Fillable 6124 CITY OF HEMET

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6124 CITY OF HEMET

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  • 33 other fields

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File type: PDF

U.S.A. forms for City of Hemet

BROWSE CITY OF HEMET (CA) FORMS

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City of Hemet CDBG Request for Funding
2020/21
1
1. Name of Agency/Department _________________________________________
2. Federal Identification Number _________________________________________
3. DUNS Number _________________________________________
4. Physical Address/Location _________________________________________
of Agency/Department _________________________________________
5. Mailing Address _________________________________________
of Agency/Department _________________________________________
6. Name/Title of Director _________________________________________
7. Director Phone Number _________________________________________
8. Director E-Mail Address _________________________________________
9. Name/Title of Project Manager _________________________________________
10. Project Manager Phone Number _________________________________________
11. Project Manager E-mail address _________________________________________
Is your agency considered a faith-based organization? Yes ☐ No ☐
Is your agency registered as a HUD Section 3 Business? Yes ☐ No ☐
Include the following documentation:
A) Organization’s incorporation as a legally incorporated private
nonprofit organization with 501 (c)(3)current tax exempt status
B) Current listing of Board of Directors
C) Organizational chart
D) Current overall agency budget
E) Current balance sheets and/or most recent annual report
*additional supporting documentation may be requested upon approval for CDBG funding:
-copies of most recent State and Federal Tax returns;
-current copy of adopted by-laws
City of Hemet CDBG Request for Funding
2020/21
2
Activity/Project Name _____________________________________________________
Specific Location ________________________________________________________
of Activity/Project ________________________________________________________
CDBG Funding Requested $________________(amount for this activity/project only)
Provide a detailed budget spreadsheet as attachment #1, including and identifying
other anticipated funding sources, for the entire activity/project. Specifically identify the
anticipated City of Hemet CDBG reimbursed costs (minimum $10,000).
*Funding requests for Infrastructure or Public Facility activities must include at least one
cost estimate from a licensed and insured contractor.
Provide a detailed description of proposed activity/project to be assisted with CDBG
funding. Identify your agency’s timeline for the proposed activity/project; if funded, can
this activity/project proceed on July 1, 2020 and be complete by June 30, 2021? If this is
a public service activity/project, identify the service as new, substantially increased or
improved. Attach additional pages if needed.
City of Hemet CDBG Request for Funding
2020/21
3
Proposed number of persons or households to be served by this activity/project if fully
funded: __________
Of these how many are expected to be City of Hemet residents?_________________
Proposed number of low/moderate income persons or households to be served by this
activity/project if fully funded: __________
Of these how many are expected to be City of Hemet residents?_________________
Is the purpose of this activity/project to:
Help prevent homelessness? Y __ N __
Help the homeless? Y __ N __
Help those with HIV/AIDS? Y __ N __
Primarily help persons with disabilities? Y __ N __
Identify the goals and objectives of the activity/project and how these will be measured
and evaluated to determine success of the project/activity? How will this activity/project
directly benefit low/moderate income persons? What methods will be used to assure that
all who might benefit from the project are provided an opportunity to participate?
Attach additional pages if needed.
City of Hemet CDBG Request for Funding
2020/21
4
Describe your agency’s experience in administering and implementing activities/projects
with federal funds. Include previous CDBG funding years and jurisdictions. Provide title,
name and qualifications of key personnel responsible for the administration and
implementation of the proposed activity/project. Attach additional pages if needed.
City of Hemet CDBG Request for Funding
2020/21
5
Describe your agency’s management policies and procedures regarding personnel, conflict
of interest, procurement, record keeping and financial management, including whether or
not they are written and adopted. Attach additional pages if needed.
City of Hemet CDBG Request for Funding
2020/21
6
CERTIFICATION
The undersigned hereby certifies that:
1. The information contained in the project proposal is complete and accurate.
2. The agency shall comply with all Federal and City policies and requirements
affecting the CDBG program.
3. Sufficient funds are available to complete the project as described, if CDBG funds
are approved.
4. On behalf of the applying agency I have obtained authorization to submit this
application for CDBG funding.
**Attach Minute Action and/or signed Board Approval**
Type Name and Title of Authorized Representative
_________________________________________
Signature of Authorized Representative
_________________________________________ Date: _______________
Telephone: (___) __________________
Email: _________________________________________
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6124 CITY OF HEMET

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Completed 13 July 2020

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