Dss Form 3359 - Application For Participation
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South Carolina Department of Social Services
Emergency Shelters Program (ESP)
APPLICATION FOR PARTICIPATION
Agreement Number:
Federal Identification Number:
Name and Address of Organization
1. Name:
Telephone:
Fax:
Mailing Address:
Street or P.O. Box
City
Zip
Select County ...
Physical Address:
Street
City
Zip
County
Select County ...
County:
Name of Contact Person:
2. Date you would like to be approved to claim meals for reimbursement:
3. Check the one which applies:
n
n
n
n
Government Organization (Public)
Educational Institution
n
n
n
n
Private Nonprofit Organization/Secular
For-Profit Organization
(Attach a copy of the letter from IRS granting federal tax exemption)
n
n
n
n
Private Nonprofit Organization/Faith-Based
Other:
(Specify)
4. What is the primary purpose of your shelter?
n
n
To provide temporary shelter and food services to unaccompanied children through age 18.
n
n
To provide temporary shelter and food services to homeless children and their family.
n
n
To provide residential child care services.
(Answer question 5)
n
n
Other:
(Please describe)
5. If your organization is a residential child care institution (RCCI), do you serve a distinct group of homeless children
n
n
n
n
who are not enrolled in the RCCI’s regular program?
Yes
No
6. What is the age range of participants accepted at your facility?
From
to
7. Does your organization now participate or have you participated in programs funded through the Food and Nutrition
Service in the past three years?
(If “Yes,” give name of program and dates of participation, and with which organization if not same
n
n
n
n
Yes
No
as current.)
8. Does your organization participate in any other federally funded programs?
(If “Yes,” give name of program and dates
n
n
n
n
Yes
No
of participation.)
9. Has your organization been terminated from participating in any publicly funded programs within the past seven
n
n
n
n
years?
Yes
No
(If “Yes,” give name of program, dates of participation and reason(s) for termination.)
10. Number of sites your organization will sponsor for the Emergency Shelters Program:
11. Does your organization maintain documentation indicating the full names, dates of birth and periods of all children in
n
n
n
n
residency?
Yes
No
If so, what is the title of this document?
Who is responsible for recording this information?
(Include name(s) and title(s))
Where will the ESP documentation be housed?
(Originals and any copies)
DSS Form 3359 (MAR 15) Edition of APR 10 is obsolete.
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