Attachment G - Home Certification Form.pdf

Attachment G – Home Certification Form

ANNUAL HOME 20% CERTIFICATION

CONTRACTOR’S NAME: __________________________________________________________________________

CONTRACT/GRANT NUMBERS OF ALL HOME FUNDED PROJECTS:

The certification at the time of proposal submission is based on information at the time of proposal submission and assumes that HOME funds constitute (100%) of the total evaluated amount of the base period and assumes on award an award at the time of proposal submission. In addition, the offeror shall include all OTHER HOME funded projects in the calculation. If the amount of HOME funds crosses fiscal years, it is to be assumed that HOME funds will be allocated equally over a period of 12 months.

Actual for last fiscal year:

1. FOR FISCAL YEAR ENDING (Month, Day and

Year):

2. TOTAL HOME FUNDS AWARDED:

3. FIRM’S OPERATING BUDGET (revenue):

4. PERCENT OF HOME FUNDS IN OPERATING

BUDGET (item 2 divided by item 3):

Projected for current fiscal year:

1. FOR FISCAL YEAR ENDING (Month, Day and

Year):

2. TOTAL HOME FUNDS AWARDED:

3. FIRM’S OPERATING BUDGET (revenue):

4. PERCENT OF HOME FUNDS IN OPERATING

BUDGET (item 2 divided by item 3):

The firm’s operating budget is attached.

I hereby certify that the amount of HOME funds expended by this organization from all awarded HOME-funded contract, cooperative agreements, and grants did not exceed 20 percent of this organization’s revenue during the fiscal year.

Signature of Authorized Official

Title

Date