FY 2018 & FY 2019CITY GENERAL FUND & FEDERAL FUNDS (CDBG, HOME, ESG, &

HOPWA) REQUEST FOR FUNDING CHECKLIST

Check Box Below:

City General Fund (CGF) CDBG HOME ESG HOPWA

City General Fund Applicants: Complete pages (1-11)

Federal Fund Applicants: Complete Pages (1-15) Federal Fund Applications are for FY 2018 only.

Project Name:      

Applicant (Organization) Name:      

Request for Funding Package: (Submit 3 hardcopies/ 2 USB Flash Drives)

Application (Pages 1-11)Activity Budget Sheet (Pages 12-15) Federal Funds Only

Overall Budget Sheet

Attachments: (Provide if applicable, list on Attachment List pg. 7) Submit attachments on USB Flash Drive Federal Tax Exempt Certification

Latest IRS 990 Report

Previous Fiscal Year Audit/Financial Statements

Current Year Operating Budget (mandatory for CGF Applicants)

By-Laws

Articles of Incorporation

Organizational Chart

1

Business Strategic Plan (mandatory for CGF Applicants)

List of Board of Directors, Members, and Executive Officers

List of Full- and Part- time Employees to Work on Project

Employee Resumes Partnership Agreements with other agencies

Site Control, Building or Zoning Documentation

Corporation Commission Certification

SAM Registration (Federal Funds Applicants)

Council Adopted Plan

Personnel Manual

Policy/Procedures Manual

Other (Specify)     FY 2018 & FY 2019

CITY GENERAL FUND & FEDERAL FUNDS (CDBG, HOME, ESG, HOPWA) REQUEST FOR FUNDING APPLICATION

Instructions: This form must be fully completed by all organizations and agencies applying for funds. PLEASE NOTE: You must complete a separate application form for each project.

1. Funds Requested: City General Fund CDBG HOME ESG HOPWA

2. Organization Information:

Organization Name:     

DUNS Number:      

Federal Tax ID:      

Project Name:      

Project Contact Person:      

Mailing Address:      

Phone:       Facsimile:       Email:      

Board Chairperson:       Signature:      

2

Is your organization incorporated? (include applicable attachments) Yes No

Is your organization: (include applicable attachments) A government entity Yes No A non-profit with approved Federal tax exempt certification?

Yes No A for-profit business Yes No

Total operating budget for the organization, including income/revenues for all sources.      

(Attach a copy of your current year’s operating budget)

3. Location of Project:

A. Is the project City-wide or does it serve a specific project area? City-wide Specific Project area

B. Name and Geographic Boundaries of Project Area (Include street names):      

C. Census Tract(s):       Council District(s):       NiB Area:      4. Description of Project: Provide a concise description of the proposed project and the clients to be served, to include how additional services will be provided as a result of this funding or if an existing service will be discontinued without funding. For construction projects provide a detailed timeline from acquisition to completion including occupancy.

     

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5. Community Impact: Briefly describe the neighborhood to be served, highlighting such items as: population to be served, housing conditions, median household income, neighborhood strengths/weaknesses and describe how the project will positively impact the community.

     

6. Description of Organization and Overall Capacity:

A. Briefly describe organization’s background and mission.

     

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B. Briefly highlight the organization’s significant achievements, including the capacity to complete current projects and development activities.

     

C. Attach a list of all full- and part- time employees, resumes, and percentage of time that will be spent on the project.

D. Attach a list of current board members including address, occupation and role on board.

E. Describe your organizational structure, record keeping and financial/audit system, policies and procedures, and program evaluation results. (attach most recent audit report and/or financial statements, and organizational chart)

     

F. Provide a brief description of any financial default or involvement in legal actions during the last 3 years. This would include lawsuits, tax delinquency, bankruptcy, client

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complaints, and violations of building, zoning, and environmental codes.

     

7. Consistency with Seven Focus Areas and Consolidated Plan (see Attachments A & C)

A. Describe how the project meets the priorities listed in Attachment B, Attachment B-1

(Human Service Projects) or Attachment B-2 (Economic & Community Development Project).

     

B. How is you project consistent with the City’s Consolidated Plan? – Attachment C (applies to Federal

Funds projects and Economic & Community Development CGF projects)

     

C. Describe how your project contributes to crime prevention. (applies to Federal Fund projects only)

     

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D. Detail which activity category applies to your proposal. Each activity category mustinclude all staff time and other costs that are necessary to support

that activity. (applies to Federal Fund projects only) – See Attachment F

     

8. Evidence of Neighborhood/Partnership Support: Describe the neighborhood/partnership support for the proposal, including NiB Partnership, civic association, City department support, and groups that will assist in the implementation or be directly affected by the project. (attach written partnership agreements)

     

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9. Sustainable/Green Practices: Describe any sustainable or “green” aspects or design elements that will be incorporated as part of the implementation of the proposed project.

     

10. Evidence of Site Control: If the project involves the development of a public facility, organizational offices or housing (attach plans and documentation of site control) If you have an existing facility, provide documentation that the facility is in compliance with building and zoning codes for the services provided.

     

11. Marketing Strategy: Briefly describe your strategies and methods for marketing your program and the target population of your efforts.

     

12. Section 3 Residents or Section 3 Businesses: Detail if your organization or business will target Section 3 residents or if your business is a Section 3 business. (Federal Fund Applicants only – see page 3 of Application Guidelines)

     

13. Funds Received Previously for this Project by Year of Allocation:

Previous Current Request Request 8

2016 2017 for2018

for2019

CITY GENERAL FUND: $      $      $      $     

CITY CAPITAL BUDGET: $      $      $      $     

CDBG: $      $      $      N/A

HOME: $      $      $      N/A

ESG: $      $      $      N/A

HOPWA: $      $      $      N/A

14. Accomplishments in the Current Fiscal YearDescribe project progress in the current fiscal year. Emphasize measurable outcomes and project benefit to the community.

Fiscal Year 2017Objectives

Fiscal Year 2017Accomplishments to

Date

# of Units

# of Client

s

# of Othe

r                                                                                                                                                                                                           

Proposed Objectives and Outcomes:

Fiscal Year 2018Objectives

Fiscal Year 2018Outcomes

# of Unit

s

# of Clients

# of Other

                                                                                                                                                                                                           

Fiscal Year 2019ObjectivesObjectives

Fiscal Year 2019Outcomes

# of Unit

s

# of Clients

# of Other

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15. Project MatchList all sources of funds you will receive for Fiscal Year 2018 and 2019 for this project. (Denote all funds you anticipate receiving with an asterisk [*]).(Denote all funds you anticipate receiving with an asterisk [*]).

Program Year

Dollar

Source of Funds Status Dates Amount

1.                   $     

2.                   $     

3.                   $     

4.                   $     

5.                   $     

6.                   $     

7.                   $     

8.                   $     

9.                   $     

10.                   $     

2018 Matching Total: $     

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1.                   $     

2.                   $     

3.                   $     

4.                   $     

5.                   $     

6.                   $     

7.                   $     

8.                   $     

9.                   $     

10.                   $     

2019 Matching Total: $     

Grand Total of Matching Funds: $     

16. Project Budget (Federal Funds)List all project expenses and sources of funds you will receive for the proposed Housing and Economic Development Budget. Please complete for all construction, economic development and job training activities. Not applicable for supportive services, administrative activities or owner occupied rehabs.

List of Expenses Cost of Expenses

Source of Funds Funding Amount

Amount Committed Y/N

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $

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$ $

$ $

$ $

$ $

$ $

Total Expenses: $ Total Funding: $

Partnership Agreements (formal agreements with other agencies, including City departments, to implement the proposal).

Contact Person

Telephone OrganizationOrganization FAXFAX AddressAddress DateDate

                                   

                                   

                                   

                                   

                                   

                                   

                                   

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Attachment List

Instructions: All attachments for the Requests for Funding form must be listed below. If attachments are not available at the time of submission, an asterisk (*) should be placed next to these items to indicate that they are anticipated, and the date that they are anticipated should be included.

b. Other Documents (please refer to the Attachments List on the cover page of the application)

Name

     

     

     

     

13

     

     

     

     

     

     

FY2018 – FY2019FEDERAL FUNDS ONLY (CDBG, HOME, ESG, & HOPWA)

ACTIVITY BUDGET SHEET

Instructions: DO NOT complete this form until you have read the guidelines that define the eligible activities. (See Attachment F). In the first column, check the funding activities requested and then show all eligible costs for each activity.

CDBG Eligible ActivitiesCDBG Eligible ActivitiesCurrent Funds

Allocation

Requested Funds

# of Units (where applicable) Fiscal Year 2017

Fiscal Year 2018

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1 Acquisition of Real Property $      $     

2 Disposition $      $     

3 Public Facilities & Improvements

$      $     

4 Clearance & Demolition $      $     

5 Public Services $      $     

6 Interim Assistance $      $     

7 Urban Renewal Completion $      $     

8 Relocation $      $     

9 Loss of Rental Income Replacement

$      $     

10 Removal of Architectural Barriers

$      $     

11 Privately Owned Utility Development

$      $     

12 Construction of Housing $      $     

13 Direct Homeownership Assistance

$      $     

14 Micro Enterprise Assistance $      $     

15 Rehabilitation $      $     

16 Lead-Based Paint Hazard Evaluation/Reduction

$      $     

17 Code Enforcement $      $     

18 Historic Preservation $      $     

19 Commercial/Industrial Improvement by Nonprofit

$      $     

20 Economic Development Services

$      $     

21 Direct Economic Development Assistance toPrivate For-Profit Entities

$      $     

22 CBDO Activities for Otherwise Ineligible Activities

$      $     

23 Planning $      $     

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24 Program Administration (For City Administration Projects Only)

$      $     

TOTAL CDBG FUNDING $      $     

HOME Eligible ActivitiesCurrent Funds

Allocation

Requested Funds

# of Units (where applicable) Fiscal Year 2017

Fiscal Year 2018

1 Acquisition of Real Property $      $     

2 Rehabilitation $      $     

3 Homeownership Assistance $      $     

4 New Construction $      $     

5 Program Administration (For City Administration Projects Only)

$      $     

6 CHDO Capacity Building $      $     

7 CHDO Loan Funds $      $     

TOTAL HOME FUNDING $      $     

ESG Eligible Activities

16

Current Funds

Allocation

Requested Funds

# of Units (where applicable) Fiscal Year 2017

Fiscal Year 2018

1 Street Outreach Component $      $     

2 Emergency Shelter Component $      $     

3 Homelessness Prevention Component

$      $     

4 Rapid Re-Housing Component $      $     

5 Homeless Management Information System (HMIS) Component

$      $     

6 Administrative Costs $      $     

TOTAL ESG FUNDING $      $     

17

HOPWA Eligible ActivitiesHOPWA Eligible ActivitiesCurrent Funds

Allocation

Requested Funds

# of Units (where applicable) Fiscal Year 2017

Fiscal Year 2018

1 Housing Information and Counseling

$      $     

2 Resource Identification and Development

$      $     

3 Acquisition, Rehab, Conversion & Repair of Facilities

$      $     

4 Lease of Facilities $      $     

5 New Construction $      $     

6 Project or Tenant-Based Rental Assistance (Long-Term)

$      $     

7 Short-Term Rent, Mortgage and Utility Payments

$      $     

8 Supportive Services $      $     

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9 Operating Costs for Housing Facilities

$      $     

10 Technical Assistance $      $     

11 Administrative Expenses (Grantee and Project Sponsor)

$      $     

TOTAL HOPWA FUNDING $      $     

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