EFSP Form

Is there any additional information about your agencies' program or operations you would like to share that has not been asked for in this application? *

Are you applying for EFSP funds for Thurston County or Mason County? *

Thurston County

Mason County

Agency's Legal Name: *

Agency's Physical Local *

Contact's First Name *

Contact's Last Name *

Contact's Phone Number *

Email *

Physical Address *

Address Line 2

City *

State *

Zip Code *

Country

Mailing Address 1 *

Agency Phone *

Agency Email *

Website *

Agency's Address for Place of Performance *

EIN *

Unique Entity Identifier (UEI) Number: *

Please answer the following questions.

What is the Mission statement of the organization? *

When does your Fiscal Year Begin and End? *

Is this Agency a: *

Non-Profit

Unit of Government

Congressional District: *

District where EFSP funded services are provided: *

Are your facilities and services complain with the American with Disabilities Act? *

Yes

No

Have you been debarred or suspended from receiving funds or doing business with the Federal Government? *

Yes

No

Types of funds and amount.

Please fill in the requested dollar amount you wish to receive. You may pick as many categories as you can support in your application. You may leave sections blank if it does not pertain to you or you do not wish to receive funding for it.

Served Food:

Other Foods:

Mass Shelter:

Other Shelter

Supplies/Equipment:

Rehabilitation

Rent/Mortgage:

Utility Assistance

PPE:

For questions 1-5, please provide a narrative answer.

Describe the need for tis service for the county for which you are applying. *

How does this program meet the needs for this service? *

Do you serve a unique population? If yes, please describe how unique it is. *

Clearly describe how the funds from this phase will be used and spent per EFSP guidelines. *

Please Attach:

A detailed PROGRAM budget. *

This is to include the proposed EFSP funds, income, and expenses.

Copy of the most recent annual audit. *

A roster of agency's board

If agency is an non-profit.

The above-named organization agrees to: *

Practice Nondiscrimination.

To the extent possible, involve homeless individuals and families in providing emergency food and shelter services.

Deliver services in alignment with the program's purpose.

Maintain proper documentation for all expenditures under this program in accordance with guidelines.

Submit reports to the Local Board by their due date.

Work with the Local Board to quickly clear up any problems related to compliance with guidelines.

Read and abide by manual provided on the EFSP website.