Agreement - Indiana Housing and Community Development Authority - Supplemental Disaster Recovery- Owner Occupied Rehab for Lead

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U.S. Department of Housing OMB Approval No. 2510-0011 (exp. 10131/2009) Applicant/Recipient and Urban Development DiSGIOSurelUpdate Report Inc frnr$inin z r.qPP Public Reoortincl Statement and. Privacy Act Statement and detailed instructions on page 2.) AmIlcant/Reci Name nt Information ame, Address, and Phone (include area code): State the name and location (street Indicate whether this is an Initial Report ❑ or an Update Report City and State) of the project or Social Security Number or Employer ID Number: 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 projector 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, Stopl You do not need to complete the remainder of this form. However, you must sign the certification at the end of the report. Part ll Other Government Assistance Prodded or Requested ! 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. peoarfinentlStatelLocal Agency Name and Address Type of Assistance Amount Expected Uses of the Funds n.,..:,v fF 4litrni,M—i (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, br 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 list of all persons with a in the (Note: Use Additional pages if necessary.) de financial interest Social Security No.J Type of Participation in the last name first) or Em to ee ID No. I Pr9Ject/ActivitZ. ,st in and Certification rm, you may subject to civil or criminal penalties under Section 1001 of Title 18 of the Warning: If you knowingly make a false statement on this fo 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 certifv that this information is true and complete. Sig (mmlddlyyyy) Form HUD-2880 (3199)