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2005-166b
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2005-166b
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Applicant/Recipient U .S . Department of Housing OMB Approval No. 2510-0011 (exp. 12/31 /2006) <br /> Disclosure/ Update Report and Urban Development <br /> Instructions . (See Public Reporting Statement and Privacy Act Statement and detailed instructions on page 2 .) <br /> Applicant/Recipient 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 /> 1840 25th Street , Vero Beach , FL 32960 59-6000-674 <br /> ( ) - 772-567-8000 x 1467 <br /> 3 . HUD Program Name Continuum of Care Homeless Assistance Program- SHP 4. Amount of HUD Assistance <br /> Requested/Received <br /> 70 , 063 . 67 <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 ElNo ❑ 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 />. <br /> Department/State/Local Agency Name and Address Type of Assistance Amount Requested/Provided Expected Uses of the Funds <br /> (Note: Use Additional pages if necessary. ) <br /> Part III Interested Parties . You must disclose: <br /> 1 . All developers , contractors, or consultants involved in the application for the assistance or in the planning , development, or implementation <br /> of the 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 $50 ,000 or 10 percent <br /> of the assistance <br /> (whichever is lower) . <br /> Alphabetical list of all persons with a reportable financial interest in Social Security No . Type of Participation in Financial Interest <br /> in <br /> the project or activity For individuals, give the last name first or Em to ee ID No . Project/Activity Project/Activity <br />($ and °b <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 <br /> 18 of the United <br /> States Code. In addition , any person who knowingly and materially violates any required disclosures of information , including intentional non-disclosure <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 : (mm/dd/yyyy) <br /> May 17 , 2005 <br /> x h.� <br />
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