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Community Development Block Grant Program Project Application ~ Program Year 2018-2019 AGENCY INFORMATION Name of Agency: Mailing Address: City: Zip Code: Phone Number: Fax Number: Contact Person: Title: Federal Tax I.D.: DUNS: Type of Agency: [ ] City [ ] Private Non-Profit [ ] Other (specify): Registered in Central Contractor Registration (CCR): [ ] Name of Program or Activity: Location of Activity: Total Funding Amount Requested for the 2018-2019 CDBG Program Year: Brief Description of Program: NATIONAL OBJECTIVE Community Development Block Grant projects must meet at least one of the following three National Objectives. Please check the National Objective the proposed project intends to meet: 1 a. Benefits LOW and MODERATE INCOME persons according to income guidelines (a minimum of 51% of those served with household income verified); or 1 b. Benefits abused children, elderly persons, battered spouses, homeless persons, handicapped persons, illiterate persons or migrant farm works (the activity must be designed so that one of these groups are benefited); or 2. Address SLUM or BLIGHT in a specific area (the area must be qualified and the activity must assist in eradication of slums or blight); or 3. Address a particularly URGENT community need for which there is no other form of assistance available (such as disaster relief). ---PAGE BREAK--- REQUIRED DOCUMENTS The following documents MUST be submitted with the application in order to be considered for funding. Applications that do not include ALL of the following items will not be considered for funding. Attach separate sheets as necessary. DETAILED PROJECT DESCRIPTION Include how the project meets at least one of HUD’s National Objectives. Describe the steps necessary to set up the project, or if applicable, to continue the project. Describe how the project will be implemented and who will be responsible for the implementation. List the measurable goals to be accomplished for the 2018-2019 CDBG program year (Quantity to be served/completed). Describe how the project meets one of HUD’s objectives of providing a suitable living environment, decent housing, or economic opportunity with an outcome of availability/accessibility, affordability, or sustainability. The Project should meet one objective and one outcome. DETAILED PROJECT BUDGET Include a detailed budget summary of program to be funded. Include all funding sources. Complete the “Personnel Costs” worksheet that is provided. Complete the “Total Operating Budget – Expenses” worksheet that is provided. Complete the “Total Operating Budget – Revenue” worksheet that is provided. Direct Assistance. ARTICLES OF INCORPORATION/BYLAWS Articles of incorporation are the documents recognized by the State as formally establishing a private corporation, business or agency. NON-PROFIT DETERMINATION Non-Profit organizations must submit tax-exemption determination letters from the Federal Internal Revenue Services and the State Tax Franchise Tax Board. LIST OF THE BOARD OF DIRECTORS A list of the current board of directors or other governing body of the agency must be submitted. This list must include names, telephone numbers, addresses, occupation or affiliation of each member and must identify the principal officer of the governing body. AUTHORIZATION TO REQUEST FUNDS Documentation must be submitted regarding the governing body’s authorization to submit the proposed application. Documentation of this requirement consists of a copy of the minutes of the meeting in which the governing body’s resolution, motion, or other official action is recorded. FINANCIAL STATEMENT AND MOST RECENT AUDIT The agency must submit the most recently completed audit of their organization along with the financial information already requested in the application. CONFLICT OF INTEREST STATEMENT The agency must provide a Conflict of Interest provision, which applies to any person who is an employee, officer, or elected official of the agency. LONG-RANGE PLAN Provide evidence that the agency had developed a comprehensive long-range plan for a three to five year period, which establishes goals, measurable objectives, and implementation strategies. EVIDENCE OF INSURANCE Submit information to provide evidence of Liability and Worker’s Compensation Insurance coverage. ---PAGE BREAK--- PERSONNEL COSTS Wages Please provide the following information for each member of your program’s staff. POSITION OR TITLE HOURLY RATE * HOURS PER WEEK # MONTHS EMPLOYED TOTAL COST CDBG SHARE $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL PERSONNEL COSTS $ 0.00 $ 0.00 * inclusive of fringe benefits. TOTAL OPERATING BUDGET - EXPENSES Use Whole Dollars Only A Audited/Most Recently Completed Year* to . B Current Operating Year to . C Proposed Budget July 1, 2018 to June 30, 2019 PERSONNEL EXPENSES Salaries (incl. benefits & taxes) Professional & Consultant Fees Other Personnel Related Items SUB-TOTAL $ 0.00 $ 0.00 $ 0.00 BUILDING EXPENSES Occupancy Utilities/Communications SUB-TOTAL $ 0.00 $ 0.00 $ 0.00 SERVICE AND SUPPLIES All supplies/equipment costs Travel, Transp., and Conference. Membership Dues Awards and Grants $0.00 Insurance $0.00 Miscellaneous Expenses Specific Assistance to Individuals Other Expenses-Explain Below SUB-TOTAL $ 0.00 $ 0.00 $ 0.00 TOTAL EXPENSES $ 0.00 $ 0.00 $ 0.00 ---PAGE BREAK--- OTHER EXPENSES Item(s): Amount: Item(s): Amount: Item(s): Amount: Item(s): Amount: Explanation of Other Expenses: TOTAL OPERATING BUDGET - REVENUE Use Whole Dollars Only A Audited or Most Recently Completed Year* to . B Current Operating Year to . C Proposed Budget July 1, 2018 to June 30, 2019 PUBLIC SUPPORT Contribution Foundation & Private Grants Fundraising/Special Events Legacies & Bequests Other Federated Organizations United Way Miscellaneous Organizations Other SUB-TOTAL $ 0.00 $ 0.00 $ 0.00 GOVERNMENT Federal State Local SUB-TOTAL $ 0.00 $ 0.00 $ 0.00 OTHER REVENUE Membership Dues Program Service Fees Investment Income Transfer from Other Fund All Other Revenue SUB-TOTAL $ 0.00 $ 0.00 $ 0.00 TOTAL REVENUE $ 0.00 $ 0.00 $ 0.00 ---PAGE BREAK--- Provide a list of other sources of funds CDBG funds from other cities or counties, private sources, United Way, etc.) with amount, source, and date awarded, if applicable. Source: Date Awarded: Amount: $ Source: Date Awarded: Amount: $ Source: Date Awarded: Amount: $ Source: Date Awarded: Amount: $ Source: Date Awarded: Amount: $ ORGANIZATIONAL INFORMATION Please check either “YES” or “NO” for the following questions and provide the requested data for the twelve (12) month period ending June 30, 2017. LEGAL REQUIREMENTS FOR NON-PROFIT AGENCIES 1. The agency is incorporated as a non-profit organization and currently has exempt tax status (501)(c)(3) of the IRS Code and 2370(d) of the California Code. Yes No 2. The agency has maintained its California tax-exempt status. Yes No 3. Agency has maintained their Non-Profit Corporation status by filing the appropriate documents: Yes No Form 990 with the IRS Yes No Form 199 with the California Franchise Tax Board Yes No Statement of Domestic Non-Profit Corporation with the Secretary of State of California Yes No ---PAGE BREAK--- The undersigned hereby certifies that: The information contained in this document is complete and accurate; The proposed program described in this application meets one of the National Objectives governing the use of Community Development Block Grant (CDBG) funds; The applicant shall comply with all Federal and City policies and requirements affecting the CDBG program; If the project is a facility, the sponsor shall maintain and operate the facility for it’s approved use throughout its economic life; and Sufficient funds are available from non-CDBG sources to complete the project, as described, if CDBG funds are not allocated to the applicant. Name and Title of Authorized Applicant Representative Signature of Authorized Applicant Representative Date Applications must be received no later than: 2:00 pm, Tuesday, January 16, 2018 at City of Palmdale, Attn: Sarah Scott, Neighborhood Services, 38250 Sierra Highway, 2nd Floor, Palmdale, CA 93550. Post marked and e-mailed applications will not be accepted. CDBG Contact Person: Sarah Scott – Housing Coordinator (661) 267-5126 or [EMAIL REDACTED] Application is available via e-mail in Microsoft Word format, upon request**