PROPOSAL DUE DATE: FRIDAY, OCTOBER 23, 2020, 4:00 P.M. MST

Before submitting your proposal, have you:

Read the Eligible Activities & General Information sheet?
Completed every part of the proposal? Agency & Contact Information Scope of Work Total Program Budget Summary (For the entire program identifying all anticipated resources and expenditures) Program Related Information
SIGNED the proposal (Proposal-Page 2)? Proposal page 2 of 2 (Requires a signature for your application to be complete) Signature line (Please click on the signature line and type is your name)
Included: Financial Statement (Most recently audited) Management Letter (Separate from the Auditor’s Report) Agency Documentation (Refer to Agency Documentation Checklist) Letter of Commitment or Memorandum of Understanding * * Refer to question 9-Program Related Information, page 1. Include this document only if the proposal requires space, staffing, grants management, in-kind contributions or services from another agency, school, city, or another jurisdiction.
Sent a signed electronic copy of your proposal to hsgrants@scottsdaleaz.gov in original Word™ format? (Please include your Agency Documentation in the email.)

This form must be checked off, completed, and submitted with proposal.

QUESTIONS? Please call Justin Boyd, (480) 312-2479

AGENCY & CONTACT INFORMATION
1.	Agency Information
Agency Name:
Phone:
Fax:
Tax ID:
Agency Mailing Address:
City:	State:	AZ	Zip:
Executive Director:
E-mail Address:
Phone:
Web Site:
2.	Person authorized to sign contract on behalf of Agency:
Name:
Title:
E-mail Address:
SIGNATURE:	Click or tap here to enter text.
3.	Indicate the number of staff and volunteers for your agency and the program you are applying for:
Number of staff members:	Agency:	Program:
Number of volunteers:	Agency:	Program:
4.	Agency overview (describe the overall mission of your Agency):
5.	Does the most recent auditor’s letter to management identify findings or administrative concerns?
Yes No
If yes, please provide a full explanation:

SCOPE OF WORK (Contract Exhibit A)

This Scope of Work and Program Budget will document specific costs to be paid for under a contract for services.

1.	Agency Name:
2.	Program Name and Location:
Name:
Address:
City:	State:	AZ	Zip:
*If this program exists in multiple locations, please record additional locations on a separate sheet and attach to the back of this page
3.	Total CDBG Public Service Funds requested for this program:
$
4.	List the service(s) to be provided, the number of units of service and number of unduplicated Scottsdale persons or households the requested funding will pay for:
Service	Units of Service	# of unduplicated Scottsdale persons or households
Total:	**
5.	Total number of unduplicated Scottsdale persons or households to be assisted:
Income Level	Persons/Households
Very Low Income (0 – 30% of median income)
Low Income (31 – 50% of median income)
Low-Moderate Income (51 – 80% of median income)
Moderate Income (81% or greater of median income)
Total:	**
**Note: The total unduplicated persons/households in item 4 must equal the total unduplicated persons/households from the four income levels in item 5.
6.	Define how you will determine client eligibility and how you will determine if you are serving Scottsdale Residents?
Client eligibility will be documented by:
Scottsdale residency will be documented by:
7.	Program Outcomes and Indicators:
Complete the Outcome Chart by identifying at least one outcome to client/participants for each proposed service. Each outcome must be supported by at least one indicator and identification of the measurement that will be used to verify that the benefit has occurred.

Service	Outcomes	Indicators	How Receipt of Service is Documented
Example: Assistance with disability claims.	Example: Clients have increased financial self-sufficiency.	Example: By June 30, 2022, 15 clients have started to receive appropriate benefits.	Example: File is considered complete upon receipt of award letter.

8.	Eligible Activity: (Check all that apply)
NATIONAL OBJECTIVE #1 - Primary Benefit of Low and Moderate-Income Persons
NATIONAL OBJECTIVE #2 - Prevention or Removal of Slum and Blight
NATIONAL OBJECTIVE #3 - Mitigation or Elimination of a Certified Emergency Condition (e.g., major catastrophes or emergencies such as floods and earthquakes)

EXHIBIT B

BUDGET & BILLING INFORMATION

9.	CDBG Public Service Funds will pay for the following costs. Actual costs reimbursed under the contract will be those costs directly attributable to this program. (Refers to Program Budget Summary located on the next page.)
Personnel Services: (For example, list FTE position(s) that this funding will pay for.)
Contracted Services: (Explain in detail what contracted services will pay for, especially professional services.)
Supplies & Miscellaneous: (Explain in detail what funding will be used for.)

TOTAL PROGRAM BUDGET SUMMARY
Funding Year: 7/01/2021 - 6/30/2022
Agency Name:
Program Name:
Column (A)	Column (B)	Sum Total of (A+B)
Revenues	City of Scottsdale	Other Sources	Committed - C or Tentative - T	TOTAL
City of Scottsdale – CDBG Public Service
TOTAL PROGRAM REVENUES
Expenditures
Personnel Services:
Salaries
ERE
Total Personnel Services
Contracted Services:
Professional Services
Telephone
Utilities
Rent
Insurance
Travel/Mileage
Other (specify)
Other (specify)
Other (specify)
Total Contracted Services
Supplies & Miscellaneous:
Office Supplies
Building Materials
Printing/Duplication
Other (specify)
Other (specify)
Total Supplies & Miscellaneous
TOTAL PROGRAM EXPENSES

Note 1: TOTAL PROGRAM REVENUES MUST EQUAL TOTAL PROGRAM EXPENSES.

Note 2: Employee related expenses cannot be reimbursed at rates greater than the actual cost.

Note 3: Indirect administrative costs will not be reimbursed unless an indirect cost allocation plan has already been approved by an appropriate federal agency and submitted with this application.

Questions regarding this page? Please call Justin Boyd at (480) 312-2479

PROGRAM RELATED INFORMATION
1.	Program Name:
2.	Program Overview:
3.	Describe the services your program will provide.
4.	Would this program/service be provided in Scottsdale? Yes No
5.	Describe the population of clients that will be served. (Include age, gender, race, disability, along with unique characteristics.)
6.	Why are these services needed?
7.	What specific problem does your program address?
8.	Why is your approach the most effective one to use with the intended beneficiaries?
9.	Will the implementation of this activity require space, staffing, grants management or in-kind contributions from another agency, a school, the city or another jurisdiction? (If yes, a letter of commitment or memorandum of understanding from the partnering agency(ies) must be submitted with this proposal.) Yes No
10.	Does your activity take place in a City of Scottsdale facility? Yes No
11.	Other Collaborative Relationships: Your program’s ability to create a greater community impact rests largely with your effort to work with other community partners to serve clients in creative and innovative ways. Please list the agency(ies) and describe the relationship(s) and explain in detail how you are planning to work more collaboratively with the agency(ies) in order to maximize the use of resources.
12.	If your program is not recommended for full funding, would you accept a lesser amount and a negotiated scope of work? (If No, please explain) Yes No
13.	If your program is not recommended for CDBG Funds, would you accept funding from another source within the city (i.e., Scottsdale Cares, General Funds or the Endowment Fund)? (If No, please explain.) Yes No
14.	If your activity is funded by the City of Scottsdale but not by other funders, will your agency be able to provide the service? (If Yes, please explain.) Yes No
15.	What contingency plans have been made for a shortfall in funding?
16.	Will this program be accessible for persons with disabilities? (If yes, what provisions have been made? If no, please explain why.) Yes No

AGENCY DOCUMENTATION

The following documentation is required from all non-profit applicants.

Please label all attachments as follows:

Agency Documentation #1: Board of Directors

Occupations and/or community affiliations

Criteria for board selection

Agency Documentation #2: Organizational Chart

Agency Documentation #3: Finance

Agency's current annual operating budget

Funding sources for the organization

Anticipated future funding sources (if different from above)

Most current audited financial statement and management letter

List of other funding sources to which this proposal has been submitted

Agency Documentation #4: Articles of Incorporation (if never funded or revised)

Agency Documentation #5: Certification of Good Standing for Arizona Corporation Commission

Agency Documentation #6: Copy of the original IRS determination letter indicating 501(c)3 tax exempt status

Agency Documentation #7: Certification of Current Tax-Exempt Status of Grantee Organization (See attached)

Agency Documentation #7

CERTIFICATION OF TAX EXEMPT

STATUS OF GRANTEE ORGANIZATION

I,	, an Officer/Director of

(Organization)

hereby certify that the organization has received a ruling from the Internal Revenue Service that it is exempt from federal income tax under Section 501(c)(3) of the Internal Revenue Code and that the organization is not a private foundation as defined in Section 509 (a) of the Internal Revenue Code.

I further certify that said exemption rulings from the Internal Revenue Service are still in effect and have not been revoked or amended.

Signature

Name (please print)

Title

Date