Free 53456.FH11 - Indiana

LIBRARY SERVICE AND TECHNOLOGY ACT (LSTA) GRANT APPLICATION
State Form 53456 (R2 / 10-08)

INDIANA STATE LIBRARY INSTRUCTIONS:

Reset Form

1. Complete each section of the application online. Mail two copies, one with an original signature. 2. Do not use binders, folders, notebooks or staples. 3. FAXED APPLICATIONS WILL NOT BE ACCEPTED.

Grant type:
Project title

Digitization

Innovative

Institutional literacy

Technology

Name of applicant (name of organization or agency) Address (number and street, city, state and ZIP code) Name of organization director Telephone number Fax number E-mail address

Web address

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Name of project director (contact person for grant purposes) Telephone number Fax number E-mail address

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Name of fiscal agent (responsible for financial reports) Telephone number Fax number E-mail address

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County Source of this number (U.S. Census, library circulation record, etc.) Total cost of project

Federal congressional district(s) Estimated number of people to be served by project Federal funds requested

Federal Library Services & Technology Act (indicate the primary purpose that best describes your project check only one) Expand services for learning and access to information and educational resources in a variety of formats, in all types of libraries, for individuals of all ages; Develop library services that provide all users access to information through local, state, regional, national, and international electronic networks; Provide electronic and other linkages between and among all types of libraries; Develop public and private partnerships with other agencies and community-based organizations; Target library services to individuals of diverse geographic, cultural, and socioeconomic backgrounds, with disabilities, and with limited functional literacy or information skills; and Target library and information services to persons having difficulty using a library and to underserved urban and rural communities, including children from families with incomes below the poverty line. Indianas LSTA Goals (indicate the primary purpose that best describes your project check only one) Indiana libraries will provide up-to-date, reliable access to information by utilizing effective telecommunications, technology, and resources. Libraries will deliver new and improved programs that anticipate and meet Indianas needs for library services. Indiana State Library will provide leadership and infrastructure for digital library initiatives. Libraries will strengthen public policy support for upgrading library services through improved communication, collaboration, and partnership efforts. Indiana State Library will provide resources and support to libraries which seek to serve special populations in the state. Indiana State Library will provide resources and support to libraries which seek to serve the un-served or underserved populations. Primary audience for the project (mark at least one, maximum of three) Pre-schoolers (0-5) Children (6-12) Youth (13-17) Adults (18-64) Seniors (65+) People with special needs Library staff Rural populations
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Urban populations Institutionalized persons Non or limited English speakers Statewide public

PART 1. This is an abstract of your entire project.

PROJECT SUMMARY (150 words or less )

PART 2.

NEEDS STATEMENT

Describe the need or problem that generated this project and how you determined this need. Identify the goal from the State Plan that this project will address and how this project will address this goal. (See the State Plan on the Indiana State Library website http://www,in.gov/library/2704.htm.)

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PART 3.

GOALS, ACTIVITIES, AND EVALUATION

First, describe the overall objectives of this project. Second, identify project staff and detail their individual roles in this project. Third, describe how you will measure the impact of this project on the target audience, as well as on the library(ies) involved. For example, describe how you will determine if the needs of the target group were actually met. Refer to http://www.shapingoutcomes.org/course/index.htm for information about outcome based evaluation (OBE), the preferred method for evaluating project success.

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PART 4

TIMELINE

Create a monthly timetable for your project. Include a list of activities indicating what will be done and by whom.
ACTIVITY IMPLEMENTATION: WHEN WHO

COMMUNICATION:

EVALUATION:

REPORTS:

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PART 5.

COMMUNICATION PLAN

How do you intend to promote the program? How will you reach the target audience? Grantees are expected and encouraged to publicize the project in available and appropriate media outlets. How and when are you planning to share the results of this project beyond your local jurisdiction? Is the project a model for replications? All grant projects are required to acknowledge IMLS on all products. For more information, go to http://www.imls.gov/recipients/communication.shtm .

PART 6.

CONTINUATION PLAN

Explain how activities or benefits from the project will continue after the LSTA funding period ends. If the program will not be continued, explain why.

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PART 7

PROJECT BUDGET

The Budget should provide an overview of all anticipated project costs from federal and local sources. Round all amounts to the nearest whole dollar. LSTA funds cannot be used to supplant local or system funds. LSTA funds may not be used for administrative overhead.
BUDGET ITEM 1. Personal Services Salaries and wages METHOD OF COMPUTATION LSTA GRANT FUNDS COST SHARING PROJECT TOTAL

0
0

0

0
Employee benefits
0 0

0 0
0

Total for Personal Services 2. Supplies Office supplies Operating supplies Other supplies Total for Supplies 3. Other Services and Charges Professional services Communication and Transportation Printing and advertising Repair and maintenance Total for Other Services and Charges 4. Capital Outlays Furniture and equipment Other capital outlays Books Periodicals and news Papers Nonprint materials AV Software Total for Capital Outlays BUDGET TOTAL Page 6 of 9

0

0

0
0
0
0

0

0

0

0

0 0 0

0

0

0
0 0

0
0 0

0
0

0 0

0

0

0

0

0

PART 8

PROJECT BUDGET NARRATIVE

Budget Narrative: Outline the project budget in narrative form using the four budget categories. If both local and LSTA funds will be used, please specify by source within the categories. Explain how the various budget items are applicable to the proposed project. Guidelines on acceptable use of LSTA grant funds are available on the Indiana State Librarys website http://www.in.gov/library/2704.htm .

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PART 9

LSTA OUTCOMES PLAN

Outcome based evaluation (OBE) is the preferred evaluation method for your grant project. For a tutorial, go to http://www.shapingoutcomes.org/course/index.htm .
PROJECT SUMMARY / PROGRAM PURPOSE

INPUTS

ACTIVITIES

OUTPUTS

OUTCOMES

EVALUATION INDICATORS

EVALUATION SOURCES / METHODS

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PART 10.

ASSURANCES

The Institute of Museum & Library Services (IMLS) requires the Indiana State Library to obtain certification from its sub-grant applicants regarding federal debt status, debarment and suspension, non-discrimination, a drug-free workplace, and other applicable assurances. These requirements are incorporated in the Assurances Statement below. Review the Statement and sign the certification form. If you receive a grant, you must comply with these requirements. By signing the application form, the authorizing official, on behalf of the applicant, assures and certifies that, should a subgrant be awarded, it will comply with the statutes outlined and all related IMLS and ISL regulations. These assurances are given in connection with any and all financial assistance from IMLS / ISL after the date this form is signed. These assurances shall obligate the applicant for the period during which Federal financial assistance is extended. The applicant recognizes and agrees that any such assistance will be extended in reliance on the representations and agreements made in these assurances, and that the United States government has the right to seek judicial enforcement of these assurances, which are binding on the applicant, its successors, transferees, and assignees, and on the authorized official whose signature appears on the application form. Certifications Required of all Applicants
1. 2. 3. 4. 5.

Financial, Administrative, and Legal Accountability; Debarment and Suspension; Non-Discrimination; Drug-Free Workplace Act of 1988; and Lobbying

Certification of Authorizing Officials I have examined this application, and I hereby certify on behalf of the applicant organization that:
1. 2. 3. 4.

The information provided is true and correct All requirements for a complete LSTA Grant application have been fulfilled; The applicant will comply with all applicable payment, accounting, and reporting requirements; and The applicant will comply with applicable certifications regarding Items 1-5 listed above under Certifications Required of All Applicants.

We, the undersigned, hereby certify that should this organization receive a sub-grant, the organization and its leaders will comply with all LSTA regulations, all statutes outlined, requirements as defined in the Indiana State Library (Library Services and Technology Act Handbook for Subgrant Applicants), and all applicable Federal statues and regulations.
Name of applicant (organization or agency) Signature of Principal Officer of applicant Project title Title of Principal Officer Date of submission (month, day, year) Date of signature (month, day, year)

STATE LIBRARY USE ONLY Project number Type of library Public Approved Not approved Amount awarded

School

Academic

Special

Multi-type

SLAA

Institutional

These grants are made available through funds from the Library Services and Technology Act appropriated by Congress and administered by the Institute of Museum and Library Services and the Indiana State Library.

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