STATE OF MISSISSIPPI
COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM
2014
PUBLIC FACILITIES APPLICATION
Applicant:
COMMUNITY SERVICES DIVISION
MISSISSIPPI DEVELOPMENT AUTHORITY
501 North West Street ● Post Office Box 849 ● Jackson, Mississippi 392050849
Telephone (601)3593179
COMMUNITY DEVELOPMENT BLOCK GRANT
APPLICATION
The application form for requesting FY 2014 funds provide a format for presenting proposed project information that can be evaluated according to program requirements and scoring factors that are presented in the 2014 CDBG Final Statement. The application should be completed in the format provided with the appropriate appendices. These instructions are designed to guide the application preparer through the 2013 application forms and should be followed closely to ensure submittal of a complete application that presents the appropriate information.
On completion of the application, the signed original and two copies of the original application form(if the Public Facility project has both water and sewer as an activity, then we will need the signed original and three copies of the application), complete with narrative requirements, budget sheets, attachments, and exhibits must be submitted to:
Mississippi Development Authority
Community Services Division
Woolfolk State Office Building, Suite B01
501 North West Street
Jackson, Mississippi 39201
MISSISSIPPI COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM
PUBLIC FACILITIES APPLICATION
PROJECT OVERVIEW
APPLICANT INFORMATION
Applicant:Street Address
P. O. Box
City/State/Zip
County
Chief Elected
Official Name
Title
Email Address
Telephone
Telefax
Population (2000)Applicant’s fiscal year ending date
Applicant’s DUNS number
Applicant’s CAGE number
Mississippi Senate District number
Mississippi House District number
Mississippi Congressional District number / If the application was prepared by someone other than the applicant, please complete the following:
Name
Agency
Street/P.O. Box
City/State/Zip
County
Telephone
Telefax
Cost to Prepare
PROJECT DESCRIPTION
APPLICANT TYPE
Select One : Small Government Regular GovernmentNATIONAL POLICY OBJECTIVE(S) ADDRESSED
Low and Moderate Income Threat to HealthCOST INFORMATION
Amount of CDBG Funds RequestedAmount of Other Funds
Total Project Cost $0.00
PUBFAC=APP
Page 8
2014
FY 2014 PUBLIC FACILITIES SUMMARY1. Project Description
Category 1 (Water or Wastewater Improvements)
Category 2 (Public Buildings, Streets/Storm Drainage, Flood Improvements, Bridges/Roads, Fire Protection, ADA, or other similar improvements)
Category 3 (Solid Waste, Public Services, GasServiceExtension or Improvements or other similar improvements)
2. MBE/WBE Objective %
List last closed-out CDBG project.
project number:
contractor/subcontractor:
amount of MBE/WBE award:
3. Financial Participation $ Regular Small Government
Source and amount of leveraging funds:
Matching funds ÷ CDBG Request = x 50 = 0.00
Additional points for funds above 100% see page 21 for points ______
4. Low/Moderate Income Benefit %
Total number of low/mod beneficiaries ÷ Total number of beneficiaries
5. Cost Benefit Ratio $
Total CDBG Request ÷ Total number of beneficiaries
6. Non-Funded Bonus Points Applicant has not been funded since 2004
7. Timely Completion: Duration of last funded PF project months
8. GAP County
9. Presentation of Application
PUBFAC=APP
Page 8
2014
SECTION A: GENERAL INFORMATION1. Community problem(s) to be addressed:
Provide a basic description of the problems being addressed by the project. Include a justification of need for this project.
2. The activity(ies) proposed to address the problem(s) identified above is/are:
Thoroughly describe the proposed activities, impact of these activities toward the resolution/
improvement of identified problem(s).
MBE/WBE OBJECTIVE
APPLICANT3. Have you achieved the targeted goals for MBE/WBE participation on the last funded CDBG Public Facility project? The basis for the point award will be as certified by State or Federal agencies for minority business or women’s business participation on the last closed out CDBG project, excluding Demonstration, Self-Help and Emergency/Urgent Needs. The applicant should attach two copies of all documentation of MBE/WBE participation in the appropriate appendix section.
These amounts should reflect the total contracts/subcontracts awarded to MBE/WBE firms. If these columns are completed, proceed to the next table and complete one chart for each CDBG project affected.
CDBG PROJECT # CDBG Award Amount $
Name of Company / Type of Company / Contract/Subcontract Amount
MBE / WBE
MBE / WBE
MBE / WBE
MBE / WBE
4. Funds required for this CDBG project:
List source and amount of all other funds committed to this project in the appropriate space. Please note that certain common sources of funds are already identified. In the column headed "Status," describe the level of commitment (i.e., application submitted, approved, or committed, etc.) and attach evidence. Examples of commitment evidence would include letters from financial institutions, letters of firm commitment from other federal agencies, and/or a resolution by the local unit of government toprovide funding. PLEASE NOTE THAT COMMITMENTS OF OTHER FUNDS MUST BE FINALIZED UPON SUBMISSION OF THE APPLICATION.
The applicant must provide a SUBTOTAL for local cash and value of inkind contributions. A TOTAL for all other funds except program income (including the above SUBTOTAL) must be provided as shown. Program income, CDBG funds requested, and the TOTAL PROJECT COST must be provided as shown.
Source Amount Status
Local Cash
Value of Local Land Donations
Other (Grants/Loans):
Grant:
Loan:
SUBTOTAL A $0.00
Value of In-Kind Contributions
Type of In-Kind Contribution:
SUBTOTAL B $0.00
TOTAL (Subtotal A + B) $0.00
Program Income
CDBG Funds Requested
TOTAL PROJECT COST $0.00
If in-kind funds are part of your matching funds commitment, please complete the Community Development Block Grant In-Kind Contributions Schedule and attach to budget page. The CDBG In-Kind Contributions Schedule can be found in the Program Manual.
SECTION B: BENEFICIARY INFORMATION
1. Total and Low-Moderate Income Beneficiaries:
For each subactivity, the applicant shall list the total beneficiaries, the total low- and moderateincome beneficiaries, and the CDBG funds requested. The amount of CDBG funds allocated to each subactivity can be obtained from the SUBTOTAL line(s) of the Public Facilities Cost Summary Report Sheet. After the information is listed for each subactivity, the CDBG FUNDS REQUESTED column should be totaled.
Subactivity / Total
Beneficiaries
Per Subactivity / Total Low-Mod
Income Beneficiaries
Per Subactivity / CDBG Funds
Requested
No. / Description
1.
2.
3.
TOTAL / $0.00
2. What is the community's total population?
(2000 census information should be used unless the following exceptions apply.)
This will normally be the community's census population with certain exceptions:
If a municipality proposes CDBG activities which extend outside its boundaries (such as water or sewer), use the total population of the municipality plus the total population of the delineated project area outside the municipal boundaries.
For projects in unincorporated portions of counties, the term “community" may be defined as the census block group(s) in which the area of benefit of the project is located.
3. Cost-Benefit Ratio:
4. Census Track and Block Group Number(s) (MUST provide documentation).
5. Project Location (Street Address of the Activity) (Please use the following website to verify the address): https://tools.usps.com/go/ZipLookup (MUST provide documentation).
6. Register with the SAM system to obtain a CAGE number (Please use the following website) https://www.sam.gov/portal/public/SAM/ (MUST provide documentation).
DATA REPORTING INFORMATION:
7. Complete the following table regarding the number of persons who will directly benefit from this project:
Total / Hispanic / Total / Hispanic
11. White / 20. Other Multi-Racial
12. Black/African American / 21. Female heads of
Household
13. Asian / 22. Number of Minorities
14. American Indian/
Alaskan Native / 23. Number of Elderly (+62)
15. Native Hawaiian/
Pacific Islander / 24. Number of Handicapped
16. American Indian/
Alaskan Native and White / 25. Number of Children 18 or
Younger
17. Asian and White
18. Black/African
American and White
19. American Indian/
Alaskan Native and
Black/African American
7. Number of beneficiaries, low/mod beneficiaries and methodology used for this determination:
If the methodology involved a survey, surveys must have been conducted after January 1, 2011. (The applicant is required to use the MDA Grant Survey Form. The completed Grant Survey Summary and Disclosure Form should accompany the application.)
Benefit area is townwide Specific project area
Total Beneficiaries Total Low/Moderate Beneficiaries
Beneficiaries determined by census Beneficiaries determined by survey
If survey, date of survey Survey Response Rate
Total households in project area Total Surveyed
If water or sewer; please complete the following for the project area:
Total number residential customers Total number commercial customers
Total number of households in project area
Total households surveyed
Total vacant Total Not Home Total No Response
8. Non-Funded Bonus Applicant never funded
Indicate whether the local government has not received a Public Facilities grant since 2004.
9. Timely Completion: Year Duration Project Number:
Indicate year and duration (number of months) of last funded Public Facilities project, excluding Emergency/Urgent Needs, Self-Help, Planning and Demonstration Projects.
SECTION C: GENERAL PROJECT INFORMATION
1. Will the proposed project require the acquisition of real property or easements? NOYes
If yes, please provide a detailed explanation.
2. Will the proposed project result in the displacement of any families or businesses? NOYES
If yes, describe the availability and type of relocation resources.
3. Will any activity (ies) take place on Sixteenth Section land? NOYES
If yes, provide a detailed explanation.
If the applicant is in the Chickasaw Cession area of the state, place N/A in the explanation.
4. Is local unit of government retaining program income? NOYES
If yes, please provide terms of agreement.
PUBFAC=APP
Page 8
2014
SECTION D: FOR WATER OR SEWER PROJECTS FOR AN UNSERVED AREA ONLY: If the project involves water or sewer hookups to a currently unserved area, please complete the following for the project area: (If not completed, project will not be considered.)Total Number of Households to be Served: Total Number Low/Mod Households:
Total Number of Persons to be Served: Total Number Low/Mod Persons:
Approximate Cost per Household:
SECTION E: FOR WATER SYSTEM PROJECTS ONLY:
(If not completed, project will not be considered.)
Has the viability determination form been completed and submitted to MDA? NoYes
(Water Viability Assessments were due on April 1, 2014)
Does the water system have plans for consolidation? NoYes
If yes, please state plans for consolidation. Include the name of the systems, approximate number of users, cost for consolidation, existing and future supply, and appropriate mapping, etc. Also, indicate the time frame for implementation. Attach additional sheets as necessary.
Please attach information on the rate structure.
If this is a water project for a new well or tank, does the community already have access to a regional water
supply facility for this need? Please explain.
ATTACHMENTS TO APPLICATION
This list is designed to aid the preparer in determining that all sections of this application have been included before signatures are attached to indicate that the application is complete.
Budget Page
Chief Executive Officer’s Certification
Application Preparer’s Certification
MBE/WBE Participation Documentation (Attach two copies in the original application)
Public Participation
Proof of Publication
Minutes of Public Hearing (Signed)
List of Persons Attending
Maps
General Characteristics Map
Detailed Project Map
If applicable, survey map
Resolution Passed by Local Unit(s) of Government Approving Application Submittal
Census Tract and Block Group Documentation
Project Location - Street Address of the Activity (please use the following website to verify the
address): https://tools.usps.com/go/ZipLookup ( must provide the documentation)
Need (for project) Documentation
Register with the SAM system to obtain a CAGE number (please use the following website to
obtain the number): https://www.sam.gov/portal/public/SAM/ ( must provide the documentation)
Engineering Report (to be tied to project description and appropriate Appendix Item A-H in the Application Manual). The report should specify project activities, timetable for implementation, and a cost estimate for each. The cost estimate should, if possible, separate CDBG and costs being paid locally or by another agency. Cost estimate must be submitted by an engineer or architect on their letterhead as a signed original and stamped. The cost estimate must also include a certification by the engineer that they have reviewed the Engineering Guidelines contained in the CDBG Application Manual and that the engineering data provided in the application was developed in accordance therewith.
Resolution passed by local unit(s) of government committing matching funds regardless of source of funds.
Evidence that matching funds have been officially applied for or are already in place.
If applicable, copy of application with maps and appropriate appendices of application submitted through another funding program (i.e., ARC, DEQ, RD, EDA, CAP).
If applicable, Grant Survey Summary and Disclosure Form (Form located in Program Development Manual)
If applicable, Community Development Block Grant In-Kind Contributions Schedule (Form located in
Program Development Manual)
PUBFAC=APP
Page 8
2014
BUDGETThe budget is the instrument that management employs to express its goals and objectives and to define the guides and controls for achieving these. It is a comprehensive plan for an operating program expressed in financial terms for a specified period of time. The budget is not only a document but also a management tool to be used in addressing general management functions such as planning, operational performance, and control. It includes projections of activities and projects comprising the program, the expenditure requirements, and the available resources.
Please note: Contingency, Engineering and Administration costs are based solely on CDBG costs.
Contingency Costs - In most cases, the budget should include a contingency allowance to cover the incidence of unexpected project costs. An allocation of 8 percent of construction cost will be allowed when applicable.
Engineering Costs - Engineering fees for basic engineering services and construction inspection for water, sewer, and storm drainage projects shall be compared with latest MDA guidelines. Engineering fees for road and street projects will be limited to a maximum of 12% which compares with the latest published guidelines promulgated by the State Aid Division of the Mississippi Department of Transportation. Engineering fees for buildings will be compared with the latest published guidelines promulgated by the Bureau of Buildings. Attach Basic Engineering report and associated Appendix.
Administration Costs - Application preparation fees will be limited to $5,000 for Public Facilities projects. Administrative fees are limited as follows: 10% of the budgeted CDBG programmatic costs (including contingencies) plus the amount allowed for application preparation; or total administrative costs of $40,000, whichever is smaller. (This does not apply to Emergency Public Facilities.)
Audit Costs- Audit cost are not allowed in the Public Facilities CDBG budget. Nor may they it be counted as match.
Legal Costs – Legal cost are not allowed in the CDBG budget. However, they may be allowed as match.
PUBFAC=APP