Project Application

Name of person submitting request:

First NameLast Name

Professional Title:

Title

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Name of Organization

Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Organization Phone

Please enter a valid phone number.Format: (000) 000-0000.

Organization Website

www.website.com

Chief Paid Executive Information

Chief Board Officer Information

Please upload a copy of your current Board of Directors roster.

Board of Directors Roster

Please upload a copy of your most recent audited financial statement:

Financial Statement

Please upload a copy of your current year budget:

Current Year Budget

Please upload a copy of your year to date with actuals:

Year to Date with Actuals

Provide a brief overview of the proposed project, including the work to be completed and its anticipated impact.

Optional: Attach other documents you feel would be helpful for our evaluation ‑‑ e.g. annual report, organization newsletter, brochures, etc. (up to five documents)

Other Documents

Support Services Provided:

Percent of clients gaining self-sufficiency through your program last year (if applicable):

How many clients do you serve yearly?

Please check if you have the following insurance in place:

Please attach a copy of your current insurance certificate(s).

Name of Proposed Project

Project Name

Project Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Person for Project

Type of Project (check all that apply):

Is this project a new build or a renovation?

Population served through this project:

How many beds will be added (or preserved) through project, if any?

How many individuals will be served each year through this project?

How long do you expect clients to stay at the facility?

Square footage of proposed project:

Do you own or fully control the site?

If you control, but do not own the site, please explain:

Are all entitlements (other than building permit) in place for intended use?

Has the project gone through local planning department reviews?

Does the project require a variance or special use permit?

If you have site plans showing the building on the site, please attach here.

Site Plans

If you have renderings/photos to share, please attach here.

Renderings/photos

If you have an engineered site plan, please attach here.

Engineered Site Plan

If you have architectural plans, please attach here.

Architectural Plans

Have the plans been approved by all required local government agencies?

If you have received building permits, please attach here.

Architectural Plans

Do you need help with architectural or engineering plans?

Estimated construction budget:

What percent of funding do you have?

How do you anticipate funding any additional programs/beds?

Please list the anticipated sources of revenue for the construction of the project:

What is the expected annual budget for the operation of the program(s) conducted at the project:

Service Provider acknowledges and agrees that it bears the ultimate financial responsibility for the completion of the project and that HomeAid Utah’s contribution to the project is limited to in-kind donations of materials and labor. Accordingly, Service Provider has diligently and thoroughly investigated and disclosed above all available and potential funding for the project.

Service Provider acknowledges its obligation to install and maintain a plaque or similar marker recognizing HomeAid Utah’s contribution to the project and featuring the HomeAid logo. Such commemorative marker shall be displayed in a prominent location at the completed project.

Applicant (aka Service Provider) acknowledges its obligation to give due credit to HomeAid Utah in any and all press releases, public announcements, award programs or other publicity about the project. Service Provider agrees to obtain HomeAid Utah’s approval for any and all press releases, public announcements, awards programs or other publicity about the project. Any such publicity that is not disapproved within seven (7) days shall be considered approved.

Service Provider acknowledges its obligation to send notice to its donor base promptly after this application is approved advising them of the contribution HomeAid Utah has agreed to make to the project. Such notice shall be shown to and approved by HomeAid Utah’s executive director prior to such mailing.

Service Provider acknowledges and agrees to provide, when requested and where reasonable, information to HomeAid Utah and HomeAid America, on client success rates, client service numbers, and program evaluation information.

Service Provider certifies that it does not engage in unlawful discrimination of any kind with respect to the persons benefited by Service Provider’s activities.

Service Provider certifies that all information in this application is true and correct as of the date entered.

Service Provider has read this Project Assistance Application and agrees that, should the project be approved, the Service Provider will abide by the covenants contained herein.

The person filling out this form is duly authorized to execute this document on behalf of the Service Provider as of the date entered.

Signature

Thank you for your application! We look forward to speaking with you soon.

For questions or comments, please contact:

Lisa Wright | Executive Director

801-674-7524 | Lisa@HomeAidUtah.org

Project Application

Section 1: Organization Information

Section 2: Project Information

Section 3: Construction Specifics

Section 3: Service Provider Covenants

Section 4: Certification