Complete and return ONE application by noon on June 29, 2018. Application should be emailed to efsp@unitedwaymiami.org. APPLICANT INFORMATION Name of Organization: Program Name: Program Address: Mailing Address: (if different from Program) Executive Director s Name: *Program Contact Name & Title: Phone: **Grant Contact Name & Title: Phone: E-mail: E-mail: Website Address: Number of Previous EFSP Awards: 0-4 5 or more Year of Last EFSP Award: TOTAL AMOUNT REQUESTED: *Program Contact: person assigned to answer programmatic questions and receive client referrals. **Grant Contact: person assigned to answer EFSP grant questions. To the best of my knowledge and belief, the data in this proposal is true and correct and the governing body of the applicant has duly authorized the enclosed documents. I understand that incomplete applications or applications submitted after the deadline will not be accepted or reviewed. In addition, I (or an agency representative) have attended the mandatory application meeting and have been fully advised of this process. By signing below, the undersigned acknowledges having read and understood the program guidelines and will be able to fully comply with the provisions of these guidelines as well as any additional applicable federal, state and local requirements, including procurement and financial management. Applicant also acknowledges that if a funding recommendation is made for less than the full amount applied for, additional documentation to include but not limited to a revised budget, scope or work, and proposed accomplishments may be requested prior to final funding determinations. Authorized Signature: Date: Printed Name: Title: 1
Required Attachments: IRS 501(c) 3 Determination Letter Board of Directors List Non-discrimination Policy FEIN Budget Form: Agency and Program Revenues and Expenses Dun & Bradstreet Number (DUNS) SECTION 1: EFSP LOCAL RECIPIENT ORGANIZATION (LRO) CRITIERIA For a local agency to be eligible for funding, it must meet the following criteria. Please provide the appropriate documentation as requested. 1. Be nonprofit or an agency of government. Please provide a copy of your organization s IRS 501(c) 3 determination letter. 2. If private, not-for-profit, have a voluntary board. Please provide a copy of your current Volunteer Board Member Roster. 3. Practice nondiscrimination (those agencies with a religious affiliation wishing to participate in the program must not refuse services to an applicant based on religion or require attendance at religious services as a condition of assistance, nor will such groups engage in any religious proselytizing in any program receiving EFSP funds). Please provide a copy of your agency s non-discrimination policy for the provision of services (this is NOT your nondiscrimination policy for employment or volunteer services). 4. Have a Federal Employer Identification Number (FEIN), (note: contact local IRS office for more information on securing FEIN and the necessary form (SS-4) (Website: www.irs.gov). Please provide a copy of your FEIN and a copy of your tax-exempt status. 2
If not, you must utilize the FEIN of a fiscal agent. A fiscal agent is another non-profit organization that may receiver Emergency Food and Shelter Program funds and maintains fiscal responsibility on behalf of another organization. 5. Does your agency attempt to involve homeless individuals and families in the provision of emergency food and shelter services (through employment, volunteer programs, etc.)? Yes (if yes, describe below how they are involved) No (if no, describe below how you plan to involve them through this program to the extent practicable). 6. If you are awarded funds, does your agency have an accounting process in place by which you would manage EFSP funding? Yes No If yes, briefly describe the process utilized and provide the name, title and contact information of the person responsible for authorizing and managing EFSP expenditures. 7. Conduct an independent annual audit if receiving $25,000 or more in EFSP. Does your agency conduct an independent annual audit? (Please note: DO NOT submit your audit with your application. If you are awarded more than $25,000 in EFSP funds you will be asked to submit your audit.) Yes No 8. EFSP is a needs-based program that must be offered to the general public. Do you consent to serve residents from all over, regardless of a client s participation in your program/services? Yes No (Please Note: Applications that do not meet all of the program requirements listed above or do not submit all necessary documentation will not be accepted or reviewed.) 3
SECTION 2: PROGRAM 1. What is your organization s mission? (25 words) 2. Describe the various programs and services provided. (250 words) 3. How does the Emergency Food and Shelter Program align with the services provided? (100 words) 4. Provide a succinct summary of the program for which you are requesting funding to include: (a) Target Population: (b) Clients Currently Served Without EFSP Funding: (c) Program Activities: (d) How will EFSP funds be used to enhance current services? 5. Describe the need for these services in or your specific service area, and provide local data to support your case for funding. 6. Please list all of the proposed service locations for the program for which you are requesting funding, hours of operation, the number of staff and/or volunteers at each site, and their role in providing these services. 7. What are the eligibility criteria for individuals requesting services and how is this documented? 8. How will these services be coordinated with other programs within your agency and within the community? 9. Describe what mechanism your agency has implemented to prevent fraud and misuse of funds. SECTION 3: BUDGET 1. Total amount of funding requested: $ The intent of the EFSP is to supplement and expand current available resources and not to substitute or reimburse ongoing programs and services or to start new programs. Services for which funding is being requested must already be provided by your agency through other funding sources. 2. For each requested category, please answer the following: (a) Describe the services currently being provided (300 words) (b) Describe the process by which the services are provided (300 words) (c) Describe what other funding sources you receive for each category that you are applying for. (200 words) 4
3. Using the tables below, please indicate number of units you propose to serve with EFSP funds, the cost per unit, the total amount of your request, other available funding for the service area, and the source of this funding for each category for which you are requesting funding. Please note: transportation costs should be included in the cost per unit for each line item for which it is applicable. Food Services Bulk Food Congregate Meals Food Vouchers Home Delivered Meals Total A B C D E F Cost Total EFSP per Request Unit (AxB=C) # of Units Current Program EFSP Funds) Sources of Current Prog ESFP) Explanation of Unit Housing/Shelter Services A B C D E F Cost per Unit # of Units Total EFSP Request (AxB=C) Current Program EFSP Funds) Sources of Current Prog ESFP) Rent/Mortgage* Mass Shelter Utilities Total *Please note: agencies receiving funding in the area of Rent/Mortgage and Utility Assistance will be required to process cases through the EFSP Clearinghouse and receive approval prior to releasing the funds on behalf of the client. Explanation of Unit Supplies & Equipment Small equipment essential to the operation of food banks or pantries Consumable supplies essential to distribution of food Consumable supplies essential to mass feeding and/or mass shelters of 5+ beds Small equipment essential to mass feeding and/or mass shelters Total Total EFSP Request ($300 max. per item) 5
If requesting Supplies & Equipment funds, please list the items you intend to purchase and for what purpose. 4. Please complete the attached revenue and expenses spreadsheet for your program AND agency (use tabs on bottom of Excel sheet). If you received EFSP funds for the current and/or previous fiscal year, please include EFSP funds in the corresponding budgets. The projected budget should NOT include EFSP funds. If there is a budget deficit, explain how you will ensure that EFSP funds are not used to meet that deficit. SECTION 4: LOCAL BOARD PRIORITIES Please check off all of the Local Board priorities that services provided by your agency address: Agencies that provide rental assistance in excess of $100,000 (non-efsp funding) to households that are facing court-ordered eviction or already homeless. (If your agency selects this priority, please answer the questions below). (a) Provide a clearly detailed list of federal, state and/or local grants (non-efsp) and funding amount that your agency currently receives to provide rental assistance to families that are homeless or facing eviction. (b) Please provide a detailed plan on how your agency would utilize EFSP funding, in conjunction with current funding streams noted above, towards rental-assistance for families that are homeless or facing eviction. Rent/mortgage and utility assistance for households Food assistance in the form of food vouchers and/or bulk food END OF APPLICATION ********************************** EFSP LOCAL BOARD/PROGRAM ADMINISTRATIVE OFFICE: CONTACT: Alexa Alvarado Tel: (305) 646-7076 E-mail: alvaradoa@unitedwaymiami.org CONTACT: Vanessa Benavides Tel: (305) 646-7085 E-mail: benavidesv@unitedwaymiami.org 6