<p> Office use only Date Received Time Received Receiver’s Initials </p><p>Homelessness Partnering Strategy (HPS) 2014-19 Application for Funding </p><p>FUNDING STREAMS:</p><p> DESIGNATED COMMUNITIES</p><p>SECTION 1 – APPLICATION FORM</p><p>A) Applicant information Organization type</p><p>Private Not for profit Municipal Health care/social service/educational institution</p><p>Other: Legal name of organization Phone number Fax number</p><p>Name of organization if different from the Legal name Web site</p><p>Mailing address </p><p>Contact name and title Phone number E-mail address</p><p>Number of employees Is a collective agreement in If applicable, has union concurrence been in organization place? received in writing?</p><p>Yes No Yes No N/A </p><p>Language of correspondence Incorporation number Incorporation date (MM-YYYY) French English (Charter/letters patent)</p><p>Business number GST numbers Tax refund percentage (Canada Revenue Agency)</p><p>Organization’s mandate</p><p>B) Legal signing officers 1. Contribution Agreement (according to letters patent or other incorporating documents) Title Name Specimen Signature 1</p><p>2</p><p>3</p><p>4</p><p>September 2011 1/4 Office use only Date Received Time Received Receiver’s Initials </p><p>5</p><p>6</p><p>7</p><p>How many signatures are required to bind the applying organization into a legal agreement? ► </p><p>From among these authorized signatures, what is the position title of the officer(s) whose signature is always required to bind the applying organization into a legal agreement? </p><p>2. Payment Claims and other reports submitted to Canada Title Name Specimen Signature 1</p><p>2</p><p>3</p><p>How many signatures should appear on applications for payment or reports submitted to Canada? ► </p><p>From among these authorized signatures, what is the position title of the officer(s) whose signature is always required on payment claims or reports submitted to Canada? Any Two of the Three</p><p>3. Cheques Title Name Specimen Signature 1</p><p>2</p><p>3</p><p>4</p><p>5</p><p>6</p><p>7</p><p>How many signatures should appear on your organization’s cheques? ► </p><p>From among these authorized signatures, what is the position title of the signing officer(s) whose signature is always required on your organization’s cheques? .</p><p>C) Accounting practices</p><p>Accounting is done internally Accounting is done by an external firm</p><p>Contact’s name Name of the external firm (if applicable) Telephone number</p><p>Manual system Computerized system Name of software used: </p><p>Organization’s fiscal year-end: </p><p>September 2011 2/4 Office use only Date Received Time Received Receiver’s Initials </p><p>D) Insurance Do you have liability insurance? Yes No If so, please specify amount ►$ </p><p>Workers’ compensation (CSST) Rate (per $100) ►$ </p><p>SECTION 2 – PROJECT PROPOSAL </p><p>2.1 Length of project (DD-MM-YYYY) 2.2. Project Location October 1, 2014 March 31, 2015 </p><p>2.3 Project Title</p><p>Your proposal should be written as a separate document with a maximum of 10 pages 8.5 x 11 in size with 12 point font. Please submit an electronic version of the proposal and application to [email protected]. You must also supply two signed originals</p><p>Please see section 20.0 in the Call for Proposal for requirements and also include:</p><p> Project Objectives (all projects)  Proposed Activities (all projects)  Target demographic (youth, adult individuals, families) etc. (all projects)  Targets and Milestones (all projects)  Applicant’s Background and Expertise including the agencies has the resources to complete the project and comply to the reporting expectations (all projects)  Completed Housing First Readiness survey (submissions are for a pilot project)  Latest agency audited financial statement (all projects)  Sustainability plan (please see Directives) (all projects)</p><p>SECTION 3 - BUDGET</p><p>PLEASE INCLUDE WITH YOUR SUBMISSION (all projects) a. Detailed project budget b. Cash flow projection for project c. Latest agency audited financial statement d. Current budget showing projected and actuals to date</p><p>SECTION 4 - DECLARATION </p><p>I/we certify that the above information accurately describes my/our organization and plans related to the above-mentioned project Applicant’s name Position Signature Date (in block letters)</p><p>Applicants are responsible for showing that the proposed project meets the HPS-related requirements and procedures, and are asked to include all information and documentation relevant to the project. For clarification purposes or to complete the analysis, additional information or supporting documentation may be requested for accepted projects.</p><p>For more information please contact:</p><p>September 2011 3/4 Office use only Date Received Time Received Receiver’s Initials </p><p>Barbara Fannin, Community Investment Coordinator United Way of Durham Region Tel: 905-686-0606 Email: [email protected] </p><p>September 2011 4/4</p>