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Rowan County Grant Application
Please note that the CDBG-CV Grant from NC Commerce is no longer accepting applications. You may complete this form for potential additional funding opportunities.
Grant Application ID
1. Agency/Applicant
Please answer all questions (you may add pages where necessary)
Name of Agency/Applicant:
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Date
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Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Name of Executive Director:
First
Last
Web Site
Phone
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Name of contact person regarding this application:
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First
Last
Title:
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Email
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Phone
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Type of Project (check one)
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Retention
Expansion
Start-up
Type of Assistance (check one)
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Housing Rehabilitation
Construction
Community Development Activities
Economic Development Activities
Homeless Services
Other
Amount of funding requested:
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2. Agency Background Information
Yes
No
Is your organization an IRS 501(c)(3) not-for-profit?
If no, is your organization a public agency/unit of government?
Did your organization file Form 990 for the most recent tax year?
Principal product/service(s) applicant provides:
Date established (should be the date on the Articles of Incorporation):
3. National Objectives
Which National Objective will your program meet:
Low income/moderate income beenfit (570.208(a)
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Area Benefit Activities (570.209(a)(1)(project within low-moderate income census tract)
Limited Clientele - benefit 51% low-moderate income persons using HUD income limits
Urgent Need (570.208(c)(National, State, or Local Emergency)
Urgent Need activities (i.e., national declared emergency)
This field is automatically selected as this relates to COVID-19.
4. Additional Agency Information
Briefly describe the agency's existing staff positions, qualifications and capacity. Identify full-time and part-time staff. Does your agency have a personnel policy manual with an affirmative action plan and grievance procedure?
Yes
No
Has the applicant/agency or any member of its management team been involved in any litigation concerning civil rights, equal employment opportunities or discrimination?
If yes, describe the circumstances and status below. (Attach additional sheets if necessary).
Attach additional sheets here for Section 4 if necessary:
5. Project Information
Project Location, Street Address, City
Description of Project:
How will your clients be made aware of this program/project?
Explain why this project/program is needed and how the proposed program will address response to or impacts from COVID19?
What are the anticipated end-of-year results of this program/project?
Project Start-up:
Project Completion:
Population served?
Geographic area served:
Lengths of time individual clients spend in the project/program?
How does the project meet CDBG guidelines?
Discuss the expected results of your project and the proposed benefit to Rowan County residents:
6. Delivery of Services
This portion explains the need for your project and impact on community
A. TOTAL NUMBER OF BENEFICIARIES SERVED (previously funded program by Rowan County)
Number of Clients served for previous grant year:
Number of low/moderate income
Percentage of low-moderate income
Number of Existing Clients (Present):
Number of low/moderate income:
Percentage of low/moderate income:
B. PROJECTED NUMBER OF NEW BENEFICIARIES FOR THIS PROPOSAL.
Number of low/moderate income:
Percentage of low/moderate income
Is this project a joint effort with another organization?
Yes
No
If yes, explain:
7. Program Objectives
Explain how you plan to reach your goals:
Please describe your criteria for success. What do you want to happen as a result of your activities?
How will you measure the program's success?
How will this program/project continue if CDBG funds are no longer available?
8. Previous Rowan County Funding
List of funds you have received from Rowan County:
Name of Project
CDBG Funding
Project 1
Project 2
Project 3
Please list other funding sources below:
Funding Source, Commitment Status, and Amount
9. Organizational Budget
Income:
Please list the dollar amount in each category:
Source of Support:
Government Grants
Foundations
Corporations
United Way or other federated campaigns
Individual contributions
Fundraising events and products
Membership fee
In-kind support
Investment income
Revenue:
Please list the dollar amount in each category:
Revenue:
Government contracts
Earned income
Other Revenue - Specify Below:
Revenue Source
Amount
Funding Source Name
Funding Source Name
Total Income/Revenue from listings above:
Expenses:
Please list the dollar amount in each category:
Item:
Salaries and wages
FICA
Medicare
Workman's Compensation
Retirement
Unemployment Insurance
Insurance and Bonds
Medical Insurance
Training
Travel
Supplies
Printing and copying
Telephone and fax
Postage and delivery
Rent and utilities
In-kind expenses
Depreciation
Other Expenses - Specify Below:
Expense Source
Amount
Expense Source Name
Expense Source Name
Total Expenses from listings above:
Difference (Income less Expense):
10. Project Budget
Please provide a narrative describing how budget amounts were determined as justifications of expenditures.
INCOME:
- Source
- Amount
- Support
- Government Grants
- Foundations
- Corporations
- United Way or other federated campaigns
- Individual contributions
- Fundraising events and products
- Membership income
- In-kind support
- Investment income
- Revenue
- Government contracts
- Earned income
- Other (specify)
- Total Income
EXPENSES:
- Item
- Amount
- %FT/PT
- Salaries and wages (breakdown by individual position and indicate full- or part-time).
SUBTOTAL:
- Insurance, benefits and other related taxes
- Consultants and professional fees
- Travel
- Equipment
- Program Supplies
- Printing and copying
- Telephone and fax
- Postage and delivery
- Rent and utilities (Program Only)
- In-kind expenses
- Depreciation
- Other (specify)
- Total Expenses
- Difference (Income less Expense)
How will CDBG Funds you requested be used in this project?
Populate in fields below:
Line Item
Amount
Justification
Line Item
Amount
Justification
Line Item
Amount
Justification
CERTIFICATIONS AND ACKNOWLEDGEMENTS
The undersigned hereby makes application to the County of Rowan through its Program Grants for funding in the amount of $ (enter amount below) for the purpose of (Describe purpose of request.)
It is understood by the applicant that this is a formal application for financial assistance. The applicant also understands that Rowan County will not be responsible for any costs incurred by the applicant in developing and submitting this application and that all applications submitted become the property of Rowan County and a matter of public record.
The applicant believes the project can be completed within the development plan and budget set forth and certifies that the information in the exhibits and attachments is true, correct and complete to the best of the applicant's knowledge and belief. The applicant understands that any false statement is this application may disqualify the agency/provider/firm from participation in the program.
By execution of the Application, the applicant understands and agrees that Rowan County will conduct its own independent review and analysis of the information provided in the application, and that such review or analysis will be made for the sole and exclusive benefit and protection of Rowan County.
It is understood and agreed by the applicant that, for the purposes of determining the terms under which a Commitment may be made, the County may require changes in the information contained herein (including attachments) or in any documentation or materials now or hereafter submitted in connection with this application. It is further understood by the applicant, that additional information may be requested in order to facilitate the decision making process.
Attest (Signature)
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Clear
Typed Name
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First
Last
Title
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Date
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MM
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DD
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YYYY
Authorized Official (Signature)
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Clear
Typed Name
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First
Last
Title
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Date
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MM
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DD
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YYYY
Please attach the following information to this application:
1. Finances
- Most recent financial statement from most recently completed year, audited if available, showing actual expenses. This information should include a balance sheet, a statement of activities (or statement of income and expenses) and functional expenses.
- Organization budget for current year, including income and expenses.
- Project Budget, including income and expenses (if not a general operating proposal).
- Additional funders. List names of corporations and foundations from which you are requesting funds, with dollar amounts, indicating which sources are committed or pending.
2. List of board members and their affiliations.
3. Brief description of key staff, including qualifications relevant to the specific request.
4. A copy of your current IRS determination letter (or your fiscal agent's), indicating tax-exempt 501(c)(3) status.
Upload any attachments or additional files here:
Add File
Proposal Checklist:
Cover Sheet
Cover Letter
Proposal narrative
Articles of Incorporation and Bylaws
State and federal tax exemption determination letters
Certificate of Good Standing with the State (aka Certificate of Existence)
IRS From 990
Name and addresses of board members and their affiliations
Board of Directors' authorization to request funds
Board of Directors' designation of authorized official
Organizational Chart
Brief description of key staff and qualifications
Resume of Program Administrator
Resume of Fiscal Officer
Annual Financial Statement(s) and most recent Audit
Conflict of interest policy
Proof of liability insurance and worker's compensation insurance
