City of Rialto 23/24 Public Service Application Page 2 of 10 I. APPLICANT AND PROJECT/ACTIVITY INFORMATION
Legal Name of
Organization/Agency
Program/Activity Title
Physical Address
City, State, ZIP
Type of Organization ☐ Non-Profit ☐ Government ☐ For-Profit Tax ID
Are you a Women owned, or a
majority Women operated
organization?
☐ Yes ☐ No ☐ Decline to state
Are you a Minority owned, or a
majority Minority operated
organization?
☐ Yes ☐ No ☐ Decline to state
If yes, please select which
category or categories is most
applicable.
☐ Black Americans ☐ Native Americans ☐ Hispanic Americans ☐ Asian/Pacific Americans ☐ Hasidic Jews
UEI Number
Name of Workers’ Compensation
Insurance (Government exempt)
Coverage Amount ($)
Expiration Date
Name of General Liability and
Property Damage Insurance
(Government exempt)
Coverage Amount ($)
Expiration Date
Name of Applicant Contact
Title
Mailing Address
City, State, ZIP
Email
Phone
Amount of CDBG Funds
Requested ($)
Approximate Total Number of
Unduplicated Beneficiaries
(Persons or Households) to be
Served
Type of Beneficiary ☐ Persons ☐ Households
Groups that the Program/Activity
will Serve
(Check all that apply)
☐ Youth
☐ Adults
☐ Seniors
☐ Homeless Persons
☐ Disabled Persons
☐ Battered Spouses
☐ Abused/Neglected Children
☐ Households
☐ Community
☐ Housing Units
☐ Public Facilities
☐ Businesses
City of Rialto - Parks, Recreation & Community Services Department Mobile Recreation
214 N Palm Ave
Rialto, CA 92376
95-6000768
N/A
N/A
City of Rialto is self insured.
N/A
N/A
N/A
N/A
Julio Salcedo
Parks, Recreation & Community Services
214 N Palm Ave
Rialto, CA 92376
[email protected]
909-421-4949
$33,000
150
City of Rialto 23/24 Public Service Application Page 6 of 10 IV. PROPOSED PUBLIC SERVICE BUDGET
Sc
ope of work and use of CDBG funds must be directly related. The CDBG funds requested must be used to provide a direct benefit/service to low - or moderate-income residents of the City of Rialto . Proof of income eligibility and current residence must be acquired from all recipients. Adequate documentation must also be provided by the Agency to support costs associated with the services provided. This includes such support as timesheets to demonstrate the amount of time spent on each service, cancelled c hecks to demonstrate payment, client intake forms to demonstrate who received the service and any other documentation deemed necessary to show a direct correlation between the service provided and the costs associated with them.
Pl
ease use the following format to present your proposed line item budget:
Column A:
Column B:
Column C:
Column D:
Column E:
List the items for which you anticipate the ne ed for CDBG Funds during FY 2023/2024.
Provide the projected request for CDBG funds.
Provide the total of other funds to be used.
List the name of the other funding source.
List the total line budget. Please round your request to the nearest ten.
Column A Column B Column C Column D Column E
BUDGET ITEM CDBG REQUEST
($)
OTHER SOURCES
($)
NAMES OF
OTHER SOURCES
TOTAL BUDGET
($)
Personnel*
Personnel Total
Non-Personnel
Rent/Lease
Supplies
Utilities
Equipment
Services
Printing
Admission/Enrollment
Other:
Other:
Other:
Other:
Other:
Other:
Non-Personnel Total
TOTAL PROJECT BUDGET
*Fo
r personnel, complete the following CDBG-Funded Personnel Tables.
N/A
N/A
N/A
N/A
N/A
N/A
$15,000.00
$3,000.00
Enclosed Trailer
$33,000.000
$15,000.00
$15,000
$15,000.00
$33,000.00
N/A
N/A
N/A
$3,000.00