EXHIBIT 1: Lead Agency Information Form

New PermanentHousing ProjectsRFP 2015

EXHIBIT 1: Lead Agency Information Form

Agency Name: Click here to enter text.

Number of Projects: Click here to enter text.

System Award Management (SAM) #: / Click here to enter text.
DUNS #: / Click here to enter text.
Agency Address: Click here to enter text.
City:Click here to enter text. / State: Click here to enter text. / Zip:Click here to enter text.
Phone:Click here to enter text. / Fax:Click here to enter text. / Email:Click here to enter text.
Grant/AgencyContact Person: / Click here to enter text.
Phone: / Click here to enter text.
Email: / Click here to enter text.
Agency Director: / Click here to enter text.
Phone: / Click here to enter text.
Email: / Click here to enter text.
HMIS Agency Contact Person: / Click here to enter text.
Title: / Click here to enter text.
Email: / Click here to enter text.
Phone: / Click here to enter text.

Project Information: Please complete the chart below for each CoC project.

Grant Name of Project: / Click here to enter text.
Project Address: / Click here to enter text.
Grant Number: / Click here to enter text.
Grant Amount: / Click here to enter text.
Grant Term: / Click here to enter text.
Expiration Date: / Click here to enter text.
Program Type: / Click here to enter text.
Primary Population: / Click here to enter text.
Annual Renewal Amount/Total Number of Units / Click here to enter text.

(Continued: Please complete the chart below for each CoC project. Copy and complete additional pages, if needed.)

Grant Name of Project: / Click here to enter text.
Project Address: / Click here to enter text.
Grant Number: / Click here to enter text.
Grant Amount:
Grant Term: / Click here to enter text.
Expiration Date: / Click here to enter text.
Program Type: / Click here to enter text.
Primary Population: / Click here to enter text.
Annual Renewal Amount/Total Number of Units / Click here to enter text.
Grant Name of Project: / Click here to enter text.
Project Address: / Click here to enter text.
Grant Number: / Click here to enter text.
Grant Amount: / Click here to enter text.
Grant Term: / Click here to enter text.
Expiration Date: / Click here to enter text.
Program Type: / Click here to enter text.
Primary Population: / Click here to enter text.
Annual Renewal Amount/Total Number of Units / Click here to enter text.

Please include the following documents:

• Attachment 1: Board of Directors’ Roster and Board Resolution to apply for 2015 CoC funding
• Attachment 2: Most recent HUD Monitoring letter and close out letter for all HUD projects
• Attachment 3: A list identifying your past 5 years of experience receiving HUD assistance or other government assistance
• Attachment 4: HUD CoC Project Application

Name, Title and Signature of Person who will complete the application:

______

Name/TitleClick here to enter text.SignatureDate

Name and Signature of Person authorized to sign the HUD application:

______

Name/TitleClick here to enter text.SignatureDate

I certify, on behalf of my agency,that all information contained in this application is accurate and true, based on our current records. I understand that falsifying information or failing to provide accurate information will have a negative impact on my overall review and may result in removal from the Continuum of Care Application to HUD.

Executive Director/CEO/PresidentDate

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