SUBGRANT FORM MDCPS-SCSS-1002.xls
XLS spreadsheet 138 KB Posted
- Attached to
- 1661-25-R-RFQF-00008
- Solicitation number
- 3140004260
- Issued by
- Mississippi
About this file
This is a Subgrant Signature Sheet from the Mississippi Department of Child Protection Services (MDCPS), a state-level government document for a potential subgrant agreement. The document appears to be a template or draft form with multiple sections for a potential subgrant, with an effective date of 07/01/2024, though specific details about the project are not fully completed. The form includes sections for budget summaries, cost support sheets, and modification tracking, suggesting it is a preparatory document for a future funding arrangement.
The financial sections of the document show zero-dollar amounts across multiple budget categories, including salaries, fringe benefits, travel, contractual services, commodities, and equipment. The form indicates the subgrant will be processed using either a current needs/cash advance or cost reimbursement payment method. The document incorporates various policy references including standard assurances, debarment policy, drug-free workplace policy, and requires documentation such as a board resolution, cost allocation plan, and indirect cost rates. While the specific funding source and exact purpose are not detailed, the form is designed to facilitate a structured subgrant agreement between MDCPS and a potential subgrantee.
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Other files
| File | Type | Posted |
|---|---|---|
| KINSHIP REVISED RFP-MDCPS SUBGRANT FOR KINSHIP NAVIGATOR PROGRAM IMPLEMENTATION (2).docx | DOCX document |
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Text version
SGSS 12
| MISSISSIPPI | |||||||||
| Form MDCPS-SCSS-1002 | |||||||||
| Revised 3/12/2021 | |||||||||
| STATE OF MISSISSIPPI | |||||||||
| MISSISSIPPI DEPARTMENT OF CHILD PROTECTION SERVICES | |||||||||
| SUBGRANT SIGNATURE SHEET | |||||||||
| P. O. BOX 346 | |||||||||
| JACKSON, MISSISSIPPI 39205-0352 | |||||||||
| MDCPS FUNDING DIVISION: | |||||||||
| 1. SUBGRANTEE'S NAME, | 2. EFFECTIVE DATE: | ||||||||
| ADDRESS & PHONE NUMBER | 07/01/2024 | ||||||||
| 3. AGREEMENT NUMBER: | |||||||||
| 4a. GRANT IDENTIFIER (funding source and year): | |||||||||
| DUN'S NUMBER: | b. CATALOG OF FEDERAL DOMESTIC ASSISTANCE (CFDA) #: | ||||||||
| SUBGRANTEE'S FISCAL YEAR END DATE: | |||||||||
| 5. BEGINNING AND ENDING DATES: | |||||||||
| NAME/TITLE OF OFFICERS: (SUBGRANT ENTITY) | through | ||||||||
| 6. SUBGRANT PAYMENT METHOD: | |||||||||
| CURRENT NEEDS/CASH ADVANCE | |||||||||
| x | COST REIMBURSEMENT | ||||||||
| CONTACT PERSON: | OTHER | ||||||||
| PHONE NUMBER: | |||||||||
| EMAIL: | 7. PAGE 1 OF 3 | ||||||||
| 8. THE FOLLOWING FUNDS ARE OBLIGATED: | |||||||||
| FEDERAL | ADMINISTRATION | ||||||||
| STATE | $ - 0 | SERVICES | |||||||
| OTHER | $ - 0 | OTHER | $ - 0 | ||||||
| TOTAL | $ - 0 | TOTAL | $ - 0 | ||||||
| 9. THE SUBGRANTEE AGREES TO ADMINISTER THIS SUBGRANT IN ACCORDANCE WITH ALL FEDERAL AND/OR STATE | |||||||||
| PROVISIONS THAT ARE APPLICABLE TO SAID SUBGRANT. THE FOLLOWING DOCUMENTS ARE INCORPORATED HEREIN: | |||||||||
| a. SUBGRANT SIGNATURE SHEET | 3) | STANDARD ASSURANCES POLICY | |||||||
| b. BUDGET SUMMARY | 4) | DEBARMENT POLICY | |||||||
| c. COST SUMMARY SUPPORT SHEET | 5) | DRUG FREE WORKPLACE POLICY | |||||||
| d. BUDGET NARRATIVE | 6) | SUBGRANT MANUAL ACCEPTANCE | |||||||
| e. SUBGRANT AGREEMENT | f. VERIFICATION OF 25% FIDELITY BOND | ||||||||
| 1) | SCOPE OF SERVICES | g. COPY OF BOARD RESOLUTION (if applicable) | |||||||
| 2) | GENERAL TERMS AND PROVISIONS | h. COST ALLOCATION PLAN & INDIRECT COST RATES | |||||||
| 10. IDENTIFICATION OF OTHER FUNDING (List all other funds requested, anticipated or held over from prior years | |||||||||
| dedicated to this or similar programs including Federal, State, Local or Private funds. If additional space is needed, | |||||||||
| please attach typed pages). | |||||||||
| SOURCE | PURPOSE | CONTRACT # | PERIOD (dates) | PERIOD (dates) | AMOUNT | ||||
| n/a | _______________ | $ _______________ | |||||||
| _______________ | $ _______________ | ||||||||
| _______________ | $ _______________ | ||||||||
| _______________ | $ _______________ | ||||||||
| 11. APPROVED FOR MDCPS: | 12. APPROVED FOR SUBGRANTEE: | ||||||||
| BY: | DATE: | BY: DATE: | |||||||
| Commissioner | Executive Director | ||||||||
| TITLE | TITLE |
Budget Summary 12
| MISSISSIPPI | MISSISSIPPI DEPARTMENT OF CHILD PROTECTION SERVICES | ||||||||||||
| Form MDCPS-BS-1006 | BUDGET SUMMARY | ||||||||||||
| Effective 03/12/2021 | Page | 2 | of | 3 | Pages | ||||||||
| 1. Applicant Agency: | |||||||||||||
| 0 | |||||||||||||
| 2. Agreement Number: | 3. Grant ID | 4. Beginning | 5. Ending | ||||||||||
| 0 | 0 | 0.00E+00 | 0.00E+00 | ||||||||||
| 6. Submitted as Part of (check one): | |||||||||||||
| a. Funding | b. Modification ( ) | c. Modification | |||||||||||
| Request | (x) | Effective Date | |||||||||||
| 7. For | |||||||||||||
| MDHS | 8. Budget Activity | Funding Sources | |||||||||||
| Use Only | Federal | State | Local | Program | In-Kind | Total | |||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| $ - 0 | |||||||||||||
| TOTAL | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
Cost Summary Support 12
| Mississippi | MISSISSIPPI DEPARTMENT OF HUMAN SERVICES | ||||||||
| Form MDHS-CSSS-1007 | COST SUMMARY SUPPORT SHEET | ||||||||
| Effective 3-01-2005 | Page | 3 | 4 | Pages | |||||
| 1. Applicant Agency | |||||||||
| 0 | |||||||||
| 2. Subgrant Number | 3. Grant ID | 4. Beginning | 5. Ending | ||||||
| 0 | 0 | 0 | 0 | ||||||
| 6. Budget Activity | |||||||||
| 0 | |||||||||
| 7. For MDHS | 8. Budget Category | 9. Description of Item and/or | |||||||
| Use Only | Basis for Cost | State | Total | ||||||
| See Attached Budget Narrative | $ - 0 | $ - 0 | |||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| $ - 0 | |||||||||
| Totals | $ - 0 | $ - 0 | |||||||
| Mississippi | MISSISSIPPI DEPARTMENT OF CHILD PROTECTION SERVICES | ||||||||
| Form MDCPS-CSSS-1007 | COST SUMMARY SUPPORT SHEET | ||||||||
| Revised 03/12/2021 | Page | 3 of | 3 | Pages | |||||
| 1. Applicant Agency | |||||||||
| 0 | |||||||||
| 2. Agreement Number | 3. Grant ID | 4. Beginning | 5. Ending | ||||||
| 0 | 0 | 0 | 0 | ||||||
| 6. Activity | |||||||||
| 0 | |||||||||
| 7. For | |||||||||
| MDHS | 8. Budget Category | 9. Budget | |||||||
| Use Only | Federal | State | Local | Program | In-Kind | Total | |||
| Salaries | $ - 0 | ||||||||
| Fringe | $ - 0 | ||||||||
| Travel | $ - 0 | ||||||||
| Contractual | $ - 0 | ||||||||
| Commodities | $ - 0 | ||||||||
| Equipment | $ - 0 | ||||||||
| TOTAL | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||
| Mississippi | MISSISSIPPI DEPARTMENT OF CHILD PROTECTION SERVICES | ||||||||
| Form MDHS-CSSS-1007 | COST SUMMARY SUPPORT SHEET | 802 | |||||||
| Revised 03/12/2021 | Page | 4 of | 4 | Pages | |||||
| 1. Applicant Agency | |||||||||
| 0 | |||||||||
| 2. Agreement Number | 3. Grant ID | 4. Beginning | 5. Ending | ||||||
| 0 | 0 | 0 | 0 | ||||||
| 6. Budget Activity | |||||||||
| 0 | |||||||||
| 7. For MDHS | |||||||||
| Use Only | 8. Budget Category | 9. Budget | |||||||
| Federal | State | Local | Program | In-Kind | Total | ||||
| Salaries | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | ||||
| Fringe | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | ||||
| Travel | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | ||||
| Contractual | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | ||||
| Commodities | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | ||||
| Equipment | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | ||||
| Indirect Cost | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | ||||
| TOTAL | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
Modification Signature Sheet 12
| MISSISSIPPI | |||||||||
| Form MDCPS-MSS-1004 | |||||||||
| Revised 3/12/2021 | STATE OF MISSISSIPPI | ||||||||
| MISSISSIPPI DEPARTMENT OF CHILD PROTECTION SERVICES | |||||||||
| SUBGRANT MODIFICATION SIGNATURE SHEET | |||||||||
| P. O. BOX 352 | |||||||||
| JACKSON, MISSISSIPPI 39205-0352 | |||||||||
| MDHS FUNDING DIVISION: | |||||||||
| 1. SUBGRANTEE'S NAME, | 2. EFFECTIVE DATE: | ||||||||
| ADDRESS & PHONE NUMBER: | |||||||||
| 0 | 3. AGREEMENT NUMBER: | ||||||||
| 0 | |||||||||
| 0 | 4. MODIFICATION # : 1 | ||||||||
| 0 | |||||||||
| FUNDING SOURCE and YEAR: | |||||||||
| 0 | |||||||||
| CONTACT PERSON: | 5. BEGINNING AND ENDING DATES: | ||||||||
| 0 | through | 0 | |||||||
| PHONE NUMBER: | 6. SUBGRANT PAYMENT METHOD: | ||||||||
| CURRENT NEEDS/CASH ADVANCE | |||||||||
| FAX NUMBER: | COST REIMBURSEMENT | ||||||||
| OTHER | |||||||||
| EMAIL: | 0 | 7. PAGE: 1 OF 3 | |||||||
| 8. AS A RESULT OF THIS MODIFICATION, FUNDS OBLIGATED ARE CHANGED AS FOLLOWS: | |||||||||
| FROM | TO | FROM | TO | ||||||
| FEDERAL | $ - 0 | ADMINISTRATION | $ - 0 | ||||||
| STATE | $ - 0 | SERVICES | |||||||
| OTHER | $ - 0 | $ - 0 | OTHER | $ - 0 | $ - 0 | ||||
| TOTAL | $ - 0 | $ - 0 | TOTAL | $ - 0 | $ - 0 | ||||
| 9. THE ABOVE SUBGRANT IS HEREBY MODIFIED AS FOLLOWS: | |||||||||
| Action | Activity | Line Item | Original | Modified | DIFFERENCE (+/-) | ||||
| from | to | ||||||||
| REASON(S) FOR MODIFICATION [If additional space is needed, please attach typed page (s)] : | |||||||||
| 10. APPROVED FOR MDHS: | 11. APPROVED FOR SUBGRANTEE: | ||||||||
| BY: | DATE: | BY: DATE: | |||||||
| 0 | |||||||||
| Executive Director | Executive Director | ||||||||
| TITLE | TITLE |
Modification Budget Summary 12
| MISSISSIPPI | Mississippi Department of Child Protection Services | |||||||||||
| Form MDCPS-BS-1006 | MODIFICATION BUDGET SUMMARY | |||||||||||
| Revised 03/21/2021 | Page | 2 | of | 3 | Pages | |||||||
| 1. Applicant Agency: | ||||||||||||
| 0 | ||||||||||||
| 2. Agreement Number: | 3. Grant ID | 4. Beginning | 5. Ending | |||||||||
| 0 | 0.00E+00 | 0.00E+00 | ||||||||||
| 6. Submitted as Part of (check one): | ||||||||||||
| a. Funding | b. Modification () | c. Modification | ||||||||||
| Request | ( ) | Effective Date | ||||||||||
| 7. For | ||||||||||||
| MDHS | 8. Budget Activity | Funding Sources | ||||||||||
| Use Only | Federal | State | Local | Program | In-Kind | Total | ||||||
| 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | ||||||||
| TOTAL | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
Mod Cost Summary Support 12
| Mississippi | MISSISSIPPI DEPARTMENT OF CHILD PROTECTION SERVICES | ||||||||
| Form MDCPS-CSSS-1007 | MODIFICATION COST SUMMARY SUPPORT SHEET | ||||||||
| Revised 03/12/2021 | Page | 3 | of 3 | Pages | |||||
| 1. Applicant Agency | |||||||||
| 0 | |||||||||
| 2. Agreement Number | 3. Grant ID | 4. Beginning | 5. Ending | ||||||
| 0 | 0 | 0 | |||||||
| 6. Budget Activity | |||||||||
| 0 | |||||||||
| 7. For | |||||||||
| MDHS | 8. Budget Category | 9. Budget | |||||||
| Use Only | Federal | State | Local | Program | In-Kind | Total | |||
| Salaries | |||||||||
| Fringe | |||||||||
| Travel | |||||||||
| Contractual Services | |||||||||
| Commodities | |||||||||
| Equipment | |||||||||
| TOTAL | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||
| Mississippi | MISSISSIPPI DEPARTMENT OF HUMAN SERVICES | ||||||||
| Form MDHS-CSSS-1007 | MODIFICATION COST SUMMARY SUPPORT SHEET | ||||||||
| Revised 03/12/2021 | Page | 4 | of 4 | Pages | |||||
| 1. Applicant Agency | |||||||||
| 0 | |||||||||
| 2. Subgrant Number | 3. Grant ID | 4. Beginning | 5. Ending | ||||||
| 0 | 0 | 0 | 0 | ||||||
| 6. Budget Activity | |||||||||
| 0 | |||||||||
| 7. For | |||||||||
| MDHS | 8. Budget Category | 9. Budget | |||||||
| Use Only | Federal | State | Local | Program | In-Kind | Total | |||
| Salaries | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||
| Fringe | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||
| Travel | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||
| TOTAL | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
Budget Changes
| 0 | |||
| Subgrant # | 0 | ||
| Budget Changes / Modification # 1 | |||
| Cost Category | Prior Budget | Modified Budget | Changes |
| Administration: | |||
| Salaries | $ - 0 | ||
| Fringe Benefits | $ - 0 | ||
| Indirect | $ - 0 | ||
| Admin Total | $ - 0 | ||
| Family Support Services: | |||
| Wages/Salaries | $ - 0 | ||
| Fringe | $ - 0 | ||
| Travel | $ - 0 | ||
| Contractual Services | $ - 0 | ||
| Commodities | $ - 0 | ||
| Equipment | $ - 0 | $ - 0 | |
| Services Total | $ - 0 | $ - 0 | |
| Grand Total | $ - 0 | $ - 0 | $ - 0 |
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