Application For FY 2012-2013
Community Development Block Grant (CDBG) Funding

Applicant:*

Mailing Address:*

City, State, Zip*

Contact Name*

Title:

Phone:*

Email:

Non-Profit Date of Incorporation:*

Date Designated 501(C)(3):*

Federal ID Number:*

DUNS Number:*

Name of Project:*

Address and/or Specific Location Of Project:

Brief Project Description: (Brief yet specific: e.g. number of people benefiting, square footage of construction, specific services, etc.):*

Proposed Project Funding Summary:

Agency Contribution $*

Other Funding and Sources*

CDBG Request $*

Total Project $*

Authorized Official:

Name:*

Title:*

Date Application Authorized for Submission:*

2012-2013 CDBG Application - Project Narrative: Please provide a brief but specific narrative answer to each of the following items as it relates to your project. (Copy and paste as needed)

A. Give a brief description of the applicant organization including history, purpose, and groups or population targeted or served.*

B. Explain the project for which CDBG assistance is requested. Be specific. If your project involves work that has several elements or components, prioritize most important to least important.*

C. Describe the unmet needs to be addressed by the project. Is the unmet need documented by special studies, surveys, or data? If yes, give titles, dates and scope of each.*

D. Can or is this unmet need being addressed by other agencies or organizations, in whole or in part? If yes, explain.*

E. Identify the geographic area to benefit from the project (including census tracks and block groups if appropriate). Briefly describe the social and economic characteristics of the neighborhood or persons who will benefit directly from the project.*

F. Total number of persons annually participating in or served by the applicant's programs each year:
*

G. Of the total number of persons you serve, indicate the projected annual number of personsthat will directly benefit from the proposed
project (Target Population):
*

H. Of the number of persons that will directly benefit, (Target Population) indicate the approximate percentage that would be considered low to moderate income (Household income of less
than 80% of median – see attached Exhibit A):*

I. Indicate the estimated percentage of the Target Population that is handicapped.*

J. Explain how the project will contribute to the achievement of the Community Development Block Grant goals and objectives.*

K. Provide a detailed project budget - itemize the total cost of the complete project for which CDBG funds are requested. Include amounts and sources of other funding, plus any matching funds to be provided by the applicant. *

L. Provide the name of the consultant, architect, or contractor providing cost estimates for the project and the date the estimate was prepared.*

M. If financial support is available to the applicant from other private, state, or federal programs indicate the amount, source and date of funding commitment.*

N. If funding requests have been or will be proposed to other private state or federal sources, provide the amount of assistance requested, and the anticipated date of commitment.*

O. Explain how the applicant will provide funding for additional or unexpected costs of the project.*

P. If fees are charged for services or participation, explain the fee structure.*

Q. What effect will the project have on future operational budgets of the applicant? Explain how the applicant will maintain the project or continue operation of the project.*

R. If the applicant has received community development assistance for other projects, list the dates, amounts, and purposes of the CDBG assistance.*

EXHIBITS FOR APPLICATION FOR CDBG ASSISTANCE

PROVIDE AS EXHIBITS TO THE APPLICATION ONE COPY OF THE FOLLOWING:

Email to: michael.uriniak@wichitafallstx.gov

1. Resolution, minute action or other documentation indicating that the governing body authorizes the submission of the application and certifies that the applicant will comply with all Community Development Block Grant requirements, assurances and conditions.

2. A list of current and immediate past governing body members.

IF CITY STAFF NOTIFIES THE AGENCY OF APPROVAL, PLEASE PROVIDE:

1. Certificate of Incorporation under the authority of the State of Texas.

2. State Tax Exempt Certificate, and/or IRS Letter of Designation as 501 (c) (3) agency, if applicable.

3. Organizational chart and list of key personnel.

4. Previous fiscal year's audit report.

5. Current fiscal year's financial statement.