I. GENERAL INFORMATION

Name of Primary Activity Sponsor:*

Mailing Address*

City/State/Zip*

Telephone Number*

DUNS Number

Contact Person*

Email*

Amount of CDBG Funds Requested*

Total Project Cost*

II. ORGANIZATIONAL HISTORY (Applicable only if you are a non-profit organization)

Date organization was founded: *

Date incorporated as a non-profit organization: *

Number of volunteers:

Number of staff:

Federal identification number:

ATTACHMENTS IA & IB: Articles of Incorporation and By-Laws
List of Current Board of Directors

*

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III. PROJECT ACTIVITY (check the applicable category(ies) your application represents)

Economic Development Capital Equipment Public Facilities Improvements (construction) Public Service

Housing Rehabilitation/Preservation Other

If other, explain:

IV. PROJECT NARRATIVE

Name of Project/Program:

Specific Location of Project:

Geographic Area (all localities, not just Bristol) to be served:

1. Provide a detailed description of the proposed project to be funded and how requested funds will be used. Describe precisely what is to be accomplished with the requested funds.

2. Provide a brief, detailed description of the project in quantifiable terms (e.g., the proposed food program will feed 1,000 unduplicated people). One or two sentences only.

3. What are the goals and objectives of the project? Short-term? Long-term?

4. Discuss this project’s benefit to low and moderate-income clients, and identify groups and neighborhoods served by this project.

5. If this is a public service activity, is this a new service provided by your organization?

Yes

No

**If service is NOT new, will the proposed activity substantially increase the existing level of service? Explain:

**In order to receive CDBG grant funds, the public service must be a new or expanded service. To qualify as an expanded service, grantees must demonstrate that there has been a quantifiable increase in the service that was delivered in the prior 12 months. This is a HUD requirement.**

6. If this is a Public Facilities Improvement or Rehabilitation/Preservation project, is the applicant the owner of the building?

Yes

No

If applicant is not the owner of the building, is the property owner a non-profit organization?

Yes

No

Please provide the name and contact information for the property owner:

7. How will you market/promote your program to assure that all who might benefit from the project are provided an opportunity to participate?

8. What are the expected results of the project? How many *unduplicated individuals are expected to be served? (*Unduplicated people served are first time clients counted only once during the project year)

9. How will you measure and evaluate how the project meets its goals and objectives? Measures should be both qualitative and quantitative.

10. Does this project provide housing to individuals/families?

Yes

No

If yes, provide number of existing housing units including how many bedrooms are in each unit:

11. Does this project provide shelter and/or services for the homeless?

Yes

No

If yes, provide the number of existing beds (list number for men, women, and families) and any services provided:

12. What evidence is there of long-term commitment to the proposal? Describe how you plan to sustain the work (project) after the grant funding ends.

V. PROJECT BENEFIT

To be eligible for CDBG funding, a project must qualify within one of the three following categories. Please indicate how the proposed project meets one of the following categories (A, B, or C) and the source of information provided. Questions D and E must be completed.

BENEFIT TO LOW-MODERATE INCOME PERSONS:
Please identify how you will document that the persons served are low to moderate-income persons by providing requested information in either Section A, B, or C (choose only one).

A. Area Benefit: B. Limited Clientele:

C. Clientele presumed to be principally low income persons:

A. Area Benefit:
The project serves only persons in the identified block groups in Census Tracts, which are 51% or more low-income. The listed Tracts and Block Groups are considered eligible.

Tract 201 Block Group 1 Tract 202 Block Group 3 Tract 202 Block Group 4

Tract 203 Block Group 1 Tract 203 Block Group 2

B. Limited Clientele:
The project serves clientele that have documented their income. Identify the procedure you currently have in place to document that the clientele you serve are low to moderate income persons/families (attach additional sheets if necessary). *Limited Clientele will require that organizations collect self-certification forms that track ethnicity, income, etc. from program/organization participants to assure that 51% or more participants are considered low income.

C. Clientele presumed to be principally low-income persons:

HUD presumes the following groups to meet this criterion: Abused children, battered spouses, elderly persons, handicapped persons, homeless persons, illiterate persons, and/or migrant farm workers. Describe your clientele to be served by the activity (attach additional sheets if necessary).

D. Please check all that apply to your organization’s project:

Helps the homeless Helps those with HIV/AIDS

Primarily helps those with disabilities

E. Please check only one for each of the following categories:

1. What is the program/project’s objective?

Create Suitable Living Environments *Benefiting communities, families, and/or individuals by addressing issues in their living environment. Provide Decent Affordable Housing *Housing activities with the purpose of meeting individual family or community housing needs

Create economic opportunities *Activities related to economic development, commercial revitalization, and/or job creation.

2. What will be the program/project’s outcome?

Availability/Accessibility *Public services, public facilities, infrastructure, housing and/or shelter made available to low to moderate income individuals and families including those with disabilities. Affordability *Services that provide affordability for low to moderate income individuals and families including those with disabilities.

Sustainability *Activities aimed at improving and sustaining communities and neighborhoods by eliminating slums and blighted areas.

VI. FINANCIAL INFORMATION

A. Complete the following project budget information to begin on July 1 of this year. Provide total Budget information and distribution of CDBG funds in the proposed budget. If these line items are not applicable to your activity, you may attach an appropriate budget. You must still provide “Total Cost” and “CDBG Share” as requested below.

(1) PERSONNEL/STAFF COSTS: Please complete the following tables. WAGES: Please provide the following information for each member of your program’s staff necessary to administer the proposed program for CDBG funding. If applicable, add additional positions needed as the result of any proposed increase in services, and estimate costs accordingly.