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Home My WebLink About940942.tiff air • (' / irlrnerREvOLVING• LOAN FUND P.O. Box S • Greeley, Colorado 80632 • (303) 356-4565 - FAX (303) 352-2436 ! ry� !!!`i23 Ali 8: 31 CLERK TO THE B0.' r:D Memo TO: Don Warden FROM: Jodi Hartmann DATE: 5/23/94 RE: RLF CDBG Application Attached are four copies of a CDBG Disclosure Report now being required with all CDBG applications and projects. It should have been included with the various documents in the recent application. Basically the report discloses all sources of financial interest in CDBG projects. I need to have this signed by Bill Webster as soon as possible. If it needs to be placed on the Commissioners' agenda, then I'd request that it be on the Wednesday, May 25 agenda. Keep one copy for your files and have the clerk call me when the others are ready to be picked up. Thanks for your assistance!ti O61 9.I� 940942 rjrOl9 `:, a 44J efku RpJ CDBG DISCLOSURE REPORT PART I - APPLICANT/GRANTEE INFORMATION 1. Applicant/grantee name, address and phone number. Weld County 915 10th Street Greeley, CO 80631 356-4000, ext. 4200 Federal employer identification number: 84-6000813 2. Indicate whether this report is: Initial X Update 3. Project Assisted/to be Assisted a. Fiscal year: 1994 b. Entitlement Grant(s) Competitive Grant X c. Amount requested/received: $ 250.000 d. Program income to be used with (c) above: $ 7.805 e. Total of (c) and (d): $ 257.805 PART II - THRESHOLD DETERMINATIONS 1. Is the amount listed at 3(e) above more than $200,000? Yes X No 2. Have you received or applied for other HUD assistance (through programs listed in instructions) which, when added to 3(e) above amounts to more than $200,000? Yes X No If the answer to either 1 or 2 of this Part is "Yes", then you must complete the remainder of this report. If the answer to bath 1 and 2 of this Part is "No", then you are only required to sign the following certification and need not complete the remainder of this report. I hereby certify that this information is true. i C/7O17 William Webster, hairman � Date Weld County Commissioners (Chief Elected OfficiavTitle) PART III - OTHER GOVERNMENT ASSISTANCE PROVIDED/APPLIED FOR 1 . Provide the requested information for any other Federal, State and/or local governmental assistance, on hand or applied for, that will be used in conjunction with the CDBG grant. (See instructions) Name and Address of Agency Providing or Type of Amount Requested or to Provide Assistance Program Assistance Provided Greeley/Weld Economic Development Economic Program Admin. $30,000 Action Partnership (EDAP) Development & Technical 810 9th St, 2nd Floor Assistance P.O. Box S Greeley, Colorado 80632 PART IV - INTERESTED PARTIES Alphabetical List of All Persons Social Financial with a Reportable Financial Security or Type of Participation Interest in Interest in the Project Employer ID # in Project Project ($ & %) None PART V - EXPECTED SOURCES AND USES OF FUNDS This Part requires that you identify the sources and uses of all assistance, including CDBG, that have been or may be used in the Project. Source Use CDBG Grant Business assistance to small businesses creating or retaining jobs benefiting low/mod persons in rural areas of Weld and Larimer counties. CDBG Grant Program administration Greeley/Weld Economic Program administration & technical assistance Development Action Partnership (EDAP) Unrestricted Program Program administration Income PART VI - CERTIFICATION I hereby certify that the information provided in this disclosure is true and correct and I am aware that any false information provided or lack of information knowingly made or omitted may subject me to civil or criminal pentalties under Section 1001 of Title 18 of the United States Code. In addition, I am aware that if I knowingly and materially violate any required disclosure of information, including intentional nondisclosure, I am subject to a civil money penalty not to exceed $10,000 for each violation. t) I-17) 6/77 7 / William H. \ebster Char Date man �' / Weld County Commissioners (Chief Elected OfficiaLTitle) CDBG DISCLOSURE REPORT PART I - APPLICANT/GRANTEE INFORMATION 1. Applicant/grantee name, address and phone number. Weld County 915 10th Street Greeley, CO 80631 356-4000, ext. 4200 Federal employer identification number: n/a 2. Indicate whether this report is: Initial X Update 3. Project Assisted/to be Assisted. a. Fiscal year: 1994 b. Entitlement Grant(s) Competitive grant X c. Amount requested/received: $250.000 d. Program income to be used with (c) above: 12,848 e. Total of (c) and (d): $262,848 PART II - THRESHOLD DETERMINATIONS 1. Is the amount listed at 3(e) above more than $200,000? Yes X No 2. Have you received or applied for other HUD assistance (through programs listed in Instructions) which, when added to 3(e) above amounts to more than $200,000? Yes X No If the answer to either 1 or 2 of this Part is "Yes",then you must complete the remainder of this report. If the answer to both 1 and 2 of this Part is "No",then you are only required to sign the following certification and need not complete the remainder of this report. I hereby certify that this information is true. 41i/ilk; iam H. Webs er, Chairman (Chief Elected Official/Title) (Dater Weld County Commissioners PART III - OTHER GOVERNMENT ASSISTANCE PROVIDED/APPLIED FOR 1. Provide the requested information for any other Federal, State and/or local governmental assistance, on hand or applied for, that will be used in conjunction with the CDBG grant. (See Instructions) Name and Address of Agency Providing or Type of Amount Requested or to Provide Assistance Program Assistance Provided Greeley/Weld Economic Development Economic Program Admir . $30,000.00 Action Partnership (EDAP) Develop- & Technical 810 9th St. , 2nd Floor ment Assistance P.O. Box S Greeley, Colorado 80632 PART IV- INTERESTED PARTIES Alphabetical List of All Persons Soc. Financial with a Reportable Financial Security Type of Participation in Interest in Interest in the Project or Employer Project Project ($ &%) • ID # None PART V- EXPECTED SOURCES AND USES OF FUNDS This Part requires that you identify the sources and uses of all assistance,including CDBG,that have been or may be used in the Project. Source Use CDBG Grant Business assistance to small businesses creating or retaining jobs benefitting low/mod individuals. CDBG Grant Program Administration Greeley/Weld EDAP Program Administration & technical assistance Unrestricted program Program Administration income PART VI - CERTIFICATION I hereby certify that the information provided in this disclosure is true and correct and I am aware that any false information provided or lack of information knowingly made or omitted may subject me to civil or criminal penalties under Section 1001 of Title 18 of the United States Code. In addition, I am aware that if I knowingly and materially violate any required disclosure of information, including intentional nondisclosure, I am subject to a civil money penalty not to exceed $10,000 for each violation.• b/tV19_A'AIA ii/(2,41140 .7 9O William H. ester, Chairman (Chief Elected Official/Title) (Date) Weld County Commissioners Hello