INSTRUCTIONS FOR SUBMITTING
2017 EMERGENCY SOLUTION GRANT APPLICATION
1. Complete pages 2 through 22 of the application.
ü All applicants must submit one copy of their latest audit or audited financial statement.
ü All new applicants must submit one copy of their ESG Written Standards.
* ”new” includes any prior applicant that was not funded in 2016
2. Answer all questions. If not applicable to your program, please mark N.A.
3. Submit ONE ORIGINAL application and supporting information.
4. The application must be signed by the appropriate official for your organization or community.
5. The applications are due in THDA’s Nashville office by 4:00 p.m. CDT, Thursday, March 16, 2017. If you are not certain that your application will be received on time if delivered through regular mail, you should make other arrangements. Applications received late will not be considered.
6. Please submit a complete application. There will be no cure period.
7. Submit application to:
Tennessee Housing Development Agency
502 Deaderick Street, Third Floor
Nashville, Tennessee 37243
ATTN: Community Programs Division
FAXED OR E-MAILED APPLICATIONS WILL NOT BE ACCEPTED.
______
2017 Emergency Solutions Grant Application Page XXX (Revised08/11/16)
TENNESSEE HOUSING DEVELOPMENT AGENCY
2017 EMERGENCY SOLUTIONS GRANT APPLICATION
PART I
1. APPLICANT INFORMATION
Name:
Mailing Address: ______
City: ______County: ______
Zip Code: ______Telephone #: ______
Applicant’s E-mail Address: ______
Federal Tax Identification: ______
DUNS Number: ______
Federal Legislative District: House: ______
State Legislative District: House: ______Senate: ______
Grantee Fiscal Year: Federal ___ State ____ Other ____
2. PROJECT ADMINISTRATOR
Name: ______
Mailing Address: ______
City: ______State: ______Zip Code: ______
Phone: ______Fax: ______
Email Address: ______
3. CONTACT PERSON FOR THE APPLICATION
Name: ______
Phone: ______
Email: ______
4. TARGET GROUP:
Chronically homeless ___ Domestic Violence _____
Homeless Youth (18-24) ___ Elderly (60+) ____
Persons with HIV/AIDS ____ Individuals with disabilities ____
Veterans ____ Homeless Adults ____
Homeless families with children ____ Other: ____
5. COUNTY OR COUNTIES TO BE SERVED: ______
______
______
6. FAITH BASED ORGANIZATION? YES NO
7. PRIOR STATE ESG FUNDING?: YES NO
Amount: ______Year: ______
8. TOTAL ESG FUNDS REQUESTED: $ ______
(Must be a minimum of $35,000 or a maximum of $150,000)
Street Outreach $ ______
Shelter Activities (Essential Services + Operations) $ ______
Prevention $ ______
Rapid Re-Housing $ ______
HMIS $ ______
Administration (Local Governments only) $ ______
MATCHING FUNDS: $ ______
TOTAL PROGRAM COST $ ______
9. ALL APPLICANTS MUST INCLUDE:
______Most Recent Audit or Audited Financial Statement
______ESG Written Standards (if not funded in 2016)
To the best of my knowledge, I certify that the information in this application is true and correct and that the document has been duly authorized by the governing body of the applicant. I will comply with the program rules and regulations if assistance is approved. I also certify that I am aware that providing false on the application can subject the individual signing such application to criminal sanction up to and including a Class B Felony.
Mayor, Executive Director or Board Chairman:
Signature: ______
Typed Name: ______
Title: ______Date: ______
Part II Applicant Narrative
1. Describe the geographic make-up of the applicant.
· Geographic area served:
· Location of main and satellite offices:
2. Describe in detail the applicant’s mission, types of programs and services currently offered and how homelessness programs fit within that mission.
3. Describe the applicant’s participation in the local coordinated entry assessment system:
4. Describe the applicant’s intake process:
· Are intakes standardized?
· What eligibility requirements (if any) have you added to your program?
· What is the average length of time between intake and assistance given?
· Describe any efforts to lower barriers to assistance:
· Describe process for giving and receiving referrals:
5. Describe how the participants in the program give input:
· Average number of responses to surveys:
· Describe any changes that have been made as a result of participant feedback:
Part III Agency Capacity
1. List administrative and fiscal staff, as well as any experience in the management of federal or state grant programs:
2. Provide information about the board of directors and/or advisory council, such as the regularity of meetings, list of subcommittees and their involvement in the agency’s activities:
3. Describe how your Agency uses volunteers in the program and/or how your Agency collaborates with community resources:
4. Describe your participation with the Homeless Management Information System (HMIS) in your Continuum of Care. Include name of Lead Agency, HMIS Service Provider or Comparable Database Software. Note: if agency service area covers multiple continua of Care, provide information for each CoC.
5. Describe how your agency makes known that use of facilities, assistance, and services are available to all on a non-discriminatory basis, including steps to make individuals aware of the availability of the facilities, services, and assistance, including those with disabilities.
6. Describe how your agency assists participants with limited English proficiency. How does the agency make known its services to these communities within the service area?
Part IV: Proposed Activities
STREET OUTREACH / EMERGENCY SHELTER
1. Does the applicant have the capacity to immediately house unsheltered persons applying for assistance? If so, please describe shelter, including number of bed available. If not, how will they be provided shelter?
2. Describe how the applicant uses resources within community to lower barriers to service and proceed with rapidly rehousing participants into permanent housing?
3. What was the average length of stay for a person sheltered in the facility from Jan 1, 2016 – Dec. 31, 2016?
4. What was the number of homeless persons sheltered from Jan. 1, 2016-December 31, 2016?
5. Of that total, how many of those moved into permanent housing?
6. Please list all position titles, percentage of time and salaries of personnel that will be billed under Street Outreach or Shelter.
Prevention and Rapid Re-Housing
1. How will you ensure that minimum habitability standards are met when rental assistance funds are used to place a homeless household into housing, or move a household to different housing? Who will conduct necessary inspections? Please attach Habitability Checklist form.
2. How will you ensure that housing occupied by families with children under the age of six comply with requirements of the Lead Based Paint Poisoning Prevention Act in accordance with 24 CFR parts 35.115(a) and 35.115.125 ? How will the applicant assure that Lead Based Paint inspections are conducted properly? Please attach LBP standard form and LBP Assessment Certification for all staff assigned.
3. Other than meeting the requirement of HUD’s homeless definition, what, if any, other eligibility requirements are included in your program (i.e., income, sobriety, employment, etc.):
4. Explain the assessment process for determining the duration of financial assistance to be provided. If applicable, how will you document that Prevention program participants receiving medium-term rent assistance (3 to 9 months of assistance) be certified for eligibility at least once every 3 months?
5. List all position titles and salaries of personnel that will be billed under Housing Relocation and Stabilization Services (Prevention and/or Rapid Re-Housing). Include salary, percentage of time billed to ESG and indicate whether the position is full- or part-time.
6. For Prevention activities only, how will you document proof of income eligibility?
7. What is the average time between client intake and obtaining permanent housing?
For Prevention activities only:
8. Describe in detail how the applicant’s program is targeting these resources in a way that reaches those “but for” this assistance would end up homeless:
9. Describe the documentation used to determine if household meets 30% of the area median income:
Homeless Management Information System (HMIS)
1. Describe the current HMIS in place and the operational aspects that assure that all required data is entered in a timely manner. Include the need for additional equipment and/or software and training:
2. For HMIS Lead Agencies, estimate the number of new local participation agreements in your service area where HMIS service fees will be charged to participating agencies or directly to ESG:
3. List all position titles and salaries of personnel that will be billed under HMIS:
Part V: ESG FISCAL INFORMATION
MATCHED FUNDS
TYPE / DOLLAR VALUE / SOURCE OF MATCH / METHOD OF CALCULATIONDonated Supplies
(clothing, furniture, equipment, etc.) / $______
Cash Donations
Or Grants / $______
Value of Donated Building
(Attach documentation) / $______
Fair Rental or Lease Value
(Attach documentation) / $______
Salaries / $______
Volunteers
(unskilled @ minimum wage)
Attach a volunteer job description or list of duties related to ESG activities and a sample time sheet or log to document the volunteer hours. / $______
Other
(Specify) / $______
MATCH TOTAL / $______
PROGRAM OPERATING BUDGET
JULY 1, 2017 – JUNE 30, 2018
Agency: ______
ACTIVITY / ESG / MATCHINGFUNDS / CONTRACT
TOTAL
Street Outreach
Salaries
Travel
Emergency Services
Client transportation
Other:______
Shelter – Essential Services/Operations
Salaries
Travel / Transportation
Utilities
Phone/Communications
Rent
Equipment
Furniture
Food
Program Supplies
Insurance
ACTIVITY / ESG / MATCHING FUNDS / CONTRACT TOTAL
Maintenance/Security Staff
Client Legal Services / Costs
Childcare
Emergency Medical
Counseling
Job/Educational Training
Hotel vouchers
Other: ______
Other: ______
Other: ______
Other: ______
HOMELESSNESS PREVENTION
Financial Assistance
Salaries
Other: ______
RAPID RE-HOUSING
Financial Assistance
Salaries
Other: ______
ACTIVITY / ESG / MATCHING FUNDS / CONTRACT TOTAL
HMIS
Salaries
Equipment
Fees
Travel
Other
*If you are budgeting for indirect costs, you MUST submit a current approved cost allocation plan.
PART VI
NON-PROFIT CHECK LIST
1. Legal Name of Organization: ______
2. IRS Tax Exempt Number: ______
3. If the nonprofit is organized and existing under the laws of Tennessee, a current Certificate of Existence from the Tennessee Secretary of State's office. The certificate must be purchased from the Secretary of State's office and must be dated no more than 30 days prior to the application due date.
OR
If the nonprofit is organized and existing in a state outside of Tennessee, (1) a current Certificate of Existence from the office of the Secretary of State in which the organization is organized and existing and dated no more than 30 days prior to the application due date AND (2) a Certificate of Authorization to do business in Tennessee from the Tennessee Secretary of State and dated no more than 30 days prior to the application date.
4. Copy of 501(c)(3) or 501(c)4 certificate or letter from IRS.
5. Copy of Charter, By-laws and resolutions.
6. List of Board members including names, home address, and occupation, a description of their primary contribution, length of service, and date the term of service expires. (Part VII of Application).
7. Attach the minutes of the most recent Board meeting.
8. Business plan or strategic management plan that demonstrates the agency’s short term and long term goals, objectives, and plans to achieve them.
9. Documentation of operating funds from other sources, including how much annually and from what sources.
10. Explanation of any other programs, other than the proposed ESG program, operated by the organization, including the program(s) and its funding source(s).
11. If applying for shelter funds, Part VIII, Approval letter from the local government in which the shelter is located for the proposed activity.
12. Part IX, Consistency with Consolidated Plan
13. Part X, Certification of Matching Funds
14. Individual Disclosure Forms completed by the organization's Executive Director and every member of the Board of Directors. ALL DISCLOSURE FORMS MUST BE NOTORIZED.
15. Corporate Disclosure Form signed by the Chairman of the Board or Executive Director on behalf of the organization. THIS FORM MUST BE NOTORIZED.
16. Part XIII: Self-certification that shelter meets minimum safety, sanitation and privacy standards of 24 CFR Part 576.403.
By signing this document, I am certifying that all the documents required by the Non-Profit Checklist are included in this application packet, OR
By signing this application for funds, I am certifying that all documents required to be electronically uploaded to the THDA Participant Management Information System (PIMS) have been uploaded and that those documents reflect the most recent and complete documents available. All applications will be evaluated based on the supporting documents in the PIMS document repository as of the application deadline.
Mayor, County Executive, Executive Director or Chairman of the Board:
Signature:
Typed Name:
Title:
Date:
Part VII
NON-PROFIT BOARD COMPOSITION
PLEASE SEE SEPARATE ATTACHMENT POSTED
Part VIII
CERTIFICATION OF LOCAL GOVERNMENT APPROVAL
FOR NON-PROFIT ORGANIZATIONS
I, ______,
(Name and Title)
duly authorized to act on behalf of the ______
(Name of Jurisdiction)
hereby approve the following shelter project(s) proposed by ______
(Name of Nonprofit)
which is (are) located in: ______.
(Name of Jurisdiction)
BY: ______
(Name and Title) (Date)
______
(Signature) (Date)
To be signed by local government official for Applicants applying for shelter only
Part ix
consistency with the consolidated plan
I certify that the proposed activities/projects in the application are consistent with the jurisdiction’s current, approved Consolidated Plan. (Type or clearly print the following information)
Applicant Name: ______
Project Name: ______
Location of the Project: ______
______
Name of the Federal Program to which the applicant is applying: ______
______
Name of Certifying Jurisdiction: ______
Certifying Official of the Jurisdiction Name: ______
Title: ______
Signature: ______
Date: ______
Part X
CERTIFICATION OF MATCHING FUNDS
The ______
(Name of local government or approved private, nonprofit organization)
certifies that the matching supplemental funds or in-kind support contribution required by the State of Tennessee’s Emergency Solutions Grant Program will be provided. Included in the program narrative is a description of the proposed sources and amount of such supplemental funds.
______
(Name and Title)