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Applicant/Recipient U.S. Department of Housing OMB Approval No, 2510-0011 (exp. 12131 /2008) <br /> Disclosure/Update Report and Urban Development <br /> Instructions. (See Public Reporting Statement and Privacy Act Statement and detailed instructions on page 2 .) <br /> ApplicantRecipient Information Indicate whether this is an Initial Report ❑ or an Update Report <br /> 1 . Applicant/Recipient Name, Address, and Phone (include area code): 2. Social Security Number or <br /> INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS Employer ID Number: <br /> 184025 TH STREET 59-6000-674 <br /> VERO BEACH , FL 32960 <br /> (772-567-8000 <br /> 3. HUD Program Name 4. Amount of HUD Assistance <br /> SUPPORTIVE HOUSING , HMIS Requested/Received <br /> 36 , 177 . 00 <br /> 5, State the name and location (street address, City and State) of the project or activity: <br /> INDIAN RIVER COUNTY <br /> Part I Threshold Determinations <br /> 1 . Are you applying for assistance for a specific project or activity? These 2. Have you received or do you expect to receive assistance <br />within the <br /> terms do not include formula grants, such as public housing operating jurisdiction of the Department (HUD) , involving the project or activity <br /> in this <br /> subsidy or CDBG block grants. (For further information see 24 CFR Sec. application, in excess of $200,000 during this fiscal year (Oct. <br /> 1 - Sep. 30)? <br /> 4.3). For further information, see 24 CFR Sec. 4.9 <br /> ® Yes ❑ No ❑ Yes ® No. <br /> If you answered "No" to either question 1 or 2 , Stop ! You do not need to complete the remainder of this form . <br /> However, you must sign the certification at the end of the report. <br /> Part II Other Government Assistance Provided or Requested / Expected Sources and Use of Funds. <br /> Such assistance includes , but is not limited to, any grant, loan, subsidy, guarantee, insurance, payment, credit, or tax benefit. <br /> Department/State/Local Agency Name and Address Type of Assistance Amount Requested/Provided I Expected Uses of the Funds <br /> (Note: Use Additional pages if necessary.) <br /> Part III Interested Parties, You must disclose: <br /> 1 . AO developers, contractors, or consultants involved in the application for the assistance or in the planning, development, or implementation of the <br /> project or <br /> activity and <br /> 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 <br />of the assistance <br /> (whichever is lower). <br /> Alphabetical list of all persons with a reportable financial interest in Social Security No. Type of Participation in Financial Interest <br /> in <br /> the project or act For individuals give the last name first or Employee ID No. ProjecttActivity Pro'ect/A $ and % <br /> (Note: Use Additional pages if necessary.) <br /> Certification <br /> 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 <br /> of the United <br /> States Code. In addition, any person who knowingly and materially violates any required disclosures of information, including intentional nondisclosure, <br /> is <br /> subject to civil money penalty not to exceed $10,000 for each violation. <br /> I certify that this information is true and complete. <br /> Signature: Date: (mmiddryyyy) <br /> X e�40 I <br /> July 13 , 2004 <br /> Caroline D . Ginn , Chairman <br />