New York State OPWDD Integrated Supportive Housing Program Application Cover Page Agency Name Agency Address
Mailing Address (if different than above)
Executive Director Phone Number/E‐Mail Primary Project Contact Phone Number/E‐Mail Developer Name Developer Phone/E‐Mail Working Name of Project County Project is Located in Has this project received a conditional Empire State Supportive Housing Initiative (ESSHI) Award?
Yes
No
Is this a subsequent phase of an earlier project?
Yes
No
If yes, please complete the information below: Project Name
Year Funded
SHARS ID
Please describe the target I/DD population for your project.
Total Number of Units
Total Units for OPWDD
Total Cost for Project
Total Units for Other Special Needs
Total Cost Per Unit
Please indicate what other (if any) special needs populations will receive preference in tenant selection in the project. Physical Disabilities Behavioral Health
Mental Health
Veterans
Substance Abuse
Sensory Disabilities
Chronically Homeless
TBI
HIV/AIDS
Other
Signature of Executive Director Date