HomeMy WebLinkAboutExhibitAGREEMENT BETWEEN MIAMI-DADE COUNTY
AND CITY OF MIAMI
FOR A 2009 SUPPORTIVE HOUSING PROGRAM GRANT FL021IB4D000802
HOMELESS ASSISTANCE PROGRAM
THIS AGREEMENT, entered this _ day of , 200 , by and between Miami -
Dade County (herein called the "Grantee") and City of Miami, (hereinafter referred to as the
"Subrecipient") under this Agreement.
WHEREAS, the Grantee has applied for and received funds from the United States Government under
Title IV of the Stewart B. McKinney Homeless Assistance Act; and
WHEREAS, the Grantee agrees to comply with all requirements of this Agreement and to accept
responsibility for such compliance by the Subrecipient to which it makes grant funds available; and
NOW. -THEREFORE, it is agreed between the parties hereto that;
STATEMENT OF WORK:
A. Activities
The Subrecipient shall adhere to the "2009 Supportive Housing Program Grant Agreement'
Attachment A, which is governed by the Supportive Housing Program rules, 24 CFR Part
583. The Subrecipient shall carry out the activities specified in the "Scope of Services"
Attachment A-1, "Housing Type, Number of Units, Bedrooms, Beds, and Participants",
Attachment A-2, achieve "Performance Measures/Goals" as stipulated in Attachment A-3,
and "Project Milestones", Attachment A-4 as applicable. The Subrecipient shall also adhere
to minimum standards of housing and services as set forth in the "Standards of Care",
incorporated herein by reference.
B. Time Schedule
1. The Grantee and the Subrecipient agree that this Agreement shall become effective on
June 1, 2010.
2. This Agreement shall expire May 31, 2011, one (1) year from the effective date. Any
cost incurred by the Subrecipient beyond this date will not be paid by the Grantee, except
as specifically provided herein. Notwithstanding any provision herein to the contrary,
certain requirements imposed on the Subrecipient by this Agreement and Federal
regulation may continue for a term of at least twenty (20) years, as provided in this
Agreement.
3. The requirements of this Agreement shall remain in effect during any time period that
the Subrecipient has control over any funds generated or provided in connection with
this Agreement, including program income.
GRANT NUMBER: FL0211B4D000802
City of Miami — Homeless Assistance Program / Page 2 of 23
C. Budget
The Grantee agrees, subject to the availability of funds and payment of funds to the Grantee
by the United States Department of Housing and Urban Development, to pay for contracted
activities according to the terms and conditions contained within this Agreement, the
Subrecipienfs application for the Supportive Housing Program, and the Subrecipient's
Technical Submission incorporated herein as Attachment B, the Budget, in an amount not
to exceed $239,116.00 for Supportive Services, and $11,955.00 for administration (minus
2.5% administrative costs to be retained by the Grantee), for a total budget of $251,071.00. If
applicable, in accordance with Federal Regulations, provider shall be reimbursed for capital
funding on an incremental basis, based on the following completion benchmarks: 30%, 30%,
30%, and 10% to be provided when a final Certificate of Occupancy is obtained from the
developer. All other activities shall be paid on a reimbursement basis following the
submission of a monthly invoice along with the appropriate support documentation.
In accordance with federal requirements, the Subrecipient agrees to provide match funds in
an amount that represents no less than twenty perent (20%) of the total supportive services
budget, or twenty-five percent (25%) of the SHP supportive services funding, and no less than
twenty-five percent (25%) of the total operations budget.
The budget figures above represent the original line item totals as delineated in the grant
agreement. Submitted budgets that shift funds by less than 10% of the original line item
totals of the grant agreement may become official only if the appropriate match is provided,
the administration total is not increased and Miami -Dade County Homeless Trust approves
the shift of funds. As such, the figures in the Technical Submission Attachment B may not
match the contracted figures delineated in the original contract and grant agreement.
Notwithstanding the above, changes of more than 10% in any line item total as delineated in
the grant agreement shall require a formal budget approval and an amendment to the grant
agreement.
The Subrecipient shall provide supportive outreach services to 3,000 homeless persons
(individuals and families). Of the 3,000 homeless persons there shall be at least 2,850
assessments and at least 1,500 placements of homeless persons. This shall occur primarily in
the City of Miami and outreach, assessments and placements within Miami -Dade County.
Additionally, of the 3000 homeless persons, the Subrecipient shall place at least 180 homeless
persons into transitional treatment supportive housing. The project's main office is located at
1490 NW 3`d Avenue, Miami, Florida.
11. RECORDS AND REPORTS
A. Financial Mana ement
The Grantee and the Subrecipient shall adhere to the requirements for financial
reporting as stated in 24 CFR Part 85.41.
2. Requests for payments, along with documentation for each line item, i.e. invoice for
services/housing, capital invoice (if applicable), lease agreement, payroll reports, shall be
submitted to the Grantee by the thirtieth (30th) of the month and shall be signed by the
GRANT NUMBER: FL0211B413000802
City of Miami — Homeless Assistance Program / Page 3 of 23
Executive Director and or the Financial Officer of the Subrecipient, in the form
incorporated herein as Attachments C and C-1.
Reimbursement shall be provided only for costs associated with the services detailed in
the budget, plus general administrative costs (not to exceed 2.5% of direct costs).
Any reimbursement may be withheld pending the receipt and approval by the Grantee of
all reports and documents required herein, including but not limited to the submission of
the Annual Progress Report.
In no event shall the Grantee's funds be advanced to any subcontractor hereunder.
The parties agree that the Subrecipient may request the revision of the schedule of
payments or the line item budget. However, such revisions shall be subject to review and
approval by the Grantee. Such requests shall only be considered at least ninety (90)
days prior to the expiration of the grant, if there is a shift of 10% or more of funds
between line items of any activity, supportive services, operations, or leasing or there is a
significant change to the program. Requests for minor modifications (for example less
than 10% shift of funds between line items) must be submited at least forty-five (45)
days prior to the expiration of the grant. Failure to submit the appropriate supporting
documentation in a timely manner may result in the Grantee's inability to amend the
budget.
7. A final request for reimbursement from the Subrecipient will be accepted by the Grantee
up to thirty (30) days after the expiration of this Agreement. If the Subrecipient fails to
comply, all rights to payments will be forfeited if the Grantee so chooses.
8. Within thirty (30) days of the termination or expiration of this Agreement, a final report
of expenditures shall be submitted to the Grantee. If after the receipt of such final report,
the Grantee determines that .the Subrecipient has been paid funds not in compliance with
the Agreement, and to which it is not entitled, the Subrecipient will be required to return
such funds to the Grantee or submit documentation demonstrating that the expenditure
was in compliance with this Agreement. The Grantee shall have the sole and absolute
discretion to determine if the Subrecipient is entitled to such funds and the Grantee's
decision in this matter shall be final and binding.
B. Records and Access to Records
Agreement Records are defined as any and all books, records, client files (including
client progress reports, referral forms, etc.), documents, infonnation, data, papers, letters,
materials, electronic storage data and media whether written, printed electronic or
electrical, however collected or preserved which is or was produced, developed,
maintained, completed, received, or compiled by or at the direction of the Subrecipient
or any subcontractor directly or indirectly related to the duties and obligations required
by terms of this contract, including but not limited to financial books and records,
ledgers, drawings, maps, pamphlets, designs, electronic tapes, computer drives and
diskettes or surreys.
2. The Subrecipient must maintain Agreement Records that document all actions to comply
with this Agreement, including those on race, ethnicity, gender, and disability status
GRANT NUMBER: FL021113413000802
City of Miami — Homeless Assistance Program / Page 4 of 23
data; and those in accordance with generally accepted accounting principles, procedures,
and practices as required in Circular OMB -122 which shall sufficiently and properly
reflect all revenues and expenditures of funds provided directly or indirectly by the
Grantee pursuant to the terms of this Agreement which shall include but not be limited to
a cash receipt journal, cash disbursement journal, general ledger, and all such subsidiary
ledgers as may be reasonably necessary.
The Subrecipient shall provide to the Grantee, upon request by the Grantee, all
Agreement Records. The requested Agreement Records shall become the property of the
Grantee without restriction, reservation, or limitation of their use and shall be made
available by the Subrecipient at any time upon request by the Grantee. The Grantee shall
have unlimited rights to all books, articles, or other copyrightable materials developed in
the performance of this Agreement. These unlimited rights include the rights of royalty -
free, nonexclusive, and irrevocable license to reproduce, publish, or otherwise use, and
to authorize others to use the work for public purposes.
The Subrecipient shall ensure that the Agreement Records shall at all times be subject to
and available for full access and review, inspection, or audit by Grantee and Federal
personnel and any other persons so authorized by the Grantee.
The Subrecipient shall include in all the Grantee -approved subcontracts used to engage
subcontractors to carry out any eligible substantive programmatic services, as such
services are described in this Agreement and defined by the Grantee, each of the record-
keeping and audit requirements detailed in this Agreement. The Grantee shall, in its sole
and absolute discretion, determine when services are eligible substantive programmatic
services and subject to the audit and record-keeping requirements described in this
Agreement. These records shall be maintained as pursuant to this Agreement.
6. If the Subrecipient received funds from or is under regulatory control of other
governmental agencies, and those agencies issue monitoring reports, regulatory
examinations, or other similar reports, then the Subrecipient shall provide to the Grantee
a copy of each report and any follow-up communications and reports immediately upon
such issuance unless such a disclosure is a violation of those agencies' rules.
C. Reports
The Subrecipient shall submit to the Grantee the reports described below or any other document in
whatever form, manner, or frequency as may be requested by the Grantee. These will be used for
monitoring the provider's progress, performance, and compliance with applicable Grantee and
Federal requirements.
Progress Reports — Subrecipient shall submit a HMIS generated, "Monthly Progress
Report (MPR)," Attachment D, along with the following monthly reports using the
forms attached hereto as "Client Contribution Report" Attachment F, as they may be
revised by the Grantee, which shall describe the progress made by the Subrecipient in
achieving each of the objectives identified in Attachment A-3.
The reports shall explain the Subrecipient's progress including comparisons of actual
versus plarmed progress forfhe-period. Thi reports are due by the thirtieth (30th) day of
GRANT NUMBER: FL0211B4D000802
City of Miami — Homeless Assistance Program / Page 5 of 23
the following month, along with the request for reimbursement, following the close of
the prior month.
2. Annual Progress Report - The Subrecipient shall submit a HMIS generated Annual
Progress Report in addition to a complete and accurate report using the United States
Department of Housing and Urban Development (HUD) form HUD -40118, "Annual
Progress Report (APR) for Competitive Homeless Assistance Programs" (Refer to
Attachment G and G -1). The complete and accurate APR is due to the Grantee sixty
days after the end of each operating year.
3. "Program Rating and Satisfaction Survey" Attachment E shall be collected and retained
monthly by the Subrecipient in a separate file and available for review and monitoring,
or as requested by the Grantee.
Audit Reports - The Subrecipient shall provide two (2) copies of an annual certified
public accountant's opinion and related financial statements on the organization to the
Grantee no later than one -hundred and eighty (180} calendar days following the end of
the Subrecipient's fiscal year, for each year during which this Agreement remains in
force or until all funds earned from this Agreement have been so audited, whichever is
later, provided that the Subrecipient has such an opinion prepared.
Annual Assurance Report - The Subrecipient who receives assistance only for leasing,
operating costs, or supportive services costs must provide an annual assurance report for
each year the assistance is received that the project will be operated for the purpose
specified in the application.
6. Employee Certification Form — Government Entities ONLY - The Subrecipient is
required to submit semi-annually certifications for those employees working solely on a
particular Supportive Housing Program (SHP) grant. The certification must be signed by
the employee and the supervisor and conform to OMB Circular A-87 Attachment B (h)
(3). "Employee Certification form" Attachment R, must be submitted in January and
July of each year with the reimbursement request.
7. Incident Reports — The Subrecipient must report to Miami -Dade County Homeless Trust
information related to any critical incidents occurring during the administration term of
its programs, form "Incident Report" Attachment S. In addition to reporting this incident
to the appropriate authorities the Subrecipient must within twenty-four (24) hours of any
incident, submit in writing a detailed account of the incident. This incident report should
be addressed to the Contract Officer or Administrative Officer assigned. This incident
report should be addressed to Miami -Dade County Homeless Trust, 111 NW First Street,
27th Floor, Suite 310, Miami, Florida 33128; telephone (305) 375-1490 and facsmilie
(305) 375-2722.
8. Disaster Plan — The Subrecipient shall submit an Agency Disaster Plan by April 15t of
each Contract year.
D. Staff Responsibility
The staff members for this grant are listed in the `Budget" document Attachment B.
GRANT NUMBER: FL0211 B413000802
City of Miami — Homeless Assistance Program / Page 6 of 23
E. Special Conditions
The Subrecipient shall follow the client referral process as listed in the "Scope of Services,"
Attachment A-1.
The Subrecipient shall provide any documentation, such as the "W-9 form" Attachment H to
facilitate the reimbursement of services.
F. General Conditions
The Subrecipient shall comply with all Federal laws, and regulations, as specified in the
Applicant Certifications Attachment I, the Renewal Grant Agreement and the accompanying
24 CFR Part 583, Supportive Housing Program regulations Attachment A, and all other
Federal requirements of this grant. The responsibility for knowledge of and compliance with
all Federal requirements is that of the Subrecipient.
The Subrecipient shall abide and be governed by the requirements of the Americans with
Disabilities Act (ADA).
In addition, the Subrecipient agrees to comply with the following requirements.
Insurance
Government Entities — If the Subrecipient is the State of Florida or an agency or
political subdivision of the State as defined by Section 768.28, Florida Statutes, the
Subrecipient shall furnish the County, upon request, written verification of liability
protection in accordance with Section 768.28, Florida Statutes. Nothing herein shall
be construed to extend any party's liability beyond that provided in Section 768.28,
Florida Statutes.
The Subrecipient shall maintain required liability insurance coverage as noted below at
all times during this contract period:
Public Liability Insurance on a comprehensive basis in an amount not less than.
$300,000 combined single limit for bodily injury and property damage. The Grantee
must be shown as an additional insured with respect to this coverage, as evidenced by a
certificate of insurance.
Automobile Liability Insurance covering all owned, non -owned and hired vehicles
used in connection with this contract in an amount not less than $300,000 combined
single limit for bodily injury and property damage.
Workman's Compensation Insurance for all employees of the Subrecipient as
required by K Statute 440.
-Flood lnsuTwnee gall ire maintained as per the requirements in 24 CFR Part 583.330(a).
GRANT NUMBER: FL0211 B4D000802
City of Miami — Homeless Assistance Program / Page 7 of 23
The insurance coverage required shall include these classifications, listed in standard
liability insurance manuals, which most nearly reflect the operations of the Subrecipient.
All insurance policies required above shall be issued by companies authorized to do
business under the laws of the State of Florida, with the following qualifications:
The company must be rated no less than "B" as to management, and no less than
"Class V" as to financial strength by the latest edition of Best's Insurance Guide,
published by A. M. Best Company, Oldwick, New Jersey, or its equivalent, subject to the
approval of the County Risk Management Division.
or
Compliance with the foregoing requirements shall not relieve the Subrecipient of its
liability and obligations under this section or under any other section of this Agreement.
No modification or waiver of any of the aforementioned insurance requirements shall be
made without thirty (30) days written advance notice to the Grantee, and is subject to the
approval of the Grantee's Risk Management Division.
2. Indemnification
Pursuant to the provisions of Section 768.28, F -S. (2008), the Subrecipient shall
indemnify and hold harmless the Grantee and its past, present, and future employees and
agents from and against any and all claims, liabilities, losses, and causes of action which
may arise out of the actions or negligence, in whole or in part, of the Subrecipient, its
officers, agents, employees, or assignees in the direct or indirect fulfillment of this
Agreement. The contractor shall pay all claims and losses of any nature in connection
therewith, and shall defend all suits, in the name of the Grantee when applicable, and
shall pay all costs and judgments which may issue thereon. It is expressly understood and
intended that the Subrecipient is an independent contractor and is not an agent of the
Grantee.
The Subrecipient shall disclose to the Grantee in writing any possible or actual conflicts
of interest or apparent improprieties of the kind addressed herein. The Subrecipient shall
make each disclosure in writing to the Grantee immediately upon the Subrecipient's
discovery of such possible conflict. The Grantee will then render an opinion which shall
be binding on all parties.
Affidavits
Complete and notarize, Miami -Dade County Required Affidavits Attachment J,
Lobbyist Registration for Oral Presentation Attachment K and Florida Statutes, on
Public Entity Crimes Attachment O, acknowledging compliance with the following
Miami -Dade County Affidavits:
a. DisaWity Nondiscrimination Affidavit Attachment J, Section VII.
b. fainilyL veflan Affidavit Attachment J, Section VI.
GRANT NUMBER: FL021113413000802
City of Miami — Homeless Assistance Program / Page 8 of 23
C. Drug-free Workplace Affidavit — Ordinance No. 92-15 Attachment J, Section V.
d. Miami -Dade County Disclosure Affidavit Attachment J, Section I.
Miami -Dade County Employment Disclosure Affidavit Attachment J, Section H.
f. All Subrecipients are advised that in accordance with Section 2-11.1 (s) of the
Code of Miami -Dade County, the Lobbyists Registration for Oral Presentation
Affidavit, Attachment K, MUST be completed, notarized, and included with the
Agreement. Lobbyist specifically includes the principal, as well as any agent,
officer, or employee of a principal, regardless of whether such lobbying activities
fall within the normal scope of employment of such agent, officer or employee.
g. Miami -Dade County Criminal Record Affidavit Attachment J, Section IV.
h. Delinquent and Currently Due Fees or Taxes - The Subrecipient has duly executed
the Affidavit regarding "Delinquent and Currently Due Fees or Taxes" as
required by Section 2-8.1(c) of the County Code and that affidavit is attached
hereto as Attachment J, Section VIII. The Subrecipient understands that the
County has relied on the aforementioned representation in entering this contract.
Affirmative Action/Nondiscrimination of Employment, Promotion and
Procurement Practices (County Ordinance 98-30) Attachment J, Section M.
Project Fresh Start (Resolutions R-702-98 and 358-99) Attachment J, Section X.
G. Civil Rights
The Subrecipient agrees to abide by Chapter IIA of the Code of Miami -Dade County
("County Code"), as amended, which prohibits discrimination in employment, housing and
public accommodations.
Where applicable the Subrecipient agrees to abide and be governed by Title VI and VII, Civil
Rights Act of 1964 (42 USC 2000 D&E) and Title VIII of the Civil Rights Act of 1968, as
amended, and Executive Order 11063 which provides in part that there will be no
discrimination of race, color, sex, religious background, ancestry or national origin in
performance of this Agreement, in regard to persons served, or in regard to employees or
applicants for employment or housing. It is expressly understood that upon receipt of
evidence of such discrimination, the County shall have the right to terminate said Agreement.
It is further understood that the Subrecipient must submit an affidavit attesting that it is not in
violation of the American with Disabilities Act, the Rehabilitation Act, the Federal Transit
Act, 49 USC § 1612, and the Fair Housing Act, 42 USC § 3601 et seq. If the Subrecipient or
any owner, subsidiary , or other firm affiliated with or related to the Subrecipient, is found by
the responsible enforcement agency, the Courts or the County to be in violation of these Acts,
the County will conduct no further business with the Subrecipient. Any contract entered into
based upon a false affidavit shall be voidable by the County. If the Subrecipient violates any
of the Acts during the term of any Contract the Subrecipient has with the County, such
Contract shall be -voidable by the .County, .even if the Subrecipient was not in violation at the
time it submitted its affidavit.
GRANT NUMBER: FL0211 B4D000802
City of Miami — Homeless Assistance Program / Page 9 of 23
The Subrecipient agrees that it is in compliance with the Domestice Violence Leave, codified
as § 11-A60 et. Seq. of the Miami -Dade County Code, which requires an employer, who in
the regular course of business has fifty (50) or more employees working in Miami -Dade
County for each working day during each of twenty (20) or more calendar work weeks to
provide domestic violence leave to its employees. Failure to comply with this local law may
be grounds for voiding or terminating this Contract or for commencement of debarment
proceedings against the Subrecipient.
The Subrecipient also agrees to abide and be governed by the Age Discrimination Act of
1975, as amended, which provides in part that there shall be no discrimination against persons
in any area of employment because of age. The Subrecipient agrees to abide and be goverened
by Section 504 of the Rehabilitation Act of 1973, as amended, 29 USC 794, which prohibits
discrimination on the basis of handicap. The Subrecipient agrees to abide and be governed by
the requirements of the Americans with Disabilities Act (ADA).
III. SUSPENSION AND TERMINATION
A. Suspension
The Grantee may, for reasonable cause, temporarily suspend the Subrecipienfs operations and
authority to obligate funds under this Agreement or withhold payments to the Subrecipient
pending necessary corrective action by the Subrecipient or both.
Reasonable cause shall be determined by the Grantee and in its sole and absolute discretion
and may include:
Ineffective or improper use of any funds provided hereunder by the
Subrecipient;
2. Failure by the Subrecipient to materially comply with any terms, conditions,
representations or warranties contained herein;
Failure by the Subrecipient to submit any documents required by this
Agreement; or
4. The Subrecipient's submittal of incorrect or incomplete documents
B. Termination
1. Termination at Will - This Agreement, in whole or in part, may be terminated
by the Grantee upon no less than fifteen (15) working days notice when the
Grantee determines that it would be in the best interest of the Grantee and/or the
recipient materially fails to comply with the terms and conditions of an award.
Said notice shall be delivered by certified mail, return receipt requested, or in
person.with proof of delivery_ Tire Subrecipient will have five (5) days from the
day the notice is delivered to state why it is not in the best interest of the Grantee
to'teiminatethe Agreement. However, it is up to the discretion of the Grantee to
make the final determination as to what is in its best interest.
GRANT NUMBER: FL0211B4D000802
City of Miami — Homeless Assistance Program / Page 10 of 23
2. Termination for Convenience - The Grantee or subrecipient may terminate this
Agreement, in whole or part, when both parties agree that the continuation of the
activities would not produce beneficial results commensurate with the further
expenditure of funds. Both parties shall agree upon the tennination conditions,
including the effective date and in the case of partial termination, the portion to
be terminated. However, if the grantee determines in the case of partial
termination that the reduced or modified portion of the grant will not accomplish
the purposes for which the grant was made it may terminate the grant in its
entirety.
3. Termination Because of a Lack of Funds - In the event funds to finance this
Agreement become unavailable, the Grantee may terminate this Agreement
upon no less than twenty-four (24) hours notice in writing to the Subrecipient.
Said notice shall be sent by certified mail, return receipt requested, or in person
with proof of delivery. The Grantee shall be the final authority to determine
whether or not funds are available.
4. Termination for Breach - The County may terminate this Agreement, in whole,
or in part, when the County determines in its sole and absolute discretion that the
Provider is not making sufficient progress in its performance of this Agreement
as outlined in Attachment A, Scope of Services, or is not materially complying
with any term or provision provided herein, including the following: 1) The
Provider ineffectively or improperly uses the County funds allocated under this
Contract; 2) the Provider does not furnish the Certificates of Insurance required
by this contract or as determined by the County's Risk Management Division; 3)
the Provider does not furnish proof of licensure/certification or proof of
background screening required by this Contract; 4) the Provider fails to submit
or submits incomplete or incorrect detailed reports of expenditures or final
expenditure reports; 5) the Provider does not submit or submits incomplete or
incorrect required reports; 6) the provider refuses to allow the County access to
records or refuses to allow the County to monitor, evaluate and review the
Provider's program; 7) the Provider discriminates under any of the laws outlined
in Section II(G) of this Contract; 8) the Provider fails to provide Domestic
Violence Leave to its employees pursuant to local law; 9) the Provider falsifies
or violates the provisions of the Drug Free Workplace Affidavit; 10) the Provider
attempts to meet its obligations under this contract through fraud,
misrepresentation or material misstatement; 11) the Provider fails to correct
deficiencies found during a monitoring, evaluation or review within the specified
time; 12) the Provider fails to meet the terms and conditions of any obligation
under any contract or otherwise or any repayment schedule to the County or any
of its agencies or instrumentalities; 13) fails to meet any of the terms and
conditions of the Miami -Dade County Affidavits; 14) the Provider fails to fulfill
in a timely and proper manner any and all of its obligations, covenants,
agreements and stipulations in this Contact. The Provider shall be given written
notice of the claimed breach and 10 business days to cure same. Unless the
Provider's breach is waived by the County in writing, or unless the Provider shall
have failed after receiving written notice of the claimed breach by the County to
take steps to cure the breach within 10 business days after receipt of the breach,
the County may, by written notice to the Provider, terminate this Agreement
GRANT NUMBER: FL0211 B4D000802
City of Miami — Homeless Assistance Program / Page 11 of 23
upon no less than twenty-four (24) hours notice. Said notice shall be sent by
certified mail, return receipt requested, or in person with proof of delivery.
Waiver of breach of any provision of this Agreement shall not be construed to be
a modification of the terms of this Agreement. The provisions contained herein
do not limit the County's right to legal or equitable remedies or any other
provision for termination under this contract. Such individual or entity shall be
responsible for all direct and indirect costs associated with such termination or
cancellation, including attorney's fees. Any individual or entity who attempts to
meet its contractual obligations with the County through fraud, misrepresentation
or material misstatement ma be disbarred from County contracting for up to five
(5) years.
IV. REVERSION OF ASSETS
A. Term of Commitment
If the Subrecipient receives assistance for acquisition, rehabilitation, or new construction,
then the Subrecipient shall agree to operate the supportive housing or provide supportive
services in accordance with this Agreement for a term of at least 20 years from the date of
initial occupancy or date of initial service provision. If the United States Department of
Housing and Urban Development (HUD) determines a project is no longer needed for use as
supportive housing or to provide supportive services, then HUD may provide authorization to
the Grantee on behalf of the Subrecipient to convert the project to a project for the direct
benefit of low-income persons pursuant to a request for such use by the Grantee on behalf of
the Subrecipient operating the project (24 CFR 5 83 .305 (a)).
B. Repayment of Grant
If the Subrecipient does not provide supportive housing or supportive services for 10 years
following the date of initial occupancy or date of initial service provision pursuant to this
Agreement, then the Grantee shall require repayment of the entire amount of the grant used
for acquisition, rehabilitation, or new construction, unless conversion of the project has been
authorized pursuant to the terms in the Term of Commitment Section, IV -A of this document
(24 CFR 583.305 (b)).
If the supportive housing is used for such purposes as stated in Section IV -A for more than 10
years, then the Subrecipient's repayment amount will be reduced by 10 percentage points for
each year beyond the 10 -year period in which the project is used for supportive housing
(24 CFR 583.305 (b)).
C. Prevention of Undue Benefits
Upon the sale or other disposition of a project assisted with acquisition, rehabilitation, or new
construction funds occurring before the expiration of the 20 -year period, the Subrecipient
must comply with such terms and conditions as HUD and the Grantee may prescribe to
prevent the Subrecipient from unduly benefiting from such sale or disposition.
The Subrecipient shall return to the Grantee, upon the expiration or termination of this
Agreement, any fwKk tm hand, ,any accounts receivable attributable to these funds, and any
GRANT NUMBER: FL0211 B4D000802
City of Miami — Homeless Assistance Program / Page 12 of 23
overpayment due to unearned funds or costs disallowed pursuant to the terms of this
Agreement that were disbursed to the Subrecipient by the Grantee.
D. Revocation of License or Permit
Notwithstanding any provision of this Agreement to the contrary, revocation of any necessary
license, permit, or approval by a governmental authority may result in immediate termination
of this Agreement upon no less than twenty-four hours notice. Said notice shall be certified by
mail or hand delivery.
E. Declaration of Restrictive Covenants and Declaration of Restrictions
If not previously recorded, the Subrecipient and the Titleholder shall sign and record as set
forth in Attachment Q and Attachment Q-1, at the time of contract execution, and
incorporated here by reference, the "Declaration of Restrictive Covenants," and the
"Declaration of Restrictions." The Declaration of Restrictive Covenants is a federal
requirement and the Declaration of Restrictions is a local Requirement on properties that are
acquired, rehabilitated or built with Supportive Housing Program funds. These convenants
restrict the use of properties located at
N/A such that the properties must be
operated for the provision of supportive housing and services for homeless persons in
accordance with the provisions of 24 CFR Part 583, Code of Federal Regulations for a term of
at least 20 years or for such other purposes as may be approved by the Grantor. The
Subrecipient agrees to inform any lender or grantor which has loaned or granted funds for the
purchase of such properties of structures thereupon and request their consent to the
recordation of and subordination to the Declaration of Restrictive Covenants and the
Declaration of Restrictions. Such consent shall be in a form acceptable to the Grantee.
V. UNIFORM ADMINISTRATIVE REQUIREMENTS
A. Accounting? Standards, Cost Principles, and Regulations
The Subrecipient shall comply with Federal accounting standards and cost principles
according to OMB Circular A-122 and SHP Regulations (24 CFR 583.135).
2. The Subrecipient shall comply with applicable provisions of applicable Federal, State,
and County laws, regulations, and rules such as OMB Circular A-110, OMB Circular A-
21, and OMB Circular A-133 and with the Energy Policy and Conservation Act (Public
Law 94-163) which requires mandatory standards and policies relating to energy
efficiency. If any provision of this contract conflicts with any applicable law or
regulation, only the conflicting provision shall be deemed by the parties hereto to be
modified to be consistent with the law or regulation or to be deleted if modification is
impossible. However, the obligations under this contract, as modified, shall continue
and all provisions of this contract shall remain in full force and effect.
If the amount payable to the Subrecipient pursuant to the terms of this contract is in
excess of"$100,000, •thee'Subrec'rpient shall comply with all applicable standards, orders,
or regulations issued pursuant to Section 306 of the Clean Air Act of 1970 (42 U.S.C.
GRANT NUMBER: FL021113413000802
City of Miami — Homeless Assistance Program / Page 13 of 23
1857 (h)), as amended; the Federal Water Pollution Control Act (33 U.S.C. 1251), as
amended; Section 508of the Clean Water Act (33 U.S.C. 1368); Environmental
Protection Agency regulations (40 CFR Part 15); Executive Order 11738; and
Environmental Review Procedures and Regulations (24 CFR Part 58 and 24 CFR Part
583.230).
B. Retention of Records
1. The Subrecipient shall retain records pertinent to expenditures and all Agreement
Records for a period of at least three (3) years (hereinafter referred to as "Retention
Period.") For all non -Grantee assisted activities the Retention Period shall begin upon
the expiration or termination of this Agreement.
2. If the Grantee or the Subrecipient has received or been given notice of any kind
indicating any threatened litigation, claim or audit arising out of the services provided
pursuant to the terms of this Agreement, the Retention Period shall be extended until
such time as the threatened or pending litigation, claim or audit is, in the sole and
absolute discretion of the Grantee, fully, completely and finally resolved.
3. The Subrecipient shall allow the Grantee or any persons authorized by the Grantee full
access to and the right to examine any of the Agreement Records during the required
Retention Period.
4. The Subrecipient shall notify the Grantee in writing both during the pendency of this
Agreement and after its expiration as part of the final close-out procedure, of the address
where all the Agreement Records will be retained.
5. The Subrecipient shall obtain the prior written approval of the Grantee for the disposal of
any Agreement Records before disposing of such Records within one year after
expiration of the Retention Period.
C. Additional Requirements
The Subrecipient must comply with the following additional requirements.
1. Client Rules and Regulations - The Subrecipient shall submit a copy of the Client
Rules and Regulations that apply to clients referred to the Subrecipient pursuant to this
Agreement; due within thirty (30) days following the execution of this Agreement.
2. Personnel Policies and Administrative Procedure Manuals - The Subrecipient shall
submit detailed documents describing the Subrecipient's internal corporate or
organizational structure, property management and procurement policies and procedures,
personnel management, accounting policies and procedures, etc. The information shall
be available to the Grantee upon a request.
3. Monitoring - The Subrecipient shall permit the Grantee and any other persons
authorized by the cirantee tosnonitor, according to applicable regulations, all Agreement
Records, facilities, goods and activities of the Subrecipient which are in any way
connected to the activities undertaken pursuant to the terms of this Agreement, and/or to
interview any clients, employees, subcontractors, or assignees of the Subrecipient. The
GRANT NUMBER: FL0211B4D000802
City of Miami — Homeless Assistance Program / Page 14 of 23
Grantee shall monitor both fiscal and programmatic compliance with all terms and
conditions of this Agreement to include a review of beneficiaries, supportive services,
operating costs, program progress, documentation for required match, record keeping,
compliance with circulars, administrative costs, technical assistance visits, and
environmental review.
The Subrecipient shall permit the Grantee to conduct site visits, client assessment
surveys, and other techniques deemed reasonably necessary to fulfill the monitoring
function. A report of the Grantee's findings may be delivered to the Subrecipient, and if
so delivered, the Subrecipient shall rectify all deficiencies cited within the period of time
specified in the report.
4. Restrictions of Funds Use - The funds received under this Agreement (or any State or
local government funds used to supplement this Agreement) may not be used to replace
state or local funds previously used, or designated for use to assist homeless persons (24
CFR Part 583.150 (a)).
The Subrecipient shall notify the Grantee of any additional .funding received for any
activity described in this Agreement, other than the "Client Contribution Report,"
Attachment F which is addressed in H -C(1). Such notification shall be in writing and
received by the Grantee within thirty (30) days of the Subrecipient's notification by the
funding source.
5. Related Parties - The Subrecipient shall report to the Grantee the name, purpose, and
any other relevant information in connection with any transaction conducted between the
Subrecipient and a related party transaction. A related party includes, but is not limited
to, a for-profit or nonprofit subsidiary or affiliate organization, and organization with
overlapping boards of directors or any organization for which the Subrecipient is
responsible for appointing members. The Subrecipient shall report this information to the
Grantee upon forming the relationship or if already formed, shall report it immediately.
Any supplemental information shall be reported in the Grantee required Agency
Narrative and Progress Report which are addressed in H -C (1).
6. Required Meeting Attendance — From time to time, the Miami -Dade County Homeless
Trust may schedule meetings and/or training sessions to assist the Subrecipient in the
performance of its contractual obligations or to inform the Subrecipient of new and/or
revised policies and procedures. Attendance at some of these meetings may be
mandatory. The Subrecipient shall receive notice no less than three (3) business days
prior to any meeting or training session that requires mandatory participation. A record
of attendance at meetings or training sessions where notice was given indicating the
Subrecipient's mandatory participation shall be kept, and the Subrecipient's contractual
compliance will be monitored. Failure to attend a meeting/training sesion for which a
mandatory notice has been provided can result in material non-compliance of the
contract/agreement, up to and including breach or default. Proof of notice shall consist of
fax record, certified mail, and/or verbal communication with the contract/agreement
contact person or other program administrative staff. The Provider may select one or
more empioyees from their agency, directly involved in the contracted program, as their
representative at the meeting/training session; the participation of the Agreement contact
person is preferred. The Subrecipient may request to be excused from a mandatory
meeting. That request must be received at least twenty-four (24) hours prior to the
GRANT NUMBER: FL021 IB4D000802
City of Miami — Homeless Assistance Program / Page 15 of 23
meeting date and time, and justification provided, including why the agency could not
send any representative. The Miami -Dade County Homeless Trust shall determine
whether or not the absence will be excused; the Subrecipient shall not be excused from
more than two (2) meetings/training sessions during each contract year. The
Subrecipieint is encouraged to attend all meetings of the Miami -Dade County Homeless
Trust and/or its Committees, as information relevant to their program or services may be
discussed.
7. Publicity and Advertisements - The Subrecipient shall ensure that all publicity and
advertisements prepared and released by the Subrecipient, such as pamphlets and news
releases already or indirectly related to activities funded pursuant to this Agreement, and
all events carried out to publicize the accomplishments of any activity funded pursuant to
this Agreement, recognize the Grantee as its funding source.
The Subrecipient shall ensure that all media representatives, when inquiring about the
activities funded pursuant to this Agreement, are informed that the Grantee is the funding
source.
Procurement - The Subrecipient shall make a positive effort to procure supplies,
equipment, construction or services necessary or related to carrying out the terms of this
Agreement from minority and women's businesses, and to provide these sources
maximum feasible opportunity to compete for subcontracts to be performed pursuant to
this Agreement.
In conformance with Section 3 of the Housing and Urban Development (HUD) Act of
1968 Attachment N, as amended, 12 U.S.C. 1701u (Section 3), work performed under
this contract are subject to requirements of this section. The purpose of Section 3 is to
ensure that 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 and to businesses that are substantially owned or
substantially employ low and very low income persons.
Property — This section applies to equipment with an acquisition cost of $5,000 or
more per unit and all real property.
a. Any real property under the Subrecipient's control that was acquired/improved in
whole or in part with funds from the Homeless Trust and any equipment
purchased for $5,000 or more shall be disposed of, at the expiration or termination
of this contract, in accordance with instruction from the Homeless Trust. Real
Property is defined as land, including land improvements, structures,
appurtenances thereto, including movable machinery and equipment. Equipment
means tangible, nonexpendable, personal property having a useful life of more
than one year and an acquisition cost of $5,000 or more per unit.
b. All equipment with an acquisition cost of $5,000 or more per units and all real
ptopertypurchased in whole or in part with funds from this and previous contracts
with the Homeless Trust, or transferred to the Subrecipient after being purchased
in 'V&Die or -in part with fimds fram the Homeless Trust shall be listed in the
property records of the Subrecipient and shall include a legal description, size,
GRANT NUMBER: FL0211B4D000802
City of Miami — Homeless Assistance Program / Page 16 of 23
date of acquisition, value at time of purchase, owner's name if different from the
Subrecipient, information on the transfer or disposition of the property, and map
indicating whether property is in parcels, lots or blocks and showing adjacent
streets and roads. Notwithstanding documentation required for reimbursement
purposes, a copy of the purchase receipt for any asset described above purchased
with Homeless Trust funds must also be included in the Subrecipient's monthly
reimbursement package submitted to the Homeless Trust in the month in which
the item was purchased along with the "Provider Asset Inventory" Attachment P.
C. All equipment with an acquition cost of $5,000 or more per unit and all real
property shall be inventoried annually by the Subrecipient and an inventory report
shall be submitted to the Homeless Trust. This report shall include the elements
listed in the paragraph listed above.
10. Management Evaluation and Performance Review - The Grantee may conduct a
formal management evaluation and performance review of the Subrecipient following
the expiration of this Agreement. The management evaluation will reflect the
Subrecipient's compliance with generally accepted fiscal and organizational standards
and practices. The performance review will reflect the quality of service provided and
the value received using monitoring data such as progress reports, site visits, and client
surveys.
11. Subcontracts and Assignments
a. The Subrecipient shall ensure that all subcontracts and assignments:
(1) Identify the full, correct and legal name of the party;
(2) Describe the activities to be performed;
(3) Present a complete and accurate breakdown of its price component;
(4) Incorporate a provision requiring compliance with all applicable regulatory
and other requirements of this Agreement with any conditions of approval
that the Grantee deems necessary. This applies only to subcontracts and
assignments in which parties are engaged to carry out any eligible
substantive programmatic service as set forth in this Agreement. The
Grantee shall in its sole and absolute discretion determine when services
are eligible substantive programmatic services subject to the audit and
record-keeping requirements described above, and;
b. In accordance with Ordinance No. 97-104, all bidders and respondents on County
contracts for purchase of supplies, materials or services, including professional
services, which involve the expenditure of $100,000 or more and all bidders or
respondents on County or Public Health Trust construction contracts which
involve the expenditure of $100,000 or more shall include, as part of their bid or
proposal submission, a listing of Provider's Disclosure of Subcontractors and
Suppliers Attachment L which identifies all first tier subcontractors who will
Verform any }part of the contract work and describes the portion of the work such
subcontractor will perform, and all contract work direct to the bidder or respondent
GRANT NUMBER: FL0211B4D000802
City of Miami - Homeless Assistance Program / Page 17 of 23
and describes the materials to be so supplied. Failure to include such listing with
the bid or proposal shall render the bid or proposal non-responsive.
Ordinance 97-104 applies to all contracts whether competitively bid by the County
or not. Those contracts that have received authorization by the Board of County
Commissioners to waive formal bidding procedures must also provide a listing of
all first tier subcontractors and direct suppliers.
Subcontractor/Supplier Listing, SUB Form 100 Attachment M may be utilized to
provide the information required by this paragraph. A bidder or respondent who is
awarded the contract shall not change or substitute first tier subcontractors or
direct suppliers or the portions of the contract work to be performed or materials to
be supplied from those identified in the listing submitted with the bid or proposal
except upon written approval of the County.
C. The Subrecipient shall incorporate in all consultant subcontracts this additional
provision:
The Subrecipient is not responsible for any insurance or other fringe benefits for
the consultant or its employees, e.g., social security, income tax withholdings,
retirement or leave benefits. The Consultant assumes full responsibility for the
provision of all insurance and fringe benefits for himself or herself and employees
retained by the Consultant in carrying out the Scope of Services provided in this
subcontract.
d. The Subrecipient shall be responsible for monitoring the contractual performance
of all subcontracts.
The Subrecipient shall receive written documentation prior to entering into any
subcontract which contemplates performance of substantive programmatic
activities, as such is determined as provided herein. The Grantee's approval shall
be obtained prior to the release of any funds to the subcontractor.
f. The Subrecipient shall receive written approval from the Grantee prior to either
assigning or transferring any obligations or responsibility set forth in this
Agreement or the right to receive benefits or payments resulting from this
Agreement.
g. Approval by the Grantee of any subcontract or assignment shall not under any
circumstances be deemed to provide for the incurring of any obligation by the
Grantee in excess of the total dollar amount agreed upon in this Agreement.
12. The Grantee's Consultant - The Grantee understands that in order to facilitate the
implementation of this Agreement, the Grantee may from time to time designate a
development consultant to work with the Subrecipient. The Grantee's consultant shall be
considered the Grantee's designee with respect to all portions of this Agreement with the
excepts aof hose -provisions relating to payment of the Subrecipient for services
rendered. The Grantee shall provide written notification to the Subrecipient of the name,
address, and employees of the Ch antee`s -r-onsnitant.
GRANT NUMBER: FL021113413000802
City of Miami — Homeless Assistance Program / Page 18 of 23
13. Participation in Homeless Management Information System - The Provider agrees to
participate in the Homeless ManagementInformation System (HMIS) selected and
established by the County. Participation will include, but is not limited to, input of client
data upon intake, daily updates of bed availability information, as well as updates of
client files upon client contact, and maintaining current data for statistical purposes. The
Provider understands that they are responsible for any ongoing cost to access the HMIS.
system.
14. Miami -Dade County Inspector General Review According to Section 2-1076 of the
Code of Miami -Dade County, as amended by Ordinance No. 99-63, Miami -Dade County
has established the Office of the Inspector General which may, on a random basis,
perform audits on all County contracts, throughout the duration of said contracts, except
as otherwise provided below. The cost of the audit of any Contract issued as a result of
this RFP shall be one-quarter (1/4) of one (1) percent of the total contract amount which
cost shall be included in the total proposed amount. The audit cost will be deducted by
the County from progress payments to the selected Proposer. The audit cost shall also be
included in all change orders and all contract renewals and extensions.
Exception: The above application of one quarter (1/4) of one percent fee assessment shall
not apply to the following contracts: (a) IPSIG contracts; (b) contracts for legal services;
(c) contracts for financial advisory services; (d) auditing contracts; (e) facility rentals and
lease agreements; (f) concessions and other rental agreements; (g) insurance contracts; (h)
revenue -generating contracts; (1) contracts where an IPSIG is assigned at the time the
contract is approved by the Commission; 0) professional service agreements under
$1,000; (k) management agreements; (1) small purchase orders as defined in Miami -Dade
County Administrative Order 3-2; (m) federal, state and local government -funded grants;
and (n) interlocal agreements. Notwithstanding the foregoing, the Miami -Dade County
Board of County Commissioners may authorize the inclusion of the fee assessment of
one quarter (I/4) of one percent in any exempted contract at the time of award
Nothing contained above shall in any way limit the powers of the Inspector General to
perform audits on all County contracts including, but not limited to, those contracts
specifically exempted above.
15. INDEPENDENT PRIVATE SECTOR INSPECTOR GENERAL REVIEW
Pursuant to Miami -Dade County Administrative Order 3-20 and in connection with any
award issued as a result of this RFP, the County has the right to retain the services of an
Independent Private Sector Inspector General ("IPSIG"), whenever the County deems it
appropriate to do so. Upon written notice from the County, the selected Proposer shall
make available, to the IPSIG retained by the County, all requested records and
documentation pertaining to this RFP or any subsequent award, for inspection and
copying. The County will be responsible for the payment of these IPSIG services, and
under no circumstance shall the Proposer's cost/price for this RFP be inclusive of any
charges relating to these IPSIG services. The terms of this provision herein, apply to the
Proposer, its oaffw"s, agents, eukaloyees and assignees. Nothing contained in this
provision shall impair any independent right of the County to conduct, audit or
-investigate the operations, activities and performance of the selected Proposer in
connection with this RFP or any contract issued as a result of this RFP. The terms of this
GRANT NUMBER: FL0211 B4D000802
City of Miami — Homeless Assistance Program / Page 19 of 23
provision are neither intended nor shall they be construed to impose any liability on the
County by the selected Proposer or third party.
16. Renegotiation or Modification - Modifications of provisions of this Agreement shall be
valid only when in writing and signed by duly authorized representatives of each party.
Additional conditions are:
a. A Subrecipient may not make any significant changes to an approved program
without prior Grantee approval. Significant changes include, but are not limited
to, a change in the Subrecipient, a change in the project site, additions or
deletions in the types of activities listed in 24 CFR Part 583.100 approved in the
Technical Submission for the program, or a shift of more than 10 percent of
funds from one approved type of activity to another, and a change in the category
of participants to be served, or other changes deemed significant by the Grantee.
Depending on the nature of the change, the Grantee may require a new
certification of consistency with the Consolidated Plan Certification from the
United States Department of Housing and Urban Development
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.
The parties agree to renegotiate this contract if the Grantee determines, in its sole and
absolute discretion, that Federal state, and/or Grantee revisions of any applicable law or
regulations, or increases or decreases in budget allocations make changes in this
Agreement necessary. The Grantee shall be the final authority in determining whether or
not funds for this Agreement are available due to Federal, state and/or Grantee revisions
of any applicable laws or regulations, or increases in budget allocations.
Notwithstanding the foregoing, the Grantee retains all the rights of suspension or
termination set forth in Section III of this Agreement. After the initial grant agreement,
the Grantee will not make revisions to increase the amount of the award to the
Subrecipient.
17. Right to Waive - The Grantee may, for good and sufficient cause, as determined by the
Grantee in this sole and absolute discretion, waive provisions in this Agreement or seek to
obtain such waiver from the appropriate authority. Waiver requests from the Subrecipient
shall be in writing. Any waiver shall not be construed to be a modification of this Agreement.
18. Disputes - In the event an unresolved dispute exists between the Subrecipient and the
Grantee, the Grantee shall refer the questions, including the views of all the interested parties
and the recommendation of the Grantee, to the CountyManager for determination. The
County Manager, or an authorized representative, will issue a determination within thirty (30)
calendar days of receipt and so advise the Grantee and the Subrecipient, or in the event
additional time is necessary, the Grantee will notify the Subrecipient within the thirty (30) day
period that additional time is necessary. The. Subrecipient agrees that the County Manager's
:determination shall Ax and,binding on all parties.
GRANT NUMBER: FL0211B4D000802
City of Miami — Homeless Assistance Program / Page 21 of 23
27. Contracts with Municipalities or Counties Outside Miami -Dade County to Provide
Homeless Housing in Miami -Dade County. - The above-named firm, corporation,
organization or individual ("provider") desiring to transact business or enter into a contract
with the County for the provision of homeless housing and /or services swears, verifies,
affirms and agrees that (1) it has not entered into any current contract, arrangement of any
kind, or understanding with any municipality outside of Miami -Dade County or any County
(collectively "locality") to provide housing and services for homeless persons in Miami -Dade
County who are transported to Miami -Dade County by or at the behest of such locality and (2)
during the term of this contract, it will not enter into any such contract, arrangement of any
kind, or understanding; provided, however, upon the written request of the Contractor prior to
entering into such contract, understanding or arrangement, the Miami -Dade County Homeless
Trust may, in its sole and absolute discretion, find and determine within 60 days of such
request that a proposed contract should not be prohibited hereby, as the best interests of the
homeless programs undertaken by and on behalf of Miami -Dade County would not be
negatively affected by such contract, arrangement, or undertaking_
VI. RELIGIOUS ORGANIZATIONS
As reported in 24 CFR Part 583.150, HUD will provide assistance to a recipient that is a primarily
religious organization, if the organization agrees to provide housing and supportive services in a
manner that is free from religious influences and in accordance with the following principles:
1. It will not discriminate against any employee or applicant for employment on the basis of
religion and will not limit employment or give preference in employment to persons on the
basis of religion;
2. It will not discriminate against any person applying for housing or supportive services on the
basis of religion and will not limit such housing or services or give preference to persons on
the basis of religion; and
3. It will provide no religious instruction or counseling, conduct no religious worship or
services, engage in no religious proselytizing, and exert no other religious influence in the
provision of housing and supportive services.
HUD will provide assistance to a recipient that is a primarily religious organization if the assistance
will not be used by the organization to construct a structure, acquire a structure or to rehabilitate a
structure owned by the organization, except as described in 24 CFR Part 583.150 (b)(2)
Attachment A.
VII. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Any person or entity that performs or assists Miami -Dade County with a function or activity
involving the use or disclosure of "individually identifiable health information (IIHI) and/or
Protected Health Information (PHI) shall comply with the Health Insurance Portability and
Accountability Act (HIPAA) of 1996 and the Miami -Dade County Privacy Standards
Administrative Larder. WAA mandates fbr privacy, security and electronic transfer standards, that
include but are not limited to:
1. Use of information only for performing services required by the contract or as required by law;
GRANT NUMBER: FL021113413000802
City of Miami — Homeless Assistance Program / Page 22 of 23
2. Use of appropriate safeguards to prevent non -permitted disclosures;
3. Reporting to Miami=Dade County of any non -permitted use or disclosure;
4. Assurances that any agents and subcontractors agree to the same restrictions and conditions that
apply to the Bidder/Proposer and reasonable assurances that IIHI/PHI will be held confidential;
5. Making Protected Health Information (PHI) available to the customer;
6. Making PHI available to the customer for review and amendment; and incorporating any
amendments requested by the customer;
7. Making PHI available to Miami -Dade County for an accounting of disclosures; and
8. Making internal practices, books and records related to PHI available to Miami -Dade County for
compliance audits.
PHI shall maintain its protected status regardless of the form and method of transmission (paper
records, and/or electronic transfer of data). The Bidder/ Proposer must give its customers written
notice of its privacy information practices including specifically, a description of the types of uses
and disclosures that would be made with protected health information.
CONTINUES NEXT ON SIGNATURE PAGE
GRANT NUMBER: FL0211B4D000802
City of Miami — Homeless Assistance Program / Page 23 of 23
IN WITNESS WHEREOF, the parties have caused this twenty-three (23) page Agreement to be
executed by their respective and duly authorized officers the day and year first above written.
WITNESSES:
NAME:
(PRINT)
NAME:
(SIGNATURE)
NAME:
(PRINT)
NAME:
(SIGNATURE)
ATTEST:
HARVEY RUVIN, CLERK
PROVIDER:
(FULL NAME OF AGENCY)
BY NAME:
(PRINT NAME OF AUTHORIZED
AGENCY REPRESENTATIVE)
(SIGNATURE OF AUTHORIZED
AGENCY REPRESENTATIVE)
(TITLE)
(AFFIX SEAL)
MIAMI -DARE COUNTY
a political subdivision
of the State of Florida
DEPUTY CLERK George M. Burgess
County Manager
(DATE)
See memorandum datedA.7 approved as to form and legal sufficiency:
Subrecipient Agreement Attachment List
Signature
Required
Attachment
TkIe
Attachment A
U.S. HUD Grant Renewal Agreement includes:
H1.T11) designated Attachments A and B
Attachment A-1
Scope of Service
Attachment A-2
Units/Bedrooms/Beds Chart and Participants Chart
Attachment. A-3
Program Goals
Attachment A.-4
Milestones (N/A for Renewal Grants)
Attachment B
Technical Submission
Attachment C
LOCCS/VRS form 11 -27053A
Attachment C-1
Copy of homeless Trust Invoice
Attachment D
FMS (HUD -401123) Monthly Progress Report
Attachment E
Program Rating of Satisfaction
Attachment F
Client Contribution Report
Attachment G
Annual Progress Report (APR)
Attachment G-1
HMIS (HUD -40118) Annual Progress Report (APR)
Signature
Attachment H
Request for Taxpayer Identification and Certification
Siunatture
Attachment I
HUD form -40090-4 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
Sobcontractor / Suppliers Listing
�i Signature
Attachment N
Section 3 Compliance Requirements
Signature
Attachment 0
Sworn Statement Pursuant to Florida Statutes
Attachment P
Provider Asset Inventory form
if applicable
Attachment Q
I Declaration of Restrictive Covenants
if a • iicable
Attachment Q-1
I Declaration of Restrictions
Attachment R
Employee Certification Form
Attachment S
Incident Report (3 -pages) i
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
0041482920000
FL0211B4D000802
Grant Number: FL0211 64/3000802
Award Amount: $251,071
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 - Miami Homeless Assistance Program
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 Grpnt Agreement Page 1 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
0041482920000
FL021113413000802
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/off.ices/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 Gra t Agreement. VoTigttt,'+benefi#, oT advantage of the Recipient
hereunder be assigned without prior written approval of HUD.
Consolidated Grant Agreement Page 2 03/10/2010
Applicant: Miami -Dade County 0041482920000
Project: FL -600 Ren - Miami Homeless Assistance Program FL0211 134D000802
For any project funded by this grant, which is also financed through the
use of the Low Income Housing Tax Credit, the following applies:
HUD recognizes that the Recipient or the project sponsor will or has
financed this project through the use of the Low -Income Housing Tax
Credit. The Recipient or project sponsor shall be the general partner of a
limited partnership formed for that purpose. If grant funds.were used for
acquisition, rehabilitation or construction, then, throughout a period of
twenty years from the date of initial occupancy or the initial service
provision, the Recipient or project sponsor shall continue as general
partner and shall ensure that the project is operated in accordance with
the requirements of this Grant Agreement, the applicable regulations and
statutes. Further, the said limited partnership shall own the project site
throughout that twenty-year period. If grant funds were not used for
acquisition, rehabilitation or new construction, then the period shall not be
twenty years, but shall be for the term of the grant agreement and any
renewal thereof. Failure to comply with the terms of this paragraph shall
constitute a default under the Grant Agreement.
A default shall consist of any use of grant funds for a purpose other
than as authorized by this Grant Agreement, failure in the Recipient's duty
to provide the supportive housing for the minimum term in accordance
with the requirements of Attachment A, noncompliance with the Act or
Attachment A provisions, any other material breach of the Grant
Agreement, or misrepresentations in the application submissions which, if
known by HUD, would have resulted in this grant not being provided.
Upon due notice to the Recipient of the occurrence of any such default
and the provision of a reasonable opportunity to respond, HUD may take
one or more of the following actions:
(a) direct the Recipient to submit progress schedules for completing
approved activities; or
(b) issue a letter of warning advising the Recipient of the default,
establishing a date by which corrective actions must be completed and
putting the Recipient on notice that more serious actions will be taken if
the default is not corrected or is repeated; or
(c) direct the Recipient to establish and maintain a management plan
that assigns responsibilities for carrying out remedial actions; or
(d) direct the Recipient to suspend, discontinue or not incur costs for
the affected activity; or
Consolidated Grant Agreement Page 3 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
(e) reduce or recapture the grant; or
0041482920000
FL0211134D000802
(f) direct the Recipient to reimburse the program accounts for costs
inappropriately charged to the program; or
(g) continue the grant with a substitute recipient of HUD's choosing;
or
(h) other appropriate action including, but not limited to, any remedial
action legally available, such as affirmative litigation seeking declaratory
judgment, specific performance, damages, temporary or permanent
injunctions and any other available remedies.
No delay or omission by HUD in exercising any right or remedy
available to it under this Grant Agreement shall impair any such right or
remedy or constitute a waiver or acquiescence in any Recipient default.
For each operating year in which funding is received, the Recipient
shall file annual certifications with HUD that the supportive housing has
been provided in accordance with the requirements of the Grant
Agreement.
This Grant Agreement constitutes the entire agreement between the
parties hereto, and may be amended only in writing executed by HUD and
the Recipient. More specifically, the Recipient shall not change recipients,
location, services, or population to be served nor shift more than 10
percent of funds from one approved type of eligible activity to another, or
make any other significant change, without the prior written approval of `
HUD.
Consolidated Grant Agreement Page 4 03/10/2010
Applicant: Miami -Dade County 0041482920000
Project: FL -600 - Ren - Miami Homeless Assistance Program FL0211 B4D000802
SIGNATURES
This Grant Agreement is hereby executed as follows:
UNITED STATES OF AMERICA
Secretary otHoup ing and Urban Development
By:
PrinT-name of signatory
Title
RECIPIENT
Name of Organization
By:
Authorized Signature and Date
Print name of Signatory
Consolidated Grant Agreement Page 5 03/10/2010
Applicant: Miami -Dade County 0041482920000
Project: FL -600 - Ren - Miami Homeless Assistance Program FL021164D000802
ATTACHMENT A
1. The recipient is Miami -Dade County.
2. HUD's total fund obligation for this project is $251,071, which shall be
allocated as follows:
Leasing $0
Supportive services $239,116
Operating costs $0
HMIS $0
Administration $11,955
3. Although this agreement will become effective only upon the
execution hereof by both parties, upon execution, the term of this
agreement shall run from the end of the Recipient's final operating year
under the original Grant Agreement or, if the original Grant Agreement was
amended to extend its term, the term of this agreement shall run from the
end of the extension of the original Grant Agreement term for a period of
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 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 Ren - Miami Homeless Assistance Program
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 plan.
Subpart C --Application and Grant Award Process
583.200 Application and grant award.
583.230 Environmental review.
583.235 Renewal grants.
Subpart D --Program Requirements
583.300 General 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
FL0211134D000802
Consolidated Grant Agreement Page 7 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
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
FL0211B4D000802
(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 LJ_S_G 11302).
Consolidated Grant Agreement Page 8 03/10/2010
Applicant: Miami -Dade County 0041482920000
Project: FL -600 - Ren - Miami Homeless Assistance Program FL0211134D000802
(b) Uses of grant assistance. Grant assistance may be used to:
(1) Establish new supportive housing facilities or new facilities to provide supportive services;
(2) Expand existing facilities in order to increase the number of 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, rehabilitation, 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 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
§ 583.110 Grants for new construction.
0041482920000
FL0211B4D000802
(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-orbyarrangement- 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 93871, Mar. 15, 1993, as amended at 59 FR 36891, July 19, 1994]
Consolidated Grant Agreement Page 11 03/10/2010
Applicant: Miami -Dade County
0041482920000
Project: FL -600.. Ren - Miami Homeless Assistance Program FL021 1 B4D000802
§ 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 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
0041482920000
FL021184D000802
(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, 19941
583.145 Matching requirements.
(a) General. The recipient must match the funds provided by HUD for grants for acquisition,
rehabilitation, and new construction with an equal amount of funds from other sources.
(b) Cash resources. The matching funds must be cash resources provided to the project by
one or more of the following: the recipient, the Federal government, State and local
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 .government 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 proselytization
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 urtder'this pa", and participation mustbe vokmtaryfor the beneficiaries of the
HUD -funded programs or services.
Consolidated Grant Agreement Page 13 1 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
0041482920000
FL0211134D000802
(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 prose lytization. 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 government 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.9'1,....
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 mustbe made by the unit ofgeneral 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 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
0041482920000
FL0211134D000802
(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, 19951
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 B. 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 03/10/2010
Applicant: Miami -Dade County 0041482920000
Project: FL -600 - Ren - Miami Homeless Assistance Program FL0211 B4D000802
(2) HUD reserves the right to reject a request from any organization with an outstanding
obligation to HUD that is in arrears or for which a payment schedule has not been agreed to, or
whose response to an audit finding is overdue or unsatisfactory.
(3) HUD will notify the recipient in writing that the request has been approved or disapproved.
(Approved by the Office of Management and Budget under control number 2506-0112)
Subpart D --Program Requirements
§ 583.300 General operation.
(a) State and local requirements. Each recipient of assistance under this part must provide
housing or services that are in compliance with all applicable State and local housing codes,
licensing requirements, and any other requirements in the jurisdiction in which the project is
located regarding the condition of the structure and the operation of the housing or services.
(b) Habitability standards_ Except for such variations as are proposed by the recipient and
approved by HUD, supportive housing must meet the following requirements:
(1) Structure and materials. The structures must be structurally sound so as not to pose any
threat to the health and safety of the occupants and so as to protect the residents from the
elements.
(2) Access. The housing must be accessible and capable of being utilized without
unauthorized use of other private properties. Structures must provide alternate means of egress
in case of fire.
(3) Space and security. Each resident must be afforded adequate space and security for
themselves and their belongings Each resident must be provided an acceptable place to sleep.
(4) Interior air quality. Every room or space must be provided with natural or'mechanical
ventilation. Structures must be free of pollutants in the air at levels that threaten the health of
residents.
(5) Water supply. The water supply must be free from contamination.
(6) Sanitary facilities. Residents must have access to sufficient sanitary facilities that are in
proper operating condition, may be used in privacy, and are adequate for personal cleanliness
and the disposal of human waste.
(7) Thermal environment. The housing must have adequate heating and/or cooling facilities in
proper operating condition.
(8) Illumination and electricity. The housing must have adequate natural or artificial
illumination to permit normal indoor activities and to support the health and safety of residents.
Sufficient electrical sources must be provided to permit use of essential electrical appliances
while assuring safety from fire.
(9) Food preparation and refuse disposal. All food preparation areas must contain suitable
space and equipment to store, prepare, and serve food in a sanitary manner.
(10) Sanitary condition. The.housing and any equipment must be maintained in sanitary
condition.
Consolidated Grant Agreement Page 16 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
0041482920000
FL0211B4D000802
(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 with 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 03/10/2010
Applicant: Miami -Dade County 0041482920000
Project: FL -600 - Ren - Miami Homeless Assistance Program FL0211 B4D000802
(e) Appeals. A person who disagrees with the recipient's determination concerning 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)0)
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 permanently 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 03/10/2010
Applicant: Miami -Dade County 0041482920000
Project: FL -600 - Ren - Miami Homeless Assistance Program FL021164D000802
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) 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]
§ 58.3.315 Resident rent.
(a) Calculation of resident rent. Each resident of supportive housing may be 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 03/10/2010
Applicant: Miami -Dade County 0041482920000
Project: FL -600 - Ren - Miami Homeless Assistance Program FL0211134D000802
(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,
acrd disability.
Consolidated Grant Agreement Page 21 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
0041482920000
FL0211B4D000802
(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).
158 FR 13871, Mar. 15, 1993, as amended at 59 FR 33894, June 30, 1994; 61 FR 5210, Feb. 9,
1996; 61 FR 51176, Sept. 30, 1996]
§ 883.330 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 Barrjar- 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 03/10/2010
Applicant: Miami -Dade County
Project: FL -600 - Ren - Miami Homeless Assistance Program
0041482920000
FL0211B4D000802
(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 governmental 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) 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 served4avviding tha prohibited conflict; and
Consolidated Grant Agreement Page 23 03/10/2010
Applicant: Miami -Dade County 0041482920000
Project: FL -600 - Ren - Miami Homeless Assistance Program FL0211 B4D000802
(vi) Any other relevant considerations.
(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 10
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 51176, 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 andTehaNlitation, or new construction:
Consolidated Grant Agreement Page 24 03/10/2010
Applicant: Miami -Dade County 0041482920000
Project: FL -600 - Ren - Miami Homeless Assistance Program FL021164D000802
(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 03/10/2010
GRANT NUMBER: FL0211 B4D000802
City of Miami — Homeless Assistance Program
ATTACHMENT A-1
SCOPE OF SERVICES
The Subrecipient shall provide supportive outreach services to 3,000 homeless persons (individuals and
families). Of the 3,000 homeless persons, there shall be at least 2,850 assessments and at least 1,500
placements of homeless persons. This shall occur primarily in the City of Miami and all homeless
outreach, assessments and placements within Miami -Dade County. Additionally of the 3,000 homeless
persons, the Subrecipient shall place at least 180 homeless persons in transitional treatment supportive
housing. The Subrecipient will conduct street outreach as well as respond to service requests from
homeless persons and service providers in the Continuum of Care. The Subrecipient shall provide
outreach, assessment and placement supportive services under this one-year grant Agreement.
The Subrecipient shall provide services as proposed in the application to U.S. HUD pursuant to the 2009
Super NOFA (incorporated herein by reference), including but not limited to:
1. Extensive outreach;
2. Assessment for residential stability and supportive services;
3. Housing placement into emergency, transitional and permanent housing, or other
positive housing environments;
4. Emergency housing to include hotel or motel assistance;
5. Referral and placement to all appropriate and available housing;
6. Referral to all applicable supportive services and programs;
7. Transportation services; and
8. Seven (7) day follow up to all services provided.
Conditions:
1. Reimbursement shall be limited to operations, supportive services, leasing, administration, and
the costs associated with these activities as described in the Subrecipient's application;
2. Reimbursement shall be made only for the cost incurred for operations, administration, and
supportive services actually provided to clients, unless the Grantee agrees, in writing, to another
mode of payment, as provided for in this Agreement;
3. Monthly progress reports and program narratives signed by the Executive Director
of the Subrecipient's agency shall be submitted by the Subrecipient, as required;
4. The Subrecipient will serve clients referred by the Grantee within available resources.
or its designee for housing and/or services through the Grantee's established referral
process;
5. Services shall be provided in accordance with the timeline submitted by the Subrecipient;
6. Any proposed modifications or revisions to the Subrecipient's program and/or services
must be submitted in writing and must receive prior approval by the Grantee; and
7. The Provider will achieve the performance measures delineated in their application to U.S. HUD.
Technical Project Number: FL021IB4D000801
Submission Project Identifier: FL14076
Exhibit 1: Project Summary ATTACHMENT A-2
Please indicate below the number of persons you have committed to serve as indicated in your application or
as modified by your Field Office (i.e., change due to funds being reduced).
D. Number of Beds, Participants, and Supportive Services (Does not apply to HMIS
projects)
Chart 1: Housing Tye 12. ❑ Multi -family Ib. ❑ Scattered Site
(Check all that apply) ❑ Single-family ❑ Project Based
❑ Congregate Facility
*4 Supportive Services Only
Complete Chart 2 and Chart 3 leased on the following instructions.
Chart 2: Units, Bedrooms, Beds
a Current
Level
(Point -in -Time)
b. New Effort or
Change in Effort
(lfApplicable)
c. Projected
Level
(col. a+col. b)
Number of Units
N/A
N/A
N/A
Number of Bedrooms
N/A
Int/A,
N/A
Number of Beds
N/A
N/A
N/A
*Do not complete information on the number of units, bedrooms and beds for Supportive Services Only
(SSO) projects. In those instances, enter 'N/A7' in the appropriate cells.
Chart 3' Partllcipants
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)
232
N/A
232
i. Number of adults in families
464
Int/A,
4®4
ii. Number of children in families
1,300
N/A
iii. Number of disabled in families
21:,300
b. Number of Single Individuals and
Other Households w/o Children
1,036
N/A
1,036
i. Number of disabled individuals
380
N/A
380
ii. Number of chronically homeless
186
N/A
186
**** participant configuration will vary dependent upon homeless.
HtTD-40090-3 a
Project Number: FL021IB4D00080-
Technical Project Identifier: FL14076
Submission Exhibit l : Project Summary ATTACHMENT A-3
(RE, NEWALS ONLY)
C. Program Goals-.
Goal: Residential Stability:
® At least 95% of 3,000 homeless outreach contacts and assessments will
move to emergency shelter from the streets.
• At least 6% of 3,000 homeless outreach contacts and assessments will
move to transitional housing (treatment) from the streets.
At least 50% of 3,000 of the homeless participants placed into housing
will remain housed for at least seven (7) days.
Goal: Increase skills and income:
At least 20% of the eligible homeless participants placed into housing
for up to seven (7) -days will be linked to resources for benefits and
employment.
Goal: Achieve greater self determination:
At least 50% of homeless participants placed will demonstrate greater
self-detennination by remaining housed for at least seven days.
At least 6% of 3,000 homeless participants will be linked or placed
directly into Mental and or Drug Abuse Treatment facilities which will
address their need for greater self-determination.
D. Number- of Units, Beds, Participants and Supportive Services
These charts need to be included only if they were incomplete, inaccurate or blank at the time of the original
application submission. Please complete these charts if your local HUD Field Office has notified you that they
are required. Submit only those that apply. The charts can be found in the New Projects Section of the
Technical Submission.
HUD -40090-3a
ATTACHT/fENT A-4
PROTECT MILESTONES
N/A
FOR THIS PROJECT
,,. of , EF� {'_Pt -�iP , E[ ,_ CF {, EE'. _, �i{ :�,DE ; f[;
II;PE ' EPI ;., EC I,,_fE IN..ifI .,' !F IFF ', !E, ;' !F .�:'. EP I' i!F', it 1.
NIEI
Technical Submission for the 2009
Supportive Housing Program
it
U.S. Department of Housing and Urban Development
Office of Community Planning and Development
Project Sponsor:
t1 I iE
City of Miami
Project Name:
121r
Miami Homeless Assistance
��FF
1 FE
=fg�
Program (MHAP)
Project Type:
?
k
Supportive Services Only (SSO)
t
�!L
Ea
Project Number:=R°
FLU'T6z,_1_1"'154V 0 0 0 8 0
iI�F`
f=11 Fr
,.
.FIAM DARE
Submitted by Selectee: Elii- jN�-
Miami -Dade County Homeless Trust
111 Northwest First Street, 27th Floor, Suite 310
�.
Miami, Florida 33128
�� 6
Telephone Number: (305) 375-1.490
it Li
FaX Number: (305 ) 375-2722
{e °
6H iEE ifi 1. FlJ tz !EI LI3 HHi 15LFJ g, 1061 _1. P I1 iO,I 1-1 IyRC �J_FEI j; BE! l -e HDI `�-,{ICI ' HCI 1t rrj'I pr, 61' 1e1�PPI f1 CC 11 EC' _,_AF
Project Number: FL0211134D000801
Technical Project Identifier: FL14076
Submission Exhibit 1: Project Summary
(cont.) (12E, NEWALS ONLY)
A. Selectee, and Sponsor Information - Fill in the information requested below. For HMIS projects fill in
the HMIS Lead. When the selectee is the same organization as the project sponsor, complete only the selectee
information.
Selectee Name
Miami -Dade County Homeless Trust
Sponsor Name
City of Miami
Contact Person
David Raymond, Executive Director-
Contact Person
Sergio Torres, Program Director
Phone
(305) 375-1490
Phone
(305) 576-9900
FAX Number
(305) 375-2722
FAX Number
(305) 400-5321
E -Mail Address
drayO miatmidade. ov
E -Mail Address
storresna.miamiIrov.com
Street Address
27t1i Floor 111 NW First Street
Street Address
1490 NW 3'd Avenue, Suite 105
City, State, Zip
Miami, Florida 33128
City, State, Zip
Miami, Florida 33136
HMIS Lead
Miami -Dade County Homeless Trust
Contact Person
Barbara Golphin
Street Address
27t1i FIoor 111 NW First Street
Phone
(305) 375-1490
City, State, Zip
Miami, Florida 33128
E -Mail Address
rmQl (t>miarrudade.gov
B. Project Budget - This section must be completed by all renewal selectees.
1. Chart 1 - Summary Project Budget
To complete Chart 1, Summary Project Budget, enter the amount of SHP funds requested by line -item in
the first column. For leasing, supportive services, operations, and HMIS, the amount entered should be for
the SHP grant term selected. In the second column, enter the amount of other cash that will be contributed
to the project. This amount plus the SHP request must equal the total budget amount for the project. Note
that match requirements for supportive services, operating costs and HMIS apply to renewal projects. The
amounts you enter are for all structures in your project. Each line item amount in this chart should match
the amounts shown in your original application as approved or Exhibits 3, 4, 5 and 6.
Requested grant term: (L year
Chart 1 - Summary Project Budget
*By law, SHP can pay no more than 80% of the total supportive services or total HMIS budget.
**By law, SHP can pay no more than 75%, of the total operating budget.
***By law, SHP can pay no more than 5% of the total SHP request.
HUD -40090-3a
Total
r x
SHP
Applicant
Project
'w 5
I Request
Cash
Budget
1. Real Property Leasing
2 Supportive Services*
239,116
59,779
298,895
3. Operations**
4. HMIS*
5. SHP Request (subtotal lines I thru 4)
239,116
59,779
298,915
6. Administration*** (up to 5% of line 5)
11,055
11,955
7. Total SHP Request (total lines 5 and 6)
251,071
59,779
310,850
*By law, SHP can pay no more than 80% of the total supportive services or total HMIS budget.
**By law, SHP can pay no more than 75%, of the total operating budget.
***By law, SHP can pay no more than 5% of the total SHP request.
HUD -40090-3a
Technical Submission Project Number: FLO211B4D000801 i
Submission Project Identifier: FL14076
Exhibit 4: Supportive Services
A. Supportive Services Budget
Chart 4A:
6. Service Activity
7. Service Activity:
8. Service Activity:
Ouantity:
9. SHP REQUEST * 80%
Year 1
Year 2
Year 3
Total
Supportive Service Expense
(a)
(b)
(c)
(d)
1. Service Activity: Outreach and Placement
230,495
230,495
Quantity: salaries including fringe benefits for
150 FTE Community Outreach Specialists
including 7.66% FICA/MICA, Group Health,
Worker's Compensation, Unemployment
Compensation Insurances plus overtime for
special outreach efforts -
Subtotal = $288,119
2. Service Activity: Cellular Phones
2,850
2,850
Quantity: service for Outreach workers to
effectively communicate with participants, and
office,to secure housing
Subtotal = $3,562
3. Service Activity: Rent of Equipment
1,100
1,100
Quantity:
Suhtotal = $1,375
4. Service Activity: Emergency Food
1,200
1,200
Quantity:
Subtotal = $1,500
5. Service Activity: Miscellaneous Supplies and
3,471
3,471
Printing ofpanzphlets, information for homeless
and conzmunih)
Quantity:
Subtotal = $4,339
6. Service Activity
7. Service Activity:
8. Service Activity:
Ouantity:
9. SHP REQUEST * 80%
$239,116
$239,116
10. Selectee's Match 20%
$ 59,779
$ 59,779
11. Total Supportive Services Budget 100%
$2.98,895
$298,895
"The SHP request cannot be more than 80% of the total supportive services budget in Line 11
HUD -40090-3a
ATTACHMENT B
Miami Homeless Assistance Program
US HUD SUPER NOFA SERVICES GRANT
Contract #
June 1, 2009 to May 31, 2010
PERSONNEL SALARIES & FRINGES
Request 80%
Cash match 20%
Total Project Budget
OUTREACH TRAINEES
Community Outreach Specialists (15 FTE)
$ 259,344.00
Overtime for special projects
$ 8,300.00
$
214,115.00
$
53,529.00
$ 267,644.00
Total Salaries
FRINGE BENEFITS
FICA @ 7.65%
$
16,380.00
$
4,095.00
$ 20,474.77
Total Findge Benefits
$
16,380.00
$
4,095.00
$ 20,474.77
SALARIES AND FRINGES
$
230,495.00
$
57,624.00
$ 288,118.77
FIXED EXPENSES
Telephone Service
$
2,850.00
$
713.00
$ 3,562.50
Rent of Equipment
$
1,100.00
$
275.00
$ 1,375.00
Emergency Food
$
1,200.00
$
300.00
$ 1,500.00
Miscellaneous Supplies
$
3,119.00
$
780.00
$ 3,898.75
Printing and Reproduction
$
352.00
$
88.00
$ 440.00
$
8,621.00
$
2,156.00
$ 10,776.25
TOTAL EXPENSES
$
239,116.00
$
59,780.00
$ 298,895.02
GRAND TOTAL
ADMINISTRATIVE COST
$
11,955.00
$ 11,955.00
$
251,071.00
$
59,780.00
$ 310,850.00
Project Number: FL0211134D000801
Technical Project Identifier: FL14076
Submission Exhibit 7: Administration
(cont.) (all projects requesting administration funds)
A. Administrative Costs
Please complete the chart below for your adnministrative 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 tluough S.
In the first column, fill in the adinnustrative activity to be paid for using SHP funds. In the Year 1 colunui, enter
the amount of SHP funds to be used to pay administrative costs in the first year. If the grant is multi-year, enter
the amount of SHP funds to be used for Year 2, and if applicable, Year 3. In the last column, (d), total the
amount of SHP funds requested for the full grant terns. Please ensure that the total requested for
administrative costs for the entire grant term, Line 6, column (d), matches that which you entered in your
project's Summary Budget in Exhibit 1.
B. Plan for Distribution of Administration Funds --
If the selectee is not the same organization as the project sponsor, attach a description of the selectee's plan for
distributing its administrative funding to address all, or a portion of the project sponsor's administrative needs.
Include a description of how the project sponsor was consulted in formulating the plan.
HUD -40090-3a
Year 1
Year 2
Year 3
Total
Administrative Costs
(a)
(b)
(c)
(d)
L. Administrative Activity: 2.5% to City of
5,977
5,977
Miami for staff time spent in compilation of
information for APR, review of documents for
reimbursement requests, audit of SHP funds
2. Administrative Activity: Miami -Dade
5,978
5,978
County Homeless Trust
2.5% APR preparation, staff time reviewing /
verifying invoices, audit of SHP program
3. Administrative Activity:
4. Administrative Activity:
5._ Administrative Activity_
6. SHP REQUEST FOR
11,955
11,955
ADMINISTRATIVE COSTS
7. Amount for Selectee
5,977
5,977
8. Amount for Project Sponsor
5,978
5,978
B. Plan for Distribution of Administration Funds --
If the selectee is not the same organization as the project sponsor, attach a description of the selectee's plan for
distributing its administrative funding to address all, or a portion of the project sponsor's administrative needs.
Include a description of how the project sponsor was consulted in formulating the plan.
HUD -40090-3a
LOCCSNRS
§;f.Pss Special Needs Assistance Program
Request Voucher for Grant Payment
See Instructions and Public Reporting Burden Statement on baa:
1. Voucher
U.S. Deparbnent of Housing OIJtB Approval No. 25350102 (exp. 1,13112004)
and Urban Development,
Office of Community Planning
and Development
ATTACHMENT C
CCS Pgrm. Area 13. Period Covered by this Request (dales)
SNAP HPAG
I i i i i i! 1HP
S. Voice Response No. (5 diads, hyphen, 5 more 6. Grantee Organization's Name
8. Grant No.
6a. Grantee Organization's TIN
4. 1 ype Ol VISM SOrneni
❑ Partial ❑ Final
9. Lire Item no.
Type of Funds Requested
Amounr (rounc to nearest acnar)
1010
Acquisition
1020
Rehabilitation
1021
New Construction
1022
Substantial Rehabilitation
1023
Moderate Rehabilitation
1030
Operating uost
1040
Rental Assistance
1050
Supportive Services
1060
( Administrative Cost
1070
Child Care
1080
l=ntpioyment Assistance
1090
Relocation
1100
Leasing
1110
Repair 8 Maintenance
1111
Prevention (RH)
1112
Capacity Buildings (PH)
1120
Other-
ther10.
10.Voucher Totall
I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.
Warning: HUD will prosecAe false claims and statements. Conviction may resultin criminaland(orcivil penafties. (18 U.S.C.1001,1010,1012; 31 U.S.C.3729, 3802)
1 t. Name & Phone Number (Including area code) of the Authorized112. Signature I ta. Date of Request
Person who called SNAPS System VRS j
Privacy Statement: Public Law 97-255, Financial Integrity Act, 31 U_S.C. 3512, authorizes the Department of Housing and Urban Development (HUD)
to collect all the information (exceptthe Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.
The Housing and Community DevetopmentAe, of'1987, 42'US.C. -%Q, 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 (LOGCS) have their access capability promptlydeleted. Provision of the SSN is mandatory.
HUD uses it as a unique identifierfor safeguarding LOCCS from unauthorized access. Failure to provide the information requested may delay the processing
of your approval for access to" LOCOS.-rhis'mfomtation will natbe tffmrvOmcliackmad or releaser, outside of HUD, except as permitted or required by law.
Fetain th1s ferns in your records for audit purposes page 1 of 2 form HUG -27053•A (2/95)
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Thisagencymay
not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
This information collection is to request payment of grant funds orto designate the appropriate officials whocan 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 CFA
Subpart C, 85.21 - PostAward Requirements, the information collection is needed in order to obtain or retain a benefit.
Instructions for the Request Voucher for Grant Payment for the Special Needs Assistance Program (SNAPs)
Item 1. Voucher Number: The first 3 digits are the prefix to your
program. Enter '001' if grant funds are being requested
for a grant awarded under a SHDP or SHP (TH, PH,
SAFAH and Renewal) grant. Enter '038' if funds are
being requested for a Housing Opportunity for Persons
with AIDs (HOPWA) competitive grant. Enter '054° if
funds are being requested for an Innovative Housing
Program (IHP) grant. (if you do not know your 3 -digit
program prefix, contact your local Field Office_) The
remaining 6 digits will be assigned by LOCCSNRS during
the telephone call. The entire 9 -digit number will have to
be entered prior to ending the call.
Item 2. LOCCS Program Area: Circle 'SNAP' (001) for SHDP
and SHP grant requests, 'HPAC' (038) for HOPWA
competitive grant requests, and 'IHP' (054) for Innova-
tive Homeless Programs.
Item 3. Enter the period covered by this request_
Item 4_ Type of Disbursement: Check 'partial' until the final
. request for grant funds is made.
item 5. Voice Response No: Enter the 10 digit Voice Response
System (VRS) project number which was sent to you by
mail. Your regular HUD project number will be repeated
back for verification after the VRS project number is
entered.
Item 6. Grantee Organization's Name: Enter the name of the
organization requesting funds. It must be the same name
that appears on the Grant Agreement.
Item 6a. Grantee Organization's Tax Identification No: Enter
the tax (employer) Identification Number (TIN).
Item 7. Not applicable.
Item 8. Grant Number: Enter the project number that appears on
the Grant Agreement.
Item 9_ Type of Funds Requested: SNAPs grant VRS draw-
downs are directed against specific funding categories
called Budget Line Item (BLIs). LOCCS associates a 4 -
digit number with each line item. Enter the amount
requested in each category (lines 1010 through 1120) and
the total funds requested under item 10, Voucher Total,
Item 11. Name & phone number (including area code) of the
authorized person who completed the call-in to VRS. The
authorized person is shown on line 3 of form HUD -27054.
Item 12. Signature of the person identified in item 11.
Item 13_ Date of this Request: Enter the date of the call-in to
request funds.
Retain this form in your records for audit purposes page2 of 2 form HUD -27053-A (2/95)
PROVIDER NAME:
PROGRAM NAME:.
CONTRACT#
MONTHLY INVOICE MIAMI-DADE IIVIELESS
MONTH: T R U S T
ATTACHMENT C-1
HT/PROJECTS
4/120082:01 PM
SUPPORTIVE SERVICES
80%
-0 T.S. % REQUST
,T ai
PCS.. IOhS DESCRlPTiCtvS I �u
Program
Total Expenses Expenses
Year to Date
SHP Year: 1 2 3
Reimbursement Total Budget For
The Year SHP Exp YTD
° at of -p
YTD
POSITIONS
0%
$ - $
$
$
$ -
#D!V/0!
POSITIONS
0%
-
#DN/0!
POSITIONS
0%
-
-
#DN/0!
POSITIONS
0%
/01
POSITIONS
0%
-
/0!
POSITIONS
p%
-
-
/0!
POSITIONS
p%
-
/0!
POSITIONS
0%
_ _
-
/0!
POSITIONS
0%
_ _
/0!POSITIONS
0%
-
-
I#DV/O!
lO!POSITIONS
0%
_
_
ID!POSITIONS
p^/0!POSITIONS
0%
-
/0!POSITIONS
0%
-
O!POSITIONS
0%
-
O!
TOTAL SAL.APJES
$
Is
$ -
S -
#UV/01
e Benefits -
0*4 of SAL. 0%
$ $
$
$ -
$
#DIYJO!
Tota! Sal $ Fringe
$ - $ -
$
- $ -
$ -
#DN/O!
DESCRIPTIONS
0%
$ - $ -
$
- $ -
$
#DNIO!
DESCRIPTIONS
0%
- -
#DN/0!
DESCRIPTIONS
0%
-
#DN/0!
DESCRIPTIONS
0%
#DN/O!
DESCRIPTIONS
0.
-
#DN/0!
DESCRIPTIONS
0%
-
#DN/0!
DESCRIPTIONS
0%
#DIVIT
DESCRIPnONS
0%
-
-
#DN/0!
DESCRIPTIONS
0%
#DN/0!
DESCRIPTIONS
0%
-
-
#D!V/0!
DESCRIPTIONS
0%-
- -
-
#DN/O!
DESCRIPTIONS
0%
-
#DN/0!
DESCRIPTIONS
0%
-
-
#DN/0!
DESCRIPTIONS
0%
#0IV/0!
DESCRIPTIONS
#DN/0!
Total Supportive Services $
- $ -
$ -
$ -
$ -
#DIVJO!
TOTAL SUPPORTIVE SVCS $
- $ -
$ -
$ -
$ -
#DIV/0!
HT/PROJECTS
4/120082:01 PM
s1,
-.-"CMI'a,�%v' Lrbl�ct°3���'•"'iY�(ips�y LS r='^SFyy aT-a�•cc'{�_MM)
�'�Y?� -,!' �^1 ys c^.-:. ""'f�- yAj. tr.t•'.;.3-X cwf r k�,3�e'�e�• � Y '5� l�,r�.r a� iS�=R 4� �`•�.'..�L '�+7nZ��'via-w �r -y t A� f �Tf.'��`,��., -.
"^+�._ .�-�^ _. _ v` `i z"' ���0� 1:: x.41 '. �'k � t' i i'! s i•�•- -.
ani ,rv� .a�.-.'•+`--r.,`21.�r.".�8— :'''fi .. .'- , . .'�, '- ._ `� ?, i` N�`A+� T� �' . ,. t; '•1...,..4.'. •4K O ..1TI. F .`NS=F .. AF,' :f
POSITIONS/DESCRIPTIONS % Total Expenses
POSITIONS 0% is -
Year to Date
Program SHP Total Year SHP Year: 1 2 3
Expenses Reimbursement Expenseso o p
SHP Exp YTD YTD
$ $ y $ M $ #DMO!
POSITIONS 0%
#DN/O!
POSITIONS 0%
#DIV/01
POSITIONS 0%
- #DN/0!
POSITIONS 0%
#DIV/0!
POSITIONS 0% -
#DN/O!
POSITIONS 0%
#DIV/O!
POSITIONS 01/.
#DIV/0!
POSITIONS 0%
_
#DIV/0!
POSITIONS
#D1V/01
POSITIONS
_
#DN/0!
POSITIONS
d.%//.
_
#DIV/01
POSITIONS -
-
#DN/01
POSITIONS
_
- #DN/0!
POSITIONS 0%
-
#DN/0!
TOTAL SALARIES $ -
$ - $
$ $ - #DIV/OI
nn a Benefits - 09A of SAL M. $ -
$ $
$ - $ #D/V/01
Total Sal & Fringe $ -
DESCRIPTIONS 0% $
; - $ -
g $
$ - $ - #DIV/0!
$ - $ - #DN/01
DESCRIPTIONS 0%
_
_ _ #DIV/O!
DESCRIPTIONS p%
_
_ #DN/O!
DESCRIPTIONS p°/
_
- #DN/0!
DESCRIPTIONS 0%
_
_ #DN/O!
DESCRIPTIONS M.
_
#DNlO!
DESCRIPTIONS 0% -
-
#DN/O!
DESCRIPTIONS 0%
_
- - #DN/O!
DESCRIPTIONS 0 %
_
- - #M10!
DESCRIPTIONS 0%
-
- #DNiO!
DESCRIPTIONS 0%
_ _
- #DN/O!
DESCRIPTIONS 0%
_
_ #DN/01
DESCRIPTIONS 0%
_
- #DN/01
DESCRIPTIONS 0%
_
- #DiV/0!
DESCRIPTIONS 0%
_
_ _ #D(V/01
Total Other Operating Services $ -
$ - $ -
$ - $ - #DIV/0!
TOTAL OPERATING SVCS $ -
POS17IONSIDESCRIPTIONS % Total Expenses
$ - $ _
Program SHP
Expenses Reimbursement
_ $ _ #DIV/0!
Year to Date
tTotal ear SHP Year: 1 2 3
Expenses ,° or Tot
SHP Exp YTD YTD
TOTAL LEASING ' O% $ -
/D
POSITIONSESCRIPTIONS Total Expenses
$ _ $ _
Program SHP
Expenses Reimbursement
$ - $ - #DN/0!
Year to Date
Total Year SHP Year: 12 3
Expenses
11 SHP Exp YTD YTD
TOTAL ADMIN COST $ _
$ _ $ _
$ - Is - #DfV/0!
GRAND TOTAL$ -
$ - $ -
$ - J$ - #DliilQ!
HT/PROJECTS
4/1120082:01 PM
ATTACHMENT'D
I�cverr•me T
-�Om_=llcnrPnlrt F'c;o��r _ 71:�.. ni� _�-.C, r }_ =-r.r 0
HUD AnnOai Progress Report (HUD-40alS)
Report Options:
S_'I=Ct Unduphcaled
-oviderMiami Gads_ County Government ("1)
Derabno Year Date Range 05/0=!?006 to 05/31/ OOb (mm/dd/yyyy)
gal Adult Age to (as defined by foster care law in your state)
Or
-Select- C.,s
_1006
1lCf ?.
5:; �1','ibl'i_O'
T IC'C �t.00111'rll]OI,71'SCIip IS,s, i�rej01 :I7L!G.7OI7 (i!14;
Served during the
1
Number of Singles Number of Adults
Number of
Children in
Number of
year.
Not in Families in Families
Families
Families
on the first day of the
E
0 p
0
0
ear.ntering
program during the
0 0
! 0
0
ar.
I
c. Number who left the program during
0 0
0
I 0
the operating year.
d. Number in the program on the last day
+ 0
C
0
of the operating year. (a+b-c=d)
0
3. Project Capacity.
Number of Singles Number of Adults
Number of
Children in
Number of
Not in Families in Families
Families
Families
a. Number on last day (From 2d, columns
0
0
1 and 4)
4. Non -homeless persons. (Sec. 8 SRO projects only)
How.many Income-ellgible non -homeless persons
were housed by the SRO program
during the operating
year?
0
5. Age and gender.
IAge
Ihia1e
Female Other/Nbt given
ngle Persons (from 2b, column Z)
Ia. 62 and over
{ 0
0 I
p
r
b. 51 61
0
I 0
0
Ic. 31 50
0
I 0 I
0
d.l� 30
� 0
t, �
o
e. 17 and under
INot given
I 0
0 I.
0
Persons in Families (from Ob, columns -2 1 3) �`. 62 and o,er
I p
f ,
Q
g. 5i -o1
0
I 0
0
h. =1 1 . ; n
IJ
CI
_1006
1lCf ?.
5:; �1','ibl'i_O'
T IC'C �t.00111'rll]OI,71'SCIip IS,s, i�rej01 :I7L!G.7OI7 (i!14;
L
o
k.
c
J
li
JNot
16a. Veterans Status.
A -ine 1-1E! n ort
1
6b. Chronically Homeless.
Hoer many parLdQ3nts v,,c,-r- chronically homeless irdiviiiiD-15?
7. Ethnicity.
0
f Hispanic
a. Hispanic or Latino
P c
b
b. Nan -Hispanic or Non -Latino
n
S. Race.
C
Race.
C)
nn
A _
a r
a. American Indian or Alaskan Native
American Indian
b
b- Aslan
0
cj
c 6 k 0 r A 'r 'c
c- Mack or African Americanii�
0
d. Native Hawallan or Other Pacific Islander
d v e ,
N a H 'i
Native
1 0
e. h i te
White 't
e rca n I n Jian/Ala.,kan Native & White
f . American
C)
0
d,
1g. Asian & white
E
V,,J
Black/African American &. White
0
, o
Ii. American Indian/Alaskan Native & Black/African American
j. Other
0
�Nlulti-Racial
k. Other/Unknown 'wn (all that do not match)
9a. Special Needs.
Ail
a. Mental
a. Mental illness
0
abuse
0
;0
2----
C. C) r
c. Drug abuse
0
Id. HIV/AIDS or related diseases
0
e. :al disability
I 0
1
0
f. Physical disability
0
0
0
19. Domestic violence
0
0
—0
LK- 0t h er (please specify)
0
—-
9b, Disabled.
How many of the particloants are disabled?
10, Prior Living Situation.
All=C
h =ro mi c
2. Nor: -housing (street, park, car, bus station, etc.)
0 0
b. Emergency shelter
0
0
Fc7T—ransj!:jDT-,?j housing For homeless per -sons
d. Psychiatric facility
e. Substance abuse treatment
0
o
g. -isun
, z
0
0
Rental hoij'--irlo
f
iLips.. tT-VlC1-Pt. Cc fl, V 111! affl. 1.1" L I n Ud. rh
1
6/ 1 006
-
111. Amount and Source of Monthly Income at Entry and Exit.
Amount
A. t�lontniy Income at Entry
G. t•lcnthly inc.-,—,.e at Ex *
All I Chroric
I All
I Chronic
2.
b.
ic. si51 < ::
0 -'
0
i
d. ;-,C�i _ w���
j r
o
) o
e. $S01 r 1000
I 0
0
G
f. $1001 61500
0 C'
0
n
p
0
h. $3000 + I
0
0
0
0
Source I
C. Income Sources at Entry I
D. Income Sources at Exit
Ail Chronic I
All
Chronic
a. Supplemental Security Income (SSI)
0 0 I
0
0
b. Social Security Disablilty Insurance (SSDI)
0 0
0
0
c. Social Security
d. General Public Assistance
I
0 I 0 {
0 I 0
0
0
I 0 {
I 0
e: Temporary Aid to Needy Families (TANF) ,
f. State Children's Health Insurance Program (SCHIP) I
0 0 I
0 0
0
0
0
I 0
g. Veterans benefits
0 0
0
I 0
h. Employment Income I
0 0 +
0
, 0
i. Unemployment Benefits
j- Veteran's Health Care
0 I 0 I
0 0
0
0
' 0
I 0
k. Medicaid
0 0
0
0
1. Food Stamps
0 0
0 I
0
m. Other (please specify)
0 0
0 I
0
n. No financial resources I
0 0
0
0 �-
12a. Length of Stay in Program. (Participants who left during operating year)
All
•Chronic
7j
a. Less than i month
0
0
b. 1 to 2 months
I 0
I
0 '
c. 3- 6 months
0
I
0
d. 7 months - 12 months
I 0
0
e. 13 months - 24 months
0
I
0
f. 25 months - 3 years
0
0
g. 4 years - S years
I 0
0
h. 6 years - 7 years
Ii. 2 years 10 years
I C
I 0
0
0
j. over 10 years I 0
(12b. Length of Stay in Program. (Participants who did not leave during operating year)
0
All
Chronic
ess than 1 month
[b.:1
I 0
0
to 2 months
0
G
- 6 months
I 0 I
0
d. 7 months - 13 months
e. 13 months - 34 months
I 0 I
0 I
0
0
f. 35 months - 3 years
I 0 I
0
e. 4 years - 5 y=_ars
D �
0
i.sfi-VICO�t.Ct0111.�r1113]ill.!SC'1DtS ;1'�1'lP0T[h.1d.1Ph U%] 006
Service Point version 4.01-015 (db build #0723)
Licensed to: miarni Dade Homeless Trust
(-c) 1999-200C, Bo,,rrr-,ian Systcrins L.L.C. All Rights Reserved.
CPT ray i,,OngAnIcrican NCJlcal P AN [--�I ,ht
D r' _nr r_ T r iF , ; or
hto, trie Amcr:clan rl5yCN8-''I[ A.S,-Icc!j',;-on, anc: are u,,,(i iil[h p?rtm.,.c;J0n herr-Ifl
rar Heo;�.r, P F.
Ta on l;C. 1 rmatil 3r.,Cj F -e --3'atloi-j C, un
'j
ti S: PlIP 6,21 1/2006
7'r-
C'.,er 10 v_7.r_ �.�
�� , i,
13. Re-nsans For Leaving.
(13
II I
C hro nir
C. N C I-, - p 2n; 1DF =,I- 'r::.:; n,",
d. Mon -
e. Criminal activicy destruction of property vj,:d,2nce
f. PPachtd maxii-nurn erne �jflov,,r--,d in
P'p 3 rn
_c� ujd
9. Need-, could noL b�', nnet by project
0
h. Disagreement with rules/persons
'e, nr
i- Death
0
0
C)
j. Other (please specify)
h. Unknown/disappeared
C)
C)
14. Destination.
All
Chronic
C
PERIIANENT (a h)
a. Rental house or apartment (no subsidy)
0
T-0 T-0
0
b. Public Housing
0
0
c. Section 8
1 0
Id. Shelter Plus Care
0-
house or apartment
0 I
0
e. HOME subsidized
house or apartment
y 0
0
f. Other subsidi7;-d
a. Homeownershlp
0
0
In Moved in with family or friends
0
0 0
TR-ANST 1DNAL (i -
-T Ii.
Transitional housing for homeless persons
0
0
[1��N
in with family or friends
0
0
Ij.
Moved
INSTITUTION (k - m) k. Psychiatric hospital
0
0
1. Inpatient alcohol/drug treatment facility
0
0
m. 3all/prison
0
0 —U
EMERGENCY SHELTER (n) n. Ernercency shelter
0
0
OTHER (o - o. other supportive housing
0
0
meant for human habitation (e.c. street)
0
0
p. places not
q. Other (please specify)
0
0
UNKNOWN r. Unknown
0
15. Supportive Services.
fqo supportive services found.
Service Point version 4.01-015 (db build #0723)
Licensed to: miarni Dade Homeless Trust
(-c) 1999-200C, Bo,,rrr-,ian Systcrins L.L.C. All Rights Reserved.
CPT ray i,,OngAnIcrican NCJlcal P AN [--�I ,ht
D r' _nr r_ T r iF , ; or
hto, trie Amcr:clan rl5yCN8-''I[ A.S,-Icc!j',;-on, anc: are u,,,(i iil[h p?rtm.,.c;J0n herr-Ifl
rar Heo;�.r, P F.
Ta on l;C. 1 rmatil 3r.,Cj F -e --3'atloi-j C, un
'j
ti S: PlIP 6,21 1/2006
�.`yI ,"11\ III ?L� ,'_i )L Ct 17 �` 1 i! 17(_)' 1�f f'_�\ Kj_'\ 1
`_ _
I'RO(r.R_A.'}'I RATING OFS-ATISFACTION
Cur000' reid all of the insvocrions beh" F�L��_ll� disiribuhn; 02 1'ro_i" ml ,'... Ann & Sa??O !c hu,
Sut"\'l'1' tU 1 Our ( rG^_rarfl p;irilC'!p;!Rts.
Gtncr.d Inf�.)rniutiun
The hrn"mrn RC'tlrig Of HtisM11rJn l:O])SM of 1 I KMS y110 pie_ Llu& W 7Cl rinllM J ChMIS 1WHALK11
with S(_'rl'1CCS My are receiving lrorin ul pro'vidcr. It is 10 be ConlPleied b." cil ?rl)'?r3f?1 1?arElcf�1(1L`� c.i�',,1_cd
in servicCs at 3 1 rusi fundad program. It must be cor-nMe ed - at a nhniniu?]i - at L1rIe all
participama It is strongly reconIrnend :d that a Procyram Ratin�a of Satisfaction sur�"ev a(su he c�.)rnpleted at
intervals as may be applicable to the propr= however. My the discharge survey Il:ust ht: inrvrnrdrd to tilt
Norneless Trust. Case manaymcrit notes should indicate specifically vit,� a Pro<<ram Ratin.o ufSatisfaCti ill
was not obtained, if that is the case (client went r.l1,%0L. institutionalized- etc.), and v,. hat efforts vHere Blade
to obtain a survey in those instances.
Be Program Rating of Satisfacticn isati a;cable in English, Spanish and CreO e. Pro\-iilers are responsible
for reproducing the appropriate survey and providing an envelope (that seals} for each respondent. &I
responses should be completed in ink
If a participant cannot read,_ providers should encourage them 0 use the same process they; use to have
other information read to them. Ar employee of the agency that is not directly responsible for the clieril's
care can read the form. This should be indicated in Section II. as a separate set of staff initials.
Filling out the form
1) A language appropriate survey and an envelope should he provided to all paricipants Tho are required
to complete the foal . On �• one form per family is required. The form must be filled out in inlc.
?) Section hI of the Program Rating of Satisfaction is to be completed by staff prior to providing the
survey document to the program participant. Staff initials refers to the initials of the case manager
responsible for the caernt's set -vice, delivery. if the survey must be read to the client, the initials of the
staff person. performing that function should also be included. In no case should the participants case
manager read items aloud to the participant.
3) Section I of the Program Rating of Satisfaction Form is to be filled out ONLY by the pr gmill
pa,-ticipant. The program participant should be provided a private place and sufficient tmie to answer
the survey.
4) Providers should reassure participants of the confidentiality of their responses. Pro\ iders may wish to
introduce the survey, as follo\vs:
`This Surrey is one \.vy, of helping tis detemnine ho\\ well ,ve are helpin,-, indi,,,iduals that
come 10 our agency For assistance. Please tale a fcw nl rives after 1 Rave to ans"Tr dos vwl
short survey as honesty; as possible. Your responses are private and \ve swill not loot: at them.
Th
1 lease sea] the envelop-- and give A to Me when you are due Q: pi A In & drop bon.,.
:) 1 he completed surae; should be placed 1n the en\ kp't by the r'tclpiint and seated. Pro','iders are
encoura!T:d to provide a dmp hog:' :.Ith a stili for competed inns.
61 The sealed v,opt(j) -1- � i);-1 (- i�n �'�ri r -D C - � i ICtCs_ Trus-[ ' l or, 3 it n lti
_ �r i.. .�e �3fi:_ CO tale t'�'ilH�`]li ted.; Ountl' t1��.I_ �,. � ;� � rn
basis.
7) The Proi'j:7er aL'w', shout .__ a il_n 01 o: -o:. (il Aly sur. J ui', Ji-7tr l u"l'd
�CCIR�,�ill:
EI: S.1TI F % C Tlti�
1 «:i� infurmed of m� ri,,zhrs :lnd respnnsinilliirs
I n'as prodded 1+ilii infurmati ,n about diffrrenl sen 'ices
I 01:11'JrC J1'JllihIc for' [lie
I
I WJS irll'UIVEJ Irl mJklnc CICCI510115 about nl\ l'arc!SC'r','Ice'.
la n o
1 �s is able Io tJlk +With staff w hen I needed to , The buddiflo and fJcilities IIJ�'e usuJllsbeen cic:1n, safe 2r1d S
I i
comfortable —
My rights }Fere respected arid protected, including run, 1-10111
to file J grievarlcc, if needed
a
My case man,22er seems qualified to help me
.6
S
I would recommend this ro�ram to others
1 am treated with res the staff IS
_
.ect.bv
The staff seems to carc about Whether 1 tet better
Program staff were knDwledgeablc about available servicesT 1 J
.3S
that could help me
-, , ;
P,ECOMMENDED 5 7. 00
1116/00
iI-DADL 1u %IET S 1 r.i_'` 1-
F' R 0 G PI=, + �I .R_A TI ' � OF S_� TI S FA C� "h f C� �`
ccti;in 1.:T�1 F,ECt�1:\U'1_i�T1 i� ��1 i'[�t;t�h_A:�I P.�.T;T1C1}'.ANT
�iisrtuc;iorts: Phase Uns"Ier ua 'lr question 6C/ow hl'jrI �p«. ta�rt'skunsc's Jn llr� cc'
fl I1CSY1r,'lIS hrll't /10 hearinn CI JI 1't>irr COi7lUtlll'"d Pr'rltclr)u/1�L1 111 the PfiiOrt(/71..-1�.L rL'.1 f�L'i;SPS clic C!l11�'ril'llli�ll,
\ h), did � ou choose to enter the pro,,ranl (ninrk onk cine
t,o conic to this ProL'rarl on niv ov,-n (throu_h outreach. referr�+. etc. )
❑I v,,'as placed 11crc thsoti�"h anothC; pry,<,ram (_sour? inler��ention, police. etc.) a�ainst In.� it
❑ I had previously participated in this or a similar proL,ram and decided 1n rclurn
OPTIONAL (nform2tion:
Name:
Today's Date:
Sex: ❑ n-1 '21e ❑ female
Please answer the fvllnsi,ino guestlorzs about the sen,ices lou received. oizlf� nirc Nu whrck hest
describes vulir feelin s about each stx7ievaent. These griestions are nrett;zl to help is iniprove rile serices provided,
so we ask that },oil tell its how Dori reallyfeel, whether or trot it is ,cood or batt.
S=ral eo lagree Agree a i Disagree Circ {vee 5rrvag!r
,4�rcc - Lrnlr - ) .4 Lirrle Disc"',
ee
5includinsg�
was informed of my rights and responsibilities, (b) (5) [�'] `3]
thea2enc)os grievance procedures i
sills provided with information about different services I fb] [51 [4] [d]
thai are ai�ailab{e forme
1
Was involved in making decisions about m_v [o) [4) f) [2) []j
care!sen ice Jan
I was able to talk with staff when I needed to
The building and facilities have usually been clean, safe
and comfortable
My rigwn my
hts were respected and protected, includin
(ri�ht to file a c7rieva nce, if needed
WTV case manager seems qualified to help me
I would recommend this program to others
1 am treated with respect by the staff
The staff seems to care about whether I tet better C
ProTrarn staff were knowledgeable about available
services that could help me
ib
fj][�'1
[=1
[) T1
[61
151
[bl
1�1
`.al
[3)
P1 [,
[e]
O
[4)
13 1
I21 f i1
(61
[l)
f_1
['] (�)
[d)
[>)
[4]
[31
121 (�]
Seciinn II.: To PE COMPLETED BY I'ROGP AM STATF
j PtirPnse of ti'tzhr¢rrnn � Current Level of Care pro"ided
1 0 At AdmissionI n ernereencyhousina
❑ At d15Char2P 0 iranSiiJcn31 houslnEful
i -
=i Other: ❑ Iran: uional housin2� nun-tx
IG' permanent hcusin2
0 service. onk,
G'_tt I Ir60U=onr.s%pr ;rumreiin�
Provider Mime:
j Prc ect n'amC.
1 Si3ff Irllli;jIs: —
I
1
, II.4INT I-DADE COUNTY HO:�]ELE SS TRUST
EVALUACION' DE LA 5.AT1SF.ACCIO)' C0N EL
Seccion I. (70',:1I'LETAD..1 Pill: EL P.tiRTIC1P.AtiTE DEL PF,, )(_;T�_,)l.a
_
-�. .]. n !1,17,1 cru- !A/ eit c/ CSnClCiii pra � rsrU r^crN r•;/�r�nrJc•,� 0 l.rs pr rur�u; ;, c .%u(i71 u;ii-iur,. L u;
r�SpuC;ra.4((Ue11sred dt a este no 0,.,,' ru
nrbsr na. TOft I,_'; las resDttcsres se rrtant_?'drdrr can��denciulnrer2.
Por que decidid ustcd participar en el proorami? (:'Marque una casilla solamen!c):
[ ) Lo d=cidi por MI cuen12 (porque Tti remindo o pbr medic de orro nro,,Fama. etc l
[ )
Ful colocado aqui mediante programa (por intery ncion dt• Jos la
policia. etc.) en contra de mi volun12d
( ] Ya habia parricipado en este prcLrama o en uno simi lar v decidi rc_,resar
Informacion OPCIONAL.:
Nombre J' gpellidD: Gcnero: M ( ( E ( )
Fecha de hog,:
Por favor resporrda a Ias pre; urrias stguientes acerca de 1us servicios que se (e iran preslaao. Inrli yore con Lin tj cru- /.�� F1'
VAA SOLA C4SILLA POR PRFGUAT.4 is forma err que usied se s1enle acerca de coda urrQ de las cucsrioncs descrilrrs.
Cornu srrs respuesrus a eslcs pre; untas nos q;wdardn a mejorar /os sendcias que presrainas, le ro; umos que rr us lrri; q saber
coma se sierrre err realidarl cc erca de nuesrros sen'icios, no impon'a si usred it"s considers buenos o nrulos.
Se me informaren cuales eran mis derechos y
re5pons2bilidades, entre ellos, los procedimientos de la
aeenci2 ara --meter uejas.
Se me dio informacion sobre !os distintos servicios a Jos
que tendo derecho.
Participe en la toma de decisiones referentes a mi plan
de atencion v servicios.
Pude hablarcon el persona! cunndo tuve necesidad de
hocerlo.
EI centro y sus servicios Por !o general se han mantenido
Jimpios, sin peli?ro v accesibies.
Se respetaron y protecieron mis derechos, entre e'los, mi
der -echo a someter uejas Si to consider- necesario.
Aparentemente, la persona encarbada de mi caso sabe Io
Lque tiene que hac.-r para avudarme
Yo !es recomendaria este proyecto j otras personas
Los empleados me trotoron respetuosomente
Aporentemente, a los empleados les interesa que yo
mejore.
Los empleados sabian que servicios pbdian ser irme de I
atiuda. I
Mur de I Dc I .-k1go de j i,o cn � En I A1ur rn
acuerde ac
acucrdo J desacutrdu desncucrdo ucsacuerdo
Seccion II.: COMPLETADA POR ENIPLEADOS DEL PROf3R_A ,1A (cornnleted by proa am staff)
Purpose of;<t,aivariorr
I Currenr Luc/ of Care pro, idcd f
D At Admissions.
❑
emer encv huu.,ii_ � Provider Name:
0 At discharee
❑
Transitional r,ousinvi Project iti'aTI) e:
„ars+ilt�n�1 hi.usm_r,-ton-r'> Staff Inihuls:
I D
[=)
[2) [1)
[6]
[5
[4][�I
[6]
[_�I
[4l
[=)
[') )
[6)
[']
[4)
[=)
['-) (1)
Seccion II.: COMPLETADA POR ENIPLEADOS DEL PROf3R_A ,1A (cornnleted by proa am staff)
Purpose of;<t,aivariorr
I Currenr Luc/ of Care pro, idcd f
D At Admissions.
❑
emer encv huu.,ii_ � Provider Name:
0 At discharee
❑
Transitional r,ousinvi Project iti'aTI) e:
„ars+ilt�n�1 hi.usm_r,-ton-r'> Staff Inihuls:
I D
pernan_-nt housir�g
i �D
services oniv
T T 7) 1 -T-
T
p "0 7 C, T) EVALYE S-ATJSFAKSVON
P 0 t
TfdLT P",FJ---F F'(-)! . \ �
-1 1 1'- ' 'N PL I jF `,,1 A
T11?t17Fi "L, /)1.V'ir7 cf)[I;.
i" /,wu /1:/
1-larl deLi/17!1/7 7(1111 7',,ia Y-qw!.,�yo
POUKI WCHW,AZJ PATJSIPE NAIN PWOG,;ZAM SJL-i. (t 11'o-2 n:if] "fill
Tenn brant):
Se m we ii ki c it u I zi r inn r :Iq In situ a (S IvL f):: P2 Si• "S C" a1 jN l ;J 11
Se Da Chwa Mwerl, Se yon 16f plvw r -)m 1;i N,O\Cnl (Z:lk f[C)
to dej:1 p3tisipc na n Yon pwogram J(Ons:� epi ruN%cri dt?sidu rcmjimcn.
Enfom2SVOII .2OU b2v Si kv vle:
Non:
Dat Jodya:
Schs (] Gason 171 Ferml
TL'17pr'rePO1l1l A-ekFP017 S'!`)`O dame SC I'll's R 01 kw,,111-11 f7fill Aare epi
17"alche ave it;. 'Keksi)olt si!,g po lapoli ede 11ol" bqvpibo7 SeI,is, 016 !7011 IM111de JJ()21 J)[J)17-epUIIS A -i r7lIg 71C,,tCIIC•
w, /"e 1i hoiz ou pu.
� Yo Fe,m k`Dnnen 'Lout CiVia mwen yo ok respons2bdile
Lm -en vo ak iin po" M"y m,koum
I n pleep nail ai2ns 13
Yo to banmwen en[6ma
syon SOU difcr_n Bevis he Mwen
kab !wenn
tCP2ti5iFJt nin lou: desizVon sou P12ni5knSvom
tn'yerl,
Am 1wave VO to toujou "--nib pou mwen pale avek v
-ote -a ak bile,
Kote a ak bildim7 yo to koujou byen pw6p, kc)nf6tnb ok
bor sekirite
Tout dN%,2 m to respekle ak pw6ttie mcilm dwa in you
moven to pore pjeilt si ne-ses,e
Noun kap okipe k:j mi -ver, in S
anble Ji kalifye you 1i
edem
Mwvn to rekomnnde pwo2ram Bila a bey )6t
I m ()un
Amplwz)),e yo trete m1N,en ak re.spe
Ameh)-aye vo sanble yo vrtmim enteresc nil n mwcn
PIV09r,"m 12 le b3,cn enfbme sou tout s&vis 16
Le �Is onib poll cde rri.
Bor, jail
dnk6
dakb
Djl:b
to_ -1-
P2,firin
1 twb dako
Ps
ditou
L
[6][3]
[6]
12 J
[6]
f 33
[21
fel 151
f -- I
[6]
�1,
[6J [ji
p
[2J
6 [5).
[4)
14 ]
21
Section If.: TO BE CO3MPLITE-D 13Y STAFF
of Care pro rif!cY
.At Admission housing
At discitar2,-i LJ marisitionad hou5m,-/ix
0
Z 7 1',,) ri a h f3 u-,7
on)v
Project No
S t2 Ff I It i ii is:
ATTACHMENT F
CLIENT CONTRIBUTION DEPORT
NAME OF AGENCY SUBMITTING REPORT:
DATE REPORT SUBMITTED:
GRANT NUNIB E R:
REPORT COMPILED BY:
MONTH OF SERVICE
CLIENT NAME:
DATE OF BIRTH: / /
IDENTIFICATION NUMBER#: —
DATE OF PROGRAM ENTRY:
/ I
INCOME:
AMOUNT FOR MONTH
SS U SSD (DISABILITY):
S
SOC. SECURITY:
AFDC/TA_NF:
$
FOOD STAMPS:
S
VETERAN'S BENEFITS:
S
EMPLOYMENT:
S
OTHER ( CHILD SUPPORT
$
ALIMONY, WORKEWS COW,
ETC.)
MEDICAID (Check One):
❑ Yes ❑ No
y� TOTAL ADJUSTED MONTHLY INCOME
TOTAL: S AMOUNT THIS MONTH TO CLIENT
TOTAL: S "AMOUNT THIS IIIONTH TO PROVIDER
MAXINRN 3,0% OF CLIENT'S ADJUSTED ENCONTE'
Revised 7/13/3007
U. S. Department of Housing
and Urban Development
Office of Community Planning
and Development
OMB Approval No. 2506-0145 (exp. ] 1/30:20C)9i
ATTACHMENT G
Annual Progress Report (APR)'
for
Supportive Housing Program
Shelter Plus Care
Section S Moderate Rehabilitation
for Single Room Occupancy
Dwellings (SRO) Program
FRID 401 I8
Public reporting burden for this collection of information is estimated to average 33 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may
not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMS control number.
General Instructions
Purpose. The Annual Progress Report (APR) is a reporting tool that HUD uses to track program progess and
accomplishments and inform the Department's competitive process for homeless assistance funding.
Filing Requirements. Recipients of HUD's homeless assistance grants must submit 2 APR'S to HUD within 90 days after
the end of each operating year. 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, Attn: APR Data Editor, Room 7262, 45176 Street,
S W, Washington, DC. 20410. Failure to submit an APR will delay receiving grant funds and may result in a determination of
lack of capacity for future funding_ An APR must be submitted for each operating year in which HUD funding is provided.
Grantees that received SHP funding for new construction, acquisition, or rehabilitation are required to operate their facilities for
20 years. They must submit an APR 90 days after the end of the first operating year and 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 in order to complete an APR. Optional
worksheets are attached_ 11ne worksheets may be used to record information manually or to design a computerized system to
store and tabulate the information. The worksheets should not be submitted to HUD with the APR.
Organization of the Report. The RPR is organized in the following manner:
Part 1; Project Progress. This portion of the report describes the progress in moving homeless persons to self-sufficiency,
documenting services received, listing project goals, and accounting for beds/units.
Part II: )Financial Information. Trds portion of the report is completed by all grantees receiving funding under SIP, S+C,
and SRO.
Final Assembly of Report. After the entire report is assembled, number every page sequentially. Mark any questions that do
not apply to your program with "NIA." for not applicable. (See Special histnictions for SSO Projects below.)
Definitions of Client/Household Types. Each client/housebold type is defined below. Note that a client's client/household
type should be based on the client's age and/or household composition at the program entry date closest to the start of the
operating year.
Families — A family is a household composed of two or more related persons, at least one of who is a child accompanied
by an adult or a 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 of The operating year. This
means that pregnant women 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.
Children in Families — Children m Families are defined as children under the age of 18 accompanied by one or more,
adults (parent, relative or guardian). Children in families also include 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 at the program entry date closest to the start of the operating year. For example,
HUD -401 18
clients who are less than. i 8 years of age on the first day of the operating year or at progra*n entry (if they entered during
the operating year) should be counted as children even if they tam 18 during the course of the operating year.
Persons in Families — Persons in families includes adults in families and children in famiiies.
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 SHP, S+C, or SRO.
Chronically homeless person — HUD defines a chronically homeless persor. 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.
HUD'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 in a Family (described above).
• Disabling condition: see the instructions under disabling condition (below) to determine whether a client is
disabled.
Did not leave the program — This term refers to clients who were in the program on the last day of the operating year.
Disabling condition - HUD defines a disabling condition as: (1) A disability as defined in Section 223 of tate Social
Security Act; (2) a physical, mental, or emotional impairment which is (a) expected to be of longi continued and indefinite
duration, (b) substandaliy impedes an individual's ability to live independently, and (c) of such a nature 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 arising from the etiological agency for acquired immunodeficiency syndrome; or (5) a diagnosable
substance abuse disorder_
Entered the program — Entered the program refers to the first day a client receives services_ For a residential program,
this date would represent the first day of residence in the program's housing. For services, this date may represent the day
of program enrollment, the day a service was provided, or the first date of a period of continuous participation in a service
(e.g., 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 eligible to count as
match.
An Extension APIA applies to SHP and S+C grantees that requested and received az extension of their grant term from
the HUD field office. The only difference between an APR for the extension period and the 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 clay 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 retm m within 30 days, do not count that client as having left the program.
For S+C programs, the,prugrmn exit date refers to the date ihe participant stops receiving rental assistance and is not
expected to return to S+C assisted housing. If the participant returns to S+C assisted housing within 90 days, the person
should not be considered as$xiting from the program. if the person returns to S+C assisted housing after 90 days, that
person is considered a new participant. The worksheet is designed to capture this information.
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 SHP, 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,
rehabilitation, and new construction are complete, after a copy of the Certificate of Occupancy is sent to the local HUD
office, and when the first participant is accepted into the project. For projects without acquisition, rehabilitation, or new
construction, the operating start date begins when the grantee accepts the fust participant. For dedicated HMIS projects,
the operating year begins when any eligible cost included in the approved project budget is incurred. For S+C (SRA,
PRA and TRA components), the first operating year begins on the date HUD signs the grant agreement. For S+C/SRO
and for Sec. 8 SRO, the first operating year begins 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 tern 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.
Project Sponsor means the organization responsible for carrying out the daily operation of the project; if the
organization is an entity other than the grantee.
Special Instructions for Sta:s[tosCifvve service ®rear ($SO) Pro-e-attts. SSO grantees should complete all questions,
unless a written agreement has been reached with the field office concerning which questions can be answered using estimates,
or in rare instances, skipped.
Below is an example of how information could be derived in a large, single -service SSO project:
A grantee/sponsor staff member could be assigned to collect information from the organizations housing the participants. The
staff person would contact these individual organisations 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 estimates.
Information could be collected for each participant or for participants receiving services at a point -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 APIC documents their progress in meeting these goals.
In some circumstances field offices and grantees may sign a Mitten agreement concerning questions that can be answered using
estimates, or in rare instances, shipped. See the special instructions below for reporting on special types of projects, such as
outreach only projects, projects providing services to children only, and transportation, medical, dental, and other single, short -
duration service projects.
SSC programs area third priority for local MAIS implementation, following emergency shelters, transitional housing programs,
outreach programs, and permanent supportive housing programs. Once SSO programs are included in the HMIS, SSO grantees
will be able to answer all APR questions using their HMIS data. SSO grantees that are not yet participating in HMIS will need
to collect data to answer the _APR mons nsingthe special .insbuctions,provided above.
Outreach Only Projects. Projects which acre solely devoted tostred outreach and connection to housing and services are
not required to track participants beyond their contact with persons on the street. It is sufficient for these projects to enter
E TD -40118
information on questions 1-10 (skipping questions 11-13 and 17). Estimates for questions 5-9 are allowed.. giver 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 Congess, 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 se -vices 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 snake 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 in 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.
Grantees may ship question 9; al other questions should be answered (except 17).
Transportation, Medical, Dental, and tither Single, Short -Duration Service Projects. Some grantees provide a
single service of fairly short duration focused ONLY indirectly on assisting homeless persons to obtain/remain in permanent
housing and increase their shills and incomes. It is sufficient for these projects to enter information on questions 1-10 and 14-
19 (question 17 may be skipped). However, with transportation services, it is unreasonable to think that someone would have
to give their age, race, and ed-micity to a bus driver to get a ride a few blocks.
For these services, provide a narrative, which gives the number of rides given during the operating year, and provides estimates
on the above statistics based on the population that utilizes the service.
S€ inial Instructions For Safe Haven (SH) Projects. grantees should report on all participants served during the
operating year. Note: this is a change from prior instructions where grantees were instructed to report on the -first 25
participants served.
Special Instructions fon- Homeless Management Information System a S) ]P`roi eets. I1tvilS grantees
should fill out the cover sheet of the API?, Part 11 Financial Information, and the HMIS Activities section.
HUL1-40I 18
THIS PAGE - TO BE COMPLETED BY ALL GFANTEES
Grantee: HUD Grznt or Project Number:
Project Sponsor: Praiect Name:
Operating ;'ear: (Circle the operating year being reported on) Reporting Period: (month/day/year)
❑1 ❑2 ❑3 [14 ❑5 ❑6 ❑7 ❑8 ❑9 ❑10
❑11 ❑12 ❑13 ❑14 015 ❑16 0I7 ❑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 Housing Program (SUP) Shelter flus Care (S+Q
❑ Transitional Housing
❑ Permanent Housing for Homeless
Persons wig Disabilities
❑ Safe Haven
[) Innovative Supportive Housing
❑ Supportive Services Only
❑ HNdiS
❑ Tenant -based Rental Assistance (TRA)
❑ Sponsor -based Rental Assistance (SRA)
❑ Project -based Rental Assistance (PRA)
❑ Single Room Occupancy (SRO)
Section 8 Moderate Rehabilitatior
❑ Single ][Zoom Occupancy
(Sec. 8 SRO)
Si.nnuiar3 of the project: (One or two sentences with a description of population, number served and accomplishments this operating year)
Mame & Title of the Person who can answer questions about this report: Phone: (include area code)
Address: Pax Number: (include area :ode)
E -snail Address
I hereby certify that all the information stated herein is trite and accurate.
Warning: FUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties, (18 U.S.C. 1001,
1010, 1012; 3) U.S.C. 3729, 3802)
Name & Title of Authorized Grantee Official: Signature & Date:
Name and Title of Authorized Project Sponsor
Signature €t Date:
X
HUD -40118
PART L TO BE Cf1mPLETED &'YALL GRANTEES (EXCEPT RMIS)
SSU GRANTEES, PLEASE SEE SPECL4L INSTRUCTIONS ON PAGE 3 OF THE APR
Part is Project Progress
1. Projected Level of Persons to be served at a given point in time. (This information comes from the most recent CoC
application.)
2. Persons Served during the operating year.
Number of
Singles Not in
Families
Number of
Number of Number of
Number of
a. Number on the first day of the operating year
Singles Not
Adults in Children
Families
b. Number entering program during the operating year
Projected Level
in Families
Families in Families
a
Persons to be served at a given point in time
2. Persons Served during the operating year.
Explanatory notes:
See Definitions of Client/Household'Types in the General Instructions above to determine which clients should be counted as Singles.Not in
Families, Adults in Families, and Children in Families. Note that this table does not account for changes in client/household type that may
occur during the course of the operating year. Instead, each client should be assigned a single client/housebold type based on the client's
age and/or household composition at the program entry date closest to the start of tke operating year. In this way, each client is counted
only once in the table.
Use the following graphic and explanations to determine who should be counted in rows a -d:
Client in program on first day of
• I operating year, left during the
yea,. count in 2a and 2c.
Client in program on first day
of operating year and last
day of operating year. count
in 2a and 2d.
Client entered and left
+---� program dudng operating
year. count in 2b and 2c.
cherd entered and left Client entered program during
program before start of • • operating year and still in
operating year. do not count in ; program on last day of year,
question 2. - count in 2b and 2d.
First day of the Lasa day of the
operating year apeMtiag year
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 stent of the -operating ye&c Do not count the client more than once even if he/she entered the program more than
once during tete operating year,
c. Number who left during the operating year: This row includes all clients who left the program or. 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 exit dates, use the exit date
HUD -40118
Number of
Singles Not in
Families
Number of
Adults in
Families
Number of
Children in
Families
Number of
Families
a. Number on the first day of the operating 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-l-b-c)=d
Explanatory notes:
See Definitions of Client/Household'Types in the General Instructions above to determine which clients should be counted as Singles.Not in
Families, Adults in Families, and Children in Families. Note that this table does not account for changes in client/household type that may
occur during the course of the operating year. Instead, each client should be assigned a single client/housebold type based on the client's
age and/or household composition at the program entry date closest to the start of tke operating year. In this way, each client is counted
only once in the table.
Use the following graphic and explanations to determine who should be counted in rows a -d:
Client in program on first day of
• I operating year, left during the
yea,. count in 2a and 2c.
Client in program on first day
of operating year and last
day of operating year. count
in 2a and 2d.
Client entered and left
+---� program dudng operating
year. count in 2b and 2c.
cherd entered and left Client entered program during
program before start of • • operating year and still in
operating year. do not count in ; program on last day of year,
question 2. - count in 2b and 2d.
First day of the Lasa day of the
operating year apeMtiag year
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 stent of the -operating ye&c Do not count the client more than once even if he/she entered the program more than
once during tete operating year,
c. Number who left during the operating year: This row includes all clients who left the program or. 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 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 operating year.
d. Number in 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 column, add the number 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.
Explanatory Notes:
Row b refers to the most recent CoC application for which the program is reporting.
4. Mote -homeless persons. This question is to be completed for Section 8 SRO projects.
How many income -eligible non -homeless persons were housed by the SRO program during the operating year?
5. Age and Gender. Of those who entered the project during, the operating year, how many people are in the following age
and gender categories?
Single Persons from 2b, column 1
me Male Female
Number of
Singles Not in
Families
Number of
Adults in
Families
Number of
Children in
Families
Number of
Families
a
Number on the last day (from 2d, columns 1 and 4)
d.
18-30
e.
17 and under
L
Number proposed in application (from 1 a columns 1 and 4)
Persons in Families (from 2b, columns 2 & 3) f.
62 and over
g.
51-61
c.Capacity
Rate (divide a by b) _ %
%
18-30
J.
%
Explanatory Notes:
Row b refers to the most recent CoC application for which the program is reporting.
4. Mote -homeless persons. This question is to be completed for Section 8 SRO projects.
How many income -eligible non -homeless persons were housed by the SRO program during the operating year?
5. Age and Gender. Of those who entered the project during, the operating year, how many people are in the following age
and gender categories?
Single Persons from 2b, column 1
me Male Female
a_
62 and over
b.
51-61
c.
31-50
d.
18-30
e.
17 and under
Persons in Families (from 2b, columns 2 & 3) f.
62 and over
g.
51-61
h.
31-50
i.
18-30
J.
1 13-17
k.
6-12
1.
1-5
m.
Underl
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 1. 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, columns 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 10 below should be the same; respond to each of those questions for all participants. Some of
the questions listed throughraA the APR will be asking information for individuals who are cbrostically homeless.
HUD -40118
6a. Veterans Status. A veteran is anvone who has ever been on active military duty status.
How many participants were veterans? tI
6b. Chronically homeless person. An unaccompanied homeless individual with a disabling condition who has either been continuously
homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years. To be considered
chronically homeless a person must have been on the streets or in an emergency shelter (i.e. not transitional housing) during
these stays. 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?
a Hispanic or Latino
b. Non -Hispanic or Non -Latino
Explanatory Notes:
Each participant should be listed in only one category_ The total number of participants in this table should equal the number of participants
in question 2b, columns 1 and 2.
& Race. How many participants are in the following racial categories?
a. I American_ Indian/Alasken Native
bj Asia.
c_ Black/African American
d. Native Hawaiian/Other Pacific Islander
e. 1 While
f American Indian/Alaskan Native & White
Asian & White
h_ j Black /African American & White
i. American Indian/Alaskan Native & Black/African American
Other Multi -.Racial
Explanatory Notes:
Each participant should be listed in only one category. A participant whose race does not correspond to categories a through i should be
counted in },_ Other Multi Racial. The total number of participants in this table should equal the number of participants in question 2b,
columns I and 2. If using HMIS data, you may combine HMIS race response categories to generate the APIC response categories.
9a. Special Needs. How many participants have the following? Participants may have more than one.
If so, count them in all applicable categories. For each condition, also indicate the number
that were chronically homeless.
All Chronic
a
Mental illness
b.
Alcohol abuse
c.
Drugabuse
d
HTWAIDS and related diseases
e.
Develo mental disability
f.
Physical disability
Domestic violence
h.
Other ( lease specify)
9b. How many of tl;e participantszm disabled? F7
Explanatory Notes:
To deternine which participants meei=s definition of "disabled," see'Usabiuig Condition" under Other Key Definitions in the General
Instructions.
HUD -40115
10. Prior Living Situation. How many participants slept in the following places in the ween 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,
columns I and 2). Also, indicate how many chronically homeless participants slept in the following places. (Choose one)
All Chronic
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.
Hos ital*
g.
IaiU rison*
h.
Domestic violence situation
i.
Living with relatives/friends
j.
Rental housing
T—
Other (please scify)
*If a participant came from an institution (psychiatric facility, substance abuse treatment facility, hospital, or jail), but was there less than
30 days and was living on the street or in emergence shelter before entering the treatment facility, he/she should be counted in either the
street or shelter category, as appropriate.
Complete questions I 1 - 15 for alt participants who left during the operating year (from 2c, columns I and 2). The tern
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 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 (Le. not transitional housing) during
these stays.
I I. !amount and Source of Monthly Income at Entry and at Exit. Of those participants who left during the operating year, how many
participants were at each monthly income level and with each source of income? Also, please place the monthly income level and each
source of income for chronically homeless persons in the second column of each chart. The number of participams in Chart A and B
should be the same.
A8 (ironic AN Chronic
HUE) -401 IS
A. Monthly Income
at Entry
a.
No income
b.
$1-150
C.
5151-$250
d_
S251-$500
e.
$501 - $1,000
f.
$1001-$1500
g.
$1501-$2000
h.
$2001 +
HUE) -401 IS
C. Income Sources At Entry
a.
Supplemental Security Income (SSI)
b_
Social Security Disability Income (SSRI)
e.
Social Security
d.
General Public Assistance
e.
Temporary Aid to Needy Families (TANF)
f.
State Children's Health Insurance Program (SCHIP)
g.
Veterans Benefits
h.
Employment Income
L
Unemployment Benefits
j.
Veterans Health Care
k.
Medicaid
1.
Food Stamps
in..
Other (please specify)
n.
No Financial Resources
HUE) -401 IS
AH Chronic AN Chronic
Explanatory Motes:
Table A: Monthly income at entry refers to the participant's monthly income on the day he/she entered the program (i.e., on the program
entry date or as close as possible to that day). You should not report on income received before entering the program 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 not report on income received during the program stay.
Table C: Income sources at entry refers to the participant's sources of income on the day he/she entered the program (i.e., on the program
entry date or as close as possible to that day). You should not report on sources of income received before entering the program or income
received during the program stay. Participants with no income at the time of program entry should be reported in category n, No Financial
Resources.
Table D. 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 report on sources of income received during the program stay. Participants with no
income at the time of program exit should be reported in category n, No Financial Resources.
12a. Of those participants who left during the operating year (from 2c, columns I a -Lid 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 left during the operating year in the second
column.
All drb—i,
. Monthly Income
Exit
4a.No
income
b.
-150
C.
51 -S250
d.
_S251 -S500
e.
$501 - $1,000
f.
$1001- $1500
g.
$1501-$2000
h.
$2001+
Explanatory Motes:
Table A: Monthly income at entry refers to the participant's monthly income on the day he/she entered the program (i.e., on the program
entry date or as close as possible to that day). You should not report on income received before entering the program 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 not report on income received during the program stay.
Table C: Income sources at entry refers to the participant's sources of income on the day he/she entered the program (i.e., on the program
entry date or as close as possible to that day). You should not report on sources of income received before entering the program or income
received during the program stay. Participants with no income at the time of program entry should be reported in category n, No Financial
Resources.
Table D. 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 report on sources of income received during the program stay. Participants with no
income at the time of program exit should be reported in category n, No Financial Resources.
12a. Of those participants who left during the operating year (from 2c, columns I a -Lid 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 left during the operating year in the second
column.
All drb—i,
D. Income Sources at Exit
a.
Supplemental Security Income (SSI)
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 (SCHIP)
g.
Veterans Benefits
h.
Employment Income
L
Unemployment Benefits
j.
Veterans Health Care
k.
Medicaid
1.
Food Stamps
M
Other (please specify)
n.
No Financial Resources
Explanatory Motes:
Table A: Monthly income at entry refers to the participant's monthly income on the day he/she entered the program (i.e., on the program
entry date or as close as possible to that day). You should not report on income received before entering the program 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 not report on income received during the program stay.
Table C: Income sources at entry refers to the participant's sources of income on the day he/she entered the program (i.e., on the program
entry date or as close as possible to that day). You should not report on sources of income received before entering the program or income
received during the program stay. Participants with no income at the time of program entry should be reported in category n, No Financial
Resources.
Table D. 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 report on sources of income received during the program stay. Participants with no
income at the time of program exit should be reported in category n, No Financial Resources.
12a. Of those participants who left during the operating year (from 2c, columns I a -Lid 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 left during the operating year in the second
column.
All drb—i,
Explanatory Notes:
Compute each participant's length of stay using the participant's program entry date and program exit date. If the participant has only one
program exit date durinzz
g the opcatmg year, calculate length ofstay by subtracting the program entry date i<om 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 tagether to produce a curnulative length of stay. Each
HUD -40118
Less than 1 month
b.
Mc.a
I to 2 months
3 - 6 months
d.
7 months - 12 months
e.
13 months - 24 months
f
T,5 months - 3 years
ye - - years
E�e:Eso-7 yeears
4h.6
Explanatory Notes:
Compute each participant's length of stay using the participant's program entry date and program exit date. If the participant has only one
program exit date durinzz
g the opcatmg year, calculate length ofstay by subtracting the program entry date i<om 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 tagether to produce a curnulative length of stay. Each
HUD -40118
participant should be associated with only one length of stay categoz7% The total, number of participants in the first column ("Ail") should
equal the nurnbie of participants in question 2c, columns I and 2.
12b. Length of Stay in Program. For those participants who did not leave during the operating year (from 2d. columns 1 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 colwrhir
All Chronic
Eapisoatory Notes:
Compute each participant's length of stay using Vie participant's program entry date and the last day of the operating year. To calculate
length of stay, subtract the program entry daze from the last day of the operating year. Each participant should be associated with only one
length of stay category. The total number of participants in the first column ("All") should equal the number of participants in question 2d,
columns I and 2.
13. Reasons for Leaving. Of those participan'—z who left the project during the operating year (from 2c, columns I and 2), how many left
for the following reasons? If a participant left for multiple reasons, include oxh? the pnfmar reason. The total number of participants
in the first column ("Al)") should equal the number of participants in question 2c, columns I and 2. Also, please place the primary
reason for chronically homeless persons who left the project during the operating year in the second column.
All Chronic
a .
Less than i month
b_
Fc.a
1 to 2 months
C.
3 - 6 months
d.
7 months -12 months
e.
13 months - 24 months
f..
25 months - 3 years
g.
4 ears - 5 years
h.
ti years - 7 years
i_
1 S years - 10 years
j.
I Over 1 d year
Eapisoatory Notes:
Compute each participant's length of stay using Vie participant's program entry date and the last day of the operating year. To calculate
length of stay, subtract the program entry daze from the last day of the operating year. Each participant should be associated with only one
length of stay category. The total number of participants in the first column ("All") should equal the number of participants in question 2d,
columns I and 2.
13. Reasons for Leaving. Of those participan'—z who left the project during the operating year (from 2c, columns I and 2), how many left
for the following reasons? If a participant left for multiple reasons, include oxh? the pnfmar reason. The total number of participants
in the first column ("Al)") should equal the number of participants in question 2c, columns I and 2. Also, please place the primary
reason for chronically homeless persons who left the project during the operating year in the second column.
All Chronic
a .
Left for a housing opportunity before completing program
b.
Completed program
C.
Non-payment of rent/occupancy charge
d.
Non-compliance with project
e.
Criminal activity / des-truction 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
HLT.; -401 I E
14. Destination. Of those participants who left during the operating year (from 2c, columns I and 2), how many left for the following
destination? Also, please place the destination of chronically homeless persons who left during the operating year in the second
column.
All Chronic
PERMANENT (a -h)
a
Rental house or apartment (no subsidy) i
b.
Public Housing
C.
Section 8
d.
Shelter Plus Care
C.
HOME subsidized house or apartment
f.
Other subsidized house or apartment
g.
Homeownership
h.
Moved in with family or friends
TRANSITIONAL (i j)
i.
Transitional housing for homeless persons
j.
Moved in with family or friends
INSTITUTION (k -m)
kPsychiatric
hospital
1_
Inpatient alcohol or other. drug treatment facility
m_
Jail/prison
EMERGENCY SHELTER (n)
n.
Emergency shelter
OTHER (o -q)
o.
Other supportive housing
P_
Places not, meant for human habitation (e.g_ street)
q.
Other (please specify)
UNKNOWN
r.
I Unknown
Explanatory Notes:
Identify each participant's destination upon leaving the program using the categories provided The response categories combine
"destination" (e.g., rental house or apartment, public housing, homeownership, etc.) and "tenure" (e.g., permanent, transitional, etc.).
Consider both destination and tenure to determine the most appropriate response, and be sure to look at all of the response categories before
making a selection. The table below provides a brief description of each response category.
Enter the number of participants under each destination category in either the first column of the table or in both columns if the participant is
chronically homeless. Only one reason for leaving should be recorded per participant. The total number of participants in the first column
("All") should equal the number of participants in question 2c, columns i and 2.
Tenure
Destination
Desert tion
Permanent a
Rental house or apartment (no
Participant is moving to an apartment or house without any subsidy.
subsidy)
b.
Public housing
Participant is moving to a public housing unit.
c_
Section 8
Participant will use a housing choice voucher (formerly knovz� as a
Section 8 voucher) to rent a house or apartment -
d.
Shelter Plus Care
i Participant is moving to a unit funded by the Shelter Plus Care
program (e.., TBA, SRA, PRA., Section 8 SRO).
e.
HOME subsidized house or
Participant is moving to a unit with rental assistance provided by the
apartment
HOME program (tenant -based or roiect-based assistance).
f.
Other subsidized house or apartment
I Participant is moving to a unit subsidized by some program other than
I
f public housing, housing choice voucher program (formerly Section 8),
Shelter Plus Care, or HOME.
Homeo ership
Participant is moving to a unit that he/she has purchased -
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).
P ticipant is moving in with family or friends and expects to live there
j. Moved in With family or friends
less than 90 days.
Institution k.
Psychiatric fimTitad I
Parlicipant is moving to a psychiatric hospital.
HUE -401 IS
i Tenure
Outreach
Destination
Description
c.
1.
Inpatient alcohol or other drug
Participant is moving to an inpatient alcohol or drug treatment facility.
e.
Mental health services
treatment facility
HN/AIDS-related services
g.
In
Jail/Prison
Participant is moving to a jail or prison.
Emergency
n.
Emergency shelter
Participant is moving to an emergency shelter for homeless people.
Shelter
Child care
1.
Transportation
Other
o.
Other supportive housing
Participant is moving into supportive housing that does not correspond
to any.of the permanent housing categories (a -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, sidewalk 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
F.
Unknown
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 he/she is.
*HUD encourages programs to limit the use of 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.
Exits 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, please place the supportive services received for chronically
homeless participants who left during the operating year in the second column. Participants may have received multiple services and all
services should be reported in the table.
41i Chronic
a
Outreach
b.
Case management
c.
Life skills (outside of case management)
d
Alcohol or drug abuse services
e.
Mental health services
f.
HN/AIDS-related services
g.
Other health care services
h.
Education
i.
Housing placemen
j.
Employment assistance
k
Child care
1.
Transportation
m.
Legal
n.
Other (please specify)
HUD -40118
16. Overall Program Goals. Under objectives, list your measurable objectives for this operating year (from your application, Technical
Submission, or APR) for each of the three goals 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:
Progress:
Next Operating Year's Objectives:
b. Increased Shills or become
Objectives:
Progress:
Next Operating Year's Objectives:
c. Greater Self-determination
Objectives:
Progress:
Next Operating Year's Objectives:
17. Beds. SHY recipients answer 17a.. S+O' recipients answer 17b. SRO recipients answer 17c. (S SS0projects do
not conWlete this question)
a SEP. 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 all participants, other family members, and care givers.)
Number of Beds: _
Number of Dwelling knits:
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 Dwelling Uni'.s:
HUD -401 18
Part 11: Financial Information
18. Supportive Services.
For Supportive Housing (SHP) this exhibit provides information to HUD on how SHP funding for supportive services was spent during
the operating year. Enter the amount of SHP funding spent on these supportive services. Include HMIS costs under "Other".
For Shelter Plus Care (S+C), this exhibit tracks the supportive services match requirement. Specify the value of supportive services from all
sources that 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 se=rvices received by homeless persons during the
operating year.
HUD -40118
Supportive Services
Dollars
a
Outreach
b.
Case management
C.
Life skills (outside of case management)
d.
Alcohol and drug abuse services
e.
Mental health services
f.
AIDS-related services
g.
Other health care services
h.
Education
i_
Housing placement
j.
Employment assistance
k_
Child care
1.
Transportation
In.
Legal
n.
Other (please specify)
o.
TOTAL (Sum of a through n)
Cumulative amount of match provided to date for the
Shelter Pius Care Pro ram under this grant
HUD -40118
19. 'Supportive Housing Program: Leasing, Supportive Services, Operating Costs, HMIS Activities and Administration
All grantees receiving funding under the Supportive Housing Program must complete these charts each operating year. For expansion
projects: if SHP grant funds are 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. Documentation 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 RTant was executed.
Summary of Expenditures. Enter the amount of SHP grant funds and cash match expended during the operating year for each activity.
This table should add up both horizontally and vertically. The SHP supportive services total should be the same as the SHP supportive -
services in Ouestion 18_
Note: Payments of principal and interest on any loan or mortgage may not he shown as an operating expense.
Sources of Cash Match. Enter the sources of cash identified in the Cash Match coiumn, above, in the following categories. Use additional
sheets, as necessary.
SHP Funds
Cash N:atch
Total Expenditures
a_
Leasing
Local government (please specify)
b.
Supportive Services
C-
Operating Costs
C. State government (please specify)
d.
HMIS Activities
C.
Administration
Community Development Block Grant (CDBG)
f.
Total
C. Foundations (please specify)
Note: Payments of principal and interest on any loan or mortgage may not he shown as an operating expense.
Sources of Cash Match. Enter the sources of cash identified in the Cash Match coiumn, above, in the following categories. Use additional
sheets, as necessary.
HUD -40118
Amount
a
Grantee/project sponsor cash
b.
Local government (please specify)
C. State government (please specify)
d_ Federal government (please specify)
Community Development Block Grant (CDBG)
C. Foundations (please specify)
f. Private cash resources (please specify)
g. Occupancy charge/ fees
h. Total
HUD -40118
20. Supportive Housing Program: Acquisition, Rehabilitation, and New Construction
All grantees that received SHP funds for acquisition: rehabilitation, or nevr construction rnust 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 SHP funds
Spent for acquisition, rehabilitation, or new construction. Documentation that matching fund's were provided is not required to be submitted
with this report but should be kept on file for possible inspection by Ht -M and Auditors.
Summary of Expenditures. Enter the amount of SHP grant funds and cash match expended during the operating year for each activity.
Cash Match. Enter the sources of cash identified in the Cash Match column, above, in the following categories. Use
additional sheets, as necessary.
SEP Funds
Cash Match
Total Expenditures
a.
Acquisition
Local government (please specify)
T.—
Rehabilitation
C.
New construction
C.
State government (please specify)
d.
Total
Cash Match. Enter the sources of cash identified in the Cash Match column, above, in the following categories. Use
additional sheets, as necessary.
HUD -40118
Amount
a.
Grantee/project sponsor cash
b.
Local government (please specify)
C.
State government (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
Describe any problems and/or changes implemented during the operating year.
Technical Assistance and Recommendations
Based on -your experience during the last year, are there any areas in which you need technical advice or assistance? If so, piease describe.
HI -ID -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
roiect. 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).
Income -eligible Pion -homeless in SRO. The SRO
program allows assistance to units occupied by
Section 8 income -eligible persons residing at the
SRO prior to rehabilitation. For SRO projects
only, indicate whether the participant is an
income -eligible, non -homeless person (Y) or not
(N). SHP and S+C projects should skip this item.
5a. hate of Birth. Enter date of birth including
month, day, and year.
5b. Age. 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: A 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
K Non -Hispanic or Non -Latino
Race. Enter appropriate letter for race.
a. American Indian or Alaskan Native
b. Asian
e. Black or African-American
d: Native Hawaiian or Other Pacific. Islander
e. White
f. American Indian/Alaskan Native & White
g. Asian & White
It. Black/African American & White
i. American IndianlAlaskan Native c
Black/African American
j. Other Multi -Racial
9a. Special Needs. Enter the letter(s) for the
category(ies) that descsil'e the participant's
disability(ies). (You may double count).
a. Mental illness
b. Alcohol abuse
c. Drug abuse
d. HIV/AIDS and related diseases
e. Developmental disability
f. Physical disabilities
g. Domestic violence
h. 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. Tail/prison*
h. Domestic violence situation
i. Living with relatives/friends
j. Rental housing
k. Other (please specify)
*1,5'a participant came from ari institution but
was there Iess 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 I a.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 I cAncome 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 (SCHLP)
g. Veterans benefits
h. Employment income
i. Unemployment benefits
j. Veterans Health Care
k. Medicaid
1. Food Stamps
m_ Other (please specify)
r.. No Financial Resources
l tUD40118
I Id.Income Sources Received at Project Exit.
Enter all rypes of income the participant is
receiving at project exit. (Use codes as in I lc.)
12a Length in Stay in Program. Calculated item.
(See Entry Date and Exit Date above.)
12b. Length of Stay in Program. (Participant did
not leave during the operating year. How long
have they been in the project?)
13. Reason for Leaving Project. Enter the primary
reason why the participant left the project.
(Complete only for participants who left the
project and are not expected to return within 90
days.
a. Left for a housing opportunity before
completing the program
b_ Completed program
c_ Non-payment of rent/occupancy charge
d. Non-compliance with project
C. Criminal activity/destruction of property/
violence
f. Reached maximum time allowed in project
g. heeds 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 8
d. Shelter Plus Care
e. HOME subsidized house or apartment
f. Other subsidized house or apartment
g. Homeownership
h. Moved in with family or friends
Transitional:
i. Transitional housing for homeless persons
j. Moved in with family or friends
Institution:
k. Psychiatric hospital.
1. Inpatient alcohol or drug treatment facility
in. Jail/prison
Emergency:
n. Emergency shelter
Other:
o. Other supportive housing.
p. Places not meartt 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
h. Education
i. Housing placement
j. Employment assistance
k. Child care
1. Transportation
m. Legal
n. Other (please specify)
__ HUD 40118
Horne
HUD r„riuo! Pro; efs R.apnrt HUD-40IIS1
ATTACHMENT G--1
Report Options:
=r If°1iaml- Dade Gov�Lrnm_nC 1)
perating fear Date F.ange05i Oii� 0 to X0371 2001
gal Adult Age i8 (as de,�rned by fDster care l7 your ft'Eic�?
Or
-Select-
�2. Persons Served duringthe Number of Singles
Number of Adults
Number of
Children in
Number of
IFamilies
operating year. Not in Families
in Families
Families
a. Number on the first day of the 0 D
0
operating year,
ff
0
b. Numberertering program durinc the 0
operating year. G j
G
I 0
11
c. Number who left the program during0
p
I 0
the operating year,
1
11
0
0
i
d. Number in the program or the last day
G 0
Of the operating year. (a+b-c=d)
I
0
D
3. Project Capacity. Number of Singles Number of Adults
Number of
Children in
Number of
Not in Families in Families
Families
Families
a. Number on last day (from 2d, columns
-T-
1 and 4) 0
0
4. Non -homeless persons. (sec. 8 SRO projects only)
How many Income-ellglble non-hornefess persons vrere housed by the SRO program during th.e operating
year?
5. Age and gender. Age+Mate
�Femafe Other/Not given
Single Persons (from 2b, column i) a. 62 and ever
0
I 0
0
Ib. 51 51
Ic. 3l 50 I
0
I 0 I
p
�d. 18 30 ;
0
I 0
0
�c. 17 -and unu'er I
Q
I 0
0
INot given
0
D
I
p
Person, in Families (from 2b, columns ? If. 5-1 and over
I 0 I
n
fig . 51 -61
I�
jh. =G'
G
0
_
I
f
Q 1
^LtrS:.ri'rV, 'i.C_TV112P1.C:),1%11i;2?lil% ui7i +I'°tir_ih1.1G.�hl
192- Special Needs.
1
All
Chronic
r,, c. t 9:,., en
1 ;C
6a. Veto-'.Fls Slatus.
'
1A vecrar is an", -me v"h� n�-'-cr, Dt�!_
6b. Chronically Homeless.
P. ri v, many p a r-, ( c P a n ts tA,� e r P CnFonir3h,/ homeless individuals
o
7, Ethnicity.
C)
a- Hl,-Fanlc or Latlrio
0
b. Non-Hl.p2nic or Noi-I-Dtino
S. Race.
' ce-
a. 7Amcrlcjn lnalan or Alaskan NeUve
b. Asloh
C,
c. Black or African American
d. Native Hawaiian cr Other pacir;c ?slander
e. White
If. Phvslca( disability
f. American Indian; Alaskan Native & White
9Aslan & White
g. Domestic violence
h. Black/African American & White
C)
i-AmerIcan Indl3n/Alaskan rlative & Black/African American
j. Cther Multi -Racial
h- nthor (nfpncp
0
k. Other/Unknown (aF that do not match)
192- Special Needs.
1
All
Chronic
0
1 ;C
a. Mental Illness
'
10
b. Alcohol abuse
C)
c. Druo abuse
0
0
d. HTV/AIDS or related diseases
e. Developmental disablIlty
If. Phvslca( disability
g. Domestic violence
h- nthor (nfpncp
9b. Disabled.
How many of the participants are dlsab)ed'
10. Prior Living Situation.
Ia. Non -housing (street, park, car, bus station, etc.)
1b. Emergency shelter -
c:. Transitional hou-shna for homeless persons
�d- Psychiatric fa-CUIL-/
le. Substance abuse treatment lacifl,"I
f. Hospital
-g. Jail/prison
h. Domestic v!olene--
i. Livinc
L
7�n
j. Ren -al houf,-
"'l ou
il
P rlhuC p
I
iDi
Chronic
All
0
0
C)
0
nc source of monthly income at Entry
and Exlt-
T-,-. o L t
7mcon-ie et Entry
Inc-
-,),, - at Exl[
til
Chronic
All
Chronic
j
d C!
0
f
f 00 1 S 5 0 0
g
0
0
h. ;'GC
0
Source
C. !nCOnle Sources at Entry
D. 1nconie
Sources at Exit
pli
Chronic
All
Chronic
a. �SufpplrCemental SccUrlLy Incon-le (EST)
3
0
__Ljrlt
b. Socla; Security D15ablllLy insurance (S -SDI)'
I--
0
ic. social securlr,/
0
0
01
0
0
Id. General Public Assistance
0
0
F)
0
le. Temporary Aid to Needy Families (TANF)
0 I
CJ
0
J—D
f. State ChlldTen 5 Health Insurance z1rocram (SCHIN
0
0
0
ig. Veterans benefits
EErnplovmnt Income
0
0
0
D—
0
0
li. Unemployment Benefits
e'eran's Health Care re
0
0
0
k. vedic'.d
0
0
0
I—V
Food SLF=Mps
m. Other (please 5pec,y)
L
0
0
0
0
n. Nfinancial resources 0
12a. Length of Stay ,n Program. fpa-,ticipants who left during operating year)
0
a - Less than I month
All
0
11
i
Chronic
0
b. I to 2 months
mon,
0
3 - 6 months
0
0,
Fcf. 7 months - 12 months
months
0
0
,
e13 months - 24 months
I 0
0
Jf"25 Months - 3 years
I 0
0
g. 4 years - 5 yea's
0,
h. 6 years - 7 years
0
0
i. 8 years - 20 years j 0
over 10 years 0
12b. Length of Stay in Program. (Pa r-ticipants who did not leave during operating year)
0
0
All
Chronic
a. Less than I month
0
b. I to 2 months
0 I
0
6 months
d. months - 12 rnor-,ttjs
0
0
0
e. 13 monchs - --,,: rnor,+js
0
0
5 months
0
years
0 11
I --ii , a7 .1 - i,, I -,, . ptsivF�rep-jr-fliud. p im
j
17
13 RE:-Isons for Ls- v -1
All I
Chronic
for a
r, c. fc- n F, Fi c,., h
0
e. L-F;Mlr-,31 activity j des'ruc'Lmn of property j violence
f. Reached ma:Jmurn time ziiloved In proje--a
0
g. NN, -,ds Could not b-,-- nrteL by prole --t
C,
0
i. peach
0
C)
Ij. Other (please speciry)
14. Destination.
AllChronic
Rental house or apartment (no subsidy)
0
0
PERMANENT (a h) a.
b. Public Housing
Ic- Section 8
d. shelter Pius Care
apartme
e- HOME subsidized housE! or nt
other 5ubsidlzed house or apartment
+f_
9. Homeownership
0
0
1h. Moved in with family o,- friends
0
i. Transjtiona�: housing for homeless par -sons
ITP—NSI TIONAL (i - J) rn
4,
0
j. Moved in with family or friends
—I
LL
JINS-FiTUTION (k - M) k_ Psychiatric hospital
J 0 I
0
IL inpatient aicoho)/dr-uQ trEatmert facility
0
0
I m, )all/prison
0
0
EMERGENCY SHELTER (n) n. Emergency shelter
0
0
OTHER (o - q) Io- Other supportive housing
G
0
Forhumanhabitation (e g, street)
0
co
p. Places not meant
q. Other (please specify)
0
0
UNKNOWN OWN r. Unknown
0
Is. Supportive Services;.
No supportive services found.
ServicePoint version 4.01-018 (db build tD723)
Licensed to: r-liorm Dade Homeless Trust
Cc.,� 1999-2006 eowman Systems L.L.C. All rights Reserved.
CPT only 167,002 Am-2rican HLj!r3j MRighLS
D -7M arid C,Si-f-[��-TT� are reoisrerLd of Lt� AIM--11C:)r) AS5CDCII`tPJn, and DT'- u5r,;,
vimi perfnfssp 11 i1trtm
h. ria,,jonj;i -.antar for 4 z1ot:"JIC5 PAll
FJ�o�rtL:C'
-aj
AS '
,
Form
W-9
Request for Taxpayer
Give form to the
(Rev. January 2003)requester.
Identification Number and Certification
Do not
Dep'•+rtinent of the Treasury
send to the IRS.
Inter nal
Rewm a service
Name
d
cn
M.
a
Business name, it different from above
0
N
'
o
Individual!
Check ❑ Sole ❑ ❑ ❑ ►
Exempt from backup
❑ i.
appropriate box: proprietor Corporation Partnership Other -----------------
withholding
o �
Address (number, street, and apt or suite no.)
Requesters name and
address (optional)
— c
j
City, state, and ZIP code
U
r
d
m
List account number(s) here (optional)
to
U)
`� Taxpayer identification Number {TIN)
Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN), social secuirity ru,mber
However, for a resident alien, stole proprietor, or disregarded entity, see the Part 1 instructions on 1
page 3. For other entities, it is your employer identification number (EIN). If you de not have a number,
see Now to get a TIN on page 3. or
Note: If time account is in more than one name, see the than on page 4 for guidelines on whose number Employer idemification number
to enter. I ,
Certification
Under penalties of perjury, I certify that
1. The number shown on this form is my correct taxpayer identification number (or J am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, -,Or (b) I have not been notified by the Internal
Revenue Service (IRS) that 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 ) am no longer subject to backup withholding, and
3. 1 am a U.S. person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN_ (See the instructions on page 4.)
SignSignature of
Here U.S. person ► Date ►
Purpose of Form
A person who is required to file an information return with
the IRS, must obtain your correct taxpayer identification
number (TIN) to report, for example, income paid to you, real
estate transactions, mortgage interest you paid, acquisition.
or abandonment of secured properly, cancellation of debt, or
contributions you made to an IRA
U.S- person. Use Form W-9 only if you are a U.S. person
Including a resident alien), to provide your correct TIN to the
person requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding,
or
3- Claim exemption from backup withholding if you are a
U.S. exempt payee.
Note. If a requester gives you a form other than Form W-9
to request your TIN, you must use the requester's form if it is
substantially similar to this Form W-9.
Foreign person. If you are a foreign person, use the
appropriate Form W-8 (see Pub. 515, Withholding of Tax. on
Nonresident. Aliens and Foreign Entities).
Nonresident alien who becomes a resident alien
Generally, only a nonresident alien individual may use the
terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a
provision known as a "saving clause." Exceptions specified"
in the saving clause may permit an exemption from tax to
continue for certain types of income even after the recipient
has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an
exception contained in the saving clause of a tax treaty to
claim an exemption from U.S. tax on certain types of income,
you must attach a statement that specifies the following five
items:
1. The'treaty country. Generally, this must be the same
treaty under which you claimed exemption from tax as a
nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions,
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under
the terms of the treaty article.
Cat. No. 10231X Form W-9 (Rev. 1-2003)
<sa
Form W-9 (Rev. 1-2003)
Example. Article 20 of the U.S.-China income tax treaty
allows an exemption from tax for scholarship income
received by a Chinese student temporarily present in the
United States. Under U.S. law, 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 -B.
What is backup withholding? Persons making certain
payments to you must under certain conditions withhold and
pay to the IRS 300/. of such payments (29% after December
31, 2003; 28% after December 31, 2005). This is called
"backup withholding." Payments that may be subject to
backup withholding include interest, dividends, broker and
barter exchange transactions, rents, royalties, nonemployee
pay, and certain payments from fishing boat operators. Real
estate transactions are not subject to backup withholding.
You will not be subject to backup, withholding on payments
you receive if you give the requester your correct TIN, make
The proper certifications, and report all your taxable interest
and dividends on your tax return.
Payments you receive will be subject to backup
withholding it
1. You do not furnish your TIN to the requester, or
2. You do not certify your TIN when required (see the Part
11 instructions on page 4 for details), or
3. The IRS tefrs the requester that you furnished an
incorrect TIN, or
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
5. You do not certify to the requester that you are not
subject to backup withholding under 4 above (for reportable
interest and dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
instructions for the Requester of Form W-9.
Penalties
Failure to furnish TiN. If you fail to furnish your correct TIN
to a requester, you are sutryect to a penalty of $50 for each
such failure unless your failure is due to reasonable cause
and not to willful neglect.
Civil penalty for false information with respect to
withholding. If you make a false statement with no
reasonable basis that results in no backup withholding, you
are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully
falsifying certifications or affirmations may subject you to
criminal penalties including fines and/or imprisonment.
.Misuse of TINs. If the requester discloses or uses TINS in
violation of Federal law, the requester may be subject to civil
and criminal penalties.
Specific Instructions
Name
if you are an individual, you must generally enter the name
shown on your social security card, However, if you have
changed your last name, for instance, due to marriage
without informing the Social Security Administration of the
name change, enter your first name, the last name shown on
your social security card, and your new last name.
If the account is in joint names, list first, and then circle,
the name of the person or entity whose number you entered
in Part I of the form.
Sole proprietor. Enter your individual name as shown on
your social security card on the "Name" line. You may enter
your business, trade, or "doing business as (DBA)" name on
the "Business name" line.
-Limited liability company (LLC). If you are a single -member
LLC (including a foreign LLC with a domestic owner) that is
disregarded as an entity separate from its owner under
Treasury regulations section 301.7701-3, enter the owner's
name on the "Name" line- Enter the LLC's name on the
"Business name" line -
Other entities. Enter your business name as shown on
required Federal tax documents on the "Name" line. This
name should match the name shown on the charter or other
legal document creating the entity. You may enter any
business, trade, or DBA name on the "Business name" line.
Note: You are requested to check the appropriate box for
your status (ndividuaf/sole proprietor, corporation, etc-)
Exempt From Backup Withholding
if you are exempt, enter your name as described above and
check the appropriate box for your status, then check the
"Exempt from backup withholding" box in the line following
the business name, sign and date the form.
Generally, individuals (including sole proprietors) are not
exempt from backup withholding. Corporations are exempt
from backup withholding for certain payments, such as
interest and dividends_
Note: fr you are exempt from backup ;withholding, you should
still complete this form to avoid possible erroneous backup
withholding.
Exempt payees. Backup withholding is not required on any
payments made to the following payees:
1. An organization exempt from tax under section 501(a),
.any IRA, or a custodial account under section 403(b)(7) if the
account satisfies the requirements of section 401(0(2);
2. The United States or any of its agencies or
instrumentalities;
3. A state, the District of Columbia, a possession of the
United States, or any of their political subdivisions or
instrurnentafities;
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:
S. A corporation;
7. A foreign central bank of issue;
8. A dealer in securities or commodities required to register
in the United States, the District of Columbia, or a
possession of the United States;
Form W-9 (Rev. 1-2003) Pace S
9. A futures commission merchant registered with the
Commodity Futures Trading Commission;
10. A real estate investment trust;
11. An entity registered at all times during the tax year
under the Investment Company Act of 1940;
12 A common trust fund operated by a bank under
section 584(a);
13. A financial institution;
14. A middleman known in the investment community as a
nominee or custodian; or
15- A trust exempt from tax under section 664 or
described in section 4947.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt recipients listed above, 1 through 15.
If the payment is for ...
THEN the payment is exempt
for .. -
Interest and dividend payments
All exempt recipients except
for 9
Broker transactions
Exempt recipients 1 through 13 -
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions
Exempt recipients 1 through 5
and patronage dividends
Payments over $600 required
Generally, exempt recipients
to be reported and direct
1 through 7 Z
sales over $5,000'
See Form 1099-MISC. Miscellaneous Income. and its instructions.
ZHowever, the following payments made to a corporation Cncluding gress
proceeds paid to an attorney under section 6045(1), even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys' fees; and paymerns
for services paid by a Federal executive agency.
Part 1. Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an
SSN, your TIN is your IRS individual taxpayer identification
number (ITIN). Enter it in the social security number box. If
you do not have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that
you use your SSN.
If you are a single -owner LLC that is disregarded as an
entity separate from its owner (see Limited liability
company (LLC) on page 2), enter your SSN (or EIN, if you
have one). If the LLC is a corporation, partnership, etc., enter
the entity's EIN.
Note: See the -chart on page 4 for further darification of
name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form S5-5,
Application for a Social Security Card, from your local Social
Security Administration office or get this form on-line at
wwwssa.gov/ordine/ss5.htrrd. 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 SS4, Application for Employer Identification
Number, to apply for an EIN. You can get Forms W-7 and
SS -4 from the IRS by calling 1 -800 -TAX -FORM
(1-800-829-3676) or from the IRS Web Site at www.irs.gov.
If you are asked to complete Form W-9 but do not have a
TIN, write -Applied For" in the space for the TIN, sign and
date the form, and give it to the requester. For interest and
dividend payments, and certain payments made with respect
to readily -tradable instruments, generally you will have 60
days to get a TIN and give it to the requester before you are
subject to backup withholding on payments. The 60 -day rule
does not apply to other types of payments. You will be
subject to backup withholding on all such payments until you
provide your TIN to the requester,
Note: Writing "Applied For" means that you have already
applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign
owner must use the appropriate Form W-8.
Form W-9 (Rev. 1-2003)
Part It. Certification
To establish to the withholding agent that you are a U.S.
person, or resident alien, sign Form W-9. You may be
requested to sign by the withholding agent even if items 1, 31
and 5 below indicate otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt recipients, see
Exempt from backup withholding on page 2.
Signature requirements. Complete the certification as
indicated in 1 through 5 below.
1. Interest, dividend, and barter exchange accounts
opened before 1984 -and broker accounts considered
active during 1983. You must give your correct TIN, but you
do not have to sign the certification.
2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accounts
considered inactive during 1983- You must sign the
certification or backup withholding will apply. If you are
subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2
in the certification before signing the form.
3. Real estate transactions. You must sign the
certification. You may cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but
you do not have to sign the certification unless you have
been notified that you have previously given an incorrect TIN.
"Other payments" include payments made in the course of
the requester's trade or business for rents, royalties, goods
(other than bills for merchandise), medical and health care
seivices (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).
S. Mortgage interest paid by you, acquisition or
abandons ent of secured property, cancellation of debt,
qualified tuition program payments (under section 529),
IRA or Archer MSA contributions or distributions, and
pension distributions. You must give your correct TIN, but
you do not have to sign the certification.
What Name and Number To Give the
Requester
For this type of N orf: _
1. Individual
The individual
2. Two or more individuals {joint
The actual owner or the account
account)
or, if combined funds, the first
individual on the account '
3. Custodian account of a minor
The minor
(Uniform Gift to Minors Act)
4. a. The usual revocable
The grantor -trustee '
savings trust (grantor is
also trustee)
b. So-called trust account
The actual owner'
that is not a legal or valid
trust under state law
S. Sole proprietorship or
The owner a
single -owner LLC
For this type of accoraa:
Give name and EIN of:
6. Sole proprietorship or
The owner a
single -owner LLC
7. A valid trust estate, or
Legal entity'
pension trust
B. Corporate or LLC electing
The corporation
corporate status on Form
8832
9. Association, club, religious,
charitable, educational, or
other tax-exempt organization
10- Partnership or mutti-member
LLC
11. A broker or registered
nominee
12- Account with the Department
of Agriculture in the name of
a public entity (such as a
state or local government,
school district, or prison) that
receives agricultural program
payments
The organization
The partnership
The broker or nominee
The public entity
'List fist and circle the name of the person whose number you furnish. If only
one person on a join, account has an SSN, that person's number must be
furnished.
'Circle the minor's name and furnish the minor's SSN.
'You must show your individual name, but you may also enter your
business or "DBA' name You may use either your SSN or EIN (if you have
one).
'List first and circle the name of the legal trust, estate, or Pension trust (Do
not furnish the TIN of the personal representative or trustee unless the legal
entity itself is not designated in the account title.)
Note: If no name is circled when more than one name is
listed, the number will be considered to be that of the first
name listed.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or
abandonment of secured property, cancellation of debt, or contributions you made to an IRA or Archer MSA. The IRS uses the
numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information
to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their
tax laws. We may also disclose this information to other countries under a tax treaty, or to Federal and state agencies to enforce
Federal nontax criminal laws and to combat terrorism.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxable
interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply..
RE
Applicant Certification
These certified statements are required by law.
Previous versions obsolete
form RUD400904
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 of, or
be otherwise subjected to discrimination under any program or activity for which the applicant
receives Federal financial assistance, and will immediately take any measures necessary to effectuate
this agreement. With reference to the real property and structure(s) thereon which are provided or
improved with the aid of Federal financial assistance extended to the applicant, this assurance shall
obligate the applicant, or in the case of any transfer, transferee, for the period during which the real
property and structure(s) are used for a purpose for which the Federal financial assistance is extended
or for another purpose involving the provision of similar services or benefits.
It will comply with the Fair Housing Act (42 U.S.C. 3601-19), as amended, and with implementing
regulations at 24 CFR part 100, which prohibit discrimination in housing on the basis of race, color,
religion, sex, disability, familial status or national origin.
It will comply with Executive Order 11063 on Equal Opportunity in Housing and with implementing
regulations at 24 CFR Part 107 which prohibit discrimination because of race, color, creed, sex or
national origin in housing and related facilities provided with Federal financial assistance.
It will comply with Executive Order 11246 and all regulations pursuant thereto (41. CFR Chapter 60-
1), which state that no person shall be discriminated against on the basis of race, color, religion, sex or
national origin in all phases of employment during the performance of Federal contracts and shall take
affirmative action to ensure equal employment opportunity. The applicant will incorporate, or cause
to be incorporated, into any contract for construction work as defined in Section 130.5 of HUD
regulations the equal opportunity clause required by Section 130.15(b) of the HUD regulations.
It will comply with Section 3 of the Housing and Urban Development Act of 1968, as amended (12
U.S.C. 1701(u)), and regulations pursuant thereto (24 CFR Part 135), which require that to the greatest
extent feasible opportunities for training and employment be given to lower-incorine residents of the
project and contracts for work in connection with the project be awarded in substantial part to persons
residing in the area of the project.
It will comply with Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), as amended, and
with implementing regulations at 24 CFR Part 8, which prohibit discrimination based on disability in
Federally -assisted and conducted programs and activities.
It will comply with the Age Discrimination Act of 1975 (42 U.S.C_ 6101-07), as amended, and
implementing regulations at 24 CFR Part 146, which prohibit discrimination because of age in projects
and activities receiving Federal financial assistance.
It will comply with Executive Orders 11625, 12432, and 12138, which state that program participants
shall take affirmative action to encourage participation by businesses owned and operated by members
of minority groups and women.
If persons of any particular race, color, religion, sex, age, national origin, familial status, or disability
who may qualify for assistance are unlikely to be reached, it will establish additional procedures to
ensure that interested persons can obtain information concerning the assistance.
It will comply with the reasonable modification and accommodation requirements and, as appropriate,
the accessibility requirements of the Fair Housing Act and section 504 of the Rehabilitation Act of
1973, as amended.
Additional for S+C:
If applicant has established a preference for targeted populations of disabled persons pursuant to 24
CFR. 582.330(a), it will comply with this section's nondiscrimination requirements within the
designated population.
20 -Year Operation Rule_
For applicants receiving assistance for acquisition, rehabilitation or new construction: The project will
be operated for no less than 20 years from the date of initial occupancy or the date of initial service
provision for the purpose specified in the application.
1 -Year Operation Rule.
For applicants receiving assistance for supportive services, leasing, or operating costs but not
receiving assistance for acquisition, rehabilitation., or new construction: The project will be operated
for the purpose specified in the application for any year for which such assistance is provided.
C. For S+C Only. Supportive Services.
It will make available supportive services appropriate to the needs of the population served and equal
in value to the aggregate amount of rental assistance funded by HUD for the full term of the rental
assistance.
D. Explanation.
Where the applicant is unable to certify to any of the statements in this certification, such applicant
shall attach an explanation behind this page.
Signature of Authorized Certifying Official: f Date:
Title:
Applicant: For FIIA. Applicants Only
(FHA Number)
MIAMI -DA -DE CGL TY HOS JELESS TRUST
1 ne c 1 ng L"Idi iduaI Gr Cnrr� ( nnvc -.1'77; , r 1P l h r ; 1 n.--,2
t11at pt"—Lain to LIl1s contT,a -[ and sr7.-:1 inClcaz_ by ., ia�I
blar;l: spaces must be liiled.
The P,1IAIM] -DAD CCDLT r i 5' 0 v '.rf%RSH7?
E1`1PL0Y? '=,''T DISCLOSURE AFFIDAZ?1, hf.yl� D:".DE l.F'; ilj�'AL P i_C)P-D :AFFIL.';vIT
DIS.=�,EILI; Y T� 0NDFS-PJMI1'dATI DN AF��IDA',IT1- and the PRU_ECT F—FESH 'T,4, .-�.r�1 i�A V1 T Shall'
not pert2in to contTacts with the United States or any of its depann,ents Or thr-eof, tl;EState or am,
Political subdivision or aecncy thereof or an), municipaiir% of this State. The l`'ll-AL I-DADL- FAMIL`A'
LEAVE ,AFFIDAVIT shall not pertain to contracts with t,'1e United States or any of its departments or aeencies
e St"
or the ofi=lorida or any political :subdivision or aecncy thcreiji; it shall, hon1ever, perain to munieipaliriF;
of the State of Florida. All other contractin entities or individuals shall read carefully' each affidavit to
determine tvl7ctlhcr or not it pertains to this contract.
I, , being first duly sworn state:
Affiant
The full legal name and business address of the person(s) or entiry contracring or transacting business "V,
Pvliarni-Dade County are (Post Office addresses arc not acceptable):
Federal Employer Identikation Number (If none, Social Securi-Ly)
acne ci Enti.y, Individual(s), Pa--Lners, or Corporation
Do;n, Business As (if same as above, leave blank)
Street Address City State yip Code
�I- MIAMI -DALE COLWti Y 01, rNEIRSHIP DISCLOSUlti AFFIDAVIT (Sec. ?-S.1 of the County Code)
1. If the contract or business transaction is with a corporation, the fu 'I lecal name and business address
shall be provided for each officer and director and each stockholder who holds directly or indirectly
five percent (5%) or more of the corporation's stock If the contract or business transaction is ti� c
partnership, the foregoing information shall be provided for each partner. If the contract or business .
transaction is vvith a trust, the full Iegal name and address shall be provided for each trustee The and each
beneficiary. foreporng requirements shall not pe fain to contracts tiv�ith' publicl}� traded
corporations or to contracts witUe
h the
United States or an, department cr agency thereof, the State or
ed
any political subdivision of a�tncy thereof or any municipality of thl'S State, 4,Ij such nam,nd
addresses are (Pest Ofzice addresses are not accep�ble .
1 of
2. The full Team n2m;z5 and dusir�ess address Cf any other (ofhel- thin
subcontrcCtoi-S, ma!ehaI Men, Suppliers, laborers, Oriendei-S) %vho have, Or'v,,(ll h2vI=, an
interest (ieg21, equllable beneficial or Ot`lerv, iSe) in the Contract or busine55 trdtls2CllOr1
with Dade County are (Post Orlce addresses are nel acceptacl ):
3. Any person who willfjlly fans. to disclose the info rnaticzl required herein, or who kno ;innly
discloses false information in this regard, shall be punished by a Fine of up to irve hundred
dolly s (5500.00) or imprisonment in the County jail for up to sixt-,, (60) days or both.
TT.ItiiI.a Ord -
DA -DE CDLNTY T- -P' O' ;tiENT DISCLOSU�i,�, AFFIDAVIT (County Ordinance No. go -
Am
133 ending sec. 2.8-i; Subsection (d)(?) of the County Code).
Except where Precluded by federal or State laws or regulations, each contract or business transaction or
renewal tlhereof which invoives the expenditure of ten thousand dollars (SI 0,000) or more shall require
the entity contraciing or transacting business to disclose the following information. The foregoing
disclosure requirements do not appiy to contracts with the United States or any departmcij, or agene,
Thereof, the State or any political subdivision or agency thereof or any n;uni cipalit-v of this State_
1. Does your firm have a collective bargaining ag-eerr,ent "vith its employees?
Yes No
2. Does }lour firn provide paid health care benefits for its employees?
Yes No
3, Provide a current bTtL) dowT (number of persons) of your fi -r,'s
'"ork force and ownership as to race national origin and gender-
White: lylales Females Asian: Males Females
Black: Males Females American Indian: Males Females
Hispanics: Males Females Aleut (Eskimo): MalesFemales
Malts Females: Males — Females
III. AFFIRt\1AT7VE OF EMPLOYNTENT, Pf",C)MJ71ONAND
PROCI:'RENi_EN_T PRACTICES (County Ordinance 98-30 codified at 2-8.1.5 of the County Code.)
In accordance with County Ordinance No. 98-30, entities with annual gross re enues in excess of
-h—OD0,000 seeking to contract %vith the Counthv shall, as a condition of eceivinn a Count) contract,
ha e: i) a written affirmative action plan which sets forth the procedures the entit> utilises to as,
that it does not discriminate in its employment and promotion practices; and ii) a �,ritten procurement
pollej' `.\'hlCh sets fa -u] the procedures the eritity j)illizes to assure L1.1t i.t does not discriminate aeainsi
mincrity and }ion�n-n�tir�ed businesses in its DVT pro,_.urernent of coo.dS, supplies and ser�,ices. Such
31t ,native cCt10r, p;ai:s and procure7l"nt pollcles Shah Fro;'lje for pertodlc reVl:;A' to de;errnme their
e1�1e`tlV'� )eSS In 355i::.11� Lfie ,en[Ir> dues not dIcCr1(nlnate:n lis en7 101T1ent pr0illoCJUn and
piOCLirement pr Ciices. ! he 7oregoin° norvt'linstandlnC, COTPorc'.te en,t'lies s;hose boa,Ls Oi dIr"Ctors are
0
2. The full Team n2m;z5 and dusir�ess address Cf any other (ofhel- thin
subcontrcCtoi-S, ma!ehaI Men, Suppliers, laborers, Oriendei-S) %vho have, Or'v,,(ll h2vI=, an
interest (ieg21, equllable beneficial or Ot`lerv, iSe) in the Contract or busine55 trdtls2CllOr1
with Dade County are (Post Orlce addresses are nel acceptacl ):
3. Any person who willfjlly fans. to disclose the info rnaticzl required herein, or who kno ;innly
discloses false information in this regard, shall be punished by a Fine of up to irve hundred
dolly s (5500.00) or imprisonment in the County jail for up to sixt-,, (60) days or both.
TT.ItiiI.a Ord -
DA -DE CDLNTY T- -P' O' ;tiENT DISCLOSU�i,�, AFFIDAVIT (County Ordinance No. go -
Am
133 ending sec. 2.8-i; Subsection (d)(?) of the County Code).
Except where Precluded by federal or State laws or regulations, each contract or business transaction or
renewal tlhereof which invoives the expenditure of ten thousand dollars (SI 0,000) or more shall require
the entity contraciing or transacting business to disclose the following information. The foregoing
disclosure requirements do not appiy to contracts with the United States or any departmcij, or agene,
Thereof, the State or any political subdivision or agency thereof or any n;uni cipalit-v of this State_
1. Does your firm have a collective bargaining ag-eerr,ent "vith its employees?
Yes No
2. Does }lour firn provide paid health care benefits for its employees?
Yes No
3, Provide a current bTtL) dowT (number of persons) of your fi -r,'s
'"ork force and ownership as to race national origin and gender-
White: lylales Females Asian: Males Females
Black: Males Females American Indian: Males Females
Hispanics: Males Females Aleut (Eskimo): MalesFemales
Malts Females: Males — Females
III. AFFIRt\1AT7VE OF EMPLOYNTENT, Pf",C)MJ71ONAND
PROCI:'RENi_EN_T PRACTICES (County Ordinance 98-30 codified at 2-8.1.5 of the County Code.)
In accordance with County Ordinance No. 98-30, entities with annual gross re enues in excess of
-h—OD0,000 seeking to contract %vith the Counthv shall, as a condition of eceivinn a Count) contract,
ha e: i) a written affirmative action plan which sets forth the procedures the entit> utilises to as,
that it does not discriminate in its employment and promotion practices; and ii) a �,ritten procurement
pollej' `.\'hlCh sets fa -u] the procedures the eritity j)illizes to assure L1.1t i.t does not discriminate aeainsi
mincrity and }ion�n-n�tir�ed businesses in its DVT pro,_.urernent of coo.dS, supplies and ser�,ices. Such
31t ,native cCt10r, p;ai:s and procure7l"nt pollcles Shah Fro;'lje for pertodlc reVl:;A' to de;errnme their
e1�1e`tlV'� )eSS In 355i::.11� Lfie ,en[Ir> dues not dIcCr1(nlnate:n lis en7 101T1ent pr0illoCJUn and
piOCLirement pr Ciices. ! he 7oregoin° norvt'linstandlnC, COTPorc'.te en,t'lies s;hose boa,Ls Oi dIr"Ctors are
r=,Couno Managn t it is in me NO inwros: Gly 10 Count [': Ot_' -
�i CGL'RR' _ nil,:::SIG:'1:.'r b',' rr3iorlT'.' •'ole t� L�" iT,(;rr,'r_." rrCli:r.,.
r
Th Ann does not have annual cross 3=11"s ;n =053 005300100
1,QV0.
the franl doe: ha'v'e alLiva. rCv'':Iues in C?,L'C'i5 of .J5100100; h , IIS BoSrt'-. Df Main; I!
reprtsenrwivt of the pop&npon anke-up of ilio n anon aro o: submiR d a nown. MAY,
I(si!n" of its Loarc: ofLirCc[Ort lnchdog tJIC rice or Mnlch, or each board rucrij Q IO tllc
County's Department of Business DeKoprnent, 175 N' .V ", Ist AVC:nue, 2S1II Flo, -!r, 1"Iiami,
Florida 33128.
The Erni has annual gross revenues in CX=ss of SWUM and the flim docs Ijuve a ; inen
affrn2live action pian and procurement policy as described above, vvich includes periodic
rKews to demn-nine e$eaQness, and has subrnitted the plan and policy to the County`s
Department of Business Development 175 N.W. 1st Avenue, 2Sth Floor, ?:Miami, Florida
3312 8;
The frm does not have an 05, native action plan and/or a procurement policy as described
Am but has been ranted a waiver.
_IV. NUANC-DALDE COLT -Ni?' FICOID AFFIDAVIa (Section 2-5.6 of the Coun, (jode)
The individual or entity entering into a contract or receiving funding from the Ceurry has
has not as of the date of this affidavit been convicted.of2 felany during the past ten (10) years.
A n OffCer, director, or ?xecutive of the entity entering into a contract or receiving fund ina frOT7 he
County has has not as of the date of this and"A been convicted of a felony Burin_ the past an (I Gj
years.
_V- I`CAAEi-DADE EINUPLO YMENT DRUG-FREE Vv0F &LACE AFFIDAVIT (County Ordinance No.
92-I5 codified as Section 2-S. 1.2 of the County Code)
That in ccrnplisce with Ordinance No. 92-15 of the Code of Miami -Dade County, Florida, the above
named person or entity is providing a drug-free «rorkpiace_ A vVrinen statement to each employee
shall inform the empioycc about; -
1. dancer of drug abuse in the workplace
?. the firm's policy of maintaining a dip -free em imnme.nt at all workplacEs
3. availability of druI7 counseling, rehabilitation and employee assistance programs
�. penalties that may imposed upon employees for drug abuse violations
The person or entity shall also require an employee to sign a statement, as a condition of employment
that the employee will abide by the terms and notiy the emplover of ary criminal drug com,iction
occur; ing no later than the (5) days after r eceiving notice of such com fiction and impose appropriate
Personnel action acaitcst the employee up to and irciuding termination.
Compliance with Ordnance M. 92-1 5 may be v.'aived if the special charac[erisiics of ths product or
s'i,-'ice Offered by the person or entity make it r,^cCSsar t' for the operatic Of i} C County or IOr the
health, Gai��i,'1t'elidr economic be.^,'=fits and Well -o -Mg of we puMb, ConQcM !riITI'. inn %din,
1` hith is pi-Rded-in, whole or In pwl by the 'lI>R&d States or the State of Flor,'d3 ON be e= n aid
frog; de Qry f" -t ; - o ns ,'j^e Ct1�t
� 'S1Gn; of"this OrutilaTl., P iii se IIISL3Ii Wert those pr 0'+Is]On5 a.`e In CC�Rt!ICt '�1'ItR
Lh a r t'u!r ff M--ntf O L;,0.Se L70',1tMM, EnWI en: !tit.
Thar in co„ !lane. j J-; - _ 1,_ ' on '_ ai ;.
,p _ �is � � iran__ ��. _ � , �, t _�!:,
tMP&ATT "is
:ac,. c* h�•e,r ( Gi �'r rot ccl�rda: err, . �_t. , _.:���� ; r_ •i�_ _„_ �;,-- ,
G.�rr7pllal�C:: ;L; a1111eI:.s lit tr'.e �iiirc'(ner.11oP,Cu or-�ili,.?nC;',.
An cmMo': _ "lo ha: Nvo7ked Ar the above flriJ A Yost On! (1) ycar :Kali W w0d to
dys off may 40, during aqsmenp-four (_24) month griod. Air rnWif reasons, W the girth x
adoption of a coil or for the car_ of a child, spouse or oth_r close rc z6vc who has a scrious heaitl,,
condition vvithoutrisk or renminabon ofamployment wemployer retaliation.
The Toregoin!z requirements shad not pelt t In to conirsc5 whh the Unlred Stat_'s or an), deip;lr{rnew or
anency thereof, or the Statc of Florida or any political subdi\ isicn or acency thereof. 1 t shall,
however, pertain to municipalities of this State.
�V?L DISABILIT'r'NON-DISCRiI`-ILNAiIONAFFIDA'`r'IT(Counr}'ResolutionF�-3S�-9d)
That the above named firm, corporation or organization is in, compliance with and agrees to continue
to comply with, and assure that any subconrractor, or third pary contractor under this project
complies with all applicable requiremenu of the hws listed below including but not limited to, those
provisions pera.cining to employmen.t, provision of programs and ser -\,ices, transportation,
communications, access to facilities, renovations, and new construction in the fo11o���inS la\vs: The
Americans with Disabilities Act of 1990 (ADA), Pub. L. 10i-336, 104 Stat 327, 42 U.S.C.
12101-12213 and 47 L_S.C. Sections 225 and 611 Including Title I, Employment Title II Public
Services; Title II1, Public Accornmodations and Services Operated by Private Entities; Title IV,
Telecommunications; and Title V, Miscellaneous Provsions; The Rehabilitation Act of 1973, 29
U.S.C. Section 794; T-ne Federal Transit Act, as amended 49 U.S.C. Section 1612; The Fair Housin;
Act as aended 42 U.S.C. Section 3601-363 L The foregoing requirements shall not pertain to
contracts with the United States or any department or agency thereof the State or any political
subdivision or agency thereof or any m.,unicipaiir of this State.
_VIII. MIA241I-RADE CGUNT'r' T.EG,A-R.D NTG DELINQUENT AND CURRENTLY DLA, FEES OR
TAXES (Sec. 2-5.1(c) of the County Code)
Except for small purchase orders and sole source contracts, that above named firm, corporation,
organization Or individual desiring to.transact business or enter into a contact \3 Li tfre County
verifies that all delinquent and currently due fees or ta.%es -- including but not lirniied to real and
property taxes, utility taxes and occupational licenses -- -' hick are collected in the normal course by
the Dade County Tait Collector as v,'ell as Dade County issued parking tickets for vehicles registered
in the name of the fiinn, corporation, organisation or individual have been paid.
_IX. CURRENT ON ALL C01-14Tr CONTRACTS, LOANS AND O i iEEP OELIGATIC)NS
The individual emir)' seeking to transact. business with the County is current in all its obligations to
the Count}' and is not cthervrise in default of sy contract, promissory Hole or other lean document
With the Count}l or any of its wcncies or instrumentalities.
PROJECT FRESH ST. RT (Resolutions 8.-702'-98 and 3 ;'-q 9)
:,.n1.' firth that has a contract wish the County that results in acruai pavrr;cnt of `500,000 or more shall
cont; ibute to P W,
rOieC: Fresh �i.?rt. thy: !'Glint'.' S ri ell3re to ',Orr: IilitlatiVF
(;g.�•, � ;�� e - He 'never; ive F�r_ent
work fore c nsal of indn� iduals �.i�h Tc
' ' ;ill ,r, i-D�de Count~.• -�
ost or v iOse ca ass,s nce bI r,_r efits forn-ierlY ' and 'vhc'+
�h ..ic to Farn,iies „ rP
t , h DePenuent Childre,;) L,
a , �llII L1 I.7` a :,S_iil PP.;IO ll -
1 _,,. C�i'=ii,i;l!i' :,i3?iCn ,",a ��- 1"f�ii,
fiat .-�CUes- �''rfz0� L':'e - , T; '�_0” �� - _� ti i the Il,ii1
u)' 2gsiremen� 'f 0_ tn� is subilia ng a
ai _, reaue,t
1 _ ._..,_.., Cots n Tor -i:?
i LE..1'i „ .^.i 1.-'. _;0
7
imn dwsirinc to do busims tj1e hOunC�' 15 Ir Or7]pli: nC' 1h0h Dommk O _ Codkari ,
llra!riaw 915, AIR at 11 -'.-60 m sed. of Q Nfil i CO<<odc, v,'i;l: ii rqu'IFeS afl
emplc'.er %vhi'ch has m the course of busines_ Nil (50) or more tmpkge_ "orlon; In
hliarikDatdt Counn, for each '.'roc dri_ day iiurin l' aach of hvC'r i\' (20') Ur nice`_' Calendar Nvori; wCA
to pro
n the current or proccuding calendar j ea s, �'ide Domestic Violence Lcam to Is cmplo�'rtn.
I hsvt carcful!v road this entire Ive Q pa `-' docum'unt entitled, "Miami-D,3dc Courcy AMiu'L,'irs" and
have indicated by an "M all affidavits that pec—& to this contract and have indicated by an "N/A" all affidavits
that do not pertain tD this contract.
By:
(Signature of Affiant)
SUBSCRIBED AND S IXOFN TO (or affirmed) before me I) is day of
?00 by
}Mov,,n to me or has presented
(Type of Identification)
(Signature of Notary)
(Print or Stamp of Notary)
(Date)
He/She is personally
as identification
(Serial Number)
(Expiration Date)
Notary Public - Stamp State of Notary Seal
(Mate)
AFFIDAVIT OF -
LOBBY= REGTSTR.ATIO, F0 � 0 `e r. PRI SE -NT -AT I
(4) Ll;t b.(] I'i'lenlUCr$ 0! the ] rcSCntatlon Tuarl V,,lio V,`1 11 E Pa:ilcIPsiin2 in ✓h't 0, 2l PTc',cntat1Gn:
N1AfNlE TITLE E1\1'LC1 ' 1` TEL.
(ATTACH ADDITIONAL SHEET IF NECESSARY)
The individuals named above are Registered and the Registration Fee is not required for the Oral Presentation 0?�LY.
Proposers are advised that any individual substituted fo.- or added to Lhe presentation tears after submittal of the proposal
end fiIiin1 by ski, MUST reister with the Clerk of the Board and pay all applicable fees.
Other than for the oral presentation, Proposers who wish to address the county commission, a county board or county
committee concerning any action, recision or recommendation of count)' persons,--] regarding this solicitation Nf'JST
register ,vkh the Clerk of the Poard (Fort,, BCCFORM2DOC) and pay all applicable fees.
17 do solemnly sti,�ear that all the foregoing facts are n-ue and correct and 1 have read or am familiar with the provisions of
Scotian 2-11.1(s) of the Code of Metropolitan Dade County as amended.
Signature of Aut -,,,orized Representative;
Title:
STATE OP
COUNTY OF
Tse foregoing instalment v,as aclmowledged before me this
by , a
(Individual, Offliccr, Partner or Agent)
to me or ,vho has produced
S;Snaturc ofperson taking aclmovdedgerncnt)
( 1unc oi'Ac1:,-iovdcdc�r t, ; ed, printed or stamped)
(1 Itie C,r Ranj I'Serlal Number, If an")
who is personally known
(Sole Proprietor, Corporation or Partnership)
as identification and who did/did not take an oat):
,Name of nLal]on:
A❑r?I-,Ss:
A l l Atm h IVI L Iv i
RE+�Li7p I) LISTII'� r OF S i' ✓ CO TI��s, -TC, r- ) CC) UNTY CO:NTR-.CT
In comc1lance wl!—� '-Dade 1-ouri.7y DrdlraI7ce�i ll-'., the C0!?? Ln 11 r u5ri7 l_r?aiizaIiori
must su I 1?i the list of f rat �icr subcontractors orsub-consult nts % ho v,,ili perform any part C the
Scope of Sel-vices 'Kort, if phi s A^reenlent is for 11 00,00C-) or move.
The Community Based Orp2nization must complete this inlrrmation. if tht Comn-lunw" Eased
Orffaniration -wi]] riot utili.,e subcontractors, then the Community Based must state
"No Subdcntractors vvill be used", do not sfate
Name of Subcontractor orSub-Consultant Address City and State
REQUIRED LIST OF SUPPLIERS ON COUNTY CONTRACT
In compliance with Mialni-Dade County Ordinance 97- 04, the CornmuniT Based Organization
must ar'ach a Iist of suppliers trho ,will supply materials for ire Scope of Services to the Con7rnunity
Based Organization, if this Contract Agreement is S100,000 or more.
The Community Based Organization must Ell out this information. if the Community Paved
Organization bill not use suppliers, the Commur-ity Based Organization must state, "No suppliers
will be used", do not state "NIA".
Nacre of Subcontractor or Sub-CorsuItnnt Address Cifyarid State
I hereby certify lhct the forcgoirzj a forrnuii0n is true, correct 1'217rl enmplete:
Sin -nature of Authorizcd Rcprescntofivc:
Title: Date:
Firm Name: Fed. ID No.:
Address: Cin/State/Zip:
Telephone:_;c;
E -Flail:
IliInri-C!:!Je ( r,ur 1'. F10,i;ia
I irnl Nor,lc of Prin,c Cuntrack-/Troposer
SU]3CONTRACTOR/SUPPL 1EI R LISTING
(Ordinance 97-104)
Rr'P Na111e
RrP Nulnhcr
'I his 1`orm, ora comparable listing meeting lite requirements of Ordinance No. 97-10,1, MUST be completed by all bidders and propclsers Poll
supplies, I'Mlcrials or services, Including pro fessiotial.services which involve expenditures of $100,000 or more, and all bidders and proposers on Cc,ulll, or I'ulllir: I lrollh l nl;t
CO S(RIC1. krlI cUnlract, t'illIc11 1111'ol'r'e expelid ilures of $100,000 or more. TIl's fort", or a co"Ipar;tble listing meeting (I,e requirelrlell(s of Ordinance Nn. '1;_1(1.1, ,1111.0 Ile
contpletrd 21111 SII.hIIIi((Cll even though.th.e bidder or proposer will not utilize subconlraclors or suppliers on the contract_ 'I -Ile bidder or prupnser sllnnld en(er (Ile
»urd "NC)NI �' antler (lie appropria(e heading of FDrn1 A-7.1 in those instances ivllere no subconlraclors 01- suppliers will be used on lire contract. ,1 I,irl,lcr ()r f'r'>I,„`,"_,
t'.'ho 1s at;,udcd lire con(r2cl shall not change or substitute first tier subcontractors or direct supltliers.or the portions of the contract stork to be prrrurnlckl or nr,tcrials to 1?c
t!L'l'licd Dont loose identified except Upon t';rilten a royal of [he Cotml'S'. i
----r' --
11t15ineS5 Nnute nd Address of ]first Tier Princip-,t� Owner Scope of Work to be Performed by(I'rinclpal C)rrncr)
Sdbconlraclor/Subcon5ultallt SLIIICOIItractor/Subconsult.int
C.;cndr r It:1CI'
lit'siness Name 2nd Address of Direct Supplier- — ----------1-------._-_
PI'lllcipal Ownel Supplies/blalerialslSen'Ices 10 be (Principal C) r 1„•, j
-- Provided b}' Supplier (ender 1:ace
1 certify that the representations contained in this Subcontractor/supplier Listing are to the hest Ofilly knott'ledhe true and accurali, -- _
:iignrrture of Proposer's
Aulhoriied Representative
Print Nsn,e
(Duplicate if;,dilitional space is n(!eded)
Print Title
ATTACIWENT N
APPLICANT OR RECIPIENT SECTION 3 COMPLIANCE
REQUIREMENTS FOR HUD -ASSISTED PROJECTS
PROJECT NAME:
PROJECT LOCATION:
PROGRAM FUNDING SOURCE:
The work to be performed under this contract is subject to the requirements of Section 3 of the Housing
and Urban Development Act of 1968; as amended, 12 U.S.C. 1701u (Section 3). The purpose of Section
3 is to ensure that employment and other economic opportunities generated by Federal assistance of
HUD -assisted projects covered by Section 3, shall to the greatest extend feasible, be directed to low and
very low-income persons, particularly persons who are recipients of HUD assistance for housing and to
businesses that are substantially owned or substantially employ low and very low-income persons.
The applicant or recipient commits to development and implementation of a Section 3 Economic
Opportunity Plan for Miami -Dade Housing Agency (MDHA) approval, prior to selection of an architect
or general contractor or other applicable contractor. This Plan shall: describe the outreach procedures
the applicant or recipient will use to recruit, solicit, encourage, facilitate and award architectural and
general contracts, where applicable, to Section 3 businesses in the project area; make a good faith effort
as defined by the regulations, to provide training, employment and business opportunities required by
Section 3 to persons from the project area; and incorporate the "Section 3 Clause" (see attachment next
page) in all contracts over $100,OW in connection with this project.
The applicant or recipient commits to including the following contractor certification in all contracts over
$100,000: `The contractor certified that any vacant employment positions, including training positions,
that are filled (1) after the contractor is selected, but before the contract or agreement is executed; and
(2) with persons other than those to whom the Section 3 regulation require employment opportunities to
be directed, are not filled to circumvent the contractor's obligation under the Section 3 regulation.
The applicant or recipient certifies and aures that it is under no contractual or other impediment which
would prevent it from complying with these requirements
Non-compliance with the Section 3 regulations may result in sanctions, termination of this contract or
agreement for default, and debarment or suspension from future HUD -assisted contracts.
OWNER'S FIRM NAME (Print or Type Name):
AUTHORIZED SIGNATURE
TITLE
SIGNATURE
Affix Notary Seal to the Right
ATTAMAENT N
"Section 3 Clause"
24'CFR Part 135 This clause must be included in all Section 3 -covered contracts.
A. The work to be performed under this contract is subject to the requirements of Section 3 of the
Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701u (Section 3). The
purpose of Section 3 is to ensure that the employment and other economic opportunities generated
by HUD assistance of HUD -assisted projects covered by Section 3, shall, to the greatest extent
feasible be directed to low and very low-income persons, particularly persons who are recipients of
HUD assistance for housing.
6: The -parties -to -this -contract -agree to comply -with -HUD's-regulations in24CFR Part 135, which
implement Section 3. As evidenced by their execution of this contract, the parties to this contract
certify that they are under no contractual or other impediment that would prevent them from
complying with the 24 CFR Part 135 regulations.
C. The contractor agrees to send to each labor organization or representative of workers with which the
contractor has a collective bargaining agreement or other understanding, if any, a notice advising the
labor organization or worker's representative of the contractor's commitments under this Section 3
clause, and will post copies of the notice in conspicuous placed at the work site where both
employees and applicants for training and employment positions can see the notice. The notice shall
describe the Section 3 preference, shall set forth minimum number and job titles subject to hire,
availability of apprenticeship and training positions, the qualifications for each; and the name and
location of the person(s) taking applications for each of the positions; and the anticipated date the
work shall begin.
D. The contractor agrees to include this Section 3 clause in every subcontract subject to compliance with
regulations in 24 CFR Part 135, and agrees to take appropriate action, as provided in the applicable
provision of the subcontract or in this Section 3 clause, upon a finding that the subcontractor is in
violation of the regulations in 24 CFR Part 135. The contractor will not subcontract with any
subcontractor where the contractor has notice or knowledge that the subcontractor has been found
in violation of the regulations in 24 CFR Part 135.
E. The contractor will certify that any vacant employment positions, including training positions, that are
filled (1) after the contractor is selected but before the contract is executed; and (2) with persons
other than those to whom the regulations of 24 CFR Part 135 require employment opportunities to be
directed, were not filled to circumvent the contractor's obligations under 24 CFR Part 135.
F. Non-compliance with HUD's regulations in 24 CFR Part 135 may result in sanctions, termination of the
contract for default, and debarment or suspension from future HUD assisted contracts.
G. Wit respect to work performed in connection with Section 3 covered Indian housing assistance,
SectiCn 7(b) of the Indian Self-^Determi�nauon and Education Assis erne Act (25 U.S.C. 450c) also
applies to the work to be performed under this contract. Section 7(b) requires that to the greatest
extent feasible (1) preference and opportunities for training and emplo9yment shall be given to
Indians, and (2) preference in the award of contracts and subcontracts shall be given to Indian
organizations and Indian -owned Economic Enterprises Parties to this contract that are subject to the
provisions of Section 3 and Section 7(b) agree to comply with Section 3 to the maximum extent
feasible, but not in derogation of compliance with Section 7(b).
TCS
F -f t7�J1��, ST.a.TL�TS= 0,�' PLt;LfC EtiTi iY 1=F'[',i;✓�
?'��il—�L—I(_}?�i J v� l _ _ ;'_I _i`l '_`�
T�-y 11-1 �tr7-=_1 1_� i lid l�� I� t) 1 �._I I-lig+ PlT
,-I.1r75.
I. This s,','c;rn statement is submincd to 11'Iionl Dade County.
for
(print ind)vidual's name and title)
(print name ofentitysubmimn2 S,vcrn staltem,-,m)
whose business address is
and (ifapplicable) its Federal Employer Identification Number (FEIN) is
(if the erttin' has no FEITI, include the Socia', Securily ?`,lumber of the ind;vidua:' 5:,t,in^ this worn
statement:) -
I understand that a "public entity crime" as defined in Paragraph 237.135(1)(a). Florida Statutes
means a violation of any state or federal law by a person ::'ith respect to and directly related to the
transaction of business with any public entity or with an agency or political subdivision of any
Other state of the United States, including, but not iirnited to, any bid or contract for moods or
services to be provided to any public entiT)' or an zgency. or political subdivision o any other state
of the United States and involving antitrust, fraud, theft, bribery, collusion, racket --Bering,
conspii-acy, ormaterial misrepresentation.
I understand that "convicted" or "conviction" as defined ir; Paragraph 257.133(1)(b' Florida
Statutes means a finding of guilt or a conviction of a public entity crime, with or without an
adjudication of wilt, in any federal or state trial court of record relating to charges brought by
indictment or information after July 1, 19S?, as a resuitofa jury ve,-dict, non -jury trial; or entry of
plea or guilty or nolo contendere,
4- I understand that an "affiliate" as defined in Paragraph 257.133 O )(a) Florida Statutes means:
a. A predecessor or successor ofa person corivi.cted ofa public entity crime; or,
b. An entiry under the control of ary natural person who is activ,-- in the management of the
entity and who has been convicted of a public entih crime. The term "affiliate: includes those
Officers, directors, executives, partners sharehoiders, erilployees, members, and agents j,,ho
are active in the management of an a`filiate. The ownership b)' one person of shares
coilstitutin—o a controlling interest in another person. or pooling of eouipment or incon-e
among persons when not for fair market value under an arras length agreernent, ;hall be a
Prima facie case that one person controls another person. A, person �Vho lno •vi.n,'.y enters
into a joint venture with a person who has been convicted ofa pubic entir,I crime in 7lorida
during the preceding:?months shall be considered an afriiiate.
1 Undersrand .2s tdeiin'd In Paragraph "1,`7 ",31 F)orlda rICC trt_nl n5 an',' nattural
pe;COl1 Cr entitT or °aniZed unctr the lanv,s of any stat;; of Di t:1 e L1, —0' Siate, 111`1[Ii [ e lei' 1 pnt'!er IO
enter m1c)v tI. d;rO anG .'L]Cn hIrr
Ur tp, JeS to �1 C^ on Ca CS
,zr le ori pion �� �z��ds or
•'1�-- b_ a }7ubll� ntir`,', Or %' hlC: othf .'I 2r!S2 ri ay I1C� ,L t _; bLl r,._. J,'I,h
en t a Y Jbi.
T to person' r lua s :hos_ r ,' r tor., p..rl
e 1T)lC, t'-5, I',l?it?beG; and t3�,-eris "no fare active In rhana^_., tnt C' all
.._�..� !..._ �i
MIS
Ui., naqnr_rs, Sit l��fril�'rs, ai;7[j�T.' .^]�e. _. =='lit: ••'P.0 :ii_ ...[I', In -,_
nide '_;TiCnt of ci" Cntli �, •. _ _ �`' h2- D_.:� rr;:F_ , ,:h art^ l .__ it J
DCb;4C L'ntif-,' CiMI C iIc t =� 36 months.
e�:ccutive,, p atiners, shareholders, employees, members, or aL.entc are cctiw. in tip_
i a'ia�,,, cnt of il1C entity, or an aFfiliate of file eniti% his bee, Ch[If"td l'.9 [il :!n con` icici of it
public c•ntir, crime within die past -6 rnonths AND (Please indic,tc witiclt additic,nal statement
aPplies)
The entity submjning this swom statement, o -r one or more of its ofrtcars, directors,
executives, partners, shareholders; employees, members, or agents who are active in the
manac,ernent of the entire, or an afftliate of the entity has been charged an convicted of a
public entity crime within the past 76 months. However, there has been a subsequent proceeding
before a Hearino Officer of he State of Florida, divis'en of Administrative Hearings and the Final
Order entered y the Hearing officer determined :hat was as not in the public interest to puce tLe
entity submitting this sli'om statement on the convicted vendor list (attach a copy or the final
order).
I UNDERSTAND THAT THE SUBMISSION OF THIS . FORM TO THE CONTRACTING
OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH I (ONE) ABOVE IS FOR
THAT PUBLIC ENTITY OINLY AND, THAT THIS FORNT :S VALID THROUGH THE LIFE OF
THE CON'TRAC'T'. I ALSO UNDERSTAND THAT IAM REQUIRED TO INFOP vi THE P(JPiLIC
ENTITY PRZIOR TO ENTERING INTO A CONTR1ACT IN EACESS OF THE THPESHOLD
AMOUNT PROVIDED IN SECTION 237.017, FLORIDA STATUTES FOR CATEGORY TWO OF
ANY CHANGE IN THE INFOR1 IATION CONTRAINED IN THIS FORM
{Si;nature) (date)
STATE OF
COUNTY OF
PERSONALLY APPEARED BEFOLE ME, the undersigned autl.oriry
(name of individual s)'nning)
uho, after, first being Svvom by me, aitised his her si nature in the space provided above on this
day of ,p
NO [ARl' PL+BLIC
1; :o; n is_icn e;;pire
MIAMI-DADE COUNTY HOMELESS TRUST
PROVIDER ASSET INVENTORY
Provider.Name:
Program Name:
Funding Source:
Deporting Period:
ATTAC14M F -NT P
description
of Property
Serial / ID
Number
Acquisition
Date
Acquisition
Cost
Vendor
Name
% of
Purchase
Cost from
Grant
Location of
Property
Use and
Condition
of Property
Who Folds
Title of
Property
ria Attach invoices for all purchases this grant reporting period.
ATTACHMENT Q
INSERT COPY OF
DECLAMATION 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 Program
(SHP) project referenced above.
By signing, I hereby cerci' that I have worked 100% of the time on the referenced Supportive
Housing Program (Slip) project during the period specified above.
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
INCIDENT REPORT
IDENTIFYING INFORMATION
ATTACHMENT S
Reporting Party Phone # Date of Incident—/—/— Time of Incident _
Reporting Party Name
Contract Provider Name
Program Name
Provider Location
Specific Program: (check all that apply)
❑ IST ❑ Primary Care ❑ SIP ❑ Emergency ❑ Challenge
Spec #! -c locatio.-Ja tdress where incident occurred.
TYPE OF INCIDENT
❑ CLIENT INJUR Y OR ILLNESS"
❑ ,SEXUAL BATTERY
❑ CLIENT DEATH
❑ THEFT
❑ SUICIDE ATTEMPT
❑ OTHER INCIDENT
Specify
PARTICIPANT (S) / WITNESS (ES)
(PIease mark W or P for either Witness or Participant)
LAST NAME, FIRST IDENTIFIER ## CLIENT
❑
❑
1 of 3
am/pm
EMPLOYEE. OTHER W / P
❑ ❑
❑ ❑
DESCRIPTION OF INCIDENT
Give detailed account — who, what, where, when, why, how — add pages if necessary
CORRECTIVE ACTION AND FOLLOW UP
Immediate corrective action taken
Is follow up action needed? ® Yes ® No
If yes, specify.
INDIVIDUALS NOTIFIED
Abuse Registry 1-800-962-2873 Applicable Law Enforcement Department
Indicate person contacted, if report was accepted, the date and the time, and if by telephone or if copy of report
available.
Incident Rep®r-ts — The Subrecipient must report to Miami -Dade County Homeless Trust information related to W
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, I I I NW First
Street, 27b Floor, Suite 310, Miami, Florida 33128; telephone (305) 375-1490 and facsrnilie (305).'175-2722.
2 of 3
A
Definitions of Reportable Incidents
a. Altercation. A physical confrontation occurring between a client and employee or
two or more clients at the time services are being rendered, or when a client is in the
physical custody of the department, which results in one or more clients or employees
receiving medical treatment by a licensed health care professional.
b. Client Death. A person whose life terminates due to or allegedly due to an accident,
act of abuse, neglect or other incident occurring while in the presence of an employee,
in Homeless Trust contracted program facility.
c. Client Injury or Illness. A medical condition of a client requiring medical treatment
by a licensed health care professional sustained or allegedly sustained due to an
accident, act of abuse, neglect or other incident occurring while in the presence of an
employee, in a Homeless Trust contracted program.
d. Other Incident. An unusual occurrence or circumstance initiated by something other
than natural causes or out of the ordinary such as a tornado, kidnapping, riot, or
hostage situation, which jeopardizes the health, safety and welfare of clients.
e. Sexual Battery. An allegation of sexual battery by a client on a client, employee on a
client, or client on an employee as evidenced by medical evidence or law enforcement
involvement.
f. Suicide Attemtit. An act which clearly reflects the physical attempt- by a client to
cause his or her own death while in the physical custody of the department or a
departmental contracted or certified provider, which results in bodily injury requiring
medical treatment by a licensed health care professional.
Property Damage
An incident involving damage to property procured x ith Homeless Trust funding.
Print Name of Person Submitting Report
3 of 3
Signature