HomeMy WebLinkAbout2006-331F. Y
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INDIAN RIVER COUNTY
GRANT CONTRACT
This Grant Contract ("Contract") entered into effective this day of October 2006, by and
between Indian River County, a political subdivision of the State of Florida ; 1840 25`h Street, Vero
Beach, Florida , 32960-3365 ; and Childcare Resources , Inc. , (Recipient), of:
Childcare Resources , Inc. ,
1801 241h Street
Vero Beach , Florida 32960
Mental Wellness Issues 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 "K 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.
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4. Grant Funds and Payment. The approved Grant for the Grant Period is : SEVEN
THOUSAND, DOLLARS ($7,000). 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
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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 .
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IN WITNESS WHEREOF, County and Recipient have entered into this Contract on the date
11
first above written .
INDIAN RIVER Ct9J 1NTY BOAf2C{ 9F COMMISSIONERS
By:
Arthur R. 1,�auberger'p , ifman
BCC Approved:
Attest: J . K. Barton , Clerk
By: - l�
Deputy Clerk
ApprovedA.
Jose h A. Baird
County Administrator
Approv as to form and legal sufficiency:
Maria . Felt, Assistant County Attoc ey
RECIPI
By: 0e 1
Childcare Resources, Inc.
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EXHIBIT A
(Copy of complete Request for Proposal)
EXHIBIT - A -
+ Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
PROGRAM COVER PAGE
Organization Name : Childcare Resources of Indian River, Inc.
Executive Director: Pamela C. King E-mail :pking@ChildcareResourcesIR.org
Address: 1801 24`s Street Telephone: 567-3202
Vero Beach, Florida 32960 Fax : 567- 1136
Program Director: Same as above E-mail :
Program Title: Psychological Services
Priority Need Area Addressed: MENTAL WELLNESS ISSUES : 1 . Increasing programs that
promote emotional-social skills. 2 . Increasing early intervention services for "borderline" children —
physical-emotional .
Brief Description of the Program : This program provides parent counseling (RP-450.650) and in-
person crisis intervention (RP- 150.330) services to Childcare Resources families and contracting
centers. Families receive individual and/or family therapy from various contracting Childcare
Resources mental health professionals. Centers receive classroom support through site visits by
therapists specializing in early childhood.
SUMMARY REPORT — (Enter Information In The Black Cells Only)
Amount Requested from Funder for 2005 /06 : $ 7 , 000 . 00
Total Proposed Program Budget for 2005 /06 : $ 38 ,000 . 00
Percent of Total Program Budget : 18 . 4 %
Current Program Funding ( 2004 /05 ) : $ 6 , 319
Dollar increase /( decrease ) in request : $ 681
Percent increase /( decrease ) in request * * 10 . 8 %
Unduplicated Number of Children to be served Individually : 20
Unduplicated Number of Adults to be served Individually : -
Unduplicated Number to be served via Group settings : 30
Total Program Cost per Client : 760 . 00
* *If request increased 5% or more, briefly explain why: Continuing need, lack of available service.
If these funds are being used to match another source, name the source and the $ amount:
United Way, Success by Six : $4,000. 00.
Organization 's Board of Directors has approved this application on (date). Mav 22, 2006
Kathv Marshall cr
Board President S ' lure �1
Pamela C. KingA, C .
Executive Director Signature
Application for 2006-2007 service period 3
SUPPORTING DOCUMENTS CHECKLIST
RFP 2006061
Cover Page
✓Application
List of current officers and directors
✓Latest Financial Audit Report & Management Letter that conforms with the
AICPA Audit Guide
1/Most recent IRS Form 990, including all schedules
✓Most recent Internal Financial Statement (i. e. : Balance Sheet and Operating
Budget
✓ Staff Organizational Chart
Most Recent Annual Report (if available)
501 (C)(3 ) IRS Exemption Letter
Articles of Incorporation
Agency's Bylaws
Agency's written policy regarding Affirmative Action
Nepotism Statement
Taxonomy Definition for each program.
XVI
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
ORGANIZATION : Childcare Resources of Indian River, Inc. (formerly known as Community Child
Care Resources, Inc.)
PROGRAM: Psychological Services
TABLE OF CONTENTS
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.
X1 Section of the Proposal Pa e #
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 7
X 5 . Awareness of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
X 6. Accessibility of program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
X D. MEASURABLE OUTCOMES (two pages maximum) . . . . . . . . . . . . . . . . . . . . . . . . . 8
X E. COLLABORATION (one page maximum) . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 10
F. PROGRAM EVALUATION (two pages maximum)
X1 . Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 11
-X 2. Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 11
X3 . Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 12
X G. TIMETABLE (one page maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
H. UNDUPLICATED CLIENT COUNT
X 1 . Projections by Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
X 2. Projections by Age Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Application for 2006-2007 service period 1
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
I. BUDGET FORMS
X 1 . Financial Budget Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 15
J. FUNDER SPECIFIC/ADDITIONAL SHEETS
K. APPENDIX
Application for 2006-2007 service period 2
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
PROPOSAL NARRATIVE
A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page)
1 . Provide the mission statement and vision of your organization.
Mission statement: To ensure the availability and affordability of high quality early childhood and
family support programs for children of income eligible working families in Indian River County.
The vision of Childcare Resources is for childcare to be available and affordable for all children
who qualify, and that the quality of childcare in Indian River County will be enhanced. In addition,
parents will be able to work secure in the knowledge their children are thriving, and families will be
strengthened and better able to nurture their children into responsible adulthood. Childcare
Resources envisions a community that embraces the mission and recognizes that community-wide
support will improve the quality of life for all citizens.
2. Provide a brief summary of your organization including areas of expertise,
accomplishments, and population served.
Childcare Resources contracts with six local childcare centers located on eight sites, to deliver
quality childcare programs for children from birth to kindergarten. Childcare Resources serves
working families who meet income eligibility guidelines.
Centers must meet Childcare Resources standards of quality. A team of early childhood
professionals are involved in the process of choosing and assessing centers. Once accepted as a
new provider, a center has provisional status for a period of at least one year. Centers receive
unannounced monitoring visits regularly. Staffs receive training and support, and center directors
meet bi-monthly with Childcare Resources staff to discuss issues that affect the delivery of a
quality program. They are reimbursed at a rate to support the required standards. The criteria for
contracting include:
• A program that is both age and individually appropriate
• Specifically trained and adequately compensated teachers
• Low adult to child ratios ( 1 : 10 for preschool) ( 1 : 8 for 2 yr. olds) ( 1 :6 for toddlers) ( 1 :4
for infants)
• Close ties with families and meaningful parental involvement
• Access to comprehensive services
Childcare Resource' program places emphasis upon a strong family support and education
component, including parenting workshops, parent/child interactive Saturday programs, mentoring,
resource and referral, and professional psychological clinical support. The progress of the children
is monitored and documented. There is parental choice among centers. Parents sign a contract
committing to a sliding fee scale, and mandatory participations in orientations, parent/teacher
conferences and parent education programs throughout the year. Childcare Resources conducts
fundraising and promotes public awareness, which are vital to the support, sustainability, and
delivery of the program.
Application for 2006-2007 service period 4
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
B. PROGRAM NEED STATEMENT (Entire Section B not to exceed one age)
1 . a) What is the unacceptable condition requiring change? b) Who has the need? c) Where do
they live? d) Provide local, state, or national trend data, with reference source, that corroborates
that this is an area of need. a. A percentage of all families face problems and stresses and need
professional psychological intervention. Recent research indicates that more children three and under
suffer from emotional stress, like adults, "but they lack the coping mechanisms years of living bring"
(Florida Association for Infant Mental Health, 2003). Childcare Resources' targeted population is more
economically needy, and these families historically face life challenges to a greater degree than the
general population. Consequently, they exhibit a greater need for psychological support. Indian River
County lacks sufficient psychological services to serve low-income families with mental health needs . In
addition, there are challenges in identifying families with such needs and encouraging them to take
advantage of available. resources. Childcare Resources centers lack clinical staff and the financial
resources to independently contract with mental health professionals.
Problems in the classroom that cannot be handled within the capabilities of the staff often result in the
expulsion of the child in crisis . Teacher requests for therapeutic intervention center on the number of
children (total class, not just Childcare Resources) exhibiting inappropriate anger towards both fellow
students and teachers.
b. The targeted population is Childcare Resources families who demonstrate a need for psychological
services in one or more of the following areas :
1) Children who exhibit behavioral, developmental, and/or emotional difficulties that seriously
impact their chances for school and life success.
2) Parents who deal with issues like : abuse, divorce, depression, anxiety, custody, substance
abuse or significant health problems.
3) Parents with "special needs" children in the family who need support.
4) Childcare Resources centers need the opportunity to receive on-site professional
psychological/behavioral support.
c. Those in need appear to be spread evenly throughout Indian River County.
d. The National Mental Health Association tells us that although one in five children has a diagnosable
mental health problem, nearly two-thirds of them get little or no help. Untreated mental health problems
can disrupt children' s functioning at home, school and in the community. Without treatment, children
with mental health issues are at increased risk of school failure, contact with the criminal justice system,
dependence on social services, and even suicide.
Professional services are only recommended after efforts by the Childcare Resources staff and center
staff have been exhausted.
2. a) Identify similar programs that are currently serving the needs of your targeted population; b)
Explain how these existing programs are under-serving the targeted population of your program.
a. Childcare Resources is the only program in the County that ties psychological services, including
direct intervention to the funding of childcare. In previous years the Early Learning Coalition had a small
amount of funding for a large population of children but even that is no longer available .
Application for 2006-2007 service period 5
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
C. PROGRAM DESCRIPTION (Entire Section C, 1 — 6, not to exceed two pages)
1 . List Priority Needs area addressed.
Mental Health Wellness
1 . Increasing programs that promote enhanced emotional-social skills.
2. Increasing early intervention for borderline children- physical/emotional.
2. Briefly describe program activities including location of services.
a. All referrals start with the Childcare Resources Family Resource Coordinator (FRC), who conferences with
the parent to assess the problem, along with the need for intervention. Already employed strategies and
resources will be reviewed and recorded.
b. Once need is established, the FRC secures authorization for the referral from the Executive Director (ED)
c. Parents select a therapist from a list of appropriate Childcare Resources providers, and give written consent
for information sharing.
d. The ED contacts the selected provider about. Childcare Resources ' funding criteria and reporting
requirements.
e. Families with medical insurance use those benefits first. Families pay the therapist a $5 . 00 fee for each
visit.
f. The FRC monitors the treatment plan through regular conferences with families, and consults with
providers (as appropriate).
g. The FRC facilitates recommended changes in the child ' s individual school program, and with the
classroom teacher monitors progress
h. Services are provided at the office of the selected therapist or at the Centers.
Psychological Support to Centers :
a. Contracting Childcare Resources therapist allots 2-3 hour time blocks to Childcare Resources centers with
documented need. Purpose: work with classroom teachers on behavioral issues that may be interfering with
social and/or cognitive learning in the classroom.
b. A teacher completes the pre-observation form prior to therapist visit. The therapist records observations,
conferences with teacher, gives written strategies and sets date for follow-up.
c. The FRC follows-up to help the classroom teacher implement and evaluate program changes.
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.
Childcare Resources recognizes that research indicates parent support and education are vital to a child' s
successful preschool experience. A child' s development does not end when he leaves the classroom. The
child that goes home to a dysfunctional family will not thrive.
Childcare Resources Psychological Support Services component is often the only source of professional
intervention for families . Dollars are best spent on childcare, when the child is able to return home to a
functional family, capable of positively reinforcing, nurturing and appreciating the child.
15 individuals sought treatment last year ( 115 individual sessions). All who had more than one session
showed improvement in their Global Assessment of Function Scores with one exception (unknown after two
visits).
Application for 2006-2007 service period 6
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
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).
Executive Director: ( 1 ) On average 8 hours per week are devoted to program.
Experience/expertise in: securing and distributing funding for the program, monitoring compliance regarding
reporting and billing procedures, maintaining a "bank" of quality therapists to serve families at a reduced
hourly billing rate.
Family Resource Coordinator: ( 1 ) On average 10 hours per week are devoted to program.
Experience/ Expertise in: assessing referrals, monitoring treatment plans, implementing program changes in
the classroom serving as a liaison among parents, therapists, and centers.
Office Manager: ( 1 ) On average 4 hours per week is devoted to the program . Experience/expertise in:
processing invoices from providers, monitoring parent compliance regarding fee payments, checking family
health insurance benefits.
5. How will the target population be made aware of the program?
Childcare Resources families are made aware of the psychological support program during intake, at the
Childcare Resources orientation, and individually through the Family Resource Coordinator. We make a
habit of having a contracting therapist available at orientation to introduce the program and encourage parent
participation. In addition, Center staffs are aware of the availability of the program, and refer families in need.
6. How will the program be accessible to target population (i.e., location, transportation, hours of
operation)?
Within the parameters of therapist specialty, there is parental choice. This enables a parent to choose a
therapist convenient to home or work. Some contracting therapists have evening and weekend appointments
available for Childcare Resources families. Some contracting therapists are willing to hold individual therapy
sessions at the child' s center. Parents unable to pay the $5 .00 fee may have it waived through Childcare
Resources Program Committee.
Application for 2006-2007 service period 7
Childcare Resources of Indian River, Inc. Psychological Services Children's services Advisory Committee
D. MEASURABLE OUTCOMES (Entire Section D not to exceed two pages)
OUTCOMES ACTIVITIES
Add all o the elements or the Measurable Outcomes) Add the tasks to accomplish the Outcome(s)
1 . 80% of those families referred for treatment will 1 a.Therapists will be introduced to families during
participate in treatment as measured by the number Childcare Resources orientations. The program
of completed Mental Health Provider forms . will be described.
Note : This goal has previously been to increase the 1 b. Therapists will come to Center Director meeting to
percentage of referrals who go to treatment. encourage their staff to talk to referred parents
Because we have attained high percentages for about the value of the services .
several years, we feel it appropriate to maintain an 1c.Referrals start with the Childcare Resources Family
80% rate in the future. Resource Coordinator (FRC), who talks with the
parent to assess the problem and need for
intervention.
ld.Once need is established, the FRC secures referral
authorization from the Executive Director (ED).
1 c. Parents select a therapist from a list of Childcare
Resources providers appropriate to address the
problem, and give written consent for sharing of
information.
If. The ED communicates Childcare Resources
funding criteria and reporting requirements to the
provider.
I g. Families with medical insurance will use those
benefits first. Families pay a $5 .00 "out of pocket"
charge directly to the therapist. If the family can ' t
afford the co-pay, the FRC will refer the case to the
Program Committee who may waive the fee.
Ih. Families schedule an initial appointment with the
therapist.
1 i.The FRC will remain in contact with the parent to
encourage the parent to call for an appointment.
2. 85 % of individuals attending more than two 2aThe therapist designs a treatment plan, and the
therapy sessions will raise their functioning within family takes responsibility for the scheduling of all
the school year, as measured by the discharge score appointments.
for Global Assessment of Functioning (GAF) test 2b.The FRC monitors the treatment plan through
or other screening devices . Baseline: Admission regular conferences with the family, and consults
GAF score. informally with therapists as appropriate.
2c.The FRC facilitates any recommended changes in
the child' s individual school program, and, with the
classroom teacher monitors progress.
Application for 2006-2007 service period 8
Childcare Resources of Indian River, Inc. Psychological services Children's Services Advisory Committee
3 . To increase the level of appropriate behavior of 3a. Classroom teacher completes a request for
children who have received clinical intervention psychological services (Observation report), and
during the 2005-2006 school year by an average of documents specific inappropriate behaviors
10% as measured by the spring DECA and/or requiring intervention.
classroom teacher assessments. Baseline : Teacher 3b. During the first visit, the Psychological Services
assessments and/or fall DECA assessments. Classroom Report is completed.
3c. The therapist works with the teacher to enhance the
classroom environment, and supports the teacher
with behavioral concerns.
3d.The therapist creates a management plan, and
conferences with the Center Director regarding
implementation of the plan.
3e. The Family Resource Coordinator (FRC) follows-
up to help implement, adjust and evaluate the plan .
3 £ If needed, the therapist makes additional visits
and/or suggestions for individual child referrals.
Application for 2006-2007 service period 9
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
E. COLLABORATION (Entire Section E not to exceed one page)
1 . List your program 's collaborative partners and the resources that they are providing to
the program beyond referrals and support. (See individual funder requirements for
inclusion of collaborative a reement letters.
Collaborative Agency Resources provided to the pTrpram
Childcare Resources Contracting All Childcare Resources therapists discount their hourly
Therapists : rate approximately 29%. Some provide evening and
Linda Asher, Ph. D. weekend hours. Some provide service at the child' s
Madeleine Laplante, M.A., LMHC center. All complete the appropriate Mental Health
Therese Cirner, M.A. NCC Provider Forms or Psychological Support Classroom
Brent A. Jeremy, L. C . S.W. Report Forms.
Dr. Robert Brugnoli, Psychologist
Community Church Partner' s The Partner' s program can transport Childcare
Program Resources families that they are working with to and
from therapy appointments. The mentor will go with the
parent to an initial appointment, if so desired. The
Partner' s Program will pay for any medication that may
be prescribed, if the parent cannot afford it. In addition,
they will provide babysitting so a parent may go to a
therapy appointment.
Indian River Public Schools and Conduct diagnostic screening on Childcare Resources
Florida Diagnostic & Learning children who have learning and behavioral concerns.
Resources System (FDLRS) The data is then used by the Childcare Resources
therapist to design a treatment plan.
Application for 2006-2007 service period 10
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
a. PROGRAM EVALUATION (Entire Section F not to exceed two pages)
2 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 ?
Data Elements Describing "Services to Families " Target Population:
a. Source of referral — (center, parent, Childcare Resources, outside agency)
b. Form of treatment plan — (child, parent, couple, family)
c. Diagnostic code (DX) number
d. Admission Global Assessment of Functioning (GAF) number
e. Anticipated number of service units that will be needed
Data Elements Describing "Services to Classrooms " target Population:
a. Number of children exhibiting behavioral concerns
b. Number of children scoring below standard norms on DECA assessment
c. Type and number of unsuccessful teacher interventions prior to requesting services
d. Type and number of teacher requests for service in individual centers
e. Number of service units used per classroom
f. Number of children referred for individual therapy
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 ?
Services to Families " Measurement Elements
a. The number of referrals made for psychological services will be collected by the Family Resource
Coordinator (FRC) and compiled in the Psychological Services Log
b Mental Health Provider Forms completed by the therapist will be collected twice a year and
compiled in the Psychological Services Log. The form documents admission and discharge GAF ' s,
Diagnosis Codes and descriptions, # of appointments made, kept, cancelled and "no show",
anticipated length of treatment, and other outside resources being used.
Services to Classrooms " Measurement Elements
a. Fall and spring DECA assessment scores will be collected in November and May and compiled in
the Psychological Services Log.
b. The numbers and types of classroom concerns are collected through the completion of the
Teacher Observation Forms. They are submitted along with the Psychological Support Classroom
Report Form to the FRC who compiles them in the psychological Services log.
c. The Psychological Support Classroom Report form is completed by the therapist and submitted to
the FRC (compiled in Psychological Services Log). This form documents type and severity of
behavioral concerns observed, description of strategies to be implemented, and the expected need
for follow-up by the therapist to the classroom.
Application for 2006-2007 service period 11
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
3. REPORTING: What will you do with this information to show that change has occurred?
How will you use or present these results to the consumer, the funder, the program, and the
community? How will you use this information to improve your program?
Services to Families- Reporting Change
a. The number of referrals for service will be compared with the number of Mental Health
Provider Forms completed. This will document the percent of families following through
on referral.
b. Data collected from the Mental Health Provider Form is used to compare the patient' s
level of functioning before and after treatment. This will document the percent of patients
who raised their GAF scores.
Services to Classrooms- Reporting Change
a. The Teacher Pre-Observation Form serves as a baseline in determining change.
b. The Psychological Services Classroom Report Form documents areas to be addressed and
strategies to be implemented.
c. Fall and spring DECA results are compared to document the percent of children exhibiting
behavioral concerns in the classroom setting before and after psychological service
intervention.
Sharing Results
With the Consumer: Therapists are involved in family orientations to describe the type of help they
can offer through Childcare Resources. Individually, therapists can help parents and children see
what they have accomplished. DECA results are interpreted for parents during conferences to better
describe how the child functions in a group, and the child ' s status with social/emotional development.
With the Funder: Results are used to show progress and measure success.
With the Program: Results are used by Board and staff to validate that the mission is being carried
forward. Evaluative information helps target areas for improvement and growth.
With the Community: Sharing measurable results about your program leads to community awareness
that in turn may lead to new sources of funding. Outcome success also results in attracting quality
people to the organization.
Application for 2006-2007 service period 12
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
G. TIMETABLE (Section G not to exceed one page)
1 . List the major action steps, activities, or cycles of events that will occur within the program
year. New programs should include any start-up planning that may occur outside the
funding year. In completing the timetable, review information detailed in prior sections.
Month/Period Activities
Psychological Support to Children and Families
1 . Ongoing 1 . Referral and authorization process
2. Ongoing 2 . Treatment
3 . Ongoing 3 . Family Resource Coordinator monitors treatment
plan with therapist and shares as appropriate with
Center.
4. December and April 4. Mental Health Provider Forms completed by
therapists.
5 . January and May 5 . Mental Health Provider Forms reviewed by staff.
Psychological Support to Centers
1 . Ongoing 1 . Documentation of need for clinical classroom support
2. Prior to Visit by therapist 2. Teacher completes classroom report prior to-
observation for psychological services provider
3 . Day of Visit 3 . Therapist completes Psychological Services Classroom
Report
4. Day of Visit 4. Behavior Management Plan put in place
5 . Ongoing 5 . Family Resource Coordinator conducts classroom
follow-up.
6. December and May 6. Psychological Services Classroom Report reviewed by
staff.
Application for 2006-2007 service period 13
Childcare Resources of Indian River, Inc. Psychological Services Children's Services Advisory Committee
H. PROJECTIONS FOR UNDUPLICATED CLIENTS
Number of Unduplicated Clients by Location
Current Fiscal Year
Location Budget 2005/06
Unduplicated Clients Unduplicated Clients Unduplicated Clients
N. Indian River County
S. Indian River County 15 40 50
Indian River Co. Total 15 40 50
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 151 401 50
Number of Unduplicated Clients by Age
Current Fiscal Year t
Location Budget 2005/06
Individual Group I ml
0 to 4 - (Pre-school) 15 20 20 1 20 30
5 to 10 - (Elementary) - - - - -
11 to 14 - (Middle) - - - - -
15 to 18 - (High School) - - - - - -
Total Children 15 20 20 20 30
19 to 59 - (Adults) - - - - -
60 + (Seniors) - - - -
Total Adults - - - - -
TOTAL SERVED 15 - 20 1 201 20 30
Application for 2006-2007 service period 14
Edit this Header. Type the organization and program name and the funder for whom it is being completed. The page Nis already set at the bottom right
of every page.
I. BUDGET FORMS - To open the Budget Forms, please double-click on the icon below.
I C
" Core Budget Forms "
15
Childcare Resoures srmologiml SeNl
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 : Childcare Resources of Indian River, Inc./Psychological Services
FUNDER: Advisory Committee-Indian River
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ . . — — — — • — • • - - - _ - . _ - - _ - - _ . - _ - - - • - p . _ - - _ - .Y - -
_ - . — • ' - -
i CAUTION : Do not enter an figures where a cell is colored in dark blue - Formulas and/or links are in lace. Gra areas should ;
: be used for calculations and to write information only. as
"'"Y"" FOR
" "" ° &
w Proposed Total Program Funder Specific Total Agency
REVENUES (eONOET R`r Budget Budget Budget
catcuuTwxsl
1 Children's Services Council-St. Lucie
2 Children's Services Council-Martin
3 Advisory Committee-Indian River 7,000.00 7,000.00 227,000.00
4 United Way-St. Lucie County
5 United Way-Martin County
6 United Way-Indian River County 4,000.00 191 , 152.00
7 Department of Children & Families
8 County Funds
9 Contributions-Cash 40,000.00
10 Program Fees 1 ,000.00 86,000.00
11 Fund Raising Events-Net 5,000.00 19,000.00
12 Sales to Public - Net
13 Membership Dues 21 ,000.00 110,000.00
14 Investment Income 600.00
15 Miscellaneous
16 Legacies & Bequests
171 Funds from Other Sources
18 Reserve Funds Used for Operating
19 In-Kind Donations (Not included in totaq 8,000.00
20 TOTAL REVENUES
(doesn't include line 19) $38,000.00 $7,000.00 $673,752.00
A B C D
EXPENDITURES - 4exYAe FM Proposed Total Program Funder Specific Total Agency
AG YUS Oo Y
(Mow cuceumesl Budget Budget Budget
21 Salaries - (must complete chart on next page) 22,793.74 0.00 118,557.27
Salary
22 FICA - Total salaries x 0.0765 7.65% 1 ,743.72 0.00 9,069.63
Retirement - Annual pension for qualified
23 staff 0.00
Life/Health - Medical/DentaUShort-term
24 Disab. 1 0.00
Workers Compensation - # employeesx
25 rate 300.00 0.00 1 ,300.00
Florida Unemployment - # projected
26 employees x $7,000 x UCT-6 rate 0.00
RIES A D
POSITION LISTING Gross Annual B C Fonder % of Gross Annual
Portion Pon of S Proposed Spa Budget Salary
Position Title / Total Hrs(wk (Agency) Program Requested(CIA)
Example: Executive Director/40 his 70,000.00 10,000.00 5,000.00 7. 14%
SII&2006 B-1
Childcare ResoufcVPsycMlogical Services
Executive Director/ 40 hours 49,672.00 9,934.40 0.00
Family Resource Coordinator/ 40 hours 39,805.27 9,951 .34 0.00%
Bookkeeper/ 40 hours 29, 080.00 2,908 .00 0.00
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIVIO!
#DIV/0!
#DIV/0 !
#DIV/0!
#DIV/0!
#DIV/O!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
Remaining positions throughout the agency
Total Salaries $118,557.271 $22,793.74 1 mool 0.00%
FRINGE BENEFITS DETAIL A
(Funder Specific Budget Funder B c n E F G
.
Pension Worker's Udemployme Total Fringes Funder
Column C on from line 22 to 27 Specific FICA 765% Health Ins.
h' � Budget (A x Vol Compens. nt Compens. Specific
Position ride / Total Hrslwk
Example: CaseManager/401im 50000.00 38250 200.00 500.00 300.00 200.00 1,582.50
Executive Director/ 40 hours 0.00 0.00 0.0
Family Resource Coordinator/ 40 hours 0.00 0.00 0.0
Bookkeeper/ 40 hours 0.00 0.00 0.00
0 0.00 0.00 0.00
0 0.00 0.00 0.0
0 0.00 0.0o 0.00
0 0.00 0.00 0.0
0 0.00 0.00 0.0
0 0.00 0.00 0.0
0 0.00 0.00 0.0
0 0.00 0.00 1 0.0
0 0.00 0.00 0.0
0 0.00 0.00 0.0
0 0.00 0.o0 0.0
0 0.00 0.00 0.0
0 0.00 0.00 0.0
0 0.00 0.00 a.o
0 0.00 0.00 0.0
0 1 0.001 0.00 10.0
0 0.00 0.001 1 0.0a
Total Funder Request Fringe Benefits 1 $0.001 $0.00 $0.001 M001 mool $0.00 $0.0
A B C D
EXPENDITURES URAYM� FOR Proposed Tota/ Program Funder Specific Total Agency
AG YWEON YTO
WOWOETAR. Budget Budget Budget
27 Travel-Daily 66.00 0.00 1 ,104.00
# of Staff x average # of miles/wk x 50 wks x
$ = Estimated Daily Travel/Mileage Reimb.
28 Travel/ConferenceslTraining 55.00 0.00 2,500.00
5119/20W a-1
CNltl m Resourrs/Psycnologic l Services
• National Conference (cost per staff)
• Training/Seminar (cost per staff)
• Other Trainings (cost of travel, lodging,
registration, food)
29 Office Supplies 276.00 0.00 4,600.00
Office supplies (monthly average x 12 -
months = estimated cost of office supplies
based on present history.
30 Telephone 193.00 0.00 3,220.00
• # 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
31 Postage/Shipping 221 .00 0.00 3,680.00
• Quarterly Mailing of Newsletter
• Special events, etc.
• Bulk mailings - appeals
32 Utilities 207.00 0.00 31450.00
• Electricity ($ x 12 months)
• Water/Sewer ($ x 12 months)
• Garbage ($ x 12 months)
33 Occupancy (Building & Grounds) 0.00 0.00 4,816.00
• Mortgage/Rent ($ x 12 months)
• Janitorial ($ x 12 months)
• Grounds Maim. ($ x 12 months)
• Real Estate Taxes
34 Printing & Publications 442.00 0.00 7,360.00
• Quarterly Newsletter ($ x 4)
• Letterheads, Envelopes, etc.
• Fundraising materials
• Other
35 Subscription/Dues/Memberships 50.00 0.00 828.00
• Membership to National Organization
• Dues
• Subscriptions to Newspapers/magazines,
etc.
36 Insurance 276.00 0.00 5,060.00
• Directors/Officers Liab.
• Commercial/General Insurance
• Bond Ins.
• Auto Insurance
37 Equipment:Rental & Maintenance 66.00 0.00 1 ,104.00
• Copier lease ($ x 12 months)
• Meter lease ($ x 12 months)
• Copier Maintenance ($ x 12 months)
• Computer Maintenance ( $ x 12 months)
• Other
38 Advertising 55.00 0.00 920.00
• Newspaper ads
• Fundraising ads/promotions
• Other (vacancies)
39 Equipment Purchases:Capital Expense - 0.00 0.00 1 ,380.00
• Computer/monitor (# x $)
• Laser Printer
40 Professional Fees (Legal, Consulting) 11 ,000.00 7,000.00 11 ,350.00
• Legal advice ( estimated #hrs x $)
• Consultant fees
• Other
41 Books/Educational Materials 90ml 0.00 1 ,500.00
• Books/videos
• Materials ($ x staff)
42 Food & Nutrition 72.001 0.00 1 ,500.00
511912006 8'1
Chgdc Resoufcs/Psyc logi lSerAces
• Meals ( # meals x clients x 5days x 50 wks)
• Snacks
43 Administrative Costs 0.00 0.00 5,091 .00
Admin. Cost (% of total budget)
44 Audit Expense 0.00 0.00 7,000.00
Independent Audit Review
45 Specific Assistance to Individuals 0.00 0.00 1 ,000.00
• Medical assistance
• Meals/Food
• Rent Assistance -
• Other
46 Other/Miscellaneous 55.00 0.00 920.00
• Background check/drug test -
• Other
47 Other/Contract 0.00 0.00 476,007.00
• Sub-contract for program services
48 TOTAL EXPENSES $37,961 .46 $7,000.00 $673,316.90
UM"
B-1
CW1aePapnv/isy yW Senps -
UNIFORM GRANT APPLICATION
TOTAL AGENCY BUDGET
AGENCY/PROGRAM NAME:Childcare Resources of Indian River, Inc./Psychological Services
FY 04105 FY 05106 FY 06107 % INCREASE
CURRENT VS.
July 1 - June 30 July 1 - June 30 July 1 - June 30 NEXT FY BUDGET
A B C D
ACTUAL TOTAL PROPOSED (col. C<ol. Byo . e
REVENUES BUDGETED BUDGETED
1 Children's Services Council-St Lucie 0.00 #DIV/01
2 Children's Services Council-Martin 0.00 #DIV/01
3 Advisory Committee-Indian River 205,537.76 207,000.00 227,000.00 9.66%
United Way-St Lucie County 0.00 #DIV101
United Way-Martin County 0.00 #DIV101
6 United Way- Indian River 172,541 .14 191,152.00 191 ,152.00 0.00%
7 Department of Children & Families 0.00 #DIV/0!
8 County Funds 0.00 #DIV/01
9 Contributions-Cash 107,005.20 73,000.00 40,000.00 A5.21%
10 Program Fees 64,748.64 60,000.00 86,000.00 43.33%
11 Fund Raising Events-Net 19,460.00 15,000.00 19,000.00 26.67%
12 Sales to Public-Net 0.001 #DIVlO!
13 Membemhip Dues 70,000.00 110,000.00 57.14%
14 Investment Income 254.29 120.00 600.00 400.00%
15 Miscellaneous 0.00 #DIV/01
16 Le aches & Bequests 0.00 #DIV101
17 Funds from Other Sources ALPI 11,115.84 3,000.00 0.00 -100.00%
18 Reserve Funds Used for 0 eratin 0.00 #DIV/01
191n-Kind Donations (Nwincim ammml 0.00 8,000.00 #DIV/0!
2a TOTAL 580,662.87 619,272.00 673,752.00 8.80%
EXPENDITURES
21 Salaries 114,875.30 125,132.00 118,557.27 -5.25%
z2 FICA 8,757.99 10,000.00 9,069.63 -9.304/a
23 Retirement 0.00 #DIV/01
24 Life/Health 0.00 #DIV/0!
25 Workers Compensation 1 ,023.00 1,100.00 1 ,300.00 18.18%
26 Florida Unemployment 0.00 #DIV10!
27 Travel-Daily 999.47 1 ,500.00 1 ,104.00 -26.40%
26 Travel/ConferenceslTrainin 60.00 2,500.00 2,500.00 0.00%
29 Office Supplies 3,362.93 5,000.00 4,600.00 -8.00%
30 Telephone 3,143.84 3,000.00 3,220.00 7.33%
31 Postage/Shipping 2,992.35 3,600.00 3,680.00 2.220/6
32 Utilities 2,667.94 3,500.00 3,450.00 71 .43%
33 Occupancy (Building & Grounds 13,326.86 21,296.00 4,816.00 -77.39%
34 Printing & Publications 6,614.27 8,000.00 7,360.001 4.00%
35 Subscri tion/Dueslhlembershi 663.75 400.00 828.00 107.00%
36 Insurance 3,944.94 4,500.00 5,060.00 12.440/a
37 E ui ment:Rental & Maintenance 1,531 .17 1 ,500.00 1 ,104.00 -26.40%
38 Advertising 2,091 .24 2,000.00 920.00 54.00%
39 Equipment Purchases:Ca ital Expense 3,000.00 0.00 1 ,380.00 #DIV/01
40 Professional Fees (Legal, Consultin 9,420.00 11 ,000.00 11 ,350.00 3.18%
41 Books/Educational Materials 992.27 2,000.00 1,500.00 -25.00%
42
Food & Nutrition 1 ,029.12 1,000.00 1 ,500.001 50.00%
43 Administrative Costs 4,500.00 5,616.00 5,091.00 -9.35%
44 Audit Expense 7,000.00 7,500.00 7,000.00 -6.67%
45 Specific Assistance to Individuals 144.00 2,000.00 1 ,000.00 -50.007
46 Other/Miscellaneous 1,228.84 1 ,750.00 920.00 17.43%
47 3ther/Contract 359,560.20 392,313.00 476,007.00 21.33%
48 TOTAL 552,929.48 616,207.00 673,316.90 9.27%
49 REVENUES OVER/ UNDER EXPENDITURES 27,733.39 3,065.00 435.10 85.80%
Ba
CN m RmamsPry� y
UNIFORM GRANT APPLICATION
TOTAL PROGRAM BUDGET
AGENCY/PROGRAM NAME:Chifdcare Resources of Indian River, IncJPsychological Services
FY O4M5 FY 05/06 FY 06107 % INCREASE
FYE JulyJune FYE July-June FYE JulyJune CURRENT VS.
NEXT FY BUDGET
A B C 0
ACTUAL TOTAL PROPOSED Icd. c<m. BycoL9
REVENUES BUDGETED BUDGETED
1 Children's Services Council-St Lucie 0.00 #DIVIO!
2 Children's Services Council-Martin 0.00 #DIV/0!
3 Advisory Committee-Indian River 7,760.00 7,000.00 7,000.00 0.00%
4 United Way-St. Lucie County 0.00 #DIV/01
United Way-Martin County 0.00 #DIV101
6 United Way - Indian River County'
oun 40000.00 4,000.00 4,000.00 0.00%
7 Department of Children & Families 0.00 #DIV/01
e County Funds 0.00 #DIV101
9 Contributions-Cash 10,100.00 11 ,502.00 0.00 .100.00%
iolProgLam Fees 3,885.00 3,600.00 1 ,000.00 -72.22%
11 Fund Raisina Events-Net 10,703.00 8,750.00 5,000.00 42.86%
1 Sales to Public-Net 0.00 #DIV/01
73 Mein rshi Dues 0.00 5,000.00 21,000.00 320.00%
14 Investment income 0.00 #DIVIO!
15 Miscellaneous 0.00 #DIV/0!
16 Le acies & Be uests 0.00 #DIV/0!
1 Funds from Other Sources 0.00 #DIVIO!
1a Reserve Funds Used for Operating 0.00 #DIVIO!
191n-Kind Donations INm Included In Win) 0.00 #DIV/01
2O TOTAL 36,448.00 39,852.00 38,000.00 4.650A
EXPENDITURES
21 Salaries 19,000.00 21 ,500.35 22,793.74 6.029%
22 FICA 1 ,453.50 1 ,641.75 1,743.72 6.02%
23 Retirement 0.00 #DIV/0!
24 LifeMea!th 0.00 #DIV10!
25 Workers Compensation 200.00 250.00 300.00 20.00016
2s Florida Unemployment 0.00 #DIV/0!
27 Travel-Dail 20.00 20.00 66.00 230.00%
28 Travel/Conferences/Trainin 0.00 0.00 55.00 #DIV/0!
29 Office Supplies 450.00 600.00 276.00 -54.00%
30 Telephone 1 ,000.00 650.00 193.00 -70.310/6
31 ;ostage[Shipping 500.00 500.00 221.00 55.809/0
32 Utilities 500.00 200.00 207.001 3.50%
33 Occupancy (Building & Grounds 1,500.00 1 ,000.00 0.00 -100.00%
34 Printing & Publication 476.00 500.00 442.00 -11 .60%
35 Subscription/Dues/Memberships 0.00 0.00 50.00 #DIVIO!
361nsurance 0.00 0.00 276.00 #DIV/01
37 E ui ment:Rental & Maintenance 0.00 0.00 66.00 #DIV/01
38 Advertising 0.00 0.00 55.00 #DIVt0!
39 Equipment Purchases:Ca ital�Expense 0.00 0.00 0.00 #OIV/0!
40 Professional Fees (Legal, Consulting) 11 ,280.00 12,300.00 11 ,000.00 -10.5778
41 Books/Educational Materials 0.00 0.00 90.00 #DIV/O!
42 Food & Nutrition 0.00 1 0.00 72.001 #DIV/01
43 Administrative Costs 0.00 0.000.00 #DIV/O!
Audit Expense 0.00 0.00 0.00 9DIV101
45 Specific Assistance to Individuals 0.00 0.00 0.00 #DIV/0!
46 Other/Miscellaneous 0.00 0.00 55.00 #DIVIO!
47 Other/Contract 0.00 0.00 0.00 #DIV/0!
48 TOTAL 36,379.50 39,165.10 37,961 .46 3.07%
49 REVENUES OVER/ UNDER EXPENDITURES 1 68.50 686.90 38.54 -94.39%
vivmas ea
Tpe Me Organization and Program Name
UNIFORM GRANT APPLICATION
FUNDER SPECIFIC BUDGET
PROGRAM EXPENSES
AGENCY/PROGRAM NAME : Community Child Care Resources, Inc./Psychological Services
FUNDER: Advisory Committee-IR A B C
FY 05/06 FY 05/06 % OF
TOTAL FUNDER TOTAL VS.
PROGRAM SPECIFIC FUNDER REQUEST
BUDGET BUDGET (col. B/col. A)
EXPENDITURES
21 Salaries 22,793.74 0.00 0.00%
22 FICA 1 ,743.72 0.00 0.00%
23 Retirement 0.00 0.00 #DIV/01
2a Life/Health 0.00 0.00 #DIV/O!
25 Workers Compensation 300.00 0.00 0.00%
26 Florida Unemployment 0.00 0.00 #DIV/01
27 Travel-Daily 66.00 0.00 0.00%
28 Travel/Conferences/Training 55.00 0.00 0.00%
29 Office Supplies 276.00 0.00 0.00%
30 Telephone 193.00 0 .00 0.00%
31 Postage/Shipping 0.00 0.00%
32 Utilities 0.00 0.00%
33 Occupancy (Building & GroundEEE
0.00 #DIV/O !
3a Printin & Publications 0.00 0.00%
35 Subscri tion/Dues/Membershi 0.00 0.00%
36 Insurance 276.00 0.00 0.00%
37 E ui ment:Rental & Maintenance 66.00 0.00 0.00%
38 Advertising 55.00 0.00 0.00%
39 Equipment Purchases:Ca ital Expense 0.00 0.00 #DIV/0!
4o Professional Fees (Legal, Consulting ) 11 ,000.00 75000.00 63.64%
41 Books/Educational Materials 90.00 0.00 0.00%
42 Food & Nutrition 72.00 0.00 0.00%
43 Administrative Costs 0.00 0.00 #DIV/O!
44 Audit Expense 0.00 0.00 #DIV/01
45 Specific Assistance to Individuals 0.00 0.00 #DIV/01
46 Other/Miscellaneous 55.00 0.00 0.000
47 Other/Contract 0.00 0.00 #DIV/0!
48 TOTAL 137,961 .46 $7,000 .00 18.44%
S 19Qg
BJ
Type the o,ganosten And PmP.m Name
UNIFORM GRANT APPLICATION
EXPLANATION FOR VARIANCES OF 16% OR MORE
TOTAL PROGRAM BUDGET
AGENCY/PROGRAM NAME: Childcare Resources of Indian River, Inc./Psychological Services
FUNDER: Advisory Committee-IR
#DIV t � ' �
#DIV/ I
#DIVI 1
#DIV/01
#DIVI I
#DIV/ I
#DIV/01
Membeirshin Due& Memberahi mgram instituted 05-06 has proven productive. 06-07 will build on that foundation,
#DW101
#DIV/01
#DIV/01
#DIV/01
#DIV/01
#DIV/0
#DIV/01
#D /01
Workers Compensation Claim in 05-06, increased premium expected.
#DIV/ 1
THIVel-Dally Reflects realignment of program expenses.
#DIV/0
#DIV/01
#DIV/01
#DIV/01
#DIV/01
#DIV/01
#DW/01
#DIV/01
#DIV/01
#DIV/01
#DIVl01
#DIV/0I
#DMOl
s,erzogs
e.s
Type the Oraanaati nand Pmg,am Name
UNIFORM GRANT APPLICATION
EXPLANATION FOR VARIANCES OF 15% OR MORE -
FUNDER SPECIFIC BUDGET
AGENCY/PROGRAM NAME: Childcare Resources of Indian River, Inc./Psychological Services
FUNDER: Advisory Committee•IR
ri .
#DIV/01
#DIV/ 1
;DIV/01
;DIV/01
#DIV/01
Professional Fees 11-agal. Consultinal No need to wrae an explanation.
;DIV/01
#DIV/01
#DN101
;DIV/01
v19= a
e5
TAXONOMY
Psychological Services
Parent Counseling (RP-450 . 650)
In -person Crisis Intervention (RP450 . 330)
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 1s' 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
18402 5th Street
Vero Beach , Florida 32960-3365
Recipient: Childcare Resources, Inc.
1801 24'" Street
Vero Beach , Florida 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 -
09 ! 27 ; 21300 16 : 48 772 " [99595 HR,H '•:ERC BEACH AGE I,
ACORD CERTIFICATE OF LIABILITY INSURANCE ; °�T11;;2
M 1
00"CE0. PtwnS ITT2) SOE 3W FM, (711, 58: 7A6G '
HILB ROGAL A HOBBS OF FLORIDA, INC. • VERO BEACH THIS CERTIFICATE IS ISSUED A8 A MATTER OF jWoRMATION
204614TH AVE. ONLY AND COMERS NO RIGHTS UPON THE CERT¢ICATE I
P 0 BOX 130 HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
VERO BEACH FL 32961 ALTER AV9RAG9 AFFORDED BY TkE AOILIDIE^ Sr:LOW.
INSURERS AFFORDING COVEAA'sE - MAIC B
INSURED -- ' —� - - -- ---- _
� Ev3URER A HARTFOR6 CASUALTY INSURANCE CO.
CHILD CARE RESOURCES OF INDIAN RIVER, INC, •— --- — . .__ _
1801 24TH STREET '� w9URER B. HART INS CO OF SOUTHEAST 027120
VERO BEACH FL 32960 '. INSURER C:
INSURER D: __ . —.. ...— . ._..._ —_..
INSURER E' -' - -
COVERAGES
FANY
UI OF ( `E L�SI'FD EEL ON kAVE BFEN ISSUED TO THE INaJ- 0 NAMED ABOVE FOR THE POLgY PERK)D INOi NOTAATNSY
ANYUIREMENT. TERM OR CONDITION `S ANY CONTRACT OR OTHER DOG 47 WITH RESPECT TD YVWH THIS CERTIFICATE My BE ISSUFC OR LNG
RTAIN, THE INSURANCE AFFORDED &Y 7ME POLICIES DESCRIBED HEREIN 16 SVL:FCT TO KLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
ITV
. AGGREGATE IIMn] SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIM]
TYIlaNSURPNCE PJLIOY NUNeBRa.)Dv' VRIRIRE TPMMUNIffy �ICTYPYIA110NLIMITSUAM
ITV
UASE
�I X I �onNAERCLuu uABwT, I 21 SBA FP89TS DV 10/14106 t0/14MS I EACH OCCURRENCF a 1,F000
04RBE T0IIlNTSD ___PAEM9EBIBb L.. _ '. f 300,000
+ CLAIMS MADE
SCF%P taw urw —_ . . _100000
P"e'nl ri
PERSONAL B ADV INJURY S 1,000000
A 1. _ .. ..
DENERAL AGcrtrW E �S 2.000.000
YEN AGGRPOA'EIMIT MpL'ES PER I --- - _
-'--, r— PRO -- I ' PRODUCTS•COMP/OPA 0 Blic
--
POLX:Y T Loc '
I I AUTOMOAILB Look M
ANYAO'p j 1 COMBINED SINGLE LMIT
aLLCP/NED NJTOS BODILY INJURY — --
SCHEDULEDAU*OS jlpwwsm) f
jHRED ALTOS
1
PR40PLY INJURY
_ ' NON-0NVNED AUTOS AUIBYnt)
' PE E�RTY�DAMA(:E S
I GARAGE UASRITY'
1ANYALTO AOTDONLY . EA ACCIDENT � F
....—_„_.__
( OTHER THAN
. . AUTO ONLY —,.y. .. ,. .__ . _ _... . . . .
AOC i
EXCESS IUMBRELLA LIASUTY IF`ACM OCCURRENCE
! i
OCCUR CAME MADE
' AOOREWTE
' DEDUCTIBLE
S
. NEl'LNTX)N t
q
i
EMPLOYERS! UAENSATKMAND 21WEC DOB422 10/14/06 IW14}08
B AMT mOVRNiw,fIMMLR2aEalma El EACH ACCOEN ' i —_. 600.060
OiFMENYEMFBR FKCLVGE'JI' F . . .
. E.L DISEASE£1EMPCUYEE ii 600,000
NveENI PIgVINIpY YNew I LEL DISEASE-POLICY LIMIT ' S 600,000
1 DTHFR.
I
DESCMPTION OF OPERATIONS!LOCATIONS/VEWCLESIERCLUSWNS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
CERTIFICATE HOLDER NAMED AS ADDITIONAL INSURED WITH RESPECTS TO GENERAL LIABILITY AS PER POLICY FORM AND
PROVISIONS
CERTIFICATE HOLDER CANCELLATION
NHOUIO ANY OF THE ABOVE DESCRIBED POLICIES BE GNNCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO AW'- 10 OAYB
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NABED 10 THE LEFT, BUT FAILURE
TO DO BO SLAU IMPOSE NG CELIW TION OR LACILTY OF ANY KIND UPON THE INSURER,
INDIAN RIVER COUNTY IT'YA , !SORREPRESENTATNFS.
1640 26TH STREET AUTHORIZED REPRE ENTAT
VERO BEACH FL 32880.3356 --'T] �//������'' 11
Attention: 978-1798 Idnev "a"" • "' '
ACORD 29 (2001108) CertificNte 0 W702 4) ACORO CORPORATION 1988
ACORD,. CERTIFICATE OF LIABILITY INSURANCEDATE
08 - 16 - 2006
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
HILB ROGAL HOBBS FL / PHS - VERO BEACH ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
227667 P : ( 866 ) 467 - 8730 F : ( 877 ) 538 - 8526 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW .
PO BOX 29611
CHARLOTTE NC 28229 INSURERS AFFORDING COVERAGE
INSURED INSURER A: Hartford Ins Co of the Southeast
CHILDCARE RESOURCES OF INDIAN RIVER , INSURER B:
INC . INSURER C :
11801 24TH ST . INSURER D:
VERO BEACH FL 32960 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED . NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY 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 ALL THE TERMS , EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR li POLICY EFFECTIVE POLICY EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER GATE MMlDDM' OATS MMlDONV LIMDS
GENERAL LIABILRY I EACH OCCURRENCE $ 1 , 000 , 000
A COMMERCIAL GENERAL LIABILITY 21 SBA FP5973 10 / 14 / 06 10 / 14 / 07 I FIRE DAMAGE (Any one fire) 3300 , 000
CLAIMS MADE I X I OCCUR MED EXP I.Rny one Permnl $ 10 , 000
VGENL
usiness Liab PERSONAL & ADV INJURY 1 , OOO , OOO
GENERAL AGGREGATE s2 , 000 , 000
GREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG 32 , O0O , OOO
ICY PRO- .
ECT X I LOC
AUTOMOBILE LIABILITY
A ANY AUTO 121 SBA FP5973 10 / 14 / 06 10 / 14 / 07 COMBINED SINGLE LIMIT $ 1 , 000 , 000
Es accident)
ALL OWNED AUTOS
BODILY INJURY $
—1 SCHEDULED AUTOS (Per person)
X HIRED AUTOS
, BODILY INJURY $
X NON-OWNED AUTOS IPer accident)
PROPERTY DAMAGE $
I . IPer eccidenq
RAGE UABIUT AUTO ONLY - EA ACCIDENT 3
ANY AUTO OTHER THAN EA ACC 3
AUTO ONLY: AGG S
EXCESS LIABILITY _ EACH OCCURRENCE $
OCCUR a CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ WC IOIMI $
WORKERS COMPENSATNSN AND T IMI OTH-RY
, EMPLOYERS' WIBIDTV
I I E.L. EACH ACCIDENT 3
E.L. DISEASE - EA EMPLOYEE S
E.L. DISEASE - POLICY LIMIT S
OTHER
DESCRIPTION OF OPERAMNS/WCATNINSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Those usual to the Insured ' s Operations . Indian River County is also an
Additional Insured per the Business Liability Coverage Form SS0008 .
CERTIFICATE HOLDER I X I ADDITIONAL INSURED: INSURER LETTER: _ CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE (10 DAYS FOR NON-PAYMENT) TO THE CERTIFICATE
Indian River County HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO
1840 25th Street RE OBLIGATION
ATOR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Vero Beach , FL 32960 A DR DR EBEN A
ACORD 25-S (7/97) 11 "'`L �jL-- ® ACORD CORPORATION 1988
U/ 26! 1200b 10 : 'iU I1r27b / 11 J7 GN1LU��,1Kt Kt SI AJNOtS YFGt tll
22 (PmicyProvisions : WC OC 00 00 A
B4
DQ INFORMATION PAGE
WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY
POLICY
INSURER : HARTFORD UNDERWRITERS INSURANCE COMPANY
HARTFORD PLAZA , HARTFORD , CONNECTICUT Ob .115
NCCI Company Number: SC456 Tx �
Company Code: 5 HART FOR D
a�
s
M
0
o
Suffix
.-[ IARS Rd9CWAL
POLICY NUMBER : 21 WEC D08422 177 10
ry
Previous Policy Number: 11 WEC D 8422
a' HOUSING CODE : SA
1 . Named insured and Mailing Address : CHILD CARL RESOUR"'ES OF INDIAN
(No , Street, Town , Slate , Zip Code) RIVER INC .
0
0
1801 24TH STREET
FEIN NUttlber: b50523165 VERO BEACH , rL 32960
State Identification Number(s):
r�
e�
� The Named Insured is : CORPORATION
Business of Named Insured : CHILD CARE ORG;LVI ZATION
i� Other workplaces not shown above : 1B01 24TH STREET
VERO BEACH FL 32960
2, Policy Period: From 10 / 14 / 06 To 10 / 14 / 07
am
arm
12 :01 a. m . , Standard tirne at the insured 's mailing �;ddress.
rrr:
Producer's Name : HILB ROGAL HOBBS FL -OSRO PEACH
�e
FO PDX 130
i VSRO BEACH , FL 32961
a_ Producer's Code: ' 21809
iiiiz
Issuing Office : '11.41 hARTF'ORD
_ 871 :. UNIVERSITY EAST DRIVE
�� Cliflh LOTTE NC 28213
n�
Total Estimated Annual Premium :
Deposit Premium :
i Policy Minimum Premium. $ 294 FL ( INCLUDES INCRt9kS6:D LIMIT MIN . PREM . }
Audit Period: ANNUAL Installment Term :
The policy is riot binding unless a :untr signed by ow authorized representative
Countersigned by
Authorized Representative Date
Form WC 00 00 Ot A ( 1 ) Pt r. ed in j S . A Page 1 (Continued on next page)
Process Date : 0 6 / 2 9 / 0 6 Policy Ex p6 ation Date : 10 / 14 % O7
OR " GINAL
10/ 20- / 20OG 15 : 18 1772557113E 12HILL " ARE ?E3r7i_IPo^ES PAGE 62
INFORMATION PAGE (Continued) P
ol 'cy Murtrber: 21 WEC LQ8 it 2
3. A. Workers Compen8ation Insurance : Pan one of the policy applies t0 the Workers Comi ens:Q , on Lew of the
states listed here' FL
B. Employers Liability insurance : Fan wo of the f'at'ty applies to work In earl sts, :e listen M !tem 3 .A
The limits of our liability under Part Two are
Bodily injury by Accident $ 500 , 000
Bodilyeach dccident
injury by Disease $ 500 , 000 policy limit
Bodily injury by Disease $ 500 , D00
each employee
C. Other States Insurance : Par. Three of the p0ficy applies to the states. if any , listed dere
m
ALL STATES EXCEPT ND , OH , WA , WG , WY , AND
STATES DESIGNATED IN ITEM 3 . A DF THE INFORMATION PAGE .
D This policy include$ these endursements aria schedule:
0
ro WC 09 04 03 WC 00 04 14 WC 00 04 19 WC 09 06 06
a
m
cr 4. The premium for this policy will be determined by our Manuals of Rules, Classifications , Rates ar :d Rat rig
ra Plans. All information required below is subject to verification and change by audit.
Premium Basis
LP Classifications Total Estimated Rates Per Estimated 4
Code Number and Annual $ 100 of Annual
Description Remuneration Remuneration Premiun _
3111111111! 13 . 58 7a '
MillerCLERICAL OFFICE EMPLGYEES NO'='
ease
INCREASED LIMITS PART TWC ( 9807 ; 130 PERCENT b
q TO EQUAL INCREASED LIMITS MINIMUM PREW:IUM ( 9848 ) 94
TOTAL ESTIMATED ANN^JAL STANDARD PREMIUM 639
1� EXPENSE CONSTANT ( 0900 ) 200
r� FOREIGN TERRORISM ( 9740 ) 136 , C00 . 030 41
Ifs TOTAL ESTIMATED AN-WAL PREMIUM 1 : 08C
soft
sum
s
Total Estimated Annual Premium ; $ 1 ( 080
> Deposit Premium :
as
= Policy Minimum Premium : $ 294 FL ( INCLUDES IN"'REASED LIMIT MIN . PREY - )
ae
Interstate/Intrastate Identification Number:
NAlCS : 511659
Labor Contractors Policy Number: SIC: 8299
Form WC 00 00 01 A 0 ) Printed in U- S .A . Page 2
Process Date : 06 1Yi 6 Policy Expiration Date: 10 / 14 / C7
10 ; G / 2006 15 : 16 1772567113E _HILL ARE ?L"dC_iRCES PriGE f� 2
INFORMATION PAGE (Continued)
Po"cyNurr) ber: 21 WBC UQ6li2
7 . A. Workers Compensation
stales listed here' FL Insurance : Part one of the policy applies to the Iklorkers Corr:F nn Law of the
B. Employers Liability Insurance : f-an wo of the policy applies 10 work .; ste in !tem 3 A
The limits of our liability under Pan 7wc are III ea lister+
Bodily injury by accident $ 500 , 000
Bodily injury by Disease each decadent
s 00 , OD0 Policylim � t
Bodily injury by Disease s �lcU , 000 each employee
P C . Other States Insurance: Pa+ ? Three rf the policy applies to the states , it any , listed hei n
STATES EXCEPT ND , r
JH , WA , W(i , WS , 14'VC
STAPES DESIGNATED IN I^.'EM J . P. OF THE INFORMATION PAGE .
n
D This Policy includes these endorsernents and schedule:
N WC 04 04 .03
WC 00 04 14 WC 00 04 19 WC 09 06 06
a
m
d. The premium for this policy will be determined by Our Manuals of Rules, Classifications. Rates and Rat rig
Plans . Ali information required belowis subject to verification and change by autlit.
Premium Basis ` — - - - -- -
Classifications Total Estimated Rates Per
Estimated
Code Number and
Annual $ 100 of Annual
Description
- -- Remuneration Remuneration Premiun
6810 —_'_-------- --- ------ 16 , 0 U 0 , � g -- �— - - — -
nowCLP'RICAL OFFICE EMPLOYEE$ NO" I3 .
INf.RF'ASED LIMITS PART, TWC ! ? B07 ` , 30 PERCENT b
i TO :QUAL INCREASED LIMTTS MTNIWtt o YREbiI JM ( 9646r 4
TOTAL ESTIMATED ;L JAL STANDARD 9
FREMIUM 644
aI� EXPENSE CONSTANT ( 0900 ) 20C
FOREIGN TERRORISM ( 47401 136 , 500 . 030 ql
TOTAL ESTIMATED ANNUAL PRF,MIiJM 06C
rc
r�
s
Total Estimated Annual Premium:
�—a Deposit Premium !
Policy Minimum Premium : — 6294 FL , IN!" LtJDES IN "cZEASE'D LIMIT MTN_PREM . '
Sale
Interstate/Intrastate Identification Number:
NAILS : 511649
Labor Contractors Policy Number: SIC: 3 .149
Form INC 00 00 01 A ( 1 ) Pirated in U S Page 2
Procass Dare ; 08 / 11 36 Policy Expiration Date : 10 / 19 / () 7