Application & Agreement for Purchase of Services

The Township of Schaumburg will accept funding applications under three committees.

1. Mental Health Board (MHB) This funding supports treatment and/or prevention services for mental health, substance use disorders, and intellectual/developmental disabilities. Questions regarding the MHB application can be sent to: quinette@tosmhb.org

2. The Disability & Senior Services Committee (DSS) funding supports services focused on older adults and individuals with disabilities that are not funded by the MHB.

3. Welfare Services (WS) This funding supports low-income households and housing-insecure residents.

The Mental Health Board (MHB) process and application differ from those of DSS and WS, and the link can be found here: https://schaumburgtownship.org/our-township/mental-health-board/. It is also important to note that the MHB applications open on October 1 and close on October 30, 2026.

Funds may be requested from multiple committees in different service areas. Please submit multiple applications if your agency is interested in funding from more than one committee, as the information provided on the application will vary based on the funding request. The WS and DSS application deadline is Tuesday, October 13. Please complete this form and email the required documentation back to:

DNelson@schtwn.org for WS apps and FBorja@schtwn.org for DSS apps.

Once applications are received, they will be reviewed, a hearing date and time will be scheduled, and the information will be shared. Welfare Services’ hearings will be held on Wednesday, November 4, 2026. Disability and Senior Services' hearings will be held on Tuesday, November 10, 2026.

Thank you for your dedication and commitment to supporting the needs of our residents; we appreciate your partnership. Together, everything is possible.

Agency Name(Required)

Date(Required)

Agency Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Person(Required)

First Last

Contact Email(Required)

Contact Phone(Required)

Parent Organization (if applicable)

Parent Organization Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Funds Requested

Funds Requested(Required)

Please identify the funding sources from which you are applying. If you are applying for funding from more than one department, please submit separate applications.

Disability & Senior Services Committee

Welfare Services

Total Grant Requested $(Required)

Purpose of Funds(Required)

Please provide a description of the specific purposes for the requested funds, including the programs, services, activities, and facilities that will be supported.

Services

Who is the target group or persons serviced by the request, and how are clients screened for eligibility?(Required)

Do you currently operate a waitlist for the requested service? How do you manage the waitlist or prioritize clients?(Required)

Are all programs, services, activities, and facilities provided by your Agency available to residents of Schaumburg Township?(Required)

Yes

If no, please describe:

Does your agency serve the entire Schaumburg Township area?(Required)

Yes

If no, please describe:

Does your agency serve any townships other than Schaumburg Township?(Required)

Yes

If yes, please list townships served:

Are services rendered at a location within the Township?(Required)

Yes

If not, please describe how Township residents access services:

Please define what a “unit of service” means in your agency. Explain how individual, small group, and large group activities are accounted for in documenting the agency’s efforts:(Required)

How many units of service did your agency provide for each classification of service for 2024 and 2025, respectively?(Required)

How many (estimated) units of service did your agency provide for each classification of service for 2026? And how many projected units of service will your agency provide for each classification of service for 2027?(Required)

How many units of service did your agency provide for each classification of service for 2024 and 2025 (respectively) - specifically for residents of Schaumburg Township?(Required)

How many (estimated) units of service did your agency provide for each classification of service for 2026 - specifically for residents of Schaumburg Township? And how many projected units of service will your agency provide for each classification of service for 2027 - specifically for residents of Schaumburg Township?(Required)

For the units of service reported above, how many individual residents from Schaumburg Township consumed those units in 2024 and 2025 respectively?(Required)

For the units of service reported above, how many individual residents from Schaumburg Township consumed those units in 2026 (estimated)? And how many individual residents from Schaumburg Township will consume those units in 2027 (projected)?(Required)

How do you measure the success of your service or program? What outcomes do you expect to achieve with this request?(Required)

Budgeting and Funding

What was the total budgeted cost for your agency for the past fiscal year?(Required)

What was the actual cost?(Required)

Funding Source Percentages

What percentage of your operational funding comes from the following sources?

Federal(Required)

State(Required)

County(Required)

Other Townships(Required)

Village/City(Required)

Private Giving: Foundations(Required)

Private Giving: United Way(Required)

Private Giving: Agency Fundraising(Required)

Client Fees(Required)

Other Sources(Required)

Attachments Required

Please include the following supporting documentation, if available: Prior Year’s Budget, Audit of past fiscal year, Proposed Budget for upcoming year, Current Strategic Plan, Most recent Annual Report, Fee Schedule, Copy of IRS 501(c)3

Required Attachments(Required)

Drop files here or

Max. file size: 16 MB.

Funding Terms (please review and submit electronic signature at the end of this section).

The Agency understands and agrees that the following conditions are incorporated into and considered with this agreement before a distribution will be made by the Township. The Agency further agrees to comply with the provisions hereinafter set forth in the event it receives the purchase of services grant from the Township.

Service Charge

The Agency agrees not to request from the Township more than the total annual funds allowed under the purchase of services grant. The Agency agrees that any charges of the Township for services rendered shall be in conformance with the per client charge negotiated at the time of the Agency’s annual grant. The Agency agrees to submit a statement of services rendered to the Township on a quarterly basis. Said charges for services shall be drawn from the total funds available in the annual purchase of services grant to that Agency. Each quarterly statement of services must include the following: The quarterly billing statement will include a list of clients served identified with their I.D. numbers and the number of contacts provided. Only direct service contacts will be accumulated quarterly for each client. Collateral hours are not to be accumulated, nor reported on the monthly statement. The quarterly statement will indicate what type of services were provided to the clients: individual, group, family, marital, residential, day treatment, rehab, etc. If more than one member of a family or marital grouping has an I.D. number, only one I.D. number will be reported unless these members are seen individually during the month.

Services Provided

The Agency agrees to provide the appropriate professional services to the residents of the Township. The Agency agrees to provide the Township with a specific description of new programs, services, activities or facilities which are initiated subsequently to the annual grant by the Township for the purchase of services.

Inspection

The Agency agrees that all financial records and client files shall be open for inspection at any time to the Township Officials and to their representatives pursuant to Section 7 of the Mental Health and Development Disabilities Confidentiality Act (Article I, Section 1, et seq. Effective January 1, 1979). The exception to this condition is the records of alcoholic clients/patients whose confidentiality is protected by the COMPREHENSIVE ALCOHOLIC ABUSE AND ALCOHOLIC PREVENTION, TREATMENT AND REHABILITATION ACT OF 1970, and related federal laws governing the treatment of alcoholic clients/patients.

Agency Representative

The undersigned Agency Representative has been empowered by the Agency and is responsible for ensuring compliance with this agreement. If the undersigned is no longer associated with the Agency, the Agency will provide the Township with written notice of the per empowered by the Agency and responsible for ensuring compliance to this agreement.

Source of Funds

The Agency understands that all funds for the purchase of services shall be distributed from the Township in the manner specified by the Township.

Term

The Term of this Agreement shall be from March 1, 2027 until February 28, 2028, and all service funds provided by the Township pursuant to this Agreement shall be required to be expended only during the Term of this Agreement.

Use

The Agency is prohibited from using grant funds to support services provided to individuals who reside outside of the Township.

Unspent Funds

Unspent funds remaining at the expiration of the Term of this Agreement shall not carry over. Upon expiration of the Term of this Agreement, any and all unspent funds shall be returned to the Township.

Method of Payment

The Township shall disburse funding to the Agency pursuant to this Agreement upon written request by an authorized representative of the Agency, and approval by the Township Supervisor.

Documentation and Audit

The Agency shall maintain all appropriate documentation of actual expenditures related to this Agreement in a manner consistent with all generally accepted audit practices. Documentation shall be presented to the Township Supervisor upon request during the Term of this Agreement, detailing the actual expenditure of grant funds under this Agreement.

Records and Reports

The Agency shall maintain, for a minimum of five (5) years after the completion of this Agreement, adequate books, records, and supporting documents to verify the amounts, recipients, and uses of all monies in any way related to this Agreement. One month prior to the expiration of the Agreement, the Agency shall provide a year-end report to the Township that will show that services were delivered to individuals with disabilities who reside in the Township, and that there was a positive impact on the targeted issue.

Independence of the Agency

Any personnel, including contractors, who may be employed by the Agency in connection with this Agreement, shall not be considered for any purpose to be agents or employees of the Township. Nothing in this Agreement shall be construed to render the Agency an agent or employee of the Township.

Assignment

This Agreement shall not be assigned without the express written consent of both the Township and the Agency.

Modification

No modification of this Agreement may be made unless agreed to in writing by both parties.

Illinois Law

This Agreement shall be interpreted in accordance with Illinois law. All disputes shall be resolved in the Circuit Court of Cook County.

Non-appropriation of Funds

This Agreement will cease immediately and without further liability, if in any fiscal year there are insufficient funds appropriated by the Township for this Agreement. In this event, the Agency will be paid for expenditures made during the period for which funds were available.

Termination

The Township and the Agency each reserve the right to terminate this Agreement upon thirty (30) days' written notice to the other party.

Indemnification

The Agency agrees to hold harmless and indemnify the Township, its officers, agents, trustees and employees against any losses, damages, judgments, claims, expenses, costs and liabilities imposed upon or incurred by or asserted against the Township, its officers, agents, trustees or employees, including reasonable attorneys' fees and expenses, arising out of the acts or omissions of the Agency, its officers, agents or employees under this Agreement.

Taxes

The Agency assumes full responsibility for the payment of all federal, state and local taxes incurred by the Agency as a result of this Agreement.

Business Licenses

The Agency represents that it possesses all professional or business licenses required by law, if any, and all qualifications necessary to provide the grant services and to fully perform its obligations contained herein.

Damages

In no event shall the Township be liable for any incidental, indirect, special or consequential damages, including, but not limited to, loss of use, revenue, profit or savings for any claims arising under the terms of this Agreement by the Agency or any third party.

Certification

The Certification Form attached hereto marked as Exhibit “A” shall be executed by the Agency, and it is agreed among the parties that the assurances contained in Exhibit “A” are each a material representation of fact upon which reliance is placed by the Township in providing grant funding under this Agreement with the Agency.

Signature

Agency Name (for electronic signature)(Required)

Entering the agency name certifies that the information contained in the application is true and correct and agree to the above provisions for the Purchase of Services Grant from Schaumburg Township.

Name(Required)

First Last

Entering the representative name certifies that the information contained in the application is true and correct and agree to the above provisions for the Purchase of Services Grant from Schaumburg Township.

Date(Required)

Title(Required)

Exhibit "A" - Certification Form (Explanation)

The following certification form will be used in the event that your agency/organization is granted funding.

The assurances hereinafter made by (*Agency), (the “Contractor”) are each a material representation of fact upon which reliance is placed by Schaumburg Township (the “Township”) in entering into the agreement with the Contractor. Schaumburg Township may terminate the agreement if it is later determined that the Contractor rendered a false or erroneous assurance.
I, (*Name of Person Certifying), hereby certify that I am the (*Office of Person Certifying) of the (*Agency) and as such hereby represent and warrant to Schaumburg Township, a unit of local government, that the Contractor and its shareholders holding more than five percent (5%) of the outstanding shares of the corporation, its officers and directors are:
(A) not delinquent in the payment of taxes to the Illinois Department of Revenue in accordance with 65 ILCS 5/11-42.1-1;
(B) not barred from contracting as a result of a violation of either Section 33E-3 (bid rigging) or 33E-4 (bid-rotating) of the Criminal Code of 1961 (720 ILCS 5/33E-3 and 5/33E-4);
(C) not in default, as defined in 5 ILCS 385/2, on an educational loan, as defined in 5 ILCS 385/1;

Exhibit "A" - Certification Form

Please complete the following in regards to the terms "Agency", "Name of Person Certifying and "Office of Person Certifying" above.

Agency Name(Required)

Name of Person Certifying (Agency Representative)(Required)

Office of Person Certifying (Title of Agency Representative)(Required)

Agency Name(Required)

In addition, the Contractor hereby represents and warrants to Schaumburg Township, that:

(A) the Contractor, pursuant to 30 ILCS 580/1 et seq. (“Drug-Free Workplace Act”), will provide a drug-free workplace by:

(1) Publishing a statement:

a. Notifying employees that the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance including cannabis, is prohibited in the Contractor's workplace;

b. Specifying the actions that will be taken against employees for violations of such prohibition;

c. Notifying the employee that, as a condition of employment on such Contract, the employee will;

i. Abide by the terms of the statement;

ii. Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction;

(2) Establishing a drug-free awareness program to inform employees about:

a. the dangers of drug abuse in the workplace;

b. the Contractor's policy of maintaining a drug-free workplace;

c. any available drug counseling, rehabilitation, and employee assistance program; and

d. the penalties that may be imposed upon employees for drug violations.

(3) Making it a requirement to give a copy of the statement required by Subsection (A) (1) to each employee engaged in the performance of the Contract, and to post the statement in a prominent place in the workplace;

(4) Notifying the Township within ten (10) days after receiving notice under paragraph (A) (1) c from an employee or otherwise receiving actual notice of such conviction;

(5) Imposing a sanction on, or requiring the satisfactory participation in a drug abuse assistance or rehabilitation program by any employee who is so convicted, as required by 30 ILCS 580/5;

(6) Assisting employees in selecting a course of action in the event drug counseling treatment and rehabilitation is required and indicating that a trained referral team is in place;

(7) Making a good faith effort to continue to maintain a drug-free workplace through implementation of this section;

(B) the Contractor has and will comply with the Equal Employment Opportunity Clause required by the Illinois Human Rights Act, and that the Contractor has not excluded and will not exclude from participation in, denied the benefits of, subjected to discrimination under, or denied employment to any person in connection with any activity funded under the contract on the basis of race, color, age, religion, national origin, disability, or sex;

(C) no Township officer, spouse or dependent child of a Township officer, agent on behalf of any Township officer or trust in which a Township officer, the spouse or dependent child of a Township officer or a beneficiary is a holder of any interest in Contractor; or, if Contractor’s stock is traded on a nationally recognized securities market, that no Township officer, spouse or dependent child of a Township officer, agent on behalf of any Township officer or trust in which a Township officer, the spouse or dependent child of a Township officer or a beneficiary is a holder of more than one percent (1%) of Contractor, but if any Township officer, spouse or dependent child of a Township officer, agent on behalf of any Township officer or trust in which a Township officer, the spouse or dependent child of a Township officer or a beneficiary is a holder of less than one percent (1%) of such, Contractor has disclosed to the Township in writing the name(s) of the holder of such interest;

(D) no officer or employee of the Township has solicited any gratuity, discount, entertainment, hospitality, loan, forbearance, or other tangible or intangible item having monetary value including, but not limited to, cash, food and drink, and honoraria for speaking engagements related to or attributable to the government employment or the official position of the employee or officer from Contractor;

(E) Contractor has not given to any officer or employee of the Township any gratuity, discount, entertainment, hospitality, loan, forbearance, or other tangible or intangible item having monetary value including, but not limited to, cash, food and drink, and honoraria for speaking engagements related to or attributable to the government employment or the official position of the employee or officer;

(F) neither the Contractor nor any of its principals, shareholders, members, partners, or affiliates, as applicable, is a person or entity named as a Specially Designated National and Blocked Person (as defined in Presidential Executive Order 13224) and that the Contractor is not acting, directly or indirectly, for or on behalf of a Specially Designated National and Blocked Person and that the Contractor and its principals, shareholders, members, partners, or affiliates, as applicable, are not, directly or indirectly, engaged in, and are not facilitating, the transactions contemplated by this Agreement on behalf of any person or entity named as a Specially Designated National and Blocked Person; and

(G) the Contractor acknowledges that, pursuant to the provisions of the Illinois Freedom of Information Act, (5 ILCS 140/1 et seq.), documents or records prepared or used in relation to work performed under this agreement are considered a public record of the Township; and therefore, within thirty (30) days of completion of the work required of the Contractor under this agreement, the Contractor shall produce to the Township, in electronic format, all records that directly relate to the governmental function performed by the Contractor under this agreement at no additional cost to the Township; and furthermore, the Contractor shall review its records and promptly produce to the Township any additional records in the Contractor’s possession which the Township requires in order to properly respond to a request made pursuant to the Illinois Freedom of Information Act (5 ILCS 140/1 et seq.), and the Contractor shall produce to the Township such records within three (3) business days of a request for such records from the Township at no additional cost to the Township.

If any certification made by the Contractor or term or condition in the agreement changes, the Contractor shall notify Schaumburg Township in writing within seven (7) days.

Date(Required)

Name of Agency(Required)

Authorized Agent of Agency/Contractor(Required)

First Last

Title(Required)

CAPTCHA

Application & Agreement for Purchase of Services