Applicant Transmittal Cover Page.pdf

Atlanta Regional Commission FY2026 Applicant Transmittal Cover

One2One Telephone Reassurance Program

*No individuals may apply*

Checklist of Required Items at Submittal:

☐ Signed Transmittal Cover Page

☐ Proposal Response Template

☐ Financial Components Workbook

☐ Organizational Chart with staff names, job titles and job descriptions

☐ DHS Pre Award Risk Assessment Form

☐ Copy of liability insurance for all programs and facilities

☐ Cost Share Policy

☐ Client Contribution Policy

☐ Complaint Policy and Procedures

☐ Most recent audit’s Financial Statement & Current Budget of Applicant Organization(s)

☐ Three references from entities that have previous or current business relationships with the applicant, wherein the role of the applicant in the relationship is clearly stated.

AGENCY NAME:

County:

Address:

City/State/Zip Code:

EXECUTIVE

DIRECTOR:

Email & phone:

FINANCIAL

CONTACT:

Email & Phone:

APPLICATION SIGNATURE:

I certify, to the best of my knowledge, that the information submitted in the attached proposal is true and accurate and that this organization has the necessary fiscal, data collection, and managerial capability to implement and manage the services bid on in this proposal in accordance with both federal regulations and Georgia Department of Human Services, Division of Aging regulations.

Signature Date

Printed Name and Title