ICDVVA FY22 Grant Application Form

SECTION 1: COVER SHEET
A. Date of Application *

Month Day Year
Date
B. Organization *
C. Organization DUNS Number *
D. Organization Federal Tax ID (EIN) *
E. Type of Organization *

Nonprofit City County University or College Hospital Tribe Other
F. Focus of Organization *

Child Abuse Service Organization Coalition Domestic and Family Violence Organization Domestic/Family Violence and Sexual Assault Organization Faith-Based Organization Organization for Underserved Victims of Crime (e.g., Drunk Driving, Elder Abuse) Sexual Assault Organization Multiservice Agency Other
G. Organization Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
H. Organization Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I. Email Address *
example@example.com

J. Online/Social Media Presence

Fill In Where Applicable

Website

Facebook

Twitter

Instagram

Other

K. Public Health District Region (see map below) *

Region 1 Region 4 Region 6 Region 2 Region 5 Region 7 Region 3

L. Contact Information *

Name

Phone

Executive Director

Project Director

Fiscal Officer

Board President

M. Funding Summary: Please indicate the specific funds requested from ICDVVA. For any funding stream you are not requesting, you may leave that box blank. ICDVVA reserves the right to adjust funding sources as necessary. *
VOCA Request
FVPSA Request
State DV Request
TOTAL Request
N. Funding Status for FY21 (July 1, 2020 - June 30, 2021) *

My organization is currently funded by ICDVVA My organization is NOT currently funded by ICDVVA

SECTION 2: INTRODUCTION
Refer to the Grant Announcement and Detailed Application Instructions document for detailed instructions. Following instructions will result in a higher application score. The Goals and Objectives questions are specific to each funding source; please develop goals and objectives specific to VOCA, FVPSA, or the State DV funds.
A. Program Mission Statement *
B. Annual Planning: Please provide a brief summary of your annual planning process to meet the needs of victims in your community. (NOT a strategic plan) *
C. Purpose of Request: Provide a description of the project(s) for which you are requesting funding. *
D. Goals and Objectives for the FY22 Grant Year (July 1, 2021 - June 30, 2022) *
E. If you currently receive funding from ICDVVA, provide your FY21 Goals and Objectives and summarize your progress made for each one. *

SECTION 4: COLLABORATION AND COMMUNITY SUPPORT
A. Collaboration: Address collaboration with other community entities and specific collaborative efforts with other victim services providers (For organizations currently funded, you may substitute this question: Describe any new collaborations with other victim services programs in your region.) *
B. Outreach: Describe the outreach efforts of your program as requested. Response is limited to 500 words. (For organizations currently funded, you may substitute this question: Have you expanded your outreach efforts in the last year? Do you plan any new outreach initiatives in the coming grant year?) *

0/500
C. Victim Resources: Describe efforts to provide victims with knowledge of available resources while they are receiving services from your program *

SECTION 5: STAFF AND VOLUNTEERS
A. How many full-time employees does your organization have? (all employees, not only ICDVVA-funded) *
B. How many part-time employees does your organization have? (all employees, not only ICDVVA-funded) *
C. Staff Who Will Be Funded by Our Grants
D. Describe turnover in grant-funded staff positions within the past year. *
E. How many volunteers does your organization have?
F. Indicate the types of volunteers (e.g., hotline, advocates, administrative, etc.) you have and the average number of hours they volunteer per week.

SECTION 6: FUNDING AND SUPPORT
A. Describe your fundraising activities during the last completed grant year (July 1, 2019 - June 30, 2020). Include results, successes, and challenges for each. *
B. Describe fundraising activities to be conducted during State Fiscal Year 2021 (July 1, 2020-June 30, 2021). Include anticipated amount of funds raised. *
C. List all funding sources, current and pending, for state fiscal year 2022 (July 1, 2021-June 30, 2022) and the percentage of funding for your program. Include grants, fundraising activities, donors, etc.
D. Describe your plans to ensure long-term financial stability. *
E. Describe the management of your program's day-to-day operations. *
F. Upload your organizational chart. *

Cancel of

SECTION 7: FISCAL MANAGEMENT
A. Describe how your program is staying in compliance with its Financial Policies and Procedures. *
B. Describe your agency’s auditing procedures and any open audit findings. *
C. Does your agency expend $750,000 or more in federal awards in your agency’s fiscal year? *
If yes, you must have a single audit conducted in accordance with § 200.514.
D. Describe your agency’s ongoing budget monitoring procedures. *
E. Describe how you will comply with ICDVVA Data Collection Reporting Procedures. *
F. Please follow this link to download the Budget Worksheet from our website. (https://icdv.idaho.gov/grantees/voca-and-family-violence-grant-application/) Complete it and upload the Excel file below.
Upload Your Completed Budget Worksheet Here. (Use the link provided above to download the Excel file):

Cancel of
G. Upload a Detailed Budget Narrative Here (It should support and justify all proposed costs in your Budget Worksheet)

Cancel of
H. Please provide the sources of match you intend to use for the amount of funding requested *
I. Describe the methods you will use to document match. *

SECTION 8: CERTIFICATIONS & ASSURANCES, AND AUXILIARY FORMS

All Certifications and Assurances should be signed and combined into one pdf, to be uploaded below.
A. Download these Certifications and Assurances. (They are also available on our website.) Please print them, sign them, and scan them to create one pdf document. Then upload them in Section B below.
B. Upload pdf with all 8 signed Certifications and Assurances Here. *

Cancel of
C. Upload Three Letters of Support Here. *

Cancel of
D. Upload Your Certificate of Liability Insurance Here. *

Cancel of
E. Upload Your Certificate of Professional Liability Insurance Here. *

Cancel of
F. Upload Your Certificate of Workers Compensation Insurance Here. *

Cancel of
G. Upload Proof of SAM (System of Award Management) Registration Here. *

Cancel of

SECTION 1: COVER SHEET