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2. Name of Agency/Organization
3. Amount Requested
4. Date Submitted
   Date Submitted
6. Project Contact & Title
7. Email
8. Phone
10. Address
12. City
13. State
14. Zip Code
16. Website
17. Additional Contacts
19. My organization is applying for:

    1. CDBG Funds
    2. HOME Funds
20. I have received CDBG and/or HOME funds in the past:

    1. Yes
    2. No
21. Is the organization a non-profit, tax-exempt as defined by the Internal Revenue Service under U.S.C. 501(c) (3)?

    1. Yes

    1. No
23. Has the organization received $500,000 or more in federal funds for the current year?

    1. Yes
    2. No
24. Does the organization have written fiscal policies and procedures?

    1. Yes
    2. No
25. Does the organization have a process or procedure to assure no conflict of interest, real or apparent?

    1. Yes
    2. No
27. Council Priorities

    Indicate which Council Priority the program addresses:

    1. Affordable Housing (including but not limited to low income housing redevelopment, priority for households at 0-50% of the area median income)
    2. Support for the Homeless and those at risk of Homelessness
    3. Workforce Development (including but not limited to efforts to bolster Section 3 training opportunities and partnerships with the City’s GO programs, support for programs that aid in self-sufficiency
    4. Micro-enterprise Assistance
    5. Mental Health and Substance Abuse Services
    6. None of the above
29. Program/Project Goal
    Describe what you will provide, to whom, and how many. Identify the beneficiaries, including demographic information and how they meet the income guidelines (e.g.: “The goal of this project is to produce/provide products or services, output).
31. Need
    Explain how the program directly and specifically affects the goal/objective. Describe local needs the program addresses. Local data must be used to describe the overall community need and the specific needs of beneficiaries.
33. Outcomes
    Describe what changes you expect as a result of the project: (so the participants/beneficiaries can). Describe outcomes with numbers and percentages (resulting ultimately in). Explain how proposed outcomes will be meaningful, client-focused and related to the service.
35. Strategies
    Describe strategies that the program uses to directly and effectively address the identified needs. State how the expected outcomes will be accomplished. Explain if evidence-based strategies and/or researched best practices are used.
37. Implementation Timeline
    Explain in detail how the program will be implemented to meet the goals starting July 1, 2020 and ending June 30, 2021. Provide an explanation of the implementation efforts by quarters Quarter 1 (July 1 through October 15), Quarter 2 (October 16 through January 15), Quarter 3 (January 15 through March 15), Quarter 4 (March 16 through June 30). At a minimum, the applicant will explain how the program will be implemented, how many beneficiaries will be served, and how much funding will be expended per quarter.
39. Evaluation Plan
    How is the program evaluated locally? What metrics are used? Why do you use those metrics? In the past, how has your evaluation of your local program informed your decisions regarding how to improve your practices?
41. Demographic Verification
    Explain how you will collect and verify household demographic information (income, race, ethnicity, type and size of household, etc.).
43. Financial Benefits
    Demonstrate the financial benefits to the City, including: return on investment; leveraging additional funds in an effort to achieve sustainability; significant use of volunteers and staff resources.
45. Collaboration
    Explain how the program collaborates with other entities to decrease duplication and improve results (i.e. information sharing, shared resources, defined measurable, partnership agreements, joint marketing, memoranda of agreement).
47. Engagement/Outreach Strategy
    Describe the program’s engagement of high need and/or underserved populations. What is the outreach strategy? How effective is the strategy? How are program beneficiaries involved in program planning and governance? Applicants are encouraged to recruit beneficiaries from the Fiscal Year 2019 Priority Neighborhood (Ridge Street). Applicants who can demonstrate outreach strategies for targeting beneficiaries within these areas will receive additional points.
49. Organizational Capacity
    Please describe and provide evidence of the organization’s capacity to carry out the project and its ability to successfully manage federal grant funds. Explain how the organization will have the capacity to ensure timely performance, provide invoices in a timely manner (quarterly basis at a minimum), meet spending deadlines, provide quarterly reports and the final report on time and follow through with a monitoring visit. Organizations and projects that received CDBG/HOME funds in the previous program year will be evaluated by staff according to past performance. Organizations will be evaluated on projected outcomes and accomplishments from the previous grant year and organizational capacity.
51. Public Service Activities

    If applying for public services funds, this service is:

    1. A new service
    2. An existing service provided by or on behalf of the City with local or state funding
    3. An existing service not provided by or on behalf of the City of Charlottesville
53. Describe how the proposed service will be a quantifiable increase in the level of service.
55. Homebuyer & Rehab Activities
    For direct homebuyer assistance projects (downpayment or closing costs), describe the housing counseling required for first-time homebuyers and if your agency is a HUD approved housing counseling agency. Also describe how you verify that the unit meets building code. If not applicable, type N/A.
57. For homeowner or multi-unit rehab projects, describe how you will verify that the unit meets building code, how you ensure that units comply with the lead safe housing rule, and how you determine the after-rehabilitation value of housing units. If not applicable, type N/A.
59. Budget
61. Funding Sources/Revenues
62. Prior Fiscal Year
63. Current Year
64. Requested Amount Fiscal 2020 and 2021
66. Funding Sources/Revenues
67. Prior Fiscal Year
68. Current Year
69. Requested Amount Fiscal 2020 and 2021
71. Funding Sources/Revenues
72. Prior Fiscal Year
73. Current Year
74. Requested Amount Fiscal 2020 and 2021
76. Funding Sources/Revenues
77. Prior Fiscal Year
78. Current Year
79. Requested Amount Fiscal 2020 and 2021
81. Total
82. Total
83. Total
84. Total
86. Provide a line item budget of the program/project expenses. Identify the amount and source of all income/financing for proposed program/project. The proposed budget should clearly demonstrate how the requested funds will be applied to the expense line items, how the amount requested is reasonable, and that the overall program budget shows a direct relationship with proposed service items.
88. Funding Uses/Expenses
89. Amount
90. Source of Funding
92. Funding Uses/Expenses
93. Amount
94. Source of Funding
96. Funding Uses/Expenses
97. Amount
98. Source of Funding
100. Funding Uses/Expenses
101. Amount
102. Source of Funding
104. Total
105. Total
106. Total
108. Provide a budget narrative (if applicable):
Leave This Blank:


110. 1. Receive an email copy of this form.
111. Email address

     This field is not part of the form submission.

112. Submit

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