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									                       CITY OF DURHAM
EMERGENCY SHELTER GRANTS PROGRAM
                     FY 08-09 Allocations

                  GUIDELINES
                 & APPLICATION
                         Amended 11.27.07
                to show all dates as 08-09 fiscal year
                 All changes have been highlighted

                 Completed applications must be received
       no later than 4:00 p.m. on Friday, December 21, 2007 by:

                           City of Durham
                       401 Lakewood Avenue
                    Durham, North Carolina 27701
                         ATTN: Larry Jarvis




Funded by: United States Department of Housing and Urban Development
                  City of Durham, ESG Grant Funding Application – FY 2008-2009



                         CITY OF DURHAM
              DEPARTMENT OF COMMUNITY DEVELOPMENT
             EMERGENCY SHELTER GRANT (ESG) PROGRAM

             Fiscal Year 2008-2009 Grant Application Package

Introduction

The Emergency Shelter Grant program is designed to supplement state, local and private
efforts to improve the quality and number of emergency shelters and transitional housing
facilities for homeless people. More specifically, state and local governments use ESG funds
to help operate these facilities, to provide essential support services to residents, and to help
prevent at-risk families or individuals from becoming homeless.

Designed as a first step in a Continuum of Care plan of assistance, the ESG program strives
to address the immediate needs of persons living in situations that were not designed for
permanent human habitation who are in need of emergency shelter and transitional housing,
and to assist in their transition to self-reliance and independent living.

While flexible in terms of serving all homeless sub-populations and preventing persons from
becoming homeless, the ESG program legislation and implementing regulations do limit the
types of activities and amounts of funds that can be spent on different activities. There are
four major categories of eligible activities and applicable limitations that are a part of the ESG
program in the City of Durham, which will be discussed shortly.

This application will be used by the City of Durham to determine the eligibility of applicant
organizations and units of local government who apply for funding under the 2008-2009 ESG
Program in Durham.

Please read the following program description carefully before completing the application.
The description contains information regarding the program’s purpose, its target beneficiary
population, activities that are eligible under the program and the grant recipient’s
responsibilities.

Questions may be directed to:

                       Larry Jarvis
                       City of Durham
                       401 Lakewood Avenue
                       Durham, North Carolina 27701
                       (919) 560-4570
                       (919) 560-4090 (FAX)




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                   City of Durham, ESG Grant Funding Application – FY 2008-2009



Program Authorization and Administration

The ESG program is authorized under subtitle B of Title IV of the Stewart B. McKinney
Homeless Assistance Act (Public Law 100-77, approved July 22, 1987). The Catalog of
Federal Domestic Assistance program number for the ESG program is CFDA No. 14.231.

The Secretary of the U.S. Department of Housing and Urban Development (HUD) makes
grants to Cities and units of general local government to be used for eligible program
activities. The City of Durham’s ESG program is administered by the Department of
Community Development.


Program Purpose

The ESG program is designed to:
• increase the availability of emergency shelter beds through the financing of renovations,
   and conversions of existing buildings,
• improve the quality of existing emergency shelters,
• help meet the cost of operating homeless shelters and transitional housing, and
• provide essential social services to homeless individuals.

ESG funds may also be used to prevent an increase in homelessness through certain
homeless prevention activities.


Available Funding FY 2008-2009

The City of Durham will receive approximately $84,000 in FY 2008-2009 ESG funds from
HUD. All but five percent of the City’s total allocation will be distributed to eligible applicants
for expenditure of approved program activities. The remaining five percent will be used by
the City for ESG grant contract administration.

HUD Allocation                                            $84,000
Applicant                Use of Funds                     Anticipated
                                                          Funding
                                                          Amount
City of Durham/          Overall management                $4,200
Administration
Sub-recipient            Funds used to assist with         $79,800
agencies                 operations, essential
                         services, homeless
                         prevention and renovation
                         activities.




                                         Page 3 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009




Program Target Beneficiary Population

According to ESG program regulations a “homeless” person or family must meet one or more
of the following criteria; they must be:

a) an individual or family that lacks a fixed, regular and adequate nighttime residence; or
b) an individual or family that has a primary nighttime residence that is:
           • a supervised publicly or privately operated shelter designed to provide
              temporary living accommodations (including welfare hotels, congregate
              shelters, and transitional housing for persons with mental illness); or
           • an institution that provides a temporary residence for individuals intended to
              be institutionalized; or
           • a public or private place not designed for, or ordinarily used as a regular
              sleeping accommodation for human beings.

The term does not include any individual imprisoned or otherwise detained pursuant to an
Act of Congress or a state law.

Youth who are considered wards of the state (i.e., the legal responsibility of a state agency,
such as a Division of Social Services) are not eligible to receive assistance under the
McKinney-Vento Act and may not be counted as homeless for purposes of the ESG
Program.

All applicants receiving FY 08-09 ESG funds must certify that ESG funds will be used for the
benefit of only for those clients meeting the “homeless” definition above and that they will
make every reasonable attempt to assure that all clients served meet this definition. Grant
recipients are required to document each client’s homeless status in a form that will be
provided by the City of Durham.


Eligible Grant Applicants

Eligible applicants for ESG grant funds include private nonprofit organizations as described
in section 501(c)(3) of the Internal Revenue Code of 1988. In addition, applications for
homeless assistance or shelter construction or operations that can show a history of success
managing similar activities will be viewed favorably. Related experience may include, but is
not limited to the following:

a) Has operated the emergency and/or transitional shelter for the homeless for which
   funding is requested for at least one year prior to the date of this application;

b) Operates the emergency and/or transitional shelter for the homeless for which funding is
   requested for a minimum of six full months out of the year;

c) Operates a safe and sanitary facility which has an average daily occupancy rate of at
   least six (6) homeless persons per night and provides one or more essential services, as
   defined by HUD, if overnight accommodations are provided; OR, provides shelter and/or




                                       Page 4 of 33
                   City of Durham, ESG Grant Funding Application – FY 2008-2009



     one or more essential services as defined by HUD to an average of 30 homeless persons
     per day, if operated during day hours only;

d) Has an established accounting system that provides for maintenance of ESG funds in
   accordance with OMB Circulars A-110 and A-122;

e) Has a voluntary board consisting of a minimum of five members;

f)   Has the ability to expend ESG funds budgeted for Operations, or Essential Services, or
     Renovations within 365 days and ESG funds budgeted for Homeless Prevention within
     180 days of the execution of the grant contract;

g) Can share the cost of the proposed program by providing matching funds in the same
   amount as the ESG grant;

h) Involves, to the maximum extent practicable, homeless persons in maintaining and
   operating facilities assisted under the ESG Program and in providing services for
   occupants for these facilities;

i)   Provides for the participation of at least one homeless or formerly homeless individual on
     its board of directors or equivalent entity that makes policies and decisions regarding the
     services provided by such facility for which ESG funding may be used.

Departments/Agencies of Durham City government are eligible ESG recipients.

Facilities funded by the City of Durham ESG Program must be permanent structures
providing safe, decent shelter for humans and must be owned or properly leased by the
applicant organization.


Eligible Activities

Each organization may only apply for funds to support one program category. Please refer
to the Eligible Activities section for more specific information. Each of the four categories of
eligible activities are further defined below:


Operations: Costs associated with the overall operation and general maintenance of the
shelter include, but are not limited to:

a) Administrative Staff Costs: (salaries and fringe benefits) are limited to 10% of total ESGP
   grant amount. Administrative staff includes only those persons directly responsible for
   the operation and management of the homeless facility for which funding is sought. Such
   staff could include the applicant organization executive director, the homeless facility
   director and weekend or night managers of the homeless facility. ESG funding may not
   be used to pay the costs of staff that provide support services such as cooks, janitors,
   secretaries, bookkeepers, administrative assistants, etc. Staff members whose salaries
   are paid, in whole or in part, with ESG funds must maintain time sheets delineating ESG
   hours worked during each pay period.
b) Communications: telephone, postage and printing


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                  City of Durham, ESG Grant Funding Application – FY 2008-2009



c) Equipment: Equipment/furniture items with a unit value of $500 or more. Adequate
   justification for equipment items must be provided by the sub-recipient.
d) Food: When food is served to people who use the sleeping accommodations of an
   emergency shelter, the food is considered an operational cost. When food is served to
   homeless people who do not reside in the shelter, the food is considered an essential
   service. If the sub-recipient organization serves food to both residents of the homeless
   facility and to homeless persons not residing in the homeless facility the costs of the food
   should be prorated and charged accordingly to the approved Operations and Services
   budget. Since only 1 category will be approved, if the above applies, the agency is to
   charge that cost to other NON-ESG funds.
e) Space Cost: Rent, utilities, routine maintenance; minor building repairs; insurance on
   facility building and contents; security systems. If ESG funds are used to pay rent, the
   applicant organization must have a current lease agreement on file.
f) Travel: Insurance, gas, maintenance on organization-owned vehicle used by
   administrative staff to conduct official business related directly to the homeless facility;
   reimbursement of such staff using personal vehicles for these purposes (indicate amount
   of reimbursement per mile and total miles). If an organization-owned van is used for both
   administrative and services purposes the cost of insurance, gas, and maintenance must
   be prorated to the approved Operations and Services budget. Since only 1 category will
   be approved, if the above applies, the agency is to charge that cost to other NON-ESG
   funds.
g) Supplies and Materials: Food costs (for facility residents); paper products; office supplies;
   equipment/furnishings with unit value of less than $500.
h) Contractual Services (under Operations) would include laundry services, cleaning
   services, security system monitoring, pest control, and bookkeeping. Costs charged to
   the ESG Program must be supported by contracts between the vendor and the ESG sub-
   recipient organization. OMB Circular A-133 prohibits federal financial participation in audit
   cost for entities that do not expend $300,000 or more in federal funds for that fiscal year.


Essential Services include direct client services in areas such as employment, health, drug
and alcohol abuse, and education and include:

a) Assistance in obtaining permanent housing
b) Medical and psychological counseling and supervision
c) Employment counseling
d) Nutritional counseling
e) Substance abuse treatment and counseling
f) Assistance in obtaining other federal, City, and local assistance including mental health
   benefits, employment counseling, medical assistance, Veteran’s benefits, and income
   support assistance including food stamps
g) Other services for the client including childcare, transportation, job placement, and job
   training
h) Client Transportation – Bus tickets/tokens/passes for clients; cost of insurance, gas and
   maintenance of applicant-owned vehicle used to transport clients to medical
   appointments, job interviews, social service agencies, legal proceedings, etc. and/or
   reimbursement for the transport of clients by staff in their privately-owned vehicles to
   such destinations
i) Staff salaries necessary to provide the above services
j) Contractual costs necessary to provide the above services


                                       Page 6 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009




Funding for essential services is available only if the service for which funding is requested
will be a new service offered by the applicant organization or if the funding will allow the
applicant organization to assist an increased number of clients with a previously offered
service. This increase must be quantifiable and documented by the applicant organization.

ESG grant recipients will be required to maintain written documentation of the services they
provide to each client and documentation of services provided by other agencies as a result
of the grant recipient’s referrals. This documentation must include the type of service
provided, the duration of the service, date(s) of service and the name of the staff member or
outside entity providing the service.

Funding for Essential Services is limited to 30% of the total ESG funding awarded which is
set in the funding allocation.


Renovation, Rehabilitation or Conversion construction costs are defined as improvements
to a structure that increase the quality and quantity of emergency shelters and transitional
housing through conversion or major rehabilitation or renovation of existing buildings to be
used as emergency shelters. Please note that Davis-Bacon requirements do not apply to
ESG-funded renovation, major rehabilitation or conversion activities. The regulations
differentiate the three types of improvements in this way:
Conversion means a change in the use of building to an emergency shelter for the homeless,
where the cost of conversion and any rehabilitation costs exceed 75 percent of the value of
the building after conversion.

a) Major rehabilitation means rehabilitation costs in excess of 75 percent of the value of the
   building before rehabilitation.
b) Renovation means rehabilitation that involves costs of 75 percent or less of the value of
   the building before renovation.
c) The market value of the building is established by an independent real estate appraiser,
   or as otherwise reasonably established by the parties to the grant contract.

       Use Restrictions on Renovation, Major Rehabilitation, and Conversion:
The program requires certain continued use standards for shelters receiving ESG funds for
improvement based upon the amount of the improvement. Each grant recipient must certify
that:

a) In the case of assistance involving Major Rehabilitation or Conversion, the recipient will
   maintain any building for which ESG funds are used as a shelter for homeless individuals
   and families for not less than a 10-year period;

b) In the case of assistance involving Renovation, the grant recipient will maintain any
   building for which ESG funds are used as a shelter for homeless individuals and families
   for not less than a 3-year period;

c) Any renovation carried out with ESG program assistance will be sufficient to ensure that
   the building involved is safe and sanitary.




                                       Page 7 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009



d) In the case of a building that was not operated as an emergency shelter for the homeless
   before receipt of the ESG grant, the 3- or 10- year periods begin on the date of initial
   occupancy as an emergency shelter for the homeless;

e) In the case of a building that was operated as an emergency shelter before receipt of the
   ESG grant, the 3- or 10-year periods begin on the date that grant amounts are first
   obligated for the shelter.

        Lead-based Paint Requirements:
Emergency housing that provides efficiency apartments, studio apartments, dormitories,
single room occupancy units, barracks, group homes, or room rentals in residential dwellings
are all excluded from the lead-based paint remediation requirements. The only ESG-assisted
housing covered under the lead-based paint requirements is longer-term transitional housing
in an apartment with one or more bedrooms that has family residents who are part of a
program requiring continual residence of more than 100 days.

Additionally, ESG projects providing essential services only are also excluded from the lead-
based paint regulations.

However, any ESG housing or services sites regularly frequented by children less than 6
years of age are encouraged to use ESG funds for testing and may use ESG rehabilitation
funds for necessary abatement procedures.

        Ineligible Activities
Ineligible rehabilitation or renovation costs include:

   Acquisition of real property
   New construction
   Property clearance or demolition
   Rehabilitation administration
   Staff training or fund raising activities associated with rehabilitation
   Building maintenance and repairs (See Operations)


Homeless Prevention means activities or programs designed to prevent the incidence of
homelessness including:

a) Short-term subsidies to defray rent and utility arrearages for individuals or families that
   have received eviction and/or utility termination notices
b) Security deposits of first month’s rent to permit a homeless individual or family to move
   into an apartment or house
c) Legal service fees for the representation of indigent tenants in eviction proceedings
d) Other payments to prevent the incidence of homelessness

If funds requested for homeless prevention are to be used to assist families that have
received eviction notices or notices of termination of utility services, the following conditions
must be met:



                                         Page 8 of 33
                 City of Durham, ESG Grant Funding Application – FY 2008-2009



a) The inability of the family to make the required payments must be the result of a sudden
   reduction in income
b) The assistance must be necessary to avoid eviction of the family or termination of
   services to the family
c) There must be a reasonable prospect that the family will be able to resume payments
   within a reasonable period of time and
d) The assistance must not supplant funding for preexisting homeless prevention activities
   from any other sources.

The applicant organization must provide active case management which precludes the
client’s continued dependence on emergency assistance funds. Evidence of such case
management must be maintained in individual client files by the organization receiving ESG
funds.

Funding for Homeless Prevention activities is limited to 30% of the total ESG funding
awarded which is set in the funding allocation.


Matching Funds Requirements

Each grant recipient must share in the cost of the program by matching all ESG funds
received dollar for dollar and spending that match money within the period of the grant on
related program activities.

Eligible matching funds are those received by the grant recipient organization from other,
non-federal sources such as foundations, church donations, and/or individual donations.

The value of time donated by volunteers (valued at $5.00/hour for unskilled labor or at
market value for skilled professionals) may also be used to meet this requirement as long as
such time is documented. Work time donated by beneficiaries/clients to the applicant
organization in return for shelter and/or services may not be counted as volunteer time
against the match.

The value of any donated materials or buildings or of any lease (valued using a method
reasonably calculated to establish a fair market value) may also be used as a source of
match for ESG funding as long as appropriate documentation is submitted and accepted by
the City of Durham prior to the execution of the grant contract.

Funds used to match ESG funds may not be used for any other purpose.

Documentary evidence of matching funds and matching funds expenditures must be
provided with each request for payment submitted to the Department of Community
Development, and payments against the grant fund will be released only to the extent that
the match requirements have been met.




                                       Page 9 of 33
                   City of Durham, ESG Grant Funding Application – FY 2008-2009



Limitations on the Use of ESG Funding by Primarily Religious Organizations

Program funding may be provided to a primarily religious organization that meets the
eligibility criteria as long as that organization agrees to provide all eligible activities in a
manner that is free from religious influences.

Organizations receiving ESG funds may conduct religious services and/or instructional
sessions in their facilities, but may not require clients to attend such services or sessions as
a condition of the client receiving shelter or services paid for, in whole or in part, with ESG
funds. Client attendance at religious services or sessions must be strictly voluntary. Clients
must be informed in writing that their attendance at religious services or sessions is not
required to receive shelter and/or services from the organization.


Federal Outcome Performance Measurement System

Effective October 1, 2006, HUD developed a new Community Development Outcome
Performance Measurement System. The system is designed to measure and report program
costs and achievements and was implemented as a direct result of the public’s growing
concern for government accountability.

The Performance Measurement System (PMS) requires that the Grantee, the City of
Durham, create an organized process for gathering information to determine how well
programs and activities are meeting established priorities, goals and needs.

Recipients of ESG funding are participants in this process; your progress reports must
provide us with the information we need to report to HUD. There are three main components
to the Performance Measurement System:

    •   Objectives;
    •   Outcomes; and
    •   Indicators

Objectives – Grant recipients must choose to satisfy one of the following objectives:
When selecting an objective, ask: What is the purpose of the activity?

a) Creating Suitable Living Environments relates to activities that are designed to benefit
   communities, families, or individuals by addressing issues in their living environment.
b) Providing Decent Housing covers the wide range of housing activities that focus on
   meeting individual family or community housing needs.
c) Creating Economic Opportunities applies to activities related to economic development,
   commercial revitalization, or job creation.

Outcomes – Grant recipients must determine what the primary benefit of their program will
be. When selecting an outcome, ask: What type of change or result am I seeking?

a) Availability/Accessibility applies to activities that make services, infrastructure, public
   services, public facilities, housing, or shelter available or accessible to low-and moderate
   income people, including persons with disabilities.



                                          Page 10 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009



b) Affordability applies to activities that provide affordability in a variety of ways to low- and
   moderate income people.
c) Sustainability applies to activities that are aimed at improving communities or
   neighborhoods, helping to make them livable or viable by providing benefit to low- and
   moderate income or by removing or eliminating slums or blighted areas, through multiple
   activities or services that sustain communities or neighborhoods.

Indicators – are benchmark achievements that help to determine how the grant recipient is
progressing toward achieving the intended results.


Reporting Requirements

ESG grant recipients will be required to submit monthly or quarterly performance and
expenditure reports to the City of Durham. These reports must provide demographic
information about each beneficiary and activity and expenditures source documents such as
copies of client intake forms, descriptions of services or activities, and copies of payroll
ledgers, cancelled checks, invoices and timesheets. Additional information may also be
required. A template that is appropriate for the program you are proposing will be developed
for you.


Selection Criteria

ESG applications will be evaluated based on proof of past success with programs similar to
those being proposed, the financial and staff capacity of the organization, the anticipated
outcome and benefit of the proposed program compared to other proposals, and an
evaluation of the past performance of the applying agency. Priority will be given to
organizations whose missions are to serve homeless individuals and families. The
approximately $84,000 will be distributed as follows:

       Category                                Maximum/Minimum Award Amount

       Operations                              $10,000 Minimum
       Essential Services                      $25,200 Approx. Maximum
       Renovations                             $79,800 Approx. Maximum
       Homeless Prevention                     $25,200 Approx. Maximum



Application Submission Requirements

Three (4) complete copies of the application for FY 08-09 ESG funding (1 original and 2
copies in printed form, and 1 copy in electronic form on a CD) must be received by the City of
Durham Department of Community Development no later than 4:00 p.m. on Friday,
December 21, 2007. Do not send more than the requested copies and do not staple the sets
together.




                                        Page 11 of 33
                 City of Durham, ESG Grant Funding Application – FY 2008-2009



Ineligible Applications

Applications received after the deadline date and time will be returned without review and the
applicant will be determined ineligible to apply for FY 08-09 ESG funding. Applications that
do not contain all requested supporting documentation or are otherwise incomplete will be
returned and the applicant will be deemed ineligible to apply ESG funding in the 2008-2009
fiscal year. Faxed applications will not be accepted under any circumstances.




Completed applications may be mailed or hand-delivered to:

                                City of Durham
                             401 Lakewood Avenue
                          Durham, North Carolina 27701
                              ATTN: ESG Program




                                      Page 12 of 33
City of Durham, ESG Grant Funding Application – FY 2008-2009




                  APPLICATION
                  DOCUMENTS




                     Page 13 of 33
                 City of Durham, ESG Grant Funding Application – FY 2008-2009



                                CITY OF DURHAM
                      EMERGENCY SHELTER GRANTS PROGRAM
                        FUNDING APPLICATION FY 2008-2009


SECTION I - APPLICANT IDENTIFICATION


Legal Name or Organization: ________________________________________

Mailing Address: __________________________________________________

Street Address: ___________________________________________________

County in which the Program Facility is Located: _________________________

Fed I.D. #: _____________________


Name of Executive Director: _________________________________________

Tel:______________________________ Fax: _________________________

Email: ___________________________         Cell: _________________________


Name of Facility/Program Director: ___________________________________

Tel:______________________________ Fax: _________________________

Email: ___________________________         Cell: _________________________


Name of Board Chairperson: ________________________________________

Tel: _____________________________ Fax: __________________________

Email: ___________________________ Cell: __________________________


Name of Shelter or Transitional Housing Facility:

________________________________________________________________

Is the address of the facility confidential? ____YES ____NO




                                      Page 14 of 33
                City of Durham, ESG Grant Funding Application – FY 2008-2009



SECTION II - CERTIFICATION:




This application for Emergency Shelter Grant Program funds has been reviewed and
approved by the applicant governing board or by a duly appointed board committee.


_____________________________________________
Typed Name of Governing Board Chairperson


Signature*___________________________________________________


_____________________________________________
Date Approved (Month/Day/Year)


      *If signed by anyone other than board chairperson, please attach a resolution of the
      applicant organization’s board authorizing the signatory.




                                     Page 15 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009




SECTION III – ASSURANCES & CERTIFICATIONS


I, __________________________________, Chairperson of the Governing Board, of
________________________________________________
                            (Name of Applicant Organization)

acknowledge that funds available under the FY 08-09 Emergency Shelter Grants Program
will be used to serve individuals and families who meet the definition of “homeless” used in
the McKinney-Vento Homeless Assistance Programs. These funds will be used for
Operations only or Essential Services, or Homeless Prevention, or Renovations or
Operations; and certify that:

1. In connection with the option selected, funds will be utilized to:

A.    Provide services concerned with employment, health, drug abuse, and education,
and may include:

       1. assistance in obtaining permanent housing
       2. medical and psychological counseling and supervision
       3. employment and nutrition counseling
       4. substance abuse treatment and counseling
       5. assistance in obtaining Federal, State and local assistance, including mental
          health benefits, employment counseling, medical assistance, Veteran's benefits,
          and income support assistance such as Supplemental Security Income benefits,
          General Assistance, Temporary Assistance for Needy Families (TANF) and Food
          Stamps
       6. other services such as child care, transportation, job placement and job training
       7. staff salaries necessary to provide the above services

       Essential services may be provided only if the service is a new service, or is a
       quantifiable increase in the level of a service above that which was provided with
       local funds during the 12 calendar months immediately preceding receipt of
       Emergency Shelter Grants Program funds; and not more than 30 percent of the total
       grant amount may be used for these services.

B.     Provide payment of costs associated with the operation of a facility providing shelter
and services to homeless individuals and families including staff costs (administrative staff
costs cannot exceed 10% of total grant amount;) rent; utilities; food and furnishings, minor
and/or routine building maintenance and repair as described; equipment; property insurance;

C.     If homeless prevention funds are sought, develop and implement homeless
prevention activities as described below:

       1. Short-term subsidies to defray rent and utility arrearages for families that have
          received eviction or utility termination notices;
       2. Security deposits of first month’s rent to permit a homeless family to move into its
          own home;
       3. Mediation services for landlord/tenant disputes;


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                     City of Durham, ESG Grant Funding Application – FY 2008-2009



           4. Legal services for the representation of indigent persons in eviction proceedings;
           5. Payments to prevent the incidence of homelessness.

          If grant funds are to be used to assist families that have received eviction notice or
          notices of termination of utility services, the following conditions must be met:

           1. The inability of the families to make the required payments must be the result of a
              sudden reduction in income.
           2. The assistance must be necessary to avoid eviction of the family or termination of
              services to the family.
           3. There must be reasonable prospect that the family will be able to resume
              payments within a reasonable period of time.
           4. The assistance must not supplant funding for preexisting homeless prevention
              activities from any other source.

           Clients receiving homeless prevention assistance will be provided or referred to
           services that may preclude their continued dependence on emergency assistance.
           These services could include individual or group budgeting, employment and/or
           educational counseling.

           Not more than 30% of the total grant amount may be expended on Homeless
           Prevention.

D.         If renovations funds are sought, the following conditions must be met:

     1.    1.Fiscal controls and accounting procedures necessary to assure proper dispersal of
           and accounting of Emergency Shelter Grants Program funds have been established
           in accordance with OMB Circulars A-110 and A-122 for non-profits. In addition,
           where combined state funds are received, used or expended of at least $15,000, but
           less than $300,000 annually, a sworn accounting of receipts and expenditures of the
           state funds and an Activities and Accomplishments Report must be filed with the
           North Carolina Department of Health and Human Services within six months after the
           end of the agency fiscal year.

     2.    All program clients and fiscal records will be retained for a period not less than three
           years following completion of the contract or until all audit findings are resolved.

     3.    Any building for which Emergency Shelter Grants Program funds are used for eligible
           activities described in 576.21(a)(2),(a)(3), and (a)(4) must be maintained as a shelter
           for the homeless for the period during which such assistance is provided. A substitute
           site or shelter may be used during this period, so long as the same general
           population is served. The Department of Community Development will be informed
           immediately if there is a change during the contract period in the operation, location
           and/or service population of any homeless facility funded with Emergency Shelter
           Grants Program funds.

     4.    To the maximum extent practicable, homeless individuals and families will be involved
           in maintaining and operating the facility and in providing services for occupants of the
           facility.



                                          Page 17 of 33
                 City of Durham, ESG Grant Funding Application – FY 2008-2009



  5.   The shelter will not use debarred, suspended or ineligible contractors in accordance
       with the requirements of 24 CFR Part 24.

  6.   The shelter will maintain a drug free workplace in accordance with the requirements
       of 24 CFR Part 24, Subpart F.

  7.   No person shall, on the grounds of race, color, national origin, or sex, be excluded
       from participation in, be denied the benefits of, or be subjected to discrimination
       under any program or activity funded in whole or in part with funds made available
       under the Emergency Shelter Grants Program. Any prohibition against discrimination
       on the basis of age under the Age Discrimination Act of 1975 or with respect to an
       otherwise qualified handicapped individual as provided in Section 504 of the
       Rehabilitation Act of 1973, 24 CFR Part 100 of the Fair Housing Act, the Housing and
       Urban Development Act of 1978-Section 3, and Executive orders 11063, 11246,
       11625, 12432, and 12138 shall also apply. Procedures will be instituted to ensure
       that this policy and available services and facilities are made known to all.

  8.   Facilities receiving Emergency Shelter Grants Program funding are subject to the
       requirements, as applicable, of the Lead-Based Paint Poisoning Prevention Act
       (LBPPPA) and the Act’s implementing regulations at 24 CFR Part 35.



________________________________________________________________
TYPED NAME OF GOVERNING BOARD CHAIRPERSON


____________________________________________________________
                SIGNATURE*                                                        DATE


*If signed by anyone other than board chairperson, please attach a resolution of the applicant
organization’s board authorizing the signatory.




                                      Page 18 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009




ASSURANCES REGARDING THE CONDUCT AND/OR PROVISION OF RELIGIOUS
SERVICES AND INSTRUCTION

I, __________________________________________, Chairperson of the Governing Board
                                     of

________________________________________________________________
                        (Name of Applicant Organization)

which ____ is _____ is not a primarily religious organization, certify that:

1. All eligible activities under the Emergency Shelter Grants Program conducted by

_______________________________________________ during the FY 08-09
(Name of Applicant Organization)

ESG grant period will be provided in a manner that is free from religious influence and in
accordance with the following principles, the organization named above:

   a. Will not discriminate against a person currently receiving its shelter and/or services or
      any person applying for shelter or any of the eligible activities under the Emergency
      Shelter Grants Program on the basis of religion and will not limit such housing or
      other eligible activities or give preference to persons on the basis of religion; and
   b. Will not engage in inherently religious activities, such as worship, religious instruction
      or proselytizing as part of the programs or services funded, in whole or part, with
      Emergency Shelter Grants (ESG) Program funding. If an organization conducts such
      activities, the activities must be offered separately, in time or location, from the
      programs or services funded with ESG funding.
   c. Will not require clients to attend religious services and/or receive any religious
      instruction as a condition of their receiving shelter and/or services provided by the
      organization.

2. A client or resident who declines to attend religious services or receive religious
   instruction offered in the facility will suffer no reprisals including withdrawal of privileges,
   termination of residence in the facility or withdrawal of essential services heretofore
   provided.


_______________________________________________________________
              TYPED NAME OF GOVERNING BOARD CHAIRPERSON

_______________________________________________________                        ___________
              SIGNATURE*                                                            DATE

*If signed by anyone other than board chairperson, please attach a resolution of the applicant
organization’s board authorizing the signatory.




                                        Page 19 of 33
                 City of Durham, ESG Grant Funding Application – FY 2008-2009




TERMINATION OF ASSISTANCE CERTIFICATION


Section 1402(d) of the Housing and Community Development Act (HCDA) of 1992 amends
Section 415 of the Stewart B. McKinney Homeless Assistance Act and states:

       "If an individual or family who receives assistance . . .. from a recipient
       violates program requirements, the recipient may terminate assistance in
       accordance with a formal process established by the recipient that
       recognizes the rights of individuals affected, which may include a hearing."

ATTACH COPY OF APPLICANT ORGANIZATON TERMINATION OF ASSISTANCE
POLICY BEHIND THIS PAGE. This policy should be approved by the organization’s
governing body and must clearly outline the procedure available to program clients/residents
to file grievances regarding program services or appeal their suspension or termination from
program services including facility residency. An acceptable termination of assistance policy
must include
     1) the name of the person/persons with whom the grievance or appeal should be filed,
     2) the person/persons who will review the grievance or appeal,
     3) the method of review to be used, i.e. formal hearing, staff/client interviews, etc.,
     4) the time requirements on the client for filing the grievance or appeal; and,
     5) the time requirements on the organization for review of the grievance or appeal and
         rendering of a final decision.
Clients should be allowed to file grievances and/or appeals orally if needed. Staff making
decisions to suspend or terminate services to the client or who are the subjects of a client
grievance may not have the authority to decide the validity of a client grievance or appeal or
be involved in the final disposition of the grievance or appeal.

I, ___________________________________________________, Chairperson

of the Governing Board of
_________________________________________________________
certify that a termination of assistance policy has been established by the governing board in
accordance with the requirements of Section 1402(d) of the Housing and Community
Development Act (HDCA) of 1992 that amends Section 415 of the Stewart B. McKinney-
Vento Homeless Assistance Act, as evidenced by the termination of assistance policy that is
attached.


_______________________________________________________________
TYPED NAME OF GOVERNING BOARD CHAIRPERSON*

_______________________________________________ ________________________
SIGNATURE                                          DATE

* If signed by anyone other than board chairperson, please attach a resolution of the
applicant organization’s board authorizing the signatory.




                                      Page 20 of 33
                 City of Durham, ESG Grant Funding Application – FY 2008-2009




STATISTICAL REPORTING REQUIREMENTS

In order to satisfactorily complete a monthly Performance Report, all FY 08-09 ESG Sub-
recipients must collect the following statistical information on the persons served and
services provided during the grant period. Monthly reports will cover the through September
30, 2008.

∗   Average daily occupancy of shelter/facility during the grant period.
∗   Number of unduplicated persons served by your agency during the grant period reported
    by total number and in the following categories:
        -Number of Single Individuals NOT in families
                - Adults: Ages 18 +
                - Children: Ages 0 - 17
        -Number of Persons in Families
                -Adults: Ages 18 +
                -Children: Ages 0 - 17
∗   Number of Families Served during the grant period
∗   Primary Reason for Homelessness Experienced by Persons Served (Report number of
    persons served in each category listed below):
    − Chronic alcoholism
    − Chronic drug abuse
    − Dual Diagnosis (both severe mental illness and chronic alcohol or other drug abuse)
    − Domestic Violence
    − Eviction
    − HIV/AIDS
    − Unemployment
    − Underemployment
    − Mental Illness
    − Natural Disaster
    − Parent/Child Conflict (Runaway)
    − Child Abuse and Neglect
    − Release from Prison
    − Transient/Relocation
    − Health Related Disability
    − Other
∗   Number of Single Female Individuals and Single Male Individuals served in following age
    groups:
        17 & under
        18 - 30
        31 – 54
∗       55 & over
∗   Number of Male Adults and Female Adults in Families Served in following age groups:
        18 - 30
        31 - 54
        55 and over




                                      Page 21 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009



∗   Number of Male Children and Female Children in Families Served in following age
    groups:
       under 1
       1-5
       6 - 12
       13 - 17

∗   Veteran Status of Male and Female Persons Served

∗   Number of Persons Served in Racial Categories Below:
      Asian/Pacific Islander
      Black
      Hispanic
      Native American/Alaskan Native
      White

∗   Amount of Increase in the Number of Persons Served in each applicable category below
    as a result of ESGP funding
        - Employment Services             - Health Services
        - Substance Abuse Services        - Education Services
        - Housing Referral Services       - Nutritional Counseling
        - Other

∗   Number of Persons who received Homeless Prevention Services and the Types of
    Services Provided.

* Financial expenditures and/or obligations

I, ___________________________________________________, Chairperson of the

governing board of _____________________________________, certify

that the statistical information noted above will be collected for reporting in the Mid-Year and
Annual Performance Reports required by the Office of Economic Opportunity during and
immediately following the grant period.


_______________________________________________
Signature of Governing Board Chairperson*

_________________
 Date

* If signed by anyone other than board chairperson, please attach a resolution of the
applicant organization’s board authorizing the signatory.




                                       Page 22 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009




SECTION IV – COMMUNITY NEEDS AND RESOURCES



NAME OF APPLICANT ORGANIZATION

________________________________________________________________


On a separate piece of paper, please answer the following questions.

In the heading of that page, state your name, the name and address of your agency, the
name of your proposed program, and the date this application was prepared.

Questions:

1. State the approximate number of homeless persons in your community/service area, and
   disclose the source of your data.


2. Describe the homeless population you serve and any changes in this population which
   you have noticed over the past two years (e.g., increase in special populations such as
   the elderly, female heads of households, working families not able to afford housing in
   your market, any decrease in overall homeless population, etc.). Please disclose the
   number of participants your organization proposes to serve during the term of the
   FY 08-09 contract.


3. Based on your experience, what are the unmet needs of homeless people in your service
   area?


4. Describe any efforts to coordinate services among human service agencies in your
   community such as a local continuum of care planning process. (Please be specific. If
   you are unaware of any efforts to coordinate services, or are not involved in these efforts,
   please indicate.)


5.   Identify the major agencies/organizations (overnight shelters, domestic violence shelters,
     day shelters, soup kitchens, etc.) in your service area that provide services to the
     homeless.




                                       Page 23 of 33
                     Please complete the project budget table. Attach other sheets as necessary.

                  A.                Category                   B.                         C.                        D.
         List all line items      (ES/OP/REN/          ESG funds requested.       Other source(s) of           Total (B + C)
           included in your          or HP)                                    funding. Identify source.
            project, service
               or activity
                 budget.
1.                                                    $                        $                           $
2.                                                    $                        $                           $
3.                                                    $                        $                           $
4.                                                    $                        $                           $
5.                                                    $                        $                           $
6.                                                    $                        $                           $
7.                                                    $                        $                           $
8.                                                    $                        $                           $
9.                                                    $                        $                           $
10.                                                   $                        $                           $
11.                                                   $                        $                           $
12.                                                   $                        $                           $
13.                                                   $                        $                           $
14.                                                   $                        $                           $
15.                                                   $                        $                           $
16.                                                   $                        $                           $
17.                                                   $                        $                           $
18.                                                   $                        $                           $
19.                                                   $                        $                           $
20.                                                   $                        $                           $
21.                                                   $                        $                           $
22.                                                   $                        $                           $
23.                                                   $                        $                           $

TOTALS                                                $                        $                           $
SECTION VII – SOURCE OF MATCHING FUNDS


Please indicate below the source(s) and amount of funds to be used to match the ESG funds
received by your organization. The amount should be at minimum equal to the amount of
funds allocated. These funds must be provided after the start date of the grant award and
may not be used to match another grant during the same period.

Additionally, following this sheet, please attach documentation of the availability of matching
funds for the proposed project as described below.
   • If funds received from units of local government, churches, foundations, or state
       government agencies will be used to match ESG funds, attach copies of funding
       award and/or commitment letters from these sources on their official letterhead and
       signed by their authorized official.
   • If the value of donated volunteer hours will be used to match ESG funds, the
       applicant organization should provide a letter on its official letterhead signed by its
       board chairperson describing the records maintained on volunteer hours, indicating
       the number of volunteer hours donated to the organization during its most recent
       fiscal year and estimating the number of volunteer hours to be donated during the
       period of the ESG grant period.
   • If the value of a donated building or any lease will be used to match ESG funds,
       provide documentation of the fair market value of the building or lease.
   • If staff salaries are used to match ESG funds, the source of the funds for these
       salaries should be identified by the applicant organization in a letter on its official
       letterhead and signed by its board chairperson.

                      Source of Matching Funds
Amount

_______________________________________________ $_______________


_______________________________________________               _______________


_______________________________________________               _______________


_______________________________________________               _______________


_______________________________________________               _______________


                         TOTAL                             $ _______________
                  City of Durham, ESG Grant Funding Application – FY 2008-2009




SECTION VIII – INVENTORY OF ADDITIONAL FUNDING


Your Agency Fiscal Year begins on ________________ and ends on ________________.

Will the applicant organization receive funding from other State or Federal funding sources
during the period of July 1, 2008 – June 30, 2009?
____ Yes _____ No

If YES, please provide the following information:

Name of State/Federal                 Funding                       Period of Funds
Agency and Program                    Amount                        Availability
Providing Funding




Please indicate below the additional sources from which the applicant organization is
expected to receive funding during the period of July 1, 2008 – June 30, 2009 and the
estimated cash funding to be received.

_____ Private Foundations                                    $___________________
_____ Churches                                               $___________________
_____ Donations (Individual and/or Business)                 $___________________
_____ Organization Owned/Operated Enterprises                $___________________
_____ Fundraising Events                                     $___________________
_____ Local Government (City/County Funding)                 $___________________
_____ Client Rent/Boarding Fees                              $___________________
_____ Client Program Service Fees                            $___________________




                                       Page 26 of 33
                City of Durham, ESG Grant Funding Application – FY 2008-2009



SECTION IX – SUPPORTING DOCUMENTATION


ATTACH THE FOLLOWING DOCUMENTS:

  •   A copy of any application or intake form used to admit and/or serve a client served by
      the homeless facility for which funding is sought.

  •   A list of staff with position titles for the homeless facility for which funding is sought.
      (Please attach résumé’s if available)

  •   Attach a copy of the form they used to verify the homelessness of clients. If the form
      in Appendix B is not selected for use by the applicant organization, the applicant
      organization should attach a copy of the verification of homelessness form they
      intend to use during the term of the contract. Any form designed by the applicant
      organization must be approved by the Department of Community Development prior
      to use.




                                      Page 27 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009



ATTACHMENT A - HOMELESS ELIGIBILITY CERTIFICATION GUIDE

         In accordance with the McKinney Act Programs, the following situations (listed below)
constitute a homeless situation. They are not all inclusive but are the most typical types of
homeless situations. If there are other situations that are not described here, contact the
HUD Field Office for clarification. Each situation listed below must have some
“documentation” to support that claim. Required types of documentation are listed. To
further stress this very important requirement, you will find a number in parentheses directly
after each situation. That number is the reference to the specific type of documentation
listed immediately after the categories of homeless show below. It is imperative that you
have the proper supporting documentation to demonstrate that a person or family is
“homeless”.
A person is considered homeless only when he/she resides in one of the places described
below:
• In places not meant for human habitation, such as cars, parks, sidewalks, abandoned
     buildings (on the street). (1 or 2)

•   In an emergency shelter. (3)

•   In transitional or supportive housing for homeless persons who originally came from the
    streets or emergency shelters (make sure you have evidence that the person came from
    the streets or emergency shelter situation). (4)

•   In any of the above places but is spending a short time (up to 30 consecutive days) in a
    hospital or other institution. (5)

•   Is being evicted within a week (7 days) from a private dwelling unit and no subsequent
    residence has been identified and the person lacks the resources and support networks
    needed to obtain housing. (6)

•   Is being discharged within a week (7 days) from an institution, such as a mental health or
    substance abuse treatment facility in which the person has been a resident for more than
    30 consecutive days and no subsequent residence has been identified and the person
    lacks the resources and support networks needed to obtain housing. (7)

•   Is being released from prison/jail with no subsequent residence identified and the person
    lacks the resources and support networks needed to obtain housing. (8)

•   Is fleeing a domestic violence housing situation, no subsequent residence has been
    identified and the person lacks the resources and support networks needed to obtain
    housing. (9)

• Is living in substandard housing that has been condemned. (10)
Please use the checklist below to make sure that the type of supporting documentation is
maintained in the participant’s or other appropriate file:

__1__ (Places Not Meant for Human Habitation) Certification form signed by the outreach
worker or service worker verifying that the person or family is homeless. This could include a
letter or certification form signed by an outreach worker or service worker from another


                                       Page 28 of 33
                   City of Durham, ESG Grant Funding Application – FY 2008-2009



organization that can verify that the person or family was, in fact, homeless as described in
the above definition, or

__2__ Written statement prepared by the participant about the participant’s previous living
place (if unable to verify by outreach worker or service worker). Have the participant sign
and date.

__3__ (Shelter) Referral agency certification that the participant has been residing on the
street or at the emergency shelter (on agency letterhead, signed and dated).

__4__ Transitional housing certification (on agency letterhead, signed and dated) if the
participant is residing at the transitional housing facility as well as written verification that the
participant was living on the streets or an emergency shelter prior to living in the transitional
housing facility (see above for required documentation).

__5__ Short-term institution (up to 30 consecutive days) certification from institution’s staff
verifying that the participant has been residing in the institution for 30 days or less. There
should also be written verification that the participant was residing on the street or in an
emergency shelter prior to the short-term stay in the institution.

__6__ Private dwelling eviction statement describing the reason for eviction (signed and
dated by person evicting). No formal eviction is required. If unable to obtain an eviction
statement, you must obtain a written statement signed and dated by the participant
describing the situation. Outreach worker or service worker must document their efforts by
providing a verification form documenting that they have made every effort to confirm that the
circumstances are true and have written verification describing the efforts and attesting to
their validity. The verification form should be signed and dated. You must also have
information on the income of the participant to verify that they lack the financial resources
and support networks needed to obtain housing.

__7__ Institution discharge (over 30 days) certification completed by institution staff stating
that the participant was being discharged within the week before receiving program
assistance. You must also have information on the income of the participant to verify that
they lack the financial resources and support networks needed to obtain housing and that
without the program assistance, the participant would be living on the street or in an
emergency shelter.

__8__ Prison/jail release certification by staff stating that the person was released from
prison with no residence identified and that the person lacks the resources and support
networks needed to obtain housing.

__9__ Domestic violence statement from the participant that he/she is fleeing a domestic
violence situation. If participant is unable to prepare a written statement, staff should prepare
the statement about the participant’s previous living situation and have the participant sign
and date it. You must document that you have verified the income of the participant and
certify that they lack the financial resources and support networks needed to obtain housing
and that without the assistance, the participant would be living on the street or in an
emergency shelter.




                                         Page 29 of 33
                 City of Durham, ESG Grant Funding Application – FY 2008-2009



__10__ Substandard housing that has been condemned requires an official condemnation
notice.

Each homeless person’s file should contain the required evidence of homelessness listed in
1-10 above.

ANSWERING “YES” TO A QUESTION ON AN APPLICATION ASKING IF A PERSON IS
HOMELESS IS NOT SUFFICIENT EVIDENCE OF HOMELESSNESS.


SEE APPENDIX B FOR A SAMPLE VERIFICATION FORM TO MAINTAIN WITH THE
REQUIRED DOCUMENTATION IN EACH CLIENT FILE.




                                      Page 30 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009



ATTACHMENT B – SAMPLE VERIFICATION OF HOMELESSNESS FORM


(Name of organization here)
                                Verification of Homelessness

NOTE TO STAFF: See Homeless Eligibility Certification Guide for detailed explanation of
documentation which must be attached to this form.

Program Applicant Name: ________________________________________________

Interviewed by Program Staff Member:______________________________________

Referred By: ___________________________________________________________

Date of Interview: ___________________

1. As of today, do you have some place in this area that you consider to be a permanent
   place where you live? A permanent place would be a house that you rent or own, an
   apartment that you rent, a room (other than a hotel room) that you rent, or a living
   arrangement with a relative or a friend to sleep in their place on a regular basis (5 or
   more days a week)?
                  Yes (STOP HERE)             No (If No, Continue)

Program Staff: An individual who is living in substandard housing that has been condemned
as unfit for human habitation could be considered homeless under HUD’s definition of
homelessness although not stated in specific program regulations.

2. If you do not have a permanent residence, where have you been living for the last 7
   days?
      Homeless Shelter
   Shelter Name and Location:______________________________________________
        ___________________________________________________________________
      Transitional Housing Facility (designed for homeless persons)

        Facility Name and Location:_____________________________________________
       ___________________________________________________________________
      In a car, van, truck, or other vehicle
      Anywhere outside (on the streets, in parks, in campgrounds)
      In a migrant worker camp
      In an Abandoned Building
      Other (Specify:________________________________________________________)



Program Staff: Letter of verification from director of homeless shelter or transitional housing
facility must be attached to this form if one of these two options is checked. If other options
are checked, document in writing the indicated living situation with law enforcement
reports/referrals, social service agency referral, staff verification, etc. and attach.



                                       Page 31 of 33
                 City of Durham, ESG Grant Funding Application – FY 2008-2009



3. Have you recently been evicted from a house that you rented or owned, an apartment
   you rented, or a room (other than a hotel room) you rented?
     Yes          No

Program Staff: Attach copy of eviction notice or letter from landlord indicating his intent to
begin eviction proceedings.


4. Were you recently asked or forced to leave a living situation by a family member or
   friend?
       Yes       No
   If yes, why were you asked/forced to leave? (Check all that apply)
       Overcrowded                    Family Dispute
       Substance Abuse                Failure to contribute to household income
       Domestic Violence              Other (Specify): _____________________

   Program Staff: If domestic violence is indicated attach statement signed by client
   attesting that he/she is fleeing domestic violence. If other options are checked, attach
   statement from family member or friend attesting to client situation. If not possible to
   obtain such a statement, attach documentation of staff efforts to secure such a
   statement.

5. What is your current income? ______________ per _________
   Do you feel you have the financial means to obtain and maintain a permanent place to
   stay?
      Yes        No


I, __________________________________________, do hereby certify that the answers I
(Printed Name of Program Applicant) have given to the preceding question are true and
accurate.
  ____________________________                        ____________________
   (Signature of Program Applicant)                           (Date)




                                      Page 32 of 33
                  City of Durham, ESG Grant Funding Application – FY 2008-2009



Persons served by this facility should be homeless according to the following definition used
by the Emergency Shelter Grants (ESG) Program.

A person is homeless if he/she is “an individual who lacks a fixed, regular and adequate
nighttime residence, or an individual who has a primary nighttime residence that is: (a) a
supervised publicly or privately operated shelter designed to provide temporary living
accommodations (including welfare hotels, congregate shelters, and/or transitional housing
for the mentally ill); (b) a public or private place that provides a temporary residence for
individuals intended to be institutionalized; or (c) a public or private place not designed for, or
ordinarily used as, regular sleeping accommodations for human beings.”

Based on the responses to the preceding questions given by the above program applicant,

I, _____________________________________________________, a staff member
                       (Printed Staff Member Name)
of__________________________________________________________,
                        (Organization/Facility Name)

find that, ____________________________ ,           is       is not homeless according to
            (Name of Program Applicant)

the definition of homelessness stated above.

__________________________________                       _________________________
  (Signature of Staff Member)                                          (Date)




This completed form, along with all necessary attachments, must be filed in the program
applicant’s file.




                                        Page 33 of 33

								
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