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Admin Tribe Selection Last updated: 09/14/2015 This is my Form. Page 1 Please select to which tribe this Organization has applied to: Salt River 1 of 1 Last updated: 09/16/2015 Page 1 General information Organization Duet: Partners In Health & Aging, Inc. Contact First name Elizabeth Contact Last name Banta Contact e-mail banta@duetaz.org Contact phone number 602-274-5022 Address Street 3938 W Kayenta Trail City Laveen State AZ ZIP Code 85339 What is the name of the program or project for which your organization is requesting grant funds? Improving Quality of Life for Elders, Grandparents adn the Children they are Raising, and Caregivers For what grant amount has the organization requested from the tribe? 7,500 1 of 1 SALT RIVER PIMA-MARICOPA INDIAN COMMUNITY 10,005 E. Osborn Road, Scottsdale, Arizona 85256 / Phone 480-362-7520 / Fax 480-362-7593 12% Gaming Contributions Application Date of Application: July 22, 2015 Organization Name: Duet: Partners In Health & Aging Organization/Municipal Government Street & Mailing Address: 555 W. Glendale Avenue Phoenix, AZ 85021 Contact Person and if different from Contact Person: Elizabeth Banta Title: Executive Director Address: 555 W. Glendale Avenue, Phoenix, AZ 85021 Phone: 602-274-5022 Fax: 602-274-6793 Email Address: banta@duetaz.org Project Name: Improving Quality of Life for Elders, Grandparents and the Children they are Raising, and Caregivers Please provide a brief description of the project submitted to the 12% SRPMIC Grant program. Salt River Pima-Maricopa Indian Community’s renewed investment will enhance health and well-being for thousands of people, as follows. We also remained committed to providing workshops for grandparents raising grandchildren, caregivers, and congregations interested in launching health programs within your community, upon request. Grandparents Raising Grandchildren: Duet will support grandparents and the children they are raising through support groups, respite, group activities, workshops, legal guidance, and information. SRPMIC funds will help 725+ children stay out of foster care. Family caregivers: Duet assists people caring for aging loved ones through support groups, information and referrals, educational workshops, and respite. Duet will assist at least 420 caregivers through SRPMIC’s generosity. Congregational Health: Duet helps congregations develop health programs by training and supporting faith community nurses. SRPMIC funds will lead to over 65,000 health interventions, including screenings, health education, referrals, or health counseling, through 68 participating congregational health programs. Homebound Adults: Duet will help elders and adults with disabilities remain living in their own homes. Duet will pair these “neighbors” who no longer drive with volunteers who will provide transportation to medical appointments, grocery shopping; visiting, home repairs; and computer and paperwork assistance. Over 775 people will receive 48,000+ hours of service. In addition, Duet would be pleased to offer workshops for grandparents, caregivers, and congregations interested in launching health programs at locations selected by SRPMIC. Beginning Date of Project: July 1, 2015 End Date of Project: June 30, 2016 Geographic Area to be served: Services will be available throughout Maricopa County for caregivers, grandfamilies, and congregations seeking to develop health promotion. Duet’s services for homebound adults are provided in Scottsdale, Fountain Hills, Phoenix, Glendale, and Peoria. ** Attach Detailed Budget** Amount of Total Project: $1,257,760* Amount of 12% Request: $7,500 (No Multi-Year Request will be accepted) * This figure represents Duet’s total organizational budget. This figure leads to help for thousands of people in need, improving quality of life while also saving dollars for taxpayers by helping individuals remain living in their own homes. If the Amount of funding received is less than the amount needed for the project, do you have other funds to complete the project? (Please Explain): Through the support of foundations, government grants and individual donors, Duet will be carry out this vital work in partnership with Salt River Pima-Maricopa Indian Community. Additional revenue is received through other foundations and corporations, special events, annual appeals, estate gifts and other individual giving efforts. Our two special events, Duet Cabaret and the Poinsettia Tea, have special "call to action" components where guests can give personal contributions to fund our services. Duet's 81 Legacy Circle members have pledged financial gifts through their estate plans. Our individual giving campaign revenue continues to grow through expanded board participation and outreach. Duet was chosen as one of six participants by the Virginia G Piper Charitable Trust to participate in their inaugural ATLAS initiative to increase capacity and develop sustainable funding resources. The Duet board has continued this effort and initiated a strategic planning process to help ensure Duet can continue to meet the increased need for our services in the future. That said, raising sufficient funds to continue services is a constant challenge and your support this year is critically needed. If you receive SRPMIC 12 % funding, will it be spent (Check One): ð Monthly ð Quarterly X Lump Sum (yet as a funding partner your contribution will help sustain services for an entire year) List of SRPMIC 12% funds you have received in the past and a list of other 12 % grants funding you are seeking from other Tribal Governments for the 2013-2014 12% cycle. Gila River Indian Community provided a $43,000 grant in 2013 to provide transportation services to homebound adults. Duet recently passed the first step for funding in 2015 – 2016 for a $35,000 request. They will make their decision in October, 2015. List any other funds you have received from the SRPMIC and identify the source: N/A Funding for project/programs may be based on available funding. As such, if funding were not available for the full the amount of request how would you prioritize funding. A.) Growing services for grandparents and the children they are raising to help children stay out of foster home ($2,500) B.) Offering aging-in-place assistance to homebound elders and adults with disabilities ($2,000) C.) Promoting health by nurturing the development of congregation-sited health programs ($1,500) D.) Guiding and support family members as they care for aging loved ones ($1,500) Which municipal governmental entity will serve as your pass through or accept 12% funds on your behalf? While Duet would be pleased to partner with any municipal government that you recommend, we previously received assistance via Maricopa County to receive your 12% grant. By execution of the 12% Gaming Contribution Grant Application the undersigned agrees that the information contained in the Application is true to the best of the Applicants knowledge. The Applicant shall notify the SRPMIC if any information in this Application changes. July 22, 2015 Signature for the Applicant Date Elizabeth Banta, Executive Director Name and Title The Application shall be signed by the senior elected official of the local government, or in the case of a non-profit entity, the Chief Executive Officer authorizes to commit the non-profit entity to apply for, accept, and implement an award from the SRPMIC utilizing 12% Gaming Contributions.