Fillable Request for Distribution of County CARES Act Funds (Polk County Missouri)

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Request for Distribution of County CARES Act Funds (Polk County Missouri)

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COVER SHEET-01
Request for Distribution of County CARES Act Funds
Cover Sheet - Application Form
Applicant Name: _____________________
Applicant Contact: _____________________
_____________________
_____________________
Application Checklist (to be completed by Applicant):
Section A - Applicant has completed all portions of Section A, including attaching all necessary
supporting documentation.
Section B – Applicant has completed all portions of Section B.
Section C – Applicant has completed all portions of Section C, including attaching all necessary
supporting documentation.
Section D – Applicant has completed those portions of Section D.1, D.2., D.3., D.4., D.5., and D.6
for which Applicant is requesting funds, including attaching all necessary supporting
documentation. An Applicant does not need to complete those portions of Section D for which
Applicant is not requesting funds.
Section E – If applicable, Applicant has provided the documentation required by Section E.
Section F – If applicable, Applicant has provided the documentation required by Section F.
Section G – Applicant has completed all portions of Section G.
Authorized Representative of Applicant has completed, signed, and notarized the Application
Applicant has submitted one (1) original and three (3) additional copies of the Application.
Application requests funds only to cover costs that:
are necessary expenditures incurred due to the public health emergency with respect to
COVID-19;
were not accounted for in the budget most recently approved as of March 27, 2020; and
were incurred during the period that begins on March 1, 2020, and ends on December
30, 2020.
Applicant has not checked a box indicating a disqualifying condition or listed any other
disqualifying condition in the Application.
Applicant acknowledges and understands that once submitted, the Application and all
supporting documentation may be subject to disclosure pursuant to the Sunshine Law under
Chapter 610, RSMo.
For Internal Use Only
App. No.___________
Phase 1
Phase 2
Phase 3
✔
✔
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
1 LOC.GOV.-NON-PROFIT-01
Section A. Applicant Background Information
1. Legal Name
2. Mailing Address
3. Primary Contact
4. City
6. State
7. Zip
Name:
Title:
8. Business Phone(s)
9. Check One in the Space Below
( ) -
( ) -
Local Government/Public Entity/Political Subdivision
City Town/Township/Village
School District
County Hospital Hospital District
Health Department
Fire Protection District
Ambulance District
Other Local Government/Public Entity:
_________________________ (List Entity Type)
Nonprofit
Non-profit Corporation
10. Facsimile
( ) -
11. Email Address
12. Tax Identification
Number
13. Is the Applicant located within the County?
Yes No
14. Does the Applicant have locations, facilities, offices, operations,
divisions, branches, or offices located outside the County? (If no, skip to
Section A.16.)
Yes No
Introduction: Full instructions are included at the end of this application.
Failure to submit required information in order to evaluate the Application and
make a funding award decision may result in denial of an Application and an
award of funds.
For Internal Use Only
App. No.___________
Phase 1
Phase 2
Phase 3
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
2 LOC.GOV.-NON-PROFIT-01
15. If the answer to Item A.14. is “Yes,” list the locations by address and county of the other
segments of the Applicant.
16. In the space below, describe the general business operations of the Applicant, such as the
services or goods provided, and the purpose or mission of the Applicant. Attach additional pages
if necessary.
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
3 LOC.GOV.-NON-PROFIT-01
Section B. Applicant - Representatives/Ownership
1. If Applicant is a local government/public entity, list the chief executive and elected officials
of the governing body by name and title.
If Applicant is a non-profit corporation, list the name and title of the chief executive and
members of the board of directors of the Applicant.
Name
Title
2. Is the Applicant presently suspended, debarred, proposed for debarment,
declared ineligible, voluntarily excluded from participation in this transaction by
any Federal department or agency, or presently involved in any bankruptcy?
Yes No
3. Has the Applicant obtained a direct or guaranteed loan from a federal or
state agency that is currently delinquent or has defaulted in the last 7 years?
Yes No
4. Is the Applicant subject to an indictment, criminal information,
arraignment, or other means by which formal criminal charges (other than traffic
citations) are brought in any jurisdiction, presently incarcerated, or on probation
or parole?
Yes No
5. Within the last 5 years, for any felony, has the Applicant:
(a) been convicted;
(b) pleaded guilty;
(c) pleaded nolo contendere;
(d) been placed on pretrial diversion; or
(e) been placed on any form of parole or probation (including probation
before judgment)?
Yes No
If the answer to Items B.2., B.3., B.4., or B.5. is “Yes,” the Application will be denied
and funds will not be awarded.
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
4 LOC.GOV.-NON-PROFIT-01
Section C. Request for Funding – General
1. Total Amount of Funds Requested by Applicant:
$
2. If awarded, will all funds be used for purposes within the
County?
Yes No
If the answer to Item C.2. is “No,” the Application will be denied and funds will not be awarded.
3. If the answer to Item A.14. is “Yes,” is the Applicant seeking
funds or anticipating the receipt of funds from any other counties where
those locations of the Applicant are located?
Yes No
4. If the answer to Item C.3. is “Yes,” in the space below please identify the counties in which
funds have been requested or will be requested, the amount of funds requested or to be received,
and the intended use of those funds. Attach any other applications, requests or other
documentation relating to this item.
5. For each of the requests set forth in Section D, below, in the event any portion of the
Application and request for funding is approved, provide responses to the following questions:
(a) Will the funds be used only to cover costs that are necessary expenditures
as defined by the CARES Act and related to the Coronavirus Disease 2019
(COVID-19)?
Yes No
(b) Will the funds be used only to cover costs that were not accounted for in
the Applicant’s budget (as described Paragraph C of the Instructions, below)
most recently approved as of March 27, 2020, or as permitted by the CARES
Act and Treasury guidance?
Yes No
(c) Will the funds be used only to cover costs that were incurred by the
Applicant during the period that begins March 1, 2020 and ends December 30,
2020?
Yes No
(d) Will the funds be used exclusively for purposes within the County?
Yes No
(e) If Applicant is a public entity, Applicant agrees the funds will not be used
as revenue replacement for lower than expected tax or other revenue collections.
Yes No
If any of the answers to Items C.5(a) – (e) is “No,” the Application will be denied and funds will not
be awarded.
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
5 LOC.GOV.-NON-PROFIT-01
D. Request for Funding - Purpose and Intended Use of Funds
1. Medical Expenses
(a) Is Applicant requesting funds for medical expenses (as described
Paragraph E.1 of the Instructions, below)?
Yes No
(b) State the amount of funds requested.
$
(c) If the answer to Item D.1(a) is “Yes,” in the space below, describe the category of
expenditure (e.g. COVID-19-related expenses of public hospitals, clinics, and similar facilities)
and proposed use of funds, and the itemized amount requested. Attach supporting
documentation for the request. Attach additional pages if necessary.
Description
Amount
(d) Explain in detail the intended use and how the intended use meets the criteria for a
“necessary expenditure” under the CARES Act (as described Paragraph B of the Instructions,
below). Attach supporting documentation. Attach additional pages if necessary.
Request for Distribution of County CARES Act Funds
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6 LOC.GOV.-NON-PROFIT-01
2. Public Health Expenses
(a) Is Applicant requesting funds for public health expenses (as described
Paragraph E.2 of the Instructions, below)?
Yes No
(b) State the amount of funds requested.
$
(c) If the answer to Item D.2(a) is “Yes,” in the space below, describe the category of
expenditure (e.g., Expenses for acquisition and distribution of medical and protective supplies)
and proposed use of funds, and the itemized amount requested. Attach supporting
documentation for the request. Attach additional pages if necessary.
Description
Amount
(d) Explain in detail the intended use and how the intended use meets the criteria for a
“necessary expenditure” under the CARES Act (as described Paragraph B of the Instructions,
below). Attach supporting documentation.
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
7 LOC.GOV.-NON-PROFIT-01
3. Payroll expenses for public safety, public health, health care, human services, and similar
employees whose services are substantially dedicated to mitigating or responding to the COVID-
19 public health emergency
(a) Is Applicant requesting funds for payroll expenses for public safety,
public health, health care, human services, and similar employees whose
services are substantially dedicated to mitigating or responding to the COVID-
19 public health emergency?
Yes No
(b) State the amount of funds requested.
$
(c) If the answer to Item D.3(a) is “Yes,” in the space below, describe the category of
expenditure (e.g. payroll expenses for public safety employees whose services are substantially
dedicated to mitigating or responding to the COVID-19 public health emergency) and proposed
use of funds, and the itemized amount requested. Attach supporting documentation for the
request. Attach additional pages if necessary.
Description
Amount
(d) Explain in detail the intended use and how the intended use meets the criteria for a
“necessary expenditure” under the CARES Act (as described Paragraph B of the Instructions,
below). Attach supporting documentation.
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
8 LOC.GOV.-NON-PROFIT-01
4. Expenses of actions to facilitate compliance with COVID-19-related public health
measures (as described Paragraph E.4 of the Instructions, below).
(a) Is Applicant requesting funds to facilitate compliance with COVID-19
related public health measures?
Yes No
(b) State the amount of funds requested.
$
(c) If the answer to Item D.4(a) is “Yes,” in the space below, describe the category of
expenditure (e.g., expenses for food delivery to residents) and proposed use of funds, and the
itemized amount requested. Attach supporting documentation for the request. Attach additional
pages if necessary.
Description
Amount
(d) Explain in detail the intended use and how the intended use meets the criteria for a
“necessary expenditure” under the CARES Act (as described Paragraph B of the Instructions,
below). Attach supporting documentation.
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
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5. Expenses associated with the provision of economic support in connection with the
COVID-19 public health emergency (as described Paragraph E.5 of the Instructions, below).
(a) Is Applicant requesting funds that will be used for the provision of
economic support in connection with COVID-19?
Yes No
(b) State the amount of funds requested.
$
(c) If the answer to Item D.5(a) is “Yes,” in the space below, describe the category of
expenditure (e.g., expenditures related to the provision of grants to small businesses to reimburse
the costs of business interruption caused by required closures) and proposed use of funds, and the
itemized amount requested. Attach additional pages if necessary.
Description
Amount
(d) Explain in detail the intended use, how the intended use meets the criteria for a “necessary
expenditure” under the CARES Act (as described Paragraph B of the Instructions, below).
Attach supporting documentation.
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
10 LOC.GOV.-NON-PROFIT-01
6. Any other COVID-19-related expenses reasonably necessary to the function of government
that satisfy the Coronavirus Relief Fund’s eligibility criteria.
(a) Is Applicant requesting funds for purposes that are not listed Items 1 – 5,
above, that otherwise satisfy the Coronavirus Relief Fund eligibility criteria?
Yes No
(b) State the amount of funds requested.
$
(c) If the answer to Item D.6(a) is “Yes,” in the space below, describe the category of
expenditure and proposed use of funds, and the itemized amount requested. Attaching
supporting documentation for the request. Attach additional pages if necessary.
Description
Amount
(d) Explain in detail the intended use, how the intended use meets the criteria for a “necessary
expenditure” under the CARES Act and attach supporting documentation (as described
Paragraph B of the Instructions, below).
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
11 LOC.GOV.-NON-PROFIT-01
E. Applicant Budget Information
Please attach a copy of the Applicant’s budget most recently approved as of March 27, 2020 (the
date of enactment of the CARES Act).
F. Applicant Corporate Documents
For non-profit corporations, please attach a copy of: (a) the Articles of Incorporation, (b) Bylaws,
and (c) and a copy of the Certificate of Good Standing.
G. Applicant Representation and Certification
1. I have read the statements included in this Application Form and
understand them and that all responses are true and correct.
Yes No
2. I have the authority to act on behalf of the above-named Applicant to
request funds from the County allocated by the State of Missouri to the County
from the Coronavirus Relief Fund as created in the CARES Act.
Yes No
3. I understand that the County will rely on the information provided by
Applicant in this Application and this Certification as a material representation in
evaluating this Application and making award decisions to the above-named
Applicant.
Yes No
4. If approved, the Applicant agrees to use the funds received pursuant to
this application only for those costs that: (1) are necessary expenditures incurred
due to the public health emergency with respect to the Coronavirus Disease 2019
(COVID-19); (2) were not accounted for in the budget most recently approved as
of March 27, 2020 for the above-named Applicant; and (3) were incurred during
the period that begins on March 1, 2020, and ends on December 30, 2020.
Yes No
5. If approved, I agree that no funds provided pursuant to this Application will
be used as a revenue replacement for lower than expected tax or other revenue
collection.
Yes No
6. If approved, I agree that no funds can be used for expenditures for which the
above-named Applicant received any other emergency COVID-19 supplemental
funding (whether state, federal or private in nature) for that same expense.
Yes No
7. I agree that the above-named Applicant will retain documentation of all uses
of the funds, including but not limited to invoices and/or sales receipts and that all
necessary documentation shall be produced to the County upon request.
Yes No
8. I agree not to use the funds in a different manner than Applicant’s purposes
and uses described in this Application.
Yes No
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
12 LOC.GOV.-NON-PROFIT-01
9. I certify that use of the funds will not violate any State or Federal law, and
the Applicant is not engaged in any activity that is illegal under federal, state, or
local law.
Yes No
10. Funds provided as a result of this Application and any subsequent award
must adhere to official federal, state, or local guidance issued or to be issued. Any
funds expended in any manner that does not adhere to official guidance shall be
returned.
Yes No
11. Applicant understands and agrees that in the event an award of funds is
made pursuant to this Application, as a condition of any award an agreement
provided by County will be required to be approved and executed prior to
disbursement of funds.
Yes No
12. I understand that County is not required or obligated to award funds to an
Applicant.
Yes No
13. If approved, the Applicant agrees to comply with all local, state, and
federal bidding, advertising and procurement requirements.
Yes No
If the answer to any of Items G.1. – G.13. is “No,” the Application will be denied and funds will not
be awarded to Applicant.
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
13 LOC.GOV.-NON-PROFIT-01
THE STATEMENTS MADE IN THIS APPLICATION ARE TRUE AND ACCURATE
TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.
This application must be signed by the authorized representative, elected official,
individual owner, a partner, or an officer of the Applicant.
___________________________________
Applicant Name
___________________________________
Authorized Representative Name
___________________________________
Authorized Representative Signature
___________________________________
Title
___________________________________
Date
Subscribed and sworn to before me this _____ day of _________, 2020.
___________________________________
Notary Public
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
14 LOC.GOV.-NON-PROFIT-01
INSTRUCTIONS
Purpose of this form:
This form is to be completed by the authorized representative of the Applicant and submitted to
the County. Submission of the requested information is required to make a determination
regarding eligibility for the funding request. Failure to submit required information in order to
evaluate the Application and make a funding award decision will result in denying the
Application and any award of funds.
Applicants are encouraged to review section 601(d) of the Social Security Act, as added by
section 5001 of the Coronavirus Aid, Relief, and Economic Security Act (“CARES Act”);
Coronavirus Relief Fund Guidance for State, Territorial, Local, and Tribal Governments issued
by the United States Department of Treasury, dated April 22, 2020; and Coronavirus Relief Fund
Frequently Asked Questions issued by the United States Department of Treasury, updated most
recently as of May 4, 2020.
Instructions regarding completing this form:
A. Requirements of the CARES Act. The CARES Act provides that payments from the Fund
may only be used to cover costs that: (1) are necessary expenditures incurred due to the public
health emergency with respect to the Coronavirus Disease 2019 (COVID–19); (2) were not
accounted for in the budget most recently approved as of March 27, 2020 (the date of enactment
of the CARES Act) for the State or government; and (3) were incurred during the period that
begins on March 1, 2020, and ends on December 30, 2020.
B. Necessary Expenditures. The requirement that expenditures be incurred “due to” the public
health emergency means that expenditures must be used for actions taken to respond to the
public health emergency. These may include expenditures incurred to allow the State, territorial,
local, or Tribal government to respond directly to the emergency, such as by addressing medical
or public health needs, as well as expenditures incurred to respond to second-order effects of the
emergency, such as by providing economic support to those suffering from employment or
business interruptions due to COVID-19-related business closures.
Funds may not be used to fill shortfalls in government revenue to cover expenditures that would
not otherwise qualify under the statute. Although a broad range of uses is allowed, revenue
replacement is not a permissible use of Fund payments.
With respect to Section 5 titled “Intended Use of Funds,” all funds must be for “Necessary
Expenditures” incurred due to the public health emergency with respect to the Coronavirus
Disease 2019 (COVID-19). On April 22, 2020, the federal government provided guidance on the
definition of Necessary Expenditure.
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
15 LOC.GOV.-NON-PROFIT-01
C. Costs Not Accounted For In The Budget Most Recently Approved As Of March 27,
2020.
The CARES Act also requires that payments be used only to cover costs that were not accounted
for in the budget most recently approved as of March 27, 2020. A cost meets this requirement if
either (a) the cost cannot lawfully be funded using a line item, allotment, or allocation within that
budget or (b) the cost is for a substantially different use from any expected use of funds in such a
line item, allotment, or allocation. The “most recently approved” budget refers to the enacted
budget for the relevant fiscal period for the particular government, without taking into account
subsequent supplemental appropriations enacted or other budgetary adjustments made by that
government in response to the COVID-19 public health emergency. A cost is not considered to
have been accounted for in a budget merely because it could be met using a budgetary
stabilization fund, rainy day fund, or similar reserve account.
D. Costs Incurred During The Period That Begins On March 1, 2020 And Ends On
December 30, 2020.
A cost is “incurred” when the responsible unit of government has expended funds to cover the
cost.
E. Eligible Expenditures
Under the federal guidance, eligible expenditures include, but are not limited to, payment for:
1. Medical expenses such as:
(a) COVID-19-related expenses of public hospitals, clinics, and similar facilities.
(b) Expenses of establishing temporary public medical facilities and other measures to
increase COVID-19 treatment capacity, including related construction costs.
(c) Costs of providing COVID-19 testing, including serological testing.
(d) Emergency medical response expenses, including emergency medical transportation,
related to COVID-19.
(e) Expenses for establishing and operating public telemedicine capabilities for COVID-
19-related treatment.
2. Public health expenses such as:
(a) Expenses for communication and enforcement by State, territorial, local, and Tribal
governments of public health orders related to COVID-19.
(b) Expenses for acquisition and distribution of medical and protective supplies,
including sanitizing products and personal protective equipment, for medical personnel,
police officers, social workers, child protection services, and child welfare officers, direct
service providers for older adults and individuals with disabilities in community settings,
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
16 LOC.GOV.-NON-PROFIT-01
and other public health or safety workers in connection with the COVID-19 public health
emergency.
(c) Expenses for disinfection of public areas and other facilities, e.g., nursing homes, in
response to the COVID-19 public health emergency.
(d) Expenses for technical assistance to local authorities or other entities on mitigation of
COVID-19-related threats to public health and safety.
(e) Expenses for public safety measures undertaken in response to COVID-19.
(f) Expenses for quarantining individuals.
3. Payroll expenses for public safety, public health, health care, human services, and similar
employees whose services are substantially dedicated to mitigating or responding to the COVID-
19 public health emergency.
4. Expenses of actions to facilitate compliance with COVID-19-related public health
measures, such as:
(a) Expenses for food delivery to residents, including, for example, senior citizens and
other vulnerable populations, to enable compliance with COVID-19 public health
precautions.
(b) Expenses to facilitate distance learning, including technological improvements, in
connection with school closings to enable compliance with COVID-19 precautions.
(c) Expenses to improve telework capabilities for public employees to enable compliance
with COVID-19 public health precautions.
(d) Expenses of providing paid sick and paid family and medical leave to public
employees to enable compliance with COVID-19 public health precautions.
(e) COVID-19-related expenses of maintaining state prisons and county jails, including
as relates to sanitation and improvement of social distancing measures, to enable
compliance with COVID-19 public health precautions.
(f) Expenses for care for homeless populations provided to mitigate COVID-19 effects
and enable compliance with COVID-19 public health precautions.
Request for Distribution of County CARES Act Funds
Local Government/Public Entity/Political Subdivision & Non-Profits
17 LOC.GOV.-NON-PROFIT-01
5. Expenses associated with the provision of economic support in connection with the
COVID-19 public health emergency, such as:
(a) Expenditures related to the provision of grants to small businesses to reimburse the
costs of business interruption caused by required closures.
For the purpose of this Request for Distribution, “small business” shall mean the
Applicant must have 500 or fewer employees as calculated by the Small Business
Administration in 13 C.F.R 121.106. Part-time and temporary workers are counted the
same as full-time employees (not on an FTE basis). Volunteers and independent
contractors are not included for purposes of the 500-employee calculation. Applicants
may elect to use either (i) the average number of employees per pay period in the 12
completed calendar months prior to the date of the Request for Distribution, or (ii) the
total number of employees by using the average for the 2019 calendar year.
(b) Expenditures related to a State, territorial, local, or Tribal government payroll support
program.
(c) Unemployment insurance costs related to the COVID-19 public health emergency if
such costs will not be reimbursed by the federal government pursuant to the CARES Act
or otherwise.
6. Any other COVID-19-related expenses reasonably necessary to the function of
government that satisfy the Fund’s eligibility criteria.
F. Examples of Excluded Expenditures. The following is a list of examples of costs that would
not be eligible expenditures of payments from the Fund.
1. Expenses for the State share of Medicaid.
2. Damages covered by insurance.
3. Payroll or benefits expenses for employees whose work duties are not substantially
dedicated to mitigating or responding to the COVID-19 public health emergency.
4. Expenses that have been or will be reimbursed under any federal program, such as the
reimbursement by the federal government pursuant to the CARES Act of contributions by
States to State unemployment funds.
5. Reimbursement to donors for donated items or services.
6. Workforce bonuses other than hazard pay or overtime.
7. Severance pay.
8. Legal settlements.
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Request for Distribution of County CARES Act Funds (Polk County Missouri)

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