HomeMy WebLinkAboutBend Spay-Neuter ProjectApplicant:
Deschutes County Community Grant Program
2014-15 Application Review
Rating Worksheet
Bend Spay and Neuter Project
Category/Grant Amount:
Title:
Other Essential Services / $11,000
Spay Neuter Your Pet Deschutes (SNYP'D)
Review Criteria:
1. Organization:
• Stable and positive history of providing services in Deschutes County.
• Experience delivering similar programs, projects, or activities as those proposed.
• Mission and goals are consistent with proposed program, project, or activity.
• Stable and experienced Board of Directors or other leadership group.
• Adequate staff and/or volunteers to implement proposed program, project, or activity.
Points awarded for this section (maximum of 25).
2. Financial Status:
• Adequate financial resources available to conduct and sustain operations.
• Broad and diverse base of funding sources.
• Financial need for a Community Grant to implement proposed program, project, or
activity.
• Proposed budget is consistent with and appropriate for the fixed grant amount
available in the selected Community Grant category.
Points awarded for this section (maximum of 25).
3. Program, Project, or Activity:
• Program, project, or activity does not address emergency food, clothing, or shelter.
(These activities are supported by Deschutes County through a separate grant
program in conjunction with United Way's Emergency Food and Shelter program.)
• Request is consistent with the fixed dollar amounts indicated in the category/grant
amount description at the top of this form.
• Number of individuals to be served is appropriate to the budget and scale of proposed
program, project or activity.
• Serves vulnerable and/or underserved populations and/or communities.
• Positively impacts welfare of the community.
• Complements, but does not duplicate, existing Deschutes County services.
• Implementation strategy is suitable to achieving the stated goals and objectives of
proposed program, project, or activity.
• Partnerships or collaboration with other agencies are included in implementation
strategy.
• Other sources of funds or in-kind support are available to supplement Community
Grant funds.
Points awarded for this section (maximum of 35).
4. Performance Management:
• Stated outputs are relevant and reasonable to the scale of the proposed program, project,
or activity.
• Stated outcomes are relevant and reasonable to the scale of the proposed program,
project, or activity.
Points awarded for this section (maximum of 15).
TOTAL NUMBER OF POINTS AWARDED:
COMMENTS:
NAME OF RATER:
Deschutes County
Fiscal Year 2013-14
Community Grant Application
Submittal Instructions and Cover Sheet
A complete application will consist afthe following:
1, This saver sheet, signed and dated.
?. Responses to the attached questions on no more than five single -sided, s%rtg]e-spaced pages.
3. Proof of the organization's 501(c)i3) tax-exempt atonia in the form of a letter from the Intern&
Revenue Service (IRS),
4. The first two pages of the organisation's most recently submitted IRS 990 form.
5. An operating budget specific to the proposed program, project, or activity.
Submit the complete application electronically to jigjtt ii*:.c.h.ut;s.osg no later than 5:00 p.m. c n
August 30, 2013. Incomplete and/or late applications will not be reviewed or considered.
Please complete the following:
Contact Name: 1' ' gemAitiliroolf.
Organization Name: ?e ,Sp11 grid Jkk . p' J
Address: ��(� S 4r 404 t �
City: t
4
Telephone Number:
State:
Zip Code:
i1 7Z
5q1-1,17- j Zi
Email Address: I me � j r fds,1 i p
Application is being submitted to which Common Grant Progam funding ca
Health, Mental Health, and Addictions Services
n Arta and Culture
'Other Essential Servizes: Includes services to youth: underserved. indigent, and?or vtalncrabI
populations; animal welfare: or the environment.
' A pre -determined number of awards will be made in each funding category for a fixed dollar
amount each. Please refer to the funding guidelines for more information.
Certification:
On behalf of the orgxnizstion specified above. l +mortify the following:
1. All info n atlon included in this application is +car t
2. I am authorized by the governing board to submit this int appiication,
3, This orpnbation is located in Deschutes County.
4. If awarded, Canter Grant funds will be used in support of Deschutes County residents
only.
S. This organization is in good standing with the U.S. Internal Revenue Service and is currently
designated as a 501(cX3) tax-exempt entity.
Signature:
Print Name:
Tide: L )y I1It f
Date: 00h_v_
BEr
2014 Deschutes County Community Grant Application
�' Spay and Neuter Project
P1 t.• d rz
R'rgani3atian:
1. Beni Spay and Neuter Project was established in January of 2005. The
dune was started by founder Sara Dice, who, as a landlord for various
apartment complexes around town, saw a need for affordable spay and
neuter services for feral and stray cats in Central Oregon. She and Dr.
Byron Maas started the clinic in the summer of 2004 in Sara's garage.
Since then, the clinic has grown to provide affordable spay and neuter
surgeries and wellness services to over 4,000 pets and strays in Central
Oregon each year, for a total of over 37,000 pets served since 2005.
All of the programs that BSNP provides are created around the idea of
keeping existing pets happy and healthy in their homes, and preventing
unwanted pets and strays from entering local shelters. We currently
provide affordable spay/neuter for pets in Central Oregon, free spay/
neuter for dogs in Jefferson County, affordable wellness services including
vaccinations and microchips, and free spay and neuter and vaccinations
for feral/stray cats. We hope to add a free spay/neuter program for low-
income residents of Deschutes County in 2015.
2. The mission of Bend Spay and Neuter Project is to provide affordable
preventative veterinary care to cats and dogs at risk of suffering in Central
Oregon in order to create a more humane community for us all, The
Long term goals of Bend Spay and Neuter Project are to: 1) reduce the
euthanasia rates of open intake shelters in Central Oregon from 31% for
cats and 11% for dogs to 10% overall by 2020, 2) Reduce the animal
homelessness rate per capita from 16 per 1 003 people to 5 per 1000
people by 2020, and 3) Create an affordable spay/neuter per capita rate of
32 surgeries per 1000 people by 2020.
3. Bend Spay and Neuter Project is managed and operated by Clinic
Executive Director Megan Wellinghoff and Clinic Medical Director Dr.
Katie Bahr, DVM. A Board of Directors consisting of 5 people oversees
the organization and they wont with an advisory Board to tackle specific
issues.
Board of Directors:
1) Gail Jett, Chair
2) Jeff Hinman, Director
3) Dorinda Pulliam, Treasurer
4) Julie Hotchkiss, Director
5) Bonnie Wilson, Director
Advisory Board:
1) Roy Dwyer. Advisory Board Member
2) Dr. Byron Maas, D1/M, Advisory Board Member
3) Jim Kone, Advisory Board Member
4. See Attached.
Financial Status:
1. See Attached.
Program, Project or Activity:
1. SNYP'D (Spay Neuter Your Pet Deschutes) Free Spay/Neuter
Vouchers
2. The goals of the proposed initiative are to' 1) reduce shelter intake
at the Humane Society of Central Oregon from Deschutes County by
3% 2014 vs. 2015 through providing free vouchers for 100 cats and
100 dogs belonging to low income residents. 2) Increase awareness
of rabies as a public health issue in Deschutes County and decrease
the number of dog bites in Deschutes County. Statistically nationwide
85% of dog bites are from dogs that have not been spayed or
neutered.
3. The target population is anyone earning less than $35K annually for
a family of two or more, those living at or below the poverty line and
those receiving government assistance. The target population will
be reached by working with local non-profit organizations to distribute
vouchers to mutual clients. Recent studies have shown that people
who make less than $35k/annually will not have their pets fixed unless
they can have it done for free. This program aims to reach those
people and those who fall into the category of living below the poverty
line to ensure their pets are fixed before they have accident& litters
that end up in our local shelters.
4. The initiative will positively impact the community by enabling low-
income pet owners to provide basic care for their pets and keep
them in their homes as opposed to surrendering them to a local
shelter_ It will also provide Deschutes County with improved public
health through fewer dog bites and a decrease in the chance of
human contact with a rabid animal. The SNYP'D voucher program
will increase the scope of the current SNAP voucher program which
is funded by the County Spay/Neuter grant and distributed by the
Humane Society of Central Oregon, but will remove the cost barrier
that some extremely low income clients still face with having to
phase the SNAP voucher. The SNYP'D voucher will be available
through three local non -profits, as well as at Bend Spay and Neuter
Project clinic and HOPE Pet Food Bank. Neighborlmpact, Family
Access Network and Cascade Youth and Family Outreach services,
who have all agreed to distribute vouchers to clients in need. By
utilizing non-profit organizations who are already serving our target
population, we will increase the likelihood that clients wig hear about
the voucher, and increase their access to a free voucher. The SNYP'D
vouchers will be completely free and will cover all costs associated
with spay/neuter surgery and rabies vaccination.
5. Anyone living in Deschutes County is eligible to receive a voucher,
though we will target our advertising and distribution sites to our
target population, those who are most likely to contribute to the pet
overpopulation problem. The benefit will be felt throughout Central
Oregon through the reduction in homeless pets and strays entering our
local shelters and a reduction in dog bites.
6. Bend Spay and Neuter Project has the capacity to provide up to 40
speylneuter surgeries per day at their clinic on Willson Ave. BSNP
will create 200 vouchers, which will be good for spay/neuter surgery
and one rabies vaccination per pet, The vouchers will be distributed
amongst the three non -profits. the HOPE Pet Food Bank and BSNP,
wfio wdl determine dient's need for a voucher. Clients will schedule an
appointment for their pet through Bend Spay and Neuter Project, bring
their voucher and their pet will be spayed/neutered and vaccinated at
no cost to the owner. Vouchers will be distributed on a first come first
served basis and at the discretion of the non-profit issuing the voucher
or by BSNP. In addition, participating non -profits will be supplied with
information on the importance of spay/neuter, rabies vaccinations and
the benefits to pet's tong -term health in order to increase awareness
and education.
7. Funding will be used to cover the cost of Bend Spay and Neuter
Project to provide 100 spay/neuter surgenes for dogs, and 100 spay/
neuter surgeries for cats at an average of $50/animal. Bend Spay
and Neuter Project will provide rabies vaccinations for every animal at
a cost of $2/animal, which we hope to have donated by our vaccine
supply company Bergstrom ingleheim.
8. The partner agencies involved are: Neighbortmpact, Family Access
Network, Cascade Youth and Family Outreach to distribute vouchers.
as wen as Brightside Animal Center and The Humane Society of
Central Oregon, who will participate through the provision of their
shelter intake data before and after the program.
9. Rabies vaccinations will be provided by Bend Spay and Neuter Project.
Bend Spay and Neuter Project will also continue to request grant
funding from other foundations in hopes of implementing a permanent
free spay/neuter program for those most in need.
10. Operating Budget Attached.
Performance Measurement
1. This program will facilitate the sterilization of 200 at risk animals in
Deschutes County. By targeting those most likely to contribute to the
overpopulation problem (those living at or below the poverty line and
those making less than S35K/annualty), we hope to reduce the intake
of cats and dogs into local open admission shettens by 3% 2014 vs
2015.
2. The anticipated outcomes of the SNYPtD voucher program are as
follows:
1) A significant decrease in the intake number of cats and dogs
entering the local open admission shelter (HSCO) and Brightside
Animal Center, a limited intake shelter 2014 vs. 2015. A significant
decease being 3%,
2) Increase public education regarding the importance of spaying/
neutering and vaccinating pets against rabies.
3) Improved public health in Deschutes County through tracking a
decrease in dog bites and the provision of rabies vaccinations for
200 at risk animals in 2015.
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2013 Federal Exempt Organization Tax Summary Page 1
BEND SPAY & NEUTER PROJECT 71-0977598
REVENUE
Contributions and grants
Program service revenue..
Investment income
Other revenue
Total revenue
2013
151,869
182, 625
-387
7,125
341,232
2012
98, 654
167,839
22
11,518
278,033
EXPENSES
Salaries, other compen., emp. benefits. 206,973 158,664
Other expenses 111,687 125,028
Total expenses 318,660 283,692
NET ASSETS OR FUND BALANCES
Revenue less expenses 22,572 -5,659
Total assets at end of year 76,117 52,903
Total liabilities at end of year 4,793 6,780
Net assets/fund balances at end of year 71,324 46,123
Diff
53,215
14,786
-409
-4,393
63,199
48,309
-13,341
34, 968
28,231
23,214
-1, 987
25,201
2013 Federal Worksheets Page 1
BEND SPAY & NEUTER PROJECT 71-0977598
Computation of Cost of Goods Sold (Form 990)
1. Inventory at start of year 0.
2. Purchases 879.
3. Cost of labor 0.
4. Additional 263A costs 0.
5. Other costs 0.
6. Total (Add lines 1 through 5) 879.
7. Inventory at end of 0.
year
8. Cost of goods sold (Subtract line 7 from line 6)........ ........ ..... 879.
Form 990, Part III, Line 4e
Program Services Totals
Program
Services
Total Form 990 Source
Total Expenses 240,568. 240,568. Part IX, Line 25, Col. B
Grants 0. 0. Part IX, Lines 1-3, Col. B
Revenue 0. 182,625. Part VIII, Line 2, Col. A
Form 990, Part IX, Line 11g
Other Fees For Services
(A) (B) (C) (0)
Program Management Fund-
Total Services & General raising
VET SERVICES 4,606. 4,606.
Total $ 4,606. $ 4,606. $ 0. $ 0.
Form 990, Part IX, Line 24e
Other Expenses
(A) (B) (C) (0)
Program Management
Total Services & General Fundraising
BANK & MERCHANT CHARGES 3,113. 1,689. 1,421. 3.
COMPUTER SOFTWARE 949. 494. 455.
DIRECT MAIL 2,723. 40. 2,683.
EVENT EXPENSES 1,103. 1,103.
FACILITIES MAINTENANCE 359. 323. 36.
FIRE PROTECTION 59. 59.
LAB FEES 1,318. 1,318.
LAPINE 870. 870.
LICENSE & SUBSCRIPTIONS 1,231. 1,231.
MICROCHIPS 2,801. 2,801.
OUTREACH 1,419. 1,119. 300.
OUTSIDEVET SERVICES 2,094. 2,094.
PAYROLL FEES 227. 227.
SECURITY 384. 326. 58.
STAFF/BOARD DEVELOPMENT 3,194. 2,556. 638.
VACCINES 4,325. 4,325.
2013 Federal Worksheets Page 2
BEND SPAY & NEUTER PROJECT 71-0977598
Form 990, Part IX, Line 24e (continued)
Other Expenses
(A)
Total
(B) (C) (D)
Program Management
Services & General Fundraising
vOLUNTEER APPRECIATION 746. 687. 59.
Total $ 26,915. $ 19,892. $ 3,234. $ 3,789.
Applicant:
Deschutes County Community Grant Program
2014-15 Application Review
Rating Worksheet
Volunteers in Action
Category/Grant Amount:
Title:
Other Essential Services / $11,000
Safety and Accessibility Program
Review Criteria:
1. Organization:
• Stable and positive history of providing services in Deschutes County.
• Experience delivering similar programs, projects, or activities as those proposed.
• Mission and goals are consistent with proposed program, project, or activity.
• Stable and experienced Board of Directors or other leadership group.
• Adequate staff and/or volunteers to implement proposed program, project, or activity.
Points awarded for this section (maximum of 25).
2. Financial Status:
• Adequate financial resources available to conduct and sustain operations.
• Broad and diverse base of funding sources.
• Financial need for a Community Grant to implement proposed program, project, or
activity.
• Proposed budget is consistent with and appropriate for the fixed grant amount
available in the selected Community Grant category.
Points awarded for this section (maximum of 25).
3. Program, Project, or Activity:
• Program, project, or activity does not address emergency food, clothing, or shelter.
(These activities are supported by Deschutes County through a separate grant
program in conjunction with United Way's Emergency Food and Shelter program.)
• Request is consistent with the fixed dollar amounts indicated in the category/grant
amount description at the top of this form.
• Number of individuals to be served is appropriate to the budget and scale of proposed
program, project or activity.
• Serves vulnerable and/or underserved populations and/or communities.
• Positively impacts welfare of the community.
• Complements, but does not duplicate, existing Deschutes County services.
• Implementation strategy is suitable to achieving the stated goals and objectives of
proposed program, project, or activity.
• Partnerships or collaboration with other agencies are included in implementation
strategy.
• Other sources of funds or in-kind support are available to supplement Community
Grant funds.
Points awarded for this section (maximum of 35).
4. Performance Management:
• Stated outputs are relevant and reasonable to the scale of the proposed program, project,
or activity.
• Stated outcomes are relevant and reasonable to the scale of the proposed program,
project, or activity.
Points awarded for this section (maximum of 15).
TOTAL NUMBER OF POINTS AWARDED:
COMMENTS:
NAME OF RATER:
Deschutes County
Fiscal Year 2014-15
Community Grant Application
Submittal Instructions and Cover Sheet
A complete application will consist of the following:
E This cover sheet, signed and dated.
2. Narrative responses to the attached questions on no more than four single -sided, single-spaced
pages.
3. Attachments:
a. Proof of the organization's 501(c)(3) tax-exempt status in the form of a letter from the
Internal Revenue Service (IRS).
b. The first two pages of the organization's most recently submitted IRS 990 or 990 EZ
form or, if the organization is not required to file either form with the IRS, a financial
statement that provides equivalent information concerning activities and governance,
revenue, expenses, and net assets or fund balances.
c. An operating budget specific to the proposed operations, program, project, or activity.
d. A roster of the organization's Board of Directors.
Submit the complete application electronically to iudithu cr deschutes.org no later than 5:00 p.m. on
October 24, 2014. Incomplete and/or late applications will not be reviewed or considered.
Please complete the following:
Contact Name:
Ms. Eve Nazarian
Organization Name:
Address:
City:
Volunteers in Action
P.O.Rox 7856
I Bend
Telephone Number:
State:
Oregon
Zip Code:
97708
(541 l 54R -701R
Email Address: viacentraloregon@hotmail.com
Application is being submitted to which Community Grant Program funding category*?
❑ Health, Mental Health, and Addictions Services
❑ Arts and Culture
Other Essential Services: includes services to youth; underserved, indigent, and/or vulnerable
populations; animal welfare; or the environment.
* Please refer to the funding guidelines for more information.
1�
Certification:
On behalf of the organization specified above, I certify the following:
1. All information included in this application is accurate.
2. 1 am authorized by the governing board to submit this grant application.
3. This organization is located in Deschutes County.
4. If awarded, Community Grant funds will be used in support of Deschutes County residents
only.
5. This organization is in good standing with the U.S. Internal Revenue Service and is currently
designated as a 501(c)(3) tax-exempt entity.
Signature:
Print Name: Eve Nazarian
Title: Executive Director
Date: 10/24/2014
Deschutes County
Fiscal Year 2014-15
Community Grant Application
Questions
Organization
1. Describe the history of the organization, including the year the organization was
established.
Volunteers in Action (ViA) is a Central Oregon nonprofit that provides non-medical
services to seniors and adults living with disabilities, helping them maintain their
independence, health, and safety. Care recipients are helped by our 180 volunteers who
provide free services such as transportation, friendly visits, ramp building, respite care,
and much more.
In 1984, the Robert Wood Johnson Foundation in Princeton, New Jersey began to build a
national volunteer effort for the care of seniors. There are currently upwards of 900
offices affiliated with the National Volunteer Caregivers Network, supporting the "Aging
in Place" concept. Volunteers in Action of Central Oregon, formerly Interfaith Volunteer
Caregivers (IVC) until December 2011, has been serving seniors and adults with
disabilities since its inception in 1996 in Bend, when the Robert Wood Johnson
Foundation provided seed funding. In 2000, ViA became an independent 501 (c) (3) tax-
exempt organization.
2. State the organization's mission and goals.
Our mission since 1996 has been to help seniors and disabled adults to stay in their
homes longer. This is accomplished by providing simple help. ViA leverages resources as
much as possible, connecting people to other community or social service agencies. The
rest of the time, ViA does its very best to fill whatever needs our care receivers may have
by utilizing the power and talents of our 180 dedicated volunteers.
Our care recipients often can no longer drive and find themselves considering going into
assisted living before they need to. Our volunteers provide transportation to doctors,
shopping, and other errands that care recipients need. Many older people have lost
friends, and their families live far away. A simple visit on a regular basis keeps these
folks feeling better knowing that volunteer, who now becomes a friend, will come again
next week. A respite break for a family caregiver will give them the emotional strength
to continue to care for a loved one. A little help with housekeeping and laundry when that
becomes burdensome can make a huge difference for this older and/or disabled
population. We also build ramps to enable safe entry/exit from their homes if necessary.
Yard work can be difficult, and volunteers gladly help out. Our volunteers are open to
other requests as they come up.
3. Describe the leadership and structure of the organization. If governed by a Board of
Directors, list the members' names and positions held.
Board of Directors:
• Douglass Myers, Director and President
• Rev. Roy Green, Director
• Nancy Farnham, Director
• Eve Nazarian, Executive Director
• Maggie O'Connor, Director
Staff:
• Eve Nazarian, Executive Director
• Vivien O'Connor, Part-time Volunteer Coordinator
Volunteers:
• One hundred and sixty (160) volunteer caregivers
4. Attach proof of the organization's nonprofit status in the form of a letter from the U.S.
Internal Revenue Service.
Please see attached.
Financial Status
Please see attached for our IRS Form 990.
Program Information
1. Provide a title of the proposed initiative for which funds are being requested.
Volunteers in Action is requesting funds for our Safety and Accessibility program.
2. Describe the goals and objectives of the proposed initiative.
Our objective is to enable safe entry to and exit from the homes of older and/or disabled
people in Deschutes County. Our goals include building accessibility ramps and installing
grab bars, which come in sets of two, in bathtubs and showers, as requested. Our Safety
and Accessibility program will result in improved access to homes and fewer accidents
and hospital stays.
3. Identify the target population that will be served.
Our target population consists of seniors over 60 years of age and adults with disabilities,
whom we help to maintain their independence with dignity.
4. Describe how the proposed initiative will positively impact the community and
complement existing services currently provided by Deschutes County.
In general, the services we provide result in fewer trips to the hospital when our care
recipients can regularly get to doctors for minor complaints. Regarding our Safety and
Accessibility program, we anticipate fewer hospital stays, fewer accidents caused by
unsafe home entry/exit, and fewer accidents caused by unsafe bathtub or shower
entry/exit.
As a result, our care recipients are less likely to resort to moving into assisted living
facilities that cost much more than if they remain in their own homes longer. These extra
costs are usually picked up by taxpayers, so this is a win-win situation. The care recipient
gets to stay home where they want to be, and money is saved by both state and federal
funding.
Services we provide also complement services offered by COBA (Central Oregon
Builders Association). Once a year, one weekend COBA has a "Ramp A Thon" where
they build ramps (approximately 10). We build ramps all year long and install grab bars
all year long whenever they are needed. We build them very economically with no frills
to safely get people in and out of their homes.
5. Identify the geographic area(s) of Deschutes County that will benefit.
We provide services for seniors over 60 years of age and adults with disabilities living in
Bend, Sunriver, La Pine, Sisters, Redmond, and Terrebonne.
6. Describe in detail how the proposed initiative will be implemented.
Within the Safety and Accessibility program, we will:
• perform initial assessment of the care recipients' homes;
• design and measure for accessibility ramps;
• source materials and secure estimates;
• deliver supplies;
• build and install accessibility ramps;
• install grab bars, transitional thresholds, safety railings;
• repair unsafe entry steps.
7. Describe specifically how the requested funds will be used.
Funds will be used to coordinate and provide direct services to seniors and adults with
disabilities. Specifically, funding the Safety and Accessibility program will result in
Deschutes County ]ow income seniors and disabled adults receiving in-home safety
assessments and accessibility devices that will help them age in place --stay in their
homes longer in a safe environment. North, Central, and South Deschutes County are the
target areas.
We are requesting $11,000. Each ramp costs approximately $400. Each set of grab bars
costs $50. Funds from the Deschutes County Community Grant Program will allow us to
build ramps, add handrails to existing stairways and ramps, replace no slip covering on
existing ramps and porches, install threshold ramps as needed, and make general repairs
when needed to keep care recipients safe.
8. Identify any partner agencies that will collaborate to implement the proposed initiative.
Newberry Habitat for Humanity in Sunriver occasionally collaborates with us; they also
help us with volunteers when needed in South County. The Central Oregon Council on
Aging (COCOA) occasionally helps with material needs. The SOS program with the
Bend Fire Department has developed a safety program that includes ViA in ramp
building. Community Justice works with us by providing volunteers, which helps those
owing community service hours to learn a trade.
9. Describe other sources of funding that will support the proposed initiative.
We have applied for a $10,000 grant from the Cow Creek Umpqua Indian Foundation,
which has helped us in the past with our ongoing Safety and Accessibility program. We
are currently waiting to hear back from them about the status of our application.
10. Attach an operating budget specific to the proposed initiative.
Please see attached.
Performance Measurement
1. Identify quantifiable outputs anticipated to be achieved through the proposed initiative.
This project's objectives are to assess the living environments of new care recipients to
ensure that the location is safe for volunteers, and to determine what accessibility needs
exist for the care recipient. We plan to provide the following services:
1. Complete in-home assessments.
2. Input information from assessments into computerized formats.
3. Custom measure, design, and install ramps with handrails.
4. Custom measure and install grab bars.
5. Custom measure and install interior and exterior threshold ramps, as needed.
6. Perform miscellaneous tasks, as needed, to ensure the safety of care recipients in
their homes
Success will be measured by completing the above six tasks.
2. Describe the anticipated outcomes of the proposed initiative.
We anticipate fewer hospital stays, fewer accidents caused by unsafe home entry/exit,
and fewer accidents caused by unsafe bathtub or shower entry/exit. We also anticipate
care recipients staying longer in their homes, rather than moving to assisted living
facilities.
rorrTi Jv
Financial Overview of 4GENCY & Proposed Budget Comparison
2
Agency Name:
(Enter program name hers)
, tail At..tuta
Check coned box
I:] CY 2012
ci FY 20112012
3
or Esthnate
FY 2012-2013
Need Year Proposed
FY 2013-204(
Support & Revenue • All Sources 1
1 Allocations from United Way of Iles County
2 Contributions (Includes designations ++a UWDC)
3 Special Events/Fundraisers ........, . t4 .......................
4 Legacies & Bequests (unrestricted)..
5 Contributed byAssociated Organ ons••••••••
6 Allocations from other United Ulla etted Funds ......
7 Grants from Commission on Children
alit Families
8 Other Government Fees & Grants... ............................
9 Non -Government Grants ..................•..... •.
10 Membership Dues.. •-• •-i- ..... • ••• ••...............
11 Program Service Fees & Net Inciderr t Revenue .............
12 Sales of Materials.......................r, ........
13 Investment Income ........................ .........................
14 Inktnd Materials &Services............
15 Miscellaneous Revenue
s Total Support 84 Rever« s (add lire 1 through 15)
Expenses
17 Salaries & Wages........ .......
18 Employee Benefits.„ . ........ ........... .........................
19 Payroll Taxes, etc ......................................
....
20 Professional Fees
"""
22 •Telecommunications ......
23 Postage & Shipping......................a......._..,.......,.........
25 Equipment Rental & Maintenance...
26 Printing & Pub1icsti0110
27 Transportationf..
28 Meetings, Conferences, & Training..... ...... .......
29 Direct Assistance to individuals (ester
30 Membership Dues
31 Awards & Grants ..........................
32 lnsuranos (employee benefits ex
33 lnldnd Materials & Services.............
34 Payment to Affiliated Organizations..
35 Board Designations for Future Year
,000
3008
4,400
3200
5193
17000.
D
0
36 Total Expenses tines 17 through 35)
37 Total Fes$ Financed by
Funds
38 licit of Revenue over
567,454
$74,791
5000
5000
5? 1/5
5000
(line 16 minus line 36)
($785)I ($8,451
(.44
J
17000
17000
-411,C
30000
20000
1000
235
240
245
1 000
100
1000
5233
5500
1409
•
$66,se9.
568,340
X90 9
45432
51957
i
341,1"9-
3152
3230
3320
4174
4519
792
4174
4519
831
" 4299
4519
850
1632
2232
%.5`'0
r
232
260
275
1083
1118
1171
229
252
284
501
I/o
285
294
323
4788
4835
5318
700
60o
600
36 Total Expenses tines 17 through 35)
37 Total Fes$ Financed by
Funds
38 licit of Revenue over
567,454
$74,791
5000
5000
5? 1/5
5000
(line 16 minus line 36)
($785)I ($8,451
(.44
Board List for Volunteers in Action
Name
Title
Brief Biography
Contact Information
Douglass
Myers
Board
President
Mr. Myers' professional
career as a healthcare
executive, consultant, and
entrepreneur has spanned
many years. Currently, he is
Managing Director of
Sunriver Institute (Central
Oregon), and President of
Orenco Healthcare Partners,
a venture management firm
focused on healthcare and
technology. He is a board
member as well as an advisor
to numerous other health
care organizations.
(541) 948-1871
Douglass.Myers@gmail.com
Reverend
Roy Green
Director
Reverend Green is the
Interim Rector of Trinity
Episcopal Church. He is also
a member of The Episcopal
Diocese of Eastern Oregon,
with deep experience in
nonprofit management,
community service and
Hospice services.
(541) 593-2345
spiritchaser@aol.com
Maggie
O'Connor
Director
Ms. O'Connor is a
Community Benefit
Executive for St. Charles
Health System (SCHS), and
former Assistant to the
President/CEO and Assistant
to the Chief Information
Officer of SCHS. She was
recommended to ViA's
Board by Jim Diegel and
Pam Steinke of SCHS
(503) 440-5860
mloconnor@a,StCharleshealthcare.org
Nancy
Farnham
Director
Ms. Farnham has a history of
devotion to volunteer
extraordinaire and current
President of Sunriver
Women's Club. She is a
resident of Sunriver and a
longtime volunteer of ViA.
She is also a former teacher.
(541) 593-9132
nfarnham@gmx.com
Eve Executive Ms. Nazarian is the
Nazarian Director Executive Director for
Volunteers in Action of
Central Oregon. She has
been with ViA since 2003.
(541) 548-7018 (office)
viacentraloregon@hotmail.com
(c)
27,
0
gJ
Form 990 -EZ
Department of the Treasury
Internal Revenue Service
Short Form
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code
(except private foundations)
P. Do not enter Social Security numbers on this foml as it may be made public.
Information about Form 990 -EZ and its instructions is at www.irs.gov/(orm990.
OMB No 1545-1150
2013
Open to Public
Inspection
A For the 2013 calendar year, or tax year beginning , 2013, and ending
FEICheck if applicable
Address change
0 Name change
0Initial return
Terminated
® Amended return
O Application pending
G
INTERACT, INC DBA
VOLUNTEERS IN ACTION
PO BOX 7856
BEND, OR 97708
D Employer identification number
93-1260201
E Telephone number
541-548-7018
F Group Exemption
Number
G Accounting Me hod Cash Accrual Other (specify)
1 Website: ' WWW . VIACENTRALOREGON .COM
J
Tax-exempt status (check only one) — J 501(c)(3) LJ 501(c) ( ) -(insert no.) ❑ 4947(a)(1) or D 527
H Check ► fl if the organization is not
required to attach Schedule B (Form
990, 990 -EZ, or 990 -PF)
K Form of organization
L
T
Corporation D Trust El Association ® Other
Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts If gross receipts are $200,000 or more, or if total
assets (Part II, column (B) below) are $500,000 or more, file Form 990 instead of Form 990 -EZ ' $
64,738.
Pad! Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part 1)
Check if the organization used Schedule 0 to respond to any question in this Part I
BAA For Paperwork Reduction Act Notice, see the separate instructions.
TEEA0803L 11/27/13
Form 99042 (2013)
1 Contributions, gifts, grants, and similar amounts received
2 Program service revenue including government fees and contracts
3 Membership dues and assessments .
4 Investment income . .
1
64,662.
2
3
4
76,
5a Gross amount from sale of assets other than inventory
b Less cost or other basis and sales expenses
5al
5bl--
ri
c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) . . . . .
5 e
6 Gaming and fundraising events - '�
E
a Gross income from gaming (attach Schedule G if greater than $15,000)
1 6 a ,„ Mn ')nr!(
E
N
b Gross income from fundraising events (not including $
of
contributions"-
from fundraising events reported on line 1) (attach Schedule G if the sum
Eof
such gross income and contributions exceeds $15,000).
c Less direct expenses from gaming and fundraising events
d Net income or (loss) from gaming and fundraising events (add lines 6a and
6b
6c
-
6b and subtract line 6c) . .
6d
1
7a Gross sales of inventory, less returns and allowances
b Less cost of goods sold
7a
7 b
c Gross profit or (loss) from sales of Inventory (Subtract line 7b from line 7a)
7c
8 Other revenue (describe in Schedule 0)
8
9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 '
9
64, 738.
10 Grants and similar amounts paid (list in Schedule 0)
10
11 Benefits paid to or for members . .
11
E
X
12 Salaries, other compensation, and employee benefits
12
53 993,
+
13
1,413.
E
13 Professional fees and other payments to independent contractors
14
N
14 Occupancy, rent, utilities, and maintenance
E
15 Printing, publications, postage, and shipping
15
578.
16 Other expenses (describe in Schedule 0) . SEE SCHEDULE 0
16
15, 543
17 Total expenses. Add lines 10 through 16 '
17
71,527.
18 Excess or (deficit) for the year (Subtract line 17 from line 9)
18
-6,789
A
NS
19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with end -of -year
EE
figure reported on prior year's return)
19
10, 883.
s
20 Other changes in net assets or fund balances (explain in Schedule 0) SEE SCHEDULE 0
Y0
1 .
21 Net assets or fund balances at end of year Combine lines 18 through 20 '
21
4,095.
BAA For Paperwork Reduction Act Notice, see the separate instructions.
TEEA0803L 11/27/13
Form 99042 (2013)
Form 990 -EZ (2013) INTERACT, INC DBA
Part II ] Balance Sheets (see the lnstructrons for Part II)
Check if the organlza Ian used Schedule Oto respond to any question in this Part II
93-1260201
Page 2
L^1
22 Cash, savings, and investments
23 Land and buildings
24 Other assets (describe in Schedule 0)
25 Total assets
26 Total liabilities (describe in Schedule O) SEE SCHEDULE 0
27 Net assets or fund balances (line 27 of column (B) must agree with line 21)
(A) Beginning of year I (S) End of year
15,137.
22
5,180.
(e) Estimated amount of
other compensation
23
5
0.
24
0.
15,137.
25
5,180.
4, 254.
26
_ 1, 085.
10, 883 ,
27
4, 09.5 .
Part III Statement of Program Service Accomplishments (see the instructions for Part III)
Expenses
(Required for section 501
(c)(3) and 501(c)(4)
organizations tr andel section
��others))trusts, optional
Check if the organization used Schedule 0 to respond to any question in this Part III
t
What is the organization's primary exempt purpose? SEE SCHEDULE 0
Describe the organization's program service accomplishments for each of Its three largest program services, as
measured by expenses In a clear and concise manner, describe the services provided, the number of persons
benefited, and other relevant information for each program title 1
28 SEE SCHEDULE 0
(Grants ) If this amount includes foreign grants, check here " I l
28a
_ 57, 837 .
29
(Grants $ ) If this amount includes foreign grants, check here ' f
29a
30
(Grants $ ) If this amount includes foreign grants, check here '' f
30a
31 Other program services (describe in Schedule O).
(Grants $ ) If this amount includes foreign grants, check here ]
31 a
32 Total program service expenses (add lines 28a through 31a) '
32
57,837 .
I Part IV ]List of Officers, Directors, Trustees, and Key Employees (list each one even if not compensated - see the instructions for Part IV)
t.,necK it tne organization usea cneauie V to respona t0 any question In ails ran iv LJ
(a) Name and Title
(b) Average hours per
week devoted to
position
(c) Reportable compensation
(Forms W2/1099•MISC)
(If not paid, enter -0-)
(d) Health benefits,
contributions to employee
benefit plans, and deferred
compensation
(e) Estimated amount of
other compensation
DOUGLASS MYERS _
PRESIDENT
5
0.
0.
0.
ROY GREEN
DIRECTOR
1
O.
O.
O.
NANCY FARNHAM -
DIRECTOR
1
0 .
O.
O.
MAGIE O'CONNOR
DIRECTOR -
1
0.
0.
0.
EVE NAZARIAN
DIRECTOR
1
0.
0.
0.
BAA
TEEA0812L 11/27/.13
Form 9904a (2013)
Deschutes County Community Grant Program
2014-15 Application Review
Rating Worksheet
Applicant: Heart of Oregon
Category/Grant Amount:
Title:
Other Essential Services / $11,000
Equipment Capital Campaign
Review Criteria:
1. Organization:
• Stable and positive history of providing services in Deschutes County.
• Experience delivering similar programs, projects, or activities as those proposed.
• Mission and goals are consistent with proposed program, project, or activity.
• Stable and experienced Board of Directors or other leadership group.
• Adequate staff and/or volunteers to implement proposed program, project, or activity.
Points awarded for this section (maximum of 25).
2. Financial Status:
• Adequate financial resources available to conduct and sustain operations.
• Broad and diverse base of funding sources.
• Financial need for a Community Grant to implement proposed program, project, or
activity.
• Proposed budget is consistent with and appropriate for the fixed grant amount
available in the selected Community Grant category.
Points awarded for this section (maximum of 25).
3. Program, Project, or Activity:
• Program, project, or activity does not address emergency food, clothing, or shelter.
(These activities are supported by Deschutes County through a separate grant
program in conjunction with United Way's Emergency Food and Shelter program.)
• Request is consistent with the fixed dollar amounts indicated in the category/grant
amount description at the top of this form.
• Number of individuals to be served is appropriate to the budget and scale of proposed
program, project or activity.
• Serves vulnerable and/or underserved populations and/or communities.
• Positively impacts welfare of the community.
• Complements, but does not duplicate, existing Deschutes County services.
• Implementation strategy is suitable to achieving the stated goals and objectives of
proposed program, project, or activity.
• Partnerships or collaboration with other agencies are included in implementation
strategy.
• Other sources of funds or in-kind support are available to supplement Community
Grant funds.
Points awarded for this section (maximum of 35).
4. Performance Management:
• Stated outputs are relevant and reasonable to the scale of the proposed program, project,
or activity.
• Stated outcomes are relevant and reasonable to the scale of the proposed program,
project, or activity.
Points awarded for this section (maximum of 15).
TOTAL NUMBER OF POINTS AWARDED:
COMMENTS:
NAME OF RATER:
Deschutes County
Fiscal Year 2014-15
Community Grant Application
Submittal Instructions and Cover Sheet
A complete application will consist of the following:
1. This cover sheet, signed and dated.
2. Narrative responses to the attached questions on no more than four single -sided, single-spaced
pages.
3. Attachments:
a. Proof of the organization's 501(c)(3) tax-exempt status in the form of a letter from the
Internal Revenue Service (IRS).
b. The first two pages of the organization's most recently submitted IRS 990 or 990 EZ
form or, if the organization is not required to file either form with the IRS, a financial
statement that provides equivalent information concerning activities and governance,
revenue, expenses, and net assets or fund balances.
c. An operating budget specific to the proposed operations, program, project, or activity.
d. A roster of the organization's Board of Directors.
Submit the complete application electronically to iudithu(d)deschutes.org, no later than 5:00 p.m. on
October 24, 2014. Incomplete and/or late applications will not be reviewed or considered.
Please complete the following:
Contact Name:
Laura M Handy, Executive Director
Organization Name:
Heart of Oregon Corps
Address: L
City:
PO Box 279
Bend
Telephone Number:
Email Address:
State:
OR
Zip Code:
97709
541-633-7834
laura.handy@heartoforegon.org
Application is being submitted to which Community Grant Program funding category*?
❑ Health, Mental Health, and Addictions Services
❑ Arts and Culture
® Other Essential Services: Includes services to youth; underserved, indigent, and/or vulnerable
populations; animal welfare; or the environment.
* Please refer to the funding guidelines for more information.
Certification:
On behalf of the organization specified above, I certify the following:
1. All information included in this application is accurate.
2. 1 am authorized by the governing board to submit this grant application.
3. This organization is located in Deschutes County.
4. If awarded, Community Grant funds will be used in support of Deschutes County residents
only.
5. This organization is in good standing with the U.S. Internal Revenue Service and is currently
designated as a 501(c)(3) tax-exempt entity.
Signature:
Print Name: r'rl 1`[ �'1 „r•l /fit (/r?J 1(i
Title: ! : . Pd ; if, ".0 D1,''�,
Date ler'.
Fleet for the Future
History
Heart of Oregon Corps (HOC) was founded in 2000, with a vision, just one stewardship crew, a grant
from the Northwest Area Foundation, and a partnership with Deschutes County Juvenile Justice. Local
community juvenile justice leaders and founders of HOC, Dennis Maloney, Dave Holmes and Dan
Saraceno recognized the need for education opportunities, job skills training and a paying job for the at
risk youth of Deschutes County. In 2003, HOC partnered with the United States Forest Service to
establish the Central Oregon Youth Conservation Corps, growing from 1 crew to 22, operating across 4
counties (Deschutes, Crook, Jefferson and Klamath).Today, HOC operates five distinct education and job -
skills based programs: Central Oregon Youth Conservation Corps (COYCC), AmeriCorps, YouthBuild,
Stewardship and a Heart of Oregon Thrift Store. Each one of our five programs exemplifies our mission
statement: To inspire and empower positive change in the lives of young people through jobs,
education and stewardship.
State the organization's mission, goals, and programs or services provided
Although each of our job skills programs have their own desired outcomes, our organization wide goal
for each and every opportunity youth we serve stays constant. We are dedicated to providing our young
people with jobs skills, and an education, wages for their hard work, and a pathway out of poverty. We
believe that our youth (ages 16-24) want to work, earn a paycheck and gain an education to earn a
better future for themselves, their families and their Deschutes County community. What the young
people have done with the opportunity HOC provides is quite inspiring. In the past 5 years, HOC youth
have provided 360,000 hours of service to Central Oregon and have earned over 5 million dollars in
wages. These wages are then put back into their local economies through work at various projects that
range from fire fuel reduction in the Deschutes National Forest to building affordable homes in
Redmond. Their hard work has not gone unnoticed by the community; our youth crews have built a
strong reputation due to their exceptional work ethic and are highly sought after for local fee for service
projects. John Allen, the Deschutes National Forests' Director calls our COYCC program, "the most
successful youth conservation corps in the whole Forest Service."
Describe the leadership and structure of the organization.
As is paramount to the success of any non-profit, the HOC Board of Directors has been vital to the
growth of HOC's impact on Deschutes County youth. Our Board provides direction to the organization,
gives guidance and leadership to the employees of HOC, and are positive role models for the youth that
we serve. In recruiting and electing members, the Board has found an appropriate balance of members
who have the skills to oversee the business-related functions of governance and others who have the
experiences to advocate for mission -rich, quality services. For example, member Chris Ochs, Director of
Marketing at Hayden Homes has business-related experience that contributes to the success of our
organization in a different way than the mission -related experience of member Sarah LaRocque,
Customer Care Representative at BendBroadband. Sarah is a 2007 alumnus of HOC who struggled pre-
program, but turned her life around during her time in our AmeriCorps program, and is now successful
in the professionally and personally. Some members embody both sides of this business/mission
balance, such as Lee Bouck, General Manager ofJELD-WEN who shares, "My experience as an employer
allows me to provide input on the realities of the job market. This provides valuable insight, allowing
HOC to develop/modify programs needed by our youth for their long term success. I also grew up with
challenges similar to what many of our youth face. Achieving sound employment allowed me to turn my
life around and later move into the position I hold today. I believe that work is a fundamental
requirement for young people."
Heart of Oregon Corps Page 1
Fleet for the Future
Goals and objectives
By December, 2016, Heart of Oregon Corps (HOC) will finalize an equipment capital campaign to
modernize its vehicle and equipment fleet by working with foundations, businesses, and individual
donors. In two years, 60% of our fleet will be over 17 years old and 78% will be over 9 years old. With
some of these vehicles traveling up to 50,000 miles a year, it is easy to see why the Board of Directors
has identified the success of this campaign as our organization's most pressing need in order to
continue successfully impacting the lives of young people in Deschutes County. The two-year campaign
fundraising goal is $515,000. HOC will purchase 6 passenger vans and sell 4 to increase the total of
passenger vans to 12. These vans are used to transporting youth crews from their home communities to
project sites such as the Pronghorn Golf Course and Redmond's Habitat for Humanity site. Four-wheel-
drive vehicles are essential in safely transporting youth crews through some of our rough rural roads and
due to the age of our existing units, 2 need to be sold and 2 need to be purchased to bring our total to 3.
The remaining funds will be utilized to purchase 6 trailers to increase our total to 11, and 4 project
equipment units such as a chipper and bobcat that are used for our most intensive and complex jobs.
Along with the new purchases, HOC will implement an effective fleet management system to ensure
proper, preventive maintenance and care of the 18 new assets.
Because Heart of Oregon Corps' model is centered on securing contracted fee-for-service projects far
afield from our program headquarters, a safe, low maintenance, and effective fleet is paramount to
sustainable operations. Fee-for-service contracts are the foundational revenue source for the agency.
Contracts with public lands agencies or housing authorities to build affordable housing secure matching
funds that allow us to secure large federal AmeriCorps or YouthBuild grants. Contracts with local
homeowner's associations or local recycling and waste center create real -wage earning jobs that school
districts are eager to have their students involved in. Our most foundational unit is a van, a crew leader,
and a crew. Without a reliable fleet, the fulcrum point of HOC's sustainability model is vulnerable.
The majority of funding for this campaign will come from the sale of our current units and a matching
grant from the Maybelle Clark Morgan (MCM) Foundation matching grant. This grant will allow us to
match outside funding from other future partners at a minimum of a 1:1 ratio up to $175,000. Since our
inception, the MCM Foundation has believed in what we are trying to do here at HOC and has given
$497,354.00. Their first investment provided the funds to purchase our first fleet units that have
transported over 2,000 local youth, many of which we still have today. In 2006, MCM supported a
previous capital campaign that allowed us to purchase our current operations center in Bend. Because
of this historical partnership, we are fully confident in the upcoming success of the Fleet for the Future
campaign.
Target population
Heart of Oregon Corps' programs serves youth ages 16-24, 67% are male and 33% are female. HOC
youth are 70% White, 14% Hispanic, 7% Native, 6% Multi -Racial, 2% Asian and 1% Black. Demographics
vary by program (some strictly serve disadvantaged youth while others have opportunities for all youth).
In YouthBuild, located in Redmond, youth are 63% very low-income, 69% high school drop outs, 77%
basic skills deficient, 9% homeless, 38% youth with disabilities, 2% foster care, 6% parental
incarceration, and 60% previously court involved. Many HOC teenagers are considered "opportunity
youth," disconnected from school and work, but full of potential. Not only does HOC address the
economic, employment and educational challenges that face our community as a whole, it generates
hope in the futures of our young people. The young people HOC serves are at a tipping point in their
Heart of Oregon Corps Page 2
Fleet for the Future
lives, when a series of small changes become important enough to lead to a significant transformation.
Through our programs, these small changes come in the form of job skills training, a GED/diploma,
opened up channels for postsecondary opportunities, an aptitude and true drive for community service,
and a realization of self-worth. These are the momentous changes, and on their heels follows a
generation of young people who believe in themselves enough to rise up as leaders in the community,
and in the world. This outcome is vital, and not readily attained without unique programs like HOC.
The geographic area of Deschutes County that will benefit
The first HOC work crew originated right here in Deschutes County and was led by local citizen leaders
and youth from Sisters and Bend. 15 years later, the majority of the youth we serve still call La Pine,
Redmond, Bend, Terrebonne and Sisters home. Our main operating center is located in NE Bend, where
youth from all over the county start their work and education days. Our YouthBuild program, which has
been housed in Redmond for the past 5 years, will now be moving just outside of Sisters to begin an
exciting new partnership with the Sisters School District. This new, larger facility will allow our
YouthBuild program to expand its reach throughout Deschutes County by providing more space for local
youth to come learn construction skills on-site and more classroom space to reengage in education. Our
youth crews have worked throughout Deschutes County in places like Pronghorn, Skyliners Ridge,
Tumalao Falls, Big Eddy, Redmond's Housing Works development, Cloverdale, Green Lakes Trail, Mt.
Bachelor, just to name a few but the list could go on and on.
HOC's impact on the community and complementing existing services
HOC has an extensive history in collaborating with local existing services that benefit all of Deschutes
County residents. Our philosophy is to partner with rather than compete against the efforts of
organizations addressing similar issues such as Central Oregon Intergovernmental Council,
HousingWorks, community justice departments, and regional school districts in Redmond, Sisters, Bend
and Madras. Cheryl Puddy of the Oregon Community Foundation believes that "Laura Handy (Executive
Director) is a leader in Bend and does a great job of collaborating with other organizations."
Describe in detail how the proposed initiative will be implemented
Below is the proposed timeline created by the Board of Directors and Executive Director:
2014:
• Capital Campaign Planning with Board
• detailed analysis of fleet and identification of needs
• Applications to MCM Fund for Matching Challenge Grant, Mt Bachelor, Deschutes Co.
2015:
• Secure initial matching funding grant (MCM Foundation $175k)
• Capstone Grant (Meyer Memorial Trust $50k)
• Secure local Corporate Sponsorships from auto and equipment dealers and maintenance shops
• Recruit in-kind consultants to assist in implementing new fleet management system
• Decommission and sale of older fleet units
• Procure new and gently used units
2016:
• January: Gala at the Riverhouse (if applicable)
• Leverage capstone matching grant at conclusion of fundraising period
• Fully implement new fleet management system
• Establish Fleet Replacement Fund
Heart of Oregon Corps Page 3
Fleet for the Future
How the requested funds will be used
The Deschutes County 11k investment in HOC will be leveraged to procure matching funds with the
MCM Matching Challenge. This sum at minimum will be matched at a 1:lratio with the potential of
becoming a higher amount. Not only is your gift an opportunity to purchase a new fleet unit, it is a vote
of confidence in HOC's mission and will be pivotal in increasing other funder's confidence in the success
of the capital campaign. If for some unexplained reason the capital campaign were not to be successful,
your investment in HOC would still go towards the purchase of a fleet unit. Without the capability of
safely transporting our youth to and from job and education sites, HOC will no longer be able to
achieve our mission. We would significantly have to cut back on the projects our youth crews perform
that benefit all of Deschutes County and the number of youth we serve. Once this campaign is
complete, HOC will have the capacity to further our reach into Deschutes County and give more youth
the chance "work, earn and learn" their way to a better future.
Identify any partner agencies which will collaborate to implement the proposed initiative.
The following private foundations have in been successful partners in the growth of HOC and will once
again be utilized to build organizational capacity: Cambers Family, Foundation Collins Foundation, Jeld
Wen Foundation, Flour Foundation, Ford Family Foundation, Oregon Community Foundation and MJ
Murdock. HOC will also seek other Deschutes County community partners through corporate
sponsorships, individual donors, community fundraising events, corporate giving programs and
furthering our in-kind donations to services so that we can potentially divert funds to this endeavor.
Along with the aforementioned funds, 100% of our Board of Directors have pledged to give towards this
project and concentrate their efforts on attracting their own donors for the campaign.
Other sources of funding that will support the proposed initiative
MCM Fund Challenge Matching Grant: 175k (pending)
Meyer Memorial Trust: Capstone Grant: 50k (pending)
Mt. Bachelor Charity Ski: 10k (pending)
Deschutes County Community Grant: 11k (pending)
US Dept. of Labor YouthBuild: $24k for van (secured)
Sign Pro: $2,000 (secured)
Outputs forecasted specifically for HOC programs
• Hours of academic and vocational certification instruction: 1,500
• Deschutes County participants served: 150
• Hours of job skills training through community stewardship projects: 50,000
• Youth enrolled in AmeriCorps Post -Secondary Scholarship Opportunity: 85
Anticipated outcomes of the collective HOC programs in Deschutes County
• Increase literacy and numeracy in participating youth by two levels.
• Increase the number of Deschutes Co. youth will attain a GED/Diploma
• Increase the number of Deschutes Co. youth will complete a college course.
• Increase the number of Deschutes Co. youth who have an industry recognized workforce
certification
• Increase the number of youth to complete 200 hours of jobs skills training in a HOC program.
• Increase the number of youth who earn a post- secondary scholarship of at least $1,100
Heart of Oregon Corps Page 4
HEART of
OREGON
VP CORPS
Empoweriny chanyt
Fleet for the Future
Equipment Capital Campaign
Breakout of Total
Budget: Deschutes
Revenue Total Budget County and 1:1 Match
Contributions
Individual (matched 1:1) $ 10,000
Event (matched 1:1) $ 45,000
Corporate Gifts/Grants/Sponsorships
Cash (matched 1:1) $ 10,000
In -Kind $ 10,000
Grants
Federal $ 24,000
Matching Challenge Grants
Initial $ 175,000 $
Capstone $ 40,000
State/County/Local Grants $ 11,000 $
Private Foundations (matched 1:1) $ 120,000
Sale of Assets
Depreciated Fleet Units $ 15,000
Land for Replacement Fund 5 40,000
11,000
11,000
REVENUE TOTAL $ 500,000 $
Expenses
Capital Equipment $ 400,000 $
Passenger Vehicles, Four -Wheel -
Drive Vehicles, Trailers, Heavy
Equipment
Initial Repair/Maintenance of used equipment $ 15,000
Modifications to equipment $ 7,500
racks/ladders, trailer
brakes/controllers, signage,
safety equipment, etc. $
Establishment of Replacement Fund $ 40,000
Fleet Management Software/Training $ 2,500
eTapestry Development Software $ 5,000
Development Assistant Personnel $ 30,000
22,000
20,500
1,500
EXPENSES TOTAL $ 500,000 $ 22,000
ot/il. HEART of
OREGON
IFCORPS
Empowering chary
Steve Welbourn
President / Joined Board: 2004
Chaplain, Oregon Department of Corrections
Provides nonprofit expertise and counseling
Jeff Lichtenberg
Board of Directors
Vice/Past President/Joined Board: 2006
Director, Jefferson County Community Justice
Provides expertise in justice and public admin.
Katy Fitzsimons
Treasurer/Secretary/Joined Board: 2011
Marketing Development Manager
Coca-Cola Refreshments
Provides marketing and job creation expertise
Lee Bouck
Board Member/ Joined Board: 2012
General Manager, JELD-WEN
Provides management and business expertise
Deborah Goodall
Board Member/Joined Board 2014
Retired, President, Metro Community College
Gives expertise in post -secondary pathways
Chris Ochs
Board Member/Joined Board 2013
Director of Marketing, Hayden Homes
Gives expertise in business and marketing
Sarah LaRocque
Board Member/Joined Board 2014
Customer Service Rep 2, Bend Broadband
Heart of Oregon Corps Alumnus (2007)
Represents alumni voice for mission integrity
Joshua Sims
Board Member/Joined Board 2014
Owner, The Gear Fix
Provides small business owner insights
Last Updated: 10/23/2014
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Applicant:
Deschutes County Community Grant Program
2014-15 Application Review
Rating Worksheet
The Bloom Project
Category/Grant Amount:
Title:
1 Other Essential Services
The Bloom Project: Central Oregon
Review Criteria:
1. Organization:
• Stable and positive history of providing services in Deschutes County.
• Experience delivering similar programs, projects, or activities as those proposed.
• Mission and goals are consistent with proposed program, project, or activity.
• Stable and experienced Board of Directors or other leadership group.
• Adequate staff and/or volunteers to implement proposed program, project, or activity.
Points awarded for this section (maximum of 25).
2. Financial Status:
• Adequate financial resources available to conduct and sustain operations.
• Broad and diverse base of funding sources.
• Financial need for a Community Grant to implement proposed program, project, or
activity.
• Proposed budget is consistent with and appropriate for the fixed grant amount
available in the selected Community Grant category.
Points awarded for this section (maximum of 25).
3. Program, Project, or Activity:
• Program, project, or activity does not address emergency food, clothing, or shelter.
(These activities are supported by Deschutes County through a separate grant
program in conjunction with United Way's Emergency Food and Shelter program.)
• Request is consistent with the fixed dollar amounts indicated in the category/grant
amount description at the top of this form.
• Number of individuals to be served is appropriate to the budget and scale of proposed
program, project or activity.
• Serves vulnerable and/or underserved populations and/or communities.
• Positively impacts welfare of the community.
• Complements, but does not duplicate, existing Deschutes County services.
• Implementation strategy is suitable to achieving the stated goals and objectives of
proposed program, project, or activity.
• Partnerships or collaboration with other agencies are included in implementation
strategy.
• Other sources of funds or in-kind support are available to supplement Community
Grant funds.
Points awarded for this section (maximum of 35).
4. Performance Management:
• Stated outputs are relevant and reasonable to the scale of the proposed program, project,
or activity.
• Stated outcomes are relevant and reasonable to the scale of the proposed program,
project, or activity.
Points awarded for this section (maximum of 15).
TOTAL NUMBER OF POINTS AWARDED:
COMMENTS:
NAME OF RATER:
Deschutes County
Fiscal Year 2014-15
Community Grant Application
Submittal Instructions and Cover Sheet
A complete application will consist of the following:
1. This cover sheet, signed and dated.
2. Narrative responses to the attached questions on no more than four single -sided, single-spaced
pages.
3. Attachments:
a. Proof of the organization's 501(c)(3) tax-exempt status in the form of a letter from the
Internal Revenue Service (IRS).
b. The first two pages of the organization's most recently submitted IRS 990 or 990 EZ
form or, if the organization is not required to file either form with the IRS, a financial
statement that provides equivalent information concerning activities and governance,
revenue, expenses, and net assets or fund balances.
c. An operating budget specific to the proposed operations, program, project, or activity.
d. A roster of the organization's Board of Directors.
Submit the complete application electronically to judithu@deschutes.org no later than 5:00 p.m. on
October 24, 2014. Incomplete and/or late applications will not be reviewed or considered.
Please complete the following:
Contact Name: Heidi Berkman
Organization Name: The Bloom Project
Address: 70 SW Century Drive, Suite 100-256
City: Bend State: OR Zip Code: 97702
Telephone Number: 541-480-8700
Email Address: h.berkman(a,thebloomproject.org
Application is being submitted to which Community Grant Program funding category*?
❑ Health, Mental Health, and Addictions Services
❑ Arts and Culture
x❑ Other Essential Services: Includes services to youth; underserved, indigent, and/or vulnerable
populations; animal welfare; or the environment.
* Please refer to the funding guidelines for more information.
Certification:
On behalf of the organization specified above, I certify the following:
1. All information included in this application is accurate.
2. I am authorized by the governing board to submit this grant application.
3. This organization is located in Deschutes County.
4. If awarded, Community Grant funds will be used in support of Deschutes County residents
only.
5. This organization is in good standing with the U.S. Internal Revenue Service and is currently
designated as a 501(c)(3) tax-exempt entity.
Signature:
AvkleAkaii4L--
Print Name: Heidi Berkman
Title: Founder/Board President
Date: October 23, 2014
The Bloom Project:
Deschutes County Fiscal Year 2014-15
Community Grant Application
Organization
1. Describe the history of the organization, including the year the organization was established.
The Bloom Project began in the garage of founder Heidi Berkman in 2007 with donated flowers
and a few volunteers who had recently experienced the loss of a loved one in hospice care.
Seven years later, our largely volunteer -driven program donates flower bouquets on a weekly
basis through six hospice and palliative care locations serving Deschutes County, receives regular
donations of re -purposed flowers and vases from a total of twenty-seven businesses including
local grocery stores, florists, hotels and resorts, and has benefitted from over 18,000 hours of
volunteer time, and delivered over 38,000 bouquets to patients and their caregivers.
2. State the organization's mission, goals, and programs or services provided.
Our mission is to donate fresh bouquets of flowers to hospice and palliative care patients,
demonstrating beauty, giving and joy during end of life care. Our volunteers gather, arrange and
deliver re -purposed flowers to those who need a bit of beauty during a difficult time. The Bloom
Project organizes donations of flowers and vases from wholesale floral supporters and grocers,
community members' special events and more. Bloom Project volunteers turn these donations
into beautiful bouquets and additional volunteers deliver the bouquets to hospice and palliative
care organizations. The bouquets are in turn delivered to patients in their home or care facility by
staff, clergy, social workers and facility/organization volunteers.
This simple act of kindness powerfully impacts individuals and families at a time when they are
most vulnerable. In the words of one supporter, "What an amazing thing to realize that although
a patient may be preparing to die (and feeling like the world will go on without them), someone
took the time to think about them and create this beautiful gift."
3. Describe the leadership and structure of the organization.
Board President Heidi Berkman founded and has been the driving force behind the organization's
successful growth over the past seven years. Heidi, an experienced meeting and event planner,
has guided the board of directors in incorporating the organization; putting in place board,
financial and fundraising systems; developing a strong volunteer base and relationships with
local businesses; overseeing the organization's programs; fundraising; and managing volunteer
administrative and program staff. Heidi is joined by a committed group of six business and
community leaders who together guide this robust, grassroots organization that is well -loved and
supported by volunteers, businesses, care providers, patients and families alike.
The success of our business model is its ability to attract and engage community members to
resource and carry out our work. Volunteers power our program activities and local businesses
donate floral materials and supplies, a beautiful workspace, equipment, and various professional
services. In order to manage our growing volunteer -driven effort, we hired a part-time Site
Coordinator in June 2014 to organize and motivate our team of 100 volunteers and a full-time
Project Manager in August 2014 to provide leadership, manage our growing relationships with
community partners and businesses, and assist our board of directors in its fundraising activities.
October 23, 2014
The Bloom Project: Deschutes County Community Grant 2014-15 page 2/4
Program, Project, or Activity
1. Provide a title of the proposed initiative for which funds are being requested.
The Bloom Project: Central Oregon.
2. Describe the goals and objectives of the proposed initiative.
In 2015, The Bloom Project Central Oregon will:
• Engage 130 volunteers in securing materials, arranging, and delivering 200-225 bouquets
weekly to hospice and palliative care patients,
• Increase the number of volunteer hours, floral suppliers and businesses supporting the
organization resulting in a total of $539,386 in contributed in-kind income, and
• Carry out service learning projects with 12 middle school students from REALMS and 38
children attending Camp Courage—a hospice grief program for youth offered by Partners
In Care.
3. Identify the target population that will be served.
Our work is targeted at hospice and palliative care patients receiving end of life care at home, in
the hospital, or at an assisted living facility. While the dying individual is the primary
beneficiary, our work also supports grieving family members and a multitude of caregivers who
are involved with patients including social workers, hospice and hospital nurses, chaplains and
community hospice volunteers.
4. Identify the geographic area(s) of Deschutes County that will benefit.
Bend, LaPine, Redmond and Sisters
5. Describe how the proposed initiative will positively impact the community and complement
existing services currently provided by Deschutes County.
Our program directly improves the wellbeing of a very vulnerable population within our county,
while also supporting community livability, citizen engagement and a healthier environment.
We support the wellbeing of patients and families alike during the very difficult transition at the
end of life. Many families who contract with hospice care are scared, worried and try to go it
alone, refusing visits from hospice staff and volunteers. Our donated bouquets give staff an
opportunity to make a visit and simply provide a thoughtful gesture in hopes that this gift will
open the door to additional much-needed care to the patient and support to the family. It is also
true that many people at the end of life find themselves alone and the gift of flowers helps to
reconnect them with the love, care and compassion of others.
A hospice social worker shared that last Valentines Day she brought flowers to a patient who had
spent most of his life in prison. With tears in his eyes, he told her that no one had ever given him
flowers before and proceeded to share stories from his life. She said he died a few days later, but
that she was amazed at how such a small gift could touch someone in such a profound way.
October 23, 2014 The Bloom Project: Deschutes County Community Grant 2014-15 page 3/4
Our program also gives citizens and local businesses a very tangible way of caring for others in
their community and extends the life of an enormous amount of floral material that would
otherwise be disposed of after its shelf life in the local grocery or at the end of a local event.
6. Describe in detail how the proposed initiative will be implemented.
The work of The Bloom Project is simple but immensely powerful. Each morning, an email goes
out to 100 Central Oregon volunteers with requests to pick up donated flowers and vases from
local businesses, special events and community businesses. Mid-morning, volunteers begin to
arrive at our donated workspace at The Cascade Village Shopping Center with the floral
materials they have collected. They then spend the next 3-5 hours creating beautiful bouquets and
delivering them to local hospices and palliative care providers. Chaplains, social workers, nurses
and volunteers then take the bouquets with them on their visits, offering this expression of beauty
and human warmth to those in their care.
7. Describe specifically how the requested funds will be used.
Our total annual budget for 2015 is $642,181 - 84% percent of which will come from contributed
in-kind goods and services. This grant of $11,000 will help to fund the very modest cash revenue
portion of our annual operating expenses that totals $102,795. This is the total cash required to
carry out program, administration and fundraising efforts altogether. Our strong base of
volunteer and business support will account for the remaining $539,386 in contributed in-kind
resources that we use to carry out our work.
8. Identify any partner agencies that will collaborate to implement the proposed initiative.
We have developed strong, long-standing relationships with many medical institutions within
Central Oregon who are involved in end of life care, including: Partners in Care Hospice and
Home Health, St. Charles Palliative Care and Hospice Programs, and Heart 'n Home Hospice
(Bend & La Pine).
9. Describe other sources of funding that will support the proposed initiative.
Our board of directors has committed to helping us raise $65,750 in private donor revenue during
2015. This includes $35,000 from individual and business donors, and $30,750 from our annual
spring fundraising event. Additionally, we have secured $14,000 to date toward our 2015 grant
goal of $40,000. This includes a grant of $12,000 from the Oregon Community Foundation, and
a grant of $2,000 from the Ronald McDonald House Charities. We will pursue an additional
$26,000 in grant funding.
Performance Measurement
1. Identify quantifiable outputs we anticipate to achieve through the proposed initiative (examples:
number of persons served, programs or events held, animals rescued, acres restored or protected).
We anticipate the following quantifiable outputs for 2015:
• Hospice and palliative care patients served: 200 week
• Floral bouquets donated and delivered to patients: 10,000 annually
• Volunteers/volunteer hours: 130 individuals resulting in a total of 9,175 hours annually
October 23, 2014 The Bloom Project: Deschutes County Community Grant 2014-15 page 4/4
• Youth involved in service learning activities: 50
• Businesses contributing materials: 27 businesses (grocers, florists, hotels and resorts)
2. Describe the anticipated outcomes of the proposed initiative (examples: fewer persons
institutionalized, greater knowledge and understanding of local history, fewer animals in shelter
care, more natural areas available for wildlife and recreation).
We anticipate the following outcomes for 2015:
The dying are comforted by the gift of beauty and expression of care by another.
Caregivers are provided with an opportunity to reach out to patients and family members
at a time when they most need it, but may be resistant to help.
Grieving family members are supported and comforted in their loved one's final days.
Community members and businesses have an avenue to express their concern for others
and provide another element of dignity at the end of life.
• Youth learn what it means to be a volunteer, have opportunities to discuss death/dying
with volunteer facilitators, and provide a thoughtful gift to those at the end of life.
• Resources that would normally be thrown away at the end of their shelf life or intended
use are re -purposed.
• Community awareness is raised and misconceptions dispelled about the benefits of end of
life care through hospice and palliative care opportunities.
The Bloom Project: 3 -Year Organization Budget Projection
Income:
Grants
Individual and Business
Total Contributions
Central Oregon
2014 Budget
Projected
2015
Projected
2016
Advertising and Promotion
Flowers and Vases
Fundraiser
Professional Services
Utilities
Volunteer Hours
Workspace
Total In -Kind Income
Donations
Sponsorship
Ticket Sales
Total Fundraiser
Total Income
Expenses:
Advertising and Promotion
Flowers and Vases
Fundraiser
Professional Services
Utilities
Volunteer Hours
Workspace
Total In -Kind Expenses
Advertising and Promotion
Bank Charges
Board Expense
Dues and Subscriptions
Event Expense:
Spring Fundraiser
Volunteer Appreciation
Gift Expense
Insurance:
General Liability
D&O
Workers' Comp
Licenses and Registrations
Meals and Entertainment
Miscellaneous Fees
Office Supplies
Payroll:
Project Manager
Site Coordinator
Payroll Taxes
Direct Deposit Fees
Postage and Delivery
Printing and Copying
Professional Services:
Bookkeeping
Grant Writer
Graphic Design
Legal
Supplies and Equipment
Training and Seminars
Website Expense
Project Expense:
Database
Service Learning
Other Expenses
Total Expenses
Change over
Base Year
25,000 40,000 35,000 10,000 40%
25,000 35,000 45,000 20,000 80%
50,000 75,000 80,000 30,000 60%
8,000 9,000 10,000 2,000 25%
300,000 315,000 320,000 20,000 7%
1,000 1,000 1,000 0%
2,500 2,500 3,000 500 20%
3,000 3,000 3,000 0%
175,318 195,886 204,000 28,682 16%
22,000 22,000 22,000 - 0%
503,818 539,386 553,000 49,182 10%
12,000 20,000 25,000 13,000 108%
2,500 2,500 3,500 1,000 40%
6,000 8,250 9,625 3,625 60%
20,500 30,750 38,125 17,625 86%
574,318 645,136 671,125 96,807 17%
8,000 9,000 10,000 2,000 25%
300,000 315,000 320,000 20,000 7%
1,000 1,000 1.000 - 0%
2,500 2,500 3,000 500 20%
3,000 3,000 3.000 - 0%
175,318 195,886 204.000 28,682 16%
22,000 22.000 22,000 0%
503,818 539,386 553,000 49,182 10%
2,000 2,500 3,000 1,000 50%
60 60 60 - 0%
4,000 500 1.000 (3,000) -75%
500 500 500 0%
5,900 8.250 9.625 3,725 63%
900 950 1.000 100 11%
350 350 350 - 0%
425 425 425 _ 0%
1,093 1,160 1.250 157 14%
550 550 550 - 0%
75 75 75 0%
250 300 350 100 40%
115 115 115 - 0%
200 300 400 200 100%
22,500 45,000 45,000 22,500 100%
6,500 13,000 13,000 6,500 100%
3,200 6,400 6,400 3,200 100%
20 40 45 25 125%
400 500 600 200 50%
2,000 2,500 3,000 1,000 50%
4,020 4,020 4,020 - 0%
3,000 3,000 3,000 - 0%
1,750 3,500 5,000 3,250 186%
2,000 1,000 1,000 (1,000) -50%
1,750 2,000 2,500 750 43%
50 200 300 250 500%
3,000 4,000 4,500 1,500 50%
1,500 1,500 1,500 - 0%
100 100 100 0%
68,208 102,795 108,665 40,457 59%
572,026 642,181 661,665 89,639 16%
Net Income 2,292 2,955 9,460 7,168 313%
The Bloom Project
Board of Directors
Heidi Berkman, President/Founder
The Bloom Project
70 SW Century Drive, Suite 100--256
Bend, OR 97702
541-480-8700
h.berkman@thebloomproject.org
Kim Curley Reynolds (Operations), Vice President & Secretary
Community Outreach Director, Commute Options
1310 NE Hollinshead Drive
Bend, OR 97701
541-408-6111
kim@commuteoptions.org
Mathew Hamlin (Financial), Treasurer
Jones & Roth, CPAs & Business Advisors 3
300 SW Columbia Street, Suite 201
Bend, OR 97702
541-382-3590
MHamlin@jrcpa.com
Kelly Herman (Public Relations)
Owner, Kelly Herman & Co — Coaching & Consulting
456 NW Kansas Avenue
Bend, OR 97701
541-419-8855
Kelly@kellyherman.com
Sue Jones (Human Resources)
HR Consultant, KLS Group
22310 Sweetgrass Drive
Bend, OR 97702
541-639-7555
Sue@theklsapproach.com
Michelle Martin (Floral)
Gairdin — Home + Garden
50 SW Bond Street, Suite 1
Bend, OR 97701
541-788-5735
admin@gairdin.com
Helen Riser (Hospice)
19570 Green Lakes Loop
Bend, OR 97702
541-385-5265
hriser@bendcable.com
21114 Rnarri of flirpr..tnrc/Aelvicnry lnmmittpp Rnctpr 1
Advisory Committee Members
Erin MacDonald (Legal)
Karnopp Peterson LLP
1201 NW Wall Street, Suite 200
Bend OR 97701
541-382-3011
EKM@karnopp.com
Romy Mortensen (Marketing)
Director of Marketing, Brooks Resources Corporation
409 NW Franklin Avenue
Bend, OR 97701
541-382-1662
romy@brooksresources.com
2(114 Rnarri of flirPr'tnrc/Arivicnry fnmmittPP RnGtP.r
Form
CT -1 2
For Oregon Charities
Charitable Activities Section
Oregon Department of Justice
1515 SW 5th Avenue, Suite 410
Portland, OR 97201-5451
Email: charitable.activities@doj.state.or.us
Website: http://www.doj.state.or.us
VOICE (971) 673-1880
TTY (800) 735-2900
FAX (971) 673-1882
For Accounting Periods Beginning in:
2013
Section I. General Information
1.
REGISTRATION #: 39041
THE BLOOM PROJECT
70 SW CENTURY DR, STE 100-256
BEND, OR 97702
PHONE: (541) 480-8700
PERIOD BEGINNING: 1/1/2013
PERIOD ENDING 12/31/2013
Cross Through Incorrect Items and Correct Here:
(See instructions for change of name or accounting period.)
Registration #:
Organization Name:
Address:
City, State, Zip:
Phone:
Email:
Fax:
Period Beginning: / / Period Ending:
/ /
Amended
Report?
111
2. Did a certified public accountant audit your financial records? - If yes, attach a copy of the auditor's report, financial statements,
accompanying notes, schedules, or other documents supplementing the report or financial statements.
3, Is the organization a party to a contract involving person-to-person, advertising, vending machine or telephone fund-raising in
Oregon?
If yes, write the name of the fund-raising firm(s) who conducts the campaign(s).
4 Has the organization or any of its officers, directors, trustees, or key employees ever signed a voluntary agreement with any
government agency, such as a state attorney general, secretary of state, or local district attorney, or been a party to legal action
in any court or administrative agency regarding charitable solicitation, administration, management, or fiduciary practices? If
yes, attach explanation of each such agreement or action. See instructions,
5 During this reporting period, did the organization amend its articles of in po tion, bylaws, or trust documents, OR did the
organization receive a determination letter from the Internal Revenue S ice relating to its tax-exempt status? If yes, attach a
copy of the amended document or letter.
0
6. Is the organization ceasing operations and is this the final repos If yes, see instructions on how to close your registralion,)
7. Provide contact information for the person responsible for retaining the organization's records.
Yes
❑ Yes
L,CI No
No
ri Yes IV I No
❑ Yes [71 No
Yes [rn1 No
Name
Position
Phone
Mailing Address & Email Address
HEIDI BERKMAN
PRESIDENT
541-480-8700
70 SW CENTURY DR, STE 100-256
BEND, OR 97702
8. List of Officers, Directors, Trustees and Key Employees — List each person who held one of these positions at any time during the year even if they did
not receive compensation. Attach additional sheets if necessary. If an attached IRS form includes substantially the same compensation information,
the phrase "See IRS Form" may be entered in lieu of completing that section. (Oregon law requires a minimum of three directo s )
Form Continued on Reverse Side
(A) Name, mailing address, daytime phone number
and email address
(B) Title &
average weekly
hours devoted to
position
(C)
Compensation
(enter $0 if
position unpaid)
Name:
SEE ATTACHED LIST - NO COMPENSATION
Address:
Phone:
/
`
Email:
(
/
Name:
Address:
Phone:(
)
Email:
Name:
Address:
Phone:
(
)
Email:
Form Continued on Reverse Side
Section II. Fee Calculation
Total Revenue
(From Line 12 (current year) on Form 990; Line 9 on Form 990 -EZ; Part I, Line 12a on Form 990 -PF; Line 9 on Form 1041
or see page 3 of the instructions if no federal tax return was prepared. Attach explanation if Total Revenue is $0.)
10. Revenue Fee
(See chart below. Minimum fee is $10, even if total revenue is a negative amount.)
Amount on Line 9 Revenue Fee
$0 - $24,999 $10
$25,000 - $49,999 $25
$50,000 - $99,999 $45
$100,000 - $249,999 $75
$250,000 - $499,999 $100
$500,000 - 5749,.999 $135
$750,000 - $999.999 $170
$1,000,000 or more $200
11 Net Assets or Fund Balances at End of the Reporting Period ...... 11.
(From Line 22 (end of year) on Form 990, Line 21 on Form 990 -EZ, or Part III, Line
6 on Form 990 -PF; or see page 3 of CT -12 instructions to calculate )
12. Net Fixed Assets Used to Conduct Charitable Activities
(Generally, from Part X, Line 10c on Form 990, Line 23B on Form 990 -EZ or Part
II, Line 14b on Form 990 -PF; or see page 4 of CT -12 instructions to calculate See
instructions 1 organization owns income-producing )
$34,355.00
12.
$0.00
13. Amount Subject to Net Assets or Fund Balances Fee
(Line 11 minus Line 12 If Line 11 minus Line 12 is less than $50,000, write $0.)
13
$52,090.00
$34,355.00
14. Net Assets or Fund Balances Fee
(Line 13 multiplied by ,0001, If the fee is less than $5, enter $0. Not to exceed $1,000 Round cents to the nearest whole dollar.)
15.
Are you filing this report late? Ti Yes No
(If yes, the late fee is a minimum of $20. You may owe more depending on how late the report is, See Instruction 15 for additional information or contact the
Charitable Activates Section at (971)573-108D lo obtain tate fee amount)
16. Total Amount Due
(Add Lines 1D, 14, and 15. Make check payable to the Oregon Department of Justice.)
14.
$45.00
$0.00
15.
16.
5.00
Attach a copy of the organization's federal 990 or other return all supporting schedules and attachments that were filed with the IRS with the
17. exception that Form 990 & 990EZ filers do not need to attach a copy of their Schedule B. Also, if the organization did not file with the IRS or filed a
990-N, but had Total Revenue of $25,000 or more, or Net Assets or Fund Balances of $50,000 or more, see the instructions as the organization may
be required to complete certain IRS forms for Oregon purposes only. If the attached return was not filed with the IRS, then mark any such return as
"For Oregon Purposes Only." If your organization files IRS Form 990-N (e -Postcard) please attach a copy or confirmation of its filing
Please
Sign
Here
Under penalties of perjury, I declare that I have examined this return, including all accompanying forms, schedules, and attachments, and
to the best of my knowledge and belief, it is true, correct, and complete.
Signature of officer
PRESIDENT
Date Title
Paid
Preparer's
Use Only
Preparer's signature
4/3/14 541-389-8289
Date Phone
CASEY I. TERADA, CPA PO BOX 9388, BEND, OR 97708
Preparer's name Address