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Home My WebLink About2005-145 T E_S17RE COAST QST HONMELESS SERVICES COUNCIL,CIL., INC . i 2525 ST. LI CIE AVENUE VER® BEACH, FL 32960 72 - 567- 77904 WWW,tchelmot. m 11hsclh ( aol. com Indian River County Board of County Commissioners County Administration Building 184025 th Street Vero Beach, FL 32960 Project Number : FL29B409003 Dear Commissioners : April 20, 2005 This is a request that you vote to allow Commissioner Tom Lowther, as Chair of the Board of County Commissioners, to sign the Technical Application transmitted by the US Department of Housing and Urban Development for his signature . The Technical submission represents a successful application to HUD by the Treasure Coast Homeless Services Council, Inc . for a one year renewal of an existing grant which you have previously approved and signed for staffing at the Homeless Family Center. The Grant renewal is for $24, 581 . 00 to be provided by HUD . The cash match for this grant is $6, 145 . 25 to be provided by the Homeless Family Center, Inc . The County is not required to provide any cash match for this project . Thank you for your continued support in allowing the Treasure Coast Homeless Services Council to work with Indian River County to secure funds to prevent and alleviate homelessness in Indian River County. If you have any questions, please feel free to contact me a 772-567- 7790 . Sincerel , uiws Hub and Executive Director U. S. Department of Housing and Urban Development Office of Community Planning and Development OMB Approval No. 2506-0112 (exp . 8/31 /2006) 2004 Technical Submission for the Supportive Housing Program FL29B409003 Family Options Transitional Housing Supportive Services(formerly) I F 2 THIS SECTION FOR RENEWAL PROJECTS ONLY OMB Approval No. 2506-0112 (exp. 8/31/2006) HUD40076-2 2 TREASURE COAST HOMELESS SERVICES COUNCIL , INC. CONTINUUM OF CARE MOONED Technical Project Number _ FL2911409003 Submission Project Identifier— FL 13168 (RENEWALS ONLY) Recipient' s Name : HUD Project Number: FL2911409003 Indian River County Board of County Commissioners Check the program component/type that classifies your project: ® Transitional Housing ('114) ❑ Permanent Housing for Homeless Persons with Disabilities (PH) ❑ Supportive Services Only (SSO) ❑ Safe Haven/Transitional Housing (SH/TH) — Characteristics of TH/participant not required to execute a lease ❑ Safe Haven/Permanent Housing (SH/PH) — Characteristics of PH/participant required to execute a lease ❑ Homeless Management Information System (H1VIIS) ❑ Innovative Supportive Housing (ISH) Table Of Contents (Enter the page number for each Exhibit in the space provided below . ) 3 Exhibit I Project Summary 7 Exhibit 2 Real Property Leasing, Supportive Services, HMS and Operating Budget Certification : Name & Title of the Person who can answer questions about this document: Phone (include area code) : Louise Hubbard, Exec. Director, Treasure Coast Homeless Services Council, Inc. 772-567-7790 Address : 2525 St. Lucie Avenue, Vero Beach, FL 32960 I hereby certify that all the information stated herein is true and accurate. Warning: HUD will prosecute false claims and statements . Conviction may result in criminal and/or civil penalties. ( 18 U. S . C. 1001 , 1010, 1012; 31 U. S . C. 3729, 3802) Name & Title of Authorized Official: ignature & Date : Commissioner Thomas Lowther 1840 25" Street Vero Beach, FL 32960 -- May 3 2005 OMB Approval No. 2506-0112 (exp. 8/31/2006) HUD-40076-2 3 TREASURE COAST HOMELESS SERVICES COUNCIL , INC. CONTINUUM OF CARE Project Number - FL29B409003 Technical Project Identifier — FL 13168 Submission Exhibit 1 : Project Summary (cont . ) (RENEWALS ONLY) A. Selectee, and Sponsor Information - Fill in the information requested below. For HMIS projects fill in the BMIS Lead. When the selectee is the same organization as the project sponsor, complete only the selectee information. Selectee Name Indian River County Board of Sponsor Name County Commissioners Contact Person Joyce Johnston Carlson Contact Person Phone 772- 5674000x1467 Phone FAX Number 772-978- 1798 FAX Number E-Mail Address jcarlson@ircgov. com E-Mail Address Street Address 1840 25 St, Street Address City, State, Zip Vero Beach, FL 32960 City, State, Zip HMIS Lead Treasure Coast Homeless Contact Person Services Council, Inc. Street Address 2525 St. Lucie Avenue Phone City, State, Zip Vero Beach, FL 32960 E-Mail Address B. Project Budget - This section must be completed by all renewal selectees. 1 . Chart 1 - Summary Project Budget To complete Chart 1 , Summary Project Budget, enter the amount of SHP funds requested by line-item in the first column. For leasing, supportive services, operations, and HMIS, the amount entered should be for the SHP grant term selected. In the second column, enter the amount of other cash that will be contributed to the project. This amount plus the SBP request must equal the total budget amount for the project. Note that match requirements for supportive services, operating costs and HMIS apply to renewal projects. The amounts you enter are for all structures in your project. Each line item amount in this chart should match the amounts shown in your original application as approved or Exhibits 3 4 5 and 6 Requested grant term (1 , 2, or 3 years): _1 Chart 1 - Summary Project Budget Total Project SHL Applicant Budget Re uest Cash 1 . Real Property Leasing 2 Supportive Services* 24, 581 .00 6, 145. 25 307726. 25 3 . rations* * 4. BMIS* 5 . SHP Request (subtotal lines 1 thnr 4) 6 . Administration* * * (up to 5% of line 5) 7 . Total SHP Request (total lines 5 and 6) 24, 581 .00 *By law, SHP can pay no more than 80% of the total supportive services or total HMIS budget. * * By law, SHP can pay no more than 75% of the total operating budget. * * *By law, SHP can pay no more than 5% of the total SHP request. OMB Approval No. 2506-0112 (exp. 8/31/2006) HUD40076-2 4 TREASURE COAST HOMELESS SERVICES COUNCIL , INC. CONTINUUM OF CARE Project Number _FL29B409003 Technical Project Identifier — FL13168 Submission Exhibit 1 : Project Summary (RENEWALS ONLY) C. Program Goals - The goals for SUP are to help program participants (a) obtain and remain in permanent housing, (b) increase their skills and/or income, and (c) achieve greater self-determination. In order to meet these program goals, each project should develop specific performance measures. Performance measures have three major components. First, they must relate to the outcomes (e.g. , the program participant will successfully complete substance abuse treatment), rather than inputs (e. g. , the program participant will attend 25 substance abuse sessions) . Second, they must have a time frame for achievement and, third, they must have a percentage/number indicating a level of achievement. In a separate narrative which should be submitted as an attachment to this exhibit, please describe the performance measures that will be used for each of the SHP goals and how success in meetmg each of the goals will be measured Please include both housin�Yand services in your discussion. At least one performance measure for the skills/income goal must address accessing mainstream health and human service programs. You will be reporting on your success in meeting the performance measures in your Annual Progress Report. Examples of performance measures for each of the SHP goals are : Goal: Obtain and remain in permanent housing • 70% of those families entering the program will receive Section 8 certificates when exiting the program. Goal: Increase skills and income • 80% of the participants who receive no benefits upon entry will receive entitlement benefits within 6 months. Goal: Achieve greater self-determination • 85% of clients will meet at least one goal on their Individual Service Plan. D. Number of Beds, Participants and Supportive Services - These charts need to be included only if they were incomplete, inaccurate or blank at the time of the original application submission. Please complete these charts if your local HUD field office has notified you that they are required. Submit only those that apply. The charts can be found on page 17 of the New Projects Section of the Technical Submission. OMB Approval No. 2506-0112 (exp. 8/31/2006) HUD40076-2 5 r TREASURE COAST HOMELESS SERVICES COUNCIL , INC. CONTINUUM OF CARE Project Number Project Number - FL29B409003 Technical Project Identifier — FL 13168 Submission Exhibit 1 : Project Summary (RENEWALS ONLY) Program Goals - The goals for SHP are to help program participants (a) obtain and remain in permanent housing, (b) increase their skills and/or income, and (c) achieve greater self-determination. In order to meet these program goals, each project should develop specific performance measures. Performance measures have three major components. First, they must relate to the outcomes (e.g. , the program participant will successfully complete substance abuse treatment), rather than inputs (e. g. , the program participant will attend 25 substance abuse sessions) . Second, they must have a time frame for achievement and, third, they must have a percentage/number indicating a level of achievement. SBP Goal (a) Obtain and remain in permanent housing . Program Goal : ➢ Program participants will achieve safe, affordable housing for rental or purchase upon completion of the program . Performance Measure : ➢ 60% of the families who remain in the program for more than 6 months will secure fair market housing . SHP Goal (b)Increase skills and/or income . Program Goal : ➢ Program participants will achieve appropriate employment to increase their income . Performance Measure : ➢ 60% of the families completing the program will increase their income during the first year. SBP Goal ( c )Achieve greater self-determination. Program Goal : ➢ Program participants will maximize their access to mainstream entitlement programs . Performance Measure : ➢ 90% of the families who remain in the program for more than 6 months will be personally assisted to apply for all entitlements for which they are eligible . OMB Approval No. 2506-0112 (exp. 8/31/2006) HUD-40076-2 6 TREASURE COAST HOMELESS SERVICES COUNCIL , INC. CONTINUUM OF CARE Project Number - FL29B409003 Technical Project Identifier - FL 13168 Submission Exhibit 2. Real Property Leasing, Supportive Services, Operations and HMIS (RENEWALS ONLY) This exhibit covers Real Property Leasing, Supportive Services, Operations , HMIS as it pertains to Site Control, Match Documentation and other applicable Certifications . Please refer to the narrative under the New Projects Section of the Technical Submission for a more detailed explanation of each of the exhibits . Other sections in this exhibit may need to be completed if required by your local HUD Field Office . ALL RENEWAL GRANTEES/PROJECT SPONSORS MUST COMPLETE SITE CONTROL, MATCH DOCUMENTATION AND JOB AND ADMINISTRATION CERTIFICATIONS. If you are required to resubmit or complete real property leasing, supportive services, operations or HMIS, pull the charts from the pages of the New Projects Section of this technical submission that apply . For leasing use pages 21 -24, supportive services pages 25 -28 , operations pages 29-32 and HMIS pages 33 -36 of the New Pro.jects Section . You do not have to complete the leveraging and administration exhibits for renewals . A. Site Control Check the appropriate box(es) Leasing ❑ Supportive Services ® Operations ❑ A project sponsor requesting renewal funding for an existing SHP project must complete the certification below . No other site documentation is required for renewal projects . As a recipient of SBP funds, the _Indian River County Board of County Commissioners, Selectee (sponsor organization) certifies that it currently has an executed lease agreement, or a deed or other proof of ownership for the property(ies) in use to house and/or provide services to homeless persons under HUD ' s existing grant number. In addition, sponsor organizations using SBP funds for leasing activities further certify that the (project sponsor the conditional grantee or their Mgt organizations fill in the appropriate one-) do not own these leased site(s) . This includes organizations that are members of a general partnership where the general partnership owns the structure(s), both parties are parts of the same governmental unit or the governmental unit creates an authority or similar entity to acquire and lease the facilities to the governmental unit and other parties, and no operating grant funds will be used for the payment of utilities, maintenance and repairs, or management fees associated with the site(s), under HUD ' s existing grant number FL2913409003 Signature of authorized representative Q f , . Name _Thomas S Lowther . Chairman Title Chair, Indian River County Board of County Commissioners Date OMB Approval No. 2506-0112 (exp. 8/31/2006) HUD40076-2 7 1 TREASURE COAST HOMELESS SERVICES COUNCIL , INC. CONTINUUM OF CARE Technical Project Number FL2911409003 Submission Project Identifier- FL 13168 Exhibit 2 . Real Property Leasing, Supportive Services, Operations and HMIS (RENEWALS ONLY) B. Documentation of Match for Year 1 Supportive Services ® Operations ❑ HMIS ❑ A selectee must currently have firm commitments for its cash resources for Year lfor supportive services, operating costs and HMIS and must submit documentation of those resources as an attachment to this Exhibit. These firm commitments must be documented on letterhead stationery, signed and dated by an authorized representative, and attached to this Exhibit. Each letter must, at a minimum, contain the following elements: 1 . The name of the organization providing the cash resource; 2 . The amount; 3 . The type of activity for which the funds will be used (e.g. , case management, child care, education); 4 . The name of the project sponsor organization to which the cash will be contributed and/or the name of the project; and 5 . The date the funds will be available. C. Certification of Match for Year 2 and Year 3, if applicable (N/A-One year renewal) Supportive Services ❑ Operations ❑ HMIS ❑ The following certification must be completed for Year 2, and Year 3 if applicable, of your grant term to certify that non-SHP cash resources will be used to meet your supportive services, operations and BMS match requirement in each of these years. The amount specified in this certification for supportive services must match the amount shown on line 4 of the Supportive Services Chart submitted with your original application OR Line 11 of the Supportive Services Budget from Exhibit 4 of the New Projects Section. No other documentation regarding the supportive services match requirement for Year 2 and Year 3 of your grant term is required at this time. However, match commitment for Years 2 and 3 will be identified at time of submission of Annual Progress Reports for those years. The amount specified in this certification for operations costs must match the amount shown on line 11 of the Operations Cost Chart submitted with your original application OR Line 13 of the Operations Budget from Exhibit 5 of the New Project Section. No other documentation regarding the operations match requirement for Year 2 and Year 3 of your grant term is required at this time. However, match commitment for Years 2 and 3 will be identified at time of submission of Annual Progress Reports for those years. The amount specified in this certification for IMS must match the amount shown on the "Selectee ' s Match ' on the last line of the IMS Chart submitted with your original application OR the last line of the IMS Budget from Exhibit 6 of the New Projects Section. No other documentation regarding the FMS match requirement for Year 2 and Year 3 of your grant term is required at this time. However, match commitment for Years 2 and 3 will be identified at time of submission of Annual Progress Reports for those years. OMB Approval No. 2506-0112 (exp. 8/31/2006) HUD-40076-2 8 TREASURE COAST HOMELESS SERVICES COUNCIL , INC. CONTINUUM OF CARE Technical Project Number - FL29B409003 Submission Project Identifier- FL 13168 Exhibit 2. Real Property Leasing, Supportive Services, Operations and HMIS (RENEWALS ONLY) B. Documentation of Match for Year 1 Supportive Services ® Operations ❑ HMIS ❑ A selectee must currently have firm commitments for its cash resources for Year lfor supportive services, operating costs and IMS and must submit documentation of those resources as an attachment to this Exhibit. These firm commitments must be documented on letterhead stationery, signed and dated by an authorized representative, and attached to this Exhibit Each letter must, at a minimum, contain the following elements: 1 . The name of the organization providing the cash resource ; The Homeless Family Center, Inc. formerly known as Family Options Transitional Housing is providing the cash match for this one year grant renewal. 2 . The amount ; The amount of the cash match is $6, 145. 25 3 . The type of activity for which the funds will be used (e . g . , case management, child care, education) ; The type of activities for which the funds will be used will be to provide: a. Employment Assistance to TH clients in residence. b. Housing Follow-up Services to TH clients placed in permanent housing 4 . The name of the project sponsor organization to which the cash will be contributed and/or the name of the project : The Homeless Family Center, 720 4t' Street, Vero Beach, FL 32962 5 . The date the funds will be available . Funds are currently available and identified in the program' s budget as match. OMB Approval No. 2506-0112 (exp. 8/31/2006) HUD-40076-2 9 1 , ` TREASURE COAST HOMELESS SERVICES COUNCIL , INC. CONTINUUM OF CARE Technical Project Number = FL29B409003 Submission Project Identifier- FL 13168 Exhibit 2 . Real Property Leasing, Supportive Services , Operations and HMIS (RENEWALS ONLY) C. Match Certification (continued) N/A — One year renewal The (selectee organization) certifies that it will provide cash resources in the amount of $ from non-SHP funding sources for Year(s) of this grant term to be used to provide HNUS, services and/or for operating costs of housing for homeless persons under HUD ' s grant number Signature of authorized representative Name Title Date D. Job Description Certification The Indian River County Board of County Commissioners (selectee organization) certifies that the job responsibilities of each position as it relates to the project have not changed since the previous technical submission. If the position or responsibilities have changed, submit a new position description for the new or added position. Signature of authorized representative(\` Name Thomas S . Lowther Title Chair, Indian River County Board of County Commissioners Date May 3 , 2005 E. Administration Certification The Indian River County Board of County Commissioners, (selectee organization) certifies that funds are being used for eligible administrative costs. If the Distribution of Fands is not the same, a new/revised plan is submitted. Signature of authorized representative Name Thomas S . Lowther Title Chair, Indian River County Board of County Commissioners Date May 3 , 2005 OMB Approval No. 2506-0112 (exp. 8/31/2006) HUD-40076-2 10 �1vFR SECTION NUMBER DATE EFFECTIVE ADMINISTRATIVE PERSONNEL AH- 806 . 1 01 - 24 - 95 MANUAL SUBJECT PAGE * * CONFLICTS OF INTEREST ETHICS CODE 1 F Ref : Indian River County Ordinance 94 - 21 Indian River County Ordinance 95 = 02 This Cade of Ethics addition confli tenChapter 112 the betwee� , FS . and Chapter 112t Floridalo Statutes . Where there is a this code the more stringent requirement shall apply . _This code shall apply to county commissioners and county employees . The term " person " includes commissioners and county employees & written requests for interpretative rulings concerning the applicability of this code may be submitted to the county attorney for written reply . 3 . Information concerning any incident or situation in which it appears that a board appointed county employee or county commissioner may have engaged in conduct contrary to this code should be forwarded by complaint affidavit to the state attorney for the Nineteenth Judicial District for his investigation and appropriate action . A,.A person shall avoid any action , whether or not specifically prohibited by this section , which might result in : a ) using public office for private gain ; b ) giving preferential treatment to any person ; or c ) making a government decision outside official channels . 5 . ( a ) Except as provided in paragraph ( b ) and ( c ) of this subsection , a person shall not solicit or accept , directly or indirectly , any gift , gratuity , favor , entertainment , loan , or any other thing of monetary value , from anyone who : 1 ) has , or is seeking to obtain , contractual or other business or financial relations with the county ; 2 ) conducts operation or activities that are regulated by the county ; or 3 ) has interests that may be substantially affected by the performance or nonperformance of the person ' s official duty : or 4 ) is in any way attempting to affect the person ' s off ficial actions at the county . 5 ) is offering anything of monetary value , including food and refreshments , to an employee because of the person ' s official position . I wFJ7 C� SECTION NUMBER DATE EFFECTIVE ADMINISTRATIVE PERSONNEL AM- 806 . 1 01 - 24 - 95 POLICY MANUAL SUBJECT PAGE * CONFLICTS OF INTEREST ETHICS CODE 2 OF 4 5= ( b ) The prohibitions enumerated in paragraph ( a ) and ( c ) of this section do not apply in the situations enumerated below : 1 ) where obvious family ( such as those between the parents , children , or spouse of the person ) or other personal relationships flake it clear that it is those relationships rather than the business of the persons concerned which are the motivating factors . 2 ) Food and refreshments . Under Chapter 112 , F . S . , the word " gift " is defined to exclude " Food or beverage consumed at a single sitting or event " . Pursuant to Section 112 . 326 , F . S . , it is the purpose of this code to require more stringent county disclosure requirements than provided for in Chapter 112 , F . S . Therefore , and notwithstanding any other section to the contrary , county commissioners , and county employees may accept food or beverage consumed at a single sitting or event only if the cost for said food or beverage does not exceed the Chapter 112 , F . S . , rate for the Appropriate per diem allowance for said meal . If , under circumstances beyond the control of the donee , the cost exceeds the per diem rate then within five ( 5 ) working days of the acceptance , the donee shall file a written disclosure statement with the executive aide to the commission on a form provided by said aide . In addition , food or beverage may be accepted when ( i ) offered free in the course of a meeting or other group function not connected with an inspection or investigation , at which attendance is desirable because it will assist the person in performing his or her official duties ; or ( ii ) provided to all panelists or speakers when a person is participating as a panelist or speaker in a program , seminar or educational conference . 3 ) Loans may be obtained from banks or other financial institutions on customary terms to finance proper and usual activities of persons such as home mortgage loans . 4 ) Unsolicited advertising or promotional material such as pens , pencils , note pads , calendars and other items of nominal intrinsic value may be accepted , as well as job related literature . 5 ) Gifts given for participation in a program , seminar or educational conference may be accepted only when such gifts are ( i ) of nominal intrinsic value ( ii ) in the nature of a remembrance traditional to the particular sponsoring entity and ( iii ) provided to all participants in the program . AVER SECTION NUMBER DATE EFFECTIVE r1 ADMINISTRATIVE pERSONNEL AM - 806 . 1 01 - 2495 " POLICY PAGE MANUAL SUBJECT # # , CONFLICTS OF IN I�'j,�R pt► 6 ) Contributions or expenditures reported pursuant to Chapter 106 , F . B . , campaign - related personal services provided without compensation by individuals volunteering their time , or any other contribution or expenditure by a political party . ' NOTB : Exclusions 7 ) through 11 ) were added 1 - 24 - 95 by Ordinance 95 - 02 . 7 ) Awards of nominal value , plaques and dinners given by a civic or business organization to honor. individual or groups for meritorious service , acts of heroism , and similar conduct . 6 ) Local outings offered to all county employees or with prior approval . of the Board of County Commissioners , units of county employees . 9 ) Acceptance of invitations given by organizations as a ceremonial gesture with prior approval of the Board of county commissioners needed for events outside the county . 10 ) Discounts and other inducements offered by various theme parks and other entertainment interests for all county or state employees . 11 ) Free flu shots offered to all county employees . 5 . ( c ) A person shall not solicit a contribution from another person for a gift to an official superior , make a donation as a gift to an official superior , or accept a gift from a person receiving less pay than himself . However , this paragraph does not prohibit a voluntary gift of nominal value or donation in a nominal amount made on a special occasion such as marriage , illness , or retirement . 6 . No county employee may engage in outside employment or other outside activity , with or without compensation , which is in conflict with or otherwise not compatible with the full and proper discharge of his duties and responsibilities to Indian River County . Incompatible activities include but are not limited to : 1 ) acceptance of a fee , compensation , gift , payment of expenses , or any other thing of monetary value in circumstances in which acceptance may result in a conflict of interest situation ; or I ave SECTION NUMBER DATE EFFECTIVE ADMINISTRATIVE PERSONNEL POLICY a1M- 806 . 1 01 - 24 - 95 pit : MANUAL SUBJECT PAGE CONFLICTS OF INTEREST ETHICS CODE 4 OF 4 2 ) outside employment which tends to impair his mental or physical capacity to perform his duties and responsibilities in an acceptable manner ; or 3 ) outside employment or activities ( excluding the publication of articles ) which reasonably might be regarded as official actions of the county or which might bring discredit upon the county . 7s It shall . be the duty of each commissioner , board appointed county employee , department head and professional staff member to become familiar . with the code of ethics for public officers and employees , DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U .S .C . 1352 orae-ooas rStatus e for ublic burden disclosure . ) 1 . Type of Federal Action : Federal Action : 3 . Report Type: la . bidloffer/application ( bl a . initial filing b l a . contract J t J b. material change L 1 b . grant b , initial award c . post-award For Material Change Only : c . cooperative agreement p year quarter d . loan date of last report e . loan guarantee f. loan insurance 4. Name and Address of Reporting Entity : 5. ff Reporting Entity in No . 4 is a Subawardee, Enter Name [] Prime ❑ Subawardee and Address of Prime: Tier , if known : . COUNTY DOES NOT ENGAGE IN LOBBYING ACTIVITY Con ressional District , if known : Con ressional District , if known : �1111111 1111111111 111 111 1111 1111 111 1 11 1 1 1111111111 111 7 . Federal Program Name/Description : 6. Federal Department/Agency: CFDA Number, if applicable : 8 . Federal Action Number, if known : 9 . Award Amount, if known $ [NONE: e and Address of Lobbying Registrant b. Individuals Performing Services (including address if dividual, last name, first name, Ml ): different from No. 1Oa ) ( last name, first name, Ml ): NONE mationrequested thmugh the form is authorized by title 31 U.S.C. section Signature:2. This disclosure of lobbying acbvities is a material representation of factupn which reliance was placed by the tier above when this transaction was made Print Name: COMMISSIONER TOM LOWTHER or entered into. This disclosure is required pursuant to 31 U.S-C. 1352. This information will be available for public inspection. Any person who fails to file the Title: RIVER CO. BOARD OF COUNTY COMMISSIONERS required disclosure shall be subject to a civil penalty of not less than $10,000 and ? 0 0 5 not more than $100.000 for each such failure. Telephone No . : 772-567- 8000 Date: 5 Authorized for Local Reproduction Federal Use Only : Standard Form LLL (Rev. 7-97)