Fillable Application Checklist (City of Baton Rouge / Parish of East Baton Rouge)

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Application Checklist (City of Baton Rouge / Parish of East Baton Rouge)

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The Application Checklist (City of Baton Rouge / Parish of East Baton Rouge) form is 9 pages long and contains:

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  • 42 check-boxes
  • 122 other fields

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File type: PDF

U.S.A. forms for City of Baton Rouge / Parish of East Baton Rouge

BROWSE CITY OF BATON ROUGE / PARISH OF EAST BATON ROUGE (LA) FORMS

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Page 1 of 9
Application Checklist
B
e sure to include all items requested on the Application Checklist:
Completed application pack
et
Application signed by authorized official
Three (3) copies of completed application
Proof of IRS 501(c)3 status (if applicable)
List of Organization’s Board of Directors
Proof of registration and good standing with Louisiana Secretary of State
Copy of most recent financial audit
Application Certification
• Organization has no conflict of interests with City-Parish appointed or elected representatives and do not employ
C
ity-Parish appointed or elected representatives of their families.
• O
rganization will comply with federal requirements to be observed by organizations being funded with HUD funds
,
including compliance with Federal Labor Standards, Section 3, Segregated Facilities, Equal Opportunity, Non-
Discrimination, FFATA, Section 109, Title VI and EO
11246.
• A
uthorized official certifies that this Application packet has been reviewed and all information provided in this
application and attachments is true and correct
.
_________
____________________________________ _____________________
Signature of Authorized Organization Representative Date
_____________________________________________
Printed Name
_________
____________________________________
Title
_________
____________________________________
Organization
click to sign
signature
click to edit
Page 2 of 9
City of Baton Rouge – East Baton Rouge Parish
HUD Funding Project Application
1. Organization Information
______________________________________________________
CDBG
______________________________________________________
______________________________________________________
______________________________________________________
Yes No Supporting Documents Attached
______________________
______________________
Proposed Project Name/Title
Type of Funding Requested
(Select One)
Amount of Funds Requested
Name of Organization
Executive Director/CEO
501(c)3 Status
DUNS Number
Tax ID Number
Physical Address
Mailing Address
Phone/Fax Number
Website
Project Manager
Phone Number
Email Address
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Type of Organization
CDC
CHDO CBDO
CDBG
Page 3 of 9
2. Organization History and Experience
Using ONLY the space below, provide a brief history of the agency, including a description of the history,
mission, services of the organization, description and experience of staff, and federal grant management
experience:
Page 4 of 9
3. Project Details
Proposed Project Title: ____________________________________________________________
Project Location & Service Area
In the space provided below, describe the location where the services are delivered as well as the geographic
area(s) that are served:
Program Beneficiary Population
Select one or more to describe the population served by your project:
Low- to moderate-income population (individual household income will be demonstrated via
documentation provided by beneficiary); OR
Presumed Benefit (check one or more below)
Battered Spouses Homeless Individuals
Elderly Individuals Abused Children
Persons Living with AIDS Adults with Disabilities
Beneficiary Goal
How many UNDUPLICATED individuals will this program serve? _________________________________
Outcome Statement
Please provide an outcome statement to be achieved through the use of federal funding:
___________________________ will receive ___________________________________________________
Number of Units Served Type and amount of service
Type of Activity
(Check all that apply):
Senior Services Domestic Violence Services Health Services
Handicapped Services Employment Training Mental Health
Legal Services Crime Awareness/Prevention Homeownership
Youth Services Fair Housing Activities Rental Subsidies
Transportation Services Housing Counseling Food Banks
Housing Neighborhood Revitalization Child Care Services
Homelessness Slums/Blight Reduction Other
I
f "other" provide further detail: __________________________________________________
Page 5 of 9
4. Project Description
Using only the space below, describe the Scope of Work for the proposed project. Detail each service
activity the program will undertake, describe the intake procedures, location and hours of operation, as
well as the staffing and outreach plan:
Page 6 of 9
5. Project Need
In the space below, explain our community’s need for this type of service and how the proposed project
will address that need:
Do other organizations provide similar services that the address the needs described above? How will the
proposed project/program differ from similar programs?
Page 7 of 9
6. Project Goals and Sustainability
If the proposed project is not awarded the full amount requested, how will the organization be
able to implement the project with partial funding?
How will the organization be able to continue to provide these services if these federal funds are not
awarded next year?
Program Milestones
In the space provided below, please outline the goals and milestones your organization will meet
throughout the funding year. Include information such as the number of people served or units of service
to be provided.
Quarter of
Activity
Activity/Action
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Page 8 of 9
7. Proposed Budget
Use the chart below to detail the budget for the proposed project. Be sure to include other funding sources,
if applicable, to demonstrate leveraging of funds/
Specific Cost
Item/Description
Federal Funding
Request
Other Funding Source
Other Funding
Amount
Total Amount
Federal + Other Source
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Total Federal Funds Requested
$
Total Program Cost (Federal + Other)
$
Page 9 of 9
8. Budget Justification
Please provide specific details as to how the requested amount for each line item was determined:
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Application Checklist (City of Baton Rouge Parish of East Baton Rouge)

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Completed 2 August 2020

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