APPLICATION FORM For the purposes of this application, the agency is defined as the legal entity contracting for funds. The program is defined as all activities directly related to the funding request. The program budget should reflect full costs for all activities related to the funding request. Name of Agency Primary Contact Name, Title, Phone, Fax Secondary Contact Name, Title, Phone, Fax Email Addresses (Alternate Contact should be able to answer questions regarding EFSP proposal) Physical and Mailing Address City County Zip Code Date: Amount Being Requested: Type of Program: Check all that apply ( ) Served Meals ( ) Emergency Shelter ( ) Transitional Shelter () Food Pantry ( ) Rental or Mortgage Assistance ( ) Utility Assistance I certify that all information in this application is true and correct. I agree to abide by the rules of the application process and policies adopted by the local EFSP Board, including the Appeal/Grievance procedures as provided. Signature(s) Date: Director Date: Board Chair 1. Mission Statement: Provide the mission statement. Rev: 1/5/12 Page 1 of 7
2. Program Summary: Provide a one paragraph summary of the program for which EFSP funds will be utilized (not to exceed 100 words). 3. Program Information: For purposes of evaluating this application, the applicant is requested to provide sufficient detail with regard to both descriptive and financial aspects of the program, for which EFSP funds will be utilized. The applicant is not required to provide information with regard to the agency, for which the funded program may only be one aspect of such. A. Past Service: Describe your program s past service in the category in which funding is requested. The description should include the type and volume of service(s) provided. If your program has had compliance issues such as findings, late reports, slow spending, etc. describe the procedures you have implemented to avoid repeating these problems. B. Use of Funds: Describe specific use of the requested EFSP funds for Phase 34. C. Staff Involvement: Describe how your staff is involved in operating this program (include use of paid staff, purchasing procedures, use of volunteers, etc.) Rev: 1/5/12 Page 2 of 7
D. Target Population: Describe the target population(s) to be served by this program. Include detailed information about geographic area covered by the project, ADA accessibility, limitations on sexes and ages served, and other client demographics. E. Client Eligibility: How do you determine client eligibility for services to be funded by this program? F. Documentation of Services: What records do you keep of services provided? G. Continuity of Services: Where are these records stored, and how is the information protected? What is the agency s plan for continuity of service in the event of disaster? H. Collaboration: Describe how your agency collaborates with other agencies providing similar programs and services. I. Duplication of Services: If you are applying for Rent/Mortgage or Utilities, please describe your procedures to ensure non duplication of services. This should include coordination with other agencies with similar programs to avoid duplication between projects. Rev: 1/5/12 Page 3 of 7
J. Monitoring: Describe the process for monitoring program funding. What information is tracked? Do other entities fund this program and audit the use of funds? If so, describe method and results. K. Evaluation: How do you determine the effectiveness of the program? Program effectiveness should include both short-term results (food and shelter) and long-term results (housing and self-sufficiency). What type of evaluation tools do you use? Who evaluates the program and how do you use the information obtained to make adjustments and changes to the program? Rev: 1/5/12 Page 4 of 7
Program Funding: List all of your funding sources (for last and current year) for Emergency Food & Shelter program(s) that you are applying. Please break down funding source by category. PLEASE DEFINE YOUR FISCAL YEAR IN FIRST ROW COLUMNS THREE AND FOUR. You may add or delete lines as needed. Source EFSP - Mass Shelter Other Shelter Mass Meals Other Meals Rent/Mortgage Utilities Description Last Fiscal Year to Current Fiscal Year to % of Total For Current Fiscal Year Federal State Local Foundations Corporations Individuals Total Rev: 1/5/12 Page 5 of 7
DEFINITION OF UNITS OF SERVICE: For SERVED MEALS (hot meals, bag lunches, delivered meals), this is the actual number of meals 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) 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. Units of Service: If your program received EFSP funding in previous phase, please provide the total funds received and units of service provided for that phase. Additionally, delineate the total funds requested and the units of service to be provided under current phase. Request Profile Amount Requested ($) for Last Year s Funding Units of Service for Last Year s Funding Request ($) For Current Funding Units of Service for Current Funding Meals Served Other Emergency Shelter Mass Other Rent / Mortgage Utilities Administrative Total $ # $ # Rev: 1/5/12 Page 6 of 7
A completed application includes: Application Form *Local Recipient Organization Certification Form (once available) *Certification Regarding Lobbying (once available) *Fiscal agent/fiscal Conduit Agency Relationship Certification Form (once available) Memorandum of Agreement Your current Board of Directors, with officers designated, should include contact information and terms. Disaster Recovery Plan *Documents are currently not available. Once the documents are received by the Emergency Food and Shelter Program Local Board, we will send them to the Local Recipient Organization (LRO) for signatures. No handwritten applications will be accepted. Applications will be available online at www.unitedwayelpaso.org You must provide one original signed copy and one pdf electronic format by the deadline set at the mandatory training session. LATE OR INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. If you have questions or need assistance in completing the application, please contact, Gail Gale at 533-2434 or Xavier Banales at 915-298-6999. Gail Gale United Way of El Paso County 100 N. Stanton, Suite 500 El Paso, TX 79901 Rev: 1/5/12 Page 7 of 7