Recovery Management Support Services Program

STATE OF DELAWARE

APPLICATION AND CERTIFICATION

PREVENTION AND RECOVERY SUPPORT SERVICES FUND

AMERICAN RESCUE PLAN ACT (ARPA) FUNDS

Instructions

To be considered for American Rescue Plan Act (ARPA) funds, please complete this Application and Certification electronically.

This Application is not a commitment for funds, nor does it obligate the State of Delaware or any State agency to grant or lend any form of financial assistance.

The filing of this Application and Certification, and any attached documents, are considered public information subject to the Delaware Freedom of Information Act, 29 Del. C. ch. 100 (FOIA). An Applicant may request that certain documents or portions of documents submitted to be held confidential. The Applicant must state the legal basis for confidentiality. Notwithstanding the Applicant’s request, the final determination of whether the information is public record is exclusively within the discretion of the State of Delaware. The Applicant recognizes, understands, and agrees that the State of Delaware may share the information provided with other government or law enforcement agencies for investigative or auditing purposes.

I. Applicant Information

Entities eligible to apply: Nonprofit organizations, faith-based organizations, for-profit providers. Please provide the following information for your organization and any other individual, organization, municipality or other government agency partnering with your organization:

Organization Name: *

Detailed Project or Transaction Description:*

Estimated Total Cost of Project or Transaction:* $

Amount of State ARPA Funds Requested:* $

(note this is one-time funding)

Any State Agency, Municipal, Private Sector, or Nonprofit Group Partner(s):*

Target Completion Date:*

Compliance with ARPA:

Describe or list how your proposed project addresses health, economic, educational, or social disparities caused or exacerbated by the COVID-19 pandemic. Please include information on how the proposed service fits into or enhances the state’s existing continuum of care for support services. *

How will this project engage communities disproportionately impacted by the COVID-19 pandemic and link identified individuals with support services that address the social determinants of health? *

How will this project achieve one or more of the following goals/priorities?

The creation, expansion, or enhancement of a workforce development opportunity to support Delaware’s support services landscape.
The increase or expansion of community outreach efforts to engage, screen, and/or support individuals within hard-to-reach populations.

How does this initiative align with the Delaware Developmental Framework to make Delaware a trauma-informed state? The work of your organization should be aligned with the Delaware Developmental Framework for Trauma-Informed Care. *

View the Delaware Developmental Framework for Trauma-Informed Care

II. Identification of Organization and Principals

Transaction Contact Person Name:*

First Name

Initial (optional)

Last Name

Suffix (optional)

Title: *

Street Address: *

Address Line 1

City

State

ZIP Code

Telephone:*

Fax:

Email Address:*

BUSINESS INFORMATION: Doing Business As (If Applicable):

State of Incorporation:

State

Established (mm/yyyy):

Tax I.D. (FEIN):

License & Type (If a Business):

Brief Description of Organization:

Provide Non-profit organization documents, including bylaws, articles of incorporation, and any amendments to those documents.

No File Chosen

File uploads may not work on some mobile devices.

III. Management & Ownership Information

Provide the following information for any Officers, Directors, or Managers of the organization or any person, entity, or government with 10% or more controlling interest.

1) Name:

First Name

Middle Name (optional)

Last Name

Suffix (optional)

2) % Control:

3) Management Role:

4) Address, Phone and Email (if Different from Applicants):

Address Line 1

City

State

ZIP Code

Phone

Has the Applicant or any person listed above:

1) Been debarred or suspended from contracting with any state or federal agency or from receiving financial assistance from any state or federal agency?

Yes No

2) Been denied any license or permit or had any license or permit revoked or suspended by any federal, state or local agency or governmental body?

Yes No

3) Been convicted of a crime?

Yes No

4) Filed a voluntary petition in bankruptcy or had an involuntary petition in bankruptcy filed against the Applicant, in any bankruptcy court, or been subject to any other state or federal insolvency or receivership proceedings?

Yes No

5) If the answer to any question above is “yes,” furnish details on a separate page and attach as: “Exhibit: Ownership & Management”

No File Chosen

File uploads may not work on some mobile devices.

Describe the governance structure of your organization and which committees and/or individuals within your organization are responsible for oversight of the Project or Transaction and accountable for its outcomes.

Describe the experience of your organization, committees and/or individuals overseeing similar projects and transactions?

V. Applicant Performance Information

Provide the following information regarding the specific project, service, sale, or other obligation for which you seek ARPA funds:

1) Describe and list all professional services (e.g., consultants, individuals, partners, or facilitators) that will be retained in relation to the Project or Transaction, providing details of costs for each such service:*

2) Describe the materials, equipment or other costs that will be incurred in relation to the Project or Transaction providing details of the costs for such materials, equipment and other costs: *

3) Please list other Public and/or Private funding sources and amounts to cover Project or Transaction costs:*

4) Describe any operating costs associated with the Project and Transaction (both pre- and post- completion) and your plans and funding sources to cover any such operating costs:*

5) Describe several detailed, quantifiable metrics that will be used to measure the outcome of the Project or Transaction within the projected timeframe:

6) If this Project or Transaction requires approval by other governing authorities, please list all such required approvals and whether such approvals been granted?

Approval Date:

Anticipated Approval Date:

Anticipated Date of Presentation (if applicable):

REQUIRED CERTIFICATION

Eligibility for distribution of funding for the transaction requested by the Applicant is determined by the information presented in this Application and in the required exhibits and attachments. You are required to update the Department of Justice and contracting state agency with any changes in the project.

I, the undersigned, being duly sworn upon my oath say:

The Applicant, as noted below, is the recipient of the funds.
The undersigned is authorized to bind the Applicant and any other recipient of funding pursuant to this Application.
The filing of this Application, attached documents, and the Application is public information subject to the Delaware Freedom of Information Act, 29 Del. C. ch. 100 (FOIA). Although an Applicant may request that certain documents or portions of documents submitted to the State of Delaware be held confidential, it is exclusively within the discretion of the State of Delaware to determine whether any and all documents submitted in the Application, including supporting documentation, are public record.
The Applicant consents that the State of Delaware may provide all Application documents and any other documents related to this Project or Transaction to law enforcement agencies for investigative and auditing purposes.
The Applicant hereby agrees, if this Application is approved, to comply with all federal, state, and local laws and regulations affecting the operation of the proposed Project or Transaction.
The Applicant hereby acknowledges and agrees that the State of Delaware reserves the right to and may disclose any information contained in this Application and its supporting documents to the staff and attorneys of the State of Delaware, at any public hearing held on this Application, in any published notice of such hearing in accordance with the open meetings requirements of the Delaware Freedom of Information Act.
The Applicant hereby agrees that any officers, employees, agents or attorneys of the State of Delaware may have access to and copy any and all information in any form pertaining to Applicant, including, but not limited to, tax returns and information from tax returns as used in 30 Del. C. §368, in the custody of any State of Delaware, or other State, department, agency, instrumentality, division, office, board, bureau, council, commission, committee, panel or “public body,” as that term is defined in the Delaware Freedom of Information Act, 29 Del. C. § 10002(a), including, but not limited to, the Departments of Finance, State, Labor, and Natural Resources and Environmental Control of the State of Delaware, the United States Environmental Protection Agency, the United States Department of Labor, the National Labor Relations Board or any other agency of the federal government having custody of information deemed pertinent by the AGENCY staff or attorneys in evaluating Applicant’s Application.
I have carefully read this Application, including all attachments and exhibits, and the information contained in this Application, including all attachments and exhibits, is true, accurate and complete to the best of my information and belief.
These representations are made in support of a request for government funds.
The undersigned understands that if the undersigned has intentionally made a false statement in this Application, or someone else has made a false statement herein that the undersigned knows or believes to be false, the undersigned and the entity that undersigned acts on behalf shall be subject to criminal and civil prosecution.
The Applicant understands that no funds will be used for refinancing existing debt.
The Applicant understands that no funds may be used for speculative real estate ventures.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Progress

Instructions

I. Applicant Information

Compliance with ARPA:

II. Identification of Organization and Principals

BUSINESS INFORMATION: Doing Business As (If Applicable):

III. Management & Ownership Information

IV. Applicant Responsibility Questionnaire

V. Applicant Performance Information

REQUIRED CERTIFICATION