APEX Accelerator Streamlined Application_Version 2.0- June 2024.pdf

Streamlined Application

Applicant Name

Applicant Unique Entity Identifier

Applicant Address

Applicant Point of Contact

By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S.

Code, Title 18, Section 1001).

** I Agree

Authorized Representative Name Title Signature

Attachment 1- Certification of Cost Matching Funds APEX Program

This form is to certify that matching funds as described below are available at the program level and committed to the proposed program during the proposed performance period starting and ending

Total contribution from the applicant:

Total in-kind from third parties:

Total contributions (from all sources):

1. For each individual third-party donor, list the value of the in-kind donation

Name of Third-Party Contributor Value of In-kind

2. The undersigned certifies that no federal funds are being used as match, except those that are specifically authorized by law to be used as match and that the APEX Accelerator is not part of any other federal award program.

3. The undersigned certifies that in-kind that has been used as match on any other program requiring cost match has not been used as cost match on this program.

4. The undersigned certifies that APEX Accelerator clients, counseling hours, events, and contract award achievements are not reported as achievements of any other federal award.

APEX Name:

Signature:

Name:

Title:

Date:

Attachment 2- Third Party Letter of Commitment APEX Accelerator Program

Third Party Letters of commitment are provided for the below entities.

Entity Name Entity Unique Identity Number

Combine all third-party letters into a single PDF, and Attach here ATTACH

ATTACH

Attachment 3- Fringe Rate Basis

In the space below, provide information to describe and provide a basis for fringe benefit amounts included in your budget. Simply stating what the rate is (e.g., 30%) does not adequately fulfill this requirement. Where fringe benefit rates have been approved in conjunction with an indirect cost rate, the negotiated rate memorandum should be provided, and no further explanation is necessary. Attach any supporting information as necessary.

Provide any supporting information for Fringe Rate Basis here

Provide support for any subawards greater than 20% of the total program cost by attaching documentation here

Attachment 4- Indirect Costs Indirect Costs are:

Not proposed for the program year

Proposed at the de minimis rate

In accordance with a negotiated rate memorandum from the cognizant Federal Agency

- Attach negotiated rate memorandum here

Independently proposed.

If “independently proposed” is selected above, utilize the space provided below to justify why the indirect rate is reasonable and realistic. The applicant shall include forecasted pools and bases for the current year. Additionally, the applicant shall support these rates with three (3) years historical actual pools and bases information that validates the calculations. Attach any supporting information as necessary

Provide any additional supporting documentation here

Provide support for any subawards greater than 20% of the total program cost by attaching documentation here

Attachment 5- Distressed Area Analysis

A distressed area Budget is:

Not proposed for the program year.

Is proposed for the current program year.

Is proposed and designated by BIA regions (No analysis required)

If “is proposed” is selected above, utilize the space provided below to provide an analysis verifying that your proposed service area meets the definition of a distressed area.

Provide any additional supporting documentation here ATTACH

Attachment 6- Determination of Statewide Coverage

Statewide Coverage is:

Not proposed for the program year.

Is proposed for the current program year and will cover the entire state.

Is proposed for the current program year but will NOT cover the entire state.

If you propose a statewide program but will cover less than the entire state, utilize the space provided below to provide an analysis to verify that your service area meets the definition of statewide coverage.

Provide any additional supporting documentation here ATTACH

Attachment 7- Program Execution Plan Attach your program execution plan in either Microsoft word or Adobe PDF describing how you will comply with the “Program Requirements” section of the APEX Accelerator Award Specific Terms and Conditions.

Include all information necessary for us to conduct an evaluation of your application.

Ensure the below information is specifically addressed in the description.

1. Background on the individual program

2. Discussion on service area/demographics and facilities, trends in the service area

3. Personnel Qualifications: experience and education

4. Discussion on how you will reach your goals using various types of outreach and technical assistance.

5. Describe the process of technical assistance/counseling.

6. Describe your program implementation plan, if applicable. Applicants who are not current APEX Accelerators must have a program implementation plan.

Program Income is:

Not proposed for the program year (if checked, move onto attachment 8)

Is proposed for the program year (If checked, respond to prompts on next page)

1. Include a discussion concerning the amount of fees to be charged and how this income will be used to further program objectives.

2. Provide your assertion of your understanding that you are required to report gross income on the SF 270 and SF 425

I understand.

3. Are you proposing to utilize program income as part of the applicant cost share?

Yes No

4. If yes, provide a narrative detailing how you will ensure compliance with:

a) The Award Specific Terms and Conditions percent cap on the value of program income that may be applied as the cost match.

b) The statutory limitations at 10 U.S.C 4955(d) related to program income utilized in a subsequent fiscal year.

Attach Program Execution Plan and Program Income Discussion Here ATTACH

Attachment 8- Program Manager Resume

If the Program manager is different from previous fiscal year award, provide their resume via attachment here

Attachment 9- Single Audit Act

Attach a copy (or URL) of your latest audit in accordance with Subpart F of 2 CFR Part 200 (formerly OMB Circular A-133). Attach Audit here

If available, you may provide the URL (i.e., web address) of an audit that is available on the internet in lieu of attaching a copy. Link:

If you did not expend Federal awards exceeding the thresholds that trigger these audit requirements, describe the amounts and sources of Federal awards that you did expend during your last fiscal year.

Attachment 10- Personnel Costs

Support for personnel costs is provided through submission of:

a. Published Salary Data, with information mapping to position title in proposal

- Attach supporting documentation here

b. Payroll records and/or paystubs showing rate of pay and referenced to the specific personnel or position title in the proposal.

- Attach supporting documentation here

c. Salary Survey data, which shall include, at a minimum, the following

i. Source of data;

ii. Job title and description;

iii. Geographic location; and

iv. Range of salary amounts with reference to applicability of amounts

- Attach supporting documentation here

Note- For any subawards greater than 20% of the total program cost, provide justification for the Personnel Costs proposed in accordance with the above instructions.

ATTACH