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ESG 2014.2015 <br />APPLICATION FORM <br />DUE DATE: 5:00 p.m., December 18, 2013 <br />THIS APPLICATION IS FOR: <br />(PLEASE CHECK ONLY ONE) <br />El STREET OUTREACH <br />❑ SHELTER <br />❑ HOMELESS PREVENTION <br />❑ RAPID RE- HOUSING <br />I. <br />A. <br />B. <br />C. <br />D. <br />E. <br />G. <br />H. <br />II. <br />A. <br />:1 <br />ORGANIZATIONAL <br />Legal Organizational Name: <br />Proposed Program Name: <br />Mailing Address: <br />Service Address(es): <br />Contact Name: <br />Title: <br />Telephone: <br />Fax: <br />E -Mail: <br />Name of Representative with <br />Contract Signing Authority <br />Title: <br />Federal Tax ID #: <br />DUNS #: <br />SERVICE AND FUNDING <br />How many unduplicated individuals (both Santa Ana residents and Non -Santa Ana residents) will <br />this program plan to serve during 2014 -2015? <br />Of the number from II.A. how many will be City of Santa Ana residents? <br />C. Amount of ESG funding requested for FY 14 -15 <br />III. HISTORY <br />A. Total people served by the proposed program <br />B. Of III.A. number of Santa Ana residents <br />C. Total expense of the proposed program <br />D. Total amount of Santa Ana grants received for this program. <br />E. How many years has the organizations been in existence: <br />F. How many years has the program been in existence: <br />IV. PROGRAM DESCRIPTION- SUMMARY <br />5 <br />19D-8 <br />2011 -2012 <br />2010 -2011 <br />