Section 2: Applicant History 2.1 Yes No Have you received a grant from the State of Illinois within the last 3 years? Provide number of grants received from the State of Illinois within the last 3 years. If yes, provide Agency: the following #: for each grant Amount: received in last Grant Term: 3 years: General Description: Issues: 2.2 If applicable, list all and FEINs that are registered to your organization or have been registered during the past 3 years. Name FEIN 2.3 In the past twelve months, have been any changes in the following key staff? Check all that apply. Provide detail for any boxes checked including names of the person who left the position and the name of their replacement. Indicate the number of months the position has been vacant if the position is currently vacant. CEO/Executive Director/Chief Elected Official CFO/Controller Grant Administrator Grant Administrative Support Staff (i.e. Reporting, correspondence, document control) Bookkeeper/Accountant for Grant No Changes Provide detail for any checked boxes: 2.4 If your proposed budget includes any staff costs for this grant, please indicate the type of documentation that will be maintained and used to allocate staff costs to the DCEO grant. Time sheets Cost allocation plans Certifications of time spent please describe: None 2.5 Yes No Has the applicant or any principal formed a business that existed for less than two If yes, provide name(s) of the business and reason(s) that it existed for less than two years. 2.6 Has the applicant or any principal experienced foreclosure, repossession, judgment Yes No or criminal penalty (or been a party to a consent decree) within the past seven years as a result of any violation of federal, state or local law applicable to its business? If yes, identify the nature (including case number and venue) of the action and the disposition. If the action/proceeding is still pending or unresolved, provide a status identifying the unresolved issues. 2.7 Is the applicant or any principal the subject of any proceedings that are pending, or to the best of applicant’s knowledge, threatened against applicant and/or any principal that may Yes No result in any adverse change in applicant’s financial condition or materially and adversely affect applicant’s operations? If yes, provide requested information.
Section 2: Applicant History 2.1 Have you received a grant from the State of Illinois within the last 3 years? Yes No Provide number of grants received from the State of Illinois within the last 3 years. If yes, provide the following for each grant received in last 3 years: Agency: #: Amount: Grant Term: General Description: Issues: 2.2 If applicable, list all and FEINs that are registered to your organization or have been registered during the past 3 years. Name FEIN 2.3 In the past twelve months, have been any changes in the following key staff? Check all that apply. Provide detail for any boxes checked including names of the person who left the position and the name of their replacement. Indicate the number of months the position has been vacant if the position is currently vacant. CEO/Executive Director/Chief Elected Official CFO/Controller Grant Administrator Grant Administrative Support Staff (i.e. Reporting, correspondence, document control) Bookkeeper/Accountant for Grant No Changes Provide detail for any checked boxes: 2.4 If your proposed budget includes any staff costs for this grant, please indicate the type of documentation that will be maintained and used to allocate staff costs to the DCEO grant. Time sheets Cost allocation plans Certifications of time spent please describe: None 2.5 Has the applicant or any principal formed a business that existed for less than two Yes No If yes, provide name(s) of the business and reason(s) that it existed for less than two years. 2.6 Has the applicant or any principal experienced foreclosure, repossession, judgment or criminal penalty (or been a party to a consent decree) within the past seven years as a result of any violation of federal, state or local law applicable to its business? Yes No If yes, identify the nature (including case number and venue) of the action and the disposition. If the action/proceeding is still pending or unresolved, provide a status identifying the unresolved issues. 2.7 Is the applicant or any principal the subject of any proceedings that are pending, or to the best of applicant’s knowledge, threatened against applicant and/or any principal that may result in any adverse change in applicant’s financial condition or materially and adversely affect applicant’s operations? Yes No If yes, provide requested information.