Mission Statement of Directors List Collaborative Relationship Chart (if applicable) Collaborative Letters of Agreement (if applicable) Job Descriptions Agency Licensures and/or Certifications Budget for each proposed service Budget Justification Narrative for each proposed service Documentation of 501(c)(3) status Most recent Single Independent Audit Report C1. ORGANIZATION DIVERSITY TABLE Board and Staff – Organization Totals for Gender, Ethnicity, and Race must equal the same number. Organization Total for Other Racial or Ethnic Groups may be less than or equal to the other totals. Complete table for the ENTIRE Agency rather than for the proposed program. Paid ORGANIZATION TOTAL SUBTOTAL Board of Executive Professional Support Staff Paid Staff Directors # % Director Staff Gender: Male Female Transgender TOTAL: Ethnicity: Hispanic or Latino/a Not Hispanic or Latino/a TOTAL: Race: White Black or African American Native Hawaiian/ Pacific Islander American Indian/ Alaskan Native Unknown or Unreported* Other Racial or Ethnic Groups: African Haitian Brazilian Portuguese
Mission Statement of Directors List Collaborative Relationship Chart (if applicable) Collaborative Letters of Agreement (if applicable) Job Descriptions Agency Licensures and/or Certifications Budget for each proposed service Budget Justification Narrative for each proposed service Documentation of 501(c)(3) status Most recent Single Independent Audit Report C1. ORGANIZATION DIVERSITY TABLE – Board and Staff Organization Totals for Gender, Ethnicity, and Race must equal the same number. Organization Total for Other Racial or Ethnic Groups may be less than or equal to the other totals. Complete table for the ENTIRE Agency rather than for the proposed program. Paid SUBTOTAL Paid Staff Board of Directors ORGANIZATION TOTAL Executive Director Professional Staff Support Staff # % Gender: Male Female Transgender TOTAL: Ethnicity: Hispanic or Latino/a Not Hispanic or Latino/a TOTAL: Race: White Black or African American Native Hawaiian/ Pacific Islander American Indian/ Alaskan Native Unknown or Unreported* Other Racial or Ethnic Groups: African Haitian Brazilian Portuguese