Emergency Solutions Grant Program

EMERGENCY SOLUTIONS GRANT PROGRAM

TABLEOFCONTENTSANDCHECKLIST

LeadApplicantname: ______

ProviderorSub-recipientnamedinthisapplication:______

Thisisapplicationis#___ofatotal#___ofapplicationsbeingsubmittedbythisleadapplicant.

Leadapplicantsareresponsibleforsubmittingcompleteapplicationsandrequiredattachmentsbythedeadline.Contentsoftherequiredtwocopiesoftheapplicationmustbetabbedandorganizedasfollows:

TAB#1–APPLICANTINFORMATION– Applicantinformation,non-profitserviceproviderinformation,projectsite,typeoffundingrequested,thenumberofapplicationssubmitted,totalfundingrequest,chartoffundingrequest,chartandstatusofpriorESGawards.

TAB#2–PROGRAMPROJECTNARRATIVE–Anoverviewofthesetofprojectsbeingsubmittedbytheleadagency, includingtheirrelationshiptooneanother;and,asummaryofthespecificprojectsubmittedinthisapplication. Thisisrequiredforallleadapplicationsandislimitedtofourpages.

TAB#3–STATEMENTOFNEED–(35points)Populationtobeservedrelativetolocalneeds,performancemeasurementsystem,andanyobstaclestootherfunding.

TAB#4–PROJECTDESIGN,BUDGETTIMELINE – (45points)Projectdescription,projectbudget,descriptionofactivities/projects,typeanduseofmaintenance,operatingexpenses,casemanagement,directclientservices,shelterstaffingcosts,administrativefundsandprojectoractivitydetailsoffinancing.

TAB#5–PROVIDERCAPACITYEXPERIENCE–(10 points)Prioradministrativeandprojectexperience,clienttrackingsystem,homelessnesspreventionassistance,overallcapacity.

TAB#6–SUPPORTIVESERVICES–(25points)Availabilityofsupportiveservicesandabilityofproviderstoconnectclientstothem;howtheactivitywillenhanceacommunity-widerangeofcare.

TAB#7–PROGRAMREQUIREMENTSANDCERTIFICATION–Signedcertificationbythehighestelectedofficial.

TAB#8–BUILDINGANDHABITABILITYCERTIFICATION–SignedbytheExecutiveDirector

TAB#9– CONCURRENCEOFSUPPORTFROMTHECoC–SignedbytheLeadCoC

TAB#10–ADDITIONALINFORMATIONATTACHMENTS-photographsoftheproject(s), etc.

Introduction

TheEmergencyShelterGrantsProgram(ESG),originallyestablishedbytheHomelessHousingActof1986toaddresshomelessnessamongmen,women,andchildrenintheUnitedStates, was incorporated in 1987 into subtitleBofTitleIVoftheStewartB.McKinney-VentoHomelessAssistanceAct(42U.S.C.§§11371-11378).In2009,PresidentObamasignedtheHomelessEmergencyAssistanceandRapidTransitionto

Housing(HEARTH)Act,abillthatreauthorizedtheMcKinney VentoHomelessAssistanceprogramsandsubstantiallyrevisedtheEmergencyShelterGrantsProgram,renamingittheEmergencyShelterGrantsprogram(ESG).

ESGfundsmaybeusedtoassisthomelesspersonsandthoseatriskofbecominghomeless.TheStateofMarylandwillreceiveapproximately$953,756infederalESGfundsforthefederal2014 fiscalyear. Theadministeringagencyforthisfunding istheDepartmentofHousingandCommunityDevelopment(“theDepartment”)throughitsDivisionofNeighborhoodRevitalization.FederalESGregulationsprovidethattheStateshallallocateallfederalESGfundsto localgovernmentsandnonprofitsratherthanadministeringactivitiesdirectly.

Federalguidelineslimit 60%ofthefederalESGallocationtobeusedfor“ShelterEssentialsandOutreach”. Inaddition,federalofficialsareencouragingincreaseduseoffunds for RapidRehousing, andtheStateisinterestedinmovinginthatdirection. OthereligibleactivitiesarelistedbelowandexplainedfurtherintheESGProgramGuide.

Inaddition,theMarylandlegislaturerecentlypassedtheGovernor’srequestforabudgetallocationof justover$2millioninstateoperatingfundstomatchandenhancefederalESGfunds, allowingtheDepartmenttoexpanditsfiscalyear2015supportforactivitiesthatassistthehomelessorthoseatriskofhomelessness.Acombinedtotalofjustunder$3millionisnowbeingmadeavailablethroughthis Request for Proposal(RFP). Thetotalmaximumallowablerequest,perleadapplicant(localgovernment),is$145,000includingamaximumof $65,000infederalfundsandamaximumof $80,000instatefunds.

EligibleApplicants:

A.LeadApplicants:Leadapplicantsareunitsof localgovernment.Aleadapplicantwillsubmitoneormoreapplicationsforprojectsthattheywilladministerdirectlyorthattheywillsponsoronbehalfoflocalsub-recipients. LeadApplicantsareresponsibleformonitoringandcomplianceoftheirsubrecipients.

B.SubRecipients: Sub-Recipientsmaybeunitsoflocalgovernmentornonprofits.

EligibleActivities:

ThiscombinationofstateandfederalESGfundsmaybeusedforthefollowingeligibleactivitiesbelow,whicharefurtherdefinedintheESGProgram Guide:

StreetOutreach:toengagehomelessindividualsandfamilieslivingonthestreet,
EmergencyShelter:toimprovethenumberandqualityofemergencysheltersforhomelessindividualsandfamilies; and,toimprovetheeffectiveoperationofemergencyshelters;provideessentialservicestoshelterresidents,
HomelessPrevention:topreventfamiliesandindividualsfrombecominghomeless,
RapidRehousing:torapidlyre-househomelessindividualsandfamilies,
HMIS:tosupportexpensesrelatedtodatatrackinganddatacoordinationamongawardeesandCoCmembers, and
AdministrativeExpenses:tosupportoperatingexpenseofupto5%oftotalprojectcosts.

Fundsmayalsobeusedforessentialservices,suchascasemanagement,inconnectionwiththeaboveactivitiesinordertoassist clientsinmakingthetransitiontopermanenthousingandindependentliving. ApplicantsareencouragedtothoroughlyreadtheProgramGuide andrelatedandongoingHUDguidanceasallawardeeswillberequiredtoadheretoallstateandfederalrequirementsforESGfunding.

ApplicationSubmittalandReviewProcess:

Reviewteamswillreadandscoreallapplicationsbasedonthepointscalebelow. Thereviewteamswilljointlydevelopawardrecommendations.Particularconsiderationwillbegiventotheextentofhomelessnessintheareasservedbytheapplicant(s)basedondataprovidedbytheU.S.DepartmentofHousingandUrbanDevelopmentandU.S.Censusaswellasadditionalinformationthatmaybesuppliedbytheapplicant.

Applicationratingandrankingwillbebasedonthefollowingpointsystem:

StatementofNeed(35points)
ProjectDesign,BudgetTimeline(45points)
ProviderCapacityExperience(20points)
SupportiveServices(25points)

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EMERGENCY SOLUTIONS GRANT PROGRAM

PART1–COREAPPLICATION(TAB1)

A. Local Government Applicant Information:

Applicant:
FederalID#
DUNS#
ApplicantStreetAddress:
City: / County: / ST: / ZipCode:
Phone# / WebAddress:
LOCALGOVERNMENTCONTACTPERSON
ContactPerson: / Title:
ContactAddress:
City: / State: / ZipCode:
Phone# / Email:

Checkhereifgrantfundswillbeutilizedonlybythelocalgovernmentlistedabove,

andthenskiptosection3below.Iffundswillbeutilizedbyoneormoresub-recipients,

proceedtoSection#2below.

B. LocalGovernmentOrNonprofitServiceProvider

LocalGovernmentorNonprofitServiceProvider Name
FederalID#
StreetAddress:
City: / County: / ST: / ZipCode:
Phone# / WebAddress:
ESGNon-ProfitServiceProvider: / Faith-Based: / Public: / OtherNon-Profit:
Local Government OrNonprofitServiceProviderContactPerson
ContactPerson: / Title:
ContactAddress:
City: / ST: / ZipCode:
Phone# / Email:
ProjectSite
NameofProjectSite
StreetAddress:
City: / County: / ST: / ZipCode:
Phone# / WebAddress:
LegislativeDistrictoftheProjectSite:

C. Applicant’sContinuumOfCare(CoC)Information

LeadAgency:
HUDID#
StreetAddress:
City: / Jurisdiction(s): / ZipCode:
Phone# / ContactPerson:

D.ProjectActivities:

Checkallthatactivitiesapplytothisprojectapplication.

HomelessnessPreventionRapidRehousingStreetOutreach
EmergencyShelterHMIS Administrative

E.FederalESGfundingrequestforthisprojectapplication:

($65,000-totalmaximumperleadapplicant)

AmountrequestedbythisapplicationforthisServiceProvider: $__

TotalfederalESGfundsrequestedforallFFY2014projectapplications: $_____

F. StateESGfundingrequest for this project application: ($85,000-totalmaximumperleadapplicant)

AmountrequestedbythisapplicationforthisServiceProvider:$__

TotalStateESGfundsrequestedforallFFY2014applications: $_____

G.PriorYearESGAwards:

PleaselistallfundspreviouslyawardedtoTHISESGPROVIDER forthepast4years.

ProjectName / FiscalYear / FundsAwarded / FundsExpended / Balance

PleaseindicatebelowthepercentageofprioryearESGfundsexpendedasofthedateof thisapplicationsubmission.Inaddition,pleasedescribehowwellthisproviderachievedtheprojecta goal for which funding wasawardedinprioryears.Discussanyfactorsthatmayhavehinderedprogressofimplementingprojectsin prior years and what is beingdonetoovercomefuture barrierstoprogress.

H.Sub-RecipientInformation:

Ifthisapplicationinvolvessupportforasub-recipientserviceproviderthatisanonprofitorganization,theleadapplicantisresponsibleforconfirmingthatthefollowinginformationiscollectedandreviewedbytheleadapplicantandisavailableforDHCDreview.

1.ArticlesofIncorporationAmendments

a.Articlesofincorporationaredated:

b.Articlesarecurrentlyineffectandhavenotbeenamended. YesNo

c. Ifapplicable,amendmentsdatedareavailablealongwiththearticlesofincorporation.
YesNo NA

2.By-laws

a.Bylawsaredated

3.CharitableOrganizationDesignation

a.InternalRevenueServiceletterrecognizingtheorganizationasexemptfromincometaxationunderSec.501(c)(3)oftheIRSCode

b.Theorganization’smostrecentIRSForm990isdated:

c.TheorganizationhasacurrentcertificateofgoodstandingfromDepartmentofAssessmentandTaxation.YesNo

e.Theorganization’sfinancialandaccountingmanualwasadoptedormostrecentlyrevised .

4.GoverningBoard

a.ListofBoardofDirectorsYesNo

b.Officerswerelastelectedonthefollowingdate: _____.

All lead applicantsarerequiredtocompleteon-sitemonitoringoftheirfundedproviders; thisincludesfinancialandprogrammaticmonitoring.

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EMERGENCY SOLUTIONS GRANT PROGRAM

PART2- PROGRAMPROJECTNARRATIVE: (TAB2)

Inthissection,infourpagesorfewer,brieflyaddresseachofthefollowingsections: (theanswertosectionAwillbethesame/duplicatedbytheleadagencyincaseswheremultipleprojectapplicationsaresubmittedbytheleadagencyonbehalfofsub-recipients).

A.OverallESGStrategy:

Describetheleadapplicant’soverallstrategyforuseofESGprogramforthetotalstateandfederalfundingbeingrequestedandhowtheindividualprojectsbeingfundedworktogethertomeettheemergencyneedsofhomelesspersonsinyourjurisdiction.

B.ProjectActivitiesandMethods:

Forthespecificprojectproposedinthisapplication,describetheeligibleactivitiesthatwillbeundertakenandthemethodsforaccomplishingtheseactivities.Describethespecificsub-populationstobeassisted.

C.RelationshiptoCoCandtheCoCPlan:

Describehowtheprojectinthisapplicationrelates to and addressestheneedsidentifiedbytheCoCplanforthisjurisdiction.

D.LocalCoordination:

Arethereotherservicesthataddressthesameneedinyourjurisdiction?Ifso,howaretheseservicescoordinated?

E.Accessing Services:

Explainhowthosethatare homelessorat-riskofhomelessnessaretriagedtofindtheappropriateservice(s)inthisjurisdiction (forinstancethroughacentralizedorcoordinatedassessmentsystem).DescribeiforhowtheproviderforthisprojectutilizestheCoC’scentralizedorcoordinatedassessmentsystem.

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EMERGENCY SOLUTIONS GRANT PROGRAM

PART3– STATEMENTOFNEED(TAB3)(35points)

A. ProjectServiceArea:

Describeyourservicearea. Attachamapoftheserviceareaandindicatethesiteofanyproviders,shelter(s),campswheretheunshelteredmaycongregate,andotherrelevantinformation.

B. PerformanceMeasurement:(30points)

1. ProjectGoals:(10points)
Indicatethisproject’sspecificgoalsfor thenumberofindividualsandfamiliestobeassistedinthefollowingcategories:emergencyshelter,streetoutreach,rapidrehousing,andhomelessnesspreventionassistanceduringthetwo-yearmaximumgrantperiodOctober1,2014–September30,2016.

2. HUDmetrics:
UsingtheselectedHUDobjectiveandselectedoutcomesindicatedinthechartbelow,estimate thenumber of peopleexpectedtobeprimarilyserved. Forfurtherguidance,pleaseusethe2014ESGProgramResourceandGuide(“PerformanceMeasurement”)section

OBJECTIVE–SuitableLivingEnvironment
OUTCOME– Availability/Accessibility / *Individualsproposedtobeserved / Familiesproposedtobeserved
SuitableLivingEnvironment–EmergencyShelters,TransitionalHousingPrograms,StreetOutreachandEssentialServices)
OBJECTIVE–DecentHousing
OUTCOME– Affordability / Individualsproposedtobeserved / Familiesproposedtobeserved
DecentHousing(HomelessnessPreventionAssistance,EvictionPrevention)

*Individual-personwithoutaspouseorchildren

3. ProjectNeed: (10points)

Describetheneedfortheservicesdescribedinthisapplication,includingthelevelofhomelessnessoverallandforsub-populationsinyourservicearea. Emphasizeanytrendsoverthepastyear(s)inthenumbersortypesofhomelesspersonsandthoseat-riskofhomelessnessserved. Documentthesefactorsandtrendsbycitingstatisticsandindicatethesourceforthestatistics.

4.DataTracking:(10points)

Describehowyouragencytracksdataandhowthedataisusedtosetgoalsandmonitorprogress,suchasfor:

Successatreducingthenumberofindividualsandfamilieswhobecomehomeless
Overallreductioninthenumberofhomelessindividualsandfamilies
Thelengthoftimeindividualsandfamiliesremainhomeless
Theextenttowhichindividualsandfamilieswholeavehomelessnessexperienceadditionalspellsofhomelessness
Jobsandincomegrowthforhomelessindividualsandfamilies
Thethoroughnessofaward recipientsinthegeographicareainreachinghomelessindividualsandfamilies

5.MSHDWParticipation:(5points)

DescribeyourparticipationintheMarylandStateHomelessDataWarehouse(MSHDW),includinghowtheproviderandtheCoCcoordinate.

PART 4 -- PROJECTDESIGN, BUDGET AND TIMELINE TAB5 (45 POINTS)

A.ProjectDesign: (15points)

Asapplicabletothisproject:Describeprojectactivities(s)forwhichfundingisbeingsoughtinthisapplication. Providedetailsonallphasesoftheactivity/project. Provideevidenceoftheeffectivenessofthisproject’sapproach,particularlyifthisisacontinuationofactivitiesfundedinprioryears.

1. StreetOutreach:

DiscusshowtheServiceProviderwilllocate,identifyandbuildrelationshipswithunshelteredhomelesspersonsforthepurposeofengagementandservices.

2.EmergencyShelter:

Discussthetypeandusageoffundsbeingrequested.Inaddition:

Hastheshelterexperiencedanyviolentornon-violentincidentsinthepast24months,ifso,istheshelterrequestingESGforsecurity?
DescribehowtheshelterhascompliedwiththeShelterandHousingstandards.
Discussthetypeandusageofshelterstaffingcostsbeingrequested. (Donotincludecasemanagersorserviceproviderscoveredunderessentialservices)

3. RapidRehousing:

Describe the RapidRehousingservicestobeprovidedandhowtheserviceswillbeadministered.In addition:

DiscussthemonthlyamountofrentassistanceforRapidRehousing,perESGparticipant.IsthisamountconsistentwiththeCoCrentalassistancewrittenstandards?
Discussthecostofahousinginspectionandhowtheagencywillcoverthecost.
Explainhoweligibilityandpaymentsaredeterminedandprocessed.

4.HomelessPrevention:

Describe theHomelessPreventionservicestobeprovidedandhowtheserviceswillbeadministered.In addition:

DiscussthemonthlyamountofrentassistanceforHomelessPrevention,perESGparticipant.IsthisamountconsistentwiththeCoCrentalassistancewrittenstandards?
Discussthecostofahousinginspectionandhowtheagencywillcoverthecost.
Explainhoweligibilityandpaymentsaredeterminedandprocessed.

5.HMIS:

Describetheprovider’suseoftheHomelessManagementInformationSystem(HMIS)and use of funding if needed. In addition, provide the following:

NameoftheHMISsoftware:
HMISServiceProviderName:
HMISServiceProviderAddress:

6. Administrative Services:

Describethetypeandusageofadministrativefundsbeingrequested(up to5%ofthetotalprojectcosts).

7. EssentialServices:

Describethecasemanagementandotherdirectclientservicestobefundedbythisgrantandhowtheseserviceswillbeadministered.

B.ProjectBudget:(15points)

Fully complete theattachedProjectBudgetworksheet. Inaddition:

ESG Budget: ExplainandjustifyeachproposedbudgetlineitemandwhyESGfundsarerequested.Willtheapplicantandsub-applicantdrawdownESGfundsquarterly,explain?

Non-ESG Support:Providedetailsofotherfinancialsupportforthisproject,including:

Identifyproposedresourcesforothercashand/ornon-cash;
Explainthecommitmentstatusofothercashand/ornon-cashcontributions;
Identifyandexplainhowothersourcesofrequiredcashornon-cash,notcurrentlycommittedwillbesecured;and
Providedetailsofanyothercontributions,grants,donationsorawardsthatorganizationreceives.

FundingObstacles:PleasediscussanyobstaclesthisprojectorproviderhasingainingaccesstootherhomelessfundinginyourCoCjurisdiction

C.ProjectTimeline:(5points)

Describetheworkplanandtimelineforprojectimplementationforeacheligibleactivitydescribedinthisapplication. Includemilestonesformeetingprogramandbudgetgoalsforthegrantperiod.

D.RelationshiptoCoCandLocalDataReporting:(5points)

CoC participation:Describetheprovider’sparticipationinthelocalCoC.WhatroledidthisproviderhaveindevelopingtheCoC’swrittenstandards?

CoC objectives:Explainhowthisproject/activityaddressesContinuumofCare(CoC)homelessnesspreventionobjectivesinyourCoCjurisdiction.

E.MatchingFunds:(5points)

DescribefundsthatwillmatchorfurtherenhancetheuseofESGfunds.ThisnarrativemustrelatedirectlytotheinformationsummarizedonMatchingFundsChartbelow.Alsopleasenote:

Applicantmustprovidewrittendocumentationthatthesefundswillbeavailableduringthegrantterm.Thesecan belettersofsupportorotherformsofdocumentationthatconfirmsthematchamount.PlacethesedocumentsunderTAB#10andlabelthem“MatchingFundsSupportDocuments”.
Atleast20percentofthematchshouldbeincashandnon-cashcontributionfromtheprivatesector
Acashand/ornon-cashcontributionbythelocalgovernmentisstronglyencouraged.Pointsinthissectionwillbeheavilyinfluencedbythelevelofmatchingsupportfromthelocalgovernment.

SourceofMatchingFunds / Amount / DateofLetter / Private/LocalSupport / Committed

PART5-- PROVIDERCAPACITYEXPERIENCE (TAB5) (10Points)

A. ProviderCapacity: (10points)

Describetheprovider’scapacitytoundertakeandimplementtheproposedprojectorprogram. Thediscussionshouldinclude,butnotbelimitedto,itemssuchasstaffing,organizationalstructure,coordinationwithotherservices,recentrecognitionorawards,andexperiencewithotherprogramsthatservethehomelessorvulnerablepopulations.

B. ProviderExperience: (10points)

Asapplicabledescribetheprovider’strack recordintherecentprovisionofthe followingservices (FFY2012):

ShelterManagementandServices:

IftheproviderhasadministeredanESG-fundedshelterpreviously,discusstheresultsoftheseefforts. Forshelterproviders,thediscussionshouldincludedatasuchasthebednightsprovidedandtheaveragelengthofstayaswellashowmanyofthosewhowereshelteredmovedtotransitionalshelters,howmanybecomeemployed,howmany,ifany,becameself-sufficientandotheroutcomeinformation(useinformationbelow-FFY2012data).(5points)

HomelessPrevention:

Forprovidersofhomelesspreventionassistance,completethefollowingitemizationforthemostrecentyearofservice:

AmountofESGfundsusedforhomelessnessprevention$

Amountofotherfundsusedforhomelessnessprevention$
NumberofhouseholdsassistedwithESGfundsfor:

Evictionprevention
Utilityassistance(includingheatingoilorothernon-meteredheatsources.)
Mortgageforeclosureprevention
Securitydeposit/firstmonth’srentassistance

Numberofhouseholdsassistedwithother(non-ESG)homelessnesspreventionfunds

WereESGfundsusedtoprovideemergency(e.g.motel)short-termplacementinlieuofshelterplacement? Yes No

Ifso,howmanybednightswereprovided?

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EMERGENCY SOLUTIONS GRANT PROGRAM

RapidRehousing:

Forprovidersofrapidrehousingassistance,completethefollowingitemizationforthemostrecentyearofservice:

AmountofESGfundsusedforrapidrehousing$
Amountofotherfundsusedforrapidrehousing$
NumberofhouseholdsassistedwithESGfundsfor:

Evictionprevention
Utilityassistance(includingheatingoilorothernon-meteredheatsources.)
Mortgageforeclosureprevention
Securitydeposit/firstmonth’srentassistance

Numberofhouseholdsassistedwithother(non-ESG)homelessnesspreventionfunds

WereESGfundsusedtoprovideemergency(e.g.motel)short-termplacementinlieuofshelterplacement? Yes No

Ifso,howmanybednightswereprovided?

PART 6-- SUPPORTIVESERVICES(TAB6)(25Points)

A. ServiceConnections: (10points)

Discussindetailtheneedforandtheserviceprovider’sabilitytoconnectclientstorelevantsupportiveservicesinordertoimprovetheirhousingstabilityandself-sufficiency. Providedatathatsupportstheidentifiedneedsfromstatisticalsources,i.e.U.S.CensusBureau,AmericanCommunitySurvey(ACS),CurrentPopulationSurvey(CPS),MarylandDepartmentofPlanning,andMarylandDepartmentofLabor,LicensingandRegulation(DLLR.

B. SupportiveServices: (10points)

Listthesupportiveservicesandidentifyhowtheseserviceswillassistwiththeproposedactivityorproject. Examplesofservicestobeaddressedare: jobsearchandjobtraining,substanceabusetreatment,medicalandhealthcareservices,daycare,lifeskillstraining,housingandtransportation.

C. ConnectiontoCoCplan:(5points)

Howdo thesesupportiveservices,assistinthecoordinationofESGactivitieswith theCoC.AretheregapsintheCoCjurisdictionforsupportiveservices? Ifso,whatneedsarenotadequatelyaddressed,orinwhatareas,couldcoordinationofservicesbeimproved?

PART7-- PROGRAMREQUIREMENTSANDCERTIFICATION(TAB7)

TheformofthisapplicationconformstotheprovisionsofDHCD’sFFY2014ESGProgramandResourceGuide(the“Guide”). TheGuidedescribesthefederalandstaterequirementsgoverningtheuseofthegrantfunds. AnapplicantcannotreceiveitsfundsunderanESGawardunlessithasexecutedanagreementwithDHCDcertifyingitswillingnesstocomplywiththerequirementsdescribedintheGuideandotherrequirementsasmaybedirectedbytheFederalgovernment,whichincludesbutnotlimitedtotherequirementtoinputclientdataintoaHomelessManagementInformationSystem(HMIS)orcomparablesystem.

TheundersignedherebycertifiesthatthesubmissionofthisapplicationforEmergencySolutionsGrantfundsisauthorizedunderlocallawandthattheleadapplicant,possessestherequisiteauthoritytoadministertheEmergencySolutionsGrantactivitiescontemplatedbytheapplicationinaccordancewithapplicablelawandregulationsoftheU.S.DepartmentofHousingandUrbanDevelopmentandoftheStateofMaryland.

Theundersignedfurthercertifiesthattheinformationsetforthinthisapplicationandintheattachmentsinsupportoftheapplicationistrue,correctandcompletetothebestoftheundersigned’sknowledgeandbelief.

Inwitnesswhereof,theapplicanthascausedthisdocumenttobedulyexecutedinitsnameonthis______dayof______,2014.

______

(Nameof leadapplicant,aunitoflocalgovernment)

By:

______

(Signatureofchiefelectedofficial)

Title:

______

CERTIFICATIONOFBUILDINGANDHABITABILITYSTANDARDS

FORSERVICEPROVIDERSRECEIVINGESGFUNDSFROMSTATE

I,______(nameandtitle),dulyauthorizedtoactonbehalfofthe______(NameofShelter);herebycertifythatfollowingrequirementsaremet:

□Sheltermeetsthelocalgovernmentsafetyandsanitationstandards

□SheltermeetsESGprogramsafe,sanitary,andadequatelymaintainedstandards:

□StructureandMaterialssound

□Accessible

□AdequateSpaceandSecurityforparticipants

□InteriorAirQuality

□WaterQualityandSupply

□Accessible

□SanitaryFacilities

□ThermalEnvironment

□IlluminationandElectricity

□ProperFoodPreparation

□SanitaryConditions

□Fire-SafetySleepingandCommonAreas

By:______

SignatureofExecutiveDirectorandDate

______

PrintExecutiveDirectorName

______

Title

CERTIFICATIONOFCONTINUUMofCARE(CoC)CONCURRENCE

I,______(nameandtitle),dulyauthorizedtoactonbehalfofthe______(CoC),herebyapprovetheapplicationprovidedby______(serviceprovider) fortheESGactivity(ies)whicharetobelocatedin______(nameoftheofthejurisdiction):

TheCoCcertifiestothefollowing:(checkallthatapply)

□CentralizedorCoordinatedAssessmentSystemisestablished.

□Sub-applicanthasaHMISandentersdatathatmeetstheCoCqualitydatastandards.

□Sub-applicantusestheCoordinatedAssessmentSystem.

□WrittenstandardsfortheCoCjurisdictionareinplace.

□Sub-applicantparticipatesinthelocalplanningprocessofcommunity-wideCoC

Please explain, if the sub applicant has not met the above requirements:

______

By:______

SignatureofLeadAgencyoftheCoCandDate

______

PrintNameofSignatoryofLeadCoCPerson

______

Title

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