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FVPSA Forms

 

FVPSA Forms

Forms

Submit to

How to Submit 

Due Date

FVPSA Monthly Reimbursement Report and Reimbursement Report Summary Page FVPSA Coordinator Electronically  to  NCFVPSA@doa.nc.gov  10th of each month
FVPSA Monthly Reimbursement Report Guidance For applicant Use to assist with preparation of report  
FVPSA Budget Transfer Request aka BTR FVPSA Coordinator Electronically  to  NCFVPSA@doa.nc.gov  As needed
FVPSA Semi-Annual Performance Report for Prevention-Specialized Service Providers FVPSA Coordinator Electronically by clicking on the link  April 15
October 15
FVPSA Semi-Annual Performance Report for Domestic Violence Service Providers FVPSA Coordinator Electronically by clicking on the link  April 15
October 15
FVPSA Semi-Annual Performance Report Guidance Form  For applicant use only Use to assist with preparation of report  
Electronic Payment Form (Complete for reimbursement) (PDF) OSC Support Services Center
Mail:
1410 Mail Service Center
Raleigh, NC 27699-1410
 
FVPSA Domestic Violence Grant Application  Preparation and Guide Checklist Form  For applicant use only  Use to assist with submission of grant application   
FVPSA Domestic Violence Grant Application For applicant use only 
Electronically  to  NCFVPSA@doa.nc.gov
And 
Mail to 1320  Mail Service Center
Raleigh, NC 27699-1320
 
May 1st, 2019
FVPSA Prevention-Specialized Service Provider Grant Application Preparation Guide and Checklist For applicant use only   Use to assist with submission of grant application

 

FVPSA Prevention-Specialized Service Provider Grant Application For applicant use only 
Electronically  to  NCFVPSA@doa.nc.gov
And 
Mail to 1320  Mail Service Center
Raleigh, NC 27699-1320
 
May 1st, 2019

FVPSA Grant Contract Items for Nonprofit Agency

Attachment A (General Terms and Conditions)

Attachment B  (Scope of Work)

Attachment C  (Budget)

Attachment D  (Reporting Requirements)

Attachment E  (No Overdue Tax Debts)

NC CFWYI FVPSA Verification of No Overdue Tax Debts

Attachment F (Verifications of 501(C)(3) Status)

Attachment G (Tobacco Smoke)

Attachment H  (Lobbying)

Attachment I  (Debarment Suspension)

Attachment J (Drug-Free Workplace)

Assurance of Compliance with Grant Requirements

FVPSA Grant Cover Sheet Private Non-Profit

FVPSA Contract Checklist 

 

 

 

 

FVPSA Coordinator

FEDEX/UPS/HAND DELIVERY:

Attention FVPSA Staff 116 West Jones Street Raleigh NC 27603

US Mail:

Attention FVPSA Staff 1320  Mail Service Center Raleigh NC 27699-1320

 

FVPSA Grant Contract Items for Government Agency

Attachment A (General Terms and Conditions)

Attachment B  (Scope of Work)

Attachment C  (Budget)

Attachment D  (Reporting Requirements)

Attachment E  (No Overdue Tax Debts)

NC CFWYI FVPSA Verification of No Overdue Tax Debts

Attachment G (Tobacco Smoke)

Attachment H  (Lobbying)

Attachment I  (Debarment Suspension)

Attachment J (Drug-Free Workplace)

Assurance of Compliance with Grant Requirements

FVPSA Grant Cover Sheet Government Entity

FVPSA Contract Checklist 

FVPSA Coordinator

FEDEX/UPS/HAND DELIVERY:

Attention FVPSA Staff 116 West Jones Street Raleigh NC 27603

US Mail:

Attention FVPSA Staff 1320  Mail Service Center Raleigh NC 27699-1320

 
Sample Budget      
FVPSA Actual Budget FY19-20 and FY20-21 For DV and Prevention-Specialized Service   Updated 9/4/2019