1Statement of Responsibilities2Applicant Information3Funding Request4Budget Narrative5Agency Narrative6Authorization Statement of ResponsibilitiesWhich county are you applying for?(Required)If you are applying for more than one county, please submit a separate application for each.Select OneBryan CountyEffingham CountyLiberty County I certify that my organization: Is a non-profit or agency of government Is not debarred or suspended from receiving Federal funding Has a checking account and can accept EFT Has an accounting system or fiscal agent that will pay all vendors by an approved method of payment Has a Federal Employer Identification Number (FEIN) Has or will be able to attain a Unique Entity Identifier (UEI) Has a valid email address for program communication and electronic signature processes Has conducted or will conduct an independent annual audit if receiving $100,000 or more in EFSP funds Has conducted or will conduct a yearly audit if expending $750,000 in Federal funds, in compliance wit the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards at 2 CFR 200 of the Office of Management and Budget (Uniform Guidance) Provides services and uses other resources in the area in which I am seeking funding Practices nondiscrimination (Agencies with a religious affiliation just not refuse services to an applicant based on religion or require attendance at religious services as a condition of assistance, nor engage in religious proselytizing or religious counseling in a program receiving Federal funds) Have a voluntary board if private non-profit To the extent possible, involve homeless individuals and families through employment, volunteer programs, etc., in providing emergency food and shelter services Will comply with the program requirements as detailed on the EFSP website: https://www.efsp.unitedway.org/efsp Statement of Responsibilities(Required) **Yes, the information above is accurate and true.**(Required) Our agency certifies that we have read and understand the Local Recipient Organization responsibilities listed above.(Required)Please InitialOur agency agrees to comply with all Emergency Food and Shelter Program requirements.(Required)Please Initial Applicant InformationAgency's Legal Name(Required) Agency Principal (Board President or Executive Director)(Required) First Last Agency Principal - Phone Number(Required)Agency Principal - Email(Required) Agency Contact for EFSP Application and Grant (If Funded)(Required) First Last Agency Contact - Phone Number(Required)Agency Contact - Email(Required) Agency Physical Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Agency Mailing Address (If Different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Federal Employer Identification Number (FEIN)(Required) 501(c)3 Tax Certificate(Required)Accepted file types: jpg, pdf, png, Max. file size: 6 MB.Unique Entity Identifier (UEI)(Required) Proof of UEI(Required)Accepted file types: jpg, pdf, png, Max. file size: 6 MB.Agency Type(Required) Nonprofit Government Funding Request See the Guide to Eligible Spending to ensure that your agency will charge EFSP only for allowable expenses. Served Meals (Direct costs or $3/meal)Amount RequestedPeople Served Add RemoveOther FoodAmount RequestedPeople Served Add RemoveMass Shelter (Direct cost or $12.50/night)Amount RequestedPeople Served Add RemoveOther ShelterAmount RequestedPeople Served Add RemoveSupplies/EquipmentAmount RequestedPeople Served Add RemoveRehabilitation/Emergency RepairsAmount RequestedPeople Served Add RemoveRent/MortgageAmount RequestedPeople Served Add RemoveUtilitiesAmount RequestedPeople Served Add RemoveIs your agency a fiscal conduit/fiscal agency?(Required) Yes No If yes, for how many agencies? Budget NarrativeBudget Narrative(Required)Please provide an explanation for each category of funding requested. How will the funds be used? How else is your agency funded for these categories? How does your request fit into your overall agency budget for these categories? Agency NarrativePlease answer the following questions in approximately two to five sentences.1. Describe your agency's mission.(Required)2. Provide a brief overview of the programs/services your agency will provide with EFSP funding.(Required)3. What cities or neighborhoods does your agency serve?(Required)4. How many people were served by your agency in 2022 year-to-date?(Required)5. What is the target population for your EFSP program?(Required)6. What challenges does your agency encounter in serving this population?(Required)7. What is the screening process for persons seeking food assistance?(Required)8. How are program services tracked/monitored and who reviews the information?(Required) Authorization of InformationAuthorization(Required) I attest that the provided information is true and accurate to the best of my knowledge. Name(Required) First Last Signature(Required)Date(Required)MM/DD/YYYY MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
