THIS AREA FOR STAFF USE ONLY.
City of Fort Collins
Competitive Process
PUBLIC SERVICE APPLICATION
FY 2009-2010 Spring Cycle
Date received:
Project #
P RO J E C T I N FO RM AT I O N
1.
Project Name:
2a. Amount of Public Service Funds Requested: $
b. Total Project Cost: $
c. Project Summary (brief description):
AP P L I C AN T I NF O RM AT I O N
3.
Lead Applicant/Organization Name:
Contact Person & Title:
Complete Address:
Phone//Fax:
Email:
4.
Is your organization:
□
□
A Non-Profit with 501(c)3 status
□
None of the Above
A For-Profit authorized to participate
under 570.201(o), which includes
providing assistance to facilitate economic
development and support of micro-enterprises
5.
Do you describe your organization as faith-based?
6.
Federal Tax or Employer Identification Number:
7.
DUNS (Data Universal Number System) Number:
□
Yes
□
No
To obtain a DUNS number, you need to call 1-866-705-5711. The process is free and
takes an average of 10 minutes. Additional information can be obtained at:
http://www.whitehouse.gov/omb/grants/duns_num_guide.pdf
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8.
Does your organization mainly serve (check one, if applicable):
□
□
□ Battered Spouses □ Severely Disabled Adults □
□ Persons with AIDS □ Migrant Farm Workers □
Abused Children
Homeless Persons
Illiterate Adults
Elderly
H U D P E RF O RM AN C E M E AS U R E M E N TS
9a. Objectives (See Definitions) – This Proposed Activity (check one):
□
□
□
Creates a Suitable Living Environment
Provides Decent Affordable Housing
Creates Economic Activities
b. Outcomes (See Definitions) – This Proposed Activity Addresses (check one):
□
Availability/Accessibility
□
Affordability
□
Sustainability
P RO J E C T C O NT E X T
10. Location of Proposed Project (Street Address or Assessor’s Parcel Number):
C O NS O LI D AT E D P L AN O B J E CT I V E S
11. The City’s current Consolidated Housing and Community Development Plan: FY 2005-2009
is located on the web at http://www.fcgov.com/affordablehousing/documents.php.
On Page 43, the Public Services objective states that the City will: “Support and enhance
public services which focus on providing basic services to low-income citizens and
families”. Describe specifically how your project will address this objective.
P RO J E C T G O AL S
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12a. Using bullet points, list the goals of the project (concrete, measurable tasks):
b. In addition, please indicate (to the best of your ability) the number of unduplicated persons
to benefit from your proposed project according to the following categories. Income
guidelines for Fort Collins are provided in the application packet:
Income Levels of Unduplicated Persons
Income Level of 0-30% AMI (Area Median Income)
Income Level of 31-50% AMI (Area Median Income)
Income Level of 50-80% AMI (Area Median Income)
Total Number of Persons to be Served
Number of Persons
G E N E R AL D E S C RI P TI O N O F AC T I V I TI E S
13. List major activities of the project (how do these activities address your goals listed in
12a).
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P RO J E C T IM P LE M E N T AT I O N
14. What items do you want Public Service funds to pay for and how will that help achieve your
goals as listed in item 12a? List the cost of each item.
F U N DI NG LE V E L S
15.
□
We will accept funding for an amount no less than $
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C U R RE N T FI NAN C I AL C AP AC I T Y
□
□
16a. Has your organization borrowed money in the last 12 months?
Yes
No
If yes, what was the purpose for borrowing? Please provide the terms and conditions for
repayment:
b. Is there any financial restructuring anticipated by the organization to address financing
shortfalls, debt restructuring, working capital, etc. in the next year?
□ Yes
□ No
If yes, please explain:
c.
Based on your organization’s most recent audit, were there any outcomes or findings that
changed the way the organization does business?
□ Yes
□ No
If yes, please explain (cite any examples from the audit that helped improve the
organization’s performance):
d . What is your organization’s goal amount for reserves?
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How much do you have in reserves at this time?
Has your organization had to use any of the reserves in the last 12 months?
□ Yes
□ No
If yes, explain:
F U N DS LE V E RAG I N G
17. Your ability to leverage other funding is very important to the success of your application.
Please complete this information in detail. You must report all sources of other expected
funding used to support this request. Report the funding under the appropriate category.
Figures used should apply to this project/program only:
Amount of
Funding
Requested
Funding Source (include name)
and Type of Funds
City of Fort Collins – Public Service Funds
Federal Funds – Public (list specific sources):
State Funds – Public (list specific sources):
Other Public Funds (list specific sources):
Private Funds – Grants, Donations, Fundraising
(list specific sources):
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Status of
Funds:
Anticipated or
Committed
anticipated
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P RE V I O US CI TY F U NDI NG
18. Please list City Public Service funds received in the LAST THREE YEARS, most recent first,
and the status of that funding for this project.
Awarded
Amt Expended
Year
Project Name
Amount
to Date
B O AR D O F DI RE C TO RS I N FO RM AT I O N
19a. Please attach a one-page list of your current Board members and indicate the experience
and background they bring to your Board.
b. If applicant is a non-profit, please include evidence (see Board of Directors
Acknowledgement Form) that the proposed project has the support of the organization’s
Board of Directors.
C LI E NT I NP U T I NF O RM AT I O N
20. How does your organization obtain input from low-income persons potentially benefiting or
affected by your proposed project?
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S I G N AT U R E BL O C K
21.
The information contained in this application is truthful and accurate, to the best of the
applicant’s knowledge. The applicant acknowledges that the failure to include in this
application all information necessary for a competent and complete review, or the inclusion of
information in this application that is untruthful, may result in the rejection by the City of Fort
Collins of this application and the summary termination of any Agreement resulting therefrom.
Name (PRINT)
Title, Board of Directors
(must have signatory authority)
Date
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