501(c)(2) X 501(c)(3) 501(c)(4) 502(c)(3)

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1 II. APPLICANT INFORMATION 1. Organization: Cristo Rev Community Center 2. Contact Person: Robert Vogel Title: Executive Director Organization's Address: 1717 North High Street Lansing, Michigan Phone Number: (517) Fax Number: (517) WEB: 6. Proposal Title: Prescription Assistance Program Amount Requested: $ 4, Federal Tax Identification Number: Ingham County communications regarding community agency funds shall be sent to address: rvogel@camw.net & valmaguer@cristorey.com 10. Please indicate the names and titles of persons who are authorized to execute agreements on behalf of your organization: Name: Robert Vogel Name: Title: Executive Director Title: 11. Nonprofit Organization: Please Check One 501(c)(2) X 501(c)(3) 501(c)(4) 502(c)(3) []Other (specify) 12. Business organization (profit): 13. Unit of government including schools (specify): : 14. Not incorporated (specify legal and/or professional status of the requesting individual): 15. How long has the applicant's organization been in business? Since What is the number of fulltime equivalent positions currently employed? 28_ 17. How many volunteers are currently involved? 30

2 18. a. How does your proposal involve coordination or collaboration with County services, other local governments, or other agencies? The Cristo Rey Prescription Assistance Program has created partnerships with many area agencies: Ingham County Health Department, Capital Area United Way 211, doctor's offices in the community, homeless shelters, and resources books such as Capital Area Community Services, who refer their clients to our program. Clients are also referred to our program through the Cristo Rey Family Health Clinic. b. What other programs similar to your program are operating in the County? There are programs similar to ours offering assistance with applications for pharmaceutical companies' patient assistance programs only for their patients. Or they offer emergency vouchers but not assistance with pharmaceutical programs. However our program is unique because we do both. Our program accepts referrals from the Cristo Rey Family Health Clinic as well as referrals from other doctors' offices in the community. These advocacy services are provided in both English and Spanish to meet the needs of our community. 19. Is this your first request for funds from Ingham County? yes X no 20. a. Have you sought funds for this proposal or concept from any other entity? Please identify who and the response. X yes no We receive $38,000 from Capital Area United Way, $1,000 from City of Lansing, $19,979 from Capital Region Community Foundation and $4,000 from Ingham County Deputy Controller's Office. We will continue to request funding from these sources. b. Does the proposal anticipate utilizing funds from other sources? X yes no c. To what extent is the other funding assured? All funding is currently in place.

3 III. DETAILED SCOPE OF WORK The Scope of Work should be one page or less and contain: 1. A statement regarding the general nature of the services and population with which your agency concerns itself. The Cristo Rey Prescription Assistance Program will help guide lowincome individuals without medical insurance for prescription coverage to access needed medications for chronic diseases free of charge from pharmaceutical companies' patient assistance programs. Other characteristics may include; unemployed without Medicaid benefits, the employed without health insurance benefits unable to afford medications, individuals who are not enrolled in the Ingham County Health Plan, and elderly with Medicare who do not have prescription coverage and who need help obtaining medications. Another service we provide is vouchers for emergency medications. The purpose of this program is to help lowincome individuals without medical insurance who has an emergency need for a prescription to cover the onetime cost of the prescription in a local pharmacy. 2. A statement explaining how the proposal will address the County's longterm objective of Meeting Basic Needs. (See the attached Resolution #12200 Resolution Approving Criteria for Ranking 2013 Applications for Community Agency Funding Access to prescription medication is a critical link for individuals to manage their illnesses, decreasing the chance of incurring expensive hospital stays and lost time at work. The high drug costs hinder the affordability and accessibility of medications. This is an enormous challenge that forces individuals to choose between medicines and other basic needs. In 2011, we received funds totaling $62,797 which allowed us leveraged $1,196,147 worth of free medicines from the pharmaceutical companies' patient assistance programs. Our program will address the County's objective by: * Allow lowincome individuals who do not have medical insurance to have access to the medications they desperately need for their chronic diseases and can not afford. One of the components of our program is assisting clients in accessing pharmaceutical companies' patient assistance programs. * Help guide the uninsured to the best program for them. Many of the patients we serve are minorities, who are disproportionately uninsured and cannot afford the medications their illness requires. * Our program is able to leverage funding to bring additional resources into the community. In 2011 the funds contributed leveraged $1,196,147 worth of free medications from the pharmaceutical companies' patient assistance programs for our clients. * Since 2003, the Cristo Rey Prescription Assistance Program has been filling a vital need in our community. The program has helped individuals received 11,675 medications valued at $5,939,873 from as many as 100 pharmaceutical companies, and with $59,192 in vouchers for emergency medications for Ingham county residents that allowed us paid for 2,204 emergency medications. 3. A statement detailing the specific services which will be provided by Ingham County's appropriation. A statement of the specific target group for these areas. Funding from the Office of Ingham County Controller is essential to continue providing access to needed medications for lowincome, indigent and uninsured individuals. If expected funding does not come through or is reduced significantly, our ability to provide this access will diminish. As a result, if individuals are unable to manage their illnesses, hospital emergency rooms will be flooded.

4 The target population of this program consists of lowincome, individuals without medical insurance for prescription coverage. With the rising costs of medications, most individuals are not able to afford their medications. They have no health insurance of any kind and little money. These individuals desperately need help. Many of the elderly that we serve are monolingual in Spanish and have difficulties reading and understanding communications they are receiving from Medicare. Many live in absolute fear of not being able to get needed medications. 4. A statement describing the eligibility criteria for these services. (See the attached Resolution #12200 Resolution Approving Criteria for Ranking 2013 Applications for Community Agency Funding and must serve residents of Ingham County are eligible.) To be eligible for the Cristo Rey Prescription Assistance Program you must be: * Lowincome individual without medical insurance for prescription coverage. * Elderly with Medicare without prescription coverage. * Employed whose employer doesn't provide medical insurance benefits and cannot pay for medications. * Unemployed without Medicaid benefits. * Mentally ill and do not have medical insurance or do not qualify for a program that provides prescription assistance for needed psychotropic medications. 5. A statement describing the time for the performance of these services. Services will be provided January 1, 2013 to December 31, 2013

5 IV. PROTECT BUDGET The Proposed Line Item Budget should be structured to address four major areas: Personnel Services, Professional and Contractual Services, Operating Expenses, and Direct Services to Ingham County Residents. Please be advised that for 2013 emphasis will be placed on provision of direct services to county residents and COUNTY REQUESTED AMOUNT OTHER SOURCES 1 Personnel Services a. Salaries & Wages b. FICA c. Unemployment d. Fringe Benefits (may be further subdivided) e. Overtime f. Temporary g. Work Study Wages $3,500 $250 $35 $215 $46, $3, $ $3, L Professional and Contractual a. Medical Services (for recipient population) b. Accounting Services c. Membership/Subscriptions d. Federal or State grant match e. Office Equipment Leases f. Maintenance Agreements $407 Operating Expenses a. Telephone b. Rent c. Utilities d. Postage e. Office Supplies i. 1 ravel g. Insurance $430 $510 $517 $291 $529 $433 4 Direct Services to Ingham County Residents a. Food b. Utilities c. Shelter/Housing d. Other Direct Assistance 1'OTAL $4,000 $3,000 $59,122.26

6 _ 1 Cristo Rey Community Center Statement of Activities For the Year Ended March 31, 2011 With Comparative Totals for 2010 Support and revenues Diocese of Lansing Capital Area United Way Grants and contracts Collections/members fees Client service fees Medicaid/ Medicare Contributions Fundraising Interest income Miscellaneous Donated assets Insurance gain due to fire Net assets released from restrictions Total support and revenues Expenses General Employment Program Senior Citizens Prevention Program City Diversion Child Services Health Clinic Migrant Program City Handicapper Inoculation Program Rose Bud Preschool Direct Assistance Office of Drug Control Policy Counseling Program Treatment Program Family Nurturing Program Prescription Assistance Living Free Women's Services Dislocated Workers Work First Ingham United Way Employee Assistance Michigan Nutrition Network Roots and Wings/ Anger Management Drug Free Communities Department of Corrections Home Renovation Program Total expenses Increase (decrease) in net assets Net assets at beginning of the year Net assets at the end of the year Unrestricted $ 85,829 1,134,346 14, ,117 97, ,871 37, ,237 7, ,467 2,456, , ,913 42,487 85,142 31,560 5, ,978 2,761 27,242 6, ,811 43,488 34, ,791 35,081 53,649 53, , ,216 38,828 27,603 93,518 57,504 2,737,046 (280,245) 472, ,345 Temporarily Restricted (636,467) (7,053) 2011 $ 9,286 JP 95,115! 82, ,923 82,205 1,672,269 14,334 (7,053) 27, ,117 97, ,871 37, ,237 7,000 2,449, , ,913 42,487 85,142 31,560 5, ,978 2,761 27,242 6, ,811 43,488 34, ,791 35,081 53,649 53, , ,216 38,828 27,603 93,518 57,504 2,737,046 (287,298) 499, $ 102,681 76,438 1,748,421 20, , ,943 66,257 21, ,357 I 2,484, , ,792 50, ,997 34,627 22, ,255 2,716 22,928 13,571 56,777 42,517 44, ,050 29,652 55,901 47, , ,296 12,254 40,133 19, ,610 79, ,589,960 (105,310) 604,916 19,963 $ 212,308 $ 499,606 See Accompanying Notes to the Financial Statements 4

7 CRISTO REY BOARD MEMBERS 2011/2012 Mason, Marylou, President(2/4) 611 W Ottawa, 4th Floor Lansing, Ml Bus(517) Fax(517) masonml@michigan.gov Occ: Ex. Director, Commission on Spanish Speaking Affairs CASTILLOROWAN, JUAMTA,Secretary(l/4) Small Folks Development Center 3140 S. Pennsylvania Avenue Lansing, MI Bus(517) Fax(517) smallfolks@hotmail.com Occ: Director, Small Folks Development Center BALTIMORE, TONY (1/3) 1000 W. St. Joseph Lansing, MI Bus(517) Fax(517) tony.baltimore@mail.house.gov Occ: Director of Constitutent Relations And Outreach,U.S.House of Reps. CARDENAS, JUDITH (1/4) 655 Aquilla Drive East Lansing, MI Bus(517) Res(517) Fax(517) judcard@comcast.net Occ: Contract Administrator FERRO, FRANK(2/5)*** 2913 Truman Circle Lansing, MI Bus(517) Cell(517) ferro3000@gmail.com Occ: Business Development Mgr. Michigan Economic Dev. Corp, State of MI OLIVAREZ, RICK (2/5)*** 6616 Old River Trail Lansing, MI Cell: rolivarezl21@gmail.com SHINKLE, NORMAN (1/4) 2683 Donna Drive Williamston, MI Bus(517) Res(517) Fax shinkle@cablespeed.com Occ: Attorney SPRINGER, STEVEN (1/5)** 5930 Patriots Way East Lansing, MI Bus(517) springers@mich.gov Occ: Health Specialist, Michigan Dept. Community Health THELEN, FR. FRED (1/3) 201 W. Miller Rd. Lansing, MI Bus(517) Fax(517) fredt@cristoreychurch.org Occ: Priest ROOT, CHRIS, EXOFFICIO Catholic Charities 300 W. Ottawa Lansing, MI Bus(517) Fax(517) xroot@dioceseoflansing.org Occ: Director, Catholic Charities 1. Recommended by Board/Confirmed by Bishop 2. Appointed by Bishop 3. Term expires June Term expires June Term expires June 2011 *Can be appointed for one more 3year term **Can be appointed for two more 3year terms ***Cannot be reappointed

8 INTERNAL REVENUE SERVICE P. 0. BOX 2508 CINCINNATI, OH DEPARTMENT OF THE TREASURY Date: CRISTO REY COMMUNITY CENTER 1717 N HIGH ST LANSING, MI Employer Identification Number: DLN: Contact GARY RICE Person: Contact Telephone Number. (877) Accounting Period Ending: MARCH 31 Public Charity Status: 170(b)(1)(A)(vi) Form 990 Required: YES Effective Date of Exemption MARCH 24, 2004 Contribution YES Deducibility: Advance Ruling Ending Date: MARCH 31, 2008 ID# Dear Applicant:!! "! PiSaSed touinform >ou that UP» review of your application for tax exempt status we have determined that you are exempt from Federal income tax Aeta Y01(C)(3) f ths Intemal RSVenUe C de" Contributions to yo^are f ths Ode Y U are also ^lified to receive transfsrs r SiftS Und "«ioa 2055 Io6 reaard ^^ this letter C Uld help resolve «Y questions regardmg your exempt status, you should keep it in your permanent records. Organizations exempt under section 501 (c) (3) of the Code are further classified as either public charities or private foundations. During your advance Zltnl period, you will be treated as a public chanty. Your advance ruling pesod endin3?t T ^^^ date f ^ Ur option and ends with advance Sing ending date shown in the heading of the letter. S Shortly before the end of your advance ruling period, we will send you Form he 1 TTTt SChfUl f r MVanCe RUlin9 Peri0d You wil1 ha 90 dayfster then nl f ^^ ^ ^^ ^^ to retum the ^P^ted form. We will then notify you, in writing, about your public charity status. Inforraation for E^mpt Organizations Under Section organization "1PfUl information about V^r responsibilities as an exempt Letter 1045 (DO/CG)

9 2 CRISTO REY COMMUNITY CENTER Sincerely, Lois G. Lerner Director, Exempt Organizations Rulings and Agreements Enclosures: formation for Organisations Exempt Under Section 501(c) (3) Letter 1045 (DO/CG)