2013-2014 REVISED Homeless Grants Program Application

Feb. 28, 2013 post-training

Application Components

  1. HEED all items noted on the February 28, 2012 Application Training.
  2. Complete all sections of Application – 12 pt type -Times New Roman or 11 pt - Arial
  3. FAILURE to submit required ATTACHMENTS will result in a deduction of 5 pts.
    Attach to original and copies as instructed.
  4. Add Agency/Date to footer. Number all pages.
  5. Assemble in order. No Staples. No Dividers. No Folders or Jackets. Binder Clip only.
  6. Submit one original & ten copies & one electronic version.
  7. Mark Submissions as Original & Copy. Original should include original signatures.
  8. Application questions are to be submitted electronically to – questions and subsequent answers will be shared with all training attendess.
  9. Scoring: 100 points

15 points:HMIS – Contributory HMIS Organization Performance

50 points:Program Performance

10 points: Target Population

10 points:Service Coordination

10 points:Program Design

5 points:Organizational Structure

  1. Due:

Monday, March 18, 2013 by 4:30 p.m. to:TLCHB Office

1946 N. 13th St.,Suite 437, Toledo, Ohio

1

2013-14 CoC REVISED Homeless Grants Program Application (ESG, CDBG Homeless Service & HCRP)

TLCHB 2013-2014Homeless Grants Program Application

Project: ______

Agency: ______

Delivered by: ______

Received by: ______

Date: ______

Once completed, TLCHB to retain original and make a copy for agency

Applicant Information
Name of Lead Agency
Executive Director/CEO:
Street Address: / City: / Zip Code:
Telephone: / Fax: / E-Mail:
Applicant Federal Tax ID Number:
Federal DUNS Number:
Application Preparer/Contact
Telephone: / Fax: / E-Mail:
PROJECTS
Name of Activity / Request
TOTAL / $

2. Threshold Requirements - ALL

Check all the below threshold requirements that apply to your agency

Signed TLCHB Standards on file

Executed MOU Housing Collaborative Network on file1

HCN active participant2

Executed CHO agreement3

HMIS active participant4

No outstanding audit findings of a material nature regarding administration of program

No major HUD violation issued in the past twelve months

Review and/or update of agency’s strategic plan, action plan and/orgoals/objectives implementation plan

Maintenance of its Internal Revenue Service (IRS) approved tax-exempt status under Subtitle of the code

Agency operation for at least five years

Same or comparable service for at least two years

Fund Accounting system that operates according to Generally Accepted Accounting Principles (GAAP)

Nondiscrimination practice in provision of assistance

Current with all property and payroll liability taxes

2a. Threshold Requirements – CDBG*HS Applicants

All must be met to be considered for 2013-14 CDBG*HS Funding

Re-house clients quickly

Funding brings additional resources to the CoC for services that would become unavailable to the CoC except for this funding

Fill an identified need for special population (DV, PSH, AIDS, Chronic

By checking the threshold requirementabove, you are affirmatively asserting that your agency / application meets that threshold requirement. Allrequirements checked are subject to verification by TLCHB.

1 An agency not currently receiving ESG,If funded, this requirement is mandatory. CDBG Homeless Service, HCRP and/or CoC funding, these applicants are exempt from this threshold requirement. If funded, this requirement is mandatory.

2 An agency must attend 75% of the HCN general meetings after executing HCN MOU. For applicants not currently receiving ESG, CDBG Homeless Service, HCRP and/or CoC funding, these applicants are exempt from this threshold requirement.

3 An agency not currently receiving ESG, CDBG Homeless Service, HCRP and/or CoC funding, these applicants are exempt from this threshold requirement.

4 An agency must attend100 % of the CHO meetings after executing CHO Agreement. For applicants not currently receiving ESG, CDBG Homeless Service, HCRP and/or CoC funding, these applicants are exempt from this threshold requirement.

3. Contributory HMIS Organization Performance – 15%

1.Enter Accrued % from Calendar 2012 CHO Tracker for Agency _____

2.Identify any findings of non-compliance with HMIS Security & Privacy policies during monitoring in 2012 and the status of any corrective action plan (Use same provided below).

4. Performance Outcomes – 50%

Unless otherwise noted, data is from CY 2012 HMIS General Program Report (GPR)

  1. Year-round beds for program in 2012 Housing Inventory Chart: ______
  1. Total service night capacity: ______(Year-round beds x 364)
  1. Total service nights: ______(GPR)
  1. Unduplicated persons served: ______(GPR)
  1. Traffic (GPR)
  1. Householdsb. Persons

______households entering______persons entering

______households exiting ______persons exiting

  1. Length of Stay (GPR)
  1. Average (mean): ______
  2. First quartile: ______
  3. Median: ______
  4. Third quartile: ______
  1. Exits to Permanent Housing (GPR)
  1. Persons exiting to permanent housing (PH) destinations: ______
  2. Percent of persons exiting to PH destinations: ______
  3. Households exiting to PH destinations: ______
  4. Percent of households exiting to PH destinations: ______
  1. Total Budget (Expense Budget)

$______Total Budget

$______Total Project Budget

$______Total ESG Project Budget

  1. Cost per successful outcome (Manual: divide appropriate expense budget total by the total number of person exiting to PH)

$______Total Project Budget / PH Outcome

$______Total ESG Project Budget / PH Outcome

  1. Cost per service night (Manual: divide appropriate expense budget total by the total number of Service-Nights provided)

$______Total Project Budget / Service-Nights provided

$______Total ESG Project Budget / Service-Nights provided

  1. Recidivism (Contact HMIS administrator for information)

a. Percent of persons returning to homelessness within six months of PH: _____%

  1. Income Improvement (GPR)
  2. Percent of households with improved income at program exit: _____%
  1. Employment (GPR)
  2. Percent of adult persons employed at program exit: _____%
  1. Reasons for Leaving (GPR)
  2. Percent of households with positive discharge reasons: _____%
  3. Percent of households with negative discharge reasons: _____%
  4. Percent of households with neutral discharge reasons: _____%
  1. Permanent Supportive Housing retention (GPR)
  2. Percent of households retained in PSH more than six months: _____%

5. Target Population – 10%

  1. Target A(choose all applicable targets)

Please identify percentage of household Target A population selected

FY 2012 FY 2013

_____% Single female_____% Single female

_____% Single male_____% Single male

_____% Single male & single female_____% Single male & single female

_____% Families with children_____% Families with children

2. Target B (Optional -- choose only one)

The project must serve at least 75% of theto be served of Target A populations

FY 2012FY 2013

_____ Chronically homeless_____ Chronically homeless

_____ Veterans_____ Veterans

_____ Domestic violence victims_____ Domestic violence victims

_____ Mental illness_____ Mental illness

_____ Substance abuse_____ Substance abuse

6. Service Coordination –10%

  1. Complete Housing Grants Program Benefit/Services Chart.

b. If applicable, beyond Referral and Access Assistance to community services, describe other linkage activities between the project and the community service provided that quantifiably impacts/benefits housing stability – be specific! (Two additional pages maximum)

7. Program Design – 10%

a. Describe in concise detail your proposed program design. Include service delivery, termination/discharge policy, expected outcomes, case manager/client ratio, consistency with vision and strategic plan and project performance indicators. Explain any proposed changes in program design from current program design. (Maximum - two and ½ pages)

b. Attach Agency Activity Work Plan for next fiscal year

c. Attach Agency Revenue Budget, Agency/Activity Expense Budgetand Salary and Wage form for next fiscal year following narrative by line-item by section type.Describe in narrative form line-item expenses in the Expense Budgets. NOTE: Request for funds must be matched $1 - $1(No more than two pages)

d. Describe your current strategic or action plan, including the effective dates, date of last review and description of any based upon the last review. (Maximum - 1/2 page)

8. Organizational Structure – 5%

a. Describe personnel and organization’s years of service experience with target population. Please provide organization chart. (Maximum – one page)

b. Describe board’s make-up as it reflects or not diversity, that is, reflective of our community. Attach Board of Director’s Information form.

c. Describe client termination and grievance process, including the number of client termination and reasons for termination, and the number of client grievance episodes and results.
(Maximum – one page)

d. Does agency evaluate client satisfaction? If yes, describe process and % of clients participating in the process and the result. If no, why? (Maximum – one page)

ATTACHMENTS

TO BE INCLUDED IN ORIGINAL & COPIES

FY2013 – 2014 Housing Grants Program Benefit/Service Chart

FY 2013 – 2014 Activity Work Plan

FY 2013 – 2014 Activity Revenue Budget Form

FY 2013 – 2014 Activity Expense Form

FY 2013 – 2014 Salary and Wage From

Most recent Agency Year End Income/Expense Budget Report

Most recent Homeless Program Year End Income/Expense Report(s)

2013 Organizational Chart

Board of Director’s Information Form

Board of Trustees (Directors) Roster noting officers, terms board attendance for CY2012

TO BE INCLUDED IN ORIGINAL ONLY

ALL

Most Recent 990 Form

Most recent Agency Audit – if older than 2011 include explanation

FY 2013 – 2014 Match & Leverage Requirement Documentation

Certifications

Local Assurance

Provider Certifying Statement

Tax Affidavit

Conflict of Interest

Procurement Policy & Procedure

Client/Consumer/Resident Termination Policy & Procedure

Agency CY2012 HMIS General Program Report

ADDITIONAL - NEW APPLICANTS ONLY

Most Recent Strategic Plan

Code of Regulations and/or By-laws

ADDITIONAL - RENEWAL APPLICANTS

Revised Code of Regulations since last year’s submission – NOTE IF N/A

Update/review strategic plan and/or action plan and/or goals-objectives implementation plan

ADDITIONAL – TRANSITIONAL HOUSING PROVIDERS

Client/Resident Occupancy Agreement Template

ATTACHMENTS ORDER

Italics indicate form to be completed

  1. Most Recent 990 (original only)
  2. Most Recent Agency Audit (original only)
  3. FY 2013-14 Match & Leverage Requirement Documentation (original only)
  4. Certifications: (original only)
  5. Local Assurances,
  6. Provider Certifying Statement,
  7. Tax Affidavit
  8. Conflict of Interest
  9. Procurement Policy & Procedure (original only)
  10. Client/Consumer/Resident Termination Policy & Procedures (original only)
  11. Most recent Strategic Plan (original – new applicants only)

7. Revised Code of Regulations (original – renewals only) mark if N/A

  1. Code of Regulations and /or By-Laws (original – new applicants only)

8. Update/review strategic plan etc… (original – renewals only) mark if N/A

9.Client/Resident Occupancy Agreement Template (original – transitional housing only)

10. Agency CY2012 HMIS General Program Report

All below in Original (following last numbered attachment) and Copies

  1. FY2013 – 2014 Housing Grants Program Benefit/Service Chart
  2. FY 2013 – 2014 Activity Work Plan
  3. FY 2013 – 2014 Activity Revenue Budget Form
  4. FY 2013 – 2014 Activity Expense Form
  5. FY 2013 – 2014 Salary and Wage From
  6. Most recent Agency Year End Income/Expense Budget Report
  7. Most recent Homeless Program Year End Income/Expense Report(s)
  8. 2013 Organizational Chart
  9. Board of Director’s Information Form
  10. Board of Trustees (Directors) Roster noting officers, terms board attendance for CY2012