2. Instructions
   This program is designed to support Loudoun County food assistance programs with emergency funds due to increased demand for their services during the COVID-19 pandemic. To be eligible, an organization must be located in Loudoun County, be a 501(c)(3) or religious institution and provide food assistance on at least a bi-weekly basis to Loudoun residents.
   
   If your organization meets the criteria above, please complete this application for initial emergency funds. Once this application is processed, you will receive notification from county staff on its status. If approved, your organization will receive its initial payment within two to three weeks.
   
   Questions may be submitted by email or by calling 703-777-0539.
4. Funding Guidance and Eligibility
   Review funding guidance and eligibility requirements before applying.
6. Organization Name*
8. Street Address*
   Including City, State, Zip Code
9. Phone Number*
11. Email Address*
12. Fax
14. Number of Loudoun County Residents Served (Pre-Emergency)*
    (Average number of weekly clients as of February 2020)
15. Number of Loudoun County Residents Served (Current Data)*
    (Average number of weekly clients from 3/12 – 4/15)
17. Funding Requests*

    Please check the boxes and provide information for the categories for which you are seeking funding. County staff will use your pre-emergency data to determine the amount of increase from a typical operating basis to emergency operations based on population needs.
    
    For the purpose of this request, the County will prioritize food assistance costs over operating and supply expenses.
    

    1. Food Costs
    2. Operating Costs (If applicable)
    3. Supply Costs (If applicable)
19. Food Costs (Pre-Emergency)
    (Average number of weekly clients as of February 2020)
20. Food Costs (Current Data)
    (Average number of weekly clients from 3/12 – 4/15)
22. Operating Costs (Pre-Emergency)
    (Average number of weekly clients as of February 2020)
23. Operating Costs (Current Data)
    (Average number of weekly clients from 3/12 – 4/15)
25. Supply Costs (Pre-Emergency)
    (Average number of weekly clients as of February 2020)
26. Supply Costs (Current Data)
    (Average number of weekly clients from 3/12 – 4/15)
28. Total Funds requested for this period*
    Include all costs listed in categories above (food, operating, supply)
30. Additional details
    The county will calculate the food cost-per-client. If your current food cost per client is significantly higher than your previous, please use the space below to describe the circumstances why it is significantly higher (e.g., grocery store food donations have stopped, private donations are lower than average, etc).
34. Food Safety Guidelines
    Review and follow these guidelines.
35. Personnel Checklist
    Review and follow these personnel guidelines.
37. W-9 Information and Non-Profit Status Documentation
    After submitting this form, please email your documentation to complete your application.
39. Attestation - Signature and Date
    By signing above, I attest that my organization's mission supports food assistance to individual and families, and has additional needs related to COVID-19 which are not available in our organization's current budget. Our organization follows the Agency Food Safety Guidelines and the Personnel Checklist for COVID-19 linked above. The organization also permits County staff overseeing these funds to conduct site visits as necessary.
41. County Response
    The county will contact you within two business days of your request. Thank you!
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field