ANNEX A-Forms Instructions - New Jersey€¦ · Web viewPlease complete the ORR 6 (Schedule A and...

DEPARTMENT OF HUMAN SERVICES

DIVISION OF FAMILY DEVELOPMENT

CONTRACT ADMINISTRATION UNIT

CONTRACT RENEWAL PACKAGE

FY 16

Refugee Programs (Social Services, Cuban-Haitian Social Service, Elderly Social Service and TAG)

FY 16 Renewal Instructions and Deadlines

Important Deadlines and Reminders:

1. The renewal package must be submitted to the DFD Contract Administrator 45 days prior to the start date of the contract period..

2. Any renewal contract package not received by that date will risk forfeiture of the contract award.

3. DFD will not authorize any service without the timely receipt of a contract renewal package. Until final DFD approval of the scope of work detailed in the Annex A, DFD assumes no liability for the services rendered and the costs incurred.

4. Any contract not submitted in accordance with the instructions and within the timeframe required or failure to respond to all requests for additional documentation that prevents the execution of the contract before 60 days after the contract start date will result in the rescission of the contract awards.

5. The renewal package submitted must be the FY 16 package and forms.

New for FY 16

1. The Annex B must include a written, detailed budget narrative explaining the proposed costs included in the budget. The narrative should explain all proposed staff and costs in the budget and how the costs were estimated.

Specific comments regarding proposed program staff, subcontractors, vendors, and consultants, indirect cost rates (including fringe benefits and General and Administrative (G&A)) must be included in the narrative. The narrative should explain the sources of funding when the DFD contract is not the sole source of funding for the program.

The Annex B and narrative should include details of all fringe benefits and the indirect cost pool, the indirect cost base, and allocation methodology for the allocation of the indirect costs.

DFD must easily understand the total proposed budget and identify what services are being provided and at what cost – both direct and indirect. The budget should be very detailed and include specific proposed costs for all expenditures (office supplies, travel, provider training, staff development training, postage, printing,

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meeting expense, conference, mileage, etc.). The budget narrative should then explain the purpose of each expense included in the proposed budget, how the cost was estimated (i.e. number of trips/mileage to be reimbursed at $.xx per mile) and also include commentary on the purpose for the expense and explain the relationship to the delivery of service and accomplishment of the program goals and objectives.

Annex A Reminders:

The Annex A consists of two parts; Part I is the written narrative that must be thorough and include specific details of the program services, manner and method of delivery including program services, client eligibility, subcontractor and/or vendors that will provide services. The narrative should include commentary regarding the client universe, eligibility factors, determination methods, documentation and level of service to be provided. This requires a detailed discussion for each service component, including vendor, projected level of service to be provided, number of clients, rates and total cost. The information detailed in the narrative must reconcile to the Projected Level of Service (LOS) reports required as part of the renewal package. Part II requires a response to the questions.

Please make sure all mathematical computations in the projected LOS are correct and the rates do not exceed the DFD authorized rates.

The lack of details and incorrect data in the Annex A and LOS prevent the timely approval of program services and will delay the approval of the contract. Any contract not submitted in accordance with the instructions and the timely manner required or failure to respond to all requests for additional documentation that prevents the execution of the contract before 60 days after the start of the contract period will be rescinded.

Subcontract agreements should be submitted to DFD and approved before the start of the contract, but are due to DFD no later than 30 days after the start of the contract period. Failure to submit and obtain approval will result in disallowed costs and risk of reduction in the contract ceiling.

Annex B Reminders:

The contract renewal notice includes a grid detailing the funding component as well as the client services and administrative cost information for each component. Each component and service (client service and administrative cost) must be detailed in a

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separate column in the Annex B. Please note that administrative costs can be used for direct client services but will require approval and contract modification. Direct client services can’t be transferred to administrative costs.

All budgeted costs must adhere to the DHS cost principles contained in the DHS Cost Reimbursement Manual – specifically Section 4. DFD will review the budgeted costs for allowability, allocability and reasonableness.

Administrative costs are limited to the amount specified in the contract award notification.

DEFINITION OF ADMINISTRATIVE COSTS

In accordance with the Final Temporary Assistance for Needy Families (TANF) regulations, specifically 45 CFR Part 263.0(b), administrative costs include and exclude the following:

ADMINISTRATIVE COSTS INCLUDE:

Administrative costs are those expenses necessary for general administration and coordination of TANF (including indirect and overhead), including:

Salaries and benefits of staff performing administrative and coordination functions;

Activities related to eligibility determinations;

Preparation of program plans, budgets, reports, schedules and other documents;

Monitoring of programs and projects;

Fraud and Abuse units;

Public relations;

Services related to procurement, accounting, litigation, audits, property management and personnel;

Management Information Systems not related to the tracking and monitoring of

TANF requirements (e.g., payroll and personnel systems for staff administering TANF);

Costs for the goods and services required for administration (e.g., activities mentioned above) of TANF, such as:

Supplies

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Equipment

Travel

Postage

Utilities

Office space

ADMINISTRATIVE COSTS EXCLUDE:

Direct costs (salaries, benefits, related direct administrative costs) of staff providing program services, such as:

Providing Early Employment Initiative (Diversion) funding

Providing program information to clients

Screening and assessments

Development of Employability Plans

Work activities

Post-employment services (e.g., child care and transportation)

Work supports

Case management

All costs for contracts devoted entirely to the above services.

Please note the special contract terms for:

Salary – See SLD P2.01, Sections 5.16 and 5.17

Conferences/Meetings – See SLD P2.01, Section 5.22 and CRM Section 4.6 (requires 30 days pre-approval)

Travel – See SLD P2.01, Section 5.20 and CRM Section 4.6

Subcontracts – See SLD P2.01, Section 5.02, CRM Section and DHS Policy P99.24

ANNEX B - Helpful Hints

Detailed instructions for completing the Annex B including the DHS Cost Reimbursement Manual (CRM), Section 5.3 and an Annex B tutorial are located at

http://www.state.nj.us/humanservices/dfd/info/

The budget should detail all costs to administer program and meet program goals and objectives in accordance with required cost principles and instructions of the CRM.

The budget must:

Reflect the total County program budget/costs – even if DFD is not the full funding source

Include details of all other grants/contracts and specify those also contributing towards funding the program

Specify all proposed costs as direct or indirect For all indirect costs - identify the indirect cost basis of allocation Detail all subcontract/vendor services

Have two (2) original signatures on the summary page

Copies of consultant and subcontract agreements must be submitted

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http://www.state.nj.us/humanservices/dfd/info/

Other Important Reminders

Required Documents: (DHS Policy P1.01)

All required contract documents, forms, signatures (original) with the required number of copies and signatures must be returned.

Modifications: (DHS Policy P1.10) (final request due to DFD no later than 30 days prior to the end of the contract period)

Reporting: (Detailed in the Annex A and SLD Section 3.02)

Contract Acquired Equipment and Disposal: (DHS Policy P4.05)

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Contract Renewal Package

Annex A:

Contract Summary Sheet

Authorized Signatures

Service Delivery Information

Part I - Program Narrative

Part II – Questions

Projected Level of Service (see separate excel worksheet)

Renewal Documents:

Index of Required Contract Documents

Contract Checklist

Document Verification Sheet (DVS)

Executive Order 129

Certification of Suspension and Debarment

FAFTA

Disclosure of Investment Activities in IRAN

List of Contracts/Grants

Contract Forms (List of Required Documents Available on DFD Website)

Federal Award Information

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ANNEX A-Forms Instructions

Contract Summary Sheet

Enter all data requested in the form. Enter Official responsible for the program administration.

Authorized Signatories

Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board Resolution).

IMPORTANT - This is the address where the signed contract and all relevant legal correspondence will be mailed – so please ensure this is the accurate address.

Service Delivery Information

Please complete all details for the service delivery

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STATE OF NEW JERSEY - DIVISION OF FAMILY DEVELOPMENT

ANNEX A – CONTRACT SUMMARY SHEET – FY 16

Provider Agency

Contract # RF

Mailing Address

Federal III

Telephone Number

Provider Agency Fiscal Year End

County

Contract Effective Date

to

Contract Ceiling

$

Organization Type

County

Board of Social ServicesCWA

Non-Profit

Program A

Agency Official Executive Officer

Title Mailing

Address

Telephone Number

Fax Number E-Mail

Address

All routine notices relevant to the administration of the program should be sent to:Name & Title

Mailing Address

Telephone Number

Fax Number E-Mail

Address

Do you currently receive payment by Automatic Deposit (ACH) for this contract? Yes No

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Division of Family DevelopmentAnnex A - Authorized Signatures – FY 16

List names and positions of persons authorized to sign the following and number of persons required to sign each transaction.

Name/Address Position# of Signatures

Required

Contract1

2 3

Quarterly and Final Financial Reports

1

2 3

ContractBudget Modification

1

2 3

Checks1

2 3

Other Contract Documents: Program

Reports

1

2 3

Note: - Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board Resolution). This is the address where the signed contract and all relevant legal correspondence will be mailed. This should be the individual who signs the SLD (page 23). This may not be the same individual as noted in the Annex A summary sheet. In the event of emergency notification, please include e-mail and fax number.

Contract Signatory Title Mailing Address

Telephone Number Fax Number E-Mail Address

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FY 16 Division of Family Development

Annex A -Service Delivery Information

Program Name: Site Address:

City, State, and Zip Site Phone Number:

Program Director/Coordinator Telephone #:

Fax: E-Mail:

Service will be provided as follows (designate time):From To

Sunday Monday Tuesday

Wednesday Thursday

Friday Saturday

Services will not be provided on the following occasions: # Holidays _______

Date (s) Occasion

Emergency Provisions: Describe any special arrangements which have been made to handle emergencies, e.g. voice mail instructions, special telephone numbers etc.:_________________________________________________

Contract #

Division of Family DevelopmentANNEX A - PROGRAM OPERATIONS

Introduction and Instructions:Following are the contract components to be administered for the program. The Provider Agency shall describe the components as they are administered internally. The Annex A, Program Description information should reconcile to the projected Level of Service (LOS) data and reconcile to the details included in the Annex B - Budget.

The Provider Agency must provide information in the Annex A narrative describing how each service component of this contact will be administered including internal processes and controls for each program/service component. Answer all questions by providing information that is quantifiable and qualifiedly measurable to the extent feasible.

Key Statutory and Regulation Requirements of the contract

a. Determine who is eligible to receive Federal and State financial assistance;b. Have internal controls and performance measures to determine that all Federal and State

rules are accurately applied;c. Adherence to applicable Federal rules and State program compliance requirements; andd. Assurance of appropriate use of allowable government funds to carry out the goals and

objectives of the program.

The Provider Agency assures that it will comply with the following statutory requirements and ensure Federal and State funds are applied to:

Eligible Clients – By statue – only clients that meet program eligibility criteria

Staffing - The agency agrees to l provide notification of any program administration staff changes to the DFD Contract Administrator and Program Representative within 20 days of the change.

Personnel Requirements

The Agency Director or program designee must attend and participate in DFD-sponsored in-person meetings and trainings and conference calls as directed by the DFD Contracts and Program Staff.

Fiscal Standards and Accountability

Recipients and sub-recipients of Federal and State funds are responsible for the proper use of such fund. Funds must only be used for the intended purpose and in compliance with all Federal, State and contract regulations. All parties are responsible for the transparency and accountability for the funds and are subject to administrative, contractual and legal sanctions for the misuse and/or improper use of these funds. Provider Agencies are considered sub-grantee/recipients under this contract and are subject to Federal laws, regulations and provisions of this contract as set forth in this document; and must ensure adherence to all applicable regulations.

The agency must meet all contract expectations as described in the RFP as well as those detailed in this contract. Failure to meet any performance standard and contract expectations can be grounds for revision of the contract whereby current funding is reduced, contract is suspended or terminated and can affect future consideration for funding.

In addition to the core areas of program delivery, Provider Agencies must maintain administrative and fiscal accountability, meet reporting requirements, and ensure program integrity to meet all program compliance and performance standards. As recipients of government funds, all agencies must adhere to all federal and state laws and regulations as stated above.

Grant Cost Principles – Costs incurred for the delivery of the services will be based on Federal and State cost principles and include only those costs deemed allowable, allocable and reasonable per the regulations.

Fiscal Requirements:

The agency is a third party provider of services to DFD subject to administrative, fiscal and programmatic monitoring and oversight from DFD. The provider agencies are responsible to adhere to all DHS and DFD contract rules and regulations and to follow all directives issued by DFD. Provider Agencies’ acceptance and use of Federal and State funds from this contract constitutes the agency’s acceptance of these terms and conditions.

Recipients and sub-recipients of Federal and State funds are responsible for the proper use of such funds. Funds are used for the intended purpose and in compliance with all Federal, State and contract regulations. All parties are responsible for the transparency and accountability for the funds and are subject to administrative, contractual and legal sanctions for the misuse and/or improper use of these funds. Provider agencies are considered sub-grantee/recipients under this contract and are subject to federal laws, regulations and provisions of this contract as set forth in this document and must ensure that:

Contract funds are allocated to meet program objectives and for the purpose as intended; Fiscal and accounting procedures are sufficient to permit the preparation of required

reports and the proper reconciliation of expenditures to adequate source documentation to establish funds have been used appropriately for the intended purpose in accordance with all applicable laws, regulations, and contract cost principles;

Annual completion of the Single Audit, as required; Funds are not used to support inherently religious activities, such as religious instruction

or activities; Funds are not used to support lobbying activities to influence proposed or pending

Federal or State legislation or appropriations; and Funds are expended in accordance with all pertinent laws and regulations.

Allowable Cost

The determination of allowable costs is defined in the SLD, RFP, DHS and DFD Cost Reimbursement Manual (CRM) and the DHS Contract Policy and Information Manual (CPIM). Expenditures are defined as those costs which are restricted to activities related to programmed

plan development; complaint files management; public hearing information; program monitoring and coordination; report preparation; evaluation of program outcomes; personnel management; travel; equipment; supplies; audits and response management; and indirect costs such as maintenance of facilities, utilities, and general management staff.

Reporting Requirements

The agency is required to submit program and fiscal reports within the required timeframes. At a minimum, the following reports are required:

I. Fiscal Reports

A. Report of Expenditures (ROE)

Fiscal reporting is required on a quarterly basis combining subcontracted and direct agency expenditures. Actual expenditures must be reported using the Annex B form on a cumulative basis by the 20th day of the following month after the close of each calendar quarter.

The Final ROE is due 120 days after the contract period ends.

The expenditure reports must contain an original signature of the CEO and fiscal officer designated by the county for this program.

An initial advance payment will be issued when the contract is fully executed. Future quarterly reimbursements will occur subsequent to DFD’s receipt and review of the expenditure report for the previous quarter and as long as all other contract deliverables are met.

All reports must be sent to:

DFD, Office of Contract Administration P.O. Box 716 Trenton, New Jersey 08625-0716

Attention: Contract Fiscal Unit

II. Program Reports

Program reports are to be submitted to the DFD Program Office as specified in the Annex A.

III. Payment Terms

The initial advance payment representing 25% of the contract ceiling will be issued when the contract is approved and signed. Subsequent quarterly advance payments are issued upon receipt and review of the quarterly report of expenditures (ROE) and, assuming all other contract

obligations are current and there are no violations of any other contract provisions. Adjustments to a quarterly payment may be made for a variety of reasons, including provider agency spending patterns, DFD fiscal review issues, audit matters that come to our attention, or as needed to meet program delivery and DFD Budget/ Fiscal issues.

DIVISION OF FAMILY DEVELOPMENT

ANNEX A FOR SOCIAL SERVICES, CUBAN-HAITIAN, ELDERLY SOCIAL SERVICES AND TAG

GENERAL:

The contract award may include funding for Social Services, Cuban-Haitian, Elderly Social Services and Target Assistance Grant (TAG). The Annex A includes detailed scope of work requirements for the each component. Provider agencies must complete a separate Annex A narrative and response to the applicable questions for each component awarded (as specified in the award letter).

Annex B - Budget Details

The website provides guidance on the preparation of the Annex B. Complete detailed instructions for the Annex B may be found in Section IV of the "Contract Reimbursement Manual".

Subcontracts are to be shown under Budget Category "F, Other". If services are directly provided by the contracted agency then each budget category line item (i.e. personnel, materials and supplies, etc.) detail is required in the Annex B. Refer to detailed discussion of subcontracts in the renewal guidance for additional subcontract requirements.

This section must be completed by any agency receiving funding for the Refugee Social Services component.

Division of Family Development

REFUGEE SOCIAL SERVICES PROGRAMANNEX A

PROGRAM GOALS AND DESCRIPTION

The Department of Human Services (DHS) Division of Family Development (DFD) recognizes that critical social services and supports are needed for new refugee arrivals and eligible populations resettling in New Jersey to help them transition to their new life. Refugee Social Services (RSS) under the Office of Refugee and Resettlement Program (ORR) is 100% federally funded, under Part 400 of Title 45 under the Code of Federal Regulations (CFR) to provide an array of employability and supportive services that foster personal responsibility, promote economic self-sufficiency and social adjustment.

Categories of Refugees and Eligible Immigration Status for ORR services:

Refugees in possession of an I-94 stamped “Admitted as a Refugee Pursuant to Section 207 of the Act” are eligible for services;

Parolees who have an I-94 with “paroled as a refugee” or “207” stamped or written on the document are eligible;

Cuban/Haitian entrants who have been granted parole, applied for asylum, or are in exclusion or deportation proceedings but have not received a final order of deportation;

Asylees; Special Immigrant Visas (SIVs) from Iraqi and Afghan; and Certified Victims of Trafficking.

The primary purpose of New Jersey’s RSS is to assist eligible populations to adjust socially and attain the skills needed to find employment and becoming self-sufficient as quickly as possible through an array of services. These services are provided in collaboration with a network of service providers to ensure that the necessary support and assistance is given in accordance with ORR’s priority in providing services.

Priority in Providing Services

All newly arriving refugees during their first year in the U.S. who apply for services; Refugees who are receiving cash assistance; Unemployed refugees who are not receiving cash assistance; Employed refugees in need of services to retain employment, achieve job upgrades, or

attain economic independence.

Services Available and Time Limits

Providers should consider the strengths, resources, and community capacity to ensure that refugees access the highest quality of services within their community. These services are an important aspect of helping refugees integrate and become contributing members of their communities as quickly as possible.

The Division believes that successful resettlement requires a continuum of support and services of State and local government, public and private partners, community-based agencies, and refugee resettlement agencies. DFD strives to provide a comprehensive approach to the RSS program through a network of culturally competent providers and resettlement agencies, local community resources, and supportive social services through the County Welfare Agencies (CWAs) and employment services, such as the One Stop Career Centers (OSCCs) to foster social and economic self-sufficiency as soon as possible.

Description of Possible Services as indicated in 45 CFR 400.154

Employment Services – must include an Individual Employment Plan (IEP) and Family Self Sufficiency Plan (FSSP) to determine the appropriate skills, training and services necessary to help the individual or family become self-sufficient through timely employment. Examples of services include:

1. Employment Assessment Services – adjunct services (aptitude for certain professions, skills testing, job coaching and development).

2. Job search, placement, and follow-up. 3. On the job training – provided by prospective employers with expected outcome of

employment.4. Vocational Training – that provide ready skills in a short period of time and part of the

IEP and FSSP plans a. Tuition reimbursement –available for vocational training, skills certification,

licenses, etc. upon DFD’s approval. 5. Skills Certification – recertification of licenses; except for certain restrictions – must

meet the criteria for appropriate training in 45 CFR 400.81(b). 6. English language instruction – with emphasis on formal and certified instruction, and as it

relates to obtaining and retaining a job – no other resources available a. ESL – details of type and services – certified, schedule, duration

(ESL and vocational training must be provided to the fullest extent feasible outside normal working hours to avoid employment interference).

7. Transportation – when necessary for employability services or for acceptance or retention of employment – no other resources available.

8. Translation and interpreter services, when necessary in connection with employment or participation in an employability service.

9. Case Management Services – as defined as the determination of specific service(s) to which to refer a refugee in accordance with an employability plan, referral to such service(s), and tracking of the refugee’s participation in such services employable.

10. Other Service – for example, information and referral services, (these were previously mentioned above).

11. Social Adjustment Services – household budget & management, health related services, short-term counseling (crisis).

The employment-related descriptions listed above are specific eligible social service activities for the purpose of obtaining gainful employment in accordance with ORR guidelines. For all individuals accessing services under this grant, individuals must be given every opportunity to quickly access services and supports to assist them in becoming integrated members of American society and employed and to become self-sufficient. In addition, they should not be duplicative of existing service delivery systems.

Though social services are up to 60 months, as established by 45CFR 400.152, priority for providers should be for those that have been in New Jersey for less than 12 months.

Learning English is a very critical and primary component of obtaining employment. Instruction can take place in a wide range of settings which must be considered when referring or providing these services to ensure that individual needs and varying schedules are being met. If certified and flexible ESL services are offered in the community, individuals should be informed of those services to consider meeting the schedules of the families.

Another important component of the ORR program is refugees easily accessing culturally and linguistically supportive social services. The resettlement agencies are required to refer individuals to the CWA to obtain federally funded benefits and services, such as medical, food and if eligible, cash assistance to assist them in becoming integrated into their new society. This is in an effort to meet their basic needs while emphasizing self-sufficiency. The referral process will ensure expedited services to these appropriate and critical benefits.

Likewise, the CWA also will refer eligible individuals that need culturally and linguistic ORR employability social services; such as cultural orientation, job readiness, preparation and placement, as well as, supportive and ESL services to the local resettlement agencies.

The resettlement agency contracted with DFD must provide those prescribed employability services as outlined above in accordance with ORR’s regulatory provisions at 45 CFR 400.154.

Annex A - Narrative and QuestionsA. Narrative

Please provide a detailed written narrative of your agency’s proposed program. The program description should present a clear picture of the program’s structure, staffing, description and implementation of specific services to be provided (as detailed in the Annex A scope of work) and service delivery methods/process, referral process if applicable, coordination with other collaborators/stakeholders and local service providers as applicable. The agency’s description should explain how and where the services will be provided and by whom – detailing the use of all consultants and subcontractors with details of the agency’s monitoring of the services from consultant and subcontractors.

The narrative should include a detailed implementation plan for the completion of the DFD program including all components detailed in the scope of work.

B. Annex A Questions

Please concisely respond to the questions below:

1. Staffing: Describe staff positions, responsibilities and provide staffing structure information. (Provide their position, titles, duties, and the percentage of time worked in the program).

a. If staff time is charged to more than one program and/or grant, describe the process used to ensure the allocation of time spent on each program/grant is correct or supported.

b. Who supervises the provision of services/activities/outcomes and ensures they are timely, documented and reported?

c. What kind of staff in-service training do you provide to the program staff? d. Will any services be provided by consultants or subcontractors? If so, please

provide details of the consultant/subcontractor (i.e. scope of work, terms of the agreement, reimbursement terms, key staff including areas of expertise and credentials). Copies of the agreement must be attached or contract approval will be delayed.

2. Provide a brief overview of your agency’s program and specific role with administering the ORR program. The narrative should include:

a. Your agency’s success and/or challenges administering the program last year.b. Provide statistics of how many clients were served through ORR funds – and the

services provided – indicate the types of populations serviced. c. Explain the goals and objectives for this contract period.d. Describe the need for the grant and how it is going to be utilized. e. Indicate other Federal, match dollars and amount, etc.; used for the same or

similar services and/or populations. f. Describe what employability services your agency will provide. Include the

following: i. Type of employability services, as outlined above.

ii. If ESL is provided, please provide details – (certified instructors, type of instruction basic, structured, classroom or home setting; on-site or referred, various levels, number of hours per week, how many instructors,

language spoken etc.). g. Description of how you will ensure that the prioritized populations are being

serviced. Priority is for new arrivals and the unemployable – within the first year of arrival.

h. Explain your referral process with the CWA and other community resources and collaboration efforts. Accessing supportive social services is paramount due to the urgent need to obtain basic services.

i. Provide details of your staffing composition – experience and language, percentage of time allocated under this contract, and projected staff to client ratio. Cultural and linguistically competent staff is essential due to the language and social barriers many of the populations face.

3. Describe how your internal process and monitoring procedures ensure that refugees do not receive duplicated services if they are eligible for services under more than one grant.

4. Describe how your agency plans to evaluate the program. Explain how your agency plans to collect data. Identify any strengths and weaknesses from prior evaluations.

5. Explain the monitoring and quality assurance of the program including:

a. Submit a copy of the Agency’s Quality Assurance and Monitoring Policies and Procedures.

b. Provide information on refugee’s satisfaction survey for program services. How often is this survey done? If your agency does not have a customer survey, please describe your plan to implement one.

c. Does the agency have a wait list for any services? If yes, how does the agency determine which refugees receive services and when?

6. What systems are in place to ensure that accurate records are maintained for completing all required program and fiscal reports?

7. How does your agency provide linguistically and culturally appropriate services to clients? Provide information on your program staff’s multi-lingual capacity (languages, cultural and translation services).

a. How does your program ensure compliance with Title VI (LEP policy)? Are program forms, flyers and other written materials translated into client’s native language? Do clients sign forms indicating their understanding of the program requirements and services? How is this issue addressed with illiterate clients?

b. Describe your agency’s English language and literacy services.

8. What barriers or challenges do you anticipate in the implementation of the program goals, objectives, activities and achieving its outcomes?

a. Identify any challenges, limitations, or restrictions on services and coordination.

b. What will be your agency’s strategy for addressing the challenges?

9. Describe how your agency will meet the objectives, goals, and deliverables of the contract as detailed in the scope of work.


11. Describe your agency’s purpose, philosophy, goals, and objectives.

12. How does the mission of the program align with your agency’s mission? Describe how the program will benefit/impact the community?

13. Identify and describe any unique capabilities of your agency in delivering the service.

14. Identify any changes, challenges, limitations, restrictions, and priorities on meeting the scope of work requirements.

15. Identify past year program goals and summarize performance outcomes. Provide a summary of select agency accomplishments. If this is a renewal contract, describe at a minimum how has your program developed and made progress toward its goals in the past.

16. What barriers, if any, have impacted your agency’s ability to meet program goals?

17. Describe the agency’s outreach efforts and communication efforts for the program.

18. If fees will be collected from recipients of any services outlined in the Contract Requirements, state the anticipated annual amount of revenue. Also state how those revenues will be used to offset the contract’s costs.

DIVISION OF FAMILY DEVELOPMENTREFUGEE TRAINING AND/OR VOCATIONAL SERVICES

SUPPORTIVE SERVICES AND TUITION ASSISTANCE REQUEST

Date of Referral:Agency:Contract #

Student’s Name:

Address:

Employed Yes or No If Yes how longType of Support or Services

Vocational Training Computer Training

License or Certification *Alternative ESL (non-traditional)

*Transportation Services Child CareBeginning and End DatesReason for Training

Your signature below verifies that these statements are true: Student has been in the United States a maximum of 60 months Training is to help obtain employment or upgrade employment No other financial assistance was received that would duplicate this request for

assistance No other resources available in the County or accessible transportation

Student Signature: Date:

Agency Staff Signature: Date:

DIVISION OF FAMILY DEVELOPMENT USE ONLY

Amount Requested: $Amount Approved: $Amount Disapproved: $Staff Signature: Date:

Supervisor’s Approval: Date:

* Transportation - must complete a separate transportation reporting form* ESL – must be a certified structured program and individual must be working

Compliance Standard Indicators/Documentation

Cultural and Linguistically Competent Employment Orientation

Orientation provided in clients’ language or in partnership with a Translator.

Materials and information of ORR benefits in clients language or translated

Ensure Person eligible for services Status, arrival data, intake and case notesEmployment Cultural Orientation completed within 5 days of arrival in their language

Intake forms along with any documents and case notes

Person informed of ORR program and social service grant services for up to five years

Signed document

Person informed of welfare benefits & work requirements; as well as other relevant supportive services - ESL programs, and social service supports.

Case notes

Person informed of ESL and Vocational Training tuition assistance through social service grant

Case notes

Person informed of modes of transportation and assistance through the social service grant

Case notes or signed receipt

Person informed of Rights and Responsibility Signed document

Person informed of Agency’s Grievance Policy Signed document

Employment and Self-Sufficiency Plan Plan included in case file, along with any documents and case notes.

Comprehensive Employment and Self Sufficient Assessment conducted utilizing a standardized form – identifying strengths, challenges, and plan of action.

Signed Plan

Joint self-sufficiency or Employment Plan developed with individual’s and staff signature

Signed Self Sufficiency Plan included in case file

Referrals and Supportive Services

Person referred for supportive services no later than one week after arrival

Official DFD referral document in file

Person accompanied to initial visit to Board of Social Services with a translator if required

Case note

Medical Insurance (Medicaid) obtained within 30 to 45 days

Application Date

Food Stamps obtained within 30 to 45 days Application DateTransportation provided for employment related appointments

Log Sheet and case notes

Referred for ESL Assessment and Placement Test Include assessment in file, start date, and schedule.

Refugee Resettlement ProgramSocial Service Grant

Contract Compliance Standards

Employment ServicesReadiness, Preparation, and Placement

Provided Job readiness services; i.e. coaching, counseling, resume, job etiquette and expectation

Indicated on Employment Plan and case notes

Person notified of job leads, interviews or openings in accordance with Employment Plan

Document in case notes and referral services

Referred to jobs and/or interviews Referral in case file and documented in case notesPerson escorted for job interview Documented in case notesTransportation assistance provided Receipt and client signaturePlaced in Job Documented in case file

ESLReferred to Free ESL classes Referral formEnrolled in certified formal ESL Instruction Documented in case file

TrainingVocational Training Assistance Provided Tuition Application – must be eligible and

aligned with IEP and SSPReferred to Community Resource Programs Referral notification

Case Management and Follow-upPerson assisted with obtaining social and supportive services at the local welfare agency

DFD Referral Form

Helped obtained immigration and citizenship information and services, and documentation

Case notes and/or referral

Person assisted with school enrollment, medical services, other eligible supportive services etc.

Case notes

Separate case record or section for ORR social services

Case File

Follow-up on employment at 60, 90 & 180 days Documented in file with outcomesFollow-up on ESL, training completion and job placement or upgrade

Documented in file with outcomes

Staffing and Administrative OversightAdequate staff to meet contract deliverables Full-time employment specialist staff for 50+

caseloadStaff culturally and linguistically compatible with clients servicing

Services provided in a manner that is compatible with clients language and cultural background

Knowledgeable staff on refugee and social service Experience and backgroundTimely submission of all required DFD reports Submission of reportCollaborative partners and community resources Referral types and placementsTimely complaint resolution Quick Turnaround time to resolve issue



I have read the ORR social service grant Program Deliverables and Contract Compliance Standards and agree to comply with each deliverables and standard:

Authorized Signature: Date: Print: Title:



The below individual(s) have been admitted to the United States, and meet Office of Refugee and Resettlement Program eligibility immigration status and identification requirements as sited in N.J.A.C 10:90-10:6.

Date: CWA:

Referring Agency: Staff:

APPLICANT INFORMATION

Applicant Name: ___________________________________ D.O.B.:

Family Unit Size: Language(s) Spoken:

USCIS Status: ______________ Alien #:

Date of Arrival or Status was Granted: _____________ *Match Grant Program: ( ) Yes ( ) No

Phone #: Address:

Services and/or Benefits Requesting Cash Assistance Food Stamps Medicaid

A Translator will be present: ( ) Yes ( ) No Name of Translator:

Refugee AgenciesCatholic Charities Diocese of Camden1845 Haddon Ave, Camden, NJ 08103856-342-4100

Catholic Charities of the Archdiocese of Newark, 976 Broad St, Newark, NJ 07102973-733-3516

Lutheran Social Ministries of NJ189 South Broad St, Trenton, NJ 08601609-393-4900

Jewish Family & Vocational Service of Middlesex32 Ford Avenue, 2nd floor, Milltown, NJ 08850732-777-1940 ext 1124

International Rescue Committee10 West Grand St., Suite A, Elizabeth, NJ 07201908-351-5116

Jewish Vocational Services111 Prospect St., East Orange, NJ 07017973-674-3672

Church World Services26 Journal Square, Suite 600Jersey City, NJ 07306973-722-6726/ 201-659-0468

26

*Individuals who are enrolled in the Match Grant Program cannot receive cash assistance benefits.

Title 45: Public Welfare - PART 400—REFUGEE RESETTLEMENT PROGRAMAny cash grant received by the refugee under the Department of State or Department of Justice Reception and Placement programs may not be considered in determining income eligibility. N.J.A.C. 10:90-10.1 - Any cash assistance from the referring agency or sponsor shall be treated as unearned income.

27

This section must be completed by any agency receiving funding for the Cuban- Haitian Social Services component.


REFUGEE RESETTLEMENT CUBAN AND HAITAIN E-TECH PROGRAM

ANNEX A

BACKGROUND

The Department of Human Services (DHS) Division of Family Development (DFD) recognizes that critical social and self-sufficiency services are needed to help Cuban and Haitian arrivals successfully transition to their new life in their American community. The Office of Refugee Resettlement (ORR) has provided funding for DFD’s English, Technology and Employment for Cubans and Haitians (E-TECH) program which will provide services that foster self-sufficiency and acculturation to Cuban and Haitian refugees, asylees, parolees and entrants in Essex, Union and Hudson Counties (See the E-TECH Goals, Objectives, Activities and Outcomes Attachment).

The E-TECH Program’s Three Strategic Goals include:

1) English language proficiency (LEP), employment, vocational, basic educational and technology skills training which promote economic self-sufficiency, acculturation and citizenship;

2) Identify/address tangible, social, cultural, emotional and health barriers to economic self-sufficiency, acculturation and citizenship; and

3) Coordination of services to maximize funding, utilization and reduce duplication through a consortia or coalition among the E-TECH funded refugee agencies; refugee agencies are also expected to identify and coordinate with other service providers and community stakeholders to build a continuum of services.

Examples of Allowable E-TECH Services/Activities include:

1) Assessment and pre-employment counseling, job training, development and placement, employment services, customer service training, other employment-market driven trainings, professional refresher training, and recertification services;

2) Adult vocational and educational services including English language training through the use of technology, (e.g. literacy training, short-term skills training, Adult Basic Education) and other evidence based and promising practices;

3) Transportation to help refugees participate in employment readiness services and employment;

4) Social and other services including medical and/or mental health care coordination not covered under existing publicly funded programs (e.g. Refugee Medical Assistance,

28

Medicaid, State funds available to all residents) where these employment barriers/needs have been recognized and approved by DFD.

5) Upon approval from DFD, refugee agencies may offer services to assist program eligible Cubans and Haitians with their applications to adjust to United States permanent residency and citizenship. Services may also be offered to assist disabled Cubans and Haitians in obtaining disability waivers from English and civics requirements during the naturalization process. Federal funds awarded under this program cannot be used to reimburse clients for any fees paid to U.S. Citizenship and Immigration Services (USCIS).

Scope of Work-Program Benchmarks:

The E-TECH Program’s Target Population includes:

1) Cuban and Haitian individuals newly arrived who have been in this country 3 years or less and are most in need of additional support, including individuals without family or voluntary agency supports and/or the long-term unemployed who are unable to access adequate services through mainstream assistance. The objective is to provide services and activities in one or more of the above listed categories to localities affected by increased Cuban and Haitian arrivals.

29

Annex A - Narrative and Questions

C. Narrative



D. Annex A Questions





c. What kind of staff in-service training do you provide to the program staff?

d. Will any services be provided by consultants or subcontractors? If so, please provide details of the consultant/subcontractor (i.e. scope of work, terms of the agreement, reimbursement terms, key staff including areas of expertise and credentials). Copies of the agreement must be attached or contract approval will be delayed.

2. Describe how your agency will coordinate/collaborate with refugee agencies and other service providers to implement and share services. It is recommended that Refugee agencies have a formal Memorandum of Agreement on the sharing of services.

a. How will the agency identify and outreach to the target population?

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b. What direct services/activities will your agency provide and location where services are provided?

c. What agencies and service providers will your agency coordinate with in the community? How will your agency coordinate services with other service providers and coordinate services within your agency for refugees who are eligible for multiple programs? Is your agency involved with local coalitions/collaborations and community service providers and please describe?

d. Describe the program’s processes and documentation of intakes, assessments, site coordination, referrals, outreaches and follow-ups.

e. Describe your agency’s process for determining eligibility for the E-TECH services.

f. Describe your agency’s process for documentation of secondary migration?

g. Describe your agency’s plan to engage and retain clients in services.

h. Describe your agency’s criteria for closing cases.


4. How are services evaluated? Describe how your agency plans to evaluate the effectiveness of the E-Tech program. Explain how your agency plans to collect data. Identify any strengths and weaknesses form prior evaluations.







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8. What barriers or challenges do you anticipate in the implementation of the E-Tech Program goals, objectives, activities and achieving its outcomes?





11. How does the mission of the E-Tech program align with your agency’s mission? Describe how the E-Tech program will benefit/impact the community?






If fees will be collected from recipients of any services outlined in the Contract Requirements, state the anticipated annual amount of revenue. Also state how those revenues will be used to offset the contract’s costs.

32

INSTRUCTIONS FOR PROGRAM PROGRESS REPORTING

DISCRETIONARY GRANTS

*Please submit Narrative Progress Reports to the Division of Family Development, Transitional Services Unit, no later than April 15 and October 15.

THE PROGRESS REPORT SHOULD INCLUDE THE FOLLOWING:

1. Grant Number _________________________

2. Period cover by report:_______________________ thru ______________________

3. Major activities and accomplishments during this period – Recommend use of project task charts from approved grant application and/or project work plan with this section. Describe any draft/final products in this section.

4. Problems – Describe any deviations or departures from the original project plan including actual/anticipated slippage in task completion dates, and special problems encountered or expected. Use this report section to advise Project Officer and Grants Management Specialist of assistance needs.

5. Significant findings and events – (To be noted by project officer, or reported to regions, State, other agencies, Program Director/Commissioner, Assistant Secretary, Secretary, etc.)

6. Dissemination activities - Briefly describe project related inquiries and information dissemination activities carried out over the reporting period. Itemize and include a copy of any newspaper, newsletter, magazine articles or other published materials considered relevant to project activities, or used for project information or public relations purposes.

7. Other Activities – Briefly describe

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8. Activities planned for next reporting period – Briefly describe

9. Author’s Name and Telephone Number: __________________________________

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This section must be completed by any agency receiving funding for the TAG component.


REFUGEE TARGETED ASSISTANCE PROGRAM (TAG)

BACKGROUND

The Department of Human Services, Division of Family Development (DFD) recognizes that critical social and self-sufficiency services are needed to help refugees transition to their new lives in America. The Office of Refugee Resettlement (ORR) has provided funding for DFD’s Refugee Targeted Assistance Program (TAG) which will provide services that foster self-sufficiency and acculturation for refugees in Union County, New Jersey.

Purpose:

The purpose of Targeted Assistance formula grants is to provide, through a process of local planning and implementation, direct services intended to result in the economic self-sufficiency and reduced welfare dependency of refugees through job placements. Section 412 (c)(2) (B) of the Immigration and Nationality Act (INA) provides that Targeted Assistance grants shall be made available “(i) primarily for the purpose of facilitating refugee employment and achievement of self-sufficiency, (ii) in a manner that does not supplant other refugee program funds and that assures that not less than 95 percent of the amount of the grant award be made available to the county or other location entity.”

The goals and objectives of the Targeted Assistance formula grant is to provide assistance to the identified population gain employment and become self-sufficient by:

1) Outreach and engagement of refugees in Union County;

2) Assist with the improvement of English Language Proficiency, employment, technology, and social adjustment skills;

3) Identify barriers to employment and self-sufficiency;

4) Identify and improve the coordination with community resources to provide continuum of services; and

5) Develop individual and family plans to self-sufficiency.

Examples of Allowable TAG Services/Activities include:

6) Assessment and pre-employment counseling, job training, job skills development and placement, services;

35

7) Adult vocational and educational services including English language training through the use of technology, (e.g. literacy training, short-term skills training, Adult Basic Education) and other evidence based and promising practices;

8) Outreach through advertisement and community events; and

9) Social and other services including medical and/or mental health care coordination not covered under existing publicly funded programs (e.g. Refugee Medical Assistance, Medicaid, State funds available to all residents) where these employment barriers/needs have been recognized and approved by DFD.

Scope of Work - Program Benchmarks:

Improve English Proficiency for refugees through use of pre and post testing.

Improve technology skills.

Obtain employment or job readiness.

Obtain employment with health benefits.

Obtain employment with wages of at least $10.00 per hour.

Sustain job retention for at least 90 days.

The Elderly Grant’s Target Population includes:

Refugees who have been in Union County and are most in need of additional support, including individuals without family or voluntary agency supports and/or the long-term unemployed who are unable to access adequate services through mainstream assistance. The objective is to address education, cultural, employment needs of refugees in Union County.

In accordance with 45 C.F.R. 400.314, States are required to provide Target Assistance services to refugees in the following order of priority, except in certain individuals extreme circumstances: (a) refugees who are cash recipients; (b) unemployed refugees who are not receiving cash assistance; and (c) employed refugees in need of services to retain employment or to attain economic independence.

36

PROGRAM REPORTING REQUIREMENTS

The goal of program reports is to use data to improve program services, service delivery and utilization. Submit required program, service statistics, Level of Service (LOS) reports, and other data as requested, including but not limited to the monthly and trimester reports.

a. Please submit monthly statistical reports with brief narrative – due to DFD no later than the 15th day of the month for the preceding month;

b. Please complete the ORR 6 (Schedule A and C) – due to DFD February 15 th, June 15th and October 15th. Additionally, the client identification data sheet should provide the following:

i. Did the program meet the goals, objectives and outcomes; strengths and challenges?

ii. Identify the ethnicity, age, gender of each refugee. Please include the length of time they have lived in the United States, their prior education, previous employment, skills, and work experience?

iii. What were the previous patterns of employment for refugees?

iv. Include feedback from refugees on how to improve services and service delivery; identify the services refugees want?

v. Include the proportion of secondary migrants to locally resettled refugees.

vi. Describe how frequently refugees use services; what are the outcomes for engagement and retention and what are the barriers?

c. In addition, please submit quarterly statistical reports with trend analysis on service/client utilization information on the number of individuals in the TAG program; and - due to DFD on the 20th day of the month following the preceding quarter.

i. Outreach, referrals to services/programs, follow-ups and outcomes.

ii. Describe demographics (age, gender, family constellation, locality, education, etc.).

d. Please submit quarterly progress report (See attached form) to DFD no later than the 20th day of the month following the preceding quarter (April, July, October and January).

e. Other reports as requested by DFD in the timeframe required.

37

All program reports should be submitted to Renee Ingram at [email protected]

38


E. Narrative



F. Annex A Questions







2. Describe how your agency will coordinate/collaborate with refugee agencies and other service providers to implement and share services. It is recommended that refugee agencies have a formal Memorandum of Agreement on the sharing of services.


39

b. What direct services/activities will your agency provide and where are services provided?



e. Describe your agency’s process for determining eligibility for program services.





4. How are services evaluated? Describe how your agency plans to evaluate the effectiveness of the TAG program. Explain how your agency plans to collect data. Describe how your agency plans to evaluate the effectiveness of the program. What are the results?

5. Identify strengths and weaknesses noted in prior evaluations.





40




8. What barriers or challenges do you anticipate in the implementation of the TAG Program goals, objectives, activities and achieving its outcomes?






12. How does the mission of the TAG program align with your agency’s mission? Describe how the TAG program will benefit/impact the community?






41


42

This section must be completed by any agency receiving funding for the Elderly Grant component.


ELDERLY GRANT PROGRAM

BACKGROUND

The Department of Human Services, Division of Family Development (DFD) recognizes services to refugees must be provided that critical social and self-sufficiency services are needed to help refugees transition to their new lives in America. The Office of Refugee Resettlement (ORR) has provided funding for DFD’s Refugee Elderly Grant which will assist elderly population in accessing services locally and statewide.

Purpose:

The purpose of Elderly Grant is to provide, services to refugees age 60 and above. In accordance with 45 C.F.R. Part 400 Subpart I Refugee Social Services, 400.154 Employability Services and 400.155 other services. States may provide services to refugees aged 60 and above who have been in the country up to 60 months (5years) with the exception of referral and interpreter services and citizenship and naturalization preparation services for which there is no time limit.

The goals and objectives of the Elderly Grant are to provide assistance to all older refugees for the purpose of accessing available aging services.

Mainstream Outreach- Establish and/or expand a working relationship with the State Agency on aging; gain access to Aging Services locally and statewide; ensure elder refugees will be linked to main stream aging services in the community

Service Enhancement- Provide appropriate services to all elderly refugees that are not currently being provide in the community;

Independent Living- Create opportunities to enable refugee to live independently as long as possible; and

Naturalization- Develop services for or link elderly refugees to naturalization services, especially for those who have lost or are at risk of losing Supplemental Security Income and other Federal benefits

Examples of Allowable Elderly Grant Services/Activities include:

Access to senior community centers, supportive services, intergenerational activities. Congregate nutrition services and meals delivered to homebound client residences; Transportation Interpretation and translation

43

Home care, adult day care and respite care; Elder abuse prevention; Nursing home ombudsman services; Citizenship and naturalization for elderly refugees. Allowable activities include services

such as outreach, civics instruction and counseling and application assistance. Application fees for citizenship examination are not allowable using the set aside funds

The Elderly Grant Program’s Target Population includes:

Refugees who are 60 years and above; been in the country up to 60 months (5years). Agencies will provide assistance to all older refugees for the purpose of accessing available aging services locally and statewide for the elderly. The objective is to ensure elderly refugees are linked to mainstream aging services.

In accordance with 45 C.F.R. Part 400 Subpart I Refugee Social Services, 400.154 Employability Services and 400.155 other services. States may provide services to refugees aged 60 and above who have been in the country up to 60 months (5years) with the exception of referral and interpreter services and citizenship and naturalization preparation services for which there is no time limit.

PROGRAM REPORTING REQUIREMENTS

The goal of program reports is to use data to improve program services, service delivery and utilization. Submit required program, service statistics, Level of Service (LOS) reports, and other data as requested, including but not limited to the monthly and trimester reports.

a. Please submit monthly statistical reports with brief narrative – due to DFD no later than the 15th day of the month for the preceding month;

b. Please complete the ORR 6 (Schedule A and C) – due to DFD February 15 th, June 15th and October 15th. Additionally, the client identification data sheet should provide the following:

i. Did the program meet the goals, objectives and outcomes; strengths and challenges?

ii. Identify the ethnicity, age, gender of each refugee. Please include the length of time they have lived in the United States, their prior education, previous employment, skills, and work experience?

iii. What were the previous patterns of employment for refugees?

44

iv. Include feedback from refugees on how to improve services and service delivery; identify the services refugees want?

v. Include the proportion of secondary migrants to locally resettled refugees.

vi. Describe how frequently refugees use services; what are the outcomes for engagement and retention and what are the barriers?

c. In addition, please submit quarterly statistical reports with trend analysis on service/client utilization information on the number of individuals in the Elderly Grant; and - due to DFD on the 20th day of the month following the preceding quarter.

vii. Outreach, referrals to services/programs, follow-ups and outcomes.

viii. Describe demographics (age, gender, family constellation, locality, education, etc.).

d. Please submit quarterly progress report (See attached form) to DFD no later than the 20th day of the month following the preceding quarter (April, July, October and January).

e. Other reports as requested by DFD in the timeframe required.

All program reports should be submitted to Renee Ingram at [email protected]

45


G. Narrative



H. Annex A Questions







20. Describe how your agency will coordinate/collaborate with refugee agencies and other service providers to implement and share services. It is recommended that refugee agencies have a formal Memorandum of Agreement on the sharing of services.


46

b. What direct services/activities will your agency provide and where are services provided?



e. Describe your agency’s process for determining eligibility for program services.





22. How are services evaluated? Describe how your agency plans to evaluate the effectiveness of the Elderly Grant. Explain how your agency plans to collect data. Describe how your agency plans to evaluate the effectiveness of the program. What are the results?

23. Identify strengths and weaknesses noted in prior evaluations.





47




26. What barriers or challenges do you anticipate in the implementation of the Elderly Grant goals, objectives, activities and achieving its outcomes?






30. How does the mission of the Elderly Grant align with your agency’s mission? Describe how the Elderly Grant will benefit/impact the community?






48


REMINDERS:

All program details must reconcile to the Annex A narrative details, the Annex B and the LOS.

Please ensure the mathematical accuracy of the data presented.

49

STATE OF NEW JERSEY

DIVISION OF FAMILY DEVELOPMENTCONTRACT

ADMINISTRATOR: CONTRACT NUMBER:

NAME OF AGENCY:

CONTRACT PERIOD:

INDEX OF REQUIRED CONTRACT DOCUMENTS

This index provides details of all required documents that must either be included with the contract package (see checklist) or must be available on site for inspections as noted in the Document Verification Sheet (DVS). Forms that are not included in the following pages, can be found by accessing the website at www.state.nj.us/humanservices/dfd/info and clicking on the link for Standard Contract Documents.

DocumentRequired with first Contract and as

Amended

Required Annually

and as Amended Checklist

Required for on-site Verification - DVS

Form

Check if submitted

with package

Contract DocumentsStandard Language Document (SLD) with original signatures (additional copies requested must also have original signature)

2copies

Annex A (including summary sheet and supporting schedules) 3 copies

Annex B – Budget Form with all required forms, schedules, and signatures and required Budget Narrative.

3copies

Executive Order 129 (Public Law 2005, Chapter 92) Source Disclosure Certification Form ●

Federal Funding Accountability and Transparency Act (FFATA) Worksheet (if applicable) ●

Certification of Suspension and Debarment ●Disclosure of Investment Activities in Iran Form ●

1. AgreementsCopies of Subcontract/Consultant Agreement(s) ●Private/Public Donor Agreement (s) for Match Responsibilities ●

HIPAA Business Associate Agreement (BAA) ● ●

A copy of the Acknowledgement of Receipt of the New Jersey State Policy and Procedures for EEO/AA ●

2. Insurances/Licenses/CertificatesLiability Insurance Declaration Page and/or Malpractice Insurance ●

Bonding Certificate ●

Applicable Licenses (business and professional licenses) ●

Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302 – Affirmative Action Employee Information Report)

●

Health/Fire Certificates, Certificate of Occupancy ●

50

Rev. 201

Page 2 DocumentRequired with first Contract and as

amended

Required Annually

and as Amended Checklist

Required for on-site Verification – DVS

Form

Check if submitted

with package

.Lease or Mortgage for Property and Equipment ●

Certificate of Incorporation●

New Jersey Business Registration Certificate with the Division of Revenue (Public Law 2001, Chapter 134)

●

Documents Required for Non Profit Agencies and as applicable for Profit Agencies

S. Dated List of Names, Titles, Addresses, and Terms of Board of Freeholders or Directors

●

Copy of the most recently approved Board Minutes ●

Agency By-Laws ●

Tax Exempt Certification ● ●

Form 990 – Return of Organization Exempt From Income Tax ●Documents Required for Profit Agencies onlyU.S. Corporation Income Tax Return, Form 1120 ●

Chapter 51/Executive Order 117 Vendor Certification and Disclosure of Political Contributions (formerly known as Executive Order 134) and copy of NJ Business Registration Certificate (see separate link)

bi-annual

Ownership Disclosure Form (Chapter 51) bi-annual

Agency Policies and Organizational Information

Organizational Chart ●

Personnel Manual and Employee Handbook (including job descriptions of staff)

●

Affirmative Action Policy/Plan ●

Conflict of Interest Policy ●

Procurement Policy ●

51

Equipment Inventory (contract acquires property with DFD funds) ●

AuditNotification of Licensed Public Accountant (NLPA) - include copy of Accountant’s Certification (see separate link) ●

Copy of Single Audit or Independent Audit for recent FY ●Other Supporting DocumentsAnnual Report to Secretary of State ●Annual Report – Charitable Organizations ●

Page 3 DocumentRequired with first contract

Required Annually

and as Amended

Required for on-site Verification – DVS

Form

Check if submitted

with package

ACH – Credit authorization for automatic deposits (for new requests only) ●

W-9 Form (for new Agencies only) ●

Additional Division/Office Specific Forms

Document Verification Sheet (DVS) ●

List of Agency Grants / Contracts ●

Standard Board Resolution (indicating authorized signatories for contracts)

●

Checklist and Copy of Award Letter ●

Other:

The county agency agrees to submit, to the DFD Contract Administrator, any and all changes regarding the information presented in these documents during the term of the contract. All documents should be current and reflect the approval of the county officials, when applicable.

The index is for reference and is not required to be retuned with the contract package. All documents noted here are either included in the Checklist or Document Verification Sheet (DVS). The checklist and DVS must be returned with the contract package.

52

DFD OFFICE OF CONTRACT ADMINISTRATIONCONTRACT CHECKLIST

CONTRACT ADMINISTRATOR:

CONTRACTNUMBER:

NAME OFAGENCY:

CONTRACTPERIOD:

PROVIDER INSTRUCTIONS: This checklist must be completed and returned with all documents prior to contract approval. The correct number of copies and any additional Division documents must be returned to your Contract Administrator. Forms that are not included in the following pages, can be found by accessing the website at www.state.nj.us/humanservices/dfd/info and clicking on the link to Standard Contract Documents.

DocumentNumber of copies to

be submitted

Please check if submitted with

package

If not submitted with package, indicate anticipated date of submission or reason

for non-submission

Complete copy of signed DHS Standard Language Document (SLD) 2

Checklist, DVS and Award Letter 1 Executive Order 129 Source Disclosure 1 Certification of Suspension or Debarment 1 Standardized Board Resolution indicating who is authorized to sign: Contracts and Checks 1

Annex A – Parts I and II (including summary sheets, supporting schedules and LOS).

3

Annex B –Budget Form (Expense Summary, Details and Schedules 1-6) and required Budget Narrative.

3

List of Grants / Contracts 1

Contract Acquired Equipment Inventory 1

Liability Insurance 1 Bonding Certificate 1

Names, Titles, Addresses and Terms of Board of Freeholders / Directors 1

Copy of Audit Report 1

Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302)

1

Disclosure In Investment Activities in Form 1

Federal Funding Accountability and Transparency Act (FFATA) Worksheet (if applicable) 1

Copies of Subcontracts 1

53

Document Number of Copies to

be submitted

Notification of Licensed Public Accountant (NLPA) (include copy of Accountant’s Certification)

1

Private/Public Donor Agreement for Match Responsibilities 1

Organization Chart 1

Conflict of Interest Policy 1

1

Disclosure In Investment Activities in Form 1

As Applicable:

ACH – Credit authorization for automatic deposits (for new requests only) 1

W-9 Form (for new providers) 1

Other: 1

1

54

NEW JERSEY DEPARTMENT OF HUMAN SERVICESDIVISION OF FAMILY DEVELOPMENT

DOCUMENT VERIFICATION SHEET (DVS)

Contract Number Contract Period

The Provider Agency hereby certifies that the following documents are on file and are available to the Division of Family Development (DFD) for review. The contracting Provider Agency also agrees that it will inform the DFD contract administrator of any and all changes involving these documents that may occur during the term of the contract. All documents should be current and reflect board approval.

Please do not submit documents listed below with renewal package.

Please Check as Appropriate On FileNot

Applicable

1. Certificate of Incorporation and NJ Business Registration Certificate (filed with the Division of Revenue)

2. Annual Report to Secretary of State and Ownership Disclosure Form

3. Annual Report - Charitable Organization

4. Agency By-Laws and Copy of Board Meeting Minutes5. Business Associate Agreement (unless new provider or revised

agreement)

6. Business and Professional Licenses7. Personnel Manual and Employee Handbook (including current job

descriptions for staff)

8. Tax Exempt Certification, Copy of Form 990

9. U.S Corporation Income Tax Return, Form 1120

10. Procurement Policy11. Certificate of Occupancy or Continued Certificate of

Occupancy and Health and Fire Certificates

12. Property Lease/Mortgage and Equipment Leases

13. Affirmative Action Policy and copy and acknowledgment of NJ State Police Policy on EEO/AA

I hereby certify that all documents are current and are available for review.

Agency Director (Please Print or Type) Agency Director’s Signature

Agency Date

55

EXECUTIVE ORDER 129 CERTIFICATION

SOURCE DISCLOSURE CERTIFICATION FORM

Bidder: Solicitation Number:

I hereby certify and say:

I have personal knowledge of the facts set forth herein and am authorized to make this Certification on behalf of the Bidder.

The Bidder submits this Certification as part of a bid proposal in response to the referenced solicitation issued by the Division of Purchase and Property, Department of the Treasury, State of New Jersey (the “Division”), in accordance with the requirements of Executive Order 129, issued by Governor James E. McGreevy on September 9, 2004 (hereinafter “E.O. No. 129”).

The following is a list of every location where services will be performed by the bidder and all subcontractors.

Bidder or Subcontractor Description of Services Performance Location(s) by Country

Any changes to the information set forth in this Certification during the term of any contract awarded under the referenced solicitation or extension thereof will be immediately reported by the Vendor to the Director, Division of Purchase and Property (the “Director”).

I understand that, after award of a contract to the Bidder, it is determined that the Bidder has shifted services declared above to be provided within the United States to sources outside the United States, prior to a written determination by the Director that extraordinary circumstances require the shift of services or that the failure to shift the services would result in economic hardship to the State of New Jersey, the Bidder shall be deemed in breach of contract, which contract will be subject to termination for cause pursuant to Section 3.5b.1 of the Standard Terms and Conditions.

I further understand that this Certification is submitted on behalf of the Bidder in order to induce the Division to accept a bid proposal, with knowledge that the Division is relying upon the truth of the statements contained herein.

I certify that, to the best of my knowledge and belief, the foregoing statements by me are true. I am aware that if any of the statements are willfully false, I am subject to punishment.

56

Bidder: Name of Organization or Entity

By: Title: Print Name: Date:

New Jersey Department of Human ServicesDivision of Family Development

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary ExclusionLower Tier Covered Transactions

1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by an Federal or State department or agency.

2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

Name and Title of County Official __________________________________

Signature _________________________

Date _____________________________

This certification is required by the regulations implementing Executive order 12549, Debarment and Suspension, 29 CFR Part 98, Section 98.510

57

STATE OF NEW JERSEYDIVISION OF FAMILY DEVELOPMENT

STANDARDIZED BOARD RESOLUTION FORM – page 1 of 2

Supporting Information for Contract #:

Contract Period: to

Agency:

Certification:

We certify that the information contained in, or attached to, this contract document is accurate and complete.

__________________________________ ________________________Chair, Board of Directors Date

(Original signature)

__________________________________ ________________________Executive Director Date (Original signature)

Please List Authorized Signatories for contract documents, checks, and invoices:(List full name and title)

Name Title

Name Title

Name Title

58

STANDARDIZED BOARD RESOLUTION FORM – page 2 of 2

The Board endorses the following commitments as defined in this document:

1. Health Insurance Portability and Accountability Act (HIPAA)*

Specific to HIPAA (Health Insurance Portability and Accountability Act), the above noted Provider Agency is deemed a covered entity and must submit the required Business Associate Agreement.

Once executed, the BAA will be included in the Department’s official contract file. The BAA will be considered applicable for this contract. Any changes in the Provider Agency’s status, information or the content of the BAA, is the responsibility of the contracted Provider Agency to revise the BAA.

The Board agrees to notify the Department of any change in its BAA Status and provide the appropriate information within 10 business days.

2. Legal Advice

The Board acknowledges that the Division of Family Development does not and will not provide legal advice regarding the contract or any facet of its relationship with the Provider Agency. The Board further acknowledges that any and all legal advice must be sought from the Provider Agency's own attorneys and not from the Division of Family Development.

3. Public Law 2005, Chapter 51

The Board agrees that the Public Law 2005, Chapter 51 (formerly known as Executive Order 134) compliance forms submitted with the contract is accurate.

4. Public Law 2005, Chapter 92

The Board agrees that the Public Law 2005, Chapter 92 (formerly known as Executive Order #129) compliance forms submitted with the contract are accurate.

59

STATE OF NEW JERSEYDIVISION OF FAMILY DEVELOPMENT

List of Contracts/Grants

Check here if this information already appears on the Annex B, Schedule 2 - Contract Information Form. If so, then it is not necessary to duplicate the information here.

Contracting Division/Offic

eProgra

m Name

Type of

Service

Contract

NumberContract Term

Amount

Division/Office

Contact Person and

Phone Number

Provider Agency Contact Person

and Phone Number

60

CONTRACT FORMS

Available at the DFD website:

AA 302

Federal Financial Accountability Transparency Act (FFATA) Worksheet

Notification of Licensed Public Accountant

Disclosure of Investment Activities in Iran

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FY 14 and FY 15 Federal Award Information

Refugee:

Resettlement

FY 15:Grant No. 1501NJRSOC CFDA 93.566

FY 16:Grant No. 1604NJRSOC CFDA 93.566

Refugee – Cuban Haitian (RF)

FY 15:Grant number is 90RQ0039-01 CFDA 93.576

FY 16:Grant number is 1601NJRSOC CFDA 93.566

Elderly Social Service

FY 16: Grant No. 1601NJRSOC CFDA 93.566

Refugee TAG (Formula)

FY 16:Grant No. 1601NJRTAG CFDA 93.584

Refugee TAG (Discretionary)

FY 16: Grant No. 90RT0185-03-00 CFDA 93.576

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