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4W 40 �► Applicant/Recipient U.S. Department of Housing OMB Approval No. 2510-0011 (exp. 1131193) and Urban Development DiscicsurelUpdate Report Instructions. (See Public Reporting Statement and Privacy Act Statement and detailed instructions on page 2.) ApplicantlReciplent Information Indicate whatherthis Is an Initial Report C] or an update Report 1. Applicant/Recipient Name, Address, and Phone (include area code): 2. Soda? Security Number or INDIAN RIVER COUNTY Employer ID Number. BOARD OF COUNTY COMMISSIONERS - 3, HUD Program Name 4. Amount of HUD Assistance Requeslod/Racelved SUPPORTIVE HOUSING PROGRAM 5. Stale the name and location (street address, City and State) of the project or activity. Parti 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 judsdichon of the Department (HUD) , involving the project or activity In subsidy or CDBG black grants. (For lurcher information see 24 CFR Sec. this application, in excess of $200,000 during this fiscal year (Oct, t - 4.3). Sop. 30)7 For further information, see 24 GFR Sec, 4.9 Yes r-1 No ❑ Yes ® No. If you answered "No" to either question t or 2, Stopi You do not need to complete the remainder of this foram. However, you must sign the certification at the end of the report. Part li Other Government Assistance Provided or Requested l 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. DepanmentlStaleftOcai Agency Name and Address Type of Ass+stance Amount Expecled Uses of the Funds RequestedlProvlded (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 proiecl or aclnrlly 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). Aiphauetical list of all persons with a reponabie Financial interest in the protect or activity (Fpr individuals, give the last name first) Social Security NOF or Employee ID No. Type of Participation in ProjecUActivity Flnandal Interest in ProecVAclIvll is ano 1.) tnv¢e use naomonai 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 TIOe 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. X (-WddWyy) May 23, 2000 Form HUD -280013199)