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2. Application Package
   Application Package

   Please begin the application by first downloading and thoroughly reading the Application Package. The package includes information on the program, specific instructions on answering the questions, additional information you may need while completing the application and fillable budget worksheets.
4. 1. Applicant
6. First Name*
7. Last Name*
8. Title (if applicable)
10. Enter Email Address*
11. Telephone*
13. Address1*
15. Address2
17. City*
18. State*
19. Zip*
21. Contact Person
23. First Name*
24. Last Name*
25. Title
27. Enter Email Address*
28. Telephone*
30. Address1*
32. Address2
34. City*
35. State*
36. Zip*
40. 2. Project Information
42. Project Title*
43. Location*
    Address or specific description
45. Total number of persons this project will serve?*
46. How many are low-to-moderate income?*
47. How many are White Plains residents?*
49. CDBG Funding Request*
50. Total Project Cost*
52. 3. Project Eligibility*

    To be eligible for CDBG funding, a project must qualify as an eligible activity under the CDBG Program. Check the category that applies to your project.

    1. Affordable Housing Rehabilitation
    2. Community Facilities and Rehabilitation
    3. Historic Preservation Rehabilitation
54. 4. Project Benefit*

    To be eligible for CDBG funding, a project must meet the HUD National Objective of benefit to low- and moderate-income persons. Select the National Objective that applies to your project, descriptions can be found in the application instructions.

    1. Low-/Mod- Area Benefit
    2. Low-/Mod- Limited Clientele (Presumed Benefit)
    3. Low-/Mod- Limited Clientele (Income Verification)
56. 5. Scope of Work*
    Describe the proposed project and the work to be performed. Include the purpose for the project, the needs or problems to be addressed, how the needs were determined, how will success of the project be determined, etc. Provide as much detail as possible.
58. 6. Performance Outcome Measures
    The U.S. Department of Housing and Urban Development (HUD) has instituted performance measures to determine the effectiveness of programs funded with CDBG. Information obtained on the local level will be reported to HUD which will enable HUD to describe performance results at the National level. HUD's outcome performance measurement system has three objectives and three outcomes which are listed in the following questions.
60. A. Select one of the following that best fits your project objective:*

    1. Suitable living environment
    2. Decent affordable housing
    3. Create economic opportunity
61. B. Select at least one of the following that describes the outcome your project will achieve:*

    Descriptions provided in instructions

    1. Availability/Accessibility
    2. Affordability
    3. Sustainability
63. 7. Project Site

    Please indicate the status of the project site. You will be asked to attach documentation of site control at the end of the application; Attachment L.

    1. Applicant owns property
    2. Project site is owned by another entity
64. Date property acquired
    Date property acquired
68. 8. Relocation*

    Does this project require temporary or permanent relocation or moving occupants of a structure?

    1. Yes; the project will be subject to The Uniform Relocation Assistance and Real Property Acquisition Policies Act (URA)
    2. No
70. How many units are vacant?
71. How many units are occupied?
72. Identify the type of relocation

    1. Temporary
    2. Permanent
    3. Displacement
74. How many units are owner occupied?
75. How many units are renter occupied?
76. How many units are business occupied?
78. What is the total relocation cost for the project?
79. Describe the relocation plans
    Including timetable, notification to seller and occupants
83. 9. Accessibility for Persons with Physical Disabilities
    Federal regulations require that all facilities and/or services assisted with CDBG funds be accessible to the disabled, whenever feasible.
85. Is this project for physical improvements or a development project?

    1. Yes
    2. No
86. Will the completed project meet ADA standards for accessibility by the disabled?

    1. Yes
    2. No
87. Describe accessibility prblems and methods to address problems, including funding and timetable
91. 10. Employment and Client Participation
93. Non-Discrimination*

    Do you notify the public that you do not discriminate based on race, color, religion, gender, sexual orientation, nation or origin, age or disabilities in hiring practices or provision of services?

    1. Yes, currently

    1. Not currently

    1. Willing to adopt practice
97. 11. Receipt of Prior CDBG Funds
99. Has this organization received CDBG Rehab funding in the past year?

    1. Yes
    2. No
100. Prior awards
     Please list the year(s) of the award(s) and the amount(s)
102. 12. Organization Information
     Please include the following: A. Background – Include the length of time the agency has been in operation, date of incorporation, the purpose of the agency and type of corporation. B. Describe all services and programs offered. If a license to operate your agency is necessary, submit a copy of the license. C. Describe the agency’s existing staff positions and qualifications. D. Do you have a personnel policy manual with an affirmative action plan and grievance procedure? E. Describe the agency’s fiscal management including financial reporting, record keeping, accounting systems, payment procedures and audit requirements. F. Provide evidence of financial accountability such as a recent audit or annual accounting with balance sheets. *Note: Audit Requirements – CDBG Loan Recipients must comply with the Office of Management and Budget SuperCircular 6 2 CFR Part 200, Uniform Administrative Requirement, Cos Principles, and Audit Requirements.
106. 13. Conflict of Interest Questionnaire
     If you are approved for funding and have answered YES to any of the above questions, a disclosure notice must be issued and a 15-day public comment period must be held prior to execution agreement or release of funds.
108. A. Are any employees, agents, consultants, officers, or elected officials of the agency requesting funds in a position to participate in the decision making process for approval of this application?

     1. Yes

     1. No
110. B. Are any employees, agents, consultants, officers, or elected officials of the agency requesting funds in a position to gain inside information with regard to approval of this application?

     1. Yes

     1. No
112. C. Will any employees, agents, consultants, officers or elected officials of the agency requesting funds obtain a financial interest from this activity?

     1. Yes

     1. No
114. D. Will any employees, agents, consultants, officers of the agency requesting funds have an interest in any contract, subcontract or agreement with respect to funding this application, either for themselves or those with whom they have family or business ties during the 2016 program year and one year thereafter?

     1. Yes

     1. No
118. 14. - 16. Budget
     Please attach fully completed budget worksheets (right)
119. Budget Worksheets*
123. 17. Attachments
     Please attach the required materials below
125. A. Articles of Incorporation and Bylaws*
     Documents recognized by the State as formally establishing a private corporation, business or agency. (501 (c)(3) documentation)
126. B. FEDERAL Tax Exemption Determination Letters*
     Non-profit organizations must submit tax-exemption determination letters from the Federal Internal Revenue Service
128. C. List of Board of Directors*
     A list of the current Board of Directors or other governing body of the agency must be submitted. The list must include the name, telephone number, address, occupation or affiliation of each member and must identify the principal officers of the governing body.
129. D. Organizational Chart*
     An organization chart must be provided which describes the agency’s administrative framework and staff positions, which indicates where the proposed project will fit into the organizational structure, and which identifies any staff positions of share responsibility.
131. E. Most recent audit/financial statement*
132. F. Copy of IRS Form 990 – Return of Organization Exempt from Income Tax*
134. G. Most recent Annual Report *
135. H. Documentation of Committed Funds (e.g. award letter, letter from lender, etc)*
137. I. Project architectural and/or engineering reports and documents, if available
138. J. Documentation of historical status, if applicable
140. K. W-9*
141. L. Copy of the deed of the property and/or a notarized letter from the property owner agreeing to the project and verification of a 5-year (minimum) lease. *
145. Certifications*

     1. By checking this box, I certify that the applicant meets the conditions specified in the application instructions and will be able to carry out the proposed services in concert with these conditions.
Leave This Blank:


147. 1. Receive an email copy of this form.
148. Email address

     This field is not part of the form submission.

149. Submit

* indicates a required field