AMERICAN RESCUE PLAN PROGRAM APPLICATION

Project & Program Information

Project Name: Enter Project Name

Program Category: (Select up to four program categories from the list below for the project.)

1	Choose an item.
2	Choose an item.
3	Choose an item.
4	Choose an item.

Program Type: (Select one)	☐ Single year	or	☐ Multiple year

Objective: (Briefly state the objective of the project/program.)

State the objective of the project/program.

Description: (Provide a detailed description of the project, service(s) to be provided, need for the project, population to be served, and impact expected from the project. Be sure to include the sources of the data used to justify the project.

Provide a detailed description of the project.

Eligibility and Requested Funding

Eligibility: (Select the appropriate expenditure category from the appendix that corresponds to the program category selected above and provide a description indicating how the project is eligible. List all data sources that document the eligibility being claimed.)

ARP Expenditure Category	Eligibility Description
1	Choose an item.	Enter how the project is eligible under this expenditure category.
2	Choose an item.	Enter how the project is eligible under this expenditure category.
3	Choose an item.	Enter how the project is eligible under this expenditure category.
4	Choose an item.	Enter how the project is eligible under this expenditure category.

Funding: (Enter to total dollar amount requested for each expenditure category in the appropriate year the funds are being requested for. Include a budget that details each amount included below.)

Year	Category 1	Category 2	Category 3	Category 4
2022	Amount	Amount	Amount	Amount
2023	Amount	Amount	Amount	Amount
2024	Amount	Amount	Amount	Amount

Contact Information

Organization:

Organization Name:	Enter Organization Name.
Organization Type:	Government ☐ Non – Profit ☐ Business ☐ Other ☐

Contact Person:

Name:	Enter Name.
Title:	Enter Title.
Address:	Enter Address.
City:	Enter City.
Phone Number:	Enter Phone Number.
Email Address:	Enter email address.

Detail Budget Information

If the project only covers one year, only complete the Total Project budget information. If it includes multiple years, complete the Total Project budget information and one for each individual year of the project.

Total Project: (Include all costs for the entire project period.)

Budget Category	Category 1	Category 2	Category 3	Category 4	Total
Salaries	Amount	Amount	Amount	Amount	0.00
Fringe Benefits	Amount	Amount	Amount	Amount	0.00
Travel	Amount	Amount	Amount	Amount	0.00
Consultants	Amount	Amount	Amount	Amount	0.00
Supplies	Amount	Amount	Amount	Amount	0.00
Construction	Amount	Amount	Amount	Amount	0.00
Equipment	Amount	Amount	Amount	Amount	0.00
Subgrants	Amount	Amount	Amount	Amount	0.00
Other	Amount	Amount	Amount	Amount	0.00
Totals	0.00	0.00	0.00	0.00	0.00

Enter the costs associated with each year of funding requested for the project in the forms below.

Year 1:

Budget Category	Category 1	Category 2	Category 3	Category 4	Total
Salaries	Amount	Amount	Amount	Amount	0.00
Fringe Benefits	Amount	Amount	Amount	Amount	0.00
Travel	Amount	Amount	Amount	Amount	0.00
Consultants	Amount	Amount	Amount	Amount	0.00
Supplies	Amount	Amount	Amount	Amount	0.00
Construction	Amount	Amount	Amount	Amount	0.00
Equipment	Amount	Amount	Amount	Amount	0.00
Subgrants	Amount	Amount	Amount	Amount	0.00
Other	Amount	Amount	Amount	Amount	0.00
Totals	0.00	0.00	0.00	0.00	0.00

Year 2:

Budget Category	Category 1	Category 2	Category 3	Category 4	Total
Salaries	Amount	Amount	Amount	Amount	0.00
Fringe Benefits	Amount	Amount	Amount	Amount	0.00
Travel	Amount	Amount	Amount	Amount	0.00
Consultants	Amount	Amount	Amount	Amount	0.00
Supplies	Amount	Amount	Amount	Amount	0.00
Construction	Amount	Amount	Amount	Amount	0.00
Equipment	Amount	Amount	Amount	Amount	0.00
Subgrants	Amount	Amount	Amount	Amount	0.00
Other	Amount	Amount	Amount	Amount	0.00
Totals	0.00	0.00	0.00	0.00	0.00

Year 3:

Budget Category	Category 1	Category 2	Category 3	Category 4	Total
Salaries	Amount	Amount	Amount	Amount	0.00
Fringe Benefits	Amount	Amount	Amount	Amount	0.00
Travel	Amount	Amount	Amount	Amount	0.00
Consultants	Amount	Amount	Amount	Amount	0.00
Supplies	Amount	Amount	Amount	Amount	0.00
Construction	Amount	Amount	Amount	Amount	0.00
Equipment	Amount	Amount	Amount	Amount	0.00
Subgrants	Amount	Amount	Amount	Amount	0.00
Other	Amount	Amount	Amount	Amount	0.00
Totals	0.00	0.00	0.00	0.00	0.00

Certification

I certify and acknowledge, on behalf of myself and the applicant, that:

Per the Minnesota Government Data Practices Act, responses submitted by an applicant are private or nonpublic until the responses are opened. Once the responses are opened, the name and address of the applicant and the amount requested is public. All other data in a response is private or nonpublic data until completion of the evaluation process, which for the purposes of this award, is when all award agreements have been fully executed. After Hubbard County has completed the evaluation process, all remaining data in the responses is public with the exception of trade secret data as defined and classified in Section 13.37. A statement by an applicant that the response is copyrighted or otherwise protected does not prevent public access to the response.

Signature	Date