No. 1252 Feb. 5.

2010 4:00PM

p,

EFSP
Agency's Legal Name Agency Principal Agency Contact for Application Questions Agency Contact for EFSP, iffunded Agency physical address Agency tnaiHng address Agency address for services Agency phone Agency fax. ~ Agency email (for individuals above) .

Emergency

Food and Shelttlr

._' !'Iiltio~t!lB~ardrogram P

Agency web site

CD"Q,Df'

Agency Federal Employer Identification Numbe~'(FErn) Amount of EFSP funding requested by program area (food. !ent~ utilities, etc.)
Agenoy operating budget (total) Agency budget for the program requested (food. rent, utilities, etc.) annual audit area

34 - \\ 2)lLD D \
$1.50D. ()O

$ $

J /

i q I P DO. QQ . ;\INI se n) ()/- (YJ e a t.s

(j5CO. cr>

Provide copy of agency's most recent Is agency non~pro:fit or unit

of

government?

If non-profit

- provide a J.'oster of the agency's volunteer board

Deadlino (date and time) for applications to be received (including contact, mailing address, location for d~livery)

64

Feb.

4.

2010

10: 14AM

No. 1245

P.

LOCAL RECIPIENT ORGANIZATION CERTIFICATION FORM

ero be retained by Local Board)
'\s a recipient of Emergency Food anp Shelter National Board Pr0S'l:aInfunds made available for :Phase July authorized representative ?rivateorganization:
~'...

').7 and a6

the

O.EY~PI\f'eC\~ti\lr\-t~f1i'J{Y1mi<;:-'\"'~ ( MBOFLRO)
n'~N~

fin ftljtn3' I certify that my public or

'.-~~~t4e'b;:;~"'J.P enaf'i:I;fr!)fu:;' .Oi,6U~ ... "' 1."... ,. " 't"~)- " .

e"

~ii;iii'\;Pe-di:~,Ii!j,;~tldsj ". ",g_ .._.,._.':tI'~ _

.

Has the capability to provide em~rgency food mdj or shelter services, Will we funds to suppleme1'\t and extend existing re6()urc~S and not to Substitute or reimburse ongoing programs and service~, Is nonprofit or an agency of govemment Has an accounting system, and will pay aU vendorfl by LRO check, LRO vendor issued credit card or LRO debit card, Will conduct an independent annual review /audit if receiving $25.000 or more in EFSP funds. Unden:tandG that ~;\$h payments (Including peU" caSh)are not eligible under EFSP.
Has a Federal Employer Identification Number (FEIN),

Practices non-discrimination (LROs with a religiolls affiliation will not refuse service to an applicant based on religion- nor engage in religious proselytizing or religious counseling with Fedet'a! ftmds),

H~sa '9'olun.taryboard if private, not.forAprofit,

Will comply with the P~e 27 Responsibilities & &quirements Manual, particularly the Eligible and Ineligible Costs section, and~ inform appropriate staff or volunteers or EFSF requirements, . Will provide all required reports to the Local Board in a timely manner; (e.g., SecOnd Payment/Interim and Final Reports), Will expend monies only on eligible cos~ and keep complete documentation (copies or canceled LRO checks - front and back, invoices, receipts, etc.) on all expenditures for a minimum of three years
after end of program.

Will svend an funds and dose-out the prop-am by my jurisdiclion's selected end-oI-program date <lnd retum any unused funds to the National Board ($5.00 Or more; make checks payabJe to UX\\~ed Way of America/Emergency Food and Shelter National 'BoardFrogram)J
Wilt provide complete documentation of eXpenilesto the Local Board. if requested, no later than one month foIlowjtlg my jurisdictionS selected end-ai-program date, Will comply with the o.ffice of Management and Budget Circi.tlar A-133 if expending $500,000 or m.ore Federal funds .

ill

Will comply with lobbying prohibition certification and disclosurE:of lobbyh\g <lcnviHesif receiving $100,000 or more ill '2FSP lunds, if applicable, and
Has no known EFSP compliance exceptions in this Orany other jurisdiction.

Please check 0 Ha'Ve read, understand Re'nth-eJt\ent$ Manual

and agree to abide by the BFSr

Respo:MibiUties and

Signature;,

PlintName:
Date:

'~rIJ(\1\
t>a ~CJ . II

~\6Y~

n
Lo D

LROID#:

FEIN#:

3Y_- nee

Address:

If) ~\VP(.siOf

.l\c
\ i!\--\

~L'( il\.>

City/State/Zip:

,J~i\'1\1

L\4~<6o

Feb.

4.

2010

10: 14AM

No, 1245

p,

CERTIFICATION REGARDING LOBBYING

Cettification for Contracts, Grants, Loans, and Cooperative Agreements The undersigned certifiesl to the best of his or her knowledge and belief, that: 1. No Federal appropriated funds ha'V'e been paid or will be paid by or on the behalf of the undersigned, to any person for influencing or attempting to influence an offker or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congr~ss in connection with the awarding of any Federal contract...he making of any Federal grant, the making of any Federal t loan... the entering into of any cooperative agreement, and the extensionl contribution, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. 2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract...grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form LLL,"Disclosure Form to Report Lobbying," in acco:r:dance with its instructions. 3. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tie:r$(including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and tha.t all sub-recipients shall certify and disclose accordingly. This certification is a roaterial.repl'esentation of fact upon which reliance was placed when this transaction WaS made or entered into. Subnrl5$ion of this certification is a prerequisite for making or entering into this transacrron imposed by Title 31 U.S.c. 1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

LRO Name

j p n~c n. {'IOU ~\ D{\.

~3

'

rDfI'\f\\ \S~\r:;'\

Local Board ID number

Name/Signature

Date

NOTE: Standard Form LLL and instructions are available from the National Board
office.