1

Organization Name

 *

Organization Name

2

Organization Mailing Address

 *

Organization Mailing Address

3

Organization Contact Name

 *

Organization Contact Name

4

Organization Contact Email Address

 *

Organization Contact Email Address

5

Organization Contact Telephone Number

 *

Organization Contact Telephone Number

6

Is the organization a nonprofit?

 *

Is the organization a nonprofit?

Yes

No

7

If yes: What type of nonprofit (choose one)?

 *

If yes: What type of nonprofit (choose one)?

Tax Exempt Under IRC Section 501(c)(3)

Political Subdivision

Other

If other is checked please explain

8

Amount of Grant Funds Requested (max of $150,000)

 *

Amount of Grant Funds Requested (max of $150,000)

9

Provide an overview of the proposed derelict building removal project for which grant funds are requested.

 *

Provide an overview of the proposed derelict building removal project for which grant funds are requested.

10

Provide the physical address/location of each derelict building that the organization remove as part of the project.

 *

Provide the physical address/location of each derelict building that the organization remove as part of the project.

11

How many of the derelict building locations identified above are within a U.S. Census Tract classified as a disadvantaged by the Climate & Economic Justice Screening Tool (geoplatform.gov)?

 *

How many of the derelict building locations identified above are within a U.S. Census Tract classified as a disadvantaged by the Climate & Economic Justice Screening Tool (geoplatform.gov)?

12

How many of the derelict building locations identified above are within a County of Accomack Community Development Block Grant Priority Area (limited to East Horntown, Wishart's Point, Graysville, Whitesville, Linhaven, Bayside, Sanford)?

 *

How many of the derelict building locations identified above are within a County of Accomack Community Development Block Grant Priority Area (limited to East Horntown, Wishart's Point, Graysville, Whitesville, Linhaven, Bayside, Sanford)?

13

Describe how the applicant will ensure grant funds are used effectively and efficiently.

 *

Describe how the applicant will ensure grant funds are used effectively and efficiently.

14

What percentage of grant proceeds are requested to be used for expenses directly or indirectly relating to the administration of the program (Maximum of 10% of award)

 *

What percentage of grant proceeds are requested to be used for expenses directly or indirectly relating to the administration of the program (Maximum of 10% of award)

15

CERTIFICATION:

To the best of my knowledge, all information in this application is true and correct, the document has been duly authorized by the governing body of the applicant, and the applicant will comply with the program's terms and conditions if selected for funding.

 *

CERTIFICATION: To the best of my knowledge, all information in this application is true and correct, the document has been duly authorized by the governing body of the applicant, and the applicant will comply with the program's terms and conditions if selected for funding.

Yes

No

16

Please attach the following

Tax-exempt status (if applicable)

Please attach the following Tax-exempt status (if applicable) Click button for uploading file Clear Maximum size allowed: 25 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

17

Please attach the following

Picture 1

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18

Please attach the following

Picture 2

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19

Please attach the following

Picture 3

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