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OFFICE OF CHILD CARE AND REGULATORY SERVICES CARES ACT GRANT APPLICATION The Office of Child Care and Regulatory Services is providing grants to Child Care Providers and other Early Childhood Education Providers that are facing financial hardship due of the COVID-19 pandemic. These grants are funded through the US Department of Health and Human Services Administration for Children and Families Office of Child Care by the Coronavirus Aid, Relief and Economic Security (CARES) Act. GRANT APPLICATION INSTRUCTIONS 1. Insert the date when the application is completed. 2. Insert the name of the owner of the facility for which the grant is being requested. 3. Insert the name of the facility (Business Name). 4. Insert the facility’s current business license number, issued by DHS OCCRS. 5. Insert the physical address of the Facility for which the grant is being requested. 6. Insert the mailing address of the Facility for which the grant is being requested. 7. Insert the Employee Identification Number or Taxpayer Identification Number associated with the Facility and its Owner. 8. Insert a working telephone number where the Applicant can be contacted. 9. Insert a working email address by which the Applicant can be contacted. 10. Please indicate, whether this business is registered with SAM.GOV. 11. Insert this facility/business’ Unique Entity Identifier number. 12. Please complete the Grant Category and Amounts Section completely. See example below: GRANT CATEGORY REQUESTED AMOUNT x OCCRS-1 Health and Safety $10,500.00 Brief description: To purchase first aid kits, child-proofing items and facility modifications. 13. Please complete and attach a budget sheet that justifies the grant amount being requested for each grant category. For each grant category for which you apply, a budget sheet must be attached to the application. 14. You must submit an application for each facility. Do Not apply for grants for different Facilities on the same application. GRANT APPLICATIONS MUST BE SUBMITTED BY SEPTEMBER 10, 2022 HOW DO I APPLY? 1. Download this grant application from the Department of Human Services website (www.dhs.gov.vi) on the Child Care and Regulatory Services page (www.dhs.gov.vi/occrs/index.html). 2. Complete each application thoroughly. 3. Mail, email, or place the completed application in a drop box location identified below: Mail to: St. Thomas/St. John District - Office of Child Care & Regulatory Services 1303 Hospital Ground, Knud Hansen Complex Bldg. A, Suite 1 St. Thomas, Virgin Islands 00802 St. Croix District – Office of Child Care & Regulatory Services #129 Golden Rock Christiansted, St. Croix Virgin Islands Email to: childcarevigrants@dhs.vi.gov Drop box locations: St. Thomas/St. John District - Office of Child Care & Regulatory Services 1303 Hospital Ground, Knud Hansen Complex Bldg. A, Suite 1 St. Thomas, Virgin Islands 00802 St. Croix District – Office of Child Care & Regulatory Services #129 Golden Rock Christiansted, St. Croix Virgin Islands If you have questions about the application please contact us at: St. Croix District Tahena Ayala (340) 772-7147 Email: tahena.ayala@dhs.vi.gov St. Thomas District Lori Pickering (340)774-0930 extension 4186 Email: lori.pickering@dhs.vi.gov 1 Revised 07/25/2022 CARES ACT GRANT APPLICATION SECTION I. IDENTIFYING INFORMATION 1. Date of Application: _____________ 2. Owner Name: ____________________________________________ 3. Facility Name: ___________________________________________ (Each site requires a separate application) 4. Department of Human Services License # (if applicable): _____________________ SECTION II. GRANT CATEGORIES AND AMOUNTS A provider may apply for up to eight (8) grants per facility from the indicated categories. The combined grants request may not exceed a total of thirty thousand dollars ($30,000) per facility. • Place a check mark “√” or “x” in front of each category for which funding is being requested. • Indicate the amount being requested next to each category. • The total amount of the grant application must not exceed $30,000.00 • If the total amount of the grant application exceeds $30,000.00, the entire application will be disqualified. Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 ph • (340) 774-4673 fax 3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 718-2980 ph • (340) 719-9763 fax 5. Physical Address: City: State: Zip Code: 6. Mailing Address: City: State: Zip Code: 7. EIN: TIN: Employer Identification Number Taxpayer Identification Number 8. Contact Number: 9. Email Address: 10. Active SAM.gov registration: Yes No 11. Unique Entity Identifier (UEI): GRANT CATEGORY REQUESTED AMOUNT OCCRS-1 Health and Safety Brief description: OCCRS-2 Professional Cleaning Services Brief description: OCCRS-3 Personal Protective Equipment (PPE) Brief description: OCCRS-4 Technology (Laptops, software, etc.) Brief description: OCCRS-5 Behavioral Health and Wellness Brief description: OCCRS-6 Afterschool/Camps Supplies Brief description: OCCRS-7 Rental/Mortgage Brief description: OCCRS-8 Utility Expenses Brief description: Total Amount Requested: PLEASE ATTACH A PROPOSED BUDGET FOR EACH CATEGORY FOR WHICH GRANT FUNDS ARE BEING REQUESTED. I ______________________ (applicant name), am duly authorized to apply for funding on behalf of ______________________________________________(Business Name) and agree to provide a closeout/summary of spending report along with original receipts/proof of payment for services or purchases in accordance with the budget and categories identified above, to the Office of Child Care and Regulatory Services in my district within 30 days of written request for the same. I agree to comply with the terms of this agreement and will return all funds not verified with appropriate receipts or proof of purchase. I understand that failure to submit documentation may disqualify me from future grants administered through the Department of Human Services, Office of Child Care and Regulatory Services. Applicant Name: ________________________________________ Date: ___________ Print/Sign GRANT APPLICATION MUST BE SUBMITTED BY September 10, 2022 2 Revised 07/25/2022 SECTION III: BUDGET SHEET/BUDGET JUSTIFICATION Select Grant Category for this Budget Sheet. Create a separate budget on a different sheet for each grant category (place check mark “√” or “x” in front of the category for this Budget Sheet) Health and Safety Behavioral Health and Wellness Professional Cleaning Services Afterschool/Camps supplies Personal Protective Equipment Rental/Mortgage Technology (laptops, software, etc.) Utility Expenses Budget Description: 3 Revised 07/25/2022 BUDGET SHEET/BUDGET JUSTIFICATION Select Grant Category for this Budget Sheet. Create a separate budget on a different sheet for each grant category (place check mark “√” or “x” in front of the category for this Budget Sheet) Health and Safety Behavioral Health and Wellness Professional Cleaning Services Afterschool/Camps supplies Personal Protective Equipment Rental/Mortgage Technology (laptops, software, etc.) Utility Expenses Budget Description: 4 Revised 07/25/2022 BUDGET SHEET/BUDGET JUSTIFICATION Select Grant Category for this Budget Sheet. Create a separate budget on a different sheet for each grant category (place check mark “√” or “x” in front of the category for this Budget Sheet) Health and Safety Behavioral Health and Wellness Professional Cleaning Services Afterschool/Camps supplies Personal Protective Equipment Rental/Mortgage Technology (laptops, software, etc.) Utility Expenses Budget Description: 5 Revised 07/25/2022 BUDGET SHEET/BUDGET JUSTIFICATION Select Grant Category for this Budget Sheet. Create a separate budget on a different sheet for each grant category (place check mark “√” or “x” in front of the category for this Budget Sheet) Health and Safety Behavioral Health and Wellness Professional Cleaning Services Afterschool/Camps supplies Personal Protective Equipment Rental/Mortgage Technology (laptops, software, etc.) Utility Expenses Budget Description: 6 Revised 07/25/2022 BUDGET SHEET/BUDGET JUSTIFICATION Select Grant Category for this Budget Sheet. Create a separate budget on a different sheet for each grant category (place check mark “√” or “x” in front of the category for this Budget Sheet) Health and Safety Behavioral Health and Wellness Professional Cleaning Services Afterschool/Camps supplies Personal Protective Equipment Rental/Mortgage Technology (laptops, software, etc.) Utility Expenses Budget Description: 7 Revised 07/25/2022 BUDGET SHEET/BUDGET JUSTIFICATION Select Grant Category for this Budget Sheet. Create a separate budget on a different sheet for each grant category (place check mark “√” or “x” in front of the category for this Budget Sheet) Health and Safety Behavioral Health and Wellness Professional Cleaning Services Afterschool/Camps supplies Personal Protective Equipment Rental/Mortgage Technology (laptops, software, etc.) Utility Expenses Budget Description: 8 Revised 07/25/2022 BUDGET SHEET/BUDGET JUSTIFICATION Select Grant Category for this Budget Sheet. Create a separate budget on a different sheet for each grant category (place check mark “√” or “x” in front of the category for this Budget Sheet) Health and Safety Behavioral Health and Wellness Professional Cleaning Services Afterschool/Camps supplies Personal Protective Equipment Rental/Mortgage Technology (laptops, software, etc.) Utility Expenses Budget Description: 9 Revised 07/25/2022 BUDGET SHEET/BUDGET JUSTIFICATION Select Grant Category for this Budget Sheet. Create a separate budget on a different sheet for each grant category (place check mark “√” or “x” in front of the category for this Budget Sheet) Health and Safety Behavioral Health and Wellness Professional Cleaning Services Afterschool/Camps supplies Personal Protective Equipment Rental/Mortgage Technology (laptops, software, etc.) Utility Expenses Budget Description: 10 Revised 07/25/2022