2017-2018 older americans act (oaa) title iii bid … americans act … · web view2017-2018...

The 2017-2018 Bid Packet consists of the components listed below. Please make sure you have downloaded and reviewed all components.

Word Documents: AAA7 2017-2018 OAA Bid Packet AAA7 2017-2018 OAA Bid Packet, Appendix A

Excel Documents: Exhibit E-1Exhibit E-1AExhibit E-2

PDF Document: Declaration Regarding Material Assistance/ Non-Assistance to a Terrorist Organization

AREA AGENCY ON AGING DISTRICT 7, INC.

2017-2018 OLDER AMERICANS ACT (OAA) TITLE III BID PACKET

AREA AGENCY ON AGING DISTRICT 7, INC.2017-2018 BID PROPOSAL PACKET

OLDER AMERICANS ACT (OAA)TITLE III-B, TITLE III-C1 AND TITLE III-C2

TABLE OF CONTENTS

General Information for OAA Title III Bid Packet Submissions OAA Title III Proposal Packet Submission Checklist Instructions for Exhibits Exhibits:

Exhibit A-1 Application for Service Provision Exhibit B-1 Certification Regarding Debarment Exhibit B-2 Certification for Contracts and Grants Exhibit B-3 Section 504 Assurance Exhibit B-4 Title VI Civil Rights Exhibit B-5 Claims Agreement Exhibit B-6 Fiscal & Recordkeeping Agreement Exhibit B-7 Declaration Regarding Assistance to Terrorist Organizations Exhibit B-8 Standard Affirmation and Disclosure Form for Grants Exhibit C-1 Organizational Information Exhibit C-2 Organizational Chart Exhibit D-1 Governing Board Exhibit D-2 Articles of Incorporation/Certificate of Continuing Existence Exhibit D-3 Certification of Organizational Documentation Exhibit E-1 Planned Service Demographics Exhibit E-1A Planned Budget Exhibit E-2 Matching Funds/Resources Exhibit F-1 Social Services Exhibit F-2 Nutrition Services: Home-Delivered Meals Exhibit F-3 Nutrition Services: Congregate Meals Exhibit G Request for Variance from Prescribed Taxonomy Exhibit H Minority Agency Certification Exhibit I Proof of Insurance Exhibit J Insurance Claim Filing Exhibit K Grievance Policy Exhibit L Emergency Plan Exhibit M Documentation Regarding Debarment Exhibit N ServSafe Certificates/Training Exhibit O Food Service License(s) Exhibit P County Maps with Transportation and HDM Routes

APPENDIX A

2017-2018 OAA Bid Packet AAA7 Page 1

GENERAL INFORMATION FOR OLDER AMERICANS ACT (OAA) TITLE III BID PACKET SUBMISSION

1. Older Americans Act (OAA) Title III funds will continue to be awarded through a competitive bid process. Tentative funding levels will be available at the Mandatory Bidder’s Conference.

2. In order for consideration of the applicant’s submission, a representative from that organization or agency MUST attend the Mandatory Bidder’s Conference on Wednesday, June 29, 2016 at the Pike County Health Department (Conference Room) at 14050 US 23 North, Waverly, Ohio beginning at 9:00 a.m. (registration at 8:30 a.m.), and attendees must remain for the entire meeting. Please RSVP to [email protected] with the names of your attendees no later than Monday, June 27, 2016.

3. No individualized instruction or clarification will be given after the conclusion of the Mandatory’s Bidders Conference.

4. Applicants must submit one original and one copy that have been three-hole punched. Do not enclose them in binders or folders. (Please secure with binder clips or rubber bands.)

5. Funds available are:

a. Older Americans Act Title III-B: Social Servicesb. Older Americans Act Title III-C1: Congregate Mealsc. Older Americans Act Title III-C2: Home-Delivered Meals

6. The Area Agency on Aging District 7, Inc. Board of Trustees has determined the following services to be funded:

OAA Title III-B: TransportationPersonal CareHomemakerAdult Day ServiceLegal Counsel

OAA Title III-C: Congregate MealsHome-Delivered Meals

7. If applicant is applying for more than one sub-part (Title III-B, Title III-C1, Title III-C2) of OAA funding, the applicant needs to provide only ONE set of Exhibits B-1 through Exhibits D-3 and Exhibits H-N.

8. When preparing budget exhibits, all funding sources and corresponding units must be included.


mailto:[email protected]

9. Please review Appendix A document “Proposal Evaluation Criteria by Service”. This is the scoring sheet that AAA7 will utilize for awarding the contracts. If all of the Section I requirements are not met, we will not review the remainder of the bid packet – NO EXCEPTIONS.

10. If your agency is also applying for the Senior Community Services Care Coordination Program and/or the OAA Title III-E National Family Caregiver Support Program as a provider, the unit rates included on Sections 8D and 8E of Exhibit E-1A of the OAA Title III budget must be used as your requesting unit rate for those programs.

11.All awardees of OAA Title III funds will be required to submit budget exhibits each year of the two-year contract.

12.Providers selected under Older Americans Act Title III will be required to provide the following information during the contract year(s):

A. All specified monthly, quarterly, and yearly reports on the type and number of clients receiving contracted services, and units of service provided. This will include, but may not be limited to:

1) Monthly Invoice with applicable attachments2) Daily/Monthly Meal Recaps (meal providers only)3) Quarterly Sub-Recipient Financial Reports4) Final Sub-Recipient Financial Reports

B. Correctly completed client registry information outlined in the federally-mandated National Aging Program Information System (NAPIS) by use of the Social Assistance Management Systems (SAMS) software program, or paper report forms.

13.Successful applicants for nutrition programs must have an approved Food Service License from the county in which they will provide service, and provide a copy of such. Facilities of new applicants will have an on-site review by AAA7 personnel prior to contracting for the service(s).

In addition, successful nutrition applicants must provide proof that an adequate number of employees have obtained ServSafe Certification to ensure there is a ServSafe-certified employee in the kitchen at all times. Copies of ServSafe certificates must be included with the bid packet.

14.OAA Title III funds must not represent more than 85% of the funds spent for OAA Title III services. The 15% match requirement may be cash and/or in-kind contributions. Local includes, but is not limited to: local levy, United Way, general donations, and other fundraising. OAA Title III funding may be not used to replace


services currently being offered by other government funds. Match above the 15% requirement will be considered in awarding contracts.

15.OAA Title III proposals may include all available dollars of that particular sub-part to be spent on the services designated, or include a portion of the available dollars to be spent on any of the services designated, and include all or a portion of a specific geographic area. For example: OAA Title III-B funds may be requested to provide only Transportation, or for Transportation and Homemaker, or any combination of the listed services. If the agency is submitting a proposal for only a portion of the available funds, matching funds of 15% are required only for the portion requested.

16.Proposals for delivery of home-delivered meals and congregate meals must include preparing and serving of the menus specifically developed or approved by the AAA7 Registered Dietitian. In addition, the provider will be required to make arrangements for congregate meals Nutrition Education per AAA7 Policy OAAN-009. Providers must also cooperate with AAA7 to provide Nutrition Education for home-delivered meal consumers.

17. If received from the United States Department of Agriculture (USDA), AAA7 will provide a partial reimbursement for raw food costs through the Nutrition Services Incentive Program (NSIP) for qualifying meals. Estimated allocations for NSIP will be provided at the Mandatory Bidder’s Conference.

18.AAA7 will purchase, as deemed necessary, the Social Assistance Management System (SAMS) licenses that are required to report consumer information and service delivery.

19.AAA7 retains the right to contact the applicant to request clarification of any and all information provided in the application packet.


PROPOSAL PACKET SUBMISSION CHECKLIST

☐ Exhibit A-1: Application for Funding☐ Exhibit B-1: Certification Regarding Debarment, Suspension, Ineligibility and Voluntary

Exclusion Pursuant to 45 CFR Part 97 Lower Tier Transaction☐ Exhibit B-2: Certification for Contracts, Grants, Loans and Cooperative Agreements☐ Exhibit B-3: Department of Health and Human Services Assurances of Compliance

with Section 504 of the Rehabilitation Act of 1973, as amended☐ Exhibit B-4: Assurance of Compliance with the Department of Health and Human

Services Regulation under Title VI of the Civil Rights Act of 1964☐ Exhibit B-5: Claims Agreement☐ Exhibit B-6: Fiscal and Recordkeeping Agreement☐ Exhibit B-7: Declaration Regarding Material Assistance/Non-Assistance to a Terrorist

Organization☐ Exhibit B-8: Standard Affirmation and Disclosure Form for Grants☐ Exhibit C-1: Organizational Information☐ Exhibit C-2: Organizational Chart☐ Exhibit D-1: Governing Board and/or Statement of Ownership☐ Exhibit D-2: Articles of Incorporation AND Certificate of Continuing Existence☐ Exhibit D-3: Certification of Organizational Documentation☐ Exhibit E-1: Planned Service Demographics☐ Exhibit E-1A: Planned Budget (one per service)☐ Exhibit E-2: Matching Funds/Resources☐ Exhibit F-1: Social Services (one per service)☐ Exhibit F-2: Nutrition Services-Home-Delivered Meals☐ Exhibit F-3: Nutrition Services-Congregate Meals☐ Exhibit G: Request for Variance from Prescribed ODA Service Taxonomy☐ Exhibit H: Minority Agency Certification☐ Exhibit I: Proof of Insurance☐ Exhibit J: Insurance Claim Filing☐ Exhibit K: Grievance Policy☐ Exhibit L: Emergency Plan☐ Exhibit M: Documentation Regarding Debarment☐ Exhibit N: ServSafe Certificates/Training☐ Exhibit O: Food Service License(s)☐ Exhibit P: County Maps with Routes


INSTRUCTIONS FOR EXHIBITS

1. Exhibit A-1: Application Applicant agency information is self-explanatory. Project information is completed only if an agency sponsors a specific program for seniors in a different location, i.e., separate division of the agency. All applicable lines must be completed and/or signed.

2. Exhibit B-1 through Exhibit B-8: Assurances These are required assurances that must be completed and signed by the executive director or his/her designee. Failure to agree to these requirements will make the applicant ineligible for consideration. These assurances will become a part of the contract, if funds are awarded.

3. Exhibit C-1: Organizational Information Leave questions in the document. The person(s) reviewing the proposals may not be familiar with your organization and its operations, so make sure you answer the questions as you would to someone that is unfamiliar with your organization and its operations. Include additional information if you think it is beneficial for our understanding of your organization. To answer each question, click on area that says “Click Here to Enter Text” and space will automatically be given for any length of answer.

4. Exhibit C-2: Organizational Chart If AAA7 is the primary funding source for the agency budget (through OAA Title III, Senior Community Services, PASSPORT, etc.), show all employees. If your agency is a multi-service agency and AAA7 funds only one or two activities, show all employees paid in total, or in part, from AAA7 funds, and show their relationship to the agency director. You must identify which position is in charge in the absence of the executive director. Indicate positions that are solely funded through the PASSPORT Medicaid Waiver program, if applicable.

5. Exhibit D-1: Governing Board and/or Statement of Ownership Provide names and addresses of the current Board of Directors and/or a list of persons (and their addresses) that hold 5% or more ownership. Please identify demographic information requested for each person.

6. Exhibit D-2: Articles of Incorporation AND Certificate of Continuing Existence Attach a copy of your Articles of Incorporation AND your current Certificate of Continuing Existence.

7. Exhibit D-3: Certification of Organizational Documentation Complete and sign the certificate.

8. Exhibit E-1: Planned Service Demographics Applicant is to list services and accompanying demographic data for all services for which funds are being requested.


9. Exhibit E-1A: Planned Budget Applicant must complete a Planned Budget for each service for which funds are being requested. This detail corresponds with the budget line items required on the Sub-Recipient Quarterly Financial Report.

10.Exhibit E-2: Matching Funds/Resources For each service in the bid packet application, list the amount of total matching funds to be contributed. Neither project income nor cost-sharing revenue received from OAA Title III services can be considered matching funds. Do not list OAA Title III allocations on this summary.

11.Exhibit F-1: Social Services Applicant is to complete a Service Narrative for each service for which funds are being requested. (Social services are Transportation, Personal Care, Homemaker, Adult Day Service and Legal Counsel.) Leave questions in the document. The person(s) reviewing the proposals may not be familiar with your organization and its operations, so make sure you answer the questions as you would to someone that is unfamiliar with your organization and its operations. Include additional information if you think it is beneficial for our understanding of your organization. To answer each question, click on area that says “Click Here to Enter Text” and space will automatically be given for any length of answer.

12.Exhibit F-2: Nutrition Services – Home-Delivered Meals Leave questions in the document. The person(s) reviewing the proposals may not be familiar with your organization and its operations, so make sure you answer the questions as you would to someone that is unfamiliar with your organization and its operations. Include additional information if you think it is beneficial for our understanding of your organization. To answer each question, click on area that says “Click Here to Enter Text” and space will automatically be given for any length of answer.

13.Exhibit F-3: Nutrition Services-Congregate Meals Leave questions in the document. The person(s) reviewing the proposals may not be familiar with your organization and its operations, so make sure you answer the questions as you would to someone that is unfamiliar with your organization and its operations. Include additional information if you think it is beneficial for our understanding of your organization. To answer each question, click on area that says “Click Here to Enter Text” and space will automatically be given for any length of answer.

14.Exhibit G: Request for Variance from Prescribed Taxonomy Submit this exhibit if your agency is requesting to provide a service differently than is defined by the Ohio Department of Aging (service definitions are found in Appendix A).


15.Exhibit H: Minority Agency Certification Complete this exhibit if the agency can certify it is a minority organization based on the criteria listed.

16.Exhibit I: Insurance Policy Enclose a copy of the page of your Insurance Policy which shows that you have commercial liability insurance in the amount of $1,000,000 (one million) or more. Do not send your entire insurance policy.

17.Exhibit J: Insurance Claim Filing Enclose a copy of your written policy/procedure that is provided to consumers explaining how they can file an insurance claim.

18.Exhibit K: Grievance Policy Enclose a copy of your agency’s Grievance Policy and all related forms.

19.Exhibit L: Emergency Plan Enclose a copy of your agency’s Emergency Plan.

20.Exhibit M: Documentation Regarding Debarment This information can be found at https://www.epls.gov . Access the information for your agency and print the page to enclose for this exhibit.

21.Exhibit N: ServSafe Certificates/Training Documentation (meal providers only)Enclose copies of ServSafe certificates and/or proof of training for all employees of your nutrition program.

22.Exhibit O: Food Service License (meal providers only)Enclose a copy of your current state or county food service license(s).

23.Exhibit P: County Maps If applying for transportation and/or home-delivered meals, please provide a map (showing townships) that depicts your routes.


https://www.epls.gov/

EXHIBIT A-1

APPLICATION FOR SERVICE PROVISIONS OF THE OLDER AMERICANS ACT PROGRAMS

Date Submitted: Click here to enter text.

Legal Name of Applicant Organization: Click here to enter text.

Address: Click here to enter text.

Phone: Click here to enter text. FAX: Click here to enter text.

Executive Director/CEO: Click here to enter text.

Executive Director/CEO Signature:

Executive Director/CEO E-Mail Address: Click here to enter text.

Board President: Click here to enter text.

Board President Signature:

Project Name or d/b/a (if applicable): Click here to enter text.

Address (if different from above): Click here to enter text.

Phone: Click here to enter text. FAX: Click here to enter text.

Project Director: Click here to enter text.

County(s) to be served: Click here to enter text.

Proposal Scope (check all that apply): ☐Title III-B ☐ Title III-C1 ☐ Title III-C2

Application Contact: Click here to enter text. E-Mail: Click here to enter text.

Fiscal Contact: Click here to enter text. E-Mail: Click here to enter text.

Federal Tax ID Number: Click here to enter text.

CONTRACT YEARS: January 1, 2017 through December 31, 2018Area Agency on Aging District 7, Inc.

PO Box 500, F32-URGRio Grande, Ohio 45674


EXHIBIT B-1

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION PURSUANT TO 45 CFR PART 76

LOWER TIER TRANSACTIONS

Click here to enter text.

(Name of Agency or Organization)

certifies by submission of this proposal that neither it or its principles is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.

Where the agency is unable to verify any of the statements in this certification, such agency shall attach an explanation to this proposal.

Signature of Authorized Individual

Name and Title of Authorized Individual: Click here to enter text.

Date: Click here to enter text.


EXHIBIT B-2

CERTIFICATION FOR CONTRACTS, GRANTS, LOANSAND COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief that:

1. No federal appropriated funds have been or will be paid, by or on behalf of the undersigned to any person for influencing or attempting to influence an officer or employee of this agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.

2. If any funds other than federally-appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit the form, “Disclosure Form to Report Lobbying”, in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

STATEMENT FOR LOAN GUARANTEES AND LOAN INSURANCE

The undersigned states, to the best of his or her knowledge and belief, that if any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this commitment providing for the United States to ensure or guarantee a loan, the undersigned shall complete and submit the form, “Disclosure Form to Report Lobbying”, in accordance with its instructions.

Submission of this statement is a pre-requisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Signature, Agency Director Date

Signature, Chair of Board of Directors Date


EXHIBIT B-3

DEPARTMENT OF HEALTH AND HUMAN SERVICES ASSURANCES OF COMPLIANCE WITH SECTION 504 OF THE REHABILITATION ACT OF 1973,

AS AMENDED

The undersigned (hereinafter called the “recipient”) HEREBY AGREES THAT it will comply with Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), all requirements imposed by the applicable HHS regulation (45 C.F.R. Part 84), and all guidelines and interpretations issued pursuant thereto.

Pursuant to §84.5(a) of the regulation [45 C.F.R.84.5(a)], the recipient gives this Assurance in consideration of and for the purpose of obtaining any and all federal grants, loans, contracts (except procurement contracts and contracts of insurance or guaranty), property, discounts, or other federal financial assistance extended by the Department of Health and Human Services after the date of this Assurance, including payments or other assistance made after such date on applications for federal financial assistance that were approved before such date. The recipient recognizes and agrees that such federal financial assistance will be extended in reliance on the representations and agreements made in this Assurance and that the United States will have the right to enforce this Assurance through lawful means. This Assurance is binding on the recipients, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this Assurance on behalf of the recipients.

This Assurance obligates the recipient for the period during which federal financial assistance is extended to it by the Area Agency on Aging through the Department of Health and Human Services or, where the assistance is in the form of real or personal property, for the period provided for in §84.5(b) of the regulation [45 C.F.R.84.5(b)].

The recipient [check (a) or (b)]:

a. employs fewer than fifteen persons;b. employs fifteen or more persons and, pursuant to §84.7(a) of the regulation [45

C.F.R.84.7(a)], has designated the following person(s) to coordinate its efforts to comply with the Health and Human Services regulations:

Name of Designee: Click here to enter text.

Name of Recipient: Click here to enter text.

Address: Click here to enter text.

IRS Employer Identification Number: Click here to enter text.

I certify that the above information is complete and correct to the best of my knowledge.

Title: Click here to enter text.Signature of Authorized Official

Date:


EXHIBIT B-4

ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES REGULATION UNDER

TITLE VI OF THE CIVIL RIGHTS ACT OF 1964

Organization Name: Click here to enter text.

hereinafter called the “sub-grantee”, HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L.88-352) and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 80) issued pursuant to that title, to the end that, in accordance with Title VI of that Act and Regulation, no person in the United States shall, on the ground of race, color, or national origin, be denied the benefits of or be otherwise subjected to discrimination under any program or activity for which the Sub-grantee receives federal financial assistance from AREA AGENCY ON AGING DISTRICT 7, INC., a recipient of federal financial assistance from the Department (hereinafter called the “Grantor:); and HEREBY GIVES ASSURANCE THAT is will immediately take any measures necessary to effective this agreement.

If any real property or structure thereon is provided or improved with the aid of federal financial assistance extended to the Sub-grantee by the Department this assurance shall obligate the Sub-grantee, or in the case of any transfer of such property, and transferee, for the period during which the real property structure is used for a purpose for which the federal financial assistance is extended or for another purpose involving the provision of similar services of benefits. If any personal property is so provided, this assurance shall obligate the Sub-grantee for the period during which it retains ownership or possession of the property. In all other cases, this assurance shall obligate the Subgrantee for the period during which the federal financial assistance is extended to it by the Grantee.

THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all federal grants, loans, contracts, property, discounts or other federal financial assistance extended after the date hereof to the Sub-grantee by the Grantor, including installment payments after such date on account of applications for federal financial assistance which were approved before such date. The sub-grantee recognizes and agrees that such federal financial assistance will be extended in reliance on the representations and agreements made in this assurance, and that the Grantor or the United States or both shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the Sub-grantee, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Subgrantee.

Applicant Name: Click here to enter text.

Mailing Address: Click here to enter text.

Title of Authorized Official: Click here to enter text.

Signature of Authorized Official:

Date:


EXHIBIT B-5

CLAIMS AGREEMENT

A. The Service Provider shall act as an independent contractor/grantee, and not as an employee of the Area Agency on Aging District 7, Inc., in the operation of all services. The Service Provider shall be liable, and agrees to be liable for, and shall indemnify, defend and hold the Area Agency on Aging District 7, Inc. harmless, for all claims, suits, judgment, or damages arising from the operation of the aforementioned, during the course of the contract/grant.

B. The Service Provider shall protect the Area Agency on Aging District 7, Inc. against loss or damage (including cost of litigation) caused by the Service Provider.

C. The Service Provider will defend any suit against the Area Agency on Aging District 7, Inc. alleging injury or property damage as a result of this contract/grant.

D. Commercial liability insurance protection shall be carried by the Service Provider, in the minimum amount of $1,000,000 (one million).

E. The Service Provider shall notify the Area Agency on Aging District 7, Inc. in writing of all claims against the Service Provider. The Service Provider shall not settle claims without the written consent of the Area Agency on Aging District 7, Inc.

F. If the Service Provider refuses or neglects claims, the Area Agency on Aging District 7, Inc. may defend against such claims and charge the costs thereof to the Service Provider.

G. The Service Provider agrees that, in the event of non-delivery of services, alternative arrangements shall be made by the Area Agency on Aging District 7, Inc. or their representatives, and the costs and expenses shall be deducted from the contract/award.

Name and Title: Click here to enter text.

Signature:

Date:


EXHIBIT B-6

FISCAL AND RECORD KEEPING AGREEMENT

The Service Provider understands and agrees to comply with the fiscal policies and procedures as prescribed by the Area Agency on Aging.

Applicant Name: Click here to enter text. agrees to:

1. Provide necessary bookkeeping and documentation of all project income received through services in order to produce a clear record of the income and disbursements during the period of the contract award.

2. Maintain accurate and up-to-date client records, (which include, at a minimum, all documentation outlined in the service specifications) of all service(s) provided with all funds received through AAA7.

3. Maintain project income in an appropriate bank account in such a manner as to make these funds clearly and easily distinguishable from other sources of income.

4. Maintain all billing records and documentation in such a way as to make them easily accessible and useable by the AAA7 staff for unit auditing purposes.

Name and Title: Click here to enter text.

Signature:

Date:


EXHIBIT B-7

DECLARATION REGARDING MATERIAL ASSISTANCE/NON-ASSISTANCE TO A TERRORIST ORGANIZATION

This is a PDF document. Please obtain this form by clicking on the link on the front page of the AAA7 website.

Please insert signed form here.


EXHIBIT B-8

STANDARD AFFIRMATION AND DISCLOSURE FORM FOR GRANTSEXECUTIVE ORDER 2011-12K

Banning the Expenditure of Public Funds on Offshore Services

GRANTEE AFFIRMATION AND DISCLOSURE

By the signature affixed to this Affirmation and Disclosure, the Grantee identified below affirms, understands and will abide by the requirements of Executive Order 2011-12K issued by Ohio Governor John Kasich. The Executive Order is attached and is available at the following website: (http://www.governor.ohio.gov/Default.aspx?tabid=1495).

The Grantee acknowledges that for purposes of the Executive Order that grant funding provided to support a project or program of the Grantee is equivalent to a purchase of services by the State; “services” in the context of a grant means services that implement the project or program of the Grantee to the extent that such services are paid for or reimbursed with grant funds provided by the State or with match or cost share specifically required by the State as a condition to disbursement of the grant funds; investments by the Grantee in the project or program from non-State sources of funding other than amounts claimed as specifically required match or cost share are not subject to the Executive Order; the Grantee is equivalent to a “contractor,” as that term is used in the Executive Order; and sub-grantees, if any, and contractors of the Grantee are equivalent to “subcontractors,” as that term is used in the Executive Order.

The Grantee affirms that the Grantee and any of its sub-grantees and contractors shall perform no services outside of the United States to implement the grant-supported project or program which will be paid for or reimbursed with grant funds or which will be counted as match or cost share specifically required as a condition to disbursement of the grant funds.

The Grantee shall provide all the name(s) and location(s) where services will be performed in the spaces provided below or by attachment. If the Sub-grantee will not be using sub-grantees or contractors, indicate “Not Applicable” in the appropriate spaces. If the Grantee will not be storing, accessing, testing, maintaining or backing-up state data, indicate “Not Applicable” in item 3.

1. Principal location of business of Grantee:

(Address) (City, State, Zip)

Name/Principal location of business of lower-tiered sub-grantee(s) and contractor(s):

(Name) (Address, City, State, Zip)



2. Location where services will be performed by the Grantee:


Name/Location where services will be performed by sub-grantee(s) and contractor(s):



3. Location where state data will be stored, accessed, tested, maintained or backed-up, by Grantee:

(Address) (Address, City, State, Zip)

Name/Location(s) where state data will be stored, accessed, tested, maintained or backed-up by sub-grantees and contractor(s):






4. Location to where services to be performed will be changed or shifted by Grantee:


Name/Location(s) where services will be changed or shifted to be performed by sub-grantee(s) and contractor(s): (Name) (Address, City, State, Zip)






RFP/Award:

Grantee:

Signature ofAuthorized Representative:

Name:

Title:

Date:


EXHIBIT C-1

ORGANIZATIONAL NARRATIVE

ORGANIZATION NAME: Click here to enter text.

Administrative Description

1. Describe the type of organization applying to serve as the legally-responsible sponsor of this grant.


2. Describe the relationship between the sponsor and the applicant program, if applicable.


3. Describe the applicant’s service area.


4. List all services or programs currently offered by your agency/organization regardless of whether they are funded by AAA7.


Agency Capacity for Delivering the Proposed Services

5. Describe the organization’s experience in administering public funds.


6. Given the limits of federal funding, how has your organization obtained local financial and community support for your services?


7. Does your agency currently meet requirements for United Way, Community Block Grant or Title XX funds? If no, explain. Click here to enter text.

Do you receive any of these funds?


What services do they fund? Click here to enter text.

Explain if these funds have been lost and why.


8. If local cash is provided in full or in part by local levy funds, provide the following information:

a) yearly amount of levy revenues by dollar and millage amount; Click here to enter text.


b) time span covered by the levy; Click here to enter text.

c) next expiration date-month and year; d) plans for renewal, if any.


9. Does your organization have experience in GAP (General Accounting Procedures) for fiscal management? Explain. Click here to enter text.

If no, what accounting method do you utilize?


10.Describe specific efforts to be made by the applicant to increase usage of your agency services by:

a) geographically-isolated elders;


b) minority elders; Click here to enter text.

c) low-income elders; and


d) elders with limited English-speaking ability.


11.Describe efforts to provide outreach and communicate aging services information to older adults who are lesbian, gay, bisexual or transgender (LGBT).


12.Describe your organization’s program management capacity. Click here to enter text.

Does your organization currently provide the services you have applied for with any other funds?


13.Describe your organization’s method or plan to monitor the proposed services or obtain client satisfaction feedback.


What has your agency done in the last year to address the issue? Please provide results of your surveys.


14.What is your total operating budget for this fiscal year? Click here to enter text.


What are your primary sources for funds, and how are they proportioned in the budget?


15.Describe any future plans for expansion or anticipated change in service delivery.



EXHIBIT C-2

ORGANIZATIONAL CHART

Show below, or attach a copy, of your Agency Organizational Chart as it relates to your application.


EXHIBIT D-1

GOVERNING BOARD

Please list name and address and answer each demographic category. (Demographics are not mutually exclusive.) See demographic definitions in Appendix.

(If more space is needed, use your Tab key on the last ‘square’ and additional lines will be added.)

Name/Address/Office

Age 60+? (Y/N)

Participant? (Y/N)

Community Leader?

(Y/N)Minority?

(Y/N)

Term Expiration

Date


EXHIBIT D-2

ARTICLES OF INCORPORATION AND CERTIFICATE OF CONTINUING EXISTENCE

Please enclose a copy of your Articles of Incorporation AND a copy of your Certificate of Continuing Existence.


EXHIBIT D-3

CERTIFICATION OF ORGANIZATIONAL DOCUMENTATION

The applicant organization hereby verifies that the following documentation is on file for review by the Area Agency on Aging District 7, Inc., in accordance with the Ohio Department of Aging Conditions of Participation (check all that apply):

Corporate By-laws

Workers’ Compensation Certificate

Bond Certificate and list of individuals who are bonded by the agency

Medicare/Medicaid Provider Agreement Letters, if applicable

If the agency is for-profit, a copy of the latest tax return - 1120 If the agency is non-profit, a copy of the latest tax return - 990

Personnel Policy and Procedure Manual

Affirmative Action/Equal Opportunity Plan

Program/Operational Policy and Procedure Manual

Job Descriptions for positions related to service delivery

Documented training(s) for positions related to service delivery

Signature, Executive Director Date


EXHIBIT E-1

PLANNED SERVICE DEMOGRAPHICS

Exhibit E-1 is an Excel document. Please insert it here.


EXHIBIT E-1A

PLANNED BUDGET

Exhibit E-1A is an Excel document. Please insert one here for each service.


EXHIBIT E-2

MATCHING FUNDS/RESOURCES

Exhibit E-2 is an Excel document. Please insert it here.


EXHIBIT F-1SOCIAL SERVICES INFORMATION


SERVICE: Click here to enter text.

(Add a separate Exhibit F-1 for each service applying for.)

Answer each question completely. Explain the service as if describing it for the first time.

1. Describe how the applicant will deliver this service, including:

a) activities to be performed; Click here to enter text.

b) schedule/frequency of each client receiving services; Click here to enter text.

c) criteria for receiving services/methods of prioritizing; Click here to enter text.

d) waiting list size/average length of wait; Click here to enter text.

e) townships served/not served; Click here to enter text.

f) areas to which service will be expanded. Click here to enter text.

Remember to include Exhibit O (Route Maps) if applying for transportation service.

2. List other agencies or organizations that provide this general service in your service area.


3. All services are defined by Ohio Administrative Code rule. Describe how the rule definition is currently being met or NOT MET.


If not met, describe what you will do in 2017-2018 to better this standard.


4. Explain the need for this service in your area, and how you will make seniors aware of its availability.



5. Describe your method (and most recent results) for evaluating consumer satisfaction with the proposed service.


6. Describe your agency’s internal quality assurance system for this system (beyond customer satisfaction surveys). Speak to supervisor oversight, required/optional training, documentation/forms utilized, etc.


7. Describe how you will encourage clients to provide project income to expand this service.


8. Describe any plans for expansion of this service.



EXHIBIT F-2NUTRITION SERVICES – HOME-DELIVERED MEALS


1. Describe your agency’s meal transportation system, including: a description of all hot and cold packaging, transport containers and vehicles used.


2. Describe how you test and record end temperatures of a home-delivered meal, including: personnel that will be responsible, how personnel will be trained, and frequency of testing.


3. If you plan to distribute frozen home-delivered meals, please describe in detail your process for meal provision (i.e., purchasing from an approved vendor, self-producing, etc.). Click here to enter text.

If self-producing, describe steps by which that process is completed, including all equipment utilized.


4. Per AAA7 Policy OAAN-006, it is required that frozen home-delivered meals be labeled with a) “use by” or “expiration” date, and b) instructions for reheating and use. Please show the wording, or attach a copy of the labeling that will be used.


5. Describe how you meet all the requirements, including qualifications of internal personnel responsible for food service monitoring/inspection, and include copies of all monitoring/inspection tools that are used for documentation.


6. Describe in detail how your individualized delivery system will be organized and function. Please include any circumstances that do not allow you to individualize for certain clients and/or delivery patterns.


7. Provide current waiting list size and average length of wait time.


8. If you are a current provider of home-delivered meals, please attach your 2015 completed documentation of community referrals for consumers with nutritional high-risk. If you are not a current provider, please explain the process by which you will track referrals to community-based organizations (i.e., JFS, food banks, soup kitchens, etc.) for individuals who are at high nutrition risk. This is a requirement of AAA7 Policy OAAN-012.



9. Describe specific geographic areas served and not served (i.e., township, city, county). Individually list townships served with the county, and areas to which services will be expanded. (Remember to include Exhibit P, Map of Home-Delivered Meal Routes.)


10.List other agencies or organizations that provide this service in your service area.


11.This service is defined by Ohio Administrative Code rule. Describe how the rule is currently being met or NOT being met. If not being met, describe what you will do in 2017-2018 to meet the standard.


12.Describe your methods and most current results (other than surveys) for evaluating consumer satisfaction with the proposed service.


13.Describe how you will encourage consumers to provide project income to expand this service.


14.Describe any anticipated plans for expansion or service delivery change(s).



EXHIBIT F-3NUTRITION SERVICES INFORMATION-CONGREGATE MEALS


1. If satellite congregate meal sites are part of your service delivery, describe your agency’s meal transportation system, including: a description of all hot and cold packaging, transport containers and vehicles to be used.


2. Describe how you will test and record end temperatures of congregate meal site foods, including: personnel that will be responsible, and how personnel will be trained to perform this function.


3. Describe how you will meet all the requirements, including qualifications of internal personnel responsible for food service monitoring/inspection. Include copies of all monitoring/inspection tools that will be used for documentation.


4. Describe in detail how your individualized delivery system will be organized and function. This includes methods used at both the main congregate site and satellite sites.


5. Do you maintain a waiting list for congregate meal participation? If yes, how many are currently on the list and what is the average length of wait?


6. Describe specific geographic areas not served by a congregate meal site. Are any other meal services available to those areas?


7. List other agencies or organizations that provide this service in your service area.


8. This service is defined by Ohio Administrative Code rule. Describe how the rule is currently being met or NOT being met. If not met, describe what you will do in 2017-2018 to better meet this standard.



9. Describe how you will encourage clients to provide project income to expand this service.


10.Describe your reservation system.


11.Per ODA Rule 173-4-07 and AAA7 Policy OAAN-009, congregate meal sites are required to provide nutrition education a minimum of two (2) times per year by a fully qualified instructor of nutrition education based upon regulations regarding the practice of dietetics found in Chapter 4759 of the Ohio Revised Code. (In most counties, OSU extension services can provide this service.) The service must include a method for participants to evaluate the education received. Please describe your method for providing this service.


12.List the physical address, site manager name, phone number, fax number, e-mail address and meal service time for all congregate sites.


13.Describe any anticipated plans for expansion or change in service delivery.



EXHIBIT G

REQUEST FOR VARIANCE FROM PRESCRIBED ODA SERVICE TAXONOMY(attached additional pages if necessary)

1. Service Name: Click here to enter text.

2. Definition of Service: Click here to enter text.

3. Detailed description of service to be provided: Click here to enter text.

4. Unit of Service: Click here to enter text.

5. Rationale for change to this service: Click here to enter text.

6. Detailed description of target population for this service: Click here to enter text.

7. Amount of OAA funds budgeted: Click here to enter text.

8. Sources and amounts of OTHER funds budgeted: Click here to enter text.

9. Describe the impact on other services caused by diverting these funds to new services and the impact on other services needed in the community:


10.Projected number of service units for the year: Click here to enter text.


EXHIBIT HMINORITY AGENCY CERTIFICATION

(complete ONLY if applicable)(This information is required by ODA and does not affect the status of the proposal)

Name of Agency/Organization: Click here to enter text.

Mailing Address: Click here to enter text.

City, State, Zip: Click here to enter text.

The above-identified Agency or Organization certifies that it is a minority organization based upon meeting the following criteria (check one):

☐ 1. Private Profit-Making Agency/Organization

☐ a. An organization whose sole ownership, or 50.1%, of whose stock is held by minorities.

☐ b. A partnership with at least 50% of the interest in the partnership controlled by a minority individual.

The ownership is as follows: Click here to enter text.

☐ 2. Non-Profit Agency/Organization (public or private)

☐a. The make-up of the board of directors/policy-making body is at least 50.1% Minority, AND

☐b. The total staff is at least 50% minority.

Signature of President or Chairman of the Board/Owner/Partner Date

Name and Title of Signatory: Click here to enter text.


EXHIBIT I

PROOF OF INSURANCE

Please enclose a copy of the page of your Insurance Policy which shows commercial liability coverage in the minimum amount of $1,000,000 (one million).

Please DO NOT submit your entire insurance policy.


EXHIBIT J

POLICY/PROCEDURE FOR FILING INSURANCE CLAIMS

Please include your written policy and/or instructions which you provide to consumers that explains to them how they can file an insurance claim.


EXHIBIT K

GRIEVANCE POLICY

Please enclose a copy of your organization’s Grievance Policy. Include all forms utilized in this process.


EXHIBIT L

EMERGENCY PLAN

Please enclose a copy of your organization’s Emergency Plan.


EXHIBIT M

DOCUMENTATION REGARDING DEBARMENT

Please access your organization’s information on the following website:

https://www.epls.gov

and attach a copy of the search results for this exhibit.


https://www.epls.gov/

EXHIBIT N

SERVSAFE CERTIFICATES/TRAINING DOCUMENTATION

Enclose copies of ServSafe certificates and/or training documentation for all employees of the nutrition program.


EXHIBIT O

FOOD SERVICE LICENSE(S)

Please enclose copies of your current food service license(s).


EXHIBIT P

COUNTY MAPS WITH TRANSPORTATION AND/OR HDM ROUTES

Please enclose a county map showing your Transportation and/or Home-Delivered Meal routes. (Make sure the map has township boundaries shown.)
