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Applicant/Recipient U.S. Department of Housing OMB Approval No. 2510-W11 (exp. 12/31/2006) <br />and Urban Development <br />Disclosure/Update Report <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 25" Street 59-6000674 <br />(772) 567-8000 <br />3. HUD Program Name 4. Amount of HUD Assistance <br />Continuum of Care Homeless Assistance — SHP Requested/Received <br />25,856 <br />5. State the name and location (street address, City and State) of the project or activity: <br />1840 25"' Street, Vero Beach, F132960 <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 within the <br />terms do not include formula grants, such as public housing operating jurisdiction of the Department (HUD) , involving the project or activity in this <br />subsidy or CDBG block grants. (For further information see 24 CFR See. application, in excess of $200,000 during this fiscal year (Oct 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 <br />or 2, Stop! You <br />do not need to <br />complete the remainder of this form. <br />However, you must sign the certification <br />at the end of the <br />report. <br />Part <br />Such <br />II Other <br />assistance <br />Government Assistance Provided or Requested / Expected Sources and <br />includes, but is not limited to, any grant, loan, subsidy, guarantee, insurance, payment, credit, <br />Use of Funds. <br />or tax benefit. <br />Department/State/Local Agency Name and Address <br />Financial <br />jecVA <br />TVpe of Assistance <br />Amount R uested/Provided <br />Expected <br />Uses of the Funds <br />(Note: Use Addftional 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 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 $50,000 or 10 percent of the assistance <br />(whichever is lovrer). <br />Alphabetical list of all <br />the project or activity <br />persons with a reportable financial interest in <br />For individuals, give the last name first <br />Social <br />orEmploveelDNo. <br />Security No. <br />Type of Participation in <br />ProjectlActivityPr <br />Financial <br />jecVA <br />Interest in <br />$ 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 of the United <br />States Code. In addition, any person who knowingly and materially violates any required disclosures of information, including intentional non -disclosure, 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: <br />May 16, 2006 <br />