FUND COMMUNITY PROJECTS (OSFC)

TOMPKINS COUNTY OPIOID SETTLEMENT FUND COMMUNITY PROJECTS (OSFC)

Application Instructions + Overview
Organization name
Address
Phone
Website
Federal Tax ID #
Primary Product or Service
Entity Type:

Non-profit (501c3 or 501c19)LLCC-CorpGovernmentDBA/PartnershipOther
Number of employees
Is the organization current* on all local, state, and federal taxes and obligations?

YesNo
Primary Contact Name
Phone
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:

Training/educationCoordinated overdose responseCommunity outreach and education (especially for harder-to-reach populations)Improve access to overdose prevention supplies
Expand Harm Reduction Strategies and Improve Collaboration:

Installation or initiation of a community resource/interventionInter/Intra-organizational relationships/collaborationData
Workforce Investment:

Staff investment/well-beingInter/Intra-organizational relationshipsExpand capacity of service network (bringing on new staff)
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?

YesNo
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

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

YesNo
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

W-9Non-profits only - 501(c) IRS Determination letterTompkins County Hold Harmless and Insurance RequirementsLivable Wage FormType option 5Other
File Upload

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Signature

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Date

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Date
Name

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Title
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