Agency Form

Current EFSP Phase

* = required field

Current Phase EFSP Agency Information

Agency Name *

Agency DUNS Number *

Agency FEIN *

Agency Mailing Address *

Executive Director Name *

Agency Contact for EFSP *

Agency Contact Title *

Agency Contact Email *

Agency Contact Phone *

Agency URL *

Agency Mission Statement *

Describe the agency's (or fiscal agent's) accounting process by which you would manage EFSP funding and what procedures your agency has implemented to prevent fraud and misuse of funds, should they be awarded.

Please indicate below the category or categories for which your agency is applying to receive funding. An Application Form must be completed for EACH category selected.

Rent/Mortgage Assistance

Utility Assistance

Hotel/Motel Assistance

Food Assistance

PLEASE NOTE: Once funds are awarded to a category, Local Board approval is required to change the use of funds.

Does your organization agree to utilize EFSP funds, should they be awarded, to provide services to Erie County clients only?

Yes

BUDGET, LRO, and 990 Form Submissions

Budget Form*

LRO Form*

990 Form*