Small Grants Combined Eligibility and Application FormCOMMUNITY PRESERVATION
COMBINED SMALL GRANT
ELIGIBILITY AND APPLICATION FORM
SMALL GRANTS COMBINED ELIGIBILITY AND APPLICATION INSTRUCTIONS
Please familiarize yourself with the relevant portions of the CPC Plan at a minimum: eligibility (Appendix A, Allowable Use Table), general evaluation Criteria, and applicable program
criteria.
Please consult with the CPC staff prior to submitting any application materials. Coordinating early will help ensure that your proposal is eligible for CPA funds, and increase the chances
of a favorable decision. CPC staff can be reached at 413-587-1263.
Complete the Combined Eligibility and Application Form.
We would prefer that you keep to the space provided. But if you need additional space, please continue on separate pieces of paper; number all the pages submitted. Ten copies are required.
Attach any letters of support, funding commitments or landowner permission
Attach any of the following if relevant:
photographs, renderings or design plans of the site, building, structure or other subject for which the application is made
USGS topographical map, assessors map, or other map as appropriate, showing location of the project
Information regarding Natural resource limitations (wetlands, flood plain) or zoning (district, dimensional and use regulations as applies to the land)
Mass. Historic Commission Historic inventory sheet
Historic structure report or existing condition reports
Names and addresses of project contractors, and consultants
Evidence that appropriate professional standards will be followed if construction, restoration or rehabilitation is proposed.
Project Title:
Project location, including address and parcel number:
Project Sponsor/Organization:
Contact Name:
Property Owner, if applicable:
Mailing Address:
Daytime phone #:
Fax #:
E-mail address:
For the following, please refer to the Small Grant Eligibility Chart: http://northamptonma.gov/DocumentCenter/View/4185
CPA Program Area (check those that apply):
� Open Space � Historic Preservation
� Community Housing � Recreation
Project Purpose (check those that apply) :
� Preservation
� Rehabilitation/Restoration
Applicant’s Signature: ____________________________
Date Submitted: ____________________________
For CPC Use Eligible: _____ Not Eligible: _____ Date: __________ Reviewer: ____________________
Appropriate for Small Grant Process_____
Referred to Traditional Funding Round______
Total Project Budget (not to exceed $6,000.00): $
CPA Funding Request (not to exceed $3,000.00): $
Funding from other sources: $
List any in-kind donations of labor or materials:
CPA Request as % of Total Budget: $
Budget Summary: Please specify how CPA funds will be spent. Itemize all projected expenditures. If budget is based on a quote, please attach it. List any additional funding sources
or donations of in-kind service. These funds must be secured at the time of application, as evidenced by a signed commitment letter referencing the content of the application, and including
any restriction on the use of funds.
1) Please provide a brief description of the project.
2) What Community Preservation criteria – both general and program-area specific – does this project meet? Please refer to the Overview CPA Plan Section, Page 6), and applicable program
criteria. (Historic Preservation – Page 14, Community Housing, Page 22, Open Space, Page 24, Recreation, Page 31)
3) What community need(s) does this project serve? If the project serves multiple needs and populations, please describe them. If the project serves a population that is currently
underserved, please describe.
4) What specific guarantees will assure the long-term preservation of the project?
5) What community support does the project have? Explain the nature and level of the support.
6) How will the success of this project be measured?
7) Is ongoing maintenance and upkeep required? If yes, please explain how this will be accomplished.
8) Explain the various steps of the project and when they will be completed
9) Provide any additional information you think would be useful in considering your project.