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Contract/Agreement Exhibits

The exhibits included in the FY 2008-2009 contracts and/or agreements with certified domestic violence centers and Legal Clearinghouse providers are located in this section. The forms should be downloaded and saved for use by the provider when submitting required reports and information to FCADV.

Agreement Exhibits for Legal Service Providers
(Under $25,000.00)

• Exhibit A: Provider Attorney List (Word)
  Legal Clearinghouse providers who will have more than one attorney performing services, shall use this form to list the contact information for each attorney.
• Exhibit B: Legal Clearinghouse Claim Request Invoice (Word)
  Legal Clearinghouse providers shall use this electronic document to prepare their request for reimbursement for services rendered. The invoice is due to the FCADV Contract Manager no later than the 10th day of the month following the month in which services were delivered.
• Exhibit C: Activities Report for LCH Agreements (PDF)
  This is a monthly narrative and statistical report of Legal Clearinghouse related activities for the month. This report is to be completed on-line at forms.fcadv.org. The activity report is due to the FCADV Contract Manager, through the STARS system no later than the 10th day of the month following the month in which services were delivered.
• Exhibit D: Direct Deposit Authorization (Word)
  This form shall be completed upon contract execution to ensure timely payment for services rendered through electronic funds transfer.

Contract Exhibits for Legal Service Providers
(Over $25,000.00)

• Exhibit A: Provider Attorney List (Word)
  Legal Clearinghouse providers who will have more than one attorney performing services, shall use this form to list the contact information for each attorney.
• Exhibit B: LCH Budget Form (Word)
  This form is to be used to develop a line item budget to support the funding being awarded.
• Exhibit C: Legal Clearinghouse Claim Request Invoice (Word)
  Legal Clearinghouse providers shall use this electronic document to prepare their request for reimbursement for services rendered. The invoice is due to the FCADV Contract Manager no later than the 10th day of the month following the month in which services were delivered.
• Exhibit D: Activities Report for LCH Agreements (PDF)
  This is a monthly narrative and statistical report of Legal Clearinghouse related activities for the month. This report is to be completed on-line at forms.fcadv.org. The activity report is due to the FCADV Contract Manager, through the STARS system no later than the 10th day of the month following the month in which services were delivered.
• Exhibit E: Direct Deposit Authorization (Word)
  This form shall be completed upon contract execution to ensure timely payment for services rendered through electronic funds transfer.
• Exhibit F: IRR (Word)
  This is the official form to be used when requesting to purchase Information Technology Resources. Written approval shall be obtained from the FCADV Contract Manager prior to making a purchase using the Information Resource Request (IRR) Form.
• Exhibit G: Apportionment of Service Units (Word)

Agreement Exhibits for Legal Clearinghouse DV Centers

• Exhibit A: Claim Request Invoice (Word)
  Legal Clearinghouse DV centers shall use this document to prepare their request for reimbursement for services rendered. The invoice is due to the FCADV Grants Specialist no later than the 10th day of the month following the month in which services were delivered.
• Exhibit B: Monthly Activity Report (Word)
  This is a monthly narrative and statistical report of Legal Clearinghouse related activities for the month. This report is to be completed and submitted via email, fax, or regular mail to the FCADV Grants Specialist. The activity report is due no later than the 10th day of the month following the month in which services were delivered.
• Exhibit C: Direct Deposit Authorization (Word)
  This form shall be completed upon contract execution to ensure timely payment for services rendered through electronic funds transfer.

Agreement Exhibits for Stimulus Legal Clearinghouse Service Providers

• Exhibit A: Attorney Listing (Word)
  Legal Clearinghouse providers who will have more than one attorney performing services, shall use this form to list the contact information for each attorney.
• Exhibit B: Claim Request Invoice (Word)
  Legal Clearinghouse providers shall use this document to prepare their request for reimbursement for services rendered. The invoice is due to the FCADV Grants Specialist no later than the 10th day of the month following the month in which services were delivered.
• Exhibit C: Monthly Activity Report (PDF)
  This is a monthly narrative and statistical report of Legal Clearinghouse related activities for the month. This report is to be completed and submitted via email, fax, or regular mail to the FCADV Grants Specialist. The activity report is due no later than the 10th day of the month following the month in which services were delivered.
• Exhibit D: Direct Deposit Authorization (Word)
  This form shall be completed upon contract execution to ensure timely payment for services rendered through electronic funds transfer.
• Exhibit F: Apportionment of Service Units (Word)

Agreement Exhibits for Stimulus Legal Clearinghouse DV Centers

• Exhibit A: Claim Request Invoice (Word)
  Legal Clearinghouse DV centers shall use this document to prepare their request for reimbursement for services rendered. The invoice is due to the FCADV Grants Specialist no later than the 10th day of the month following the month in which services were delivered.
• Exhibit B: Monthly Activity Report (PDF)
  This is a monthly narrative and statistical report of Legal Clearinghouse related activities for the month. This report is to be completed and submitted via email, fax, or regular mail to the FCADV Grants Specialist. The activity report is due no later than the 10th day of the month following the month in which services were delivered.

Contract Exhibits for Certified Domestic Violence Centers FY 09/10

• Exhibit A: Deliverables (PDF)
  This document lists all of the tasks and deliverables to be provided by the certified domestic violence centers. This document is tailored specific to each center. General domestic violence and prevention services have the same deliverables and units of service for all centers. This document also includes the deliverables for centers who receive Rural and American Recover and Reinvestment Act funding (ARRA). The deliverables are the same for all centers that receive this funding, but the units of service vary among the centers.
• Exhibit B: Payment Chart (PDF)
  This document details the unit rate for all deliverables in the contract template. This document is specific to each center. All deliverables are the same for centers, but the unit rates may vary.
• Exhibit C: 2009-2010 Fixed Price Monthly Invoice (Excel)
  Certified domestic violence centers that are on a fixed price contract shall use this electronic document to prepare their request for reimbursement for services rendered. The invoice is due to the FCADV Contract Manager no later than the 15th day of the month following the month in which services were delivered. This invoice must be submitted electronically.
• Exhibit C: 2009-2010 Cost Reimbursement Monthly Invoice (Excel)
  Certified domestic violence centers that are on a cost reimbursement contract shall use this electronic document to prepare their request for reimbursement for services rendered. The invoice is due to the FCADV Contract Manager no later than the 15th day of the month following the month in which services were delivered. This invoice must be submitted electronically along with full and complete back-up.
• Exhibit C: 2009-2010 CPI Cost Reimbursement Monthly Invoice (Excel)
  Certified domestic violence centers that are on a cost reimbursement contract shall use this electronic document to prepare their request for reimbursement for services rendered. The invoice is due to the FCADV Contract Manager no later than the 15th day of the month following the month in which services were delivered. This invoice must be submitted electronically along with full and complete back-up.
• Exhibit C: 2009-2010 DDP Cost Reimbursement Monthly Invoice (Excel)
  Certified domestic violence centers that are on a cost reimbursement contract shall use this electronic document to prepare their request for reimbursement for services rendered. The invoice is due to the FCADV Contract Manager no later than the 15th day of the month following the month in which services were delivered. This invoice must be submitted electronically along with full and complete back-up.
• Exhibit D: Alice Monthly Report Sample (Excel)
  The Monthly Statistical Report shall be submitted by the 15th day of the month following the month in which services were rendered. Centers have the option of reporting this data through the Alice report system or through STARS.
• Exhibit E: Status Report for DV Center (Word)
  This is a monthly narrative report of domestic violence related activities for the month. The status report is due to the FCADV Contract Manager no later than the 15th day of the month following the month in which services were delivered.
• Exhibit F: Monthly Financial Report: General DV, Prevention Services and Rural Only (Excel)
  The center shall submit the Monthly Financial Report each month during the 4th quarter documenting total expenditures for the period in accordance with their approved operating budget. This report shall be submitted to the Contract Manager no later than the 15th day of the month following the month in which services were delivered and must accompany the Exhibit C. This report must be submitted electronically in excel format.
• Exhibit F: Monthly Financial Report: American Recovery and Reinvestment Act - ARRA (Excel)
  The center shall submit the Monthly Financial Report each month during the 4th quarter documenting total expenditures for the period in accordance with their approved operating budget. This report shall be submitted to the Contract Manager no later than the 15th day of the month following the month in which services were delivered and must accompany the Exhibit C. This report must be submitted electronically in excel format.
• Exhibit F: Monthly Financial Report: DCF VAWA STOP (Excel)
  The center shall submit the Monthly Financial Report each month during the 4th quarter documenting total expenditures for the period in accordance with their approved operating budget. This report shall be submitted to the Contract Manager no later than the 15th day of the month following the month in which services were delivered and must accompany the Exhibit C. This report must be submitted electronically in excel format.
• Exhibit G: Quarterly Financial Report: General DV,Prevention Services and Rural Only (Excel)
  The center shall submit the Quarterly Financial Report documenting total expenditures for the period in accordance with their approved operating budget. This report shall be submitted by the 15th day of the month following the quarter in which expenditures were made. This report must be submitted electronically in excel format.
• Exhibit G: Quarterly Financial Report: American Recovery and Reinvestment Act - ARRA (Excel)
  The center shall submit the Quarterly Financial Report documenting total expenditures for the period in accordance with their approved operating budget. This report shall be submitted by the 15th day of the month following the quarter in which expenditures were made. This report must be submitted electronically in excel format.
• Exhibit G: Quarterly Financial Report: DCF VAWA STOP (Excel)
  The center shall submit the Quarterly Financial Report documenting total expenditures for the period in accordance with their approved operating budget. This report shall be submitted by the 15th day of the month following the quarter in which expenditures were made. This report must be submitted electronically in excel format.
• Exhibit G: Quarterly Financial Report: L & C (Excel) The center shall submit the Quarterly Financial Report documenting total expenditures for the period in accordance with their approved operating budget. This report shall be submitted by the 15th day of the month following the quarter in which expenditures were made. This report must be submitted electronically in excel format.
• Exhibit H and/or I: Legal Clearinghouse Service Activity Report (STARS) (PDF)
  This is a monthly narrative and statistical report of Legal Clearinghouse related activities for the month. This report is to be completed on-line at forms.fcadv.org. The activity report is due to the FCADV Contract Manager, through the STARS system no later than the 15th day of the month following the month in which services were delivered.
• Exhibit H: Rural Service Activity Report (STARS) (PDF)
  This is a monthly statistical report of rural domestic violence related activities for the month. This report is to be completed on-line at forms.fcadv.org. The activity report is due to the FCADV Contract Manager, through the STARS system no later than the 15th day of the month following the month in which services were delivered.

Contract Forms for Legal Assistance for Victims (LAV) FY 2008-2010

Only LAV forms are located on the website. If you need electronic copies of Exhibit A, Monthly Invoice or Exhibit B, Monthly Activity Report, please contact your FCADV Contract Manager at Contract_Manager@fcadv.org. The exhibits are customized for each LAV service provider.

• Case Selection Criteria (Word)
• Budget Template (Word)
• Provider Contact Information Form (Word)
• Attorney/Center Assignment Form

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