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Community Facilities and Historic Preservation Rehabilitation Application

  1. 1. Applicant
  2. Contact Person
  3. 2. Project Information
  4. Address or specific description
  5. 3. Project Eligibility*
    To be eligible for CDBG funding, a project must qualify as an eligible activity under the CDBG Program. Check the category that applies to your project.
  6. 4. Project Benefit*
    To be eligible for CDBG funding, a project must meet the HUD National Objective of benefit to low- and moderate-income persons. Select the National Objective that applies to your project, descriptions can be found in the application instructions.
  7. Describe the proposed project and the work to be performed. Include the purpose for the project, the needs or problems to be addressed, how the needs were determined, how will success of the project be determined, etc. Provide as much detail as possible.
  8. 6. Performance Outcome Measures
    The U.S. Department of Housing and Urban Development (HUD) has instituted performance measures to determine the effectiveness of programs funded with CDBG. Information obtained on the local level will be reported to HUD which will enable HUD to describe performance results at the National level. HUD's outcome performance measurement system has three objectives and three outcomes which are listed in the following questions.
  9. A. Select one of the following that best fits your project objective:*
  10. B. Select at least one of the following that describes the outcome your project will achieve:*
    Descriptions provided in instructions
  11. 7. Project Site
    Please indicate the status of the project site. You will be asked to attach documentation of site control at the end of the application; Attachment L.
  12. 8. Relocation*
    Does this project require temporary or permanent relocation or moving occupants of a structure?
  13. Identify the type of relocation
  14. Including timetable, notification to seller and occupants
  15. 9. Accessibility for Persons with Physical Disabilities
    Federal regulations require that all facilities and/or services assisted with CDBG funds be accessible to the disabled, whenever feasible.
  16. Is this project for physical improvements or a development project?
  17. Will the completed project meet ADA standards for accessibility by the disabled?
  18. 10. Employment and Client Participation
  19. Non-Discrimination*
    Do you notify the public that you do not discriminate based on race, color, religion, gender, sexual orientation, nation or origin, age or disabilities in hiring practices or provision of services?
  20. 11. Receipt of Prior CDBG Funds
  21. Has this organization received CDBG Rehab funding in the past year?
  22. Please list the year(s) of the award(s) and the amount(s)
  23. Please include the following: A. Background – Include the length of time the agency has been in operation, date of incorporation, the purpose of the agency and type of corporation. B. Describe all services and programs offered. If a license to operate your agency is necessary, submit a copy of the license. C. Describe the agency’s existing staff positions and qualifications. D. Do you have a personnel policy manual with an affirmative action plan and grievance procedure? E. Describe the agency’s fiscal management including financial reporting, record keeping, accounting systems, payment procedures and audit requirements. F. Provide evidence of financial accountability such as a recent audit or annual accounting with balance sheets. *Note: Audit Requirements – CDBG Loan Recipients must comply with the Office of Management and Budget SuperCircular 6 2 CFR Part 200, Uniform Administrative Requirement, Cos Principles, and Audit Requirements.
  24. 13. Conflict of Interest Questionnaire
    If you are approved for funding and have answered YES to any of the above questions, a disclosure notice must be issued and a 15-day public comment period must be held prior to execution agreement or release of funds.
  25. A. Are any employees, agents, consultants, officers, or elected officials of the agency requesting funds in a position to participate in the decision making process for approval of this application?
  26. B. Are any employees, agents, consultants, officers, or elected officials of the agency requesting funds in a position to gain inside information with regard to approval of this application?
  27. C. Will any employees, agents, consultants, officers or elected officials of the agency requesting funds obtain a financial interest from this activity?
  28. D. Will any employees, agents, consultants, officers of the agency requesting funds have an interest in any contract, subcontract or agreement with respect to funding this application, either for themselves or those with whom they have family or business ties during the 2016 program year and one year thereafter?
  29. 14. - 16. Budget
    Please attach fully completed budget worksheets (right)
  30. 17. Attachments
    Please attach the required materials below
  31. Documents recognized by the State as formally establishing a private corporation, business or agency. (501 (c)(3) documentation)
  32. Non-profit organizations must submit tax-exemption determination letters from the Federal Internal Revenue Service
  33. A list of the current Board of Directors or other governing body of the agency must be submitted. The list must include the name, telephone number, address, occupation or affiliation of each member and must identify the principal officers of the governing body.
  34. An organization chart must be provided which describes the agency’s administrative framework and staff positions, which indicates where the proposed project will fit into the organizational structure, and which identifies any staff positions of share responsibility.
  35. Certifications*
  36. Leave This Blank:

  37. This field is not part of the form submission.