HomeMy WebLinkAboutOTHER-2020-006 Tab 6 Document S
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CONFLICT OF INTEREST CHECKLIST
To assist applicants with determining if a potential conflict of interest exists , as defined in 24 CFR Part
570 . 489 ( h ) , please provide responses to the following questions . For any "yes " response, refer to
Bulletin 1M for next steps .
1 . Does any person involved with this potential CDB & CV project have family or business ties with
any of the local government elected officials or local government staff?
❑ Yes ® No, if yes , please describe .
2 . Has any person involved with this potential CDBG-CV project requested or received an opinion
about a potential conflict of interest from an attorney or from the North Carolina Ethics
Commission ?
❑ Yes ® No, if yes , please describe .
3 . Does any person involved with this potential CDBG-CV project have an ownership interest in an
entity that is directly affected by activities proposed in the application ?
❑ Yes ® No, if yes , please describe .
4 . Will any person involved with this potential CDB &CV project derive any income or commission
as a direct result of action taken by the local government elected board or its staff?
❑ Yes ® No, if yes , please describe .
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FEDERAL REQUIREMENTS AND CERTIFICATIONS
The applicant hereby assures and certifies that .
a ) It will comply with all applicable federal and state laws , regulations , rules and Executive Orders .
b ) It possesses legal authority to apply for the grant , and to execute the proposed program .
c ) Its governing body has duly adopted or passed as an official act a resolution , motion or similar
action authorizing the filing of the application , including all understandings and assurances
contained therein , and directing and authorizing the identified as the official representative of
the applicant to act about the application and to provide such additional information as may be
required .
d ) It is following a detailed , written citizen participation plan which will provide opportunities for
citizen participation , hearings , and access to information with respect to its community
development program that are comparable to those required of grantees under Section 104 ( a )
of the Act and in accordance with Rule . 1002 of the North Carolina Community Development
Block Grant Administrative Rules .
e ) Its chief elected official or other officer of the applicant if assistance is approved by Rural
Economic Development Division .
1 . Consents to assume the status of the " responsible Federal Official " as that term is used in
Section 102 of the National Environmental Policy Act ( NEPA ) , Section 104 (f) of Title 1 of
the Housing and Community Development Act of 1974, as amended , and other provisions
of Federal law, as specified in 24 CFR 58 . 5 which further the purposes of NEPA .
2 ) Is authorized and consents on behalf of the applicant and himself to accept the
jurisdiction of the Federal courts for the purpose of enforcement of his responsibilities as
such an official .
3 ) Consents to review and comment on all Environmental Impact Statements prepared for
Federal projects which may have an impact on the applicant' s/ recipient ' s community
development program .
4 ) Consents to perform all coordination functions required under 24 CFR Part 58 and 40 CFR
Parts 150M508 .
f) The NC CDB &CV Program has been developed to give maximum feasible priority to activities
which will benefit low and moderate - income families or aid in the prevention or elimination of
slums and blight . The requirement for this certification will not preclude Commerce from
approving an application where the applicant certifies , and Commerce determines , that all or
part of the NC CDBG-CV Program activities are designed to meet other community development
needs having urgency as specifically explained in the application in accordance with Section
. 0800 of 4 NCAC 19L of the North Carolina Administrative Code .
g ) Its program will be conducted and administered in conformity with Public Law 88 -352 and Public
Law 90 -284, and that it will affirmatively further fair housing .
h ) It will comply with all provisions of 4 NCAC 19L of the North Carolina Administrative Code,
entitled North Carolina Community Development Block Grant Program .
i ) It will give Commerce , HUD and the Comptroller General through any authorized representative
access to and the right to examine all records , books , papers or documents related to the grant .
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j ) It will establish safeguards to prohibit employees from using positions for a purpose that is or
gives the appearance of being motivated by a desire for private gain for themselves or others ,
particularly those with whom they have family, business , or other ties .
k ) It will follow a residential anti - displacement and relocation assistance plan that is in accordance
with the provisions of Section 104 ( d ) and all other provisions of the Act .
1 ) It will not attempt to recover any capital costs of public improvements assisted in whole or part
under Section 106 of the Act or with amounts resulting from a guarantee under Section 108 of
the Act by assessing any amount against properties owned and occupied by persons of low and
moderate income , including any fee charged to assessment made as a condition of obtaining
access to such public improvements, unless ( 1 ) funds received under Section 106 are used to pay
the proportion of such fee or assessment that relates to the capital costs of such public
improvements that are financed from revenue sources other than under this title ; or ( ii ) for
purposes of assessing any amount against properties owned and occupied by persons of low
and moderate income who are not persons of very low income , the grantee certifies to the
Secretary or such State, as the case may be , that it lacks sufficient funds received under Section
106 to comply with requirements of clause ( 1 ) .
m ) It has or will develop a plan that identifies community development and housing needs ,
including the needs of low and moderate - income persons , and the activities to be undertaken to
meet such needs .
n ) Its notification , inspection , testing and abatement procedures concerning lead - based paint will
comply with 24 CFR Part 35 .
o ) When issuing statements , press releases , request for proposals , bid solicitation and other
documents describing the above - mentioned program such as the environmental review, public
hearings , fair housing notices , etc . , it shall clearly state :
1 ) The percentage of the total cost of the project which will be financed with CDB & CV money,
and 2 ) the dollar amount of CDBG-CV funds for the project .
P )
1 ) No Federal appropriated funds have been paid or will be paid , by or on behalf of the
undersigned , to any person for influencing or attempting to influence an officer or
employee of any agency, a Member of Congress , an officer or employee of Congress , or
an employee of a Member of Congress in connection with the awarding of any Federal
contract , the making of any Federal grant , the making of any Federal loan , the entering
into of any cooperative agreement, and the extension , continuation , renewal ,
amendment, or modification of any Federal contract , grant, loan , or cooperative
agreement .
2 ) If any funds other than Federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of Congress , or
an employee of a Member of Congress in connection with this Federal contract, grant ,
loan , or cooperative agreement , the undersigned shall complete and submit Standard
Form - LLL, " Disclosure Form to Report Lobbying, " in accordance with its instructions .
3 ) The undersigned shall require that the language of this certification be included in the
award documents for all sub awards at all tiers ( including subcontracts , sub grants , and
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contracts under grant, loans , and cooperative agreements ) and that all sub recipients
shall certify and disclose accordingly .
q ) It has adopted and will enforce a policy prohibiting the use of excessive force by law
enforcement agencies within its jurisdiction against any individuals engaged in nonviolent civil
rights demonstrations and has adopted and is enforcing a policy of enforcing applicable state
and local laws against physically barring entrance to or exit from a facility or location which is
the subject of such nonviolent civil rights demonstration within its jurisdiction in accordance
with Section 519 of Public Law 101 - 144, (the 1990 HUD Appropriations Act ) .
r ) All project areas are either not in a floodplain , or if the project area is in a floodplain , the
applicant participates in the flood insurance program . All properties assisted in the project will
be covered for flood insurance prior to beginning construction , and all public facilities will be
constructed to comply with applicable floodplain regulations .
CERTIFICATION OF ABILITY
The County of Orange hereby certifies its ability to meet Federal Performance and Procurement
Requirements with Certification as further expanded in the preceding attachments .
Name of Chief Elected Official Penny Rich �d � °�
Title ChaMBoard of CorRmmiss ' ners � oil ss;
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Signature � 'w��
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Date v lf!
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Disclosure Report Instructions
Who should complete the report .
All applicants who expect to receive an aggregate amount of covered federal assistance for a project or
activity that exceeds $ 200, 000 are required to make certain disclosures . State CDBG-CV funds are
covered by the requirement, as are most other programs where funds are administered by or passed
through the U . S . Department of Housing and Urban Development . Therefore , all applicants of more than
$ 200, 000 in State CDBG-CVfunds , including anticipated program income , should complete the report . In
addition , any applicants to a State grantee for a sub grant should complete the report if more than
$ 200, 000 in covered assistance is or can reasonably be anticipated . The requirement addresses the
aggregate amount of assistance . Therefore, if the applicant anticipates less than $ 200, 000 in CDBG
assistance but, intends to combine the funds with enough other covered assistance ( such as Section 8
project- based Housing Assistance Payments ) to exceed $ 200, 000 in total assistance, the applicant must
make the disclosures . Any applicant/ recipient who is required to complete a disclosure report for
another agency in conjunction with a project assisted with State CDB & CVfunds may submit a copy of
that disclosure report to the Rural Economic Development Division rather than completing a separate
report .
Recipients who have previously filed disclosure reports must file update reports if the information in the
original report changes either because of later developments subject to disclosure, or because of
changes in the amount of government assistance, the sources of funds , or the uses of funds equal to the
lower of $ 250, 000 or 10 percent of the applicable base ( usually total project costs ) , or because of an
increase in the financial interest of a person equal to the lower of $ 50, 000 or 10 percent of such
interest .
Detailed Instructions .
1 . Enter the name , address , and telephone number, including area code, of the applicant or recipient .
2 . Indicate whether the report is an initial report or an update report .
3 . Enter the Social Security Number or the Employer Identification Number of the applicant or
recipient .
4 . Enter the project name and indicate the location as detailed and specific as possible . In the case of
update reports , give the CDB &CV grant number .
5 . Enter the total amount of assistance being requested as stated in the application , including
anticipated program income . In the case of update reports , enter the total amount of assistance
provided per the funding approval and anticipated program income .
6 . Indicate whether other government assistance is being provided , or can reasonably be expected to
be provided , for the project . Other government assistance includes any loan , grant, guarantee ,
insurance payment, rebate, subsidy, credit, tax benefit , or any other form of direct or indirect
assistance from the Federal government, a State , or a unit of general local government, or any
agency or instrumentality thereof, that is , or is expected to be made , available with respect to the
project or activities for which the assistance is being sought .
If other government assistance is provided , or expected to be provided for the project, all such
assistance must be disclosed on attachments incorporated into the report . The disclosures should
list the granting agency, the program and type of assistance ( e . g . , grant , loan , guarantee ) , and the
amount expected to be made available .
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Disclosures need only be made once , so that if this information is given in the Sources and Uses
attachments , this may be indicated by checking the appropriate blank under " 6 . Other Government
Assistance " on the Attachments page of the report .
7 . Indicate whether there are persons with a reportable financial interest in the project . " Person "
means an individual , corporation or business, unit of general local government or other
governmental entity or agency or any other organization or group of people . A reportable financial
interest is any financial involvement in the project including equity interest, shares in any profit on
resale or distribution of cash or other assets , or receipt of compensation for goods or services
provided in connection with the project or activities , which can be expected to exceed the lower of
$ 50, 000 or 10 percent of the assistance sought . Compensation for performance of a contract
procured under Federal procurement regulations is not, by itself, a covered financial interest .
Residency of an individual in housing for which assistance is being sought is not, by itself, considered
a covered financial interest .
If there are parties with a reportable financial interest, the name and pecuniary interest of the
parties must be disclosed in referenced attachments . If the party is an entity such as a unit of
government or a corporation , the disclosure must include an identification of each officer, director,
and/ or principal stockholder . The pecuniary interest disclosure must include the type of
participation ( such as owner, contractor, investor) and the amount of the financial interest
expressed both as a dollar amount and as a percentage of the amount of assistance involved .
8 . Reference the statement or statements attached to the report showing the sources and uses of the
funds available for, or expected to be available for, the project . Disclosure must be made of the
gross amount of funds from all sources , including both governmental and non -governmental sources
of funds and private capital resulting from tax benefits . For most projects , the financial forms in the
appropriate guidelines will be adequate to document sources and uses . Please note , however, that if
the " Other Government Assistance " disclosure section references the Sources and Uses Disclosures ,
then these Disclosures must identify the program and type of assistance .
9 . Certification : The signatory certifies that all information in the report is complete and accurate . That
is , except as disclosed in the report and attachments , there is no other government assistance, no
other interested parties , and no other sources and uses of funds .
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DISCLOSURE REPORT
1 . Applicant/ Recipient Name , Address , and Phone : Orange County, NC
PO Box 8181, Hillsborough, NC 27278
919 - 245 -2490
2 . Check One : ® Initial Report ❑ Update Report
3 . Social Security Number or Employer ID Number : 56- 60000327
4 . Project Name and Location : Emergency Housing Assistance — Orange County ( countywide )
5 . Total Amount requested / received ( including anticipated program income ) : $ 900 , 000
6 . Other government assistance . ( Check One ) .
No other government assistance is , or is expected to be , provided for this project
X All other government assistance provided for this project is listed on the table
below/attached page ( s ) .
( Note : Disclosures must be complete and accurate but , need to be made only once for this report . If
assistance is reported in the Sources and Uses disclosure section , then it need not also be reported here .
If there is assistance reportable here , but reported only in the Sources and Uses disclosure , ( check here ) :
X Assistance is disclosed in Sources and Uses Attachments
Agency Name and Address Program and Type of Amount Requested / Received
Assistance
Orange County, NC Coronavirus Relief Fund $ 1 , 000 , 000
PO Box 8181
Hillsborough , NC 27278
7 . Interested Parties . ( Check One ) :
X No parties have a reportable financial interest in this project . Interested parties include
developers , contractors , consultants , individuals , entities including units of government with a
financial interest greater than $ 50 , 000 or 10 percent of the assistance ( whichever is lower; being
a party to a contract procured under Federal procurement regulations at 2 CFR Part 200 does
not, by itself, constitute a reportable financial interest ) .
All parties with a reportable financial interest are listed on table below/ attached page ( s ) .
Name and Address Type of Participation Interest ($ and %)
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8 . All expected sources of funds available or expected to be available for the project or activity and
all reportable uses of funds are included in the application for funds and on the following forms
( check all that apply ) .
® CDB & CV PROJECT BUDGET
® CDB &CV LOCAL COMMITMENT FORM
❑ Other Attachment ( s ) . Describe :
9 . Certification .
I hereb rtify that all i f rmat " n in this report and its attachments is true and complete .
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STATE CDB & CV PROGRAM REGULATIONS
Citizen Participation
If funded , the grantee will have documentation on file of compliance with citizen participation
requirements in the application process 4 NCAC 19L . 1002 ( b ) : publisher' s affidavits of notices and
minutes signed by the town or county clerk of the two required public hearings .
Project Administration
The grantee is responsible for CDB & CV oversight . If funded , the grantee will supervise the
implementation of the project as follows :
✓ The local government manager reviews and signs off on all project reports .
✓ The project administrator or local government staff will present and give at least quarterly written
status reports to the elected board . A signed copy of the quarterly report must be submitted to the
grant representative for review .
✓ At least two persons from the local government listed on the signatory cards will review and sign off
on invoices and requests for payment .
✓ Maintain all project files at the local government offices and make them available to citizens during
regular business hours .
Audits/ Compliance
CDB & CV grantees expending $ 25 , 000 or more in a fiscal year are required to have funds audited for the
CDB & CV program . CDB & CV funds can be used to pay for the CDB & CV portion of the audit provided
the grantee has expended $ 500 , 000 or more in the fiscal year in total federal awards ( CDB & CV and
other federal funds ) . If the grantee has expended less than $ 500 , 000 in total federal awards , the grantee
may budget local funds in the administrative line item in the CDB & CV application to pay for the CDB &
CV portion of the audit and claim the local administrative funds as local commitment .
Program Income
Local governments must develop and submit a plan for reuse of program income to REDD approval .
Legally Binding Commitment ( LBC )
The local government will develop and execute a LBC with the non - profit or for- profit
developer/ business subject to REDD requirements .
The applicant hereby assures and certifies that by his/ her signature, its duly authorized official has
read and understands the State CDBG -CV Program Standards and , if funded , will adhere to all
standards applicable to the funded project .
Name of Chief Elected Official Penny Rich
Title C ai , Board of C4 T1 si ners
Signature
Date o 0 � 7 411�4
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