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DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> h) Describe what would happen if requested funding is not awarded at all or if a reduced <br /> allocation is recommended. <br /> 1. Without Orange County funding we could not provide serves in court. A reduced <br /> allocation would be problematic as all court dates need to be covered. <br /> 2. Without funding or with reduced funding, we could not offer family clients a <br /> sliding scale that starts at $25 for a two-hour session. Many of these clients are <br /> unemployed or in financial distress, and would not have other options. <br /> i) Include any other pertinent information. <br /> We are requesting an additional 5% as our costs have grown since 2011. Our long-tenured <br /> professional staff has received 1-2% cost of living increases each year. In addition, getting in to <br /> compliance with the ACA has meant additional costs, as we now provide payments in lieu of health <br /> insurance on a taxable basis, which is more costly to staff and the agency. <br /> The agency has also lost United Way funding due to United Way's change in emphasis. More <br /> recently, the Town of Hillsborough has stopped providing funds to nonprofit agencies including <br /> DSC. <br /> Program/Project Information <br /> j) Complete the Target Population and Program Beneficiary Demographics Chart <br /> k) Complete the Schedule of Positions Chart for Program Staff <br /> I) Disclosure of Potential Conflicts of Interested must be signed <br /> m) Complete the Work Statement Chart to describe the work to be performed, and be sure to <br /> attach copies of all data collection tools that will be used to verify achievement of program <br /> goals and objectives. Describe who will be responsible for monitoring progress. <br /> Information to Complete <br /> j.) Target Population <br /> Complete the following tables to the best of your ability. Show numbers of participants and <br /> percentages, as applicable, in each category. <br /> Please indicate whether this project/program will serve: x Persons ❑ Households ❑ Units <br /> Program: Mediation <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 274 292 300 <br /> Female 365 368 350 <br /> Total 639 660 650 <br /> Main Application 5/24/2016 9:47:14 AM P of 2 <br />