FY2023 State Domestic Violence Grant Application

Use this online form to complete and submit the application. Refer to the FY2023 State Domestic Violence Grant Request for Application located at CJCC's Funding Opportunities page for instructions and details about this funding opportunity. In the event that you must exit this application prior to completion please click the "Save Answers and Resume Later" link to ensure that your information is saved.

Applicant Agency

Applicant Agency Name*

Applicant Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

+4 Zip Code*

Last four digits following the basic five-digit zip code

Click here to lookup your Zip+4.

Applicant Phone*

Applicant Fax

Is the Implementing Agency for this project the same as the Applicant Agency?*

Yes No

The implementing agency is defined as the entity actually administering the program or project and/or providing the service(s).

Implementing Agency Name*

Implementing Agency Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Implementing Agency Phone*

Implementing Agency Fax

Is the mailing address the same as the Implementing Agency's physical address?*

Yes No

Physical Address*

Address Line 1

Address Line 2

City

State

ZIP Code

+4 Zip Code*

Last four digits following the basic five-digit zip code

Click here to lookup your Zip+4.

Applicant Agency Continued

Is your agency registered in the System for Award Management (SAM)?*

Yes No

SAM Expiration Date:*

Is your agency certified to receive Local Victim Assistance Program (5%) funds?*

Yes No

Please upload 5% certification letter*

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Is your agency certified as a Human Trafficking Victim Assistance Organization?*

Yes No

Before you continue please take note of the following:

Your agency must be registered in System for Award Management (SAM) Database before it will be allowed to draw down State funding. To register please visit www.sam.gov.

Your agency must be certified to receive 5% funds before it will be allowed to draw down State funding. To meet this requirement please click here to learn more and/or certify your agency to receive 5% funding.

Designation of Grant Officials

Project Director - This official must be an employee of the applicant agency or from a contractor organization, at the applicant’s option, who will be directly responsible for operation of the project. This person will be the primary contact for the application and the post-award phase.
Financial Officer - This person must be the chief financial officer of the applicant agency such as the county auditor, city treasurer or comptroller.
Authorized Official - This person is the official who is authorized to apply for, accept, decline or cancel the grant for the applicant agency. This person must be the executive director of a state agency, chairperson of the county Board of Commissioners, mayor, chairperson of the City Council, or Chair of an agency Board of Directors. All official correspondence regarding the grant and the application (assurances, disclosures, certifications, award documentation, subgrant expenditure reports, subgrant adjustment reports) must be signed by the authorized official. Once an award has been made, the authorized official may designate someone to sign this documentation by submitting a letter on agency letterhead to the Council.

Please Note: No two officials can be the same person.

Project Director

PD Name*

Prefix

First Name

Last Name

PD Title/Position*

PD Address*

Address Line 1

Address Line 2

City

State

ZIP Code

PD Email*

PD Phone*

PD Fax

Financial Officer

FO Name*

Prefix

First Name

Last Name

FO Title/Position*

FO Address*

Address Line 1

Address Line 2

City

State

ZIP Code

FO Email*

FO Phone*

FO Fax

Authorized Official

AO Name*

Prefix

First Name

Last Name

AO Title/Position*

AO Address*

Address Line 1

Address Line 2

City

State

ZIP Code

AO Email*

AO Phone*

AO Fax

Agency/Project Description

Number of Certified Shelter Beds*

Number of Actual Shelter Beds*

Does your agency allow pets in shelter? *

Yes No Other

"Pets" include all animals that may or may not be considered emotional support animals.

If "other" please explain.*

"Pets" includes all animals that may or may not be considered emotional support animals.

How many full time equivalent (FTE) staff members does your agency employ?*

*Staff member at 25% equals .25

How many FTE staff members does your agency pay through state funding? *

Does your agency provide counseling onsite (at your shelter)?*

Yes No

Please list Domestic Violence Task Force(s) (DVTF) that the agency's staff participates on or leads for each county within the proposed service area. Please share how often the group meets. If your judicial circuit does not have a formal DVTF, describe applicant's collaboration with community partners within the proposed area. If serving more than one county, please provide the information for each county. *

What are the community outreach and awareness activities that the agency has been able to provide the last year, and what is the plan for providing these events this upcoming year? What are the proposed activities for the upcoming grant year.*

Describe any updates or changes in service provision in regards to the following core service: (1) Safe, Confidential Shelter, (2) Case Management /Service Planning, (3) Safety Planning, (4) Children's Advocacy, (5) Individual and Group Counseling and Support, (6) Legal Advocacy, (7) Social Service Advocacy, including Medical, Financial and Household Establishment Services, (8) Transportation Access, (9) Parenting Support and Education (10) Non-Residential Support Services, (11) Follow-Up. *

Evaluation Plan

How will your agency utilize the data collected to guide the direction of program services?*

Please attach any surveys or evaluation tools your agency utilizes.

No File Chosen

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Sustainability Plan

What other sources of funding will be used to support and sustain the proposed project?*

Describe your ability to maintain adequate cash for for this project for at least 90 days.*

How many fundraising activities did your agency complete during the FY2022 grant year (July 1, 2021 - June 30, 2022)? Please include details about each fundraising event, such as date of event, number of attendees, event theme, amount raised, etc. *

Did your agency submit grant applications for other funding sources? If so, please list any submissions in FY22 and if any applications were awarded. *

Please describe any projected long-term impacts on your agency's sustainability due to COVID-19. *

Agency/Project Budget

Agency Fiscal Year: Start Date*

Agency Fiscal Year: End Date*

Agency/Project Budget Continued

State Funds* $

Total Domestic Violence Program Budget* $

Total DV program budget across all funding sources.

Attachments

Budget Narrative*

No File Chosen

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Detailed Budget Worksheet*

No File Chosen

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Full Operating Budget*

No File Chosen

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Organizational Chart*

No File Chosen

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Include names & titles

Supporting Documentation for Budgeted Items

No File Chosen

File uploads may not work on some mobile devices.

i.e. job descriptions, quotes, contracts

FY2023 State Domestic Violence Grant Application

Applicant Agency

Applicant Agency Continued

Before you continue please take note of the following:

Designation of Grant Officials

Project Director

Financial Officer

Authorized Official

Service Area & Congressional District

Service Area Continued

Agency/Project Description

Evaluation Plan

Sustainability Plan

Agency/Project Budget

Agency/Project Budget Continued

Attachments