Emergency Food and Shelter Application

Emergency Food and Shelter Program Application for Funding

Submit Applications by 5 p.m. on January 22, 2021. All fields are required. If any of the questions are not applicable to your organization, please indicate N/A in the space.

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Agency's Legal Name *

Agency Chief Officer *

Agency Email Address *

Agency Contact for Application Questions (Include name, phone number, and email address) *

Agency Contact for EFSP, if funded (Include name, phone number and email address) *

Agency Physical Address & Congress District *

Agency Mailing Address (if different from physical address) *

Agency Address for Services *

Agency Phone *

Agency Fax *

Agency Website *

Agency Federal Employer Identification Number *

Agency DUNS Number *

If this is the first time your agency is applying for EFSP funds, describe your agency's services and how EFSP funds will be used to supplement/expand your current program. *

Amount of EFSP funding requested and for what program area (Ex: FOOD, RENT, UTILITIES, ETC)

Amount Requested *

Program Area *

Agency Operating Budget (total) *

Agency Budget for the program area requested (This is money you have in your budget for the category you are requesting funding: FOOD, RENT, UTILITIES, ETC) *

Provide copy of agency's most recent audit (if revenue is over $100,000). For revenue less than $100,000 the agency's most recent financial statement (profit & loss) must be submitted. *

Files must be less than 2 MB.
Allowed file types: jpg jpeg png pdf doc docx.

Date of Audit provided: *

Is agency non-profit or unit of government? *

If non-profit, provide a roster of agency's volunteer board. (Attach file). *

Files must be less than 2 MB.
Allowed file types: jpg jpeg png pdf doc docx.

Is agency debarred or suspended from receiving funds or doing business with the Federal Government? *

Yes

Certification Statement: To the best of our knowledge and belief, the information contained in this application and attachment is true and correct. The Marshall County EFSP Board is hereby authorized to verify all information contained herein, and we understand that any inaccuracies, omissions or any other information found to be false may result in rejection of this application or elimination of funding after it is awarded.

I affirm that the Agency will use EFSP funds for the purposes as submitted in this Application for funding.

I understand that the Agency must meet the eligibility criteria to be considered for EFSP funding and that an incomplete application and/or omitting required attachments may disqualify the agency's application.

I further understand that meeting the eligibility crieria in no way ensures that the agency will receive EFSP funding. Funding are determined by service needs of the community, availability for funds, and other factors.

Signature *

Title *

Date *

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Emergency Food and Shelter Application

Emergency Food and Shelter Program Application for Funding