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2. 
4. Overview

   West Norriton Township is offering a total of $100,000 in grants via American Rescue Plan funds to assist local non-profit organizations in providing public services to address adverse impacts of the Coronavirus.

   DEADLINE TO SUBMIT APPLICATION IS ROLLING UNTIL FUNDS ARE EXPENDED.

   Complete each section and attach all required documents to be considered for the West Norriton Non-profit Public Service Support Grant. The platform facilitates secure submission of supporting documentation. 

   Upon successful submission, a confirmation message will be received at top of the page. Users are encouraged to print/save a copy of the application for their records. 

   Due to anticipated response, staff will not provide feedback regarding the status of submissions. Applications will be reviewed in the order received. Contact will be limited to businesses selected to move forward in the process. 

6. Program Overview

   Eligibility

   • IRS designated 501(c)3 entity.
   • Located within West Norriton Township and in operation as of March 1, 2020.

   Funding

   • Grant funding must be used for the provision of public services including, but not limited to food, housing, homelessness, transportation, and education assistance.
   • Up to 25% of funds may be used for operational costs (payroll, rent, mortgage, utility, COVID mitigation).
   •  Program period/expenditure time-frame is March 1, 2020-September 1, 2021.
   • During the program period, proof of payment must be submitted to document eligible use of grant funds.
   • The recipient will be required to certify that the Township's assistance is not duplicative of any other funding.

   Awards 

   Award amounts will be based on number of eligible applications submitted at conclusion of the application deadline. 

   Recipient Responsibilities 

   • Enter into a formal, written, funding agreement with West Norriton Township.
   • Provide documentation to support expenditure of funds.
   • Make every effort to continue business operations through October 1, 2022.
   • Retain all related records for 3 years after receipt of grant close out letter.
   • If the 501(c)3 closed because of COVID advise the Township of organizations closure by letter from Owner with last day of operation and detailed reason for closure.

   Fraud & Repayment 

   Applicants are advised that making false statements, concealing information, submitting altered documents, utilizing funds for ineligible purposes, or similar actions are considered fraudulent and may result in repayment of the grant award or other legal action. 

   Submission 

   • Applications should only be submitted by the owner, partner, or authorized corporation member. 
   • Applications may only be submitted using the online platform.
   • Applications will be reviewed in the order received.
   • Incomplete applications will not be considered for funding.

   
   

10. AUTHORIZED AGENT SUBMITTING APPLICATION
12. First Name*
13. Last Name*
15. Address1*
17. Address2
19. City*
20. State*
21. Zip*
23. ORGANIZATION INFORMATION
25. Organization Name*
27. Address1*
29. Address2
31. City*
32. State*
33. Zip*
35. Opening Date at this Location*
36. Agency Phone*
38. Website
39. Facebook
40. Twitter
41. Instagram
43. Ownership Structure*
44. Business Type*

    1. Retail
    2. Health & Beauty

    1. Entertainment
    2. Restaurant

    1. Other
46. Total Current Full Time Paid Staff Positions*
47. Total Current Part Time Paid Staff Positions*
49. Total Full Time Volunteer Positions*
50. Total Part Time Volunteer Positions*
52. ADDITIONAL ORGANIZATION INFORMATION
54. Is business currently closed?*

    1. Yes

    1. No
55. If closed, when is reopening expected?
57. Describe the organization's background, experience, and capacity to provide services?
59. Since March 3, 2020 has application been made to other financial resources? If so, detail resources and status. If funding has been received, detail how funds were used and whether all funds have been exhausted?
61. Describe why the organization needs assistance. Be specific as possible. Detail any closures, reduced capacity requirements or reduced income resulting from effects of the COVID-19 pandemic.
63. Detail the proposed program to be funded and its response to COVID-19. The narrative should include WHAT you will do, When the project will begin, and WHO you will service, WHY the project in needed, location WHERE you will provide services and exactly HOW you will notify the public.
65. What adjustments have been made to sustain business operations during the Coronavirus?
67. REQUIRED UPLOADS
69. IRS Tax Exemption Determination Letter*
70. 2019 IRS Form 990*
71. 2020 IRS Form 990*
73. OPTIONAL UPLOADS

    Attach payroll, rent, mortgage, utility or COVID mitigation expenses incurred March 3, 2020 through application that West Norriton Township funding will be used for. Be sure that items HAVE NOT and WILL NOT be funded or reimbursed by any other source. 

75. Payroll, Rent, Mortgage, Utility, COVID Expenses
76. Payroll, Rent, Mortgage, Utility, COVID Expenses
77. Payroll, Rent, Mortgage, Utility, COVID Expenses
79. CERTIFICATIONS & ACKNOWLEDGEMENTS
81. Certify*

    I certify that this American Rescue Plan assistance is not duplicative of other public or private funding received.

    1. Yes
    2. No
83. Certify*

    I certify that this American Rescue Plan assistance will be used to provide services which address the adverse impacts of Coronavirus. 

    1. Yes
    2. No
85. Certify*

    I certify that the organization/agency will make consistent and assertive efforts to continue operations through October 1, 2022.

    1. Yes
    2. No
87. Certify*

    I certify that I am not aware of any conflicts of interest that exist between the organization/agency, myself, or any person who is an employee, agent, consultant, officer, elected official, or appointed official of West Norriton Township and is in the position to participate in a decision making process or are responsible for the administration or oversight of the Non-profit Public Service Support Grant.

    1. Yes
    2. No
89. Acknowledgement *

    I acknowledge that, if selected, a formal agreement will be signed with West Norriton Township.

    1. Yes
    2. No
91. Acknowledgement *

    I acknowledge that, if selected, the program requires that an IRS Form W9 be completed in order to receive payment.

    1. Yes
    2. No
93. Acknowledgement *

    I understand that making false statements, concealing information, submitting altered documents, utilizing funds for ineligible purposes, or similar actions are considered fraudulent and may result in repayment of the grant award or other legal action. I also understand that failure to submit timely and adequate documentation may result in repayment of funds received.

    1. Yes
    2. No
95. AUTHORIZED SIGNATURE

    By signing and submitting this document, I certify that I am the sole proprietor, general partner, or member of the aforementioned LLC/corporation. Further, I have made the necessary notifications and received the appropriate authorization to submit an application on behalf of the business/company. I attest that I have thoroughly reviewed the application. The information presented is true and accurate.

97. First Name*
98. Last Name*
100. Today's Date*
     Today's Date

     Today's Date
Leave This Blank:


102. 1. Receive an email copy of this form.
103. Email address

     This field is not part of the form submission.

104. Submit Submit and Print

* indicates a required field