Attachement B - Division Of Housing Disclosure Report printable pdf download

Attachement B - Division Of Housing Disclosure Report

ATTACHMENT “B”

DIVISION OF HOUSING DISCLOSURE REPORT

1. Are you requesting more than $200,000 from the Division of Housing?

Yes

2. Have you received or applied for other HUD funding for this project that would make the total amount of HUD funds

in the project more than $200,000?

Yes

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.

______________________________________________

_________________

Chief Elected Official/Executive Director/President

Date

3. Interested Parties

Alphabetical List of All

Soc.

Role in Project

Financial

with a Financial Interest in the

Security

Interest in

Project of over $50,000 or 10%

or Employer

Project ($ & %)

of Total Project Costs

ID #

4. 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.

Chief Elected Official/Executive Director/President

Date

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Attachement B - Division Of Housing Disclosure Report