New Jersey Department of Health

INSTRUCTIONS FOR COMPLETION OF

“APPLICATION FOR MINI-GRANT FUNDS” (FS-77)

General Instructions - This is the standard form used by applicants requesting funding for a Mini-Grant. Applicants will complete all items. If an item is not applicable, write “N/A”. If additional space is needed insert an asterisk (“*”) and submit an additional sheet.

B.	Detailed Instructions and Definitions – See the Request for Application for specific instructions.

Face Sheet (Page 1): (An explanation follows for each item).

1.	Name of Applicant: If the applicant is a non-profit corporation or other entity, the full name must be used, not the name of the individual completing the form.

2.	Address: Official address of applicant.

3.	Fiscal Contact, Title, Telephone Number: The name of the individual who is responsible for the financial activities of the applicant.

4.	Name of Attorney for Agency and Telephone Number: The name and telephone number of the individual who is responsible for all the legal activities of the applicant.

5.	Principal Contact, Title, Telephone Number: The name of the individual who will be supervising the activity on a day-to-day basis, who can make necessary decisions affecting the project, and who can officially represent the applicant.

6.	Employer Identification Number: All applicants must complete this section. If you do not have an Employer Identification Number issued by the Internal Revenue Service, one must be obtained prior to submission of the application.

7.	Certificate of Need Project No.: Information and an application can be secured by calling the Department of Health, Certificate of Need and Acute Care Licensure Program (609) 292-6552.

8.	Proposed Grant Title: Use a concise descriptive title.

9, 10.	Location of Project: If the project activities are located in the same facility as the official address, identify the room number. If the project activity will take place elsewhere, identify location(s) in the space provided under Site Locations.

11.	Board of Directors/Trustees Inquiries (a. & b.) – Must be completed. Self-explanatory. If Yes, please provide an explanation on separate sheet.

Payment (c. & d.) – Indicate type of payment plan preferred and where payment should be sent.

12.	Type of Agency: Indicate the proper description of your agency.

13.	Licensure Requirement - If the applicant is required to hold a current and valid N. J. License to provide the service described in the application, indicate the type of license required and attach a copy of the official license.

14.	Agency Fiscal Year Ends: Self-explanatory.

15.	Agency Accounting System: Mark the appropriate box indicating the type of accounting system used by your agency when preparing financial reports.

16.	Type of Request: Refer to the Request for Application to determine the type of request.

a. Budget Period – The period of time for which a project is to be funded. The period covered should not be longer than 12 months unless otherwise indicated in the Request for Application.

b. Project Period – The period of time expected to complete the project. The period covered may be longer than 12 months, if indicated in the Request for Application.

17.	Merit System Requirement: No grant funds may be granted to any county or municipality for salaries unless they are covered by an approved merit system which, in New Jersey, is usually the New Jersey Civil Service Merit System. If a county or municipality has its own system that has been formally accepted by the State or Federal Government, a copy of the acceptance document MUST accompany the application.

18.	Affirmation Action Plan: One of the two boxes MUST be marked. This requirement is in compliance with New Jersey Statute 10:5-36 (P. L. 1975, C.127) entitled Affirmative Action Regulations.

19.	Supplanting Funds: Indicate whether an award under this application will be used to replace funds which would be otherwise available from another source. If yes, explain on separate page.

20.	Cost of the Project:

a.	Total Funds Needed - Amount needed from each contributor during the project period. Total of items 20b. and 20c.

b.	Funds Requested from State – Amount requested from the Department of Health during the project.

c.	Funds from Other Sources – Amount needed from any other sources during the project period.

21.	NJDOH Representative and Program (a. & b.) - Self-explanatory.

22.	Certification: Application must be signed by a certifying representative of the agency. This certification possesses legal authority to apply for the grant; that a resolution, motion or similar action has been duly adopted or passes as an official act of the applicant’s governing body, authorizing the filing of the application, including all instructions and attachments contained therein, and directing and authorizing the person identified as the official representative of the applicant to act in connection with the applicant and to provide such additional information as may be required.

Assessment of Need(s), Objective(s), and Cost of Project (Page 2): (Use as many pages as required to describe project.)

Assessment of Need(s) – Briefly list the need(s) which document the reason for the project.

Objective(s) of Project – Briefly list what will be done to alleviate the need(s) described above. An objective is a specific and measurable statement that summarizes expected achievement in meeting the described need.

Cost of Project – Indicate costs related to project.

C.	Reference Requirements

The applicant must comply with the following administrative and financial requirements that are applicable to the various types of agencies that receive grant awards from the New Jersey Department of Health. Applicant should be familiar with these requirements prior to submission of the application. Signing the application is certification of full knowledge and agreement to abide by these requirements.

1.	Compliance requirements: Applicable to this grant application. Copies of these requirements are provided with the request for application.

2.	Grantee’s Terms and Conditions for Administration of Grant Funds: The following cost principles mentioned in this document apply to the specific agency as noted.

a.	Cost Principles for State and Local Governments (OMB Circular A-87)

b.	Cost Principles for Educational Institutions (OMB Circular A-21)

c.	Cost Principles for Non-Profit Organizations (OMB Circular A-122)

d.	Cost Principles for Hospitals (Appendix E Title 45 CFR 74)

INSTRUCTIONS FOR COMPLETION OF

“APPLICATION FOR MINI-GRANT FUNDS” (FS-77)

(Continued)

FS-D4

AUG 12	-3-

AUG 12	-1-

FS-D4, Instructions for Application for Mini-Grant Funds (FS-77)

FS-D4, instructions, mini-grant funds, application, FS-77, financial services

EWhite

2004-04-13

NJDOH