HomeMy WebLinkAboutOshkosh NonProfit ARPA Questionare 1
American Rescue Plan Act (ARPA)
Funding Application
Non-Profit, Community Groups, and Neighborhood Associations
DEADLINE: Friday, July 2, 2021
Application must be completed in full to be considered.
Submit complete application & budget sheet electronically to citymgr@ci.oshkosh –or-
Mail - City Managers Office, 215 Church Ave – PO Box 1130, Oshkosh WI 54903-1130 -or-
Place in City Hall Dropbox
Attachments, brochures or other materials may be included as part of the application packet.
The electronic version (including email message and all attachments) cannot exceed 10 MB
GENERAL INFORMATION
1. Name of Project/Program:
2. Organization Name:
3. Address:
4. Primary Contact Person:
5. Title: PHONE:
6. E-mail
7. If applicable: Federal Tax Identification Number:
8. If applicable: DUNS number:
Provide Mission Statement/Purpose:
PROPOSAL OVERVIEW – must match Budget Overview sheet
Funds Requested Total Project Cost Annual Organizational Budget
$ $ $
2
PROPOSAL DETAILS
(Please limit to 700 words)
1. PROGRAM/PROJECT APPROACH – include the following details, as applicable:
a) Briefly describe the program/project you are requesting funds for.
b) Describe the need for your program/project.
c) Identify any other organizations in Oshkosh that address this need.
d) Describe your level of collaboration with other agencies on this project.
e) Is this a new, existing, or changed program?
f) Specifically, what will you use ARPA funds for?
g) Who will benefit and how?
h) How will you prevent the duplication of benefits to end users?
i) How many individuals/families will be served by this program/project?
j) How will these funds help you respond to, or recover from COVID-19?
k) For existing programs: How many people were served during the last program
year? How many were from the City of Oshkosh?
l) If existing, describe measurable impact has the program achieved to date (with
examples)
2. PROJECT OUTCOMES
a) If this is a continuing activity, describe a measurable outcome of your previous
year's work regardless of funding source.
b) Describe two anticipated measurable outcomes for your proposed
project/program.
3. DESCRIBE THE AGENCY'S AUDITING AND FISCAL CONTROLS
a) Briefly describe your agency's fiscal oversight / internal controls to minimize
opportunities for fraud, waste and mismanagement.
b) How does your agency plan to segregate ARPA funds from other agency funds
for purposes of identification, tracking, reporting and audit?
4. CONTINGENCY PLAN
a) If your grant request is not fully funded, what adjustments are you prepared to
make?
5. PROJECT BUDGET
a) Briefly explain project revenues and expenses related to this proposal. This
should match with the Budget Overview sheet.
b) Be specific about how ARPA dollars would be spent.
PLEASE COMPLETE THE ATTACHED BUDGET OVERVIEW AND SUBMIT
WITH YOUR APPLICATION.
3
2021 BUDGET OVERVIEW / INCOME AND EXPENSES
ORGANIZATION NAME: ____________________________________________________
REVENUE SOURCE PROJECTIONS
Estimated
Funding for this Project/Program
Proposed ARPA Funding
Other Government Grants - list :
OACF Funding
OAUW Funding
Donations/Other Fundraising
Internal/Self-Funding
Other – list:
TOTAL REVENUES $
EXPENSES
REGULAR OPERATING
EXPENSES
Project/Program
Budget
(PROPOSED)
Salaries/Benefits
Occupancy
Professional Fees/
Contracted Services
Program/Office Materials
Marketing/Printing
Professional Development
Supplies/Materials
Other – list:
Other – list:
Other – list:
COVID RELATED EXPENSES
(please identify)
Other
Other
Other
TOTAL EXPENSES $
NOTE: Revenues and Expenses must balance
4
THE APPLICATION CERTIFIES TO THE BEST OF ITS KNOWLEDGE:
1. The information submitted to the city of Oshkosh (“City“) in this application, and
substantially in connection with this application, is true and correct.
2. The applicant is in compliance with applicable laws, regulations, ordinances and
orders applicable to it that could have an adverse material impact on the project.
Adverse material impact includes lawsuits, criminal or civil actions, bankruptcy
proceedings, regulatory action by a governmental entity or inadequate capital to
complete the project.
3. The applicant is not in default under the terms and conditions of any grant or loan
agreements, leases or financing arrangements with its other creditors that could have
an adverse material impact on the project.
4. The applicant has to close, and will continue to disclose, any occurrence or event that
could have an adverse material impact on the project.
THE APPLICANT UNDERSTANDS:
1. This application and other materials submitted to the City may constitute public
records subject to disclosure under Wisconsin’s Public Records Law. The applicant
may mark documents “confidential” if the documents contain sensitive information.
2. Submitting false or misleading information in connection with an application may result
in the applicant being found ineligible for financial assistance under the funding
program, and the applicant or its representative may be subject to civil and/or criminal
prosecution.
YES NO (circle one) I certify that the requested funding is needed to ensure this project will
happen in the City of Oshkosh.
Signature Date
Authorized representative of Applicant/Organization
PRINTED NAME:
TITLE OF APPLICANT:
ORGANIZATION NAME: