6. Funding Acknowledgement Form.pdf
PDF 185 KB Posted
- Solicitation number
- 40DHHS-S3333
- Issued by
- Nevada
About this file
The Funding Acknowledgement Form is issued by the Nevada Department of Health and Human Services, specifically the Nevada Division of Public and Behavioral Health, Bureau of Behavioral Health Wellness and Prevention. The form is designed to document additional funding sources for projects related to behavioral health, substance use prevention, mental health services, and related programs. The form requires agencies to provide comprehensive details about their current funding sources, including various grants and funding streams such as the Substance Use Prevention Treatment and Recovery Services (SUPTRS) Block Grant, Mental Health Community Services Block Grant, Partnership for Success (PFS) Grant, State Opioid Response (SOR) Grant, and Opioid Settlement Dollars.
The document reveals multiple funding sources primarily from the Bureau of Behavioral Health Wellness and Prevention, with additional funding from entities like Funds for Resilient Nevada, county agreements, and Southern Nevada Health District. Notable funding sources include grants for specific focus areas such as Overdose Data to Action (OD2A), Projects for Assistance in Transition from Homelessness (PATH), and the Clinical High Risk Psychosis Program for Youth (CHR-P). The form requires agencies to certify the accuracy of their funding information, with a warning that misrepresentation could result in disqualification or termination of funding. The form provides space for agencies to list multiple funding sources, amounts, and additional notes, ensuring comprehensive financial transparency for behavioral health-related projects.
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Other files
| File | Type | Posted |
|---|---|---|
| 3. NV SUPTRS RFA Application.docx | DOCX document | |
| 4. Scope Template.docx | DOCX document | |
| 2. SUPTRS RFA Announcement Informational Resource.pdf | ||
| Quote Instructions.pdf | ||
| 5. Budget Template.xlsx | XLSX spreadsheet |
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Text version
Joe Lombardo Governor
Richard Whitley, MS
Director
Cody Phinney, MPH
Administrator
Ihsan Azzam, Ph.D., M.D.
Chief Medical Officer
FUNDING ACKNOWLEDGEMENT FORM
This form is designed to document any additional funding sources your agency is receiving for projects similar to the one being submitted. Please complete all sections accurately. This form will be requested annually to the Bureau of Behavioral Health Wellness and Prevention.
Section 1: Agency Information
• Agency Name: ____________________________________________
• Contact Person: __________________________________________
• Phone Number: ___________________________________________
• Email Address: ____________________________________________
Section 2: Project Information
• Name of the Project being funded: _____________________________________
• Brief Description of the Project: _____________________________
Section 3: Additional Funding Sources
Please provide information about any other funding your agency is receiving for projects similar to the one being submitted. Use additional sheets if necessary.
Checkmark Funding Source Funder Amount Name of Project Funded
Additional Notes
Substance Use Prevention Treatment and Recovery Services (SUPTRS) Block Grant
Bureau of Behavioral Health Wellness and Prevention
Mental Health Community Services Block Grant
Bureau of Behavioral Health Wellness and Prevention
Partnership for Success (PFS) Grant
Bureau of Behavioral Health Wellness and Prevention, or
OTHER
State Opioid Response (SOR) Grant
Bureau of Behavioral
Opioid Settlement Dollars
Funds for Resilient Nevada, Director’s Office of Department of Health and Human Services
Opioid Settlement Dollars
Funded through the County (One Nevada agreement)
State General Funds Bureau of Behavioral
Overdose Data to Action (OD2A) Grant
Bureau of Behavioral Health Wellness and Prevention, or through Southern Nevada Health District
Projects for Assistance in Transition from Homelessness (PATH)
Bureau of Behavioral
Clinical High Risk Psychosis Program for Youth (CHR-P)
Section 4: Certification
I certify that the information provided above is accurate and complete to the best of my knowledge. I understand that any misrepresentation of funding sources may result in disqualification or termination of funding.
• Authorized Representative Name: ____________________________
• Title: ____________________________________________________
• Signature: ________________________________________________
• Date: ____________________________________________________
| Agency Name: |
| Contact Person: |
| Phone Number: |
| Email Address: |
| Name of the Project being funded: |
| Brief Description of the Project: |
| Authorized Representative Name: |
| Title: |
| Date: |
| Check Box2: Off |
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| Check Box6: Off |
| Check Box7: Off |
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| Check Box11: Off |
| Check Box12: Off |
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| Signature15_es_:signer:signature: |
| Amount: |
| Project Funded: |
| Notes: |
| Funder: |
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