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C-1 <br />+! <br />Request for Release of Funds M& pepArtment of Housing CMB No.25t1is <br />�► and Certification and Urban Development [eMp.6r3o"20c <br />Office of Community Planning <br />and Development <br />This form is to be used by Responsible Entities and Recipients (as defined in 24 GFR 58.2) when requesting the release of funds, ar <br />requesting the Authority to use such funds, for HUD programs identified by statutes that provide for the assumption of the environment <br />review responsibility by units of general local government and States. Public reporting burden for this collection of information is estimate <br />to average 36 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering a- <br />maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, ar <br />a person i.; not required to respond to, a collection of information unless that collection displays a valid OMS control number. <br />Part 1. Program Description and R nest for Release of funds to be completed by lies onsible Entit <br />1. Program titles) 2 HUOJStale Identlfieal on Number 3. RedpienI Id anGficabon Number <br />Options TRansitional Housing Program FL2913009001 (optional) <br />4. OMB Catalog Nurnber[s) S. Name and address of responsible entity <br />Joyce Johnston Carlson <br />1840 25th Street <br />S. For inlvrmation about this request, contact (name S phone number) Vero Beach, FL 32960 <br />Louise Hubbard 56.1-567-7790 561-567-8000 ext. 467 <br />7. Name and address ;�e eRtityl <br />o. HUD or State Agency and office unit to receive request <br />CPD -Jacksonville <br />The reetptent(s) of assistance under the program(s) listed above requests the release of funds and removal or environments <br />grant conditions governing the use of the assistance for the roflowing <br />9. Program ActivityllesYProjectName(s) 10. Location (Street address, city, county, State) <br />Supportive Housing Program 720 4th Street <br />Family options Transitional Housing Vero Beach, FL 32960 <br />11. Program Aclivlly/Project)]escripbon <br />Rehabilitation of an exisiting structure to bring sewer and <br />water up to code and to add transitional living space for up <br />to twelve additional families at one time, <br />Contact <br />Jiro Davis, Director Public Works <br />561-567-8000 ext. 245 <br />Previous aditionsaro obsclato form HUG -7073.15 (1199 <br />