2016 community development block grant program application part I: Application Summary


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Name2016 community development block grant program application part I: Application Summary
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OFFICE USE ONLY:
DATE REC’D _______
APPL #:______

CITY OF GRAND FORKS

2016

COMMUNITY DEVELOPMENT BLOCK GRANT

PROGRAM APPLICATION




Part I: Application Summary



ORGANIZATION NAME: ________________________

MAILING ADDRESS: _________________________

CONTACT PERSON & TITLE: _________________________

EMPLOYMENT IDENTIFICATION NUMBER (EIN):      

DUNS NUMBER:       CCR REGISTRATION NUMBER:      

(The Office of Management and Budget is requiring all recipients of Federal funds to register on the Central Contractor Registry (CCR) and have a Data Universal Number System (DUNS) number. Please see the attached instructions on how to obtain both numbers.)

PHONE NUMBER: _________________________

E-MAIL ADDRESS: _________________________
FUNDING TYPE: Select only one  Public Service  Bricks & Mortar

Agencies requesting both types of funds must submit separate applications
PROJECT TITLE: ________________________________________
BRIEF DESCRIPTION: ________________________________________

FUNDING REQUEST (NOTE: These totals will be brought forward automatically from Project Budget)
AMOUNT YOU ARE REQUESTING:      

FUNDS FROM OTHER SOURCES:      

TOTAL PROJECT/ACTIVITY COST:      

To the best of my knowledge and belief, the data contained herein is true, correct and complete, and this application has been duly authorized by this agency’s governing board.
________________________________________ ____________________________

Name Title
_________________________________________ _____________

Signature Date

Part II. Project/Activity Eligibility





Projects and programs must assist low-to-moderate income people and address one of the following Priority Community Needs (check all that apply):



Housing



Special Needs Populations



Health Care



Emergency Assistance




In addition, preference may be added for (check all that apply):



“Legacy” projects/programs



Collaborative programs/projects



Programs that address transportation needs



Programs that promote economic independence and self sufficiency



Programs that affirmatively further fair housing choice



Select one HUD Objective

Select one HUD Outcome

 Suitable Living Environment

Activity benefits communities, families, or individuals by addressing issues in their living environment.



 Availability/Accessibility
Activity makes services, infrastructure, or shelter available and accessible. Note: Accessibility does not refer only to physical barriers.


 Decent Affordable Housing

Housing activity that meets individual or community needs. This objective should not be used for activities where housing is an element of a larger effort.

 Affordability

Activity provides affordability in a variety of ways including: creation/maintenance of affordable housing, infrastructure hookups, or services such as transportation/daycare.


 Creating Economic Opportunity

Activity relates to economic development, commercial revitalization, and job creation.


 Sustainability

Activity provides livable/viable communities/ neighborhoods by providing services or by removing slums/blight.



Part III. Project/Activity Information




A. DESCRIPTION:


  1. Provide a detailed description of the project/program that includes

  • location of the project

  • the Priority Community Need(s) it will address

  • project timetable (preparation of plans and specs, bid, award, project start date, construction schedule, and final completion)


__________________________________________________
2. Benefit low/moderate income people:


  1. How many LMI people do you anticipate helping in the next calendar year?

__________________________________________________


  1. Describe the process you use to determine if people are low/moderate income. Attach sample forms.

__________________________________________________


  1. Describe your method of tracking numbers of people served.

__________________________________________________

3. Explain why CDBG funds are appropriate for this activity:      


  1. Describe efforts to obtain other funding.

__________________________________________________


  1. Explain how the project will be continued or maintained in the future, including funding sources operations.

__________________________________________________


  1. Describe the effect of partial or no CDBG funding on the activity:

__________________________________________________


  1. d. Describe the unmet need this activity will address:      

__________________________________________________
4. Describe your security measures to ensure that client applications or other documents containing beneficiary’s personal information (i.e. birthdates, Social Security numbers, financial information, etc.) will be kept confidential and in a secure location. __________________________________________________


Does your agency include a confidentiality clause in applications, program descriptions, and/or other documents to assure beneficiaries that any personal information will be kept safe and secure?      

__________________________________________________

B. BUDGET:


Please check ONE of the following:



Public Service - New Program/Project



Bricks & Mortar - One-Time Funding Request



Public Service – Expanded Existing Program/Project



Bricks & Mortar - Part of Capital Improvements Plan







CDBG

Funds

Other

Funds

Source(s) of Other Funds

(e.g., fundraising, capital reserves, loan, grant)

Type

(Mark with X)

Status

(Mark with X)

P = Pending

C = Committed

USES:




In-Kind

Cash

P

C

Salaries & Wages

0.00

0.00

     









Benefits

0.00

0.00

     









Facility costs (rent, utilities, insurance)

0.00

0.00

     













Professional fees (audit, legal, memberships)

0.00

0.00

     













Operations (office sup-plies, printing, postage)

0.00

0.00

     









Acquisition of property

0.00

0.00

     









Appraisal, title insur-ance, filing fees, etc.

0.00

0.00

     









Rehab of existing facility (labor & materials)

0.00

0.00

     









New construction (labor & materials)

0.00

0.00

     









A/E fees, permits

0.00

0.00

     









Other (Specify)

__________

0.00

0.00

     









TOTAL

$ 0.00

$ 0.00

















C. ANTICIPATED OUTPUTS/OUTCOMES WORKSHEET

PROGRAM/PROJECT DESCRIPTION

ANTICIPATED OUTPUTS


(What you hope to accomplish; to include number of persons served, units rehabbed, etc.)

ANTICIPATED OUTCOMES


(What long-term measurable community benefits will be achieved by this project.)

___________________________________

___________________________________

___________________________________



Part IV. Required Attachments and Checklist



 Application forms, including

 Part I: Application Summary

 Part II: Project/Activity Eligibility

 Part III: Project/Activity Information (Budget and Anticipated Outputs/Outcomes

Worksheet)

 Copy of most recent audit or current financial statement

 List and structure of current governing board

 Proof of non-profit status
List the regulating agencies your organization is monitored by and provide the date and results of most recent site visits/reviews (e.g., Public Health, Fire Department, etc.):

     


Please provide the following information on past CDBG or HOME-funded activities

Year

Final grant amount

Amount submitted for reimbursement

Project completed?

Y/N

2014

$     

$     

     

2015

$     

$     

     



Additional Comments:

     

U. S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
CCR & DUNS INSTRUCTIONS
Data Universal Number System (DUNS) number is required as part of the CCR registration process.
The DUNS number is a unique nine-character identification number provided by the commercial company Dun & Bradstreet.
The process to request a DUNS number takes about 10 minutes and is FREE of charge.
Call Dun & Bradstreet at 866-705-5711 or TTY number 866-814-7818 for persons with a hearing impairment.

You may register for a Central Contractor Registration identification (CCR) online at the System for Award Management website (www.sam.gov). If you encounter a problem accessing sam.gov via Internet Explorer, you can try another browser such as Google Chrome (google.com/chrome). To make the process easier, HUD suggests that you download CCR’s Registration Worksheet and complete it prior to registering.

To register, go to the sam.gov home page and clicking on “Create User Account”. Then click “Create an Account” under “Individual Account Details”. Once you have completed filling out the form on paper form, go back to the same location, fill in the information, and send.
It is important to note that the entire process, including the steps that need to be taken by the CCR, takes about 5 to 10 days.
CCR numbers must be maintained annually.
To verify that you are registered with sam.gov, go to the home page and click on “Search Records”. Type in your business name (must be exact), DUNS number & CAGE number. If you have had a CCR number for awhile, it's strongly recommended that you search sam.gov to make sure you were switched over from the old CCR system. If your organization does not appear, you will need to complete the registration process.

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