HomeMy WebLinkAbout2006-331H. a onto X331
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" Street, Vero
Beach , Florida , 32960-3365; and Gifford Youth Activity Center (Recipient), of:
Gifford Youth Activity Center
4875 43 ° Avenue
Vero Beach , Florida 32967
Mental Health Services 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 . Backqround 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 .
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4. Grant Funds and Payment. The approved Grant for the Grant Period is : THIRTY
THOUSAND , DOLLARS ($30,000). The County agrees to reimburse the Recipient from such
Grant funds for actual documented costs incurred for 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 . Reeipient haBe entered into this Contract on the date
first above written .
INDIAN RIVER COUNTY BOARD OF COMMISSIONERS
By:
Arthur R. NeubergefVlhairran
BCC Approved : /0 ' 3 - O b
Attest: J . K. Barton , Clerk UnA
By: ` a
Deputy Clerk
Approved : O P
tJos4eAaird
unty Administrator
Approved as to form and legal sufficiency:
,AAurian E. Fell , Assistant County Attorney
R,ECI 1 NT: z
Gifford Youth Activity Center
exo. w4c vt1j , \- L. CA O {
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EXHIBIT A
(Copy of complete Request for Proposal)
EXHIBIT - A -
ORGANIZATION: GIFFORD YOUTH ACTIVITY CENTER/MENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: CHILDREN'S SERVICES ADVISORY COMMITTEE
PROGRAM COVER PAGE
Organization Name: Gifford Youth Activity Center
Executive Director: Michael S. Hubler E-mail: mhublerW yvac . cc
Address: 4875 43rd Avenue Telephone_ (772) 794- 1005
Vero Beach, FL 32967 Fax: (772) 569-5563
Program Director: Michael Williams E-mail : mwilliams &gyac .cc
Address: 4875 43`d Avenue Telephone : (772) 794- 1005
Vero Beach, FL 32967 Fax: (772) 569-5563
Program Title: Mental Health Services for Children & Families
Priority Need Area Addressed: Mental wellness issues for children preschool to age 18 and
parental support and education.
Brief Description of the Program: The Mental Health Services Program is desiPated to offer individual
and group services to preschoolers, elementary school children teens and parents to assist youth to
improve the emotional and behavioral problems which are negatively impacting their ability for
personal growth, development and academic achievements. Taxonomy Definition — Mental Health
Care and Counseling.
SUMMARY REPORT — (Enter Information In The Black Cells Onl
Amount Requested from Funder for 2006 /07 : $ 605673 . 96
Total Proposed Program Budget for 2006 /07 : $ 763815 . 26
Percent of Total Program Budget : 79 . 0 %
Current Program Funding (2005 /06 ) : $ _
Dollar increase/( decrease ) in request : $ 60 , 674
Percent increase/(decrease) in request * * # DIV ; O !
Unduplicated Number of Children to be served Individually : 75
Unduplicated Number of Adults to be served Individually : 60
Unduplicated Number to be served via Group settings : 60
Total Program Cost per Client : 393 . 92
* *If request increased 5 % or more, briefly explain why:
If these funds are being used to match another source, name the source and the $ amount:
The Organization 's Board of Directors has approved this application on (date). UA
John H. Dean
Name of President/Chair of the Board <igPnagRf
Michael S. Hubler I
Name of Executive Director/CEO Signature
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ORGANIZATION: GIFFORD YOUTH ACTIVITY CENTER/MENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: CHILDREN 'S SERVICES ADVISORY COMMITTEE
ORGANIZATION: Gifford Youth Activity Center
PROGRAM: Mental Health Services for Children & Families
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.
X Section of the Proposal Pa e #
TABLE OF CONTENTS (check list) 1
X COVER PAGE (with signatures). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
X A, ORGANIZATION CAPABILITY (one page maximum) 4
X 1 . Mission and Vision of organization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
X 2. Summary of expertise, accomplishments, and population served . . . . . . . . . . . . . . . . 4
X B. PROGRAM NEED STATEMENT (one page maximum) 5
X 1 . Program Need Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 5
X 2. Programs that address need and gaps in service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
X C, PROGRAM DESCRIPTION (two pages maximum) 6
X1 . Funding priority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 6
X 2 . Description of program activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . . . . . . . 6
X 3 . Evidence that program strategy will work. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
X4. Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 4 . . . . . . . . . . . 7
X 5 . Awareness of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . . .
. . . 7
X 6 . Accessibility of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . 4 . . . . . . . . . . . . . . . . . . . .
. . . 7
X D. MEASURABLE OUTCOMES (two pages maximum) . . . . . . . . . . . . 4 . . . . . . . . . . . . 8
X E, COLLABORATION (one page maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
X F. PROGRAM EVALUATION (two pages maximum) 10
X1 . Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 10
X2 . Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 10
X3 . Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 11
X G. TIMETABLE (one page maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
X H, UNDUPLICATED CLIENT COUNT 13
X 1 . Projections by Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 13
X 2. Projections by Age Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . . . . . . . . . .
13
X 1. BUDGET FORMS 14
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. ORGANIZATION : GIFFORD YOUTH ACTIVITY CENTER/MENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: CHILDREN'S SERVICES ADVISORY COMMITTEE
1 . Financial Budget Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . .
J. FUNDER SPECIFIC/ADDITIONAL SHEETS
K. APPENDIX
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• ORGANIZATION : GIFFORD YOUTH ACTIVITY CENTER/MENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: 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 for the Mental Health Association (MHA) — To work for America' s mental
victory over mental illness by education, promoting and/or providing services and programs for
support, research, and education.
Mission Statement for the Gifford Youth Activity Center - With God' s guidance our vision is to
establish a partnership among youth, adults and the Gifford-Indian River County area that
develops self-esteem, teaches character and encourages each individual to his/her ultimate
potential .
The vision of the Mental Health Services Program is :
• To build awareness and knowledge of mental health issues in the community as well as
offer mental health programs and services to those in need.
• We believe by strengthening our community, the GYAC and the MHA are working toward
better mental health in Gifford/Indian River County and victory over mental illness.
2. Provide a brief summary of your organization including areas of expertise,
accomplishments, and population served.
The Gifford Youth Activity Center, Inc., hereafter referred to as the GYAC , a 21St Century
Learning Center, provides a holistic approach to meeting the needs of families in the Gifford and
adjacent communities of Fellsmere, Sebastian, Vero Beach and Wabasso. Currently, there are
over 30 different programs provided at the Gifford Youth Activity Center, in collaboration with
37 different community agencies. The GYAC has served over 12,000 youth and adults during
the 2005-06 fiscal years.
The GYAC received the 2005 Outstanding Florida Minority Education Community Organization
Award. This award was presented by Governor Jeb Bush, and Education Commissioner, John
Winn on behalf of the Florida African-American Education Alliance. The GYAC has very
talented and dedicated staff and utilizes the expertise of its many partner organizations to offer
quality programs.
With the MHA, currently 19 staff, 7 contracted mental health professionals and over 75
volunteers provide an array of mental health services to our community. Services include crisis
intervention, individual mental health assessments and treatment, group classes on substance
abuse, anger management, and domestic violence, support groups, children' s programs and
socialization programs (drop-in centers) for adults in recovery from mental illness. The MHA is
a leader in providing immediate access for mental health needs and addressing community needs
in mental health.
In 2005 , 3200 calls were responded to through the Crisis Line which has been in operation for 20
years. Programs and services reached over 7000 individuals needing support. The TurtleTrax —
Overcoming Hurdles with Turtles fund raising campaign was a tremendous success in increasing
community awareness of mental health needs and reducing the stigma often associated with
mental illness.
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ORGANIZATION: GIFFORD YOUTH ACTIVITY CENTERIMENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: CHILDREN'S SERVICES ADVISORY COMMITTEE
B. PROGRAM NEED STATEMENT (Entire Section B not to exceed one page)
1 . a) What is the unacceptable condition requiring change? b) Who has the need?
c) Where do they live? d) Provide local, state, or national trend data, with reference
source, that corroborates that this is an area of need.
The unacceptable condition requiring change is:
• One in 5 children has a diagnosable mental, emotional or behavioral disorder, however
approximately 70% of the children do not receive mental health treatment (NIMH, 1999) .
• An estimated 2 . 7 million children (nearly 5%) are reported by their parents to suffer from
definite or severe emotional or behavioral difficulties (Report, "America' s Children: Key
National Indicators of Well-Being 2005). Children from poor families were more likely to have
emotional or behavioral difficulties than other children.
• Mental health issues in children can lead to underachievement and social isolation
(NIMH, 1999).
• Indian River County has 4294 (21 . 1 %) of children living in poverty (IRC Children' s
Services Advisory Committee 2002-2005 Community Assessment & Plan).
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.
Children needing mental health services whose families qualify for Medicaid and/or have
insurance, may access services provided by Sun Coast. Children may also be able to access
services provided by New Horizons to the various public schools.
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ORGANIZATION: GIFFORD YOUTH ACTIVITY CENTERIMENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES _
FUNDER: CHILDREN'S SERVICES ADVISORY COMMITTEE i
C, PROGRAM DESCRIPTION (Entire Section C, I — 6, not to exceed two pages)
1 . List Priority Needs area addressed.
Focus Area I — Mental Wellness Issues for Children Pre-school to age 18 . This program
improves the capacity of children in Indian River County to succeed to adulthood in a safe,
healthy, and productive manner by meeting the following objectives : Promotes enhanced
emotional and social skills; Provides early intervention screening for children; Promotes life
skills training and effective use of emotional and social skills; Promotes independent living
skills; Promotes accessible locations for healthy, productive activities.
Focus Area II — Families Support & Education. This program supports parents/guardians, 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 by meeting several stated objectives. Increases the
availability of affordable quality after school summer children' s educational programs; increases
access to cultural and ethnic activities; increases tutorial and mentoring programs.
2, Briefly describe program activities including location of services.
The Mental Health Program will be serving preschoolers, elementary school age children, teens,
and parents. All activities will occur at GYAC . Mental health services shall focus on the
following for children: building self-esteem, improving attitudes and behaviors, caring for others,
identification of feelings, anger management and strategies for non-aggressive behaviors. The
parental component shall focus on: parenting strategies, crisis intervention for family issues,
behavior management issues and educating parents on the developmental needs of children.
Family mental health services will be targeted to indigent families who have no insurance
coverage nor means to pay for services.
Activities will include both group and individual counseling. Age appropriate materials will be
used with the children and include activities which engage children. Activities such as games,
drawing, self-expressions, skits, puppets, etc. will be incorporated. Mediation will be used to
assist youth with conflict resolution. Parents will receive individual family assessment of mental
health needs, individual consultations, information, referrals and counseling . Where appropriate,
behavioral observations, behavior plans and follow-up will be provided to address specific
problems the child may be experiencing in the family, in, social settings, at school , etc.
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,
Since 1990 the Search Institute in Minneapolis, MN has researched and promoted their program
of "Healthy Communities" (www. search-institute.orel. Their approach is based on the 40
Developmental Assets which are the building blocks of healthy development that help young
people grow up healthy, caring, and responsible. Their internal assets for development include
developing positive values, social competencies, and a positive self identity. Concepts proposed
in this mental health program are similar to those proposed by Dr. Peter Benson, Ph.D. in his 40
Developmental Assets.
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ORGANIZATION: GIFFORD YOUTH ACTIVITY CENTER/MENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: 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).
Mental Health Professional (# 1 ) — 32-40 hours per week — Certified/Licensed Mental Health
Professional . Mental Health Professional (#2) — 12 hours per week — Volunteer
Family Counselor (# 1 ) — 8 hours per week each
Family Counselor (42) — 8 hours per week — Volunteer
5. How will the target population be made aware of the program?
Various marketing strategies will be implemented. Progiam flyers will be distributed home to
parents and children through GYAC, Headstart, local child care providers and local churches.
MHA and GYAC will utilize the media (newspapers, TV, radio) to publicize the program.
In addition, GYAC staff will identify mental health needs from the existing 400 children served
daily; referrals will be made to the Mental Health Professional Staff via the student dean.
Families will be scheduled for appointments with Mental Health Professional Staff to address
needs based on behavior, attitude, and academic performance.
6. How will the program be accessible to target population (i.e., location, transportation,
hours of operation)?
The Mental Health Program will operate Monday — Thursday with services available during the
day, after school and some evenings. During the school year, the schedule is as follows: Pre-
kindergarten, M-Th, 9 :30AM — 11 :OOAM; After school program, M-Th, 4 :OOPM — 6:OOPM.
During the summer, the activities will take place 9 :OOAM — 5 :OOPM. Family Counseling will be
available in the evenings M-Th, 5 :30PM — 8 : OOPM.
Since the program is located at GYAC it is easily accessible to the Gifford/Indian River County.
The target population is already used to utilizing the Center. Children are also provided
transportation from school to the Center for activities.
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• ORGANIZATION: GIFFORD YOUTH ACTIVITY CENTER/MENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: CHILDREN'S SERVICES ADVISORY COMMITTEE
D. MEASURABLE OUTCOMES (Entire Section D not to exceed two pages)
OUTCOMES ACTIVITIES
Add all o the elements for the Measurable Outcome(s) Add the tasks to accom lish the Outcomes
1 . Increase the ability of 15-20 1 . Provide 12 lessons to enrolled
preschoolers to recognize and preschoolers twice a week for 12
demonstrate feelings and emotions by weeks .
displaying positive social interactions
with their peers as measured by
pre/post tests by 9/30/07 .
2. To decrease aggressive and/or angry 2. Provide anger management sessions
behavior in 30-35 elementary school and/or mediations to enrolled children,
children by learning to manage anger as as behaviors are demonstrated, by
evidenced by pre/post tests and 9/30/07.
mediations by September 30, 2007.
3 . To decrease depression and feelings of 3 . Provide individual and/or group
hopelessness in 30 teens by enhancing counseling sessions, as needed.
self-esteem as evidenced by satisfaction
surveys by 9/30/07
4 . To increase knowledge of parenting 4 . Satisfaction surveys to be completed by
strategies and behavior management of parents by 9/30/07 .
their child(ren) with 35 -40 parents.
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ORGANIZATION: GIFFORD YOUTH ACTIVITY CENTER/MENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: 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 agreement letters.
Collaborative Agency Resources provided to the program
Mental Health Associates of Indian River Mental Health Counselors
County Indigent Care, group sessions, individual sessions
at GYAC
EOC Head Start of Indian River County Program participants
(3 centers)
Ross Small World Day Care Program participants
Turner' s Day Care Program participants
Bright Beginnings Day Care Program participants
Theresa' s Day Care Program participants
Indian River Leaming Center Program participants
Sun Coast Mental Health Mental Health Counselors
Insured Care
Dr. John Fitzgerald Contracted family counselor
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ORGANIZATION: GIFFORD YOUTH ACTIVITY CENTER/MENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: CHILDREN'S SERVICES ADVISORY COMMITTEE
F. PROGRAM EVALUATION (Entire Section F not to exceed two pages)
1 . DEMOGRAPHICS: What information (data elements) will you need to collect in order
to accurately describe your target population including demographics (age, gender, and
ethnic background) required by the funder in Section H? What are the pieces of
information that qualify them for your target population? How do you document their
need for services or their "unacceptable condition requiring change" from Section Bl ?
A "Mental Health Services Referral Form" will be utilized by GYAC staff and parents to
identify problem behaviors and/or mental health needs of the child. Parents may also request
services on the form. The Mental Health Counselor will then follow-up on the referrals and
schedule for services. The referral form will provide basic demographics regarding age, gender,
mental health issues, etc.
2. MEASURES: What data elements will you need t0 collect to show that you have
achieved (or made progress toward) your Measurable Outcomes in Section D? What
tools or items are you using as measures (grades, survey scores, attendance, absences,
skill levels) for your program? Are you getting baseline information from a source on
your Collaboration List in Section E? Are there results from your Activities in Section
D that need to be documented? How often do you need to collect or follow-up on this
data?
Data will be collected on a weekly, monthly, and quarterly basis utilizing the following
measures:
• Pre/post tests to determine comprehension of teaching materials regarding feelings,
emotions, and anger.
• Number of conflicts between youth which are mediated and result in positive resolutions.
• Progress reports, provided by parents, teachers and youth, regarding specific behavioral
and/or mental health issues.
• Satisfaction surveys, obtained from parents and teens, regarding mental health services
received.
10
ORGANIZATION: GIFFORD YOUTH ACTIVITY CENTERMENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: 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?
The results of the information obtained from the above measures will be used in quarterly reports
to the funder. Additionally, the GYAC and the MHA Administration and Board will obtain a
report on the progress and the program outcomes . Information will be used to determine
program successes and improvements.
11
ORGANIZATION : GIFFORD YOUTH ACTIVITY CENTER/MENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: 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
DAILY SCHEDULE Preschool Age Children
Monday - Friday 8:30 AM - Bus departs GYAC to pick up children.
9 :00 — 9 :25 AM — Children arrive at the GYAC .
9 :05 — 9 :30 AM — Children walk orderly to the library in the rear of the
building.
9 : 10 — 9 :30 AM — Children will break up into groups at staff direction
and begin their first session.
10: 15 AM — Switch learning activities and begin their second session.
11 :00 AM — Program ends. Bus ride from GYAC back to preschool .
Monday — Thursday After-school Program
4:00 — 6 :00 PM
Monday — Thursday Summer Program
9 :00 AM — 5: 00 PM
Monday — Thursday Family Counseling
5:30 — 8 :30 PM
12
ORGANIZATION: GIFFORD YOUTH ACTIVITY CENTERIMENTAL HEALTH ASSOCIATION
PROGRAM: MENTAL HEALTH SERVICES FOR CHILDREN & FAMILIES
FUNDER: CHILDREN'S SERVICES ADVISORY COMMITTEE
H. PROJECTIONS FOR UNDUPLICATED CLIENTS
Number of Unduplicated Clients by Location
LSt . Xe x; Current Fiscal Year Neer# it
Location Actual 20042005 Budget 2005/06 Proiections?L006/t1'1' '
Unduplicated Clients Unduplicated Clients Unduplicated Clients
N. Indian River County 98
S . Indian River County - - 98
Indian River Co. Total 196
Greater Stuart - - -
Hobe Sound - -
1ndiantown - -
Jensen Beach -
Palm City - -
Martin County Total - - -
Fort Pierce - -
Port Saint Lucie - - -
St. Lucie Co. Total - -
Other Locations - -
TOTAL SERVED - 196
Number of Unduplicated Clients by Age
Last Fiscal Year Current Fiscal Year Neat FSscal Yeas
Location Actual 2004/2005 ; Budget 2005/06 Projections 2006J07`
Individuals Group Individuals Group ImIdividuab Group
0 to 4 - (Pre-school) - - 24 24
5 to 10 - (Elementary) - - - - 60 30
11 to 14 - (Middle) - - - 36 6
15 to 18 - (High School) 15
Total Children - - 135 60
19 to 59 - (Adults) 60 -
60 + (Seniors) - - -
Total Adults - - - 60 -
TOTAL SERVED - - - - 195 60
13
Edit this Header. Tyne the organization and program name and the funder for whom it is being completed. The page N is already set at the bottom right
of every page.
I. BUDGET FORMS - To open the Budget Forms, please double-click on the icon below.
" Core Budget Forms "
14
GYAC - Mental Health Services Pmgram
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 : Gifford Youth Activity Center - Mental health Services Program
FUNDER: Children 's Services of indian River County
_ . _ . . _ . . _ . . _ . . _ . . _ - . _ . . _ . . _ . . _ - . _ . . _ . . . . . . . . . . . . . . . . . . . . . - . _ . . _ . . _ . - _ . . _ . . _ - . . . . . . . . . . . . .
. . . _ . . — —,
I
CAUTION : Do not enter any figures where a cell is colored in dark blue - Formulas and/or links are in lace. Gra areas should I
Abe used for calculations and to write information only.
Proposed Total Program Funder Specific Total Agency
REVENUES "®1Y1°` O1LY mos g P
'c„°1amorr„& Budget Budget Budget
1 Children's Services Council-St Lucie
2 Children's Services Council-Martin
3 Advisory Committee-Indian River 60,673.96 60,673.96 153,673.96
4 United Way-St. Lucie County
5 United Way-Martin County
6 United Way-Indian River County 0.00 0.00 90,000.00
7 Department of Children & Families
8 County Funds 0.00 0.00 163,000.00
9 Contributions-Cash 0.00 0.00 228,623.00
10 Program Fees 0.00 0.00 73,500.00
11 Fund Raising Events-Net 0.00 - 0.00 60,000.00
12 Sales to Public - Net
13 Membership Dues 0.00 0.00 6,300.00
14 Investment Income
15 Miscellaneous 0.00 0.00 96,636.04
16 Legacies & Bequests
17 Funds from Other Sources
18 Reserve Funds Used for Operating _ 16, 141 .30 0.00 207,000.00
19 In-Kind Donations (Not Included In total 0.00 0.00 30,000.00
20 TOTAL REVENUES
(doesn't include line 19) $76,815.26 $60,673.96 $1 ,078,733.00
A B C D
EXPENDITURES UPAYM FM Proposed Total Program Funder Specific Total Agency
n Wy esE way
isawwaaunoasi Budget Budget Budget
21 Salaries - (must complete chart on next page) 69,563.26 48,640.00 567,650.00
Salary
22 FICA - Total salaries x 0.0765 7.65% 3,720.96
Retirement - nnua pension W qua I le
23 staff
800.00
Life/Health - iCa sofa ort- erm
24 Disab. 4,000.00
Workers ompensa on - emp oyees x
25 rate
0.00
ore a Unamployment - If projected
26 employees x $7,000 x UCT-6 rate 2,013.00
SALARIES A e o
POSITION LISTING Gross Annual Portion of Salary on Proposed C % of Gross Annual
Salary Program Funder Specific Budget Salary
Position Tide / Total Hrs/wk (Agency) Requested(GA)
Example: ExecuWe Dlrector140hm 70,000.00 109000.00 5,000.00 7.14%.
92312006
B-1
GVAC - Mental Health services Program
Mental Health Counselor ( 1 )/40 hrs 40,000.00 40,000.00 40,000.00 �100.00OA
Family Counselor (1 )/8 hrs 8,640.00 8,640. 00 8,640.00 100.00°
Student Dean (1 )/40 hrs 33,200. 00 16,600.00 0.00 0.00°
Mental Health Counselor (1 ) - vol./12 hrs #DIV/0!
Family Counselor (1 ) - volunteer/8 hrs #DIV/01
Executive Director ( 1 )140 hrs 66,950.00 669.50 0. 0 0.00%
Admin. Of Development & Mkt ( 1 )/40 hrs 51 , 904.00 519,04 0.00 0.00
Education Coordinator (1 )/40 hrs 30,000.00 300.00 0.00 O.00Y
Administrative Assistant (1 )/40 hrs 30,000.00 300.00 0.00 0.00°
Receptionist (1 )/40 hrs 23,456.00 234.56 0.00 0.00°
Custodian (1 )/40 hrs 26,020. 00 260.20 0.00 0.00°
Mentor Coordinator (1 )/25 hrs 15,000.00 750.00 0.00 0.00
Camp Counselors/Teachers (15)/40 hrs 76,020.00 760.00 0.00 0. 00%
After School Teachers (10)/15 hrs 76,020.00 760.00 0.00 0.00
Recreation Leaders (2)/20 hrs 18,804.00 - 188.00 0.00 0.00
Asst. Academic Coordinator (1 )/20 hrs 10, 136. 00 101 .00 0.00 0.00°b
Librarian (1 )/40 hrs 32,500.00 0.00 0.00 0.00%
Librarian (1 )/20 hrs 12,500.00 0.00 0.00 0.00%
Bus Driver (1 )/30 hrs (Summer) 4, 500.00 0.00 0.00 0.00%
Bus Driver (1 )/30 hrs (School ear) 12,000.000.00 0.00 0.00
Remaining positions throughout aq�ency
en
Total Salaries $567,650.00 $69,563.26 $48,640.001 5700
FRINGE BENEFITS DETAIL A
(Funder Specific Budget Funder a c v E F c
Specific FICA 7.65% eaIns.PensOon Health IWorker's 1Memployme Total Fringes Funder
Column C only, from line 22 to 27) (A x %) Compens. nt Com
Position Title / Total Hrs/wk Budget Pens" Speciale
ExMPW Case Managsa,/40hm 5.000.00 382.50 200.00 500.00 300-ie 208.001 !.582.50
Mental Health Counselor (1 )/40 hrs 40,000.00 3,060.00 800.00 4,000.00 1 ,656.00 9,516.0
Family Counselor (1 )/8 hrs 8MM
640.00 66096 357.00 11017.9
Student Dean ( 1 )140 hrs 0 0.0
01
Mental Health Counselor (1 ) - vol./12 hrs 00 0.001
Family Counselor (1 ) - volunteer/8 hrs 00 i 0 001
Executive Director (1 )/40 hrs o 0.001
Admin. Of Development & Mktg (1 )/40 hrs 0 0.001
Education Coordinator ( 1 )/40 hrs 0 0.0Administrative Assistant (1 )/40 hrs 0 0.001
Receptionist (1 )/40 hrs 0 0.001
Custodian ( 1 )140 hrs 0.00 0.00 0.0
Mentor Coordinator (1 )/25 hrs 0.00 0.00 0.0
Camp Counselors/Teachers (15)/40 hrs 0.00 0.00 0.0
After School Teachers ( 10)/15 hrs 0.00 0.00 0 0
Recreation Leaders (2)/20 hrs 0.00 0.00 0.001
Asst. Academic Coordinator ( 1 )/20 hrs 0.00 0.00 0.0
Librarian ( 1 )/40 hrs 0.00 0.00 0.0
01
Librarian (1 )/20 hrs 0.00 0.00 A(, (,
Bus Driver (1 )130 hrs (Summer) 0.00 0.00 Bus Driver (1 )/30 hrs (School year) 0.00 0.00
Total Funder Request Fringe Benefits $48.840.00 $3,720.961 $800.00 x,000.001 $0.00 $2,013.00 10,533.
A B C D
EXPENDITURES QMYAaEAeFOR Proposed Total Program FunderSpecifrc Total Agency
AOENLYUMONLYT0
MMMNL Budget Budget Budget
27 Travel-Daily 600.00 23,738.00
# of Staff x average # of miles/wk x 50 wks x
$ = Estimated Daily Travel/Mileage Reimb.
28 Travel/Conferences/Training 800.00 600.00 22,430. 00
5=006
S-1
GYAC - Mental Health services Program
National Conference (cost per staff)
• Training/Seminar (cost per staff)
• Other Trainings (cost of travel, lodging,
registration , food)
29 Office Supplies 250.00 150.00 29,815.00
• Office supplies (monthly average x 12
months = estimated cost of office supplies
based on present history.
30 Telephone 175.00 6, 500.0
• # 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 50.00 2,850.00
• Quarterly Mailing of Newsletter
• Special events, etc.
• Bulk mailings - appeals
32 Utilities 305.00 28,000.00
• Electricity ($ x 12 months)
• Water/Sewer ($ x 12 months)
• Garbage ($ x 12 months)
33 Occupancy (Building & Grounds) 6,000.00
• Mortgage/Rent ($ x 12 months)
• Janitorial ($ x 12 months)
• Grounds Maint. ($ x 12 months)
• Real Estate Taxes
34 Printing & Publications 250.00 7, 500.00
• Quarterly Newsletter ($ x 4)
• Letterheads, Envelopes, etc.
• Fundraising materials
• Other
i
35 Subscription/Dues/Memberships 150.00 750.00
• Membership to National Organization
• Dues
• Subscriptions to Newspapers/magazines,
etc.
36 Insurance 495.00 48,500.00
• Directors/Officers Liab.
• Commercial/General Insurance
• Bond Ins.
• Auto Insurance
37 Equipment: Rental & Maintenance 1 ,700.00
• Copier lease ($ x 12 months)
• Meter lease ($ x 12 months)
• Copier Maintenance ($ x 12 months)
' Computer Maintenance ( $ x 12 months)
• Other
38 Advertising 2,500.00
• Newspaper ads
• Fundraising ads/promotions
• Other (vacancies) ,
39 Equipment Purchases :Capital Expense 11 , 500.00
• Computer/monitor (# x $)
• Laser Printer
40 Professional Fees (Legal, Consulting) 32,500.00
• Legal advice ( estimated #hrs x $)
• Consultant fees
• Other
41 Books/Educational Materials 1 ,500.00 750.00 6.250.00
• Books/videos
• Materials ($ x staff)
42 Food & Nutrition t -
150.00 15, 560.00
5n3rz006
e-�
GYAC - Mental Health Services Program
• Meals ( # meals x clients x 5days x 50 wks)
• Snacks
43 Administrative Costs 2,237.00 83,000.00
• Admin. Cost (% of total budget)
44 Audit Expense 50.00 5,000.00
• Independent Audit Review -
45 Specific Assistance to Individuals x,000.00
• Medical assistance
• Meals/Food
• Rent Assistance
• Other
46 Other/Miscellaneous 240. 00 0.00 1 ,920.00
• Background check/drug test
• Other
47 Other/Contract 171 ,070.00
• Sub-contract for program services
48 TOTAL EXPENSES $76,615.28 $60,673.96 $1 ,078,733.00
5=006
B-1
cunt - u.vu rx.m scare vby. �
UNIFORM GRANT APPLICATION
TOTAL AGENCY BUDGET
AGENCY/PROGRAM NAME: GYAC - Mental Health Services Program
FY 04105 FY 05M FY 06!07 % INCREASE
FYE FYE FYE CURRENT VS.
NEXT FY BUDGET
A B C D
ACTUAL TOTAL PROPOSED Ica. C<a. Byca. 8
REVENUES BUDGETED BUDGETED
I Children's Services Council-St Lucia 0.00 #OIV101
2 Children's Services Council-Martin 0.00 11DIVI01
3 Advisory Committee-Indian River 30 D00.00 92 400.00 153 673.96 66.31%
4 United Wa St Lucie County 0.00 #DIV701
5 United Way-Martin County 0.00 #DIV701
6 United Way-Indian River County 38 250.00 90 000.00 135.29%
7 Department of Children & Families 0.00 #DIV/01
a County44
Funds 1223.00 182939.00 163000.00 -10.90%
9 Contributions-Cash 136750.00 526083.00 228623.00 56.54%
10 Pro ram Feas 7350000 #DIV/01
11 Fund Raising Events-Net 7,00000 4 528.00 60 000.00 1225.09%
12 Sales to Public-Net 0.00 #DIV/0I
13 ;e�mbemhlp Dues 7 500.00 3864500 630000 53.70%
14 Investment Income 100000.00 9301 .00 0.00 -100.00%
15 Miscellaneous 22816.00 96636.04 323.55%
16 Legacies & Bequests 0.00 #DIV701
17 Funds from Other Sources 199 500.00 30 793.00 0.00 -100.00%
19 Reserve Funds Used for Ovemitina 207 000.00 ;DIV/01
19 In-Kind Donations (N Incwwe in ro q 30 000.00 #DIVI01
20 TOTAL 603 193.00 945 755.00 1 078 733.00 14.06%
EXPENDITURES
21 Salaries 294226.00 472156.00 667650.00 20.23%
22 FICA 22 919.00 36 120.00 0.00 -100.00%
23 Retirement 8,988.00 12 842.00 0.00 -100.00%
24 Life/Health 28184.00 34877.00 0.00 -100.00%
25 Workers Compensation 12 853.00 19 574.00 0.00 -100.00%
26 Florida Unemployment 7 944.00 12 748.00 0.00 -100.00%
27 Travel-Daily 11358.00 13561.DO 23738.00 - 75.05%
29 TravellConferencestTrainin 6148.00 22430.00 264.83%
29 Office Su lies 16002.00 18668.00 29815.00 59.80%
30 Telephone 18 002.00 8 430.00 69500.00 -22.89%
31 Postage/Shipping 3,501 .00 3,723.00 2 550.00 -23.45%
32 Utilities 37 900.00 29 540.00 28 000.00 5.21 %
33 Occupancy Buildin BGrounds) 27900.00 6000.00 6000.00 0.00%
34 Printing & Publications 4978.00 7500.00 50.66%
35 Subscri tion/Dues/Membershi 35 654.00 3,460.00 750.00 -78.32%
30 Insurance 48771 .00 48500.00 -0.56%
37 E ui ment:Rental & Maintenance 29 461.D0 170000 -94.23%
38 Advertising 2240.00 2500.00 11.61%
39 Equipment Purchases:Ca ital Ex ense 11,500.00 #DIV/01
40 Professional Fees (Legal. Consultin 10 306.00 32 600.00 215.35%
41 Books/Educational Materials
5,628.00 6.250.00 11.05%
42 Food & Nutrition 945200 15 660.00 64.62%
43 Administrative Costs 61 087.00 81 000.00 83 000.00 2.47;
as Audit Expense 6 500.00 5 000.00 51000.00 0.00%
45 Specific Assistance to Individuals 4000.00 #DIV701
46 Other/Miscellaneous 8,81500 11920.00 A'DIVl01
47 Other/Contract 71t028.00 171 070.00 140.85%
4a TOTAL 603A33.00 945 701.00 107873300
14.07%
49 REVENUES OVERT UNDER EXPENDITURES 540.00 64.001 0.00 -100.00%
MENOMONIE iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillilI iiiiiiiiiiiiiiiiiiiillillillillillillilI MONSOON! MINE III 1111111
GYAG - M�YY XrN 3 nrm Pm�m
UNIFORM GRANT APPLICATION
TOTAL PROGRAM BUDGET
AGENCY/PROGRAM NAME: GYAC - Mental Health Services Program
FY 04105 FY 05109 FY 09107 % INCREASE
FYE FYE FYE CURRENT VS.
NEXT FY BUDGET
A B C D
ACTUAL TOTAL PROPOSED (col. Cul. aycal. 9
REVENUES BUDGETED BUDGETED
1 children's services Council-St. Lucie 0.00 #DIV/01
2 Children's Services Council-Martin 0.00 #1
3 Advisory Committee-Indian River 60671.96N#D1
4 United Way-St Lucie County0.0015 United Wa -Martin Coun 0.0019 United Wa -Indian River Coun 0.0017 Deartment of
Children & Families 0.0018 Coun Funds 0.0019 Contributions-Cash 0.00110 Pro ram Fees 0.
00111 Fund Raisin Events-Net 0.00t
12 Sales to Public-Net 0.00 #DIVI01
13 Memberehi Dues 0.00 #DIVIOI
M Investment Income 0.00 #DIV/OI
1s Miscellaneous 0.00 #DIVI01
19 Le acies & Bequests 0.00 #DIV/01
17 Fonds from Other Sources 0.00 #DIVI01
19 Reserve Funds Used for Operating 16,141 #DIVI01
191n-Kind Donations Ism Included mloa0 0.00 #DIV/01
20 TOTAL 0.00 0.00 76 815.26 #DIV/01
EXPENDITURES
21 Salaries 69 563.26 #DIV/01
22 FICA 0.00 #DIV101
23 Retirement 0.00 #DIV/01
24 Life/Health 0.00 #DIV/01
25 Workers Compensation 0.00 #DIVXII
2s Florida Unemployment O.DO #DIV/01
27 Travel-Dai 600.00 #OIV/01
29 Travel/ConferencestTrainin 800.00 #DIV/01
29 Office Supplies 250.00 #DIV/01
30 Telephone 175.00 #DIV/01
31 Postage/Shipping60.00 #DIV/01
32 Utilities 305.00 #DIV/OI
33 Occupancy Buildin & Grounds 0.00 #DIV/01
34 Printing & Publications 250.00 #DIV/01
35 Subscri -on/DueslMembershi 150.00 #DIVI01
36 Insurance 495.00 #DIVI01
37 E ui ment:Rental & Maintenance 0.00 #DIV/01
M Advertising 0.00 #DIVIOI
39 Equipment Purchases:Ca ital Expense 0.00 #DIV/ol
w Professional Fees ILegal, Consulting) 0.00 #6I1
41 Books/Educational Materials 150000 #0I1
42 Food & Nutrition 150.00 00I11/01
u Administrative Costs 2,237.00 #DIV/01
44 Audit Expense 50.00 #DIV/01
4s Specific Assistance to Individuals 0.00 #DIV/Ol
46 Other/Miscellaneous 240.00 #DIV/01
47 Other/Contract 0.00 #DIV/01
49 TOTAL 0.00 0.00 76 815.26 #DIV/01
49 REVENUES OVER/ UNDER EXPENDITURES 0.00 0.00 0.00 #DIVf01
z a ea
GYAC - Menpl HeaM Services P o ram
UNIFORM GRANT APPLICATION
FUNDER SPECIFIC BUDGET
PROGRAM EXPENSES
AGENCY/PROGRAM NAME : GYAC - Mental Health Services Program
FUNDER: Children's Services of IRC A B C
FY 06107 FY 06107 % OF
TOTAL FUNDER TOTAL VS.
PROGRAM SPECIFIC FUNDER REQUEST
BUDGET BUDGET col. B/col. A
EXPENDITURES
21 Salaries 69 563.26 48l640.00 69.92%
22 FICA 0.00 3,720.96 #DIV/01
23 Retirement 0.00 800.00 #DIV/01
24 Life/Health 0 .00 4,000.00 #DIV/01
25 Workers Compensation 0.00 0.00 #DIV101
26 Florida Unemployment 0.00 2,013.00 #DIV/01
27 Travel-Daily 600.00 0.00 0.00%
28 Travel/Conferences/Training 800.00 600.00 75.00%
29 Office SLIPPlieS 250.00 150.00 60.00%
3o Telephone 175.00 0.00 0.00%
31 Postage/Shipping 50.00 0.00 0.00%
32 Utilities 305.00 0.00 0 .00%
33 Occupancy (Building & Grounds 0.00 0.00 #DIV101
34 Printing & Publications 250.00 0.00 0 .00%
35 Subscription/Dues/Memberships 150.00 0.00 0 .00%
36 Insurance 495.00 0.00 0 .00%
37 Eg ui ment: Rental & Maintenance 0.00 0.00 #DIV/01
38 Advertising 0.00 0.00 #DIV/01
39 Equipment Purchases : Capital Expense 0.00 0.00 #DIV/01
40 Professional Fees (Legal, Consulting) 0.00 0.00 #DIV/01
41 Books/Educational Materials 11500.00 750.00 50 .00%
42 Food & Nutrition 150.00 0.00 0.00%
43 Administrative Costs 2,237.00 0.00 0.00%
44 Audit Expense 50.00 0.00 0.00%
45 Specific Assistance to Individuals 0.00 0.00 #DIV/O!
46 Other/Miscellaneous 240.001 0.00 0 .00%,
47 Other/Contract 0.001 0.00 #DIV/01
48 TOTAL $76,815.26 $60,673.96 78 .99%
232006 B4
GYAL . Mwla1 H OM $em W Pmgam
UNIFORM GRANT APPLICATION
EXPLANATION FOR VARIANCES OF 15% OR MORE
TOTAL PROGRAM BUDGET
AGENCYIPROGRAM NAME: GYAC - Mental Health Services Program
FUNDER: Children's Services of Indian River County
LINE ITEM EXPLANA77ON FOR VARLINCE
#DIV101
#DIv/01
#1)IV/01
#DN 1
#DN101
#DN/01
#DN/01
#DIV/01
#DN101
#DIVI01
#DNI01
#DN/01
#DNI01
MIMI
#DN/01
#DNIa!
#DIV/O!
Mv/01
9DIV101
#DN101
#DNI 1
#DN/01
#DIV/01
#DN/01
#DIv/01
#DIV I
Mv/01
#DN/O1
#DIV/01
#DIV101
#DIV101
#DNroI
#DNroI
#DIVIDI
#DIVI01
#DN101
#DN101
#DN/01
#01v101
#ON101
#DIV/01
#DN/01
#DNIO!
#DN101
#DN I
4D1V101
sa3rzegs
as
' GYA Menb He h Se P,Nlw
UNIFORM GRANT APPLICATION
EXPLANATION FOR VARIANCES OF 15% OR MORE
FUNDER SPECIFIC BUDGET
AGENCYIPROGRAM NAME : GYAC - Mental Health Services of IRC
FUNDER: Children's Services of Indian River County
LINE ITEM 770M FOR VARLANCE
Ta�lam New program.
#DN101
#DIVI01
#DN101
#DIVl01
#DIV/01
Tra"MonferencestTraining New pmgram.
Office SuDalles New program.
#DIV/01
#DIVroI
XON101
MR1101
#DIVl01
Books/Educational Materials New program.
i#DIV/01
#DIV101
arz,rzcoa e-s
NOT FOR PROFIT AGENCY CERTIFICATION
The County of Indian River requires, as a matter of policy, that any Consultant or firm
receiving a contract or award resulting from the Request for Qualifications issued by the
County of Indian River, Florida , shall make certification as below. Receipt of such
certification, under oath , shall be a prerequisite to the award of contract and payment
thereof.
I (we) hereby certify that if the contract is awarded to me, our firm, partnership, or
corporation, that no members of the elected governing body of Indian River County, nor
any professional management, administrative official or employee of the County, nor
members of his or her immediate family, including spouse, parents, or children , nor any
person representing or purporting to represent any member or members of the elected
governing body or other official, has solicited , has received or has been promised,
directly or indirectly, any financial benefit, including but not limited to a fee, commission ,
finder's fee, political contribution , goods or services in return for favorable review of any
Proposal submitted in response to the Request for Qualifications or in return for
execution of a contract for performance or provision of services for which Proposals are
herein sought.
The undersigned certifies that he/she is a principal or officer of the firm applying for
consideration and is authorized to make the above acknowledgments and certifications
for and on behalf of the applicant.
The undersigned certifies that the Applicant has not been convicted of a public entity
crime within the past 36 months, as set forth in Section 287. 133, Florida Statutes.
Failure to sign this form will result in disqualification
Handwritten Signature of Authorized Principal(s): DATE:
NAME:
TITLE: Xr 0-.
NAME OF F,IIR;M/PARTNERSHIP/CORPORATION : ^ Wit`;
FOR AND ON BEHALF OF THE APPLICANT:
Sworn to and subscribed to
Notary Public, this
day of , 2006. BY:
(SEAL) (TYPE NAME & TITLE)
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Y f�1M - Ilab Of Rodda
Bpw�M3V17.11b7
CaftlTWbn Y DDI 94076
Bwxi,d fiy Nntbr d Notary Asan
XI
SWORN STATEMENT UNDER SECTION 105.08,
INDIAN RIVER COUNTY CODE, ON DISCLOSURE OF RELATIONSHIPS
THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR
OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS.
1 . This sworn s ate en i su'led with RFP No. 200 1 for
CniC4 UA r, S
2 . This sworn statement is submitted by: 'Ab
J (Name of entity submitting Statement)
�whho7
se business address is:
and
(if applicable)
its Federal Employer Identification Number (FEIN ) is =j �5ESo t
(If the entity has no FEIN , include the Social Security Number of the individual signing
this sworn statement
3 . My name is _ t `7 C� QI �.11✓tQ
(Please print name of individual signing)
and my relationship to the entity named above is
4 . 1 understand that an "affiliate" as defined in Section 105. 08, Indian River County
Code , means:
The term "affiliate" includes those officers , directors , executives , partners, shareholders,
employees, members , and agents who are active in the management of the entity.
5. 1 understand that the relationship with a County Commissioner or County employee
that must be disclosed as follows:
Father, mother, son , daughter, brother, sister, uncle, aunt, first cousin,
nephew, niece , husband, wife, father-in-law, mother-in-law, daughter-
in-law, son-in-law, brother-in-law, sister-in-law, stepfather, stepmother,
stepson , stepdaughter, stepbrother, stepsister, half brother, half sister,
grandparent, or grandchild .
6. Based on information and belief, the statement, which I have marked below is true in
relation to the entity submitting this sworn statement. [Please indicate which statement
applies.]
XIII
Z3I 04, (signature)
(date)
STATE OF t I0Y 1
COUNTY OF C)Ln �+ �2J✓
The foregoing instrument was ackpn w edged before me this D 1 ` day of
2006 , by M , NLL ► IU �E V who is ❑Pr%mQy_ known to me
or who Was produced as identification.
NOTARY PUBLIC
SIGN : —= �• '
PRINT: _I�2x��x 'D. 'Revue r
State of Florida at Large
My Commission Expires: rvNan k,:"f1906q
(Seal)
1W:WCQMMftL10n
ean �ac �. a17,2007
MI DD194076Ln f0nd&d8V NaMorK0 N0laryAw
XV
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
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)
�01 (C)(3) IRS Exemption Letter
Articles of Incorporation
/Agency's Bylaws
c� gency's written policy regarding Affirmative Action
/ Nepotism Statement
t/Taxonomy Definition for each program.
XVI
EXHIBIT A
(Copy of complete Request for Proposal)
EXHIBIT - A -
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 18' 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 301h) 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: GYAC
4875 43"' Avenue
Vero Beach , Florida 32967
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 -
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
184026th Street
Vero Beach , Florida 32960-3365
Recipient: Gifford Youth Activity Center
4875 43rd Avenue
Vero Beach , Florida 32967
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 -
A4CORD CERTIFICATE OF LIABILITY INSURANCE DATIOIDS/20 6 n
TM
PRODUCER Pba (m) 952 5%9 Fac (1`72) 56za S THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
HILS ROGAL & HOBBS OF FLORIDA, INC. - VERO BEACH ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2045 14TH AVE. HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P O BOX 130 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
VERO BEACH FL 32861
INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURERA. GRANITE STATE INS CO
GIFFORD YOUTH ACTIVITY CENTER INSURER B: Pto_g
VERO BEACH FL 32967 resslva American Insurance Co. 24252
43RD AVE INSURER G: ZENITH ]NIS COMPANY
VER _ .. . _ ._ . .
INSURER D: _
NSURER E:
COVERAGES ,
THE POLICIES OF WSURANCE 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 RAVE BEEN REDUCED BY PAID CLAIMS.
INl� aO TYPEO (INSURANCE POUCYNUMDER POUCYEFFECtNE PDLICi EVIRATan LIMITS
LTR WSR DATE M DATE M
GENERALLWBIUTY 07LX-0489330-01000 05115/06 06115107 EACH OCCURRE'NCE S 1 ,000,000
X COMMERCIAL GENERAL U QILT' OAMALE TO PENiFA
Pq 100,000
REWI a rtrc[I
CLANS MADE OCCUR MED. EXP (Arlr pop parwn) S 5,000
B X BBPD DEDUCIBLE 51,000 PERSONAL B MV INJURY S 1 ,000,000
GENERALAGGREGATE S 3,000,000
GENL AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG s
e -IP ._ I—I PRA- nLOC ' — • . _-. .__ _ 1 ,000,000
COW , !ECT
AUTOMDBILEULBILRY 02626305-2 04123106 04/23107 COMBINED SINGLE LIMIT
X ANY ALTO (Ea u=dpnO 4 1 ,000,000
ALL OWNEOAUTOS BODILY INJURY
SCHEDULEDAUTOS (Par pawn) 5
B X HWEDAUTOS
BODILY IWURY
X NON.OWNEDAUTOS (Per Oeedwi) S
PROPERTY DAMAGE 9
fpvawdem
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S
ANY AUTO OTHERTH/W EA ACC
AUTO ONLY. AGG S
EXCESS/ UMBRELLA LIABILITY EACH OCCURRENCE 5
OCCUR 71 CLAIMS MADE AGGREGATE 3
S _-
DEDUCTIBLE S
RETENTION $ - -- -
8
WORKERS COMPENSATION AND ZOSSO06301 01104IDS 01104107 TDRYrIIMMEE Qr"D'I
EMPLOYERS LIABILITY
C ANY PROPRIBiOPIPMINEPIEaEcvrNE 91 EACNACCIDENT S 100,000
OFFlCER1MFNBgl El10L0FDl
E.L DISEASE-EA EMPLOYEE S 100,000
11 yv, dvnlee ueasr -
9PfCwL PAwIaaNS talo. EL DISEASE-0OLICY LIMIT S $00,000
OTHER:
DESCRIPTION OF OPERATIONS7LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
INDIAN RIVER COUNTY IS NAMED AS AN ADDITIONAL INSURED AS THEIR INTEREST MAY APPEAR.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE TIE
EXPIRATION DATETHEREOF, THE ISSUING INSURER WILLENDEAVORTO MAILIO DAYS
WRITTEN NOTICE TO -THE CERMEICATE HOLDER NAMED TO THE LEFT, BUTFAILURE
TO DO SO SHALLJMPOSE NO OBLICATION•OR LIABIUTY OF ANY KIND UPON THE INSURER,
INDIAN RIVER COUNTY ITS AGENTS OR REPRESENTATIVES.
1840 25TH STREET
VERO BEACH FL 32960 AL'ThORZEDREPRESENTATNE
Attention: _ . cUe . Thi
ACORD 26 (2001108) Certificate 9 98907 ® ACORD CORPORATION 1988