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Important Instructions: Completed applications must include all of the following: ONE original single-sided complete FY 2015/2016 Application signed in blue ink AND SIX double-sided complete copies of the Application. (BACK-TO-BACK TO SAVE PAPER.) ONE electronic version of your completed Application (via zip drive, CD or email) ONE full copy of your Agency’s Accounting Policies and Procedures and Program Policy and Procedures. At a minimum these shall include: Internal Controls, Procurement, Petty Cash, Retention, Payroll, Vacation, Sick Leave and Affirmative Action Plan. PLEASE HIGHLIGHT THESE TOPIC AREAS ON EITHER YOUR TABLE OF CONTENTS OR IN THE DOCUMENTS FOR EASY IDENTIFICATION If applicable, SEVEN copies and ONE electronic version of your Agency’s most recent independent financial audit. The audit must have been completed within the last 12 months (between June 1, 2013 and July 1, 2014). The only exceptions to this requirement is for newly formed agencies (in operation less than 18-months) which are requesting start-up funding or agency’s whose gross revenues do not exceed $2 million dollars. FAILURE TO PROVIDE ANY OF THESE ITEMS WILL DISQUALIFY THE APPLICATION. CITYOF ANAHEIM 2015/2016 CDBG FUNDING APPLICATION CONFIRMATION BY AGENCY REPRESENTATIVE By my signature below, I confirm that I am an official of this Agency legally able to sign Agreements on behalf of the Agency, and that the information provided in this application is true and correct to the best of my knowledge. If funding in any amount is allocated to this Age ncy through the Fiscal Year 2015/2016 Community Development Block Grant (CDBG) funding process, I agree that those funds will be used to provide program(s)/service(s) exclusively to the City of Anaheim, unless otherwise approved by the City of Anaheim. Agency Name: Official’s Signature: (Please sign in blue ink only) Official’s Printed Name: Title: Date: ---PAGE BREAK--- 2 CITY OF ANAHEIM Application Due Date CDBG PUBLIC SERVICE June 27, 2014, 4:45 pm FUNDING APPLICATION - FY 2015/2016 (See Instructions Document) I. SUMMARY INFORMATION (ENTIRE AGENCY) A. Applying Agency B. Program Name C. Program Phone D. Program Address E. Program Contact Person and Title F. Mailing Address (If different from program address) G. Contact Phone H. Contact Email Address I. Federal DUNS Number: J. State EFIN K. Revenue sources of $5,000 or more for the total agency/organization must be listed. Projected (Attach a separate page if necessary) FY 2013/2014 FY 2014/2015 FY 2015/2016 All Other In-Kind Donations (non-volunteer hours) Of the total revenue sources listed above, how much and what percentage is applied in FY2015/2016 to the program for which you are requesting funds? L. Anaheim CDBG funds requested for FY 2015/16: Total For This Program/Project only: $ M. Cities/Communities/Population to be served (be specific) for this Program/Project: N. Anaheim CDBG Funds will be used for: (In 1-3 sentences, be specific and concise at to what program/project the CDBG funds will support O. List the Entire Employee Count and Labor Costs Totals for this Agency: Actual 12/13 Projected 13/14 Proposed 14/15 Proposed 15/16 Number of Full-Time Employees Number of Part-Time Employees Total Salaries and Benefits Total Operating Expenses P. Is the Agency incorporated in California as a non-profit organization? If “YES”, please provide the Date of Incorporation: If “NO,” but the Agency is sponsored by a non-profit organization, please state the name of that organization: ---PAGE BREAK--- 3 II. PROPOSED PROGRAM INFORMATION Provide only information in A thru G below for the proposed program or project for which you are requesting CDBG funding. DO NOT provide information for the entire Agency. A. Name/Title of Program/Project: B. Provide a brief description of the need/problem your program/project will address and include a description of the population to be served: (Max 250 words) C. What is the “Statement of Purpose” or “Mission Statement” for the program/project: (Max 250 words) D. In bullet format, provide the program/project Goals and Objectives: (Max. 250 words) E. Describe your Performance Measurement Outcome System. Please refer to the Instructions Document for information on how to complete this section. Include the following elements in your description by subtitle: Productivity – Level of efficiency (quantity, quality, and pace) ---PAGE BREAK--- 4 Program Impact – Extent to which the activities yield the desired outcomes in the community or in the lives of persons assisted. Performance Measurement Tools - What performance measurement tools do you use? CDBG Program Objectives: Identify which HUD National Objective your Agency will meet: • Activities Benefiting Low and Moderate Income People • Prevention/Elimination of Blight • Urgent Need Identify which HUD objective(s) your program/project will meet: • Create a Suitable Living Environment • Provide Decent Housing • Create Economic Opportunities In the space provided, describe how you will meet the objective(s): (Max. 250 words) Identify which HUD outcome(s) your proposed program/project will improve: • Availability or accessibility of units or services • Affordability not just of housing but also of other services • Sustainability by promoting viable communities In the space provided, describe how your program/project will achieve the outcome(s). (Max. 250 words) ---PAGE BREAK--- 5 F. In the space provided, identify any service voids your proposed program will address and explain how those services will achieve the program goals and objectives. (Max. 250 words) G. If your agency is applying for funds for a duplicative service (a service already funded and provided by another agency), please provide information that would demonstrate a quantifiable increase in services to be provided through the program. For these purposes a 15% increase is determined to be a quantifiable increase. (Max. 250 words) H. What is your agency’s plan to continue moving ahead with this program/project should CDBG funding not/no longer be available to fully or partially fund it? (Max 250 words) ---PAGE BREAK--- 6 III. TARGET POPULATION FOR PROPOSED PROGRAM/PROJECT A. Indicate the number of individuals you served or expect to serve for the proposed program/project: FY 13/14 FY 14/15 FY 15/16 B. Estimate the number of individuals served or you expect to serve with income below 80% of the county median. (See attachment – 2011 HUD Income Guidelines): FY 13/14 FY 14/15 FY 15/16 C. Indicate the number of ANAHEIM residents you served or expect to serve for the proposed program/project: FY 13/14 FY 14/15 FY 15/16 Calculate the % of Anaheim clients by dividing the number of Anaheim clients by the total number of clients served % of total that are from Anaheim % of total that are from Anaheim % of total from Anaheim Please explain the indicators used to determine the number of clients served by income level: D. Explain how your agency will verify residency of households/persons served. (Example: Drivers License, etc.) E. Indicate the percentage of clients to be served from each ethnic group: White Asian AND White Black / African-American American Indian / Native American AND Asian Black / African American American Indian or Alaskan Native Other Multi-Racial Native Hawaiian or Pacific Islander Hispanic American Indian / Alaskan Native AND White Black / African American AND White F. Percentage of clients of each gender to be served: Male Female Female – Head of Household (FHH) (From all the clients served the percentage that are FHH). Calculate the percentage by dividing the number of FHH by the sum of male and female clients. G. Percentage of clients to be served from each age group: 0-5 Years 22-54 Years 6-12 Years 55-75 Years 13-21 Years 76+ Years ---PAGE BREAK--- 7 IV. PROGRAM/PROJECT SPECIFIC - SALARIES & BENEFITS BUDGET SCHEDULE Include all labor expenses for the proposed program/project . Do not limit your information to expenses that will be funded with Anaheim CDBG dollars. Current Year Labor Budget FY 15/16 Proposed Labor Budget Salaries & Benefits Total All Funds Non City CDBG Funds ( Other Funds) City CDBG Funds Total All Funds Non City CDBG Funds (Other Funds) City CDBG Funds Below list titles of all positions for FY 15/16. Include, to the right, the numbers of positions with those titles that are full-time (FT), part-time (PT), or contract for FY 15/16. No. of FT No. of PT No. of C Example: Outreach Worker 1 1 0 30,000 30,000 0 45,000 30,000 15,000 Benefits: List each Retirement Medical/Dental/Vision Other: Such as housing or car allowance Other Labor Expense Totals: A. FY14/15 CBDG Proposed Labor Request V. PROGRAM/PROJECT STAFF POSITION, TITLE, AND QUALIFICATIONS ---PAGE BREAK--- 8 TITLE OF POSITION / DESCRIPTION QUALIFICATIONS 1. (Use bullet points) 2. 3. 4. 5. V1. PROGRAM/PROJECT OPERATING EXPENSE BUDGET SCHEDULE ---PAGE BREAK--- 9 Include all (non-labor) other operating expenses associated with this program/project, no solely those to be funded by CDBG. Current Year Operating Budget FY 2015/16 Proposed Budget Operating Expenses for the Proposed Program Total $ Other Sources City CDBG Total $ Other Sources City CDBG 1. Rent/Mortgage 2. Utilities 3. Telephone 4. Mileage Reimbursement 5. Office Supplies/Equipment 6. Program Supplies/Equipment 7. Maintenance 8. Rehabilitation 9. Maintenance Supplies/Customer Service 10. Conference/Travel 11. Consultant Services 12. Insurance/General Liability 13. Insurance/Director’s Liability 14. Audit 15. Other: a. Other Operating Expense Totals: B. FY15/16 CBDG Proposed Other Operating Request: TOTAL FY15/16 CDBG REQUEST (Section IV-A + Section VI-B) (Total Must Match Section I-L on Page 2014 HUD INCOME GUIDELINES ---PAGE BREAK--- 10 The following is a table designed to aid in classifying the financial status of beneficiaries. For example: a beneficiary from a family of 4 members with a family income less than $27,450 is classified as extremely low income, and a beneficiary from a family of 6 with a total income less than $53,100 is classified as very low income. NUMBER OF FAMILY MEMBERS LOW INCOME LIMITS (80% MFI) VERY LOW INCOME LIMITS (50% MFI) EXTREMELY LOW INCOME RANGE (30% MFI) 1 $50,600 $31,650 $19,000 or less 2 $57,800 $36,150 $21,700 or less 3 $65,050 $40,650 $24,400 or less 4 $72,250 $45,150 $27,100 or less 5 $78,050 $48,800 $29,300 or less 6 $83,850 $52,400 $31,450 or less 7 $89,600 $56,000 $33,650 or less 8 $95,400 $59,600 $35,800 or less * MFI = Median Family Income