Attachment_A_-_CDBG_Public_Services_Program_Fund_Application.pdf

ATTACHMENT A

COMMUNITY DEVELOPMENT BLOCK GRANT

PUBLIC SERVICES PROGRAM

APPLICATION FOR GRANT

BREVARD COUNTY, FLORIDA

FLORIDA’S SPACE COAST

2725 Judge Fran Jamieson Way

Building C, Suite 303

Viera, Florida 32940

Table of Contents

INTRODUCTION

CONTACT AND AGENCY INFORMATION

3- MINUTE SUMMARY

KEY AGENCY STAFF

PROGRAM DESCRIPTION

PROGRAM LOGIC MODEL INFORMATION

AGENCY FINANCIAL PROFILE & AGENCY-WIDE BUDGET

PROGRAM BUDGET INFORMATION

PROGRAM BUDGET JUSTIFICATION

PROGRAM BUDGET NARRATIVE

CERTIFICATION

COMMUNITY DEVELOPMENT BLOCK GRANT REQUIREMENTS AND NATIONAL

OBJECTIVES

SELF-DECLARATION OF ELIGIBILITY AND HUD FY 2025-26** AREA MEDIAN INCOME

(AMI) LIMITS CHART

INDEMNIFICATION AND INSURANCE REQUIREMENTS

DISCLOSURE FORM

CONTRACTOR AFFIDAVIT REGARDING SCRUTINIZED COMPANY LIST

CERTIFICATE OF CORPORATE OFFICER

FOREIGN COUNTRY OF CONCERN ATTESTATION

INTRODUCTION

Brevard County receives funds through the Federal Community Development Block Grant Program (CDBG). The County anticipates that $202,563.30 will be allocated to Public Services programs with a minimum grant request of $25,000.00 and a maximum of $50,000, with a 25% match requirement. Agencies must demonstrate that their Public Service program addresses one of three national CDBG objectives:

1. Benefit low and moderate-income persons; or

2. Aid in the prevention or elimination of slums or blight; or

3. Meet community development needs with a particular urgency.

Any of the objectives listed above that are available to residents in an area where at least fifty-one (51) percent of the residents are low- and moderate-income persons are considered an area benefit activity. Examples include Public Service programs for the homeless, Meals on Wheels for the elderly, and vocational training for youth and adults.

Public Service programs are limited to residents from the unincorporated areas of Brevard County as well as the City of Cocoa Beach, the Town of Indialantic, the City of Indian Harbour Beach, the Town of Melbourne Village, the Town of Palm Shores, the City of Rockledge, and the City of Satellite Beach.

Estimated Period of Performance: October 1, 2025, through September 30, 2026

Eligibility: Applicants must meet the following criteria:

1. The agency must qualify as exempt under the Internal Revenue Code Section

501(c)(3) before the submittal of the application; and

2. The agency's Public Service programs must solely serve the unincorporated areas of Brevard County and the cities and towns listed above. To verify the service area, find the client’s taxing district on https://www.bcpao.us/PropertySearch/#/nav/Search; and

3. The agency must demonstrate in its application the need for the proposed Public Service program by using existing community studies or priorities identified in the Board of County Commissioners-approved 5-year Consolidated Plan.

4. The agency must be operating in Brevard County before the submittal of the application;

and

5. The agency is legally, administratively, and fiscally responsible for the grant awarded to them; and

6. The agency must comply with all city, county, state, and federal licensing and/or accreditation/certification and regulatory requirements and provide documentation to support these requirements.

Disqualifying Criteria:

1. An agency that is not qualified as exempt under the Internal Revenue Code, Section 501(c)(3) prior to submitting the application.

2. The agency may not use the grant funds to supplement its own funds.

3. An agency may not be reimbursed for any costs associated with preparing and submitting the application.

4. Submittals received after Application due date will not be considered.

5. A submittal deemed incomplete due to missing information on documents.

6. A submittal that does not address the national CDBG objective (benefit low – and mod-income persons).

7. An agency that is not in compliance with all local and state regulations and/or accreditation.

Review Process:

1. The Housing and Human Services Department reviews the applications submitted for disqualifying criteria.

2. The applications will be reviewed in a public meeting by the Selection Committee, comprised of the County’s Community Development Block Grant Citizen Advisory Board (the CDBG Board). The CDBG Board will evaluate, score, and rank all qualified applications based on the following criteria:

a. Program Description Possible 35 Points

b. Program Logic Model and Evaluation Plan Possible 25 Points

c. Agency Financial Profile and Agency-Wide Budget Possible 25 Points

d. Program Budget Possible 15 Points

3. The CDBG Board will make funding recommendations.

4. Notice of Intended Award will be posted.

5. Agreements drafted and executed

Documentation Required to be Submitted Checklist:

Submit the completed Public Services Program Application.

Copy of a letter that identifies your agency as exempt under Internal Revenue Code Section 501(c)(3). **

Conflict of Interest Certification **

Program Certification **

The agency’s Agency-Wide Budget, prior year, and current year projected revenues and expenditures.

The most recent Audit Report and Management Letter, or, if the agency is not required to have an Audit, the most recent financial statement (income statement and balance sheet), are acceptable. **

The most recent Bank Statement (showing three months’ worth of reserves equal to the requested grant amount). **

Articles of Incorporation/By-Laws

List of the Agency’s Board of Directors

The agency's most recent Internal Revenue Form 990. **

The agency’s signed Board Minutes/Letter Approving Application Submittal and Signature Authority. **

The agency’s licenses/certifications

The agency’s Certificate of Insurance for the Public Services Program **

The agency’s leverage documentation

The agency’s letters of commitment (for funding or in-kind services) will include details on the contribution amount.

Job descriptions of persons responsible for managing the Public Service program.

Resumes of key persons who will be working on the Public Service program.

Completed Foreign Influence Disclosure Form. **

Completed Contractor Affidavit Regarding Scrutinized Company List Form **

Certificate of Corporate Officer Form **

Foreign Country of Concern Attestation Form **

E-Verify Memorandum of Understanding (MOU). **

Documents indicated with ** are to be included in the original application only.

The agency’s licenses/certifications

The agency’s Certificate of Insurance for the Public Services Program **

The agency’s leverage documentation

The agency’s letters of commitment (for funding or in-kind services) will include details on the contribution amount.

Job descriptions of persons responsible for managing the Public Service program.

Resumes of key persons who will be working on the Public Service program.

Completed Foreign Influence Disclosure Form. **

Completed Contractor Affidavit Regarding Scrutinized Company List Form **

Certificate of Corporate Officer Form **

Foreign Country of Concern Attestation Form **

E-Verify Memorandum of Understanding (MOU). **

Documents indicated with ** are to be included in the original application only.

Complete all Sections of the Application. Include all the documentation required to be submitted on the checklist with your application.

CONTACT AND AGENCY INFORMATION

Agency Legal Name: ____________________________________________________

Agency d/b/a (if applicable): _______________________________________________

Street Address: _________________________________________________________

Mailing Address: ________________________________________________________

Agency Web Address: ___________________________________________________

Federal Identification Number: _____________________________________________

Main Telephone: _______________________ Main Fax: _______________________

How long has the agency offered services in Brevard County? ____________________

Program Name:

Program Site:

Primary Geographic Service Area: ☐ North ☐ Central ☐ South ☐ County-wide

Application Type: ☐ New ☐ Existing

Amount Requested for Funded Program FY 2024-2025:

Amount Requested for Funded Program FY 2025-2026:

Percentage of Change:

Will Community Development Block Grant Public Service funds be used to leverage funds from another source?

☐ Yes ☐ No

If yes, the amount of funds: $ ________________________

Will Community Development Block Grant Public Service funds be used to match funds from another source?

☐ Yes ☐ No

If yes, the amount of funds: $ ________________________

Check which Brevard County Board of County Commissioner priority the program will address:

Public Services Priorities

☐ Youth Activities (Education and Recreation) ☐ Adult Activities ☐ Educational Programs ☐ Nutrition Programs ☐ Services For Youth in Foster Care ☐ Health Services (Mental, Physical, Developmental) ☐ Homeless Services ☐ Senior Programs ☐ Substance Abuse ☐ Childcare Services ☐ Unaccompanied Youth Services ☐ Transportation ☐ Social/Recreational/Cultural Programs

3-MINUTE SUMMARY

1. Greeting: Tell us about yourself.

2. Summarize in 1-2 sentences what your agency does. Describe the benefits your agency provides to the community. Use a sentence to list what sets your services apart from others.

3. Please tell us how many staff members work for your agency and how long your agency has been providing services in Brevard County. Describe the results your agency has achieved to date.

4. Tell us what program it is that needs this CDBG funding, the identified priority this program will meet and what eligible CDBG activity and population the program targets.

5. Please tell us how much funding you are seeking for the program.

6. Provide a brief list of other agencies that you collaborate with to enhance your services.

7. Identify your program’s mission in one sentence.

8. Briefly describe why Brevard County should fund this program with CDBG funds.

KEY AGENCY STAFF

Chief Professional Officer (CPO):

Name & Title:

Length of Service: Email:

Telephone: Fax:

Lead Agency Program Staff Person (if other than CPO):

Name & Title:

Length of Service: Email:

Telephone: Fax:

Fiscal Officer:

Name & Title:

Length of Service: Email:

Telephone: Fax:

Chief Volunteer Officer:

Name & Title:

Length of Service: Email:

Telephone: Fax:

PROGRAM DESCRIPTION

1. Statement of Need (maximum of ½ page)

A. What is the need or the problem to be addressed, and how is it consistent with one or more of the Brevard County Board of County Commissioners’ priorities and the Community Development Block Grant Program’s National Objectives?

B. How was the problem or need identified? How does that relate to the Community Development Block Grant Program’s National Objectives and the County’s priorities?

2. Scope of Services (maximum of ½ page)

A. Provide a detailed description of the purpose of your Agency’s proposed program.

B. What is the target population and proposed number of clients to be serviced (unduplicated)?

C. What activities will your Agency be providing?

D. What are your Agency’s program goals and objectives?

3. Trends/Changes (maximum one page)

1. What are the most significant trends and/or changes currently affecting the Agency’s operation, the people served, the type of programs offered, etc.?

2. Are there anticipated changes that will significantly impact the foreseeable future, such as over the next two to three years?

3. Program Promotion (maximum of ½ page): Describe the efforts and methods used to promote this program to ensure that appropriate individuals and/or families are aware of these services.

4. Job description (maximum of six pages): Identify job titles/positions of persons responsible for managing the project and staff devoted to service provision. Provide job descriptions for the program for which you are seeking funding. Please include resumes of key persons who will be working on the program.

PROGRAM LOGIC MODEL INFORMATION

Provide an overview of how you will achieve intended results and/or outcomes during the twelve-month period.

1. Describe how the program flows or works from resources to goals. It should be a breakdown of your scope of services.

A. Program Resources: List various resources included in the program. These resources may include, but are not limited to, service provider(s), program setting, collaboration, service technologies, funding sources, and participants.

B. Activities: List program activities relating to the resources.

C. Units of service/outputs: The number of people who will be served (duplicated or unduplicated) by the amount of service, the number and type of participants, the activities provided, and the durations. For example, ninety parents will receive parenting classes in three sessions during a six-week workshop.

D. Outcomes: Expected outcomes based on program activities for a one-year period.

What difference does this program make in the life of your clients?

E. Goals: Overall aim of the program, the end result that activities will achieve, and outcomes described.

2. Evaluate Plan: Describes how the agency will measure and track program outcomes and attain the defined goals.

A. What difference does this program make in the life of your clients?

B. Indicators: Number and percentage of what is being measured. Indicators will determine whether or not measurable outcomes are being met. Examples of indicators are action words such as increase, decrease, maintain, and expand.

C. Baseline Measure: The starting point for evaluating the program. For example, the number of meals delivered last year, the number of students at the target school who are reading below grade level, etc.

D. Measurement Tool/Approach: The program’s way of determining whether a change has occurred, such as the number of meals distributed, assessment of nutrition levels for individuals on the meal program, and pre- and post-reading levels test.

E. Sampling Strategy and Sample Size: How will the program determine who to measure, such as all participants, 20 percent of participants?

F. Frequency and Schedule of Data Collection: When will data be collected, such as pre- and post-testing, key points during the program, quarterly, or monthly?

AGENCY FINANCIAL PROFILE & AGENCY-WIDE BUDGET

Respond to the following:

A. What is the percentage of program cost in relation to the total agency budget?

B. What is the percentage of Community Development Block Grant Public Service program funding requested in relation to total program funding?

C. Does your agency have at least three months of operating reserves available? (Please include your agency’s most recent bank statement showing three months’ worth of reserves of the requested grant amount. For Example, if an agency is requesting $40,000, the agency should have $10,000 in cash reserves.)

D. Does your agency provide subsidies, scholarships, or a sliding fee scale? If yes, provide a brief explanation. If not, what is your referral procedure for clients who do not qualify for services?

E. Does your agency follow Generally Accepted Accounting Practices?

F. Does your agency have internal accounting procedures for revenue and expenses? If no, explain:

G. Does your board review financial activity at each meeting?

H. Does your agency have a strategic and/or long-range plan?

I. Does your agency have any areas of noncompliance with funding, regulatory, or licensing bodies?

Agency-Wide Budget:

Attach your Agency’s agency-wide budget, which will be referred to and labeled as Agency- Wide Budget, at the top of the page in your application, to include the prior year's and current year’s revenue and expenses for your agency’s fiscal year.

Audit Reports:

Attach a copy of your Agency’s most recent Audit Report and Management Letter. If the agency is not required to have an Audit, the most recent financial statement is acceptable.

PROGRAM BUDGET INFORMATION

Each section of the PROGRAM(S) - BUDGET INFORMATION must be completed. The following information will assist you with providing the required information for each section of the form.

Section A – Public Services Program Budget Summary:

Community Development Block Grant Public Service Program - enter the name of the program for which you are requesting funding from the Brevard County Board of County Commissioners. Please enter your fund request for the period starting October 1, 2025 through September 30, 2026.

Community Development Block Grant Public Service Match – (for Public Services ONLY) enter the amount of match for each program. Applicants are required to provide a minimum twenty-five percent match for Public Services. This amount should equal Match in Section E.

Total – enter the total amount of your Community Development Block Grant Public Service fund request and Community Development Block Grant Public Request match. (Fund Request + Match = Total).

Section B – Program Budget Categories to be Funded Program – amount for each budget category that will be provided by Community Development Block Grant Public Service funding. Include eligible identified expenses required to achieve successful completion of the program. Any category of expense not applicable to your budget may be deleted and any category of expense that is not listed can be inserted. Section B should coincide with the Budget Justification.

Section C – Unit Cost Budget Breakdown: Enter the description of the unit, the number of units, the cost per unit and the total unit program cost for your program. The unit cost is the amount of funds required to provide one given unit of service. For example, a fifteen-minute Unit of Case Management Services costs $12.50. This amount is based on staff salary/time, allotted facility costs, etc.

Section D – Cost per Unit Justification: List program Units of Service and their costs. Enter the expenses that total the cost per unit and/or justify the cost per unit.

Section E – Community Development Block Grant – Public Service Match: (Provide Additional Form for Multiple Match Sources).

Program Name - enter the name of the program for which you are requesting funding from the Brevard County Board of County Commissioners.

Unrestricted Agency Cash – funds contributed by the agency that have not been designated for any other program or purpose.

In-Kind Goods and Services – goods or services (i.e., donated items, volunteer time) that will be contributed as an integral part of this program.

Other Sources Restricted Non-Agency Funds – funds provided by another source (i.e., state grant) that will be dedicated to this program.

Totals – total of all sources of Community Development Block Grant Public Services match.

Section A – Public Services Program Budget Summary

Program Name: ___________________________________________________

Community Development Block Grant – Public Service Program Fund Request:

Community Development Block Grant – Public Service Match ONLY (Section I):

Public Service Program Fund Request + Public Service Match: _______________________

Section B - Program Budget Categories to be Funded

Budget Categories Program Amount per Category 1a. 1b.

2a. 2b.

3a. 3b.

4a. 4b.

5a. 5b.

6a. 6b.

7a. 7b.

Total Community Development Block Grant Public Services Program Funds:

Section C - Unit Cost Budget Breakdown

Description of Unit Number of Units Cost per Unit Unit Program Cost 1a. 1b. 1c. 1d.

2a. 2b. 2c. 2d.

Requested Community Development Block Grant Public Services Program Funding

Total: $__________________

Section D – Cost Per Unit Justification

Program Units of Service Program Unit Costs 1a. 1b.

2a. 2b.

3a. 3b.

4a. 4b.

5a. 5b.

Section E – Community Development Block Grant – Public Service Match

Program Name Unrestricted Agency Cash

In-Kind Goods and Services

Other Sources

Restricted Non-Agency

Funds

Totals

1a. 1b. 1c. 1d. 1e.

2a. 2b. 2c. 2d. 2e.

3a. 3b. 3c. 3d. 3e.

4a. 4b. 4c. 4d. 4e.

5a. 5b. 5c. 5d. 5e.

Section F - The Agency requests a Unit Cost Budget, Expenditure Schedule, and Payment.

PERFORMANCE

PERIOD

AMOUNT TOTAL PERCENT EXPENDED

FIRST PERIOD

(10/1/2025-12/31/2025)

$ $ 25%

SECOND PERIOD

(1/1/2026-3/31/2026)

$ $ 50%

THIRD PERIOD

(4/1/2026-6/30/2026)

$ $ 75%

FOURTH PERIOD

(7/1/2026-9/30/2026)

$ $ 100%

TOTAL BUDGET: $

PROGRAM BUDGET JUSTIFICATION

PROGRAM:

LOCAL MATCH:

Personnel:

1. Job Title:

Name:

Annual Salary:

Level of Effort:

Salary Requested:

2. Job Title:

Name:

Annual Salary:

Level of Effort:

Salary Requested:

3. Job Title:

Name:

Annual Salary:

Level of Effort:

Salary Requested:

4. Job Title:

Name:

Annual Salary:

Level of Effort:

Salary Requested:

Personnel Cost Subtotal: $

Personnel Justification:

Fringe Benefits:

Type of Benefit:

Fringe Benefits Subtotal: $

Fringe Benefits Justification:

Travel:

1. Description of Travel:

Method of Calculation:

Method of Calculation:

Requested Amount: $ ___________________

Method of Calculation:

Requested Amount: $ __________________

2. Description of Travel:

3. Description of Travel:

Requested Amount: $ _____________________

Travel Subtotal: $

Travel Justification:

Equipment:

1. Description of Equipment:

Method of Calculation:

Requested Amount: $

2. Description of Equipment:

Method of Calculation:

Requested Amount: $

3. Description of Equipment:

Method of Calculation:

Requested Amount: $

Equipment Subtotal: $

Equipment Justification:

Supplies:

1. Type of Supplies:

Cost: $

2. Type of Supplies:

Cost: $

3. Type of Supplies:

Cost: $

Supplies Subtotal: $

Supplies Justification:

Contractual Services:

1. Type of Contractual Services:

Service Provider:

Requested Amount: $

2. Type of Contractual Services:

Service Provider:

Requested Amount: $

3. Type of Contractual Services:

Service Provider:

Contractual Justification:

Requested Amount: $

Contractual Subtotal: $

Other Types of Expenses:

1. Description of Expense:

Cost: $

2. Description of Expense:

Cost: $

3. Description of Expense:

Cost: $

Other Types of Expenses Subtotal:

Justification:

Total Direct Charges (includes subtotals of Personnel, Fringe Benefits, Travel, Equipment, Supplies, Contractual Services, and Other Types of Expenses):

PROGRAM BUDGET NARRATIVE

Please provide a response for items “a-g” below. Do not repeat the entire question;

only repeat the numbering format. If an area does not apply, please respond with N/A.

a. What percent of your total program budget will go for direct services versus administration?

b. Describe your required match for the Public Services Application. Is it cash, grants, or in-kind? If an award is made, all funds identified as dedicated to this program (including funds used for match/in-kind) will be subject to applicable cost principles, auditing, and reporting requirements (OMB #’s A-110, A-122, and A- 133).

c. If applicable, describe additional resources that will be utilized to implement this program.

d. List all other funding entities for which you have applied for funds to support this program.

e. List other funding sources that have already committed resources for this program.

f. Funding Reduction: Explain in detail what will happen to the program if less than the requested amount of Community Development Block Grant Public Service funding is received.

g. Has your award ever been recaptured by another funding entity due to non-performance of contract provisions? If yes, please explain.

CERTIFICATION

I certify that this Application is made without prior understanding, agreement, or connections with any corporation, firm, or person submitting an Application for the same materials, supplies, or equipment, and is fair and without collusion or fraud. I certify that I am authorized to sign this Application for the Agency. In submitting an Application to Brevard County (the “County”), the Agency offers and agrees that if the Application is accepted, the Agency will convey, sell, assign, or transfer to the County all rights, title, and interest in and to all causes of action it may now or hereafter acquire under the antitrust laws of the United States and the State of Florida for price fixing relating to the particular commodities or services purchased or acquired by the County. At the County’s discretion, such assignment shall be made and become effective when the County tender the final payment to the Agency. The Agency has reviewed and agrees to all of the General Conditions, Terms, and Provisions included in the Request for Application, acknowledges that all information provided in the RFA, Application, and any attachments hereto is true and correct, and further agrees to provide any required certification under Section. 287.135(5), Florida Statutes as amended, upon entering into an Agreement with the County. The agency is familiar with all laws and regulations that may affect the work's cost, progress, and performance.

AUTHORIZED SIGNATURE

NAME (PRINTED)

TITLE DATE

*THIS MUST BE NOTARIZED AND RETURNED WITH YOUR APPLICATION*

Sworn to and subscribed before me this _____ day of _____________ 20____.

Personally known: ___ Or produced identification: ___ Type of ID:__________

SIGNATURE OF NOTARY PUBLIC STATE

________________________________ My Commission Expires ________

NAME OF NOTARY PUBLIC (PRINTED)

COMMUNITY DEVELOPMENT BLOCK GRANT

REQUIREMENTS AND NATIONAL OBJECTIVES

1. Consolidated Plan & Annual Action Plan

The Brevard County Consolidated Plan is a five-year (FY 2022-2026) collaborative process whereby a community establishes a unified vision for community development actions with one-year Annual Action Plan updates. Consolidating the submission requirements offers local jurisdictions a better chance to shape the various programs into effective, coordinated neighborhood and community development strategies. It also creates the opportunity for strategic planning and citizen participation to take place in a comprehensive context and to reduce duplication of effort at the local level.

2. Background

The Community Development Block Grant Program was established by Congress through the Housing and Community Development Act of 1974, as amended, to provide local governments and residents with the funds needed to work comprehensively towards the improvement of the quality of life in low- and moderate-income areas. It consolidated the old categorical funding programs to allow for local flexibility in determining needs and to develop strategies to address those needs.

Community Development Block Grant funds are distributed to areas and agencies that are determined eligible for funding. Therefore, everyone in Brevard County benefits from community development activities. Not only does community development enhance the quality of life, but it also provides a stepping stone to public improvements in all types of community issues.

Basic Federal Role

Enact the program and raise money to fund it.

Allocate program funds among communities based on a formula.

Establish minimum federal standards for the use and administration of program funds, including standards on eligibility, national objectives, citizen participation, equal opportunity, environmental protection, etc.

Monitor to ensure federal standards are met.

Basic Local Role

Accomplish the following with citizens' involvement:

Identify the development and housing needs of the community;

Set short and long-term community development objectives that are in accordance with the primary objective and the requirements of Title I;

Set local priorities in deciding which of the large number of eligible activities are to be carried out;

Administer the implementation of the chosen activities in a manner consistent with national standards; and

Monitor the use of program funds and the relationship of such use to the local and national objectives.

3. Overview of the Program Primary Objectives

The primary objective of the Community Development Block Grant program is the development of viable urban communities. The Housing and Human Services Department works toward meeting this objective by providing decent housing, a suitable living environment and expanding economic opportunities, principally for persons of low and moderate income.

National Objectives: Each CDBG activity must address the national objectives:

Benefit low- and moderate-income persons;

Aid in the prevention or elimination of slums or blight; or

Meet community development needs having a particular urgency.

4. Activities to Benefit Low- and Moderate-Income Persons

The activity must meet one of the following qualifying criteria:

a. An activity available to all the residents in a particular area, where at least 51% of the residents are low-and moderate-income persons, is considered an area benefit activity. The service area must be primarily residential and meet the identified needs of low-and moderate-income persons. Examples include street improvements, water and sewer lines, neighborhood facilities, and facade improvements in neighborhood commercial districts.

b. Activities that benefit a specific group of persons where at least 51% of whom are low- and moderate-income persons meet qualifications for funding. Examples include the Construction of a senior center, public services for the homeless, meals on Wheels for the elderly, and the construction of job training facilities for severely disabled adults. Additional criteria for this type of benefit are as follows:

(1) The activity must benefit a clientele that is generally presumed to be principally low and moderate-income such as abused children, battered spouses, elderly persons, severely disabled adults, homeless persons, illiterate adults, or persons living with AIDS, and migrant farm workers; or

(2) Be a special project directed at the removal of material and architectural barriers that restrict mobility and accessibility of elderly or persons with disabilities to publicly and privately-owned non-residential buildings, facilities, improvements, and the common areas of residential structures containing more than one dwelling unit.

(3) Information must be required on family size and income to document that at least 51% of the clientele are persons whose family income does not exceed Section 8 low- and moderate-income limits.

(4) The activity must have income eligibility requirements which limit the activity exclusively to low- and moderate-income persons.

(5) The activities must be of such nature and in such location that it may be concluded that the activity’s clientele will primarily be low and moderate-income persons.

5. Activities which aid in the prevention or elimination of slums or blight:

a. An activity that aids in the prevention or elimination of slums or blight outside a slum or blighted area. Examples include the elimination of faulty wiring, falling plaster, or other similar conditions that are detrimental to all potential occupants, the historic preservation of a public facility, and the demolition of a vacant, deteriorated abandoned building. The activity must meet the following qualifying criteria:

(1) The activity must be designed to eliminate specific conditions of blight or physical decay on a spot basis.

(2) The activity must be limited to acquisition, clearance, relocation, historic preservation, and/or rehabilitation of buildings. Rehabilitation is limited to the extent necessary to eliminate specific conditions detrimental to public health and safety.

6. Activities designed to meet community development needs having a particular urgency.

Examples include major catastrophes or emergencies. The activity must meet the following qualifying criteria:

a. Pose a serious threat to the health or welfare of the community;

b. Are of recent origin or recently became urgent;

c. The grantee is unable to finance on its own; and

d. Other resources of funds are not available

7. Eligible Activities

The federal assistance provided in this program can be used for the support of community development activities, as seen in the Code of Federal Regulations, which are available for review in the Housing and Human Services Office and at: Housing and Urban Development's Community Development Block Grant Laws and Regulations.

HOUSING AND HUMAN SERVICES

SELF-DECLARATION OF ELIGIBILITY

June 1, 2025

To ensure that the program benefits households who meet the U.S. Department of Housing & Urban Development (HUD) eligibility requirements, please take a moment to complete the form below. This information is confidential and will only be used for the purpose of determining your family’s eligibility for the program. (LIST ONLY THOSE

RECEIVING SERVICES IN THE HOUSEHOLD)

PARTICIPANT NAME (S): ___________________________________________________

ADDRESS: ________________________________________________________________

STREET ADDRESS CITY ZIP

HUD 2025 AREA MEDIAN INCOME (AMI) LIMITS

PROGRAM

Step1: Circle the number of persons in your household. Step 2: Circle the income range to the right of the circled household size that describes your household’s annual gross income.

UP TO 30% AMI

(EXTREMELY

LOW)

UP TO 50% AMI

(VERY LOW)

UP TO 80% AMI

(LOW) INELIGIBLE

PERSON $0 to $21,000 $21,001 to $35,000 $35,001 to $55,950 Over $55,951

PERSON $0 to $24,000 $24,001 to $40,000 $40,001 to $63,950 Over $63,951

PERSON $0 to $27,000 $27,001 to $45,000 $45,001 to $71,950 Over $71,951

PERSON $0 to $29,950 $29,951 to $49,950 $49,951 to $79,900 Over $79,901

PERSON $0 to $32,350 $32,351 to $53,950 $53,951 to $86,300 Over $86,301

PERSON $0 to $34,750 $34,751 to $57,950 $57,951 to $92,700 Over $92,701

PERSON $0 to $37,150 $37,151 to $61,950 $61,951 to $99,100 Over $99,101

PERSON

$0 to $39,550 $39,551 to $65,950 $65,951 to $105,500 Over $105,501

*NOTE: Your household’s annual gross income is the total al ALL income received by ALL persons living in your home including employment, social security, SSI, SSD, unemployment WAGES, child support, alimony, retirement, investment income, etc.

The following information is needed for reporting purposes only:

Please indicate your race. (MUST CHECK ONE)

☐ White ☐ Black/African American ☐ Asian or Pacific Islander ☐ American Indian or Alaskan Native ☐ American Indian/Alaskan Native & White ☐ Asian & White ☐ Black African American & White ☐ American Indian/Alaskan Native & Black African American ☐ Native Hawaiian/Other Pacific Islander

Please indicate ethic group. (MUST CHECK ONE)

☐ Hispanic ☐ Non-Hispanic

Is this a female-headed household? (MUST CHECK ONE) Yes ☐ No ☐

I understand that under U.S.C. Title 18, Section 1001, any untruthful or deliberately misleading information given by me can result in a fine and/or imprisonment if found guilty.

PARTICIPANT SIGNATURE DATE

PARTICIPANT SIGNATURE DATE

PARTICIPANT SIGNATURE DATE

PARTICIPANT SIGNATURE DATE

BREVARD COUNTY BOARD OF COUNTY COMMISSIONERS

INDEMNIFICATION AND INSURANCE REQUIREMENTS

HOUSING AND HUMAN SERVICES DEPARTMENT

COMMUNITY DEVELOPMENT BLOCK GRANT PUBLIC SERVICES

RFA-5-25-11

INDEMNIFICATION

The County shall be held harmless against any and all claims for bodily injury, sickness, disease, death, personal injury, damage to property or loss of use of any property or assets resulting therefrom, arising out of or resulting from the performance of the products or from the services for which the County is contracting hereunder, provided such is caused in whole or in part by any negligent, reckless, or intentionally wrong act or omission of the Contractor, or any subcontractor or any of their agents or employees, or arises from a job-related injury.

The Contractor agrees to indemnify the County and pay the cost of the County’s legal defenses, including fees of attorneys as may be selected by the County, for all claims described in the hold harmless clause herein. Such payment on behalf of the County shall be in addition to any and all other legal remedies available to the County and shall not be considered to be the County’s exclusive remedy.

It is agreed by the parties hereto that specific consideration has been received by the Contractor under this Contract for this hold harmless/indemnification provision.

INSURANCE REQUIREMENTS

The Contractor providing services under this Contract will be required to procure and maintain, at their own expense and without cost to the County, until final acceptance by the County of all products or services covered by the purchase order or contract, the following types of insurance. The policy limits required are to be considered minimum amounts:

General Liability Insurance policy with a $1,000,000 combined single limit for each occurrence to include the following coverage:

Operations, Products and Completed Operations, Personal Injury, Contractual Liability covering this contract, “X-C-U” hazards, and Errors & Omissions.

Auto Liability Insurance which includes coverage for all owned, non-owned and rented vehicles with a $1,000,000 combined single limit for each occurrence.

Workers’ Compensation and Employers Liability Insurance Workers Compensation insurance providing statutory benefits as required in the State of Florida. The Contractor shall require any subcontractor to provide evidence of this coverage. Additionally, if the contract requires working on or around a navigable waterway, the Contractor and all subcontractors shall provide evidence of United States Longshoremen’s and Harbor Workers (USL&H) coverage and contingent coverage of Jones Act (Marine Employers Liability) in compliance with Federal statutes or proof of exemption. The Contractor shall be responsible for compliance with these requirements by each subcontractor or supplier when applicable.

In the event that the contract involves professional or consulting services, in addition to the aforementioned insurance requirements, the Contractor shall also be protected by a Professional Liability Insurance Policy in the amount of $2,000,000 per claim. If policy is written as claims made, coverage shall remain continuous four years post term of the contract.

In the event the contract involves services related to construction projects, the Contractor shall also procure and maintain a Builders Risk Insurance Policy or Installation Floater with loss limits equal to the value of the construction project.

In addition to the above, Specialty Insurance policies covering specific risks of loss (including but not limited to, for example;

Longshore coverage, Crane and Rigging, Inland Marine, etc.) may be required by Brevard County Insurance and Risk Management.

Any additional specialty insurance coverage requirement will be dictated by the specific goods, products or services provided under the subject contract and insurance underwriting standards, practices, procedures or products available in the commercial insurance market at the time of the contract inception. The Contractor is required to procure and maintain all such specialty coverage in accordance with prudent business practices within the Contractors industry.

The Contractor shall have five (5) days to provide certificates of insurance to the County demonstrating that the aforementioned insurance requirements have been met prior to the commencement of work under this contract. The certificate(s) of insurance (COI) shall indicate that the policies have been endorsed to cover the County as an additional insured (a waiver of subrogation in lieu of additional insured status on the workers compensation policy is acceptable) and that these policies may not be canceled or modified without thirty (30) days prior written notice to the County.

The insurance coverage enumerated above constitutes the minimum requirements and shall in no way lessen or limit the liability of the Contractor under the terms of the contract. Subcontractor’s insurance shall be the responsibility of the Contractor.

HOUSING AND HUMAN SERVICES DEPARTMENT

FY 2025-26 COMMUNITY DEVELOPMENT BLOCK GRANT PUBLIC SERVICES

RFA-5-25-11

DISCLOSURE FORM

FOREIGN INFLUENCE ON CONTRACTS OR GRANTS HAVING A VALUE OF $100,000 OR MORE

Summary of Form: In order for the County to comply with section 286.101, Florida Statutes, all prospective contractors and grant recipients seeking to contract with the County, or receive a grant from the County, where said contract or grant has a value of $100,000 or more must disclose to the County (1) any current or prior interest of, (2) any contract with, or (3) any grant or gift received from a foreign country of concern (defined as the People’s Republic of China, the Russian Federation, the Islamic Republic of Iran, the Democratic People’s Republic of Korea, the Republic of Cuba, the Venezuelan regime of Nicolas Maduro, and the Syrian Arab Republic, or an agency or other entity under the significant control of such foreign country of concern) if such interest, contract, or grant or gift has a value of $50,000 or more and such interest existed at any time or such contract or grant or gift was received or in force at any time during the previous five years. The disclosure is specified below. Within one year before applying for any grant or proposing any Contract, such entity must provide a copy of such disclosure to the Department of Financial Services. Disclosure is not required in certain circumstances, outlined below. A Contract is any agreement for the direct benefit or use of any party to such agreement, including an agreement for the sale of commodities or services. A Gift is any transfer of money or property from one entity to another without compensation. A Grant is a transfer of money for a specified purpose, including a conditional gift. An interest in an entity means any direct or indirect investment in or loan to the entity valued at 5 percent or more of the entity’s net worth or any form of direct or indirect control exerting similar or greater influence on the governance of the entity.

I. SECTION I. Please answer yes or no to each statement below:

YES I AM BIDDING ON A CONTRACT/APPLYING FOR A GRANT WITH A POTENTIAL VALUE

UNDER $100,000. If yes, this disclosure form as been completed. Please sign and date at the bottom.

OR

YES NO I AM BIDDING ON A CONTRACT/APPLYING FOR A GRANT WITH A POTENTIAL VALUE OF

OVER $100,000. If yes, proceed to the next question.

YES NO I HAVE MADE A FOREIGN INFLUENCE DISCLOSURE ONLINE WITH THE DEPARTMENT

OF FINANCIAL SERVICES. If yes, please proceed to SECTION IV and provide the date of the disclosure, your name and address. Then sign and date at the bottom.

II. SECTION II. Please answer yes or no to the statement below:

YES NO Bidder/Grantee has (1) a current or prior interest of, any contract with, or any grant or gift received from a foreign country of concern (defined as the People’s Republic of China, the Russian Federation, the Islamic Republic of Iran, the Democratic People’s Republic of Korea, the Republic of Cuba, the Venezuelan Regime of Nicolas Maduro, and the Syrian Arab Republic, or an agency or other entity under the significant control of such foreign country of concern); and (2) such interest, contract, or grant or gift has a value of $50,000 or more; and (3) such interest existed, or such contract or grant or gift was received or in force at any time during the previous five years.

III. SECTION III. If you answered NO to SECTION II, you have completed this form. Please sign/date at the bottom. If you answered YES to SECTION II, then answer YES or NO to the following:

NO

YES NO This is a proposal to sell commodities through an online procurement programs established pursuant to section 287.057(22), Florida Statutes.

YES NO This is a proposal from an entity that discloses foreign gifts or grants under section 1010.25 or section 286.101(2), Florida Statutes.

YES NO This is a proposal from a foreign source that, if granted or accepted, would be disclosed under section 286.101(2) or section 1010.25, Florida Statutes.

YES NO This is a proposal from a public or not-for-profit research institution with respect to research funded by any federal Agency.

IV. SECTION IV. If you answered YES to any question in SECTION III, you have completed this form. Please sign/date at the bottom. If you answered NO to all of the questions in SECTION III, then you must make the following disclosures online to the State of Florida Department of Financial Services before the County may contract with you or award you said grant. Please disclose the following:

Date Disclosure of the information below was made by Bidder/Grantee to the State of Florida Department of Financial Services online: ___________________________

Name of Bidder/Grantee:_______________________________________

Mailing Address of Bidder/Grantee: _______________________________

Value of the Contract/Grant or Gift: _______________________________

Foreign Country of Concern or the Agency or other entity under the significant

Control of such Foreign country of Concern: ________________________

Date of Termination of the contract or interest with the Foreign Country of Concern:

Date of Receipt of the Contract/Grant or Gift: _______________________

Name of the agent or controlled entity that is the source or interest holder: _____________

I verify that the information provided on this form is true and correct, and that I am duly authorized to make said binding disclosures on behalf of myself or my Company, as applicable.

Company Name___________________________________________________________

Signature: ____________________________ Date: __________________________

Title: ____________________________________________________________________

STATE OF FLORIDA

COUNTY OF __________________

Sworn to and subscribed before me by means of ☐ physical presence or ☐ online notarization, this _____ day of______________, ________, by (name of person making statement).

[Notary Seal] Notary Public

Name typed, printed or stamped

My Commission Expires: ___________

_______ Personally Known OR ________ Produced Identification

Type of Identification Produced ___________________________

FY 2025-26 COMMUNITY DEVELOPMENT BLOCK GRANT PUBLIC SERVICES

RFA-5-25-11

CONTRACTOR AFFIDAVIT REGARDING SCRUTINIZED COMPANY LIST

Awarded Contractor shall certify that it and its subcontractors are not on the Scrutinized Companies that Boycott Israel List. Pursuant to Section 287.135, F.S. If the Contract is for more than $1,000,000 the Contractor further certifies that it and its subcontractors are also not on the Scrutinized Companies with Activities in Sudan, Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or engaged with business operations in Cuba or Syria as identified in Section 287.135, F.S.

For Contracts of any amount, if the County determines the Contractor submitted a false certification under Section 287.135(5), F.S., or if the Contractor has been placed on the Scrutinized Companies that Boycott Israel List, or is engaged in a boycott of Israel, the County shall either terminate the Contract after it has given the Contractor notice and an opportunity to demonstrate the County’s determination of false certification was in error pursuant to Section 287.135(5)(a), F.S., or on a case-by-case basis the County may choose to maintain the Contract if the conditions of Section 287.135(4), F.S., are met. For Contracts $1,000,000 and greater, if the County determines the Contractor submitted a false certification under Section 287.135(5), F.S., or if the Contractor has been placed on the Scrutinized Companies with Activities in the Sudan List, or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, the County shall either terminate the Contract after it has given the Contractor notice and an opportunity to demonstrate the County’s determination of false certification was in error pursuant to Section 287.135(5)(a), F.S., or on a case-by-case basis the County may choose to maintain the Contract if the conditions of Section 287.135(4), F.S., are met.

STATE OF FLORIDA

COUNTY OF ________

BEFORE ME, the undersigned authority, personally appeared _________________, who, being by me first duly sworn, made the following statement:

1. The Business address of (name of contractor) is

2. My relationship to ______________________________________ (name of contractor) is

_______________________ (relationship such as sole proprietor, partner, president, vice president).

3. I understand that “Boycott of Israel” has the same meaning as defined in Section 215.4725, F.S., and means refusing to deal, terminating business activities, or taking other actions to limit commercial relations with Israel, or persons or entities doing business in Israel or in Israeli-controlled territories, in a discriminatory manner. A statement by a company that it is participating in a boycott of Israel, or that it has initiated a boycott in response to a request for a boycott of Israel or in compliance with, or in furtherance of, calls for a boycott of Israel, may be considered by the State Board of Administration to be evidence that a company is participating in a boycott of Israel. The term does not include restrictive trade practices or boycotts fostered or imposed by foreign countries against Israel.

4. I understand that “business operations” means, for purposes specifically related to Cuba or Syria, engaging in commerce in any form in Cuba or Syria, including, but not limited to, acquiring, developing, maintaining, owning, selling, possessing, leasing, or operating equipment, facilities, personnel, products, services, personal property, real property, military equipment, or any other apparatus of business or commerce.

5. __________________________ (name of contractor) is not on the Scrutinized Companies that Boycott Israel List, created pursuant to Section 215.4725, F.S., or is engaged in a boycott of Israel.

6. __________________________ (name of contractor) is not on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, created pursuant to Section 215.473, F.S.

7. __________________________ (name of contractor) is not engaged in business operations in Cuba or Syria.

Signature

Sworn to and subscribed before me in the state and county first mentioned above on the ___________ day of ____________________, 20____.

Notary Public

My commission expires: ______

(AFFIX SEAL or STAMP)

FY 2025-26 COMMUNITY DEVELOPMENT BLOCK GRANT PUBLIC SERVICES

RFA-5-25-11

CERTIFICATE OF CORPORATE OFFICER

STATE OF

COUNTY OF

I HEREBY CERTIFY that at a meeting of the Board of Directors of

, a corporation under the laws of the State of Florida, held on

______________, 20 , the following resolution was duly passed and adopted:

"RESOLVED, that , as of the corporation, is hereby authorized to execute the Contract dated to be determined between Brevard County, Florida, and this corporation, and that the execution…