Form A
Joint Funding Cover Sheet
The City of Charlotte, Neighborhood & Business Services (NBS) and Mecklenburg County, Community Support Services (CSS)
partnered to release a joint Request for Proposals for NBS Emergency Solution Grant federal funds and for CSS Housing Stability
and Supportive Services local funds. Please complete this cover sheet and attach this sheet with each copy of your funding
proposal/application. Follow the submittal instructions for each funding source as described in the Request for Proposals.
Funding Source:
Which funding source are you applying for? You may check Emergency Solutions Grant only; Housing Stability and Supportive
Services only or both funding sources.
Emergency Solution Grant (City, NBS)
Rapid Re-Housing – Financial Assistance
Housing Stability and Supportive Services (County, CSS)
Rapid Re-Housing – Case Management & Services
Emergency Shelter – Operating Costs
Emergency Shelter – Shelter Services
Prevention Services
Street Outreach
HMIS
Rapid Re-Housing- Case Management & Services
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Form A
Funding Request:
What is your funding request? You may request funding from one and/or both sources.
City, NBS Emergency Solution Grant Funding Request: $_____________________
County, CSS Housing and Supportive Services Funding Request $_________________
If you are requesting County, CSS funding, check how many years.
1 Year
2 Years
If requesting County, CSS funding, what is your source of rental assistance (if not ESG funds)?
_______________________________________________________________________________
I.
APPLICANT INFORMATION
Full Legal Name of Applicant:
Applying as (Check one):
Non-Profit or Government Agency
For-Profit Organization
Address:
City/State/Zip:
Contact Person: _____________________________________________________________________
Title:
______________________________
Telephone Number: __________________________
E-mail:___________________________________
What is your organization’s mission statement?______________________________________________
____________________________________________________________________________________
Incorporation date (Month and Year)?_____________________________________________________
Estimated Agency Total Budget for Current Fiscal Year: $_________________________________
Number of staff employed (full-time equivalents):
________________________________
Years of supportive housing experience (in years):
_____________________________________
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Form A
II. BRIEF PROJECT DESCRIPTION
Project Name:______________________________________________________________
Project Street Address:_______________________________________________________
Total Project Budget:
$___________________________
Check one:
Existing Single site location
OR
Existing Scattered site units
Number of New Housing Units to be added: ___________________
Number of New clients to be served:
Daily: ________________
Annually:_________________
Check one:
Which income group does your project serve?
30% or less Area Median Income (AMI)
31%-50% AMI
Which eligible population does your project serve?
Homeless Families with Children
People with HIV/AIDS
Elderly (over 60)
Veterans
Disabled (not elderly)
Homeless Individuals
Other – Identify ________________
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Form A
III. DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
Are any of the Board Members or employees of your agency, which will be carrying out this project, or members of their
immediate families, or their business associates:
a) Employees of or closely related to employees of the City or County? YES_______ NO________
b) Members of or closely related to Members of Charlotte City Council
or Board of County Commissioners?
YES________ NO _________
c) Beneficiaries of the program for which funds are requested, either as clients
or as paid providers of goods or services?
YES________ NO__________
If you have answered YES to any question, please attach a full explanation to the application. The existence of a potential
conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may
result in the termination of any funding awarded. The disclosure statement must be signed and dated. There is a Conflict of Interest
Policy (Form E) to be completed for County Fund Requests only.
Authorized Signature of Applicant: To the best of my knowledge and belief, all information in this application is true and
correct. The document has been duly authorized by the governing body of the applicant who will comply with all contractual
obligations if the proposal is awarded funding.
Signature of Authorized Representative:_______________________________________________________
Print Name and Title:______________________________________________________________________
Date Signed: ______________________________________________________________________
RFP City ESG and County Support Service Requests
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