KENTUCKY FUNDERS TABLE:  RECOVERY/MITIGATION FUNDING REQUEST FORM
This form has been designed to assist local governments and community agencies to request assistance from the Kentucky Funders Table (KFT).

For a disaster event to be activated under the KFT, the disaster event must meet the following criteria:

A natural or human-caused disaster event for which:
--a coordinated multi-agency response was required; and 
--local capacity has been overwhelmed; and
--insurance and government supports are not available (or not expected) to support relief or recovery.

An eligible disaster can be considered one, or a combination of, the following rapid onset events: fire, tornado, earthquake, flood, landslide, ice storm, thunderstorm, terrorist event/mass shooting, chemical spill/leak.  Other scenarios will be considered on a case-by-case basis.

In order to be eligible for a KFT activation, the requesting entity must be a non-profit, church, long-term recovery group, local government or business association. 

For preparedness / mitigation requests specifically, the request must meet the following criteria:

--Funding requested must be specifically dedicated to reducing the impact of disaster, or breaking the cycle of damage, reconstruction, and repeated damage. 
--Examples of community/individual preparedness or mitigation projects range from readiness education programming, family disaster kits, building tornado safe rooms, replacing low water crossings, stabilizing stream banks, and purchasing generators for critical facilities.

Please note submitting a request is not a guarantee or commitment of funding; therefore, it is important that you thoroughly address each of the listed items in this request for funding. Your responses will be shared with other community funding sources.

Please complete and submit the questions below. If you have questions, please contact Roberta Steutermann at 502-292-5343 or roberta.steutermann@uwky.org.

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PLEASE COMPLETE THE FOLLOWING APPLICANT INFORMATION:
REQUESTING ENTITY NAME *
TAX ID NUMBER *
ADMINISTRATIVE OFFICE ADDRESS *
GRANT CONTACT *
GRANT CONTACT EMAIL *
PHONE NUMBER *
REQUESTING ENTITY WEBSITE
REQUESTING ENTITY INCORPORATION STRUCTURE *
EVENT TYPE *
Please identify the type of event for which you are requesting funding to support relief or recovery.
EVENT DATE *
Please list the date of the event.
MM
/
DD
/
YYYY
KENTUCKY LOCALITY/LOCALITIES TO BE SERVED *
BACKGROUND/IMPACT JUSTIFICATION *
Detail how the event has impacted individuals or agencies and how your local government or agency has responded to date. Include an overview of any private or public infrastructure, homes or facilities damaged. 
EXPECTED RESPONSE / RECOVERY MEASURES *
(select all that apply)
Required
DETAIL RECOVERY ACTIVITIES IDENTIFIED AS NECESSARY TO ADDRESS CRITICAL UNMET NEEDS *
List detailed activities that may be undertaken through requested grant funds to assist the community in recovering from this disaster (e.g. food, counseling for impacted residents, facilitation of temporary short-term and longer-term housing for displaced residents, facilitation of business economic recovery, capacity building, coordinating rehabilitation of impacted ecosystems, etc.)
REQUESTED FUNDING AMOUNT FOR DIRECT CLIENT SERVICES / CASE MANAGEMENT AND ASSOCIATED MATERIALS *
Insert estimated cost expected to be incurred under the above relief measure(s), if known.
REQUESTED FUNDING AMOUNT FOR REPAIR/RESTORATION/REPLACEMENT OF HOUSING, FACILITIES, OR EQUIPMENT *
Insert estimated cost expected to be incurred under the above relief measure(s), if known.
REQUESTED FUNDING AMOUNT FOR PREPAREDNESS/MITIGATION *
Insert estimated cost expected to be incurred under the above relief measure(s), if known.
WHAT IS THE CURRENT YEAR OPERATING BUDGET FOR THE REQUESTING ENTITY? *
ARE YOU WORKING WITH OTHER AGENCIES TO SUPPORT THIS UNMET NEED, OR ARE YOU AWARE OF ANY OTHER AGENCIES CURRENTLY SEEKING TO ADDRESS THIS NEED IN THE COMMUNITY? *
List any other agencies (state, local government, non-profit organization, private companies, etc) currently responding or with which you intend to partner to respond to address this specific need.
WHICH OF THE FOLLOWING KENTUCKY DISASTER RELIEF AND RECOVERY FUNDERS HAVE PROVIDED A GRANT TO YOUR ORGANIZATION WITHIN THE LAST THREE YEARS? *
Required
ADDITIONAL INFORMATION
Include any other information not detailed above to support this request.
SUPPORTING DOCUMENTATION
Click the following link to Microsoft OneDrive to upload supporting documentation for the requesting entity, including each of the following: 1) a current W-9, 2) IRS determination letter, and 3) organizational budget.  A funding decision will not be made without these documents.

Also upload any documentation pertinent to this request, e.g. Situation Reports, Road Closure Reports, Photos, etc. Additional documentation may be requested prior to a funding determination.  

NOTE: YOU MUST ALSO CLICK SUBMIT BELOW TO COMPLETE THIS FORM.

CLICK HERE TO UPLOAD SUPPORTING DOCUMENTS (THE LINK WILL OPEN IN A SEPARATE BROWSER TAB): 
KFT SUPPORTING DOCUMENT UPLOAD PORTAL
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