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2006-331U.
INDIAN RIVER COUNTY a t) u 6 - 3J GRANT CONTRACT This Grant Contract (" Contract") entered into effective this G%G 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 Indian River County Healthy Start Coalition , Inc. ( Recipient), of: Indian River County Healthy Start Coalition , Inc 1603 10" Avenue Vero Beach , Florida 32960 TLC 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 . Purpose 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: TWENTY FIVE THOUSAND , DOLLARS ($25, 000) . 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 . INDIAN RIVER COUNTY BOARD OF COMMISSIONERS By: l' �al ''wl Gary 'C.. --Wee/ler, Chairman BCC Approved:, Attest: J . K. 114hon , Clerk ) By "SCA Jw X Deputy Clerk Approved . _ l Josep i A. Baird County Administrator Approved as to form and legal sufficiency: j2Mari�an E . Fell , Assistant unty Attorney RECIPIENT: By: Indian River County Healthy Start Coalition , Inc - 4 - EXHIBIT A (Copy of complete Request for Proposal ) EXHIBIT - A - ` Indian River County Healthy Start Coalition , Inc. TLC Newborn Program Children's Sen ices Advisory Committee Grant 2006-07 PROGRAM COVER PAGE for 2006-2007 Organization Name : Indian River County Healthy Start Coalition, Inc. Executive Director: Leslie Spurlock E-mail : Ispurlock(apirchealthystart .org Address : 1603 10th Avenue Telephone : 772-563 -9118 Vero Beach. FL 32960 Fax : 772-563 -9125 Program Director: Linda Roberts E-mail : Linda_Roberts2@doh . state . fl .us Address: IRC Health Department Telephone : 772-794-7484 190027 Ih Street, Vero Beach, FL 32960 Fax : 772-794-7482 Program Title: TLC Newborn Program Priority Need Area Addressed: Parental Support and Education Support caregivers, a child ' s most important resource, to be and do what is needed to shepherd children to adulthood in a safe healthy, and productive manner. Brief Description of the Program : TLC Newborn is a responsive accessible evidence based non- iudgmental parenting resource and support program designed to assist all IRC parents and babies in establishing a healthy emotional, physical and mental environment during baby ' s first year of life The TLC (Touch, Love, Communicate) Newborn Program falls under two taxonomies: PH-610. 180 — Expectant/New Parent Assistance, which provides services and education for new parents to prepare them for emotional and practical aspects of parenting and to promote bonding and nurturing of the newborn PH-620. 150 — Communication Training - helps parents communicate with children health professionals and other parent/infant interaction skills focusing on positive growth and development SUMMARY REPORT — (Enter Information In The Black Cells Only) Amount Requested from Funder for 2006 /07 : $ 25 , 000 . 00 Total Proposed Program Budget for 2006 /07 : S 993700 . 00 Percent of Total Program Budget : 25 . 1 % Current Program Funding ( 2005 ;06 ) : $ 20 , 000 Dollar increase /( decrease ) in request: $ 51000 Percent increase /(decrease ) in request * * 25 . 0 % Unduplicated Number of Children to be served Individually : 15657 Unduplicated Number of Adults to be served Individually : 1 , 426 Unduplicated Number to be served via Group settings : _ Total Program Cost per Client : 32 . 34 * *If request increased 5 % or more, briefly explain why: The budget includes : one additional staff to serve a target population projected to increase by 17% funds to certify personnel as lactation counselors ; 1 additional clerk position needed as a result of revising program evaluation and the program' s database because data collection and input will increase. If these funds are being used to match another source, name the source and the $ amount: NA. The Organization 's Board of Directors has approved this application on (date).) J j '7� 1�2 C�� Debbie True Name of President/Chair of the Board i _tura , Leslie S urlock Name of Executive Director/CEO ig ature 3 Indian River County Healthy Start Coalition, Inc. TLC Newbom Program Children's Services Advisory Committee Grant 2006-07 ORGANIZATION : Indian River Countv Healthv Start Coalition, Inc. PROGRAM : TLC Newborn Program TABLE OF CONTENTS for 2006-2007 Please X" the parts of the grant application to indicate that they are included. Also, please put the page number where the information can be located. Section of the Proposal Pa e # X TABLE OF CONTENTS (check list) 1 .2 X COVER PAGE (with signatures) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 A. ORGANIZATION CAPABILITY (one page maximum) X 1 . Mission and Vision of organization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 X 2. Description of program activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 X 3 . Evidence that program strategy will work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 X4. Staffing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 -7 X 5 . Awareness of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 X 6 . Accessibility of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 D. MEASURABLE OUTCOMES (four pages maximum) . . . . . . . . . . . . . . . . . . . . . . . . . X 1 . Measurable Outcomes — Proposed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 -9 X E. COLLABORATION (one page maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 F. PROGRAM EVALUATION (two pages maximum) X1 . Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 X2. Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 X3 . Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 X G. TIMETABLE (one page maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 H. UNDUPLICATED CLIENT COUNT X 1 . Projections by Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 X 2 . Projections by Age Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1 Indian River County Healthy Start Coalition, Inc. TLC Newborn Program Children's Services Advisory Committee Grant 2006-07 I. BUDGET FORMS 1 . Financial Budget Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 X 1 . Budget Narrative Worksheet 4pages B- ] A, 113, 1C, 1D X 2. Total Agency Budget 1 page B-2 X 3 . Total program Budget 1 page B-3 X 4. Funder Specific Budget 1 page B-4 X 5 . Explanation for Variances 2 pages B-5A, 5B J. APPENDIX X 1 . List of Current Officers and Directors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 X 2. IRC Healthy Start Coalition Financial Audit — Year ending June 30, 2005 16-31 X 3 . IRC Healthy Start Coalition IRS Form 990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-51 X 4. IRC Healthy Start Coalition Balance Sheet and Operating Budget . . . . . . . . . 52- 53 X 5 . Staff Organizational Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 X 6 . 501 (c)3 IRS Exemption Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 -57 X 7 . Articles of Incorporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58-64 X 8 . Agency Bylaws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65-72 X 9. Agency policy regarding Affirmative Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 X 10. Not for Profit Agency Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 X 11 . Authorization for Release of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 X 12. Nepotism Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76-77 X 13 . Taxonomy Definition for Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 X 14. Goal Testing Materials - Attached 2 ' Indian Riser County Healthy Start Coalition, Inc. TLC Newbom Program Children's Services Advisory Committee Grant 2006-07 PROPOSAL NARRATIVE A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page) F e mission statement and vision of your organization. Our mission is to system in Indian River County that guarantees all women access to prenatal care ants access to services that promote normal growth and development. Our vision is every family the opportunity to maximize their child' s potential before, during and . Our programs concentrate on the significance of caregivers ' relationships with the use caregivers are the infant ' s environment; an environment that impacts the infants physical well being and emotional/mental health for life. 2. Provide a brief summary of your organization including areas of expertise, accomplishments, and population served. The Coalition, incorporated in 1993 is a private not for profit established by Indian River citizens interested in having local control of state and federal dollars for maternal child health. Through a state legislated grant for this private- public partnership, the Coalition is annually awarded operating funds of 5150,000 per year to plan, implement and evaluate maternal child health in Indian River County. Through contracts with the State of Florida the Coalition is the sub-recipient of federal and state dollars. These program dollars are allocated to providers for services for pregnant women and infants by the Coalition board. The Coalition is authorized by statute to establish collaboration among maternal child health providers that promotes and expands access to services for pregnant women and infants up to age five. Since the Coalition was organized, the county' s infant death rate has dropped from a rate of 12. 04 in 1993 to 3 . 63 in 2003 . All pregnant women and infants in the county are served by the universal Healthy Start risk screenings and depending on their need, are provided opportunities to participate in Healthy Start, TLC Newborn and Healthy Families. Universal screening of newborns has risen from a low of 41 % three years ago to 93 % in 2005 . Healthy Start and Healthy Families programs provide services for children beginning prior to birth. Both Coalition and program staff work with IRMH and providers (obstetric and pediatric) to facilitate entry. Additionally the Coalition administers MomCare, a Medicaid Choice Counseling program that is contracted out to IRC Health Department. Because the Coalition is the lead agency for all four, we are in a position to implement efficiencies, eliminate duplication and facilitate movement of families between programs as their needs are identified. Indian River Healthy Start Coalition uniquely focuses on programs that provide child services at the earliest stages of a child' s life because research has shown that bonding; of parent to child, and attachment; of child to parent, has a lifelong impact on a child ' s life affecting school readiness and their mental, emotional and physical health as they grow into adulthood. 4 Indian River County Healthy Starz Coalition, Inc . TLC Newborn Program Children 's Services Advisory Committee Grant 2006-07 &PROGRAM NEEDS STATEMENT (Entire Section B not to exceed one page) a) What is the unacceptable condition requiring change? Upon arriving home a day or two after giving birth, mothers are thrust into monumental change, unexpected fatigue and never ending demands of a newborn infant. It is her time to bond with baby, but confidence wanes over sleep patterns, breastfeeding and family dynamics, especially if there is difficulty breastfeeding. Professional support is critical in the first few weeks post delivery' . If she becomes unsure, she may feel guilty and desperate about being unable to cope. Without the necessary support that will nurture her and her baby, it may lead to feelings of loneliness, insecurity or depression2; conditions that are unacceptable for a newborn' s mental, emotional and physical well being. Mothers need accurate information and one on one support that is responsive, timely, accessible, impartial, and non-judgmental. b) Who has the need? All mothers (families), because the need for accurate information and support does not stop at birth. If mothers lack this necessary support after childbirth, especially if breastfeeding it may put the infant' s environment, development and the family at risk. c) Where do they live? Indian River County. d) Provide local, state, or national trend data, with reference source, that corroborates that this is an area of need. For information on parenting, breastfeeding and child development, new parents most often turn to each other, their own mothers and pediatricians. Promotion and support of breastfeeding are critical health needs as defined by Healthy Goals 2010. New parents lack knowledge, physicians limit time with families and there is a significant gap in grandparents ' knowledge about appropriate responses to a child ' s needs . Although it is an appropriate response, 60% of grandparents and 44% of parents believe picking up a 3 month old every time she cries will likely spoil a child. They are misinformed about the effects of not always responding to a baby' s cry. Only one third of parents feel "very prepared" for parenthood even though 71 % of them understand infant brain development and experiences in the first years of life have a significant impact. A parent experiencing depression or anxiety can have a detrimental affect on the infant' s development, yet 61 % of all adults and 55% of parents did not know when young babies begin to be affected by the moods of others. "How corn etP ent a parent feels can be a major factor in the parent ' s support of their child's development. "' The need is met when supportive, responsive TLC Newborn family associates connect with parents and relay appropriate, research based, up to date information that will increase confidence, breastfeeding success, parenting skills and the baby' s environment. Confident parents armed with updated information and appropriate responses to their baby' s needs enhance their baby' s environment and their mental, emotional and physical well-being. b) 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. Through universal Healthy Start risk screening, Healthy Start and Healthy Families serve a small percentage of pregnant women (33 %) and newborn families ( 13 %) identified at risk for poor outcomes. A universal screen is used to evaluate the pregnant woman ' s eligibility for these two home visiting programs that address specific risks. For every $ 1 invested in Healthy Start support services $6 are saved in costs of caring for an unhealthy baby. Although effective, eligibility is based on risk not need. All parents need a source for accurate information that will establish a healthy environment during baby' s first year. TLC support services are unique because they are available to families of ALL babies born to residents of Indian River County regardless of risk. Ryser FG. Breastfeeding attitudes, intention and initiation, Journal of Human Lactation 2004; 20(3):300-5 3 What Crown-Ups Know About Child Development, a National Benchmark Survey , www.zerolothree.org ' DYG, Inc., What Grown- Ups Understand About Child Development: A Nab'onal Benchmark Survey- Zero to Three. Executive Summary.July 2000 5 Indian River County Healthy Start Coalition . Inc. TLC Newborn Program Children 's Services Advisory Committee Grant 2006-07 C. PROGRAM DESCRIPTION (Entire Section C, 1 — 6, not to exceed two pages) 1 . List Priority Needs Area. Parental Support and Education. Support caregivers, a child ' s most . important resource, to be and do what is needed to shepherd children to adulthood in a safe, healthy, and productive manner. rknown . 71atch be program activities including location of services. Mom is introduced to tal, where a Family Associate conducts a needs assessment; gently exploring ce, concerns, and support system. IRMH personnel highlight specific needs if ding moms receive extra postpartum education ; TLC associates help foster and positioning, assist mom in reading baby ' s feeding cues, give written all her within 1 -2 days after discharge to check on progress and offset potential problems. Moms are called within 7 days if not breastfeeding. Calls are made weekly the first month, bi-weekly the second, then once a month until the baby is six months of age. With TLC, mom can discuss her concerns and receive current information about sleep patterns, breastfeeding, family dynamics, postpartum check up, outside support, and emotional disposition as well as baby' s recognition of parents, bonding, discomforts experienced, vocalizing, check-ups, and immunizations. Concurrently an age appropriate newsletter is mailed out monthly during baby' s first year. Moms report looking forward to receiving calls and the newsletters. 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 . Through conversation with TLC, mom is provided accurate, non judgmental, evidence based information and gains confidence to parent with appropriate responses to baby' s cries and physical needs (feeding or breastfeeding and newborn care). Her responses to her baby are the environment that nurtures baby' s mental and emotional need for attachment. Monitoring of weight gain for breastfeeding babies is paid special attention. Because TLC protocols monitor or facilitate well baby check-ups, immunizations, weight gain and breastfeeding support, TLC supports baby' s physical needs. Written information requested by mom on topics specific to each family' s needs is immediately mailed. If needs are identified but are outside the capacity of TLC, (i. e. domestic violence, post partum depression, or substance abuse) mom is referred to outside resources. TLC continues to call and give specific support, such as breastfeeding counseling, that is not provided by outside resources. 4. List staffing needed for your program, including required experience and estimated hours per week in program for each staff member and/or volunteers. Staffing currently includes a Program Manager 32hrs/week, Assistant Manager 20 hrs/week, three Family Associates and one Clerical Assistant who work 10 hours a week. Linda Roberts - Program Manager, BS . Certified Labor Assistant/Doula. Certified Lactation Counselor. Experience: Director of Arbitration, Better Business Bureau; Director of Constituent Services; NYS Senator; Dealer Operations Coordinator, Chevrolet division of GM . TLC 3 years . Susan Holland . RN - Assistant coordinator. RN, MPH . Experience: Nursing Instructor. She has been with TLC 9 years, since inception. Carmen Stork BS, Bilingual Family Associate. Experience : Cellular Biologist. TLC 6 years. Maureen Campeau, Family Associate. Experience : 18 years with the 6 Indian River County Healthy Start Coalition, Inc. TLC Newborn Program Children's Services Advisory Committee Grant 2006-07 Childbirth Education Association, Sibling Instructor and Lamaze Assistant. TLC 1 year. Mary Rainer, Family Associate . Accredited LaLeche League Leader, Midwife Assistant, Board of Directors Treasure Coast Breastfeeding Task force. Experience: Breastfeeding Counselor for St . Lucie County WIC. With TLC nearly 1 year. Maggie Foreman BS, Clerk. Experience: Indian River County School Teacher. With TLC 3 . 5 years. We propose an additional Family Associate and Data Assistant to handle an increase in the target population and increased program evaluation. 5. How will the target population be made aware of the program? TLC initiates contact at the hospital after the birth of the baby. IRMH personnel are knowledgeable and enthusiastic supporters of TLC ' s Family Associates, talking to new families and recommending TLC resources . Because TLC Newborn is in its eighth year, and has served over 8, 000 babies and their families (at least another 8 ,000 mothers), new mothers are often made aware of the program through word of mouth, or from obstetric and pediatric offices, Healthy Start, Indian River County Health Department, Healthy Families, MomCare, and Indian River Memorial Hospital. TLC brochures describing program services are distributed through these providers . Some births occur at home, in adjacent counties by choice or because of medical risks . Because TLC is widely known, they are sometimes notified of an impending birth by the mother herself or by local physicians and midwives. Coalition and TLC personnel promote TLC Newborn by participating in community events . The community at large is made aware through publication of fundraising events, local news articles and letters to the editor. The Coalition has begun working with CareNet, a local crisis pregnancy center to promote TLC, as well as other Coalition programs, prenatal care and Medicaid accessibility. 6. How will the program be accessible to target population (i.e., location, transportation, hours of operation)? TLC Family Associates adjust their schedules to visit moms in the hospital six out of seven days a week (including holidays, Saturdays and Sundays). They consult with staff at IRMH every day of the week so the most number of deliveries can be accommodated. If moms are breastfeeding, IRMH nurses often refer them to TLC ' s certified breastfeeding counselors for postpartum breastfeeding support while they are in the hospital. One of the two certified breastfeeding counselors on TLC ' s staff will respond to the mother's needs. 7 Indian River County Healthy Start Coalition, Inc. 'ILC Newborn Proo am Children 's Services Advisory Committee Grant 2006 K D-2. MEASURABLE OUTCOMES - PROPOSED. (Section D-2 not to exceed two pages) OUTCOMES ACTIVITIES List all o the elements for the Measurable Outcome(s) List the tasks to accomplish the OutcomlHealthy 1 . GOAL : 93 % of mothers visited by TLC 1 . Moms will be visited and offered th Family Associates in the hospital will accept program in the hospital after birth of th the invitation to participate in the TLC The program will continue to be promo Newborn Program. through obstetric and pediatric offices, Start, Indian River County Health Department, Healthy Families, MomCare, and Indian River Memorial Hospital . 2. GOAL : 15% of families enrolled in TLC 2 . This goal has been increased from 7.5 % will call to request additional information, based on last year' s actual of 13 % plus 2%. validation or referrals. Families enrolled with TLC will continue to be encouraged to call associates with questions and issues of concern about parenting their baby. 3. GOAL : 80% of TLC families responding 3 . Surveys will be mailed to all participants at to the survey will agree that TLC Newborn 3 months and at one year. This goal measures is a valuable resource for parents. TLC ' s strength as a local, accessible resource for new parents. [Whereas survey response rates of 10% are considered successful, TLC receives a 20%-40% rate of response to its surveys. ] 4. GOAL : 50 % of TLC families responding 4. Surveys will be mailed to all participants at to the survey will report they are better able 3 months and at one year This is a new goal to meet their baby' s needs because of reflecting the value parents place on information received from TLC. information received from the program . Surveys will be modified to collect data. 5. GOAL : 75% of families calling to request 5 . A new goal with a projected baseline of additional information will report their 75%. Actual will be established during FY 06- issue resolved or managed by TLC ' s 07 . TLC Associates will conduct follow-up response. calls with participants. Follow up calls will require asking parents if TLC information helped them to resolve or manage their parenting issue(s) and it will be documented in record. (6. on next page) 8 Indian River County Healthy Start Coalition, hic. TLCNe%vbom Program Children 's Services Advisory Committee Grant 2006-07 D-2 . MEASURABLE OUTCOMES - PROPOSED . (Section D-2 not to exceed two pages) OUTCOMES ACTIVITIES List all of the elements or your Measurable Outcome(s) List the tasks to accomplish the Outcome(s) 6. GOAL : 75 % of TLC parents who wish to 6 . All TLC Associates will provide evidence breastfeed their infant will receive evidence based lactation education when visiting new based lactation education in the hospital moms in the hospital. We propose to certify from TLC Newborn staff. two additional TLC Family Associates as lactation counselors in 06-07 . 7. GOAL : 75% of Indian River County 7. Evidence based lactation information and maternal/child health practices will have a best practices guidelines will be distributed in minimum of one staff person equipped with cooperation with IR-MH to professionals on evidence based lactation information and staff, IRC Health Department, pediatric and best practices guidelines. obstetric offices . Staff will be invited to join the IRC Breastfeeding Task Force, established this year as a community forum for improving the lactation experience for new babies and moms. It provides and disseminates evidence based lactation information and best practices to IRC maternal/child health professionals. The IRC Breastfeeding Task Force will link certified lactation counselors with maternal/child health practitioners, a minimum of 4 times a year to promote best practices, lactation education and training. 9 Indian River County Healthy Start Coalition, Inc. TLC Newborn Proe am Children's Services Advisory Committee Grant 2006-07 E. COLLABORATION (Entire Section E not to exceed one page) 1 . List your program's collaborative partners and the resources that they are providing to the program beyond referrals and support Collaborative A en Resources provided to the program Indian River County Health IRCHD provides free personnel services, payroll services, Department storage space, cleaning, office space, conference rooms, fax All resources provided without an and phone service and access to office equipment for administrative ee. copying, printing and postage. Indian River County Healthy Start IRHSC provides program development, training Coalition opportunities, integration and consistent communication among programs and the community, grant writing and All resources provided without an development, fundraising, PR, QA/QI, budgeting and fiscal administrative fee. accountability, marketing, presentations, and representation of TLC in the community. Indian River Memorial Hospital Provides access to mothers with strict adherence to confidentiality guidelines ; storage space for TLC All resources provided without an paperwork, manuals and references, positive promotion of administrative fee. TLC by hospital staff, access to labor and delivery staff, and communication between medical providers and TLC staff. IRC Healthy Start Care Care coordinators raise awareness of TLC through contact Coordination Program with mothers of babies born outside of IRC and coordinate services between TLC and Healthy Start depending on the family's risk factors. For families who have been identified as having a specific risk, Healthy Start will provide risk appropriate case management for up to three years if needed; serving families who are not capable of managing the risk themselves (i .e. teen moms, homeless, multiple births, medical needs, developmental delays, domestic violence, drug or alcohol abuse, postpartum depression) . If a specific risk is not identified, care coordinators offer to link moms with TLC support. IRC Healthy Families Program Family Support Workers begin during the prenatal period to link parents to TLC services and Wee Wisdom newsletter. Provides parenting guidance through structured home visits; teaches Great Growing Kids curriculum, enhancing parenting skills and the child' s development. 10 Indian River County Healthy Stan Coalition. Inc. TLC Newbom Program Children 's Services Advisory Committee Grant 2006-07 F. PROGRAM EVALUATION (Entire Section F not to exceed Avo pages) 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 Bl ? The TLC Associate visiting mom in the hospital uses the TLC Intake Form to collect demographic data. We will collect the family' s address to qualify them for our target population . Being a resident of Indian River County with a newborn baby is the only requirement qualifying a family for TLC. If baby is born at home or has had to be transferred out of county for medical reasons, TLC will contact the family by phone to offer the program, collect the data and conduct an intake. By accepting the invitation to participate in the TLC Newborn program, the parents of newborns reveal their need for the program ' s resources and the method in which they are delivered. MEASURES : What data elements will you need to collect to show that you have achieved (or made progress toward) your Measurable Outcomes in Section D? What tools or items are you using as measures (grades, survey scores, attendance, absences, skill levels) for your program? Are you getting baseline information from a source on your Collaboration List in Section E ? Are there results from your Activities in Section D that need to be documented? How often do you need to collect or follow-up on this data? Data elements collected by Family Associates will be the number of families accepting the invitation to participate during intake, the number of families calling to request additional information, validation or referrals, and the number of families reporting their issues resolved or managed by TLC ' s responses. These will be collected per encounter and documented in TLC records . Revised surveys will be the vehicle to collect data on the number of families who agree TLC is a valuable resource and who report they are better able to meet their baby' s needs (using a 5 point Likert scale) . Revised surveys will be mailed at 3 months and 12 months after initiating services. Lactation education will be collected at intake and follow-up. The distribution of lactation guidelines and training attendance will be documented by the Coalition. REPORTING : What will you do with this information to show that changer has occurred? How will you use or present these results to the consumer, the funder, the pogram, and the community? How will you use this information to improve your program? The report will track successful promotion of TLC Newborn, entry and use of the program, the value parents place on TLC as a resource, and the effectiveness TLC has in helping parents solve issues with their newborn infant. One component will track lactation education that prepares moms and babies for a healthy and successful breastfeeding experience . Reports are presented to all funders, the Coalition Board of Directors, the Health Department and the TLC Advisory Committee. TLC ' s program manager meets with Coalition personnel to review program successes, challenges, and solutions at the Program Manager' s meeting (conducted bi-monthly) . Periodic verbal reports are given at TLC Advisory meetings (quarterly) and Coalition Board meetings (held monthly). Consumers suggest improvements to the program through conversation with Family Associates and through surveys. Funding agencies provide suggestions for improvements through the grant process and site reviews . We plan to provide an annual report to consumers that will be mailed to parents with their TLC newsletter. 11 Indian River County Healthy Start Coalition, Inc. TLC'. newborn Proe m Children 's Services Advisory Committee Grant 2006-07 G. TIMETABLE (Section G not to exceed one age) 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 All components of the TLC Newborn Program are in place, with a veteran TLC staff providing services. Hospital visits take place six days a week including weekends and holidays. The major programmatic action steps and activities of the TLC program are the following: Daily Hospital visit by TLC Associate * Retrieve security badge from Social Workers office. * Visit matemity ward nurses station for list of new deliveries . * Review list with TLC log for families who have been previously visited. * Prepare intake and request for services forms as well as TLC brochure. * Present TLC program to mom and family of newborn. * Complete intake form and have mom sign agreement to services form. * Repeat visit to all mothers of newborns not previously seen. * Complete TLC log located at hospital. I " month Office: * Continue intake process, including logging information on computer and setting up file of family. * Assign families of newborns to TLC Associate within one week. * Send customized mailing based on family' s needs. * Call families of newborns weekly for one month after birth of newborn. * First "Wee Wisdom" newsletter is mailed. Monthly * During second month (from birth), phone calls are made every two wks. * From third to sixth month (from birth), calls are made one time per month. * Age (month) appropriate newsletter is mailed each month. * On second Friday of each month, newsletters are compiled for monthly mailings. * After 3r and 12t month, appropriate program evaluation surveys are mailed. 12 Indian River County Healthy Start Coalition, Inc. TLC Newbom Program Children's Services Advisory Committee Grant 2006-07 H. PROJECTIONS FOR UNDUPLICATED CLIENTS Number of Unduplicated Clients by Location Last Fiscal Year Current Fiscal Year Next Fiscal Year Location Actual 2004/2005 Budget 2005/06 Projections 2006/07 Unduplicated Clients Unduplicated Clients Unduplicated Clients N. Indian River County 2, 142 2,571 3 ,083 S. Indian River County - - - Indian River Co. Total 2, 142 2,571 35083 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 1 2, 142 25571 3,083 Number of Unduplicated Clients by Age Last Fiscal Year Current Fiscal Year Next Fiscal Year Location Actual 2004/2005 Budget 2005/06 Projections 2006/07 IndividualGroup Individual Group Individuah Group 0 to 4 - (Pre-school) 11074 1288 15545 - 5 to 10 - Elementary - _ _ - _ 11 to 14 - (Middle) 4 6 6 - 15 to 18 - (High School) 73 88 - 106 Total Children 1,151 1382 1,657 - 19 to 59 - (Adults) 991 11189 - 1426 60 + (Seniors) - - - Total Adults 991 15189 - 1 ,426 TOTAL SERVED 25142 - 2 ,571 - 35083 - 13 Indian River County Healthy Start Coalition, Inc_ TLC Newbom Program Children's Services Advisory Committee Grant 2006-07 I. BUDGET FORMS - To open the Budget Forms, please double-click on the icon below. In the Excel portion of this RFP you will find the following pages/tabs : BUDGET FORMS CONTENTS 6. Budget Narrative Worksheet 4pages B- IA, 1B , IC 1D 7 . Total Agency Budget 1 page B-2 8 . Total program Budget 1 page B -3 9. Funder Specific Budget 1 page B-4 10. Explanation for Variances 2 pages B-5A, 5B Make sure to print all the forms by going to each tab and selecting the Print icon. 7J 'Cat? Elj:lg I 14 Indian River County Healthy Start Coalition - TLC Newborn Program 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 : Indian River Co. Healthy Start Coalition , TLC Newborn Program FUNDER: Indian River County Children 's Advisory Committee 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 Total Agency Budget Budgef 1 Children's Services Council-St. Lucie 2 Children's Services Council-Martin 3 Advisory Committee-Indian River 25,000.00 25,000.00 25,000.00 4 United Way-St. Lucie County 5 United Way-Martin County 6 United Way-Indian River County 45,200.00 45,200.00 7 Department of Children & Families 8 County Funds 9 Contributions-Cash 10 Program Fees 11 Fund Raising Events-Net 15,000 .00 15,000 .00 12 Sales to Public - Net 13 Membership Dues 14 Investment Income 15 Miscellaneous 16 Legacies & Bequests 17 Funds from Other Sources 14,500.00 14,500.00 18 Reserve Funds Used for Operating 19 In-Kind Donations (not included in total) 20 TOTAL REVENUES (doesn't Include line 19) $99, 700.00 $25,000 .00 $99 , 700.00 A B C EXPENDITURES Proposed Total Program Budget Funder Specific Total Agency Budget Budget 21 Salaries - (must complete chart on next page 73,528 .00 23,223.00 73,528.00 22 FICA - Total salaries x 0.0765 5,624 .90 1 , 776 . 56 5,624.90 Retirement - Annual pension Tor qua l le 23 staff 0.00 0 .00 0.00 Life/Health - e Ica ental ort-term 24 Dib. 0 .00 0 .00 0 .00 Lkers ompensatlon - emp ogees z 25 rate 0.00 0.00 0 .00 Florida unemployment - V projected 26 employees x $7,000 x UCT-6 rate 0 .00 0 .00 0.00 b,,1 !2006 a1 Inman River County Healthy Stan Coalition - TLC Newborn Program SALARIES I Gross 11 IV Annual Sala Portion of Sala on Proposed III % of Gross Annual POSITION LISTING �' Salary P (Agency) Program Funder Specific Budget Salary Position Title / Total Hrs/wk Requested(C/A) Example: Executive Direct"140hrs 70,000.00 10,000.00 5,000.00 7. 14% Program Manager/32 hrs/wkx52x$17/hr 28 ,288.00 28 ,288.00 14, 143.00 50.00% Assistant Manager/20hrslwkx52x$ 13.5/hr 14 ,040 .00 14,040.00 7,000.00 49 . 86% Family Associate A/10hrs/wkx52x$10/hr 5,200.00 5,200 .00 2,080.00 40 . 00% Family Associate B/10hrs/wkx52x$ 10/hr 5,200.00 5,200 .00 0 .00 % Family Associate C110hrs/wkx52x$10/hr 5,200 .00 5,200.00 0.00% Family Associate D/10hrs/wkx52x$10/hr 5,200 . 00 5,200.00 0 .00% Clerical Assistant A/10hrs/wkx52x$10/hr 5,200 .00 5,200.00 0 .00% Clerical Assistant B/10hrs/wkx52x$ 10/hr 51200.00 5,200.00 0.00% #DIV/01 #DIV/0 ! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0 ! #DIV/0 ! #DIV/0 ! #DIV/0! #DIV/0! Remaining positions throughout the agency Total Salaries 1 $73,528 . 00 $73,528.00 $23,223.00 31 .58% FRINGE BENEFITS DETAIL (Funder Specific Budget I Funder 11 m IV v w v11 Specific Budget FICA 7.65% Column C only, from line 27 to 26) Pension Health Worker's Unemployme Total Fringes Funder(A x %) fns. Compens. nt Compens. Specific Position Title / Total Hrs/wk Example: Case Manag"140hrs 5,000.00 382.50 200.00 500.00 300.00 200.00 1,582.50 Program Manager/32 hrs/wkx52x$ 17/hr 14. 143.00 1 ,081 .94 1 ,081 .94 Assistant Manager120hrs/wkx52xS13 .5/hr 7,000.00 535. 50 535.50 Family Associate A/10hrs/wkx52x$10/hr 1 2,080,001 159. 12 159 . 12 Family Associate 3/10hrs/wkx52x$10/hr 0.00 0.00 0 .00 Family Associate C/10hrslwkx52x$101hr 0, 00 0 .00 0 .00 Family Associate D/ 10hrs/wkx52x$10/hr 0. 00 0 .00 000 Clerical Assistant A110hrs/wkx52x$ 10/hr 0. 00 MD 0.00 Clerical Assistant B/10hrs/wkx52x$ 10/hr 0.00 0.00 0. 00 0 0.00 0.00 0. 00 0 0 .00 0.0o 0. 00 0 0 .00 MID o.00 0 0.001 0. 00 D oo 0 o.00l 0.00 0 .00 0 0001 0.00 0 .00 0 O.Co 0 .00 0.00 0 0. 00 0 .00 0.0 0 0. 00 0.00 0.00 0 0.00 0.00 0.00 0 0 .00 0.00 0. 00 D 0 .00 0.00 0. 00 Total Funder Request Fringe Benefits 2 , 223.00 1 , 77 .56 0.00 .0 0.00 2 +3 5/1/2006 6-0 Indian R.ver County Healtny Start Coalition - TLC Newborn Program A B C EXPENDITURES Proposed Total Program Budget Funder Specific Tota/ Agency Budget Budget 27 Travel-Daily 1 ,647 . 00 1 ,647. 00 # of Staff x average # of miles/wk x 50 wks x $ = Estimated Daily TravellMileage Reimb. Approximately 16 miles/wk x 52 wks x 5 employees @ .29/mile = $1206 28 Travel/Conferences/Training 2,500 .00 2,500 .00 • National Conference (cost per staff) • Training/Seminar (cost per staff) • Other Trainings (cost of travel, lodging, 5 attendees to Brevard Co. Early Intervention training 2 day conference, 2 attendees to National Breastfeeding registration, food) 5 day certification, and professional events. 29 Office Supplies 780 .001 780 . 00 Office supplies (monthly average x 12 months = estimated cost of office supplies based on present history. Office supplies $65 x 12 months 30 Telephone 0 .00 0 .00 # Phone lines x average cost per month x 12 months = local phone cost Average long distance calls x 12 months = Estimated cost of long distance Provided in-kind from Indian River County Health Department 31 Postage/Shipping 5,850 .00 5,850 .00 • Quarterly Mailing of Newsletter • Special events, etc. • Bulk mailings - appeals 32 Utilities 0.00 Electricity ($ x 12 months) 0.00 • Water/Sewer ($ x 12 months) • Garbage ($ x 12 months) Provided in-kind from Indian River County Health Department 33 Occupancy (Building & Grounds) o.001 0.00 • Mortgage/Rent ($ x 12 months) • Janitorial ($ x 12 months) • Grounds Maint. ($ x 12 months) • Real Estate Taxes Provided in-kind from Indian River County Health Department 34 Printing & Publications 3 ,000.00 3 , 000.00 • Quarterly Newsletter ($ x 4) • Letterheads, Envelopes, etc. • Fundraising materials • Other Printing of Wee Wisdom, age appropriate newsletters for baby's first year, business cards, & envelopes 35rSubscription/Dues/Memberships 0.00 0.00rshipto National Organizationptions to Newspapers/magazines,36e 0.000.00 • s/Officers Liab. • rcial/General Insurance • Bond Ins. • Auto Insurance General liability - Indian River County Health Department, D & O In-kind from IRC Healthy Start Coalition 37 Equipment:Rental & Maintenance 0.001 0.00 • Copier lease ($ x 12 months) • Meter lease ($ x 12 months) • Copier Maintenance ($ x 12 months) • Computer Maintenance ( $ x 12 months) • Other 38 Advertising 300.00 300.00 • Newspaper ads • Fundraising ads/promotions • Other (vacancies) 39 Equipment Purchases:Capital Expense 1 ,600 .00 1 ,600.00 • Computer/monitor (# x $) Laser Printer iizuub et 1C Indian River County Healthy Start Coalition - TLC Newborn Program 40 Professional Fees (Legal , Consulting) 150.00 150 . 00 • Legal advice ( estimated #hrs x $) • Consultant fees • Other 41 Books/Educational Materials 500 .00 500.00 • Books/videos • Materials ($ x staff) Issue specific brochures for parents; i.e. postpartum depression, breastfeeding 42 Food & Nutrition 0.00 0.00 • Meals ( # meals x clients x 5days x 50 wks) • Snacks 43 Administrative Costs 2 ,970.00 2,970 .00 • Admin. Cost (% of total budget) 1 °% of total budget. 44 Audit Expense 1 , 100 . 00 1 , 100.00 Independent Audit Review 10% of annual $11 ,000 audit expense 45 Specific Assistance to Individuals 0.001 0.00 • Medical assistance • Meals/Food • Rent Assistance • Other 46 Other/Miscellaneous 15o.001 150 .00 • Background check/drug test • Other Background checks for new employees 47 Other/Contract 0 .001 0.00 Sub-contract for program services 48 TOTAL EXPENSES $99 ,699.90 $24,999 .56 $99 ,699.90 �. .1 5/1 (2006 B-1 I ntlm RiwCojnly Hedlhy Se,l CoaJan -T.4 � , P,p ,r UNIFORM GRANT APPLICATION TOTAL AGENCY BUDGET AGENCY/PROGRAM NAME: Indian River County Healthy Start Coalition , Inc./TLC Newborn Program 06-07 FY 04105 FY 05/06 FY 06107 % INCREASE FYE 6130/05 FYE 6130106 FYE 6/30107 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (col. Ccel. B)IC& 8 REVENUES BUDGETED BUDGETED 1 Children's Services Council-St. Lucie 0.00 #DIV/0! 2 Children's Services Council-Martin 0.00 #DIV/0! 3 Advisory Committee-Indian River 15,000.00 20,000.00 25,000.00 25.00% 4 United Way-St. Lucie County 0.00 #DIV/e! s United Way-Martin County 0.00 #DIVIO! 6 United Way-Indian River County 46,000.00 40,000.00 45,200.00 13.00% 7 Department of Children & Families 0.00 #DIV/0! 8 County Funds 0.00 #DIV/0! 9 Contributions-Cash 0.00 #DIV/0! io Program Fees 0.00 #DIV/el 11 Fund Raising Events-Net 12,000.00 15,000.00 25.00% 12 Sales to Public-Net 0.00 #DIVIO! 13 Membership Dues 0.00 #DIVIO! 14 Investment Income 0.00 #DIVIO! is Miscellaneous 0.001 #DIV/0! 16 Legacies & Bequests 0.00 #DIV/0! 17 Funds from Other Sources 12,500.00 12,500.00 14,500.00 16.00% 18 Reserve Funds Used for Operating 0.00 #DIV/el 197n-Kind Donations /Not mclWe4 in total) 0.00 #DIV/01 20 TOTAL 73,500.00 84,500.00 99,700.00 17.99% EXPENDITURES 21 Salaries 60,589.00 58,136.00 73,528.00 26.48% 22 FICA 4,635.00 4,447.00 5,624.90 26.49% 23 Retirement 0.00 #15IV/01 24 Life/Health 0.00 #DIV/01 25 Workers Compensation 452.00 0.00 #DIV/01 26 Florida Unemployment 0.00 #DIV/01 27 Travel-Dail 2,419.00 1 ,200.00 1 ,647.00 37.25% 28 TravellConferences/Treinin 11000.00 1 ,000.00 2,500.00 150.00% 29 Office Supplies 651 .00 700.00 780.00 11 .43 30 Telephone 0.00 #DIV/0! 31 ;ostage/Shipping 4,374.00 5,200.00 5,850.00 12.50% 32 Utilities 0.00 #DIV/01 33 Occu anc (Building & Grounds) 0.00 #DIV/01 34 Printing & Publications 2,217.00 2,800.00 3,000.00 7.14% 35 Subscri tion/Dues/Membershi s 150.00 0.00 -100.00% 36 Insurance 0.00 #DIVIO! 37 E ui ment:Rental & Maintenance 0.00 #DIV/0! 38 Advertising300.00 300.00 0.00% 39 Equipment Purchases:Ca ital Expense 1 ,600.00 #DIV/0! 40 Professional Fees (Legal, Consulting) 1 ,125.00 150.00 150.00 0.00% 41 Books/Educational Materials 500.00 500.00 500.00 0.00% 42 Food & Nutrition 0.00 #DIV/01 43 Administrative Costs 2,970.00 #DIV101 44 Audit Expense 1 ,100.00 #DIV/0l 45 Specific Assistance to Individuals 0.00 #DIVIO! 46 Other/Miscellaneous 276.00 51000.00 150.00 -97.00% 47 Other/Contract 0.00 #DIVIO! 48 TOTAL 78,238.00 79,583.00 99,699.90 25.28% 49 REVENUES OVERT UNDER EXPENDITURES -4,738.00 4,917.00 0.10 -100.00% � z =n¢wc az Incan Nrv¢' Wun,y nealtliy Sial Goa,uon 1..MrvMm °�ga i UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME : Indian River County Healthy Start Coalition, Inc./TLC Newborn Program 06-07 FY 04/05 FY 05106 FY 06/07 % INCREASE FYE 6130105 FYE 6130106 FYE 6/30/07 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED !col. Ccol. el/col. B REVENUES BUDGETED BUDGETED 1 Children's Services Council-St Lucie 0.00 #DIV/0! 2 Children's Services Council-Martin 0.00 #DIV/01 3 Advisory Committee-Indian River 15,000.00 20,000.00 25,000.00 25.00% 4 United Wa St. Lucie County 0.00 #DIV/01 5 United Way-Martin County 0.00 #DIV101 6 United Way-Indian River County 41 ,000.00 40,000.00 45,200.00 13.00% 7 Department of Children & Families 0.00 #DIVIO! 8 CountyFunds 0.00 #DIVIO! 9 Contributions-Cash 0.00 #DIV/01 10 'Program Fees 0.00 #DIV/01 11 Fund Raising Events-Net 12,500.00 12,500.00 15,000.00 20.00% 12 Sales to Public-Net 0.00 #DIVlO! 13 Membership Dues 0.00 #DIV/0! 14 Investment Income 0.00 #DIV/01 15 Miscellaneous 0.00 #DIVIO! 16 Legacies & Bequests 0.00 #DIVIO! 17 Funds from Other Sources 14,500.00 '#DIVIO! 16 Reserve Funds Used for Operating 0.110 #DIVIO! 191n-Kind Donations Not incw4e4 In total D.DO #DIV/0! 20 TOTAL 66,500.00 72,500.00 99,700.00 37.520/6 EXPENDITURES 21 Salaries 60,589.00 56,136.00 73,528.00 26.480/6 22 FICA 4,635.00 41447.00 5,624.90 26.49% 23 Retirement 0.00 #DIV/01 24 Life/Health 0.00 #DIVIO! 25 Workers Com enation 452.00 0.00 #DIV/O! 26 Florida Unemployment 0.00 #DIV/0! 27 Travel-Daily 29419.00 1 ,200.00 1 ,647.011 37.25% 28 Trave#Conferencesrrrainin 1 ,000.00 1 ,000.00 2,500.00 150.00% 29 Office Supplies 651 .00 700.00 780.00 11 .43•/. 30 Telephone 0.00 #DIV/01 31 PostagelShipping 4,374.00 5,200.00 5,850.00 12.50% 32 Utilities 0.00 #DIV101 33 Occupancy (Building & Grounds 0.00 #DIV/01 34 ;7rinting & Publications 2,217.00 2,800.00 3,000.00 7.14% 35 Subscri tionlDues/Membe-mhi s 150.00 0.00 -100.00% 36 Insurance 0.00 #DIVIO! 37 Equipment: Rental & Maintenance 0.00 #DIV/0! 38 Advertising 300.00 300.00 0.00% 39 Equipment Purchases:Ca ital Expense 1 ,600.00 WEIV/0! 40 Professional Fees (Legal, Consulting) 19125.00 150.00 150.00 0.00% 41 Books/Educational Materials 500.00 500.00 500.00 0.00% 42 Food & Nutrition 0.00 #DIV/0I 43 Administrative Costs 0.00 2,970.00 #DIVIO! 44 Audit Expense 1 ,100.00 #DIVIO! 45 Specific Assistance to Individuals 0.00 #DIVIOI 46 Other/Miscellaneous 276.00 1 150.00 #DIVIO! 47 Other/Contract 0.00 #DMD! 48 TOTAL 78,238.00 74,583.00 99,699.90 33.66% -2,083.00 49 REVENUES OVER/ UNDER EXPENDITURES -9,738.00 0.10 -100.00% 33 a.3 Indian River County Healthy Stan Caalifon - T-C M1ewborn Program UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : Indian River Co. Healthy Start Coalition/Healthy Families IRC FUNDER : IRC Children's Services Advisory A B C FY 05106 FY 05106 % OF TOTAL FUNDER TOTAL VS. PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET (col. B/col. A) EXPENDITURES 21 Salaries 73,528.00 23,223.00 31 .58% 22 FICA 0.00 11776.56 #DIV/0 ! 23 Retirement 0 .00 0 .00 #DIV/0 ! 24 Life/Health 0.00 0.00 #DIV/01 25 Workers Compensation 0.00 0.00 #DIVlO ! 26 Florida Unemployment 0 .00 0.00 #DIV/0 ! 27 Travel -Daily0.00 0 .00 #DIV/01 28 Travel/Conferences/Training 0.00 0.00 #DIV/0 ! 29 Office Supplies 0 .00 0 .00 #DIV/0 ! 30 Telephone 0.00 0.00 #DIV/O ! 31 Postage/Shipping0.00 0.00 #DIV/01 32 Utilities 0 .00 0 .00 #DIV/O ! 33 Occupancy (Building & Grounds) 0.00 0.00 #DIV/0 ! 34 Printing & Publications 0.00 0 .00 #DIV101 35 Subscription/Dues/Memberships 0.00 0.00 #DIV/0 ! 36 Insurance 0.00 0.00 #DIV/0 ! 37 Equipment: Rental & Maintenance 0.00 0.00 #DIV/0 ! 38 Advertising 0 .00 0 .00 #DIV/0 ! 39 Equipment Purchases : Capital Expense 0.00 0 .00 #DIV/O ! 40 Professional Fees (Legal , Consulting) 0.00 0.00 #DIVIO ! 41 Books/Educational Materials 0 .00 0.00 #DIV/0 ! 42 Food & Nutrition 0.00 0. 00 #DIV/0 ! 43 Administrative Costs 0. 00 0.00 #DIVIO ! 44 Audit Expense 0.00 0 .00 #DIV/0 ! 45 Specific Assistance to Individuals 0 .00 0.00 #DIV/0 ! 46 Other/Miscellaneous 0. 00 0.00 #DIV/O ! 47 Other/Contract 0.00 0 .00 #DIV/O ! 48 TOTAL $739528.00 $249999 .56 34.00 % srarzgos �� Bd IrWan P-rer 21n1 y HeallOy Sjv CO,Mor RC NmmProgrm UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 15% OR MORE TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME : Indian River County Healthy Start Coalition, InC1TLC Newborn Program 06-07 FUNDER: IRC Children's Services Advisory Committee LINE ITEM =clerks EXPLANA7lON FOR VARIANCE rAdviso� andntly eam less than $10/hr. An increase of $5000 will tna aiuld nearly fund the salary of mittee-Indian Riversociate for a year. #DMO! #DIV/0! #0N/O! #DIM We increased our 2007 -06 was rind poo revenue to reflec[ o e 2006 Taste of the Treasure Coast net of approximately $ 15 000. Fund Raisin Events-Net This eats budget for DS-06 was based upon TOTC 2005 net proceeds of $12,000. #DNIO! #DN/01 #DIV/O! #DN/01 #DIV/0! #DIV/0! #DN/O! #DNIO! The coalition is applying for funds from a foundation to upgrade TLC's data sofkvare, computers and plans to revise the database. This salaries valance reflects the need for an additional clerk to gather and enter data. We also project the need for an additional family Salaries associate to serve a target population that is expected to increase by 17% over last year. FICA Increase corresponds to increase in salaries. #131)(10! #DIV/O! #DN/0! ill 7ravel-0ai It a expected Me FL legislature wrl increase mileage rate by 52% from .29 cents to .44 cents'mile The increase will albw 2 more TLC associates INS` troinetl as cerfified breastfeeding counselors; and send 5 aftendees to a 2 day Travel/Conforencesrrrainina Early IntervenLon conference. #Dil #DN/0! #DN/0! #DIVI01 #DN/O! #DN/0! #DIM #DIV10! #DMO! #DN/0! Ml #DNIO! _n;zco5 SA B5 Inaiar Riva- CaunlyHrz , SIMCDY11 -TLCTeu mProgram UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 15% OR MORE FUNDER SPECIFIC BUDGET AGENCY/PROGRAM NAME: Indian River County Healthy Start Coalition, hri Newborn Program 06-07 FUNDER: IRC Children's Services Advisory Committee LINE ITEM EXPLANATION FOR VARW NCE The coalition is applying for funds from a foundation to upgrade TLC's data software, computers and plans ro revise the database. This salaries variance reflects the need for an additional clerk to gather and enter data. We also project the need for an additional family Salaries associate to serve a target population that is expected to increase by 17% over last year. #DN/01 #DN/01 #DIV/0! #DNI01 #DN/O! #DN/0! #DN/O! #OHIO! #DNR ! #DMO! #DN/0! #DN/0! #DN/0! #DNR ! #DN/D! #DN/0! #DIV/O! #DN101 #DIVRII #DIVRI! #DNro! #DN/O! #DN/O! #DN/O! #DN/O! #DNIO! B 5 ►3 Sc2CgE es 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 15` 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 30`h) 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: IRC Healthy Start 1603 10`h Avenue Vero Beach , FL 32960 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 - till-IV ACID RD CERTIFICATE OF LIABILITY INSURANCE DATE (MM OD 11/0212006 rn PHILBRODUCER Phone: (772) 562-3369Fax:FLORIDA, INC. - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 2045 14TH 8 HOBBS OF IDAINC. - VERO BEACH ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 204514TH AVE. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P O BOX AC ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. VERO BEACH FL 32961 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: AUTO-OWNERS INSURANCE COMPANY + INDIAN RIVER COUNTY HEALTHY START, INC. (INSURER B: HARTFORD UNDERWRITERS INSURANCE C _OMPNY - - - 1603 10TH AVE. -- VERO BEACH FL 32960 INSURER C: UNITED STATES LIABILITY INSURANCE COMPANY INSURER D: COVERAGES ' INSURER E: - -- - - 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATELIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. (NSR ADDTYPEDFINSURANCE - - - ---- -- -- - LTR (NSR POLICY NUMBER PDTE1 MEFFECTIVE pnA= ia PIRATON LIMITS MND pgiE MM1VDp GENERAL LIABILITYpATE NDO100554443 . 08108106 08106107 EACH OCCURRENCE _ g ___ _ 1 ,000, 000 COMMERCIAL GENERAL LIABILITY - MMAGETORENE! - -- -- PREMISES (Fa uJ t 50,000 LGEgLA�G_GREGATE LAIMS MADE OCCUR - -- - MED EXP (Any one person) $ _ 5,000 C PERSONAL BADV INJURY �$ 1 ,000,000 GENERAL AGGREGATE $ 1 ,000,000 LIMBAPPLIES PER: PRODUCTS-COMP/OP ACG. $PR0. 1 ,000,000 JECT LOC AUTOMOBILE LIABIUTY ANYAUTO COMBINED SINGLE LIMIT (Ea amldent) S ALL OWNED AUTOS ------ — URY SCHEDULED Al1T0S (Per person) g 7jHIREDAUTOS [BODILY - - - —1111 BODILY INJURY " $ yI NON-OWNED AUTOS (Per amldent) PROPERTY DAMAGE -�- -- - (Per accident) E I GARAGE LUIBILITY � AUTO ONLY - EA ACCIDENT � $ ANY AUTO I AUTOOTHER ONLY. EA ACC ' E AUTO ONLY: --'- _- - - AGG $ EXCESS ! UMBRELLA LI ABILITY OCCUR CLAIMS MADE EACH OCCURRENCE $ -- ❑ AGGREGATE g DEDUCTIBLE $$ RETENTION E ----- -- WORKER$ COMPENSATION AND I 21LYEC GD77�u we srgTLL R Dn , $ EMPLOYERS' LWBILTfY I i 05/03/06 00/03/07 TDRYDMRS B ANY PROPDETORNARTNERIIXECIIfNE I E.L. EACH ACCIDENT S 100,000 OFFICERNIEMBER EXCLUDED? _ Irp., "se"wunser ' E.L. DISEASE-EA EMPLOYEE $_ 100,000 SPECIAL PapvralpNa Mlox: E.L. DISEASE-POLICY LIMIT $ 500,000 C OTHER: DIRECTORS AND OFFICERS ND01005544G 08/06/06 08/08/07 $1 ,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CERITIFICATE HOLDER NAMED AS AN ADDITIONAL INSURED WITH RESPECTS TO GENERAL LIABILITY AS PER POLICY FORM AND PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, INDIAN RIVER COUNTY ITS AGENTS OR REPRESENTATIVES. 1840 25TH STREET VERO BEACH FL 32960 AUTHORIZED REPRESENTATIVE L Attention: 978-1798 MARIANNE MASTERSON Idney a�a� ACORD 25 (2001108) Certificate # 99876 © ACORD CORPORATION 1988 ,Aiaa4. ... . •.�. ..vaNvtauVtt •wwnnon, 4�u MFENSATION EMPLOYERS LIABILITY moiINSURANCE POLICY-INFORMATION PAGE 34 ,;'FL 232-0303 - Policy Number Fro molicy Period To WCX 0014034 10 / 03 / 2006 10 / 03 /2007 12-01 A.M. Standard Time at the desa-be locebon RENEWAL DECLARATION TtanSaCtfOn RenewallRewrite Of Policy No .q.: DIRECT BILL WCX 0014034 .. . . . . . . .. . . .. . • " Named insured and Address KIDS CONNECTED BY DESIGN INC Agent 117 ATLANTIC AVENUE BRAISHFIELD FL FT PIERCE FL 34950 5955 T G LEE BLVD STE 200 ORLANDO FL 32822 - 4423 Telephone: 407 - 825 - 9911 Carrier p FEIN # 0002244 13714Risk ID ! Entity of Insured 650948854 091423537 CORPORATION Additional Locations: See Site Location Schedule 2 . The Policy Period is from 10 / 03 / 2006 to 10 / 03 / 200712: 01 a . m . Standard Time at the Insured 's mailing address . 3 . A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: FL B. Employers Liability Insurance : Part TWO of the policy applies to work in each state listed in Item 3A . The limits of our liability under Part TWO are: Bodily Injury by Accident $ 100 , ODO each accident Bodily Injury by Disease $ Soo , 000 Bodily Injury by Disease $ policy limit 100 , 000 each employee C . Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: ALL STATES EXCEPT NORTH DAKOTA , OHIO , WASHINGTON , WEST VIRGINIA , WYOMING , STATES DESIGNATED IN ITEM 3 . A . D. This policy includes these endorsements and schedules: See attached schedule. 4• The premium for this policy will be determined by our Manuals of Rules , Classifications , Rates , and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 275 Total Estimated Annual Premium $ 11 , 357 Expense Constant $ 200 Premium Discount $ - 696 Deposit Premium $ 11 , 357 ❑ This is a Three Year Fixed Rate Policy Premium Adjustment Period: ® Annual ; ❑ Semiannual ; ❑ Quarterly; ❑ Monthly :ountersigned this Day of : sued Date: 09 / 19 /2006 r ;suing Office Sarasota , FL Authorized ,_p're,46ntative( 4 '0074071-1 Ed. (09-04) :DDDODIA 405-881 INSURED COPY Page 1 of 4 .nsuralmvw %�urporanon wURKERS COMPENSATION EMPLOYERS LIABILITt °r7 INSURANCE POLICY -F' L 34232-0303 Policy Number: WCX0074034 Named Insured : KIDS CONNECTED BY DESIGN INC Agent: 5HAISHFIELD FL 0002244 EXTENSION OF INFORMATION PAGE CLASSIFICATION OF OPERATIONS Code Premium Basis Rate Per No. Total Est. Annual Estimated Classification Description S100of Annual FloridaRemuneration Remuneration Premium Unit 00001 8742 SALESPERSONS , COLLECTORS OR MESSENGERS -OUTSIDE 8810 CLERICAL OFFICE EMPLOYEES NOC rJ � 724 , 123 1 . OOD00 7o241 Unit Total 758 , 697 0 . 58000 � 4 , 400 8740 FOREIGN TERRORISM - $ 11e64 : 98981 , 482 , 820 0 . 03000 EXPERIEISCE MODIFICATION 445 006311 , 641 0 . 98000 PREMIUM DISCOUNT - 233 0900 EXPENSE CONSTANT - 11 , 408 D . 06100 - 696 State Total 200 Policy Total $ 11 , 357 $ 11 , 357 L Uc� . . Cfl Issued Date: 09 / 18 / 2006 04 SP001405 Ed. 102-01 ) &C998901 (02-01 ) INSURED COPy Page 2 of 4 . ._. ..- . . . , . . . . _ � . 91i Otl+ 177c 11 : 64 1 ! r [ 4b ? 'LiL6Naa HEALA hi'.' START m : PAGE: I. IN COMMON POLICY DECLARATIONS ..:OI INSURANCE COMPANY relten & 4440ctete9 9201 FOREST HILL AVENUE 2011 Cacdisul Drive POLICY NUMBER P900 Sax 3*88 RICHMOND, VA 2325$ V6re Seschs n , 32964- R 3488 ENEW97__ RENEWAL QF NEW UnderwI by Colony Mm+ogemenlService, Inc. PROGRAM CODE : ~-- �- 1 , NAMED INSURED AND MAILING ADDRESS; PRODUCER: 09012 �— — KIDS CGNNEC"I BY DESIGN, INC. 117 ATLANTIC AVENUE ROEHRIG $ MACOUFF (ST PETE) FORT PIERCE, FL 34850 111 2Nd AVE NE SUITE 810 SAINT PETERSBURG , FL 33701 2. POLICY PpbOO: From r 200 to 7tak2b0 7 12:01 A. M. Standard Time al your Mailing Add.•ets above. p RE1LetN ROR ' pATMEN7 THE PREUIUN, J 6§IJ ECT TOAit OA THE TFRNS OF TMIS POLICY, "OVWE TNF aISURAII AS 87ATED IN TMS POLICY;— NE AORE:E Wn'H VOU 3• THIS POLICY CONSISTS OF THE FOLLOWING COVERA - THIS PREMIUM MAY 86 SUBJECT TEN O ADJUSTMT, OE PARTS FOR WII 1 AxP "IUM 15 INDICATED, 1 It WAMAJF i+F_. V 11I ------ ��_ COVERAGE UC�Nsr ar x;F PREMIUM CCMERCIAL GENERA:. LIABILI "_'Y COVERAGE PARIw ublwnw: 1 �,q �6ys .. SG , b6b . UO i� POA ROININI , IN3t4Axr+r0 6ur..rtµ rC1 I i 14[ IY 11; N . 4 ,.1. WL/11 (k A&MVEM Mr. . r .. ;., 11114 •. .a . n ;. 1 , Premium Charge for coverage ofrbfted Acts of terrorism : is (Per POlicyholder Discl )sure TRIA2002N060a• 1202 atWohed . ) j COVE er rage for certified acts of terrorism hes been 11"00cf0d; exclusion attached , (Per POlicyhoider Disclosure TRIA2002NOtiC¢- 12pQ attached ) _ ISSUED DB / oe /2006 SG I+ `_ PremWm shown 4 06rabh at Inception. v TORI Policy Prsmlumy— 56 , b65 . DO 4. FORMS APPLICABLE TO ALL COVERAGES: Irapsetion Fee: $125.00 1`4960160 . 00 See Fam UOD1 - Sohedoe 6f Gama aro £ndorteman;s Tavas 1334 . 93 _ TOTAL 070180 . 95 59 BUSINESS DES TPICR IDN SOCIAL SERVICE CASE MANACEMENT Au rw.aen4llrs ""��-- w'�rtrP>1N1M wrwyef Yvurlw i.,viq+ On +. va ,� A-.wvn DCJ6650 (07102)