Nc esg application Form: Project Application


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NC ESG Application Form: Project Application

2016-2017 (Funding for January 1, 2017 – December 31, 2017)

For submission information, refer to the NC ESG Application Information Packet, Section IV: Application Submission Information. This application must be delivered or postmarked by Friday, October 21, 2016.



If applying for:

  • Rapid Re-housing answer questions 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 38, 39, 40, 41, 42, 43, 44 and 45




  • Targeted Prevention answer questions 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 23, 24, 25, 26, 27, 28, 38, 39, 40, 41, 42, 43, 44 and 45




  • Emergency Shelter answer questions 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 29, 30, 31, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44 and 45




  • Street Outreach answer questions 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 29, 30, 31, 32, 33, 38, 39, 40, 41, 42, 43, 44 and 45




  • HMIS answer questions 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 41, 44 and 45


Section One: Project Application Summary


1. Applicant Information

Applicant Organization Name:

     


Counties Served by Applicant Organization:

     


Street Address:

     


Applicant Contact Person:

     


City, State, Zip:

     


Contact Person Title:

     

Mailing Address:

     


Contact Person E-mail:

     


City, State, Zip:

     

Contact Person Telephone:

     


Telephone:

     


Fax:

     

Website:

     

The applicant’s fiscal year is (mm/yy)       to      

Federal Tax ID:

     


DUNS #:

     


2. Signatory Authority-who is authorized to sign contracts for your organization?

Name:

     

Title:

     


Telephone:

     

E-mail:

     


3. Contract Administrator-who is the point person for the contract?

Name:

     


Title:

     

Telephone:

     

E-mail:

     


4. If awarded funds, who do you want to receive emails?

For contract issues? If needed, add additional names and emails on a separate piece of paper, placed behind this one.

Name(s):

     

Email(s):

     

For program implementation information? If needed, add additional names and emails on a separate piece of paper, placed behind this one.

Name(s):

     

Email(s):

     




5. Activity Information

Type of Project (check all that apply) REFER TO CoC POLICIES:

Funds Requested

Estimated # of Households to be Served

Emergency Response Activities: Note: A maximum of 60% may be allocated for ER.







 Street Outreach

$     

     

 Emergency Shelter

$     

     

 HMIS

$     

     

Housing Stabilization Activities: Note: A minimum of 40% must be allocated for HS







 Rapid Re-Housing

$     

     

Targeted Prevention

$     

     

 HMIS

$     

     

Total

$     

     

Counties served by this application:

     

5a. Did the applicant agency receive NC ESG funding during the 2015-2016 Program Year?

 Yes  No

5b. If yes, as of October 1, 2016, what percentage of funds have been submitted for reimbursement to NC ESG Program?

 80% - 100%

 70% - 79%

 51% - 69%

 0 - 50%


6. Please complete the following information about the Applicant Organization.

6a. Check which of the following apply:

 Non-profit or  Local Government


6b. If a nonprofit, how long has your organization had its 501(c) 3 status?

 Does not have a 501(c)3 status

 1-5 years

 6-10 years

 More than 10 years

6c. Check the item that best describes your agency:

 Homeless Services Provider

 Community Action Agency

 Division of Social Services

 Housing Authority

 City (division:       )

 County (division:       )

 United Way

 Local Management Entity

 Council of Government

 Community Development Corporation

 Veteran Services

 Veteran Medical Center

 Domestic Violence Agency

 Other      


6d. Is your organization licensed by the Dept. of Health and Human Services?

 Yes  No


6e. If yes, is your organization’s goal to follow a "Housing First" approach that prioritizes providing people experiencing homelessness with permanent housing as quickly as possible - and then providing voluntary supportive services as needed.

 Yes  No


7. ESG funds require a 100% match (dollar for dollar). The match can be provided through in-kind services or cash. If your organization is using cash, the match must come from a non-ESG source and must be used for eligible ESG activities. Funds used for ESG match cannot be used as a match for other types of funds. Please indicate the source of your organization’s match below.

 Cash Source:      

 In-kind services Source:      

 Combination Source:      

 Match to be provided by the regional committee, not the agency

Note: Organizations can change source(s), if needed, at a later date.


Section Two: Organizational Capacity


8a. Staffing

Overall Organization

ESG Program

Total FTEs:      

Total FTEs:      

Number of Paid Staff:      

Number of Paid Staff:      

Number of volunteers filling a position that would otherwise be paid staff:      

Number of volunteers filling a position that would otherwise be paid staff:      

8b. Program Positions

Position (sample job descriptions for the following positions are below)

Filled with Paid Staff

Filled with Volunteer Staff

Unfilled

Position Doesn’t Exist

Executive Director









Intake Worker









Case Manager(s)









HMIS/Data Entry









Fiscal Officer/Bookkeeper









Shelter Director/Manager (shelters only)









Executive Director (nonprofits) or project manager (local governments): Staff responsibility for the organization. Position reports to the Board of Directors (non-profits) or department/division supervisor (local governments).

Intake Worker: Staff responsible for meeting with households that are applying for ESG eligible services, completing eligibility documentation

Case Manager(s): Staff responsible for connecting households to services needed, working with ESG eligible households to create and implement housing plans

HMIS/Data Entry: Staff responsible for entering data into NC HMIS or if a DV shelter, a comparable data system

Fiscal Officer/Bookkeeper: Staff responsible for financial transactions and recordkeeping for ESG eligible activities

Shelter Director/Manager (shelters only): Staff responsible for operating and managing a homeless shelter serving ESG household and implementing ESG eligible activities.



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