Seattle



Metro Human Services Reduced Fare Bus Ticket Program2012 Additional Allocation ApplicationCity of Seattle Human Services Department Mail or drop off completed applications to:City of Seattle Human Services Department Transitional Living and Support DivisionAttention: Lindsey Zimmerman700 5th Avenue Suite 5800PO Box 34215 Seattle, Washington 98124-4215OR Email your completed application to: Lindsey.Zimmerman@Completed 2012 applications must be received (hard copy or email copy only) no later than 4:00 p.m. on Friday, November 2, 2012APPLICATION CHECKLISTA complete application packet will consist of the following:I.One Completed Application (including signature of authorized agency representative).II.A copy of the Agency’s Human Services Reduced Fare Bus Ticket Program Policies and Procedures. The policies and procedures should not exceed 3 pages, with a minimum of 11-point font and one-inch margins.III.A completed 2012 Bus Ticket Usage Log for each program (required if your agency was funded in 2012). The log will include January 1, 2012 – October 31, 2012 data.Incomplete or late applications will not be considered. Please Note: All agencies who meet the program eligibility and funding priorities are eligible to apply for this one-time 2012 process. You do not need to be currently participating in the Human Services Reduced Fare Bus Ticket Program to apply.A Letter from the Transitional Living and Support Division DirectorI am pleased to offer this application for discounted Metro bus tickets through the Metro Transit Human Services Reduced Fare Bus Ticket Program. The Program provides subsidized Bus Tickets to eligible human service agencies serving persons who are homeless and/or have low-to-moderate incomes. Allocation priority will be given to fund agencies/programs that will utilize Metro Human Services Ticketbooks to help homeless persons access shelters, health care agencies, employment, and related services critical to personal and residential stability. Approximately $312,000 in total ticket value is expected to be available for this additional 2012 allocation. Agencies that receive an allocation will be required to pay 20 cents for every 80 cents of subsidy received. Last year, the City of Seattle’s share of the Ticketbook Program allocation was distributed to 70 organizations that serve homeless people and people at risk of pleted applications for Metro Bus Tickets through the Seattle Metro Transit Human Services Reduced Fare Bus Ticket Program must be received no later than 4 p.m, on Friday November 2, 2012. Please submit applications to:Seattle Human Services DepartmentApplication Response: Transitional Living and SupportAttention: Lindsey Zimmerman700 5th Avenue, Suite 5800P.O. Box 34215Seattle, Washington 98124-4215If you have questions regarding the application process, please contact Lindsey Zimmerman by phone at (206) 684-0106 or by email at lindsey.zimmerman@ I appreciate your interest in the City’s Metro Transit Human Services Reduced Fare Bus Ticket Program and look forward to seeing your application in the near future.Sincerely,Al Poole, DirectorTransitional Living and Support Division City of Seattle Human Services Department 2012 ADDITIONAL ALLOCATION APPLICATIONHUMAN SERVICES REDUCED FARE BUS TICKET PROGRAM A.APPLICANT INFORMATION (Please submit one application for all your agency’s programs)Agency Name FORMTEXT ?????Contact Person/Title FORMTEXT ?????Program Name(s) FORMTEXT ?????Phone Number FORMTEXT ?????Street Address: FORMTEXT ?????Fax Number FORMTEXT ?????City FORMTEXT ????? Email Address FORMTEXT ?????State FORMTEXT ?? Zip FORMTEXT ????? Only nonprofit or public housing and support service organizations, and local governments that meet eligibility requirements outlined in the Application Guidelines are eligible to apply for funding.B.BUS TICKET REQUEST AND USAGE INFORMATIONAmount of Request:The Human Services Reduced Fare Bus Ticket Program authorizes approved eligible agencies to purchase up to an authorized amount of bus tickets. The agency pays 20 percent of the value of the tickets, with King County Metro Transit Division covering the remaining 80 percent of the value of the tickets.Total Value of Tickets Requested (100 percent of ticket value):______________Amount Agency will pay for tickets (20 percent of the above number):______________(For example, if you wish to purchase $1000 worth of tickets, the number on the first line will be $1000 and the number on the second line will be $200, which is the amount that you will pay for the tickets.)Was your program previously awarded Human Services Reduced Fare Bus Tickets in 2012? FORMCHECKBOX Yes FORMCHECKBOX NoC.BUS TICKET PROGRAM POLICIES AND USAGE INFORMATIONDefinitions:HOMELESS: Any individual or family with a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping groundAn individual or family who is homeless and living in a supervised publicly or privately operated shelter designated to provide temporary living arrangement (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs for low-income individuals).LOW INCOME: (see the 2012 Housing and Urban Development Income Guidelines for King County listed below)All households served through the King County Human Services Reduced Fare Bus Ticket Program must be at or below 50 percent of area median income for family size.FAMILY SIZE12345678Income not more than:$30,800$35,200$39,600$44,000$47,550$51,050$54,600$58,100Program Policies: (**New Requirement**) Each agency must provide typewritten policies on how the Human Services Reduced Fare Bus Ticket Program is or will be administered. Please submit a separate policies and procedures document with your bus ticket application (not to exceed three pages, using 11-point font and one inch margins). Note: Policies and Procedures must be approved by HSD and/or DCHS prior to being able to purchase allocated tickets from Metro.How bus tickets are stored (at a minimum they must be stored in a locked room and container)Who has access to the ticketsHow tickets are prioritized for useThe number and types of tickets distributed to individuals at any given timeHow tickets are logged/tracked (see the Application Guidelines for details on what information must be tracked at a program level)How income and homeless status are verifiedHow your agency monitors multiple programs or sites that are distributing ticketsThe process for reporting tickets to HSD or DCHS if tickets are lost or stolenPopulation Approximately what percentage of these tickets will be used for homeless clients? (see definition of “homeless” above) FORMTEXT ?????%Approximately what percentage of these tickets will be used for low-income (not including homeless) clients? (see definition of “low income” above) FORMTEXT ?????%Total100%Approximately what percentage of these tickets will be used by programs located in the City of Seattle? FORMTEXT ?????%Approximately what percentage of these tickets will be used by programs located in King County, outside of the City of Seattle? FORMTEXT ?????%Total100%What types of activities will the bus tickets be used for: (Check all that apply) FORMCHECKBOX Shelter FORMCHECKBOX Clothing FORMCHECKBOX Food banks FORMCHECKBOX Permanent housing search FORMCHECKBOX Employment FORMCHECKBOX Health care FORMCHECKBOX Job training FORMCHECKBOX Day care FORMCHECKBOX Transitional housing FORMCHECKBOX Day Services FORMCHECKBOX Rent payment assistance FORMCHECKBOX Shower/hygiene facilities FORMCHECKBOX Public assistance/Social Security etc. FORMCHECKBOX Dental care FORMCHECKBOX Alcohol/drug treatment FORMCHECKBOX Mental health services FORMCHECKBOX Utility assistance FORMCHECKBOX Other (Specify)Did you also submit an application to the King County DCHS for Bus Tickets? (Note: Agencies should submit an application to King County DCHS for programs primarily serving King County residents, outside the City of Seattle.) FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, note total amount requested from DCHS: ______________D.AGENCY / PROGRAM INFORMATIONBriefly describe the mission of your Agency.Describe specific services to low- income and homeless clients provided by your program.List the name(s) and location(s) of the program(s) included in this application. What was your total agency budget in 2012?$ FORMTEXT ? ????What is your total agency budget projected for 2013?$ FORMTEXT ??? ??What matching fund sources(s) will be used to purchase tickets:E.AGENCY CERTIFICATIONSThe Agency hereby certifies that the information presented in this application is true and complete to the best of its knowledge and the Agency is a non-profit or eligible public agency. The Agency further certifies that:Any tickets purchased by the agency through this program will only be dispensed to low-income persons enrolled in our programTickets purchased through this program will not be resold for any reasonTickets will only be used for the agency’s low-income clients and they may not be used to cover the transportation needs of agency staff and/or volunteers, including staff receiving stipendsThe agency will properly safeguard all tickets received under this agreement and track issuance of such tickets by completing the ticket usage log by programAgency agrees to maintain a business like system for documenting the income and, if applicable, the homeless status of clientele that receive ticketsIf bus tickets purchased through this program are lost or stolen the agency will immediately notify HSD, DCHS, and Metro.The Agency further understands that there are penalties for submitting false information and misusing the tickets from their intended purpose. Failure to adhere to these certifications will be grounds for sanctions, including loss of eligibility to participate in the program. The Agency further agrees that it will repay the full value of all tickets determined to be lost or misused, due to negligence or mismanagement of tickets received under this program. Name: FORMTEXT ?????Title: FORMTEXT ?????Date: FORMTEXT ?????Signature of Agency Director or Authorized Representative: FORMTEXT ?????2012 City of Seattle Metro Transit Human Service Reduced Fare Bus Ticket Program – Sample Usage LogProgram Name:________________________________Instructions for Completion:This form is to be completed by month for each program. Example: If you hand out 1,000 tickets in January, the form should show how many went to children, teens, and adults as well as whether any of the recipients were homeless. You also need to list the purpose of the bus ticket and indicate approximately how many tickets for each purpose.Clients ServedBus Ticket PurposeMonthChild(<13)Teen(13-19)Adult(20+)Total # of Tickets GivenOf total, # who are home-lessHomeless & Housing ServicesEmergency Food ProgramAging/Disability ServicesDV PreventionImmigration/Refugee Community SupportChildren/Youth & Family/ChildcareEmployment/Job TrainingOtherJan FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????Feb FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????Mar FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????Apr FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????May FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????June FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????July FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????Aug FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????Sept FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????Oct FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????Nov FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????Dec FORMTEXT ???? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download