IDesILaytags_1 05180d052012ASDDSHS05_180d+4j P%-)*0*+lH,m_ -$  &,28>DJPV\bhntz6`Submit 6 ˬXY[6s6$64*35140800190180187jH4workpage-#####;#####-####() -(###) ###-####@@X  9 @@@@@@ @@@@@. .T8T Tݲ90/_T09/5M 8T.M lT/|LN M N TM "T/'T0/TLA./T..\AM   A.  A.@@@  @@N6833 1&@XXjdVXXdʜ(?d fp H  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~HContractNumber ProgramArea DateStamp AgencyNameAgencyTelephone AgencyFAXAgencyAddress_StreetAgencyAddress_CityAgencyAddress_StateAgencyAddress_ZipAgencyMailingAddress_StreetAgencyMailingAddress_CityAgencyMailingAddress_StateAgencyMailingAddress_ZipImplementingNameImplementingAddress_StreetImplementingAddress_CityImplementingAddress_StateImplementingAddress_ZipImplementingTelephoneSSN ProjectTitleLegalAuthorityNameAgencySignatureDateAcceptance_Yes Acceptance_NoOJJSignatureDateProjectDirectorNameProjectDirectorAddress_StreetProjectDirectorAddress_CityProjectDirectorAddress_StateProjectDirectorAddress_ZipProjectDirectorTelephoneProjectDirectorFAXProjectDirectorEmailFinancialOfficerNameFinancialOfficerAddress_StreetFinancialOfficerAddress_CityFinancialOfficerAddress_StateFinancialOfficerAddress_ZipFinancialOfficerTelephoneFinancialOfficerFAXFinancialOfficerEmail AgencyName1Date ProjectTitle1A_PositionTitles A_StateFunds A_CashMatchA_ProjectTotalA_StateFunds_TotalCashMatch_TotalA_ProjectTotal_TotalA_Justification AgencyName2Date1 ProjectTitle2 B_Listing B_StateFunds B_CashMatchB_ProjectTotalB_Total C_Listing C_StateFunds C_CashMatchC_ProjectTotalC_TotalB_StateFunds_TotalB_CashMatch_TotalC_StateFunds_TotalC_CashMatch_Total AgencyName3Date2 ProjectTitle3 D_Listing D_StateFunds D_CashMatchD_ProjectTotalD_Total E_Listing E_StateFunds E_CashMatchE_ProjectTotalE_TotalD_StateFunds_TotalD_CashMatch_TotalE_StateFunds_TotalE_CashMatch_Total AgencyName4Date3 ProjectTitle4 F_Listing F_StateFunds F_CashMatchF_ProjectTotalF_Total G_Listing G_StateFunds G_CashMatchG_ProjectTotalG_TotalF_StateFunds_TotalF_CashMatch_TotalG_StateFunds_TotalG_CashMatch_Total AgencyName5Date4 ProjectTitle5ProposedTime_FromDateProposedTime_ToDateA_Personnel_TotalB_Supplies_Total C_Other_TotalD_CapitalOutlay_TotalE_Travel_TotalF_Contractual_TotalTotalDirectChargesG_IndirectCharges_TotalTotalProjectCostProjectSummaryA_Personnel_StateFundsB_Supplies_StateFundsC_Other_StateFundsD_CapitalOutlay_StateFundsE_Travel_StateFundsF_Contractual_StateFundsTotalDirectCharges_StateFundsG_IndirectCharges_StateFundsTotalProjectCost_StateFunds AgencyName6Date5 ProjectTitle6 AgencyName7Date6 ProjectTitle7 ProjectPlanrcePercent2OtherSourcePercent3OtherSourcePercent4A_Personnel_StateFundsB_Supplies_StateFundsC_Other_StateFundsD_CapitalOutlay_StateFundsE_Travel_StateFundsF_Contractual_StateFundsTotalDirectCharges_StateFundsG_IndirectCharges_StateFundsTotalProjectCost_StateFunds AgencyName6Date5 ProjectTitle6 AgencyName7Date6 ProjectTitle7 ProjectPlan AgencyName8Date7 ProjectTitle8ProjectOutcomes1Projec`  @ @p  5P  AGENCY NAME,@$ @q  6P$ DATE@0 2STATE GANG PREVENTION AND INTERVENTION APPLICATION @$ @r@  #7A$  PROJECT TITLE.@ $S  411. DESCRIPTION OF THE PROJECT (START ON THIS PAGE)     /p"0$ PAGE 8  /@$D@s0  801$ :Project's Plan to hire a qualified, independent evaluator:    P008r:   ` DRAFTN=HH^=M  N/P/ DSHS 05-180E (05/2012)  ] masterpage masterpageterpageN%Z3Submit )f 05180d052012T8T 1TR<`ASD_T`R<DSHSXJI05_180d\T/l<*0l3'3'&3'd'`=@ʜS od6*r+ SignatureVersion Data Vers\$ Blue Keys*Graphics0Header6 FieldList\< Form Infof LayoutPropsl'x DesPathInfol'~CellDisplayName6+~thisR],TK  {ROFFICE OF JUVENILE JUSTICE (OJJ) State Gang Prevention and Intervention Application Please read all instructions carefully.   ! T    For assistance, contact the Department of Social and Health Services (DSHS) Office of Juvenile Justice at (360) 902-7526 or FAX (360) 902-7527. @@Fle Fel  Fle,Arial (V1MFor assistance, contact the Department of Social and Health Services (DSHS) (_CCOffice of Juvenile Justice at (360) 902-7526 or FAX (360) 902-7527.@  dp CONTRACT NUMBER=0@P  eQp  PROGRAM AREA10$S $ S FOR OJJ USE ONLY,U U, Fle ,U,Arial ( FOR OJJ USE ONLY00$@  g@$  DATE STAMP'0$Sp  (1. APPLICANT: DO NOT USE PERSON'S NAME`@`  ha  AGENCY NAME,`@`  iap TELEPHONE NUMBER@`$@`  ja$  FAX NUMBER'` @  kp STREET ADDRESS7` $` @  lpp CITY` @   mp STATE` $@   np$ ZIP CODE  `@  `  o  a MAILING ADDRESS7  `$  `@  `  p  ap CITY  `@  `  q  a STATE  `$@ `  r  a$ ZIP CODE ` $S  " |2. IMPLEMENTING AGENCY: ENTER AGENCY, DEPARTMENT OR CONTRACTOR DIRECTLY IMPLEMENTING THE PROJECT (DO NOT USE PERSON'S NAME  @   s   NAME @  t  STREET ADDRESS7 p@  u  ` CITY p@  v  STATE@  w  ZIP CODE  $@   y  $ TELEPHONE NUMBER@ $@p  z q$ eFEDERAL EMPLOYER IDENTIFICATION NUMBER OR SOCIAL SECURITY NUMBER (MANDATORY FOR FEDERAL TAX PURPOSES)`T `T ,U `T,Arial (k:FEDERAL EMPLOYER IDENTIFICATION NUMBER OR SOCIAL SECURITY (k+NUMBER (MANDATORY FOR FEDERAL TAX PURPOSES)@$S@0 ;3. PROJECT TITLE: ENTER BRIEF, DESCRIPTIVE PROJECT TITLE @$@  #{`$ NAMEp$Sp 4. APPLICANT'S AGREEMENTf+ /0$  Omission of any required information or certification may be cause for denial of the application. The Department shall take a final approval/disapproval action on all applications within 90 days of receipt by the Department of a conforming application, together with all required certifications. The Department shall not consider an application conforming unless the applicant has completed all items in accordance with instructions and has submitted the necessary certifications. The applicant must submit two signed completed applications to: OFFICE OF JUVENILE JUSTICE, DEPARTMENT OF SOCIAL AND HEALTH SERVICES, PO BOX 45828, OLYMPIA WA 98504-5828. llJ J  J,Arial ("Omission of any required information or certification may be cause for denial of the application. The Department shall take a final approval/disapproval ("action on all applications within 90 days of receipt by the Department of a conforming application, together with all required certifications. The ("Department shall not consider an application conforming unless the applicant has completed all items in accordance with instructions and has submitted ("the necessary certifications. The applicant must submit two signed completed applications to: OFFICE OF JUVENILE JUSTICE, DEPARTMENT OF ("ASOCIAL AND HEALTH SERVICES, PO BOX 45828, OLYMPIA WA 98504-5828.0$@0  1$ NAME AND TITLE OF AUTHORIZED OFFICER (PERSON WITH LEGAL AUTHORITY: COUNTY COMMISSIONERS' CHAIRMAN OF THE BOARD, MAYOR, CITY/TOWN MANAGER, AGENCY DIRECTOR),0$@  @$ DATEP APPLICANT'S SIGNATURE M0 0 *ACCEPTANCE OF OFFER COUNTEROFFER FOR DSHS !0  ` ! 0@  p!   Acceptance - `0! @  p! Non-acceptance > 0P $OJJ CONTRACTING OFFICER'S SIGNATURE  !0!0$@ 0   1$ DATE!0!$S!p!# ~5. PROJECT DIRECTOR: PERSON IN DIRECT CHARGE OF PROJECT (DAY-TO-DAY OPERATIONS AND PREPARATION OF REQUIRED PROGRESS REPORTS)!#`@"`  !"a NAME AND TITLE2#`$@#  #p# STREET ADDRESS7$&`$&` p@%`  $%a ` CITY$ p&`@%`  $ %a STATE$&`@ %`  $%a ZIP CODE!#`$@!"`  !"a$ TELEPHONE NUMBER@#`$$@"#  #p#$  FAX NUMBER'$&`$@#%`  $%a$ E-MAIL ADDRESS3&`'$S&'$ 6. FINANCIAL OFFICER: PERSON IN CHARGE OF FISCAL MATTERS (ACCOUNTING, FUNDS MANAGEMENT, EXPENDITURE, VERIFICATIONS, FINANCIAL REPORTS)+'(@$'  ' ' NAME AND TITLE2(*@%)  () STREET ADDRESS7*+*+ p@&*  * * ` CITY* p+@'*  * * STATE*+@(*  * * ZIP CODE'($@)'  ' '$ TELEPHONE NUMBER@(*$@*)  ()$  FAX NUMBER'*+$@+*  * *$ E-MAIL ADDRESS3 $  The applicant is applying for a grant award in the amount shown in the proposed BUDGET SUMMARY (Section 8 of this application) for the purposes identified in this application. By signing and submitting this application, the applicant agrees that this document, together with the STANDARD CONDITIONS AND CERTIFICATIONS (Attachment A of this application), becomes an offer to contract with Washington State Department of Social and Health Services (DSHS or the Department) which, if accepted, binds the applicant to the following: 2rJ 2Jr  2rJ,Arial (D"The applicant is applying for a grant award in the amount shown in the proposed BUDGET SUMMARY (Section 8 of this application) for the purposes (O"identified in this application. By signing and submitting this application, the applicant agrees that this document, together with the STANDARD (Z"CONDITIONS AND CERTIFICATIONS (Attachment A of this application), becomes an offer to contract with Washington State Department of Social and (e"bHealth Services (DSHS or the Department) which, if accepted, binds the applicant to the following: $  The applicant agrees that this offer becomes a binding contract when a copy of this page is signed by the OJJ Office Chief and returned to the applicant together with an Approved Budget and Special Conditions form provided, however: aJ aJ 2rJ aJ,Arial (s"The applicant agrees that this offer becomes a binding contract when a copy of this page is signed by the OJJ Office Chief and returned to the applicant (~"Otogether with an Approved Budget and Special Conditions form provided, however:@   a. z6 z6 aJ z6,Arial ("a.@$  In the event any budget category amount differs from the amount shown in Section 8 of this application, as modified by the Approved budget and Special Conditions, that amount shall be considered to be a counteroffer. The Department shall consider the counteroffer accepted by the applicant unless rejected in writing within 30 days after the date of mailing of such counteroffer by the Office of Juvenile Justice (hereinafter referred to as OJJ) to the applicant. z"J "zJ z6 z"J,Arial (,In the event any budget category amount differs from the amount shown in Section 8 of this application, as modified by the Approved budget and (,Special Conditions, that amount shall be considered to be a counteroffer. The Department shall consider the counteroffer accepted by the applicant (,unless rejected in writing within 30 days after the date of mailing of such counteroffer by the Office of Juvenile Justice (hereinafter referred to as OJJ) (,to the applicant.    b. 6 6 z"J 6,Arial ("b. $  Upon acceptance of this offer/counteroffer, the applicant shall be referred to as the "Contractor" and the Contractor agrees to accept and abide by the special terms and conditions. VV"J "J 6 "J,Arial (,Upon acceptance of this offer/counteroffer, the applicant shall be referred to as the "Contractor" and the Contractor agrees to accept and abide by the (,special terms and conditions.p$+/@$/p"0$ PAGE 1 HBGrant ApplicationP001`I?HoBGrant Application ``@$ DRAFTN=HH=MGrant ApplicationE/p"0$ PAGE 1 :- L@ @,  P  AGENCY NAME,@$@-  P$ DATE@0 2STATE GANG PREVENTION AND INTERVENTION APPLICATION @$ @.@  #A$  PROJECT TITLE.@ $S  p ,10. BUDGET DETAILS: CATEGORY A. PERSONNEL    /p"0$ PAGE 3  $p 4 This category is for services rendered by all personnel employed by the project. Costs incurred include salaries, benefits, uniforms, and special clothing. SALARIES AND WAGES: Payment for personal services rendered in accordance with rates, hours, terms and conditions as authorized by law or stated in employment contracts. OVERTIME, HAZARDOUS DUTY, ETC. PERSONAL BENEFITS: FICA, retirements, insurance, etc. UNIFORMS AND CLOTHING: Only uniforms for special clothing required by the nature of the employment and paid for by the employer may be listed. NOTE: Project funds may not be used to pay a percentage of the compensation of any person who was employed by the implementing agency before the project starting date without prior specific authorization from the Department separate from the grant approval. Specific authorization is not required if a person currently employed by the applicant or the implementing agency is transferred from his/her prior position to the project if the transfer creates a personnel vacancy to be filled by hiring a new employee.   K }   ^Q ^Q "J ^Q,Arial (p"This category is for services rendered by all personnel employed by the project. Costs incurred include salaries, benefits, uniforms, and special clothing. ("SALARIES AND WAGES(}: Payment for personal services rendered in accordance with rates, hours, terms and conditions as authorized by law or stated ("in employment contracts. ("OVERTIME, HAZARDOUS DUTY, ETC. ("PERSONAL BENEFITS: (}$ FICA, retirements, insurance, etc. ("UNIFORMS AND CLOTHING:(z Only uniforms for special clothing required by the nature of the employment and paid for by the employer may be listed. ("NOTE: Project funds may not be used to pay a percentage of the compensation of any person who was employed by the implementing agency before the ("project starting date without prior specific authorization from the Department separate from the grant approval. Specific authorization is not required if a ("person currently employed by the applicant or the implementing agency is transferred from his/her prior position to the project if the transfer creates a ("8personnel vacancy to be filled by hiring a new employee.p$@/  Title  p @/    LIST POSITION TITLES V p@/   0 ANNUAL SALARY  y y ^Q y,Arial ( ANNUAL SALARYp 0@/    PERCENT OF TIME TO PROJECT     y  ,Arial ( PERCENT OF (TIME TO ( PROJECT 0p$ @/   @$  ITEM TOTAL / $p p  H0 p!Pq  2. Match  % p 0 H1 p!Pq  2. Match  % p 0$ H2 p!Pq  2. Match  %  CATEGORY TOTAL Ip p 0p 0$/@$D@3!  !!$  JUSTIFICATION AND EXPLANATION: Justify all positions in terms of days and/or hours required to perform the GOALS, OBJECTIVES, AND TASKS set forth. Calculate fringe benefits for each position or class of positions. xxT T   T,Arial (JUSTIFICATION AND EXPLANATION: Justify all positions in terms of days and/or hours required to perform the GOALS, OBJECTIVES, AND TASKS set (Jforth. Calculate fringe benefits for each position or class of positions.PP 0 %     pP 0 %     P@ 0 %     P` 0 %     P 0 %     P 0 %     P 0 %     0P 0 %     PP 0 %     pP 0 %     P@ 0 %     P` 0 %     @ %     Budget 1P0021 2. Match   %  $$ %    `$ `$H= p!Pq  2. Match  "% @$$ %    `$ H> p!Pq  2. Match  "%  `H? p!Pq  2. Match  "%  ` $H@ p!Pq  2. Match  "% `$ $ %    ` $ ` HM  TOTAL PROJECT FUNDS   l  `$HN p!Pq  2. Match   % $$ %    `$p$Cpp D9. PROJECT SUMMARY: GIVE A BRIEF NARRATIVE SUMMARY OF THE PROJECT.p/@$HO p!Pq  2. Match  "% /`/ BDSHS 05-180 (REV. 09/2002) PROPOSED REVISION - DO NOT PRINT MILLIE/p"0$ PAGE 2  @HA p!Pq  2. Match  "%  @ `HB p!Pq  2. Match  "%  `@$HC p!Pq  2. Match  "% $@$ %    `@$@`HD p!Pq  2. Match  "% @` `HE p!Pq  2. Match  "% @ ``$HF p!Pq  2. Match  "% $`$ %   @ ``$`HG p!Pq  2. Match  "% ` `HH p!Pq  2. Match  "% ` `$HI p!Pq  2. Match  "% $$ %   ` `$HJ p!Pq  2. Match  "%  `HK p!Pq  2. Match  "%  `$HL p!Pq  2. Match  "% $$ %    `$(-m$e@ @4  P  AGENCY NAME,@$ @5  P$ DATE@0 2STATE GANG PREVENTION AND INTERVENTION APPLICATION @$ @6@  #A$  PROJECT TITLE.@ $S @  +10. BUDGET DETAILS: CATEGORY B. SUPPLIES    /p"0$ PAGE 4  `$p  This category is for articles and commodities which are consumed or materially altered when used. The following are types of supplies. OFFICE SUPPLIES: For example, office stationery, forms, small items of equipment, and maps, films, books, periodicals, and tapes. OPERATING SUPPLIES: For example, chemicals, drugs, medicines, laboratory supplies, cleaning and sanitation supplies, fuel, household and institutional supplies, and clothing. REPAIR AND MAINTENANCE SUPPLIES: For example, building materials and supplies, paints and painting supplies, plumbing supplies, electrical supplies, motor vehicle repair materials and supplies, other repair and maintenance supplies, and small tools.       _Q _Q T _Q,Arial (q"This category is for articles and commodities which are consumed or materially altered when used. The following are types of supplies. ("OFFICE SUPPLIES:(ls For example, office stationery, forms, small items of equipment, and maps, films, books, periodicals, and tapes. ("OPERATING SUPPLIES:(~w For example, chemicals, drugs, medicines, laboratory supplies, cleaning and sanitation supplies, fuel, household and ("&institutional supplies, and clothing. (" REPAIR AND MAINTENANCE SUPPLIES:(l For example, building materials and supplies, paints and painting supplies, plumbing supplies, electrical ("nsupplies, motor vehicle repair materials and supplies, other repair and maintenance supplies, and small tools. $@7  Title   0@8      *ITEMIZED LISTING (DESCRIPTION OF THE ITEM)  0@9    @  UNIT   0@:      UNIT COST + 0$ @;    @ $  ITEM TOTAL /  $ 0 0$ H: p!Pq  2. Match  % @ CATEGORY TOTAL I 0$$S P =10. BUDGET DETAILS: CATEGORY C. OTHER SERVICES AND CHARGES   @ ". $@;  Title  ". 0@8"  "" HITEMIZED LISTING (WORD OR WORDS DESCRIBING THE COST ITEM, I.E., POSTAGE) E"0. @9"  "@" UNIT ". 0@:"  ""  UNIT COST +" 0. $ @;"  " @"$  ITEM TOTAL /. /@ 0. 0/@$ H> p!Pq  2. Match  % ./@ CATEGORY TOTAL I. 0/@$P !#  This category is for services other than PERSONNEL which are required in the administration of the project. Such services may be provided by some agency of the government unit or by private business organizations. The following are types of services and charges classified under this category. COMMUNICATION: For example, telephone, telegraph, and postage. TRANSPORTATION: For example, freight and express charges, and messenger service. ADVERTISING PUBLIC UTILITY SERVICE PRINTING AND BINDING REPAIRS AND MAINTENANCE INSURANCE RENTALS: For example, buildings, and equipment and machinery. MISCELLANEOUS: For example, tuition and other training fees, dues, subscriptions and memberships, and taxes. ) 8 i y   T c RR#F F# _Q #F,Arial ("This category is for services other than PERSONNEL which are required in the administration of the project. Such services may be provided by some ("agency of the government unit or by private business organizations. The following are types of services and charges classified under this category. ("COMMUNICATION: (l1 For example, telephone, telegraph, and postage. ("TRANSPORTATION: (qB For example, freight and express charges, and messenger service. (" ADVERTISING ("PUBLIC UTILITY SERVICE ("PRINTING AND BINDING ("REPAIRS AND MAINTENANCE (" INSURANCE ( " RENTALS: ( L6 For example, buildings, and equipment and machinery. ("MISCELLANEOUS: (l^ For example, tuition and other training fees, dues, subscriptions and memberships, and taxes."$0 @8 p!Pq  2. Match  %  0 @9 p!Pq  2. Match  % . 0/@ @< p!Pq  2. Match  % . /@ 0 @= p!Pq  2. Match  % Budget 2P003% Budget 2P003 2. Match  `% Budget 2by private business organizations. The following are types of services and charges classified under this category. ("COMMUNICATION: (m1 For example, telephone, telegraph, and postage. ("TRANSPORTATION: (qB For example, freight and express charges, and messenger service. (" ADVERTISING ("PUBLIC UTILITY SERVICE ("PRINTING AND BINDING ("REPAIRS AND MAINTENANCE (" INSURANCE ( " RENTALS: ( L6 For example, buildings, and equipment and machinery. ("MISCELLANEOUS: (m^ For example, tuition and other training fees, dues, subscriptions and memberships, and taxes.S_0~3(###) ###-#########;#####-#### // r###000#,##0.002###0#,##0@@X   @@@@@@ @@@@@A0S|b0Sb6?"b60Sb60Sb6?"<b6A<?"6ptbl6aA<A66A@A6A>AbB> M bB*<Q9P<QK<@@@ @@X  " @@@  @@X   @@@   @@X   @@6D"<b@@X 2 HNT     @@X   @@@NT@ @?  P  AGENCY NAME,@$ @@  P$ DATE@0 2STATE GANG PREVENTION AND INTERVENTION APPLICATION @$ @A@  #A$  PROJECT TITLE.@ $S ! ;10. BUDGET DETAILS: CATEGORY D. CAPITAL OUTLAY/EQUIPMENT   2 /p"0$ PAGE 5  $p > This category is for nonexpendable outlays which result in the acquisition of, rights to, or additions to fixed assets, other than structures. The following are some of the types of charges under this category. NOTE: Exclude small tools. MACHINERY AND EQUIPMENT: For example, communications equipment (typewriter, microcomputer), janitorial; laboratory, office furniture and equipment, heavy duty work equipment, and other machinery and equipment.   _Q _Q #F _Q,Arial (q"This category is for nonexpendable outlays which result in the acquisition of, rights to, or additions to fixed assets, other than structures. The following are (|"Osome of the types of charges under this category. NOTE: Exclude small tools. ("MACHINERY AND EQUIPMENT(s: For example, communications equipment (typewriter, microcomputer), janitorial; laboratory, office furniture and ("Hequipment, heavy duty work equipment, and other machinery and equipment. p$@B  Title   p0@? P    Q )ITEMIZED LISTING (DESCRIBE THE COST ITEM)  p0@@ P   @ Q UNIT  p 0@A P    Q  UNIT COST + p 0$ @B P   @ Q$  ITEM TOTAL /  p$ 0 0$ HE p!Pq  2. Match  % ` CATEGORY TOTAL I 0$$S0 P )10. BUDGET DETAILS: CATEGORY E. TRAVEL    . $@F  Title  . 0@A   ITEMIZED LISTING F0. @B  @ UNIT . 0@C    UNIT COST + 0. $ @D   @$  ITEM TOTAL /. /@ 0. 0/@$ HI p!Pq  2. Match  % ./@ CATEGORY TOTAL I. 0/@$p 0#  Travel costs are for domestic travel. Contractors may follow their own established rate for staff travel as long as the rate does not exceed the allowable state rate. Air fare should be the lowest coach fare. F F _Q F,Arial ("Travel costs are for domestic travel. Contractors may follow their own established rate for staff travel as long as the rate does not exceed the allowable (" state rate. ("* Air fare should be the lowest coach fare.$0 @C p!Pq  2. Match  %  0 @D p!Pq  2. Match  % . 0/@ @G p!Pq  2. Match  % . /@ 0 @H p!Pq  2. Match  % Budget 3P004 Match  % Budget 3P004 2. Match  `% Budget 3TE@ FEDERAL GRANT APPLICATION T|@$ @z@  #n@ @J  P  AGENCY NAME,@$ @K  P$ DATE@0 2STATE GANG PREVENTION AND INTERVENTION APPLICATION @$ @L@  #A$  PROJECT TITLE.@ $S 710. BUDGET DETAILS: CATEGORY F. CONTRACTUAL SERVICES    /p"0$ PAGE 6  $p  The following types of personal services may be contracted: EVALUATION/RESEARCH LEGAL ACCOUNTING MEDICAL AND HEALTH SERVICES AUDITING SOCIAL SERVICES  _Q _Q F _Q,Arial (q"?@ABCDEFGHIJ;:9\]^_`abcdefghiMLKzyx~}|{& h& {>:%;\:(;\:%;\& h& & {>:%>;\:%;\:%;\:%;\:%;\:%;\& h& & {>;\:%;\>;\:%:%;\:%:%;\:%;\& h& & {>:%>;\:%:%;\:%;\:%;\:%;\& h& & {& & & & & &  ;\;\,;\@T ;\h  %;\|  & R2%,& & & & & &  ;\;\,;\@T ;\h  %|  & R2;\%,& h& & {& h& & {ArialTimes New Roman &  ;\;\,;\@T ;\h  %|  & R2;\%,& h& & {& h& & {& lH< =@l_mrkJnj@pqorh%+S'5i0 2 1     b $K n U  I C }d  I _ T   6 7_(6g r b  n   [  0  < #  K  x +uaG    s  }          u.vGtwasyye'C `{8&{=e)7z    ContractNumber ProgramArea DateStamp AgencyNameAgencyTelephone AgencyFAXAgencyAddress_StreetAgencyAddress_CityAgencyAddress_StateAgencyAddress_ZipAgencyMailingAddress_StreetAgencyMailingAddress_CityAgencyMailingAddress_StateAgencyMailingAddress_ZipImplementingNameImplementingAddress_StreetImplementingAddress_CityImplementingAddress_StateImplementingAddress_ZipImplementingTelephoneSSN ProjectTitleLegalAuthorityNameAgencySignatureDateAcceptance_Yes Acceptance_NoOJJSignatureDateProjectDirectorNameProjectDirectorAddress_StreetProjectDirectorAddress_CityProjectDirectorAddress_StateProjectDirectorAddress_ZipProjectDirectorTelephoneProjectDirectorFAXProjectDirectorEmailFinancialOfficerNameFinancialOfficerAddress_StreetFinancialOfficerAddress_CityFinancialOfficerAddress_StateFinancialOfficerAddress_ZipFinancialOfficerTelephoneFinancialOfficerFAXFinancialOfficerEmail AgencyName1Date ProjectTitle1A_PositionTitles A_StateFunds A_CashMatchA_ProjectTotalA_StateFunds_TotalCashMatch_TotalA_ProjectTotal_TotalA_Justification AgencyName2Date1 ProjectTitle2 B_Listing B_StateFunds B_CashMatchB_ProjectTotalB_Total C_Listing C_StateFunds C_CashMatchC_ProjectTotalC_Total AgencyName3Date2 ProjectTitle3 D_Listing D_StateFunds D_CashMatchD_ProjectTotalD_Total E_Listing E_StateFunds E_CashMatchE_ProjectTotalE_Total AgencyName4Date3 ProjectTitle4 F_Listing F_StateFunds F_CashMatchF_ProjectTotalF_Total G_Listing G_StateFunds G_CashMatchG_ProjectTotalG_Total AgencyName5Date4 ProjectTitle5ProposedTime_FromDateProposedTime_ToDateA_Personnel_TotalB_Supplies_Total C_Other_TotalD_CapitalOutlay_TotalE_Travel_TotalF_Contractual_TotalTotalDirectChargesG_IndirectCharges_TotalTotalProjectCostProjectSummary AgencyName6Date5 ProjectTitle6 AgencyName7Date6 ProjectTitle7 ProjectPlanA_Personnel_StateFundsB_Supplies_StateFundsC_Other_StateFundsD_CapitalOutlay_StateFundsE_Travel_StateFundsF_Contractual_StateFundsTotalDirectCharges_StateFundsG_IndirectCharges_StateFundsTotalProjectCost_StateFundsB_StateFunds_TotalB_CashMatch_TotalC_StateFunds_TotalC_CashMatch_TotalD_StateFunds_TotalD_CashMatch_TotalE_StateFunds_TotalE_CashMatch_TotalF_StateFunds_TotalF_CashMatch_TotalG_StateFunds_TotalG_CashMatch_TotalctCharges_TotalTotalProjectCost Federal_TotalMatch OtherSourceOtherSourceAmountSourceOfFunds_TotalProjectSummary OtherSource1OtherSourceAmount1 OtherSource2OtherSourceAmount2 OtherSource3OtherSourceAmount3 OtherSource4OtherSourceAmount4FederalPercentMatchPercentageOtherSourcePercentSourceOfFunds_PercentOtherSourcePercent1OtherSourcePercent2OtherSourcePercent3OtherSourcePercent4 AgencyName6Date5 ProjectTitle6 AgencyName7Date6 ProjectTitle7 ProjectPlan AgencyName8Date7 ProjectTitle8ProjectOutcomes1ProjectObjectives1Month1_1Month2_1Month3_1Month4_1Month5_1Month6_1Month7_1Month8_1Month9_1 Month10_1 Month11_1 Month12_1 AgencyName9Date8 ProjectTitle9ProjectOutcomes2ProjectObjectives2Month1_2Month2_2Month3_2Month4_2Month5_2Month6_2Month7_2Month8_2Month9_2 Month10_2 Month11_2 Month12_2 AgencyName10Date9ProjectTitle10 AgencyName11Date10ProjectTitle11ProjectEvaluatorSupervisor ProjectPlan1 AgencyName12Date11ProjectTitle12LogicModel_OutcomesLogicModel_Indicators LogicModel_DataCollectionMethods"LogicModel_DataCollectionFrequencyLogicModel_SamplingStrategyA_Personnel_StateFundsB_Supplies_StateFundsC_Other_StateFundsD_CapitalOutlay_StateFundsE_Travel_StateFundsF_Contractual_StateFundsTotalDirectCharges_StateFundsG_IndirectCharges_StateFundsTotalProjectCost_StateFundsB_StateFunds_TotalB_CashMatch_TotalC_StateFunds_TotalC_CashMatch_TotalD_StateFunds_TotalD_CashMatch_TotalE_StateFunds_TotalE_CashMatch_TotalF_StateFunds_TotalF_CashMatch_TotalG_StateFunds_TotalG_CashMatch_Totalevelop your own. These may be case records, assessments, inte?P: @ @m  'P  AGENCY NAME,@$ @n  (P$ DATE@0 2STATE GANG PREVENTION AND INTERVENTION APPLICATION @$ @o@  #)A$  PROJECT TITLE.@ $S`  111. DESCRIPTION OF THE PROJECT (START ON PAGE 8)    /p"0$ PAGE 7  # oSubmit a description of the project using the outline format shown below. Address all topics listed. Attach as many pages as required to properly address the topics. I. GENERAL NEEDS STATEMENT A. State the need this project is designed to alleviate. B. Support the need by statistical (local based) data/information. C. Clearly define target population as to number and characteristics. D. List other possible community resources. E. Indicate why other community resources are not adequate to meet the need. F. State how the project will address the need. II. IMPLEMENTATION AND METHODS A. Describe the research-based methods and techniques to be used to meet the outputs and identify the research approach. Program must be based on sound theory supported by positive or promising research results. B. Identify the sources, expected number of referrals, and the manner in which those referrals are likely to occur. C. As applicable, outline the involvement of any other community organization/agency (human services, juvenile court, schools, law enforcement, support groups, service clubs, etc.). D. Identify agencies from which letters of agreement will be obtained. E. Describe staffing and staff qualifications. III. LOGIC MODEL Use the Logic Model below to describe the resources, activities, outputs, outcomes, and goal(s) of the project.    >  ]      vv_H _H  _H,Arial (s"|Submit a description of the project using the outline format shown below. Address all topics listed. Attach as many pages (",as required to properly address the topics. ("I. GENERAL NEEDS STATEMENT(,:A. State the need this project is designed to alleviate. (,DB. Support the need by statistical (local based) data/information. (,GC. Clearly define target population as to number and characteristics. (,-D. List other possible community resources. (,OE. Indicate why other community resources are not adequate to meet the need. (,1F. State how the project will address the need. ( "II. IMPLEMENTATION AND METHODS(,qA. Describe the research-based methods and techniques to be used to meet the outputs and identify the research (),k approach. Program must be based on sound theory supported by positive or promising research results. (7,uB. Identify the sources, expected number of referrals, and the manner in which those referrals are likely to occur. (E,xC. As applicable, outline the involvement of any other community organization/agency (human services, juvenile court, (S,F schools, law enforcement, support groups, service clubs, etc.). (a,HD. Identify agencies from which letters of agreement will be obtained. (o,0E. Describe staffing and staff qualifications. ("III. LOGIC MODEL(,oUse the Logic Model below to describe the resources, activities, outputs, outcomes, and goal(s) of the project. /@$$SSSSS#p  EProgram inputs. Elements or ingredients that constitute the program.    _H ,Arial (Program inputs. (Elements or ingredients (that constitute the (program.#p  LMethods for providing the program. Specific processes or events undertaken.     ,Arial (Methods for providing (the program. Specific (processes or events ( undertaken.#p  LUnits of service or product units. How many, how often, over what duration?  i i  i,Arial (Units of service or (product units. How (many, how often, over (what duration?#p"P |Short intermediate or longer-term changes anticipated in participants' lives and/or in organization or community conditions.  jje/ e/ i e/,Arial (oShort intermediate or (olonger-term changes (oanticipated in (oparticipants' lives and/or (oin organization or (!ocommunity conditions.#p$!p# XUltimate impact(s) expected to occur, usually beyond what one program alone can achieve.  44!I I! e/ !I,Arial (Ultimate impact(s) (expected to occur, (usually beyond what (one program alone can (achieve.#p- $$  For example:   8 %P&`  Three FTEs.   2 %` %`&@'` %After school facility and playground.  Z! !Z !I Z!,Arial (k+After school facility (v+and playground.&` &`()p` College student volunteers.  w! !w Z! w!,Arial (+College student (+ volunteers.(0 (p`)*p` Foundation funding.   O ) * `#p- $$  For example:   8 %P &` After school mentoring.  Ku Ku  Ku,Arial (\ After school (g mentoring.%` % `' '` Homework assistance.   Z ' 'P `( )`  Health snack.   6 ( )0 `) +` 3Positive reinforcement for non-aggressive behavior.    Ku ,Arial (Positive reinforcement (for non-aggressive ( behavior.) * `#p- $$  For example:   8 %P'`` BThree-hour program every day after school for 40 at-risk students.  Kp Kp  Kp,Arial (\ Three-hour program (g every day after school (r for 40 at-risk students.%` %`')` One hour homework assistance.  qp qp Kp qp,Arial ( One hour homework ( assistance.' (`)p*` One hour sports and exercise.  p p qp p,Arial ( One hour sports and ( exercise.) )`+,p` One hour snack and reading.  p p p p,Arial ( One hour snack and ( reading.+  +``#p- $$  For example:   8 %P'`` /Increase in grades (GPA) at end of school year.  Kq qK p Kq,Arial (\{Increase in grades (g{(GPA) at end of school (r{year.%` %`')` !Increase in pro-social behaviors.  qq qq Kq qq,Arial ({Increase in pro-social ({ behaviors.' (`)`*` !Decrease in aggressive behaviors.  q q qq q,Arial ({ Decrease in ({aggressive behaviors.)p )`+,p` Decrease in recidivism.  q q q q,Arial ({ Decrease in ({ recidivism.+  +``#p- $$$#  For example:   8 %P&$` #Prevention of juvenile delinquency.  KuP KPu q KuP,Arial (\Prevention of juvenile (g delinquency.%` %`'(`$` Prevention of violent behavior.  fP fP  fP,Arial (wPrevention of violent ( behavior.' 'P`  Resources   3   Activities   ,  Outputs   #  Outcomes   . $ Goal(s)   # -p .0 *    -p.# This was adapted from page 31, Outcomes for Success 2000 Edition, by the Evaluation Forum, Organization Research Services, Inc. and Clegg and Associates.  ::!G !G fP !G,Arial (+qThis was adapted from page 31, Outcomes for Success 2000 Edition, by the Evaluation Forum, Organization Research (+(Services, Inc. and Clegg and Associates.` Process   ' P P` Outcome   + $  $ *, ` At-risk sixth grade students.  ! ! !G !,Arial (+At-risk sixth grade (+ students.* + `' (0 `' (` Sports and exercise.   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