CDBG PROGRAM INCOME FUNDED WAIVER REQUEST
–PUBLIC SERVICES –

GRANTEE: / CONTACT PERSON: / PHONE:
EMAIL:
DATE SUBMITTED BY GRANTEE: / CDBG REPRESENTATIVE:
  1. INDICATE CDBG ACTIVITY and MATRIX CODE:
Contract(s) this activity is to be added to: ______,______,______
  1. ELIGIBLE CDBG ACTIVITY (NON-REVOLVING) (Select only one)
Senior Services (05A) Child Care Services (05L)
Services for the Disabled (05B) Health Services (05M)
Legal Services (05C) Abused & Neglected Children (05N)
Youth Service (05D) Mental Health Services (05O)
Transportation Services (05E) Screening for Lead (05P)
Substance Abuse Services (05F) Subsistence Payments (05Q)
Battered and Abused Spouses (05G) Security Deposits (05T)
Employment Training (05H) Food Banks (05W)
Crime Awareness (05I) Housing Counseling (05U)
Tenant/Landlord Counseling (05K) Neighborhood Clean-Up (05V)
Fair Housing (05J) Code Enforcement (15)
Other Public Services (05): (Specify) Homeless/AIDS Programs (03T)
A-1. Economic Development Microenterprise Technical Assistance (18C)
  1. INDICATE LEVEL OF SERVICE: (Supplanting of local or State funds with CDBG funds is not allowable.)

A new service
An existing service to be increased:
  • Currently funded by: In the amount of:
  • Anticipated increase in service: %
An existing service with no change in funding level, funded by prior CDBG Funds.
List Grant #: Date funded out of PI:

Rev. 7/1/2014

CDBG PROGRAM INCOME FUNDED WAIVER REQUEST
–PUBLIC SERVICES –
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GRANTEE:
  1. INDICATE PROGRAM COST and FUNDING SOURCES:

  1. TOTAL CDBG FUNDS NEEDED: $
What specific pieces of the Scope of Work discussed in 4.A and B, below, will CDBG funds pay for?
  1. TOTAL OTHER FUNDING COMMITTED: $
Sources of Other Committed Funding:
(i)
(ii)
  1. TOTAL OTHER FUNDING NEEDED (is there a gap): $
  1. WHAT PERIOD OF TIME (LENGTH) WILL THESE FUNDS COVER:
NOTE: PUBLIC SERVICES HAVE AN ANNUAL CAP OF 15% OF THE STATES OVERALL EXPENDITURE RATE IN A GIVEN FISCAL YEAR. THIS MAY RESULT IN THE DEPARTMENT NOT BEING ABLE TO FUND A PUBLIC SERVICE SUPPLEMENTAL ACTIVITY.
  1. ACTIVITY DESCRIPTION:

  1. PROPOSED PROGRAM: (Total Scope of Services)
  1. SCOPE OF WORK FOR CDBG:
  1. TIME FRAME OF PROPOSED PROGRAM: (Program Start Up, Program Closeout Dates)

Comments:
CDBG PROGRAM INCOME FUNDED WAIVER REQUEST
–PUBLIC SERVICES –
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GRANTEE:
  1. ELIGIBILITY:

  1. NATIONAL OBJECTIVE:
/ 1) Low/ModerateIncome Benefit(Low/Mod)
2) Urgent Need
  1. HUD LOW/MOD BENEFIT:
National Objective must be met by either:
1)Beneficiaries meet Low/Modincome restriction;
2) Beneficiaries are designated Limited Clientele; or,
3) Service area being primarily Low/Mod individuals (>51%).
Check the box above that describes how this Public Service Program will meet the National Objective, and describe the details requested. / Income Restricted (100 percent HUD Low/Mod Income)
Limited Clientele
List Type(s) of Limited Clientele:
Low/Mod Area Benefit:
List % of total:
Based on HUD Low/Mod Charts
Based on Income Survey
(Prior Department approval is requiredfor submission of this form)
Jurisdiction-Wide Service Area
  1. DESCRIPTION OF SERVICE AREA:
Submit Map(s) and Identify:
(1) Census Tract/ Block Group; and,
(2) Zoning in description
Note:Service area information is needed regardless of which Low/Mod benefit is being used. / Entire Jurisdiction
Service Area(s):
Describe Service Area of Project:
Map must be included
Comments:
CITIZEN PARTICIPATION: / No CDBG Activity can be approved without the required Citizen Participation being completed.
Public Notice: Completed Not Completed Comments:
Resolution of the Governing Body (Authorizing submittal of the Supplemental Activity Request,designating the Authorized Representative)
Completed Not Completed Comments:
Please submit evidence of the above with this request.
CDBG PROGRAM INCOME FUNDED WAIVER REQUEST
–PUBLIC SERVICES –
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On behalf of the City/County of: I submit this CDBG Program Income Waiver Request and understand that, upon approval, the need to clear all applicable General and Special Conditions, which includes meeting all applicable federal overlay requirements. I understand the City/County of: cannot incur costs until prior written Department approval is given.
Authorized Representative Signature: ______
Date:
Print Name and Title of Authorized Signer:
Print Name of Preparer: Date:
Additional Comments:
(FOR USE BY CDBG PROGRAM ONLY)
JURISDICTION:
  1. ACTIVTY APPROVAL:
APPROVED
APPROVED WITH SPECIAL CONDITIONS:
______
Activity Eligibility 105(a): ______
NOT APPROVED Date: ______
  1. REASONS FOR NOT APPROVING:
______
______
______
CDBG Representative: ______Date:______
CDBG Program Manager: ______Date:______
CDBG Section Chief: ______Date:______

Rev. 7/1/2014