Okaloosa County BOCC — May 17, 2016 — 2016 Emergency Solutions Grant App — reading text

other homeless and mainstream housing and service applicants. Submit an HMIS Report for service providers that indicates referrals for clients assisted, which includes the referring service provider and the type of service referred to. 5. Does the applicant use the CoC centralized or coordinated assessment system as required by HUD? (DV applicants are not required to participate). Yes _______ No _______ DV _______ 6. The applicant, __________________________________________, has submitted ESG projects included in the CoC Plan, or is approved by the CoC. Yes _______ No _______ Street Outreach ONLY: 1. If applicable, based upon the CoC HMIS System, during February 1, 2015 and January 31, 2016, the applicant has achieved the following outcomes for housing permanency in the planning area: (a) For Outreach clients assisted, ________% of clients who received emergency health services on an outpatient basis by licensed medical professionals. (b) For Outreach clients assisted, ________% of clients who received emergency mental health services on an outpatient basis by licensed medical professionals. (c) For Outreach clients assisted, ________% of clients who were sheltered as a result of referral from the applicant’s street outreach program to community housing applicants. Emergency Shelter ONLY: 1. If applicable, based upon the CoC HMIS System, during February 1, 2015 and January 31, 2016, the applicant has achieved the following outcomes for housing permanency in the planning area: (a) For Shelter Facilities clients housed, ________% of clients exited the facility to permanent housing. (b) For Shelter Facilities clients housed, ________% of clients left the facility with employment income. 2016-17 Emergency Solutions Grant Application 40  (c) If applicable, the applicant’s outcomes achieved with its’ DCF 2014 shelter award furthered the goals and objectives of the CoC. Yes _______ No ________ Prevention and Rapid Re-housing ONLY: 1. Based upon the CoC HMIS System, or comparable database for domestic violence (dv) applicants, during February 1, 2015 and January 30, 2016, the applicant has achieved the following outcomes for housing permanency in the planning area: (a) For Prevention clients assisted, % of the clients remained in their permanent housing as of ninety (90) days following the last date of assistance provided by the applicant’s program. (b) For Rapid Re-Housing clients assisted, % of the clients remained in permanent housing provided as of ninety (90) days following the last date of assistance provided by the applicant’s program. On behalf of this CoC (HUD FL_ ,), the above certifications made, and are true and accurate. Further, I am duly authorized to make this certification on behalf of the CoC. Name of Certifying Official: Title: Signature of Official: Date Signed: 2016-17 Emergency Solutions Grant Application 41  Exhibit 9 OVERALL PROJECT BUDGET AND MATCH FORM Agency Number of Existing New Grant $ Requested $ Match Provider Persons Service Service Activity/Project Amount Name Homeless To Be Served 1 ____________ ___________ ________ ___________ _____ _____ ____________ 2 ____________ ___________ ________ ___________ _____ _____ ____________ 3 ____________ ___________ ________ ___________ _____ _____ ____________ 4 ____________ ___________ ________ ___________ _____ _____ ____________ 5 ____________ ___________ ________ ___________ _____ _____ ____________ ____________ TOTAL GRANT $__________ $________ __________ Total Persons To Be Served Instructions Please list your grant projects on the above chart. The maximum grant shall be $250,000 in FY2016-17. At least 40% of the total project budget must be allocated to prevention and re- housing activities. 1. Grant Activity / Project Please use the same title or description used in the narrative. Be sure to identify and list each activity to be funded, if more than one is proposed for funding. 2. $ Requested List the amount of ESG Funds requested for each activity or use separately and the total amount of the Challenge Grant requested. 3. $ Match Amount List the amount of matching funds that will be submitted for invoicing purposes. 4. Provider Name Identify the specific entity, person, or agency to carry out each activity or use of the ESG Funding. If the lead agency will perform the activity directly, cite the name of the lead agency. If another entity will carry out the activity under contract with the lead agency, provide the legal name of that entity. Complete a separate budget for each provider of service. 5. Existing or New Service Specify whether the activity or use to be funded will support an existing service or use, or whether the funded activity is a new service to fulfill an unmet need. 6. Number of Homeless Persons Served For each activity, identify the estimated number of homeless persons to be served. 2016-17 Emergency Solutions Grant Application 42  BUDGET AND MATCH FORM Prevention and Re-Housing Service Provider: Grant $ Match $ 1. Rapid Re-Housing A. Rental Assistance $ $ B. Housing Relocation and Stabilization i. Financial Assistance Costs $ $ ii Services Costs $ $ 2. Homeless Prevention A. Rental Assistance $ $ B. Housing Relocation and Stabilization i. Financial Assistance Costs $ $ ii Services Costs $ $ 3. HMIS A. Cost of contributing data to HMIS for CoC $ $ B. HMIS Lead Agency Costs for hosting and maintaining system $ $ C. Victim Services provider costs for comparable database $ $ 4. Administrative Costs [Cap 5%] A. Local government $ $ B. Private non-profit organization $ $ TOTAL BUDGET $ $ Submit a separate form for each prevention service provider. Attach a detailed list of the sources of the required match, including the breakdown by amount of cash match, and/or in-kind services and valuation of such in-kind match. Applicant: MATCH SOURCES: 2016-17 Emergency Solutions Grant Application 43  BUDGET AND MATCH FORM Emergency Shelter Facilities Service Provider: Grant $ Match $ 1. Essential Services (list activities) A. $ $ B. $ $ i. $ $ ii $ $ 2. Shelter Operations (list activities) A. $ $ B. $ $ i. $ $ ii $ $ 3. Hotel or Motel Vouchers A. ONLY if there is no emergency shelter available or appropriate for a homeless family or individual $ $ 4. Renovations $ $ 5. HMIS $ $ 6. Administrative Costs [Cap 5%] A. Local government $ $ B. Private non-profit organization $ $ TOTAL BUDGET $ $ Submit a separate form for each service provider. Attach a detailed list of the sources of the required match, including the breakdown by amount of cash match, and/or in-kind services and valuation of such in-kind match. Applicant: MATCH SOURCES: 2016-17 Emergency Solutions Grant Application 44  BUDGET AND MATCH FORM Street Outreach Program Service Provider: Grant $ Match $ 1. Engagement $ $ 2. Case Management $ $ 3. Outpatient Health Services by licensed professionals $ $ 4. Outpatient Mental Health Services by licensed professionals $ $ 5. Transportation of outreach workers or unsheltered persons to $ $ services 6. Services for special populations $ $ (youth, victim services, persons with HIV/AIDS) HMIS $ $ Administrative Costs [Cap 5%] A. Local government $ $ B. Private non-profit organization $ $ TOTAL BUDGET $ $ Submit a separate form for each service provider Attach a detailed list of the sources of the required match, including the breakdown by amount of cash match, and/or in-kind services and valuation of such in-kind match. Applicant: MATCH SOURCES: 2016-17 Emergency