DHCS FY 18 Application Checklist.pdf

USDA is an equal opportunity provider, employer and lender.

DELTA HEALTH CARE SERVICE GRANT PROGRAM 2018

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 (see links below for fillable 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. 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

USDA is an equal opportunity provider, employer and lender.

☐ 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