Form A
Joint Funding Application
Funding Requests: Check requested funding source. (You may check more than one.)
Foundation For The Carolinas (Targeted Prevention)
Foundation For The Carolinas (Supportive Services/Rental Assistance)
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/Program:
________________________________________________________________________
________________________________________________________________________
Estimated Number of Subsidized Housing Units:________________________________
Estimated Number of families to be served: Daily:____________Annually:___________
A Way Home Targeted Prevention Funding Request: $ _____________
A Way Home Housing Assistance Funding Request: $ _______________
Mecklenburg County Supportive Service Funding Request: $__________________
II. INCOME LEVELS AND SUB-POPULATIONS
Please complete the following tables to the best of your ability. Show actual or estimated
number of units for the occupants, not percentages.
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Income Group
30% or less of area median income (AMI)
31-50% of AMI
TOTAL
Number of Units
Permanent Housing Sub-Populations:
Category
Number of Units
Homeless Families with Children
Homeless Veteran Families with Children
Other - Identify
TOTAL
III. APPLICANT DESCRIPTION
Please provide the following information for the organization that will carry out the
project/program.
A. ORGANIZATION
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 supportive service experience (in years): _____________
6.
Years of rental subsidy experience (in years): _________________
___________
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 Mecklenburg County YES ___ NO ___
b) Employees of or closely related to employees of Foundation For The Carolinas YES _ NO __
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c) Members of or closely related to Members of the Board of County Commissioners
YES ___ NO___
d) Members of or closely related to Members of the Foundation For the Carolinas Board
YES ___ NO___
e) 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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