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HomeMy WebLinkAbout2005-166d APPLICATION FOR Version 7/03 FEDERAL ASSISTANCE 2. DATE SUBMITTED Applicant Identifier 1 . TYPE OF SUBMISSION : 3. DATE RECEIVED BY STATE State Application Identifier Application Pre-application H I Construction ❑ Construction 4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier Non-Construction El Non -Construction 5. APPLICANT INFORMATION Legal Name : Organizational Unit: INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS Department: Organizational DUNS : Division : 59-6000-674 Address : Name and telephone number of person to be contacted on matters Street: involving this application (give area code) Prefix : First Name : 1840 25TH STREET JASON City' Middle Name VERO BEACH , FL County: Last Name COUNTY BROWN State : Zip Code Suffix : FLORIDA 32960 BUDGET DIRECTOR Country: Email : 6. EMPLOYER IDENTIFICATION NUMBER (E/N): Phone Number (give area code) Fax Number (give area code) 5❑ Y _© Ka 0❑ © 7❑ ® 772-567-8000 772-567-5991 8. TYPE OF APPLICATION : 7. TYPE OF APPLICANT: (See back of form for Application Types) IF New F1 Continuation Revision B If Revision , enter appropriate letter(s) in box(es) (See back of form for description of letters .) ❑ ❑ her (specify) Other (specify) 9. NAME OF FEDERAL AGENCY: 10 . CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: 11 . DESCRIPTIVE TITLE OF APPLICANTS PROJECT: n: — i [ 5❑ TRANSITIONAL HOUSING ONE YEAR RENEWAL TITLE (Name of Program) : 12 . AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.): 13 . PROPOSED PROJECT 14. CONGRESSIONAL DISTRICTS OF : Start Date: Ending Date : a . Applicant b. Project 08/01 /2006 07/01 /2007 15 5 15. ESTIMATED FUNDING : 16 . IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS? a . FederalYes. �Q THIS PREAPPLICATION /APPLICATION WAS MADE a . 24 ,581 .00 AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 b . Applicant PROCESS FOR REVIEW ON c. State DATE : d . Local b No . PROGRAM IS NOT COVERED BY E . O. 12372 e . Other $ OR PROGRAM HAS NOT BEEN SELECTED BY STATE 6 , 145.25 FOR REVIEW f. Program Income UU 17 . IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT? g . TOTAL ❑ Yes If "Yes" attach an explanation . No 30 ,726 .25 18 . TO THE BEST OF MY KNOWLEDGE AND BELIEF , ALL DATA IN THIS APPLICATION/P EAPPLICATION ARE TRUE AND CORRECT. THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED. aap. Authorized Representative CF1&MAN First Name fiddle Name S . Last Name Suffix LOWTHER b. Title c. Telephone Number _ , a e ode) CHAIR, BOARD OF COUNTY COMMISSIONERS 772M� (MK 2b - � 06 Signature of Authorized Representative . Date Si ned Signature May 7 , 2005 Previous Edition Usable Standard Form 424 (Rev.9-2003) Authorized for Local Reproduction Prescribed by OMB Circular A- 102 SURVEY ON ENSURING U. S . DEPARTMENT OF HOUSING otvMNo. 1890-0014 EQUAL OPPORTUNITY AND URBAN DEVELOPMENT (EXP. 1/31 /2006) FOR APPLICANTS Purpose: The Federal government is committed to ensuring that all qualified applicants, small or large, non-religious or faith- based, have an equal opportunity to compete for Federal funding. In order for us to better understand the population of applicants for Federal funds, we are asking nonprofit private organizations (not including private universities) to fill out this survey. Upon receipt, the survey will be separated from the application. Information provided on the survey will not be considered in any way in making funding decisions and will not be included in the Federal grants database. While your help in this data collection process is greatly appreciated, completion of this survey is voluntary. Instructions for Submitting the Survey: If you are applying using a hard copy application, please place the completed survey in an envelope labeled "Applicant Survey." Seal the envelope and include it along with your application package. If you are applying electronically, please submit this survey along with your application. Applicant' s (Organization) Name : _INDIAN RIVER CO . BOARD OF COUNTY COMMISSIONERS Applicant' s DUNS Number : _079-208-989 Grant Name : COC HOMELESS ASSISTANCE PROGRAM CFDA Number : 14-235 4 . Is the applicant a faith-based/religious 1 . Does the applicant have 501 (c) (3 ) status? organization? [j Yes a No [j Yes No 2 . How many full-time equivalent employees does 5 . Is the applicant a non-religious community-based the applicant have? (Check only one box). organization? 3 or Fewer 15 -50 Q Yes No 4-5 51 - 100 6- 14 over 100 6 . Is the applicant an intermediary that will manage the grant on behalf of other organizations? 3 . What is the size of the applicant ' s annual budget? Yes No (Check only one box.) Less Than $ 150,000 7 . Has the applicant ever received a government grant or contract (Federal, State, or local ? $ 15000 - $2991999 Yes ❑ No $300 , 000 - $499, 999 $ 500,000 - $ 999 ,999- 8 . Is the applicant a local affiliate of a national organization? $ 1 ,000, 000 - $4, 999, 999 (� Yes No $5 , 000,000 or more SF 424-SUPP (4/2004) Applicant Assurances U . S . Department of Housing OMB Approval No . 2501 -0017 and Certifications and Urban Development (expires 01 /31 /2008) Instructions for the HUD-424-B Assurances and Certifications As part of your application for HUD funding , you, as the official authorized to sign on behalf of your organization or as an Individual must provide the following assurances and certifications. By submitting this form , you are stating that to the best of your knowledge and belief, all assertions are true and correct. As the duly authorized representative of the applicant, I certify that the 5 . Will comply with the acquisition and relocation applicant [Insert below the Name and title of the Authorized Representative , requirements of the Uniform Relocation Assistance name of Organization and signature] : and Real Property Acquisition Policies Act of 1970 , Name : May 17 , 2 itte : CHAIR as amended (42 U .S . C . 4601 ) and implementing Organization : COUNTY COMMISSION . Date : 05/19/2005 . regulations at 49 CFR Part 24 and 24 CFR 42 , 1 . Has the legal authority to apply for Federal assistance , has the Subpart A. Institutional , managerial and financial capability (Including funds to pay 6 . Will comply with the environmental the non-Federal share of program costs) to plan , manage and complete requirements of the National Environmental the program as described In the application and the governing body Policy Act (42 U .S .C .4321 at seq. ) and related has duly authorized the submission of the application, Including these Federal authorities prior to the commitment or assurances and certifications, and authorized me as the official expenditure of funds for property acquisition and representative of the applicant to act in connection with the application physical development activities subject to and to provide any additional Information as may be required . implementing regulations at 24 CFR parts 50 or 58 . 2 . Will administer the grant in compliance with Title VI of the Clvll Rights 7 . That no Federal appropriated funds have been Act of 1964 (42 U .S .C . 2000 (d )) and implementing regulations (24 CFR paid , or will be paid , by or on behalf of the applicant, Part 1 ), which provide that no person in the United States shall , on the to any person for Influencing or attempting to grounds of race , color or national origin, be excluded from participation influence an officer or employee of any agency, a in, be denied the benefits of, or otherwise be subjected to discrimination Member of Congress, and officer or employee of under any program or activity that receives Federal financial assistance Congress , or an employee of a Member of Congress, OR if the applicant is a Federally recognized Indian tribe or its tribally in connection with the awarding of this Federal grant designated housing entity, is subject to the Indian CMI Rights Act or Its extension , renewal, amendment or modification . (25 U .S. C . 1301 -1303). If funds other than Federal appropriated funds have 3 . Will administer the grant in compliance with Section 504 of the or Will be paid for Influencing or attempting to Rehabilitation Act of 1973 (29 U .S . C . 794), as amended , and Implement- influence the persons listed above , I shall complete ing regulations at 24 CFR Part 8 , and the Age Discrimination Act of 1975 and submit Standard Form-LLL, Disclosure Forth to (42 U .S . C . 6101 -07 ), as amended , and implementing regulations at 24 Report Lobbying . I certify that I shall require all sub CFR Part 146 which together provide that no person in the United States awards at all tiers (including sub-grants and contracts) shall , on the grounds of disability or age, be excluded from participation to Similarly certify and disclose accordingly. in, be denied the benefits of, or otherwise be subjected to discrimination Federally recognized Indian Tribes and tribally under any program or activity that receives Federal financial assistance; designated housing entities (TDHEs) established by except If the grant program authorizes or limits participation to designat- Federally-recognized Indian tribes as a result of the ed populations , then the applicant will comply with the nondiscrimination exercise of the tribe's sovereign power are excluded requirements within the designated population . from coverage by the Byrd Amendment, but State- r . Will comply with the Fair Housing Act (42 U .S .C. 3601 -19 ), as recognized Indian tribes and TDHEs established amended , and the implementing regulations at 24 CFR Part 100 , which under State law are not excluded from the statute's prohibit discrimination in housing on the basis of race , color, religion, coverage. sex , disability, familial status, or national origin ; except an applicant These certifications and assurances are material which is an Indian tribe or its instrumentality which is excluded by representations of the fact upon which HUD can rely statute from coverage does not make this certification ; and further when awarding a grant. If it is later determined that, except if the grant program authorizes or limits participation I the applicant, knowingly made an erroneous to designated populations, then the applicant will comply with the certification or assurance; I may be subject to nondiscrimination requirements within the designated population. criminal prosecution. HUD may also terminate the grant and take other available remedies. form HUD-424-B (0212004) TREASURE COAST HOMELESS SERVICES COUNCIL, INC. CONTINUUM OF CARE Attachment 8 . Applicant Certifications (These certified statements are required by law. ) A. For the Supportive Housing (SHP), Shelter Plus project be awarded in substantial part to persons Care (S+C), and Single Room Occupancy (SRO) residing in the area of the project. programs : It will comply with $ection 504 of the Rehabilitation Act of 1973 (29 U. S .C . 794), as 1. Fair Housing and Equal Opportunity. amended, and with implementing regulations at 24 CFR Part 8, which prohibit discrimination based on It will comply with Title VI of the Civil Rights Act of disability in Federally-assisted and conducted 1964 (42 U. S. C . 2000(d)) and regulations pursuant programs and activities. thereto (Title 24 CFR part I), which state that no It will comply with the Age Discrimination Act of person in the United States shall, on the ground of 1975 (42 U. S. C . 6101 -07), as amended, and race, color or national origin, be excluded from implementing regulations at 24 CFR Part 146, which participation in, be denied the benefits of, or be prohibit discrimination because of age in projects and otherwise subjected to discrimination under any activities receiving Federal financial assistance. program or activity for which the applicant receives It will comply with Executive Orders 11625 , Federal financial assistance, and will immediately take 124327 and 12138, which state that program any measures necessary to effectuate this agreement. participants shall take affirmative action to encourage With reference to the real property and structure(s) participation by businesses owned and operated by thereon which are provided or improved with the aid members of minority groups and women. of Federal financial assistance extended to the If persons of any particular race, color, religion, applicant, this assurance shall obligate the applicant, sex, age, national origin, familial status, or disability or in the case of any transfer, transferee, for the period who may qualify for assistance are unlikely to be during which the real property and structure(s) are reached, it will establish additional procedures to used for a purpose for which the Federal financial ensure that interested persons can obtain information assistance is extended or for another purpose concerning the assistance. involving the provision of similar services or benefits. It will comply with the reasonable modification and It will comply with the Fair Housing Act (42 accommodation requirements and, as appropriate, the U. S . C. 3601 - 19), as amended, and with implementing accessibility requirements of the Fair Housing Act and regulations at 24 CFR part 100, which prohibit section 504 of the Rehabilitation Act of 1973 , as discrimination in housing on the basis of race, color, amended. religion, sex, disability, familial status or national origin. Additional for S+C : It will comply with Executive Order 11063 on If applicant has established a preference for targeted Equal Opportunity in Housing and with implementing populations of disabled persons pursuant to 24 CFR regulations at 24 CFR Part 107 which prohibit 582 . 330(a), it will comply with this section' s discrimination because of race, color, creed, sex or nondiscrimination requirements within the designated national origin in housing and related facilities population. provided with Federal financial assistance. It will comply with Executive Order 11246 and all regulations pursuant thereto (41 CFR Chapter 60- 1 ), B. For SHP Only. which state that no person shall be discriminated against on the basis of race, color, religion, sex or 1 . Maintenance of Effort. national origin in all phases of employment during the It will comply with the maintenance of effort performance of Federal contracts and shall take requirements described at 24 CFR 583 . 150(a) . affirmative action to ensure equal employment opportunity. The applicant will incorporate, or cause 2. 20-Year Operation Rule. to be incorporated, into any contract for construction work as defined in Section 130 . 5 of HUD regulations For applicants receiving assistance for acquisition, the equal opportunity clause required by Section rehabilitation or new construction: The project will be 130. 15 (b) of the HUD regulations . operated for no less than 20 years from the date of It will comply with Section 3 of the Housing and initial occupancy or the date of initial service Urban Development Act of 1968, as amended ( 12 provision for the purpose specified in the application. U. S . C . 1701 (u)), and regulations pursuant thereto (24 CFR Part 135 ), which require that to the greatest 3. 1 -Year Operation Rule. extent feasible opportunities for training and employment be given to lower-income residents of the For applicants receiving assistance for supportive project and contracts for work in connection with the services, leasing, or operating costs but not receiving HUD40076-CoC (2003) OMB Approval No . 2506-0112 (exp. 08/31/2006 ) TREASURE COAST HOMELESS SERVICES COUNCIL, INC. CONTINUUM OF CARE assistance for acquisition, rehabilitation, or new construction: The project will be operated for the D. For SRO Only. purpose specified in the application for any year for which such assistance is provided. 1. Standards, Definitions, and $3, 000 Minimum . C. For S+C Only. The proposed site meets HUD' s site and neighborhood standards (24 CFR 882. 803(bx4)), 1. Maintenance of Effort. meets the regulatory defmition of single room occupancy housing (24 CFR 882. 802), and the It will comply with the maintenance of effort rehabilitation costs will met the per unit rehabilitation requirements described at 24 CFR 582. 115(d). minunum of $3 ,000 . 2. Supportive Services. E. For SBP and SRO It will make available supportive services 1. Nonprofit Board of Directors . appropriate to the needs of the population served and For private nonprofit applicants, members of its equal in value to the aggregate amount of rental Board of Directors serve in a voluntary capacity and assistance funded by HUD for the full term of the receive no compensation, other than reimbursement rental assistance and that it will fund the supportive for expenses, for their services. services itself if the planned resources do not become available for any reason. F. For SBP and S+C. 3. Components : Standards, Definitions, and 1. Lead-Based Paint. $3,000 Minimum It will comply with the requirements of the Lead- Based Paint Poisoning Prevention Act, 42 U. S. C. (a) For the SRO component only, the proposed site 4821 -4846, and implementing regulations at 24 CFR meets HUD ' s site and neighborhood standards Part 35 . (24 CFR 882. 803 (b)(4), and meets the regulatory definition of single room occupancy housing (24 G. For S+C and SRO. CFR 882 . 802 ). (b) For the SRO and PRA with rehabilitation 1. PHA Qualification. components, the rehabilitation costs will meet the For PHA applicants, that it qualifies as a Public per unit rehabilitation minimum of $3 ,000 . Housing Agency as specified in 24 CFR 882. 102 and is legally qualified and authorized to cant' out the proposed project(s). H. Explanation. Where the applicant is unableA certify to any of the statements in this certification, such applicant shall attach an xplanati behj� Chit pax Signa ure of Authorized Certifying Official: Date: May 17 , 2005 Title: Chairman, Board of County Commissioners Applicant: For PHA Applicants Only: (PHA Number) Indian River County Board of County Commissioners HUD40076-CoC (2003 ) ONIB Approval No. 2506-0112 (exp. 08/31/2006) DISCLOSURE -OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U . S . C . 1352 0348-0046 See reverse for public burden disclosure . ) 1 . Type of Federal Action : 2 . Status of Federal Action : 3 . Report Type : [ b 1 a . contract ! a ] a . bid/offer/application f a 1 a . initial filing 1 b . grant l J b . initial award I J b . material change c . cooperative agreement c . post-award For Material Change Only : - d . loan year quarter e . loan guarantee date of last report f. loan insurance 4. Name and Address of Reporting Entity : 5 . If Reporting Entity in No. 4 is a Subawardee, Enter Name ❑ Prime ❑ Subawardee and Address of Prime : Tier if known : INDIAN RIVER CO . BOARD OF COUNTY COMMISSIONERS THIS ENTITY DOES NOT ENGAGE IN LOBBYING Congressional District, if known : Congressional District , if known : 15, 16 6 . Federal Department/Agency : 7 . Federal Program Name/Description : US DEPT. OF HUD CFDA Number, if applicable : 8 . Federal Action Number, if known : 9 . Award Amount, if known : 10 . a. Name and Address of Lobbying Registrant b. Individuals Performing Services ( including address if ( if individual, last name, first name, Ml ) : different from No. 1Oa ) ( last name, first name, M/ ) : NONE dq 11Information requested through this forth is audarized by title 31 U.S. C. section . 1352. This disclosure of lobbying activities is a material representation of fact Signature : upon which reliance was placed by the tier above when this transaction was made print Name : THOMAS LOWTHER, CHAIRMAN or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for Chairman public inspection. Any person who fails to file the required disclosure shall be Title : subject to a civil penalty of not less that $10,000 and not more than $100,000 for each such failure. Telephone No . : 772 - 226 - 1490 Date : 5 / 17 / 2005 Authorized for Local Reproduction Federal Use Only : Standard Form LLL (Rev. 7-97) 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 ) Applicant/Recipient Information Indicate whether this is an Initial Report ❑ or an Update Report 1 . Applicant/Recipient Name, Address, and Phone (include area code): 2. Social Security Number or INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS Employer ID Number: 1840 25" STREET, VERO BEACH , FL 32960 59-6000-674- (772-567-8000) - 3. HUD Program Name 4. Amount of HUD Assistance CONTINUUM OF CARE HOMELESS ASSISTANCE PROGRAM -SHP Requested/Received $24 , 581 . 00 5. State the name and location (street address, City and State) of the project or activity: INDIAN RIVER COUNTY Part I Threshold Determinations 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 terms do not include formula grants, such as public housing operating jurisdiction of the Department (HUD) , involving the project or activity in this subsidy or CDBG block grants. (For further information see 24 CFR Sec. application , in excess of $200,000 during this fiscal year (Oct. 1 - Sep. 30)? 4.3). For further information, see 24 CFR Sec. 4. 9 ❑ Yes ElNo ❑ Yes ® No . 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 II 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. Department/State/Local Agency Name and Address Type of Assistance Amount Requested/Provided Expected Uses of the Funds (Note: Use Additional pages if necessary.) Part III 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 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 (whichever is lower). Alphabetical list of all persons with a reportable financial interest in Social Security No. Type of Participation in Financial Interest in the project or activity For individuals, give the last name first or Employee ID No. Project/Activity Pro ect/Activi $ 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 1001 of Title 18 of the United States Code. In addition , any person who knowingly and materially violates any required disclosures of information , including intentional non-disclosure, is subject to civil money penalty not to exceed $10,000 for each violation . I certify that this information is true and complete . Signature: Date: (mm/dd/yyyy) X May 17 , 2005 TREASURE COAST HOMELESS SERVICES COUNCIL, INC. CONTINUUM OF CARE Special Project Certification Coordination and Integration of Mainstream Programs All applicants must certify for their grant and submit this certification along with form SF-424 as part of their Continuum of Care application. (You may submit a single certification covering all of your projects . ) I hereby certify that if our organization ' s grant application is selected for funding as a result of this competition, we will coordinate and integrate our homeless program with other mainstream health, social services, and employment programs for which homeless populations may be eligible, including SSI, Temporary Assistance for Needy Families, Medicaid, Food Stamps, State Children ' s Health Insurance Program, Workforce Investment Act and Veterans Health Care programs . Chairman, Board of County Commissioners Authorized signature of applicant Position Title (required for all applicants) _May 17 , 2005 Date HUD40076-CoC (2003) OMB Approval No . 2506-0112 (exp. 08/31/2006 ) TREASURE COAST HOMELESS SERVICES COUNCIL, INC. CONTINUUM OF CARE Special Project Certification Discharge Policy Required of all State and local government applicants . Submit this certification along with form SF-424 . (You may submit a single certification covering all of your projects . ) I hereby certify that as a condition for any funding received as a result of this competition, our government agrees to develop and implement, to the maximum extent practicable and where appropriate, policies and protocols for the discharge of persons from publicly funded institutions or systems of care (such as health care facilities, foster care or other youth facilities, or correction programs and institutions) in order to prevent such discharge from immediately resulting in homelessness for such persons . I understand that this condition for award is intended to emphasize that States and units of general local government are primarily responsible for the care of these individuals, and that McKinney-Vento Act funds are not be to used to assist such persons in place of State and local resources . v , < Chair, BoUd of County Commissioners_ Authorized signature of applicant Position Title (required only for applicants that are States or units of general local government) May 17 , 2005 Date HUD-40076-CoC (2003) OMB Approval No. 2506-0112 (exp. 08/31 /2006) Attachment 7 . OMB Approval No . 2506-0112 ( exp 9/30/2005) Continuum of Care Applicant Certifications (These certified statements are required by law . ) A. For the Supportive Housing (SHIP) , Shelter Plus feasible opportunities for training and employment be Care (S+C) , and Single Room Occupancy (SRO) given to lower- income residents of the project and programs . contracts for work in connection with the project be 1 . Fair Housing and Equal Opportunity . awarded in substantial part to persons residing in the It will comply with Title VI of the Civil Rights Act of area of the project.It will comply with Section 504 of the 1964 (42 U. S . C . 2000(d)) and regulations pursuant Rehabilitation Act of 1973 (29 U . S . C . 794), as thereto (Title 24 CFR part I), which state that no person amended, and with implementing regulations at 24 in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be CFR Part 8 , which prohibit discrimination based on denied the benefits of, or be otherwise subjected to disability in Federally-assisted and conducted programs discrimination under any program or activity for which and activities . the applicant receives Federal financial assistance, and It will comply with the Age Discrimination Act of will immediately take any measures necessary to 1975 (42 U. S . C . 6101 -07), as amended, and effectuate this agreement . With reference to the real implementing regulations at 24 CFR Part 146, which property and structure(s) thereon which are provided or prohibit discrimination because of age in projects and improved with the aid of Federal financial assistance activities receiving Federal financial assistance . extended to the applicant, this assurance shall obligate It will comply with Executive Orders 11625 , the applicant, or in the case of any transfer, transferee, 12432, and 12138 , which state that program for the period during which the real property and participants shall take affirmative action to encourage structure(s) are used for a purpose for which the participation by businesses owned and operated by Federal financial assistance is extended or for another members of minority groups and women . purpose involving the provision of similar services or If persons of any particular race, color, religion, benefits . sex, age, national origin, familial status, or disability It will comply with the Fair Housing Act (42 who may qualify for assistance are unlikely to be U. S . C . 3601 - 19), as amended, and with implementing reached, it will establish additional procedures to regulations at 24 CFR part 100, which prohibit ensure that interested persons can obtain information discrimination in housing on the basis of race, color, concerning the assistance . religion, sex, disability, familial status or national It will comply with the reasonable modification origin. and accommodation requirements and, as appropriate, It will comply with Executive Order 11063 on the accessibility requirements of the Fair Housing Act Equal Opportunity in Housing and with implementing and section 504 of the Rehabilitation Act of 1973 , as regulations at 24 CFR Part 107 which prohibit amended . discrimination because of race, color, creed, sex or Additional for S+C : national origin in housing and related facilities If applicant has established a preference for targeted provided with Federal financial assistance . populations of disabled persons pursuant to 24 CFR It will comply with Executive Order 11246 and all 582 . 330 (a), it will comply with this section ' s regulations pursuant thereto (41 CFR Chapter 60- 1 ), nondiscrimination requirements within the designated which state that no person shall be discriminated population . against on the basis of race, color, religion, sex or national origin in all phases of employment during the B . For SHP Only. performance of Federal contracts and shall take affirmative action to ensure equal employment 1 . Maintenance of Effort . opportunity. The applicant will incorporate, or cause to It will comply with the maintenance of effort be incorporated, into any contract for construction requirements described at 24 CFR 583 . 150(a) . work as defined in Section 130 . 5 of HUD regulations the equal opportunity clause required by Section 2. 20-Year Operation Rule. 130 . 15 (b) of the HUD regulations . For applicants receiving assistance for acquisition, It will comply with Section 3 of the Housing and rehabilitation or new construction : The project will be Urban Development Act of 1968 , as amended ( 12 operated for no less than 20 years from the date of U. S . C . 1701 (u)), and regulations pursuant thereto (24 Initial occupancy or the date of initial service provision CFR Part 135 ) , which require that to the greatest extent for the purpose specified in the application. IND-40076-CoC (2003) 3 . 1 -Year Operation Rule . D. For SRO Only. For applicants receiving assistance for supportive services, leasing, or operating costs but not receiving 1 . Standards , Definitions, and $3 ,000 Minimum . assistance for acquisition, rehabilitation, or new The proposed site meets HUD ' s site and neighborhood construction: The project will be operated for the standards (24 CFR 882 . 803 (b)(4)), meets the regulatory purpose specified in the application for any year for definition of single room occupancy housing (24 CFR which such assistance is provided. 882 . 802) , and the rehabilitation costs will met the per unit rehabilitation minimum of $3 , 000 . C. For S+C Only. E. For SHP and SRO 1 . Maintenance of Effort . 1 . Nonprofit Board of Directors . It will comply with the maintenance of effort For private nonprofit applicants, members of its Board requirements described at 24 CFR 582 . 115 (d) . of Directors serve in a voluntary capacity and receive 2. Supportive Services . no compensation, other than reimbursement for expenses, for their services . It will make available supportive services appropriate to the needs of the population served and equal in value F. For SHP and S+C. to the aggregate amount of rental assistance funded by HUD for the full term of the rental assistance and that it 1 . Lead-Based Paint. will fund the supportive services itself if the planned It will comply with the requirements of the Lead-Based resources do not become available for any reason. Paint Poisoning Prevention Act, 42 U. S . C . 4821 -4846 , and implementing regulations at 24 CFR Part 35 . 3. Components : Standards , Definitions , and $3,000 Minimum. G. For S+C and SRO. (a) For the SRO component only, the proposed site meets HUD ' s site and neighborhood standards (24 CFR 1 . PHA Qualification . 882 . 803 (b)(4), and meets the regulatory definition of For PHA applicants, that it qualifies as a Public single room occupancy housing (24 CFR 882 . 802) . Housing Agency as specified in 24 CFR 882 . 102 and is (b) For the SRO and PRA with rehabilitation components , legally qualified and authorized to carry out the the rehabilitation costs will meet the per unit proposed project(s) . rehabilitation minimum of $3 , 000 . H. Explanation. Where the applicant is unable to certify to any of the statements in this certification, such applicant shall attach an explanation behind this page . Signature of Authorized Certifying Official : Date : S May 17 , 2005 Title: Chair, Indian River County Board of County Commissioners Applicant: For PHA Applicants Only: ( PHA Number) Indian River County Board of County Commissioners Public reporting burden for this collection of information is estimated to average 0. 1 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The information collection requirements contained in this application have been submitted to the Office of Management and Budget (OMB) for review under the Paperwork Reduction Act of 1995 (44 U. S. C. 3501 -3520). This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. Information is submitted in accordance with the regulatory authority contained in each program rule. The information will be used to rate applications, determine eligibility, and establish grant amounts. Selection of applications for funding under the Continuum of Care Homeless Assistance are based on rating factors listed in the Notice of Fund Availability (NOFA), which is published each year to announce the Continuum of Care Homeless Assistance funding round. The information collected in the application form will only be collected for specific funding competitions. HUD-40076-CoC (2003) U. S. Department of Housing OMB Approval No. 2506-0112 and Urban Development (exp 9/302005) Office of Community Planning and Development The information collection requirements contained in this application have been submitted to the Office of Management and Budget (OMB) for review under the Paperwork Reduction Act of 1995 (44 U. S. C. 3501 -3520). This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. Information is submitted in accordance with the regulatory authority contained in each program rule. The information will be used to rate applications, determine eligibility, and establish grant amounts. Selection of applications for funding under the Continuum of Care Homeless Assistance are based on rating factors listed in the Notice of Fund Availability (NOFA), which is published each year to announce the Continuum of Care Homeless Assistance funding round. The information collected in the application form will only be collected for specific funding competitions. Public reporting burden for this collection of information is estimated to average 10 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 ) Exhibit 2R : Supportive Housing Program — Renewal Project Instructions (Exhibit 2R is the application for a renewal SBP project, consisting of forms HUD 40076-COC -2RA through form HUD 40076-CoC-2RE, plus narrative text as specified in the instructions for each form. ) Previous versions obsolete form HUD40076-CoC (04/2004) Applicant Name : INDIAN RIVER CO . BOARD OF COUNTY COMISSIONERS DUNS #_079 -208 - 989 ProjectName : Family Options Transitional Housing II ( One Year Renewal ) Exhibit Me SHP Project Information Project Information 1 . Basic Identification a. Grantee Name : Indian River County Board of County Commissioners b . Project Name : Family Options Transitional Housing c. Sponsor Name : Indian River County Department of Human Services d . Address : 720 4u' Street, Vero Beach, FL 32962 e . Telephone : 772 -567-7790 f. Fax Number: 772-567-5991 g . Contact Person: Louise Hubbard h . Project Congressional District: 15 , 16 i . Project 6-digit Geographic Code : 129061 J . Project Number of Grant Being Renewed FL2913409003 PIN: FL13168 k. Component/Type : (please check one) THE PHO SSO❑ SH-Th❑ SH-Ph ❑ HMIS❑ IH❑ 1. Priority Number on Exhibit 1 : 4 2 . Number of Beds/Number of Participants Chart 1 : Beds Beds Current Level Number of Bedrooms* 12 Number of beds* 28 *Do not complete information on the number of bedrooms and beds for Supportive Services Only (SSO) or Dedicated IIIvIIS projects. In those instances, enter "N/A" in the appropriate cells. Chart 2 : Participants Current Level No. Projected to Participants (if applicable) be served over the Pan ant term 16 Number of families with children Of persons in families with children 4 a. number of disabled b. number of other adults c. number of children Of single individuals not in families a. number of disabled individuals a. 1 . number of disabled individuals who are chronically homeless b. number of other individuals Form HUD 40076 CoC-2RA page 1 Applicant Name : INDIAN RIVER CO . BOARD OF COUNTY COMMISSIONERS DUNS #_079 - 208 - 989 ProjectName : Family Options Transitional Housing II ( One Year Renewal ) Exhibit Me. SHP Project Information - Continued Number of Participants/Number of Beds - Instructions Chart 1 is for recording the number of beds/bedrooms in the project . Do not complete Chart 1 if the project is for supportive services only (SSO) or dedicated HMIS projects . Chart 2 is for recording the number of participants to be served . Information for each project should be entered in this section except for dedicated HMIS projects . 1 . In the first column, please enter the requested information for all items at a point in time (a given night) . 2 . In second column, enter the number of persons to be served over the grant term. Note : If your project is funded you will be responsible for achieving the numbers submitted . 3 . Performance a. Are there any significant changes in the project since the last funding approval : ❑ Yes �1 No If "yes ", briefly describe the changes . (Attach additional pages as needed) b . If one or more extensions have been provided for your current grant, please indicate : ❑ Yes E No If yes, please indicate the number of extensions approved : The extension period (e .g . , two months, one year) : For each extension please indicate the extension period, providing dates and number of weeks or months . ■ Extension l : weeks, or months ■ Extension 2 : weeks, or months List additional extensions as necessary . For each extension, identify the reason for the extension . If not operating at full capacity, please explain . The Project is operating at full capacity . 4 . Additional Key Information a . Check the Predominately Serve box if your project primarily targets the given subpopulation, i . e . , 70 or more of the persons you serve or the Serve box if less than 70 %. Subpopulation Serve Less Predominantly Serve than 70 % 70 % or more Chronically Homeless -Severely Mentally Ill X Chronic Substance Abuse X Veterans Persons with HIV/AIDS X Victims of Domestic Violence X Women with Children X Youth (Under 18 years of age) Form HUD 40076 CoC-2RA page 2 Applicant Name : INDIAN RIVER CO . BOARD OF COUNTY COMMISSIONERS DUNS # 079 - 208 - 989 ProjectName : Family Options Transitional Housing II ( One Year Renewal ) Exhibit 2R : SHP Project Information - Continued b . Project is in a rural area: ❑ Yes E No c . Is the sponsor and/or applicant of the project a religious organization, or a religiously affiliated or motivated organization? (Note : This characterization of religious is broader than the standards used for defining a religious organization as "primarily religious" for purposes of applying HUD ' s church/state limitations . For example, while the YMCA is often not considered "primarily religious " under applicable church/state rules , it would likely be classified as a religiously motivated entity. ) Sponsor : ❑ Yes Applicant: ❑ Yes ❑ No E No d. Is the Logic Model attached? Please see the General Section for instructions . E Yes ❑ No Project Information Instructions Items 1 , 2 and 3 are self-explanatory . Renewal applicants for a dedicated HMIS project answer items 1 , 2c, and 3 . Item 4 . — Additional Key Information a . Check the subpopulations your project will assist . (Check the Predominantly Serve box if your project primarily targets the given subpopulation, i . e . , 70 percent or more of the persons you propose to serve, or the Serve box if less than 70 percent . ) Please identify all that apply . Responses will also be used to measure compliance with the requirement that no less than 10% of the funds awarded are for projects predominantly serving individuals experiencing chronic homelessness . New this year, existing permanent housing projects may only replace those exiting the project with homeless persons who come from the street, emergency shelter or transitional housing, not "Other" populations . Form HUD 40076 CoC -2RA page 3 Applicant Name : INDIAN RIVER CO . BOARD OF COUNTY COMISSIONERS DUNS #_079 - 208 - 989 ProjectName : Family Options Transitional Housing II ( One Year Renewal ) Exhibit 2R : SHP Supportive Services Chart Supportive Services Chart Supportive Service Expense Year 1 Year Year 3 Total 2 1 . Service Category and Quantity a. Service Category : Dedicated 30, 726 . 25 Permanent Housing Specialist Quantity : 1 FTE b . Service Category : Quantity : c . Service Category : Quantity d . Service Category : Quantity e . Service Category : Quantity f. Service Category : Quantity g . Service Category : Quantity 2. Total Supportive Services Budget 30 , 726 . 25 (add lines under item 1 to obtain the total Supportive Services Budget) 3. SHP REQUEST 24 ,581 . 00 4. Selectee' s Match (Line 2 minus Line 62145 . 25 3) Form HUD 40076 CoC -2RB page 1 Applicant Name : INDIAN RIVER CO . BOARD OF COUNTY COMMISSIONERS DUNS #_079 - 208 - 989 ProjectName : Family Options Transitional Housing II ( One Year Renewal ) Exhibit Me. HMIS Budget — Dedicated Projects and Shared Costs - Instructions Complete the entire HMIS Budget Chart for a dedicated HMIS project. A project for shared HMIS costs with other projects need only complete the "Subtotal" lines of the chart. HMIS costs are those costs associated with the implementation of an HMIS . If requesting SHP HMIS funds , only the portion of the costs directly related to the HMIS is eligible . In the personnel section, the number of staff positions in Full-Time Equivalents (FTEs) should be present for each category, where appropriate . EXAMPLE : Personnel Year 1 Year 2 Year 3 Total Project Management / Coordination $437000 $43 , 000 $43 , 000 $ 129, 000 1 - . 5 FTE @$56,000/annual x 3 years =$ 84, 000 Data Analysis 1 - . 25 FTE @$28 ,000/annual x 3 years=$21 , 000 Administrative Support Staff 1 - . 5 FTE @$ 16, 000/annual x 3 years =$24, 000 1 . In the Year 1 column of the form, enter the total amount of funds to be used to pay for the first year expenses . If the grant is a multi-year grant, enter the total funds to be used for the second and third years, if applicable . 2 . In the last column, total the amount of funds needed to help pay for the identified HMIS expenses for the grant term. 3 . Documentation of firm commitments of the cash resources for year I of your grant term will be required prior to grant execution . Please note that the match requirement for Year 2 and Year 3, if applicable, must be met by the end of each of those years . 4 . Homeless Management Information System Participation a. Date (mm/yyyy) this project began participating (entering data) into the HMIS _6_/ 2003_ If not yet participating, please explain why and when you intend to begin participating : b . Are all clients served by this project entered into the HMIS ? X Yes ❑ No If not all clients served are entered into the HMIS , please explain why : Form HUD 40076 CoC-2RC page 2 Applicant Name : INDIAN RIVER CO . BOARD OF COUNTY COMMISSIONERS DUNS #_079 - 208 - 989 ProjectName : Family Options Transitional Housing II ( One Year Renewal ) Exhibit 2R : SHP- Project Budget Project Budget Please fill out your proposed project budget and term of grant for the activities in which you are requesting funds, including the cash match resources and the total project budget . Grant Term : (please check one) 1 0 2 n 3 Proposed Activities SHP Request Applicant Cash Total Budget Col. 1 + Col. 2 1 . Real Property Leasing 2 . Supportive Services 24, 581 . 00 61145 . 25 307726 . 25 3 . Operations 4 . IMS 5 . SHP Request (subtotal lines 1 through 4) 247581 . 00 6 . Administrative Costs (up to 5% of line 5) 7. Total SHP Request (total lines 5 and 6) 247581 . 00 * By law, SHP funds can be no more than 80% of the total supportive services and B IIS budget. * * By law, SHP can pay no more than 75% of the total operations budget. * * * Applicants may request up to 5% of each project award for administrative costs, such as accounting for the use of the grant funds, preparing HUD reports, obtaining audits, and other costs associated with administering the grant. State and local government applicants and project sponsors must work together to determine the plan for distributing administrative funds between applicant and project sponsor (if different) . NOTE : The total SHP Request on line 7 cannot exceed the dollar amount on the Priority Chart in Exhibit 1 for the project. Form HUD 40076 CoC -2RE