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Applicant/Recipient U.S. Department of Housing <br />Disclosure/Update Report and Urban Development <br />OMB Approval No. 2510.0011 (exp. 12/31/2006) <br />Indicate whether this is an Initial Report U or an <br />nu <br />INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS Employer ID Number: <br />1840 25' Street 59-6000674 <br />(772)567-8000 <br />Continuum of Care Homeless Assistance — SHPI Requested/Received <br />70,063 <br />z_nameandiocanon(street-st-iress,cityand9. <br />1 2e Street, Vero Beach, FI 32960 <br />Part I Threshold Determinations <br />1. Are you applying for assistance for a specific project or 'see 2. Han you received or do you expect to receive assistance within the <br />terms do not include formula grants, such as public houm in jurisdiction of the Department (HUD) , involving the project or activity in this <br />subsidy or CDBG block grants. (For further information see 4 Mae. application, in excess of $200,000 during this fiscal year (Oct. 1 - Sep. 30)? <br />4.3). For further information, see 24 CFR Sec. 4.9 <br />If you answered "No" to either question 1 or 2, Stop! You do not need to complete the remainder of this form. <br />However, you must sign the certification at the end of the report. <br />or <br />and Use of Funds. <br />Such assistance includes, <br />but is not <br />limited to, <br />any grant, <br />loan, subsidy, guarantee, insurance, payment, <br />credit, <br />or tax benefit. <br />Department/State/l-ocal <br />Agency <br />Name and <br />Address <br />Type of Assistance <br />Amount RequestedlProvided <br />Expected <br />Uses of the Funds <br />Part III Interested Parties. You must disclose: <br />1. All developers, contractors, or consultants Involved in the application for the assistance or in the planning, development, or implementation of the project or <br />activity and <br />ZT <br />Alphabetical list of all <br />the project or activity <br />persons with a reportable financial interest in <br />(For individualgive the last name fust <br />Social Security No. <br />or Employee ID No. <br />Type of Participation in <br />Project/Activity Project/Activity <br />Financial <br />ProlectlActivity <br />Interest in <br />($ and % <br />(Note: Use Additional pages if necessary.) <br />Certification <br />Warning: If you kroMrrgly make a false statement on this form, you may be subject to civil or criminal penalties under Section 1001 of Ttile 18 of the United <br />States Code. in addition, any person who knowingly and materially violates any required disclosures of information, including intentional nondisclosure, is <br />subject to civil money penalty not to exceed $10,000 for each violation. <br />1 certify that this Information is true and complete. <br />May 167 2006 <br />