Form C
Mecklenburg County Community Support Services
Housing Stability and Supportive Services Application
Agency:
Address:
Director:
Agency Contact:
Phone Number:
Total Funding requested from
County for this proposal $
Email:
Please respond to the following areas in the space provided. You may refer to
Mecklenburg County’s section of the Request for Proposals (RFP) for further information.
1.
Applicant Capacity and Experience
Describe your agency’s experience providing housing and/or services to the eligible population identified in this proposal. (This is the eligible population you selected on Form A.) Provide a brief history of your agency, including its purpose, current programs, and number of staff persons. Include outcomes for services that are provided to the identified eligible population.
2.
Capacity of Service Provider
Describe your agency’s experience and capacity to coordinate, provide, and/or act as a referral agent for community-based services that support persons of the identified eligible population.
Identify a public agency or experienced service provider with which a written agreement has been executed to refer eligible persons and families for the eligible units.
County Funding Application – Must be completed to receive funding. Page 1

Form C
Partnership History
If partners are a part of your proposed project, provide information on your history collaborating with one another and how the partnership will facilitate a streamlined process for participants’ access to the housing and/or services being offered.
3.
Funding Request
Check the funding sources and write the amount you are requesting from each source. In the narrative box, explain how the funding will be used and whether all funding is required for your project to move forward. Explain how you propose to maximize or leverage existing or committed funding by pairing with the funding sources in this RFP. If you are not requesting
ESG funds for rental assistance, please identify your source of rental assistance/subsidy in the narrative box provided.
Note: If your agency is applying for the County’s Supportive Service dollars, please download the Support Service dollars budget Excel form, complete the form and attach it to your RFP response. If your agency is applying for ESG funding through the City of Charlotte, be sure to complete the City’s ESG application.
Check one or both and write in your funding request:
City ESG Grant – Rapid Re-Housing Financial Assistance
Rapid Re-Housing – Case Management & Services
$_________________
$_________________
County Funding Application – Must be completed to receive funding. Page 2

Form C
4.
Project Description
Indicate your agency’s commitment to receiving referrals only through Coordinated
Assessment and utilizing the designated Homeless Management Information System. Briefly describe how the supportive services are structured to meet the needs of the intended eligible population. Include a description of how this project provides an integrated housing solution for the identified eligible population. Describe how the project collaborates with the
Continuum of Care planning process.
County Funding Application – Must be completed to receive funding. Page 3

Form C
5.
Supportive Services Plan
Provide a detailed description of supports and services to be provided to residents, including the project’s referral, service plan, crisis intervention plan, client right’s, and other clientfocused items. Explain how services will increase stability for participants. Explain how residents’ needs for services are identified and individual service plans are developed.
Also, provide information on how the project will help create linkages for participants to other resources in the community.
6.
Sustainability Plan
For the purposes of this proposal, housing is permanent and not transitional. Subsidies may be temporary. Describe this project’s sustainability plan and state how your agency will ensure families maintain housing at the end of the subsidy.
County Funding Application – Must be completed to receive funding. Page 4