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2. Pre-Agreement Consultation
   Information provided in this form will be used to develop a contractual Agreement between the Recipient and the City of Dubuque. The Agreement will contain outcomes and indicators necessary to evaluate and monitor progress towards meeting identified City Council Goals. Agreement. "Agreement" means the Agreement and all of the leases, assignments, and similar documents identified in the Agreement and all other instruments or documents executed by the Recipient or otherwise required in connection with the Agreement, including the information from the Application together with any related submittal documents. Completion of this form does not constitute an Agreement with the City of Dubuque.
4. Recipient Information
   Recipient. "Recipient" means any public or private agency, institution, organization, or other entity or any person receiving directly, or through any successor, assignee, or transferee of a receipt, but excluding the ultimate beneficiary, of financial assistance from the City of Dubuque.
6. Recipient Name:*
   Full legal name of Recipient, as it should appear in the Agreement.
7. Name of Authorized Representative*
   Person authorized to legally enter Agreement or contract with the City of Dubuque on behalf of the recipient.
8. Title of Authorized Representative*
   Ex: Executive Director, Board Chair
10. Recipient Mailing Address*
11. Address2
13. City*
14. State*
15. Zip*
17. Primary Contact for Project
    Project. "Project" means a discrete item of work as determined to be eligible for funding through Agreement with the City of Dubuque.
19. Name of Primary Contact for Project*
20. Email Address*
22. Phone Number
23. Should the Agreement be mailed to the Recipient mailing address listed above?

    1. Yes

    1. No
25. Mailing Address1*
26. Mailing Address2
28. City*
29. State*
30. Zip*
32. Project Timeline
34. Describe the Project timeline:*
    Include information on concept development, planning, production/operation, completion, and evaluation.
36. Project Start Date and End Date*
    Project Start Date and End Date Start Date

    —

    Project Start Date and End Date End Date
    Enter the desired time of performance for the Project. The services of the Recipient are to commence as of the Agreement Start Date and shall be undertaken in such sequence as to assure their expeditious completion. All agreed upon services should be completed on or before the Agreement End Date.
38. Will you have eligible expenses that occured prior to the execution of the Agreement?*

    1. Yes

    1. No
40. How will you document eligible expenses?*
42. Performance Measures
44. Primary City Council Goal*
    -- Select One --Robust Local Economy: Diverse Businesses and Jobs with Economic ProsperityVibrant Community: Healthy and SafeLivable Neighborhoods and Housing: Great Place to LiveFinancially Responsible, High Performance City Organization: Sustainable, Equitable, and Effective Service DeliverySustainable Environment: Preserving and Enhancing Natural ResourcesPartnership for a Better Dubuque: Building our Community that is Viable, Livable, and EquitableDiverse Arts, Culture, Parks, and Recreation Experiences and ActivitiesConnected Community: Equitable Transportation, Technology, Infrastructure, and Mobility
46. Project services benefit:*
    -- Select One --IndividualsHouseholds (or Housing Units)AreaBusiness/Organization
47. Service goal for 12 month period:*
49. Check the location(s) where services will be provided:*

    1. City Wide
    2. Downtown
    3. Hill/College
    4. North End

    1. Point Neighborhood
    2. South End
    3. Other
50. Describe the population in the Project service area:*
52. Describe the service area:*
54. The Project provides/creates:

    1. Suitable Living Environment: Relates to activities that are designed to benefit communities, families, or individuals by addressing issues in their living environment.
    2. Decent Housing: Provide or improve housing & housing conditions that meet household or specific community needs. For City-wide efforts, use Suitable Living Environment.
    3. Economic Opportunities: Applies to economic development, commercial revitalization, or job or business creation or expansion.
56. The long-term Project impact intends to provide/create:

    1. Availability/Accessibility: Make services, infrastructure, facilities, housing, or shelter available and accessible to people where they live. Referes to more than removal of physical barriers.
    2. Affordability: Provide affordability in a variety of ways in the lives of people. Includes creating or maintaining affordable housing, basic infrastructure, or transportation, & child care services.
    3. Sustainability: Improving communities or neighborhoods, benefiting persons by removing blighted conditions or through activities that increase livability.
58. Sources & Uses
60. Sources of Funding*

    In addition to funding from the City of Dubuque, please identify all sources of funding for the Project:

    1. Private
    2. Local Government
    3. State
    4. Federal
    5. None, the project is 100% City funded
    6. Other:
62. List source and amount of funding:
64. At this time, is the cash match, scale, scope, or use of funding for the Project different than stated in the request for funding or the application?*

    Check all that apply.

    1. Cash Match
    2. In-Kind Match
    3. Scale and scope of Project
    4. Use of funds
    5. Other
66. Adjusted Cash Match*
67. Adjusted In-Kind Match*
68. Describe changes to scale and scope of Project*
70. Other: Describe what changed*
71. Identify new, changed, or removed uses of funds:*
73. Thank you for partnering with the City of Dubuque. A representative will contact you to finalize a draft Agreement. Final agreements are subject to the City Council or designated authority.
Leave This Blank:


75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

* indicates a required field