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This form is intended to collect the required information to draft your contract for public funds leveraged in this pilot and to register your organization as a new vendor in LISC's financial management system.

Please complete this form by end of Tuesday, July 30.

Please select "Next Page" to begin. If you have any questions or concerns regarding the form, please reach out to Minh Nguyen at mnguyen@lisc.org

SECTION 1: VENDOR REGISTRATION

Has your organization been confirmed as registered with the LISC's financial management system

Yes

Vendor Registration

**The contact person should have access to tax and banking documents for your organization. For example, this person could be an accountant or finance staff member.

First Name

Last Name

Email Address

Phone Number

Registration Process Overview:

The contact person provided will receive an email from LISC within 2-3 business days after submitting this form. The email will contain detailed instructions on how to create an account and log in with Tipati.
They will be requested to update your organization's information and upload tax and banking documents, including a W9 and a voided check on TIpati.
Once this step is completed and LISC confirms that all information has been uploaded correctly, your organization will be successfully registered as a new vendor and ACH verified with LISC.
If you have any questions during the process, please contact Minh Nguyen at mnguyen@lisc.org.

SECTION 2: CONTRACT INFORMATION

General Information

**Enter N/A for fields that are not applicable

1. Name of Organization
(appears as on official tax documents)

2. Year obtained 501(c)(3) Status if applicable

3. Unique Entity Identifier (UEI)#
(A unique identifier assigned to entities doing business with the U.S. federal government when registering on SAM.gov)

*LISC cannot proceed with an award of federal funds with an entity that is not registered in SAM or has an expired registration.

*If your organization has not registered in SAM, click here for instructions on how to do so.

*If you’re already registered, click here for instructions on how to find your UEI #

4. EIN #

5. Congressional District of Organization

6. Is Organization faith-based?

Yes

7. Size of Organization Staff

8. Predominant Race/Ethnicity of Organization Staff (FTEs)

9. Size of Organization Board

10. Predominant Race/Ethnicity of Board

Contact Information

**Enter N/A for fields that are not applicable

12. Main Contact Name
(for this program)

13. E-mail Address

14. Phone Number

15. Fax Number

16. Executive Director

17. E-mail Address

18. Phone Number

19. Fax Number

SECTION 4: ORGANIZATION INFORMATION

**Provide the following general information about your organization. Please limit your answer to one or two paragraphs per question.

1. Brief Organization History, Description, and Mission:

2. Strength of Staff and Board:

3. Capacity to achieve goals outlined in proposal:

4. Steps taken to mitigate any financial risks:

SECTION 5. PROGRAM INFORMATION (OUTOUTS)

**Click on Projection and Proposed Grant Activity boxes to read definition.

**Please do your best given the provided definitions. These projections may be revisited once the program begins.

Projection Proposed Grant Activity

Related to Outputs

1. Number of individuals served through the financial opportunity center services

If individuals will be the primary, direct beneficiaries of funds within grant term, count discrete individuals to be served. Ex. a person receiving weekly financial coaching would be counted once.

2. Number of web-based engagements

Number of web-based interactions from finance opportunity center services. For example: client intakes via online forms or virtual appointments, virtual client consultations, web-based counseling sessions, remote assistance with financial documents, virtual job fairs, etc. (Formal trainings are counted separately.)

3. Number of in-person engagements

Number of in-person interactions from finance opportunity center services. For example: client intakes, client consultations, counseling sessions, assistance with financial documents, job fairs, etc. (Formal trainings are counted separately.)

4. Number of web-based trainings offered

Count of trainings delivered through web-based methods. For example: webinar series on improving credit scores and understanding credit reports, online workshops on investment strategies and retirement planning, web-based training modules on navigating tax filing and deductions, etc.

5. Number of in-person trainings

Count of trainings delivered through in-person methods. For example: series on improving credit scores and understanding credit reports, workshops on investment strategies and retirement planning, training on navigating tax filing and deductions, etc.

6. Total number attendees at web-based and in-person engagements

Count of individuals attending events, supported with attendance records.

SECTION 6: ATTACHMENTS

1. 501(c)(3) or IRS Determination Letter

2. Audited Financial Statements for the last 3 years

Internal financials and 990 Form may be accepted the first year of funding. Additional funding may be contingent upon the completion of a review with the expectation to complete an audit the next fiscal year.

Audited Financial Statements

Audited Financial Statements

3. Active System for Award Management (SAM) registration confirmation

Organizations applying for HUD Section 4 Capacity Building grants must: 1) Be registered in SAM. 2) Maintain an active SAM registration during LISC grant term. SAM registrations must be renewed on an annual basis. https://www.sam.gov/portal/SAM/

4. Partner Memorandum of Agreement (if applicable)

If in a partnership, please submit a signed MOA between the groups and expected roles and responsibilities.

By typing your name below and submitting the form, you confirm that the information provided about you and your business/non-profit are true in all material respects.

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SECTION 1: VENDOR REGISTRATION

SECTION 2: CONTRACT INFORMATION

SECTION 3: QUESTIONAIRE

SECTION 5. PROGRAM INFORMATION (OUTOUTS)

SECTION 6: ATTACHMENTS