Susquehanna County

*Applicant Legal Name:

*Applicant’s Affiliation Organization:

Pa. Dept. of State Business File Number:

*Project Title:

Sponsor/Co-Applicant (if applicable):

Sponsor/Co-Applicant Contact:

Amount of Funding Request:

Brief Description of the Project:

Applicant Phone Number:

Email

Required

*Authorized Signatory (for contracts):

Authorized Signatory Title:

Authorized Signatory Phone Number:

Authorized Signatory Email:

Grant Writer (if applicable):

Grant Writer Phone Number:

Grant Writer Email:

Opioid Remediation Applicable Use(s) Schedule A Core Strategies:

Opioid Remediation Applicable Use(s) Schedule B Approved Uses:

A brief description of the project or program (limit response to 300 words):

An outline of the project or program objectives expected outcomes, and measurable project deliverables:

Identify how the proposed project will mitigate the harms stemming from opioid use disorder:

A description of the local and community support for the project or program:

A projected schedule and detailed timeline of the project or program:

A description of the attached budget for the project (attach below) of the basis of costs for the project and sources of funding and identifying the financial sustainability of the project or program:

Note:

The application should identify the percentage that Opioid Remediation funds will constitute of the total project budget and details on how the project will leverage funds from other sources. For any multi-year project, cost information should be broken into phases, and applicants must detail the projected sources of funding for all phases and project completion.

If the Applicant is requesting grant funding to support new or existing staff salaries, insurance, or benefits, identify the time dedicated by the personnel in the positions to the provision of services pertaining to Opioid Use Disorder, Substance Use Disorder, or Mental Health-related programming:

Evidence of prior and anticipated interaction and/or work with the sponsoring organization/co-applicant:

Note:

Municipal and Nonmunicipal applicants submitting applications sponsored by or joined by a co-applicant should show how the applicant and sponsor or co-applicants have interacted and/or worked together in the past as well as anticipating future interactions.

Evidence of conformity of the program or project with organizational strategic plans; if applicable:

A statement disclosing any instances of fraud or theft of applicant funds in the last five (5) years and measures taken by the applicant to prevent future theft and fraudulent events:

Describe any litigation, administrative proceeding and/or governmental approval related to the project:

Note:

Litigation, administrative proceedings and governmental approvals should be identified whether or not the matter(s) could cause a delay, potentially prevent the project from being completed or otherwise have an impact on the project

Outline in detail the community impact and performance measurement. The overall quality strategy must include the following components: An organizational culture that supports (through human capital and resources) and values a continuous improvement process. Adequate resources to support the planned activities of the project or program. Evidence of the desired health or performance outcomes:

Note:

Additional information on success and performance measurement can be found in Appendix D.

A statement providing where the project ranks on the sponsor’s list of priorities if the applicant has more than one project:

Proposed Budget:

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Support Documents:

Documentation of support from the affected community, as well as any professional or expert studies, analyses or support related to the project or its need, uses, or costs.

Support Document's

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Support Document's

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Support Document's

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Support Document's

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Support Document's

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Extra Documents

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Extra Documents

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Agreement:

By typing in my information below, I understand that subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities, I hereby certify that neither the Opioid Remediation Grant Applicant, nor its affiliated entity or political subdivision, have engaged any person to lobby on its behalf in regard to its Opioid Remediation Grant Application in exchange for compensation contingent in whole or in part upon the approval, award, receipt, or denial of funds. I understand that such violation or false certification hereunder shall be cause for the immediate termination and repayment of any Opioid Remediation Grant awarded to the Applicant. This certification is given in support of the Susquehanna County Opioid Remediation Grant Application submitted by the Applicant.

Name of Applicant:

Phone Number:

An Authorizated Representative Of (Organization):

Date Selector