2016
Workforce Development Program (WDP)
Application
Indiana Office of Community and Rural Affairs
Community Development Block Grant Program
One North Capitol, Suite 600
Indianapolis, Indiana 46204
July 2016
APPLICATION COMPLETION CHECKLIST
DO NOT INCLUDE THIS CHECKLIST IN YOUR APPLICATION!
Please place information in the application in the following order so that the OCRA staff can review the information efficiently. Use tabs (preferred) or some other mechanism to separate appendices, and number pages for easy reference.
Application Information (Cover page) (2 Pages)
MAKE APPLICANT INFORMATION PAGE THE VERY FIRST PAGE OF THE APPLICATION
All blanks must be completed
Does Local Match meet minimum % of Total Project Cost?
Table of Contents
Media Information
Original signature of Chief Elected Official
Application Narrative
Project Description Questions
Project Need Questions
Financial Impact Questions
Project Specific Project Development Issue Questions
Community Performance Indicator (CPIs)
Project Completion Timetable
Corresponds to sample
Completion within 24 months of grant award
Project Budget
Are calculations correct on project budget?
Is the grant request allowable according to the maximum grant matrix?
Is detailed budget included?
Does detailed budget break out CDBG, Local, etc?
Do all budget figures agree?
Figures correspond to amounts listed on cover page
National Objective Form
Appropriate national objective indicated
Answered all questions related to the selected national objective
Beneficiaries Form
Do the numbers add up?
Do numbers correspond to income survey results or census?
The CDBG request divided by the total number of beneficiaries does not exceed $5,000 per beneficiary
Citizens Participation
Include all public hearing documentation
Original publisher’s affidavits for both public meetings
Were ads published at least 10 days prior to meetings?
Attach signed minutes of both public hearings
Attach list of attendees for both hearings
Copy of response(s) to comments and/or complaints (if applicable)
Copy of Four Factor Analysis
Copy of Language Access Plan (if applicable)
Documentation of third party authorization to take minutes
Multi-jurisdictional (if applicable)
Citizen participation for each jurisdiction
Two (2) hearings held for each jurisdiction
Readiness information
Readiness to proceed certification, signed in all appropriate places
Financing information/local match documentation
Municipal Resolution authorized by governing body authorizing application and committing local match
Statement from Chief Financial Officer stating funds are available and have been dedicated to this project
Environmental Review information
Environmental Review Form 7 – ER Agency Contact Listing (Copies of letters should not be included.)
Permit information
Site Control information
In-kind Documentation
Legal information
Displacement Assessment
Displacement Plan (see sample)
Assurances and Certifications with Original signature of Chief Elected Official
Civil Rights Certification with Original signature of Chief Elected Official
Federal Funding Transparency Form (FFATA)
Disclosure Report (see Contract Development Form 1 from CDBG Handbook)
Copy of Fair Housing Ordinance
Copy of Drug Free Workplace Policy
Cooperation Agreements (if applicable)
APPENDIX A: National Objective Documentation
Sample In-Take Document (One for each county with correct income limits)
APPENDIX B: Project Description Documentation
Scope of work
Facility conditions
Marketing plan
All Project Development Issues documented
APPENDIX C: Local Effort And Economic Conditions Documentation
Documentation of Need (studies, surveys, etc.)
Training locations and proposed marketing area boundaries or location clearly defined
Partnership Agreement(s)
All Project Development Issues documented
APPENDIX D: Financial Impact Documentation
All Project Development Issues documented
APPLICANT INFORMATION
LEAD (LEGAL) APPLICANT:
CHIEF ELECTED OFFICIAL:TITLE:
MAILING ADDRESS:
CITY: COUNTY: CDBG County Code:
ZIP+4: PHONE: FAX:
E-MAIL:
CHIEF FINANCIAL OFFICER: TITLE:
PHONE: EMAIL:
FEDERAL I.D. /TAX NUMBER: DUNS NUMBER:
CAGE/SAMS CODE (required at application): SAMS EXPIRATION DATE:
SUBRECIPIENT(if applicable):
CHIEF EXECUTIVE OFFICER:
MAILING ADDRESS:
CITY: ZIP+4: PHONE: FAX:
E-MAIL:
FEDERAL I.D. /TAX NUMBER: DUNS NUMBER:
GRANT ADMINSTRATOR:
ORGANIZATION:
ADDRESS:
CITY: ZIP+4: PHONE: FAX:
E-MAIL:
DATE CERTIFICATION FROM OCRA EXPIRES:
PROJECT TYPE:
LMI %: (FROM NATIONAL OBJECTIVE IDENTIFICATION PAGES)
# OF BENEFICIARIES:
PROJECT FUNDING SOURCES
Amount1. CDBG Request
2. Lead and/or Joint Applicants
3. Loans
4. CDBG Program Income
5. Philanthropic Match
6. In-Kind Match*
7. Private and/or Local Grants
8. Other Government Grants
List sources:
9. TOTAL MATCH(add lines 2-8)
10. SUBTOTAL(add lines 1 & 9)
11. Ineligible Costs
12. TOTAL PROJECT COST(add lines 10 & 11)
*In-kind maximum of 5% of grant request.
APPLICANT INFORMATION
(CONTINUED)
List Grant Administrator:
METHOD OF PROCUREMENT (check one):
Grant Administrator: RFPLocal FundsNot Yet ProcuredNA
FAIR HOUSING ORDINANCE: Attached
What year was the policy adopted?
DRUG FREE WORK-PLACE POLICY: Attached
In what Indiana Senate District(s) is this project?
In what Indiana House of Representatives District(s) is this project?
In what US Congressional District is this project?
State Senator(s) representing this district:
State Representative(s) representing this district:
WDP Application 2016
SAMPLE MEDIA INFORMATION TO BE USED IF FUNDED
Please complete the following information to serve as the basis of any future press releases regarding this project.
The (city, town, county) of (name)has been awarded a (program name)CDBG grant application by the Office of Community and Rural Affairs (OCRA) for(describe the proposed project).
This project will(insert summary of scope of work here)
The total estimated cost of the project is $(estimated cost), which includes $(grant request amount) of OCRA CDBG funds and $(local match amount) in local match. It will benefit residents (explain who this project will serve or how it will impact residents).
This project wouldn’t be possible without the following partnerships(list partners and describe roles).
The district is served by (State Senator(s) and(House Representative(s).
Please contact (local contact person’s name and title) at (phone number)regarding this project for all local inquiries.
CEO CERTIFICATION APPROVING THE ABOVE INFORMATION:
______
SignatureDate
Name: (typed or printed)Title:
Preferred CEO contact information to be reached for an initial quote, if awarded:
NARRATIVE / PROJECT DEVELOPMENT ISSUES (PDIS)
PROJECT DESCRIPTION:
Be sure to address all Project Development Issues. If not applicable, please note why.
Limit responses to these questions to two (2) pages total. Include appropriate documentation in Appendix B.
1.) Give a detailed description, in non-technical terms, of the proposed project and desired outcomes at conclusion of the grant period. Include the scope of work, including any ineligible items.
2.) What is the estimated enrollment in trainings per calendar year? How many classes are expected?
3.) Will training result in recognized certification? If so, please explain the reach of the recognition.
4.) Where will the training occur? What are the conditions and locations of the training facility? Please attach color pictures with captions of current conditions in Appendix.
5.) Explain any staff and/or volunteer commitments for the program.
6.) How will the program be marketed and where? Who is the target clientele?
7.) What is the screening process for applications and who will be responsible for this process?
8.) Describe the strategy for job placement assistance or why a strategy is not needed.
LOCAL EFFORT AND ECONOMIC CONDITIONS:
Be sure to address all Project Development Issues. If not applicable, please note why.
Limit responses to these questions to two (2) pages total. Include appropriate documentation in Appendix C.
9.)What brought this project to the forefront (i.e., is there a need for specific certifications)?
10.) Can any survey results, studies, prior planning, community input, or other data be cited to explain the need? Please attach applicable copies of the information in the Appendix.
11.)Who will be served (i.e. city, town, county, region, etc) (reference map as applicable)?
12.)Who are the partners/organizations committed to providing programs and services? A Partner Letter of Commitment from all outside agencies is required, outlining contribution.
13.)Is this a new service, or the expansion of a current program? If so, describe the expansion (i.e., new service, extended service, additional target clientele, etc.)
14.)Explain all previous efforts of the region to address this issue. Explain lessons learned from prior efforts.
FINANCIAL IMPACT:
Be sure to address all Project Development Issues. If not applicable, please note why.
Limit responses to these questions to one(1) page total. Include appropriate documentation in Appendix D.
15.)Who will be providing the local match? Eligible local match can be local cash, debt or in-kind sources. Federal, state, and local government grants are considered eligible match. A Partner Letter of Commitment from all outside agencies is required, outlining contribution.
16.)Are private industries contributing? Are local and/or economic development organizations contributing?
17.)What is the strategy for sustaining the program past the grant period?
COMMUNITY PERFORMANCE INDICATORS (CPIs)
Applicants are asked to make a reasonable case for how the proposed project would improve one or more of these indicators in the area served by the proposed project.
Please answer one or more of the following questions in 250 words or less for each question. Statistical references for each metric can be found in the instructions.
1.) How will this project positively affect Gross Assessed Valuation?
(Limit response to 250 words)
2.) How will this project positively affect Population Growth?
(Limit response to 250 words)
3.) How will this project positively affect Public School Enrollment?
(Limit response to 250 words)
4.) How will this project positively affect Educational Attainment?
(Limit response to 250 words)
5.) How will this project positively affect Per-capita Income?
(Limit response to 250 words)
PROJECT COMPLETION TIMETABLE
Beginning with the application submission date, outline below a reasonable timetable for project completion. Include all significant milestones, emphasizing those related to plans, permits, bids, contracts, financing, acquisition of property, construction, and completion.
Applicant Name: Project Name:
TASK / DATE*Environmental Release is due two (2) months after grant award;
*Bid Deadline is six (6) months after grant award, if applicable;
*Release of Funds Deadline is eight (8) months after grant award.
*ALL ACTIVITIES MUST BE COMPLETED WITHIN 24 MONTHS OF GRANT AWARD DATE.
PROJECT BUDGET
Please complete the table below.Also, immediately following this page, attach itemized cost estimates for each line item.Do NOT include any miscellaneous, contingency, general costs, etc. in budget.
ACTIVITY / CDBG / LOCAL(with eligible In-kind) / INELIGIBLE / TOTAL
Professional Fees
Materials
Overhead
Marketing
Office Supplies
Grant Administration
(Max 5% of CDBG)
Environmental
(Max $500)
TOTAL
NOTES:
* In-kind up to 5% of the grant amount or $12,500, whichever is less, may be included in the Local column of the budget, all amounts in excess should be included in the Ineligible column.
* Program Delivery: (maximum 10% of total project costs): includes Overhead, Marketing, Office Supplies
* Marketing: maximum of 2% of grant amount to be allowed as match or within grant request
List sources of local match and leveraged funds:
(Documentation of financial commitments from all sources is required)
Source / AmountTOTAL LOCAL LEVERAGE
Detailed PROJECT BUDGET
ITEM / CDBG / LOCAL / INELIGIBLE / TOTALNATIONAL OBJECTIVE IDENTIFICATION
ALL PROJECTS MUST PROVIDE ALL INFORMATION REQUESTED ON THIS PAGE.
Include appropriate documentation in Appendix A.
NATIONAL OBJECTIVE (check one):
WDP Application 2016
Benefit Low-and Moderate-Income Persons: Limited Clientele
1) List percentage of population of low to moderate income persons served by this project: %
2) Source: General PresumedIntake Document (Appendix A)
WDP Application 2016
3) If generally presumed, which category?
4) List the census tract number(s) that are included in the project area:
5) List the census tract block group(s) that are included in each of the census tracts listed above:
6) Below, explain your selection of the above H.U.D. National Objective and how this project meets the National Objective selected. REFER TO THE INSTRUCTIONS FOR QUESTIONS TO BE ADDRESSED REGARDING THE NATIONAL OBJECTIVE SELECTED.
BENEFICIARIES
Total Beneficiaries must equal the sum of 1-10.L/M and Non-L/M must equal the sum of 1-10.
Project Title: Total Beneficiaries (all activities):
Total / Of the total population in the service area how many are Hispanic? / Activity DescriptionNumber of People
SINGLE RACE / 1. Number of Whites
Percent
2. Number of Blacks / AfricanAmericans
Percent
3. Number of Asian
Percent
4. Number of American Indian / Alaskan Native
Percent
5. Number of Native Hawaiian / Other Pacific Islander
Percent
MULTI-RACE / 6. American Indian / Alaskan Native & White
Percent
7. Asian & White
Percent
8. Black / African American & White
Percent
9. American Indian / Alaskan Native & Black / African American
Percent
10. Balance / Other
Percent
Number of Handicapped
Percent
Number of Elderly People
Percent
Number of Female-headed Households
Percent
Number of Low/Moderate-Income People
Percent
Number of Non-Low/Moderate People
Percent
CITIZEN PARTICIPATION REPORT
CDBG information to the public / DateNotice of first public hearing
Date of first public hearing
Notice of second public hearing
Date of second public hearing
Describe the methods used to solicit participation of low to moderate income persons:
Denote any adverse comments/complaints received and describe resolution:
Describe outcomes of 4-Factor Analysis for Limited English Proficiency:
WDP Application 2016
Immediately following this page, attach the documents below in the order listed:
Hearing Ad/Publisher’s Claim for First & Second Hearing
Hearing Minutes for First & Second Hearing
Sign-In Sheet for First & Second Hearing
Copy of response(s) to comments and/or complaints.
Copy of Four Factor Analysis
Copy of Language Access Plan (if required)
Third Party Authorization Letter (if applicable)
WDP Application 2016
READINESS TO PROCEED CERTIFICATION
The (City/Town/County) of namehereinafter referred to as “Applicant”, submits this certification to the Indiana Office of Community and Rural Affairs, hereinafter referred to as “OCRA” respective to the Applicant’s application to OCRA for federal Community Development Block Grant (CDBG) funding. This certification is submitted to OCRA to assure that the Applicant has attained sufficient readiness in order to complete the subject project within twenty-four (24) months after award of the CDBG grant by OCRA. The Applicant warrants that the project will be completed within twenty-four (24)months following CDBG grant award, and herein indicates the level of readiness-to-proceed respective to the following areas:
* Project Financing
* Completion of required environmental review process
* Project engineering and/or architectural services
* Control of all interests in real property necessary to complete the project (site control)
* Obtaining necessary local, state and federal permits to complete the project
Project Financing
As Chief Elected Official (CEO) of the Applicant, I hereby certify that all non-CDBG sources of funding necessary to carry out the project as listed in the project application have been secured and are available for expenditure immediately upon full execution of the CDBG grant agreement between Applicant and OCRA, and subsequent release of funds by OCRA. I further certify that all such project matching funds will be placed into, and disbursed from, a separate special fund in accordance with I.C. 36-1-8-12, as amended by House Enrolled Act 1542 of the Acts of the 1997 General Assembly. Pertinent comments respective to this certification are indicated below.
______
SignatureDate
Name: (typed or printed)Title:
(List any comments regarding this section here)
STATUS OF REQUIRED ENVIRONMENTAL REVIEW PROCESS
As Chief Elected Official (CEO) of the Applicant, I hereby certify that the subject project activity will require the following type of environmental review respective to 24 CFR Part 58:
Fill in the type of activity: (Exempt, Categorical Exclusion, Environmental Assessment)
Except for an exempt activity, I further certify that all applicable local, state and federal agencies have been contacted in writing and the present status of the environmental review process for this project is as follows (you must check one box for every line):
YESN/AAll agencies have been contacted and all responses by these agencies have been received no negative environmental comments received.
All agencies contacted - all responses received - negative environmental comments received - mitigation necessary; actions necessary to mitigate negative environmental concerns are as follows: (list actions below)
All agencies contacted - no negative environmental comments received from commenting agencies; comments still pending from following agencies: (list agencies below)
The Indiana Department of Natural Resources has required that an archaeological reconnaissance be conducted, and this reconnaissance has been conducted, and no negative findings resulted there from; OR, negative findings resulted and the following mitigation steps are necessary: (list steps below)
Format II Equivalency completed. (N/A for Categorically Excluded)
Environmental assessment completed - Finding of No Significant Impact (FONSI) determined - ready to publish combined notice (N/A for Categorically Excluded)
Notice of Intent to request Release of Funds - ready to be published (Categorically Excluded only)
Certification of Exemption Form completed
______
SignatureDate
Name: (typed or printed)Title:
(List any comments regarding this section here)
PROJECT ENGINEERING AND/OR ARCHITECTURAL SERVICES
As Chief Elected Official (CEO) of the Applicant, I hereby certify that all preliminary architectural and/or engineering services necessary to complete the environmental review process have been completed and the Applicant is prepared to immediately proceed with final architectural and/or engineering services upon award of the CDBG grant by OCRA.
______
SignatureDate
Name: (typed or printed)Title: