NYSDOH - Division of Nutrition - Bureau of Nutrition Risk Reduction
Hunger Prevention and Nutrition Assistance Program (HPNAP)
RFA #1003220225
Direct Service Project Application
Please ensure that the following application is completed in its entirety. Applications must be typed
and submitted by the deadline on the first page of the RFA. Handwritten applications will not be
accepted. The applicant is responsible for ensuring that the typed responses are visible in the
space provided. Incomplete applications may not be considered for funding.
Applicant Organization Name:
Address:
Phone:
Email Address:
Total Funding Request:
Project Director Name:
Project Director Signature:
I hereby attest to the above applicant organization having a minimum of 12 months experience providing the
services described in this application.
Printed Name:_____________________________Signature:___________________________________
Please check type(s) of programs you are applying for. Please refer to pages 3-6 of the RFA for
program description(s):
Client Choice Food Pantry - the client choice model(s) provided must be provided below.
If Food Pantry and/or Soup Kitchen services are offered at more than 1 site location, they must be
directly operated by the applicant and operate under the applicant organization's 501c3.
Table
Window
Inventory List
Supermarket
Walk-Through
Soup Kitchen
If Soup Kitchen and/or Food Pantry services are offered at more than 1 site location, they must be
directly operated by the applicant and operate under the applicant organization's 501c3.
Special Nutrition Initiative
Please submit the following eligibility documents:
A copy of the Certification of Incorporation, documenting your agency's incorporation status.
A copy of the US Dept. Of Treasury, Internal Revenue Service correspondence stating your agency's
Federal Tax ID number.
A copy of your agency's New York State Department of State form which indicates your charity
registration number.
Audited Financial Statements
Proof of 501c3 Not-For-Profit Status
Page 1 of 20
A. Project Summary
Maximum 10 points
A1. Describe the project or service for which you are requesting funding.
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A. Project Summary continued
A2. Describe the anticipated outcomes and the measurement methodology.
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A. Project Summary continued
A3. Identify your site(s) location(s) and hours of service or operation.
A4. Identify the target population(s), service area(s).
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A. Project Summary continued
A5. Describe your experience in providing the proposed service including the length of time providing
the service.
A6. Summarize how minorities, Lesbian/Gay/Bisexual/Transgender persons, and persons with disabilities
are incorporated into the development and implementation of services.
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A. Project Summary continued
A7. Highlight your accomplishments in providing services for persons in need of food assistance.
A8. Describe any additional benefits to food and services offered by your organization to support the
success of the proposal (e.g. matching or other funding, in-kind or volunteer support, outreach services,
etc.).
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B. Description of Need
Maximum 15 points
B1. Describe the social, economic and/or other indicators of need for emergency food services in your
target area such as employment levels, poverty statistics, etc. Include a description of the lack/
inadequacy of existing emergency food relief services available to the target population.
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B. Description of Need continued
B2. Describe the methods and types of data used to identify the target population and estimate the
number of persons in need of emergency food assistance in the target area. Provide the basis for this
estimate.
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B. Description of Need continued
B3. Describe the extent to which the proposed project will address the described un-met need. Be precise
as to how your organization provides services that may exceed or compliment other services in your
catchment area.
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C. Applicant Organization
Maximum 10 points
C1. Include (as Attachment C1) a description or diagram of the organizational structure of your agency
and a listing of your Board of Directors. The organizational chart should include hierarchy within your
agency and parent organization (if applicable), key positions and staff associated with your emergency
food relief services; and names, positions, address and phone numbers of the Board of Directors.
Organizational structure should be conducive to providing quality services.
Included Attachment C1
Not Included
C2. Include (as Attachment C2) letters of cooperation and collaboration and/or letters of support that
verify the current or requested services and demonstrate partnerships that support the proposed
service(s).
Included Attachment C2
Not Included
C3. List your organizations major funding sources. (Major funding sources provide 20% or more of your
organizations total funding). Funding sources should demonstrate the viability of your organization.
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C. Applicant Organization continued
C4. List licenses/certifications held by program (e.g. local Department of Health operating or food
handlers certificate, thrift shop permits, etc.). The list should demonstrate that your organization
possesses all required licenses/certifications to provide the proposed service(s).
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C. Applicant Organization continued
C5. Provide your agencies Mission/Vision statements. Explain how your organization's statements are
consistent with HPNAP's Mission/Vision.
C6. Describe your cost containment and purchasing policies and procedures. Policies and procedures
should demonstrate that efficiency and quality are maintained.
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D. Project Activities
Maximum 35 points
D1. In the first two boxes below, state the number of meals and the number of pounds to be distributed
with HPNAP funds. In the third box, describe your plan for how the proposed service will be provided as
well as your service goals with measurable objectives including projected service level. Goals should be
reasonable.
Projected total number of meals that will be provided (reported through
HPNAP MIS reports) with HPNAP funds.
Projected number of pounds of food to be distributed with HPNAP funds
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D. Project Activities continued
D2. Describe the kinds and amounts of work and project activities to be accomplished over the course of
the year for each objective listed. Include collaborations or partnerships with other community agencies
that may enhance the stability of the project. Project activities should demonstrate that the proposed
objectives can be achieved.
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D. Project Activities continued
D2. continued
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D. Project Activities continued
D3. Provide the plan to ensure that people in need of emergency food assistance in the catchment area
have access to food without discrimination. Include strategies for access to and participation in your
services by minorities, Lesbian/Gay/Bisexual/Transgender persons and persons with disabilities.
D4. Describe your plan for obtaining, providing and/or implementing nutrition and food safety and
sanitation support services or assistance. If applying as a Special Nutrition Initiative, include the plan to
provide nutrition education.
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D. Project Activities continued
D5. If foods are to be purchased with HPNAP funds, describe your food purchasing practices that minimize
cost while maximizing nutrition. If applicable, include how local foods will be considered and any voucher/
coupon models that will be utilized. Include your nutrition standards as Attachment D5.
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D. Project Activities continued
D6. Describe the methods of conducting HPNAP needs assessments and/or client satisfaction studies to
develop action plans for improving services such as client choice, referral/outreach needs, cultural
preferences, etc. where applicable. Include how this information may affect services.
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E. Project Evaluation
Maximum 10 points
E1. Summarize how the proposed service will be evaluated to determine that progress is being made
and objectives are being met. Include measures and time frames for each objective.
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F. Budget
Maximum 20 points
Applicants should keep in mind that Program funds are limited and that the cost effectiveness of an
organization's proposal will directly impact the scoring of this section. The budget request should identify
only those funds that are necessary to provide proposed services. Scoring will be based on the budget's
clarity, completeness and feasibility. Final budgets and work plans will be determined when HPNAP
contracts are established.
F1. Complete and include the budget package (Attachment #8). Include a justification below for each
cost or include it as Attachment F1 (up to 3 additional pages, if needed.) Justifications must fully explain
the intent of the funding for the budget category as well as how the amount was computed. For all
existing staff, the Budget Justification must delineate how the percentage of time devoted to this initiative
was determined. Include job descriptions as Attachment F1.
Print Form
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