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2021 Mid-Year Funding Application

  1. Jackson County COMBAT

  2. Important

    To submit this form you do not have to sign in or create a Form Center account above. However, you will have to complete the form in its entirety without the option to save your progress unless you do create an account.

  3. Submission Deadline

    Completed applications must be submitted no later than 4:00 p.m. (central) on Friday, April 23, 2021.

  4. COMBAT Program Director

    Individual who will directing program that would receive COMBAT funding

  5. Organization's Executive Director

  6. Anti-Violence Area Of Focus

    Please select which of these issues your agency will address.

  7. Youth Employment

    COMBAT is seeking proposals that focus on hiring youth 13-17 to work in their communities from June 2021 to June 2022.

  8. Domestic Violence

    COMBAT is seeking to fund proposals that will provide essential services for domestic violence and sexual assault survivors, in addition to domestic violence prevention programs that promote healthy relationship skills. A point of emphasis is Trauma Counseling for survivors , their children and any potential witnesses, with counseling made available as immediately as possible following the domestic violence and/or sexual violence occurrence. We will also fund programs that focus on assuring that survivors are fully informed of all resources and services available to them, including counseling, sheltering and victim advocacy.

  9. 1) Is this an existing program for your agency?*

  10. 2) Is this program currently funded by COMBAT?*

  11. 4) Program Summary

    Describe your proposed Anti-Violence/Anti-Drug Prevention program based on your selected area of focus. If funded, this will be the program description used by COMBAT on our website and publications about our funded programs. Address the purpose, target population, services/activities to be provided and expected outcome of your program.

  12. Program Description

  13. 1) Please Discuss Program Purpose Statement

    The purpose of a program is to achieve outcomes. It is driven by audience needs and considerations (for whom). It provides a solution to meet those needs (what we do). It fulfills the organization's mission. It defines audience, activities, services, and outcomes.

  14. 2) Please Discuss Program Goal(s)

    Goals are typically broad general statements that describe what the program plans to accomplish. Goals establish the overall direction for and focus of a program. Goals define the scope of what the program should achieve and serve as the foundation for developing program objectives.

  15. 3) Please Discuss The Need

    What problem or opportunity does the program addresses? Who experiences it?

  16. Schedule & Location(s)

  17. Will the program be offered year-round?*

  18. What days of the week will the program will be offered?*

    Check all that apply

  19. Will you program/project be at one site or multiple sites?*

  20. Program/Project Location

  21. If you selected other under "Location Type," specify that location type here.

  22. Include name of commuinity center, school, church, etc. if applicable.

  23. More Locations (List ALL Below)

  24. Target Population

    List age, ethnic breakdown, gender, and geographic area to be served. Describe your outreach strategy and how clients will be recruited. If referred from other agency(ies), you must include a letter stating that these agencies are aware that they will be part of a COMBAT project, as an Appendix to your proposal. Failure to provide current proof of referring partner will result in 10-point deduction.

  25. Age

  26. % In This Age Group

  27. % In This Age Group

  28. % In This Age Group

  29. % In This Age Group

  30. % In This Age Group

  31. % In This Age Group

  32. % In This Age Group

  33. % In This Age Group

  34. Gender

  35. % Of Male Clients

  36. % Of Female Clients

  37. Ethnicity

    Percentage of clients expected to serve from each of these ethnic/racial groups.

  38. (Not Hispanic or Latino)

  39. (Or Other Pacific Islander)

  40. Geography

  41. Estimates

  42. Key Partners

    Who are your key partners who will enhance your ability to conduct this project? Describe their role(s) related to the project and expertise as well. You must include a current letter stating that these partners are aware that they will be part of a COMBAT project.

  43. Staff Expertise & Experience

    Describe the experience and expertise of key staff (and contract positions) for the proposed project (including experience or training in selected strategies). Identify the person who will be the Coordinator/COMBAT Program contact and other staff. Include job descriptions for each staff or contract person

  44. 2021 Program Budget Information

  45. Personnel (Salaries)

  46. Proposed

  47. Other Funding Amount

  48. Total Cost

  49. Number of Other Sources

  50. Fringe Benefits

    Maximum 10% of Salaries (Describe Benefits Below)

  51. Proposed

  52. Other Funding Amount

  53. Total Cost

  54. Number of Other Sources

  55. Auditing/Accounting Services

  56. Proposed

  57. Other Funding Amount

  58. Total Cost

  59. Number of Other Sources

  60. Evaluation

  61. Propsed

  62. Other Funding Amount

  63. Total Cost

  64. Number of Other Sources

  65. Postage

  66. Proposed

  67. Other Funding Amount

  68. Total Cost

  69. Number of Other Sources

  70. Printing

  71. Proposed

  72. Other Funding Amount

  73. Total Cost

  74. Number of Other Sources

  75. Meeting Expense

  76. Proposed

  77. Other Funding Amount

  78. Total Cost

  79. Number of Other Sources

  80. Mileage (Local Travel)

  81. Proposed

  82. Other Funding Amoung

  83. Total Cost

  84. Number of Other Sources

  85. Training

  86. Proposed

  87. Other Funding Amount

  88. Total Cost

  89. Number of Other Sources

  90. Stipends

  91. Proposed

  92. Other Funding Amount

  93. Total Cost

  94. Number of Other Sources

  95. Insurance

  96. Proposed

  97. Other Funding Amount

  98. Total Cost

  99. Number of Other Sources

  100. Other

  101. Proposed

  102. Other Funding Amount

  103. Total Cost

  104. Number of Other Sources

  105. Other

  106. Proposed

  107. Other Funding Amount

  108. Total Cost

  109. Number of Other Sources

  110. Other

  111. Proposed

  112. Other Funding Amount

  113. Total Cost

  114. Number of Other Sources

  115. Other

  116. Proposed

  117. Other Funding Amount

  118. Total Cost

  119. Number of Other Services

  120. Other

  121. Proposed

  122. Other Funding Amount

  123. Total Cost

  124. Number of Other Services

  125. TOTAL PROPOSED BUDGET

  126. Proposed

  127. Other Funding Amount

  128. Total Cost

  129. Number of Other Sources

  130. Required Documents

  131. Jackson County Compliance Report Form completed and signed or existing certificate (if you have one). Download This Form (PDF)

  132. Copy of Paid Jackson County Property tax receipt or current exemption certificate.

  133. Copy of evidence of liability insurance coverage for at least $1 million.

  134. Copy of current IRS Form 990 (within past two fiscal years 2018 or 2019).

  135. Copy of full Certified Financial Audit (within past two fiscal years 2018 or 2019).

  136. Copy of letter indicating current IRS 501(c)(3) tax-exempt status (if applicant is not a governmental agency, e.g., city, school district or court in Jackson County).

  137. Certificate of Good Standing from the Missouri Secretary of State.

  138. List of Staff with titles and copies of certifications

  139. List of Board of Directors

  140. Acknowledgement*

    By clicking "Agree," you agree and acknowledge that information and statements provided in this application are, to the best of your knowledge, true and accurate.

  141. By typing your name in the "Signature" box below, you acknowledge that this "electronic signature" is valid and binding upon you to the same force and effect of a traditional handwritten signature.

  142. Leave This Blank:

  143. This field is not part of the form submission.