Name of grantor agency that you are applying to:
(eg. DHHS, OCFS, private foundation name, etc.)

Title of Grant:

1. Is this letter of support a requirement of the grant application?   Select Yes or No Yes No

   Grant Application Deadline: 
    (For Deadline, Please use Calendar Button or enter in YYYY-MM-DD format)
   Grant Period: 

   Is this a continuation, expansion or new project?
   Continuation   Expansion   New Project

2. County department(s) from which you are seeking a letter of support from:
   (Choose Required or Requested or leave as None if not seeking from this department)

   Department of Social Services	Required   Requested   None
   Employment and Training	Required   Requested   None
   Mental Health	Required   Requested   None
   Office for Aging	Required   Requested   None
   Probation	Required   Requested   None
   Public Health	Required   Requested   None
   Youth Bureau	Required   Requested   None
   Other	Required   Requested   None

   If other, please name department:
   

3. Brief summary or abstract of the proposed project/program:
   (target population, target area, program capacity, etc.)
   
4. Briefly describe your needs assessment process. What data supports the need?
   
5. Amount of funds being requested:
   
   
6. Are matching funds required?  What type?
   Select Yes or No Yes No Select Match Type Tax Match In-Kind Match Cash Match n/a
   If yes, please document the source of your matching funds:
   
7. Please list your partners or collaborators:
   
8. What are the expected measureable outcomes of the project/program?
   
   If this is a continuation or expansion project, please document the current outcome attainment to date:
   
9. To the best of your knowledge, is your agency the only local project/program submitting an application under this funding opportunity? Select Yes or No Yes No
   If No, please list other applicants if known:
   
   How is your proposal unique or innovative?
   
10. In regards to the service you will be providing, please cite the research that supports this as an evidence-based practice or model.
    
11. Why is your organization best suited to provide this service? Please list prior experience with the proposed target population and past accomplishments in providing the proposed services.
    
12. How will you sustain the program after the funding is gone?
    
13. Please send, in a separate email to icp@co.broome.ny.us, a draft letter of support as a Word Document or upload the Word Document below. Please include the appropriate address of where it should be sent.
    
14. Upload Draft Letter of Support. (Word .doc file types only)