Fillable March 09, 2021 Dear Emergency Solutions Grant (ESG)

Fill Online, Printable, Fillable, Blank March 09, 2021 Dear Emergency Solutions Grant (ESG) Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

March 09, 2021 Dear Emergency Solutions Grant (ESG)

On average this form takes 66 minutes to complete

The March 09, 2021 Dear Emergency Solutions Grant (ESG) form is 38 pages long and contains:

  • 10 signatures
  • 63 check-boxes
  • 195 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
2021-2022 Kansas ESG
REV. 03/04/2021
1
March 09, 2021
Dear Emergency Solutions Grant (ESG) Applicant,
Attached you will find the ESG Application for Program year 2021.
The amount of funding for the 2021 ESG is $1,654,437.00.
This application requires that you certify that if awarded a 2021 ESG grant, your agency and your
sub recipient agencies are in compliance with the Uniform Administrative Requirements, Cost
Principles and Audit Requirements for Federal Awards at 2 CFR part 200.
All agencies must use a Homeless Management Information System (HMIS) or HUD compliant,
comparable database and able to meet all ESG and Continuum of Care reporting requirements.
One (1) original and three (3) copies of the application must be postmarked by;
Tuesday, May 25, 2021.
Applications submitted via mail or other delivery system should be sent using that company’s
return receipt process, as this will be your notice that the application has been received. For the
2021 ESG, The ESG grant period will be for twelve (12) months, July 01, 2021 through June 30,
2022. HMIS funds will be capped at 1.5% of the total amount of ESG funds awarded. All shelters
must complete the ESG Shelter Habitability Checklist (att. 14).
Submit the application package to:
James Chiselom
Kansas Housing Resources Corporation
611 S. Kansas Avenue, Suite 300
Topeka, Kansas 66603-3803
If you have questions or need additional information, please feel free to contact me at:
(785) 217-2046.
Sincerely,
James Chiselom
Program Manager - ESG
Enclosure
REV. 03/04/2021 2
2021
KANSAS EMERGENCY SOLUTIONS GRANT APPLICATION
SECTION I: SUB RECIPIENT APPLICANT INFORMATION (City, County)
Sub Recipient is responsible for the administration of the ESG and coordination of the ESG programs in
the geographical jurisdiction.
A. Applicant Information
Sub Recipient
Authorized
Representative
Title
Address:
City
Federal I.D. Number:
State
Zip Code
Contact to whom
questions about
this application should be directed:
Telephone
Fax
E-mail Address
B. Total ESG REQUEST (all applying agencies)
ESG Agency
Street
Outreach
Shelter
Homeless
Prevention
Rapid
Re-Housing
HMIS
Totals
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Sub Totals
$
$
$
$
$
$
C. Counties
1.)
4.)
2.)
5.)
3.)
6.)
2021-2022 Kansas ESG
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
2021-2022 Kansas ESG
REV. 03/04/2021
3
D. PERFORMANCE OUTCOME MEASURES
The U. S. Department of Housing and Urban Development (HUD) is instituting performance measures to
gather
information to determine the effectiveness of programs funded with CDBG, ESG, HOME and
HOPWA. 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 perfor
mance measurement system
has three objectives and three outcomes which are listed below.
1.
Select one of the following that best fits your project objective:
Suitable living environment
Decent affordable housing
Creating economic opportunity
2.
Select at least one of the following that describes the outcome your project will achieve:
(NOTE: Outcomes show how programs benefit a community or people served.)
Availability/Accessibility (Applies to activities that make services, infrastructure, housing,
shelter,
or
employment opportunities available or accessible to low income persons by improving or
providing new services, etc.)
Affordability
(This applies to making an activity more affordable for low income persons.)
Sustainability
(Using ESG resources in a targeted area to help make that area more viable/livable.)
3.
Please describe the process to establish and select the above objectives and outcomes.
(Must be included)
Certification: To the best of my knowledge and belief, the data in this application are true and correct. This
document has been duly authorized by the governing body of the applicant. The applicant will ensure
compliance with the ESG regulations of 24 CFR Part 576, the Uniform Administrative Requirements Cost
Principles and Audit Requirements for Federal Awards at 2 CFR part 200, the ESG grant agreement and
federal and state regulations if assistance is approved
.
Signature of Authorized Official of Governing Body Date
Title
click to sign
signature
click to edit
2021-2022 Kansas ESG
REV. 03/04/2021
4
SECTION II: ESG PROGRAM DESCRIPTION
EMERGENCY SOLUTIONS GRANTS (ESG)
CFDA Number: 14.231
Agency: Department of Housing and Urban Development
Office: Office of Community Planning and Development
(24 CFR Part 576 – Emergency Solutions Grants Program)
Objectives:
The Emergency Solutions Grants Program (ESG) program provides funding to: (1) engage homeless
individuals and families living on the street; (2) improve the number and quality of emergency shelters for
homeless individuals and families; (3) help operate these shelters; (4) provide essential services to shelter
residents, (5) rapidly re-house homeless individuals and families, and (6) prevent families and individuals
from becoming homeless.
Eligibility Requirements:
Applicant Eligibility:
Kansas Housing Resources Corporation (KHRC) as a State Recipient must sub grant all of their ESG funds
(except for funds for administrative costs and, under certain conditions, HMIS costs) to units of general-
purpose local government and/or private nonprofit organizations. KHRC as recipient must consult with the
Continuum(s) of Care operating within the jurisdiction in determining how to allocate ESG funds.
Beneficiary Eligibility:
The minimum eligibility criteria for ESG beneficiaries are as follows: For essential services related to street
outreach, beneficiaries must meet the criteria under paragraph (1)(i) of the “homeless” definition under §
576.2. For emergency shelter, beneficiaries must meet the “homeless” definition in 24 CFR 576.2. For
essential services related to emergency shelter, beneficiaries must be “homeless” and staying in an
emergency shelter (which could include a day shelter). For homelessness prevention assistance,
beneficiaries must meet the requirements described in 24 CFR 576.103. For rapid re-housing assistance,
beneficiaries must meet requirements described in 24 CFR 576.104. Further eligibility criteria may be
established at the local level in accordance with 24 CFR 576.400(e).
Credentials/Documentation:
Recipients must certify they will meet program requirements and applicable federal requirements.
Government recipients and sub recipients must comply with Uniform Administrative Requirements Cost
Principles and Audit Requirements for Federal Awards at 2 CFR part 200.
Regulations, Guidelines, and Literature:
The program regulations can be found at 24 CFR Part 576. Guidance on the program can be found at
www.hudexchange.info/esg
.
2021-2022 Kansas ESG
REV. 03/04/2021
5
SECTION III: ESG PROGRAM COMPONENTS AND ELIGIBLE ACTIVITIES
Emergency Solution Grant Funding can be used for five program activities: street outreach, emergency
shelter, homelessness prevention, rapid re-housing assistance, and HMIS; as well as administrative
activities.
Eligible Activities:
A) Street Outreach – Funds may be used for costs of providing essential services necessary to reach
out to unsheltered homeless people; connect them with emergency shelter, housing, or critical
services; and provide urgent non-facility-based care to unsheltered homeless people who are
unwilling or unable to access emergency shelter, housing or an appropriate health facility.
B) Emergency Shelter – Funds may be used for costs of providing essential services to families and
individuals in emergency shelters, renovating buildings to be used as emergency shelter for
homeless families and individuals, and operating emergency shelters.
C) Homeless Prevention – Funds may be used to provide housing relocation and stabilization services
and short- or medium-term rental assistance necessary to prevent an individual or family from
moving into an emergency shelter and prevent incidences of homelessness.
D) Rapid Re-Housing – ESG funds may be used to provide housing relocation and stabilization services
and short- or medium-term rental assistance necessary to help a homeless individual or family move
as quickly as possible into permanent housing and achieve stability in that housing.
E) HMIS – ESG funds may be used to pay the costs of contributing to the HMIS designated by the
Continuum of Care for the area including the costs of purchasing hardware, software licenses or
equipment, obtaining technical support, completing data entry and analysis, monitoring and
reviewing data quality, training, reporting, and coordinating and integrating the system. The HMIS
funds will be limited to 1.5% of the total funds awarded.
F) ADMINISTRATION - KHRC as the recipient may use up to 7.5 percent of its ESG grant for the payment
of administrative costs related to the planning and execution of ESG activities. This does not include
staff and overhead costs directly related to carrying out activities eligible under ESG, because those
costs are eligible as part of those activities. As such KHRC will provide 2.5% of ESG awarded funds as
administrative costs to all ESG Sub recipients. (576.108. (4) (B))
Assistance to Eligible Persons/Households funded through the Emergency Solutions Grant cannot
exceed 24 months of rental assistance, 24 months of utility payment assistance or 6 months of
arrears (utility/rent) during any three-year period.
Evaluation and documentation of client eligibility for financial assistance shall be reassessed at least
every three months for program participants receiving homelessness prevention assistance and not
less than once annually for program participants receiving rapid re-housing assistance (576.401 (b))
to ensure they meet the eligibility criteria, review program and appropriateness standards and to
re-evaluate the continuation of services.
2021-2022 Kansas ESG
REV. 03/04/2021
6
SECTION IV: ESG APPLICATION (completed by each agency providing ESG services)
A) SUB RECIPIENT AGENCY
Sub recipient agency is required to be an existing Emergency Shelter, Homeless Services Provider or
Other Program that provides services to homeless clients. It is also required to be a Local Government or
nonprofit 501 (c) (3).
Agency’s Legal Name: ______________________________________ Federal ID#: _________________________
Street/P.O. Box: ___________________________________________ Phone # _____________________________
City: ___________________ State: ______________ Zip: _______________ County: _________________________________
Chief Executive Officer: ___________________________ CEO Email: ___________________________________________
Chief Financial Officer: ____________________________ CFO Email: ___________________________________________
ESG Contact Person: (name and title): _____________________________________________________________________
Email of ESG Contact Person: ______________________________ Phone # ______________________________________
Alt. ESG Contact Person (required): (Name and Title): _____________________________________________________
Email of Alt. ESG Contact Person (required): ____________________________ Phone # _________________________
B) AGENCY TYPE:
Day Shelter
Emergency Shelter – 90 days or less
Homeless Services Provider (Homeless Prevention or Rapid Re Housing)
Street Outreach
Other (Provide Description) ___________________________________________
Please identify the primary at risk homeless category the program will serve. Please check the
appropriate categories below:
Chronically homeless Persons or families
HIV/AIDS
Elderly
Veterans
Mental Health
Youth
Domestic Violence Victims
Substance abuse
Other _________________________________________
2021-2022 Kansas ESG
REV. 03/04/2021
7
C) PROGRAM PARTNERSHIPS
Please
identify and describe
all partnerships with other agencies related to service delivery to your
identified program beneficiaries needs. Agency contact (name of person, email and phone) information
must
be included. (att. 1)
D) PROPOSED PROJECT ACCOMPLISHMENTS
Please list expected program accomplishment(s) if funding is awarded:
(Accomplishments must be described in terms of households served, people served, etc.)
PROPOSED ACCOMPLISHMENTS:
Total number of households to be served: _____________
Total unduplicated individuals to be served: _____________
Indicate the number of unduplicated adults to be served: _____________
Indicate the number of unduplicated children to be served: _____________
Prior ESG (if previous grantee) accomplishments: YES ____ NO ____
Total number of households to be served: _____________
Total unduplicated individuals to be served: _____________
Indicate the number of unduplicated adults to be served: _____________
Indicate the number of unduplicated children to be served: _____________
E) Attach 501 (C) 3 status letter (must be IRS letter) (att. 2)
F) Attach Certificate of Good Standing (must be copy of
current certificate
from Kansas Secretary of
State) (att. 3)
G) Attach Certification of Local Unit of Government Approval Statement and Signature Form. (att. 4)
Agency Certification: To the best of my knowledge and belief, the data in this agency’s portion of this ESG
application are true and correct.
Signature Date
Title
click to sign
signature
click to edit
2021-2022 Kansas ESG
REV. 03/04/2021
8
SECTION V: ESG ACTIVITY FUNDING
Please provide details on EACH activity your agency will provide if funded.
A. Street Outreach
Street Outreach
Amount Requested
Engagement Activities
Case Management
Emergency Health Services
Emergency Mental Health Services
Transportation
TOTAL
Street Outreach: Please provide a
detailed description
of your program and service delivery.
$ 0.00
2021-2022 Kansas ESG
REV. 03/04/2021
9
B. Emergency Shelter
Emergency Shelter
Amount Requested
Essential Services
Renovation Activities
Shelter Operations
Vouchers (Hotel or Motel where ES unavailable)
TOTAL
Emergency Shelter: Please provide a
detailed description
of your program and service delivery
$ 0.00
2021-2022 Kansas ESG
REV. 03/04/2021
10
C. Homeless Prevention
Homeless Prevention
Amount Requested
Rental Assistance (Short-Term / Medium-Term)
Utility Assistance
Rental Arrears (1-time payments of up to 6 months)
Security Deposits (up to 2 months)
Moving Costs
Services Costs
Homeless Prevention: Please provide a
detailed description
of your program and service delivery
$ 0.00
2021-2022 Kansas ESG
REV. 03/04/2021
11
D. Rapid Re-Housing
Rapid Re-Housing
Amount Requested
Rental Assistance (Short-Term / Medium-Term)
Utility Assistance
Rental Arrears (1-time payments of up to 6 months)
Security Deposits (up to 2 months)
Moving Costs
Services Costs
Rapid Re-Housing: Please provide a
detailed description
of your program and service delivery
$ 0.00
2021-2022 Kansas ESG
REV. 03/04/2021
12
E. HMIS
HMIS: Please provide a
detailed description
of your program and service delivery
HMIS – up to 1.5% of the total ESG funds requested
Amount Requested
Hardware / Software
Equipment Costs
Data Entry / Analysis
Data Quality
Training
Reporting
TOTAL
$ 0.00
2021-2022 Kansas ESG
REV. 03/04/2021
13
F. MATCH REQUIRMENTS
ESG requires a 100% match. The sub recipient must make matching contributions to supplement the ESG
program in an amount that equals the amount of ESG funds provided by KHRC. The sub recipient must
identify the source of match at the time of applying for ESG.
Matching contributions may be obtained from any source, including any federal source other than the ESG
program, as well as state, local, and private sources. However, the following requirements apply to matching
contributions from a federal source of funds:
• The sub recipient must ensure the laws governing any funds to be used as matching contributions
do not prohibit those funds from being used to match Emergency Solutions Grant (ESG) funds.
• If ESG funds are used to satisfy the matching requirements of another federal program, then
funding from that program may not be used to satisfy the matching requirements under this
section.
The sub recipient may count as match the value specified in 2 CFR 200.306(d) for any building the recipient
or subrecipient donates for long-term use in the recipient's ESG program, provided that depreciation on
the building is not counted as match or charged to any Federal award. If a third party donates a building to
the recipient or subrecipient, the recipient may count as match either depreciation of the building and fair
rental charges for the land for each year the building is used for the recipient's ESG program or, if the
building is donated for long-term use in the recipient's ESG program, the fair market value of the capital
assets, as specified in 2 CFR 200.306(h)(2), (i), and (j). To qualify as a donation for long-term use, the donation
must be evidenced by a recorded deed or use restriction that is effective for at least 10 years after the
donation date. If the donated building is renovated with ESG funds, the minimum period of use under
§576.102(c) may increase the period for which the building must be used in the recipient's ESG program.
(d)
Eligible types of matching contributions.
The matching requirement may be met by one or both of the
following:
(1)
Cash contributions.
Cash expended for allowable costs, as defined in OMB Circulars A-87 (2 CFR part
225) and A-122 (2 CFR part 230), of the recipient or subrecipient.
(2)
Noncash contributions.
The value of any real property, equipment, goods, or services contributed to the
recipient's or subrecipient's ESG program, provided that if the recipient or subrecipient had to pay for them
with grant funds, the costs would have been allowable. Noncash contributions may also include the
purchase value of any donated building.
(e)
Calculating the amount of noncash contributions.
(1) To determine the value of any donated material or
building, or of any lease, the recipient must use a method reasonably calculated to establish the fair market
value.
(2) Services provided by individuals must be valued at rates consistent with those ordinarily paid for similar
work in the recipient's or subrecipient's organization. If the recipient or subrecipient does not have
employees performing similar work, the rates must be consistent with those ordinarily paid by other
employers for similar work in the same labor market.
(3) Some noncash contributions are real property, equipment, goods, or services that, if the recipient or
subrecipient had to pay for them with grant funds, the payments would have been indirect costs. Matching
credit for these contributions must be given only if the recipient or subrecipient has established, along with
its regular indirect cost rate, a special rate for allocating to individual projects or programs the value of those
contributions.
(f)
Costs paid by program income.
Costs paid by program income shall count toward meeting the
recipient's matching requirements, provided the costs are eligible ESG costs that supplement the
recipient's ESG program.
2021-2022 Kansas ESG
REV. 03/04/2021
14
Match Certification form (att. 5)
Sub Recipient Agency:
Sub Recipient Agency DUNS #:
Address: City/State/Zip:
Executive Director:
Executive Director Email:
Executive Director Phone:
MATCH CERTIFICATION:
• The ESG applicant completing this Match Certification has verified the eligibility of the
match item(s) to which this certification relates;
• The ESG applicant has reviewed the Federal Guidelines regarding the match requirement
(24 CFR 576.201 and 2 CFR 200.306)
• The ESG applicant has verified that the funds used to Match the ESG Program are not being
used to match any other grant;
• The ESG applicant has / will collect valid documentation of Match for which this certification
relates; and,
• The ESG applicant Executive Director has reviewed the Match documentation to which this
Match Certification relates and has verified that all the representations made in this Match
Certification are true and correct.
Signature: Date:
Title:
Requested Activity
Amount
Requested
Amount
of Match
Match Description
Street Outreach
Emergency Shelter
Homeless
Prevention
Rapid Re Housing
HMIS
Total
$ 0.00
$ 0.00
2021-2022 Kansas ESG
REV. 03/04/2021
15
SECTION VI: AGENCY CAPACITY
A. How long has your organization served homeless populations?
10 or more years
5-9 years
Less than 5 years
B. Is your organization an active member of any of the following? Please check those that apply.
Balance of State Continuum of Care:
Regional/Local Planning Meetings
State/Local Consolidated Plan Process
Regional/Local Homeless Committees
Please provide documentation of membership to organizations (letter signed by organization chair).
(att.6)
C. How does sub recipient agency staff participate in these meetings/groups?
- Please describe level of involvement.
D. Briefly describe the organization’s board of director’s fiscal oversight committee. How many members
does it have, how often does it meet, and what are its responsibilities? Are there policies and
procedures?
If so, what entity is responsible for oversight?
1. Attach List of Board Members for sub recipient agency (att. 7)
2. Attach an Organization Chart of sub recipient agency (att. 8)
E. What type of financial management system does the organization have? Describe the organization’s
system of checks and balances in its fiscal management. What is the division of responsibilities to
ensure good fiscal oversight? Explain who maintains the organization’s accounting records and if there
is a software system utilized, please be specific as to the type and capabilities of the software or
accounting system.
1. Attach a copy of the agency’s most recent audit. (att. 9)
2. Attach a completed W-9 Form for Sub recipient. (att. 10)
2021-2022 Kansas ESG
REV. 03/04/2021
16
F. Does your agency have pending civil or criminal proceedings filed or being processed currently or have
been processed over the past three years? If the answer is “yes” an explanation must be provided with
official documentation or court record that demonstrates the status of the issue:
G. Provide an address and physical description of the shelter and/or service delivery site.
Domestic Violence providers provide only physical description:
H. Explain how your agency will identify and document homeless status of a client. Per 576.500
Recordkeeping and reporting requirements (b) Homeless Status:
I. Are there any current HUD findings against the agency? If yes, please explain:
J. Attach a copy of all program rules and policies. (att. 11)
K. Attach agency termination / grievance policy and procedures - Per 576.402
Terminating assistance.
(att. 12)
2021-2022 Kansas ESG
REV. 03/04/2021
17
SECTION VII: PERFORMANCE OUTCOMES
A. Written Standards for Provision of ESG Assistance
1. Standard policies and procedures for evaluating individuals' and families' eligibility for assistance under
Emergency Solutions Grant (ESG). The policies and procedures must be consistent with the recordkeeping
requirements and definitions of "homeless" and "at-risk of homelessness" in the federal ESG regulations at:
24 CFR 576.2 and 24 CFR 576.500 (b-e).
2. Standards for targeting and providing essential services related to street outreach.
3. Policies and procedures for admission, diversion, referral, and discharge by emergency shelters assisted
under ESG, including standards regarding length of stay, if any, and safeguards to meet the safety and
shelter needs of special populations, (
e.g.,
victims of domestic violence, dating violence, sexual assault, and
stalking; and individuals and families who have the highest barriers to housing and are likely to be homeless
the longest).
4. Policies and procedures for assessing, prioritizing, and reassessing individuals' and families' needs for
essential services related to emergency shelter.
5. Policies and procedures for coordination among emergency shelter providers, essential services
providers, homelessness prevention, and rapid re-housing assistance providers; other homeless assistance
providers; and mainstream service and housing providers. The required coordination may be done over an
area covered by the Continuum of Care or a larger area.
6. Policies and procedures for determining and prioritizing which eligible families and individuals will
receive homelessness prevention assistance and which eligible families and individuals will receive rapid
re-housing assistance. For homeless prevention, include the risk factors used to determine who would be
most in need of this assistance to avoid becoming homeless.
7. Standards for determining what percentage or amount (if any) of rent and utilities costs each program
participant must pay while receiving homelessness prevention or rapid re-housing assistance. If the
assistance will be based on a percentage of the participant's income, specify this percentage, and how
income will be calculated.
8. Standards for determining how long a particular program participant will be provided with rental
assistance and whether and how the amount of that assistance will be adjusted over time. One-year lease
required for project-based assistance. Annual participant evaluations required with rapid re-housing
assistance; three-month evaluations required with homeless prevention assistance. Individual assistance
cannot exceed 24 months in a three-year period.
2021-2022 Kansas ESG
REV. 03/04/2021
18
9. Standards for determining the type, amount, and duration of housing stabilization and/or relocation
services to provide to a program participant, including the limits, if any, on the homelessness prevention or
rapid re-housing assistance that each program participant may receive, such as the maximum amount of
assistance, maximum number of months the program participant may receive assistance, or the maximum
number of times the program participant may receive assistance. Note: ESG regulations limit this
assistance to no more than 24 months in a three-year period. Housing stability case management is limited
as specified on pp. 75979-80 of the
federal regulations.
10.
Participation in HMIS.
The recipient must ensure that data on all persons served and all activities
assisted under ESG are entered into the applicable community-wide HMIS in the area in which those
persons and activities are located, or a comparable database, in accordance with HUD's standards on
participation, data collection, and reporting under a local HMIS.
Please certify you have established applicable Written Standards for ESG.
(Do not attach at this time, agencies will be required to submit standards before receiving an award).
(att.13)
Name ____________________________________ Title __________________________
Signature ________________________________ Date __________________________
2021-2022 Kansas ESG
REV. 03/04/2021
19
MINIMUM HABITABILITY STANDARDS FOR EMERGENCY SHELTERS: CHECKLIST 2021 ESG:
(att. 15)
Carefully read each statement and indicate the shelter’s or unit’s status for each requirement (Approved
or Deficient). Add any comments and corrective actions needed in the appropriate box. The reviewer
should complete the information about the project, and sign and date the form. This template includes
space for an “approving official,” if the recipient or subrecipient has designated another authority to
approve the review.
When the assessment is complete, review it with program staff and develop an
action plan for addressing any areas requiring corrective action.
The Emergency Solutions Grants (ESG) Program Interim Rule establishes different habitability standards
for emergency shelters and for permanent housing (the Rapid Re-housing and Homelessness Prevention
components).
• Emergency Shelter Standards.
Emergency shelters that receive ESG funds for renovation or shelter operations must meet the
minimum standards for safety, sanitation, and privacy provided in §576.403(b).
In addition, emergency shelters that receive ESG funds for renovation (conversion, major
rehabilitation, or other renovation) also must meet state or local government safety and
sanitation standards, as applicable.
• Permanent Housing Standards. The recipient or subrecipient cannot use ESG funds to help a
program participant remain in or move into housing that does not meet the minimum habitability
standards under §576.403(c). This restriction applies to all activities under the Homelessness
Prevention and Rapid Re-housing components.
Recipients and subrecipients must document compliance with the applicable standards. Note that these
checklists do not cover the requirements to comply with the Lead-Based Paint requirements at §576.403(a).
For more discussion about how and when the standards apply, see
ESG Minimum Standards for
Emergency Shelters and Permanent Housing,
located at http://OneCPD.info/esg.
The checklists below offer an optional format for documenting compliance with the appropriate standards.
These are intended to:
1. Provide a clear summary of the requirements and an adaptable tool so recipients and subrecipients
can formally assess their compliance with HUD requirements, identify and carry out corrective
actions, and better prepare for monitoring visits by HUD staff.
2. Provide a tool for a recipient to monitor that its subrecipient is in compliance with HUD
requirements. Where non-compliance is identified, the ESG recipient can use this information to
require or assist the subrecipient to make necessary changes.
Prior to beginning the review, the subrecipient should organize relevant files and documents to help
facilitate their review. For instance, this may include local or state inspection reports (fire-safety, food
preparation, building/occupancy, etc.), or policy and procedure documents related to emergency shelter
facility maintenance or renovations.
2021-2022 Kansas ESG
REV. 03/04/2021
20
MINIMUM STANDARDS FOR EMERGENCY SHELTERS
Instructions: Place a check mark in the correct column to indicate whether the property is approved or
deficient with respect to each standard. A copy of this checklist should be placed in the shelter’s files.
Approved Deficient
Standard
(24 CFR part 576.403(b))
1.
Structure and materials
:
a.
The shelter building is structurally sound to protect the residents from the
elements and not pose any threat to the health and safety of the residents.
b. Any renovation (including major rehabilitation and conversion) carried out with
ESG assistance uses Energy Star and Water Sense products and appliances.
2.
Access
. Where applicable, the shelter is accessible in accordance with:
a. Section 504 of the Rehabilitation Act (29 U.S.C. 794) and implementing regulations
at 24 CFR part 8;
b. The Fair Housing Act (42 U.S.C. 3601 et seq.) and implementing regulations at 24
CFR part 100; and
c. Title II of the Americans with Disabilities Act (42 U.S.C. 12131 et seq.) and 28 CFR part
35.
3.
Space and security
: Except where the shelter is intended for day use only, the shelter
provides each program participant in the shelter with an acceptable place to sleep
and adequate space and security for themselves and their belongings.
4.
Interior air quality
: Each room or space within the shelter has a natural or mechanical
means of ventilation. The interior air is free of pollutants at a level that might threaten
or harm the health of residents.
5.
Water Supply
: The shelter’s water supply is free of contamination.
6.
Sanitary
Facilities
: Each program participant in the shelter has access to sanitary
facilities that are in proper operating condition, are private, and are adequate for
personal cleanliness and the disposal of human waste.
7.
Thermal environment
: The shelter has any necessary heating/cooling facilities in
proper operating condition.
8.
Illumination and electricity
:
a. The shelter has adequate natural or artificial illumination to permit normal indoor
activities and support health and safety.
b. There are sufficient electrical sources to permit the safe use of electrical appliances
in the shelter.
9.
Food preparation
: Food preparation areas, if any, contain suitable space and
equipment to store, prepare, and serve food in a safe and sanitary manner.
10.
Sanitary conditions
: The shelter is maintained in a sanitary condition.
11.
Fire safety
:
a. There is at least one working smoke detector in each occupied unit of the shelter.
Where possible, smoke detectors are located near sleeping areas.
b. All public areas of the shelter have at least one working smoke detector.
c. The fire alarm system is designed for hearing-impaired residents.
d. There is a second means of exiting the building in the event of fire or other
emergency.
12. If ESG funds were used for renovation or conversion, the shelter meets state or local
government safety and sanitation standards, as applicable.
13.
Meets additional recipient/subrecipient standards (if any).
click to sign
signature
click to edit
2021-2022 Kansas ESG
REV. 03/04/2021
21
CERTIFICATION STATEMENT
I certify that I have evaluated the property located at the address below to the best of my ability and find
the following:
Property meets all of the above standards.
Property does not meet all of the above standards.
ESG Recipient Name: __Kansas Housing Resources Corporation__
ESG Subrecipient Name (if applicable): ____________________________________________________________
Emergency Shelter Name: _______________________________________________________________________
Street Address: ___________________________________________________________________________________
City: _________________________________ State: _________ Zip: _______________
Evaluator Signature: _________________________________ Date of review: ______________________
Evaluator Name: _____________________________________________________________________
Approving Official Signature (if applicable): ______________________ Date: ____________________
Approving Official Name (if applicable): ________________________________________________________
COMMENTS:
2021-2022 Kansas ESG
REV. 03/04/2021
22
CERTIFICATION REGARDING LOBBYING
Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies to the best of his or her knowledge and belief that:
a. No federal appropriated funds have been paid or will be paid by or on behalf of the undersigned to
any person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or any employee of a Member of Congress
in connection with the awarding of any federal contract, the making of any federal grant, the making
of any federal loan, the entering into of an cooperative agreement and the extension, continuation,
renewal, amendment, or modification of any federal contract, grant, loan or cooperative agreement.
b. If any funds other than federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress,
an officer or employee of Congress, or an employee of a Member of Congress in connection with this
federal contract, grant, loan or cooperative agreement, the undersigned shall complete and submit
Standard Form III "Disclosure Form to Report Lobbying", in accordance with its instructions.
c. The undersigned shall require that the language of this certification be included in the award
documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under
grants, loans and cooperative agreements), and that all sub-recipients shall certify and disclose
accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by Section 1352 title 31 U.S. Code. Any person who fails to file the required certification
shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
_____________________________________________
Authorized Signature
_____________________________________________
Title
_____________________________________________
Date
2021-2022 Kansas ESG
REV. 03/04/2021
23
STATEMENT REGARDING DISCRIMINATION
The applicant agrees and warrants that in the performance of an executed third party contract with the
state that it will not discriminate or permit discrimination against religious creed, age, marital status,
national origin, sex, mental retardation or physical disability including, but not limited to, blindness, unless
it can be shown by the applicant that such disability prevents performance of work involved in any manner
prohibited by the laws of the United States or of the State of Kansas, and the applicant further agrees to
provide the Commission on Equal Opportunities with such information requested by the Commission
concerning the employment as they relate to the provisions of this section.
I, ___________________________________ (the duly authorized representative of the applicant) do hereby certify
that all the facts, figures and representations made in this application are true and correct, to the best of
my knowledge and belief.
__________________________________________________________
Authorized Signature
__________________________________________________________
Title
__________________________________________________________
Date
2021-2022 Kansas ESG
REV. 03/04/2021
24
STATEMENT ASSURING COMPLIANCE WITH APPLICABLE
ENVIRONMENTAL REGULATIONS
The use of federal funds triggers the requirement of compliance with federal environmental regulations
developed by the Department of Housing and Urban Development (HUD). These regulations, contained in
24 CFR Part 50 and Part 58 "Environmental Review Procedures for Recipients Assuming HUD
Responsibilities", require compliance with the National Environmental Policy Act (NEPA), as well as several
related federal laws, regulations and Executive Orders. In order to ensure compliance with these
environmental regulations, the state shall require a complete description of all physical work to be
undertaken, including specifications and drawings where applicable. This information is necessary to
ensure that all environmental reviews and paperwork can be completed by the state in order to satisfy HUD
requirements. No funds will be released, or vouchers paid for physical activities unless environmental
clearance has been obtained from HUD. NO construction activities may occur without formal notification
from the City that the release of environmental conditions has occurred.
All physical projects must comply, where applicable, with environmental requirements, guidelines and
statutory obligations in the following areas, as outlined in 24 CFR Parts 50 and 58, Historic Properties
Protection; Flood plain Management and Wetland Protection; Coastal Zone Management Requirements;
Sole Source Aquifer Protection; Wildlife, Endangered Species, and Wild and Scenic River Protection; Water
Quality Regulations; Air Quality; Solid Waste Management Regulations; Farmland Protection; and other
HUD Environmental Standards.
All work plans will be reviewed to ensure compliance with applicable environmental standards. The
following sections briefly outline the statutory compliance areas which will affect most physical activities
undertaken with CDBG funds.
Historic Properties: All properties to be rehabilitated, renovated, demolished or physically changed in any
manner will be reviewed to determine if they are contained on the State of Kansas Historic List. If a structure
is contained on the Historic List, rehabilitation or renovation activities must adhere to the National Secretary
of the Interior's Standards for Rehabilitation. Any proposed activity which does not adhere to the Secretary
of the Interior's Standards must be reviewed by the Kansas State Historic Preservation Office (SHPO) prior
to commencement of the activity. All requirements outlined by SHPO and, where necessary, the Advisory
Council on Historic Preservation, must be met before funds can be released. These requirements also
pertain to demolition activities.
Air Quality/Asbestos Abatement: Prior to any rehabilitation, demolition or heating and ventilation
improvement activity, all areas to be disturbed must be inspected for the presence of asbestos containing
materials (ACM’s). If asbestos is found in areas to be disturbed, all asbestos-containing materials must be
completely removed by a NESHAP certified asbestos removal contractor and disposed of in accordance
with all local, state and federal laws and requirements prior to the commencement of any construction or
demolition work. All records documenting compliance with local, state and federal laws and regulations
must be presented to the state prior to the commencement of any construction activity to obtain the
click to sign
signature
click to edit
2021-2022 Kansas ESG
REV. 03/04/2021
25
release of funds. If the inspection determines that no asbestos is present in the areas to be disturbed, a
signed letter stating the date of inspection and the absence of asbestos must be presented to the state.
Lead-Based Paint Abatement: Prior to the rehabilitation of any residential structure or non-dwelling
facility commonly used by children under seven years, all applicable surfaces of units constructed prior to
1978 shall be inspected to determine if lead-based paint surfaces exist. If defective lead-based painted
surfaces are present, notification and abatement, in accordance with all local, state and federal laws and
regulations must occur prior to the release of funds. If no lead-based paint is present, a signed letter, stating
the date of inspection, the name of the inspector, and the absence of lead-based paint, must be presented
to the state.
Other Applicable Statutory Requirements:
If a property to be rehabilitated is located within a flood zone, wetland area or coastal zone, the proposed
project must be reviewed to ensure consistency with applicable local, state and federal regulations. If the
subject property is located in an airport clear zone or within an industrial/commercial area, the project must
be reviewed to ensure that any potential site safety hazards are addressed.
To t
he best of your knowledge:
Does the proposed project area contain lead-based paint?
______ Yes ______ No ______ Unsure
Does the proposed project area contain asbestos containing materials?
______ Yes ______ No ______ Unsure
As t
he applicant, the undersigned assures the commitment to compliance with the Environmental
Regulations outlined by HUD.
_______
______________________________________________
Authorized Signature
_____________________________________________________
Title
_______
______________________________________________
Date
2021-2022 Kansas ESG
REV. 03/04/2021
26
CERTIFICATION OF LOCAL GOVERNMENT APPROVAL
FOR NONPROFIT ORGANIZATIONS RECEIVING
2021 EMERGENCY SOLUTIONS GRANT (ESG)
I, _________________________________________ (
name and title
), duly authorized to act on behalf of the
_____________________ (
name of jurisdiction
), hereby approve the following emergency solutions grant
activities proposed by ________________________ (
name of nonprofit organization
), which are to be located in
_______________________ (
name(s) of jurisdiction(s)
):
By: ________________________________________________________________________________________
Signature and Date
______________________________________________________________________________________________
Typed or Written Name of Signatory Local Official
______________________________________________________________________________________________
Title
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

March 09, 2021 Dear Emergency Solutions Grant (ESG)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document