1 Create a ZoomGrants™ account (below) or log in to your existing account (above) 2 Select a Program to apply for, then click the Apply button to get started 3 Answer the questions and/or fill in the fields in each tab 4 If necessary, upload any requested documents 5 Submit your application and wait for a decision 6 If you are selected to receive funding, you might be required to submit invoices or reports through your application
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By entering your initials here you certify this submission truthfully and accurately represents your application and is hereby submitted for review. Submission of this application does not, in any way, guarantee that your application will yield a favorable result.
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Application Title/Project Name
Amount Requested Maximum gant amount is $2,000,000
Total Project Costs Include all costs associated with purchasing property (land) or a building or remodeling either an existing facility or a new facility.
Applicant Information
First Name
Last Name
Telephone
Email
Address 1
Address 2
City
State/Province
ZIP+4/Postal Code
Country
Organization Information
(changes to this data will be reflected on all other applications for this organization)
Organization Legal Name/Entity Name
Address 1
Address 2
City
State/Province
ZIP+4/Postal Code
Country
Telephone
Fax(optional)
Website(optional)
Federal Tax ID (EIN) (XX-XXXXXXX)
Project Manager Contact (can be same as Primary Applicant above)
First Name
Last Name
Title
Email
Pre-Application
(answers are saved automatically when you move to another field)
This Pre-Application section must be submitted and Approved by the Administrator (not ZoomGrants) before you can fill out the rest of the application. Click the Submit Pre-Application button at the top or bottom of this tab to submit this section to be reviewed.
Application Questions
(answers are saved automatically when you move to another field)
This application closes at 5:00 p.m. PDT on 06/11/2018.
APPLICATION QUESTIONS:
1. Project Address Please answer in the following format: Address, City, State, Zip, County
2. Project State Legislative District
3. Are you registered in the state of Washington as a business? This information is from the Secretary of State.
4. Washington Statewide Vendor Number:
5. Under what RCW or WAC are your facility(s) licensed? Please list all statutes, license numbers and expiration dates.
Project Type: You must answer Question #6 first before you answer the questions that follow. Note: Question #6 is branched and depending upon your answer, a certain set of questions will appear and/or disappear. All applicants are required to answer Questions 1 through 16. If Enhanced Service Facility, please answer Questions 17-21 For all other Behavioral Health Grants, please answer Questions 22-29
6. Please check which grant you are applying for: Note: You may apply for more than one grant, but not for the same project. You will need to create a separate application if applying for more than one project. Click the tab "Open Programs" in the upper left hand corner of the page and "apply again"
7. If you are applying for more than one application type, please indicate the priority of the grants/projects. If applying for only one application, type N/A.
8. Please provide a narrative description of the project scope.
9. Are you constructing a new facility on property you already own? If yes, please upload a legal description for the property, including city and zip code in the Documents section.
10. Are you renovating a facility that you own? If yes, please upload a legal description for the property, including city and zip code in the Documents section.
11. Are you renovating a facility that you are leasing? If yes, please upload a copy of the lease in the Documents section.
12. Is this a stand-alone facility or part of an existing facility?
13. How many beds will the project create? Numbers only please.
14. Regarding the project timeline, please provide the following dates: Please answer with the following date format only please: MM/DD/YYYY
15. Are the Budget costs presented in the "Use of Funds" table in the Budget tab based on preliminary or final bids? Please upload both types of bids in the Documents section.
16. Is there a commitment by the applicant to maintain the beds or facility for at least a ten-year period
Enhanced Service Facilities (ESF) Scoring Questions
17. Is there a commitment from the applicant to work with the local Behavioral Health Organization or Fully Integrated Managed Care entity to support the coordination of behavioral health services for individuals served by the ESF.
18. Are there any local or partner resources applied to the project, including, but not limited to, regional non-Medicaid operating reserves or fund balances
19. Explain your commitment to serving people with personal care & complicated behaviors who are discharging or diverting from state hospitals into services provided through the Dept. of Social & Health Services (DSHS) Aging & Long-Term Support (ALTSA)
20. Are you working with ALTSA to understand the need for an ESF that serves ALTSA clients in the county in which you propose to develop an ESF.
21. Are you familiar with the licensing requirements of an ESF as outlined in WAC 388-107?
All other Behavioral Health Grants Scoring Questions
22. Explain how the application was developed in collaboration with one or more behavioral health organizations or entities that assume the responsibilities of the BHO in regions where Health Care Authority(HCA) is purchasing services through contracts Note: As defined in RCW 71.24.025 and pursuant to RCW 71.24.380.
23. Explain how you have assessed and would meet gaps in geographical behavioral health services needs in the region.
24. Explain your commitment to serve persons who are publicly funded and persons detained under the involuntary treatment act under chapter 71.05 RCW
25. Explain your commitment to work with local courts & prosecutors to ensure that prosecutors & courts in the area served by the hospital or facility will be available to conduct involuntary commitment hearings & proceedings under chapter 71.05 RCW
26. Are there any local or partner resources applied to the project, including, but not limited to, regional non-Medicaid operating reserves or fund balances? Please explain.
If a community hospital or freestanding evaluation and treatment facility is applying for a grant to develop capacity for beds to serve individuals on 90 to 180 civil commitments as an alternative to treatment in state hospitals, additional criteria include:
27. Please confirm the following additional criteria if this application is for a community hospital or freestanding evaluation and treatment facility: Check all that apply. Select Not Applicable if necessary.
If a community provider is applying for a grant to develop psychiatric residential treatment beds to service individuals being diverted or transitioned from state hospitals, additional criteria include:
28. Please confirm the following additional criteria if this application is for a grant to develop psychiatric residential treatment beds: Check all that apply. Select Not Applicable if necessary.
If the applicant is applying for a grant to increase behavioral health services and capacity for children and minor youth, additional criteria include:
29. Please confirm the following additional criteria if this application is to increase behavioral health services and capacity for children and youth: Check all that apply. Select Not Applicable if necessary.
Budget
(answers are saved automatically when you move to another field)
Sources of Funds
Please fill in the chart below with sources of funds. The total sources of funds must equal the total project costs. Note: Please upload Statements of Commitment for any of the funds listed below in the Documents tab above. Possible sources of funds:
Local resources, including non-Medicaid operating reserves and regional fund balances
Other (please briefly explain)
Please fill in the chart below with sources of funds. Note: the total sources of funds must equal the total project costs.
Item Description
Amount
Total $ 0.00
Use of Funds
Please fill in the chart below with costs. Note: Commerce does not pay for any in-house labor or administrative costs, only project related capital costs.
Item Description
Cost
Total $ 0.00
Tables
(answers are saved automatically when you move to another field)
Documents Requested (please upload as requested in the application)
If you are you constructing a new facility on property you already own, please upload a legal description for the property, including city and zip code.
If you are you renovating a facility that you own, upload a legal description for the property, including city and zip code.
If you are renovating a facility that you are leasing, please attach a copy of the lease.
Please upload any preliminary or final bids for the project.
Please upload Statements of Commitment for any funds listed in your Sources of Funds table (other than the Commerce grant request).
If the project includes buildings over 50-years old and/or proposes ground-altering activities, provide upload a letter from the Dept. of Archaeology and Historic Preservation stating that the project complies with . EO 05-05 requirements
Letters of Support and/or additional documents to support your application.