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Job Application Forms for Food Places document sample
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APPLICATION DUE: APRIL 9TH, 2010 at 3:00 PM
1. Agency Information
Name of Agency:
Agency's Federal ID #:
Agency's DUNS #:
Agency's Mailing Address:
Main Phone Number:
Main Fax Number:
Position Name Direct Line Email
Agency Director
Program Manager
HMIS Contact
Fiscal Contact
2. Program Site
Name of Program
Street Address:
City/Town:
State & Zip Code:
Hours of Operation:
Program Site: Owned
(Choose One) Leased
3. Program Information
Application Type: First Time Applicant (Estimate client numbers when applicable)
(Choose One) Repeat Applicant
Day Program/Drop-In Center
Emergency Apartment Program (Family or Couple Units )
Emergency Hotel/Motel Voucher Program
Emergency Shelter for the Homeless (incl. Operation First Step)
Homeless Prevention
Type of Program: Night-to-Night Shelter
(Choose One)
Specialized Shelter, Specify:
Supportive Service Only (Transportation Coordination, Legal Clinic, Services in
Housing (Limited), or Specialized Case M gmt)
Transitional Housing Facility (Limited)
Other Activity, Specify:
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4. Capacity Information
Total # of Units for Unaccompanied Individuals:
Total # of Units for Families:
Grand Total: 0
# of Unaccompanied
Unit Breakdown by Type # of Families Total
Adults
Single Room Occupancy 1 1
1 Bedroom 0
2 Bedroom 0
3 Bedroom 0
Total: 1 0 1
4a. Actual Number of Persons at a Given Point in Time (Average)
# of Unaccompanied Adults
Given Point in Time:
# of Families # of Adults in Families # of Children
Given Point in Time:
Total Number of Persons: 0
4b. Persons Served in 2009 Calendar Year (Jan 2009 - Dec 2009)
# of Unaccompanied Adults
Enrolled as of 1st Day
New Intakes
Exited
Currently Enrolled 0
# of Families # of Adults in Families # of Children
Enrolled as of 1st Day
New Intakes
Exited
Currently Enrolled 0 0 0
Total Persons Intaked: 0
Total Persons Exited: 0 2
5. Population Served
Indicate the approximate percentages of homeless participants served by the funded program
Population Type Percentage (%)
Unaccompanied Women
Unaccompanied Men
Single Parent Families
Two Parent Families
Adult Couples w/out Children
Total: 0% <- Should equal 100%
Indicate the approximate percentages of homeless sub-population served by the funded program
Sub-Population Categories Percentage (%)
Chronically Homeless (HUD Def)
Long-term Homeless Families
Chronic Substance Abusers
Veterans
Persons with HIV/AIDS
Victims of Domestic Violence
Other: ______________
5a. Prior Living Situation
Indicate the residency status for clients that ENTERED the program in the 2009 Calendar Year
Place of Last Residence # of Participants
In-State Living Situation
Out-of-State Living Situation:
Please list where clients slept in the week prior to their program entry (For each client, choose one place)
Living Situation All Chronic
Non-Housing (Street, park, car, bus station, etc.)
Emergency Shelter
Transitional Housing for Homeless Persons
Psychiatriac Facility*
Substance Abuse Treatment Facility*
Hospital*
Jail/Prison*
Domestic Violence Situation
Living with Relatives/Friends
Rental Housing
Other: _____________
Total: 0 0
*If a participant was living in an institution for 30 days (or less) and was living on the street or in an emergency shelter before entering the facility,
he/she should be counted in either the street or shelter catefory, as appropriate.
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6. Services & Agency Resources
Please mark all that apply with an X or client numbers
# of Clients
Provided # Clients Non-Written Written
Exited Who
Directly by Referred Agency Agency
Received
Agency Elsewhere Collaboration Collaboration*
Service
Case Management
Health/Medical
Job/Employment
Transportation
Mental Health
Legal
Education
Child Care
Substance Abuse
Housing Search
Domestic Violence
Counseling
Youth Services
Outreach
Rental/Utility Assistance
Other:________
Other:________
Duplicative Total: 0 0
* Only count collaborations that can be documented through MOU or support letters from collaborating agencies
Please list the following information for the ENTIRE AGENCY (Not just the Program)
# of Beds for
# of Units for
Housing Type Program Name(s) Unaccomp.
Families
Adults
Shelter
Transitional
Permanent Supportive
Total: 0 0
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7. Income and Mainstream Resources
Please complete for the number of participants that EXITED the program in the 2009 Calendar Year.
Monthly Income at ENTRY Monthly Income at EXIT
All Chronic % Of Total All Chronic % Of Total
No Income No Income
$1-$150 $1-$150
$151 - $250 $151 - $250
$251 - $500 $251 - $500
$501 - $1000 $501 - $1000
$1001 - $1500 $1001 - $1500
$1501 - $2000 $1501 - $2000
$2000+ $2000+
Total: 0 Total: 0
Income Sources At ENTRY Income Sources At EXIT
All Chronic All Chronic
Supplemental Security (SSI) Supplemental Security (SSI)
Social Security Disability (SSDI) Social Security Disability (SSDI)
Social Security Social Security
General Public Assistance General Public Assistance
Temporary Aid to Needy Families Temporary Aid to Needy Families
(TANF) (TANF)
State Children's Health Insurance State Children's Health Insurance
Program (SCHIP) Program (SCHIP)
Veterans Benefits Veterans Benefits
Employment Income Employment Income
Unemployment Benefits Unemployment Benefits
Veterans Health Care Veterans Health Care
Medicaid Medicaid
Food Stamps Food Stamps
Other (please specify) Other (please specify)
No Financial Resources No Financial Resources
Program Results
Number of Participants still in program that have improved income
Number of Participants still in program that have been placed in employment since entering program
Number of Participants that exited that improved monthly income
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7. Income and Mainstream Resources (Continued…)
Indicate the Level of Involvement of Homeless Individuals in the Operation of the Agency
Does your Agency….. Y/N
Have employed/salaried homeless/formerly homeless individuals in its CHF-funded Programs?
Have policies which directly involve homeless/formerly homeless individuals in the decision making process
(e.g. homeless representation on Board)?
Involvement homeless/formerly homeless individuals in the provision of supportive services to other
clients?
Have a specific procedure/form which assesses "client satisfaction" with the program at discharge?
Utilized homeless individuals in the maintenance responsibilities of the facility (non-salaried)?
8. Discharge
Please complete for the number of participants that EXITED the program in the 2009 Calendar Year.
Housing Status Upon Discharge All Chronic % of Total
Rental house or apartment (no subsidy)
Public Housing
Section 8
PERMANENT Shelter Plus Care 0%
HOME subsidized house or apartment
Other subsidized house or apartment
Homeownership
TRANSITIONAL Transitional housing for homeless persons
Psychiatric hospital
Inpatient alcohol or other drug treatment facility
INSTITUTION 0%
Jail/Prison
DCYF
EMERGENCY Emergency shelter (All types of emergency shelter
SHELTER facilities)
FAMILY & FRIENDS Moved in with Family/Friends
Other supportive housing
OTHER Places not meant for human habitation (e.g. street) 0%
Other (please specify)
UNKNOWN Unknown
Total: 0
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9. Fundraising/Fiscal Information:
Will your agency match funds awarded through this process? If yes, identify source(s).
Has your agency adopted a fundraising plan? Please briefly describe.
Does your agency have staff devoted to fundraising and grant writing (other than the Executive
Director)?
What percentage of your Agency's Budget is from non-government sources
(Federal/State/Local)? If yes, how much?
Does your agency charge program fees? If yes, how much?
Does your agency have mandatory savings for program participants? If yes, please describe.
What additional resources or technical support is needed to develop your agency's
fundraising/grant writing capacity?
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10. Detailed Budget Worksheet (PROGRAM BUDGET)
Applicant: 0
Program: 0
Please detail your PROGRAM'S PROJECTED Budget for the GRANT PERIOD
1. Personnel Estimated Hours Rate per Estimated Cost
(Include fringe in Rate per Hour) (Yearly) Hour
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
Total Personnel & Fringe Benefits Cost: $ -
2. Support Service & Quantity Unit Cost Estimated Cost
Direct Assistance Costs
$ -
$ -
$ -
$ -
$ -
$ -
Total SS & DA Cost: $ -
3. Operating Costs (YEARLY) Estimated Cost
Audit
Equipment
Fundraising
Furnishings
Housekeeping Supplies
Insurance
Legal
Maintenance
Office Expense
Program Expenses
Telephone/Internet
Training
Trash Removal
Total Operating Costs $ -
4. Administrative Costs (YEARLY) Estimated Cost
Total Administrative Cost $ -
Grand Total Estimated Cost: $ -
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11. Detailed Description of Program Funding for FY'2010
Please list your agency's source(s) of funding for your program (Not Entire Agency)
Program Funding for Fiscal Year Ending June 30, 2010
Federal (CDBG, Other Homeless Funds)
Total: $ -
State (Legislative Grants, other State Agencies)
Total: $ -
Local (City & Town Grants)
Total: $ -
Foundations (Donations such as United Way)
Total: $ -
Program Income (Revenues generated by the agency-such as program fees)
Total: $ -
Other
Total: $ -
GRAND TOTAL: $ -
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12. Additional Information
Please provide information on any discrepancies, changes in program services, target population, or
staffing, or any other issues you consider relevant to the evaluation of your program
ATTACHMENTS:
1. Resolution of the Board of Director or other body of the eligible provider authorizing
participation in the Consolidated Homeless Fund.
2. Agency's Overall Operating Budget
CERTIFICATION:
I certify that the information provided in this application is accurate to the best of my
knowledge.
Date
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