EFSP funding application

Application for funding - Phase 42
Is the organization debarred/suspended from receiving funds or doing business with the Federal Government?*

yesno
I have verified that the information in our organization's national efsp.unitedway.org account is accurate. I understand that it must match the information below and that if funded, important information, required certification documents via DocuSign and email from the local board, will be sent to the email address in our EFSP account.

Basic Information
Agency Legal Name*
Name must match Federal Employee Identification Number and UEI number.
Agency is:*

Non-profit 501(C)3Unit of government
LRO ID*
9 digit Local Recipient Organization (LRO) ID number (more info: efsp.jcunitedway.org)
Agency FEIN*
Agency Federal Employer Identification Number (FEIN)
Agency Unique Entity ID (UEI) #*
12-character alphanumeric ID assigned to an entity by SAM.gov Entities can get their Unique Entity ID at SAM.gov , “Get a Unique Entity ID” aka “UEI” Video: https://www.youtube.com/watch?v=0uv1YNAsINk
Agency's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency Website URL
Agency's Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Congressional district where agency is physically located*
Place of Performance (Address where EFSP funded services are provided)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Congressional district Place of Performance (where EFSP funded services are provided)*

Upload required files
The following three attachments are required and must be submitted with this application. Click each "Browse Files" below, locate the file and click "Open". When the file has successfully uploaded, you will see it listed under the "Browse Files" button.
Upload Agency Financials (whole agency)*

Agency’s total current year budget, YTD actual AND prior year's year-end actual.
Cancelof
Upload Program Specific Budget*

Program (food, etc.) current budget, YTD actual AND prior year's year-end actual.
Cancelof
Non Profit Board of Director's List*

Include name, address, phone # & email address. If a government entity, upload an org chart with names, addresses, phone #s & email addresses.
Cancelof

Agency Contacts
Principal Contact Name: (The person this entity legally appoints to act on its behalf. CEO, President, Director etc.)*

First NameLast Name
Principal Contact's E-mail*
example@example.com
Principal Contact's Phone Number*
Principal Contact's Fax Number
Application Questions Contact (Must be a different contact than "Principal" )*

First NameLast Name
Ap Questions Contact's Email*
example@example.com
Phone Number*
Fax Number
Contact Person for EFSP if funded*

First NameLast Name
Contact Person if funded Email*
example@example.com
Phone Number*
Fax Number

Use of Funds
How will these funds be spent? *
Summarize the objectives, focus, need, target population etc.
Prior Year Program Report*
Must include numbers served and outcomes for the program(s) itself.

Category for Phase 42 Request (Spend Period has not been announced)*

	Amount requested
Served Meals
Other Foods
Mass Shelter
Other Shelter
Supplies / Equipment
Repairs
Rent / Mortgage
Utility Assistance
Admin
Emergency Repairs Building Code
Personal Protective Equipment
Supplies
TOTAL Phase 42 REQUEST

Required LRO Training
Required LRO Training*

Two or more agency representatives have completed the LRO training for Phase 42.Two or more representatives WILL complete the LRO training for Phase 42 by the application due date https://efsp.jcunitedway.org/LROtraining.htm
List the names of all representatives who have (or will) completed the LRO training for Phase 42*

SIGN & SUBMIT—Print a copy for your records
Name of the person submitting and signing this application*

First NameLast Name
Email of the person submitting and signing this application*
example@example.com
Signature*

Clear
Comments / suggestions

Use the "Contact Us" form on our website if you have comments or suggestions to improve this application.
Agency DUNS
Agency’s nine digit DUNS Number
Should be Empty:

Application for funding - Phase 42