Form A
Joint Funding Application for Supportive Housing
Funding Requests:
Which funding source are you applying for? Check the box for the funding source your
agency is applying for. You may apply for one or both sources of funding.
City of Charlotte (Development/Capital Funding)
Mecklenburg County (Supportive Services)
I.
APPLICANT INFORMATION
Full Legal Name of Applicant:
Applying as: Non-Profit or Government Agency
(Check one) For-Profit Organization
Address:
City/State/Zip:
Contact Person:
Title:
Telephone Number:
Fax number:
___ E-mail:
Name of Project:
Project Type:
_________________________________________________________
Number of Units: _________________________________________________________
Number of clients to be served:
Daily: ____________ Annually: _______________
City of Charlotte Funding Request: $__________________________________
Mecklenburg County Funding Request: $__________________________________
II. BRIEF PROJECT DESCRIPTION
Project Name: __________________________________________________________
Project Street Address: ____________________________________________________
Neighborhood: ___________________ Census Tract: ___________________________
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Form A
Total Project Budget: _____________________________________________________
(To qualify for both city and county funding, this project must be located in the
City of Charlotte and/or Mecklenburg County.)
III. TYPE OF ACTIVITY (check applicable activity)
____ Multi-Family Rental – New Construction units online by __________
____ Multi-Family Housing Rental - Rehabilitation
____ Existing Single site location (N/A for City of Charlotte Housing Trust Fund)
____ Existing scattered site units (N/A for City of Charlotte Housing Trust Fund)
IV. INCOME LEVELS AND SPECIAL NEEDS
Please complete the following tables to the best of your ability. Show actual or estimated
number of units for the project occupants/beneficiaries, not percentages.
Put the number of units to be added to the current housing stock for each income group
listed in Table 1.
Table 1
Income Group
30% or less of area median income (AMI)
31-50% of AMI
51-60% of AMI
TOTAL
Number of Units
If your agency is applying for City of Charlotte funding, put the number of units to be
added to the housing stock for each category listed in Table 2.
Table 2: Supportive Housing Eligible Populations (City use):
Category
Number of Units
Elderly (over 60)
Disabled (not elderly)
Homeless
People with HIV/AIDS
Veterans
Other - Identify
TOTAL
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Form A
If you agency is applying for Mecklenburg County funding, put the number of units, the
number of clients served daily and the number of clients served annually for each
category listed in Table 3.
Table 3: Supportive Housing Eligible Populations (County use):
Category
Number
of units
Client
Served
Daily
Client
Served
Annually
Chronically Homeless Person
Chronically Homeless Families
Homeless Families with Children
Homeless Households without Dependents
Homeless Older Adult (> 55 years)
Homeless Young Adult (18 to 25 years)
Homeless Youth (< 18 years)
TOTAL
V.
TYPE OF FUNDING REQUESTED:
Form of City funding (check one):
Grant
Loan
Form of County funding (check one):
1 YR.
2 YRS.
3 YRS.
VI. APPLICANT DESCRIPTION
Please provide the following information for the organization that will actually carry out the
project.
A. ORGANAIZATION
1.
What is your organization’s mission statement? ____________________________
2.
Incorporation date (Month and Year)? ____________________________________
3.
Estimated Agency Budget for Current Fiscal Year: $ ____________
4.
Number of staff employed (full time equivalents):
5.
Years of housing development experience (in years): ____________
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Form A
B. DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
Are any of the Board Members or employees of the 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 of Charlotte
YES ___ NO ___
b) Members of or closely related to Members of Charlotte City Council
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.
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: __________________________________________________________________
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