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Home My WebLink AboutExhibit 6U_ S. Department of Housing and Urban Development Office of Community Planning and Development 0Jv1I3 Approval No. 2506-01-45 (c --p. ] 1i30!2009' ATTACHN ENT G Annual Progress Report (AYT\-", for Supportive Rousing Program Shelter Plus Care and Section 8 Moderate Rehabilitation for Single Room Occupancy Dwellings (SRO) Program form HUD -40118(0812003 ) Public reperi.bre burden for this col Iact ion of Zonnation is estimated to average 33 hours per response, including the time for reg ie« ing nistjutaiuns. search ng e>is,ing data sources, gathering and maintaining the dant need:d, and completing and rdvie \rins the colleztiall of information. 111is agency inay not conduct or sponsor, and n person is not required to respond to. a collection of inibrntntiOil uriess that collection displo)•s a valid OMB control number. General Instructions Purpose. The Arurttal Progress Report (APR) tracks program progress and accomplislunents in the Department's competitive homeless assistance pro rams. Filing Requirements_ Recipients of HUD's homeless assistance grants roust submit 2 AYR'S to HUD withi 190 elms ;titer the end of cacti operating year. One copy of the report roust be submitted 10 the CPD Division Director in the local HUD Field Office responsible for managing the grant. The other cope must be submitted to HUD Headquarters; Department of Housing and Urban Development, Attn: APR Data Editor, Room 7262, 451 7d' Strcet, SW, Washington, DC. 20410. Failure to submit an APR will delay receiving grant funds and may result in a determination of lack of capacity for future funding. An APR must be submitted for each operating year in which HUD funding is provided. Grantees that received SHP funding for new construction, acquisition, or rehabilitation are required to operate their facilities for 20 years. They must submit an APR 90 days after the end of the first operating year and any year in which they use SHP funding for leasing, supportive services, or operations_ For years in which they do not receive SHP funding, they must submit an Annual Certification of Continued Project Operation throughout the 20 years. The certi-ication can be found at the back of this APR. A separate report must be submitted for each HUD grant received. For Shelter Plus Care, a separate APR must be submitted for each Shelter Plus Care component For those grantees receiving an ettension, a separate report covering that period. must be submitted (see E --tension below)_.. Recordkeeping. Grantees must collect and maintain information. on each participant in order to complete an APR Optional worksheets are attached- The worksheets may be, used to record information manually or to design. a computerized system to store and tabulate the information. The worksheets should not be submitted to HUD with the APR- -Organization PR -Organization of the Report. The APR is organized in the following manner: Part I: Project Progress. This portion of the report describes the progress in mMng homeless persons to self-sufficiency services received,project goals, and beds created. Part II: Financial Information. This portion of the report is completed by all grantees receiving funding under SHP, S+C and SRO. Final Assembly of Report. After. the entire report is assembled, number every page sequentially. Mark any questions that do not apply to your program with "N/A" for not applicable. (See Special Instrtictioas for SSO Projects below.) Definitions. The folloiiing terms are used in the APR Asindicated,:in sonic cases, terms are applied differently depending on whether the funding is from SHIP, S+C, or SRO. Clr.ronically homeless person — HUD defines a chronically homeless person as "an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years_" To be considered chronically homeless a person must have been on the streets or in an emergency shelter (i.e.not transitional housing) during these stays. Disabling condition - HUD defines "disabling condition" as "a diagnosable substance use disorder, serious mental illness, developmental disability, or chronic physical illness or disability, including die co -occurrence of two or more of these conditions. A disabling condition limits an individual's ability to va,ork or perform one or more actil,rities of daily luring.' Entered the p rograrn for S+C and SRO projects means `when the participant starts tO receive rental assistance. For S+C, services provided prior to this point are recognized as necessan for outreact>lenrollment and are eligible to count as match. Conn HUD -40118((0£.2003) An Extension APR applies to SF -IP and S+C grantees U-iat requested and received an eNtension of their grant term from the HUD field office. The only difference between an APR for the extension period and the regular .A -PR (besides the amount of time covered) is the signature page. Grantees should circle "yes' to indicate the APR is for an exlension period and circle die operating year for which the report is an eXtenSion. For example, if the grantee is extending tear 3. the grantee should submit an APR as usual for year 3 and subrnit another APR for the ex-terision period, indicating the second is an extension and also circling year 3 on the signature page. - Family means a household composed of two or more related persons. at ]cast one of whom is an adult. Caregivers are not reported on in the APR- Gr.mtee means a direct recipient of the HUD award. Left the program for S+C projects means when the participant stops receiving rental assistance and isnot expected to return to S+C assisted housing. If the participant returns to S+C assisted housing within 90 days, the person should not be considered as exiting from the program. If the person returns to S+C assisted housing after 90 days, that person is considered a new participant. The worksheet is designed to capture this information. Match for S+C means the value of supportive services received by participants in the S+C project which, in the aggregate, must at least equal die value of the S+C rental assistance provided over the life of the project- For SBP, match means cash used to provide the grantee's portion of acquisition, rehabilitation, new construction, operations and supportive services expenses. Operating ye,2r- for SHP means the date when participants begin to receive housing and/or services. The first operating year begins alter development activities for acquisition, rehabilitation, and new construction are complete; after a copy of the Certificate of Occupancy is sent to the local HUD office, and when the first participant is accepted into the project. For projects without acquisition, rehabilitation, or nrw construction, the operating start date begins when the grantee accepts. the first participant. For S+C (SRA, PRA and TRA components), the first operating year begins on the date HUD signs the grant agreement_ For S+C/SRO and for Sec. 3 SRO, the first operating year begins with the effective date of the Housing Assistance Payments (HAP) Contract. To deternune which operating year to circle on the APR cover page, begin counting from. the initial grant operating start date and include renewals grants. For example, a project receiving, an initial grant for three years and a renewal grant for two years would circle years 1; 2, and 3 respectively on the APR cover sheet for the initial grant and would . circle 4 and 5 respectively for the renewal grant. For any future renewal grants, the grantee would begin by circling 6 on the APR cover sheet. Participant means single persons and adults in families. who received assistance during the operating year_ Participant does not include children or caregivers who live with the adults assisted., Project Sponsor means the organization responsible for carrying out the daily operation of the project, if the organization is an entity other than the grantee. Special Instructions For Supportive Service Only Projects_ SSO grantees should complete all questions, unless a written agreement has been reached with. the field office concerning tivluch questions can be answered using estimates, or in rare instances, skipped. Below is an example of holy information could be derived in a large, single -service SSO project: A grantee/sponsor staff member could be assigned to collect information from the organizations housing the participants. The staff person .would contact these individual organizations to request infor cation regarding the persons in that facility that use the sen -ice. For participants living on the street, the grantee/project sponsor may .. provide estimates. Information could be collected for each participant or for participants receiving sen. -ices at a point -in -.time. If estimates or point -in -tune counts are used; the method used must be described in the APR and the documentation kept on file. form HUD -4o1 I Byov,o03) As ivith all projects fielded under HUD's homelessness assistance grants: grantees operating SSO projects arc ex-pected to complete all .APR questions that are applicable to thein. Note that all projects have been awarded funds as a result of responding to the program ;oats of assisting hoineless persons obtain/remain in permanent housing and increase their skills and income. The APR documents their progress in meeting these goals. In some circumstances field offices and grantees may sign a written agreement concerning questions which can be answcred using estimates, -037 in rare instances, skipped. Below are some considcraLions for reporting on particular hhes of projects: Outreach Only Projects. - Projects which are solely devoted to street outreach and corulection to housing and services are not required to track participants beyond their contact )vjfli persons on the street. It is sufficient for these projects to enter information on questions 1-10 (slopping questions 11-13 and 17). Estimates for questions 5-9 are allowed, given that participants may be reluctant to answer personal questions. Answering the questions will demonstrate that the grantee is senting the appropriate nunnber of people, providing basic demographic information for Congress, demonstrating that homeless persons are being served, demonstratiug the types of housing participants are connected to, and the type of services they are receiving. Hotline Projects. - Hotline services are similar to outreach projects, but contact between grantee and participant is often of very short duration - people enter and leave the program nearly simultaneously. It is sufficient for these projects to answer questions 1-5 (skipping 4), 10, and 14-19 (slipping 17). Projects Providing Services.To Childs -en Only. - Projects that provide child care, after school care, counseling for children, etc. inakc an important contribution toward moving a fancily out of lionielessness. Wldle the main focus of the project is pro -,riding services to the.children, it is the adults who are reported on in questions 5-16 of the APR Lilce all other Projects, this type is also targeted toward getting the families into Housing and increasing the families' incomes. Gmiatees may slip question 9; all oilier questions should be answered (except 17). Transportation, Medical. Dental, and Other Single, Short -Duration Service Projects. - Some grantees provide a single service of fairly short duration focused ONLY indirectly on assisting homeless persons to obtain/remain in permanent housing and increase their skills and incomes. It is sufficient for these projects to enter information on questions 1-10 and 14-I9 (question 17 may be slapped). However, with transportation services, it. is unreasonable to think that someone would have to give their age; race, and ethnicity to a bus driver to get a ride a few blocks. For these services, proiride a narrative, -which gives the number of rides given during the operating year, and provides estimates on the above statistics based on the population that utilizes the service. Special Izistructions For Safe Haven (SH) Projects. - Grantees are reminded that they are to report ONLY on the number of participants- the application seas approved for (cannot exceed 25 participants). Homeless li' xm;a ,einent Inforrn.2tion System (HMIS) Pro iects. -HMIS grantees should fill out the cover sheet of the APR (marking HivIIS at the bottom) and Part II Financial Information. The APR also has a sheet that lists HNIIS activities. form HUD-4011B((OS^003) r THIS P4 GE - TO BE CO.hIPLETED BY ALL GR,LNTEES Grantee: HUD Grant or Project Number: Project Sponsor: Project MUDC2: Operating Year: (Circle the operating year being reported on) Repor-ma Period: (month/dey/ycar) M 02 ❑3 04 ❑5 ❑6 ❑7 ❑8 ❑9 •010 ❑11 012 ❑13 ❑14 ❑15 ❑16 ❑17 ❑la E119 ❑20 Indicate. If e\-ienslotl: ❑ Yes ❑ No lions: to: Indicate if renewal: ❑ Yes ❑ No Previous Grant INIwnbers for this project: Check the component for the program on whiclh you are reporting. Supportive Housing Proorani (SBP) Shelter PIus Care (S;-) ❑ Transitional Housing ❑ Permanent Housing for Homeless Persons with Disabilities ❑. Safe Haven ❑ Innovative Supportive Housing ❑ Supportive Sendces Only ❑ HMIS ❑ Tenant -based Rental Assistance (TRA) ❑ Sponsor -based Rental Assistance (SRA) ❑ Project -based Rental Assistance (PRA) ❑ Single Room Occupancy (SRO) I-. Section 8 Moderate Rehabilitation ❑ Single Room Occupancy (Sec. 8 SRO) Suriunary of the project: (One or two sentences with a description of population, number served and accomplishments this operatinc, year) Name &: Title of the Person who can answer questions about this report: Phone: '(include area code) Address: Fax Number. (ulclude area code) E-mail Address I hereby certify that all the information stated herein is true and accurate. Wornino: I -M 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 Grantee Official: Signature & Date: Name and Title QlAuthorized Project Sponsor Official. Signature & Date: form HUD -401 18((08"2003) i P.4 -RTI. TO BE COMPLETED B FALL GE.-iNTEES (FXCEPT HA[IS) SSO GRANTEES, PLE4 SE SEE SPE CLAL I's'STR UCTIONS O:Y PAGE 3 OF THE APR Part I: Project Progress 1. Projected Level of Persons to be served at a given Point in time. (from the application, STIP- Sec. F-, SPC- Sec. D; SRO- Sec. D) 2. Persons Served during the operating year. Number of Number of Number of Number of I. Number on the first day of the operating year Suiglas Not Adults ui Children Families b. Number entering program dLn* the operating year ui Families FmuiIies in Families Projected Level a. Persons to be served at a given point in time 2. Persons Served during the operating year. 3_ Project Capacity. Number of Singles Not in Families Number of Adults in Families Number of Children in Families Number of Families I. Number on the first day of the operating year c. Capacity Rate (divide a by b)-= % % l b. Number entering program dLn* the operating year c. Number who left the program- during the operating year d. Number in the program on the last day of the operating year (a+b-c)=d 3_ Project Capacity. 4. Non -homeless persons. This question is to be completed for Section 8 SRO projects How many income -eligible non -homeless persons were housed by the SRO program during the operating year? 5. Age and Gender. Of those who entered the project during the operating }rear, liow many people are in the foIloNvzng age and gender categories? Single Persons (from 2b, column 1) Age Male FenzaIe a. 62 and over b. 51-61 C. 31-50' d- 18-30 C. 17 and lander . Persons in Families (from 2b, columns 2 a'.- 3). f.E561 over 51-61 h.i.j. k. 6-12 1. 1-5 in. Under 1. ' (j Ivan i-1UQ40118((DS/�'UU= ) Number of Number of Num4?fNurnber of Singles Not in Adults m ChildFarmilies Families Fam a. Number on the last day (from 2d, columns 1 and 4) b. Number proposed in application (from Ia, columns 1 and 4) c. Capacity Rate (divide a by b)-= % % l 4. Non -homeless persons. This question is to be completed for Section 8 SRO projects How many income -eligible non -homeless persons were housed by the SRO program during the operating year? 5. Age and Gender. Of those who entered the project during the operating }rear, liow many people are in the foIloNvzng age and gender categories? Single Persons (from 2b, column 1) Age Male FenzaIe a. 62 and over b. 51-61 C. 31-50' d- 18-30 C. 17 and lander . Persons in Families (from 2b, columns 2 a'.- 3). f.E561 over 51-61 h.i.j. k. 6-12 1. 1-5 in. Under 1. ' (j Ivan i-1UQ40118((DS/�'UU= ) I " Anslver questions 6 - 10 onl}' for participants ti}•iio eniered the lirojcei dul�ilp iuc Ojiei Htiu"{D iCar � rvlll ')�, i v, .:wluirTii]j i �z. 2). The tern participant means single persons and adults in families. It does not include children or caregi},ers_ NOTE: The total for questions, 7, 8 and 10 below should be the same; respond to each of those questions for all participants. Soule of the questions listed tllrou,hout the APR will be asking information for individuals ivho are chronically homeless. Ga Veterans Status. A veteran is anyone -,,fig has ever been on active rlulitary duty stanis. How many participants were veterans? C� 61). Chronically homeless person. An Lulaccoml><'mied homeless individual xvith a disabling condition who has either been contilnlously homeless for a year or more OR has had at least four (4) episodes of homelessness it the past three (3) years. To be considered chronically homeless a person inust have been on the streets or in all emergency shelter (i.e. not transitional housing) during these stays. How many participants were chronically homeless uidividuals? L--� 7. Ethnicity. How many participants are in the following ethnic categories? a Hi spanjc or Latino b.. Non -Hispanic or Non -Latino 8. Race_ How many participants are in the following racial categories? a. American Indian/Alaskan Native b. Asian c. Black/African American d. Native Hawaiian/Other Pacific Islander e. Whits f. American Indian/Alaskan Native & IArliite A Asian & White h. Black/Afncan American & White i American Indian/Alaskan Native & Black/African American j. . Other Multi -Racial 9a. Special Needs. Haw many participants have the following? Participants may have more than one. If so, count thein in all applicable categories. For each condition, also indicate the dumber that were chronically homeless. All Chronic a Mental illness b. Alcohol abuse c. Drug abuse d_ EIWAIDS and related diseases C. Develo Amental disability . Physical disability 01Lf. Domestic violence Other (please specify) 9b. Iiow many of the participants are disabled? E] 7 fomi HUD-40115((0S,20Q3) 10. Prior LiN-in -Situ ation. KoNv maaiyparticipants slept in the follo\\•in5 places u1 the week pfior to enterin, the project? (For each participant, Choose one place). Also, indicate how many chronically homeless particip�uits slept ul the folloW-u1g places. (Choose one) All Chronic a. Non -housing. (street_ park, car, bus station, e(c.) b. Erncr=icy shelter C. Transitional housing for tlornelcss persons d. Psychiatric facility' e. Substance abuse treatment facility* f. Ilos )ita1' v Jail/ rison* h. Domestic violence situation i. Livui. with relatives/friends j. Rental housing L Other (please specify) *If a participant carne from an institution but ivas there less than 30 days and was living on the street.or in emergency shelter before entering the treatment facility, he/she should be counted in either the street or shelter category, as appropriate.' Complete questions 11 - 15 for all participants who Jeft during the operating year (fi-om 2c, columns 1 and 2). The term participant means single persons and adults in families. It does not include children or caregivers. The teen chronically homeless Berson means an unaccompanied homeless indMdual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years. To be considered chronically homeless a person. must have been on the streets or in an emergency shelter (i.e. not transitional housing) during these stays. 11.. ,Amount and Source of Monthly Income at Entry and at Esit Of those participants who leis during the operating year, how many participants were at each monthly income level and with each source of income? Also,.please place the monthly income level and each source of income for chronically homeless persons in the second column of each chart. The number of participants in ChartA and B should be the same. All Cluvnic A. Monthly Income at Entry a. No income b. $I-150 c. $151. -S250 d. $251-500 C- $501 - $1,000 f. SIDDI- S1506 g. $1501-52000 11. $2001 + All Cilivnic C. Income Sources At Entry a. Supplemental Security Income (SSI) b.. Social Security Disability Income (SSDI) c_ Social Security I General Public Assistance e_ Temporary Aid ID. Nee dyFamilies (TANF). f.. State Children's Health Insurance Prno„raln (SCHF) M_ Veterans Benefits h. Employment Income i. Unerriployment Benefits j. Veterans Health Care k. Medicaid 1. Food Stamps n1 Other (please specify) n. No Financial Resources form HUD -40115((0&'2003) 411 Chronic E. h4Dnthly hicome at Exit a. No income b. $1-150 c. ;6250 d. $251- $500 e. $501 - $1,000 L $1001-$1500 $1501-$2000 h. $2001 + .411 Chmnir 12a. Length of Stay in Program. Of those participants alio Wit during the operating year (from 2c, columns 1 and 2), how many were in the project for the following lengths of tinge? Also, please place the length of stay for chronically homeless persons in the second columm_ All Chronic a. Less than. l month b. 1 to 2 months c. 3 - G months d. 7 months - 12 months e. 13 months -.24 months f. 25.months - 3 ears 4 years - 5 years h 6 years - 7 years i. 8 years - 10 years j" Over 10 years 12b. Length of Stay in Program. For those participants that did not lefive during the operating year (from 2d, colunuzs 1 and 2), how long have they been in the project? Also, please'place the length of stay for chronically homeless persons in the second colunun. .gill Chronic 9 form HUD-40118(('OM003) s than I month 2 months6 monthsonths - 12 months onths - 24 months F ontlLs - 3 yearsars - 5 vears ars - 7 years ars - 10 years 10 Years 9 form HUD-40118(('OM003) 13. Reasons for Leatinn. Of those participants who left the project during the operatune year (from ?c, columns I and 2), how niany left for the following reasons? Ya participant left for multiple reasons, incLrde onli, flee primas) ree.on. .also, please place the priman-reason for chrun ically homeless persons in the second column. All Chronic a. Lell for a housing opportunity before completing program b. Completed program C. Non-payment of rent/occupwic), charge d. Non-compliance with project e. Criminal activity / destruction of property / violence f. Reached maximum tune allowed in project g. Needs could not be met by project h. Disagreement with rules/persons i. Death . j. Other (please specify) k_ UnknowLVdisappeared 14. Destination. Of those participants who left during the operating year (from 2c, colunuis 1 and 2), how many left for the following destination? Also, please place the destination of chronically homeless persons in the second column.. IO form HUD ^0118((0 2003) All Chraui PERMANENT (a -h) a. Rental house or apartment.(no subs)dy) b. Public Housing . c. Section 8 d. Shelter Plus Care e. HOME subsidized house or apartment f Other subsidized house or apartment g. Homeownership h. Moved in with family or friends TRANSITIONAL (i j) i. 'Transitional housing for homeless persons j. Moved in with family or friends INSTTIUIION (k -m) k. Psychiatric hospital 1. Inpatient alcohol or other drug treatment facility m. Jail/prison EMERGENCY SHELTER (n). I n. Emergency shelter OTHER (o -q) o. Other supportive housing p. Places not meant for human habitation (e.g. street) q. Other (please specify) UNKNOWN r: UnkiloV41 IO form HUD ^0118((0 2003) 15. Supportive Sen -ices. Of those participants who left during the operating year (front 2, colunnis I and 2), how many received the following supportive services during their tune in the project? Also, please place the supportive services received for chronically homeless participants wlio lett during the operating year in the second colunui. All Chroni a. Outmich b. Case management C. Life skills (outside, of ease man agement) d. Alcohol or drug abuse services C. Mental health services f. HIV/AMS-related services g. Other health care services It. Education i. Housing placement j. Ennpioynnent assistance k. Child care 1. Trannsportintion. m. Legal n. Other (please specify) L: 11 fomi HUD -40118((08/2003) 1 G. Overall Prom rn in Coals. Under objectives: list your measurable objectives for this operating year (from your application, Tecl-mical Submission, or APR) lbr each of ilie three goals listed below. Under Progress, describe ,our progress in meeting the objectives. Under Nza7 Operating Year's Objectives, specify tie measurable objectives for the next opernti.ng year. a. Residential Stability Objectives: Proe.ress: Ncst Operating Year's Objectives: b. Increased Slalls or Income Objectives: Progress: Next Operating Year's Objectives: C. Greater Self-determination Objectives: Progress: Next Operating Year's Objectives: 17. Beds. SHP recipients answer 17a. S+C recipients ms -i ler 17b. SRO recipients answer 17e. (SHP--SSO projects do tzot cofirplete this cquestiorzj a. SHP. How many beds were included in the application approved for this project,under `Current Level'. and under `New Effort'? How many of theseNew Effort beds were actually in place at the end of the operating year? Current Level New Effort New Effort in Place Number of Beds: _ b. S+C_ How many beds and dwelling units were being assisted'Aith project funds at the end of the operating year? (Include beds for all participants, other family members, and care givers.) Number of Beds: _ Number of Dwelli ng Units: _ C. SRO. How many dwelling units -were being assisted at the end of the operating year? (Include units occupied by "int place" non -homeless persons who qualify for assistance.) Number of Dvvelling Units: 1� torn HUD -40118((08/200,) Part If: Financial Information 18. Supportive Senices. For Supportive Housing (SHP). this exhibit provides information to I-= on hove SHP funding for supportive services ,vas spent during the operating year. Enter the amount of SI3P funding spent on these supportive scn+ ccs. Include I-DvDS costs under "Other". For Shelter Plus Care (S+C), Us exhibit tracks the supportive services match requirement. Specify the value of supportive services f-oin all sources tluit can be cotntled as match that all hoctieless persons received during the upern ting year. (S+C grantees should keep ctoetm�entation on fele, including source, amount, and type of supportive services.) For Section 8 SRO, this e.�hibit provides information to HUD on the value of supportive services received by homeless persons during the operatine year. 13 form HUD -4011 B((OV20 3) Supportive Services Doilars. a. Outreach b. Case management C. Life skills (outside of case management) d. Alcohol and dnrg abuse services e. Mental health services f. AIDS-related services g. Other health care services IL Education i. Housing placement j- Employment assistance k Child care 1. Transportation in Legal n. Other (please specify) o. TOTAL (Sum of a through n) Chunu[ative amount of match provided to date for the SbelterPlus CarePrograrn under this op -ant 13 form HUD -4011 B((OV20 3) 19. Supportive Housing Pro -ram: Lcasinb, Supportive SM-iccs, Operating Costs, HMIS Activities and Ad Ministration AI D'attiecs rueiving fit Haig under the Supportive Dousing ?rounmi must complete Mese charts each operating year. For c.�p:nuiun Projects: if SHP ;rani funds are for the expansion of pre--c:.istbig hottr_less facility, only tht people and eNpendltw es for tate additional expansion may be included, as in the original applicalion or any grant amrttdrnems. Docvmentaliun of resources used is not required to be stbmined .with this repon but should be kept on LIc for possibIt inspection by HUD artd Auditors. Do not include am expenditure made- before the SHP Luant was ezeculed. SU mill t} of Lrpenditu res. Enter the amount of SIP grant funds and cash match expended durim, the opera Ling year for each activity. This table should add up both horizontally and vertically. Talc Sly' supportive sen -ices total should be the same as Uie SHP supportive sern•it;es in Ouestion I S Note: PZyments of principal and imerest on any Ioan or mvrtgagt may not be shown as an operating expense. Sources of Cash Match_ Bnter the sources of cash identified in the Cash Match col Luna, above, in the foilcti"iug cate.�ones. Use aaatttonat sweets, as necessary. �� -Amount j a- I Grantee/project sponsor cash . !! b. j Local government (please specify) I. c. I State government (please specify) I I ( d I Federal bovernmeat (please specify) - • . I Coninilmity Development Block Grant (CDBG) J e. I Foundalions (please specify) I f. I Private cash resources (please specify) ,. I Oceupaney charse / fees �h. Total 14 form HUD -40118((0&-''_001) SI -T lauids Cash hh- to t Total E ,pendi tures a. � Leasuig It. Supportive Services C. Operatill, Costs d. I-RvIlS Activities e. Administration f Total Note: PZyments of principal and imerest on any Ioan or mvrtgagt may not be shown as an operating expense. Sources of Cash Match_ Bnter the sources of cash identified in the Cash Match col Luna, above, in the foilcti"iug cate.�ones. Use aaatttonat sweets, as necessary. �� -Amount j a- I Grantee/project sponsor cash . !! b. j Local government (please specify) I. c. I State government (please specify) I I ( d I Federal bovernmeat (please specify) - • . I Coninilmity Development Block Grant (CDBG) J e. I Foundalions (please specify) I f. I Private cash resources (please specify) ,. I Oceupaney charse / fees �h. Total 14 form HUD -40118((0&-''_001) i 20. Supportive Housing Pro ran). Acquisition, Rehabilitation, ani) Nell' Construction All arantees dial received SIH' funds for acquisition, rehabilitation, or ne,v constrtution must complete these charts in the year one ApR ortly. flus exhibit will demonstrate to HUD that Uie grantee has contributed enough cash to at least equally match the amount of SHP funds spent for acquisition, rehabilitation, or nes', constriction. Documentation that matching funds %+-ere pro,,,ided is not required to be submitted with this report but should be kept on file for possible inspection by HUD and Auditors. Sumunnn, of Expenditures. Enter Uie amount of SIIP gTmit. funds and cash match expended dwing the operating year for each activity. SI -1P Funds Cush Match � Total Expenditures a. Acquisition b. Rehabilitation C. New construction CL Total Cash MatctL Enter the sources of cash identified in the Cash Match coluran, above, in the following categories. Use additional sheets, as necessary - I i fonn HUD -40118((0812003) Amount a. Grantee/project sponsor cash b. Local government (please specify) c. State govenunent (please specify) d. Federal government (please specify) Co=unityDevelopment Block Grant (CDBG) e. Foundations (please specify) f. Primate cash resources (please specify) g. Occupancy charge/ Cees h.. Total I i fonn HUD -40118((0812003) T, OR H11IIS .4 CTI V7TIES ONLY 21. For Sopnortive Housinfr (SHP) —HKIS Activities This exhibit provides information to HUD on how SHI'-I-DvZS fundlllg for supportive services .vas spent during the operating year. Dater tl)c amount of SI -11' -HMS funding spent on these activities. H111ISActivilles Only vollars Equipment Central Sen er(s) Personal Computers and Printers Networking Subtotal SOft YV are Sof vie / User Licensing Sofmare Installation Support. and Maintenance Supporting Software Tools Subtotal 'Services • . . Training by Third Parties . Hosting % Technical Services Programming: Customization Programming: System Interface Programnu.ng: Data Conversion Security Assessment and Setup' On-line Connectivity (Internet Access) Facilitation Disaster and Recovcry Subtotal Personnel Project Management / Coordination Data Analysis Programnung Tecluucal Assistance and Training Administrative Support Staff Subtotal HMIS Space and Operations Space Costs Operational Costs Total 16 form HUD -401 Describe any problems and/or changes implemented during the operating year. Technical Assistance and Recommendations Based on your eN:perience during the last year, are there any areas in vdl cll you need techudcal aNce or assistance? If so, please describe_ 17 . form HUD -40118((08;2003) Annital Certiftcation of Confinuerl Project Operation Supportive Rousing Program Project Number: Project Name: Operating Start Date: Grantees that received Supportive Housing Program funding for new construction acquisition, or rehabilitation are required to operate their facilities for 20 years. L , certify that the facility that received assistance for acquisition, rehabilitation, or new construction from the Supportive Housing Program has operated as a facility to assist homeless persons from to I also 'cer-tify that the grant.is still serving number of (mo/yr) (mo/yr) persons at (site address) and all the regdir,cnmeuts of the grant agreement are being satisf ed. (Si,gzzature) (Title) *Current Year (Date of Certification) 1 fume HUD-40116((OV20 D3) Persons Serw(I Vilorksheet -HUD Annual Progress Report This workslwet is oplionat and is intended to help you collect u>formation needed to complete the Annual Progress Report; Instructions and Codes foilow, Do not submit this worksheet to .TTIJD, - -- y- -- — - Name Relationship Entry Date Exit Number of Months in Number of 1\[on"Is in New Participant Non -Homeless (SRO Date of Birth Age Gender Date Project (calculate) Project—PaiIicipant (Y 1 N) Only) Sa 12a did not leave (Y /. i !) 3c (calculate) 4 12b IlUD-1o1 IR 19 Persons Served Worksheet (continuecl) Do not submit this uorlcsheet to HUD No. Veterans Chronically Elltnicity Race Special Needs Special Needs Status (Y(N) Homeless (code) (code) (code) (code) 6n (Y.IN 7 8 9a 9b 6b Prior Living lvlonU y I,!, n,o hlonUill' Income Situation Al Project Entr}' Al Project Exit (code) Ila 1Ib 10 Income Sources At Entry (code) llc Income Sources At Exit (code) lid 20 11UD-401 13 Persons Served Worh5beet (continued) Do wit submit this work5licet to HUD 110. Reason fur Lepving Destination Supportive Services- Notes' Program (code) (code) (code) 13 '14 15 21 1iUD-401IS `-1 Instructions and Codes for Persons Served Worksheet The use of this worksheet is optional. It -,vas designed to help you collect information on participants needed to complete the Annual Progress Report. If the workshect is updated as participants mare in and move out of your project, most of the information required for completion A. -ill be contained in the worksheet. Do not submit this worksheet witli the APR. For projccfs that serve families, HUD only requires reporting on the number of children served, and the age and gender of these children. Only name, relationship, date of birth, and ape on the worksheet need to be completed for children. Assign the adults a number, but not each family member_ Use this number to transfer to the other pages of -the worksheet. Beginning with number 4, the numbers in the columns refer to the questions on the APR form. If any questions are answered with "Other," please enter the " specific "Other" answer for inclusion in the APR. . Participnut Number. This column allows you to either number participants consecutively or to assign a case number. One num_ ber should be assigned to each adult. Name. Names of persons will not be reported to HUD. The use of names is for.your record keeping .convenience. Relationship. Enter the appropriate relationship: Examples include: Self, Head of household, Spouse, Child. Entry Date. Enter date participant entered the ro"ect. Usually this will be the date of actual physical move -in for a Housing project. Exit Date. Enter date participant left the protect. Usually this will be the date the participant pHysically moved out for a housing project. Do not include a participant who temporarily left the proicct and is expected to return in less than 90 days (e.g_ hospitalization). Income -eligible Non -boneless in SRO. The SRO program allows assistance to units occupied by Section 8 income -eligible persons residing at the SRO prior to rehabilitation. For SRO projects only, indicate %whether the participant is an income -eligible, non-llonieless person (Y) or not (NI). SHP and S+C projects should skip this item. 5a. Date of Birth. Enter date of birth including morph, day, and year. gib. Ave. Enter agc at entry. 5c. Gender. Entcr appropriate letter for vender. M -Male F- Female. 6a. Veterans Status. Indicate if the participant is a veteran. Please note: A verernu is ancone who Iins ever been on active niililary duty status for the United States. 6b. Chrunically hnnicless person. Indicate the number of participants that are chronically homeless. 7. Ethnicity. Enter appropriate letter for ethnic group. a. Hispanic or Latino b. Non -Hispanic or Non -Latino Race. Enter appropriate letter for race. a. American Indian or Alaskan Native b. Asian c. Black or African-American d. Native IIawaiian or Other Pacific Islander C. White f. American Indian/Alaskan Native & White g. Asian & White h. Black/African American & White i. American Indian/Alaskan Native L, Black/African American i. Other Multi -Racial 9a. Special Needs. Enter the letter(s) for the category(ies).that describe the participant's disability(ies). (You may double count). a. Mental illness b. Alcohol abuse c.. Drug abuse d. HIWAIDS and related diseases e. Developmental disability f. Physical disabilities g Domestic violence h. Other (please specify) 9b_ Enter the number of participants witIi a. disability. 10. Prior Living Situation. Enter the letter that best describes where the participant slept in the week prior to entering the project. Do not double count. a. Non -housing (street, park, car, bus station, etc b. Emergency shelter c. Transitional Housing for homeless persons d. Psychiatric facility" e. Substance abuse treatment facility* f. Hospital* Jail/prison* li. Domestic violence situation i. Living with re la lives/friends j. Rental housing HUD -401 is k. Other (please specify) "If a participant came from an institution but was there less than 30 days and vas living on the street or in an emergency shelter before entering the facility, he/she should be counted in either the street or shelter category, as appropriate. Instruction Codes for Persons Served Worksheet (continued) I la.Gross Monthly Income at Project Entry. Enter the amount of gross monthly income the Participant is receiving at entry into the project. I lb.Gross Monthly Income at Project Exit. Enter the gross monthly income the participant is receiving when exiting the project. I lc -Income Sources Received at Project Entry. Enter all types of assistance the participant is receiving at entry to the project. a. Supplemental Security Incotne (SSI) b. Social Security Disability Insurance (SSRI) c. Social Security d. General Public Assistance e. Temporary Aid Needy Families (TANF) f. State Children's Health Insurance Pro_aTam (SCHIP) g. Veterans benefits h. Employment income i. Unemployment benefits j. Veterans Health Care k- Medicaid I. Food Stamps in. Other (please.specify) n. No Financial Resources lld.Iiacome Sources Received at Project Exit. Enter all types of income the participant is receiving at project exit. (Use codes as in 11 c.) 12a Length in Stay in Program, Calculated item. (See Entry Date and Exit Date above.) 12b. Length of Stay in Program. (Participant did not leave during the operating year. How long have they been in the project?) 13. Reason for Leaving Project- Enter, the primary reason why the participant left the project. (Complete only for participants who left the project and are not expected to return within 90 days. a. Left for a housing opportunity before completing the program b. Completed program c- Non-payment of rent/occupancy charge d. Non-compliance with project e. Criminal activity/destruction of property/ violence f. Reached maximum time allowed in project g. Needs could not be met by project h. Disagreement -vith rules/persons i. Death j, Other (please specify) k. Unkno-wii/disappeare d 14. Destination. Enter the destination of those leaving the project. Permanent: a. Rental house or apartment (no subsidy) b. Public Housing e. Section 8 . d. Shelter Plus Care e. HOME subsidized house or apartment f. Other subsidized house or apartment g. Homeownership h. Moved in with family or friends Transitional: i. Transitional housing for homeless persons J. Moved in with family .or friends Institution: k. Psychiatric hospital. 1. Inpatient alcohol or drug treatment facility M_ Jail/prison Emergency: n. .Emergency shelter Other: o. Other supportive housing. p. Places not meant for,hurnan habitation (e.g_, street) q. Other (please specify) Unknow: r. Unknown 15. Supportive Services. Enter all types of supportive services the participant received during the tune in the project. a. Outreach b. Case management c. Life skills (outside of case management) d. Alcohol or drug abuse services e. Mental health services -f. HIV/AIDS-related services g. Other health care services h. Education i. Housing placement j. Employment assistance k. Child care I Transportation m Legal n. Other (please specify) 23 HUD -401 IF Home I CllentPoint ( Resource Point HUD Annual Progress Report (HUD -40118) Miami Da , Homeless Trust Jun 14, 2006 Miami -Dade County Government; ShelterPofnt I SkanPoint I )Reports I Admin I Help I Loo -off ATTACHMENT G Report Options: Select- Unduplicated F,' rovider lizml-Dade County Government (41) 11,5rq; perating Year Date Range 05/01/2006 to 05/31/2006 (mm/dd/yyyy) =gal Adult Age 18 (as defined by foster care law in your state) Or 2. Persons Served during the Number of Singles Number of Adults Number of Children in Number of D perating year. Not in Famines in.Families Families Families a. Number on the First day of the C D 0 0 operating year. b. Numberentering program during the 0 0 0 operating year. 0 c. Number who left the program during . 0 D 0 the operating year. p 11d. Number In.the program on the last day 0 0 0 of the operating year. (a+b-c=d) 0 Number of Singles 3. Project Capacity. Number of Adults Number of Children in Number of Not in Families in Families Families Families a. Number on last day (from 2d, columns 1 and 4) 0 D 4. Non -homeless persons. (Sec. s SRO projects only) . How many Income -eligible non -homeless persons were housed by the SRO program during the operating year? 0 S. Age and gender. Age Male Female Other/Nbt given Single Persons (from 2b, column -1) Ia. 62 and over 0 0 0 51 - 61 0 0 p Ib. c. 31 - 50 0 0 0 d. 18 - 30 0 0 0 e. i7 and.under 0 0 I 0 Not given 0 0 0 Persons in Families (from 2b, columns 2 & 3) f. 62 and over 0 0 p g. 51 - 61 0 0 0 h. 31 - 50 C 0 0 I,rt+- C.H....... - + / : : / tom/ .mon rfhii.� —Inn iii A/ 0AIr, d. Native Hawaiian or Other Pacific Islander i. ]8-3D I 0 0 0 I 0 g. Asian & White j. 13-17 0 0 0 '0 d. HIV/AIDS or related diseases k.6-12 0 0 I 0 0 0 0 0 0 0 6a. Veterans Status. m. Under 1 NotgivenD 0 0 0 0 0 0 A veteran Is anyone who has ever been on active military duty status. •0 Howmany of the participants are disabled? 10. Prior Living Situation. 0 61J. Chronically Homeless. How many participants were chronically homeless individuals? All Chronic 0 7. Ethnicity. 0 0 b. Emergency shelter 0 Ia. Hispanic or Latino Fb. Non -Hispanic or Non -Latino c. Transitional housing for homeless persons 0 D 0 8. Race. 0 e. Substance abuse treatment facility ( 0 a. American Indian or Alaskan Native f. Hospital 0 0 b. Asian 0 h. Domestic violence sltuation 4100) 0 Rlarir nr Gfriran Lmcrlran i. Living with relatives/friends 0 d. Native Hawaiian or Other Pacific Islander 0 e. White 0 f. American Indian/Alaskan Native & White I 0 g. Asian & White 0 h. Black/African American & White 0 L Indlan/Alaskan dative & Black/African American r MUltl-Racial k. Other/Unknown (all that do not match) 9a. Special Needs. j. Rental housing All 0 Chq:onic a. Mental Illness 0 0 b. Alcohol abuse c. Drug abuse 0 0. '0 d. HIV/AIDS or related diseases 0 i0 e. Developmental disability 0 0 f. Physical disabfifty 1 0 0 g. Domestic violence 0 '0 h. Other (please specify) 9b. Disabled. 0 •0 Howmany of the participants are disabled? 10. Prior Living Situation. 0 All Chronic a. Non -housing (street; park, car, bus station, etc.) 0 0 b. Emergency shelter 0 0 c. Transitional housing for homeless persons 0 d. Psychlatrc-faclllty 0 e. Substance abuse treatment facility ( 0 f. Hospital 0 g. Jail/prlson 0 h. Domestic violence sltuation 0 i. Living with relatives/friends 0 j. Rental housing 0 r,hn t5/14/=100 6' k. Dther (please Specify) All -Chronic a. Less than 1 month c 11, Amount and Source of Monthly Income at Entry and Exit. b. 1 to..2 months 0 0 Amount a A. Monthly Income at Entry B. Monthly Income at Exit d. 7 months - 12 months All Chronic All Chronic a. No Income 0 0 I 0 I 0 b. $1-150 0 0 0 0 c. $151 - $250 0 0 0 0 d. $251 - $500 0 0 0 + 0 e. $501 - $1000 0 0 I 0 0 f. $1001 - $1-500 0 0 0 0 g. $1501 - $2000. 0 0 0 0 h. $2000 + 0 0 0 0 Source C. Income Sources at Entry D. Income Sources at Exit All Chronic All Chronic a. Supplemental Security Income (SSI) 0 0 0 0 b. Social Security Disability Insurance (SSDI) 0 0 0 0 c. Social Security 0 0 0 p d. General Public Assistance 0 0 0 p e. Temporary Aid to Needy Families (TANF) 0 0 0 p f. State Children's Health Insurance Program (SCHIP) 0 0 0 p g. Veterans beneflts 0 0 0 0 oyment Income 0 0 0 0 ployment Benefits 0 0 0 p n's Health Care I D D 0 p aid 0 0 0 p tamps jNoflnanclal D 0 0 0 r (please specify) 0 0 0 0 ancial resources 0 0 0 0 gth of Stay in Program. (Participants who left during operating year) All -Chronic a. Less than 1 month 0 0 b. 1 to..2 months 0 0 c. 3 - 6 months 0 0 d. 7 months - 12 months D p e. 13 months - 24 months 0 p f.•25 months - 3 years p p g. 4 years - 5 years 0 0 h. 6 years - 7 years 0 0 i. 6 years - 10 years 0 0 j. over 10 years 0 0 12b. Length of Stay in Program. (Pa r-ticipants who did not leave during operating year) All Chronic a. Less than 1 month 0 0 b. 1 to 2 months 0 0 c. 3 - 6 months 0 0 d. 7 months - 12 months 0 0 e. 13 months - 24 months p I p f. 25 months - 3 years 0 0 g. 4 years - 5 years 0 0 h. 6 years - 7 years 0 0 D 0 i. B years 10 years D 0 c. Section 8 j. over 10 years 0 0 13. Reasons for Leaving. 0 D 0 All Chronic a. Left for a housing opportunity before completing program I 0 0 b. Completed program 0 0 c. Non-payment of rent/occupancy charge 0 0 d. Non-compliance with project 0 0 e. Criminal activity / destruction of property / violence 0 0 f. Reached maximum time allowed In project 0 g. Needs could not be met by project 0 h. Disagreement with rules/persons In. Emergency shelter i. Death OTHER (o - q) o. Other supportive housing j. Other (please specify) 0 4AUChoronic k. Unknown/disappeared14. 0 0 Destination. q. Other (please specify) Ir. 0 0 JNKNOWN L5. Supportive Services. Unknown PERMANENT (a - h) a. Rental house or apartment (no subsidy) b. Public Housing D 0 0 0 c. Section 8 0 jo 0 d. Shelter Plus Care e. HOME subsidized house or apartment 0 D 0 If. Other subsidized house or apartment g. Homeownersh-Ip h. Moyed in with family or friends 0 0 0 0 0 p TRANSITIONAL (1 - j) i. Transitional housing for homeless persons 0 0 j. Moved -in with famlly or friends 0 0 INSTITUTION (k - m) 7k. Psychiatrlc hospital - 0 0 1. Inpatient alcohol/drug treatment facility 0 0 m. Jall/prison 0 0 EMERGENCY SHELTER (n) In. Emergency shelter 0 0 OTHER (o - q) o. Other supportive housing 0 0 p. Places not meant for human habitation (e.g. street) 0 0 q. Other (please specify) Ir. 0 0 JNKNOWN L5. Supportive Services. Unknown 0 0 No supportive services found. ServicePoint version 4.01.018 (db b.uild #0723) Licensed to: Miami Dade Homeless Trust © 1999-2006 Bowman Systems L.L.C. All Rights Reserved. CPT only X)200;' Amtrlcan Medical A-sodatlon. All Right:S Reserved. DSta and 051,1 -W -TR ere reoist=_red trademarks of me Amcrican Psyrhiatrtc Association, and are used wlth permis51an herein. 1CD-9-CM, CD1994 National Center for Health StalistiCS (ICD-9 , World Health Organiz.ation). All Rights R=_se,-ved. "re>:onemy Cr.)] 283-2003 Information and Referrat Federation of Los Angeles County, inc. All Righs Reserved. Form VV -zV - Request for Taxpayer / Give form to the (Rev. January 20°3)_antification Number and Certific�_�on requester. °o not 6epartmem a the Treasuy - send to the IRS. Imernal Revenue Service n Name N m m a Business name, it different from above c D N o Individual/ Check ❑ Sole El ❑ Par Exem t from backup U appropr ate oox: proprietor Corporation nership Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _TO. ithhoding 02 c N Address (number, street, and apt. or suite no.) Requester's name and address (optional) c a u City, state, and ZIP code U Qf d d List account number(s) here (optional) d Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). social security number However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIHJ. If you do not have a number, see How to get a TiN on page 3. or Note: !f the account is in more Ulan one name, see the chart on page 4 for guidelines on whose number Employer identification rrmtber to enter. Certification Under penalties of perjury, I certify that 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Intemal Revenue Service (iRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that 1 am no longer subject to backup withholding, and 3. 1 am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been noted by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt contributions to an individual retirement arrangement (iRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. (See the instructions on page 4.) Sign Sigvaitcre of Here I Us. person, ► elate IN - Purpose Purpose of Form A person who is required to file an information return with the IRS, must obtain your correct taxpayer identification number (TiN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IPA U.S. person. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. Note: If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. Foreign person. If you are a foreign person, use the appropriate Form W-8 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties coniain a provision known as a "saving clause." Exceptions specified in the saving Cause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement that specifies the following five items 1. The treaty country. Generally, this must be the same treaty under which you daimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Cat. No. 10231X Form W-9 (Rev. 1-2003) Example. Article 20 of the U.S.-Cf 'ncome tax treaty allows an exemption from tax for sc..,arship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completed Form W-8. What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 30% of such payments (29% after December 31, 2003; 28% after December 31, 2005). This is called "backup withholding.'" Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, or 2- You do not certify your TiN when required (see the Part II instructions on page 4 for details), or 3. The iRS tells the requester that you furnished an incorrect TIN, or 4- The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Instructions for the Requester of Form W-9. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 _penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment Misuse of nNs. If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties. Specific Ins(` ctions Name If you are an individual, you must generally enter the name shown on your social security card. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name. If the account is injoint names, list first, and then circle, the name of the person or entity whose number you entered in Part i of the form. Sole proprietor. Enter your individual name as shown on your social security card on the "Name" line. You may enter your business, trade, or "doing business as (DBA)" name on the "Business name" line. Limited liability company (LLC). If you are a single -member LLC Including a foreign LLC with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section 301.7701-3, enter the owner's name on the "Name" line. Enter the LLC's name on the "Business name" line. Other entities. Enter your business name as shown on required Federal tax documents on the "Name" line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the "Business name" line. Note: You are requested to check the appropriate box for your status Crndividual/sole proprietor, corporation, etc.). Exempt From Backup Withholding If you are exempt, enter your name as described above and .check the appropriate box for your status, then check the "Exempt from backup withholding" box in the line following the business name, sign and date the form. . Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. Note: if you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. Exempt payees. Backup withholding is not required on any payments made to the following payees: 1. An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(0(2); 2. The United States or any of its agencies or instrumentalities; . 3. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentafities; 4. A foreign government or any of its political subdivisions, agencies, or instrumentalities; or 5. An international organization or any of its agencies or instrumentalities. Other payees that may be exempt from backup withholding include: 6. A corporation; 7. A foreign central bank of issue, S. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States; 9. A futures commission merchani-i gistered with the Commodity Futures Trading Commission; 10. A real estate investment trust; 11. An entity registered at all times during the tax year under the investment Company Act of 1940; 12. A Common .trust fund operated by a bank under section 584(a); 13. A financial institution; 14. A middleman known in the investment community as a nominee or custodian; or 15. A trust exempt from tax under section 664 or described in section 4947. The chart below shows types of payments that may be exempt from backup withholding. The chart applies to the exempt recipients listed above, 1 through 15. If the payment is for ... THEN the payment is exempt for... Interest and dividend payments All exempt recipients except for 9 Broker transactions Exempt recipients 1 through 13. Also, a person registered under the Investment Advisers Act of 1940 who regulatfy acts as a broker Barter exchange transactions Exempt recipients 1 through 5 and patronage dividends Payments over 5600 required Generally, exempt recipients to be repc%ed and dui i through 1 2 sales over $5,000' 'See Form 1099-MtSC, Miscellaneous Income, and its instructions. ZHowever, the following payments made to a corporation (including gross proceeds paid to an attorney under section 6045(1), even if the attorney is a corporation) and reportable on form 1099-MISC are not exempt from backup withholding: medical and health rare payments, attorneys' fees; and payments for services paid by a Federal executive agency. Part I. Taxpaye, dentification Number (TIN) Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter a in the social security number box. If you do not have an ITIN, see How to get a TIN below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN. If you are a single -owner LLC that is disregarded as an entity separate from its owner (see Limited liability company (LLC) on page 2), enter your SSN (or EIN, if you have one). If. the LLC is a corporation, partnership, etc., enter the entity's EIN. Note: See the chart on page 4 for further clarification of name and TIN combinations. How to get a TIN. If you do not have a.TIN, apply for one immediately. To apply for an SSN, get Form SS -5, Application for a Social Security Card, from your local .Social Security Administration office or get this form on-line at wwwssa.gov/online/ss5.html. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for iRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS -4, Application for Employer Identification Number, to apply for an EIN. You can get Forms W-7 and SS -4 from the IRS by calling 1 -800 -TAX -FORM (1-800-829-3676) or from the IRS Web Site at www.irs.gov. if you are asked to complete Form W-9 but do not have a TIN, write "Applied For" in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60 -day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. Note: Writing "Appried For" means that you have already applied for a T7N or that you intend to apply for one soon. Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8. Part IL Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 3, and 5 below indicate otherwise. For a joint account, only the person whose TIN is shown in Part I should sign (when required). Exempt recipients, see Exempt from backup withholding on page 2. Signature requirements. Complete the certification as indicated in 1 through 5 below. 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1963 and broker accounts considered inactive during 1993. You must sign the certification or, backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification_ You may cross out item 2 of the certification. 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (nduding payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations). 5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA or Archer MSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. What Name aC plumber To Give the Requester For this Vpe of accord: Give name and SSN of: 1. Individual The individual 2. Two or more individuals point The actual owner of the account account) or, if combined funds, the First individual on the account ' 3. Custodian account of a minor The minor z (Uniform Gift to Minors Act) 4. a. The usual revocable The grantor -trustee' savings trust (grantor is also trustee) b_ So-called trust account The actual owner' that is not a legal or valid trust under state law 5. Sole proprietorship or The owner' sin le -owner LLC For this type of account Give name and EIN of 6. Sole proprietorship or The owner' single -owner LLC 7. A valid trust, estate, or Legal entity ' pension trust a. Corporate or LLC electing The corporation corporate status on Form 8832 9. Association, club, religious, The organization charitable, educational, or other tax-exempt organization 10. Partnership or mutti-member The partnership LLC 11. A broker or registered The broker or nominee nominee 12. Account with the Department The public entity of Agriculture in the name of a public entity (such as a state or local government, school district, or Prison) that receives agricultural program payments ' List First and circle the name of the person whose number you fumish. If only one person on a joint account has an SSN, that person's number must be furnished. 'Circle the minors name and furnish the minor's SSN. 3You mast show your individual name, but you may also enteryour business or "DBA' name. You may use either your SSN or E1N (f you have one). ' List first and circle the name of the legal trust, estate, or pension trust IDo not furnish the 11N of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Note: If no name is circled when more than one name is listed, the number wN be considered to be that of the first name fisted. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA or Archer MSA_ The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, or to Federal and state agencies to enforce Federal nontax criminal laws and to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply. LJ 1.—>�� i ._� f ILA? TI- DAD E C0t�TY H0' TE LESS TRUtiT CD' iNT p EQI 1T rJ iJ`' 1 i 1 ne contracting indi\'idual or er,tin- or o he,-.;'ise) shall indicate b"; anit:, that perL3ln to Luis conII"act and Shall Indlc:Le by an ? /A" all srfid.,vIts thai do not pe,ialn to ti:ls ^omr z)', �.II blank- spaces must bt filled. The -DADE COUNTY 0V,WE, ..SHIP DISCLOSUR-E 6LFFID.a.VIT; I,11.1Ai]-D..:�.DE COLT Ty EMPLOYI\TENT DISCLOSURE AFFIDA "IT, 1vfI.AMl-DADE_ C PJ N11INAL PrCDF'T-) AFFID.='VIT; DISABILITY NONDISCRII\FiINATION AFFIDAVIT; and the PROJECT FLESH START .'JFJDAVlT shall not pertain to contracts v,'ith the United Stales or any of its departments or agencies th.reof, the State or am, political subdivision or agency thereof or any municipality of this State. The lVilAl,dl-DADE FAA'IILY LEAVE AFFIDAVIT shall not pertain to contracts with the United Shies or any of its deparimenis or agencies or the State of Florida or any political subdivision or agency thereof it shall, how-e\,er, pertain to Municipalities of the State of Florida. All other contracting entities or individuals shall read carefully each affidavit to determine whether or not it pertvins to this contract. being first duly sworn state: Affiant The full Iegal name and business address of the person(s) or entity! contracting or transacting business with hMiami-Dade County are (Post Oii-ice addresses are not acceptable): Federal Employer Identi kation Number (Ifnone, Social Security). Name ofEntity, indrvfdual(s), PaTrers, or Corporation Ing Business As (if same as above, leave blank)- . Street Address City State Zip Code `I. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2-8.1 of the County Code) 1. If the contract or business transaction is with a corporation, the full legal name and business address shall be provided for each officer and director and each stockholder who holds directly or indirectly five percent (5%) or more of the corporation's stock. If the contract or business transaction is with a partnership, the foregoing information shall be provided for each partner. If the contract or business transaction is with a trust, the full legal name and address shall be provided for each trustee and each beneficiary. The foregoing requirements shall not pertain to contracts with publicly traded corporations or to contracts with the United States or any department or agency thereof, the State or any political subdivision oir agency thereof or any municipality of this State. All such names and addresses are (Post Office addresses are not acceptable): 1 of 5 Full Le:!,( m= Address rship, The full legal names and business address of any other individual (oiher than subcontractors, ma!erial men, suppliers, laborer, or lenders) who have, or will hag any interest (legal, equitable beneficial or otherwise) in the contract or business transaction with Dade County are (Post O; ice addresses are not acceplable): Any person, who willfully fails to disclose the information required herein, or who l:no��,Irngly discloses false information in this regard, shall be punished b), a fine of up to five hundred dol lass (.1500.00) or imprisonment in the Countyjail for up to sixty (60) days or both. —11. MI?2Vff-DADE COUN TY EMP LOY-N ENT DISCLOSURE AFFIDAVIT (Co unry Ordinance No. 90- 133, Amending sec. 2.8-1; Subsection (d)(2) of the County Code)_ Except where .precluded by federal or State laws or regulations, each contract or business transaction or renew, a] thereof which involves the expenditure of ten thousand dollars (S] 0,000) or more shall require the entity contacting or transacting business to disclose the following information. The foregoing disclosure requirements do not apply to contracts 'with the United States or any dep �L ent or agency thereof, the State or any political subdivision or agency thereof or any municipality of this State. 1. Does your firm have a collective bargaining agreement with its employees? Yes No =r- Does your firm provide paid health care benefits for its employees? Yes No 3• Provide a current breakdown (number ofpersons) of your firm's work force and ownership as to race, national origin and bender: White: Males Females Asian: Males Females Black: Males Females American Indian: Males Females Hispanics: Males Females Aleut (Eskimo): Males Females — Males Females: Males . es: 'Females _III. AFFIRMATIVE ACTION/NONDISCRINfINATION OF ENIFLO)`MENT, PROMOTION AND PROCUREMENT PRACTICES (County Ordinance 98-30 codified at 2-8-1.5 of the County Code.) In accordance with County Ordina-rice No. 98-30, entities with arnnua) gross re\,enues in excess of 55,000,000 seeking to contract with the Coun=ty shall, as a condition of receiving a County contract have: i) a ,vr1Eten affFr native action plan -which- sets forth the procedures the entity utilizes to assure that it does not discriminate in its employment and promotion practices; and ii) a WT1.t-ien procurement Policy - which sets forth the procedures the entity -utilizes to assure that it does not discriminate aeainst minority and women-ommed businesses in its o ,m procurement of goods supplies and se rices. Such a irmati�ve, action plans and procurement policies shall provide for periodic re`-iew to determine their ef;ectiveness in assuring tete entit; does not discriminate in its emplo��nenr promotion and Procurement practices- The foregoing not~ ithstanding, corporate entities whose boards of din ectors are recres_nLvive GI _OpL11atIOn ,mal:e-UD Oi the nation s„all oresumad to )have non dlsii lmE,'3i^r "TIDIo..ment and p)gcurernen[ pollcles, anv shall not L,e r:::;L_ _� IV nal': XV lit`,) 2[1\'C ° , pint= end prOCllit-Me . r'DIIJ)cS in C16-fT ID tocol, = a,Cour �CfrT2 f. Tne 10r _p!nc De r'-DuileL-�. 1-171 ieGUUr Mt�nit of CDun7' Or01i ance 7v'o. 4,1,-30 m3T G' ','_f`red U Cin th_` „Jaen TCOf' en7]ilG G; the Counn, Manager that it is in theb_si intens: of the Count. to do s o and upon appro, al n; the �oarc Cf CounrV t-Dmmi aloners by majority `.•oto ofthe members present. The firm does not have annual 1_ro55 revenues ;n excess of SS;OD0,000. The turn does have annual revenues in C>:CtSs of y5,000,000; h0 -,Ver, its Board of Directors !- representative of the popularion make-up of the nation and has submitted a v,7111,,n_ detailed lisunr, ofits Board of Directors, including the race or ethnicin, of each board member, to the County's Department of Business Development, 175 1`r.«lst Avenue, 2Sih Floor, Aliami. Florida 33128. The firm has annual gross revenues in excess of $5,000,000 and the firm does have a wriren aff—inrlative action plan and procurement policy as described above, which includes periodic reviews to deiermine. effectiveness, and has submitted the plan and police to the County's Department of Business Development 175 N.W. 1 st Avenue, 28th Floor, Miami, Florida 33 12 8; I ne firm does not have an affirmative action plan and/or a procurement policy as described above, but has been granted a waiver. 1V. 2`CAND-DADE COUNTY CIZIAIINAL RECORD AFFIDAVIT (Section 2-8.6 of the County Code) The individual or entity entering into a contract or receiving funding from the County itas has not as of the date ofthis affridavit been convicted.of a felony during the past ten (10) years. An of%cer, director, or executive of the entity entering into a contract or receiving funding from the County has has not as of the date of this affidavit been convicted of a felony during the past ten (10) years. _V. MIAMI-DADE ENLPLOYMENT DRUG-FREE ` 'ORIS°LACE AFFIDAVIT (County Ordinance No. 92-15 codified as Section 2-$.1? of the County Code) That in compliance with Ordinance No: 92-15 of the Code of Miami -Dade County, Florida, the above named person or entity is providing a drug-free workplace. A written statement to each employee shall infor—in the employee about: - I. danger of drug abuse in the workplace 21 the firm's policy of maintaining a drug-free environment at all workplaces 3. availabilitj, of drug counseling, rehabilitation and employee assistance programs 4. penalties that may be imposed upon employees for drug abuse violations The person or entity shall also require an employee to sign a statement, as a condition of employrricnt that the employee will abide by the terns and notify the employer of any criminal drug conviction occurring no later than Give (S) days after receiving notice of such conviction and impose appropriate personnel action against the employee up to and including termination. Compliance v-ith Ordinance No. 92-15 may be waived if the special characteristics of the product or service offered by the person or entity make it necessary for the operation of the County or for the health, safety, welfare, economic benefits and well-being of the public. Contracts involving funding ~Which is provided -in whole or -in paL by the United States or the State of Florida shall be exempted from the provisions of this o,-dinance in those instances v;here those provisions are in conflict with requirements of those zo\,ernmental entities. A IrDA\rlT (Counp )rcinSTI c_ r;_� as Section l seq or" That In cornpllance 1,,•1in Drdin3nct Nio. 1= 91 0' Tile rod: .of i.11ar111-D30. t Courip'','. i iCr 103, 1;i emplOVer v"Itn Ili1' (.50) Or more emplo.•'oos 11.'0r:Ina In :)Ude CDU 7P-,' 10T earn Ll'Or i;inE d3 dUfl ^ each of 11 enrt' (�0) or more calendar xorl: v, tela, shall pru, id: the folio.', in infor;,ation in compliance; win all items in the aforementioned ordina ce: An employee vho has �vorl:ed i -or the above firm at least one (1) gear shall be entitled to ninon {9D) days offamik, leave during any ra.enT>-four (24) month period, for medical reasons, for t}1e cir h or adoption of a child, or for the care of a child, spouse or other close relative who has a serious health condition without risk of termination of emplo},mentor employer retaliation. The foregoing requirements shall not pertain to contracts %with the United States or ant' department or agency thereof, or the Slate of Florida or any political subdil ision or agency thereof. It shall, however, pertain to municipalities of this State. . DISApILI1 Y NON-DISCIZll\ENATI0?a AFFIDAVIT (County Resolution R-385-95) That the above named neem, corporation or organization is in compliance with and agrees to continue TO comply with, and assure that any subcontractor, or third party contractor under this project complies with all applicable requirements of the laws listed below including, but not limited to, those provisions pertaining to employment, provision of programs and services, transportation, communications, access to facilities,. renovations, and new construction in the fo]jo%ying la%�,S: The Americans With Disabilities Act of 1990 (ADA), Pub- L. 101-336, 104 Stat 327, 42 U.S.C. 12101-I2213 and 47 U.S.C. Sections 225 and 6.11 including Title I, Employment; Title II, public Services; Title III, Public Accommodations and Services Operated by Private Entities; Title IV, T elecommunications; and Title V, Miscellaneous Provisions; The Rehabilitation Act of 1973 29 U.S.C. Section 794; The Federal Transit Act, as amended 49 U.S.C. Section 1612); The Fair Housing Act as amended, 42 U.S.C. Section 3601-30531. The foregoing reouiremerts shall not periain to contracts With the United States or any departrnent or agency thereof, the State or any political subdivision or agency thereof or any municipality of this State. _VIII. NEAIVE-DARE COUNTY REGARDING DELINQUENT AND CLiRP EN T LY DUE FEES OR . TAXTS (Sec. 2-8.2(c) of the County Code) Except for small purchase orders and sole source contracts, that above named firm, corporation, organization or ind.ividuaI desiring to.transact business or enter into a contract with the County Verifies that all delinquent and currently due fees or taxes -- including but not limited to real and Property taxes, utility takes and occupational licenses -- «'hich are collected in the normal course by the Dade County Ta -x Collector as well as Dade County issued parking tickets for vehicles registered IT) the name of the fire, corporation, organization or individual have been paid- ____IX- CURRENT ON ALL COUNTY CONTRACTS, LOANS AND OTHER OBLIGATIONS The individual entity seeking to transact business with the County is current in all its obligations to the County and is not otherwise in default of any contract, promissor-v note or other loan document With the County or any of its agencies or instrumentalities. _X. PROJECT FRESH ST,4RT (Resolutions R -702-9S and 358-99) -any firTn that has a contract with the County that results in acival payment of S500 000 or more shall con—L, ibute to Project Fresh Start, the County's Welfare to 'Work Initiative. Ho�ever if five percent (5%0) of the firm; wort: force consists of individuals who reside in Miami -Dade Country and �tino h2vf! lost or v.ill lest cash assistance benefits (forrrlerk Aid to Families with Dependent Children) as a result of the Personal Responsibiliry and ork Opportunity Reconciliation ,pct of 19G6, the finin ma}' reouest waiver horn tl-, e r?quirements of R -702-9S and R-358-99 by submitting a v,.aiver reouest ai?td;rit: Tn jregoinv .eeuiremt-m does nor pe; min TO coy er�,ment - or2z^i2 r _ enr,ti� , rc. ;or pro;-,,: ��rionS Dr re-tp this of _'ran, aa� -a:--is. YT 'DOJO JE,- C VJ0; ENCE LEAVE (Resolution lS3-001 9 0- 5 CodinedAT I i x-00 Fr. Sey. or the ?1ia,��i-�,;de CounY Code). The Ij-, cesirin2 to do business ,vith the Counry is in compliance v,°ith Domestic Leave Ordinance, Ordinance 99-�, codified at I 1 A-60 et. seq. of he M amni fade Ccun ty Code, v, h ich requires an emplovtr v.hich has in the regula, course of business flit (30) or more employe; s v, -Di -king in 1�Fiami-Dade County for each workin, day during eachoffn,,enry (20) or mora cu ler dar %%ork weeks in the current or proceeding calendar years, to pro%ride Domestic Violence Leave to its emplo}'ees. I have carefully read this entire five (a) pare document entitled, "M;ami-Dade Counry .zifiidavits" and hate indicated by an all affidavits that pertain to this contract and have indicated by an "N/A" all affidavits that do not pertain ro this contract. Ey: (S i anarure -of Affiant) SUBSCRIBED .PND SWORN TO (or affirmed) before me this ?00 by }mown to me or has presented (Type of Identification) (Sigfiature of Notary) (Print or Stamp of Notary) Notary Public — Stamp State of _ (S tate) (Date) Jay of He/She is personal l_y as identification. (Serial lumber) (Expiration Date) Notary Seal v - 1 a• I L_ I Y 1 I x _ �rIDAVI T O.F 1111A)1I-DA-DE C�Ti�7Y LOB_ _ IST REGISTRATION FGR OF -.SE'\ T -ATI ON (I) Projectiitl:• O FirmProposer's Name: _ Add, Css: Pusir.ess , eltphone: (d) List All i,4embers of the Presentation Team Who Will Be Pariicipating in t c Oral Presentation: tdd ",fE TiTLE i EEL N0. (ATTACH ADDITIONAL SHEET IF NECESSA_M The individuals named above are Registered and the Registration Fee is not required for the Oral Presentation ONLY. Proposers are advised that any individual substituted for or added to the presentation tears a; er submirtal of the proposal and filling by stars 14UST resister v ith the Glerk of the Board and pay all applicable fees. Other than forthe oral presentation, Proposers who wish to -address the count) commission, a counryboard or county corrimittee conceming any action, decision or recommendation of county UST personnel regarding this solicitation M register n•ith the Clerk of the Board (Form BCCFOP2,,UD0C) and pay all applicable fees. . I do solemnly swear that all the foregoing facts are true and correct and 1 have read or am familiar with the provisions of Section 2-I 1.I(s) of the Code of Metropolitan Dade County as amended. Signature of Authorized Representative; Title: STATE OF COUNTY OF The foregoing instrument was acknowledged before me this by a (Individual, OiTtcer, Partner or Agent) to me or who has produced Signature of person taking aclmmvledgement) (?Jame of.ackno,vledger ty-ped, printed or stamped) (Title or Rank) (Serial Number, if any) A-2 - rev. vvho is personally known (Sole Proprietor, Corporation or Partnership) . as identification and who did/did not take an oath. Name of Organization. 4,ddress: 'P,EnUIP.ED LISTIINC OF SUBCONTRACTORS O -N CC)UNTY CONTRACT In compliance with Miarni-Dade Counry Ordinance 97-104, the Commur,itj' Lased C>rna_njzatior, must submit the list of first tier subcontractors or sub -consultants \,,,ho will perform any part of the Scope of Servicts 'Work, if this .4greemernt is for Sl 00;000 or more. The Community Based Organization must complete this irfoTmation. If the Cornmur7iry Based Organization will not utilize subcontractors, then the Community Based Organization must state, "No Suboontraetors will be used", do not state "N/A". Name of Subcontractor or Sub -Consultant Address Cite and State REQUIRED LIST OF SUPPLIERS ON COUNTY CONTRACT In compliance with Mlami-Dade County Ordinance 97-104, the Community Based Organi%ation must attach a list of suppliers uvho will supply materials for the Scope of Services to the Community Based Organization, if this Contract Agreement is $100,000 or more_ The Community Based Organization must fill out this information. If the Community Based Organization will not use suppliers, the Community Based Organization must state, "No suppliers wiI] be used", do not state Name of Subcontractor or Sub -Consultant Address City and State I hereby cerfif & fliaf the foregouzg information is true, correct and complete: Signature of Authorized RepresentatiNle: Title: Firm hT2me: _Address: Telephone: Fax: E-IN•1ail: Fed. ID No.: City/State/Zip: ate: c ,-ounty. Florida SUBCONTRIICTORISUPPLIEk LISTING 3 (01-dilaalice 97-104) lrirnt Mime of Prince Contractorfrr-uposer RI, P (`tante RFP Number supplies, materials of sen'ices, including pro fessional.sefvices which involve expenditures of $100,000 or more, and all bidders and proposers on County or Public I )ealllt '1 construction contracts hshich involve expendilttres,of $100,000 or more. This 1701-111, or a comparable listing meeting the requirements or Ordinance No. '17-In•t ,mist completed and submitted everi tliougb the bidder or pro Poser will riot utilize subconlractor5 or suppliers on the contract. The ItiddCt- or- prupr uscshould word "NONE" rider the npproprinte heading of Form A-7.1 in those instances where no subconlruCtorS or suppliers is -ill be used on Ilse contract. i% biddcr or,..apr Who is awarded the contract shall not change or substitute first tier subcontractors or direct suppliers -or, clic portions of the contact work to be performed or materials w sltpplicd from those identibed except upon written a rowel oClhe cuutlty'it. 1111sluess NAl1le ant) Address of Mrst Tier Priuvip-hh Omiet' Scope of Work to be L'crformed bT (Principal (liner; StlhCt)lltract0i/S1YbCOnSllll'allt Subconlrflclor/5ubcunsultnnt (;cnrICr liaCc `t ISusiness Name and Address Of Direct Supplier Pt"i11Clt)tll 0\5'17 C1'SuPplies(hlaterials/Services to be 0,611611AOn ncr) Provided by Supplier (; RNST.ATEiNIE.NTPLrF5LtANTT05ECT1�!-'-- FLORIDA STATUTES. O,ti PUBLIC ENTITY CRI. -MES THIS r CR -M 1,1UST EE SIGs'• ED .zND S1 -VOP -N TC) lid THE PI' f-SENC r OP NOT,'—R)l PUBLIC OR. OT HER OFFICI?.L -.UTH)Rj7ED TO �.0:T,JL' ISTFF; OATHS. 1. This sworn statement is submined to Aliami-Dade Countr•: by for (print individual's name and title) (print name of entity submitting sworn statement) whose business address is and (if applicable) its Federal Employer Identification Number (FEIN) is (ifthe entity has no FEIN, include the Social Security Number of the individual si_n•ing this sworn statement:) ` 2. I understand that a "public entity crime" as defined in Paragraph 207.133(1)(g), Florida Statutes means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state of the United States, includin*a, but not limited to, any bid or. contract fo,- goods or services to be provided to any public entity or an agency or political subdivision of any other state of the United States -and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, ormaterial misrepresentation. I undersfand that "convicted" or "conviction" as defined in Paragraph 257.133(I)(b) Florida Statutes. means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1959, as a result ofa jury verdict, non jury trial, or entry of plea ofguilty or nolo contendere. 4_ - 1 understand that an "affiliate" as defined in Paragraph 287.133(])(a) Florida Statutes, means: a. A predecessor or successor of a person convicted ofa public entity crime; or, b. An entity under the control of any natural person who is active in the management of the entit, and who has been convicted of a public entity crime. The term "affiliate: includes those officers, directors,, executives, partners shareholders, employees, members, and agents who are active in the management of. an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or pooling of equipment or income among persons when not for fair market value unde,- an arms length agreernent, shall be a prima facie case that one person controls another person. A person who kno�ryingly enters into a joint venture with a person who has been convicted ofa pubic entity crime in Florida during the preceding 36 months shall be considered an affiliate. I understand that a "person" as defined in Parazraph 287.1 3(1)(e), Florida Statutes. means any natural person or entity oreaniZed under the lays of any state or o. the United States v.ith the le«al pov;er to enter into a bindins contract and which bids or applies to bid or,, contracts for th pror°ision o>.n000s or sen ices let by a public entire, or which otherwise transacts or applies to trnsact business with a public entire. The to t char_holders, m "p_r.,on" inclsdes hose ofUcers, dir_�tors, _xec!�t!r�e;, partners, o employees, m=mbers. and a_ents ,,ho are active in,-nanacenent of an entin E. D.Ts eC on Ir. ia:!Dr, Ln ll;fri ,t S.1`?.. e I !, '•'rilC i G_, tio , niari:ed t '• 1$ t-uf !ri rt):2 ciri iD ir,e er;[1! ✓ m 1: n. !n° C"Ii5 ;„'Orn siale+menI. (f lease Ind!:c!t ',h!cn st2le:?)`nI appl!es), Ntithcr the emir,, submi'mna [his sv-,oiil s[a tmeAt, nor any of ICS of"tictrs, d;ffC(Ors. e::eculives, partners, shareholders, emplo •c -s, rn°mbers, or agents Xho are activin the manaeemerit of the entit,,', nor the affiliate of the tnfiry has bt-rt char ed With and convicted of a public entiD,crime within the past 36 months. The entity subminM2 this w,om statement, or one or more of its officers, directors. executives, partners, sharehold(.rs, employees, members, or agents rho are active in the management of the entity, or an affiliate of the entity has been charged v,pith an convicted of a Public entity crime within �)e past 36 months AND (Please indicate which additional siateniew applies) The entity submitting this sworn statement, or one or more of its ofFlcers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with an convicted of a public entity crime within the past 36 months. However, there has been a subsequent proceeding before a Hearin; Officer of the State of Florida, division of Administrative Hearings and the Final Order entered by, the Pleasing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list (attach a copy of the final order). I UNDERSTAND THAT THE SUBMISSION OF THIS FOF.Iv1 TO THE CONTRACTING OFFICER.FOR THE PUBLIC ENTITY IDENTIFIED.IN PARAGPAPIi I (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH THE LIFE OF THE CONTRACT. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUELIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287,017,FLORTDA STATUTES FOR CATEGORY TIVO OF ANY CHANGE IN THE INFORMATION CONTRAINED IN THIS FORM. (Signature) (date) STATE OF COUNTY OF PERSONALLY APPEARED BEFORE ME, the undersigned authority. (name of individual signing) who, after, first being swom by me, affixed his/her signature in the space provided above on this day of 20 NOTARY PUBLIC My commission e:,:pires: MIAMI-DADE COUNTY HOMELESS TRUST PROVIDER ASSET INVENTORY Provider Name: Program Name: Funding Source: Reporting Period: ATTACHMENT P Description of Property Serial / ID Number Acquisition Date Acquisition Cost Vendor Name -%o f Purchase Cost from Grant Location of Property Use and Condition of Property Who holds Title of Property ** Attach invoices for all purchases this grant reporting period.