Form B
City of Charlotte
Funding Request Application- Emergency Solution Grant (ESG)
FY2017 (July 1, 2016-June 30, 2017)
Agency:
Address:
Director:
Agency Contact:
Phone Number:
Total Funding requested from City
for upcoming fiscal year
Email:
$
Funding Priorities
The City of Charlotte will award funds to activities consistent with the following funding priorities.
1)
2)
3)
4)
5)
6)
7)
Rapid Re-Housing - Financial Assistance
Emergency Shelter – Operating Costs
Emergency Shelter – Shelter Services
Prevention Services
Street Outreach
Homeless Management Information System (HMIS)
Rapid Re-Housing – Case Management & Services
More information about these activities can be found at https://www.hudexchange.info/esg/.
Agency and Program Information
Provide description of your agency. If requesting City-funding for a specific program within your agency,
also provide the name and description of the specified program along with your agency’s description:
Agency and Program (if applicable) Description:
Agency Mission Statement:
Agency Vision Statement:
Describe the benefits or results of agency or program services.
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The City Council has identified five Focus Areas that reflect community priorities and guide strategic
planning and decision making. Indicate the City Council Focus Area(s) which your agency or program
support? For additional Focus Area(s) information, click here.
Community
Safety
Housing &
Neighborhood
Development
Transportatio
n
Economic
Development
Environment
Scope of Services: Describe how agency or program activities support the City Council Focus Area(s) identified.
Program Objectives: Consistent with the Balanced Scorecard performance management approach, the
City uses 16 Corporate Objectives to measure its achievement. Indicate the Corporate Objective(s) which
your services most directly contribute and list specific initiatives, measures, and targets that link to the
City’s Corporate Objectives. For additional Corporate Objective(s) information, click here.
Corporate Objective
Initiative
Measure
Target
(Press the “tab" key for
additional rows)
Has your Board of Directors approved these program objectives?
_____ Yes
_____ No
Program minimum requirements

Programs referral must be received through Coordinated Assessment.
(Note: Coordinated Assessment will be demonstrating a prioritization process for families
during this funding cycle.)

Agencies must enter HUD required data elements into the Homeless Management Information
Network (HMIS) identified by the CoC. (Domestic Violence Agencies do not have to meet this
requirement).

A representative from the funded activity within your agency is required to participate at
minimum of 50% of Continuum of Care Committee meetings. Currently meetings are held bimonthly beginning in July. (Note: Meeting schedule may be changed to monthly. Notification of
this change will be made via the CoC email distribution list)
.
2
Total Agency Budget
Provide total expense and revenue budget information for entire agency including all programs and
funding sources. For purposes of this application, the budget information provided should coincide with
the City’s fiscal year, July 1, 2016 through June 30, 2017.
Personnel Expenses
FY2016 BUDGET
FY2017 PROJECTED
BUDGET
FY2017 BUDGET
REQUEST FROM CITY
FY2016 BUDGET
FY2017 PROJECTED
BUDGET
FY2017 BUDGET
REQUEST FROM CITY
Salaries
Merit
Benefits
Total Personnel
Expenses
Operating Expenses
Communications (e.g.
publishing, marketing)
Travel & Training
Facilities (e.g. rent,
utilities)
Technology
Other
Total Operating
Expenses
Total Expenses
Please include all revenues, excluding revenues received from the City of Charlotte and Mecklenburg
County, in the fields below.
Revenues
FY2016 BUDGET
FY2017 PROJECTED
BUDGET
Government Grants &
Funding
Foundation Grants &
Funding
Donor Contributions
Service Fees
Other Revenue
Total Revenues
Indicate the amount of total funds received from Mecklenburg County, if applicable, for each fiscal year
listed below.
Fiscal Year
FY2016
FY2017 (as requesting)
Total Funds
3
Program Budget
If requesting City-funds for a specific program within your agency, provide the expense and revenue
budget information for the specified program including all funding sources. For purposes of this
application, the budget information provided should coincide with the City’s fiscal year, July 1, 2016
through June 30, 2017.
Personnel Expenses
FY2016 BUDGET
FY2017 PROJECTED
BUDGET
FY2017 BUDGET
REQUEST FROM CITY
FY2016 BUDGET
FY2017 PROJECTED
BUDGET
FY2017 BUDGET
REQUEST FROM CITY
Salaries
Merit
Benefits
Total Personnel
Expenses
Operating Expenses
Communications (e.g.
publishing, marketing)
Travel & Training
Facilities (e.g. rent,
utilities)
Technology
Other
Total Operating
Expenses
Total Expenses
Please include all revenues, excluding revenues received from the City of Charlotte and Mecklenburg
County, in the fields below.
Revenues
FY2016 BUDGET
FY2017 PROJECTED
BUDGET
Government Grants &
Funding
Foundation Grants &
Funding
Donor Contributions
Service Fees
Other Revenue
Total Revenues
Indicate the amount of total funds received from Mecklenburg County, if applicable, for each fiscal year
listed below.
Fiscal Year
FY2016
FY2017 (as requesting)
Total Funds
4
FY2017 Program Objectives
Activity
Example: Emergency
Shelter- Operating Cost
TOTAL AMOUNT
REQUESTED
$10,000
NUMBER OF HOUSEHOLDS TO
BE SERVED
100
COST PER HOUSEHOLD
$1000
Emergency Shelter
(Operating Cost)
Emergency Shelter (Shelter
Services)
Rapid Re-Housing (Financial
Assistance)
Rapid Re-Housing (Case
Management & Services)
Prevention Services
Street Outreach
Homeless Management
Information System (HMIS)
Share the strategies to sustain your agency or program. Indicate plans for obtaining funds
outside of City-funding.
If City-funding is denied, describe the impact on agency or program.
If your agency received City-funding for the current fiscal year and is requesting a change in the
City-funding level for the upcoming fiscal year, provide the reason(s) for requesting a change in
the City’s funding level:
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All Proposals submitted must include:





Joint Funding Cover Sheet
Completed Funding Request Application
Financial Audit (most current)
Project Budget
E-Verify Certification
Proposals must be submitted via email to Rebecca Pfeiffer at rpfeiffer@charlottenc.gov
no later than Thursday, May 19, 2016.
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E-Verify Certification
This E-Verify Certification is provided to the City of Charlotte (the “City”) by the company signing below
(“Company”) as a prerequisite to the City considering Company for award of a City contract (the “Contract”).
1.
Company understands that:
a.
E-Verify is the federal program operated by the United States Department of Homeland Security and
other federal agencies to enable employers to verify the work authorization of employees pursuant to
federal law, as modified from time to time.
b. Article 2 of Chapter 64 of the North Carolina General Statutes requires employers that transact
business
in this state and employ 25 or more employees in this state to: (i) verify the work authorization of
employees who will be performing work in North Carolina through E-Verify; and (ii) maintain records of
such verification (the “E-Verify Requirements”).
c.
2.
3.
North Carolina General Statute 160A-20.1(b) prohibits the City from entering into contracts unless the
contractor and all subcontractors comply with the E-Verify Requirements.
As a condition of being considered for the Contract, Company certifies that:
a.
If Company has 25 or more employees working in North Carolina (whether now or at any time during
the term of the Contract), Company will comply with the E-Verify Requirements in verifying the work
authorization of Company employees working in North Carolina; and
b.
Regardless of how many employees Company has working in North Carolina, Company will take
appropriate steps to ensure that each subcontractor performing work on the Contract that has 25 or
more employees working in North Carolina will comply with the E-Verify Requirements.
Company acknowledges that the City will be relying on this Certification in entering into the Contract, and that
the City may incur expenses and damages if the City enters into the Contract with Company and Company or
any subcontractor fails to comply with the E-Verify Requirements. Company agrees to indemnify and save the
City harmless form and against al losses, damages, costs, expenses (including reasonable attorney’s fees)
obligations, duties, fines and penalties (collectively “Losses”) arising directly or indirectly from violation of the
E-Verify Requirements by Company or any of its subcontractors, including without limitation any Losses
incurred as a result of the Contract being deemed void.
_____________________________________________
Signature of Company’s Authorized Representative
_________________
Date
_______________________________________________________________
Print Name & Title
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