CITY OF CHICAGO



CITY OF CHICAGO

COMMUNITY DEVELOPMENT BLOCK GRANT

PROGRAM YEAR XXXVII-2011

WORK PROGRAM AND BUDGET

Department:

Program: Fax #:

Contact Name: Phone #:

Part I: Delegate Information

Parent Organization Name:

Parent Organization Address:

Parent Organization City, State, Zip:

Delegate:

Site Address:

City, State, Zip:

Executive Director:

Delegate Contact:

Phone #: Fax #:

Office Hours: Program Service Hours:

Total Budget for this Project (including other share):

CDBG Year XXXVII Allocation:

Grant Agreement Period: From To

Federal Employer Identification Number:

|For Internal Use Only |

|Log #: |

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|Vendor Code #: _ |

|Service Grant Agreement #: |

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|Fund-Department-Organization #: |

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Part II: Description of Project

In a clear and concise manner, provide a narrative summary of this CDBG funded project: its scope, problems addressed, and results anticipated. Please do not add additional pages.

Part III: Monitoring and Evaluation Procedures

A. Describe the methods your agency will employ to evaluate the project's progress and record project accomplishments.

B. Describe how your agency will monitor program expenditures and ensure that appropriate fiscal controls and records are in place.

Part IV: Auditing Requirements

Is your agency (check only one)? 9 not-for-profit 9 education institution

9 governmental agency 9 for-profit

A. What is your agency's fiscal year?

B. When do you intend to conduct an audit of this grant agreement?

C. Below please list all contracts and grants that your agency anticipates receiving during the 2011 fiscal year. Identify if the source is Federal or Other and the amount.

Funding Source

Contracts/Grants Federal Other Total Amount Requested

D. If you are applying to other City departments for CDBG grants please list the department, the program and the amount requested below:

Department Program CDBG Amount Requested

Form 1

Budget Summary

|A. Delegate F. Vendor Code # |

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|B. Program Name G. Vendor Site # |

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|C. Department H. PO # _ |

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|D. Contract Term 1/1/2011 to 12/31/2011 I. Release # _ |

|E. 2011 Allocation: J. | _ |

|Funding Strip: | |

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|K: CFDA#: | |

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L. Project Budget Summary for Year XXXVII - 2011

Note: The entire budget for this project must be shown.

|(1) Item of Expenditure |(2) Account # |(3) CDBG Share ($) |(4) Other Share($) |(5) Total Cost ($) |

|Personnel |0005 | | | |

| | | | | |

|Fringe Benefits |0044 | | | |

| | | | | |

|Operating/Technical |0100 | | | |

| | | | | |

|Professional and Technical Services |0140 | | | |

| | | | | |

|Materials and Supplies |0300 | | | |

| | | | | |

|Equipment |0400 | | | |

| | | | | |

|Other (please specify) |0900 | | | |

| | | | | |

|Other (please specify) | | | | |

|TOTAL | | | | |

| | |

|M. Percentage of total project costs paid | |

|by Other Share (column 4 ÷ column 5): ___________% | |

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| | |

|N. Delegate Authorization |O. City Authorizations |

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|_ |_ |

|Signature of Delegate Official Date |Signature of Department Official Date |

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|_ |_ |

|Name and Title (Type or Print) |Name and Title (Type or Print) |

Form 2

Personnel Budget

A. Delegate C. Project Name _

B. Department Program D. Federal Employer Identification # _

E. Personnel Budget Allocation for Year XXXI- 2011

| Position/Title | No. |Rate ($) |% of Time Spent |CDBG Share ($) |Total Cost ($) |Brief Summary of Job Responsibilities |

|(1) |(2) |(3) |(4) |(5) |(6) |(7) |

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|(8) Totals | | | | | |Totals must match Budget Summary - Form 1, Account #0005 |

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|F. Fringe Benefits and Total Personnel Costs | | | |

|Type of Fringe Benefit |CDBG Share ($) |Total Cost ($) |Please show calculation below: |

| (9) a. Social Security Tax | | |= .0620 x line 8 |

|(9) b. Medicare | | |= .0145 x line 8 |

|(10) State Unemployment Insurance | | | |

|(11) State Workers Compensation | | | |

|(12) Other (please list) | | | |

|(13) Other (please list) | | | |

|(14) Total Fringe Benefits (Add lines 9-13) | | |Totals must match Budget Summary - Form 1, Account #0044 |

|(15) Total Personnel Costs (Line 8 plus line 14) | | | |

Form 3

Non-Personnel Budget

|A. Delegate _ | |

| |C. Project Name |

|B. Department Program _ | |

D. Non-Personnel Allocation for Year XXXVII - 2011

| | |CDBG Share | |Line Item Description and Justification |

|Item of Expenditure |Account # |of Cost ($) |Total Cost ($)) |(Please show justifications for Total Cost and CDBG Share) |

|(1) |(2) |(3) |(4) |(5) |

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| (6) TOTAL | | | | |

Form 4

WORK PROGRAM

A. Delegate D. Strategy: ____________________________________________________________

B. B. Department Program

C. Project Name

E. Work Program For Year XXXVII- 2011

|(1) |(2) |(3) | |

|Program / Sub Program |Program Deliverables |2011 Planned Output by Quarter & Year | |

|Activities | |Total. List of Projected quantifiable |(4) |

| |State what quantifiable units will be |units for each program deliverable. |Performance Measures |

|Elements which |used to measure the progress of the | | |

|describe the activities |proposed project. Example: classes | | |

|that will accomplish |held; units built; referrals. | | |

|program objectives. | | | |

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| | |1st Qt |

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|Total | | |

4. Overall % Low/Mod (Total of column 2 ÷ Total of column 3): _

Form 7

Survey of Monitoring and Evaluation Procedures

(To be completed by City Department)

A. Department -

B. Department Program _

C. Staff in charge of monitoring _

The purpose of this form is to ensure that monitoring and evaluation procedures are followed by City departments and by individual subrecipient agencies in monitoring subrecipient projects. A copy should accompany each subrecipient grant agreement.

HUD cautions in its Fraud Information Bulletin that a city which funds subrecipients must always be aware of the possibility of fraud and abuse by the subrecipients due to poor management or to deliberate violation of the law; of conflict of interest; or abuses in the contracting process of subrecipients; of false or inadequate documentation of program accomplishments.

1) Describe the methods that the department will employ to monitor and evaluate its subrecipients' programs to ensure their progress and accomplishments, including the frequency of such monitoring.

2) Describe how the department will monitor subrecipient expenditures.

3) Specify the particular records the subrecipient must maintain and/or submit.

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