Emergency Food & Shelter Program Phase 32 Application for Funding
Emergency Food and Shelter Program
Phase 32 Application – 2014-15
York County Local Jurisdiction
Section I: Agency Information
Application Prepared Date:Legal Name of Agency*:
Federal Employer ID#
(FEIN):
DUNS #
Congressional District:
Program Name:
Mailing Address:
City: / State: SC / Zip:
Program Site Address:
City: / State: SC / Zip:
Primary Contact Person:
Contact Person Title:
Telephone:
Alternate Phone:
Email:
Executive Director/CEO:
Executive Director telephone:
Email:
When did the agency begin delivering services locally?
Agency incorporation date:
Agency website (if applicable)
Executive Director Signature: / Date:
Board Chairman Signature: / Date:
*If an agency is serving as a fiscal agent for another agency, the name of the Agency should read “ the X fiscal agent for Agency Y”, and the mailing address should be the fiscal agent’s address.
Section II: Funding Request
Please indicate below the categories and amount for which the applicant agency is applying for funding.
Then, complete pages 2-8 as appropriate. Do NOT submit blank or unused pages in your final application.
Please be aware that once funds are awarded to a category, Local Board approval is required to change the use of the funds.
Category / Funding Request1. Rent/Mortgage Assistance
(complete Category 1 on page 6) / $
2. Utility Assistance
(complete Category 2 on page 7) / $
Total Funds Requested for Agency: / $ 0.00
(click on the dollar amount above, then right click and choose ‘update field’ to total the categories)
Section 3: Certification Form
Please review the following Local Recipient Organization (LRO) Certification Form carefully. Check EACH ITEM and fill in the blanks as indicated. Note that if any agency meets all of the criteria except the annual audit and/or accounting system, another agency that meets these requirements may be approved to serve as the fiscal agent. Signing this form DOES NOT guarantee funding. The form is used ONLY to certify to the Local Board and National Board that your agency is eligible to receive and manage EFSP funds. Incomplete information on this form will result in a denial of your agency.
As a recipient of Emergency Food and Shelter National Board Program (EFSP) funds made available for Phase 32 and as the duly authorized representative of the below-named agency, I certify that my public or private organization:
ü please manually check that your organization meets these standards:
1. q Has the capability to provide emergency food, aid, and/or shelter services
2. q Will use the funds to supplement and extend existing resources and not to substitute or reimburse ongoing programs and services. Will not use EFSP funds as a cost-match for other Federal funds or programs
3. q Is non-profit or an agency of the government
4. q Has an accounting system and will pay all vendors by an approved method of payment
5. q Conduct an independent annual review if receiving $25,000-$49,999/ an annual audit if receiving $50,000 or more in EFSP funds, and an OMB Circular A-133 if receiving $500,000 or more in Federal Funds
6. q Has not received an adverse or no opinion audit
7. q Is not disbarred or suspended from receiving Federal funds
8. q Understands that cash payments including money orders are not eligible under EFSP
9. q Understands that interest income must be reported on final report and used on allowable program expenditures
10. q Has provided a Federal Employee Identification Number and a Data Universal Number System
(DUNS) number issued by Duns & Bradstreet (D&B) and required associated information to
EFSP
11. q Practices non-discrimination (if an agency with a religious affiliation, will not refuse service to an applicant based on religion, nor engage in religious proselytizing or religious counseling in any program receiving Federal funds
12. q Will not charge a fee to clients for EFSP funded services
13. q If private, not-for-profit, has a voluntary board of directors
14. q Will comply with the Phase 32 Responsibilities and Requirements Manual, particularly the Eligible and Ineligible Costs section* -read carefully prior to dispersing funds
15. q Will provide required client information and reports to the Local Board:
a. q Interim Report and 2nd Payment Request as stated in EFSP Manual for Phase 30, including Addendum for Phase 31 and Phase 32
b. q Final Report and documentation as required by the National Board – stated in EFSP
Manual for Phase 32
c. q Submit rent, mortgage or utilities assistance documentation to the Local Board or
EFSP Coordinator
18. q Will expend monies only on eligible costs and keep complete documentation (copies of cancelled checks, front and back, invoices, receipts, etc.) on all expenditures for a minimum of three years after end-of-program date, and for compliance issues until resolved
19. q Will spend all funds and close out the program by selected end-of-program date and return any unused funds to the National Board ($5.00 or more)
20. q Provide complete, accurate documentation of expenses to the Local Board, if requested, following my agency’s jurisdiction’s selected end of program date
21. q Will comply with OMB Circular A-133 if receiving over $500,000 total in federal funds
22. q Will comply with lobbying prohibition certification and disclosure of lobbying activities (if applicable, if receiving more than $100,000 in Emergency Food & Shelter Program funds
23. q Has no known EFSP compliance exceptions in this, or any other jurisdiction
24. q If funded, will send representation to the required LRO training scheduled by the Local Board
Organization Name:Executive Director Signature: : / ______/ Date:
Typed Name:
Section 4. Service Eligibility
Please give a brief description of your overall program.
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
Please manually check if your agency targets specific client populations by choosing up to three from the list below: (Double click box and select default value checked or manually check after printing)
Chemically addicted / Single womenPeople with AIDS/HIV / Families with children
Domestic violence victims / Single men
Mentally disabled / Unaccompanied minors
Elderly / Native Americans
Veterans / Other minorities
Other targeted populations
No special populations targeted/serve general population
Please give a brief description of specific services provided that target the needs of the population(s) checked above.
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
Please give a brief description of other services provided by your organization.
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
Does this program utilize the services of and/or involve homeless or formerly homeless persons in the organization’s daily operation? Please manually enter your response:
YES / NOIf yes, please describe how they are involved.
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
In the space below, please summarize how EFSP funds will supplement your current services:
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
Please identify your service area(s): (Double click box and select default value checked or manually check after printing)
Rock Hill / Sharon
Fort Mill / McConnells
Tega Cay / Hickory Grove
York / Other: (list)
What percentage of your clients, to a total of 100%, fall within the following annual income ranges: (Double click box and enter default value to add data)
0 % / $0 - $11,925 (50% or less of 2014 Federal Poverty Guideline (FPG) for family of 4)0 % / $11,926 - $23,850 (51% - 100% of 2014 FPG for family of 4)
0 % / $23,851 - $35,775 (101% - 150% of 2014 FPG for family of 4)
0 % / $35,776 - $47,700 (151% - 200% of 2014 FPG for family of 4)
0 % / More than $47,701
0% / TOTAL (click on the % amount to the left, then right click and choose ‘update field’ to total the categories)
Did this agency receive EFSP funds from this jurisdiction during previous Phase 31?
YES / NOIf yes, what is your LRO number?
Does this agency anticipate receiving EFSP funds from ANOTHER jurisdiction during current Phase 32?
YES / NOIf yes, list OTHER jurisdictions:
What other agencies, if any, provide similar assistance to residents in your service area:
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
Note below any other service providers with which this program collaborates, and describe in a few words or short phrase the collaboration focus:
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
Will this EFSP award assist you in securing or leveraging funds from other sources?
YES / NOWhat is the TOTAL OPERATING budget for this AGENCY (include all costs)? / $
What is the TOTAL OPERATING budget for this PROGRAM (include all costs)? / $
Section 5: Service Category Request Detail
CATEGORY 1: RENT MORTGAGE ASSISTANCE
Rent and Mortgage Assistance – past due rent or mortgage, first month’s rent or mortgage
Over 50% of funding should come from sources other than EFSP.
EFSP amount requested for RENT & MORTGAGE ASSISTANCE Funds: / $What is the anticipated budget DIRECT SERVICES for the RENT & MORTGAGE ASSISTANCE program? Exclude EFSP request, salaries administrative costs and overhead. / $
List other sources of funds supporting RENT & MORTGAGE ASSISTANCE activities – DO NOT include EFSP funds
Federal Funds / $
State Funds / $
Local Government Funds / $
Other: Specify / $
Other: Specify / $
TOTAL / $0.00
(click on the dollar amount above, then right click and choose ‘update field’ to total the categories)
Please list the dollar amount that you anticipate using for the following expenses:
First Month’s Rent or Mortgage? / $
Past Due Rent or Mortgage? / $
What year did the agency begin providing rent/mortgage assistance?
How many bills did the agency pay last year?
What is the maximum amount of assistance per household? / $
What method does your agency use to allocate EFSP funds to support clients who cannot pay?
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
Please indicate if participation in any class or religious service is required of clients and describe:
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
Section 5: Service Category Request Detail
CATEGORY 2: UTILITY ASSISTANCE
Utility Assistance – electric, gas, propane, firewood, water; no telephone
Over 50% of funding should come from sources other than EFSP.
EFSP dollar amount requested for UTILITY ASSISTANCE Funds: / $What is the anticipated budget DIRECT SERVICES for the UTILITY ASSISTANCE program? Exclude EFSP request, salaries administrative costs and overhead. / $
List other sources of funds supporting UTILITY ASSISTANCE activities – DO NOT include EFSP funds
Federal Funds / $
State Funds / $
Local Government Funds / $
Other: Specify / $
Other: Specify / $
TOTAL / $0.00
(click on the dollar amount above, then right click and choose ‘update field’ to total the categories)
Estimated number of bills to be paid with these funds.
What year did the agency begin providing utility assistance services?
How many utility assistance bills did the agency pay last year?
What is the maximum amount of assistance per household?
What method does your agency use to allocate EFSP funds to pay utility bills?
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
Please indicate if participation in any class or religious service is required of clients and describe:
This section provides limited space and will lock after 750 characters. Please format your narrative accordingly.
Section 6: APPLICATION CHECKLIST
Item Description / Please check and initial by hand if included in this application: / Approved as United Way of York County, SC Eligible Organization for FY 2014-15· Original application signed by both the Board Chairman and Executive Director/CEO
· Attachment A1: Copy of the agency’s income and expense reports – most recently closed fiscal year
· Attachment A2: Copy of the agency’s current year-to-date income and expense reports
· Attachment B: Copy of the agency’s 501 ( c ) (3)
· Attachment C: Copy of the agency’s most recent annual audit
· Attachment D: Copy of the agency’s most recent IRS Form 990
· Attachment E: Copy of the agency’s current registration as a charitable organization with SC Secretary of State
· Attachment F: A list of the agency’s Board of Directors, including professional affiliations, officers, contact information including email address, and term of service.
I certify by my signature that (name of organization) has submitted the above referenced documents in support of this EFSP request for funding.
Name of Preparer:Title
Signature / ______
Date
Phase 32 Federal Emergency Food & Shelter Program (2014)
United Way of York County, SC Page 3 of 8