Form B

City of Charlotte

FundingRequest Application-Emergency Solution Grant (ESG)

FY2019 (July 1, 2018 -June 30, 2019)

Agency:
Address:
Director:
Agency Contact:
Phone Number: / Email:
Total Funding requested from City for upcoming fiscal year / $

Funding Priorities

The City of Charlotte will award funds to activities consistent with the following funding priorities.

1)Rapid Re-Housing - Financial Assistance

2)Emergency Shelter – Operating Costs

3)Emergency Shelter – Shelter Services

4)Prevention Services

5)Homeless Management Information System (HMIS)

6)Street Outreach

7)Rapid Re-Housing –Case Management & Services

More information about these activities can be found at

Program minimum requirements

  • Programs referral must be received through Coordinated Entry Process.

(Note: New and/or updated Coordinated Entry priorities for this funding cycle will be approved by the Continuum of Care committee).

  • Agencies must enter HUD required data elements into the Homeless Management Information Network (HMIS) identified by the CoC. (Domestic Violence Agencies must use a comparable data base).
  • A representative from the funded activity within your agency is required to attend a minimum of 50% of Continuum of Care Committee meetings. Currently meetings are held the second Tuesday in the months of January, March, May, July, September, November from 2:00pm-3:30pm at Hope Haven, 3815 N. Tryon Street, Charlotte, NC.(Note: Notification of meeting changes will be made via the CoC email distribution list)
  • Agencies must ensure that monthly invoices are submitted per requirementsoutlined in contract.

1.0 Agency and Program Information

Provide description of your agency. If requesting City-funding for a specific program within your agency, also provide the name and description of the specifiedprogram along with your agency’s description:

1.1 Agency and Program Description(Please provide a description of agency’s experience in working with Emergency Response or Housing Stabilization and the target population in which you will serve):
1.2 Agency Mission Statement:
1.3 Agency Vision Statement:
1.4 Describe the benefits or results of agency or programservices (Please describe how services adequately and appropriately meet anticipated service needs):
1.5 For Emergency Response applicants only: Does the agency have a relationship with a Rapid Re-Housing program?
1.6 For Housing Stabilization applicants only: Are there agreements for linkages with mainstream resources?

2.0 AgencyFinancial Contract Compliance

2.1 FY2017 (July 2016 – June 2017) ESG Expenditures (if applicable):
1) If you were unable to use all allocated funding provide an explanation and any strategies
used to utilize funding.
(Note: If awarded funds in this FY2019 application, any FY2017 unspent funds will be required to be spent no later than December 31, 2018 and may be deducted from overall award.)
2.2FY2018(July 2017 – June 2018) ESG Expenditures (if applicable):
1) If you were unable to use all allocated funding provide an explanation and any strategies used to utilize funding.
2) If awarded funds in FY2019 what additional strategies will you utilize to ensure that funds are used in their entirety?
(Note: If awarded funds in the FY2019 application, any FY2018 unspent funds may be deducted from overall award).
2.3Contract Compliance: Describe theprocess for ensuring all agency staff understandand will meet ESG contract requirements around required reporting and submitting invoices.

3.0 Connection to the Community

3.1 How does your agency participate in the COC’s Coordinated Entry System?
3.2Does your agency participate in the COC’s meetings and workgroups?
3.3How does your agency collaborate with other entities in the community?

4.0 Proposed Project Budget

If requesting City-funds for a specific program within your agency, provide from total operation the expense and revenue budget information for the specified program including all funding sources. For purposes of this application, the budget information provided should coincide with the City’s fiscal year FY2019, July 1, 2018 through June 30, 2019.

4.1 Projected Expenses

Personnel Expenses / Projected Budget / Budget Request from City
Salaries
Merit
Benefits

Total Personnel Expenses

Operating Expenses / Projected Budget / Budget Request from City
Communications (e.g. publishing, marketing)
Travel & Training
Facilities (e.g. rent, utilities)
Technology
Other

Total Operating Expenses

Total Expenses(Personnel & Operating)

4.2 Projected Revenues

Please include all revenues, excluding revenues received from the City of Charlotte and Mecklenburg County, specifically to this project, in the fields below.

Revenues / Projected Budget
Government Grants & Funding
Foundation Grants & Funding
Donor Contributions
Service Fees
Other Revenue
Total Revenues

4.3 Mecklenburg County Funds Requested

If applicable, indicate the amount of total funds requestedfrom Mecklenburg County, specifically to this project, in the fields below.

Fiscal Year / Total Funds
FY2019 (as requesting)

5.0 Budget Worksheet

Activity / Total Amount Requested / Number of Households to be Served / Cost per Household
Example: Emergency Shelter- Operating Cost / $10,000 / 100 / $1000
Emergency Shelter (Operating Cost)
Emergency Shelter (Shelter Services)
Rapid Re-Housing (Financial Assistance)
Rapid Re-Housing (Case Management & Services)
Prevention Services
Street Outreach
Homeless Management Information System (HMIS)

6.0 Agency and Program Capacity and Stability

6.1 Share the strategies to sustain your agency or program. Indicate plans for obtaining funds outside of City-funding.
6.2 If City-funding is denied; describe the impact on agency or program.
6.3 If your agency received City-funding for the current fiscal year and is requesting a change in the City-funding level for the upcoming fiscal year, provide the reason(s) for requesting a change in the City’s funding level:
6.4 For Prevention and Rapid Re-housing Only: Please describe in detail how inspections for properties will be handled.

All Application packages submitted must include:

  • FormA: Funding Cover Sheet
  • Form B: Funding Request Application

Additionally, please attach the following documents (noting Attachment Number in top right corner):

  • Attachment 1: Financial Audit (most current)
  • Attachment 2: Current Year operating budget (Include Revenues and Expenditures)
  • Attachment 3: E-Verify Certification
  • Attachment 4: Data Quality/Completeness Report for March 2018 (if currently using HMIS)
  • Attachment 5: Data Entry Process Flow Chart

Applications must be submitted via email to Rebecca Pfeiffer at no later than Wednesday, May 16, 2018, 10:00a.m.

E-Verify Certification

This E-Verify Certification is provided to the City of Charlotte (the “City”) by the company signing below (“Company”) as a prerequisite to the City considering Company for award of a City contract (the “Contract”).

1. Company understands that:

a. E-Verify is the federal program operated by the United States Department of Homeland Security and

other federal agencies to enable employers to verify the work authorization of employees pursuant to

federal law, as modified from time to time.

b. Article 2 of Chapter 64 of the North Carolina General Statutes requires employers that transact business

in this state and employ 25 or more employees in this state to: (i) verify the work authorization of

employees who will be performing work in North Carolina through E-Verify; and (ii) maintain records of

such verification (the “E-Verify Requirements”).

c. North Carolina General Statute 160A-20.1(b) prohibits the City from entering into contracts unless the

contractor and all subcontractors comply with the E-Verify Requirements.

2. As a condition of being considered for the Contract, Company certifies that:

a. If Company has 25 or more employees working in North Carolina (whether now or at any time during

the term of the Contract), Company will comply with the E-Verify Requirements in verifying the work

authorization of Company employees working in North Carolina; and

b. Regardless of how many employees Company has working in North Carolina, Company will take

appropriate steps to ensure that each subcontractor performing work on the Contract that has 25 or

more employees working in North Carolina will comply with the E-Verify Requirements.

3. Company acknowledges that the City will be relying on this Certification in entering into the Contract, and that

the City may incur expenses and damages if the City enters into the Contract with Company and Company or

any subcontractor fails to comply with the E-Verify Requirements. Company agrees to indemnify and save the

City harmless form and against al losses, damages, costs, expenses (including reasonable attorney’s fees)

obligations, duties, fines and penalties (collectively “Losses”) arising directly or indirectly from violation of the

E-Verify Requirements by Company or any of its subcontractors, including without limitation any Losses

incurred as a result of the Contract being deemed void.

______

Signature of Company’s Authorized RepresentativeDate

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Print Name & Title

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