GRANT RE DENTAL SEALTANT PRGM WITH DELTA DENTAL AF.PDF

DELTA DENTAL OF ARIZONA FOUNDATION
Giving people a reason to smile
August 26, 2013
Kirsten Roling, DDS, Program Supervisor
Maricopa County Department of Public Health, Office of Oral Health
1645 E. Roosevelt St.
Phoenix, AZ 85006
Re: 2013 -2014 Grant Agreement for Dental Sealant Program
Dear Dr. Roling:
Congratulations on the grant award for the Delta Dental, Dental Sealant program. The grant is
being awarded based upon the proposal received and dated June 6, 2013 and the final
attachments added by your office and included in this agreement as reference. The total grant
award is $88,375.00 and it will be disbursed upon receipt of the signed and approved grant
agreement enclosed.
The grant period is one year. Future funding may be considered based upon successful program
outcomes, as well as, the availability of Foundation resources. Please note it is the
organization's responsibility to seek future funding at the appropriate time.
This letter of understanding is the organization's agreement with the Foundation. The following
terms apply to this grant award:
• The time period for this grant award is Julyl, 2013 June 30, 2014.
• The organization must complete the interim report due by February 1, 2014 and a final
report no later than August 15, 2014. The Foundation will provide the format and questions for
these reports to your organization no later than one month prior to the due dates.
• The organization must also submit a separate financial report detailing the use of the
grant funds with the interim and final reports.
• The organization must maintain adequate financial records and books, and the
Foundation has the right to inspect them at any time, upon reasonable notice to the
organization.
• The Foundation may make public disclosure of the amount and intent of the grant and
the identity of the organization as the recipient if the Foundation elects to do so.
5656 West Talavi Blvd. •.!,• Glendale, AZ 85306 602.938.3; 3 / Federal Tax ID 486 - 0842694
www_deltadentalaz_corn/loundation • www.Go/f4Smiles.org

The organization cannot use any grant funding for private benefit, political purposes, or
carrying on propaganda.
It is our understanding that the organization is an eligible government entity. The organization
must promptly notify the Foundation if that tax status changes. The organization will return the
unused portion of the grant funding, if at any time the organization's status with the IRS is
terminated. Funding may be withdrawn at the sole discretion of the Foundation if there are
any claims, charges, or investigations of alleged fraud, misrepresentation, crime, or regulatory
infraction by the organization, or its principals or affiliates.
It is mutually understood that the organization will promptly notify the Foundation in writing of
any material change in the budget or operations that exceeds ten percent (10%) of the
proposed budget as outlined in the grant proposal. The organization will only use the grant
funding for the purpose outlined in your grant application. Any unused portion of the grant
funding must be remitted back to the Foundation at the end of the grant period.
Please keep the Foundation informed of any and all events related to the Program. You agree
to provide the Foundation with copies of all related news releases, articles, newsletters and/or
other communications. Any external communications and publicity related to the grant funded
by the Foundation must include the following public acknowledgement:
"Generously funded by the Delta Dental of Arizona Foundation serving uninsured and
underserved children and families in Arizona."
This letter constitutes the entire Foundation agreement with the organization as to the grant
and any modifications must be in writing and signed by an authorized representative of each
party. This letter supersedes any prior oral communications or agreements.
The organization may not assign its rights and/or obligations under this agreement to any other
party.
After signing both copies, please keep one copy for your records, and mail the second copy to
my attention, Dr. Sandi Perez, Vice President of Communications and Community Benefit, Delta
Dental of Arizona Foundation, 5656 West Talavi Blvd., Glendale, AZ, 85306. All correspondence
and questions should be sent to my attention at this address. Please feel free to contact me or
my staff by phone at 602-588-3929 or via email at: sperez@deltadentalaz,com if you have any
questions.
The Foundation is honored and excited to support your work to improve oral health for the
children and youth of our state. On behalf of the Foundation Board of Directors, we thank you
for your ongoing commitment to oral health and wish you the best of luck.

Sincerely,
Sandi Perez, Ph.D.
Vice President of Communications and Community Benefit
Enc:
Cc: Ashlee Dailey, Manager Finance Department, Delta Dental of Arizona
By signing this agreement, I represent that I have the authority to and intend to bind the
organization to the terms of this agreement.
Signature: Date
Organization: Title:

C-86-14-046-3-00 ATTACHED TO AND A PART OF
Delta Dental of Arizona Foundation
2013-14 Grant Agreement for Dental Sealant
Program
IN WITNESS WHEREOF, the parties agree to enter into this Contract:
FOR AND ON BEHALF OF
MARICOPA COUNTY
By
Chairman, Board of Supervisors
Date
ATTEST:
Clerk of the Board
Date
APPROVED AS TO FORM:
Attorney for Maricopa County
Date

2013- 2014 $13,817 $13,817 $2,226 $2,661 $4,887 $9,396 $6,600 $4,680 $10,989 $7,794 $39,459 $9,000 $1,000 $600 $4,000 $1,332 $600 $2,152 $18,684 $76,848 $11,527 $88,375 $16,052 $12,669 $28,721
July June
Total Total Expenses 15%
2014 Sub @$33/hour $33/hour Sub @ Costs
June Expenses hrs. hrs.@ Services Operating Indirect
2013- Related DH DH Other
July annual annual Professional
Period: Employee 200 333 Total
Item narrative each= hrs.@$18/hour each hrs.@$18/hour months Training/Conferences
Budget Line FTE 6min 20min .555/mile/12
Foundation .25 budget @ DA @ DA $50/month cost
Coordinator see $18/hr screens annual seals annual @ @ of 25% 20%
Dental and salaries, @ 2,000 260 - 1,000 - -433 supplies miles/month @ Development/Staff @ 25%
Delta Program FTE total hours Hygienist- Assistant Hygienist Assistant Supplies Office 200 staff for Manager @
Sealant per $8,904 of 19.26% annual Dental Dental Dental Dental Dental Evaluation General Printing - Mileage Blackberry Professional Program Accountant
EXPENSES 522 Costs
entry Team Team EXPENSES
SERVICES Program
Category SERVICES RELATED asst/data Screening Sealant
Budget admin Dental Dental OPERATING Direct of Costs Kind
PERSONNEL EMPLOYEE PROFESSIONAL Temps, OTHER Subtotal Indirect Total Kind In Total
in