Agreement - Indiana Housing and Community Development Authority - Lead Hazard Reduction Demonstration Grant Program

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ApplicantlRecipient U.s, Department of Housing OMB Approval No. 2510-0011 (exp. 10/31/2009) Disclosure/Update Report and Urban Development Instructions. (See Public Reporting Statement and Privacy Act Statement and detailed instructions on page 2.) A licant/Reci lent Information Indicate whether this Is an Initial Report ❑ or an Update Report ❑ , Address, and Phone (include area code): 3. HUD Program Name 5. State the name and location (street address, City and State) of the project or activity: 2. Social Security Number or Employer 1D Number: 4. Amount of HUD Assistance Requested/Received Part I Threshold Determinations 1. Are you applying for assistance for a specific project or activity? These 2. Have you received or do you expect to receive assistance within the terms do not include formula grants, such as public housing operating jurisdiction of the Department (HUD) , involving the project or activity in subsidy or CDBG block grants. (For further information see 24 CFR Sec. this application, In excess of $200,000 during this fiscal year (Oct. 1 - 4.3). Sep. 30)? For further information, see 24 CFR Sec. 4.9 ❑ Yes ❑ No ❑ Yes ❑ 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 1 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 Use Additional 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 in the project or activity For individuals, give the last name first Social Security No. or Employee ID No. Type of Participation in Project/Activity Financial Interest in Pro ect/Activif $ and (Note: Use Additional pages if necessary.) Certification Warning: if you knowingly make a false statement on this form, you may be subject to civil or criminal penalties under Section 1001 of Title 18 of the United States Code. In addition, any person who knowingly and materially violates any required disclosures of information, including intentional non- disclosure, is subject to civil money penalty not to exceed $10,000 for each violation. I certify that this information is true and complete. Date: (mmldd/yyyy) X Form HUD-2880 (3199)