HomeMy WebLinkAboutExhibit 4ATTACHMENT D
NOT APPLICABLE
Miami -Dade County Homeless Trust
Invoice For Services
NAME OF AGENCY:
SERVICE PERIOD:
NAME OF GRANT:
GRANT NUMBER:
TOTAL AWARD AMOUNT:
The City of Miami
TO
Attachment F
Memoranda of Agreement (MOA) Program
PC -0910 -MOA
AMOUNT OF FUNDS REQUESTED THIS MONTH:
AMOUNT OF FUNDS RECEIVED TO DATE:
BALANCE REMAINING ON GRANT:
(following payment of this request)
Signature of Agency Representative
Printed Name of Agency Representative
Date
$ 340,000.00
$340,000.00
i—, I I % '•..✓ I i I '•f I I 'q I' --,
off f t"s Dade F ai—neie�'G Trust �1't � i:t, �
�r I Better tklalt Share (FLilo 7Oo G48 ri •-.•
a n"i
'cngData As: Better ViloV a�)
Curr•enth; .chadovding: Glenn Bernstei i
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HUD Annual Progress Report (HUD=40118) (ServicePoint 4.05 version)
Report Options:
'rovider
%This provider AND its children. ('iThis provider ONLY.
,perating Year Date Range — to U (mm/dd/yy)"y)
I
egal Adult Age [_ {as defined by foster care lain in your state)
Or
-Select-
2. Persons Served during the +Number of Singles Number of
Adults in
jNumber of
in
Number of
operating year. Not in Families
Families
(Children
Families
Families
Ia. Number on the first day of the
�_ 0
0
i
operating year.
0
b. Number entering program during 0
t 0
the operating year.
c. Number who felt the program 0
0
during the operating year.
0
d. Number in the program on the last 0
0
day of the operating year. (a+b-c=d)
0
Y f• Number of
of Singles
ONumber of
�Pumi;er of
lNumber
3. Project Capacity. t : Adults in
+ado.. in Families lFamiiies
Children in
lFarnilies
j
(Families
a. Number on last day (from 2d, I
!
I
columns 1 and 4) i
0
4. Non -homeless persons. (Sec. 8 SRC, projects only)
How many income -eligible non -homeless persons were housed by the SRO program during the
operating year'
fill 0
S. Age and Gender. Of those who entered during the operating year, how many people are in the
following age and gender categories %,
lAge iMale
f Female Other/Nat given
Single Persons (from 2b, column I) +a. 62 and over '
0 !
G
Jb. 51 - 61 J
0
0
htr,�c^!(u�vi��iL1 cr�rvir.�-'n1 ('(llll/ill'.;]llli'.SCI'll"�tS�S�'l7I'i:`•j.10;t1]L1C�-i(}�.}�l�)�
3
Fc. O1 - 50 I 0 0 1
jo. I - 30 I I p I 0
e. 17 and under 0 I 0 0
INot given 0 0 0
Persons in Families (from 21b, columns 2 C, 3) f. 62 and over � 0 0 ' 0 t
9. 51 61
, 0
0
0
h. 31 50
0
0
0
r. 12 30
0 (
0
D
i. 13 17
0
0 I
0
1 I<. 6- 12
f 0
0
0
11.1 - 5
0
0
0
m. Under 1
f 0
e. White
D
Not givers
o' - 1Q. Participants; who entered during the operating year.
0
6a. Veterans Stets.
A veteran is anyone who has ever been on active military duty status:.
6b. Chronically Homzeiess.
How many participants vilere chronically homeless individuals?
7. Ethnicity.
a. Hispanic or Latino
b. Non -Hispanic or Non -Latino
S. Race.
a. American Indian or Alaskan Native
0
Ix. Asian
0
Hc. Black or African American
d. Native Hawaiian or Other Pacific Islander
0
e. White
f. American Indian/Alaskan Native & White
0
g. Asian & White
0
11, Slack/African American & White.
0
"L American Indian/Alaskan Native & Black/African American
0
j. Other Multi -Racial
0
k. Other/Unl<nokt\m (all that do not match)
9a. Special Needs.
0
Alf
Chronic
_ -- -- v
Mental illness 0
I b. Alcohol abuse
1c. Drug abuse I
lid. HIWAIDS o, relate diseases j 0 0
1
e. DevelopmenLai disability 0 0
f. Physical disability _ 0 j 0
a. Domestic violence 0 0
h. Other (p{ease specify) 0 0
Ob. Disabled.
How many of the participants are disabled? I 1
10. Prior Living Situation. Participants slept in the following places the week prior to entering.
iCCI) .r. >m'miami'sr.;-i>>tsisnjorcpol-01Lid405.1)11p i 0/15/_009
All I Chronic
+a. 'Jon -housing (street, para;, car, bus station, etc.)
b. "Emergency shelter I 0
�c. Transitional housing for homeless persons 0
�cf. Psychiatric facility
e. Substance abuse treatment facility I 0
r'. Hospital
g. Jail/prison
li. Domestic violence situation 0
i. Living with relatives/Friends
j. Rental housing i 0
Ic. Other (please specify) 0
1.1. Amount and Source of Monthly Income at Entry and Exit. Participants who left during the operating
year.
if
Amount
A. Monthly income at � B. Monthly Income at
Entry I Exit
All
Chronic
All
Chronic
a. No Income
b. $1-150
0
0
0
0
c. $151 - $250 I
0
0
0
0
d. $.251 - $500 I
0
0
p
0
e. ;501 - $1000
0
! 0
f. $1001 -$1500
0
0
0
0
g. $1501 - $2000
0
0
I 0
0
h..$2000 + I
0
0
0
0
So urce
C. Income Sources at
Entry
D. income Sources at
Exit
All
Chronic
All
Chr®nic
a. Supplemental Security Income (SSI) !
j
0
0 P
b. Social Security Disability Insurance .("ESDI)
0
0
0
f 0
c. Social Security (
0
0
0
0
d. General Public Assistance
0 f
0
0
0
"Temporary Aid to Needy Families (TANF) I
0
0
0
0
1e.
f. State Children's Health Insurance Program (SCHIP) `
0
0
0
0
g. Veterans benefits
0
0
0
0
i11 h. Employment Income
0
0
0 i
Ili. Unemployment Benefits
0
0
0
0 i
1j. Veteran's Health Care I
0
0
0
0
1c. Medicaid_
0 I
0
0
0
1. Food Stamps I
0
0
0
0
m. Other (please specify) '
0
0
0 I
0
in. No financial resources
12a. Length of Stay in Program. Participants who left during the operating year.
J All
Chronic
a. Less than 1 month
b. I to 2 months
I !
c..= - o months
( '
0 �)
1ud4l05. php ] 0..'1 t)`)c;
Id. 7 months 12 months I 0 I U
Ie. 13 months - 24 months I 0 I 0
IFg'4
25 months - 3 years0 0
years - 5 years 0 0
h. 6 years - 7 years
0 I
U
i, 8 years - 10 years I
0
0
j. over.10 years
0
0
12b. Length of Stay in Program. Participants who did not leave during the operating year.
1
0
All
Chra nic
Less than 1 month
0
h. Disagreement with rules/persons
0
11a.
b. 1 to 2 months
D
i. Death
0
c. 3 - 6 months
0
j. Other" (please specify)
I
Id. 7 months - 12 months0
0
'
0
e. 13 months - 24 months
0
"
0 1
f. 25 months - 3 years
0
`PEi:f�tAfdEl1T (a - h) �a. Rental house or apartment (no subsidy}
0
g. 4 years - 5 years
0
b. Public Housing
0
�l
h. 6 years - 7 years
0
1 c. Section 8
0
i. 8 years - 10 years 1
0
1d. Shelter Plus Care
0
J. over 10 years
13. Reasons for Leaving. Participants who left during the operating year.
0 I
0
la.
All
I Chronic
Left for a housing opportunity before completing program
I
I 0
b. Completed program
1g. Homeownership _
0
;c. Non-payment of rent/occupancy charge
` b'
0
0
hi[1�s:;'%\�- �vd1.iC1"�']C;Cj7L.G^171/1171 11171!SC1"110115/2,009
I e. Criminal activity / destruction of property / violence
0
0
f. Peached maximum time aliowed in project
0
1
0
g. Needs could not be met by project
0
0
h. Disagreement with rules/persons
0
(
D
i. Death
0
0
j. Other" (please specify)
I
0
!.. Unknown/disappeared
F1.4. Destinations. Participants who left during the operating year.:
"
All
Chronic
`PEi:f�tAfdEl1T (a - h) �a. Rental house or apartment (no subsidy}
0
0
b. Public Housing
0
0
1 c. Section 8
0
0
1d. Shelter Plus Care
0
0
ie. HONE -subsidized house oraoartment
0'
0
�f. Other subsidized house or aparrrnent
0 I
0
1g. Homeownership _
1
0 I
0
Ih. Moved in with family or friends
0
TPANSITIOhtAL (i - j) (i. Transitional housing for homeless persons
I
0
0
1j. Moved in with family or friend;
0
0
INSTITUTION (k - m) Ik. Psychiatric hospital
D 1
0
11. Inpatient alcohol/drug treatment facility
0
hi[1�s:;'%\�- �vd1.iC1"�']C;Cj7L.G^171/1171 11171!SC1"110115/2,009
+ im. �aii/prison I 0 0
EMERGENCY SHELTER (n) ,n. Emergency shelter j 0 0
OTHER (o - qj �o. other supportive housing I 0 I 0
1p. Places not meant for human habitation (e.g. street) 0 + 0
q. other (please specify) 0
r
I UFdKtdOWN r. Unknown
IT --7S upportive Services. Participants who left during the operating year.
NOTE:The below services were given to participants who left during the operating year. ,odd the
following counts into the appropriate category for question 15.
Service Service Code All Chronic
1 1. Transitional Housing/Shelter BH -8600
Serrice Point version 4.06.022 (dig build #.1222)
Licensed to: Miami Dade Homeless Trust
J 299°9-2009 Bavvman Systems L.L.C. All Fights i'ceserved.
CHT only ?2004 AY,erican Medical Association. All Rights Reserved. (9/10/2004)
DSM and DSM -!V -TR are registered trademarks of the American Psychiatric Association, and are used with permission herein. (2000)
ICD -9 -Ch1 ?1994 Plational Center for Health Statistics (ICD-9 ?World Health Organization). All P.Ights Reserved.
Taxonomy of Human Services ?1983-2D06Information and Referral Federation of Los Angeles County, Inc. All Rights Reserved. (6/2 /2009)I
���-,,,�.;i,inaniil cr•.1-V'1Gl?1�L.Ct�il1/ii111P]1i:�Cl-1?�ZS�SV���2-���t)i�1L)C1�O=�.��h�� j��]_ii_r`l)i.)t}
ATTACHMENT H
NOT APPLICABLE
ATTACHMENT
NOT APPLICABLE
ATTACHMENT J
NOT APPLICABLE
ATTACHMENT K
NOT APPLICABLE
ATTACHMENT L
Miami -Dade County Homeless Trust
Annual Actual Expenditure Report
The City of Miami - Memoranda of Agreement (MOA)
Contract Period: October 1, 2009 - September 30, 2010
Name of Agency The City of Miami
Contract Number: PC -0910 -MOA
$ 340,000.00
Month of Services Amount Paid
October -09
November -09
December -09
January -10
February -10
March -10
April -10
May -10
June -10
July -10
August -10
September -10
Total Requested
Balance Remaining $ 340,000.00
A 1 1 UJ71l1 Ott\,i ivt
Request f3C Taxpayer Give form to the
identification Number and C'ertffi'caticm requester. Go not
send to the IFS.
nein-, if ,^jli^ren'. 1rcw i:UW'c
(.,heci: =DronriulE ':o:i. iii InJividuil L'JUIe pic Dnetor 'D Co:Jo.'ak'. I_' t'cnre.-Inu
7-7
. ! Limned ilabi!Iiy Como<rinv inter th:. ,. C;a F'ihcalJon DU Jsreoaroed enllly. -tion,
1 '
p
Diner (ser irrtrucacnz) r eya,L
AddresE: inumber, rireet, and apt. O!SUIIC- nU.i Rc.q:le in;"r, name and aO!11'?c:: foptionall
City. ;:at'., and ZIP code
Lis! ac:counl nun1C•Vr(5) mere ropLoral)
=1 Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name givenon Line 1 to avoid Social security number
backup withholding. For individuals, this is your social security number (SStJ). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIIJ). If you do not have a number, see Hnw io get a TIN on page 3 or
Note. if the account is in more than one name, see the chart on cage 4 for guidelines on whose Employer identification number
---- - — --- I --
number to anter.
Certification
Under penalties of perjury, I certify that
1. The number shown on this form is my correct taxpayer identification number for i am wafting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup Wthholding, 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 IFS has
notified me that I am no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person (defined belovv).
Cert fication 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 elate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured proper y, cancellation of debt, contributions to an individual retirement
arrangement (JRA), and generally, payments other than interest and dividends, you are not required to sign the Cahincation, but you must
provide your correct TiN. See the instructions on page 4.
Sign Signature of
;fere I U.S. person Cate Ji-
Genei-af Ji-
Genes-a
Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.
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 r'epo+2, for example, income paid to you, real estate
transactions, mo!lgaue interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
Use Form IN -g only if you are a U.S. person (including a
resident alien.), io provide your correct TIN to the person
"�':iuesting it ('the rvquesi r} and, when uu7,iC3bfe. to:
1. Ger-tifv that the TIN VOL) are giv!r!g is correct (or you at-
`,/aillrip for z numb•"!' to b Issued)
_. rrclrlify illat you at'e fro! ;„j;tC'.Gt t0 t:ackup v;'ithhoidlnu, or
,�. C;3im =. e:nnn 1o1 iron -r u:7: 1<.Jh witrinOl in,, I `;Oil
ernpi p at'�_. I+ a�pii::a: ie Icer are so e,liivuul that a
r on, our aD:; nLiic.' F.haz :,mw irl-ornc irCan':
U.S. tradr.' or busrn-:- .s . not su`_i!�cl tc the v,"iIif•roldinc or
Note. 1' c)",'z.;. V11111 r: !ot'i'1 C41-je ihi7.r, -nr^..
re^u_'�, •r'nur -1'; ','c. r,' .... ._. the �� !_..._ _ t:,,,., ,. It .-.
Definition of a U.S. person. For federaf tax purposes, you are
considered a U.S. person if you are:
e An individual who is a U.S. citizen or U.S. resident aiien,
Q A parinershio, corporation, company, or association created or
organized in the United States or under the laws of the United
States,
An estate (other than a foreign estate), or
t A domestic trust (as defined in Regulations section
,01.7701-7).
,pecial rules for partnerships. Pailner'ships that conduct a
trade or business in the United States aree generall,r required to
pay a wilhhoiding ta>: on any foreign pariners' share of income
i+on'I such bucine Further, in certain cases where a Form Vv -9
has not L»=en received. a partner --hip is requned to :nresu!: - !hat
partner is a ioieign person, and pay the witthuldi ig tax.
Therefore, if you are a U.S. person thal is a partner in a
paltnershrp C.onducrnc a iraoe or busncss in the United Stale::.
provide Forn- V,1-5 to the parinersnip tr,-,s,abl! s, your J.z.
and o�,roidi vr,rlhholu!nn ;n "^u:' ;Ii r'e o' parui:! h;
rlcame.
he .'e! sof v✓hr ;!vl�. -orm !r,: -r' k, Til-
nu! asses of eStabhShi+,c ir; l S ;Mira, enc
itC ai:o;,..oh:' ah,.,. 2' . -.. in::ame ir-: the -.hi”
:;:till M',
�prr,. y,'- c rFirr. lir _'bc7,
£ Ing .�J. a:_:or .. ..,..E:r o':!.�'ne, E C-: -It or tr •.:.,. all', nom. .. .�
arc .. -
t, The I_,. tri. . lL•.. i.,, than -r2MY it L'S`; ?nC,' 110' .tile
Foreign person. if lou area foreign pe! --non, cc, no! L c corm
Instead, use tn� apprco!rte orm �l+-G !tic= uofl,aiion
515, ! viinhoidtog of a3' ari Nonresident Jens and Fore gn.
EntitieSi.
Nonresident ahen 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. Lay, on cel-tain types of income.
However, most tat treaties contain a provision known as a
''saving clause." Exceptions specified in the saving clause may
permit an exemption from tar, to continue for certain types of
income even after the payee has othermse become a U.S.
resident alien for ta;: purposes,
If you are a U.S. resident alien vvho 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 to Form 'VV -9 that specifies the following five
items:
1. The treaty country. Generally, this must be the same treaty
under which you claimed exemption from tar, as a nonresident
alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty !hat
contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the
exemotion from tat.
5. Sufficient facts to justify the exemption from tax under the
terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows
an exemption irom tax for scholarship income received by a
Chinese student temporarily present in the United States. Under
U.S. lava, 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, 1954) allows the provisions of
Article 20 to continue to apply even a er 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 N-9 a statement that includes the
information described above to support that exemption.
f you are a nonresident alien ora foreign entity not subject to
backup withholding, give the requester the appropriate
completed Form '6-8.
What is backup withholding? Persons makinq certain payments
to you must under certain conditions withhold and pay to the
IRS 28%6 of such payments. This is called "backup withholding."
Payments that may be subject to backup withholding include
interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate
transactions are nol subject to backup withholding.
You '.will not be subjecl to backup withholding on payments
,!nu rec ive if.yrou give ttie requester your correct TIN. make the
proper cel tifica;lons. and report alt your t3Xaolw mte;est 21c
dividends on ynu!" tax return.
Payments you receive will be subject to backup
withholding if:
I . You do trot .;urnish vour TriN' 10 the rc;qu%si^r•
'IN v,ri lin r=^t.nr.>.•o I<"fie° the Par; li
!r;-tructi �r:;. or! p:•;;e 3 ioi ci-fair..;.
ilk II=1_ tEa!F il'i .. >ie:ii,c1 fLWITS'I
I I!.
4.fIe h,.:eiL v tr,a) VD1.1 are -c? 1:,
:l!iL. c):_) nol . aI' •VOLJ-`i ..ere. . .,. C
d:VICEind� Oil Dur ta)' .-Turn liol'
--iVldenj5 orlly; 7r
�. i'ou ctc• not c_: -i-, :c th= reouestar that yr !! ar= not cu !ecs
r;Z�h:U� Vllf hn�ic!I-ig unoer 6 active ('o'' reporiaole Irr.Eii'est aril
dlV ldend accounts opened' u'Jnryi
Ceriair payee- anc pa;mentc are exempt iron-, bact;up
withholding. See the instructions below and the separate
Instructions for the Requester,:),!' Form V'.'-9.
P.!so see c pecial ruie:; for Dartnershrps or, pacle 1.
Penalties
Failure to furnish TIN. If you fall to furnish your correct Tit,] to a
requester, you are subject to a penalty of 250 for each sucl i
failure uniecs your Lailure is due to reosonabie cause and not to
'arillful nealect.
Civil penalty for false information with respect to
withholding. If you make a false staten'?ent with no reasonable
basis that results in no backup withholding, you are subject to a
2500 penalty.
Criminal penalty for falsifying inforr? ration- 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 TINIS 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 income tax return. However, if you have changed
your fast 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 ?art I
of the form.
Sole proprietor.nler your individual name as shown on your.
income tax return 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). Check the "Limited fabiiity
company" box only and enter the appropriate code for the tar,
classification ("D" for disregarded entity, "C" for corporation, "P"
for partnership) in the space provided.
For a single -member LLC (including a foreign LLC with a
domestic owner) that is disregarded as an entity separate from
its owner under Regulations section 3017701-3, enter the
owner's name on the "Name" line. Enter the LLC's name on the
"Business name" line.
For an LLC classified as a partnership or a corporation, enter
the LLC's nanle on the "Name" line and any business, trade, or
DEA name on the "Business name" line.
Other entities. Enter yqur bu sine, s !lame as shown or required
,eaeral tar, oocumeni s on the ";dame" title. -his name should
n!aicn the name sno✓ n on the charier o) other fecal document
c.rsaiina thc.- enlitV. YOU may easier arn' business. trace, of DE.L,
r,.:me or: the 'Business flame" hne.
!Vote.:gu Dr r<_•que lett to h ci< the ai:lproprl i• t,r):: i )I ,,r,ul
IH?d;vldllaL'SOIJ t�rCpl" in!. C:pl';a Gi'atipr:. Sl::;.
exempt Payee
1' V7,U :r-E!Yirpt nror'l i:jD,*,-c, vvithhokilnc ctrl- -ou; .. r
C]-- rburi a:.LPF avid ch—,Ci, in=- r?n). fel
ihen ciie , !r. I;—lint
t:•usinea- ..cmc, crI .-:nc -. �.... ti-i� fpr C",.
:rl.•...e..., Sol- �G('i�LJ i. -.� I'I•J� - I7'�i;i
.,._TI bC:= .-... .. iirlli Jl:Jlrlc ��7r✓7!"a:!�J:�� ai ". -•�-m+ rr Jr;l a..r.
Note. I` icu _..., :':,; for -r acku: .,itnhoid!ny vGJ
"r Jnieous
TP,- f olovving payee_ are exempt imm: backup v+.thlloidin:;
1. An orcan.i=ation exe-pt from tax under section ;,01;a , any
IRA, or _= cust,dia! acco!mt under section 403(b)(7j if the account
saiicfies the requiremenis of section 401(t)(2).
2. The United States or any of its agencies or
instrumentalities,
3. A slate, 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 organl_ation 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,
o. A dealer in securities or commodities required to register in
the United States, the District of Columbia, or a possession of
the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A. real estate investment trust,
I I. An entity registered at all times during the tax year under
the Inves ment 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 payees listed above, 1 throueil IS.
iF the payment is for ... THEN the payment is exempt
for...
Interest and dividend payments All exempt payees except
for 9
Broker Transactions Exernpf payees 1 through 13.
Also, a person registered under
the Investment Advisers Act of
11940 who regularly acts as a
brol<er
Caner :xchanoe transactions � Exempt payees 1 through 5
and patronage dividends !
Divi t. _ °rte• i'(f (�.��„ o.v i .:. ..,.� il;r, _ -emnt n_Ivf Cls
ic, be repo ,ed and direct
ov(n'
..' i"carr:: 1(lac.;��il':i.:. Lh•.;�::al:ineal.c.l:r,:;rme_ anc! !.....s:nleii;'x::',.
Fiu'n`i^.`el, !!i•, i<::krvarin hent;. n-',a(ir• n c:rn' sora:Kin Icllli, r -11;1r1 q-sp -
.;:r :.....: ...... .. u. .-.,;1rir..,., lin 0:':1 .'llnn i,C if ti ..i: 1. llli= 0tletrno6 r.. ..
.::':)J7 ll N. �:. 1('� t .;;17... I. � . ':i - .1;... I..' .. _.� J1:.. .. ..•.. i1.^,' :rC n'i
v✓:!hir.�eiirr- ❑-i_:(1„-.;1: aha nealt;� .;lr;: ravn',e•'!s. nC(:rn^;`c- ,....... ai:
.i...
Part 1.i ; Ja�fer igen tilication
Number mer ('T 11\)
Enter your TIN in the appropriate box. It you are
....ef. and vob JG not na':re anc are nrri eiIo iL- ti: Tei -nl-; •!.
ur Tlh! ! vou! IF,. inciv;Jt.c >; a r ioentificatior! number
(j7l14). Enter it in the ._ ial securiv nuc!ber bo):. If yo- do nc;
na`.re an MW. s_e .Povr !o get a Tltl below.
It you arc- a sol- proprietor and you have' air _IN, %,,ru nlay
enier either your S°tJ or EIPi. Hov✓ever. the IRS prefers that you
use your SSW.
If you are a single -member LLC that is disregarded as an
entity separate from its owner (see Limited liability company
(LLG) on pane 2), enter the owner's SSN (or EIN, if the owner
has one). Do riot enter the disregarded entity's EIN. It the LLC !s
cozsnied as a corporation or partnership, enter the entity's EIl'•l.
Note. See the chart on page 4 for further clarification of name
and TIP' 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 online at wwwssa.gov. You
may also get this form by calling 1-000-; 72-1213. 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
apply for an EIN online by accessing the IRS website at
www.irs.gov/businesses and clicking on Employer Identification
Number (EIN) under Starting a Business. You can get Forms W-7
and SS -4 from the IRS by visiting www.irs.gov or by calling
J -800 -TAX -FORM (1-800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN,
write "Applied For" in the space for the TIN!, sion 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. Entering "Applied For" means that you have already
applied for a TII4 or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign owner
must use ?he appropriate Farm I//-8.
Part R. Certification
To establish to the withholding agent that you are a U.S. person,
or resideni alien, sign Form Utr-9. You may be requested to sicn
by the withholding agent even if items 1, 4, and 5 below indicate
otherwise.
For a joint account, only the person whose TIN is shown in
Pari I should sign (vvhen required). Exempt payees, see i vamps
Payee on page 2.
Signature requirements. Complete the, certification as indicated
it 1 through 5 helow.
i. interest, dividend, and barter exchange accounts
opened before 1964 and broker accounts considered active
11:'. ttul yctj C10 nc!
have t., sign the cenificalion. J
2. Interest, dividend, broker, and barter exchange
accounis opened i tei 1983 and broker accounts consider;;d
inactive during 19E3. r.>Li must sign llv, c: rt:fic,iiori or'xici.?rn
rr!thtroldrng ,rill _.,IGIv. I .i .,._ _,ui:n<_:ci?c'"^:i<.u� ..ahlioiriir;
31 -id ) JL! arc' J;-nersdy provic! c, vont coi'reci TIN f c lriP rE'6Uii51c
^I, t -nisi _._ Dul ..c`;l't _ .;5 ll...
ilirn,. .
3. Rea l estate transactions. 'ou mss: sigrl in= -e iii: allot:
`'ou n3\' Cro3s oui nem _ of The c-_- i.:.caflon.
4. Other payments. `'cu mus a!ve ':'our regi TI b_l yc l
oo not .-;8:/e to sig,, title „enlm!c2tior, ur.ies Jou have Jeer;
notified Thal you nz'•<< previcuz;y giver. an incorrect
pa;anents" :ncjucje paymenis rnade ;rr tree course of Th-
requesters tradC or business for rents, rovaitie, goods (other
Ihart bills for merchan'disei, medlca! and he3fth care services
(including payments to corporations), payments to a
nonempioyee for services, payments to certain fishing boat crew
members and fishermen, and groes proceeds paid to attorneys
(including payments to corporaiiois).
5. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529), IRA,
Coverdell ESA, Archer MSA or HSP. 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 type of account I Give name and SSN of:
. Individual
2. Two or more individuals (Dint
account)
3. Custodian account of a minor
(Uniform Gift to Minors Act)
4. a. The usual revocable savings
trust (grantor is also trustee)
b. So-called trust account that is
not a legal or valid trust under
state law
5. Sole proprietorship or disregarded
entity owned by an individual
The. indivldun!
The actual owner of the account or,
it combined funds, the first
Individual on the account
The minor
The grantor -trustee
The actual owner
The owner'
For this type of account
i Give name and EIN w.,
6. Disregarded entity not owned by -an
The owner
id
indivuaf
I!
7. A valid trust, estate, or pension Inst
Leoai entity
3. Corporate or 11C electing
The corporation
corporate status on Form 8332
g. Association, club, religious,
The organisation
charitable, educational, or other
.ax -exempt organization
i0. Partnership or multi -member LLC
The partnership
11. A broker or registered nominee
The broker or nominee
12. Account with the Department of
The public entity
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
uol iiml and rircle the name of the person whose number you furniSh. If only one person
on a joint account has an sGld, that porcon's number must be rumished.
Circle the rrt mor':: namr: and furnish Inc minor'; Ssrd.
You mug 1 -row your individual name- anti you may also color your business or"UEIA"
rame on Iho: svcono namr: bne. You may use eitimr your °,SIJ or EIN Q( you have oriel.
btu Ilv, IP.S r:nrouraneo VW 10 uc:e y0ul Z3h1.
UI t Itmi and ::rale Iho nan're n: the trrte'.l, e :arc, rrr Denson i ruci. (Cal not iwnr,h the TIN
or the per.pv al run,vrcmabvc or im, nlec unim IN, legit ^miry itself :: net drsinnalted Irl
it it, acroum 1,141.; Also ;atO $nncral rule:err p::pi: t.
Ili' e than name is Ilsfed.
`i0 ie_ fS fig i131'1'te rc, gil"v d.•'hi:r; more
the numgrer will be considered io be that of the first name i!_ted.-
Privacy Act Notice
r'arie 4
j?CUI"0 Your Tay ?CCOfcdSfrom idCflLf}✓ iii�ii
In ,,,r terror' SUcrl a:: volJr an'!e. ocia; cvnty nurnbJ_r !ESM, c.r
other *-m-iiying informal ort• w;ahoul your perrnisslon. 1C. comlrlil
fraud or other crimes. `,n i' -entity trite: 712Y Use your P; iG o ei
iob o!mar fhL E: to): reiurn ,.sine' yoar SSI, re -eft v a refunc.
I G reg U::`_ vOUI' nGi::
E Proten, your CJI\.
Ensure your employer IS proteCiing your JI'1. and
e Be careful when choosing a tae: pieparer.
Call the IRS at 1-80G-29-1 0_40 i1 you think your Identity has
peen used Inappropriately for tae: purposes.
Victims of identity theft who are experiencing economic harm
or a system problem, or are seeking help in resolving tae:
problems that have not been resolved through normal channels,
may be eligible for Tax ' Dayer Advocate Service (TAS) assistance.
You can reach TAS bycaping the TAS toll-free case intake line
at 1-877-777-1776 or TTY/TDD 1-200-6?9-4059.
Protect yourself from suspicious emails or phishing
schemes. Phishing is the creation and use of email and
websites designed to mimic legitimate business emails and
websites. The most common act is sending an email to a user
falsely claiming to be an established legitimate enterprise in an
attempt io scam the user into surrendering private information
that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails.
Also, the IRS does not request personal detailed information
through email or ask taxpayers for the PIN numbers, passwords,
or similar secret access information for their credit card, bank, or
other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
Forward this message to phishino(olirs.gov. You may also report
misuse of the IRS name, logo, or other IRS personal property to
the Treasury Inspector General for Tay Administration at
1-800-366-4484. You can forward suspicious emails to the
Federal Trade Commission at: spam@uce.00v or contact them at
www.cop,sumer.gov/idth-3, or 1-877-IDTHEFT(438-4336).
Visit the IFS website at wwvvJrs.gov to learn more about
identity theft and how to reduce your 11SK.
CIO: ... r __ -'" _ r. ,_ - i.n ,:irf !-...� Tii: 7r• _'f`n: t?'.'1(. : u:.• III( !'li ttl'n i..,..,., rn.:lrrl::.Jll:t 1, !!. i� r.':)(+1't lnit•
CIO:; !;: :I1N .:1 ter, r,.t' lis v�n,L - C' I !r l^ .Ir.....
ern• r,...r ...t, .. ,,, .. ,r ., r.-, ..,.,,..t I ..
JIVldcnds. Ling cf,rtaln n1te mcnIne, _ ',l I( 1,()U mof7;Jafw :nt8rt ,,m; -gird. Ilr.. ncU: .,,l(i:m , c,;:Mconm^ni of SE:r:xeci .., , dn';. :emci:'Vior .,: Cent. D:
; Onu( Uu o'i(. '. c,l n'J_7:' ;r In/, oI /'r: nr h.`... n• I L;� `:t< IRS t.. :..' ri t: to n. :.rt 'ol unrr,m.:;i;or. (+:u'nosr::: an;; Ir+n tier it ^.r ta;.ra:_cv of y., . i'l.:•t
y
Inv IP' : -.-,.. 11"6 oro Yid^ tnl:. INol.r-:ai;rin 1(: t:P.• ..JC; ". i:rt(. . .... ..... . ... . - ., ..... _ . .. .1.:,,..
,: „1nt :�, .,vp -P�,r:-mn'r!ia,:at'��r '•.��-;;l1er Irn�l.v: _.(•:Irt - ru' -
PC'n:':X:^kN1' "• "irr:' r1U1 "1"n tri) ;PwL, \n,_ I,: rC;:.^.IC::C' 111:r. In:()irnitio"i 1r, ...`:i.'tii'IF.c it ,m 'm:A. I: ledr,;v. f;rd ..,illi. ^.en ie:. I(' ^.rl((11
n n'.. J•:ilt:.'. l ... i J_ .. .. 1: :. :. '.l ..f• ,7 'l"' Imo,.,, il!J (`nom, a•7 ^.nC.ly; "n:�.'.1 ..:fr: t: i,,lr
1 C+(1 ^..l :lrt :rine. r(1,1: cif :pt ,rr '1:; ..1 t:,Jll.. I(' , I...r „)' ",Ii; , r.: os! -. '.t ._ ... Iltt_,,:,_, n:l�� �. "1:� ... i . ,
ATTA CH'',�fE:"T
INCIDENT REPORT
CHECK_ IF CIRITICAL
Tte.pcn tin,1'ar[y Phone # Die of Incident _ _/ Time of Incident _ a.m!pm
Repallin , Party Name
Contract Provider Name
Pro,ram Name
Pro\!ider Location
Specific Progl,am: (check all that apply)
!_:_f HT Q Primary ary Care LJ SIP ❑ Emergency ❑ Challe.nae
, rRccifrc location/auldress w1icre incitIcn-t occurrent:
U -4-7 TER CATIOAT
TYPE OF INCIDENT
❑ CL IFNT 1T AT11
0 CLIFATT I-AIJUR 1' O R ILL, FSS ❑ T" EFT
SE117-JAL-BATTER�T
J SUICIDE ATTEMOT
U 1'R OTFR 7-11 D -11A IYA GE ❑ OTHEP� Jly'C DfA7T
Specii;�
j tyARTICTP,k\-T (,S) / '�VITNESS
(ES)
r
(Plc. se MAJ-h 'W` <rr P for either WImes; or f'arricilwnt i
L.,,S7'N.6,TAE,1-1RST iC1ENTiF1ERT CLIENT N91'L,L CiTHER i'
❑ ❑
J
U U
DESCRIPTION OF INCIDENT
We detailed account — u; ho w'ilai_ where- m0n. Ay. WA — add pates if ncasury
CORRECT'ItTE ACTION ANTI) FOLLOW UP
Immediate corrective action iakell
Is follow up action needed? ❑ 1`es ❑ No
If yes; specify
Ii\TI)TVIDIJ a LS NOTIFIED
ATTACHivIEN T i,,i
Abuse Registry 1-£ 00-O62-287- App) icabie, Law Enforcement Department
Indicate name of person contacted, if report was a.eecpted, the date and time ifcal!ed or cope ofreport
Incident Reports — The Suhrecihicnt rnus: J*Cporl In Mi-,lnli-Bade Fount\ Homeless Tru,i inforn'.Mi0n rc±alyd to rnv .
CI-I[1cJl II1Cldf-lilt nCCtli'f"I II S' �L1rI!?" illi' :IdI11111tSirJtion 1Crm, l)1 IIS ilrnS[-ams. ill 9ddi-ti n to r po11in this Illcidcn 1(t
Hhe uppr,pri�;lc nuthc hlvs the Subrecil-ii,ill n)ust within I} ci)rv-four('_,) hours. (if' e;r inciduril. slibillil in ^itim, a
f"
dclaile.d : cc(uw l,f o incident. This AM Flinn by _ addressed in the Miami <l,ilcer or Rdminisu"utiv,
ttic r „st:i_Il d. This inciuenl sh<luld he oddre:-scd In Miami -Dade May '- el:as Trust. 1 11 K\V Firs!
Sll'etn 271" I-innl.. SIIinc 10. N'llall?l. I-Illrlda 37128: idephrin 00504- W) and i..nllAw GOR
OR
—til l Dr DE } �a
Definitions of Reportable lncidents
TTA C;-iTN4 ',: T N
a. AIt.erca,,jo 1. .-'i ph)'AN conf]'onmhon OCCurri l IL Lvveen a chem and tnip10 gee Or
TWO Or m0]'e ClienB nt Me Law services = 012 rKtrtd, or vdhe�n a client is in iht
phydcal custody of the departrnmt, Nvhicl] results in one or ]pore clients or en)ployees
receiving medical treatment l», a licensed health care professional.
b. Client Death, A person whose life terminates due to or allege.dly due to an accident,
act of ah mn retTlect T1]' other Wideni occuri']n,' v, bile in the presence of an employee,
in HOn)eless Trust contracted program fa.ciiity
C. Client Injury or Illness. A medical condition of a client requiring medical treatment
by a licensed health care professional susiairned or allegedly sustained due to an
accident, act of abu-se, neglect or other incident occurring, while in the presence of an
employee, in a Homeless Trust contracted progam.
d. Other Incident. An unusual occurrence or circumstance initiated by son)ething other
than natural causes or out of the ordinary such as a tornado. kidnapping, riot, or
hostage situation. `%,7I7ich jeopardizes the health, safety and welfare of clients.
e. Sexual £atterv. Am allegation of sexual battel71 by a client on a client, employee on a
client, or client on an employee as evidenced by medical evidence or la«v enforcement
involvement.
f. Suicide A ttenmt. -kn act - which clear]), reflects tl)e physical attempt by a client to
cause his or her olvn death ivhile in the physical custody of the departlnent or a
departmental contracted or certifed provider, which results in bodily in7jur3, requiring
m --di ca) treatment IDy a licensed health care prof ssional.
Property Dan)age
An incideI7t Involving dairla�Te to 17r0�C]'ty procured vAth 11on7eless T7u.3t fL71)L1177'
0
Provider Nalue:
Progiam Plame,
Funding
i -1 T
v Numbi
Al MO IN! M!, U
MIATVII.-DADE COUNTY HOMELESS TRUST
PROVIDER ASS ETINVENTORY
-. Amich i"voices For A purchases this gru"t repor(hy period.
1111k.N11 DARE COU TYHOME"LESS TRUST
CL1E'1'TSEf:i'10ES CERTIFiCATiON REFERp;.AL NORM FOR EMPLOYEES OF
HOMELESS TRUST FUNDED PROGR.A MS
LNSTRUCTiO-'S: Provider rnai,inc referral must complete this nvo-pace form, inciudinl, signaFures
1_Il, s,nplicant Lmd Provider Rcpresentatives. FLx completed farms to Provider Pcccivinc Referral fur
Housirl; and ur•Scrvices.
Date: ReferrinL, Provider:
contact Person:
Name Title I'iume iJumher
INFORMATION ON HEAD OF HOUSEHOLD:
Last Name: First Name:
Date of Birth: SS #:
INFORMATION ON OTi HER H OUSEHOLD MEMBERS:
2tiame (�
Age j Sex (� Relationship + EnlAJover
I I I
IS ,ANY MEVI ER OF THE H OUSE14OLD EMPLOYED DY, OR RELATED TO A.N EMPLOYEE
OF, ,A PI0rvIELESS TRCIST r Uf\r.DED PFcOG1t,A Jul? Yes No
If ves:
1-Janle of Employee:
Employin, Provider:
Relationship to Applicant:
r�r=rTIF1C4TION
I, the undersi,ned. do he.rchy certify_ that the above infornizwon provided h\v me is rrue and cnrrc:ci l.n the
hesl of 1111' hnrn� led e.
:�111111C8111 S Ni1111E'
.�,!LIV,IuFc: I)iltC
I:P1:i'i'illn Pr1�\'�U`''I' '�lIII1Cil'I?�d %�ill•Ctiell'iat;\;�:
Nal lc: __ _ _ SI_'ii;llnrC I ntt
ATTACHMENT P
PROVIDER h;L:l"L.RRAL FOR10 PAGE TWO
Applicants''; m
If the Appiicant or a m0ber of their household is an employee of the referring provider, the
approval of the f`r mider Executive Director is hereby indicated by Agn cure:
?varneawc
Dare
If the Applicant or a member of their household is an cmnloyee orthe pr"j&r where services wi(I he
Provided., the approval of T he Provider Executive Director, the homeless Trust Execuse Director,
> nd the Homeless Trust Ptrar d Chair are hereby indicated bysigr:ature:
Provider Executive Director
Ivfiami-Dade Cpunt_y Homeless Trust Chairperson
Date
Date
Miami -Dade County Homeless Trust Executive Director Date
ADDITIONAL HOUSEHOLD TNFOP3/1ATION:
Vtrttere is the household living, noY (Facility name, exact address)
Date of present homelessness:
Explain the homeless situation, and what caused the cur rent
homelessness:
NOTE TO PEFERRDY(71'RO%IDER:
T)ROVTDLNG THE ABOVE INTFORMATION DOES NOT ENSURE A J1,ROti,4L FOR FIOUSING
OR OTHER SERVICES REQUESTI✓D. A DETERMINATION NAITLL BE MADE FOLLOWING A
COMPLETE ASSESSMENT OF THE .APPLICANT'S C�.SE.
THIS SECT101Y'!ORA?WCEPRO i'IDER STAFFCIJEOAT):
Alecr;v Eligihifinr 0—ircrir: FES NO
"6.1177e1! Pr(')vicicr SLLr:::lj 111« 5i'gff
PLEASE NIA 1N'T.AJN i'r E• \ECUTEI} CUPY CUPOF THIN DOCLAI ENT IN 111ECLfENT FiLEOF
THE SERAlC1NG PRONADER AND, PERSONNEL FILE OF REFEITIUNG PRO" DER.