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• 40 • Applicant/RecipientU.S. Department of Housing OMB Approval No. 2510.0011 {exp. 1131199} Disclosure/Update e/Update Report and Urban Development Instructions, (See Public Reporting Statement and Privacy Act Statement and detailed instructions on page 2.) Appiicant/Reclpient Information Ind tests whether this is on Initaal Report Q or an update Report (] 1, ApphcantlReciplent Name, Address, and Phone (include area code): 2. Social Saatdty Number or Employer ID Number: INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS 3. HUD Program Name 4, Amount of HUO Assistance Requested/Recelved SUPPORTIVE HOUSING PROGRAM 5. Stale the name and location (skeet address, City and State) of the projector activity: Part i Threshold Determinations 1. Are you applying for assisiance for a specific project or activity? These 2. Have you received w do you expect to receive assistance within the terms do not include formula grants, such as public arousing operating jurisdiction of the Department (HUD). involving the project or activity in subsidy or CDBG block grants. (For further inlormation see 24 CFR Sec. this application, in excess or S200,000 during this fiscal year (Oct. 1 4,3), Sep, 30)7 For further Information, see 24 CFR Sec. 4.9 Yes D No L] Yes No. If you answered "No" to either question 1 or 2, Stopl You do not need to complete the remainder of this form. However, you must sign the certification at the end of the report. Part 11 {`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. DeparlmenUStatell-ocal Agency Name and Address I Type of Assistance J Amount I Expected Uses of the Funds 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 activily and 2. any other person who has a financial interest In the project or activity for which the assistance Is sought that exceeds 550,000 or 10 percent of the a SSa Slance (whichever is lower). Alphabalical list of all persons with a reporlable financial interest Social Security No. I Type of Participation in Financial Interest fin in the project or activity (For individuals, give the Iasi name first) or Employee ID No. I Project/Activity I ProjectlActivl ly (S and 1%) (Note. Use Additional pages if necessary.) Certification Warming: If you knowingly make a false statement on this form, you may be subject to civil or criminal penalties under Section 1001 of Title is of the United States Code. In addition, any person who knowingly and materially violates any required disclosure- of information, Including Intentional non- dhsclosure, Is subject to civil money penalty net to exceed $10,000 for each violation. I cerlhty that this information is true and complete. x (mmrddlyyyy) May 23, 2000 Form I1UO.288') (3199)