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<br />_. <br /> <br />ApplicanURecipient <br />Disclosure/Update Report <br /> <br />U.s. Department of Houalng <br />and Urban Development <br />Office 01 Ethics <br /> <br />~ <br />,r <br />OMe Apptllvo/ No. 252S-<)10t (up, t2l31~) <br /> <br />Inllructlona, (See Pub~c Re-porbng Sta~nl and Privaey Act Stal."..nt and dtlailed inlb"uction. on pape ~.) <br />Part I AppllcantlReclplent Information IndlCAlo wholher lhlo 10 on Inhlal Roport 0 <br />t. ApphcanVRK;p;"nl Norno. ~". and Phone (inc:lvdo aroo codo) <br /> <br /> <br />2. Proj&c:tMsisl8CV 10 be AuiJ\ed (Proj6eVA=vtty nama and/or number and its location by Shet 1ddr8", City, and S\II18) <br /> <br />3. Assistance Requeste<1lReeer...ed <br /> <br />4. HUD Propnom <br /> <br />5. Amount ~'Ite4'Rec::ei'to9d <br />S <br /> <br />Part II. Threshold Determinations - Applicants Only <br /> <br />1. Are you requesting HUD assistance lor a spec~ic projec1 or ac1ivity, as provided by 24 CFR Pan 12. Subpan C. <br />and have you t&ceived, or can you reasonably expect to receive, an aggregate amount of aU forms of cover&d <br />assistance from HUD, States, and units of general local government. in excess of $200,000 during the F~.ral <br />liscal year (Oc1ober 1 through September 30) in which Ihe application is submined? 0 Veo <br />If Yes, you must complete the remainder of this report. <br />If No. you must sign the certification below and answer thl next question. <br />I hereby cel1ily that this inlormation Is true. (Signaturo) Date <br /> <br />2. Is Ihis application for a specifIC housing projOClthal involves other government assistance? 0 Veo 0 No <br />If Yes, you must complete the remainder of this report. <br />tf No. you must sigh this certification. <br />I hereby cenily Ihat this inlormation is lrue. (Signature) Date <br />H your answers 10 both queslions are No, you do not need to completo Pons III. IV, or V. but you must sign the cenification at the end 01 the ,_rt. <br />Part III. Olher Governmenf Assistance PrOvldedlRequested <br /> <br />ONo <br /> <br />~partmentlStatell.ocal ~~ Name ancfAdO-eSI <br /> <br />~~rarn <br /> <br />J'ype 01 ASSistance <br /> <br />Arnoun1 Rewhle-dlProo.;c:led <br /> <br />Is there other government asslSlance that IS reponable In thIS Pan and In Pan V. but IhatlS reponed only In Pan V? oVes <br /> <br />If 1here is no other government assistance, you musl C8r1ify thal1his information is true. <br />I hereby Clr1ify that this in10rma:ion is 1rue. (Signa1ure) <br /> <br />oNO <br /> <br />Oal. <br /> <br />P'ptt 1 of 7 <br /> <br />101m HUD-2IaG <'>92) <br />ref. See: 102. HRA 1989; PL 101 .235 <br />