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HomeMy WebLinkAboutAgreement Attachment ListSubrecipient Agreement Attachment List Signature Required Attachment Title Attachment A U.S. HUD Grant Renewal Agreement includes: HUD designated Attachments A and B Attachment A-1 Sco e of Service Attachment A-2 Units/Bedrooms/Beds Chart and Partici ants Chart Attachment. A-3 Program Goals Attachment A4 Attachment B Milestones (N/A for Renewal Grants) Technical Submission Attachment C Attachment C-1 LOCCS/VRS form HUD -27053A Copy of Homeless Trust Invoice Attachment ID Attachment E HMIS (HUD -40118) Monthly Progress Report Pro am Ratiri of Satisfaction Attachment F Client Contribution Report Attachment G Annual Pro ess Re rt (APR) Signature Attachment G-1 Attachment H FMS (HUD40118) Annual Progress Report (APR) Request for Taxpayer Identification and Certification Signature Attachment I HUD form -40090-4 Applicant Certification Signature Attachment 3 Miami -Dade County Required Affidavits Signature Attachment K Affidavit Lobbyist Registration for Oral Presentation Signature Attachment L Disclosure of Subcontractors and Suppliers Signature Signature Signature Attachment M Attachment N Attachment 4 Subcontractor / Suppliers Listing Section 3 Compliance Requirements Swom Statement Pursuant to Florida Statutes Attachment P Provider Asset Inventory form if applicable Attachment Q Declaration of Restrictive Covenants if applicable Attachment Q-1 Declaration of Restrictions Attachment R Employee Certification Form Attachment S Incident Report (3 -pages) ATTACHMENT A Recipient: Miami -Dade County Address: 11.1. NW 1" Street, 27`h Floor, Suite 31.0, Miami, FL 33128 Tax ID #: 59-6000573 Project Location: Miami -Dade County 2008 SUPPORTIVE HOUSING PROGRAM RENEWAL GRANT AGREEMENT This Grant Agreement is made by and between the United States Department of Housing and Urban Development (HUD) and the Recipient, which is described in section 1 of Attachment A, attached hereto and made a part hereof. The assistance which is the subject of this Grant Agreement is authorized by the McKinney-Vento Homeless Assistance Act 42 U.S.C. 11381 (hereafter "the Act"). The term "grant" or "grant funds" means the assistance provided under this Agreement. This grant agreement will be governed by the Act, the Supportive Housing rule codified at 24 CFR 583, which is attached hereto and made a part hereof as Attachment B, and the Notice of Funding Availability (NOFA) that was published in two parts. The first part was the Policy Requirements and General Section of the NOFA, which was published March 19, 2008 at 73 FR 14882, and the second part was the Continuum of Care Homeless Assistance Programs NOFA Section of the NOFA, which was published July 10, 2008 at 73 FR 39840. The term "Application" means the original and renewal application submissions on the basis of which a Grant was approved by HUD, including the certifications and assurances and any information or documentation required to meet any grant award conditions. The Application is incorporated herein as part of this Agreement, however, in the event of conflict between the provisions of those documents and any provision contained herein, this Renewal Grant Agreement shall control. The Secretary agrees, subject to the terms of the Grant Agreement, to provide the grant fiends in the amount specified at section 2 of Attachment A for the approved project described in the Application. The Recipient agrees, subject to the terms of the Grant Agreement, to use the grant funds for eligible activities during the grant term specified at section 3 of Attachment A. The Recipient must provide a 25 percent cash match for supportive services. The Recipient agrees to comply with all requirements of this Grant Agreement and to accept responsibility for such compliance by any entities to which it makes grant funds available. The Recipient agrees to participate in a local Homeless Management Information System (HMIS) when implemented. The Recipient and project sponsor, if any, will not knowingly allow illegal activities in any unit assisted with grant funds. The Recipient agrees to draw grant funds at least quarterly. Miami -Dade County FL0211B4D000801 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 FL0211B413000801 (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 FL0211B4D000801 SIGNATURES This Grant Agreement is hereby executed as follows: UNITED STATES OF AMERICA Secretary of Housing and Urban Development By: Signature and Date .1 Maria R. Ortiz -Hill _Director. Community Planning and Development Title RECIPIENT Miami -Dade County Name of Organization Authorized Signature and Date Print name of signatory Title Miami -Dade County FL0211134D000801 ATTACHMENT A 1. The Recipient is Miami -Dade County. 2. HUD's total fund obligation for this project.is $ 251,071 , which shall be allocated as follows: a. Leasing $0 b. Supportive services $239,116 c. Operating costs $0 d. HMIS $0 e. Administration $11,955 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 FL0211B4D000801 ArrAcNAnE,q-r B Pt. 583 submitted in response to the most re- cently published notice of fund avall- ability and select applications for Fund - ng with the deobligated funds. Such selections would be made in accordance with the selection process described in §582.22(1 of this part. Any selections made using deobligated funds will be subject to applicable appropriation act requirements governing the use of deobligated funding authority. (Approved by the Office of ,'vlanagement and Budget under control number 2506-0118) PART 583—SUPPORTIVE HOUSING PROGRAM Subpart A—General Sec. 583.1 Purpose and scope. 583.5 Definitrons. Subpart 6 --Assistance Provided 583.100 Types and uses of assistance - 563.105 Grants for acquisition and rehabill- cation. 583.110 Grants for new construction. 583.1 IS Grants for leasing. 583.120 Grants for supportive service costs. 583.125 Grants for operating costs. 583.130 Commitment of grant amounts for leasing, supportive services, and open acing costs. 583.135 Administrative costs. 583.140 Technical assistance. 583.145 Matching requirements. 583.150 Limitations on use of assistance. 583.155 Consolidated plan. Subpart C—Application and Grant Award Process 583.200 Application and grant award. 583.230 Environmental review. 583.235 Renewal grants. Subpart D—Program Requirements 583 300 General opera Uun. 583.305 Terra of commitment: repayment of grants: pre,'entlon of undue benetits. 583.310 t)isptacement, relocation. and arqui si[ion. 583.315 Resident rent. 583 320 Site control. 583 32.3 Nondiscrfrnination and equal oppor tunivY requirements. 583.330 Applicabllity of other Federal re- quirements Subpart E—Administration 583.400 Grant agnrement. 248 24 CFR Ch. V (4-1-05 Editlon) 583.405 Program changes. 583.410 Obligation and deobligatlon of funds. At,THORITY: 42 U.S.C. 1.1389 and 3535(d). SOURCE: 58 FR 13871. Mar. 15. 1993, unless otherwise noted. Subpart A --Genera{ 6583.1 Purpose and scope. (a) General. 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) Components. 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. 158 FR 13871, Mar. 15, 1993, as amended at 61 FR 51175. Sept. 30, 19961 3 583.5 Definitions. As used in this part; Applicant is defined in section 4220) of the \McKinnev Act (42 U.S.C. 113820)). For purposes of this defini- tion, governmental entities include those that 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 that a jurisdiction prepares and submits to NLD in accordance with 2.1 CFR part 91. Ofc. of Asst. Secy., Comm. Plonning, Develop., HUD Dale of initial occupancy means the date that the supportive housing is ini tially occupied by a homeless persor for whom HUD provides assistance under this part. if the assistance is for an existing homeless facility, the dalf 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 that is described in section 103 of the McKinney Act (42 U.S.C. 11302). rlletropolitan 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 those cities that are eligible for an entitlement grant under 24 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 McKinney .Act (42 U.S.C. 11382(7) (A), (B), and (D)). The organization must 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. S583.100 Pmject 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 means the improve- ment or repair of an existing structure or an 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. 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- tfon 425 of the McKinney 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 § 583.300(J). 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)(5) of the Housing and Cornmu- 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. 161 FR 51175. Sept. 30. 1996) 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 §§583.105 through 583.125. Ap- plicants may apply for more than one type of assistance. (b) Uses of grant assistance. Grant as- sistance may be used to: (1) Establish now supportive housing facilities or new facilities to provide supportive services; (2) Expand existing facilities in order to increase the number of homeless persons served: (3) Bring existing facilities up to a level Char meets State and local gov- ernment health and safety standards; 249 § 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 tinder 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. 158 FR 13871. Mar. 15. 1993, as amended at 59 FR 36891. July 19. 19941 .4583.105 Grants for acquisition and rehabilitation. (a) Use. HUD will grant funds to re- cipients to: (I) 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 that 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 coward tine cost. (c) Increased amounts. In areas deter- mined by HUD to have high acquisition 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. §583.110 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 that 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 constriction. For purposes of this cost comparison, costs associated with rehabilitation or new construc- tion may include the cost of reai prop- erty acquisition. (b) Amount. The maximum grant available for new construction is the lower of: (1) S400,000; 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- vidual housing units, the rent paid MUSE be reasonable in relation to rents being charged for Comparable units, raking into account the location, size, t}'pe, quality, amenities, facilities, and manage mens services. In addition, the 250 Ofc. of Asst. Secy., Comm. Manning, 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 HUD -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. (58 FR 13871, Mar. 15. 1993, as amended at 59 FR 36891, July 19. 19941 4 583.120 Grants for supportive serv- ices 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 lup to rive 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, supportive 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 transi- tional housing facility. (58 FR 13871. Mar. 15. 1993, as amended at 59 FR 36691, July 19. 1994) 4583.125 Grants for operating costs. (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 hOtlS- ing. They also include the actualex- penses that a recipient incurs for con- ducting on-going assessments of the supporrive services needed by residents and the availability of such services; relocation assistance under §583.310, in. eluding payments and services. and in- stirance. 251 § 583.140 (c) Recipient 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 riot 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. Mar. 15. 1993, as amended at 61 FR 51175, Sept. 30. 1996; 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 riot 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 or Management and Budget under OMB control number 2506-0112) f59 FR 36891. July 19. 19941 4583.135 Administrative costs. (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 tinder §§ 583.105 through 593.125. t5B FR 13871. filar. 15, 1993, as amended at 61 FR 51175. Sept. 30. 19961 §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 persons in the transition from homelessness, and promoting the provision of sup- portive housing to homeless persons to enable them to live as independently as possible. (b) Uses of technical assistance. HUD 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 rhe technical assistance. 159 FR 36892, July 19, 19941 § 583.145 Matching requirements. (a) General. 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) ,ldaintenance of effort. State or local government funds used in the matching contribution are subject to the maintenance of effort requirements described at §583.150(a). §583.150 Limitations on use of assist- ance. (a) ,kfaincenance of effort. No assist- ance provided under this part (or any State or local government funds used to supplement this assistance) may be used to reprice State or local funds previously used, or designated for use, to assist homeless persons. 252 24 CFR Ch. V (4-1-05 Edition) (b) Faith -based activities. U) Organiza- tions that are religious or faith -based are eligible, on the same basis as any other organization, to participate in the Supportive Housing Program. Nei- ther the Federal government nor a State or local government receiving funds under Supportive Housing pro- 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- tlon 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 prose lytizatton. 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'. 0fc. of Asst. Secy., Comm. Planning, Develop., HUD (5) Prograrn funds may not be used for the acquisition, construction, or re- habilitation of structures to the extent that those structures are used for In- herently religious activities. Program funds may be used for the acquisition, construction, or rehabilitation of 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- counting requirements applicable to Supportive Housing Program funds 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, 1s 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 farnily or in- dividual remains in the same housing without further assistance under this part, that applicant may not request assistance for acquisition, rehabilita- tion, or new construction. 158 FR 13871. ,filar 15. 1993, as amenihd ar 59 FR 36892. July 19. 1993: 68 FR 56407. Sept. 30. 211031 253 4 583.165 Consolidated pian. § 583.155 (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, 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 Cuam, 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 that 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 certifl- cation submissions. Unless otherwise set Forth in the NOFA, the required certifi- cation chat 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. 160 FR 16380. ;41ar. 30, 19951 § 583.200 Subpart C—Application and Grant Award Process §583.200 Application and grant award. When funds are made available for assistance, HUD wilt publish a notice of funding availability (NOFA) In the FEDERAL REGISTER, 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 NGFA. 161 FR 51116. Sept. 30. 19961 5583.230 Environmental review. (a) Activities under this part are sub- ject to HUD environmental regulations in part 56 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 entitles 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 §58.11(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) perforins the envi- ronmental review, the recipient shall supply all available, relevant informa- tion necessary for the responsible enti- ty (or HUD, if applicable) to perforin 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). (b) The recipient, its project,partners and their contractors may riot acquire, rehabilitate, convert, lease, repair, dis- pose of, demolish or construct property 24 CFR Ch. V (4-1-05 Edfflon) 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 5582 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 (i.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 § 583.235 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 or 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 Funding period: and 254 Ofc. of Asst. Secy., Comm. Planning, Develop.. HUD (3) An allowance for cost increases. (c) HUD review (i) HUD will review the request for renewal and will evalu- ate the recipient's performance in pre- vious years against the plates 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 to 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 unsatisfactory. (3) HUD will notify the recipient in writing that the request has been ap- proved or disapproved. (.approved by the Office of Management and Budget under control number 2506-6112) Subpart D --Program Requirements §583.300 General operation. (a) State and local requirements. Each recipient of assistance under this part must provide housing or services chat are in compliance with all applicable State and local housing codes, licens- ing requirements, and any other re- 255 § 583.300 quirements in the jurisdiction in which the prciect 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) Access. 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. (4) 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) N%ater supply. The water supply must be free from contamination. (6) Sanitary 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- rnai indoor activities and to support the health and safety of residents. Suf- ficient electrical sources must be 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. §583.300 24 CFR Ch. V (4-1-05 Edition) (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 (11) Fin safety. (i) Each unit must In- policies and decisions. See also elude 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 prat- uals and families, through empioy- 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 raining. 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-im- (g) Records and reports. Each recipient paired person. of assistance under this part must keep (ii) 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 nlcity, 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) Confidentiality. Each recipient community rooms, day care centers, that provides family violence preven- hallways, 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 authoriza- (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 ance 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- (1) Participation of homeless persons. (1) tunny cc present written or oral objec- 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 hlcKin- who trade or approved the termination ne:y Act (42 U.S.C. 11386(8)). This re- decision: and r 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 Oft. of Asst. Secy., Comm. Planning, Develop., HUD 0) Limitation of stay In transitional housing. A homeless individual or fam- ily may remain in transitional housing For a period longer than 24 months, if permanent housing for the Individual or family has not been located or if the individual or family requires addi- tional time to prepare for Independent living. However, HUD may discontinue assistance for a transitional housing project if more than half of the home- less individuals or families remain in that project longer than 24 months. (k) Outpatient health services. Out- patient health services provided by the recipient must be approved as appro- priate by HUD and the Department of 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 amencled at 59 FR 36892, July 19. 1994: 61 FR 51175, Sept. 30, 19%) 4583.303 Term of commitment; repay- ment of grants; prevention of undue benefits. (a) Term or commitment 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 Nic'Kinney Act (42 U.S.C. 11383(b)(1). 11383(bl(3)). (b) Repayment of grant and prevention of undue benefits. In accordance with section 423(c) of the McKinney Act (42 U.S.0 11383(c)), HUD wilt 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(b)(3)). (61 FR 51176, Sept. 30. 1996) § 583.310 4583.310 Diepiacement, relocation, and acquisition. (a) Nfinimizing displacement- Con- sistent with the other goals and objec- tives of this part, recipients must as- sure that they have taken all reason- able steps to minimize the displace- ment of persons (families, individuals. businesses, nonprofit organizations, and farms) as a result of supportive housing assisted under this part. (b) Relocation assistance for displaced persons. A displaced person (defined in paragraph (f) of this section) must be provided relocation assistance at the levels described In, and in accordance 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 B. (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 recipients deter- mination on his or her appeal may sub- mit a written request for review of that determination to the HUD field office. 257 § 583.3 10 24 CFR Ch. V (4-1-05 Edition) (f) Definition of displaced person. (1) does not return to the building/corn- For purposes of this section, the term plex, if either: "displaced person" means a person (A) A tenant is not offered payment (family. Individual, business, nonprofit for all reasonable out-of-pocket ex- organizadon, 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 terr- a direct result of acquisition, rehabili- porary relocation are not reasonable. Cation, or demolition for supportive (v) A tenant of a dwelling who moves housing projects assisted under this from the btrilding/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 - site) 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 mics to HUD the application or appli- paragraph (0(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- Oi) Any person, Including a person tion assistance under the URA or this who moves before the date described in section), if. paragraph (f)(1)(1) 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) Atenant-occupant of a dwelling law, or other good cause, and HUD de - unit who moves permanently from the termines that the eviction was not un - building/complex on or after the date of dertaken for the purpose of evading the the "initiation of negotiations" (see obligation to provide relocation assist - paragraph (g) of this section) if the ance; (ii) The person moved into the prop - move occurs before the tenant has been .erty after the submission of the appli- 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 conditions must include a monthly the fact that the person would not "displaced qualify as a 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 negotlacions 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 maximum, there must 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 renant of a dwelling who is re- (g) Definition of iniriation of negoria- quired to relocate temporarily. but lions. For purposes of determining the 258 O/c. of Asst. Secy., Comm. Ptanninq, Develop„ HUD formula for computing the replacement housing assistance to be provided to a residential tenant displaced as a direct result of privately undertaken rehabili- tation, demolition, or acquisition of the real property, the term "initiation of negotiations" means the execution of the agreement between the recipient and HUD. (h) Dennition of project. For purposes of this section, the term ''project" means an undertaking paid for in whole or in part with assistance under this part. Two or more activities that are Integrally related, each essential to the others, are considered a single project, whether or not all component activities receive assistance under this part. 158 FR 13871. Mar. 15, 1993. as amended at 59 FR 36892, July 19, 19941 4 583.315 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 theex- pense deductions provided in 24 CFR 5.611(x), 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 mems, 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 he reserved, in whole or in part, to assist residents of transitional housing in moving to permanent housing. §583.320 (c) Fees. In addition to resident rent, recipients may charge residents rea- sonable fees for services not paid with grant funds. f58 FR 13871, Mar. 15. 1993, as amended at 59 FR 36892. July 19, 1994; 66 FR 6225. Jan. 19, 2001) 4583.320 Site control. (a) Site control. (1) Where grant funds will be used for acquisition, rehabilita- tion, or new construction to provide supportive housing or supportive 5erv- Ices, or where grant funds will be used 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 sites 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 deobligated 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 under 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 deobligate the award of assistance. (c) Failure to obtain sire control within nne near. HUD will recapture or deobligate anv award for assistance under this part if the recipient is not in 259 5 583.325 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) General. 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- tunity 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 (THAs) when established by the exercise of such powers. When an IHA 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 hOtiS- ing, the recipient must establish addi- tional procedures that will ensure that such persons can obtain information concerning availability of the housing. (2) The recipient must adopt proce- dures to make available information on the existence and locations of facili- ties and services that are accessible to persons with a handicap and maintain evidence of itnplernentation of the pro- cedirres. (d) Accessibility requirements. The re- cipient must comply with the new con - 24 CFR Ch. V (4-1-05 Edflion) striation accessibility requirements of the Fair Housing Act and section 504 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 5Z10, Feb. 9. 1996: fit 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. 4001-4128) 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. pplica- tion. (Z) 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 or seq.) may apply to proposals tinder this part, de- pending on the assistance requested. 260 Ofc. of Asst. Secy., Comm. Planning, Develop., HUD (c) AppticabiiitY of DMB Circulars. The policies, guidelines, and requirements of OMB Circular No. A-87 (Cost Prin- ciples Applicable to Grants, Contracts and Other Agreements with State and Local Governments) and Z4 CFR part 85 apply to the award, acceptance, and use of assistance under the program by governmental entities, and OMB Cir- cular Nos. A-110 (Grants and Coopera- tive Agreements with Institutions of Higher Education, Hospitals, and Other Nonprofit Organizations) and A-122 (Cost Principles Applicable to Grants, Contracts and Other Agreements with Nonprofit institutions) apply to the ac- ceptance and use of assistance by pri- vate nonprofit organizations, except where inconsistent with the provisions of the McKinney Act, other Federal statutes, or this part. (Copies of OMB Circulars may be obtained from E.O.P- Publicatfons, room 2200. New Executive Office Building, Washington. DC 20503, telephone (202) 395-7332. (This is not a toll-free number.) There is a limit of two free copies. (d) Lead-based paint. The Lead -Based Paint Poisoning Prevention Act (42 U.S.C. 48Z1-4946), the Residential Lead - Based Paint Hazard Reduction Act of 1992 (42 U.S.C. 4851-4856), and imple- menting regulations at part 35, sub- parts A, B, J, K, and R of this title apply to activities under this program. (e) Conl7icrs of interest. (1) In addition to the conflict of interest requirernents in 24 CFR part 85, no person who is an employee, agent, consultant, officer, or elected or appointed official of the re- cipient and who exercises or has exer- cised any functions or responsibilities with respect to assisted activities, or who is in a position to participate in a decisionmaking process or gain inside information with regard to such activi- ties. may obtain a personal or financial interest or benefit from the activity, or have an interest in any contract, sub- contract, or agreement with respect thereto, or the proceeds thereunder, ei- ther for himself or herself or for those with whom he or she has family or business ties. during his or her tenure or for one year thereafter. Participa- tion by homeless individuals who also are participants under the program in policy or decisionmaking under 261 § 583.330 §583.300(!) does not constitute a con- flict of interest. (Z) Upon the written request of the recipient. HUD may grant an exception to the provisions of paragraph (e)(1) of this section on a case-by-case basis when it determines that the exception will serve to further the purposes of the program and the effective and effi- cient administration of the recipient's project. An exception may be consid- ered only after the recipient has pro- vided the following: (1) For States and other govern- mental entities, a disclosure of the na- ture of the conflict. accompanied by an assurance that there has been public disclosure of the conflict and a descrip- tion of how the public disclosure was made: and 00 For all recipients, an opinion of the recipient's attorney that the inter- est for which the exception is sought would not violate State or local law. (3) In determining whether to grant a requested exception after the recipient has satisfactorily met the requirement of paragraph (e)(Z) of this section. HUD will consider the cumulative effect of the following factors, where applicable: (i) Whether the exception would pro- vide a significant cost benefit or an es- sential degree of expertise to the project which would otherwise not be available: 00 Whether the person affected is a member of a group or class of eligible persons and the exception will permit such person to receive generally the same interests or benefits as are being made available or provided to the group or class: (iii) Whether the affected person has withdrawn from his or her functions or responsibilities, or the decisionmaking process with respect to the specific as- sisted activity in question; (iv) Whether the interest or benefit was present before the affected person was in a position as described in para- graph (e)(1) of this section: (v) Whether undue hardship will re. stilt either to the recipient or the per. son affected when weighed against the public interest served by avoiding the prohibited conflict: and (vi) Any other relevant consider- ations. § 583.400 (f) Audit. The financial management systems used by recipients tinder thi: 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. (g) Davis -Bacon Act. The provision of the Davis -Bacon Act do not apply to this program. 158 FR 13871. Mar. 15. 1993, as amended at 61R FR 5211. Feb. 9, 1996: 64 F 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, and a change in the category or 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 selecred. (b) Documentation of other changes. Any changes to an approved program that do riot require prior HUD approval 24 CFR Ch. V (4-1-45 Edition) must be fully documented in the recipi- ent's records. (.58 FR 13871, Mar. 15. 1993. as amended at 61 FR 51176. Sept. 30. 19%) 583.410 Obligation and deobligation of funds. s (a) Obligation of funds. When HUD and the applicant execute a grant agree- ment, funds are obligated to cover the 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) Deobligatlon. (1) HUD may deobligate all or parts of grants for ac- quisition, rehabilitation, acquisition and rehabilltation, or new construc- tion: (i) 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: (i) Readvertise the availability of funds that: have been deobligated under this section in a notice of fund avail- ability under §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 § 585.3 notice of fund availability, and in ac- SouRcE: 60 FR 9737. Feb. 21. 1995, unless cordance with subpart C of this part. otherwise noted. PART 585—YOUTHBUILD PROGRAM Subpart A --General Sec. 585.1 Authority, 585.2 Program purpose. 585.3 Program components 585.4 17e fin i t ions. Subpart B [Reserved] Subpart C—Youthbuild Planning Grants 585.201 Purpose. 585.202 Award limits. 585.203 Grant term. 585.204 Locational considerations. 585.205 Eligible activities. Subpart D—Youthbuild Implementation Grants 585.301 Purpose, 585.302 Award limits. 5135.303 Grant term. 585.304 Locational considerations. 585.305 Eligible acclvicies. 585.306 Designation of costs. 585.307 Environmental procedures and standards. 585.308 Relocation assistance and real prop- erty acquisition. 585.309 Project -related restrictions applica- ble to Youthbuild residential rental housing. 585.310 Project -related restrictions applica- ble to Youthbulid transitional housing for the hiorneless. 585.311 Project -related restrictions applica- ble to Youthbuild homeownership hous- ing. 585.312 Wages, Iabor standards, and non- discrimination. 585.313 Labor standards. Subpart E—Adminhstratlon 585 401 Recordkeeping by recipients. 585.402 Grant agreement. 585.403 Reporting requirements. 585.404 Program changes. 585.405 Obligation and deobligation of funds. 585406 Faith -based activities. Subpart F—Applicability of Other Federal Requirements 585 501 Application of OMB Circulars. 385502 Certifications 585.503 Conflict of Interest. 585 504 Use of dcbarrt,d. Suspended, or ineli Bible. contractors. At: nuOR(TY' 42 VS C. 3535(4) anti 8011. 263 Subpart A- -General §585.1 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. ?f 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"). (61 FR SZ187. Oct. 4, 19%1 0585.3 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 housing designated for homeless persons and low- and very low-income families. A Youthbuild planning grant is designed to give re- cipients sufficient rime 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 optional: (a) Educational sets ices. including: (1) Services and activities designed to meet the basic educational needs of GRANT NUMBER FL1413800032 / FL021111413000801 City of Miami — Homeless Assistance Progrm ATTACFIMENT A-1 SCOPE OF SERVICES The Subrecipient shall provide supportive outreach services to 3,000 homeless persons (individuals and families). Of the 3,000 homeless persons, there shall be at least 2,850 assessments and at least 1,500 placements of homeless persons. This shall occur primarily in the City of Miami and all homeless outreach, assessments and placements within Miami -Dade County. Additionally of the 3,000 homeless persons, the Subrecipient shall place at least 180 homeless persons in transitional treatment supportive housing. The Subrecipient will conduct street outreach as well as respond to service requests from homeless persons and service providers in the Continuum of Care. The Subrecipient shall provide outreach, assessment and placement supportive services under this one-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. Assessment for residential stability and supportive services; 3. Housing placement into emergency, transitional and permanent housing, or other positive housing environments; 4. Emergency housing to include hotel or motel assistance; 5. Referral and placement to all appropriate and available housing; 6. Referral to all applicable supportive services and programs; 7. Transportation services; and 8. Seven (7) day follow up to all services provided. Conditions: 1. Reimbursement shall be limited to operations, supportive services, leasing, administration, and the costs associated with these activities as described in the Subrecipients 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 Subrecipient's 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: FL0211114D000801 / FL14B8000032 Submission Project Identifier: FL14076 Exhibit 1: Proiect Summary ATTACHMENT 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 EMS projects) Chart 1• Housing Type la. ❑ Multi -family lb. ❑ Scattered Site (Check all that apply) ElSingle-family E]Project Based ❑ Congregate Facility ** Supportive Services Only Complete Chart 2 and Chart 3 based on the following instructions. Chart 2 • Units, Bedrooms, Beds a. Current Level (Point in -Time) b. New Effort or Change in Effort (If Applicable) c. Projected Level (col. a+ col. b) Number of Units N/A N/A N/A Number of Bedrooms N/A N/A N/A Number of Beds N/A N/A N/A *Do not complete information on the number of units, bedrooms and beds for Supportive Services Only (SSO) projects. In those instances, enter "N/A" in the appropriate cells. Chart 3 • Participants a Current Level (Point -in -Time) b. New Effort or Change in Effort (IfApplicable) c. Projected Level (col. a+ col. b) a. Number of Families with Children (Family Households) 232 N/A 232 i. Number of adults in families 464 N/A 464 ii. Number of children in families 1,300 N/A 1,300 iii. Number of disabled in families b. Number of Single Individuals and Other Households w/o Children 1,036 N/A 1,036 i. Number of disabled individuals 380 N/A 380 ii. Number of chronically homeless 186 N/A 186 **** participant configuration will vary dependent upon homeless - HUD -40090-3a Project Number: FL0211B4D000801 / FL14B800032 Technical Project Identifier: FL14076 Submission Exhibit 1: Project Summary ATTACHMENT A-3 (RENEWALS ONLY) C. Program Goals-. Goal: Residential Stability: • At least 95% of 3,000 homeless outreach contacts and assessments will move to emergency shelter from the streets. • At least 6% of 3,000 homeless outreach contacts and assessments will move to transitional housing (treatment) from the streets. • At least 50% of 3,000 of the homeless participants placed into housing will remain housed for at least seven (7) days. Goal: Increase skills and income: • At least 20% of the eligible homeless participants placed into housing for up to seven (7) -days will be linked to resources for benefits and employment. Goal: Achieve greater self-determination: • At least 50% of homeless participants placed will demonstrate greater self-determination by remaining housed for at least seven days. • At least 6% of 3,000 homeless participants will be linked or placed directly into Mental and or Drug Abuse Treatment facilities which will address their need for greater self-determination. 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 ATTACHMENT A-4 PROJECT MILESTONES N/A ATTACHMENT B 1� I� 'All 1� li 1 li ,i It l ��11 _ 1 1 1 __lll 11 11 jsll. 11 _ _11 11 _ _11 aE 11 _�'ll II _E 11 =!1 cll _=11 _� 11 X11 11 � 1111 II oa oo' Technical Submission for the 2008 oa Supportive Housing Program o° U.S. Department of Housing and Urban Development a° Office of Community Planning and Development o° ao = oD �D Project Sponsor: Cityof Miami UD Da as Project Name: 0 -- Miami Homeless Assistance Miami ON a� oD oo Program (MHAP) -A 00 oD; Project Type: o Do Supportive Services Only (SSBI) ao �a Do Project Number: FL14B'_*-000""`Y?'.4'Z`as °o �° � F L� B 4 D 0 0 0 8 0 1 Do' ,00 0 f 1 f r �hCJ� Submitted by Selectee. t Do Miami -Dade County Homeless Trust° 111 Northwest First Street, 27th Floor, Suite 310 Miami, Florida 33128 Z-° Telephone Number: (305) 375-1490 L oa Fax Number: (305) 375-2722 Project Number: FL0211B4D000801 / FL14B800032 Technical Project Identifier: FL14076 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, Executive Director Contact Person Sergio Torres, Program Director Phone (305)375-1490 Phone (305)576-9900 FAX Number (305) 375-2722 FAX Number (305) 400-5321 E -Mail Address I dra (a,miamidade. ov E -Mail Address storres(o),miami ov.com Street Address 27`' Floor 111 NW First Street Street Address 1490 NW 3`d Avenue, Suite 105 City, State, Zip Miami, Florida 33128 City, State, Zip Miami, Florida 33136 HMIS Lead Miami -Dade County Homeless Trust Contact Person Barbara Golphin Street Address 27`t' Floor 111 NW First Street Phone (305) 375-1490 City, State, Zip Miami, Florida 33128 E -Mail Address rrnglQmiamidade.cyov 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 fust 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 improved or Exhibits 3, 4, 5 and 6. Requested grant term: (Lyear Chart 1 - Summary Proiect Budget *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 Total ! 1 SHP Applicant Project Request Cash Budget 1. Real Property Leasing 2 Supportive Services* 239,116 59,779 298,895 3. erations** 4. HMIS* 5. SHP Request (subtotal lines 1 thru 4) 239,116 59,779 298,915 6. Administration*** (up to 5% of line 5) 11,955 11,955 7. Total SHP Request (total lines 5 and 6) 251,071 59,779 310,850 *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 Technical Submission Project Number: FL0211B4D000801 / FL14B800032 Submission Project Identifier: FL14076 Exhibit 4: Supportive Services A. Supportive Services Budget Chart 4A: 6. Service Activity 7. Service Activity: 8. Service Activity: nrnantity 9. SHP REQUEST * 80% Year. l Year 2 Year 3 Total Supportive Service Expense (a) (b) (c) (d) 1. Service Activity: Outreach and Placement 230,495 230,495 Quantity: salaries including fringe benefits for 1S.0 FTE Community Outreach Specialists including 7.66% FICA/MICA, Group Health, Worker's Compensation, Unemployment Compensation Insurances plus overtime for special outreach efforts - Subtotal = $288,119 2. Service Activity: Cellular Phones 2,850 2,850 Quantity: service for Outreach workers to effectively communicate with participants, and office to secure housing Subtotal = $3,562 3. Service Activity: Rent of Equipment 1,100 1,100 Quantity: Subtotal = $1,375 4. Service Activity: Emergency Food 1,200 1,200 Quantity: Subtotal = $1,500 5. Service Activity: Miscellaneous Supplies and 3,471 3,471 Printing of pamphlets, information for homeless and community Quantity: Subtotal= $4,339 6. Service Activity 7. Service Activity: 8. Service Activity: nrnantity 9. SHP REQUEST * 80% $239,116 $239,116 10. Selectee's Match 20% $ 59,779 $ 59,779 11. Total Supportive Services Budget 100% $298,895 $298,895 *The SHP request cannot be more than 80% of the total supportive services budget in Line 11. HUD -40090-3a 9 ATTACHMENT B Miami Homeless Assistance Program US HUD SUPER NOFA SERVICES GRANT Contract # June 1, 2009 to May 31, 2010 PERSONNEL SALARIES & FRINGES Request 80% Cash match 20% Total Project Budget OUTREACH TRAINEES Community Outreach Specialists (15 FTE) $ 259,344.00 Overtime for special projects $ 8,300.00 $ 214,115.00 $ 53,529.00 $ 267,644.00 Total Salaries FRINGE BENEFITS FICA @ 7.65% $ 16,380.00 $ 4,095.00 $ 20,474.77 Total Findge Benefits $ 16,380.00 $ 4,095.00 $ 20,474.77 SALARIES AND FRINGES $ 230,495.00 $ 57,624.00 $ 288,118.77 FIXED EXPENSES Telephone Service $ 2,850.00 $ 713.00 $ 3,562.50 Rent of Equipment $ 1,100.00 $ 275.00 $ 1,375.00 Emergency Food $ 1,200.00 $ 300.00 $ 1,500.00 Miscellaneous Supplies $ 3,119.00 $ 780.00 $ 3,898.75 Printing and Reproduction $ 352.00 $ 88.00 $ 440.00 $ 8,621.00 $ 2,156.00 $ 10,776.25 TOTAL EXPENSES $ 239,116.00 $ 59,780.00 $ 298,895.02 GRAND TOTAL ADMINISTRATIVE COST $ 11,955.00 $ 11,955.00 $ 251,071.00 $ 59,780.00 $ 310,850.00 Project Number: FL0211134D000801 / FL14B800032 Technical Project Identifier: FL14076 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 S. 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 11 Year 1 Year 2 Year 3 Total Administrative Costs (a) (b) (c) (d) 1. Administrative Activity: 2.5% to City of 5,977 5,977 Miami for staff time spent in compilation of information for APR, review of documents for reimbursement requests, audit of SHP funds 2. Administrative Activity: Miami -Dade 5,978 5,978 County Homeless Trust 2.5% APR preparation, staff time reviewing / verifying invoices, audit of SHP program 3. Administrative Activity: 4. Administrative Activity: 5. Administrative Activity: 6. SHP REQUEST FOR 11,955 11,955 ADMINISTRATIVE COSTS 7. Amount for Selectee 5,977 5,977 8. Amount for Project Sponsor 5,978 5,978 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 11 Project Number: FL02111341)000801 / FL1413800032 Technical Project Identifier: FL14076 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 SIP project must complete the information below. No other site documentation is required for renewal projects. As a recipient of SHP funds, City of Miami Homeless Assistance Program (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 numberFL14 B800032 Signature of authorized representative �l Nam: Sergio Torres F ` Title Administrator Date -Z_ HUD -40090-3a Technical Project Number: FL0211B4D000801 / FL14B800032 Submission Project Identifier: FL14076 Exhibit 2. Real Property Leasing, Supportive Services, Operations and HMIS (RENEWALS ONLY) B. Documentation of Match for Year 1 Supportive Services ® Operations ❑ HMIS ❑ A selectee must currently have firm commitments for its cash resources for Year 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. LETTER ATTACHED HUD -40090-3a 6 QLttg of ffltamt Tuesday, May 12, 2009 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 14B800032- City of Miami Homeless Assistance Program Commitment of Matching Funds. Dear Mr. Raymond This letter is to certify that the City of Miarni will provide a cash match in the amount of $59,779 for 2009 HUD SHP 2009 Grant. These funds will support the overall operations of the program, including the provision of outreach, assessments, referral and placements of homeless individuals in the City of Miami. The funds will be available upon the start of this SHAD 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 ministrator City of Miami Homeless Assistance Program OFFICE OF HOMELESS ASSISTANCE PROGRAMS 1490 NW 3rd Avenue, Suite 9105, Miami, FL 33136 / Phone: (305) 576-9900 Fax: (305) 576-9970 Technical Project Number: FL021IB4D000801 / FL1413800032 Submission Project Identifier: FL14076 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 $59,799.00 from non-SHP funding sources for Year(s)I 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 FL14B800032. Signature of authorized representative: Name (Print): Sergio Torres Title: Administrator Date: May 12, 2009 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 2008 application budget chart(s). If the position or responsibilities have changed, submit a new position description for the new or added position. P e Signature of authorized representative: �—---- a Name (Print): Sergio Torres Title: Administrator Date: May 12, 2009 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 �S submitted. Signature of authorized representative: Name (Print): Sergio Torres Title: Administrator Date: May 12, 2009 HUD -40090-3a 7 L-C%CSNRS U.S. Department of Housing OMB Approval No. 2535-0102 (exp. 1/31/2004) 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 ATTAC"HMENT C 1. Voucher Number 2. LOCCS Pgrm. Area 3. Period Covered by this Request (dates) SNAP HPAC IHP 5. Voice Response No. (5 digits, hyphen, 5 more 6. Grantee Organization's Name 8. Grant No. 6a. Grantee Organization's TIN 4. 1 ype Of ulsOUrsement Partial F-] Final 9. Line Item no. Type of Funds Requested rnnluuru irouna to nearest aouap 1010 Acquisition 1020 Rehabilitation 1021 New Construction 1022 Substantial Rehabilitation 1023 Moderate Rehabilitation 1030 Operating Cost 1040 Rental Assistance 1050 Supportive Services 106.0 Administrative Cost 1070 Child Care 1080 Employment Assistance . 1090 Relocation 1100 Leasing 1110 Repair & Maintenance 1111 Prevention (RH) 1112 Capacity Building (RH) 1120 Other. 10. Voucher Total I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. Waming; HUD will prosecute false claimsand statements. Conviction may result in criminal and/orcivil penalties. (18 U.S.C.1001,1010,1012; 31 U.S.C.3729, 3802) 11. Name & Phone Number (including area code) of the Authorized 12 Signature 113. Date of Request Person who called SNAPS System VRS 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 their access capability promptly deleted. Provision of the SSN is mandatory. HUD uses it as a unique identifierfor safeguarding LOCCS from unauthorized access. Failure to provide the information requested may delay the processing of your approval for access to LOCCS. 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 date sources, gathering and maintaining the data needed, and completingand 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 OMB 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 designedto help the recipientwhen 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 VAS. 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) PROVIDER NAME: PROGRAM NAME: CONTRACT# MONTHLY INVOICEMIAMI-DADE MELESS MONTH: T R U S T ATTACHMENT C-1 POSITIONS/DESCRIPTIONS % SUPPORTIVE SERVICES 80% "` T.S. % R 5QUST Year to Date Total Expenses Program SHP Year: 1 2 3 Expenses Reimbursement Total Budget For The Year SHP Exp YTD Iya o ot Exp YTD POSITIONS 0% $ $ $ $ - $ #D!V/01 POSITIONS 0% #DN/O! POSITIONS 0% - - - #DN/O! POSITIONS 0% - #D7/n1 POSITIONS 0% - - #DN/01 POSITIONS 0% - #M/0! POSITIONS 0% - #DIV/0! POSITIONS 0% - - - #DN/O! POSITIONS 0% - - #DN/0! POSITIONS 0% - - - #w/01 POSITIONS 0% - - #DN/01 POSITIONS 0% - #DN/0! POSITIONS 0% - - - - - #DN/0! POSITIONS 0% - - - #DN/0! POSITIONS TOTAL SALARIES 0% $ - S $ $ - $ - #DIV/0! #DIV/01 do a Seneffts - O°.6 of SAL. 01% $ - $ - $ $ - $ - #DIV/0! ESCRIPTIONS Total Sal & Fringe 0% $ $ - $ - $ $ - $ $ - $ $ - - $ #DN/O! #DN/O! DESCRIPTIONS 0% - - - #DN/0! DESCRIPTIONS 0% - - - #DN/01 DESCRIPTIONS 0% - - - #DNIO! DESCRIPTIONS 0% _ - - #DN/0! DESCRIPTIONS 0% - - - #DIV/0! DESCRIPTIONS 0% - - - #Dr//0! DESCRIPTIONS 0% - - #DN/0! DESCRIPTIONS 0% #DtV/0! ESCRIPTIONS 0% #DN/0! DESCRIPTIONS 0% - - - #DN/01 DESCRIPTIONS 0% #DN/0! DESCRIPTIONS 0% - - #DN10! DESCRIPTIONS 0% - - #DN/0! ESCRIPTIONS 0% Total Supportive Services $ - $ - $ - - $ - $ - #DN/O! #DN/01 TOTAL. SUPPORTIVE SVCSj$ Is - $ - $ - $ - #DIV/O! HT/PROJECTS 411/20082:01 PM li g g. i . . . . . . . . . . . . . . . w- w - 5 A POSITIONSIDESCRIPTIONS % Total Expenses Program Expenses SHP Reimbursement Total Year SHP Expenses Year to Date Year: 12 3 'o SHP Exp YTD SHP Exp YTD YTD ; IONS 0% POSITIONS $ $ - $ $ M IV $ #DfV/O! il TIONS 0% POSITIONS 90fV0 IV, TIONS 0% POSITIONS #DN/0! TIONS 0% POSITIONS #DfV10! POW TIONS 0% #-DIV/O! POSITIONS 0% MWO! POSITIONS 0% AtDrV/O! POSITIONS 0% #DIV/O! POSITIONS 0% #DFV/01 POSITIONS 0% #Dfv/0I POSITIONS 0% #Dtv/o! POSITIONS 0% #Di POSITIONS 0% #DfV/01 0* POSITIONS 0% #DIVIO! POSITIONS 0% -TOTAL SALARIES n 'n a '9�er hn a Benefits - 01% of SAL 0% gs 4Fnn $ $ $ 4$-_ $ 1$ $ $ - $ - #DIVIO! $ #DIV101 $ #01V/01 Total Sal 8 Total Sal & Fringe e DESCRIPTIONS 0. DESCRIPTIONS0% $ $ $ $ $ $ $ $ $ $ #DIVIO! $ #DfV10l S DESCRIPTIONS ESCRIPTIONS 0% #DIV/O! DESCRIPTIONS 0% #DFV/01 DESCRIPTIONS 0% #Di DESCRIPTIONS 0% *Dfv/o! DESCRIPTIONS 0% #DfV/O! DESCRIPTIONS 0% #DIV/01 DESCRIPTIONS 0% #DrV/O! DESCRIPTIONS 0% #DIV/01 DESCRIPTIONS 0% #DfV10I DESCRIPTIONS 0% #DIV/0! DESCRIPTIONS 0% #DiV10! DESCRIPTIONS 0% #DR(/Ol DESCRIPTIONS 0% #DIVIO! -DESCRIPTIONS 01% Total Other Operating Services p TOTAL OPERATING SVCS POSITIONSIDESCRIPTIONS % TOTAL LEASING 0% POSITIONS/DESCRIPTIONS $ $ Total Expenses $ - Total Expenses Program Expenses $ Program Expenses SHP Reimbursement I $ - SHP Reimbursement $ $ Total Year SHP Expense? $ Total Year SHP Expenses #DIV10! #DIV/01 #DIV/01 Year to Date Year: 1 2 3 6 of Tat F_xP SHP Exp YTD YTD $ - #DiV10I Year to Date Year: 12 3 % of Tot Exp SHP Exp, YTD YTD AL ADMIN COST I $ - 1 $ - 1$ - 1 $ . Is - I #DIV/01 GRAND TOT HT/PROJECTS 411/20082-01 PM miarnl uauL, rlomeltss I ju5[ jun lu, )uut MEIIYIYIT"f) A 1T ! / TA 1CH Government ! Ho ne ClientPelnt Res r e a P int SkanFoint FP,_ or:, admin �e , ourcePoint �h It_r o �P p HUD Annual Progress Report (HUD -:0113) Ii Report Options; Select- .' Unduplicated Provider Miami -Dade County Govemmert (#1) Operating Year Date Range 05/0 1/20CTI to 05/31/2006 (mm/ddlyyyy) Legal Adult Age 18 (as de`ined by foster care law in your stare) Or ?S1Uy `l `l a Select- LYi 12- Persons Served during the Number of Singles Number of Adults Number of Children in Number of ope year. Not in Families in Families Families Families II a. Number on the first day of the 1 0 0 0 1 operating year. Not given I 0 0 p b. Numberentering program during the , 0 I II 0 0 g. 51 - 61 operating year. I 0 0 0 0 c. Number Nho left the program during 0 I 0 the operating year. 0 0 I 0 Number in the program on the last day Lodithe operating year. (a+b-c=d) 00 0 0 3. Project Capacity. Number of Singles Number of Adults Number, of Children in Number of Not in Families in Families Families Families a. Number on last day (from 2d, columns 1 and 4) 0 0 4. Non -homeless persons. (Sec. 8 SRO projects only) How many Income-eilgible non -homeless persons were housed by the SRO program during the operating year? 0 5. Age and gender. ,Age Male Female Other/Nbtgiven Single Persons (from 2b, column 1) a. 62 and over 0 0 0 +b. S1 61 0 0 G c. 31 50 0 I 0 0 d. 13 30 0 0 0 e. 17 and under . I 0 0 + 0 Not given I 0 0 0 Persons in Families (from 2b, columns Z & 3) If, 62 and over , 0 I 0 I 0 g. 51 - 61 0 + 0 0 L j h. 31 - 50 0 0 I 0 httpsservicept.col?,✓n1;aI711(SCrl pts/svpreportnud.ph6114/?006 i. j,3 30 �) J J t'' Ij. I� " l ` 0 I 0 I 0 k. 6 i s 0 0 0 �I. 1 0 0 0 m. Unger i �' 0 Not given ' 0 I 0 i �� Ga. Veterans Status A veteran i; anyone who has ever been on anti e- mi!itar/ du'y stacus. � 0 6b. Chronically Homeless. Hots many participant_ were chronically homeless individuals? 0 7. Ethnicity. a. Hispanic or Latino AIO b. Non -Hispanic or Non-Lalino 0 8. Race- — -- -- n 4. 1111iC111U11 lllu 1011 VI NOUVC 1 b. Aslan 0 c. Black or African American 0 d. Native Hawaiian or Other Pacific Islander 0 e. White � 0 f. American Indian/Alaskan Native & White 0 I 0 g. Asian & White Chronic h. Black/African AmPrlran & White 0 i. American Indian/Alaskan Native & Black/African American j. Other Multi -Racial k. Other/Unknown (all that de not match! 9a. Special Needs. All Chronic a. Mental 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 f. Physical disability 0 0 g. Domestic violence 0 I 0 h. Other (please specify) 9b. Disabled. 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 0 0 c.. Transitional housing For homeless persons 0 ! d. Psychiatric facillty 0 e. Substance abuse treatment facility 0 f. Hospital 0 g. Jail/ prison 0 i h. Domestic vioienc=_ situation 0 i. Living v:,ith relatives/friends r j. Rental housing ' 0 . httl?s:i/n1�.w�.scr�,icep t.con-Ji-niamlllscripts/svprep orthud-php 6/14/2006 J K. ULIICr (piease specify) 11 Amount and Source of Monthly Income at Entry and Exit 0 Amount I A. Monthly Income at Entry B. Monthly Income at Exit All Chronic I All Chronic a. fdo Income 0 0 I p 0 b. g1-150 I 0 I 0 I 0 0 �. $151 ., 0 �I 1 0 I o d. $251 - $500 I 0 I 0 I 0 0 e. $501 - $1000 f. $1001 -$1500 g. $1501 - $2000 I 0 I 0 0 0 0 0 I I I 0 0 0 0 I 0 0 h. $2000 + 0 0 0 0 Source C. Income Sources at Entry I All Chronic I D. Income Sources at Exit All I Chronic a. Supplemental Security Income (SSI) 0 0 I 0 0 b. Soclal Security Disability Insurance (SSDI) 0 0 I 0 0 c. Social Security 0 I 0 I 0 0 d. General Public Assistance 0 I 0 0 ( 0 e. Temporary Aid to Needy Families (TAN F) 0 0 0 0 f. State Children's Health Insurance Program (SCHIP) 0 0 0 0 g. Veterans benefits h. Employment Income 0 0 I 0 0 I 0 0 0 0 Unemployment Benefits 0 0 0 I 0 1i. j. Veteran's Health Care 0 I 0 0 0 k. Medicaid 0 0 0 I 0 I. Food Stamps I 0 0 0 I 0 m. Other (please specify) 0 I 0 0 0 n. No financial resources I 0 0 12a. Length of Stay in Program. (Participants who left during operating year) All 0 + 0 -Chronic a. Less than 1 month 0 0 b. 1 to 2 months c. 3- 6 months I 0 I 0 I 0 0 d. 7 months - 12 months 0 I 0 e. 13 months - 24 months f. 25 months - 3 years 0 0 I 0 0 g. 4 years - 5 years 0 0 h. 6 years - 7 years 0 0 i. 8 years - 10 years I 0 0 j. over 10 years 0 12b. Length of Stay in Program. (Participants who did not leave during operating year) 0 a. Less than 1 month I All I 0 Chronic 0 b. 1 to 2 months c. 3- 6 months I I 0 0 I 0 0 d. 7 months - 12 months 0 I 0 e. 13 months - 24 months 0 I 0 f. 25 months - 3 years I 0 I 0 c. 4 years - 5 years 0 0 https:/AA/7 vv3.ServiCcpt.Con-I/mialni/scriptsisvpreporthud.pi-gyp 6/14/2006 a. Left for a nousina opDortunity b. Completed program C: Non-payment of rent/ occupancy d. felon-compliance with project e. Criminal activity / destruc.ion F. Reached maximum time g. Needs could not be met h. Disagreement with rules/persons All before completing program III charge 0 0 of property / violence I 0 allowed in project 0 by project I 0 0 3 I Chronic 0 0 0 0 0 0 0 i. Death 0 0 j. Other (please specify) 0 0 k. Unknown/disappeared 0 0 14. Destination. AfIEhr PERMANENT (a - h) a. Rental house or apartment (no subsidy) 0 b. Public Housing 0 0 c. Section 8 0 0 Id. Shelter. Plus Care 0 0 house or apartment 0 0 e. HOME subsidized f. Other subsidized house or apartment ( 0 , 0 Ig. Homeownership 0 0 h. Moved in with family or friends 0 I 0 TRANSITIONAL (i - 1) i. ---------------- Transitional housing for homeless persons I 0 0 Ji. Moved in with family or friends 0 0 INSTITUTION (k - m) k. Psychiatric hospital + 0 I 0 I. Inpatient alcohol/drug treatment facility 0 0 'm. )all/prison 0 0 EMERGENCY SHELTER (n) shelter 0 0 OTHER (o - q) #nE,mergency er supportive houslna 0 0 meant for human habitation (e.g. street) 0 0 ces not q. Other (please specify) 0 ( 0 UNKNOWN r. Unknown 0 0 15. Supportive Services. No supportive services found. ServicePoint version 4.01.018 (db build #0723) Licensed to: Miami Dade Homeless Trust Co 1999-2006 Bowman Systems L.L.C. All Rights Reserved. CPT on] y rc?2004 AM. cr can r•tcGtcal Assoc@[ion. Ail RlGnts P. 5^turd. DSI, and DSH-I1.1-TR a.= reois:erGc' cradeTarks of the ,4,,ner:o?n Psychiai r Association, and are used vilih permission hereon. ` 199y PNtroca! Center For H-aith Star,stic; JCD-0 :'n'dorld Health &r.ani7ation). All Rights Peserve0 ra>:oncmy !F)i9'13-2003 lfnf::)rr-. abor. and >•e�,eradon of L_; Ance!e; co;nty, inc. All Rignts _heel. https://www3.servIcept.conl'miami/scripts/svprep orthud.pllp 6/14%3005 N141! �-1I-D_�DE C0L? y,T " Hca ��L ESS TRUST PRQGRANI RST -NG OF SATISFACTION INS TP CTIO�, .S Carefully read all of the instructions below BLrOI:E distributing rhe Pro,rani Rarin- of.Sarisi-acr, sun'ev to your program Participants. GeneralInfurrnation The Program Eating of Satisfaction consists of I I items which arc used to detcnmine a clicnt*s s nisfaciiOn �x:itl? sen ices they are receiving from a provider. It is to be Completed by all Program parucipu;lis enLa;ed in services at a Trust -funded program. It must be completed - at a minimum - at time of dischar�,e for all participants. It is strongly recommended that a Program Rating of Satisfaction survey also be completed at intervals as may be applicable to the program: however. only the discharge survey must be fon,arded 10 Elie Homeless Trust. Case management notes should indicate specifically why a Program Rating of Satisfaction was not obtained, if that is the case (client went AWOL, institutionalized, etc.), and «Tat efforis ��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 H,- If nkIf a participant cannot read, providers should encourage them to use the same process they use to have gency that is not directly responsible for the client's other information read to them. An employee of the a care can read the form. This should be indicated in Section II. as a separate set of staff initials. Filling out the form 1) A language appropriate survey and an envelope should be provided to all participants .vho are required to complete the form. Only one form per family is required. The form must be filled out in ink.. ?) Section hI of the Program Rating of Satisfaction is to be completed by staff prior to prop idin, the survey document to the program participant. Staff initials. refers to the initials of the case mananer 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 Procrarn Rating of Satis action Form is to be filled out ONLY by the Program participant. The program participant should be provided a private place and sufficient time to answer the surrey. 4) Providers should reassure participants of the confidentiality of their responses. Providers mai, wish to introduce the survey, as allows: "This survey is one way of helping us determine ho\,v xell %ve are helping individuals that come to our agenev for assistance. Please take a few minutes after I leave to answer this ver-", short survey as honestly as possible. Your responses are private and %ve will riot look at them. Please seal the envelope and rive it to me then Vou are done (or: put it in the drop 5) The completed Survey s.'iould be placed in the env elope by the recipient and sealed. Providers are encoura_ed to provide a "drop box" a slot for completed forms. 61) The sealed envelope(s) sl°nuld be fon,arded to the. I liami-Dade County Homeless Trust on a monthly basis. i) The provider acency should maintain a lot, cf how rnan sure, s art disiril used. DETER- IIX ATI0N OF P'"I\It`ll-kYERaGE SCCI RE FOR C0"I`SU'NIER S.ATISF.CTICi'\ SLR% I Uh�l Ctlilil'c7!c!'l �I1', :L'C%1'i 1 was informed of my riL7hts and responsibilities I was provided with information about different servicesI -t\; that are available for me 9 I was involved in making decisions about my carciservice Ian I xasable to talk with staff when I needed to I, The building and facilities have usually been clean, safe and I I I S I comfortable MY rights were respected and protected, including my right N/A I 0 I to file a grievance, if needed My case manager seems ualified to hel me 1 I would recommend this procram to others � s i ;.36 1 am treated with respect by the staff I S The staff seems to care about whether I get better Program staff were knowledgenble about available services 14 .3S that could help me G"7 it RECOMMENDED 57.00 11/6/00 ?VIIAINII-DADE COP-, T` HO NMELESS TRUST PROGRAM RATING OF SAT'ISRAC 11- ON Section I.:7U_EE C0 1PLI✓TED BY PROGRAM PARTICIPANT Iirsrructiairs: Please ulrs-wcr eacli quesllon below bV placln; an /-AY ur t/IC spllCe ern •ided. ].()us reser lrse°s ti llle,sc que.s'lions have nn bearing on tour continued Dariic.ipurlon iii Mc pros,r(iln..-ILL responses nre' cntlficlentiltl. VVhy did 1:ou choose to enter the program (mark only one box): I decided to come to this program on my own (throu_h outr?ach. referral, etc.) D I was placed here tluou�rh another program (court intervention, police. etc.) a2ainsl mv 0 I had previously participated in this or a similar program and decided to return OPTIONAL Information: Name. Today's Date: Sea: ❑ male ❑ female Please answer the following questions about the services you received. Mark (.YJ orr/t• one box which hest describes your feelin-s about each statement. These questions are nreartt to help us inrpro re 1/re service's- provided, SO we ask that )you tell us how-yoti really feel, whether or not it is good or bad Srronolr Agreef !gree a + Disagree Disagree � Srrorr;fr ,4�rer I Liule -? Little DisaFree I was informed of my rights and responsibilities, I [6] [3) [4] [3] [3] [1] including the agency's (Yrievance procedures l was provided with information about different services that are available for me I was involved in making decisions about my 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 ?rieva nce, if needed )lY case manager seems qualified to help me I would recommend this proaram to others I am treated with respect by the staff � The staff seems to care about whether I tet better Program staff were knowledgeable aboutovailabie services that could help me [6] [5] erneraency housing 0 transitional housin,!o; [61 [5) C permanent housing 12] [ l] [6) [5) fa) 133 [2) [I) [6] [e1 [51 15 [Y) (al (3) [3] 121 [i) f61 151 [4'1 [3] 1221 [1) [6) [51 [41 [3) (61 [>) 11.41 13 1221 II) [6] 1�1 [41 [3) [z] [I) Section II.: TO BE COMPLETED BY PROGRAM STAFF Purpose of Evahration 0 At Admission 1 0 At discharge 1 =i Other: I R.e', I Ii6i00 Firrr .prGerarnraunc Current Level of Care provided ❑ erneraency housing 0 transitional housin,!o; ❑ transitional housins%nc.n-tx C permanent housing ❑ services only l ProNider h'arne: Project (` amc: Staff Initials: �TL4 II -D SDE COUNTYHOMELESS TRUST EVALUACIOVr DE L.A SATISFACC16N CON EL PROGRA)IA Seccion I. COIIPLETADA POP, EL PARTI(IPANTE DFL PR()GRAMA Irrsrruccionesr Por fu,or caloque u a a cru-- [\j en e/ espaciu pro, istu para r:•spondcr o !as pre; urrrus a cow;1r mn"iein. L,m respueStus flue usted dt a esle cuestion tr;u nrn in�uirun de fnrmu nlPuiru s hre lu cuntinuncirii� dc' w nar'icvr auc V;ir <"I c,re, proranrna. TOIJAS las reSpuestas se rnarrtcrtdr6rr canfrdennciuimenre. Por que decidio usted participar en cl programa" (Marque una casilla sol:;mente): [ J Lo decidi por rni cucnia (porque fui remitido o Por medio de on programa. etc-) Fui colocado aqui mediance orro programa (por ince-vencion de !os tribunal --s, la Policia, etc.) cm contra de mi voluntad [ ] Ya habia participado en este prog:,-ama o en uno similar v decidi re<,resar Informaci6n OPCIONAL: Nombre y opellido: Genero: M [ ] F ( j Fechn de ho}: Por favor responda a las pregurztas s ; uierrtes acercrt de losservicios que se le /tan presrado. Iadique con una crux LIN4 SOLA C4SILLA POR PREGUAITA la forma en nue usted se siertle acerca de cada utra de /us cuesiio+les deseritt7,r. Con10 sus respuestas a estas pregunras nos al^tdararr n mejorar los servicios que p restamos, le roo amps (Me nus Ira; a saber Como se sierlte en realidad acerca de nujesrros ser vicias, rro inrporta si usred los corzsidera buenos o n:ulns. Seccion II.: COMPLETADA POR EMPLEADOS DEL PROGRLA IA (ramolcted_bi Program staf Perrpose of EValuariorr Current Levc1 of Care provided Al Admission I Q ernerLTtnc housing h 'Provider .Name: D apt diseharee n Transitional housinitz Project Name: D Other: I transitional housing/non-r< I Staff Iniriafs: [ permanent housing I 0 ser � ices only Ntu, de De + .-Igo de i Aslio rC.9j En I :itut" cn acuerdo acuerdo ( acucrdo dccuerdu ! desacucrdo desacuerdo e me iaformaron cuales eran mis derechosy Fres�poasabiljdadEs, [6] [d] (4] entre elios, los procedimientos de la uncia ara someter ue'as. Se me dio inform3ci6n sobre los distintos servicios a los [6] [) [4] [�] [2] [1] ue tendo derecho. Participe en In toma de decisiones references a mi plan f [6] (>] [4] [3) (�� (1] de atenci6n v servicios. Pude hablar con el personal cuando tune necesidad de [6] [6] [4] (.] (23 [ 1] hacer(0. El centro y sus servicios por to general se han mantenido [6] [S] [4] (_ ] [?] [ 1] lim nos, sin eli2ro y accesibles. Se respetaron y protegieron mis derechos, entre ellos, mi [6] (? ] [I] derecho a someter quejas si Io considero necesario. Aparentemente, la persona encaraodn de mi caso sabe to [6] [6] [4] [_] [-j fl] ue tiene que hacer parn avudarme. Yo les recomendaria este provecto a otras personas. [6] N [4] (3] (2) 1] Los em leados me trataron res etuosamente. 6] (iI (4) (=j [2i (1] Aparentemente, a los empleados les interesa que yo [ti] [ ] [4] [3] [?] [1] mejore. ' 11 Los empleados sob inn queservicios podia aser;irniede [6] [4] [;] [3] (l] ativda. Seccion II.: COMPLETADA POR EMPLEADOS DEL PROGRLA IA (ramolcted_bi Program staf Perrpose of EValuariorr Current Levc1 of Care provided Al Admission I Q ernerLTtnc housing h 'Provider .Name: D apt diseharee n Transitional housinitz Project Name: D Other: I transitional housing/non-r< I Staff Iniriafs: [ permanent housing I 0 ser � ices only IMIA'N/1I-DADE COUNTY HOMELESS TRUST MVOGR--�M POU EVALYE S_aMSEAKSY0N �ec?ion I. TOUT P.ATISIP N N'AN PW0GPy-AM SILA A FET PQU hLaNPLI EnstriksYurt: Tanpri repunrr clrak kekst'orr arrba la a epi f> n ti k'u�rr/r/ rr(rrr espnski rirl lu. RCT? 0 s rims hrrt V o pnn deranic %asun non 1nowinve paristpe hair n� o� (Xrarrr silo a. Torrt rcTrons -vo rip PVUKI W CHWAZI PATISII'E N,.kN pvv0GR-I M SILA A (fe yon (i 'N ,a non von ;rcnn bwat): O Se rnwen ki chwazi vinn non pwoornm silo a (swa po refernns, swa pa se,•is espesyn) asistans hiblih etc.) (] Se pa chi}•a mti,en, se yon lot pwoorom ki vvverr, (Zak trihinal; lapolls etc) [) Mwen to dejn patisipe nanyon pwohram konsa epi riwcn Beside retvunrnen. Enfornasyon you bav si Nv vie: Non: Dat Jody -a: Seks (l Cason [) Fenrn Tarrpri reponn Aeksyorz Bila yo dapre seeds w reseviva. Fe yon kwa /.LJ tram yon sel ti Attire epi chwal-i reports ki plis rrratche ave w. Keksyorr silo yo la pori ede iron ba_v pi hnn Se�vis, 016 110L,trrarrde nou bap rcpons ki plis Illatche live w,kelibon oupa. Section II.: TO BE COMPLETED UY PRO GFZ-MV1 STAFF Purpose of Ei,aluation I Curreru Lepel of Care provided C:, At Admission ❑I emer,..ncy housing Provider Mo ame: At discharee ([7 t-ansition,al hrusin^!t>; Project N'amc: r -I nther: i ) i , � �/ r � Staitinitials: G transinona, ho��in_ nen-r.: i r permanent housing se, ices only., Rc;.11l61/00 Forrn;iprogranraiine Bon jan dako I Dako I N'finn I Pa dak6 Pa dako dako tou pili two dako ditou_ Yo fem konnen tout dwa mwen yo ak responsabilite 1 [6] [5) [4] [3) [2] [1] mN+�en vo ak kouman ou mwen lenven non ajans la f Yo to banmwen enfomas},on sou diferan sevis ke mNven I [6) [6] [a) [3) [2] [I) ka b j wenn h1v}yen tepntisipe non tout desizvon sou planifi<asy=on I [6) (5) (4] [3) [3] [I] swen/sevis mwen i Am IINave Yotou ou Bis ou mwen pale 2%,e), vo [b] [5] [) [ ] f 2 Kole a ak bi[ding yoto toujou pwonfbtab ak [6] [s] ] [2] ([I1 ]] bosekie I) Tout dura m to respekte ak pw6teje rnenm dti mwen to ote tentsi nesese Moun kap okipe ka mwen an sanble li kalifye you li 1 [6) [6] [i] I'll, [2] [i] edem M wen to rekomande tivo�ram si(a a bay lot moon 61 O [4j ] (? I] Am Jwa)�e Yo trete mwen ak respe ( [6) (-5] [d) Am h ave Yo sanble vo vreman enterese nan mwen (6, (5] 4) (_ (2] (I) Ampinayepwogram la to byen enfome sou tout sevis ki f [6) [y] [�) [3) [�] [I] to disponib you ede M. Section II.: TO BE COMPLETED UY PRO GFZ-MV1 STAFF Purpose of Ei,aluation I Curreru Lepel of Care provided C:, At Admission ❑I emer,..ncy housing Provider Mo ame: At discharee ([7 t-ansition,al hrusin^!t>; Project N'amc: r -I nther: i ) i , � �/ r � Staitinitials: G transinona, ho��in_ nen-r.: i r permanent housing se, ices only., Rc;.11l61/00 Forrn;iprogranraiine ATTACHMENT F CLIENT CONTRIBUTION REPORT NAME OF AGENCY SUBMITTING REPORT: DATE REPORT SUBMITTED: GRANT NUMBER- REPORT UMBERREPORT 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 NUMBER#: AMOUNT FOR MONTH S S ❑ Yes ❑ No TOTAL ADJUSTED MONTHLY INCOME TOTAL: S AMOUNT THIS MONTH TO CLIENT TOTAL: S 'k AMOUNT THIS MONTH TO PROVIDER MAXIMUM 30% OF CLIENT'S ADJUSTED INCOME Revised 7/12/3007 U. S. Department of Housing, and Urban Dcvelopment OfFiice of Community Planning and Development OMB Approval No_ 2.506-0145 (e,,p. 111-10"2009) ATTACHMENT G Annual Progress Report (APR) for Supportive l3ousiuor Peobram Smelter Plus Care and Section S Moderate Rehabilitation for Single Room Occupancy Dwellings (SRO) Program form HUD40118MS 2003) I'uhlic report in; burden Ibr this-11cchon ofbtformadoll is mimated to avera_-,e 33 1tours per response, including the tittle 16r re%ic wuig iLr;uv,--tious. ;,arching existing data sources, Gmaintaining and maintaining the data needed, uid colrpieting and revicn itic dl, collection of infomt2tion. 'Ms agent) may n of conduct <r .^..po+lsnr, and a person is nut retluirLd !u reshon to, a Collection of information unless that coil-=flOfl jjI PjJ VS a P;Llid MILD control number. General Instructions Pul-pose Tile A�mittal Progress Repori (APR) trrlcks pro,rnlu proeress and accomplislunents in the Department's competitive Irorrreless assistance progran.s. Filing P.CquirCrncnts_ Recipients of HUD's homeless assistance "'rants must Su bruit 2.APR's to -HUD cFithill 91) clays after the end of each 0[)critirig bear. One copy of the report must besubmitted to the CPD Division Director in the locn.l HUD Field Office responsible for managing the <,rant. Tike other copy must be submitted to PND Headquarters. Dcpartmcnt of Housing and Urban Development, Attn: APR Data Editor, Room 7262, 451 ia' Street, SW, Washington, DC. 20410. Failure to submit an APP, will delay receiving grant funds and may result in a determination of lack of capacity for t-uturc funding. An APR must be submitted for each operating year in much HUD fundin is provided. Grantees that received SIS 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 yeu in which Ll-rcv use Sip funding for leasing, supportive services, or operations. For years in ivluch they do not receive SIIP finding, 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 ench HUD grant received. For Shelter Plus Care, a separate APR must be submitted for each Shelter Plus Care component For those grantees receiving an e. -,tension, a separate report covering that period must be subnvttcd (see Extension below).. Record keeping. Grantees must collect and maintain information on each participant in order to complete an APR Optional worksheets are attached. The worksheets may be used to record information manually or to design a computerized system to store and tabulate the inforination. The worksheets should not be submitted to HUD with the APR. Organization of tare Report. The APR is organized in the folloiving manner: Part I: Project Progress. This portion of the report describes the progress in mor,ng homeless persons to self-sufficiency services received,project goals; and beds created. Part II: Financial In ormatiou. This portion of the report is completed by all grantees receiving funning under SET, S=C and SRO. final Assembly of Report. After, the entire report is assembled, number every page sequentially. Mark any questions that do not apply to your program with "N/A" for not applicable. (See Special Instnictions for SSO Projects below.) Defillitions. The following terms are used in the APR As indicated, in some cases, terms are applied differently depending on whether the funding is from Sffi', S+C, or SRO. Chronically lkomeless person — HUD defines a chronically homeless person as "an unaccompanied homeless individual with a disabling condition who has either been continuously horneless for a year or more OR has had at least. four (4) episodes of honmelessuess in the past three (3) years." To be considered chronically hortneless a person must have been on the sti-ects or in an emergency shelter (i.e.not transitional housing) during these stays. Disabling condition - HUD defines "disabling condition" as "a diagmosable substance use disorder, serious mental illness, dm cloprrtental disabilij', or chronic physical illness or disability, including the co -occurrence of tla o or more of these conditions. A disabling condition limits an individual's abilir ' to WDrk or perforin one or more activities of6lily livinz. hrrtered the pro�llranr for S+C and SRO projects means when the participant starts to receive rental assistance. For S=C, ser.ices provided prior to this paint are recogmi zcd as nccessan for outreach/eniolIinerit and are elioiblc to count as rnatcli. Cone HUD -401 1&.(0S,-2003) AR Extension APR applies to STP and S+C grantees dial requested and received an c..tension of their Grant term from the fT fD field office. Tile orliv difference lictwccri an APR for t]ac extension period and the regular APR (besides the amount of time covered) is the signature page. Grantees should circle "yes' to indicate tine APR is for ail etitensien DMod t.nd circle Uae operaung ., car for N, hich Cite report is an cx-tension. For c::ampIc, if tIte f rantce is extending year 3, the erantce should submit an APR as usual for year 3 and submit aaotlicr APR for- dic c.,tcnsion period. indicatine Clic second is an extension and also circling near 3 on the signature pa,e. Family means a household composed of hro or more related persons. at least one of tir°Itoin is an ,adult. Carcgivers are not reported on in laic APR. Grantee means a direct recipient of Clic HUD award Left the pro,rrana for S+C projects means when the participant stops receiving rental assistance and is not expected to return to S+C assisted housing. If the participant returns to S+C assisted housing within 90 days, the person should not be considered as e.,Liting from the program. IS the person returns to Si -C assisted housing after 90 days, that person is considered a neve participant. The workshect is designed to capture this information. Match Por 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 die life of the project. For SH.P, match means cash used to provide the grantee's portion of acquisition, rehabilitation, new construction, 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 = office, and when the first participant is accepted into the project. For projects without acquisition, rehabilitation, or new construction, tlae operating start date begins when the grantee accepts the first participant. For S+C (SRA, PR_A 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 ,i itla the effective date of die Housing Assisiance Payments (HAP) Contract. To determine 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 rent- `val a ant for ttivo years would circle years 1, Z, and 3 respectively on die APR cover sheet for the initial grant and would circle 4 and 5 respectively for die renewal grant. For any future renewal grants, the grantee would begin by circling 6 on tae 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 vi,ho live with [lie adults assisted. Project Sponsor means the organization responsible for carrying out the daily operation of the project, if tie organization is an entity other than the grantee. Special Instructions For Supportive Service Only Pro jects. SSO grantees should complete aII questions, tulless a tivritten agreement has been reached avith the field office concerning which questions can be artswered-using estimates, or in rare instances, skipped. Below is an example of how information could be derived in a large, single -service SSO project: A grantccrsponsor sniff nicnaber could be assigned to collect information from Uae or-ariizauons housing the participants. The staff person would contact tltcse individual organizations to request information regarding the persons in that facilit-V that use the seMce. For participants living on the street, Ute grantee/project sponsor may provide estunates. Information could be collected for each participant or for participants receiving sen ices 'It a point-in-tivae. If estirnates or point-in-timc counts are used. the method used must be described in the APR and the documentation kepi on file. fonu HUD-4017&((0SI?C0?j As witl) all projects funded under HUD's Homelessness assistance -f-mints, grantees operaling SSO projects are cxp•_cteci to comple!e all a,PR questions tlh�rt are applicable to them_ Note that all projects h,,)ve been awarded funds as a re-suit of responding to (lie prooraur goals of assistin- homeless persons obtain/remain in pcnnnncnt housing and increase ttreir skills and incon e. The APR docrrrmcnts their pro,ress in rnc-�tinY thcsC ,o<ils. In some circumstances field offices mid oraluees mal sign a WrittCn a Ircernent concerring questions Mhich can be ,rnso,cred using estimates, or in rare inst ,aces, skipped. Sclo%arc some considerltions for reporting on parucrrlar types of pro;ecis: Outreach Only Proiects. - Projects whiclr arc solely devoted to street outreach and comncction to housing aiid scry ices arc not required to tI'ocic participants beyond their contact with persons on the street. It is sufeicnt for these projects t:o enter information on questions .1-10 (skipping questions 11-13 and 17). Estimates Cor questions j-9 are allowed, given that particip,rnts may be reluctant to answer personal questions. Answering Ure questions ilI demonstrate that the grantee is sclving the appropriate number of people, providing basic demographic information for Congress, demonstrating ilial homeless persons are being scn ed, demonstrating the types of housing participants are connected to, and the type of services they are receiving. Hotline Projects. - I-Jotlinc services are similar to outreach projects, but contact between grantee and participant is often of very short duration - people enter and leave the program nearly silnultaneously. It is suf5cicnt for these projects to ans,ver questions 1-5 (skipping 4), 10, and 14-19 (shipping 17). Proiects Providing Services To Children Only. - Projects that provide child care, alter school care, counseling for cluldrea, etc, make an important contribution tovrud moving a family out of homelessness. While the main focus of the project is providing services to the children, it is the adults who are reported on in questions 6-16 of the APR Like all other Projects, this type is also targeted toward getting the fantilies into housing and increasing the families' incomes. Grantees niay skip question 9; all other questions should be answered (except 17). Transportation. Medical Dental and Other Sinale. Short-Duration Service Projects. - Some grantees provide a single service of fairly short duration focused ONLY indirectly on assisting homeless ,persons to obtain/reauain in permanent housing and increase their sldlis and incomes. 'It is sufficient for these projects to enter information on questions 1-10 and 14-19 (question 17 may be slapped). However, with transportation services, it is unreasonable to tliinli: that someone would have to give their age, race, and ethnicity to a bus driver to get a ride a feiv blocks. For these seMces, provide a narrative, -�ilhich gives the number of rides given during the operating ycaT, and provides estimates on the above statistics based on tine population that utilizes the service. Special Instructions For Safe Maven (SH) Proiects. - Grantees are reminded that they are to report ONLY oil the number of participants the application -,vas approved for (cannot exceed 25 participants). PIornetess M-Inagernent Iriformratioll SVStem (IfNIIS) Projects. -HMS grantees should fill out the coverslreef of tIre APR (marking HMIS at the bottom) and Part II Financial Information. The .APR also has a sheet that lists HMIS activities. rune HUD==01I8((0&-no_) THIS` PA GE - TU BE CC)AtPLETED .81'ALL CIrA rGrTEE, HULA Grant or Project Numbcr: Project Spoilsor: Project Nurn.: 011et'atirlg, freer: (Circle the opmllillpear baing rcpon Jon ) Rcl�orfjttg Fenod: (mvnLi�i�iayi�ear) ❑1 ❑2 ❑D ❑a 03 Ota [J7 ❑s ❑9 010 111 ❑12 ❑17 ❑14 ❑15 ❑16 ❑1- ❑15 71`> ❑21) hidicLitc if estetuion: ❑ Yus ❑ No Indicate if renewal: ❑ Yee ❑ No Previous Grant Ntunbers for this project Check the component for the grog ani on which you are reporting. Supportive Housing Prograin (SHP) SlielterPlus rare (S+Q ❑ Transitional Housing ❑ Permanent Housing for Homeless Persons with Disabilities ❑ Safe Haven ❑ Innovative Supportive Housing ❑ Supportive Services Only ❑ HMI ❑ Tenant -based Rental Assistance (TRA) ❑ Sponsor -based Rcntal Assistance (SRA) ❑ Project -based Rental Assistance (PRA) ❑ Single Room Occupancy (SRO) �.J Section S Moderate Rehabilitation ❑ , Single Room Occupancy (Sec. S SRO) Stmunary of the project: (One or ttvo sentences wiul a description of population, number served and accomplishments this operating year) Name & Title of the Person who can answer questio>>.s about this report: Phone: (include area code) Address: Fa\ Number: Oiclude area code) D -mail Address I hereby certify that all the information stated herein is true and accurate. 'amine: HUD will prosecute False claims wid statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012, 31 U.S.C. 3729 3802) Came & Title or Authorized Grantee OlTicial: Sigmatwe & Date: Nara and Tice ofAuthorizcd Project Sponso; Otllcial: si,nawre & Date: X 5 f,�mi HUD—' -01 I a(I('0,",,!2003) PART L TO BE COMPLETEr BFALL GR4ATTEEs (EXCEPT H.1111S) SSD GRANTEES, PI EA SE ,SEE .SPL• CIAL INSTR UCTIOI'VS U/Y PAGE 3 OF THE APR Part I: Project Progress 1. Projected Level of Persons to be seri ed at a gi-,en point in time. (from the application, Sl Sec. P SPC- Sec. D; SRO- Sec. D) 2. Persons Served during the operating Fear. A,e I Male Female Number of' NUITiher of N mbcr of NU111b r of a. Number on the first day of the operating year Singles Not AdUItS ill children Families b. Number entering program during the operating year ul Families F,uuilics in Families 51 -61 C. Projected Level i. 113 - 30 I f a. Persons to be served at it given point in time 1. 1-5 nn. I Under I 2. Persons Served during the operating Fear. 3. Project Capacity. A,e I Male Female Number of SulglesNot in Farrulies Nlurnber of Adults uT Families: Number of Children in Families Number of Families a. Number on the first day of the operating year b. Number proposed in application (from la, columns 1 and 4) e. 117 and under b. Number entering program during the operating year Persons in Families (from 21), colunuts 2 u 3) f. 62 and over I 51 -61 C. Number ho left the program during the operating year i. 113 - 30 I f d. Number di the program on the last day of the operating year (a+b-c)=d 1. 1-5 nn. I Under I 3. Project Capacity. 4. Non -homeless persons. This question is to be completed for Section 8 SRO projects. How many income -eligible non -homeless persons were housed by the SRO program during the operating year? 5. Age and Gender. Of those who entered the project during the operating year, how many people are in the following age and gender categories? Single Persons (from 2b, column 1) I A,e I Male Female Number ol: Singles Not in Families Number of Number of Number of I Adults in I Children in I Families Families Families a. Number on the last day (from 2d, colunuts 1 and 4) c. 31-50 b. Number proposed in application (from la, columns 1 and 4) e. 117 and under C. Capacity Rate (divide a by b)= % Persons in Families (from 21), colunuts 2 u 3) f. 62 and over I 4. Non -homeless persons. This question is to be completed for Section 8 SRO projects. How many income -eligible non -homeless persons were housed by the SRO program during the operating year? 5. Age and Gender. Of those who entered the project during the operating year, how many people are in the following age and gender categories? Single Persons (from 2b, column 1) I A,e I Male Female a. 62 and over b. 51-61 c. 31-50 d. 15-30 e. 117 and under I I Persons in Families (from 21), colunuts 2 u 3) f. 62 and over I 51 -61 h. -,I 50 i. 113 - 30 I f k. 6-12 1. 1-5 nn. I Under I lona HUD -40118((08/700_ ) -- 2t �ruyver questions - iU only for participnnis yvilo enieryd the project (anti ittc oriel2tit Cir (ruI)) _J, col'u!"'S I LL 2). The term participant means sirnale persons and adults in families. It does not include cliildren or caregivcrs. NOTE: The toil for questions, 7. 5 and IU below should be the samc, respond to encu of [).lose quesdotis for a I I participants. Sonic of the questions listed throughout the APR ivill be asking inforn-ttion for indis iduals who are chronically' homeless. Ga. Veterans Status. A veteran is aitvone % bo has over beun on active utilimry dutp status. Ross' many participants %ve.re veterans? Gh. Chronically homeless person. An Uuatccompattied homeless iudividsai with a disablisto coudi!ion Who leas either been cont' nuotLsty homeless for a year or more OR has had at Ieast four (4) episodes of homelessness in the past three (3) years. To be consider -cd chronically homeless a person must have been oil the streets or in an emergency shelter- (i.e. not transitional housing) during these Stay& How inatty participants were chronically homeless individuals? 7. Etlmicity. How many participants are in the foliMing ethnic categories? a. I His panic or Latino b. I Non -Hi, anic or Non -Latino 8. Dace. How many participants are u) the following racial Categones? 9,1. Special Needs. How many participants have the following? Participants may have more than one. If so, count them in ail applicable categories. For each condition, also indicate the number that were chronically homeless. All Chronic 9b. Ilow many of the participants are disabled? a font FiUD-4-01 1S((OS:'UO3) 10. Prior Living Situation. F-Iow man}' participants slept ul the rollo%sin� lilaces u� the �s'eek prior to enteral, the project? (For each participant, Choose one place;). Also, indicate. howmany chronically homeless participtuits slept in the following places. (Choose one) All Chronic a. Nun -housing (street, park_ car, hus station, etc.) h. Fuiemcncy shelter c. Transitional housing for hoiucacss Pcr-sons d. Psychiatric facilily° e .Rental Substance abuse treatment facility* e. llos �i�o1" f Lh.e. Jail/ prison* kf. 12. Domestic violence situation i. Livutg with relatives/friends i. housing 1`. Otlper (ulearse soecifv ) -If a participant came from an institution but was there less than 30 days and was living on the street or in. emergency shelter before entering tlpe treatruent facility, he/she should be counted in either the street or shelter category, as appropriate. Complete questions 11 - 15 for all participants who left during the operating year (from 2:c, columns 1 and 2). The term participant means single persons and adults in families. It does not include children or caregivers. The term chronically homeless person means an unaccompanied homeless individual with a disabling condition Rho 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 Exit. Of those participants who left during the operating year, how marry participants were at each monthly income level yid with each source of income? Also, please place the monthly income level and participants each source of income for chronically homeless persons in the second column of each chart. The number of participants in Chart A and B should be the same. AR C-7tr"fic All Clwonic A. Monthly Income at Entry a. I No income b. $1-150 C. $151 -3250 d. S251-3500 e. $501 - $1,000 f Lh.e. $1001- $1500 g. $1501-$2000 h. $2001 + All Clwonic form HUD-40118((0S'2o0,) Income Sources At Entry ntal Security Income (SSI) ESociC. alurity Disability Income (SSDI) urity d. General Public Assistance e. Temporary Aid to Needy Families (TANF) f. State Children's Health hisurance Pro. am (SCH1P) a. Velerms Benefits h. Employmcrtl hicome i. UnemploymentBcnefits j. Veterans Health Care Ic. Medicaid 1. I Food Slumps ni I 011ier (please specity) I t. No Financial Resource; form HUD-40118((0S'2o0,) Alt Chrmic L'. Mon(hiv IriC'nNIC at E.cit I No incorue � I b. 5I-1 c. .I 5151 - 52it) d. 5251 $500 j e. 5501 - 31,000 j I'. S1ooI-5I50(i 51 5U (- t. ' 5200 l + All Chninic D. lncsim� Soi.irccs a( Exit a. Lip Security Lrcome b Social: Securit)' Disability ILtC0111c (SSI)I) L:, Social Security d. General Public Assistunce e. Tempormy Aid to Needy Families (TANF) f. Slane Chill -en's I ,:�LIIln brsurance Pl.=am (SCUIP) Veterans L'ec;el tti h. rmploynicnt Income i. Unemployneut LICI7c11tS j. Veteraiis Health Care k_ Medicaid 1. Food Stamps i ni Other (please specify) n. No Financial Resources 12a. Length of Stay in Program. Of those participants who left durng- die operating year (from 2c, columns 1 and 2), how many were in the project for the following Iengths of tune? Also, please place the length 01st2y for chronically houieless persons in the second colunui. All Chronic 12b. Length or stay in Program. For Mose pruticipanls that did not leave during the operating year (from 2d, colunms I and 2), limy long have diet' been in the project? .Also, please'piace the length of stay for chronically homeless persons in the second colimui. All Chronic Fonu HUD -4C1 18((0`-'2003) 13. Reasons for Learing. Of those participants who left the project during the operatii'•e Year (Cron )c; colunuis I and 21), how maim; left for the lolloiAina reasons? If a p''articipant left for multiple reasons, inchl le nn(r (lie print zip) � rea,.un. Also, please place tlie priman reason Cor ChronicnIk' homeless persons in the second column. All Chronic rb for a housing cppnrtuiuty be Core campleti 12 pro(7rani pleted progr un C.-pa}anent of renUoccup;uicy cl-large -conrpliauce %�rith project 'tJ ,ictiviry / destruction of°property / violei)ce litcl ma"anum tune allowed in project s could not be met by project reement with rules/persons j. Other (please specify) k. + Uaknown/disnppeared 14. Destination. Of those participants wlio left during the operatiulg year (from 2c, columns 1 and 2), how many left for the Collowing destination? Also, please place the destination of chronically bomeles s persons in the second column. All Chronic PERMANENT (a -h) a. Rental house or apartment (no subsidy) b. Public Housing C. Section S d. Shelter Plus Care e. HOME subsidized house or apartment f. Other subsidized house o: apartment g. Homeowuerslip h. Moved in with Runily or fiends (i j) i. Transitional housizig Per homeless persons j. Moved in with family or friends k -m) k. Psychiatric hospital 1. Inpatient alcohol or other drug treatment facility i PEI�T-RGGENCY m. lzoprisoil HELTER (n) n. Emergency shelter o. Other supportive housing p. Places not meant for hurum habitation (e.g. street) q. I Other (please specify) UNKNOWN I r: ' Uiikiaown to form HUD -401 I 8(Ml.003) 13. Supportive Services. Of these participaiits who left duriii- the operating, Year (from ?, coli mis l and 2), lto"a many received the folloms ilg supportINT SCUICe5 durule their time in the project^ Also, please place the supportive° services received for chronicully homeless parLicipants %vlm left during the opcmtui_ ,ear iii the second C011111111. All Chronic a. Outreach b. Case inanageuient C. Life skills (outside of case mraingernunt) d. I Alcohol or dru, abuse scn,ices C. Mental hcaldi services f.HMAIDS-related services ' n. Other health care services h. Education L ' 1-Iousina placement j. ' Emplo}mient assistmice lc Cldld care I. Trai:spor4ition m. ILegal ii I Other (please specify) I1 fore HUD -40 8r(08/200,) 16, Overall Program Goals. Under objcctiv a, list your measurable objectives for this operating year (frons VOLLr application, Tecimical Subnussion, or APRj for tach of the tinr�e goals hstel helow. Undo PmSress, descnbc four pro«ress in mcetin he ohjeetives. Under Neat Operating Ycar's Objectives, sh_cif, the measurable objectives for the IICNt operating vcar. a. Rasideolial Swbilih� Objectives Profess: Next Operating Ycar's Objcctives: b. Increased Skills orIncome Objectives: Progress: Next Operating Year's Objectives: c. Greater Self-determination Objectives: Progress: Next Operating Year's Objectives: 17. Beds. SHP recipients answer 17a. S=C. recipients v:swer 17b. SRO recipients answer 17c. (SHP-SSOprojects dO not corlsplete this question) a. SBP. IIow 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, S+C. How many beds and dwellin; units were being assisted with project funds at the end of the operating year? (Include beds for all participants, ether family members, and care givers.) Number of Beds: _ Number of Dwellhlg Units: c. SRO. How many dwelling units Were being assisted at the eud of the operating year? (hlcludC Units occupied bj' �Lll place" non -homeless persons who qualify for assistance.) Number of Dwelling Units: 1 form HUD -4011 c"i (o3i200?i Part fl: Financia[ Information 18. Supportive Senices. For Saimortive Housing (S'-iY), 11is eNju bit provides information to I -IUD un hov, SHP funding for sappoilive son ices Was spent during the operatimt; vcur. Enter lite amount of SNP funding spent cm these supportive services. Include IMPS costs under "Other'. For Shelter Phre Care (S+C), this exhibit tracks t11c supportive services match requirement. Specil)' tht aloe oC supportive services from all sources, flet cal] be cowited as match Lhat all homeless persous received during the operating year. (S+C antecs should keep dncntnent bon on 111e; inclrrdina source, amowit., and nVe of'supportive services.) For Section 8 SRO, this e>.hibit provides infortnalion to HUD on the value of sopportivc services received by lionleless persons during the Operating year. Supportive Senices Dollars ObC,sc Outreach management ife shills (outside of case management) d. Alcohol and dnrg abuse services e. Mental health services f. AIDS-related services fji'. Other health services Education IHousing placement Employment careassist<,nce k. Child care 1. I Transportation M. Legal n. Other (please specify) o. TOTAL (Stun of a through n) Cumulative amount of match provided to date for the Sbelter Plus Care program raider this grant 23 form HUO-4DI15((o°2�U31 19. Supportive Rousing Pro(rrarn: Lcasin„ Suppor-ti�c Ser) ices, QjrcratIfY,? Costs, HNIIS Activities and A.dalinistration I grantees receiving finding under the Supporti� c Itousir:g Procrani must complete tJtasc ci-larts e:rcI, operating Year For ON'pansiun projects: IfSIIP grarrt funds are for the expmr;ion of a prc-n istirg homeless faciliv-, only the people and expenditures for the additional ospaosion ❑tny be ncluded, as in tl;e ori_' nal application or anygr:uu anlendrneut Documentation of resources usid is not reiluircd to be submirled'.ti'i!h this report but should be kept en file for pmxsioleinspeLlion by HUD mldAldi Iors. Do not include amexpenditure Heade before the S H P Lr wI %:a?xeculed, SuIll lnary of ripenditilres. Enter Cite mnount oCSI1P «rant fitllds and cash match during the operating year for cavil activity. 'I'llis, table should add up holh horizontally anti vertically. 7111 SI -11) st1,)1)ortlVe sCn'Ices total should be the sLme as the SI -1P suppt�rtive smices ill Ouestloll 1 S. SI411 l:tulds Casll WWII Total L.x_pcadiLures Ll. L.eas'ing b. Supportive Services c. Operalutg Costs I d- IINIiS llclivities e. I AciministraLion f. Total — Note: Payments of principal and interest oil any Juan or mortgage may not be shown as mi operating expense. Sources of Cash Match. Entcr the sources of cash identified in the Cash Match coltun i, above, in the folle)tving categories. Use additional sheets, as necessary. Aluoullt jb.al'eggco�e ct sponsor cash ent (ple: se specify) ent (please specify) d: federal government (please specify) Conu unity Development Block Grallt (CDBG) e. Foundations (please specify) f. Private cash resources (please spccif} ) I c fl. I Total I I -1 form HUD-40118((OS:_2(!03) '_Q. Suppoudi:e Housing Program: Acquisition, RehatAlitation, and Nu Constnictioll grantee:; U,at received SNP funds, for acquisition, rehabilitation, or neve constnUction iznrst coruhlete d]ese charts in the year one APR urllti: This in ibit will demonstrate Co Ii?JD that the �.,rantei jibs contributed enough cash to at teastequall} match the anuxuit of SHP fwtds spent for acquisition, rchabilitatiun; or rIcka construction. Documentation duff matching Puads "'ere provided is not ricluired to be submitted with this report but nhoui�! l+c Irl ou file for possible inspection by IITIL and Auditor-,. Suntmanl of Expendiiures. Gnlcrdie amount of S1 LP Dant funds and GIS11 rnatciz exploded durum the operating year for each activity. SHP Funds + Cash Match total E,:pcndituris a. I Accluisiti°tt I I h. t I2ehabilit<rliou i. Ne ✓ 1 1 uctian d. Total Cash hatch. Enter the sources of cash identiGcd in the Cash Match column, above, in the following categories. Use additional sheets; as necessary. Amount %b.Local ee/project sponsor cash government (please specify) C, State government (please specify) d. Federal govercunenl (please specify) ConmmnityDevelopment Block Grant (CDBG) e. Foundations (please specify) f Private cash resources (prase specify) Occuptuicy charac/ fees lt. Total 1 i term HUD -401 I 8((OS/300.1) FOR HYIIIS -A CTI 'TIES ON -1 I1 21. For Sun nortiveFlo usin«(SHP)—Hb1:ISActi�,itius This exhibit provides uiConratio�r to HUD on how Sl p'-13i� IS CUndiu- for supportive n i es ��'as spent Jurin * [hc oticrutiny year-, Enter the amount oC SIT-N-iv11S funding spent on tltesc actisities. II1175'.4clitiities Only Dollam Ec ui rtre,=�t Central Scrvcr(s) Personal Computers and Printers Networking Security S"ubtotal Sn ftware Software / User Licensing Softw3rc Installation Support and Maintenance Supporting Software Toois j Subtotal Services Training by Third Parties Hosting / Technical Services Prograumring: Customization Programming Systern Interface Progranunin-: Data Conversion Security Assessment and Setup On-line Connectivity (Internet Access) Facilitation Disaster and Recovery Subtotal Personnel Project Management / Coordination Data, Arrah'sis Programming Technical Assistance and Training Administrative Support Staff Subtotal HMIS Space and Operatic tt.v Space Costs Operabcnal Costs Total 16 Corn HUD -401 18((03,200-73) Describe any problems and/or changes implemented during the operating pear• Technica[ Assistance and Recommendations Based on your experience during the last year, are there any areas in which you need technical advice or assistance? If so, please describe. 17 Conn HUD-40113((OV2003) A mmal CL'rtifleatioll of CUnf llf"ed Project Opertifioll SLIPPortive Iionsiitd Pi-og am Project Number - Project Name: Operating Start Date.- Grantees ate: Grantees that received Supportive HousirS, Program funding for new, construction, acquisition, or rehabilitation are required to operate their facilities for 20 years. L , cer-tify that the facility that received assistance for acquisition, rehabilitation, or new constriction from the Supportive Housizig Program has operated as a facility, to assist homeless persons from to I also certify that the grant is still serving number of ('DO/YT) (IUO/YT) persons at (site address) az)d all the repirements of the grant agreement are being satisfied. (S i ziatzu-e ) (Title) 'Current Year (Date of Certification) is lune Hue --'01 Persons Servet) Worlcslleet - T UD Annual Progress Report `This worksh, et is optional aml is intended to help you collect information needed to complete the Annual Progress Report. Instructions and Colles follow. Do not suhmiI this tt urksheet to 111)D. Name Relationship Entry Date Exit Number of Mondis in Number of Montlis in New Participant Non-Homeless (SRO pate of t]irrli Age tlend r Dale Project (calculate) Project—Participant (ti' / h) Only) 5a 5b. t lrl'1 12a did not leave (Y ! ti) ; c (calculate) 4 126 19 11 )ill--IO1 18 Pet -sons Served NVOI.I.sheet (continuecl) Do not submit this worksheet to HUD No. Veterans Chronically Ethnicity Race Special Needs Special Needs Prior Living Montlily Income hlonthly Income Incoure Sources Income S_o_w_rces status (Y", IN) homeless (code) (code) (coda) (code) Situation At Project Enti)- At Project Eut At Finn, At F �jt 6a (YIN) 7 8 9a 9b (code) It. ]]b (code) ('codcl 6 1 10 !lc Ild 20 I IUD -401 1 S Persons ,served Worksheet (continue(l) 'Do not submit this worksheet to IIUD Reason for Leaving Destination Supportive Services. Notes - Pwgram (code) (code) (code) 13 14 IS 21 111.ID-4111 1S Instructions and Codes fnr-Persons Served NVorkshcet The use of this ,vorksheut is optional.. I1 Inas designed to help you collect information on participants needed to complete the Annual Progress Rc-port. If the v,,orksheet is updated as purticiprints move in and move out of your project, ill )SL of the information required for completion Will bc: contained in the worksheet. Do not submit this workshect with the APR. For projects that serve families, I -IUD only requires reporting on the number of children served, and the age and gender of these children. Only name, relationship, date of birth, and ape on the worksllcet need to be 'completed for children. Assi 2n the adults a number, but not each family member. Use this number to transfer to the other pages of t11e worksheet. Beginning with number 4, the numbers in the columns refer to the questions on the APR form_ if any questions are answered with "Dther," 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. N. me. 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 project. Usually this will be the date of actual physical move -in for a housing project. Beit 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 Ieft the project and is expected to return in less than 90 days (e.g. llospi (a112atlon), Income -eligible Non -homeless in SRO. The SRO proeraill allows assistance to units occupied by Section 3 income -eligible persoiis residin; at the SRO prior to rehabilitatiou. For SRO projects only, indicate %,nether the participant is an income-cli,*ible, non -homeless person (Y) or not (N). SHP and S+C projects should skip tills item. 5a. Date of Sirtll. Enter date of birth Mcludin; L7101101- drly, cued �'ear. ;b. A, -Ie, Eu ter a_Lc at entry. Dc. Geri der. Entcr appropriate letter Cor gcrnder. M -Male I'- Ferrule. 6a. veterans Status. ludicate if the participunt is a velcrun. Ple(lsr' !lute: ,t vetercnr !S L77l1'U,1L' i+h, has ever been on active niililu,ly duty slalus for 1120 United Slates. Cb. Chronic.tlly homeless person. Indicate the numbercf participants that are chronically homeless. 7. Ethnicity. Enter appropriate letter for ethnic group. a. Hispariic or Latino b. Non -Hispanic or Non -Latino Race. );titer appropriate letter for race. a. American Indian or Alaskan Native b. Asian c. Black or African-American d. Native IIawaiian or Other Pacific Islander e. White F. American Indian!Alaskan Native &; White Asian & White h. Black/African American 8c 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 participanl's disability(ies). (You may double count). a. Mental illness b. Alcohol abuse c. Drug abuse d. HIV/AIDS and related diseases c. Developmental disability f. Physical disabilities g. Domestic violence h. Other (please specify) 9b. Enter the number of participants witli a disability. J0. Prior Living Situation. Enter the letter drat best describes where the participant slept in the week prior to entering the project. Do not double co un t. a: Non -housing (street, park, car, bus station, etc.) b. Erncr-cncy shelter C. Transitional lrousin'- for homeless persons d. Psychiatric facility" e. Substance ahrsc: treatment Facility* F. Hospital" g. Lail/prison* h. Domestic violence situation i. Living wit11 relativ,esrfricn ds i. Rental housinE. HttD-40:1 S k. Other (please specify) f. Reached ular;immn time allowed in project bleeds could not he mct by project 'if a participant came frons an instiluticrn but h. Disagrcelnent v,,ith rules/persons "vas there less than 30 clays and rag livin, on tht i. lleallt street or iu an emergency sheltcr befor�- entering the j. other (please Specify) facility, he/311C should be counted in citltk�r the strcat isagpcate,l or sheltcr catcory, as appropriate. Instruction Cortes for Pcr.sons Served Worksheet (continued) lla.Grms Monthly Income at Project hatry. Enter the amount of gross monthly income the participant is receiving: at entry into the project. 11b.Gross Monthly Income at Project Frit. Enter the gross tnouthly income the participant is receiving when exiting the project. 11c.Incorne Sources Received at Project Entry. Enter ail types of assistance the participant is receiving at entry to the project. a. Supplemental Security Incoine (SSI) b. Social Security Disability Insurance (SSRI) c. Social Security d. General Public Assistance e. Temporary Aid Needy Families (TANF) f. State ChiIdren's Health Insurance Program (SCI -EP) Veterans benefits h. Employment income i. Unemployment benefits j. Veterans Health Care k. Medicaid 1. Food Stamps in. Other (please specify) n_ No Financial Resources Ild.Iucome Sources Received at Project Txit. Enter all types of income the participant is receivin, at project exit. (Use codes as in Ile.) Ila Length in Stay in Program. Calculated item. (See Entry Date and Exit Date above.) 12b. Length of Stay in Progrum. (Pt;rticipant did not leave during the operating year. I7ow long have they been in the project?) 13. Reason for Leaving Project. Entcr l(te primary reason why the participant left the project. (Complete only for participants who left the project and are not expected to ret'-rrnt within 90 days. n. Left frr a ]lousing opporurlity before cninpleling, the program b. Contpleed prosra.n C. Non-payment of rent/occupancy charge d hfon-compliance with project c. Criminal actin ityidestructiotl of property/ vialence 14. Dcstit:ation. Enter the destination of those leaving tlae project Permanent: a. Rental house or apartment (no subsidy) b. Public Housing r. Section S d. Shelter Plus Care e. HOME subsidized house or apartment f. Other subsidized house or apartment g. Homeownership h. Moved in with family or friends Transitional: I . Transitional housing for homeless persons j. Moved in with farnily or friends Iastituti on: k. Psychiatric hospital. 1. Inpatient alcohol or drug treatment facility in..lail/prison Emergency: n. Emergency shelter Other: o. Other supportive housing". p. Places not meant for human habitation (e.;., street) q. Other (please specify) UuknoTvn: r. Unknown 15. Supportive Services. Enter all types o£ supportive services the participant received during the time in the project. a. Outreach b. Case mana,ement c. Life skills (outside of case management) d. Alcohol or drug abuse services c. Mcntal health services E HIWAIDS-related services g. Other health care services h. Educatiotr i. Housing placement j. Enrployrnent assistance K-. Child care 1. 'fra:tspertation m. Leryal n. 011ier (please specifi,) 23 HUD -10I 13 Home CllentPolnt R.esourcePolnt Sh°'.terPclnt I HUD Annual Progress Report (HUD -40118) Miami -Dade County Government,' anPoinL /r,_p;urts A.drnin I help + Lo?^i. ATTACHMENT G-1 Report Options: Select �'' Unn_uplicated (— Provider Itiarnl Dade County Government (.t1) ;��!; Operating Year Date Range 05/01/2006 to 05/31/2006 (mm/dd/yyyy) Legal Adult Age 18 (as defined by foster care law in your state) 111 ME Or "`zn`= '-r-Select- I2. Persons Served during the Number of Singles (Number of Adults Number of Children in Number of operating year. Not in Families in Families Families Families a. Number on the first day of the 0 0 0 operating year. 0 b. Numb-re r entering program during the 0 I 0 0 or peating year. III 0 c. Number who left the program during 0 I 0 0 the operating year. ( 1 0 d. Number In the program on the last day 0 I 0 0 of the operating year. (a+b-c=d) 0 3. Project Capacity. Number of Singles Number of Adults Children iNumber of n Number of Not in Families in Families Families Families Ia. Number on last day (from 2d, columns 1 and 4) 0 D 4. Non -homeless persons. (Sec. 8 SRO projects only) How many Income-ellglble non-homefess persons were housed by the SRO program during the operating year? 0 5. Age and gender. Age IMafe +Female +Other/Nbt given Single Persons (from 2b, column 1) a. 62 and over 0 0 0 1b. 51 61 0 0 0 c. 31 50 0 I 0 0 d. is 30 0 I 0 I G �e. 17 and under I 0 0 1 0 Not given I 0 0 0 Persons in Families (from 21p, columns 2 & If. 62 and over 0 Q 0 19, 51 - 61 0 0 I 0 50 I 0 I 0 G hrtps:/,`,,, w�,v3.ser•deep(.com/nlia.mi/scripts/s�Trc-porthud.php 4/2 U06 13 - 17 0 0 �k. 0 12 I D I n 0 b. Asian O I 0 Und=r ? p 0 Not given !! 0 HAa. Veterans Status. veteran is anyone ',,aho has ever ;been on active 1r-ilii3r)dUt:' =`8tU5 I6b. Chronically Homeless. How many participants were chronlcail y homeless individuals' ( 0 I 7. Ethnicity. a. Hispanic or Latino 0 b. Non -Hispanic or Non -Latino 0 8. Race. I a. American Indian or Alaskan Native 0 b. Asian c. Black or African American 0 d. Native Hawaiian or Other Pacific Islander 0 to e. White I 0 f. American Indian/Alaskan Native & White 0 Asian & White 1g. i 0 h. Black/African American & White i. American Indlan/Alaskan Native & Slack/African American 0 ` j. Other Multi -Racial 0 jj k. Other/Unknown (all that do not match) f 0 11 9a. Special Needs. All Chronic a. Mental Illness 0 b. Alcohol abuse 0 0 c. Drug abuse 0 0 d. HIV/AIDS or related diseases 0. 0 I e. Developmental disablllty I 0 _0 f. Physical disability 0 ! 0 g. Domestic vlolence I 0 0 EI h. Other (please specify) 0 + 0 9b. Disabled. How many or 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 I 0 0 c. Transitional housing for homeless persons 0 d, Psychiatric facility 0 e. Substance abuse treatment facility 0 I f. Hospital 0 g. Jail/prison 0 h. Domestic vlcfence situatlon 0 I i. Cluing with relatives/Friends 0 j. Rental housing ( 0 https:/hv,-W,1",3.SCT1-jcept.con1/I Jami:%scripts/s,-pr�portl.ud.php 6/1412C'06 11, Amount and Source of Monthly Income at Entry and Exit. Amount I A. Monthly Income at Entry B. Monthly Income at Exit a. No Income All I Chronic 0 0 I All I 0 I Chronic 0 b. $1-'_50 c. $151 $250 I 0 I 0 I 0 0 0 I 0 0 I 0 d. $2_,1 - $700 - e.$501 $1000 I 0 I 0 I 0 0I 0 0 0 0 f. $1001 $1500 I 0 I 0 i 0 0 g. $1501 - $2000 0 0 0 0 h. $-2000 + 0 0 I 0 0 Source C. Income Sources at Entry D. Income Sources at Exit Fa. All Chronic All Chronic Supplemental Security Income (SSI) 0 I 0 0 0 b. Social Security Disability Insurance (SSDI) 0 0 0 0 C. Soclai Security I 0 0 0 0 d. General Public Asslstance 0 I 0 f 0 0 e. Temporary Aid to Needy Families (TANF) 0 0 0 I p f. State Children's Health Insurance Program (SCHIP) 0 0 0 0 Veterans benefits 0 0 0 0 Employment Income Lh. 0 0 00 Unemployment Benefits 0 ED 0 0 j. Veteran's Health Care I I 0 0 0 k. Medlcald 0 0 1 0' 0 I. Food Stamps 0 0 I 0 0 m. Other (please specify) 0 I 0 0 0 n. No Flnandal resources 0 I 0 I 12a. Length of Stay in Program. (Participants who left during operating year) 0 0 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 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 1. 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 I month I 0 0 b. 1 to 2 months 0 0 c. 3 - 6 months 0 0 d. 7 months - 12 months 0 I 0 e. 13 months - 2u months 0 I 0 F. 25 months - 3 years 0 I 0 g. " years - 5 years 1 0 0 hips:%%1,;1',,w3.seI Lice pt•COIN.`1771aI111,'Scrlpts,s�prepOril7ud.pilp 6i 1 —1i2 0(if ,.. , ,..-._ . , _„„ 0 0 i.o years 10 years b. Public Housing j. over 10 years I v I 0 a _ � 13. Reasons for Leaving. 0 I All + Chronic a. Left for a housing opportunity befor = completinq program G ! r I 0 0 0 b. Compictad program 0 I 0 c. Non-payment of rent/ocr_upancy charge 0 0 0 0 0 d. Non-compliance 'vilth protect 0 TRANSITIONAL (i - j) e. Criminal activity / destruction of property / violence 0 0 f, reached maximum Lime allowed In project G 0 0 0 I G g. Needs could not be met by project 0 f. Inpatlent alcohol/drug treatment facility 0 0� h. Disagreement vaith rules/persons m. Jail/prison 0 0 0 n. Emergency shelter i. Leath 0 EF�11 j. Other (please specify) 0 0 0 k. Unknovin/disappeared q. Other (please specify) 14. Destination. 0 UNKNOWN PERMANENT (a - h) I I a. Rental house or apartment (no subsidy) + All 0 Chronic 0 b. Public Housing 0 I 0 c. Section 8 0 0 d. shelter Pius Care 0 0 ,e. HOME subsidized house or apartment I 0 0 If. Other subsidized house or apartment 0 I 0 g. h'omeownersh.ip 0 I 0 h. Moved in with family or friends I 0 0 TRANSITIONAL (i - j) i. Transitional housing for homeless persons I 0 0 j. Moved in with family or friends 0 0 INSTITUTION (k - m) I k. Psychiatric hospital I 0 0 f. Inpatlent alcohol/drug treatment facility 0 0 m. Jail/prison 0 0 EMERGENCY SHELTER (n) n. Emergency shelter ( 0 I 0 OTHER (o - q) o. Other supportive housing ( 0 + 0 p. Places not meant for human habitation (e.g. street) 0 0 q. Other (please specify) 0 I 0 UNKNOWN r. Unknown 0 0 +15. Supportive Services. No supportive services found. ServicePoint version 4.01.019 (db build #0723) Licensed to: Miarni Dade Homeless Trust G 1999-2006 Bo'.vman Systems L.L.C. All Rights Reserved. CPT only 2)2004 Arnerlcan hicdicai F.ssocialion. All Riyhts RCS-crved. D50 and O. P1 Il' -Th ate registered trademarks of Che Amer!cDn ?syc:`!ainc ,..soclanon, and are used valth permissUn ILr-m rc)I Cern of for a ,";v,�nrl-d Health Organization). All Rights F,_served. ICC -9 Cit 9t national _. Health Sraostics (iCD-'. .-. Tai:onc,7v ! ii`a 3-2 OD3 Irforrn2ilon and F:e _rr2l r_g?r. tucn of L_, Ange;e,_ Cn'un"'., i.^,C. '-II Pese",ecl httpsai,:�Icept.corn%n7i ,il/scripts/svprepOrthLid..piip 6r'14/=006 Form Request Request for Taxpayer Give form to the (Rev. January 2003)requester. Identification Number and Certification Do not Departmentof the Treasury send to the IRs. Internal Revenue Service c i Name 0 M to CL Business name, if different from above c O N yIndividual/ El❑ ElEl Exempt from backup ❑ ` ? Check appropriate box: Sole proprietor Corporation Partnership Other► ------------------ withholding mAddress (number, street, and apt. or suite no.) Requester's name and address (optonai) 1 v City, state, and ZIP code E ro CL m list account number(s) here (optional) d N Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). social security number However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on I I I ( l 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. Certification Under penalties of perjury, I certify that 1. The number shown on this form is my correct taxpayer identification number (or l 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 I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that 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, Rem 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation or 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.) SignI Signature of Here U.S. person ► Date ► 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: ff 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) Form W-9 (Rev. 1-20031 Page 2 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, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completed Form W-8. What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 30% of such payments (29% after December 31, 2003; 28% after December 31, 2005). This is called "backup withholding." Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if - 1. You do not furnish your TiN to the requester, or 2, You do not certify your TIN when required (see the Part 11 instructions on page 4 for details), or 3. The IRS tells the requester that you furnished an incorrect TIN, or 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Instructions for the Requester of Form W-9. Penalties Failure to furnish TIN. if you fail to furnish your correct TiN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of 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" line. Enter the LLC's name on the "Business name" line. Other entities. Enter your business name as shown on required Federal tax documents on the "Name" line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the "Business name" line. Note: You are requested to check the appropriate box for your status (ndividuabsole 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(1)(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) 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 2 sales over $5,000' 'See Form 1099-MISC, Miscellaneous Income, and its instructions. =However, 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 not exempt from backup withholding: medical and health care payments, attorneys' fees; and payments for services paid by a Federal executive agency. Part I. 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 chart on page 4 for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS -5, Application for a Social Security Card, from your local Social Security Administration office or get this form on-line at www.ssa.gov/online/ssS.html. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS -4, Application for Employer Identification Number, to apply for an EIN. You can get Forms W-7 and SS -4 from the IRS by calling 1 -800 -TAX -FORM (1-800-829-3676) or from the IRS Web Site at www.irs.gov, If you are asked to complete Form W-9 but do not have a TIN, write "Applied For" in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60 -day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester, Note: Writing 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) Page 4 Part It. 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. What Name and Number To Give the Requester For this rfpe of account Give name and SSN or: 1. Individual The individual 2. Two or more individuals (joint 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 Giftto Minors Act) 4. a. The usual revocable The grantor -trustee ' savings trust (grantor is also trustee) b. So-called trust account The actual owner' that is not a legal or valid trust under state law 5. Sole proprietorship or The owner' sin le -owner LLC For this type of account: Give name and EIN of_ 6- Sole proprietorship or The owner' single -owner LLC 7. A valid trust, estate, or Legal entity 4 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 government, school district, or prison) that receives agricultural program payments The organization The partnership The broker or nominee The public entity 'List first 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 famish the minors SSN. 3 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 test (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. -0 Applicant Certification These certified statements are required by law. Previous versions obsolete form HUD -40090-4 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 CFR 582.330(a), 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 yeaf 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 Oficial: I Date: Title Applicant: For PHA Applicants Only: (PHA Number) 1-IIAIMI-D-ADE CO L7. TY HO_��IE LESS TRUST NfL , ft. -1 -DE CGI Y T -:' F (.tU, I !=D .�,I FID -','�'I T The conzracttng individual or ent:iv or otht- �vi5c) � ad IndicjIf bV a:' that pertain to this ConGaCt and shall Indicate ay an "N"'A" all ilial do noI �c ;il [C� thl ; ontra�t li blank spaces must be filled. The MIAMI -RADE COUNT' N,g4ERSFEP DISCLOSUP E AFFIDAVIT- �41,`_i N-D,-�DE CGL? T`,' EP,,lPLO'r'AvfENT DISCLOSURE AFFIDAt,gT; lvfL�11-D,4DE CR. NIINAL R_E !O` 4FFID:;A'IT; DISAL'ILITI' NO2-dDTSCR ,1vfINATION AFFIDAVIT; and the PROTECT FRESH START .M-FIDAVIT shall not pertain to contracts v,'Ith the United States or ail_y of its departments or agencies th._reof, the State or an", political subdivision or agency thereof or any municipality of this State, The NfIAR1I-DADL- FAMILY LEAVE AFFIDAVIT shall not pertain to contracts with the United States or any of its departments or agencies or the State of Florida or any political subdivision oragency thereof; it shali, hoA'ever, pertain to municipalities of the State of Florida. All other contracting entities or individuals shall read Carefully each affidavit to determine tivhcther or not it pertains to this contract. I, Affiant being first duly sworn state: The felt legal name and business address of the person(s) or entity contractine, or transacting business with N iami-Dade County are (Post Office addresses are not acceptable): Federal Employer Identification Number (If none, Social Security-) Name ofEnti y, Individual(s), Partners, or Coi7oration Doing Business As (if same as above, leave blank) Str get Address City State Zip Code MIAMI -DADS COUNTY 0' NERSFEP DISCLOSURE AFFIDAVIT (Sec. ?-S.1 of the County Code) I. If the contract or business transaction is with a corporation, the full legal name and business address five shall be provided for each officer and director and each stockholder v,,ho holds directly or indirectly percent (S%) or more of the corporation's stoat. 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 e3 h Trustee and each beneficia y. Tne foregoing requirements shall not pertain to contracts with publicly traded corporations or to contracts with the United States or any department or agency !hereof, the State or any political subdivision of agency thereof or any municipality of this State. All such names and addresses are (Post Off -ice addresses are not acceptable): Full Legal ?,�,`arnc 0��.•ner,ri�� 0 a c The full legal names and business address of any other individual (other than subcontractors, material men, suppliers, laborers, or lenders) v -Aho have, or have, any interest (legal, equii2bie bene`iciai or other^✓Ise) in the contract or busines, transaotion with Dade County are (Post Orice addresses are not acceptable): Any person, who willfully fails to disclose the information required herein, or vvjlo knolmingly discloses false information in till's regard, shall be punished by a tine of up to five hundred dollars (5500.00) or imprisonment in the CountyjaiI for up to sixt, (60) days or both. —II. MI-TWI-DADE COUNTY ENIPLOI'7,ENTDISCLOSiIREAFFIDAVIT(County Ordinance No. 90- 133, Amending sec. 2.8-1; Subsection (d)(2) of the County Code). Except where precludedby federal or State laws or regulations, each contract or business transaction or renewal thereof which invo,'ves the expenditure of ten thousand dollars ($1 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 or any political subdivision or agency thereof or any municipality of this State. Does your firm have a collective bargaining agreement with its employees? Yes No Does your fi•;n provide paid health care benefits for its employees? — Yes No Provide a current breakdown (number of persons) of your firm's work force and ownership as to race, national origin and gender: White: Males Females Asian: Black: Males Females American Indian: Males_ Males Females —Females Hispanics: Males Females Aleut (Eskimo):Females Males — Males Females: —Males Females ^III. AFFIR2vLATIVE Ar-IION/,,,roNrDISCR-7.vfIN,ATIUN OF EMPL0}`21EiJT, PROMOTIONAND PnOCUP1 El',ENT PRACTICES (Count, Ordinance 95-30 codified at 2-5,1.5 of the County Code.) In accordance with Count}, Ordinance No. 9S-30, entities with annual gross revenues in excess of 55,000,000 seeking to contract with the County sha[:, , a condition of receiving a County contract, have: i) a vTitter a�rmanve action plan which sets fonh the procedures the ent I utilizes to assure that it does not discriminate in firs employment and promotion practices; and ii) a v,rit en procurement polis}' which sets fnr h the procedures the ent;rr ;Itilizes to assure that 1.1 does not discrim rate against minority and uromep_oTTti•ned businesses in its ov�_rt procurement of goads, supe les and se;� ices. Such afirrmatlVe action plans and procurement policies shall provide for Periodic rev ItA' to determine their et,ecziv mess in assuring Lhe entire does not discriminate in its ernplo,. ent rornotion procurement practices. The forezoing norv,it,istand* co and rporate enures -hose boards efdirectors are i� v retires_ -mauve of the population make-up o; the nation shall be presu,i,ed to havf nor Olsirlm: ai_ empin_.ment and procurement poiicie, and shall not be required to ha, v,ri?en zfit; :a _ plans androcurement poticle� in rrcer io rece,. a CGUn . contr�:t. 1112 for ^Jln^ nr P - _ _ .--su;npuon ri2% [)e rtbucieL-2. 1-4 he requirements of Country OFdlnance 7qo, 9„-30 may be wa)V.-d upon the `, rl-en re omrnenaanun the Counry Manager Chat It Is in the best interest of the Counry to do _o and upon approval 0,:[h,- Boar; of Cournir Commissioners by majorirr vote of the members present. The flim does not have annual gross revenues in excess of55,000.000. lee firm does have annual revenues irI e :cess of .85,000,000; ho:`.cver, its Board of Directors i represcritati-ve of the population make-up of the nation and has submitted a o.Tirten. detailed listing of its Board of Directors, including the race or ethnicity of each beard member, to the County's Department of Business Development, 17:5 1.L``', 1st Avenue, 2Sth Floor, 1�41airt. Florida 33125. The firm has annual gross revenues in excess of `D5,000,000 and the firm does have a wuirten affimiative action plan and procurement policy as described above, `,vhich includes periodic reviews to determine effectiveness, and has submitted the plan and policy to the Countri''s Department of Business Development 175 N.W. Ist Avenue, 28th Floor, Miami, Florida 33 12 8; The firm does not have an affirmative action plan and/or a procurement policy as described above, but has been granted a waiver. `IV. AUAIvfl-DADE COUNTY CR1N/JSNA.L RECORD AFFIDAVIT (Section 2-8.6 of the County Code) The individual or entity entering into a contract or receiving funding from the County ha has not as of the date of this affidavit been convicted.of a felony during the past ten (I0) years. An officer, director, or executive of the entity entering into a cont act or receiving funding from the County has has not as of the date of this affidavit been convicted of a felony during the past ten (10) years. _V. MAMi-DADE EMPLOYMENT DRUG-FREE WORKPLACE AFFIDAVIT (Counry Ordinance No. 92-15 codified as Section 2-5.1.2 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 writrten statement to each employee shall inform the employee about: _ 1. danger of drug abuse in the workplace 2 the _fin'e's policy of maintaining a drug-free environment at all workplaces 3, availability of dr-ury counseling, rehabilitation and employee assistance programs 4. penalties that may be imposed upon employees for druc, abuse violations The person or entity shall also require an employee to sign a statement, as a mcondition of empio5rnent that the employee will abide by the ters and notify the employer of any criminal drug conviction occurrinc no later than ive (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. 92-15 may be waived if the special characteristics of the product or senVice offered by the person or entity make it necessary for the operation of the County or for the health, safet,' welfare, economic benefits and cell-hein? of the public. Contracts involving funding which is provided -in whole or in part by the United States or the State of Florida shall be exempted from the proVisions of this ordinance in those instances xhfre those provisions are in cdn ict ” ith the requirements of those governmental entities. �, 3 Z� 5 ADE: Lh LO`i >'EiYT F ,,;' 17LY LEAs'"E .s., r iD.1`rI T !�-ounr, r,.cinancc ?:c,. -9coo" ;rled cs S-_. C 1 ,on 1 iA _ 0 ... S _ C, T}lat In compliance 1 iii Drnlnanc` o1 ';'fe CO 4f of ,M2m,!-D3u: Co!;nn, Fltorld:;, an empiover with fife' (IO) or more e I plo..'e s orlon n Cia Court for each v,orl:in da ' duri,n, tach of tv,'enn (20) or more calendar wcrl: t'reelS, shall pro'�'Jdt th. IoIn_ InrOT3U0n in compliance w idi all Items In the arorcrricr on:=u ordinance: Ar employee Who has worked Tut the above fire at ;,,cast one (1) v car shall be entitl d to diner,,, (90) days of family' leavt during ary ���ernrI-four (2-1) month period, for medical reasons, ;or the birth or adoption of a child, or for the case of a child, spouse or other close relatihas a serious hz.alth condition Without risk of terr.1riation of emp!oymentoremp)oYcrretaliation. The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof, or the State of Florida or any political subdivision or agency thereof. It shall, however, pertain to municipalities of this State. _VII. DISABILITYNON-DISCP,- *,iNATIONAFFIDAVIT(Count-yResolutI-3S;-95) That the above named firTn, 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 pro -rams and sen -ices, transportation, communications, access to facilities, renovations, and new construction in the followl*ng laws: The Americans with Disabilities Act of 1990 (ADA), Pub. L. 10I-3.36, 103 Stat 327, 42 U.S.C. 12)01-I2213 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 Housinfy Act as amended, 42 U.S.C. Section 3601-3631. The foregoing requirernerts 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-DADE COU ,TTS' F.EGAR.DING DELINQUENT AND CURR—ENTLY DUE FEES OR . TAXES (Sec. 2-S.1(c) ofthe County Code) Except for small purchasQ orders and sole source contracts, that above named f-ITm, corporation, organization or individual desiring to.transact business or enter into a contract w,th 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 -- )vhich are collected in the normal course by the Dade County Tat Collector as yell as Dade County issued panting 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 OTI'_'F_R OBLIGATIONS The individual entity seekin(7 to transact business with the County is current in all its obligations to the County and is not cthcr rise in default of any contract, promissory note or other loan document N" th the County or any of its agencies or instrumentalities. _X - FRO.TECT FRESH STA -RT (Resolutions R -702-9S and 35S-99) Any firm that his a contract with the County that results in actual payment of 5500,000 or more shall connibfit oto Project Fresh Start, the County's -Vr'el,are to `1'r orh IniciatiVe. Ho'"ierer, ii live percent o t12 tin's ,i'orl.: force consists of individuals �,ho reside in ;rami -Dade County and who have Jost or v.'di Iese ca_i assiswrice benefits (forneriv kid to Families 1, ilh D ependent Children) s a result o:` the Pe„ona( Responsibilir, arid %',"ork Opportunir✓ Reccnciliation Aci o; ^ 'uG6 ., , the Ertl; maj' reouest Waiver from the rrOUlr e gnu of :� - /02'-9rS and R -3,S-99 by submlrtln 3 '.4'ai ,'� P ' _r r..que,t aitid tit Tne forecoin_1 requirement d - no[ ern ro e,mm nrQ �t:Qn; or - Oe_ J- 17 _p, eni enti[iet, no: "or pr recipients of grant a,, cruJs. o;,r VIOLENCE LEAVE (Resolution 1135-00; 99 Co -4 fiLd At ]LA -60 Et. Seq, or the i,liami-Dade Count, Code). The firm desirina to do business v.'ith tt,e Counry' is in compl fiance ,vith Domestic Lea,,e Ordinance, Ordinance 99-5, codified at IIA -60 et. seq. of the Nil=1 Dade Counry Code, which requires an emplcver wich has to the reLular course of business limy' (50) Or more emplovees worl;ina in Ivliami-Dade Count,, for each workirt; day during each of ttiventy (10) or more calendar �� ork weeks in the current or proceeding calendar }'errs, to provide Domestic Violence Lcave to its emplovees. I have carefully read this entire five (5) page document entitled, "Miami -Dade Counry Afudavits" and have indicated by an "Y" all affidavits that pertain to this contract and have indicated b}, an "N/A" all affidavits that do not pertain to this contract. By: (Signature of Aunt) SUBSCRIBED AND SWORN TO (or affirmed) before me this ?00 by known to me or has presented (Type of Identification) (Signature of Notary) (Print or Stamp of Notary) Notary Public — Stamp State of (S tate) day of (Date) He/She is personally as identification. (Serial Number) (Expiration Date) Notary Seal _-AFFIDAVIT OF MI-011-D_OE COL1'�TY LOEBI IST REGISTRATION FOR ORAL PRESENTATIO-N (i i Proje..Ti,le (:) FLM- rroposers Name: r.ddress: Business Telephone: (�J lip: (4) List All lvlembers of -the Presentation Team lVho Will Be Participating in the Oral Presentation: NAIME TITLE EMPLOYED BY TEL. 1,40. (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 recommendation of county personnel regarding this solicitation 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 ,.vho has produced Signature of person taking acknowled;emcnt) Manic of Acknov,ledger t), -ped, printed or stamped) (Title or F.ar}:) (Serial Number, if an; ) .-i-- - P,ev. /!12/93 who is personally known (Sole Proprietor, Corporation or Partnership) as identification and vvlio did/did not tale an oath. roof-rt;y-,-�� P,_1o4ATTACHMENT L Name of Organization: Address: REQUIRED LISTING OF SUBCONTIRACTORS ON COUNTY CONTR-�CT In compliance tivith tiliarni-Dade Ccunry Ordinance 97-104, the Community Based Or anization must submit the list of first Tier subcontractors or sub -consultants v;ho ,,�41l perform any par of the Scope of Sen;ices Work, if chis Acreement is for S100,000 or more. The Community Based Organization must complete this information. if the Community Lased Organization will not utilize subcontractors, Hien the Con:muniry Based Organization must state, "No Subcontractors will be used", do not state "N/A". Name of Subcontractor orSub-Consultant Address Citi, and State REQUIRED LIST OF SUPPLIERS ON COUNTY CONTRACT In compliance with Itliarzi-Dade County Ordinance 97-104, the Community Based Organization must attach a list of suppliers who will supply materials for the Scope of Services to the Community Based Organization, if this Contract Agreement is S100-000 or more. The Community Based Organization must fill out this information. If the Community Based Organizatiori will not use suppliers, the Community Based Organization must state, "No suppliers will be used", do not state "N/A". Name of Subcontractor or Sub -Consultant Address City and State 1h ereby certrfylhal lheforegoina uzformation is true, correct and complete: Sibnature of Authorized Representative: Title: Firm :'earn e: _Address: Telephone: Fay: E -Mail: Date: ed. ID No.: Cite/State/Zip: ;.(i;nni (titer (' mrY, i toria'a trirm Name of Prime Contraclor(Proposer SUB CONTRA CTbRISUPPLIEP,. LISTING (Ordinance 97-104) Rl7AP Name P_FP Number — tea+ "This forst, oro coutpamble listing rttecting the requirements of Ordinance No. 97-104, MUST be completed by all bidders and proposers on Counly conlracls for purchase of ; supplies, maicrials or services, including pro Cessional.services which involve expenditures of $]00,000 or more, and all bidders and proposers on County or Public l lcallh "frust construction contracts which involve expendim-es ors100,000 or more. This form, or a contparable listing meeting the requirements of Ordinance. No. 97-10.1, trust be completed and submitted even IlioughAlle bidder or proposer will not utilize subcontractor's or suppliers oil the contract. The bidder or proposer shoubl enter tl,e Nvord "NONE" under the appropriate heading of Form A-7.1 in those instances where no subcontractors or suppliers will be used on the contract. A bidder or proposer who is awarded the contract shall not change or substitute first tier subcontractors or direct suppliers .or the portions of the contract worl; to be perforated or materials to be supphcd froth those ideutifled exec t upon written a rovai of the CountYti,. Iiusiness Natttc and Address of rirst Tier Pr'tttcipa101vnet` Sco�10�'ork to be Performed by (Principal OivucrSuhcontraclor/Subconsultant tractor/Subconsullant (;ender Race 1-- ._ _ -- --- - ----- — 1------ ltusiness Nnnte mud Address of Direct Supplier Principal O1'1'IIeI" - -- SuppliesPubaterialslServices to be (i'rincil}al Owner) Provided by Supplier (;etltler lace I certify that rite representations contained in this SnhCOntractor/Sulip tier Listing are to the best of m)' knowledge true and accurate. Signnture of Proposer's Authorized Representative Print Name (Duplicate if additional space is needed) Print Tille D'I t e 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 Plan 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 imrzediment which would prevent it from complying with these reouirements. 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 ATTAMMENT 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 tides 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, ,action 7(b) of the Indian Self -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). SW0R,, ' STATE,SIE.NT PURSU.,NT TO SECTi&N _25%.1_3 (_) (ni. FLORIDA STATUTES. ON PUELIC ENTITY CRIAlES THIS FORM, MUST 3E SIGT Ell ^ND SV, -0 .'J Ti--)' RN TrE PI,.LSE` rE t)L �iOT,y�,`t` PUBLIC OR OTHER OFFICL� r 11.7 I(D i -'ZED TCl OATHS. I. This sworn statement is subrnined to Miami -Dade Count.-,,: b Y (print individual's name and title) for (print name ofentihy submitting sworn statement) whose business address is and (if applicable) its Federal Employer Identification, Number (FEIN) is (if the entirY has no FEIN, include the Social Security Number of the individual si`tning this sworn statement:) I understand that a "public entity crime" as defined in Paragraph 297.133(1)(g), Florida Statutes means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or politica; 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 257.133(1)(b) Florida Statutes. rneans a finding of guilt or a conviction of a public entity crime, with or without an adiudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1959, as a result ofa jury verdict, non Jury trial, or entry of P123 of guilty or nolo contendere. 4. I understand that an "affiliate" as defined in Paragraph 257.133(1)(a) Florida Statutes, means: a. A predecessor or successor of a person convicted of a public entitty crime; or, b. An entity under the ccntrol of any natural person MIO is active in the management of the entity and who has been convicted ofa 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 constitutir;a a controlling interest in another person, or pocling of equipment or income among persons when not for fair market value under an arm's length aLyeement, shall be a prima facie case that one person controls another person. o person who ;'Iowingly enters into a joint venture �,vith a person who has been convicted cf a pubic entity crime in Florida during th,; preceding 36 months sha!l be considered an affiliate. I understand that a "person" as defined in.Paragraph 257.1:3(1 )(-),.Florida Statutes means an,, natural person or emir, organized under the laws of any state or of the United 5tatcs with the le of pollvcr ro enter into a binding contract and which bids or applies to bid on coni:_ for the proo[I or eeods or SL'r'ICeS let by a Dubiic emir,', orithic;h other,,.ise transacts or appites to Iran aCi business t�'i(+i a pubi;r en-i^y. The term `parson' includes those ofuctrs, dire tors, .ecuti, ' '' perners, shareholders, emplo;:ee , irne,nbers, and age^.i; ,�.ho are active in manacernent or an .nUi, A, r) - . . - �'�"d Un I iGrTT;at!on _„d belle the S: a•...;_r,i ''f1ich I h''vt nnaii:eG I-- 1,D,,. ISi:,7,j in ,c12-,_ -n iU ir„ 2ntir; Su`Jmi-,:n'2 L'IIS S,','Orn Siaterneni. i�l"?,e Ind!Caie 1';h!r_jl s[3t":71, (I ay�nli''j. l-161[hur the Critlr" Submirina Chis S",D, 7, statement, nOr an': of lu Ot"ICErS, ulr CiGr; e:CeCut14'es, Dahners, sharcho ders, emPI'D ees, niembers, or agenic tvno ars dive In (i manaz4rnent of the enti�;, nor the affiliate of the en'in, his been Char,'ed �%`h and convicte of a public emit ' crime within the past 36 months. The emir, submitting this s�';orn statcmcnt, or one or more of its of ;errs, directors. executives, panners, shareholders, employees, members, or went; v;ho are uctive in the manaUnlent of the entity, or an affiliate of the entity, has been charged with an comic ed of a Public eniky crime within die post 36 rnonths AND (Plea -se indicate which additions( st3ternerl( applies) The entity submitting this Swom statement, or 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 of Bate 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 Lefore a Hearing Officer of the State of Florida, division of Administrative I-Iearings and the Final Order entered by the Hearing Officer deternained that it was not in the public interest to place the entity submittina this sworn statement on the convicted vendor list (attach a copy of the final order), I UNDERSTAND THAT THE SUBMISSION OF THIS . FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH l (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORINT IS VALID THROUGH THE LITE OF THE CONTRACT, I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY' PRIOR TO ENTERING INTO A CONTR4CT_ IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 237.0I7, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTRAINED IN THIS FORM, (Signature) (date) STATE CF COUNTY OF PERSONALLY APPEARED EEFOP.E ME, the undersigned authority (narne of individual signing) who, after, first being swom by me, affixed his/her sig -nature in the space prot'idcd above on this day cf , 20 NO TART' PUBLIC My commission 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. 10'r;An . Count) Anunw) S MTV, MINN& Counn unchmenr Q DECL_ KIMON DF RESTRICTIVE COVENANTS TIIS DECL. FLAT1UN OF RrSTR1CTIVE dLited a of 200_, by (Proiect Sponsor...t and ("Titleholder"), their successors and wsigrw. is given to the United State Department of Housing and Urban Development (HUD.). RECITALS WTIEP.L-AS, the Project Sponsor participated in a consolidated application to HUD_ dated as of for a Supportive Housing- Grant; which Grant was av, arded; a ---id WHEREAS Miami -Dade County (the Recipient) entered inic a Supportive Housing Grant (FL14B ), on ; and WHERE:? S, the Recipient entered into an Agreernent dated ,vith the Project Sponsor (the Project Sponsor Agreement) in which the Project Sponsor is obligated to acquire and rehabilitate directly or th.rollQh its single -asset affiliate as defined belo� and operate a supportive housing project on praperty described in E:.hibit A hereto (the ' Property "), which is to be maintained and operated as supportive housing as defined Ly the Agreement; and W-HEREAS, the ProlectSponsor has created (thz "Titleholder"l all aff Bated single -asset corporation whose board of directors is the saint as the board of directors of the Project Sponsor, for the At purpose of acquiring and reha�ilitatin T the Pr openy ; and WHEREAS, the ,'McKinney-Vento Homeless Assistance Act, 42 USC 113S1 et. seq. ("AC T" j imposes use and repayment requirerner,ts on projects receiving= acquisition, rehabilitation and new construction funding; and -WHEREAS, the Recipient is required b}' the A ,reement to require the Project Sponsor, and the Project Sponsor is required by the Pro-iect Sponsor Agreement, to cause to be executed an instrument in recordable fornl which obligates the Prgkt Sponsor. its successurs and assigns, to operate and maintain the supportive housing In wcortmce `ill' the ?, reer;lCnt. the ACT, and HL1D regulations as provided for in the A0recInerlt: and \''NEP --AS_ the Project Sponsor and Be Tid6older uiidCi tlils De _ r l3r ,it:011 1IlCClldS, i7-2dares and co\ mints tii.at the r;'Slrlcm covtIlarets St" Vin; ill hemi;n shall be and are Qvtnants running- t'itri [hf ProDe-Fy to t!le term described herein, an.: an bod o .,yin_ upon all su �� f bsec�_Il, ci%vilers of the f �r ��D?,- r �1. ,_. _ -. j f�1 s��_7 t iIT.. w'Zd rite ;]Oi n7"�; ;' �,Lr�L1:�31 cU'', eI;ants � if he p�(� �r 1..,_ i Sponsor arij thr Ti!._ir�i er 3IHEREF_LE in cons o tn' i �.d �_;.I:,.. ','a113o1� Cinsl�C: a[i Vin. t^..,_ row of - r: Sponsor TAKA27. their succ .:__rs or aasi_ns. shall c'r LiZ;:-O`,,jdw sl!�p!?r'i!',e st, ice., duoL�2houi a [�thod if to gin: (_ill _nLJConLrnCnC-iD2 FroLr! the date of initial occupancy or the pt(`�;ston o ti,iti,]_l icr't, pith ter tr of th "Fe n. ment. ttie �.C�. I,,'�1D reSul-ltions, c-md all appiieabi f�' r, 1. stat a .c_ local �. If, pursuant to a request from the Project Sponsor, HUD determines [hat the p,oiIci is no lon`,er needed for use as supportive housing, HUD may authorize the Project Sponsor and thr Titleholder, their successors or assigns, to convert the use Of the project for the direct benefit of low-income persons. Upon expiration of the period during uvhich the Project Sponsor is obligated to operate the Property in accordance Wily the Agreement, this DeelsraJcn shall terminate and shall no to lamer be effective. 3. The Project Sponsor and the Titleholder agree, that if the project ceases to be used as supportive housing v,ithin ten (10) gears after the project is placed in service, the Project Sponsor and the Titleholder, their successors or assigns, shall be obligated to repay HUD one hundred Percent (100,0) of any assistance received for acquisition, rehabilitation and new constniction 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 by ten (10) percentage points for ew h no in excess of ten (I0) that the project is used as Supportive housi-ng. 4. HUD, acting by and through a duly authorized off cial, may approve such action as may be necessary to allow the transfer, conveyance, assigl rnent, leasing. ,,;oi t7a<,in` or encumbering of the Property orto accomplish the acts described above. 5. This Declaration and tl,e covenants set forth herein regulating and restricting tilt use and Occupancy of the Property (i) shall be and are covenants ruruiing %vith the Property, encumbering the Prope;iy for the term of this Declaration, and binding upon the Project Sponsor's successors in title anJ all subsequent O�vllcrs of the Properrt', (ii) are not merely Personal covenants of the Project Sponsor, and (iii) shall bind the Project Sponsor and its respective successors and assigns Burin; the term of this Declaration. 6. Any and all requirements of the laws of the State to be satisfied in order for the provisions of this Declaraticn to constitute deed restrictions and COVenarnts na,uning v, ith the land shall be deemed to be satisfied in On and that am' requirements or privileges 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 Laid eV03 contract, deed, or other instrument hereafter tx0cuted convayin�l the Prcperly or portion thereof shall eymssiv provide that such Conve`.'ance is subject t0 this Decllwadon, pIov!ded h, ,'ever, that MW Col'enWE contained herein shall sur` iAT and be Wcctivc rtgardless Ot 'a,'helner Such COMM, And or 00tr instnirnent hereat`tzr c?;eCu'led COFP, � 1 P provides � that 1 i'1n, ii7e reps, 1 �,f p��n]C'„7 thereof p -des t�. .3. j;;\'' .'ance is sCbleci to ti`]'_' D_'l. grail' 1 n' in = l='[( -, of -n ciausf, pari or Pro'Ii'=to:i 21 t'_l5 L!=- =:tUr . ;i3'? 'i•.>? ,_:__:r ,.._ irlJ P',, �I, i 'll"ES , ,L'EP—;--!)C, ihc, irV) tCt Spc,rsor h2 L,S_ repre,entativas of th t, day and yfar fiat abollle 111Th PROJrC T SPO1dSCi?; TIT -LE H� jLDEF, SI L,1131Ure BY: S i gnanuc Title Tide STATE OF FLORIDA j SS. COUNTY OF i�,1IAl 1U -RADE ) I HEREBY CERTIFY that the Foregoing DECLARATION OF RESTRICTIVE COVENANTS vvcls executed and acknowledged before me on ihis day Lr'. as PRESIDENT, of INC. who is: And by Personai;v Iaio«n 0 Produced Identification Type of identification Produced as PRESIDENT, of , INC. who is: Personaily Known OR °roduced Identification Type of Identification Produced before me, a Notan- public duly, au[horize.d in the State and couniv named �&,ovc to tril;r acknowlcdgrnents and did O did not [ake an oath. «'itnesseth my hand and official seal in the State and ComiFv ,shore_ This N''Ci T,L,!?' PUBLIC. State of Fiorid . da -, of A,tLachment Q-1 DECLAR kTIO,N OF RESTRICTIONS THIS DECLARATION OF RESTRICTIOi\S rnadc this da':' of 00 by the -eferred to as the "Declarant", IVTEREAS, Miani-Dade County, acting tlirouEh and on behalf ofthe Miami -Dade County Homeless Trust, has applied for and received funds from the United States Government under Title IV of the Stewart B. McP-Huey Homeless Assistance Act; and NVII:EkkS, Miami -Dade County agreed to comply Wit`i requirements of the United States Government in connection tinth the receipt of such funds; and IWILTRAS, pursuant to the '-)—Supportive Housing Program Grant Agreement, v,,hich Miami -Dade County entered with the United States Government, acting through its U.S. Department of Housing and Urban Development (the "Grant"), Miami -Dade County is responsible for repaying the Grant in accordance «nth the provisions of 2? CFR part 5S3,Code of Federal Regulations; and NVM AS, Miami -Dade County, in the exercise of due diligence, must take steps to ensure that the Grant -minded capital project is used for its intended purpose for a term of at least 20 years from the date of initial occupancy or date of initial service; WHEREAS; Miami -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 THEP-EFOF t , 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 benef is of said property and of each and every person or entity who no�v or in the future owns any portion or portions of said property. LAIND USE — The subject Prope tY and an,,' rehabilitated structures or ne%v construction thereon must be operated for the provision of supponive housing and seri ices for homeless persons in accordance «7th the provision o "24 CFR par 533, Code of Federal ReLTulatiOnS (as Ii1_ay be amended i:orn time to t! Me) for a Term of at J'east 20 veal's or iOr sL,ch other pu_T,oses cv t`la`.' G' ap-pro�'e� by tyle L.T.S. L1Cp21 �I ?rlf of �01-,ng and UrDa .'i Dfv21c.Pmtnt. TERM — This co'renant is to nn '�.1th t_n.e land ands 111 be bindimz on all pa ie; a,:d a 1 persons claiming ander them for a period of u,vtni,, (20) ''ears Erc:-n t t d, to the o 121rla 1 CU`:enst v,'`S recorded, the date 0f initial oCCllu1C}'. Or date ofinitial cr: iCc proisi o- %vhichc-"tr is later. ENFORCEMENT — Upon Declaration's, fad ure to comply 1vldi the requiren;enrs Cf this Declaration, the Declarant shall ivitturn 30 days of written notice of non-con7pliailce ,Znd request for conveyance shall convey the subject property to N i=I-Dade Coosa,,. Enforcement shall be by proceedings at lav or inequity against any person or persons violating or attemptirng to violate any covenant either to restrain violation, compel compliance with the provision of this declaration or recover darnages. Such action may be brought by Miaml-Dade County, or its successor in interest. SEVEILABILITY — 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. tiYITfiiESSES: STATE OF FLORIDA ) SS. COUNTY OF INIIAMI-DADS ) D E CLAR4NT: By: (Marne of President) ATTEST: Secretary of the Board I HEREBY CERTIFY that the foregoing DECLARATION OF RESTRICTIVE COVENANTS was executed and ackno,,vledged before me on this day of , 2004 by as Of Personally Kno,,�-n OR Produced Iderntizicaticn T_.7pe of Identif-ication Produced 4n b,, as rl Produced IdtntlilcaLlon T,, -Pe of Tdentirlcation Produced be;;Ore me, a Notary public dul v authorized in the State and count_ named ahovt to take a6-.nov,-Icd--nents and ,vho ( ) did ( ) did not take an oath. V✓itnesseth my hand and oMiciai seal in the State and County above, this day of , 2f04. ATTACHMENT R FOR GOVERNMENT ENTITIES ONLY - Semi -Annual Emplovee Certification for Supportive Housing Programs Agency: Project Number: Project Name: Period Covered: "This form is to be submitted to the Miami -Dade County Homeless Trust every six months. FL14B The following employee/s worked solely on SBP 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 SEP project during the period specified above. Supervisor Certification Name 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 MIAMI•I?Ap 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 Specifw locationl address where incident occurred: TYPE OF INCIDENT ❑ ALTERCATION ❑ CLIENT INJURY OR ILLNESS ❑ SEXUAL BATTERY ❑ PR OPER TY DA AM GE ❑ CLIENT DEATH ❑ THEFT ❑ 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 1 of 3 EMPLOYEE OTHER W / P M11A M i•jADE DESCRIPTION OF INCIDENT Give detailed account — who, what, where, when, why, how — add pages if necessary 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, 111 NW First Street, 27h Floor, Suite 310, Miami, Florida 33128; telephone (305) 375-1490 and facsmilie (305) 375-2722. 2 of 3 MIAM1-10 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 tornado, kidnapping, riot, or hostage situation, which jeopardizes the health, safety and welfare of clients. 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