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					Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program
                                         Application Checklist
  Applicant:                                        Project:
  Review the following list of documentation requirements. Three copies are required for submittal. ALL
  copies submitted must include the following attachments in the stated order. Copies that do not contain
  all of the following information will be considered ineligible .


  Tab 1                  Application Checklist

  Tab 2                  Exhibit A: Applicant Information
                              Attachment A-1: Project Service Area Map

  Tab 3                  Exhibit B: Project Information
                              Attachment B-1: Long term lease (if applicable)
                              Attachment B-2: Site control documentation (if applicable)
                              Attachment B-3: Completed appraisal (if applicable)
                              Attachment B-4: Property survey (if applicable)
                              Attachment B-5: Relocation policy (if applicable)
                              Attachment B-6: Color photographs
                              Attachment B-7: Construction schedule (if applicable)
                              Attachment B-8: Design plans (if applicable)
                              Attachment B-9: Cost estimates (if applicable)

  Tab 4                  Exhibit C: Organizational Information
                              Board of Directors
                              Conflict of Interest Disclosure
                              Attachment C-1: Articles of Incorporation
                              Attachment C-2: 501 (c) (3) documentation from IRS
                              Attachment C-3: Agency organization charts
                              Attachment C-4: Project organization charts
                              Attachment C-5: Job descriptions
                              Attachment C-6: Résumés of key personnel
                              Attachment C-7: Letters of funding commitment
                              Attachment C-8: 90- day working capital documentation

  Tab 5                  Exhibit D: Statement of Work/Scope of Services
                              Attachment D-1: Policy and Procedures Manual

  Tab 6                  Exhibit E: Financial Information
                              Public Service Budget Summary
                              Combined Activity Budget (one per Service Activity)
                              Non-Personnel Detail (one per Service Activity)
                              Personnel Detail (one per Service Activity)
                              Leverage Summary (one per Service Activity)
                              Rehab Budget (if applicable)
                              Rehab Budget Cash Flow (if applicable)
                              Attachment E-1: Audit/Financial Statements and IRS Form 990
                              Attachment E-2: Single Audit (if applicable)
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

                              Emergency Shelter Grants Program
                                        Application
                                             Original             Copy

Exhibit A – Applicant Information (5 Points)
Part 1- General Information
  1. Type of Organization:                   Non-Profit                                  Government
                                             Other (Please Specify):
  2. Organization Legal Name:
  3. Project Name:
  4. Mailing Address:
     City, State, and Zip Code:
  5. Physical Address of Project:
     City, State, and Zip Code:
  6. Precinct:                                                9. Fax:
  7. Telephone                                               10. Tax ID:
  8. Provide the following information:
                                Name/Title                   Phone                   Email
Program Contact
Person managing the
project on a daily basis
Finance Contact
Person able to provide
budget information.
Application Contact
Person writing this
application.
Authorized Contact
Person authorized to sign
on behalf of the
organization.
  I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT AND THAT IT CONTAINS NO
  FALSIFICATIONS, MISREPRESENTATIONS, INTENTIONAL OMISSIONS, OR CONCEALMENT OF MATERIAL FACTS. I FURTHER CERTIFY
  THAT NO CONTRACTS HAVE BEEN AWARDED, FUNDS COMMITTED OR CONSTRUCTION BEGUN ON THE PROPOSED PROJECT AND
  THAT NONE WILL BE DONE PRIOR TO ISSUANCE OF A RELEASE OF FUNDS BY HARRIS COUNTY.



     Signature of Authorized Person Listed Above                                     DATE


     Print Name                                                                      DATE




                                                                                                                   A2
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program
Part 3 - HMIS Participation
  1) Does your agency participate in the Homeless Management Information System (HMIS)?
                       Yes             No           Domestic Violence Program
  If yes, please provide the month and year this project began participating.     MM/DD/YYYY
  If no, please provide the date the project anticipates beginning participation. MM/DD/YYYY

  2) Will client-level data be included in the HMIS for all persons served by this project?
                         Yes             No
Part 4 - Program Funding
      1) Requested Amount                                                                                 -
      2) Other Funding                                                                                    -
      3) Total Project Cost                                                                               -
      4) Percentage of Harris County
                                                                                      #DIV/0!
      funds **
           **Organizations must match ESG funds 100 percent**

Part 6 - Project Description
 A. Please provide a brief description of the proposed project in the space below. The description
 should be no more than five sentences and describe the project (not the organization), the purpose
 and the number of unduplicated persons the project will serve during the contract period.

  Example: ABC Agency will provide case management and job training skills to 40 unduplicated persons .




  B. Describe the service area. Please be specific. (i.e. streets, zip codes, key maps). Include a
  copy of your project service area map as Attachment A-1. Do not submit the Harris County
  Service Area Map as your project map.




                                                                                                              A3
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

Exhibit B – Project Information (12 Points)
Part 1 – Measurable Objectives
  A. Which PY2008-2012 Consolidated Plan Objective will the proposed project address? Refer to
     descriptions of the Consolidated Plan Measurable Objectives in the Guidebook.

                                        Objectives                                                    Priority Level**
               Objective 1: Essential Services                                                              High
               Objective 2: Homeless Prevention                                                             High
               Objective 3: Emergency and Transitional Shelters                                             High
  ** Please note, Harris County Community Services Department reserves the right to change the priority levels of the
  above objectives.
Part 2 - Project Need and Beneficiaries
 A. Please identify the primary beneficiaries this project will serve. Be cognizant of the target
     population you name in the narrative portion of this proposal. Please check the appropriate
     categories below:
      Project Beneficiary Population (Please check only one , “1” or “2”)
           1. Low-income population
           2. Presumed Benefit (Please check one below)
              Illiterate adults                         Migrant farm worker
              Battered spouses                          Homeless individuals
              Elderly individuals                       Abused children
              Persons living with AIDS                  Adults with disabilities
  B. Who are the project beneficiaries (target group) to be served? Please check all that apply.
          Male                                             Special Needs
          Female                                           Elderly, Frail Elderly
          Substance Abusers                                Veterans
          At-risk of Becoming Homeless                     Youth* ages       (                      to                       )
                                                           *Please include youth age range, not to exceed 19 years of age.

  C. Number of unduplicated persons from the Harris County Service Area to be
     served:




                                                                                                                                 B4
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

Part 3– Rehabilitation, Renovation, and Conversion Projects ONLY

  A. If the project includes Rehabilitation/Renovation, is it:
                                                                      Yes      No
     Major Rehabilitation?*
     Minor rehabilitation?
     *Major rehabilitation is defined as rehabilitation that involves costs in excess of 75 percent of the value
     of the building before rehabilitation. The value of the building means the monetary value assigned to
     a building by an independent real estate appraiser, or as otherwise established by the grantee or the
     State recipient.

  B. If project involves the acquisition, rehabilitation, renovation, or conversion of a physical
      structure, provide the date the structure was constructed.                  MM/DD/YYYY
  C. Does your project involve rehabilitation, renovation, or conversion on property not
     owned by you?
            Yes (Please include long term lease as Attachment B-1)
            No

  D. Do you have site control?
            Yes (Please include supporting documentation as Attachment B-2)

         **HCCSD will not consider applications for projects without site control**

  E. Do you have a completed property appraisal?
             Yes (Please include as Attachment B-3)
             No
  F. Do you have a completed property survey?
             Yes (Please include as Attachment B-4)
             No
  G. Will your project involve temporary or permanent relocation of residents or businesses?
             Yes (Please include full relocation policy as Attachment B-5)
             No


Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program




                                                                                                                   B5
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

  H. Is your property or project site located within the Harris County service area?
              Yes              No
     If no, explain other HUD entitlement jurisdiction's roles and financial obligations to this project.




  I. Is property/project in 100 year floodplain?
               Yes             No
  J. Is property/project site within 1,000 feet of a highway, freeway or major arterial?
              Yes            No
     If yes, indicate which highway, freeway or major arterial:
  K. Is property/project site within 500 feet of a railroad?
             Yes              No
  L. Is property/project site in Runway Clear Zone / Clear Zone? (Areas immediately beyond the
     ends of a runway of a civil or military airport)
             Yes              No
  M. Is property/project site in an Accidental Potential Zone? (Areas at military airfields which are
     beyond the Clear Zone; does not apply to civil airports)
            Yes              No
  N. Please include a minimum of five (5) current color photographs from various angles of the
  property/project site and minimum of two (2) current color photographs of adjacent properties – at least
  3” x 5” and no larger than 8” x10”. Attach or print photos on 8 ½” x 11” sheets of paper as Attachment
  B-6.
  O. Is a construction schedule available?               Yes (Please include as Attachment B-7)
                                                         No

  P. Are project designs available?                      Yes (Please include as Attachment B-8)
                                                         No

  Q. Are project cost estimates available?               Yes (Please include as Attachment B-9)
                                                         No




                                                                                                            B6
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

Exhibit C: Organizational Information (30 points)
Part 1 - Organizational Experience
  Provide an organizational overview of your agency, including:
  A. A description of the history and purpose of the organization




  B. Is the organization applying for funding incorporated?               Yes          No
     If so, what year was the organization incorporated?                    MM/DD/YEAR
     As a requirement of this application, please submit copies of your Articles of
     Incorporation as Attachment C-1.

     Please include 501 (c ) (3) documentation from the IRS as Attachment C-2.

  C. Provide the agency’s organizational chart as Attachment C-3.

  D. Provide the project organizational chart as Attachment C-4.

  E. Please list the staff members who will be working directly with the project. This information
     should match the information included on both the agency organizational and project
     organizational charts. Provide job descriptions as Attachment C-5 and resumes as
     Attachment C-6 for the persons listed below.
             Name and Title                Years of Relevant          Federal Grant Experience
                                          Program Experience




                                                                                                     C7
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

Part 2 – Previous Project Experience

  A. Are you aware of services or activities similar to your project provided by other
     organizations in Harris County?                       Yes              No
     If yes , how is your proposed project different or unique from other similar projects?
     Briefly explain in the space provided.




  B. Does the proposed project collaborate with other organizations in Harris County to
     provide this service?*               Yes            No
  *If the program is a collaborative effort with other existing programs, services or agencies
  explain the partnership(s) and if the partners are committed to the program.
  *If there is not a current partnership, explain how you will engage the partner(s) if one is
  proposed in the future?




  C. If requesting funding for healthcare facilities, is the organization a member of the
     Harris County Healthcare Alliance?                       Yes             No




                                                                                                 C8
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

Part 3 – Financial Leverage

  A. Indicate the funding for this project from other sources in the following table. For each
     funding source listed, attach a letter of funding commitment (dated no more than 6 months
     prior to the application) as Attachment C-7.

                                                            Status - Approved,
            Funding Source                  Amount                                  Award Date
                                                            Pending or Denied
                                                                                  MM/DD/YEAR
                                                                                  MM/DD/YEAR
                                                                                  MM/DD/YEAR
                                                                                  MM/DD/YEAR
                                                                                  MM/DD/YEAR

                  Total                        0

  C. Describe your 90-day working capital for this project in the space below. Indicate the source
  of the working capital and attach documentation to the application providing evidence of the
  source as Attachment C-8.




                                                                                                     C9
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

Part 4 – Board of Directors
  Complete the table below for each current member of the applicant's Board of Directors
  and attach additional pages if necessary. (Not applicable for Government entities)

                                            Board of Directors

                                                                   Occupation/
      Board Member               Company Affiliation                                 Term*
                                                                 Area of Expertise




  *Beginning and ending years




                                                                                             C10
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

Part 5 – Conflict of Interest Disclosure
  All Applicants
  The standards in OMB Circular A-110, Subpart C, provide that no employee, officer, or agent shall participate in
  the selection, award, or administration of a contract supported by Federal funds if a real or apparent conflict of
  interest would be involved. Such a conflict would arise when an employee, officer, or agent, any member of his or
  her immediate family, his or her partner, or an organization which employs or is about to employ any of the parties
  indicated herein, has a financial or other interest in the firm selected for an award.

  CDBG and HOME Applicants Only
  The CDBG regulations at 24 CFR 570.611 and HOME regulations at 24 CFR 92.356 provide that no person who is
  an employee, agent, consultant, officer, or elected official or appointed official of the recipient or subrecipient that
  are receiving CDBG or HOME funds and (1) who exercises or has exercised any functions or responsibilities with
  respect to activities assisted with CDBG funds; or (2) who is in a position to participate in a decision-making
  process or gain inside information with regard to these activities, may obtain a financial interest from a CDBG-
  assisted or HOME-assisted activity, or have any interest in any contract, subcontract, or agreement with respect
  thereto, or the proceeds there under, either for themselves or those with whom they have family or business ties,
  during their tenure or for one (1) year thereafter.

  A disclosure of the nature of any perceived or actual conflict must be made prior to the execution of agreements
  utilizing CDBG or HOME.
  IF NO CONFLICT EXISTS, COMPLETE THE FOLLOWING:
      I certify that no conflict of interest exists between Harris County and (name of
      organization)
      I certify that no conflict of interest exists between the subcontractors of and name of
      organization)
  IF A CONFLICT EXISTS, COMPLETE THE FOLLOWING:
      I certify that a conflict of interest does exist between Harris County and name of
      organization)
      I certify that a conflict of interest does exist between (name of subcontractor)
                                 and (name of organization)
  Describe the nature of the conflict of interest below. Identify the individual, employment and the
  conflict or potential conflict, and their affiliation with your organization.




  Signature of Authorized Agency Official                                                            Date


  Typed Name and Title

                                                                                                                         C11
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

  CONFLICT OF INTEREST QUESTIONNAIRE                                                                        FORM CIQ
  For vendor or other person doing business with local governmental entity                         OFFICE USE ONLY

  This questionnaire is being filed in accordance with chapter 176 of the Local                    Date Received
  Government Code by a person doing business with the governmental entity

  By Law this questionnaire must be filed with the records administrator of the
   local government not later than the 7th business day after the date the person
  becomes aware of facts that require the statement to be filed. See Section
  176.006, Local Government Code.

  A person commits an offense if the person violates Section 176.006, Local
  Government Code. An offense under this section is a Class C misdemeanor.

  1. Name of person doing business with local governmental entity.

  2.
       Check this box if you are filling an update to a previously filed questionnaire.
  (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later
  than September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is
  pending and not later than the 7th business day after the date the originally filed questionnaire becomes
  incomplete or inaccurate.)

  3. Describe each affiliation or business relationship with an employee or contractor of the local
     governmental entity who makes recommendations to a local government officer of the local
     governmental entity with respect to expenditure of money.




  4. Describe each affiliation or business relationship with a person who is a local government
     officer and who appoints or employs a local government officer of the local governmental
     entity that is the subject of this questionnaire.




                                                                                                                       C12
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

  CONFLICT OF INTEREST QUESTIONNAIRE                                                                          FORM CIQ
  For vendor or other person doing business with local governmental entity                                      Page 2
  5. Name of local government officer with whom filer has affiliation or business relationship.
     (Complete this section only if the answer to A, B, or C is YES.)

       This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has
       affiliation or business relationship. Attach additional pages to this Form CIQ as necessary.

       A.   Is the local government officer named in this section receiving or likely to receive taxable income from the
            filer of the questionnaire?        Yes         No
       B.   Is the filer of the questionnaire receiving or likely to receive taxable income from or at the
            direction of the local government officer named in this section AND the taxable income is not
            from the local governmental entity?                Yes         No
       C.   Is the filer of this questionnaire affiliated with a corporation or other business entity that
             the local government officer serves as an officer or director, or holds an ownership of
            10 percent or more?                     Yes         No
       D.   Describe each affiliation or business relationship.




  6. Describe any other affiliation or business relationship that might cause a conflict of interest.




  7.


       Signature of person doing business with the governmental entity                                 Date




                                                                                                                         C13
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

  LOCAL GOVERNMENT OFFICER                                                                                                       FORM CIS
  CONFLICTS DISCLOSURE STATEMENT
  This is the notice to the appropriate local governmental entity that the                                            OFFICE USE ONLY
  following local government officer has become aware of facts that require the
  officer to file this statement in accordance with chapter 176, Local Government                                     Date Received
  Code.
  1. Name of Local Governmental Officer



  2. Office Held



  3. Name of person described by Sections 176.002(a) and 176.003(a), Local Government Code



  4. Description of the nature and extent of employment or business relationship with person named in Item 3




  5. List gifts if aggregate value of the gifts received from person named in item 3 exceeds $250

  Date Gift Received                                      Description of Gift                                         Did Not Accept Gift
  Date Gift Received                                      Description of Gift                                         Did Not Accept Gift
  Date Gift Received                                      Description of Gift                                         Did Not Accept Gift

  6. AFFIDAVIT
                                                          I swear under penalty of perjury that the above statement is true and correct. I
                                                          acknowledge that the disclosure applies to a family member (as defined by
                                                          Section 176.001(2), Local Government Code) of a government officer. I also
                                                          acknowledge the statement covers the 12-month period described by Section
                                                          176.003(a)(2)(b), Local Government Code.


                                                                                      Signature of Local Government Officer

  AFFIX NOTARY STAMP/SEAL ABOVE
  Sworn to and subscribed before me, by the said                                      , this the                     day of
            ,20                 , to certify which, witness my hand and seal of office.



  Signature of officer administering oath                 Printed name of officer administering oath      Title of officer administering oath




                                                                                                                                                C14
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program
Exhibit D – Statement of Work/Scope of Services (25 Points)
Part 1 – Program Development and Delivery (Use only the space provided.)
  A. Work Plan
      ● What are the hours of operation?




      ● Please detail your intake procedures and how you will utilize the Harris County
        Individual Eligibility Form (located in the Guidebook) in your documentation
        process?




      ● Describe your recruitment/marketing plan for clients and volunteers.




      ● Explain your project evaluation plan.




                                                                                          D15
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

   ● Do you currently have a policy and procedures manual?

          Yes            No

     If yes, please attach any portion of the manual that relates to the program as
     Attachment D-1.
     If no, please indicate when you plan to have them written.




   ● State how your organization will involve at least one homeless or formerly homeless
     in a decision making position.




                                                                                           D16
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

B. Time Table and Service Activity Table

   1. Time Table
      Outline project plan activities/events that will take place each month of the award
      period. This information will be used to structure the scope of services portion of
      the agreement with Harris County.

   2. Service Activity Table
      Activities are the measurable objectives of the program directly funded with Harris
      County grant funds. Service units should be defined in measurable terms, such as one
      hour of child care, one three-hour counseling session, number of food packets
      distributed, or number of immunizations provided. Do not include activities that are part
      of the program and are solely funded through other sources.
       For each Service Activity, include:
               a brief description of the activity,
               whether the service is new or a current service, and
               the unit costs associated with each Service Activity.

       The Cost Per Unit of Service is calculated on the budget forms. See Exhibit E – Budget
       Summary in the budget forms for the Unit Cost for each activity.

       Note that the Total Harris County Project Cost should equal the amount requested in Line
       1 of the Program Funding Table under Part 3 of Tab 2.




                                                                                                  D17
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program

   Time Table
   Outline project plan activities/events that will take place each month of the award period.
   This information will be used to structure the scope of services portion of the agreement
   with Harris County

   Month of                Activity/Action

   Month:
   March 2009
   Contract Begins
   Month:


   Month:


   Month:


   Month:


   Month:


   Month:


   Month:


   Month:


   Month:


   Month:


   Month:
   February 2010
   Contract Ends




                                                                                                 D18
  Harris County Unsolicited Application
  Emergency Shelter Grants (ESG) Program

     Service Activity Table

  **For each activity please select either: New Project – Any activity not currently funded by Harris County,
  Expansion – An established activity currently funded by Harris County Funds or Renewal – Current activity
  funded by Harris County. The proposed activity must directly benefit low-income persons served.



                                                     Total Units of
                                Units of Service                    Cost per Unit of        Total Cost
        Service Activity                              Service per
                                  per Month                            Service               per year
                                                         Year

Activity 1:




  New     Expansion   Renewal

Activity 2:




  New     Expansion   Renewal




                                                                                                           D19
 Harris County Unsolicited Application
 Emergency Shelter Grants (ESG) Program
Exhibit E: Project Budget Information (28 Points)
Part 1- Entity-wide Financial Management & Systems Questionnaire
 A. Please describe your organization’s fiscal management practices & systems related to
 financial reporting, accounting systems, financial capacity, budgetary and internal controls and
 audit requirements by completing the Financial Management questionnaire below.
                                               FINANCIAL MANAGEMENT
                                                   (QUESTIONNAIRE)
                                                  YES      NO            COMMENT
 ACCOUNTING SYSTEM:
 1. Does your organization have and
 maintain a standard chart of accounts?
 2. Does your accounting system include a
 project cost ledger that can be used for
 recording expenditures for “each” program
 by required budget cost categories?
 3. How do employees account for their
 time and effort? Please explain.
 FINANCIAL CAPABILITY:
 1. Does your organization prepare annual
 financial statements?
 2. Are those financial statements reviewed
 formally and approved/accepted by your
 Board or Officers?
 3. Are the financial statements subject to
 an annual Audit?
 4. Describe which basis of accounting your
 organization uses, e.g. (accrual, cash, or
 other) and what authoritative guidance
 your organization relies for accounting for
 general and grant funded activities.

 5. Has the organization established line(s)
 of credit? If so, identify source and
 amount.
 BUDGETARY CONTROLS:
 1. Are there budgetary controls in effect
 (e.g. comparison of budget with actual
 expenditures on a monthly basis) to
 preclude exceeding budgetary limitations?

 2. Are all purchases made by PO whereby
 that encumbers/earmarks funds available
 for use?
 3. Does someone in your organization
 periodically perform analysis and
 recommends/makes adjustments to
 budgetary spending levels due to
 identification of unforeseen or potential
 cash flow problems resulting from the
 analysis? If so, name the
 person(s)/position(s) responsible for these
 activities                                                                               Page F20
 INTERNAL CONTROLS
 1. Are there written procedures for the
 following?
   a.Accounting entries are supported by
   appropriate documentation; e.g.
   purchase orders and vouchers.
   b.Separation of responsibility in the
   receipt, payment, and recording of cash.

   c.Procedures for procurement and
   practices are consistent with applicable
   governing regulations.
   d.Travel is reviewed and approved and
   consistent with program guidelines and
   applicable to job functions.
   e.Timekeeping and payroll functions
   having segregation, proper review,
   approval, and support documentation of
   hours worked by activity and program.
 f. Disclosures of Board, Officers or
    employees for related party
    transactions.
 2. Describe the safeguards your entity has
 instituted to ensure adequate internal
 controls in the company (e.g. Officially
 adopted policies and procedures, all
 expenses approved by board, documented
 and required annual review of policies).


Part 2 – Financial Statements (Not Applicable to Harris County Departments)
 A. Does organization have revenues in excess of $300,000?              Yes            No
     If yes, you MUST attach an audit performed by a Certified Public Accountant, along with the
     organization’s most recently filed IRS Form 990 as Attachment E-1.
     Does organization have revenues less than $300,000?                Yes            No
     If yes, you MUST attach the organization’s most recently filed IRS Form 990, along
     with the items from either (a) or (b) as Attachment E-1:
         a) A set of Basic Financial Statements, which MUST include the industry equivalent of
            a Balance Sheet, Statement of Cash Flows, Income Statement and the Notes to the
            Financial Statements. These must have been certified as official financials and
            evidenced by a copy of the board minutes showing that they were presented and
            accepted as official financial statements by the entity’s board or governing body.
                                                   OR
         b) b) A compiled set of Basic Financial Statements, along with a letter that the
            compilation was performed in accordance with American Institute of Certified Public
            Accountants’ industry standards. The compilation must include the industry’s
            equivalent of the Balance Sheet, Statement of Cash Flows, Income Statement and
            the Notes to the Financial Statements.



                                                                                        Page F21
Harris County Unsolicited Application
Emergency Shelter Grants (ESG) Program
B. Did organization received more than $500,000 in Federal funding in the preceding year?
                          Yes          No
   If yes, please attach as Attachment E-2, a copy of your required “single audit”. If your audit
   has not been completed, please note when this audit is to be completed.
   Date:
C. Financial Statement & Single Audits Findings
   If there were findings noted in either your most recent Financial Statement audit or Single
   Audit, please describe the nature of the findings and what steps your organization has taken




                                                                                         Page F22
                CDBG/ESG Public Services
                     Budget Forms

                                     START:
                                 Form: Exhibit B -
                                 Budget Summary




 Complete the Yellow highlighted areas in Column A, Rows 7-9 with the name of
               each Activity (Counseling, Case Management, etc.)

   Also, complete Column C, Rows 7-9, with the number of units for each activity

   Each application must have a minimum of one activity and a maximum of two
                                   activities.




      Complete Column A, Lines 12-14, with the name of the entity providing the
     leverage for each activity. There may be more than one name on each line.




     Complete a Personnel and Non-Personnel form for each activity listed on
                            the Budget Summary.



                     Complete the Leverage Summary Form.

The total leverage for each activity must match the amounts that has been entered in
  the Personnel and Non-Personnel forms, which is summarized in the Combined
                                 Actvity Budget page.




                                   Save your work.
                                    Print the entire
                                      workbook.




                                                       Harris County Community Services Department
                                                                      PY2009 Request for Proposals
                                    Public Services Budget Summary
                           Program Year:               2009

                         Name of Project:
                                               Activity   No. of       Direct           HCCSD         LEVERAGE        TOTAL            HCCSD
                                                                                         Award                       PRGM/ACT
1. Grant Funds Requested by Activity             No.      Units        Costs            (Share)                       COSTS           Unit / Price

                                                  1        n/a                  -   $         -            -     $            -   $            -

                                                  2        n/a                  -   $         -            -                  -   $            -
                                  Subtotals:                                    -   $             -   $    -     $            -
2. Summary of Funds from other sources                                                                                                  $
(Entity name and type) of funding              Activity   No. of                                                                  Contribution /
(Leveraging):                                   No.       Units                                                                       Unit

                                                  1        n/a                  -                                                 $            -

                                                  2        n/a                  -                                                 $            -
                                   Subtotal:                       $            -


                Summary of Project Funding

Harris County - Direct                                             $            -

Total Other Sources of Funding (Leveraging)                        $            -

Project Budget Total:                                              $            -
Harris County Percentage of Total Funding
(Harris County Grant Funds / Total Revenues of Activities)                 0.00%
Important note to this form: For Activity lines not used (above), you must insert "n/a" in the "No. of Units" field
in order for the form to calculate properly.




                                                                                              Harris County Community Services Department
                                                                                                             PY2009 Request for Proposals
                                   Combined Activity Budget
Note: You should complete one set of budget forms for each billable activity listed in your RFP
Your grant application may include multiple deliverables (activities) which will ultimately be billed to
HCCSD in terms of units and unit costs.

Service Activity #                                          1

Activity; Title / Description:                                                                                 -



Number of Units to be Provided:                            n/a

                                                     Harris County          Leveraging
              Expense Category                       Grant Funds              Funds             TOTAL BUDGET

Personnel                                           $             -     $             -     $              -
Professional Fees/Contract Services                               -                   -     $              -
Travel                                                            -                   -     $              -
Lease Space                                                       -                   -     $              -
Consumables and Supplies                                          -                   -     $              -
Rent, Lease Equipment                                             -                   -     $              -
Other (telephone, insurance, office content,
bond insurance)                                                   -                   -     $              -
Total Activity Cost:                                $             -     $             -     $              -
Unit Cost:                                          $             -



Service Activity #                                          2

Activity; Title / Description:                                                                                 -


Number of Units to be Provided:                            n/a

                                                     Harris County          Leveraging
              Expense Category                       Grant Funds              Funds             TOTAL BUDGET

Personnel                                           $             -     $             -     $              -
Professional Fees/Contract Services                               -                   -     $              -
Travel                                                            -                   -     $              -
Lease Space                                                       -                   -     $              -
Consumables and Supplies                                          -                   -     $              -
Rent, Lease Equipment                                             -                   -     $              -
Other (telephone, insurance, office content,
bond insurance)                                                   -                   -     $              -
Total Activity Cost:                                $             -     $             -     $              -
Unit Cost:                                          $             -




                                                                      Harris County Community Services Department
                                                                                     PY2009 Request for Proposals
                                                  Personnel Detail
                                                                                                                        2009
Service Activity #              1
Activity:                                                                                                 -


                                          Monthly         No. of           Harris County      Other Sources
Position                  FTE             Salary          Months           Grant Funds         of Funding         TOTAL
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                 Salary Subtotal $                     -      $           -   $           -
Fringe Benefits
FICA (7.65%)                                                                           -                                  -
Fringe Benefits                                                                                                           -
Worker's Compensation (not to exceed 5%)                                                                                  -
Insurance                                                                                                                 -
Retirement                                                                                                                -
                                      Fringe Benefits Subtotal $                       -      $           -   $           -
                                    Operations Personnel Total $                       -      $           -   $           -



                                                                                                                        2009
Service Activity #              2
Activity:                                                                                                 -


Please note:
You should include only those personnel, or portion of FTE that contributes directly to the production of
an activity's unit cost. Personnel, such as a counselor, food preparer or individual that directly supports
another individual that is "direct"ly responsible for counseling or serving a program participant is an
example of Direct personnel costs that should be considered in arriving at unit costs.



                                          Monthly         No. of           Harris County      Other Sources
Position                  FTE             Salary          Months           Grant Funds         of Funding         TOTAL
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                                                       -                                  -
                                                 Salary Subtotal $                     -      $           -   $           -
Fringe Benefits
FICA (7.65%)                                                                           -                                  -
Fringe Benefits                                                                                                           -
Worker's Compensation (not to exceed 5%)                                                                                  -
Insurance                                                                                                                 -
Retirement                                                                                                                -
                                      Fringe Benefits Subtotal $                       -      $           -   $           -
                                    Operations Personnel Total $                       -      $           -   $           -


                                                                              CEDD                OTHER       TOTAL FTE(S)
SAL ALL ACTIVITIES:                                                    $               -      $           -   $        -
BENEFITS ALL ACTIVITIES                                                $               -      $           -   $        -
SAL & PAY EXP & BEN FOR ALL ACTIVITIES:                                $               -      $           -   $        -
FTE'S ALL ACTIVITIES                                                                   -                  -        0



                                                                                           Harris County Community Services Department
                                                                                                          PY2009 Request for Proposals
                                                                Non-Personnel Detail
Costs for Activity No.                                                                                   1
Activity :                                                                                                                                             -


                                                                                                   Harris County       Leveraging
                                              Expense                                              Grant Funds           Funds              TOTAL
Professional Fees/Contract Services (Ineligible shelter cost)
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                         Subtotal $           -    $            -    $                 -
Travel & Training (Ineligible shelter cost)
Type of Training
                                                                                                                                     $                 -
                                                                                                                                     $                 -
Type of Travel (non-mileage)                                                                                                         $                 -
                                                                                                                                     $                 -
                                                                                                                                     $                 -
                                                                                                                                     $                 -
Mileage:

___ mi./mo. x ___ mos. x 50.5 cents/mi.                                                                                              $                 -
                                                                                         Subtotal $           -    $            -    $                 -
Building leases/rent/utility expenses
Space Costs (provide location):
Location:                                                                                                                                              -
Rent: ___ sq. ft. @ $___ /ft./year                                                                                                                     -
Utilities $ / month x's months                                                                                                                         -
                                                                                                                                                       -
Utilities:                                                                                                                                             -
Electricity                                                                                                                                            -
Water                                                                                                                                                  -
Telephone                                                                                                                                              -
Other Utilities:                                                                                                                                       -
                                                                                         Subtotal $           -    $            -    $                 -
Consumable Supplies (describe)
                                                                                                                                                       -

                                                                                                                                                       -
                                                                                                                                                       -
                                                                                         Subtotal $           -    $            -    $                 -
Rent, Lease of Equipment and Furniture (Ineligible shelter cost)

                                                                                                                                     $                 -
                                                                    Rent, Lease Furniture Subtotal $          -    $            -    $                 -
Other Costs (Ineligible shelter cost)
Direct Audit Costs                                                                                                                                     -
Postage                                                                                                                                                -
Direct payments / benefits to clients                                                                                                                  -
Program specific insurance                                                                                                                             -
Rental Assistance                                                                                                                                      -
Other (specify)                                                                                                                                        -
Other (specify)                                                                                                                                        -
                                                                           Other Costs Subtotal $             -    $            -    $                 -
                                                                     Non-Personnel Detail Total $             -    $            -    $                 -




                                                                                                         Harris County Community Services Department
                                                                                                                        PY2009 Request for Proposals
                                                                Non-Personnel Detail
Direct Costs for Activity No.                                                                            2                                   2009
Activity :                                                                                                                                             -


                                                                                                   Harris County   Leveraging
Expense                                                                                            Grant Funds     Funds            TOTAL
Professional Fees/Contract Services (Ineligible shelter cost)
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                         Subtotal $           -    $            -    $                 -
Travel & Training (Ineligible shelter cost)
Type of Training
                                                                                                                                                       -
                                                                                                                                                       -
Type of Travel (non-mileage)                                                                                                                           -
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                                                                                       -
Mileage:                                                                                                                                               -

___ mi./mo. x ___ mos. x 50.5 cents/mi.                                                                                                                -
                                                                                         Subtotal $           -    $            -    $                 -
Space Costs (provide location)
Location:                                                                                                                                              -
Rent: ___ sq. ft. x $___ /ft./year                                                                                                                     -
Utilities: $__ / month x __ months                                                                                                                     -
                                                                                                                                                       -
Utilities:                                                                                                                                             -
Electricity                                                                                                                                            -
Water                                                                                                                                                  -
Telephone                                                                                                                                              -
Other Utilities                                                                                                                                        -
                                                                                         Subtotal $           -    $            -    $                 -
Consumable Supplies
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                                                                                       -
                                                                                         Subtotal $           -    $            -    $                 -
Rent, Lease of Equipment and Furniture (Ineligible shelter cost)

                                                                                                                                     $                 -
                                                                    Rent, Lease Furniture Subtotal $          -    $            -    $                 -
Other Costs (Ineligible shelter cost)
Direct Audit Costs                                                                                                                                     -
Postage                                                                                                                                                -
Direct payments / benefits to clients                                                                                                                  -
Program specific insurance                                                                                                                             -
Rental Assistance                                                                                                                                      -
Other (specify)                                                                                                                                        -
Other (specify)                                                                                                                                        -
                                                                           Other Costs Subtotal $             -    $            -    $                 -
                                                                     Non-Personnel Detail Total $             -    $            -    $                 -




                                                                                                         Harris County Community Services Department
                                                                                                                        PY2009 Request for Proposals
                                      Summary of Match/Leveraged Funds By Activity

                                                                                           Activity 1


                                                                  Match/
                     Expense Category                           Leveraging          Description / Name of Source                      %

Personnel                                                               -

Professional Fees/Contract Services                                     -

Travel                                                                  -

Lease Space                                                             -

Consumables and Supplies                                                -

Rent, Lease Equipment                                                   -

Other (telephone, insurance, office content, bond insurance)            -

Total Activity 1 Leverage:                                              -



                                                                                            Activity 2


                                                                  Match/
                     Expense Category                           Leveraging          Description / Name of Source                      %

Personnel                                                       $       -

Professional Fees/Contract Services                                     -

Travel                                                                  -

Lease Space                                                             -

Consumables and Supplies                                                -

Rent, Lease Equipment                                                   -

Other (telephone, insurance, office content, bond insurance)            -

Total Activity 2 Leverage:                                      $       -


**Sources for match must correspond with documentation provided as Attachment C-7




                                                                                        Harris County Community Services Department
                                                                                                       PY2009 Request for Proposals
                              Rehab Project Summary

                Description                       HCCSD       Match       TOTAL
Project Costs
  I. Rehabilitation, Renovation or Conversion $       -   $       -   $        -



                                                     Project Detail
                                                                                    Description / Name of Source for
                                               HCCSD          Match       TOTAL                   Match
                                             Direct Construction/Rehab Costs
Concrete                                                                $     -
Masonry                                                                 $     -
Metals                                                                  $     -
Woods and Plastics                                                      $     -
Thermal and Moisture Protection                                         $     -
Roof Covering                                                           $     -
Doors and Windows                                                       $     -
Finishes                                                                $     -
Specialties                                                             $     -
Equipment                                                               $     -
Furnishings                                                             $     -
Special Construction                                                    $     -
Conveying Systems (Elevators)                                           $     -
Mechanical (HVAC; Plumbing)                                             $     -
Electrical                                                              $     -
Lead-Based Paint Abatement                                              $     -
Asbestos Abatement                                                      $     -
Utility Connections                                                     $     -
Common Laundry & Community Facility
Rehab & Construction                                                    $      -
Landscaping                                                             $      -
Other Common Area Rehab                                                 $      -
Other (specify)                                                         $      -
Subtotal Direct Construction & Rehab:      $        -    $         -    $      -
Contingency - (10%)                                                     $      -
Subtotal "Other Direct" Construction & Rehab:
                                           $        -    $         -    $      -
                   Total                   $        -    $         -    $      -
**Sources for match must correspond with documentation provided as Attachment C-7
Cash Flow Projections
(fill in all highlighted fields with numeric values)

Starting Date:

                                                                             Y1
                                                         Q-1        Q-2             Q-3        Q-4
                                                       Estimate   Estimate        Estimate   Estimate
Cash in Bank (prior month's ending cash position)
Cash Receipts
 Taxes
 Special Revenues & Grants
 Other cash infusion from other sources                      -          -
Total Cash Receipts                                          -          -               -          -
Total Cash On-Hand                                           -          -               -          -

Cash Paid Out
  Purchases
  Salaries
  Payroll taxes
  Outside services
  Rent
  Utilities
  Insurances
  Taxes
  Interest
  Loan payments
  Lease payments
  Other expenses
  Other misc, exemptions, rebates
Total Cash Paid Out                                          -          -               -          -

Cash Position                                                -          -               -          -
  Y2         Y3         Y4         Y5

Estimate   Estimate   Estimate   Estimate




       -          -          -          -
       -          -          -          -




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