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w 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.) Information Indicate whether this is an Initial Applicant/Recipient Name, Address, and Phone (include area code): INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS 1840 25TH Street (7721567-8000 Continuum of Care Homeless Assistance — SHP Employer ID Number: 59-6000674 WT -7 �Klii 1840 2EP Street, Vero Besch, FI 32960 Part I Threshold Determinations Department1. Are you applyng for assistance for a specific project or 2. Have you received the terms do not include formula grants, such as public hou jurisdiction of the , expect. ) , involving the project or activity ` subsidy or .: $200 ,000 during 4.3). For turther information, am 24 CFR Sec. 4.9 M Yes ■ No ■ Yes /. 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 11 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. 01 PartIII 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 fres 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 the project or persons with a For individuals reportable financial interest in the last name first Social Security No. or Emplovee ID No. Type of Participation in P Act- ' P Financial ' A ' Interest in ' $ and % PartIII 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 fres 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 the project or persons with a For individuals reportable financial interest in the last name first Social Security No. or Emplovee ID No. Type of Participation in P Act- ' P Financial ' A ' Interest in ' $ 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 1 D01 of Title 18 of the United States Code. In addition, any person who knowingly and materially violates any required disclosures of information, including intentional nondisclosure, is subject to civil money penalty not to exceed $10,000 for each violation. I certify that this information is true and complete. May 16, 2006