DDRC - Provider Support Program Funds Application

Section I: Organization Information

Organization Name: Organization Street Address: City: State: Zip: Contact Name: Contact Phone: Contact Email: Name of Organization Lead: Title of Organization Lead: How many years of experience does the organization have with supporting individuals with intellectual disabilities and/or delays? Provide a brief list of current programs and services offered: During the past fiscal year, how many unique individuals with I/DD were served? In the last 12 months, how many unique individuals served reside in Jefferson County while served? What is the legal status of your organization? Is your organization a Program Approved Service Agency (PASA)? Yes Explain where you are in the approval process if pending approval: What are the funding sources your organization uses/accepts? What is the organization staff size? What is your organization's annual budget? Does the organization have experience managing outside funding? Yes Select the type of funding request:

Select a funding sub-category (select all that apply): Organizations serving all ages. Organizations building capacity with the purpose of alleviating long wait times for services, and fulfilling Requests for Providers (RFPs) as related to day programming, supported employment, CHRP, respite, Self-Determination, residential, etc. Organizations supporting and fulfilling unmet needs as they relate to stability, camp supports, new community and connection activities, technology, new projects, higher education opportunities, social groups, and supplies. Organizations that support getting help connecting to the I/DD system (testing, pre-enrollment supports, etc.), greater independence and/or integration in the home and/or community and helping to avoid out-of-home and/or institutional placements. Organizations that support health, safety, behavioral, and medical needs not otherwise met. Expansion opportunities that increase service times, areas, populations served and/or total number of people served. Innovation that creates new service offerings. Staff Capacity support to address the current direct support hiring crisis.

Section II: Proposal/Request

Title of Proposal/Request: Total Amount Requested: What is the Project Budget Total (if different than the amount requested): Will this provider support funding help launch a new program? Yes How many total individuals w/IDD living in Jefferson County do you anticipate serving with this proposal? Describe the proposed project/program: What is the issue or opportunity addressed? What are the primary goals of this request? What resources are needed to accomplish goals? How is this innovative or new to your program and/or the community?

Section III: Proposal Project Planning

Describe the project plan: How will you evaluate the success of this funding? Describe how the impact of this project will be measured: List collaborations/partnerships related to proposal: Describe the sustainability plan: List other funding sources utilized to support this project: Proposed Project Start Date: Proposed Project End Date:

Section IV: Supporting Documentation

Year End Financial Statement: Annual Budget: Balance Sheet (List of assets and liabilities): Project Budget: W9: Other Supporting Documentation (Project Plan, Gantt Chart, Letters of Support, Estimates/Price Quotes, etc.) (Note this upload supports multiple documents): Is the organization budget attached?
Yes
No Is the project budget attached?
Yes
No

I certify that these funds will be used to support only Jefferson County residents with an Intellectual Developmental Disability or delay, and understand these funds are not to be used in any other manner.

Yes