RES 2023-0060 - Agmt with Omaha ForUs to create a LBGTQ+ Center to support the LBGTQ+ community - 2023 City Clerk Office Use Only:
Publication Date (if app icable):
RESOLUTION NO. -tJ ) ,
Agenda Date: 0
Department: 4. Dry l tYi
Submitter:
CITY OF OMAHA
LEGISLATIVE CHAMBER
Omaha, Nebraska
RESOLVED BY THE CITY COUNCIL OF THE CITY OF OMAHA:
WHEREAS, the Omaha ForUs, a Nebraska non-profit corporation, has signed an agreement
with the City of Omaha, which is attached hereto, to provide specified services; and,
WHEREAS, pursuant to such agreement Omaha ForUs shall operate the LGBTQ+ Center,
during the period of January 1, 2023 to December 31, 2023; and,
WHEREAS, the Mayor recommends approval of the agreement in the amount of twenty
thousand dollars ($20,000) to Omaha ForUs for financial support of such activities; and,
WHEREAS, funding for the agreement is budgeted in the amount of twenty thousand dollars
($20,000) from 2023 Keno/Lottery Proceeds Fund 12118, Organization 126089
WHEREAS, it is in the best interest of the citizens of the City of Omaha to approve the
agreement; and,
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF OMAHA:
THAT, as recommended by the Mayor, the agreement between the City of Omaha and Omaha
ForUs in the amount of twenty thousand dollars ($20,000) to operate the LGBTQ+ Center, during the period of
January 1, 2023 to December 31, 2023, and incorporated herein by this reference, and funding of such project,
is hereby approved.
FURTHER THAT, the Finance Director is authorized to provide payment twenty thousand
dollars ($20,000) from 2023 Keno/Lottery Proceeds Fund 12118, Organization 126089; and in accordance with
the contract terms.
APPROVEDAS Te FORM:
Apt _ L24 VZ.6
A CITY °TTORNEY DATE
RESOLUTION NO. 2V13 0010
Adopted: JAN 10 2023 V
Attest: G► ItifCtV
DEPUTY City Clerk
Approved:
Mayor
AGREEMENT
This Agreement is made and entered into this u�i'day of(inida by and between the
City of Omaha,a Nebraska municipal corporation(hereinafter referred to as"Jty")and the Omaha ForUs,
2101 S 42nd St, Omaha,NE, 68105 (hereinafter referred to as"Contractor").
WHEREAS, the City of Omaha, in furtherance of its statutory authority to promote public health,
welfare,and safety to its citizens and residents,wishes to contract with the Contractor,as described below,
to obtain the Contractor's services in the implementation of this Grant Award; and,
WHERAS, the City has set-aside funding from the 2023 Community Service allocation for the
implementation of this Grant Award.
NOW, THEREFORE, in consideration of the mutual covenants and agreements herein contained,
the City and the Contractor mutually undertake and agree as follows:
I.
DUTIES OF THE CONTRACTOR
The Contractor agrees to do the following, along with all other obligations expressed or implied in
this Agreement:
A. The Contractor will provide the services and duties as stated more fully in the Omaha
ForUs Nebraska 2023 Community Services Application, and any future approved budget modifications.
The Contractor will create programs and initiatives to support the LGBTQ+community of Omaha
with an end goal of creating a central gathering space for the community to congregate and enjoy
the programmatic offerings.
MENTOR Nebraska
Item Computation Cost
Office Furniture See Budget Details $4,500
Laptop See Budget Details $1,225
General Office Supplies See Budget Details $3,295
Laser Printer See Budget Details $1,250
Rent See Budget Details $9,730
Grant Award Amount: $20,000
B. The Contractor will be responsible for all aspects of the project including day-to-day
management of the Program. The identity of the chief executive of the Contractor and any changes thereof
shall be provided to the City.
C. The Contractor shall maintain an accounting system that accurately tracks income and
expenditures associated with this Grant Award separate from other agency funds.
D. The Contractor agrees to comply with the financial and administrative requirements set
forth in the City of Omaha Grants Management Handbook.
E. The Contractor understands and agrees that funds may be frozen if the Contractor does not
respond in a timely fashion to requests to address audit findings and financial or programmatic monitoring
findings.
F. The Contractor shall allow the City to have access to the Contractor's records and program
site for the purpose of financial and/or program audits,as may be required in the sole discretion of the City
or its authorized designee. The Contractor shall retain all documents for a minimum of three years
following the completion of this Grant Award.
G. The Contractor will implement and enforce, as to its employees, a drug-free workplace
policy substantiality similar to the City of Omaha's policy which is on file with the Human Resources
Department.
H. The Contractor will provide an executed W-9 Verification form.
I. The Contractor is required and hereby agrees to use a federal immigration verification
system to determine the work eligibility status of new employees physically performing services within the
State of Nebraska. A federal immigration verification system means the electronic verification of the work
authorization program authorized by the Illegal Immigration Reform and Immigrant Responsibility Act of
1996, 8 U.S.C. 1324a,known as the E-Verify Program, or an equivalent federal program designated by the
United States Department of Homeland Security or other federal agency authorized to verify the work
eligibility status of a newly hired employee.
If the Contractor is an individual or sole proprietorship,the following applies:
1. The Contractor must complete the United States Citizenship Attestation Form, available on the
Department of Administrative Services website at www.das.state.ne.us.
2. If the Contractor indicates on such attestation form that he or she is a qualified alien,the Contractor
agrees to provide the US Citizenship and Immigration Services documentation required to verify the
Contractor's lawful presence in the United States using the Systematic Alien Verification for Entitlements
(SAVE)Program.
3. The Contractor understands and agrees that lawful presence in the United States is required and the
Contractor may be disqualified or the contract terminated if such lawful presence cannot be verified as
required by Neb. Rev. Stat. §4-108.
J. The Contractor must ensure that all individuals coming into contact with minors are
suitable, as defined by the Grant Award Special Condition(included herein)prior to interaction with
participating minors. This requirement applies regardless of an individual's employment. The Contractor
may not permit any covered individual to interact with any participating minor in the course of activities
under the award,unless the Contractor has made written determination of the suitability of that individual
to interact with participating minors as outlined in the Grant Award Special Condition.
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II.
TERM
This Agreement shall become effective on January 1, 2023 and shall terminate on December 31,
2023. Either party may immediately terminate this Agreement upon mailing prior written notice thereof to
the other party;provided,that in the event of such early termination,the Contractor shall immediately return
to the City all unexpended funds advanced to the Contractor under this Grant Award.
In the event the Contractor requires an extension to the terms of this Grant Award, requests must be
submitted in writing to the City's Grant Manager no later than 45 days prior to the end of the Award term.
In the event of an extension approval, the Agreement shall automatically be extended to the end of the
approved extension.
III.
COMPENSATION
The City shall compensate the Contractor in an amount not to exceed, under any circumstances,
$20,000 ("Maximum Compensation"). Following the execution of this Agreement, the Contractor must
submit quarterly reimbursement requests by the due by dates outlined under IV. Reporting Requirements.
Quarterly Reimbursement Requests must detail funds expended during the quarter, along with clear,
concise, and detailed backup documentation supporting all expenses. Quarterly Reimbursement Requests
are required even if no funds were expended during the time period. All requests for reimbursement shall
be submitted electronically to the City of Omaha, Mayor's Office, Grant Manager. Originals shall be
retained in the Contractors records and made available upon request for audit purposes.
Any tangible equipment purchased by the Contractor with funds pursuant to this Agreement shall
be the property of the Contractor.
IV.
REPORTING REQUIREMENTS
The Contractor shall comply with all reporting, data collection and evaluation requirements, as
prescribed below and as outlined in the City of Omaha Grants Management Handbook. All reports for
reimbursement shall be submitted electronically to the City of Omaha, Mayor's Office, Grant Manager.
Originals shall be retained in the Contractors records and made available upon request for audit purposes.
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A. Quarterly Report Filing Schedule: Programmatic performance reports, and fiscal
expense and reimbursement requests are due quarterly as identified below during the term of this Grant
Award.
B. Close Out Reporting: Grant Awards will only be closed out once all final documentation
has been received from the Contractor and approved by the City. Final programmatic performance reports,
and fiscal expense and reimbursement requests are due by the deadline identified below.
Reporting Schedule
Reporting Programmatic Report &Fiscal Reimbursement Request
Period Due by Date Delinquent After _
January—March 4/30/23 4/30/23
April—June 7/30/23 7/30/23
July—September 10/30/23 10/30/23
October—December 1/30/24 1/30/24
Final Close Out
C. Grant Award Adjustment: Grant Award funds must be used for the purposes identified
in the Contractor's 2023 Community Services Application. The Contractor shall not undertake any work
or activities that are not described in the Application, and that uses staff, equipment, or other goods or
services paid for with Grant Award funds,without prior written approval from the City's Grant Manager.
The Contractor must submit an adjustment request to the City when any of the following will occur:
the focus of the Contractor's funded Project changes; there is a change in the start or end date of the funded
project; a new project director or fiscal officer is assigned to the Project by the Contractor; or a budget
modification is requested by the Contractor to transfer dollars between budget line items. No budget
revisions are to be made by the Contractor without prior written approval from the City's Grant Manager.
V.
INDEMNITY
To the extent allowed by law,the Contractor covenants and agrees to indemnify and hold harmless
the City of Omaha, their officers, agents and employees, their successors and assigns, individually or
collectively, from and against all liability for any fines, claims, suits, demands, actions or causes of action
of any kind and nature asserted by the Contractor or by anyone else,for personal injury or death,or property
damage in any way arising out of or resulting from the acts of the Contractor's employees or agents pursuant
to this Agreement, and the Contractor further agrees to pay all expenses in defending against any claims
made against the city of Omaha provided, however, that the Contractor shall not be liable for any injury,
damage or loss occasioned by the sole negligence or willful misconduct of the City, its agents or employees.
The Contractor, and the City of Omaha shall give prompt and timely written notice of any claim
made or suit instituted which, in any way, directly or indirectly, contingently or otherwise, affects or
might affect the other parties.
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VI.
EQUAL EMPLOYMENT OPPORTUNITY CLAUSE
During the performance of this contract,the contractor agrees as follows:
1. The Contractor shall not discriminate against any employee applicant for employment
because of race, religion, color, sex, age, sexual orientation, gender identity, disability or national origin.
The Contractor shall ensure that applicants are employed and that employees are treated during employment
without regard to their race, religion, color, sex, age, sexual orientation, gender identity, disability or
national origin. As used herein, the word "treated" shall mean and include, without limitation, the
following: recruited, whether by advertising or by other means; compensated; selected for training,
including apprenticeship;promoted;upgraded;demoted; downgraded;transferred;laid off; and terminated.
The Contractor agrees to and shall post in conspicuous places, available to employees and applicants for
employment, notices to be provided by the contracting officers setting forth the provisions of this
nondiscrimination clause.
2. The Contractor shall, in all solicitations or advertisements for employees placed by or on
behalf of the Contractor, state that all qualified applicants will receive consideration for employment
without regard to race, religion, color, sex, sexual orientation, gender identity or national origin, age,
disability.
3. The Contractor shall send to each representative of workers with which he has a collective
bargaining agreement or other contract or understanding a notice advising the labor union or worker's
representative of the Contractor's commitments under the equal employment opportunity clause of the City
and shall post copies of the notice in conspicuous places available to employees and applicants for
employment.
4. The Contractor shall furnish to the Human Rights and Relations Director all federal forms
containing the information and reports required by the Federal Government for federal contracts under
federal rules and regulations, including the information required by section 10-192 to 10-194, inclusive,
and shall permit reasonable access to his records. Records accessible to the Human Rights and Relations
Director shall be those which are related to paragraphs (1) through (7) of this subsection and only after
reasonable notice is given the contractor. The purpose of this provision is to provide for investigation to
ascertain compliance with the program provided for herein.
5. The Contractor shall take such actions with respect to any subcontractor as the City may
direct as a means of enforcing the provisions of paragraphs (1)through(7) herein, including penalties and
sanctions for noncompliance; however, in the event the Contractor becomes involved in or is threatened
with litigation as the result of such directions by the City, the City will enter into such litigation as is
necessary to protect the interests of the City and to effectuate these provisions of this division; and in the
case of contracts receiving federal assistance, the Contractor or the City may request the United States to
enter into such litigation to protect the interests of the United States.
6. The Contractor shall file and shall cause his subcontractors, if any to file compliance
reports with the Contractor in the same form and to the same extent as required by the Federal Government
for federal contracts under federal rules and regulations. Such compliance reports shall be filed with the
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Human Rights and Relations Director. Compliance reports filed at such times as directed shall contain
information as to the employment practices, policies, programs and statistics of the Contractor and his
subcontractors.
7. The Contractor shall include the provisions of paragraphs (1) through (7) of this section,
"Equal employment opportunity clause," and section 10-193 in every subcontract or purchase order so that
such provisions will be binding upon each subcontractor or vendor.
VII.
DEBARMENT OR SUSPENSION BY ANY FEDERAL AGENCY
Office of Management and Budget(OMB) guidelines require that any individual or entity that has
been placed on the Excluded Parties List System(EPLS -available for review through www.sam.gov)may
not be a participant in a Federal Agency transaction that is a covered transaction or act as a principal of a
person participating in one of those covered transactions. These guidelines apply to covered transactions
under a grant award from any Federal agency for which a recipient expects to receive reimbursement for
expenditures incurred or an advance on future expenditures.
The Contractor providing goods and/or services to the City of Omaha,by acceptance and execution
of this Agreement agrees, that neither it nor its principals is presently debarred, suspended, proposed for
debarment,declared ineligible,or voluntarily excluded from participation in this transaction by any Federal
department or agency. Contractor further agrees,by accepting and executing this Grant Award, that it will
include this clause without modification in all lower tier transactions, solicitations, proposals, contracts,
and subcontracts. Where the Contractor or any lower tier participant is unable to certify this statement, it
shall attach an explanation to this Agreement.
VIII.
INDEPENDENT CONTRACTOR
It is understood and agreed by and between the parties that any and all acts that the Contractor or
its employees, agents, contractors or servants perform pursuant to the terms of this Agreement shall be
undertaken as independent contractors and not as employees of the City. Neither Contractor nor any of its
employees or agents shall be construed to be the employee or agent of the City for any purpose whatsoever.
Contractor shall not be entitled to any benefits of the City. The City shall not provide any insurance
coverage to the Contractor or its respective employees including,but not limited to workers' compensation
insurance. Contractor and the City shall each pay all wages, salaries and other amounts due to its respective
employees and shall be responsible for all reports, obligations, and payments pertaining to social security
taxation, income tax withholding, workers' compensation, unemployment compensation, group insurance
coverage, collective bargaining agreements or any other such similar matters.
Contractor shall have no authority to bind the City or by or with any contract or agreement, nor to
impose any liability upon the City. All acts and contracts of the Contractor shall be in its own name and
not in the name of the City,unless otherwise provided herein.
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IX.
CAPTIONS
Captions used in this contract are for convenience and are not used in the construction of this
contract.
X.
APPLICABLE LAW
Parties to this contract shall conform to all existing and applicable city ordinances,resolutions,state
laws, federal laws, and all existing and applicable rules and regulations. Nebraska law will govern the
terms and the performance under this contract.
XI.
CONFLICT OF INTEREST
A. No elected official nor any officer or employee of the City shall, during their tenure and
one year thereafter, have a financial interest, direct or indirect, in this Grant Award or in any funds
transferred hereunder. Any violation of this section shall render the Agreement voidable by the City or the
Contractor.
B. The Contractor covenants that it presently has no interest and shall not acquire any interest,
direct or indirect, which would conflict with the performance required to be performed under this
Agreement; it further covenants that, in the performance of this Grant Award, no person having any such
interest shall be employed.
XII.
WARRANTY AS TO COMMISSIONS
The Contractor warrants that it has not employed any person to solicit or secure the Agreement
upon any agreement for commission,percentage, brokerage, or contingent fee.
XIII.
MERGER
This Agreement shall not be merged into any other oral or written contract, lease or deed of any
type. This is the complete and full agreement of the parties.
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XIV.
MODIFICATION
This Agreement contains the entire agreement of the parties. No representations were made or
relied upon by either party other than those that are expressly set forth herein. No agent, employee or other
representative of either party is empowered to alter any of the terms hereof unless done in writing and
signed by an authorized officer of the respective parties.
XV.
ASSIGNMENT
Neither party may assign its rights under this Agreement without the express prior written consent
of the other party.
XVI.
CONTRACT DOCUMENTS
The Contractor is responsible for review of and compliance with each of the terms of this Grant
Award. The parties agree that this Agreement shall include, as if fully set forth herein, the contractor's
2023 Community Services Application; Revised Application; FFATA Reporting Form; and Audit
Certification which are attached hereto.
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XVII.
AUTHORIZED REPRESENTATIVE
In further consideration of the mutual covenants herein contained, the parties hereto expressly agree that
for purposes of notice, including legal service of process, during the term of this Agreement and for the
period of any applicable statute of limitations thereafter, the following named individuals shall be the
authorized representatives of the parties:
(a) CITY OF OMAHA
Jean Stothert,Mayor
Office of the Mayor
1819 Farnam Street, Suite 300
Omaha,Nebraska 68183
Contact: Amber Parker, Grant Manager
Phone: (402)444-5211
(b) CONTRACTOR
Omaha ForUs
JohnCarl Denkovich,Director of Programs
2101 S 42nd Street
Omaha,Nebraska 68105
Phone: (402) 680-3973
EXECUTED this I if/ day of C , 2 ,
CITY OF OMAHA,NEBRASKA MEN R NEBRASKA
kik
"IA.1, -12/1/2[2,3 11 kV
Jean Stothert,Mayor Da Jo mCarl Denkovich, Director of Programs
Date
ATTEST:
W ~ 111 2
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City Cler ate
KirnbtrI� Ain/t D P n T Y
APPROVE AST ORM:
Assistant City Attorney Date
- 9 -
o aMnxn.NpRR
tt,;(74
�1ED FE8RV
AUDIT CERTIFICATION
Grantee Name: Omaha ForUs
Grantee Address: 2101 S 42nd Street/Omaha,NE 68101
Contact Name and Title: JohnCarl Denkovich,Director of Programs Phone#: (402) 814-1146
Grant#(s): Tax ID#: 87-3089786 Fiscal Period End Date: 12/31/2022
For fiscal years beginning on or after December 26,2014.If you are a non-Federal entity that expended$750,000 or more in
Federal funds(from all sources including pass-through subawards)in your organization's fiscal year(12-month turnaround reporting
period),then you are required to arrange for a single organization-wide audit conducted in accordance with the provisions of Title 2
C.F.R. Subpart F(i 200.500 et seq.)
For fiscal years beginning before December 26,2014.if you are a non-Federal entity(other than a for-profit/commercial entity)that
expended$500,000 or more in Federal funds(from all sources including pass-through subawards)in your organization's fiscal year
(12-month turnaround reporting period),then you are required to arrange for a single organization-wide audit conducted in accordance
with the provisions of Office of Management and Budget(OMB)Circular A-133 Compliance Supplement 2014.
If you are a non-Federal entity that expended less than the applicable audit threshold a year in Federal awards,you are exempt from
Federal audit requirements for that year.However,you must keep records that are available for review or audit by appropriate officials
including the Federal agency,pass-through entity,and U.S. Government Accountability Office(GAO).
Please complete the appropriate section below and submit the completed and signed form and required documentation
within 60 days after the end of your fiscal year to:
Grant Administrator, City of Omaha Office of the Mayor
1819 Farnam Street, Suite 300, Omaha,Nebraska 68183-0300
Section A: Organization subject to the requirements of OMB Circular A-133
Please check one of the following and provide all appropriate documents:
n I hereby certify that for the fiscal year ended (date):
1.The auditor's report on financial data states that the audited information is fairly stated in all material respects; and
2.The administration of our federal projects has been audited in accordance with OMB Circular A-133 and there were
no material instances of noncompliance with federal laws and regulations or reportable conditions; and
3.There were no findings of noncompliance in the audit report that are specifically related to the subrecipient
award(s); and
4.Management has addressed the resolution of previous-year findings from prior audit reports if related to the
subrecipient award(s).
Auditor's report filed on (date). Enclosed is a copy of the audit report.
n We have completed our OMB Circular A-133 audit for the fiscal year ended (date), and material
noncompliance issues and/or reportable conditions were noted. Enclosed is a copy of the audit report and our
response.
n We have not completed our OMB Circular A-133 audit for the fiscal year ended (date).
We expect the audit to be completed by (date). Within thirty(30)days of completion of the A-133 audit we will
provide a new Audit Certification along with the audit report and response(if applicable).
10/01/15 City of Omaha,Nebraska Page 1 of 2
Policies&Procedures Supporting Documentation—Audit Certification
Section B: Organization subject to the requirements of Uniform Guidance: Title 2 C.F.R. 200 Subpart F
Please check one of the following and provide all appropriate documents:
n I hereby certify that for the fiscal year ended (date):
1. The auditor's report on financial data states that the audited information is fairly stated in all material respects; and
2.The administration of our federal projects has been audited in accordance with the Uniform Guidance: Title 2 C.F.R
200 Subpart F and there were no material instances of noncompliance with federal laws and regulations or
reportable conditions; and
3. There were no findings of noncompliance in the audit report that are specifically related to the subrecipient
award(s); and
4. Management has addressed the resolution of previous-year findings from prior audit reports if related to the
subrecipient award(s).
Auditor's report filed on (date). Enclosed is a copy of the audit report.
n We have completed our A-133 audit for the fiscal year ended (date), and material noncompliance issues and/or
reportable conditions were noted. Enclosed is a copy of the audit report and our response.
n We have not completed our A-133 audit for the fiscal year ended (date).
We expect the audit to be completed by (date). Within thirty(30) days of completion of the A-133 audit we will
provide a new Audit Certification along with the audit report and response(if applicable).
Section C: Organization NOT subject to the requirements of OMB Circular A-133 or Title 2 C.F.R. 200 Subpart F
Our organization is not subject to the requirements of OMB Circular A-133 or Title 2 C.F.R. Subpart F because we
(please check one of the following):
® Did not expend above the minimum threshold in federal funds during the fiscal year(complete federal funds
expenditure chart below).
n Are a for-profit organization.
n Are exempt for other reasons (explain):
Federal Grantor Pass-through Grantor Program Name CFDA Number Expenditures
Treasury Department Douglas County Omaha ForUs ARPA 1 $228,185
Total Federal Expenditures for this Fiscal Year $228,185
Failure to submit this or a similar statement, or failure to submit a completed single audit package as required by the
required due date may result in suspension of funding and may affect eligibility for future funding.
JohnCarl Denkovich Director of Programs
Authorized Signature Printed Name Title
10/01/15 City of Omaha,Nebraska Page 2 of 2
Policies&Procedures Supporting Documentation—Audit Certification
htAAHA7y,,,
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l 'a
f R•0'b Ff.9 NA"''O
City of Omaha
Federal Funding Accountability and Transparency Act (FFATA) Reporting Form
Business/Agency Information
Legal Name Omaha ForUs INC
Physical Address 2101 S 42nd Street
Mailing Address 2101 S 42nd Street
City Omaha State NE Zipcode 68105
Congressional District 2
Business/Agency Data Universal Numbering System(DUNS)Number RKA7G2MLR266
Business/Agency Annual Gross Revenue from Prior Fiscal Year Exceed 80%o or
More in Federal Funds Yes ❑ NoRI
Business/Agency Annual Gross Revenue from Prior Fiscal Year Equal or Exceed Yes ❑ No
$25 million in Federal Funds
If'NO' was selected for either of the above boxes,DO NOT COMPLETE THE FOLLOWING:
Business/Agency's Five(5)Highest Compensated Officers
Only complete if'YES' was selected for both annual gross revenue boxes.
Name Compensation
Comments:
i
Signature of Authorized Official -,1 1tik.:)I ,.e\I Date 11/28/2022
i
Typed/Printed Name JohnCarl Denkovich
Typed/Printed Title Director of Programs
Typed/Printed Email johncarl@OmahaForUs.org
11/30/15 City of Omaha,Nebraska Page 1 of 1
Federal Financial Act Transparency Form
Form W�9 Request for Taxpayer Give Form to the
(Rev.October2018) Identification Number and Certification requester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service ►Go to www.irs.gov/FormW9 for instructions and the latest information.
1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank.
Omaha ForUs Inc
2 Business name/disregarded entity name,if different from above
co
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to
rofollowing seven boxes. certain entities,not individuals;see
instructions on page 3):
p ❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑Trust/estate
ai c single-member LLC Exempt payee code(if any)
4=0 ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)►
p 2 Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
rn LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
code(if any)
a U another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
'y ® Other(see instructions)► 501(c)(3) nonprofit organization (Applies to accounts maintainedoinside the U.S.)
O.
5 Address(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional)
a3 2101 S 42nd Street
6 City,state,and ZIP code
Omaha, NE 68105
7 List account number(s)here(optional)
Part I Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid I Social security number
backup withholding.For individuals,this is generally your social security number(SSN).However,for a
resident alien,sole proprietor,or disregarded entity,see the instructions for Part I,later.For other — —
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN, later. or
Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and I Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
87 - 3 0 8 9 7 8 6
Part II Certification
Under penalties of perjury,I certify that:
1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2.I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3.I am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,
acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments
other than interest and dividends,you are not r_.required to sign the/certifiCation,but you must provide your correct TIN.See the instructions for Part II,later.
I n �. ,
Sign Signature of / t _
Here u.s.person► r\'' )t ' ,J :`� �`Jk jJ \ Date► G-) 7
General Instructions •Form 1099-DIV(dividends,including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise •Form 1099-MISC(various types of income,prizes,awards,or gross
noted. proceeds)
Future developments.For the latest information about developments •Form 1099-B(stock or mutual fund sales and certain other
related to Form W-9 and its instructions,such as legislation enacted transactions by brokers)
after they were published,go to www.irs.gov/FormW9. •Form 1099-S(proceeds from real estate transactions)
Purpose of Form •Form 1099-K(merchant card and third party network transactions)
An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest),
information return with the IRS must obtain your correct taxpayer 1098-T(tuition)
identification number(TIN)which may be your social security number •Form 1099-C(canceled debt)
(SSN),individual taxpayer identification number(ITIN),adoption •Form 1099-A(acquisition or abandonment of secured property)
taxpayer identification number(ATIN),or employer identification number
(EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S.person(including a resident
amount reportable on an information return.Examples of information alien),to provide your correct TIN.
returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might
•Form 1099-INT(interest earned or paid) be subject to backup withholding.See What is backup withholding,
later.
Cat.No.10231X Form W-9(Rev.10-2018)
2023 Community Services Program
Grant Application Cover Sheet
ORGANIZATION CONTACT INFORMATION
Organization Name Omaha ForUs
Program Name: LGBTQ+Center
Address 2101 S 42°d Street
City Omaha State NE Zip 68105
Head of Organization JohnCarl Denkovich
Phone: (402) 680-3973 Email johncarl@OmahaForUs.org
Primary Contact Person JohnCarl Denkovich
Phone: Same Email Same
Financial Point of Contact Beth Mulder, Controller
Phone: (402) 552-7490 Email bmulder(cheartlandfamilyservice.org
Is the organization an IRS 501(c)(3) not-for-profit? VI Yes fl No
If no, is your organization a public agency/unit of government? [' Yes No
Employer Identification Number(EIN):
EXECUTIVE SUMMARY
Briefly state the need or issue addressed by the request. State the purpose of this funding request,
including information about the population served and geographic area(s) that will benefit from
this proposal.
Problem: Insufficient culturally responsive supports exist for specific spaces exist for
Omaha-based LGBTQ+people. This lack of supports exacerbate negative social determinants
of health, negatively impacting the community at-large. LGBTQ+populations face barriers to
accessing what few resources do exist. Omaha's closest center requires a five-hour roundtrip
commute. Omaha is one of only seven of the country's top 50 cities without an LGBTQ+
center. A 2019 strengths and needs assessment surveyed LGBTQ+ Omaha residents, who
disproportionately reported less than half(45%) experienced Omaha as "open minded," 25% are
experiencing or have experienced homelessness, 4:5 respondents have serious mental health
concerns, and majorities supported an"all-ages LGBTQ+ gathering space not centered around
alcohol."
Purpose: Establish an Omaha-based LGBTQ+ center which builds intentional community and
creates equitable space for this historically marginalized and under-resourced community. The
Center seeks to bridge gaps in LGBTQ+ supports with three strategies:
1) Co-locate & coordinate local LGBTQ+ organizations/initiatives to leverage existing
programs and increase their reach.
2) Build intentional community with culturally responsive, LGBTQ+focused
programs prioritizing mental health and point-of-access care/referral while cultivating
healthy social-emotional support networks.
3) Create equitable space where LGBTQ+people gather, study, celebrate, and exist
authentically, safely, and without judgment.
Service Area: While Omaha ForUs is Omaha-based and Omaha-focused, it's proximity and
distance from other LGBTQ+ centers position it to serve eastern Nebraska and western Iowa
LGBTQ+ individuals and families.
Community Service funds are being requested for:
[XI A new program within the organization
n Expansion of an established program
n Continuation of a public service provision
BUDGET OVERVIEW
Total grant funding requested: $ 371,809
Annual cost of the program: $ 686,406
Annual organization budget: $ 715,609