DHCS Application Checklist.docx

Delta Health Care Service Grant 2017

Application Checklist Program requirements are detailed in the Notice of Funding Availability and the information contained in the Application Guide.

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

Required Forms ☐ Form SF 424, “Application for Federal Assistance” ☐ Form SF-424A “Budget Information – Non-Construction Programs” ☐ Form SF-424B “Assurances- Non-Construction Programs” ☐ Form AD-3030, “Representations Regarding Felony Conviction and Tax Delinquency Status for Corporate Applicants” (required only for corporate applicants)

Construction Applications Must Include:

☐ Form SF 424, “Application for Federal Assistance” ☐ Form SF-424C “Budget Information - Construction Programs” ☐ Form SF-424D “Assurances- Construction Programs” ☐ RD Form 1940-20 “Request for Environmental Information” ☐ Form AD-3030, “Representations Regarding Felony Conviction and Tax Delinquency Status for Corporate Applicants” (required only for corporate applicants)

Section 1. Project Abstract ☐ Legal Name of Lead Applicant – Consortium Partner 1 ☐ Lead Applicant DUNS Number ☐ Lead Applicant SAM Registration CAGE Code and Expiration Date ☐ Lead Applicant Employer Identification Number (EIN) ☐ Legal Name of Consortium Partner 2 ☐ Legal Name of Consortium Partner 3 ☐ Additional Consortium Partners Included in Appendices ☐ Applicant Type ☐ Purpose ☐ Requested Grant Amount ☐ Proposed Grant Period Start & End Date ☐ Brief Summary of the Proposed Project

Section 2. Executive Summary ☐ Description of your proposed project, not to exceed two pages

Section 3. Evidence of Eligibility ☐ Legal Authority and Existence – Appendix B ☐ Consortium Located in the Delta Region ☐ Project Area Located in a Rural Community ☐ Multiple Grant Eligibility – Appendix C ☐ Currently Active DHCS Award – Appendix C ☐ Certification of 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 4. Consortium Agreement ☐ Agreement between all Consortium members. – Appendix D

Section 5. Scoring Documentation ☐ Rurality of the Project and Communities Served ☐ Community Needs and Benefits Derived ☐ Project Management and Organizational Capability

Section 6. Work Plan & Budget ☐ Specific Activities ☐ Line Item Costs; Including Grant Funds and Other ☐ Key Personnel Involved with Each Activity ☐ Specific Time Frames for Completion of Each Tasks

Section 7. Financial Information and Stability ☐ Financial Information and Stability – Appendix E

Section 8. Evidence of Input Solicited from Local Stakeholders ☐ Evidence of Input Solicited form Local Stakeholders – Appendix F

Section 9. Matching Funds ☐ Matching Funds

Section 10. Service Area Maps ☐ Service Area Maps – Appendix H

Appendices ☐ Appendix A – Additional Consortium Members ☐ Appendix B - Legal Responsibility and Authority ☐ Appendix C - Certifications ☐ Appendix D – Consortium Agreement ☐ Appendix E – Financial Information and Sustainability ☐ Appendix F – Evidence of Input from Local Stakeholders ☐ Appendix G – Documentation for Verification of Matching Funds ☐ Appendix H – Service Area Maps