CDBG-Northampton-ADA-Ramps-WF1-24-2019CITY OF NORTHAMPTON
Community Development Block Grant Funding Application
For Construction, Public Infrastructure, Public Facilities and Demolition
Projects
DATE:
I.APPLICANT Agency Name
Address
Federal Tax ID ______________ DUNS #_____________
Registered in www.sam.gov? Yes No
This project is federally funded, a DUNS No and registration in the System
for Award Management (SAM) is required. Documentation of registration
is required. Register at www.sam.gov
Contact Person
Phone Number
E-mail Address
Development Consultant
II.REQUEST FOR CDBG FUNDS
Type and Amount:
III.PROJECT
Address
Description (rehab vs. new construction, # of units, rental vs. ownership, unit sizes)
Describe site (relevant environmental concerns, proximity to public transportation,
neighborhood amenities, etc.)
Describe nature and extent of rehab or new construction
IV.NEED
Describe public benefit to be derived from the project:
Intended Beneficiaries:
Describe how the project will impact the City’s prioritized community development
needs:
_______
V.UNIT COMPOSITION AND RENTS
# Units Below
Market Market Proposed Rent
Bedroom Mix Rate Rate with Subsidy Without
#1 bdrm.
#2 bdrm.
#3 bdrm.
#4 bdrm.
# of units available to: % of total units
Households with < 30% of median income:
< 60% of median income: _______________
< 80% of median income: _______________
VI.FINANCIAL INFORMATION:
Total project costs
Total cost per unit
Project Cost Breakdown:
Pre-Development
Acquisition
Rehab/New Construction
Site Improvements
ENCLOSE: Letters of commitment from secured funding sources.
Financial pro forma for a 10 year operating period.
List Funding Sources Secured or Sought
Source Type Amount Use of Funds Status
1.
2.
3.
VII.USE OF CDBG FUNDS: Describe the purpose of the CDBG funds:
What % of the total project cost will be covered by the CDBG funding?
Describe why this amount of CDBG funding and the terms outlined are necessary
for the success of the project?
VII.AFFORDABILITY:
Describe the affordability mechanism to be used and duration:
Describe how the rents or sales prices will be restricted and for how long:
VIII.PROJECT IMPLEMENTATION:
Yes No
Yes No
Yes No
Yes No
Will lead paint abatement be occurring?
Will asbestos abatement be occurring?
Does the project involve changes in land use from non-residential to residential or from one type of residential zoning to another?
Does the project involve a zone changeor other zoning permits?
Will the project involve any temporary or permanent relocation of residents?Yes No
If relocation will occur, please describe:
Describe time line proposed and project phases:
Describe state and/or local permits required:
Describe the contractor selection process and plans for construction supervision:
Describe the efforts to comply with Section 3 hiring practices:
IX.DEVELOPER QUALIFICATIONS:
List members of the development team and describe their qualifications:
Describe selection method if not yet selected:
Describe past experiences/projects:
Describe qualifications of property manager (if rental project)
ENCLOSE THE FOLLOWING: for the Project Owner and Project Sponsor
-Most recent 12 month financial statement, including at a minimum a balance
sheet and revenue and expense statement; (audited if available)
-Interim financial statement (if more than 12 months has lapsed since date of
annual financial statements), and;
-Current year’s organizational budget
-Evidence of www.sam.gov registration
X.SUPPLEMENTAL INFORMATION: (Please include if the documents exist)
Evidence of Site Control (if not included, please explain status
of site control) -- all projects are on public rights-of-way
Purchase and Sale Agreement
Property/Building Appraisal
21 E Report
Site Plan
Rehab/Construction Specifications
Construction Cost Breakdown
Evidence that Rents/Sales Prices can be supported by the
market
Sources and Uses of Funds Statement/ Spreadsheet
Rental Project/ provide 5 year operating budget
Ownership Project/ demonstrate sales price affordability to target
population
Equal Opportunity Statement
________________________________ (company name) will not discriminate against
any employee or applicant for employment because of race, color, sex, age, religion,
handicap or national origin and takes affirmative action to ensure applicants are
employed and employees are treated equally during their employment without regard
to race, color, sexual orientation, gender identity, veteran or disability status.
Note: Any questions about this application and the submission materials required can
be referred to the Housing Planner at 587-1288 Mon. - Friday 9:00 a.m. to 5:00 p.m.
Office of the Mayor, City Hall, 210 Main Street, Northampton, MA, or at
pkeller@northamptonma.gov
APPLICATION PREPARED BY:
Name
Title
Organization
e-mail Address
Date Received:
(For office use only)
Rev. Jan. 2019