Agency Organizational Capacity Assessment and Certifications
Agency Name: / Administrative Office Address:
Agency Federal ID #: / Agency Duns #:
Agency Fiscal Year: / Total Agency Budget:
Executive Director:
Fiscal Contact:
HMIS Contact:
  1. Capacity Assessment:

  1. Describe your agency’s experience and background in working with the homeless population.

  1. Agency Certifications:

Write “YES” if the agency performs the function described and “NO” if it does not. Some functions listed in section are compulsory and required for funding.

FINANCIAL MANAGEMENT
A. / Do the accounting records for the organization (or agency) identify the source and use of all funds, including information on:
  1. All grant awards received
  2. Authorizations or obligations of awards received
  3. Un-obligated balances
  4. Assets and liabilities
  5. Program income
  6. Total actual outlays or expenditures to date

B. / Are the accounting records of the agency supported by adequate source documentation such that the combination of source documentation and accounting records provides a complete audit trail, documenting when a purchase was requested and by whom, how it was formally approved, what funds were used to pay for it, when it was paid and for how much?
C. / Does the agency use employee timesheets that allow employees to track grant funded time spent on CHF related activities separately from time spent and funded from other resources?
D. / Does the agency have a system in place for maintaining its financial records for four years or until any litigation, claim, audit, or other action involving the records has been resolved, whichever comes later?
E. / Does the agency have a current financial policy and procedure manual that covers basic accounting procedures such as those for recording financial transactions, for maintaining accounting records, and for approving grant funded expenditures?
HUD/COC CAPACITY ASSESSMENT
A. / With regards to the COC assessment completed on your agency, is there any other information that you would like the committee to consider relative to your agency’s capacity. Please discuss below:
HOMELESS CONSUMER PARTICIPATION
A. / Does the agency have representation of a person who is homeless or formerly homeless on the board of directors or a policymaking entity directly responsible for making policy for the project(s) for which funding is being requested?
CLIENT HMIS DATA
A. / Does the agency fully participate in HMIS, or if the agency is a victim service's agency, a HUD compliant, HMIS comparable database.
POINT-IN-TIME COUNT
A. / Does the agency participate in the semi-annual street counts in January and July?
PROHIBITION AGAINST INVOLUNTARY FAMILY SEPARATION AND DISCRIMINATION
B. / Families with children under age 18 are not denied admission because of the age of any child under age 18.
C. / The agency does not engage in or require participation in inherently religious activities, such as worship, religious instruction, or proselytization as part of the programs or services funded under ESG.
D. / The agency serves clients regardless of gender identification, sexual orientation
E. / Families in family programs are not denied admission based on gender identification, sexual orientation, family status or the age of a child.
F. / Families in family programs are not separated when entering the program.
CLIENT RIGHTS
A. / Does the agency have published and accessible grievance and termination procedures that meet the requirements of § 576.402 - Terminating assistance?
B. / Does the agency release client-specific data only insofar as it is required for the client’s case plan or in the course of business and with the client’s permission?
CASE MANAGEMENT, REFERRAL AND COORDINATED ASSESSMENT
A. / The agency complies with the case management requirements of § 576.401 Evaluation of program participant eligibility and needs and actively links clients to appropriate services within the COC.
B. / The agency participates regularly in local COC meetings.
C. / The agency participates in the operation or development of the local coordinated assessment / centralized intake.
GOOD STANDING
A. / The Lead Agency qualified for tax exemption under 501(c)(3) of the internal revenue code or a unit of government?
B. / The agency is an equal opportunity employer in accordance with all federal regulations?
C. / In the last two prior years, if applicable, a financial audit was conducted in compliance with OMB A-133 standards and submitted to the Department of Administration.
D. / In the last two prior years in that audit, there was no finding or unresolved question cost in the financial audit in which funds were requested to be returned because of misappropriation or ineligible expenses?
E. / In the last two prior years, there were no fines or liens levied against the agency (paid or unpaid)?
Example: a fine for not paying payroll tax.
F. / In the last two prior years, no funds from other grants that serve homeless individuals from any other funder were required to be returned?
  1. Attachments:

Please attach copies of the following materials:
Current agency audit report (less than 18 months)
B. / Year to date agency profit and loss statement (less than 45 days old)
C. / Agency budget for current fiscal year

I certify that the information contained above is accurate and complete.

Signature and Title:
Date: