PA AmeriCorps RFA PDF

PennSERVE:
The Governor’s Office of Citizen Service

1306 Labor & Industry Building
651 Boas Street
Harrisburg, PA 17121
2011-2012 PENNSYLVANIA AMERICORPS*STATE

APPLICATION/AGREEMENT INSTRUCTIONS
RFA#-2011-ACS-01
The Honorable Edward G. Rendell

Governor, Commonwealth of Pennsylvania
Sandi Vito
Secretary, Pennsylvania Department of Labor & Industry
Karen Kaskey
Executive Director, PennSERVE: The Governor’s Office of Citizen Service
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IMPORTANT NOTICE
These Application/Agreement Instructions are to be used by new and recompeting applicants interested in
applying for grant funding for: Pennsylvania AmeriCorps*State Competitive and Formula grants, including
Professional Corps, Education Award program or EAP, and Full-time Fixed Amount. Eligible organizations
include public or private nonprofit organizations, including labor organizations, community and faith-based
organizations, institutions of higher education, government agencies, and partnerships or consortia. Applicants
who are funded may expect grant awards in August 2011. Grant awards are generally for three years with
funding in annual increments. Grantees are eligible for continuation funding in the second and third year
contingent on availability of appropriations, compliance and satisfactory performance.
AmeriCorps is a national service program that provides opportunities for citizens to serve their country in local
communities. Each year participants of AmeriCorps, called members, join a local program and provide
specific, intensive community services such as: tutoring students who need extra help, teaching community
residents about issues directly affecting them and other services that strengthen communities. AmeriCorps is a
program funded by the U. S. Congress under the Catalog of Federal Domestic Assistance number 94.006. The
national organization supporting AmeriCorps is the Corporation for National and Community Service, or
CNCS. CNCS receives AmeriCorps program funding from congress and awards funding to state commissions,
such as PennSERVE: The Governor’s Office of Citizen Service, to grant and oversee AmeriCorps programs in
their state.
Applicants for the Pennsylvania AmeriCorps*State grant should carefully read and follow these 2011-2012
PA AmeriCorps*State Application/Agreement Instructions. In addition, applicants should also consult the
Corporation for National and Community Service website (www.cns.gov) to access the Notice of Federal
Funding Opportunity, or NOFO overview and the AmeriCorps Regulations, 45 CFR §§ 2520–2550.
The PA AmeriCorps*State Application/Agreement Deadline is 3p.m. Friday, Dec. 3, 2010. Late, emailed or
faxed application submissions will not be accepted. Applications may be mailed, but must be received by the
deadline at PennSERVE: The Governor’s Office of Citizen Service, 1306 Labor & Industry Bldg., 651 Boas
St. (7th and Forster Streets), Harrisburg, PA 17121.
Successful applicants will be required to enter final applications into eGrants, the federal grants system. In
preparation, applicants need to establish an eGrants account. To do so, please access the following link:
https://egrants.cns.gov/espan/main/login.jsp and select ―Create an account.‖
A federal requirement stipulates that all grant applications must include a Dun and Bradstreet Data Universal
Numbering System, or DUNS number. The DUNS number is known as the universal identifier and helps the
federal government improve statistical reports on federal grants and cooperative agreements. The DUNS
number will not replace the Employer Identification Number, or EIN. DUNS numbers may be obtained at no
cost by calling the DUNS number request line at (866) 705-5711 or on-line at http://www.dnb.com. It may
take up to 30 days to receive a DUNS number after applying.
A Pennsylvania requirement stipulates that all grant applications/agreements and contracts must include a
Pennsylvania Vendor Number. All applicants must be registered as vendors to submit a bid, to be awarded a
contract, or to be paid. Vendor numbers may be obtained at no cost by calling the Central Vendor
Management Unit at 717-214-CVMU (2868) or 1-866-775-2868, or on-line at
www.vendorregistration.state.pa.us. It may take up to two weeks to receive a vendor number after applying. If
you are unable to obtain a Pennsylvania vendor number in a timely fashion, you may submit the application
prior to receiving your vendor number; however, your grant will not be awarded without the vendor number.
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INTRODUCTION
PennSERVE: The Governor’s Office for Citizen Service announces the availability of grant funding for the
operation of AmeriCorps national service programs by community and faith-based organizations, government
agencies, and educational institutions. AmeriCorps*State grants support the efforts of organizations to recruit and
deploy AmeriCorps members and the volunteers with whom they work to address unmet needs. AmeriCorps*State
grants will be awarded on a competitive basis to eligible organizations that identify a problem(s) and persuasively
demonstrate how deploying AmeriCorps members and community volunteers will produce significant impact.
AmeriCorps members will be recruited, trained, supervised, and managed by the funded organization, and may
receive a living allowance and other benefits while serving. Upon successful completion of their service,
AmeriCorps members are eligible to receive a Segal AmeriCorps Education Award from the National Service
Trust. The grants support the administration of volunteer service programs that meet locally-identified needs in the
areas of education, the environment, health, veterans, economic opportunity, disaster services and other critical
areas.
An AmeriCorps member is an individual who is enrolled in an approved national service position and engages in
community service. Most AmeriCorps programs place members with local organizations that share the program’s
vision for change and have committed to helping meet the community need. The AmeriCorps members often work
at partner sites to address a specific need, expand each organization’s capacity and build community involvement
and support.
One of the most important roles AmeriCorps can play for an organization is the generation of volunteers. Through
local volunteer generation, AmeriCorps members help sustain services in communities beyond the AmeriCorps
grant period. Members also help nonprofit, charitable, and community faith-based organizations improve and
expand the quality of services provided in a community.
Grant funds partially cover the expense of operating an AmeriCorps program and do not cover general
organizational expenses. A cash or in-kind match of at least 24% of overall budget is required for first time
applicants. Applicants that have been previously funded for AmeriCorps are subject to a higher match and should
contact PennSERVE for more details.
Special Requirements for AmeriCorps Programs in Pennsylvania
PennSERVE will fund programs that consist of no less than 10 members. Typical award for 10 members
is $133,000 since maximum cost per member cannot exceed $13,300.
Funded programs are required to include the word ―AmeriCorps‖ in their program name.
Every AmeriCorps program is required to submit formal performance measures that will be used to
determine progress toward objectives. If adequate progress is not achieved annually, corrective action
plans are required. Continued lack of adequate progress could affect funding.
Every AmeriCorps program that is funded must include volunteer generation as a program activity and set
an annual numerical target.
Every AmeriCorps program is required to participate in local disaster preparedness planning efforts,
including, but not limited to, emergency management training and management of volunteers.
AmeriCorps members may be asked, or offered the opportunity, to participate in disaster services as
needed.
Applications from under-represented PA counties are encouraged.
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TABLE OF CONTENTS
INTRODUCTION…………………………………………………………………………….……..…….3
APPLICATION/AGREEMENT SUBMISSION REQUIREMENTS…………………………...……….6
OVERVIEW: SELECTION PROCESS AND CRITERIA ………………………………...…….…..…..8
APPENDIX A: INSTRUCTIONS FOR THE PA SUB- GRANTEE

APPLICATION/AGREEMENT…...…………………………………………………………………….10
APPLICATION /AGREEMENT……………………………………………………………….……......11
APPENDIX B: INSTRUCTIONS FOR FACESHEET………...………………………………….…....12

APPLICATION FACESHEET (PA ATTACHMENT 1)..……………..………………..…….………...15
APPENDIX C: PROGRAM MODEL & DESIGN/ISSUE AREAS (PA ATTACHMENT 2) …….....16
APPENDIX D: INSTRUCTIONS FOR NARRATIVE (PA ATTACHMENT 3)……….…..………...20
APPENDIX E: INSTRUCTIONS FOR PERFORMANCE MEASUREMENTS ……………….…….27

PERFORMANCE MEASUREMENT WORKSHEETS(PA ATTACHMENT 4) ……………………..28
APPENDIX F: EVALUATION SUMMARY/PLAN/REPORT (PA ATTACHMENT 5) ….………..32
APPENDIX G: INSTRUCTIONS FOR BUDGET……………………………………….……………33

BUDGET WORKSHEET (PA ATTACHMENT 6A)…………………………………………..……….40
BUDGET FORM (PA ATTACHMENT 6B)………………………………………………………….....44
BUDGET ANALYSIS CHECKLIST ………………………….……………………..………….……...46
BUDGET INSTRUCTIONS -EAP/FIXED-AMOUNT ……………………………………….………..48
BUDGET WORKSHEET (PA ATTACHMENT 6C FIXED AMOUNT)………………….......………50
APPENDIX H: INSTRUCTIONS FOR VOLUNTARY SURVEY ON ENSURING EQUAL

OPPORTUNITY FOR APPLICANTS……………………………………………………....…………..51
SURVEY ON ENSURING EQUAL OPPORTUNITY FOR APPLICANTS
(PA ATTACHMENT 7) …………………………………………………………..………………….....52
APPENDIX I: CERTIFICATIONS & ASSURANCES INSTRUCTIONS……………….…………..53

CERTIFICATION AND ASSURANCES SIGNATURE PAGE (PA ATTACHMENT 8) ……………59
AUDIT CLAUSE (PA ATTACHMENT 8A) …………………………………………………………...60
ADDITIONAL CONDITIONS (PA ATTACHMENT 8B) ……………………………………………..61
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AMERICORPS*STATE APPLICATION/AGREEMENT
INSTRUCTIONS
Applicants are required to:
 Submit one (1) single-sided original paper application and six (6) copies prepared in
Microsoft Word, along with one computer diskette or CD that contains a saved copy of the
complete application. Faxed, emailed and/or late submissions will not be accepted.
 Organize your application/agreement in the sequence outlined in these instructions.
 Type and double-space the application in Microsoft Word, Times New Roman, 12-point
font size with one-inch margins. (Use only uppercase letters for all section headings and
other information you would like to highlight in your narrative. Do not use bold face,
bullets, underlines, or other types of formatting, charts, diagrams, and tables.)
 Number the narrative pages.
ALL APPLICATION/AGREEMENT PACKAGES MUST BE RECEIVED BY

3p.m., FRIDAY, DEC. 3, 2010
AT
PENNSERVE: THE GOVERNOR’S OFFICE OF CITIZEN SERVICE
1306 LABOR & INDUSTRY BLDG.
651 BOAS ST. (7TH AND FORSTER STREETS)
HARRISBURG, PA 17121
TECHNICAL ASSISTANCE WORKSHOP

To assist applicants in completing this AmeriCorps*State application, a technical assistance
workshop has been scheduled. Please call PennSERVE to register.
Location: PA Dept. of Labor & Industry, E-100 Conference Room
First Floor, Labor & Industry Bldg, 651 Boas Street, Harrisburg, PA 17121
Date: Tuesday, Nov. 9, 2010
Time: 1p.m. – 4p.m.
QUESTIONS
Questions about the AmeriCorps*State Application/Agreement may be e-mailed to PennSERVE
at pennserve@state.pa.us. You may also telephone PennSERVE at 717-787-1971 or toll-free
by dialing 1-866-6SERVE-U (1-866-673-7838).
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OVERVIEW: APPLICATION SUBMISSION
A complete PA AmeriCorps Application package will include the following submitted
documents. See the instructions for each component of the Application/Agreement at the noted
Appendix.
Applicants must submit an Application/Agreement that consists of the following components in

the following order:
I. PA AmeriCorps Sub-grantee Application/ Agreement (Appendix A)
II. PA Attachment 1: SF424 Facesheet (Appendix B)
III. PA Attachment 2: Program Model /Issue Areas (Appendix C)
IV. PA Attachment 3: Narrative (Appendix D)
V. PA Attachment 4: Performance Measures Worksheet (Appendix E)
VI. PA Attachment 5 Evaluation Summary/Plan/Report (Appendix F)
VII. PA Attachment 6: Budget Form/Worksheet (Appendix G)
VIII. PA Attachment 7: Voluntary Survey (Appendix H)
IX. PA Attachment 8: Certifications & Assurances (Appendix I)
I. PA AmeriCorps Sub-grantee Application/Agreement: Each AmeriCorps application

must be submitted with a signed PA AmeriCorps Program Sub-grantee Agreement. Read
the Application/Agreement carefully and complete the Agreement form where
appropriate. An authorized representative must sign the Agreement. See Appendix A for
Pennsylvania AmeriCorps Program Sub-grantee Application/Agreement form. This
completed form will be the first document of your submitted application.
II. SF424 Facesheet: Complete Facesheet. See Appendix B for form and instructions.
III. Program Model and Design/Issue Areas: Applicants will indicate design of program
and service categories to facilitate aggregate data collection. See Appendix C for forms.
IV. Narrative: The Narrative covers the program plan and justification for awarding
requested funds. The narrative is a major component of the application. It will be
reviewed using the published selection criterion that appears in the AmeriCorps
Guidelines. See Appendix D for specific instructions on preparing the program narrative.
The narrative cannot exceed 50,000 characters and include an executive summary (no
more than 500 characters) and the following categories:
 Program Design (50%)

Rationale and Approach-10%
Member Outputs and Outcomes-20%
Community Outputs and Outcomes-20%
 Organizational Capacity (25%)
 Cost Effectiveness and Budget Adequacy (25%)
Cost Effectiveness-15%
Budget Adequacy-10%
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V. Performance Measures: Instructions in Appendix E provide detail on performance
measurements and how to complete the required performance measure worksheets.
VI. Evaluation Summary or Plan: (Appendix F) Submission instructions are provided

for new applicants and existing grantees that are recompeting.
VII. Budget Worksheet & Form: Follow the instructions in Appendix G and Appendix G
(Fixed Amount) to prepare your detailed budget on the budget worksheet and budget
form. Both the form and the worksheet must be submitted with the application. A
budget analysis checklist is included to assist applicants.
--Note: Pennsylvania’s maximum cost per member: $13,300, Member Living
allowance: minimum $12,100 and maximum $24,200, Match Requirement:
Minimum grantee share is 24% of total program costs (Sum of Budget Section
I, Budget Section II and Budget Section III). Funding is dependent on federal
resources available in this year and subsequent years.
--Note: The Commonwealth of PA requires AmeriCorps programs to meet its budgeted
match (rather than the minimum match).
Education Award Program, or EAP and Fixed Amount applicants are not required
to submit a detailed budget. Please follow budget instructions in Appendix G (Fixed
Amount).
VIII. Voluntary Survey on Applicant Equal Opportunity: The purpose of this voluntary
information collection is to compile statistics on the types of organizations that apply
for these funds. This form is for applicants that are nonprofit private organizations,
not including private universities. (See Form and Instructions in Appendix H).
IX. Certifications & Assurances: Read the certifications and assurances in Appendix I of
these instructions carefully. When you have done so, complete the form which
certifies that your organization will comply with all required federal and state
assurances and certifications. The form must be signed in two signature areas by an
authorized representative. Please note that applicants should attach to their a
pplication the Certifications and Assurances (PA Attachment 8), including the original
signature page, the Audit Clause (Attachment 8A,) and Additional Conditions
(Attachment 8B).
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Overview: Selection Process and Criteria
PennSERVE and CNCS select applications for funding using a multi-stage process that may
include review by panels of experts, community members, state and federal staff, and approval by
the PA Community Service Advisory Board and CNCS Board of Directors. The review panels
include individuals such as community service practitioners, educators, non-profit administrators,
former national service participants, and specialists in education, the environment, health, public
safety, human services and other relevant fields.
Because the participants on these panels are outside reviewers, do not assume that they are
familiar with your grant program, even if you are recompeting. Please provide sufficient
information in your application to make your program clear to a reviewer.
In evaluating your application for funding, reviewers will assess your program design,
organizational capability, and the program’s cost-effectiveness and budget adequacy. The
weights assigned to each category and sub-category are listed in the chart on the next page (Basic
Selection Criteria). Reviewers will measure your application narrative against these criteria, and
weight them accordingly. For additional detail regarding these criteria and what reviewers will
assess in each category of your narrative, please see Appendix D.
As part of the grant selection process, PennSERVE reserves the option of not selecting an
applicant for funding based on geographic location, regardless of selection rating. This is an effort
to attain geographic diversity throughout the state, achieve state service strategies, and/or help to
improve AmeriCorps opportunities in underrepresented areas.
The grant selection process includes the following steps:
1. Determining whether your proposal complies with the application requirements, such
as deadlines and eligibility requirements.
2. Applying the basic selection criteria articulated in the AmeriCorps regulations.
3. Applying additional selection factors announced in the applicable Notice and in the
AmeriCorps Regulations, 45 CFR §§ 2520–2550. Please also note that Pennsylvania
has included in this RFA specific requirements for its funded AmeriCorps programs.
4. Ensuring innovation and geographic, demographic, and programmatic diversity across
the AmeriCorps portfolio.
Staff may conduct interviews to elicit more information concerning your application in person or
through conference call as needed.
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Basic Selection Criteria: Categories, Sub-Categories, and Respective Weights
Category Percentage Sub-Categories and Weights
Rationale and Approach – 10%

Program Design 50%
Member Outputs and Outcomes – 20%
Community Outputs and Outcomes – 20%
Organizational Capability 25% No sub-categories
Cost-Effectiveness – 15%
Cost-Effectiveness and Budget 25%
Adequacy Budget Adequacy – 10%
2011 National Service Priority Areas

The federal funding for AmeriCorps is provided to states via the Corporation for National and Community
Service. The Corporation’s mission is to improve lives, strengthen communities, and foster civic
engagement through service and volunteering. In the FY 2011 competition, the corporation’s funding
priorities are projects that address compelling, unmet needs in one or a combination of the following
national service priority areas which are described more fully below:
Education: Increase graduation rates for students & Improve grade-level performance.
Healthy Futures: Improve the health and wellness of individuals in the areas of obesity prevention, aging
in place and access to health services.
Environmental Stewardship: Decrease consumption of fossil fuels, improves environmental education
and restore/improve natural resources.
Veterans: Increase economic, education and health opportunities for veterans and military families by
leveraging national service, including veterans serving veterans.
Opportunity: improve financial stability, access to affordable housing, and employment opportunities for
economically vulnerable families.
Disaster Services: Increase capacity of communities to serve vulnerable populations in the event of a
disaster and improve communities in disaster-affected areas
Encore Programs: significant number of participants age 55 or older serving as AmeriCorps members,
agency takes advantage of the skills and experience that such participants offer in the design and
implementation of the program.
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APPENDIX A: INSTRUCTIONS FOR COMPLETING THE PA SUB-GRANTEE
APPLICATION/AGREEMENT
Each application for AmeriCorps*State program funding in Pennsylvania must include a

completed and signed Sub-grantee Application/Agreement.
Read the Application/Agreement carefully. When you have done so, complete the
Application/Agreement form with requested applicant information at the top of the form. The
Application/Agreement form must be signed and dated by an authorized representative of your
organization. (Other than the signature of your organization’s authorized representative, the
remaining signature lines at the lower portion of the form should remain blank. (Commonwealth
of PA officials will use these for approvals.)
Be sure to include the original of the signed Application/Agreement form with your submitted
Application/Agreement package. This completed form will be the first document of your
submitted Application/Agreement, followed by all required attachments.
Following these instructions is an Application/Agreement form that is included for your use in
fulfilling this requirement.
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COMMONWEALTH OF PENNSYLVANIA
AMERICORPS*STATE PROGRAM SUB-GRANTEE APPLICATION/AGREEMENT DOCUMENT NO.
Subgrantee Applicant: _______________________________ Address: ____________________________

City: _________________________ State ____ Zip Code: ___________ Phone: ____________________
Fax: ____________________ Contact: ___________________________ Title: ______________________
E-Mail Address: __________________________________ Type of Organization: ___________________
DUNS #: ______________________________ FEIN #___________________ SAP Vendor #___________
Start Date: _____________________________ End Date: ___________________________
If/when fully executed, this application becomes a grant agreement between the Pennsylvania Department of Labor
and Industry (“Department”) and the applicant, who would then be considered a sub-grantee of the corporation for
National and Community Service (“Corporation”) for the purposes of carrying out the conditions of an
AmeriCorps*State Program and in accordance with any laws, regulations, provisions, guidelines and instructions
covering this program and any policies provided and established by the Department and the Corporation.
In compliance with the grant application, provisions, requirements, conditions and specifications, the undersigned, on
behalf of the sub-grantee, which intends to be legally bound, offers and agrees, if the grant application is accepted,
to provide the specified services in accordance with:
PA Attachment 1: SF 424 Facesheet; PA Attachment 2: Program Model and Design/Issue Areas; PA Attachment 3:
Program Narrative; PA Attachment 4: Performance Measurement Worksheet; PA Attachment 5: Evaluation
Summary/Plan; PA Attachments 6A and 6B or 6C for fixed amount grant; Budget Worksheet and Budget Form; PA
Attachment 7: Voluntary Survey on Ensuring Equal Opportunity; PA Attachment 8: Certification and Assurances
Signature Page; PA Attachment 8A: Audit Clause; and PA Attachment 8B: Additional Conditions.
This agreement may entitle you as an AmeriCorps program to apply for, and, if approved by PennSERVE, receive
reimbursement for expenses pursuant to PennSERVE’s PDAT and disability grants from the Corporation.
*_______________________________ ____________________ _________

Signature of Authorized Representative Title Date
__________________________________________ _________
Deputy Secretary Date
______________________________________________ _________
Office of Chief Counsel, Department of Labor & Industry Date
______________________________________________ _________
Office of General Counsel Date
______________________________________________ _________
Office of Attorney General Date
_____________________________________________ _________
Comptroller Date
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APPENDIX B: SF 424 Facesheet Instructions
This form is required for applications submitted for federal assistance.
Item #
1. Filled in for your convenience.
2. Self-explanatory.
3. 3. a. and 3. b. are for state use only (if applicable).
4. Item 4. a: Leave blank.
Item 4. b: If you are a recipient in year 2 or 3 of an already-awarded grant, enter the grant number,
otherwise, leave blank.
5. Enter the following information:
a. The complete name of the organization that will be legally responsible for the grant, not the
name of the organizational unit within the legally responsible organization. (For example,
indicate ―National University‖ instead of ―Liberal Arts Department.‖)
b. The name of the primary organizational unit that will undertake the assistance activity, if
different from 5. a.
c. Your organization’s DUNS number (received from Dun and Bradstreet).
d. Your organization’s complete address with the 5 digit ZIP code. The four-digit extension is
optional.
e. The name and contact information of the project director or other person to contact on matters
related to this application.
6. Enter your Employer Identification Number (EIN) as assigned by the Internal Revenue Service.
7. Item 7. a.: Enter the appropriate letter in the box.
Item 7. b.: Please enter the characteristic(s) that best describe your organization.
K-12 Education Non-Profit Organizations

1 School (K-12) 11 Community-Based Organization
2 Local Education Agency 12 Faith-Based Organization
3 State Education Agency 13 Chamber of Commerce/Business Association
14 Community Action Agency/Program
Higher Education 15 Service/Civic Organization
4 Vocational/Technical College 16 Volunteer Management Organization
5 Community College 17 Self-Incorporated Senior Corps Project
6 2-year College 18 Statewide Association
7 4-year College 19 National Non-Profit (Multistate)
8 Hispanic Serving College or University 20 Local Affiliate of National Organization
9 Historically Black College or University 21 Tribal Organization (Non-government)
10 Tribally Controlled College or University 22 Other Native American Organization
Government
23 Local Government-Municipal 28 Other State Government
24 Health Department 29 Tribal Government Entity
25 Law Enforcement Agency 30 Area Agency on Aging
26 Governor’s Office 31 U.S. Territory
27 State Commission/Alternative Administrative Entity
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8. Check the appropriate box for type of application and enter the appropriate letter(s) in the
lower boxes:
a. Check ―New‖ if your organization has never held an AmeriCorps State and Territory
Competitive program grant before.
b. Check ―New Application/Previous Grantee‖ if your organization has held an
AmeriCorps State and Territory Competitive program grant in the past and the
application is for a new grant.
c. Check ―Continuation‖ if you are a grantee applying for an additional year of funding
within an existing multi-year grant project period. AmeriCorps State and Territory
program grants are typically awarded for three year periods.
d. Check ―Amendment‖ if you are a grantee proposing any measurable change in an
existing grant award; e.g., a budget amendment, extension, changes in the program
scope or goals, etc.
If you are proposing an amendment to your grant, check the type of revision you are
submitting.
a. Select ―Augmentation‖ if you are an AmeriCorps State and Territory Competitive
grantee submitting a revised budget to incorporate a Corporation-authorized increase.
b. Select ―Budget Revision‖ to make a change in the grant budget, including slots.
c. Select ―No-cost Extension‖ to request an extension of the grant period, then enter the
extension date requested in the blank following the checkbox. No-cost extensions can
be requested only in the third year of the 3-year grant cycle and must be requested
before the project period ends.
d. Select ―Other,‖ as applicable, and specify in the blank provided.
9. Filled in for your convenience.
10. Use the following list of CFDA (Catalog of Federal Domestic Assistance) numbers for the
applicable program listing, or other source if so instructed in the Notice: 94.006
AmeriCorps State and National.
11. Enter the project title.

a. When applying for a Continuation or Amendment, please use the same title as used for
their existing grant program. When applying as a ―New Applicant/Previous Grantee‖
if the application is for re-funding of a previous grant program, use the same title as
was used in the prior grant program if appropriate (i.e., if the program is unchanged).
b. Enter the name of the Corporation’s program initiative, if any, as provided in the
instructions corresponding to the Notice for which you are applying; otherwise, leave
blank.
12. List only the largest political entities affected (e.g., counties, and cities).
13. (See item 8) New application or new application/previous grantee: Enter the dates for the
proposed project period. Continuation or Amendment application: Enter the dates of the
approved project period.
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14. Check the appropriate box to indicate the grant year for which funding is being requested.
Enter the amount requested or to be contributed during this budget period on the
appropriate line, as shown below. Include the value of in-kind contributions in these
amounts, as applicable. For revisions (See item 8), if the action will result in a dollar
change to an existing award, include only the amount of the change. For decreases, enclose the
amounts in parentheses.
a. Federal The total amount of federal funds being requested in the budget.
b. Applicant The total amount of the applicant share as entered in the budget.
c. State The amount of the applicant share that is coming from state sources.
d. Local The amount of the applicant share that is coming from local governmental
sources (e.g., city, county, and other local government sources).
e. Other The amount of the applicant share that is coming from non-governmental
sources.
f. Program The amount of the applicant share that is coming from income generated by
Income programmatic activities (i.e., use of the additive option where program
income is used to increase the size of the program).
g. Total The applicant's estimate of the total funding amount for the agreement.
15. Indicate if this application is subject to review by the State Executive Order 12372 Process by
checking the box. Executive Order 12372, Intergovernmental Review of Federal Programs, was
issued with the desire to foster the intergovernmental partnership and strengthen federalism by
relying on state and local processes for the coordination and review of proposed federal financial
assistance and direct federal development. The Order allows each state to designate an entity to
perform this function. A list of these Single Point of Contact entities can be found at:
www.whitehouse.gov/omb/grants/spoc.html
Contact the Single Point of Contact to determine whether your application is subject to the state
intergovernmental review process.
a. If Yes, indicate the date a copy of your application was submitted to the state for review
under the Executive Order 12372 Process.
b. If No, check the appropriate box.
16. Check the appropriate box. This question applies to the applicant organization, not the person who
signs as the authorized representative. Categories of debt include delinquent audit allowances,
loans, and taxes. If yes, attach an explanation.
17. The person who signs this form must be the applicant’s authorized representative. A copy of
the governing body’s authorization for this official representative to sign must be on file in
the applicant’s office.
Note: Falsification or concealment of a material fact, or submission of false, fictitious or fraudulent

statements or representations to any department or agency of the United States Government
may result in a fine of not more than $10,000 or imprisonment for not more than five (5)
years, or both (18 U.S. Code Section 1001).
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PA Attachment 1
APPLICATION FOR FEDERAL ASSISTANCE
Modified Standard Form 424 (Rev. 11/02 to conform to the Corporation’s eGrants system) 1. TYPE OF SUBMISSION:
Application Non-Construction
2. DATE SUBMITTED TO CORPORATION FOR 3. a. DATE RECEIVED BY STATE: 3.b. STATE APPLICATION IDENTIFIER:
NATIONAL AND COMMUNITY SERVICE (CNCS):
4. a. DATE RECEIVED BY CNCS: 4.b. CNCS GRANT NUMBER:
APPLICATION FOR FEDERAL ASSISTANCE

5. APPLICANT INFORMATION
5e. NAME AND CONTACT INFORMATION FOR PROJECT DIRECTOR OR OTHER
5a. LEGAL NAME:
PERSON TO BE CONTACTED ON MATTERS INVOLVING THIS APPLICATION
5b. ORGANIZATIONAL UNIT: (including area code):
5c. ORGANIZATIONAL DUNS:
5d. ADDRESS (give street address, city, county, state and zip code): NAME:
TELEPHONE NUMBER: ( ) -
FAX NUMBER: ( ) -
INTERNET E-MAIL ADDRESS:
6. EMPLOYER IDENTIFICATION NUMBER (EIN): 7.a. TYPE OF APPLICANT: (enter appropriate letter in box)
WEBSITE:
- A. State
B. County
H. Independent School District
I. State Controlled Institution of Higher Learning
8. TYPE OF APPLICATION (Check appropriate box): C. Municipal J. Private University
D. Township K. Indian Tribe
NEW NEW/PREVIOUS GRANTEE
E. Interstate L. Individual
CONTINUATION AMENDMENT F. Intermunicipal M. Profit Organization
G. Special District N. Private Non-Profit Organization
If Revision, enter appropriate letter(s) in box(es): O. Other (specify)
7. b. CNCS APPLICANT CHARACTERISTICS
A. AUGMENTATION: B. BUDGET REVISION:
Enter appropriate code in each blank: ______, ______, ______, ______, ______
C. NO COST EXTENSION: to (enter date)
9. NAME OF FEDERAL AGENCY:
E. OTHER (specify below):
Corporation for National and Community Service
10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: 11. a. TITLE OF APPLICANT’S PROJECT:
___________________________________________________
12. AREAS AFFECTED BY PROJECT (List Cities, Counties, States, etc.): 11. b. CNCS PROGRAM INITIATIVE (IF ANY):
13. PROPOSED PROJECT: START DATE: END DATE:

14. ESTIMATED FUNDING: Check applicable box: Yr 1: Yr.2: or Yr 3: 15. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER 12372 PROCESS?
a. FEDERAL
$
a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE
b. APPLICANT TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR
$
REVIEW ON:
c. STATE DATE ___________________________________
$
d. LOCAL $ b. NO. PROGRAM IS NOT COVERED BY E.O. 12372
e. OTHER $ OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR

REVIEW
f. PROGRAM INCOME $
16. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
g. TOTAL YES If ―Yes,‖ attach an explanation. NO
$
TO17. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE DOCUMENT HAS BEEN DULY
AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. TYPED NAME OF AUTHORIZED REPRESENTATIVE: b. TITLE: c. TELEPHONE NUMBER:
d. SIGNATURE OF AUTHORIZED REPRESENTATIVE: e. DATE SIGNED:
15
APPENDIX C: Project Model and Design PA Attachment 2
SECTION I: PROJECT MODEL
Section I: Project Models (select one for primary and another for secondary).
A full-time year-round youth corps program or full-time summer youth
corps program, such as a conservation corps or youth service corps that
undertakes meaningful service projects with visible public benefits;
Youth Corps
includes as participants youths and young adults between the ages of 16
and 25 inclusive, including out-of-school youths and other
disadvantaged youths.
A community corps program that meets unmet human, educational,
environmental, or public safety needs and promotes greater community
Community
unity through the use of organized teams of participants of varied social
Corps
and economic backgrounds, skill levels, physical and developmental
capabilities, ages, ethnic backgrounds, or genders.
A campus-based program that is designed to provide substantial service
Campus-based in a community during the school term and during summer or other
Model vacation periods through the use of students who are attending an
institution of higher education.
A pre-professional training program in which students enrolled in an
institution of higher education receive training in specified fields, which
may include classes containing service-learning; perform service related
Pre-Professional
to such training outside the classroom during the school term and during
Corps
summer and other vacation periods; and agree to provide service upon
graduation to meet unmet human, educational, environmental, or public
safety needs related to such training.
A professional corps program that recruits and places qualified
Professional participants to meet unmet human, educational, environmental, or
Corps public safety needs in communities with an inadequate number of such
professionals.
A national service entrepreneur program that identifies, recruits, and
Entrepreneur
trains gifted young adults of all backgrounds and assists them in
Corps
designing solutions to community problems.
An intergenerational program that combines students, out-of-school
Intergenerational youths, and older adults as participants to provide needed community
Program services, including an intergenerational component for other national
service programs described in this subsection.
A program that provides specialized training to individuals in
Service- service-learning and places the individuals after such training in
Learning positions, including positions as service-learning coordinators to
Program facilitate service-learning in programs eligible for funding under Learn
and Serve America School-Based and Community-Based Grants.
A program designed to meet the needs of rural communities, using
teams or individual placements to address the development needs of
Rural Corps
rural communities, including health care, education, and job training,
and to combat rural poverty.
Hunger A program that seeks to eliminate hunger in communities and rural
Elimination areas through service in projects involving food banks, food pantries,
Program and nonprofit organizations that provide food during emergencies.
16
SECTION II: PROJECT DESIGN
 Section II: Project Design (please check as many as apply).

A program where members regularly function as a team during the
Team-Based
service week.
Individual
A program that places one or two members at sites in a variety of
Placement
locations.
/Scattered Site
Intermediary organizations provide the mechanism by which a
number of community or faith-based organizations or grassroots
groups may access AmeriCorps and other Corporation resources. We
define intermediaries as national, regional, state, or local
Intermediary
organizations that agree to provide the technical and financial support
Organization
to assist community or faith-based organizations that do not have the
capacity to perform these functions. Intermediaries serve as the legal
applicant for a Corporation grant, thereby ensuring that the systems to
manage a federal grant are in place.
Statewide A program that operates throughout the state and may or may not
Initiative have a single issue focus.
SECTION III: APPLICATION LOCATION
 Section III: Geography (please check one)

Urban A program designed to meet the needs of urban communities.
Rural A program designed to meet the needs of rural communities.

A program designed to meet the needs of both urban and rural
Both
communities.
Areas of Need Identification: Check all that apply (optional)
Areas Affected by
Areas adversely impacted by reductions in defense spending or the
Military
closure or realignment of military installations.
Downsizing
Empowerment
Communities designated as empowerment zones or redevelopment
Zones or
areas that are targeted for special economic incentives, or otherwise
Redevelopment
identifiable as having high concentrations of low-income people.
Areas
Environmentally
Areas that are environmentally distressed.
Distressed Areas
Areas Affected by Areas adversely affected by federal actions related to the management
Management of of federal lands that result in significant regional job losses and
Federal Lands economic dislocation.
Areas with High Areas that have an unemployment rate greater than the national average
Unemployment unemployment for the most recent 12 months for which satisfactory
Rates data are available.
17
SECTION IV: PROJECT FOCUS
 Section IV: Program Focus (Choose one or more program focus areas as applicable).
African American Pre-school Children At-risk Youth
community
Asian American K-12 Students Children of Prisoners
community
Latin American Young Adults (17-24) Foster Children
community
Native American College Students
community
Families/Parents Incarcerated Seniors
Individuals and Ex-
Offenders
Homeless Low-Income Unemployed
Community
Homeless Veterans Low-Income Housing Veterans
Residents
Immigrants Mentally/Physically Victims/Potential
Challenged Victims of Crime
Persons with
HIV/AIDS
Asset Accumulation Community and faith-based organizations that conduct activities
that empower the poor through asset accumulation programs
including home ownership, individual development accounts,
and financial literacy.
Strengthening Community and faith-based organizations that conduct activities
Families that strengthen families to break the intergenerational cycle of
poverty.
SECTION V: Issue Areas and Service Categories

In this section you will select service categories that describe your program activities. First select an issue area, and
then choose one or more service categories. When you have selected all applicable service categories, indicate
which service category is the primary one by entering a 1 next to the check box, and which is the secondary by
entering a 2 next to the checkbox. Only one service category can be indicated as the primary, and one as the
secondary.
Issue Areas and Service Categories (Issue Areas in Bold)
Community and Economic Development Regional/State/City Planning

Community-based Volunteer Programs Small/Minority Business Development
Community Revitalization/Improvement Social Services Planning & Delivery
Consumer Education Systems/Community Organization
Cooperatives/Credit Unions Tax Counseling/Counseling
Food Production/Community Gardens/Farming Technology Access
Job Development/Placement Thrift Store
Management Consulting Transportation Services
Micro Enterprise Welfare to Work
Other Economic and Community Development
Public Safety Disaster Recovery/Relief
18
Disaster Mitigation Maternal/Child Health Services
Disaster Preparedness Mental Health
Disaster Recovery Mental Retardation
Disaster Response Other Health/Nutrition
Other Disaster Physical Disabilities Programs
Substance Abuse
Education Homeland Security

Adult Education and Literacy Disaster Preparedness/Relief
After School Programs Public Health
America Reads Other Homeland Security
Computer Literacy Public Safety
Cultural Heritage Human Needs
ESL Adoption
Elementary Education Adult Day Care/Senior Center
GED/Dropouts Companionship/Outreach
Head Start/School Preparedness Crisis Intervention
Job Preparedness/School to Work Intensive Mentoring (at least 1 hour weekly for
Library Services at least 9 months)
Other Education Mentoring
Pre-Elementary Day Care Other Human Needs
Secondary Education Respite
Service-Learning Senior Center Program (Non Residential)
Special Education Senior Citizen Assistance
Tutoring & Child Literacy—Elementary Teen Pregnancy/Abstinence/Parent Support
Tutoring & Child Literacy—High School
Tutoring & Child Literacy—Middle School Housing
Vocational Education Home Management Support/Education
Youth Leadership/Development Homeless
Housing Referrals/Relocation/Other
Environment Housing Rehabilitation/Construction
Clean Air Independent Living—Disabled
Clean and Safe Water Independent Living—Seniors
Community Restoration/Clean Up Other Housing
Energy Conservation Tenant Organizing
Environmental Awareness Transitional Housing
Indoor Environment
Other Environment Public Safety
Toxic Waste Management Adult Offender/Ex-Offender
Waste Reduction, Management, and Recycling Services/Rehabilitation
Wildlife, Land & Vegetation Protection or Child Abuse/Neglect
Restoration Children & Youth Safety Programs
Community Policing/Community Patrol
Conflict Resolution/Mediation
Health/Nutrition Crime Awareness/Crime Avoidance
Boarder Babies Elder Abuse/Neglect
CHIOS/SCHIPS Family Violence
Congregate Meals Improvement of Household Security
Delivery of Health Services Juvenile Justice, Delinquency, Gangs
Food Distribution/Collection Legal Assistance
HIV/AIDS Neighborhood Watch/Block Watch
Health Education Other Public Safety
Health Screening Safe Havens
Hospice/Terminally Ill Safety/Fire Prevention/Accident Prevention
Immunization Sexual Abuse/Rape
In-Home Care Victim/Witness Assistance
19
APPENDIX D: Narrative Instructions PA Attachment 3
The first page of your Narrative will be a cover sheet that is labeled ―Executive Summary‖ that
you will utilize to provide a clear and concise summary of key elements of your program design,
including name of your organization, where you are serving, the type of activities your members
are participating in and brief information on the outcomes you are seeking to achieve. The
Executive Summary should be no longer than 500 characters. To complete your narrative,
use the specific directions outlined here for each section. The narrative, including Executive
Summary, that is submitted as a part of your application should be labeled PA Attachment 3. The
Federal Corporation for National & Community Service will publish the Executive Summaries
of all successful applications on their website.
The narrative will include Executive Summary, Program Design, Organizational Capacity and
Cost Effectiveness and Budget Adequacy. You may not exceed 50,000 characters in all
sections combined, about 25 double-spaced pages. The character count includes spaces and
punctuation.
Lead from your program strengths and be explicit. Do not make the mistake of trying to
stretch your proposed program description to fit each funding priority and special
consideration articulated in the regulations or the Notice.
Be clear and succinct. Reviewers are not interested in jargon, boilerplate, rhetoric, or
exaggeration. They are interested in learning precisely what you intend to do, and how your
project responds to the selection criteria presented below.
Avoid circular reasoning. The problem you describe should not be defined as the lack of the
solution you are proposing.
Explain how. Avoid simply stating that the criteria will be met. Explicitly describe how the
proposed project will meet the criteria.
Don’t make assumptions. Even if you have received funding from the Corporation in the
past, do not assume your reviewers know anything about you, your proposed program, your
partners, or your beneficiaries. Avoid overuse of acronyms.
Use an impartial proofreader. Before you submit your application, let someone who is
completely unfamiliar with your project read and critique the project narrative.
Follow the instructions and discuss each criterion in the order they are presented in the
instructions. Use headings to differentiate narrative sections according to the criteria.
External and staff reviewers will assess your application against the selection criteria. The bullets that
follow the criteria are recommendations on how to best respond to the criteria. To best respond to the
criteria, we suggest that you include a brief discussion of each bullet if it pertains to your application.
Selection Criteria
Each application must clearly describe a project that will effectively deploy AmeriCorps
members to solve a significant community problem.
1. Program Design. (50%)

In assessing Program Design, reviewers will examine the degree to which the applicant clearly
describes and convincingly links four major elements: (1) the problem(s) identified, (2) the
solution that will be carried out by AmeriCorps members and community volunteers, (3) ways in
20
which AmeriCorps members are particularly well-suited to deliver the solution, and (4) the
anticipated outcomes. Specifically, reviewers will assess the extent to which the applicant:
Provides persuasive evidence that the identified problem exists in the targeted
community(ies).
Demonstrates that individuals recruited and selected to be AmeriCorps members will:
o Have the appropriate backgrounds, qualifications and skills to succeed;
o Receive orientation, training, and supervision to ensure impact in the community,
and the necessary support to have a high-quality service experience.
Makes the case that engaging AmeriCorps members is a highly effective means of
solving the identified community problem.
Describes how the activities in which AmeriCorps members and volunteers will engage
will have a measurable impact on the identified community problem.
If a new applicant is already working on the problem identified in the application, the applicant
should describe efforts and impact to date and describe how the proposed use of AmeriCorps
members will add value, i.e., be more effective than what is currently being implemented, or
enhance existing efforts.
In meeting the criteria, please include your response to the following:
a. Problem
Describe the problem(s) you will be working on. Why did you choose this problem? Provide
documentation of the extent/severity of the problem in the target community. Describe the target
community. Why did you select this population to be served?
b. Solution: AmeriCorps Member Roles and Responsibilities

Why are you proposing to use AmeriCorps to solve the identified problem? What will members
do? How many members are you requesting? What types of slots (service terms) are needed for
these members? If you are requesting different slot types, explain how the different slot types
align with your program design and activities.
c. AmeriCorps Member Selection, Training, and Supervision

Describe your plans for recruiting members for your program. Describe how the applicants
selected for your program will reflect a diverse member corps. Describe how members will be
included from the local communities to be served by your program.
Describe your plan for orienting members to AmeriCorps, the community they are serving, their
placement site, and to the service they will perform. Describe how you will ensure that training
provided to members will prepare members to perform all the activities they will engage in
during their term of service. Describe, as necessary, the ongoing training provided to members
throughout their terms. What are the anticipated training topics and the timeline for member
training? Demonstrate how you will provide structured opportunities for participants to reflect on
and learn from their service in order to promote a lifelong ethic of service and civic
responsibility
21
Describe your plan for supervising members, and how it ensures that members will receive
adequate support and guidance throughout their terms. Who will supervise the AmeriCorps
members? Describe how supervisors are selected and trained. Describe how your program
provides training, oversight, and support to supervisors.
d. Outcome: Performance Measures

What is the overall change you want to see by the end of the three-year grant cycle? How will
you measure impact? How will you report on this on an annual basis? How did you determine
your performance measure targets?
e. Volunteer Generation
Describe how the proposed program will recruit volunteers to expand the reach/impact in the
community. How will volunteers help meet the identified community needs? What will be the
role(s) of volunteers? What role will AmeriCorps members have in volunteer recruitment and
management?
f. Partnerships and Collaboration

Who are your community stakeholders and partners? How are they involved in planning and
implementing the proposed program?
g. Sustainability
Outline your plans for ensuring that the impact of your program in the community is sustainable
beyond the presence of federal support. For example, you might describe how your community
relationships will lead to community investment in the program’s continued operation; how you
will diversify your funding sources to include a wide range of stakeholders (such as state, local,
and private sector funding); how your strategies for recruiting and supporting volunteers will
sustain member activities after your AmeriCorps grant ends; or how the community will
maintain your project once it is completed.
h. Multi-state Applicants Only

Describe the manner and extent to which you consulted with the State Commission in the states
in which you plan to operate.
i. Multi-Site Programs Only

Identify your proposed member service sites (if known). Describe your process for selecting
service sites and ensuring they have adequate programmatic and financial capabilities. How will
your site selection process incorporate the criteria required by the AmeriCorps regulations 45
CFR §2522.475 (quality, innovation, sustainability, quality of leadership, past performance,
community involvement), and the special considerations found in 45 CFR §2522.450 (program
models, program activities and programs supporting distressed communities)? What are your
current or previous programmatic and funding relationships with the sites?
j. Tutoring Programs Only

If you are proposing to operate a tutoring program, describe how your process complies with
AmeriCorps requirements for member tutoring qualifications. Members who tutor must have a
high school diploma, and successfully complete high-quality, research-based pre- and in-service
22
training for tutors. This requirement does not apply to a member enrolled in a secondary school
who is providing tutoring through a structured, school-managed cross-grade tutoring program.
Describe how your strategy for training members complies with AmeriCorps requirements for
member tutor training that is high quality and research based, consistent with the instructional
program of the local agency and with state academic content standards [section 1111 of the
Elementary and Secondary Education Act of 1965 (20 U.S.C. 6311)], includes appropriate
member supervision by individuals with expertise in tutoring, and provides specialized pre-
service and in-service training consistent with the activities the member will perform.
k. Current Grantees Only

Enrollment: If you enrolled less than 100% of slots received during your last full year of
program operation, provide an explanation, and describe your plan for improvement. Enrollment
rate is calculated by dividing regular slots filled plus refill slots filled by regular slots awarded.
Retention: If you were not able to retain all of your members during your last full year of
program operation, provide an explanation, and describe your plan for improvement. While we
recognize retention rates may vary among equally effective programs depending on the program
model, we expect grantees to pursue the highest retention rate possible. Retention rate is
calculated by dividing the number of members exited with award (full or partial award) by the
number of members enrolled.
2. Organizational Capability (25%)

Reviewers will assess the extent to which:
The organization has the experience, staffing, and management structure to plan,
implement and evaluate the proposed program.
The organization has secured, or describes an effective plan for securing, the financial
and in-kind resources necessary to support program implementation and to demonstrate
community stakeholder support
Multi-state applicants have consulted with state and territory service commissions to
ensure non-duplication and coordination of Corporation resources.
Current or previous AmeriCorps grantees filled the member positions they were awarded
and retained the AmeriCorps members they enrolled.
The organization has a well-developed plan for expanding on its success through
expansion or assuring adaptation of its program model by other organizations.
In meeting the criteria, please include your response to the following:
a. Organizational Background
Identify the primary and secondary contacts for the grant application. Describe your
organization’s prior experience administering AmeriCorps grants or other federal funds.
Describe your organization’s experience raising funds to support service activities and initiatives.
Please list all sources of organizational funding in this section, and what percent the proposed
project represents in your budget. If you have received support from CNCS during the last five
years, please specify what type of support you received. What percentage of your total funding
comes from CNCS?
23
If you already operate an AmeriCorps program, describe how it is integrated and supported
within your organization. Include information explaining your organization’s management
structure and how the board of directors (if applicable), administrators, and staff members will be
used to support your program.
b. Staffing
Who will staff the AmeriCorps program and what is their specific role? What is their relevant
experience? If positions are currently vacant, please describe the desired qualifications for each
open position. What are your plans for: providing financial and programmatic orientation;
training and technical assistance; and monitoring for compliance to your program and service
sites?
c. Special Circumstances
In applying the organizational capability criteria to each proposal, reviewers may also take into
account the following circumstances of individual organizations: The age of your organization
and its rate of growth; and whether your organization serves a resource-poor community, such as
a rural or remote community, a community with a high poverty rate, or a community with a
scarcity of philanthropic and corporate resources.
3. Cost Effectiveness and Budget Adequacy (25%)

For cost-reimbursement grants, reviewers will assess the extent to which:
The budget is clear, reasonable, cost-effective, and in alignment with the program
narrative.
The requested funds do not exceed the maximum cost per Member Service Year (MSY),
or for existing programs, have not increased over previous years.
For EAPs and full-time fixed amount grants, reviewers will assess:
The amount requested per member. Fixed-amount applicants are encouraged to request
less than the full maximum amount allowed per MSY. The amount requested is a
competitive factor in the selection process.
The applicant’s understanding of total program cost and capacity to raise additional
resources beyond the fixed-amount.
a. Cost Effectiveness
The Corporation cost per MSY is determined by dividing the Corporation’s share of budgeted
grant costs by the number of MSYs you are requesting in your grant. It does not include child
care or the cost of the education award. One MSY is equivalent to at least 1700 service hours, a
full-time AmeriCorps position. The Corporation cost per MSY will be automatically calculated
once you enter your budget in eGrants.
The maximum PA cost per MSY is $13,300. Cost effectiveness will be evaluated by analyzing
cost per MSY in relation to your program design. If you request above the maximum, please
justify. This is rarely approved.
24
Demonstrate how your program has or will obtain diverse non-federal resources for program
implementation. Indicate how much funding your program needs from non-Corporation sources
to support the project. Indicate the non-Corporation resource commitments (in-kind and cash)
that you have obtained to date and the sources of these funds. Indicate what additional
commitments you plan to secure, and how you will secure them.
b. Current Grantees Only:

Describe the extent to which you are increasing your share of costs to meet or exceed program
goals, or the extent to which you are proposing deeper impact or broader reach without a
commensurate increase in Federal funds.
c. Special Circumstances
In applying the cost-effectiveness criteria, the Corporation will take into account the following
circumstances of individual programs: program age, or the extent to which your program brings
on new sites; whether your program or project is located in a resource-poor community, such as
a rural or remote community, a community with a high poverty rate, or a community with a
scarcity of corporate or philanthropic resources; whether your program or project is located in a
high-cost, economically distressed community, measured by applying appropriate Federal and
State data; and whether the reasonable and necessary costs of your program or project are higher
because they are associated with engaging or serving difficult-to-reach populations, or achieving
greater program impact as evidenced through performance measures and program evaluation.
d. Budget Adequacy
Unless you are applying for an EAP or Full-time Fixed-amount grant, discuss the adequacy of
your budget to support your program design including how it is sufficient to support your
program activities and desired outputs and outcomes.
e. EAPs and Full-time Fixed-amount Applicants Only

The extent to which a current grantee is increasing its share of costs will not be considered in
assessing a fixed-amount application. However, all other indicators described under Cost
Effectiveness and Budget Adequacy apply and the section will be weighted 25% of the total
application. Fixed-amount applicants are encouraged to request less than the full maximum
amount allowed per MSY. The amount requested is a competitive factor in the selection process.
Discuss how you will raise the resources you will need to manage and operate an AmeriCorps
program and identify the total amount you have budgeted to operate the program, both the CNCS
share and grantee share. Keep in mind that full-time AmeriCorps program costs include
expenditures for the AmeriCorps living allowance, health care and criminal history checks.
Education Award Programs are not required to pay living allowances or cover health care for
less-than-full-time members, but must conduct criminal history checks. You will not be required
to track or report on your expenditures. However, you must demonstrate that you have planned
for total costs. Reviewers will assess the adequacy of your plan to secure resources to support
your program design.
25
F. Evaluation Summary or Plan
If you are competing for the first time, please enter N/A in the Evaluation Summary or Plan form
( See Appendix F) since it pertains only to recompeting grantees. If you are recompeting for
AmeriCorps funds for the first time you must submit a summary of your evaluation efforts or
plan to date in the Evaluation Summary or Plan. If you are recompeting for the second time, you
must submit your evaluation report. An evaluation report may be submitted in place of an
evaluation plan.
A formula program that re-applies and is submitted as a competitive application will be

considered a recompeting application, if it satisfies the Corporation’s definition of ―same
project,‖ below. If your project satisfies the definition, you will be required to submit an
evaluation plan, summary, or evaluation report when you recompete. If your project does not
satisfy the definition, it will be considered new and will not be required to submit an evaluation
plan, summary, or completed evaluation.
Two projects will be considered the same if they:

address the same issue areas;
address the same priorities;
address the same objectives;
serve the same target communities and population;
utilize the same sites; and
use the same program staff and members.
26
Appendix E: Performance Measure Instructions & Worksheet
You are required to align at least one set of performance measures in your primary service
category. On the worksheet you will align the measures by entering three different Result
Types and Result Statements for one Performance Measurement Title. The three Result
Types are Output, Intermediate Outcome, and End Outcome.
The Corporation for National and Community Service (CNCS) has introduced national
performance measures that are optional for 2011. CNCS has indicated that it will provide
additional details on National Performance Measures via a future Amendment. Please check the
PennSERVE website ( www. dli.state.pa.us/pennserve) for any updates. The national
performance measures are in the areas of: education, the environment/clean energy, healthy
futures, economic opportunity, veterans and disasters. If you chose to opt-in to the national
performance measures, important information and frequently-asked questions may be found at:
http://nationalserviceresources.org/national-performance-measures/home.
Whether you choose to use applicant-determined performance measures or national performance

measures, PennSERVE will need completed worksheets submitted with your application.
Successful applicants will eventually be required to submit via eGrants at a later date.
In order to align a set of performance measures:

Enter the Title, the Measure Category, and the Service Category.
Enter Needs and Activities, and Result Type: output, intermediate outcome, end outcome.
For the Output Result Type, enter a Result Statement, Indicators, Targets, Number or
Percentage, Instruments, and Performance Measure Statement.
For the Intermediate Outcome, enter a Result Statement, Indicators, Targets, Number or
Percentage, Instruments, and Performance Measure Statement. Finally, for the End
Outcome, enter Result Statement, Indicators, Targets, Number or Percentage,
Instruments, and Performance Measure Statement.
Once you have aligned one set of measures, i.e., completed three Result Types for one
Performance Measurement Title, you may (if you desire, but not required) to Add New
Performance Measures as appropriate for your program design.
You may also find the Performance Measurement Toolkit, on the Corporation’s web site useful
in developing your performance measures.
(http://nationalserviceresources.org/resources/online_pubs/americorps/pmtoolkit.php).
27
Performance Measure Worksheet PA Attachment 4
Please fill in the performance measure information for each section.

General Info
Performance Measurement Title:
Measure Category (choose one):

Needs and Service Activities
Participant Development
Strengthening Communities
Service Category addressed by this Performance Measure Worksheet
(see Appendix C, Service Categories):
Needs and Activities

Briefly describe the need to be addressed (4,000 characters or less):
Briefly describe how you will achieve this result (4,000 characters or less):
How many AmeriCorps members will be participating in this activity?

How many days per week (on average) will this activity occur?
How many hours per day (on average) will this activity occur?
When does this activity begin?
When does this activity end?
Results
The outputs and outcomes you intend to track for a particular activity:
Result Type
Outputs are counts of the amount of service members or volunteers have completed, but do not
provide information on benefits to or other changes in the lives of members and/or beneficiaries.
Intermediate-outcomes specify changes that have occurred in the lives of members and/or
beneficiaries, but are short of a significant benefit for them.
End-outcomes specify changes that have occurred in the lives of members and/or beneficiaries
that are significant.
28
Result: Output
Result Statement:
1-2 sentences stating the expected result.
Indicator: A specific, measurable item of information that specifies progress toward achieving a
result.
Indicator:
Other Indicator:
Targets
Target Description:
# (number) or % (percent):
Instruments: Specific tool to collect information (e.g. behavior checklist, tally sheet, attitude
questionnaire, interview protocol).
Result: Intermediate Outcome

Result Statement:
result.
29
Indicator:
Other Indicator:
Targets
Target Description:
Result: End Outcome

Result Statement:
result.
Indicator:
Other Indicator:
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Targets
Target Description:
Performance Measure Statement (summary)

Combine expected results and targets into a sentence:
31
APPENDIX F: Evaluation Report or Summary or Plan
PA Attachment 5
If you are an existing grantee recompeting for AmeriCorps funds for the first time since the
AmeriCorps rule took effect (July, 2005), you must submit a summary of your evaluation efforts
or plan to date, or a copy of any evaluation that has been completed, as part of your application
for funding.
1) Existing grantees who are recompeting for the first time since July 2005, please enter
your Summary of Evaluation Efforts or Plan below and submit this sheet as PA
Attachment 5 with your application. (If you have a completed evaluation that you wish to
submit with this application, please label it as PA Attachment 5).
OR
2) Existing grantees who are recompeting for the second time since July 2005, please submit
this sheet along with your completed Evaluation report in hard copy, with this
Application and label the report as PA Attachment 5.
OR
3) Submit this sheet with your application. New applicants are not required to complete this
section, but need to state below that they are a New Applicant.
NOTE: Your evaluation requirements are different depending on the amount of your grant, as
described in the AmeriCorps Regulations, Section 2522.710:
If you are State or National grantee (other than an Education Award Program grantee),
and your average annual Corporation program grant is $500,000 or more, you must
arrange for an independent evaluation of your program, and you must submit the
evaluation with any application to the Corporation. If you are State or National grantee
whose average annual Corporation program grant is less than $500,000, or an Education
Award Program grantee, you must conduct an internal or an external evaluation of your
program, and you must submit the evaluation with any application to the Corporation.
Check box that applies:
 I am competing as a New Applicant for the first time and am not required to submit this
information.
 I am recompeting for the first time since 7/05, and will submit summary of Evaluation
Efforts or Plan with application.
 I am recompeting for the second time since 7/05, and will submit a completed Evaluation
Report with application.
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APPENDIX G: Budget Instructions (includes Worksheet & Form)
NOTE: For Education Award and other Fixed Amount program applicants, please use Budget
Instructions and Budget Worksheet in Appendix G (Fixed Amount) that follows this section.
A. Overview of Key Budget Requirements
Program requirements, including requirements on match, are located in the AmeriCorps
regulations, modified by 2008 appropriations language, and summarized below.
Table 3: Match Requirements in the AmeriCorps Regulations

Competition Match Requirement
State and Territory Competitive, States and Territories Minimum grantee share is 24% of program costs for the
without Commissions, National Direct, National first three years. Overall grantee share of total program
Professional Corps, Indian Tribes costs increases gradually beginning in Year 4 to 50% by
the tenth year of funding and any year thereafter.
State EAP Fixed-Amount Grants There are no specific match requirements for fixed-
amount grants. Grantees pay all program costs over $800
per MSY provided by the Corporation.
Professional Corps Fixed-Amount Grants There are no specific match requirements for fixed-
amount grants. Grantees pay all program costs over the
$2000 per MSY provided by the Corporation.
Full-time Fixed-Amount Grants There are no specific match requirements for fixed-
amount grants. Grantees pay all program costs over the
$13,000 per MSY provided by the Corporation
Equipment costs must not exceed 10% of the total Corporation share.
Administrative costs must not exceed 5% of the total Corporation funds requested.
If you are applying for the first time, you must match with cash or in-kind contributions at
least 24% of the project’s total Operating Costs (Section I) plus Member Costs (Section II)
plus Administrative Costs (Section III). If you are recompeting, PennSERVE can tell you
where you are in the match schedule.
The acceptable sources of matching funds are federal, state, local, private sector, and/or
other funds in accordance with applicable AmeriCorps requirements.
In Sections I, II, and III of the budget, you should clearly and specifically identify the source
and total dollar amount of cash match from private, state and local and federal funds, and the
source and total amounts of in-kind support. Define all acronyms the first time they are used.
Note: The Corporation’s legislation permits the use of non-Corporation federal funds as match
for the grantee share of the budget. Please discuss your intention of using federal funds to match
an AmeriCorps grant with the other agency prior to submitting your application. Section
121(e)(5) of the National Community Service Act requires that grantees that use other federal
funds as match for an AmeriCorps grant report the amount and source of these funds to the
Corporation. The Federal Financial Report (FFR) will be used to collect the federal match data.
If a grantee uses federal funds as match, they will be required to report the sources and amounts
on the FFR.
B. Preparing Your Budget

Your proposed budget should be sufficient to allow you to perform the tasks described in your
proposal narrative. Reviewers will consider the information you provide in this section in their
assessment of the Cost-Effectiveness and Budget Adequacy selection criterion.
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Follow the detailed budget instructions, below, to prepare your budget. We recommend that you
prepare your budget in the same order as indicated in the Budget Worksheets. The Budget
Checklist is a resource for you to ensure your budget is complete.
As you prepare your budget:
All the amounts you request must be defined for a particular purpose. Do not include
miscellaneous, contingency, or other undefined budget amounts.
Your detailed budget narrative must provide a full explanation of the proposed costs
including their purpose.
Present the basis for all calculations in the form of an equation.
Do not include unallowable expenses, e.g., entertainment costs (which include food and
beverage costs) unless they are justified as an essential component of an activity.
Do not include fractional amounts (cents).
Please refer to the relevant OMB Circulars on allowable costs for further guidance. The OMB
circulars are online at www.whitehouse.gov/OMB/circulars.
A-21 - Cost Principles for Educational Institutions, 2 CFR 220
A-87 - Cost Principles for State, Local, and Indian Tribal Governments, 2 CFR 225
A-122 - Cost Principles for Non Profit Organizations, 2 CFR 230
Programs must comply with all applicable federal laws, regulations, and OMB circulars for grant
management, allowable costs, and audits, including providing audits to the A-133 clearinghouse
if they expend over $500,000 in federal funds, as required in OMB Circular A-133.
Detailed Budget Instructions

These instructions do not apply to applicants for State EAP and other fixed amount grants.
Please see Appendix G (Fixed Amount) for detailed budget instructions.
Source of Match
Enter a brief description of the Source of Match, the amount, the match classification (Cash, In-
kind, or Not Available) and Match Source (State/Local, Federal, Private, Other or Not
Available). Define any acronyms the first time they are used.
Section I. Program Operating Costs
Complete Section I, Program Operating Costs, of the Budget Worksheet by entering the ―Total
Amount,‖ ―CNCS Share,‖ and ―Grantee Share‖ for Parts A-I, as follows:
A. Personnel Expenses
Under ―Position/Title Description,‖ list each staff position separately and provide a brief 5 or 6
word position description, salary, and percentage of FTE devoted to this award. Each staff
person’s role must be described in the application narrative and each person mentioned in the
narrative must be listed in the budget as either CNCS or Grantee share. Because the purpose of
this grant is to enable and stimulate volunteer community service, do not include the value of
direct community service performed by volunteers. However, you may include the value of
volunteer services contributed to the organization for organizational functions such as
accounting, audit work, or training of staff and AmeriCorps members.
34
B. Personnel Fringe Benefits
Under ―Purpose/Description,‖ identify the types of fringe benefits to be covered and the costs of
benefit(s) for each staff position. Allowable fringe benefits typically include FICA, Worker’s
Compensation, Retirement, SUTA, Health and Life Insurance, IRA, and 401K. You may provide
a calculation for total benefits as a percentage of the salaries to which they apply or list each
benefit as a separate item. If a fringe amount is over 30%, please list separately. Holidays, leave,
and other similar vacation benefits are not included in the fringe benefit rates but are absorbed
into the personnel expenses (salary) budget line item.
C. 1. Staff Travel
Describe the purpose for which program staff will travel. Provide a calculation to include costs
for airfare, transportation, lodging, per diem, and other travel-related expenses multiplied by the
number of trips/staff. Where applicable, identify the current standard reimbursement rate(s) of
the organization for mileage (not to exceed the federal mileage rate), daily per diem, and similar
supporting information. Only domestic travel is allowable.
We expect applicants to include funds in this line item for travel for staff and site staff to
attend Corporation-sponsored technical assistance meetings. There are two to three such
opportunities per year, including opportunities for new grantee orientation, financial
training, and the National Conference on Volunteering and Service.
For example: Two staff will attend the Nat’l Conference on Volunteering and Service in New Orleans. 2
staff x $750 airfare + $50 ground transportation + (1 day) x $400 lodging + $35 per diem = $2,470.
C. 2. Member Travel
Describe the purpose for which members will travel. Provide a calculation to include costs for
airfare, transportation, lodging, per diem, and other related expenses for members to travel
outside their service location or between sites. Costs associated with local travel, such as bus
passes to local sites, mileage reimbursement for use of car, etc., should be included in this budget
category. Where applicable, identify the current standard reimbursement rate(s) of the
organization for mileage, daily per diem, and similar supporting information.
D. Equipment
Equipment is defined as tangible, non-expendable personal property having a useful life of more
than one year AND an acquisition cost of $5,000 or more per unit (including accessories,
attachments, and modifications). Any items that do not meet this definition should be entered in
E. Supplies below. Purchases of equipment are limited to 10% of the total Corporation funds
requested. If applicable, show the unit cost and number of units you are requesting. Provide a
brief justification for the purchase of the equipment under Item/Purpose.
E. Supplies
Include the amount of funds to purchase consumable supplies and materials, including member
service gear and equipment that does not fit the definition above. You must individually list any
single item costing $1,000 or more. Except for safety equipment, grantees may only charge the
cost of member service gear to the federal share if it includes the AmeriCorps logo. Grantees
35
may also add the AmeriCorps logo to their own local program uniform items using federal funds.
All safety gear may be charged to the federal share, regardless of whether it includes the
AmeriCorps logo. All other service gear must be purchased with non-CNCS funds.
F. Contractual and Consultant Services

Include costs for consultants related to the project’s operations, except evaluation consultants,
who will be listed in Section H., below. Payments to individuals for consultant services under
this grant may not exceed $750 per day (excluding costs for indirect expenses, travel, supplies,
etc.). The $750 daily rate is a ceiling, and we anticipate budgeted daily rates at considerably
lower levels. Indicate the daily rate for consultants you are proposing to use and their contractual
services. Indicate the daily rate, number of days, and total cost.
G. 1. Staff Training
Include the costs associated with training staff on project requirements and training to enhance
the skills staff need for effective project implementation, i.e., project or financial management,
team building, etc. If using a consultant(s) for training, indicate the estimated daily rate, not to
exceed the daily rate limit.
G. 2. Member Training
Include the costs associated with member training to support them in carrying out their service
activities. You may also use this section to request funds to support training in Life After
AmeriCorps. If using a consultant(s) for training, indicate the estimated daily rate, not to exceed
the daily rate limit.
H. Evaluation
Include costs for project evaluation activities, including additional staff time or subcontracts, use
of evaluation consultants, purchase of instrumentation, and other costs specifically for this
activity not budgeted in Personnel Expenses. This cost does not include the daily/weekly
gathering of data to assess progress toward meeting performance measures, but is a larger
assessment of the impact your project is having on the community, as well as an assessment of
the overall systems and project design. Indicate daily rates of consultants, where applicable.
I. Other Program Operating Costs

Allowable costs in this budget category should include when applicable:
Criminal history background checks for all members and for all employees or other
individuals who receive a salary, education award, living allowance, or stipend or similar
payment from the grant (federal or non-federal share).
Office space rental for projects operating without an approved indirect cost rate agreement
that covers office space. For national office space, rental may be unallowable; check relevant
OMB Circulars. If space is budgeted and it is shared with other projects or activities, the
costs must be equitably pro-rated and allocated between the activities or projects.
Utilities, telephone, Internet and similar expenses that are specifically used for AmeriCorps
members and AmeriCorps project staff, and are not part of the organizations indirect
cost/admin cost allocation pool.
Recognition costs for members. List each item and provide a justification in the budget
narrative. Gifts and/or food in an entertainment/event setting are not allowable costs.
36
Section II. Member Costs
Member Costs are identified as ―Living Allowance‖ and ―Member Support Costs.‖ Your
required match can be federal, state, local, or private sector funds.
A. Living Allowance
The narrative should clearly identify the number of members you are supporting by category
(i.e., full-time, half-time, reduced-half-time, quarter-time, minimum-time, 1st and 2nd Years of 2-
year half-time) and the amount of living allowance they will receive, allocating appropriate
portions between the Corporation’s share (CNCS Share) and grantee match (Grantee Share).
Members – Enter the total number of members you are requesting in each category. Enter the
amount of the living allowance for each type of member. Enter the number of members for
which you are not requesting funds for a living allowance, but for which you request education
awards.
Table 4. Minimum and Maximum Living Allowance
Service Term Minimum # of Ed Award MSY Minimum Living Maximum Total

Hours Allowance Living Allowance
Full-time 1700 $5,550 1.000 $12,100 $24,200
One-year Half-time 900 $2,775 0.500 n/a $12,800
Two-year Half-time 900 $2,775 0.250 n/a $12,800
Reduced Half-time 675 $2,114 0.381 n/a $9,600
Quarter-time 450 $1,468 0.265 n/a $6,400
Minimum-time 300 $1,175 0.212 n/a $4,300
Notes:
1. There is no requirement to pay a living allowance to less than full-time members.
2. The amount of the maximum for less than full-time living allowance is rounded to the nearest dollar.
* For a two year half-time position, the living allowance can be split between two years, e.g. 0.250 in Year 1 and
0.250 in Year 2. The total MSY factor is .500.
B. Member Support Costs

Consistent with the laws of the state where your members serve, you must provide members with
the benefits described below.
FICA for Members. Unless exempted by the IRS with accompanying documentation (note
in the narrative and provide documentation with application), all projects must pay FICA for
any member receiving a living allowance, even when the Corporation does not supply the
living allowance. In the first column next to FICA, indicate the number of members who will
receive FICA. Calculate the FICA at 7.65% of the total amount of the living allowance.
Worker’s Compensation: Some states, including Pennsylvania, require worker’s
compensation for AmeriCorps members. Successful applicants are required to pay worker’s
compensation.
Health Care. You must offer health care benefits to full-time members in accordance with
AmeriCorps requirements. Except as stated below you may not pay health care benefits to
37
less-than-full-time members with Corporation funds. You may choose to provide health care
benefits to less-than-full-time members from other sources (i.e., non-federal). Less-than-full-
time members who are serving in a full-time capacity for a sustained period of time (such as
a full-time summer project) are eligible for health care benefits. In your budget narrative,
indicate the number of members who will receive health care benefits. The Corporation will
not pay for dependent coverage.
Unemployment Insurance and Other Member Support Costs. Include any other required
member support costs here. Pennsylvania does not allow unemployment coverage for their
AmeriCorps members.
Section III. Administrative/Indirect Costs

Definitions
Administrative costs are general or centralized expenses of the overall administration of an
organization that receives Corporation funds and do not include particular project costs. These
costs may include administrative staff positions. For organizations that have an established
indirect cost rate for federal awards, administrative costs mean those costs that are included in
the organization’s indirect cost rate agreement. Such costs are generally identified with the
organization’s overall operation and are further described in Office of Management and Budget
Circulars A-21, A-87, and A-122.
Options for Calculating Administrative/Indirect Costs (choose either A. OR B.)
Applicants can choose to use one of two methods to calculate allowable administrative costs – a
Corporation fixed percentage method or a federally approved indirect cost rate method.
Regardless of the option chosen, the Corporation’s share of administrative costs is limited by
statute to 5% of the total Corporation funds actually expended under this grant.
A. Corporation Fixed Percentage Method

Five Percent Fixed Administrative Costs Option
The Corporation fixed rate allows you to charge administrative costs up to a cap without
a federally approved indirect cost rate and without documentation supporting the
allocation. If you choose the Corporation Fixed Percentage Method, you may charge, for
administrative costs, a fixed 5% of the total of the Corporation funds expended. In order
to charge this fixed 5%, the grantee match for administrative costs may not exceed 10%
of all direct cost expenditures.
1. To determine the Corporation share for Section III: Multiply the sum of the Corporation
funding shares of Sections I and II by 0.0526. This is the maximum amount you can request as
Corporation share. The 5% maximum is calculated by multiplying the sum of the Corporation’s
share of Section I and Section II by the factor 0.0526. The factor 0.0526 is used to calculate the
maximum amount of federal funds that may be budgeted for administrative (indirect) costs,
rather than 0.0500, as a way to mathematically compensate for determining Section III costs
when the total budget (Sections I + II + III) is not yet established. (If 0.0500 was used, the
resulting Section III costs would be less than the maximum 5% of total costs that are permitted
under the Corporation’s regulations.) Enter this amount as the Corporation share for Section III
A.
38
2. To determine the Grantee share for Section III: Then multiply the total (both Corporation and
grantee share) of Sections I and II by 10% (0.10) and enter this amount as the grantee share
for Section III A.
3. Enter the sum of the Corporation and grantee shares under Total Amount.
B. Federally Approved Indirect Cost Rate Method
If you have a Federally Approved Indirect Cost (IDC) rate and choose to use it, the IDC rate will
constitute documentation of your administrative costs including the 5% maximum payable by the
Corporation. Specify the Cost Type for which your organization has current documentation on
file, i.e., Provisional, Predetermined, Fixed, or Final indirect cost rate. Supply your approved
IDC rate (percentage) and the base upon which this rate is calculated (direct salaries, salaries and
fringe benefits, etc.). It is at your discretion whether or not to claim your entire IDC rate to
calculate administrative costs. If you choose to claim a lower rate, please include this rate in the
Rate Claimed field.
1. Determine the base amount of direct costs to which you will apply the IDC rate, including
both the Corporation and Grantee’s shares, as prescribed by your established rate agreement (i.e.,
based on salaries and benefits, total direct costs, or other). Then multiply the appropriate direct
costs by the rate being claimed. This will determine the total amount of indirect costs allowable
under the grant.
2. To determine the Corporation share: Multiply the sum of the Corporation funding share in
Sections I and II by 0.0638. This is the maximum amount you can claim as the Corporation share
of indirect costs.
3. To determine the Grantee share: Subtract the amount calculated in step b (the Corporation
administrative share) from the amount calculated in step a (the Indirect Cost total). This is the
amount the applicant can claim as grantee share for administrative costs.
Increasing Grantee Overall Share of Total Budgeted Costs --Grantees are required to meet an
overall matching rate that increases over time. You have the flexibility to meet the overall match
requirements in any of the three budget areas, as long as the minimum match of 24% for the first
three years, and the increasing minimum in years thereafter, are maintained
39
Budget Worksheet PA Attachment 6A
Section I. Program Operating Costs
A. Personnel Expenses
Position/Title/Description Qty Annual Salary % Time Total Amount CNCS Share Grantee Share
Totals
B. Personnel Fringe Benefits

Grantee
Purpose/Description Calculation Total Amount CNCS Share
Share
Totals
C.1. Staff Travel

Purpose Calculation Total Amount CNCS Share Grantee Share
Totals
C. 2. Member Travel
Totals
D. Equipment
Item/ Purpose/Justification Qty Unit Cost Total Amount CNCS Share Grantee Share
Totals
E. Supplies
Totals
40
F. Contractual and Consultant Services
Daily
Purpose Calculation
Rate Total Amount CNCS Share Grantee Share
Totals
G.1. Staff Training

Daily
Purpose Calculation
Totals
G.2. Member Training

Daily
Purpose Calculation
Totals
H. Evaluation
Daily
Purpose Calculation
Totals
I. Other Program Operating Costs

Daily
Purpose Calculation
Totals
Total Amount CNCS Share Grantee Share

Subtotal Section I:
41
Section II. Member Costs
A. Living Allowance
Total
Item # Mbrs Allowance # w/o CNCS Share Grantee Share
Rate Allowance Amount
Full Time (1700 hrs)
Half Time (900 hrs)
1st Year of 2-Year Half Time
2nd Year of 2-Year Half Time
Reduced Half Time (675 hrs)
Quarter Time (450 hrs)
Minimum Time (300 hrs)
Totals
B. Member Support Costs

Daily
Purpose Calculation
Totals
Total Amount CNCS Share Grantee Share

Subtotal Section II:
Subtotal Sections I + II:
Source of Match
Source(s), Type, Amount, Intended Purpose
Private State and/or Local Federal Sources

In-kind $ $ $ .
Cash $ $ $
Total $ $ $
42
Section III. Administrative/Indirect Costs
A. Corporation Fixed Percentage Method
Purpose Calculation Total CNCS Share Grantee Share

Amount
Totals
B. Federally Approved Indirect Cost Rate Method
Cost Cost Calculation Rate Rate Total CNCS Grantee

Type Basis Claimed Amount Share Share
Total
Total Sections I + II + III: CNCS Share Grantee Share
Amount
Total
Budget Total: Amount CNCS Share Grantee Share
43
BUDGET FORM PA Attachment 6B
SECTION I: PROGRAM OPERATING COSTS
Column 1 Column 2 Column 3 Column 4 Column 5
%Time Total Corporation
A. Personnel Annual Spent on Program Funds Grantee Match
Salary Program Cost Requested
Subtotal - Personnel $ $ $
B. Benefits (includes FICA, Worker’s Comp, Leave, other Fringe, etc.)
C. 1. Staff Travel
C. 2. Member Travel
D. Equipment (not greater than 10% of total CNCS budget costs)
E. Supplies (includes Member Service Gear)
F. Contracts & Consultants
G.1. Training – Staff
G.2. Training – Member
H. Evaluation (Consultant daily rate not to exceed CNCS maximum
$750/day)
I. Other (includes CNCS-sponsored meetings)
Subtotal SECTION I. $ $ $
SECTION II: MEMBER COSTS Column 3 Column 4 Column 5
Living Allowance No. of Members No. without
with living allowance living allowance
1 year FT 1700 hours $ # #
1 year PT 900 hours $ # #
Expanded PT 675 hours $ # #
Quarter Time 450 hours $ # #
Minimum Time 300 hours $ # #
B. FICA (7.65% of Total Member Living
Allowances)
C. Worker’s Compensation (or other Death & Dismemberment
coverage)
D. Health Care (required for FT Members, optional for PT)
E. Other Member Costs (includes unemployment coverage if required by
State law)
Sub Total $ $$
Subtotal SECTION II. $ $ $

SECTION III: ADMINISTRATIVE COSTS
A. Grantee Administrative Costs (CNCS Admin not to exceed 5 %
of CNCS Section I + Section II) (Up to 10% Match allowed without
approved Indirect Cost Rate)
B. Federally-approved or State-established Indirect Cost Rate
Subtotal SECTION III. $ $ $
44
TOTAL PROGRAM OPERATING BUDGET (Sum of SECTIONS I,
II and III)
TOTAL BUDGET COSTS $ $ $
Corporation Cost per MSY $___________
45
Budget Analysis Checklist
Below is a checklist to help you make certain that you submit an accurate budget narrative that meets
AmeriCorps requirements.
In Compliance? Section I. Program Operating Costs

Costs charged under the Personnel line item directly relate to the operation of the AmeriCorps
Yes __ No __ project? Examples include costs for staff that recruit, train, place, or supervise members as well as
manage the project.
Staff indirectly involved in the management or operation of the applicant organization is funded
Yes __ No __ through the administrative cost section (Section III.) of the budget? Examples of administrative
costs include central management and support functions.
Staff fundraising expenses are not charged to the grant? You may not charge AmeriCorps staff
members’ time and related expenses for fundraising to the federal or grantee share of the grant.
Yes __ No __
Expenses incurred to raise funds must be paid out of the funds raised. Development officers and
fundraising staff are not allowable expenses.
Yes __ No __ Brief position descriptions are provided for each staff member listed on the grant?
The types of fringe benefits to be covered and the costs of benefit(s) for each staff position are
described? Allowable fringe benefits typically include FICA, Worker’s Compensation, Retirement,
SUTA, Health and Life Insurance, IRA, and 401K. You may provide a calculation for total benefits
Yes __ No __ as a percentage of the salaries to which they apply or list each benefit as a separate item. If the
fringe amount is over 30%, please list separately. Holidays, leave, and other similar vacation
benefits are not included in the fringe benefit rates but are absorbed into the personnel expenses
(salary) budget line item?
Holidays, leave, and other similar vacation benefits are not included in the fringe benefit rates but
Yes __ No __
are absorbed into the personnel expenses (salary) budget line item?
Yes __ No __ The purpose for all staff and member travel is clearly identified?
Yes __ No __ You have budgeted funds for staff travel to CNCS sponsored meetings in the budget narrative?
Funds to pay relocation expenses of AmeriCorps members are not in the federal share of the
Yes __ No __
budget?
Funds for the purchase of equipment (does not include general use office equipment) are limited to
Yes __ No __
10% of the total grant amount?
Yes __ No __ All single equipment items over $5000 per unit are specifically listed?
Yes __ No __ Justification/explanation of equipment items is included in the budget narrative?
Yes __ No __ All single supply items over $1000 per unit are specifically listed?
You only charged to the federal share of the budget member service gear, with the exception of
Yes __ No __
safety equipment, that includes the AmeriCorps logo?
Are all consultant services budgeted below the maximum federal daily rate of $750/day? Is the
Yes __ No __
daily rate noted in all sections of the budget narrative where consultants are proposed?
Yes __ No __ Does the budget reflect adequate budgeted costs for project evaluation?
Have you provided budgeted costs for background checks of members and grant-funded staff that
Yes __ No __ will have recurring access to vulnerable populations (i.e. children, frail elderly, and/or persons with
disabilities)?
Yes __ No __ Are all items in the budget narrative itemized and the purpose of the funds justified?
46
In Compliance? Section II. Member Costs
Are the living allowance amounts correct? Full-time AmeriCorps members must receive at least the
minimum living allowance as indicated in the chart in the budget instructions.
Yes __ No __ Note: Programs in existence prior to September 21, 1993 may offer a lower living allowance than
the minimum. If such a program chooses to offer a living allowance, it is exempt from the
minimum requirement, but not from the maximum requirement.
Living allowances are not paid on an hourly basis? They may be calculated using service hours and
Yes __ No __ program length to derive a weekly or biweekly distribution amount. Divide the distribution in equal
increments that are not based on the specified number of hours served.
Is FICA calculated correctly? You must pay FICA for any member receiving a living allowance.
Yes __ No __
Unless exempted by the IRS, calculate FICA at 7.65% of the total amount of the living allowance.
Is the Worker’s Compensation calculation correct? Some states require worker’s compensation for
AmeriCorps members. Check with your local State Department of Labor to determine whether or
not you are required to pay worker’s compensation and at what level (i.e., rate). If you are not
Yes __ No __
required to pay worker’s compensation, you need to provide similar coverage for members’ on-the-
job injuries through their own existing coverage or a new policy purchased in accordance with
normal procedures (i.e., Death and Dismemberment coverage).
Health care is provided for full-time AmeriCorps members only (unless half-time serving for a
sustained full-time period of time such as summer service)? If your project chooses to provide
health care to other half-time members, you may not use federal funds to help pay for any portion of
Yes __ No __ the cost. Projects must provide health care coverage to all full-time members who do not have
adequate health care coverage at the time of enrollment or who lose coverage due to participation in
the project. In addition, projects must provide coverage if a full-time member loses coverage during
the term of service through no deliberate act of his/her own.
In Compliance? Section III. Administrative/Indirect Costs

Applicant has chosen Option A – Corporation fixed percentage method and the maximum federal
Yes __ No __ share of administrative costs does not exceed 5% of the total federal funds budgeted? To
determine the federal administrative share, multiply all other budgeted federal funds by .0526.
Applicant has chosen Option A – Corporation fixed percentage method and the maximum grantee
Yes __ No __
share is at 10% or less of total budgeted funds?
Applicant has chosen Option B – federally approved indirect cost rate method and documentation
on file? Administrative costs budgeted include the following: (1) indirect costs such as legal staff,
central management and support functions; (2) costs for financial, accounting, audit, internal
Yes __ No __
evaluations, and contracting functions; (3) costs for insurance that protects the entity that operates
the project; and (4) the portion of the salaries and benefits of the director and any other project
administrative staff not attributable to the time spent in direct support of a specific project.
Applicant has chosen Option B – The maximum grantee share is at 10% or less of total budgeted
Yes __ No __
funds, less the 5% CNCS share?
In Compliance? Match
Yes __ No __ Is the overall match being met at the required level, based on the year of funding?
For all matching funds, the source(s) [private, state and local, and federal], the type of contribution
Yes __ No __
(cash or in-kind), and the amount (or an estimate) of match, are clearly identified in the narrative?
Please note that the Commonwealth of PA requires all AmeriCorps programs to meet its budgeted
match (rather than the minimum required match)
47
Appendix G Budget Instructions for Fixed Amount Applicants
These instructions apply only to applicants for fixed-amount grants, including education
award programs (EAPs).
EAP and Fixed-Amount applicants may only request a fixed amount of funding per MSY.
Therefore, fixed-amount applicants are not required to complete a detailed budget. In addition,
the matching requirements in 45 CFR §§ 2521.40– 2521.95 do not apply to EAP and other fixed-
amount grant applicants. Fixed-Amount applicants, except for EAP applicants, must include only
full-time members.
Budget Section II. AmeriCorps Member Positions
A. Budget Section II: Fixed Amount Grants
Enter the number of full-time positions you are requesting under the column labeled w/o living
allowance. You may not request less than full-time positions under this competition.
Under ―calculation‖ you will enter the calculation for your grant request. Leave all other
columns blank.
Member Positions Cost per MSY Total Cost
_____Full-time (1700 hours) x _________ = $
Type the total amount requested in the ―Total Amount‖ & ―CNCS Share‖ columns. Leave the
―Grantee Share‖ blank.
Please note that the final amount that a program receives will be adjusted to reflect actual hours
served if a member does not serve the minimum number of hours necessary to complete a full
term of service.
B. Budget Section II: Education Award Program Applicants
Member Positions
Identify the number of Education Award members you are requesting by category (i.e. full-time,
half-time, reduced half-time, quarter-time, minimum-time) and list under the column labeled
#w/o Allow (without CNCS-funded living allowance.) Leave all other columns blank.
The total number of member service years (MSY) is to be calculated at the bottom of the
Member Positions chart.
48
Amounts of fixed awards are based on the member service years which are calculated as follows:
Calculation MSY
Member Positions
_____Full-time (1700 hours) (______ members x 1.000) =
_____1-Year Half-time (900 hours) (______ members x 0.500) =

st
_____ 2-Year Half-time (1 Year)
(______ members x 0.500) =
(generally 450 hours)
_____ 2-Year Half-time (2nd Year)*
(______ members x 0.000)* =
(generally 450 hours)
_____Reduced half-time (675 hours) (______ members x 0.3810) =
_____Quarter-time (450 hours) (______ members x 0.2646) =
_____Minimum-time (300 hours) (______ members x 0.2117) =
Total MSY
* Grantees receive the total amount for 2-Year Half-time members in the first year. Therefore, 2-Year Half-time
members serving in their second year are not included in the calculation for funds.
Under ―Calculation,‖ you will enter the calculation for your grant request. Applicants may
request up to $800 per member service year (MSY).
Display your calculation in the following format:

Total # of MSYs ________ x MSY amount (up to $800)_______ = Total Grant Request $____
Type the total amount requested in the ―Total Amount‖ & ―CNCS Share‖ columns. Leave the
―Grantee Share‖ blank. See example below:
Purpose Calculation Total CNCS Grantee edit del

Amount Share Share
Program Grant 47.5 MSY $19,000 $19,000 $0
Request
X $800/MSY view
Subtotal $19,000 $19,000 $0
49
Budget Worksheet for Fixed Amount Grants PA Attachment 6C (Fixed)
If you are applying for a Fixed Amount grant, complete only the full-time fields in this
Table.
Education Award Program applicants may complete other than full-time fields.
Item # Allowance # w/o Total CNCS Grantee edit del

Mbrs Rate Allow Amount Share Share
Full Time (1700 hrs)
1-Year Half Time (900

hrs)
st
2-Year
2-Year Half
Half Time
Time (1
(1st
Year)
Year)
nd
2-Year
2-Year Half
Half Time
Time (2
(2nd
Year)
Year)
Reduced
Reduced Half
Half Time
Time
(675
(675 hrs)
hrs)
Quarter
Quarter Time
Time (450
(450 hrs)
hrs)
Minimum
Minimum Time
Time (300
(300 hrs)
hrs)
Subtotal
Subtotal MSY
MSY Cost/MSY
Cost/MSY
$
Member Positions
Purpose Calculation Total CNCS Share Grantee
Amount Share
Program Grant
Request
Subtotal
50
APPENDIX H
Survey Instructions on Ensuring Equal Opportunity for Applicant
The Corporation and other federal agencies are collaborating with the White House Office of
Faith-Based and Community Initiatives to conduct a survey of organizations that apply for
federal funding. The purpose of this voluntary information collection is to compile statistics on
the types of organizations that apply to the Corporation for funds, such as number of employees,
budget size, and self-identification as a faith-based/religious organization or a non-religious
community-based organization.
This form is for applicants that are nonprofit private organizations, not including private
universities. All information from the attached survey will be confidential and the responses
will be aggregated for a summary report. Information provided on your form will not be released
and will not be considered in any way in making funding decisions
On the survey form, provide the applicant’s (organization) name and DUNS number
and the grant name and CFDA number.
2. Self-identify.
3. Self-identify.
4. 501(c)(3) status is a legal designation provided on application to the Internal Revenue Service
by eligible organizations. Some grant programs may require nonprofit applicants to have
501(c)(3) status. Other grant programs do not.
6. For example, two part-time employees who each work half-time equal one full-time
equivalent employee. If the applicant is a local affiliate of a national organization, the
responses to survey questions 2 and 3 should reflect the staff and budget size of the local
affiliate.
7. Annual budget means the amount of money your organization spends each year on all of its
activities.
51
APPENDIX H PA Attachment 7
SURVEY ON ENSURING
EQUAL OPPORTUNITY FOR APPLICANTS
O
Purpose: The Federal government is committed to ensuring that all qualified applicants, small or large, non-religious or faith-based, have an equal
MB
opportunity to compete for Federal funding. In order for us to better understand the population of applicants for Federal funds, we are asking
nonprofit private organizations (not including private universities) to fill out this survey.
NO.
Upon receipt, the survey will be separated from the application. Information provided on the survey will not be considered in any way in making
189
funding decisions and will not be included in the Federal grants database. While your help in this data collection process is greatly appreciated,
completion of this survey is voluntary.
0-
Instructions for Submitting the Survey: If you are applying using a hard copy application, please place the completed survey in an envelope labeled
―Applicant Survey.‖ Seal the envelope and include it along with your application package. If you are applying electronically, please submit this
survey along with your application.
001
4
Applicant’s (Organization) Name:
EXP
___________________________________________________________________
Applicant’s DUNS Number:
.
___________________________________________________________________
1/13
Federal Program: ___________________________ CFDA Number:_____________ 1/20
06
1. Has the applicant ever received a grant or 4-5 51-100
contract from the Federal government?
6-14 over 100
Yes No
7. What is the size of the applicant’s annual budget?
2. Is the applicant a faith-based organization? (Check only one box.)
Yes No  Less Than $150,000
3. Is the applicant secular organization?  $150,000 - $299,999
Yes No  $300,000 - $499,999

4. Does the applicant have 501(c)(3) status?  $500,000 - $999,999
Yes No
 $1,000,000 - $4,999,999
5. Is the applicant a local affiliate of a national
$5,000,000 or more
organization?
Yes No
6. How many full-time equivalent employees does

the applicant have? (Check only one box).
3 or Fewer 15-50
52
APPENDIX I
INSTRUCTION FOR CERTIFICATIONS AND ASSURANCES
NOTE: Read all Certifications and Assurances and sign form in both places and
return, along with PA Attachment 8, 8A and 8B.
By signing and submitting this application, as the duly authorized representative of

the applicant, you certify that the applicant will comply with the Certifications and
Assurances described below in the following manner:
a) Inability to certify: Your inability to provide the certifications or assurances listed

below will not necessarily result in denial of a grant. You must submit an
explanation of why you cannot do so. We will consider your explanation in
determining whether to enter into this transaction. However, your failure to
furnish an explanation will disqualify your application.
b) Erroneous certification or assurance: The certifications and assurances are

material representations of fact upon which we rely in determining whether to
enter into this transaction. If we later determine that you knowingly submitted an
erroneous certification or assurance, in addition to other remedies available to
the federal and state government, we may terminate this transaction for cause or
default.
c) Notice of error in certification or assurance: You must provide immediate written

notice to us if at any time you learn that a certification or assurance was
erroneous when submitted or has become erroneous because of changed
circumstances.
d) Definitions: The terms “covered transaction”, “debarred”, “suspended”,

“ineligible”, “lower tier covered transaction”, “participant”, “person”, “primary
covered transaction”, “principal”, “proposal”, and “voluntarily excluded” as used in
the certification, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Federal Executive Order 12549, (34 CFR
Section 85.510). An applicant shall be considered a “prospective primary
participant in a covered transaction” as defined in the rules implementing
Executive Order 12549. You may contact us for assistance in obtaining a copy
of those regulations.
53
CERTIFICATIONS AND ASSURANCES
Certification – Debarment, Suspension, and Other Responsibility Matters

This certification is required by the regulations implementing Executive Order 12549,
Debarment and Suspension, 34 CFR Part 85, Section 85.510, Participants’
responsibilities.
A. As the duly authorized representative of the applicant, I certify, to the best of my

knowledge and belief, that neither the applicant nor its principals:
• Is presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any federal department or
agency.
• Has, within a three-year period preceding this application, been convicted of, or
had an adverse civil judgment entered in connection with, fraud or other criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(federal, state or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property.
• Is presently indicted for or otherwise criminally or civilly charged by a
governmental entity (federal, state or local) with commission of any of the
offenses enumerated in paragraph (1) (b) of this certification, and
• Has not, within a three-year period preceding this application, had one or more
public transactions (federal, state or local) terminated for cause or default;
B. If you are unable to certify to any of the statements in this certification, you must
attach an explanation to this application.
Certification – Drug-Free Workplace

This certification is required by the regulations implementing the Drug-Free Workplace
Act of 1988, 34 CFR Part 85, Subpart F. The regulations require certification by
grantees, prior to award, that they will maintain a drug-free workplace. The certification
set out below is a material representation of fact upon which reliance will be placed
when the agency determines to award the grant. False certification or violation of the
certification may be grounds for suspension of payments, suspension or termination of
grants, or government-wide suspension or debarment (see 34 CFR Part 85, Section
85.615 and 85.620).
As the duly authorized representative of the grantee, I certify, to the best of my
knowledge and belief, that the grantee will provide a drug-free workplace by:
A. Publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession or use of a controlled substance is prohibited
in the grantee’s workplace and specifying the actions that will be taken against
employees for violation of such prohibition;
54
B. Establishing a drug-free awareness program to inform employees about—
• the dangers of drug abuse in the workplace,
• the grantee’s policy of maintaining a drug-free workplace.
• any available drug counseling, rehabilitation, and employee assistance
programs, and
• the penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
C. Making it a requirement that each employee to be engaged in the performance of

the grant be given a copy of the statement required by paragraph (A);
D. Notifying the employee in the statement required by paragraph (A) that, as a

condition of employment under the grant, the employee will:
• abide by the terms of the statement, and
• notify the employer of any criminal drug statute conviction for a violation
occurring in the workplace no later than five days after such conviction.
E. Notifying us within ten days after receiving notice under subparagraph (D) from an
employee or otherwise receiving actual notice of such conviction;
F. Taking one of the following actions, within 30 days of receiving notice under
subparagraph (D), with respect to any employee who is so convicted—
• Taking appropriate personnel action against such an employee, up to and
including termination; or
• Requiring such employee to participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a federal,
state, or local health, law enforcement, or other appropriate agency;
G. Making a good faith effort to continue to maintain a drug-free workplace through

implementation of paragraphs (A) through (F).
Certification – Lobbying Activities

As required by Section 1352, Title 31 of the U.S. Code, as the duly authorized
representative of the applicant, I certify, to the best of my knowledge and belief, that:
No federal appropriated funds have been paid or will be paid, by or on behalf
of the applicant, to any person for influencing or attempting to influence an
officer or employee of any agency, a member of Congress, an officer of
Congress in connection with the awarding of any federal contract, the making
of any federal loan, the entering into of any cooperative agreement, or
modification of any federal contract, grant, loan, or cooperative agreement;
55
If any funds other than federal 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 applicant will
submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in
accordance with its instructions;
The applicant will require that the language of this certification be included in
the award documents for all subcontracts at all tiers (including subcontracts,
sub-grants, and contracts under grants, loans and cooperative agreements)
and that all sub-recipients will certify and disclose accordingly.
ASSURANCES
As the duly authorized representative of the applicant, I certify, to the best of my

knowledge and belief, that the applicant:
Has the legal authority to apply for federal assistance, and the institutional,
managerial, and financial capability (including funds sufficient to pay the non-
federal share of project costs) to ensure proper planning, management, and
completion of the project described in this application.
Will give the awarding agency, the Comptroller General of the United States,
and if appropriate, the state, through any authorized representative, access to
and the right to examine all records, books, papers, or documents related to
the award; and will establish a proper accounting system in accordance with
generally accepted accounting standards or agency directives.
Will establish safeguards to prohibit employees from using their position for a
purpose that constitutes or presents the appearance of personal or
organizational conflict of interest, or personal gain.
Will initiate and complete the work within the applicable time frame after
receipt of approval of the awarding agency.
Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C.
4728-4763) relating to prescribed standards for merit systems for programs
funded under one of the nineteen statutes or regulations specified in
Appendix A of OPM’s Standards for a Merit System of Personnel
Administration (5 CFR 900, Subpart F).
Will comply with all federal statutes relating to nondiscrimination. These
include but are not limited to: Title VI of the Civil Rights Act of 1964 (P.L. 88-
352) which prohibits discrimination on the basis of race, color, or national
origin; (b) Title IX of the Education Amendments of 1972, as amended (20
U.S.C. 1681-1683, and 1685-1686). which prohibits discrimination on the
basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended
(29 U.S.C. 794), which prohibits discrimination on the basis of disability (d)
56
The Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107),
which prohibits discrimination on the basis of age; (e) The Drug Abuse Office
and Treatment Act of 1972 (P.L. 92-255), as amended, relating to
nondiscrimination on the basis of drug abuse; (f) The Comprehensive Alcohol
Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970
(P.L. 91-616), as amended, relating to nondiscrimination on the basis of
alcohol abuse or alcoholism; (g) sections 523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. 290dd-3 and 290ee-3), as amended, relating
to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the
Civil Rights Act of 1968 (42 U.S.C. 3601 et seq.), as amended, relating to
nondiscrimination in the sale, rental or financing of housing; (i) any other
nondiscrimination provisions in the National and Community Service Act of
1990, as amended; and (j) the requirements of any other nondiscrimination
statute(s) which may apply to the application.
Will comply, or has already complied, with the requirements of Titles II and III
of the Uniform Relocation Assistance and Real Property Acquisition Policies
Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of
persons displaced or whose property is acquired as a result of federal or
federally assisted programs. These requirements apply to all interests in real
property acquired for project purposes regardless of federal participation in
purchases.
Will comply with the provisions of the Hatch Act (5 U.S.C. 1501-1508 and
7324-7328) which limit the political activities of employees whose principal
employment activities are funded in whole or in part with Federal funds.
Will comply, as applicable, with the provisions of the Davis-Bacon Act (40
U.S.C 276a and 276a-77), the Copeland Act (40 U.S.C 276c and 18 U.S.C.
874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. 327-
333), regarding labor standards for Federally assisted construction sub-
agreements.
Will comply, if applicable, with flood insurance purchase requirements of
Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234)
which requires the recipients in a special flood hazard area to participate in
the program and to purchase flood insurance if the total cost of insurable
construction and acquisition is $10,000 or more.
Will comply with environmental standards which may be prescribed pursuant
to the following: (a) institution of environmental quality control measures
under the National Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating facilities pursuant to
EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of
flood hazards in floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved state management program developed
under the Coastal Zone Management Act of 1972 (16 U.S.C 1451 et seq.); (f)
conformity of federal actions to State (Clean Air) Implementation Plans under
Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. 7401 et
57
seq.); (g) protection of underground sources of drinking water under the Safe
Drinking Water Act of 1974, as amended (P.L. 93-523); and (h) protection of
endangered species under the Endangered Species Act of 1973, as amended
(P.L. 93-205).
Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C 1271 et
seq.) related to protecting components or potential components of the
national wild and scenic rivers system.
Will assist the awarding agency in assuring compliance with Section 106 of
the National Historic Preservation Act of 1966, as amended (16 U.S.C. 470),
EO 11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (16U.S.C. 469a-l et
seq.).
Will comply with P.L. 93-348 regarding the protection of human subjects
involved in research, development, and related activities supported by this
award of assistance.
Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as
amended, 7 U.S.C. 2131 et seq.) pertaining to the care, handling, and
treatment of warm blooded animals held for research, teaching, or other
activities supported by this award of assistance.
Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C.
§§ 4801 et seq.) which prohibits the use of lead based paint in construction or
rehabilitation of residence structures.
Will cause to be performed the required financial and compliance audits in
accordance with the Single Audit Act of 1984, as amended, and OMB Circular
A-133, Audits of States, Local Governments, and Non-Profit Organizations
(See Audit Clause attached as Attachment 8A).
Will comply with all applicable requirements of all other Federal laws,
executive orders, regulations, application guidelines, and policies governing
this program.
Understands Additional Conditions- See Attachment 8B.
58
Certification and Assurances Signature Page PA Attachment 8
CERTIFICATION SIGNATURE NOTE: Sign this form and include in the

application.
Before you start: Before completing
certification, please read the Certification
Instructions.
SIGNATURE: By signing this Certification page, you certify

that you agree to perform all actions and support
all intentions in the Certification sections of this
application. The three Certifications are:
 Certification: Debarment, Suspension and
Other Responsibility Matters
 Certification: Drug-Free Workplace
 Certification: Lobbying Activities
Legal Applicant:
Project Name:
Name and Title of Authorized Representative:
Signature:
Date:
ASSURANCE SIGNATURE NOTE: Sign this form and include in the
application.
SIGNATURE: By signing this assurances page, you certify that

you agree to perform all actions and support all
intentions in the Assurances section.
Organization Name:
Project Name:
Name and Title of Authorized Representative:
Signature:
Date:
59
AUDIT CLAUSE TO BE USED IN AGREEMENTS WITH ENTITIES RECEIVING FEDERAL AWARDS
FROM THE COMMONWEALTH AUDIT REQUIREMENT PA Attachment 8A
The Subgrantee must comply with all federal and state audit requirements including: the Single Audit
Act, as amended, 31 U.S.C. 7501 et. Seq.; Office of Management and Budget (OMB) Circular A-133,
Audits of States, Local Governments, and Non-Profit Organizations, as amended; and any other
applicable law or regulation and any amendment to such other applicable law or regulation which may be
enacted or promulgated by the federal government. If the Subgrantee is a local government or non-profit
organization and expends total federal awards of $500,000 or more during its fiscal year, received either
directly from the federal government or indirectly from a recipient of federal funds, the Subgrantee is
required to have an audit made in accordance with the provisions of OMB Circular A-133.
If the Subgrantee is a for-profit organization and expends total federal awards of $500,000 or more
during its fiscal year, received either directly from the federal government or indirectly from a recipient
of federal funds, the Subgrantee is required to have a program-specific audit made in accordance with the
provisions of OMB Circular A-133, and in accordance with the laws and regulations governing the
programs in which it participates.
If the Subgrantee expends total federal awards of less than $500,000 during its fiscal year, it is exempt
from these audit requirements, but is required to maintain auditable records of federal awards and any
state funds which supplement such awards, and to provide access to such records by federal and state
agencies or their designees.
SUBMISSION OF AUDIT INFORMATION TO THE COMMONWEALTH
The Subgrantee shall submit copies of the audit report package to the Commonwealth, which shall
include:
1. Data Collection Form.
2. Financial statements and schedule of expenditures of federal awards.
3. Auditor’s reports on the financial statements and schedule of expenditures of federal awards,
internal control and compliance as well as a schedule of findings and questioned costs.
4. Summary of schedule of prior audit findings.
5. Corrective action plan.
6. Management letter comments.
In instances where federal program-specific audit guide is available, the audit report package for a
program- specific audit may be different and should be prepared in accordance with the audit guide and
OMB Circular A-133.
The number of copies to be submitted shall equal one for the Bureau of Audits (archival copy) plus one
for each Commonwealth agency which provided federal pass-through awards to the entity, as reflected in
the entity’s Schedule of Expenditures of Federal Awards. The audit report package should be submitted
to the:
Office of the Budget/Bureau of Audits
Division of Sub-recipient Audit Review
Bell Tower - Sixth Floor
303 Walnut Street
Phone: 717-783-9120
Fax: 717-783-0361
NOTE: If you are a new or recompleting applicant, you must provide your most recent A-133 audit, your
organization’s financial audit, or your financial statements if you have not had a formal audit. This
PennSERVE request is in addition to the requirement for submission of audit information to the
Commonwealth Office of Budgets/Bureau of Audits. Please attach a copy of the 424 Application Facesheet
and submit to PennSERVE with your Application.
60
ADDITIONAL CONDITIONS PA ATTACHMENT 8B
1. The applicant understands and agrees that the Department may exercise such rights and
responsibilities and seek the same remedies as allowed to the Federal Government and the
Corporation by the federal laws, regulations and program guidelines and handbooks as Department
deems necessary and appropriate for the proper administration of the AmeriCorps State program.
2. The applicant understands that in addition to the expenditures provided for in the Budget, the
Department may reimburse the applicant for costs incurred for attendance by employees of the
applicant at training or conferences, when so directed by the Department. In such cases, the
Department will provide a written authorization naming the affected employees of the applicant and
listing the category and amounts of expenditure authorized.
3. The applicant understands that the Department may unilaterally extend this agreement, upon receipt
of the applicant’s Request for No Cost Extension, in order to allow enrolled members to complete
their term of service. Such an extension will be evidenced by a ―Letter of Modification‖ issued by the
Department and will become part of this agreement.
4. The applicant understands that the Department may unilaterally revise the budget, upon applicant’s
Request for a Budget Revision. Such a revision, which does not include an increase in the maximum
amount of this agreement, will be evidenced by a ―Letter of Modification‖ issued by the Department
and will become part of this agreement.
5. TERMINATION PROVISIONS
The Commonwealth has the right to terminate this contract of any Purchase Order for any of the
following reasons. Termination shall be effective upon written notice to the Contractor.
a. TERMINATION FOR CONVENIENCE: The Commonwealth shall have the right to
terminate the Contract or a Purchase Order for its convenience if the Commonwealth
determines termination to be in its best interest. The Contractor shall be paid for work
satisfactorily completed prior to the effective date of the termination, but in no event shall the
Contractor be entitled to recover loss of profits.
b. NON-APPROPRIATION: The Commonwealth’s obligation to make payments during any
Commonwealth fiscal year succeeding the current fiscal year shall be subject to availability
and appropriation of funds. When funds(state and/or federal) are not appropriated or
otherwise made available to support continuation of performance in a subsequent fiscal year
period, the Commonwealth shall have the right to terminate the Contract or a Purchase Order.
The Contractor shall be reimbursed for the reasonable value of any nonrecurring costs
incurred but not amortized in the price of the supplies or services delivered under the
Contract. Such reimbursement shall not include loss of profit, loss of use of money, or
administrative or overhead costs. The reimbursement amount may be paid for any
appropriations available for that purpose.
c. TERMINATION FOR CAUSE: The Commonwealth shall have the right to terminate the
Contract or a Purchase Order for Contractor default under Paragraph 17, Default, upon
written notice to the Contractor. The Commonwealth shall also have the right, upon written
notice to the Contractor, to terminate the Contract or a Purchase Order for other cause as
61
specified in the Contract or by law. If it is later determined that the Commonwealth erred in
terminating the Contract or a Purchase Order for cause, then, at the Commonwealth’s
discretion, the Contract or Purchase Order shall be deemed to have been terminated for
convenience under the Subparagraph 19.a.
6. CONTRACTOR RESPONSIBILITY PROVISIONS

a. The Contractor certifies, for itself and all its subcontractors, that as of the date of its
execution of this Bid/Contract, that neither the Contractor, nor any subcontractors, nor any
suppliers are under suspension or debarment by the Commonwealth or any governmental
entity, instrumentality, or authority and, if the Contractor cannot so certify, then it agrees to
submit, along with its Bid, a written explanation of why such certification cannot be made.
b. The Contractor also certifies, that as of the date of its execution of this Bid/Contract, it has no
tax liabilities or other Commonwealth obligations.
c. The Contractor’s obligations pursuant to these provisions are ongoing from and after the
effective date of the contract through the termination date thereof. Accordingly, the
Contractor shall have an obligation to inform the Commonwealth if, at any time during the
term of the Contract, it becomes delinquent in the payment of taxes, or other Commonwealth
obligations, or if it or any of its subcontractors are suspended or debarred by the
Commonwealth, the federal government, or any other state or governmental entity. Such
notification shall be made within 15 days of the date of suspension or debarment.
d. The failure of the Contractor to notify the Commonwealth of its suspension or debarment by
the Commonwealth, any other state, or the federal government shall constitute an event of
default of the Contract with the Commonwealth.
e. The Contractor agrees to reimburse the Commonwealth for the reasonable costs of
investigation incurred by the Office of State Inspector General for investigations of the
Contractor’s compliance with the terms of this or any other agreement between the
Contractor and the Commonwealth, which results in the suspension or debarment of the
Contractor. Such costs shall include, but shall not be limited to, salaries of investigators,
including overtime; travel and lodging expenses; and expert witness and documentary fees.
The Contractor shall not be responsible for investigative costs for investigations that do not
result in the Contractor’s suspension or debarment.
f. The Contractor may obtain a current list of suspended and debarred Commonwealth
contractors by either searching the internet at http://www.dgs.state.pa.us/or contacting the:
Department of General Services

Office of Chief Counsel
603 North Office Building
Telephone No. (717) 783-6472
FAX No. (717) 787-9138
7. AMERICANS WITH DISABILITIES ACT

a. Pursuant to federal regulations promulgated under the authority of The Americans With
Disabilities Act, 28 C.F.R. § 35.101 et seq., the Contractor understands and agrees that it
shall not cause any individual with a disability to be excluded from participation in this
Contract or from activities provided for under this Contract on the basis of the disability. As a
62
condition of accepting this contract, the Contractor agrees to comply with the ―General
Prohibitions Against Discrimination,‖ 28 C.F.R. § 35.130, and all other regulations
promulgated under Title II of The Americans With Disabilities Act which are applicable to
all benefits, services, programs, and activities provided by the Commonwealth of
Pennsylvania through contracts with outside contractors.
b. The Contractor shall be responsible for and agrees to indemnify and hold harmless the
Commonwealth of Pennsylvania from all losses, damages, expenses, claims, demands, suits,
and actions brought by any party against the Commonwealth of Pennsylvania as a result of
the Contractor’s failure to comply with the provisions of subparagraph a above.
8. SET OFF
The Contractor agrees that the Commonwealth may set off the amount of any state tax liability or
other obligation of the Contractor or its subsidiaries to the Commonwealth against any payments due
the Contractor under any contract with the Commonwealth.
9. AUTOMATED CLEARING HOUSE (ACH)

The Commonwealth will make contract payments through Automated Clearing House (ACH).
a. Within 10 days of award of the contract or purchase order, the contractor must submit or must
have already submitted their ACH information within their user profile in the
Commonwealth’s procurement system (SRM).
b. The contractor must submit a unique invoice number with each invoice submitted. The
unique invoice number will be listed on the Commonwealth of Pennsylvania’s ACH
remittance advice to enable the contractor to properly apply the state agency’s payment to the
invoice submitted.
c. It is the responsibility of the contractor to ensure that the ACH information contained in SRM
is accurate and complete. Failure to maintain accurate and complete information may result
in delays in payments.
10. GRANT PROVISIONS – RIGHT TO KNOW LAW 8-K-1580

a. Grantee or Subgrantee understands that this Grant Agreement and records related to or arising
out of the Grant Agreement are subject to requests made pursuant to the Pennsylvania Right-
to-Know Law, 65 P.S. §§ 67.101-3104, (―RTKL‖). For the purpose of these provisions, the
term ―the Commonwealth‖ shall refer to the granting Commonwealth agency.
b. If the Commonwealth needs the Grantee’s or Subgrantee’s assistance in any matter arising
out of the RTKL related to this Grant Agreement, it shall notify the Grantee or Subgrantee
using the legal contact information provided in the Grant Agreement. The Grantee or
Subgrantee, at any time, may designate a different contact for such purpose upon reasonable
prior written notice to the Commonwealth.
c. Upon written notification from the Commonwealth that it requires Grantee’s or Subgrantee’s
assistance in responding to a request under the RTKL for information related to this Grant
Agreement that may be in Grantee’s or Subgrantee’s possession, constituting, or alleged to
constitute, a public record in accordance with the RTKL (―Requested Information‖), Grantee
or Subgrantee shall:
63
1) Provide the Commonwealth, within ten (10) calendar days after receipt of written
notification, access to, and copies of, any document or information in Grantee’s or
Subgrantee’s possession arising out of this Grant Agreement that the
Commonwealth reasonably believes is Requested Information and may be a public
record under the RTKL; and
2) Provide such other assistance as the Commonwealth may reasonably request, in
order to comply with the RTKL with respect to this Grant Agreement.
d. If Grantee or Subgrantee considers the Requested Information to include a request for a Trade
Secret or Confidential Proprietary Information, as those terms are defined by the RTKL, or
other information that Grantee or Subgrantee considers exempt from production under the
RTKL, Grantee or Subgrantee must notify the Commonwealth and provide, within seven (7)
calendar days of receiving the written notification, a written statement signed by a
representative of Grantee or Subgrantee explaining why the requested material is exempt
from public disclosure under the RTKL.
e. The Commonwealth will rely upon the written statement from Grantee or Subgrantee in
denying a RTKL request for the Requested Information unless the Commonwealth
determines that the Requested Information is clearly not protected from disclosure under the
RTKL. Should the Commonwealth determine that the Requested Information is clearly not
exempt from disclosure, Grantee or Subgrantee shall provide the Requested Information
within five (5) business days of receipt of written notification of the Commonwealth’s
determination.
f. If Grantee or Subgrantee fails to provide the Requested Information within the time period
required by these provisions, Grantee or Subgrantee shall indemnify and hold the
Commonwealth harmless for any damages, penalties, costs, detriment or harm that the
Commonwealth may incur as a result of Grantee’s or Subgrantee’s failure, including any
statutory damages assessed against the Commonwealth.
g. The Commonwealth will reimburse Grantee or Subgrantee for any costs associated with
complying with these provisions only to the extent allowed under the fee schedule established
by the office of Open Records or as otherwise provided by the RTKL if the fee schedule is
inapplicable.
h. Grantee or Subgrantee may file a legal challenge to any Commonwealth decision to release a
record to the public with the Office of Open Records, or in the Pennsylvania Courts,
however, Grantee or Subgrantee shall indemnify the Commonwealth for any legal expenses
incurred by the Commonwealth as a result of such a challenge and shall hold the
Commonwealth harmless for any damages, penalties, costs, detriment or harm that the
Commonwealth may incur as a result of Grantee’s or Subgrantee’s failure, including any
statutory damages assessed against the Commonwealth, regardless of the outcome of such
legal challenge. As between the parties, Grantee or Subgrantee agrees to waive all rights or
remedies that may be available to it as a result of the Commonwealth’s disclosure of
Requested Information pursuant to the RTKL.
i. The Grantee’s or Subgrantee’s duties relating to the RTKL are continuing duties that survive
the expiration of this Grant Agreement and shall continue as long as the Grantee or
Subgrantee has Requested Information in its possession.
64
11. LABOR UNION CONCURRENCE
If you have employees represented by a local labor organization who are engaged in the same or
substantially similar work as that which will be carried out by AmeriCorps members, the applicant
must submit the written concurrence of the local labor organization with its application. This
requirement applies to any applicant for assistance or approved national service positions to the
Corporation, to a state commission, or to a Corporation grantee or subgrantee.
CONTRACTOR INTEGRITY PROVISIONS
It is essential that those who seek to contract with the Commonwealth of Pennsylvania
(―Commonwealth‖) observe high standards of honesty and integrity. They must conduct themselves in a
manner that fosters public confidence in the integrity of the Commonwealth procurement process.
In furtherance of this policy, Contractor agrees to the following:
1. Contractor shall maintain the highest standards of honesty and integrity during the performance
of this contract and shall take no action in violation of state or federal laws or regulations or any
other applicable laws or regulations, or other requirements applicable to Contractor or that govern
contracting with the Commonwealth.
2. Contractor shall establish and implement a written businesvs integrity policy, which includes, at a
minimum, the requirements of these provisions as they relate to Contractor employee activity
with the Commonwealth and Commonwealth employees, and which is distributed and made
known to all Contractor employees.
3. Contractor, its affiliates, agents and employees shall not influence, or attempt to influence, any
Commonwealth employee to breach the standards of ethical conduct for Commonwealth
employees set forth in the Public Official and Employees Ethics Act, 65 Pa.C.S. §§1101 et seq.;
the State Adverse Interest Act, 71 P.S. §776.1 et seq.; and the Governor’s Code of Conduct,
Executive Order 1980-18, 4 Pa. Code §7.151 et seq., or to breach any other state or federal law or
regulation.
4. Contractor, its affiliates, agents and employees shall not offer, give, or agree or promise to give
any gratuity to a Commonwealth official or employee or to any other person at the direction or
request of any Commonwealth official or employee.
5. Contractor, its affiliates, agents and employees shall not offer, give, or agree or promise to give
any gratuity to a Commonwealth official or employee or to any other person, the acceptance of
which would violate the Governor’s Code of Conduct, Executive Order 1980-18, 4 Pa. Code
§7.151 et seq. or any statute, regulation, statement of policy, management directive or any other
published standard of the Commonwealth.
6. Contractor, its affiliates, agents and employees shall not, directly or indirectly, offer, confer, or
agree to confer any pecuniary benefit on anyone as consideration for the decision, opinion,
recommendation, vote, other exercise of discretion, or violation of a known legal duty by any
Commonwealth official or employee.
7. Contractor, its affiliates, agents, employees, or anyone in privity with him or her shall not accept
or agree to accept from any person, any gratuity in connection with the performance of work
under the contract, except as provided in the contract.
65
8. Contractor shall not have a financial interest in any other contractor, subcontractor, or supplier
providing services, labor, or material on this project, unless the financial interest is disclosed to
the Commonwealth in writing and the Commonwealth consents to Contractor’s financial interest
prior to Commonwealth execution of the contract. Contractor shall disclose the financial interest
to the Commonwealth at the time of bid or proposal submission, or if no bids or proposals are
solicited, no later than Contractor’s submission of the contract signed by Contractor.
9. Contractor, its affiliates, agents and employees shall not disclose to others any information,
documents, reports, data, or records provided to, or prepared by, Contractor under this contract
without the prior written approval of the Commonwealth, except as required by the Pennsylvania
Right-to-Know Law, 65 P.S. §§ 67.101-3104, or other applicable law or as otherwise provided in
this contract. Any information, documents, reports, data, or records secured by Contractor from
the Commonwealth or a third party in connection with the performance of this contract shall be
kept confidential unless disclosure of such information is:
a. Approved in writing by the Commonwealth prior to its disclosure; or

b. Directed by a court or other tribunal of competent jurisdiction unless the contract requires
prior Commonwealth approval; or
c. Required for compliance with federal or state securities laws or the requirements of
national securities exchanges; or
d. Necessary for purposes of Contractor’s internal assessment and review; or
e. Deemed necessary by Contractor in any action to enforce the provisions of this contract
or to defend or prosecute claims by or against parties other than the Commonwealth; or
f. Permitted by the valid authorization of a third party to whom the information, documents,
reports, data, or records pertain: or
g. Otherwise required by law.
10. Contractor certifies that neither it nor any of its officers, directors, associates, partners, limited
partners or individual owners has not been officially notified of, charged with, or convicted of
any of the following and agrees to immediately notify the Commonwealth agency contracting
officer in writing if and when it or any officer, director, associate, partner, limited partner or
individual owner has been officially notified of, charged with, convicted of, or officially notified
of a governmental determination of any of the following:
a. Commission of embezzlement, theft, forgery, bribery, falsification or destruction of
records, making false statements or receiving stolen property.
b. Commission of fraud or a criminal offense or other improper conduct or knowledge of,
approval of or acquiescence in such activities by Contractor or any affiliate, officer,
director, associate, partner, limited partner, individual owner, or employee or other
individual or entity associated with:
(1) obtaining;
(2) attempting to obtain; or
(3) performing a public contract or subcontract.
Contractor’s acceptance of the benefits derived from the conduct shall be deemed
evidence of such knowledge, approval or acquiescence.
c. Violation of federal or state antitrust statutes.
d. Violation of any federal or state law regulating campaign contributions.
e. Violation of any federal or state environmental law.
f. Violation of any federal or state law regulating hours of labor, minimum wage standards
or prevailing wage standards; discrimination in wages; or child labor violations.
66
g. Violation of the Act of June 2, 1915 (P.L.736, No. 338), known as the Workers’
Compensation Act, 77 P.S. 1 et seq.
h. Violation of any federal or state law prohibiting discrimination in employment.
i. Debarment by any agency or department of the federal government or by any other state.
j. Any other crime involving moral turpitude or business honesty or integrity.
Contractor acknowledges that the Commonwealth may, in its sole discretion, terminate the
contract for cause upon such notification or when the Commonwealth otherwise learns that
Contractor has been officially notified, charged, or convicted.
11. If this contract was awarded to Contractor on a non-bid basis, Contractor must, (as required by
Section 1641 of the Pennsylvania Election Code) file a report of political contributions with the
Secretary of the Commonwealth on or before February 15 of the next calendar year. The report
must include an itemized list of all political contributions known to Contractor by virtue of the
knowledge possessed by every officer, director, associate, partner, limited partner, or individual
owner that has been made by:
a. Any officer, director, associate, partner, limited partner, individual owner or members of
the immediate family when the contributions exceed an aggregate of one thousand dollars
($1,000) by any individual during the preceding year; or
b. Any employee or members of his immediate family whose political contribution
exceeded one thousand dollars ($1,000) during the preceding year.
To obtain a copy of the reporting form, Contractor shall contact the Bureau of Commissions,
Elections and Legislation, Division of Campaign Finance and Lobbying Disclosure, Room 210,
North Office Building, Harrisburg, PA 17120.
12. Contractor shall comply with requirements of the Lobbying Disclosure Act, 65 Pa.C.S. § 13A01 et
seq., and the regulations promulgated pursuant to that law. Contractor employee activities prior to
or outside of formal Commonwealth procurement communication protocol are considered
lobbying and subjects the Contractor employees to the registration and reporting requirements of
the law. Actions by outside lobbyists on Contractor’s behalf, no matter the procurement stage, are
not exempt and must be reported.
13. When Contractor has reason to believe that any breach of ethical standards as set forth in law, the
Governor’s Code of Conduct, or in these provisions has occurred or may occur, including but not
limited to contact by a Commonwealth officer or employee which, if acted upon, would violate
such ethical standards, Contractor shall immediately notify the Commonwealth contracting
officer or Commonwealth Inspector General in writing.
14. Contractor, by submission of its bid or proposal and/or execution of this contract and by the
submission of any bills, invoices or requests for payment pursuant to the contract, certifies and
represents that it has not violated any of these contractor integrity provisions in connection with
the submission of the bid or proposal, during any contract negotiations or during the term of the
contract.
15. Contractor shall cooperate with the Office of Inspector General in its investigation of any alleged
Commonwealth employee breach of ethical standards and any alleged Contractor non-compliance
with these provisions. Contractor agrees to make identified Contractor employees available for
interviews at reasonable times and places. Contractor, upon the inquiry or request of the Office of
Inspector General, shall provide, or if appropriate, make promptly available for inspection or
copying, any information of any type or form deemed relevant by the Inspector General to
Contractor's integrity and compliance with these provisions. Such information may include, but
shall not be limited to, Contractor's business or financial records, documents or files of any type
or form that refers to or concern this contract.
67
16. For violation of any of these Contractor Integrity Provisions, the Commonwealth may terminate
this and any other contract with Contractor, claim liquidated damages in an amount equal to the
value of anything received in breach of these provisions, claim damages for all additional costs
and expenses incurred in obtaining another contractor to complete performance under this
contract, and debar and suspend Contractor from doing business with the Commonwealth. These
rights and remedies are cumulative, and the use or non-use of any one shall not preclude the use
of all or any other. These rights and remedies are in addition to those the Commonwealth may
have under law, statute, regulation, or otherwise.
17. For purposes of these Contractor Integrity Provisions, the following terms shall have the
meanings found in this Paragraph 17.
a. ―Confidential information‖ means information that a) is not already in the public domain;
b) is not available to the public upon request; c) is not or does not become generally
known to Contractor from a third party without an obligation to maintain its
confidentiality; d) has not become generally known to the public through a act or
omission of Contractor; or e) has not been independently developed by Contractor
without the use of confidential information of the Commonwealth.
b. “Consent‖ means written permission signed by a duly authorized officer or employee of
the Commonwealth, provided that where the material facts have been disclosed, in
writing, by pre-qualification, bid, proposal, or contractual terms, the Commonwealth
shall be deemed to have consented by virtue of execution of this contract.
c. “Contractor‖ means the individual or entity that has entered into this contract with the
Commonwealth, including those directors, officers, partners, managers, and owners
having more than a five percent interest in Contractor.
d. ―Financial interest‖ means:
(1) Ownership of more than a five percent interest in any business; or
(2) Holding a position as an officer, director, trustee, partner, employee, or holding
any position of management.
e. ―Gratuity‖ means tendering, giving or providing anything of more than nominal monetary
value including, but not limited to, cash, travel, entertainment, gifts, meals, lodging,
loans, subscriptions, advances, deposits of money, services, employment, or contracts of
any kind. The exceptions set forth in the Governor’s Code of Conduct, Executive Order
1980-18, the 4 Pa. Code §7.153(b), shall apply.
f. ―Immediate family‖ means a spouse and any unemancipated child.
g. ―Non-bid basis‖ means a contract awarded or executed by the Commonwealth with
Contractor without seeking bids or proposals from any other potential bidder or offeror.
h. ―Political contribution‖ means any payment, gift, subscription, assessment, contract,
payment for services, dues, loan, forbearance, advance or deposit of money or any
valuable thing, to a candidate for public office or to a political committee, including but
not limited to a political action committee, made for the purpose of influencing any
election in the Commonwealth of Pennsylvania or for paying debts incurred by or for a
candidate or committee before or after any election.
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PA AmeriCorps RFA PDF

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PennSERVE:

The Governor’s Office of Citizen Service

2011-2012 PENNSYLVANIA AMERICORPS*STATE

The Honorable Edward G. Rendell

Special Requirements for AmeriCorps Programs in Pennsylvania

APPLICATION/AGREEMENT SUBMISSION REQUIREMENTS…………………………...……….6

OVERVIEW: SELECTION PROCESS AND CRITERIA ………………………………...…….…..…..8

APPENDIX A: INSTRUCTIONS FOR THE PA SUB- GRANTEE

APPENDIX B: INSTRUCTIONS FOR FACESHEET………...………………………………….…....12

APPENDIX C: PROGRAM MODEL & DESIGN/ISSUE AREAS (PA ATTACHMENT 2) …….....16

APPENDIX D: INSTRUCTIONS FOR NARRATIVE (PA ATTACHMENT 3)……….…..………...20

APPENDIX E: INSTRUCTIONS FOR PERFORMANCE MEASUREMENTS ……………….…….27

APPENDIX F: EVALUATION SUMMARY/PLAN/REPORT (PA ATTACHMENT 5) ….………..32

APPENDIX G: INSTRUCTIONS FOR BUDGET……………………………………….……………33

APPENDIX H: INSTRUCTIONS FOR VOLUNTARY SURVEY ON ENSURING EQUAL

APPENDIX I: CERTIFICATIONS & ASSURANCES INSTRUCTIONS……………….…………..53

Applicants are required to:

 Organize your application/agreement in the sequence outlined in these instructions.

 Number the narrative pages.

ALL APPLICATION/AGREEMENT PACKAGES MUST BE RECEIVED BY

TECHNICAL ASSISTANCE WORKSHOP

Location: PA Dept. of Labor & Industry, E-100 Conference Room

Date: Tuesday, Nov. 9, 2010

Time: 1p.m. – 4p.m.

Applicants must submit an Application/Agreement that consists of the following components in

I. PA AmeriCorps Sub-grantee Application/Agreement: Each AmeriCorps application

 Program Design (50%)

VI. Evaluation Summary or Plan: (Appendix F) Submission instructions are provided

The grant selection process includes the following steps:

Rationale and Approach – 10%

Organizational Capability 25% No sub-categories

2011 National Service Priority Areas

Each application for AmeriCorps*State program funding in Pennsylvania must include a

Subgrantee Applicant: _______________________________ Address: ____________________________

*_______________________________ ____________________ _________

K-12 Education Non-Profit Organizations

9. Filled in for your convenience.

11. Enter the project title.

b. If No, check the appropriate box.

Note: Falsification or concealment of a material fact, or submission of false, fictitious or fraudulent

4. a. DATE RECEIVED BY CNCS: 4.b. CNCS GRANT NUMBER:

APPLICATION FOR FEDERAL ASSISTANCE

13. PROPOSED PROJECT: START DATE: END DATE:

e. OTHER $ OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR

d. SIGNATURE OF AUTHORIZED REPRESENTATIVE: e. DATE SIGNED:

 Section II: Project Design (please check as many as apply).

SECTION III: APPLICATION LOCATION

 Section III: Geography (please check one)

Rural A program designed to meet the needs of rural communities.

SECTION V: Issue Areas and Service Categories

Community and Economic Development Regional/State/City Planning

Education Homeland Security

1. Program Design. (50%)

In meeting the criteria, please include your response to the following:

b. Solution: AmeriCorps Member Roles and Responsibilities

c. AmeriCorps Member Selection, Training, and Supervision

d. Outcome: Performance Measures

f. Partnerships and Collaboration

h. Multi-state Applicants Only

i. Multi-Site Programs Only

j. Tutoring Programs Only

k. Current Grantees Only

2. Organizational Capability (25%)

Subgrantee Applicant: ___ Address:

*___________________ _

Yes No Justification/explanation of equipment items is included in the budget narrative?

_Full-time (1700 hours) x _____ = $

_1-Year Half-time (900 hours) (__ members x 0.500) =

_Quarter-time (450 hours) (__ members x 0.2646) =

_Minimum-time (300 hours) (__ members x 0.2117) =