MOD Municipal Grant Application

Commonwealth of Massachusetts	Municipal Grant Application	Office on Disability
The Applicant portion under this section refers to the person submitting the grant application and will be the person contacted in all matters related to this grant. The Responsible Employee (ADA Coordinator) portion under this section refers to the person specifically designated to coordinate the 5 Administrative Responsibilities under Title II of the Americans with Disabilities Act. Please see the Application Instructions and Addenda materials for further information. The application form will time-out after 40 minutes of inactivity. If you let the form sit idle for 40 minutes, you will need to restart the application submission process. More information about this can be found on our Apply for a Municipal ADA Improvement Grant webpage, under the heading "What You Need".

Section 1 - Requestor Information

Applicant (Required)	Grant Type (Required)
Contact Full Name (Required)	Contact Phone (Required)	Contact email (Required)
Contact Address 1 (Required)	Contact Address 2
Contact City (Required)	Contact State (Required)	Contact Zip (Required)
Responsible Employee (ADA Coordinator) Info Same as Contact
Responsible Employee Full Name (Required)	Responsible Employee Phone (Required)	Responsible Employee email (Required)
Responsible Employee Address 1 (Required)	Responsible Employee Address 2
Responsible Employee City (Required)	Responsible Employee State (Required)	Responsible Employee Zip (Required)

Section 2 - Qualification

Responsible Employee (Required)		Responsible Employee Document
Posting of Non Discrimination (Required)		Public Posting of Non Discrimination Document
Grievance Procedures (Required)		Grievance Procedures Document
Self Evaluation (Required)		Self Evaluation Document
Transition Plan (Required)		Transition Plan Document
Duly Established COD (Required)
Member of Community Compact (Required)
Public Accessibility Best Practice
Matching Funds (Required)		Matching Funds Amount

Section 3 - Planning Grant

Section 3.1 - Planning Request
	The type and scope of the proposed Planning Grant. Please select the appropriate grant type and please describe the specific request under the Grant Scope section
Grant Type	Self Evaluation Transition Update Amount Requested (Required)
Grant Scope
	Renovation/Construction history of applicant
Renovation and Construction History
	History of Applicant's prior planning efforts related to disabilities or access, if any
Applicant History
	Any other information relevant to the Applicant's request or need for planning monies under this Project (Please be advised, all work must be invoiced no later than June 30)
Additional Planning Information
Section 3.2 - Impact Information
	U.S. Census microdata or other projection that provides estimates of the number of persons with disabilities residing in the applicant municipality, district or region, if any
Census Data
Section 3.3 - Other Information
	Applicant's planning grant submission team and contact information, including any persons with disabilities involved in application process
Applicant Team
	Applicant's history of interactions with the state's Architectural Access Board, if any
Architectural Board History
	Applicant's history of interactions with any state and/or federal agencies with regards to accessibility related issues
State and Federal Agency History

Section 3 - Project Grant

Section 3.1 - Project Request
	The type and nature of the project, including description of the project, and whether project is renovation/repair of existing facility or asset or new facility or asset
Grant Type	Amount Requested (Required) Please note: Maximum amount not to exceed $250,000. Please be advised, only capital related expenses will be covered. Items such as, but not limited to, design plans, feasibility studies, and applicant salaries are not eligible expenses to be covered. Those types of expenses can be in-kind services or covered by the applicant.
Grant Scope
	Is the proposed project identified in the current Self-Evaluation and/or Transition Plan?
Proposed Work	If Yes Explain
	Cost estimate of project
Cost Estimate
	Proposed project schedule or timeline (Please be advised, all work must be invoiced no later than June 30)
Project Timeline
	The proposed use and/or programming for the project, including proposed user fees if any for project
Proposed Use
	The proposed operating, staffing and maintenance plans for the project, if applicable
Staffing and Maintenance Plan
	Renovation/construction history of the affected facility or asset if applicable
Renovation and Construction History
	Any other expected sources of funding, support or participation in project, including Applicant's and third parties
Additional Funding Sources
Section 3.2 - Impact Information
	Number of persons with disabilities that will or are expected to be impacted by the project
Impact on People
	The impact that the project will have on the overall access to the facility and/or the Projects
Impact on Access
	Data or projection regarding the average monthly use of the facility and/or Project
Monthly Usage
	U.S. Census microdata that provides estimates of the number of persons with disabilities residing in the applicant municipality, district or region
Census Data
Section 3.3 - Other Information
	Applicant's planning grant submission team and contact information, including any persons with disabilities involved in application process
Applicant Team
	Applicant's history of interactions with the state's Architectural Access Board, if any
Architectural Board History
	Applicant's history of interactions with any state and/or federal agencies with regards to accessibility related issues
State and Federal Agency History

Section 4 - Acknowledgement

Confirmation (Required) By selecting "YES", you certify that the information in this form is truthful and accurate

Contact Name (Required) Same as Contact Full Name in Section 1

Section 5 - Office Use Only

Application Score		Amount Requested		Amount Recommended		Amount Funded
Date Submitted				Date Processed		Date Approved

Municipal Grant Application

Section 1 - Requestor Information

Section 2 - Qualification

Section 3 - Planning Grant

Section 3.1 - Planning Request

Section 3.2 - Impact Information

Section 3.3 - Other Information

Section 3 - Project Grant

Section 3.1 - Project Request

Section 3.2 - Impact Information

Section 3.3 - Other Information

Section 4 - Acknowledgement

Section 5 - Office Use Only