Item C14 C.14'
i�`
CountCounty ��Monroe. ,y, ? "tr, BOARD OF COUNTY COMMISSIONERS
y M T� \�1a� Mayor Michelle Coldiron,District 2
�1 1 nff `_ll Mayor Pro Tem David Rice,District 4
-Ile Florida.Keys Craig Cates,District 1
Eddie Martinez,District 3
w Mike Forster,District 5
County Commission Meeting
April 21, 2021
Agenda Item Number: C.14
Agenda Item Summary #3073
BULK ITEM: Yes DEPARTMENT: Budget and Finance
TIME APPROXIMATE: STAFF CONTACT: Janet Gunderson (305) 292-4470
No
AGENDA ITEM WORDING: Approval of Human Services Advisory Board (HSAB) application
for the FY 2022 cycle as reviewed and approved the HSAB advisory board and approval to authorize
staff to implement changes to the HSAB application in the future as requested by the HSAB
advisory board.
ITEM BACKGROUND: The HSAB advisory board reviews and amends the HSAB application as
needed in order to address and inquire into matters of interest to the advisory board. The application
is presented to the BOCC today for approval of the HSAB FY 2022 application and seeks
authorization for staff to implement changes to the HSAB application in the future as directed by the
advisory board. Most changes incorporated are minor and primarily address current economic and
social aspects that may affect and be of importance to the advisory board in reviewing the
applicants' request for funding. Final recommendation allocations of from the HSAB advisory board
as brought before the BOCC for final approval.
PREVIOUS RELEVANT BOCC ACTION: On September 16, 2020, (Special Meeting-Budget,
Agenda Item J.1)the BOCC approved the FY2021 recommendations of the Human Services
Advisory Board and agreements with the human services organizations.
CONTRACT/AGREEMENT CHANGES:
N/A
STAFF RECOMMENDATION: Approval
DOCUMENTATION:
FY2022 HSAB Application
FY2022 HSAB Application Instructions
FY2022 Schedule of Funding Cycle
FINANCIAL IMPACT:
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C.14
Effective Date: N/A
Expiration Date: N/A
Total Dollar Value of Contract: N/A
Total Cost to County: N/A
Current Year Portion: N/A
Budgeted: N/A
Source of Funds: N/A
CPI: N/A
Indirect Costs: N/A
Estimated Ongoing Costs Not Included in above dollar amounts: N/A
Revenue Producing: N/A If yes, amount: N/A
Grant: N/A
County Match: N/A
Insurance Required: N/A
Additional Details: N/A
None
REVIEWED BY:
Christine Limbert Completed 04/01/2021 10:52 AM
Christina Brickell Completed 04/06/2021 4:40 PM
Maria Slavik Completed 04/06/2021 5:33 PM
Liz Yongue Completed 04/06/2021 5:36 PM
Board of County Commissioners Pending 04/21/2021 9:00 AM
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MONROE COUNTY-FISCAL YEAR tots C.14.b
HUMAN SERVICES ADVISORY BOARD
APPLICATION INFORMATION AND INSTRUCTIONS
Board Members: Michael Ingram,appointed by Commissioner Craig Cates, District 1
Sandra Higgs,Secretary,appointed by Mayor Michelle Coldiron, District 2
Ginny Stones,Vice-Chairperson,appointed by Commissioner Eddie Martinez, District 3
David Manz,Chairperson,appointed by Mayor Pro Tern David Rice, District 4
Laura Lietaert,appointed by Commissioner Mike Forster, District 5
Monroe County will again provide funding for eligible human service providers for County Fiscal Year 2022. The
application and instructions will be made available on the Monroe County Human Service Advisory Board(HSAB)page
of the County website at the following web address: http://www.monroecounty-fl.gov/318/Human-Services-Advisory-
Board .The application will be submitted electronically as instructed in the application.Any questions regarding the
application should be directed to Janet Gunderson,Gunderson-Janet@monroecounty-fl.gov 305-292-4470, Monroe
County Office of Management and Budget, iloo Simonton Street, Room 2-213, Key West, FL 33040.The application �
must be submitted electror�icall} before 1 2:oo PM ednesday, lyla , —)o—)ia The electronic applications will 0.
be distributed to the HSAB for evaluation and recommendation. Each applicant is responsible for ensuring all
required information is provided and the application is complete. Please note the instructions below in addition to any
on the application.
Background: Funding recommendations are made by the Human Services Advisory Board (HSAB), created in 1991. 76
Each County Commissioner appoints one member,and the County Grants Coordinator provides staff support. Funding
recommendations may be altered by the Board of County Commissioners and are not final until the Commission
adopts the budget in September. �--
The HSAB will make its recommendations based on the service needs of Monroe County,availability of funds, prior o
years'performance,the information contained in your application,and so on. These recommendations will be finalized
at a meeting of the HSAB to be held on June 2,2021.
Presentations at the meeting are not required. However,applicants may address the HSAB if they wish to update any
information provided in their application or to request a change to their funding category. In addition,applicants are
encouraged to be present to address potential questions related to their applications from the HSAB. For the purposes 2
of updates,category changes or questions,applicants will be scheduled to speak in the order the applications were
received,and the schedule will be made available prior to the meeting.
All meetings of the HSAB are open to the public and are advertised in the local newspaper.You may attend any of these
meetings and you will have an opportunity to address the HSAB if you should choose to. The HSAB funding
recommendations will be considered for approval by the Monroe County Board of County Commissioners during its
budget process which concludes in September. �-
A sample contract with attachments is available upon request. Please note Monroe County funding is on a
reimbursement basis only, and certain expenses are not eligible(such as,fees,penalties and capital items). All
funding provided through the HSAB must be spent for the benefit of Monroe County.
VERY IMPORTANT
You MUST use Acrobat: Reader M or Acrobat Reader DC to complete and subs-nit the l...ISAB application.
if you do not currently have either version of Acrobat Reader,Acrobat Reader DC can be downloaded free.
Link to download free Adobe Acrobat..Reader DC: https:llget.adobe.com/readeJr
the application to your computer and close the file.
Using Acrobat Reader M or Acrobat Reader DC,open the application document.
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MONROE COUNTY-FISCAL YEAR tots C.14.b
HUMAN SERVICES ADVISORY BOARD
APPLICATION INFORMATION AND INSTRUCTIONS
1. Read the instructions and the application before entering data.
2. If you need your board's approval to apply,start the process early.
3. Assemble all required documents and have them available electronically if they need to be attached to the
application.
4. Complete the application,referring to the instructions below for each question.
5. When completing the application,do your best to put yourself in the place of the reviewer. Our board
members review about thirty applications in their spare time without financial compensation. Answers that
are not to the point will unnecessarily take up additional time and space.All fields are now character
limited.
6. Resist the urge to answer every question with a general narrative about your organization.Space is limited
so confine your response to the question asked. One of the most common errors occurs when applicants do
not answer the specific question being asked.
7. Be sure to read all questions and follow instructions carefully. Failure to do so may result in your application
not being considered.
8. Organize and title attachments to be placed on the Attachment Checklist using the attachment icon in the
corresponding attachment field.
g. It is a good idea to have a neutral person in your organization review and provide comments on the 2
completed application. Ask them to make sure every question is answered directly and completely. Better
for them to find the mistakes and omissions than for us to.
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lo. Make sure the individuals required to sign the application's certification will be available when it's
completed. The Certification signatures MUST be witnessed by two individuals and attached to Item P on
the Attachment Checklist.
11. Retain backup information used in preparing this application to justify amounts, client counts, etc.
These may be examined in an audit by County staff. cv
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12. Please note that your application and all attachments become public record and will be available for public
inspection. Do not include any confidential organization or client information.
13. Review the application again, making appropriate changes suggested by the reviewer, and checking to see if
you have completely answered each question. Remove extra words and phrases that add nothing to the
meaning of your answers.
14. Review the instructions and be mindful of the due date,Wednesday,May 5,2021 before 12:00 PM (noon).
15. Review your work one last time, make corrections if needed,you can save an electronic copy of the
application and then"Submit" in Acrobat Reader X! or Acrobat Reader D( when ready.
16. Do not contact HSAB members directly; any issues arising after the application has been submitted, or
topics not addressed in your application,should be discussed at the HSAB public meeting.Should an HSAB
member have questions regarding your application our office will contact you with the question.Your
response through us will then be provided to all the HSAB members.
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MONROE COUNTY-FISCAL YEAR tots C.14.b
HUMAN SERVICES ADVISORY BOARD
APPLICATION INFORMATION AND INSTRUCTIONS
INSTRUCTIONS
FY2022 Application Format
1. From the HSAB page of the Monroe County website, http://www.Monroecounty-fl.90v/318/Human-Services-
Advisory-Board select FY2022 HSAB Application(Fillable) Form.
2. Once it opens download the document to your computer and close the file. Using Acrobat Reader XI or
Acrobat Reader DC open the document.You MUST use Acrobat Reader M or Acrobat Reader DC to
cornplete and subs-nib .the application. If you do not currently have either version of Acrobat Reader you can
download it(https:[/ et.adobe.com/reader/)to your computer at no charge.
3. All answer fields are shaded blue.
4. All questions require a response. Should any question or required document not be applicable to your
organization, please explain-including the items listed on the Attachment Checklist.
5. If you are requesting$5,000 or less in funding there are a few questions which will state in the answer field,
`Response not required if applying for$5,000 or less'. In those instances,you may provide a response or 76
indicate you are requesting$5,000 or less.
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6. All answer fields are character limited.You may delete or backspace over any instructions or titles in the
answer fields.You may copy from a word document into the answer fields. Please make sure your response y
is visible in the text/answer field.Only what is visible in the answer field will be captured on the application.
Answers should be brief and to the point.
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7. If you absolutely require additional space to specifically answer a question you can state `see Item Q'at the
end of the text field. On the Attachment Checklist(pg.20)for Item Q—Other,you may attach additional
information. On the Attachment Checklist in the Comments field reference the question number and be sure o
to include the question number you are responding to in the document you are attaching. If you need
assistance with this,please contact us!
8. Some questions require a`Yes'or`No'response.Click inside the circle to make your selection. Based on your
response additional fields may appear or disappear from the form.
g. On#34.Agency Compensation Detail,#36.County HSAB Funding Budget,#37.Agency Expenses and#38.
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Agency Revenue be sure to enter your organization's fiscal year end month and day. Please realize Monroe cv
County Fiscal Year tots funding is for the period of October 1,2021 through September 30, 2022,regardless U_
of what months your fiscal year covers. We are interested in what your annual expenses and revenues are,
no matter what fiscal year you use, and you do not need to pro-rate your figures to fit the County fiscal m
year.
lo. On#36. County HSAB Funding Budget and #37.Agency Expenses you may add additional expense line
items/categories used by your agency,except for the personnel line items. Expense line items/categories
have been entered as examples; if your agency uses different line items/categories,you may enter them in
the available fields on the form,as long as they are reasonable and clear.
11. For currency figures, please round all amounts to the nearest dollar.Calculations are built into the form
fields and will calculate totals and percentages for you.
12. Label your attachments with the attachment item letter in the title and/or name of the file you are attaching
to make it easier to locate the file.You may want to place all files to be attached in one location on your
computer.
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MONROE COUNTY-FISCAL YEAR tots C.14.b
HUMAN SERVICES ADVISORY BOARD
APPLICATION INFORMATION AND INSTRUCTIONS
13. Please be sure that all required information and attachments are submitted in the application. It is not the
County's responsibility to find and notify you of errors or omissions or to ensure they are corrected. Your
application may not be considered if it is incomplete or if any required documentation is missing at the time
of the application deadline.
14. Once you have completed and reviewed the application you may save a copy to your computer. In
Acrobat Reader XI or DC, hit the`Submit'button in the upper right-hand corner on page one(1)of
the document to electronically submit the application via email.The`Reset Form'button in the
upper left-hand corner of page one will clear all data entered if you need to restart the application.
15. Once your application is submitted and has been received electronically,we will provide you with an
email confirmation acknowledging receipt of the application. Please do not wait until the last
minute to try and submit your application.Should you experience technical difficulties with the
application form or submitting the application please contact Janet Gunderson (305)292-4470. If you do not receive a confirmation email 48 hours after submitting the application, PLEASE
CONTACT US!
Instructions for FY2022 Application Questions
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Page 2. Cover Letter(Required) 76
Part I: Provide a brief overview of your organization. Part II: Indicate any change in organizational structure
specific to services or method of providing services. The intent is to inform the HSAB of any consolidating,
combining,or merging with other agencies to avoid duplication of services.
(Part I : Please provide an overview of your organization.
(Part II): If no changes to the organizational structure you may respond, "No Changes".
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1. Who prepared your application?(select one)
Select the answer that best describes who prepared your application. If other, enter a brief explanation in text field.
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2. List any overlap,common associations,common services,working relationships or sub-contractor relationships
with any other organizations i.e., board members, personnel,or shared services.
3. Describe any networking arrangements or collaborations that are in place with other agencies.
This is more than referrals or association memberships.Referrals to your agency are addressed in Question#20,and
referrals from your agency to other agencies would have been included as one of your services in Question#6.
Examples include cost-sharing,joint projects,and the like.
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4. What unique role in the community does the proposed program fulfill that no one else does? U_
Provide a brief description of how the services described in question#7 are unique to this community or the
people/area they serve.
5. Insert your agency's board-approved mission statement.
This should concisely describe your agency's mission and must have been discussed and approved by your Board of '
Directors.
6. List the services your agency provides.(General)
You may simply insert a list here;explanations or descriptions need only be entered for those not commonly
understood.
7. What specific services will be funded by this request? (Specific)
If the answer is the same as Question#6,just enter"same." Ensure this matches the description of services, clients,
and client numbers required on#35. Profile of Clients, Client Numbers and Services.
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APPLICATION INFORMATION AND INSTRUCTIONS
8. Have you previously been funded by HSAB? YES or NO
YES--Would you like the HSAB to consider changing your funding category?
YES--Which funding category best matches your services?Select from the drop-down menu—Medical, Core, or
Quality of Life
Medical Services:medical,mental,and dental care for the economically disadvantaged.
Core Services:essential services such as food, clothing,or housing;emergency disaster relief;family violence issues,
etc.
Quality of Life Improvement Services:services provided to improve the quality of life for individuals or the
community such as educational,preventative,training, recreational and cultural services, etc.
NO--Proceed to question#g.
NO--not previously funded,then-Which funding category best matches your services?Select from the drop-
down menu—Medical, Core Services or Quality of Life(see definitions above).
g. Will County HSAB funds be used as match for a grant? YES or NO
YES--then enter pop up fields, Grant Award Title, Purpose,Granting Agency,Amount,Award Date and Match
Requirement for each applicable grant.
NO--Proceed to question#io.
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lo. If your organization was awarded HSAB funds in FY 2021,please briefly and specifically explain:
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a. How have the 2021 HSAB funds been spent?
b. Were all HSAB funds awarded in FY 2020 spent?Will all HSAB funds awarded in FY 2021 be spent?
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c. Were HSAB funds used to leverage additional funding in FY 2021 and if so how?
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d. How much additional funding was received?
e. How was the additional funding spent? c
11. Have you experienced any changes specific to:
Please briefly and clearly state what the specific change is.
a. Mission Statement. YES or NO
1. YES—What Changed?
2. NO--Proceed to b.
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b. Goals. YES or NO
1. YES—What Changed?
2. NO--Proceed to c. m
c. Expansion or contraction of services,staff or location. YES or NO
1. YES--What Changed?
2. NO--Proceed to d.
d. How prior year funds were spent. YES or NO
1. YES—How prior year funds were spent.
2. NO--Proceed to question#12.
12. Did your agency lose any funding,or partial funding in 2021?YES or NO
YES--How much? From what source?Why was funding lost?
NO—Proceed to question#13
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APPLICATION INFORMATION AND INSTRUCTIONS
13. Do you plan to allocate any part of this HSAB grant, if awarded, as a sub-grant to another organization? YES
or NO
YES-- List the recipient(s),the purpose(s), and amount(s). (You can backspace over the titles in the text fields
for added characters).
Please make sure any sub-grants are included on#36 County HSAB Funding Budget under"Grants to Other
Organizations".
NO—Proceed to question#14.
14. Does your organization allocate sub-grants to other organizations using other(non-County)sources of
funding? YES or NO
YES-- List the recipient(s),the purpose(s), and amount(s).(You can backspace over the titles in the text fields
for added characters).
Please make sure any sub-grants are included on#37 Agency Expenses under"Grants to Other Organizations". 0.
NO--Proceed to question#15.
15. Will you or have you applied for other sources of Monroe County funding? YES or NO
YES--List all other sources of County funding you have applied for and/or have received,and the amounts.
An example would be the Sheriff's Shared Asset Forfeiture Fund (SAFF).Make sure these sources/amounts are 76
also reflected on#38 Agency Revenue.
NO--Proceed to question#16.
16. What needs or problems in this community does your agency address?
This should be a short response for each need addressed.For example, if you provide after-school programs for c
children, the problem that you address might be stated as, "the lack of supervision and activities for school-age
children in the afternoon and early evening." Do not discuss your program or services here. y
17. What statistical data supports the needs listed in Question#16?
(if applying for$5,000 or less,a response to this question is not required.)Summarize and explain any data that
shows the existence of the problem.You may include crime statistics, census bureau data,studies by impartial
organizations, Bureau of Labor Statistics reports, objective surveys,etc.Be sure to cite your sources.You should
include data showing the number of people in your target population. If needed,you may use Attachment Item 0-
Data showing need for your program, to attach additional information, reports,etc.The amount of service you
provide does not, in itself,support the need.
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18. What are the causes(not the symptoms)of these problems? `V
(if applying for$5,000 or less,a response to this question is not required.) Be sure to discuss only causes. Using the
example in Question#16,you might list things such as, "high cost of living and low wages that force both parents to
work,single-parent families,and lack of support from relatives."
19. Describe your target population as specifically as possible.
This should be a rather narrow definition of the people affected by the problems noted in Question#16. Include all
relevant characteristics,such as gender,age,geographic location,family situation,etc. For example, "children of
both sexes,from age three to fifteen,from single-parent families in the middle keys,with no adult supervision after
school."
2o. How are clients referred to your agency?
For example, this could be referral from another agency,self-referral,or referral from a family member or neighbor.
21. What steps are taken to ensure prospective clients are eligible and the neediest clients are given priority?
Describe your evaluation or screening process. Depending on the source of your referrals, this may have been done
by the referring agency;if so,please explain.
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MONROE COUNTY-FISCAL YEAR tots C.14.b
HUMAN SERVICES ADVISORY BOARD
APPLICATION INFORMATION AND INSTRUCTIONS
22. List all sites and hours of operation. Please note which of these sites will be using HSAB funding.
Street address is not necessary;city or town will suffice.If services are offered at clients'places of residence,please
note that,along with hours.
23. What financial challenges do you expect in the next two years,and how do you plan to respond to them?
(if applying for$5,000 or less,a response to this question is not required.) This might include economic or political
changes that would increase or decrease your revenue or expenses,and your plan to deal with these changes.
24. What organizational challenges do you expect in the next two years,and how do you plan to respond to them?
(if applying for$5,000 or less,a response to this question is not required.)This might include demographic,political,
social, or economic changes that would increase or decrease your target population or staff,and your plan to deal
with these changes.
25. How are clients represented in the operation of your agency?
If,for example,your clients are represented on your board of directors,or on an advisory board,please tell us about 0.
it.
26. Is your agency monitored by an outside entity? If so,by whom and how often?
(if applying for$5,000 or less,a response to this question is not required.) This may be a state or federal
government agency,an independent auditor, etc.You don't have to go into much detail;a copy of the monitoring 76
report will be inserted as Attachment Item N.Must include a summary of deficiencies and suggested corrective
action;may include your responses and actions taken.
27. hours of program service were contributed by volunteers in the last year.
Fill in the numbers of volunteers and hours donated.Do not include board or committee meetings—only program
service hours.
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28. Will any services funded by the County HSAB award be performed under subcontract by another agency? If so,
what services,and who will perform them?
Monroe County would like for the funds to go only to the applicant shown on this form.It is not normal practice for c
the County to fund subcontract arrangements such as this. It may be done only with Commission approval,and your
contract amended to reflect it.
29. What measurable outcomes do you plan to accomplish in the next funding year?
Outcomes are different from goals.Outcomes are the benefits to your clients,and may be related to knowledge,
skills,self-sufficiency, improved health,etc.For example,a nutrition program may have a goal of serving 1,500 meals
but strive for a measurable outcome of better health for 75%o f its clients.
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3o. How will you measure these outcomes? U_
Tell us how you will know if the outcomes above have been attained. Examples include surveys,arrest records,
follow-up visits,student grades,truancy rates,etc.
31. Provide information about units of service below.
(if applying for$5,000 or less,a response to this question is not required.) List the service in the left column,and <
enter the unit definition in the center column,and the cost per unit in the right column. If any requested
information is not applicable, please explain.
Service Unit hour,session,day,etc. Cost per unit current year
----------------------------------------------------------------------------------------------------- - -� ------------------------------------------------) ----------------------------------------------(-----------------------------------
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32. Address any topics not covered above(optional).
33• Board Information-Mostly self-explanatory;for"A f filiation/Title,"examples might be, "postal worker, U.S.
Postal Service,""Vice-President,XYZ Bank,""Retired,""client representative,"and so on.
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34• Agency Compensation Detail-Fill in dates to correspond with your fiscal year in the appropriate spaces. This
should include salary and all benefits,such as insurance, retirement, travel, or housing allowances, etc. Positions
can be listed together,such as"caseworkers;5.5 FTE;150,000, etc."Note that a twenty-hour position would be.5
FTE. Be sure to identify the benefits in the field below the totals. We realize that employees come and go,and an
existing long-time employee may be replaced by someone making a different salary. To avoid this problem,for
both years,you may use budgeted figures. Or, if you prefer,for the current year's projection,you may,for
example,add the YTD total compensation for all caseworkers and project that to an annual total, then do the
same for all other positions.We are also asking for a breakdown of program versus administrative
salaries/positions.
35• Profile of Clients,Client Numbers and Services—List all services offered by your agency in the first column. In the
next column, describe the target population in detail for each service. Include all characteristics of the target
population,such as gender, income level, etc. For example, "all single females, up to 125%of poverty level, with —
dependent child(ren), of all races."(Use two rows if needed).Then enter the number of persons in the target
population(this may be a larger number than the number of clients served). In the"Area"column, describe the
area served,such as"Marathon,""Key West to Big Pine Key,""Middle Keys,"etc. In the column, "Total#of
Clients Served during most recent completed fiscal year,"enter the total number of clients that received each
service for the most recent year. In the column, "Current#of Clients as of_/ enter the number of clients
(not cumulative)receiving the service on a recent date(such as the date of the application, or more likely a recent
month-end). (You will enter the actual"snapshot"date in the text box fields on the row"Current number of
unduplicated clients for the entire agency("snapshot")as of_/_/ ".)This number will most likely be less
than the number in the previous column. For example, in a shelter with 5o beds,you may have served ioo residents <
in a year's time, but no more than 50 on any given day.
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On the rows, "...unduplicated clients for entire agency..."enter data in the single column to the right. Do not
total the numbers already entered above. Note that, if a client receives two services, he or she must be counted
only once on this line. These numbers will likely be less than those entered in the upper portion of the form. Please
also indicate how many clients served are Monroe County residents in the final row.
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There is sample data entered;delete it or backspace over it.
Below the chart on the form,please list the achieved measurable outcomes for the targeted population.
36. County HSAB Funding Budget--Please indicate how you plan to use the COUNTY FUNDS requested in the
upcoming year. The total must agree with the amount requested on page i. Enter the month and day of your
fiscal year end. We are asking for a breakdown of program versus administrative salaries/positions. Line
items/categories have been filled in as examples. If your categories are different,feel free to add them in the fields cN
provided under, "List others below"except for those in the Personnel section. Totals and percentages will
automatically populate as data is entered.
37. Agency Expenses-Enter the month and day of your fiscal year end. Enter expense figures in the appropriate
fields. You may change expense line items/categories, except those in the Personnel section, to fit your
organization.Make annual projections based on YTD figures for the current year and use proposed budget figures
for the upcoming year. We are asking for a breakdown of program versus administrative salaries/positions. Totals
and percentages will automatically populate as data is entered. Percentages may be reflected as a whole number.
"Revenue over/(under)expenses"fields will automatically be calculated. However,please review the results to be
sure they appear correct. Mistakes in entering data in the expense and revenue fields can result in unusual results
here.
38. Agency Revenue—As on the previous form, enter the ending dates for your fiscal years where requested. Enter
revenue information for all sources of revenue in the appropriate fields. Unlike question#37,you may not change
existing categories;enter figures for those that apply, and add all other types of revenue in the"All Other Sources"
section,such as interest earned,fees collected, etc. If you receive free rent or donated supplies,for example, those
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would be entered in the"in-Kind"column.Make annual projections based on YTD figures for the current year;use
proposed budget figures for the upcoming year. Totals and percentages will automatically populate as data is
entered. Percentages may be reflected as a whole number.
39• What is the current number of employees,full-time and part-time,on the payroll for the entire
organization?"There are employees("snapshot")as today's date ". Enter the number of
employees and the date.
40. Please list the position,if any,within your organization that are currently vacant and explain why each position
is vacant.
A.I. NEW ADDENDUM TO THE FY2022 HASB APPLICATION —COVID-ig ASSISSTANCE
Did your organization receive any local,state,federal assistance(i.e.,Paycheck Protection Program,EIDL, 2
CARES Act)or insurance for your COVID-19 related impacts?
If Yes,complete the table:
Enter revenue information for all sources of revenue in the appropriate fields. Indicate if the payback has been
forgiven and how the funding was used. If you receive free rent or donated supplies,for example, those would
be entered in the"in-Kind"column.
41. Instructions for Question #41 Application Checklist
An example is provided in the first two rows. Help is available on screen to provide information on how to attach
documents as well as an explanation for the information requested on each item in the Help column.
How To Attach-To save attachments to PDF files,you will need to use Acrobat Reader XI,or newer(DC).To attach a u2
file to the form,first select the Attachment Tool:
In XI: select"Comment>Annotations>Attach file(paperclip icon)".
In DC: select"Tools >Comment>Attach file(paperclip icon)".
Then click on the`Attachment Field", next to the corresponding Attachment Title you intend on attaching.
Next,you will be prompted to select the Attachment from your computer.
Optionally,while the paperclip icon is still selected(it will be blue)you can fine tune its location with the arrow keys.
Preferred Format: PDF. Accepted Format: .docx, .xlsx,.jpg, .png
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Attachment Checklist-Select YES or NO in the appropriate column to indicate whether the attachment is included in your
application. You must enter comments for any attachment that is not included.Place the attachment icon(the
paperclip)in the Attachment column in the appropriate row for the item.
Attachment Item A-Evidence of Annual Election of Officers-Attach evidence of annual election of officers(i.e., copy of
minutes of meeting in which most recent elections took place.)
Attachment Item B,Audited Financials-A copy of your organization's unqualified audited financial statement from the
most recent fiscal year(2020)is required if your organization's expenses are$150,000 or greater, or if you received
$ioo,000 or more in grants from Monroe County;if qualified,include a statement of deficiencies with corrective actions
recommended/taken;If your organization's expenses are less than$150,000,a Statement of Functional Expenses for the
most recent fiscal year is required.
Attachment Item C,IRS Form 990-For FYzz,you should be submitting your zozo IRS 990 Form. I f you do not have the
zozo year,please specify why not in the attachment checklist. If you have filed for an extension,please submit that
extension letter with your 2019 form. The 990 form must be the version that was filed with the IRS.
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MONROE COUNTY-FISCAL YEAR tots C.14.b
HUMAN SERVICES ADVISORY BOARD
APPLICATION INFORMATION AND INSTRUCTIONS
Attachment Item D,Fee Schedule—A copy of your current fee schedule is required.
Attachment Item E and E.i,Proof of Registration or Exemption with the FI.Dept.of Agriculture&Consumer Services
—Proof of registration with the Florida Department of Agriculture&Consumer Services as required by Florida Statute
496.405 or proof of filing documentation as required by Florida Statute 496.4o6 for exemption from registration or
alternatively a sworn statement from the Organization's representative confirming that it does not conduct solicitation
activities. Pursuant to F.S. 496.403, F.S.496.405 does not apply to religious institutions, educational institutions and state
agencies or other governmental entities and thus this requirement does not apply to those organizations.
Attachment Item F and F.i,IRS Letter of Determination&GUIDESTAR—In addition to providing a copy of the actual IRS
Letter of Determination indicating 501c3 status, please provide a current printout from GUIDESTAR that shows your
organization has current 501c3 status. This can be a printed copy of the online screen. Please be sure the printout indicates
current status with the IRS.
Attachment Item G,Personnel Policy and Procedures Manual—Documentation of hiring policies for all staff, drug and
alcohol-free workplace provisions,and equal employment opportunity provisions are required.
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Attachment Items H through K,Copy of County/State/Federal Licenses/Permits-Provide a copy of Monroe County and 76
City occupational licenses,State and/or Federal licenses,permits or certifications in the appropriate field. Please provide a
comment for any that do not apply to your agency.
Attachment Item L,Audit Documentation—If you receive$ioo,000 or more in grant funding from the County an audit
shall be prepared by an independent certified public accountant.Attach the following items from the auditor performing
the required audit: 2
i. A copy of a current, in good standing,State of Florida Board of Accountancy CPA license.
2. A copy of membership document with the American Institute of Certified Public Accountants(AICPA).
3. A copy of malpractice insurance covering the audit services provided. o
4. A letter from the Auditor,stating, the County shall be considered an `intended recipient'of said audit.
Attachment Item M,Organization's Corporate Bylaws—Provide a copy of the current bylaws.
Attachment Item N,Evaluation or Monitoring Reports—A copy of your most recent evaluation or monitoring report,
including a summary of deficiencies,and suggested corrective action;may include your responses and actions taken.
CD
Attachment Item O,Needs Data—This pertains to Question#17 of the application. (if applying for$5,000 or less,a
response to question#17 is not required).
Attachment Item P,Certification Page—Download the blank certification form by selecting the paperclip icon next to the
title. Complete the form and secure all required signatures including the witness signatures. Scan the signed, completed
form back onto your computer and attach the form and place the attachment icon in the corresponding field.
Attachment Item Q,Other-You may add an attachment of your choice,as Attachment Q. This may include a brochure,
letters of support, or other additional responses to earlier questions you were not able to include in your application due to
character limitations.Additional responses MUST identify the questions number the answer is for.All required documents
must be included as attachments to the application.
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C.14.c
HUMAN SERVICES ADVISORY BOARD
SCHEDULE OF THE FY2022 FUNDING CYCLE
❖ FY2022 First HSAB Meeting
Date: Friday, March 10, 2021
Details: Discussion of the upcoming FY2022 budget period of October 1, 2021 through
September 30, 2022
❖ FY22 Notice of Funding Solicitation &Application Released to the Public
Date: Friday, March 19, 2021
■ Notices sent to local, interested, 501c3 human service organizations.
■ Grant application available for download on HSAB website:
htt ://www.� onroecomty-fl.gov/31 / urn-Services-Advisory-Board
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Date: Week of Monday March 22. 2021
■ Legal Notice of"Funding Availability"published in local newspapers: The 0
Citizen, Free Press, News Barometer and Keys Weekly >
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❖ FY2022 Grant Application Deadline
Date: Wednesday, May 5, 2021 (Due before Noon)
Details: Applications are to be submitted electronically
❖ FY2022 HSAB Funding Meeting
Date: Wednesday, June 2, 2021
Details: Discussion of the applications received from the human services organizations �-
& recommendations for funding.
❖ BOCC Approval of HSAB Recommendations for FY2022
Date: After approval of the FY2022 Budget for Monroe County.
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