EFSP funding application

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

Agency Legal Name
Name must match Federal Employee Identification Number and UEI number.
Agency is:
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)

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

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
Format: (000) 000-0000.
Principal Contact's Fax Number
Format: (000) 000-0000.
Application Questions Contact (Must be a different contact than "Principal" )

First NameLast Name
Ap Questions Contact's Email
example@example.com
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Contact Person for EFSP if funded

First NameLast Name
Contact Person if funded Email
example@example.com
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.

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)

Rows	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
List the names of all representatives who have (or will) completed the LRO training for Phase 42

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
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