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Home My WebLink AboutItem 8.1 Dublin High School Exh 8 CITY OF DUBLIN C~~p~N JAN 3 0 2009 CITYMANAOER'SOFF~ COMMUNITY GROUP/ORGANIZATIONAL FUNDING REQUEST. APPLICATION PACKET Fiscal Yeur 2009-2010 Section 2: Application for Community Group/Organizational Funding SECTION 2 - Page 1 of 16 EXHIBIT ~_ CITY OF DUBLIN Fiscal Year 2009-2010 COMMUNITY GROUP/ORGANIZr~TION -APPLICATION FOR FUNDS COVER PAGE AGENCY NAME: !~'~~~~ ~ ~`,~~ ~c:,~c t v PROPOSED PROJECT/PROGRAM l~LAME: -- { FUNDING AMOUNT REQUESTED: ~ ~,~~ F ~~ SECTION 2 Page 2 of 16 R ~ CITY OF DUBLIN Fiscal Year 2009-2010 t'~l~~vi_ :~;yL~c ii APPLICATION FOR FITNDS 1. Please select one expense category. ^ Capital operating 2. Applicant Information: Organization/Agency Name __ Mailing Address Street Address ~, ~ City ~~~\eJ, Statc ~l `~~(~ Zip ~ yJ [n~ ~.~L ~ ~~o~~i~1o: ~_ rtl~r'C. ~ _ ~~'"L~. ~~j ~~~c~ ~~ -~,; z~ cc:;~~ ~a,~°=ll~~l~~,~ Kll,t~,.k -? ofr Executive Director/Chjairperson Work Phone Emiail J/G'L~I~..+4~. .'1~~..~1_~oL~S® ~~k1';~ ~Gi~1~2.3""~Gld+v,G~ '~7,L(~+k7(1../3.1C.12.-C d:. °{~ (~ira;d r.,, t Board President (if applicable) Work Phone Email Please list the Primary Project Contact Person who would be able to answer questions about this application and proj'ect/program during the funding period. ~ +`~ ~Cs`~I..SG~ ~c:~t :~"T _`>S t~ ~~~i~ ~'' ~,n C; i IJG~ -~- Contact Person for Project/Program Job Title r~ ~,., j,, j, i L, ~j C~.~.~.. ~~ L ~,~liL?.L. C~ f~l C' "t (1 ~ ~~ G ~L`L ~ ~L~ ~'~13 H Z,~i~ ~ U. ~ ! ~ ~ ° 7J 7 ~'' ~ ~ ~~ «T,~,-1~ Dl,~,r,oT,mail~ F'8X Federal Tax Identification No. (required) a~~~~~~~ City of Dublin Business License No. (required) SECTION 2 Page 3 of 16 Application for Funds 3. Proposed Project/Program Information (Do not describe organization.) Amount of Funds Requested ~ '-~~~ ~~ C~ -cx C (Maximum .$25,000 per project.) Proposed Project/Program Name ~, Proposed Project/Program Date(s):` Start Cs'~ / ~ `~~ / ILk and End Cc / I~ l 1 - mo. day yr. mo. day yr., Please note: City Council Grant Funds are. distributed on a reimbursement basis. If your Agency needs a 100% disbursement at the beginning of the h'i cal Year, please indicate this below and please provide justification for this need. ..-Agency is requesting 100% disbursement at the br;giiuiing of the Fiscal Year. If selecting this option, please provide justification in the blank space below.: ^Agency is not requesting 100% disbursement at the beginning of the Fiscal 'Year. Please provide the frequency that reimbursements will be submitted to the Cii~ in the blank space below; e.g., monthly, quarterly, at project completion, etc. SECTION 2 Page 4 of 16 ~. City of Dublin Fiscal Year 2009-2010 Application fog Funds a. How would the requested funds be used? ^ Describe, in detail, the PROPOSED PROJECT/PROGRAM (not the Agency). ^ Bulleted text is acceptable... ^ Identify if the proposed project/program is a new service, or extension of an existing,one. ^ An additional page may be added,. if needed. ~''~ N Y ~~ iS \' \Z ~ K~ .~ ~ .1i..~ /i~ EL~IC.~'T '~i9 r jlc~ .u `tom F_~1V~t'~w~e~i} 'tUS S~nc~tr~~"S ~~ ~'`~~° y ~`''0 cJ~3i,(~tn~;~ ~/1. ~•\~S zS G.~t c~~i ' /l i c~~it 1 C~~"1>~ >i:nc~ ~<~~~.- ~..I'~ ~- ~~~~ur~ b. How would the PROPOSED PROJECT/PROGRAM address an unmet.. ,community need. and improve the quality of life for Dublin residents. ' Why is this project/program 'needed? (Additional page maybe added, if needed).:... ~J / f ~jr.. i ~'Yz-off. ~ ~'~ ~~~~ ~''1' "'' ~ s ~' ~'^ t~~ ~ ti~i 1 ;/~~i /~.~ C.J'~y~l L7..f ~~ aP 4 ~~ z l c. What documentation/data/records support the need for this PROPOSED PROJECT/PROGRAM? Please identify your data sources.' (Additional page may be added, if needed.) }~. C=,~-,:_yt ~' ~ bl~' ~~~~~ ~ ~ ~ dam\: <e ~~ ~ ~l~~ i . ~•i ~c~. ~^t:-'~ rY ~ ' ~~, ~2x-<- ~ z~vc_ 0a-zr.~, re o ~: ~ c: < c~. c ,; ~-~i c~-IE" ~-~ ~'i ~ ~ S Y'i 4~' ~ i.% /~ ~ ~ c•_ r `.>-~a c~ r .,~~E3 'zs.y~ "~~ ~ ig~~f ~,-~ s~:~-Y~-^~~ , ~ ~"~ _ SECTION 2 Page 5 of 16 City of Dublin Fiscal Year 2009-2010 Application foY Funds d. Specify the PROPOSED PROJEC`T'/PROGRAM population to be served. V l~V'L~- zx:_ N i t,~\ i~ c~,. 3 . +'e ~ P'A~~ G}.ju. c''1,3+~ ~ "~~ `JOB ri t a, t . ~ CC~~ 1 J `c ~` ` ` ~„, `` 'l~Z%R 4.. \ /~ 4r S~~V~:'a it ., ~J'~ `t~'J .r d9+a.3~.`~i.1 '. ~`~il ~J ~w 4~~.. `2_~, ~~ ~CZ, 5~~..4ttm\-E.$ i,+\ ~C6i~~.i\c~.vltc e. Projects/programs must be evaluated to determine if they are being carried out efficiently and if project/program goals are. being met. Please describe how you plan to monitor your project/program's success and impact. ^ An additional page may be added, if needed. ~. Aat} ~ ~ ~ ~~ a-n c ~., J ~` ~2 f. Specify numbers of clients served by agency, then by PROPOSED PROJECT/PROGRAM: ~<~cn~•~~ I'articipa-~t~ Total Number of Partici ants .Served by Agency (if applicable) ~~ ~ -~ Total Number of Dublin Residents Served by A~enev (if applicable) 3c: ~ ~ _ 1'rnjcct; Prow Parti~a~it, Total Proposed Participants Served by this Projeet/Program ~~:~ -'~ Total Number of Dublin Residents Served by this Project _ {~l! s a SECTION 2 Page 6 of 16 City of Dublin Fiscat Year 2009-2010 Application for Funds 5. Financial Information. -Operating Budget a. Expense Budget ~~, Fl" 2009-?O10 ~'.Al'I~ \SI~' Blll(:F:"1' ~ nR(;:~~I7_<~T~IO'~ ' Tll[s PH~>.1H:c~~r/ PROGIZ.~~1~1 ~.11~~~"l~ IZF~OLI~;Sl~ Per~Unncl Costs _ -- Non-Personnel (.'ost~ _ I Services & Supplies _ _ ~ Q p ~ Capital Costs Other (please specify) Other (please specify) -TOTAL .~ ~ ~ ~' u Further Comments/EXplanations (if necessary): LLC.J~ a1~ J Zr_L4L1~~`~~ Y~~i `~..~1.. ~..J ¢ "~111~~. ~"~ l~ ~ '~`'~a\ Y~:,+s'~^~-°'~ ~ ~'ai~.i) 'M"+,'°^ tae: `° t +~~e° ~,ea~~ fi: S ~ ~l ~ GI`.~~g'.R:~ ~ C. v ~.n,,P`j L ' 4 `i SECTION 2 Page 7 of 16 City of Dublin Fiscal Year 2009-2010 Application for Funds b. Revemue Budget Fh' 2009-2U1 U ~~- - - - R1-~~1~,~~1:r [~1~l~r;rT ! Olz~:~~~iz:~~ro~~~ PRU.II~;CT/PK~~c~.~z;r~~tii 'Committed/Rcst--ictcd Funds (~~~L 1t~ SOLII"Gt) ~ _ _. ',:lion-Cornrnitted/IZesrricted Funds ~~!~ ~~ If S~~CCII~" Sl)UI'Cc) _ - _ -_ - -- TOTAL Further Comments/Explanations (if necessary): ~~ SECTION 2 Page 8 of 16 ~; City of Dublin Fiscal Year 2009-2010 Application for Funds 6. General Agency Information - Past grant applicants may check this box in lieu of completing item 6 (a-d) if the program organizational description on file with the City is correct and current. a. List all years that Organization has previously received City of Dublin funding (not Community Development Block Grant - CDBG). b. Describe the -population(s) served by theOrganization. c. Describe all the services the Organization currently provides to Dublin residents. ^ An additional page may be added, if needed. d. Has your agency ever previously received funds from the City of Dublin? If yes, please specify in what Fiscal Years and the amount received each year. SECTION 2 Page 9 of 16 Fiscal Year 2009-2010 Application foY Funds 7. Required Attachments: E Z o Please label attachments: A, B, C, etc. ^ A. Names of Governing Board; identify current Board officers. ^ -B. Current total. Organization operating budget, including revenue. ^ Clearly label~identify the .program that-includes the PROPOSED PROJECT/PROGRAM. ^ C. Most recent audit report or tax return (i E applicable). ^ D. Resolution, letteror other dacumentproviding evidence. of Board/Organization approvalof application. and date approval was granted. ^ Board/Organization approval maybe pending. E. Organization's certificate of insurance showing coverage for liability and workers' compensation. ^ F. Application Verification Declaration Signature Page.. o G. Signed affidavit form from each'collaborating agency'named in proposed project/program plan (if applicable). ^ H. Copy of IRS Letter of Determination indicating tax exempt status. i o Only one (1) copy per Agency of each of the following is required, even with multiple projects/programs submitted. o Applications. without the following documents'. will not be reviewed for funding. SECTION 2 Page 10 of 16 ~, City of Dublin Fiscal Year 2009-2010 Application foY Funds APPLICATION VERIFICATION I attest that the information contained in this FY2009-2010 grant application is accurate and that the funds requested will not supplant any other monies secured by the organization'. Attached is a resolution, letter, or other document providing_evidence that the Board of Directors approved the application as submitted. Successful applicants'are required to submit a summary report as soon as possible after submitting the reimbursement request, but not later than August 3 1, 2010. Failure to submit. a report will result in ineligibility for future funding. Signatures: Executive Director- ~ ate ~~ F ~~( ~, Board Presi ent/Chaff erson Dat / ~ ~ v..- U i, SECTION 2 Page 11 of 16