Shelter Assistance Application
Page 6
PROJECT APPLICATION FORM
Housing Assistance (Type III, major)
E-mail or mail the
original application Beth Kang, Executive Director
and 3 copies to: HomeAid Sacramento 916-751-2746
1536 Eureka Road
Roseville, CA 95661
______
I. APPLICANT INFORMATION
Name of Care Provider/Agency:
Phone: ()
Address: Fax: ()
Email:
Chief paid executive, title Phone Email
Chief lay officer, title Phone Email
Name, title of individual submitter Phone Email
II. SHELTER INFORMATION
Name of Housing Project: Phone: ()
Project Address: Fax: ()
Facility Website:
Project Key Contact Phone Email address
______
Shelter Site Contact Phone Email address
Type of Shelter (Circle all that apply):
Emergency / Short-Term / Long-Term / Permanent(1-5 nights) / Transitional / Transitional / Supportive
(1-6 months) / (7-24 months) / Housing
Federal ID #
Years of operation
Age of Facility ______
Do you own or just control the site? (Circle one)
If you control, but do not own the site, explain the relationship
III. AGENCY DESCRIPTION
Does the Agency mission include services to the temporarily homeless? Yes No
Number of clients served per year
Percentage of clients gaining long-term independent housing
Describe the demographic make-up of the clientele served by your organization.
Attachment #1 Agency Narrative
Provide a narrative that describes your agency, mission, history, objectives, programs and services. Be as brief as possible while providing the requested information. Please differentiate between those programs and services provided by the organization and those provided by the proposed shelter project, if different.
Attachment #2 A copy of the Strategic and/or Business Plan
Attachment #3 Verification of 501(c)(3) status
Attachment #4 Board of Director Documentation
_____ Roster of the Board of Directors
______Number of meetings held during the past fiscal year
______Average number of directors present at meetings
______Number of directors making financial contributions to the organization in past fiscal year
______Total amount of directors' financial contributions to organization in past fiscal year
______Number of directors actively engaged in fund raising for organization
Number of paid staff: _____ Full-time Professional _____ Full-Time support staff
_____ Part-time professionals _____ Part-time support staff
Number of volunteers: _____ Programs and services _____ Fund raising
Volunteer hours last year: ______
How is the community involved in the housing programs?
How has the community been encouraged to become involved?
Describe collaborations with other agencies to provide services or complete specific projects?
Describe how elected officials and/or community leaders support your organization.
List names and include letters of support as ATTACHMENT #5
Number of families the shelter can accommodate at one time (if applicable):
Currently Through proposed project:
Number of individuals the shelter can accommodate at one time (if applicable):
Currently Through proposed project:
Number of families the shelter can serve annually (if applicable):
Currently Through proposed project:
Number of individuals the shelter can serve annually (if applicable):
Currently Through proposed project:
Describe the means used by your agency to measure success.
Rate the track record of graduates attaining and sustaining self-sufficiency using your measurements.
______
IV. PROJECT INFORMATION
The proposed project is 1) a renovation
2) new construction
3) a combination of both
Does the project add beds? Yes No # ______Preserves beds? Yes No # ______
What clients will be served in this new project (single adults, families, domestic violence victims, mentally
disabled, others). Please be specific.
Describe the nature of the proposed project. Include whether the proposed project is a renovation of an existing facility or a new construction. If renovation, describe the nature of the proposed improvements. Explain the need
for the project. Attach additional pages if needed.
Which staff, board members and volunteers do you have committed to work on this project?
What are their roles?
Are entitlements in place? YES NO
Has the project undergone Planning Department Review? YES NO
If YES, have you started? YES NO
Does the project require a Variance or Use Permit? YES NO
Does the project require zoning modifications? YES NO
Does the project require review by any other peripheral YES NO
organization. (i.e., an architectural review committee,
a neighborhood review board, etc.)?
Do you have renderings or photos? If yes, include as YES NO
ATTACHMENT # 6
Do you have site plans showing the building on the site? YES NO
If yes, include as ATTACHMENT # 7
Do you have an engineered site plan? If yes, include as YES NO
ATTACHMENT # 8
Do you have architectural plans completed? If yes, YES NO
include as ATTACHMENT # 9
If yes, have plans been approved by the local YES NO
government agency?
Do you require assistance with architectural or engineering YES NO
plans?
Do you have building permits? If yes, include as YES NO
ATTACHMENT # 10
V. PROJECT FINANCIAL INFORMATION
Estimated construction cost: $
ATTACHMENT #11 Current Construction Budget
Estimated total project cost: $
(include construction, permit fees, school fees and other project costs)
ATTACHMENT #12 Project Budget
Funding reserved for the project $
If needed, state plans for raising the additional money needed to complete the project
Amount of projected money pledged to date: $
Amount of project money received to date: $
Amount pledged to capital expenses: $
Amount pledged to program services $
What in-kind donations have been committed to the project?
Provide a Copy of the Board Pledge
ATTACHMENT #13
Provide a copy of the Grant Award
ATTACHMENT #14
Provide a copy of any Fund Restrictions
ATTACHMENT #15
List all pledges and grants by amount and source (mark * for pledges not yet received)
Amount / Source / Amount / Source$ / $
$ / $
$ / $
$ / $
List other funding sources being approached for the project, e.g. corporations, foundations, individuals. Indicate amount sought from each.
Amount / Source / Amount / Source$ / $
$ / $
$ / $
$ / $
$ / $
VI. ORGANIZATIONAL FINANCIAL INFORMATION
Use most recent audited financial statements, rounding off all figures
Reporting on fiscal year ending: In /Thousands (circle one)
Attach the Management Letter from your most recent audit and a copy of the latest audited Financial 990
ATTACHMENT # 16
General Fiduciary Questions
Amount of debt to banks, other lending institutions or individuals at year-end
$
Of this sum, $was secured; $was unsecured.
Of this sum, how much was due to:
Operating debt? $ Capital debt? $ Other? $
Total outlay for interest expense the past fiscal year? $
How long will it take to pay off this debt? ______
ATTACHMENT # 17 Current Year Budget of Organization
ATTACHMENT # 18 Projected Budget of Organization, if available.
VII. INSURANCE INFORMATION
Insurance carrier name
Insurance Policy #
ATTACHMENT # 19 Copy of current insurance policy.
VIII. ADDITIONAL INFORMATION
Please attach additional information you feel would be helpful for our evaluatione.g. annual report, organization newsletter, brochures, etc.
Additional comments:
IX. SERVICE PROVIDER COVENANTS
A. Service Provider acknowledges its obligation to give due credit to HomeAid Sacramento in any and all press releases, public announcements, award programs or other publicity about the project. Service Provider agrees to obtain HomeAid Sacramento approval for any and all press releases, public announcements, awards programs or other publicity about the project. Any such publicity that is not disapproved within seven (7) days shall be considered approved.
Service Provider’s Initials: ______
B. Service Provider acknowledges its obligation to send notice to its donor base promptly after this application is approved advising them of the contribution HomeAid Sacramento has agreed to make to the project. Such notice shall be shown to and approved by HomeAid Sacramento’s executive director prior to such mailing. Service Provider agrees to complete, execute and submit to HomeAid Sacramento the affidavit of mailing attached hereto as ExhibitA promptly after such mailing.
Service Provider’s Initials: ______
C. Service Provider acknowledges its obligation to install and maintain a plaque or similar marker recognizing HomeAid Sacramento’s contribution to the project and featuring the HomeAid logo. Such commemorative marker shall be displayed in a prominent location at the completed project.
Service Provider’s Initials: ______
D. Service Provider acknowledges and agrees that it bears the ultimate financial responsibility for the completion of the project and that HomeAid Sacramento’s contribution to the project is limited to in-kind donations of materials and labor. Accordingly, Service Provider has diligently and thoroughly investigated and disclosed above all available and potential funding for the project.
Service Provider’s Initials: ______
E. Service Provider acknowledges and agrees to provide, when requested and where reasonable, information to HomeAid Sacramento and HomeAid America, on client success rates, client service numbers, and program evaluation information.
Service Provider’s Initials:
X. CERTIFICATION
A. Service Provider certifies that it does not engage in unlawful discrimination of any kind with respect to the persons benefited by Service Provider’s activities.
Service Providers Initials: ______
B. The undersigned hereby certifies that all information given by the Service Provider in this application is true and correct as of the date hereof.
C. The undersigned hereby certifies that the Service Provider has read this Shelter Assistance Application and the Service Provider agrees that, should the project be approved, the Service Provider will abide by the covenants contained herein.
D. The undersigned is duly authorized to execute this document on behalf of the Service Provider as of the date written below.
This application must be signed by a board officer (lay person) and the staff officer (employee) to whom future questions and correspondence may be addressed. Signatories attest to the accuracy of the information. Any figures that are estimated should be marked (e).
Submitted this ______day of ______, ______.
Lay Officer of Service Provider Staff Officer of Service Provider
By: By:
Name: Name:
Title: Title:
XI. ATTACHMENTS CHECKLIST
If not required for your circumstances, mark “NA”
☐ #1 Narrative of Agency
☐ #2 Copy of Strategic and/or Business Plan
☐ #3 Verification of 501 (c) (3) Status
☐ #4 Board of Director Documentation
☐ #5 Letters of Support
☐ #6 Renderings or Photos of Plans
☐ #7 Building Site Plans
☐ #8 Engineering Site Plans
☐ #9 Architectural Plans
☐ #10 Building Permits
☐ #11 Current Construction Budget
☐ #12 Total Project Budget
☐ #13 Public and Private Funding Documentation
☐ #14 Board Pledge
☐ #16 Grant Award
☐ #17 Fund Restrictions
☐ #18 Management Letter and latest audited Financial 990
☐ #19 Current Year Budget of Organization
☐ #20 Projected Organizational Budget
☐ #21 Current Insurance Policy
Form 1003 updated 3/18/14