Fillable CARES Act Funding Request Application (Christian County Government)

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CARES Act Funding Request Application (Christian County Government)

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The CARES Act Funding Request Application (Christian County Government) form is 6 pages long and contains:

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  • 17 check-boxes
  • 106 other fields

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File type: PDF

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CARES Act Funding Request Application
Page 1 of 8
CARES Act Funding Request Application
This application is geared primarily for future projects seeking funding (Phase II), but also
includes a section for reimbursement of eligible expenditures already made (Phase I).
All applications received will be reviewed and evaluated by the Christian County
CARES Act Funds Distribution Committee as appointed by the Christian County
Commission
Name of Entity making Request
Name of Project
Amount Requested
Has your Organization Received any
other CARES Act related funding
Yes No If yes – amount received
$_________________
Partial Funding - The Distribution Committee
reserves the right to only offer partial funding
for projects, regardless of ranking
Able to accept partial funding for project to be
completed
Not able to accept partial funding for project.
(Without full funding, the project will not be able
to be completed)
This Request is for: Check One
Reimbursement for an expenditure related to
COVID-19 which has already occurred
A new planned expenditure which addresses an
eligible priority need related to the Coronavirus
emergency.
Other
Type of Applicant - Check One
Local Government Entity or Institution
Christian County Govt Office
Non-Profit Organization
Other (Describe)
Location(s) Of Project
Community/City(s) that will be served
Public Entity ONLY
Federal Tax ID:
Christian County CARES Act Committee
1106 W. Jackson St.
Ozark, MO 65721
(417) 581-7242
caresact@christiancountymo.gov
Application No: _____________ Date received: __________________
CARES Act Funding Request Application
Page 2 of 8
Please Provide a Brief Description of the Project or Expenditure
1,000 characters or less
Remote Working Public education
Social Distancing Communication
Sanitation Health Dept.
Wage reimbursement PPE
CARES Act Funding Request Application
Page 3 of 8
Itemized Listing of Expenditures Already Made (Phase I type expenses)
Line Item Request
Description
Date Expense was Incurred
Amount
Total
Evaluation of Expenditures
Please explain how these expenditures allowed your entity to directly respond to the COVID-19 emergency
in terms of:
• What the expense included
• How it relates to the emergency
CARES Act Funding Request Application
Page 4 of 8
Requests for Funding Planned Activity to Be Implemented 1
(Phase II type requests)
Line Item Budget for Request
Line Item
Quantity
Price
Total
Funds Requested
Total
Project Evaluation 2
Please describe how this expenditure has or will benefit the community in terms of:
• Reducing the risk of transmission of COVID-19
• Enhancing overall social distancing
• Educating to the public about recommended actions/practices
• Responding in some other way to the COVID-19 emergency
CARES Act Funding Request Application
Page 5 of 8
Project Implementation 3
Please describe how this project/expenditure will be implemented in terms of:
• Key personnel and qualifications
• Location where expenditures will be utilized
• Time frame from beginning to end of the project or expected lifespan of equipment
For educational projects, list the estimated number of people educated/contacted, number of programs
conducted, etc.: 4
CARES Act Funding Request Application
Page 6 of 8
Executive Summary of the project or expense to be reimbursed 5
Within the $2.2 trillion CARES Act package there are funding streams directed through
Federal agencies to specific sectors. These include but are not limited to:
• Small Business Administration
• Department of Commerce
• Department of Justice
• Department of Education
• Department of Health and Human Services
• Department of Labor
• Department of Agriculture
If your entity is eligible to apply for assistance intended for your sector through one of
these avenues you should be prepared to demonstrate that you have applied for and
been unsuccessful in obtaining that assistance.
Ineligible Costs - Is the application free of all ineligible costs listed? 6
Operating Expenses already covered within the entity’s current budget
Yes No
Costs incurred prior to March 1, 2020 or after December 31, 2020
Yes No
Expenses which are not documented by receipt or paid invoice
Yes No
CARES Act Funding Request Application
Page 7 of 8
Signature Page
Project Reporting Requirements
If approved for disbursement of CARES Act funding, we subsequently agree to furnish
receipts or paid invoices, and/or any other information relevant to the expenditures being
reimbursed.
Final Project Reporting Certification
The Recipient hereby agrees that any equipment purchased pursuant to this agreement
shall be used for the purposes described in this application during the period ending
December 31, 2020. The Grantee shall submit a statement as provided by the County
certifying the use(s) of said funding or equipment is for project activities.
I (We) hereby certify that the information provided in this CARES Act Funding Application is
true and correct. We agree to the Reporting Requirement and the Final Project Certification
Agreement.
Signature of Authorized Official Date
CARES Act Funding Request Application
Page 8 of 8
Contact
If you plan to apply, contact the Cares Act Committee at (417) 581-7242 or
caresact@christiancountymo.gov before beginning your application.
Time Table & Work Plan
Because these funds must be utilized by December 31, 2020, please make clear
when these funds will be utilized.
Line Item Budget
If the space within line item expense listing or project budget is not sufficient,
please feel free to attach additional pages
Documents
If your funding application is approved, an authorized official of the entity will be
required to execute a Final Project Certification agreement which documents the
amount being provided, the intended use and any other requirements including
clawback provisions for funding not utilized or utilized outside the intended
purpose of this program.
Price Quote
Please provide price quote(s) on vendor letterhead for any budget line item
purchase in excess of $4,000.
For any equipment purchase (regardless of cost) you must provide price quote(s)
on vendor letterhead.
501(c)3 Documents
If your organization has 501(c)3 status, please submit documentation.
Application Documents
The Committee will contact grantees after applications are submitted, if needed,
to assure that all required documentation has been provided
If you require additional room to complete any part of this application, please feel
free to reference “attached additional documents”
Other Information
Please submit any other items you would like to include.
Email application and documents to caresact@christiancountymo.gov. Print one copy of the signature page, sign, and
mail or deliver to: Christian County Resource Management Office, Attn; CARES Act Committee, 1106 W. Jackson St., Ozark,
MO 65721
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CARES Act Funding Request Application (Christian County Government)

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Completed 19 January 2021

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