Download - Application I, Emergency Shelter ApplicantShelter stays should be avoided, if possible, and when not possible, limited to the shortest time necessary to help participants regain permanent

Application I, Emergency Shelter

HSOnlineApplicant (Agency) Legal Name

Contact Person

Contact Person Phone

Contact Person Email

HMIS Project Name

From the ESG regulations, “emergency shelter means any facility, the primary purpose of which is to provide atemporary shelter for the homeless in general or for specific populations of the homeless and which does notrequire occupants to sign leases or occupancy agreements.” In limited cases emergency shelter may includehotel/motel vouchers. Shelter stays should be avoided, if possible, and when not possible, limited to the shortesttime necessary to help participants regain permanent housing. Emergency shelter projects should be closelylinked to an array of projects within the community in order to accomplish this goal of stable permanent housingincluding, but not limited to, rapid re-housing, transitional housing, affordable housing placement, andemployment. Linkages should also be made to applicable mainstream projects such as SOAR, SNAP, TANF, etc

Applicant

List Primary Site Name(s) to be Utilized for Program: Local Approval(s) for This Project Submitted From:

NALocal Approval is Not Required for My Agency

HSOnline

000-0000

[email protected]

Name:

Name:

Name:

Street

City

Zip

Number of Sites

YES

NO

YES

NO

Currently Receives Funding

Suppress Address

* Please Note that Project Name should be EXACTLYas it appears in the HMIS system. It will be used byDCA to identify the project for scoring purposes, andin all future correspondence if a grant is awarded. Ifthis is a new project, please enter the project nameEXACTLY as you want it to appear in the HMISsystem.

Name(s)

Project Information

*ESG Amount Requested:

*Matching Funds:

*Total Budget:

$0.00

$0.00

$0.00

Applicants may apply for up to $60,000 in funding.*Budget and Cost Per Person Served are calculated fromBudget and Persons Served Sections of the Application


*2019 Projected Cost Per Person Served:

*Gray Text Boxes indicate these fields are prepopulated from calculations later in the application.

?

HUD Local Consolidated Plan Certification of Consistency for this program attached from:AlbanyAthens-ClarkeAtlantaAugusta-RichmondBrunswickCherokee County

Clayton CountyCobb County (including Marietta)Columbus-MuscogeeDaltonDeKalb CountyFulton County (including Roswell)

GainesvilleGwinnett CountyHenry CountyHinesvilleJohns CreekMacon Bibb County

RomeSandy SpringsSavannahValdostaWarner RobinsNA – BoS

Does this program exclusively serve victims of domestic violence?Are you applying for operating assistance?

Are you applying for supportive services?Are you also applying for HMIS funding for this program?

YES NOYES NOYES NOYES NO

HMIS Assistance Requested

ESG Funding

Match Funding

Total Funding for HMIS Data Entry

How many staff members will support HMIS efforts for this project in this grant year?

This year there will not be a separate HMIS application competition. 100% Match will still be required for anyHMIS award amount.

Briefly describe the data requirements for this project, including methods and timeframes for entering datafrom intake and assessment into the system. (500 Character Limit)


COMPLIANCE

Organizations that provide ESG funds for projects that serve families with children under age 18 may not denyadmission to any family based on the age of any child. Will you accommodate all families regardless of familialstatus?

1 Family Separation

If Yes, describe arrangements to be provided in order to accommodate all families with children, particularlythose with teenage boys. (500 character limit)

N/A this project does not serve families with childrenYes, applicant assures that its projects are in compliance with this HEARTH Act provisionNo, the applicant is unable to comply with this HEARTH Act provision

2. Bed and Unit Capacity for this project:

How many beds does this project have TOTAL?

How many beds does this project have for households without children?

How many beds does this project have for households with children?

PROJECT DESIGN


Do the household types in the beds fluctuate based on need? YES NONotes on Capacity: (250 character limit)

3. PERSONS SERVED

ApplingAtkinsonBaconBakerBaldwinBanksBarrowBartowBen HillBerrienBibbBleckleyBrantleyBrooksBryanBullochBurkeButtsCalhounCamdenCandlerCarrollCatoosa

CherokeeClarkeClayClaytonClinchCobbCoffeeColquittColumbiaCookCowetaCrawfordCrispDadeDawsonDecaturDeKalbDodgeDoolyDoughertyDouglasEarlyEchols

FanninFayetteFloydForsythFranklinFultonGilmerGlascockGlynnGordonGradyGreeneGwinnettHabershamHallHancockHaralsonHarrisHartHeardHenryHoustonIrwin

JenkinsJohnsonJonesLamarLanierLaurensLeeLibertyLincolnLongLowndesLumpkinMaconMadisonMarionMcDuffieMcIntoshMeriwetherMillerMitchellMonroeMontgomeryMorgan

OglethorpePauldingPeachPickentsPiercePikePolkPulaskiPutmanQuitmanRabunRandolphRichmondRockdaleSchleyScrevenSeminoleSpaldingStephensStewartSumterTalbotTaliaferro

ThomasTiftToombsTownsTreutlenTroupTurnerTwiggsUnionUpsonWalkerWaltonWareWarrenWashingtonWayneWebsterWheelerWhiteWhitfieldWilcoxWilkesWilkinson

3a. Check all the counties that will have access to services offered by this project. Onlyselect counties where services will be delivered to project participants.


3b. Number Clients Projected for each County served.

COUNTY COUNTY COUNTY# Served # Served # Served

CharltonChathamChattahoocheeChattooga

EffinghamElbertEmanuelEvans

JacksonJasperJeff DavisJefferson

MurrayMuscogeeNewtonOconee

TattnallTaylorTelfairTerrell

Worth

3c. Cost per Person or Household Served in 2019 (PROJECTED)PERSONS SERVED (Continued)

Number of Projected Clients served from January 1, 2019 thru December 31, 2019(Please note: If funded, this number will be referenced later to determine project progress.)

Projected Cost per Person ServedTotal Projected Expenses / Projected # Served

$0

?Projected Cost per

Person Served:

Projected Total Persons to be served in 2019

Projected Total Households Served:2019)

*Note: Households include single individuals served and families

Projected Cost per Household* ServedTotal Projected Expenses / Projected # Served

$0

?Projected Cost perHousehold Served:

Total Budget (2019)

Projected Total Persons Served: (2019)

Total Budget (2019)

Projected Total Households to be served in 2019

**Note: Gray boxes require completion of Budget Page later in Application


3d. Cost per Person Served in 2018 (as Reported in HMIS)

Total Clients SERVED in Project from January 1, 2018 thru December 31, 2018(Please note: This number should be obtained from HMIS report.

Cost per Person ServedTotal Expenses / Persons Served

Cost per Person Served(2018):

Total Persons served in 2018

**Total Households* (2018)

*Note: Households include single individuals served and families as reported in HMIS

Cost per Household* ServedTotal Expenses / Households Served

Cost per Household Served(2018):

Total Cost (2018)

** Total Persons (2018)

Total Cost (2018)

Total Households served in 2018

**Note: Gray boxes require completion of Data Entry from data above.

4. Length of Stay

Explain rationale for average and maximum lengths of stay.: (500 character limit)

What is the average length of stay (in days) for this project?

What is the maximum length of stay (in days) for this project?


5. Site InformationBriefly discuss layout, conditions, and hours of operation, if 24-hour staff available on site or on call. Include adescription of any hours during which participants are required to be inside the facilities (curfews) or are requiredto leave the facilities (reverse curfews) (1000 character limit)

Notes on Capacity: (250 character limit)

Organizational Policies and Procedures (250 character limit)

Indicate which of the following written items your agency has currently.

Organizational policies and proceduresPolicies and procedures specific to the project in this applicationFormal termination/eviction process for participantsGrievance procedure for participantsAppeal procedures for termination/eviction and grievance decisions

6. Other Project Information


Policies and procedures specific to the project in this application (250 character limit)

Formal termination/eviction process for participants: (250 character limit)

Grievance procedure for participants (250 character limit)

Other Project Information (Continued)


YESNO

Yes, the agency will create these items within 60 days of award, if any award is made for this application.No, the agency is unable to create these items within 60 days of award, if award is made for this application.

If an award is made for this application, does the agency agree to create any of the items listed above that itdoes not have currently within 60 days of such award?

Appeal procedures for termination/eviction and grievance decisions (250 character limit)

CASE MANAGEMENT AND STABLE HOUSING7. Case Management

Does the applicant develop goals and a personalized, formal plan for participants? Discuss how supportiveservices OUTSIDE OF THOSE APPLIED FOR IN THIS APPLICATION are provided to shelter residents (on

Application I, Emergency Sheltersite, off site, other agencies involved, etc.).

On how many occasions will participants receive a case management service from your agency during anaverage enrollment period?

Describe (500 character limit)

This project does not provide case management

Describe services for which you are seeking DCA ESG shelter funding in the table provided at the end of thisapplication.(500 character limit)


CASE MANAGEMENT AND STABLE HOUSING

If awarded funding, do you agree to incorporate the elements of the Housing Support Standards into your casemanagement structure?

DCA Housing Support Standards

If no, please explain. (500 character limit)

YES NO


If your project received DCA funding in the past year, describe any exceptions to the Housing SupportStandards in your service delivery model (500 character limit)(500 character limit)

DCA Housing Support Standards (Continued)

8. Summary of Supportive Services REQUESTED in this application


a. Life SkillsDescribe:

b. Ongoing Case ManagementDescribe:

c. Employment Assistance /Job TrainingDexcribe:

YES

YES

YES

YES

YES

YES

YES

YES

YES

Service TypeServices must be related toemergency shelter or streetoutreach.

Applied forin this

application?

Name the key staff personor outside organization

responsible for providingeach service

Provider of Service

Applicantor staffmember

OutsideAgency

Please indicate only those services requested as a part of this application. Note that for ESG eligibility,services must be related only to "emergency shelter or street outreach." All services provided by theapplicant or its partners are not expected to be ESG-eligible! (300 character limit)


Summary of Supportive Services REQUESTED in this application, (Continued)

f. Outpatient Health ServicesDescribe: YE

SYES

YES


Applied forin this

application?



Provider of Service


OutsideAgency

Please indicate only those services requested as a part of this application. Note that for ESG eligibility,services must be related only to "emergency shelter or street outreach." All services provided by theapplicant or its partners are not expected to be ESG-eligible!

d. Substance Abuse ServicesDescribe:

e. Education ServicesDescribe:

YES

YES

YES

YES

YES

YES


Summary of Supportive Services REQUESTED in this application, (Continued)

f. Outpatient Health ServicesDescribe: YE

SYES

YES


Applied forin this

application?



Provider of Service


OutsideAgency

Please indicate only those services requested as a part of this application. Note that for ESG eligibility,services must be related only to "emergency shelter or street outreach." All services provided by theapplicant or its partners are not expected to be ESG-eligible!

d. Substance Abuse ServicesDescribe:

e. Education ServicesDescribe:

YES

YES

YES

YES

YES

YES


9. Staffing

What is the total staff and/or volunteers utilized for this project?

List staff employed by your agency to work in this project by position (house managers, case managers, etc.).Check the box that describes their employment status, and describe their duties and qualifications as relevant.Please upload staff and job description in Organizational Documents. (250 Character Limit)

b. Position:

Full Time or Equivalent Part Time Volunteer


Number of staff members with this position:

Employment Status:

Duties:

a. Position:



Employment Status:

Duties:

c. Position:


Application I, Emergency ShelterEmployment Status:

Duties:

Staffing (Continued)



d. Position:


Employment Status:

Duties:

e.Position:


Employment Status:Duties:

List staff employed by your agency to work in this project by position (house managers, case managers, etc.).Check the box that describes their employment status, and describe their duties and qualifications as relevant.



f. Position:


Employment Status:

Duties:

Homeless Management Information Systems or Comparable Database

10. DV Comparable Database (DOMESTIC VIOLENCE PROJECTS ONLY)

Are you currently using the DV Comparable Database to track participants served by this project?

11. Homeless Management Information System (HMIS) (NON-DOMESTIC VIOLENCE AGENCIES)

MATCHING

12. Match Sources

A 100% match is required. The applicant may include the value of any donated material or building, the valueof any lease on a building, any salary paid to staff to carry out the project of the recipient, and the value of thetime and services contributed by volunteers to carry out the project according to guidance provided by DCA in

Answer "N/A" if your agency is not a domestic violence agency.

Does your agency currently use ClientTrack?

YES NO N/A

YES NO


the application guidelines. Describe match that will be used in the budget for this project, including matchsources and calculations of value for in-kind match. (1000 character limit)

MATCHING

Other Cash and Matching Resources Available for Emergency Shelter Project

A 100% match is required. The matching requirement may be met by one or both of the following:(1) Cash contributions.(2) Non-cash contributions. The value of any real property, equipment, goods, or services contributed to the grantee’s ESGproject, provided that if the grantee had to pay for them with grant funds, the costs would have been allowable. Noncashcontributions may also include the purchase value of any donated building.

Calculating the amount of non-cash contributions.(1) To determine the value of any donated material or building, or of any lease, the grantee must use and document a methodreasonably calculated to establish the fair market value.(2) Services provided by individuals must be valued at rates consistent with those ordinarily paid for similar work in the

Application I, Emergency Sheltergrantee’s organization. If the grantee does not have employees performing similar work, the rates must be consistent withthose ordinarily paid by other employers for similar work in the same labor market.(3) Some noncash contributions are real property, equipment, goods, or services that, if the grantee had to pay for them withgrant funds, the payments would have been indirect costs. Matching credit for these contributions must be given only if thegrantee has established, along with its regular indirect cost rate, a special rate for allocating to individual projects or projectsthe value of those contributions.

DCA will verify these amounts for compliance! Be realistic and be prepared to provide verification if funds are awarded!

Other Funds Provided for THIS PROJECT ONLY!Funds otherwise provided to the agency may not be included!

2. Project Name 3. Non-cash 4. Cash

Subtotal:Total Cash and Non-Cash:

a. HUD Continuum of Careb. Local Government (City)c. Local Government (County)d. GA Dept. of Human Serve. GA Dept. BH & DDf. United Wayg. Faith Based Organizationsh. Foundationsi. Fundraising Eventsj. In-kind Professional Serv.k. Donationsl. Volunteer Servicesm. Participant Feesn. Othero. Other

1. Source


Provide a COMPLETE budget below. Include all matching funds in Column c. whether you are seeking DCAfunding for that category or not.

13. EmergencyShelter Project Budget

a. ItemCase Management1. Personnel / Services2. Matching, Name:3. Matching Name:

b. ESGRequest

(Cash Only)

c. Matching(May

be Non-Cash) d. Total

Child Care4. Personnel / Services5. Matching, Name:6. Matching Name:Education Services7. Personnel / Services8. Matching, Name:9. Matching Name:Employment Assistance and Job Training

10. Personnel / Services11. Matching, Name:12. Matching Name:

Legal Services13. Personnel / Services14. Matching, Name:15. Matching Name:

Life Skills Training16. Personnel / Services17. Matching, Name:18. Matching Name:Mental Health Services19. Personnel / Services


20. Matching, Name:

Outpatient Health Services21. Personnel / Services22. Matching, Name:

Continue to Next Page

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Emergency Shelter Project Budget (Continued)

a. Item b. ESGRequest

(Cash Only)

c. Matching(May

be Non-Cash) d. TotalSubstance Abuse Treatment Services23. Personnel / Services

28. Matching, Name:

0 0 0

24. Client Intake and Assessment

25. Outpatient Treatment

26. Group and Individual Counseling

27. Drug Treatment

Transportation29. Public Transportation for Consumers

33. Matching, Name:

30. Mileage Allowances for Staff

31. Leasing / Vehicle Operations

32. Public Transportation for Staff

Shelter Operations34. Maintenance / Repairs

35. Rents

36. Security

37. Equipment, Name:

38. Insurance

Emergency Shelter 1 (page 21 of 24)


44. Matching, Name:

39. Utilities

40. Food

41. Furnishings, Name:

42. Supplies, Name:

43. Hotel / Motel Vouchers

45. Matching, Name:

46. Total Expenses: 0 0 0

Column C must meet or exceed Column A to document the 100% match required*Note that matching funds by source must be disclosed. If this project is approved for ESG funds,DCA may, at its sole discretion, choose not to participate in all “proposed” cost items.

HSOnlineApplicant (Agency) Legal Name

Contact Person

Contact Person Phone

Contact Person Email

HMIS Project Name

Application Submission Page

HSOnline

000-0000

[email protected]

Applicants may apply for up to $60,000 in funding.

SUBMIT

03/04/2019 12:55:18 PM

ESG Amount Requested:

Matching Funds:

Total Budget:

$0.00

$0.00

$0.00
