OCFS-5001 (Rev. 1/2011) Page 1 of 3

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

INDIVIDUAL PROGRAM APPLICATION

Program Information
Program Title:

QYDS ID# (For County Use Only):

Program Year:

Direct Services will NOT be provided by this program
Funding Information
Funding Category:

County:

Funding Type:

Sponsoring County/Municipality:

Fund Amounts	Authorized Voucher Signee
Total Program Amount:

1.	Last Name:

OCFS Funds Requested:

First Name:

Youth Bureau Allocated [Youth Bureau ONLY]:

Title:

60% State Aid [RHYA Programs ONLY]

% Tax Match

2.	Last Name:

% Agency Cash:

% In Kind

First Name:

Agency/Municipality Information:
Title:

This Agency is:

Private, Not for Profit Public Religious Corporations
Contact Person for Agency/Municipality:
Federal ID #:

Charities Reg.#:

Last Name:

First Name:

Agency Website:

Title:

Implementing Agency/Municipality:

Phone Number:

Extension:

Mailing Address:

Fax Number:

Address Line 2:

E-Mail:

City:

State:

Zip Code:

Period of Actual Program Operation:
FROM:	TO:
Executive Director for Agency/Municipality	Hours of Operation:
Last Name:

First Name:

FROM:	TO:
Daily Other (Explain)

Title:

Phone Number:

Extension:

Fax Number:

E-Mail:

Check if: Joint Program

1. Name of participating municipalities:
2. Name of primary disbursing municipality:
Check if: Purchase of Service

1. Agency providing service:
2. Agency purchasing service:

Executive Directory/Board Chairperson Signature
Disclaimer: Please note that submission of these forms to the County/Municipal Youth Bureau does NOT guarantee funding will be allocated to your program.

Changes have been submitted on the electronic OCFS-5001, 5002, 5003.

OCFS-5001 (Rev. 1/2011) Page 2 of 3

New York State

Office of Children and Family Services

INDIVIDUAL PROGRAM APPLICATION

Agency Summary Instructions

Implementing Agency: Enter name of incorporated agency responsible for program.

Program Title: Enter the title of the program.

QYDS ID#: County Use Only. This number will be provided to you after the application has been entered into QYDS. Municipalities and Contract Agencies will get this number from their County Youth Bureau. All programs will have new QYDS ID#’s for 2011.

Program Year: Enter the year the program will operate.

Direct Services will NOT be provided by this program: If the program applying for funding does not provide a direct service for youth ages 0-21, check the box. The only programs that can check the “No Direct Service Provided” box are the Youth Bureau Application, RHYA Coordinator Application, 13% SDPP A Administrative Funding Application and the municipalities who purchase services (Purchase of Service). If this box is checked, the program then skip to the OCFS 5003 (see special notes on the instructions for OCFS 5003).

Funding Information

Funding Category: To be completed by the County/Municipal Youth Bureau or Municipality. Categories include: YDDP, SDPP-A, SDPP-B or RHYA.

County: Enter County where program applying for funding is located.

Funding Type: To be completed by the County/Municipal Youth Bureau or Municipality. Categories include; Recreation, Youth Service, Youth Initiatives, Youth Bureau, SDPP-A, SDPP-B, RHYA I or RHYA II.

Sponsoring County/Municipality: Enter the County/Municipality that will be submitting the State Aid Voucher (providing the funding for the program). This is the County/Municipality that will receive reimbursement from OCFS.

Funding Amounts

Total Program Budget: Enter the total Program Budget.

OCFS Funds Requested: Enter the state aid being requested from the County/Municipal Youth Bureau or Municipality (Note: Please be sure that if you are requesting funds where matching dollars are required (Recreation, Youth Service, Youth Bureau, RHYA or Youth Initiatives funding) that the total program budget is at least equal to the state aid requested + the local match. Please reference the Fiscal Policies and Procedures Manual for information).

Youth Bureau Allocation: To be completed by the County or Municipal Youth Bureau. This figure should be what the Youth Bureau is actually allocating to the program applying for funds. (Special note: Please make sure that if you are allocating funds where matching dollars are required, that the appropriate percentages are met. Please reference the Fiscal Policies and Procedures Manual for information).

RHYA Programs only:

RHYA I: Provides 60/40 state-local matching funds for coordination of services, as well as short-term (30-60 days) residential and non-residential services to runaway and homeless youth under age 21. i.e. Interim Family Programs (Host Home).

RHYA II: Provides 60/40 state-local matching funds for residential and non-residential services to youths ages 16-21 for up to eighteen months. i.e.. Transitional Independent Living Support Programs.

Authorized Voucher Signee: Enter the person(s) and title (limit two names), responsible for signing and submitting claims on behalf of the Sponsoring County/Municipality. These are the only individuals whose signature will be accepted by Finance on a County/Municipality voucher.

Agency/Municipal Information: Enter the type of agency; Federal ID#; Charities Registration#; and Agency Website (if Applicable). Enter the name, address, city, state, and zip code of the incorporated agency or municipality responsible for operation of the program.

OCFS-5001 (Rev. 1/2011) Page 3 of 3

Executive Director for Agency/Municipality: Enter name, title, phone number, extension (if applicable) fax number and e-mail of the person who can sign on behalf of the applying agency. Special note: For Municipalities this should be your chief elected official (i.e. Mayor, Supervisor).

Contact Person for Agency/ Municipality: Enter information for the person to contact for this program. The e-mail should be a business or official e-mail address.

Period of Actual Operation: Enter the month and year that the program begins (FROM) and the month and year that the program ends (TO).

Hours of Operation: Enter the hours that the program begins (FROM) and ends (TO). Then check if the program is offered Daily or other and indicate (i.e. weekly, twice a week, monthly).

Joint Program: Two or more municipalities join together to operate one program. If this is the case enter the participating municipalities and the municipality that is the primary disburser. Special Note: Single Disburser (Primary Disburser) Two or more municipalities join together to operate one program, with a single municipality acting as disburser and paying all expenses. The non-disbursing municipalities make payment for their share of the program costs to the disbursing municipality. The disbursing municipality is responsible for coordinating the submission of claims for all participating municipalities. The Chief Fiscal Officer of each municipality is responsible for preparing and signing the respective claim.

For municipalities seeking individual reimbursement - each participating municipality must submit a State Aid Voucher (AC 1171). The non-disbursing participating municipalities must enter a check number; date of check; amount and payee on the AC 1171 to verify funds were turned over to the disburser. Only the disburser is required to file the complete claim package, State Aid Voucher (AC 1171), OCFS-3125, and appropriate OCFS-3126 thru OCFS-3130. Expenditures reported by the disbursing municipality must be sufficient to allow a 50 percent state aid reimbursement to the disburser and all participating municipalities.

Purchase of Service: One municipality operates a program and another municipality purchases services from that program for their youth participation for an agreed amount. The municipality operating the program must file its claim before the municipality purchasing the service files its claim. The operating municipality must account for match requirements by submitting a claim with expenditures sufficient to total twice its state aid as well as the funds received from the purchasing municipality.

The purchasing municipality submits only the State Aid Voucher (AC-1171) indicating “Purchase of Service” and the name of the municipality, check number, date of check and amount paid over to the municipality operating the program.

Disclaimer: Check the box only if there have been changes to the 5001, 5002 and/or 5003. If there are no changes a hard copy of the 5001 must still be sent to the County Youth Bureau with an original signature.

OCFS-5001

Individual Application and county Administered Funds Instructions

OCFS-5001; 5001 form; Application; County Administered Funds Instructions; Individual Program Application

ax9740

2011-06-28

afoy

Youth Development

New York State