FY16 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:
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• 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
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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
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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.
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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
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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.
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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.
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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 $12,500 for April 15, 2016 -April 14, 2017.
2. Attach financial statements (audits, compilations, or forms 990) for the most recent 2
fiscal years. If deficits were incurred, how were they covered?
See attached:
3. In the table below, please list the organization's Sources of Funding and amounts over
the previous 2 years by category (private, grants, fee for service, etc.)?
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Last Revised: 10/27/2015 (JGD)
Previous Sources of Fundins (Past 2 Fiscal Years)
FY 2014
23,000
Home Community Care Block Grant 957,253
NC DOT Transportation Grant
112,500
Family Caregiver Respite
23,000
Cape Fear Memorial Foundation
7,500
Catherine Kennedy Home Foundation 5,000
Foster Grandparent
152,693
RSVP
111,097
WAVE -ROAP Transportation
42,841
Health Promotion
4,000
Sr. Center General Purpose
11,680
Senior Health Insurance Info.
4,329
SHIIP -Low Income Subsidy
1.000
Total$
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
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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