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HomeMy WebLinkAboutAttachmentsSubrecipient Agreement Attachment List Signature Attachment Title Re uired Attachment A U.S. HUD Grant Renewal Agreement includes: HUD designated Attachments A and B Attachment A-1 Scope of Service Attachment A-2 Units/Bedrooms/Beds Chart and Participants Chart Attachment. A-3 Pro am Goals Attachment A4 Milestones (N/A for Renewal Grants) Attachment B Technical Submission Attachment C LOCCS/VRS form HUD -27053A Attachment C-1 Copy of Homeless Trust Invoice Attachment D FMS (HUD -40118) Monthly Pro ess Re rt Attachment E ProEM Rating of Satisfaction Attachment F Client Contribution Re rt Attachment G Annual Progress Re rt (APR) Attachment G-1 IMS (HUD -40118) Annual Progress Report (APR) Signature Attachment H Request for Taxpayer Identification and Certification Signature Attachment I HUD form -400904 Applicant Certification Signature Attachment J Miami -Dade County Required Affidavits Signature Attachment K Affidavit Lobbyist Registration for Oral Presentation Signature Attachment L Disclosure of Subcontractors and Suppliers Signature Attachment M Subcontractor / Suppliers Listing Signature Attachment N Section 3 Compliance Requirements Signature Attachment O Sworn Statement Pursuant to Florida Statutes Attachment P Provider Asset Inventory form if applicable Attachment Q Declaration of Restrictive Covenants if jpElicable Attachment Q-1 Declaration of Restrictions Attachment R Em loyee Certification Form Attachment S Incident Report (3 -pages) HUD notifications to the Recipient shall be to the address of the Recipient as written above, unless HUD is otherwise advised in writing. Recipient notifications to HUD shall be to the HUD Field Office executing the Grant Agreement. No right, benefit, or advantage of the Recipient hereunder be assigned without prior written approval of HUD. For any project funded by this grant, which is also financed through the use of the Low Income Housing Tax Credit, the following applies: HUD recognizes that the Recipient or the project sponsor will or has financed this project through the use of the Low -Income Housing Tax Credit. The Recipient or project sponsor shall be the general partner of a limited partnership formed for that purpose. If grant funds were used for acquisition, rehabilitation or construction, then, throughout a period of twenty years from the date of initial occupancy or the initial service provision, the Recipient or project sponsor shall continue as general partner and shall ensure that the project is operated in accordance with the requirements of this Grant Agreement, the applicable regulations and statutes. Further, the said limited partnership shall own the project site throughout that twenty-year period. If grant funds were not used for acquisition, rehabilitation or new construction, then the period shall not be twenty years, but shall be for the term of the grant agreement and any renewal thereof. Failure to comply with the terms of this paragraph shall constitute a default under the Grant Agreement. A default shall consist of any use of grant funds for a purpose other than as authorized by this Grant Agreement, failure in the Recipient's duty to provide the supportive housing for the minimum term in accordance with the requirements of Attachment A, noncompliance with the Act or Attachment A provisions, any other material breach of the Grant Agreement, or misrepresentations in the application submissions which, if known by HUD, would have resulted in this grant not being provided. Upon due notice to the Recipient of the occurrence of any such default and the provision of a reasonable opportunity to respond, HUD may take one or more of the following actions: (a) direct the Recipient to submit progress schedules for completing approved activities; or (b) issue a letter of warning advising the Recipient of the default, establishing a date by which corrective actions must be completed and putting the Recipient on notice that more serious actions will be taken if the default is not corrected or is repeated; or (c) direct the Recipient to establish and maintain a management plan that assigns responsibilities for carrying out remedial actions; or (d) direct the Recipient to suspend, discontinue or not incur costs for the affected activity; or Miami -Dade County FL0190B4D000801 (e) reduce or recapture the grant; or (f) direct the Recipient to reimburse the program accounts for costs inappropriately charged to the program; or (g) continue the grant with a substitute recipient of HUD's choosing; or (h) other appropriate action including, but not limited to, any remedial action legally available, such as affirmative litigation seeking declaratory judgment, specific performance, damages, temporary or permanent injunctions and any other available remedies. No delay or omission by HUD in exercising any right or remedy available to it under this Grant Agreement shall impair any such right or remedy or constitute a waiver or acquiescence in any Recipient default. For each operating year in which funding is received, the Recipient shall file annual certifications with HUD that the supportive housing has been provided in accordance with the requirements of the Grant Agreement. This Grant Agreement constitutes the entire agreement between the parties hereto, and may be amended only in writing executed by HUD and the Recipient. More specifically, the Recipient shall not change recipients, location, services, or population to be served nor shift more than 10 percent of funds from one approved type of eligible activity to another, or make any other significant change, without the prior written approval of HUD. Miami -Dade County FL0190B4D000801 SIGNATURES This Grant Agreement is hereby executed as follows: UNITED STATES OF AMERICA Secretary of Housing and Urban Development Signature and Date Maria R. Ortiz -Hill Director, Community Planning and Development Title RECIPIENT Lo Miami -Dade County Name of Organization Authorized Signature and Date Print name of signatory Title Miami -Dade County FL0190134D000801 ATTACHMENT A 1. The Recipient is Miami -Dade County. 2. HUD's total fund obligation for this project is $ 138.789 which shall be allocated as follows: a. Leasing $0 b. Supportive services $132,180 c. Operating costs $0 d. HMIS $0 e. Administration $6,609 3. Although this agreement will become effective only upon the execution hereof by both parties, upon execution, the term of this agreement shall run from the end of the Recipient's final operating year under the original Grant Agreement or, if the original Grant Agreement was amended to extend its term, the term of this agreement shall run from the end of the extension of the original Grant Agreement term for a period of one year. Eligible costs, as defined by the Act and Attachment B, incurred between the end of Recipient's final operating year under the original Grant Agreement, or extension thereof, and the execution of this Renewal Grant Agreement may be paid with funds from the first operating year of this Renewal Grant. Miami -Dade County FL0190B4D000801 ATTA,A- P M E N T 9), Pt. W submitted in response to the most re- ceridy published notice of fund avail- ability and select applications for fund- ing with the deobligated Funds. Such selections would be made in accordance with the selection process described in §582.220 of this part. Any selections made using deobiigated funds will be subject to applicable appropriation act requirements governing the use of deobligated funding authority. (Approved by the Office of Management and Budget under control number 2506-0118) PART 583—SUPPORTIVE HOUSING PROGRAM Subpart A—General Sec. 583.1 Purpose and scope. 583.5 Definitions. Subpart B—Assistance Provided 583.100 Types and uses of assistance. 583.105 Grants for acquisition and rehabill- ta[ton- 563.110 Grants for new construction. 583.115 Grants for leasing. 583.120 Grants for supportive service costs. 593.(25 Crants for operating costs. 583.130 Commitment of grant amounts for leasing- supportive smites, and oper- ating costs. 583.135 Administrative costs. 583.140 Technical assistance. 583.145 Matching requirements. 583.150 Limitations on use of assistance. 583.155 Consolidated pian. Subpart C—Application and Grant Award Proce$3 583.200 Application and ,grant award. 583.230 Environmental review. 583.235 Renewal grants. Subpart D—Program Requirements 583.300 General operation. 583.305 Term of commicrttent: repayment of grants: prevention of undue benefits. 583.310 Displacement, relocation, and ac qul� sition. 583.315 Resident rent. 583 320 Site control. 583325 Nondiscrimination and equal oppor- tunity requirements. 583.330 Applicability of other Federal re. quirements Subpart E—Administration 583.400 Grant agreement. 24 CFR Ch. V (4-1-05 Edition) 583.405 Program changes. 583.410 Obligation and deobl igation of funds. AC.THORtT*Y'. 42 U.S.C. 11389 and 3535(d). Stx,-RCE: 58 FR 13871, Mar. 15, 1993, unless otherwise noted. Subpart A --General 4583.1 Purpose and scope. (a) Ceneral. The Supportive Housing Program Is authorized by title IV of the Stewart B. McKinney Homeless As- sistance Act (the McKinney Act) (42 U.S.C. 11381-11389). The Supportive Housing program is designed to pro- mote the development of supportive housing and supportive services, in- cluding innovative approaches to assist homeless persons in the transition from homelessness, and to promote the provision of supportive housing to homeless persons to enable them to live as independently as possible. (b) Cornponenrs. Funds under this part may be used for: (1) Transitional housing to facilitate the movement of homeless individuals and families to permanent housing: (2) Permanent housing that provides long-term housing for homeless persons with disabilities: (3) Housing that is, or is part of, a particularly innovative project for, or alternative methods of, meeting the immediate and long-term needs of homeless persons: or (4) Supportive services for homeless persons not provided in conjunction with supportive housing. [58 FR 13871. Mar. 15. 1993, as amended at 61 FR 51175, Sept. 30. 1996) 4 583.5 Definitions. As used In this part: -lpplicatir is defined in section 422(1) of the McKinney Act (42 U.S.C. 1I382(1)). For purposes of this defini- tion, governmental entities Include those [liar have general governmental powers (such as a city or county), as well as those that have limited or spe- cial powers (such as public housing agencies). Consolidated plan means the plan chat a jurisdiction prepares and submits to HUD in accordance with 24 CFR part 91. 248 01c. of Asst. Secy., Comm. Planning, Develop., HUD Date of Initial occupancy means the date that the supportive housing is ini- tially occupied by a homeless person for whom HUD provides assistance under this part. If the assistance is for an existing homeless facility. the date of Initial occupancy is the date that services are first provided to the resi- dents of supportive housing with fund- ing under this part. Date of initial service provision means the date that supportive services are initially provided with funds under this part to homeless persons who do not reside in supportive housing. This defi- nition applies only to projects funded under this part that do not provide sup- portive housing. Disability is defined in section 422(2) of the McKinney Act (42 U.S.C. 11382(2)). Homeless person means an individual or family chat is described in section 103 of the McKinney Act (42 U.S.C. 11302). 14etropolitan city is defined in section 102(a)(4) of the Housing and Commu- nity Development Act of 1974 (42 U.S.C. 5302(a)(4)), In general, metropolitan cit- ies are chose cities that are eligible for an entitlement grant under Z4 CFR part 570, subpart D. New construction means the building of a structure where none existed or an addition to an existing structure that increases the floor area by more than 100 percent. Operating costs is defined In section 422(5) of the McKinney Act (42 U.S.C. 11382(5)). Outpatient health services is defined in section 422(6) of the McKinney Act (42 U.S.C. 11382(6)). Permanent housing for homeless persons With disabilities is defined in section 424(c) of the McKinney Act (42 U.S.C. 11384(c)). Private nonprofit organization is de- fined in section 422(7) (A), (B), and (D) of the McKinnev Act (42 U.S.C. 11382(7) (A), (B), and (D)). The organization roust also have a functioning account- ing system that is operated in accord- ance with generally accepted account- ing principles, or designate an entity that will maintain a functioning ac- counting system for the organization in accordance with generally accepted accounting principles. 249 5583.100 Project is defined in sections 422(8) and 424(d) of the McKinney Act (42 U.S.C. 11382(8). 11384(d)). Recipient is defined in section 422(9) of the McKinney Act (42 U.S.C. 11382(9)). Rehabilitation rneans the improve- ment or repair of an existing structure or art addition to an existing structure that does not increase the floor area by more than 100 percent. Rehabilitation does not include minor or routine re- pairs. e- pa1rs. State is defined in .section 422(11) of the McKinney Act (42 U.S.C. 11382(11)). Supportive housing is defined in sec- tion 424(a) of the McKinney Act (42 U.S.C. 11384(a)). Supportive services is defined in sec- tion 425 of the kicKinney Act (42 U.S.C. 11385). Transitional housing is defined in sec- tion 424(b) of the McKinney Act (42 U.S.C. 11384(b)). See also §583.3000). Tribe is defined in section 102 of the Housing and Community Development Act of 1974 (42 U.S.C. 5302). Urban county is defined in section 102(a)(6) of the Housing and Commu- nity Development Act of 1974 (42 U.S.C. 5302(a)(6)). In general, urban counties are those counties that are eligible for an entitlement grant under 24 CFR part 570, subpart D. (61 FR S1175, Sepc_ 30. 19%1 Subpart B—Assistance Provided §583.100 Types and uses of assistance. (a) Grant assistance. Assistance In the form of grants is available for acquisi- tion of structures, rehabilitation of structures, acquisition and rehabilita- tion of structures, new construction. leasing, operating costs for supportive housing, and supportive services, as de- scribed in §5583.105 through 583.125. Ap- plicants may apply for more than one type of assistance. (b) Uses ofgrani assistance. Grant as- sistance may, be used to: (1) Establish new supportive housing facilities or new facilities to provide supportive services: (2) Expand existing facilities in order to increase the number of hometess persons served: (3) Bring existing facilities up to a level that meets State and local gov- ernment health and safety standards: 5 583.105 (4) Provide additional supportive services for residents of supportive housing or for homeless persons not re- siding in supportive housing; (5) Purchase HUD -owned single Fam- ily properties currently leased by the applicant for use as a homeless facility under 24 CFR part 291; and (6) Continue funding supportive hous- ing where the recipient has received funding under this part for leasing, supportive services, or operating costs. (c) Structures used for multiple pur- poses- Structures used to provide sup- portive housing or supportive services may also be used for other purposes, except that assistance under this part will be available only in proportion to the use of the structure for supportive housing or supportive services. (d) Technical assistance. HUD may offer technical assistance, as described in §583.140. (58 FR 13871, Mar. 15, 1993, as amended at 59 FR 36891, July 19. 19941 4683.105 Grants for acquisition and rehabilitation. (a) Use. HUD will grant funds to re- cipients to: (1) Pay a portion of the cost of the acquisition of real property selected by the recipients for use in the provision of supportive housing or supportive services, including the repayment of any outstanding debt on a loan made to purchase property chat has riot been used previously as supportive housing or for supportive services; (2) Pay a portion of the cost of reha- bilitation of structures. including cost- effective energy measures, selected by the recipients to provide supportive housing or supportive services; or (3) Pay a portion of the cost of acqui- sition and rehabilitation of structures, as described in paragraphs (a)(1) and (2) of this section. (b) Amount. The maximum grant available for acquisition, rehabilita- tion. or acquisition and rehabilitation is the lower of: (1) 5200,000; or (2) The total cost of the acquisition, rehabilitation, or acquisition and reha- bilitation minus the applicant's con- tribution toward the cost. (c) increased amounts. In areas deter- inined by HUD to have high acquisition 250 24 CFR Ch. V (4-1-05 Edition) and rehabilitation costs, grants of more than $200,000, but not more than $400,000, may be available. 4583.110 Grants for new construction. (a) Use. HUD will grant funds to re- cipients to pay a portion of the cost of new construction. including cost-effec- tive energy measures and the cost of land associated with chat construction, for use In the provision of supportive housing. If the grant funds are used for new construction, the applicant must demonstrate that the costs associated with new construction are substan- tially less than the costs associated with rehabilitation or that there is a lack of available appropriate units that could be rehabilitated at a cost less than new construction. For purposes of this cost comparison, costs associated with rehabilitation or new construc- tion may include the cost of real prop- erty acquisition. (b) Amount. The maximum grant available for new construction is the lower of: (1) $400,000: or (2) The total cost of the new con- struction, Including the cost of land as- sociated with that construction, minus the applicant's contribution toward the cost of same. §583.115 Grants for leasing. (a) General. HUD will provide grants to pay (as described in §583.130 of this part) for the actual costs of leasing a structure or Structures, or portions thereof, used to provide supportive housing or supportive services for up to five years. (b)(1) Leasing structures. Where grants are used to pay rent for all or part of structures, the rent paid must be rea- sonable in relation to rents being charged in the area for comparable space. In addition, the rent paid may not exceed rents currently being charged by the same owner for com- parable space. (2) Leasing individual units. Where grants are used to pay rent for Indi- vidtiai housing units, the rent paid must be reasonable in relation to rents being charged for comparable units, taking into account the location, size, I ype, quality, amenities, facilities, and management services. in addition, the Ofc. of Asst. Secy., Comm. Planning, Develop., HUD rents may not exceed rents currently being charged by the same owner for comparable unassisted units, and the portion of rents paid with grant funds may not exceed HtiD-determined fair market rents. Recipients may use grant funds in an amount up to one month's rent to pay the non -recipient landlord for any damages to leased units by homeless participants. 158 FR 13871, Mar. 15. 1993, as amended at 59 FR 36891. July 19. 19941 §583.120 Grants for supportive serv- ices ereices costs. (a) General. HUD will provide grants to pay (as described in §583.130 of this part) for the actual costs of supportive services for homeless persons for tip to five years. All or part of the supportive services may be provided directly by the recipient or by arrangement with public or private service providers. (b) Supportive services costs. Costs as- sociated with providing supportive services include salaries paid to pro- viders of supportive services and any other costs directly associated with providing such services. For a transi- tional housing project, supporcive serv- ices costs also include the costs of serv- ices provided to former residents of transitional housing to assist their ad- justment to independent living. Such services may be provided for up to six months after they leave the cransi- tional housing facility. 158 FR 1.3871. Mar. 15. 1993. as amended at 59 FR 36891. July 19, 1994) ,§583.125 Grants for operating costa. (a) General. HUD will provide grants to pay a portion (as described in §583.130) of the actual operating costs of supportive housing for up to five years. (b) Operating costs. Operating costs are those associated with the day-to- day operation of the supportive hous- ing. They also include the actual ex- penses that a recipient incurs for con- ducting on-going assessments of the supportive services needed by residents and the availability of such Services; relocation assistance under § 583.310, in- cluding payments and services, and in- Stirance. 251 §5".140 (c) Reciplenl match requirement for op- erating costs. Assistance for operating costs will be available for up to 75 per- cent of the total cost In each year of the grant term. The recipient must pay the percentage of the actual operating costs not funded by HUD. At the end of each operating year. the recipient must demonstrate that it has met its match requirement of the costs for that year. 158 FR 13871. !molar. 15. 1993, as amended at 61 FR 51175. Sept. 30, 19%; 65 FR 30823. May 12. 20001 §583.130 Commitment of grant amounts for leasing, supportive services, and operating costs. Upon execution of a grant agreement covering assistance for leasing, sup- portive services, or operating costs, HUD will obligate amounts for a period not to exceed five operating years. The total amount obligated will be equal to an amount necessary for the specified years of operation. less the recipient's share of operating costs. (Approved by the Office of Management and Budget under OMB control number 2506-0112) 159 FR 36691. July 19, 19941 §583.135 Administrative costa. (a) General. Up to five percent of any grant awarded under this part may be used for the purpose of paying costs of administering the assistance. (b) Administrative costs. Administra- tive costs include the costs associated with accounting for the use of grant funds, preparing reports for submission to HUD, obtaining program audits, similar costs related to administering the grant after the award, and staff sal- aries associated with these administra- tive costs. They do not include the costs of carrying out eligible activities under §§583.105 through 583.125. (58 FR 13871. filar. 15, 1993, as amended at 61 FR 51175, Sep(. X. 19%) §583.140 Technical assistance - (a) General. HUD may set aside funds annually to provide technical assist- ance, either directly by HUD staff or indirectly through third -party pro- viders, for any supportive housing project. This technical assistance is for §583.145 the purpose of promoting the develop ment of supportive housing and sup portive services as part of a continuum of care approach, including innovative approaches to assist homeless person in the transition from homelessness and promoting the provision of sup- portive housing to homeless persons t enable them to live as independently a possible. (b) Uses of technical assistance. HU may use these funds to provide tech- nical assistance to prospective appli- cants, applicants, recipients, or other providers of supportive housing or serv- ices for homeless persons, for sup- portive housing projects. The assist- ance may include, but is not limited to. written information such as papers, monographs, manuals, guides, and bro- chures: person-to-person exchanges: and training and related costs. (c) Selection of providers. From time to time, as HUD determines the need, HUD may advertise and competitively select providers to deliver technical as- sistance. HUD may enter into con- tracts, grants, or cooperative agree- ments, when necessary, to implement the technical assistance. 159 FR 36892, July 19, 19941 li 583.145 Matching requirements. (a) Ceneral. The recipient must match the funds provided by HUD for grants for acquisition, rehabilitation. and new construction with an equal amount of funds from other sources. (b) Cash resources. The matching funds must be cash resources provided to the project by one or more of the following: the recipient, the Federal government, State and local govern- ments, and private resources. (c) Maintenance of effort. State or local government funds used in the matching contribution are subject to the maintenance of effort requirements described at g 583.150(a). 1583.150 Limitations on use of assist- ance. (a) ,Waintenarwe of effort. No assist- ance provided under this part (or any State or local government funds used to ,iupplenient this assistance) may be used to replace State or local funds previously used, or designated for use, to assist homeless persons. 24 CFR Ch. V (4-1-05 Ed[Hon) (b) Faith -based activities. (1) Organiza- tions that are religious or faith -based are eligible, on the same basis as any other organization, to participate in s the Supportive Housing Program_ Nei- ther the Federal government nor a State or local government receiving o funds under Supportive Housing pro- s grams shall discriminate against an or- ganization on the basis of the organiza- tion's religious character or affiliation. (2) Organizations that are directly funded under the Supportive Housing Program may not engage in Inherently religious activities, such as worship, religious instruction, or proselytiza- tion as part of the programs or services funded under this part. If an organiza- tion conducts such activities, the ac- tivities must be offered separately. In time or location. from the programs or services funded under this part, and participation must be voluntary for the beneficiaries of the HUD -funded pro- grams or services. (3) A religious organization that par- ticipates in the Supportive Housing Program will retain its independence from Federal, State, and local govern- ments, and may continue to carry out its mission, including the definition, practice, and expression of its religious beliefs, provided that it does not use di- rect Supportive Housing Program funds to support any inherently reli- gious activities, such as worship, reli- gious instruction, or proselytization. Among other things, faith -based orga- nizations may use space in their facili- ties to provide Supportive Housing Program -funded services, without re- moving religious art, icons, scriptures, or other religious symbols. in addition, a Supportive Housing Program -funded religious organization retains its au- thority over its internal governance. and it may retain religious terms in its organization's name, select its board members on a religious basis, and in- clude religious references in its organi- zation's mission statements and other governing documents. (4) An organization that participates in the Supportive Housing Program shall not, in providing program assist- ance, discriminate against a program beneficiary or prospective program beneficiary on the basis of religion or religious belief. 252 Oita. of Asst. Secy., Comm. Planning, Develop., HUD §583.155 (5) Program funds may not be usec for the acquisition, construction, or re habilitation of structures to the extent that those structures are used for in heremly religious activities. Program funds may be used for the acquisition, construction, or rehabilitation o structures only to the extent that those structures are used for con- ducting eligible activities under this part. Where a structure is used for both eligible and inherently religious activi- ties, program funds may not exceed the cost of those portions of the acquisi- tion, construction, or rehabilitation that are attributable to eligible activi- ties in accordance with the cost ac- cotrnting requirements applicable to Supportive Housing Program hinds in this part. Sanctuaries, chapels. or other rooms that a Supportive Housing Program -funded religious congregation uses as its principal place of worship, however, are ineligible for Supportive Housing Program -funded improve- ments. Disposition of real property after the term of the grant, or any change In use of the property during the term of the grant, is subject to gov- ernment -wide regulations governing real property disposition (see 24 CFR parts 84 and 85). (6) If a State or local government vol- untarily contributes its own funds to supplement federally funded activities, the State or local government has the option to segregate the Federal Funds or commingle them. However, if the funds are commingled, this section ap- plies to all of the commingled funds. (c) Participant control ofsite. Where an applicant does not propose to have con- trol of a site or sites but rather pro- poses to assist a homeless family or in- dividual in obtaining a Lease, which may include assistance with rent pay- ments and receiving supportive serv- Ices. after which time the farnlly or in- dividual remains in the same housing without further assistance under this part, that applicant may not request assistance for acquisition, rehabilita- t ion, or new construction 158 FR 13871, 'star. 15. 1993, as amendad at 59 FR 36892. Juin 19, 1.993: 68 FR 56.101. Sept. 30. 20031 253 §W165 Consolidated plan. (a) Applicants that are States or units of general local government. The appli- cant must have a HUD -approved com- plete or abbreviated consolidated plan, f in accordance with 24 CFR part 91, and must submit a certification that the application for funding is consistent with the HUD -approved consolidated plan. Funded applicants must certify in a grant agreement that they are fol- lowing the HUD -approved consolidated plan. (b) Applicants that are not States or units of general local government. The applicant must submit a certification by the jurisdiction in which the pro- posed project will be located that the applicant's application for funding is consistent with the jurisdiction's HUD - approved consolidated plan. The cer- tification must be made by the unit of general local government or the State, in accordance with the consistency cer- tification provisions of the consoli- dated plan regulations. 24 CFR part 91. subpart F. (c) Indian tribes and the Insular Areas of Guam. the U.S. Virgin Islands. Amer- ican Samoa, and the Northern Mariana Islands. These entities are not required to have a consolidated plan or to make consolidated plan certifications. An ap- plication by an Indian tribe or other applicant for a project that will be lo- cated on a reservation of an Indian tribe will not require a certification by the tribe or the State. However, where an Indian tribe is the applicant for a project chat will not be located on a reservation, the requirement for a cer- tification under paragraph (b) of this section will apply. (d) Timing of consolidated plan certifi- cation submissions. Unless otherwise set forth in the NOEA, the required certifi- cation that the application for funding is consistent with the HUD -approved consolidated plan must be submitted by the funding application submission deadline announced in the NOFA. (60 FR 16380, Mar. 30, 19951 g 689.200 Subpart C—Application and Grant Award Process 1583.200 Application and grant award, When funds are made available for assistance. HUD will publish a notice of funding availability (NOFA) In the FEDERAL RECI5TER- in accordance with the requirements of 24 CFR part 4. HUD will review and screen applications in accordance with the requirements in section 426 of the McKinney Act (42 U.S.C. 11386) and the guidelines, rating criteria, and procedures published in the NOFA. 161 FR 51176, Sept. 30. 19961 §583.230 Environmental review. (a) Activities under this part are sub- ject to HUD environmental regulations in part 58 of this title. except that HUD will perform an environmental review in accordance with part 50 of this title prior to its approval of any condi- tionally selected applications for Fis- cal Year 2000 and prior years that were received directly from private non- profit entities and governmental enti- ties with special or limited purpose powers. For activities under a grant that generally would be subject to re- view under part 58, HUD may make a finding in accordance with 558.11(d) and may itself perform the environmental review under the provisions of part 50 of this title if the recipient objects in writing to the responsible entity's per- forming the review under part 58. Irre- spective of whether the responsible en- tity in accord with part 58 (or HUD in accord with part 50) performs the envi- ronmental review, the recipient shall Supply all available, relevant informa- tion necessary for the responsible enti- ty (or HUD, if applicable) to perform for each property any environmental review required by this part. The re- cipient also shall carry out mitigating measures required by the responsible entity (or HUD, if applicable) or select alternate eligible property. HUD may eliminate from consideration any ap- plication that would require an Envi- ronmental Impact Statement (EIS). (h) The recipient, its project partners and their contractors may not acquire, rehabilitate, convert, lease, repair, dis- pose of, demolish or construct property 24 CFR Ch. V (4-1-05 Edition) for a project under this part, or com- mit or expend HUD or local funds for such eligible activities under this part. until the responsible entity (as defined in §58.2 of this title) has completed the environmental review procedures re- quired by part 58 and the environ- mental certification and RROF have been approved or HUD has performed an environmental review under part 50 and the recipient has received HUD ap- proval of the property. HUD will not release grant funds if the recipient or any other party commits grant funds (1.e., incurs any costs or expenditures to be paid or reimbursed with such funds) before the recipient submits and HUD approves its RROF (where such submission is required) 168 FR 56131. Sept. 29, 20031 §M.235 Renewal grants. (a) General. Grants made under this part, and grants made under subtitles C and D (the Supportive Housing Dem- onstration and SAFAH, respectively) of the Stewart B. McKinney Homeless As- sistance Act as in effect before October 28, 1992, may be renewed on a non- competitive basis to continue ongoing leasing, operations, and supportive services for additional years beyond the initial funding period, To be con- sidered for renewal funding for leasing, operating costs. or supportive services, recipients must submit a request for such funding in the form specified by HUD, must meet the requirements of this part, and must submit requests within the time period established by HUD. (b) Assistance available. The first re- newal will be for a period of time not to exceed the difference between the end of the initial funding period and ten years from the date of initial occu- pancy or the date of initial service pro- vision, as applicable. Any subsequent renewal will be for a period of time not to exceed five years. Assistance during each year of the renewal period. sub- ject to maintenance of effort require- ments under §583.150(a) may be for: (1) Up to 50 percent of the actual op- erating and leasing costs in the final year of the initial funding period: (2) Up to the amount of HUD assist- ance for supportive services in the final year of the Initial finding period: and 254 Otc. of Asst. Secy., Comm. Plonning, Develop., HUD (3) An allowance for cost increases. (c) HUD review (1) HUD will review the request for renewal and will evalu- ate the recipient's performance in pre- vious years against the plans and goals established in the initial application for assistance, as amended. HUD will approve the request for renewal unless the recipient proposes to serve a popu- lation that is not homeless. or the re- cipient has not shown adequate progress as evidenced by an unaccept- ably slow expenditure of funds, or the recipient has been unsuccessful in as- sisting participants in achieving and maintaining independent living. In de- termining the recipient's success in as- sisting participants to achieve and maintain independent living, consider- ation will be given co the level and type of problems of participants. For recipients with a poor record of suc- cess, HUD will also consider the recipi- ent's willingness to accept technical assistance and to make changes sug- gested by technical assistance pro- viders. Other factors which will affect HUD's decision to approve a renewal request Include the following: a con- tinuing history of inadequate financial management accounting practices, in- dications of mismanagement on the part of the recipient, a drastic reduc- tion in the population served by the re- cipient, program changes made by the recipient without prior HUD approval, and loss of project site. (2) HUD reserves the right to reject a request from any organization with an outstanding obligation to HUD that is in arrears or for which a payment schedule has not been agreed to, or whose response to an audit finding is overdue or Lit satisfactory. (3) HUD will notify the recipient in writing that the request has been ap- proved or disapproved. (approved by the Office of Nianagernent and Budget under control number 2506-0112) Subpart D --Program Requirements 583.300 General operation. (a)State and local requirernenu. Each recipient of assistance under this part must provide housing or services that are in compliance with all applicable State and local housing codes. licens- ing requirements, and any other re - 255 5 583.300 quirements in the jurisdiction in which the project is located regarding the condition of the structure and the op- eration of the housing or services. (b) Habitability standards. Except for such variations as are proposed by the recipient and approved by HUD, sup- portive housing must meet the fol- lowing requirements: (1) Structure and materials. The struc- tures must be structurally sound so as not to pose any threat to the health and safety of the occupants and so as to protect the residents from the ele- ments. (2) Acress. The housing must be acces- sible and capable of being utilized without unauthorized use of other pri- vate properties. Structures must pro- vide alternate means of egress in case of fire. (3) Space and security- Each resident must be afforded adequate space and security for themselves and their be- longings. Each resident must be pro- vided an acceptable place to sleep. (A) Interior air quality. Every room or space must be provided with natural or mechanical ventilation. Structures must be free of pollutants in the air at levels that threaten the health of resi- dents. (5) Wafer supply. The water supply must be free from contamination. (6) 5ati Lary facilities. Residents must have access to sufficient sanitary fa- cilities that are in proper operating condition, may be used in privacy, and are adequate for personal cleanliness and the disposal of human waste. (7) Thermal environment- The housing must have adequate heating and/or cooling facilities in proper operating condition. (8) Illumination and electricity, The housing must have adequate natural or artificial illumination to permit nor- mal indoor activities arid to support the health and safety of residents. Suf- ficient electrical sources must he pro- vided to permit use of essential elec- trical appliances while assuring safety from fire. (9) Food preparation and refuse dis- posal. .all food preparation areas must contain suitable space and equipment to store, prepare, and serve food in a sanitary manner. §563.300 24 CFR Ch. V (4-1-05 f dirion) (10) Sanitary condition. The housing for HUD approval to otherwise consult and any equipment must be maintained with homeless or formerly homeless in sanitary condition. persons in considering and making (it) Fire safety. (i) Each unit must in- policies and decisions. See also clude at least one battery-operated or §583.330(e). hard -wired smoke detector, in proper (2) Each recipient of assistance tinder working condition, on each occupied this part must, to the maximum extent level of the unit. Smoke detectors practicable, involve homeless individ- must be located, to the extent prac- uals and families, through employ- ticable, in a hallway adjacent to a bed- ment, volunteer services, or otherwise, room. If the unit Is occupied by hear- in constructing, rehabilitating, main- ing-impaired persons, smoke detectors taming, and operating the project and must have an alarm system designed in providing supportive services for the for hearing-impaired persons in each project, bedroom occupied by a hearing -(m- (g) Records and reports. Each recipient paired person. of assistance under this part must keep (it) The public areas of all housing any records and make any reports (in - must be equipped with a sufficient eluding those pertaining to race, eth- number, but not less than one for each nicity, gender, and disability status area, of battery-operated or hard -wired data) that HUD may require within the smoke detectors. Public areas Include, timeframe required. but are not limited to, laundry rooms, (h) Conl7dentlality. Each recipient community rooms, day care centers, that provides family violence preven- hailways, stairwells. and other com- tion or treatment services must de- mon areas. velop and implement procedures to en- c) Meals. Each recipient of assist- sure: ante under this part who provides sup- (1) The confidentiality of records per- portive housing for homeless persons raining to any Individual services: and with disabilities must provide meals or (2) That the address or location of meal preparation facilities for resi- any project assisted will not be made dents, public, except with written auchoriza- (d) Ongoing assessment of supportive tion of the person or persons respon- services. Each recipient of assistance sible for the operation of the project. under this part must conduct an ongo- (I) Termination of housing assistance. Ing assessment of the supportive serv- The recipient may terminate assist - ices required by the residents of the ante to a participant who violates pro - project and the availability of such gram requirements. Recipients should services, and make adjustments as ap- terminate assistance only In the most propriate, severe cases. Recipients may resume (e) Residential supervision. Each re- assistance to a participant whose as- cipient of assistance under this part sistance was previously terminated. In must: provide residential supervision as terminating assistance to a partici- necessary to facilitate the adequate pant, the recipient must provide a for - provision of supportive services to the mal process that recognizes the rights residents of the housing throughout of individuals receiving assistance to the term of the commitment to operate due process of law. This process, at a supportive housing. Residential super- minimum, must consist of: vision may include the employment of (1) Written notice to the participant a full- or part-time residential super- containing a clear statement of the visor with sufficient knowledge to pro- reasons for termination: vide or to supervise the provision of (2) A. review of the decision. in which supportive services to the residents. the participant is given the oppor- (f) Participation of homeless persons. (1) tunity to present written or oral object Each recipient must provide for the tions before a person other than the participation of homeless persons as re- person (or a subordinate of that person) quired in section 426(g) of the NIcKin- who made or approved the termination ney Act (42 U.S.C. 11386(8)). This re- decision: and quirement is waived if an applicant is (3) Prompt written notice of the final unable to meet it and presents a plan decision to the participant. 256 O(c. of Asst. Secy., Comm. Planning, Develop.. HUD u) Limitation of stay in transirlon housing. A homeless individual or fam ily may remain in transitional housin for a period longer than 24 months.i permanent housing for the individua or family has not been located or if th individual or family requires addi tional time to prepare for Independen living. However, HUD may discontinue assistance for a transitional housing project if more than half of the home- less individuals or families remain i that project longer than 24 months. (k) Outpatient health services. Out- patient health services provided by th recipient must be approved as appro- priate by HUD and the Department o Health and Human Services (HHS). Upon receipt of an application that proposes the provision of outpatient health services. HUD will consult with HHS with respect to the appropriate- ness of the proposed services. (1) Annual assurances. Recipients who receive assistance only for leasing, op- erating costs or supportive services costs must provide an annual assur- ance for each year such assistance is received that the project will be oper- ated for the purpose specified in the ap- plication. (Approved by the Office of Management and Budget under control number 2506-0112) 158 FR 13871, Mar. 15, 1993, as amended at 59 FR 36892, July 19, 1994: 61 FR 51176, Sept. 30. 19961 4 583.305 Term of commitment; repay- ment of grants; prevention of undue benefits. (a) Tenn orcommlrment and conversion. Recipients must agree to operate the housing or provide supportive services in accordance with this part and with sections 423 (b)(1) and (b)(3) of the N,IrKinney Act (42 U.S.C. 11383(6)(1), 11383(b)(3)). (b) Repayment ofgrant and prevention of undue beneflts. In accordance with section 423(c) of the McKinney Act (42 U.S.C. 11383(c)). HUD will require re- cipients to repay the grant unless HUD has authorized conversion of the project under section 423(b)(3) of the McKinney Act (42 U.S.C. 11383(6)(3)), 161 FR 51176. Sept. 30. 1998) § 583.310 al 4583.310 Displacement, relocation., and - acquisition. g (a) hfinimWng displacement- Con - f sistent with the other goals and objec- I tives of this part, recipients must as- e sure that they have taken all reason- - able steps to minimize the displace - t ment of persons (families. individuals, businesses, nonprofit organizations, and farms) as a result of supportive housing assisted under this part. n (b) Relocation assistance for displaced persons. A displaced person (defined in paragraph (f) of this section) must be e provided relocation assistance at the levels described in. and in accordance f with, the requirements of the Uniform Relocation Assistance and Real Prop- erty Acquisition Policies Act of 1970 (URA) (42 U.S.C. 4601-4655) and imple- menting regulations at 49 CFR part 24. (c) Real property acquisition require- ments. The acquisition of real property for supportive housing is subject to the URA and the requirements described in 49 CFR part 24, subpart S. (d) Responsibility of recipient. (1) The recipient must certify (i.e.. provide as- surance of compliance) that it will comply with the URA, the regulations at 49 CFR part 24, and the requirements of this section, and must ensure such compliance notwithstanding any third party's contractual obligation to the recipient to comply with these provi- sions. (2) The cost of required relocation as- sistance is an eligible project cost in the same manner and to the same ex- tent as other project costs. Such costs also may be paid for with local public funds or funds available from other sources. (3) The recipient must maintain records in sufficient detail to dem- onstrate compliance with provisions of this section. (e) Appeals. A person who disagrees With the recipient's determination con- cerning whether the person qualifies as a '-displaced person." or the amount of relocation assistance for which the per- son is eligible, may file a written ap- peal of that determination with the re- cipient. A low-income person who is dissatisfied with the recipient's deter- mination on his or her appeal may sub- mit a written request for review of that determination to the HUD field office. 257 5583.310 24 GFR Ch. V (4-1-05 EdmoN M Definition of displaced person. (1) does not return to the building/com- For purposes of this section. the term plex, if either: "displaced person" means a person (A) A tenant is not offered payment (farnily, individual, business, nonprofit for all reasonable out-of-pocket ex - organization, or farm) that moves from penses incurred in connection with the real property, or moves personal prop- temporary relocation, or erty from real property permanently as (B) Other conditions of the tem - a direct result of acquisition, rehabili- porary relocation are not reasonable. tation, or demolition for supportive (v) A tenant of a dwelling who moves housing projects assisted tinder this from the building/complex perma- part. The term "displaced person" in- nently after he or she has been re- cludes, but may not be limited to: quired to move to another unit in the (I) A person that moves permanently same building/complex. if either: from the real property after the prop- (A) The tenant is not offered reim- erty owner (or person in control of the bursement for all reasonable out -of - Issues a vacate notice. or refuses Pocket expenses incurred in connection to renew an expiring lease in order to with the move: or evade the responsibility to provide re- (B) Other conditions of the move are location assistance, if the move occurs not reasonable. on or after the date the recipient sub- (2) Notwithstanding the provisions of mits to HUD the application or appli- paragraph (f)(1) of this section, a per - cation amendment designating the son does not qualify as a ''displaced project site. person" (and is not eligible for reloca- (li) Any person, including a person tion assistance under the URA or this who moves before the date described in section), if: paragraph (f)(1)(i) of this section, if the (i) The person has been evicted for se - recipient or HUD determines that the rious or repeated violation of the terms displacement resulted directly from ac- and conditions of the lease or occu- quisition, rehabilitation, or demolition panty agreement. violation of applica- for the assisted project. ble Federal, State, or local or tribal (iii) A tenant -occupant of a dwelling law, or other good cause, and HUD de - unit who moves permanently from the termines that the eviction was not building/complex on or after the date of dertaken for the purpose of evading the the the "initiation of negotiations" (see obligation to provide relocation assist - paragraph (g) of this section) if the ante; (ii) The person moved into the prop - move occurs before the tenant has been erty after the submission of the appii- provided written notice offering him or cation and, before signing a lease and her the opportunity to lease and oc- commencing occupancy, was provided cupy a suitable, decent, safe and sani- written notice of the project, its pos- tary dwelling in the same building/ sible impact on the person (e.g., the .complex, under reasonable terms and person may be displaced, temporarily conditions, upon completion of the relocated, or suffer a rent Increase) and project. Such reasonable terms and the fact that the person would not conditions toast include a monthly qualify as a "displaced person" (or for rent and estimated average monthly any assistance provided under this sec - utility costs that do not exceed the tion), if the project is approved; greater of: (Iii) The person is ineligible under 49 (A) The tenant's monthly rent before CFR 24.2(g)(2): or the initiation of negotiations and esti- (iv) HUD determines that the person mated average utility costs. or was not displaced as a direct result of (B) 30 percent of gross household in- acquisition, rehabilitation, or demoli- come. If the initial rent is at or near tion for the project. the Maximurn, there roust be a reason- (3) The recipient may request, at any able basis for concluding at the time time. HUD's determination of whether the project is initiated that future rent a displacement is or would be covered increases will be modest. under this section. (iv) A tenant of a dwelling who is re- (g) Deflnition of initiation of negorla- quired to relocate temporarily, but tions. For purposes of determining the 258 0(c. of Assf. Secy., Comm. Planning, Develop., HUD formula for computing the replacemen housing assistance to be provided to residential tenant displaced as a direc result of privately undertaken rehabili Cation, demolition, or acquisition o the real property, the term "initiatio of negotiations" means the executio of the agreement between the recipien and HUD. (h) Deflnition of project. For purpose of this section, the term "project' means an undertaking paid for 1 whole or in part with assistance under this part. Two or more activities that are integrally related, each essential t the others, are considered a single project, whether or not all component activities receive assistance under this part. f58 FR 13871, Mar. 15. 1993, as amended at 59 FR 36892, July 19. 19941 §583.315 Resident rent. (a) Calculation of resident rent. Each resident of supportive housing may be required to pay as rent an amount de- termined by the recipient which may not exceed the highest of: (1) 30 percent of the family's monthly adjusted income (adjustment factors include the number of people in the family, age of family members, medical expenses and child care expenses). The calculation of the family's monthly ad- justed income must include the ex- pense deductions provided in 24 CFR 5.611(a), and for persons with disabil- ities, the calculation of the family's monthly adjusted income also must in- clude the disallowance of earned in- come as provided In 24 CFR 5.617, if ap- plicable, (2) 10 percent of the family's monthly gross income: or (3) If the family is receiving pay- ments for welfare assistance from a public agency and a part of the pay ments, adjusted in accordance with the family's actual housing costs, is spe- cifically designated by the agency to meet the family's housing costs, the portion of the payment that is des- ignated for housing costs. (b) Use of rent. Resident rent may be used in the operation of the project or may be reserved, in whole or in part. to assist residents of transitional housing in moving to permanent housing. § 583.320 t (c) Fees. In addition to resident rent, a recipients may charge residents rea- t sonable fees for services not paid with grant funds. f (58 FR 13871, Mar. 15, 1993, as amended at 59 n FR 36892. July 19. 1991. 66 FR 6225, Jan. 19. n 20011 t §5".320 Site control. s (a) Site control. (1) Where grant funds will be used for acquisition, rehabilita- n tion. or new construction to provide supportive housing or supportive serv- Ices, or where grant funds will be used o for operating costs of supportive hous- ing, or where grant funds will be used to provide supportive services except where an applicant will provide serv- ices at sttes not operated by the appli- cant, an applicant must demonstrate site control before HUD will execute a grant agreement (e.g.. through a deed. lease, executed contract of sale). If such site control is not demonstrated within one year after initial notifica- tion of the award of assistance under this part, the grant will be deobiigated as provided in paragraph (c) of this sec- tion. (2) Where grant funds will be used to lease all or part of a structure to pro- vide supportive housing or supportive services, or where grant funds will be used to lease individual housing units for homeless persons who will eventu- ally control the units. site control need not be demonstrated. (b) Site change. (1) A recipient may obtain ownership or control of a suit- able site different from the one speci- fied in its application. Retention of an assistance award is subject to the new site's meeting all requirements tinder this part for suitable sites. (2) If the acquisition, rehabilitation, acquisition and rehabilitation. or new construction costs for the substitute site are greater than the amount of the grant awarded for the site specified in the application, the recipient must pro- vide for all additional costs. If the re- cipient is unable to demonstrate to HUD that it is able to provide for the difference in costs. HUD may deobiigate the award of assistance. (c) Failure to obtain site control uirhin one near. HUD will recapture or deobligate any award for assistance under this part if the recipient is not in 259 § 583.325 control of a suitable site before the ex- piration of one year after initial notifi- cation of an award. 9583.325 Nondiscrimination and equal opportunity requirements. (a) Ceneral. Notwithstanding the per- missibility of proposals that serve des- ignated populations of disabled home- less persons, recipients serving a des- ignated population of disabled home- less persons are required, within the designated population, to comply with these requirements for nondiscrimina- tion on the basis of race, color, reli- gion, sex, national origin, age, familial status, and disability. (b) Nondiscrimination and equal oppor- trrnlry requirements. The nondiscrimina- tion and equal opportunity require- ments set forth at part 5 of this title apply to this program. The Indian Civil Rights Act (25 U.S.C. 1301 et seq.) ap- plies to tribes when they exercise their powers of self-government, and to In- dian housing authorities (114As) when established by the exercise of such powers. When an MA is established under State law, the applicability of the Indian Civil Rights Act will be de- termined on a case-by-case basis. Projects subject to the Indian Civil Rights Act must be developed and oper- ated in compliance with its provisions and all implementing HUD require- ments, instead of title VI and the Fair Housing Act and their implementing regulations. (c) Procedures. (1) If the procedures that the recipient intends to use to make known the availability of the supportive housing are unlikely to reach persons of any particular race, color. religion, sex, age, national ori- gin, familial status, or handicap who may qualify for admission to the hOUS- ing. the recipient must establish addi- tional procedures that will ensure that such persons can obtain informatlon concerning availability of the housing. (2) The recipient must adopt proce- dures to make available information on Lite existence and locations of facili- ties and services that are accessible to persons with a handicap and maintain evidence of implementation of the pro- cedures. (d) Accessibility requirements. The re- cipient must comply with the new con - 24 CFR Ch. V (4-1-05 Edition) struction accessibility requirements of the Fair Housing Act and section SO4 of the Rehabilitation Act of 1973, and the reasonable accommodation and reha- bilitation accessibility requirements of section 504 as follows: (1) All new construction must meet the accessibility requirements of 24 CFR 8.22 and, as applicable, 24 CFR 100.205. (2) Projects In which costs of reha- bilitation are 75 percent or more of the replacement cost of the building must meet the requirements of 24 CFR 8.23(a). Other rehabilitation must meet the requirements of 24 CFR 8.23(b). 158 FR 13871. Mar. 15, 1993, as amended at 59 FR 33894, June 30. 1994: 61 FR 5210, Feb. 9. 1996: 61 FR 51176, Sept. 30. 19961 §583.330 Applicability of other Federal requirements. In addition to the requirements set forth In 24 CFR part 5, use of assistance provided under this part must comply with the following Federal require- ments: (a) Flood Insurance. (1) The Flood Dis- aster Protection Act of 1973 (42 U.S.C. •1001-4128) prohibits the approval of ap- plications for assistance for acquisition or construction (including rehabilita- tion) for supportive housing located in an area identified by the Federal Emer- gency Management Agency (FEMA) as having special flood hazards, unless: (i) The community in which the area is situated is participating in the Na- tional Flood Insurance Program (see 44 CFR parts 59 through 79), or less than a year has passed since FEMA notifica- tion regarding such hazards: and (ii) Flood insurance is obtained as a condition of approval of the applica- tion. (2) Applicants with supportive hous- ing located in an area identified by FEMA as having special flood hazards and receiving assistance for acquisition or construction (including rehabilita- tion) are responsible for assuring that flood insurance under the National Flood Insurance Program is obtained and maintained. (b) The Coastal Barrier Resources Act of 1982 (16 U.S.C. 3501 et seq.) may apply to proposals under this part, de- pending on the assistance requested. 260 Otc. of Asst. Secy., Comm. Monning, Develop., HUD § 583.330 (c) Applicability ot-OMB Circulars- The y583.300(f) does not constitute a con, policies, guidelines, and requirements flict of interest. of OAIB Circular No. A-87 (Cost Prin- (2) Upon the written request of the ciples Applicable to Grants. Contracts recipient. HUD may grant an exception and Other Agreements with State and to the provisions of paragraph (e)(1) of Local Governments) and 24 CFR part 85 this section on a case-by-case basis apply to the award, acceptance, and when It determines that the exception use of assistance under the program by will serve to further the purposes of governmental entities, and OMB Cir- the program and the effective and effi- cular Nos. A-110 (Grants and Coopera- tient administration of the recipient's tive Agreements with Institutions of project. An exception may be consid- Higher Education, Hospitals, and Other ered only after the recipient has pro - Nonprofit Organizations) and A-122 vided the following: (Cost Principles Applicable to Grants, (i) For States and other govern - Contracts and Other Agreements with mental entities, a disclosure of the na- Nonprofit Institutions) apply to the ac- ture of the conflict, accompanied by an ceptance and use of assistance by pri- assurance that there has been public vale nonprofit organizations, except disclosure of the conflict and a descrip- where Inconsistent with the provisions tion of how the public disclosure was of the McKinney Act, other Federal made; and statutes. or this part. (Copies of OMB (ii) For all recipients, an opinion of Circulars may be obtained from E.O.P. the recipient's attorney that the Inter - Publications, room 2200. New Executive est for which the exception Is sought Office Building, Washington. DC 20503, would not violate State or local law. telephone (202) 395-1332. (This is not a (3) In determining whether to grant a toll-free number.) There is a limit of requested exception after the recipient two free copies. has satisfactorily met the requirement (d) Lead-based paint. The Lead -Based of paragraph (e)(2) of this section, HUD Paint Poisoning Prevention Act (42 will consider the cumulative effect of U.S,C. 4821-4846), the Residential Lead- the following factors, where applicable: Based Paint Hazard Reduction Act of (1) Whether the exception would pro - 1992 (42 U.S.C. 4851-4856), and imple- vide a significant cost benefit or an es- menting regulations at part 35, sub- sential degree of expertise to the parts A, B, J, K, and R of this title project which would otherwise not be apply to activities under this program. available: (e) Conllicrs or interest. (1) In addition (ii) Whether the person affected is a to the conflict of interest requirements member of a group or class of eligible in 24 CFA part 85, no person who is an persons and the exception will permit employee, agent, consultant, officer, or such person to receive generally the elected or appointed official of the re- some interests or benefits as are being cipient and who exercises or has exer- made available or provided to the cised any functions or responsibilities group or class: with respect to assisted activities, or (iii) Whether the affected person has who is in a position to participate in a withdrawn from his or her functions or decisionmaking process or gain inside responsibilities. or the decisionmaking information with regard to such activi- process with respect to the specific as - ties, may obtain a personal or financial sisted activity in question: interest or benefit from the activity, or (iv) Whether the interest or benefit have an interest in any contract, sub- was present before the affected person contract, or agreement with respect was in a position as described in para - thereto, or the proceeds thereunder. ei- graph (e)(1) of this section: ther for himself or herself or for those (v) Whether undue hardship will re - with whom he or she has ramify or stilt either to the recipient or the per - business ties, during his or her tenure son affected when weighed against the or for one year thereafter. Participa- public interest served by avoiding the tion by homeless individuals who also prohibited conflict: and are participants under the program in (vi) Any other relevant consider - policy ur decisionmaking under ations. 261 § 583,400 (f) Audit. The financial management systems used by recipients under this program must provide for audits in ac- cordance with 24 CFR part 44 or part 45, as applicable. HUD may perform or re- quire additional audits as it finds nec- essary or appropriate. 24 CFR Ch. V (4-1-05 EcWon) must be fully documented in the rectpl- ent's records. (58 FR 13871. Mar. 15. 1993. as amended at 61 FR 51176. Sept. 30, 19%) 4583.410 Obligation and deobligation of funds. (g) Davis -Bacon Act. The provisions (a) Obligation of funds. When HUD and of the Davis -Bacon Act do not apply to the applicant execute a grant agree - this program. ment, funds are obligated to cover the (58 FR 13871, Mar. 15. 1993, as amended at 6 FR 5211. Feb. 9, 1996: 64 FR 50226, Sept. 15 1999) Subpart E --Administration § 583.400 Grant agreement. (a)General. The duty to provide sup- portive housing or supportive services in accordance with the requirements of this part will be Incorporated In a grant agreement executed by HUD and the recipient. (b) Enforcement. HUD will enforce the Obligations in the grant agreement through such action as may be appro- priate, including repayment of funds that have already been disbursed to the recipient. § 583.405 Program changes. (a) HUD approval. (1) A recipient may riot make any significant changes to an approved program without prior HUD approval. Significant changes include, but are not limited to, a change in the recipient, a change in the project site, additions or deletions in the types of activities listed in §583.100 of this part approved for the program or a shift of more than 10 percent of funds from one approved type of activity to another, anda change in the category of partici- pants to be served. Depending on the nature of the change, HUD may require a new certification of consistency with the consolidated plan (see §583.155). (2) Approval for changes is contin- gent upon the application ranking re- maining high enough after the ap- proved change to have been competi- tively selected for funding in the year the application was selected. (b) Documentation of other changes. Any changes to an approved program chat do not require prior HUD approval 1 amount of the approved assistance under subpart B of this part. The re- cipient will be expected to carry out the supportive housing or supportive services activities as proposed In the application. (b) Increases. After the initial obliga- tion of funds, HUD will not make revi- sions to increase the amount obligated. (c) Deobllgation. (1) HUD may deobligate all or parts of grants for ac- quisition, rehabilitation, acquisition and rehabilitation, or new construc- tion: (1) If the actual total cost of acquisi- tion, rehabilitation, acquisition and re- habilitation, or new construction is less than the total cost anticipated in the application; or (ii) If proposed activities for which funding was approved are not begun within three months or residents do not begin to occupy the facility within nine months after grant execution. (2) HUD may deobligate the amounts For annual leasing costs, operating costs or supportive services in any year: (i) If the actual leasing costs. oper- ating costs or supportive services for that year are less than the total cost anticipated In the application; or (ii) if the proposed supportive hous- ing operations are not begun within three months after the units are avail- able for occupancy. (3) The grant agreement may set forth in detail other circumstances under which funds may be deobligated, and other sanctions may be imposed. (4) HUD may: (1) Readverrise the availability of funds that have been deobligated under this section in a notice of fund avail- ability under 5:583.200, or (ii) Award deobligated funds to appli- cations previously submitted in re- sponse to the most recently published 262 Ofc. of Asst. Secy., Comm. Planning, Develop., HUD notice of fund availability, and in ac cordance with subpart C of this part. PART 585—YOUTHBUILD PROGRAM Subpart A—General Sec. 585.1 Authority, 585.2 Program purpose. 585.3 Program coinponents. MA Definitions. Subpart 3 (Reserved] Subpart C—Youthbuild Planning Grants 585.201 Purpose. 585.202 Award limits. 585.203 Grant term. 585.204 Locatlonal considerations. 585.Z05 Eligible activities. Subpart D—Youthbulld Implementation Grants 585.301 Purpose. 585.302 Award limits. 585.303 Grant term. 585.304 Locational considerations. 585.305 Eligible activities. 585.306 Designation of costs. 585.307 Environmental procedures and standards. 585.308 Relocation assistance and real prop- erty acquistcion. 585.309 Project -related restrictions applica- ble to Youthbuild residential rental housing. 585.310 Project -related restrictions appItca- ble to Youthbulld transitional housing__ far the homeless. 595.311 Project -related restrictions applica- ble to Youthbuild homeownership hous- Ing. 585.312 Wages, Iabor standards, and non- discrimination. 585.313 Labor 5tandards. Subpart E—Administrotlon 585.401 Recordkeeping by recipients. 585.402 Grant agreement. 585.403 Reporting requirements. 585.404 Program changes. 585.40.5 Obligation and deobligation of funds 585.406 Faiih-based activities. Subpart F—AppBcabillty of Other Federal Requirements 585 501 Application of UMB Circulars. 585.502 Certifications. 585.503 Conflict of interest. 585 504 Use of debarred. susp(Inded. or ineli Bible contractors. ALMORiTY:42 U.S C 35351d) and 8011. 263 § 585.3 SOGRCE: 60 FR 9737. Feb. 21. 1735, unless otherwise rioted. Subpart A --General 4 586.1 Authority. (a) General. The Youthbuild program is authorized under subtitle D of title IV of the National Affordable Housing Act (42 U.S.C. 8011). as added by section 164 of the Housing and Community De- velopment Act of 1992 (Pub. L. 102-550). (b) Authority restriction. No provision of the Youthbuild program may be con- strued to authorize any agency, officer, or employee of the United States to ex- ercise any direction, supervision, or control over the curriculum, program of instruction, administration, or per- sonnel of any educational institution, school, or school system, or over the selection of library resources, text- books, or other printed or published in- structional materials used by any edu- cational institution or school system participating in a Youthbuild program. 4 585.2 Program purpose. The purposes of the Youthbuild pro- gram are set out in section 451 of the National Affordable Housing Act (42 U.S.C. 12899) (--NAHA" ). 161 FR 52187, Oct. 4. 1996] 0 585.3 Program components. A Youthbuild implementation pro- gram uses comprehensive and multi- disciplinary approaches designed to prepare young adults who have dropped out of high school for educational and employment. opportunities by employ- ing them as construction trainees on work sites for hotising designated for homeless persons and low- and very low-income families. A You[hbuild planning grant is designed to give re- cipients sufficient time and financial resources to develop a comprehensive Youthbuild program that can be effec- tively implemented. Youthbuild pro- grams must contain the three compo- nents described in paragraphs (a), (b) and (d) of this section. Other activities described in paragraph (c) of this sec- tion are opt tonal: (a) Fdurotlonal sen -ices. including: (l) Sen ices and activities designed to mt•et the basic educational needs of GRANT NUMBER: FL1413800040 / FL O190134D000801 City of Miami — Miami Metro Homeless Assistance Program South ATTACHMENT A-1 SCOPE OF SERVICES The Subrecipient shall conduct outreach, assessment and placement with seven (7) day follow up services to at least 2,260 homeless persons which will ensure continued residential stability. At least 50% (1,130) of all outreach contacts will be assessed, placed into appropriate housing and provided follow up services.. The Subrecipient will accept referrals from emergency shelters, transitional housing facilities, outreach teams and other service providers in the Continuum of Care. The Subrecipient shall provide a outreach, assessments and placements of homeless persons under this Agreement over the tern of the one (1) year Grant Agreement. The Subrecipient shall provide services as proposed in the application to U.S. HUD pursuant to the 2008 Super NOFA (incorporated herein by reference), including but not limited to: 1. Extensive outreach; 2. Initial assessment and evaluations; 3. Referral and placceanent in housing where appropriate and available; 4. Referrral to all appropriate and available services; 5. Transportation services; 6. Seven �7) day follow up Conditions: 1. Reimbursement shall be limited to operations, supportive services, leasing, administration, and the costs associated with these activities as described in the Subrecipient's application; 2. Reimbursement shall be made only for the cost incurred for operations, administration, and supportive services actually provided to clients, unless the Grantee agrees, in writing, to another mode of payment, as provided for in this Agreement; 3. Monthly progress reports and program narratives signed by the Executive Director of the Subrecipienfs agency shall be submitted by the Subrecipient, as required; 4. The Subrecipient will serve clients referred by the Grantee within available resources. or its designee for housing and/or services through the Grantee's established referral process; 5. Services shall be provided in accordance with the timeline submitted by the Subrecipient; 6. Any proposed modifications or revisions to the Subrecipient's program and/or services must be submitted in writing and must receive prior approval by the Grantee; and 7. The Provider will achieve the performance measures delineated in their application to U.S. HUD. Technical Project Number: FL01"B4D000801 / FL14B800040 Submission Project Identifier: FL14084 Exhibit 1: Proiect Summary ATTACW4ENT A-2 Please indicate below the number of persons you have committed to serve as indicated in your application or as modified by your Field Office (i.e., change due to funds being reduced). D. Number of Beds, Participants, and Supportive Services (Does not apply to HMS projects) Section D is composed of three charts. Chart I is for recording the housing type. Chart 2 is for recording the number of unit&%eds/bedrooms in the project Do not complete Chart 2 if the project is for supportive services only (SSO). Chart 3 is for recording the number of participants to be served. Information on ul! projects should be entered in this section except for M41S activities. Complete Chart 2 and Chart 3 based on the following instructions. ` 1. In column a., please enter the requested information for all items at a point in time. You should fill out this column only if you checked "Yes" in Section III, Part K, #9 or you are proposing a renewal project. If you checked "No" in section E enter "N/A" in this column. 2. In column &, enter the new number of beds and persons served at a point in time if this project is funded 3. In column c-, enter the projected level (columns a and b added together) that your project will attain at a point -in -time. Chart 2: Units, Bedrooms, Beds a- Current b. New Effort or c. Projected Level Cnange in snort Level Change in Effort Level (Point -in -Time) (If Applicable) (col. a+ COI. b) Number of Units N/A N/A. N/A Number of Bedrooms N/A N/A N/A l�Tnml�ar of Rac. t N/A N/A N/A 355 _-� iii_ Number of disabled in families 55 ! N/A ! 55 ! xl';.n n01 rn-t-ia i.,.ta—miaiia n nn the nnnit7 r of limits, bedroorns and reds �4ir _ urmn—. up C'- (�`i,• i,� O) projects. in those instances, enter "N/A" in the appropriate cells. lz qs f• � lk,— i a. Camera I b. New Eiori or i c. Projected j` Level Cnange in snort ievei a- Number of Families with 310 N/A 310 Children(Family Households) i. Number of adults in families 665 N/A 6V-7 IN iii u,i .t ux Gili.1 ' '�11e l lIl falne_ s -- 355 �_ i^vi' A �_ 355 _-� iii_ Number of disabled in families 55 ! N/A ! 55 ! E. of qof and ?;' A T i-- - _ UWer ricniselloicls IN o t.Ilil( cil I 1. Number of disabled individuals 83 ! N/A i R3 .� tet,. N i f --.:., v! :-%i viif lf. tAk CIAi v _(E6_Rf tt:4 i -ii jD_eiflilQ(}_ ,a S; Project Number: FL01"B4D000801 / FL1411800040 Technical Project Identifier: FL14084 Submission Exhibit l: Project Summary ATTACHMENT A-3 (RENEWALS ONLY) C. Program Goals - Goal: Residential Stability Conduct outreach, assessment and placement and 7 -day follow up services at least 2,260 homeless persons (individuals and families of various combinations), during the term of the grant which will ensure continued residential stability. At least 50% (1,130) of all outreach contacts will be assessed placed and provided 7 -day follow up services into appropriate housing in the Continuum of Care. Goal: Increase skill and income Provide outreach to 2,260, assessment, and placement with seven (7) follow up services for at least 1,130 persons (individuals and families of various combinations). Of those that were available for the 7 day follow up at least 11%, (124 participants) of the eligible, assessed, placed participants will be employed. At least 25%, of the eligible, assessed, placed participants will be linked to agencies that provide other sources of income or benefits. Goal: Achieve greater self-determination Provide outreach, assessment, and placement with seven (7) follow up services for at least 1,130 persons (individuals and families of various combinations), which will link them to individual service plans that ensure greater self-determination. The Miami -Dade County Homeless Outreach Assessment and Placement Program — South maintains the same goals and mission as the Miami -Dade County, Department of Human Services, which is to provide indigent and homeless persons with the assistance they need in order to begin new lives of self- sufficiency and independence D. Number of Units, Beds, Participants and Supportive Services These charts need to be included only if they were incomplete, inaccurate or blank at the time of the original application submission. Please complete these charts if your local HUD Field Office has notified you that they are required. Submit only those that apply. The charts can be found in the New Projects Section of the Technical Submission. HUD -40090-3a 4 ACHMENT A -a PROJECT MILESTONES FOR TI -HS PROJECT 111 zWRIEve" � . DIl Technical Submission for the 2008 Do Supportive Housing Program o° ro° (Change in Project Sponsor) o0 .° U.S. Department of Housing and Urban Development � Office of Community Planning and Development Do Project Sponsor: o° City of Miami 0 °0 . Project Name: Miami Metro Homeless Assistance ° DO °° program South (MMHAP — South) Do o° Do Project Type: :. °o Do Supportive Services Only (SSO) o° Project Number: D0 FL14B8'000 0° `Dv " Doi 0o F 4 D 0 0 0 01 ` 1 9"Ur" B Da !711- tiP4 ADE °o 0o Submitted by Selectee: €h4 o0 00 Miami -Dade County Homeless Trust 00 111 Northwest first Street, 27th Floor, Suite 310 00 DD Miami, Florida 33128 - o� Do 'Telephone Number: (305) 375-1490 ao o° Fax Number: (305) 375-2722 °o -DD -DO DD 00 Technical Project Number: FL0190B4D000801 / FL14B800040 Submission Project Identifier: FL14084 (CHANGE IN PROJECT SPONSOR) Recipient's Name: Miami -Dade County Homeless Trust HUD Project Number: Sponsor's Name: City of Miami June 1, 2009 — May 31, 2010 Miami Metro Homeless Assistance Program South (MMHAP-S) Check the program component/type that classifies your project: ® Supportive Housing ❑ Transitional Housing (TH) ❑ Permanent Housing for Homeless Persons with Disabilities (PH) ❑ Supportive Services Only (SSO) ❑ Safe Haven/Transitional Housing (SH/TH) — Characteristics of TH/participant not required to execute a lease ❑ Safe Haven/Permanent Housing (SH/PH) — Characteristics of PH/participant required to execute a lease ❑ Homeless Management Information System (HMIS) ❑ Innovative Supportive Housing (ISH) Table Of Contents (Enter the page number for each Exhibit in the space provided below.) Q Exhibit 1 Project Summary Q Exhibit 2 Supportive Services Q Letters of Match Commitment and Leveraging Certification: Name & Title of the Person who can answer questions about this document: Phone (include area code): Sergio Torres (305) 576-9900 Address: 1490 Nw 3`d Ave. Suite 105 Miami, Florida 33136 Email Address: stores@miamigov.com I hereby certify that all the information stated herein is true and accurate. Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802 Name & Title of Authorized Official: Signature & Date: Sergio Torres Program Administrator L.. <E � `� off, HUD -40090-3a 2 Project Number: FL0190B4D000801 / FL14B800040 Technical Project Identifier: FL14084 Submission Exhibit 1: Project Summary (cont.) (RENEWALS ONLY) A. Selectee, and Sponsor Information - Fill in the information requested below. For HMIS projects fill in the HMIS Lead. When the selectee is the same organization as the project sponsor, complete only the selectee information. Selectee Name Miami -Dade County, Homeless Trust Sponsor Name City of Miami Contact Person David Raymond, Director Contact Person Sergio Torres Phone (305) 375-1490 Phone (305) 576-9900 FAX Number (305) 375-2722 FAX Number (305) 576-9967 E -Mail Address Dray@miami-dade.gov E -Mail Address storresl7a iami ov.com Street Address 111 N.W. 1St Street, Suite 2710 Street Address 444 SW 2"d Avenue, 5` Floor City, State, Zip Miami, Florida 33128 City, State, Zip Miami, Florida 33130 HMIS Lead Miami -Dade County, Homeless Trust Contact Person Barbara Golphin Street Address 111 N. W. I" Street, Suite 2710 Phone (305) 375-1490 City, State, Zip Miami, Florida 33128 E -Mail Address R.mgl@miamidade.gov B. Project Budget - This section must be completed by all renewal selectees. 1. Chart 1 - Summary Project Budget To complete Chart 1, Summary Project Budget, enter the amount of SHP funds requested by line -item in the first column. For leasing, supportive services, operations, and HMIS, the amount entered should be for the SHP grant term selected. In the second column, enter the amount of other cash that will be contributed to the project. This amount plus the SHP request must equal the total budget amount for the project. Note that match requirements for supportive services, operating costs and HMIS apply to renewal projects. The amounts you enter are for all structures in your project. Each line item amount in this chart should match the amounts shown in your original application as approved or Exhibits 3, 4, 5 and 6. Requested grant term (1, 2, or 3 years): 1 Chart 1 - Summary Project Budget - 0t'111 1 q, Y,�.t .i a 3 ` SHP Request Applicant Cash Total Project Budget 1. Real Property Leasing 2 Supportive Services* 132,180 33,045 165,227 3.Operations** 4. HMIS* 5. SHP Request (subtotal lines 1 thru 4) 132,180 33,047 165,227 6. Administration*** (up to 5% of line 5) 6,609 6,609 7. Total SHP Request (total lines 5 and 6) 138,789 33,047 171,836 *By law, SHP can pay no more than 80% of the total supportive services or total HMIS budget. * *By law, SHP can pay no more than 75% of the total operating budget. ***By law, SHP can pay no more than 5% of the total SHP request. HUD -40090-3a 3 Technical Submission Project Number: FL0190B4D000801 / FL14B800040 Submission Project Identifier: FL14084 Exhibit 4: Supportive Services A. Supportive Services Budget Chart 4A: Year 1 Total Supportive Service Expense (d) Service Activity: Community Outreach 59,811 59,811 Specialist 1 Quantity: 3.0 FTE @ $24,921 Annual salary plus taxes and fringe benefits = $74,764 Service Activity: Community Outreach 68,517 68,517 Specialist 2 Quantity: 3.0 FTE @ $28,548 Annual salary plus taxes and fringe benefits = $85,646 Service Activity: Communication for Outreach 1,191 1,191 Quantity: phone lines, cell phones, radios, network between office and outreach staff $1,489 Service Activity: Equipment & Related 1,190 1,190 Services Quantity: bottled water machines and services, copier machine, additional computer software and management equipment $1,489 Service Activity: Residential Stability follow- 1 1 up Quantity: Items needed to conduct follow up services of participants placed in various locations in the continuum of care $2 Service Activity: Postage & Related Services 280 280 Quantity: mailing of materials printing and reproduction, brochures etc. $350 Service Activity: Supplies 1,190 1,190 Quantity: safety equipment, first aid kits, sanitary supplies, pens, pencils, paper, markers etc $1,489 SHP REQUEST* 132,180 132,180 Selectee's Match (Line I l minus Line 9) 33,047 33,047 Total Supportive Services Budget 165,227 165,227 *The SHP request cannot be more than 80% of the total supportive services budget in Line 11. HUD -40090-3a 11 Project Number: FL0190114D000801 / FL14B800040 Technical Project Identifier: FL14084 Submission Exhibit 7: Administration (cont.) (all projects requesting administration funds) A. Administrative Costs Please complete the chart below for your administrative costs budget. If you are a selectee who will also be the project sponsor, complete Lines 1 through 6. If you are the selectee and a different organization will be the project sponsor, complete lines 1 through 8. In the first column, fill in the administrative activity to be paid for using SHP funds. In the Year 1 column, enter the amount of SHP funds to be used to pay administrative costs in the first year. If the grant is multi-year, enter the amount of SHP funds to be used for Year 2, and if applicable, Year 3. In the last column, (d), total the amount of SHP funds requested for the full grant term. Please ensure that the total requested for administrative costs for the entire grant term, Line 6, column (d), matches that which you entered in your project's Summary Budget in Exhibit 1. B. Plan for Distribution of Administration Funds If the selectee is not the same organization as the project sponsor, attach a description of the selectee's plan for distributing its administrative funding to address all, or a portion of the project sponsor's administrative needs. Include a description of how the project sponsor was consulted in formulating the plan. HUD -40090-3a 12 Year 1 Year 2 Year 3 Total Administrative Costs (a) (b) (c) (d) Administrative Activity: Miami -Dade County 3,305 3,305 Homeless Trust 2.5% for eligible activities including staff time spent reviewing / verifying maintaining and managing invoices for grant funds, audit of SHP funds, preparation of APR Administrative Activity: City of Miami 2.5% 3,304 3,304 eligible activities including preparation of Annual Progress Report, audit of SHP, staff time spent reviewing/verifying invoices for grant funds 4. Administrative Activity: 5. Administrative Activity: 6. SHP REQUEST FOR 6,609 6,609 ADMINISTRATIVE COSTS 7. Amount for Selectee 3,305 3,305 8. Amount for Project Sponsor 3,304 3,304 B. Plan for Distribution of Administration Funds If the selectee is not the same organization as the project sponsor, attach a description of the selectee's plan for distributing its administrative funding to address all, or a portion of the project sponsor's administrative needs. Include a description of how the project sponsor was consulted in formulating the plan. HUD -40090-3a 12 Project Number: FL01"B4D000801 / FL14B800040 Technical Project Identifier: FL14084 Submission Attachment: Budget Narrative The City of Miami is requesting funds for a change in project sponsor to renew in the one (1) year program of 2008 for the Miami Metro Homeless Assistance Program South (NMEF AP -S), will coordinate services in the current offices at North Dade area 1490 NW 3`d Avenue, Miami, Florida 33136 and add services in the South Dade area at the Homestead Homeless Assistance Center 28205 SW 125 Avenue, Homestead, Florida. The staff for this program will be located in the South Dade area location. SUPPORTIVE SERVICES ONLY Service Activity: Community Outreach Specialist 1 and 2 include three (3) full time COS I staff members and three (3) full time COS 2 staff members Fringe Benefits: All fringe benefits are inclusive in the job title line -item in the budget and are figured at approximately: FICA/ MICA @ 7.65% Workmen Comp @ 8 % Medical and Dental Health Insurance (Range varies monthly therefore averaged). Communication for Outreach - phone lines, cell phones, radios, network between office and outreach staff Equipment & Related Services - bottled water machines and services, copier machine, additional computer software and management equipment Residential Stability follow-up - Items needed to conduct 7- day follow up services for participants placed in various locations in the continuum of care, including residential supplies — blankets, possible transportation needs. Postage & Related Services - mailing of materials printing and reproduction, brochures etc for the clients. Supplies: Safety equipment, first aid kits, sanitary supplies, stationary or office supplies etc ADNDMSTRATION Administration ($560.00): 5% administrative fee of the requested supportive services only funding is split equally between City of Miami and Miami -Dade County Homeless Trust, for eligible activities which include staff time spend reviewing, managing and maintaining the records of the invoices, preparation of the Annual Progress Report (APR) and audit of the SHP funds. HUD -40090-3a 14 Project Number: FL0190B4D000801 / FL1411800040 Technical Project Identifier: FL14084 Submission Exhibit 2. Real Property Leasing, Supportive Services, Operations and HMIS (RENEWALS ONLY) This exhibit covers Real Property Leasing, Supportive Services, Operations, HMIS as it pertains to Site Control, Match Documentation and other applicable Certifications. Please refer to the narrative under the New Projects Section of the Technical Submission for a more detailed explanation of each of the exhibits. Other sections in this exhibit may need to be completed if required by your local HUD Field Office. ALL RENEWAL GRANTEES/PROJECT SPONSORS MUST COMPLETE SITE CONTROL, MATCH DOCUMENTATION AND JOB AND ADMINISTRATION CERTIFICATIONS. If you are required to resubmit or complete the real property leasing, supportive services, operations or HMIS exhibits, pull the charts from the pages of the New Projects Section of this technical submission that apply. For leasing use Exhibit 3 charts, supportive services use Exhibit 4 charts, operations use Exhibit 5 charts and HMIS use Exhibit 6 charts. You do not have to complete the leveraging and administration exhibits for renewals. A. Site Control Check the appropriate box(es): Leasing ❑ Supportive Services ® Operations ❑ A project sponsor requesting renewal funding for an existing SHP project must complete the information below. No other site documentation is required for renewal projects. As a recipient of SHP funds, the CITY OF MIAMI (sponsor organization) currently has an executed lease agreement, or a deed or other proof of ownership for the property(ies) in use to house and/or provide services to homeless persons under HUD's existing grant number. In addition, sponsor organizations using SHP funds for leasing activities (project sponsor, the conditional grantee or their parent organizations -fill in the appropriate one-) do not own these leased site(s). This includes organizations that are members of a general partnership where the general partnership owns the structure(s), both parties are parts of the same governmental unit or the governmental unit creates an authority or similar entity to acquire and lease the facilities to the governmental unit and other parties, and no operating grant funds will be used for the payment of utilities, maintenance and repairs, or management fees associated with the leased site(s), under HUD's existing grant number. Signature of authorized representative Name: Sergio Torres Title: Administrator Date: 04/08/09 HUD -40090-3a 5 Technical Project Number: FL0190B4D000801 / FL1413800040 Submission Project Identifier: FL14084 Exhibit 2. Real Property Leasing, Supportive Services, Operations and HMIS (RENEWALS ONLY) B. Documentation of Match for Year 1 Supportive Services ® Operations ❑ HMIS ❑ A selectee must currently have f= commitments for its cash resources for Year 1 for supportive services, operating costs and HMIS and must submit documentation of those resources as an attachment to this Exhibit. These firm commitments must be documented on letterhead stationery, signed and dated by an authorized representative, and attached to this Exhibit. Each letter must, at a minimum, contain the following elements: 1. The name of the organization providing the cash resource; 2. The amount; 3. The type of activity for which the funds will be used (e.g., case management, child care, education); 4. The name of the project sponsor organization to which the cash will be contributed and/or the name of the project; and 5. The date the funds will be available. HUD -40090-3a 6 07-flj of F !� p�CO3 0 Thursday, August 21, 2008 David Raymond, Executive Director Miami -Dade County Homeless Trust 111 NW 1St Street, Suite 2710 Miami, FL 33130 PEDRO G. HERNANDEZ, P.E. City Manager RE: City of Miami / 2008 FL 14B800040 -Metro Miami Homeless Assistance Program Commitment of Matching Funds. Dear Mr. Raymond This letter is to certify that the City of Miami will provide a cash match in the amount of $33,047 for 2007 HUD SHP 2008 Grant. These funds will support the overall operations of the program, including the provision of outreach, assessments, referral and placements of homeless individuals in Miami -Dade County. The funds will be available upon the start of this SHAP contract. Please feel free to contact me at 305 576 9900 if you have any question or require any additional information. Sincerely, Sergio Torres, A inistrator City of Miami, Metro Homeless Assistance Program � low a OFFICE OF HOMELESS ASSISTANCE PROGRAMS 1490 NW 3rd Avenue, Suite #105, Miami, FL 33136 / Phone: (305) 576-9900 Fax: (305) 576-9970 Technical Project Number: FL0190B4D000801 / FL14B800040 Submission Project Identifier: FL14084 Exhibit 2. Real Property Leasing, Supportive Services, Operations and HMIS (RENEWALS ONLY) C. Match Certification (continued) The City of Miami (selectee organization) certifies that it will provide cash resources in the amount of $33,047.00 from non-SHP funding sources for Year(s) 1 of this grant term to be used to provide HMIS, services and/or for operating costs of housing for homeless persons under HUD's grant number FL14B700029. Signature of authorized representative: Name (Print): Sergio Torres Title: Administrator Date: 04/08/09 D. Job Description Certification The City of Miami (selectee organization) certifies that the job responsibilities of each position as it relates to the project are the same as those indicated on the 2006 application budget chart(s). If the position or responsibilities have changed, submit a new position description for the new or added position. Signature of authorized representative: �-- Name (Printf: Sergio Torres Title: Administrator Date: 04/08/09 E. Administration Certification The City of Miami (selectee organization) certifies that funds are being used for eligible administrative costs. If the Distribution of Funds is not the same, a new/revised plan is submitted. I' Signature of authorized representative: Name (Print): Sergio Torres Title: Administrator Date: 04/08/09 HUD -40090-3a 7 COMMUNITY OUTREACH SPECIALIST I, HOMELESS ASSISTANCE PROGRAM Occupational Code: 9282 Salary Range: 04T Status: Temporary FLSA: Non -Exempt Established: 2/08 This is specialized work responsible for providing direct outreach and referral services to homeless individuals. An employee in this classification must be able to identify and engage homeless individuals in public places; under bridges, in abandoned buildings, and other outdoor areas in an attempt to engage them in a non- threatening way, build relationships, and assist them in recognizing and defining their own service needs. Reports to a higher level administrator. Duties include, but are not limited to: working in a team setting engaging homeless individuals on the streets, conducting outreach assessment to determine needs, and informing them of available services; providing referrals to the various homeless service providers; providing documentation in accordance with program standards; collaborating and coordinating services with other City Departments including but not limited to: NET Offices, MPD, Solid Waste and outside agencies such as shelters, substance abuse and mental health treatment programs; may assist with supervising and training staff, hiring, disciplinary actions and recommending terminations; and performing other related duties as required. An employee in this classification should have knowledge of available community services and programs'- effective rograms;effective oral; written and interpersonal skills; ability to maintain effective working relationships with fellow employees, the public and representatives of other agencies, often under complex and stressful situations; ability to work independently, and exercise good professional judgment; and ability to prioritize multiple job responsibilities. REQUIREMENTS: High school graduation or equivalent and (6 months — 2 years) experience performing clerical, administrative or public contact work. Experience working with the homeless population is desirable. A Valid Driver's License from any state (Equivalent to a State of Florida Class E) may be utilized upon application, however prior to appointment a State of Florida Driver's License (Class E or higher) must be presented to the Department of Employee Relations. SPECIAL NOTE: Must be willing to work flexible hours including evenings, weekends and nights. COMMUNITY OUTREACH SPECIALIST II HOMELESS ASSISTANCE PROGRAM Occupational Code: 9283 Salary Range: 05T Status: Temporary FLSA: Non -Exempt Established: 2/08 This is specialized work responsible for providing direct outreach and referral services to homeless individuals. An employee in this classification must be able to identify and engage homeless individuals in public places, under bridges, in abandoned buildings, and other outdoor areas in an attempt to engage them' in a non- threatening way, build relationships, and assist them in recognizing and defining their own service needs. This class is distinguished from the classification of Community Outreach Specialist I by the level independent judgment allowed and that this classification will be assigned the more difficult and complex assignments. Reports to a higher level administrator. Duties include, but are not limited to: working in a team setting engaging homeless individuals on the streets, conducting outreach assessment to determine needs, and informing them of available services; providing referrals to the various homeless service providers; providing documentation in accordance with program standards; collaborating and coordinating services with other City Departments including but not limited to: NET Offices, MPD, Solid Waste and outside agencies such as shelters, substance abuse and mental health treatment programs, may assist with supervising and training staff, hiring, disciplinary actions and recommending ternamations- and performing o erre ateduties as required- An equire _ An employee in this classification should have knowledge of available community services and programs; effective oral, written and interpersonal skills; ability to maintain effective working relationships with fellow employees, the public and representatives of other agencies, often under complex and stressful situations; ability to work independently, and exercise good professional judgment; and ability to prioritize multiple job responsibilities. REOU)CREMENTS: High school graduation or equivalent and (2 - 4 years) experience performing clerical, administrative or public contact work. Experience working with the homeless population is desirable. A Valid Drivel's License from any state (Equivalent to a State of Florida .Class E) may be utilized upon application, however prior to appointment a State of Florida Driver's License (Class E or higher) must be presented to the Department of Employee Relations. SPECIAL NOTE: Must be willing to work flexible hours including evenings, weekends and nights. L�~VVV�V�V U.J. Lieparulienl UI r7ViIWE-11 •,•• •yr lonf. v�ucw and Urban Development SNAPS Special Needs Assistance Program Office of Community Planning Request Voucher for Grant Payment and Development See Instructions and Public Reporting Burden Statement on back ATTACHMENT C 1. Voucher Number 2. LOCCS Pgrm. Area 13, Period Covered by this Request (dates) 4. Type of Disbursement SNAP HIP) C Partial 7 Final I 1HP 5. Voice Response No. (5 digits, hyphen, 5 more ) 16. Grantee Organization's Name 8. Grant No. 6a. Grantee Organization's TIN 9. Line Item no. Type of Funds Requested Amount (round to nearest dollar) 1010 Acquisition 1020 Rehabilitation 1021 New Construction 1022 Substantial Rehabilitation 1023 Moderate Rehabilitation 1030 Operating Cost 1040 Rental Assistance 1050 Supportive Services 1060 Administrative Cost 1070 Child Care 1080 Employment Assistance . 1090 Relocation 1100 Leasing 1110 Repair & Maintenance 1111 Prevention (RHI) 1112 Capacity Building (RH) 1120 Other. 10. Voucher Total 1 hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. Wam ft:HUDwill prosecutefalse 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) 11. Name & Phone Number (including area code) of the Authorized 112 Signature 113. Date of Request Person who called SNAPs System VRS X Privacy Statement: Public law 97-255, Financial Integrity Act, 31 U.S.C. 3512, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions. The Housing and Community Development Act of 1987,42 U.S.C. 3543, authorizes HUD to collect the SSN. The data are used to ensure that individuals who no longer require access to Line of Credit Control System (LOCCS) have th ei r access capabil ity promptly deleted. Provision ofthe SSN is mandatory. H U D uses it as a unique identifier for safeguarding LOCCS from unauthorized access. Failure to provide the information requested may delay the processing of your approval for access to LOCOS. This information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Retain this form in your records for audit purposes page 1 of 2 form HUD -27053-A (2/95) public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information_ This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMG control number. This information collection is to request payment of grant funds or to designate the appropriate officials who can have access to HUD voice activated payment system. The HUD voice activated payment system has been especially designed to help the recipient when calling in for a request of funds and improves the payment process so the recipient will know right away whether their request will be paid or not_ This information collection is required under 24 CFR Subpart C, 85.21 - Post Award Requirements, the information collection is needed in order to obtain or retain a benefit. Instructions for the Request Voucher for Grant Payment for the Special Needs Assistance Program (SNAPs) Item 1. Voucher Number: The first 3 digits are the prefix to your program. Enter '001" if grant funds are being requested for a grant awarded under a SHDP or SHP (TH, PH, SAFAH and Renewal) grant. Enter '038' if funds are being requested for a Housing Opportunity for Persons with AIDs (HOPWA) competitive grant. Enter '054' if funds are being requested for an Innovative Housing Program (IHP) grant. (If you do not know your 3 -digit program prefix, contact your local Field Office.) The remaining 6 digits will be assigned by LOCCSNRS during the telephone call. The entire 9 -digit number will have to be entered prior to ending the call. Item 2. LOCCS Program Area: Circle 'SNAP' (001) for SHDP and SHP grant requests, 'HPAC' (038) for HOPWA competitive grant requests, and 'IHP' (054) for Innova- tive Homeless Programs. Item 3. Enter the period covered by this request. Item 4. Type of Disbursement: Check 'partial' until the final request for grant funds is made. Item 5. Voice Response No: Enter the 10 digit Voice Response System (VRS) project number which was sent to you by mail. Your regular HUD project number will be repeated back for verification after the VRS project number is entered. Item 6. Grantee Organization's Name: Enter the name of the organization requesting funds. It must be the same name that appears on the Grant Agreement. Item 6a. Grantee Organization's Tax Identification No: Enter the tax (employer) Identification Number (TIN). Item 7. Not applicable. Item 8. Grant Number: Enter the project number that appears on the Grant Agreement. Item 9. Type of Funds Requested: SNAPs grant VRS draw- downs are directed against specific funding categories called Budget Line item (BLIs). LOCCS associates a 4 - digit number with each line item. Enter the amount requested in each category(lines 1010 through 1120) and the total funds requested under item 10, Voucher Total. Item 11. Name & phone number (including area code) of the authorized person who completed the call-in to VRS. The authorized person is shown on line 3 of form HUD -27054. item 12. Signature of the person identified in item 11. Item 13. Date of this Request: Enter the date of the call-in to request funds. Retain this form In your records for audit purposes page 2 of 2 form HUD -27053-A (2/95) MONTHLY INVOICE MIAMI-DADE *iOMELESS MONTH: T R U S T PROVIDER NAME: PROGRAM NAME: ATTACHMENT C - 1 CONTRACT IN HTJPROJECTS 4!1!20082:01 PM OT. --l- . �' 1-,`„ 5] I l•'� . 9 - (t "°r'Y,9+Aa..vi�3"$�+- G�aas S i-4+�vr .�V {F f +w 3:µ\{+fi��F F1 hr15 "I'll 4 W it ?' - p9 f'"�5� • • • -:, fr i F t s rtnq-,� T" wJ..L._,.�.,3:`_.��.,•uc .. :l":'^...--.2"'^ - -t T.-sR �.:.�/�.f..v..i,.fu.n�vxrinn�t. .. •: . Total Year SHP SHP - ..- Reimbursement 1: Expenses Y .:1 2L .. '�-. I .7, '•r';-� {L �1 w.�.. �.�...�.:'..�K_ �'a�i i�.L�J�f rl...� w .•J � .Y �'L�si. - • � ������� ■tea . . HTIPROJECTS 411/20082.01 PM HUD Annual Progress Report (HUD -4011S) iiia i - -- -- --•• — ATTACHMENT OLDGovernment/ Shelter?Dint SVanFoint /r.=port, r.dr m H�Ip to,;,f; Report Options: Select ;'. Unduplicated rovider Miarni-Dade County Government ("1) perating Year Date Range 05/01/2006 to 05/31/2006 (mm/dd/yy),'y) !gal Adult Age 18 (as defined by foster care law in your state) Or ara j .,� •. Select- :'GY erved during the Number of Singles Number of Adults Number of Children in Number of operating ar. Ea Not in Families Families Families Families the first day of the +in 0 t 0 0 . b. Nurnberentering program during the E operating year• 0 0 0 c. Number who left the program during 0 I the operating year. f 0 Id, Number in the program on the last day 0 of the operating year. (a�b-c=d) 0 0#Families roject Capacity. Number of Singles Number of Adults Number :in Children La.Number Not in Families in Families Families on last day (from 2d, columnsT_ d 4) 4. Non -homeless persons. (Sec. a SRO projects only) [Howmany Income -eligible non -homeless persons were housed by the SRO program during the operating ear? 0 S. Age and gender. IAge (Male Female Other/Nbt given Single Persons (from 2b, column 1) a. 62 and over 0 0 0 I b. 51 61 0 I 0 0 Ic. 31 50 0 0 0 d. 18 - 30 0 0 0 e. 17 and under . I 0 0 0 Notgiven0 0 I 0 Persons in Families (from 2b, columns 2 °x 3) If. 62 and over I 0 I 0 I 0 g. 51 - 61 I 0 I 0 I 0 h. 3, - 50 0 0 0 haps:;/��ri1•-.,,-3.;er%icept.convnalain i!scripts/s,,/preporthud. ph p, 6/14/2' 006 i. io - 30 0 1 U. I j 17 I 0 I 0 I 0 Ik. 6 i- 0 0 0 II. 1 0 I 0 0 m. Und=r 1 I C, n I 0 Not given 0 I 0 0 6a. Veterans Status. A veteran is anyone Who has ever been on active military duty status. 6b. Chronically Homeless. How many participants were chronically homeless individuals? 7. Ethnicity. a. Hispanic or Latino b. Non -Hispanic or Non -Latino S. Race. a. American Indian or Alaskan Native b. Aslan c. Black or African American d. Native Hawaiian or Other Pacific Islander e. White If. American Indian/Alaskan Native & White g. Asian & White h. Black/African American & White i. American Indian/Alaskan Native & Black/African American j. Other Multi -Racial k. Other/Unknown (all that do not match) 9a. Special Needs. M 0 All Chronic a. Non -housing (street, park, car, bus station, etc.) 0 0 b. Emergency shelter 0 0 c-Transitlonal housing for homeless persons 0 d. Psychiatric facility 0 e. Substance abuse treatment facility I 0 f. Hospital I 0 g. Jail/prison 0 h. Domestic vicdene=_ situation 0 i. Living vvith relatives/friends 0 j, Rental housing I 0 l�ttps: %�ti�t�v seri icept.con�/n�iac�ii/scripts/svpreporthud.php 6/14/2006 All Chronic a. Mentaf illness 0 :0 b. Alcohol abuse 0 ;0 c. Drug abuse 0 I 0 d. HIV/AIDS or related diseases I 0 0 e. Developmental disability 0 I 0 f. Physical disability I 0 0 g. Domestic violence 0 0 h. Other (please specify) 0 0 9b. Disabled. How many of the participants are disabled? 0 10. Prior Living Situation. All Chronic a. Non -housing (street, park, car, bus station, etc.) 0 0 b. Emergency shelter 0 0 c-Transitlonal housing for homeless persons 0 d. Psychiatric facility 0 e. Substance abuse treatment facility I 0 f. Hospital I 0 g. Jail/prison 0 h. Domestic vicdene=_ situation 0 i. Living vvith relatives/friends 0 j, Rental housing I 0 l�ttps: %�ti�t�v seri icept.con�/n�iac�ii/scripts/svpreporthud.php 6/14/2006 U 11. Amount and Source of Monthly Income at Entry and Exit. Amount A. Monthly Income at Entry B. Monthly Income at Exit All Chronic I All Chronic Ila. No Income 0 _ 0 I All b. $1-1S0 I G I 0 I 0 I 0 c. $151 - 50 0 0 0 0 d. $251 $500 I 01 0 I 0 0 e. $501 - $1000 I 0 I 0 I 0 0 f. $1001 -$1500 0 0 0 0 g. $1501 - $2000 h. $:2000 + 0 j 0 0 0 0 0 C 0 Source C. Income Sources at Entry D. Income Sources at Exit All Chronic All Chronic a. Supplemental Security Income (SSI) 0 0 I 0 0 b. Social Security Dlsablllty Insurance (SSRI) 0 0 0 0 c. Social Security 0 I 0 I 0 0 d. General Public Assistance 0 0 0 I 0 e. Temporary Aid to Needy Families (TAN F) , 0 0 0 0 f. State Children's Health Insurance Program (SCHIP) 0 0 0 T 0 g. Veterans benefits 0 0 0 0 h. Employment Income 0 0 I 0 0 i- Unemployment Benefits 0 0 0 I 0 j. Veteran's Health Care 0 0 0 0 k. Medicaid 0 0 0 0 I. Food Stamps , 0 0 0 I 0 m. Other (please specify) 0 0 0 0 n. No financial resources 0 0 0 0 12a. Length of Stay in Program. (Par-ticioants who left during operating year) . All -Chronic a. Less than 1 month 00 . b. 1 to 2 months 0 I 0 c. 3 - b months 0 0 d. 7 months - 12 months 0 0 e. 13 months - 24 months 0 0 f. 25 months - 3 years 0 0 g. 4 years - 5 years 0 0 h. 6 years - 7 years a ( o i. 8 years - 10 years EOj. over l0 years 0 12b. Length of Stay in Program. (Participants who did not leave during operating year) All Chronic a. Less than 1 month 0 b. 1 to 2 months 0 c. 3 - 6 months 0 I d. 7 months - 12 months 0 I i0l e. 13 months - 24 months I 0 f. 25 months - 3 years I 0 1g. 4 years - 5 years 0 I https://w- —w.').serviccpt.com/mIatni/scripts/svpreporthud.pl,p 6/14/2006 • v jco,� - year, � years - 10 years }. over 10 years 0 I 0 13. Reasons for Leaving. All Chronic a. Left for a hOUSInO opocrtunity before completing program I 0 I 0 b. Complete program 0 0 C. idon-payment of rent/occupancy charge 0 d. fJDn-compliance with project G 0 e. Criminal activity / destruction or property / violence G 0 f. Reached mayimum time allowed in project I 0 0 g. Needs could not be met by project 0 0 h. Disagreement with rules/persons 0 0 i, Death 0 0 j. Other (please specify) 0 0 k. Unknown/disappeared 0 0 14. Destination. All Chronic PERMANENT (a - h) a. Rental house or apartment (no subsidy) 0 0 b. Public Housing 0 0 C. Section 8 0 0 �d. Shelter Plus Care 0 0 e. HOME subsidized house or apartment 0 0 If. other subsidized house or apartment ( 0 0 g. Homeownership 0 R h. Moved in with family or friends0 TRANSITIONAL (i - j) i. Transitional housing for homeless persons I 0 0 j. Moved in with family or friends 0 0 INSTITUTION (k - m) k. Psychiatr(c hospital 0 I 0 1. Inpatient alcohol/drug treatment facility 0 0 1m. )all/prison 0 0 EMERGENCY SHELTER (n) n. Emergency shelter 0. 0 OTHER (o - q) o. other supportive housing 0 0 meant for human habitation (e.g. street) 0 0 p. Places not q. Other (please specify) o 0 UNKNOWN r. Unknown 0 0 15. Supportive Services. No supportive services found. Service Point version 4.01.018 (db build #0723) Licensed to: Miami Dade Homeless Trust Cc 1999-2006 Bowman Systems L-L.C. All Rights Reserved. CPT only rU 0o4 A.mencan htedlcal A.SSOC'@!nn. 1,II Rights Pes•21-cd. DSht and osf•I-I:'-TR ar= regis;erEd rradernarks of the .tirnerican Psychiatric Assoclation, and are used with permission herein. �'I'='?ti u2t!ona' Cen[er for fleallh=to"t!stic< (ICD-9 ;c:Vd^rld H?aitn Gi canisatlon). All :1,jgnts P.eServeO. Ta::on my «i198"s 'OG3 infor-,atior. and Referral=ederatlon of L=.s Aneeles County, Inc. All Ri^nt, Res2r)en sept. c,onv'mI am[IS cripts%svp repo rthud.php 6/14/2006 �II_�hTI-D �1DE COUNTY HOMELESS TRL�ST PROGR= NI R-.TIN'G OF SATISFACTION I�STF tCT10�S Carefully read all of the instructions below BEFOIE distributin�T rhe Pro,,rnm Rating of Surisfucriun sun'ev to your program participants. General Information The Program Rating of Satisfaction consists of 1 1 items which are used to dC:ermine J c11cn1 s s"tisfactwn with sen ices they are receiving from a provider. It is to be completed b� all program panic ipainS enLa;cd in services at a Trust -funded program. It must be completed - at a minimum - at time of dischar Le for all participants. It is strongly recommended that a Program Rating of Satisfaction survey also be completed at inten!als as may be applicable to the program; however, only the discharge survey must be foF arded to the Homeless Trust. Case managernent notes should indicate specifically why a Program Rating of Satisfaction was not obtained, if that is the case (client rent ANVOL, institutionalized, etc.), and what efforts v ere made to obtain a survey in those instances. The Program Rating of Satisfaction is available in English, Spanish and Creole. Providers are responsible for reproducing the appropriate survey and providing an envelope (that seals) for each respondent. All responses should be completed in ink If a participant cannot read; providers should encourage them to use the same process they use to have other information read to them. An employee of the agency that is not directly responsible for the client's care can read the form. This should be indicated in Section II. as a separate set of staff initials. HIM out the form 1) A language appropriate survey and an envelope should be provided to all participants who are required to complete the form. Only one form per. family is required. The form must be filled out in Irk - 2) Section II of the Program Rating of Satisfaction is to be completed by staff prior to providing the survey document to the program participant. Staff initials refers to the initials of the case maria-er responsible for the client's service delivery. If the survey must be read to the client, the initials of the staff person performing that function should also be included. In no case should the participant's case manager read items aloud to the participant. 3) Section I of the Program Rating of Satisfaction Form is to be filled out ONLY b} the program participant. The program participant should be provided a pri\-ate place and sufficient time to answer the sun ey. 4) Providers should reassure participants of the confidentiality of their responses. Providers maN, wish to introduce the survey, as follows. - "This survey is one way of helping us determine ho�v yell we are helping individuals that come to our aaerncy for assistance. Please take a fey, minutes after I leave to answer this very short survey as honestly as possible. Your responses are private and we tiwil l not look at them. Please seal the envelope and Live it to me %- hen you are done (or: put it in the drop box)." fj The completed survey should be placed in the envelope by the recipient and sealed. Providers are encouraged to provide a "drop box" with a slot for completed forms. 6l The sealtd envelope(s) should be fonl,arded to the Miami -Dade Count' Homeless Trust on a montifly basis. i) The provider agency should maintain a lot, o1rhow r,Zanv sur:cys are distributed. DETER-MINATIC» OF '\II�I-N'fDI VEP A GE SCQR- TC FOR CONSUkIER SATISFaCTICI 1116100 i I was Informed of m\rl°hts and reS onslblllUes I was Provided with information about different serN'ices U that are available for me I was involved in makina decisions about mvc.arc/service Ian 1 xas able to talk with staff wlien I needed to The building and facilities have usually been clean, safe and I t I I �.I S com forty b I c My ribhts were respected and protected, including n» ribht 1\' A I to file a �rievancc, if needed I i 47 My case manager seems qualified to help me I would recommend this program to others S 1 x.26 1 am treated with respect by the staff IS 5. ,' The staff seems to care about whether I get better ?0 I I Probram staff wereknoivledbenble about available services T 1=l D.35 that could hel me 57.17 RECOMMENDED 57.00 1116100 /ILAIN-II-DADE D -HT TY HOMELESS TRUST PROGR NT RLM:NrG OF SATISFACTION Section I.:TO BE COMPLETED BY PR(7GR_-0T PARTICIPA:'�'T Irrstructiort.c: Please answer each quesfioii below b} p/acirr, art /Ay irr the space prai'idcd. Your response c r,r r/resc questions have no hearing an tour continuedparticiparinrr ill the proorwn. ALL responses arc carr/irlc'rrtrr/. Why did You choose to enter the program (mark onk one box): I decided to come to this program on n)y ovm (thsou<uh outreach. referral. etc. r 1 was paced here throb! h another program (court inter�,ention, police. etc.) acal list I11\ 0I had previously participated M this or a similar program and decided to return OPTIONAL Information: Name: Today's Date: Sea: ❑ male ❑ female Please answer t/re foliowinb quesrions ahout the services you received. hlrrrk /,Yf only One hn_.' which hest descrihesyoirr feelings about each stateinerrt. These questiars are meant to help as improve t/re servi.ces-provided, SO we asi4- drat you tell us how yori really feel; whether or not it is Good or had. 5rrorzg4r I Agree Agree a Disagree Disagree Srrrirrg(r Agee I Linie 4 Lirrre D' I was informed of my rig tits and responsibilities, including the ageney's grievance procedures I was provided with information about different serTices that are as'aiiable for me I Was involved in making decisions about mV care/service lan I was able to talk with staff when I needed to The building. and facilities have usually been clean, safe and comfortable My rights were respected and protected, including my right to file a ariev'ance, if needed 511' case mannoer seems qualified to help me _I should recommend this program to others I am treated with respect bi, the staff ) The staff seems to care about whether I gel better Program staff were knowledgeable aboutavailable services that could help me [6] [5) [4) [31 Coor 121 [1) [6] [5] [41 13J [21 (I] [6] [j] [4] [3] [21 [I] [61 151 [!] [=] [21 [I] [6] [5) [4] [3] ['1 [1) [61 [51 [41 ['] [-') [11 [6) [,) [4) [=1 [71 [11 [61 [51 141 [3] ['l [1] [6) [5) [41 [=J [?) [11 [6I [) [4] 131 [2] [1] Section II.: TO BE COMPLETED BY PROGRAM STAFF Purpose of Eualuation 0 At Admission D At discharge _1 Other: f: e', J t.•'iii0o ForrmS%prGeramrai�n_ Current Level of Care pro rided Q emergency housing ❑ transitional housin^_!cx 0 transitional housinainon-c:< 0 permanent housing -1 ser.,ices only Pro%ider Name: Project game: Staff Initials: IMI. II-DADE COUNTYHOMELESS TRUST EVALUACI0'N- DE LA SATISF.ACCION CON EL PROGR-A)I.A Seccion L COMPLET-ADA POR EL P.ARTICIP.A�JE DEL PRO GRA�I.A Instrucciones: Por furor colo que una cru„ f:A% eir el espuciu proristo parry respIlid Cr a loS pry uruuc n CM I fill It :Jc'j(itl. L rr respuesrus que usred de a este cuestioarario no inl7uirdn de Loris alfyima whre io curuhruaciri ; de su porricirucir n en e-,rc• mL mna. TOG.-1SIus respuestasse matrrertdrdn conf7derrciu1n1e17re. ,,Por que decidi6 usted participar en d programa'.' (.Marque una casilla solamente): ( ) Lo decidi por mi cuenta (porque fui remitido o por medio de otro programa, etc ) [ J Ful colocado aqui medianle otro programa (por inrervencion de los tribunaics. la Policia, etc.) en contra de mi voluntad [ J Ya habia participado en este programa o en uno similar v decidi re-uresar Informacion OPCIONAL: Nombre y apeIlido: Fecha de hov: Gencro: M ( ) P 1 ) Por favor responda a las pregullfas siguierues acerco de los servicios que se le hutr preslado. In dique con una cru,; [Y/ EN UN4 SOLA CASILLA POR PREGUNT.4 la forma en que usred se siente acerco de Cade una de las cuestiones dascritas. Corzro sus respuestas a esnzs preguutas nos apudardn a rnejorar los servicios que presratnos, le rvounrus que nus hu; a saber coma se siente err realidad acerco de nuesrras servicios, no importa si usred los c•orzsidera bueiros o nurin.r. Se me jnformaron cuales eran mis derechosy responsabilidades, entre ellos, los procedimientos de la agencia ora ---- Se -mSe me dio informacion sobre los distintos servicios a los ue tenon derecho. Pnrtidpe en la toma de decisiones referentes a mi plan de atencion Y servicios. Pude hablar con el personal cuando rove necesidad de hacerio. EI centrH servicios por to general se han mantenido Jim jos, i;ro Y accesiblesSe respety protegieron mis derechos, entre ellos, mi derecho ter ue(as si to considero necesaric. Aparentemente, la persona e.ncargada de mi vaso sabe to _que tiene que pacer para avudarme Yo les recomendaria este provecto a otras personas. Los empleados me trataron respetuosamente Aparentemente, a ins empleados les interesa que yo me ore. Los empleados sabian que servicios pbdian servirme de avuda, Blur de I De I .Algo de I Algo en I£n acuerdo + acuerdo -ac-- -1 1 dcsdesa ncucrdu cucrd [6] [5] [` ] [=J [2J I u " N en acucrda [1J [6] 15l [4] [31 [-J [ 1l [6] 141 [31 ['J [1l [6) [61 [4) [=J ['] [11 [6] [d1 [4] ['J [ 1) [6] P] 141 1-1 121 (i ) [6] N [a) 131 12 (1) [6) fel (41 1-1 ['J [11 [b] 151 [41 [3) [6J [51 1411 [31 [') [ 1 J Seccion IT.: COMPLET4DA POR EMPLEADOS DEL PROGRA,NJA (completed b� proLyram stat Purpose of Evaluation C-urrent Level of Cure provided 1 D At ,Admission O Erne r-encv housing � Provider Notre: J At dischame ❑ transitional housingitx I Project Name: D Other I D riansiiional housineinon-n Staff [nitiais: O perm-aneni housing 0 sen ices onk, � Li 11. N11-DADE COU3NITY HOINIELESS TRUST M170GR1 M POU E VALYE S_-"kTJSFAKS Y0 pec: c;7 I. TOUT P.�TISII' \' \'-1\ PWr)GRaM SILa -\ FET PQU I\'_AN['LI J A.J :SA A Ensrri..si on: Tunpri reponn chak keksvoIt urlha /u a epi fietan ti kwa /.1,/ nanL'.Spl1,S k! vii la. Rc rlons noii hen• r u Lin ilerunic a.son it rip Aorainve alisi e nan wn,(=ram si/n u. Tour rcpolls- yo iip seri-. POUI:I W CHWAZI P.ATISCPE N,AN PW'OGRAA'I SILA A (fe son ti kwa nan con Brenn bwnt): O Se nneen ki chwazi vinn nan pwo,<..*,ram silo a (swa po referans, swa pn s6•is cspesv.i[ asist.ins piblik e[c.) (( Se pa chwa mwen, se yon )bt pwogram ki vosem (zak ti-ibinal, lapolis etc) j] Mwen to dejn potisipe nan yon pwogrom konsa epi mwen deside retounnen. Enfomasyon you bav si 'w vle: Non: Dat Jodya: Seks [] Cason [] Fcnrn Tarrpri reponln keksyon Bila yo dapre sevis w rescvyva. Fe yon Awa I.q 17111 Yon se1 ii kare epi clrrua i rC jJons ki plr:s matehe ave w. Keksyon silo vo la you ede nou b:a_y pi boll sevis, alb 1101/ 17ande tiou brit' repoiis ki plis- matcke rive w, ke Ii boll ou pa. Section II.: TO BE COMPLETED BY PROGRA.NI STAFF Purpose of Ei,aivarion I Currew Leve( of Care pro vided At Admission i ❑ emergency housing ! At discharge I E) mansitional housing!t>: C Ct i h r C transirtonai houslnv%non-tx jpermanent housing i—, services only Rel. 11/6/00 Furms.'croeranra(HIE Provider Name: Project Name: Staff initials: Bon jan dak6 I Dak6 Pa Finn I Pa dak6 Pa dak6 dako tou iti two dako ditou Yo fern konnen tout dwa mwen yo ak responsabilite [6] [5] [a] [3] [2] [)] mwen vo ak kouman ou mwen plenven nan awns la Yo to banmwen enf6masyon sou diferan sevis ke mwen [6] [6) [a] [3] [2] [I] �kab'wenn I Mwen to patisipe nan tout desizyon sou planifikasyon [6] [5] [=1] [3] [2) O] swen/sevis mwen Am (wave yo to toujou dis -nib pou mwen pale avek vo [6 15 [a) 31 1 [2) O ) Kote a ak bilding yo to toujou byes psvbp, konf6tab ak [6] [5] [4] [3] [2] [ I ] bon sekirite Tout dwa m to respekte ak pw•6teje menm d.wa m you [6] [6] [4] [3] [2] [l ] mwen to pote 21entsi nesese Aloun kap okipe ka mwen an sanble Ii kalifye you Ii [6] [5] [4] [3] [2] [i) edem Mwen 13 rekomande pwnram silo —abay lot moun 61 14 3j [21 I Am Iwaye yo trete mwen ak respe (6 [� (4] (3) 2 I ] Am hva),e yosanble s'o vreman enterese nan mwen (6 [?] 1 4j 131[2 (I Amplw•aye pivogram la to byen enf6mesou tout sevis ki [6] PI [-t] [3] [2] [I] to disponib you ede m. Section II.: TO BE COMPLETED BY PROGRA.NI STAFF Purpose of Ei,aivarion I Currew Leve( of Care pro vided At Admission i ❑ emergency housing ! At discharge I E) mansitional housing!t>: C Ct i h r C transirtonai houslnv%non-tx jpermanent housing i—, services only Rel. 11/6/00 Furms.'croeranra(HIE Provider Name: Project Name: Staff initials: ATTACHMENT F CLIENT CONTRIBUTION REPORT NAME OF AGENCY SUBMITTING REPORT - DATE REPORT SUBMITTED: GRANT NUMBER: REPORT COMPILED BY: MONTH OF SERVICE CLIENT NAME: DATE OF BIRTH: .DATE OF PROGRAM ENTRY: INCOME: SS U SSD (DISABILITY): SOC. SECURITY: AFDC/TANF: 'FOOD STAMPS: VETERAN'S BENEFITS: EMPLOYMENT: OTHER ( CHILD SUPPORT ALIMONY, WORKER'S COMP, ETC.) MEDICAID (Check One): IDENTIFICATION NUMER#: AMOUNT FOR MONTH S ❑ Yes ❑ No t*$ TOTAL ADJUSTED MONTHLY INCOME TOTAL: S AMOUNT THIS MONTH TO CLIENT TOTAL: S AMOUNT THIS MONTH TO PROVIDER **"- MAXIMUM 30% OF CLIENT'S ADJUSTED INCOME Revised 7/12/2007 U. S. Depart'nient of Housin�� and Urban Development Office of Connmuniiy Planning and Development U YID Approval No. 2506-U 135 (exp. 111110,12009) ATTACHMENT G Annul Progress Report (APR' for Supportive Rousing P> -ogram Shelter Plus Care and Seet�on S Moderate Rehabilitation for Single Room Occupancy Dwellings (SRO) Program form HUD -40118(08;_003) Public report in; burden lbr this collection of utfonnation is estimated to awra;;e 33 hours per rtspunse, including tht time l6r reviewing instructions, se:trclLim_ existing data sources, gadicring and mainLtining the data ne�d,-d, and completing and reviewing, dr: collection ol` n orntation. 'tlus agency may not conduct or sponsor, Jud a Person is not required to respoadyto, a collecaiou of inG,rnration unless that eollrction displas s a valid OMD control nutnhcr. General Instructions Purpose. The Aiuu>al Proeress Report (APR) track pro -rain pro, -,Tess and aecomplislunents in the DepLutmenCs competitive lionicless assistance progrtinis. Filing Requirements. Recipients of HUD's homeless assistance r'rants must subrnil 2 APR'S to HUD Ividhiu 90 tiuvs after the end of each opei.ztin,, `e it One copy of the report must be submitted to the CPD Division Director itt [lie local HUD Field Off -ice responsible for iruuiaging the ,rant. The other copy must be submitted to HUD Headquarters_ Department of Housing and Urban Development, Attn: APR Data Editor, Room 7262, 45I 7`i' Strcct, SW, Washington, DC. 20110. 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 whicli HUD funding is provided. Grantees that received SI -2 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 ivhich they use Sip funding for leasing, supportive services, or operations. For years in iviucli they do not receive SII' funding, they must submit an Annual Certification of Continued Project Operation throughout the 20 years. The certification can be found at the back of this APR, A separate report must be submitted for each HUD grant received. For Shelter PIus Care, a separate APR must be submitted for each Shelter Plus Care component. For those grantees receiving an extension, a separate report covering that period must be. submitted (see E�dension below).. Recordkeeping. Grantees must collect and maintain information. on each participant in order to complete an APR_ Optional nrorkshwts 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 subrriitted to HUD with the APR. Organization of the Report. The APR is organized in the following manner: Part T: Project Progress. This portion of the report describes the progress in moving 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 SIIP, S+C and SRO. Final kisernhly of Report. After. the entire report is assembled, number every page sequentially. Mark any questions dint do not apply to your program with "N/A" for not applicable. (See Special Instructions for SSO Projects below.) Definitions. The foUoiiving tents are used in the APR As indicated, in some cases, terms arc applied differently depending on svhetlier the funding is from SHP, S+C, or SRO. Chronicall-y- liorneless person - HUD defines a chronically hotueless person as "an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR leas liad at least four (4) episodes of homelessness in the past three (3) years." To be considered cluonicallylionieless a person must have been on the streets or in an emergency shelter (i.e.not transitional housing) during these stays. Disabling eonelition - HUD defines "disabling condition" as "a diagnosable substance use disorder, serous mental illness, dn!elopmental disability, or chronic physical illness or disability, including the co -occurrence of til:o or snore of these conditions. A disabling condition Iiniits an individual's abilily to work or perform one or niorc activities of daily Iiving.'' 1:ntered the program for SLC and SRO projects nicans wlicrt the participant starts to receive rental assistance. For S=C, semces provided prior to this point are recognized as nccessan, forotitreach/enrollment and are eligible to count as match. fume HUD -40113((0S;2003) An Extension APR applies to SI -IP and S+C grantees that requested and rcccivcd an extension of their ,rant term from the HUD field office. The only difference bem ecn an APR for the extension period and the rcwlar.APR (besides the amount of tune covered) is the siimat-urc pa,ye, Grantees should circle "yes" to indicate the APR is for an cmeIlslon period and circle the operaiing year for «hich the report is an c :-t.nsion. For example, if the grantee is eatendin- vear 3. the arLuilee should submit an APR as usimf lc)r }rtr 3, and submit another APP. for' the C%tcnsion period. indication the second is an extension and also circling year 3 on the signature page. Fancily nlcans a Irouscliold composed of two or more related persons, at least one ON houl is an adult. Caregivers are not reported on in the APR. Grantee nlcans a direct recipient of the HUD award, Left the program for S+C projects ntemis when the participant stops receiving rental assislance and is not expected to return to S+C assisted housing, If the participant returns to S+C assisted housing wAllin 90 days, the person should not be considered as exiting from lite program. If dic person returns to SA -C assisted housing after 90 days, that person is considered a new participant. The wcrkshect is designed to capture this inforntalion. 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 the value of the S+C rental assistance provided over Cite Iife of the project. For SHIP, match means cash used to provide the grantee's portion of acquisition, rehabilitation, new coristruction, operations and supportive services expenses. Operating year for SHP means the date when participants begin to receive housing and/or services. The first operating year begins after 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 new 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. 8 SRO, the first operating year begins Rrith the effective date of the Housing Assistance Payments (HAP) Contract. To detern.ine 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 grunt for two years would circle years 1, Z. and 3 respectively on Vie APR cover sheet for the initial grant and. would circle 4 and 5 respectively for the renewal gr,-mt. 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 cairying out the daily operation of the project, if the orzaniz atioa 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 tvffli the field office concerning wltich questions can be answered -using estimates, or in rare instances, skipped. Below is an example of houv information could be derived in a large, single -sen ice SSO project: A grantee/sponsor staff member could be assigned to collect information from the oiganizadons housing the participants. The st.alfperson would contact these individual organizations to request information regarding the persons in that facility that use the sen -ice. For participants living on the street, the grantee/project sponsor may provide estunates. Information could be coll::cted for each participant or for participants receiving sen ices it a point -in -tine. Lf estimates or point-in-tinic counts are used, the method used must be described in the APR and the documentation kept on 61c fonu HUD-10118((U�'?pUZ) As 11.411 all projects fiinded under HUD's homelessness assistance grants, grantees operating SSO projects arc expected to complete all APF, questions that are applicable to them. Note chat all projects have been awarded funds as a result or. respondin, to (lie pro -ram foals of assisting, Homeless persons obtain/remain ill perrnanernt liousinq, and increase their skills and income. The APP, documents dhcir pro ress in nion.ng these .10a1s. In some circumstances field offices and -raritees rna) siu'n a wriuen 1,rccment concerning questions w hicir can be answered using estimates, or in rare instances. skipped. Bclow are some considerations for reporting on purbCUIar V%Ws of projects: Outr-cach Only Projects. - Projects ,viiicli arc solely devoted to street outreach and connection to Housing and scn ices are not required to track participants beyond their contact with persons on the street. It is suflicicnt fol' these projects to enter information on questions 1-1.0 (skipping questions 11-13 and 17). Estimates for cluestioirs 5-9 are allowed, given that P' may be reluctant to. viswer personal questions. Answering the questions -,will demonstrate that the grantee is serving the appropriate number of people, providing basic dcurographic information for Congress, demonstrating that homeless persons are being served, demonstrating the types of housing participants are connected to, and the type of services they arc receiving - Hotline Fro ieets. - Hotline services are similar to outreach projects, but contact bchwcen grantee and participant is often of very short duration - people enter and leave the program nearly simultaneously. It is sufficient for these projects to ailstver questions 1-5 (skipping 4), 10, and 14-19 (skipping 17). Pr-oiects Providing Services To Children Only. - Projects that provide cILild care, after school care, counseling for children; etc. irralce an important contribution toward moving a family out of homelessness. While the main focus of the project is providing services to the children, it is the adults wbo are reported on in questions 6-16 of the APR Lilce all other projects, this type is also targeted toward getting the families into housing and increasing the families' incomes. Grantees may slap question 9; all other questions should be answered (except 17) - Transportation Medical Dental and Other Single Short-I3urstion 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 I-10 and 14-19 (question 17 maybe sldpped). 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 feiv blocks. For these services, provide 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 I,IStr-uCtions For Safe Haven (SH) Projects - Grantees are reminded that they are to report ONLY on the number of participants the application was approved for (cannot exceed 25 participants). HOMeless 19/tana!� eznent Inform.1tion System (HNTISS Projects. -HM1S grantees should fill out tite coverslteet of the APR (marking WTS at the bottom) and Part 11 Financial Information. The APR also has a sheet that Iists HMI activities. fomi HUD -401 I &1(0&:1uo-,) THIS Pa GE - TO BE COAIPLETED BYALI GI=4.,NTEES Grit t hM-) Grant or Proje:;t Number: Project Sponsor: Project None Reportntg Period: (month/dawycar) Operating, Year: (Circle the opc, ating year being reponcd on ) 01 02 03 ❑4 ❑5 ❑6 07 ❑S ❑`I 010 ❑ll 012 013 ❑14 ❑15 ❑16 017 ❑13 719 020 ludicatc if extetuiori. ❑ 7'cs ❑ IJo 1roiii: to: Lidicate if renewal: ❑ Yes ❑ No Previous Grant iJtunbers for this project: Check the component for the program on which. you are reporting. Supportive Eousinb Program (SEP) Shelter Plus Care (S+C') ❑ Transitional Housing ❑ Permanent Housing for Homeless Persons with Disabilities ❑ Safe Haven ❑ Innovative Supportive Housing ❑ Supportive Sen,ices Only ❑ HMIS ❑ Tenant -based Rental Assistance (TRA) ❑ Sponsor -based Rcntal Assistance (SRA) ❑ Project -based Rental Assistance (PRA) ❑ Single Room Occupancy (SRO) Section S Moderate Rehabilitation ❑ Single Room Occupancy (Sec. S SRO) Sunutlary of the project: (One or two sentences with a description of population, number served and accornplislmlents this operating yam) Name & Title of the Person who can ansiver questions about bis report: Address: E-mail Address Phone: (include area code) fax Number: (amlurYe area coae) I hereby certify that all the information stated herein is true and accurate. Warninb: I -M will prosecute false clauns 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: SiImathire & Datc: 1 lame and Title of Authorized Prgieci Speasor Official: Signature &, Date: N i form HUD -40118((O& UO3 ) PART L TO BE COMPLETED BYALL GR4NTEE,S (EXCEPT MANS) SSO GRANTEES, PLE: I SE .SEE SPECIAL LYSTR UCTIONS ON P, I GE 3 OF THE APER Part Z: Project Progress L Projected Level of Persons to be seii ed ata given point in time. (Frocri the application, SfJI'- Sec. F; SPC- Sec. DI- SRO- ;SRO- Sec. D) 2. Persons Served dtirin;g the operative, year. Number of Tlurnbzr of Number of hiunrbe, of Singles Not Adults ur Children Families ui F:mrilies Fuuilics nFmnilies FrojecledLevel a. Persons to i served at given point in tizn 2. Persons Served dtirin;g the operative, year. 3_ Project Capacity. Number of Number of Number of Number of Singles Not in Adults in Children in Families Fara&s Families Families a. Number on the last day (from 2d, columns I and 4) b. Number proposed in application (from. la, columns I and 4) J I C. Capacity Rate (divide a by b)= 4. Non -homeless persoas. This question is to be completed for Section S 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 catered the project during the operating }rear, bow many people are in the foIIolS�ing age and gender categories? i mrt HUD-40118((OS/?00, ) Number of I�`umber of Number of Number of Singles Net in Adults ui Children in FanuIies Farnilies Families Families the first day of tie operating year Fbuniber tering program during the operatuig year C, Number who left the program during the operating E— d. Number ut the proon die last day of the operat graiii, (a+b-c)=d 3_ Project Capacity. Number of Number of Number of Number of Singles Not in Adults in Children in Families Fara&s Families Families a. Number on the last day (from 2d, columns I and 4) b. Number proposed in application (from. la, columns I and 4) J I C. Capacity Rate (divide a by b)= 4. Non -homeless persoas. This question is to be completed for Section S 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 catered the project during the operating }rear, bow many people are in the foIIolS�ing age and gender categories? i mrt HUD-40118((OS/?00, ) A11smr questions 6 - 10 on!y for particiI)ani.s Iflio Cniered CLIC I)roeci (aur iil� tilt oyer utiuc Gar (frori 10. Prior Linins Situation. Hov,,, nlany participants slept bi the follo\tarL places Ln Qle %veck prior to enter lig the project? (For each participant, Choose one place). Also iudicale how many chronically liomeless participcuits slept in tile follov ing plac:s. (Choose one) rail Chronic' a. Non -housing, (street, park. car, hos station, etc-) b. Emergency shelter c. Transitional housing ibr honicicss persons .d. Psychiatric fucilil- * C. Substance abuse treatment facility* E Hospital" ga Jail/)risorn* h. Domestic violence situation i. Living v�nth reialives/friends j. Rental housim-, I. Other (please specify) *If a participant came from an institution but was there less than 30 days and was living on the street or ill emergency shelter before entering the treatment faculty, he/she should be counted un either the street or shelter category, as appropriate. Complete questions 11 -15 for all participants i4'h0 left during the operating year (from 2:c, columns 1 and 2). The term participant mems single persons and adults in families. It does not include children or caregivers. The tenu chronically Homeless person means gut 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. 11. Amount and Source of Monthly Income at Entry and at Esit. Of those participants who left during the operating year, howmany participants were at each mondily 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 coluum of each chart. The number of participants ill Chart A and B should be the sante. All Cluxmic A. Monthly Income at En thy a. No income b. $1-150 c. $151 -3250 d. $251- $500 e. $501 - $1,000 f. $ION $1500 g. S1501-$2000 h. $2001 + ?11 Cluonic foriu HUD -401 18((osz200 ; dl! Ckynnir All Chru it 12a. Leagth of Stay in Program. Of diose participants who left during the operating year (from 2c, columns 1 and 2), howmmiy were ui the project for the f0howing lengths of tune? Also, please place the length of sUdy for chrouicaily bGuieless persons in the second column_ All Chronic 12b. Length of Stay in Program. Por those participants that did not le.rre during the operating year (from 2d, colnunns 1 toad 2), how IM -4 hanle they been in the project? Also, please'place the lengtix of stay for Chronically homeless persons in the second colunm. ,All Chronic form HUtl-4011 18((0 '2003) B. N1011Lhh' hicome at Exit a. No income I i b. 11-I io i C. 1151 - 3-150 d. 1251- 1500 C. $501 - 51,000 I: 110(11-11505') g 1I (2000 Ii. 52001 + All Chru it 12a. Leagth of Stay in Program. Of diose participants who left during the operating year (from 2c, columns 1 and 2), howmmiy were ui the project for the f0howing lengths of tune? Also, please place the length of sUdy for chrouicaily bGuieless persons in the second column_ All Chronic 12b. Length of Stay in Program. Por those participants that did not le.rre during the operating year (from 2d, colnunns 1 toad 2), how IM -4 hanle they been in the project? Also, please'place the lengtix of stay for Chronically homeless persons in the second colunm. ,All Chronic form HUtl-4011 18((0 '2003) 13. Reasons for Tarn+•in.;. OCthose participants who lefr the project during the operating (Crow ?c. colunuis ] and 2), how ulama left for the 1'611ouing reasons? TCa p Lrticip int left for multiple reasons, include the prin ary reervu. Also, please place the prim.iry reason for chronicalh homeless persons in the second cohunn. Aft Chronic 14. Destination. Of those participants who left during the opernlulg year (from 2c, columns 1 and 2), how many left for the following destination? Also, please place the destination of chronically Locneless persons in the second column. All Chronic 10 form HUD -4011 S(r0S/2003) IS Supporthe Sen•ices. Of those participants who Iert durin^ the operating Year (Cron, 2, columns I and ?), hots• Imam• rece,Ived the fbllon^n; suppo tisc services during their time in the project? Also, please place the supportive senices received for ci�ronicnlly homeless participants who led during the operatuig ycx w the second column. All Chronic I I tomi HUD-40118i(08/2oo, ) 16. OveraII Program Gums_ Under objectiVeS, list your measurable Objectives for this OP-LItirie Your (frons tour applicatiun, TeclrtricaI Subnussion, or APR) for each of the three goals listecl huw. Undo: Progress, describe your pro_ ess in meeting the ohjectives. Under Ne, t Op,rating s'car's (?bjecti�es, s}�°cal}' lbe measurable obj, ctives for the next opiating rear. a. Rc.eidrufia! Stubilih Objectives: Process: Next Operatnrg Ycur's Objectives: b. Increased Skills orincome Objectives: Progress: NeA Operating Year's Objectives: c Greater Self determination Objectives: Progress: Next Operating Year's Objectives: 17. Betas. SIP recipients ,answer 17a. S+C recipients answer 17b. SRO recipients answer 17c. (SHP-SSO projects do not complete this questiotl) a. SHP. How many beds were included in the application approved for this project under `Current Level' and under `New Effort'? How, many of these New 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. S4 -C. Horn many beds and dwelling units were being assisted project funds at the end of the operating year? (Include beds for all participants, other family members, and care givers.) NumbcrofBeds: _ Number of Dtivellulg Units: _ c. SRO. How many dwelling units were being assisted at the end of the operating year? (Include units occupied by "ii place" non -homeless persons who qualify for assistance.) Number of Dwelling Units: 1? form HUD -14011 8((0v%?00_) Part fl: Financial Information 18. Supportive Senices. For Sunnortive Flousino (SHIT; t]1is e"lubit provides infort union to HUD on hosti SHP Curtding for supportive services evas spcttt during the operating year. EntCr the amount o(Sf-ir funding spent nu these supportive services. Incltale l-I[v[[S costs under "Other". For Shelter Flus Care (S+( ), this e>atibit tracks the supportive ser vices match requirement. Specify Ute value of supportive services from all sotnces Ilut um be cotulted as atatch Utat all homeless persons received during tite uperating year. (S+C grantees should keep c[octill ell InLifill oil file; incltu!irtg Sot.trce, amniuit, and hpe of supportive services.) Par Section 8 SRO, this exhibit provides in(orination to HUI) oil the value: oCsupportive sen'ices received by ]tonteless persons durin', the operating year. 13 Port HUD -401 18((08/2003) 19. Supportive Housing Pro!"rarn: Leasing. Supportive Sen ices, Qlteratin!T Costs, HNUS Activities :end Administration .-J1 receiviu5 binding under the Supportive Flousur; Proeram nws[ ::ompletr these charts each uperatui_ year. For expansion projects: U -SUP grant thuds are for the esp:u cion of a prc-c:;istuig homcless (acilitv, only the people mid e>:penditurss for the additional espurLsioa mat' be included. as in the original application or any jant amendrnemt . Documematiun of resources used is not required to be submitted "vitlt dl's report but should be kept on file for p„ssible insp.uion hy, HUD and Auditor♦•. Do not include am. eXpendrture made- betixe the SHP _rant was executed. Sunman of Expenditures. Fitter Cite auount of SI-iP sant Lulds :rtld cash match eNpendcd durin, the operQtulg year for cacti activity. This table should add up both horizontally and vertically. The SI-fP supportive services total should be die same as the SHP supportiae services i.n Question 18 SIT) l:tulds Cash Match Tolal F' pcnditures u- Leasing b. Supportive Services c. ( Operatutg Costs d. I I-IMIS Activities e. AdminisL LiLton 1: Total Note: Paymcuts of principal and utLerest on any loan or mortgage may not be shown as an operating expense. Sources of Cash Match. Eerier the sources of cash idendffied iu the Cash Match collum, above, in the following catel-ories. Use additional sheets, as necessary. • •.4znotuit rt Grantee/project sponsor cash b. I Local goverriment (please specify) I c. ( State government (please specify) I I Ld. Federal goverrunelit (please specify) Couirntttiity Development Block Gault (CDBG) I C. I Foundations (please specify) _ f. I Private cash resources (please specify) f g. � Oceu}�auc�charge 1 lees h. Tota ) 1 14 1form HUD-40113((pS:?(10}) 20. Supportive ffousiri!�Program: Acquisition, Rchallilitation, and (Veil Constniciion .111 ^_,ranges du( received SIE" funds for acquisition, rehabilitation, or new constrtmtion mus( cernpiete these charts in the year one APR oiill. ibis cshibit will dcmonslrate to HUD that elle grantee ltus contributed enoa-h ca�h to at Icust equally mafeh the amotult of SI -1p lauds slxru for acquisition, rehabilitation, or net.i construction. Docuniculation that malcl iti=' Ponds \acre provided is no( rexluired to be submitted with this rePor( bul should be kept 01) file for mssible inspection by FTUD and Auditors. Summary of Expenditures. Eliter die amount of SMP grant funds and cash match expencPed during the operatin" year for each activity. SHI Funds I Cash Match 'I'otal ii:,.pcnditures a. I Acquisilioa b. Rehabililialion C. New construction d. Total Cash Match. Enter elle sources of cash identified in the Cash Match column, above, in the following categories. Use additional sheets; as necessary. 15 Ibrna HUD -4011 6((OV2003) FOR HHTS.4cTXl-,7TIES 01,NI Y 21. For SueportiveHowhinv (SHP)—Hh1.1S Activities This c> :Mbit provides ulfonnation to I -{UD on howSI!1'-IDAJS funding for supportive services Baas spent during the operating scar. Enter the amount of S1111-1-11AIS funding, spent on these activities. IMISActivities Only Dollars Equipment ment Central Scrver(s) Personal Computers and Printers Networking Security Safil'afaf &I tware Soltzvare / User Licensing Sofiirarc Installation Support and Maintenance Supporting Software Tools Subtotal Services Training by Third Parties Hosting 1 Tecluucal Services Programming: Customization Programming: System Interface Prograu n-dn;: Data Conversion Security Assessment and Setup On-line Connectivity (Internet Access) Facilitation Disaster and Recovery Subtotal Fersorazel Project Management / Coordination Data. Analysis Prog ra.nuiung Teclulical Assistance and Training Administrative Support Staff Subtotal HMIS Space and Operation s Space Costs i Operabonal Costs Total 16 form HUD -401 15((01'209 ) Describe any problems arid/fir changes implemented during the operating year. Technical Assistance and Recommendations Based on your experience di the last year, are there any areas in which you need technical advice or assistance? If so, please describe. 17 fonn HUD-401118((OS,'2003) A11111rcr.t C'c,rtific(ition cf Continued Pro'ec�t Operas"oll SLIppol-tive 11ousing Program Project Number: Project Name: Operating Start Date: Grantees that received Supportive Housing Program funding for new constiuctioa, acquisition, or rehabilitation axe required to operate their facilities for 20 years. cea Lify 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 certify that the grant is still serving number of (mo/yr) (mo/yr) persons at (site address) aiid all the re quirem.ents of the grant agreement are being satisfied. (S ignature) (Title) `Current Year (Date of Certification) is hriv HUD -101 18((031,2003) Persons Servet) Worksheet - HUD Annual Progress Report '17111*,, Iaorksh,of is optional and is intended to help you collect ntformation needed to complete the Annual Progress Report. Instructions and Codes follow. Do tint suhmit this n urksheet to 111J D. Mame Relationship Entry Date Exit Number of \4onlbs in Number of btonths in New Participant Non -Homeless (SRO Dane of Binh .-age Gend.:r Dale Project (calculate) Project —Participant (Y / N) Only) 5a 51) N(-1') 12a did not leave (Y 1 N) (calculate) d 12b 19 MID -1011p, Persons Served Worksheet (continued) Do not submit this worksheet to HUD No. Veterans Status (1'r'N) 6a Chronically Ethnicity Race Special Needs Special Needs Prior Livi ig lvlonllaly Income Nforiddy Income Income Sources Income S„ rcas Homeless (code) (code) (code) (code) Sihialion At Project Entry At Project Exit At Entry .41 Evl (Y/J'\') 7 8 9a 9b (code) lln 11b (code) (co.1e) 6b 10 1 I ltd 20 1 11- D-4111 I PUSons Servet) Worhshe.et (continued) Do not submit this lvorluheet to Htm Ala Reoson for Leaving Deslinalion Supportive Services' Notes Program (code) (code) (code) 13 '14 15 21 11l iD-4t) I I S Instructions and Codes for Persons Seri cd "Nor•kshect The use of this .vcr1,shcct is optional. It was desi`uned to help you collect information on participants needed to complete the Annual Progress Report. If the worksheet is updated as participants move in and move out of your project, most of tine information required for completion will be contained in the worksheet. Do not submit this wclrksHeet With the APR. For projects that serve families, HUD drily requires reporting nn the number of children served, and the age and gender of these children. Only name, relationship, date of birth, and age 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. Participant Number. This column allows you to either number participants consecutively or to assign a case number. One number 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 proiect. Usually this will be the date the participant physically moved out for a housing project. Do not include a participant who temporarily left the project and is expected to return in less than 90 days (e.cl. hospllilizatioI1), Income-elk,ible Nou-homcless in SRO. The SRO proerani allows assistance to units occupied by Section 3 income -eligible persons residing at the SRO prior to rehabilitation. For SPO projects only, indicate whether the participant is an income -eligible, non -homeless person (Y) or not (N). SHP and S+C projects should skip tills Item. 5a. Date of Birtll. Later date of birth iucludin. nlorltti, dti y, and year. ?h. Ag,, e. Enter aec at entry 5c. Gender. Enter appropriate letter for ender. lvi•1`.1ale :I�- FCmule. 6a. Veterans Status. Indicate if the participant is a veteran. Ple(ISe 110le: 14 v(terrru is ur moue 11-hohas ever been on aclllle ruifilury duly slahl.s for I/le Uriilecl Slaic's. 6b. C'hronica ll), homeless person. Indicate the number of participants that are clironically Homeless . 7. Ltlinicity. Entcr appropriate letter for ethnic "roup. a. IIispariic 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 Hawaiian or Other Pacific Islander e. White f. American Indian/Alaskan Native & White g. Asian & White It. Black/African American & White i. American Indian/Alaskan Native & 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. HIV/AIDS and related diseases e. Developmental disability f. Physical disabilities Domestic violence h. Other (please specify) 9b. Enter the number of participants ,iitli a disability. 10. Prior Living Situation. Enter the letter that best describes where the participant slept in the week- prior eekprior to entering the project. Do not double count. Noll -}lousing (street, park, car, bus station, etc.) Emergency shelter Transitional Housing for homcless persons Psychiatric facility' Substance abuse treatment facility* Hospital* JaiUprison* Domestic violence situation Living iiitlt relaLlves/friends Rental Hotlsinp FrUD-4011 S k. (Other (please specify) 1. Reached uiat;imunt time allowed in project NecJs could nc;t be met by project "If a participant carne from an institution but b. Disagreement with rules/persons was there Less than 30 days and taus living on the i. Death street or in an emergency shelter before cnterin� the j. Other (please specify) facility, Ire/she should be counted in either the street k. Unknuarn/disappcarel or shelter cate-gory, as appropriate. Instruction Codes for Persons Served Worksheet (continued) I la.Gniss Monthly Income at Prujcct Entry. 14. DestinatiOu. Enter the destination of those Enter the amount of gross monthly income the Ieavino the project. participant is receivins at entry into the project. Permanent: a. Rental house or apartment (no subsidy) I Ib.Gross Monthly Income at Project Exit. Enter b. Public Housing the gross monthly incnine the participant is C. Section 8 receiving when exiting the project. d. Shelter Plus Care e. HOME subsidized house or apartment I1c.Incorne Sources Received at Project Entry. f. Other subsidized house or apartment Enter all types of assistance the participant is g. Homeownership receiving at entry to the project. h. Moved in with family or friends a. Supplemental Security Income (SSI) Transitional: b. Social Security Disability Insu Insurance (SSDI) i. Transitional housing for homeless persons c. Social Security j. Moved in with family .or friends d. General Public Assistance Institution: e_ Temporary Aid Needy Families (TANF) k. Psychiatric hospital. f. State Cluldren's Health Insurance Progxam (SCHIP) 1. Inpatient alcohol or drug treatmeait facility g. Veterans benefits M. Jail/prison h. Employment income Emergency: i. Unemployment benefits n. Emergency shelter j. Veterans Health Care Other: k. Medicaid o. Other supportive housing. 1. Food Stamps p. Places not meant for. human habitation m_ Other (please specify) (e.g. street) n. No Financial Resources q. Other (please specify) Unknown: Ild.Income Sources Received at Project Exit. r. Unknown Enter all types of income the participant is receiving at project exit. (Use codes as in 11c.) 15. Supportive Services. Enter all types of supportive services the participant received 12a Length in Stay in Program. Calculated item. during the time in the project. (See Entry Date and Exit Date above.) a. Outreach b. Case management 12b. Length of Stay in Prugrain. (Participant did c. Life skills (outside Of CdSe inaRaoetllCnt) not leave during the operating year. How long d. Alcohol or dying abuse services have they been in the project'?) e. Mental liealth services f. HIV/AIDS-related services 13. Rcason for Leaving Project. Enter. the primary g. Other health care services reason why the participant left the project. ]r. Education (Complete only for participants who left the i. Housing placement project and are not expected to return within 90 j. Einrployrnept assistance days. k.. Child care a. Left for a housing opportunity before 1. Transportation completing the program ni. Leea] b. Completed program n. Other (please specify) c. Non-payment of rent/occupancy charge d. Non-compliance with project e. Criminal activity' /destruction of property'/ violence 2 i 14UD-1011:1 s • 1f r �• 11 i )r Home CllentPolnt Resource Point Sht-lterrclnt I HUD Annual Progress Report (HUD -40115) Miami -Dade County Government SI:an--omn YP.eports I AJrnin I Help I Lo?^c ATTACHMENT G-1 Report Options: Select t;'t Unduplicated Provider I°tiami-Dade County Government Operating Year Date range F05/01/20076 to 05/31/200ti (rnm/dd/yy) y) Legal Adult Age i8 (as defined by foster care law in your state) Or t .. , •. r' -Select- 6 2. Persons Served during the Number of Sin les Number of Adults 9 Number of Children in Number of o eratin ear. P g y Not in Familie in Families Families Families a. Number on the first day of the operating year. 0 0 0 J 0 b. Number entering program during the operating year. 0 0 0 0 c. Number who left the program during ! the operating year. 0 I 0 0 III 0 d, Number In the program on the last day of the operating year. (a+b -c=d) 0 0 0 0 3. Project Capacity.Number Number of Singles Number of Adults of Children in Number of Not in Families in Families Families Families a. Number on last day (from 2d, columns 1 and 4) 0 I 0 4. Non -homeless persons. (Sec. 8 SRO projects only) How many Income-ellgible non -homeless persons were housed by the SRO program during the operating year? 0 5. Age and gender. Age k4afe (Female Other/Nbt given Single Persons (from 2b, column 1) a. 62 and over 0 0 0 b. 51 61 0 0 0 c. 31 50 0 ' 0 0 Id. IS'- 30 0 0 0 e. 17 and under I 0 0 I 0 Not given I 0 0 0 Persons in Families (from 2b, columns 2 3) f. 62 and over 0 0 l 0 g. 51 61 1 0 0 I 0 Ih.3i SO j 0 ' 0 0 hrtps:l;�,��^,.��3.ser�icept.com/mialni/script;/s'��preporthuu.php i��l s/yUh� 6a. Veterans Status. A veteran Is anyone who has ever been on activP rnllita r'y' dut, StatUS 6b. Chronically Homeless. How many participants were chronically homeless individuals' 7. Ethnicity. Ia. Hispanic or Latino b. Non -Hispanic or Non -Latino S. Race. a. American Indian or Alaskan Native b. Aslan c. Black or African American d. Native Hawaiian or Other Pacific Islander e. White f. American Indian;Alaskan Native & White g. Aslan & White h. Black/African American & White i. American Indian/Alaskan Native & Black/African American j. Other Multi -Racial k. Other/Unknown (all that do not match) 9a. Special Needs. it I I I Ali + Chronic k 6 0 I n I 0 I-5� 0 0 m. under 1 0 0 0 'Not given I I 0 0 6a. Veterans Status. A veteran Is anyone who has ever been on activP rnllita r'y' dut, StatUS 6b. Chronically Homeless. How many participants were chronically homeless individuals' 7. Ethnicity. Ia. Hispanic or Latino b. Non -Hispanic or Non -Latino S. Race. a. American Indian or Alaskan Native b. Aslan c. Black or African American d. Native Hawaiian or Other Pacific Islander e. White f. American Indian;Alaskan Native & White g. Aslan & White h. Black/African American & White i. American Indian/Alaskan Native & Black/African American j. Other Multi -Racial k. Other/Unknown (all that do not match) 9a. Special Needs. it I I I All Chronic a. Non -housing (street, park, car, bus station, etc.) 0 , 0 b. Emergency shelter I 0 0 c. Transitional housing for homeless persons 0 d. Psychiatric facility 0 e. Substance abuse treatment faculty 0 F. Hospital 0 g. Jafi/prison I 0 h. Domestic violence situation II 0 i. Living �r,ith relatives/friends f 0 j. Rental housing I 0 jI https://��,.tiw2.ser; icept.com/Iniarni/scripts/svpreporthud.php 6/14/2006 Ali + Chronic a. rental Illness 0 :0 b, Alcohol abuse 0 0 c. Drug abuse 0 0 d, HIV/AIDS or related diseases 0. 0 e. Developmental disability 0 0 If. physical dlsablllty 0 0 9. Domestic violence h. Other (please specify) 9b. Disabled. 0 I 0 0 0 How many 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 I 0 0 c. Transitional housing for homeless persons 0 d. Psychiatric facility 0 e. Substance abuse treatment faculty 0 F. Hospital 0 g. Jafi/prison I 0 h. Domestic violence situation II 0 i. Living �r,ith relatives/friends f 0 j. Rental housing I 0 jI https://��,.tiw2.ser; icept.com/Iniarni/scripts/svpreporthud.php 6/14/2006 11. Amount and Source of Monthly Income at Entry and Exit. Amount A. Monthly Income at Entry I B. Monthly Income at Exit No Income All I Chronic I I 0 I 0 All 0 I Chronic O �a. b. s1-150 0 0 0 I 0 c. $151 - $250 d. $251 5500 e.$501 $1000 0 0 I 0 I 0 I 0 I 0 I 0 0 0 0 0 I 0 f. $1001 $1500 0 0 I 0 0 g-51501 $2000 0 I 0 I 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 I 0 0 0 b. Social Security Disability Insurance (SSRI) 0 0 0 0 c. Social Security 0 0 0 0 d. General Public Assistance 0 0 0 0 e. Temporary Aid to Needy Families (TANF) 0 I 0 0 + 0 f. State Children's Health Insurance Program (SCHIP) I 0 0 0 0 g. Veterans benefits I 0 0 0 0 h. Employment Income 0 0 0 ! 0 i. Unemployment Benefits I 0 0 0 0 j. Veteran's Health Care I 0 I 0 0 0 k. Medlcald 0 0 0 ( 0 I. Food Stamps 0 0 0 0 m. Other (please specify) 0 0 0 0 n. No financial resources 0 I 0 12a. Length of Stay in Program. (Participants who left during operating year) 0 0 All , -Chronic a. Less than i month 0 0 b. 1 to 2 months 0 I 0 c. 3- 6 months I 0 I 0 d. 7 months - 12 months 0 0 e. 13 months - 24 months 0 0 f.•25 months - 3 years I 0 0 g. 4 years - 5 years 0 0 h. 6 years - 7 years 0 0 i. 8 years - 10 years 0 0 j. over 10 years 0 0 12b. Length of Stay in Program. (Participants 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 I 0 0 d. 7 months - 12 months, 0 I 0 e. 13 months - 24 months I 0 I 0 f. 25 months - 3 years I 0 I 0 g. 4 years - 5 years 0 0 ht-tps:/;"WT,-W3',serviceptami/scripts/svpreptu-thud.pilp 6/14/2006 I. 6 years - 10 years IL over 10 year,C 0 I13. Reasons for Leaving. All ++ Chronic a. Left for a housing opportunity before completing program 0 I 0 b. Completed program 0 I 0 �c. Non-payment of rent/ocr-upanc/ charge I ( 0 d. Pilon -compliance vdlth project 0 1 n e. Criminal activity / destruction of property / violence U==0=' f. Reached maximum time allowed In proiect 0 0 g. Needs could not be met by project 0 G h_ Disagreement with rules/persons 0 0 i. Death 0 0 j. Other (please specify) 0 0 k. Unknown/disappeared 0 0 14. Destination. 'h. Moved in with family or friends I 0 All Chronic PERMANENT (a h) a. Rental house or apartment (no subsidy) ( 0 0 b. Public Housing 0 I 0 c. Section 8 0 0 d. Shelter Plus Care 0 0_ e. HOME subsidized house or apartment 0 , 0 f. Other subsidized house or apartment 0 I 0 g. Homeownership 0 0 'h. Moved in with family or friends I 0 0 TRANSITIONAL (i - j) Ii. Transitional housing for homeless persons 0 0 1j. Moved' in with family or friends 0 0 INSTITUTION (k - m) k. Psychiatric hospital 0 , 0 Il. Inpatient alcohol/drug treatment facility 0 0 m, ]all/prison0 0 EMERGENCY SHELTER (n) n. Emergency shelter 1 0 I 0 OT14ER {o - q) o. Other supportive housing 0 I 0 p. Places not meant for human habitation (e.g, street) 0 =0 q. Other (please specify) 0 0 UNKNOWN is. Supportive Services. Ir. Unknown 0 0 No supportive services found. ServicePoint version 4.01.018 (db build #0723) Licensed to: tdiami Dade Homeless Trust C> 1999-2006 Bowman Systems L.L.C. All Flights Reserved. CPT only (0200' Am^flCan MCdiC81 Association. All Rly'hl:S RCSCrv_d. DShI and DSH-I'd-TR are registered t'ademarks of title Arnc'ric3n Psechictrc ASSc;clailon, and arc used ',',41 l permisslCn litrelit. ICD -9 -CM, x6)1994 Na tonal Center for Health Statistics 0CD-9 ")World Health ClrQan!La•`.lon), All Rights R_serred. Tazonom>' a�1983-2003 information and Re _rral Federation of Lcs X^,r Lle, Cou-., inc. All 2 p^.ts P.=-ser,;ed icepLcol;l"nala li/scripts;'svpreportlaud.plip 6x'1412006 Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). social security amber 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 (EIN). If you do not have a number, see How to get a TIN on page 3. or Note: If the account is in more than one name, see the chart on page 4 for guidelines on whose number Employer identification number to enter. I � I I l_-1 I ' Under penalties of perjury, I certify that 1. The number shown on this form is my correct taxpayer identification number (or J 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 Internal Revenue Service (IRS) that 1 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 I 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 notified 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 Signature of Here I us. person 0- Date 00 - 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 IRA. 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 contain a provision known as a "saving clause." Exceptions specified in the saving clause 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 claimed 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) W-9 Farm Request for Taxpayer Give form to the (Rev. January 2003) Identification Number and Certification requester: Do not Department of the Treasury send to the IRS. Internal Revenue Service N Name uT to a Business name, if different from above c 0 N ` 7 Individuall Check appropriate box: ❑Sole proprietor Corporation Partnership Other ► _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Exempt from backup ❑withholding o r = N Address (number, sweet, and apt. or suite no.) Requester's name and address (optional) •� c ao City, state, and ZIP code �= 0 N a List account number(s) here (optional) au GM TaxPayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). social security amber 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 (EIN). If you do not have a number, see How to get a TIN on page 3. or Note: If the account is in more than one name, see the chart on page 4 for guidelines on whose number Employer identification number to enter. I � I I l_-1 I ' Under penalties of perjury, I certify that 1. The number shown on this form is my correct taxpayer identification number (or J 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 Internal Revenue Service (IRS) that 1 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 I 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 notified 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 Signature of Here I us. person 0- Date 00 - 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 IRA. 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 contain a provision known as a "saving clause." Exceptions specified in the saving clause 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 claimed 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) Forth W-9 (Rev. 1-2003) Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, tdis 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 If 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 sut4ect 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 TINS. If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties. Specific Instructions 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 in joint 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" fine. 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 Individual/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(f)(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 instrumentalities; 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; 8. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States; . Form W-9 (Rev. 1-2003) Page 3 9. A futures commission merchant registered 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 regularly acts as a broker Barter exchange transactions Exempt recipients 1 through 5 and patronage dividends Payments over $600 required Generally, exempt recipients to be reported and direct 1 through 7 Z sales over $5,000 See Formol 1099-MISC, Miscellaneous Income, and its instructions. ZHowever, the following payments made to a corporation (including gross proceeds paid to an attorney under section 6045(f), even if the attorney is a corporation) and reportable on Form 1099-MISC are rwt exempt from backup withholding: medical and health care payments, attorneys' fees: and payments for services paid by a Federal executive agency. Part 1. Taxpayer Identification 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 it 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 char on page 4 for further clar6cation 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 www.ssa.gov/online/ss5.htrd. 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 Applied For" means that you have already applied for a TIN 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. Form W-9 (Rev. 1-2003) Part If. 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 1983 and broker accounts considered inactive during 1983. 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 (including 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. Page 4 What Name and Number To Give the Requester For this of accoL": Give name and SSN or; 1. Individual The individual 2. Two or more individuals aoint 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 S. Sole proprietorship or The owner a single -owner LLC For this type of account; Give name and EIN of: 6. Sole proprietorship or The owner 3 single -owner LLC 7. A valid trust, estate, or Legal entity ' pension trust 8. Corporate or LLC electing The corporation corporate status on Form 8832 9. Association, club, religious, charitable, educational, or other tax-exempt organization 10. Partnership or multi -member LLC 11. A broker or registered nominee 12. Account with the Department of Agriculture in the name of a public entity (such as a state or local govemmerit, school district, or prison) that receives agricultural program payments The organization The partnership The broker or nominee The public entity 'List fast and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person's number must be furnished, =Circle the minor's name and furnish the minor's SSN. 'You must show your individual name, but you may also enter your business or "DBA" name. You may use either your SSN or EIN (if you have one). ' List first and circle the name of the legal trust, estate, or pension trust (Do not furnish the TIN 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 will be considered to be that of the first name listed. 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. 9 Applicant Certification These certified statements are required by law. Previous versions obsolete form HUD-MO904 A. For the Supportive Housing (SHP), Shelter Plus Care (S+C), and Single Room Occupancy (SRO) programs: Fair Housing and Equal Opportunity. It will comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000(d)) and regulations pursuant thereto (Title 24 CFR part I), which state that no person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the applicant receives Federal financial assistance, and will immediately take any measures necessary to effectuate this agreement. With reference to the real property and structure(s) thereon which are provided or improved with the aid of Federal financial assistance extended to the applicant, this assurance shall obligate the applicant, or in the case of any transfer, transferee, for the period during which the real property and structure(s) are used for a purpose for which the Federal financial assistance is extended or for another purpose involving the provision of similar services or benefits. It will comply with the Fair Housing Act (42 U.S.C. 3601-19), as amended, and with implementing regulations at 24 CFR part 100, which prohibit discrimination in housing on the basis of race, color, religion, sex, disability, familial status or national origin. It will comply with Executive Order 11063 on Equal Opportunity in Housing and with implementing regulations at 24 CFR Part 107 which prohibit discrimination because of race, color, creed, sex or national origin in housing and related facilities provided with Federal financial assistance. It will comply with Executive Order 11246 and all regulations pursuant thereto (41 CFR Chapter 60- 1), which state that no person shall be discriminated against on the basis of race, color, religion, sex or national origin in all phases of employment during the performance of Federal contracts and shall take affirmative action to ensure equal employment opportunity_ The applicant will incorporate, or cause to be incorporated, into any contract for construction work as defined in Section 130.5 of HUD regulations the equal opportunity clause required by Section 130.15(b) of the HUD regulations. It will comply with Section 3 of the Housing and Urban Development Act of 1968, as amended (12 U.S.C. 1701(u)), and regulations pursuant thereto (24 CFR Part 135), which require that to the greatest extent feasible opportunities for training and employment be given to lower-income residents of the project and contracts for work in connection with the project be awarded in substantial part to persons residing in the area of the project. It will comply with Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), as amended, and with implementing regulations at 24 CFR Part 8, which prohibit discrimination based on disability in Federally -assisted and conducted programs and activities. It will comply with the Age Discrimination Act of 1975 (42 U.S.C. 6101-07), as amended, and implementing regulations at 24 CFR Part 146, which prohibit discrimination because of age in projects and activities receiving Federal financial assistance. It will comply with Executive Orders 11625, 12432, and 12138, which state that program participants shall take affirmative action to encourage participation by businesses owned and operated by members of minority groups and women. If persons of any particular race, color, religion, sex, age, national origin, familial status, or disability who may qualify for assistance are unlikely to be reached, it will establish additional procedures to ensure that interested persons can obtain information concerning the assistance. It will comply with the reasonable modification and accommodation requirements and, as appropriate, the accessibility requirements of the Fair Housing Act and section 504 of the Rehabilitation Act of 1973, as amended. Additional for S+C: If applicant has established a preference for targeted populations of disabled persons pursuant to 24 GFR 582.330(x), it will comply with this section's nondiscrimination requirements within the designated population. B. For SHP Only. 20 -Year Operation Rule. For applicants receiving assistance for acquisition, rehabilitation or new construction: The project will be operated for no less than 20 years from the date of initial occupancy or the date of initial service provision for the purpose specified in the application. 1 -Year Operation Rule. For applicants receiving assistance for supportive services, leasing, or operating costs but not receiving assistance for acquisition, rehabilitation, or new construction: The project will be operated for the purpose specified in the application for any year for which such assistance is provided. C. For S+C Only. Supportive Services. It will make available supportive services appropriate to the needs of the population served and equal in value to the aggregate amount of rental assistance funded by HUD for the full term of the rental assistance. D. Explanation. Where the applicant is unable to certify to any of the statements in this certification, such applicant shall attach an explanation behind this page. Signature of Authorized Certifying Official: I Date: Title: Applicant: For PHA Applicants Only: (PRA Number) - ,T T .%CT -I Oy ,T ,j 1IL� 1I -D -SDE COUWTY HO-' IELESS TRUST COUNTY RLQ-UUIFL ED -AFFID ITS Tne con actin, individual or crit iry eovcmmcntaI or ocher -,v 5f: sha11 in by as a:. that pertain to this contract and shall indicate by an "N/A" all a,`r"idavits than do not -sura : _a l ", a, it blah}: s a�,.� - r- i� [o p must be fi Iled. The I<IIA1vLl-DADS COUNTY OWNERSH P DISCLOSURE AFFIDAVIT; NIJ,A{ n (1-D,=,D1✓ Col_;,, ' .:r E1v1PL0)'1,.1E14T DISCLOSUP7 AFFIDAVIT; NfLAM1-D. DE CRPv1NAI- F=CJF:D AFFIDAVIT; DISABILITY NONDISCRIT,ENATION AFFIDAVIT; and the FRO-TECT FRESH START AFFIDA'v1T shall not pertain to contracts with the United States or any of its departments or a`erncies thereof, the State or ariv political subdivision or agency Li ereof or any municipality of this State. The MIAMI-DADE FAk4ILY LEAVE AFFIDAVIT shall not pertain to contracts with the United States or any of its departments or ,agencies or the State of Florida or an), political subdivision or agency thereof; it shall, however, pemain to municipalities of the State of Florida. All other conn -acting entities or individuals shall read carefully each affidavit to determine whether or not it pertains to this contract. I, Affiant being first duly sworn state: The full legal name and business address of the person(s) or entity contracting or transacting business with Miami -Dade County are (Post Office addresses are not acceptable): Federal Employer Identification Number (Ifnone Social Security) Name of Entity, Individual(s), Partners, or Corporation Doing Business As (if same as above, leave blank) Street Address City State Zip Code _I. MIAMI -DADS COUNTY OWNERSHIP DISCLOSURE AFFIDA`1IT (Sec. ?-S_1 ofthe County Code) 1. If the contract or business transaction is with a corporation, the full lcgal name and business address shall be provided for each officer and director and each stockholder «-ho holds directly or indirectly five percent (S%) 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 !o contracts «ith publicly traded corporations or to contracts" with the United States or any department or agency thereof the State or any political subdivision or acency d�ereof or any municipality of this State. All such names and addresses are (Post Office addresses are not acceptable): I aft Full Leal ream, dress 0 •ners;,ip 0 0 0 The full legal names and business address of any other individual (other than subcontractors, maien2l men, suppliers, 12borers, or lenders) :vho have, or v,/ill have, any interest (legal, equitable beneficial or otherwise) in the contract or business transaction With Dade County are (Post Office addresses are not acceptable): Any person who willfully fails to disclose the information required herein, or who knowing.ly discloses false information in this regard, shall be punished by a fine of up to five hundred dollars (5500.00) or imprisonment in the County jail for up to sixty (60) days or both. II. MI -A -MI -DARE COUNTY EMPLDYNfENT DISCLOSURE AFFIDAVIT (County 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 renewal thereof which involves the expenditure of ten thousand dollars (SI 0,000) or more shall require the entity contracting or transacting business to disclose the following information_ The foregoing disclosure requirements do not apply to contracts with the United States or any department or agency thereof, the State cr any political subdivision or agency thereof or any municipality of this State. 1• Does your firm have a collective bargainingagreement with its employees? Yes _ No 2. Does your firm provide paid health care benefits for its employees? Yes No 3• Provide a current breakdown (number ofpgrsons) of your firm's work force and ownership as to race, national origin and gender: White: Males Females Asian: Males Females Black: Males Females American Indian: Males Females Hispanics: Males Females Aleut (Eskimo): Males Females — Males Females: Males Females —III. AFFIF2 AT7VE ACT10N/N0Nr1DISCRIPfINATl0N OF EMPLOYh1ENT, FROMOTIONAND PROCURENfENT PRACTICES (County Drdinance'98-30 codified at 2-8.1.5 of the County Code.) In accordance � ith County Ordinance No. 9S-30, entities with annual gross revenues in excess of 55,000,000 seeking to contract with the Count} shall, as a condition of receiving a County contract, have: i) a ,,-mitten affirmative 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 written procurement Policy 'Ahich sets forth the procedures the entity utilizes to assure that iz does not discriminate aeainst minority and women-o�tned businesses in its 0%`M procurement of roods, supplies and se vices. Such aiiurmative action plans and procurement policies shall provide for periodic FeVle"y to determine thei of;e`ti''eness in assurinL7 the enti7' r does not discriminate in its empIo}7nent promotion and procurement practices. The foregoing norvithstanding, corporate entities whose boards ofdirectors are represe;;tative of the population make-up of the nation shall be presumed to have non giscrirn; to-c =mplovmenlet and procurement pollc, and shall not b2 HJ'' r to h2vf 'ff?en a - Gla7s and procurement Fcdicles In or'�_er io rec-fl',­_ a Counr., contraot. Th toren in' pf �� Iptf�n f i oe rebu rid. The requirements of Count}' Ordinance No. 95-30 may be wo ved upon the vM'Flen reC in, men, jon c,; the County., Mana,:�er that It is in the best interest of the County. to do so and upon approval of the Soar d of Counn• Commissioners by maiorirr vote of the members present. The firm does not have annual gross revenues in excess of 55,000.000. The firm does have annual revenues In c:cess of 53.000,000; horvc%,cr, its Board of Directors i_, representative of the population ma::e-up of the nation and has submitted a v,7inen. detailed listing of its Loard of DIr�L'tOrS, including the race or ethnicity of each board member, to the County's Department of Business Development, 175 N.W, lst Avenue, 2Sth Floor, Miami. Florida 33128. The firm has annual gross revenues in excess of 53,000,000 and the firm does hay e a written aftirniative action plan and procurement policy as described above, which includes periodic revlevvs to determine effectiveness, and has submitted the plan and policy to the County's Department of Business Development 175 N.W. I St Avenue, 28th Floor, Miami, Florida 33125; The firm does not have an affirmative action plan and/or a procurement policy as described above, but has been aranted a waiver. _IV. MIA.Mi-DADE COUNTY CRIMINAL RECORD AFFIDAVIT (Section 2-8:6 of the County Code) The individual or entity entering into a contractor receiving funding from the County has has not as of the date of this affidavit been convicted.of a felony during the past ten (I 0) years. An officer, director, or executive of the entity entering into a contract or receiving furndln, 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 -DADS EPTLOYNENT DRUG-FREE WORKPLACE AFFIDAVIT (County Ordinance No. 92-15 codif ed as Section 2-8.1.2 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 inform the employee about.- I. bout:1. danger of drug abuse in the workplace 2. the _firm's policy of maintaining a drug-free environment at all workplaces 3. availability ofdratg 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 emplo}anent that the employee will abide by the terms and notify the ernployer of any criminal drug conviction occurring no later than five (5) days after receiving notice of such conviction and impose appropriate personnel action against the employee up to and including termination. Compliance with Ordinance. No. 92-13 may be waived if the special characteristics of the: product or service off --red by the person or entity make it necessary for the operation of the County or for the health, safety, welfare, economic benefits and well-bein, of the public. Contracts involving funding v"hich is provided -in whole or in part by the Llnited States or the State of Florida shall be exempted from tine provisions of this ordinance in those instances ..here those provisions are in conflict 'with requirements ofthos,- entities. EI�LG'Yi� i l FAirffL�' LFAs L ?.Pr%D.1 �'IT (`Dunn.' Ordinsn 142-91 codii-reds Section 1 iA-29 et. seq of 1' t Cour Cc),J That in compliance !vi[h Ordinance .14o. 142-91 of L'1e Code of 1'�Il:11`7; i -Dade Cocnr, , Florida, an empioyer with fifty (50) or more emplavees wori:ing in Dade Counr.• for each �voFking day Burin, each of t-o.,crinf (20) or more calendar Mork v,,ee)s, shall provide the folln\rine rnforranon in compUance ",A all items in the aforementioned ordinance: An employee who has worked for the above firm at least one (1) year shall be entitled to niner., (90) days of family leave durin« any r enty-four (24) month period, for medical reasons, For the birth or adoption of a child, or for the care of a child, spouse or other close relative xho has a serious health condition without risk of termination of employment or employer retaliation. The foregoing requirements shall not pertain to contracts with the United States orany department or agency thereof, or the State of Florida or an}' political subdivisior, or agency thereof. It shall, however, pertain to municipalities of this State. `VII. DISABILITY" NON-DISCRIMIINATION AFFIDAVIT (County Resolution R-385-95) That the above named firm, 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, transponation, communications, access to facilities, renovations, and new construction in the following lasses: The Americans with Disabilities Act of 1990 (ADA), Pub. L. 101-336, 104 Stat 327, 42 U.S.C. I2I01-I22I3 and 47 U.S.C. Sections 225 and 611 including Title I, Employment; Title II, Public Services; Title III, Public Accommodations and Services Operated by Private Entities; Title IV, Telecommunications; 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 3601-3631. The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof, the State or any political subdivision or agency thereof or any municipality of this State. _VIII. MIAMI -DADS COUNTY REGARDING DELINQUENT AND CURRENTLY DUE FEES OR TAXES (Sec. 2-8.1(c) ofthe County Code) Except for small purchase orders and sole source contracts, that above named firm, corporation, organization or individual desiring to .transact business or enter into a contact with the County verifies that all delinquent and currently due fees or taxes -- including but not limited to real and Property taxes, utility taxes and occupational licenses -- which are collected in the normal course by the Dade County Tax Collector as well as Dade County issued parking tickets for vehicles registered in the name of the firm, 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 al) its obligations to the County and is not otherwise in default of any contract, promissory note or other loan document with the County or any of its agencies or instrumentalities. —X. PROJECT FRESH START (Resolutions R-702-98 and 358-99) Any firm that ha -s a contract «'ith the Country that results in actual payment of 5500,000 or more shall contribute to Project Fresh Start, the County's -Welfare to ','Fork Initiative. However, if Five percent (5°:0) of the firm's �sorl: force consists of individuals svho reside in Miami -Dade County and vvho have lost or will lose cash assistance benefits (for-merl-v Aid to Families v:ith Dependent Children) as a result of the Personal Responsibility and Work Opportunity Reconciliation ,pct or^ 1996, the firm M4 request waiver from the requirement; of R -702-9S and P -358-9c' by submitting a .vaivei- request aiitdam7t. T'n` reoulremeni does not pe=rn to _,tiernme0i ennrie_, nr: ;or rc•;i rf orreciri_nts of«rant a+,ar �. I ,� M}JTS—FIC V70LtNCE LE -AT (Resolution 135-001 o9-5 Codified At 114-60 -bC Et. Sea, or the !Miami -Dade Counry Code). The hrrn desirinc to do business ivlth dlc Count-,! is in compliance vvlth Domestic Lea`.`c Ordinance, Ordinance 99-5, codified at I I A-60 et. seq. of the I`fiami Dade Cournty Code, which requires an employer which has in the reLrular course of business fiery (50) or more employees workinc in ?Miami -Dade County for each working day during each of twenr� (20) or more calendar work weel•_s M the current or proceeding calendar years, to provide Domestic Violence Leave to its employees. I have carefully read this entire five (5) page document entitled, "Miami -Dade Country Affidavits" and have indicated by an "X" all affidavits that pertain to this contract and have indicated by an "N/A" all aff-idavits that do not pertain to this contract. By: (Signarure of Affiant) SUBSCRIBED AND SWORN TO (or affirmed) before me this 200_ by known to rime or has presented (Type of Identification) (Signature of Notary) (Print or Stamp of Notary) Notary Public —Stamp State of (State) (Date) day of He/She is personally as identification. (Serial Number) (Expiration Date) Notary Seal r-1 11 1-1 1 11 v I L l V! (\ AFFIDAVTT OF MIAMI-D_OE COti:",TI' LOBEI"IST REGISTRATION FOR ORAL PRESENT.ATIONI (i) ProjectT ifl:: �arrmenr. (-) FiTl-"Proposers ;,'am Addie,,. Busine--s Telephone: (_) ?. ["I 0.. 1p: (l) List All Members of the Presentation Team Who Will Be Participating in the Oral Presentation: PJAME TITLE EMPLOYED BY TEL. 1,10. (ATTACH ADDITIONAL SHEET IF NECESSARY) 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 team after submittal of the proposal and filling by staff, MUST register with the Clerk of the Board and pay all applicable fees. Other than for the oral presentation, Proposers who wish to address the county commission, a county board or county committee concerning any action, decision or recorunendation of county personnel regarding this soficitation MUST register with the Clerk of the Board (Form BCCFORM2DOC) and pay all applicable fees.. I do solemnly swear that all the foregoing facts are true and correct and I have read or am familiar with the provisions of Section 2-11.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, Officer, Partner or Agent) to me or who has produced Signature of person taking aclmowledgemcnt) (?Jame ofAclnowledger ryTed, printed or stamped) (Title or RanJ,) (Serial Number, if any) .-f-' - Rev. J!2"'93 , who is personally known (Sole Proprietor, Corporation or Partnership) as identification and who did/did not take an oath. -- - (ORDIrN'.-i!'C£9i-1U4) ATTACHMENT L Name of OrCanization: Address: REQUIRED LISTING OF SUBCONTR4CTORS ON C0L1JNTY C0.NTRA.CT In compliance with Miami -Dade County Ordinance 97-104, the Community Dased Omani-73tion must submit the Iist of first tier subcontractors cr sub -consultants Who will perfcM any part of the Scope of Sen ices Worl:, if thi s ,Acreement is for 5100,000 or more. The Community Based Organization must complete this information. If the Community Lased Organization will not utilize subcontractors, then the Community Based Organization must state, "No Subcontractors will be used", do not state "N/A". Name of Subcontractor orSub-Consultant Address Cite and State REQUIRED LIST OF SUPPLIERS ON COUNTY CONTRACT In compliance with Miami -.Dade County Ordinance 97-104, the Community Based Organization must attach a list of suppliers uho wild supply materials for the Scope of Services to the Community Based Organization, if this Contract Agreement is $100,000 or more. The Cornmunity Based Organization must fill out this information. If the Community Based Organizatioh will not use suppliers, the Community Based Organization must state, "No suppliers wiII be used", do not state "N/A". Name of Subcontractor or Sub -Consultant Address Cit -y and State I hereby, certify that the foregoing information is true, correct alzd cornplete: Signature of Authorized Repr esentatIV.: Title: Firm Name: -Address: Telephone: Fax: E -Mail: Date: Fed. ID No.: Cin /State/Zip: finmi-Dodc Cowify, Florida limn Name of Primc Contractor/Proposer SUBCONTRACTOR/SUPPLIE, ft.LISTING (Ordinance 97-104) RI+P Name RFP Number f l til i:'�t_'iiiAiiIN I I Ills lonu, or a comparable listing meeting the requirements of Ordinance No. 97-104, MUST be completed by all bidders and proposers on Count), contracts for pu tchase of supplies, malerials or services, including professional services which involve expenditures of $100,000 or more, and all bidders and proposers on County or Public Ilci lth TrLISI construction contracts which involve expenditures oF$100,000 or more. This form, or a comparable listing meeting (lie requirements or Ordinaucc No. 97-10-t, must be completed and submitted even though.ih.e bidder or proposer will not utilize subcontractor's or suppliers on the contract. The bidder or proposer 511011[(1 enter the word "NONIs" wider the appropriate heading of Form A -7A in [[lose instances where no subcontractors or suppliers will be used on (lie contract. A Uiddcr or proposer wluo is awarder[ tlhc contract shall not change or substitute first tier subcontractors or direct suppliers .or the portions of the contract work to be performed or materials to be su[Ijlicd from those identified except upon writ(en ilpprcivat of the Countyi,. r; Business Nanie and Address of First Tier. Priticip-A Owner.Scope orWork to be Pe'rfonned by (I'rincipal Owner) — Subcontracior/5ubconsuItaiit SabcositracIor/SubconSnit:int GCntIet Race: Business Name anti Address o(UirectSupplier �'rjI7Ci1]Aj Oli'IlCt' Supplies/Materials/Services to be (I'rincip�al Owner) Provided by Su�piier (.;cttdcr l:acc I certify that the representntions contained in this Subcontractor/Supplier Listing are to the best of my knowledge true and occuraic. Signnture of Pruposer's Print Name Print Title Uatc Atithori7.ed Representative (Duplicate if additional space is needed) i ,,, ,,, A-7.it,, „. ATTACHMENT N APPLICANT OR RECIPIENT SECTION 3 COMPLIANCE REQUIREMENTS FOR HUD -ASSISTED PROJECTS PROJECT NAME: PROJECT LOCATION: PROGRAM FUNDING SOURCE: The work to be performed under this contract is subject to the requirements of Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701u (Section 3). The purpose of Section 3 is to ensure that employment and other economic opportunities generated by Federal assistance of HUD -assisted projects covered by Section 3, shall to the greatest extend feasible, be directed to low and very low-income persons, particularly persons who are recipients of HUD assistance for housing and to businesses that are substantially owned or substantially employ low and very low-income persons. The applicant or recipient commits to development and implementation of a Section 3 Economic Opportunity Pian for Miami -Dade Housing Agency (MDHA) approval, prior to selection of an architect or general contractor or other applicable contractor. This Plan shall: describe the outreach procedures the applicant or recipient will use to recruit, solicit, encourage, facilitate and award architectural and general contracts, where applicable, to Section 3 businesses in the project area; make a good faith effort as defined by the regulations, to provide training, employment and business opportunities required by Section 3 to persons from the project area; and incorporate the "Section 3 Clause" (see attachment next page) in all contracts over $100,000 in connection with this project. The applicant or recipient commits to including the following contractor certification in all contracts over $100,000: "The contractor certified that any vacant employment positions, including training positions, that are filled (1) after the contractor is selected, but before the contract or agreement is executed; and (2) with persons other than those to whom the Section 3 regulation require employment opportunities to be directed, are not filled to circumvent the contractor's obligation under the Section 3 regulation. The applicant or recipient certifies and agrees that it is under no contractual or other impediment which would prevent it from complying with these reauirements Non-compliance with the Section 3 regulations may result in sanctions, termination of this contract or agreement for default, and debarment or suspension from future HUD -assisted contracts. OWNER'S FIRM NAME (Print or Type Name): AUTHORIZED SIGNATURE SIGNATURE Affix Notary Seal to the Right ATTACHMENT N "Section 3 Clause" 24 CFR Part 135 This clause must be included in all Section 3 -covered contracts. A. The work to be performed under this contract is subject to the requirements of Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701u (Section 3). The purpose of Section 3 is to ensure that the employment and other economic opportunities generated by HUD assistance of HUD -assisted projects covered by Section 3, shall, to the greatest extent feasible be directed to low and very low-income persons, particularly persons who are recipients of HUD assistance for housing. B. The parties to this contract agree to comply with HUD's regulations in 24 CFR Part 135, which implement Section 3. As evidenced by their execution of this contract, the parties to this contract certify that they are under no contractual or other impediment that would prevent them from complying with the 24 CFR Part 135 regulations. C. The contractor agrees to send to each labor organization or representative of workers with which the contractor has a collective bargaining agreement or other understanding, if any, a notice advising the labor organization or worker's representative of the contractor's commitments under this Section 3 clause, and will post copies of the notice in conspicuous placed at the work site where both employees and applicants for training and employment positions can see the notice. The notice shall describe the Section 3 preference, shall set forth minimum number and job titles subject to hire, availability of apprenticeship and training positions, the qualifications for each; and the name and location of the person(s) taking applications for each of the positions; and the anticipated date the work shall begin. D. The contractor agrees to include this Section 3 clause in every subcontract subject to compliance with regulations in 24 CFR Part 135, and agrees to take appropriate action, as provided in the applicable provision of the subcontract or in this Section 3 clause, upon a finding that the subcontractor is in violation of the regulations in 24 CFR Part 135. The contractor will not subcontract with any subcontractor where the contractor has notice or knowledge that the subcontractor has been found in violation of the regulations in 24 CFR Part 135. E. The contractor will certify that any vacant employment positions, including training positions, that are filled (1) after the contractor is selected but before the contract is executed; and (2) with persons other than those to whom the regulations of 24 CFR Part 135 require employment opportunities to be directed, were not filled to circumvent the contractor's obligations under 24 CFR Part 135, F. Non-compliance with HUD's regulations in 24 CFR Part 135 may result in sanctions, termination of the contract for default, and debarment or suspension from future HUD assisted contracts. G. Wit respect to work performed in connection with Section 3 covered Indian housing assistance, Section 7(b) of the Indian SeJf-Determination and Education Assistance Act (25 U.S.C. 450c) also applies to the work to be performed under this contract. Section 7(b) requires that to the greatest extent feasible (1) preference and opportunities for training and emplo9yment shall be given to Indians, and (2) preference in the award of contracts and subcontracts shall be given to Indian organizations and Indian -owned Economic Enterprises Parties to this contract that are subject to the provisions of Section 3 and Section 7(b) agree to comply with Section 3 to the maximum extent feasible, but not in derogation of compliance with Section 7(b). S\1'OR ' ST.ATL: TENT PUIISUANT TO SECTIO!' _S?. 131 (3) (aj, FLORIDA STATUTES. ON PUBLIC L,iTITY CMiNlES' THIS FORN4 MUST BE SIGNED AND TO RN THE PI'ISE\CE OF Al NOTARY PUBLIC Or. OTHER OFFICIAL . THORIA ZED TO .Dh-fI1;[STFF; OA THS. 1. This sworn statement is subnnirted to Miarni-Dade County: by (print individual's name and title) for (print name ofentity submitting sworn statement) whose business address is and (if applicable) its Federal Employer Identification Number (FEIN) is (if the entity has no FEIN, include the Social Security Number of the individual sin.ing this sworn staternent:) I understand that a "public entity crime" as defined in Paragraph 257.133(1)(8) 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, including, but not limited to, any bid or contract for 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, or material misrepresentation. I understand that "convicted" or "conviction" as defined in Paragraph 2S7.133(1)(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 resultofa jury verdict, non jury trial, or entryof plea of guilty or nolo contendere. 4. I understand that an "affiliate" as defined in Paragraph 2S7..133(1)(a) Florida Statutes, means: a. A predecessor or successor of a person convicted of a public entity crime; or, b. An entity under the control of any natural person who is active in the management of the entity 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 under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who kno4vingly enters into a joint venture with a person who has been convicted of a pubic entity crime in Florida during the preceding 36 months shall be considered an affiliate. I understand that a "person" as defined in. Paragraph 287.1341 )(e), Florida Statutes. means any natural person or entity organized under the laws of any state or of the United States with the lec,a! po ,er to enter into a binding contract and which bids or applies to bid on contracts for the prop ision or goods or services let by a public entity, or which other -wise transacts o; applies to r-,nsactb -iness w th a public entity. The term "person" includes those officers, directors, ecuGves, parsers, shareholders, emploYe.es, rrnerribers, and agenis v. -ho are active in manacement of M :ntir,. 6. °;.,ed Oil i7,5rrrnatlon and b:_hf , the S`-ate-mcnt, v,'hic:n I have rr,arr,ed bt'10`.4' Is iru,2 in rel2:1ion io ih- entiry submirin2 this s;';orn staie„ient. (P lease indicate '%�,hich statemenf applies)1 t'Jeithcr the entity submiring this sv,oni statement, nor an; of its officers, directors, e::ecutives, parners, shareholders, emeloyees, me nbe;s, or agents who are a tIve in the management of the entity,, nor the affiiiate of the entire has been oared Frith and convicted of a public entih, crime within the past 36 monk. The entity submitting this sworn statement, or one or more of its officers, director;. 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 in convicted of a public entity crime within the past 36 months .4ND (Please indicate which additional statement applies) The entity submitting this sworn statement, OT one or more of its officers, 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 Hearing Officer of the State of Florida, division of Administrative Hearings and the Final Order entered by the Hearing 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 UNDERST.,4ND THAT THE SUBMISSION OF THIS . FORM TO THE CONTRACTING OFFICER,FOR THE PUBLIC ENTITY IDENTIFIED. IN PARAGRAPH 1 (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 PUBLIC ENTITY PRIOR TO ENTERING I_NTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTRAINED IN THIS FORM. (Signature) STATE OF COUNTY OF PERSONALLY APPEARED BEFORE ME, the undersigned authority, (date) (name of individual signing) who, after, first being s-wom by me, affixed his/her sigrtature in the space provided above on this day of , 20 NOTARY PUBLIC h4y 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 % of 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. I il! ln_trur eni '. prep '; ea b -v :v ii illI �L, hrc .=:7-_t:::l':�. 1_C'!!�ir .�, i�fi::,�1-L>adc Ccunt�, Attachmeor C) DECLARATION OF RESTR-ICTI`'E COVENANTS THIS DECLARATION OF RESTR-fCTIVE C0VE:r;la;,tTS ("Declaration) Llecl as or X00_ by ("Prolcct Sponsor..) and ("Titleholder"), their successors and assi`ns. is Civet] to the United State Department of Housing and Urban Development (HUD). RECITALS W-HEP,.EAS, the Project Sponsor participated in a consolidated application to HUD. dated as of for a Supportive Housing Grant; which Grant was aAvarded; and WHEREAS Miami -Dade County (the Recipient) entered into a Supportive Housing Grant (FL14B ), on : and WHEREAS, the Recipient entered into an Agreement dated with the Project Sponsor (the Project Sponsor Agreement) in which the Project Sponsor is abli2ated to acquire and rehabilitate directly or through its single -asset affiliate as defined below and operate a supportive housing project on property described in Exhibit A hereto (the "Propert} is to be maintained and operated as supportive housing as def ned by the Agreement; and WHEREAS, the Project Sponsor has created (the "Titleholder"). an affiliated sin,le-asset corporation wl ose board of directors is the same as the board of directors Of the Project Sponsor, for the sole purpose of acquiring and rehabilitating the Property ; and WHEREAS, the Mck_innev-Vento Homeless Assistance Act, 42 USC �� I13SI et. seq. ("ACT') imposes use and repayment requirements on projects receiving acquisition, rehabilitation and new construction funding; and WHEREAS, the Recipient is required by the Aueement to require the Project Sponsor, and the Project Sponsor is required by the Project Sponsor Agreement. to cause to be executed an instrument in recordable form which obligates the Project Sponsor, its successors and assigns, to operate and maintain the supportive housing in accordance \- ith she A`reement. the ACT, and HUE) regulations as pnavided for in the .q��re,2mcnt; and \ HEREAS. the Pro'ect Sponsor and the Titleholder under this > 1 eclarat on 11ILLIlds, d'Clares arid cOV--nants thiat the resuictive co`,'?Ilants -C[ Forth heleln shall be and are co\'enanls runrtnr� 1,'1t!i tn?Prange;',for the tern; described hereln, and are binoln_a upon all subsequent ott'ners of tile Proo:r:v for Ltc❑ it -i -m. .`-nd art- no'. i-n-,�,,L°I ' p�rS1:i3( COier?IltS G: ille rr0(e:I Sponsor and the T1tl'iloljcr; ?` 1 t4, T: REFUF F, 1P COP.S1C7eraIl� 1 oI tCe C:Oit?ts'-- 21ndC01" a7,T: I,fT L d Qi Jir' aluaol� cotSld::ation, ti? rC lI, _T) j1TIiCIf:1C1 Cit ',',r).::i? �•?C'r_J77,=::i.^.: ]. Th;: Pry_ i-ct Spon_or nttd the Tit] ._hoIder, thf1i successors or assigns. _h:li SL!ppVril`,'C hough'` and prC'vi,dG supporilve se1`1cts d -JO i'_'liou; 3 Qerlod of cOnlrtlericin-c from the date of initial occuCaric} or the provision Ol 1?11t?al SCi . IC' In with terms of the ALre-.merit, the ACT, HUD regulations, and all , pplic ibl': fc-Jd r_l. ;tai- ani local If, pursuant to a request from the Project Sponsor. HUD determines that the proiec is no longer needed for use as supportive housing, HUD trtav authorize the Protect Sponsor and the Titleholder, their successors or assigns, to convert the use of the project for the direct benefit of lo,w-income persons. Upon expiration of the period during which the Prosi obliJated to operate the Property in accordance with the Agreement, this Declaration' shall terminate and shall no lonser be effective. 3. The Project Sponsor and the Titleholder agree, that if the project ceases to be used as supportive housing within ten (10) years after the project is placed in service, the Project Sponsor and the Titleholder, their successors or assigns, shall be oblizated to repay HUD one hundred percent 0 00%) of any assistance received for acquisition, rehabilitation and new construction under the Agreement. If such project is used as supportive housing for more than ten (10) years, HUD shall reduce the percentage of the amount required to be repaid bti' ten ('10) percentage Points for each ✓ear in excess of ten (10) that the project is used as supportive housing , 4. HUD; actin, by and through a duly authorized official, may approve such action as may be necessanv to allow the transfer, convevance, assignment, leasing, mottRa_ing, or encumbering of the Property or to accomplish the acts described above. 5. This Declaration and the covenants set forth herein regulating and restrictine the use and occupancy of the Property (i) shall be and are covenants rutining ti,ith the Property, encumbering the Property for the term of this Declaration, and binding upon the Project Sponsor's successors in title and all subsequent owners of the Property, (ii) are not merely personal covenants of the Project Sponsor, and (iii) shall bind the Project Sponsor and its respective successors and assizns during the term of this Declaration. 6. Any and all requireni-ents of the laws of the State to be satisfied in -order for the provisions of this Declaration to constitute deed restrictions and covenants run -?in" with the land shall be deemed to be satisfied in full; and that any requirements or privi-Jertes of estate are intended to be satisfied, or in the alternate, that an equitable servitude has been created to insure that these restrictions run with the land. For the term of this Declaration, each and ever -n! contract, deed, or other instrument hereafter executed com,eVing the Properr or portion thereof shall e>,,re;sll,: 1,rovid�2 that such convevance is subject to this Declaration, provided, however, that these covenants contained herein shall survive and be effective re`ardless of whether such c•ontmcts, Ceed Or Other tn5tr ar 1 -ill hereafter executed conv:- fng the Proper.,' r r portior the l"C"ides ii -31 such Conveyance ' reof - 1'et'anC tS StlbleCl to ii`l: DeClar3ilOn. TV ln1'311CIC'',' oI amy CIausn pari or pi0'J&W of Qi li 1ir', of th_ r-,aai. mg po::ions tnfreo . I7`+ 0,-71l FESS 'il,'H, Fl (3117, tn-. P,cjJ� c t Sromor has can W reWAC)tatM! an of he da': and yea; Am above "Tit PROWT SPONSOR TI 1 LE HOLDEFL F Y: Si«nature Title STATE OF FLOUR, ) SS. COUNTY OF A IA n I-DADE } LY: Sir_Tnarurc Title I HEREBY CERTIFY that the foregoing DECLARATION OF RESTRICTIVE COVENANTS V,"s executed and acknowledged before me on this dna' by as PF ES !DENT, of And by Personally I;nm n OR Produced IdentiFicaiion Type of ldentification Produced as PRESIDENT, of Personally' Known Or. Produced Identification Type of Identification Produced before me, a No[ar , public du" authorized in [he State and coulir.named abovc to aIle acknowledgmems and who ( ) did ( )did not Me an oa[ll. \Vitresseth my hand and o`ficial seal in the State ;lnd a nin' above, (his 2004 NOTARY PUBLK, Stale of Florida My Ci:mmis ion Egirw INC, iNIto is: INC. who is: day- of Attachment 0-1 DECL_4R4TION OF RESTRICTIONS THIS DECLAR.-�TION OF RESTPUCTIONS made this da,,, of 30Ci by the undersigned hereinafter refereed to as the "Declarant wTa� IZEAS, A41arni-Dade County; acting throuch and on behalf of the Miami -Dade County Homeless Trust has applied for and received funds from the United States Government under Title IV of the Stewart B. Mc?,Imey Homeless Assistance Act; and WTIERAS, Miami -Dade County agreed to comply �,�th requirements of the United States Government in connection 1vith the receipt of such funds; and «'TIRAS, pursuant to the 2 Supportive Housing Program Grant Agreement, which Miami -Dade County entered «th the United States Goverment, acting through its U.S. Department of Housing and Urban Development (the "Grant"), Miami -Dade County is responsible for repaying the Grant in accordance -with the provisions of 24 CFR part 583,Code of Federal Regulations; and iV_ERAS, Miami -Dade Coun), ,, in the exercise of due diligence must tale steps to _ ensure that the Grant -funded capital project is used for its intended purpose for a terra of at least 20 years from the date of initial occupancy, or date of initial service; WHEREAS, Miarni-Dade County requires that the subrecipient of the Grant, referred to as the Declarant herein, impose a restrictive covenant on the subject land purchased with the capital funds provided through this Grant; and Legal description: NOW THEREFORE, Declarant declares that said property shall be held, transferred, encumbered; used, sold, conveyed, leased, and occupied, subject to the covenants and restrictions hereinafter set forth expressly and exclusively for the use and benefits of said propel and of each and even, person or entity who no�v or in the fixture owns any portion or portions of said property. L.4 -IND USE — The subject Property and any rehab.ilitated structures or rev, construction thereon rnust be operated for the provision of supporti,,e housing and services for homeless persons in accordance «zth the prop inion of �4 CFR pari �S3, Code of Federal Re Mations (as may be amended om time to tune) for a terra of at least 20 years or for sutra ot_nerpurposcs as rnav be approved by the U.S. -Ual`ur'ent of Hous ne and Urban D',n-tlopmant, TERM— This covenartt is to nrn Jt_h Ln-_ Iand and shall be binding on all panics, a. -rd :,I1 persons clarmzn; under therefor a period of nver:� r (10) vears frorn tiae date the o?ici n`i cotienant ' :a recorded, the date of initial occupant}, or date of initial scrTic_- pro".isi nn. %vh-ichever is later. ENFORCEMENT — Upon Declaration's, failure to compl)' the requirements of this Declaration, the Declarant shall vvithin 30 days of «rotten notice of non-compliance and request for conveyance shall convey the subject property to Miami -Dade Count}. Enforcement shall be by proceedings at law or inequity against any person or persons violating or attempting to violate any covenant either to restrain violation, compel compli .race with the provision of this declaration or recover damages. Such action may be brought by Miami -Dade County, or its successor in interest. SEVEILA-BrLITY — Invalidation of any of these covenants by judgement or court order shall in no wise affect the other provisions that shall remain in full force and effect. WITNESSES: DECLARANT: (Name of President) ATTEST: Secretary of the Board STATE OF FLORIDA ) SS. COUNTY OF ML•AMI-RADE ) I HEREBY CERTIFY that the foregoing DECLARATION OF RESTRICTIVE COVENANTS was executed and acknowitdged before me on this day of , 2004 by as , of Personally KnouvTi OR Produced identification Type of Identification Produced And by as , Of ',,hG. PersonaNy Enov.7 OP Produced fdenrificarion Tvpe of J&= ntificaricn Produced before me, a Notary public du l � authorized in the State and -county named above to take acknowled�rnents and ;; ho did Odid not take an oath. Witnesseth my hand and ofncial seal in the State and County above, this day of - 2004. ATTACHMENT R FOR GOVERNMENT ENTITIES ONLY - Semi -Annual Employee Certification for Supportive Housing Programs "This form is to be submitted to the Miami -Dade County Homeless Trust every six months. Agency: Project Number: FL14B Project Name: Period Covered: The following employee/s worked solely on SHP project Employee Name/Names: Name Signature Date Name Signature Date Name Signature Date Name Signature Date By signing, I hereby certify that I have worked 100% of the time on the above referenced SHP project during the period specified above. Supervisor Certification Title Signature Date I hereby certify as the supervisor of the above named individual/s that they have worked solely on the above referenced grant during the above referenced time period MIAM NDADE INCIDENT REPORT IDENTIFYING INFORMATION ATTACHMENT S Reporting Party Phone # Date of Incident / / Time of Incident _ am/pm Reporting Party Name Contract Provider Name Program Name Provider Location Specific Program.: (check all that apply) ❑ HT ❑ Primary Care ❑ SBP ❑ Emergency ❑ Challenge Specific location/ address where incident occurred. ❑ ALTERCATION TYPE OF INCIDENT ❑ CLIENT DEATH ❑ CLIENT INJURY OR ILLNESS ❑ THEFT ❑ SEXUAL BATTERY ❑ PROPERTYDAMAGE ❑ SUICIDE ATTEMPT ❑ OTHER INCIDENT Specify PARTICIPANT (S) / WITNESS (ES) (Please mark W or P for either Witness or Participant) LAST NAME, FIRST IDENTIFIER # CLIENT El 11 1\of3 EMPLOYEE OTHER W / P ❑ ❑ ❑ ❑ MIAM��FLA4DE 0 DESCRIPTION OF INCIDENT Give detailed account — who, what, where, when, why, how — add pages if necessary CORRECTIVE ACTION AND FOLLOW UP Immediate corrective action taken Is follow up action needed? ❑ Yes ❑ No If yes, specify. INDIVIDUALS NOTIFIED Abuse Registry 1-800-962-2873 Applicable Law Enforcement Department Indicate person contacted, if report was accepted, the date and the time, and if by telephone or if copy of report available. Incident Reports — The Subrecipient must report to Miami -Dade County Homeless Trust information related to any critical incidents occurring during the administration term of its programs. In addition to reporting this incident to the appropriate authorities the Subrecipient must within twenty-four (24) hours of any incident, submit in writing a detailed account of the incident. This incident report should be addressed to the Contract Officer or Administrative Officer assigned. This incident report should be addressed to Miami -Dade County Homeless Trust, 1 I 1 NW First Street, 27th Floor, Suite 310, Miami, Florida 33128; telephone (305) 375-1490 and facsmilie (305) 375-2722. 2 of 3 MlAM10 Definitions of Reportable Incidents a. Altercation. A physical confrontation occurring between a client and employee or two or more clients at the time services are being rendered, or when a client is in the physical custody of the department, which results in one or more clients or employees receiving medical treatment by a licensed health care professional. b. Client Death. A person whose life terminates due to or allegedly due to an accident, act of abuse, neglect or other incident occurring while in the presence of an employee, in Homeless Trust contracted program facility. c. Client Injury or Illness. A medical condition of a client requiring medical treatment by a licensed health care professional sustained or allegedly sustained due to an accident, act of abuse, neglect or other incident occurring while in the presence of an employee, in a Homeless Trust contracted program. d. Other Incident. An unusual occurrence or circumstance initiated by something other than natural causes or out of the ordinary such as a tomado, kidnapping, riot, or hostage situation, which jeopardizes the health, safety and welfare of clients. e. Sexual Battery. An allegation of sexual battery by a client on a client, employee on a client, or client on an employee as evidenced by medical evidence or law enforcement involvement. f. Suicide Attempt. An act which clearly reflects the physical attempt by a client to cause his or her own death while in the physical custody of the department or a departmental contracted or certified provider, which results in bodily injury requiring medical treatment by a licensed health care professional. Property Damage An incident involving damage to property procured with Homeless Trust funding. Print Name of Person Submitting Report Signature 3 of 3