Factor I – Capacity of the Applicant and Relevant Organizational Experience Key Personnel Partners
Key Personnel
Name and Position Title (please include the organization position titles in addition to those shown)	Percent of Time Proposed for this Grant	Percent of Time to be spent on other HUD grants	Percent of time to be spent on other activities
1.1 Overall Project Director
Name:
Organization Position Title:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:
1.2 Day-to-Day Program Manager
Name:
Organization Position Title:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:
1.3 Other
Name:
Organization Position Title:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:
Partners
Name and contact information	Description of Commitment	Proposed Activities to be Conducted by Partner	Resource and leveraged resource commitment ($ value for services)
Name:
Organization Position Title:
Sub-recipient: Yes No
Address:
Phone Number:
Email:
Name:
Organization Position Title:
Sub-recipient: Yes No
Address:
Phone Number:
Email:
Name:
Organization Position Title:
Sub-recipient: Yes No
Address:
Phone Number:
Email:
Name:
Organization Position Title:
Sub-recipient: Yes No
Address:
Phone Number:
Email:
Factor 2 – Need and Extent of the Problem Housing Costs Economic Opportunity Environmental Quality Fresh Food Access Transportation Access Healthy Communities Socioeconomic Inequity
Housing Costs
Median Regional Housing Prices Relative to Household Income	1.2 Proportion of Regional Population Paying More than 45% of Income to Combined Housing and Transportation Costs
YEAR	median regional rental prices	median regional household income	rent to income ratio	median housing to income ratio	Location	regional housing and transportation cost	regional income level	portion spending more than 45% of Income
1990	Region-wide
2000	Community 1
2008	Community 2
Community 3
Source:	http://www.hud.gov/sustainability	Source:	http://htaindex.cnt.org/
Date Documented:	Date Documented:
Environmental Quality
2.1 Urbanized Land per Capita	2.2 Total Miles of Distribution of Water Infrastructure per Population Served
YEAR	urbanized land (acres)	population of region	urbanized land per capita	year	miles of distribution of water infrastructure	population of region	water distribution service population	miles of distribution of water infrastructure per population served
1990	1990
2000	2000
2008	2008
Source:	http://www.hud.gov/sustainability	Source:	Public Utilities; http://www.hud.gov/sustainability
Date Documented:	Date Documented:
Transportation Access
Vehicle Miles Traveled per Capita	Portion of Regional Trips: Automobile, Transit, Walking, and Bicycling
Year	total road mileage (all modes)	vehicle miles traveled	vehicle miles traveled per capita	Years	Automobile	Transit	Walking	Bicycling
trips	% of total	trips	% of total	trips	% of total	trips	% of total
1990
2000	1990
2009	2000
2010
Total
Source:	http://www.hud.gov/sustainabitly	Source:	http://www.hud.gov/sustainabitly
Date Documented:	Date Documented:
Socioeconomic Inequity
4.1 Segregation by County
County Name	2009 Black/White Dissimilarity Index	2009 Asian/White Dissimilarity Index	2009 Hispanic/White Dissimilarity Index
1
2
3
4
5
4.2 School Lunch Eligibility
County Name	2009 Black/White Dissimilarity Index	2009 Asian/White Dissimilarity Index	2009 Hispanic/White Dissimilarity Index
1
2
3
4
5
Source: http://www.s4.brown.edu/cen2000/SchoolPop/SPDownload.html; http://www.nces.ed.gov/ ; instructions at http://www.hud.gov/sustainabitly
Date Documented:
Economic Opportunity
5.1 Availability of Subsidized Affordable Housing near Employment Centers (Note: please list the five largest employers and the housing conditions related to it)
employment center (name / SIC designation)	# of employees	number of housing units within 2 miles of the employment center	% of housing near employment center that is subisdized
1
2
3
4
5
Source: Local Economic Development Departments, Offices of Housing.
Date Documented:
Fresh Food Access
6.1 Proximity of Full-Service Grocery Stores for Low-Income and Auto-Dependent Households
% households with no car and > 1 mile to grocery store	% low-income people living > 1 mi to grocery store
Regional Average
County 1
County 2
County 3
County 4
County 5
Source : http://www.ers.usda.gov/foodatlas/
Date Documented:
Healthy Communities
7.1 Prevalence of Preventable Disease
County:
Race:	White	Native American	African American	Hispanic	Asian American/ Pacific Islander	Other
Indicator	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000
Asthma hospitalization
Childhood Obesity
Diabetes
Heart Disease
Lead Poisoning
Low birth weight
Source : County and State Health Departments also http://www.communityhealth.hhs.gov
Date Documented:

County:
Race:	White	Native American	African American	Hispanic	Asian American/ Pacific Islander	Other
Indicator	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000
Asthma hospitalization
Childhood Obesity
Diabetes
Heart Disease
Lead Poisoning
Low birth weight
Source : County and State Health Departments
Date Documented:
County:
Race:	White	Native American	African American	Hispanic	Asian American/ Pacific Islander	Other
Indicator	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000
Asthma hospitalization
Childhood Obesity
Diabetes
Heart Disease
Lead Poisoning
Low birth weight
Source : County and State Health Departments
Date Documented:
County:
Race:	White	Native American	African American	Hispanic	Asian American/ Pacific Islander	Other
Indicator	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000	Incidence Per 1000
Asthma hospitalization
Childhood Obesity
Diabetes
Heart Disease
Lead Poisoning
Low birth weight
Source : County and State Health Departments
Date Documented:

Factor 4 – Leveraging Resources
Name and contact information of the organization or entity that will partner with applicant	Work To Be Accomplished In Support of the Program	Value of In-Kind or Cash Match Contribution*	Additional Leveraged Funds Contribution	Total of Match and Leveraged Contributions
Name:
Type of Organization
Partner Receiving Award Grant Funds:	Yes No
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:
Name:
Type of Organization
Partner Receiving Award Grant Funds:	Yes No
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:
Name:
Type of Organization
Partner Receiving Award Grant Funds:	Yes No
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:
Name:
Type of Organization
Partner Receiving Award Grant Funds:	Yes No
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:
Name:
Type of Organization
Partner Receiving Award Grant Funds:	Yes No
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:
Name:
Type of Organization
Partner Receiving Award Grant Funds:	Yes No
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email:
Total Amount

Factor 5 – Achieving Results and Program Evaluation
Regional planning issue to be addressed	Long-term outcome desired	Livability Principle(s) addressed	HUD goals addressed	Applicable Activity in the Regional Plan for Sustainable Development	Anticipated 6-month progress	Measure of progress	Anticipated 12-month progress	Measure of progress	Anticipated 24-month progress	Measure of progress
Disconnection between low- and moderate-income workforce to employment options (sample)	Increased proportion of low- and very-low income households within to transit commute of major employment centers (sample)	Providing More Transportation Choices; Increasing Economic Competitiveness	Strengthen Communities. (2) Enhance sustainability of communities by expanding economic opportunities.	Workforce Transportation 2020 plan that cements agreements between major employers and regional transit agency (sample)	Identify potential long term employers willing to participate in program; secure participation of transit agency (sample)	Letters of commitment from participating agencies	Convene working group that has 4-month charge to develop agreements to incorporate into the RPSD (sample)	Summaries of meetings; strategic plan outline	Draft plan submitted to leadership Team for review and incorporation into the RPSD – review process commenced (sample)	Draft plan, ratification by RPSD
Creation of shared elements in regional transportation, housing, water, and air quality plans tied to local comprehensive land use.
Reduced social land economic disparities for the low-income and communities of color within the target region.
Decrease in per capita VMT and transportation-related emissions for the region.
Decrease in combined housing and transportation costs per household.
Increased participation and decision-making in developing and implementing a long range vision for the region by populations traditionally marginalized in public planning processes.
Increased proportion of low-and very-low income households within to transit commute or major employment centers.