CITY OF CHARLESTON, WEST VIRGINIA

GENERAL INFORMATION

Name of Project/Program:

Organization Name:

ADDRESS

Address Line 1

Address Line 2

City/Town

State/Province

ZIP/Postal Code

PRIMARY CONTACT PERSON

First Name

Last Name

Title

Phone

Email

Federal Tax ID :

If applicable: DUNS Number:

To obtain a DUNS number please visit https://fedgov.dnb.com/webform After obtaining, please register your organization with the System for Award Management at https://sam.gov/SAM/

List organization owner(s), Board of Directors, senior staff members, and other key members.

Describe any partner organizations, their roles, and your relationship with them :

BUDGETARY OVERVIEW – Must match Budget Worksheet

Funds Requested	Total Program/Project Cost	Annual Organization Budget
$	$	$

1. The funding will be used to:

2.If funded, will the program/project be completed within FY 2022?

Yes

If No, expected completion Year:

Please check all that apply:

Public Health

Negative Economic Impacts

Premium Pay

Infrastructure

Services to Disproportionately Impacted Communities

Other…

4. Briefly describe the program/project funds are requested for:

5. Describe the need for your program/project

1. Identify the target recipients of proposed services. Specify the number of City residents the program will serve during the fiscal year and explain the basis upon which this number is calculated:

3. If this is a continuing activity, describe a measurable outcome of your previous year's work regardless of funding source.

Name	Estimated Funding for this Project/Program
Proposed City ARPA Funding	Amount $
Other Government Grants - list:	Amount $
Other Grant	Amount $
Other Grant	Amount $
Donations/Other Fundraising	Amount $
Internal/Self-Funding	Amount $
Other – list:	Amount $
TOTAL REVENUES	$ 0

Expense Category	Amount Requested from City	Amount from Other Sources	Total Estimated Program/Project Expenses
Salaries/Wages	Salaries/Benefits_amt $	Salaries/Benefits_amtG $	Salaries/Benefits_amtG3 $
Benefits & Matchings	Occupancy_amt $	Occupancy_amtP $	Occupancy_amtP1 $
Contracted Services	Professional Fees/ Contracted Services_amt $	Professional Fees/ Contracted Services_amt4 $	Professional Fees/ Contracted Services_amt44 $
Program Materials	Program/Office Materials_amt $	Program/Office Materials_amt1 $	Program/Office Materials_amt12 $
Marketing	Marketing/Printing_amt $	Marketing/Printing_amt1 $	Marketing/Printing_amt11 $
Supplies	Professional Development_amt $	Professional Development_amt1 $	Professional Development_amt11 $
Other - List:	Supplies/Materials_amt $	Supplies/Materials_amt1 $	Supplies/Materials_amt14 $
Other:	Salaries/Benefits_amt $	Salaries/Benefits_amt1 $	Salaries/Benefits_amt12 $
Other:	$	$	$
TOTAL EXPENSES	$ 0	$ 0	$ 0

NOTE: Revenues and Expenses must balance, and the use of requested funds must be directly related to COVID-19 recovery efforts.

1. Describe the history of your organization and its current programs and activities:

2. Provide your organization’s mission statement/purpose:

Signature

Today's Date

PRINTED NAME:

TITLE OF APPLICANT :

ORGANIZATION NAME:

CITY OF CHARLESTON, WEST VIRGINIA

American Rescue Plan Act (ARPA)

Funding Application

Non-Profit, Community Groups, Neighborhood Associations, and Businesses.

APPLICATION DEADLINE: November 30th 2021

Request Summary

REQUESTED BUDGET WORKSHEET

Revenue Source Projections

THE APPLICANT UNDERSTANDS:

City Hall