Opioid Grant Application

APPLICANT INFORMATION

Entity Type(Required)

County Department

Non-Profit (Applying entity must provide services to Berkeley County residents.)

Applicant Name(Required)

EIN Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Does the requesting entity, or any of its board members or employees, have any personal, financial, or other relationship with any member of the S.C. Opioid Recovery Fund Board that may be reasonably be viewed as a conflict of interest for that Member?(Required)

Yes

APPLICATION POINT OF CONTACT

Contact Name(Required)

Title(Required)

Phone Number(Required)

Email Address(Required)

FUNDING REQUEST

Award Amount Requested(Required)

Approved Abatement Strategy and Number(Required)

From the list of Approved Abatement Strategies, please list the strategy, number or letter/number combination of the strategy your proposal aligns with. Indicate the related Approved Abatement Strategy and Number below:

REQUIRED DOCUMENTATION

To be approved for funding, all requests must include

Technical proposal documentation(Required)

Max. file size: 64 MB.

Provide budget documentation(Required)

Max. file size: 64 MB.

Certification of Contents signed and dated(Required)

Max. file size: 64 MB.

DOCUMENTATION REQUIREMENTS:

Text must be legible. Pages must be typed in black, single-spaced, and using a font of Times New Roman 12, with all margins (left, right, top, bottom) at least one inch each. Please include the name of the Entity/Requestor and a page number at the bottom of each page.

Applicants may use Times New Roman 10 for charts and tables only, if applicable.

CERTIFICATION OF CONTENTS(Required)

The information provided in this application for SC Opioid Recovery Funds is true, complete, and accurate and all funds requested will only be used for approved purposes. In the event an applicant entity/organization is approved to receive funds from the SC Opioid Recovery Fund, the undersigned (authorized official signing for the applicant entity/organization) certifies that any false, fictitious, or fraudulent statements or claims may subject him or her to criminal, civil or administrative penalties.

I certify all of the above as truthful and accurate

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APPLICANT INFORMATION

APPLICATION POINT OF CONTACT

FUNDING REQUEST

REQUIRED DOCUMENTATION

DOCUMENTATION REQUIREMENTS:

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