COC 2012 Attach AP re applic form by K2Tytb9


									                                               Attachment A
                         - Pre-Application Form -
                          2012 Hennepin County
              Continuum of Care Homeless Assistance Program

Date pre-application received:
(completed by Hennepin County)

1. Project Information:
Project Name
Project Address
(if known)
City (if known)
County                   Hennepin County
Continuum of             Hennepin County
Care Region

2. Applicant Information:
Applicant Name
Contact Person/Title
Address (city/zip code)
Email Address
DUNS number
Employer/Taxpayer ID #
Check Type of Applicant            Nonprofit   Unit of government   Housing Authority   other   , please
(to check box- double left-click   explain
on box then click default value
Project Sponsor(s) Name, if
different from applicant.
Others (List development
and/or service partners)
Is the sponsor a Faith-
Based Organization?

3. Funding Type Requested:





   Rental Assistance

                                    Attachment A: Pre-Application Form - 2012
                              Hennepin County Continuum of Care Homeless Assistance
4. Experience of Applicant, Sponsor, and Partners
  (Describe the experience as it relates to providing supportive services and housing for homeless persons,
    and carrying-out the activities of this project.)

5. Project Description:
      a. Describe the housing proposal concept and proposed use of funds:

       b. Describe target population(s) and number of housing units/beds project will

       c. Indicate the priorities in the Heading Home Hennepin Plan to End Homelessness
          this project will address (

       d. Type of support services that will be provided on-site and/or off-site and who will
          provide them:

       e. Outreach to persons and/or families in shelter or on the streets (indicate percent of
          persons who will come from shelter, streets, or transitional housing):

       f.   Summarize proposed resident goals and objectives for supportive housing:

       g. Summarize some of your best practices in achieving and demonstrating
          successful outcomes in serving this population:

       h. Describe your organization’s mission and how it aligns with this project.

                               Attachment A: Pre-Application Form - 2012
                         Hennepin County Continuum of Care Homeless Assistance
6. Target Homeless Population:
  Number of people or
                               Homeless Population (must meet HUD definition of “Homeless” or “Chronically
  households served            Homeless” described under “General Requirements” (page 4) of this solicitation.)
    (program capacity)
                            Single Adults (disabled*)
                            Chronically Homeless Single Adults
                            Families with Children (disabled head of household*)
                            (enter number of families)
                            Chronically Homeless Families
                            Unaccompanied Youth (disabled*)
                            Unaccompanied Youth with children (disabled*)
                            Chronically Homeless Unaccompanied Youth
    * Supportive housing requires residents to be disabled.

If your project will serve       Check the primary sub-population(s) you will serve:
disabled persons indicate          Mentally Ill
which population(s) will           Chemically Dependent
primarily (>70%) be served.        Physically Disabled
                                   Developmentally Disabled
                                   Multi- Diagnosed
                                   Other: indicate here-

Non-Homeless: Will this project also serve non-homeless households?  Yes      No
              Enter number of units to be occupied by non-Homeless people or households-

7. Outreach:
List Shelters, street
outreach and other referral
sources you will use for new
project participants

8. Support Services: ( Indicate types of supportive services to be provided (check all that apply)
                   Type                         Name of Primary Service          Funding      $ Amount Secured at
                                                       Provider                  Source       this time
  Case management
  Life skills (outside of case management)
  Job training
  Alcohol and Drug Abuse Services
  Mental Health and Counseling Services
  HIV/AIDS Services
  Health Related & Home Health Services
  Education and Instruction
  Employment Services
  Child Care

                                 Attachment A: Pre-Application Form - 2012
                           Hennepin County Continuum of Care Homeless Assistance
   Other (specify *)

Describe experience of applicant and/or            Do you currently report measurable outcomes for clients in your
service provider in serving this population.       other housing or service programs?
                                                      Yes     No. If yes, check method for reporting outcomes:
                                                   HUD- APR,      Hennepin County contract requirement,      State
                                                   agency contract requirement,     Other- please describe:

9. Housing Units:
Number of units by bedroom size for capital, support services tied to housing units, leased units or
rental assistance projects:

SRO (Single Room Occupancy)              Number of units                         Number of bedrooms/beds
0 Br (efficiency)
1 Br
2 Br
3 Br
4 Br

10. Project Location:

Indicate type of project:         scattered-site       congregate/single-site

For congregate/single-site
projects, indicate location (if
known) If location has not
been identified indicate           Do you have site control:     Yes      No If no, when do you expect to have site-
‘unknown.’                         control?

                                   Note: Site control is not required to receive HUD McKinney/Vento Act funding.

11. HUD Contract Deadline:

Explain how this project will be under contract by
September 30, 2014:*
*Construction activity must begin within 18 months of
grant award letter and completed w/in 36 months. All
other activities, independent of construction, must
begin w/in 12 months of grant award letter.

                                   Attachment A: Pre-Application Form - 2012
                             Hennepin County Continuum of Care Homeless Assistance
12. Total Project Budget:
Total Project Budget
Estimated HUD Request

13. Budget and HUD Request Grant
Complete all applicable components. To estimate budget, use budget charts in Attachment B:

     HUD Budget Summary                      $ Total HUD    Budgeted     Number of       $ Project Total      HUD Request
     Type of Expenditure                        request      Match &     Years HUD                            as Percent of
                                                           other funds    funding                                 Total
                      a.                         b.             c.           d.                 e.                  f.
                                             $                 NA            3          $
 1   Leasing (no match req’d)
                                             $             $             5 yrs or 10    $
 2   Rental Assistance                                                    w/rehab

     Capital- acquisition, new
 3                          1
     construction, or rehab
 4   Operations

                               1                                              3
 5   Supportive services
                       2                                                      3
 6   Administration

 7                                 Total $                                                                        100 %

1. Match required.- figure 25% of HUD award pending final regulations under the HEARTH Act.
2. Applicants can request up to 10% of HUD award for administrative costs. See “Supportive Housing Program
Deskguide- Section D” for a list of eligible expenditures
under this category.

                                     Attachment A: Pre-Application Form - 2012
                               Hennepin County Continuum of Care Homeless Assistance

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