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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 />... - ... - <br />licant/Reci lent Information Indicate whether this is an Initial Report ❑ or an Update Report 19 <br />Applieant/Reciplart 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 />Continuum of Care Homeless Assistance — S+CI Requested/Received <br />110,808 <br />5. SGte me name R'F, SF. -) of me project7t <br />r 2EP Street, Vero Beach, FI 32960 <br />Part I Threshold Determinations <br />1. Are you p <br />applyingterms do not include formula grants, such as public housing in jurisdiction of the Deparknent (H UID) . involving the project or act" in this <br />subsidy or D : _ - -$200,000, , (O- A <br />4-3)- For furthier information, see 24 CIFR Sec. 4.9 <br />/1 F]►/�, <br />If you answered "No" to either question 1 or 2, Stop! You do not need to complete the remainder of this form. <br />However, you must sign the certification at the end of the report. <br />Part II Other Government Assistance Provided or Requested / Expected Sources and Use of Fun <br />Such assistance includes, but is not limited to, any grant, loan, subsidy, guarantee, insurance, payment, credit, or tax benefit. <br />Part III Interested Parties. You must disclose: <br />1. All developers, contractors, or consultants involved in the application for the assistance or In the planning, development, or Implementation of the project or <br />activity and <br />Alphabetical list of all <br />the project or activity <br />persona with a reportable financial interest in <br />For individuals give the lost name first <br />Social <br />or Employee <br />Security No. <br />ID No. <br />Type of Participation in <br />ProjectiActivily <br />Financial Interest in <br />ProtectlActivity$ and % <br />(Note: Use Additional pages If necessary.) <br />Certification <br />Warning: If you knowingly make a false statement on this form, you rrwy be subject to civil or criminal penalties under Section 1001 of Title 18 of the Untied <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 />Date: (mm/dd/yyyy) <br />May 16, 2006 <br />