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Resolution No CRA 04-19-1092RESOLUTION NO. CRA 04-19-1092 A Resolution authorizing the SMCRA Director to execute a contract and all ancillary documents with Miami -Dade County relating to Community Development Block Grant (CDBG) contributions for the Madison Square project. WHEREAS, the SMCRA inter -local agreement with Miami -Dade County describes the Madison Square project as a SMCRA mixed -use redevelopment proposal intended to create an anchor for the north end of the Church Street (a current streetscape improvement project) and to help stimulate revitalization efforts in the area"; and WHEREAS, the SMCRA has acquired the property to build Madison Square, partially using Community Development Block Grant (CDBG) money from Miami Dade County (MDC); and WHEREAS, the $394,000 of CDBG money was received by the SMCRA in 2007, but the County never signed the grant agreements nor recorded them with the clerk; and WHEREAS, the original grant agreements have caused problems with the ability of the developer, Abreu Development, to obtain financing and new grant agreements are required to close the transaction; and WHEREAS, the County Attorney and Public Housing and Community Development Department have determined that the new grant agreements need to be approved by the County Commission before being signed; and WHEREAS, in 2007 the SMCRA approved Resolution 28-07-281 which authorized the Executive Director to sign the old grant agreements and related documents, that resolution does not authorize the SMCRA Director to sign the new grant agreements and ancillary documents; and WHEREAS, the SMCRA desires to have these matters approved during the February cycle of the County Commission and urges MDC to provide all waivers necessary to accomplish this goal; and WHEREAS, the SMCRA desires to accomplish the objectives as outlined in the revised grant agreement with Miami -Dade County. NOW THEREFORE BE IT RESOLVED BY THE COMMUNITY REDEVELOPMENT AGENCY OF THE CITY OF SOUTH MIAMI, FLORIDA THAT: Section 1. The South Miami Community Redevelopment Agency Board authorizes the SMCRA Executive Director to execute a contract and all ancillary Page 1 of 2 Res No. CRb-04-19-1092 documents with Miami -Dade County relating to Community Development Block Grant (CDBG) contributions for the Madison Square project that have been approved by the SMCRA general counsel and that do not increase the existing commitments that were previously made to the County; and urging the Miami -Dade County Commission to approve the new grant agreements as quickly as possible. Section 2. Severability. If any section clause, sentence, or phrase of this resolution is for any reason held invalid or unconstitutional by a court of competent jurisdiction, the holding shall not affect the validity of the remaining portions of this resolution. Section 3. Effective Date. This resolution shall become effective immediately upon adoption by vote of the Agency. PASSED AND ADOPTED this 5th day of February, 2019. ATTEST: APPROVED: a.P W GEN YSECRE ARY (!HAIKMAN READ AND APPROVED AS TO FORM, AGENCY VOTE: 4-o LANGUAGE, L ITY AND Chairman Stoddard: Yea EXECUTIO OF Vice Chairman Harris: yea Member Gil: Vea Member Liebman: yea Member Welsh: yea Member Jackson: kbsent �r*Lt E Member Kelly: yea Page 2 of 2 Agenda Item No:1. Special South Miami Community Redevelopment Agency Agenda Item Report Meeting Date: February 5, 2019 Submitted by: Evan Fancher Submitting Department: Community Redevelopment Agency Item Type: Resolution Agenda Section: Subject: A Resolution authorizing the SMCRA Director to execute a contract and all ancillary documents with Miami -Dade County relating to Community Development Block Grant (CDBG) contributions for the Madison Square project. Suggested Action: Attachments: Madison Square Memo.doc Resolution_granting_Dir Auth to sign_new_Co�grant_docs_2_ docx Authorizing Signatures Form FY 2018.doc Developer's Affidavit TAxes paid.docx Contractor Due Dilligence.docx Uniform Affidavits (52) Attachment is Fillable 8-17-16.doc CERTIFICATION REGARDING LOBBYING.DOC Disclosure About Related Parties.doc Resolution Authorizing Execution of A Contract FY 2018.doc Subcontractor Supplier Listing Attachment H(53) - Attachment Blank 8-17-....doc Fair Subcontracting Policies (51)_Blank Attachment.doc Agreement for Records review and Retention (CD)_Blank Attachment.docx Ethic Commission Disclosure Form for all PHCD Program Applicants.pdf CDBG Attachment B-2(44).docx List of Persons - Business Assisted - Economic Development (28).xlsx Required Docs for Income Verification LMA-LMJ-LMC-LMH (58).docx Job Creation Verification (NON-NRSA) (25) 4-24-18.doc INTAKE FORM for LMI-LMC-LMJ-LMH (17)-Spanish Version 4-18-18 Spanish.docx INTAKE FORM for LMI-LMC-LMJ-LMH (17) 4-16-18.docx Quarterly Expenditure and Progress Report (14) sc.docx Performance & Benefit Data - Economic Development - Suplemental to Quarterly Expenditure &Job Created(16).docx Job Creation Verification (NRSA) (24).doc Employee Roster as Roster as of (20).xlsx Job Creation Business Agreement Form rev 6-21-12.pdf Employee Roster as Roster as of (19).xlsx ED Checklist.doc 2 e®e Mma ��I„I,�l SMCRA Zwmgo.iery�mnaoot acammUe � w+er- CITY OF SOUTH MIAMI COMMUNITY REDEVELOPMENT AGENCY OFFICE OF THE DIRECTOR INTER -OFFICE MEMORANDUM To: The Honorable Chairman & Members of the SMCRA Board FROM: Evan Fancher, Director DATE: February S, 2019 SUBJECT: A resolution authorizing the SMCRA Director to execute a contract and all ancillary documents with Miami -Dade County relating to Community Development Block Grant (CDBG) contributions for the Madison Square project. BACKGROUND: The 2004 Redevelopment Plan describes Madison Square as "a SMCRA mixed -use redevelopment proposal intended to create an anchor for the north end of the Church Street (a current streetscape improvement project) and to help stimulate revitalization efforts in the area." The plan called for the construction of the project to be completed by 2007-2008. The SMCRA has been acquiring properties to effectuate the goal of building Madison Square. In 2007, the city used the US HUD's Community Development Block Grant program to acquire the land necessary to build the project ($394,000). The CDBG money used to purchase the property brought with it restrictions to create and retain 12 full-time permanent jobs within the commercial/retail center (for at least five years after completion of the project). The agreement between Miami -Dade County and the SMCRA for the CDBG also calls for the completion of the project within three years. The SMCRA signed the documents, but the County never did. Staff met with County officials, as well as the Developer, and determined that the old documents are outdated and unable to be signed by the County. We have agreed on a path forward, but the SMCRA Director needs authorization to sign the documents and the County Commission needs to approve the new agreement. In preparing the agenda item for the County Commission, the SMCRA has already been presented with 26 documents to sign to effectuate the agreement. Therefore, the SMCRA Director needs broad authority to effectuate all documents that will be needed. The County has also requested this resolution that makes clear that the Director is empowered to do so. ATTACHMENTS: County Documents already received 3 AUTHORIZING SIGNATURES CONTRACTOR: DATE: This form certifies the names, titles and signatures of individuals authorized by the contractor's by-laws or board resolution to sign contracts, checks, budget revision requests, payment requests and any other requests, (e.g. purchase requisitions, purchase orders, receiving reports, direct bills) that are required by the Public Housing and Community Development (PHCD) for disbursement of funds. NAME TITLE SIGNATURE (Type or Print) (Type or Print) I. Prime Contracts Subcontracts II. Checks (List Amount Limits) III. Budget Revision Requests L NAME TITLE SIGNATURE (Type or Print) (Type or Print) IV. Payment Requests V. Other Administrative Matters (e.g. Status Reports, Purchase Orders, Travel Requests) * These signatures authorized are retained by PHCD for auditing purposes. * You are required to submit updates to this list as it becomes necessary. GO PUBLIC HOUSING AND COMMUNITY DEVELOPMENT DEVELOPER'S AFFIDAVIT THAT MIAMI-DADE COUNTY TAXES, FEES AND PARKING TICKETS HAVE BEEN PAID (Section 2-8.1 (c) of the Code of Miami -Dade County, as amended by Ordinance No. 00-30) and THAT DEVELOPER IS NOT IN ARREARS TO THE COUNTY (Section 2-8.1 (h) of the Code of Miami -Dade County, as amended by Ordinance No.00-67) I, . being first duly sworn, hereby state and certify that the foregoing statements are true and correct: That I am the Developer (if the Developer is an individual), or the (fill in the title of the position held with the Developer) of the Developer. 2. That the Developer has paid all delinquent and currently due fees or taxes (including but not limited to, real and personal property taxes, utility taxes, and occupational taxes) collected in the normal course by the Miami -Dade County Tax Collector, and County issued parking tickets for vehicles registered in the name of the above developer, have been paid. 3. That the Developer is not in arrears in excess of the enforcement threshold under any contract, final non -appeasable judgment, or lien with Miami -Dade County, or any of its agencies or instrumentalities, including the Public Health Trust, either directly or indirectly through a firm, corporation, partnership or joint venture in which the Developer has a controlling financial interest. For purposes hereof, the term "enforcement threshold" means any arrearage under any individual contract, non -appeal able judgment, or lien with Miami -Dade County that exceeds $25,000 and has been delinquent for greater than 180 days. For purposes hereof, the term "controlling financial interest' means ownership, directly or indirectly, of ten percent or more of the outstanding capital stock in any corporation, or a direct or indirect interest of ten percent or more in a firm, partnership, or other business entity. By: 20 Date Signature of Affiant Printed Name of Affiant and Title Federal Employer Identification Number Printed Name of Firm Address of Firm SUBSCRIBEDAND SWORN TO (oraffirmed) before methis day of 20 by He/She is personally known to me or has presented as identification. Type of Identification Signature of Notary Print or Stamp Name of Notary Notary Public -State of Notary Seal Serial Number Expiration Date 0 MM PUBLIC HOUSING AND COMMUNITY DEVELOPMENT CONTRACTOR DUE DILIGENCE AFFIDAVIT Per Miami -Dade County Board of County Commissioners (Board) Resolution No. Rf3-14, County Vendors and Contractors shall disclose the following as a condition of award for any contract that exceeds one million dollars ($1,000,000) or that otherwise must be presented to the Board for approval: (1) Provide a list of all lawsuits in the five (5) years prior to bid or proposal submittal that have been filed against the firm, its directors, partners, principals and/or board members based on a breach of contract by the fine; include the case name, number and disposition; (2) Provide a list of any instances in the five (5) years prior to bid or proposal submittal where the firm has defaulted; include a brief description of the circumstances; (3) Provide a list of any instances in the five (5) years prior to bid or proposal submittal where the firm has been debarred or received a formal notice of non-compliance or non-performance, such as a notice to cure or a suspension from participating or bidding for contracts, whether related to Miami -Dade County or not. All of the above information shall be attached to the executed affidavit and submitted to the Procurement Contracting Officer (PCO)/ AE Selection Coordinator overseeing this solicitation. The Vendor/Contractor attests to providing all of the above information, if applicable, to the PCO. Contract No.: Contract Title: Notary Federal Employer Identification Number (FEIN): Pdnted Name of Affiant Printed Title of Affiant Signature of Affiant Name of Firm Date Address of Firm Stale Zip Code Notary Public Information County of Subscribed and sworn to (or affirmed) before methis day of, 20_ By He or she is personally known to me ❑ or has produced identification ❑ Type of identification produced Signature of Notary Public Print or Stamp of Notary Public 2/2014 Serial Number Expiration Date Notary Public Seal g MIAMIDADE E PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) UNIFORM AFFIDAVITS ATTACHMENT Federal Employer Identification Number (FEIN) Dun & Bradstreet Number (D-U-N-SO) A) Name of Entity, Individual(s), Partners or Corporation B) Doing Business As (If same as line A, leave blank) Street Address (P.O. Box Number is not permitted) City State (U.S.A) Country Zip Code 1. MIAMI-DADE COUNTY OWNERSHIP DISCLOSUREAFFIDAWT (Sec. 2-8.1 of the Miami -Dade County Code) Firms registered to do business with Miami -Dade County, shall require the person contracting or transacting such business with the County to disclose under oath his or her full legal name, and business address. Such contract or transaction shall also require the disclosure under oath of the full legal name and business address of all individuals having any interest (legal, equitable, beneficial or otherwise) in the contract other than subcontractors, malerialmen, suppliers, laborers or lenders. Post office box addresses shall not be accepted hereunder. If the contract or business transaction is with a corporation the foregoing information shall be provided for each officer and director and each stockholder holding, directly or indirectly, five (5) percent or more of the outstanding stock in the corporation. If the contract or business transaction is with a partnership, the foregoing information shall be provided for each partner. If the contract or business transaction is with a trust, the foregoing information shall be provided for the trustee and each beneficiary of the trust. The foregoing disclosure requirements shall not apply to contracts with publicly - traded corporations, or to contracts with the United Stales or any department or agency thereof, the State or any political subdivision or agency thereof, or any municipality of this State. Use duplicate page if needed for additional names. If no officer, director or stockholder owns (5%) ormore of stock, please write "None" below. PRINC( IPA FULL LEGAL NAME TITLE ADDRESS OWNERS CHECK BOXES BELOW FULL LEGAL NAME TITLE a_ x N ; O LL O X ADDRESS GENDER RACE I ETHNICITY M F m m m u a s m a m m a"w E�` z Q N e N za o ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 01010101 ❑ 1 ❑ ❑ If a percentage of the firm is owned by a publicly traded corporation, Indicate below in the space 'Other Corporations' OTHER CORPORATIONS ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 10 Pagel Of 9 CD/52/31413N MIAMH)AM PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) UNIFORM AFFIDAVITS 2. MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT (County Ordinance No. 90-133, amending Section 2.8-1 (d) (2) of the Miami -Dade County Code) The following information is for compliance with all items in the aforementioned Section: 1. Does your firm have a collective bargaining agreement with its employees? Yes ❑ No ❑ 2. Does your firth provide paid health rare benefits for its employees? Yes ❑ No ❑ 3. Provide a current breakdown (number of persons) in your firm's work force indicating race, national origin and gender. 3. MIAMI-DADE EMPLOYMENT DRUG -FREE WORKPLACE AFFIDAVIT (Section 2-8.1.2(b) of the Miami -Dade County Code) All persons and entities that contract with Miami -Dade County are required to certify that they will maintain a drug -free workplace and such persons and entities are required to provide notice to employees and impose sanctions for drug violations occurring in the workplace. In compliance with Ordinance No. 92-15 of the Code of Miami -Dade County, the above named firm is providing a drug -free workplace. A written statement to each employee shall inform the employee about: 1. Danger of drug abuse in the workplace 2. The firm's policy of maintaining a drug -free environment at all work places 3. Availability of drug counseling, rehabilitation and employee assistance programs 4. Penalties that may be imposed upon employees for drug abuse violations The firth shall also require an employee to sign a statement, as a condition of employment that the employee will abide by the terms of the drug -free workplace policy and notify the employer of any criminal drug conviction occurring no later than five (5) days after receiving notice of such conviction and impose appropriate personnel action against the employee up to and including termination. Firms may also comply with the County's Drug Free Workplace Certification where a person or entity is required to have a drug -free workplace policy by another local, state or federal agency, or maintains such a policy of its own accord and such policy meets the intent of this ordinance. 4. MUIMPDADE COUNTY DISABILfTYAND NON-DISCRIMINATION AFFIDAVIT (Article 1, Section 2-8.1.5 Resolution R-182-00 Amending R-385-95 of the Miami -Dade County Code) Firms transacting business with Miami -Dade County shall provide an affidavit indicating compliance with all requirements of the Americans with Disabilities Act (A.D.A.). I, state that this firm, is in compliance with and agrees to continue to comply with, and assure that any subcontractor, or third party contractor shall comply with all applicable requirements of the laws including, but not limited to, those provisions pertaining to employment, provision of programs and services, transportation, communications, access to facilities, renovations, and new construction. The American with Disabilities Act of 1990 (AD.A.), Pub. L. 101-336, 104 Stat 327, 42 U.S.C. Sections 225 and 611 including Titles I, II, III, IV and V. The Rehabilitation Act of 1973, 29 U.S.C. Section 794 The Federal Transit Act, as amended, 49 U.S.C. Section 1612 The Fair Housing Act as amended, 42 U.S.C. Section 3601-3631 I hereby affirm that I am in compliance with the below sections: Section 2-10.4(4)(a) of the Code of Miami -Dade County (Ordinance No. 82-37), which requires that all property licensed architectural, engineering, landscape architectural, and land surveyors have an affirmative action plan on file with Miami -Dade County Section 2-8.1.5 of the Code of Miami -Dade County, which requires that firms that have annual gross revenues in excess of five Page 2 of 9 CD/52/31413/V MIAMI DADE Er PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) UNIFORM AFFIDAVITS (5) million dollars have an affirmative action plan and procurement policy on file with Miami -Dade County. Firms that have a Board of Directors that are representative of the population make-up of the nation may be exempt. 5. MI AMI-DADE COUNTY DEBARMENT DISCLOSUREAFF/DAVIT (Section 10.38 of the Miami -Dade County Code) Firms wishing to do business with Miami -Dade County must certify that it's contractors, subcontractors, officers, principals, stockholders, or affiliates are not debarred by the County before submitting a bid. I, confirm that none of this firms agents, officers, principals, stockholders, subcontractors or their affiliates are debarred by Miami - Dade County. 5. MIAMI-DADE COUNTYAFFIDAVIT RELATING TO INDIVIDUALS AND EN77TIES ATTESTING BEING CURRENT /N THEIR OBLIGATIONS TO MIAMI-DADE COUNTY (Ordinance 99-162, amending Section 2-8. 1; Ordinance 00-30, amending Section 2-8.1 (c), and Ordinance 00.67, amending 2-8.1 (h), of the Miami -Dade County Code) Firms wishing to transact business with Miami -Dade County must certify that all delinquent and currently due fees, taxes and parking tickets have been paid and no individual or entity in arrears in any payment under a contract, promissory note or other document with the County shall be allowed to receive any new business. I, confirm that all delinquent and currently due fees or taxes including, but not limited to, real and personal property taxes, convention and tourist development taxes, utility taxes, and Local Business Tax Receipt collected in the normal course by the Miami -Dade County Tax Collector and County issued parking tickets for vehicles registered in the name of the above firm, have been paid. 7. MIAMPDADE COUNTY CODE OF BUSINESS ETHICS AFFIDAVIT (Article 1, Section 2-8. Ili) of the Miami -Dade County Code through (6) and (9) of the County Code and County Ordinance No 00-1 amending Section 2-11. 1(c) of the County Code) Firms wishing to transact business with Miami -Dade County must certify that it has adopted a Code that complies with the requirements of Section 2-8.1 of the County Code. The Code of Business Ethics shall apply to all business that the contractor does with the County and shall, at a minimum; require the contractor to comply with all applicable governmental rules and regulations. I confirm that this firm has adopted a Code of business ethics which complies with the requirements of Sections 2-8.1 of the County Code, and that such code of business ethics shall apply to all business that this firm does with the County and shall, at a minimum, require the contractor to comply with all applicable governmental rules and regulations. 8. MIAMI-DADE COUNTY FAMILY LEAVE AFFIDAVIT (Article V of Chapter 11, of the Miami -Dade County Code) Firms contracting business with Miami -Dade County, which have more than fifty (50) employees for each working day during each of twenty (20) or more work weeks in the current or preceding calendar year, are required to certify that they provide family leave to their employees. Finns with less than the number of employees indicated above are exempt from this requirement, but must indicate by letter (signed by an authorized agent) that it does not have the minimum number of employees required by the County Code. I confirm that if applicable, this firm complies with Article V of Chapter 11 of the County Code, which requires that firms contracting business with Miami -Dade County which have more than fifty (50) employees for each working day during each of twenty (20) or more work weeks in the current or preceding calendar year are required to certify that they provide family leave to their employees. 9. MUAMI-DADE COUNTY LIVING WAGE AFFIDAVIT (Section 2-8.9 of the of the Miami -Dade County Code) All applicable contractors entering into a contract with the County shall agree to pay the prevailing living wage required by this section of the County Code. I confirm that if applicable, this firm complies with Section 2-8.9 of the County Code, which requires that all applicable employers entering a contract with Miami -Dade County shall pay the prevailing living wage required by the section of the County Code. 12 Page 3 of 9 CD/52/31413fV MIAMFd1DE 0 PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) UNIFORM AFFIDAVITS 10. MIAMI-DADE COUNTY DOMESTIC LEAVE AND REPORTING AFFIDAVIT (Article 8, Section 1 1A-60 — 1 IA-67 of the of the Miami -Dade County Code) Firms wishing to transact business with Miami -Dade County must certify that it is in compliance with the Domestic Leave Ordinance. I confirm that if applicable, this firm complies with the Domestic Leave Ordinance. This ordinance applies to employers that have, in the regular course of business, fifty (50) or more employees working in Miami -Dade County for each working day during the current or preceding calendar year. 11. M/AMPDADE COUNTY CRIMINAL RECORD AFFIDAVIT (Section 2-8.6 of the Miami -Dade County Code) The individual or entity entering into a contract or receiving funding from the County ❑ has ❑ has not as of the date of this affidavit been convicted of a felony during the past ten (10) years. An officer, director, or executive of the entity entering into a contract or receiving funding from the County ❑ has ❑ has not as of this date been convicted of a felony during the past ten (10) years. Swom to and subscribed before me this Personally Or produced identification (Type of identification) (Signature) day of 20 Notary Public State of My commission expires (Print, type or stamp commission name of notary public) 13 Page 4 of 9 CD/52/31413/V MIAMIDADE C _ _ PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) UNIFORM AFFIDAVITS SWORN STATEMENT PURSUANT TO SECTION 287.133 (3) (a) FLORIDA STATUTES ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. 1.- This form statement is submitted to by for (Print individual's name and title) (Print name of entity submitting sworn statement) whose business address is and if applicable its Federal Employer Identification Number (FEIN) is If the entity has no FEIN, include the Social Security Number (SSN) of the individual signing this sworn statement: SSN - - 2: 1 understand that a "public entity crime" as defined in paragraph 287.133 (1) (g), Florida Statutes, means a violation of any state or federal law by a person with respect to, and directly related to the 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 public entity or agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misinterpretation. 3.- 1 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 an adjudication of guilt, in a 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: 1 understand that an "Affiliate" as defined in paragraph 287.133 (1)(a), Florida Statutes means: a) A predecessor or successor of a person convicted of a public entity crime or; b) An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The 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 moths shall be considered an affiliate. 5: 1 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 within the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or 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 relation to the entity submitting this sworn statement. (Please indicate which statement applies) 14 Page 5 of 9 CD/52/31413N 6.. MIAMUNWE EMIR PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) UNIFORM AFFIDAVITS Neither the entity submitting sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. 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 an affiliate of the entity, or an affiliate of the entity had been charged with, and convicted of a public entity crime subsequent to July 1, 1989, AND (please indicate which additional statement applies). 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, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (attach a copy of the final order). I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THAT PUBLIC ENTITY PRIOR TO ENTRING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017 FLORIDA STATUTES FOR A CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. Sworn to and subscribed before me this day of Personally known Or produced identification Notary Public -State of _ My commission expires (Type of identification) (Signature) 20 (Print, type or stamp commission name of notary public) 15 Page 6 of 9 CD/52/31413/V MIAM MIMI PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) UNIFORM AFFIDAVITS AFFIDAVIT OF FINANCIAL AND CONFLICTS OF INTEREST 1: Do you have any past due financial obligations with Miami -Dade County? Single Family House Loans Yes ❑ No ❑ Multi -Family Housing Rehab Yes ❑ No ❑ CDBG Commercial Loan Project Yes ❑ No ❑ U.S.HUD Section 108 Loan Yes ❑ No ❑ Other HUD Funded Programs Yes ❑ No ❑ Other (liens, fines, loans, occupational licenses, etc.) Yes ❑ No ❑ If YES, please explain 2: Do you have any past due financial obligations with Miami -Dade County? YES ❑ NO ❑ If YES, please explain: 3.- Are you a relative of or do you have any business or financial interests with any elected Miami -Dade County official, Miami -Dade County Employee, or Member of Miami -Dade County's Advisory Boards? YES ❑ NO ❑ If YES, please explain: Any false information provided on this affidavit will be reason for rejection and disqualification of your project -funding request to Miami -Dade County The answers to the foregoing questions are correctly stated to the best of my knovdedge and belief. By: (Signature of Applicant) (Date) Sworn to and subscribed before me this day of Personally known Or produced identification (Type of identification) Notary Public -State of My commission expires 20 (Print, type or stamp commission name of notary public) 16 Page 7 of 9 CD/52/31413N MIAM ME PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) UNIFORM AFFIDAVITS COLLUSION AFFIDAVIT (Code of Miami -Dade County Section 2-8.1.1 and 10-33.1) (Ordinance No. 08-113) BEFORE ME, A NOTARY PUBLIC, personally appeared (Insert Name of Affiant) who being duly swom states: I am over 18 years of age, have personal knowledge of the facts stated in this affidavit and I am an owner, officer, director, principal shareholder and/or I am otherwise authorized to bind the bidder of this contract. I state that the bidder of this contract: ❑ is not related to any of the other parties bidding in the competitive solicitation, and that the contractor's proposal is genuine and not sham or collusive or made in the interest or on behalf of any person not therein named, and that the contractor has not, directly or indirectly, induced or solicited any other proposer to put in a sham proposal, or any other person, firm, or corporation to refrain from proposing, and that the proposer has not in any manner sought by collusion to secure to the proposer an advantage over any other proposer. OR ❑ is related to the following parties who bid in the solicitation which are identified and listed below: Note: Any person or entity that fails to submit this executed affidavit shall be ineligible for contract award. In the event a recommended contractor identifies related parties in the competitive solicitation its bid shall be presumed to be collusive and the recommended contractor shall be ineligible for award unless that presumption is rebutted by presentation of evidence as to the extent of ownership, control and management of such related parties in the preparation and submittal of such bids or proposals. Related parties shall mean bidders or proposers or the principals, corporate officers, and managers thereof which have a direct or indirect ownership interest in another bidder or proposer for the same agreement or in which a parent company or the principals thereof of one (1) bidder or proposer have a direct or indirect ownership interest in another bidder or proposer for the same agreement. Bids or proposals found to be collusive shall be rejected. By: Signature of Affiant Print Name of Affiant and Title all' _/_ _/ / / / /_/_/ Federal Employer Identification Number Print Name of Firm Address of Firm 17 Page 8 of 9 CD/52/31413N MIAM 111 PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) UNIFORM AFFIDAVITS SUBSCRIBED AND SWORN TO (or affirmed) before me this day of , 20_ He/She is personally known to me or has presented identification. Signature of Notary Print or Stamp Name of Notary Notary Public State of as Type of identification Serial Number Expiration Date Notary Seal `U. Page 9 of 9 CD/52/31413N CERTIFICATION REGARDING LOBBYING Certification for Contracts, Grants, Loans and Cooperative Agreements The undersigned certifies, to the best of his or her knowledge and belief, that: 1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. 2. If any of the funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. 3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreement in excess of $100,000) and that all subrecipients shall certify and disclose accordingly. 4. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. By: (Signature of Authorized Representative) Print: (Print Name of Firm and Authorized Representative) Title: Date: 19 Agency's letterhead SAMPLE AGENCY NAME DISCLOSURE ABOUT RELATED PARTIES (DATE) THERE ARE NO BOARD MEMBERS OF THE (AGENCY NAME) WHO HAVE ANY RELATIONSHIP OR HAVE MADE ANY TRANSACTION WITH OTHER ENTITIES THAT MIGHT RESULT IN A CONFLICT WITH (AGENCY NAME) OPERATIONS. 20 SAMPLE RESOLUTION AUTHORIZING EXECUTION OF A CONTRACT WITH MIAMI-DADE COUNTY AND FOR THE PROVISION WHEREAS, this Board desires to accomplish the objectives as outlined in the scope of service of the contract with Miami -Dade County. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF DIRECTORS of with Miami -Dade County for the maximum amount of $ the provision of authorizes to execute same for and on behalf of approves one (1) contract for services for the Fiscal Year 2018 and and The foregoing resolution was offered by , who moved its adoption, the motion was seconded by , and upon being put to a vote was as follows: The Chairperson/President thereupon declared this resolution duly passed and adopted this day of , Signature -Chairperson or Secretary Agency Seal 21 HIAM PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) ATTACHMENT H SUBCONTRACTOR/SUPPLIER LISTING (Ordinance 97-104) Firm Name of Prime Contractor/Developer This form, or a comparable listing meeting the requirements of Ordinance No. 97-104, MUST be completed by the developers on County contracts for purchase of supplies, materials or services, including professional services which involve expenditures of $100,000 or more, and all developers on County or Public Health Trust construction contracts which involve expenditures of $100,000 or more. This form, or a comparable listing meeting the requirements of Ordinance No. 97-104, must be completed and submitted even though the developer will not utilize subcontractors or suppliers on the contract. The developer should enter the word "NONE" under the appropriate heading on this form in those instances where no subcontractors or suppliers will be used on the contract. The developer who is awarded the contract shall not change or substitute first tier subcontractors, direct suppliers or the portions of the contract work to be performed, or materials to be supplied from those identified, except upon written approval of the County. Business Name and Address of First Tier Subcontractor/ Sub- consultant Scope of Work to be Performed by SubcontractorlSub- consultant Principal Owner (Principal Owner) Gender Race Business Name and Address of Direct Supplier Supplies/Materials/Services to be Provided by Supplier Princi pal Owner (Principal Owner) Gender Race I certify that the representations contained in this Subcontractor/Supplier Listing are to the best of my knowledge true and accurate. Signature Developer(s) Date Print Name Print Title Authorized Representative 22 (Duplicate if additional space is needed) /\ Page 1 of 1 CD/53/31413N 1J MIAMF� PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) ATTACHMENT G FAIR SUBCONTRACTING POLICIES (Ordinance 97-35) FAIR SUBCONTRACTING PRACTICES In compliance with Miami -Dade County Ordinance 97-35, the Developer submits the following detailed statement of its policies and procedures of awarding subcontracts: I hereby certify that the foregoing information is true, correct and complete. Signature of Authorized Representative: Title: Firm Name: Address: Telephone: City: Zip Code: Fax: Date: FEIN: State: CD/51/31313N 23 covNrr _ PUBLIC HOUSING AND COMMUNITY DEVELOPMENT Agreement To Authorize Examination of Records and Adhere to Records Retention Requirements The undersigned agrees to the stipulations noted below for all work, materials, and services provided under this agreement dated and/or for all other third -party agreements/contracts for labor, materials, and services related to the work covered by this agreement for the projectlactivity. The undersigned shall ensure, and shall require all parties with whom it contracts to ensure, that Miami -Dade County, the Department of Housing and Urban Development, or Comptroller General of the United States, or any of their duly authorized representatives shall, have access to and the right to examine any of the following records from the awardee, sub -recipient, developer, contractor, subcontractor, suppliers and/or any other entity involved in any rapacity in the above -referenced project/activity, for seven (7) years after final payment under contract. Records shall include, but are not limited to, the following: Contracts, sub -contracts, audits, financial books, ledgers, copies of canceled checks (front and back), wire transfer confirmations, payment requests (draws), invoices, receipts, drawings, maps, pamphlets, designs, electronic tapes, computer drives and diskettes, other media storage, pertinent books, documents, papers, or other records —whether physical, electronic, or in any form— involving transactions related to this contract for the purpose of making audits, examinations, excerpts, and transcriptions. The awardee, sub -recipient, developer, contractor, sub -contractor, sub -tier, suppliers and or any other entity involved in any capacity in the above -referenced project shall adhere to the following records retention requirements: a) Maintain, and require that its sub -contractors and suppliers maintain complete and accurate records to substantiate compliance with the requirements set forth in the contract/agreement documents for this project. b) The undersigned shall retain such records, and all other documents related to the services and materials furnished for this project, for a period of three (3) years from the completion of the activity or project. Other information: a) The County may conduct unannounced visits to offices, satellite offices, work sites, supplier warehouse, etc. of all entities involved in any capacity in the above -referenced project. b) Pursuant to the contract, there maybe additional records requirement not listed in this agreement. Entity Name: Employer ID #/FID #: Full Address (including City, ST and Zip) and Email Address Signature: Print Name: Date: Title: Check one, as applicable: _ Developer _ Prime -Contractor Sub -contractor or sub -tier sub -contractor — Other (specify) _ 24 ®z itThis material is available in an accessible format upon request. CD/61/31616 25 PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) ETHICS COMMISSION DISCLOSURE STATEMENT FOR ALL PHCD PROGRAMS Applicant: Co -Applicant: In accordance with Section 2-11.1 Subsection (c), and (d) of the Miami -Dade County Conflict of Interest and Code of Ethics Ordinance, covered persons defined under 2-11.1(b) are required to request an Ethics Opinion if they are seeking to participate in housing assistance programs administered by the PHCD. Check if any of the following applies to you: ❑ Itwe do not currently work for Miami -Dade County (no additional action is required). ❑ Itwe amlare a School Board or Federal Employee. These employees are not covered under Section 2-11.1 of the Miami -Dade County Conflict of Interest and Code of Ethics Ordinance (no additional action is required). ❑ Ilwe amlare an appointed or elected County Official (Ethics Opinion must be sought - http.Aethics. miamidade. go v/frequently-used-forms. asp) ❑ I/we am/are a Miami -Dade County Employee (Ethics Opinion must be sought - http://ethics. miamidade. govArequently-used-forms. asp). • Please provide the department and division name below: ❑ Itwe amlare immediate family to a Miami -Dade County employee, appointed or elected official. (*) Immediate family is defined as spouse, domestic partner, parents, stepparents, children and stepchildren (Ethics Opinion must be sought - http://ethics. miamidade.gov/frequently-used-forms. asp). • Please provide the following information regarding the County employee, appointed or elected official: Name of employee, appointed or elected official: Department, Division, or Board: Signature of Applicant: Signature of Co -Applicant: Date: Warning: Title 18, US Code Section 1001, states that a person who knowingly and willingly makes false or fraudulent statements to any Department or Agency of the United States is guilty of a felony. State law may also provide penalties for false or fraudulent statements. 26 10 ALC/AM/CA/CD/1 /62414N M2 PUBLIC HOUSING AND COMMUNITY DEVELOPMENT (PHCD) ATTACHMENT B-2 Community Development Block Grant (CDBG) Program A. Schedule of Units — For Awardees undertaking the development of for -sale ownership or rental housing, the description of the proposed units to be completed is as follows (to be completed by Awardee): Schedule of Units Unit Description Total Number of Units Total Number Set -Aside Units Square Feet Sale Price/Net Rent Amount % of AM] Efficiency/Studio $ % 1 Bedroom/1 Bath $ % 2 Bedroom/1 Bath $ % 2 Bedroom/1.5 Bath $ % 2 Bedroom/2 Bath $ % 3 Bedroom/1 Bath $ % 3 Bedroom/1.5 Bath $ % 3 Bedroom/2 Bath $ % 4 Bedroom/2 Bath $ % 4 Bedroom/2.5 Bath $ °/0 Other $ % Total: For Awardees undertaking rental housing, the Awardee agrees with respect to the Development for the period beginning on the date of recordation of the Mortgage and Security Agreement securing the PHCD Loan, that: 1. The Awardee shall designate and set -aside units for very low, low-income, or moderate income families in the configuration as described in the Schedule of Units referenced herein. 2. At the very minimum, the Awardee shall be required to equip each unit with the following: refrigerator, oven, carpeting/tile, and central air conditioning. 3. Each unit shall meet the energy efficiency standards promulgated by the HUD Secretary. 4. The Awardee must verify that all households assisted have annual incomes that do not exceed 80% of the Area Median Income (AMI). The awardee must report to PHCD the number of set -aside housing units completed and occupied, including demographic information on each head of household. 27 Page 1 of 5 CD/44/71114 B. AWARDEE OBLIGATIONS AND DUTIES 1. The Awardee shall begin construction no later than twelve (12) months after execution of the RFA Funding Agreement. All construction shall be completed within twenty- four (24) months of execution of the Agreement. Construction is completed when a Certificate of Occupancy (CO) is issued. 2. The Awardee shall submit to PHCD, in writing, all requests for project construction start- up and completion extensions, including a revised timetable for completion of the project. Such written requests must be submitted to PHCD at least sixty (60) days prior to the expiration date of the contract or amendment. If the extension request is not timely submitted, the funding award shall be automatically forfeited by the Awardee. 3. The Awardee shall obtain prior written approval from PHCD before undertaking any and all changes to the project, including, but not limited to changes in the proposed unit sales prices or rents (as applicable), start-up and completion date extension request, unit set - aside, floor plans and amounts to be contributed towards closing. The Awardee shall send PHCD notice of such changes within thirty (30) days of any such increase. 4. The Awardee shall execute a Rental Regulatory Agreement, Note, and Mortgage delineating a set -aside of units that is proportionate to the level of funding received pursuant to the funding sources. 5. The Awardee shall forward to PHCD within fifteen (15) days of execution of this contract an Affirmative Marketing Program to attract and identify prospective renters or homebuyers (as applicable), regardless of sex, of all minority and majority groups, to the Project, particularly groups that are not likely to be aware of the Project. The Marketing Plan should include efforts designed to make such persons/groups aware of the available housing, including, but not limited to the following activities: Submit proof of advertising in The Miami Herald, Diario Las Americas, Miami Times, or an equivalent newspaper in an effort to afford all ethnic groups the opportunity to obtain affordable housing. The Awardee shall provide proof of other special marketing efforts including advertising Multiple Listings Service (MLS) through a licensed real estate professional. 6. The Awardee shall provide PHCD with a complete set of permitted plans, approved specifications, and permits for each building or unit model, as applicable, upon approval by the appropriate controlling municipality prior to commencing construction. 7. The Awardee shall provide to PHCD for approval prior to awarding the construction contract for the Development, the name of the General Contractor. 8. Prior to the commencement of construction, the Awardee shall provide to PHCD the General Contractor's Payment & Performance Bond (P&PB). At PHCD's discretion, based on the Awardee's organizational capacity, track record, and experience, an irrevocable Stand-by Letter of Credit may be accepted in lieu of the P&PB. In such event, the Letter of Credit must be issued by a Florida chartered bank or national bank operating in Florida in the amount of ten percent (10%) of the construction contract amount, in US funds, with Miami -Dade County listed as the beneficiary. 9. The Awardee shall schedule a Pre -Construction Conference with PHCD at least sixty 28 (60) days prior to the commencement of construction. Page 2 of 5 CD/44/71114 10. The Awardee shall provide PHCD with a written commitment for construction financing from a financial institution(s) at the time of construction loan closing. 11. The Awardee agrees to notify PHCD in writing within fourteen (14) days of any key personnel or location changes in the management company. 12. During the Design Stage, the Awardee shall obtain Professional Liability Insurance in the name of the Awardee or the licensed design professional employed by the Awardee in an amount of not less than $250,000, and shall furnish to PHCD the relevant Certificates of Insurance evidencing the prescribed insurance coverage in accordance with ATTACHMENT B-1 of this contract. C. PHCD OBLIGATIONS AND DUTIES 1. PHCD shall manage its own disbursements and act as the disbursement agent for all construction loan funding draws. 2. PHCD will monitor the project for adherence to plans, unit layout and deadlines for project completion in accordance with the Contract and the Scope of Services. 3. PHCD shall forward to the County's Risk Management all required and applicable Certificate(s) of Insurance. 4. PHCD shall disburse the awarded funding only after the Awardee closes on the construction loan, all required loan documents have been recorded, and the Awardee has timely submitted funding draw requests and relevant invoices in the prescribed manner and as satisfactory to PHCD. 5. PHCD shall notify the Awardee of any address/location changes to PHCD's contact information within forty-five (45) days of its occurrence. D. NATIONAL OBJECTIVE In accordance with 24 CFR Section 570.208 of the federal regulations, the Awardee shall be required to achieve the national objective of Benefit to Low and Moderate Income Persons or Households (LMI). For activities designed to meet the LMI national objective, the Awardee shall ensure and maintain documentation, acceptable to PHCD in its sole discretion that conclusively demonstrates that each activity assisted in whole or in part with CDBG funds is an activity that provides benefit to persons where no less than 51 % of those benefitted are low- and moderate -income persons with household incomes at or below 80% of Area Median Income (AMI), as further defined in the chart below: Miami -Dade County: FY 2018 Income Limits Summary Number of Persons in Family Median Income 1 2 3 4 6 6 7 8 Income Limits 30% of AMI $16,550 $18,900 $21,250 $25,100 $29,420 $33,740 $38,060 $42,380 $52,300 AM% of $27,550 $31,500 $35,450 $39,350 $42,500 $45,650 $48,800 $51,950 80% of AMI $44,100 $50,400 $56,700 $62,950 $68,000 $73,050 $78,100 $83,100 (NOTE: Income Limits subect to change annually.) Source: htfp://www.huduser.org/portal/datasetsrl/i12018/20l8summary.odn 29 Page 3 of 5 CD/44/71114 The Awardee may achieve the LMI national objective by undertaking activities that fall under one of four (4) primary LMI cagegories: 1. To benefit Low Mod Area (LMA) For activities designed to meet the LMI national objective category of Low Moderate Area Benefit (LMA), the Awardee shall ensure and maintain documentation, acceptable to PHCD in its sole discretion that conclusively demonstrates that each activity assisted in whole or in part with CDBG funds is an activity that provides benefit to residents in a particular area, where at least 51% of the residents are LMI persons. The service area of the activity must be primarily residential and the activity must meet the identified needs of LMI persons. A service area is considered to meet the test of being LMI if at least 51 % of the persons residing in the service area are low- to moderate -income, as determined by: a. the most recently available decennial Census information, together with the Section 8 income limits that would have applied at the time the income information was collected by the Census Bureau; or b. a current survey of residents of the service area. If the proposed activity's service area is generally the same as a census tract or block group, then the Census data may be used to justify the income characteristics of the area served. 2. To benefit Low Mod Limited Clientele (LMC) For activities designed to meet the LMI national objective category of Low Moderate Limited Clientele (LMC), the Awardee shall ensure and maintain documentation, acceptable to PHCD in its sole discretion that conclusively demonstrates that each activity assisted in whole or in part with CDBG funds is an activity in which no less than 51% of the beneficiaries of the activity are LMI persons. Activities in this category provide benefits to a specific group of persons rather than everyone in an area. It may benefit particular persons without regard to their residence, or it may be an activity that provides a benefit to only particular persons within a specific area. With respect to determining the beneficiaries of activities as LMI and qualifying under the limited clientele category, activities must meet one of the following tests: a. Benefit a clientele that is generally presumed to be principally LMI. This presumption covers abused children, battered spouses, elderly persons, severely disabled adults, homeless persons, illiterate adults, persons living with AIDS and migrant farm workers; or b. Require documentation on family size and income in order to show that at least 51 % of the clientele are LMI; or c. Have income eligibility requirements limiting the activity to LMI persons only; or d. Be of such a nature and in such a location that it can be concluded that clients are primarily LMI. 3. Low Mod Job Creation or Retention Activities (LMJ) The job creation and retention Low Moderate Job (LMJ) benefit national objective category addresses activities designed to create or retain permanent jobs, at least 51 % 30 of which, computed on a full-time equivalent basis, will be made available to, or held by, Page 4 of 5 CD/44/71114 LMI persons. For Awardees undertaking activities to create jobs, there must be documentation indicating that at least 51 % of the jobs will be held by, or made available to LMI persons. For Awardees undertaking activities that retain jobs, there must be sufficient information documenting that the jobs would have been lost without the CDBG assistance and that one or both of the following applies to at least 51 % of the jobs: a. The job is held by a LMI person; or b. The job can reasonably be expected to turn over within the following two years and steps will be taken to ensure that the job will be filled by, or made available to, a LMI person. For the purpose of determining if the preceding requirements are met, a person may be presumed to be LMI if: i. He/she resides in a Census tract/block numbering area that has a 20% poverty rate (30% poverty rate if the area includes the central business district); and the area evidences pervasive poverty and general distress; or ii. He/she lives in an area that is part of a Federally -designated Empowerment Zone (EZ) or Enterprise Community (EC); or iii. He/she resides in a Census Tract/block numbering area where at least 70% of the residents are LMI. 4. Low Mod Housing Activities (LMH) The housing category of LMH benefit national objective qualifies activities that are undertaken for the purpose of providing or improving permanent residential structures which, upon completion, will be occupied by LMI households. In order to meet the housing LMI national objective, structures with one unit must be occupied by a LMI household. If the structure contains two units, at least one unit must be LMI occupied. Structures with three or more units must have at least 51 % occupied by LMI households. a. Rental buildings under common ownership and management that are located on the same or contiguous properties may be considered as a single structure. b. For rental housing, occupancy by LMI households must be at affordable rents as established annually by the U.S. Department of Housing and Urban Development (HUD) and consistent with standards adopted and publicized by PHCD. The Awardee shall comply with all applicable provisions of 24 CFR Part 570 and shall carry out each activity in compliance with all applicable federal laws and regulations described therein. If the Awardee is a primarily religious entity, it shall comply with all provisions of 24 CFR 570.200 0). For Housing, Rehabilitation, and Construction activities, all conditions in this section will apply throughout the regulatory period identified in the national objective. Throughout that period, the Awardee will be required to submit an annual report regarding its compliance with the national objective, and PHCD will have the right to monitor the activity. The Awardee shall comply with all applicable uniform administrative requirements as described in 24 CFR 570.502. 31 Page 5 of 5 CD/44/71114 nun B Date: Recipient Name: Activity Name: IDIS Number: PUBLIC HOUSING AND COMMUNITY DEVELOPMENT List of Persons (Job Creation) or Businesses (Assisted( - Economic Development Supplement to Quarterly Expenditure and Progress Report Reporting Period lad Quarter (Jan - Mar) (� 2nd Owner [Apr -Jun) ❑ 3rd Quarter(Jul - Sept) ❑ am Donner(Oct- DacyAnnual Report ❑ 1. Persons lJob Creation) 2. Business (Assisted) 3. Personis) or Business(es) Address 4. NRSA htto,//gisweb miamidade ow/Community5emices/ Last Name First Name Legal Name DUNS Number New Eaadnp Facade House Number Deal Street Name Street Type Uses in a NRSA? Nameof NRSA Rehab ❑ ❑ ❑ Yes ❑ No 1 ❑ ❑ ❑ Yea ❑ No 2 ❑ ❑ ❑Yes ❑No 3 ❑ ❑ ❑Yea ❑No 4 ❑ ❑ ❑Yes ❑No 6 ❑ ❑ ❑Yes ❑No 6 ❑ ❑ ❑ Yes ❑ No T ❑ ❑ ❑Yes ❑No e ❑ ❑ ❑Yes ❑No 9 ❑ ❑ ❑Yea ❑No s ❑ ❑ ❑Yes ❑No p ❑ ❑ ❑Yes ❑No k ❑ ❑ ❑Yes ❑No ri ❑ ❑ ❑Yea ONO If ❑ ❑ ❑Yea ONO k INSTRUCTIONS 1. Fill in name of the person for which the job was created or the legal name of the assisted busines: 2. Fill in the Data Universal Numbering System 19-dgd number) of the assisted business. 3. Enter an X in the column that matches the business status (Nev, or Existtr 4.Enler Yesor NoasapplirableifFegade or Rehab improvements comp)eted for the assisted business, 5. Enter the Complete address of the person or business, e.g. House Number, Direction, Street Nama, & S1mel Typi 6. Enter Yes or No as applicable it the person Was in, job is located in or the business is located in ono of the NRSAs. ?. it yes, view NRSA map at http://gisweb.miamidede.gov/CommundySemices/ to determine Correct NRSA location and fill in the name of the NRSA: Goulds, Leisure City, Melrose, Model City, Opa-Locka, Perrin, South Miami, or West Little River. Wamep red 16, US Coda Sxmn tom. setae Nat a person M:c knewnpry and WHO" makes riled or eaudmem daemon W on, oepanm hl or offer, cl the Unded emA b pwly of v many State law may ale. pmNae peoalan for /false a eaue.0ent WWmenn. Tl:e matddvl k avalable In an acceeersle Shrill upon re0ueel. Ca28112513N 32 <Wnir PUBLIC HOUSING AND COMMUNITY DEVELOPMENT REQUIRED DOCUMENTATION FOR INCOME VERIFICATION If an agency has an activity that has been classified as Low -Mod Clientele (LMC), Low -Mod Jobs (LMJ), or Low - Mod Housing (LMH), the agency will be required to obtain information from low -to -moderate income households/persons in order to verify income eligibility. Please note that income eligibility is determined based on household income and size. Below is a list of acceptable documentation to confirm income eligibility. It is important to note that all funded agencies will be responsible to maintain such documentation on file for five years after the Public Housing and Community Development (PHCD) has informed the agency through an official close out/report or letter that activity is closed. • Client's Paycheck Stubs, Social Security Insurance (SSI) Checks, TANF (Temporary Assistance for Needy Families) checks, or other public assistance checks — A photocopy should be made of the two (2) most recent pay period check stubs, benefit checks received by the client, or the notification of electronic transfer; • SSI, SSD, Food Stamp, or Other Benefit Cards/IDs — If the cards indicate the income level of the client, a photocopy of the card can document income; • W2 Form or Tax Return Form — A photocopy of the client's W2 form from his/her most current employer for wages earned or a photocopy of the client's most recent tax return form may document income; • SSI and TANF Letters of Notification of Benefits — Social Security and the Department of Children and Families issue letters of notification of benefits to clients informing them of their approval for benefits and the amounts of the benefits to be received. A photocopy of these letters will be sufficient proof of income; • Other benefit notification letters may be acceptable if they indicate the client's income level (e.g., Social Security Administration, Medicaid, Medicare, Food Stamps, etc); Letter of acceptance from the school lunch program HUD INCOME LIMITS FOR MIAMI-DADE COUNTY FY 2018 U.S. HUD INCOME LIMITS For Miami -Dade County Effective April 1, 2018 Area Median Income (AMI): $ 52,300 EXTREMELY LOW (30% of Median) VERY LOW (50% of Median) LOW (80% of Median) FAMILY SIZE LESS THAN: VERY LOW GREATER THAN: 1 person $16,550 $27,550 $44,100 2 persons $18,900 $31,500 $50,400 3 persons $21,250 $35,450 $56,700 4 persons $26,100 $39,360 $62,960 5 persons $29,420 $42,500 $68,000 6 persons $33,740 $45,650 $73,050 7 persons $38,060 $48,800 $78,100 8 persons $42,380 $51,950 $83,100 New tables are published yearly by USHUD and will be provided to the Agency when available. cm CD/58/32615 ■ MIAMIDADE PUBLIC HOUSING AND COMMUNITY DEVELOPMENT COMMUNITY DEVELOPMENT BLOCK GRANT JOB CREATION VERIFICATION (NON-NRSA) THE COMPANY IN WHICH YOU ARE APPLYING FOR EMPLOYMENT HAS RECEIVED FEDERAL ASSISTANCE THE INFORMATION REQUESTED IN THIS FORM IS REQUIRED BY THE US DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT. Name of Employer: Street Address: City: State: Zip Code: Phone Number: Name of Employee: Street Address: City: Phone Number: State: Zip Code: Date of Hire: Were you unemployed prior to taking yourjob? ❑ Yes ❑ No Does your employer offer employer sponsored healthcare benefit? ❑ Yes ❑ No Please check the box next to the job title that best describes your position: ❑ Officials and Managers ❑ Sales ❑ Operatives (semi -skilled) ❑ Professional ❑ Office and Clerical ❑ Laborer (unskilled) ❑ Technicians ❑ Craft work (skilled) ❑ Service workers Job Title: Full Time: ❑ Yes ❑ No If part-time, number of hours: / wk Gender: ❑ Male ❑ Female Ethnicity: ❑ Hispanic ❑ Not Hispanic Racial Cate -gory (select one below): ❑ White ❑ Black/African American ❑ Asian ❑ Black/African American & White ❑ Asian & White ❑ Native Hawaiian/Other Pacific Islander ❑ American Indian or Alaskan Native & Black/African American ❑ American Indian/Alaskan Native ❑ American Indian/Alaskan Native & White ❑ Other: Multi Racial TOTAL FAMILY SIZE (Please circle one): 1 2 3 4 5 6 7 8 TOTAL FAMILY SIZE INCOME: $ NOTE: EMPLOYER MUST INCLUDE A COPY OF THE ABOVE EMPLOYEE'S FIRST PAY STUB — NO EXCEPTIONS. 4:� Please see reverse side for family size and household income. M 1 of CD/25/61512N2 34 CWNtt PUBLIC HOUSING AND COMMUNITY DEVELOPMENT COMMUNITY DEVELOPMENT BLOCK GRANT JOB CREATION VERIFICATION (NON-NRSA) FY 2018 INCOME LIMITS Effective April 1, 2018 Please check the appropriate family size and income. Family Size Extremely Low 30% of Median Very Low 50% of Median Low 80% of Median ❑ 1 ❑ $16,550 ❑ $27,550 ❑ $44,100 El 2 ❑ $18,900 $31,500 $50,400 3 ❑ $21,250 $35,450 $56,700 ❑ 4 ❑ $25,100 ❑ $39,350 ❑ $62,950 5 ❑ $29,420 $42,500 $68,000 ❑ 6 ❑ $33,740 $45,650 $73,050 ❑ 7 ❑ $38,060 ❑ $48,800 ❑ $78,100 ❑ 8 ❑ $42,380 $51,950 L $83A00 BY MY SIGNATURE, I ACKNOWLEDGE THAT ALL INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I AM AWARE THAT IF I MAKE ANY WILLFUL FALSE STATEMENT IN THIS CERTIFICATION OR ANY OTHER DOCUMENTATION THAT I PROVIDE FOR PROGRAM ELIGIBILITY, I MAY BE PUNISHED WITH FINES OR IMPRISONMENT OF UP TO FIVE (5) YEARS, OR BOTH, UNDER SECTION 1001 OF TITLE 18, UNITED STATES CODE, AND I ALSO MAY BE SUBJECT TO CIVIL AND/OR ADMINISTRATIVE PENALTIES AND SANCTIONS. Employee's Name (PrintfType) Employee's Signature Date Warning., Title 18, US Code Section 1001, states that a person who knowingly and willingly makes false or fraudulent statements to any Department or Agency of the United States is guilty of a felony. State law may also provide penalties for false or fraudulent statements. 35 This material is available in an accessible format upon request. CD/25/61512N3 2 of VIVIENDA PUBLICA Y DESARROLLO COMUNITARIO MIAM �J FORMULARIO GENERAL DE ADMISION PARA CDBG INGRESOS (LMI', porsussiglaseningles) CLIENTES (LMC", porsussiglaseningles) EMPLEOS (LMJ*'*, porsussiglaseningles) VIVIENDAS (LMH"", por sus siglas eningles) BAJOS Y MODERADOS NOMBRE: DIRECCION: TELEFONO: CODIGO POSTAL: Genero: ❑Masculino ❑Femenino Origen ❑ Hispano ❑ No Hispano etnico: Roza (Por favor, marque la categoria de raze que le corresponde): ❑ Blanco ❑ Negro/Afro Americano ❑ Indigene Estadounidense/Nativo de Alaska ❑ Asiatico ❑ Negro/Afro Americano y Blanco ❑ Indigena Estadounidense/Nativo de Alaska y Blanco ❑ Asiatico y Blanco ❑ Nativo de Hawai/ Otras Islas del Pacifico ❑ Otros: Multi Racial ❑ Ind igena Estadounidense / Nativo de Alaska / Afro Americano Menci6nese a Usted mismo y a todas las personas que ocupan la Vivienda Parentesco Genero Edad Empleado? 1. Aut6nomo 2. [EEIIN LJ 3. 4. ❑ Si 5. ❑ No Si 6. ❑ No ❑ S1 7. ❑ No Si 8. ❑ No DATOS DE LA VERIFICAC16N DE INGRESOS La ayuda que Listed recibe se determina an parte por el nGmero de miembros en su nGcleo familiar y de sus ingresos. Todos los ingresos y los bienes deberan ser verificados antes de que la elegibilidad sea concedida. El ingreso incluye todas las sumas de dinero que reciben todos los miembros del nGcleo familiar mayores de 18 anos. Los salados, sueldos, propinas, comisiones; los ingresos como trabajador por cuenta propia; Pensiones de jubilaci6n, de supervivencia, por discapacidad; la jubilaci6n del Seguro Social o del Ferrocanil, el Ingreso Suplementario de Seguridad, la Ayuda a las Families con Ninos Dependientes (AFDC, por sus siglas an ingles), la Ayuda Temporaria a las Families Necesitadas (TANF, por sus siglas en ingles), los Sellos para Alimentos, u otro tipo de ayuda publica, o de programas pGblicos de ayuda social, o de ingresos provenientes de patrimonios o fideicomisos; asi como otras Fuentes regulares de ingresos, incluyendo los pagos a los Veteranos (VA, por sus siglas an ingles), la compensaci6n por desem leo, la pensi6n alimenticia la manutenci6n de menores deberan ser declarados. Miembro del NGcleo Familiar Fuente de Ingresos Monto del Ingreso Bruto Mensual Recibido 1. $ 2. $ 3. $ 4. $ 5. $ Documentaci6n Aceptable Para veriflicar la Elegibilidad a partir de los Ingresos: Copia de las colillas de pago (del empleador anterior), la Ayuda a las Familias con Ninos Dependientes (AFDC, por sus siglas an ingl6s) o la Ayuda Temporara a las Familias 36 Necesitadas (TANF, par sus siqlas en ingles) la Impresi6n o la Carta Oficial de las Estampillas de Alimentos, la Carta confinnando I I* CD/17/51712N3 P3gina 1 de 3 VIVIENDA PUBLICA Y DESARROLLO COMUNITARIO MIAM MM FORMULARIO GENERAL DE ADMISI6N PARA CDBG la cantidad de beneficios percibidos por desempleo, la prueba de Is manutenci6n de menores o del pago de Is pensi6n alimenficia, Is prueba del SSA/SSI o de los Beneficios de los Veterans o Is prueba de los ingresos por jubilaci6n. DEBERA ADJUNTARSE UNA COPIA DE LOS DOCUMENTOS — SIN EXCEPCI6N. Quien suscribe, el solicitante, por medio de la presente autodzo a a fin de que verifique mis antecedentes personales, incluyendo: (Maw) los salarios, pensiones a inversiones. Se entiende que esta autorizaci6n se otorga con el tinico prop6sdo de cerfificar mi elegibilidad pars la ayuda financiera federal, y que toda la informaci6n adquirida en este sentido seguir6 siendo confidencial. CON MI FIRMA, RECONOZCO QUE TODA LA INFORMAC16N QUE HE PROPORCIONADO ES VERDADERA Y CORRECTA A MI LEAL SABER Y ENTENDER. SOY CONCIENTE DE QUE SI HAGO ALGUNA DECLARAC16N FALSA INTENCIONALMENTE EN ESTA CERTIFICAC16N O EN CUALQUIER OTRA DOCUMENTAC16N QUE PROPORCIONE PARA LA ELEGIBILIDAD DEL PROGRAMA, PUEDO SER CASTIGADO CON MULTAS O CON LA CARCEL DE HASTA CINCO (5) ANOS, O AMBOS, BAJO LA SECC16N 1001 DEL TITULO 18, DEL C6DIGO DE LOS ESTADOS UNIDOS, Y QUE TAMBI�-N PODRIA ESTAR SUJETO A LAS MULTAS Y SANCIONES CIVILES Y/O ADMINISTRATNAS PERTINENTES. Firma del Solicitante Fecha ELEGIBILIDAD DE LOS INGRESOS PARA EL SUBSIDIO EN 24 CFR 570.208 BLOQUE PARA EL DESARROLLO COMUNITARIO (CDBG, or sus si las an in 16s Actividad clasificada bajo los ingresos y la composici6n del 24 CFR 570.208(a)(2)(i)(B) 24 CFR 570.506(b)(3)(iii) ru o familiar La acbvidad se clasifica a partir de los requisitos de elegibilidad 24 CFR 570.208(a)(2)(i)(C) 24 CFR 570.506(b)(3)(iii) de los ingresos que se limitan exclusivamente a las personas de ingresos bajos y moderados DEFINICIONES / 24 CFR 570.3 Familia: Se refiere a todas las personas que vivan an Is misma casa, que est6n relacionadas por nacimiento, matrimonio o adopci6n. Nucleo Familiar: Se refiere a todas las personas que ocupan Is vivienda. Los ocupantes podrian ser una Bola familia, una persona viviendo sola, dos o mas familias viviendo juntas o cualquier otro grupo de personas relacionadas o no que compartan las condiciones en materia de vivienda. Ingresos: Con el fin de detenninar si los ingresos de una familia o de un nucleo familiar son bajos o moderados dentro de la Subsecci6n C de esta secci6n, los beneficiarios podrian seleccionar cualquiera de las tres definiciones enumeradas abajo para cada actividad, salvo que las actividades integralmente relacionadas que sean del mismo tipo y que califiquen dentro del mismo apartado del 570.208(a) deban utilizer Is misma definici6n de los ingresos. La opci6n de elegir una definici6n no se aplica a las actividades que califican con el 570.208(a)(1) (Actividades de beneficio del area), salvo cuando el beneficiario Ileve a cabo una investigaci6n de acuerdo con el 570.208(a)(1)(vi). Las actividades que califican de acuerdo con el 570.208(a)(1) generalmente deberbn utilizer los datos de ingresos del area provistos por HUD a los beneficiarios. Las tres definiciones son las siguientes: (i) Los ingresos anuales tal como se los define an el programs de Pagos de Ayuda pars Is Vivienda de Is Secci6n 8 en el Titulo 24 del C6digo Federal de Regulaciones 813.106 (salvo que Is ayuda pars Is CDBG que se proporcione tenga relaci6n con la rehabilitaci6n al propietario de acuerdo con el 570.202, el valor de la residencia principal del propietario se podria excluir del calculo de los Activos Netos de la Familia); o bien Calcular los ingresos anuales de una familia o de un nucleo familiar efectuando una proyecci6n de Is tasa predominante de ingresos de cada persona al momento de proporcionarsele Is ayuda a la persona, a la familia o al nucleo familiar (segun corresponda). El Incireso anual estimado deberb incluir los ingresos de toda la familia o de los miembros del nucleo familiar, segun sea el caso. La mejora en los ingresos o an los bienes derivada de la actividad de la ayuda del CDBG no se considerara para calcular los ingresos anuales. Hogar de ingresos bajos v moderados se refiere a un nucleo familiar que tiene un ingreso igual o inferior al limite de bajos ingresos de Is Secci6n 8 establecido por HUD. (LMH, por sus siglas en ingl&s) Advertencia: El Titulo 18, Articulo 1001 del C6digo de los Estados Unidos establece que una persona sera hallada culpable de un delito penal grave cuando intencionalmente haga declaraciones falsas o fraudulentas ante cualquier departamento o agencia de los Estados Unidos. La ley estatal 37 podria prever sanc/ones pare las declaraciones falsas o fraudulentas. itEste material esta disponible an un founato accesible a petici6n. CD/17/51712N3 2 de VIVIENDA PUBLICA Y DESARROLLO COMUNITARIO MIAM IMFORMULARIO GENERAL DE ADMISION PARA CDBG Persona de ingresos baios y moderados se refiere a un miembro de la familia cuyo ingreso es equivalents o inferior al limits de ingresos bajos de la Secci6n 8 establecido por HUD. Los individuos no emparentados se considerarAn families unipersonales pare este prop6sito. (LMI, por sus siglas en ingl6s) How de ingresos baios se refiere a un hogar con un ingreso igual o inferior al Iimite de ingresos muy bajo de Is Secci6n 8 establecido por HUD. (LMH, por sus siglas en ingl6s) Persona de Baios Ingresos se refiere a un miembro de una familia cuyo es un ingreso igual o inferior al limits de ingresos muy bajos de la Secci6n 8 establecido por HUD. Los individuos no emparentados deberdn considerarse como familias unipersonales oara este oroo6sito. (LMC. oor sus sialas an inales) INSTRUCCIONES PARA LA AGENCIA DE EJECUC16N Usted deben! pedir primeramente Is verificaci6n de terceros. Se trata de una verificaci6n proveniente directamente de la Puente de ingresos. La solicitud puede ser enviada por correo, por fax o por correo electr6nico. Deberfi quedar bien claro que fue recibida de', Is fuente. Limites de los Ingresos para el Ano Fiscal 2018 (Vigente desde el 1 ro de Abril, 2018) Por favor marque la cajita correspondiente al tamano de su grupo familiar y a la cantidad de su ingreso Tamano del Grupo Familiar Extremadamente bajo (30% de Is media) Muy bajo (50% de la media) Bajo (80% de la media) 1 $16,550 $27,550 $44,100 2 $18,900 $31,500 $50,400 3 $21,250 $35,450 $56,700 4 $25,100 $39,350 $62,950 5 $29,420 $42,500 $68,000 6 $33,740 $45,650 $73,050 7 $38,060 $48,800 $78.100 8 $42,380 $51,950 $83,100 Note: LMI* (LOW -MODERATE INCOME): Ingresos bajos o moderados LMC" (LOW -MODERATE CLIENTELE): Clientele de Ingresos bajos o moderados LMJ'"" (LOW -MODERATE JOBS): Empleos de Ingresos bajos o moderados LMH'""" (LOW -MODERATE HOUSING): Vivienda de Ingresos bajos o moderados Advertencia: El Tltulo 18, Articulo 1001 del Cddigo de los Estados Unidos establece qua una persona send hallada culpable de un delito penal grave cuando intencionalmente haga declarations falsas o fraudu/entas ante cualquier departamento o agencia de los Estados Unidos. Le ley estatal 38 podda prover sanc/ones pare las declarations falsas o fraudulentas. Este material estA disponible an un formato accesible a petici6n. CD/17/51712N3 3 de PUBLIC HOUSING AND COMMUNITY DEVELOPMENT M64M in GENERAL CDBG INTAKE ELIGIBILITY FORM LIMITED INCOME (LMI) LIMITED CLIENTELE (LMC) / LIMITED JOBS (LMJ) / LIMITED HOUSING (LMH) NAME: PHONE: ADDRESS: ZIP: Gender: ❑ Male ❑ Female Ethnicity: ❑ Hispanic ❑ Not Hispanic Race (Please check the race category which applies to you) ❑ White ❑ Black/African American ❑ American Indian/Alaskan Native ❑ Asian ❑ Black/African American & White ❑ American Indian/Alaskan Native & White ❑ Asian &White ❑ Native Hawaiian/Other Pacific Islander ❑ Other: Multi Racial ❑ American Indian or Alaskan Native & Black/African American List Yourself and all Other Persons Occupvinq Home Relationship Gender Age Employed? 1. Self ❑ Yes ❑ No 2. ❑ Yes ❑ No 3. ❑ Yes ❑ No 4. ❑ Yes ❑ No 5. ❑ Yes ❑ No 6. 1❑ Yes ❑ No 7. ❑ Yes ❑ No 8. Yes No INCOME VERIFICATION DATA The assistance you receive is determined in part by the size of your household and your income. Al income and assets will require verification before eligibility will be granted. Income includes all money coming into the household from all persons over 18 years old. Wages, salaries, tips, commissions; Self-employment income; Retirement, Survivor, or Disability pensions; Social Security or Railroad retirement; Supplemental Security Income, Aid to Families with Dependent Children (AFDC), Temporary Assistance to Needy Families (TANF), Food Stamps, or other public assistance, or public welfare programs; Interest, dividends, net rental income, or income from estates or trusts; and any other sources of income received regularly, including Veterans' (VA) payments, unemployment compensation, alimony, and child support must be disclosed. Household Member Source of Income Gross Monthly Amount Received 1. $ 2. $ 3. $ 4. $ 5. $ Income Eligibility Acceptable Documentation: Copy of Pay Stubs (from previous employer), Aid to Families with Dependent Children (AFDC) or Temporary Assistance to Needy Families (TANF) Official Printouttletter, Food Stamp Official Printout/letter, Letter confirming amount of unemployment benefits received, proof of child support or alimony, proof of SSA/SSI or Veteran's Benefits, or proof of retirement income. MUST ATTACH A COPY OF DOCUMENTS — NO EXCEPTIONS. I, the undersigned applicant, do hereby authorize to verify my personal records, including p�dAg qh wages, pensions, and investments. It is understood that this authorization is granted for the sole purpose of certifying my eligibility for federal financial assistance, and that all information acquired in this regard will remain confidential. BY MY SIGNATURE, I ACKNOWLEDGE THAT ALL INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I AM AWARE THAT IF I MAKE ANY WILLFUL FALSE STATEMENT IN THIS CERTIFICATION OR ANY OTHER DOCUMENTATION THAT I PROVIDE FOR PROGRAM ELIGIBILITY, I MAY BE PUNISHED WITH FINES OR IMPRISONMENT OF UP TO FIVE (5) YEARS, OR BOTH, UNDER SECTION 1001 OF TITLE 18, UNITED STATES CODE, AND I ALSO MAY BE SUBJECT TO CIVIL AND/OR ADMINISTRATIVE PENALTIES AND SANCTIONS. 39 Signature of Applicant 0 Pagel of 2 CD/17/51712N3 PUBLIC HOUSING AND COMMUNITY DEVELOPMENT ® GENERAL CDBG INTAKE ELIGIBILITY FORM CDBG INCOME ELIGIBILITY 124 CFR 570.208 Activity classified under family size and income 24 CFR 570.208 a 2 i B 24 CFR 570.506 b 3 iii Activity is classified based on income eligibility requirements that restrict it exclusive) to low- and moderate -income persons 124 CFR 570.208(a)(2)(i)(C) 24 CFR 570.506(b)(3)(iii) DEFINITIONS / 24 CFR 570.3 Family means all persons living in the same household who are related by birth, marriage or adoption. Household means all the persons who occupy a housing unit The occupants may be a single family, one person living alone, two or more families living together, or any other group of related or unrelated persons who share living arrangements. Income. For the purpose of determining whether a family or household is low- and moderate -income under subpart C of this part, grantees may select any of the three definitions listed below for each activity, except that integrally related activities of the same type and qualifying under the same paragraph of 570.208(a) shall use the same definition of income. The option to choose a definition does not apply to activities that qualify under 570.208(a)(1) (Area benefit activities), except when the recipient carries out a survey under 570.208(a)(1)(vi). Activities qualifying under 570.208(a)(1) generally must use the area income data supplied to recipients by HUD. The three definitions are as follows: (i) Annual income as defined under the Section 8 Housing Assistance Payments program at 24 CFR 813.106 (except that if the CDBG assistance being provided is homeowner rehabilitation under 570.202, the value of the homeowner's primary residence may be excluded from any calculation of Net Family Assets); or Estimate the annual income of a family or household by projecting the prevailing rate of income of each person at the time assistance is provided for the individual, family, or household (as applicable). Estimated annual income shall include income from all family or household members, as applicable. Income or asset enhancement derived from the CDBG-assisted activity shall not be considered in calculating estimated annual income. Low- and moderate -income household means a household having an income equal to or less than the Section 8 low- income limit established by HUD. Low- and moderate -income oerson means a member of a family having an income equal to or less than the Section 8 low- income limit established by HUD. Unrelated individuals will be considered as one -person families for this purpose. j Low-income household means a household having an income equal to or less than the Section 8 very low-income limit established by HUD. Low-income person means a member of a family that has an income equal to or less than the Section 8 very low-income limit established by HUD. Unrelated individuals shall be considered as one -person families for this purpose. INSTRUCTIONS FOR IMPLEMENTING AGENCY _ You must first seek third party verification. This is a verification that is received directly from the source of income. The request can be by mail, fax, or email. It must be clearly evidenced that it was received from the source. Income Limits for Fiscal Year 2018 (Effective 04/01/2018) Please check the appropriate familv size and income. Family Size Extremely Low (30% of Median) Very Low d (50% of Median) Low (80% of Median) 1 $16,550 $27,550 $44,100 2 $18,900 $31,500 $50,400 3 $21,250 $35,450 $39,350 $56,700 $62,950 4 $25,100 5 $29,420 $42,500 $68,000 6 $33,740 $45,650 $73,050 7 $38,060 $48,800 $78,100 8 $42,380 $51,950 $83,100 Warning. Me 18, US Code Section 1001, states that a person who knowingly and willingly makes false orfraudulent statements to any Department or 40 Agency of the United States is guilty of felony. State law may also provide penalties forfalse orfraudulent statements. This material is available in an accessible format upon request. CDI17I51712N3 2af2 ~®a PUBLIC HOUSING AND COMMUNITY DEVELOPMENT QUARTERLY EXPENDITURE AND PROGRESS REPORT FY 20 Reporting Period: ❑ 1 s' Quarter [Jan -Mar] ❑ 2nd Quarter [Apr -Jun] fiction I: General Information Recipient Name (Organization): Contact Person (Name & Title): Activity Name (Project Title): Activity Address: Activity Description: ❑ 3' Quarter [Jul -Sept] ❑ 4'h Quarter [Oct -Dec] / Annual Report Telephone Number: Program Income: (if IDIS #. Funding Source: Funded Amount: applicable) $ Activity Category: ❑ Administration ❑ Capital Improvement ❑ Economic Development ❑ Historic Preservation ❑ Public Service ❑ Housing ❑ Homebuyer Assistance ❑ Tenant -Based Rental Assistance (TBRA) ❑ Homeless Housing Objective: ❑ Create suitable living environments ❑ Provide decent affordable housing ❑ Create economic opportunities Outcome: ❑ Availability/Accessibility ❑ Affordability ❑ Sustainability Section II: Financial Information At the time the Awardees has been paid or otherwise recei1. ved fifty1. percent (50%) and seventy percent (70%) of the Agreement Funds, the Awardees reporting these expenditures must submit documentation to show that Awardees has accomplished 50% and 70%, respectively, of the Activities described herein. A B C D E F G H Actual Reimbursed Projected Approved Total Expenditures Cumulative Cumulative Projected Cumulative Category Budget Ex ended p Cumulative [Through end of Percents e g Expenditures Expenditures [this Quarter] [Through end of this quarter] is & D] [Next Quarter] [By end of Contract thisquarter] Period] Personnel $ $ $ $ % $ $ Contractual $ $ $ $ % $ $ Operating $ $ $ $ % $ $ Costs Commodities $ $ $ $ % $ $ Capital $ $ $ $ % $ $ utla TOTAL r $ $ $ $ % $ $ Program Income The disposition of Program Income not specifically listed in the approved Program Income budget requires prior written approval from PHCD. 1. Does this activity generate Program Income? ❑ Yes ❑ No 2. If yes, indicate the amount generated this quarter. $ 41 CD114151712 1 of 3 =mnix PUBLIC HOUSING AND COMMUNITY DEVELOPMENT QUARTERLY EXPENDITURE AND PROGRESS REPORT FY 20 ACTIVITY STATUS AND ACCOMPLISHMENT INFORMATION 1. Activity Status: ❑ Cancelled ❑ Underway ❑ Completed 2. Environmental Status: ❑ A=Exempt ❑ C=Completed ❑ D=Underway 3. Is this activity still in compliance with the original project schedule? ❑ Yes ❑ No Section III: ❑ Work in Progress [On -going Activities] ❑ 50% and 70% benchmark ❑ Accomplishment Narrative [Activity Completed] Check appropriate box and reference the Scope of Services, included in your contract, as the basis for reporting the work in progress or accomplished in a brief narrative format. [ r Attach Scope of Services ] Section IV: Other Supporting Efforts Provide a description, using quantifiable data, of all other supporting efforts that have begun, partially implemented, or completed during this period. Section V: Problems Encountered Provide a brief description of any problems or delays encountered during this period or anticipated. Section VI: Technical Assistance If your organization has a need or anticipate a need for technical assistance during this period, please describe the nature of the assistance required. Section VII: Performance Measurement 'Notes: A Supplemental Performance & Benefit Data Report must be submitted if any actual achievements are reported during this reporting period and all HOME funded projects must submit applicable activity set-up form. Accomplishment Type: ❑ People [01] ❑ Households [04] ❑ Businesses [08] ❑ Organizations [09] ❑ Housing Units [10] ❑ Public Facilities [11] ❑ Jobs [13] National Objective: ❑ Area Wide Benefit [e.g. LMA, LMAFI, LMASA, SBA] -or- ❑ Direct Benefit [e.g. LMC, LMH, LMJ] People or Households • Achievements: ❑ Yes ❑ No If yes, what is the accomplishment type? ❑ People -or- ❑ Households People Households (LMH activities oniv) Total People Low / Mod Total Households Low / Mod Female Headed Projected Goal Actual This Quarter Actual Cumulative Supplemental Report Attached Y / N Performance & Benefit Data: 42 CD114151712 Rev 11114117 2 of Y4WF M® PUBLIC HOUSING AND COMMUNITY DEVELOPMENT QUARTERLY EXPENDITURE AND PROGRESS REPORT FY 20 ❑ Housing —or— ❑ Public Service & Administration —or— ❑_ Capital Improvement & Public Facilities !Housing Units • Achievements: ❑ Yes ❑ No I Owner Rental Bu er Total Projected Goal Actual This Quarter Actual Cumulative Supplemental Report Attached Y / N ❑ Performance & Benefit Data: Housing Jobs or Businesses • Achievements: ❑ Yes ❑ No If yes, what is the accomplishment type? ❑ Jobs -or- ❑ Businesses Total Job Count Total Weekly Hours Percent Jobs Created Full -Time (FT) FT Low / Mod Part -Time (PT) PT Low / Mod Low / Mod Jobs Projected Goal Actual This Quarter Actual Cumulative Assistance to Businesses Projected Goal Actual This Quarter* Actual Cumulative New Businesses Existing Businesses Total Supplemental Report Attached Y / N ❑ Performance & Benefit Data: Economic Development PERFORMANCE CERTIFICATION: ❑ This certifies that No Accomplishments occurred during this Quarter. Initials NOTE: Submittal of Supplemental Form — Performance & Benefit Data is not required at this time based on the certification that no accomplishments occurred during this quarter. CERTIFICATION This is to certify that the data and other information provided in this Report is correct, based on official accounting system and records, and that expenditures and obligations shown have been made for the purpose of and in accordance with applicable Terms and Conditions of the Contract and Funding Requirements. Report Prepared by: Name Signature of Certifying Official: Title: Title: Date: Date: FOR PHCD USE ONLY Activity IDIS Number: Report ❑ is / ❑ is not complete • Report ❑ is / ❑ is not accurate Initial review for completeness and accuracy completed by — Name: Project Manager Name: Date: Supervisor Warning: Title 18, US Code Section 1001, states that a person who knowingly and willingly makes false or fraudulent statements to any Department or 43 Agency of the United States is guilty of a felony. State law may also provide penalties for false or fraudulent statements. This material is available in an accessible format upon request. CD114151712 3of3 COUNTY PUBLIC HOUSING AND COMMUNITY DEVELOPMENT PERFORMANCE & BENEFIT DATA: ECONOMIC DEVELOPMENT Supplement to Quarterly Expenditure & Progress Report FY 20 Recipient Name: Activity Name: IDIS# : HUD Activity Matrix Code: _ HUD Matrix Code Description: Activity Category: Accomplishment Type: Reporting Period 15t Quarter Jan -Mar ❑ 2nd Quarter [Apr -Jun] 3'd Quarter [Jul -Sept] 41, Quarter [Oct -Dec] / Annual Re ort ❑ Indicate in the table below, the number of jobs created for this activity. Total Job Count Total Weekly Hours Percent Jobs Created Full -Time FT FT Low / Mod Part-Time(PT) PT Low / Mod Low / Mod Jobs Expected to Create Actual This Quarter Actual Cumulative / YTD 'Note: Details of all Jobs Created must be included on the Supplement List of Persons (Job Created) / Business (Assisted) Form in electronic format i.e. name and address of each beneficiary placed in a created job. 2. Indicate in the table below, the type of jobs created for this activity. ACTUAL THIS QUARTER CUMULATIVE TOTALS TYPE OF JOB CREATED NUMBER OF JOBS NUMBER OF JOBS Officials & Managers Professional Technicians Sales Office & Clerical Craft Workers (skilled) Operatives (semi -skilled) Laborers (unskilled) Service Workers Totals NOTE: Details of all assistance to businesses provided below must be reported on the Supplement List of Persons (Job Created) Business (Assisted) Form in electronic format. 1. Number of Businesses Assisted during this program year: a) Number of New Businesses Assisted b) Number of Existing Businesses Assisted Total 2. Of the Existing Businesses Assisted, enter the number of: a) Expanding Businesses b) Relocating Businesses Total 3. Number of Businesses Assisted with commercial facade treatment / business building rehab: 4. Number of Businesses Assisted that provide good or services to meet the needs of a services area, neighborhood community: 5. Specify DUNS Number for each Business Assisted on the Supplement List of Persons (Job Created) / Business (Assisted) Form. CC! CD116151712V 1 of 3 MI,= PUBLIC HOUSING AND COMMUNITY DEVELOPMENT PERFORMANCE & BENEFIT DATA: ECONOMIC DEVELOPMENT Supplement to Quarterly Expenditure & Progress Report FY 20 PART 3 — BENEFIC ATION 71 1. Complete the Direct Benefit Information in the table below for the actual jobs created for this activity. DIRECT BENEFIT DATA RACE & ETHNICITY CATEGORY Instructions: (1) Indicate the total number of persons or households served in each Racial Category for this reporting period and the cumulative total. (2) From the total number depicted in each Racial Category, indicate the numbers that are of Hispanic Ethnicity for this reporting period and the cumulative total. Report Period Totals Race I Ethnicity Racial Categories Total Number # His anic Cumulative / YTD Totals Race Ethnicity Total Number # Hispanic White [11] Black / African American [12] Asian [13] American Indian / Alaskan Native [14] Native Hawaiian / Other Pacific Islander [15] American Indian / Alaskan Native & White [16] Asian & White [17] Black / African American & White [18] American Indian or Alaskan Native & Black / African American 19 Other / Multi Racial [20] Totals OTHER DIRECT BENEFIT INFORMATION Report Period Totals Cumulative / YTD Totals Total Number Income Levels Total Number Extremely Low (30% or less) Low (31 % - 50%) Moderate (51 % - 81 %) Non Low/Mod (81% or greater Totals Number of Female Headed Households 4.Of the actual jobs created, how many jobs have employer sponsored health care benefits? 5.Of the actual jobs created, how many were unemployed prior to taking the job created? 6. If employment levels are less than initially proposed, explain reductions or indicate when the proposed goals will be met. AREA BENEFIT INFORMATION Census ( C) or Survey (S) Data Used: Total # of Low/Mod in Service Area: Percent of Low/Mod in Service Area: Census Tract: Block Groups: Census Tract: Block Groups: Census Tract: Block Groups: If (S), enter # of Low/Mod & Total Population: Total Low/Mod Universe Population in Service Area: W 2 of CD116151712V MIAMI DAD'c M. PUBLIC HOUSING AND COMMUNITY DEVELOPMENT PERFORMANCE & BENEFIT DATA: ECONOMIC DEVELOPMENT Supplement to Quarterly Expenditure & Progress Report FY 20 Is this activity located in a NRSA? ❑Yes ❑No If yes, the NRSA must be identified, as applicable, using the maps provided via Miami -Dade County's website — Services Near You: htto://gisweb.miamidade.gov/CommunitvServices/ A cony of the printout must be included with this report. Provide the following information: NRSA Location / Project Address: Location / Project Address: Location / Project Address: # of Clients Served NRSA # of Clients Served Street / City / Zip Code —or- Folio Number is there is no street address Street / City / Zip Code —or- Folio Number is there is no street address / Zip Code —or- Folio Number is there is no street address $ 1. CDBG Funds 2. HOME Funds 3. ESG Funds $ 4. Section 108 Loan Guarantee $ 5. Program Income Funds $ 6. Other Federal Funds 7. State / Local Funds 8. Private Funds 9. Other: Name of Funding Source Total Funds t- REQUIRED ATTACHMENTS [if applicable]: 1) Certificate of Completion; 2) Printout of NRSA map, if applicable; 3) Documentation of performance / accomplishments, e.g., new or improved access to services, facility, or infrastructure upgrade; and 4) Documentation as described in the Contract or Scope of Services, or as instructed by the County. Report Prepared by: Print Name Signature of Certifying Official: Title: Title: Date: Date: Warning: Title 18, US Code Section 1001, states that a person who knowingly and willingly makes false or fraudulent statements to any Department or 46 Agency of the United States is guilty of a felony. State law may also provide penalties for false or fraudulent statements. 19 This material is available in an accessible format upon request. CD116151712V 3 of n® PUBLIC HOUSING AND COMMUNITY DEVELOPMENT COMMUNITY DEVELOPMENT BLOCK GRANT JOB CREATION VERIFICATION (NRSA) THE COMPANY IN WHICH YOUAREAPPLYING FOR EMPLOYMENT HAS RECEIVED FEDERALASSISTANCE THE INFORMATION REQUESTED INTHIS FORM IS REQUIRED BYTHE US DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT. - To determine if the business and/or employee is located and/or lives in an NRSA please go to: http://qisweb.miamidade.gov/CommunityServices/ (Must attach map printout, copy of a valid driver's license and one (1) of the following: utility bill (e.g., FPL or Water and Sewer bill), or school records.) Name of NRSA: _ Name of Employer: Street Address: _ City: Phone Number: Name of Employee: Street Address: _ City: Phone Number: _ Date of Hire: State: Zip Code: State: Zip Code: Were you unemployed prior to taking your job? ❑ Yes ❑ No Does your employer offer employer sponsored healthcare benefit? ❑ Yes ❑ No Please check the box next to the job title that best describes your position: ❑ Officials and Managers ❑ Sales ❑ Operatives (semi -skilled) ❑ Professional ❑ Office and Clerical ❑ Laborer (unskilled) ❑ Technicians ❑ Craft work (skilled) ❑ Service workers Job Title: Full Time: ❑ Yes ❑ No If part-time, number of hours: / wk DEMOGRAPHIC INFORMATION Gender: ❑ Male ❑ Female Ethnicity: ❑ Hispanic ❑ Not Hispanic Racial Category (select one below): ❑ White ❑ Black/African American ❑ American Indian/Alaskan Native ❑ Asian ❑ Black/African American & White ❑ American Indian/Alaskan Native & White ❑ Asian & White ❑ Native Hawaiian/Other Pacific Islander ❑ Other: Multi Racial ❑ American Indian or Alaskan Native & Black/African American TOTAL FAMILY SIZE (Please circle one): 1 2 3 4 TOTAL FAMILY SIZE INCOME: $ NOTE: EMPLOYER MUST INCLUDE A COPY OF THE ABOVE EMPLOYEE'S FIRST PAY STUB — NO EXCEPTIONS. BY MY SIGNATURE, I ACKNOWLEDGE THAT ALL INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I AM AWARE THAT IF I MAKE ANY WILLFUL FALSE STATEMENT IN THIS CERTIFICATION OR ANY OTHER DOCUMENTATION THAT I PROVIDE FOR PROGRAM ELIGIBILITY, I MAY BE PUNISHED WITH FINES OR IMPRISONMENT OF UP TO FIVE (5) YEARS, OR BOTH, UNDER SECTION 1001 OF TITLE 18, UNITED STATES CODE, AND I ALSO MAY BE SUBJECT TO CIVIL AND/OR ADMINISTRATIVE PENALTIES AND SANCTIONS. Employee's Name (Print/Type) Employee's Date 47 Waming: Title 18, US Code Section 1001, states that a person who knowingly and willingly makes false or frudulent statements to any Department or Agency of the United States is guilty of a felony. State law may also provide penalties for false or fraudulent statements. This material is available in an accessible format upon request. CDI24I61512N2 1 of 1 PUBLIC HOUSING AND COMMUNITY DEVELOPMENT EMPLOYEE ROSTER AS ROSTER AS OF Roster must be comnleted and submitted to PHCD orior to completion/submission of Job Creation Verification Form(s) BUSINESS NAME: BUSINESS CONTACT PERSONS : BUSINESS ADDRESS: BUSINESS DUNS NUMBER: BUSINESS TELEPHONE: List of Current Employees (please use an additional sheet(s) if necessary) Name Last First Job Title Date Hired Full Time (yes or no) Part Time (yes or no) Hourly Pay Rate List of Vacant Positions Job Title # of Positions # of Positions Hourly Pay Rate Full Time Part Time Proposed Number of Jobs to be Created (# 1 Job Title # of Positions Projected Hiring Date # of Positions Full Time Hourly Pay Rate Full Time Part Time Warning: Title 1a, US Code Section 1001, stales that a person who knowingly and willingly makes false or fraudulent statements to any Department or Agency of the United States is guilty of a felony. State law may also provide 48 penalties for false or fraudulent statements. itThis material Is available In an accessible format upon request. CD/20/51712 Page 1 of 1 COGNIY PUBLIC HOUSING AND COMMUNITY DEVELOPMENT Attachment C-1 AGREEMENT FOR FINANCIAL ASSISTANCE/TECHNICAL ASSISTANCE SERVICES FOR THE CREATION OF JOBS In order to receive the various forms of Financial/Technical Assistance available through businesses must enter into an Agreement to make "available" and to "document" the job creation for the benefit of low and moderate -income residents resulting from the technical assistance and/or financial assistance provided to your business. Through this Agreement, you are committing your business operating under the name of to: 1) Make available 51% of the resulting jobs to low- and moderate -income individuals. 2) Provide a list of the job titles of the permanent jobs expected to be created, which will be available to low/moderate-income individuals and which jobs require special skills or education and which are part-time, if any; 3) Provide a description of steps to be taken by your business to ensure that low- and moderate - income individuals receive first consideration for the jobs created; 4) Maintain a list of permanent jobs filled, available to low- and moderate -income individuals, and a brief description of the hiring process; and 5) Complete an annual report of all jobs created with names, income status, position titles, healthcare benefits, if any, and whether persons hired were unemployed at the time of hiring. The applicant signing below understands the information in this Agreement, understands that will not provide all the assistance requested by your business until action is executed. (Agreed By) Signature of Applicant Duns Number — Required/Mandatory (To obtain a DUNS #, PLEASE CALL 1-866-705-5711) Intake Office (Name of Agency) Date Date Warning: Title 18, US Code Section 1001, states that a person who knowingly and willingly makes false or fraudulent statements to any Department or Agency of the United States is guilty of a felony. State law may also provide penalties for false or fraudulent statements. 49 This material is available in an accessible format upon request. AMCD/ 162112 1 Of 1 a cotralr Agency Name: Contact Person: Phone Number: Fax Number: PUBLIC HOUSING AND COMMUNITY DEVELOPMENT CURRENT EMPLOYEE ROSTER SUMMARY Activity Title: Funding Source: Date: Funding Amount: Number of Jobs: (Accomplishments per contract agreement) Employer/ Business Name Address House Street Number Direction Street Name Type Employee Name Last First Unemployed Prior to this Job? Y or N Date of Date of Hire Job Title' Full -Time' Part -Time Family Size Racial Cate o Elhr icit Job Titles (select one): -Officials & Managers -Professional -Technicians -Sales -Office & Clerical -Craft Workers (skilled) -Operatives (semi -skilled) -Laborers (unskilled) -Service Workers Job Status: Full-time (FT) 30 hour per week or more or- Part-time (PT) less than 30 hours per weei Racial Categories (select all that apply): •W =White •B=Black or African American •A=Asian •AI=Amedcan Indian or Alaska Native •N=Native Hawaiian or Other Pacific Islander •O=Other I hereby certify under the penalty of perjury that the information provided is true, correct, and complete to the best of my knowledge. Further, I acknowledge that the information is subject to verification by authorized government officials. Certification by: Signature Print Name and Title Date Certified: Warning: Title 18, US Cade Section 1001. slates Chet a person who knowingly and willingly makes false or fauduent statements to any Department or Agency of the United Stales is guilty of a felony. State law may also provide Penalties for false or fraudulent statements. This material is available in an accessible formal upon request. CD/19/52112 J 50 Page i of 9 COUNTY Agency Name: Contact Person: Phone Number: Fax Number: PUBLIC HOUSING AND COMMUNITY DEVELOPMENT CURRENT EMPLOYEE ROSTER SUMMARY Activity Title: Funding Source: Funding Amount: Number of Jobs: Date: (Accomplishments per contract agreeme 'Em.. Business Name Address Number Direction .. o Date .. �� Family Racial :. . Warning: Title 18, US Code Section 1001, states that a person who knowingly and willingly makes false or fraudulent statements to any Department or Agency of the United States is guilty of a felony. State law may also provide penalties for false or fraudulent statements. Page 2 of 9 51 N tO C N 0 E a c 'p E c Q LL Z N �W F- W O lz W W O J IL W aj Z F- e W CO) V C V ¢ C LL L: W .0 E z x m LL ai o E a z c Co c m c o Q U a co LO COUNN Agency Name: Contact Person: PUBLIC HOUSING AND COMMUNITY DEVELOPMENT CURRENT EMPLOYEE ROSTER SUMMARY Activity Title: Funding Source: Funding Amount: Date: Phone Number: Fax Number: Number of Jobs: (Accomplishments per contract agreeme Employer/'EmployeeDate Business Name d- Number Direction Street Name Type Last First , ., of Date of Hire Full -Time Part -Time Family Size Racial Cate o 3 Warning: Title 18, US Code Section 1001, states that a person who knowingly and willingly makes false or fraudulent statements to any Department or Agency of the United States is guilty of a felony. State law may also provide penalties for false or fraudulent statements. Page 6 of 9 ,�1 co LO C N a a O O E Q o c � `o E c � a LL Z N oC N O w W W O J o. W y Z H LU o V Q c LL m E Z x co LL c :: CD o a 12 zw c .. z r- o rn Q U a LO c PHCD SUBMITTAL OF ECONOMIC DEVELOPMENT JOB CREATION CHECKLIST ........................................................................................................... Agency Activity Name Funding Source / Year Amount /IDIS # : Project Location DOCUMENTS SUBMITTAL Yes No 1. Agreement for Financial Assistance/Technical Assistance Services for the Creation of Jobs (filled out in its Entirety) ❑ ❑ 2. Employee Roster As of (Current Date) ❑ ❑ ❑ List All Current Employees ❑ List All Vacant Positions ❑ List all Proposed Number of Jobs to Be Created 3. General CDBG Intake Eligibility Form (Current Income Must be Attached - Select 1 below) ❑ Pay Stub(s) ❑ ❑ ❑ Aid to Families with Dependent Children (AFDC) or Temporary Assistance to Needy Families (TANF) ❑ ❑ ❑ Food Stamp Official Print out Letter ❑ ❑ ❑ Unemployment Benefits Letter with Amount ❑ ❑ ❑ Proof of Child Support or Alimony ❑ ❑ ❑ Proof of SSA/SSI or Veteran's Benefits ❑ ❑ ❑ Proof of Retirement Income ❑ ❑ ❑ Other Income ❑ ❑ 4. Job Creation Verification Form (NON-NRSA - Income Must be Attached) (Must include Copy of Employee Pay Stub) ❑ ❑ 5. Job Creation Verification Form (NRSA ) - Proof Must be Attached) ❑ ❑ REQUIRED DOCUMENTATION- NO EXCEPTIONS Yes No Obtain documentation that shows the client lives at the address which is located in an NRSA - Select 1 below Yes No * Proof of location: * Child(ren) School Records (showing home address) ❑ ❑ * Driver License ❑ ❑ * Utility Bill (FPL, Water & Sewer, etc) ❑ ❑ REQUIRED DOCUMENTATION- NO EXCEPTIONS Yes No * PHCD General CDBG Intake Eligibility Form (Must be Attached) ❑ ❑ *Services Near You Print Out (Must be Attached) (httg://pisweb.miamidade.gov/CommunityServices/ ❑ ❑ NOTE: SHOULD ANY OF THE ABOVE NOT BE PROVIDED, QUARTERLY PROGRESS REPORTS WILL BE RETURNED TO THE AGENCY AND WILL BE CONSIDERED NON -COMPLIANT Page 1 of 2 59 PHCD SUBMITTAL OF ECONOMIC DEVELOPMENT JOB CREATION CHECKLIST Neighborhood Revitalization Strategic Areas (NRSA) 1. Biscayne North 2. Cutler Ridge 3. Goulds 4. Leisure City/Naranja 5. Model City 6. Opa-Locka 7. Pemne 8. South Miami 9. West Little River 6. Current Employee Roster Summary ❑ ❑ (Must show New Hired Employee) Prepared by (Print) Agency Official Signature and Date NOTE: SHOULD ANY OF THE ABOVE NOT BE PROVIDED, QUARTERLY PROGRESS REPORTS WILL BE RETURNED TO 60 THE AGENCY AND WILL BE CONSIDERED NON -COMPLIANT Page 2 of 2