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06 APPLICATION FOR Version 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 /> Construction ❑ Construction 4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier <br /> Non-Construction Q 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 /> Ci�tyy: Middle Name <br /> VERO 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@IRCGOV .COM <br /> 6. EMPLOYER IDENTIFICATION NUMBER (EIN): Phone Number (give area code) Fax Number (give area code ) <br /> ao411EKIO © EI ® 772-567-8000 772-567-5991 <br /> 8. TYPE OF APPLICATION : 7. TYPE OF APPLICANT : (See back of form for Application Types ) <br /> New F) 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 /> [❑ pi[3 [-51 COCWIDE HMIS - ONE YEAR 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 /S 1 1 .4;- <br /> 15. <br /> s15. ESTIMATED FUNDING : 16. IS APPLICATION SUBJECT TO REVIEW BY STATE <br /> EXECUTIVE <br /> ORDER 12372 PROCESS ? <br /> a . Federal Do a . Yes . �Q THIS PREAPPLICATION /APPLICATION WAS MADE <br /> 36 , 1777 . 00 AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 <br /> b . Applicant PROCESS FOR REVIEW ON <br /> c. State GU DATE : <br /> d . Local b . No . 07j PROGRAM IS NOT COVERED BY E . O . 12372 <br /> e . Other n OR PROGRAM HAS NOT BEEN SELECTED BY STATE <br /> 9 , 044 . 25 FOR REVIEW <br /> f. Program Income UU 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT? <br /> g . TOTAL <br /> 45 , 221 .25 0 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 /> aaP. Authorized Representative <br /> MATI2MAN <br /> First Name Mi die Name <br /> Last Name Suffix <br /> LOWTHER <br /> b. Title c . Telephone Number (give area code) <br /> CHAIR , BOARD OF COUNTY COMMISSIONERS 772>GXxxxi ( 226 - 1490 <br /> Signature of Authorized Representative e . Date SignedMav T7 . 2005 <br /> Previous Edition Usable Standard Form 424 ( Rev . 9-2003 ) <br /> Authorized for Local ReDroduction Prescribed by OMB Circular A- 102 <br />