Maryland Department of Agriculture Spay and Neuter Grants Program 2019 CAPITAL EXPENSE/EQUIPMENT REQUEST APPLICATION

The following application form is used for projects that are requesting funds for large capital expenses/equipment: mobile clinics and non exhaustible surgical equipment for clinics and mobile clinics.

Projects with the focus on pets or feral cats need to use the Pet-Focused or Feral Cat-Focused Application form.

Applicants seeking funds for capital expense/equipment funds should be aware of the following criteria and requirements:

Municipal or county governments or non-profit animal welfare organizations with tax exempt status under 501 (c)(3) are eligible to apply to facilitate and promote the provision of spay and neuter services for cats and dogs.

A competitive grant proposal:

Shall target low–income communities and populations to the maximum extent possible and detail how that goal is to be accomplished;

Shall efficiently and effectively facilitate and promote and increase the provision of spay and neuter services for cats and dogs; and

May include public education and outreach components.

Projects must meet the purpose of the Fund. Grant projects that most effectively and efficiently facilitate, promote and increase spay and neuter services for cats and dogs for low income Marylanders and feral cats will be given priority.

Applicants must comply with all other statutory and regulatory requirements pertaining to the Spay/Neuter grant program. Applicants should familiarize themselves with those provisions of the Maryland Code. Program Regulations.

Applicants must be in good standing with the State of Maryland.

Applicants with shelters must be in compliance with the Standards of Care requirements set forth by Sections 2-1701 through 2-1705 under Subtitle 17, Animal Shelters, in the Agricultural Article of the Annotated Code of Maryland.

The Applicant and personnel who will work on the project must have the qualifications and resources (reflected in the application) necessary to perform and complete the work proposed in the application.

Applicants and their organizations should have no history of violations or fines with Maryland Animal Control authorities and any history of violations may be a basis for denying funding.

Applicants shall coordinate with local animal control and shelter staff to confirm their project would impact intake and euthanasia.

Applicants must complete and submit the grant application, with any required attachments as specified in the Instructions document and on the application form by close of business (5:00 PM EST) on or before the posted grant deadline as it appears on the Request for Proposals (RFP) and on the MDA website (Spay and Neuter Grants Program webpage).

REVIEW THE INSTRUCTIONS BEFORE STARTING THIS APPLICATION.

READING AND ADHERING TO THE INSTRUCTIONS DOCUMENT IS CONSIDERED A REQUIREMENT OF THE APPLICATION PROCESS.

MARYLAND DEPARTMENT OF AGRICULTURE

SPAY AND NEUTER GRANTS PROGRAM

2019 CAPITAL EXPENSE/EQUIPMENT APPLICATION FORM

The purpose of the program is to reduce animal shelter overpopulation and cat and dog euthanasia rates by financing grants to local government facilities and animal welfare organizations for programs that most efficiently and effectively facilitate and promote the provision of spay and neuter services for cats and dogs in the State.

All fields are MANDATORY. Application fields left blank may cause your application to be deemed incomplete and ineligible for further consideration. Any fields that are not applicable to your application should be indicated by entering “N/A”. The text fields in this form will expand as you enter your narrative. You may also attach extra page(s) if necessary.

Please carefully proofread all of your text and check your math before submitting your application.

A. Proposal Administration INFORMATION
Title of Proposed Project:	(for MDA use only) Proposal Ref Number:
Total Amount Requested (Greater than $5,000): $	Address, City, State, Zip Code:
Name of Requesting Organization(s):
Phone | Fax of Applying Organization: Phone: Fax:	Website Address, if any:
MDA Spay and Neuter Grants Program Criteria and Requirements By checking the following appropriate boxes, the applicant certifies that the applicant meets our program basic criteria and requirements. CHECK: The Applicant has read and adhered to the 2019 Instructions for Capital Expense/Equipment Request Applications AND: Being a Municipal or County Government, OR Being a Private Organization contracted by a county to provide animal services, OR Being an Animal Welfare Organization with tax exempt status under 501 (c) (3). If so, please attach a PDF of your most current IRS Form 990 if applicable. AND: Being an Applicant that is in good standing with the State of Maryland. If the Applicant shelters animals, the Applicant is in compliance with Standards of Care requirements of Sections 2-1701 through 2-1705, Subtitle 17, Animal Shelters, in the Agricultural Article of the Annotated Code of Maryland. Applicant guarantees that their project personnel or organization has no history of fines or violations with any Maryland Animal Control Authorities or if so has clarified the matter with MDA prior to submittal.
B. POINT OF CONTACT & ORGANIZATION INFORMATION
Project’s Primary Point of Contact (POC):	Financial Point of Contact (FPOC):
Title:	Title:
Phone (and ext. if applicable):	Phone (and ext. if applicable):
Email:	Email:
Employer Identification Number:
Applying Organization: Number of Staff: Number of Volunteers: Briefly describe your organization (i.e. when established, # of animals you typically intake in a quarter, the area you service, etc.) Only include information pertinent to the work you are proposing in this application: Operating Budget for 2018: Operating Budget for 2017: Number of spay/neuter procedures your facility/organization has provided or facilitated for the last 3 years: # of procedures for 2016: # of procedures for 2017: # of procedures for 2018: If the number of surgeries your organization has facilitated has decreased from previous years, please explain why:
Summarize any grants your organization has received in the last 3 years, including grants from MDA (you should be brief: From whom, how much, what was accomplished and where):
Are you applying for another grant from this Program for this cycle? CHECK appropriate box. NO, this is our only application for this cycle. Proceed to Section C. YES, we are submitting more than one application to this program for this cycle. IF YES- Please confirm that your organization has the capacity to perform all the tasks for all the applications proposed: If your 2 applications are related to the same project, please state whether your organization has the capacity and resources to move forward with the project if MDA recommends funding one of your applications but not the other: If your 2 applications are independent from each other, please indicate which application you feel should have priority if the Program can only fund one of your applications:
PLEASE BE SURE TO SUBMIT YOUR ORGANIZATION’S MOST RECENT IRS 990 IF REQUIRED BY IRS.
C. PROJECT DETAILS
C-1-Period of Performance: Give the start date and completion date to your project (month and year). The completion date should be 5 years from your start date: Start: Completion:
C-2- Expense TYPE: CHECK all that apply: Equipment for a new clinic. Equipment for an expansion of an existing clinic. Equipment for a mobile clinic Other: Give a brief description (several paragraphs only) of what will be done with the grant. (The details should be provided in subsequent sections of the application form.): C-3-State of Readiness: CHECK: If applying for equipment to expand an existing clinic: Applicant confirms that the space for the equipment is fully constructed and ready for equipment installation. CHECK: If applicant is applying for equipment for a new clinic (stationary or mobile): Applicant confirms that (if applying for equipment for a new clinic) that the space for the equipment is fully constructed, are either licensed or in the process of obtaining all licenses and permits, and have secured a veterinarian for your facility. Detail at what stage you are currently:
D. Need For Request
CHECK and PROVIDE information for ONE of the below: D-1-A-Need For Equipment To ExpanD AN Existing Clinic: Describe your present operating capacity and service area and why expansion is necessary (quantify client backlog, demand for services, etc): OR D-1-B-NEED FOR Equipment for New Clinics (stationary or mobile): Describe the target area(s) and the need for a clinic: OR D-1-C-Other: Describe the target area(s) and the need for the requested item:
D-2-Relevant Shelter Data: If you need more space for additional shelters, please attach a page.
Shelter Name and County:
Total Intake for: 2016/2017/2018	Total Euthanasia for: 2016/2017/2018
Cats	/ /	/ /
Dogs	/ /	/ /
2nd Shelter Name and County (if applicable):
Cats	/ /	/ /
Dogs	/ /	/ /
Additional Information: If you have additional data from other sources, discuss here: CHECK: Required MAP of the service area is included with this application.
E-BENEFITS from this Request
E-1-Expected benefits: Discuss any benefits that will be derived from this capital expense/equipment request:
E-2-A-Commitment to provide service: Due to the high dollar amount of capital expense requests, the Program expects recipients of funds of this nature to make a commitment to provide no cost/low cost procedures for no less than the period of performance (5 years). CHECK: Applicant understands and agrees to the requirement to provide 3,000 low cost/no cost spay/neuter procedures during the first 2 years of operation and 3,000 low cost/no cost spay/neuter procedures each year after until the completion of the project’s period of performance, without additional funding from MDA. What percent of the spay/neuter procedures you anticipate performing with this equipment will be for pets of low income Marylanders or feral cats? What percent of these spay/neuter procedures will be NO-COST sterilizations for pets of low-income Marylanders or feral cats? E-2-B-Means Test: Provide a copy of the means test (i.e. the specific criteria you will use to determine if a pet owner qualifies for the service) you propose to use should your application be approved. It may be provided in the space below or attached: OR The required copy of the proposed means test is attached.
F. Qualifications
F-1-Specific Qualifications: Describe your organization’s specific qualifications/any prior experience with operating a stationary/mobile clinic: F-2-Business Plan: Applicants must include a Business Plan, including financial data and budgets. Applicants proposing the purchase of a mobile clinic must provide an Operation and Maintenance Section in the plan. CHECK: Required Business PLAN has been provided with this application. CHECK: If requesting mobile clinic, Operation and Maintenance Plan has been included in the Business Plan.
F-3-High Quality/High Volume (HQHV) Training Requirement: CHECK one of the following boxes: YES, our personnel (including at least one veterinarian) have HQHV training or equivalent skills. The personnel with this training are (list name, and position of each person with training, and date and location of training): OR NO, we do not have staff or at least one veterinarian with this training or the equivalent skills. We are including a training element to our application. IF NO: Provide details of coordination with the Humane Alliance regarding the type of training you will be proposing (Budget Specifics for this item are to be presented in the budget section):
G. BUDGET AND OTHER FUNDS
G-1-Budget Line Items: List the equipment and the cost below. Attach a page if more spaces are needed.
Specific ITEM	COST	Specific ITEM	COST
$	$
$	$
$	$
$	$
$	$
$	$
$	$
$	$
HQ/HV TRAINING: List the people, cost: travel, lodging, and registration fee. (If not applicable, enter N/A.):	$
DOUBLE CHECK your calculations and totals. Make sure your totals match the amount requested in Section A	Total Request	$
CHECK: Required price quotes are included with the application form.
G-2-EXPENSE RESEARCH: Discuss what steps you took to ensure your request is the best possible price/option available (what options did you explore, and why you chose the option you are proposing:
G-3-Equipment And Vehicle Ownership Agreement: By checking this box, the Applicant acknowledges and agrees to the terms and limitations of use and ownership of equipment purchased with Grant funds. CHECK
G-4-Cost Sharing: Describe and quantify what your organization or any partner organizations are contributing to this described effort. If you need more space, attach pages.
Organization	Description of Cost-Share	EST. VALUE
$
$
$
TOTAL ESTIMATED VALUE:	$
G-4-Matching Grants/Funding: If this project is dependent on another grant/funding from either this program or another source or sources, please discuss in detail:
H. Project Support
Project Support: Discuss and attach copies of any endorsements you have obtained or sought from animal control, local shelters, government agencies, and other animal welfare organizations that may benefit from your project: CHECK: Copies of all Letters or e-mails of Support and Endorsement, or documentation of coordination attempts, are included with the application.
Final Acknowledgements
CHECK: The Applicant reviewed and adhered to the 2019 Instructions for Capital Expense/Equipment Request Application. All fields in this application have been filled in. Any field not applicable to this application should be indicated by the entry “N/A”. The Applicant understands that blank fields may be interpreted as missing information and may cause the application to been deemed incomplete and removed from further consideration. To the best of the Applicant’s knowledge all information provided in this application is true and accurate. The Applicant has included our organization’s most recent IRS 990 if required by IRS. The Applicant has included the required map of service area. The Applicant has included the required Business Plan and any other plans or financial data per the Instructions. The Applicant has included price quotes for all requested items. The Applicant has met the HQHV training requirement by having at least 1 vet with the specialized training or has included training as part of this application. The Applicant is in good standing with the State of Maryland and in compliance with all laws discussed in the Instructions. The Applicant has included copies of all support letters. The Applicant has read, understand and agree to the conditions of ownership as specified in the Instructions. Name of Submitter: Date Submitted: SUBMIT completed applications and attachments before the close of business (5:00 PM EST) as per the due date stated in the RFP. Submit as an email attachment to: mda.spayandneuter@maryland.gov. Applications submitted to any other email address, faxed or mailed will not be accepted. Once submitted, changes are not permitted. If you have any questions, please contact the Program Coordinator as listed on the Program webpage or call MDA Spay and Neuter Program 410-841-5766.