1994-081-RES WHEREAS, the U.S. Department of Housing and Urban Development, Office of Public and Indian
RESOLUTION NO. 94-081
WHEREAS, the U.S. Department of Housing and Urban Development, Office of
Public and Indian Housing, Office of Resident Initiatives Drug-Free Neighborhoods
Division provides funding for Public and Indian Housing Youth Sports Program grants;
and,
WHEREAS the City Council of the City of Paris is desirous of processing a grant
application for the Public and Indian Housing Youth Sports Program, at a maximum total
cost of $125,000.00, with $62,500 to be provided by grant and $62,500.00 to be
provided by the City of Paris Police Athletic League and the Boys Club; NOW,
THEREFORE,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PARIS:
I. That an application be made to the U.S. Department of Housing and Urban
Development, Office of Public and Indian Housing, Office of Resident Initiatives Drug-
Free Neighborhoods Division for a Public and Indian Housing Youth Sports Program
Grant in the approximate amount of $62,500.00 being approximately 50 % of the
estimated cost of the Public and Indian Housing Drug Elimination Grant Program, with
the City of Paris Police Athletic League and the Boys Club providing approximately
$62,500.00 in kind services and funds.
2. That Michael E. Malone, City Manager of the City of Paris, be, and he is
hereby, appointed as the Authorized Official of said project and is authorized and directed
to execute on behalf of the City of Paris the application for grant in the form attached
hereto as Exhibit A.
3. That Karl Louis, be, and he is hereby, appointed as Project Director and
is hereby authorized to execute and deliver on behalf of the City of Paris all reports,
communications, assurances and documents necessary for the completion of said project.
4. That W. E. Anderson, Director of Finance, be, and he is hereby, authorized
and directed to serve as the Financial Officer for said project and to receive and distribute
funds for the City of Paris Police Department's participation in the Public and Indian
Housing Youth Sports Grant Program.
PASSED AND ADOPTED this 11th day of July, 19 ~.
ATTEST:
TAB 1
YOUTH SPORTS APPLICATION FACT SHEET
HOUSING AUTHORITY:
STATE:
PHNIHA #:
IRS EMPLOYER IDENTIFICATION NUMBER:
REGION:
FIELD OFFICE:
CONTACT PERSON:
CONTACT PERSON PHONE #:
CHECK ONE: PHA
iliA
DURATION OF PROGRAM: _MONTIIS
AMOUNT REOUESTED. BY PROGRAM AREA. UNDER THIS APPLICATION:
The catagorical infonnation should only reflect the dollars that will be provided by the actual
grant funding. This does not include the matching funds. Matching will be shown under
''Non-Federal Matching Funds" reflecting the total amount of matching funds for this
application.
YOUTH SPORTS EFFORTS:
RECREATIONAL FACILITIES:
YOUTH DRUG EDUCATION FACILITIES:
YOUTH EDUCATIONAIlVOCATIONAL ACTIVITIES:
GRANT AMOUNT REQUESTED:
NON-FEDERAL MATCHING FUNDS:
SUMMARY OF PROGRAM:
A brief summary of the program proposed in this application (100 words or less). This
narrative will be used for Congressional Notification.
OMI A.....o,w., Mo. 0)4..1..00.&.)
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ApplicanURecipient
Disclosure/Update Report
U.s. Department of Houalng
and Urban Development
Office 01 Ethics
~
,r
OMe Apptllvo/ No. 252S-<)10t (up, t2l31~)
Inllructlona, (See Pub~c Re-porbng Sta~nl and Privaey Act Stal."..nt and dtlailed inlb"uction. on pape ~.)
Part I AppllcantlReclplent Information IndlCAlo wholher lhlo 10 on Inhlal Roport 0
t. ApphcanVRK;p;"nl Norno. ~". and Phone (inc:lvdo aroo codo)
2. Proj&c:tMsisl8CV 10 be AuiJ\ed (Proj6eVA=vtty nama and/or number and its location by Shet 1ddr8", City, and S\II18)
3. Assistance Requeste<1lReeer...ed
4. HUD Propnom
5. Amount ~'Ite4'Rec::ei'to9d
S
Part II. Threshold Determinations - Applicants Only
1. Are you requesting HUD assistance lor a spec~ic projec1 or ac1ivity, as provided by 24 CFR Pan 12. Subpan C.
and have you t&ceived, or can you reasonably expect to receive, an aggregate amount of aU forms of cover&d
assistance from HUD, States, and units of general local government. in excess of $200,000 during the F~.ral
liscal year (Oc1ober 1 through September 30) in which Ihe application is submined? 0 Veo
If Yes, you must complete the remainder of this report.
If No. you must sign the certification below and answer thl next question.
I hereby cel1ily that this inlormation Is true. (Signaturo) Date
2. Is Ihis application for a specifIC housing projOClthal involves other government assistance? 0 Veo 0 No
If Yes, you must complete the remainder of this report.
tf No. you must sigh this certification.
I hereby cenily Ihat this inlormation is lrue. (Signature) Date
H your answers 10 both queslions are No, you do not need to completo Pons III. IV, or V. but you must sign the cenification at the end 01 the ,_rt.
Part III. Olher Governmenf Assistance PrOvldedlRequested
ONo
~partmentlStatell.ocal ~~ Name ancfAdO-eSI
~~rarn
J'ype 01 ASSistance
Arnoun1 Rewhle-dlProo.;c:led
Is there other government asslSlance that IS reponable In thIS Pan and In Pan V. but IhatlS reponed only In Pan V? oVes
If 1here is no other government assistance, you musl C8r1ify thal1his information is true.
I hereby Clr1ify that this in10rma:ion is 1rue. (Signa1ure)
oNO
Oal.
P'ptt 1 of 7
101m HUD-2IaG <'>92)
ref. See: 102. HRA 1989; PL 101 .235
-
Part V. Report on Expecled Sources and Uses 01 Funds
Sou..,.
U thoro are no sources of funds, you must certify that this information Is truo.
I heroby certify that this information is truo. (Signatur.)
Date
u..
If there are no uses of funds, you must certify that this informatao!111 true.
f heroby certify that this iniormalion Is truo. (Signatur.)
ConIllcadon
Warning: II you knowingly rnokealolso '''_on lhi'lonn.yournaybo aubj<<:lto eM or_~ undors.ction 1001 olTIIIo 18 of'" UrllOdSlolK
Code. In adcllion, 81f'J _ who knownpIy and malOriolly ....Ia... 0l1'f requirod chdoauro of nlormdon. ~n; n..MlonaJ _ura. II IlAljoQ to eM
monoy pono/I)' not to OXOMd$IO.OOO lor oach ".;ofollon.
I oonify hllhi, nlonnation Ia .". and complo...
Sipna"'ro
Oalo
PaQO 3 of 7
100..
bnn HU~2:UO
b. For all programs, other than thoSl administered by the Assistanl
Secrelary tor Communily Planning and Development:
For projects receiving a tax credit und.r Federal, Stat., or local law,
any change in a sourc. of funds that was previously disclosed.
For all other proj8C1S, any change in a sourc. otfunds that exceeds
lne lower of:
The amount previously disclosed for that source of funds by
$250,000, or by' 0 percent of the amount previously disclosed for that
source, whichever is bwer; or
The amount previously disclosed for all sources of funds by
$250,000, or by '0 percent of the amoun1 previously disclosed tor all
sOlJl'ces of funds, whichever is lower.
c. For all programs, 01h,r than those administered by the Assistant
Secretary tor Community Planning and Development:
Forprcjects recliving a tax cred~ under Federal, Stat., or local law,
any change in a use of funds tha1 was previously disclosed.
For all other projeCls, any change in a use of funds that exceeds the
bwerof:
The amount previously disclosed for 1hat use of funds by
$250,000, or by '0 percent of the amoun1 previously disck)$&d for Ihat
t:se, whichever is lower; or
The amount previously disclosed for all uns of funds by
S250,OOO, or by 10 percent of the amount previously disclosed for all
uses of funds. whichever is lower.
Nole: Updale ropons must bo submitted whhin 30 days of the change
requiring the update. The requirement to provide update reports only
applies if the application for the underlying assistance was submined
on or ahllthe effeetive dale of Subpan e.
II. llne-by.llnl Insl,uc1lons.
A. Part I. AppllcanVRlclpllnllnlo,matlon.
All applicants 10' HUO assiS1lnce spocifi~ In S8c1ion l.e.1 .L, above,
as WIU as all recipients required to submit an update repor1 under
Section 1.0., aboY., must complete the information required by Part I.
The applanttrec:ipient must indicat. whether the disclosure is an
ini:ial or an update rapon. Line-by-line guidance for Pan I follows:
,. Entllthe IuD name, address, c~y, Sta18, zip code, and telephone
number (including area c::ode) of the applicanVrecipient. Where the
applicant/recipient is an individual. the last name, first name, and
middle inhial must be entlled. Entry of the applicanVrocipienl's SSN
or EIN, as appropriate, is optional.
2. Applicants enter the name and full address of the projec1 or adivny
lor which the HUD assistanca is sought. Reeipi.nts enl.r the name
and full address of the HUD-assisted project or aaivity to whch the
u.:;dat. repon r.lates. The most appropriate government identifying
number must be used (e.g., RFP No.; IFB No.; grant announcement
No.; or contract, grant, or loan No.) Include prefixes.
3. Applicants describe the HUe assistanc. referred to in Section
1.e.l.a that is being r.quest.d. Recipients describe the HUD assis.
ta~ce to which the upclate report relat.s.
.l. Applicants enler the HUe program name under which th. ass is.
lance is being requesled. Recipients enter the HUO program name
ur,der which the assislanc., that relates to the update repon, was
provided..
5. Applicants Inter 1he amount of HUD assistanc. thai is being
requesled. Recipients emle' the amount of HUD assistance that has
bun provided and 10 wheh the update repon relates. The amounts
are those stated in the application or award documentatkm. NOTE: In
the case of assistance that is provided pursuant 10 contrac1 over a
p&riod of time (SUCh as projed.based assistance under secticn a orthe
Un~.d States Housing Ad of 1937). the amount of auistane.10 be re-
pened includes all amounts that arelo be provided over the1erm ofth.
comract, iuespeCl;ve of when Ihey are to be recerved.
Note: In the case of Mortgage Insurance under 24 CFR Subtitle B,
Chapter II, Ihe mortgagor is responsible for making 1he applant
disclosures, and the mortgagee is responsibl. for furnishing 11'1.
mongagor's disclosures 10 the Departm.nt Updal' repons must be
submitted dir8c11y '0 HUO by the mongagor.
Note: In the case of 1he Project.Based eertHa.te program under 24
CFR Part 882, Subpart G, the owner is responsible for making Ihe
applieanf"dis.,flosures, and the PHA is responsible for furnishing the
own.r's disclosures to HUD. Update reports must be submined
through the PHA by 'he owner.
B. Plrt Il Th,uhold Oltermlnatlona _ Appllcantl Only
Pan llcontains informal ion to help the applicanl dOlo,mine whethorthe
remainder of 1he form must be completed. ~.clpl.nt. filing Update
R.porta shOUld not compl.te this Part.
1. The first question asks whether the applant meets the Nature of
Assistance and Dollar Threshokj requiremen1s set fonh in StClion
I.C.'. above.
tf the answer is Yes, the applicant must compl.te the remainder of the
form. tithe answer is No, the form asks the applicanllo certify that its
rosponu is corred, and to complete the next question.
2. The second question asks wh.ther the application is for a speciftc
housing project that involves other government assistance, as de-
scribed in Sedion I.C.2. above,
tf the answer is Ves, the applicant mus1 complete the remainder of th.
form. If the answer is No, the form asks the 8.pj)rlC8nt 10 certify that its
response is correct.
If the answer 10 both questions1 and 2 is No, the applicant n.ed not
complete Pans III. IV, or V of the "pon. but must sign the cenWicalion
at the end of 'he form.
C_ Part III. Other Government A..'atance.
This Pan is 10 bo completed by both applicants filing apprlCant
disclosure ..pons and recipients filing update ropons. Applicants
must repon any other government assistance involved in the project
or activity for which assis1ance is sought. Aecir>ients must report any
other governmem assistance involv~ in the project or ad;vity, 10 Ih,
extent required under Section 1.0.1.. 2., or 3., above.
Other government assistance is defin.d in not. 5 onth,lasl pag.. For
purposes of this definition, olher government assistance is expec.1ed
10 be made available if; based on an assessment of all the circum-
stancls involved, there is reasonable grounds 10 anticipate that the
assistanee will be forthcoming.
Both applicant and recipient disclosures must include allot her govern-
mint assistance involved with 1h, HUD asststance, 8S well as any
other government assis1ance that was made available before the
request. but Ihat has continuing vila lily at th. Hme of the request.
Examples of this laner category include tax credils that provtde for a
number of years of 1ax benefits, and grant assi$tance that continues
to benefh the projed at the 1ime of the assistance requHt.
The toUowing information mus1 b. provid&d:
,. Enter ihe name and addr.ss, city, Stal., and Zip code of the
government agency making the assistance available. Include at least
on. organizational level below the agency name. For Ixample, U.S.
Oepanment of Transponalion. U.S. CoaS1 Guard: Oepanment of
Safety. Highway Patrol.
2. Enter tho program name and any "Ievanl identffying numbors. 0'
other means of identiHcation, tor the other government assistanc..
3. Slate the type of 01her povernment assistance (I.g., loan, grant,
loan insuranc.).
4. Enter the donar amoun1 of the ather government assislance that is,
or is expected 10 be, made availabl. with resped to the project or
Ictivities for which lhe HUD assistance is sought (applicants) or has
be.n provided (recipi.nts).
Pape5of7
form HUD-2aa.O
r: Ih" applicant has no o:h.r QaVemment auista~ to disclou. iI must
cenity that this assenion is coned:.
To avoid duplication. ifth.r. is oth.r po....rnm.nt Usllt.not und.r this
Part and Part V,lh. &;>plunVr.cipi.nt.hould d>.o.th. appropriol.
box in this Part and listth. inlormation in Part V, cl8ar~ dutgnatir.g
which sources are o1her govemmenl assis1ance.
D. P.rtIV. Int"nl.d I'Irtl...
This Part i. to bt compl.,od by bolh applicant. r~ing applicant
disclosure r.p)r'\s and r.opients filing updat. r.porta,
Apprcants must providl information on:
(1) All dev.bpers, contradorl, or consutlantl invoJve.d in the applica-
tion for the assistanc. or in the planning, dlvebpmlnt. or impllmen-
tation of thl projlct or aC'..;""r.y: and
(2) Any olhor person who has a fin.ncial inl"..t In th. projod 0(
adivi'ty for which the a.s.sis:anca ~ sought that .x~e<Js $50,000 or '0
percent of the assis1a.")CI (whichlver is Iow.r).
R~ipients must make the additional disclosures rltl.rre<J to in Sldion
1.0.1..2.. or 4. abav..
Nols,: A financial interest means any fsnanciaJ invotvlm.nt in th.
project or ac:ivity, inchx:!i.~ (but not limiled to) s.ituations in which an
individual or onlhy has an equity inlor..t in tho projtcl or aclivhy,
shares in any profit on resale or any distnbutionof su~us cash or other
assets of the projed or a:=',Nil'y, or receives compln~ation for any
goods or slrvice-s provided in connld.ion whh thl pro}ed or activity.
A..id.ncy of an individual in housing for which ...isIanco is being
$ought is not, by itself, considlr~ a ccv.r~ financial intereSl
Tj)il} information requited below must be provide<J,
L Enter thl fuD names aM acSdr.ss.es of all persons ref.rr.cl \0 in
paragraph It) or (2) ollhis Pan. ~ th. person is an onlily, tho listing
must includ. the full name a each offtCer. director, and prirdj)al
slockholdll olth. onlity. All nam.. must boo tis10d alphabetically. and
Ih. nam.. 01 individuals mu.t be shown with tho~ last nam.. first.
2. Enlry of th. Social Socurily Numbtr (SSN) or Employnldontif'oc:a-
tion Number (EtN). as a;>proprialt, lor tad> porson lislod is oplionaL
3. Entor th. Iype of panicipalion in tho projocl or aclivity lor tad>
person tislOd: t... tho person's spocilic rol. In th. projtcl (..g.,
contrador, eonsutl.ant. planner, investor),
4. Enlll Ih. financial inl"'" in th. projtcl or aclivily for tad> person
listed. The interest must be expressed both as a dollar amount and as
a parcentage of the amount of thl HUD assista.nc:e invotv.d.
~ thl applicant has no pers.ons wil.h financial int.rests to disclose, k
must cenity tha11his as.sinion is correct,
5. Part V. R.port on Sour... and UN' 01 FundI. This Part is 10 bt
complet&d by b::Ith appfi:ants filing applicant dis.cbsurt r"POrts and'
recipients filing upda~. r';>or..s.
The apprant disc10sure repon must $pecify aJI .xp.ct.cS s.ources 01
lunds - bothlrom HUe and from any other s.ource -thll'l haye be.n,
or are to bI. made availabl. for the project or adivity, Non.HUD
sources offunds typ)cally includl (bUl &f8 not limher \0) other gov8rn~
ment assistance refen.d to in Part 111, equity, and' amount. from
foundations and priva~e contributions. The report must also specify an
~xp&d.d uses to which fur.ds are to be put. All sources and US4lS of
1unds must be list&d, ft, bu.d on an assessment 01 all the circum-
stances invo~.d, there art reasonabl. grour.ds to anticipat. that the
:s.oUIC. or un win be tort~c:oming.
Nolo that ~ any olth. sourea!uso Inlormalion roquirod by this llpotI
has be.n provid.d ols.whor. in this application pac:l<ago, tho appIi.
cant need not repe-'- thl intormation, but nMd only refer to thl fonn
and Iocalion 10 incorporalt ~ inlo this llport. (h is 1i<.1y thai $Om. 01
Ih. informalion IIqu~od by this llport has been providod on SF 424....
and on various budg.tlorms accompanying tM appfeation.) "this
Jeport reQuires intormation beyond thm provWjtd els.wh.,. in t.....
a.pplic;tiOn packag., the applicant mUI' include in this rtport an the
addiltonal information re-quir&d.
Rt<:ipilna must submh an upd~. repon for any chang. in pr.viousty
dis<:lo.od sources and us.. of lund. II p<ovidod in Soc:ion 1.0.5.,
ahoy..
G.n.rallnstrUdions - J.OUfces of funds
Each raport.bI. $Ourca 01 fund. mu.'lndical.:
a. The natfl.....nd addr.... clty, Stat., and zip code of th. individual or
.nOty making the asaista.nce available. At ~ast on. organil.tbnal
~Yel bebw thl ag.ncy nama shou'd be induded. For .xampll, U.S.
D.partmont of Transponlllion. U.S. Coasl Guard; D.panm.nt 01
Sof.ly. Highway Palrol.
b. The prDglram name and arry r.llvant identifyinQ numb.rs, or other
means 01 identifICation, for thl assistancI.
c. The type of assis1a.1lC$ (I.g., loan. grant. loan insuranee).
Specific instructions - sourCClS of funds.
(') For progra.ms adminisl.rtd by the Assistant Secretaries for Fair
Housing and Equal Opponunity and Policy Doy.lopmont and Ro.
uaren, each source of funds mus1 indica1e th. lotal amount of
approved, and reeaiY&d; and must be listed in descending order
ac::cording to the amount i,..dicat~.
(2) For programs adminis1er&d by the Assistant Seerelanes for
Housing-F$der&l Housing Commissioner, Community Planning and
O.yebpment. and Pubic and Indian Housing, each source of funds
must indicalotho tolal amount oIlunds involvod, and must be [l$lod in
descand'ing orO$r according to th. amount indicate<!,
(3) If Tax Cre<Jits are invotved, thl report must indatt aa syndation
proceeds and equity involvod.
Gen.ral instrudion~s8S of funds,
Each reportablou.. ollunds musl citaMyidontifytho purpos.to whid>
th.y ar.1O be put. Rnsonabl. aggregations may be usod, such as
.,otal strudur.. to indudl a number of struc::2uraJ costs, such as roof.
.vevators. ext.rior masonry. .tc.
SpeciftC instructions - us.s of funds,
(') For program. administllod by Ih. Assistant Secrolws lor Fair
Housing and Equal Opponunity and porcy D.v.lopmont and R..
soarch, .ach us. of funds must indicalo tho tolal amount 01 funds
Involvod: must bt brcl<.n down by amount commillod, budg.tod. and
plannod; and must be ~S1od in doscending ordor according to tho
amount iM'ica1.-d,
~Q For programs adminis1ered by thl Assistant Secrltaries for
Housing-F&dlraJ Housing Commissioner, Community Planning and
Oey.bpment, and pubrc and lndian Housing, tach us. of funds must
indica1. the total amoum of funds involv.d and must bI lis1ed in
deSC8ndir.g order a.cc:ording 10 the amount inyotv~,
(ill) If any program adminis11red by the Assistant SlCfltary for
Housing-Fed..,al Housing Commission.r is involved, the report must
indicat. all vses paid from HUD sources and oth.r sources. including
syndication proceeds. Uses paid should includl the followinQ
amounts.
AMPO
Archiled'S 1M - design
Archit&d's fee - supervision
Bond premium
Builder's gen.ral overhead
BuDdor's proll
Construc.1.ion interlst
Consutlant te.
Contingency Rlserve
Cost CQnlfieation audit 1ee
FHA examination '.e
FHA in~on '"
p.~ 6 01 7
iorm Hue-2nO
FHA MIP
Fmancing fe.
FNMA / GNMA I..
Generallequiremenls
Insurance
legal- construC1icn
legal- organization
Other f88s
Purchase price
Supplemental management fund
TaxIs
Tnls and recording Operating defici1 reserve
Resident initiative fund
Syndication expenses
Working capital reserve
TOlalland improvement
Total sHuc1ures
Uses paKJ from syndicalion musl include th, foUowing amounts:
Addi1ional acquisition price and expenses
Bridge loan inlerest
Oevelopma'.)J fee
Operating deficit reserve
Restdent initiative fund
Syndication expenses
Working capital ruerve
Footnotes:
1. All citations are 10 24 CF;:1 Part 12. which was published in tle Federal
Register on March '4. '~1 8156 Fed. Reg. 11032.
2. A lisl 01 the covered assis~rICe proQrams can be found at 24 CFR S 12.30.
Of in the rules or adminisvati...e inSlruc1ions goyeming the program invotv&d.
Note; The list 01 covered proilrams will be updated perQdieaJly.
3 Auistance means any t>>"otract. grant, loan, cooperative agr&ement, or
other form of assistance, a,....::fuding the insurance or guarantee of a loan or
mOi"igagt', that is proYidedwitl'lrespect to. speeffic projector aeliYity under
a program administered by D'le Department The I8rm does not include
eonll'ac:ts, s.uch 8$ pT't>C\lrernems contracts, that are subjecl10 t'le Federal
AcqJisition Regulation (FAR) (4.8 CFR Chapter 1).
(. See 24 CFR U'2.32 (a){2) and (3) lor delaDed gu;clanee on how ...
threshold is calculated.
S. "Other go~mmenl assistance' is defi~d 10 include any loan, grant.
guarantee, insurance, payment, rebate, subsKfy, credit, tax benefit, or any
other 1000m of direct or incirec1 assistance trom V'le Federal gOyemmenl
(other than that requested from HUD in the applicatiOl"\), a State, or a unit 01
grmeral local govemment, 0( any agency or insvumentality thereol, tnal is,
or is ellpeetfld 10 be made, available wi1!'l res.pe<:1 to the project or actiyjltes
for which Ihe assistance is sought
6. For furt'ler guidance on this ahenon, and for a fist of eoyer~ programs, Jet
2( CFR f'2.50.
7. For purposes of Pan '2, a person means an individual (including a
consultant, lobbyist, or lawyer); corporation; company; aSs.oc:iation: author.
ity; firm; pannership; society; $LI\e, unil of general bc:al ~yemm.nt, Q(
other povemment entity, or apency thereof (including a publ~ housing
aQ8nc:y); Indian tribe; and any other organization or group 01 people.
Page 7 01 7
lorm HUD-2nO
III (a)(2)--TAB 2
CERTIFICATION ASSURANCES
The
offers assurances that:
(Housing Authority Name)
The applicant will supplement the amount provided by a grant under this program with an amount of
funds from non-federal sources equal to or greater than 50 percent of the amount provided by the granL
Section III(a) (2) (i)
Yes No
The activities or facilities funded by the Youth Sports grant will serve primarily youth from the public or
Indian housing developments in which the activities or facilities are operated. Section m(a)(2)(ii)
Yes No
The facilities receiving Youth Sports funding conform to all applicable local or tribal building
requirements for recreational facilities, if any. Section III(a)(2)(iii)
Yes No
The applicant maintains a Drug-Free Workplace in accordance with the requirements of 24 CPR Part 24,
Subpan F. (Complete form HUD-5oo70) Section III(a)(2)(iv)
Yes No
The applicant will provide certification and disclosure in accordance with the requirements of Public Law
101-121 (approved October 23, 1989) as implemented by HUD's interim final rule published in the
Federal Reruter of February 26, 1990 (55FR 6736) using the Anti-Lobbying Certification Standard Form
SF-llL or form HUD-5oon, which ever is applicable. Section III(a)(2)(v)
Yes No
The grant funds provided under this program and any State, tn'bal, or local funds used to supplement grant
funds under this program will not be used to replace other public funds previously used, or designated for
use, for the purpose of this program. Section III(a) (2) (vi)
Yes No
The applicant has assessed its potential liability under State, local or tn'ballaw, and that, upon being
notified of a Youth Sports grant award, the applicant will obtain adequate insurance coverage to protect
itself against any potential liability arising out of the eligible activities under this program. Section III
(a) (2) (vii)
Yes No
The applicant will comply with TItle VI of the Civil Rights Act of 1964 and Section 504 of the
Rehabilitation Act of 1973. Section III (a)(2) (viii)
Yes No
Signed this
day of
,1994
by:
Housing Authority CEO or Other Authorized Representative
Drug Elimination Program Application
Certification for a Drug-Free Workplace
u.s. Oopanmonl 01 !iou,ln;
and Urban De.*I'"..nt ..
OOOoool"",,",,-_~
~
,r
01.1II No. 2577~ Co",. 11>'31.92)
"""" Roponng _lot.............. 01.._ ia __ ""_ 0.25 ""'" po< _. nducling tie _lor --.0 nd\Oon'.
.......,-d\ng .xisDng"~, ~.net rnantaftng fowI..,..cliIJd. It'd _'.A~411"ld --.0 '" c:oIec:Iion 01 :.jl....~I. $w'ld .,bl.JMntI
~ng .. b4.rdrM'l HtirnaIlt or WPf 01'* ~ of.... coIedion 01 ~ ~ . _ ~. let f'IGJdng .... ~. " .. AIJ.ponI "'--o-..lNrt
O!f<oor. Olfa 01 In_ _ and era-. U.S. DOl' .._.01 Houan; end Ur\ootI 0. " . ._.l, WaaIOnpn. D.C. 2l>l10.0000: end '" tie 0II00t 01
~ end 8uclQol. p~ _ . . Pnljoc:l (2577~) W.............. D.C. 2ll503.
~~:
...._.........__G<wc~:I.........1
Do'. t ronl DclAP D~Slbaklt DS0c..22LoModHouol-4
II).. .14llUW: .
.........~y...ln.....,
..................-~:
.~ .....,Of~ 22,
__.. PHA,-wH4', FtcI/'t.. E.......
".." "'* .. .... . .... ......, :
Acting tel behalf 01 !he above IIImed PHAIIHA as ill AIIIhorbod 0IIicial.11IlIb dle foIIowiDI .."ntv-........ e>d.....u>cDlS III dle 0.,- ~..ull
of Housing and Urban Devdop<ntDI (HllD) rcpn1iDI!he" tiIIcd beIcIr.
1. I <<rtIl'y tha11hc Ibove DOmed PHA/IHA will provide a tlro&.free "",IJ ,-- by:
L PubIishing a swemcnt J>OlifyiIlg employeea Ihal dle tlZlIawfa1
manu!a<:llR. cli.sttibulica. clist-ang. V . "". or ... 01 a
controUed subslance is prohibiled in lheP!iA'I!lHA'1 WOllcpIa<:e
and spccifyinJ the ac:tio<u that will be 1a1= apinst c.mpIo)'eeI
for vio1atioa 01 sueh prohibition.
b. EslablishiDga drug-bee lw5...... prccram lO infCl'lll employ-
ees about dle foDowing:
(I) The danIen of dnlJ obalIe ill !he wcd:pIacc::
(2) TheP!iA'I!lHA'lpoIicycilN"'~'drva.free~.II~' :
(3) AzJy available tlro& 1:00"_11'\1. ,.~""-. e>d e;llpo,oee
all' IU 1JW:+ams;1Dd
(4) Thep-'.ltlH Ihalllll)'beimpollld IIpCIIl '''I~~ec:a fortlro&
abase violaDons oc::carrinI iD die W- _1. j 'r-
Co Ma1:iDJ It a requi>=>eDl tbal-., " ': ee ci!he PHAIIHA be
Jiv= a CI:IY1 of !he .' ~ - requirecI to)' JC8PIFIla.+
do NOllfyinJ !he employee ill lbe 11" - reqaired to)' ...........
L 1hal, as a condidClCl 01 emplol- wilb lbe PHA/IHA. lbe
employee wiI1 do Ihc followilll:
0) Abide to)' dle _ ci the -= ond
(2) Nocily dle emplo)'er ci..y c:rimil>aI drug SWllte convi<:titel
for a vioIaDca oc:=rioJ in !he wcrl:place no l.cer than fIVe
days afw IIICh caniclicIl:
.. NocifyinJ lbe HUD Field 0fIi::e within = clays arlOt rcoeivinJ
DOlic:e IlDllet ~ cI. (2) frc:c .. employoe or 0Iberwisc
r=ivm, a=aI DOlic:e ci IIICh coaviclioa:
r. Tama oee ci!be fcllowi.o& aoas wi1biD 30 days ci r=ivin&
DOlic:e IlDllet Illbpmcnrpb cI. (2) with rapecllO ..y e::np\o)'ee
wbo II all..c6. icled:
0) TaII:lDI ~ .... I acDoa apinIllllC:ll .. em.
plo)oee. lip 10 aDd iDcIlICIiIlI_....ftnn. or
(2) ReqairiJlIIlldl empIcyet lO ... ~ -'''........;!y ill a
draa abaIe."'; CI' ~ L ""'.,~ propam -n-'" .cd Cor
Illdl JAM' -. to)' a FedlnI. S-. or Ioca1 be:aIIh. law to>-
L .... orocber-t"t".......~apocy;
.. MaIciIlI a pld bldl dfon III CO"o4ft"f lO .....ntom a tlro&-free
_tl'-~~"'r' ~~ol~Llbnaf.
WARN1lICl: ,.U.a.C. 1001 proooolcloa,""""'ll_........_"-_b.tj, end-.,;,.......or_a__ .Mllorwdliltl.......J..o ..,,-.-.
or hl.OJwI\ ..._ or 1IffI1'/. n .." ..-.... ... jlIlodoIion "''''' '. ,...d or 0I1t""f "'... Ur*d ..... ..... be finocl .... -- _110/:1:10 or
ilIpriaonod lor noc I1ICft ..... ... )'WI. or .......
2.. 51,," ror Work PtrlOl'1lW>Oe- TDePHAJ1HA IbaIlIill ill dle space po.illcd beIoo< the sho(l) fordle porfcrmance 01 """'" clone ill ~ ~ "
wilh the HUD fundin& of the propsrnJactivlI r:bowll abcM:: Place ci Perfcrmanoe sbaI1 incIs>lIe dle - adcfta. city, coanty, S-. aIlCI
zip code. (lfmore Ipeet is ncede4.auacll a6diIionaI pllC(l) !he_si2eu this form. 1don1ifycacb slle<t willi !he PHA/IHA llAlI>O aM addrcsI
and the propam/Iclivity r=ivm, Jl'AlIl flmdiDc.)
~1J~b'f:(NIrftt.,...a~tI~~~
i'if,<:) 10"":
-.-:
x
torm~(IMO)
IOI.llo.. ~ . I 7.'7.1.7.71. \3.7-' 1
D'JdOSURE OF LOBBYING AGh.fIES
APpfCWrO by OMB
OJ~
Complete this form to disclose lobbying acth;iti~s pursuant to 31
(See reverse for public burden disclosure.)
use. 1352
1. Type or F~tnl Action:
D a. contract
b. &rant
c. cooper,ltivf: "I,ee-me-nt
d. loan
t. loan luarantee
f. loan insurance
2. St.otu. 01 Fed...ol Action:
D ... bid/offer/application
b. Initial award
c. post-award
3. aeport Typo:
D.. initial filina
b. material chanle
For Matori.1 Ch.n.e Only:
year quarter
d.te of I..t ,eport
S. If aeportlnl Entity in No.4 I. Subaw.rd~, Ent...
N.... .nd Addross of Pri...:
4. N.me .nd Add,e.. of aeportin. Entity:
o Prime
o Subawardee
Tier _. if known:
Consreniona,1 District, if known:
6. Feder.1 Dep.rtment/Alencr:
COn&~nll District, il known:
7. Foder.ll'roIr.m N.moIDHcription:
10. .. N.me .nd Add.... of Lobbyinl Entity
(if individual, Ian name, firs! n.ame, MI):
(FDA Number. if .pplicable:
9. Aw.rd Amount, ff known:
S
b. Indlvidu.l. "erlonnlna Services
(including address if different (rom No. lOa)
(last name, first name, MI):
8. Feder,,1 Action Number, if 1-nown:
r,UlKh COtuinu"iOft ~fJl SF.LLt...... jf nK~U'Y'
s
o actual
o plannod
13. Typo of Paymonl (check .11 th.t .pply):
o I. retainer
o b. one-time fee
o c. commission
o d. continaent fee
o e. deferred
o f. other; specify:
11. Amount of "ayment (check .11 th.t .pply):
12. Form of ".yment (check .11 th.t apply):
o I. cash
o b. in.kind; speCify: nature
value
t4. Brief Description of Services "erlormed or 10 be "erlonned .nd O.te(.) of Service, indudin. officerl.),
employ~l.), or Membe"l.) cont.cted, for ...ym.nt Indic.tod in item 11:
(.auKh CCIo"II;"II.aIOorl S/'lf'f'lfl} Sf.lLt.A. i/lW'('ftI,.lIryJ
IS. Contlnu.tion Sh~I(.) SF.LLL.A .ttached:
DYe.
o No
16. l"fQfI'l'l.atoOl'l rtoq"'HIt'dlh'Oo.Ilh Ihlllo'''' n.uthorizt'd bytit!t l1 use.
N'<liOl" 1352 Thit dit.clclIIuP'I' of Ic>bbyi". ...eli"ititt is... 1'1'I.1,,"...1 r~
1'1001'1 of bel IIpoi'! ....hiCh rtli,I'IU "'.11I pl.act'd by 1M tOtf ,boy, whrI'I
thil u.anuelton _,. m,dt Of ."ttft'd '1'110. Thil cl'ICIOtllf. iIIPQ",ift'd
P\lfll.la"l to )1 U 5 C. 1352 Th'l ",ronn...lton will bot ft'PO"td to the
Conlft'lI u-mi",.,.""lly anclwm bot' ,,,,d,ble for pub4ic inlpt'(lioft Afty
pe-f~ who billlo tilt the ft'Quift'd di~lon"f ltall brt Il.Ib;t-clto. civil
pt'n.l1y of Mtl I,u Ih.n no,ooo .ncl nol mOlt Ih.an $100,000 tor tleh
I...chbil""t.
Slln.ture:
Print N.me:
Title:
r e1ephone No.'
O..te:
Z~ ~ ~ '/ ,,- v -i" ,
"";:~:"~i~~'ij~~~:'; ,:;;{"'::~,?V ':;~ ':., , ~ ", ' , .
~-x~","'J:..~ :'>>~'~M' iU,' ,,V, ,
-' ,,,' --~-~~- - .., .,
Authoriuod'Of Loullt'prod...ctiol'l
Sul'ld"cl FomI . UL
--
D1SCLI.. URE OF LOBBYING ACTIVIT. J
CONTINUATION SHEET
^ppro...~d by OMS
03411.Q046
Reporting Entity:
Page
of
-.
Avthorind for Lou! ~
-
:;enitication for
:;ontracts, Grants, Loans &
:::ooperative Agreements
"ublic Housing Agency I Indian Housing Authority
u.s. uepartment C?t Housing
and Urt:an.Oevelopment
Office of Public and Indian Housing
~
't'\A!lHA Nam.:
If o\h.r than Opera ling Subsidy or Sec-
tion 23. en"" lho Foderal Fiscal Yoar In
which lho funds aro oxpoClod to be
reserved :
II ep.ratlng Subaldy or S.ctlon 23,
enter PHA'sJ1HA', FtscaJ Year Ending
date In whk:h func!s alB expeded lo be
obngated;
P",gramlAcIMty ReceivIng Fode..1 Grant ovor $100.000: (marllono)
~ Operating Subsidy ~CGP
. Development ClAP
Drug Elimination Grants MROP
880.23 Leased Housing Other: (dKC1be)
Adjustments
Acting on behalf of the above nam~ PHNlHA as its Authoriud Official. I make the following
certifications to the Deparonent of Housing and Urban Development (HUD):
(I) No F~eraI appropria1ed funds have been paid or will be paid. by or on behalf 9f the
undersign~. to any person for influencing or attempting to influence an officer or employee
of any agency, a Member of Congress in connection with the awardiJig of any F~eraI
contract. the rna1:ing of any F~eraI grant. the making of any FMeraI loan. the entering into
of any cooperative agreement, and the extension, continuation, rene\\'al. amendment, or
modification of any F~eraJ contraCt. grant. loan, or cooperative agreemenL
(2) If any funds other than F~eraI appropriat~ funds have been paid or will be paid to any
person for influencing or anempting to influence an officer or employee of any agency. a
Member of Congress, an officer or employee of Congress, or any employee of a Member
of Congress in connection with this F~eraJ contraCt. grant. loan, or cooperative agreement,
the IUldersign~ shall complete and submit Standard Form.llL. Disclosure of Lobbying
Activities, in accordance with its instructions.
(3) The undersigned shall require thai the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts. subgrants, and contraCts
IUlder grants, loans, and cooperative agreemenlS) and thaI all subrecipients shall certify and
disclose accordingly.
'This certification is anwerial representation offact upon which reliance was plac~ when this transaction
was made orentu~ into. Submission of this certification is a prerequisite for making or entering into this
tranSaction imposed by Section 1352, Title 31, U.S. Code. My pel'Son who fails 10 file t1ie required
certification shall be subject to a civil penalty of not less than SIO,OOOand not more than SI 00,000 for each
such iailu:~.
I certify under penalty of perjury that the foregoing is true and corrett
AulhorizC'C: PHAIIHA Official: Na.>n. J,n,.:
Si~natur. & Oal':
x
lonn HUD 50071 (1/92)
lot HoodOOooks 7417.1. 7475.13. 748S.1. & 7485.3
III (a)(3)--TAB 3
PROPOSED PROGRAM
Please include a narrative description of the services to be provided by the proposed
program, including an explanation of the way in which the activities address the particular
needs of the area to be served by the program:
(please use additional sheets as needed)
III (a)(4)-TAB 4
WORKPLAN AND TIMELINE
Using this page please develop a workplan with a month-by-month task timeline
providing an implementation schedule for the Youth Sports activities. Please be
reminded that the maximum length of this timeline--is 18 months.
(please use additional sheets as needed)
III (a)(5)-TAB 5
-.
BUDGET
Please submit a budget describing the financial and other resources committed to each
activity and service of the program. This budget must include a description of the share
of costs to be provided by the Youth Sports grant as well ~ a description of the funds
me,d other resources from non-Federal sources and how they will be obtained. (Use
matching funds worksheet on following page.)
(please use additional sheets as needed)
MATCHING FUNDS
BUD requires that applicants obtain commitments of non-federal resources equalling at
least half (50%) of the amount for which you apply. (See Section I(c) (3) (v) of the
NOFA) Please use this sheet to compute your matching resources. Include supporting
data on additional sheets as necessary.
-.
FUNDS
State
Local Government
Indian Tnbal Government
Private Contributions
S1 AFF
Salary paid to staff (by the above sources) to carry out YSP
activities of the pHA/IHA. See Section I(c) (3) (i) of the
NOFA.
VOLUNTEERS
x hrs @ $5/hr.
VOLUNTEER PROFESSIONAL SERVICES
(Use customary hourly rate for your community)
DONATED MATERIAL EOUIPMENT OR BUll..DING
(You MUST document the fair market value of the donated item at the
time of the donation)
Material
Equipment
Building
Document value of lease by referencing an existing, or no more
than one year old, lease from the building involved; or evidence,
such as advertisements or appraisals, of the value of leases for
comparable buildings.
TOTAL MATCH
(Total Match must equal at least 50% of Grant Amount Requested)
+ GRANT AMOUNT REQUESTED
TOTAL PROGRAM FUNDS
III (a)(6)-TAB 6
SELECTION CRITERIA STATEMENT
You must submit a thorough statement that your application meets the selection criteria
outlined in Section I(d) of the NOFA. Explain how your proposal fulfills each criterion
where points are offered. _
(please use additional sheets as needed)
III (a)(7)-TAB 7
PHNIHA CURRENT DRUG ELIMINATION PLAN
Provide a current year plan prepared in accordance with 24 eFR 961.15. Or, you may
submit a copy of the Needs Assessment and Current Activities sections of your HUD-
approved FY92 Public and Indian Housing Drug Elimination Program grant application,
provided that you can demonstrate the proposed youth sports activities will be operated
as, in conjunction with, or in furtherance of that plan. If that is not available, please
submit an abbreviated plan addressing the following factors:
III (a) (7) (i) (A) and (B)
ASSESSMENT OF THE PROBLEM
A description of the drug-related problems in the projects proposed for funding under
t.'ti.:, program. This should include objective data (crime statistics from the local police
precinct) and other information from other sources which have a direct bearing on drug-
related problems in the targeted developments.
(please use additional sheets as needed)
III (a)(7)(ii)
-0
CURRENT ACTIVITIES
A narrative discussion of your current activities, if any, to eliminate drug-related
problems in the targeted communities. You must also include a discussion of how your
proposed youth sports activities will be operated in the context of your current plan.
--
(please use additional sheets as needed)
III (a)(8)--TAB 8
ESTIMATE OF NUMBER OF yourn IN PROGRAM
Please use the box below to estimate the number of youth to be involved in the program.
-.
Program Component:
# of Youth (Total):
b Youth Leadership positions:
(team managers, captains, group leaders, etc.)
JI...nnual, Seasonal, or Sessional Breakdown by Activity:
Breakdown by Age:
5-8 yrs:
9-12 yrs:
13.16 vrs:
,
17-21 yrs:
Breakdown by Sex:
# of Male Participants:
# of Female Participants:
Breakdown by ResidentINon-Resident:
# of Residents:
# of Non-Residents:
(please make copies of this sheet and lill out for each program component.)
III (a)(9)-TAB 9
FACll..ITIES
Following the requirements of Section /II (a)(9)(i), please descnbe the facilities to be
used in the proposed program in terms of their dimensions, location and the number of
youth that can be accommodated at one time.
--
!ll (a) (9) (i) (A) - Specify how youth from the Indian Housing development will have
8"".eSS to the facility (If applicable).
III (a)(9)(ii) - Explain/justify all facility acquisition, construction, rehabilitation,
operation, redesign or modification proposed for funding under this program.
III (a) (9) (ii) (A) -- Specify what percent of the facility will be used for youth activities.
This percentage may not be less than the percentage of Youth Sports funding provided
for the facility.
III (a)(9)(iii) - Identify the entity that will be responsible for the operation of the facility
funded by a Youth Sports grant.
(please use additional sheets as needed)
III (a)(lO)--TAJ3 10
..
STAFFING AND ORGANIZATION
Please describe the staffing and organization of your proposed program:
III (a)(lO)(i) - Describe any consultations with RMCs/RCs:
--
III (a)(lO)(ii) - Position descriptions of the staff responsible for operating the program:
III (a)(lO)(iii) - Procedures to be used to ensure that the proposed activities will
primarily serve youth in the public or Indian housing development to be assisted by this
grant:
(please use additional sheets as needed)
III (a)(11)-TAB 11
INVOLVEMENT OF LOCAL SPORTS ORGANIZATIONS OR FIGURES
Descnbe the involvement of any local sports, cultural, recreational or educational
organizations or sports, cultural, recreational or educational figures:
III (a) (11) (i) - Provide documentation of the level of on-site or other participation by
local and nationally affiliated sports organizations with at least two years of
organizational and operational experience. The participation of these groups must be
focused on the youth activities for which the application is prepared.
III (a) (l1)(ii) - Descnbe and demonstrate the involvement of local or national sports,
cultural, recreational or educational figures, such as athletes, coaches, artists, entertainers
and teachers in place of, or in addition to, the participation of organizations. The
participation of these figures must be focused on the youth activities for which the
application is prepared.
(please use additional sheets as needed)
/II (a)(12)--TAB 12
ABD....ITY TO CONTINUE OPERATION OF PROGRAM
'-
Describe the plans and resources available to continue the operation of this program
after the grant funding expires, including the commitments of governmental, corporate,
co=unity organizations and individuals to continue-their involvement in the proposed
program.
(please use additional sheets as needed)