street Vero Beach FL 32960 04/18/06 No 30* Fax : 772-770-5333 Attn : Linda Jones Description of Operations *10 days nonpayment of premium . INDIA-2 Indian River County 1840 25th Street Vero Beach FL 32960 04 /18/06 No 30* Description of Operations *10 days non-payment of premium . Certificate Holder is named as an Additional Insured for General Liability coverage . INFOR-1 For Information Purposes Only 04 /18/06 No 10 hJARTI-6 Martin County Chamber of 1650 S Canner Hwy Stuart FL 34994 04/18/06 No 10 Commerce Description of P Operations Chamber Expo Philadelphia Insurance Companies One Bala Plaza, Suite 100, Bala Cynwyd , Pennsylvania 19004 ( Philadelphia Indemnity Insurance Company COMMON POLICY DECLARATIONS Policy Number: PHPK163969 Named Insured and Mailing Address : Producer: 1365 The Exchange Club Center for the HARBOR INSURANCE AGENCY Prevention of Child Abuse 2222 COLONIAL ROAD PO Box 12908 SUITE 100 Fort Pierce , FL 34979 -2908 FORT PIERCE , FL, 34950 Policy Period From: 03/26/2006 To: 03/26/2007 at 12:01 A.M. Standard Time at your mailing address shown above. Business Description : Non Profit Organization IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED . THIS PREMIUM MAY BE SUBJECTTO ADJUSTMENT. PREMIUM Commercial Property Coverage Part 81487.48 ( Commercial General Liability Coverage Part 3, 698 . 00 Commercial Come Coverage Part 513 . 00 Commercial Inland Marine Coverage Part 11348 . 00 Commercial Auto Coverage Part Businessowners Workers Compensation Employee Benefits 300 .00 Professional Liability 5, 336 . 00 Sexual/Physical Abuse INCLUDED Total $ 19, 682.48 Total Includes Fees and Surcharges (See Schedule Attached) 12.48 Total Includes Federal Terrorism Risk Insurance Act Coverage 76. 00 FORM (S) AND ENDORSEMENT (S) MADE A PART OF THIS POLICY AT THE TIME OF ISSUE Refer To Forms Schedule Omits applicable Forms and Endorsements if shown in 7speafic Coverage Part/Coverage Form Declarations Countersignature Date Authorized Representative -,t4ut0- Owners Page 1 19020 ( 10 - 80 ) Issued 01 - 03 - 2006 INSURANCE COMPANY AUTOMOBILE POLICY DECLARATIONS 6101 ANACAPRI BLVD . , LANSING , MI 48917 - 3999 AGENCY FLOWERS - YATES INSURANCE INC Renewal Effective 02 - 17 - 2006 12 - 0172 - 00 MKT TERR 051 ( 772 ) 461 - 3171 POLICY NUMBER 42 - 209 - 850 - 00 INSURED EXCHANGE CLUB CASTLE Company Use 20 - 04 - FL - 0002 ADDRESS PO BOX 12908 Company POLIC=TERM Bill 12 : 01 a . m .FORT PIERCE FL 34979 - 2908 02 - 17 - 2006 In consideration of payment of the premium shown below , this policy is renewed . Please attach this Declarations and attachments to your policy . If you have any ques{ ions , lease consult with p your agent . DESCRIPTION OF ITEM INSURED AGE SYMBDL/COST TERRITORY CLASS/PG Comprehensive Liability - . 027 SPL St Lucie County , FL COVERAGES LIMITS PREMIUM Combined Liability S 500 , 000 occurrence FOREIGN TERRORISM 5123 . 99 - CERTIFIED ACTS SEE FORM 59350 1 . 24 TOTAL $ 125 . 23 Additional Forms For This Item : 79547 ( 03 - 99 ) 79539 ( 03 - 99 ) PREMIUM BASIS : Estimated cost of hire - liability 5 If Any ( Subject to audit ) 140 1 . 1999 FORD WINDSTAR 8 VIN : 2FMZA5147XBB03813 027 8CA St Lucie County , FL COVERAGES LIMITS PREMIUM . Combined Liability $ 500 , 000 occurrence 5943 . 00 Uninsured Motorist $ 500 , 000 person/$ 500 , 000 occurrence Medical Payments S 10 , 000 181 . 00 Personal Injury person 18 . 00 Protection 5 10 , 000 34 . 00 Comprehensive Actual Cash Value - $ 500 deductible 103 . 00 Collision Actual Cash Value - 5 500 deductible Additional Expense $ 40 /Day , $ 1200 Maximum 230 . 00 FOREIGN TERRORISM - 60 . 00 CERTIFIED ACTS SEE FORM 59350 - 15 . 69 TOTAL $ 1 , 584 . 69 Interested Parties : None Additional Forms For This Item : 79255 ( 12 - 01 ) 79308 ( 01 - 01 ) 79402 ( 07 - 94 ) 79537 ( 06 - 92 ) 79539 ( 03 - 99 ) 79939 ( 03 - 05 ) PREMIUM BASIS : Radius of operation - within a 100 mile radius . USE CLASS ( 00552 ) : NDC Not Wholesale Or Retail Delivery . 140 0020500 `-'� F CASTLE OUR MISSION IS TO IMPROVE THE QUALITY OF FAMILY LIFE AND PREVENT CHILD ABUSE AND NEGLECT BY PROVIDING COMMUNITY EDUCATION, SUPPORT AND RESOURCES FOR PARENTS IN NEED OF ASSISTANCE. The CASTLE does not use an agency vehicle to transport clients. Doug Bo Assistant Direct r �+� eae ® 25 YEARS OF SERVICE AS THE PARENTING PROFESSIONALS OF THE TREASURE COAST CCZ OREECHO BEE CASTLE ST. LUCIE COUNTY MARTIN COUNTY INDIAN RIVER COUNTY MAILING ADDRESS 3525 S.W. MIDWAY ROAD 3814 S. E. DIXIE Hwy, 1275 OLD DIXIE Hwy. P.O. Box 12908 FORT PIERCE, FL 34981 STUART, FL 34997 VERO BEACH, FL 32960 FORT Please, FL 34979 P : 772-465-6011 P: 772-781 -4510 P: 772-567-5700 F: 772-465-6013 F: 772-219-0791 F: 772-567-7133 WWW. EXCHANGECASTLE . ORG The CASTLE is sponsored in part by the State of Florida and the Department of Children & Families, United Way or Indian River, Martin, St. Lucie and Okeechobee Counties, Children's Services Councils of Martin and St. Lucie Counties, Children's Services Advisory Committee of Indian River County, United for Families, Safe Havens - Office of Viatence Against Women, J. League of Indian River County, and Exchange Clubs. FW A FLORIDA WORKERS' COMFENSATION JOINT NNDERWRNING ASSOCIATION, INC. WORKERS COMPENSATION I AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER : ( GFR1 3UB - 281 7CG1 - 8 - 05 ) NEW- O5 INSURER : FLORIDA W . C . JUA 1 . NCCI CO CODE: 80179 INSURED: EXCHANGE CLUB CENTER FOR THE HARBOR INSURANCE AGENCY PREVENTION OF CHILD ABUSE OF AN AFFILATE or HA"OR rEOEx Ls VrNr BAN[ PO BOX 12908 2222 Colonial Road • Suite 100 FT PIERCE FL 34979 _ Fort Pierce, FL 34950-5309 772-461 -6040 FAX 772-460-2315 harboria- com Insured Is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 12 - 06- 05 to 12 -06 - 06 12:01 A. M . at the insured 's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: FL B . EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 500000 Each Accident Bodily Injury by Disease: $ 500000 policy Limit Bodily Injury by Disease: $ 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT FWCJUA 03 01 D . This policy includes these endorsements and schedules: r� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY . DATE OF ISSUE: 01 - 06 - 06 HS ST ASSIGN : FL OFFICE: FLORIDA WC JUA 821 PRODUCER: HARBOR INSURANCE AGCY 2369) 016133 FWC FLORIDA WORKERS ` COMPENSATION JOINT UNDERWRITING ASSOCIATION , INC . P. O. Box 48957, Sarasota , FL 34230- 5957 Tel (941 ) 376-7400 Fax (941 ) 378- 7406 12/ 19/2005 app # : 72570 Effective Date : 12/06/2005 Binder Number : 2817C618 EXCHANGE CLUB CENTER FOR THE PREVENTION OF CHILD ABUSE OF THE TREASURE COAST IN PO BOX 12908 FORT PIERCE FL 34979 RE , WORKERS COMPENSATION AND EMPLOYERS LIABILITY BINDER. ,This is to acknowledge receipt of an estimated or deposit premium payment and your application for coverage through the Florida Workers' Compensation Joint Underwriting . Association , Inc. ( FWCJUA) . The FWCJUA is providing coverage under this binder for 30 days, beginning at 12 : 01 a . m . on the effective date shown above . Coverage is provided under the Workers ' Compensation Law of Florida only. Employers Liability coverage is also provided subject to the following standard limits : Bodily Injury By Accident : $ 100, 000 - each accident Bodily Injury By Disease : $ SOO, 000 - policy limit Bodily Injury By Disease : $ 100, 000 - each employee If additional limits were requested, those limits are detailed on the following page. The policy issued will be written in the name of the Florida Workers Compensation Joint Underwriting Association , Inc. and services will be provided by the company listed below. Please retain this binder as evidence of coverage until you receive your policy. :-r 1 : COMPANY: TRAVELERS P. O . Box 3556 Orlando FL 32802 (800) 247-7218 AGENCY: CINDY MCCALL HAYNES & HAYNES INSURANCE 2222 COLONIAL ROAD SUITE 100 FORT PIERCE FL 34950- 5309 (772) 461 -6040 2817C618 / 72570 _ _ 1 FWC I FWC] UA Premium Calculation This premium calculation is ESTIMATED based upon information presented . L - EXCHANGE CLUB CENTER FOR THE PREVENTION OF CHILD ABUSE OF THE TREASURE COAST INC DBA EXCHANGE CLUB CASTLE Tier 3 Effective Date : 12/06/2005 Governing Class - 8861 Increased Limits - soo/soo/500 (See Page Two for Officer Information) Class Code Emolovees Payroll Rate Premium 8861 CHARITABLE OR WELFARE ORGANIZATION 49 $810,000 .00 1 .68 . _ . $ 13, 608 9110 CHARITABLE OR WELFARE ORG.-ALL OTHER 0 - $0 . 00 9.38 $0 Officers Total Payroll $0 $0 $0 Employees Total Payroll $810,000 $ 13,608 $ 13,608 Voluntary Market Terrorism Surcharge 0. 03 $243 . 00 Increased Limits Factor 0. 80 $ 109 Experience Modification 0 .92 97 Risk Adjustment Program Surcharge Factor 1 .00 $-1 ,0$0 $0 JUA Surcharge 1 . 70 $0 $22,207 Plus Expense Constant Assigned Risk Flat Fee $200 Total Estimated Annual Premium $475 $35,745 Advanced Premium Required 0. 50 1 ,000 Minimum 17,872 Deposit Required 0.50 $6500 0 Total Down Payment Required 17,872 Actual Deposit $ 19,354.00 Sufficient Additional Premium Due $ 0.00 Printed : 12/15/2005 4 : 47 : 12PM Assignment Additional Notice Notice COVERAGE FOR THIS EMPLOYER HAS BEEN PLACED THROUGH THE FLORIDA WORKERS ' COMPENSATION .. , . JOINT UNDERWRITING ASSOCIATION , INC . ( FWCJUA) . AS THE FWCJUA IS THE MARKET OF LAST RESORT, COVERAGE SHOULD CONTINUE TO BESOUGHT THROUGH THE STANDARD/VOLUNTARY MARKET. PLEASE NOTE THAT PREMIUMS IN THE FWCJUA MAY BE HIGHER THAN THE STANDARD/VOLUNTARY MARKET AND THIS EMPLOYER MAY BE SUBJECT TO FUTURE ASSESSMENTS . IF AN OFFER OF COVERAGE IS OBTAINED FROM A VOLUNTARY MARKET INSURER GROUP SELF-INSURERS ' FUND, COMMERCIAL SELF-INSURANCE FUND, OR AN ASSESSABLE MUTUAL INSURER, THIS EMPLOYER IS NO LONGER ELIGIBLE FOR COVERAGE THROUGH THE FWCJUA . ACCEPTANCE OF COVERAGE THROUGH THE FWCJUA BY AN EMLOYER CREATES A CONCLUSIVE PRESUMPTION THAT THE EMPLOYER IS AWARE OF THIS POTENTIAL. EMPLOYER : SINCE YOU HAVE BEEN UNABLE TO SECURE WORKERS ' COMPENSATION INSURANCE THROUGH ANY OTHER INSURANCE PROVIDER, YOUR COVERAGE IS BEING OFFERED THROUGH THE FLORIDA WORKERS ' COMPENSATION JOINT UNDERWRITING ASSOCIATION ( FWCJUA) AND YOUR PREMIUM IS SURCHARGED . If a policy issued, pursuant to an assignment under the FWCJUA, is cancelled due to the employer's failure to comply with terms or conditions of the policy, such employer may be ineligible for further coverage under the FWCJUA. 1 Service Provider: Form UCT-6 or its equivalent is attached . 2 Service Provider: A list of all employees for this employer is attached. 3 Service Provider: Experience Rating Worksheet is attached . 4 ERM- 14 is attached 5 Service Provider: Applicant 's Affidavit is attached . 6 Service Provider: Employment and Wage Information Release Agreement attached. 7 Employer: Since you have been unable to secure workers' compensation insurance through any other insurance provider, your coverage is being afforded by the Florida Workers Compensation Joint Underwriting Association. ( FWC3UA) and your premium is surcharged . 8 The FWCJUA does provide limited coverage for exposures in other states that are incidental with respect to Florida employers and employees, but the FWCJUA will not provide coverage for any known or anticipated workers' compensation exposures in states other than Florida . .9 You have been assigned to Tier III, which is an assessable plan and is subject to a 170% surcharge on the annual premium . Employers qualifying for Tier III shall be required to contribute on a pro- rata-earned-premium basis the money necessary to meet any assessment levied to cover any deficit attributable to Tier III. 10 All Parties : For purposes of coverage with the FWCJUA, any employer enrolled in an employee leasing arrangement will be deemed the Employer for both its leased and non-leased workers. Therefore, a client/ employer entered into a leasing arrangement to fulfill its statutory obligations to its workers through the FWCJUA shall be responsible to pay premiums to the FWCJUA that includes remuneration paid to both leased and non -leased workers . AA Increased Limits : (in thousands) 500 / 500/ 500 zai 7Ce1 a i 72570 2 Failure to submit the information requested may result in cancellation of the policy. fo report a claim prior to policy issuance, please call 1 - 800 - 832 - 7839 . Producer/ Employer: A State Authorized $2, 500 Deductible Plan is available . Please contact the Service Provider for an application and information regarding how to qualify . There is no premium credit associated with this option . WORKPLACE SAFETY The FWCJUA is constantly seeking effective ways to provide our Insureds with opportunities to improve safety in the work place . To enhance the many loss control and safety services provided by our Service Provider, St. Paul Travelers, the FWCJUA has partnered with The Online Safety and Security Store ( "TOSSS " ) . TOSSS provides " best in class" safety products, programs and services to clients in order to save lives, reduce costs and increase companies' profitability . TOSSS serves as the Internet's one stop safety store, which empowers FWCJUA customers to shop for safety products, take online safety related courses, catch up on the latest safety related news and OSHA regulations, or find an additional consulting service that is right for their companies - all from a single place on the Web . In order to access the site, click on the " Loss Control & Safety bar in the " Employer" section of the FWCJUA Homepage and then click on the "The Online Safety Store " link . l 2817C618 172570 3 I WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 20 TERRORISM RISK INSURANCE ACT ENDORSEMENT This endorsement addresses requirements of the Terrorism Risk Insurance Act of 2002. Definitions The definitions provided in this endorsement are based on the definitions in the Act and are intended to have the same meaning. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments. "Act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case the United States mission or certain air carriers or vessels. d. The act has been committed by an individual or individuals acting on behalf of any foreign person or foreign interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. ( _ "Insured terrorism or war loss" means any loss resulting from an act of terrorism (including an act of war, in the -- case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at United States missions or to certain air carriers or vessels. "Insurer deductible" means: a. For the period beginning on November 26, 2002 and ending on December 31 , 2002, an amount equal to 1 % of our direct earned premiums, as provided in the Act, over the calendar year immediately preceding November 26, 2002. b. For the period beginning on January 1 , 2003 and ending on December 31 , 2003, an amount equal to 7% of our direct earned premiums, as provided in the Act, over the calendar year immediately preceding January 1 , 2003 c. For the period beginning on January 1 , 2004 and ending on December 31 , 2004, an amount equal to 10% of our direct earned premiums, as provided in the Act, over the calendar year immediately preceding January 1 , 2004. d. For the period beginning on January 1 , 2005 and ending on December 31 , 2005, an amount equal to 15% of our direct earned premiums, as provided in the Act, over the calendar year immediately preceding January 1 , 2005. FLORIDA rurrrn of Ditlrsvision of Workers' Compensation FWARC[AL E[ [ CES j Tom Gallagher, Chief Financial officer . IMPORTANT WORKERS' COMPENSATION INFORMATION FOR CONTRACTORS • • ' - • every employee. The contractor or loos not have a valid workers' must notify the employee leasing corn 1 ) A contractor or subcontractor who company o£ the names of alt The ration exemption; the Florida contractor must contact his or her is engaged in-the construction covered employees and any workers' compensation insurance industry and employs one or moreadditional employees that are carrier to employees must have Flonda working on a jobsite that ma have update his or her policy to . workers Y include such sub-contractor and any compensation insurance. been excluded from the employee Corporate offwwers, In addition to leasing arrangement_ Any clean personsMatis employed by such limited tiabrTdy � in duties performed by the ° company members, lob pe sole Proprietors, partners, and employees must also be reported to Independent contractors engaged the en?ployee leasing company, • ' in the'cbnstniction industry are y considered employees under 5) Flease see the reverse side of this 1 ) The Florida Division of Workers' Florida's workers' flyer for information about obtaining Compensation is responsible for . compensation workers' compensation insurance enforcing emptoye(ixrmpfiar>ce law. However, a contractor or and for the eligibility requirements for i with the coverage requirements' sub-contractor who Is engaged in a construction Indust ex of the workers' the construction in Industry exemption. compensation law. industry and is a corporate,officer oca member of a • f rance-investigators have Compf fimited-TiablTiiy • • . ® the authority to conduct on-site . can apply irispectiorns of job sites to ensure for and obtain avalid construction 1).. An outof-sfate contractor ennployer corWkV1ce. trivestigators industryexerrnptionI .Wow• must immediately notify his or can also request an employer's compensation insurance is salt her insurance business records. An em required for ft Contractor's or .. company ' must produce the ptoyer subcontractors or insurance agent that it has .. ' required business employees: employees that are engaging. in work : records within fixe business days 2) A'contractor shall 'require any in Florida. of the di visibn:s written request subcontractor who sub contracts for.recocds. if the employer fails to work from a contractor to. 2) An out-of-state construction Industry respond to the request within five provide contractor who has employees evidence of Florida workers business days, the division will . engaged in work in Florida, usstop compensation insurance. If t issue a either obtain a Florida workers' work order upon, the, the sub contractor has a valid �tnptoygr requrrfn l the emplayvr £o ezern Gon. .. ca�rPensation insurance policy or ceaseAlf business P them the subcontractor an errdorsement.must be added to state. oPe(atloKs m tfie shatl also provide a copy of his or therout zif3tate co her certificate of exemptionfttractors policy 2) A stop work order will also be ` to the that tilts no in recti°n 3A of the , contractor. issued to policy. any employer who is 3) A change in job duties performedLrequired to secure Florida workers' by employees orae increase in the 3) A Florida construction contractor compensation coverage but fails to engaged In work in this state do so. A stop work ceder will also be amount of payroll of a business issued in cases where an employer must be reported to the Insurance ° contracts with outof-state company- contractors, must require proof of may have a workers' compensation a Florida workers' compensation policy but understates or conceals 4) If a contractor has secured workersPolicy or an endorsement to the out- i Payroll, misrepresents or conceals compensation coverage for his or of-state contractor's policy that lists employee dales or falls to utilize her employees by entering into an Florida in section 3A, of the policy. Florida's class codes and workers' employee leasing arrangement, If the out-of-state subcontractor compensation rates. the contractor must specifically does not provide proof of .a Florida 3) In order for the division to release a identify coverage for each and workers' compensation policy or stop work order, an employer must of an endorsement to the policy, provide evidence that is has .come