APPLICANT STATIONARY

Date

VIA ELECTRONIC & REGULAR/OVERNIGHT MAIL

Mr. Mark Luckner

Executive Director

Maryland Community Health Resources Commission

45 Calvert Street, Room 336

Annapolis, MD 21401

Re: Maryland Community Health Resources Commission – COVID-19 EMERGENCY RELIEF FUNDING -

Letter of Request

Dear Mr. Luckner,

This Letter of Request, submitted by	[Name of Organization]	(the “Applicant”), a [non/for-profit organization / type of community health resource]	, located	[Address]	, whose mission serves	[Service Area/Target Population]	, hereby requests emergency funding in the amount of	[ not to exceed $50,000	] from the Maryland Community Health Resources Commission (“CHRC”), in light of the SARS-CoV-2 (“COVID-19 virus”) public health emergency affecting the operations of	[Program Name]	(the “Program”). These funds will be used to offset expenses incurred due to the COVID-19 virus since March 5, 2020 and will be expended not later than December 31, 2020.

Please accept [Organization Name’s] our financial statements for the last three years which outlines the usual and customary funding needed to operate the Program and a profit & loss statement since the implementation of the Governor’s State of Emergency Declaration (Existence of Catastrophic Health Emergency) on March 5, 2020. With the submission of these financial documents, we further certify that [Organization Name] is and has been financially stable for a period of at least three (3) years.

Below please find additional information required by the MCHRC in order to grant temporary emergency funding:

Name, Telephone # and email address of Official authorized to execute contracts on the Applicant’s behalf:	Click here to enter text.
Name, Telephone # and email address of the Applicant’s Director and a contact person (if different than the Director):	Click here to enter text.
1. Has the CHRC certified the organization as a “Community Health Resource” in the past six months? Please note: the default response is set for NO; select YES if this is the correct response. If NO, click here to see if your organization meets the definition of a “Community Health Resource.
2. Briefly describe the nature, mission and significance of the Program, including its history of serving vulnerable populations and the geographic area in which it operates. Please also include information about the number and area of residence of low income, underinsured or uninsured persons served by the Program on a monthly, quarterly, or annual basis:
3. Detail how the infusion of emergency relief funds issued by the Commission will help you mitigate the impact of the COVID-19 virus pandemic on the vulnerable populations that you currently serve (or are currently unable to serve) with specific focus on how these funds help to address the impact of the pandemic on social determinants of health and health disparities:
4. Describe how the requested emergency funds will be used to specifically support the provision of essential health services for low income, underserved and minority populations who are disproportionately impacted by the COVID-19 virus. Please describe below and include the accompanying line-item budget detail, which is required. If the space below is not sufficient, applicants are permitted to include a written description.
5. Briefly describe the Program’s organizational and financial structure including the customary amount of funds needed to provide services on a monthly, quarterly or annual basis, as well as the normal and usual funding source or sources for the Program:
6. Explain how the emergency funds will be used to stabilize the Program (NOTE: this emergency funding may not be used to offset revenue losses due to a reduction in patients/clients, reduced service utilizations, etc.):
7. Upon expiration of the CHRC emergency funds, please summarize the reasonable likelihood of that the applicant will be able to continue to serve low income, underserved, minority populations and achieve longer-term sustainability of services:
8. Please provide a list of all other potential sources of funding, both internal and external, that have been approached by the Applicant for this temporary emergency and their responses:
9. To illustrate the economic impact of the COVID-19 virus pandemic on your business, please provide a short statement about your business prior to COVID-19, what the effects have been, and a specific dollar amount (or range) estimate of the financial impact on your business based on your previous revenues and/or expenses:
10. Please provide a concise explanation of why the temporary emergency for which funding is sought could not have been anticipated:

By signing below, the Applicant attests that the funding requested above will not duplicate funding made possible by other local, state and federal agencies. Furthermore, I attest that to the best of my knowledge and belief, all the information contained in the foregoing Letter of Request is accurate and complete.

Official Authorized to Execute Contracts:

Printed Name:	Date:

Title:

Signature: