Department of Human Services s21

DEPARTMENT OF HUMAN SERVICES

DIVISION OF FAMILY DEVELOPMENT

CONTRACT ADMINISTRATION

CONTRACT AWARD or RENEWAL PACKAGE

REFUGEE SOCIAL SERVICE PROGRAM Contract Renewal Package Required Documents and Forms

Annex A:

Program Summary

Contract Summary Sheet

Authorized Signatures

Service Delivery Information

Program Narrative

Renewal Documents:

Index of Required Contract Documents

Contract Checklist

Document Verification Sheet (DVS)

Executive Order 129

Certification of Suspension and Debarment

List of Contracts/Grants

Contract Forms (List of Required Documents Available on DFD Website)

Annex B Helpful Hints

Federal Award Information

G. Instructions

Program Summary Enter the information on the site where services for this program are provided.

Contract Summary Sheet

Enter Agency Name, Address, Telephone and Contract No., Federal Identification No., Contract effective dates (as noted in the DFD contract award letter) and contract ceiling (per Annex B).

Enter CEO and Agency notice information. All data must be completed.

Authorized Signatories

Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board Resolution).

IMPORTANT - This is the address where the signed contract and all relevant legal correspondence will be mailed – so please ensure this is the accurate address.

Service Delivery Information

Service will be provided as follows for each day of the week, enter the hours the agency will provide contracted services. Please indicate if there is a difference among any of the contracted services in the program specific narrative.

Emergency Provisions Describe any special arrangements which have been made to handle emergencies, e.g. voice mail instructions, special telephone numbers etc.

Service will not be provided on the following occasions List the occasions and dates when service will not be provided, e.g. December 25-Christmas, July 4-Independence Day, etc.

Program Narrative

*Please see specific instructions attached to this section ANNEX A - Program Summary

Program Name: Site Address: City, State, and Zip Site Phone Number: - - Program Director/Coordinator Telephone #: - - Fax: - - E-Mail: STATE OF NEW JERSEY - DIVISION OF FAMILY DEVELOPMENT

ANNEX A – CONTRACT SUMMARY SHEET Provider Agency Contract # Mailing Federal ID # Address

Telephone - - ProviderNumber Agency Fiscal Contract to Contract $ Effective Date Ceiling Organization County Type Municipal (i.e. School) Private, Non-Profit

Private, For-Profit % Indicate % of profit charged towards contract Faith-Based Hospital-Based

Chief ExecutiveTitle Mailing Address

Telephone - - NumberFax - - NumberE-Mail Address All routine notices relevant to the administration of the program should be sent to: Name & TitleMailing Address

Telephone - - NumberFax - - NumberE-Mail Do Addressyou currently receive payment by Automatic Deposit (ACH) for this contract?

Yes No Division of Family Development Annex A Authorized Signatures

List names and positions of persons authorized to sign the following and number of persons required to sign each transaction.

Name/Address Position # of Signatures Required 1 Contract 2 1 3 1 Quarterly and Final 2 1 Financial Reports 3 Contract 1 Budget Modification2 1 3 1 Checks 2 3 Other Contracts and1 Agreements 2 3

Note 1 - Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board Resolution). This is the address where the signed contract and all relevant legal correspondence will be mailed. This should be the individual who signs the SLD (page 23). This may not be the same individual as noted in the Annex A summary sheet. In the event of emergency notification, please include e-mail and fax number.

Contract Signatory Title Mailing Address

Telephone Number - - Fax Number - - E-Mail Address Contract # Division of Family Development Annex A Service Delivery Information

Program Name: Site Address: City, State, and Zip Site Phone Number: - - Program Director/Coordinator Telephone #: - - Fax: - - E-Mail:

Service will be provided as follows (designate time):

From To Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Services will not be provided on the following occasions:

Date (s) Occasion Division of Family Development ANNEX A PROGRAM OPERATIONS NARRATIVE

REFUGEE SOCIAL SERVICES PROGRAM ANNEX A

PROGRAM GOALS AND DESCRIPTION

The Department of Human Services (DHS) Division of Family Development (DFD) recognizes that critical social services and supports are needed for new refugee arrivals and eligible populations resettling in New Jersey to help them transition to their new life. Refugee Social Services (RSS) under the Office of Refugee and Resettlement Program (ORR) is 100% federally funded, under Part 400 of Title 45 under the Code of Federal Regulations (CFR) to provide an array of employability and supportive services that foster personal responsibility, promote economic self-sufficiency and social adjustment. Categories of Refugees and Eligible Immigration Status for ORR services:  Refugees in possession of an I-94 stamped “Admitted as a Refugee Pursuant to Section 207 of the Act” are eligible for services;  Parolees who have an I-94 with “paroled as a refugee” or “207” stamped or written on the document are eligible;  Cuban/Haitian entrants who have been granted parole, applied for asylum, or are in exclusion or deportation proceedings but have not received a final order of deportation;  Asylees;  Special Immigrant Visas (SIVs) from Iraqi and Afghan; and  Certified Victims of Trafficking.

The primary purpose of New Jersey’s RSS is to assist eligible populations to adjust socially and attain the skills needed to find employment and becoming self-sufficient as quickly as possible through an array of services. These services are provided in collaboration with a network of service providers to ensure that the necessary support and assistance is given in accordance with ORR’s priority in providing services. Priority in Providing Services  All newly arriving refugees during their first year in the U.S. who apply for services;  Refugees who are receiving cash assistance;  Unemployed refugees who are not receiving cash assistance;  Employed refugees in need of services to retain employment, achieve job upgrades, or attain economic independence.

Services Available and Time Limits

Providers should consider the strengths, resources, and community capacity to ensure that refugees access the highest quality of services within their community. These services are an important aspect of helping refugees integrate and become contributing members of their communities as quickly as possible.

8 The Division believes that successful resettlement requires a continuum of support and services of State and local government, public and private partners, community-based agencies, and refugee resettlement agencies. DFD strives to provide a comprehensive approach to the RSS program through a network of culturally competent providers and resettlement agencies, local community resources, and supportive social services through the County Welfare Agencies (CWAs) and employment services, such as the One Stop Career Centers (OSCCs) to foster social and economic self-sufficiency as soon as possible.

Description of Possible Services as indicated in 45 CFR 400.154

Employment Services – must include an Individual Employment Plan (IEP) and Family Self Sufficiency Plan (FSSP) to determine the appropriate skills, training and services necessary to help the individual or family become self-sufficient through timely employment. Examples of services include:

1. Employment Assessment Services – adjunct services (aptitude for certain professions, skills testing, job coaching and development). 2. Job search, placement, and follow-up. 3. On the job training – provided by prospective employers with expected outcome of employment. 4. Vocational Training – that provide ready skills in a short period of time and part of the IEP and FSSP plans a. Tuition reimbursement –available for vocational training, skills certification, licenses, etc. upon DFD’s approval. 5. Skills Certification – recertification of licenses; except for certain restrictions – must meet the criteria for appropriate training in 45 CFR 400.81(b). 6. English language instruction – with emphasis on formal and certified instruction, and as it relates to obtaining and retaining a job – no other resources available a. ESL – details of type and services – certified, schedule, duration (ESL and vocational training must be provided to the fullest extent feasible outside normal working hours to avoid employment interference). 7. Transportation – when necessary for employability services or for acceptance or retention of employment – no other resources available. 8. Translation and interpreter services, when necessary in connection with employment or participation in an employability service. 9. Case Management Services – as defined as the determination of specific service(s) to which to refer a refugee in accordance with an employability plan, referral to such service(s), and tracking of the refugee’s participation in such services employable. 10.Other Service – for example, information and referral services, (these were previously mentioned above). 11.Social Adjustment Services – household budget & management, health related services, short-term counseling (crisis).

The employment-related descriptions listed above are specific eligible social service activities for the purpose of obtaining gainful employment in accordance with ORR guidelines. For all individuals accessing services under this grant, individuals must be given every opportunity to quickly access services and supports to assist them in becoming integrated members of American society and employed and to become self- sufficient. In addition, they should not be duplicative of existing service delivery systems.

Though social services are up to 60 months, as established by 45CFR 400.152, priority for providers should be for those that have been in New Jersey for less than 12 months.

Learning English is a very critical and primary component of obtaining employment. Instruction can take place in a wide range of settings which must be considered when referring or providing these services to ensure that individual needs and varying schedules are being met. If certified and flexible ESL services are offered in the community, individuals should be informed of those services to consider meeting the schedules of the families.

Another important component of the ORR program is refugees easily accessing culturally and linguistically supportive social services. The resettlement agencies are required to refer individuals to the CWA to obtain federally funded benefits and services, such as medical, food and if eligible, cash assistance to assist them in becoming integrated into their new society. This is in an effort to meet their basic needs while emphasizing self-sufficiency. The referral process will ensure expedited services to these appropriate and critical benefits.

Likewise, the CWA also will refer eligible individuals that need culturally and linguistic ORR employability social services; such as cultural orientation, job readiness, preparation and placement, as well as, supportive and ESL services to the local resettlement agencies.

The resettlement agency contracted with DFD must provide those prescribed employability services as outlined above in accordance with ORR’s regulatory provisions at 45 CFR 400.154.

MONITORING AND QUALITY ASSURANCE

1. DFD will conduct a minimum of two annual site and chart reviews.

2. DFD will conduct unannounced site and chart reviews.

3. The State refugee coordinator should be informed, or made aware of, critical or unusual events (such as criminal or federal investigation); all monitoring/site visits from ORR and/or the national agency and a copy of that agency’s final report; budget and/or funding reductions; staffing changes and/or other changes or events which could affect your agency’s operations or could cause concerns and/or problems to the community and/or the State of New Jersey.

Administrative General Requirements

10  Participate in collaborative meetings and committees with key partners related to the scope of work outlined in this contract.  Employ adequate qualified and bilingual staff to meet the performance requirements or deliverables of the contract.  Develop and utilize sound fiscal and programmatic accountability procedures and policies, which are approved by DHS/DFD.  Train staff on confidentiality practices and implement policies to safeguard confidential and private information.  Maintain accurate and current client information in accordance with State and Federal recording requirements.  Identify disaster recovery protocol and procedures for shifting services in the event of extreme circumstances, such as a natural disaster or significant damage to the service location, and provide a detailed Business Continuity and Disaster Recovery Plan that will be implemented in the event of an emergency.  Conduct an annual self-assessment and evaluation to ensure that program services are informed by research, best practices and to measure the impacts of service delivery on programs and clients.  Establish a process to extract and analyze data.

Key Statutory and Regulatory Requirements under this contract:

The provider agency assures that it will comply with required statutory requirements and ensure Federal and State funds are utilized for eligible clients and services in accord with DHS/DFD policies and regulations. At a minimum, the agency will: a. Have internal controls and performance measures to determine whether the rules are accurately applied; b. Adhere to applicable Federal rules and State program compliance requirements; and c. Assure appropriate use of funds for allowable services to carry out the goals and objectives of the program.

Eligible Clients

In accordance with program funding requirements – only clients that meet program eligibility criteria should receive services. The provider agency is required to maintain a system of internal control and appropriate processes to ensure the integrity of program funding.

Personnel Requirements

The agency director or program designee must attend and participate in DFD- sponsored in-person meetings and trainings, or conference calls as directed by the DFD Program Staff.

Fiscal Standards and Accountability

Recipients and sub-recipients of Federal and State funds are responsible for the proper use of such fund. Simply, this means that the funds are used for the intended purpose with compliance with all Federal, State and contract regulations. All parties are responsible for the transparency and accountability for the funds and are subject to administrative, contractual and legal sanctions for the misuse and/or improper use of these funds. Provider Agencies are considered sub-grantee/recipients under this contract and are subject to Federal laws, regulations and provisions of this contract as set forth in this document; and must ensure adherence to all applicable regulations, including: a) Contract funds are allocated to meet program objectives and for the purpose as intended. b) Fiscal and accounting procedures are sufficient to permit the preparation of required reports and the proper reconciliation of expenditures to adequate source documentation to establish funds have been used appropriately for the intended purpose in accordance with all applicable laws, regulations, and contract cost principles. a) Annual completion of the Single Audit, as required. b) Funds are not used to support inherently religious activities, such as religious instruction or activities. c) Funds are not used to support lobbying activities to influence proposed or pending Federal or State legislation or appropriations. d) Funds are expended in accordance with all pertinent laws and regulations.

Allowable Cost The determination of allowable costs is defined in the Standard Language Document (SLD), RFP, DHS and DFD Cost Reimbursement Manual (CRM) and the DHS Contract Policy and Information Manual (CPIM). Expenditures are defined as those costs which are restricted to activities related to programmed plan development; complaint files management; public hearing information; program monitoring and coordination; report preparation; evaluation of program outcomes; personnel management; travel; equipment; supplies; audits and response management; and indirect costs such as maintenance of facilities, utilities, and general management staff.

General Program Requirements The use of State and Federal funds must adhere to all governing laws and regulations including those contained in the: d.i)New Jersey regulations. d.ii) DHS/DFD Contract terms contained in the SLD and RFP. d.iii) DHS/DFD contract rules and regulations contained in the CRM and CPIM. d.iv) DFD instructions and guidance memos, including all approved amendments or revisions. d.v) All other Federal, State and local laws and regulations.

The agency must meet all contract expectations as described in the RFP as well as those detailed in this contract. Failure to meet any performance standard and contract expectations can be grounds for revision of the contract whereby current funding is reduced, contract is suspended or terminated and can affect future consideration for funding.

In addition to the core areas of program delivery, provider agencies must maintain administrative and fiscal accountability, meet reporting requirements, and ensure program integrity to meet all program compliance and performance standards. As 12 recipients of government funds, all agencies must adhere to all Federal and State laws and regulations as stated above.

DFD PROGRAM AND FISCAL REPORTS

The goal of program reports is to use data to improve program services, service delivery and utilization. Monthly, Quarterly and Annual Reports may include but not be limited to:

1. Monthly and Quarterly reports on every client serviced is required and should include but not be limited to: a. Federally required reports (monthly, trimester and a the Annual Goal Plan) b. DFD required reports: 1. Arrival data b.i. 2. Asylees data b.ii. 3. Number of clients serviced b.iii. 4. Number of employment placements unduplicated

2. Other program reports as requested by DFD in the timeframe required.

All program reports should be submitted to Renee Ingram at [email protected]

Fiscal Reporting Requirements

The agency is required to submit program and fiscal reports within the required timeframes. At a minimum, the following reports are required:

Fiscal reporting is required on a quarterly basis combining subcontracted and direct agency expenditures. Actual expenditures must be reported using the Annex B form on a cumulative basis by the 20th day of the following month after the close of each calendar quarter.

The Final Report of Expenditures (ROE) is due 120 days after the contract period ends.

The expenditure reports must contain an original signature of the CEO and fiscal officer designated by the agency for this program.

An initial advance payment will be issued when the contract is fully executed. Future quarterly reimbursements will occur subsequent to DFD’s receipt and review of the expenditure report for the previous quarter and as long as all other contract deliverables are met.

All reports are to be sent to: DFD, Office of Contract Administration P.O. Box 716 Trenton, New Jersey 08625-0716 Attention: Contract Fiscal Unit Payment Terms

The initial advance payment representing 25% of the contract ceiling will be issued when the contract is approved and signed. Subsequent quarterly advance payments are issued upon receipt and review of the quarterly ROE and, assuming all other contract obligations are current and there are no violations of any other contract provisions. Adjustments to a quarterly payment may be made for a variety of reasons, including provider agency spending patterns, DFD fiscal review issues, audit matters that come to our attention, or as needed to meet program delivery and DFD Budget/ Fiscal issues.

14 Annex A - Narrative and Questions A. Narrative

Please provide a detailed written narrative of your agency’s proposed program. The program description should present a clear picture of the program’s structure, staffing, description and implementation of specific services to be provided (as detailed in the Annex A scope of work) and service delivery methods/process, referral process if applicable, coordination with other collaborators/stakeholders and local service providers as applicable. The agency’s description should explain how and where the services will be provided and by whom – detailing the use of all consultants and subcontractors with details of the agency’s monitoring of the services from consultant and subcontractors.

The narrative should include a detailed implementation plan for the completion of the DFD program including all components detailed in the scope of work.

B. Annex A Questions

Please concisely respond to the questions below:

1. Staffing: Describe staff positions, responsibilities and provide staffing structure information. (Provide their position, titles, duties, and the percentage of time worked in the program). a. If staff time is charged to more than one program and/or grant, describe the process used to ensure the allocation of time spent on each program/grant is correct or supported. b. Who supervises the provision of services/activities/outcomes and ensures they are timely, documented and reported? c. What kind of staff in-service training do you provide to the program staff? d. Will any services be provided by consultants or subcontractors? If so, please provide details of the consultant/subcontractor (i.e. scope of work, terms of the agreement, reimbursement terms, key staff including areas of expertise and credentials). Copies of the agreement must be attached or contract approval will be delayed.

2. Provide a brief overview of your agency’s program and specific role with administering the ORR program. The narrative should include: a. Your agency’s success and/or challenges administering the program last year. b. Provide statistics of how many clients were served through ORR funds – and the services provided – indicate the types of populations serviced. c. Explain the goals and objectives for this contract period. d. Describe the need for the grant and how it is going to be utilized. e. Indicate other Federal, match dollars and amount, etc.; used for the same or similar services and/or populations. f. Describe what employability services your agency will provide. Include the following: f.i. Type of employability services, as outlined above. f.ii. If ESL is provided, please provide details – (certified instructors, type of instruction basic, structured, classroom or home setting; on- site or referred, various levels, number of hours per week, how many instructors, language spoken etc.). g. Description of how you will ensure that the prioritized populations are being serviced. Priority is for new arrivals and the unemployable – within the first year of arrival. h. Explain your referral process with the CWA and other community resources and collaboration efforts. Accessing supportive social services is paramount due to the urgent need to obtain basic services. i. Provide details of your staffing composition – experience and language, percentage of time allocated under this contract, and projected staff to client ratio. Cultural and linguistically competent staff is essential due to the language and social barriers many of the populations face.

3. Describe how your internal process and monitoring procedures ensure that refugees do not receive duplicated services if they are eligible for services under more than one grant. 4. Describe how your agency plans to evaluate the program. Explain how your agency plans to collect data. Identify any strengths and weaknesses from prior evaluations. 5. Explain the monitoring and quality assurance of the program including: a. Submit a copy of the Agency’s Quality Assurance and Monitoring Policies and Procedures.

b. Provide information on refugee’s satisfaction survey for program services. How often is this survey done? If your agency does not have a customer survey, please describe your plan to implement one.

c. Does the agency have a wait list for any services? If yes, how does the agency determine which refugees receive services and when?

6. What systems are in place to ensure that accurate records are maintained for completing all required program and fiscal reports? 7. How does your agency provide linguistically and culturally appropriate services to clients? Provide information on your program staff’s multi-lingual capacity (languages, cultural and translation services). a. How does your program ensure compliance with Title VI (LEP policy)? Are program forms, flyers and other written materials translated into client’s native language? Do clients sign forms indicating their understanding of the program requirements and services? How is this issue addressed with illiterate clients? b. Describe your agency’s English language and literacy services.

8. What barriers or challenges do you anticipate in the implementation of the program goals, objectives, activities and achieving its outcomes?

16 a. Identify any challenges, limitations, or restrictions on services and coordination. b. What will be your agency’s strategy for addressing the challenges?

9. Describe how your agency will meet the objectives, goals, and deliverables of the contract as detailed in the scope of work.

10.What systems are in place to ensure that accurate records are maintained for completing all required program and fiscal reports?

11.Describe your agency’s purpose, philosophy, goals, and objectives.

12.How does the mission of the program align with your agency’s mission? Describe how the program will benefit/impact the community?

13.Identify and describe any unique capabilities of your agency in delivering the service.

14.Identify any changes, challenges, limitations, restrictions, and priorities on meeting the scope of work requirements.

15.Identify past year program goals and summarize performance outcomes. Provide a summary of select agency accomplishments. If this is a renewal contract, describe at a minimum how has your program developed and made progress toward its goals in the past.

16.What barriers, if any, have impacted your agency’s ability to meet program goals?

17.Describe the agency’s outreach efforts and communication efforts for the program.

18.If fees will be collected from recipients of any services outlined in the Contract Requirements, state the anticipated annual amount of revenue. Also state how those revenues will be used to offset the contract’s costs.

DIVISION OF FAMILY DEVELOPMENT REFUGEE TRAINING AND/OR VOCATIONAL SERVICES SUPPORTIVE SERVICES AND TUITION ASSISTANCE REQUEST

Date of Referral: Agency: Contract #

Student’s Name:

Address:

Employed Yes or No If Yes how long Type of Support or Vocational Training Computer Training Services License or Certification *Alternative ESL (non-traditional)

*Transportation Services Child Care Beginning and End Dates Reason for Training

Your signature below verifies that these statements are true:  Student has been in the United States a maximum of 60 months  Training is to help obtain employment or upgrade employment  No other financial assistance was received that would duplicate this request for assistance  No other resources available in the County or accessible transportation

Student Signature: Date:

Agency Staff Signature: Date:

DIVISION OF FAMILY DEVELOPMENT USE ONLY

Amount Requested: $ Amount Approved: $ Amount Disapproved: $ Staff Signature: Date:

Supervisor’s Approval: Date:

* Transportation - must complete a separate transportation reporting form * ESL – must be a certified structured program and individual must be working Compliance Standard Indicators/Documentation

Cultural and Linguistically Competent Employment Orientation Orientation provided in clients’ language or in partnership Materials and information of ORR benefits in clients with a Translator. language or translated Ensure Person eligible for services Status, arrival data, intake and case notes Employment Cultural Orientation completed within 5 days of Intake forms along with any documents and case notes arrival in their language DIVISION OF FAMILY DEVELOPMENT REFUGEE TRAINING AND/OR VOCATIONAL SERVICES SUPPORTIVE SERVICES AND TUITION ASSISTANCE REQUEST Person informed of ORR program and social service grant Signed document services for up to five years

Person informed of welfare benefits & work requirements; as Case notes well as other relevant supportive services - ESL programs, and social service supports. Person informed of ESL and Vocational Training tuition Case notes assistance through social service grant

Person informed of modes of transportation and assistance Case notes or signed receipt through the social service grant

Person informed of Rights and Responsibility Signed document Person informed of Agency’s Grievance Policy Signed document

Employment and Self-Sufficiency Plan Plan included in case file, along with any documents and case notes.

Comprehensive Employment and Self Sufficient Assessment Signed Plan conducted utilizing a standardized form – identifying strengths, challenges, and plan of action. Joint self-sufficiency or Employment Plan developed with Signed Self Sufficiency Plan included in case file individual’s and staff signature

Referrals and Supportive Services

Person referred for supportive services no later than one week Official DFD referral document in file after arrival

Person accompanied to initial visit to Board of Social Case note Services with a translator if required

Medical Insurance (Medicaid) obtained within 30 to 45 days Application Date

Food Stamps obtained within 30 to 45 days Application Date Transportation provided for employment related appointments Log Sheet and case notes

Referred for ESL Assessment and Placement Test Include assessment in file, start date, and schedule.

Refugee Resettlement Program Social Service Grant Contract Compliance Standards

Employment Services Readiness, Preparation, and Placement Provided Job readiness services; i.e. coaching, counseling, Indicated on Employment Plan and case notes resume, job etiquette and expectation Person notified of job leads, interviews or openings in Document in case notes and referral services accordance with Employment Plan Referred to jobs and/or interviews Referral in case file and documented in case notes Person escorted for job interview Documented in case notes Transportation assistance provided Receipt and client signature Placed in Job Documented in case file DIVISION OF FAMILY DEVELOPMENT REFUGEE TRAINING AND/OR VOCATIONAL SERVICES SUPPORTIVE SERVICES AND TUITION ASSISTANCE REQUEST ESL Referred to Free ESL classes Referral form Enrolled in certified formal ESL Instruction Documented in case file Training Vocational Training Assistance Provided Tuition Application – must be eligible and aligned with IEP and SSP Referred to Community Resource Programs Referral notification Case Management and Follow-up Person assisted with obtaining social and supportive services DFD Referral Form at the local welfare agency Helped obtained immigration and citizenship information and Case notes and/or referral services, and documentation Person assisted with school enrollment, medical services, Case notes other eligible supportive services etc. Separate case record or section for ORR social services Case File

Follow-up on employment at 60, 90 & 180 days Documented in file with outcomes Follow-up on ESL, training completion and job placement or Documented in file with outcomes upgrade Staffing and Administrative Oversight Adequate staff to meet contract deliverables Full-time employment specialist staff for 50+ caseload Staff culturally and linguistically compatible with clients Services provided in a manner that is compatible with servicing clients language and cultural background Knowledgeable staff on refugee and social service Experience and background Timely submission of all required DFD reports Submission of report Collaborative partners and community resources Referral types and placements Timely complaint resolution Quick Turnaround time to resolve issue Refugee Resettlement Program Social Service Grant Contract Compliance Standards

I have read the ORR social service grant Program Deliverables and Contract Compliance Standards and agree to comply with each deliverables and standard:

Authorized Signature: Date:

Print: Title:

Refugee Resettlement Program Social Service Grant Contract Compliance Standards

The below individual(s) have been admitted to the United States, and meet Office of Refugee and Resettlement Program eligibility immigration status and identification requirements as sited in N.J.A.C 10:90-10:6.

Date: CWA:

Referring Agency: Staff: APPLICANT INFORMATION Applicant Name: ______D.O.B.: Family Unit Size: Language(s) Spoken: USCIS Status: ______Alien #: Date of Arrival or Status was Granted: ______*Match Grant Program: ( ) Yes ( ) No Phone #: Address:

Services and/or Benefits Requesting  Cash Assistance  Food Stamps  Medicaid

A Translator will be present: ( ) Yes ( ) No Name of Translator:

Refugee Agencies Catholic Charities Diocese of Camden Catholic Charities of the Archdiocese of Newark, 976 1845 Haddon Ave, Camden, NJ 08103 Broad St, Newark, NJ 07102 856-342-4100 973-733-3516 Lutheran Social Ministries of NJ Jewish Family & Vocational Service of Middlesex 189 South Broad St, Trenton, NJ 08601 32 Ford Avenue, 2nd floor, Milltown, NJ 08850 609-393-4900 732-777-1940 ext 1124 International Rescue Committee Jewish Vocational Services 10 West Grand St., Suite A, 111 Prospect St., East Orange, NJ 07017 Elizabeth, NJ 07201 973-674-3672 908-351-5116

*Individuals who are enrolled in the Match Grant Program cannot receive cash assistance benefits.

Title 45: Public Welfare - PART 400—REFUGEE RESETTLEMENT PROGRAM Any cash grant received by the refugee under the Department of State or Department of Justice Reception and Placement programs may not be considered in determining income eligibility. N.J.A.C. 10:90-10.1 - Any cash assistance from the referring agency or sponsor shall be treated as unearned income. STATE OF NEW JERSEY

DIVISION OF FAMILY DEVELOPMENT CONTRACT CONTRACT ADMINISTRATOR: NUMBER: NAME OF CONTRACT AGENCY: PERIOD: INDEX OF REQUIRED CONTRACT DOCUMENTS

This index provides details of all required documents that must either be included with the contract package (see checklist) or must be available on site for inspections as noted in the Document Verification Sheet (DVS). Forms that are not included in the following pages, can be found by accessing the website at www.state.nj.us/humanservices/dfd/info and clicking on the link for Standard Contract Documents.

Required Required Required for on- with first Annually site Document Contract and as Verificati Check if and as Amende on - DVS submitte Amende d Form d with d Checklist package Contract Documents 2 Standard Language Document (SLD) with original signatures copie (additional copies requested must also have original signature) s 3 Annex A (including summary sheet and supporting schedules) copie s 3 Annex B – Budget Form with all required forms, schedules, copie and signatures s Executive Order 129 (Public Law 2005, Chapter 92) Source ● Disclosure Certification Form Federal Funding Accountability and Transparency Act (FFATA) ● Worksheet (if applicable) Certification of Suspension and Debarment ● 1 . Agreements

Copies of Subcontract/Consultant Agreement(s) ● Private/Public Donor Agreement (s) for Match Responsibilities ● HIPAA Business Associate Agreement (BAA) ● ● A copy of the Acknowledgement of Receipt of the New Jersey ● State Policy and Procedures for EEO/AA 2 . Insurances/Licenses/Certificates

Liability Insurance Declaration Page and/or Malpractice ● Insurance Bonding Certificate ●

22 Required Required Required for on- with first Annually site Document Contract and as Verificati Check if and as Amende on - DVS submitte Amende d Form d with d Checklist package Applicable Licenses (business and professional licenses) ● Current Affirmative Action Certificate or copy of renewal application sent to Treasury (AA302 – Affirmative Action ● Employee Information Report) Health/Fire Certificates ● Certificate of Occupancy or Continued Certificate of ● Occupancy

Required for on- site Page Required Required Verificati 2 Document with first Annually on – Check if Contract and as DVS submitte and as Amended Form d with amended Checklist package Lease or Mortgage for Property and Equipment ● .

● Certificate of Incorporation

New Jersey Business Registration Certificate with the ● Division of Revenue (Public Law 2001, Chapter 134) Documents Required for Non Profit Agencies and as applicable for Profit Agencies

Dated List of Names, Titles, Addresses, and Terms of Board ● of Directors

Copy of the most recently approved Board Minutes ● Agency By-Laws ● Tax Exempt Certification ● ● Form 990 – Return of Organization Exempt From Income ● Tax Documents Required for Profit Agencies only U.S. Corporation Income Tax Return, Form 1120 ● Chapter 51/Executive Order 117 Vendor Certification and Disclosure of Political Contributions (formerly known as bi- Executive Order 134) and copy of NJ Business Registration annual Certificate (see separate link) bi- Ownership Disclosure Form (Chapter 51) annual Agency Policies and Organizational Information Organizational Chart ● Personnel Manual and Employee Handbook (including job ● descriptions of staff) Affirmative Action Policy/Plan ● Conflict of Interest Policy ● Procurement Policy ● Equipment Inventory (contract acquires property with DFD ● funds) Audit Notification of Licensed Public Accountant (NLPA) - include ● copy of Accountant’s Certification (see separate link) Copy of Single Audit or Independent Audit for recent FY ● Other Supporting Documents Annual Report to Secretary of State ● Annual Report – Charitable Organizations ●

Required for on- Required Check if Required site Annually submitte Page 3 with first Verificati Document and as d with contract on – Amended package DVS Form

ACH – Credit authorization for automatic deposits (for new ● requests only) W-9 Form (for new Agencies only) ● Additional Division/Office Specific Forms Document Verification Sheet (DVS) ● List of Agency Contracts ● Standard Board Resolution (indicating authorized signatories ● for contracts) Checklist and Copy of Award Letter ● Purchase and Property Disclosure Form (Iran Form) ●

The contracted agency agrees to submit, to the DFD Contract Administrator, any and all changes regarding the information presented in these documents during the term of the contract. All documents should be current and reflect the approval of the agency’s Board of Directors, when applicable.

The index is for reference and is not required to be retuned with the contract package. All documents noted here are either included in the Checklist or Document Verification Sheet (DVS). The checklist and DVS must be returned with the contract package.

24 DFD OFFICE OF CONTRACT ADMINISTRATION CONTRACT CHECKLIST

CONTRACT CONTRAC ADMINISTRATOR: T NUMBER: NAME OF CONTRAC AGENCY: T PERIOD:

PROVIDER INSTRUCTIONS: This checklist must be completed and returned with all documents prior to contract approval. The correct number of copies and any additional Division documents must be returned to your Contract Administrator. Forms that are not included in the following pages, can be found by accessing the website at www.state.nj.us/humanservices/dfd/info and clicking on the link to Standard Contract Documents.

Number If not submitted with Please check of copies package, indicate if submitted Document to be anticipated date of with package submitted submission or reason for non-submission Complete copy of signed DHS Standard 2 Language Document (SLD) Checklist, DVS and Award Letter 1 Executive Order 129 Source Disclosure 1 Certification of Suspension or Debarment 1 Standardized Board Resolution indicating who is 1 authorized to sign: Contracts and Checks

Annex A (including summary sheet and 3 supporting schedules)

Annex B –Budget Form (Expense Summary, 3 Details and Schedules 1-6) List of Contracts 1

Equipment Inventory 1 Liability Insurance 1 Bonding Certificate 1 Names, Titles, Addresses and Terms of Board of 1 Directors Copy of Audit Report 1

Current Affirmative Action Certificate or copy of 1 renewal application sent to Treasury (AA302)

Chapter 51, Public Law 2005—For-Profit agencies only 1 Federal Funding Accountability and Transparency Act (FFATA) Worksheet (if applicable) 1 Copies of Subcontracts 1

Document Number Check if data If not submitted, provide date of Copies is submitted when document will be provided to be with package submitted

Notification of Licensed Public Accountant 1 (NLPA) (include copy of Accountant’s Private/Public Donor Agreement for Match Responsibilities 1 Organization Chart 1 W-9 Form (for new provider only) 1 Conflict of Interest Policy 1

1 As Applicable:

ACH – Credit authorization for automatic deposits 1 (for new requests only) W-9 Form (for new providers) 1 Other: Purchase and Property Disclosure Form 1 (Iran Form) 1

26 NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF FAMILY DEVELOPMENT

DOCUMENT VERIFICATION SHEET (DVS)

Contract Number Contract Period

The Provider Agency hereby certifies that the following documents are on file and are available to the Division of Family Development (DFD) for review. The contracting Provider Agency also agrees that it will inform the DFD contract administrator of any and all changes involving these documents that may occur during the term of the contract. All documents should be current and reflect board approval. Please do not submit documents listed below with renewal package.

Not Please Check as Appropriate On File Applicable

1. Certificate of Incorporation and NJ Business Registration Certificate (filed with the Division of Revenue) 2. Annual Report to Secretary of State and Ownership Disclosure Form 3. Annual Report - Charitable Organization 4. Agency By-Laws and Copy of Board Meeting Minutes 5. Business Associate Agreement (unless new provider or revised agreement) 6. Business and Professional Licenses 7. Personnel Manual and Employee Handbook (including current job descriptions for staff) 8. Tax Exempt Certification, Copy of Form 990 9. U.S Corporation Income Tax Return, Form 1120 10.Procurement Policy 11.Certificate of Occupancy or Continued Certificate of Occupancy and Health and Fire Certificates 12.Property Lease/Mortgage and Equipment Leases 13.Affirmative Action Policy and copy and acknowledgment of NJ State Police Policy on EEO/AA

I hereby certify that all documents are current and are available for review.

Agency Director (Please Print or Type)Agency Director’s Signature

Agency Date EXECUTIVE ORDER 129 CERTIFICATION

SOURCE DISCLOSURE CERTIFICATION FORM

Bidder: Solicitation Number:

I hereby certify and say:

I have personal knowledge of the facts set forth herein and am authorized to make this Certification on behalf of the Bidder.

The Bidder submits this Certification as part of a bid proposal in response to the referenced solicitation issued by the Division of Purchase and Property, Department of the Treasury, State of New Jersey (the “Division”), in accordance with the requirements of Executive Order 129, issued by Governor James E. McGreevy on September 9, 2004 (hereinafter “E.O. No. 129”).

The following is a list of every location where services will be performed by the bidder and all subcontractors.

Bidder or Subcontractor Description of Services Performance Location(s) by Country

Any changes to the information set forth in this Certification during the term of any contract awarded under the referenced solicitation or extension thereof will be immediately reported by the Vendor to the Director, Division of Purchase and Property (the “Director”).

I understand that, after award of a contract to the Bidder, it is determined that the Bidder has shifted services declared above to be provided within the United States to sources outside the United States, prior to a written determination by the Director that extraordinary circumstances require the shift of services or that the failure to shift the services would result in economic hardship to the State of New Jersey, the Bidder shall be deemed in breach of contract, which contract will be subject to termination for cause pursuant to Section 3.5b.1 of the Standard Terms and Conditions.

I further understand that this Certification is submitted on behalf of the Bidder in order to induce the Division to accept a bid proposal, with knowledge that the Division is relying upon the truth of the statements contained herein.

I certify that, to the best of my knowledge and belief, the foregoing statements by me are true. I am aware that if any of the statements are willfully false, I am subject to punishment.

Bidder: Name of Organization or Entity By: Title: Print Name: Date:

New Jersey Department of Human Services Division of Family Development

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions

1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by an Federal or State department or agency.

2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

Name and Title of Authorized Representative ______

Signature ______

Date ______

This certification is required by the regulations implementing Executive order 12549, Debarment and Suspension, 29 CFR Part 98, Section 98.510 STATE OF NEW JERSEY DIVISION OF FAMILY DEVELOPMENT

STANDARDIZED BOARD RESOLUTION FORM – page 1 of 2

Supporting Information for Contract #:

Contract to Period:

Agency:

Certification:

We certify that the information contained in, or attached to, this contract document is accurate and complete.

______Chair, Board of Directors Date (Original signature)

______Executive Director Date (Original signature)

Please List Authorized Signatories for contract documents, checks, and invoices: (List full name and title)

Name Title

Name Title STANDARDIZED BOARD RESOLUTION FORM – page 2 of 2

The Board endorses the following commitments as defined in this document:

1. Health Insurance Portability and Accountability Act (HIPAA)*

Specific to HIPAA (Health Insurance Portability and Accountability Act), the above noted Provider Agency is deemed a covered entity and must submit the required Business Associate Agreement.

Once executed, the BAA will be included in the Department’s official contract file. The BAA will be considered applicable for this contract. Any changes in the Provider Agency’s status, information or the content of the BAA, is the responsibility of the contracted Provider Agency to revise the BAA.

The Board agrees to notify the Department of any change in its BAA Status and provide the appropriate information within 10 business days.

2. Legal Advice

The Board acknowledges that the Division of Family Development does not and will not provide legal advice regarding the contract or any facet of its relationship with the Provider Agency. The Board further acknowledges that any and all legal advice must be sought from the Provider Agency's own attorneys and not from the Division of Family Development.

3. Public Law 2005, Chapter 51

The Board agrees that the Public Law 2005, Chapter 51 (formerly known as Executive Order 134) compliance forms submitted with the contract is accurate.

4. Public Law 2005, Chapter 92

The Board agrees that the Public Law 2005, Chapter 92 (formerly known as Executive Order #129) compliance forms submitted with the contract are accurate. STATE OF NEW JERSEY DIVISION OF FAMILY DEVELOPMENT

List of Contracts/Grants

Check here if this information already appears on the Annex B, Contract Information Form. If so, do not duplicate information here.

Division/Offi Type ce Contact Provider Contracting Progra of Contrac Person and Agency Contact Division/Offi m Servic t Contrac Amoun Phone Person and ce Name e Number t Term t Number Phone Number CONTRACT FORMS

Available at the DFD website:

AA 302

Federal Financial Accountability Transparency Act (FFATA) Worksheet

Notification of Licensed Public Accountant

Purchase and Property Disclosure Form (Iran Form) ANNEX B - Helpful Hints

Detailed instructions in completing the Annex B including the Cost reimbursement Manual (CRM), Section 5.3 and an Annex B tutorial are located at

http://www.state.nj.us/humanservices/dfd/info/

The budget should detail costs to administer program and meet program goals and objectives including:

Personnel Fringe Benefits Consultants and Subcontractors Materials Equipment Facility Costs and Other Costs

The budget must be:

Agency wide budget Include list of all other contracts/revenue Identify costs as direct and indirect Detail the indirect cost basis of allocation G&A Costs Have two (2) separate original signatures on the summary page

Copies of consultant and subcontract agreements must be submitted FY 14 and FY 15 Federal Award Information

TANF (SH, TS, NC, LG, DV, SF, UF)

FY 14 - Grant Number G-1402NJTANF CFDA 93.558

FY 15 - Grant Number G-1502NJTANF CFDA 93.558

CCDF (UC, KU, SP, TP, FS)

FY 14: Grant Number 2014G996005 CFDA 93.575 Discretionary Contract Grant Number 2014G999004 CFDA 93.596 Mandatory Grant Number 2014G999005 CFDA 93.596 Matching

FY 15: Grant Number 2015G996005 CFDA 93.575 Discretionary Contract Grant Number 2015G999004 CFDA 93.596 Mandatory Grant Number 2015G999005 CFDA 93.596 Matching

Refugee:

Resettlement

FY 14: Grant No. 1401NJRSOC CFDA 93.566

Refugee – School Impact (RF)

FY 13: Grant number is 90ZEO165-01-02 CFDA 93.576

FY 14: Grant number is 90ZE0165-02-01 CFDA 93.576

Refugee – Cuban Haitian (RF)

FY 13: Grant number is 90RQ0039-01 CFDA 93.576

FY 14: Grant number is 90RQ0039-02-01 CFDA 93.576 Refugee REAP (RF)

FY 14: Grant number is 90RT0185-01-02 CFDA 93.576

Food Bank (FB) Department of Agriculture

FY 14 Grant Number is 1NJ400404 CFDA 10.561

FY 14 Grant Number is 2013G99WREE CFDA 93.667

FY 13: Grant Number FEMA-DR-4086 CFDA 97.088