United Way of Westchester and Putnam

RECOVERY FUND GRANT APPLICATION

For Organizations

Application Submission Period:

Hurricane Sandy Recovery Fund –Phase 3

Deadline –Wednesday, October 30, 2013 by 5 pm

Submit via email to:

Reporting Period: 45 days from receiving the Funds

Please do not exceed five pages or the maximum word count per question.

Date of Submission: Amount Requested: $

Organization Information

Organization Name:

Federal Tax ID Number:

Street Address:

City:State: NYZip:

Executive Director:Title:

Phone: Email:

Project Administrator Contact Information (if different from Executive Director)

Name:Title:

Office Phone: Extension:

Office Fax:

E-mail:

  1. County(ies) where the recovery work will take place:

Westchester _____Putnam _____

  1. List the geographic area(s) that will be served:
  1. Describe the process your organization has taken to identify community needs as a result of Hurricane Sandy. (50 words or less)
  1. Check off the populations that will be served by this funding:

___ seniors ___ youth ___disabled ___immigrant/undocumented

___ low income ___ other (describe) ______

  1. Describe expected outcomes/results and their benefits.(250 words or less)
  1. Measure of progress/performance:

(Describe method used to measure the project’s progress/performance. For example, collection of specific data such as number of clients served, etc. (200 words or less).

  1. Describe the accountability or structure that will be used to ensure that these funds address the unmet needs of your organization’s clients, and that there is no duplication of funds.(250 words or less).
  1. List the organization(s) in your community that will partner with you to do this recovery work.
  1. Describe the process and systems in place to track funds and outputs such as people served, services provided, volunteers coordinated. (250 words or less)
  1. Are you working with a Long-Term Recovery Coalition? ___ Yes ___ No

Project Start Date: // Project End Date: //

Certify information to be correct: Signature______Date______

Recovery Project- Using the following charts belowpleasebriefly describe the intended purpose and budget for this application.

The immediate needs listed below are eligible for Disaster Recovery Fund assistance providing that public or private sources do NOT cover these expenses.

Immediate Needs / Budgeted $ Amount / Intended Purpose (Includes estimated or actual number of individuals and families that will be served)
Cleaning supplies including mold eradication supplies (sump pumps, generators, fans, dehumidifiers to dry residences)
Medical and mental health services including prescriptions and medical supplies not covered by insurance (e.g. ensure, adult diapers)
Rental or home mortgage payments (including security deposits and brokerage fees for rentals)
Short-term financial assistance
Utility assistance
Transportation assistance and/or car repair
Ongoing unmet basic needs including food, food supplies, diapers, infant formula and supplies, school supplies, winter outwear, etc.
Support for the applying organization for re-establishing or continue their services if also affected by the disaster
Other immediate needs (be specific)
TOTAL IMMEDIATE NEEDS

The long-term needs listed below are eligible for Disaster Recovery Fund assistance providing that public or private sources do NOTcover these expenses.

Long-Term Needs / Budgeted $ Amount / Intended Purpose (Includes estimated or actual number of individuals and families that will be served)
Employment/Job Retraining
Organization infrastructure and/or service support
Disaster Case Management Services
Mental Health Supports (e.g. Post-Traumatic Stress Disorder)
School or After School Based Youth Supports
Legal Assistance (e.g. documentary recovery, workman’s compensation papers, insurance documents, etc.)
Specific Populations Services (e.g. limited information, language barriers, or immigration status).
Other long-term needs (be specific) identify
TOTAL LONG-TERM NEEDS
TOTAL IMMEDIATE AND
LONG-TERM NEEDS