FUND COMMUNITY PROJECTS (OSFC)

TOMPKINS COUNTY OPIOID SETTLEMENT FUND COMMUNITY PROJECTS (OSFC)

Application Instructions + Overview

Organization name

Address

Phone

Format: (000) 000-0000.

Website

Federal Tax ID #

Primary Product or Service

Entity Type:

Number of employees

Is the organization current* on all local, state, and federal taxes and obligations?

Primary Contact Name

Phone

Format: (000) 000-0000.

Email

example@example.com

Project Name

Description

What Activities will your organization undertake if funding is awarded?

Are these activities part of a larger project? If so, describe the full project.

What need or gap will this project fulfill?

Who will benefit from this project? Be specific.

Project Location (address or service area)

Describe the project beneficiaries or population served

Describe how the project addresses the needs of the community?

Describe successful program management or other examples of successfullyimplementing projects/strategies

Describe your organizational history in serving the focus population

Describe your organizational history of collaboration with other agencies around this type of work

Select which OSFC program areas your project aligns with:

Expand Harm Reduction Strategies and Improve Collaboration:

Workforce Investment:

How will you pay for project costs prior to reimbursement of OSFC funds?

Project Budget

Fill in the amount to be spent on each expense type. Ensure that all OSFC funds are allocated to eligible uses for your organization and project type.

Expense Type 1

Note 1

Total 1

Expense Type 2

Note 2

Total 2

Expense Type 3

Note 3

Total 3

Expense Type 4

Note 4

Total 4

Expense Type 5

Note 5

Total 5

Would the project move forward if a partial award of OSFC funding were awarded?

If yes, what is the minimum award amount that would allow the project to move forward?

Project Timeline - assume award and contracting complete by 8/1/2023

Project Start Date

Date

Are any additional approvals, permits, funding awards, etc. needed prior to project start?

Yes-If yes, describe:

Project Outcomes: Below you will be asked to describe project outcomes. Note that you will be required to track and report on any success and project metrics.

What are the project's proposed metrics and goals for each metric? Note: Include metric and goal

Forms & Other Documentation: Attach the following forms, listing any additional attachments being submitted as verification/justification

File Upload

Signature

Date

Name

First NameLast Name

Title