Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
PART III-A – REQUIRED PROGRAM INFORMATION:
Cover Sheet and District Summary Information
Cover Sheet
Applicant
Agency:
Program
Coordinator:
Address:
Phone:
(
Email:
)
Total number of children/youth served by the sites
included in this 21stCCLC proposal during the
following years:
Below please list the
sites included in this
application in the
corresponding level for
which they seek funding
for FY16-FY18.
Site Name
FY13
FY14
FY15
1.
Promising
FY13-FY15 Fund Code
647-B1 Grantee
2.
3.
1.
Practitioner
FY13-FY15 Fund Code
647-B2 Grantee
2.
3.
Demonstration
FY10-FY12 and
FY13-FY15 Fund Code
647-B2 Grantee
1.
2.
3.
Total FY16 21st CCLC Fund Code 647-B2 Funds Requested
% Funds that will be matched in FY16
(As noted in the RFP Funding section, applicants are required to demonstrate through a combination of
matching funds, in-kind resources, and/or collaborations/partnerships their ability to sustain their current
programming levels and/or enhance the amount and quality of services offered.)
Amount/Value ($) of FY16 Match
FY16 Fund Code 647-B2 Part III-A - Required Program Information - page 1
$
%
$
FY16:
(Projected)
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
Instructions for completing this document:
 Please address each of the applicable questions on the following pages within the indicated page limits.
 Responses should be provided within this document leaving the questions above each response.
 Please do not delete questions that are not applicable – this will re-number questions and may lead to
confusion in responding to questions that reference earlier questions.
 Please do not change the font size or margins.
 All questions are shaded in gray and responses should be written in the white space below each question.
 Narrative and/or bulleted responses are acceptable.
District Summary- Please complete one (1) district summary for all schools/sites included in this application.
A. District Support and Sustainability (5 pages maximum):
1. Describe the district’s strategy and goals for out-of-school time programming. Note: The response to
this question should provide a general overview of the district strategy. School-specific
needs/priorities will be described in the School/Site Implementation Plan(s).
2. Describe how the district (and lead applicant if not the district) and proposed school(s)/site(s)
collaborate to support implementation of this grant, including:

How the district (and lead applicant if not the district) and school(s)/site(s) collaborate to support
goals described above.

How budgetary decisions are made.

How the 21st CCLC coordinator fits into the district/school’s organizational structure.

How the district/school supports 21st CCLC leadership development (e.g., district and site
coordinators) as well as program staff professional development.
3. Describe the lead applicant’s participation in the 21st CCLC regional networks; include how the
program(s)/staff benefitted.
4. Describe the additional resources, other than this grant, that demonstrate the ability to sustain the
current programming levels and/or enhance the amount and quality of services offered. Include all of
the following:

Ways in which lead applicant contributes financially and non-financially towards sustaining the
applicant sites.

How this grant is/will be coordinated with other federal, state and local programs with
compatible/complementary services (e.g., McKinney-Vento, Title I, Title III, Adult Basic Education,
Wrap Around Services After School & Out of School Time Quality grant, Department of Early
Education and Care, etc.); and

Planned/anticipated support (financial and other) from municipalities, counties, school districts,
and/or private/community foundations.

Also, complete the chart on the next page listing the non 21st CCLC amounts and sources that
will be leveraged to support the proposed site(s). Be specific in noting the resources secured
and/or anticipated.
FY16 Fund Code 647-B2 Part III-A - Required Program Information - page 2
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
A. District Support and Sustainability (continued)
For each proposed site list the source(s) and amount of additional resources secured or anticipated
that will support any or all of the categories below. NOTE: The funds listed below may be actual
funding or the value of in-kind contributions.
TOTAL Anticipated
Non-21st CCLC
Funds
Site 1
TOTAL Anticipated
Non-21st CCLC
Funds
Site 2
TOTAL Anticipated
Non-21st CCLC
Funds
Site 3
TOTAL Anticipated
Non-21st CCLC
Funds
Site 4
TOTAL Anticipated
Non-21st CCLC
Funds
Site 5
Funding
Category
(list site name
below)
(list site name
below)
(list site name
below)
(list site name
below)
(list site name
below)
Staffing (example)
Title I $2,500
Title III $1,500
School Budget
$3,000
Staffing (including,
but not limited to,
administrators,
instructional staff,
planning time,
substitutes, etc.)
Professional
Development
Partners/Vendors
Materials/Supplies
Transportation
Other: (please
describe below)
Total Anticipated
Non 21st-CCLC
FY16 Costs
5.
If the applicant is not a school district describe the following:
a. The system that is used to establish effective means of communication and coordination between
the school, school day teachers, and the 21st CCLC program.
b. The system for sharing pertinent data including state and other school assessment data (with
appropriate confidentiality). Include how the proposed program will ensure completion of SAYO
surveys.
FY16 Fund Code 647-B2 Part III-A - Required Program Information - page 3
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
Budget Notes/Reminders:

As noted in the Funding Opportunity RFP’s Required Forms section, submit two complete Part I-II
Budget Workbooks. Complete the School Year Part I Signature Page (prints to one page) and the
School Year Part II Budget and Budget Narrative Pages (prints to four pages) for expenditures that
will occur September 1, 2015 through June 30, 2016. Similarly, complete the Summer Part I
Signature Page and the Summer Part II Budget and Budget Narrative Forms for expenditures that will
occur July 1, 2016 through August 31, 2016 .

In constructing the budgets, please note that all costs must be reasonable and necessary to
implement program activities. Additionally, applicants must complete a budget narrative that
demonstrates clear and specific links to the project activity plan. Out of state travel is not allowed,
other than for approved conferences.

Programs must be equally accessible to all students targeted for services, regardless of their ability to
pay. Income generated from fees, services, or other public or private funds must be used to fund
additional costs consistent with the grant application and cannot be carried over beyond the three
year grant cycle. Append to this application a description of any projected revenues and how they will
be used to support additional costs consistent with implementing the proposed program.

Funds allocated under this program may be used only to supplement, not supplant, funds that local
schools and community-based organizations would otherwise expend for programs of this type.
Rental of space, cash stipends to students to attend the program, cell phones, telephone and utilities,
overhead costs and the purchase of materials that are used during the school day are not allowable
expenses under this grant.

Funded applicants requesting to subcontract funds through Line 5, Contractual Services, will be
required to submit a detailed budget for each vendor that will receive $5,000 or more. Vendors must
follow the fund use requirements described in the Fund Code 647-B2 Grant RFP. For the purposes
of the narrative below, please provide a brief description of the anticipated services and rates.
Contracted providers must be held to the same budget requirements as the applicant agency.

Indirect Costs are not allowed for Fund Code 647-B2 applications. Costs normally charged to indirect
may be considered in-kind or an additional resource.
FY16 Fund Code 647-B2 Part III-A - Required Program Information - page 4