Application for rapid response covid-19 funding



Background: On March 27, 2020, the Federal government signed into law the Coronavirus Aid, Relief, and Economic Security (CARES) Act. A portion of the funds, made available to Fairfax County, are being utilized to support small businesses that are organized as tax-exempt nonprofit organizations described in section 501(c)3 of the Internal Revenue Code (IRC) or a tax-exempt veterans organization described in section 501(c)19 of the IRC. Nonprofit organizations supporting social safety net services, as detailed below in Part A: Social Safety Net Categories, to Fairfax County residents are encouraged to complete the below application in order to seek financial assistance to address service interruptions and organizational constraints related to the impacts of COVID-19. How to Apply: Please complete the application below, which is limited to five (5) pages. Up to one page of additional information (not inclusive of the 990) may be attached. The County will accept either electronic or hardcopy submissions of the application. All submissions must be received by May 22, 2020 at 2:00 P.M. Applications received after the aforementioned submission due date/time will not be considered for award. Electronic submissions of this application with supporting documentation must be submitted to dpmmNSGRANT@. Hardcopy submissions must be submitted by mail to the following address and be postmarked by May 22, 2020:Fairfax County Department of Procurement and Material ManagementAttn: Nonprofit Sustainability Grant12000 Government Center Parkway, Suite 427Fairfax, Virginia 22035Questions: Please submit questions regarding this grant application to dpmmnsgrant@ or 703-324-2861. ---Nonprofit Organizational Information: Name: Click or tap here to enter text.Street Address: Click or tap here to enter text.City, State, Zip: Click or tap here to enter text.DUNS # (if available):Click or tap here to enter text.Contact Person: Click or tap here to enter text.Telephone #: Click or tap here to enter text.E-Mail: Click or tap here to enter text.% of direct service staff serving Fairfax County residents: Click or tap here to enter text.# of full-time-equivalent staff your organization has working in Fairfax County: Click or tap here to enter text.Statement of Need: Briefly describe any issues your organization has encountered due to the COVID-19 pandemic that have resulted in interruptions to your services caused by required closures or service modifications and/or other operational challenges.Click or tap here to enter text. Social Safety Net Services: Part A: Social Safety Net Categories: Please select the Social Safety Net Categories that represent services that your organization provides in Fairfax County. Click here for Example Services by Category. ? Financial Stability ? Food and Nutrition ? Health? Literacy/Educational Development Attainment ? Housing ? Positive Behaviors/Healthy Relationships ? Support/Community/Social Networks Part B: Service(s) Description: Briefly describe the specific program(s) providing services in Fairfax County and how these services contribute to our local Social Safety Net.? Click or tap here to enter text.Funding Utilization: Please describe the specific expenses these funds will be used for (e.g., employee retention, equipment and materials, rent payments, debt payment, technology upgrades). Funding must utilized in accordance with Federal guidelines. These guidelines permit the County to use these funds “to respond to second-order effects of the emergency, such as by providing economic support to those suffering from employment or business interruptions due to COVID-19-related business closures.” In describing how you will spend these funds, please clarify how the need is attributable to “business interruptions” due to COVID-19. Click or tap here to enter text.Financial Documentation: All organizations must submit their most recently filed IRS 990 Form and identify below the most recent year filed with the IRS.? 2019? 2018? 2017Required Certification:By entering your signature below, you are certifying on behalf ofClick or tap here to enter text. (Enter nonprofit organization name above)that the following statements are accurate:Funds received from Fairfax County in response to this application for sustainability grant funding will only be used to cover costs that:Are reasonable and necessary expenditures incurred due to the public health emergency with respect to the Coronavirus Disease 2019 (COVID-19);Were incurred during the period that begins on March 1, 2020, and ends December 30, 2020; and, Are in accordance with all applicable state, local, and federal laws. Click or tap here to enter text.Vendor Legally Authorized Signature**DateClick or tap here to enter text.Print Name and TitleBy entering your signature information above and clicking “I Agree” below, you certify that the statements contained in this application are true and correct to the best of your knowledge.Choices:?1409400122150 I Agree ? I Do Not Agree **Legally Authorized Signatures may include electronic signatures (i.e. DocuSign). ................
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