1. Healthcare

Application for Economic Development
Grants
DUE January 30, 2015 by 4:00 pm
AWARD DATE: By March 1, 2015
Funds Available: July 1, 2015
Submit all documents to:
Coos County Board of Commissioners Office
Attn: Grant Applications
250 N. Baxter, Coquille, OR 97423
Or
[email protected]
Applicant/Organization
Mailing Address
Contact Name
Contact E-mail
Contact Phone No
Contact Name #2
Contact E-mail
Contact Phone No
Federal Tax ID
IRS Class (Exemption)
Total Grant Request
Page 1
PLEASE ANSWER THE FOLLOWING QUESTIONS COMPLETELY.
ARE DETAILED AT THE END OF THE QUESTIONS SECTION
ADDITIONAL SUBMITTAL REQUIREMENTS
1.
Describe the purpose and objectives of your organization and mission statement (from bylaws, articles of
incorporation or board adopted mission statements).
2.
Provide a short history of your organization.
3.
Describe the purpose and objectives of this grant request and summarize the programs/events utilized to meet the
purpose/objectives (Include descriptions for each funding category of your request)
If your grant request is for date specific events, programs or activities, please complete the following table:
(If completing electronically, double click the table to enter data)
Anticipated Dates
of Event
Program/Event Title
Funding Request
4.
Describe how your grant proposal meets and accomplishes the desired outcomes for Economic Development,
specifically to improve and advance the economic growth and prosperity of Coos County.
5.
If you do not receive the full amount of your request, describe how your organization would use a smaller amount of
funds.
6.
Describe what, if any, actions your organization takes in developing and securing other revenue sources beyond
the Coos County Economic Development grant funds.
7.
What percentage of your total annual revenue would come from this grant?
8.
What percentage of your organization’s total annual expenditures will go toward the grant activity/program/event
proposed in this application?
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9.
Describe your organization’s strategies and efforts to minimize administrative overhead costs for your organization
in general and for the specific programs, activities or events being applied for in this application, including
collaboration and/or leveraging of other partner organizations. What is your administrative overhead cost rate?
10.
Describe data collection and reporting systems that will be utilized for gathering the data for the outcomes on the
use of the grant funds.
ADDITIONAL SUBMITTAL REQUIREMENTS
If applicable, please include:
1) List of all Board members, their occupations, and years on the board.
2) Organizational Client Demographic Profile
3) Grant Program Budget (for activities/programs/events that are a part of this grant application)
4) 1 copy of your organization’s 501(c) letter verifying your non-profit status
5) 1 copy of your organization’s corporate bylaws
6) 1 copy of your organization’s most recent Form 990 IRS filing (summary page only)
7) 1 copy of your organization’s previous year financial statement summarizing expenses and revenues
8) Acknowledgement of ability and intent to provide the County with Certificate of General Liability Insurance in the
amount of $1,000,000 or more naming Coos County, its officers and employees as additional insured. See Insurance
Requirements, Attachment A. Only required once you are notified of pending award.
I understand and commit that, if awarded grant funding, our organization is able and willing to provide the insurance
certificate described above. I also understand that a final grant report will be required, and if not provided, my
organization will not be eligible for any future grant funding from Coos County.
Name (print)
_____________________________________
Name (signature)
_____________________________________
Title
_____________________________________
Incomplete Applications May Be Rejected
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Applicant Organization Board Member Information Reporting Sheet
Name
Address
Phone
Page 4
Occupation
Title
Years on Board
COOS COUNTY
GRANT PROGRAM BUDGET
Please use this page to identify the program within your organization that you are requesting
funds for.
APPLICANT/ORGANIZATION: _______________________________________________________________
PROJECT NO.: ______________
PROGRAM/EVENT TITLE: ______________________________
PROJECT PERIOD: _____ to _____. If not completed by proposed date, funding may be terminated.
REVENUE
Coos County Funds/Identify:
Other State or Federal Funds/Identify:
Other Funds/Identify:
$
$
$
$
$
TOTAL REVENUE
$
EXPENDITURES
A. PERSONAL SERVICES (List Employees by Position Title)
$
Total Salaries
% of time to project
1.___________________________________
______%
2.___________________________________
______%
3.___________________________________
______%
4.___________________________________
______%
Total Benefits
1.___________________________________
2.___________________________________
3.___________________________________
4.___________________________________
TOTAL PERSONAL SERVICES $
B. MATERIALS & SERVICES:
$
$
$
$
TOTAL MATERIALS & SERVICES $
C. CAPITAL OUTLAY (must constitute part or all of funded public service
$
activity to be eligible expense)
$
Equipment
Furnishings
Other capital expenses /Identify:
$
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TOTAL CAPITAL OUTLAY
$
$
TOTAL EXPENDITURES (Sum of A, B & C)
$
$
Page 6
Attachment A: Insurance Requirements
A.
CONTRACTOR shall not commence work under this Contract until it has furnished COUNTY with
satisfactory proof of the coverage of insurance as specified below:
1.
Workers’ compensation coverage as required by law with a Waiver of Subrogation in favor
of Coos County and to include employer’s liability with limits of not less than $1,000,000 per occurrence;
or, alternatively, CONTRACTOR shall provide documentation establishing that CONTRACTOR is exempt
from workers’ compensation coverage pursuant to ORS Chapter 656.
2.
General commercial liability coverage for damages as a result of death or bodily injury
(including personal injury) to any person’s destruction or damage to any property with limits of not less
than $1,000,000 each occurrence, $2,000,000 policy aggregate. Such coverage shall include, but is not
limited to, the following: commercial general liability coverage, products liability including completed
operations, premises operations including X (explosion), C (collapse), U (underground), broad form
property damage including fire fighting expense which is also known as “loggers’ broad form,” personal
injury. All coverage shall be on an occurrence basis and not on a claim made basis.
3.
Automobile liability insurance as a result of death or bodily injury to any persons, or
destruction of or damage to any property arising out of the ownership, maintenance, or use of any owned,
non-owned, or hired motor vehicle with limits of not less than $1,000,000 per occurrence. All coverage
shall be on an occurrence basis and not on a claim made basis.
4.
Excess/Umbrella Liability coverage as follows:
a.
If this is a contract for a public improvements, or personal services contracts with
architects, engineers, and land surveyors, then CONTRACTOR shall maintain an
excess/umbrella liability policy of not less than $1,000,000 each occurrence and aggregate
that will provide excess limits of liability over the commercial general liability, automobile
liability, employer’s liability, and professional liability.
b.
For contracts other than public improvements or personal services contracts with
architects, engineers, and land surveyors, an excess/umbrella liability policy is not
required, but may be used in conjunction with a general commercial liability policy to
satisfy the primary insurance limit requirements.
c.
All excess/umbrella liability coverage shall be on an occurrence basis and not on a
claim made basis.
5.
For personal services contracts, professional liability insurance, including errors and
omissions, with limits of not less than $2,000,000 per occurrence and $4,000,000 policy aggregate.
B.
The following inclusions to CONTRACTOR’S certificate of insurance shall be made:
1.
Waiver of transfer of rights of recovery against others to Coos County. The preferred form
is “CG 2404 05/09.”
2.
It is agreed that this insurance is primary to and non-contributory with any insurance
maintained by Coos County.
3.
The general liability coverage and automobile liability, if required, shall include
endorsements for additional insured, naming “Coos County, its elected officials, employees, agents, and
volunteers” as an additional insured. The additional insured endorsement shall be attached to the
certificate of insurance.
4.
The additional insured shall contain a severability of interest provision in favor of Coos
County and a Waiver of Subrogation in favor of Coos County.
5.
All required coverage shall be written with companies that have at least an AmBest rating
of B+ VII.
6.
The insurance shall provide a 30 day notice of cancellation or material change.
7.
For public improvement contracts or architectural, land surveying, or engineering
personal services contracts, CONTRACTOR shall carry the required insurance for at least three years after
acceptance of completed project.
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BOARD OF COMMISSIONERS
250 N. Baxter Street, Coquille, Oregon 97423
(541) 396-7535
FAX (541) 396-1010 / TDD (800) 735-2900
E-Mail: [email protected]
Robert “Bob” Main
John Sweet
Melissa Cribbins
LETTER OF UNDERSTANDING
Contribution to [RECIPIENT]
[INSERT RECIPIENT ADDRESS]
Dear [RECIPIENT]:
This letter shall serve as confirmation of the Coos County Board of Commissioners’ commitment, on behalf of Coos
County, to contribute $_________ from the County’s Economic Development Fund to [RECIPIENT], and of
[RECIPIENT]’s acknowledgment and agreement to the terms and conditions of the disbursement as set forth herein.
This contribution is to be used solely and exclusively for the purpose of _____________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________________________.
The County will provide the funds ___________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________.
[RECIPIENT] will _________________________________________________________________
__________________________________________________________________________________________________
________________________________________________________________.
The County reserves the right to audit or request additional documentation from [RECIPIENT] evidencing how funds
were expended. Additionally, the County may require the return of funds upon [RECIPIENT]’s refusal to permit an audit
or provide such documentation, or upon a determination in the County’s sole discretion that the funds were not used in a
manner consistent with this agreement.
COOS COUNTY
[RECIPIENT]
____________________________
John Sweet, Chair
_______________________________
Signature
____________________________
Robert “Bob” Main, Commissioner
_______________________________
Name
____________________________
Melissa Cribbins, Commissioner
_______________________________
Title
____________________________
Date
_______________________________
Date
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