Community Development Block Grant Renewal Application



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Community Development Block Grant

Renewal Application

2017-2018 PY

The competitive Request For Proposals (RFP) process for the CDBG Human Service Agency funding is released every two years. This process allows for new programs and agencies to seek funding for programs that serve the City’s most vulnerable populations. The next competitive RFP process will be announced in the fall of 2017 for the 2018-2019 program year.


Agencies that were awarded CDBG funding during the 2016-2017 program year are invited to apply for funding under the Renewal Application process for the 2017-2018 program year. The renewal application will renew funding to agencies for the programs awarded under the 2016-2017 competitive RFP process. The deadline for submission of completed Renewal Applications is Tuesday, January 3, 2017 at 4pm.
Renewal Applications will be reviewed by Office of Planning and Economic Development Staff and Application Review Committee members for program performance, community impact, community need and financial performance. The request is to be for 2016-2017 funded programs at the funding level approved by the Application Review Committee and City Council under the 2016-2017 Annual Action Plan.

One hard copy of the Renewal Application with documentation must be mailed to the City of Auburn, Office of Planning and Economic Development, 24 South Street, 2nd Floor, Auburn, NY 13021. Please put it to the Attention of CDBG Application. In addition, the application (without documentation) must be submitted electronically to rjensen@auburnny.gov and to the attention of CDBG Application.

Please feel free to contact the Office of Planning and Economic Development at 315-255-4115 or rjensen@auburnny.gov with any questions.
There will not be presentations to the Application Review Committee. Presentations are only required with open competitive Request for Proposals.

The Application Checklist below lists all of the information required for a complete application.
_____ 1. Title Page

_____ 2. Program Summary

_____ 3. Success Story

_____ 4. Budget and Budget Narrative

_____ 5. Documents that must be submitted on an annual basis with the RFP

(Please note - Only one copy is needed of these annual documents.)

_____ a. List of Board of Directors

_____ b. Board of Directors’ authorization to request funds

_____ c. Board of Directors’ designation of authorized official

_____ d. Financial statement and most recent audit

_____ e. Conflict of Interest Questionnaire (attached)



Please send the original application with additional documentation via mail to the address below. In addition, please submit just the application electronically to rjensen@auburnny.gov

Send the original application with additional documentation to:

City of Auburn

Office of Planning & Economic Development, 2nd floor

24 South Street

Auburn, NY 13021
Please put to the Attention of: CDBG APPLICATION

If you have any problems completing or sending the application electronically, please contact Renee Jensen at 315-255-4115 or rjensen@auburnny.gov

Title Page

Name of Agency:


Address:
Telephone:
DUNS #: __________________________________ Federal ID#:________________________________
Project/Program Name:
Contact Person & Email:
Priority Need* the Program will address (please check only one box):

 Housing Services  Youth Services

 Child Care and Parenting Programming  Transportation

 Coordination/ Consolidation of Human Services  Counseling Services

 Senior and/or Disabled Support Services  Health Services

 Other: _____________________________


National Objective* the Program will meet:

 Benefit to low/moderate income person  Elimination of slums and blight

 Urgent Need (response to a natural disaster)
Please identify the Performance Measure* that you believe the project most closely aligns to (please check only one box in both the Objective and Outcome category):

Objective: Outcome Category:

 Suitable Living Environment  Availability/Accessibility

 Decent Housing  Affordability

 Creating Economic Opportunities  Sustainability


Total Agency Budget: $ Total Program Budget: $
CDBG Assistance: $

Other Funding Sources: $
Total estimated number of unique, unduplicated clients to be served by the program:

Of the above number, estimated number of CDBG-Eligible clients to be served:


Does this application have approval of the Board of Directors: ___________

Signatures:

Please Print:

Executive Director Chairman, Board of Directors

Proposed Budget

Name of Agency: ___________________________________________________________

Name of Program: ___________________________________________________________

Principal Contact: ___________________________________________________________


Total Program Budget: ______________ CDBG Request:_____






ITEM


CDBG Request


Other Sources

(Identify)


TOTAL

























































































On a separate piece of paper, please justify each expense listed in a Budget Narrative. A justification includes describing what each line item will pay for and, where appropriate, how that cost will provide a direct benefit to the client. Please indicate a dollar amount for additional funding in the column labeled "other sources", if appropriate. Identification of the additional funding sources (if any) should be included in the budget narrative.

Conflict of Interest Questionnaire

Federal, State and City Law prohibit employees and public officials of the City of Auburn from participating on behalf of the City in any transaction in which they have a financial interest. This questionnaire must be completed and submitted by each applicant for City funds. The purpose of this questionnaire is to determine if the applicant, or any of the applicant’s staff, or any of the applicant’s Board of Directors would be in conflict of interest.


1. Is there any member(s) of the applicant’s staff or any member(s) of the applicant’s Board of Directors or governing body who currently is or has/have been within one year of the date of this questionnaire (a) a City employee or (b) a member of City Council?


YES _____ NO _____

If yes, please list the name(s) below:


On a separate piece of paper, please indicate the job title or role each person listed above has with respect to the applicant. State whether each person listed above is a City employee, consultant, or member of City Council, and identify the City Department in which he/she is employed.


2. Will the City funds requested by the applicant be used to award a subcontract to any individual(s) or business affiliate(s) who is/are currently or has/have been within one year of the date of this questionnaire a City employee, consultant, or member of City Council?
YES _____ NO _____

If yes, please list the name(s) below:


On a separate piece of paper, please state whether each person listed above is a City employee, consultant or member of City Council, and identify the City Department in which he/she is employed.


3. Is there any member(s) of the applicant’s staff or members of the applicant’s Board of Directors of other governing body who are business partners or family members of a City employee, consultant, or member of City Council?
YES _____ NO _____

If yes, please list the name(s) below:


If yes, please identify on a separate sheet of paper the City employee, consultant or member of City Council with whom each individual has family or business ties.


Name of applicant:

Signature of applicant’s representative:

Date:

Program Summary

Please provide a brief summary of your program and explain how the program will impact low to moderate income clients as well as the City of Auburn community. Please include how the program will be evaluated.




Success Story
In the space provided below, please relay a success story that best illustrates your program outcomes. The story should illustrate your program’s effect on a single individual or family. Limit your response only to this page.



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