Section I - Agency Information

Organization/Agency Name: / Employer Federal I.D. Number:
Website: / Faith Based Organization?
Yes No
Mailing Address: / City: / State: / Zip:
Telephone: / Fax: / DUNS: / CCR:
Which program are you applying to: / HOME CDBG PBV’S
Are you a non-profit organization? / YES NO
Has this program received HOME funding or a commitment of it in the past? / YES NO
Executive Director / Project Administrator / Finance Officer
Name:
Title:
Address:
Phone:
Fax:
E-Mail:

Section II - Project Information

Name of Project:
Location of Project: / Census Tract(s):

Section III - Project Funding Sources(also complete included financial worksheet)

REQUESTED THIS APPLICATION / $
OTHER FEDERAL / $
OTHER CITY FUNDS / $
STATE FUNDS / $
PRIVATE FUNDS / $
OTHER – LIHTC Equity, etc. / $
TOTAL / $

Section V –Completion Checklist

Each applicant must indicate if they possess the items indicated below.
They will be required to be submitted to DHNP if their project is funded.
YES / NO / On File / N/A
  1. Application Completed & Signed Certification

  1. Articles of Incorporation and Bylaws

  1. State and Federal Tax Exemption Determination Letters

  1. Federal Employment Identification Numbers

  1. List of Board of Directors, their Titles and Contact Information

  1. Board of Director’s Designation of Authorized Official

  1. Most Recent Organization Chart

  1. Job Description of Each CDBG/HOME Program Salaried Position

  1. Financial Statement and Most Recent Audit Report

  1. Matching Funds Commitments Documentation

  1. List of Collaborative Partners and their role

  1. 504 Self Evaluation Plan (Americans with Disabilities Act) Agencies with 15 Employees or More

  1. Project Implementation Timeline & Additional Outcome Objectives

  1. Are your DUNS and CCR numbers on file?

Section VI - Agency Narrative & Project Description

  1. Provide Project Information and Analysis in the chart below:

Item / Amount / Explanation
Amount of DHNP funds requested
Total housing units to be created or rehabilitated
Number of units to receive HOME funds
Total 1 BR units
Total 2 BR units
Total 3 BR units
Total 4 BR units
# of Units to be affordable at
60 % or below of AMI
61-80% of AMI
81-100% of AMI
101-120% of AMI
# of households by type to be served:
Seniors (state minimum age)
Veterans
Homeless
Disabled
Other/multiple categories (describe)
Total Project Cost
Total project cost/unit
Building cost only (exclude site, predevelopment, developer fee, etc)
Building cost/unit
DHNP proposed cost/unit
DHNP cost/unit as a % of total cost/unit
Debt coverage ratio if applicable
Proposed total debt/unit
Proposed total developer fee, if any
List other public or subsidized funding and amounts
List any funding from foundations and amounts
  1. Describe how the provision of the requested HOME funds for your project will create, preserve orenhance the affordability level of the units and/or the quality of the units.

  1. Describe the effect of non-provision of requested funding on the project. Will the project go forward, if not, why not, how will the project be affected?

  1. Describe the organization’s experience and capacity to carry out the project. Especially relevant is experience completing the same activity as you are requesting funds for. Include information about the financial capacity of your organization.

  1. Describe how the project will preserve or enhance the neighborhood or area in which it is proposed, and how the project is consistent with the Comprehensive Plan and any applicable area plans.

  1. Describe how the project is consistent with the city’s Consolidated Plan, Ten-Year Plan to End Homelessness, or other applicable plan.

  1. Summarize the key reasons, if not already stated above, that this project should be funded.

Section VII-Budget

  1. Provide the basic project financial information on the separate finance worksheet. Provide any necessary narrative to fully explain the figures in the space below. You will also be required to complete a multifamily housing financial worksheet. Please request the template from Bill Doré at 757-385-5736 or .

SectionVIII -Statement of Applicant

The undersigned acknowledges the following:

  1. That, to the best of its knowledge and belief, all factual information provided is true and correct and all estimates are reasonable.
  2. That this request may be forwarded for consideration under other budget processes if it is determined that alternative sources may be appropriate.
  3. That no revised proposals/applications may be made in connection with this application once the deadline for applications has passed.
  4. That the applicant will participate in required interview for project assessment and cooperatively assist in the review process.
  5. The City of Virginia Beach reserves the right not to fund any submittals received.
  6. By submission of this application, the organization agrees to abide by the federal regulations applicable to this program.
  7. That, if the project(s) is funded, the organization agrees to abide by the City’s locally established policies and guidelines
  8. That past program and financial performance will be considered in reviewing this application.
  9. That, if the project(s) is funded, the City or a designated agency may conduct an accounting system inspection to review internal controls, including procurement and uniform administrative procedures, prior to issuance of payments for projected expenditures.
  10. That, if the project(s) is funded, the City will perform an environmental review prior to the obligation of funds.
  11. That, if the project(s) is funded, a written agreement that includes a statement of work, records retention and reporting, program income procedures, local and federal requirements, circumstances that would trigger grant suspensions and terminations, and reversions of assets may be required between the organization and the City.
  12. Provide written signatory authority from the organization’s governing body indicating who can execute contracts and amendments on its behalf.
  13. Agrees to abide by the City of Virginia Beach’s Conflict of Interest policy. Items of concern would include staff members serving on the Board of Directors, staff members’ families serving on the Board of Directors, and other matters that may give the appearance of a conflict of interest.
  14. Agrees to comply with the following: Fair Housing Act, Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act of 1990, Davis Bacon Act, Section 3 and other Federal Regulations.

PENALTY FOR FALSE OR FRAUDULENT STATEMENT
U.S. Code Title 18, Section 1001, provides that a fine of up to $10,000 or imprisonment for a period not to exceed five years, or both, shall be the penalty for willful misrepresentation and the making of false, fictitious statements, knowing same to be false.

By signature below, the applicant acknowledges the above on this ___day of ______, 2017.

Signature / Title / Organization

Due By JANUARY 20, 2017 BY 5:00 PMPage 1 of 8