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2012 Intent to Apply for Balance of State Emergency Solutions Grant Funds Form
This form is for agencies that intend to apply for State ESG funding through the BoS CoC in the 2012 cycle. Please answer all of the questions. If you have any questions, please contact NCCEH at 919-755-4393 or
bos@ncceh.org
.
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* Indicates required question
Name of Organization
*
Your answer
Counties Served by Your Agency
*
Your answer
Contact Person
*
Your answer
Title
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Agency Website
Your answer
Did your agency receive ESG funds for June 2011-June 2012?
*
Yes
No
If yes, what was the amount?
Your answer
Did your agency receive HPRP funds?
*
Yes
No
If yes, what was the amount your agency received from July 2011-June 2012?
Your answer
What general population will your program serve?
*
Families with Children
Individuals
Both Families and Individuals
Will your program serve victims of domestic violence?
*
Yes
No
Interested in applying for (check all that apply):
*
Shelter Operations Funding
Rapid Re-housing Funding
Prevention Funding
Required
What Regional Committee of the Balance of State do you belong to?
*
Your answer
Do you, or someone from your agency, attend Regional Committee meetings?
*
Yes
No
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