2024 Pike County Nonprofit Application - Community Development Block Grant

FFY 2024 Pike County Application - Community Development Block Grant

Applications are due Friday June 21st 4 p.m.
Name of Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person*

First NameLast Name
Title of Contact Person*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Tax ID# (EIN)*
Executive Director*

First NameLast Name
Board President*

First NameLast Name
Project/Activity Name*
Total Project/Activity Budget*
Amount of Funding Requested*
Provide a brief history of your organization.*
Provide a brief description of the project/activity.*
What community needs does this project/activity address?*
Who is eligible to benefit from this project? How are participants and the public educated and informed about the project/activity? How many people will benefit?*
What are the specific goals of this project/activity?*

What other funding does your organization have for this project/activity?

	Funder	Amount	Committed or Requested
Source 1
Source 2
Source 3
Source 4
Source 5

Who will be responsible for administration of this grant? Describe your staff's and organization's experience managing federal funding or similar projects.*
Which of the following CDBG objectives does this project/activity meet?*

Benefit low- and moderate-income (LMI) individualsAid in the elimination of slums and blightMeet a need having a particular urgency
Explain how the project/activity meets this CDBG objective.*
When will the project begin and end? What are the key milestones for this project?*
Is this a new program or service, or will there be a 25% increase in people served?*

New program or service (never funded by CDBG before)25% or more increase in people servedNeither of the above
Do your facility and operations comply with the Americans with Disabilities Act?*

YesNo
Project/Activity Budget*

Cancelof
Annual Organizational Budget*

Cancelof
Most Recent Audited or Reviewed Financial Statements*

Cancelof
Board List

Cancelof
IRS Determination Letter*

Cancelof
Authorization to Request Funds (board meeting minutes stating: 1) name of person authorized to submit application; 2) amount of funding requested; and 3) purpose of funding)*

Cancelof
Articles of Incorporation*

Cancelof
Documentation of General Liability Insurance*

Cancelof
Documentation of Workers' Compensation Insurance*

Cancelof
Documentation of Fidelity Bond Coverage*

Cancelof
Additional Documents (not required)

Cancelof
By signing this form, the undersigned acknowledges and certifies that they:
- have read this application and its guidelines in their entirety;
- will comply with all applicable laws and regulations, including but not limited to CDBG regulations, the Civil Rights Acts, the Fair Housing Act, and the Americans with Disabilities Act; and
- are in compliance with 24 CFR Part 5 and 24 CFR Part 570.609, use of debarred, suspended, or ineligible contractors or subrecipients.
CERTIFICATION

I hereby certify that the information contained in this application is true and correct to the best of my knowledge and that I am authorized to submit this application for CDBG funding.
Signature*

Clear
Name*

First NameLast Name
Title*
Today's Date*

MonthDayYear
Date
Should be Empty:

FFY 2024 Pike County Application - Community Development Block Grant