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2021 Mid-Year Funding Application

  1. Jackson County COMBAT
  2. Important
    To submit this form you do not have to sign in or create a Form Center account above. However, you will have to complete the form in its entirety without the option to save your progress unless you do create an account.
  3. Submission Deadline
    Completed applications must be submitted no later than 4:00 p.m. (central) on Friday, April 23, 2021.
  4. COMBAT Program Director
    Individual who will directing program that would receive COMBAT funding
  5. Organization's Executive Director
  6. Anti-Violence Area Of Focus
    Please select which of these issues your agency will address.
  7. Youth Employment
    COMBAT is seeking proposals that focus on hiring youth 13-17 to work in their communities from June 2021 to June 2022.
  8. Domestic Violence
    COMBAT is seeking to fund proposals that will provide essential services for domestic violence and sexual assault survivors, in addition to domestic violence prevention programs that promote healthy relationship skills. A point of emphasis is Trauma Counseling for survivors , their children and any potential witnesses, with counseling made available as immediately as possible following the domestic violence and/or sexual violence occurrence. We will also fund programs that focus on assuring that survivors are fully informed of all resources and services available to them, including counseling, sheltering and victim advocacy.
  9. 1) Is this an existing program for your agency?*
  10. 2) Is this program currently funded by COMBAT?*
  11. 4) Program Summary
    Describe your proposed Anti-Violence/Anti-Drug Prevention program based on your selected area of focus. If funded, this will be the program description used by COMBAT on our website and publications about our funded programs. Address the purpose, target population, services/activities to be provided and expected outcome of your program.
  12. Program Description
  13. 1) Please Discuss Program Purpose Statement
    The purpose of a program is to achieve outcomes. It is driven by audience needs and considerations (for whom). It provides a solution to meet those needs (what we do). It fulfills the organization's mission. It defines audience, activities, services, and outcomes.
  14. 2) Please Discuss Program Goal(s)
    Goals are typically broad general statements that describe what the program plans to accomplish. Goals establish the overall direction for and focus of a program. Goals define the scope of what the program should achieve and serve as the foundation for developing program objectives.
  15. 3) Please Discuss The Need
    What problem or opportunity does the program addresses? Who experiences it?
  16. Schedule & Location(s)
  17. Will the program be offered year-round?*
  18. What days of the week will the program will be offered?*
    Check all that apply
  19. Will you program/project be at one site or multiple sites?*
  20. Program/Project Location
  21. If you selected other under "Location Type," specify that location type here.
  22. Include name of commuinity center, school, church, etc. if applicable.
  23. More Locations (List ALL Below)
  24. Target Population
    List age, ethnic breakdown, gender, and geographic area to be served. Describe your outreach strategy and how clients will be recruited. If referred from other agency(ies), you must include a letter stating that these agencies are aware that they will be part of a COMBAT project, as an Appendix to your proposal. Failure to provide current proof of referring partner will result in 10-point deduction.
  25. Age
  26. % In This Age Group
  27. % In This Age Group
  28. % In This Age Group
  29. % In This Age Group
  30. % In This Age Group
  31. % In This Age Group
  32. % In This Age Group
  33. % In This Age Group
  34. Gender
  35. % Of Male Clients
  36. % Of Female Clients
  37. Ethnicity
    Percentage of clients expected to serve from each of these ethnic/racial groups.
  38. (Not Hispanic or Latino)
  39. (Or Other Pacific Islander)
  40. Geography
  41. Estimates
  42. Key Partners
    Who are your key partners who will enhance your ability to conduct this project? Describe their role(s) related to the project and expertise as well. You must include a current letter stating that these partners are aware that they will be part of a COMBAT project.
  43. Staff Expertise & Experience
    Describe the experience and expertise of key staff (and contract positions) for the proposed project (including experience or training in selected strategies). Identify the person who will be the Coordinator/COMBAT Program contact and other staff. Include job descriptions for each staff or contract person
  44. 2021 Program Budget Information
  45. Personnel (Salaries)
  46. Proposed
  47. Other Funding Amount
  48. Total Cost
  49. Number of Other Sources
  50. Fringe Benefits
    Maximum 10% of Salaries (Describe Benefits Below)
  51. Proposed
  52. Other Funding Amount
  53. Total Cost
  54. Number of Other Sources
  55. Auditing/Accounting Services
  56. Proposed
  57. Other Funding Amount
  58. Total Cost
  59. Number of Other Sources
  60. Evaluation
  61. Propsed
  62. Other Funding Amount
  63. Total Cost
  64. Number of Other Sources
  65. Postage
  66. Proposed
  67. Other Funding Amount
  68. Total Cost
  69. Number of Other Sources
  70. Printing
  71. Proposed
  72. Other Funding Amount
  73. Total Cost
  74. Number of Other Sources
  75. Meeting Expense
  76. Proposed
  77. Other Funding Amount
  78. Total Cost
  79. Number of Other Sources
  80. Mileage (Local Travel)
  81. Proposed
  82. Other Funding Amoung
  83. Total Cost
  84. Number of Other Sources
  85. Training
  86. Proposed
  87. Other Funding Amount
  88. Total Cost
  89. Number of Other Sources
  90. Stipends
  91. Proposed
  92. Other Funding Amount
  93. Total Cost
  94. Number of Other Sources
  95. Insurance
  96. Proposed
  97. Other Funding Amount
  98. Total Cost
  99. Number of Other Sources
  100. Other
  101. Proposed
  102. Other Funding Amount
  103. Total Cost
  104. Number of Other Sources
  105. Other
  106. Proposed
  107. Other Funding Amount
  108. Total Cost
  109. Number of Other Sources
  110. Other
  111. Proposed
  112. Other Funding Amount
  113. Total Cost
  114. Number of Other Sources
  115. Other
  116. Proposed
  117. Other Funding Amount
  118. Total Cost
  119. Number of Other Services
  120. Other
  121. Proposed
  122. Other Funding Amount
  123. Total Cost
  124. Number of Other Services
  126. Proposed
  127. Other Funding Amount
  128. Total Cost
  129. Number of Other Sources
  130. Required Documents
  131. Jackson County Compliance Report Form completed and signed or existing certificate (if you have one). Download This Form (PDF)
  132. Copy of Paid Jackson County Property tax receipt or current exemption certificate.
  133. Copy of evidence of liability insurance coverage for at least $1 million.
  134. Copy of current IRS Form 990 (within past two fiscal years 2018 or 2019).
  135. Copy of full Certified Financial Audit (within past two fiscal years 2018 or 2019).
  136. Copy of letter indicating current IRS 501(c)(3) tax-exempt status (if applicant is not a governmental agency, e.g., city, school district or court in Jackson County).
  137. Certificate of Good Standing from the Missouri Secretary of State.
  138. List of Staff with titles and copies of certifications
  139. List of Board of Directors
  140. Acknowledgement*
    By clicking "Agree," you agree and acknowledge that information and statements provided in this application are, to the best of your knowledge, true and accurate.
  141. By typing your name in the "Signature" box below, you acknowledge that this "electronic signature" is valid and binding upon you to the same force and effect of a traditional handwritten signature.
  142. Leave This Blank:

  143. This field is not part of the form submission.