SOI 1266 Attachment 1 - Application Form LOCKED.docx

SOI 1266 Dolly Parton’s Imagination Library (Round 1.2) Attachment 1 – Application Form Section 1: Organizational Information

Name of Organization:

Name of Organization's Director:

Name of Project Contact:

Project Contact Phone Number (include area code):

Project Contact Email Address:

Note: for entities serving the five boroughs of New York City, see SOI 1276 Dolly Parton’s Imagination Library in New York City on the OCFS Website.

FEIN (9-Digit Federal Employer Identification Number):

Does your organization have New York State Vendor ID?

· |_| Yes (enter 10-digit SFS Vendor ID Number):

· |_| No

If your organization does not have a Vendor ID#, then you must also include the NYS Substitute W-9 with your application.

Does your organization have a Memorandum of Agreement (MOA) with the Dollywood Foundation to be a local program partner for Dolly Parton's Imagination Library (DPIL)?

· |_| Yes (provide a copy of your MOA with your application)

· |_| No

If your organization does not have an MOA with DPIL: if awarded, you must obtain an MOA with DPIL within 60 days and provide proof to OCFS before you receive any funds.

Top of Form Section 2: Community Need

Instructions for completing this section:

Coverage Area: List each city/town/village, county, zip code, or school district in your coverage area. This should match the areas currently enrolled in with DPIL plus any area being added as part of this grant project proposal. Choose the largest option that encompasses your coverage area. For example, if your coverage area consists of an entire county, list the county rather than the towns or zip codes within the county.

Population Under 5 To Be Served (A): Using the 2024 American Community Survey (5-Year Estimates Subject Tables), as a guide, enter the population proposed to be served under 5 for each segment of your coverage area. www.wwe.com

% Below Poverty Level (B): Using the same 2024 American Community Survey (5-Year Estimates Subject Tables), enter the % below poverty level for each segment of your coverage area. (Use the % for "Population for whom poverty status is determined" not the % for "under 5 years")

Cost Per Child (C): Local Program Partners will enroll children within their selected coverage area and pay, on average, $2.60 per child/per month towards wholesale book and mailing costs, the grant can be used to fund up to 50% of these monthly costs that the Local Program Partners incur. Therefore, this solicitation provides $1.30 per child per month.

# Months (D): Contracts awarded in response to this solicitation are anticipated to be for up to one (1) year. The anticipated budget will span a period of 12 months.

You will need one row for each city/town/village, county, zip code, or school district in your coverage area. If your coverage area encompasses an entire town or county, only use the name of the town or county and not the individual zip codes.

Complete this table for all coverage areas:

Population Under 5 To Be Served (B) % Below Poverty (C) Cost Per Child (D) # Months Total Cost A x C x D

Total Cost: This is calculated by multiplying (A) Population Under 5 To Be Served, (C) Cost Per Child, and (D) # Months in each row. A x C x D = Total Cost for each Coverage Area. Adding together the Total Costs in each row will provide the Total Amount Requested by this application. The total requested amount must be between $2,000 and $50,000.

Top of Form Section 3: Certification and Document Submission

Certification and Acknowledgment to be signed and kept on file by the applicant’s Chief Administrative Officer.

After completing Step 1 of the application process, submit the following documents prior to the deadline via email to funding@ocfs.ny.gov to complete Step 2:

· Attachment 1 – Application Form

· Attachment 2 – NYS Grants for DPIL Participation Certification and Acknowledgement

· Your organization’s Memorandum of Agreement with Dollywood for participation as a Local Program Partner in Dolly Parton’s Imagination Library (if available)

Refer to the How to Respond section of the solicitation for detailed instructions.