HomeMy WebLinkAbout2004-229X U
0 ndlan River County Grant Contract ' ZZ9 L
This Grant Contract ("Contract") entered into effective this 1st day of October 2004 by and
between Indian River County, a political subdivision of the State of Florida , 1840 25th Street,
Vero Beach FL , 32960 ("County') and Dasie Bridgewater Hope Center, Inc . ( Recipient) , of:
. 0�. Box 701483
Wabasso , FL 32970
Background Recitals
A. The County has determined that it is in the public interest to promote healthy children in a
healthy community.
B . The County adopted Ordinance 99- 1 on January 19 , 1999 ("Ordinance") and established the
Children 's Services Advisory Committee to promote healthy children in a healthy community
and to provide a unified system of planning and delivery within which children 's needs can be
identified , targeted , evaluated and addressed .
C . The Children 's Services Advisory Committee has issued a request for proposals from
individuals and entities that will assist the Children 's Services Advisory Committee in fulfilling
its purpose .
D . The proposals submitted to the Children 's Services Advisory Committee and the
recommendation of the Children 's Services Advisory Committee have been reviewed by the
County.
E . The Recipient, by submitting a proposal to the Children 's Services Advisory Committee , has
applied for a grant of money ("Grant") for the Grant Period (as such term is hereinafter
defined ) on the terms and conditions set forth herein .
F . The County has agreed to provide such Grant funds to the Recipient for the Grant Period (as
such term is hereinafter defined ) on the terms and conditions set forth herein .
NOW THEREFORE , in consideration of the mutual covenants and promises herein contained , and
other good and valuable consideration , the receipt and adequacy of which are hereby acknowledged ,
the parties agree as follows :
1 . Background Recitals The background recitals are true and correct and form a material
part of this Contract .
2 . Purpose of Grant The . Grant shall be used only for the purposes set forth in the
complete proposal submitted by the Recipient attached hereto as Exhibit "A" and
incorporated herein by this reference (such purposes hereinafter referenced as "Grant
Purposes") .
3 . Term The Recipient acknowledges and agrees that the Grant is limited to the fiscal
year 2004/2005 ("Grant Period") . The Grant Period commences on October 1 , 2004
and ends on September 30 , 2005 .
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4 . Grant Funds and Payment The approved Grant for the Grant Period is Sixty- Five
Thousand Dollars ($65 , 000 ) . The County agrees to reimburse the Recipient from
such Grant funds for actual documented costs incurred for Grant Purposes provided in
accordance with this Contract. Reimbursement requests may be made no more
frequently than monthly. Each reimbursement request shall contain the information , at
a minimum , that is set forth in Exhibit " B" attached hereto and incorporated herein by
this reference . All reimbursement requests are subject to audit by the County . In
addition , the County may require additional documentation of expenditures , as it
deems appropriate .
5 . Additional Obligations of Recipient.
5 . 1 Records . The Recipient shall maintain adequate internal controls in order to
safeguard the Grant . In addition , the Recipient shall maintain adequate records fully
to document the use of the Grant funds for at least three (3 ) years after the expiration
of the Grant Period . The County shall have access to all books , records , and
documents as required in this Section for the purpose of inspection or audit during
normal business hours at the County's expense , upon five (5) days prior written
notice .
5 . 2 Compliance with Laws . The Recipient shall comply at all times with all applicable
federal , state , and local laws , rules., and regulations .
5 . 3 Quarterly Performance Reports , The Recipient shall submit Quarterly Performance
Reports to the Human Services Department of the County within fifteen ( 15) business
days following : December 31 , March 31 , June 30 , and September 30 .
5 .4 Audit Requirements . If Recipient receives $25 , 000 or more in the aggregate from
all Indian River County government funding sources , the Recipient is required to have
an audit completed by an independent certified public accountant at the end of the
Recipient's fiscal year. Within 120 days of the end of the Recipient's fiscal year, the
Recipient shall submit the audit to the Indian River County Office of Management and
Budget . The fiscal year will be as reported on the application for funding , and the
Recipient agrees to notify the County prior to any change in the fiscal period of
Recipient . The Recipient acknowledges that the County may deny funding to any
Recipient if an audit required by this Contract for a prior fiscal year is past due and has
not been submitted by May 1 .
5 .4 . 1 The Recipient further acknowledges that, promptly upon receipt of a
qualified opinion from it's independent auditor, such qualified opinion shall
immediately be provided to the Indian River County Office of Management and
Budget. The qualified opinion shall thereupon be reported to the Board of
Commissioners and funding under this Contract will cease immediately. The
foregoing termination right is in addition to any other right of the County to
terminate this Contract .
5 .4 . 2 The Indian River County Office of Management and Budget reserves the
right at any time to send a letter to the Recipient requesting clarification if there
are any questions regarding a part of the financial statements , audit comments , or
notes .
5 . 5 Insurance Requirements . Recipient shall , no later than September 21 , 20041
provide to the Indian River County Risk Management Division a certificate or
certificates issued by an insurer or insurers authorized to conduct business in Florida
that is rated not less than category A- : VII by A. M . Best, subject to approval by Indian
River County's risk manager, of the following types and amounts of insurance :
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(i ) Commercial General Liability Insurance in an amount not less than
$ 1 , 000 , 000 combined single limit for bodily injury and property damage ,
including coverage for premises/operations , products/completed operations ,
contractual liability, and independent contractors ;
( ii ) Business Auto Liability Insurance in an amount not less than $ 1 , 000 ,000
per occurrence combined single limit for bodily injury and property damage ,
including coverage for owned autos and other vehicles , hired autos and other
vehicles , non-owned autos and other vehicles ; and
(iii ) Workers ' Compensation and Employer's Liability (current Florida statutory
limit)
5 . 6 Insurance Administration . The insurance certificates , evidencing all required
insurance coverages shall be fully acceptable to County in both form and content,
and shall provide and specify that the related insurance coverage shall not be
cancelled without at least thirty (30) calendar days prior written notice having been
given to the County. In addition , the County may request such other proofs and
assurances as it may reasonably require that the insurance is and at all times
remains in full force and effect . Recipient agrees that it is the Recipient's sole
responsibility to coordinate activities among itself, the County, and the Recipient's
insurer(s ) so that the insurance certificates are acceptable to and accepted by
County within the time limits set forth in this Contract . The County shall be listed as
an additional insured on all insurance coverage required by this Contract, except
Workers ' Compensation insurance . The Recipient shall , upon ten ( 10 ) days ' prior
written request from the County, deliver copies to the County, or make copies
available for the County's inspection at Recipient's place of business , of any and all
insurance policies that are required in this Contract . If the Recipient fails to deliver or
make copies of the policies available to the County; fails to obtain replacement
insurance or have previous insurance policies reinstated or renewed upon
termination or cancellation of existing required coverages ; or fails in any other regard
to obtain coverages sufficient to meet the terms and conditions of this Contract, then
the County may, at its sole option , terminate this Contract .
5 . 7 Indemnification , The Recipient shall indemnify and save harmless the County, its
agents , officials , and employees from and against any and all claims , liabilities ,
losses , damage , or causes of action which may arise from any misconduct, negligent
act, or omissions of the Recipient, its agents , officers , or employees in connection
with the performance of this Contract.
5 . 8 Public Records . The Recipient agrees to comply with the provisions of Chapter
119 , Florida Statutes ( Public Records Law) in connection with this Contract .
6 . Termination . This Contract may be terminated by either party, without cause , upon
thirty (30 ) days prior written notice to the other party. In addition , the County may
terminate this Contract for convenience upon ten ( 10 ) days prior written notice to the
Recipient if the County determines that such termination is in the public interest .
7 . Availability of Funds . The obligations of the County under this Contract are subject
to the availability of funds lawfully appropriated for its purpose by the Board of
County Commissioners of Indian River County.
8 . Standard Terms , This Contract is subject to the standard terms attached hereto as
Exhibit C and incorporated herein in its entirety by this reference .
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IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date
first above written .
INDIAN RIVER COUNTY BOARD OF OUNTY COMMISSIONERS
By:04
Arthur R . Neu4 65 Chairman
BCC Approved :
At S : J . arton , Clerk : .
By. d)7
Deputy Clerk` ' s
q(
Approved :
Josh A. Baird
County Administrator
App ed as to form and legal su ien
n4EFAss yAttorney
RE( IP NT:
1 : 1
By:
Dasie Bridgewater Hope Center, Inc
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EXHIBIT A
[Copy of complete proposal/application]
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PROPOSAL NARRATIVE
A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page)
1 . Provide the mission statement and vision of your organization .
Dasie Hope Center Mission statement: Offering a nurturing environment where youth and adults
can learn, dream and aspire by developing their self-esteem and learning life survival skills.
Dasie Hope Center Vision : Through a dedicated commitment from the community, become an
agency that will inspire residents to grow by improving their employability skills and filling them
with a sense of self-worth and pride.
2 . Provide a brief summary of your organization including areas of expertise, accomplishments ,
and population served.
Dasie Hope Center was established September 5 , 2001 in memory of Dasie Bridgewater a lifelong
resident of Wabasso . Mrs . Bridgewater believed in and did give back to anyone in need . Since its
inception Dasie Hope Center has provided the youth with a safe place to attend after school where they
have gained a sense of pride and hope . The Center is a nurturing environment for learning,
experiencing and exploring new skills which include the following :
After school tutoring
Interpersonal Skill Development (Etiquette, leadership and social skills)
Art expressions
Girl Scouts
Reading Academy
Peer Shadowing/Mentoring
Peer Business Leadership classes
FCAT Tutorial
Dasieville Mall
Seven (7) week Summer Recreation Program
The listed programs are designed for youth of North Indian River County ranging in ages 5 - 18 .
Special emphasis is placed on a reading and tutorial after school program, whereas , all third-graders
(attending Dasie Hope Center) passed the reading portion of the FCAT, with 90 % passing the math
portion.
The population to be served includes all of the Wabasso community which is North Indian River
county.
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Be 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.
Research has linked participation in youth development and after school programs with reduction in
negative behaviors , such as alcohol use, drug abuse, sexual activities and violence, as well as increases
in positive behaviors, such as better relationships with peers and improved conflict resolution
skills(Beuhring, Blum, Rinehart, 2003 )
Quality after-school programs can meet family needs by providing responsible adult supervision of
children duting non-school hours . By offering young people rewarding, challenging, and age-
appropriate activities in a safe, structured, and positive environment, after-school programs help to
reduce and prevent juvenile delinquency and to insulate children from injury and violent victimization.
After-school programs give children and teenagers positive things to say "yes" to .
Population* : 112 , 947
Persons below poverty 11 . 2%
Children below poverty 20 . 3 %
*taken from quick1facts. census.gov.
Youth ( 18 years or younger) comprise about 20% of the entire population. Almost 1/4 of every
household in the county houses a person or persons less than 18 years of age . Therefore, there is an
urgent need to deliver programs to help these youth targeted to Indian River County youth.
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.
Youth within the Wabasso lack the acquired transportation to attend Gifford Youth Activities
Center or the Boys & Girls Club that would transport them round trip to their programs . Most
youth who attend Dasie Hope Center live within the Wabasso community and can ride the school
bus or live within walking distance of the Center. Without adequate transportation and no after
school programs , youth within the Wabasso area would be forced to go home to an empty house, to
the streets or petty drugs or unacceptable sexual
activities .
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C. PROGRAM DESCRIPTION (Entire Section C, I — 6, not to exceed two pages)
1 . List Priority Needs area addressed.
a) general operating expenses, b) STAFF c) snacks d) internet access e) f) program supplies
g 3 computers
2 . Briefly describe program activities including location of services .
Dasie Hope Center is located at 8445 -64th Ave . , Wabasso , FL 32970 . Dasie Hope is located in the
heart of the Wabasso community, which is within walking distance . Youth ranging in ages 5 - 18 come
directly after school to programs offered at the center.
All programs are provided on site at the Dasie Hope Center after school daily. Youth arrive as early as
3 : 00 p . m. and leave approximately 6 : 45 p .m. where they are supervised in the following programs :
• Homework Tutoring
• Interpersonal Skill Development
• Art Expression classes
• Girl Scouts
• AKA Reading Academy
• Peer Business Leadership classes
• FCAT Tutorial
• Computer Training
• Dasieville Mall
• Community Improvement Projects
• Summer recreation camp
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 .
After school programs not only keep children safe and out of trouble, but they also provide a prime
opportunity to increase learning . Young people attending formal after-school programs spend more
time in academic activities and in enrichment lessons than do their peers left unsupervised after school .
Programs that include tutoring in reading and writing as well as reading for pleasure can increase
reading achievement for students . Quality, researched-based tutoring programs , which fit well into
after school programs , produce improvements in reading achievement. Tutoring can also lead to
greater self-confidence in reading, increased motivation to read and improved behavior.
Dasie Hope Center is designed to follow the methodology of improving academic performance through
tutoring, teach violence prevention through conflict resolution, and improve behavior through etiquette
and social skills classes . The curriculum followed is as follows :
Tutoring : Students participate daily with teacher, some with one-on-one training
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Reading Academy: Designed to increase literacy and language skills and increased self-
confidence in themselves
Study Skills : After school study skills are designed for at risk students whose lack of
study and comprehension skills may hamper their academic achievement .
Academic Subject : Computer training and research projects, are designed to increase
computer usage and improve computer skills
Community Involvement : Social/Interpersonal skills are taught to all students , and encouraged
participate in all community service projects to give them pride in their
community. Community services are performed on a monthly basis to
develop motivation and behavior skills.
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 to
the information in the Position Listing on the Budget Narrative Worksheet) ,
Position One — Director (40 hours per week)
The Board of Directors approved Verna Wright to be Center ' s Director. Mrs . Wright worked with
Indian River County School District,
Paid Staff
Verna Wright Director 40 hours weekly
Eloise Harden Program Asst. 40 hours weekly
Needed Staff
Program Coordinator 32 hours weekly
Peer Business Teacher 32 hours weekly
5 . How will the target population be made aware of the program?
Dasie Hope Center will be made aware to the target population by word-of-mouth, newsletter, church
announcements , local TV station, local radio , local magazine, fliers posted throughout the school
district, door-to -door recruitment, programs offered through advertisement and referrals .
6. How will the program be accessible to target population (i. e. , location, transportation, hours
of operation) ?
The Dasie Hope Center is located in the heart of the Wabasso community which makes its accessible to
most residents during the hours of 10 :00 a.m . — 6 : 00 p . m . Youth come directly to Dasie Hope Center
after school by school bus .
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D . MEASURABLE OUTCOMES (Description of Intent)
Use the Measurable Outcomes orm. This descri tion pgge does not need to be included in the proposaL
In order to show the. impact that your program is having on the target population and the community, the
funders are requiring measurable outcomes . Please review the examples and summaries below to insure
your understanding of what is expected.
OUTCOMES : Describes what you want to achieve with the target population. Indicates the results of
the services you provide, not the services you provide . Outcomes utilize action words such as maintain,
increase, decrease, reduce, improve, raise and lower.
ACTIVITIES : Describes the tasks that will be accomplished in the program to achieve the results
stated in the outcomes . Activities utilize action words such as complete, establish, create, provide,
operate, and develop . The activities should reflect the services described in the PROGRAM
DESCRIPTION (C2) .
Use the following elements to develop your outcomes. All elements must be included:
• Direction of change • Timeframe
• Area of change • As measured by
• Target population • Baseline: The number that you will be
• Degree of chane measuring against
Example 1 (Outcome) .
To decrease (direction of change) number of unexcused absences (area of change) of enrolled boys and
girls (target population) by 75 % (degree of change) in one year (timeframe) as reported by the 2003
School Board attendance records (as measured by) . Baseline : 2003 School Board attendance records for
enrolled boys and girls .
Example 1 (Activity) :
To provide anger management classes to enrolled boys and girls 2 times a week for 12 weeks .
Example 2 (Outcome) :
75 % (degree of change) of youth (target population) who have participated in the academic enrichment
activities (as measured by) for 6 months or more (timeframe), will improve (direction of change) their
scores in one or more subject area (area of change) . 25 % of participants in academic enrichment
activities will maintain the initial level of performance assessed at entry. Baseline : Pre-test scores from
the academic enrichment test.
Example 2 (Activity) : .
1 ) Provide pre and post-test exercises on the Advanced Learning System software ; 2) Participants will go
through the one lesson per week and be graded for 10 weeks .
IMPORTANT NOTE ,
Keep in mind when developing your PROGRAM OUTCOMES , that if funded, this will be what you are
held accountable to accomplish. Also , the PROGRAM OUTCOMES should reflect the information
described in the PROGRAM NEED STATEMENT (131 ) .
All Program Need Statements should flow from the Mission & Vision . Measurable Outcomes should be
based on and measure program needs . Activities are the tasks you do that are going to influence the
outcome and impact the unacceptable condition in your Program Need Statement.
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D . MEASURABLE OUTCOMES (Entire Section D not to exceed two pages)
OUTCOMES ACTIVITIES
Add all of the elements or the Measurable Outcomes Add the tasks to accomplish the Outcome(s)
1 ) To decrease the number of positive 1 ) Random drug screening will be conducted on
drug screens of enrolled youth by at middle and high school youth enrolled(with
least 55 % during the 1 " semester parental consent) ,
following program participation during
the 2004-2005 school year.
2) To decrease the number of absenteeism 2) Awards and incentives will be place on
of youth by 50% during the 2nd academic programs , which will require daily
semester following program attendance to obtain incentive. In the Peer
participation during the 2004-2005 Business Program attendance will be an
academic year. Attendance records extremely important component(e. g. , job
generated from within the Indian River attendance) . Along with attendance, academics
County School District. will also be very important.
Baseline : Students 2004 attendance
records .
3 ) To increase academic performance of 3 ) A reading academy has been institute for the entire
enrolled youth by at least 40% during academic school to increase reading skills and six
the 2nd semester following program weeks of Summer Success Reading in our summer
participation during the 2004-2005 camp . Teachers and coaches from within the Indian
academic year. River County School District will teach in both reading
Baseline : Students 2004 academic camps along with volunteers from the Alpha Kappa
records . Alpha sorority on a daily basis .
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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
Teachers, reading supplies and books
Indian River County School District
Business curriculum program, certificates , and
Fla. A & M University possibility of college scholarships
Juvenile violence prevention programs
Indian River Sheriff Department
Random drug screening. Drug prevention materials and
Substance Abuse Council supplies ,
Provide a monthly Reading buddies program which
Indian River Charter High School consist of the Key Club
Volunteers and support
Disney Resort of Vero Beach
Volunteers and golf lessons during summer camp
Redstick Golf Club
Established an "AKA Reading Academy" and provide
Alpha Kappa Alpha Sorority weekly volunteers
Provides a weekly art teacher
Indian River Cultural Council
Provide six Girl Scout Troop leaders every other
Charlotte Terry Realtor Tuesday
Classes in etiquette, social behavior and interior design
Paula Holden Interior Designs (which sometimes result in field trips)
The Girl Scouts annual end of the year tea is held there
Ocean Grill Restaurant and guest speakers are provided
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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 131 ?
The majority of youth that attend Dasie Hope Center are from low income single parent
household who live within the Wabasso community. Dasie Hope center is the only after-school
program in the Wabasso area to service these youth that attend daily.
Youth participation is tracked through daily attendance at Dasie Hope Center, if two straight
days are missed a telephone call will be made to the parent) . Academic performance will also be
tracked with our in house database program on a bi-weekly basis .
An initial pre test is given to each enrolled youth to determine their level of progress and will be
tracked as they progress . If extra help is needed, the youth will receive one-on-one tutoring.
Youth receive tutoring in areas of weakness as needed by volunteers and retired school instructor
from Indian River County School District,
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?
At the beginning of each intake application a pretest (variety math, reading, social skills test) is
administrator to . each youth. Depending upon the results determines where academically and
socially the youth is presently.
Progress reports from the Indian River County School District is collected every 9 weeks and
compared to the results of Dasie Hope program progress . The comparison will determine if
adjustments in course of daily tutoring is needed or progress to the next level .
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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?
Dasie Hope Center has a monthly parent forum, where parent(s) attend, review and ask questions
about their child progress . If more structured tutoring is required this is discussed with the
parent and age appropriate action is taken to improve the child ' s progress .
Outcome results are reported to funders that require this information for funding purposes . Also ,
to inform funder of success and accomplishments .
Academic sticcess of youth are reported to the local newspaper, Dasie Hope Youth Newsletter,
board members and their assigned mentor to boost youth self esteem and pride, which
encourages them to do even better.
A performance file is kept on each youth and their progress reports and report cards are filed in
each folder. The Director will review each of these reports before filing is complete and make
necessary recommendations .
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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
May 2004 Dasie Hope Center moves to 8445 -64th Ave. ( a new building)FCAT
results
June 7 , 2004 Summer Camp begins/Jr. Achievement Program
July 2004 ' Summer Camp
August 2004 Academic year starts — "Back 2 School Bash"-school supplies issued
September 2004 Peer Business Program begins for 10 months
October 2004 Fundraiser (to be announced)/Girl Scout "Pinning Ceremony"
November 2004 Academic/Business Competition Games
December 2004 Youth Christmas Holiday Pageant /Peer Business Academic
Presentation
January 2005 Parent Recognition Ceremony/FCAT Tutoring
February 2005 FCAT Tutoring/Pre Testing
March 2005 Dasie Hope Center Annual Crab Fest fundraiser/Trip to Fla. A & M
University-Tallahassee
April 2005 Volunteer Recognition Ceremony
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H. PROJECTIONS FOR UNDUPLICATED CLIENTS
Number of Unduplicated Clients by Location
a Current Fiscal Year
Location a ` 0Z` 0 Budget 2003/04
c
Unduplicated Clients Unduplicated Clients Unduplicated Clients
N. Indian River County - 110
S . Indian River County
Indian River Co. Total - 110 -
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 - 110 -
Number of Unduplicated Clients by Age
a z 1 a Current Fiscal Year a al yea
Location
a 20. Budget 2003/04 0
WN uaMoInd
s *Ivi
duals Group " ` its
Ir I ell
0 to 4 - (Pre-school)
5 to 10 - (Elementary) - _ 37
11 to 14 - (Middle) - - 55 - -
15 to 18 - (High School) - - 18
Total Children - - 110
19 to 59 - (Adults)
60 + (Seniors)
Total Adults
TOTAL SERVED - - 110
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L BUDGET FORMS - To open the Budget Forms, please double-click on the icon below.
" Core Budget Forms "
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Type the Organization and Program Name
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.
DASIE HOPE CENTER TUTORIAL PROGRAM
CHILDREN SERVICE NETWORK
I CAUTION : Do not enter any figures where a cell is colored in dark blue • Formulas and/or links are in place. Gray areas should
I
�` used for calculations and to write information only.
GRAY AREA$ FOR Proposed Total Program Funder Specific
REVENUES AGENCYUSEONLY P g p Total Agency
r tca CUULnnONS Budget Budget Budget
1 Children's Services Council -St, Lucie
2 Children's Services Council -Martin
3 Advisory Committee-Indian River 100,000 . 00 100,000. 00 1009000 . 00
4 United Way-St, Lucie County
5 United Way-Martin County
6 United Way-Indian River County 60 ,000.00 60 ,000.00
7 Department of Children & Families
8 County Funds
9 Contributions-Cash 10 ,000 . 00 10 ,000. 00
10 Program Fees
11 Fund Raising Events-Net 15 ,000 . 00 15,000 . 00
12 Sales to Public - Net
13 Membership Dues
14 Investment Income
15 Miscellaneous
16 Legacies & Bequests
17 Funds from Other Sources
18 Reserve Funds Used for Operating
19 In -Kind Donations (Not Included in total
20 TOTAL REVENUES
(doesn't include line 19) $ 185 ,000 . 00 $ 100,000.00 $ 185 , 000 . 00
A B C D'
EXPENDITURES GRAY AREAS'FOR Proposed Total Program Funder Specific Total Agency
AGENCY USE ONLY .7 y
(SNOW CALCULAMNS) Budget Budget Budget
21 Salaries - (must complete chart on next page) 102,500 . 00 559329.00 1029500 .00
Salary
22 FICA - Total salaries x 0.0765 7.65% 7,841 .25 , 4,232.67 7 ,841 .25
Retirement - Annual pension For qua i fe
23 staff
0 .00
Life/Health - e ica enta ort-term
24 Disab. 0.00
Workers ompensation - emp oyees x
25 rate 1 ,219.44 658.251 11219.44
Florida Unemployment - # pro)ec e
26 employees x $7 , 000 x UCT-6 rate 756 . 00 408.08 756. 00
SALARIES A D
Gross Annual B C % of Gross Annual
POSITION LISTING Salary Portion of Salary on Proposed Funder Specific Budget Salary
Position Title / Total Hrs/wk (Agency) Program
Requested(CIA)
Example: Executive Director / 40 hrs 70,000.00 10, 000.00 51000.00 7. 14 %
Director/40 his . per wk. 1 35,000.001 350000 .00 18,893. 00 53 .98%
5/25/2004
s-t
' • • • • • • • - 11 11 11 11 11 • •
' - - - - • - 1 111 11 1 111 11 1 • . 11 - . • : • ,
Secretary/40 per 1 11 11 11 1 1 1 1 1
• 1 1
Milp
ME
Total Salaries
_— • s 1
• � 1
• 1 1
• 1 1 .
• 1 1
• t 1
• 1 1
• 1 1
• 1 1
• 1 1
1 11 11 $ 102,500.00
" • 1 / • '
(FunderFRINGE BENEFITS DETAIL A
Specific • • - Funder
AMsion Worker's • • r r - r
spnly, from line 22 to 27) eciric rr -
Position Title / Total HrsAvk
Example: Case —now
r 1 1 1 1 1
Director/40 per : • 11
Program • • • • per 11 MEMO 1 • --� 1 1 • 1
Peer Business Teacher/25 hrs . per wk. ME13061111111MEMI Me
1 hrs . per 11 1 r1 I 1 1 • , • ,
11
11
11
1 111 111 --- 111
1
k it s ,. Fes",:, `,`^t',1 si s'.a AJ
• • . , • - - , ;� 11 ® -,, .11 . 111 � , .. • 1 : 1 : • • :i"l
D
ProposedEXPENDITURES . . Agency
BudgetBudget Budget
• • 1 / 11 1 • 11 11
INUMM17onarels Mfum- Mvin - - 9 - M Ina *� M
rm- IN • • 111 11 • : 1 111 11
. .
Type the Organization and Program Name
• National Conference (cost per staff)
• Training/Seminar (cost per staff)
• Other Trainings (cost of travel, lodging,
registration, food)
29 Office Supplies5,000.00 2 ,699.00 5 ,000 .00
Office supplies (monthly average x 12
months = estimated cost of office supplies
based on present history.
30 Telephone 21500 .00 1 ,349.50 2,500A0
• # 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 1 ,500 .00 809.70 19500.00
• Quarterly Mailing of Newsletter
• Special events , etc.
• Bulk mailings - appeals
32 Utilities 5 ,000.00 2,699.00 51000. 00
• Electricity ($ x 12 months)
• Water/Sewer ($ x 12 months)
• Garbage ($ x 12 months)
33 Occupancy ( Building & Grounds ) 500.00 269.80 500.00
• Mortgage/Rent ($ x 12 months)
• Janitorial ($ x 12 months)
• Grounds Maint. ($ x 12 months)
• Real Estate Taxes
34 Printing & Publications 29000.00 11079.60 29000.00
Quarterly Newsletter ($ x 4)
Letterheads , Envelopes , etc.
Fundraising materials
Other
35 Subscription/Dues/Memberships 500 .00 269. 80 500.00
• Membership to National Organization
• Dues
• Subscriptions to Newspapers/magazines ,
etc.
36 Insurance 81000.00 41318.40 81000 . 00
• Directors/Officers Liab.
• Commercial/General Insurance
• Bond Ins .
• Auto Insurance
37 Equipment : Rental & Maintenance 11500.00 809.70 11500 . 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 ,000 .00 1 ,079.60 21000.00
• Newspaper ads
• Fundraising ads/promotions
• Other (vacancies )
39 Equipment Purchases : Capital Expense 15,000.00 81097.00 15,000 . 00
• Computer/monitor (# x $)
• Laser Printer
40 Professional Fees (Legal , Consulting ) 61000.00 31238.80 61000 . 00
• Legal advice ( estimated #hrs x $)
• Consultant fees
• Other
41 Books/Educational Materials 1 70000 .00 33778.60 71000 .00
• Books/videos
• Materials ($ x staff)
5/25/2004
B-1
Type the Organization and Program Name
42 Food & Nutrition
000.00 2, 159.20 49000.00
• Meals ( # meals x clients x 5days x 50 wks)
• Snacks
43 Administrative Costs 19850.00 998.63 11850.00
Admin. Cost (% of total budget)
44 Audit Expense 41500. 00 21665.90 4,500.00
Independent Audit Review
45 Specific Assistance to Individuals 250.00 134 . 95 250.00
• Medical assistance
• Meals/Food
• Rent Assistance
• Other
46 Other/Miscellaneous 683.31 269. 80 683.31
• Background check/drug test
• Other
47 Other/Contract
Sub-contract for program services
48 TOTAL EXPENSES $ 185,000 .00 $ 100 , 000 .00 $ 1859000.00
5/25/2004
s•t
EXHIBIT B
[From policy adopted by Indian River County Board Of County Commissioners on February 19 ,
2002]
" D . Nonprofit Agency Responsibilities After Award of Funding
Indian River County provides funding to all nonprofit agencies on a reimbursement basis
only.
All reimbursable expenses must be documented by an invoice and/or a copy of the canceled
check . Any expense not documented properly to the satisfaction of the Office of Management &
Budget and/or the County Administrator may not be reimbursed .
If an agency repeatedly fails to provide adequate documentation , this may be reported to the
Board of Commissioners . In the event an agency provides inadequate documentation on a
consistent basis , funding may be discontinued immediately. Additionally, this may adversely
affect future funding requests .
Expenditures may only be reimbursed from the fiscal year for which funding was awarded . For
example , no expenditures prior to October 1St may be reimbursed with funds from the following
year. Additionally, if any funds are unexpended at the end of a fiscal year, these funds are not
carried over to the next year unless expressly authorized by the Board of Commissioners .
All requests for reimbursement at fiscal year end (September 30th) must be submitted on a timely
basis . Each year, the Office of Management & Budget will send a letter to all nonprofit agencies
advising of the deadline for reimbursement requests for the fiscal year. This deadline is typically early
to mid October, since the Finance Department does not process checks for the prior fiscal year
beyond that point .
Each reimbursement request must include a summary of expenses by type . These summaries
should be broken down into salaries , benefits , supplies , contractual services , etc . If Indian River
County is reimbursing an agency for only a portion of an expense (e . g . salary of an employee) , then
the method for this portion should be disclosed on the summary. The Office of Management &
Budget has summary forms available .
Indian River County will not reimburse certain types of expenditures . These expenditure types are
listed below .
a . Travel expenses for travel outside the County including but not limited to ; mileage reimbursement,
hotel rooms , meals , meal allowances , per Diem , and tolls . Mileage reimbursement for local travel
(within Indian River County) is allowable .
b . Sick or Vacation payments for employees . Since agencies may have various sick and vacation
pay policies , these must be provided from other sources .
c . Any expenses not associated with the provision of the program for which the County has awarded
funding .
d . Any expense not outlined in the agency's funding application .
The County reserves the right to decline reimbursement for any expense as deemed necessary."
- 1 -
EXHIBIT C
STANDARD TERMS FOR GRANT CONTRACT
1 . Notices : Any notice , request, demand , consent, approval or other communication required or
permitted by this Contract shall be given or made in writing , by any of the following methods
:
facsimile transmission ; hand delivery to the other party; delivery by commercial overnight courier
service ; or mailed by registered or certified mail (postage prepaid ) , return receipt requested at the
addresses of the parties shown below:
County: Joyce Johnston-Carlson , Director
Indian River County Human Services
1840 25th Street
Vero Beach , Florida 32960-3365
Recipient : Verna Wright
Dasie Bridgewater Hope Center, Inca
P . O . Box 701483
Wabasso , FL 32970
2 . Venue : Choice of Law: The validity, interpretation , construction , and effect of this Contract shall
be in accordance with and governed by the laws of the State of Florida , only. The location for
settlement of any and all claims , controversies , or disputes , arising out of or relating to any part of
this Contract, or any breach hereof, as well as any litigation between the parties , shall be Indian
River County, Florida for claims brought in state court , and the Southern District of Florida for
those claims justifiable in federal court.
3 . Entirety of Agreement: This Contract incorporates and includes all prior and contemporaneous
negotiations , correspondence , conversations , agreements , and understandings applicable to the
matters contained herein and the parties agree that there are no commitments , agreements , or
understandings concerning the subject matter of this Contract that are not contained herein .
Accordingly, it is agreed that no deviation from the terms hereof shall be predicated upon any prior
representations or agreements , whether oral or written . It is further agreed that no modification ,
amendment or alteration in the terms and conditions contained herein shall be effective unless
contained in a written document signed by both parties .
4 . Severability: In the event any provision of this Contract is determined to be unenforceable or
invalid , such unenforceability or invalidity shall not affect the remaining provisions of this Contract,
and every other term and provision of this Contract shall be deemed valid and enforceable to the
extent permitted by law. To that extent, this Contract is deemed severable .
5 . Captions and Interpretations : Captions in this Contract are included for convenience only and are
not to be considered in any construction or interpretation of this Contract or any of its provisions .
Unless the context indicates otherwise , words importing the singular number include the plural
number, and vice versa . Words of any gender include the correlative words of the other genders ,
unless the sense indicates otherwise .
6 . Independent Contractor. The Recipient is and shall be an independent contractor for all purposes
under this Contract. The Recipient is not an agent or employee of the County, and any and all
persons engaged in any of the services or activities funded in whole or in part performed pursuant
to this Contract shall at all times and in all places be subject to the Recipient's sole direction
,
supervision , and control .
7 . Assignment , This Contract may not be assigned by the Recipient without the prior written consent
of the County.
- 1 -
INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY
P . • O . BOX 2508
CINCINNATI , OH 45201
Employer Identification Number :
Date : 0
2 7 244 DLN= 0633089
FEBC 6j 17053343041003
DASIE BRIDGEWATER HOPE CENTER INC Contact Person :
C / o VERNA M WRIGHT JOSEPH R HERR ID# 31128
PO BOX 701483 8465 62ND AVE Contact Telephone Number :
WABASSO , FL 32970 ( 877 ) 829 - 5500
Accounting Period Ending :
December 31
Foundation Status Classification :
509 ( a ) ( 1 )
Advance Ruling Period Begins :
July 8 , 2002
Advance Ruling Period Ends :
Decmber 31 , 2006
_ Addendum Applies :
No
Dear Applicant :
Based on information you supplied , and assuming your operations will be as
stated in your application for recognition of exemption , we have determined you
are exempt from federal income tax under section 501 ( a ) of the Internal Revenue
Code as an organization described in section 501 ( c ) ( 3 ) ,
Because you are a newly created organization , we are not now making a
final determination of your foundation status under section 509 ( a ) of the Code .
However , we have determined that you can reasonably expect to be a publicly
supported organization described in sections 509 ( a ) ( 1 ) and 170 ( b ) ( 1 ) (A ) (vi ) .
Accordingly , during an advance ruling period you will be treated as a
publicly supported organization , and not as a private foundation . This advance
ruling period begins and ends on the dates shown above .
Within 90 days after the end of your advance ruling period , you must
send us the information needed to determine whether you have met the require -
ments of the applicable support test during the advance ruling period . If you
establish that you have been a publicly supported organization , we will classi -
fy you as a section 509 ( a ) ( 1 ) or 509 ( a ) ( 2 ) organization as long as you continue
to meet the requirements of the applicable support test . If you do not meet
the public support requirements during the advance ruling period , we will
classify you as a private foundation for future periods . Also , if we classify
you as a private foundation , we will treat you as a private foundation from
your beginning date for purposes of section 507 ( d) and 4940 .
Grantors and contributors may rely on our determination that you are not a
private foundation until 90 days after the end of your advance ruling period .
If you send us the required information within the 90 days , grantors and
contributors may continue to rely on the advance determination until we make
Letter 1045 ( DO / CG )
- 2 -
DASIE BRIDGEWATER HOPE CENTER INC
a final determination of your foundation status .
If we publish a notice in the Internal Revenue Bulletin stating that we
will no longer treat you as a publicly supported organization , grantors and
contributors may not rely on this determination after the date we publish the
notice . In addition , if you lose your status as a publicly supported organi -
zation , and a grantor or contributor was responsible for , or was aware of , the
act or failure to act , that resulted in your loss of such status , that person
may not rely on this determination from the date of the act or failure to act .
Also , if a grantor or contributor learned that we had given notice that you
would be removed from classification as a publicly supported organization , then
that person may not rely on this determination as of the date he or she
acquired such knowledge .
If you change your sources of support , your purposes , character , or method
of operation , please let us know so we can consider the effect of the change on
your exempt status and foundation status . If you amend your organizational
document or bylaws , please send us a copy of the amended document or bylaws .
Also , let us know all changes in your name or address .
As of January 1 , 1984 , you are liable for social security taxes under
the Federal Insurance Contributions Act on amounts of $ 100 or more you pay to
each of your employees during a calendar year . You are not liable for the tax
imposed under the Federal Unemployment Tax Act ( FUTA) .
Organizations that are not private foundations are not subject to the pri -
vate foundation excise taxes under Chapter 42 of the Internal Revenue Code .
However , you are not automatically exempt from other federal excise taxes . If
you have any questions about excise , employment , or other federal taxes , please
let us know .
Donors may deduct contributions to you - as provided in section 170 of the
Internal Revenue Code . Bequests , legacies , devises , transfers , or gifts to you
or for your use are deductible for Federal estate and gift tax purposes if they
meet the applicable provisions of sections 2055 , 2106 , and 2522 of the Code .
Donors may deduct contributions to you only to the extent that their
contributions are gifts , with no consideration received . Ticket purchases and
similar payments in conjunction with fundraising events may not necessarily
qualify as deductible contributions , depending on the circumstances . Revenue
Ruling 67 - 246 , published in Cumulative Bulletin 1967 - 2 , on page 104 , gives
guidelines regarding when taxpayers may deduct payments for admission to , or
other participation in , fundraising activities for charity .
You are not required to file Form 990 , Return of Organization. Exempt From
Income Tax , if your gross receipts each year are normally $ 25 , 000 or less . If
you receive a Form 990 package in the mail , simply attach the label provided ,
check the box in the heading to indicate that your annual gross receipts are
normally $ 25 , 000 or less , and sign the return . Because you will be treated as
a public charity for return filing purposes during your entire advance ruling
period , you should file Form 990 for each year in your advance . ruling period
Letter 1045 ( DO / CG )
- 3 -
DASIE BRIDGEWATER HOPE CENTER INC
that you exceed the $ 25 , 000 filing threshold even if your sources of support
do not satisfy the public support test specified in the heading of this letter .
. If a return is required , it must be filed by the 15th day of the fifth
month after the end of your annual accounting period . A penalty of $ 20 a day
is charged when a return is filed late , unless there is reasonable cause for
the delay . However , the maximum penalty charged cannot exceed $ 10 , 000 or
5 percent of your gross receipts for the year , whichever is less . For
organizations with gross receipts exceeding $ 1 , 000 , 000 in any year , the penalty
is $ 100 per day per return , unless there is reasonable cause for the delay .
The maximum penalty for an organization with gross receipts exceeding
$ 1 , 000 , 000 shall not exceed $ 50 , 000 . This penalty may also be charged if a
return is not complete . So , please be sure your return is complete before you
file it .
You are not required to file federal income tax returns unless you are
subject to the tax on unrelated business income under section 511 of the Code .
If you are subject to this tax , you must file an income tax return on Form
990 - T , Exempt Organization Business Income Tax Return . In this letter we are
not determining whether any of your present or proposed activities are unre -
lated trade or business as defined in section 513 of the Code .
You are required to make your annual information return , Form 990 or
Form 990 - EZ , available for public inspection for three years after the later
of the due date of the return or the date the return is filed . You are also
required to make available for public inspection your exemption application ,
any supporting documents , and your exemption letter . Copies of these
documents are also required to be provided to any individual upon written or in
person request without charge other than reasonable fees for copying and
postage . You may fulfill this requirement by placing these documents on the
Internet . Penalties may be imposed for failure to comply with these
requirements . Additional information is available in Publication- 557 ,
Tax - Exempt Status for Your Organization , oe you may call our toll free
number shown above .
You need an employer identification number even if you have no employees .
If an employer identification number was not entered on your application , we
will assign a number to you and advise you of it . Please use that number on
all returns you file and in all correspondence with the Internal Revenue
Service .
If we said in the heading of this letter that an addendum applies , the
addendum enclosed is an integral part of this letter .
Because this letter could help us resolve any questions about your exempt
status and foundation status , you should keep it in your permanent records .
We have sent a copy of this letter to your representative as indicated
in your power of attorney .
Letter 1045 ( DO / CG)
- 4 -
DASIE BRIDGEWATER HOPE CENTER INC
If you have any questions , please contact the person whose name and
telephone number are shown in the heading of this letter .
Sincerely yours ,
Lois G . emer , .
Director , Exempt Organizations
Rulings and Agreements
Enclosure ( s ) :
Form 872 - C
i
Letter 1045 (DO / CG )
Date : 12/03 / 04 Time : 03 : 04 PM To : 978-1798 Page : 001 -002
AGDRpY CERTIFICATE OF LIABILITY INSURANCE iii30/Zoo
PRODUCER, ( 772) 231 - 2828 FAX ( 772) 231 - 4413 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Felten & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2911 Cardinal Drive ( 32963 ) HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P , O . Box 3488 -
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Vero Beach , FL 32964 - 3488 INSURERS AFFORDING COVERAGE NAIC
INSURED The Dasie Bridgewater Hope Center Inc ,NSUFEaA Colony Insurance. Company
8445 64th Ave INSUFEi3Florida Retail Federation
Wabasso , Fl. 32970 INsoFEaa
INSUIPF a D.
�NSuPE �; E'
OVERAQU
THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUEC TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDIN
ANY RECUIREMENT , TERM OR CONDITION OF ANY COYTRACT OR OTHER DOCUMENT V✓ITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAlfJ, THE INSURANCE AFFORDED BY THE POLICIES DES,.,
RISED HEREIN IS SUBJECT TO ALL THE TERMS , EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES . AGGREGATE LIMITS SHO'IAW MAY HAVE BEEN REDUCED BY PAID CLAIMS .
INSR DD' TYPE OF INSURANCE POUCYNUMBER POLICYEFFECTIVE POUCYEXPIRATiON LIMITS
GENERAL LIABILITY APS38042 11/23 /2004 11/23 /2005 EACHCj=RRENCE 5 11000 , 000
X :CNVEtrIALGENERALLi.nBlLl -Y DAMAGE T(.; RENTED $ SO OO
EE A -
X C?.AjNSMADE I OCCUR MED EXP iAny cne persrn) b
EXCLUDE
A X 5000 ded per claim PERSCNAL & ACV 1NJLiRY s 11000 , 00
X Prof Li ab G91*F=1A1_ AGGFEG.A'E 1 000 00
GEN'LAGGREGATE UVIT APPJFES ?ER: PACCUCTS - COMP,!OP AGG 5 INCLUDE
qC -
F'G_ICY JECT LCC
AUTOMOBILE LIASIUT(
, OVRNED
ANYA.jiO b
ALL OWN EDAUT
BOD: _`( -'NJUPY b
S?^)
H ' nED Arj70S
60Dl _Y 1NJORY
NON-OWNED AUTOS ;Per w...:iZlt)
PROPERTY DAMAGE
GAFAGELIABIUTY AOT; ONLY - SAACCIDFNT F
ANY A:TU
:JTHEF THA' EA Aid.:
AtJ ' G ON _V
EXCE$.WMBRELLA LIABILITY EACH OC -:.J"«;EN E
! 1`..0-IJ 7 C4AIYS MALE `
AG:3REGATE 5
b
DED JC.T:BLE R
RcfEN110N $
F
WORKERS COMPENSATION AND
778900 12/03 /2004 12/03 /2005 )(FY c r rt
EMPLOYERS' LIABILITY
B AN" PR.WP ETOR/= ARTN =_gFXFCtITIVF E.L. EAC-1 Al, :r- NT 1009000
C ' ^ tiF;MEkiBER EXCLUDED` E.L . DIaEA-c " >. "eMFUJ" t 500 , 000
I": yep QBSMbe �K YR Y
SPECIAL FFi'r,.5cl!JN5 � :~a. r,. . o,
_. . sEAs _ ;Cr! .; n: - , £ 100 , 00
OTHER APS08042 11/2. 3 / 2004 11/23 /2005 x, 25 , 000 each claim
A
[exual /Physical Abuse
$ 50 , 000 aggregate
DFSCRIPTION OF OPERATIONS ; LOCATIONS ! VEHICLES ; EXC. USIONS ADDED BYENPORSEMENT f SPECIAL PROVISIONS
ertificate holder is named additional insured
10 day notice of cancellation for non - payment of premium
CERTIFICATE ,
SHCULD ANY OF THE ABOVE. DESCRIBED POUCI t S HE CANCELLI O BEFORE VHE
EXPIRATION DATE THEREOF, THE ISSUING INSURER t'/ILL ENDEAVOR TO rAAIt
INDIAN RIVER COUNTY = 30 i)4YSt9fiITTEN NOTICE TO THE CERTIFIC 4TE iOLDER NAr4ED TC THP LEF
BOARD OF COMMISSIONERS BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE f J OBLIGATION OR LIAS& _IT
1840 25TH STREET OF ANY KIND UPON THE INSURER, ITS AGENTS OR At +RESENTATIV S.
VERO BEACH , FL 32960 - 3365 1. JTHORIZEE, AtPRESENTATIVE /
Kenneth D . Felten LUTCF ]APe011
ACORD 25 (2001 /08) T. ACORD CC) HPORATIG` N 1988
Date : 12 /03/04 Time : 03 : 04 PM To : 978- 1796 Page : 002 -002
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED , the policy ( ies) must be endorsed , A statement
on this certificate does not ccnfer rights to tha certificate no !Cer In Ileu of such endorsement(s) .
If SUBROGATION IS WAIVED , subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement (s) ,
DISCLAIMER
The Cartifcate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s) , authorized representative or proa1acer, and the certificate holder, nor does it
affirmatively or regatitee!y amend , extend or alter the coverage afforded by the policies listed thereon ,
ACO RD 25 (2001 im
DEC - 04 - 2004 03 : 51 AM P . 01
'bat dvo) A cv c
dke'.", t?L : �