Gadsdenrescue.com



NON-PROFIT ORGANIZATION ASSISTANCE PROGRAM APPLICATIONThe “Gadsden County American Rescue Plan” (GCARP) Non-Profit Organization Assistance Program will assist non-profit organizations located in Gadsden County that have been impacted by COVID-19. As a “super non-profit organization,” the Gadsden Community Health Council (GCHC) will serve as a “clearing house” for this program to identify county non-profits who would be considered for and receive the assistance funds. The GCHC is a partner with the Gadsden County Health Department (GCHD) and assists with various functions and logistics for the GCHD, and donates to over 60-70 organizations within Gadsden County. Non-profit organizations who may apply would have to have been providing the following services within the community: medical, food, educational, or childcare services prior to March 1, 2020. All grants will be provided on a “First qualified, first served” basis. A Gadsden County Applicant/ Organization can only qualify and receive funding through one program under the Gadsden County American Rescue Plan Programs. No Applicant/ Organization is eligible to receive funding assistance through more than one program under the Gadsden County American Rescue Plan Programs. NOTE: Non-profit organizations who are registered/ operate as a non-profit “healthcare” provider or organization would apply for funding through the NON-PROFIT HEALTHCARE ORGANIZATION ASSISTANCE PROGRAM APPLICATION, not this program application. In order to qualify, small businesses located in Gadsden County must provide the following information and documentation:Non-Profit Organization (NPO) Company Name: ___________________________________________ # of Employees: _______ (Part-time) # of Employees: _______ (Full-time)NPO Executive Director/ Administrative Head Name: _______________________________________NPO Company Physical Address: ______________________________________________________City: _________________________ State: _______________ Zip Code: ________________Phone #: __________________________ Alternate Phone #: _________________________NPO Executive Director/ Administrative Head email address:________________________________APPLICATION QUESTIONNAIRE:1.Non-Profit Organization Company was in operation prior to March 1, 2020: YES NO2.Non-Profit Organization Company is CURRENTLY in operation: YES NO3.Select all that apply (due to COVID-19): Non-Profit Organization Company experienced negative reduction/ loss in revenue. Non-Profit Organization Company experienced increased expenditures. Non-Profit Organization Company experienced increased, additional eligible service(s) to the community.APPLICATION SUPPORT DOCUMENTATION/ CHECKLIST:1.Non-Profit Organization Executive Director/ Administrative Head MUST submit copy of Florida Driver’s License, State ID or other documentation validating that the business is located in Gadsden County. YES NO 2.Non-Profit Organization Executive Director/ Administrative Head MUST submit tax returns or other business records reflecting loss of revenue in 2020 compared to 2019, or increased expenditures/ costs due to operating in a COVID-19 environment. YES NO3.Non-Profit Organization Company MUST submit documentation showing the lost donations/ revenue due to the COVID-19 pandemic with a description of how this loss negatively impacted the community. YES NO4.Have a copy of 501c3 determination letter (Non-profit organization certificate) or, State of Florida TaxExemption Certification. YES NO5.Have a copy of most recent 2021 utility bill for Gadsden County address verification. YES NO6.Non-Profit Organization Executive Director/ Administrative Head MUST submit a completed IRS W-9 Form prior to receipt of funding. YES NO7.Did the business receive any Payroll Protection Program (PPP) funding or other COVID-19 related grant funding in 2020 or 2021? YES NO (If YES, then LOSS CALCULATION will be reduced by the amount received through other assistance programs. Other grant award documentation will need to be submitted for Gadsden County American Rescue Plan (GCARP) Program staff review).8.Non-Profit Organization Company/ Applicant provided one of the following services: medical, food, educational and/ or childcare services to residents in Gadsden County during the COVID-19 pandemic. The service(s) that our organization provides is the following: _____________________________________ service(s). NON-PROFIT ORGANIZATION ASSISTANCE PROGRAM APPLICATIONTERMS & CONDITIONSGoverning Laws & Venue: This Application and terms and conditions shall be governed by the laws, rules, and regulations of the State of Florida, and venue shall be in Gadsden County, Florida.Program Policies: This Application is subject to the policies and procedures of the Program as adopted by the County, which are incorporated in this Application by reference.Availability of Funds: The obligations of the County under the Program are subject to the availability of funds lawfully appropriated for such purposes. In the event sufficient funds to fund an award under this this Application become reduced or unavailable or are subsequently determined not to be eligible to fund such award, County shall notify Awardee of such occurrence, and County may terminate such award, without penalty or expense to the County, upon no less than twenty‐four (24) hours written notice to Awardee. County shall be the final authority as to the availability of funds and how available funds will be allotted. Public Records: This Application, including attachments, is subject to disclosure under Florida’s public records law subject to limited applicable exemptions. Awardee acknowledges, understands, and agrees that, except as noted below, all information in its application and attachments will be disclosed, without any notice to Awardee, if a public records request is made for such information, and the County will not be liable to Awardee for such disclosure. If Awardee believes that information in the Application, including attachments, contains information that is confidential and exempt from disclosure, Awardee must include a general description of the information and provide reference to the Florida statute or other law which exempts such designated information from disclosure in the event a public records request is made. The County does not warrant or guarantee that information designated by Applicant as exempt from disclosure is in fact exempt, and if the County disagrees, it will make such disclosures in accordance with its sole determination as to the applicable law.Equal Opportunity; Non‐Discrimination: Awardee shall also comply with the requirements of all applicable federal, state, and local laws, rules, regulations, ordinances, and executive orders prohibiting and/or relating to discrimination, as amended and supplemented. All of the aforementioned laws, rules, regulations, and executive orders are incorporated herein by reference.Public Entity Crimes: Awardee hereby represents and warrants that it has not been convicted of a public entity crime and that it is not on the State of Florida’s convicted vendor list. Awardee also represents that it is not prohibited from submitting this Application by Section 287.133, Florida Statutes. NON-PROFIT ORGANIZATION ASSISTANCE PROGRAM APPLICATIONCERTIFICATION(Check all that apply) I/we acknowledge and agree that, to the fullest extent permitted by law, I shall forever Release, Hold Harmless, Discharge and Agree to Defend and Indemnify, the County of Gadsden, FL from any liabilities, claims, demands, or causes of action that they may hereafter have, without limitation, for personal, bodily, or mental injuries, property damages, economic losses, attorney’s fees, or any other type of injury or damage arising out, resulting from, or in connection with, this application. I/we received a copy of, and acknowledge and agree with the Terms & Conditions for this program. I/we agree to provide additional documentation upon request to help verify the economic hardship suffered as a result of the COVID-19 emergency, including tax returns, PPP loan information, financial statements, and other financial data. I/we hereby certify that the information provided, contained herein and attached hereto is accurate and correct to the best of my knowledge. SIGNATURE: ____________________________________ DATE: ________________ATTESTATIONI, _____________________________________________________, (Non-Profit Organization Executive Director/ Administrative Head / Applicant) who operates _______________________________________________________________(Company Name) located at __________________________________________________________________________ (Non-Profit Organization Company/ Physical Address) ATTEST that the above non-profit organization company was operational prior to March 1, 2020, and it is currently operational and serving the community of Gadsden County, FL. I ATTEST that the reported losses are accurate, valid, and true. I ATTEST that all documentation and information provided on and related to this application is truthful and valid. I acknowledge that I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil, or administrative penalties for fraud, false statements, false claims or otherwise. I certify that I have only submitted one application for assistance through the Gadsden County – American Rescue Plan Programs. I, _____________________________________________________ further acknowledge that by submitting this application for financial assistance, if funding is awarded that I, as the “Applicant/ Awardee” have read, understand, and agree to be bound by the Terms and Conditions:Signature: ____________________________________________Phone #: __________________________________ Date: ___________________________The “Gadsden County American Rescue Plan” (GCARP) Non-Profit Organization Assistance Program will assist Gadsden County non-profit organizations that have experienced a loss of revenue or increased expenditures due to COVID-19 and the pandemic’s economic impact on the community. All grants will be provided on a “First qualified, first served” basis. ................
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