Section 1:



North Carolina Emergency Solutions Grants Program FY 2020-2021 Project ApplicationFunding for the 2020 Program Year (January 1, 2021 – December 31, 2021)For submission information, refer to the NC ESG Application Instructions.Section 1: Organization InformationApplicant Organization InformationLegal Name of Organization (as it appears on your Organization’s tax return): FORMTEXT ?????Physical Address Street, City, State and Zip: FORMTEXT ?????Mailing Address (if different from physical address) Street, City, State and Zip: FORMTEXT ?????Telephone: FORMTEXT ?????Website: FORMTEXT ?????Federal Tax ID Number: FORMTEXT ?????DUNS #: FORMTEXT ?????Select Organization Type: FORMDROPDOWN Date of Incorporation: FORMTEXT mm/ FORMTEXT dd/ FORMTEXT yyyyName of Contact Person for Organization: FORMTEXT ?????Title of Contact Person: FORMTEXT ?????Phone Number of Contact Person: FORMTEXT ?????Which CoC/LPA is your organization in? FORMDROPDOWN Email Address for the Contact Person: FORMTEXT ?????What counties does your organization currently serve?(include all, even if in a different CoC/LPA) FORMTEXT ?????Organization MissionDescribe the organization’s mission and how homeless programs fit within that mission. FORMTEXT Enter Response Here- Maximum 1500 Characters Signatory Authority Provide the information for the person authorized to sign contracts for the organization.Name: FORMTEXT ?????Title: FORMTEXT ?????Telephone: FORMTEXT ?????E-mail: FORMTEXT ?????Mailing Address, including City, State and Zip Code: FORMTEXT ?????Provide the information for the person(s) authorized to sign requisitions (if different from above) for the organization.Name: FORMTEXT ?????Title: FORMTEXT ?????Telephone: FORMTEXT ?????E-mail: FORMTEXT ?????Mailing Address, including City, State and Zip Code: FORMTEXT ?????Second authorized requisition signatory (if applicable)Name: FORMTEXT ?????Title: FORMTEXT ?????Telephone: FORMTEXT ?????E-mail: FORMTEXT ?????Mailing Address, including City, State and Zip Code: FORMTEXT ?????Application CertificationTo the best of my knowledge and belief, all information in this application is true and correct. Name of Applicant Organization: FORMTEXT ?????Name of Authorized Official: FORMTEXT ?????Title: FORMTEXT ?????Date: FORMTEXT ?????SignatureSection 2: Organizational Capacity & StabilityFinancial Capacity Applicant organization’s fiscal year: FORMTEXT mm/ FORMTEXT dd to FORMTEXT mm/ FORMTEXT dd What type of accounting software does your organization use, specifically for NC ESGfunds? (Examples include – QuickBooks, SAP, Raisers Edge, etc.) FORMTEXT ????? Explain how your organization monitors activities to ensure that NC ESG dollars arespent in a timely manner FORMTEXT Enter Response Here- Maximum 2000 Characters Provide the difference (positive or negative) in revenue and expenses for theorganization over the last three completed fiscal years.2018Fiscal Year End Date: FORMTEXT mm/ FORMTEXT dd/ FORMTEXT yyyyDifference in Revenue and Expenses FORMTEXT $2017Fiscal Year End Date: FORMTEXT mm/ FORMTEXT dd/ FORMTEXT yyyyDifference in Revenue and Expenses FORMTEXT $2016Fiscal Year End Date: FORMTEXT mm/ FORMTEXT dd/ FORMTEXT yyyyDifference in Revenue and Expenses FORMTEXT $Provide an explanation for any negative balances over the past three years. FORMTEXT Enter Response Here- Maximum 2000 CharactersThe NC ESG Office may request additional financial documentation after application anization Capacity Has the organization received any HUD findings, resolved or unresolved, within thepast 5 years? FORMDROPDOWN Has the organization received any ESG findings (County, City or State), resolved orunresolved within the past 5 years? FORMDROPDOWN Has the organization had any ESG contract (County, City or State) terminated? FORMDROPDOWN If yes, what steps has the organization taken to ensure the deficiencies identified to warrant contract termination, have not and will not be repeated? FORMTEXT Enter Response Here- Maximum 2000 Characters How does the organization self-monitor for success and HUD/ESG compliance? FORMTEXT Enter Response Here- Maximum 2000 CharactersBoard Information Total number of current board members: FORMTEXT ????? Does the current board include a person with lived experience of homelessness? FORMDROPDOWN If no, when does the organization anticipate adding a person with lived experience to theboard? FORMTEXT Enter Response Here- Maximum 1000 Characters Provide a brief explanation of how board members are selected. FORMTEXT Enter Response Here- Maximum 1000 Characters What is the term length for board members in your bylaws? FORMTEXT Enter Response Here- Maximum 500 CharactersPast Awards Did the applicant organization receive NC ESG funding during the 2020 Program Year? FORMDROPDOWN If you answered no because you did not receive NC ESG funding during the 2019 calendaryear, has the applicant organization been a subrecipient in previous years? FORMDROPDOWN If you have previously been a subrecipient, what was the most recent year you werefunded? FORMTEXT ?????Section 3: Staff Capacity Organizational Staff Information Complete the charts below.Entire OrganizationNC ESG ProgramTotal FTEs: FORMTEXT ?????Number of FTEs paid with NC ESG Funds FORMTEXT ?????Total PTEs: FORMTEXT ?????Number PTEs Paid with NC ESG Funds: FORMTEXT ?????Number of Volunteers: FORMTEXT ?????Number of Volunteers with ESG Program: FORMTEXT ?????PositionFilled with Paid StaffFilled with Volunteer StaffUnfilledPosition Does Not ExistExecutive Director FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Intake Worker FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Case Manager(s) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX HMIS Organization Administrator FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Fiscal Officer/Bookkeeper FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shelter Director/Manager FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Housing Specialist/LandlordEngagement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Describe which NC ESG activities are performed by volunteers and what the activityentails. FORMTEXT Enter Response Here- Maximum 2000 CharactersSection 4: Connection to CommunityCoC/LPA ParticipationExplain how the organization coordinates with other organizations to provide nonduplication of services AND access to mainstream resources such as TANF, Food Stamps, Housing Assistance, etc. FORMTEXT Enter Response Here- Maximum 2000 CharactersCoordinated EntrySubrecipients are required to participate in the local coordinated assessment process as designed by your Continuum of Care/LPA and only take referrals from the coordinated assessment system. Does the organization as a whole, regardless of funding source, fully participate in thecoordinated entry process in the CoC/LPA? FORMDROPDOWN Does the organization, as a whole, regardless of funding source, ever take referralsfrom sources outside of the coordinated entry system? FORMDROPDOWN If yes, provide the other sources outside of the coordinated entry system, where theorganization accepts referrals. Note whether or not this exception is included in the approved coordinated entry plan for the CoC/LPA. FORMTEXT Enter Response Here- Maximum 2000 CharactersWritten StandardsSubrecipients are required to adhere to written standards of the CoC/LPA. Does the organization operate programs according to all of the CoC’s/LPA’s writtenstandards? FORMDROPDOWN If no, which written standards does the organization decline to adhere? FORMTEXT Enter Response Here- Maximum 2000 CharactersFeedback from ParticipantsDescribe how the organization receives and responds to feedback from participants inthe program. FORMTEXT Enter Response Here- Maximum 2000 CharactersSection 5 Data:Data CollectionWhat is the name of the software the organization uses to comply with the datacollection and reporting requirements? FORMTEXT Enter Response Here- Maximum 2000 CharactersIs the software capable of producing a CAPER? FORMDROPDOWN Does the organization deny services if clients refuse to provide any of the HUD required data elements? FORMDROPDOWN If yes, which data elements? FORMTEXT Enter Response Here- Maximum 2000 CharactersHow does the organization ensure that client files are kept confidential? FORMTEXT Enter Response Here- Maximum 2000 Characters Does the organization have a designated staff member to enter data, pullreports and attend user meetings? FORMDROPDOWN Is the employee a Full-time or Part-time staff person or a volunteer? FORMDROPDOWN Is the employee’s primary job responsibility data entry? FORMDROPDOWN How many licensed users does your organization have? FORMTEXT ?????Section 6 Activities:Complete only the activity section(s) for which the organization is seeking NC ESG funding. Street OutreachEmergency ShelterRapid RehousingHomelessness PreventionHMIS/Comparable Database[This page intentionally left blank]Street OutreachStreet Outreach Project DescriptionPopulation to be served: FORMCHECKBOX single men FORMCHECKBOX single women FORMCHECKBOX households with children FORMCHECKBOX youth 18-24 FORMCHECKBOX unaccompanied youth 17 years old and under FORMCHECKBOX Other (specify): FORMTEXT ?????Does this program exclusively serve victims of domestic violence (DV)? FORMDROPDOWN Fill out the following chart. Outreach ActivityProvided with NC ESG fundsProvided with other fundsReferral (Or does not provide this service)Years of experience providing service (if none mark n/a)Contact Activities(formerly Engagement) must be provided with NC ESG funds. FORMCHECKBOX -- FORMTEXT ?????Engagement Service – Case Management FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Engagement Service –Emergency Health Services FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Engagement Service – Emergency Mental Health Services FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Engagement Service – Transportation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Engagement Service – Services for special populations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????If the organization does not provide an outreach activity listed above, with NC ESGfunds or other funds, explain how referrals are made. FORMTEXT Enter Response Here- Maximum 2000 CharactersIf the organization received funding in the prior year for street outreach, what has beenaccomplished to improve the organization’s service delivery? FORMTEXT Enter Response Here- Maximum 2000 CharactersWhat days and times are services available for program participants? FORMTEXT Enter Response Here- Maximum 2000 CharactersExperienceExplain any experience the organization has in implementing street outreach.Specifically, include the years of experience of staff involved in implementing/administering the NC ESG funds. FORMTEXT Enter Response Here- Maximum 2000 CharactersStreet Outreach Program Design and PhilosophyDescribe how outreach is conducted, how participants are contacted and engaged, and how often outreach is done. FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program screen out participants based on any of the following: FORMCHECKBOX Having too little or no income FORMCHECKBOX Active or history of substance abuse (alcohol and/or drugs) FORMCHECKBOX Having a criminal record (with exceptions for state mandated restrictions) FORMCHECKBOX History of domestic violence (e.g. lack of protective order, of separation from abuse, or law enforcement involvementIf any box above is checked, explain: FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program terminate participants based on the following: FORMCHECKBOX Failure to participate in support services FORMCHECKBOX Failure to make progress on a service plan FORMCHECKBOX Loss of income or failure to improve income FORMCHECKBOX Domestic violence FORMCHECKBOX Any other activity not covered in a lease agreement typically found in the program’s geographic areaIf any box above is checked, explain: FORMTEXT Enter Response Here- Maximum 2000 CharactersDescribe how the program is housing focused. FORMTEXT Enter Response Here- Maximum 2000 Characters How does the program partner with shelters in the CoC/LPA? FORMTEXT Enter Response Here- Maximum 2000 CharactersHow does the program partner with Rapid Rehousing and Permanent SupportiveHousing programs in the CoC/LPA to provide permanent housing? FORMTEXT Enter Response Here- Maximum 2000 CharactersWhat role does the organization play in the coordinated entry system? (check all that apply): FORMCHECKBOX Assess households that you outreach FORMCHECKBOX Refer households to coordinated entry upon engagement FORMCHECKBOX Transport households to coordinated entry points for assessment FORMCHECKBOX Other (specify): FORMTEXT ?????Provide an estimated number of persons to be served by this funding request. CategoryProgram EstimateTotal Persons Served FORMTEXT ?????Percentage of Persons Exiting to Positive Housing Destinations FORMTEXT ?????Cost Per Household FORMTEXT ?????Optional: In the space below, provide any additional information that would be helpful for the NC ESG Review Committee to know regarding this program. This must be a narrative, not a reference to attached additional documentation. FORMTEXT Enter Response Here- Maximum 2500 Characters[This page intentionally left blank]Emergency ShelterEmergency Shelter Program DescriptionPopulation to be served: FORMCHECKBOX single men FORMCHECKBOX single women FORMCHECKBOX households with children FORMCHECKBOX youth 18-24 FORMCHECKBOX unaccompanied youth 17 years old and under FORMCHECKBOX Other (specify): FORMTEXT ?????Does this program exclusively serve victims of domestic violence (DV)? FORMDROPDOWN Indicate which services will be provided by the organization and which will be providedby another through referral. Emergency ShelterProvided with NC ESG fundsProvided with other fundsReferral (Or does not provide this service)Years of experience providing service (if none mark n/a)Case Management FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Childcare FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Education services FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Employment assistance & job training FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Life skills training FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Legal services FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Mental health services FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Substance abuse services FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Transportation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Services for special populations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Shelter Operations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????If the organization does not provide an emergency shelter activity, listed above, withNC ESG funds or other funds explain how referrals are made. FORMTEXT Enter Response Here- Maximum 2000 CharactersWhat days and times are services available for program participants? FORMTEXT Enter Response Here- Maximum 2000 CharactersIf the shelter does not operate 24 hours a day for 7 days a week (including holidays),describe how households access emergency services when the shelter is closed: FORMTEXT Enter Response Here- Maximum 2000 CharactersExperienceExplain any experience the organization has in providing emergency shelter services. Specifically, include the years of experience of staff involved in implementing/administering NC ESG funds. FORMTEXT Enter Response Here- Maximum 2000 CharactersEmergency Shelter Program Design and PhilosophyWhat are the eligibility requirements to access emergency shelter and/or services? FORMTEXT Enter Response Here- Maximum 2000 CharactersWhat are the reasons that someone may be turned away or asked to leave the shelter? FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program screen out participants based on the following: FORMCHECKBOX Having too little or no income FORMCHECKBOX Active or history of substance abuse (alcohol and/or drugs) FORMCHECKBOX Having a criminal record (with exceptions for state mandated restrictions) FORMCHECKBOX History of domestic violence (e.g. lack of protective order, of separation from abuse, or law enforcement involvementIf any box above is checked, explain: FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program terminate participants based on the following: FORMCHECKBOX Failure to participate in support services FORMCHECKBOX Failure to make progress on a service plan FORMCHECKBOX Loss of income or failure to improve income FORMCHECKBOX Domestic violenceIf any box above is checked, explain: FORMTEXT Enter Response Here- Maximum 2000 CharactersDescribe how the program is, or moving towards, a low-barrier and housing first model: FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program have dedicated staff whose responsibility is to identify and recruitlandlords and encourage them to rent to homeless households served by the program? FORMDROPDOWN If no, do the case manager’s responsibilities include landlord recruitment andnegotiation? FORMDROPDOWN How does the organization utilize Rapid Rehousing and Permanent Supportive Housingprograms within the CoC/LPA. FORMTEXT Enter Response Here- Maximum 2000 CharactersIf the organization received funding in the prior year for emergency shelter, what hasbeen accomplished to improve the organization’s exits to a positive destination? FORMTEXT Enter Response Here- Maximum 2000 CharactersWhat role does the organization plan in the coordinated entry system? FORMCHECKBOX Shelter serves as an access point for coordinated entry FORMCHECKBOX Shelter staff completes assessments FORMCHECKBOX Shelter accepts referrals from coordinated entry FORMCHECKBOX Other (specify): FORMTEXT ?????Provide estimates of who will be served by this funding request.CategoryProgram EstimateTotal Number of Persons served FORMTEXT ?????Total Number of Persons Enrolled (entered into HMIS/DV Comparable) FORMTEXT ?????Percentage of Persons Exiting to Positive Housing Destinations FORMTEXT ?????Cost Per Household FORMTEXT ?????Optional: In the space below, provide any additional information that would be helpful for the NC ESG Review Committee to know regarding this program. This must be a narrative, not a reference to attached additional documentation. FORMTEXT Enter Response Here- Maximum 2500 Characters[This page intentionally left blank]Rapid RehousingRapid Rehousing Program DescriptionPopulation to be served: FORMCHECKBOX single men FORMCHECKBOX single women FORMCHECKBOX households with children FORMCHECKBOX youth 18-24 FORMCHECKBOX Other (specify): FORMTEXT ?????Does this program exclusively serve victims of domestic violence (DV)? FORMDROPDOWN Indicate which services will be provided by the organization and which will be providedthrough referral. Rapid RehousingProvided with NC ESG fundsProvided with other fundsReferral(Or does not provide this service)Years of experience providing service (if none mark n/a)Rental Application Fees FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Security Deposits FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Last month’s rent FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Utility deposits FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Utility payments FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Moving costs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Housing search and placement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Housing stability and case management FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Mediation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Legal services FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Credit repair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Short term rental assistance (up to 3 months) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Medium term rental assistance (up to 24 months) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Payment of arrears FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????If the organization does not provide a rapid rehousing activity, listed above, with NC ESG or other funds, explain how referrals are made. FORMTEXT Enter Response Here- Maximum 2000 CharactersWhat days and times are services available for program participants? FORMTEXT Enter Response Here- Maximum 2000 CharactersIf participant and/or landlord have an issue outside of operating hours, how are theseissues addressed: FORMTEXT Enter Response Here- Maximum 2000 CharactersExperienceExplain the organization’s experience in implementing a rapid rehousingProgram(s). Specifically, include the years of experience of staff involved in implementing/administering the NC ESG funds. FORMTEXT Enter Response Here- Maximum 2000 CharactersRapid Rehousing Program Design and PhilosophyHow does the organization partner with emergency shelters? FORMTEXT Enter Response Here- Maximum 2000 CharactersWhat are the eligibility requirements to be accepted into the Rapid Rehousing program? FORMTEXT Enter Response Here- Maximum 2000 CharactersWhat are the reasons that someone may be turned away or asked to leave the RapidRehousing program? FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program screen out participants based on the following: FORMCHECKBOX Having too little or no income FORMCHECKBOX Active or history of substance abuse (alcohol and/or drugs) FORMCHECKBOX Having a criminal record (with exceptions for state mandated restrictions) FORMCHECKBOX History of domestic violence (e.g. lack of protective order, of separation from abuse, or law enforcement involvement)If any box above is checked, explain: FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program terminate participants based on the following: FORMCHECKBOX Failure to participate in support services FORMCHECKBOX Failure to make progress on a service plan FORMCHECKBOX Loss of income or failure to improve income FORMCHECKBOX Domestic violence FORMCHECKBOX Any other activity not covered in a lease agreement typically found in the program’s geographic areaIf any box above is checked, explain: FORMTEXT Enter Response Here- Maximum 2000 CharactersDescribe how the program is, or moving towards, a housing first model: FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program have dedicated staff whose responsibility is to identify and recruitlandlords and encourage them to rent to homeless households served by the program? FORMDROPDOWN If no, do the case manager’s responsibilities include landlord recruitment and negotiation? FORMDROPDOWN Does the program offer a standard, basic level of support to all landlords? FORMDROPDOWN If yes, describe FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program use a progressive approach, where financial assistance is notstandard “package” and is flexible enough to adjust to households’ unique needs and resources, for determining the duration and amount of rental assistance provided? FORMDROPDOWN Explain: FORMTEXT Enter Response Here- Maximum 2000 CharactersIs participation in services voluntary? FORMDROPDOWN Does the organization have a relationship with employment and income programs to which to refer RRH participants? FORMDROPDOWN If yes, describe, including the names of the employment and income programs. FORMTEXT Enter Response Here- Maximum 2000 CharactersWhat role does the organization play in the coordinated entry system? FORMCHECKBOX Assess households FORMCHECKBOX Refer households to coordinated entry upon engagement FORMCHECKBOX Transport households to coordinated entry points for assessment FORMCHECKBOX Provide diversion services FORMCHECKBOX Other (specify): FORMTEXT ?????Provide estimates of who will be served by this funding request. CategoryProgram EstimateTotal Persons Served** FORMTEXT ?????Total New Persons Served?(entered after January 1, 2020) FORMTEXT ?????Total Returning Persons Served?(entered before January 1, 2020) FORMTEXT ?????Percentage of Persons Exiting to Positive Housing Destinations FORMTEXT ?????Cost Per Household FORMTEXT ?????**Total of new plus returning personsOptional: In the space below, provide any additional information that would be helpful for the NC ESG Review Committee to know regarding this program. This must be a narrative, not a reference to attached additional documentation. FORMTEXT Enter Response Here- Maximum 2500 Characters[This page intentionally left blank]Homelessness PreventionHomeless Prevention Program DescriptionPopulation to be served: FORMCHECKBOX single men FORMCHECKBOX single women FORMCHECKBOX households with children FORMCHECKBOX youth 18-24 FORMCHECKBOX Other (specify): FORMTEXT ?????Does this program exclusively serve victims of domestic violence (DV)? FORMDROPDOWN Indicate which services will be provided by the organization and which will be providedby another through referral. Homeless PreventionProvided with NC ESG fundsProvided with other fundsReferral(Or does not provide this service)Years of experience providing service (if none mark n/a)Rental Application Fees FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Security Deposits FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Last month’s rent FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Utility deposits FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Utility payments FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Moving costs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Housing search and placement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Housing stability and case management FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Mediation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Legal services FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Credit repair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Short term rental assistance (up to 3 months) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Medium term rental assistance (up to 24 months) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Payment of arrears FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????If the organization does not provide a prevention activity, listed above, with NC ESG orother funds, explain how referrals are made. FORMTEXT Enter Response Here- Maximum 2000 CharactersWhat days and times are services available for program participants? FORMTEXT Enter Response Here- Maximum 2000 CharactersIf participant and/or landlord have an issue outside of operating hours, how are theseissues addressed: FORMTEXT Enter Response Here- Maximum 2000 CharactersExperienceExplain below any experience the organization has in implementing a homelessnessprevention program that you have proposed in this application. Specifically, include the years of experience of staff involved in implementing/administering the NC ESG funds. FORMTEXT Enter Response Here- Maximum 2000 CharactersHomeless Prevention Program Design and PhilosophyDoes your organization have prior experience with providing rapid rehousing with NC ESG,SSVF or other funding? FORMDROPDOWN If yes, describe: FORMTEXT Enter Response Here- Maximum 2000 CharactersHow are you targeting this assistance to those most likely to become homeless or returnto homelessness? FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program screen out participants based on the following: FORMCHECKBOX Having too little or no income FORMCHECKBOX Active or history of substance abuse (alcohol and/or drugs) FORMCHECKBOX Having a criminal record (with exceptions for state mandated restrictions) FORMCHECKBOX History of domestic violence (e.g. lack of protective order, of separation from abuse, or law enforcement involvementIf any box above is checked, explain: FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program terminate participants based on the following: FORMCHECKBOX Failure to participate in support services FORMCHECKBOX Failure to make progress on a service plan FORMCHECKBOX Loss of income or failure to improve income FORMCHECKBOX Domestic violence FORMCHECKBOX Any other activity not covered in a lease agreement typically found in the program’s geographic areaIf any box above is checked, explain: FORMTEXT Enter Response Here- Maximum 2000 Characters FORMTEXT ?????Does the program have dedicated staff whose responsibility is to identify and recruitlandlords and encourage them to rent to homeless households served by the program? FORMDROPDOWN If no, do the case manager’s responsibilities include landlord recruitment andnegotiation? FORMDROPDOWN Is staff trained in landlord recruitment? FORMDROPDOWN If yes, describe. FORMTEXT Enter Response Here- Maximum 2000 Characters Does your program offer a standard, basic level of support to all landlords? FORMDROPDOWN If yes, describe. FORMTEXT Enter Response Here- Maximum 2000 CharactersAre program staff trained on regulatory requirements of all prevention funding streamsand on the ethical use and application of a program’s financial assistance policies, including, but not limited to, initial and ongoing eligibility criteria, program requirements, and assistance maximums? FORMDROPDOWN If yes, describe FORMTEXT Enter Response Here- Maximum 2000 CharactersDoes the program use a progressive approach, where financial assistance is not astandard “package” and is flexible enough to adjust to households’ unique needs and resources, for determining the duration and amount of rental assistance provided? FORMDROPDOWN If yes, describe FORMTEXT Enter Response Here- Maximum 2000 CharactersAre program participants involved in creating a mutually agreed-upon time, place, and frequency of meetings with the case manager? FORMDROPDOWN Do meetings occur in a participant’s home and/or in a location of the participant’s choosing whenever possible? FORMDROPDOWN Is participation in services voluntary? FORMDROPDOWN Do you have a relationship with employment and income programs to which to refer HP participants? FORMDROPDOWN If yes, describe, including the names of the employment and income programs FORMTEXT Enter Response Here- Maximum 2000 CharactersHow does your program participate with coordinated entry (check all that apply): FORMCHECKBOX Assess households FORMCHECKBOX Refer households to coordinated entry upon engagement FORMCHECKBOX Transport households to coordinated entry points for assessment FORMCHECKBOX Provide diversion services FORMCHECKBOX Other: FORMTEXT ?????Provide estimates of who will be served by this funding request. These numbers are estimates and should not be seen as a cap on the total number served by the program. CategoryProgram EstimateTotal Persons Served FORMTEXT ?????Percentage of Persons Exiting to Positive Housing Destinations FORMTEXT ?????Cost Per Household FORMTEXT ?????Optional: In the space below, provide any additional information that would be helpful for the NC ESG Review Committee to know regarding this program. This must be a narrative, not a reference to attached additional documentation. FORMTEXT Enter Response Here- Maximum 2500 Characters[This page intentionally left blank]HMIS/DV Comparable DatabaseWhile Victim Service Providers cannot participate in HMIS, these agencies can apply for HMIS funds to be used on the costs associated with the required comparable database. Database Project DescriptionWhich type of database does the organization currently use? FORMDROPDOWN Does the organization applying for database project dollars, exclusively serve victims of domestic violence (DV)? FORMDROPDOWN If the organization uses a DV comparable database, which database do you use? FORMTEXT Enter Response Here- Maximum 2000 CharactersIs the organization requesting financial assistance or operations funding only? FORMDROPDOWN If yes, choose which expenses in column 1 below, will be covered by NC ESG funds.If no, choose which expenses in column 2 below, will be covered by NC ESG funds. HMIS/DV Comparable Column 1Column 2Supplies, Hardware, and Software FORMCHECKBOX FORMCHECKBOX Salary and/or Fringe Benefits FORMCHECKBOX N/ADatabase Licenses and Fees FORMCHECKBOX FORMCHECKBOX Describe how these funds will contribute to your ability to collect, analyze, and report data. FORMTEXT Enter Response Here- Maximum 2000 CharactersRegional Applicants only: Only CoC Collaborative Applicants, as defined in the application instructions, are able to apply for NC ESG funds to cover the following eligible HMIS costs. HMIS/DataRequesting NC ESG HMIS fundsContinuum of Care Staff Cost FORMCHECKBOX HMIS Lead Organization Costs FORMCHECKBOX HMIS Local System Administrator Costs FORMCHECKBOX Describe how these funds will contribute to your ability to collect, analyze, and report data. FORMTEXT Enter Response Here- Maximum 2000 CharactersExperienceExplain below any experience the organization has in implementing HMIS activities thatyou have proposed in this application. S Specifically, include the years of experience of staff involved in implementing/administering the NC ESG funds. FORMTEXT Enter Response Here- Maximum 2000 CharactersOptional: In the space below, provide any additional information that would be helpful for the NC ESG Review Committee to know regarding this program. This must be a narrative, not a reference to attached additional documentation. FORMTEXT Enter Response Here- Maximum 2500 Characters[This page intentionally left blank]Application Required Documents Note: Each application must be submitted with separate, lettered tabs as outlined on this checklist. TABDocumentNonprofit ApplicantUnit of Local Govt ApplicantASigned, Completed Application ??BProject budget worksheet ??CCAPER (January 1, 2020 – September 30, 2020)??DCurrent year operating budget for the entire organization, not just NC ESG (with Revenues and Expenditures)?-ECoC Participation and Coordination Agreement Form??FOrganizational Chart for the entire organization, not just the NC ESG program?-GBoard of Directors Information. List of names, email addresses, telephone numbers, occupations, with officers identified. Indicate board member with lived homeless experience. ?-HThe organization’s audit for most recent closed fiscal year. ORIf the organization does not have an audit submit a sworn financial statement. A sworn financial statement template is included as an optional form if the organization does not have one. Form 990 is not considered an audit?-IESG Program Operations Guidelines.??JHUD Corrective Action Plan (if applicable)??NC ESG Corrective Action Plan (if applicable)??City or County ESG Corrective Action Plan (if applicable)??KNC DHHS Required Contract Certification Forms & Documents in the order below1. No Overdue Taxes Certification Form ?-2. Annual IRS Tax Exemption Verification Form ?-3. Annual Conflict of Interest Verification ?-4. Conflict of Interest Policy?-5. Current Certificate of Insurance?-6. IRS Tax exemptions Letter?-7. W-9??LOrganization’s Financial Policies??MSHELTER SERVICES AND OPERATIONS PROJECTS ONLY – Submit Shelter Habitability Inspection that occurred no earlier than September 2020 ?? ................
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