Emergency Food & Shelter Program Phase 40 | United Way of Harrison and Doddridge Counties

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Agency

Executive Director

Contact Person

Email Address

Office Phone/Cell Phone

Fax

Federal Employer Identification Number (FEIN)

UEI # (Required by EFSP National Board)

1. Provide mission statement and brief summary of agency function, including client population and geographic area served.

2. List client eligibility guidelines.

Rent/mortgage: Amount of funding requested and number of clients to be served.

Utilities: Amount of funding requested and number of clients to be served.

Mass Shelter: Amount of funding requested and number of clients to be served.

Other Food: Amount of funding requested and number of clients to be served.

Served Meals: Amount of funding requested and number of clients served.

Supplies/Equipment: Amount of funding requested and number of clients to be served.

Rehab/Emergency Repairs: Amount of funding requested and number of clients to be served.

4. Please briefly explain how your organization will use this funding to help individuals and families by providing emergency food, shelter services, rent and utility assistance or other.

5. Are similar services offered throughout Harrison County? If so, provide an explanation for the use of funding to meet a specific need. If so, describe coordination with the other similar services AND/OR give reason(s) if no coordination is necessary or possible.

6. This application reflects a request for funds specific to food and shelter. Explain how the agency plans to support these services with additional funding. Supporting information may include agency budget or summary of financial information. Financial information must include line item budget amount referenced for each EFSP category with summary of all available funding.

Please type the name of the certifying applicant. This will serve as a signature for the application.

Date

This form is due on or before March 24, 2023.

Please submit a copy of your non-profit 501c3 IRS verification if it is not already on file at United Way of HDC.

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