By Carl Carter,2014-06-17 04:50
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    Children’s Trust Fund


     Carefully read all instructions and guidelines that relate to your program

A. General Instructions

1. Type the application.

2. Submit additional forms as requested on Application Checklist.

3. Confine the narrative to the space provided. Do not submit any additional

     material as an appendix, unless listed on the attachment checklist above.

4. Complete applications must be received at the Children’s Trust Fund by the specified deadline noted.

     Copies sent by fax will NOT BE ACCEPTED.

5. Send all application materials to the Children’s Trust Fund, 450 Capitol Avenue, Hartford, CT 06106.


     Indicate whether this program is funded by State or Federal funds.

     1. Indicate type of program or service.

     State the program name and location where services will be delivered.

     2. Indicate ONLY the Primary Targeted Population to be served. Note either children or parents, or both by

     selecting families.

     3. Indicate the COMPLETE LEGAL name of your agency. State your mailing address (not the program


     4. If you are applying as an agency state your Federal ID (FEIN) number; or a city or town state your town


     5. Specify the towns to be served by this program; or if your program will serve an entire region, state

     the region.

     6. Indicate the name, telephone, and fax number of the Executive Director.

     7. Indicate the person that may be contacted regarding program issues.

     8. Indicate the person that may be contacted regarding budget issues.

     9. Indicate the funding period.

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     10 & 11. Indicate the Fiscal Year information requested on each face sheet. State the amounts and

     percentages of Income and Expenses for this program for each fiscal year. The total of #10 must be the

     same as the total of #11.


     1. Program Description:

     Provide a thorough, yet succinct, description of the services to be provided during the contract period.

     Specify only those services to be carried out under this award. Do not reduce the type. All program

     guidelines indicated in the RFP must be addressed.

     2. Provide a description of the target population for the program, including age, gender, ethnicity, income

     level, geographic area, and any other factors that characterize the group. (i.e. adverse living conditions,

     family structure and dynamics, physical and/or emotional health, educational status, etc.)

     3. Describe the service model or approach the program will utilize. Provide the rational behind this program


     4. Briefly describe the staffing plan.

     5. Not Applicable leave blank

     6. A. Subcontractors: List agencies or individuals with whom you have an agreement to provide services for

     this program, and for which there will be a monetary compensation. Identify the agency or individual and

     state the specific services they will provide for this program. Signed letters specifying the services,

     compensation and other agreements must be attached.

     B. Coordination: Identify any agencies that will be directly involved in implementing the program and

     that will not receive any compensation for the service. State the service that each listed agency will

     provide. If the service is critical to the implementation of your program (i.e. primary referral source,

     training, resource for volunteers) letters of agreement must be attached.

     7. Provide a breakdown of the Primary Clients to be served by this program.

     The number must agree with the number indicated on Page 1 of this application. Explain how the numbers

     were determined. Identify the age range of children and youth to be served by this program. Children’s

     Trust Fund prevention programs should serve only a small percentage of CTF Clients - 1 to 2%.


     A. Indicate the specific hours the PROGRAM (not agency) will be in operation. These are the hours in

     which the contractor agrees to provide program services directly or through another agency (agreement

     must be attached).

     B. Indicate the total number of weeks per year the program will be in operation. DO NOT subtract weeks

     to account for staff member vacation schedules. DO indicate whether the program is funded for a partial

     of .

     year or if the program operates on a school calendar year or full year schedule. If the entire agency

     (program) closes during certain weeks (i.e. Christmas) DO not include these in the total weeks of

     program operation per year.

     C. Describe how a request for service after normal hours will be handled, and how emergency referrals

     after program hours will be managed. Please explain any on-call arrangements.

     9. Indicate the estimated percentage of time that service will be delivered at each of the settings listed during

     the contract period.

     10. The information in this chart must agree with the staffing pages of the budget. Indicate all staff

     (including those to be hired) who will be providing services in the program, whether funded by CTFC or

     other sources. For each of the categories, indicate both the full time equivalency of all staff in the

     particular category as well as the actual number of staff who are included in the FTE’s. Some staff may

     be recorded twice in the chart if they work in both direct service and administration. For staff to be hired,

     complete the FTE’s and # of positions. You do not need to identify gender or ethnicity for those to

     be hired.

     11. PROJECT WORK PLAN. Present a work plan for the program services you previously described in #1.

     The work plan included activities for the entire program, not just the CTFC funded portion. Attach as

     many additional pages as necessary.


     A. GOALS - Please note stated program goals in the Request for Proposal

     B. OBJECTIVES - State specific result to be achieved. Include major steps to be taken to

     implement the program; i.e. recruit program participants, provide supervision to staff.

     C. ACTIVITIES -Actions which describe the steps to be taken to achieve the objectives. Clearly

     state who, how, where and when.

     D. STAFF POSITIONS RESPONSIBLE - Indicate the specific staff person who will be

     responsible for each activity.


     Indicate what you hope to accomplish. Describe how this accomplishment will be measured both

     qualitatively and quantitatively. Outcomes and measures of success should relate to the objective,

     not the activities, and should be client/participant related whenever possible.

     F TIMETABLE - Indicate specific dates when the work on an objective and related activities will

     begin and end. DO NOT USE “ongoing” or “July - June” in the timetables. Be as specific as


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     Children’s Trust Fund

     450 Capitol Avenue

     Hartford, CT 06106

     Part III


State Funds_______ Federal Funds_________

1) Type of Program/Service:____________________________________________________________

     Program Name:____________________________________________________

     Program Location: _________________________________________________



    # Children ___________________ # Families __________________ # Parents ___________________

3) Legal Name of Contractor:

     Mailing Address:


    4) Federal Identification No./Social Security No./ Town and Dept. Code:

    5) Towns to be served:


    6) Executive Director Telephone #: Fax #: ______________________________________________________________________________________________________________

    7) Program Contact Person: Telephone #: Fax #: ______________________________________________________________________________________________________________

    8) Fiscal Contact Person: Telephone #: Fax #: ______________________________________________________________________________________________________________

    9) FY_________Funding Period Begin Date: Ending Date:


    10) FY________ EXPENSES 11) FY__________ INCOME A. Direct Service A. Amount Requested

     Personnel $_____________ _____% from CTFC $____________ ______%

    B. Admin/Support B. Other State funds ____________ ______%

     Perssonnel _____________ _____%

     C. Municipal Funds-Cash ____________ _______%

C. Fringes _____________ _____%

     D. In-Kind ____________ ______ %

    D. All Other Expenses _____________ _____%

     E. All Other Income ____________ _______%

    E. TOTALS $_____________ _____% F. TOTALS $____________ _______%

     of .

1. The following services will be provided on an annual basis:

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     Target Population

2. The contractor will serve the following target population annually:

3. Describe the service model or approach the program will utilize.

4. Describe the staffing plan.

5. Describe plan for in-service training, supervision and administrative support.

     of .

6a. Subcontractors will have a written agreement specifying their responsibilities

     in the implementation of the program.

    Individual/Organization Services to be Provided

6b. Coordination of Services

    The following agencies will be directly involved in implementing the program:

    Agency/Organization Services to be Provided

     of .

    It is estimated that approximately percent of 7. Contractor will serve a minimum of the following: children and youth to be served are actual DCF (a) Number of families to be served. FY: ______ cases. ___________ African American ___________ Age range of children and youth to be served from Hispanic to . ___________


     ___________ Multi-Racial/Multi-Cultural

     ___________ Other _________


(b) Number of children and youth to

     be served.

     ___________ African American

     ___________ Hispanic

     ___________ White

     ___________ Multi-Racial/Multi-Cultural

     ___________ Other ___________


(c) Number of parents to be served.

     ___________ African American

     ___________ Hispanic

     ___________ White

     ___________ Multi-Racial/Multi-Cultural

     ___________ Other ___________


    (d) Other service beneficiaries. ___________

     Please specify.



    The number of families (a), children and youth (b), parents (c) and other service beneficiaries (d) were determined by:

     of .

8. Program Operating Hours

(A) Contractor agrees to provide program services during the following hours.

    Summer Hours, if Daytime Hours Evening Hours Total # different Day Hours From To From To








    (B) The total number of weeks per year the program will be in operation is weeks.

(C) After hour services will be provided for in the following manner:

     of .

    9. Service Location Settings Anticipated % Contractor agrees to provide Direct Services in the following locations during the contract period: (a) Agency Office ___________

    (b) Client/Participant Home ___________

    (c) School ___________

    (d) Neighborhood Center ___________

    (e) Satellite Office ___________

    (f) Other (specify): ___________ __________________________


     TOTAL 100%

10. Staffing: Contractor agrees to hire or contract for the following staff for this program:

     Male Female

    To Be Totals Afro/Amer. Hisp. White Other Afro/Amer. Hisp. White Other Hired

    Administrative Full time Support Staff equivalent

    (Management) # of positions

    Administrative Full time Support Staff equivalent

    (Non-management) # of positions

    Direct Service Full time Staff equivalent

     # of positions

    Contractual Full time Staff equivalent

     # of positions

     Full time Totals equivalent

     # of positions

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