DHCS 2022 Application Template-Guide.docx

Delta Health Care Services Grant Program 2022

Delta Health Care Services Grant 2022

APPLICATION GUIDE

Table of Contents

Program Overview

The Delta Health Care Services Grant Program is authorized under Section 379G of the Consolidated Farm and Rural Development Act, as amended.

The Delta Health Care Services Grant Program is designed to provide financial assistance to address the continued unmet health needs in the Delta Region, through cooperation among non-profits, health care professionals, institutions of higher education, research institutions, and other entities in the Delta Region. Grant funds may be utilized for the development of health care services; health education programs; health care job training programs; and for the development and expansion of public health-related facilities in the Delta Region.

Before You Get Started

Please read the Notice published in the Federal Register on May 13, 2022. A copy is available at the Agency Web site:

http://www.rd.usda.gov/programs-services/delta-health-care-services-grants

This Application Guide is intended to provide practical step-by-step help to assist applicants through the process. However, should anything in this guide appear to conflict with the Notice, the Notice takes precedence.

While using this Application Guide is not required, applicants are highly encouraged to utilize it.

Checklist Program requirements are detailed in the Notice and the information contained in this guide.

Before you submit your application, please ensure that you have addressed all the following elements.

Required Forms (see links below for fillable forms) ☐ Form SF 424, “Application for Federal Assistance” ☐ Form SF-424A “Budget Information – Non-Construction Programs”

Construction Applications Must Include:

☐ Form SF 424, “Application for Federal Assistance” ☐ Form SF-424C “Budget Information - Construction Programs” ☐ RD Form 1940-20 “Request for Environmental Information”

Section 1. Executive Summary ☐ Description of your proposed project, not to exceed one page

Section 2. Evidence of Eligibility ☐ Legal Authority and Existence – Appendix B ☐ Consortium Located in the Delta Region ☐ Certification – Multiple Grants (Appendix C) ☐ Certification – Currently Active DHCS Grant (Appendix C) ☐ Certification – Federal Judgements (Appendix C) ☐ Applicant Type ☐ Lead Applicant- Consortium Partner 1 ☐ Consortium Partner 2 ☐ Consortium Partner 3 ☐ Indicate Eligibility of Additional Consortium Partners Individually

Section 3. Consortium Agreement ☐ Agreement between all Consortium members. – Appendix D

Section 4. Scoring Criteria ☐ Community Needs and Benefits Derived ☐ Project Management and Organizational Capability ☐ Work Plan and Budget ☐ Local Support ☐ Administrator Discretionary Points

Section 5. Financial Information and Stability ☐ Financial Information and Stability Narrative ☐ Financial Statements – Appendix E

Appendices ☐ Appendix A – Additional Consortium Members ☐ Appendix B - Legal Authority and Existence ☐ Appendix C – Certifications ☐ Appendix D – Consortium Agreement ☐ Appendix E – Financial Information and Sustainability – Financial Statements ☐ Appendix F – Documentation for Local Support ☐ Appendix G – Documentation for Verification of Matching Funds (If applicable) ☐ Appendix H – Service Area Maps

Required Standard Forms

All SF Forms https://www.grants.gov/web/grants/forms/sf-424-family.html

RD FORM 1940-20, “Request for Environmental Information” http://www.rd.usda.gov/files/IA_1940-20.pdf

Important Application Resources

SAM Registration Cage Code or evidence of having begun registration process. Register at no charge

Application Template

SECTION 1: EXECUTIVE SUMMARY OF PROJECT

[Insert a description of your project containing the following information; 1) legal name of lead applicant, 2) consortium members, 3) applicant type (including consortium members) 4) application type (development of health care services, health education programs, health care job care training programs, or the development and/or expansion of health related facilities, 5) and a summary of your project and tasks to be completed. Limit one page.]

SECTION 2: EVIDENCE OF ELIGIBILITY

Use Section A. Program Description of the Notice, “Definitions”, to address this section. Certify the following by reading and checking the following statements:

2.1 Evidence of Legal Authority & Existence

☐ We have or can obtain the legal authority to carry out the purpose of the grant and are in good standing in the State where our business is incorporated and/or in the State that is the primary location of our business operations for the DHCS project.

☐ In Appendix B, please attach a copy of, or excerpt from your organizational documents showing legal authority to carry out the purpose of the grant on behalf of your organization, along with a Certificate of Good Standing or letter from a State agency or equivalent authority.

2.2 Located in the Delta Region

[Insert a discussion demonstrating that each Consortium member is located in the Delta Region as defined in Section A of the Notice.]

2.3 Multiple Grant Eligibility

Applicants (including its members) may not submit more than one application for funding under this Notice. We will NOT accept applications from Consortiums that include members who are also members of other Consortiums that have submitted applications for funding under through this program.

☐ In Appendix C, each Consortium member must certify that it is submitting only one application in response to the Notice.

2.4 Currently Active DHCS Award

If the lead entity, or any of its Consortium members, has an existing DHCS award, it must be performing satisfactorily to be considered eligible for a funding through this program. Satisfactory performance includes, but is not limited to, being up-to-date on all financial and performance reports and being current on all tasks as approved in the work plan.

☐ In Appendix C, each Consortium member must certify if it currently has an active DHCS award.

2.5 No Current Outstanding Federal Judgements

☐ In Appendix C, each Consortium member must certify that it does not have any outstanding judgements against it.

2.6 Applicant Type

[Insert a discussion demonstrating how each Consortium member meets the definition of an eligible entity (academic health and research institute, economic development, or regional institution of higher education) as defined under the Definitions of the Notice.]

Example: Lead Applicant (Consortium Member 1), a non-profit organization located in Anywhere, Alabama, is an economic development entity with a mission to support, represent and promote the local business community while enhancing successful partnerships that are vital to the region. Lead Applicant’s goal is to relieve unemployment in the State, encourage the increase of business activity and commerce and a balanced economy in low and moderate income communities throughout Anywhere County. Our nutrition services business incubation program has graduated 9 companies and supported 244 employees...

SECTION 3: CONSORTIUM AGREEMENT

Your Consortium agreement must be included in Appendix D. Agreements must include the following (at minimum):

☐ Legal name of each consortium member partnering on the project ☐ Negotiated arrangements for administering the project ☐ Consortium member’s responsibilities to comply with administrative, financial and reporting requirements of the grant ☐ Signature of the authorizing official from each Consortium member

A sample agreement is included in Appendix D.

SECTION 4: SCORING CRITERIA

The Agency will select and rank applications for funding based on the score an application has received in response to the Scoring Documentation. For each criterion, you must demonstrate how the project has merit and provide rationale for the likelihood of success. Responses that do not address all aspects of the criterion in a meaningful way, or that do not convey relevant project information will receive lower scores. DHCS is a competitive program, so your responses will be evaluated on the quality of each response. Simply providing an answer will not guarantee higher scores. The maximum number of points that will be awarded to an application is 110. The minimum score necessary to receive funding is 60 points. You must review the Notice at section E.1. for a detailed description of the graduated scoring thresholds for each criterion.

4.1 The Community Needs and Benefits Derived from the Project (0-30 points)

This section should document how the Project will meet the communities need for health services and public health related facilities and specifically describe the benefits to the people living in the Delta Region. It should lead clearly to the identification of the Project participant pool and the target population for the Project and provide convincing links between the Project and the benefits to the community to address its health needs.

(1) Describe the Health care needs/ issues/challenges facing the service area and explain how the identified needs/issues/challenges were determined. Discussion should also identify problems faced by the residents in the region.

[Insert Description]

(2) Discuss the proposed assistance to be provided to the service area and how the Project will benefit the residents in the region.

[Insert Description]

(3) Explain how the project will be implemented and provide milestones which are well-defined and can be realistically completed.

[Insert Description]

(4) Discuss expected outcomes of the proposed Project and how they will be tracked and monitored. You should attempt to quantify benefits in terms of outcomes from the Project; that is, ways in which peoples’ lives, or the community, will be improved. Provide estimates of the number of people affected by the benefits arising from the Project.

0. How many businesses assisted as a result of the project? Click here to enter text.

0. Number of jobs expected to be created _______ or saved ________

0. Number of individuals assisted ________ or trained ________

It is permissible to have a zero in a performance element. When you calculate jobs created, estimates should be based upon actual jobs to be created by your organization as a result of the DHCS funding or actual jobs to be created by businesses as a result of assistance from your organization. When you calculate jobs saved, estimates should be based only on actual jobs that have been lost if your organization did not receive DHCS funding or actual jobs that would have been lost without assistance from your organization.

You can also suggest additional performance elements for example where job creation or jobs saved may not be a relevant indicator. These additional criteria should be specific, measurable performance elements that could be included in an award document.

4.2 Project Management and Organizational Capability (0-30 points)

This section should document the project’s management and organizational capability. The Agency will evaluate the applicant’s experience, past performance, and accomplishments addressing health care issues to ensure effective project implementation.

1) Describe the organization’s management and fiscal structure including: well-defined roles for administrators, staff, and established financial management systems. Applicant is encouraged to describe the actual financial system used in managing funds.

[Insert Description]

2) Describe the qualifications, capabilities, and educational background of the identified key personnel (at a minimum the Project Manager) who will manage and implement programs and how they will contribute to the success of the project.

[Insert Description]

3) Describe the applicant’s current successful and effective experience (or demonstrated experience within the past five years) addressing the health care issues in the Delta Region.

[Insert Description]

4) Describe the applicant’s experience managing grant-funded programs. Applicant should provide a list of current and past grants, and an indication of whether the grants are still open or if they have been successfully closed.

5) Describe how administrative/management costs are balanced with funds designated for the provision of programs and services. Applicant should provide a clear description of the percentage of funds being used for administrative vs. programmatic costs.

6) Detail the extent and depth of membership in the applicant’s Consortium of regional institutions of higher education, academic health and research institutes and economic development entities located in the Delta Region, providing a detailed description of the roles of each member.

[Insert Description]

4.3 Work Plan and Budget (0-30 points)

Provide a detailed work plan and budget below that shows how the project’s goals will be accomplished in accordance with the requirements in the NOTICE, including:

1. the specific activities, such as programs, services, trainings, and/or construction-related activities for a facility to be performed under the Project;

2. the estimated line item costs associated with each activity, including grant funds and other necessary sources of funds;

3. the key personnel who will carry out each activity (including each Consortium member’s role); and

4. the specific time frames for completion of each activity.

An eligible start and end date for the Project and for individual Project tasks must be clearly shown and may not exceed Agency specified timeframes for the grant period. You must show the source and use of both grant and other contributions for all tasks.

a. Insert Work Plan narrative here (upload additional pages as needed):

[Insert work plan narrative]

b. Project Budget Summary

Summarize the total project budget by task. Insert additional rows as needed. Sample included below.

TOTAL PROJECT

c. Task Budget Format

Provide a budget table for each task that will be completed for each main activity listed above.

Edit budget categories and add additional task tables as needed.

Task #1 Example Budget Categories

DHCS

Grant Funds Cash Contributions Total

Personnel

Fringe Benefits

Travel

Office Equipment

Supplies

Contractual

Other

Provide explanation/clarification for each task budget, including the basis for budget figures:

[Insert task budget explanation]

4.4 Local Support (0-10 points)

Your discussion should include documentation detailing support solicited from local government, public health care providers, and other entities in the Delta Region. Evidence of support can include;

but is not limited to surveys conducted amongst Delta Region residents and stakeholders, notes from focus groups, or letters of support from local entities. The letter/surveys/supporting documentation should be included in Appendix F. Summaries should include date of the letter and name and position of the author. Surveys should include dates the surveys were conducted, survey questions, results of the survey and demographic of the participants included in the survey. You will score higher if you demonstrate strong support from potential beneficiaries and other developmental organizations.

[Insert Discussion]

4.5 Administrator Discretionary Points (0-10 points)

The Administrator may choose to award up to 10 points to support geographic distribution of funds and/or key priorities as follows (more details available at https://www.rd.usda.gov/priority-points):

• Assisting rural communities recover economically from the impacts of the COVID-19 pandemic, particularly disadvantaged communities (3 points),

• Ensuring all rural residents have equitable access to RD programs and benefits from RD funded projects (3 points); and

• Reducing climate pollution and increasing resilience to the impacts of climate change through economic support to rural communities (3 points).

Applicants that provide a clear and comprehensive response to how they are addressing the Administration’s priorities (1 point)

[Insert Discussion]

SECTION 5: FINANCIAL INFORMATION & SUSTAINABILITY

You must provide a narrative description demonstrating sustainability of the project, detailing sufficient resources and expertise to undertake and complete the project and how the project will be sustained following completion. Current financial statements and 3-years of pro-forma statements must be included in Appendix E.

[Insert Narrative Description]

☐ Current financial statements included in Appendix E.

☐ Balance Sheet (Most Current) ☐ Income Statement (Most Current) ☐ Audited Financial Statement (Most Current) ☐ 3-years pro-forma statements include in Appendix E.

PROCEED TO APPENDICES

Delta Health Care Services Grant Program 2022

APPENDICES

APPENDIX A: Additional Consortium Members Please feel free to continue to add as necessary.

Legal Name of Consortium Member 4: Click here to enter text.

Applicant Type:

☐Academic Health & Research Institute ☐Economic Development Entity ☐Institution of Higher Education

Legal Name of Consortium Member 5: Click here to enter text.

Applicant Type:

☐Academic Health & Research Institute ☐Economic Development Entity ☐Institution of Higher Education

Legal Name of Consortium Member 6: Click here to enter text.

Applicant Type:

☐Academic Health & Research Institute ☐Economic Development Entity ☐Institution of Higher Education

Legal Name of Consortium Member 7: Click here to enter text.

Applicant Type:

☐Academic Health & Research Institute ☐Economic Development Entity ☐Institution of Higher Education

APPENDIX B: Evidence of Legal Authority and Existence Please attach evidence of Legal Authority and Existence (Examples: By-Laws, Articles of Incorporation or Organization, Letter or Certificate of Good Standing from your Secretary of State or equivalent agency).

APPENDIX C: Certifications

Each Consortium Member Must Certify the Following:

We, [Insert Name of Consortium Member], certify the following to the best of our knowledge and belief, that:

Multiple Grant Eligibility

☐We are submitting only one application in response to this solicitation.

Currently Active Delta Health Care Service Award

☐We DO NOT have a currently active DHCS grant with unused funds.

OR

☐We DO have a currently active DHCS grant with unused funds and are performing satisfactorily, as defined in Section C.3.f. of this Notice.

☐Scheduled completion date of currently active DHCS grant: Click here to enter a date.

Certification of Federal Judgements

☐ The United States has not obtained an unsatisfied judgment against my property and we will not use grant funds to pay any judgments obtained by the United States.

Print Name of Consortium Authorized Representative: _______________________________________________

Title of Consortium Authorized Representative: _____________________________________________________

Signature of Consortium Member Authorized Representative: _______________________________________________ Date: ________________

APPENDIX D: Consortium Agreement

CONSORTIUM AGREEMENT TEMPLATE

This Agreement, which includes any referenced attachments, is made among the organizations listed below.

[INSERT NAME OF LEAD APPLICANT/MEMBER 1], whose registered office is at [insert address]; and

[INSERT NAME OF MEMBER 2], whose registered office is at [insert address]; and

[INSERT NAME OF MEMBER 3], whose registered office is at [insert address].

These organizations will be referred to individually as a “Member” and collectively as “Members” throughout this Agreement.

I. Purpose. The purpose of this Agreement is to specify the responsibilities of the Consortium Members in carrying out the Project, to identify the rights and obligations of the Members, and to complete the Project, including producing deliverables, as described in Attachment A – Work Plan.

II. Duration. This Agreement shall commence on the Effective Date and continue until the completion of the Project on [INSERT DATE]. The duration of this Agreement may be extended beyond the completion date, at any time prior to that date, by written agreement of the Members.

III. Definitions. The following terms are defined for this Agreement.

Confidential Information means all information that is marked as Confidential and is disclosed by one Member to the others for the purpose of completing the Project. It includes, but is not limited to, the following: ideas, financial information, marketing information, work plans, computer systems and software, products and services, records, reports, documents, papers, and any other materials that are generated through work on the Project.

Consortium means the Members collectively.

Effective Date means the date when all members have signed this Agreement.

Lead Institution means the Member who is designated in Section IV of this Agreement. This Member is authorized as the Consortium’s agent to sign agreements in the Consortium’s name and on behalf of the Project in accordance with Section IV of this Agreement.

Project means the work described in Attachment A – Work Plan.

Project Manager means the person appointed by the Lead Institution to run the day-to-day operation of the Project and report directly to the Lead Institution.

Personnel means any employee, director, agent, contractor, or other individual engaged by a Member.

IV. Lead Institution. The Lead Institution for this Agreement is designated as [INSERT NAME OF LEAD APPLICANT]. The Lead Institution is responsible for the following:

· Taking all reasonable steps to seek and obtain the prior approval of each of the other Members before signing agreements for the benefit of the Project;

· Monitoring Project progress and notifying other Members of any concerns in meeting progress goals;

· Ensuring completion of Project tasks by assigning tasks to other Members, completing tasks with its Personnel, and/or by contracting with qualified individuals on behalf of the Consortium;

· Providing deliverables to USDA/Rural Development and other funding partners as required by any financial assistance agreements related to the Project;

· Submitting all progress, performance, and financial reports to USDA/Rural Development and other funding partners as required by any financial assistance agreements related to the Project;

· Appointing a Project Manager; and

· Managing the Project’s finances in accordance with appropriate accounting principles, applicable State and Federal laws and regulations, and any financial assistance agreements related to the Project.

V. Project Resources.

A. Allocation of Funds. The chart below lists the funds contributed to the Project.

B. Distribution. Funds for the Project that are received from non-Consortium organizations will be paid to the Lead Institution and then distributed to Members as needed to carry out the Project as described in Attachment A – Work Plan. When necessary, the Lead Institution will also be responsible for receiving contributions from Members to pay for Project expenses.

C. Invoicing. When allowable costs are incurred by Members, an invoice should be submitted to the Lead Institution as soon as they have been paid. Supporting documentation for the costs should be included with the invoice.

VI. Responsibilities of the Members. The Members agree to undertake the following:

· To procure and maintain its own liability insurance, to cover the Member’s liabilities and those of its Personnel;

· To comply with and to assist the Lead Institution with compliance with all applicable laws, regulations, and financial assistance agreements related to the Project;

· To indemnify and hold harmless the other Members from and against all costs, liabilities, injuries, direct, indirect or consequential loss (all three of which terms include, without limitation, pure economic loss, loss of profits, loss of business, depletion of goodwill and like loss), damages, claims, demands, proceedings or legal costs (on a full indemnity basis) and judgments which they incur or suffer as a result of a breach of this Agreement or negligent acts or omissions or willful misconduct of the Member and/or its Personnel including without limitation any resulting liability the Consortium has to the funder or to any third Member;

· To provide appropriate facilities and services as necessary to achieve proper performance of the Member’s assigned tasks;

· To provide Personnel, as needed, to perform assigned tasks and to attend Project-related meetings;

· To complete the tasks assigned to it by the Lead Institution and any other obligations under this Agreement;

· To provide all information, such as financial records and progress reports, needed by the Project Manager and Lead Institution to fulfill the obligations incurred by this Agreement;

· To notify each of the other Members when the Member becomes aware of any significant delay in performance;

· To inform each of the other Members when a Member receives relevant communications from a third Member about the Project;

· To ensure the accuracy of any information it provides under this Agreement, to the best of the Member’s ability; and

· To avoid issuing press releases or other publicity materials relating to the Consortium and/or the Project without obtaining prior approval from the other Members.

The signatories below certify that they have authority to enter into this Agreement.

Approved by an Authorized Representative of [INSERT NAME OF MEMBER 1]:

______________________________________________________________________________Name (Please Print) _____________________________________________________________________________Title (Please Print)

Signature Date

Approved by an Authorized Representative of [INSERT NAME OF MEMBER 2]:

______________________________________________________________________________Name (Please Print) _____________________________________________________________________________Title (Please Print)

Signature Date

Approved by an Authorized Representative of [INSERT NAME OF MEMBER 3]:

______________________________________________________________________________Name (Please Print) _____________________________________________________________________________Title (Please Print)

Signature Date

ATTACHMENT A – WORK PLAN

APPENDIX E: Financial Information & Sustainability Attach copies of the lead applicant’s current financial statement as well as 3-years of pro-forma financial statements for the project.

APPENDIX F: Documentation - Local Support

In this section, attach copies of letters of support, surveys and/or other documentation demonstrating support of the project from local stakeholders in the Delta Region.

APPENDIX G: Documentation for Verification of Matching Funds

Documentation verifying matching funds must be included in your application. If grant funds are awarded, this information will be re-verified upon execution of the grant agreement. Verification Templates are included in this Application Guide for each type of contribution to the project, and you may select the template(s) appropriate for your project: 1) Applicant cash; 2) Applicant approved loan or line-of-credit; and/or 3) Third-Party cash.

If you have questions about your project budget or eligible use of grant and/or matching funds, please contact your Rural Development State Office. Contact information is available for each state at http://www.rd.usda.gov/contact-us/state-offices.

APPENDIX G.1 Verification of Matching Funds (Other Contributions): Applicant Cash

The use of this form is optional, but highly recommended. If the applicant is contributing cash-on-hand to pay for goods and/or services during the grant period that are eligible expenses for the project, the expenditure is considered as a “matching fund”. The applicant must sign this statement to verify (a) the amount of cash contribution, (b) the source of the cash contribution and (c) use of the cash contribution. A copy of a bank statement with an ending date within one month of the application submission deadline and showing an ending balance equal to or greater than the amount of Cash Contribution proposed is also required at time of application (note: please redact any account numbers appearing on your statement).

Legal Name of Applicant: _______________________________________________________________

Title of Applicant’s DHCS Project: ________________________________________________________

Total Project Cost: $____________ DHCS Grant Request: $_____________ Total Applicant Cash Contribution: $_____________

Identify all source(s), amounts, and uses of Applicant Cash Contribution that your organization currently has available and committed to eligible DHCS project expenditures during the grant period proposed in the SF424 form and Section 6. Include a copy of an account statement from each source dated within 30 days of the application submission showing an ending balance equal to or greater than the amount of Cash Matching Funds proposed.

Checking Account

Savings Account

Certificate of Deposit

Money Market

Mutual Funds

Other

Total Cash

Has your organization formally approved the Cash Contribution and Purpose at time of application?

☐Yes ☐ No ________________Date of Approval ☐ ______N/A

Print Name of Applicant/Authorized Representative: _________________________________________________

Title of Applicant/Authorized Representative: _______________________________________________________

Signature of Applicant or Authorized Representative: ______________________________________________ Date: ________________

APPENDIX G.2 Verification of Matching Funds (Other Contributions): Applicant Approved Loan or Line of Credit

Use of this form is optional, but highly recommended. Ask your lending institution to provide all of the information below, at time of application, to verify your approved Loan or Line of Credit that will be used as matching funds for your DHCS project during the grant period proposed in the SF424 form and Section 6 – Work Plan and Budget.

For purposes of facilitating the Work Plan and Budget Activities identified in the associated DHCS application, and as an Authorized Representative of the lending institution identified below, I verify and confirm the following information:

Legal Name and Address of Lender Providing Loan or Line of Credit for Delta Health Care Service Grant Matching Funds:

Legal Name and Address of Intended Recipient/Borrower of Loan DHCS application:

Total Amount of Loan or Line of Credit to be Used for Eligible DHCS Project Purposes: $____________

Brief Description of Borrower’s Use of Loan/LOC Funds: [Insert description]

Will the Loan or Line of Credit be provided to the Borrower during the proposed grant period, or on a specific date within the proposed grant period? ☐Yes ☐ No

Date(s) of Transfer or Availability of the Funds to Borrower (month/day/year): ________________

Date of Loan/LOC Approval ____________________ ☐ N/A

Print Name of Authorized Representative for Lending Institution: ____________________________________________________________________________

Title of Authorized Representative: __________________________________________________________________

Signature of Authorized Representative: _____________________________________________ Date: _________

APPENDIX G.3 Verification of Matching Funds (Other Contributions): Third-Party Cash

The use of this form is optional, but highly recommended. The Third-Party contributor must complete and sign where indicated to verify the (a) amount of cash to be donated, and (b) when it will be donated, indicating specific dates (month/day/year) corresponding to the grant period proposed in the SF424 form and Section 6-Work Plan and Budget, or to dates within the grant period, when matching funds will be made available to the project.

For purposes of facilitating the Work Plan and Budget Activities identified in the associated FY2020 Delta Health Care Services Grant (DHCS) application, and as an Authorized Representative of the third-party organization identified below, I verify and confirm the following information:

Legal Name and Address of Third-Party providing Matching Funds:

Legal Name of Intended Recipient of Third-Party CASH Match:

Total Amount of Third-Party CASH Contribution Match to be Donated for Eligible DHCS Project Purposes:

Will the Third-Party CASH Match be provided to the Intended Recipient during the proposed grant period?

☐Yes ☐ No

Dates of Transfer/Availability___________________ (month/day/year)

Name of Financial Institution currently holding Third-party cash match to be transferred to Intended Recipient: __________________________________________________________________

Does your organization understand that cash matching funds from third-parties cannot be used to provide services which directly benefit the third-party contributor, and that contributors of cash matching funds may not limit how or where the funds are used? ☐Yes ☐ No

Has your organization approved the Third-Party CASH transfer amount and DHCS general purpose?

☐ Yes ☐ No Date of Approval______________ ☐ N/A

Print Name of Authorized Representative For Third-Party Organization: ___________________________________________________________________

Title of Authorized Representative: _______________________________________________________________

Signature of Authorized Representative: ____________________________________ Date: _________________

APPENDIX H: Service Area Maps Attach maps with sufficient detail to show the area that will benefit from the proposed services and/or facilities and the location of the facilities improved or purchased with grant funds (if applicable).

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