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C elle oq Applicant/ Recipient U . S . Department of Housing OMB Approval No . 2510-0011 (exp . 10/31 /2012 ) Disclosure/ Update Report and Urban Development Instructions . (See Public Reporting Statement and Privacy Act Statement and detailed instructions on page 2 . ) Applicant/ Recipient Information Indicate whether this is an Initial Report ❑ or an Update Report Q 1 . Applicant/Recipient Name , Address , and Phone ( include area code ) : 2 . Social Security Number or Indian River County , 1801 27th St , Vero Beach , Florida 32960 , ( 772 ) 226 - 1243 Employer ID Number: 596 -00 -0674 3 . HUD Program Name 4 . Amount of HUD Assistance Neighborhood Stabilization Program Community Development Block Grant Requested/Received $4 , 680 , 825 . 00 5 . State the name and location ( street address , City and State ) of the project or activity : Indian River County Part I Threshold Determinations 1 . Are you applying for assistance for a specific project or activity? These 2 . Have you received or do you expect to receive assistance within the terms do not include formula grants , such as public housing operating jurisdiction of the Department (HUD) , involving the project or activity in subsidy or CDBG block grants . ( For further information see 24 CFR Sec. this application , in excess of $200 , 000 during this fiscal year ( Oct . 1 - 4 . 3 ) . Sep . 30) ? For further information , see 24 CFR Sec. 4 . 9 ✓❑ Yes ❑ No ❑✓ Yes ❑ No. If you answered " No " to either question 1 or 2 , Stop ! You do not need to complete the remainder of this form . However, you must sign the certification at the end of the report . Part II Other Government Assistance Provided or Requested / Expected Sources and Use of Funds . Such assistance includes , but is not limited to , any grant , loan , subsidy , guarantee , insurance , payment , credit , or tax benefit. Department/State/Local Agency Name and Address Type of Assistance Amount Expected Uses of the Funds Requested/Provided ( Note : Use Additional pages if necessary . ) Part III Interested Parties . You must disclose : 1 . All developers , contractors , or consultants involved in the application for the assistance or in the planning , development, or implementation of the project or activity and 2 . any other person who has a financial interest in the project or activity for which the assistance is sought that exceeds $50 , 000 or 10 percent of the assistance (whichever is lower) . Alphabetical list of all persons with a reportable financial interest Social Security No . Type of Participation in Financial Interest in in the project or activity For individuals , give the last name first or Employee ID No . Project/Activity Project/Activity( $ and Fred Fox Enterprises , Inc . 59244 - 3697 Administration $ 200 , 000 . 00 4 . 28 % Treasure Coast Homeless Services Council , Inc 522 -25-4571 Developer $2 , 1019264 . 50 44 . 89 % Indian River County Housing Authority 592 - 16 -3836 Sub -recipient $ 21101 , 264 . 50 44 . 89 % ( Note : Use Additional pages if necessary . ) Certification Warning : If you knowingly make a false statement on this form , you may be subject to civil or criminal penalties under Section 1001 of Title 18 of the United States Code . In addition , any person who knowingly and materially violates any required disclosures of information , including intentional non- disclosure , is subject to civil money penalty not to exceed $ 10 , 000 for each violation . I certify that this information is true and complete . Signature : Date : ( mm/dd/yyyy) •••• \11 ..11 . •M" `•V n nn x "•.•�� C0MM[SS J U 11, Cvl Ao I I c •,•m9 f Q�Q,� "•• R COUNT;.••• ••r .• • 11 •••• Form HUD-2880 (3/99)