EMERGENCY FOOD AND SHELTER PROGRAM PHASE 33( ) SANTA FE COUNTY APPLICATION FORM AGENCY: DATE: AUTHORIZED REP. TITLE: ADDRESS: TELEPHONE:

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1 EMERGENCY FOOD AND SHELTER PROGRAM PHASE 33( ) SANTA FE COUNTY APPLICATION FORM AGENCY: DATE: AUTHORIZED REP. TITLE: ADDRESS: TELEPHONE: ADDRESS: FAX NUMBER: TOTAL FUNDING REQUEST: Agency mission Statement and brief description of applicant agency s program(s): Signature: (Executive Director) Date: 1

2 DEFINITION OF UNITS OF SERVICE: (Use these definitions to complete the following page) For SERVED MEALS (hot meals, bag lunches, delivered meals), this is the actual number of meals served. Please note, LRO must select one of two reporting options: 1. Reimbursement of actual direct eligible costs 2. Per meal allowance of exactly $2 per meal served For OTHER MEALS (vouchers, boxes, food pantries), estimate the number of meals per food box or voucher. For example, a food box/voucher to feed a family of 4 for 3 days would be estimated as 36 meals (4 people x 3 meals x 3 days = 36). For EMERGENCY SHELTER (number of nights), multiply the number of people in a family times the number of nights in the assistance period. For example, a family of 5 receiving one month of emergency shelter assistance would be 150 nights lodging (5 people x 30 nights = 150). Please note, LRO must select one of two reporting options: 1. Reimbursement of actual direct eligible costs 2. Per diem allowance of exactly $12.50 per person per night for mass shelter providers For EMERGENCY RENT, MORTGAGE OR UTILITY ASSISTANCE (number of bills), estimate the number of bills paid. In other words, use the total number of eviction notices or utility shut off notices paid with EFSP funds. Prior Year Funding: If your agency received Emergency Food and Shelter Program funding in Phase 32 ( ), please indicate the amount of funding received and the units of service provided with that funding, as follows: SERVICE FUNDING UNITS OF FUNDED AMOUNT SERVICES Served meals (meals) Other meals (meals) Mass shelter (nights) Other shelter (nights) Rent/mortgage (bills) Utilities (bills) Total $ 2

3 EFSP PHASE 33 ( ) FUNDING REQUEST REQUEST PROFILE REQUEST UNITS OF SERVICE MEALS: Served meals (hot meals, bag lunches, delivered meals) Other meals (vouchers, boxes, food pantries) EMERGENCY SHELTER: Mass shelter Other shelter (motel) EMERGENCY RENT, MORTGAGE OR UTILITY ASSISTANT: Rent/mortgage Utilities TOTAL REQUEST $ 3

4 PLEASE NOTE: THIS APPLICATION MUST BE ACCOMPANIED BY A COPY OF YOUR AGENCY S LATEST AUDIT ONLY IF YOU EXPENDED MORE THAN $500,000 IN TOTAL FEDERAL FUNDS. Original application is DUE BY 5 PM July 12, Please mail or deliver to: Mona Kay, VP of Finance United Way of Santa Fe County 440 Cerrillos Rd., Ste. A Santa Fe, NM LATE APPLICATIONS WILL NOT BE ACCEPTED. If you have questions or need assistance in completing the application, please contact Mona at or monak@uwsfc.org. 4

5 SANTA FE COUNTY EMERGENCY FOOD & SHELTER PROGRAM LOCAL BOARD APPEALS PROCESS FOR PARTICIPATION/FUNDING The appeals process is for eligible agencies concerning the Emergency Food & Shelter Program participation and funding. This appeals process is initiated by a written request to the Local Board. The request must include the basis for appeal and be signed by the Chief Professional Officer of the organization. Appeals on funding decisions must be submitted within 48 hours of receipt or within 5 working days of the postmark of notification of funding decisions (whichever is later). The Local Board or the Executive Committee of the Local Board will review the appeal and make a decision on the appeal within 10 business days. If necessary, the decision may be made by a phone poll of Local Board members. The decision of the Local Board will be communicated to the organization making the appeal in writing within one month of receiving the appeal. In the case that the basis of the appeal is fraud or other abuse of Federal funds, the agency has the right of referral to the Emergency Food & Shelter National Board. Only when there is a significant question of misapplication of guidelines, fraud, or other abuse on the part of the Local Board, will the National Board consider action. 5