PROJECT WORK SHEET - Download as DOC by 5lbWQPRi


									                                          PROJECT WORK SHEET

Board Name: ____________________________________________________________

Biennium in which Application would be submitted to Department:

_____SFY 09-10             _____SFY 11-12            _____SFY 13-14

This project is designated priority #__________ of __________ projects. (For the indicated biennium)

The process by which the Board reached conclusions in projecting general project priorities:

Type of Project (check all that apply):

_____  Subsidized Housing: # units_____ # persons_____                           Housing Projects part of
_____   Subsidized Housing with Supportive Services: # units_____ # persons_____ written Board Housing Plan
_____  Residential Treatment: # beds_____                                        ____Yes ____No
_____  Consumer Operated Recovery Space: # estimated sq. ft._____
_____  Program/Service Space: # estimated sq. ft._____                           For 09-10 projects: can be
       Check all that apply for program/service space:                           developed by May, 2009
       ____ Vocational     ____Crisis     ____Partial Hospitalization            ____Yes ____No ____NA
_____ Mobile Team Home Base: # staff on team _____
_____ Other – describe:__________________________________________________________________________

Population to be Served (check all that apply):

_____Adults: #/month _____Children: #/month_____
_____Adults with severe mental disabilities: #/month_____
_____Children with serious emotional disturbance: #/month_____
_____General public: #/month_____

Proposed Owner of Property and Project:____________________________________________________________

Proposed Service Provider(s):_____________________________________________________________________

Project Description:                                                            Estimated Project Cost:

_____ New Construction                                                          Purchase Cost    $_________
_____ Purchase/Renovation                                                       Construction     $_________
_____ Addition to Existing                                                      Miscellaneous    $_________
_____ Renovation only                                                           Equip./Furnish   $_________
_____ Purchase only                                                             Total Cost       $_________

Capital Funding:

Amount of ODMH Assistance Required              $__________
(up to 75% of total cost)
Amount of Other Funds:                          $__________
Source(s) of Other Funds: ________________________________________________________________________
Operating Costs (annual):                       $__________
Source(s) of Operating Costs:_____________________________________________________________________

Attach a brief (1 paragraph) description of the project.

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