Emergency Food and Shelter Program Phase 41&42 Agency Application

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Check jurisdiction *

Montgomery County PHASE 41 (870200) $32,868
Montgomery County PHASE 42 (870200) $28,153
Radford City PHASE 41 (883400) $7,252
Radford City PHASE 42 (883400) $6,309
Pulaski County PHASE 41 (873000) $10,537
Pulaski County PHASE 42 (873000) $8,848

Funds are only available to be utilized in the jurisdiction awarded in.

Check funding source

Federal
State Set-Aside

FEIN (Federal Employer ID#) *

FSP LRO# for this jurisdiction (3 digits)

Agency UEI (Unique Entity Identy) *

Legal name of agency *

Name of program (if applicable)

Agency's Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Congressional District of physical address *

Agency's Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Congressional District where services are provided *

Service Delivery Address *

Address Line 1

Address Line 2

City

State

Zip Code

Program or Agency website *

Agency Principal Name *

First

Last

Agency Principle Title *

Agency Principal Phone Number *

Is applying agency/proram affiliated with New River Community Action *

Agency Principal Email Address *

for New have

EFSP Contact Name *

EFSP Contact Title *

EFPS Phone Number *

EFSP Contact Email Address *

Check ONE *

Government Agency
Private, Non-Profit Agency

Is applying program affiliated with New River Community Action? *

Is agency debarred or suspended from receiving funds or doing business with the Federal government *

If Private, Non-Profit, is your agency classified by the Internal Revenue Service as a 501(c)(3) organization? *

If Private, Non-Profit, is your agency listed with the Virginia Office of Consumer Services for Charitable Contributions? *

If Private, Non-Profit, does your agency have a volunteer board? *

(A volunteer board is one where board members do not receive any compensation for their board services and paid staff does not serve in voting positions.)

Does your agency have an accounting system or fiscal agent? *

If expending $750,000 or more in federal funds – do you conduct an annual audit in compliance with 2CFR of the Federal OMB? *

Total Agency Budget (Programs and operations) *

Upload copy of agency's IRS Exemption Statement certifying 501 (c)(3) status of applying organization

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Upload copy of agency's most recent audit

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Board Roster

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With this application, attach the agency section of the budget for the service area/s requested (food, rent, utilities, etc.)

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