cmo.smcgov.org€¦  · Web viewUse the following checklist to ensure that all documents and forms necessary to respond to this Request for Proposals (RFP) have been included.

RFP# OCA1001APPENDIX 1: Application Form

CENSUS 2020 COMMUNITY OUTREACH & SUPPORT FUNDING APPLICATION

PROPOSAL COVER SHEET

Date:

Applicant: Phone:

Address: Fax:

Email:

Web:

ProjectContact: Title:

CONTRACT CATEGORY:

Community Action Team Lead for Region(s):________________________

Coordination of Community Action Teams across San Mateo County

Questionnaire Assistance Center in Region(s):_______________________

Amount Being Requested: $__________________

Minimum Qualifications Required to Submit Proposal:

Are you legally authorized to do business in the State of California?

Are you located in San Mateo County and/or serve San Mateo County residents?

Have you actively and normally been engaged in community outreach and/or service provision for the past 5 years?

Are you a current certified 501(c)(3)?

CENSUS 2020 COMMUNITY OUTREACH & SUPPORT FUNDING APPLICATION

APPLICATION CHECKLIST

Use the following checklist to ensure that all documents and forms necessary to respond to this Request for Proposals (RFP) have been included. Submit a copy of this checklist as the second page of your application as indicated below. All documents, unless otherwise specified, are required for a proposal to be considered complete. Incomplete proposals will not be accepted.

☐ 1. Cover Sheet

☐ 2. Cover LetterProvide a 1-page cover letter on official letterhead with details requested in Section III.2 of the Request for Proposals.

☐ 3. Application Checklist (this page)

☐ 4. Application Form (following pages) Includes: Proposal Narrative, Budget, and Budget Narrative with all sections accurately and fully completed. NOTE: A separate application form is required for each contract category.

☐ 5. Organizational Capacity and Experience StatementApplicants must submit all of the required information detailed in Section IV.2 of the Request for Proposals regarding experience, proposed staff and partners.

☐ 6. References Contact SheetApplicants must submit details requested in Section IV.3 of the Request for Proposals for three references.

☐ 7. Financial DocumentsApplicants must submit all the documents and details requested in Section III.2 of the Request for Proposals.

☐ 8. Insurance Certificate and Endorsement LettersApplicants must provide proof of insurance coverage that meets the County of San Mateo’s insurance requirements as listed in Section V. Applicants must provide the following documents to demonstrate appropriate coverage: Certificate(s) of Liability Insurance listing Count of San Mateo as the certificate holder. Endorsement Letter(s) listing “County of San Mateo, its officers, agents and employees” as

additional insured on the policy.

☐ 9. 501(c)(3) Status Determination Letter

☐ 10. Proof of Legal Business Status from the California Secretary of State

☐ 11. Letters of Support from proposed Community Action Team members*

*Only if applying to serve as Community Action Team lead.

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CENSUS 2020 COMMUNITY OUTREACH & SUPPORT FUNDING APPLICATION

APPLICATION FORM

Date:

Applicant: Phone:

Address: Email:

Web:

ProjectContact: Title:

Fed EIN: IRS Code:Year

Incorporated:Date of Last

Annual Audit:[501(c)(3)

Annual Operating Budget: $

Total Project Budget: $

Amount Being Requested: $

CONTRACT CATEGORY

REGIONS HARD TO COUNT/LEAST LIKELY TO RESPOND POPULATIONS

Community Action Team Lead

Coordination of Community Action Teams

Questionnaire Assistance Center

1: Daly City + Unincorp. 2: South SF, San Bruno + Unincorp. 3: Millbrae, Burlingame + Unincorp. 4: San Mateo, Foster City, Belmont 5: Redwood City, North Fair Oaks 6: East Palo Alto, Menlo Park 7: Half Moon Bay + Unincorp. 8: Pacifica + Unincorp.

African American Asian/Pacific Islander Children (0-5) Disabled Hispanic/Latinx Homeless Immigrants/ Refugees LGBTQ+ Limited English Proficient Limited/No Internet Access

Low Income Native American Public Benefits Recipients Public Housing Residents Renters SRO Residents Seniors (65+) Veterans Young Adults (17-25) Other-

_________________

Short Project Description:

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CENSUS 2020 COMMUNITY OUTREACH & SUPPORT FUNDING APPLICATION

PROPOSAL NARRATIVE

1. Project Description - please provide a one-page description of your proposed plan for your Census 2020 project, including your approach and specific strategies for implementation. Indicate how your proposal will achieve the overall objectives and outcomes outlined in the RFP.

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2A. Hard to Count/Least Likely to Respond Populations – Clearly describe the target HTC/LLTR populations that will be served through the proposed efforts based on maps/data provided in the RFP Appendix 2 as well as additional research and experience.

2B. Strategies to Target HTC/LLTR Populations – For each HTC/LLTR population, detail how many residents live in the project region, your proposed strategies for outreach/support, expected challenges to outreach/support and how they will be addressed. Provide one table per region as defined in Appendix 2. This table can be expanded as needed.

Region: ___________________________________________

HTC/LLTR Population

Number living in this Region

Outreach/ Support

Strategies

Expected Challenges

Strategies to Address

Challenges

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3. Activities and Intended Outcomes – Describe proposed activities and intended outcomes to meet the objectives and milestones in the scope of work outlined in Section II of the RFP for your contract category. Detail any areas in which you will be leveraging existing programs and activities.

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4. Milestone and Deliverables – Indicate your ability to meet the milestones and deliverables outlined in the RFP for your contract category. If you foresee any challenges, explain them and propose a revised timeline. Describe any additional metrics or indicators that you will use to assess and demonstrate the impact of the program.

5. Collaboration Plan - Please describe your plan for collaborating with partners to plan, implement, and evaluate the proposed project. Applicants to lead CATs should also include roster of proposed team members with required details and letters of support.

6. Other Funding - Are you receiving (or plan to apply for) other funding to support Census 2020 outreach and support? If so, please specify the amount, timeframe, and source of fund.

7. Exceptions – Please list any exceptions to the final solicitation, if any.

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Applicant: Date:Organizational Budget: Amount Being Requested:Fiscal Year Ends: Project Contact:

PROJECT BUDGET

EXPENSETotal Salaries $Total Benefits Consultant & Professional Fees Rent/Space Expenses Supplies/Equipment Employee Expenses Including TravelEvents and MeetingsOutreach and Promotion Printing and PublicationsOther (specify)

TOTAL PROJECT BUDGET $

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BUDGET WORKSHEET

BUDGET NARRATIVE Please provide a budget narrative that includes:

1. The total cost of the project and how much you are requesting from the County.

2. A description of how contract funds will be used and a line-item explanation of how the amounts were arrived at or why they are justified. This should correlate with the line-items on the Budget Form.

3. For salaried positions, please indicate the full-time equivalent in relation to percentage of time which that person will actually devote to the requested contract budget. (For example, .25 FTE x $40,000 = $10,000)

A. TOTAL SALARIES: List each position by title and name of employee, if available. Show the annual salary rate and the percentage of time to be devoted to the project. Compensation paid for employees engaged in contract activities must be consistent with that paid for similar work within the applicant organization. Describe the duties and supervision of each position:

TOTAL SALARIES COSTS: $ __________

B. TOTAL BENEFITS: Benefits should be based on actual known costs or an established formula. Benefits are for the personnel listed in budget category (A) and only for the percentage of time devoted to the project.

TOTAL BENEFITS: $ __________TOTAL SALARY AND BENEFITS COSTS (A & B): $ __________

C. CONSULTANT & PROFESSIONAL FEES

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TOTAL CONSULTANT & PROFESSIONAL FEES: $ __________

D. RENT/SPACE EXPENSES: Provide a detailed description of an occupancy expenses you may incur. List the location, time and duration of any occupancy.

TOTAL OCCUPANCY COST: $ __________

E. SUPPLIES/EQUIPMENT: List all items that will be purchased. Explain how the equipment is necessary for the success of the project.

TOTAL SUPPLIES/EQUIPMENT COST: $ __________

F. EMPLOYEE EXPENSES INCLUDING TRAVEL: Itemize employee expenses of project personnel by purpose (e.g., staff to training, advisory group meeting, etc.). Show the basis of computation.

TOTAL EMPLOYEE EXPENSES: $ __________

G. EVENTS AND MEETINGS: Itemize meeting costs and describe specific costs incurred.

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TOTAL CONFERENCES AND MEETINGS COSTS: $ __________

H. OUTREACH AND PROMOTION: Please list specific promotion activities and related costs:

TOTAL OUTREACH AND PROMOTION COSTS: $ __________

I. PRINTING AND PUBLICATIONS: Please list and describe printing and publication costs associated with the project.

TOTAL PRINTING AND PUBLICATION COSTS: $ __________

J. OTHER (SPECIFY): Please describe and itemize other costs that have not been mentioned in previous categories:

TOTAL OTHER COSTS: $ __________

GRAND TOTAL: $ _________

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