Organization/Agency

Executive Director

Contact Person

Title

Address

City

State

Zip

Telephone

Federal ID Number

Contact Person’s Email Address

Key Programs/Services (Top 5 only please)

Total # of Clients Served (FY’10)

Estimated # of GDSS Clients Served (FY’10)

# of Locations

Greenwich Location

Description:

Strategic Fit with GDSS’ Priorities:

 Education  Housing  Medical/Mental Health Personal Safety

Client Demographics:

Expected Use of GDSS Funds:

Current Staff Resources Supporting

Program/ Service

 Development of new service/program

 # Full-time

 Maintenance of current service/program

 # Part-time

 Expansion of current service program

Total 

Funding Request:

Aggregate Funding History With GDSS (Last 5 Years)

Nature of Request

Explanation:

How will services be effected and targeted population assisted with the GDSS funding?

What criteria will be used to measure the efficiency of funded programs?

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

1. Overall Organization (Please also provide latest audited Financial Statement)

‘10

‘09

‘08

i. Total Revenues

$

a. Fee-based Income

b. Donations/Fundraising/Grants

c. Other government funds

ii. Total Expenses

iii.Surplus/Deficit (i - ii)

$

$

$

$

$

2. Target Program/Service (Please provide Program/Service Budget vs. Actual)

‘10

‘09

‘08

a. Total Revenues Generated

$

b. Development Dollars Allocated (from above)

$

c. Total Cost

$

d. Surplus/Deficit (a + b) – (c)

$

3. Costs of Target Program (for FY’10 only)

% related to Salaries

% related to General & Admin Costs

% related to Other Costs

Provide any other explanation (if desired)

Question

Representation

Yes

No

1. Is the information supplied as accurate as possible to the best of your knowledge?

2. Are you aware that the contract term for the proposed funding spans July 1, 2012 to June 30, 2013?

3. Do you acknowledge that any funding agreed to for the proposed contract term does not guarantee future funding?

4. Do you agree that you will only contact Dr. Alan Barry, Commissioner of Social Services for the Town of Greenwich, with any questions/comments regarding the funding evaluation process?

5. Will you provide a Profit & Loss of your organization (for your past fiscal year)?

6. Will you provide a Profit & Loss for the target program/service (for the last fiscal year)? If a new program/service, please provide the Budget.

7. Are you receptive to meeting 2-3 times during FY ’13 to review program progress?

8. Are you aware that GDSS is expecting to receive quarterly progress reports from you throughout FY ’13?

9. Are you receptive to GDSS assisting in the format and content requirements of the progress reports?

10. Are you supportive of the proposed funding payout schedules (tied to GDSS’ fiscal year and in percentage terms as a percent of the total funding amount)?

a. Upfront payment (July 30) 20%

b. Progress payment (within three weeks of receiving

first quarterly report covering July 1 – September 30) 20%

c. Progress payment (within three weeks of receiving

second quarterly report covering Oct. 1 – Dec. 30) 20%

d. Progress payment (within three weeks of receiving third

quarterly report covering Jan. 1 – March 30). 20%

e. Progress payment (within three weeks of receiving fourth

quarterly report covering April 1 – June 30). 20%

11. Have you read the RFP’s Terms and Conditions (T&C’s)?

12. Are you supportive of all T&C’s?

13. Is the contact person indicated in Section I of this response aware that we may contact him/her as part of our evaluation process?

14. Did the contact person complete this Proposal Response Form?

15. Did the Executive Director sign-off on Response?