City of Chicago

CITY OF CHICAGO

COMMUNITY DEVELOPMENT BLOCK GRANT

PROGRAM YEAR XXXVII-2011

WORK PROGRAM AND BUDGET

Department:

Program: Fax #:

Contact Name: Phone #:

Part I: Delegate Information

Parent Organization Name:

Parent Organization Address:

Parent Organization City, State, Zip:

Delegate:

Site Address:

City, State, Zip:

Executive Director:

Delegate Contact:

Phone #: Fax #:

Office Hours: Program Service Hours:

Total Budget for this Project (including other share):

CDBG Year XXXVII Allocation:

Grant Agreement Period: From To

Federal Employer Identification Number:

For Internal Use Only
Log #: _
Vendor Code #: _
Service Grant Agreement #: _ _
Fund-Department-Organization #: _

Year XXXVII 2011 CDBG Delegate Work Program

Part II: Description of Project

In a clear and concise manner, provide a narrative summary of this CDBG funded project: its scope, problems addressed, and results anticipated. Please do not add additional pages.

Part III: Monitoring and Evaluation Procedures

A. Describe the methods your agency will employ to evaluate the project's progress and record project accomplishments.

B. Describe how your agency will monitor program expenditures and ensure that appropriate fiscal controls and records are in place.

Part IV: Auditing Requirements

Is your agency (check only one)?  not-for-profit  education institution

 governmental agency  for-profit

A. What is your agency's fiscal year?

B. When do you intend to conduct an audit of this grant agreement?

C. Below please list all contracts and grants that your agency anticipates receiving during the 2011 fiscal year. Identify if the source is Federal or Other and the amount.

Funding Source

Contracts/Grants Federal Other Total Amount Requested

If you are applying to other City departments for CDBG grants please list the department, the program and the amount requested below:

Department Program CDBG Amount Requested

Year XXXVII 2011 CDBG Delegate Work Program

DO NOT USE THE BUDGET FORM IN THE WORD DOCUMENT. INSTEAD, PLEASE USE THE EXCEL FILE.

Form 1

Budget Summary

A. Delegate F. Vendor Code # _
B. Program Name G. Vendor Site # _
_
C. Department H. PO # _
D. Contract Term 1/1/2011 to 12/31/2011 I. Release # _
E. 2011 Allocation: J. Funding Strip:
K: CFDA#: / _
_

L. Project Budget Summary for Year XXXVII - 2011

Note: The entire budget for this project must be shown.

(1) Item of Expenditure / (2) Account # / (3) CDBG Share ($) / (4) Other Share($) / (5) Total Cost ($)
Personnel / 0005
Fringe Benefits / 0044
Operating/Technical / 0100
Professional and Technical Services / 0140
Materials and Supplies / 0300
Equipment / 0400
Other (please specify) / 0900
Other (please specify)
TOTAL
M. Percentage of total project costs paid
by Other Share (column 4 ÷ column 5): ______%
N. Delegate Authorization
_
Signature of Delegate Official Date
_
Name and Title (Type or Print) / O. City Authorizations
_
Signature of Department Official Date
_
Name and Title (Type or Print)

Year XXXVII 2011 CDBG Delegate Work Program

DO NOT USE THE BUDGET FORM IN THE WORD DOCUMENT. INSTEAD, PLEASE USE THE EXCEL FILE.

Form 2

Personnel Budget

A. Delegate C. Project Name _

B. Department Program D. Federal Employer Identification # _

E. Personnel Budget Allocation for Year XXXI- 2011

Position/Title / No. / Rate ($) / % of Time Spent / CDBG Share ($) / Total Cost ($) / Brief Summary of Job Responsibilities
(1) / (2) / (3) / (4) / (5) / (6) / (7)
(8) Totals / Totals must match Budget Summary - Form 1, Account #0005
F. Fringe Benefits and Total Personnel Costs
Type of Fringe Benefit / CDBG Share ($) / Total Cost ($) / Please show calculation below:
(9) a. Social Security Tax
(9) b. Medicare / = .0620 x line 8
= .0145 x line 8
(10) State Unemployment Insurance
(11) State Workers Compensation
(12) Other (please list)
(13) Other (please list)
(14) Total Fringe Benefits (Add lines 9-13) / Totals must match Budget Summary - Form 1, Account #0044
(15) Total Personnel Costs (Line 8 plus line 14)

Year XXXVII 2011 CDBG Delegate Work Program

DO NOT USE THE BUDGET FORM IN THE WORD DOCUMENT. INSTEAD, PLEASE USE THE EXCEL FILE.

Form 3

Non-Personnel Budget

A. Delegate _
B. Department Program _ / C. Project Name

D. Non-Personnel Allocation for Year XXXVII - 2011

Item of Expenditure / Account # / CDBG Share
of Cost ($) / Total Cost ($)) / Line Item Description and Justification
(Please show justifications for Total Cost and CDBG Share)
(1) / (2) / (3) / (4) / (5)
(6) TOTAL

Year XXXVII 2011 CDBG Delegate Work Program

Form 4

WORK PROGRAM

A. Delegate D. Strategy: ______

B. B. Department Program

C. Project Name

E. Work Program For Year XXXVII- 2011

(1)
Program / Sub Program
Activities
Elements which
describe the activities
that will accomplish
program objectives. / (2)
Program Deliverables
State what quantifiable units will be
used to measure the progress of the
proposed project. Example: classes
held; units built; referrals. / (3)
2011 Planned Output by Quarter & Year
Total. List of Projected quantifiable
units for each program deliverable. / (4)
Performance Measures
1st Qt / 2nd Qt / 3rd Qt / 4th Qt / Total
(5) Total Unduplicated Clients/Units:

Year XXXVII 2011 CDBG Delegate Work Program

Form 5

CDBG National Objective/Eligibility

A. Delegate

B. Department Program

C Project Name

D. Eligible CDBG Activity:

E. National Objective:

The qualifying National Objective is “Activities Benefitting Low and Moderate Income Persons”. Please check the box nest to the appropriate underlined criterion listed below. Also, any additional instructions in parenthesis.

[ ] Area Benefit (LMA) (Fill out all of Form 6 -- must be 51% or higher)

[ ] Limited Clientele (LMC)* (Check the appropriate box below)

[ ] Service is limited to one or more of the following groups presumed by HUD to be

low/moderate income (check only one):

Senior Citizens Homeless Persons

Persons with Disabilities Illiterate Persons

Battered Spouses Migrant Workers

Abused Children Persons Living with AIDS

[ ] Records are kept which contain the household size and total household income of

proving that 51% are low and moderate.

[ ] The City Department has determined that the nature and location of the activity

will ensure that the majority of clientele will be low and moderate income in

accordance with HUD criteria. No other feasible way of qualifying the activity

exists. (If this box is checked, all of FORM 6 must be completed).

Department Approval %Low/Mod (Must be 70% or higher)

[ ] L/M Housing (LMH)*

[ ] L/M Jobs (LMJ)*

*Note: All programs which directly benefit a person/household must compile the following information during the upcoming year:

1) The total number of persons/households served; and

2) the total number of clients which are:

Income Levels Race

Moderate Income White American Indian or Alaskan

Low Income Black/African American Native Asian

Extremely Low Income American Indian/Alaskan Native and Other/Multiracial

Female-Head of Household Black/African American

American Indian/Alaskan Native and White Ethnicity

Asian and White Hispanic Yes [ ] No [ ]

Native Hawaiian/other Pacific Islander

Black/African American and White

Year XXXVII 2011 CDBG Delegate Work Program

Form 6

Service Area Information

A. Delegate _

B. Department Program _

C. Project Name

D. Name and address of facility providing the services:

Name of the Facility Site Address

In what Ward, Community Area, and Census Tract is the facility providing the services located?

Ward: Community Area Census Tract:

E. Indicate Program Service Area:

This project will provide services citywide to all eligible individuals.

This project will primarily serve the following Ward(s), Community area(s), and Census tract(s):

Ward(s): Community Area(s):

Census Tract(s):

What are the approximate boundaries of the area from which your clients are drawn (specify by street name)?

North: South:

East: West:

F. Low/Moderate Income Area Census Information

Note: Complete the chart below only if your activity is qualified under the Area Benefit National Objective or if the City Department and the Office of Budget and Management have determined that the nature and location of the activity will ensure that the majority of your clients will be low and moderate income in accordance with HUD criteria (Form 5).

1. Census Tracts / 2. Total Low-Mod Persons / 3. Total Persons
Total

4. Overall % Low/Mod (Total of column 2 ÷ Total of column 3): _

Form 7

Survey of Monitoring and Evaluation Procedures

(To be completed by City Department)

A. Department -

B. Department Program _

C. Staff in charge of monitoring _

The purpose of this form is to ensure that monitoring and evaluation procedures are followed by City departments and by individual subrecipient agencies in monitoring subrecipient projects. A copy should accompany each subrecipient grant agreement.

HUD cautions in its Fraud Information Bulletin that a city which funds subrecipients must always be aware of the possibility of fraud and abuse by the subrecipients due to poor management or to deliberate violation of the law; of conflict of interest; or abuses in the contracting process of subrecipients; of false or inadequate documentation of program accomplishments.

1) Describe the methods that the department will employ to monitor and evaluate its subrecipients' programs to ensure their progress and accomplishments, including the frequency of such monitoring.

2) Describe how the department will monitor subrecipient expenditures.

3) Specify the particular records the subrecipient must maintain and/or submit.

Year XXXVII 2011 CDBG Delegate Work Program