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Exhibit B (OBSOLETE)
PROJECT APPLICATION FORMS TGHI - Island District Development 29 PROPOSAL CHECK -OFF LIST COMPLETE "SUBMITTED" COLUMN AND INCLUDE FORM WITH APPLICATION PROJECT NAME: Island District Development APPLICANT NAME: Thelma Gibson Health Initiative DOCUMENTS (SUBMIT PROPOSAL AS LISTED) SUBMITTED (YES/NO) City Staff COMMENTS -- Table of Contents (sequentially numbered with document) -- Application Form 1. Project Narrative (Description) 2. Location Map 3. Original Photographs of Site/Existing Buildings 4. Dimensional Schematic Plans 5. Evidence of Site Control 6. Narrative: History of Developer(s) or Agency(ies) 7. Narrative: Development Team or Service Team Background 8. Applicant's (or Principal's) Most Recent Financial Statements 9. Applicant's (or Principal's) Most Recent Federal Income Tax 10. Organizational Chart 11.Joint Venture/Partnership Description and Agreement 12. Project Development or Service Schedule 13. Sources and Uses form 14. Project Feasibility and Ability to Proceed with required documentation including: General Marketing Plan, Affirmative Fair Housing Marketing Plan, U.S. HUD Release Grant Conditions 15. Evidence of Additional Financing (i.e. commitment letters) 16.Justification of HCP Subsidy (if applicable) 17. One Year through Thirty Year Operating Budget 18. Declaration of Financial Interests 19. Certification Regarding Debarment Suspension 24. Sworn Statement on Public Entity Crime DO NOT WRITE BELOW THIS LINE I HAVE REVIEWED ALL REQUIRED OPERATIONAL DOCUMENTS AND FIND THEM TO BE ACCEPTABLE City Staff Representative 30 Date City of Miami Affordable Housing Pipeline Application APPLICATION APPLICANT INFORMATION: NAME: STREET ADDRESS: 3640 Grand Avenue Thelma Gibson Health Initiative CITY, STATE, ZIP CODE: Miami, FL, 33133 PHoNE: (305) 446-1543 FAx: N/A CONTACT PERSON: Joseph King, TGHI - C.O.O. EMAIL: jking@tghimiami.org LEGAL ENTITY TYPE: Florida 501(c)(3) TAX ID #: 45-2835589 TYPE OF PROJECT: n NEW CONSTRUCTION RENTAL HOUSING: n NEW CONSTRUCTION HOME OWNERSHIP HOUSING: CITY OF MIAMI FUNDING: Proposed Funding Sources Amount Requested TBD $4,500,000 DID THIS PROJECT PREVIOUSLY RECEIVE CITY FUNDING? YES IF YES, LIST AMOUNT AND FUNDING YEAR: $ N/A LEGAL ENTITY: NO X YEAR: N/A n Sole Proprietor n Partnership n Corporation X❑ Non -Profit _ LLC n Other PROJECT DESCRIPTION: PROJECT NAME: Island District Development 31 PROJECT'S ADDRESS: 3640 Grand Avenue CITY OF MIAMI DISTRICT 2 NUMBER OF BUILDINGS TO BE CONSTRUCTED: 1 NUMBER OF FLOORS PER BUILDING: 5 NUMBER OF TOTAL HOUSING UNITS: 27-36 NUMBER OF CITY HOM E) ASSISTED UNITS: 27-36 HOUSING TYPE (HIGH RISE, TOWN HOMES, ETC.): Midrise apartment building LOT DIMENSIONS / TOTAL SQUARE FOOTAGE: 33,100 sq. ft. IF MIXED USE, PROVIDE DESCRIPTION OF COMMERCIAL PORTION: Bahamian Cultural Museum+neighborhood retail DISTANCE TO SURROUNDING STRUCTURES): Abutting DESCRIPTION OF ANY EXISTING STRUCTURES: 1 story old office buildings, and several small multifamily residential structures. • ATTACH A MAP PLOTTING SITE AND SURROUNDING AMENITIES See attachment • ATTACH A LEGAL DESCRIPTION OF PROJECT SITE See attachment RENTAL UNIT TYPES (INDICATE WHICH UNITS ARE CITY AND NON -CITY ASSISTED UNITS) CITY OR NON- CITY # OF UNITS # OF BEDROOMS # OF BATHS CONSTRUCTION COST/UNIT SQ. FT. OF COST PER SUNIT F. UNIT RENTAL COST AVG. CITY SUBSIDY PER UNIT x 4 0 95200 680 140 853 X 1 0 95200 680 140 1,708 X 5 1 165200 1,180 140 914 X 1 1 165200 1 ,180 140 1,829 X 6 2 205800 1,470 140 1,097 X 2 2 205800 1,470 140 2,195 X 7 3 259000 1,850 140 1,267 X 3 3 259000 1,850 140 2,535 204,545 TOTAL CITY ASSISTED UNITS 27 32 %AMI 50 100 50 100 50 100 50 100 ACKNOWLEDGEMENT On I, , as authorized representative of the Applicant, state that Applicant understands that if an award is made by the City of Miami to the Applicant in connection with this RFP, applicant must meet applicable administrative and regulatory rules to meet Federal, State and Local codes or other conditions as determined by the City Attorney. I acknowledge that it is the Applicant's responsibility to be familiar with these requirements prior to accepting the award and commencing contract negotiations with the City of Miami. Signature of Authorized Representative 33 Print Name Title PROJECT FEASIBILITY & ABILITY TO PROCEED SITE CONTROL: • ATTACH EVIDENCE OF SITE CONTROL • BUILDING AND ZONING: CURRENT ZONING ALLOWS 36 UNITS PER ACRE. WILL THERE BE ANY ADDITIONAL BUILDING OR ZONING REQUIREMENTS DUE TO THE Loss OF GRANDFATHERED ZONING RIGHTS AS THE PROJECT GOES THROUGH PERMITTING? There are two possible configurations, one with rezone of T3 to T4. IF APPLICABLE, PROVIDE DETAILS REGARDING ALL PERMITS OR VARIANCES THAT MIGHT BE REQUIRED • IF APPLICABLE, ATTACH PERMIT OR DETERMINATION OFA BUILDING DEPARTMENT OFFICIAL AS TO WHAT PERMITS MIGHT BE REQUIRED IF THE PROPOSED BUILDING IS 40 YEARS OR OLDER, THE 40 YEAR RE- CERTIFICATION REPORT FROM THE CITY OF MIAMI'S BUILDING DEPARTMENT MUST BE PROVIDED. N/A ARCHITECTURAL PLANS: IF APPLICABLE, PROVIDE DETAILS REGARDING ARCHITECT QUALIFICATIONS AND SELECTION N/A SITE ACCESSIBILITY: LIST ANY EASEMENTS ON THE PROPERTY: No easements IF APPLICABLE, DESCRIBE POTENTIAL EFFECT OF EASEMENTS WITH THE PROPOSED PROJECT? DESCRIBE THE ACCESS TO THE PROJECT I.E. PAVED ROAD, ACCESS EASEMENT, ETC.): Entrance from Grand Ave. Secondary entrance from Thomas Ave ENVIRONMENTAL SAFETY: DESCRIBE THE PREVIOUS USE OF THE PROPOSED SITE FROM 1940 TO PRESENT: HAS THE PROPERTY EVER BEEN USED FOR STORAGE OF HAZARDOUS OR TOXIC MATERIALS? YES x No ARE THERE ANY POTENTIAL ENVIRONMENTAL HAZARDS? • ATTACH PHASE I ENVIRONMENTAL REPORT To be completed before execution of contract. USE OF EXISTING INFRASTRUCTURE: DESCRIBE AVAILABLE UTILITIES AND INFRASTRUCTURE AT THE PROJECT SITE. ELECTRICITY: Current site has electricity WATER/SEWER: Current site has water and sewer 34 ROADS: Frontage on Grand Avenue • ATTACH LETTERS FROM THE LOCAL GOVERNMENT VERIFYING AVAILABLE INFRASTRUCTURE. MARKETING PLAN: IS THERE A MARKETING PLAN? X YES NO WHO WILL MANAGE MARKETING? Thelma Gibson Health Initiative • ATTACH A COPY OF THE MANAGEMENT PLAN (THE PLAN SHOULD INCLUDE: FAIR HOUSING COMPLIANCE PROCEDURES, OWNER QUALIFICATION PROCEDURES, AND RECORD KEEPING) EMPLOYMENT —JOB CREATION HOW MANY JOBS ARE PROJECTED TO BE RETAINED BY THIS PROJECT: 7 HOW MANY JOBS ARE PROJECTED TO BE CREATED BY THIS PROJECT: • HOW MANY OF THESE NEW JOBS ARE PROJECTED TO BE FILLED BY SECTION 3 RESIDENTS: • GENERAL CONTRACTOR INFORMATION: PLEASE DESCRIBE PROCESS TO SELECT GENERAL CONTRACTOR: ALSO, IF SELECTION OF GENERAL CONTRACTOR (GC) HAS OCCURRED, PROVIDE THE FOLLOWING: GENERAL CONTRACTOR NAME: MARCELO O. FERNANDES ADDRESS: 3936 Main Highway Coconut Grove, FL 33133 TELEPHONE: 305-648-0005 FLORIDA CONTRACTOR'S LICENSE No.: CGC1 512252 YEAR OF ISSUANCE: 1 0/27/2006 35 AND COPY • COPY OF ADVERTISED BID FOR GENERAL CONTRACTOR SERVICES • REFERENCES); ATTACH ADDITIONAL PAGES IF NECESSARY • ATTACH A LIST OF AFFORDABLE HOUSING PROJECTS CONSTRUCTED BY THE GC. INCLUDE THE NAME, ADDRESS, PROJECT DESCRIPTION, COST, DATE OF COMPLETION, OR CURRENT STATUS. • COPY OF SCOPE OF SERVICES, SCHEDULE OF VALUES, AND SIGNATURE PAGE see proposal EVIDENCE OF AVAILABILITY OF PROJECT FINANCING (THIS INFORMATION MUST MATCH SOURCES LISTED IN SOURCES AND USES) FOR EACH SOURCE OF FINANCING, SPECIFY AS FOLLOWS: ATTACH ADDITIONAL PAGES IF NECESSARY) NAME OF INSTITUTION OR ENTITY: TELEPHONE NUMBER: FL US Congress District 24 HUD-EconomicDevelopmentlnitiatives CONTACT PERSON: Staff, Frederica Wilson, Member of Congress (305) 690-5905 CPFGrants@hud.gov AMOUNT OF LOAN/GRANT: $ 1 ,540,000 INTEREST RATE: N/A TERMS: AMORTIZATION: TYPE OF COMMITMENT: Grant for Bahamian Museum of Arts and Culture ACKNOWLEDGEMENT ON I, , AS AUTHORIZED REPRESENTATIVE OF THE APPLICANT, STATE THAT APPLICANT UNDERSTANDS THAT IF AN AWARD IS MADE BY THE CITY OF MIAMI TO THE APPLICANT IN CONNECTION WITH THIS RFP, APPLICANT MUST MEET APPLICABLE ADMINISTRATIVE AND REGULATORY RULES TO MEET FEDERAL, STATE AND LOCAL CODES OR OTHER CONDITIONS AS DETERMINED BY THE CITY ATTORNEY. I ACKNOWLEDGE THAT IT IS THE APPLICANT'S RESPONSIBILITY TO BE FAMILIAR WITH THESE REQUIREMENTS PRIOR TO ACCEPTING THE AWARD AND COMMENCING CONTRACTS NEGOTIATIONS WITH THE CITY OF MIAMI. AUTHORIZED REPRESENTATIVE SIGNATURE PRINT NAME OF AUTHORIZED REPRESENTATIVE (Title of authorized representative) 36 -a EVIDENCE OF AVAILABILITY OF PROJECT FINANCING (THIS INFORMATION MUST MATCH SOURCES LISTED IN SOURCES AND USES) FOR EACH SOURCE OF FINANCING, SPECIFY AS FOLLOWS: ATTACH ADDITIONAL PAGES IF NECESSARY) NAME OF INSTITUTION OR ENTITY: TELEPHONE NUMBER: FL US Congress District 24 HUD -Economic Development Initiatives (305) 690-5905 AMOUNT OF LOAN/GRANT: $ 2,615,000 INTEREST RATE: CONTACT PERSON: TERMS: AMORTIZATION: Staff, Office of Frederica Wilson TYPE OF COMMITMENT: Grant for Bahamian Museum of Arts and Culture ACKNOWLEDGEMENT ON I, , AS AUTHORIZED REPRESENTATIVE OF THE APPLICANT, STATE THAT APPLICANT UNDERSTANDS THAT IF AN AWARD IS MADE BY THE CITY OF MIAMI TO THE APPLICANT IN CONNECTION WITH THIS RFP, APPLICANT MUST MEET APPLICABLE ADMINISTRATIVE AND REGULATORY RULES TO MEET FEDERAL, STATE AND LOCAL CODES OR OTHER CONDITIONS AS DETERMINED BY THE CITY ATTORNEY. I ACKNOWLEDGE THAT IT IS THE APPLICANT'S RESPONSIBILITY TO BE FAMILIAR WITH THESE REQUIREMENTS PRIOR TO ACCEPTING THE AWARD AND COMMENCING CONTRACTS NEGOTIATIONS WITH THE CITY OF MIAMI. AUTHORIZED REPRESENTATIVE SIGNATURE PRINT NAME OF AUTHORIZED REPRESENTATIVE (Title of authorized representative) 36-b SUPPLEMENTAL FORMS See Attachments A. Deeds of Sale for IDDQOZB Properties B. Deeds of Sale IDD Properties C. - D. - E. TGHI Form 990 F. Unaudited Financial Statement G. TGHI Operating Budget H. MOU - TGHI/SilverBluff I. MOU - IDD/TGHI/IDDQOZB J. Development Schedule K. Sources & Uses L. Sources Projection M. IDD Pro Forma N. - O. Affirmative Fair Housing Marketing Plan (AFHMP) P. TGHI CFP22 Funding Notification Letter Q. OCPD Commitment Email R. TGHI 30 Year Pro -Forma S. Declaration of Financial Interests T. Debarment Certification U. Public Entity Crime Affidavit V. Resilience Checklist W. Insurance requirements X. Authorized Representative Statement Y. Sound Fiscal Management Certification Z. Estimate of Impact Fees AA. Conflict of Interest Form 37 Thelma Gibson Health Initiative Island District Development Table of Contents Section I: Project Application and Narrative 3 Description of Project 3 Location Map 3 Project Brief 5 Unit Breakdown (Rent Restriction) 5 Unit Breakdown (with Rezone of Thomas T3 to T4) 6 Photographs of Existing Properties 7 Dimensional Schematic Plans 8 Evidence of Site Control - 364o Grand Ave. 9 Evidence of Site Control - 3661 Thomas Ave. io Evidence of Site Control - 3649 Thomas Ave. 11 Evidence of Site Control - 3637 - 3543 Thomas Ave. 12 Section II: Statement of Capacity: Organizational Experience 13 History of Applicant: Thelma Gibson Health Initiative i3 Development Team Background - Fernandes Group i4 Marcelo Fernandes - Principal i4 Ottoni C. Fernandes - Fiscal Officer i4 Eduardo A. Fernandes - Construction Manager i4 Renee Traad - Administration i4 Applicant's Most Recent Financial Statements i5 Section III: Statement of Capacity: Organizational Structure i6 Project Organizational Chart i6 MOU Between TGHI and Developers i6 Section IV: Proposed Approach to Providing the Services Summary of Unit Marketing and Operations 17 17 TGHI - Island District Development Section V: Project Readiness, Feasibility, and Affordability Project Development Schedule Sources and Uses Project Feasibility and Ability to Proceed General Marketing Plan Affirmative Fair Housing Marketing Plan Employment Generation Evidence of Additional Financing Thirty Year Operating Pro -Forma Declaration of Financial Interests Certification Regarding Debarment Suspension Sworn Statement on Public Entity Crime Section VI: Resiliency Components Resilience Checklist 18 18 19 20 20 20 20 21 22 23 23 23 24 24 Section VII: Technical Information 25 Legal description of the properties: 25 Phase I Environmental Report (optional at time of application, required before funding) 26 Insurance requirements as stipulated herein 27 Section VIII: Supplemental Forms Public Entity Crime Affidavit Authorized Representative Statement Debarment Certification Sound Fiscal Management Certification Declaration of Financial Interests Estimate of Impact Fees Sources and Uses Budget Development Schedule Conflict of Interest Disclosure Forms Schedule of Attachments 28 28 28 28 28 28 28 28 28 28 29 2 TGHI - Island District Development Section I: Project Application and Narrative Description of Project Island District Development will be a mixed -use Housing and Community Business development built by the Grove for the Grove. Thelma Gibson Health Initiative (TGHI), a Florida not for profit corporation, has partnered with neighbors to assemble almost a full acre of land along Grand Avenue in the heart of the historic West Grove. TGHI will build out 26+ rent -restricted apartments with rents affordable to their clients and neighbors in Coconut Grove, as well as 7,000+ sq. ft.of commercial space for badly needed community businesses spaces and a new cultural attraction in the Wilson Bahamian Museum sponsored by US Congresswoman Frederica Wilson. Rapid increases in the prices of homes and rent in West Coconut Grove have far outstripped increases in income. Residents across West Coconut Grove are finding fewer affordable housing options as land values rise and evictions are spreading across the community. TGHI is working to give the people a safe and comfortable place to call home in their neighborhood even as Coconut Grove continues to increase in cost. 3 TGHI - Island District Development Location Map 364o Grand Avenue 4 TGHI - Island District Development Project Brief Miami City Commission District: Miami -Dade Census Block Group: Folios included in development: Agency Name: Applicant's Mailing Address: Telephone Number: Email Address: Name/Title: Employer Identification Number (EIN): REQUESTED AMOUNT: 2 120860072002 3640 Grand - 01-4121-007-4130 3649 Thomas - 01-4121-007-4240 3643 Thomas - 01-4121-007-4250 3661 Thomas - 01-4121-007-4230 Thelma Gibson Health Initiative, Inc. 364o Grand Avenue, Miami, Fl, 33133 (305) 446-1543 jking@tghimiami.org Joseph King, TGHI - C.O.O. 45-2835589 54,500,000 Unit Mix by Right (Rent Restriction) Units will be restricted by Covenant and Rent -Regulatory Agreement running with the land for 3o years. Affordable to Income Level: Unit Size 5o% AMI i00% AMI Market Total Retail (700o sq.ft.) - - 1 1 Studio (68o sq.ft) 4 1 — 5 1-BR (1,18o sq.ft.) 5 1 - 6 2-BR (1,470 sq.ft.) 6 2 — 8 3-BR (1,85o sq.ft.) 7 1 - 8 TOTAL 22 5 1 28 5 TGHI - Island District Development Unit Mix with Rezone of Thomas T3 to T4 (Rent Restriction) Units will be restricted by Covenant and Rent -Regulatory Agreement running with the land for 3o years. Affordable to Income Level: Unit Size 50% AMI i00% AMI Market Total Retail (700o sq.ft.) - - 1 1 Studio (68o sq.ft) 5 2 - 7 i-BR (1,18o sq.ft.) 7 1 - 8 2-BR (1,47o sq.ft.) 8 3 - u 3-BR (1,85o sq.ft.) 9 1 - io TOTAL 36 29 7 1 37 Rezoned Unit Breakdown to be used as a representative guide for final development, subject to additional funding. 6 TGHI - Island District Development Photographs of Existing Properties 364o-3648 Grand Avenue 3643-3661 Thomas Avenue 7 TGHI - Island District Development Dimensional Schematic Plans F Conceptual Massing Option r GRAND AVE RETAIL UNIT 02 THOMAS AVE Conceptual Floorplan Option UNIT 03 a uq LOBBY PROPERTVUNEI BASEBULOINGUNE T5-O T4-L (T3-O) TRANSECTUNE TOWEIPBOVE UT,. MESE-MUCK FROM SETPACK 8 TGHI - Island District Development Evidence of Site Control - 364o Grand Ave. PROPERTY INFORMATION 1 Folio: 01-4121-007-4130 Sub -Division: FROW HOMESTEAD Property Address 3640 GRAND AVE Owner ISLANDE DISTRICT DEVELOPMENT 002B LLC Mailing Address 3162 COMMODORE PLAZA STE 2C MIAMI. FL 33133 PA Primary Zone 6101 CEN-PEDESTRIAN ORIENTATIO Primary Land Use 1111 STORE : RETAIL OUTLET Beds I Baths / Half Floors Living Units Actual Area Living Area Adjusted Area Lot Size 0/0/0 5.735 Sq.Ft 13,100 Sq.Ft 364o Grand Ave. Deed - ATTACHMENT A 9 TGHI - Island District Development Evidence of Site Control - 3661 Thomas Ave. PROPERTY INFORMATION Folio: 01-4121-007-4230 Sub -Division: FROW HOMESTEAD Property Address 3661 THOMAS AVE Owner ISLAND DISTRICT DEVELOPMENT OOZB LLC Mailing Address 3162 COMMODORE PLAZA2C MIAMI, FL 33133 PA Primary Zone 5700 DUPLEXES -GENERAL Primary Land Use 0603 MULTIFAMILY 2-9 UNITS : MULTIFAMILY 3 OR MORE UNITS Beds/Baths/Half 6/6/0 Floors 2 Living Unite 6 Actual Area Living Area Adjusted Area 2,309 Sq.Ft Lot Size 5,000 Sq.Ft 3661 Thomas Deed - ATTACHMENT A 10 TGHI - Island District Development Evidence of Site Control - 3649 Thomas Ave. PROPERTY INFORMATION Folio: 01-4121-0074240 Sub -Division: FROW HOMESTEAD Property Address 3649 THOMAS AVE Owner ISLAND DISTRICT DEVELOPMENT LLC Mailing Address 3634 GRAND AVE COCONUT GROVE, FL 33133 PA Primary Zone 5700 DUPLEXES -GENERAL Primary Land Use 0081 VACANT RESIDENTIAL VACANT LAND Beds/Baths/Half 0/0/0 Floors 0 Living Units 0 Actual Area Living Area Adjusted Area 0 0 Lot Size 5,000 Sq.Ft Year Built 0 3649 Thomas Deed - ATTACHMENT B 11 TGHI - Island District Development Evidence of Site Control - 3637 - 3543 Thomas Ave. PROPERTY INFORMATION o Folio: 01-4121-007-4250 Sub -Division: FROW HOMESTEAD Property Address 3643 THOMAS AVE 3635 THOMAS AVE 3637 THOMAS AVE Owner ISLAND DISTRICT DEVELOPMENT LLC Mailing Address 3634 GRAND AVE COCONUT GROVE, FL 33133 PA Primary Zone 5700 DUPLEXES -GENERAL Primary Land Use 0803 MULTIFAMILY 2-9 UNITS : MULTIFAMILY 3 OR MORE UNITS Beds / Bathe / Half 7/3/0 Floors 1 Living Units 3 Actual Area Living Area Adjusted Area 2,928 Sq.Ft Lot Size 10,000 Sq.Ft Year Built Multiple (Sae Building Info.) 3637 - 3543 Thomas Ave. Deed - ATTACHMENT B 12 TGHI - Island District Development Section II: Statement of Capacity: Organizational Experience History of Applicant: Thelma Gibson Health Initiative TGHI Mission Dedicated to improving lives in low-income neighborhoods with programs for critical needs, better health, new skills, jobs, housing and economic stability. About TGHI Since inception in 2000 TGHI has been fighting the effects of poverty in communities where 1 in 4 families battle poverty, illiteracy, drug dependency, HIV, delinquency, teen pregnancy, gangs, crime and hopelessness. The initial focus of the Health Initiative was to reduce HIV and substance abuse in the West Grove, South Miami, and Coral Gables, and to help residents find resources for critical living problems with a staff of Master's -level Counselors and Clinical Social Workers. Within a few years, the agency added programs to help families with education, teen violence, and social and life skills. Recently TGHI has added job training and placement for all ages in our CANTEEN Jobs Program, and our Passport Curriculum for Practical Skills. Plans are underway to replicate the Canteen Jobs Program and Passport Curriculum in more locations in Miami -Dade County. TGHI employs a caring and experienced group of professionals including Masters Level Counselors, Certified Behavior Analysts, Case Managers, and Vocational Training Staff. We are dedicated to moving each client forward towards healthy, more skilled, and better organized lives, helping them find jobs which can lead to a career and a successful life in the community of their choice. Partners TGHI partners with schools, colleges, neighborhood housing agencies, legal support entities and others to provide non-credit classes and administrative support. Interns from UM School of Nursing & Public Health teach nutrition and health, and help with data collection and case management. Miami -Dade College provides non -degree practical reading and math classes at the Gibson Educational Center on Grand Avenue. Popular Community Bank provides instruction in banking, budgeting and credit. Other partners provide funding to improve the social and organizational skills needed for jobs advancement and economic stability. 13 TGHI - Island District Development Development Team Background - Fernandes Group Marcelo Fernandes - Principal Marcelo Fernandes has proven financial management success with his experienced computer programming abilities. His technological abilities and experience has placed him in the forefront of the real estate industry. His accomplishments include the administration of strict construction budgets and the control of large inventories of electronic merchandise and specialized medical products. Ottoni C. Fernandes - Fiscal Officer Ottoni Fernandes is solely responsible for the establishment of many organizations involved in the purchase and renovation of raw properties. His building experience extends from commercial warehouses and office buildings to residential townhouses and luxury homes. Among all the companies and/or partnerships controlled by Ottoni Fernandes there exists an extensive list of successful accomplishments. Having established a consistent control of various business enterprises for over 45 years, Ottoni Fernandes has proven experience in a diverse field of large scale business finance. Eduardo A. Fernandes - Construction Manager Eduardo Fernandes is responsible for the complete management and execution of all the construction for Oxford Universal Corp. Eduardo A. Fernandes is a graduate from Gulliver Academy High School, Miami Florida and University of Florida, Gainesville, FL. He earned a Bachelor of Arts degree in Business Administration. His building experience includes on -site management of diversified types of projects since 199o. Attention to detail, strict budget management and hands-on schedule control are his main priorities which have been the key factors for his continued success. All the projects he manages are integrated into a detailed project management software and system that keeps track of critical path progress and keeps all involved personnel notified of events, milestones and goals. Renee Traad - Administration Renee has over 20 years experience in accounting, property service work and marketing and international business. 14 TGHI - Island District Development Applicant's Most Recent Financial Statements ATTACHMENT E - TGHI IRS Form 990 ATTACHMENT F - Unaudited Financial Statement ATTACHMENT G - TGHI Operating Budget 15 TGHI - Island District Development Section III: Statement of Capacity: Organizational Structure Project Organizational Chart TGHI Board Merline Barton President & Co -Founder Joseph King Vice President of Operations 1 Thelma Gibson Health Initiative Applicant - Property Co -Owner Contact MOU Island District Development Development LLC Silver Bluff Real Estate, LLC Peter Gardner, Principal MOU MOU Grove Properties, LLC Marcelo Fernandes, Developer Island District Development, QOZB Property Co -Owner MOU Between TGHI and Developers ATTACHMENT H - MOU Between TGHI and Silver Bluff ATTACHMENT I - MOU Between TGHI, IDD and IDD-QOZB Property Management Housing Property Management i6 TGHI - Island District Development Section IV: Proposed Approach to Providing the Services Summary of Unit Marketing and Operations TGHI will use these affordable units to house members of its service community in need of housing who qualify for rents in the restricted income range. A portion of each rent collection will be set aside in a maintenance account. Regular maintenance will be conducted to keep property in good operational order. 17 TGHI - Island District Development Section V: Project Readiness, Feasibility, and Affordability Project Development Schedule ATTACHMENT J TGHI - Island District Development Sources and Uses ATTACHMENT K - Sources and Uses ATTACHMENT L - Source Projections ATTACHMENT M - Operating Pro -Forma 19 TGHI - Island District Development Project Feasibility and Ability to Proceed General Marketing Plan General Marketing Plan - ATTACHMENT N Affirmative Fair Housing Marketing Plan Affirmative Fair Housing Marketing Plan - ATTACHMENT 0 Employment Generation Island District Development will house the Bahamian Arts, History, and Cultural Center. The Center will be open to the public at least 5 days per week and will attract an estimated minimum of too visitors per day in cruise season, Soo per week and generate and sustain forward after initial funding with approximately S5,000 week in visitor, admission and merchandise purchases. As well, this arts, history and cultural center will provide jobs to between to and 20 local applicants in need of employment and who have a passion for art, culture, and community. Funding will not only provide neighborhood change but it also will enhance and compliment an adjacent cultural site consisting of a historic theater which sits next door to this project and will be updated into a multi -purpose space - all helping to reimagine our impoverished community further. 20 TGHI - Island District Development Evidence of Additional Financing COMMITTEE ON EDUCATION AND LABOR CIIAraWoMAN,SUecoMNIT[Er ON HIGHER EDUCATION AND WORKIORCE INVESTMENT SUBCOMMITTEE ON EARLY CHILDHOOD, ELEMENTARY. AND SECONDARY EUUGrION COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE SuocoMMrrEE ON HIGHWAYS AND TRANSIT SuocoMMITrEE ON WATER RESOURCES AND ENVIRONMENT SUBCOMMITTEE ON EAI30000S, PIPELINES, AND 1-Aznoon0s M*Tr0Als April 13, 2022 FREDERICA S. WILSON CONGRESS OF THE UNITED STATES 24. DISTRIGr, Roan. Via email: jking@tghimiami.org Joseph King Thelma Gibson Health Initiative 3646 Grand Avenue Coconut Grove, FL 33133 Dear Mr. King: DEMOCRATIC STEERING Arm POLICY Cammlrroe REPRESENTATIVE, REGION VIII U.S. COMMISSION ON THE SOCIAL STATUS OP BLACK MEN AND Bons FOUNDER AND CHAIR CONGRESSIONAL. BLACK CAUCUS SECRETARY FLORIDA Panrs CAUCUS POUNDER AND CHAIR CAUCUS ON THE U.S. COMMISSION oN THE SOC1aa STATUS oe BLACK MEN AND BOOS FOUNDERAND CHAIR Congratulations! I am pleased to inform you that your organization will receive $2,200,000 for the Frederica Roberts Bahamian Museum of Arts and Culture from Florida District 24 Congressional Fiscal Year 2022 Community Project Funding due to the application I submitted on your behalf. Use this information as you plan and develop your budget. Additional information is listed at the end of this letter and we will share more as it becomes available. The funding will be used to create the Frederica Roberts Bahamian Museum of Arts and Culture that will serve the purpose of celebrating and recognizing the originally settled Bahamian community in Coconut Grove, Miami, and the original Afro -Bahamian culture, which is disappearing right in front of us. The creation of this center would bring about both an arts infusion and economic development engine to the community. As the Congressional representative for the 24th District of Florida, I remain committed to ensuring that Dade and Broward communities and nonprofits like yours have the necessary assistance to serve the South Florida community, maintain their organization's financial health, and support our residents and children. I recognize that these past two years have put an immense strain on local governments, organizations, and residents, including parents and children. Many entities have faced funding cuts and residents have dealt with economic hardships and illness, which is why I have fought in Congress for the necessary community funding to help all of us weather the pandemic, meet economic challenges, and restore and build new modern infrastructure for a strong America. As Chair of the Committee on Education and Labor Subcommittee on Higher Education and Workforce Investment and a senior member of the Committee on Transportation and Infrastructure, I remain committed to ensuring that local governments, organizations, and community members have the necessary support and resources to thrive. I will continue to advocate for robust investment and community project funding during these trying times and beyond. WASHINGTON, DC ORrrcE Hosorw000 MIAMI GARDENS WEST PARK 2445 RAYBURN HOB 2600 Hourwaon BOULEVARD 18925 NW 2No AVENUE, SUITE 355 WEST PARK CITY HAu W ASHINC,roN, DC 20515 Ow LIBRARY. I sr FLoor MIAMI GA4089s, FL 33169 1965 SOUTH STATE ROAD 7 (202) 225-4506 HOLLYWOOD, FL 33020 (305) 690-5905 Warr PART, FL 33023 (202) 226-0777 (04() (954) 921-3682 (305) 690-5951 (EA0) (954) 989-2688 WILSON.HOU5E.G0V I FACEROOK.COM/REPWILSON I TWITFER.COM/REPWILSON I LNSTAGRAM.COMIREPWJLSO0 Funding Letter - ATTACHMENT P Funding Email - ATTACHMENT Q 21 TGHI - Island District Development Thirty Year Operating Pro -Forma 3o Year Pro Forma - ATTACHMENT R TGHI - Island District Development Declaration of Financial Interests Declaration of Financial Interests - ATTACHMENT S Certification Regarding Debarment Suspension Certification Regarding Debarment - ATTACHMENT T Sworn Statement on Public Entity Crime Sworn Statement on Public Entity Crime - ATTACHMENT U 23 TGHI - Island District Development Section VI: Resiliency Components Resilience Checklist Resilience Checklist - ATTACHMENT V 24 TGHI - Island District Development Section VII: Technical Information Legal description of the properties: 364o Grand Ave.: FROW HOMESTEAD PB B-io6 LOT 7 LESS NioFT FOR ST BLK 26 LOT SIZE 100.00o X 131 OR 19441-0406 1200 1 3661 Thomas Ave.: FROW HOMESTEAD PB B-io6 W1/2 OF LOT 18 BLK 26 LOT SIZE 50.00o X ioo OR 20264-4463 02/2002 1 COC 26147-4870 12 20071 3649 Thomas Ave.: 21 54 41 FROW HOMESTEAD PB B-io6 E1/2 OF LOT 18 BLK 26 LOT SIZE 50.00o X ioo COC 22439-4907 05 2004 4 3643 - 3637 Thomas Ave.: FROW HOMESTEAD PB B-io6 LOT 19 BLK 26 LOT SIZE 10o X ioo OR 16881-0776 07951 25 TGHI - Island District Development Phase I Environmental Report (optional at time of application, required before funding) N/A 26 TGHI - Island District Development Insurance requirements as stipulated herein ATTACHMENT W 27 TGHI - Island District Development Section VIII: Supplemental Forms Public Entity Crime Affidavit ATTACHMENT U Authorized Representative Statement ATTACHMENT X Debarment Certification ATTACHMENT T Sound Fiscal Management Certification ATTACHMENT Y Declaration of Financial Interests ATTACHMENT S Estimate of Impact Fees ATTACHMENT Z Sources and Uses Budget ATTACHMENT K - Sources & Uses ATTACHMENT L - Sources Estimate Development Schedule ATTACHMENT J Conflict of Interest Disclosure Forms ATTACHMENT AA 28 TGHI - Island District Development Schedule of Attachments A. Deeds of Sale for IDDQOZB Properties B. Deeds of Sale IDD Properties C. - D. E. TGHI Form 990 F. Unaudited Financial Statement G. TGHI Operating Budget H. MOU - TGHI/SilverBluff I. MOU - IDD/TGHI/IDDQOZB J. Development Schedule K. Sources & Uses L. Sources Projection M. IDD Pro Forma N. - O. Affirmative Fair Housing Marketing Plan (AFHMP) P. TGHI CFP22 Funding Notification Letter Q. OCPD Commitment Email R. TGHI 3o Year Pro -Forma S. Declaration of Financial Interests T. Debarment Certification U. Public Entity Crime Affidavit V. Resilience Checklist W. Insurance requirements X. Authorized Representative Statement Y. Sound Fiscal Management Certification Z. Estimate of Impact Fees AA. Conflict of Interest Form 29 Thelma Gibson Health Initiative, Inc. ISLAND DISTRICT DEVELOPMENT QOZB WARRANTY DEEDS �3640 GRAND AVENUE v3661 THOMAS AVENUE Prepared by: Barry L. Simons, Esq. Attorney at Law Law Office of Barry L. Simons, P.A. 9100 South Dadeland Blvd. Suite 400 Miami, FL 33156 305-670-7020 File Number: 21-122 Return to: LEOPOLD KORN, P.A. 20801 BISCAYNE BLVD, SUITE 501, Aventura, FL 33180 [Space Above This Line For Recording Data) CFN: 20210946134 BOOK 32911 PAGE 561 DATE:12/17/2021 10:42:57 AM DEED DOC 10,410.00 SURTAX 7,807.50 HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY Warranty Deed This Warranty Deed made this 17th day of November, 2021 between PIERRE BLEMUR and FERNANDE BLEMUR, husband and wife whose post office address is 10940 SW 106th Ave, Miami, FL 33176, grantor, and ISLAND DISTRICT DEVELOPMENT QOZB, LLC, a Florida limited liability company whose post office address is 3162 Commodore Plaza, Suite 2C, Miami, FL 33133, grantee: (Whenever used herein the terms "grantor" and "grantee" include all the parties to this instrument and the heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations, trusts and trustees) Witnesseth, that said grantor, for and in consideration of the sum of TEN AND NO/I00 DOLLARS ($10.00) and other good and valuable considerations to said grantor in hand paid by said grantee, the receipt whereof is hereby acknowledged, has granted, bargained, and sold to the said grantee, and grantee's heirs and assigns forever, the following described land, situate, lying and being in Miami -Dade County, Florida to -wit: LOT 7 LESS THE NORTH 10 FEET, BLOCK 26, AMENDED PLAT OF THE FROW HOMESTEAD, ACCORDING TO THE PLAT THEREOF AS RECORDED IN PLAT BOOK B, PAGE 106, OF THE PUBLIC RECORDS OF MIAMI-DADE COUNTY, FLORIDA. Parcel Identification Number: 01-4121-007-4130 Subject Property a/k/a: 3640 Grand Avenue, Miami, FL 33133 Together with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever. And the grantor hereby covenants with said grantee that the grantor is lawfully seized of said land in fee simple; that the grantor has good right and lawful authority to sell and convey said land; that the grantor hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever; and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 2021. DoubleTim&n CFN: 20210946134 BOOK 32911 PAGE 562 written. In Witness Whereof, grantor has hereunto set grantor's hand and seal the day and year first above Signed ealed and delivered i our presence: s ame: Witness Nam r rrecN PIERRE BLEMUR • —uJ me: rrec/ ERN ND , BLEMUR Witness Name: CW-2, State of Florida County of Miami -Dade The foregoing instrument was acknowledged before me by means o notarization, this 17 f ? day of November, 2021 by PIERRE BL U are personally known or [X] have produced a driver's license a [Notary Seal] 1 a►%''u' .. LiSAPI AURORA MONTERREY *°! -,�.•. ¢1 Notary Pub{ic - State of Fiorfda .;.�y�; Commission : 172973 7. �"� My Comm. Expires Sep 7, 2025 3orded through National 1/44otariAssr. Notary Pu Print 1 ame: My Commission Expires: e--"17 (Seal) presence or LI online NANDE 1 EMUR, who Warranty Deed • Page 2 DoubleTime) Prepared by and return to: Barry L. Simons, Esq. Attorney at Law Law Office of Barry L. Simons, P.A. 9100 South Dadeland Blvd. Suite 400 Miami, FL 33156 305-670-7020 CFN: 20210946139 BOOK 32911 PAGE 583 DATE:12/17/2021 10:44:38 AM DEED DOC 5,250.00 SURTAX 3,937.50 HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY [Space Above This Line For Recording Data] Warranty Deed This Warranty Deed made this 8th day of December, 2021 between ISLAND DISTRICT DEVELOPMENT LLC, a Florida limited liability company, whose post office address is 3646 Grand Avenue, Coconut Grove, FL 33133, grantor, and ISLAND DISTRICT DEVELOPMENT QOZB, LLC, a Florida limited liability company whose post office address is 3162 Commodore Plaza, Suite 2C, Miami, FL 33133, grantee: (Whenever used herein the terms "grantor" and "grantee" include all the parties to this instrument and the heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations, trusts and trustees) Witnesseth, that said grantor, for and in consideration of the sum of TEN AND NO/100 DOLLARS ($10,00) and other good and valuable considerations to said grantor in hand paid by said grantee, the receipt whereof is hereby acknowledged, has granted, bargained, and sold to the said grantee, and grantee's heirs and assigns forever, the following described land, situate, Tying and being in Miami -Dade County, Florida to -wit: The West 1/2 of Lot 18, Block 26, Frow Homestead, according to the plat thereof as recorded in Plat Book B, Page 106, Public Records of Miami -Dade County, Florida. Parcel Identification Number: 01-4121-007-4230 Together with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever. And the grantor hereby covenants with said grantee that the grantor is lawfully seized of said land in fee simple; that the grantor has good right and lawful authority to sell and convey said land; that the grantor hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever; and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 2021. In Witness Whereof, grantor has hereunto set grantor's hand and seal the day and year first above written. DoubleTime CFN: 20210946139 BOOK 32911 PAGE 584 Signed, sealed and delivered in our presence: ISLAND ISTI ICT ' EVI✓LOPMENT LLC BY: Walter Joseph King, Manager State of Florida County of Miami -Dade The foregoing instrument was acknowledged before me by means of [X] physical presence or L1 online notarization, this 8th day of December, 2021 by Walter Joseph King, Manager of ISLAND DISTRICT DEVELOPMENT LLC, on behalf of the company, who [X] is personally known to me or [_] has produced a driver's license as identification. [Notary Seal] ............ BARRY L. SIMONS ,. 'i.„1 MY COMMISSION # co 348659 `�:.��•Q3 EXPIRES: August 16, 2023 Bonded fire Notary public Underwriters Notary Public Printed Nafne: My Commission Expires: Warranty Deem - Page 2 DoubleTime� City of Miami Department of Housing & Community Development CONFLICT OF INTEREST DISCLOSURE FORM Conflict of Interest Regulation U.S. HUD's Conflict of Interest provisions are set forth at 24 CFR 570.611(b) which provide in relevant part that "...no persons described in paragraph (c) of this section who exercise or have exercised any functions or responsibilities with respect to CDBG activities assisted under this part, or who are in a position to participate in a decision snaking process or gain inside information with regard to such activities, may obtain a financial interest or benefit from a CDBG-assisted activity, or have a financial interest in any contract, subcontract, or agreement with respect to a CDBG assisted activity, or with respect to the proceeds of the CDBG-assisted activity, either for themselves or those with whore they have business or immediate family ties, during their tenure or for one year thereafter.." 24 CFR 570.611 (c) describes the persons covered by the above rule as being applicable to "Persons covered. The conflict of interest provisions of paragraph (b) of this section apply to any person who is an employee, agent, consultant, officer or elected official or appointed official of the recipient, or any designated public agencies, or of subrecipients that are receiving funds under this part." The purpose of this document is to assist in the determination of whether additional restrictions, oversight, or other conditions might be advisable prior to execution of any contract, finding or providing assistance. The term "Conflict of Interest" refers to situations in which financial or other personal considerations may compromise or have the appearance of compromising professional judgment in following the rules and regulation of the program. Please mark the appropriate box for each question and complete the attachment if indicated. This form (with Attachment, if required) must be completed and returned to your Contract Compliance Analyst. Agency Name:,, eWA_rii 6301^ I hr J{ Funding Source: 4-1 o Address: 1flb (>� 0 AveliUC Contract Amount: if, S`,4%%I110i City, State, Zip: JV (6114 I - ' 3 (.) 3 Project #: 11)D A. Family Relationships: Does any employee, board member or person (as described above) in your agency have a family member directly or indirectly involved or employed with the Department of Housing & Community Development and/or City of Miami that creates a conflict of interest or the appearance of a conflict under the Conflict of Interest Regulation? ❑YES 1)10 (if YES, please complete Part A of the Attachment) B. Program Relationships: Does any employee, board member and/or person (as described above) in your agency serve or is appointed in a Department of Housing & Community Development and/or City of Miami Board/Committee that may create a conflict of interest or the appearance of a conflict under the Conflict of Interest Regulation? ❑YES YNO (if YES, please complete Part B of the Attachment) Does an employee of the Department Housing & Community Development and/or City of Miami serve in the agency's Board of Directors, which may create a conflict of interest or the appearance of a conflict under the Conflict of Interest Regulation? DYES (if YES, please complete Part B of the Attachment) Does any elected official of the City of Miami serve on your agency's Board of Directors, which may create a conflict of interest or the appearance of a conflict under the Conflict of Interest Regulation? EYES 10 (if YES, please complete Part B of the Attachment) Is any employee, board member and/or person (as described above) in your agency involved in any other activity, directly or indirectly, with the Department of Housing & Community Development and/or City of Miami that may create a conflict of interest or the appearance of a conflict under the Conflict of Interest Regulation? EYES NO (if YES, please complete Part B of the Attachment) C. Business Relationships: Is any employee, board member or person in your agency or a family member (spouse, child, stepchild, parent, sibling, or domestic partner) involved as an investor, owner, employee, consultant, contractor, or board member with an entity that has a contractual relationship with the Department of Housing & Community Development and/or City of Miami to provide goods or services, sponsor development activities and/or receive referrals from the Department of Housing & Community Development and/or City Of Miami? DYES NO (if YES, please complete Part C of the Attachment) I have read and understand the Conflict of Interest Disclosure Form. I have disclosed all information required by this disclosure, if any, in an attached statement. I agree to comply with any conditions or restrictions imposed by the Department of Housing & Community Development and/or City of Miami to reduce or eliminate actual and/or potential conflicts of interest. I will update this disclosure form promptly if relevant circumstances change. I understand that this Disclosure is not a confidential document. If U.S. HUD determines that a conflict of interest e.vi.sts. this contract may be terminated and you may be required to return any and all funding allocated, whether used or not used. Print Name: a� �il9 Date: O`(i Signature: Date: GVI / 1)1 /2L CONFLICT OF INTEREST DISCLOSURE FORM ATTACHMENT Agency Name: '1d `'M ijS3is lU 4 } + IJFunding Source: nF/1/ Address: `Jl9 `v { 3y 0 ` e-Contract Amount: 4q. i f✓►) I bO City, State, Zip Mini, it 3g Project#: f �1i1 If you answered YES to any question on the previous page, please complete the relevant section(s) below. If you answered NO to all questions, you may discard this attachment. Give your complete form to your Program Representative. PART A: FAMILY RELATIONSHIPS 1. Name of the family member (s) directly or indirectly involved or employed at Department of Housing & Communit Development and/or City of Miami: 2. Do any of the family mem.ers work in the program area? 3. Are any of the family membe s elected officials of the City of Miami? 4. Relationship: Department: Position: Supervisor: PART B: OGRAM RELATIONSHIPS 1. Other Activities: Name and describe the ac vity and/or program that you are directly or indirectly involved with: 2. Have you used the agencies' name, resources (facili 'es, personnel, or equipment), or confidential information in connection with the activity and/or pro am described in #1 ? oYES LINO if YES, describe the resource used: 3. Name of the employee, board member or person (as described . bove) serving or appointed to serve in a Department of Housing & Community Development a d/or City of Miami Committee or Board: 4. Name of Board: 5. Name of the Department of Housing & Community Development and/or City of Miami Committee employee or City official who serves on your agency's Board of Directors. Name: Position: Department: Supervisor: PART C: BUSINESS RELATIONSHIPS Please complete this sectio 1 for each business relationship, or attach a separate explanation of business and research activi es. l . Name of business: 2. Categorize the business' relatio hip with the Department of Housing & Community Development and/or City of Miami. ❑ Consultant or advisor u Research activities ❑ Business or referrals o Other contractual or busines relationship Briefly, describe the business, or licensin activity: 3. Who is involved with the business? Check all t at apply: ❑ Employee (Name) ❑ Family member (name and relationshi Describe the position or involvement (check 11 that apply): o Owner/Investor o Board Member o Employee/Manager ❑ Other 4. Are you receiving any type of compensation? ❑No ❑Yes If yes, describe: 5. Who at the Department of Housing & Community Development and/or City of Miami oversees the relationship with this business? Name: Title: Department-. Phone: Print Name: Executive Direct Signature: Date: Date: CITY OF MIAMI CONFLICT OF INTEREST Section 2-612. Transacting business with the city; appearances before city boards; post -employment restrictions; participation in the award of certain contracts under the procurement ordinance; penalties, etc. d) The director of the department and/or his designee and/or members of the selection committee who are city employees recommending a contract award of not less than $500,000.00, shall be restricted for a two- year period, after the director and/or his designee and/or the member has left city service or terminated city employment, from receiving compensation or employment from any contractual party when the director/or his designee and/or the member participated in the award of the contract subject to the procurement ordinance of the city, including without limitation waivers, with the following conditions and definitions: 1. The word "member" as used in this section shall include all city employees who are members of the selection committee which has recommended a contract award; 2. The word "director" shall mean the director, or his/her designee, of any city department, division, authority, board, of office recommending a contract award, and with respect to the boards referenced in section 18-72, the executive director of such board, or his/her designee, providing, however, that his section shall not apply to the community redevelopment agency; 3. The word "director" shall exclude the city manager and the chief procurement officer as defined in section 18-73; 4. This section shall not preclude the member or director, or his/her designee, from working for the contractual party on an entirely unrelated contract. The phrase "contractual party" is defined in section 18-73. The employment or contractual relationship cannot relate directly to the contract that was recommended by the selection committee in which the member participated and/or that was recommended by the director or his/her designee. e) Penalties. A violation of this ordinance may be punished by imposition of the maximum fine and/or penalties allowed by law. Additionally, violations may be considered by and subject to action by the Miami - Dade County Commission on Ethics. 1 have read and understand the conflict of interest section above, and it does not apply to the Applicant's principals and/or consultants, sub -consultants, contractors or subcontractors : Print name: Signature: Thelma Gibson Health Initiative, Inc. TGHI ISLAND DISTRICT DEVELOPMENT LLC WARRANTY DEEDS �3643 THOMAS AVENUE v3649 THOMAS AVENUE CFN: 20190314674 BOOK 31450 PAGE 2770 DATE:05/21 /2019 09:48:57 AM DEED DOC 3,360.00 SURTAX 2,520.00 HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY Prepared by and return to: Barry L. Simons, Esq. Attorney at Law Law Office of Barry L. Simons, P.A. 9100 South Dadeland Blvd. Suite 400 Miami, FL 33156 305-670-7020 File Number: 19-030 {Space Above This Line For Recording Data] Warranty Deed This Warranty Deed made this day of May, 2019 between Reimagine 3643 Thomas LLC, a Florida limited liability company whose post office address is 3936 Main Highway, Coconut Grove, FL 33133, grantor, and ISLAND DISTRICT DEVELOPMENT, LLC, a Florida limited liability company whose post office address is 3634 Grand Avenue, Coconut Grove, FL 33133, grantee: (Whenever used herein the terms "grantor" and "grantee" include all the parties to this instrument and the heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations, trusts and trustees) Witnesseth, that said grantor, for and in consideration of the sum of TEN AND NO/100 DOLLARS ($10.00) and other good and valuable considerations to said grantor in hand paid by said grantee, the receipt whereof is hereby acknowledged, has granted, bargained, and sold to the said grantee, and grantee's heirs and assigns forever, the following described land, situate, lying and being in Miami -Dade County, Florida to -wit: Lot 19, Block 26, Frow Homestead, according to the map or plat thereof as recorded in Plat Book B, Page 106, Public Records of Miami -Dade County, Florida. Parcel Identification Number: 01-4121007-4250 Subject Property Address: 3635, 3637& 3643 Thomas Ave, Miami, FL 33133-5709 Together with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever. And the grantor hereby covenants with said grantee that the grantor is lawfully seized of said land in fee simple; that the grantor has good right and lawful authority to sell and convey said land; that the grantor hereby fully warrants the title to said land and will defend the same against the lawful clairns of all persons whomsoever; and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 2018. DoubleTime® CFN: 20190314674 BOOK 31450 PAGE 2771 In Witness Whereof, grantor has hereunto set grantor's hand and seal the day and year first above written. Signed, sealed and delivered in our presence: Reimagine 3643 Tho : s LLC, a Florida limited Iiabi, company By: State of Florida County of Miami -Dade MARCELO `+ ' DES, Manager The foregoing instrument was acknowledged before me this P- day of May, 2019 by MARCELO FERNANDES, Manager of Reimagine 3643 Thomas LLC, a Florida limited liability company, on ' . of the limited liability company. He [] is personally known to me or [X] has produced a driver's license as identific [Notary Seal] DAARYL $I MONK MYCOMMISSION 0FF90E638 EXPIRES: August 16,2019 Banded Th,v Notary PabEs Underwrka Notary Public Printed Name My Commission Expires: Warranty Deed - Page 2 DoubleTIm0 Prepared by and return to: Lisppi A. Monterrey Legal Assistant Law Office of Barry L. Simons, P.A. 9100 South Dadeland Blvd. Suite 400 Miami, FL 33156 305-670-7020 File Number: 19-031 CFN: 20190314670 BOOK 31450 PAGE 2753 DATE:05/2112019 09:48:36 AM DEED DOC 1,800.00 SURTAX 1,350.00 HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY (Space Above This Line For Recording Data] Warranty Deed This Warranty Deed made this (sift -day of May, 2019 between Reimagine 3649 Thomas LLC, a Florida limited liability company whose post office address is 3936 Main Highway, Coconut Grove, FL 33133, grantor, and ISLAND DISTRICT DEVELOPMENT, LLC, a Florida limited liability company whose post office address is 3634 Grand Avenue, Coconut Grove, FL 33133, grantee: (Whenever used herein the terms 'grantor" and "grantee" include all the parties to this instrument and the heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations, trusts and trustees) Witnesseth, that said grantor, for and in consideration of the sum of TEN AND NO/100 DOLLARS ($10.00) and other good and valuable considerations to said grantor in hand paid by said grantee, the receipt whereof is hereby acknowledged, has granted, bargained, and sold to the said grantee, and grantee's heirs and assigns forever, the following described land, situate, lying and being in Miami -Dade County, Florida to -wit: The East half of Lot 18, Block 26, Amended Plat of the Frow Homestead, according to the plat thereof as recorded in Plat Book B, Page 106, Public Records of Miami -Dade County, Florida. Parcel Identification Number: 01-4121-007-4240 Subject Property Address: 3649 Thomas Avenue, Miami, FL 33133 Together with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever. And the grantor hereby covenants with said grantee that the grantor is lawfully seized of said land in fee simple; that the grantor has good right and lawful authority to sell and convey said land; that the grantor hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever; and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 2018. DoubloTim0 CFN: 20190314670 BOOK 31450 PAGE 2754 In Witness Whereof, grantor has hereunto set grantor's hand and seal the day and year first above written. Signed, sealed and delivered in our presence: State of Florida County of Miami -Dade The foregoing instrument Manager of REIMAG company. He [Notary Seal] RE[MAGINE 3649 THOMAS LLC, a Florida limited liability company By: O . ERNANDES, Manager was acknowledged before me this ' day of May, 2019 by MARCELO FERNANDES, 49 THOMAS LLC, a Florida limited liability company, on behalf of the limited liability wn to me or [X] has produced a driver's license as identjication. BARRY L SIM N S MY CO). SSION 9 FF 906538 EXPIRES: August 16, 2019 Bonded Thai t ia+Y Pubrc UMafwiie's Notary Public Printed Name: My Commission Expires: Warranty Deed - Page 2 DoubleTfine ' 990EF EF Transmission Status (Keep for your records) 2020 Name(s) as shown on retum THELMA GIBSON HEALTH INITIATIVE INC EIN number 45-2835389 The following will be transmitted to the IRS. n 990 ❑ 990-T ❑ Amended 990 ❑ 8868 ❑ 4720 ■ FinCEN 114 ❑ Amended 990-T The following state retums will be transmitted: The following retums have been suppressed or are not eligible and will NOT be transmitted. EF Notes 990EF.L0 Form 990 (2020) THELMA GIBSON HEALTH INITIATIVE INC 95-2835389 Page 2 Part III Statement of Program Service Accomplishments Check if Schedule 0 contains a response or note to any line in this Part III ❑ 1 Briefly describe the organization's mission: THE ORGANIZATION WAS FORMED TO PROVIDE AND BUILD HEALTHY MINDS AND BODIES THROUGH QUALITY SOCIAL SERVICES TO UNDERSERVED GROUPS IN COCONUT GROVE, SOUTH MIAMI AND AJOINING CORAL GABLES. 2 Did the organization undertake any significant program services during the year which were not listed on the prior Form 990 or 990-EZ? ❑ Yes ®No If "Yes," describe these new services on Schedule O. 3 Did the organization cease conducting, or make significant changes in how it conducts, any program services? ❑ Yes ® No If "Yes," describe these changes on Schedule O. 4 Describe the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others. the total expenses, and revenue, if any, for each program service reported. 4a (Code: ) (Expenses $ 785 , 921 including grants of $ ) (Revenue $ BUILDING HEALTHY MINDS AND BODIES THROUGH PROVIDING QUALITY SOCIAL SERVICES TO UNDERSERVED GROUPS. 4b (Code: ) (Expenses $ including grants of $ ) (Revenue $ 4c (Code: ) (Expenses $ including grants of $ ) (Revenue $ 4d Other program services (Describe on Schedule O.) (Expenses $ including grants of $ ) (Revenue $ ) 4e Total program service expenses ► 785,421 EEA Form 990 (2020) Form 990 (2020) THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 Page 3 Part IV 1 Checklist of Required Schedules 1 Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule A 2 Is the organization required to complete Schedule B, Schedule of Contributors See instructions' 3 Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part I 4 Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part 11 5 Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C, Part 111 6 Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part 1 7 Did the organization receive or hold a conservation easement, including easements to preserve open space, the environment, historic land areas, or historic structures? If "Yes,'' complete Schedule D, Part I1 8 Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part 111 9 Did the organization report an amount in Part X, line 21, for escrow or custodial account liability, serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? if "Yes," complete Schedule D, Part IV 10 Did the organization, directly or through a related organization, hold assets in donor -restricted endowments or in quasi endowments? If "Yes," complete Schedule D, Part V 11 If the organization's answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable. a Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes," complete Schedule D, Part VI b Did the organization report an amount for investments of its total assets reported in Part X, line 16? If "Yes," c Did the organization report an amount for investments - other securities in Part X, line 12, that is 5% or more complete Schedule D, Part VII - program related in Part X, line 13, that is 5% or more of its total assets reported in Part X, line 16? If "Yes," d Did the organization report an amount for other assets complete Schedule D, Part VIII in Part X, line 15, that is 5% or more of its total assets reported in Part X, line 16? If "Yes, " complete Schedule D, Part IX e Did the organization report an amount for other liabilities in Part X, line 25? If "Yes,"complete Schedule D, PartX f Did the organization's separate or consolidated financial statements for the tax year include a footnote that addresses the organization's liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes,'' complete Schedule D, PartX 12a Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes, " complete Schedule D, Parts XI and XII b Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional 13 Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes,"complete Schedule E 14a Did the organization maintain an office, employees, or agents outside of the United States? b Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts 1 and IV 15 Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If "Yes," complete Schedule F, Parts II and IV 16 Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If "Yes,' complete Schedule F, Parts 111 and IV 17 Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I See instructions 18 Did the organization report more than 515,000 total of fundraising event gross income and contributions on Part VIII, lines lc and 8a? If "Yes,'' complete Schedule G, Part 11 19 Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes, " complete Schedule G, Part 111 20 a Did the organization operate one or more hospital facilities? If "Yes,' complete Schedule H b If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? 21 Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? 1f "Yes," complete Schedule I, Parts 1 and 1! . Yes No 1 2 3 4 X 5 6 7 8 9 10 11a x lib 11c X 11d 11e 11f 12a X 12b 13 14a x X X 14b 15 16 17 18 19 20a 20b 21 X Form 990 (2020) EEA 37 38 Part Form 990 (2020) THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 Part IV Checklist of Required Schedules (continued) 22 Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If "Yes," complete Schedule !, Parts 1 and 111 23 Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization's current and former officers, directors, trustees, key employees, and highest compensated employees? If 'Yes," complete Schedule J 24a Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If "Yes, "answer lines 24b through 24d and complete Schedule K. If "No," go to line 25a b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? c Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt bonds? d Did the organization act as an "on behalf of issuer for bonds outstanding at any time during the year? 25a Section 501(c)(3), 501(c)(4), and 501(c){29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? if "Yes," complete Schedule L, Part/ b Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization's prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part / 26 Did the organization report any amount on Part X, line 5 or 22, for receivables from or payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member or any of these persons? If ''Yes," complete Schedule L, Partll 27 Did the organization provide a grant or other assistance to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity (including an employee thereof) or family member of any of these persons? if "Yes,"complete Schedule L, Part III 28 Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions, for applicable filing thresholds, conditions, and exceptions): a A current or former officer, director, trustee, key employee, creator or founder, or substantial contributor? If "Yes, " complete Schedule L, Part IV b A family member of any individual described in line 28a? If "Yes," complete Schedule L, Part IV c A 35% controlled entity of one or more individuals and/or organizations described in lines 28a or 28b? If "Yes," complete Schedule L, Part IV 29 Did the organization receive more than $25,000 in non -cash contributions? If "Yes," complete Schedule M 30 Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M 31 Did the organization liquidate, terminate, or dissolve and cease operations? if "Yes," complete Schedule N, Part 32 Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part 11 33 Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I 34 Was the organization related to any tax-exempt or taxable entity? 1f "Yes," complete Schedule R, Part ll, Ill, or 1V, and Part V, line 1 35a Did the organization have a controlled entity within the meaning of section 512(b)(13)" b If "Yes" to fine 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 36 Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non -charitable related organization?If "Yes," complete Schedule R, Part V, line 2 Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes,"complete Schedule R, Part VI Did the organization complete Schedule 0 and provide explanations in Schedule 0 for Part VI, lines 11b and 19? Note: All Form 990 filers are required to complete Schedule 0, V Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule 0 contains a response or note to any line in this Part V 1 a Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable la 5 b Enter the number of Form W-2G included in line la. Enter -0- if not applicable c Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? lb 0 Yes 22 23 24a 24b 24c 24d 25a 25b 26 Page 4 No X X X X X X 27 x 28a 28b 28c 29 30 31 x 32 x 33 34 x 35a 35b 36 37 38 Yes No lc EEA Form 990 (2020) Form 990 (2020) THELMA GIBSON HEALTH INITIATIVE INC Part V Statements Regarding Other IRS Filings and Tax Compliance (continued) 45-2835389 Page 5 2a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements, filed for the calendar year ending with or within the year covered by this return b 2a 0 Yes No If at least one is reported on line 2a, did the organization file all required federal employment tax returns? Note: If the sum of lines la and 2a is greater than 250, you may be required to e-fife (see instructions). 3a Did the organization have unrelated business gross income of $1,000 or more during the year? b If "Yes," has it filed a Form 990-T for this year? If "No" to line 3b, provide an explanation on Schedule 0 4a At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign county (such as a bank account, securities account, or other financial account)? b If "Yes," enter the name of the foreign country ► See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR). 5a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction? c If "Yes" to line 5a or 5b, did the organization file Form 8886-T? 6a Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? b if "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? 7 Organizations that may receive deductible contributions under section 170(c). a Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor7 b If "Yes," did the organization notify the donor of the value of the goods or services provided? c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? d If "Yes," indicate the number of Forms 8282 filed during the year e Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? f Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? 7d g If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? h If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? 8 Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? 9 Sponsoring organizations maintaining donor advised funds. a Did the sponsoring organization make any taxable distributions under section 4966? b Did the sponsoring organization make a distribution to a donor, donor advisor, or related person? 10 Section 501(c)(7) organizations. Enter: a Initiation fees and capital contributions included on Part VIII, line 12 FlOa b Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities 10b 11 Section 501(c)(12) organizations. Enter: a Gross income from members or shareholders 11a b Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them ) 12a Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041? b If "Yes," enter the amount of tax-exempt interest received or accrued during the year 12b 13 Section 501(c)(29) qualified nonprofit health insurance issuers. a Is the organization licensed to issue qualified health plans in more than one state? Note: See the instructions for additional information the organization must report on Schedule O. b Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans 13b c Enter the amount of reserves on hand 14a Did the organization receive any payments for indoor tanning services during the tax year? lib 13c b If "Yes," has it filed a Form 720 to report these payments? If "No, " provide an explanation on Schedule 0 15 Is the organization subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or excess parachute payment(s) during the year? If "Yes," see instructions and file Form 4720, Schedule N. 16 Is the organization an educational institution subject to the section 4968 excise tax on net investment income's If "Yes," complete Form 4720, Schedule O. 2b 3a 3b 4a 5a 5b X 5c 6a 6b 7a 7b 7c 7e 7f 7g 7h 8 9a 9b 12a 13a 14a 14b 15 16 EEA Form 990 (2020) Form 990 (2020) THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 Governance, Management, and Disclosure For each 'Yes" response to lines 2 through 7b below, and for a "No" response to line 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule 0. See instructions. Check if Schedule 0 contains a response or nole to any line in this Part VI Section A. Governing Body and Management Part VI la Enter the number of voting members of the governing body at the end of the tax year la 6 If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain on Schedule O. b Enter the number of voting members included in line 1 a, above, who are independent 2 Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? 3 Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors, or trustees, or key employees to a management company or other person 4 Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? 5 Did the organization become aware during the year of a significant diversion of the organization's assets? 6 Did the organization have members or stockholders? 7a Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? b Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following: a The governing body? b Each committee with authority to act on behalf of the governing body? 9 Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization's mailing address? If "Yes,"provide the names and addresses on Schedule 0 1b Section B. Policies (This Section 8 requests information about policies not required by the Internal Revenue Code.) 6 10a Did the organization have local chapters, branches, or affiliates? b It "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? 11a Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? b Describe in Schedule 0 the process, if any, used by the organization to review this Form 990. 12a Did the organization have a written conflict of interest policy? If "No,'' go to line 13 b Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? . c Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule 0 how this was done 13 Did the organization have a written whislleblower policy? 14 Did the organization have a written document retention and destruction policy'? 15 Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision'? a The organization's CEO, Executive Director, or top management official b Other officers or key employees of the organization If "Yes" to line 15a or 15b, describe the process in Schedule 0 (see instructions). 16a Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? b If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization's exempt status with respect to such arrangements? Section C. Disclosure Yes Page 6 No 2 3 4 5 6 7a 7b 8a 8b 9 Yes 10a X X X X x X X X x X No X 10b lia 12a 12b 12c 13 14 15a 15b x 16a 16b 17 List the states with which a copy of this Form 990 is required to be filed 18 Section 6104 requires an organization to make its Forms 1023 (1024 or 1024-A if applicable), 990, and 990-T (Section 501(c) (3)s only) available for public inspection. Indicate how you made these available. Check all that apply. ❑ Own website ❑ Another's website Q Upon request ❑ Other (explain on Schedule 0) 19 Describe on Schedule 0 whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year. 20 State the name, address, and telephone number of the person who possesses the organization's books and records THELMA GIBSON HEALTH INITIATIVE INC (305)446--1543, 3646 GRAND AVENUE, Miami, FL 33133 EEA Form 990 (2020) Form 990 (2020) THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 Page 7 Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Check if Schedule 0 contains a response or note to any line in this Part VII Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees la Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization's tax year. • List all of the organization's current officers, directors, trustees (whether individuals or organizations), regardless of amount of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid. • List all of the organization's current key employees, if any. See instructions for definition of "key employee." • List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations. • List all of the organization's former officers, key employees, and highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations. • List all of the organization's former directors or trustees that received, in the capacity as a former director or trustee of the organization, more than $10,000 of reportable compensation from the organization and any related organizations. See instructions for the order in which to list the persons above. Part VII ® Check this box if neither the organization nor any related organization compensat (A) Name and title (E) Average hours per week (list any hours for related organizations below dotted line) (c) Position (do not check more Than one box, unless person is both an officer and a director/trustee) (D) Reportable compensation From the organization (W-2I1099-MISC) (E) Reportable compensation from related organizations (W-211099-MISC) (F) Estimated amount of other compensation from the organization and related organizations IndIvieual 'trustee or director msnmuonai trustee C 6 m , 3 ,o m nIgnesz compensated employee _ o m (1) DAMIAN THOMAS DIRECTOR 2.00 X 0 0 0 (2) WILLIAM LORD DIRECTOR 2.00 X 0 0 0 (3) JOHN GELETY DIRECTOR 2.00 X 0 0 0 (4) LAIR HALL BOARD CHAIRMAN 2.00 X 0 0 0 (5) GORDON FALES FIRST VICE CHAIRMAN 2.00 X 0 0 0 (6) FREDDIE YOUNG SECOND VICE CHAIR 2.00 X 0 0 0 (7) MERLINE BARTON EXECUTIVE DIRECTOR 40.00 X 0 0 0 (8) (9) (10) (11) (12) (13) (14) EEA Form 990 (2020) Form 990 (2020) THELMA GISSON HEALTH INITIATIVE INC 45-2835389 Part VII Page 8 Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued (A) Name and title (5) Average hours per week (list any hours for related organizations below dotted line) (C) Position not check more than one box, unless person is both an officer and a director/trustee) (n) Reportable compensation from the organization (W-211099-MISC) (E) Reportable compensation from related organizations (W-211099-MISC) ( } (F) Estimated amount of other compensation from the organization and related organizations o 5_ o a < o E. g " m 0 +nsututionai trustee x — - m m 5 o highest compensated employee o ``L° (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) 1 b Subtotal ► c Total from continuation sheets to Part VII, Section A ► d Total (add lines 1b and lc) P. 0 0 0 2 Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization ► 3 Did the organization list any former officer, director, trustee, key employee, or highest compensated employee on line 1 a? If "Yes, " complete Schedule J for such individual 4 For any individual listed on line la, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such individual 5 Did any person listed on line la receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person Section B. Independent Contractors 1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax year. Yes 0 No 3 4 5 X (A) Name and business address (e) Description of services (C) Compensation 2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization ► EEA Form 990 (2020) Form 990 (2020) THELMA GIBSON HEALTH INITIATIVE INC Statement of Revenue Check if Schedule 0 contains a response or note to any line in this Part VIII Part VIII 45-2835389 Page 9 (A) Total revenue (B) Related or exempt function revenue (C) Unrelated business revenue (b) Revenue excluded from tax under sections 512-514 la Federated campaigns la 806, 243 y b Membership dues lb c c c Fundraising events lc c? E d Related organizations 1d a e Government grants (contributions) . . le o of"E `oN _ f All other contributions, gifts, grants, and similar amounts not included above lf 806,243 acu w ',0 o g g Noncash contributions included in lines la-1( lg $ 10 h Total. Add lines is-1f ► Program Service Revenue Business Code 2a b c d e f All other program service revenue g Total. Add lines 2a-2f ► Other Revenue 3 Investment income (including dividends, interest, and other similar amounts) 4 Income from investment of tax-exempt bond proceeds 5 Royalties N. . . . ► ► (i) Real (ii) Personal 6a Gross rents 6a b Less: rental expenses . . 6b c Rental income or (loss) 6c d Net rental income or (loss) ► 7a Gross amount from (i) securities flit other sales of assets other than inventory 7a b Less: cost or other basis and sales expenses . 7b c Gain or (loss) 7c d Net gain or (loss) ► 8a Gross income from fundraising events (not including $ of contributions reported on line 1 c). See Part IV, Ilne 18 8a b Less: direct expenses 8b c Net income or (loss) from fundraising events ► 9a Gross income from gaming activities, See Part IV, line 19 9a b Less: direct expenses 9b c Net income or (loss) from gaming activities ► 10a Gross sales of inventory, less returns and allowances 10a b Less: cost of goods sold 10b c Net income or (loss) from sales of inventory Pi - Business Code in 3 11a c= b IC = v y c gIY d At other revenue e Total. Add lines 11a-11d ► 12 Total revenue. See instructions ► 806,243 0 0 0 EEA Form 990 (2020) Form 990 (2020) THELMA GIBSON HEALTH INITIATIVE INC Part IX Statement of Functional Expenses 45-2835389 Page10 Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A). Check if Schedule 0 contains a response or note to any line in this Part IX Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 1Ob of Part Vlll. (A) Total expenses (B) Program service expenses (c) Management and general expenses (D) Fundraising expenses 1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 . . . 2 Grants and other assistance to domestic individuals. See Part IV, line 22 3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16 . . . 4 Benefits paid to or for members 5 Compensation of current officers, directors, trustees, and key employees 6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) 7 Other salaries and wages 8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) . 9 Other employee benefits 10 Payroll taxes 11 Fees for services (nonemployees): a Management b Legal c Accounting d Lobbying e Professional fundraising services. See Part IV, line 17 f Investment management fees g Other. (If line 11g amount exceeds 10% of line 25, column (A) amount, list line llg expenses on Schedule O.) . 12 Advertising and promotion 13 Office expenses 14 Information technology 15 Royalties 16 Occupancy 17 Travel 18 Payments of travel or entertainment expenses for any federal, state, or local public officials 19 Conferences, conventions, and meetings 20 Interest 21 Payments to affiliates 22 Depreciation, depletion, and amortization 23 Insurance 24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses on line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.) a UTILITIES 400,117 378,894 21,223 30,724 28, 977 1,747 160, 033 145,800 14 ,233 7 , 608 7,119 489 14,400 12,884 1,516 85,500 85,500 64 , 278 64 ,278 15, 673 15, 673 11,080 10,925 155 b MEMBER FEES 925 920 5 c CLIENT ASSISTANCE 14,029 14,029 d PROGRAM ACTIVITIES AND SUPPL 5,875 5,875 e All other expenses 14,564 14 ,547 17 25 Total functional expenses. Add lines 1 through 24e. . 824, 806 785,921 39,385 0 26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here to. ❑ if following SOP 98-2 (ASC 958-720) EEA Form 990 (2020) Form 990 (2020) THELMA GIBSON HEALTH INITIATIVE INC Balance Sheet Check if Schedule 0 contains a response or note to any line in this Part X Part X 45-2835389 Pageii (A) Beginning of year (B) End of year Assets 1 Cash - non -interest -bearing 2 Savings and temporary cash investments 3 Pledges and grants receivable, net 4 Accounts receivable, net 5 Loans and other receivables from any current or former trustee, key employee, creator or founder, substantial contributor, controlled entity or family member of any of these persons 6 Loans and other receivables from other disqualified persons under section 4958(f)(1)), and persons described in section 7 Notes and loans receivable, net 8 Inventories for sale or use 9 Prepaid expenses and deferred charges 10a Land, buildings, and equipment cost or other basis. Complete Part Vi of Schedule D b Less: accumulated depreciation 11 Investments - publicly traded securities 12 Investments - other securities. See Part IV, line 11 13 Investments - program -related. See Part IV, line 11 14 intangible assets 15 Other assets. See Part IV, line 11 16 Total assets. Add fines 1 through 15 (must equal line 33) officer, (as 4958(c)(3)(B) 10a director, or 35% defined 2 , 292 , 783 48 , 385 1 46, 610 2 29,186 3 90 ,2 65 4 5 6 7 8 9 2,259,669 10c 2,202,695 10b 90,088 11 12 13 14 32,060 15 46 , 933 2,369,300 16 2,386,503 Liabilities 17 Accounts payable and accrued expenses 18 Grants payable 19 Deferred revenue 20 Tax-exempt bond liabilities 21 Escrow or custodial account liability. Complete Part IV of Schedule D 22 Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons 23 Secured mortgages and notes payable to unrelated third parties 24 Unsecured notes and loans payable to unrelated third parties 25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D 26 Total liabilities. Add lines 17 through 25 10,923 17 7, 948 18 19 20 21 22 1,728,382 23 1,786,204 24 , 787 24 25 1,764,092 26 1,794,152 Net Assets or Fund Balances Organizations that follow FASB ASC 958, check here ► and complete lines 27, 28, 32, and 33. 27 Net assets without donor restrictions 28 Net assets with donor restrictions Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33. 29 Capital stock or trust principal, or current funds 30 Paid -in or capital surplus, or land, building, or equipment fund 31 Retained earnings, endowment, accumulated income, or other 32 Total net assets or fund balances 33 Total liabilities and net assets/fund balances a 605,208 27 592,351 ► ❑ funds 28 29 30 31 605,208 32 592,351 2,369,300 33 2,386,503 EEA Form 990 (2020) Form 990 (2020) THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 PartXI Reconciliation of Net Assets Check if Schedule 0 contains a response or note to any line in this Part XI 1 Total revenue (must equal Part VIII, column (A), line 12) 2 Total expenses (must equal Part IX, column (A), line 25) 3 Revenue less expenses. Subtract line 2 from line 1 4 Net assets or fund balances at beginning of year (must equal Part X, line 32, column (A)) 5 Net unrealized gains (losses) on investments 6 Donated services and use of facilities 7 Investment expenses 8 Prior period adjustrnents 9 Other changes in net assets or fund balances (explain on Schedule 0) 10 Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 32, column (B)) 1 2 3 4 Page 12 806,243 824,806 (18,563) 605,208 5 6 7 8 9 10 5,706 0 592,351 No Part XII Financial Statements and Reporting Check if Schedule 0 contains a response or note to any Ilne in this Part XII 1 Accounting method used to prepare the Form 990: ❑ Cash ❑X Accrual ❑ Other If the organization changed its method of accounting from a prior year or checked "Other," explain in Schedule 0. 2a Were the organization's financial statements compiled or reviewed by an independent accountant? If "Yes," check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both: ❑ Separate basis ❑ Consolidated basis ❑ Both consolidated and separate basis b Were the organization's financial statements audited by an independent accountant? If "Yes," check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated bass, or both: X❑ Separate basis ❑ Consolidated basis ❑ Both consolidated and separate basis c If "Yes" to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain on Schedule O. 3a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? b If "Yes;' did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why on Schedule 0 and describe any steps taken to undergo such audits Yes 2a 2b 2c 3a 3b EEA Form 990 (2020) SCHEDULE A (Form 990 or 990-EZ) Department of the Treasury Internal Revenue Service Public Charity Status and Public Support Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable tru Attach to Form 990 or Form 990-EZ. ► Go to www.irs.gov/Form990 for instructions and the latest information. OMB No. 1545-0047 2020 Open to Public Inspection Name of the organization Employer fdentificatIon number THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 Part I Reason for Public Charity Status. (All organizations must complete this part.) See instructions. The organization is not a private foundation because it is: (For lines 1 through 12, check only one box.) 1 ❑ A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i). 2 ❑ A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ).) 3 ❑ A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii). 4 ❑ A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state: 5 ❑ An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part I1.) 6 ❑ A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v). 7 X❑ An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part 11.) 8 ❑ A community trust described in section 170(b)(1)(A)(vi). (Complete Part 11.) 9 ❑ An agricultural research organization described in section 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non -land-grant college of agriculture (see instructions). Enter the name, city, and state of the college or university: 10 ❑ An organization that normally receives: (1) more than 33 1/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions - subject to certain exceptions; and (2) no more than 33 1/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.) 11 ❑ An organization organized and operated exclusively to test for public safety. See section 509(a)(4). 12 ❑ An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g. a ❑ Type 1. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B. b ❑ Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or managernent of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C. c ❑ Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E. d ❑ Type III non -functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V. e ❑ Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non -functionally integrated supporting organization. Enter the number of supported organizations f 9 Provide the following information about the supported organization(s). (i) Name of supported organization (li) SIN (iii) Type of organization (described on lines 1-10 above (see instructions)) (iv) Is the organization listed in your governing document? (v) Amount of monetary support (see instructions) Ivi) Amount of other support (see instructions) Yes No (A) (B) (C) (D) (E) Total For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990•EZ, EEA Schedule A (Form 990 or 990-EZ) 2020 Schedule A (Form 990 or 990-EZ) 2020 THELMA GIBSON HEALTH INITIATIVE INC 45-2935399 Page 2 Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part Ill. If the organization fails to qualify under the tests listed below, please complete Part III.) Section A. Public Support Calendar year (or fiscal year beginning in)► 1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") 2 Tax revenues levied for the organization's benefit and either paid to Part ll or expended on its behalf 3 The value of services or facilities furnished by a governmental unit to the organization without charge 4 Total. Add lines 1 through 3 5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f) 6 Public support. Subtract line 5 from line 4 Section B. Total Support (a) 2016 (b) 2017 (c) 2018 (d) 2019 (e) 2020 (f) Total 151,351 638,676 1,429,810 469,659 806,243 3,495,739 151,351 638,676 1,429,810 469,659 806,243 3,495,739 3,495,739 Calendar year (or fiscal year beginning in) 7 Amounts from line 4 8 Gross income from interest, dividends, payments received on securities loans, rents, royalties, and income from similar sources 9 Net income from unrelated business activities, whether or not the business is regularly carried on 10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) 11 Total support. Add lines 7 through 10 . 12 Gross receipts from related activities, etc(s (a) 2016 (b) 2017 (c) 2018 (d) 2019 (e) 2020 (f) Total 151,351 638,676 1,429,810 469,659 806,243 3,495,739 3,495,739 12 13 First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here Section C. Computation of Public Support Percentage 14 Public support percentage for 2020 (line 6, column (f), divided by line 11, column (f)) 15 Public support percentage from 2019 Schedule A, Part II, line 14 15 100.00 % 16a 33 113% support test - 2020. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box and stop here. The organization qualifies as a publicly supported organization ► b 33 113% support test - 2019. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this box and stop here. The organization qualifies as a publicly supported organization ► ❑ 17a 10%-facts-and-circumstances test - 2020. If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 10% or more, and if the organization meets the facts -and -circumstances test, check this box and stop here. Explain in Part VI how the organization meets the facts -and -circumstances test. The organization qualifies as a publicly supported organization ► ❑ b 10%-facts-and-circumstances test - 2019. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or more, and if the organization meets the facts -and -circumstances test, check this box and stop here. Explain in Part VI how the organization meets the facts -and -circumstances test. The organization qualifies as a publicly supported organization ► ❑ 18 Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see instructions 14 100.00 % EEA Schedule A (Form 990 or 990-EZ) 2020 Schedule A(Form 990or990-EZ)2020 THELMA GIBSON HEALTH INITIATIVE INC Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.) Part III Section A. Public Support 45-2835389 Page 3 Calendar year (or fiscal year beginning in)► 1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") 2 Gross receipts from admissions, merchandise sold or services performed, or facilities fumished in any activity that is related to the organization's tax-exempt purpose 3 Gross receipts from activities that are not an unrelated trade or business under section 513 4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf 5 The value of services or facilities furnished by a governmental unit to the organization without charge 6 Total. Add lines 1 through 5 7a Amounts included on lines 1, 2, and 3 received from disqualified persons . . b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year c Add lines 7a and 7b 8 Public support. (Subtract line 7c from line 6.) (a) 2016 (b) 2017 (c) 2018 (d) 2019 (e) 2020 (f) Total __ Section B. Total Support Calendar year (or fiscal year beginning in)► 9 Amounts from line 6 10a Gross income from interest, dividends, payments received on securities loans, rents, royalties, and income from similar sources . b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975 c Add lines 10a and 1 Ob 11 Net income from unrelated business activities not included in line lob, whether or not the business is regularly carried on 12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) 13 Total support. (Add lines 9, 10c, 11, and 12.) 14 First 5 years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here I. ❑ (a) 2016 (b) 2017 (c) 2018 (d) 2019 (e) 2020 (f) Total Section C. Computation of Public Support Percentage 15 Public support percentage for 2020 (line 8, column (f), divided by line 13, column (f)) 16 Public support percentage from 2019 Schedule A, Part III, line 15 Section D. Computation of Investment Income Percentage 15 16 % 17 Investment income percentage for 2020 (line 10c, column (f), divided by line 13, column (f)) 17 % 18 Investment income percentage from 2019 Schedule A, Part III, line 17 . .. 18 19a 33 113% support tests - 2020. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization . . ► ❑ b 33 113% support tests - 2019. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3%, and line 18 is not more than 33 113%, check this box and stop here. The organization qualifies as a publicly supported organization ► ❑ 20 Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions . . . ► ❑ EEA Schedule A (Form 990 or 990-EZ) 2020 Schedule A (Form 990 or 990-EZ) 2020 THELMA GIBSON HEALTH INITIATIVE INC Supporting Organizations (Complete only if you checked a box in line 12 on Part I. If you checked box 12a, Part I, complete Sections A and B. If you checked box 12b, Part I, complete Sections A and C. If you checked box 12c, Part I, complete Sections A, D, and E. If you checked box 12d, Part I, complete Sections A and D, and complete Part V.) Part IV 45-2835389 Page 4 Section A. All Supporting Organizations 1 Are all of the organization's supported organizations listed by name in the organization's governing documents? If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose, describe the designation. If historic and continuing relationship, explain. 2 Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2). 3a Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer lines 3b and 3c below. b Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes,"describe in Part VI when and how the organization made the determination. c Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use. 4a Was any supported organization not organized in the United States ("foreign supported organization")? If "Yes," and if you checked 12a or 12b in Part 1, answer Tines 4b and 4c below. b Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If "Yes," describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations. c Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If "Yes," explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(8) purposes. 5a Did the organization add, substitute, or remove any supported organizations during the tax year? If "Yes," answer lines 5b and 5c below (if applicable). Also, provide detail in Part VI, including (1) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document). b Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document? c Substitutions only. Was the substitution the result of an event beyond the organization's control? 6 Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization's supported organizations? If "Yes," provide detail in Part VI. 7 Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (as defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If "Yes," complete Part I of Schedule L (Form 990 or 990-EZ). 8 Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If "Yes," complete Part I of Schedule L (Form 990 or 990-EZ). 9a Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons, as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If "Yes," provide detail in Part VI. b Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If "Yes," provide detail in Part VI. c Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If "Yes," provide detail in Part VI. 10a Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non -functionally integrated supporting organizations)? If "Yes," answer 10b below. b Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720. to determine whether the organization had excess business holdings. Yes No 1 2 3a 3b 3c 4a 4b 4c 5a 5b 5c 6 7 8 9a 9b 9c 10a 10b EEA Schedule A (Form 990 or 990-EZ) 2020 Schedule A (Form 990 or 990-EZ) 2020 THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 Pages Part IV Supporting Organizationsjcontinued) Yes No 11 Has the organization accepted a gift or contribution from any of the following persons? a A person who directly or indirectly controls, either alone or together with persons described in lines 11 b and 11c below, the governing body of a supported organization? b A family member of a person described in line 11 a above? c A 35% controlled entity of a person described in 11 a or 11 b above? If "Yes" to line I la, 11 b, or 11c, provide detail in Part VI. Section B. Type I Supporting Organizations Did the governing body, members of the governing body, officers acting in their official capacity, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization's officers, directors, or trustees at all times during the tax year? if "No," describe in Part Vt how the supported organization(s) effectively operated, supervised, or controlled the organization's activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove officers, directors, or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year. 2 Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If "Yes," explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised, or controlled the supporting organization. Section C. Type II Supporting Organizations 1 Were a majority of the organization's directors or trustees during the tax year also a majority of the directors or trustees of each of the organization's supported organization(s)? If "No," describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s). Section D. All Type Ili Supporting Organizations 1 Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization's tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization's governing documents in effect on the date of notification, to the extent not previously provided? 2 Were any of the organization's officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? if "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s). 3 By reason of the relationship described in line 2, above, did the organization's supported organizations have a significant voice in the organization's investment policies and in directing the use of the organization's income or assets at all tunes during the tax year? If "Yes," describe in Part VI the role the organization's supported organizations played in this regard. 11a 11b 11c Yes No 1 2 Yes 1 Yes No 1 2 3 Section E. Type III Functionally Integrated Supporting Organizations 1 Check the box next to the method that the organization used to satisfy the integral Part Test during the year (see instructions). a ❑ The organization satisfied the Activities Test. Complete line 2 below. b ❑ The organization is the parent of each of its supported organizations. Complete line 3 below. c ❑ The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions). 2 Activities Test. Answer lines 2a and 2b below. Yes No a Did substantially all of the organization's activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? if "Yes,'' then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities. b Did the activities described in line 2a, above, constitute activities that, but for the organization's involvement, one or more of the organization's supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organizations position that its supported organization(s) would have engaged in these activities but for the organization's involvement. 3 Parent of Supported Organizations. Answer lines 3a and 3b below. a Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? If "Yes" or "No," provide details in Part VI. b Did the organization exercise a substantial degree of direction over the policies, programs, and activities of each of its supported organizations? If "Yes," describe in Part VI the role played by the organization in this regard. 2a 2b 3a 3b EEA Schedule A{Form 990 or 990-EZ) 2020 Schedule A(Form 990arS90-EZ)2020 THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 Page Type III Non -Functionally Integrated 509(a)(3) Supporting Organizations 1 ❑ Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part Vi). See instructions. All other Type III non-functionarly integrated supporting organizations must complete Sections A through E. Part V Section A -Adjusted Net Income (A) Prior Year (B) Current Year (optional) 1 Net short-term capital gain 1 2 Recoveries of prior -year distributions 2 3 Other gross income (see instructions) 3 4 Add lines 1 through 3. 4 5 Depreciation and depletion 5 6 Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) 6 7 Other expenses (see instructions) 7 8 Adjusted Net Income (subtract lines 5, 6, and 7 from line 4) 8 Section B - Minimum Asset Amount (A) Prior Year (B) Current Year (optional) 1 Aggregate fair market value of all non -exempt -use assets (see instructions for short tax year or assets held for part of year): a Average monthly value of securities la b Average monthly cash balances 1b c Fair market value of other non -exempt -use assets lc d Total (add lines la, lb, and lc) 1d e Discount claimed for blockage or other factors (explain in detail in Part VI): 2 Acquisition indebtedness applicable to non -exempt -use assets 2 3 Subtract line 2 from line ld. 3 4 Cash deemed held for exempt use. Enter 0.015 of line 3 (for greater amount, see instructions). 4 5 Net value of non -exempt -use assets (subtract line 4 from line 3) 5 6 Multiply line 5 by 0.035. 6 7 Recoveries of prior -year distributions 7 8 Minimum Asset Amount (add line 7 to line 6) 8 Section C - Distributable Amount Current Year 1 Adjusted net income for prior year (from Section A, line 8, Column A) 1 2 Enter 0.85 of line 1. 2 3 Minimum asset amount for prior year (from Section 8, line 8, Column A) 3 4 Enter greater of line 2 or line 3. 4 5 Income tax imposed in prior year 5 6 Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions). 6 7 ❑ Check here if the current year is the organization's first as a non -functionally integrated Type III supporting organization (see instructions). EEA Schedule A (Form 990 or 990-EZ) 2020 Schedule A (Form 990 or 990-EZ) 2020 THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 Part V Page 7 Type III Non -Functionally Integrated 509(a)(3) Supporting Organizations (continued Section D - Distributions Current Year 1 Amounts paid to supported organizations to accomplish exempt purposes 1 2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity 2 3 Administrative expenses paid to accomplish exempt purposes of supported organizations 3 4 Amounts paid to acquire exempt -use assets 4 5 Qualified set -aside amounts (prior IRS approval required) - provide details in Part VI) 5 6 Other distributions (describe in Part V!). See instructions. 6 7 Total annual distributions. Add lines 1 through 6. 7 8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions. 8 9 Distributable amount for 2020 from Section C, line 6 9 10 Line 8 amount divided by line 9 amount 10 Section E - Distribution Allocations (see instructions) (i) Excess Distributions (ii) Underdistributions Pre-2020 (iii) Distributable Amount for 2020 1 Distributable amount for 2020 from Section C, line 6 2 Underdistributions, if any, for years prior to 2020 (reasonable cause required - explain in Part V!). See instructions. 3 Excess distributions carryover, if any, to 2020 a From 2015 b From 2016 c From 2017 d From 2018 e From 2019 f Total of lines 3a through 3e g Applied to underdistributions of prior years h Applied to 2020 distributable amount i Carryover from 2015 not applied (see instructions) j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. 4 Distributions for 2020 from Section D, line 7: $ a Applied to underdistributions of prior years b Applied to 2020 distributable amount c Remainder. Subtract lines 4a and 4b from line 4. 5 Remaining underdistributions for years prior to 2020, if any. Subtract lines 3g and 4a from line 2. For result greater than zero, explain in Part VI. See instructions. 6 Remaining underdistributions for 2020. Subtract lines 3h and 4b from line 1. For result greater than zero, explain in Part VI. See instructions. 7 Excess distributions carryover to 2021. Add lines 3j and 4c. 8 Breakdown of line 7: a Excess from 2016 . . . . b Excess from 2017 . . . . c Excess from 2018 . . . . d Excess from 2019 . . . . e Excess from 2020 . .. . EEA Schedule A (Form 990 or 990-EZ) 2020 Schedule A (Form 990 or 990-EZ) 2020 Page 8 Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, fine 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines lc, 2a, 2b, 3a, and 3b; Part V, line 1; Part V, Section B, line le; Part V, Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions.) Part VI EEA Schedule A (Form 990 or 990-EZ) 2020 SCHEDULE D (Form 990) Department of the Treasury Internal Revenue Service Supplemental Financial Statements P. Complete if the organization answered "Yes" on Form 990, Part IV, Tine 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b. ► Attach to Form 990. Go to www.irs.gov/Form990 for instructions and the latest information. OMB No. 1545-0047 2020 Open to Public Inspection Name of the organization THELMA GIBSON HEALTH INITIATIVE INC Employer identification number 95--2835389 Part 1 Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6. 1 Total number at end of year 2 Aggregate value of contributions to (during year) 3 Aggregate value of grants from (during year) 4 Aggregate value at end of year 5 Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization's property, subject to the organization's exclusive legal control? ❑ Yes ❑ No 6 Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ❑ Yes ❑ No Conservation Easements. Complete if the organization answered "Yes" on Form 990, Part IV, line 7. (a) Donor advised funds (b) Funds and other accounts Part II 1 Purpose(s) of conservation easements held by the organization (check all that apply). ❑ Preservation of land for public use (e.g., recreation or education) ❑ Preservation of a historically important land area ❑ Protection of natural habitat ❑ Preservation of a certified historic structure ❑ Preservation of open space 2 Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year. a Total number of conservation easements b Total acreage restricted by conservation easements c Number of conservation easements on a certified historic structure included in (a) d Number of conservation easements included in (c) acquired after 7/25106, and not on a historic structure listed in the National Register 3 Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the tax year 1.- 4 Number of states where property subject to conservation easement is located ► 5 Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ❑ Yes ❑ No 6 Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year Held at the End of the Tax Year 2a 2b 2c 2d 7 Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year $ 8 Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? ❑ Yes ❑ No 9 In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement and balance sheet, and include, if applicable, the text of the footnote to the organization's financial statements that describes the organization's accounting for conservation easements. Part III Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets. Complete if the organization answered "Yes" on Form 990, Part IV, line 8. la If the organization elected, as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII the text of the footnote to its financial statements that describes these items. b If the organization elected, as permitted under FASB ASC 958, to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items: (i) Revenue included on Form 990, Part VIII, line 1 ► $ (ii) Assets included in Form 990, Part X ► $ 2 If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the following amounts required to be reported under FASB ASC 958 relating to these items: a Revenue included on Form 990, Part VIII, line 1 ► $ b Assets included in Form 990, Part X ► $ For Paperwork Reduction Act Notice, see the Instructions for Form 990. EEA Schedule D (Form 990) 2020 Schedule D(Form 99Q)2020 THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 Page 2 Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued) Part III 3 Using the organization's acquisition, accesson, and other records, check any of the following that make significant use of its collection items (check all that apply): a ❑ Public exhibition d ❑ Loan or exchange programs b ❑ Scholarly research e ❑ Other c ❑ Preservation for future generations 4 Provide a description of the organization's collections and explain how they further the organization's exempt purpose in Part XIII. 5 During the year, did the organization solicit or receive donations of art, historical treasures, or other similar assets to be sold to raise funds rather than to be maintained as part of the organization's collection? ❑ Yes ❑ No Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21. Part IV la Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not included on Form 990, Part X? b if "Yes," explain the arrangement in Part XIII and complete the following table: c Beginning balance d Additions during the year e Distributions during the year f Ending balance 2a b ❑ Yes ❑ No Amount lc ld le if Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ❑ Yes ❑ No If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided on Part XIII ❑ Endowment Funds. Part V Complete if the organization answered "Yes" on Form 990, Part IV, line 10. la b c d e f g Beginning of year balance Contributions Net investment earnings, gains, and losses Grants or scholarships Other expenditures for facilities and programs Administrative expenses End of year balance (a) Current year (b) Prior year (e). Two years back (d) Three years back (e) Four years back 2 Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as: a Board designated or quasi -endowment ► b Permanent endowment ► c Term endowment ► The percentages on lines 2a, 2b, and 2c should equal 100%. 3a Are there endowment funds not in the possession of the organization that are held and administered for the organization by: (i) Unrelated organizations (ii) Related organizations b If "Yes" on line 3a(ii), are the related organizations listed as required on Schedule R? 4 Describe in Part XIII the intended uses of the organization's endowment funds. Land, Buildings, and Equipment. Complete if the organization answered "Yes" on Form 990, Part IV, line 11 a. See Form 990, Part X, line 10. Part VI 3a(i) 3a(ii) 3b Yes No Description of property (a) Cost or other basis (investment) (b) Cost or other basis (other) ic) Accumulated depreciation (d) Book value la Land b Buildings c Leasehold improvements d Equipment e Other 1,743,297 1,743,297 509,353 509,353 34,468 34,468 2,265 2,265 3,400 90,088 (86,688) Total. Add lines la through le. (Column (d) must equal Form 990, Part X, column (8), line 1(1c) ► 2,202,695 EEA Schedule D (Form 990) 2020 Schedule D (Form 990) 2020 THELMA GIBSON HEALTH INITIATIVE INC Investments - Other Securities. Complete if the organization answered "Yes" on Form 990, Part IV, line 11 b. See Form 990, Part X, line 12. 45-2835389 Part VII Page 3 (a} Description of security or category (including name of security) (b) Book value (c) Method of valuation_ Cost or end -of -year market value (1) Financial derivatives (2) Closely -held equity interests (3) Other (A) (B) (C) (D) (E) (F) (G) (H) Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.) ► Part VIII 1 Investments - Program Related. Complete if the organization answered "Yes" on Form 990, Part IV, line 11c. See Form 990, Part X, line 13. (a) Description of investment (b) Book value (c) Method of valuation: Cost or end -of -year market value (1) (2) (3) (4) (5) (6) (7) (8) (9) Total. (Column (b) must equal Form 990, Part X, col. (B) line 13.) ► Part IX 1 Other Assets. Complete if the organization answered "Yes" on Form 990, Part IV, line 11d. See Form 990, Part X, line 15. (a) Description (b) Book value (1))THER ASSETS 46,933 (2) (3) (4) (5) (6) (7) (8) (9) Total. (Column (b) must equal Form 990, Part X, col. (B) line 15.) ► 96,933 Part X Other Liabilities. Complete if the organization answered "Yes" on Form 990, Part IV, line 11e or lif. See Form 990, Part X, line 25. 1. (a) Description of liability (h) Book value (1) Federal income taxes (2) (3) (4) (5) (6) (7) (8) (9) Total. (Column (b) must equal Form 990, Pad X, col. (0) line 25.) . ► 2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote 10 the organization's financial statements that reports the organization's liability for uncertain tax positions under FASB ASC 740. Check here if the text of the footnote has been provided in Part XIII ❑ EEA Schedule D (Form 990) 2020 Schedule D (Form 990) 2020 THELMA GIBSON HEALTH INITIATIVE INC 45-2835389 Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered "Yes" on Form 990, Part IV, line 12a. 1 Total revenue, gains, and other support per audited financial statements 2 Amounts included on line 1 but not on Form 990, Part VIII, line 12: a Net unrealized gains (losses) on investments 2a b Donated services and use of facilities c Recoveries of prior year grants d Other (Describe in Part XIII.) e Add lines 2a through 2d 3 Subtract line 2e from line 1 4 Amounts included on Form 990, Part VIII, line 12, but not on line 1: a Investment expenses not included on Form 990, Part Vlll, line 7b 4a b Other (Describe in Part XIII.) c Add lines 4a and 4b 5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part!, line 12.) Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered "Yes" on Form 990, Part IV, line 12a. 1 Total expenses and losses per audited financial statements 2 Amounts included on line 1 but not on Form 990, Part IX, line 25: a Donated services and use of facilities 2a b Prior year adjustments c Other losses d Other (Describe in Part XIII.) e Add lines 2a through 2d 3 Subtract line 2e from line 1 4 Amounts included on Form 990, Part IX, line 25, but not on line 1: a Investment expenses not included on Form 990, Part VIII, line 7b 4a b Other (Describe in Part XIII.) c Add lines 4a and 4b 5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part 1, line 1 8 ) Supplemental Information. Part XI Part XII Part XIII 2b 2c 2d 4b 2b 2c 2d 4b 1 2e 3 4c 5 1 2e 3 4c 5 Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines la and 4; Part IV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information. Page 4 806,243 806,243 806,243 825,269 825,269 825,269 EEA Schedule D (Form 990) 2020 Form 8868 (Rev, January 2020) Department of the Treasury Internal Revenue Service Application for Automatic Extension of Time To File an Exempt Organization Return ► File a separate application for each return. ► Go to www.irs.gov/Form8868 for the latest information. OMB No. 1545-0047 Electronic filing (e-file). You can electronically file Form 8868 to request a 6-month automatic extension of time to file any of the forms listed below with the exception of Form 8870, Information Return for Transfers Associated With Certain Personal Benefit Contracts, for which an extension request must be sent to the IRS in paper format (see instructions). For more details on the electronic filing of this form, visit www.irs.gov/e-file-providers/e-file-for-charities-and-non-profits. Automatic 6-Month Extension of Time. Only submit original (no copies needed). Ail corporations required to file an income tax return other than Form 990-T (including 1120-C filers), partnerships, REMICs, and trusts must use Form 7004 to request an extension of time to file income tax returns. Type or print Name of exempt organization or other filer, see instructions. THELMA GIBSON HEALTH INITIATIVE INC Taxpayer identification number (TIN) 45-2835389 File by The due date for filing your return. See Instructions. Number, street, and room or suite no. If a P.O, box, see instructions. 3646 GRAND AVENUE City, town or post office, state, and ZIP code. For a foreign address, see instructions. Kiami FL 33133 Enter the Return Code for the return that this application is for (file a separate application for each return) 0 1 Application Is For Form 990 or Form 990-EZ Form 990-BL Form 4720 (individual) Form 990-PF Form 990-T (sec. 401(a) or 408(a) trust) Form 990-T (trust other than above) Return Code 01 02 03 04 05 06 Application Is For Return Code Form 990-T (corporation) Form 1041-A Form 4720 (other than individual) Form 5227 Form 6069 Form 8870 • The books are in the care of ► THELMA GIBSON HEALTH INITIATIVE INC, 3646 GRAND AVENUE Miami FL 33133 Telephone Not 305-446-1543 FAX No. ► • If the organization does not have an office or place of business in the United States, check this box • If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN) for the whole group, check this box ► ❑ . If it is for part of the group, check this box. . . . ► ❑ and attach a list with the names and TINs of all members the extension is for. . If this is 1 I request an automatic 6-month extension of time until 05-16 , 20 22 , to fife the exempt organization return for the organization named above. The extension is for the organization's retum for: ► ❑ calendar year 20 or ► ❑X tax year beginning 07-01 , 20 20 , and ending 06-30 ,20 21 2 If the tax year entered in line 1 is for less than 12 months, check reason: ❑ Initial return ❑ Final return ❑ Change in accounting period 07 08 09 10 11 12 3a if this application is for Forms 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits, See instructions. $ b If this application is for Forms 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated tax payments made. Include any prior year overpayment allowed as a credit. c Balance due. Subtract line 3b frorn line 3a. Include your payment with this form, if required, by using EFTPS (Electronic Federal Tax Payment System). See instructions. 3c $ Caution: If you are going to make an electronic funds withdrawal (direct debit) with this Form 8868, see Form 8453-EO and Form 8879-E0 for payment 3a 3b For Privacy Act and Paperwork Reduction Act Notice, see instructions. EEA Form 8868 (Rev. 1-2020) Theo, i,a Gibson Health Initiative, inc. Unaudited Statement of Financial Position As of June 30, 2022 ASSETS CURRENT ASSETS $ CITY NATIONAL 11,705 PAYPAL 43 POPULAR CD 40,922 POPULAR FUNDRAISING #1 1,184 POPULAR BANK - OPERATING 63,267 TOTAL CASH IN BANK 117,121 OTHER CURRENT ASSETS GRANT RECEIVABLE 34,474 OTHER RECEIVABLES 3,630 DUE FROM ISLAND DISTRICT 43,072 TOTAL OTHER CURRENT ASSETS 81,176 TOTAL CURRENT ASSETS 198,298 FIXED ASSETS OFFICE FURNITURE & EQUIPMENT LEASEHOLD IMPROVEMENT TOTAL FIXED ASSETS 3,063 40,936 43,999 OTHER ASSETS INVESTMENT IN SUBSIDIARIES - Island District Development LLC 860,000 Little Bahamas QOF LLC 21,892 Security Deposits 383 TOTAL OTHER ASSETS 882,275 TOTAL ASSETS $ 1,124,572 LIABILITIES & NET ASSETS LIABILITIES OTHER CURRENT LIABILITIES: DUE TO/FROMVM LITTLE BAHAMAS DIST PAYROLL LIABILITIES TOTAL OTHER CURRENT LIABILITIES 5,357 5,357 TOTAL LIABILITIES 5,357 NET ASSETS 1,119,215 TOTAL LIABILITIES & NET ASSETS $ 1,124,572 Thelma Gibson Health ➢nitiative, Inc. Unaudited Operating Statement For the twelve months ended June 30, 2022 REVENUES $ DONATIONS 139,777 GRANT INCOME 510,146 INTEREST INCOME 32 Total Revenues 649,955 EXPENDITURES BANK CHARGES 355 CLIENT ASSISTANCE 3,222 DONATIONS 3,650 EQUIPMENT MAINTENANCE & REPAIR 3,810 EQUIPMENT LEASE 3,947 FACILITY MAINTENANCE & REPAIR 4,669 INSURANCE 14,076 INTEREST EXPENSE 374 LICENSES & PERMITS 640 MARKETING/ADVERTISING 2,406 MEMBERSHIP FEES 875 MOVING EXPENSE 582 OFFICE SUPPLIES & EXPENSES 9,584 OPERATING FEES 1,293 PAYROLL EXPENSES 485,041 PROFESSIONAL SERVICES 25,943 PROGRAM ACTIVITIES & SUPPLIES 7,656 RENT 15,900 STAFF TRAINING/RECRUITMENT 385 TRAVEL & MEETINGS 3,687 UTILITIES 10,952 Total Expenditures 599,048 OTHER INCOME OTHER INCOME (PPP Loan Forgiveness) Total Other Income 167,800 167,800 CHANGE IN NET ASSETS 218,707 NET ASSETS, AT BEGINNING OF YEAR NET ASSETS, AT JUNE 30, 2022 900,508 $ 1,119,215 8/21/2022 2021 -2022 LINE ITEM ALLOCATION LINE ITEM DESCRIPTIONS J YEARLY TOTAL CITY 10/1/21- 9/30/22 CHI (Cr( 10/1/21- 9/30/22 MDC (HIV( 10/1/21 - 9/30/22 MDC (PAC) 10/1/21 - 9/30/22 MDC (PTP( 10/1/21 - 9/30/22 MDC (PHCD) Seniors 1/1/21- 12/31/21 MDC (PHCD) Jab Readiness 1/1/21 - 12/31/21 RELATED 1/1/21- 12/31/21 STATE Florida Health (HIV( Sept 2021 - Aug 2022 United HomeCare (Seniors) Sept 2021- Feb 2022 United HomeCare (Caregivers( Sept 2021-JuEy 2022 GRANTS FUNDRAISING DIFFERENCE S15,840 S19,200 52,799 54,563 518,344 58,447 55,119 55,380 59,1eS $8,338 525,905 50 $102,061 FUNDRAISING EXPENSES r 50 00 50 FRINGE BENEFITS S1CA/MICA (7.65%) $35,222 $3,837 $10,006 $1,010 5857 $1,504 $2,769 52,668 51,042 53,125 S357 5229 60 57,808 50 Worker Comp (1.5951) S8,011 S798 S2,276 $230 5197 5342 $576 $555 $217 S711 574 548 $0 51,990 $0) Unemployment (.001% of first$7,000) $53 511 $23 $35 $21 $28 521 $21 $0 $13 50 -$110 CLIENT ASSISTANCE Family Stabilization 50 So 5D Other Client Assistance $1,000 $1,000 50 $0 EQUIPMENT MAINT. & REPAIR Computer Services 51,000 $500 50 5500 501 FACILITY MAW: & REPAIRS $01 Canteen Cuisine Location $0 1 SC $0 INSURANCE Director & Officer $1,763 5500 5279 $235 5549 SO 50 Commercial / Prof Liability $5,477 51,500 $456 52,640 $660 5221 50 SO LEASES (BUILDING/EQUIPMENT) ' Canteen Cuisine: Rent -$1,200 mth 514,400 S2,789 511,611 50 50 Copier Lease (5323.50 month) 53,979 51,500 5996 5900' 51,200 50 -5617 LICENSE/PERMITS/FEES Permit Fees 50 $0 50 'Canteen Cuisine- Permit Fees S0 50 50 License Registration Fees 5600 $75 $75 50 5450 50 2021 -2022 LINE ITEM ALLOCATION LINE ITEM DESCRIPTIONS YEARLY TOTAL CITY 10/1/21- 9/30/22 CHI (CT) 10/1/21 - 9/30/22 MDC (HiV) 16/1/21 - 9/30/22 MDC (PAC) i 10/1/21 - 9/30/22 MDC (PTP) 10/1/21 - 9/30/22 MDC(PHCD) Seniors 1/1/21- 12/31/21 MDC (PHCD) Job Readiness 1/1/21 - 12/31/21 RELATED 1/1/21- 12/31/21 STATE Florida Health (HIV) Sept 2021-Aug 2022 United HomeCare (Seniors) Sept 2021 - Feb 2022 United lomeCare (Caregivers) Sept 2021-July 2022 GRANTS FUND RAISING DIFFERENCE tun -4U22 LJNI 11 UV: ALLULA ()LEV UNE ITEM DESCRIPTIONS NON CAP. EQUIP- (less than $I,000) Computers/Printer/Projector S500 5500 S0 SO' OFFICE SUPPLIES Office: Copy Overages, Stamps & Courier/Cleaning & Office Supplies $3,395 $500 $749 $49 5240 $1,557 $300 $0 50 OPERATING FEES (MONTHLY DEBITS) S1,000 $1,{700 $0 PROFESSIONAL FEES $0 Accountant ($550.00 mth) $5,600 $2,000 $1,200 $1,600 $1,600 S0 $D Auditor $7,000 $2,200 $300 $300 S400 $1,070 $0 $2,730 $b Contracted Services $18,900 $6,300 $12.,600 $0 $0 PROGRAM ACTIVITIES & SUPPLIES Community Events $0 $0 St) Activity/Training Suppiies $8,170 $970 57,200 $0 $0 Advertising/Marketing $323 $0 $323 $D INCENTIVE'S/STIPENDS $9 835 $2,400 $1,507 $5,828 S0 $0 STAFF TRAINING/RECRUITMENT 1jII Advertising (Positions Available) $175 $b $175 Background (4 @ $65 each) S260 $65 $130 $0 $65 50 First Aid & CPR (Staff (8} & Interns (4) @ $27 each} $324 $0 $324 $D Training $400 $400 $0 5D Uniforms S2,000 $D S2,oDD $O TRAVEL & MEETINGS $0 Meals/Food/Snacks 5100 SO $1D0 $o Meetings $1,000 $0 $1,000 56 Mileage $3,007 $239 5485 S12Z $0 52,160 $6 Parking/Tolls S1.50 _ $0 $150 SO 2021-2022 LINE ITEM ALLOCATION LINE ITEM DESCRIPTIONS YEARLY TOTAL CITY 10/1/21- 9/30/22 CHI {CT) 16/1/21 - 9/30/22 MDC (HIV) 10/1/21- 9/30/22 MDC (PAC) 10/1/21- 9/30/22 MDC (PTP) 10/1/21- 9/30/22 MDC (PHCD) Seniors 1/1/21- 12/31/21 MDC (PHCD) Job Readiness 1/1/21 - 12/31/21 RELATED 1/1/21- 12/31/21 STATE Florida Health (HIV) Sept 2021-Aug 2022 United HomeCare (Seniors) Sept 2021- Feb 2022 United HomeCare {Caregivers) Sept 2021-July 2022 GRANTS FUND RAISING DIFFERENCE UTILITIES AT&T Cell Phones/Tablets ($120 mth) 51,440 $1E0 51,398 $180 g,o -$318 COMCAST Internet/Office Phones ($325 'rah) $3,900 $975 5975. $1,039 5523 5621 $144 $0 -$377 ' Canteen Cuisine: FPL ($ 216 mth) 52.000 $R00 52,000 SO -$6D0 ' Canteen Cuisine. Water (560 qtr( $240 10 SO 50 ' Canteen Cuisine: Burglar Alarm Monitoring ($55. 96 mth) $671 50 -$156 • Canteen Cuisine: Natural Gas $0 _ 0 $0 Canteen Cuisine: Fire Alarm 03r Monitor / Yrly Inspection- $500 $0 $0 $142,906 $15,840 $19,200 $2,843 $4,698 $18,392 $8,447 $5,119 $6,380 $9,149 $8,338 $25,905 50 S122,335 $0 $0 -$44 -$35 -$48 $0 $0 $0 $0 $0 $0 $0 CANTEEN CUISINE EXPENSES COUNTY PAC & PTP BUDGET NOT COVERED 517,311 517,311 $6 8/21 /2022 FY 2021-2022 PROJECTED REVENUE MONTHLY REVENUE GRANTS FUNDR CITY 10/1/21- 9/30/22 CHI (CT) 10/1/21 - 9/30/22 MDC (HIV) 10/1/21 - 9/30/22 MDC (PAC) 10/I/21 - 9/30/22 MDC (PIP) 10/1/21 • 9/30/22 MDC (PHCD) Seniors 1/1/21 - 12/31/21 MDC (PHCD) Job Readiness 1/1/21 - 12/31/21 RELATED 1/1/21- 12/31/21 STATE Florida Health (HIV) Sept 2021- Aug 2022 United HomeCare (Seniors) Sept 2021 - Feb 2022 United HomeCare {Caregivers} Sept 2021 - July 2022 AGENCY AMOUNT EVENT July $5,500.00 912,500.00 $1,333.33 $1,333.33 $3,166.66 93,72054 $3,333.33 $5,000.00 August $5,500.00 $12,500.00 $1,333.33 $1,333.33 $3,166.66 $3,720.54 $3,333.33 $4,545.45 September $5,500.00 $12,500.00 $1,333.33 $1,333.33 $3,166.66 93,72054 $3,333.33 $4,545.45 $2,600.00 $3,211.11 October $5,500.60 $12,500.00 $1,333.33 $1,333.33 $3,166.66 53,721 54 $3,333.33 $5,000.00 $4,545.45 $2,600.00 93,21111 November $5,500.00 $12,500.00 91,333.33 $1,333.33 $3,166.65 53,720.54 $3,333.33 $4,545.45 $2,600.00 $3,211.11 December $5,500.00 $12,500.00 $1,333.33 $1,333.33 $3,166.66 $3,720.54 $3,333.33 $4,545.45 $0.00 $0.00 January $5,500.00 $12,500.00 $1,333.33 $1,333.33 $3,166.66 $3,720.54 $3,333.33 $5,060.00 $4,545.45 92,600.00 $3,211.11 February $5,500.00 $12,500.00 $1,333.33 $1,333.33 $3,166.66 $3,720.54 $3,333.33 $4,545.45 $2,600.00 $3,211.11 March $5,500.00 912,501100 $1,333.33 $1,333.33 $3,166.66 $3,720.55 $3,333.34 $4,545.45 $0.00 $3,211.11 April $5,500.00 $12,500.00 $1,333.33 $1,333.33 $3,166.66 $3,720.55 $3,333.34 $5,000.00 $4,545.45 $3,211.11 May $5,500.00 $12,500.00 $1,333.33 $1,333.33 $3,166.66 $3,720.55 $3,333.34 $4,545.45 $3,211.11 June $5,500.00 $12,500.00 $1,333.37 $1,333.37 $3,166.74 $3,720.55 53,33334 $4,545.56 $3,211.11 YEARLY GAINS $66,000.00 $150,000.00 $16,000.00 $16,000.00 $38,000.00 $44,646.52 $40,000.00 $20,000.00 $50,000.00 $13,000.00 $28,899.99 $0.00 $0.00 0.00 ADDT'L REVEN AISING GRANT BREAKDOWN REVENUE AMOUNT TOTAL REVENUE MONTHLY $35,887.19 $35,432.64 $41,243.75 $46,243.75 $41,243.75 535,432.64 $24,214.77 $41,243.75 $38,643.77 $43,643.77 $32,643.77 $38,643.98 $0.00 $460 517.53 IUE REQUIRED 2021 -2022 SALARY & FUNDING ALLOCATION H 0 U R S HOURLY WAGE YEARLY I SALARY CITY ' 10/1/21- 9/30/22 CHt (CT) 10/1/21- 9/30/22 MDC (HIV) 10/1/21- 9/30/22 MDC (PAC) 10/1/21. 9/30/22 MDC (PTP) 10/1/21- 9/30/22 MDC (PHCD) Seniors 1/1/21- 12/31/21 MDC (PHCD) lob Readiness 1/1/21 - 12/31/21 RELATED 1/1/21- 12/31/21 STATE Florida Wealth (HIV) Sept 2021 - Aug 2022 United HomeCare (Seniors) Sept 2021 - Feb 2022 United HomeCare (Caregivers) Sept 2021 - July 2022 GRANTS Staff Name /T-st1e $66,000.00 5150,000.00 516,000.00 $16,000.60 $38,000.00 $44,646.52 540,000.00 $20,000.00 550,000.00 513,000.00 $28,899.99 $0.00 Balderramos, Erick - Family Care Coordinator 40.M $22.00 $45,760 543,730 $0 Barton, Merline -President 40.00 $37.50 578,000 510,080 53,900 98,137 $6,137 56,137 $4,,500 $5,481 52,400 $19.020 $p Bryan, Diallo- Care Coordinator 32-00 $27.01 $44,945 $3,000 $7,755 57,000 $4,360 $2,050 50 Cherry -McDowell, Khurshiba - Family Care Coordinator 40-°° $22.00 $45,760 $45,7G0 50 King, Joseph - V.P. of Operations 4o14 $36.54 $76,003 $1,029 $3.816 $11,400 $17,500 S12,880 50 Mercugiiano, Sherry- Dir. of Admin "Jlic $22.50 $23,400 51,080 $1,918 51,518 $1,97.8 $5,000 55,000 $1,620 $2,824 $462 5946 $0 Woods,Donna - Community Coordinator 4°2O $17.00 535,360 518,000 52,369 51,768 50 Milagros Garcia, BASIN - Director of Elderly & Community Services 44.W $27.00 $56,160 $18,000 51,748 $15,300 59,600 $4,200 $0 VACANT- Natural Helper/intake Coordinator 40.00 $18.90 $39,312 $27,518 $3,282 $0 VACANT - Coordinator of Outreach & Enrollment 1640 $18.90 $15,725 $7,862 $0 SO 5o $460,425 $50,160 5130,800 $13,201 $11,337 $19,656 536,200 34 88, $13,620 $40,852 $4,662 $2,995 50 $15,840 $19,200 $2,799 54,663 518,344 $8,447 $5,119 $6,380 $9,146 58,338 $25,905 50 FUNDRAISING DIFFERENCE $o $14,208 $o $20,780 $0 $0 $29,448 $0 $715 $0 $13,223 $0 $7,312 $0 $8,512 $0 $7,853 $0 $0 iax ass STAFF NAME Erick Merlins Diallo Khurshiha Joe Sherry Donna Milagros VACANT VACANT GRANT BREAKDOWN SALARIES 0 0 0 0 0 0 0 0 $0.00 $0.00 50.00 50.00 $0.00 $0.00 $0.00 $0,00 50.00 $0.00 $0.00 $0.00 50.00 50.00 50.00 50.00 50.00 50.00 s0.00 $o So 00 So So $o So $o SD Memorandum of Understanding This Memorandum of Understanding between Thelma Gibson Health initiative, Inc. (TGHI) and Silver Bluff Real Estate, LLC, and/or assigns (Developer) in reference to the properties located at 3640 Grand Ave, 3649, 3643, 3661 Thomas Ave (Properties). TGHI, through its affiliate (Island District Development, LLC) agrees to sell ? properties to Developer, pursuant to terms to be agreed upon and set for under separate agreement, as fee simple title to 100% of all land, buildings and improvements free and clear. The Developer intends to create a single purpose Limited Liability Company to purchase the properties as an Opportunity Zone Fund. Developer intends to develop the Properties into a multi -use development to include retail/office spaces on the ground floor fronting Grand Avenue and residential units on the upper floors with onsite parking, as required by the City of Miami. All the units are to be rental units with all the residential units to be leased at workforce housing rates. The intent is also to offer as many units as possible to residents of the West Grove community to help reduce the segregation and displacement that has been taking place over the past many years. Developer represents and TGHI acknowledges that Developer does not have a proposed site plan or approvals at this time and therefore cannot commit to any specific number, size or type of units. The Developer will commit that this will be a rental project with no intention to sell any units for a minimum of 10 years. Developer agrees to give TGHI the first right of offer to rent any or all of the residential or commercial units once they are available to the marketplace. The Developer will offer the units, as they become available, to TGHI at a price, terms and conditions the Developer deems appropriate. TGHI will have 48 hours to submit a lease contract to Developer once notified in writing that its offer is acceptable to Developer. Developer also agrees to work with TGHI in trying to create a program to give back and assist the West Grove community. Developer agrees to review all the programs available thru TGHI and to try to incorporate as many of these programs into the future project as is reasonably possible. TGHI agrees to use it best effort to assist in all ways possible to promote, encourage and endorse all of Developer's effort to maximize the design, sustainability and success of the future project and to assist Developer in securing all waivers, warrants and government approvals needed to successfully maximize the amount of affordable and workforce housing units that can be built on the Properties. This Memorandum of Understanding may not be recorded among the Public Records of Miami -Dade County and TGHI acknowledges that this Memorandum of Understanding and specifically its right of first offer are subordinate to the rights of any future lender in connection with any financing by Developer, as well as to any governmental body with respect to the development of the Properties. TGHI agrees to acknowledge same, in writing and immediately, if so requested by Developer. Signature on Next Page DEVELOPER: TGH[: SILVER BLUFF REAL ESTATE, LLC, A FLORIDA LIMITED LIABILITY By: COMPANY By: 7- Name: y���.,��, Title: p^R-r, G0t- Date signed by Developer: 7, 1 / 5/.2,f Name: (1f7i-Ch- Date signed by TGHI: 02 1 Ili( e f 1 norl-REAL'Puinle Gr upSvlser Bluff- Pr4P.rues 364o 3649 3663 3(1 VIOL -Slew of Uoderiundkn_-:R dot Memorandum of Understanding Between Island District i)eveloprnent, LLC (IDD) & island District i]eveloyrnent QOZB, LLC (IDDQOZB) & Thelma Gibson Health initiative (TGHI) 1. IUD will assign the purchase contract to IDDQOZB to acquire the property located at 3640 Grand Ave. IDDQOZB will purchase this property for cash without placing any mortgage or lien on the property. 2. IDDQOZB agrees hold the property and not sell or mortgage hunt!! November 30, 2022 or until IDD, TGHI and IDDQOZB can agree on how to proceed with t he development, whichever comes first (Detlsion Date). 3, After Decision Date, If IDDQOZB decides to sell the property, Ilmustgive IDD the first right of refusal to purchase 1t for$1,750,000.00 ($1.735M plus carry costs & property taxes). IDD must secure a fully executed purchase contract within 30 days of written notice received from iDDQOZB. 4. IDD currently owns adjacent properties to 3640 Grand Ave locatedat 3661, 3649, 3643, 3637 and 3635 Thomas Ave (Thomas Properties). IDD agrees to held Thomas Properties and not sell or mortgage it until November 30 2022, or until IDD, TGHI endIDDQOZB can agree on how to proceed with the development, whichever comes first (Decision Date). 5, After Decision Date, if IDD decides to sell all or some of the Thomas Properties, it must give IDDQOZB the first right of refusal to purchase It for $1,950,000D0 ($1.950M plus carry costs & property taxes). IDDQOZB must secure a fully executed purchase contract within 30 days of written notice received from IDD. 6, All parties acknowledge that the properties are more valuableassembled together rather than as individual parcels. These parcels should be developed together as an assemblage by the parties and not sold to a third party. 7. From execution date of this Memorandum to Decision Date, IDD, IODQOZB and TGHI agree to work together In assembling additional adjacent properties tomaxirnize this development. The goal is for all three parties to create a healthy and fair joint venture to develop the site into a mixed -use project that will hest serve the Village West Commutlty. 2. The intent is for the future development or improvements to the site to be awned by the three parties jointly or have the future protect create a conclornlniurnandthe ability for each party to own units in the project Individually. 9, Ail parties see this future development as a great opportunity to combine all their powerful resources to create a unique project with the intent to best serge the community and help TGHI expand their social services work focused on helping and empowering the residents of Village West, 10, The parties agree that Marcelo Fernandes, and or his companies, shall serve as the developer of the project and offer his guidance and expertise and be compensated at a fair market value. 11. The parties agree the goal is to create the best development possible for the Village West community and still protect the assets, capital Investments andprofits of all partners and shareholders. The mission statement that will underline the prep ose ofthls future joint venture Is not solely to maximize return on Investment but also to equally consider efforts towards creating a protect that results to a positive Impact to the residents of Village West. 12, The parties agree that the joint venture will evaluate and consider contributions by each partner/shareholder not only In monetary terms but also In regards to political power and influence, that results in increase In value of the project such as, but not limited to, increase In zoning density, increase In building volume, credits for parkirg requirements and social services type funding by private or public sectors. isian District Development, MC Name: C Peter C Gardner (Aug 9, 20n 14:41 EDI) /VOv1`� 2 2/ Date Afer Title: 1 4 -W f I00 Aug 9, 2022 Island District Development, QOxe Date Name: -peter C Gardner Thelma Gibson Health Initiative Title: Manager 1/—/' jfie6,Date Name: C.:Tc"I,1j0Ac Title: % Name: Marcelo Fernandes, Developer ; r7:›•v ///f/).7 August 20, 2022 *DEVELOPMENT SCHEDULE Scope of Work Estimated Date Actual Date Closing on Total Project Financing by Source a. Land Acquired - Cash Transaction b. Construction funding - Equity - in place c. Construction funding - Grants/Government d. Finalize Partnership --MOU Executed Selection of Architect Completed Appraisal/Market Study Land/ Sites Engineering Report Land/ Sites Architectural Plans and Specifications Preliminary City or County Environmental Clearance Site Plan Approval Working Drawings Completed Submit Drawings for Permit Approval Construction Bids Selection of General Contractor Building Permits Issued Start of Construction Construction Completion @ 40% Construction Completion @ 80% Construction Completed - C.Q. Rentals — 90% Occupancy Temporary/Permanent Relocations Month/Year Month/Year Dec - 2021 Aug 2022 Dec 2023 Sept 2022 Sept 2022 Sept 2022 Nov 2022 Dec 2022 April 2023 May 2023 August 2023 Sept 2023 Nov 2023 Dec 2023 June 2024 Jan 2025 Oct 2025 Feb 2026 Feb 2026 *Not limited to format or detail but must include these items. Nov 2021 August 2022 CITY OF MIAMI DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT SOURCES AND USES: NEW CONSTRUCTION/REHABILITATION AFFORDABLE RENTAL HOUSING APPLICANT: Thelma Gibson Health Initiative PROJECT NAME: Island District Development Evidence of source must be included Financing Sources: Specify Name Total Project HOME Funds Fed FL -US 24 Other Financing Other: Award Other: City Miami Other: Grant Equity Investment Fed FL -US 24 Award Land Acquisition $3,685,00 $3,685,00 Hard Costs $6,520,000 $1,540,000 $2,615,000 $2,365,000 Construction (incl. Site work) Construction contingency $195,600 $195,600 Construction: Concrete/Soil Test $12,000 $12,000 Appliances $98,000 $98,000 Construction Supervision $400,000 $400,000 Total Hard Costs $7,224,972 Soft Costs $350,000 $350,000 Arch Design, Civil Engineering Impact & School Fees $233,650 $233,650 Permits / Fees $75,000 $75,000 Legal $50,000 $50,000 Licenses / Environmental / Utility Fees $50,000 $50,000 Appraisal / Surveys $15,000 $15,000 Insurance: Construction Period $80,000 $80,000 Marketing / Advertising $75,000 $75,000 Loan Closing / Financing Fees N/A Interest / Carrying Costs N/A Title Insurance & Recording N/A Temporary/Permanent Relocation Fees $15,000 $15,000 Taxes $183,000 $183,000 For Use by City: City incurred costs $50,000 $50,000 Developer's Fees & Overhead $445,750 $445,750 Soft Cost Contingency $67,000 $2,600 $64,400 Total Soft Costs $1,690,000 Total Project Cost $g 915,760 $1,540,000 $2,615,000$4,500,000 $260,000 TGHI'S PROJECTED FUNDING FOR USE IN PARTNERSHIP/NEW LAND SOURCE US CONGRESS DISTRICT 24 CITY OF MIAMI D2 VARIOUS COMMUNITY GRANT(S) TARGET DATE OCTOBER 2022 NOVEMBER 2022 OCTOBER 2022 AMOUNT $2.2 MIL. $1,54 MIL. FOR PROJECT $4.5 MIL. $260,000 NOTES AWARD LETTER IN -HAND H.U.D. COMMISSION MEETING SEPTEMBER 2022 AWAITING RESOLUTION OF AWARD FROM CITY TO LEVERAGE THIS US CONGRESS DISTRICT 24 OCTOBER 2023 TOTAL TO CONSIDER FOR PROPERTY/PROJECT $4.0 MIL $2.615 MIL. FOR PROJECT SEE LETTER ENCLOSED $8,915,760 THIS DOES NOT INLCUDE FUNDING FROM PARTNER OXF ORD UNIVERSAL DESPGH L AUILD Island District Development Annual Property Operating Data Avg Lease Rate Potential Rental Income: Total Number of Units 1 Retail @ $20Net $ 4 Eff Units @ 1 Eff Units @ 5 1 Bed Units @ 1 1 Bed Units @ 6 2 Bed Units @ 2 2 Bed Units @ 7 3 Bed Units @ 1 3 Bed Units @ Potential Monthly Income Vacancy Factor : Effective Rental Income Other Income - Laundry / Parking Total Monthly Income Gross Operating Income - (Yearly) Operating Expenses: Estimated Based Cost p/ unit Estimated Property Taxes Total Monthly Expenses Total Operating Expenses - (Yearly) Net Operating Income - (Yearly) 3% 28 SF Size 11,667 7,000 $ $ 853 680 $ $ 1,706 680 $ $ 914 1,180 $ $ 1,828 1,180 $ $ 1,097 1,470 $ $ 2,194 1,470 $ $ 1,276 1,850 $ $ 2,552 1,850 $ $ 28 $ 2,877.56 (based on two comparables in the area) $ 138,705.88 Monthly 11,667 3,412 1,706 4,570 1,828 6,582 4,388 8,932 2,552 45,636.67 (1,369.10) 44, 267.57 $ 44,267.57 PROPS RSIES GOING GREEN AMI - 50% AMI - 100% AMI - 50% AMI - 100% AMI - 50% AMI - 100% AMI - 50% AMI - 100% $ 531,210.80 $ (80,571.81) $ (138,705.88) $ (219,277.69) 311,933.11 COMMITTEE ON EDUCATION AND LABOR CHAIRWOMAN, SUBCOMMITTEE ON HIGHER EDUCATION AND WORKFORCE INVESTMLNT SUBCOMMITTEE ON EARLY CHILDHOOD, ELEMENTARY, AND SECONDARY EDUCATION COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE SUBCOMMITTEE ON HIGHWAYS AND TRANSIT SUBCOMMITTEE ON WATER RESOURCES AND ENVIRONMENT SUBCOMMITTEE ON RAILROADS, PIPELINES, AND HAZARDOUS MATERIALS April 13, 2022 FREDERICA S. WILSON CONGRESS OF THE UNITED STATES Via email: jking©tghimiami.org Joseph King Thelma Gibson Health Initiative 3646 Grand Avenue Coconut Grove, FL 33133 Dear Mr. King: 24TH DISTRICT, FLORIDA DEMOCRATIC STEERING AND POLICY COMMITTEE REPRESENTATIVE, REGION VIII U.S. COMMISSION ON THE SOCIAL STATUS OF BLACK MEN AND BOYS FOUNDER AND CHAR CONGRESSIONAL BLACK CAUCUS SECRETARY FLORIDA PORTS CAUCUS FOUNDER AND CHAIR CAUCUS ON THE U.S. COMMISSION ON THE SOCIAL STATUS OF BLACK MEN AND BOYS FOUNDER AND CHAIR Congratulations! I am pleased to inform you that your organization will receive $2,200,000 for the Frederica Roberts Bahamian Museum of Arts and Culture from Florida District 24 Congressional Fiscal Year 2022 Community Project Funding due to the application I submitted on your behalf. Use this information as you plan and develop your budget. Additional information is listed at the end of this letter and we will share more as it becomes available. The funding will be used to create the Frederica Roberts Bahamian Museum of Arts and Culture that will serve the purpose of celebrating and recognizing the originally settled Bahamian community in Coconut Grove, Miami, and the original Afro -Bahamian culture, which is disappearing right in front of us. The creation of this center would bring about both an arts infusion and economic development engine to the community. As the Congressional representative for the 24th District of Florida, I remain committed to ensuring that Dade and Broward communities and nonprofits like yours have the necessary assistance to serve the South Florida community, maintain their organization's financial health, and support our residents and children. I recognize that these past two years have put an immense strain on local governments, organizations, and residents, including parents and children. Many entities have faced funding cuts and residents have dealt with economic hardships and illness, which is why I have fought in Congress for the necessary community funding to help all of us weather the pandemic, meet economic challenges, and restore and build new modern infrastructure for a strong America. As Chair of the Committee on Education and Labor Subcommittee on Higher Education and Workforce Investment and a senior member of the Committee on Transportation and Infrastructure, I remain committed to ensuring that local governments, organizations, and community members have the necessary support and resources to thrive. I will continue to advocate for robust investment and community project funding during these trying times and beyond. WASHINGTON, DC OFFICE 2445 RAYBURN HOB WASHINGTON, DC 20515 (202) 225-4506 (202) 226-0777 (FAX) HOLLYWOOD 2600 HOLLYWOOD BOULEVARD OLD LIBRARY, 1ST FLOOR HOLLYWOOD, FL 33020 (954) 921-3682 MIAMI GARDENS 18425 NW 2ND AVENUE, SUITE 355 MIAMI GARDENS, FL 33169 (305) 690-5905 (305) 690-5951 (FAx) WEST PARK WEST PARK CITY HALL 1965 SOUTH STATE ROAD 7 WEST PARK, FL 33023 (954) 989-2688 WILSON.HOUSE.GOV I FACEBOOK.COM/REPWILSON I TWITTER.COM/REPWILSON I INSTAGRAM.COM/REPWJLSON Please feel free to reach out to my staff at (305) 690-5905 with any questions or to share any further concerns. Sincerely, Frederica S. Wilson Member of Congress Your project is funded via HUD -Economic Development Initiatives. Please contact that department as follows for details on your funding and deadlines: HUD/Economic Development Initiatives Inquiries can be sent to the program office inbox at CPFGrants(a�hud.gov. HUD is requesting that the following information be included to better help answer questions: • Name of the Authorized Representative (the person that has the authority to sign the Grant Agreement) • Title • Grantee name (name of the organization) • Grantee name (i.e. department, division) • Full Street address (no P.O. Box numbers) • City, state, zip code • Email address for the Authorized Representative U.S. DEPARTMENT OF MOUSING AND URBAN DEVELOPMENT WA SUB D.C. 20410-1000 OFFICE OF COMMUNITY PLANNING AND DEVELOPMENT July 18, 2022 Mr. Joseph King Authorized Representative Thelma Gibson Health Initiative 3646 Grand Avenue Coconut Grove, FL 33133 Email: jking@tghimiami.org Dear Mr. King: In the Consolidated Appropriations Act, 2022, (P.L. 117-103) (the Act), Congress made available "grants for the Economic Development Initiative for the purposes of Community Project Funding/Congressionally Directed Spending." These Community Project Funding (CPF) awards are administered by the Department of Housing and Urban Development (HUD). Pursuant to the requirements associated with the Act, this Letter of Invitation (LOI) is an important step in the grant award process and outlines the grant award requirements and the information needed from you to prepare the Grant Agreement for execution. Once we receive and verify your information, we will send your Grant Agreement for signature. The information we received about your project in the Act's Joint Explanatory Statement (JES) is below. A Grant Number has been generated and will be the unique identifier for your project during the grant process. The Grant Number is noted below. Grantee: Thelma Gibson Health Initiative Project Description: The Bahamian Museum of Arts and Culture Grant Atnonnt: $2,200,000.00 Grant Number: B-22-CP-FL-0230 The next step is for you to provide 1) your organization's Authorized Representative, 2) a detailed project narrative, 3) a line -item budget, and 4) certain Federal forms. The detailed project narrative should capture the maximum anticipated scope of the proposal, not just a single activity that the CPF grant is going toward. It should include all contemplated actions that are part of the project. The line -item budget should identify the use of the CPF grant funds in context of the full project budget. The "FY2022 Community Project Funding Grant Guide" (CPF Grant Guide) provides instructions for completing the requested information and filling out the required administrative forms. The CPF Grant Guide also provides information on the appropriations -specific and cross -cutting Federal requirements that govern these funds. Links to the required forms are included in the Grant Guide as an attachement to this letter and on our website at this link: ilttps ://w vw.hud. gov/program__offices/comm_planning!edi-grants Island District Development Annual Property Operating Data - 30 Year Projection Year 1-10 Cost Increase Year 11-20 Cost Increase Year 21-30 Factor Factor Gross Revenues $ 531,210.80 5.90% $ 562,552.24 5.90% $ 595,742.82 Overhead Expesnes $ (80,571.81) 5.90% $ (85,325.54) 5.90% $ (90,359.75) Property Taxes $ (138,705.88) 5.90% $ (146,889.53) 5.90% $ (155,556.01) Net Income $ 311,933.11 $ 330,337.16 $ 349,827.06 Note: Cost of living factor as per Social Security and Sec 8 trend in increase over 10 year period average. No Financing expected for this project DECLARATION OF FINANCIAL INTERESTS 1. Do you have any past due financial obligations with the City of Miami? Single Family Housing Loans Multi -Family Housing Rehab CDBG Commercial Loan Project U.S. HUD Section 108 Loan Other HUD Funded Programs Others (liens, fines, loans, Occupational licenses, etc.) If YES, please explain: 2. Do you have any past due financial obligations] th Miami Capital Development, Inc. (MCDI)? YES ❑ NO If YES, please explain: 3. Are you a relative of or do you have any business or financial interests with any elected City of Miami Official, City of Miami Employee, or Member of the City's Advisory Boards? YES ❑ NO If YES, please explain: Ai N Any false information provided on this application will be reason for rejection and disqualification of your project -funding request to the City of Miami. The answers to the foregoing questions are correctly stated to the best of my knowledge and belief. VV/t 1.4-rit- J4 "r�1� k ii ice V 4 C-CAA. ITE: C/i,7/'ji, Name and Title of Authorized Representative / DATE: 1 Signat e o A thorize epresentative CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS PRIMARY COVERED TRANSACTIONS 1, The Applicant certifies to the best of its knowledge and belief, that it and its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from covered transactions by any Federal department or agency. b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or Local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or falsification or destruction of records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State, or Local) with commission of any of the offenses enumerated in paragraph 1.b of this certification; and d. Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State, or Local) terminated for cause or default. 2. Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall submit an explanation to the City of Miami. w z-Mk_ c, 16/ APPLICANY /DEVELOPER / — (/lP�l 6 T , PRINT NAME OF CE IFYING OFFICIAL SIGNATUI F ING OFFICIAL DATE 6,0.P4„ MARCELO FERNANDES r r °* Commission # GG 283765 c` Expires April 12, 2023 Bond®d7hmBudge NOUrySerk4i SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(A). FLORIDA STATUTES ON PUBLIC ENTITY CRIME THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. 1. This sworn statement is submitted to Bytth-4- „kepi) t /6. sl viC ff it ,L - I- Ores, (print this individual's name and title) %i -? Am-kftaz 7siA-no For � llll 6:1(35o,-{ / }-L /N i -NPR-A/c: //lc (print name of entity submitting statements) Whose business address is <-12(3 o 6/:-/tiewo A-Vr-Alu /km/ >r . ?/3_3 and if applicable is Federal Employer Identification Number (FEIN) is 445-2ti35 38 If the entity has no FEIN, include the Social Security Number of the individual signing this sworn Statement: 2. I understand that a "public entity crime" as defined in paragraph 287.133(1)(a), Florida Statutes, mean a violation of any state or federal law by a person with respect to and directly related to the transactions of business with any public entity or with an agency or political subdivision of any other state or with the United States including, but not limited to any bid or contract for goods or services to be provided to any public entity or any agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes means a finding of guilt or a conviction of a public entity crime, with or without adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a Jury verdict, non -jury trial, or entry of a plea of guilty or nolo contendere. 4. I understand that an "affiliate" as defined in paragraph 287.133(1)(a), Florida Statutes, means: 1. A predecessor or successor of a person convicted of public entity crime; or 2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 5. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, executives, partners, shareholders, employees, members, and agents who are active in management of an entity. 6. Based on information and belief, the statement which I have marked below is true in a relation to the entity submitting this sworn statement. (Please indicate which statement applies). Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or any affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months. Ch.., The entity submitting this sworn statement, or one or more of its officers, directors, ecutives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months. AND (Please indicate which additional statement applies). l(T-f) The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months. However, there has been a subsequent proceeding before a Hearing Officers of the State of Florida, Division of Administrative Hearings and the Final Order by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attached is a copy of the final order). I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THE PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED AND FOR THE PERIOD OF THE CONTRACT ENTERED INTO, WHICHEVER PERIOD IS LONGER. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. (Signature) Sworn to me and subscribed before me this 2 - day of Personally Wkr J i' 65 h k ✓i� larprcnttrastfrereiffifIratturi Notary Public —State of rLtln1 ()A A My (Type of Identification) ,213. known commission expires (Printed, typed or commissioned name of notary public) 9lraravm�i, MARCELO FERNANDES Commission # GG 283765 Expires Arid 12,2023 1 QFBondodThruBudget NotarySlrvklti CITY OF MIAMI DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT RESILIENCY CHECKLIST The following list of resilience criteria items is included as part of the Request for Proposal. Please indicate which will be incorporated into the properties being constructed or rehabilitated. First` Category Items: (Must check all items) ✓ Water -Conserving Appliances and Fixtures (toilets, shower heads, faucets) f% Energy Star Appliances (refrigerator and stove) Efficient Lightning Interior/ Exterior t/ Construction Waste Management ✓ Low/no Volatile Organic Compounds (VOC) Paints and Primers try _Exhaust Fans — Bathroom/Kitchen (j Storm Drain Labels Building Maintenance Manual 1,f�enant's Manual Tenant Orientation Plant native shade trees on -site, especially near the building as a cooling feature, Second Category: Five (5) Items: (Must pick 5 from this second category) Recycled Content Material V Reduce Heat -Island Effect: Roofing Reducing Heat-island Effect: Planting Urea Formaldehyde -free Composite Wood / Green label Certified Floor Coverings Water Heaters: Mold Prevention Materials in Wet Areas: Surfaces/ Tub and Shower Enclosures Water Drainage V Clothes Dryer Exhaust Integrated Pest Management Lead -Safe Work Practices Healthy Flooring Materials: alternative sources Water -Permeable Walkways Water -Permeable Parking Areas Smoke -free Building Combustion Equipment (includes space & water -heating equipment) Provide essential equipment, especially electrical/HVAC, is elevated 2-5 ft above base flood elev. On -site backup power generation. Create or ensure access to parks and open/natural spaces. Ensure and/or facilitate connectivity to public transit. Ensure a safe a pleasant pedestrian through bike lanes, shaded sidewalks, and LED street lights, Parking electric vehicle (EV) charger capability. EV charger in at least one parking spot INSURANCE REQUIREMENTS FOR A CERTIFICATE OF INSURANCE - CD CONSTRUCTION PROJECTS CONSTRUCTION REQUIREMENTS- DEVELOPER I. Commercial General Liability (Primary and Non Contributory) Limits of Liability Bodily Injury and Property Damage Liability Each Occurrence $1,000,000 General Aggregate Limit $ 2,000,000 Products/Completed Operations $ 1,000,000 Personal and Advertising Injury $1,000,000 Endorsements Required City of Miami included as an Additional Insured Premises and Operations Liability Contingent Liability Contractual Liability Explosion, Collapse and Underground Hazard II. Business Automobile Liability Limits of Liability Bodily Injury and Property Damage Liability Combined Single Limit Any Auto Including Hired, Borrowed or Non -Owned Autos Any One Accident $ 1,000,000 Endorsements Required City of Miami included as an Additional Insured III. Worker's Compensation Limits of Liability Statutory -State of Florida Waiver of subrogation IV. Employer's Liability A. Limits of Liability $100,000 for bodily injury caused by an accident, each accident $100,000 for bodily injury caused by disease, each employee $500,000 for bodily injury caused by disease, policy limit The above policies shall provide the City of Miami with written notice of cancellation or material change from the insurer not less than (30) days prior to any such cancellation or material change. Companies authorized to do business in the State of Florida, with the following qualifications, shall issue all insurance policies required above: The company must be rated no less than "A-" 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. All policies and /or certificates of insurance are subject to review and verification by Risk Management prior to insurance approval. INSURANCE REQUIREMENTS FOR A CERTIFICATE OF INSURANCE - CONSTRUCTION REQUIREMENTS CD PROJECTS I. Commercial General Liability A. Limits of Liability Bodily Injury and Property Damage Liability Each Occurrence $1,000,000 General Aggregate Limit $ 2,000,000 Products/Completed Operations $ 1,000,000 Personal and Advertising Injury $ 1,000,000 B. Endorsements Required City of Miami listed as an additional insured Contingent and Contractual Liability Premises and Operations Liability Explosion, Collapse and Underground Hazard Primary Insurance Clause Endorsement II. Business Automobile Liability A. Limits of Liability Bodily Injury and Property Damage Liability Combined Single Limit Any Auto Including Hired, Borrowed or Non -Owned Autos Any One Accident $ 1,000,000 B. Endorsements Required City of Miami listed as an Additional Insured III. Worker's Compensation Limits of Liability Statutory -State of Florida Waiver of subrogation Employer's Liability B. Limits of Liability $1,000,000 for bodily injury caused by an accident, each accident. $1,000,000 for bodily injury caused by disease, each employee $1,000,000 for bodily injury caused by disease, policy limit IV. Umbrella Policy A. Limits of Liability Bodily Injury and Property Damage Liability Each Occurrence $2,000,000 Aggregate $2,000,000 City of Miami listed as an additional insured Excess Follow Form over all applicable liability policies contained herein V. Owners & Contractor's Protective Each Occurrence General Aggregate City of Miami listed as named insured $1,000,000 $1,000,000 VI. Payment and Performance Bond $ Full Value City of Miami listed as an Obligee VII. Builder's Risk/Installation Floater Causes of Loss: All Risk of Direct Physical Damage or Loss Valuation: Replacement Cost Deductibles: 5% Wind, Hail, and Flood Coverage Extensions included City of Miami listed as an additional insured and loss payee The above policies shall provide the City of Miami with written notice of cancellation or material change from the insurer not less than (30) days prior to any such cancellation or material change, or in accordance to policy provisions. Companies authorized to do business in the State of Florida, with the following qualifications, shall issue all insurance policies required above: The company must be rated no less than "A-" 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. All policies and /or certificates of insurance are subject to review and verification by Risk Management prior to insurance approval. APPLICANT: AUTHORIZED REPRESENTATIVE STATEMENT Provide the name(s) and telephone number of the person(s) who has been designated the responsibility within the following areas: POSITION Chairman of the Board Exec. Director of the Project Project Director Affirmative Action Officer Personnel Officer Fiscal Management Officer NAME: TITLE: NAM E 6"0 `--• Rat L J o. -v:' ) r /L- Y1(:'b ( U)& 6A-14-77) A4(iwCA 1. PERSON(S) AUTHORIZED TO SIGN CHECKS Y►I 111501--.- h e, AjL � f ul - " _/ o TELEPHONE: � `'f L IJ 1 SIGNATURE: NAME: Prc'� ``rl,�, TITLE: f £'+ ) h— TELEPHONE: 'A 0 I 61 TURE: TELEPHONE NUMBER 3c ' `-� �f L tY V 3 [s /3 �y `/N6 ).s3 c/ (/6 (-1(4 (6 I.i2{� SIGN 2. PERSON(S AUTHORIZED TO SIGN REIMBURSEMENT PAC AGES NAME: OVA AI r W NAME: ,� -'). , t LjAq— TITLE: A[ -C I e TELEPHONE: `ice SIGNATURE: NAME: TITLE: TELEPHONE: SIGNATURE: eitUrijcf TITLE: V TELEPHONE: 13 SIGNATURE: 3. PERSON(S) AUTHORIZED TO SIGN CONTRACTS h0 TITLE: V GP 12 0 f i 3 TELEPHONE: ,3,. Li LA(Q If) _� 3 SIGNATURE: 1jI,t, A �-- rNAME: �r! UT CITY OF MIAMI DEPARTMENT OF HOUSING & COMMUNITY DEVELOPMENT CERTIFICATION OF SOUND FISCAL MANAGEMENT We, Mature J "' l oo k, as the Executive Director, and J nt-Vii ICE/ (Full Name) Name) (Full Name) as the Chief Fiscal Officer of . 1 LA G-i a, 1 61.1nowledge that as a condition of (Organization) receiving funds from the City of Miami, have the need to establish and m intain so nd fin n ial a d fiscal controls and management systems. We hereby certify that "%f ( 4 1 ,(k t 1 (Organization) has established internal controls which are adequate to safeguard the assets of the agency, monitor the accuracy and reliability c�fi _accounting data, promote operating efficiency and insure compliance with prescribed policies . prose• res. Signature (Executive Director) Signature (Chief Fiscal Officer) Cr�L 2 Dat am a duly licensed certifie public accountant and have been engaged to review the accounting systems of 6{V5,} A, _which is private (_ profit/,»non-profit) organization (Organization) that will operate programs for the City of Miami. I have reviewed the financial systems that this Agency has established. This review was completed on few 1s 2.0 Z1 . At the time of review, the Agency had established internal controls which were adequate to safeguard the assets of the Agency, monitor the accuracy and reliability of accounting data, promote operating efficiency, and insure compliance with prescribed management policies. C.P.A61A c - (Name of Firm) 4-u iDLey (Typed Name f Accountant) electronic authorization 08/22/22 C.P.A. Audfey Porter, BAS (Date) (Signature of Accountant) If any modifications are required to this certificate due to the nature of the engagement between the Agency and the C.P.A., attach a substitute report as explanation. APPLICANT: DEPARTMENT HOUSING AND COMMUNITY DEVELOPMENT ESTIMATE OF CITY AND COUNTY IMPACT FEES CITY OF MIAMI ITEM RATE SQ. FOOTAGE FAR TOTAL Poi i'e.e, S. 1 L Li 2`1 ,,,,,i A ``f, Ii to Voo-Re,s,(40)- ,,,,1 $, 55,1 W `1, t2g--i',el. 42w, (ass. Un Co mvvveve;\."1 1 okl tv 4 , - 5- 1 `-7, a nV sC 4 50 z 51 CipurktvC:on t/ o i ,r 14, 7 5 1 5, v Op S �i -C-- � 4 3,-7 .5 5 Flit ti Ie 5cut, If (pt ci 2,c1 ,n a-5 A I"1 oiS" i Put) �4sat,,, .c-\ FitZr 4 ' 3 S5 7, o 0 0 S�°'F1- i 2 , La wOA gts4tv01-w,,I. Ci/b .- , 35 5 7, poO �G1 - 4a,1/4LISC C-, /0 * , 355 5,aa0 5p .- 4 ,11 ?s Cle,,rcil evtAQ, 1.ry `' IDio3 29 uo;rS 1U, 5 2-1 PrAvl(-s- { R 0,..,4,0. . ov, 112 , 01 d , 8 1- 2'1 ;, ri ; k-S 0.®I9 , n S 3 7 e) Please contact the City of Miami Planning and Zoning Department for City impact Fee estimates. MIAMI-DADE COUNTY ITEM RATE SQ. FOOTAGE FAR TOTAL 130hb1 41 2,4+3.77 2ci/ (11, (a H 75,7�36.s7 ki ;,r�. $ Z1,i\ 3 3 L, PO t.se, f 1-, lvt . 1.3.' 1, „ l� G\ Vie- 0 2, 1,O 177 '7 t 4 i 1 Sv1Nun1 4 . Li046 ri, 40P-i 5er“- $ 1ci, 302. 441 1,4/ F . Li01'+.8 h,5-0 0 SPk I, *i,f-t I logo f / g. f- . t-t bLi. % c , o t7D S Gl'Erl' '2-0 1-1