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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   (Updated 11-4-19) 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 Prevention-Specialized Service Provider Grant Application Preparation Guide and Checklist For applicant use only   Use to assist with submission of grant application

 

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