$50,000...601 bayview 608-661-4089 kabzuag vaj service strategies (see instructions) 43-2023570...

APPLICATION FOR 2016 CRISIS/SENIORS FUNDS 3. SIGNATU

1. AGENCY CONTACT INFORMATION AFFIRMATIV Legal Name of OrganizationMailing AddressTelephoneFAXDirectorEmail Address LIVING WAG Additional ContactEmail AddressLegal Status

Federal EIN:State CN:

DUNS # CITY OF MA

2. AGENCY PROGRAM SUMMARY 2016Program Name Letter Request

A $50,000

Contact: Kabzuag Vaj Phone: 608-217-7754 Email:B Our organiza

Contact: Phone: Email:C

4. SIGNATUContact: Phone: Email:

D

Contact: Phone: Email: Enter name:E $0

Contact: Phone: Email:F $0

By ent Contact: Phone: Email:

G $0

Contact: Phone: Email: DATEH $0

Contact: Phone: Email:TOTAL REQUEST $50,000

[email protected]

Freedom Inc601 Bayview608-661-4089 Kabzuag Vaj

Service Strategies (See Instructions)

43-2023570 361258663

Sexual Assault services/advocacy for Hmong/Khmer/Black Queer

Select a Priority Statement from the Drop-Down


Select a Priority Statement from the [email protected]

Private: Non-Profit

Identify and enter the relevant Program Goal and Priority statement Crisis Support 2: Emergency Response to Sexual Assault (CSC)



Program E

Program F

Collaborative

Program G



URE PAGE

VE ACTION

If funded, applicant hereby agrees to comply with City of Madison Ordinance 39.02 and file either an exemption or an affirmative action plan with the Department of Civil Rights. A Model Affirmative Action Plan and instructions are available at www.cityofmadison.com/dcr/aaForms.cfm.

GE ORDINANCE

If funded, applicant hereby agrees to comply with City of Madison Ordinance 4.20. This ordinance requires allemployees paid under this contract be paid (at least) the Living Wage for 2016 as established by the City ofMadison. In 2015 the Living Wage was $12.62 hourly, in 2016 it will be $12.83 hourly.

ADISON CONTRACTS

If funded, applicant agrees to comply with all applicable local, State and Federal provisions. A sample contract thatincludes standard provisions may be obtained by contacting the Community Development Division at 266-6520.If funded, the City of Madison reserves the right to negotiate the final terms of a contract with the selected agency.

ation will also be completing an application for 2016 CDD funding for continuing funds. YES

URE

tering your initials in the box KV you are electronically signing your name and agreeingto the terms listed above

7/16/2015

Kabzuag Vaj

ORGANIZATION: Freedom Inc REQUESTED AMOUNT:PROGRAM/LETTER: A Sexual Assault services/advocacy for Hmong/K 50,000PRIORITY STATEMENT:

1. SERVICE DESCRIPTION - Describe the proposed service(s). Include key aspects of program design: structure ofprogramming, staffing, expected frequency of client contact, duration of client contact, focus of curriculums as applicable, e

2. IMPACT: Describe how the proposed program will contribute to the Community Goals and the Community Indicators of S identified in the 2016 Plan for Community Development Division Provision of Adult Senior or Crisis Support Services (refer t

Crisis Support 2: Emergency Response to Sexual Assault (CSC)

ORGANIZATION: Freedom IncPROGRAM/LETTER: A Sexual Assault services/advocacy for Hmong/Khmer/Black Queer victims/su

3. ACCESSIBILITY: Describe how aspects of your program ( e.g. hours of availability, response time, location, staffing,and outreach and engagement efforts) ensure that a diverse client base will find your program accessible,culturally responsive, welcoming and effective in achieving increased well being and safety.

tc.

4. POPULATION SERVED: Describe in terms of age, income level, limited English proficiency, literacy, cognitive or physical disabilities or challenges.

Success to instructions).

5. PROPOSED SERVICE NUMBERS: Include number of unduplicated clients to be served, number of service hours to be provided, number of workshops/classes, etc.)

45 unduplicated clients to be served (25 Hmong/Khmer and 20 Queer Black individuals.) 20hrs week x 52 weeks x 2 advocates total

of 2,080 hours per year. Service hours include one-on-one individual case management, support group activities/coordination, in-

service training/community training and outreach. The majority of the service hours will be spent providing sa

support/advocacy/services/resources to individuals.

6. LOCATION: Location of service and intended service area (include specific boundaries of service area, if applicable).

The program is intended to provide services to Madison residents-city-wide project/ traveling services to meet community need-l due

to language, mobility, ability, and safety concerns.

ORGANIZATION: Freedom IncPROGRAM/LETTER: A Sexual Assault services/advocacy for Hmong/Khmer/Black Queer victims/su

7. OUTREACH: Describe how you use, or will use, marketing and outreach strategies with your intended service populationHow will these efforts improve your services?

Freedom Inc staffs/volunteers/board members are from Hmong/Khmer/Queer Black communities therefore we use their

connections and networks to distribute materials/spread awareness/information and recruit for this project. Due to safety issues both

for the advocates and clients the agency does not publicly promote our DA/SA services. In the past 10 years outreach has occurred

through word of month and personal or professional referrals. Advocates are active in these communities and usually meet clients

everywhere; family gatherings, cultural and religious gatherings at people's homes or at the Buddhist temple or at churches. Other

services are provided as a gateway to safely allow our clients to interact with the agency.

8.COLLABORATION: Describe your agency's experience and success in collaborating with other organizations to deliverservices to the target population for this program. To what extent are you using collaborative approaches in this program de

Due to the lace of culturally appropriate Hmong/SEA services within our communities, we often have to create new services with the ad

of parents and youths that can better address the needs of our communities. For example, while many

of our youths are homeless and poor (often) they do not seek services from mainstream service providers therefore we connect them

to “safe” family members/trusted friends/relatives/friends within the community when children or teens need housing, food, and othe

We always look for new systems of accountability and services for our communities who don’t feel they can seek services from already

existing services. For this project FI will: RISE Law Center, Cambodian Temple, Rape crisis center (as needed) local DV shelter as needed

National Asian Pacific Islander Domestic Violence Institute, public health nurse, churches, Kajsiab House.

The people we serve often become our biggest supporter and most active volunteers.

9. How are volunteers utilized in this program? (select one) N/ANumber of volunteers utilized in 2014?Number of volunteer hours utilized in this program in 2014?

10. EXPERIENCE: Describe how the experience and qualifications of your program staff will contribute to the success of the proposed program?

Kabzuag Vaj, our domestic/sexual violence expert (over 20 years of sa/dv experience) will help manage/supervise the project, train the

persons, and develop victim-center services for the project. MaivNyiaj Moua, our Hmong Family Strengthening domestic violence advo

will work closely to provide staffs support for this position as needed. The new advocates will be responsible to provide basic core servic

for (SA) victims and survivors, which will include: on-going day-to-day case management, participant needs assessments, safety plannin

legal/housing/economic advocacy, interpretation/translations services, coordinating and facilitating weekly support groups, co-advocac

local agencies, and provide support services for victims/survivors. Kabzuag Vaj, will be responsible for program oversight, administrativ

program support, program reports, program sustainability/fiscal management of grant funds, staff oversight, staff training, facilitating a

coordinating in-service trainings/community/victims/survivor leadership trainings/retreats/gatherings. Advocates will both be responsi

community outreach, networking, and the overall project progress, benchmarks, documentation, and outcomes. The two advocates wi

encourage to attend as many trainings, workshops, conferences, skills development, leadership trainings as possible. Kabzuag will work

closely with the advocates to connect them to local resources, national SA and DV organizations. The advocate will have access to all th

Wisconsin Women’s Training Institute’s (DV/SA trainings, social justice trainings).

ORGANIZATION: Freedom IncPROGRAM/LETTER: A Sexual Assault services/advocacy for Hmong/Khmer/Black Queer victims/s

11. PROGRAM STAFFING 2016: Identify all positions that are involved as staff to this program.Madison Living Wage Ordinance requires that all staff performing work in a contracted service receive Madison Living W

Staff Title FTE Hourly Wage*SEA SA Advocate 0.5 $16.83SEA Black Advocate 0.5 $16.83Co-Ex Director 0.1 $25.00

0000000

esign? 0TOTAL 1.1 *(LIVING WAGE FOR 2016 IS $12.83)

dvise

PURPOSEIn allocating resources to address service needs, we are committed to supporting organizations that are welcominclusive and culturally responsive environments for all of Madison's residents. Accordingly, we will be gatherininformation about your service populations, your staffing and your governing boards that will help us gain grea into our capacities as a community to engage and serve an increasingly diverse population.

12. How is your client demographic information (gender, age, race, ethnicity, and disabilities) collected?

Client demographic information is collected through intake surveys (oral interviews or written by client) Normally collected at begin

of services. Normally collected at beginning of services.

13. Do you currently collect household income levels for participants? YESIf yes, how do collect this information?

Yes, through intake surveys (oral interviews or written by client)

Specific questions are asked about income, services needed, services recieved from gov. staff

14. What measure do you use to identify or describe client income levels? ces YES Qualification for free and reduced lunch ng, YES Dane County median Income

cy with YES Federal Poverty e YES Food Share qualification

and YES Other: ble for

ll be

k

e

project training and oversight

Coordinate, manage project, provide direct services, advocac Duties

cultural factors, example numbers of people living in household no

Coordinate, manage project, provide direct services, advocac

ORGANIZATION: Freedom IncPROGRAM/LETTER: A Sexual Assault services/advocacy for Hmong/Khmer/Black

15. What is your best estimate for the percentage of your program population that is low income 80 Wage.

16. DEMOGRAPHICS: Complete the following chart for unduplicated participants served by this program in 2014. Indic and percentage for the following characteristics. For new programs, estimate projected participant numbers and descri

DESCRIPTOR PART # PART % STAFF # STAFF % GEN % POV % R/POV**RACEWHITE/CAUCASIAN 0 0% 0 0% 80% 67% 16%BLACK/AFRICAN AMERICAN 20 44% 0.5 45% 7% 15% 39%ASIAN 25 56% 0.6 55% 8% 11% 28%AMERICAN INDIAN/ALASKAN NATIVE 0 0% 0 0% <1% <1% 32%NATIVE HAWAIIAN/OTHER PACIFIC ISLAND 0 0% 0 0% 0% 0% 0%MULTI-RACIAL 0 0% 0 0% 3% 4% 26%BALANCE/OTHER 0 0% 0 0% 1% 2% 28%

TOTAL RACE 45 100% 1.1 100%ETHNICITYHISPANIC OR LATINO 0 0% 0 0% 7% 9% 26%NOT HISPANIC OR LATINO 45 100% 1.1 100% 93% 81% 74%

TOTAL ETHNICITY 45 100% 1.1 100%AGE *REPORTED MADISON RACE AND ETHNICITY PERCENTAGES ARE

<2 0 0% ED ON 2009-2013 AMERICAN COMMUNITY SURVEY FIGURES.

2 - 5 0 0% AS SUCH, PERCENTAGES REPORTED ARE ESTIMATES.

6 - 12 0 0% See Instructions for explanations of these categories.

13 - 17 10 22%18 - 29 10 22% **R/POV=Percent of racial group living below the poverty line.

30 - 59 15 33%60 - 74 10 22%75 & UP 0 0%

TOTAL AGE 45 100%PERSONS WITH DISABILITIES 20 44%RESIDENCYCITY OF MADISON 45 100%DANE COUNTY (NOT IN CITY) 0 0%OUTSIDE DANE COUNTY 0 0%

TOTAL RESIDENCY 45 100%TOTAL 45 100%MALE 2 4%FEMALE 38 84%UNKNOWN/OTHER 5 11%

MADISON*

ORGANIZATION: Freedom IncPROGRAM/LETTER: A Sexual Assault services/advocacy for Hmong/Khmer/Black Queer victims/s

17. The City is interested in addressing issues of poverty and racial equity for residents of Madison. Examine the complet question 16 on Madison demographics. Please comment on your programs current service participants and identify your underserved population(s). Explain how you understand any disparities and plans you have to address these issues.

ptors.

18. Does the staffing of the program reflect the racial and cultural diversity of the residents served? If not, what plans do yhave to address this?

Yes, it does. Currently, we have 3 full time staffs and 1 part-time staff (2 Hmong and 1 Queer Black gender-non-conforming

full time, and 1 Queer Hmong part-time staff) 1 Hmong youth consultant,

2 Hmong adult programming/admin consultant, and 1 khmer dv advocate

19. How does this program serve non-English speakers?

This program will serve Hmong/Khmer English speakers, no-limited English speakers, native speakers by

providing access to Hmong/Khmer advocates who are bi-cultural/bi-lingual. Depending on who the hired

Hmong/Khmer advocate is hired FI work with existing Southeast Asian advocates in FI to cover the needs of the

no-met SEA community. We have Khmer and Hmong speaking staffs at FI that can easily provide

translations/interpretation services to either community. We are fully prepared to meet the needs of both these communities.

ORGANIZATION: Freedom IncPROGRAM/LETTER: A Sexual Assault services/advocacy for Hmong/Khmer/Black Queer victims/surivor

PROGRAM BUDGET20. 2015 BUDGET

SOURCE SPECIALREVENUE SOURCE TOTAL PERSONNEL OPERATING SPACE COSTSDANE CO HUMAN SVCS 0 0 0 0 0DANE CO CDBG 0 0 0 0 0MADISON-CDD 0 0 0UNITED WAY ALLOC 0 0 0 0 0UNITED WAY DESIG 0 0 0 0 0OTHER GOVT 0 0 0 0 0FUNDRAISING DONATION 0USER FEES 0 0 0 0 0OTHER 0 0 0 0 0TOTAL REVENUE 0 0 0 0 0

21. 2016 PROPOSED BUDGET you SOURCE SPECIAL

REVENUE SOURCE TOTAL PERSONNEL OPERATING SPACE COSTSDANE CO HUMAN SVCS 0 0 0 0 0DANE CO CDBG 0 0 0 0 0MADISON-CDD 50,000 40,500 5,500 4,000 0UNITED WAY ALLOC 0 0 0 0 0UNITED WAY DESIG 0 0 0 0 0OTHER GOVT* 55,500 40,500 10,000 5,000 0FUNDRAISING DONATION 5,000 0 0 0 5,000USER FEES 0 0 0 0 0OTHER** 0 0 0 0 0TOTAL REVENUE 110,500 81,000 15,500 9,000 5,000

*OTHER GOVT 2016Source AmountDOJ-Office of Justice Wisco 55,500

0000

TOTAL 55,500**OTHER 2016Source AmountFundraiser 0

0000

TOTAL 0

ACCOUNT CATEGORY

TermsWritten 6/15/2015 will know in Oct 2015

Terms5000

rs and their families

ORGANIZATION: Freedom Inc

PROGRAM BUDGET (See Instructions) 1. 2015 BUDGETEDREVENUE SOURCE SPECIALSOURCE TOTAL PERSONNEL OPERATING SPACE COSTSDANE CO HUMAN SVCS 0 0 0 0 0DANE CO CDBG 0 0 0 0 0UNITED WAY ALLOC 0 0 0 0 0UNITED WAY DESIG 0 0 0 0 0OTHER GOVT 189,101 160,000 23,000 6,101 0FUNDRAISING DONATIONS 44,639 20,000 20,000 0 4,639USER FEES 590 0 0 590OTHER 67,000 50,000 9,000 0 8,000TOTAL REVENUE 301,330 230,000 52,000 6,101 13,229

2. 2016 PROPOSED BUDGETREVENUE SOURCE SPECIALSOURCE TOTAL PERSONNEL OPERATING SPACE COSTSDANE CO HUMAN SVCS 0 0 0 0 0DANE CO CDBG 0 0 0 0 0UNITED WAY ALLOC 0 0 0 0 0UNITED WAY DESIG 0 0 0 0 0OTHER GOVT* 188,000 160,000 20,000 8,000 0FUNDRAISING DONATIONS 43,600 20,000 18,000 0 5,600USER FEES 0 0 0 0 0OTHER** 38,000 20,000 10,000 0 8,000TOTAL REVENUE 269,600 200,000 48,000 8,000 13,600

*OTHER GOVT 2016Source AmountDept Children Family 160,000DOJ-office of Justice 28,000

000

TOTAL 188,000**OTHER 2016Source AmountFundraising/donations 38,000

000

TOTAL 38,000

ACCOUNT CATEGORY

ACCOUNT CATEGORY

TermsAnnual Jan- to DecOct 2015 to Sept 2016

unrestricted/foundations 1 yearTerms

ORGANIZATION: Freedom Inc

AGENCY ORGANIZATIONAL PROFILE

1. AGENCY MISSION STATEMENT

FI has a unique approach: it provides programs that are designed to be language, gender and culture-specific to women, gender-non-

conforming/transgender folks, and youth in Black/Hmong/SEA communities. Our mission is to create social change that end violence

against women, gender-non-conforming and transgender folks, and children within communities of color. FI works to challenge the

root causes of violence, poverty, racism and discrimination. Our belief is that people most impacted must have voice, power

, opportunities/resources order for true justice and liberation to happen.

2. AGENCY EXPERIENCE AND QUALIFICATIONSFreedom, Inc. (FI) is a non-profit organization that provides services to low- to no-income communities of color in Dane County--is the only

organization in Dane County that specifically works on Southeast Asian women’s and youth issues, and LGBTQ Southeast Asian and Black peo

Freedom, Inc. began in 2003, as a Southeast Asian (SEA-Hmong and Khmer) girls support group; our primary goal consisted of looking at new

definitions and solutions to ending violence against women and children. FI has a unique approach: it provides programs that are designed to

language, gender and culture-specific to women, gender-non-conforming and transgender folks, and youth in Black and Hmong/SEA commun

Since 2003, Freedom Inc has served and advocated for hundreds of poor people SEAfamilies, victim of domestic/sexual violence, youths,

Black Queer folks, elders, children, poor/homeless folks), built strong leaders from these communities, and most importantly contributed to

improving the quality of life for Madison’s most impacted (by racial disparity). Freedom, Inc, has a long history working with Hmong/Khmer/a

Queer Black youths, women, and elders. We have a committed group of volunteers, staffs/ board members that reflect the community we se

FI’s leading staffs have combined over 35 years experiences working to serve Hmong/Khmer/Queer Black communities. We have a proven tra

record within these communities as well as building and running a solid non-profit organization.

3. AGENCY UPDATE: Describe any significant change or shifts that the agency has experienced in the last year, or that you may anticipate in the next few years. For example, changes in leadership, significant turnover in staffing, strategic planning processes, expansions or loss of funding. What, if any, affects will these shifts have on the agency'sability to provide contracted services? If there were no changes, write "no changes" in box below.

Yes, there is a slight shift in our agency services. Over the past 15 years, our services have shifted to meet the needs of our most

underserved community members. We want to specific increase services to meet the needs of sexual assault victims in the

Hmong/Khmer/Black (specifically Queer folks). In addition, there is an increase request/need for services/advocacy from 1. Hmong

families (especially children/teens/elders/women--with the closing of United Asian/lack of services) 2. Black Queer teens/youths (due

to FI’s intentional work within this community) 3. Khmer families (women and children—literally no culturally appropriate

services/advocacy programs –outside of mental health services). Since the mis-management/defunding of United Asian there has

literally been no other agency in town that can provide the basic support services needed for poor/working poor/homeless

Hmong/Khmer families/individuals. Current socio-economic/racial disparity within the Hmong and Khmer communities, coupled

with the lack of culturally appropriate services (especially women, children, elders) these two communities continue to struggle to

meet their basic human needs. We want to expand our services to meet the needs of single parent fem-queer-homes, elders (ages 55

and up- who are not served by Journey Mental Health Southeast Asian services---Kajsiab House/Cambodian Temple) including

retired-elders, disabled elders, and physically isolated Southeast Asian elders that are not receiving any services due to language,

culture, ability, and mobility. There is a need for services to queer teen/youth of color especially Hmong/Black. In the past 5 years,

we’ve helped to create space and services to meet their specific needs through national funding. The funding ended this summer. We

want to continue to provide services/advocacy/support to them-specifically those with mental health/wellness challenges. In the past

year, we provided worked with 10 individuals (8 with mental health challenges). In addition, we want to secure office

space/community space to specific work with Southeast Asian families (currently non-exist within Madison-outside of Kajsiab

House—which has it’s limitations as a treatment center)

4. ENGAGEMENT: Describe how you integrate, or will integrate, community input into your agency strategic planning(e.g., input or involvement in the creation, design, implementation, and feedback for services)? How will these efforts improveyour services? Include specific strategies that address client and participant engagement, along with relevant community engaThe foundation to all FI’s work is to end gender-based violence against violence of women, girls, children, gender-queer/gender

non-conforming, two spirited, and boy-girl/trans folks in poor communities of color. Our core beliefs is that those most impacted must lea

We believe they know best and should be given the opportunity to develop their capacity. To ensure that those most impacted drive the w

and that FI is accountable to underrepresented communities of color (specifically victims, and survivors) FI’s staffs/volunteers/leaders/Boa

Directors reflect the membership of those we serve. Example: FI has had an advisory Hmong female elder’s council for the past 10 years-t

are well-respected mothers, grandmothers, and community leaders (3-5 women)/ Youth of Color Health Council, and who provide voice a

leadership for us. FI is able to recruit, and maintain such high numbers of youth in our programs-- we are from the communities we serve

organize within. Our youth staff and teen contractors (who work closely with staff listed below) are instrumental in recruiting/rooting us in

communities and making sure FI is meeting folks where they. Each program is designed to meet cultural-, gender-, and age-specific needs

communities. Due to the different cultural and social practices of these various SEA groups, LGBTQ identities, and Black identities, FI. prom

staff and volunteer diversity to meet specific cultural linguistic needs of each community served and develops cultural competence as a

fundamental principle, so staff and volunteers are most often from the communities we serve and organize within. Most importantly, FI m

it a priority to hire women, gender-non-conforming and transgender folks, and youths to work with women, gender non-conforming

and transgender people, and youths. To ensure that those most impacted drive FI's work and FI is accountable to underepresented

underrepresented communities of color (especially youths and children), FI's staffs and voard reflect the membership of those we serve.

FI takes a non-hierarchical, shared power model, for making decisions and growing the organization, so members of all our youth groups

are at the table for decision-making and strategic visioning of FI programs. Board admin. staffs follow the leadership of people who work

who work closely with the community. This model of work ensures that FI will continue to develop leaders from the grassroots, keep the

keep the program effective, and keep our leadership inextricably connected to and reflective of the communities they are working in.

This is a key fundamental principle to our creating and maintaining cultural competency within our agency.

The following information will be used to assist CDD in future funding processes. Answer the following questions as succinctly as possible.

5. COLLABORATION: Describe the common needs, challenges or obstacles, which are not addressed by your organization,that prevent your clients from being successful. Are these needs or challenges addressed by another organization(s) in the coIf yes, please describe how those needs are addressed. How might these services be better coordinated?What, if anything, could be done to help support such efforts?

6. CAPACITY BUILDING: Please help the City understand any capacity building needs that affect your agency's ability to provide quality services. Identify three such needs that, if addressed, would assist the agency in delivering quality service How might the City help address these needs?

Capacity Building activities are defined as intentional, coordinated and mission-driven efforts aimed at strengthening the mand governance of nonprofits to improve their performance and impact. Examples of capacity building activities:- Programmatic: program evaluation, program best-practices/improvement- Organizational capacity: Budgeting, strategic planning, collaborative planning and relationships, administrative functions - Governance: Board development, operational investments, fund development- Cultural competency and capacity: Diversity of staff, board and volunteers, language access, overall cultural competenc

n the

of

motes

makes

mmunity?

7. BOARD-VOLUNTEER DEMOGRAPHICSIndicate by number the following characteristics for your agency's current board and volunteers. Refer to application instrucfor definitions. You will receive an "ERROR" until completing the demographic informa

GENERAL POVERTY R/POV**Number Percent Number Percent Percent Percent Percent

TOTAL 5 100% 20 100%GENDERMALE 1 20% 5 25%FEMALE 3 60% 11 55%UNKNOWN/OTHER 1 20% 4 20%

TOTAL GENDER 5 100% 20 100%AGELESS THAN 18 YRS 0 0% 6 30%18-59 YRS 5 100% 5 25%60 AND OLDER 0 0% 9 45%

TOTAL AGE 5 100% 20 100%RACEWHITE/CAUCASIAN 0 0% 0 0% 80% 67% 16%BLACK/AFRICAN AMERICAN 0 0% 6 30% 7% 15% 39%ASIAN 3 60% 12 60% 8% 11% 28%AMERICAN INDIAN/ALASKAN NATIVE 0 0% 0 0% <1% <1% 32%NATIVE HAWAIIAN/OTHER PACIFIC ISLAND 0 0% 0 0% 0% 0% 0%MULTI-RACIAL 0 0% 0 0% 3% 4% 26%BALANCE/OTHER 2 40% 2 10% 1% 2% 28%

TOTAL RACE 5 100% 20 100%ETHNICITYHISPANIC OR LATINO 2 40% 2 10% 7% 9% 26%NOT HISPANIC OR LATINO 3 60% 18 90% 93% 81% 74%

TOTAL ETHNICITY 5 100% 20 100%PERSONS WITH DISABILITIES 1 20% 13 65%

*REPORTED MADISON RACE AND ETHNICITY PERCENTAGES ARE BASED ON 2009-2013 AMERICAN COMMUNITY SURVEY FIGURES.

AS SUCH, PERCENTAGES REPORTED ARE ESTIMATES. See Instructions for explanations of these categories.

**R/POV=Percent of racial group living below the poverty line.

8. Does the board composition and volunteer pool of your agency represent the racial and cultural diversity of the residents If not, what is your plan to address this?

DESCRIPTORBOARD VOLUNTEER

MADISON*

9. AGENCY REVENUE DETAILED BY PROGRAM 10. AGE ctions

REVENUE 2014 2015 2016 2016 PROPOSED PROGRAMS This char SOURCE ACTUAL BUDGET PROPOSED A B C D Where po

DANE CO HUMAN SVCS 0 0 0 0 0 0 provided DANE CO CDBG 0 0 0 0 0 0 You will r MADISON-CDD 0 0 50,000 50,000 0 0 0UNITED WAY ALLOC 0 0 0 0 0 0 Account UNITED WAY DESIG 0 0 0 0 0 0 A.OTHER GOVT 189,101 243,500 55,500 0 0 0FUNDRAISING DONATION 0 44,639 48,600 5,000 0 0 0USER FEES 590 0 0 0 0 0OTHER 67,000 38,000 0 0 0 0TOTAL REVENUE 0 301,330 380,100 110,500 0 0 0

B.REVENUE 2016 PROPOSED PROGRAMS CONT.SOURCE E F G COLL NonApp

DANE CO HUMAN SVCS 0 0 0 0DANE CO CDBG 0 0 0 0 C.MADISON-CDD 0 0 0 0 0UNITED WAY ALLOC 0 0 0 0UNITED WAY DESIG 0 0 0 0OTHER GOVT 0 0 0 188,000FUNDRAISING DONATION 0 0 0 43,600 D.USER FEES 0 0 0 0OTHER 0 0 0 38,000TOTAL REVENUE 0 0 0 0 269,600

E. s you serve?

NCY EXPENSE BUDGET 11. AGENCY GOVERNING

rt describes your agency's total expense budget for 3 separate years. How many Board meetings w ossible, use audited figures for 2014 Actual. Budget and Proposed Subtotals will autofill from information yHow many Board meetings h

in the individual program budgets, Center Support and Non-City worksheets in this application. How many Board seats are i receive an "ERROR" until the amounts equal the autofilled Budget and Proposed subtotals. List your current Board of Dir

2014 2015 2016 Namet Description ACTUAL BUDGET PROPOSED Home AddressPERSONNEL OccupationSalary 0 186,000 225,000 RepresentingTaxes 0 15,000 20,000 Term of OfficeBenefits 0 29,000 36,000 NameSUBTOTAL A. 0 230,000 281,000 Home Address

OccupationOPERATING RepresentingAll "Operating" Costs 0 52,000 63,500 Term of OfficeSUBTOTAL B. 0 52,000 63,500 Name

Home AddressSPACE OccupationRent/Utilities/Maintenance 0 6,101 17,000 RepresentingMortgage (P&I) / Depreciation / Taxes 0 0 0 Term of OfficeSUBTOTAL C. 0 6,101 17,000 Name

Home AddressSPECIAL COSTS OccupationAssistance to Individuals 0 4,229 3,600 RepresentingSubcontracts, etc. 0 9,000 15,000 Term of OfficeAffiliation Dues 0 0 0 NameCapital Expenditure 0 0 0 Home AddressOther: 0 0 0 OccupationSUBTOTAL D. 0 13,229 18,600 Representing

Term of OfficeSPECIAL COSTS LESS CAPITAL EXPENDITURE 0 13,229 18,600 NameTOTAL OPERATING EXPENSES 0 301,330 380,100 Home AddressTOTAL CAPITAL EXPENDITURES 0 0 0 Occupation

RepresentingTerm of OfficeNameHome AddressOccupationRepresentingTerm of OfficeNameHome AddressOccupationRepresentingTerm of Office

BODY AGENCY GOVERNING BOD

were held in 2014? 4 Name has your governing body or Board of Directors scheduled for 2015? 2 Home Address ndicated in your agency by-laws? 3 Occupation

rectors or your agency's governing body. RepresentingTerm of OfficeNameHome AddressOccupation

From: 06/2013 To: 06/2018 RepresentingTerm of OfficeNameHome AddressOccupation





From: mm/yyyy To: mm/yyyy RepresentingTerm of OfficeNameHome AddressOccupation

From: mm/yyyy To: mm/yyyy RepresentingTerm of OfficeNameHome AddressOccupation

From: mm/yyyy To: mm/yyyy RepresentingTerm of Office

910 Mohican Pass, Madison WI 53711

Board ChairIndependent Consultant, Business Owner

Nancy Vue

1246 40th Ave Kenosha, WI 53144

CommunitySenior Director Women of Color Network National

Lina Juarbebotella

Kayleb Her

Student/Commuity Member1525 Lake View Ave Madison, WI 53704

Community/Youth

Mario Sierra

Program Coordinator Madison Gas & Electric615 West Main St. #310 Madison,WI 53703

Student/Commuity Member

Jackie Yang434 W. Mifflin Street, Apt 203 Madison,WI 53703

Treasurer

Secretary

DY cont.

From: mm/yyyy To: mm/yyyy









$50,000...601 bayview 608-661-4089 kabzuag vaj service strategies (see instructions) 43-2023570...

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