WAP Needs Assessment and Service Plan

NCWAP

02/15

FY 2016 APPLICATION FOR FUNDING

(July 1, 2015 - June 30, 2016)

Weatherization Assistance Program

Heating and Air Repair and Replacement Program

[AGENCY NAME]

North Carolina Department of Environment and Natural Resources

Division of Energy, Mineral, and Land Resources

4345 Mail Service Center

Raleigh, North Carolina 27699-4345

Telephone: (919) 707-9198

Fax: (919) 707-715-1117

______

SECTION I. IDENTIFICATION______

Agency Name:

Mailing Address:

Street Address (if different from above):

Agency Website:

Telephone Number:

Fax Number:

Board Chairperson:

Board Chairperson Email Address:

Executive Director:

Finance Director:

Finance Director Email Address:

Contact Person for Program Narrative:

Contact Person for Budget:

In addition to a signed hard copy of the application, please submit an electronic version of the Application, Budget, and the One-Year Work Programs to your agency’s program analyst.

SECTION II. CERTIFICATION

THIS IS TO CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT AND RECEIVED APPROVAL FOR SUBMISSION BY THE BOARD OF DIRECTORS OR DULY AUTHORIZED BODY.

Typed Name of Board Chairperson

Signature of Board Chairperson

Date of Certification

SECTION III. PROGRAM NARRATIVE __

Needs Assessment, Resource Analysis and Service Plan

1. Describe how your agency will identify and recruit applicants for the program from the following demographic groups:

1. Elderly
2. Disabled
3. Households with young children
4. Households with a high energy burden
5. Households that are considered high energy users

PROGRAM NARRATIVE (Cont.)

1. Identify all staff members below that are currently paid directly, in whole or in part, with weatherization funds. Attach a current resume and job description for each individual and position listed (certifications, licenses, etc.).

1. Attach a current agency wide organization chart that includes all positions that are to be paid, directly or indirectly in whole or in part, with weatherization or HARRP funds.

1. Does your agency plan to subcontract weatherization work (including shell work, insulation placement, and duct sealing) during FY 2015-2016?

1. Identify all firms and individuals that your agency currently contracts with and intends to contract with to perform standard weatherization services including insulation installation and HVAC.

1. Can your agency commit to having a different Auditor and Quality Control Inspector (QCI) on every weatherization job?

1. List the name, BPI number and expiration date of your agency’s certified QCI.

1. If no one on staff is QCI certified, fill out the information below.

1. Attach a copy the agency’s most recent cognizant approved indirect cost rate and full proposal (with supporting calculations) submitted to the cognizant.

1. Attach a copy of agency’s Entity Record from the System of Award Management Site that reflects an expiration date of February 1, 2016 or later.

1. Describe the local training and technical assistance activities that your agency plans to provide for staff and subcontractors using Weatherization Training and Technical Assistance funds received during FY 2016 (identify tentative dates, topics, trainers and costs). Training sponsored directly by the State Weatherization Office should not be listed here.

Date

1. Describe what type of State Weatherization Office sponsored training and technical assistance activities that your agency would like to see planned for the FY 2016 (please reference the NC Training Plan for topics).