Excel Sheet Download 11433 | Sample Adsd Competitive Social Services Grant Application Fy2018 Part1

Partial file snippet.

Sheet 1: Applicant Information

	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
		TO BE COMPLETED BY ADSD ONLY 
		
		

		

		

		

	
	
		

		

		

		

		

		

		

		

		
 
		
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		Application Number:
		
 
		
		
 
		
		
 
		
		
 
		
		

		

		

		

		

	
	
		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		Nevada Aging and Disability Services Division (ADSD)
Competitive Grant Application - Social Services (Aging Services)
Two-Year Grant Cycle for Fiscal Years 2018 and 2019
Reporting Period, 1st Year (FY18): July 1, 2017 - June 30, 2018
		

		

		

		

	
	
		

		
 
		
		
	
		APPLICANT INFORMATION
		

		
	
		  1. TYPE OF APPLICATION:
		

		 2.  AMOUNT REQUESTED:
		  3. TYPE OF ORGANIZATION:
		

		

		

		

	
	
		

		

		New Applicant or Type of Service
		

		For-Profit
		   Non-Profit
		     Governmental
		

		

		

		

	
	
		

		

		

		

		

		

		

		

		
		This figure populates from information you enter into the Budget Detail Worksheet.
		$54,238
		

		

		

		

		

	
	
		

		

		Currently Funded ADSD Grant:
		

		

		

		

		

		

		

	
	
		

		

		FY 17 Grant #:
		001-00-LX-17
		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		4. APPLICANT INFORMATION
		

		

		

		

	
	
		SPONSOR
		PROGRAM  
		

		

		

		

	
	
		Name:
		Nevada County
		

		Name:
		

		Nevada County Transportation
		

		

		

		

	
	
		Address:
		Main Street
		

		Address:
		State Street
		

		

		

		

	
	
		City, State:
		Any Town, NV
		

		City, State:
		Any Town, NV
		

		

		

		

	
	
		ZIP Code:
		89800
		

		ZIP Code:
		89800
		

		

		

		

	
	
		County:
		Nevada
		

		County:
		

		Nevada
		

		

		

		

	
	
		Sponsor Contact Information
		Program Director Contact Information
		

		

		

		

	
	
		First & Last Name:
		
		This should not be the same as the program director. This person has oversight of the grant as a whole and will receive fiscal and programmatic reports along with the program director for accountability purposes. (i.e., board president, CEO)
		Mr. County Manager
		

		First & Last Name:
		
		This should not be the same as the sponsor contact info. There must be a separate sponsor and program director.
		Mr or Ms. Program Director
		

		

		

		

	
	
		Title:
		County Manager
		

		Title:
		Program Director
		

		

		

		

	
	
		E-Mail:
		countymanager@nevadacounty.gov
		

		E-Mail:
		programdrname@nevadacounty.gov
		

		

		

		

	
	
		Phone Number:
		775 555-5555
		

		Phone Number:
		775 555-5556
		

		

		

		

	
	
		Fax Number:
		775 777-7777
		

		Fax Number:
		775 777-7778
		

		

		

		

	
	
		   5. EMPLOYER IDENTIFICATION NUMBER (EIN):
		   7. SOURCE FOR FUNDING:         
		

		

		

		

	
	
		

		

		

		

		

		Choose one source from this drop down menu:
		

		

		

		
	
		

		

		

		

		

		

		

		

		

		

		

		
 
		
		

		
	
		   6. DATA UNIVERSAL NUMBERING SYSTEM (DUNS) #:
		

		

		
	
		

		

		

		

		

		9. SUMMARIZE SERVICES TO BE PROVIDED IF FUNDS ARE AWARDED (Use Bullets)
		

		
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		   8. TYPE OF SERVICE TO BE FUNDED:
		

		

		

		

		

	
	
		

		Choose one service from this drop down menu:
		

		(Only include services that would be ADSD-funded. Examples for various services: ride to medical appointment, ride to social activities, wash dishes, change linens, meal preparation, training, one-on-one counseling, two phone calls per week, grocery shopping, respite care, etc.)
		

		

		

		

	
	
		

		
 
		
		

		

		

		

		

	
	
		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		   10. AREAS TO BE SERVED BY PROJECT:               
		

		
 
		
		Rides to medical appointments
		

		

		

		

	
	
		

		 (List city, town, county or statewide service areas)
		

		

		
 
		
		Rides to pharmacy
		

		

		

		

	
	
		

		Within a 10 miles radius of the Nevada County Senior Center
		

		

		
 
		
		Rides to grocery store
		

		

		

		

	
	
		

		

		

		
 
		
		Rides to senior center nutrition
		

		

		

		

	
	
		

		

		

		
 
		
		Rides to post office
		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		   11. PRIORITY  POPULATIONS:
		

		
 
		
		Rides to social activities
		

		

		

		

	
	
		

		 (e.g., age 60 and older, rural, minority, frail, homeless, etc.)
		

		

		
 
		
		

		

		

		

		

	
	
		

		
 
		
		Age 60 years or older
		

		

		
 
		
		

		

		

		

		

	
	
		

		
 
		
		Rural
		

		

		
 
		
		

		

		

		

		

	
	
		

		
 
		
		Frail
		

		

		
 
		
		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		12. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL INFORMATION IN THIS APPLICATION IS TRUE AND CORRECT. THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
		

		

		

		

	
	
		

		

		

		

	
	
		Authorized Representative (Print or Type)
		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		First Name:
		

		Last Name:
		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		Title: 
		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		Signature of Authorized Representative
		

		Date
		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	

 
 
 
 
 
 
 
 
 
 
 
 




Sheet 2: Application Checklist

	
	
	
	
	
	
		

		

		

		

		

		FY 2018
	
	
		APPLICATION CHECKLIST
		
	
		

		

		

		

		

		

	
	
		Assemble the application in the order shown below, check off each item completed and submit with your application package as directed.
		
	
		

		

		

		

		

		

	
	
		Staple the application in the top left-hand corner. Do not use binder or paper clips.
		
	
		

		

		

		

		

		

	
	
		NOTE: If any of the following items are incomplete or missing, the application will be rejected:
		

		

		

		

		

	
	
		

		

		

		

		

		

	
	
		Excel File:
		

		

		

		

		

	
	
		
 
		
		Applicant Information
		
	
		
 
		
		Application Checklist
		
	
		
 
		
		Budget Detail Worksheet
		
	
		
 
		
		Budget Form A
		
	
		
 
		
		Budget Form A-1
		
	
		
 
		
		Other Funding
		

		

		

		

	
	
		
 
		
		Projected Output Measures
		
	
		Word File:
		

		

		

		

		

	
	
		
 
		
		Applicant Questionnaire
		
	
		
 
		
		

		

		

		

		

	
	
		
 
		
		Organizational Standards
		
	
		
 
		
		Assurances/Certifications
		
	
		Attachments: (If included, will not count towards page limit. Unsolicited attachments are prohibited.)
		

		

		

		

		

	
	
		
 
		
		Your Sliding Fee Schedule and/or Cost Sharing Procedure (if applicable)
		
	
		
 
		
		Contracts or Memorandums of Understanding (if applicable to the program/service)
		
	
		
 
		
		Full Program Budget (optional)
		
	
		

		

		

		

		

		

	
	
		APPLICATION SUBMITTAL INFORMATION
		
	
		Deadline:
		

		Tuesday, March 21, 2017 (hand-delivered by 4:00 p.m. or postmarked)
		
	
		Number:
		

		One original and four copies for each application being submitted
		
	
		Locations:
		

		Mail to the Las Vegas Office ONLY or hand-deliver by 4:00 p.m. to any of the following ADSD offices:
		
	
		Carson City Office
		

		

		Elko Office
		Las Vegas Office
		Reno Office
	
	
		3416 Goni Road
		

		

		1010 Ruby Vista Drive
		1860 E. Sahara Avenue
		9670 Gateway Drive
	
	
		Bldg. D, Suite 132
		

		

		Suite 104
		Las Vegas, NV 89104
		Suite 200
	
	
		Carson City, NV 89706
		

		

		Elko, NV 89801
		

		Reno, NV 89521
	



Sheet 3: Budget Detail Worksheet

	
	
	
	
	
	
	
	
		

		

		

		

		

		

		FY 2018
		

	
	
		THE BUDGET
		

	
	
		BUDGET DETAIL WORKSHEET
		

	
	
		Agency/Organization Name:
		
		This will copy from the Program Name.
		Nevada County Transportation
		

		

	
	
		Type of Service:
		

		

		

		

	
	
		Type of Grant: 
		
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		Briefly describe the expenses for the proposed project in each of the ADSD-funded budget categories using the following as a guide for each category of expense. Be sure to explain how each expense is related to the project and identify any one-time costs. Only include resources in "Grantee Match" column if match is required for the funding source you selected. Do not include excess match in this form. Instead, describe the additional resources that will be used to support the project in the appropriate space on Budget Form A-1. Totals from this form will populate Budget Form A. 
		

	
	
		Note: This form will only accept whole numbers. 
All category worksheets are to be submitted even though no funds have been budgeted for the category.
		

	
	
		

	
	
		

	
	
		Funding Source Selected:
		Aging Services - Independent Living Grant (ILG)
		

	
	
		Match Requirement for the Funding Source Selected: 
		Match is required.
		

	
	
		Total amount requested from ADSD multiplied by 0.15
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		PERSONNEL: List administrative staff that would provide direct service under the proposed program, name(s), and costs to be charged to the grant (percentages will be calculated automatically). Costs associated with administrative staff providing indirect services may only be included in this section in fixed-fee proposals. Also list program staff names, positions and costs (percentages will be calculated automatically). Asterisk (*) all new positions. Calculate and document the cost per position as shown in the example. (Number of hours per week multiplied by the number of weeks worked multiplied by the hourly wage.)
		

	
	
		Position Title and Salary Calculations
		Annual Salary
		% Time
		ADSD       Request
		Grantee Match
		Program Salary
		

	
	
		Example: Program Director, Jane Doe
18 hrs wk x 52 wks x $16.83 hr = $15,753
		$35,000
		45.01%
		$9,452
		$6,301
		$15,753
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		Position Title and Salary Calculations
		Annual Salary
		
		This field will calculate the total percentage of time the staff person will spend on the proposed service/grant. The calculation is based on the "Program Salary", which is comprised of the ADSD Request and Grantee Share, compared to the "Annual Salary".
		(Auto Calculation)    % Time
		ADSD    Request
		Grantee Match
		Program Salary
		

	
	
		Program Director, Jane Doe,  20 hrs wk X 52 wks X $18 hr = $18,720
		$37,440
		50.00%
		$15,912
		$2,808
		$18,720
		

	
	
		Driver, John Henry, 20 hours wk X 52 wks X $15 hr = $15,600.  
		$31,200
		50.00%
		$13,260
		$2,340
		$15,600
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		#DIV/0!
		

		

		$0
		

	
	
		

		

		TOTALS
		$29,172
		$5,148
		$34,320
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		FRINGE BENEFITS: List each position and provide a breakdown of the type of fringe benefits provided, such as health insurance, Medicare, FICA, retirement, etc., per the example. List the ADSD-requested amount and any match you are allocating toward this expense, if applicable (percentages will be calculated automatically).
		

	
	
		Description of Fringe by Position
		Program Salary
		% Fringe
		ADSD       Request
		Grantee Match
		Total Amount
		

	
	
		Example:                                                                        Program Director - FICA & Medicare
		$15,753
		7.65%
		$1,000
		$205
		$1,205
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		Description of Fringe by Position
		Program Salary
		
		This field will calculate the total percentage of benefits/fringe that will be applied to the staff person for the proposed service. The calculation is based on the "Total Amount", which is comprised of the DAS Request and Grantee Share, compared to the "Program Salary".
		(Auto Calculation)    % Wage
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		Program Director, FICA, WC, Retirement, Insurance
		$18,720
		25.00%
		$3,978
		$702
		$4,680
		

	
	
		Driver, FICA, WC, Retirement, Insurance
		$15,600
		25.00%
		$3,315
		$585
		$3,900
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		$0
		#DIV/0!
		

		

		$0
		

	
	
		

		

		TOTALS
		$7,293
		$1,287
		$8,580
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		CONTRACTUAL/CONSULTANT SERVICES: Explain the need and/or purpose for the contractual or consultant service. Only include costs for which there is a written agreement or contract. Identify and justify these costs. Follow the example. 
		

	
	
		Purpose/Description
		Calculation
		ADSD       Request
		Grantee Match
		Total Amount
		

	
	
		Example: Clinical Evaluations
		$85 hr x 40 hrs = $3,400
		$2,000
		$1,400
		$3,400
		

	
	
		

		

		

		

		

		

		

		

	
	
		Purpose/Description
		Calculation
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		TOTALS
		$0
		$0
		$0
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		STAFF TRAVEL/PER DIEM: Identify staff that will travel, the purpose, mileage, cost per mile and frequency. Grant funding will not pay more than the GSA.gov per diem and mileage rates. Follow the example.
		

	
	
		Description and Purpose of Travel by Position
		Calculation
		ADSD       Request
		Grantee Match
		Total Amount
		

	
	
		Example: Program Director -  Travel to Satellite Office
		50 mi/mo x $0.535 x 12 mo
		$321
		

		$321
		

	
	
		

		

		

		

		

		

		

		

	
	
		Description and Purpose of Travel by Position
		Calculation
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		Director travel to other sites
		200 mi. X 12 mo. X .54 per mile
		$1,296
		

		$1,296
		

	
	
		Director airfare  to ADSD Conference in October 2017
		1 trip X $600
		$600
		

		$600
		

	
	
		Director per diem/incidentals for 2 day in Las Vegas, NV @ $64.00 per day
		2 days X $64
		$128
		

		$128
		

	
	
		Director lodging for 2 days in Las Vegas, NV at $102 per night plus 12% tax
		2 nights X $114.24
		$229
		

		$229
		

	
	
		Director car rental for 2 days in Las Vegas, NV @ $50 per day
		2 days X $50
		$100
		

		$100
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		TOTALS
		$2,353
		$0
		$2,353
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		SUPPLIES: List tangible and expendable personal property such as office supplies, program supplies, etc. List any computer equipment which cost less than $1,000. Justify these expenditures. Follow the example, be as specific as possible. 
		

	
	
		Item(s)/Purpose
		Calculation
		ADSD       Request
		Grantee Match
		Total Amount
		

	
	
		Example: Paper, pens, notepads
		12 mo. X $35 mo. = $420
		$200
		$220
		$420
		

	
	
		

		

		

		

		

		

		

		

	
	
		Item(s)/Purpose
		Calculation
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		General Office Supplies, e.g. paper, pens, misc. office
		$25 per mo. X 12 mo.
		$300
		

		$300
		

	
	
		Vehicle Tires
		$200 X 4 tires
		$800
		

		$800
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		TOTALS
		$1,100
		$0
		$1,100
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		OCCUPANCY: Identify and justify any facility costs associated with the proposed program (not the agency as a whole), such as rent, maintenance expenses, insurance, as well as utilities such as power, water and telephone. Follow the example.
		

	
	
		Program Occupancy Cost Description/Purpose
		Calculation
		ADSD       Request
		Grantee Match
		Total Amount
		

	
	
		Example: Building Repairs @ 30% program share
		$500 each quarter = $2,000 x 30% = $600
		$500
		$100
		$600
		

	
	
		

		

		

		

		

		

		

		

	
	
		Program Occupancy Cost Description/Purpose
		Calculation
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		Rent @ 25% program share
		$1000 X 25% =
		$250
		

		$250
		

	
	
		Utilities @ 25% program share, e.g. electricity, propane
		$2000 X 25% = $500
		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		TOTALS
		$250
		$0
		$250
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		PUBLIC INFORMATION: Identify and justify any such costs (printing of brochure, etc). This category can also include costs for appropriate project promotion, such as media buys, etc. Follow the example.
		

	
	
		Item Description/Purpose
		Calculation
		ADSD       Request
		Grantee Match
		Total Amount
		

	
	
		Example: Media Advertising
		4 events x $100 ea = $400
		$350
		$50
		$400
		

	
	
		

		

		

		

		

		

		

		

	
	
		Item Description/Purpose
		Calculation
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		Program brochures
		1000 X .17 ea =
		$170
		

		$170
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		TOTALS
		$170
		$0
		$170
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		OTHER EXPENSES: Identify and justify all other expenditures that cannot be identified in another category. These costs may include any relevant expenditure associated with the proposed project, such as training, car insurance, volunteer mileage, etc. These costs are to be included only if they are associated exclusively with this program. If they are associated with multiple sources of funding, the costs are to be included in Administrative Expenses. Follow example.
		

	
	
		Expense Description/Purpose
		Calculation
		ADSD       Request
		Grantee Match
		Total Amount
		

	
	
		Example: Car Insurance
		$189 mo x 12 mo = $2,268
		$1,433
		$835
		$2,268
		

	
	
		

		

		

		

		

		

		

		

	
	
		Expense Description/Purpose
		Calculation
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		Vehicle Insurance
		$200 X 12 mo = $2,400
		$2,400
		

		$2,400
		

	
	
		Vehicle Maintenance, e.g. oil change, routine maintenance
		$100 X 12 mo. = $1,200
		$1,200
		

		$1,200
		

	
	
		Background checks, 6 employees
		$50 X 6 = $300
		$300
		

		$300
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		

		

		$0
		

	
	
		

		

		TOTALS
		$3,900
		$0
		$3,900
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		

		

		REQUEST
SUBTOTAL                                (Direct Project Costs)
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		

		

		$44,238
		$6,435
		$50,673
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		ADMINISTRATIVE EXPENSES: Administrative expenses for categorical grants do not have to be assigned to a specific category. Instead, they are to be used to help cover costs associated with depreciation and use allowances, facility operation and maintenance, general administrative expenses such as accounting, payroll, legal and data processing, and any personnel not providing direct services to the project. The expenses must be adequately described and are limited to no more than 8% of the direct project costs requested from ADSD. Fixed-fee programs may incorporate the expenses in the above line items. List detailed expense descriptions in the first column and provide a dollar amount for the expenses. Administrative expenses do not apply to equipment. Follow the example.
		

	
	
		Description
		ADSD       Request
		Grantee Match
		Total Amount
		

	
	
		Example: Accounting Services
		$500
		

		$500
		

	
	
		

		

	
	
		Description
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		For fixed fee grants: Use regular line item categories above to describe administrative costs.
		

	
	
		Accounting, IT, other
		

		

		

		$6,300
		

		$0
		

	
	
		

		

		

		$0
		

	
	
		

		

		

		$0
		

	
	
		

		

		

		$0
		

	
	
		

		

		

		$0
		

	
	
		

		

		TOTALS
		$0
		

		$0
		

	
	
		

		

		

		

		

		

		

		

		
	
		EQUIPMENT: List equipment to purchase, which cost $1,000 or more, and justify these expenditures. Equipment costing less than $1,000 should be listed under Supplies.
		

	
	
		Item/Purpose/Justification
		Unit Cost
		Qty
		ADSD       Request
		Grantee Match
		Total Amount
		

	
	
		Example: Photocopier
		$3,300
		1
		$3,000
		$300
		$3,300
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		Item/Purpose/Justification
		Unit Cost
		Qty
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		New vehicle @ $35,000
		$35,000
		1
		$10,000
		$1,701
		$11,701
		

	
	
		

		

		

		

		

		$0
		

	
	
		

		

		

		

		

		$0
		

	
	
		

		

		

		

		

		$0
		

	
	
		

		

		

		

		

		$0
		

	
	
		

		

		

		

		

		$0
		

	
	
		

		

		

		

		

		$0
		

	
	
		

		

		

		

		

		$0
		

	
	
		

		

		TOTALS
		$10,000
		$1,701
		$11,701
		

	
	
		

		

		

		

		

		

		

		

		

	
	
		

		

		TOTAL REQUEST
		ADSD    Request
		Grantee Match
		Total Amount
		

	
	
		

		$54,238
		$8,136
		$62,374
		

	
	
		
 
		
		

		

	
	
		

		

	
	
		

		

		

		

		

		

		

		

		

	
	
		Use the following boxes to determine if your match is correct, or if this is a current grant with multiple funding sources, please check the NGA for the total required match amount.
		

	
	
		

	
	
		These boxes will calculate automatically to help you determine your match amount:
		

	
	
		Amount of match required for this funding request according to ADSD Requested Amount:
		

	
	
		$8,136
		

	
	
		Amount of match entered on this form:
		

	
	
		$8,136
		

	
	
		Difference:
		

	
	
		$0 
		

	
	
		After all information is entered, the difference should be $0. 
(If you are completing a budget revision for an existing grant, only show match at the amount listed on the NGA.)

The words contained in this file might help you see if this file matches what you are looking for:

...Sheet applicant information to be completed by adsd only application number nevada aging and disability services division competitive grant social twoyear cycle for fiscal years reporting period st year fy july june type of amount requested organization new or service forprofit nonprofit governmental this figure populates from you enter into the budget detail worksheet currently funded lx sponsor program name county transportation address main street state city any town nv zip code contact director first amp last should not same as person has oversight a whole will receive programmatic reports along with accountability purposes ie board president ceo mr manager info there must separate ms title email countymanager nevadacountygov programdrname phone fax employer identification ein source funding choose one drop down menu data universal numbering system duns summarize provided if funds are awarded use bullets include that would adsdfunded examples various ride medical appointment activi...

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					*FY 2018*
APPLICATION CHECKLIST

Assemble the application in the order shown below, check off each item completed and submit with your application package as directed.

Staple the application in the top left-hand corner. Do not use binder or paper clips.

NOTE: If any of the following items are incomplete or missing, the application will be rejected:

*Excel File:*
	Applicant Information
	Application Checklist
	Budget Detail Worksheet
	Budget Form A
	Budget Form A-1
	Other Funding
	Projected Output Measures
*Word File:*
	Applicant Questionnaire

	Organizational Standards
	Assurances/Certifications
*Attachments: (If included, will not count towards page limit. Unsolicited attachments are prohibited.)*
	Your Sliding Fee Schedule and/or Cost Sharing Procedure (if applicable)
	Contracts or Memorandums of Understanding (if applicable to the program/service)
	Full Program Budget (optional)

APPLICATION SUBMITTAL INFORMATION
Deadline:		Tuesday, March 21, 2017 (hand-delivered by 4:00 p.m. or postmarked)
Number:		One original and four copies for each application being submitted
Locations:		Mail to the Las Vegas Office ONLY or hand-deliver by 4:00 p.m. to any of the following ADSD offices:
Carson City Office			Elko Office	Las Vegas Office	Reno Office
3416 Goni Road			1010 Ruby Vista Drive	1860 E. Sahara Avenue	9670 Gateway Drive
Bldg. D, Suite 132			Suite 104	Las Vegas, NV 89104	Suite 200
Carson City, NV 89706			Elko, NV 89801		Reno, NV 89521

						*FY 2018*
THE BUDGET
BUDGET DETAIL WORKSHEET
Agency/Organization Name:	This will copy from the Program Name. Nevada County Transportation
Type of Service:
Type of Grant:

Briefly describe the expenses for the proposed project in each of the ADSD-funded budget categories using the following as a guide for each category of expense. Be sure to explain how each expense is related to the project and identify any one-time costs. Only include resources in "Grantee Match" column if match is required for the funding source you selected. Do not include excess match in this form. Instead, describe the additional resources that will be used to support the project in the appropriate space on Budget Form A-1. Totals from this form will populate Budget Form A.
Note: This form will only accept whole numbers. All category worksheets are to be submitted even though no funds have been budgeted for the category.


Funding Source Selected:			Aging Services - Independent Living Grant (ILG)
Match Requirement for the Funding Source Selected:			Match is required.
			Total amount requested from ADSD multiplied by 0.15

PERSONNEL: List administrative staff that would provide direct service under the proposed program, name(s), and costs to be charged to the grant (percentages will be calculated automatically). Costs associated with administrative staff providing indirect services may only be included in this section in fixed-fee proposals. Also list program staff names, positions and costs (percentages will be calculated automatically). Asterisk (*) all new positions. Calculate and document the cost per position as shown in the example. (Number of hours per week multiplied by the number of weeks worked multiplied by the hourly wage.)
Position Title and Salary Calculations		Annual Salary	% Time	ADSD Request	Grantee Match	Program Salary
Example: Program Director, Jane Doe 18 hrs wk x 52 wks x $16.83 hr = $15,753		*$35,000*	*45.01%*	*$9,452*	*$6,301*	*$15,753*

Position Title and Salary Calculations		Annual Salary	This field will calculate the total percentage of time the staff person will spend on the proposed service/grant. The calculation is based on the "Program Salary", which is comprised of the ADSD Request and Grantee Share, compared to the "Annual Salary". (Auto Calculation) % Time	ADSD Request	Grantee Match	Program Salary
Program Director, Jane Doe, 20 hrs wk X 52 wks X $18 hr = $18,720		$37,440	50.00%	$15,912	$2,808	$18,720
Driver, John Henry, 20 hours wk X 52 wks X $15 hr = $15,600.		$31,200	50.00%	$13,260	$2,340	$15,600
			#DIV/0!			$0
			#DIV/0!			$0
			#DIV/0!			$0
			#DIV/0!			$0
			#DIV/0!			$0
			#DIV/0!			$0
			#DIV/0!			$0
			#DIV/0!			$0
			#DIV/0!			$0
			#DIV/0!			$0
			#DIV/0!			$0
			#DIV/0!			$0
		TOTALS		$29,172	$5,148	$34,320

FRINGE BENEFITS: List each position and provide a breakdown of the type of fringe benefits provided, such as health insurance, Medicare, FICA, retirement, etc., per the example. List the ADSD-requested amount and any match you are allocating toward this expense, if applicable (percentages will be calculated automatically).
Description of Fringe by Position		Program Salary	% Fringe	ADSD Request	Grantee Match	Total Amount
*Example: Program Director - FICA & Medicare*		*$15,753*	*7.65%*	*$1,000*	*$205*	*$1,205*

Description of Fringe by Position		Program Salary	This field will calculate the total percentage of benefits/fringe that will be applied to the staff person for the proposed service. The calculation is based on the "Total Amount", which is comprised of the DAS Request and Grantee Share, compared to the "Program Salary". (Auto Calculation) % Wage	ADSD Request	Grantee Match	Total Amount
Program Director, FICA, WC, Retirement, Insurance		$18,720	25.00%	$3,978	$702	$4,680
Driver, FICA, WC, Retirement, Insurance		$15,600	25.00%	$3,315	$585	$3,900
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		$0	#DIV/0!			$0
		TOTALS		$7,293	$1,287	$8,580

CONTRACTUAL/CONSULTANT SERVICES: Explain the need and/or purpose for the contractual or consultant service. Only include costs for which there is a written agreement or contract. Identify and justify these costs. Follow the example.
Purpose/Description		Calculation		ADSD Request	Grantee Match	Total Amount
*Example: Clinical Evaluations*		*$85 hr x 40 hrs = $3,400*		*$2,000*	*$1,400*	*$3,400*

Purpose/Description		Calculation		ADSD Request	Grantee Match	Total Amount
						$0
						$0
						$0
						$0
						$0
						$0
						$0
		TOTALS		$0	$0	$0

STAFF TRAVEL/PER DIEM: Identify staff that will travel, the purpose, mileage, cost per mile and frequency. Grant funding will not pay more than the GSA.gov per diem and mileage rates. Follow the example.
Description and Purpose of Travel by Position		Calculation		ADSD Request	Grantee Match	Total Amount
*Example: Program Director - Travel to Satellite Office*		*50 mi/mo x $0.535 x 12 mo*		*$321*		*$321*

Description and Purpose of Travel by Position		Calculation		ADSD Request	Grantee Match	Total Amount
Director travel to other sites		200 mi. X 12 mo. X .54 per mile		$1,296		$1,296
Director airfare to ADSD Conference in October 2017		1 trip X $600		$600		$600
Director per diem/incidentals for 2 day in Las Vegas, NV @ $64.00 per day		2 days X $64		$128		$128
Director lodging for 2 days in Las Vegas, NV at $102 per night plus 12% tax		2 nights X $114.24		$229		$229
Director car rental for 2 days in Las Vegas, NV @ $50 per day		2 days X $50		$100		$100
						$0
						$0
						$0
						$0
						$0
		TOTALS		$2,353	$0	$2,353

SUPPLIES: List tangible and expendable personal property such as office supplies, program supplies, etc. List any computer equipment which cost less than $1,000. Justify these expenditures. Follow the example, be as specific as possible.
Item(s)/Purpose		Calculation		ADSD Request	Grantee Match	Total Amount
*Example: Paper, pens, notepads*		*12 mo. X $35 mo. = $420*		*$200*	*$220*	*$420*

Item(s)/Purpose		Calculation		ADSD Request	Grantee Match	Total Amount
General Office Supplies, e.g. paper, pens, misc. office		$25 per mo. X 12 mo.		$300		$300
Vehicle Tires		$200 X 4 tires		$800		$800
						$0
						$0
						$0
						$0
						$0
						$0
						$0
						$0
						$0
		TOTALS		$1,100	$0	$1,100

OCCUPANCY: Identify and justify any facility costs associated with the proposed program (not the agency as a whole), such as rent, maintenance expenses, insurance, as well as utilities such as power, water and telephone. Follow the example.
Program Occupancy Cost Description/Purpose		Calculation		ADSD Request	Grantee Match	Total Amount
*Example: Building Repairs @ 30% program share*		*$500 each quarter = $2,000 x 30% = $600*		*$500*	*$100*	*$600*

Program Occupancy Cost Description/Purpose		Calculation		ADSD Request	Grantee Match	Total Amount
Rent @ 25% program share		$1000 X 25% =		$250		$250
Utilities @ 25% program share, e.g. electricity, propane		$2000 X 25% = $500				$0
						$0
						$0
						$0
						$0
						$0
						$0
						$0
						$0
						$0
		TOTALS		$250	$0	$250

PUBLIC INFORMATION: Identify and justify any such costs (printing of brochure, etc). This category can also include costs for appropriate project promotion, such as media buys, etc. Follow the example.
Item Description/Purpose		Calculation		ADSD Request	Grantee Match	Total Amount
*Example: Media Advertising*		*4 events x $100 ea = $400*		*$350*	*$50*	*$400*

Item Description/Purpose		Calculation		ADSD Request	Grantee Match	Total Amount
Program brochures		1000 X .17 ea =		$170		$170
						$0
						$0
						$0
						$0
						$0
						$0
						$0
						$0
						$0
		TOTALS		$170	$0	$170

OTHER EXPENSES: Identify and justify all other expenditures that cannot be identified in another category. These costs may include any relevant expenditure associated with the proposed project, such as training, car insurance, volunteer mileage, etc. These costs are to be included only if they are associated exclusively with this program. If they are associated with multiple sources of funding, the costs are to be included in Administrative Expenses. Follow example.
Expense Description/Purpose		Calculation		ADSD Request	Grantee Match	Total Amount
*Example: Car Insurance*		*$189 mo x 12 mo = $2,268*		*$1,433*	*$835*	*$2,268*

Expense Description/Purpose		Calculation		ADSD Request	Grantee Match	Total Amount
Vehicle Insurance		$200 X 12 mo = $2,400		$2,400		$2,400
Vehicle Maintenance, e.g. oil change, routine maintenance		$100 X 12 mo. = $1,200		$1,200		$1,200
Background checks, 6 employees		$50 X 6 = $300		$300		$300
						$0
						$0
						$0
						$0
						$0
						$0
		TOTALS		$3,900	$0	$3,900

		REQUEST SUBTOTAL (Direct Project Costs)		ADSD Request	Grantee Match	Total Amount
				$44,238	$6,435	$50,673

ADMINISTRATIVE EXPENSES: Administrative expenses for categorical grants do not have to be assigned to a specific category. Instead, they are to be used to help cover costs associated with depreciation and use allowances, facility operation and maintenance, general administrative expenses such as accounting, payroll, legal and data processing, and any personnel not providing direct services to the project. The expenses must be adequately described and are limited to no more than 8% of the direct project costs requested from ADSD. Fixed-fee programs may incorporate the expenses in the above line items. List detailed expense descriptions in the first column and provide a dollar amount for the expenses. Administrative expenses do not apply to equipment. Follow the example.
Description				ADSD Request	Grantee Match	Total Amount
*Example: Accounting Services*				*$500*		*$500*

Description				ADSD Request	Grantee Match	Total Amount
For fixed fee grants: Use regular line item categories above to describe administrative costs.
Accounting, IT, other				$6,300		$0
						$0
						$0
						$0
						$0
		TOTALS		$0		$0

EQUIPMENT: List equipment to purchase, which cost $1,000 or more, and justify these expenditures. Equipment costing less than $1,000 should be listed under Supplies.
Item/Purpose/Justification		Unit Cost	Qty	ADSD Request	Grantee Match	Total Amount
*Example: Photocopier*		*$3,300*	1	*$3,000*	*$300*	*$3,300*

Item/Purpose/Justification		Unit Cost	Qty	ADSD Request	Grantee Match	Total Amount
New vehicle @ $35,000		$35,000	1	$10,000	$1,701	$11,701
						$0
						$0
						$0
						$0
						$0
						$0
						$0
		TOTALS		$10,000	$1,701	$11,701

		TOTAL REQUEST		ADSD Request	Grantee Match	Total Amount
				$54,238	$8,136	$62,374



Use the following boxes to determine if your match is correct, or if this is a current grant with multiple funding sources, please check the NGA for the total required match amount.

These boxes will calculate automatically to help you determine your match amount:
Amount of match required for this funding request according to ADSD Requested Amount:
$8,136
Amount of match entered on this form:
$8,136
Difference:
$0
After all information is entered, the difference should be $0. (If you are completing a budget revision for an existing grant, only show match at the amount listed on the NGA.)

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