Grant Program Application Form

Community Development Block Grant (CDBG) Application

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1. Basic information

Please fill out the below information.
Program/Project Title:
Program/Project Category
Funding Requested:
Matching Funds Available:
Organization Name
Type of Organization
Federal Tax ID Number
XX-XXXXXXX
Unique Entity ID #
Applicants must be registered through SAM.gov
Organization Website
Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For construction projects only, please provide the address and parcel number for proposed project (must be within the City of Prescott):
Primary Program/Project Leader's Full Name

First NameLast Name
Phone Number
Email

2. Program/Project Details

Please answer the questions to the best of your ability.
Please give a concise overview of the proposed program/project. (Limit your response to two to three sentences)

0/100
How will the program/project be implemented? Provide a comprehensive explanation that covers the full project lifecycle, including specific implementation steps, staff resources and their roles, a projected timeline with key milestones, any partnerships or external support, and strategies for addressing potential challenges.
What community need is being addressed by the proposed program/project?
Describe organization's experience with similar programs/projects.
How many LMI (Low- and Moderate-Income) Prescott residents will this program/project serve during Program Year 2025 (July 1st, 2025 to June 30th, 2026)?

3. Meeting HUD Guidelines

Please follow the below instructions.
Please confirm that the funds awarded by this grant will be exclusively used to support residents of the City of Prescott. Any services provided to individuals outside the jurisdiction must be funded separately, and proper tracking will be maintained to ensure that CDBG funds are solely allocated to Prescott residents in compliance with the program requirements.

YesNo
How will the program/project meet HUD's National Objective: Benefit to Low- and Moderate-Income (LMI) Persons or Households? (category descriptions provided below)

Low Mod Area Benefit (LMA)Low Mod Limited Clientele (LMC)Low Mod Housing Activities (LMH)Low Mod Job Creation or Retention Activities (LMJ)Unsure
For applicant's reference:

LMA: The area benefit category is the most commonly used national objective for activities that benefit a residential neighborhood. An area benefit activity is one that benefits all residents in a particular area, where at least 51 percent of the residents are LMI persons.

LMC: The limited clientele category is a second way to qualify specific activities under the LMI benefit national objective. Under this category, 51 percent of the beneficiaries of an activity have to be LMI persons. In contrast to the area benefit category, it is not the LMI concentration of the service area of the activity that determines whether the activity will qualify or not, but rather the actual number of LMI persons that benefit from the activity. Activities in this category provide benefits to a specific group of persons rather than everyone in an area. It may benefit particular persons without regard to their residence, or it may be an activity that provides a benefit to only particular persons within a specific area.

LMH: The housing category of LMI benefit national objective qualifies activities that are undertaken for the purpose of providing or improving permanent residential structures which, upon completion, will be occupied by LMI households.

LMJ: The job creation and retention LMI benefit national objective addresses activities designed to create or retain permanent jobs, at least 51 percent of which (computed on a full-time equivalent basis) will be made available to or held by LMI persons.
Download and review the below CDBG Matrix Codes. Which best matches your organization's program or project?
For public facilities and improvements, select a CDBG Matrix Code from the following dropdown menu:
For public service programs, select a CDBG Matrix Code from the following dropdown menu:
For housing programs/projects, select a CDBG Matrix Code from the following dropdown menu:
For economic development programs, select a CDBG Matrix Code from the following dropdown menu:
Monitoring requirements: Explain how the applicant will track, collect, and report income requirements from clients of the program or activity.
Applicants will be required to provide quarterly and a final close out reports indicating the total LMI persons/households and Fair Housing protected groups that benefited from the activity.
For construction projects only. Describe your organization's experience with Davis-Bacon Act requirements for federally funded construction projects. Explain your understanding of prevailing wage regulations, your process for ensuring compliance, and provide specific examples of past projects where you have successfully implemented Davis-Bacon wage standards. Are you new to Davis-Bacon requirements? Don't worry. Describe the steps you will take to learn and implement these federal wage requirements.
For all things Davis Bacon, please refer to the following U.S. Department of Labor website: https://www.dol.gov/agencies/whd/government-contracts/construction

4. Program/Project Budget
Please indicate if the applicant has financial management policies and procurement standards in place that meet the federal regulations regarding the expenditure of federal funds pursuant to 2 CFR Part 200.

YesNo
Is the requesting organization a past recipient of Prescott CDBG funds?

YesNo
Please indicate if the applicant will accept a partial award of funds. By selecting “No” the application will only be evaluated for award based on the full amount of the request.

YesNo
Budget Submission Options: Download the provided budget template ("Attachment A" for public service programs, "Attachment B" for construction projects). Create your own budget document using the template as a guide. Submit a budget document specific to your organization that clearly follows the same line-item format and includes all required budget categories.
Upload your program/project budget:

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Describe plans to use other funds on the program/project. In this section only describe funds that are secured. Provide the source of funds, amounts, and how these funds will be used. Make sure to identify all other government funding in detail.

Completing the Application
Are the financial statements of the organization prepared in accordance with generally accepted accounting principles?

YesNo
Was an audit of financial records obtained annually (or biennially)?

YesNo
Please attach a copy of your current audit summary letter, and / or your income statement / balance sheet.

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Please attach any other documents which are pertinent to the proposed program/project. Other documents could be, but are not limited to: quotes from contractors, building plans, pictures highlighting the urgency of need, available public flyers and/or education materials, etc.

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REQUIRED CERTIFICATIONS FOR CDBG PUBLIC SERVICES and CONSTRUCTION ACTIVITIES APPLICATION: The Agency Representative with Binding Authority below certifies the following statements:

The organization has no conflict of interest with the City of Prescott appointed or elected representatives under the provisions of ARS Title 38, Chapter 3, Article 8 regarding conflict of interest and exceptions thereto, and including the City of Prescott Procurement Code dated September 23, 2004.

The organization will comply with federal requirements to be observed by organizations being funded with CDBG/HUD funds, including compliance with Federal Labor Standards, Section 3, Segregated Facilities, Equal Opportunity, and Non-Discrimination; Section 109, Title VI and EO 11246. All requirements are described in 24 CFR 570 (CDBG Entitlement Grants).

Sufficient supplementary funds are available from non-CDBG sources to complete the project, as described, if CDBG funds are allocated to the applicant.

The authorized official’s signature below certifies that this CDBG Application Package has been reviewed and all information provided in this application and any
attachment(s) thereto are true and correct.
First Name Last Name Signature Date Position
Should be Empty:

Community Development Block Grant (CDBG) Application

1. Basic information

2. Program/Project Details

3. Meeting HUD Guidelines

4. Program/Project Budget

Completing the Application