Application for Title III or Church Street Home Fund Grant

Application for Community Services Grant Title III of the Older Americans Act or Church Street Home Fund

Please submit the title page, narrative, and budget using this form.
All applications must be submitted through this form; emailed or paper applications will not be accepted.

For reference only: a full question list is available on the LifePath website.
Title of Proposed Project:*
Requested Grant Amount:*
Service Category (choose one):*

Title IIIB Supportive ServicesTitle IIIB Legal ServicesTitle IIID Health Promotion and Disease PreventionTitle IIIE CaregiverChurch Street Home Fund - Senior CentersChurch Street Home Fund - Home Repair
Organization Information
Name of Applicant Organization*
Mailing Address of Applicant Organization*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization EIN or Tax ID*
Contact Information
Name of Program Contact*

First NameLast Name
Phone Number of Program Contact*
Please enter a valid phone number.Format: (000) 000-0000.
Email of Program Contact*
example@example.com
Name of Fiscal Contact*

First NameLast Name
Phone Number of Fiscal Contact*
Please enter a valid phone number.Format: (000) 000-0000.
Email of Fiscal Contact*
example@example.com
Signature
Signature of Submitter*
Date

MonthDayYear
Date
Name of Submitter*

First NameLast Name
Title of Submitter*

Narratives
Summary Program Description
1. One-paragraph description of the proposed project, including what makes the project innovative or how it was successful in the past.*
Program Narrative
1. List the reasons why this project is needed. Describe any evidence that the project is needed.*
2. List the measurable objectives of your proposed project (i.e. what are the intended outcomes of the project?) Objectives should be measurable within a specified time frame. *
3. Scope of project:
a) Number of elders you plan to serve by the end of the grant: Enter Number
b) Average number of elders you plan to serve each month: Enter Number*
4. Describe the target population you plan to serve through this project.*
5. Describe the geographical area in which the project will be operated.*
6. Describe the efforts that will be made to encourage the participation of low-income, persons with disabilities, isolated, and minority elders in your project.*
7. All Title III programs must provide opportunities for voluntary and anonymous donations. No fees may be charged to participants. Describe what methods will be used to enable and encourage participants to donate toward the cost of providing the proposed services. For CSHF, charges for services are allowed; if applying for CSHF, describe any need to charge a fee here.*
See the Handbook of Subgrantee Responsibilities for details.
8. If there are any staff positions to be funded through this proposed project, attach a job description for each position. The job description should include position title, number of weekly hours and number of weeks this person would be assigned to the proposed project, main responsibilities, and proposed salary costs. Include resume of key personnel or consultant(s) if available.

Leave blank if no positions will be funded through this proposed project.
Cancelof
Applicant Agency Profile
1. List all elder services provided by your agency or organization.*
2. Is your proposed project a new program, an expansion of an existing program, or the continuation of an existing program? Please explain.*

Budget
Budget Narrative
Please complete the budget template below.

A. Budgets may not exceed 12 months in duration, but may be for a shorter period of time. Amounts requested from LifePath must be matched by other funding sources at least 15% or total program costs for Title IIIB and IIID projects and 25% for Title IIIE projects. No match is required for Church Street Home Fund projects. Add explanatory notes on line items as needed. “Type” should indicate cash or in-kind contributions.

B. All Title III/CSHF program costs, regardless of the planned source of income, must be reflected on the budget summary. Only include costs that are part of the proposed project.

Proposed Project Budget*

Rows	Amount of Grant Funds Requested	Match Amount	Match Type	Total
Salary
Fringe
Travel
Rent and Utilities
Phone and Postage
Supplies
Equipment (attach itemized list)
Professional Services
Other 1
Other 2
Other 3
Other 4
Other 5
Total

Please describe "other" lines in the budget narrative below.
Please provide a paragraph or bullet points explaining the costs and how they will contribute to the project.*
If you are requesting funds to purchase equipment, provide an itemized list below:
Optional: leave blank and proceed if not requesting funds to purchase equipment.

Supporting Documents

Please complete A & B with your application. C is for awareness if grant awarded.
A. Compliance with Civil Rights Act of 1964

ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES REGULATIONS UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964
Applicant Name*   (Hereinafter called the “Applicant”) HEREBY AGREES THAT it will comply with title VI of the Civil Rights Act of 1964 (P.L. 88352) and all requirements imposed by or pursuant to the Regulation of the Department of Health, Education, and Welfare (45 CFR Part 80) issued pursuant to that title, to the end that, in accordance with title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement.

If any real property or structure thereon is provided or improved with the aid of Federal financial assistance extended to the Applicant by the Department, this assurance shall obligate the Applicant, or in the case of any transfer of such property, any transferee, for the period during which the real property or structure is used for a purpose for which the Federal financial assistance is extended or for another purpose involving the provision of similar services or benefits. If any personal property is so provided, this assurance shall obligate the Applicant for the period during which it retains ownership or possession of the property.  In all other cases, this assurance shall obligate the Applicant for the period during which the Federal financial assistance is extended to it by the Department.

THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all Federal grants, loans, contracts, property, discounts or other Federal financial assistance extended after the date hereof to the Applicant by the Department, including installment payments after such date on account of applications for Federal financial assistance which were approved before such date. The Applicant recognizes and agrees that such Federal financial assistance will be extended in reliance on the representations and agreements made in this assurance and that the United States shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the Applicant, its successors, transferees, and the assignees, and the person or persons whose signatures appear below are authorized to sign this assurance of behalf of the Applicant.

Date*

Signature*

First Name*   Last Name*
B. Compliance with Section 504 of the Rehabilitation Act of 1973

ASSURANCE OF COMPLIANCE with Section 504 of the REHABILITATION ACT OF 1973, AS AMENDED
Applicant Name*   herein agrees to comply with Section 504 of the Rehabilitation Act of 1973 (29 USC 794) and the regulations promulgated thereto (45 CFR 84), which prohibits discrimination against qualified handicapped individuals on the basis of handicap in any program or activity receiving or benefiting from federal financial assistance and which requires programs and activities, when viewed in their entirety, to be readily accessible to handicapped persons.

Date*

Signature*

First Name*   Last Name*
C. Certificate of Insurance

A current Certificate of Insurance demonstrating coverage is required if grant awarded.
Should be Empty:

Application for Community Services Grant Title III of the Older Americans Act or Church Street Home Fund

Organization Information

Contact Information

Signature

Narratives

Summary Program Description

Program Narrative

3. Scope of project:

Applicant Agency Profile

Budget

Budget Narrative

Supporting Documents