PHASE 34EMERGENCY FOOD AND SHELTER PROGRAM

LOCAL AGENCY APPLICATION

APPLICATION & REQUEST FOR FUNDS

Please choose application status: New recipient Current Recipient Former Recipient

Agency Name: ______

Executive Director: ______

Address Physical & Mailing: ______

City, State, Zip Code: ______

Preferred Contact Person: ______

NOTE: This individual should be available to answer questions regarding the EFSP proposal.

Telephone: FAX: _ E-Mail:

Federal ID:DUNS #: _ Web-Site:

Please provide your Phase 34 EFSP request broken down in the following categories. Use the unit of service definitions included in this packet:

CATEGORY / $$ REQUEST / ESTIMATED
UNITS OF
SERVICE / UNIT
COST / OTHER FUNDING SOURCES / AGENCY TOTAL
BUDGET FOR
EACH CATEGORY
  1. Served Meals per diem $2.00

  1. Other Food

  1. Mass Shelter per diem $12.50

  1. Other Shelter

  1. Rent/Mortgages

  1. Utility Payments

Total Request
(add A through F)

Please answer the following questions: How much EFSP funding did you receive in Phase 33 _

How many people were served by this program in Phase 33?What were the total costs for this program in Phase 33

?

Please return to:

Delisa Deavenport

United Way of Grayson County

713 E Brockett, Sherman, Texas

P O Box 1112, Sherman, TX 75091-1112

(903) 893-1920 Ext. 4

NO LATE PROPOSALS OR INCOMPLETE SUBMISSIONS WILL NOT BE REVIEWED.

Submit 10 copies of the application and 1 copy of additional documents.

DEADLINE: July 21, 20175:00p.m. (Applications must be received at the above address by this deadline).

PHASE 33 EMERGENCY FOOD AND SHELTER PROGRAM

APPLICATION

In this section, please summarize your program request. You may include additional page if needed. Incomplete submissions will not be reviewed.

PLEASE PROVIDE A CURRENT & COMPLETE LIST OF YOUR ORGANIZATION’S BOARD MEMBERS

Is agency nonprofit or unit of government? _

Is agency debarred or suspended from receiving funds or doing business with the federal government?

  1. WHAT IS YOUR PROGRAM MISSION AND WHO WILL YOU SERVE? Describe the program and target population this program is designed to serve. Please state demographics of clients and geographic area(s) to be served.
  1. WHAT IS THE CLIENT ELIGIBILITY CRITERIA FOR YOUR EFSP FUNDING? Briefly describe the criteria or the process you use to determine eligibility for individuals who apply for benefits using these funds. If feasible, attached a sample of the application form you use to determine eligibility.
  1. WHERE WILL SERVICES BE DELIVERED? List all sites from which your agency plans to provide services to clients seeking funds from the Emergency Food & Shelter Program. Include the day(s) and time(s) clients may access services at these locations.
  1. WHAT SERVICES WILL YOU PROVIDE? Provide a brief narrative of the services you are offering. Describe the services in relation to the funding category listed on the Application cover page. If you will provide shelter services, please indicate specifically how you will ensure the safety and quality of the living environment and how you will ensure that the cost is reasonable.
  1. WHO IS GOING TO DO IT? Provide a brief narrative of your organization’s administrative structure and proposed staffing plan for this program.
  1. HOW WILL YOUR AGENCY PROVIDE CASE MANAGEMENT? Briefly describe case management activities you will coordinate with your clients? How do you coordinate with other case managers regarding the same client and duplication of services with other EFSP funded agencies?
  1. HOW LONG HAS YOUR AGENCY BEEN IN EXISTENCE? How long have you been providing emergency support services? If you have a shelter facility, how long has the facility been operational?
  1. WHAT IS YOUR TOTAL AGENCY BUDGET? Please attach a copy of your current operating budget, including revenue and expenses.
  1. IF YOU ARE REQUESTING $25,000 OR MORE, YOU MUST SUBMIT YOUR MOST CURRENT AUDIT. If you arerequesting under $25,000, please provide an audit, if available, or your most current financial statement. Please attach.

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