Brevard County Home Consortium 2027–2032 Consolidated Plan Public Service Agency Questionnaire Brevard County is conducting a survey to identify desired services needed by low and moderate income families/households within Brevard County. The survey results will be one tool used to develop the 2027–2032 Consolidated Plan that prioritizes the expenditure of these funds. Question Title * 1. Please indicate the services needed by the customers you serve. Select all that apply. Adult Day Care Services Child Care Services Drug/Alcohol Substance Abuse Services Food Bank/Food Programs Handicapped Services Health Services HIV/Aids Health Services Housing/Homeless Service Literacy Services Mental Health Services Other Special Needs Pharmaceuticals Senior Services Transportation Services Transitional Housing/Emergency Shelters Youth Services Other (please specify) Question Title * 2. Does your organization serve low-to-moderate income clients in any of the following categories? Abused/Battered Women Children Handicapped/Disabled HIV/Aids Patients Homeless Mentally Challenged Seniors Youth Other (please specify) Question Title * 3. Based on your agency’s goals for next fiscal year, enter the number of low to moderate-income clients that you plan to serve. Question Title * 4. Based upon your agency’s capacity, please quantify the number of people and the financial ($) gap between your short-term (1 year) capacity and the perceived short-term (1 year) need by low-to-moderate-income people. Short Term People Gap Short Term Financial Gap ($) Question Title * 5. Based on your agency’s long-term goals for the next fiscal year, enter the number of low to moderate-income clients that you plan to serve. Question Title * 6. Based upon your agency’s capacity, please quantify the number of people and the financial ($) gap between your long-term (5 year) capacity and the perceived long-term (5 year) need by low to moderate-income people. Long Term People Gap Long Term Financial Gap ($) Question Title * 7. Please indicate any assistance that you need to help increase your capacity as a public service agency. Select all that apply. Board Development Fundraising Grant Writing Measures/Objectives Program Evaluation Other (please specify) Question Title * 8. Please indicate how much ($) your agency will require from all sources in total funding over the next five years. Question Title * 9. Please indicate your agency’s current funding source(s). Select all that apply. Business Contributions Federal Government Foundations Fund Raising State Contributions Trusts-Endowments United Way Other (please specify) Question Title * 10. If you plan to apply for funding through Community Development Block Grant (CDBG) Public Service programs over the next 5 years, please enter the estimated amount ($) you expect to request for each jurisdiction below: Brevard County City of Cocoa City of Melbourne City of Palm Bay City of Titusville Updated Agency Contact Information Question Title * 11. Agency Name Question Title * 12. Agency’s Preferred Mailing Address Question Title * 13. Agency’s Contact Question Title * 14. Agency’s Telephone Number Question Title * 15. Agency’s Fax Number Question Title * 16. Agency’s Email Address Done