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/i71 <br /> baa g " -� � �► <br /> APPLICATION FORVersion 7/03 <br /> FEDERAL ASSISTANCE 2. DATE SUBMITTED Applicant Identifier <br /> 1 . TYPE OF SUBMISSION : 3. DATE RECEIVED BY STATE State Application Identifier <br /> Application Pre-application <br /> C Construction C Construction <br /> 4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier <br /> Non-Construction D Non -Construction <br /> 5. APPLICANT INFORMATION <br /> Legal Name : Organizational Unit: <br /> INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS Department: <br /> COUNTY GOVERNMENT <br /> Organizational DUNS : Division : <br /> 079-208-989 <br /> Address : Name and telephone number of person to be contacted on matters <br /> Street: involving this application (give area code) <br /> 184025TH STREET Prefix : First Name: <br /> JASON <br /> Cityy: Middle Name <br /> CIA: <br /> BEACH <br /> County: Last Name <br /> INDIAN RIVER BROWN <br /> State : Zip Code Suffix : <br /> FLORIDA 32960 BUDGET DIRECTOR <br /> Country: Email : <br /> UNITED STATES JBROWN@I!RCGOV .COM <br /> 6. EMPLOYER IDENTIFICATION NUMBER (EIN): Phone Number (give area code) Fax Number (give area code) <br /> 5❑ H — © 9 0❑ E © E ® 772-567-8000 772-567-5991 <br /> 8. TYPE OF APPLICATION : 7. TYPE OF APPLICANT: (See back of form for Application Types ) <br /> V New [71 Continuation Revision B <br /> If Revision , enter appropriate letter( s ) in box( es ) <br /> See back of form for description of letters . ) ❑ ❑ Other ( specify) <br /> Other (specify) 9. NAME OF FEDERAL AGENCY : <br /> US DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT <br /> 10 . CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER : 11 . DESCRIPTIVE TITLE OF APPLICANT'S PROJECT: <br /> FAMILY TIONS TRANSITIONAL HOUSING - ONE YEAR <br /> RENEWAL <br /> TITLE (Name of Program ) : <br /> CONTINUUM OF CARE HOMELESS ASSISTANCE - SUPPORTIVE HOUSING <br /> 12 . AREAS AFFECTED BY PROJECT (Cities, Counties. States, etc.): <br /> INDIAN RIVER COUNTY , FLORIDA <br /> 13. PROPOSED PROJECT 14. CONGRESSIONAL DISTRICTS OF: <br /> Start Date : Ending Date: a . Applicant b. Project <br /> 5/01 /2006 4/30/2007 <br /> 15. ESTIMATED FUNDING : 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE <br /> ORDER 12372 PROCESS ? <br /> a . Federal a . Yes. 10 THIS PREAPPLICATION /APPLICATION WAS MADE <br /> 70 , 063 . 67 AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 <br /> b . Applicant ou PROCESS FOR REVIEW ON <br /> c. State DATE : <br /> d . Local 00 b No WrJ PROGRAM IS NOT COVERED BY E . O . 12372 <br /> e . Other 00 n OR PROGRAM HAS NOT BEEN SELECTED BY STATE <br /> 17 , 515 . 00 FOR REVIEW <br /> f. Program Income ou 17 . IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT ? <br /> g . TOTAL <br /> 87 , 578 . 67 Q Yes If "Yes" attach an explanation . No <br /> 18 . TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION /PREAPPLICATION ARE TRUE AND CORRECT. THE <br /> DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE <br /> ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED . <br /> a . Authorized Representative <br /> CWANMA First Name <br /> fiddle Name <br /> S . <br /> Last Nam CoA—( <br /> Suffix <br /> LOWTHER S , V ` <br /> b . Title c . Telephone Number give area code) <br /> CHAIR , BOARD OF COUNTY COMMISSIONERS 772-%x-xxmx — <br /> Signature of Authorized Representative . Date Signed _ <br /> Ma �1 <br /> Previous Edition Usable Standard Form 424 ( Rev . 9-2003) <br /> Authorized for Local Reoroduction Prescribed by OMB Circular A- 102 <br />