Community Development Block Grant Form

Community Development Block Grant Form

Applicant Information

Project Summary

Project Title:

Census Tract or Block Group (if known):

Budget Breakdown

Provide a detailed budget for activities to be funded by the grant. Enter amounts in U.S. dollars.

Funding Sources

List other committed or anticipated sources of funding for this project and the amount from each source.

Compliance and Certifications

By submitting this application, the Applicant certifies under penalty of perjury that the information contained herein is true and correct to the best of the Applicant's knowledge. The Applicant further certifies that, if awarded funds, the Applicant will:

• Use grant funds only for the activities and budget items described in this application and in compliance with applicable program requirements and procurement standards;
• Maintain required records and make records available for inspection and audit by authorized representatives;
• Comply with applicable nondiscrimination policies and applicable labor and wage standards where required by law;
• Notify the grant administrator promptly of any change in project scope, budget, or schedule and obtain written approval prior to reallocating grant funds;
• Disclose any potential conflicts of interest and refrain from benefiting employees, officers, or board members except as allowed under applicable rules.

The Applicant acknowledges that award of funds is subject to program availability, review of required documentation, and execution of a formal grant agreement containing standard conditions, audit rights, and termination for cause provisions.

Assurances and Attachments

The following items must be attached or provided with this application where applicable. Check each box to indicate inclusion or state when the item will be provided.

Administrative Use Only

Application received by:    Date received:

Review status:

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