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Home My WebLink About037 05 - Q. tt ') & .13'O~ j,U~ -) . V tU1 i *~ P.Jro-hJer {d5. tS- JEFFERSON COUNTY STATE OF WASHINGTON Certifications of Compliance for CDBG } Application Requesting Funds From } Washington State Department of Community, } Trade and Economic Development for the } South 7 Senior Village Project } RESOLUTION NO. 37-05 WHEREAS, Jefferson County is applying to the State Department of Community, Trade and Economic Development for funding assistance; WHEREAS, it is necessary that certain conditions be met as part of the application requirements; WHEREAS, John F. Fischbach, County Administrator, or Allen Sartin, Acting County Administrator, is authorized to submit this application to the State of Washington on behalf of Jefferson County; NOW, THEREFORE, BE IT RESOLVED that Jefferson County authorizes submission of this application to the State Department of Community, Trade and Economic Development to request $238,834 to Olympic Community Action Programs for its development of the South 7 Senior Village, and certifies that, if funded, it: Will comply with applicable provisions of Title I of the Housing and Community Development Act of 1974, as amended, and other applicable State and Federal laws; Has provided opportunities for citizen participation comparable to the State's requirements (those described in Section 104(a)(2)(3) of the Housing and Community Development Act of 1974, as amended); has complied with all public hearing requirements and provided citizens, especially low- and moderate-income persons, with reasonable advance notice of and the opportunity to present their views during the assessment of community development and housing needs, during the review of available funding and eligible activities, and on the proposed activities; Has provided technical assistance to citizens and groups representative of low- and moderate-income persons that request assistance in developing proposals; Will provide opportunities for citizens to review and comment on proposed changes in the funded project and program performance; Will not use assessments against properties owned and occupied by low- and moderate- income persons or charge user fees to recover the capital costs ofCDBG-funded public improvements from low- and moderate-income owner-occupants; . .... .RESOLUTION NO. 31dl5 re: Certifications of Compliance for CDBG Application for South 7 Senior Village Project - Olympic Community Action Council Will establish a plan to minimize displacement as a result of activities assisted with CDBG funds; and assist persons actually displaced as a result of such activities, as provided in the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, as amended; Will conduct and administer its program in conformance with Title VI of the Civil Rights Act of 1964 and the Fair Housing Act, and will affirmatively further fair housing (Title VIII of the Civil Rights Act of 1968); and has adopted (or will adopt) and enforce a policy prohibiting the use of excessive force by law enforcement agencies within its jurisdiction against any individuals engaged in nonviolent civil rights demonstrations; and has adopted and implemented a policy of enforcing applicable state and local laws against physically barring entrance to or exit from a facility or location that is the subject of such nonviolent civil rights demonstration within its jurisdiction, in accordance with Section 104(1) of the Title I of the Housing and Community Development Act or 1974, as amended; and Will provide, upon request, and prior to any obligation of funds being made, a complete and accurate CDBG Federal Funds Disclosure Report detailing the required applicant/grantee information and, as appropriate, other government assistance provided or applied for, interested parties and expected sources, and uses of funds. Jefferson County designates John F. Fischbach, County Administrator, or Allen Sartin, Acting County Administrator, as the authorized Chief Administrative Official and the authorized representative to act in all official matters in connection with this application and Jefferson County's participation in the State of Washington CDBG Program. .~ APPROVED: AND SIGNED this /3 day of June 2005. SEAL: ,..,,,-. .I'" ",,'" I ;) .'),,, '. /': "~. . .;;l~J~', I '" . ' ., 'I' ;..,:JE. '. of' ..... I~. ';4j:-O :~~'~. I;~I . . - ,: .' ... : ~ -Ii' '. -.:, ' .. ~ : " .".' .... I ~ I ~ '~, ,," ~~', ..... _ J · ~ , ~. .", ..~ .. 4" \. ~ ~",. _ ~.r.,. _ .. I" ~. .,. ., .. "'\ . / . ~ ,. t ,v j J" ,,' ,/ '", ~,., ,......".....-~ ATTEST: ,fJC(,[J 7r;a Ij~'p -' erne Julie Matthes, CMC Clerk of the Board f'" 2 RESOLUTION WITH CERTIFICATIONS OF COMPLIANCE INSTRUCTIONS The applicant's local legislative body must pass a resolution authorizing the chief administrative official to submit the CDSG application to CTED and certifying compliance with state and federal laws and specific program requirements. See Appendix D for a summary of these federal and state regulations. Retype the sample resolution provided on the previous page, inserting local and project specific information as indicated. This resolution may be reformatted to meet the jurisdiction's requirements for official resolutions. The resolution must be signed by the authorized chief administrative official, and a signed copy must be included with the application. The chief administrative official is the mayor, county commission chair, county administrator or city manager. A resolution that references another project submitted previously for CDSG funding will not be accepted. Page 1 of 1 Leslie Locke From: Phil Johnson Sent: Tuesday, June 07,20051 :35 PM To: Leslie Locke Subject: FW: CDBG forms for South 7 From: Vanessa Brower[SMTP:VBROWER@OLYCAP.ORG] Sent: Tuesday, June 07, 2005 1 :36:32 PM To: John Fischbach; Pat Rodgers; Phil Johnson; David Sullivan Subject: CDBG forms for South 7 Auto forwarded by a Rule Attached are forms and resolution that need to be signed for the street improvements for South 7. Please add the resolution to the consent agenda then signed by a commissioner, have Allen sign 16A and HUD 2880. If you have questions please call me on my 0011301-3201. Please call when the forms are signed and I will pick them up for delivery to the state with other forms. Vanessa Brower No virus found in this outgoing message. Checked by A VG Anti-Virus. Version: 7.0.323 / Virus Database: 267.6.4 - Release Date: 6/6/2005 6/7/2005 FORM 16A CDBG HOUSING ENHANCEMENT PROJECT SUMMARY 1. Applicant Jurisdiction: Jefferson County Address: P.O. Box 1220 Port Townsend, W A 98368 Phone: (360) 385-9100 FAX: (360) 385-9382 Tax ID #: 91-6001322 County: Jefferson .3. Subrecipient Organization: Olympic Community Action Programs Contact Person: Vanessa Brower Address: P.O. Box 1540 24 Seton Road Port Townsend, W A 98368 Phone: (360) 385-2571 Email: vbrower(a),olvcao.org 6. State Legislative District: 24 Congressional District: 6 7. Project Summary: Olympic Community Action Programs will be using the CDBG Housing Enhancement funds to develop off -site infrastructure, including streets, sidewalks, utilities and bust stop. This infrastructure will allow for the development of 15 units of low-income independent senior housing. 8. Project Category (Please check the categories that apply.) X Housing Community Facilities 9. National Objective Addressed (please check the applicable objective.) -X- Principally benefits low- and moderate-income households, 100 % _ Prevents or eliminates shuns or blight N/ A Meets urgent community development needs which pose a serious & immediate threat to public health or safety 10. Total Project Budget: 11. Project Location: CDBG $238.834 Census Tract(s) 9503 Other Federal 1.409.364 Block Group(s) 5 Housing Trust Fund 748.754 12. Project Beneficiaries: Local Public 108.366 # Persons: 15 Private 120.655 # LMI Persons: 15 TOTAL $ 2.625.973 # Households: 15 # LMI Households: 15 2. Contact Person: John F. Fischbach Title or Affiliation: County Administrator Address: P.O. Box 1220 Port Townsend, W A 98368 Phone: (360) 385-9100 FAX: (360) 385-9382 Email: fischbach((i}co.iefferson.wa.us 4. Consultant: Dan Landes. Common Groun Address: 401 Second Avenue. Suite 500 Seattle, W A 98104 Phone: (206) 461-4500.e xt. 115 Email: danl@commongroundwa.org 5. Fiscal Year from J an to Dec 13. Certification of Chief Administrative Official n () 11, tL.'JJ-.L Signature -if=- John F. Fischbach Name (please type or print) County Administrator Title t (, s-l a~ Date CDBG Housing Enhancement January 2005 " .. HOUSING ENHANCEMENT PROJECT SUMMARY FORM (16A) INSTRUCTIONS The Project Summary Form 16AServes as the cover page for the application. 1. The applicant jurisdiction must be a non-entitlement city or county (see Chapter 6 - Appendix A on pages 6-5 and 6-6). The Tax Identification number is usually a "91-" number. 2. Provide information on the person to be contacted, should more information regarding the threshold requirements or project proposal be needed by the CTED staff. 3. Provide information on any subrecipient organization that will benefit from the project or receive CDBG funds as a pass through. 4. Provide information on the consultant used to develop the proposal, if applicable. 5. List the month and day of the beginning and end dates of the applicant's fiscal year. 6. List the numbers of the state and congressional districts. 7. Provide a brief project summary, highlighting what is to be accomplished and the major elements of the project. 8. Check the appropriate project category. 9. Indicate which CDBG Program national objective this application addresses. Also list the percentage oflow- and moderate-income (LMQ benefit, as documented with the Low Income Households Benefit Table. All General Purpose Grants must address the national object of "principally benefiting low- and moderate-income households" by meeting threshold requirements. It is not necessary to address more than one national objective. ,. 10. List the project budget. These amounts must correspond with Form 16C - CDBG Housing Enhancement Project Budget. 11. List the Census Tract(s) and Block Group(s) that are within the project area. Sources of assistance are the local or county planning office, the U.S. Census website: (http://www.census.govl) or the State Data Center/Census 2000 website: (http://www.ofm.wa.gov/census2000/index.htm). The State Data Center telephone number is (360) 902-0592. 12. List number of people, households, people qualifying as low- and moderate-income and households qualifying as low- and moderate-income that will benefit from the project. 13. This form must be signed by the Chief Administrative Official (mayor, county commission chair, county administrator, or city manager as applicable). An original signature must be submitted. Please clearly state the official's name and title. COBG Housing Enhancement January 2005 ~,;,. Appl icantlReci pient Disclosure/Update Report U.S. Department of Housing and Urban Development OMS Approval No. 2510-0011 (exp. 12/31/2006) Instructions. (See Public Reporting Statement and Privacy Act Statement and detailed instructions on page 2.) IicantlReci ient Information Indicate whether this Is an Initial Report t8I or an Update Report 0 1. Applicant/Recipient Name, Address, and Phone (include area code): 2. Social Security Number or Jefferson County Employer 10 Number: P.O. Box 1220, Port Townsend, WA 98368 (360) 385-9100 3. HUO Program Name COBG 4. Amount of HUO Assistance RequestedlReceived $238,834 5. State the name and location (street address, City and State) of the project or activity: South Seven Senior Village, 100 Church Lane, Port Hadlock, WA 98339 Part I Threshold Determinations 1. Are you applying for assistance for a specific project or activity? These tenns do not include fonnula grants, such as public housing operating subsidy or COSG block grants. (For further information see 24 CFR Sec. 4.3). Il;J Yes D No 2. Have you received or do you expect to receive assistance within the jurisdiction of the Department (HUD) , involving the project or activity in this application, in excess of $200,000 during this fiscal year (Oct. 1 - Sep. 30)? For further infonnation, see 24 CFR Sec. 4.9 Il;J Yes D No. If you answered "No" to either question 1 or 2, Stop! You do not need to complete the remainder of this form. However, you must sign the certification at the end of the report. Part II Other Government Assistance Provided or Requested I Expected Sources and Use of Funds. Such assistance includes, but is not limited to, any grant, loan, subsidy, guarantee, insurance, payment, credit, or tax benefit. Department/State/Local Agency Name and Address Type of Assistance Amount Expected Uses of the Funds RequestedlProvided HUD Section 202 $1,409,364 Development of units Washington State Housing Trust Fund $748,754 Development of units Jefferson County 2060 Funds 108,366 Development of units (Note: Use Additional pages if necessary,) Part III Interested Parties. You must disclose: 1. All developers, contractors, or consultants involved in the application for the assistance or in the planning, development, or implementation of the project or activity and 2. any other person who has a financial interest in the project or activity for which the assistance is sought that exceeds $50,000 or 10 percent of the assistance (whichever is lower). ' Alphabetical list of all persons with a reportable financial interest Social Security No. Type of Participation in Financial Interest in in the r' ct or activi For individuals ive the last name first or Em 10 ee 10 No. Pr 'ectlActivi P 'ectlActivi $ and % South Seven Senior Village 73-1676594 Owner 100% Olympic Community Action Programs 91-0814319 Sponsor Common Ground 91-1128864 Dev. Consultant ARC Architects 91-1255360 Architect Triple 0 Construction 91-1616304 General Contractor 179,000 200,000 1,800,000 (Note: Use Additional pages if necessary.) Certification Warning: If you knowingly make a false statement on this fonn, you may be subject to civil or criminal penalties under Section 1001 of TiUe 18 of the United States Code. In addition, any person who knowingly and materially violates any required disclosures of infonnation, including intentional non- disclosure, is subject to civil money penalty not to exceed $10,000 for each violation. I certify that this infonnation is true and complete. Signature: Date: (mmlddlyyyy) 4,~~ Fonn HUD-2880 (3/99) CDSG General Purpose Grant Application 53 September 2004 , Public reporting burden for this collection of information is estimated to average 2.0 hours per response, induding the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection information unless that collection displays a valid OMB control number. Privacy Act Statement. Except for Social Security Numbers (SSNs) and Employer Identification Numbers (EINs), the Department of Housing and Urban Development (HUD) is authorized to collect all the information required by this form under section 102 of the Department of Housing and Urban Development Reform Act of 1989, 42 U.S.C. 3531. Disdosure of SSNs and EINs is optional. The SSN or EIN is used as a unique identifier. The information you provide will enable HUD to carTY out its responsibilities under Sections 102(b), (c), and (d) of the Department of Housing and Urban Development Reform Act of 1989, Pub. L. 101-235, approved December 15,1989. These provisions will help ensure greater accountability and integrity in the provision of certain types of assistance administered by HUD. They will also help ensure that HUD assistance for a specific housing project under Section 102(d) is not more than is necessary to make the project feasible after taking account of other government assistance. HUD will make available to the public all applicant disdosure reports for five years in the case of applications for competitive assistance, and for generally three years in the case of other applications. Update reports will be made available along with the disclosure reports, but in no case for a period generally less than three years. All reports, both initial reports and update reports, will be made available in accordance with the Freedom of Information Act (5 U.S.C. ~552) and HUD's implementing regulations at 24 CFR Part 15. HUD will use the information in evaluating individual assistance applications an~ in performing intemal administrative analyses to assist in the management of specific HUD programs. The information will also be used in making the determination under Section 102(d) whether HUD assistance for a specific housing project is more than is necessary to make the project feasible after taking account of other govemment assistance. You must provide all the required information. Failure to provide any required information may delay the processing of your - application, and may result in sanctions and penalties, induding imposition of the administrative and civil money penalties specified under 24 CFR ~.38. Note: This form only covers assistance made available by the Department. States and units of general local government that carTY out responsibilities under Sections 102(b) and (c) of the Reform Act must develop their own procedures for complying with the Act. Instructions Overview. A. Coverage. You must complete this report if: (1) You are applying for assistance from HUD for a specific project or activity and you have received, or expect to receive, assistance from HUD in excess of $200,000 during the during the fiscal year; (2) You are updating a prior report as discussed below; or (3) You are submitting an application for assistance to an entity other than HUD, a State or local govemment if the application is required by statute or regulation to be submitted to HUD for approval or for any other purpose. B. Update reports (filed by "Recipients" of HUD Assistance): General. All recipients of covered assistance must submit update reports to the Department to reflect substantial changes to the initial applicant disclosure reports. Une-by-Line Instructions. AppIicanUReclpient Information. ; All applicants for HUD competitive assistance, must complete the information required in blocks 1-5 of form HUD-2880: 1. Enter the full name, address, city, State, zip code, and telephone number (induding area code) of the applicant/recipient. Where the applicant/recipient is an individual, the last name, first name, and middle initial must be entered. 2. Entry of the applicant/recipient's SSN or EIN, as appropriate, is optional. 3. Applicants enter the HUD program name under which the assistance is being requested. 4. Applicants enter the amount of HUD assistance that is being requested. Recipients enter the amount of HUD assistance that has been provided and to which the update report relates. The amounts are those stated in the application or award documentation. NOTE: In the case of assistance that is provided pursuant to contract over a period of time (such as project-based assistance under section 8 of the United States Housing Act of 1937), the amount of assistance to be reported indudes all amounts that are to be provided over the term of the contract, irrespective of when they are to be received. 5. Applicants enter the name and full address of the project or activity for which the HUD assistance is sought. Recipients enter the name and full address of the HUD-assisted project or activity to which the update report relates. The most appropriate govemment identifying number must be used (e.g" RFP No.; IFB No.; grant announcement No.; or contract, grant, or loan No.) Indude prefixes, Part I. Threshold Determinations - Applicants Only Part I contains information to help the applicant determine whether the remainder of the form must be completed. Recipients filing Update Reports should not complete this Part. If the answer to either questions 1 or 2 is No, the applicant need not complete Parts II and III of the report, but must sign the certification at the end of the form. Part II. Other Government Assistance and Expected Sources and Uses of Funds. A. Other Govemment Assistance. This Part is to be completed by both applicants and recipients for assistance and recipients filing update reports. Applicants and recipients must report any other government assistance involved in the project or activity for which assistance is sought. Applicants and recipients must report any other government assistance involved in the project or activity. Other government assistance is defined in note 4 on the last page. For purposes of this definition, other govemment assistance is expected to be made available if, based on an assessment of all the circumstances involved, there are reasonable grounds to anticipate that the assistance will be forthcoming. Both applicant and recipient disclosures must indude all other govemment assistance involved with the HUD assistance, as well as any other govemment assistance that was made available before the request, but that has continuing vitality at the time of the request. Examples of this latter category indude tax credits that provide for a number of years of tax benefits, and grant assistance that continues to benefit the project at the time of the assistance request. The following Information must be provided: 1. Enter the name and address, city, State, and zip code of the government agency making the assistance available. 2. State the type of other government assistance (e.g., loan, grant, loan insurance). 3, Enter the dollar amount of the other govemment assistance that is, or is expected to be, made available with respect to the project or activities for which the HUD assistance is sought (applicants) or has been provided (recipients). 4. Uses of funds. Each reportable use of funds must dearly identify the purpose to which they are to be put. Reasonable aggregations may be used, such as "total structure" to indude a number of structural costs, such as roof, elevators, exterior masonry, etc. B. Non-Government Assistance. Note that the applicant and recipient disclosure report must specify all expected sources and uses of funds - both from HUD and any other source - that have been or are to be, made available for the project or activity. Non-govemment sources of Form HUD-2880 (3/99) CDSO General PUlpOse Grant Application September 2004 54 " funds typically include (but are not limited to) foundations and private contributors. Part III. Interested Parties. This Part is to be completed by both applicants.and recipients filing update reports. Applicants must provide information on: 1, All developers, contractors, or consultants involved in the application for the assistance or in the planning, development, or implementation of the project or activity and 2. any other person who has a financial interest in the project or activity for which the assistance is sought that exceeds $50,000 or 10 percent of the assistance (whichever is lower), Note: A financial interest means any financial involvement in the project or activity, including (but not limited to) situations in which an individual or entity has an equity interest in the project or activity, shares in any profit on resale or any distribution of surplus cash or other assets of the project or activity, or receives compensation for any goods or services provided in connection with the project or activity. Residency of an individual in housing for which assistance is being sought is not, by itself, considered a covered financial interest. The information required below must be provided. 1. Enter the full names and addresses. If the person is an entity, the listing must include the full name and address of the entity as well as the CEO. Please list all names alphabetically. 2, Entry of the Social Security Number (SSN) or Employee Identification Number (EIN), as appropriate, for each person listed is optional. 3. Enter the type of participation in the project or activity for each person listed: Le., the person's specific role in the project (e.g., contractor, consultant, planner, investor). 4. Enter the financial interest in the project or activity for each person listed. The interest must be expressed both as a dollar amount and as a percentage of the amount of the HUO assistance involved. Note that if any of the source/use infonnation required by this report has been provided elsewhere in this application package, the applicant need " not repeat the information, but need only refer to the form and location to incorporate it into this report. (It is likely that some of the information required by this report has been provided on SF 424A, and on various budget forms accompanying the application.) If this report requires information beyond that provided elsewhere in the application package, the applicant must include In this report all the additional infonnation required. Recipients must submit an update report for any change in previously disclosed sources and uses of funds as provided in Section 1.0.5., above. Notes: 1. All citations are to 24 CFR Part 4, which was published in the Federal Register. [April 1, 1996, at 63 Fed. Reg. 14448.] 2. Assistance means any contract, grant, loan, cooperative agreement, or other fonn of assistance, including the insurance or guarantee of a loan or mortgage, that is provided with respect to a specific project or activity under a program administered by the Department. The term does not include contracts, such as procurements contracts, that are subject to the Fed. Acquisition Regulation (FAR) (48 CFR Chapter 1). 3. See 24 CFR ~.9 for detailed guidance on how the threshold is calculated. 4. "Other govemment assistance" Is defined to include any loan, grant, guarantee, Insurance, payment, rebate, subsidy, credit, tax benefit, or any other form of direct or indirect assistance from the Federal govemment (other than that requested from HUO in the application), a State, or a unit of general local government, or any agency or instrumentality thereof, that Is, or is expected to be made, available with respect to the project or activities for which the assistance is sought. 5. For the purpose of this form and 24 CFR Part 4, "person" means an individual (including a consultant, lobbyist, or lawyer); corporation; company; association; authority; firm; partnership; society; State, unit of general local government, or other government entity, or agency thereof (including a public housing agency); Indian tribe; and any other organization or group of people, Form HUD-2880 (3199) COBG General Purpose Grant Application September 2004 55