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Home My WebLink AboutFY16 SRC Cape Fear Memorial Foundation Prescr Drug Asst applicationC6pe Fear D Grant Application Instructions' Please submit one (1) copy of the Application to the Foundation office. Applications with original signatures must be RECEIVED in the Foundation office by 5:00 p.m. on January 151h, 2016, to be considered for a grant. Please submit Applications via USPS Mail or hand deliver to: (CAPE FEAR MEMORIAL FOUNDATION DOES NOT ACCEPT CORRESPONDENCE REQUIRING A SIGNATURE OF RECEIPT): Ms. Anna Erwin, CPA, President Cape Fear Memorial Foundation 2508 Independence Boulevard Suite 200 Wilmington, NC 28412 Please call (910) 452 -0611 if you have any questions. - Thank you for submitting your grant application to Cape Fear Memorial Foundation. * This Application for Funding will only be accepted if a Letter of Inquiry has been received and approved for an Application by Cape Fear Memorial Foundation. Cape Fear Memorial Foundation - Grant Application Form Page 1 of 15 Last Revised: 10/27/2015 (1GD) Cape ear MORIAL FOUNDATION Grant Application Form Organization Information Name: New Hanover County Senior Resource Center Physical 2222 S. College Road Address: Wilmington NC 28403 Mailing Address: 2222 S. College Road Wilmington, NC 28403 Telephone #: (910)798 -6400 Fax #: (910)798 -6411 Contact Information Primary Contact: Amber Smith Telephone #: (910)798 -6410 EXT: E -mail Address: asmithPnhceov.com CEO /Executive Director Information Name: Avril Pinder Telephone #: (910)798 -7184 E -mail Address: apinder @nhcgov.com Title: Director Fax # : (910)798 -6411 Title: Deputy County Manager Fax # : (910)798 -7277 1. Summarize the organization's history and current operations. (Please limit response to 1000 words) Mission Statement: To act as the focal point for aging services in New Hanover County by providing services which promote wellness, encourage independence, and enhance quality of life for all older persons. Cape Fear Memorial Foundation - Grant Application Form Page 2 of 15 Last Revised: 10/27/2015 (JGD) Please attach an organizational chart or summarize the organization's management /personnel structure. (Please limit response to 500 words). SERVICES: BLOOD PRESSURE CHECK: Blood pressure health screenings are offered on the 4" Monday of each month by Interim Health Care. CONGREGATE MEALS: Individuals 60 years of age and older may participate in the Congregate Meal service, Monday- Friday from 9:30 AM to 1:00 PM. Meal is served 11:30 to 12:00. A voluntary donation of $1.50 is recommended. Visit the Senior Center @ 2222 South College Road and register with the nutrition site manager Margaret Bryant. INCONTINENCE SUPPLIES PROGRAM: Offers absorbent underwear (Depends /Poise /etc.) at a reduced cost. Contact Valorie Hatten @ 798 -6485 or vhatten(&nhcgov.com or any Social Worker. EMERGENCY ASSISTANCE: Assists persons 60+ up to $50.00 per year for basic needs (i.e. electric or water bills, meds) Contact Gavle Ginsberg @ 798 -6402 or gginsberg(&nhcgov.com or Jean Wall 798 -6443 or jwallPncgov.com ENSURE /BOOST /GLUCERNA: Available for purchase. Contact Richard @ 798- 6444. FITNESS /HEALTH PROMOTIONS & FAIRS /HEALTH SCREENINGS: A listing of exercise classes and other health promotion opportunities is available at the Ambassador's Desk and is published in our newsletter. The Senior Center also has treadmill and exercise bike equipment available on a first - come- first -serve basis. Prior to using Senior Center exercise equipment, the individual must sign a release of responsibility waiver. Waivers are in the switchboard office. The Hugh MacRae nature Trail is located adjacent to the Senior Center with a 0.3 and 0.6 mile trail for nature walks. FANS PROGRAM: Fans are provided for seniors with no means of cooling their home. FAMILY CAREGIVER RESPITE SUPPORT: Provides short term respite services to caregivers who are caring for a family member or friend over the age of 60. Contact Gavle Ginsberg @ 798 -6402 or Jean Wall @ 798 -6443. FOSTER GRANDPARENT PROGRAM: Individuals 55+ (who meet an income requirement) volunteer to nurture and mentor at -risk children in pre - schools, elementary schools and after - school programs, and nurture babies at the Kelly House. Contact Beth Wooten @ 798 -6408 or bwootenpnhcgov.com HOME DELIVERED MEALS: Participants must be 60 years of age and older, homebound, and unable to prepare his /her own meal adequately. For information, Contact Jean Wall @ 798 -6443 and arrange an appointment for an in- home assessment. To volunteer to deliver meals, contact Ashley Huffman @ 798- 6423 or ahuffman(cbnhcgov.com. INSURANCE (MEDICARE A B & D) COUNSELING: The Senior Health Insurance Information Program (SHIIP) has RSVP volunteer insurance counselors trained by the SHIIP program and the NC Department of Insurance. Volunteer counselors are available for walk -in service on Tuesdays and Thursdays from 11:00 AM to 1:00 PM. For more information, contact Valerie Smith @ 798 -6406 or vsmith(cDnhcgov.com NEWS LETTER: Individuals can subscribe for only $10.00 per year; copies are available bi- monthly. Cape Fear Memorial Foundation - Grant Application Form Page 3 of 15 Last Revised: 10/27/2015 (1GD) PHONE PALS FOR FRIENDSHIP: Designed to provide companionship for isolated and home -bound elderly by matching them with an RSVP volunteer caller. Contact Valorie Hatten @ 798 -6485 or vhatten(u nhcgov.com PRESCRIPTION DRUG ASSISTANCE: Voluntary free service to evaluate prescription programs that can assist with lowering prescription cost. Counselor works with the consumer and appropriate agencies to determine the most cost effective option. Your cooperation is essential and will require a signed partnership agreement. Contact Pam Wall @ 798 -6422 or pwall(cD_nhcgov.com RETIRED AND SENIOR VOLUNTEER PROGRAM (RSVP): Matches the varied interests and skills of volunteers age 55 and older with community needs by offering a diversity of volunteer service opportunities through a wide range of placements. Contact Tracy Ash @ 798 -6407 or tasha)nhcgov.com or Valerie Smith @ 798 -6406 or vsmith(a)nhcgov.com SENIOR CENTER ACTIVITIES DEPARTMENT: Schedules classes, programs, workshops, dances, games, contests, and special events. Contact Shantel Davis @ 798 -6409 or srdavis(a-,)nhcgov.com or Greg Kennedy (5)798 -6403 SENIOR GAMES: A year -round health promotion program for persons 55 and older to participate in competitive sport and art events on a local, State, and National level. Contact Mark Sinclair @ 251 -9622 or mark. sinclair (a)wilmingtonfamilyymca.org SPECIAL NEEDS REGISTRY: A database of individuals with special needs who may require additional assistance prior to, during, and after an emergency event such as a hurricane. The Registry is maintained by trained RSVP volunteers in support of the NHC Special Needs Task Force which evaluates and allocates available resources to meet determined needs. Contact Jeanette Bell@ ibell(a)nhcgov.com SUPPORT GROUPS: Call the Switchboard at 798 -6400 for information on individual contact and time listings or refer to the newsletter for Support Groups for Blind & Visually Impaired, Family Caregiver, Parkinson's & Lewy Body Dementia, and others. TAX ASSISTANCE: The Volunteer Income Tax Assistance (VITA) Program is available each year from February 1 through April 15. VITA volunteers prepare basic State and Federal Tax Returns for individuals at no charge, however donations to the Senior Resource Center helps the Center continue to sponsor this program. Contact Valerie Smith @ 798 -6406 or vsmith(aDnhcgov.com or Tracy Ash @ 798 -6407 or tash(a)nhcgov.com TRANSPORTATION- GENERAL AND MEDICAL: Provided for qualified individuals 60+ for medical appointments, to SRC nutrition site, and small group shopping. Contact Chris @ 798 -6413 for an application. INFORMATION, REFERRAL and CASE ASSISTANCE: A Social Worker and Case Worker collaborate with community agencies to assist clients and locate resources that meet their needs. Contacts: Aimee Watson -Green @ 798 -6445, awatson- green(ilnhcgov.com Valorie Hatten @ 798 -6485, vhatten(ai)nhcgov.com Gayle Ginsberg @ 798 -6402, gginsberg(a?nhcgov.com Jean Wall @ 798 -6443, jwall(a�nhcgov.com • ADULT DAY CARE, ADULT DAY HEALTH & GROUP RESPITE: • FAMILY CAREGIVER SUPPORT PROGRAM: • DISASTER PREPAREDNESS PLANNING/RESPONSE: • ENERGY ASSISTANCE: • FOOD DISTRIBUTION: Cape Fear Memorial Foundation -Grant Application Form Page 4 of 15 Last Revised: 10/27/2015 (JGD) • HOME HEALTH SERVICES: • HOME REPAIR AND MODIFICATION: • HOSPICE CARE REFERRAL: • HOUSING REFERRAL: • IN -HOME AIDE SERVICES: Provided via contract. • LONG TERM CARE FACILITIES: • MEDICAID: • MENTAL HEALTH: • NOTARY SERVICES: • REHABILITATION SERVICES: • REPORT SUSPECTED ABUSE, NEGLECT OR EXPLOITATION: • RESPITE CARE: COMPREHENSIVE ANNUAL FINANCIAL REPORT' New Hanover County available on -line at www.nhcgov.com 2. Please attach an organizational chart or summarize the organization's management /personnel structure. (Please limit response to 500 words). Amber Smith, SRC Director Chris Dodson, Transportation Program Coordinator Harold "Sam ", Norris Transportation Program Assistant Richard Loeser, Administrative Specialist Greg Kennedy: Activities Program Manager Tina Heath, Administrative Specialist Marion Johnson - McIntyre, part-time switchboard Operator Senior Community Service Employee Title V Worker /part-time switchboard operator (not county employee) Aimee Watson- Green, Social Work Supervisor Life Enrichment Program (LEP) Gayle Ginsberg, social worker Jean Wall, social worker Valorie Hatten, economic caseworker Rebecca "Becky" Hayes, LEP Program Assistant Pam Wall, Prescription Assistance Counselor Ellen Conner, Nutrition Program Manager Ashley Huffman, Nutrition Program Coordinator, volunteer drivers Darlene Williams - Gantz, Nutrition Program Assistant, packer Margaret Bryan, Nutrition Program Assistant, congregate site manager Karla Bridgers, Nutrition Program Assistant, truck route Tracy Ash, Retired and Senior Volunteer Program (RSVP) and Foster Grandparent Program (FGP), Manager Valerie Smith, RSVP Program Coordinator Jeanette Bell, RSVP Program Assistant, (part-time) Beth Wooten, FGP Coordinator 3. Summarize the background of organization's key personnel. (Please limit response to 500 words) The New Hanover County Senior Resource Center (SRC) is responsible to the New Hanover County Board of Commissioners. The manager of the Department reports directly to Avril Pinder, New Hanover Deputy County Manager. The SRC works with Cape Fear Memorial Foundation -Grant Application Form Last Revised: 10/27/2015 (1GD) Page 5 of 15 two advisory committees: VOCAL, Inc. (Volunteer Older Citizen Action League, Inc.) and the Home Care and Community Block Grant Committee ( HCCBG). Both of these advisory committees provide advice and direction as well as recommendations to the NH County Board of Commissioners for distribution of Home and Community Block Grant federal and state funds. Key Personnel include: Amber Smith: Director, Amber has worked for the county for more than 14 years. She has a Bachelor of Social Work and was previously as Adult Protective Services Social Worker at DSS. Aimee Watson - Green: Social Work Supervisor, Aimee has 13 years of service within county government, and 2 years with state government. She holds both a Bachelors and Master's Degree. She was previously Program Manager for both Child and Adult Protective Services. Aimee is Mrs. Wall's supervisor. Pam Wall: Program Assistant, holds an Associate Degree in Business Administration from Cape Fear Community College, was formerly a licensed Insurance Agent for NC Property & Casualty, Life & Health, worked as a physician's office claims and billing clerk and came to the SRC from Onslow County DSS as a Medicaid Case Worker. Pam Wall was instrumental in establishing the SRC prescription assistance program as the primary referral source to assist seniors with prescription assistance in New Hanover County. Referrals come from DSS, doctor's offices, Social Security Administration, Health Department, social workers, churches, and pharmacists. 4. Is the organization accredited by any agency or is any accreditations planned? If yes, please provide details. The New Hanover County Senior Resource Center is a certified "Center of Excellence" by the North Carolina Division of Aging and Adult Services Briefly discuss the organization's board and staff development policies. Additionally, discuss the organization's participation in the offerings for development offered by QENO. (Please include future plans) The Senior Resource Center works with two advisory committees: Vocal, Inc. (Volunteer Older Citizen Action League, Inc.) composed of active senior community leaders attuned to senior issues, and the Home Care and Community Block Grant Committee ( HCCBG) whose appointment is approved by County Commissioners. Both of these advisory committees provide advice and direction as well as recommendations to the NH County Board of Commissioners for distribution of Home and Community Block Grant federal and state funds. VOCAL committee requires initial orientation from SRC management and monthly updates. The HCCBG Advisory Committee receives additional training from the Cape Fear Council of Governments Area Agency on Aging. New Hanover has a variety of training and development programs to support a culture of continuous learning by providing a comprehensive offering of training and professional development opportunities for our employees. NHC is committed to developing the most knowledgeable, experienced, and dedicated staff of Cape Fear Memorial Foundation - Grant Application Form Last Revised: 10/27/2015 (JGD) Page 6 of 15 professionals in local government. NHC does this by providing organizational and employee development opportunities that support the county's mission and strategic goals, effectively and efficiently serving the public as the Model of Good Governance. The Core Curriculum identifies courses of general application to all employees; examples include Customer Service, technology proficiency (MS Outlook, MS Word, MS Excel...), Diversity Awareness, and Interpersonal Relations. Customer Service Certification Curriculum - Elevated customer focus is an organization -wide standard by which all customers come away from contact with us feeling they have been served professionally and respectfully, and that they are our priority. Another new program, NHC SERVE, is available to all management level employees to assist them in their professional growth. While NHC values QENO, NHC does not currently participate in QENO trainings. NHC does access all other aspects of UNCW training in particular the Swain Center's Professional and Continuing Education. We are committed to staff development and see UNCW as a valuable resource for our department and for New Hanover County. Does the organization have any affiliations with national organizations to which dues or fees are paid? Not Applicable 7. Does your organization now, or does it plan, to engage in the promotion of political causes or in affecting any state or federal legislation? If yes, please explain. The SRC collaborates with the NC Senior Tarheel Legislature (STHL) program established by the NC General Assembly on July 24, 1993. Each county has one representative and an alternate who reports and makes recommendations to the NC General Assembly. They provide information and education to senior adults on the legislative process and matters being considered by the NC General Assembly. They promote citizen involvement and advocacy concerning aging issues, and assess the legislative needs of older adults by concerning a forum modeled after the NC General Assembly. PART II: PROJECT /PROGRAM (quantify whenever possible) What is the purpose of this request? (Please limit response to one sentence) The NHC SRC is requesting funding for the Prescription Assistance Counseling Program which provides education, guidance on the complex Medicare prescription drug plans, and to assist seniors in identifying, completing application, and obtaining low /or no cost prescription medications from pharmaceutical companies, subsidy companies, physician samples, and other resources. Cape Fear Memorial Foundation - Grant Application Form Page 7 of 15 Last Revised: 10/27/2015(JGD) What is the geographic area and target population to be affected? The area serviced will be New Hanover New Hanover County and the target population is residents who are 60+ years of age in New Hanover County. Is this a new or an existing program /project? This is an existing program. Summarize the program /project. (Please limit response to 2000 words) The Prescription Assistance Counseling Program's primary focus is to assist seniors one - on -one in obtaining low and /or no cost prescription medications from pharmaceutical companies, subsidy programs, physician samples, and other resources that may be identified. Another focus will be to continue to assist seniors with applications for the Low Income Subsidy program. In addition, grant funds will be used to meet the demand for one -on -one counseling, assistance and enrollment services as well as continuing our community outreach and education initiatives for this coming year Outreach and Collaboration Strategy. An important aspect ofthe Prescription Assistance Drug Program has been to provide a central location where people can get answers to their questions. The Program Coordinator provides education to seniors and community groups in New Hanover County about prescription assistance. The goal is to educated seniors about assistance programs so they can become their own advocate in seeking prescription assistance on an ongoing basis to avoid seniors omitting costly medications which could put them at risk of long term health complications. The prescription assistance program educates individuals in asking for samples or how to access programs that can reduce their cost of medications. Scope of the Program The seniors in our community are frustrated and confused by the Medicare Prescription Drug Plan and the rising cost of prescriptions while living on a fixed income. The most important aspect of the project has been to provide a local resource where people can get face to face answers to their questions and get some relief from the stress now being experienced by many of our seniors. This also helps reduce the burdens that have been passed along to families. Pam Wall educates clients about the gaps in Medicare D coverage and discusses options that will have the lowest financial impact on them while they are in the Medicare D "donut hole ". The donut holes exist because the majority of plans offer no gap coverage for prescription cost between $2,850 and $6,455. After a Medicare beneficiary spends a total of $4,550 out -of- pocket for prescription drugs, Medicare will pay 95% of the cost. This means that a married couple may have to pay $9,100 out -of- pocket in a year before their prescription drugs are covered at 95 %. From April 1, 2015 through December 30, 2015, more than 465 residents benefited from Cape Fear Memorial Foundation - Grant Application Form Page 8 of 15 Last Revised: 10/27/2015 (1GD) this health care counseling. The prescription assistance program saved clients $120,615.96 (Aprill,2015through December 30, 2015) in prescription cost by assisting them in getting medications directly from pharmaceutical companies, samples, RX programs, exc. Without assistance most of these individuals would have gone without their medications or would have cut them in half. The number of individuals needing prescription assistance continues to grow and the demand is now greater than ever because of the aging baby boomer population. Beneficiaries are required to navigate a new system that is changing rapidly, in part, because of requirements imposed by the new health care law. 5. Is this an evidence based intervention (Cite previous use /success and sources)? "Not applicable" is an acceptable answer to this question. Not applicable 6. Define the roles of the program /project's key personnel (please specify the personnel as new or existing in the organization) and other partner agencies (include letters of agreement from any collaborative partner). Pam Wall has been the Prescription Assistance Coordinator at NHC Senior Resource Center since 8/2013. The Prescription Assistant Coordinator's essential job responsibilities include: • Interviews and registers eligible clients or the responsible party of a client which includes fielding telephone inquiries, assessing eligibility, completing state /federal forms, and conducting periodic assessments. • Conduct in -depth face to face assessments (home and office) with seniors (60 +) to review current prescription medications and available resources to evaluate what assistance may be available to reduce prescription cost. • Conduct research of free /low cost prescription drug programs (approximately 100 programs) and match medication plans to client needs. • Communicate to clients the procedure for receipt of free /low cost prescription drugs and assist clients with application process to secure medication. • Network with physician offices for receipt of medication for clients. • Network with and make client referrals to pharmacists for medication review and education. • Make referrals to other sources of long term assistance programs (i.e. Medicaid). • Maintain a computer database of all clients served. • Attend training, as required by the state, to operate and maintain the medication Access and Review Program Software. • Prepare monthly reports as required by the grants. • Performs various public relation duties including preparing and delivering presentations to community groups. The Prescription Assistance Coordinator reports directly to the Senior Resource Center Social Work Supervisor, Aimee Watson- Green. Pam's knowledge of the ins and outs of the prescription plans, local resources, and drug companies provide a high level of service to our senior citizens. The Senior Resource Center Director, Amber Smith, will provide all reports to the Foundation regarding this grant. Cape Fear Memorial Foundation -Grant Application Form Page 9 of 15 Last Revised: 10/27/2015 (JGD) What are the program /project quantitative measures (number served, success rate)? Quantitative and qualitative performance measures will be identified as the outset of the funding period and adjusted as necessary throughout the period of funding. The Coordinator will collect baseline data for this purpose as well as preparing needs for future years. This information will be provided to the Senior Resource Center Program Manager and the Social Work Supervisor on a monthly basis and to the Cape Fear Memorial Foundation, quarterly. This will include data such as numbers of individuals counseled by categories, outcomes and dollar savings, outreach events /activities, and certain demographic information. 1. Identify /Define results of the program /project. (Please limit response to 1000 words) The goal of Prescription Drug Assistance program is to provide one location where seniors in New Hanover County can go for information, one -on -one counseling, special assistance with navigating the complicated Medicare and prescription drug plan system, education about Medicare D, and receive assistance in locating prescription medications at a free or reduced cost as well as providing prescription assistance education. The program will serve approximately 1000 people in the next year through the following services: • Assistance with prescription drug/contacting pharmaceutical companies • Enrollment in Medicare Part D assistance • Billing /Statement help • Donut Hole Counseling • NCRx enrollment • Medicare Advantage issues • Education on how to navigate Medicare and prescription assistance programs. 2. List the program /project critical steps and timeline for completion. The most critical step for this program is securing additional funding. Since the program is already in existence, the relationships with referring agencies, pharmacies, and physicians are very strong. Many pharmacist, doctors, and referral sources call Pam Wall for help in guiding their customers to the right plan or assisting clients in locating prescription funding because the individual is unable to afford their medication. Timeline- ongoing. We are researching grants and private funding sources to support this vital program. Cape Fear Memorial Foundation - Grant Application Form Page 10 of 1 Last Revised: 10/27/2015(JGD) We are at a crucial time for seniors. Health Care Reform has attempted to make it easier for seniors, but he "Donut Hole" continues to exist. Senior Medicare premiums continue to remain high and there are several medications that are not covered because they are not on the Medicare formulary. There are many seniors who simply cannot afford their medications and do not know how to access prescription assistance programs. As more and more baby boomers reach Medicare age, the need for assistance has steadily increased. It is imperative that the coordinator be well versed in Health -Care Reform and its impact on seniors. Timeline- ongoing. 3. What milestones will the organization recognize as steps toward success in the timeline? The most critical milestone is obtaining funding for this vital program. This program relies on grant funds. The demand for assistance has increased, therefore the funding needed to continue this program will also need to increase. The current position has only had enough funding for 25 hours a week. In order to keep up with the demand of providing assistance, the position hours will need to increase to 30 hours a week. This prescription assistance program is one of the most vital programs offered to citizens. Almost all of the other services provided by the Senior Resource Center are grant funded or generate revenue. This program is vital, yet falls into the category of non - mandated, does not generate revenue because we do not charge for services, making it vulnerable when county budgets tighten. 4. Cite expected benefits to the community as a whole upon success of this program /project. This program assists more than 1000 seniors in New Hanover County over a 12 month period. This program was able to help seniors more than $150,000 in prescription cost last year -for many seniors that meant not having to choose between their medicines and groceries. It provides a single place where seniors can get information, assistance in accessing programs, and education on how to receive long term prescription assistance. 1. Please state the amount and term for which funding is requested. If funds are being requested for multiple years, please state clarifies the amount requested for each term in addition to the full amount requested. The New Hanover County Senior Resource Center is requesting grant funding in the amount of $12,500 for April 15, 2016 -April 14, 2017. 2. Attach financial statements (audits, compilations, or forms 990) for the most recent 2 fiscal years. If deficits were incurred, how were they covered? See attached: 3. In the table below, please list the organization's Sources of Funding and amounts over the previous 2 years by category (private, grants, fee for service, etc.)? Cape Fear Memorial Foundation -Grant Application Form Page 11 of 1 Last Revised: 10/27/2015 (JGD) Previous Sources of Fundins (Past 2 Fiscal Years) FY 2014 23,000 Home Community Care Block Grant 957,253 NC DOT Transportation Grant 112,500 Family Caregiver Respite 23,000 Cape Fear Memorial Foundation 7,500 Catherine Kennedy Home Foundation 5,000 Foster Grandparent 152,693 RSVP 111,097 WAVE -ROAP Transportation 42,841 Health Promotion 4,000 Sr. Center General Purpose 11,680 Senior Health Insurance Info. 4,329 SHIIP -Low Income Subsidy 1.000 Total$ 1,432,893 FY 2015 Home Community Care Block Grant 977,353 NC DOT Transportation Grant 157,500 Family Caregiver Respite 23,000 Cape Fear Memorial Foundation 9,500 Catherine Kennedy Home Foundation (applied by VOCAL) 5,500 Foster Grandparent 111,474 RSVP 111,097 WAVE -ROAP Transportation 80,354 Health Promotion 8,793 Sr. Center General Purpose 11,397 Senior Health Insurance Info. 5521 SHIIP -Low Income Subsidy 3485 Total$ 1,504,474 Cape Fear Memorial Foundation - Grant Application Form Page 12 of 1. Last Revised: 10/27/2015 (1GD) 4. In the table below, please provide the complete Program /Project Budget including expenses and income for the period the funds are requested. From: 04/15/2016 To:04/14/2017 Expenses (By Category) Income (By Sources) Salary(30 hours week X $15 /hour 23,400 Cape Fear Memorial Foundation 12,500 FICA 1,755 Catherine Kennedy Foundation 5,000 Overhead cost 10,378 VOCAL 5,000 requested 13,033 New Hanover County 13,033 Total Expenses: $1 35,5331 Total Income: $ 35,533 5. In the table below, please itemize the Sources of Funding for this Request. Include public, private, fee for service, fundraising and other sources in addition to the status (budgeted, pending, approved, or declined) of the projection. Funds Requested for this Project From: 04/15/2016 To: 04/14/2017 Organization Status Amount Cape Fear Memorial Foundation requested 12,500 Catherine Kennedy Home Foundation VOCAL requested 5,000 VOCAL requested 5,000 New Hanover County Government requested 13,033 35,533 6. In the table below, please provide a complete Organization Operating Budget including expenses and income for the period the funds are requested. Cape Fear Memorial Foundation - Grant Application Form Page 13 of 1 Last Revised: 10/27/2015 (1GD) Organization Operating Budget: From: 04 /15/2016 To:04/14/2017 Expenses (By Category) Income (By Sources) HCCBG services 1,486,734 HCCBG services 977,3531, RSVP 152,119 RSVP Volunteer Program 111,097 Foster Grandparent 186,158 Foster Grandparent 152,693 Evidenced -Based Health Promotioi 8,525 Evidence Based Health Promotion 7,548 Prescription Asssitance- 35,533 Prescription Assistance 22,500 Senior Center General Purpose 11,3971 Senior Center General Purpose 11,397 Family Caregiver 23,000 Family Caregiver 23,000.00 Transportation 80,354 Transportation - NC DOT 80,354 7. In the table below, please itemize the Sources of Funding for the Organization as a whole. Include public, private, fee for service, fundraising and other sources in addition to the status (budgeted, pending, approved, or declined) of the projection. VOCAL Home and Community Care Block Grant approved approved 5000 977353 DOT 5310 Transportation Grant approved 112500 Family Caregiver Respite Grant appproved 23000 Foster Grandparent Grant approved 152693 Retired and Senior Volunteer Program Grant (RSVP) approved 111097 WAVE -ROAP Transportation Grant approved 42841 Sr. Center General Purpose grant approved 11680 Senior Health Information Program Grant approved 4329 8. If the funds requested are to be used for capital acquisition, please attach quotes or estimates. N/A 9. If the program /project increases operating costs, how will these increases be funded after this grant period? We will seek grant funding from other sources and will ask New Hanover County for support. 10. How will this program /project increase the sustainability of the organization as a whole? The program allows the New Hanover County Senior Resource Center to continue to focus on its mission "To act as the focal Point for Aging Services in New Hanover County by providing services which promote wellness, encourage independence and enhance quality of life for all older persons." We are the primary organization in New Hanover County providing this valuable service to seniors. 11. Does the organization have any endowment funds? What are the restrictions on these funds? N/A Cape Fear Memorial Foundation -Grant Application Form Page 14 of 1. Last Revised: 10/27/2015 (JGD) PLEASE NOTE - Cape Fear Memorial Foundation requires periodic progress reports to be completed informing the Foundation of the progress made by the organization's program /project and its associated expenses. Grant payments are contingent upon receipt and review of these reports. Preliminary Progress Report forms for current grants will be mailed in the beginning of January and due on February 15, 2016. Typed or Printed Name of CEO /Executive Typed or Printed Name Director of Board Chair Signature of CEO /Executive Director Signature of Board Chair Title Date — I / 1 2J, �0 Date Cape Fear Memorial Foundation - Grant Application Form Page 15 of 1 Last Revised: 10/27/2015 (JGD) Grant Document Routing 101 Start date: 1/12/16 From: Teresa Hewett, Finance Department (7408) Signatures required: _ Avril Pinder, Deputy County Manager IX Beth Dawson, Chairman Return to Teresa Hewett, Finance Department (7408) Type(s) of document(s) attached: 1 copy — SRC Cape Fear Memorial Foundation grant application Explanation of document(s): S� The Cape Fear Memorial Foundation grant for the Prescription Assistance Counseling Program is a recurring grant that is effective April 15`h to April 14`h each year. It this current application receives a grant award a budget amendment will be placed on the agenda to accept the grant for the FYI 6. This application is due January 15, 2016_ . Please let me know if you have any questions. Thank you --------------------------- - - - - -- for finance department use-------------------------------------------- - - - - -- DATE ADDED TO LASERFICHE PICKED UP BY: Print Name & Date Signature