APPLICANT NAME: ___________________________________

FY2021 PROPOSAL To Provide Services Under the Muskegon

County Senior Millage

Administered by: Senior Resources of West Michigan

DEADLINE FOR SUBMISSION is 12:00 PM (noon) on Thursday, July 2, 2020

Questions? Contact Karla Betten 231-733-3593 kbetten@seniorresourceswmi.org

Date/Time Stamp: Senior Resources will record this information

Please submit via email a single scanned PDF format file of the complete application including all attachments and original

signatures to RFP@seniorresourceswmi.org. An automatic email reply will be sent to confirm receipt.

Application for Funding Checklist

The following is a checklist of the required submissions. Items should be assembled and labeled as listed when submitted.

Application: ____ MCSM FY2021 Agreement and Assurances (between Applicant and Senior Resources of West Michigan) ____ MCSM FY2021 Grant Proposal* ____ MCSM FY2021 Service Budget*

*If requesting funds for more than one service, a set of these items should be completed andcollated for each service and included with the application section.

Management Section Attachments (only one set is required for all services):

Please note: If your organization already receives MCSM funding, it is not necessary to submit attachments below unless changes have been made to your previous documents. ____ Attachment A - Organization Chart ____ Attachment B - Agency or Service Brochure ____ Attachment C - Non-Profit Status Letter from IRS (if applicable) ____ Attachment D - Proof of Insurances ____ Attachment F - Board Member Listing (include yes/no for age 60+ and minority status) ____ Attachment G - Program income policy and materials ____ Attachment H – Most Recent Independent Auditors Report (if applicable) ____ Attachment I - Grievance Policies ____ Attachment J – Privacy Policy/Notice

The approved application will become part of the negotiated contract, inclusive of policies, service definitions, minimum standards, and service specifications and limitations.

Submit applications in the following format:

1) Submit a single scanned PDF format file of the complete application with attachments andoriginal signatures to RFP@seniorresourceswmi.org by 12:00 PM on Thursday, July 2,2020. An automatic email reply will be sent to confirm receipt.

1. Proposal Authorized Signature Page

AUTHORIZED SIGNATURE PAGEI certify that all information contained in this proposal is accurate and complete to the best of my knowledge.

I further certify that key staff have read and understood the policies and procedures contained within the Muskegon County Senior Millage Policy and Procedure Manual* as amended.

On behalf of my organization, I agree, if chosen as an applicant, to follow all terms and conditions contained within the Muskegon County Senior Millage Policy and Procedure Manual* as amended.

_________________________________________ _________________________________________ Signature Date

_________________________________________ _________________________________________ Printed Name Title

Must be signature of person authorized to sign contracts

*The MCSM Policy and Procedure Manual can be found on our website: https://seniorresourceswmi.org/

2. Proposal Content

a) Agency Overview:

Applicant Name: Phone:

Website (if applicable): Fax:E-mail:

Address:

Executive Director Name: Phone: E-mail:

Proposal Contact Name: Phone: E-mail:

Fiscal (Accounting) Contact Name: Phone: E-mail:

Applicant Board Chair Name.1 Board Chair Mailing Address:

Phone: Email:

City, State, Zip:

Board Chair's term expires: Tax ID DUNS:

Legal Status of applicant: ☐Public Agency ☐ Private Non-Profit Agency ☐ For Profit Agency☐Other (Describe)

1. For-profit agencies do not need to complete this section.

b) Proposed Services and Funding Request Summary:Proposed Service

*ServiceCategory

*2021Amount

Requested

Is This a New

Service? (Yes or

No)

**Geographic Area to be

Served

*Please see category chart below.**Funding requested should include total dollars for units of service and start-up costs.

***Geographic Area could be all of Muskegon County, a city, township or other portion of Muskegon County.

CATEGORY CHART: Please choose the category that BEST fits the purpose of each service proposed. While we understand that services offered often meet needs in multiple categories, it is important for the proposal process that you choose the category that most closely represents the core purpose of the service being proposed. When proposing funding amounts, understand that multiple organizations will be awarded funding within each category; so please propose funding amounts that are in alignment with the awards available.

CATEGORY % OF TOTAL AWARDS

FUNDING CAP PER CATEGORY

Educational 5% $100,000 Health 20% $400,000 Housing 20% $400,000 Legal 10% $200,000 Mobility 10% $200,000 Nutritional 20% $400,000 Social, Recreational, and Emotional 15% $300,000

TOTAL AWARDED PER YEAR 100% $2,000,000

c) Fund Development:

Complete the following chart. Explain any additional funding opportunities that have been pursued for this service in the past 12 months. Include all grants written and/or agencies who were contacted, the amount of funding requested, the reason for the request, and the results of your efforts to each request or fundraising effort. Be specific.

Funding Agency or

Fundraising Efforts

Funding Request

Reason for Request (be concise) *Results **Funding Cycle Dates

*Results can be answered by listing the dollar amount raised, denied, or pending.**Funding Cycle Dates are to include the length of the contract or to be used in a specific fiscal year.

END OF FUND DEVELOPMENT SECTION

d) Service Design and Description:

Complete this section separately for EACH service proposed. • Limit response to one additional page per service or two pages if your request includes start-up costs (see

question #7).Proposed Service Name:

Proposed Service Category:

Start-up Funding: $ Service Funding: $ Total Funding Requested: (Service Funding Start-up Funding = Total Funding)

Define Unit (See Service Standards): One Unit=

Proposed # of Units: Unit Rate ($ per unit):

Proposed # of Clients Served: Estimated Program Income: Estimated Cost Share (if applicable):

Cost Share is required for most millage services. Definitions for both program income and cost-share can be found in the Muskegon County Senior Millage Policy & Procedure MM.1.04a. Could this service be provided in a reduced capacity if not funded at the above request?

Yes No Explain.

Please answer questions 1-7 on a separate document (there are not fillable text options for these questions)

1. Describe the proposed service.At a minimum, incorporate the following in your response:

a. Describe in detail how this service will be impacted by COVID 19.b. How will you market this service to the older adults, family member/support team?c. Where do you expect your referrals to come from?d. Components of the service delivery from initial intake through the delivery of the servicee. Frequency of the service and termination from the programf. Locations of all sites/office that will provide the proposed serviceg. How many local volunteers were utilized last year?

i. What activities did they perform?ii. How many service hours did they provide?

iii. Who coordinates your volunteers?

2. How do you know there is a need for this service? (Cite 2010 census data, American Community Surveydata, 2019 Muskegon County Needs Assessment data or your own data.)

3. How do you plan to service unique, diverse, and under-served populations? What impact will this service have on its recipients?

4. Is the funding request for this service?one-time short term (# of years) on-going

5. When will this service become self-sustaining?

6. How will this service be promoted or advertised?

7. If the requested funding for this service includes start-up costs, please address the following with timeframes and the title of the staff person responsible for each task* (Senior millage funds cannot be usedfor bricks and mortar.) Will you need start-up funds? Yes No

a. If yes, how much?

(The amount listed here is part of the funding request. If start-up funds are needed, adjust thenumber of units to be served based on service funding amount and not the total fundingrequested. Start-up funds are only available at the beginning of a grant’s first year ofprogramming.)

Provide the following information if start-up funds are needed:

• Staffing needs (address hiring & training)• Equipment needs (include cost of equipment to be purchased)• Marketing• Transition of current clients from another millage provider (if applicable)• Other (please describe)• When will you serve the first client?• If this is an evidence-based health promotion program or exercise class, list the estimated dates

and locations of classes/workshops.

END OF SERVICE DESIGN & DESCRIPTON SECTION