20-LCM-06 - Attachment 2 - Coronavirus Aid, Relief, and ...
ANDREW M. CUOMOGovernorMICHAEL P. HEINCommissionerBARBARA C. GUINNExecutive Deputy CommissionerCARES ActEmergency Solutions Grant (ESG CV)ApplicationDistrict: FORMTEXT ?????District Contact: FORMTEXT ?????Telephone: FORMTEXT ?????E-mail: FORMTEXT ?????County Department of Health (DOH): FORMTEXT ?????DOH Contact: FORMTEXT ?????Telephone: FORMTEXT ?????E-mail: FORMTEXT ?????County Emergency Management Office (EMO): FORMTEXT ?????EMO Contact: FORMTEXT ?????Telephone: FORMTEXT ?????E-mail: FORMTEXT ?????Continuum of Care (CoC): FORMTEXT ?????CoC Contact: FORMTEXT ?????Telephone: FORMTEXT ?????E-mail: FORMTEXT ?????Total New York State CARES Act-ESG CV funds: $ FORMTEXT ?????Describe the collaboration between the district, the CoC, DOH and EMO and other important community stakeholders to determine the county’s COVID-19 needs. FORMTEXT ?????Describe additional anticipated CARES Act funding from other sources (such as CDBG, FEMA, etc.). List the source and anticipated amount. FORMTEXT ?????Describe what resources are being utilized to address the county’s COVID-19 response needs. Include the anticipated uses of any ESG CV direct allocation of funds (funds allocated directly to the County or Cities within the County). FORMTEXT ?????Describe the impact COVID-19 has had on homeless and at-risk households in the County. Provide any quantifiable evidence of the impact. FORMTEXT ?????Describe in detail the unmet local needs that have arisen as a result of COVID-19. Please indicate the proposed uses for the ESG CV funds. Affirm the funds are a means of last resort. FORMTEXT ?????Describe the rationale for selecting the entity(s) that will contract with OTDA for receipt of ESG CV funds. FORMTEXT ?????Describe how program eligibility requirements will be determined. If prevention funds are being requested include how at-risk of homelessness will be determined. FORMTEXT ?????Describe how the Homeless Management and Information System (HMIS) requirement will be met. FORMTEXT ?????Provide a detailed timeline that demonstrates the ability to implement this program in a timely fashion. FORMTEXT ?????Indicate acknowledgment and agreement to all requirements pursuant to the CARES Act and identified in this application.Choose an item.In the chart below indicate which entity(s) will be receiving ESG CV funds and the activity those funds will support. Please indicate if the agency will directly hold the contract with OTDA or be a subcontract to another agency.ProviderAmountESG CV ActivityDirect Contract or SubcontractEX: Agency X$50,000Rapid RehousingSubcontract FORMTEXT ?????$ FORMTEXT ?????Choose an item.Choose an item. FORMTEXT ?????$ FORMTEXT ?????Choose an item.Choose an item. FORMTEXT ?????$ FORMTEXT ?????Choose an item.Choose an item. FORMTEXT ?????$ FORMTEXT ?????Choose an item.Choose an item. FORMTEXT ?????$ FORMTEXT ?????Choose an item.Choose an item.I the undersigned, approve of all components of the attached application and agree that the provisions in the application will remain valid until the ESG CV funds are no longer available.?? FORMTEXT ?????1139700(Commissioner’s Name - Please print or type)?? FORMTEXT ?????1127000(Signature)??Date: FORMTEXT ????? ................
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