Complete the table below for the proposed activity(s) included in this Application. This information should match the budget information in the Excel workbook Activity Project Name(s) and Address Total Application Amount Requested HMIS (Limited to 10% of Total Application amount) Grant Administration (Max amount- $200 -Local Indirect Costs (Limited to 10% of Total Application Amount or a higher percentage with letter from federal agency Example Emergency Shelter Mary’s House Harbor Day Center 123 Main St Any town, CA XXXXX $125,000 Emergency Shelter Street Outreach (Stand Alone Activity) Rapid Assistance HMIS Homelessness Prevention (limited to 10% of total application amount) Street Outreach “add-on” (limited to 10% of total application amount) Only)
Column B is total number of Individual Leavers who exited to any destination for the applicable activity in the reporting period. A Total # of Individual Leavers who exited to a Permanent Housing Destination: B Total # of Individual Leavers who exited to any destination: C A÷Bx100=C (%) Place supporting documentation behind Attachment F. System-Level Performance Data for the Proposed Activity Instructions: Reports submitted must be consistent with HUD’s May 2015 System Performance Measures guide. Data for Measures 1,2,3,5 and 7 must be submitted to HCD. Scoring will be based on a CoC’s ability to produce the information for the entire CoC Service Area. Place supporting documentation behind Attachment F. Measure 1: Length of Time Persons Remain Homeless: Measure 2a:The Extent to which Persons who Exit Homelessness to Permanent Housing Destinations Return to Homelessness within 6 to 12 months: Measure 2b: The Extent to which Persons who Exit Homelessness to Permanent Housing Destinations Return to Homelessness within 2 years: Measure 3: Number of Homeless Persons: Measure 5: Number of Persons who Become Homeless for the First Time: Measure 7a: Successful Placement from Street Outreach: Measure 7b: Successful Placement in or Retention of Permanent Housing: COST EFFICIENCY (10 Points) Instructions for Cost Efficiency analysis a) The following definitions should be used when completing this question. Individual Leavers:
Total 12-month Program Expenditures Divided by # of Individual Leaver Exits to a Permanent Housing Destination* Equals Average Cost per Permanent Housing Outcome / = *Should match the Project Level performance data provided in the Impact and Effectiveness section, Question 2, Column A SECTION VI– REQUIRED APPLICATION DOCUMENTS DOCUMENTS ATTACHED ATTACHMENTS DOCUMENTS LOCAL GOVERNMENT NON-PROFITS SERVING VICTIMS OF DOMESTIC VIOLENCE A Authorizing Resolution X X X B Statement of Certifications X X X ` C Certification of Local Approval N/A X X D Activity Summary X X X E Need for Funds and Certification Documentation X X X F HMIS or Comparable Database Reports X X X G Cost Efficiency X X X H Incorporation Documents N/A X X I Site Control (Emergency Shelter Applicants X X X J Payee Data Record X X X
ATTACHMENT C EMERGENCY SHELTER CERTIFICATION OF LOCAL GOVERNMENT APPROVAL (Private Non-Profits Only) Instructions: If the Emergency Shelter is located in a city, the Certification of Local Approval must be completed by the city. If the Project is located in the unincorporated area of a county, the Certification must be from the county. I, (Name and Title of City/County Official) , duly Authorized to act on behalf of (Name of City/County) , hereby approve of the operation of the following Emergency Shelter(s) (see list below) proposed by (Insert Name of Applicant) which is/are to be located/operated in (Name of City/County) . CERTIFICATION OF LOCAL APPROVAL PRINTED NAME OF CITY/COUNTY OFFICIAL TITLE
12-Month Program Expenditures Attach the complete 12-month expenditures for your program activity for the federal fiscal year 2014-15, (October 1, 2014 - September 30, 2015), or for those programs not in operation during this entire time period, the most recent 12-month period. The expenditures submitted should include HMIS, administration, and indirect costs associated with the requested activity. In the table below, provide the page number of your expenditure documentation where the specified data for each outcome measure can be found. Oct 1, 2014 – Sept 30, 2015 OR Most recent 12-month period. Total 12-month Program Expenditures pg. pg. ATTACHMENT H INCORPORATION INFORMATION (Private Non-Profits Only) Attach the following documents behind this page: Articles of Incorporation Evidence of IRS Tax-Exemption (501(c) Status) ATTACHMENT I EVIDENCE OF SITE CONTROL (25 CCR 8401) (Emergency Shelter Applicants)* Attach Site Control documentation as evidenced by one of the documents below: A deed (Demonstrating ownership in fee title)
INDIVIDUAL OR SOLE PROPRIETOR ENTER SOCIAL SECURITY NUMBER: — — (SSN required by authority of California Revenue and Tax Code Section 18646) 4 PAYEE RESIDENCY TYPE California resident—qualified to do business in California or maintains a permanent place of business in California. California nonresident (see reverse side)—Payments to nonresidents for services may be subject to State income tax withholding. No services performed in California. Copy of Franchise Tax Board waiver of State withholding attached. 5 I hereby certify under penalty of perjury that the information provided on this document is true and correct. Should my residency status change, I will promptly notify the State agency below. AUTHORIZED PAYEE REPRESENTATIVE’S NAME (Type or Print) TITLE SIGNATURE DATE TELEPHONE ( ) 6 Please return completed form to: Department/Office: Housing and Community Development - Financial Assistance Division Unit/Section: EMERGENCY SOLUTIONS GRANTS PROGRAM Mailing Address: 2020 West El Camino, MS 400 City/State/ZIP: Sacramento, CA 95833 Telephone: FAX: (916) 263-3391