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Applicant/Recipient U .S . Department of Housing OMB Approval No . 2510-0011 (exp. 12/31 /2006) Disclosure/Update Report and Urban Development Instructions . (See Public Reporting Statement and Privacy Act Statement and detailed instructions on page 2 ) Applicant/Recipient Information Indicate whether this is an Initial Report ❑ or an Update Report 1 . Applicant/Recipient Name, Address, and Phone (include area code): 2. Social Security Number or INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS Employer ID Number: 1840 25" STREET, VERO BEACH , FL 32960 59-6000-674- (772-567-8000) - 3. HUD Program Name 4. Amount of HUD Assistance CONTINUUM OF CARE HOMELESS ASSISTANCE PROGRAM -SHP Requested/Received $24 , 581 . 00 5. State the name and location (street address, City and State) of the project or activity: INDIAN RIVER COUNTY Part I Threshold Determinations 1 . Are you applying for assistance for a specific project or activity? These 2. Have you received or do you expect to receive assistance within the terms do not include formula grants, such as public housing operating jurisdiction of the Department (HUD) , involving the project or activity in this subsidy or CDBG block grants. (For further information see 24 CFR Sec. application , in excess of $200,000 during this fiscal year (Oct. 1 - Sep. 30)? 4.3). For further information, see 24 CFR Sec. 4. 9 ❑ Yes ElNo ❑ Yes ® No . If you answered " No" to either question 1 or 2 , Stop ! You do not need to complete the remainder of this form . However, you must sign the certification at the end of the report . Part II 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. Department/State/Local Agency Name and Address Type of Assistance Amount Requested/Provided Expected Uses of the Funds (Note: Use Additional pages if necessary.) 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 activity and 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 of the assistance (whichever is lower). Alphabetical list of all persons with a reportable financial interest in Social Security No. Type of Participation in Financial Interest in the project or activity For individuals, give the last name first or Employee ID No. Project/Activity Pro ect/Activi $ and % (Note: Use Additional pages if necessary. ) Certification 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 of the United States Code. In addition , any person who knowingly and materially violates any required disclosures of information , including intentional non-disclosure, is subject to civil money penalty not to exceed $10,000 for each violation . I certify that this information is true and complete . Signature: Date: (mm/dd/yyyy) X May 17 , 2005