Due Date: Friday, March 3, 2017

Agency Information Form

Texas 2017/2018ESGIntent to Apply

Contact Details
Legal Name of Agency:
Mailing Address (Include City & Zip Code):
County of Headquarters Office:
Authorized Representative Information
Chief Executive - First, Middle and Last names:
Prefix: / Mr. Ms.
Email:
Phone number:
Finance Chief Information
First, Middle and Last names:
Prefix: / Mr. Ms.
Email:
Phone number:
Application Details
Including the Lead Applicant, how many organizations are taking part in this application? (List all organizations)
Approximately what is the amount that will be requested for ESG in year one (9/1/2017-8/31/2018)?
Approximately what is the amount that will be requested for ESG in year two (9/1/2018-8/31/2019)?
Name the organization(s) in the Application that had a contract with TDHCA for 2016 ESG funds.
Collaborative Partners
Legal Name of Partner Agency #1:
Is Partner Agency #1 a private nonprofit? / Yes No
Is Partner Agency #1 planning to conduct the Emergency Shelter activity? / Yes No
Legal Name of Partner Agency #2:
Is Partner Agency #2 a private nonprofit? / Yes No
Is Partner Agency #2 planning to conduct the Emergency Shelter activity? / Yes No
Legal Name of Partner Agency #3:
Is Partner Agency #3 a private nonprofit? / Yes No
Is Partner Agency #3 planning to conduct the Emergency Shelter activity? / Yes No
Legal Name of Partner Agency #4:
Is Partner Agency #4 a private nonprofit? / Yes No
Is Partner Agency #4 planning to conduct the Emergency Shelter activity? / Yes No
Subrecipient Partners
Legal Name of Partner Agency #1:
Is Partner Agency #1 a private nonprofit? / Yes No
Is Partner Agency #1 planning to conduct the Emergency Shelter activity? / Yes No
Legal Name of Partner Agency #2:
Is Partner Agency #2 a private nonprofit? / Yes No
Is Partner Agency #2 planning to conduct the Emergency Shelter activity? / Yes No
Legal Name of Partner Agency #3:
Is Partner Agency #3 a private nonprofit? / Yes No
Is Partner Agency #3 planning to conduct the Emergency Shelter activity? / Yes No
Legal Name of Partner Agency #4:
Is Partner Agency #4 a private nonprofit? / Yes No
Is Partner Agency #4 planning to conduct the Emergency Shelter activity? / Yes No