The URL can be used to link to this page

Home My WebLink AboutAttachmentsSubrecipient 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 of Service Attachment A-2 Units/Bedrooms/Beds Chart and Participants Chart Attachment. A-3 n2gLm Goals Attachment A4 Milestones (N/A for Renewal Grants) Attachment B Technical Submission Attachment C LOCCSNRS form HUD -27053A Attachment C-1 Copy of Homeless Trust Invoice Attachment D IMS (HUD -40118) Monthly Progress Report Attachment E Program. Rating of Satisfaction Attachment F Client Contribution Report Attachment C Annual Progress Re rt (APR) Attachment G-1 FMS (HUD -40118) Annual Progress Report (APR) �1 Signature Attachment H Request for Taxpayer Identification and Certification Signature Attachment I HUD form -400904 Applicant Certification Signature Attachment J Miami -Dade County Required Affidavits signature Attachment K Affidavit Lobbyist Registration for Oral Presentation Signature Attachment L Disclosure of Subcontractors and Suppliers Signature Attachment M Subcontractor / Suppliers Listing Signature Attachment N Section 3 Compliance Requirements Signature Attachment O SWOm Statement Pursuant to Florida Statutes Attachment P Provider Asset Inventory form ifapplicable Attachment Q Declaration of Restrictive Covenants if applicable Attachment Q-1 Declaration of Restrictions. Attachment R ELnloyee Certification Form Attachment S Incident Report (3 pages) Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North A11AUI Mr;Pf1 A 004148292ODDO FL018964D000802 Grant Number: FL0189B4D000802 Award Amount: $292,660 Recipient: Miami -Dade County, 111 N.W. 1st Street, 27th floor, Suite 310, Miami, Florida 33128 Tax ID#: 59-6000573 Project Name: FL -600 - Ren - MMHAP North Component Type: SSO Official Contact Person: Mr. David Raymond, Executive Director Email Address: dray@miamidade.gov Phone: (305) 375-1490 Fax: (305) 375-2722 2009 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. Consolidated Grant Agreement Page 1 1 03/02/2010 Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North 0041482920000 FLO189B4D000802 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 December 29, 2008 at 73 FR 79548, and the second part was the Continuum of Care Homeless Assistance Programs NOFA Section of the NOFA, which is located at http://www.hud.gov/offices/adm/grants/nofa09/cocsec.pdf. 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 funds 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. 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. Consolidated Grant Agreement Page 2 03/02/2010 Appaicant: Miami -Dade County 0041482920000 Project: FL -600 - Ren - MMHAP North FL0189134D000802 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 Actor 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 Consolidated Grant Agreement Page 3 03/02/2010 Applicant: Miami -Dade County 0041482920000 Project: FL -600 - Ren - MMHAP North FL018984D000802 (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; Nr (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. Consolidated Grant Agreement Page 4 03/02/2010 Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North SIGNATURES This Grant Agreement is hereby executed as follows: UNITED STATES OF AMERICA Secretary of Housing and Urban Development m F'rinl name of signatory RECIPIENT Name of Organization . By: Authorized Signature and Date Print name of Signatory 0041482920000 FL0189B4D000802 Consolidated Grant Agreement Page 5 03/02/2010 Applicant: Miami -Dade County 0041482920000 Project: FL -600 - Ren - MMHAP North FL01896413000802 ATTACHMENT A 1. _ The recipient is Miami -Dade County. 2. HUD's total fund obligation for this project is $292,660, which shall be allocated as follows: Leasing $0 Supportive services $278,724 Operating costs $0 HMIS $0 Administration $13,936 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 12 months. 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. Consolidated Grant Agreement Page 6 03/02/2010 Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North ATTACHMENT B 24 CFR PART 583 --SUPPORTIVE HOUSING PROGRAM Subpart A --General Sec 583.1 Purpose and scope. 583.5 Definitions, Subpart B --Assistance Provided 583.100 Types and uses of assistance. 583.105 Grants for acquisition and rehabilitation. 583.110 Grants for new construction. 583.115 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 operating costs. 583.135 Administrative costs. 583.140 Technical assistance. 583.145 Matching requirements. 583.150 Limitations on use of assistance. 583.155 Consolidated pian. Subpart C --Application and Grant Award Process 583.200 Application and grant award. 583.230 Environmental review. 583.235 Renewal grants. Subpart D --Program Requirements 583.300 General operation. 583.305 Term of commitment; repayment of grants; prevention of undue benefits. 583.310 Displacement, relocation, and acquisition. 583.315 Resident rent. 583.320 Site control. 583.325 Nondiscrimination and equal opportunity requirements. 583.330 Applicability of other Federal requirements. 0041482920000 FL0189B4D000802 Consolidated Grant Agreement Page 7 03/02/2010 Applipant: Miami -Dade County Project: FL -600 - Ren - MMHAP North Subpart E --Administration 583.400 Grant agreement. 583.405 Program changes. 583.410 Obligation and deobligation of funds. AUTHORITY: 42 U.S.C. 11389 and 3535(d). SOURCE: 58 FR 13871, Mar. 15, 1993, unless otherwise noted. Subpart A --General § 583.1 Purpose and scope. 0041482920000 FL018913413000802 (a) General. The Supportive Housing Program is authorized by title IV of the Stewart B. McKinney Homeless Assistance Act (the McKinney Act) (42 U.S.C. 11381-11389). The Supportive Housing program is designed to promote the development of supportive housing and supportive services, including 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. [58 FR 13871, Mar, 15, 1993, as amended at 61 FR 51175, Sept. 30, 1996] § 583.5 Definitions. As used in this part: Applicant is defined in section 422(1) of the McKinney Act (42 U.S.0 11382(1)). For purposes of this definition, governmental entities include those that have general governmental powers (such as a city or county), as well as those that have limited or special powers (such as public housing agencies). Consolidated plan means the plan that a jurisdiction prepares and submits to HUD in accordance with 24 CFR part 91. Date of initial occupancy means the date that the supportive housing is initially occupied by a homeless person for whom HUD provides assistance under this part. If the assistance is for an existing homeless facility, the date of initial occupancy is the date that services are first provided to the residents of supportive housing with funding 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 definition applies only to projects funded under this part that do not provide supportive housing. Disability is defined in section 422(2) of the McKinney Act (42 U.S.0 11382(2)). Homeless person means an individual or family that is described in section 103 of the McKinney Act (42 U.S.0 11302). Consolidated Grant Agreement - Page 8 03/02/2010 Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North (b) Uses of grant assistance. Grant assistance may be used to: . 0041482920000 FL0189B4D000802 (1) Establish new 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 that meets State and local government health and safety standards;. (4) Provide additional supportive services for residents of supportive housing or for homeless persons not residing in supportive housing; (5) Purchase HUD -owned single family properties currently leased by the applicant for use as a homeless facility under 24 CFR part 291; and (6) Continue funding supportive housing where the recipient has received funding under this part for leasing, supportive services, or operating costs. (c) Structures used for multiple purposes Structures used to provide supportive housing or supportive services may also be used for other purposes, except that assistance under this part will be available only in proportion to the use of the structure for supportive housing or supportive services. (d) Technical assistance. HUD may offer technical assistance, as described in §,583.140. [58 FR 13871, Mar. 15, 1993, as amended at 59 FR 36891, July 19, 1994] § 583.105 Grants for acquisition and rehabilitation. (a) Use. HUD will grant funds to recipients to: (1) Pay a portion of the cost of the acquisition of real property selected by the recipients for .use in the provision of supportive housing or supportive services, including the repayment of any outstanding debt on a loan made to purchase property that has not been used previously as supportive housing or for supportive services; (2) Pay a portion of the cost of rehabilitation 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 acquisition and rehabilitation of structures, as described in paragraphs (a)(1) and (2) of this section. (b) Amount. The maximum grant available for acquisition, rehabilitation, or acquisition and rehabilitation is the lower of: (1) $200, 000; or (2) The total cost of the acquisition,.rehabilitabon, or.acquisition and rehabilitation minus -the___ applicant's contribution toward the cost. (c) Increased amounts. In areas determined by HUD to have high acquisition and rehabilitation costs, grants of more than $200,000, but not more than $400,000, may be available. Consolidated Grant Agreement Page 10 03/02/2010 Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North § 583.110 Grants for new construction. 0041482920000 FL0189134D000802 (a) Use. HUD will grant funds to recipients to pay a portion of the cost of new construction, including cost-effective 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 substantially less than the costs associated with rehabilitation or that there is a lack of available appropriate units that could be rehabilitated at a cost less than new construction. For purposes of this cost comparison, costs associated with rehabilitation or new construction may include the cost of real property acquisition. (b) Amount. The maximum grant available for new construction is the lower of: (1) $400,000; or (2) The total cost of the new construction, including the cost of land associated 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 reasonable 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 comparable space. (2) Leasing individual units. Where grants are used to pay -rent for individual housing units, the rent paid must be reasonable in relation to rents being charged for comparable units, taking into account the location, size, type, quality, amenities, facilities, and management services. In addition, the 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 § 583.120 Grants for supportive services 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 up to five years. All or part of the supportive. services may, be provided directly by the recipient or by arrangement with public or private service providers. (b) Supportive services costs. Costs associated with providing supportive services include salaries paid to providers of supportive services and any other costs directly associated with providing such services. For a transitional housing project, supportive services costs also include the costs of services provided to former residents of transitional housing to assist their adjustment to independent living. Such services may be provided for up to six months after they leave the transitional housing facility. [58 FR 13871, Mar. 15, 1993, as amended at 59 FR 36891, July 19, 1994] Consolidated Grant Agreement Page 11 03/02/2010 Applicant: Miami -Dade County 0041482920000 Project: FL -600 - Ren - MMHAP North FL0189B4D000802 § 583.125 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 -today operation of the supportive housing. They also include the actual expenses that a recipient incurs for conducting on-going assessments of the supportive services needed by residents and the availability of such services,- relocation assistance under § 583.310, including payments and services,- and insurance. (c) Recipient match requirement for operating costs- Assistance for operating costs will be available for up to 75 percent of the total cost in each year of the grant term. The recipient must pay the percentage of the actual operating costs not funded by HUD. At the end of each operating year, the recipient must demonstrate that it has met its match requirement of the costs for that year. [58 FR 13871, Mar. 15, 1993, as amended at 61 FR 51175, Sept. 30,1996,- 65 FR 30823, May 12, 2000] § 583.130 Commitment of grant amounts for leasing, supportive services, and operating costs. Upon execution of a grant agreement covering assistance for leasing, supportive services, or operating costs, HUD will obligate amounts for a period not to exceed five operating years- The total amount obligated will be equal to an amount necessary for the specified years of operation, less the recipient's share of operating costs. (Approved by the Office of Management and Budget under OMB control number 2506-0112) [59 FR 36891, July 19, 1994] § 583.135 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. Administrative 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 salaries associated with these administrative costs. They do not include the costs of carrying out eligible activities under §§ 583.105 through 583.125. [58 FR -13871, Mar- 15, 1993; as -amended at 61 FR -51175; -Sept: -30;-1996] -- § 583.140 Technical assistance. Consolidated Grant Agreement Page 12 03/02/2010 Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North 0041482920000 FL0189B4D000802 (a) General. HUD may set aside funds annually to provide technical assistance, either directly by HUD staff or indirectly through third -party providers, for any supportive housing project. This technical assistance is for the purpose of promoting the development of supportive housing and supportive 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 supportive 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 technical assistance to prospective applicants, applicants, recipients, or other providers of supportive housing or services for homeless persons, for supportive housing projects. The assistance may include, but is not limited to, written information such as papers, monographs, manuals, guides, and brochures; 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 assistance. HUD may enter into contracts, grants, or cooperative agreements, when necessary, to implement the technical assistance_ [59 FR 36892, July 19, 1994] 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 governments, and private resources, in accordance with 42 U.S.C. 11386. This statute provides that a recipient may use funds from any source,. including any other Federal source (but excluding the specific statutory subtitle from which Supportive. Housing Program funds are provided), as well as State, local, and private sources are not statutorily prohibited to be used as a match. It is the responsibility of the recipient to ensure that any funds used to satisfy the matching requirements of this section are eligible under the laws governing the funds to be used as matching funds for a grant awarded under this program. (c) Maintenance 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 assistance. (a) Maintenance of effort. No assistance provided under this part (or any State or local government funds used to supplement this assistance) may be used to replace State or local funds previously used, or designated for use, to assist homeless persons. (b) Faith -based activities. (1) Organizations that are religious or faith -based are eligible, on the same basis as any other organization, to participate in the Supportive Housing Program. Neither the Federal govemment nor a State or local government receiving funds'under Supportive Housing programs shall discriminate against an organization on the basis of the organization'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 proselAzation as part.of the programs or services funded under this part. If an organization conducts such activities, the activities 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 programs or services. Consolidated Grant Agreement Page 13 03/02/2010 Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North 0041482920000 FL018913413000802 (3) A religious organization that participates in the Supportive Housing Program will retain its independence from Federal, State, and local governments, and may continue to carry out its mission, including the definition, practice, and expression of its religious beliefs, provided that it does not use direct Supportive Housing Program funds to support any inherently religious activities, such as worship, religious instruction, or proselytization_ Among other things, faith - based organizations may use space in their facilities to provide Supportive Housing Program - funded services, without removing religious art, icons, scriptures, or other religious symbols. In addition, a Supportive Housing Program -funded religious organization retains its authority over its internal governance, and it may retain religious terms in its organization's name, select its board members on a religious basis, and include religious references in its organization's mission statements and other governing documents. (4) An organization that participates in the Supportive Housing Program shall not, in providing program assistance, discriminate against a program beneficiary or prospective program beneficiary on the basis of religion or religious belief. (5) Program funds may not be used for the acquisition, construction, or rehabilitation of structures to the extent that those structures are used for inherently 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 conducting eligible activities under this part. Where a structure is used for both eligible and inherently religious activities, program funds may not exceed the cost of those portions of the acquisition, construction, or rehabilitation that are attributable to eligible activities in accordance with the cost accounting 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 improvements. Disposition of real property after the term of the grant, or any change in use of the property during the term of the grant, is subject to government -wide regulations governing real property disposition (see 24 CFR parts 84 and 85). (6) If a State or local govemment voluntarily 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 applies to all of the commingled funds. (c) Participant control of site. Where an applicant does not propose to have control of a site or sites but rather proposes to assist a homeless family or individual in obtaining a lease, which may include assistance with rent payments and receiving supportive services, after which time the family or individual remains in the same housing without further assistance under this part, that applicant may not request assistance for acquisition, rehabilitation, or new construction. [58 FR 13871, Mar. 15, 1993, as amended at 59 FR 36892, July 19,1993; 68 FR 56407, Sept. 30, 2003] 583.155 Consolidated plan. ..(a) Applicants that are States or units of general local government. The applicant must have a HUD -approved complete 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 following 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 proposed project will be located that the applicant's application for funding is consistent with the jurisdiction's HUD approved consolidated plan. The certification must be made by the unit of general local government or the State, in accordance with the consistency certification provisions of the consolidated plan regulations, 24 CFR part 91, subpart F. Consolidated Grant Agreement Page 14 03/02/2010 Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North 0041482920000 FL0189B4 D000802 (c) Indian tribes and the Insular Areas of Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands. These entities are not required to have a consolidated plan or to make consolidated plan certifications. An application by an Indian tribe or other applicant for a project that will be located 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 certification under paragraph (b) of this section will apply. (d) Timing of consolidated plan certification submissions. Unless otherwise set forth in the NOFA, the required certification that the application for funding is consistent with the HUD - approved consolidated plan must be submitted by the funding application submission deadline announced in the NOFA. [60 FR 16380, Mar. 30, 1995] Subpart C—Application and Grant Award Process § 583.235 Renewal grants. (a) General" Grants made under this part, and grants made under subtitles C and D (the Supportive Housing Demonstration and SAFAH, respectively) of the Stewart S_ McKinney Homeless Assistance Act as in effect before October 28, 1992, may be renewed on a noncompetitive basis to continue ongoing leasing, operations, and supportive services for additional years beyond the initial funding period. To be considered 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 renewal 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 occupancy or the date of initial service provision, 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, subject to maintenance of effort requirements under § 583.150(a) may be for: (1) Up to 50 percent of the actual operating and leasing costs in the final year of the initial funding period; (2) Up to the amount of HUD assistance for supportive services in the final year of the initial funding period; and (3) An allowance for cost increases. (c) HUD review. (1) HUD will review the request for renewal and will evaluate the recipient's performance in previous years against the plans and goals established in the initial application for assistance, as amended. HUD will approve the request for renewal unless the recipient proposes to serve a population that is not homeless, or the recipient has not shown adequate progress as evidenced by an unacceptably slow expenditure of funds, or the recipient has been unsuccessful in assisting participants in achieving. and maintaining independent living. In determining the recipient's success in assisting participants to achieve and maintain independent living, consideration will be given to the level and type of problems of participants. For recipients with a poor record of success, HUD will also consider the recipient's willingness to accept technical assistance and to make changes suggested by technical assistance providers. Other factors which will affect HUD's decision to approve a renewal request include the following: a continuing history of inadequate financial management accounting practices, indications of mismanagement on the part of the recipient, a drastic reduction in the population served by the recipient, program changes made by the recipient without prior HUD approval, and loss of project site. Consolidated Grant Agreement Page 15 03/02/2010 Applicant: Miami -Dade County Project: FL -600 Ren - MMHAP North 0041482920000 FL0189B4D000802 (k) Outpatient health services. Outpatient health services provided by the recipient must be approved as appropriate 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 appropriateness of the proposed services. (1) Annual assurances. Recipients who receive assistance only for leasing, operating costs or supportive services costs must provide an annual assurance for each year such assistance is received that the project will be operated for the purpose specified in the application. (Approved by the Office of Management and Budget under control number 2506-0112) [58 FR 13871, Mar. 15, 1993, as amended at 59 FR 36892, July 19,1994; 61 FR 51176, Sept. 30, 1996] § 583.305 Term of commitment; repayment of ,grants; prevention of undue benefits. (a) Term of 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 McKinney Act (42 U.S.C. 11383(b)(1), 11383(b)(3)). (b) Repayment of grant and prevention of undue benefits. In accordance with section 423(c) of the McKinney Act (42 U.S.C. 11383(c)), HUD will require recipients 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 Displacement, relocation, and acquisition. (a) Minimizing displacement. Consistent with the other goals and objectives of this part, recipients must assure that they have taken all reasonable steps to minimize the displacement 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 Property Acquisition Policies Act of 1970 (URA) (42 U.S.C. 4601-4655) and implementing regulations at 49 CFR part 24. (c) Real property acquisition requirements. 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 assurance 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 wiff these provisions. (2) The cost of required relocation assistance is an eligible project cost in the same manner and to the same extent 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 demonstrate compliance with provisions of this section. Consolidated Grant Agreement Page 18 03/02/2010 Applicant: Miami -Dade County 0041482920000 Project: FL -600 - Ren - MMHAP North FL018964D000802 (e) Appeals. A person who disagrees with the recipient's determination conceming whether the person qualifies as a "displaced person,' or the amount of relocation assistance for which the .person is eligible, may file a written appeal of that determination with the recipient. A low-income person who is dissatisfied with the recipient's determination on his or her appeal may submit a written request for review of that determination to the HUD field office. (f) Definition of displaced person. (1) For purposes of this section, the term "displaced person" means a person (family, individual, business, nonprofit organization, or farm) that moves from real property, or moves personal property from real property permanently as a direct result of acquisition, rehabilitation, or demolition for supportive housing projects assisted under this part. The term "displaced person" includes, but may not be limited to: (i) A person that moves permanently from the real property after the property owner (or person in control of the site) issues a vacate notice, or refuses to renew an expiring lease in order to evade the responsibility to provide relocation assistance, if the move occurs on or after the date the recipient submits to HUD the application or application amendment designating the project site. (ii) Any person, including a person who moves before the date described in paragraph (f)(1)(i) of this section, if the recipient or HUD determines that the displacement resulted directly from acquisition, rehabilitation, or demolition for the assisted project. (iii) A tenant -occupant of a dwelling unit who moves permanentty from the building/complex on or after the date of the "initiation of negotiations" (see paragraph (g) of this section) if the move occurs before the tenant has been provided written notice offering him or her the opportunity to lease and occupy a suitable, decent, safe and sanitary dwelling in the same building/ complex, under reasonable terms and conditions, upon completion of the project. Such reasonable terms and conditions must include a monthly rent and estimated average monthly utility costs that do not exceed the greater of: (A) The tenant's monthly rent before the initiation of negotiations and estimated average utility costs, or (B) 30 percent of gross household income. If the initial rent is at or near the maximum, there must be a reasonable basis for concluding at the time the project is initiated that future rent increases will be modest. (iv) A tenant of a dwelling who is required to relocate temporarily, but does not return to the building/complex, if either: (A) A tenant is not offered payment for all reasonable out-of-pocket expenses incurred in connection with the temporary relocation, or (B) Other conditions of the temporary relocation are not reasonable. (v)A tenant of a dwelling who moves from the building/complex permanently after he or she has been required to move to another unit in the same building/complex, if either: (A) The tenant is not offered reimbursement for all reasonable out-of-pocket expenses incurred in connection with the move; or (B) Other conditions of the move are not reasonable. (2) Notwithstanding the provisions of paragraph (f)(1) of this section, a person does not qualify as a "displaced person" (and is not eligible for relocation assistance under the URA or this section), if. (i) Termination of housing assistance Consolidated Grant Agreement Page 19 03/02/2010 w Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North 0041482920000 FL0189B4D000802 The recipient may terminate assistance to a participant who violates program requirements. Recipients should terminate assistance only in the most severe cases. Recipients may resume assistance to a participant whose assistance was previously terminated. In terminating assistance to a participant, the recipient must provide a formal process that recognizes the rights of individuals receiving assistance to due process of law. This process, at a minimum, must consist of: (1) Written notice to the participant containing a clear statement of the reasons for termination; (2) A review of the decision, in which the participant is given the opportunity to present written or oral objections before a person other than the person (or a subordinate of that person) who made or approved the termination decision; and (i) The person has been evicted for serious or repeated violation of the terms and conditions of the lease or occupancy agreement, violation of applicable Federal, State, or local or tribal law, or other good cause, and HUD determines that the eviction was not undertaken for the purpose of evading the obligation to provide relocation assistance,- (ii) ssistance; (ii) The person moved into the property after the submission of the application and, before signing a lease and commencing occupancy, was provided written notice of the project, its possible impact on the person (e.g., the person may be displaced, temporarily relocated, or suffer a rent increase) and the fact that the person would not qualify as a "displaced. person" (or for any assistance provided under this section), if the project is approved; (iii) The person is ineligible under 49 CFR 24.2(g)(2); or (iv) HUD determines that the person was not displaced as a direct result of acquisition, rehabilitation, or demolition for the project. (3) The recipient may request, at any time, HUD's determination of whether a displacement is or would be covered under this section. (g) Definition of initiation of negotiations. For purposes of determining the formula for computing the replacement housing assistance to be provided to a residential tenant displaced as a direct result of privately undertaken rehabilitation, demolition, or acquisition of the real property, the term "initiation of negotiations" means the execution of the agreement between the recipient and HUD. (h) Definition 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. [58 FR 13871, Mar. 15, 1993, as amended at 59 FR 36892, July 19, 1994] § 583.315 Resident rent. (a) Calculation of resident rent. Each -resident of "supportive housing maybe required to pay as rent an amount determined 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 adjusted income must include the expense deductions provided in 24 CFR 5.611(a), and for persons with disabilities, the calculation of the family's monthly adjusted income also must include the disallowance of earned income as provided in 24 CFR 5.617, if applicable;. Consolidated Grant Agreement Page 20 03/02/2010 Applicant, Miami -Dade County 0041482920000 Project: FL -600 - Ren - MMHAP North FL0189134D000802 (2) 10 percent of the family's monthly gross income; or (3) If the family is receiving payments for welfare assistance from a public agency and a part of the payments, adjusted in accordance with the family's actual housing costs, is specifically designated by the agency to meet the family's housing costs, the portion of the payment that is designated for housing costs. (b) Use of rent. Resident rent may be used in the operation of the project or may be reserved, in whole or in part, to assist residents of transitional housing in moving to permanent housing. (c) Fees. In addition to resident rent, recipients may charge residents reasonable fees for services not paid with grant funds. (58 FR 13871, Mar_ 15, 1993, as amended at 59 FR 36892, July 19,1994; 66 FR 6225, Jan. 19, 2001) § 583.320 Site control. (a) Site control. (1) Where grant funds will be used for acquisition, rehabilitation, or new construction to provide supportive housing or supportive services, or where grant funds will be used for operating costs of supportive housing, or where grant funds will be used to provide supportive services except where an applicant will provide services at sites not operated by the applicant, 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 notification of the award of assistance under this part, the grant will be deobligated as provided in paragraph (c) of this section. (2) Where grant funds will be used to lease all or part of a structure to provide supportive housing or supportive services, or where grant funds will be used to lease individual housing units for homeless persons who will eventually control the units, site control need not be demonstrated. (b). Site change. (1) A recipient may obtain ownership or control of a suitable site different from the one specified 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 provide for all additional costs. If the recipient 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 site control within one year. HUD will recapture or deobligate any award for. assistance under this part if the recipient is not in control of a suitable site before the expiration of one year after initial notification of an award. § 583:325 Nondiscrimination and equal opportunity requirements. (a) General. Notwithstanding the permissibility of proposals that serve designated populations of disabled homeless persons, recipients serving a designated population of disabled homeless persons are required, within the designated population, to comply with these requirements for nondiscrimination on the basis of race, color, religion, sex, national origin, age, familial status, and disability. Consolidated Grant Agreement Page 21 03/02/2010 Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North 0041482920000 FL0189B4D000802 (b) Nondiscrimination and equal opportunity requirements. The nondiscrimination and equal opportunity requirements set forth at part 5 of this title apply to this program. The Indian Civil Rights Act (25 U.S.C. 1301 et seq.) applies to tribes when they exercise their powers of self- government, and to Indian housing authorities (IRAs) 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 determined on a case-by-case basis. Projects subject to the Indian Civil Rights Act must be developed and operated in compliance with its provisions and all implementing HUD requirements, 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 origin, familial status, or handicap who may qualify for admission to the housing, the recipient must establish additional procedures that will ensure that such persons can obtain information concerning availability of the housing. (2) The recipient must adopt procedures to make available information on the existence and locations of facilities and services that are accessible to persons with a handicap and maintain evidence of implementation of the procedures. (d) Accessibility requirements. The recipient must comply with the new construction accessibility requirements of the Fair Housing Act and section 504 of the Rehabilitation Act of 1973, and the reasonable accommodation and rehabilitation 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 rehabilitation are 75 percent or more of the replacement cost of the building must meet the requirements of 24 CFR 823(a). Other rehabilitation must meet the requirements of 24 CFR 8.23(b). [58 FR 13871, Mar. 15, 1993, as amended at 59 FR 33894, June 30, 1994; 61 FR 5210, Feb. 9, 1996; 61 FR 51176, Sept. 30, 1996] § 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 requirements: (a) Flood insurance. (1) The Flood Disaster Protection Act of 1973 (42 U.S.0 4001-4128) prohibits the approval of applications for assistance for acquisition or construction (including rehabilitation) for supportive housing located in an area identified by the Federal Emergency Management Agency (FEMA) as having special flood hazards, unless: (i) The community in which the area is situated is participating in the National Flood Insurance Program (see 44 CFR parts 59 through 79), or less than a year has passed since FEMA notification regarding such hazards; and (ii) Flood insurance is obtained as a condition of approval of the application. (2) Applicants with supportive housing located in an area identified by FEMA as having special flood hazards and receiving assistance for acquisition or construction (including rehabilitation) are responsible for assuring that flood insurance under the National Flood Insurance Program is obtained and maintained. (b) The Coastal Barrier Resources Act of 1982 (16 U.S.C. 3501 et seq.) may apply to proposals under this part, depending on the assistance requested. Consolidated Grant Agreement Page 22 03/02/2010 Appti;ant: Miami -Dade County Project: FL -600 - Ren - MMHAP North 0041482920000 FL0189B4D000802 (c) Applicability of OMB Circulars. The policies, guidelines, and requirements of OMB Circular No. A-87 (Cost Principles Applicable to Grants, Contracts and Other Agreements with State and Local Governments) and 24 CFR part 85 apply to the award, acceptance, and use of assistance under the program by governmental entities, and OMB Circular Nos. A-110 (Grants and Cooperative 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 acceptance and use of assistance by private 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. Publications, 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. 4821- 4846), the Residential Lead- Based Paint Hazard Reduction Act of 1992 (42 U.S.C. 4851-4856), and implementing regulations at part 35, subparts A, B, J, K, and R of this title apply to activities under this program. (e) Conflicts of interest. (1) In addition to the conflict of interest requirements in 24 CFR part 85, no person who is an employee, agent, consultant, officer, or elected or appointed official of the recipient and who exercises or has exercised 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 activities, may obtain a personal or financial interest or benefit from the activity, or have an interest in any contract, subcontract, or agreement with respect thereto, or the proceeds thereunder, either 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. Participation by homeless individuals who also are participants under the program in policy or decisionmaking under § 583.300(f) does not constitute a conflict of interest. (2) 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 efficient administration of the recipient's project. An exception may be considered only after the recipient has provided the following: (i) For States and other govemmental entities, a disclosure of the nature of the conflict, accompanied by an assurance that there has been public disclosure of the conflict and a description of how the public disclosure was made; and (ii) For all recipients, an opinion of the recipient's attorney that the interest 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)(2) of this section, HUD will consider the cumulative effect of the following factors, where applicable: (i) Whether the exception would provide a significant cost benefit or an essential degree of expertise to the project which would otherwise not be available; (ii) 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) lass; (iii) Whether the affected person has withdrawn from his or her functions or responsibilities, or the decisionmaking process with respect to the specific assisted activity in question; (iv) Whether the interest or benefit was present before the affected person was in a position as described in paragraph (e)(1) of this section; (v) Whether undue hardship will result either to the recipient or the person affected when weighed against the public interest served by avoiding the prohibited conflict; and Consolidated Grant Agreement Page 23 03/02/2010 Applicant: Miami -Dade County Project: FL -600 - Ren - MMHAP North (vi) Any other relevant considerations. 0041482920000 FL0189B4D000802 (f) Audit. The financial management systems used by recipients under this program must provide for audits in accordance with 24 CFR part 44 or part 45, as applicable. HUD may perform or require additional audits as it finds necessary or appropriate. (g) Davis -Bacon Act. The provisions of the Davis -Bacon Act do not apply to this program. [58 FR 13871, Mar. 15, 1993, as amended at 61 FR 5211, Feb. 9, 1996; 64 FR 50226, Sept. 15, 1999] Subpart E—Administration § 583.400 Grant agreement. (a) General. The duty to provide supportive 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 appropriate, including repayment of funds that have already been disbursed to the recipient. § 583.405 Program changes. (a) HUD approval. (1) A recipient may not 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 1.0 percent of funds from one approved type of activity to another, and a change in the category of participants 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 contingent upon the application ranking remaining high enough after the approved change to have been competitively selected for funding in the year the application was selected. (b) Documentation of other changes. Any changes to an approved program that do not require prior HUD approval must be fully documented in the recipient's records_ [58 FR 13871, Mar. 15, 1993, as amended at 61 FR 51175, Sept. 30, 1996] § 583.410 Obligation and deobligation of funds. (a) Obligation of funds. When HUD and the applicant execute a grant agreement, funds are obligated to cover the amount of the approved assistance under subpart B of this part. The recipient will be expected to carry out the supportive housing or supportive services activities as proposed in the application. (b) Increases. After the initial obligation of funds, HUD will not make revisions to increase the amount obligated. (c) Deobligation..(1) HUD may deobligate all or parts of grants for acquisition, rehabilitation, acquisition and rehabilitation, or new construction: Consolidated Grant Agreement Page 24 03/02/2010 Applicant: Miami -Dade County 0041482920000 Project: FL -600 - Ren - MMHAP North FL018984D000802 (i) if the actual total cost of acquisition, rehabilitation, acquisition and rehabilitation, 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, operating costs or supportive services for that year are less than the total cost anticipated in the application; or (ii) if the proposed supportive housing operations are not begun within three months after the units are available 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 availability under § 583.200, or (ii) Award deobligated funds to applications previously submitted in response to the most recently published notice of fund availability, and in accordance with subpart C of this part Consolidated Grant Agreement Page 25 03/02/2010 GRANT NUMBER M189B4D000802 City of Miami - Miami Metra Homeless Assistance Program North ATTACHMENT A-1 SCOPE OF SERVICES The Subrecipieut shall provide outreach assessment and placement into housing of homeless persons (individuals and families) comprised of 5,250 contacts, 2,625 assessments and 750 placements with seven (7) day follow up. The Subrecipient will accept referrals from emergency shelters, transitional housing facilities, outreach teams and other service providers in the Continuum of Care. The Subrecipient shall provide a outreach, assessments and placements of homeless persons under this Agreement over the term of the one (1) year grant. The Subrecipient shall provide services as proposed in the application to U -S_ HUD pursuant to the 2009 Super NOFA (incorporated herein by reference), including but not limited to: 1 _ Extensive outreach; 2_ Initial assessment and evaluations; 3. Referral and placement in housing where appropriate and available; 4_ Referrrai to all appropriate and available services; 5. Transportation services; 6. Seven (7) day follow up Conditions: 1. Reimbursement shall be limited to operations, supportive services, leasing, administration, and the costs associated with these activities as described in the Subrecipient's application, 2. Reimbursement shall be made only for the nacurre for operations, mlmmistrahcgl, and supportive services actually provided to clients; unless the d7antee agrees, in writing, to another mode of payment, as provided for in this Agreement; 3. Monthly progress reports and program narratives signed by the Executive Director of the Subrecipienfs agency shall be submitted by the Subrecipient, as required; 4. The Subrecipient will serve clients referred by the Grantee within available resources. or its designee for housing and/or services through the Grantee's established referral process; 5. Services shall be provided in accordance with the timeline submitted by the Subrecipient.- 6. ubrecipient;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. ATTACHMENT A-2 Technical Project Number: FL0189B4D000802 Submission Project Identifier: FL14077 Exhibit l: Proiect Summary 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 HMIS projects) Section D is composed of three charts. Chart 1 is for recording the housing type_ Chart 2 is for recording the number of unitvbeds/bedrooms in the project. Do not complete Chart 2 if the project is for supportive services only (SSO). Chart 3 is for recording the number of participants to be served. Information on nll projects should be entered in this section except for HMS activities. Chart 2: Units, Bedrooms, Beds " a Current Level (Point -in -Time) b. New Effort or Change in Effort (Lf Applicable) c. Projected Level (col. a+col. b) Number of Units N/A N/A N/A Number of Bedrooms N/A N/A NIA 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 "NIA' in the appropriate cells. Chart 3: Participants a_ Current Level (point- in -time) b. New Effort or Change in Effort (If Applicable) c. Projected Level (col. a+ col. b) a. Number .of Families with Children (Family Households) 239 N/A 239 i. Number of adults in families 1239 NIA 1 239 ii. Number of children in families 1273 N/A 1 273 ill. Number of disabled in families 194 1 94 b. Number of Single Individuals and Other Households w/o Children 1511 NIA 1 511 i. Number of disabled individuals 1118 NIA 1 118 ii. Number of chronically homeless 162 N/A 1 62 HUD -40090-3 a 9 ATTACHMENT A-3 Project Number: FL0189B4D000802 Technical Project Identifier: FL14077 Submission Exhibit 1: Project Summary (RENEWALS ONLY) C. Program Goals - Goal: Residential Stability Conduct outreach activities to at least 5,250 total homeless persons (individuals and families), with the intent to provide an entry point to residential stability. Assess at least 2,625 contacted homeless persons (individuals and families) for social services and housing needs. Place at least 750 homeless persons (individuals and families) into emergency housing, transitional housing, permanent housing or other housing opportunities in the continuum of care. Goal: Increase skill and income Provide outreach, assessment, and placement with seven (7) follow up services for at least 750 homeless persons (individuals and families). Of those that were available for the 7 day follow up at least 11% (83), of the eligible, assessed, placed participants will be linked to the agencies that provide employment. At least 25% (188), of the eligible, assessed, placed participants will be linked to agencies that provide other sources of income or benefits. Goal: Achieve greater self-determination Provide outreach, assessment, and placement with seven (7) follow up services for at least 750 homeless persons (individuals and families), which will link them to individual service plans that ensure 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 5 ATTACEBIENT A-4 PROJECT MILESTONES N/A FOR THIS PROJECT ;YJ R Ji±C Ri2i falip-1 Ir -42-5 41111 * .1_1j kiil� Irri ICE J02 [.I 5- 1 J, -I ni� Technical Submission for the 2009 ki Supportive Housing Program sir!'U.S. Department of Housing and Urban Development 1; J I i it Office of Community Planning and Development Project Sponsor: City of -M- _i ami -;R�, Project Name:' :.Miami Metro Homeless Assistance WL �L Program North (MMH P — North) R±JV AP -N Wz1_1_4J laRr.\ 5211J, Project Type: le -N J, Supportive Services Only (SSO) Project Number: FiiiJJJul'9B4DO00802' W t I A M I I :DAQ E�Ok Submitted by Selectee: M Vii: ee Miami -Dade County Homeless Trust Ill Northwest First Street, 27th Floor, Suite 310 Miami Florida3312& Telephone Number: (305) 375-1490 Fax Number: (305)375 -2722 L.- �Vj K. f1 Ep* AN R Ji±C Ri2i falip-1 Ir -42-5 41111 * .1_1j kiil� Irri ICE J02 [.I 5- 1 J, -I ni� Project Number: FL0189B4D000802 Technical Project Identifier: FL14077 Submission Exhibit 1: Project Summary 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. B. Project Budget This section must be completed by all renewal selectees. 1. Chart 1 - Summary Project Budget To complete Chart 1, Summary Project Budget, enter the amount of SHP funds requested by line -item in the first column. For leasing, supportive services, operations, and MUS, 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 HMUS apply to renewal projects.. The amounts you enter are for all structures in your project. Each line item an, ount in this chart should match the amounts shown in Your original application as approved or Exhibits 3.4. 5 and 6. Requested grant term (1, 2, or 3 years): 1 . Chart 1 - Summary Proiect Budget - combined *By law, SHP can pay no more than So% of the total supportive services or total HMIS .budget. **By law, SHP can pay.no more than 75% ofthe total operating budget. ***By law, SHP can pay rio more than 5% ofthe total SHP request HUD -40090-3a 3 WKM SHP Request I Applicant Cash Total Project Budget 1. Real Pro erty Leasing . 2 Supportive Services* 278,724 69,681 1 348,405 3. Operations** 4_ HMIS* 5. SHP Request (subtotal lines I thru 4) 278,724 69,681 348,405 6. Administration"* (up to 5%of line 5) 13,936 - 13,936 7. Total SHP Reciuest (total lines 5 and 6) 292,660 69,681 362,341 *By law, SHP can pay no more than So% of the total supportive services or total HMIS .budget. **By law, SHP can pay.no more than 75% ofthe total operating budget. ***By law, SHP can pay rio more than 5% ofthe total SHP request HUD -40090-3a 3 Technical Submission Project Number: FL0189B4D000802 Submission Project Identifier: FL14077 Exhibit 4: Supportive Services A. Supportive Services Budget Chart 4A: HUD -40090-3a 12 City of Total Supportive Service Expense Miami (1 year) Service Activity: Community Outreach 79,747 Specialist 1 Quantity: 4.0 FTE @ $24,921 plus taxes and fringe benefits - change in project sponsor = S99,684 Service Activity: Community Outreach 137,030 Specialist 2 Quantity: 6.0 FTE @ $28,548 plus taxes and fringe benefits= S171,288 Service Activity: Communication for Outreach 12,269 Quantity: phone lines, cell phones, radios, network between office and outreach staff = $15,336 Service Activity: Equipment & Related 12,269 Services Quantity: boitled water machines and services, copier machine, additional computer software and management equipment = S15,336 Service Activity: Residential Stability follow- 12,269 UP Quantity: Items needed to conduct 7- day follow up services for participants placed in various locations in the continuum of care, including residential supplies — blankets, possible transportation needs = $15,336 Service Activity: Postage & Related Services 601 Quantity: mailing of materials printing and reproduction, brochures etc- ta$75I $751 Service Activity: Supplies 12,269 Quantity: safety equipment, first aid kits, sanitary supplies, stationary or office supplies etc = 515,336 Service Activity: Transportation 12,269 Quantity: for transporting participants _ $15,336 SHP REQUEST- 278,724 Selectee's Match (Line 1 I minus Line 9) 69,681 Total Supportive Services Budget 348,405 HUD -40090-3a 12 Project Number: FL0189B4D000802 Technical Project Identifier: FL14077 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 I through 8. In the first column, fill in the administrative activity to be paid for using SHP funds. In the Year l 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 forthe 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. Year I Total Administrative Costs (a) (d) Administrative Activity_ Miami -Dade County $6,968 $6,968 Homeless Trust 2.5% staff time spent reviewing/verifying invoices, preparation of APR, and audit of SHP grant funds. Administrative Activity City of Miami (M?vII-IAP- $6,968 1 1 $6,968 North) Preparation of Annual Progress Report, audit of SHP, staff time spent reviewing/verifying invoices for grant funds 2.5% (9 months) SBT REQUEST FOR ADMINISTRATIVE $13,936 I I I $13,936 COSTS I i Amount for Selectee J. $6,968 1 . 1 1 $6,968 Amount for Project Sponsor 1 $6,968 1 I J $6,968 B. Plan for Distribution of Administration Funds If the selectee is not.the same organization -as the project sponsor, attach. a.description.ofthe. 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 13 ,.tOG �SN�S tNAPS Spt3c — #Needs Assistance Program Request Voucher for Grant Payment See Insinriions and Public Reporting Burden Statement on back 1. Voucher Number 2 tOCCS Pgrm. Area 3 1 SNAP HPAC II I I. I i IHP 5. Voice Response No. (5 digits, hyphen, 5 more) 16. Grantee Organizad 8. Grant No. u.A. V%:jAM..1.u. — ..w....., and Urbw Devek4miefd office of Community Planning and Development ATTACHMENT C Period Covered by ft.is Request (dales) I A. Type of Distwrsement Partial F-] Final Name Grandee Organization's TIN 9. Line ttemno. Type unsague T of Funds Requested Amount (round to nearest dotfarj to. voucher I 01 I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. Warming: HUDwill prosecLgefatse claims and statemerrts. Conviction may resuttin criminadand/orcivV penalties. f18 U_S.C.1001,1010,1012; 31 U.S.C. 3729, 3802)- i i. 802)`11. Name & Phone Number (including area code) of the Authorizedj t2 Signature 113. Date of Request Person who called SNAPS System VRS X Privacy Statement: Public Law 97-235, Financial Integrity Act, 31 U.S.C. 3512, authorizes the Department of Housing and urban Development (HUD) to collect alithe 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 amass capability promptly deleted. Pro.visionofthe SSN ismandatory- HUD uses itas a uniqueidsn#ifr fonsaarrigiaC#r,�CS tro,unautharized�s. Failure to provide the infomation requested may delay the processing of your appmvai for access to LOCCS. This information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. form HUIR27053-IA (2195 Retain this term in your records farata,rft•+aur�ses page 1 of 2 ) 1010 Acquisition 1020 Rehabilitation 1021 New Canstructon 1022 Substantial Rehabilitation 1023 Moderate Rehabiiitaaon 1030 Operating Gost i 11A11 to. voucher I 01 I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. Warming: HUDwill prosecLgefatse claims and statemerrts. Conviction may resuttin criminadand/orcivV penalties. f18 U_S.C.1001,1010,1012; 31 U.S.C. 3729, 3802)- i i. 802)`11. Name & Phone Number (including area code) of the Authorizedj t2 Signature 113. Date of Request Person who called SNAPS System VRS X Privacy Statement: Public Law 97-235, Financial Integrity Act, 31 U.S.C. 3512, authorizes the Department of Housing and urban Development (HUD) to collect alithe 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 amass capability promptly deleted. Pro.visionofthe SSN ismandatory- HUD uses itas a uniqueidsn#ifr fonsaarrigiaC#r,�CS tro,unautharized�s. Failure to provide the infomation requested may delay the processing of your appmvai for access to LOCCS. This information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. form HUIR27053-IA (2195 Retain this term in your records farata,rft•+aur�ses page 1 of 2 ) searching exsong date sources, gathering anti marmnng menot collect this information, and you are not required to oomplete this form, unless It displays a currentty valid OMB control number. This information collection is to request payment of grant funds orb designate the appropriate officals who can have access to HUD voice activated payment system. The HUD voice activated payment system has been especially designed to help the recipient when calling in for a request of funds and improves the payment process so the recipient will know right away whether their request will be paid or not. This information collection is required under 24 CFR Subpart C, 85.21 - Post Award Requirements, the information collection is needed In order to obtain or retain a benefit. Instructions for the Request Voucher for Grant Payment for the Special Needs Assistance Program (SNAPS) item 1. Voucher Number. The first 3 digits are the prefix to your program. Enter '001' d grant funds are being requested for a grant awarded under a SHDP or SHP (TH, PH, SAFAH and Renewal) grant Enter '038' 9 funds are being requested for a Housing Opportunity for Persons with AtDs (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' (036) for HOPWA competitive grant requests, and `IHP' (054) for Innova- tive Homeless Programs. Item 3. Erder the period covered by this request. Item 4. Type of Disbursement: Gheck 'partial' until the final request for grant funds is made_ 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 (BUs). LOCCS associates a 4 - digit number with each line item. Eater the amount requested in each category (lines 1010 through 1120) and the total funds requested under item 10, Voucher Total. Item 11- Name & phone number (including area Code) of the authorized person who completed the call-in to VRS. The authorized person is shown on line 3 oiforrn HUD -27054 - Item 12. Signature of the person identified in item 11 - item 5_ Voice Response No: Enter the 10 digit Voice Response System (VRS) project number wtach was sent to you by hem 13. Date of this Request: Enter the date of the call-in to mail. Your regular HUD project number will be repeated request funds. back for verffication after the VRS project number is entered. Retain this form in your records for audit purposes page 2 of 2 form HUD -270537A (2195) MONTHLY INVOICEMIAMI-DADS MELESS MONTH: T R U S T PROVIDER NAME: PROGRAM NAME: ATTACHMENTCONTRACT# C -1 NT/PROJECTS 4/MGG82.M PM HTIPROJECTS 41120082;01 PM �� t�• •.il �•�ti I ATTACHMENTOD�o�ernment! Home CllentPolnt F;esourcePoint Shelt�rPo,nt SkanEoint /?.=_pcs dein t ;-;p HUD Annual Progress Report (HUD -4011S) Report Options: Select- r.- Unduplicated I rovider Miami -Dade County Government (%1) perating Year Date Rance 05/01/2006 to 05/31/2006 (rnm/dd/yyyy) gal Adult Age 18 (as defined by foster tare /aw in your state) Or -Select- ! 2. Persons Served during the Number of Singles Number of Adults Number of Children in Number 0. operation year. Not in Families in Farnities Families Families a_ Numberon the first day of the D 0 j operating year. D 11 I 0 ii. Numberentering program during the 0 II dpe2ting year, 0 0 1 c. Number who left the program during y� 0 0 0 the operat)ng year. D III d. Numberin the program on the last day D 0 0 -0 of the operating year. (a+b-c=d) I '. Project Capacity. dults Number of Singles Number of.Adults Number of Childrein n Number of Not in Families in Families Families Families a. Number on last day (from 2d, columns J 1 and 4) D { III I D 4. Non -homeless persons. (Sec. 8 SRO projects only) How many Income -eligible non -homeless persons were housed by the SRO program during the operating year? 0 S. Age and gender. Age [Male Female Other/Nbt given Single.Persons (from.2b, column.l_)_ a. 62 and over I 0 0 0 b. 51 - 61 0 I 0 0 Ic. 31 50 0 0 I 0 Id -.13 - 30 0 0 0 e. 17 and under 0 I 0 0 INot given 0 0 0 Persons in Families (from.2b, colvmrLs 2 & 3) If. b2 end over I O I 0 I p g. 51 61 0 0 0 I h.31 50 1 0 1 0 0 ]Imps: //r,�ti,v',.;.ser-�rJ cult. coiia/T111ami /scripts/svpreporiliud. php 6!14000) J 1j. 13 - 17 I 0 0 I J li Ik, h 12 _ I C' I1. 1•: I 0 1 0 0 I m. Under 1. 1 U n I 0 Not given I 0 , 0 I- 0 I jNon-Hispanic erans Status. n i; anyone who has ever been on ective miliary duty status. nically Homeless. y participants were chronically homeless individuals? city_ ic or Latino ispanic or Non -Latino a. American Indian or Alaskan Native b. Asian c- Black or African American Id. Native Hawalian or Other Pacific Islander e. White f. American Indion/Alaskan Native & White g_ Asian & White h: Black/African American & white i. American Indian/Alaskan Native & Black/African American j. Other Multi -Racial k- Other/Unknown (all that do not match) 9a. Special Needs. a, Mental illness b. Alcohol abuse c. Drug abuse d. HSV/ATGS or related diseases e. Developmental disability f. Physical disability g. Domestic violence h: Other (please speciFy) 9b. Disabled. �H�owmany of the participants are disabled? 10. Prior Living Situation. a. Non -housing (street, park, car, bus station, e(c.) b. Emergency shelter c.. Transitional housing for homeless persons d. Psychiatric facility e. Substance abuse treatment facility f. Hospital g. Jail/prison h. Domestic violence situation i. Living v4th relatives/friends j. Rental housing Ali Chronic 0 :0 0 l0 0 I =0 D 0 0 0 0 0 �� -- 0 0 1 0 All j Chronic 0 0 0 0 G 0 0 0 0 0 G I 0. 0 https://titi��.sen icer t.com/mIami/scripts/svpre.parthud.php 6/14/2006 M I vi monthly Income at Entry and Ezit. Amount A. 14onthly Income at Entry All Chronic Ia. No IncomE I b. $1-150 c. $i51 S250 d.$251 $500 e. $501 - S1000 f. $1001 $150D g. $1501 - 52000 h. $2000 + II, Source i Ia. Supplemental Security Income (SSI) b. Social 5ecurlty Disability Insurance (SSDI) c. Social Security d. General Puhllc Assistance e. Temporary Aid to Needy Families (TANF) f. State Children's Health Insurance Program (SCRIP) g. Veterans benefits h. Employment Income L Unemployment Benefts j. Veteran's Health Care k. Medicaid J. Food Stamps m. other (please specify) n. No financial resources 0 , 0 I C' G p 0 U 0 4 � Q o G 0 D 0 0 C. Income Sources at Entry All Chronic 0 0 -- 0 0 0 0 � D 0 ,. p 0 0 , 0 0 I D 0 p 0 p 0 a. Less than 1 month 0 I p o p D � 0 0 B. monthly income at Exit All Chronic 0 i 0 0 ' 0 0 0 0 f 0 0 I 0 o � o G � p 0 � p D. Income Sources at Exi# All ( Chronic 0 D 0 D 0 ! D D _ D �^ 0 u I 0 0 0 �) D j D jJ 0 � 0 0 I 0 D o ) 12a. Length ofStay in Program. (Participants who le; during operating year) . All { -Chronic a. Less than 1 month 0 I 0 b. 1 tomonths 0 0 .2 c. 3 - 6 months 0 0 d. 7 months - 12 mcntns 01, D e, 13 months - 24 months I 0 ( D f. 25 months = 3 years 0 I 0 D D g. 4 years - 5 years I 0 0 h. 6 years - 7 years 0 I D Ii. 8.years' 10 years f 0 D j, over 10 years I 12b: Length-ofStay''in Pitigram. (Participant ,who did not leave during operating year) All I Chronic a. less than 1 month D 0 b. 1 to Z months I 0 0 c. 3- 6 months I 0 I 0 d. 7. months - 12 months 0 0 II e. 13 months - 24 months f 0 0 f. 25 months - 3 years I 0 0 g.'4 years - 5 years D D https:/AvN-n,v3.se.rvi cept.c.oni/miuni/s.cripts/svpreporthLid .php 6/14/2 006 IT 9V2r 10 0 13. Reasons for Leavino. All Chronic a. Left fora -housrno opportunity b=fore completing program rj f G b. Completed program G 0 c. lJon-payment of rent/occupancy charge 0 r d. IJen-compliance .vith project 0 0 e. Criminal activity J destruction of property / violence 0 0 f. Peached maximum time allowed in project 0 0 g. Needs could not be met by project 0 0 h- Disagreement with rules/persons 0 0 i. Death 0 0 j. Other (please specify) 0 0 k. Unknown/disappeared 0 0 14. Destination. 71 All Chronic PERMANENT (a - h} a_ Rental house or apartment (no subsidy) 0 0 b. Public Housing 0 I 0 c- Section 8 0 0 Id- Shelter Plus Care 0 0 HOME subsidi=ed house or aparnent 0 I 0 le f, other subsidized house or apartment 0 ' " 0 �9. Homeownership 0 0 h Moved in with family or friends 0 0 TRANSITIONAL (i - j) �i. Transitional housing for homeless persons 1j. gloved in with arnlly or friends { 0 0 INSTITUTION (k - m} k- Psychiatric hospital ! 0 0 �1. inpatient ielcohoi/drug treatmEr)-72cility 0 D Irn- )ail/.prison M 0 i 0 EMERGENCY SHELTER (n) . in. EFiergency shelter i 0 0 OTHER {n - q) o. Other supportive housing 0 . 0 �p-Places not meant for human habitation (e.g. street) 0 0 q. Other (please specify) ++ 0 1 0 UNKNOV.✓r�t r. Unknown 0 0 15. Supportive Services. No supportive services Found. ServicePoint version 4.01.013 (db build #0723) Licensed to: Miami Dade Homeless Trust Q 1949-7006 l3owman Systems L-.L.C. All Rights Reserved. CPT onk, '5)200d Arnencan Mcdlcal ASSOCiatipn, All RiehtS res3vr_d. 0511 and D5P)-IV-TR. are reor5tered cr3oe nark= or the Ame^can psychia_ric Association, and are used svlih permission l reln. m trc_ ( jCD-o ,�.:VVNU Health U ganiarion). All Rlghts Reserved. ICL?•S-Ci � Z1 9,n4 Natrona! Cen[er for i-icalih 5tat.s, Taxonomy + il'e 'u^^C3 :ororr:,ation and Rererral Federatlor, of Lo:; Anoelas County, Inc. All.Ftignts RCELrletl, htips:,,'A?n iv3.servicept.com/niianli/scripts/svprep0rthud.php _MLANTI-DA DE COUN'TY' HO MELESS TR ST PROGRANT R-ATRATG OF SA TISF_AC TIO INSTR C CTI 0 N ti C:irefull), read all of the instructions below BEFORE distriburM , rhe Pro -cram R2rin.n_ OfSurisficrion 5tjr-Vev to your prograa participants. Cenci -al Information The Yronram Dating of Satisfaction consists of 1 1 items which ars used to detcrn;ine a client s, t1-', ion (With ser,?ices they are recelvM2 from a pro��ider. It is to be completed b-\ all program participant-. ent,j, cfd I seMces at a Trusi-funded proLTam. It must be completed - at a minimum - at rime of discharg e foo- al l Participants. It is strongly recommended that a Program Rating of Satisfaction survey also be completedca intervals as may be applicable to the program- howEver. only the discharge survey must be for\vardNd to the Homeless Trust. Case management notes should indicate specifically ,v hj a Projarn Rating of Satisf3etion was not obtained, if that is the case (client went A_W'OL. institutionalized, etc.), and tQiar efforts \sere 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 %nlc �f a participant ca-?rlot read; providers should encourage them to use the s`me process they use to have other information read to them. A, employee of the agency that is not directly responsible for the clieni's care can read the fo,This should be indicated in Section Ii. as a separate set of staff initials. .Falling out the form 1) A Ianauaqe appropriate survey and an envelope should be prop-ided to all participants who are required to complete the for1n. 0711y one form per family is _required. ! he form must be filled out isn ?) Section I1 of.the Program }Latina of Satisfaction is to be cotnplcte.d by staffprior.to providing the survey document io the program paiicipant. StaTfinitials, refers.to the initials of the case manager, responsible for the client's service delivery If the survey must be read to the client, the initials of the staffperson performing that function should also be included. In no case should the participant's case m_anagerread itenls.aloud to the participant. S) Section I of the Program Rating of Satisfaction Form is to be fined out ONLY by the pro,ram participant. The program participant should be provided a private place and sufficient tinrz to arnswer the survey. -!) Providers should reassure participants of the confidentiality of their responses. Providers may wish to introduce the survey, as follows: `This suJ-v ey Is one Ova} of helping us determine how -well u e are helpin individuals that come to our agency for assistance. Picase take a fev, nninutcs after I feave.to.ans iter. this ver, short survey as honestly as possible. Your responses are priVate and ivc vvi11 not look at them. Please seal the envelope.and give it to me when you are done (or: put it in the drop boy:). ' �j The completed survey should be placed in the envelope b"' the recipient and sealei. Prop iders are encoura`red to provide a "drop box" with a slot for completed forms. ) The sealed envelope(s) should be forwarded to the Mianu-Dad:: County HomeleSs, Trust or a rnonthl�- basis. %) The provider acency should maintain a loir ofha�v m3n�� sur<e,s are dislr:buted. DET1=FOJJ` ATIUOF MINI1 U? ] ., � LILaUL C0�`SL'1IEP. S.ATISFACTIO� SLR\ E1 I1/6/OC �f�i�ltUt(ili77C!%t i!4'�' S�•C!t I was informed of mv rights and responsibilities I 1 was provided with information about different sen -ices I hi,4 i � U I that are available for me I was im,filved in makinc, decisions about mvc3re/serrice Ian � 1 I was able to talk with staff when I needed to - 2.18 The building and facilities hive usually been cicnn, safe and a comfortable My rights were respected and protected, including my right N%A to file a grievance, if needed 1 �! My case manager seems oualified to help me i j 5. 3 6 I would recommend fhis program to others � 5 I am treated with respect by the staff The staff seems to care about whether I tet better I 20 Prouram staff weIre knowledgeable about available services 14 '''S that could help me 57.17 RECOMMENDED 57.00 I1/6/OC . �tIL.��II-D_�D� CO��T�' HO �'�E! �� 1 hr✓:5 ) PROGRAM RkTING OF SATTSF.ACTI0:,\'° Section I. JO BE CO.MPLETEP BY PROGRA I PARTICIPANT IlrslrtlC'tiOtr.S: Please atrs>t.'Cr errC.h question below hi' placing an [V itt the space prorided 1'pur rCspunsCc fir /hc's"e questions hate no hearitr,(, on I°our confinued participation in rhe prorjrnnr. ALL response's ore cnurlc/c wl'aI Whv did you choose to enter the program (marl: on1v on e box): 0df'cid.ed to come 10 this program on my ov,-n (throuLyh oulreach. referral. etc.) Cl] was placed here throuLh another program (coup intervention, police_ etc.) acallltl Illi 0I had previously participated in this ora similar program and d-ecided io return OPTIONAL Information: Name: Sex: 0 male 0 female Todu's Date: Please mrsr+'er lire following quesriorzs abozrl the services yDL received Mark- [a) 01711' One hn_r which herr a'escribcs}roirrfeelings abou, each srafetnent These questions are tnennl to help tts improIle IT" SCrt'iCel prni'itled, so we ask chat yoze,ell ur/torr' )loci really -feel, whether nr 17011 f is onn.d or had - Sirongtv Agree Agree L7 Disagree Disu,•ree Srronglr APrcc I Little A Lind, Diso�rer 1 «'as informEEdEin ghts and responsibilities; [6 0 ' �l inc]udinr thrance procedures I.�3•as providrmation about different services [6] [s] 1-1] 131 [2]that are avai i vvas involved in making decisions about my [6] [5] .[4] [;] (?] [1] care/senice 1� A �n I was able to talk with staff}s,hen I needed to + 16j [?) 14) 1;] [2) [I. The building and facilities have usually been clean, safe 161 [s] 1211) [ ] [2j [ 1] and comfortable My rights were respected and protecled,-includina my { [6] HEM to file a ,rrier•ance, if needed Aly case manaoerSeems qu2liFled to help me 6] (5] [a) [;) [2] 11) 1 }'ould recommend this roarnm to others [6] [d] [-!J [;) [2) [I) I amtreated tl ith res ect by The siaff [6) [5) [?) 3) 12 [I) The statfseems to care about whether I het better [6) [5) [a] 1; Program staff were knowledgeable about zvnilable I j6] [6) [4) 131 12] [I] services that could hel me Section II_: TO BE COMPLETED BY PROD -P A '1 STAFF Purpose of Evahlarion Curren! Level of Care. provided 1 t ❑ At Admission I 0 emer2cncy housing Provider Name: [ ❑ At dischargeD transitional housing/(_ I_ - I J Other_ 0 transitional housina%'non-i'.\'Stnff.lnitials: Project Name: IC permanent housing j 0 services only I F'r1116i0o Fnrrts%prceramraune IV1I_��II-D_�.DE COi.I�\T�' HO1'IEL>✓ �s 1 x�°� � EVALVACI6.N DE LA S_�TISFACCION CON EL PROCPAM.-k .Seccion 1. CO1.IPLET.AD.A POR EL P.ARTICIPA,NTE DFL PRC/GRA�l.A lnsrruccrones: PorJI-or eologae uno cru; JAY err el espaciu prorrstu parrs responder a las pre;r/runs a i nntinItjL hill. L u%. res puesras que usted de a erre cuesrionario rrn inlluirOn rle ir:rma olrimv 3'nbre la e'ttrtlimmciritr rle.su nor/rfrnuCuv: Prr rrt� rrrl,roma. TOD.4S las respuestasse marrterrdrun conf/denciularerrte. . Por qui decidi6 usted porricipar en el programa' (A'lorque una casiffa soiamen(e): [ ] Lo decidi por mi cuenta (porque fui remitido o por medio de orro programa, etc. ) ( ) Ful colocado aqui medianre orro pro2ram3 (por iniuvencion de los rribunalcs, is policia. etc.) en conn -a de mi vol unisd [ ] Ya habia parucipado en este programa o en uno similar v decidi re2resar Informacion OPCIONAL: Nombrey apellido: - Fech2 de hov: Cencro: M J J F I Porfiavor respo,ada a las preguntas sig uientes acerca de jos servicios que se le Iran prestado. Indigire Carl una crus f.N j EY UN -4 SOLA C.,45'ILL.-' FOR PREGUNT4 lafonna err que usted se sjenle OCL -1 -CO de cnda urra de las cues-lioues descrilas. Como sus restrues;as a estaspregvwas aas atvrdarrirr a rrrejo)-ar los servicios quepresromos, le rogumus que rrus/ra;a saber . C6)770 se Sienrc err realidad acerca de rZuestrps ser .cios, ria irnporta si usled los considers buenos o.mulo_s-. Se me informaron cuafes eran mis derechos }, responsabifidades, entre ellos, los procedimientos de la a�encia para someter quejas. Se me dio informacion sabre Jos distintos servicios a los que ten2o derecho. Participe en la toma de decisiones refermtes a mi plan de atencidn y servicios. Pude hablar con el personal cuando tune necesidad de Fcenttro y sus servicios por to ;en era] se han mantenido in eli;ro Y accesibles. ron y protegieron mis derechos, entre ellos, mi someter quejas si to considero necesaric. ente, la persona encaraada de mi caso sabe to ue hacer parn avudorme. Yo les recomendaria este rol'ecto a otras personas— Los empleados me trstoron respetuosamente Apareniemente, a los empleados Jes interesa que yo meore- Los empleados sabian que servicios podian ser;irme de avuda. I Atuc de I De I .?fro de I .A Igo er:En I Aliv en esa acuerdo + acucrde acucrdo desacuerdu dcuerdo desaeucrdo [6) 1-51 [41 I= ] I>> [ J ) [6' Current Level of Care provided At Admission [') [1) emerLency housing ' Provider carne: 0 At'discharRe 0 rransiticnal housingirx � Project Name: D Other: ❑ ransirional housin2lnon-r.\ , Statf Initials: D pe,–jj-,:.n_m housing f6j ser s ices only 1411 131 j 161 [41 ['1 ['] [1] [6] 131 (41 [3l [''-J [ 1] [6) [5l [11 [=) ['1 f 1 [6) [5J [41 [3] [2)] [ 1J [b] 161 [4J 1=1 [—J [ i j Seccion I1.: COMPLET4D4 FOR ENIPLEADOS DEL PROCRA,NIA (completed b),pro2mm staf Purpose of-Evalucliorrj Current Level of Care provided At Admission 1 p emerLency housing ' Provider carne: 0 At'discharRe 0 rransiticnal housingirx � Project Name: D Other: ❑ ransirional housin2lnon-r.\ , Statf Initials: D pe,–jj-,:.n_m housing 0 ser s ices only 1��II iI-D.aDE COUNTY HO IELESS TRUS 1 MVOGRA NI POU EVALYE SADSFA SYON Section 1. TOOT PATISIP.A,, PW( C -,P A)l SIL. A FET POU I:_ANPLI PA.) S.A., FnSlriisrun: Tunpri repvnn chak keksyun unba /a u epi fe_t'ort li A-wa /.i/Holl espn.s ki virl la. A'e'nnns 111)11 het.ru rrn d&anje �a.von non knirtinJ,e Dnrisipe nun pry n rare silri a Tout rrpruts J'o up scArL. POUKI W Ci- w,AZ1 P.ATISJPL• N,.k i PW'OCRAM SILA A (fe Yon ti k-IV2 non von grcnn bwo l): I1 Se moven ki chw2zi vinrn non pwogram sila a (srr•a pa referans, Siva po seg is cspc•ss•al :rsistans piblik t -it:.) 1) Se pn chwa m -en, se yon lot pwogrim ki vovcm (zak lribinal, lapolis elc•) O hliven to deja patisipe nan yon pwngrnm konsa epi mwen Beside retounnen. EIllom2syan you bay' si .j• vle: Non: Dat hdya: Srks 1] Gason [] Fcnrn Tanpri reponn keksvnrl silo yo dapre sellzs, resevri u. Fe yon kx a (r% Han J v1) sel li kale epi c'/r u n i rcprrns ki plrs matclre ffve W. ICeksyon silo i v Irlou ede pact bay i holy seris, ala nuL mande noru ba re art p p ) p S l i Alis oral clr.t ai e ke li bon ou pa. Yo fem konnen tout drYa moven yo ak responssbilife m1�en vo ak kouman Doti m}e'en lenven non ajans la Yo to banmsien enfomasyon sou diferan sesis ke Hoven ka b j wenn f4lzven f patisipe non tout desizvon sou plar.i1k-gSvon S en/sevis mtven AmpJw.ive vo ie foujou disponib you m»'en pale avek )-o Kate 3 ak bilding yo to tou jou byer, pwop, konfotz.b ak bon sekirite Tout dwz m fe respekie ak psvoteje rnenm dwa m you mtiven to pole kentsi nesese Aloun kap okipe ka vi'en an sanble li kalifye you li edem: Mwen to retro—deps',oeram lila o bny Jot-moun 4m ] vaye yo frefe mtis•en afi res e Am livas,e yo sanble vo vreman enterese nan moven j .Amplwayepwogram ka to byen enfome sou toursevis I<i to disponib you ede m. Eon jan da1;o dakb ! DoJ:o lou piti j f a f -Inn II t�jo dako Pa dnkb f Pa dako + ditou [6) transitional housinv'non-[N [4) 13) I21 �11) 16) If f6j ['] )51 [4,) 141 (31 131 [ 121 (i ) 121 11 [6) I=) [61 151 [4) [3] ;[2j[6) '5) f'1 >1 fIl 1 (6)) (J1 61 151 (Y 11;1 (2) fl) (6) [- [4) PI ('1 [11 Section IT.: TO BE COMPLETED BY PRDGR -A.Al S=TAFF'. Purpose ofEr7Qluoriurr D .A[ Admission ' At discharee JnO:hf! Pct. 1116/00 furn;.:orcgramraime Currenrleve/ of Care provider/ l ❑ emergency housing O rransi(iona) housing/t:: i C transitional housinv'non-[N jr� pe anent housing. ser: ices onb" Provider rNatne: Project Name: _ `Staff Initials: _ 1 ATTACHMENT F CLIENT CONTRIBUTION REPORT NAME OF AGENCY SUBMITTING REPORT: DATE REPORT SUBMITTED: GRANT NUMBER: REPORT COMPILED BY: Iv1ONTH OF SERVICE CLIENT NAME: DATE OF BIRTH: I I IDENTIFICATION NU MER#: .DATE OF PROGRAM ENTRY: / / INCOME: AMOUNT FOR MONTH SS I/ SSD (DISABILITY): $ SOC. SECURITY: S AFDC/TANF: S 'FOOD STAINIPS: S VETERA.N'S BEN-EFITS: S ENaLOY-MENT: S OTHER (CHILD SUPPORT $ ALIMONY, WORREWS COMP, ETC) MEDICAID (Check One): CJ Yes 0 No TOTAL ADJUSTED MONTHLY INCOME TOTAL: SAMOUNT THISMOIr1'I-i.:T'O.CLIENT.......: . TOTAL: s 'AMOUNT THIS MONTH TO PROUDER MAXIMUM 30% OF CLIENT'S ADJUSTED INCOME' Revised 7/12/2007 US. Deportment of Housing and Urban Development. Office of Community Planning and Development OMB Approval No. 2506-0145 (exp. 11/30/2009) ATTACHMENT G Annual Progress Report (APR) for Supportive Housing Program Steelier Plus Care ,1s Section 8 Moderate Rehabitation for Single Room Occupancy Dwellings (SRO) Programs HUD -40118 Pablic rep"ag bardes for this oollectim of information is estimated to average 33 hours per response, including the time for reviewing instructions, manchn ovuing data sources, garthawg and mamtam erg the data needed, and completing and mviewmg the oollomw of information. This agency may not Conduct or sponsor, and a person is rot required to respond to, a collection of information unless that wlkcbm displays a valid OMB omtml number. General Instructions Purpose. The Annual Progress Report (APR) is a reporting tool that HUD uses to track program progress and accomplishments and inform the Department's. competitive process for homeless assistance finding. Filing Requirements. Recipients of HUD's homeless assistance grants must snbmit 2 APR'S to HUD within 90 days after the end of each operating veer_ One copy of the report must be submitted to the Community Planning and Development (CPD) Division Director in the local HUD Field Office responsible for managing the grant. The other copy must be submitted to HUD Headquarters, Department of Housing and Urban Development, Atte: APR Data Editor, Room 7262, 451 7m Street, S W, Washington, DC_ 204I0. Failure to submit an APR will delay receiving grant funds and may result in a determination of lack of capacity for fine a hmdmg_ An APR must be submitted for each operating year in which HUD finding is provided. Grantees that received SEP 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 every year throughout the 20 years. A separate report must be submitted for each HUD grant received_ For Shelter Plus Care (S+C), a separate APR must be submitted for each S+C component_ For those grantees receiving an extension, a separate report covering that period must be submitted (see Extension below). Recordkeeping. Grantees must collect and maintain information on each participant is order to complete as APR Optional worksheets are attached. The worksheets may be used to record information manually or to design a computerized system to store and tabulate the information. The worksheets should not be submitted to HUD with the APR Organi" of the Report. The APR is organized it, the following manner. Part I: Project Progress. This portion of the report descnbes the progress in moving homeless persons to self-sufficiency, doctmenting services receiv&1_listing project goals, and accounting for beds/unks_ Part Il: Financial Insform.2tion. This portion of the report is completed by all grants rexivring finding under SIT, S -r -C, and SRO. Final Assembly of Report. Ager the entire Tart is assembled, number every page sequentially. Mark any questions that do not apply to your program with "N/A" for not applicable_ (See Special instruction -for SSO Projects below.) Definitions of Client ousettold T�vgres: each cirenilho rsehold type is defined below. Note that a client's client/tousehold type should be based on the client's age and/or household composition at the progro-n entry date closest to the start of the operat-ing year. Families — A family is a household composed of two or more related persons, at least one of who is a child accompanied by as adulf ora juvenile parent_ Singles not in Families — Persons not accompanied by children, including pregnant women not accompanied by other children and unaccompanied youth, are singles not in families. When two adults, or two unaccompanied youth present together for services, each person should be counted in singles not in families.. Clients' household status should be determined based on their household composition at the program entry date closest to the start ofthe operating year- This means that pregnantwomen expected to. give_birth.during-their. program stay should still be counted as singles not in families. Adults in Families — Within a family, an adult is any person 18 years of age or older. For the purposes of APR reporting, the determination of whether a person is an adult in family should be made based on their age and household composition at the program entry date closest to the start of the operating year. Childress in Families — Children in Families are defined as children under the age of 18 accompanied by one or more adults (parent, relative or grom-diau). Children in families also rude both a juvenile parent and the parent's child(ren). For the purposes of APR reporting, the determination of whether a person is a child in -family should be made based on their age and household composition zt the program entry data closest to the start of the operating year. For example, - HUD -40118 clients who are less than 18 years of age on the fust day of the operating year or at program entry (if they entered during the operating year) should be counted as children even if they turn 18 during the course of the operating year - Persons in Families —Persons in families includes adults in families and children in families. Other Key Definitions. The following terms are used in the APR. As indicated, in some cases, terms are applied differently depending on whether the funding is from SBP, S+C, or SRO. Chronically homeless person — HUD defines a chronically homeless person as "an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years." To be considered chronically homeless, a person must have been on the streets or in an emergency shelter (i.e-, not in transitional housing) during these stays. IUD's definition of a chronically homeless person is based on the following components: • Unaccompanied homeless individual: an unaccompanied homeless individual has the same characteristics of a Single not is a Family (desen-bed above). • Disabling condition_ see the instmo ions tinder disabling condition (below) to determine whether a client is disabled_ Did not lease the program — This teras refers to clients who were in the program on the last day of the operating year. Disab1mg condition - HUD defines a disabling condition as: (I) A disabiLrty as defined in Section 223 of tate Social Security Act (2) a physical, mental, or emotional impahmeat which is (a) expeutbd to be of long -continued and indefiuite duration, (b) substantially des an individual's ability to live independently, and (c) of such a naw" that such ability could be improved by more suitable housing conditions; (3) a developmental disability as defined in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act,- (4) the disease of acquired immunodeficiency syndrome or any conditions wising from the etiological agency for acquired immunodeficiency syndrome; m (5) a diagnosable substance abuse disorder. Entered the program — Filtered the program refers to the fim day a client receives services_ For a residentia't pro, an, this date would represent the first day of residence in the program's housings. For services, this date may represent the day of progr~� enrollment, the day a s,emice was provided or the L-st elate off a period of continuous participation in a service (e --z, daily, weekly, or monthly)_ For S+C and SRO programs, the program entry date is the date that the participant starts to receive rental assistance. For S+C; services provided prior to this point are recognized as necessary for outreach/enrollment and are eligi'ole to cotmt as match. An Extension APB. applies to SF2 and S+C grantees that requested and received an extension of their grant term from the R D field office_ The only difference between an APR for the extension period and tete regular APR (besides the amount of time covered) is the signature page. Grantees should circle `yes" to indicate the APR is for an extension period and circle the operating year for which the report is an extension. For example, if the grantee is extending year 3, the grantee should submit an APR as usual for year 3 and submit another APR for the extension period, indicating the second is an extension and also circling year 3 on the signature page. Grantee means a direct recipient of the HUD award. Left the program — Left the program refers to the last day a client receives services. For a residential program, this date would represent the last day of residence in the program's housing. For services, the exit date may represent the last day a service was provided or the last date of a period of continuous service. If a client leaves the program temporarily (e -g-, for a hospitalization) but is expected to return within 30 days, do not count that client as having lett the program. For S+C programs, the program exit date refers to the date the participant stops receiving rental assistance and is not expected to return to S+Czssisted bousiag If,the participant reams to S+.0 assisted housing within 90 days, the person should not be considered as exiting from the program. If the person returns to S -!-C assisted housing after 90 days, that person is considereda newpartc4ma .'tile ivradcshwt is.desiped.to capture chis information. HUD -40118 Match for S+C is 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 the life of the project. For SIP, match is cash used to provide the grantee's portion of acquisition, rehabilitation, new construction, operations and supportive services expenses. Operating year — For SHP programs, the first operating year begins after development activities for acquisition, rehabitation, and new construction are complete, alter a copy of the Certificate of Occupancy is sent to the local HUD office, and when the fust participant is accepted into the project For projects without acquisition, rehabilitation, or new construction, the operating start date begins when the grantee accepts the first participant. For dedicated HMIS projects, the operating year begins when any eligible cost included in the approved project budget is incurred. For SC (SRA, PRA and TRA componcuts), 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 with the effective date of the Housing Assistance 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 renewal grants_ For example, a project receiving an initial grant for three years and a renewal grant for two years would circle years 1, 2, and 3 respectively on the APR cover sheet for the initial grant and would circle 4 and 5 respectively for the renewal grant For any future renewal grants, the grantee would begin by circling 6 on the APR cover sheet Participants — The term participant refers to Singles not in Families and Adults in Families as defined above. Participant does not include children or caregivers who live with the adults assisted. Froject Sponsor sans the ol-ganizaiion responsible for carrying out the daily operation of the project if the organization is an entity other than the grantee. SpeeiA Instructions for Supportive Service Oniy (SSO) Pro -r arias. SSO grantees should complete all questions, unless a wrkten.agreement has been reached with the field orice concerning which questions can be answered using estimates, or in rare h ->stances, skipped. Below is an example of how information could be derived in a large, single -service SSO project: A g-antee/sponsor staffmember could be assigned to coliec, information from the organiz :tions housing the p- ticipants. The stair person would contact these individual organizations to request information regarding the persons in that facility that use the service. For participants living on the street, the grantee/project sponsor may provide estir3aws. Iufo-:mation could be collected for each participant or for participants rece ,kg services at a poirt-in-time. If estimates or point -in -time counts are used, the method used must be described in the APR and the documentation kept on file. As with all projects funded under HUD's homelessness assistance grants, grantees operating SSO projects are expected to complete all APR questions that are applicable to them Note that all projects have been awarded funds as a result of responding to the program goals of assisting homeless persons obtain/remain in permanent housing and increase their skills and income. The APR docurueuts their progress in meeting these goals. In some circumstances field offices and grantees may sign a written agreement concerning questions that can be answered using estimates, or in rare instances, skipped See the special instructions below for reporting on special types ofprojects, such as outreach only projects, projects providing services to children only, and transportation, medical, dental, and other single, short - duration service projects. SSO programs. are a third priority for local IMS implementation, following emergency shelters, transitional housing programs, outreach programs, and permanent supportive housing programs. Once SSO programs are included in the F.ZviIS, SSO grantees will be able to answer all APR questions using their HMS data. SSO grantees that are not yet participating in HIvIHMIS will need to collect data to answer the APR questions using the special instructions provided above. outreach Only Projects. Projects which are solely devoted to street outreach and connection to housing and services are not required to track participants bond thea contact with persons rm the street. it is sufficient for these projects to enter HUD -40118 information on questions 1-10 (slapping questions 11-13 and 17). Estimates for questions 5-9 are allowed, given that Participants may be reluctant to answer personal questions. Answering the questions will demonstrate that the grantee is serving the appropriate number of people, providing basic demographic information for Congress, demonstrating that homeless persons are being served, demonstrating the types of housing participants are connected to, and the type of services they are receiving. Hotline Projects, Hotline services are similar to outreach only projects, but contact between grantee and participant is often of very short duration - people enter and leave the program nearly simultaneously. It is sufficient for these projects to answer questions 1-5 (skipping 4), 10, and 14-19 (skipping 17). Projects Providing Services To Children Only. Projects that provide child care, after school care, counseling for children, etc. make an important contribution toward moving a family out of homelessness. While the main focus of the project is providing services to the children, it is the adults who are reported on ha questions 6-16 of the APR Like all other projects, this type is also targeted toward getting the families into housing and increasing the families' incomes_ Grouters may skip question 9,- all other questions should be answered (except 17). Transportation, Medical, Rental, and Other Single, Short-Duration Service Pro*ts. Some grantees provide a single so-vice of fairly short demon focused ONLY indirectly on assisting homeless persons to obtain/ramain m permanent bousmg and increase their skills and incomes. It is sufficient for these projects to enter infornmon on questions 1-10 and 14- 19 (question 17 may be skipped). However, with transportation services, it is unreasonable to chink that someone would have to give their age, race, and ethnicity to a bus driver to get a ride a few blocks. For these services, provide a narrative, which gives the nunber of rides given dna ��ng the operating year; and provides estimates on the above statistics bases; on the population dint utilizes the service. Spe�--aal I s€ruct ionic For Safe Haven (SH) Projects. Grant=-- should report on all paiticiimts served during the opurati:49 year- Note_ this is a change hTom prior instructions where graames were ks'b ucted to report om the a si 25 parricipans served. SpecW fwtruct ions for Homeless Managetn�iat �farB€a�rsn SYste� {;�h�S} Proleets. BMs tees should fill out the cover sheet of the APP, P.--t II Financial Info-madon, and the IMS Activities section - HUD -40118 THIS PAGE - TO BE COMPLETED BY ALL GRANTEES Grantee: HUD Grant or Project Number. Project Sponsor: Project Name: Operating Year (Circle the operating year being reported on) Reporting Period: (month/day/year) ❑i 02 D3 ❑4 05 116 ❑7 ❑8 ❑9 ❑10 ❑I1 012 ❑13 ❑14 015 ❑16 ❑17 ❑18 ❑19 ❑20 Indicate if extension: ❑ Yes ❑ No from: to: Indicate if renewal: ❑ Yes ❑ No Previous Grant Numbers for this project Check the component for the program on which you are reporting. Supportive Hoesing Program (SHE') Shelter Plus Care (S+C) ❑ Transitional Housing ❑ Perinment Hausigg for Homeless Persons with Disabilities ❑ Sane Haven ❑ Iwavative Supportive Housing ❑ SL?pcurdve Services Only ❑ FMS Section 8 Moderate Rehabilitation ❑ 'Tenant- Used Rental Assistance (TRA) ❑ Sir6gle Room Occupancy ❑ Sponsor -based Rental Assistance (SRA) (Sec. 8 SRO) ❑ Project -based Rental Assistance (PRA) ❑ Single Room Occupancy (SRO) S;,Tmary of the project: (One o: two sentences with a desc;p6on of population, nlunber served and accomplish en this operafingyear) RTame & Tide of the Person veto can answer questions about this report: Phone: (include area code) Address: rax Number. (include a eG code) E-mail Address I hereby certify that all the information stated herein is true and accurate. Warning: HUD %grillprosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, _1010, 1012; 31 U"S.C. 3729:38-02) Name & Title of Authorized Grantee Official.` Signature & Date: X Name and Title of Authorized Project Sponsor Official: Signature & Date: X HUD -40118 PART I. TO BE COMPLETED BYALL GRANTEES (EXCEPT HMIS) SSD GRANTEES, PLEASE SEE SPECIAL INSTRUCTIONS ONPAGE 3 OF THEAPR Part Z: Project Progress 1. Projected Level of Persons to be served at a given point in time. (This information comes from the most recent CoC lication.) Number of Number of Number of Number of Singles Not Adult in Children Families Proected Level in Families Families in Families a Persons to be served at a given point in time 2. Persons Served during the operating year. Number of Number of Number of Number of Singles Not in Adults in Children in Families Families Families Families a Number on the first day of the operaiing year b_ Number entering program during the operating year c_ Number who left the program during the operating year d Number in the program on the last day of the operating year �a+b-c)=d Explanatory notes: See Def¢sitions of Client/Household Types in the General Instructions; above to deme whieb clients should be counted as Singles Not m Families Adults in Families, and Children in Families_ Now that this table does not account for changes in client/household type that may occur during the course of the operating year. Instew ea --h client should be assigned a single client/household type based on the clieat's age andloThousehold composition a the progrzon er-.try dare closest to the start of the operating year. In this way, each chem is counted only once in the table. Use the following graphic and explanations to detestine who should be counted in rows a s— Ch.ra centered and lett program before start of • operating year. do not count in it question 2 fiat day of the op—ahns year Cliard in program on first day of operating year, tali dtrrine the year. courd in 22 and 2c. Clierd in program an first day of operating year and last day of operating year count in 2a 2nd:2 d. Client entered and let, program during operating year. count in 2b and 2c. Last day of the aparatins year Chard entered program during operating year and still in program an last day c yea^ count in 2b and 2d. a. Number on the first day of the operating year: This row includes all clients who entered the program before the first day of the operating year and did not, leave the program until after the first day of the operating year. b. Number entering the program during the operating year: This row includes all clients who entered the program on or after the first day of the operating year, up to and including the last day of the.operating year. For clients with multiple program entry dates, use the entry date closest to the start of the operating year. Do not count the client more than once even if he/she entered the program more than once during the operating year. e. Number who left during the operating year: .This row includes all clients who left the program on or after the fust day of the operating yea_; up to and including $re last flay of tha operating, year. For clients with multiple program exit dates, use the exit date HUD -40118 closest to the end of the operating year. Do not count the client more than once even if he/she exited the program more than once during the opmating year. d. Number is the program on the last day of the operating year: This row includes all clients who were in the program as of the first day of the operating year or who entered during the operating year and who did not leave during the operating year. The number of clients or families in the program on the last day of the operating year is calculated based on the responses to rows 2a through 2c. For each colwnn, add the Dumber of clients or families in row 2a to the number of clients or families in row 2b and subtract the number of clients or families in row 2c. Therefore, 2d = 2a+ 2b — 2c. 3. Project Capacity. Number of Number of Number of Number of Singles Not in Adults in Children in Families Families Families Families a Number on the last day (from 2d, columns I and 4) b. Numberproposed in application (from la, columns I and 4) c_ Capacity Rate (divide a by b) ='% I % Explanatory Notes: Row b refers to the most recent CoC application for which the program is reporting 4. Pion -homeless persons. This question is to be completed for Section S SRO projects_ How many income -eligible noon -homeless persons were housed by the SRO pmp7arn during the opmahng year? Age and €ender. Of those who entered the project diring the operating -year, how many people am in the following age and gender -categories? Explanatory Notes: This question refers only to Singles not in Families and Persons in Families who entered the program during the operating year. Only clients who meet these criteria can be counted in this table. The total number of clients reported under Single Persons should be equal to the number reported in question 2b, column I. The total number of clients reported under Persons in Families should be equal to the sum 'of columns 2 and 3 in question 2b. Answer questions 6 - 10 only for participants who entered the project during the operating year (from 2b, colIXMs I & 2). The term participant means Singles not in Families and Adults in Families. It does not include children or caregivers. NOTE: The total for questions, 7, 8 and 4!i below,shoWd.be-the same y respond to each of those questions for all participants. Some of the questions listed throughout the APR will be asking information for individuals who are chronically homeless. H17DD 40118 6a. Veterans Status_ A veteran is anyone who has ever been on active military duty status. How many participants were veterans? 6b. Chronically boneless person. An unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year ormorc OR has had at least four (4) episodes of homelessness in the past three (3) years. To be consideied chronically homeless a person must have been on the streets or in an emergency shelter (i.e. not transitional housing) during these stays. For further discussion of the definition of chronic homelessness, see Other Key Definitions under the General Instructions above. How many participants were chronically homeless individuals? 7. Ethnicity. How ,many participants are in the following ethnic categories? or Latino ianic or Non -Latino Explanatory Notes: Each participant should be listed in only one category. ibe total number of participants in this table should equal the number of participants in question 2b, columns I and 2. 8. Race. How many participants are in the following racial categories? Explanatory Notes: Each participant should be listed in only one categoiy. A participant wihose race does not correspond to categories a through i. should be counted in j, -Other lviuld Racial. The total number of participants in this table should equal the n'ambe. of participants in cuestion 2b, colurnns I and 2. If using i7'N11S data, you may combine HNIIS race response categories to generate the APR response categories. 9a. Special Needs. How many participants have the following? Participants may have more than one. If so, cowit theme in all applicable categories. For each condition, also indicate the number that were chronically homeless. All Chronic 9b. How many of the participants are disabled? Explanatory Notes: To determhe which participants meet HUD's definition of "disabled," see "Disabling Condition" under Other Key Definitions in the General Instructions. HL D-40118 10. Prior Living Situation. How many participants slept in the following places in the we& prior to entering the project? (For each participant, choose one place. The total number of participants in the "All" column should equal the number of participants in question 2b, colurnns I and 2). Also, indicate how many chronically homeless participants slept in the following places. (Choose one) All bus b_ Fm=gcncy shelter c. Transitional housing for homeless PCMDS + e. I Substance abuse treatment facility* I I h. Domestic violence situation i. Livmg with relatives/friends i. I Rental housing k 011ier (please svecifv) *If a participant came from an institu bon (psychiatric facility, substance abase treatment facility, hospital, or jail), but was there less than 30 days and was living on the street or in emergency shelter before entering the treatment facility, he/she should be counted in either the strut or shelter category, as appropriate - Complete questions 11 - 15 for all participants who left during the oWratitag year (from" 2c, 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 who has eitber 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 /lave been on the streets or in an emergency shelter (Le. not transitional housing) during these stays. 11. Amount and Senree of Fit, ozcW- y €Dcome at Entry and, at Exit Of those participants :who le$ dig the opm—abing year, how nzty participants were at each monthly income level and with e= sow-cee of income? Also, please place the monthly income level and each source of income for chronicAy homeless persons in the second column of each chart: The numb-= ofpard6pants in Chart A and B should be the same_ Ali Chronic C. Income Sources At Entry a S-spplemmtat Security income (SSI) b. SocialSecrs,-ity Disability income (SSRI) . c. Social Security R l Public Assistance ary Aid to Needy Families (TANF) hildren's Health Insurance Program (SCH T) s Benefits ment Income i. Unemployment Benefits j. Veterans Health Care -- k. Medicaid 1. Food Stamps m.. Other (please specify) n No Financial Resources HUD -40118 AM Chrouic A Monthly income at Entry a No income b_ $1-150 c. S151 -S250 d. S251 -S500 e. $501 - $1,000 £ S100I-$.1500 g. $1501- 52000 h. $2001 + Ali Chronic C. Income Sources At Entry a S-spplemmtat Security income (SSI) b. SocialSecrs,-ity Disability income (SSRI) . c. Social Security R l Public Assistance ary Aid to Needy Families (TANF) hildren's Health Insurance Program (SCH T) s Benefits ment Income i. Unemployment Benefits j. Veterans Health Care -- k. Medicaid 1. Food Stamps m.. Other (please specify) n No Financial Resources HUD -40118 AI Clrorric D. Income Sources at Exit a Supplemental Security Income (SST) b. Social Security Disability Income (SSDI) C Social Security d. General Public Assistance e_ Temporary Aid to Needy Families (TANF) f. State Children's Health Insurance Program (SCRIP) g. Veterans Benefits h. Employment Income L Unemployment Benefits j. Veterans Health Care k Medicaid L Food Stamps in. Other (please specify) u No Financial Resources Expl-ma,ory Notes: Tabic A: Monthly income at entry refers to the participant's monthly income on the day helshe entered the program (i.e., on the program entry date -or as close as possible to chat day). You should not report on income received before entering the proms or income received during the program stay. Table B: Monthly income at exit refers to the participant's monthly income on the day he/she left the program (i.e, on the program exit date or as close as possible to that day). You should Dot report on income received drying the program stay_ Table C: Income sources at entry refers to the paracipart's sources of inoome on the day he/she entered the proms (i.e., on the program entry date or as close as possible to that day). You should not report on sources of income r&oeived before ent—criag the prozram or income received daring the p_ ogram sta-y. Par ic4mts wiffh no income at the time of progra-n entry should he reported in category n, No Financial Resources. Table 1Q: Income sources at exit refers to the participant's sources of income on the day he/she left the program (i.e., on the program exit date or as close as possible to that day). You should not repo on sources of income received during the program stay. Participants with no income at the time of program exit should be reported in cat gory n; No Financial Resources_ 12a_ Of those participants who left during the operanng year (from 2c, columns 1 and 2), how many were in the project for the following lengths of time? Also, please place the length of stay for chronically homeless persons who lett during the operating year in the second column. All Chronic Explanatory Notes: Compute each participant's length of my entry date and program exit date. if the participant has only one program exit date during the operating year, calculate length of stay by subtracting the program entry date from the program exit date. If the participant has multiple program exit dates during, the operating year; calculate the length of stay for each program stay (by subtracting the program entry date from the program exit date for each program stay) and add them together to produce a cumulative length of stay. Each I UD -40118 AN chrnuc B. Monthly'Income at Exit No income b_ I'a S1-150 C. $151-$250 d. S251-S500 e. 5501 - 51,000 f 51001-S1500 g_ $1501-52000 h. 52001 + AI Clrorric D. Income Sources at Exit a Supplemental Security Income (SST) b. Social Security Disability Income (SSDI) C Social Security d. General Public Assistance e_ Temporary Aid to Needy Families (TANF) f. State Children's Health Insurance Program (SCRIP) g. Veterans Benefits h. Employment Income L Unemployment Benefits j. Veterans Health Care k Medicaid L Food Stamps in. Other (please specify) u No Financial Resources Expl-ma,ory Notes: Tabic A: Monthly income at entry refers to the participant's monthly income on the day helshe entered the program (i.e., on the program entry date -or as close as possible to chat day). You should not report on income received before entering the proms or income received during the program stay. Table B: Monthly income at exit refers to the participant's monthly income on the day he/she left the program (i.e, on the program exit date or as close as possible to that day). You should Dot report on income received drying the program stay_ Table C: Income sources at entry refers to the paracipart's sources of inoome on the day he/she entered the proms (i.e., on the program entry date or as close as possible to that day). You should not report on sources of income r&oeived before ent—criag the prozram or income received daring the p_ ogram sta-y. Par ic4mts wiffh no income at the time of progra-n entry should he reported in category n, No Financial Resources. Table 1Q: Income sources at exit refers to the participant's sources of income on the day he/she left the program (i.e., on the program exit date or as close as possible to that day). You should not repo on sources of income received during the program stay. Participants with no income at the time of program exit should be reported in cat gory n; No Financial Resources_ 12a_ Of those participants who left during the operanng year (from 2c, columns 1 and 2), how many were in the project for the following lengths of time? Also, please place the length of stay for chronically homeless persons who lett during the operating year in the second column. All Chronic Explanatory Notes: Compute each participant's length of my entry date and program exit date. if the participant has only one program exit date during the operating year, calculate length of stay by subtracting the program entry date from the program exit date. If the participant has multiple program exit dates during, the operating year; calculate the length of stay for each program stay (by subtracting the program entry date from the program exit date for each program stay) and add them together to produce a cumulative length of stay. Each I UD -40118 participant should be associated With, only one length of stay category. The tate number of participants in the first column ("Ali") should equal the number of participants in question 2c, columns 1 and 2. 12b. Lengtb of Stay in Program. For those participants who did mot kave during the operating year (from 2d, columns I and 2), how long have they been in the project? Also, please place the length of stay for chronically homeless persons who did not leave during the operating Year in the second column. All Chronic a Lxss than 1 montb W months months ths - 12 monthsnths - 24 months nths - 3 ears - 5 years Ub-I Lyears 7 ears 10 ears years ExplanatoryNotes: Compute each participant's length of stay using the participant's program entry date and the last day of the operating year. To calculate length of stay, subtract the program entry date from the last day of the operating year- Facb participant should be associated with only ane length of stav category.. The total number, ofparticipants in the first calurm ("All") should equal the number of paztieipants m question 2d, columns 1 and 2. 13. Reasons for Leavkg. Of those participants who left the project. dz-.ng the operating Yea+ (from 2c, colun-m I and 2), how many left for the fAilowing reasons? If a participant leT for multple reasons, ine&& ot* the prrmmmy re on_ The toll namber of participans it the:first column ("All") shaald equ_t the number of paracipans in question 2c, columns 1 and 2. r-lso, please puce the primary reasar for Chronically homeless persons who let the project &uing the operating year in thesmone cohnnn. A€l a Lett for a housing opportrmi y before completing Progr-- b_ Compiemd program c. Non payment of rent/occupancy charge d- e. e. t Criminal activity /des* zrction of property / violence f Reached maximum time allowed in project & Needs could not be met by projea h. Disagreement with rules/persons L Death j_ Other (please specify) k Unknown/disappeared i HUD -40118 14, Destination. Of those participants who left during the operating year (from 2c, MUMS 1 and 2j, how many left for the following destination? Also, please place the destination of chronically boneless persons who left during the operating year in the second column. All Chronic PERMANENT (a -b) a- Rental house or apartment (no subsidy) using the categories provid,-A 3be response categories combine b. Public Housing making a selection. The table below provides a brief description of each response category. C. Section 8 chronically homeless. Only one reason for leaving should be recorded per participant The total number of participants in tie fist column d Shelter Plus Care Description e. HOME subsidized house or apartment subsidy) f Other subsidized house or apartment Partici ant is moving to a public housing unit g- Homeownership [rb- h Moved in with family or friends TRANSITIONAL (i j) i- Transitional housing for homeless persons C. HOME subsidized house or j- Moved in with family or friends INSTITUTION (k -m) k Psychiatric hospital L Inpatient alcohol or other drug treatment facility Shelter PIus Care, or HOME_ m Jail/prison 5d1ERGENCY SHELTER (n) m Emergency sheitvr OTBER (o --q) o_ Other supportive housing people p. Places not meant for human habitation (e -g. street) the Supportive Housing Program).- q- Other (please specify) UNKNOWN . r_ Unlmown Explanatory Notes: Identify each participant -s destination upon leaving the program using the categories provid,-A 3be response categories combine `destination' (e -g-, mental house or ap ent, public housing, homeownci h , etc-) and "tenure- (c -g, pern-ianent, transitional, &0 - Consider both destin2bon and tenure to det:,--mise the most appropriate response, and be sure to look at all oftbe response ca_egories before making a selection. The table below provides a brief description of each response category. -Enter the cumber of participants under each destination category in either the first column of the table or in both colucros if the participant is chronically homeless. Only one reason for leaving should be recorded per participant The total number of participants in tie fist column ("All") should equal the number of participants in question 2c, columns l and 2- Tenure ( Destination Description Permanent a Rental house or apartment (no" -Participant is moving to an apartment or house without any subsidy. subsidy) Public hons,On a Partici ant is moving to a public housing unit _ Section 8 Participant will use a housing choice voucher (formerly known as a [rb- Section 8 voucher) to rent a house or apartment d-. Shelter Plus Care Paracipant is moving to a unit funded by the Shelter Plus Car e program (e.g_, TBA, SRA, PF -A, Section 8 SRO}. C. HOME subsidized house or Participant is moving to a strut with rental assistance provided by the apartment HONE ro (tenant -based or roiml-based assistance)_ f_ Other subsidized house or apartment Participant is moving to a unit subsidized by some program other titan public housing, housing choice voucher program (formerly Section 8), Shelter PIus Care, or HOME_ Horn Partici ant is movie to a unit that he/she has urchased. �h. Moved in with family or friends Participant is moving in with family or friends and expects to live there for 90 days or more. Transitional i_ Transitional housing for homeless Participant is moving into a unit funded by a transitional housing people program for homeless people (e.g., transitional housing funded through the Supportive Housing Program).- j- Moved in with family or friends Participant is moving in with family or friends and expects to live there lessthan 90 days. Institution k- Psychiatric hosp ital Participant is moving to a psychiatric hospital. HIJD-40118 Tenure Destination Descri tion 1. hipatrent alcohol or other drug Participant is moving to an inpatient alcohol or drug treatment facility. treatment facility m laillPrison ring to a jail or prison. Emergency n. Emergency shelter Participant is moving to an emergency shelter for homeless people. Shelter Other o. Other supportive housing Participant is moving into supportive housing that does not correspond to any of the permanent housing categories (e -h) and is not transitional housing for homeless people (i), such as Section 811 housing-* p. Places not meant for human Participant is moving to a place not meant for human habitation, such habitation as a car, park, sidewak or abandoned building. q. Other (please specify) Participant is moving to a place that does not correspond to any of the categories above (a- ). Unknown r_ Un�uown This response category should be used if you are unsure about where the participant is moving or if the participant has disappeared and there is no way to find out where be/she is. *HUD encouragesprograms to limit the use o, f the "Other Supportive Housing"APR response category. Programs should report destinations to housing that are permanent or transitional in APR categories (a) through (h) or in categories (i) through 6), respectively. Flits to emergency shelters should be reported in category (n). 15. Supportive Services Of those participants who left during the operating year (from 2, columns I and 2), how many received the following supportive services during their time in the project? Also, plmse place the supportive services received for chronically homeless participants who left during the operating year in tbe second colimin. Participant may have received multiple services and all services should be reported in the table. All Chronic a O�rlreaclr b_ Case management c_ Life sUlls (outside o•1 c as-. management) d Alcohol or drug abuse services I e. Mental health. services £ MWAIDS-relate services g. Other healthcare services ii_ Education i. Housing place -..t I j. Employment assistance lc Child care 1._ Transportation rn_ Legal n. Other (please specify) HUD -40118 16. Overall Proeram Goals. Under objoctives, list your measurable objectives for this operating yew (from your application, Technical Subnrtission, or APR) for eacb of the three goads listed below. Under Progress, describe your progress in meeting the objectives. Under Next Operating Year's Objectives, specify the measurable objectives for the next operating year. a. Residential Stability Objectives: Next Operating Year's Objectives: b. Increased Skills or Income Objectives: Next Operating Year's Obiectives: c. Greater Self-deternainalion Objectives: Progress: Next OperaiiZD Year's Objectives: 17. Bemss. SIP recipients answer 17a. S -11-C recipients aaswc 17b. SRO recipients answer I7c. (Sly' SSOProieeis do not m7rpfete this quesdoa-) a_ Sly_ How many beds were included in the application approved for this project under `Current Level' and under `New Effort'? How many of these New Effort beds were actually in place at the end of the operating year? Current Level New Effort New Effort in Place Number of Beds: b. S+C- How many beds and dwelling units were being assisted with project funds at the end of the operating year? (Include beds for aU participants, other family members, and care givers.) Number of Beds: _ Number of Dwelling Units: C. SRO. How many dwelling units were being assisted at the end of the operating year? (Include units occupied by "in place" non -homeless persons who qualify for assistance.) Number of welling Units: _ HUD -40118 Part II: Financial Information 18. Supportive Services. For Supportive Housing (SIP* this exhibit provides information to HUD on how SIP funding for supportive services was spent during the operating year. Enter the amount of SHP funding spent on these supportive services. Include HNRS costs under "Other". For Sheller Phis Care (S+Q this exhibit tracks the supportive services match requirement Specify the value of supportive services from all sources #W can be"counted as match that all homeless persons received during the operating year. (S+C grantees should keep documentation on file, including source, amount, and type of supportive services.) For Section 8 SRO, this exhibit provides information to HUD on the value of supportive services received by homeless persons during the operating year. Supportive Services Dollars a- Outreach b_ Case management c. Life slaps (outside of case management) d- Alcohol and drug abuse semces e. Mental health services f AIDS-related services g. Ogler health care services h_ Education i- Housing placemmt j. Employment assistance k Child care 1. Transportation M. Legal n. Other (please specify) o. TOTAL (Sum of a through n) Cumulative amount of match provided to date for the Shelter Plus Care Program under this grant HUD -40118 19. Supportive Housing Program: Lasing, Supportive Services, Operating Costs, IMS Activities and Administration All grantees receiving funding under the Supportive Housing Program must complete these charts each operating year. For expansion projects: if SHP pant finds ane for the expansion of a pre-existing homeless facility, only the people and expenditures for the additional expansion may be included, as in the original application or any grant amendments. Doauneotation of resources used is not required to be submitted with this report but should be kept. on file for possible inspection by HUD and Auditors. Do not include any expenditures made before the SHP grant was executod. Summary of Expenditures. Enter the amount of SBP pant funds and cash match expended during the operating year for each activity. This table should add up both horizontally and vertically_ The SBP supportive services total should be the same as the SHP supportive - services in Question 18_ Note: Payments of principal and interest on any loan or mortgage may not be shown as an Operating expense_ Sources of Cash Match_ Enter the sources of cash identified in the Gash Match column, above, in the following categories_ Use additional sheets, as necessary_ Amount a GraawaiJproject sponsor cash b_ Local goveriment (please specify) c. Stats governmem (please specify) d Federal government (please specify) Community Development Block Grant (CDBG) e. Foundations (please specify) f. Private cash resources (please specify) g. Occupancy charge / fees h. Total HUD -40118 SHP Funds Cash Match Total Expenditures ervices VIMS osts ties C_ Adn inistration f Total Note: Payments of principal and interest on any loan or mortgage may not be shown as an Operating expense_ Sources of Cash Match_ Enter the sources of cash identified in the Gash Match column, above, in the following categories_ Use additional sheets, as necessary_ Amount a GraawaiJproject sponsor cash b_ Local goveriment (please specify) c. Stats governmem (please specify) d Federal government (please specify) Community Development Block Grant (CDBG) e. Foundations (please specify) f. Private cash resources (please specify) g. Occupancy charge / fees h. Total HUD -40118 20_ Supportive Housing Program: Acquisition, Rehabilitation, and Now Construction All grantees that received SBP funds for acquisition, rehabilitation, or new construction must complete these charts in the year one APR only. This exhibit will demonstrate to HUD that the grantee has contributed enough cash to at least equally match the amount of SHR funds spent for acquisition, rehabilitation, or new construction. Documentation that matching funds were provided is not required to be submitted with this report but should be kept on file for possible inspection by HUD and Auditors. Summary of Expenditures. Enter the amount of SHP grant funds and cash match expended during the operating year for each activity. SBP Funds Cash Match Total Expenditures a Acquisition b_ Rchabilitation c_ New construction d Total Cash Match. Enter the sources of cash identified in the Casb Match column, above, in the following categories. Use additional sheets, as necessary. Amotmt a Grentw4rojectsponsor cash b. Local government (please specify) c. State government (please specify) j I d. Fe&I-41 government (please specify) Com—aity Development Block Grant (CDBG) e. Fouadations (please specify) f Private cash resources (please specify) N pancy charge/ feesl HUD -40118 Describe &Ay problems and/or changes implemented during the operating year. Tecnnic:d Assistance and Recommendations Based on your experieuce during the last year, are there any area` in which you need technical advice or assisMcel If so, please describe_ HUD -40118 Name. Names of persons will not be reported to HUD. The use of names is for your record keeping convenience. Relationship. Enter the appropriate relationship_ Examples include: Self, Head of household, Spouse, Child. Entry Date- Enter date participant entered the proiect_ Usually this will be the date of actual physical move -in for a housing project. Exit Date. Enter date participant left the project. Usually this will be the date the participant physically moved out for a housing project. Do not include a participant who temporarily left the project and is expected to return in less than 90 days (e.g., hospitalization). 4_ Income -eligible Non -homeless in SRO. The SRO program allows assistance to units occupied by Section 8 income -eligible persons residing at the SILO prior to rehabilitation. For SRO projects only, indicate whether the participant is an income -eligible, non -homeless person (Y) or not (N). SHP and S+C projects should skip this item. 5a. Rate of IBirth. Enter date of birth including month, day, and year. 5b. lige. Enter age at entry. 5c. Gender. Enter appropriate letter for gender. M -Male F- Female. 6a_ Veterans Status. Indicate .if the participant is a veteran. Please note: f1 veteran is anyone who has ever been on active military duty status for the United States_ 6b. Chronically homeless person_ Indicate the number of participants that are chronically homeless. Ethnicity. Enter appropriate letter for ethnic group. a_ Hispanic or Latino b_ NTon-Hispanic or Non -Latino Raze. Enter. appropriate Ietter for race. a. American Indian or Alaskan Native b. Asian c_ Blade or African-American d. Native Hawaiian. or Other Pacific... Islander e. White f. American Indian/Alaskan Native & White g. Asian & White h. Black/African American & White i. American Indian/Alaskan Native &. Black/African American i. Other Multi -Racial 9a. Special Needs. Enter the letter(s) for the category(ies) that describe the participant's disability(ies). (You may doulcle count). a. Mental illness b. Alcohol abuse c. Drug abuse d. H1V/AIDS and related diseases e. Developmental disability f. Physical disabilities g. Domestic violence b. Other (please specify) 9b. Enter the number of participants with a disability. 10. Prior Living Situation. Enter the letter that best describes where the participant slept in the week prior to entering the project. Do not double count. a. Non -housing (street, park, car, bus station, etc,') b. Emergency shelter c. Transitional housing for homeless persons d. Psychiatric facility* e. Substance abuse treatment facility* f. Hospital* g. Jail/prison* h. Domestic violence situation i. Living with relatives/friends j. Rental housing k. Other (please specify) *lf a participant came from an institution but was there less than 30 days and was living on the street or in an emergency shelter before entering the facility, he/she should be counted in either the street or shelter category, as appropriate. Instruction Codes for Persons Served Worksheet (continued) 1 la.Gross Monthly Income at Project Entry. Enter the amount of gross monthly income the participant is receiving at entry into the project. I Ib.Gross Monthly Income at Project Exit. Enter the gross monthly income the participant is receiving when exiting the project.. . I Ic.Income Sources Received at Project Entry. Enter all types of assistance the participant is receiving at entry to the project_ a. Supplemental Security Income (SSI) b. Social Security Disability Insurance (SSDI) c. Social Security d. General Public Assistance e. Temporary Aid Needy Families (TANF) f. State Children's Health Insurance Program (SCHiP) g. 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 HUD -40118 IId.Income Sources Received at Project Exit. Enter all types of income the participant is receiving at project exit. (Use codes as in l I c.) 12a Length in Stay in Program. Calculated item. (See Entry Date and Exit Date above.) 12b. Length of Stay in Program. (Participant did not leave during the operating year. How long have they been in the project?) 13. Reason for Leaving Project. Enter the primary reason why the participant left the project. (Complete only for participants who left the project and are not expected to return within 90 days. a_ Left for a housing opportunity before completing the program b_ Completed program c_ Non-payment of rent occupancy charge d_ Nan -compliance with project e. Criminal activity/destruction of property/ violence f Reached maximum time allowed in project g_ Needs could not be met by project h_ Disagreement with rules/persons i. Death J_ Other (please specify) k_ Unknown/disappeared 14_ Destination. Enter the destination of those leaving the project. Permanent: a. Rental house or apartment (no subsidy) b. Public Housing C- Section % 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 Trsnsitional: i. Transitional housing for homeless persons j. Moved in with family or friends Institution; k_ Psychiatric hospital_ 1. Inpatient alcohol or drug treatment facility M. 3aiI/prison Emergency: n. Emergency shelter Other: o. Other supportive housing_ p. Places not meant for human habitation (e -g-, street) q. Other (please specify) Unknown: r. Unknown 15. Supportive Services. Enter all types of supportive services the participant received during the time in the project. a. Outreach b. Case management c. Life skills (outside of case management) d. Alcohol or drug abuse services e. Mental health services f. HIV/AIDS-related services g. Other health care services b. Education i. Housing placement j. Employment assistance k. Child care L Transportation in. Legal n. Other (please specify) HUD -401 18 .twin Home CllentPolnt P.esourc=Point Sh=iterPolnt S:anPpint lr._ports A.c+min help I log^i HUD Annual Progress Report (HUD -4011S) ATTACHMENT G-1 Report Options: Select- Unduplicated 17 rovider Miarni-Dade County Government (n 1) 'rT' Derating Year Date Range , 05/01/2006 o05/1(mm/dd/yy}'y) 0 gal Adult Age 18 (as defined by foster care law in your state) Or W-Select- 2. Persons Served during the Number of Singles Number of Adults Number of Children in operating year. Not in Families in Families Farnilies a. Number on the first day or the 0 I I 0 operating year. 0 11 b- Num ber entering program during the ! 0 0 operating year. 0 i c. Number who left: the program during� the operating year. 0 � 0 � 0 JJ d- Number in the program on the last day0 0 0 of the operating year. (ab -c=d) 3. Project Capacity. Number of Singles Number osp.dults ` Number of Children in Not in Families in Families Families a. Number on last day (from 2d, columns 1 and 4) 0 4. Non -homeless persons. (Sec. 8 SRO projects only) How many income -eligible nen-homeless persons were housed by the SPO program during the operating Number of Families rx year? I 0 S. Ace and gender. Age 'Male !Female Other/Nbt given Single,Persons (from 2b, column i) Ia. 62 and over 1 0 I 0 0 ----------------------------------- Ib. 51 61 I 0 0 I 0 c. 31 50 I 0 I 0 0 Id. 18 30 0 0 I p e. 17'and under I 0 0 I p INot given I 0 0 0 Persons in Families (from 2b, columns 2 & 3) If. 62 and over 0 0 p g. 51 -61 I u p I p Ih, 31 -50. I 0 I 0 0 hrtps:/,'vvwv0.ser;,;icept.com/m.]ami./scripts/svpreporthuu.php .6114/2006 hrtps:/,'vvwv0.ser;,;icept.com/m.]ami./scripts/svpreporthuu.php .6114/2006 Ik.6-I2 1 v i 5 0 0 M, Under I O INot given I 0 62. Veterans Status. A veteran Is anyone who has ever been on active military'duty status. ronically Homeless. any participants were chronically homeless individuals? FTEthnicity. 0' 0 a. Hispanic or Latino 0 b. Non -Hispanic or Non -Latino a. Race. 0 a. American Indian or Alaskan Native 0 b. Aslan 0 c. Black orAfrlcan American d. Native Hawaiian or Other Pacific Islander 0 0 e. White f. American Indian,IAlaskWhite Native & hite 0 �0 g. Aslan & White 0 h. Black /African American & White Ii. American Indlan/Alaskan Native & Black/African American 0 0 j. Other Multi -Racial 0 �k Other/Unknown (all that do not match) — --- - - 19a. Special Needs. a. Mental illness b. Alcohol abuse c. Drug abuse d. HIV/AIDS or related diseases e. Developmental disability f. Physlcai disablitty g. Domestic violence h. Other (please specify) 9b. Disabled. How many of the participants are disabled? 10. Prior Living Situation. a_ Non -housing (street, park, car, bus station, etc.) b. Emergency shelter c. Transitional houslno for homeless persons d. Psychiatric facility e- Substance abuse treatment facllity f. Hospital g. )all/prison h. Domestic violence situation iii. Livine with relatives/Friends j. Rental housing http5:ihy.,,�•�,r, ser` icept.corrl/miami/scripts/s,-preporthud.php All 0 0 0. n0. 0 0 0 Chiionic U D :0 D 0 0 0 0 chronic 0. 0 6/14/^!06 Amount A. Monthly Income at Entry .Chronic All I Chronic a. ho ]ncome I 0 I 0 b. F1.150 I 0 I G c. $151 - 5_'50 I 0 I 0 d. $? 1 - SSOG o I 0 e_ $501 $1000, I U I 0 f. $1001 $1500 g.$150? $2000 0 I 0 I 0 0 h. ?2000 + 0 0 Source C. Income Sources at Entry 0 All Chronic a. Supplemental Security Income (SSI) 0 I 0 b. Soclal Security Disability Insurance (5501) 0 0 C_ SoClal Security 0 0 d. General Public P.sslstance 0 , 0 e. Temporary Aid to Needy Families (TANF) I 0 0 . f. State Children's Health Insurance Program (SCHIP) 0 0 g. Veterans beneflts I 0 + 0 h- Employment Income 0 0 i. Unemployment Benefits I 0 0 j, veteran's Health Care I 0 I 0 +k- Nedicald 0 0 Food Stamps ! 0 0 I �1. Irn. Other (please speciry) 0 0 n- No r0nandal resources I 0 I 0 122. Length of Stay in Program- (Participants who left during operating year) B. Monthly Income at Exit All Chronic 0 I r 0 I 0 0 I 0 0 I— 0 J 1 Q 0 �— 0 0 0 0 0 D_ Income Sources at Exit All Chronic 0 0 . 0 I 0 0 0 0 0 0 I 0 0 0 0 0 0 0 0 J o I o � o 0 o 0 � 0 0 0 0 0 1� httpsJi�ti `ti';.sertiicept.cuminiami%scripis's�preporthud.php 6111 ?{x'006 I All i .Chronic Ia. Less than 1 month I 0 0 b. 1 to.2 months 0 0 c. 3 - 6 months d. 7 months - 12 months 0 0 I 0 0. j e. 13 months - 24 months I 0 0 f.,25 months - 3 years I 0 0 g. 4 years - 5 years I 0 + 0 h. 6 years - 7 years 0 0 i. a years - 10 years I 0 0 j. over 10 years 12b. Length of Stay in Program. 0 (Participants who did not leave during operating year) 0 All Chronic Less than 1 month 0 0 1 to _7 months pLd. 0 0 - 6 months 0 0 months - 12 months 0 0 3 months - 2ti months I 0 I 0 f. 25 months - 3 years 0 I 0 g. years - 5 years I 0 0 httpsJi�ti `ti';.sertiicept.cuminiami%scripis's�preporthud.php 6111 ?{x'006 Over, 1 U I v for Leaving. I f li Chronic rReasons ousing opportunity before completing program �' n;program.nt of rent/occupant/ charge i d. Non-compliance with project 0 f 0 e. Criminal activity / destruction of property J violence I 0 0 f. Reached maximum time allowed In project 0 I 0 g. Needs could not be met by project o I 0 - h- Disagreement with rules/persons 0 0 i. Death 0 0 j. Other (please specify) 0 0 k. UnknownJdlsappeared 0 0 14. Destination. All � Chronic I If PERMANENT (a - h) a- Rental house or apartment (no subsidy) 1� 0 0 b. Public Housing i 0.1 0 c- Section 8 0 0 d- Shelter Pius Care 0 0 e. HOME subsidized house or apa: �rnent 0 , 0 f- Other subsidlzed house or apartment 1 0 o Homeownershlp 0 0 h. Moved in with family or friends I 0 i 0 TF,ANSITIONAL (I -J) i. Transitional housing for homeless persons 0 , 0 �j- Moved -in with family or friends 0 0 JINSTITUT-ION (k - m)k_ Psychiatric hospital 0 1. inpatient alcohol/drug treatment ,"acillty 0 p rn. jell/prison 0 + EMERGENCY SHELTER (n) n. Emergency shelter 1II 1 0 I 0 OTHER (o - q) a_ Other supportive housing .0 0 p- Places not meant for human habitation (e.g. street) ' 0 0 ,q. Other (please specify) 0 1 0 UNKNOWN. r. Unknown .0 0 15_ Supportive Services. No supportive services found. Service Point version 4.D1.018 (db build #0723) Licensed to: Miami Dade Homeless Trust Q 1909-2006 Bowman Systems L.L.C. All Rights Reserved. CPT only re�2004 Arncrican Medical Pssociation. All RlyhCs F.cserv�d. DSI,I and D=i-r✓-Tr: are reoistered trademarks of U7e American ?s'+ch atrlc Association, and art. used whh permission hertm, 1LD-9-Cid 2.ilg9q National [.enter for HEBich Scat,stics (ICD-9 " ilh'prid Health Organization). All Rights Reserved. -rarono --n v H}1�1!3-2003 iniorni ation and Rei=rral Fe._= -ration of Lcs AngLleS Count(, inc. All Rfg,its Reserved littps:r`/��.iv,-iv;.servicept.coma/miami/scripts/sN!prep orthLid. plip 6114/200(3 zvcyuGJl Kill I4,kPdYV1 (Rev. January 2003) Identification Number and Certification oeparu n of are Trea9 y anernM newrW service Name -- .-I a uaC requestBG Do not send to the IRS. N d dT t1 Business name, if different from above c O of C y, O Individual/ Exempt from backup Check appropriate box: El Sole proprietor ❑Corporation El Partnership ❑Other ► Elwritl hold ng o------------ cAddress (number, street, and apt. or suite no.) Requester's name and address (optional) e tiny, state. and ZIP code U d [l Y1 w list account number(s) here (optional) w to Identification Number Enter your TIN in the appropriate box For individuals, this is your social security number (SSN). social mit ntxnDw however, for a resident alien, sole proprielLor, or disregarded entity, see the Part 1 insLucbons on 1 page 3- For rather entities, is is your employer identification number (EIN). If you do not have a number, see kiow to get a TW on page 3- or Note- if the account is in more Man one name, see tike chart w page 4 for guidelines on whose number mPbfe7 idenufKabon number to enter. 1 1 + +1 1) 1 Certification Under penalties of pejury, I certify that i. The number shown on this form is my correct taxpayer iderr0fication number (or I am waiting for 2 number to be issued to me), and 2. I 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 ranger subject to backup withholding, and 3. 1 am a U.S. person (IrKJud"ng a US, resident afien)- Gertirication in5buctions- You must cross out item 2 above if you have been noticed by the IRS that you are currently subject to backup .withholding because you have failed to report all interest and dividends on your tax retum. fox real estate biansactions, item 2 does not apply, For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt contributions to an individual retire nen . arrangement ORA), and generally, payments other than interest and dividends, you are not required to sign the Certification, cwt you must provide your correct TIN. (See the irtsu-uctiorts as page 4.) Sign si�3"ure Of Hem I LLS- Perm Date 0 - Purpose of Form A person who is required to file an information return with the IRS, must obtain your correct taxpayer identification number (IN) 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: ifarequestergives .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: i. The ireaty 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 tojustify the exemption from tax under the terms of the treaty article. Cat. No. 10231X Form W-9 (Rev. 1-2003) FA&npie. 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. VVhat is backup wkhholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 30% of such payments (29% atter 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. Paymerris you receive will be subject to backup untihhoiding if. You do not furnish your TIN to the requester, or 2. You do not certify your TIN when required (see the Part If instructions on page 4 for details), or 3- The IRS tells the requester that you furnished an incorrect TIN, or 4- The iRS tells you that you are 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_ 1f 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 Wilful 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 T1Ns. 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, fist first, and then circle, the name of tfhe 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 reguiations section 301.7701-3, enter the owner's name on the 'Name" line_ Enter the L LC'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. Mote: You are requested to check the appropriate box for your status findividuaUsole 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, Dien 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 tothe 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{t(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: fi. A corporation; 7. A foreign central bank of issue; S. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United'States; . 9_ A futures corrunission merchant registered with the Comrnodity 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 tfrrough 13. Also, a person registered under the Investment Advisers Act of 19411 who regularly acts as a broker Barter exchange transactions Exempt recipients 7 through 5 and patronage dividends Payments over $WO required Generally, exempt recipients to be reported and direct 1 through 7 sales over $5,0W ' 'See Form 10994M[SC. Miscellaneous income, and its instructions. ZHnweva, the ro bowing payments rnade to a corporation (nciudN gross proceeds paid to an aaomey under section, 60450, even if the aaomey is a caaporzbonJ and reportable on Form 10w94AtSC are not exempt from backup withholding: mp&e _al and health care payments, a tomeys' fees; ad payments for services paid by a Federal executive agency. Part I. Taxpayer Identification Number (T1N) Enter your TIN in the appropriate box_ If you are a resident afien 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 erther your SSN or U.N. 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 darFica6cin of name and TIN combinations. Now to get a Ttl1L 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.Sodal Security Administration office or get dws form on -fine at wwwssa_9ov1ordine/ss5_html. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS -4, Application for Employer Identification Number, to apply for an EIN. You can get Forms W-7 and SS -4 from the IRS by calling 1 -800 -TAX -FORM (i-800-829-3676) or from the IRS WebSite at wwwirs_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 instrurnerits, 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 w0l 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.aiready applied for a TIN or that you intend to apply for one soon. caution_ A disregarded domestic errity that has a foreign owner must use the appropriate Form W-8. Part II. 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 .tftrough 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 corisidered 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 thzin bills for merchandise), medical and heafth 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 #his type of account: Give name and SSN of: 1. Individual The individual 2 Two or more individuals jpirit The actual owner of the account account) or, if combined funds, the first individual on the account ' 3. Custodian account of a minor The mina (Uniform Gift ILD Minors Act 4. a. The usual revocable The grantor -trustee' savings trust (grantor is also trustee) b. So-called trust account The actual owner' that is not a legal or valid trust under state law s. Sole proprietorship or The owner ' . single -owner LLC For tivs type of accaxrt_ Give narm and EIN of_ 6_ Sole proprietorship or The owner a singieowner LLC 7. A valid trust, estate, or Legal entity pension trust 8. Corporate or LLC electing The corporation corporate status on Form 8832 9. Association, dub, religious, charitable, educational, or other tax-exempt organization 10. Partnership or muni -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 govemmeM school district or prison) that receives agricultural program payments The organization The partnership The broke or nominee The public entity Lis[ fist and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that parson's number must be furnished. 'Circle the minor's name and furrvish Vie minor's SSN. .'You mast show your individual name, bur you may also enter your business or -DBA- name_ You may use either your SSN or EIN (f you have one). 'List first and circle the name of the legal trust estate, or pension trust (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Note: if no name .is circled when more than one name is listed, the number will be considered to be that of the first name listed. Privacy Act Notice Section 616g of the Internal Revenue. Code. requires-ybu toprovide.-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 irtformatioh to other countries under a tax treaty, or to Federal and state agencies to enforce Federal norrtax 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.. z - u Applicant Certification These certified statements are required by law - Previous versions obsolete form $UD -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 1), 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 ofd 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, se;, disability, familial status or national origin. It will comply with Executive Order 11063 on Equal Opportunity in Housing and tivith 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 13 5), 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 pati to persons residing in the area of the project. It will comply'with'Section504 of the-Rehabilitation--Act-of-197-3-(29-U_S:C:=794);-8--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, an implementing regulations at 24 -CFR Part 146, which prohibit discrimination because of age in projects and activities receiving.Ftd&z, ' financial assistance. It will comply with Executive Orders 11625, 12432, and 12138, wtucn siaie uiaL PLJ61a-' Pu,.".,lr,., 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(x), it will comply with this section's nondiscrimination requirements within the designated population. B_ For SSCP Only. 20 -Year Operation Rule. For applicants receiving assistance for acquisition, rehabilitation or new construction_ The project will be- operated for no less than 20 years from the date of initial occupancy or the date of initial service provision for the purpose specified in the application - 1 -Year Operation Rule. For applicants receiving assistance for supportive services, leasing, or operating costs but not receiving assistance for acquisition, rehabilitation, or new construction_ The project will be operated for the purpose specified in the application for any year for which such assistance is provided. C. For S=C Only. Supportive Services_ It will make available supportive services appropriate to the needs of the population served and equal in value to the aggregate amount of rental assistance funded by HUD for the full term of the rental assistance. D. Explanation. Where the applicant is unable to certify to any of the statements in this certification, such applicant shall attach an explanation behind this page. Signature of Authorized Certifying Oficial: I Bate: Title: Applicant: For PHA. Applicants Only: (PHA, Number) 1I1 'STI-DADE COL".NTY HOMELESS TRUST iNq j Nf-D-I-DF COL ;T)1 KEQ)LTF'ED .-.FFIDA v- T S The convacting indivI'd uaI or :rutin, (governmental or othtrwisc) sha11 indica;: b,an ' all sJ;;,1o,, it that pertain to this contract and shall indicaie by wi "?aA" all a �-jdav its that do not p_,a in [o t!�is cc-ntrac[ Wank spaces must be filled. The 1,.II,A1\•fi-DADE COUNTY OV;NERSHIP DISCLOSURE AFFID.-, VIT; ? Il.�.r�'fl-D.=.Dr CcjLF1,7)' EMPLO)'h1ENT' DISCLOSURE AYFIDAVIT, kfl,-AM]-DADS CF]MR,,1'AL FrCCf:D AFFID.z�,VIT; DISABILITY NpNDISCPTiffNATION AFFIDAVIT; and the PROJECT FRESH ST,!,RT 1-kFFIDAVIT shall not pertain to contracts rrith the United SrZtCS or any of its departm ents or agencies therec)F the Stare or an,,, Political subdivision or aRenc}, thereof or any, municipality of this State. ThAA The Nf1il-DADE FA11•IILY LEAVE AFFIDAVIT shall not pertain to contracts with the United States or any of its departments or agencies or the State of FJorida or any political subdivision or agency thereof; it shall, however, per[ain to municipalities Of the State of Florida. ,All other cornffacring entities or individuals shall read carefully E, aftidavit to determine whether or not it pertains to this contract. I, being first duly sworn states . Affiant The Brit legal name and business address of the persons) or entit}, contracting or transacting business with?v iarni-Dade County are (Post Office addresses are not acceptable): Federzl Emplo}ger ldentirication Nunber (Ifnone, Social Securit}) iJane of Emir _lndividual(s) Parsers, or Co,�o Ltion Doing Business As (if same as above, leave blank) SL-eet Address City State Zip Code _I MIAVE-DADE COUNTY OViNFRSHIP DISCLOSURE AF- IDAVIT (Sec. 2-8.) of the County Code) 1. If the conaci or business transaction is with a corporation, the full legal name and business address shall be provided for each officer and director and each stockholder who holds directly or indirectly live percent (5%) or more of the corporation's stock_ If. the contract or business transaction is with a partnership the foregoing information shall be provided for Eachpa<<ner. If the contract or business . transaction is with a trust, the full legal name and address shall be provided for each trustee and each beneficiary. The foregoing requirements shall not peiain to contracts t�ith publicly, traded corporat[ons or to contracts with the United States or ani- department or agency thereof, the State or any political subdivision oi• agency dicreof or any municipality of this State. All such names and addresses are (Post Office addresses are not acceptable) I nf.i Full Legal h-ame -.deress V0tnc,�-,„ p 2. The full legal names and business address of any other individual (other than subcontractors, rnaleria) men, suppliers, laborers, or lenders) v"vho have, or v.vill ha�je, any interest (legal, equitable beneficial or otherwise) in the contract or business transaction with Dade County are (Post Once addresses are not acceptable).- 3- cceptable): 3. Any person who willfully fails to disclose the information required herein, or who lcno«•in,ly discloses false information in this regard, shall be punished by a fine of up to five hundred dollars (S500. or imprisonment m the Counry jail for up to sixt), (60) days or both. II. 1v1I.A 1�11-DA_DE COUNTY El`/ PLOYMfENT DISCLOSURE AFFIDAVIT (Cour,t3, Ordinance No. 90- 133, Arm tnding sec_ 2.$-1; Subsection (d)(2) of the County Code)_ Except where precluded by federal or State laws or regulations, each contract or business"sansaction or renewal thereof which involves the expenditure Often thousand dollars (51 0,000) or more shall require the erntity ccl-tracting or transacting business to disclose the foliowin� information. The fore oinC7 disclosure requirements do not apply to conu--acts with the United Stares or any depalt-MCBt ora ency thereof, the S pie or ary political subdivision or agencyThereof or any,nuni cipalit of this State_ 1 Does your firm have a collective bargaining agreement wi h im ts eployees? Yes No 2 Does your firm provide paid health care benerits for its employees? L'es No 3. Providea current breakdov n (nurnber ofpersons) ofyour fi,,. 's work force and o-wnership as to race, national origin and gender: White: Males Females Asian: Males Females Black: Males Fen ales American Indian: Hispanics: Males Females Males Females AJeut (Eskimo): Males Females — Males Females: Males Females _III. AFFIRI12.4T7VE ACTION/ CDNIDISCRINfINAT10N OF EMPLOYMENT, PROMOTION AND PROCUR-ENIENT PRACTICES (County Ordinance 98-30 codified at 2-8.1.5 of the County Code.) In accordance «ith County Ordinance No.' 9S-30, entities with annual gross revenues in excess of 55,000,000 seeking to contract with the Counh, shall, as a condition of receivin; a County contract, have: i) a �sTirten affirmative action plan which sets for`ih the procedures the entity utilizes to assure that it does not discriminate in its employment and promotion practices, and ii) a written procurement policy which sets Jr&✓ the procedures the entiry utilizes to assure that 11 does not discriminate against minority and women -owned businesses in its ON�n procurernent ofgoods, supplies and services. Such .airnative action plans and procurement policies shall provide for periodic review to determine their ef;ecui,eness in assuring *&,e entir}, does net discriminate in its emplo��nent, promotion and procurementpracrices. The fore<oin; nonvithstanding, corporate entities whose boards of directors are �j �; r`t)res_nt_;t;ve of ihf population make-up o; the nation sh2li be presumed to have =mplo_`mfnt and pro_uremfrlt policies, and shall not be reol11r,2d ro h2ve wiT17`l pians and procurernea[ p•-,hCles in CT6f]" to re= = u rOL'r - 'contrast. 1 h_' ior-tE:cin_ Gits;ump t1C'n r9 o r`Durled. 1 hie re0ulremen s ofCounn_' Ordinance No. 98-30 mal' be \\•aiV ed ucon the lM-Ezfn rE onmE;,Janon o; the Counry Marager that it is in the bestir,terest o; the Counry to do so and upon approval of the Board Of Counry Commissioners by majority vote of the members present. - The firm does not have annual _Toss revenues in e: -;cess of.S3,000.000. The firm does have annual rcv--hues in e..cess of 55.000,000; ho,vCver, its Board of Directors is represcnrarive of the population majx-up of the nation and has submitted a v71tten. detailed listing of its Board of Directors, including the race or ethniciry of each board member, to the County's Department of Business Development, 175 NT -W, lsr Avenue, 2Sth Floor, 1h91a17rii. Florida 33128_ The fire) has annual gross revenues in E),cess of S5,000,000 and the firm does have a wrlrten afrirnativt action plan and procurement policy as described above, v.,hich includes per iodic reviews to determine effectiveness, and has submitted the plan and policY to the Count_,,'s Department of Business Development 175 N_VI. 1st Avenue, 28th Floor, Miami, Florida 33 ]28; Die firm does not have an affirmative action plan and/or a procurement policy as described above, but has been granted a waiver. —IV. 1,EAIvC-DARE COUNTY CRIl4Uip T RECORD AFFIDAVIT (Section 2-8.6 of the County Code) T}lE individual or entity entering into a contact or receiving funding from theCOunry his has not as of t_he tate of this a i-idavit been convicted.of a felon} durin? the past ten (10) years. — An off cer, director, or e;ieCllilVE oft -lie Eniliv enterIP_g into a contract or recelvinc funding:Torn the County has has not as of tang date of this a=fidavit been convicted ofa felony during the past ten (10) years. L —V- NfAlvL-DADE E?vjTL0-,_, L DRUG-FFIE WORI&LACE nFFIDAV-1T (Cour.y Ordinance No. 92-15 codifed as Section 2-8.12 of the County Code) That in conpiiance With_Ordinance No. 92-I5 ofthe Code of Miami -Dade County, Florida, the above named person or entity is providing a drug-free workplace. A written statement to each employee shall inforn the employee about.- _ 1. danger of dru^ abuse in the workplace 2 the fire's policy of maintaining a dilg-Lee environment at all ~Workplaces. 3. availability of drug counseling, rehabilitation and employee assistance programs 4. penalties that may be imposed upon employees for drug abuse violations The person or entity shall also require an employee to sign a statement, as -a condition of emplo3,ment that the employee will ab.ide by the terms and notify the employer of any criminal drug conviction occurring no later, than f1ve..(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 sen -ice offered by the person or entity male it nccessary for the operation of the County or for the . health, safet-Y u'elfarE, economic benPtits and v,ell-being of the public. Contracts invoh'ing funding °•'hick is pro�'ided-in \� hole or in part b;' the L1>7ited �[ates Or the State of Florida shall be exempted from the provisions of this ordinance in' those instances where those provisions are in conflict �, e the requirement; ofthos t=ovtmrnental €rmtits- I••II?-4•17-DADSBgLOY-.,Ei 1 F,A1.9LYLL��•-..`rID.�i'IT !=��ounn• OrdinEnz- l,2 -9l cod Ifled as ``eciIon I 1 2Q et. seq Cf u t CouG- Codei That In compliance wizh Drdir,ance jtio. l �-9l OT rle Cod--Jf ,•112r ,I-D3d_` (Q( ni ,', t IGfloa, empioyer wjth tirn (50) or more employtfs "orf:in'? in Dade Counr.• for each v-.OTl:ins da.' Burin^ each of nvenry G)0) ' l l p or f77Gfe Calendar �'ofn v.'ee1:5,.Siia rJvId_ th f:;lltD't'ins-, IntGrT a(Ion In compliance with all items in the aforementioned ordinance: An employee who has worked for the above firm at least one (])year shall be entitled to ninen• (90) days of family leave during anti, n�'enn,-four (74') month period, for medical reasons, for the- birth or adoption of a child, or for the case of a child, spouse or other close relative v, -ho has a serious health condition withoutrisk of termination of employment or employErretaliation. The fortgoin, requirements shall not pertain to contracts tivith the United States or any department or agency thereof, or the State of Florida or an}' political subdi�I ion or agency thereof. It shall, however, pertain to municipalities of this State. _VII. DISABILITY NON-DISCPti.INJINATION AFFIDAVIT (County Resolution R-385-95) That the above named firm, corporation or organization is in compliance with and agrees to continue to comply with, and assure that any subcontractor, or.tttird.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 programa and services, transportation communications access to facilities, renovations, and new. construction, in the Follow, lalvs: The Americans with Disabilities Act of 1990 (ADA), Pub- L. 101-336, 104 Stat 327, 42 U.S-C- 13101-12-213 and 47 U.S.C- Sections 225 and 611 including Title I, Employment; Title L, Public Services,- Title IDI Public Accornrnodations 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; T -he Federal Transit Act, as a-men:ied 49 U.S.C. Section 161?; The Fair Housin; Act as amended, 42 U.S.C- Section 3601-3631- The foregoing requirements shall not per-iain to contracts with the United S_atcs or any deparument or agency thereof, the State or any political subdivision or agency thereof or any municipality of this State. _VIII. ALTA-vZ-DARE COUNTY F, FG.LR_D_1NC DELINQUENT AND CUtLR -N i LY DI.1-E FEES OR Tp —X—ES (Sec. 2-5-1(c) of the County Code) Except for small purchase orders and sole source contracts, that above named fi �, , corporation, organization _or individual desiring to.transact business or enter into a contact with the County verifies that -all delinquent and cu,7ently due fees or taxes -- including but not limited to real and Property taxes, utility tal;es and occupational licenses --which are collected in the normal course by the Dade County Tax Collector as yell as Dade County issued parking tickets for vehicles registered in the name ofthe firm, corporation, organization or individual have been paid. CURRENT ON ALL COUNTY CONTRACTS, LOANS AND OT HER OBLIGATIONS The individual entity seeking to transact business with the County is current in all its obligations to the County and is not other -wise in default of any contract, promissory note or other loan document With the Count), or any of its agencies or instrumentalities. --X- ' PR.OIECT FRESH STA -RT (Resolutions R -702-9S and 33S-99) Any, firm that has a contract with the County that results in actual payment of 5500,000 or more shall contribute to Protect Fresh Start, the County's Welfare to 1' �'ork'Initiative. HowEveri if Fj�,e percent ('%o) of the Tirm's work force consists of individuals who reside in Miami -Dade County• and who have lost or will lose cash ass starict {--nefits (fotinerJy Aid to Families with Dependent Children) as a result of the Personal Pcsponsibill ry and Work Opportunir- Reconciliation Act of 1996, the firm mayrep uQsr u'aiverfrom the requirernerts of R-702-98 and R-358-99 b} submitting a v,aiver request a""i^(1731'1L Tne ier-join_ reoulrt-n, f']i do' -s not tt7 n [ iOr L,rC.,j; orrt-TientS ofElranta�.'W-�s. DO;IfE'TI- VDDLE?INCE LEAVE (Ffsolution 1 `-00; 99-; Coditied.lt 11.E-uC) Er. Sett. of the Miami -Dade Coun5, Code). The fm de;irinn to do business 11,-ith d;e County is in compliance with Domestic Leavt Ordinance - Ordinance 99-5, codified at I IA -60 et. seq. of the Miami Dade County Code, wh requ ices an ernplo fr which has in the reLular course of business fit: (50) or more emplove_s ,vorlJng in Miami -Dade Count,,- for each wor}:in, day during each of I vtnty (?0) or mora ca lendar v. orl; weel s in the current or proceedint✓ calendar years, to provide Domestic Violence Lcave to its employee;. 1 have carelullv read this entire five (3) pc°e document entitled, "Miami Dade Counrl AC davits" and have indicated by an all affidavits.that pertain to this contract and have indicated by an "N/A" all aftidavirs that do not pertain to this contract. Py. (Signarure of Aunt) (Date) SUBSCRIBED ,SND SWORN TO (or affirmed) before me this day of 2100 by Hr -/She is personally IM owl' to M or has presented as ld:`ntificatSOr!. (Type of Idtnti kation) (5igriarLre of Nota: -y) (Serial Number) (Print or Siari;p of NoiLry) (Expiration Dale) Notary Public — Stzmp State of Notary Sea) (5 tate) _-issraLA Yll UI,�1I A�LI-D_'Lll� C,•U l;.ti' 1 Y LOBE I"ISTREGIS TRATIO,NFOR 6. 3_L PP-ESENTATIO,N- (I) Pr=Jest 1 i ae:_ (2) C:,p (3) FL1rrfPropcser's ;vane: _ Ad 6, e,S. Eu-�ines; Telephone: (_) Prc _,O,V. Llp: (a) List Q.111dernbers of the Presentation Team 4Y7to Will Be Participating in the Oral P;e;cntation: ME TITLE EMPLOYED BY TEL. NU. (ATTACH ADDITIONAL SHEET IF NECESSARY) The individuals named above are Registered and the Regis tion tee is not reached for the Or Presentation ONLY. Proposers are.advised that any individual substituted fa- or added to the presentation tear; aiier submi?I of the proposal and Si_lling by starT MLT STre,ist=r viith the Clerk of Lhe Board and pay all applicable fees. Other than for the oral presentation; Proposers who wish to address the county corimissior., a cosnty board or count; eornnittee concerning any action, decision or rcco=cndation ofcounty personnel regarding this solicitation MUST register v;ith i?e Clerk o: the Board (Fo= ECCI=ORL7vf-?DCC) and pay all applicable fees.. I do sole,—1nly swczr that all the foregoing facts are nue and correct and I have read o- am fanilia, wi?h the provisions of Section 2-1 1.I(s)ofthe Code of Metropolitan Dade Counyas amended. Signal -e of Authorized Representative; Title: S T ATE CF COUNTYOF• The foregoing instrument Z,,,asacI•no-wedged before me this by a (In.dividual, Officer, Partner or Agent) to me or who has produced Signature ofperson taking ack-towledgerncnt) (Name of .Achnotvledger t-> Ped, printed or stamped) (Title or Rare}:) (Serial Number, if any) ;' ' - Rev. „^; PS vaho is personally known (Sole Proprietor, Corporation or Partnership) as identification and tivho did/did not take an oath. Name of Organization: Address: REQUIRED LISTIN-C, OF SUE CONTRACTORS O.N COUI�'T�' CO.N;TRACT In compliance with l�liarni-Dade County Ordinance 97-10?, the Community Based ��r2ani?ation must submit the list of first tier subcontractors or sub -consultants who �vlll perfopare of the Scope of Sen ices Wor}:, if this Agreement is for 5100,000 or more. The Community Based Organization must complete this information. If the Communiry based Organization tivill not utilize subcontractors, then th_e Community Based Organization must state, `°Ilio Subdontractors will be used', do not state `NIA": Name of Subcontractor orSub-Consultant Address Cite and State REQUIRED LIST OF SUPPLIERS ON COUNTY CONTRACT Tn co TIP!lance with Mia -=-Dade County Ordiiizice 97-10^, t_he Corn_tnu�ity Based Organiz_�tion =lust attach allst of suppliers vvho wi11 supply materials for the Scope of Services LO the Cori -nu n;ty Based Organszation, if this Conttact,Agreenent is SI00,000 or more. The ConmrnLuaity based Organization must fill out i_his il-ifc)=ation. If Lhe Community Based Grga!-iizatio-t wi11 not use suppliers, the Co--= iryBased Organization nest state, "No suppliers r�riIl be used", do riot state "NIA". -- Name of Subcontractor or Sub -Consultant Address City and State I h erebj) cert f l tha! th e foregozii3O' information rs uric, correct and complete: Sibnature of Authorized Representsti.w:.... Title: Firm Nam e: .Address: Telephone: Fax: E -Mail: Fed. ID No.: CitylStatelZip: Date: Comm', I'lori'la SMICO-N TRA(tTC R/SUP P LIE, ft-L'18TINi!3' (ardivauce 97-1.04) N:""t ljr 1)1-""c COITIractur/Noposer RF 1-1 N.99te, UP Number This ForIll, or I colilp-,irl ble listing )IIECting the rul6ire StlPlAirs, milcrills I or services, i I including profs, -1-nQILS of or ill3VICC110. 97-104 MUST be coj*jjDl proposers Oil Call ni), cort(ws for pirlichisc _Ssion,�Ij services wlilch imolvexpendituresI -- I etcd by all b"'Irs arid �Kopllslrs all ColInt, C-xperiditures oFW0,000 or mom. Tilis form, at- ir COMPPI-1,11-11C listing Meeting (lie requi�c(lit(Its Of ot-dill-I NO. 1117-10d, lilust conslructiuit comr ofT,100,000 or more, and 911 bidders and proposers oil COLIM), or h CollipittC(I ct"d st"b"'itted tllougl,Jli,c bidder lice -ji-d "NOMP, jjjlLlc'j- the -,Ippl,o econtractThe hidder or prnpo%cr- sholild ell(cr' ldder Or PrOPOS�r Will not utilize subcontractors or suppliers it the heading OFFOI-111 A -TI in 11105C instances lyllm no subcon(i-iictors or suppliers witl be issecl on tile A bidder 6r'propo! is 'DWI)I'drd Lite contract shall not change or substitute first tier subcontraribirs or direct suppliers or. die portions of the contract worl, to Lie pci-Fomicki or m-nicl-ijI15 to i,Vriiiciji;il Owner) Gcmlcr IUCC Busi is css Nnine and Address OF Uil-ed Supplier Principal Owner to be (Prilicipill owner) Provided by Supplier Ulcc I certify lira( [lie representations containedintlii-q Subron(r:sctoi-/SUPjlHCr US(Ing FIVC (0 the best or 11)), knowledge true and i1CCA11-:11C, i Senriture OrPruj)osi!r'5 Z Print Name Print "Cine Date SPICC is needed) I'mm A l l At -ti 5U --IN 1 N APPLICANT OR RECIPIENT SEC-RON 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 bw 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 tc) development and implementation of a Section 3 Economic Opportunity Pian for Miami -Dade Housing Agency (MDHA) approval, prior to selection of an archiLa-a 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 m 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 Js 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 apQlicant or rediknt certifies and agrees fihat it is under no contractual or other impediment which would DT --Vent it from comQlving vii , 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. OWNERS FIRM NAME (Print or Type Name): AUTHORIZED SIGNATURE SIGNATURE Affix Notary Seal to the Right "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 employee and applicants for training and employment positions can see the notice. The notice shall describe the Section 3 preference, shall set forth minimum number and job titles subject to hire, availability of apprenticeship and training positions, the qualifications for each; and the nave and location of the person(s) taldng applications for each of the positions; and the anticipated date the work shalt beoin. 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 CPR 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 arose 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 regulations in 24 CFR Part 13.5 may result in sanctions, termination of the contract for default, and debarment or suspension from future HUD assisted contracts. G. (W,�i�t,� respect to work performed in connection with Section 3 covered Indian housing assistance, ✓wLiv^ 7(b) Of the %titan .3clf-0e-erminabon, and Edduc' n Assis ariCe ALL (23 U.J.C. 45uC) also applies to the work to be peiforrned 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). SWOP.N STATEME,�`T PUPSU.A:NT TO SECTION 'S 133 (:) FLOP IUA ST.ATItTES. ON'PUELIC ENTITY CRIME -S THIS FORM 1v1UST BE SIGNED AND SiVCFN TO iJ THE Pi rSENtCE OF NOT.'�F:Y PLTPLIC OR OTHE?? OFFICI.-'.L .1LITHr?j'1ZSU TO � D:�IL',tIST;LF; OATHS. I. This sworn statement is submined to Aliami-Dade County: bY (print individual's name and title) for (print name of entity submitting sworn statement) whose business address is and (if applicable) its Federal Employer Identifcation Number (FEIN) is (if the entity has no FFrN, include the Social Securjq Number of the individual signang this sworn statement:) I understand that a "public entity crime" as defined in Paragraph Z97.133(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 ennry or with an agency or po'irical subdivision of any other state of the United SLtes, including, but not limited to, any bid or contract for goods or services to be provided to any public entipY or an agency or political subdivision ofany other state Of the United States and involving antitrust, fraud, thee, bribery, collusion, rackereerin" conspiracy, Orn atetial misrepresentation. I understand that "convicted" or "conviction" as defined in Paragraph 257. l33(1)(b) Florida Statutes, means a Finding of wilt or a conviction ofa public entity crime, with or ��Iithout an adjudication of guilt, in any federal or state tial cowl of record relating to.charges brought by indictment o; information alter July 1, 1959, as a result ofa jLry verdict, nor, jury trial, or entry of Plea of guilty or nolo contendere. 4" 1 understand that an "a_iiliate" as defined in Paragraph ?87.133(1)(a) Florida Statutes. means: a. A predecessor or successor ofa person convicted ofa public entity crime; or, b. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The tern "affiliate: includes those Officers, directors, executives, partners shareholders, employees, members, and agents who are active in the management of, an affiliate. The ownership by one person of shares constituting a controlling interest -in another person, or pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters inro a joint venture with a person 4vhc has been convicted ofa pubic entity_ crime in Florida during the preceding 36 months shall be considered an affiliate. I understand that a "person" 2s defined in.Paragraph 287.133(1)(et), Florida Statutes. means any natural person or erttit:)- or cani-7ed under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid or contracts for the provision ofgoods or services let bya public entire, or which otherwise transacts or applies to transact business with a public entity. The tenT erson" includes those oiflcer5, directors, executives, arner- '- „p p �, sliareholu,.r;, emplo;'ees, members; and agents i;'I10 are score in management or" an emir. 6. i� uaS'_C UrJ In iUTai!On and b'.11.i the Et'['_:T,e.rii, �',`I11Cri 1 ham, _` JTa;a_C b_ii='.',� !S iSu` in rel2:ivn enUr,' ZUbmiliJn?S a v r ..n. _ C:'ll� ", OrTi i i Hent. ( ,Pl_•e k'cither the entity submil,im; this st°,orn state:1Jent, nor any of its OT -r-, director;. e:•:ecutJves, partners, shareholder, emplovees, members, or agents \+•ho, art a--tive n Ih; manaeerrlent of the entity, nor the affiliate of the en!i!y has b° -.n char_ -ed Jviih and convicted of a public entir, crime within the pas! 36 months. ftie, iThe entih, submirting this -Nvorn staerneni, or one or more of idrector;, e):ccutives, panmrs, shareholders, employees, members, or agents vrho are active in the management of the entip', or an affiliate of the entity has btcn charged with an comic ed of a public entity crime within the past 36 months .AND (Please indicate which additional statement applies) The entity submitting this sworn .statement, CIT one or more of its ofticers, directors, executives, partners, shareholders, employees, members, or agents who are active in the, management of the entity, or an affiliate of the entity has been charged with an convicted of a public entity crime within the past 36 months. Hovrever, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, division of Administrative Hearings and the Final Order entered by the Hearing Officer determined drat it was not in the public interest to place the entity submitting Lhis swornstate_meni on the convicteq vendor list (attach a copy of the final order). I 'UNDERSTAND THkT THE SUBMISSION OF 'THIS . FORM TO THE CONTRACTI.NG OFFICER FOR THE PUBLIC ENTITY IDENTIFIED, IN PARAGRAPH I (ONE) ABOVE IS FOR TK, T PUBLIC ENTITY OINLY AND, TF -LAT THIS FORM IS VALID THROUGH THE LJrE OF THE CONTRACT. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CCNTRACi IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN, SECTION 287.017, FLORIDA STATUTES FORCATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTRAINED IN THIS FORM, {Signature) (date) STA 1 h- OF COUNTY OF PERSONALLY APPEALED BEFORE ME, the undersigned authority (name of individual signing) 'who, after, first being sworn by rne, affixed his/her signature in the space provided above on this day of 20_ NOTARY PUBLIC HY commission e::pires: ATTACHMENT P Provider Name: Program Name: Funding Source: Reporting Period: MIAMI -RADE COUNTY HOMELESS TRUST PROVIDER ASSET INVENTORY Description Serial l ID of kroperty Number Acquisition Acquisition Vendor % of vocation of Use and Who holds Date Cost Name Purchase Property Condition Title of Cost from of Property Property Grant ** Attach invoices for all purchases this grant reporting period. ATTACMI TENT Q INSERT COPY OF DECLARATION OF RESTRICTIVE COVENANTS (IF APPLICABLE) ATTACHMENT Q-1 INSERT COPY OF DECLARATION OF RESTRICTIONS (IF APPLICABLE) ATTACHMENT R FOR GOVERNMENT ENTITIES ONLY — Semi -Annual Employee Certification for Supportive Housing Programs "This form: to be submitted to Miami -Dade County Homeless Trust every six (6) months. Agency Grant Number Program Name Duration /Period Covered to The following employee (s) worked solely on the Supportive Housing Progo rm (SHIP) project referenced above. By signing, I hereby certify that I have worked 100%, of the time on the referenced Supportive Housing Program (SHV) project during the period specified above. Su t T'8'' 4UT fit`?sitt c`r 'on: L��2me ? ctie Si,-P;at {r -e Date I I hereby certify as the, supervisor of the above named employee (s) that he /she /they have worked solely on the referenced Supportive Housing Program (SIP) project during the period specified above IIIAMPDADE INCIDENT REPORT IDENTIFYING INFORMATION ATTACHMENT S Reporting Party Phone # Date of Incident Titne of Incident am/pm Reporting Party Name Co -un -act Provider Name Program Name Provider location Specific Program: (check all that apply) El HT El Primary Care 0 SIR El Emergency El Challenge mer - .e 'where wcae7d ocwrred TWE OF INCIDENT El ALTERC,4TION 01 CLIENT DEATH - El CLIENT INJURY OR ILLNESS 0 MEFT E -j SEXU,4L BATTERY El SUICIDE A -TTEAPT El PROPER-TYDAM4GE D OTHER INCIDENT Specify PARTICIPANT. (S) /'WITNESS (ES) (Please mark W or P for either Witness or Participant) LAST NAME, FIRST IDENTIFIER # CLIENT EMPLOYEE OTBER W/P ❑ El' 1 of 3 MIA M I-i]►ADE I DESCRIPTION OF INCIDENT I Give detailed account — who, what, where, when, why, how — add pages if necessary - CORRECTIVE ACTION AND FOLLOW UP immediate corrective action taken Is follow up action needed? ❑ yes ❑ No If yes, specify I . INDIVIDUALS NOTIFIED I 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 -Bade 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 St reed 27" Floor, Suite 310, Miami, Florida 33128; telephone (305) 375-1490 and facsmilie (305) 375-2722. 2 of 3 M!A M 1 a4DE 4 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 Iniury 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, of hostage situation, which jeopardizes the health, safety and welfare of clients- e Sexual Batter -y. An aflegation 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 Attem.t. An act which clearly reflects the physical attempt- by a client to cause his or her own death whsle 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. PropertyDamage An incident involving damage to property procured with Homeless Trust funding. Print Nance of Person Submitting Report Signature 3 of 3