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EMERGENCY FOOD AND SHELTER NATIONAL BOARD PROGRAM

Local Application Form – Phase 32

Funding Period: November 1, 2014 – October 31, 2015

NAME OF AGENCY:

ADDRESS (Mailing and Street):

CONTACT PERSON: PHONE:

E-MAIL: FAX:

AGENCY TAX ID #:DUNS #:

The Data Universal Number System (DUNS) is a unique identification number used to track how federal grant money is allocated. If you do not know your DUNS number, you may obtain it from “Organization Registration”under the “Applicants”link.

FUNDS REQUESTED

Amount Per ActivityActivities

A.Served Meals

(may use $2.00 per meal per diem)______#_____meals

B.Other Food______#_____meals

C.Mass Shelter

(may use $12.50 per night per diem)______#_____nights

D.Other Shelter______#_____nights

E.Supplies/Equipment______(Purchase of equipment not to exceed $300.00)

F.Repairs/Code(Not to exceed $300/item)______

G.Rental Assistance______#______bills

H.Utility Assistance______#______bills

I.Administration (limited to 2%)______N/A______

Total Amount Requested:

Authorization of Agency Board Chair or Executive Director:

SIGNATURE: Date:

PRINT NAME:

RELATIONSHIP TO AGENCY:

DUE DATE: One original application and one electronic application must be received by 4:00 p.m. on Friday, March 20, at the United Way of San Luis Obispo County office:P.O. Box 14309, San Luis Obispo, CA 93406 (mail); 1288 Morro Street, Suite 10, San Luis Obispo, CA 93401 (physical). Postmarks are not accepted.

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HOW TO APPLY FOR PHASE 32EFSP FUNDING

Please review the following documents regarding Phase 32EFSP funding:

Priorities for the allocation of 2014 Phase 32 EFSP Funds; available online at

  • Phase 30 Responsibilities and Requirements Manual; available at the National EFSP website:

and

  • Phase 31 Addendum to the Program Manual; available online at and at

the National EFSP website,

  • Phase 32 Addendum to the Program Manual; available online at and at

the National EFSP website,

If your program meets EFSP priorities/objectives and you wish to apply for Phase 32EFSP funding:

  • Provide one electronic copy of the application face sheet and narrative, emailed to
  • Provide one original copyof theapplication face sheet and narrative
  • Number each page of your application with the face sheet as page one; you do not need to number the attachments
  • Put agency/program name on each page of narrative
  • Sign original application

APPLICATION NARRATIVE

Please assume the Local EFSP Board is not familiar with your program.

Your narrative should include:

Program information (maximum two pages):

  • Describe your services and client population, community needs addressed by your services, and how your program meets EFSP objectives.
  • Are your services duplicative? How do you cooperate/partner with other organizations to meet the needs of your client population?
  • How many unduplicated people OR families did you serve in your last 12 month fiscal year period? How many people OR families do you anticipate servingin your current 12 month fiscal year period?

ATTACHMENTS

Provide ONE copy of EITHER of the following forms:

If you are a 501(c)(3):LOCAL RECIPIENT ORGANIZATION CERTIFICATION

If you are NOT a 501(c)(3):FISCAL AGENT/FISCAL CONDUIT AGENCY RELATIONSHIP CERTIFICATION

Provide ONE copy of each of the following:

  • IRS Letter of Determination (proof of 501(c)(3) nonprofit status)
  • Current Board roster
  • Certification Regarding Lobbying form
  • Agency Operating Budget

If your request is $25,000 or more:

  • Provide one copy of your most recent agency financial review

If your request is $50,000 or more:

  • Provide one copy of your most recent agency financial audit