Kern County Emergency Food and Shelter Program

Phase 32

Local Recipient Organization (LRO) Funding Application

Agency Information

Name of Organization:	Website:

Street Address:	Congressional District:

City:	State: Zip Code: + ZIP+4 is required

Mailing Address (If different):

City:	State: Zip Code: + ZIP+4 is required

Federal Tax I.D. #:	DUNS #:	LRO #: 068400- (If new applicant, leave blank)

Name of Responsible Officer or CEO/Executive Director:

Telephone: ( )	Fax: ( )	E-mail:

Name of EFSP Program Contact:

Telephone: ( )	Fax: ( )	E-mail:

Funding Request

Service Category	Amount Requested
Served Meals	$
Other Food	$
Mass Shelter	$
Other Shelter	$
Supplies/Equipment	$
Emergency Repairs/Building Code	$
Rent/Mortgage	$
Utilities	$
Administration*	NOT APPLICABLE
TOTAL REQUEST	$

*Administration is not allowable except for use by the Administration Offices of the Kern County Local Board.

Emergency Food & Shelter Program Application

Phase 32

Is your organization a new, previous, or current recipient of the Emergency Food and Shelter funds? (Please check the appropriate box)

New Applicant	Previous (Not in Phase 31)	Current

How do you propose to allocate each category of funding to different areas of Kern County served by your organization? Provide a BRIEF explanation of your rationale.

Funding Category	Location	Amount Requested	Explanation
Ex: Rent/Mortgage	Ridgecrest /East Kern	$50,000	This area is in need of rent/mortgage assistance as a result of recent military base closures.

How many members are currently on your Board of Directors?
How many vacancies are there currently? How often does the board meet?
(Attach current board list, with affiliations)

Describe in detail the criteria used to determine client eligibility for EFSP aid. (Relevant documents may be attached)

In cases where you are unable to provide assistance (Through EFSP or other funding), to what other agencies or government assistance programs, if any, do you make referrals?

How does your organization plan to administer the Emergency Food and Shelter Program? (Provide a brief explanation of staffing (include titles), use of volunteers if any, intake procedures, how referrals will be made/received, etc.)

Does your organization receive funding from other sources for the same services for which you seek EFSP funding? Yes	No
If yes, what is the source? Amount:
a. Number of individuals served through resources other than EFSP.
b. Individuals you were unable to serve who were referred to other organizations.
c. Individuals you were unable to serve who could not be referred. (Please break down by each category of assistance such as Served Meals, Other Food, Utilities, etc.)
d. Please indicate the method used to determine unmet needs/people not served.

Provide the methodology used to count service units. (e.g. Is a family of five one service unit or five? If three days of service is provided to that family of five, is the service unit count 3 or 15? Are snacks counted as meals?)

Please provide all sources of income to the organization, (including federal, state or local government; special events; corporate and individual giving; and program revenue) the amounts of each and the projects those funds will be used for. (An attachment may be made.)

As part of this application process, all applicants are required to update their agency’s profile (range of programs & services, contact telephone numbers, etc.) with 2-1-1 Kern County, to ensure referrals are given effectively to clients in need. Please give the date within the last 30 days when your agency called 2-1-1 at either of its Business Office Numbers (661-395-2495 or 395-2496) to update your agency’s profile. Date Called

Required Attachments: One copy required unless noted

Internal Revenue Service determination of 501(c)(3) charitable status

List of current board members and officers, with affiliations

Current year operating budget (2)

Most recent CPA audit or review (2)

Rules & Regulations

Recipient agencies must maintain a separate bookkeeping system, and it is recommended a separate checking account be maintained for the EFSP Allocation.

Agencies must use the most cost effective approach in buying or leasing items or services (hotel providing lowest rates, discount grocer, etc.).

The priority of the Kern County Local EFSP Board is for current, urgent needs for food and shelter, not for prevention.

The Kern County Local EFSP Board will not authorize spending of funds on costs that differ from those allowed in the Local Board Plan, unless a request is made in advance and approved by the Kern County Local EFSP Board in writing. (See Appendix for current allowable costs)

In order to avoid duplication of benefits, agencies are required to report expenditures weekly (for Shelter, Utilities and Rent/Mortgage assistance), accept only original bills for utilities, and original eviction notices Copies are not acceptable. LROs must retain originals, and give the client a copy.

Individuals who have received assistance under previous program phases may again be recipients, providing they meet local eligibility standards and are proven in need of funding assistance.

Questions concerning cost eligibility or program procedures should be directed to United Way of Kern County, administrative arm of the Kern County Local EFSP Board.

Funds cannot be reserved for anticipated future needs in lieu of providing immediate assistance.

Funds will be re-allocated to another agency if the Kern County Local EFSP Board determines the Local Recipient Organization is unable to effectively utilize full award or funds are not being distributed according to the EFSP program guidelines.

The Kern County Local EFSP Board may make periodic visits to Local Recipient Organizations facilities to monitor programs.

Local Recipient Organization’s usual and customary client eligibility for assistance might not apply to EFSP assistance. If there is a conflict between the LRO’s eligibility criteria and EFSP criteria, EFSP criteria shall govern.

If an agency will not expend the allocation by the end of the funding period, they are to notify the Kern County Local EFSP Board in writing, 30 days in advance of the end of the funding period designated date, so funds may be re-allocated to an agency with greater need. An agency returning funds at the end of the period, without sufficient cause for not expending, may or may not be eligible to receive future funding.

Misuse of funds will result in loss of award and possible reimbursement to the EFSP National Program.

Recipient agencies must have a formal method of record keeping.

I have read the above and agree to abide by the Rules and Regulations of the Kern County Local EFSP Board. All questions in this application must be completed. Failure to fully complete this application and all requests will eliminate application from consideration.

Agency:

Signed By:	Signature:_______________________________________________

Title:	Date:

Certification Form

As a recipient of Emergency Food and Shelter National Board Program funds made available for Phase 32 and as the duly authorized representative of , I certify that my organization:

Has the capability to provide emergency food, utility, and/or shelter services;

Will use funds to supplement and extend existing resources and not to substitute or reimburse ongoing programs and services;

Is nonprofit 501(c)(3) or an agency of government;

Has an accounting system or a fiscal agent approved by the Kern County Local Emergency Food and Shelter Board;

Conducts an independent annual audit if receiving $50,000 or more in Federal funds; A CPA’s review is required for any LRO receiving from $25,000 to $49,999.

Understands that cash aid payments are not allowed under EFSP;

Has a Federal Employer Identification Number (FEIN);

Does not discriminate on the basis of age, race, sex, religion, national origin, disability, economic status or sexual orientation. An agency may not require attendance at religious services as a condition of assistance, nor will such groups engage in any religious proselytizing in any program receiving EFSP funds)

For private voluntary organizations, have a volunteer board.

Will comply with the Phase 32 Rules and Responsibilities Manual, and will inform appropriate staff or volunteers of EFSP requirements;

Will provide all requested or required reports to the Kern County EFSP Board by the deadlines set forth;

Will expend funding only on eligible costs and keep complete documentation (copies of canceled checks – front and back, invoices, receipts, etc.) on all expenditures for a minimum of three years;

Will spend all funds and close out the program by the jurisdiction’s selected end-of-program date, and return any unused funds to the National Board ($5.00 or more); make checks payable to United Way Worldwide/Emergency Food and Shelter National Board Program.

Will close all separate bank accounts/bookkeeping accounts (or bring to a zero balance) and provide complete documentation of expenses to the Kern County Local Emergency Food and Shelter Program Board, if requested, no later than one month following the jurisdiction’s selected end-of-program date;

Will comply with the Office of Management and Budget Circular A-133 if receiving $300,000 or more in Federal funds.

If applicable, will comply with lobbying prohibition certification and disclosure of lobbying activities if receiving more than $100,000 in Emergency Food and Shelter Program funds; and

That this organization has no known compliance exceptions under Emergency Food and Shelter, and is not debarred or suspended from receiving Federal funding.

Signature:______________________________ Name/Title:

OrganizationName:

Federal Tax ID#:	Jurisdiction & LRO #068400- (N/A for new applicants)

Note: Selection of LROs and eligible cost guidelines are defined in the Local Recipient Organization section of each funding phase’s manual.

Lobbying Certification Form

Certification for Contracts, Grants, Loans, and Cooperative Agreements

The undersigned certifies, to the best of his or her knowledge and belief, that:

No Federal appropriated funds have been paid or will be paid by or on the behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, contribution, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

068400-

Organization Name	Jurisdiction & LRO # (If current or past—not new—LRO)

________________________________________

Name	Signature	Date

Kern County Emergency Food & Shelter

Phase 32 Application

APPENDIX

Client Eligibility

The EFSP is a needs based program, for which clients must qualify.

The National Board does not set client eligibility criteria. Local Boards may choose to set such criteria. If the Local Board does not set eligibility criteria, the LRO may use its existing criteria or set criteria for assistance under this award. Any criteria used must provide for assistance to needy individuals without discrimination (age, race, sex, religion, national origin, disability, economic status or sexual orientation), sensitivity to the transition from temporary shelter to permanent homes and attention to the specialized needs of homeless individuals with mental and physical disabilities and illness and to facilitate access for homeless individuals to other sources of services and benefits. In providing assistance under the EFSP, verification of proof of citizenship or qualified alien status of any applicant for assistance is not required. Note: Funds allocated to a jurisdiction can only be used for permanent residents and transients within that jurisdiction. (SOURCE: EFSP Manual)

The Kern County Local Board has not established specific eligibility criteria. LRO criteria must comply with Federal non-discrimination law as described in Item 8 on the Certification Form. The Local Board may consider an LRO’s eligibility criteria in allocating funds.

A Social Security Number may not be required as a condition of assistance. LROs should not collect SSNs, nor may they deny aid based on citizenship or documentation status. Do not report Social Security Numbers on weekly reports.

Allowable Costs for Mass Shelter and Served Meals

LROs may choose reimbursement of actual direct eligible costs or per diem/per meal allowance.
If choosing the latter, the allowable rates for Phase 32 are:

Mass Shelter: $12.50 per person per night

Served Meals: $2 per meal