HOPWA FY2025 RFA Application

HOPWA FY2025 RFA Application
Organization's Legal Name*
Organization's DBA Name (if applicable)
Organization UEI#*
Organization Employer Identification Number (EIN)*
Address of Organization*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Organization*
Please enter a valid phone number.
Please provide the name of your organization's CEO or Executive Director.*

First NameLast Name
CEO/Executive Director Email Address*
example@example.com
CEO/Executive Director Office Phone Number*
Please enter a valid phone number.
Will the CEO or Executive Director specified above also be the individual that signs your contract?*

YesNo
Name of your organization's signatory

First NameLast Name
Title/Role of Organization's signatory
Email Address of Organization's signatory
example@example.com
Phone Number of Organization's signatory
Please enter a valid phone number.
In addition to the organizations CEO/Executive Director and contract signatory, is there a HOPWA Program Contact you would like us to use for your award?*

YesNo
Please provide the first and last name of one main HOPWA Program Contact at your agency:

First NameLast Name
Title/Role of HOPWA Program Contact
Email of HOPWA Program Contact
example@example.com
Phone Number of HOPWA Program Contact
Please enter a valid phone number.
Do you have another HOPWA Program Contact to add?

YesNo
Please provide the name of an additional HOPWA Program Contact at your agency:

First NameLast Name
Title/Role of HOPWA Program Contact #2
Email of HOPWA Program Contact #2
example@example.com
Phone Number of HOPWA Program Contact #2
Please enter a valid phone number.
Do you have another HOPWA Program Contact to add?

YesNo
Please provide the first and last name of an additional HOPWA Program Contact at your agency:

First NameLast Name
Title/Role of HOPWA Program Contact #3
Email of HOPWA Program Contact #3
example@example.com
Phone Number of HOPWA Program Contact #3
Please enter a valid phone number.

FY2025 Budget Request

On this page, you will enter the dollar amount your organization is requesting for each budget line item outlined in the RFA. If you do not seek funding in any of the line-items, please type "0" or "0.00" to indicate this. Afterwards, this will auto-calculate the "Grand Total of HOPWA FY2025 Funding Requested (in U.S. Dollars)."
TBRA*
Enter amount in decimals
Long-Term Program Delivery*
Enter amount in decimals
STRMU*
Enter amount in decimals
Short-Term Program Delivery*
Enter amount in decimals
Facility Operations/Facility Assistance*
Enter amount in decimals
Supportive Services*
Enter amount in decimals
Housing Information Services*
Enter amount in decimals
Permanent Housing Placement*
Enter amount in decimals
Resource Identification*
Enter amount in decimals
Administration*
Enter amount in decimals
Grand Total of HOPWA FY2025 Funding Requested (in U.S. Dollars):*
This value is auto populated once you complete the requested amounts for the other line-items listed below.

Experience with Service Provision
Please provide a description of your organization's mission and services.*
How long has your organization served persons living with HIV/AIDS, with or without HOPWA funding?*
Answers should be in number of years.
Please describe your experience with HMIS. What technical issues has your organization experienced with HMIS reporting? Does your organization need HMIS technical assistance or training?*
Please describe your organization’s experience in serving youth, veterans, VAWA-eligible clients, or those who experienced or are experiencing chronic homelessness. Please explain any services or interventions that are directly offered to these clients. Describe instances to which you refer clients to other providers. *
Is your organization an active member of any regional/local HOPWA planning or community planning committees OTHER than your regional continuum of care/regional planning council on the homeless? If yes, please list below:*

Staff and Board of Directors
Please attach a list of your organization's current Board of Directors; including names, affiliating organization(s), email addresses, and phone numbers.*

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How often does your organization's Board of Directors meet?*
If "Other" was selected for the previous question, please specify.
Please list the primary responsibilities of each member of your Board of Directors.*
Does the Board include a committee to provide fiscal oversight?*

YesNo
If yes to the previous question, what are the responsibilities and governing policies of this fiscal oversight committee?
Please attach your organization's staffing/organizational chart of HOPWA staff, including FTE employees*

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In the last year, has your program staff attended any training or continuing education on HOPWA administration or programs that assist persons living with HIV/AIDS? If so, please describe.*
How often do HOPWA staff undergo training related to confidentiality protections?*
If "Other" was selected for the previous question, please specify.

Supplementary Attachments
Updated Certificate of completion from HUD Exchange’s HOPWA Financial Management Module*

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Updated Certificate of completion from HUD Exchange’s 2 CFR 200 Online Module*

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Current Policy by which HOPWA clients are selected and approved, without documentation for current HOPWA recipients*

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Agency Confidentiality Policies and Procedures*

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Tracking Sheet of 75% served at or below 50% AMI

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Blank Housing Plan or Outline*

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One MOU with a Permanent Supportive Housing (“PSH”) provider in each Region that your organization covers (if PSH is available in the area)*

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Grievance/dispute policy*

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Termination of Assistance Policy*

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Supplementary Attachment #1

This OPTIONAL field allows you to upload any documentation that better contextualizes your application. This can be in the form of an addendum to contextualize your request or another form of documentation to showcase your ability to successfully administer HOPWA assistance. There is no penalty for providing or NOT providing documentation that you believe better contextualizes your application.
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Supplementary Attachment #2

This OPTIONAL field allows you to upload any documentation that better contextualizes your application. This can be in the form of an addendum to contextualize your request or another form of documentation to showcase your ability to successfully administer HOPWA assistance. There is no penalty for providing or NOT providing documentation that you believe better contextualizes your application.
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Certification Statement and Signature:

In order for your organization to be considered to receive funding through this application, the following certification statement must be signed by the individual affiliated with your organization who is authorized (by your organization's by-laws) to sign your agreement. 18 USC § 1001, "Fraud and False Statements," provides that, among other things, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States of America, anyone who knowingly and willfully (1) falsifies, conceals, or covers up, by any trick, scheme, or device, a material fact; (2) makes any materially false, fictitious, or fraudulent statement or representations; or(3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry; shall be fined under this title, and/or imprisoned for not longer than five (5) years. This certification must be submitted with all proposal materials. I have read the request for proposal materials and understand the intent, limitations, and requirements of services purchased through this proposal and the contractual requirements of IHCDA. I here by certify that all program information in the program proposal forms are true, correct, and accurately reflect the agency's program. I understand and will comply with the programmatic contractual requirements placed upon this agency if we are awarded funding for this application.
Signature*

Clear
First and Last Name of Individual Completing FY2025 HOPWA RFA*

First NameLast Name
Title/Role of Individual Completing FY2025 HOPWA RFA*
Legal Name of Organization Applying for FY2025 HOPWA Funding*
Today's Date*

MonthDayYear
Date

HOPWA FY2025 RFA Response
Thank you for your interest in HOPWA FY2025 funding. Due to the response(s) provided in the "Threshold Requirement Questions" section, you have indicated that your organization is ineligible to receive HOPWA funding through IHCDA.

Inquiries or an explanation on the agency's eligibility according to threshold requirements can be sent to IHCDA Community Services, communityservices@ihcda.in.gov.

Should be Empty:

HOPWA FY2025 RFA Application

FY2025 Budget Request

Threshold Requirement Questions

Financial Management Information

Experience with Service Provision

Staff and Board of Directors

Supplementary Attachments

Certification Statement and Signature:

HOPWA FY2025 RFA Response