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.Format: (000) 000-0000.
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?

Rows	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?
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?
Do your facility and operations comply with the Americans with Disabilities Act?
Project/Activity Budget

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Annual Organizational Budget

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Most Recent Audited or Reviewed Financial Statements

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Board List

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IRS Determination Letter

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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)

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Articles of Incorporation

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Documentation of General Liability Insurance

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Documentation of Workers' Compensation Insurance

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Documentation of Fidelity Bond Coverage

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Additional Documents (not required)

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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
Name

First NameLast Name
Title
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

FFY 2024 Pike County Application - Community Development Block Grant