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ESG 2015 -2016 <br />APPLICATION FORM <br />DUE DATE: 4:00 P.m., January 5, 2015 <br />THIS APPLICATION IS FOR: <br />(PLEASE CHECK ONLY ONE) <br />❑ STREET OUTREACH <br />❑ SHELTER <br />❑ HOMELESS PREVENTION <br />❑ RAPID RE- HOUSING <br />I. ORGANIZATIONAL <br />A. Legal Organizational Name: <br />B. Proposed Program Name: <br />C. Mailing Address: <br />D. Service Address(es): <br />E. Contact Name: <br />Title: <br />Telephone: <br />Fax: <br />E -Mail: <br />F. Name of Representative with <br />Contract Signing Authority <br />Title: <br />G. Federal Tax ID #: <br />H. DUNS #: <br />II. SERVICE AND FUNDING <br />A. How many unduplicated individuals (both Santa Ana residents and Non -Santa Ana residents) will <br />this program plan to serve during 2015 -2016? <br />B. Of the number from II.A. how many will be City of Santa Ana residents? <br />C. Amount of ESG funding requested for FY 15 -16: <br />III. HISTORY <br />Total people served by the proposed program <br />Of III.A, number of Santa Ana residents <br />2014 -2015 2013 -2014 <br />Total expense of the proposed program <br />Total amount of Santa Ana grants received for this program. <br />How many years has the program been in existence: <br />19D-8 <br />2012 -2013 <br />