Form 2 Senior Corps Application

Senior Corps Grant Application

SC Grant Application 2008 to 2011 Proposed changes

Senior Corps Application

OMB: 3045-0035

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3045-0035 can be found here:

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OMB Control No. 3045-0035-Expires 05/31/2011

SENIOR CORPS

GRANT APPLICATION

FACSIMILE OF ELECTRONIC FORMS

Form is Authorized for Local Reproduction

CNCS Form 424-NSSC OMB Control No. 3045-0035-Expiration: 05/31/2011

Table of Contents

INSTRUCTIONS

General Submission Instructions 3

Part I: Facesheet Instructions (eGrants “Applicant” and “Application” Sections) 4

Part II: Budget Instructions (eGrants “Budget” Sections) 6

Budget Section I: Volunteer Support Expenses 7

Budget Section II: Volunteer Expenses 8

Part III: Project Narratives Instructions (eGrants “Narratives” Sections) 9

Part III Section A: Strengthening Communities. 9

Part III Section B: Recruitment and Development of Volunteers 10

Part III Section C: Program Management 10

Part III Section D: Organizational Capacity 10

Part III Section E: Other NOFA Requirements 10

Part IV: Work Plan Instructions (eGrants “Work Plan” Sections)

Part IV Section A: Outcome/Impact and Performance Measures Work Plans 11

Part IV Section B: Volunteer Activities Not Represented in the Impact Work Plans 13

Instructions for Attachments (eGrants “Documents” Section) 14 3

FORMS:

Part I – Facesheet 15

Part II – Budget 16-17

Part IV Section A – Work Plan for Impact-Based Activities 18

Part IV Section B – Volunteer Activities Not Reflected on Impact-Based Work Plans 19

Roster of Active Volunteer Stations (Form and Instructions) 20

Standard Assurances 21

Certifications 22

SERVICE CATEGORIES BY ISSUE AREA 23

GENERAL SUBMISSION INSTRUCTIONS

Purpose:

The Senior Corps Grant Application of the Corporation for National and Community Service is for use by prospective and existing sponsors of Senior Corps projects under RSVP, the Foster Grandparent Program (FGP), the Senior Companion Program (SCP), and the Senior Demonstration Programs (SDP). The forms in this package conform to the Corporation’s web-based electronic grants management system, eGrants.

The majority of applicants use the electronic grants management system, eGrants, to submit applications. Forms in this package are to be used only by applicants unable to submit an electronic application.

Instructions in this package apply to all applicants, including those using the eGrants system. These instructions address the types of information that must be included to fulfill application and grants requirements. References to “Sections” herein refer to eGrants data entry screens and are provided for cross-reference purposes.

Applicants receiving grants based on submission of this paper application are encouraged to register to use eGrants and transfer the information contained in their paper application into eGrants after receiving notice of their selection.

Further information about eGrants is available at the Corporation’s website, www.nationalservice.org.

Application Completion and Submission Requirements:

Complete and return an original signed application plus one complete copy to the applicable Corporation for National and Community Service State Office, unless otherwise instructed. Number the pages of your submission consecutively. Do not submit the instructions as part of your application.

First-time Applicants for a Senior Corps Grant and Current Sponsors Applying for a new Multi-Year Grant:

To be considered, the application must include the following:

Part I: Facesheet (Modified Standard Form 424 NSSC) – Page 15
Part II: Budget (NSSC Form 424A) – Pages 16-17
Part III: Project Narratives (All sections) Pages 9-10
Part IV: Work Plan (Sections A and B) as applicable Pages 11-13
Attachments: Required attachments are indicated on Page 14
Assurances (Standard Form 424B) – Page 21
Certifications (NSSC Form 424C) – Page 22

Continuation Applications: Years 2 and 3 of the Multi-Year Grant:

Current sponsors are strongly encouraged to submit their continuation applications via the eGrants system. However, if that is not possible, these applicants must include the following:

Part I: Facesheet (Modified Standard Form 424 NSSC) – Page 15
Part II: Budget (NSSC Form 424A) – Page 16-17
Attachments: As specified for continuation projects on Page 14

Other: Updates of any other sections of the application or the required attachments if significant changes have occurred or are anticipated during Year 2 or Year 3.

Note: Submission of a grant application does not assure receipt of a grant award.

Disclosure Statement: OMB No. 3045-0035. The collection of this information is authorized by the provisions of the Domestic Volunteer Service Act of 1973, as amended, and the National and Community Service Trust Act of 1993. This agency informs the potential persons who may respond to the collection of information that such persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Estimated time to complete this application, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information averages 13.2 hours per response (16.5 for new applicants, 15 for previous sponsors, and 5 for revisions). If you have any comments regarding this collection of information, send them to: Corporation for National and Community Service, Senior Corps, Attn: Angela Roberts, 1201 New York Avenue, W, Washington, D.C. 20525. As required by Section 504 of the Rehabilitation Act of 1973, as amended, this application may be available in alternative formats. Make TTD/TTY inquiries to: (202) 565-2799. Direct written inquiries to: Senior Corps, 1201 New York Ave. NW, 9^th Floor, Washington, DC 20525. Direct telephone inquiries to: (202) 606-5000, Ext. 554.

PART I: FACESHEET INSTRUCTION eGrants “Applicant” and “Application” Sections

See page 14, for Standard Form-424, Face sheet. This form is required for applications submitted for federal assistance.

Item #

1. Filled in for your convenience.

2. Self-explanatory.

3. 3.a. and 3.b. are for State use only (if applicable).

4. Item 4.a: Leave blank

Item 4.b: If you are a current grantee applying for year 2 or 3 of an already-awarded grant, enter the grant number. Otherwise, leave blank.

5. Enter the following information:

The complete name of the organization that will be legally responsible for the grant. This is not the name of the organizational unit within the legally responsible organization. For example, indicate “National University” instead of “Liberal Arts Department.”
The name of the primary organizational unit that will undertake the assistance activity, if different from 5.a. Using the example above, here is the place to use “Liberal Arts Department.”
Your organization’s complete address with the 5-digit ZIP code and the 4-digit extension.
The name and contact information of the project director or other person to contact on matters related to this application.

6. Enter your Employer Identification Number (EIN) as assigned by the Internal Revenue Service.

6a. Enter your Organization’s Dun and Bradstreet Data Universal Numbering System (DUNS) number. If needed, the applicant organization may obtain a DUNS number by calling the request line at (866) 705-5711 or online at http://www.dnb.com.

7. Item 7.a.: Enter the appropriate letter in the box.

Item 7.b: Consult the following list of characteristics of applicants and enter (all that apply) the corresponding numbers, each in a separate blank.

2-year college	17. Local Government Municipal
4 year college	18. National Non-profit (Multistate)
Area Agency on Aging	19. Other Native American Organization
Chamber of Commerce/Business Association	20. Other State Government
Community Action Agency/ Community Action Program	21.School (K-12)
Community College	22. Self-Incorporated Senior Corps Project
Community-Based Organization	23. Service/Civic Organization
Faith-based organization	24. State Commission/Alternative Administrative Entity
Governor’s Office	25. State Education Agency
Grant-making Entity Operating in Two or More States	26. Statewide Association
Health Department	27. Tribal Government Entity
Hispanic Serving College or University	28. Tribal Organization (non-government)
Historically Black College or University (HBCU)	29. U.S. Territory
Law Enforcement Agency	30. Vocational/Technical College
Local Affiliate of National Organization	31. Volunteer Management Organization
Local Education Agency

8. Check the appropriate box for type of application and enter the appropriate letter(s) in the lower boxes:

Check “New” if you are applying for assistance for the first time or are reapplying for year 1 of a new grant.
Check “Continuation” if you are a current grantee applying for your second or third year of funding.
Check “Revision” if you are a grantee proposing any change in your budget, requesting a no cost extension, or revising your Work Plans.

If you are proposing a Revision to your grant, check the type of revision you are submitting.

Select “Increase Award” if you are a Senior Corps grantee submitting a revised budget to incorporate a Corporation-authorized increase.
Select “Decrease Award” if you are a Senior Corps grantee submitting a revised budget to incorporate a Corporation-authorized decrease.
Select “Increase Duration” to request an extension of the grant period, then enter the extension date requested in the blank following the checkbox. No-cost extensions can be requested only in the third year of the 3-year grant cycle and must be requested before the project period ends.
Select “Decrease Duration” to request a reduction of the grant period, then enter the new end date requested in the blank following the checkbox.
Select “Other,” as applicable, and specify in the blank provided.

9. Filled in for your convenience.

10. Use the following list of CFDA (Catalog of Federal Domestic Assistance) numbers for the applicable program listing, or other source if so instructed in the NOFA:

94.001 Retired and Senior Volunteer Program (RSVP)

94.011 Foster Grandparent Program

94.015 Senior Demonstration Program

94.016 Senior Companion Program

11. a. Enter the title of the project.

b. Enter the name of the CNCS program initiative, if any, as provided in the instructions corresponding to the NOFA for which you are applying; otherwise, leave blank.

12. List only the largest political entities affected (e.g., counties, and cities).

13. Please reference Item 8 (Above)

“New: Enter the proposed project Start and End Dates. This is a 3-year period.
“Continuation” or “Revision” application: Enter the dates of the approved project period.

14. Fill in the performance period. This is usually defined as 12-months. If other than 12-months, the NOFA or supplemental guidance will indicate the performance period.

15. Estimated Funding: Enter the amount requested or to be contributed during this performance period on the appropriate line, as shown below. The value of in-kind contributions should be included in these amounts, as applicable. For revisions (See item 8), if the action will result in a dollar change to an existing award, include only the amount of the change. For decreases, enclose the amounts in parentheses.

Federal The total amount of Federal funds being requested in the budget.
Applicant The total amount of the applicant share as entered in the budget.
State The amount of the applicant share that is coming from state sources.
Local The amount of the applicant share that is coming from local sources.
Other The amount of the applicant share that is coming from other sources.
Program
Income The amount of the applicant share that is coming from income generated by programmatic activities.
Total The applicant's estimate of the total funding amount for the agreement

16. Indicate if this application is subject to review by the state "Executive Order 12372 Process" by checking the box. Executive Order 12372, "Intergovernmental Review of Federal Programs," was issued with the desire to foster the intergovernmental partnership and strengthen federalism by relying on state and local processes for the coordination and review of proposed federal financial assistance and direct Federal development. The Order allows each state to designate an entity to perform this function. A list of these "Single Point of Contact" entities can be found at: http://www.whitehouse.gov/omb/grants/spoc.html. Contact the Single Point of Contact to determine whether your application is subject to the state intergovernmental review process.

If Yes, indicate the date a copy of your application was submitted to the state for review under the Executive Order 12372 Process
If No, check the appropriate box.

17. Check the appropriate box. This question applies to the applicant organization, not the person who signs as the authorized representative. Categories of debt include delinquent audit allowances, loans, and taxes. If Yes, attach an explanation.

18. The person who signs this form must be the applicant’s authorized representative. A copy of the governing body’s authorization for this official representative to sign must be on file in the applicant’s office.

Note: Falsification or concealment of a material fact, or submission of false, fictitious or fraudulent statements or representations to any department or agency of the United States Government may result in a fine of not more than $10,000 or imprisonment for not more than five (5) years, or both. (18 U.S. Code Section 1001)

PART II – BUDGET INSTRUCTIONS eGrants Budget Sections

Use the Senior Corps SF 424A Budget form found on Page 15 and 16. Provide a breakdown of costs by object class categories/line items for your program. Include a description of each budget item along with the cost. All costs must be allowable, reasonable, and necessary to the operation of the project.

(a) Multi-year applications - Complete the SF 424A Budget form requesting funds for the first annual budget period, following the instructions below. Multi-year project approval does not guarantee that the application will be approved for additional funding. If we approve an application and enter into a multi-year award agreement, we will issue a Notice of Grant Award (NGA) that will provide funding only for the first year. You must submit a continuation application, via eGrants or in paper form, for each year of the award to request additional funding. We will use the distribution of line item amounts proposed for the first year in budgeting for subsequent years unless you submit an application for revising the budget.

Your Corporation State Office will provide instructions for continuation applications. Following receipt of a Notice of Grant Award (NGA), you may submit applications for revision of your budget via eGrants or on paper. Paper applications for revising the budget must include Part I – Facesheet and Part II – SF 424A and completed Budget form. Additional funding is contingent upon satisfactory performance, the availability of funds, and any other criteria established by the Corporation in the NGA.

(b) Single-year applications - Complete the SF 424A Budget form for the 12-month period, following the instructions below. Unless otherwise instructed by an agent of the Corporation, or referenced in the NOFA or supplemental guidance, all grants are multi-year.

General Instructions for SF 424A Budget form Columns 1, 2, 3, and 4:

In Column 1, enter the total project cost for that line item from all sources.
In Column 2, enter the amount of Corporation funding requested for each line item and the total.
In Column 3, enter the amount of funds for the item that is expected to be covered by grantee funds or funds the grantee expects to receive from other sources, including cash and in-kind support. FGP and SCP require a non-federal share of 10% of the total project cost. For RSVP, the required non-federal share is 10% of the total project cost in Year 1, 20% in Year 2, and 30% in subsequent years. In cases of demonstrated need, as specified in the respective program regulations, exceptions to these cost-sharing requirements may be allowed.
Enter any contributions in excess of required non-federal share in optional Column 4, as stipulated in Section 224 of the Domestic Volunteer Service Act, as amended.
For each Budget Line Item, please:

Briefly describe all amounts in Columns 2, 3, and 4; and
List cash and in-kind contributions listed in Columns 3 and 4 on separate lines

Following are instructions for each line item of the budget form:

SECTION I: VOLUNTEER SUPPORT EXPENSES

NOTE:

For all line items, please put the total cost in Column 1 and then use Columns 2 – 4 to identify the source of funds as appropriate:

Line A. Project Personnel Expenses – List the title of each staff position charged to the project. List all positions/titles that are either funded by CNCS, grantee share, or excess resources. Include:

The position title
The full-time equivalent (FTE) annual salary. 100% FTE is normally 40 hours/week. Thus, if an employee works half time or 20 hours/wk for the project and is paid $10,000 from project funds, the FTE annual salary would be $20,000

3. The percentage of time the person will work for the project over a 12 month year (for example, if the employee works 10 hours per week for the project over 12 months, you would enter 25%.).

Line B. Personnel Fringe Benefits – Enter in the appropriate column the cost of fringe benefits to which employees are entitled, calculated on the same percentage time indicated under line A for each individual. In your Budget Narrative, provide details concerning the benefits provided. (E.G., Retirement contributions for all staff working over 60% time, calculated at 5% of total annual salaries of $80,000 = $4,000).

Line C. Project Staff Travel – Enter travel costs on the appropriate local or long-distance lines on the Budget form. Include only travel costs for staff listed under budget line A and who directly support the grant activities described in your application. Local travel is travel within the project service area as shown in item 12 of the Facesheet. All travel outside the service area is long distance travel. Briefly list the purpose of anticipated local travel and the basis for cost calculations. For long distance travel, show the purpose for each trip and break out for each the cost of transportation, meals and lodging, and other travel costs.

Line D. Equipment - Enter on the Budget form the cost of equipment. Items costing less than $5,000 should be listed in Line E: Supplies. Include a list of items to be purchased, the quantity of each, with their respective costs, and explain how each item will be used in the project.

Line E. Supplies - On the Budget form, enter the cost of supplies in appropriate columns. List types of supplies and their respective costs. Itemize large items.

Line F. Contractual and Consultant Services - Enter on the Budget form the cost of contracts and consultants as appropriate. In your Narrative itemize each contract or consultant and provide a brief justification of the need for each. Include here all services documented in a contract, such as clerical support, training consultants, equipment repair and maintenance, or bookkeeping services.

Line G. – Line I. Describe all other allowable Volunteer Support Expenses not included in categories A through F, such as training, evaluation services, and other items and briefly describe.

Line H. Indirect Costs – Enter indirect charges applicable to volunteer support expenses. In your Narrative, describe the type of rate (provisional, predetermined, final or fixed) in effect during the budget period, estimated amount of the base to which the indirect rate was applied, and total indirect expense. Attach a copy of the current negotiated indirect cost agreement with the cognizant federal agency.

TOTAL SECTION I - Enter the sum of direct and indirect costs from Section I in columns 1, 2, 3, and 4 as appropriate.

SECTION II: VOLUNTEER EXPENSES

Line A. Stipends – Stipends are applicable to Foster Grandparent and Senior Companion volunteers only. Please enter as appropriate the number of Volunteer Service Years (VSYs) proposed in each category and multiply the numbers of VSYs times the annual stipend. Note: Current annual stipend is $2,766 based on 1 VSY @ 1,044 hours x hourly stipend of $2.65

DO NOT include monetary incentives for Senior Companion Leaders in the stipend line item.

CNCS-funded ____ x Annual Stipend = $_________
Non-CNCS-funded ____x Annual Stipend = $______

3. Non-Stipended: ____

NOTE: Volunteer Service Year (VSY) is a budget term which equals 1,044 hours per year. For example, a volunteer serving 2088 hours per year (averaging 40 hours per week) serves 2 VSYs, while a volunteer serving 783 hours per year (averaging 15 hours per week) serves ¾ of a VSY.

Line B. Other Volunteer Costs – Enter in the respective categories the applicable costs and reimbursable expenses in columns 1, 2, 3, and 4, as appropriate. In addition to stipends, FGP and SCP allowable costs and reimbursable expenses include: Insurance, Volunteer Travel, Physical examinations, Meals, Uniforms, and Recognition. RSVP allowable costs and reimbursable expenses include: Volunteer Travel, Meals, Recognition, and Insurance. Volunteers may also be reimbursed for costs incurred while performing assignments – including transportation, equipment, supplies, etc. – provided such costs are described in the Memorandum of Understanding negotiated with the volunteer station where the volunteer is assigned and there are sufficient funds available to cover these expenses and meet all other requirements of the NGA. For SCP only, monetary incentives for Senor Companion Leaders should be listed in #7: Other Allowable Expenses. Use the Narrative for the corresponding line to provide explanation or show calculations, as needed.

Note on Volunteer Travel: Volunteer Travel includes volunteer transportation costs such as cost of agency vehicles (leased or purchased), insurance, prorated maintenance costs applicable to vehicles based on usage, and drivers’ salaries and fringe benefits chargeable to the grant. Assignment-related travel is also allowable. Please enter the totals for columns 1, 2, 3, and 4 as appropriate.

TOTAL SECTION II – Enter the sum of Volunteer Expenses in Section II.

TOTAL PROJECT COSTS – Enter the sum of the totals for Sections I and II in each column.

FUNDING PERCENTAGES – For Columns 2 and 3 only, enter the applicable percentage shares represented by the budgeted Corporation (Col. 2) and grantee resources (Col. 3). Do not include Excess Resources (Col. 4) in the calculation

PART III: PROJECT NARRATIVES INSTRUCTIONS (eGrants “Narratives” Sections)

The purpose of the program narratives and the accompanying Work Plans (see Part IV) is for you to provide a project plan with a clear and compelling justification for awarding the requested funds. Except in the case of projects seeking one-year approvals, Part III covers the multi-year proposed project period.

Remember to follow the character limits listed in the narrative section below. We use character limits rather than page limits because of the structure of eGrants. Characters are letters, punctuation, and spaces included in your document. Your word processing software can provide a character count.

PART III – SECTION A. STRENGTHENING COMMUNITIES: MAXIMUM – 4,000 characters

Complete this section only if you are a first time applicant or are a current grantee applying for year 1 of a 3-year grant to operate the established projects.

Describe the community you serve (e.g. key economic, demographic and geographic features), how you ensure local input into program design and evaluation, and how you mobilize community resources.

Describe the relationship between your program and the community, how you select community partners and the role of each partner. Provide information about how you will build public awareness of and support for the program within the community and how you will bring together people of diverse backgrounds. Describe how you mobilize community resources and how, if at all, volunteers will participate in community activities. Ensure that your narrative addresses:

a. How you will enhance the capacity of organizations and institutions within the community; and

b. How you will work to integrate senior service into the activities of other service programs within the community.

PART III – SECTION B. RECRUITMENT AND DEVELOPMENT OF VOLUNTEERS:

MAXIMUM – 4,000 characters

Describe how you will:

Assure a high quality experience for volunteers that offers opportunities such as building new skills, developing leadership potential, reflecting on the meaning of service to the community, and enhancing the quality of their own lives;
Build a corps of volunteers, including recruiting, retaining and recognizing senior volunteers; and
Provide training and technical assistance to project staff, volunteers, volunteer station supervisors, and community participation groups.

PART III – SECTION C. PROGRAM MANAGEMENT: MAXIMUM – 4,000 characters

In this section, describe specific plans and strategies for overall management of the program you propose.

Describe how you will ensure high quality program management. Address each of the following areas:

Developing and managing volunteer stations and volunteer assignments that address specified community needs and provide meaningful placements for the volunteers;
Assessing project performance to assure all goals and objectives are met and that these result in a high quality project. This should include an annual assessment of project accomplishments and impact on the community and/or client population.
Managing information and data to demonstrate the concrete impacts of the project and its volunteers.
Managing project resources, both financial and in-kind, to ensure accountability and efficient and effective use of available resources.
Securing resources, such as cash and in-kind contributions, to sustain and expand the project.

PART III – SECTION D. ORGANIZATIONAL CAPACITY: MAXIMUM – 4,000 characters

Briefly describe your organization’s capacity to operate the program you propose with respect to:

Your organization’s experience in the proposed program area.
Key staff positions responsible for program management, background, and experience of these staff members and/or plans to select and support additional staff.
Financial management systems and past experience managing federal grant funds.
Track record in successfully managing volunteer programs, involvement with seniors, and impact-based programming;
Your organization’s capacity to assure the project has adequate facilities, equipment, supplies, purchasing procedures, and personnel management support, including clearly defined roles for staff and administrators; internal policies, including a travel policy; and
Your organization’s procedures or systems for self-assessment, evaluation, and continuous improvement.

PART III – SECTION E. OTHER NOFA REQUIREMENTS

Use this section, if needed, to address any additional program requirements that appear in the published Notice of Funding Availability (NOFA) or supplemental instructions. Refer to the NOFA for specifics.

PART IV – WORK PLAN - eGrants “Work Plan” Section

PART IV. SECTION A. OUTCOME/IMPACT and PERFORMANCE MEASURES WORK PLANS

About Outcome/Impact-Based Work Plans:

What are outcome/impact-based Work Plans?

Senior Corps resources are provided for the purpose of having a positive impact on critical human and social needs within the project service area. Volunteer assignments that are impact, or outcome-based are documented in the following format:

An outcome/impact-based Work Plan is a task plan with action steps to address a specified community need. In the grant application, these Work Plans form the basis for a proposed project plan: the need the volunteers will address, what they will do, what their service should accomplish during the multi-year grant period – from the shorter to longer terms.

Work Plans follow a standard format. Use the Work Plan template on Page 17 to describe how the project will develop assignments for and placement of, the senior volunteers to meet priority community needs.

Work Plans capture the focus of the volunteers’ services in standard categories. Use the Service Categories” list found on page 23 to select the focus of the volunteers’ services for each Work Plan.

How many Work Plans are needed?

How the volunteers will be deployed determines the number of Work Plans needed. Applicants should prepare a separate Work Plan for each service category. You may submit more than one Work Plan for a given service category. Most applications contain between 8 and 12 separate Work Plans, including Performance Measures Work Plans.
All volunteers who serve or will serve in outcome/impact-based assignments must be accounted for in the Work Plans in this section.
- For RSVP, 50 percent of the volunteers must be placed in outcome/impact-based assignments.
- For FGP and SCP, 90 percent of volunteers/VSYs must be placed in outcome/impact-based assignments.

Which sections of the Work Plans must be completed?

The following sections must be completed for all Work Plans:

Community Needs Statement: Develop for each service category. This needs statement should explain the compelling need that will be impacted upon through senior service.

Fill in Part 1 of the Work Plan Template with the needs statement.
Use the Service Category list and select and enter the service category that relates to the community need.
Fill in:

The total number of Senior Corps volunteers contributing to meeting this need
The total number of volunteer stations serving as placement sites to address this need
For Foster Grandparent projects: the estimated number of children/youth to be served
For Senior Companion projects: the estimated number of clients to be served
For RSVP – if possible, estimate the total number of people to be served.

An action plan with steps should be developed addressing the following elements for each community need identified using Part 2, Column A of the Work Plan template:

Service Activity – Provide specific descriptions of the activities the volunteers will undertake to help meet the identified need.
Anticipated Inputs – Describe the resources that will be available to help meet the identified need by creating or sustaining the service effort, such as the number of volunteers/VSYs, volunteer hours, financial and staff resources, or special training;
Anticipated Accomplishments (Outputs) – In measurable terms, describe the immediate results of the volunteer service in meeting the need, such as numbers served, numbers of products produced, etd. Be specific!
Anticipated Impacts (Intermediate Outcomes and End Outcomes)– Describe the anticipated longer term or permanent change or improvement expected in the community due to services of the volunteers. This change should be measurable and directly related to the defined community need. Be specific! NOTE: “How measured?” may be left blank.

Complete Part 2, Column C of each Work Plan by indicating the dates by which the task or result will be accomplished in month/year format, such as “01/06” for January 2006.

4. What are the Performance Measures Work Plans?

a) Performance Measures Work Plans are a subset of the applicant’s total Work Plans.

b) The following Performance Measures requirements apply to Senior Corps applicants:

Applicants must propose a minimum of 3 performance measures of which one must be an Accomplishment/Output, one must be an Intermediate Impact/Outcome and one must be an End Impact/Outcome. The applicant may propose more than 3 if desired.

The required 3 Performance Measures should be contained in no more than two Work Plans.

If the application is funded:

These grantee-nominated performance measures will be referenced in the Notice of Grant Award.

Each grantee will be held accountable for achieving its performance measures within the planned period of accomplishment.

While 3 performance measures are the minimum, applicants may propose additional performance measures.

5). How are Performance Measures Work Plans completed?

a) First determine the performance measures and ensure that Work Plan(s) are included corresponding to the measures.

b) In the section “Column B, Check if Performance Measure” of the Work Plan(s) corresponding to the performance measures – Place a “check mark” or “X” to indicate the Accomplishment/Outputs or Impacts/Intermediate Outcomes or End Outcomes you propose as Performance Measures.

c) Fill out the “How Measured/Indicator/Target?” section. For Anticipated Accomplishments/Outputs, and Anticipated Intermediate Impact/Intermediate Outcomes and Anticipated End Impact/End Outcomes), please include:

- The tool/method you will use to measure results. Tools and methods could include surveys, checklists completed by volunteers, etc.

The indictor of measurement, such as improvement in literacy skills, etc.
The target outcome, such as percent of improvement expected.

Please leave Columns D and E BLANK. These columns are used to report actual project performance. The process and tools to report progress will be specified to the applicant in the event that funding is awarded.

PART IV. SECTION B. VOLUNTEER ACTIVITIES NOT REPRESENTED IN THE OUTCOME/ IMPACT- BASED WORK PLANS

Senior Corps volunteers can and do provide meaningful service that values the interests of the volunteers, but that is not reflected in the outcome/impact-based Work Plans in Part IV – Section A.

The Part IV – Section B template that corresponds to these instructions is found on Page 15.

In Column A: Volunteer Activities, list the volunteer activities anticipated. Provide a brief description of each.
In Column B: Date, enter the planned timeframes using the month/year format, such as “01/06” for January 2006.

Please leave Columns C and D BLANK. These columns are used for actual reporting. The process to report progress will be specified to the applicant in the event that funding is awarded.

When using the eGrants screens, only complete the following sections of the Work Plan:

The service category
The total number of Senior Corps volunteers contributing to meeting this need
The total number of volunteer stations serving as placement sites to address this need
The Service Activity block.
In all other sections, please enter “NA”

PART V. INSTRUCTIONS FOR ATTACHMENTS (eGrants “Documents” Section)

ATTACHMENTS REQUIRED OF ALL APPLICANTS
Description of Attachment		Applicants who must submit the attachment as part of the application
		New		Continuation
Applicant’s organizational chart showing the major components and the number, positions and reporting relationships of the proposed project staff within the sponsoring organization.		Yes		Only if changed
Project Director job description.		Yes		Only if changed
List of the sponsor’s current Board of Directors, including name, address, organizational or community affiliation.		Yes		Only if changed
Names and addresses of community participation group or advisory council		Yes		Only if changed
Copy of at least one annual assessment conducted in the past two years to assess the accomplishments and impact of the project.		No		Once during year 2 or year 3
Copy of negotiated Indirect Cost Rate Agreement, if indirect costs are requested.		Yes		Yes
Statement of audit status that indicates whether the applicant is subject to A-133 Audit requirements. If yes, provide the date of the last audit and the date forwarded to the Audit Clearinghouse.		Yes		Yes
8. Roster of Volunteer Stations (see p. 19)		Yes		Yes
ADDITIONAL ATTACHMENTS REQUIRED OF PRIVATE NON-PROFIT APPLICANTS
In addition to the Attachments listed above under Section IV.A, private non-profit applicants must also include the following:
Description of Attachment	Applicants who must submit the attachment as part of the application
	New		Continuation
1. Copy of Articles of Incorporation	Yes		Only if changed
2. 990 or financial statement audit	Yes		Only if changed
3. Aggregate annual dollar amounts of funding broken out by federal, state, local governments and other (specify type)	Yes		Yes
4. List of the names of any funding organizations/sources that provide at least 10 percent of total funding and the dollar amount of that funding in the past budget year.	Yes		Yes
Note: By signing the application, an official of the grantee organization certifies that any attachment not included has not changed from the prior submission on file with the Corporation for National and Community Service.

PART I – FACESHEET OMB No. 3045-0035 Expiration Date 5/31/11

APPLICATION FOR FEDERAL ASSISTANCE

1. TYPE OF SUBMISSION:

Application Non-Construction

2. DATE SUBMITTED TO CORPORATION FOR NATIONAL AND COMMUNITY SERVICE (CNCS):

3. a. DATE RECEIVED BY STATE:

3.b. STATE APPLICATION IDENTIFIER:

4. a. DATE RECEIVED BY CNCS:

4.b. CNCS GRANT NUMBER:

5. APPLICANT INFORMATION

LEGAL NAME:

ORGANIZATIONAL UNIT:

NAME AND CONTACT INFORMATION FOR PROJECT DIRECTOR OR OTHER PERSON TO BE CONTACTED ON MATTERS INVOLVING THIS APPLICATION (give area codes):

ADDRESS (give street address, city, county, state and zip code):

NAME:

TELEPHONE NUMBER: ( ) -

FAX NUMBER: ( ) -

INTERNET E-MAIL ADDRESS:

WEBSITE:

6. EMPLOYER IDENTIFICATION NUMBER (EIN):

6A. DUNS Number:

7.a. TYPE OF APPLICANT: (enter appropriate letter in box)

A. State H. Independent School District

B. County I. State Controlled Institution of Higher Learning

C. Municipal J. Private University

D. Township K. Indian Tribe

E. Interstate L. Individual

F. Intermunicipal M. Profit Organization

G. Special District N. Private Non-Profit Organization

O. Other (specify)

7.b. CNCS APPLICANT CHARACTERISTICS

Enter appropriate code in each blank: ______, ______, ______, ______, ______

8 . TYPE OF APPLICATION (Check appropriate box):

NEW CONTINUATION

REVISION

If Revision, enter appropriate letter(s) in box(es):

A. Increase Award: B. Descrease Award:

C. Increase Duration: to (enter date)

D. Decrease Duration: to (enter date)

E. OTHER (specify):

9. NAME OF FEDERAL AGENCY:

Corporation for National and Community Service

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

Name of Program _____________________________________________________

11. a. TITLE OF APPLICANT’S PROJECT:

12. AREAS AFFECTED BY PROJECT (List Cities, Counties, States, etc.):

14. PERFORMANCE PERIOD: Start Date End Date:

13. PROPOSED PROJECT: START DATE: END DATE:

15. ESTIMATED FUNDING: Check applicable box: Yr 1: Yr.2: or Yr 3:

16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE

a. FEDERAL

ORDER 12372 PROCESS?

a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE

b. APPLICANT

TO THE STATE EXECUTIVE ORDER 12372 PROCESSS FOR

REVIEW ON:

c. STATE

DATE ___________________________________

b. NO. PROGRAM IS NOT COVERED BY E.O. 12372

d. LOCAL

OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR

REVIEW

e. OTHER

17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?

f. TOTAL

YES If “Yes,” attach an explanation. NO

18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.

a. TYPED NAME OF AUTHORIZED REPRESENTATIVE:

b. TITLE:

c. TELEPHONE NUMBER:

d. SIGNATURE OF AUTHORIZED REPRESENTATIVE:

e. DATE SIGNED:

Modified Standard Form 424-NSSC (Rev. 3/03 to conform to the CNCS eGrants system)

PART II— BUDGET WORKSHEET AND NARRATIVE– SENIOR CORPS
SECTION 1: VOLUNTEER SUPPORT EXPENSES
NARRATIVE				WORKSHEET
A. PROJECT PERSONNEL EXPENSES				Column 1		Column 2		Column 3	Column 4
Position Title	Annualized Salary	% Time Spent on Project		Total Project Cost		Corporation Funds Requested		Non-Federal Resources	Excess Resources





TOTAL PERSONNEL EXPENSES			$		$		$		$
B. PERSONNEL FRINGE BENEFITS
TOTAL FRINGE BENEFITS
C. PROJECT STAFF TRAVEL Local Travel (Detail) Sub-Total Local Travel

Long Distance Travel (Detail) Sub-Total Long Distance Travel


TOTAL TRAVEL COSTS
D. EQUIPMENT (List)
TOTAL EQUIPMENT
E. SUPPLIES (Describe)
TOTAL SUPPLIES
F. CONTRACTUAL AND CONSULTANT SERVICES (Detail)
TOTAL CONTRACTUAL AND CONSULTANT SERVICES
G. TRAINING
H. EVALUATION
I. OTHER VOLUNTEER SUPPORT COSTS (Detail)
TOTAL OTHER VOLUNTEER SUPPORT COSTS
J. INDIRECT COSTS
TOTAL SECTION I			$		$		$		$

SECTION II: VOLUNTEER EXPENSES
NARRATIVE	WORKSHEET
	Column 1 Total Project Cost	Column 2 Corporation Funds Requested	Column 3 Non-Federal Resources	Column 4 Excess Resources
STIPENDS -Foster Grandparent and Senior Companion applicants only Number of Volunteer Service Years (VSY)s: CNCS-funded ____ x Annual Stipend = $_________ Non-CNCS-funded ____x Annual Stipend = $______ Non-Stipended: ____	$	$	$	$
B. OTHER VOLUNTEER COSTS
1. Meals
2. Uniforms
3. Insurance
4. Recognition
5.Volunteer Travel
6. Physical Examinations
7. Other Allowable Expenses
TOTAL OTHER VOLUNTEER COSTS	$	$	$	$
TOTAL SECTION 2	$	$	$	$
TOTAL PROJECT COSTS: Section 1 + Section 2	$	$	$	$
FUNDING PERCENTAGES (percent distribution between Columns 4 and 5)		%	%

NSSC Form 424A (Modified SF-424A)

Part IV. Section A.

Work Plan/Performance Measures

Applicant Organization:

Check this box, if this Work Plan contains performance measure(s).

Period Covered: Starting: _________ Ending: ____________________

Part 1. Community Need to Be Addressed:

Applicable Service Category/Categories:

Total Number of Senior Corps volunteers contributing to meeting the need: ________

Total Number of Volunteer Stations: ______

Total Number of People to be served: ___

Part 2: Action Plan, Tasks and Timeline

PROJECT PLANNING

PROJECT REPORTING

Column A

Plans, Tasks, and Activities

Column B

Check if Performance Measure

Col. C

Date

Column D

Actual Performance

Col. E

Date

Service Activity:

Actual Service Activity:

Anticipated Inputs:

Actual Inputs:

Anticipated Accomplishments (Outputs):

How Measured?

Actual Accomplishments (Outputs):

How Measured?

Anticipated Impact

Intermediate Outcome:

How Measured? Indicator? Target?

End Outcome:

How Measured? Indicator? Target?

Actual Impact

Intermediate Outcome:

How Measured? Indicator? Target?

End Outcome:

How Measured? Indicator? Target?

Note: Please reproduce or duplicate this template as needed to include all Community Needs and Work Plans. An Word version is available on request from your Corporation State Office.

Part IV. Section B.

Volunteer Activities Not Reflected on Impact-Based Work Plans

Applicant Organization: Period Covered: Starting: _________ Ending: _________

PROJECT PLANNING

PROJECT REPORTING

Column A:

Volunteer Activities

Col. B

Date

Column C.

Actual Performance

Col. D

Date