Fundingrequest Application-Emergency Solution Grant (ESG)

Form B

City of Charlotte

FundingRequest Application-Emergency Solution Grant (ESG)

FY2016 (July 1, 2015-June 30, 2016)

Agency:
Address:
Director:
Agency Contact:
Phone Number: / Email:
Total Funding requested from City for upcoming fiscal year / $

Funding Priorities

The City of Charlotte will award funds to activities consistent with the following funding priorities.

1)Rapid Re-Housing - Financial Assistance

2)Emergency Shelter – Operating Costs

3)Emergency Shelter – Shelter Services

4)Prevention Services

5)Street Outreach

6)Homeless Management Information System (HMIS)

7)Rapid Re-Housing –Case Management & Services

More information about these activities can be found at

Agency and Program Information

Provide description of your agency. If requesting City-funding for a specific program within your agency, also provide the name and description of the specifiedprogram along with your agency’s description:

Agency and Program (if applicable) Description:
Agency Mission Statement:
Agency Vision Statement:
Describe the benefits or results of agency or program services.

The City Council has identified five Focus Areas that reflect community priorities and guide strategic planning and decision making. Indicate the City Council Focus Area(s)which your agency or program support? For additional Focus Area(s) information, clickhere.

Community Safety / Housing & Neighborhood Development / Transportation / Economic Development / Environment

Scope of Services: Describe how agency or program activities support the City Council Focus Area(s) identified.

Program Objectives: Consistent with the Balanced Scorecard performance management approach, the City uses 16 Corporate Objectives to measure its achievement. Indicate the Corporate Objective(s) which your services most directly contribute and list specific initiatives, measures, and targets that link to the City’s Corporate Objectives. For additional Corporate Objective(s) information,clickhere.

Corporate Objective / Initiative / Measure / Target
(Press the “tab" key for additional rows)

Has your Board of Directors approved these program objectives? _____ Yes _____ No

Program minimum requirements

• Programs referral must be received through Coordinated Assessment.

• Agencies must enter HUD required data elements into the Homeless Management Information Network (HMIS) identified by the CoC. (Domestic Violence Agencies do not have to meet this requirement).

• A representative from funded agency is required to participate a minimum of 50% of Continuum of Care Committee meetings.

ContinuumofCare Meeting Schedule –2ndWednesday- Everyother month*
Date / Time
July8, 2015 / 2:00-3:30p.m. / HopeHaven3815N.TryonStreet–backconferenceroom
September9, 2015 / 2:00-3:30p.m. / HopeHaven3815N.TryonStreet–backconferenceroom
November11, 2015 / 2:00-3:30p.m. / HopeHaven3815 N. TryonStreet –backconferenceroom
January 13, 1016 / 2:00-3:30p.m. / HopeHaven3815N.TryonStreet–backconferenceroom
March 9, 2016 / 2:00-3:30p.m. / HopeHaven3815 N. TryonStreet –backconferenceroom
May 11, 2016 / 2:00-3:30p.m. / HopeHaven3815 N. TryonStreet –backconferenceroom

*Changes to this meeting schedule will be sent via email to the Continuum of Care email distribution list.

Total Agency Budget

Provide total expense and revenue budget information for entire agencyincludingall programs and funding sources. For purposes of this application, the budget information provided should coincide with the City’s fiscal year, July 1, 2015 through June 30, 2016.

Personnel Expenses / FY2015 Budget / FY2016 Projected Budget / FY2016 Budget Request from City
Salaries
Merit
Benefits

Total Personnel Expenses

Operating Expenses / FY2015 Budget / FY2016 Projected Budget / FY2016 Budget Request from City
Communications (e.g. publishing, marketing)
Travel & Training
Facilities (e.g. rent, utilities)
Technology
Other

Total Operating Expenses

Total Expenses

Please include all revenues, excluding revenues received from the City of Charlotte and Mecklenburg County, in the fields below.

Revenues / FY2015 Budget / FY2016 Projected Budget
Government Grants & Funding
Foundation Grants & Funding
Donor Contributions
Service Fees
Other Revenue
Total Revenues

Indicate the amount of total funds received from Mecklenburg County, if applicable, for each fiscal year listed below.

Fiscal Year / Total Funds
FY2015
FY2016 (as requesting)

Program Budget

If requesting City-funds for a specific program within your agency, provide the expense and revenue budget information for the specified program including all funding sources. For purposes of this application, the budget information provided should coincide with the City’s fiscal year, July 1, 2015 through June 30, 2016.

Personnel Expenses / FY2015 Budget / FY2016 Projected Budget / FY2016 Budget Request from City
Salaries
Merit
Benefits

Total Personnel Expenses

Operating Expenses / FY2015 Budget / FY2016 Projected Budget / FY2016 Budget Request from City
Communications (e.g. publishing, marketing)
Travel & Training
Facilities (e.g. rent, utilities)
Technology
Other

Total Operating Expenses

Total Expenses

Please include all revenues, excluding revenues received from the City of Charlotte and Mecklenburg County, in the fields below.

Revenues / FY2015 Budget / FY2016 Projected Budget
Government Grants & Funding
Foundation Grants & Funding
Donor Contributions
Service Fees
Other Revenue
Total Revenues

Indicate the amount of total funds received from Mecklenburg County, if applicable, for each fiscal year listed below.

Fiscal Year / Total Funds
FY2015
FY2016 (as requesting)

FY2016 Program Objectives

Activity / Total Amount Requested / Number of Households to be Served / Cost per Household
Example: Emergency Shelter- Operating Cost / $10,000 / 100 / $1000
Emergency Shelter (Operating Cost)
Emergency Shelter (Shelter Services)
Rapid Re-Housing (Financial Assistance)
Rapid Re-Housing (Case Management & Services)
Prevention Services
Street Outreach
Homeless Management Information System (HMIS)
Share the strategies to sustain your agency or program. Indicate plans for obtaining funds outside of City-funding.
If City-funding is denied, describe the impact on agency or program.
If your agency received City-funding for the current fiscal year and is requesting a change in the City-funding level for the upcoming fiscal year, provide the reason(s) for requesting a change in the City’s funding level:

All Proposals submitted must include:

• Form A - Joint Funding Cover Sheet
• Completed Funding Request Application
• Financial Audit (most current)
• Project Budget
• E-Verify Certification

Proposals must be submitted via email to Rebecca Pfeiffer at no later than Tuesday, May 19, 2015.

E-Verify Certification

This E-Verify Certification is provided to the City of Charlotte (the “City”) by the company signing below (“Company”) as a prerequisite to the City considering Company for award of a City contract (the “Contract”).

1. Company understands that:

a. E-Verify is the federal program operated by the United States Department of Homeland Security and

other federal agencies to enable employers to verify the work authorization of employees pursuant to

federal law, as modified from time to time.

b. Article 2 of Chapter 64 of the North Carolina General Statutes requires employers that transact business

in this state and employ 25 or more employees in this state to: (i) verify the work authorization of

employees who will be performing work in North Carolina through E-Verify; and (ii) maintain records of

such verification (the “E-Verify Requirements”).

c. North Carolina General Statute 160A-20.1(b) prohibits the City from entering into contracts unless the

contractor and all subcontractors comply with the E-Verify Requirements.

2. As a condition of being considered for the Contract, Company certifies that:

a. If Company has 25 or more employees working in North Carolina (whether now or at any time during

the term of the Contract), Company will comply with the E-Verify Requirements in verifying the work

authorization of Company employees working in North Carolina; and

b. Regardless of how many employees Company has working in North Carolina, Company will take

appropriate steps to ensure that each subcontractor performing work on the Contract that has 25 or

more employees working in North Carolina will comply with the E-Verify Requirements.

3. Company acknowledges that the City will be relying on this Certification in entering into the Contract, and that

the City may incur expenses and damages if the City enters into the Contract with Company and Company or

any subcontractor fails to comply with the E-Verify Requirements. Company agrees to indemnify and save the

City harmless form and against al losses, damages, costs, expenses (including reasonable attorney’s fees)

obligations, duties, fines and penalties (collectively “Losses”) arising directly or indirectly from violation of the

E-Verify Requirements by Company or any of its subcontractors, including without limitation any Losses

incurred as a result of the Contract being deemed void.

______

Signature of Company’s Authorized RepresentativeDate

______

Print Name & Title

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