ADAMH Funding Requests

Please review the Funding Requests Guidance for Applicants before completing and submitting the application. ADAMH will make determinations about whether an organization is qualified based on the application materials submitted and the history of the people and the organization(s) involved in the project. The organization may be required to be certified by the Ohio Department of Mental Health and Addiction Services.

Application deadlines are:

April 1 - Operational/Programmatic requests
July 15 - Operational//Programmatic requests
October 1 - Capital requests

Name of Organization *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Point of Contact Name for this Request *

First Name Last Name

Email for Point of Contact *

example@example.com

Phone Number for Point of Contact *

This request is for: *

program/operations shift of existing provider allocation capital funds

Is this an emergency request? Emergency requests are those which BOTH (1) threaten the ability of the provider to provide services and/or represent a significant safety hazard to clients or staff; and (2) could not reasonably have been foreseen. *

YES NO

Brief description of the project/request: *

You will be asked to upload a complete Project Narrative at the end of this form.

Amount of funding requested from ADAMH? Funding requests and funding provided by applicant must equal full project budget *

Amount of funding for project provided by applicant? Funding requests and funding provided by applicant must equal full project budget. *

Amount of funding for project requested by other sources (list sources and amounts)? Funding requests and funding provided by applicant must equal full project budget.

	Source	Amount	Check if pending
Source 1
Source 2
Source 3
Source 4
Source 5

Briefly describe the project timeline: *

What is the current nature of applicant's financial relationship to ADAMH? *

Receive funding as a provider and submit claims Receive funding but do not submit claims Do not currently receive funding

Project Narrative - File Upload

Please upload the project narrative to accompany this application. The project narrative should answer the following quests as outlined in guidance for applicants.

Please upload the project narrative to accompany this application. The project narrative should answer the following quests as outlined in guidance for applicants. For capital projects, answer the first set of questions. For programmatic funds, answer the second set of questions. You may cut and paste these questions, or you may answer them in the body of your narrative.

Capital Projects

What type of project is this: new build, renovation of your current structure, renovation of a structure not yours or not currently used by your organization, major repairs/maintenance?
What do you plan to do with this project? Provide a detailed description and include the reason why this project is necessary.
What will happen if you are not able to move forward with this project?
At what phase are you in the work? What is the anticipated completion date?
Do you own the land and/or structure on which you are proposing to do this work? If not, explain the nature of your organization’s financial relationship with the land/structure.
Do you have credible estimates obtained in the last six months of how much the work will cost to complete? If not, what is your basis for your project cost figure? If so, what are the estimates, and do you still consider them accurate?
If the project will be financed in part, explain the financing arrangements you have in place.
Who is the project manager for your project? How much experience does this person have with building projects?

Program Projects

Provide a detailed description of the project. Why is there a need and how do you know that the need exists? Explain how the project aligns with at least one ADAMH system of care. Is the program consistent with the ADAMH Community Needs Assessment from 2020 ?
What is the target population? Are there specific zip codes targeted for the project? How does the population align with the ADAMH Community Needs Assessment ?
Describe the capacity of your organization or partnership to implement the proposed project and to track its results.
Describe your sustainability plans for this project? ADAMH funding is not guaranteed beyond the current grant funding cycle.

Project Budget - File Upload

Please upload the proposed project budget to accompany this application. You may use your own budget forrmat as long as all budget categories outlined below as referenced in the guidance for applicants.

Complete a budget for your proposed project using the appropriate format found in this attachment, or you may use your own format if all budget categories found on this page are included. Indirect and administrative costs may be included in your request. The amount you request from ADAMH for indirect and/or administrative costs may not exceed 17% of the total project amount requested from ADAMH.

Note that your sources of funds (i.e., your revenue budget) is part of this form.

For Programmatic Requests - Include the ADAMH Request and Total Project Amount for each category below.

Personnel (including payroll taxes and fringe)
Supplies/Equipment
Consultants/Partners
Materials Development
Evaluation
Space Rental
Indirect Costs/Administration
Other (list)
TOTAL

For Capital Requests - Include the ADAMH Request and Total Project Amount for each category below.

Land
Design
Construction
Consultants (separate line for each)
Contingency (_____% of construction costs)
Permits and Legal

Funding Requests to ADAMH Board of Franklin County