Form A
Joint Funding Cover Sheet
The City of Charlotte Housing & Neighborhood Services (HNS) and Mecklenburg County Community Support Services (CSS) partnered to release a joint Request for Proposals for HNS Emergency Solution Grant federal funds and for CSS Housing Stability and Supportive Services local funds. Please complete this cover sheet and attach this sheet with each copy of your funding proposal/application. Follow the submittal instructions for each funding source as described in the Request for Proposals.
Funding Source:
Which funding source are you applying for? You may check Emergency Solutions Grant only; Housing Stability and Supportive Services only or both funding sources.
Emergency Solution Grant (City, HNS)Housing Stability and Supportive Services (County, CSS)
Rapid Re-Housing – Financial Assistance Rapid Re-Housing – Case Management &Services
Emergency Shelter – Operating Costs
Emergency Shelter – Shelter Services
Prevention Services
Street Outreach
HMIS
Rapid Re-Housing- Case Management & Services
Funding Request:
What is your funding request? You may request funding from one and/or both funding sources.
City HNS Emergency Solution Grant Funding Request: $______
County CSS Housing and Supportive Services Funding Request $______
If you are requesting County CSS funding, check how many years.
1 Year 2 Years
If requesting County CSS funding, what is your source of rental assistance (if not ESG funds)? (If you are requesting ESG funds, write Not Applicable.)
______
- APPLICANT INFORMATION
Full Legal Name of Applicant:
Applying as(Check one): Non-Profit or Government Agency
For-Profit Organization
Address:
City/State/Zip:
Contact Person:______
Title:______Telephone Number: ______
E-mail:______
What is your organization’s mission statement?______
______
Incorporation date (Month and Year)?______
Estimated Organization’s Total Budget for Current Fiscal Year: $______
Number of staff employed (full-time equivalents):______
Years of supportive housing experience (in years): ______
II.BRIEF PROGRAM DESCRIPTION
Program Name:______
Program Street Address:______
TotalProgram Budget:$______
Check one:
Existing Single site location ORExisting Scattered site units
Number of NewHousing Units to be added: ______
Number of New clients to be served:Daily: ______Annually:______
Check one:
Which income group does your project serve?
30% or less Area Median Income (AMI)
31%-50% AMI
Which eligible population does your project serve?
Homeless Families with ChildrenPeople with HIV/AIDS
Elderly (over 60)Veterans
Disabled (not elderly)Homeless Individuals
Other – Identify ______
III. DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
Are any of the Board Members or employees of your agency, which will be carrying out this project, or members of their immediate families, or their business associates:
a)Employees of or closely related to employees of the City or County? YES______NO______
b)Members of or closely related to Members of CharlotteCity Council
or Mecklenburg Board of County Commissioners?YES______NO ______
c)Beneficiaries of the program for which funds are requested, either as clients
or as paid providers of goods or services?
YES______NO______
If you have answered YES to any question, please attach a full explanation to the application. The existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any funding awarded. The disclosure statement must be signed and dated. There is a Conflict of Interest Policy (Form G) to be completed for County Fund Requests only.
Authorized Signature of Applicant: To the best of my knowledge and belief, all information in this application is true and correct. The document has been duly authorized by the governing body of the applicant who will comply with all contractual obligations if the proposal is awarded funding.
Signature of Authorized Representative:______
Print Name and Title:______
Date Signed: ______
RFP City ESG and County Support Service Requests Page 1