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Backup Documents 11/08/2011 Item #10F ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 0 p TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper.Attach to original document.Original documents should be hand delivered to the Board Office.The completed routing slip and original documents are to be forwarded to the Board Office only after the Board has taken action on the item.) ROUTING SLIP Complete routing lines#1 through#4 as appropriate for additional signatures,dates,and/or information needed.If the document is already complete with the exception of the Chairman's signature,draw a line through muting lines#1 through#4,complete the checklist,and forward to Ian Mitchell(line#5). Route to Addressee(s) Office Initials Date (List in muting order) 1. Jeff Klatzkow County Attorney 2. Ian Mitchell BCC Office , /`- tt I is I(I 6. Minutes and Records Clerk of Court's Office PRIMARY CONTACT INFORMATION (The primary contact is the holder of the original document pending BCC approval.Normally the primary contact is the person who created/prepared the executive summary.Primary contact information is needed in the event one of the addressees above,including Ian Mitchell,need to contact staff for additional or missing information.All original documents needing the BCC Chairman's signature are to be delivered to the BCC office only after the BCC has acted to approve the item.) Name of Primary Staff Wendy Klopf Phone Number 252-2901 Contact Operations Coordinator Agenda Date Item was November 08,2011 Agenda Item Number l OF Approved by the BCC Type of Document HUD SF 424 Number of Original 1 Attached Documents Attached INSTRUCTIONS& CHECKLIST Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not appropriate. (Initial) Applicable) 1. Original document has been signed/initialed for legal sufficiency.(All documents to be WK signed by the Chairman,with the exception of most letters,must be reviewed and signed by the Office of the County Attorney.This includes signature pages from ordinances, resolutions,etc.signed by the County Attorney's Office and signature pages from contracts,agreements,etc.that have been fully executed by all parties except the BCC • Chairman and Clerk to the Board and possibly State Officials.) 2. All handwritten strike-through and revisions have been initialed by the County Attorney's WK n/a Office and all other parties except the BCC Chairman and the Clerk to the Board 3. The Chairman's signature line date has been entered as the date of BCC approval of the WK document or the final negotiated contract date whichever is applicable. 4. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's WK signature and initials are required. 5. In most cases(some contracts are an exception),the original document and this routing slip WK should be provided to Ian Mitchell in the BCC office within 24 hours of BCC approval. Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified.Be aware of your deadlines! 6. The document was approved by the BCC on 11-08-11 and all changes made during WK the meeting have been incorporated in the attached document.The County Attorney's Office has reviewed the changes,if applicable. I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05 1OF 6111 MEMORANDUM Date: November 15, 2011 To: Wendy Klopf, Operations Coordinator Housing & Human Services From: Ann Jennejohn, Deputy Clerk Minutes & Records Department Re: Updated U.S. Department of Housing and Urban Development Standard Form 424 for HUD FY11-12 Action Plan Entitlement Grants Attached is an original copy of the document referenced above, (Item #10F) approved by Board of County Commissioners November 8, 2011. The Minutes and Records Department has held the second original document for the Board's Official Record. If you have any questions, please contact me at 252-8406. Thank you. Attachment lOf ,.. I �QPfstSENtopi. G f * 111)111 * First Program Yea r 4 �z �Q4N oEVS�o ( FY2O11 ) Action Plan The CPMP Action Plan includes the SF 424 and Narrative Responses to Action Plan questions that CDBG, HOME, HOPWA, and ESG grantees must respond to each year in order to be compliant with the Consolidated Planning Regulations. SF 424 Complete the fillable fields (blue cells) in the table below. The other items are pre- filled with values from the Grantee Information Worksheet. Applicant Identifier ;: B:11 UC 120016 Type of Submission Date Received by state Florida Application Pre-application •Date Received by HUD Federal Identifier ❑ Construction _ LJ,Construction Non-Construction_. 0 Non Construction Applicant Information Collier County Board of County Commissioners Contact: Kimberley Grant Public Services Division Phone: (239) 252-8442 3339 Tamiami Trail East Suite 211 Fax: (239) 252-2638 Naples, FL 34112 kimberleygrant @colliergov.net Employer Identification Number-(EIN): DUNS# - 596000558 76997790 Applicant Type: Specify Other Type if necessary: Local Government: County U.S. Department of Program Funding _ Housing and Urban Development Catalogue of Federal Domestic Assistance Numbers; Descriptive Title of Applicant Project(s); Areas Affected by Project(s) (cities, Counties, localities etc.); Estimated Funding Community Development Block Grant 14:218 Entitlement Grant CDBG Project Titles Administration, Public Facilities,Description of Areas Affected by CDBG Tenant Assistance, Mental Health, Job Creation Project(s) CoUn wide/Collier County, FL CDBG Grant Amount.$2,114,463 Additional HUD.Grant(s) Describe: Leveraged 0 Additional Federal Funds Leveraged1,405,758 Additional State Funds Leveraged 0 Locally Leveraged Funds 0 ; Grantee Funds Leveraged 0 Anticipated Program Income 0 Other(Describe) --:. Total Funds Leveraged for CDBG-based Project(s) 0 IOF 04 Home Investment Partnerships Program 14.239 HOME HOME Project Titles Administration, Homebuyer Description of Areas Affected by HOME Assistance, CHDO assistance Project(s)'Coun `wide/Collier County, FL HOME Grant Amount $662,126 'Additional HUD Grant(s Leveraged{} Describe Additional Federal Funds Leveraged$7,013,427 Additional State Funds Lever--aged° Locally Leveraged Funds° Grantee Funds Leveraged 0 Anticipated Program Income 0 Other(Describe) Total Funds Leveraged for HOME-based Project(s) Housing Opportunities for People with 14.241 HOPWA AIDS HOPWA Project Titles N/A Description of Areas Affected by HOPWA Project(s) N/A HOPWA Grant Amount $0 Additional HUD Grants) Describe Leveraged Additional Federal Funds Leveraged dditional State Funds Leveraged Locally Leveraged Funds Grantee Funds Leveraged Anticipated Program Income Other(Describe) Total Funds Leveraged for HOPWA-based Project(s) Emergency Shelter,Grants Program 14.231 ESG ESG Project Titles Administration, Abused Women Description of Areas Affected by ESG and Children Shelter Project(s) Countywide/Collier County, FL ESG Grant Amount Additional HUD Grant(s)`Leveraged Describe 94,611 Jo Additional Federal Funds Leveraged957,300 dditional State Funds Leveraged° Locally Leveraged Funds° Grantee.Funds Leveraged 0 ,fA Anticipated Program Income 0 Other(Describe) i otal Funds Leveraged for ESG-based Project(s) Congressional Districts of: Is application subject to review by state 14 1 25 Executive Order 12372 Process? Is the applicant delinquent on any federal ❑ Yes This application was made available to debt? If"Yes" please include an additional the state EO 12372 process for review document explaining the situation. on DATE X No Program is not covered by EO 12372 ❑ Yes ® No 0 N/A ' Program has not been selected by the state for review 1 t, Person to be contacted regarding this application Kimberley Grant (239) 252-8442 kimberleygrant @colliergov.net Signature of.Authorized Representative Date Signed Board of County Commissioners Collier Co t Florida cx,...,a12..._ Iti �ogi By: Fred W. Coyle, Chairman ni ATTEST: , ! Vv��, App i► �, as to form and legal sufficiency: ' -' •,i DWf HT E .' � s RAC Jeffr:` ,. latzkow "' r'' County Attorney I♦I I i.,;��i•t -s/4.1%.—: W r . - imi,8 iffnatimi aa Item# l°F Agenda I i..d'Zal 1 Date Date 11,....15.,#2/)1.1 Rec'd t Dep erk Irer • ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP OF TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper.Attach to original document.Original documents should be hand delivered to the Board Office.The completed routing slip and original documents are to be forwarded to the Board Office only after the Board has taken action on the item.) ROUTING SLIP Complete routing lines#1 through#4 as appropriate for additional signatures,dates,and/or information needed.If the document is already complete with the exception of the Chairman's signature,draw a line through routing lines#1 through#4,complete the checklist,and forward to Sue Filson(line#5). Route to Addressee(s) Office Initials Date (List in routing order) 1. 2. 3. 4. Jeffrey A. Klatzkow,County Attorney County Attorney JAK 11/21/2011 5. Ian Mitchell,Executive Manager BCC Board of County Commissioners 6. Minutes and Records Clerk of Court's Office PRIMARY CONTACT INFORMATION (The primary contact is the holder of the original document pending BCC approval.Normally the primary contact is the person who created/prepared the executive summary.Primary contact information is needed in the event one of the addressees above,including Ian Mitchell needs to contact staff for additional or missing information.All original documents needing the BCC Chairman's signature are to be delivered to the BCC office only after the BCC has acted to approve the item.) Name of Primary Staff Wendy Klopf,Operations Coordinator, Phone Number 252-2901 Contact Housing Agenda Date Item was 11/8/2011 Agenda Item Number 10-F Approved by the BCC Type of Document Funding Letters for CDBG,HOME and Number of Original 3 each(9 documents Attached ESG Documents Attached total) INSTRUCTIONS&CHECKLIST Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not appropriate. (Initial) Applicable) 1. Original document has been signed/initialed for legal sufficiency. (All documents to be JAK signed by the Chairman, with the exception of most letters,must be reviewed and signed by the Office of the County Attorney.This includes signature pages from ordinances, resolutions,etc.signed by the County Attorney's Office and signature pages from contracts,agreements,etc.that have been fully executed by all parties except the BCC Chairman and Clerk to the Board and possibly State Officials.) 2. All handwritten strike-through and revisions have been initialed by the County Attorney's JAK Office and all other parties except the BCC Chairman and the Clerk to the Board 3. The Chairman's signature line date has been entered as the date of BCC approval of the JAK document or the final negotiated contract date whichever is applicable. 4. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's JAK . signature and initials are required. 5. most cases(some contracts are an exception),the original document and this routing slip JAK should be provided to Ian Mitchell in the BCC office within 24 hours of BCC approval. Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified.Be aware of your deadlines! 6. The document was approved by the BCC on 11/8/11 and all changes made during the JAK meeting have been incorporated in the attached document.The County Attorney's Office has reviewed the changes,if applicable. I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05 08-MGR-00132/33 1 OF MEMORANDUM Date: November 21, 2011 To: Wendy Klopf, Operations Coordinator Housing & Human Services From: Teresa Polaski, Deputy Clerk Minutes & Records Department Re: Funding Letters for CDBG, HOME and ESG Attached are the three originals referenced above, (Item #10F) approved by Board of County Commissioners on Tuesday, November 8, 2011. The Minutes & Records Department has retained an original of each letter for the Board's Official records. If you should have any questions, please contact me at 252-8411. Thank you. IOF Grant Agreement U.S.Department of Housing and Urban Development Subtitle B of Title IV of the McKinney-Vento Office of Community Planning and Development Homeless Assistance Act,42 USC 11371 et seq. Emergency Shelter Grants/ Emergency Solutions Grants Program Grant Number: $662,126.00 1. Name of Grantee(as shown in item 5 of Standard Form 424) 2.Grantee's 9-digit Tax ID Number Collier County 59-6000558 3. Grantee's DUNS Number: 076997790 4. Grantee's Complete Address(as shown in item 5 of Standard Form 424) 3339 Tamiami Trail,Suite 211 East Naples, FL 34112-5361 Grant Agreement:This Grant Agreement between the Department of Housing and Urban Development(HUD)and the above named Grantee is made pursuant to the authority of Subtitle B of Title IV of the McKinney-Vento Homeless Assistance Act(42 U.S.C. 11371 et seq.). The Grantee's submissions under 24 CFR Part 91 that pertain to this Grant,the HUD regulations at 24 CFR Part 576(as now in effect and as may be amended from time to time),and any special conditions attached to this Grant Agreement constitute part of this Grant Agreement. Subject to the provisions of this Grant Agreement,HUD will make the Grant available to the Grantee upon execution of the Grant Agreement by the Grantee and HUD.The Grant may be used to pay costs incurred after the date specified in item 8 below,provided the activities to which the costs are related are carried out in compliance with all applicable requirements.The Grantee agrees to assume all of the responsibilities for environmental review,decision making,and actions,as required under the HUD regulations at 24 CFR Part 576. The grantee agrees to follow the HUD standards for participation,data,and reporting under a local Homeless Management Information System.The Grantee shall also comply with the Office of Management and Budget requirements for Universal Identifier and Central Contractor Registration and Reporting Subaward and Executive Compensation Information at 2 CFR Part 25, Appendix A to Part 25-Award Term,and 2 CFR Part 170,Appendix A to Part 170-Award Term. 5.Special Conditions(check one): ®None ❑Attached 6a.Date HUD Received Grantee's Annual Submission under 24 CFR Part 91 6b.Date Grantee Notified:(mm/dd/yyyy) 08/10/2011 7.Date of Start of Grantee's Program Year(mm/dd/yyyy) 8.Date Use of Funds May Begin(the later of the date in 6a and the date In 7) 10/01/2011 10/01/2011 9.Funding Approval(check one): IA Original ❑Amendment 10. Amount of Emergency Shelter GrantlEmergency Solutions Grant: $ 10a.Funds Reserved for this Grantee $ 10b.Funds Now Being Approved $94,611 10c. Reservation to be Cancelled(10a minus 10b) $ 11.Name and Complete Address of Department Designated to Administer the Grant Housing and Human Services Department 3339 East Tamiami Trail,Suite 211 Naples,FL 34112-5361 11a.Name of Authorized Official Kimberley Grant 11b.Title 11e.Si nat a 11d.Date(mm/dd/yyyy) MBA Interim Director ✓ %I t 8 i l l 11e.Phone Number 11f.Fax Number 11g.E-mail Address (239)252-2273 (239)252-2213 kimberleygranta,colliergov.net. 12.U.S.Department of Housing and Urban Development 13.Grantee Name Community Planning and Development Division Collier County 12a.Name of Authorized Official 13a.Name of Authorized Official Maria R.Ortiz-Hill Honorable Fred W. Coyle 12b.Title 13b.Title Dir c Chairman,Board of County Commissioners 12c.Si _ (A)i�f I 13c.Signature 12d.Date / 13d.Date(mm/dd/yyyy) 10/12/2011 A ••,14 11.° •••--.. ttl Bil IN BRO - as to form and legal sufficiency: t Jeff y latzkow County Attorney Atte ' ITL` , gnaturt' t 4 Funding Approval/Agreement U.S. Department of Housing and Urban Development 1 O F 'title I of.the Housing and Community Office of Community Planning and Development Development Act(Public Law 930383) Community Development Block Grant Program HI-00515R of 20515R 1.Name of Grantee(as shown in item 5 of Standard Form 424) 3a.Grantee's 9-digit Tax 3b.Grantee's DUNS Number. 4.Date use of funds may Collier County ID Number. 076997790 begin(mm/dd/yyyy): 59-6000558 10/01/2011 2.Grantee's Complete Address(as shown in item 5 of Standard Form 424) 5a.Project/Grant No.1 6a.Amount Approved B 11-UC-12-0016 $2,114,463 3339 Tamiami Trail East 5b.Project/Grant No.2 6b.Amount Approved Suite 211 Naples,FL 34112 5c.Project/Grant No.3 6c.Amount Approved Grant Agreement: This Grant Agreement between the Department of Housing and Urban Development(HUD)and the above named Grantee is made pursuant to the authority of Title I of the Housing and Community Development Act of 1974,as amended,(42 USC 5301 et seq.).The Grantee's submissions for Title I assistance,the HUD regulations at 24 CFR Part 570 (as now in effect and as may be amended from time to time), and this Funding Approval, including any special conditions/addendums,constitute part of the Agreement. Subject to the provisions of this Grant Agreement, HUD will make the funding assistance specified here available to the Grantee upon execution of the Agreement by the parties. The funding assistance specified in the Funding Approval may be used to pay costs incurred after the date specified in item 4 above provided the activities to which such costs are related are carried out in compliance with all applicable requirements. Pre- agreement costs may not be paid with funding assistance specified here unless they are authorized in HUD regulations or approved by waiver and listed in the special conditions to the Funding Approval. The Grantee agrees to assume all of the responsibilities for environmental review,decision making,and actions,as specified and required in regulations issued by the Secretary pursuant to Section 104(g)of Title I and published in 24 CFR Part 58. The Grantee further acknowledges its responsibility for adherence to the Agreement by sub-recipient entities to which it makes funding assistance hereunder available. U.S.Department of Housing and Urban Development (By Name) Grantee Name Title Maria R. Ortiz-Hill (=c-cd 112; Cc -r1 Title Direc s , ': unity Planni . D- - .••ment dc–,c c�r,n Sgna / � Date(mm/ddlyyyy) Sgnatu Date(mm/dd/yyyy) �� 10/12/2011 W, 'tl �In Olt• e I Assistance for this Fun. Action 8.Special Conditions 9a. ate HUD Received Submission check bne check only one) (check one) ®a.Entitlement,Sec 106(b) ®None 8/10/2011 ®a. pr Funding ❑b.State-Administered,Sec 106(d)(1) ❑Attached 9b.Date Grantee Notified Approval (mm/dd/yyyy) ❑b.Amendment ❑c.HUD-Administered Small Cities,Sec 106(d)(2)(B) 9c.Date of Start of Program Year Amendment Number El d.Indian CDBG Programs,Sec 106(a)(1) 10/01/2011 ❑e.Surplus Urban Renewal Funds,Sec 112(b) 11.Amount of Community Development ❑f.Special Purpose Grants,Sec 107 Block Grant FY 2011 FY El g.Loan Guarantee,Sec 108 a.Funds Reserved for this Grantee ( ) FY( ) b.Funds now being Approved $2,114,463 c.Reservation to be Cancelled (11a minus 11b) 12a.Amount of Loan Guarantee Commitment now being Approved 12b.Name and complete Address of Public Agency N/A Loan Guarantee Acceptance Provisions for Designated Agencies: The public agency hereby accepts the Grant Agreement executed by the Department of Housing and Urban Development on the above date with respect to the above grant number(s) as Grantee designated to receive 12c.Name of Authorized Official for Designated Public Agency loan guarantee assistance, and agrees to comply with the teens and conditions of the Agreement, applicable regulations, and other requirements of HUD now or hereafter in effect, pertaining to the Title assistance provided it. Signature HUD Accounting use Only Effective Date Batch TAC Program Y A Reg Area Document No. Project Number Category Amount (mm/dd/yyyy) F 153 — — — 176 — — — — Y Project Number Amount P t Y Project Number Amount . . . Jr Dal ntered PAS(mmlddt ryy) _i Date Entered LOCCS(mm/dd/yyyy) Batch Number Transaction Code Entered By Verified By ATTEST: S- Ap. .• to form and legal sufficiency: "TR 570 form HUD-7082(4/93) DWI T E.BRO M. .CLERK �t�1,U �` 4, '\ Jeffre -`T latzkow County Attorney r.__.....r+io.4 runamg Approval ana mumt LiQtia,u„a„tw,,,..Ua.,,9 Investment Partnerships Agreement and Urban Development (I�. 101,2) Title .R of the National Affordable Housing Act Office d Development community Planning Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number. The HOME statute imposes a significant number of data collection and reporting requirements. This includes information on assisted properties, on the owners or tenants of the properties, and on other programmatic areas. The information will be used: 1) to assist HOME participants in managing their programs; 2) to track performance of participants in meeting fund commitment and expenditure deadlines; 3) to permit HUD to determine whether each participant meets the HOME statutory income targeting and affordability requirements; and 4) to permit HUD to determine compliance with other statutory and regulatory program requirements. This data collection is authorized under Title II of the Cranston - Gonzalez National Affordable Housing Act or related authorities. Access to Federal grant funds is contingent on the reporting of certain project - specific data elements. Records of information collected will be maintained by the recipients of the assistance. Information on activities and expenditures of grant funds is public information and is generally available for disclosure. Recipients are responsible for ensuring confidentiality when public disclosure is not required. Participant Name and Address Collier County 3339 East Tamiami Trail, Suite 211 East Naples, FL 34112 -5361 6. Previous Obligation (Enter "0" for initial FY allocation) a. Formula Funds b. Community Housing Development Org. (CHDO) Competitive 7. Current Transaction (+ or ) a. Formula Funds 1. CHDO (For deobligations only) 2. Non- CHDO (For deobligations b. CHDO Competitive Reallocation or Deobllgation (see #18 below) 8. Revised Obligation a. Formula Funds b. CHDO Compettve Reallocation 9. Special Conditions (check applicable box) // • ❑ Attached 2. Participant Number M- 11 -UC -12 -0217 3. Tax Identification Number 4. DUNS Number 4. Appropriation Number 5. FY (yyyy) 2011 $0.00 $662,126. $662,126. $1 10. Date of Obligation (Congressional Release Date) This Agreement between the Department of Housing and Urban Development (HUD) and the Participating Jurisdiction/Entity is made pursuant to the authority of the HOME Investment Partnerships Act (42 U.S.C. 12701 at seq.). The Participating Jurisdiction's /Entity's approved Consolidated Plan submission /Application and the HUD regulations at 24 CFR Part 92 (as is now in effect and as may be amended from time to time) and this HOME investment Partnership Agreement, form HUD - 40093, including any special conditions, constitute part of this Agreement. Subject to the provisions of this Agreement, HUD will make the funds for the Fiscal Year specified, available to the Participating Jurisdiction/Entity upon execution of this Agreement by the parties. All funds for the specified Fiscal Year provided by HUD by formula reallocation are covered by this Agreement upon execution of an amendment by HUD, without the Participating Jurisdiction's execution of the amendment or other consent. HUD's payment of funds under this Agreement is subject to the Participating Jurisdiction's /Entity's compliance with HUD's electronic funds transfer and information reporting procedures issued pursuant to 24 CFR 92.502. To the extent authorized by HUD regulations at 24 CFR Part 92, HUD may, by its execution of an amendment, deobligate funds previously awarded to the Participating Jurisdiction /Entity without the Participating Jurisdiction's /Entity's execution of the amendment or other consent. The Participating Jurisdiction /Entity agrees that funds invested in affordable housing under 24 CFR Part 92 are repayable when the housing no longer qualifies as affordable housing. Repayment shall be made as specified in 24 CFR Part 92. The Participating Jurisdiction agrees to assume all of the responsibility for environmental review, decision making, and actions, as specified and required in regulation at 24 CFR 92.352 and 24 CFR Part 58. The Grantee shall comply with requirements established by the Office of Management and Budget (OMB) concerning the Dun and Bradstreet Data Universal Numbering System (DUNS), the Central Contractor Registration (CCR) database, and the Federal Funding Accountability and Transparency Act, including Appendix A to Part 25 of the Financial Assistance Use of Universal Identifier and Central Contractor Registration, 75 Fed. Reg. 55671 (Sept. 14, 2010) (to be codified at 2 CFR part 25) and Appendix A to Part 170 of the Requirements for Federal Funding Accountability a rr parency Act Implementation, 75 Fed. Reg. 55663 (Sept. 14, 2010) (to be codified at 2 CFR part 170). 11. For the U.S. Department of HUD (Name and Title of Authorized Official) 1 , Maria R. Ortiz -Hill Director Community Planning and Dev. 14. For the Participating Jurisdiction /Entity (Name and Title of Authorized Official) 15. r 17. Ch-AW6r" , 'ED lAtial Agreement ❑ Amendment # 18. *fundm Informabpttt "n TOME Sri s A'o to ion Code PAS Code CLERK W App and legal sufficiency: Amoun Jeffr atzkow $ Coun A tomey 13. Date 10/12/2011 16. Date Ji /9, /I/ /i a 17 Page 1 of 1 form HUD -40093 Qe U Clerit.�;� , t tl � i �6ture an . a