Carbon County

COVID-19 County Relief Block Grant Application Instructions

NONPROFIT GRANTS

The COVID-19 County Relief Block Grant Program allows the county to provide funding for a nonprofitgrant program. The County has developed an application for nonprofits to apply for funding through thisprogram. The effects of the pandemic for which the entity is requesting funding must relate to the periodthat began on March 1, 2020 and ends on December 30, 2020.

Like many things related to the COVID-19 pandemic, guidance relating to the Coronavirus Relief Fund andPennsylvania’s related COVID-19 – County Relief Block Grant Program is subject to change. Some of thelimited guidance issued by the federal government has already been revised several times. TheCommonwealth has not yet issued extensive guidance relating to the COVID-19 – County Relief BlockGrant Program but may do so in the future. Current interpretation of federal CARES Act guidance suggeststhat business and nonprofit entities with more than 500 employees would not be eligible for CARES Actsmall business grants for business interruption at this time. In the event your entity is above the applicablethresholds, a review will be conducted to determine whether any exceptions apply.

According to Federal and state guidelines, only nonprofits designated as 501(c)3 or 501(c)19 organizationsby the Internal Revenue Services (“IRS”) are eligible for funding through this program.

It should be noted that funding is limited and not all requests may be fully funded.

The applications are to be submitted to the County by July 31 and the applications must include allrequired documentation. The applications will not be processed without all required documentation.

1. Complete the Application that is provided on the County’s website.2. Details to Provide in Narrative Section

a. Describe the services you provide to the public and your mission statementb. A description of how the pandemic affected your operations, including

i. Complete Closureii. Partial Closure

iii. Steps taken responding to the pandemic to allow the nonprofit to continuecurrent or future operations

iv. Services you provided to the community to assist them with responding to thepandemic

c. Incurred Expensesi. Provide a narrative of the expenses the nonprofit incurred responding to the

pandemicii. Attach copies of all invoices or payroll records for which you are requesting

funding to reimbursed. Future Costs

i. Provide a narrative explanation of any costs for projects you foreseeundertaking to respond to this pandemic

ii. Provide a timeline for completion of the projectiii. Provide a quote for completion of the project

e. Revenue Declinei. Provide details on the effect the pandemic has had on your revenue generation,

including fees charged or fundraising opportunities that may have beencurtailed. This may include comparisons to prior years or months, or revenueexpectations for businesses recently started

3. Items to attacha. IRS 501(c)3 OR 501(c)19 determination letterb. Most recent filed copy of IRS form 990c. Most recent filed IRS Form 941, if nonprofit has employeesd. Copy of mission statement (or similar document)e. Copies of Invoices for expense incurred for which funding is requestedf. Quotations for costs of planned future project for which funding is requestedg. Support for revenue decline included in narrative. This should include documentation

that supports the lost revenue you are claiming in the narrative (financial statements,general ledger reports, etc.)

Block Grant Administration Group – Phone: 570-325-3611 Email: CovidGrantCor@carboncounty.net

Application: COVID-19 County Relief Block Grant

Organization/Business Name: _______________________________________________

Organization/Business County Relief Block Grant Category: ____________________________

If Other, explain: ______________________________________________

Organization/Business Information:

Street Address: __________________________

Municipality/Town: _____________________________

Zip Code: ___________________________________

Phone Number: ____________________________

Email: ______________________________________________

Website: ________________________________________

Facebook Page: _____________________________________________

EIN: ___________________________________

Type of Business: ____________________________________________

Did you participate in the Federal Paycheck Protection Program (PPP) or Economic Injury Disaster Loan (EIDL) Program established under the CARES ACT or any other COVID-19 grant/loan program?

Yes: ____ No: ____ If yes, which program: ____________________

If Other, indicate: ___________________________________________________________

Amount of award received: _____________________

Amount of COVID-19 Relief County Block Grant requested: _______________

Did your expenses occur between March 1, 2020 through December 31, 2020: Yes: ____ No: ____

Justification for grant funds (clear, concise & complete):

Block Grant Administration Group – Phone: 570-325-3611 Email: CovidGrantCor@carboncounty.net

Justification continued:

Primary Point of Contact:

Last Name: ______________________ First Name: _____________________________

Role in organization/business: __________________

Phone Number: _______________________

Email: __________________________

Alternate Point of Contact

Last Name: ______________________ First Name: _____________________________

Role in organization/business: __________________

Phone Number: _______________________

Email: __________________________

I certify under penalty of law that this document and the information submitted are, to the best of my knowledge and belief, true, accurate and complete. I understand that false statements made herein or in the information submitted are subject to the penalties for unsworn falsification to authorities set forth in the 18 Pa.C.S.A. § 4904.

Signature: ________________________________________________________________

Date: ______________________________________________

SUBMIT VIA EMAIL PRINT