American Rescue Plan Project Request Form

(* Denotes Required Fields)

Proposal Information
Name of Proposal: *
Submitting Organization: *
Authorized Official: *
Authorized Official Contact Email & Phone Number: *
Organization DUNS/UEI NUMBER: *
Organization Federal Employer ID Number: *
Funding Request Amount: *
Total Cost of Project: *
Priority Ranking of Proposal (Note: if you are only submitting one request enter 1): *
Is your organization a For Profit Entity?: *	Yes No
If the Yes Box is checked please provide a confirmation letter on IRS 501c (3) status. Please provide the following documentation: 1. Designation letter from the IRS or a Form 990 2. Designation letter from the Connecticut Secretary of State 3. Annual Audit Report
American Rescue Plan Funding Category (please check as appropriate)
1A: Respond to Public Health Emergency or its negative economic Impacts :	1a. Covid-19 Mitigation and Prevention 1b. Medical Expenses 1c. Behavioral Health Care 1d. Public Health and Safety Staff 1e. Expenses to Improve the Design and Execution of Health and Public Health Programs 1f. Eligible Uses to Address Disparities in Public Health Outcomes (Qualified Census Tract)
1B. Responding to Negative Economic Impacts:	1g. Assistance to Unemployed Workers 1h. Assistance to Households 1i. Expenses to Improve Efficacy of Economic Relief Programs 1j. Small Business and Non-profit Assistance 1k. Building Stronger Communities through Investments in Housing and Neighborhoods 1l. Addressing Educational Disparities 1m. Promoting Healthy Childhood Environments
2. Premium Pay for Essential Workers:	2. Premium Pay for Essential Workers
3. Revenue Loss (City of Meriden only):	3a. Provision of Government Services
4. Investments in Infrastructure (check one below):	4a. Water and Sewer Infrastructure 4b. Broadband
Project Information
PROJECT DETAILS AND NEED
#1 (Use up to 250 words): *
PROBLEM/ISSUE STATEMENT Identify a need and/or a negative impact due to the Covid pandemic that you are trying to address through this request.
#2 (Use up to 250 words): *
DESCRIPTION OF PROPOSAL FOR USE OF ARP FUNDS Describe the services, products, research, or work that will be provided through this funding. Please use non-technical language where possible.
#3 (Use up to 250 words): *
PROJECT GOALS/RESULTS Briefly describe expected project results and goals as well as how you will monitor project progress.
#4 (Use up to 250 words): *
BUDGET BREAKOUT Please include a breakout of how the requested funding will be used, such as for salaries, materials, equipment, etc.
#5 (Use up to 250 words): *
TIMELINE Please include an anticipated timeline and, if relevant, completion date for the project or program.
#6 (Use up to 250 words): *
PARTNERING ORGANIZATIONS OR ENTITIES Please list any organizations that partner in this project.
#7 (Use up to 250 words): *
PAST CITY FUNDING FOR THIS PROJECT If yes please explain.
#8 (Use up to 250 words): *
Contact Information
Name of Organization: *
Primary Point of Contact Name: *
Primary Point of Contact Title: *
Street Address: *
Street Address (2):
City: *
State: *
Zip Code: *
Primary Point of Contact Email: *
Primary Point of Contact Phone Number: *
Affirmations and Acknowledgements
Submission of a request that meets the requirements of this form as well as any subsequent requirements does not guarantee the award of ARP funding and/or the support of the City of Meriden. This request and any information submitted in support of it may be made public in part or in their entirety. Any funding award associated with this request does not guarantee support or funding in future requests.
I affirm and acknowledge the above statements:	Yes No
DIRECTIONS FOR FILLING OUT FORM
Answers are required to submit form. Once all fields are completed, forms can be submitted to: Jen Farina jfarina@meridenct.gov City Manager’s Office 142 East Main Street Meriden, CT 06450
ADDITIONAL INFORMATION
1. Proposal will be reviewed by the Meriden American Rescue Plan Steering Committee who will make a recommendation to fund or not fund the project. 2. Proposals will be presented by the proposing organization to the ARP Steering Committee at a scheduled meeting. 3. The Steering Committee will review the proposal, determine if it is an acceptable proposal per the American Rescue Plan guidelines, and provide a priority rating. The priority rating is based upon City of Meriden priorities. 4. The Steering Committee recommendation will be forwarded to the City Council who will make the final determination on funding. 5. City staff will then contact the applicant to begin the process of distributing and administering the funds.