New Jersey Department of Health

Division of HIV, STD and TB Services

GRANT APPLICATION CHECKLIST

Name of Agency

No.	Application Page Reference	Question	Response	FOR STATE USE ONLY
N/A	Yes	No
1	General	Have you indicated the method of payment you request the State to follow: Advance Payment or Cost Reimbursement?
2	General	If you have chosen the Advance Payment method, have you submitted a desired schedule of payments for each month/quarter of your grant period along with a justification for the amounts of payment?
3	General	If your grant is $100,000 or more, have you submitted evidence of having established an interest bearing account for the deposit of advance payment funds?
4	General	Have you provided a copy of one of the following forms to document the non-profit status of your organization:

- Internal Revenue 501 (C) (3)

- IRS 990

- CO8
5	General	Have you provided a copy of your agency’s current NJ Charities Registration (under authority of N.J.S.A. 45:17a-1)?
6	General	In justifying the necessity and reasonableness of all expenses, did you show how you logically estimated or calculated the expense (Basis for estimate)
7	Cost Summary

Page 5	Have you submitted a copy of any agreement between your organization and a Federal or State entity evidencing approval of a negotiated indirect cost rate covering the period of the grant?
8	Schedule A Personnel Costs	Have you provided a breakdown for the fringe benefit costs by percentage and dollar amounts for each cost?
9	Schedule A Personnel Costs	Have you provided your agency personnel policies, salary ranges and brief position description, which have been approved by your governing board and did you show the date of such approval?
10	Schedule A Personnel Costs	Are resumes included with your application package?
11	Schedule B Consultant Services Costs	Have you provided written agreements for each consultant expense to be incurred during the grant period to include:

-	complete description of the service to be provided

-	period of time of the agreement

-	rate and total allowable compensation

-	certification that a true non-employee/employer relationship exists?

GRANT APPLICATION CHECKLIST, Continued

Name of Agency

No.	Application Page Reference	Question	Response	FOR STATE USE ONLY
N/A	Yes	No
12	Schedule C

Other Costs	If this grant will cover telephone expenses have you furnished a copy of your policy for reimbursement of the expenses of personal calls made by your employees?
13	Schedule C

Other Costs	If grant funds will be used for travel expenses, have you submitted a copy of your agency’s travel policy? Mileage rate?
14	Schedule C

Other Costs	Did you include an itemized listing of each equipment purchase in excess of $500 along with a:

- description of each item

- unit cost

- justification of need
15	Schedule C

Other Costs	Did you include a complete description of any intended renovations to include detailed cost estimates? Grantee must conform to applicable procurement regulations. Justify the necessity of such renovations. If renovations are required as a result of State/Local licensure requirements, provide a copy of violation report.
16	Schedule C

Other Costs	Have you provided a copy of all lease agreements for real and personal property?
17	Schedule C

Other Costs	Have you submitted a copy of insurance quotations from your carrier with an explanation of premium increases and extent of coverage?
18	Schedule C

Other Costs	If this grant will have subgrants, have you provided written agreements for each to include:

-	complete description of the service to be provided

-	period of time of the agreement

-	rate and payment arrangement

-	statement that agency is subject to all terms and conditions of the Department’s grant process

Have you provided budgets for each subgrant?
19	Schedule C

Other Costs	Does your agency have liability insurance coverage for fire, theft, vandalism, etc., to protect agency assets? Copies must be made available to Department staff if requested.

GRANT APPLICATION CHECKLIST, Continued

Name of Agency

No.	Application Page Reference	Question	Response	FOR STATE USE ONLY
N/A	Yes	No
20	Annual Audit	Audit of this grant is required if the total of grant awards to your agency containing State or Federal funds for your fiscal year amount to $100,000 or more with additional requirements if your agency will expend $500,000 or more in Federal funds.

Do the total of grant awards to your agency containing State or Federal funds for your fiscal year amount to $100,000 or more?

Will your agency expend $500,000 or more in Federal funds during this fiscal year?

Have you budgeted funds in this grant to cover the expense of your annual audit? If not, how will audit be paid?

Explain:
21	Cost Principles	If your agency received program income and/or funds from other sources a Cost Allocation Plan must be submitted with your application. Have you submitted such a plan if needed?
THE FOLLOWING QUESTIONS CONCERN YOUR ORGANIZATION’S FISCAL AND MANAGEMENT RESPONSIBILITY:
22
Is your organization a new organization, incorporated less than one year prior to the effective date of a proposed award resulting from this application?
23
Has your organization previously received funds from the Department under the Health Services Grant System?
24
Can you demonstrate to the satisfaction of the Department a thorough knowledge of accounting for grant funds, as prescribed by the Terms and Conditions for Administration of Health Service Grants?
25
Will you have in your employment or under contract at the time of any award as a result of this application, the accounting and management expertise that can demonstrate the ability to manage a cost reimbursement or other grant?
Name of Individual Completing Form

Title

Signature

Date

DHAS-1

JUL 12	Page 3 of 3 Pages.

DHAS-1, Grant Application Checklist

DHAS-1, Grant Application Checklist, Division of HIV, STD and TB Services, grant, financial services,

ewhite

2002-10-10

NJDOH