Fiscal Sponsor S Primary Contact

[Type here]

Select your Local Planning AreaNC-500 ForsythNC-501 BuncombeNC-502 DurhamNC-503-R1 BoS Region 1NC-503-R2 BoS Region 2NC-503-R3 BoS Region 3NC-503-R4 BoS Region 4NC-503-R5 BoS Region 5NC-503-R6 BoS Region 6NC-503-R7 BoS Region 7NC-503-R8 BoS Region 8NC-503-R9 BoS Region 9NC-503-R10 BoS Region 10NC-503-R11 BoS Region 10NC-503-R12 BoS Region 12NC-503-R13 BoS Region 13NC-504 GuilfordNC-505 MecklenburgNC-506 Tri-HicNC-507 WakeNC-509 Gaston-Lincoln-ClevelandNC-511 CumberlandNC-513 OrangeNC-516 Northwest

Fiscal Sponsor Information

Name of Organization: / Select Organization Type:
Choose One501(c)3 Non-Profit OrganizationUnit of Local Government
Street Address: / Mailing Address:
Telephone: / Website:
Federal Tax ID Number: / DUNS #:
Date of Incorporation:
mm/dd/yyyy / Organization’s Fiscal Year: mm/ yy to mm/ yy

Fiscal Sponsor’s Primary Contact

Please provide the following information for the person to whom all communication regarding this application should be directed.

Name: / Title:
Telephone: / E-mail:

Signatory Authority

Please enter the information for the person authorized to sign contracts for your organization.

Name:
/ Title:
Telephone: / E-mail:
Mailing Address:

Fiscal Sponsor Capacity

1.  Does the Fiscal Sponsor have paid staff to provide administrative support for the ESG funds? Select yes or noYesNo

2.  Do you have the financial capacity to pay subrecipients while you await reimbursement from the NC ESG Office? Select yes or noYesNo

3.  Describe the procedures for reviewing projects applicants’ audits, requisitions, and grant spend down rates.

4.  Describe the follow up procedures to assure that all issues and findings are addressed.

5.  The Fiscal Sponsor is required to perform the following activities:

·  Hold the ESG contract with the State

·  Sub-contract with all other ESG agencies

·  Reimburse ESG sub-contractors for eligible ESG activities

·  Submit reimbursement requests to the State on behalf of the region

·  Be the central point of contact for all reporting requirements

·  Coordinate monitoring visits and training opportunities in the region

Does the Fiscal Sponsor commit to performing these duties? Select yes or noYesNo

Attachments

The Fiscal Sponsor must attach forms as described in Appendix A: Application Checklist found in the ESG Application Information Packet.

Certification

I certify that we understand the duties as described above and will perform them for all applicants in our Local Planning Area.

Name of LPA Lead Agency Organization
Name of Authorized Official
Title
/ Date
Signature

FY17 NC ESG Fiscal Sponsor Application 2