REDEVELOPMENT AUTHORITY

Fiscal Year 2021REQUEST FOR PROPOSAL APPLICATION (RFP) FOR

COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) FUNDS

Program/Activity: _____________________________________________________________

Due: Submit 1 signed original copy on white, 8.5” x 11” paper (collated and stapled) and send one copy electronically to cisaac@brocktonredevelopmentauthority.com. Packet must be received by 3:00 PM, Wednesday, March 31, 2021.

If you have any questions or need assistance, please contact the Brockton Redevelopment Authority at 508-586-3887 x 7.

Applications submitted after Wednesday, March 31, 2021 at 3:00 PM will not be considered for funding.

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For Office Use Only

Date Received: ____________________________

Received By: ______________________________

Contents

HUD Eligibility Checklist.................................................................................................................4

Application For Federal Community Development Block Grant Funds..........................................5

Estimated CDBG Project/Program Budget Summary Worksheet................................................15

Attacgment A: Internal Controls Checklist...................................................................................19

Attachment B: Statement Of Application.....................................................................................20

Attachment C: Conflict Of Interest Disclosure.............................................................................22

Attachment D: City Of Brockton, Massachusetts Tax Compliance Certification...........................23

Attachment E: City Of Brockton, Massachusetts Certificate Of Non-Collusion............................24

Attachment F: Signature Authorization Form..............................................................................25

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APPLICATION CHECKLIST MUST BE INCLUDED WITH RFP SUBMISSION

General Information (Item I, Page 4)

☐ Organizational Information Provided

Consolidated Plan Strategies (Item III, Pages 6-7)

☐ Goals of Program/Activity Determined (i.e., Housing, Homeless, etc.)

Proposal Outline (Item IV, Pages 8-10)

☐ Outline complete, including:

Executive Summary Needs Statement Description of Proposed Program or Project Goals and Objectives Methods of Accomplishing Goals and Objectives Organization Experience Management & Staff Experience Strategies for Building on Community Strength Program Evaluation Process Matching Funding Fiscal Management

Project/Activity Budget and Organization Budget (Item V, Pages 10-14)

☐ Completed

Performance Measures (Item VI, Page 15)

☐ Outcomes and Outputs answered

Special Needs Populations and Clientele Information (Items VII and VIII, Page 16)

☐ Outcomes and Outputs answered

Internal Controls Checklist (Page 17)

☐ Completed

Submitted by (Name/Title):

____________________________________________________________

Signature: _________________________________________ Date: ____________________________

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HUD ELIGIBILITY CHECKLIST

In order to determine compliance with all applicable HUD regulations and to help to ensure that projects will be eligible for CDBG funding, the BRA will need to address all HUD requirements. The purpose of this checklist is to point out areas where potential problems could arise. Please fill it out entirely indicating all items which are not applicable and include it as part of your proposal application.

A. General Subrecipient Information Yes No N/A1. Is your project eligible for CDBG funding? ☐ ☐ ☐2. Are previous CDBG projects complete to the degree required? ☐ ☐ ☐B. Applicant’s Background Yes No N/A1. Is the applicant a legal non-profit organization or unit of government? ☐ ☐ ☐2. Do the proposed clients or users of the project meet HUD Income

Guidelines (see page 7 from RFP Guidelines for CDBG Funds)?☐ ☐ ☐

3. Does applicant have the capability to maintain written income documentation?

☐ ☐ ☐

4. Has the applicant made a legal or financial commitment to a proposed project?

☐ ☐ ☐

5. Is the applicant primarily a religious organization? ☐ ☐ ☐6. Has the applicant administered a CDBG project previously? ☐ ☐ ☐7. Is your agency willing and able to provide all required reports and

accountability to the BRA as required by HUD☐ ☐ ☐

C. Project Location and Land Use Issues Yes No N/A1. Has a location for the project been selected? ☐ ☐ ☐2. Is the proposed project within the City’s limits? ☐ ☐ ☐3. Does the proposed project meet local zoning and land use laws? ☐ ☐ ☐4. Are any land use permits such as a Site Review required? ☐ ☐ ☐5. Have these approvals been obtained? ☐ ☐ ☐6. Does the project comply with current building code requirements? ☐ ☐ ☐7. Does the project meet handicapped accessibility requirements? ☐ ☐ ☐D. Environmental Issues Yes No N/A1. Is the project located in the 100-year floodplain? ☐ ☐ ☐2. Is a wetland located on the project site? ☐ ☐ ☐3. Has any environmental contamination been identified on the project site? ☐ ☐ ☐4. Has asbestos or lead paint been identified on the project site? ☐ ☐ ☐5. If project involves an existing structure, was it built 1978 or earlier? If year

built is known, please specify.☐ ☐ ☐

6. Is the proposed project located on a major arterial or near the railroad? ☐ ☐ ☐7. Is the proposed project located adjacent to an above ground flammable

storage tank?☐ ☐ ☐

8. Does the proposed project involve a structure that is 50 years or older? ☐ ☐ ☐E. Labor Requirements Yes No N/A1. Does the project involve construction over $2,000 in cost? ☐ ☐ ☐2. Will the project trigger Davis-Bacon wage requirements? ☐ ☐ ☐

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APPLICATION FOR FEDERAL COMMUNITY DEVELOPMENT BLOCK GRANT FUNDSBROCKTON, MASSACHUSETTS

(July 1, 2021 – June 30, 2022)

INSTRUCTIONS: This application contains the minimum amount of information necessary for proposal review. Additional information should be included as required to provide detail of funding requested. Use extra sheets, if needed. The Brockton Redevelopment Authority (BRA) may request more information from the applicants. No incomplete application will be considered for funding.

Applicants must be able to demonstrate ability to provide services as described, adhere to grant requirements, and meet a need of the Brockton community.

In accordance with Department of Housing & Urban Development (HUD) Regulations and Amendments to 24 CFR, Part 570, all activities to be funded utilizing Community Development Block Grant Funds must serve in excess of seventy percent (70%) low and moderate-income people and 100% for low and moderate benefits for activities carried out under the category of public services. Applications that are accepted for funding will be approved subject to submission of certified acceptable documentation relative to the HUD 70% Benefit Rule.

I. GENERAL INFORMATION

Organization Name: _______________________________________________________________

Project Name: _______________________________________________________________

Project Address:_______________________________________________________________

Organization Address: _______________________________________________________________

Org. Phone Number: _______________________________________________________________

Org. E-mail Address:_______________________________________________________________

Website (If Applicable):_______________________________________________________________

Social Media (If Applicable):_______________________________________________________________

Organization DUNS #:(format: nn-nnn-nnnn)

______________________

Tax ID or EIN(format: nn-nnnnnnn)

______________________

Contact Name & Title:____________________________(Name)

________________________________(Title)

Contact Phone Number:_______________________________________________________________

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Contact E-Mail Address:_______________________________________________________________

If you do not presently have a DUNS number, you will be required, if funded by HUD, to obtain one prior to contract execution.

II. BASIC ELIGIBLE ACTIVITIES

According to HUD regulations, the Community Development Block Grants (CDBG) primary objective is to improve communities by providing decent housing; a suitable living environment; and expanding economic opportunities “principally for persons of low- and moderate-income”. As a result, all projects/activities must include some method of documentation that CDBG funds used benefit persons of low to moderate-income.

Basic Eligible Activities are as follows: Acquisition, Public Facilities, Clearance Activities, Public Services, Interim Assistance, Removal of Architectural Barriers, Rehabilitation and Preservation Activities, Special Economic Development Activities, Microenterprise Assistance, Special Activities by Community Based Development Organization

Please contact BRA prior to completing the application if you are not sure that the proposed activity is eligible for CDBG funding.

Project Eligibility

The project requesting funding must meet at least ONE of the National Objectives of the CDBG Program listed below:

Benefits Low and Moderate-Income Individuals/Households Meets an Urgent Need

Must pose a serious and immediate threat to health and welfare of community, i.e., natural disaster.

Prevent or Eliminate Slum or Blight

*For National Objectives: All projects/activities should benefit low/mod income individuals or families of the City of Brockton ONLY. Brockton has no areas identified as “slums and blight” nor an

“urgent need”, as defined by HUD.

At least one of the objectives of your proposed request must achieve the following:

Enhance/Create Suitable Living Environment – In general, this objective relates to activities that are designed to benefit communities, families, or individuals by addressing issues in their living environment.

Create Decent Affordable Housing – The objective focuses on housing programs where the purpose of the program is to meet individual family or community needs and not programs where housing is an element of a larger effort (such as would be captured above under

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Suitable Living Environment). Creating Economic Opportunity – This objective applies to the types of activities related to

economic development, commercial revitalization, or job creation.

One of the following outcomes must be met by the proposed activity:

Availability/Accessibility – This outcome category applies to activities that make services infrastructure, housing, or shelter available or accessible to low and moderate-income people, including persons with disabilities. Accessibility does not refer only top physical barriers, but also making the affordable basics of daily living available and accessible to low- and moderate-income people.

Affordability – This category applies to activities that provide affordability in a variety of ways in the lives of low and moderate-income people. It can include the creation or maintenance of affordable housing, basic infrastructure hook-ups, or services such as transportation or day care.

Sustainability: Promoting Livable or Viable Communities – This outcome applies to projects where the activity or activities are aimed at improving communities or neighborhoods, helping to make them livable or viable by providing benefit to persons of low and moderate-income people or by removing or eliminating slums or blighted areas, through multiple activities or services that sustain communities or neighborhoods.

III. CONSOLIDATED PLAN STRATEGIES

The FY2018-2022 Consolidated Plan has been approved by HUD and the following strategies are part of that plan. Of the strategies listed, please indicate which goals your project will meet for FY2021 (check all goals that apply within your project’s applicable strategy):

A. Housing Strategies

☐ Use HOME and/or CDBG funds to maintain, support and preserve the existing housing stock prevent housing deterioration and vacancies.

☐ Use HOME and/or CDBG funds to underwrite the acquisition and/or rehabilitation of a property to create or preserve affordable housing.

B. Homeless Strategies

☐ Increase the stock of permanent supportive housing to reduce homelessness among individuals and families.

☐ Provide emergency and transitional shelter for homeless individuals and families.☐ Provide outreach and supportive services to homeless individuals and families.

C. Strategies to Help Persons with Special Needs

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☐ Provide the elderly with transportation and services that enable them to live independently and actively in the community.

D. Community Development Strategies

☐ Removal of Architectural Barrier Needs: Continue to bring public facilities into conformance with the Americans with Disabilities Act (ADA) and make other improvements to provide access to low- and moderate-income persons.

☐ Infrastructure Improvement Needs: Continue to improve public infrastructure in eligible areas through streetscape improvements and ADA improvements.

☐ Public Facility Needs: Construct improvements to eligible park and recreation facilities to improve the quality of life for low- and moderate-income residents.

☐ Public Service Needs: Improve and expand social service facilities and services to meet the needs of the community.

☐ Provide the elderly with social services and transportation to enable them to remain living independently and staying active in their community.

☐ Economic Development Needs: Explore ways to effectively assist businesses in Brockton and fund commercial area improvements to assist in the success of Microenterprises and other businesses in eligible areas.

Check appropriate box below. The proposed project involves:

☐ New Construction - Must be for a new unfunded activity only and must have a 100% benefit to low-income people.

☐ Rehabilitation or building alteration (must be to a municipal or a non-profit owned structure). Must be for a new or a greatly expanded on-going activity.

☐ Funding of social service program's operating expenses☐ Funding of economic development activity that will directly affect in excess of 70% low

and moderate-income people. Certified documentation on how this will be attained must be submitted by the applicant.

☐ Other:_____________________________________________________________________________________________________________________________________________

☐ If project is a new or greatly expanded activity, provide additional information, exhibits, and funding source(s).

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IV. PROPOSAL APPLICATION OUTLINE

Please submit an outline for your project covering the below information. Please be as descriptive as possible:

1. Executive SummaryClearly and concisely summarize your request for funding by explaining who will be served, how many will be served, what program is proposed, and the total amount of CDBG funds requested to operate this program.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Needs StatementDiscuss the problem or need your project is designed to address. Provide sufficient data to document the needs to be met or the problem(s) to be addressed by the program. Please cite the sources of the information used.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Description of Proposed Program Project and Target Audiencea. Describe the elements of your proposed program or project, including information on a

target population, numbers of people to be assisted, special features, level of staffing, and where services will be delivered and how. Identify the service area by boundary or perimeter streets.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b. Will this project directly benefit in excess of 70% low and moderate-income people? Explain briefly. If the project will not benefit in excess of 70% low and moderate-income people, what is the percentage?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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4. Goals and Objectives & Methods of Accomplishmenta. List and describe the goals and objectives of the proposed project. Make sure that

objectives are stated in measurable terms.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b. Describe the activities you will use to achieve the stated goals and objectives. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Strategies for Building on Community StrengthsHow do you intend to build on the strengths of the institutions, agencies within the City and/or your agency in administering your program or project with limited funding?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Program Evaluation ProcessExplain how you will evaluate the results of your project. Will this occur monthly or quarterly? How will you determine that you have accomplished the project’s goals and objectives? Please describe your method for obtaining this information from all clients served by your CDBG funded project or program.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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____________________________________________________________________________________________________________

7. Matching FundingDescribe additional funding you have in place or anticipate applying for. Provide a list of names or organizations along with exhibit copies of letters of requests and refusals. Provide documentation of public and or private agencies that are committed to provide funding for your proposed program during fiscal year 2021. Include agency name, address, contact person, telephone number and email address. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Fiscal ManagementCDBG funds are paid-out to grant recipients on a reimbursement basis. Please describe your agency’s financial capacity to operate the project on a reimbursement basis. Describe accounting procedures to ensure accurate financial reporting and fiscal control. These processes are subject to review during monitoring which will be done each fiscal year funded in some capacity.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. Schedule of Project ActivitiesIdentify all the primary tasks that will be completed as a timeline during the fiscal year as part of

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your program. This information will form the basis for determining how well your project is planned. It will also be used as an important monitoring tool if a grant is awarded for your project. Add as many activities as needed to achieve each goal.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

V. PROJECT/ACTIVITY FUNDING REQUEST AND BUDGET

1. CDBG Funds Requested: $ ___________________________Total funding anticipated to be leveraged from other sources: $ _________________________

Please use the Budget Summary Worksheet for a more specific breakdown.

NOTE: Under no circumstance may costs incurred prior to an award of CDBG funds be eligible for reimbursement through this grant program.

2. For a program to be funded for consecutive fiscal years, the program must be an expansion of the year before. This means it could be new clients from the prior year, or a new program. Please indicate below which best applies to the proposed project/activity:☐ New Program☐ Expansion of Existing Program. Description of such expansion:

_______________________________________________________________________

☐ Support of Existing Program (with no expansion). What type of support?_______________________________________________________________________ _______________________________________________________________________

☐ New “support” program_______________________________________________________________________ _______________________________________________________________________

☐ Existing “support” program (with no expansion)

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☐ Other (Explain)_______________________________________________________________________ _______________________________________________________________________

3. What is the total cost of the proposed project/activity? ☐ Attach a copy of your organization’s budget for proposed activity. Provide estimates

obtained for project costs to substantiate request for funding.a. For public services: Use Program Budget Form to provide a budget summary for the proposed

project/service. Use it to estimate all costs directly related to the proposed project or services. If approved, you may be required to further itemize costs.

b. For rehabilitation/construction projects/activities: attach a budget with sources and uses for the project. Your proposal must include copies of contractor and/or architect/engineer estimates. If you have applied for funding from any other source(s) for this project include any letter(s) of commitment for ongoing funds or approved funds from other source(s) to assist with the proposed project/services that you are requesting. Should the budgeted funds not be sufficient to carry out the approved requested improvements, the BRA will either reduce the scope of the requested improvements, request the applicant to provide matching funds in an amount sufficient to carry out the improvements or reject the project activity due to lack of funding.

NOTE: All rehabilitation and/or alterations must be carried out as determined by the Secretary of Labor in accordance with the Davis-Bacon Act, as amended, (40 USC.276a - 276a-5)

4. What is/are the current source(s) of funding for the project/service? What are your organization’s major source(s) of revenue to operate programs?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Has the organization attempted to coordinate the project/service with other agencies to avoid duplication of services? If yes, please explain._________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Please list names and addresses (to the best of your knowledge) of other agencies in the City of Brockton (including non-profit and government) that are performing the same or similar

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activity or program as contained in your CDBG funding request. How do the programs differ? How do they overlap? Is there collaboration with other agencies? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. As a prerequisite for possible funding, all agencies or non-profit groups applying for Community Development Block Grant Funds MUST SUBMIT, with their application(s), their latest copy of a certified Audit on the expenditure of Federal, State, City or private funds in carrying out their program activities. The Brockton Redevelopment Authority will utilize the Audit to not only review the qualifications of the applicant, but to also project as to whether Federal CDBG Funds will be used for a new or greatly expanded activity. The audit should also specifically outline the cost of each activity being carried out under the applicant's program.

NOTE: Applications submitted without a copy of the latest certified audit will not be reviewed by the Brockton Redevelopment Authority for possible funding. A list of all funding sources along with amounts received must also be submitted with the audit.

ESTIMATED CDBG PROJECT/PROGRAM BUDGET SUMMARY WORKSHEET

Budget Category CDBG Funding Request Other Funding Total Project Budget(should match the requested

amount)(should complete amounts

needed for project to operate)

Salary & Wages $ _______________ $ _____________

__ $ _______________

Fringe Benefits $ _______________ $ _____________

__ $ _______________

Consultant/Contract Services $ _____________

__ $ _______________ $ _____________

__

TOTAL PERSONNEL BUDGET

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Office Rent $ _______________ $ _____________

__ $ _______________

Utilities $ _______________ $ _____________

__ $ _______________

Telephone $ _______________ $ _____________

__ $ _______________

Office Supplies $ _______________ $ _____________

__ $ _______________

Equipment $ _______________ $ _____________

__ $ _______________

Printing $ _______________ $ _____________

__ $ _______________

Travel/Conference $ _______________ $ _____________

__ $ _______________

Police Detail $ _______________ $ _____________

__ $ _______________

Liability Insurance $ _______________ $ _____________

__ $ _______________

Other (specify) $ _______________ $ _____________

__ $ _______________

TOTAL NON-PERSONNEL BUDGET $ _____________

__ $ _______________ $ _____________

__

TOTAL PROJECT BUDGET $ _______________ $ _____________

__ $ _______________

*Please revise this form and annotate budget items as needed.

TOTAL PROGRAM BUDGET

Budgeted Projected Budget(FY 2020) (FY 2021)

Private Sector $ _______________ $ _______________

Contributions - General $ _______________ $ _______________

Special Events $ _______________ $ _______________

Bequests $ _______________ $ _______________

Endowments $ _______________ $ _______________

Associated Organizations $ _______________ $ _______________

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Allocations from United Way Agencies $ _______________ $ _______________

Membership Dues-Local Member Unit $ _______________ $ _______________

Program Service Fees $ _______________ $ _______________

Sale of Supplies/Services to Local Unit $ _______________ $ _______________

Sales to the Public $ _______________ $ _______________

Investment Income $ _______________ $ _______________

Miscellaneous Revenue $ _______________ $ _______________

TOTAL PRIVATE SECTOR $ _______________ $ _______________

Public Sector $ _______________ $ _______________

Federal $ _______________ $ _______________

State $ _______________ $ _______________

County $ _______________ $ _______________

Municipal $ _______________ $ _______________

Other $ _______________ $ _______________

TOTAL PUBLIC SECTOR $ _______________ $ _______________

TOTAL REVENUE $ _______________ $ _______________

*Do not include FY 2021 CDBG Request for Funding. Only other federal grants anticipated or secured.

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VI. PERFORMANCE AND OUTCOME MEASURES

The US Department of Housing and Urban Development (HUD) requires entitlement grantees to implement a performance measure system that gathers information to determine how the programs and projects are meeting local needs. Based on the intent when funding a project, the grantee should determine under which of three objectives listed below to report the outcomes of their projects and activities. Once the objective is chosen, the grantee should choose which of the three outcome categories, also listed, best reflects what the project is seeking to achieve (the results) in funding a particular activity. While maintaining the flexibility of the CDBG programs by allowing grantees to determine program objectives based on the intent of the project/activity, the system also offers a specific menu of objectives and outcomes so that reporting can be standardized, and the achievements of these programs can be aggregated to the national, state and local level.

HUD requires that all recipients of federal funds accept productivity and the impact of their programs. The following questions address your program operations and accountability:

MEASURESESTIMATED

COMPLETION

OUTPUTS

(Outputs are the direct product of the program’s activity, they are quantifiable goals, typically measured in terms of the volume of work accomplished, i.e., number of low-income households)

1. ______________________________________

______________

2. ______________________________________

______________

3. ______________________________________

______________

OUTCOMES

(Outcomes describe the intended effect or impact of the program’s activity described in the objectives and they should be put into the timeframe of the grant; answer “Why am I undertaking this activity?”)

1. _______________________________________________________

2. _______________________________________________________

3. _______________________________________________________

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VII. SPECIAL NEEDS POPULATIONS

Please identify any special needs populations (see list below) that your project will serve if known. More than one group may be identified.

Special Needs Populations Number/Estimate Only

Persons who are homeless

Persons with physical disabilities

Persons with mental disabilities

Elderly persons (62 or older)

At-risk children and/or youth, type of risk:

Other (specify):

VIII. CLIENTELE INFORMATION

How many persons in total will benefit from the proposed project?

What percentage of all funds will benefit low- and moderate-income City residents?

When did your agency begin to provide this service?

How many unduplicated clients did your agency serve last year?

Of the total unduplicated clients, what percentage were new clients?

What percentage of the total unduplicated clients are residents of the City of Brockton?

In the given funding request, what number of clients does your agency expect to serve that are of low and moderate income? Must be over 51% of program overall total served.

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ATTACHMENT A:INTERNAL CONTROLS CHECKLIST

In order for your application to be accepted, you must submit the following items to the Brockton Redevelopment Authority no later than 3:00PM on Wednesday, March 31, 2021.

☐ A completed RFP application sent as a PDF to cisaac@brocktonredevelopmentauthority.com with all questions completed (including performance evaluation criteria and budgets).

☐ All attachments required and supporting documents such as the articles of incorporation and the current list of your Board of Directors, and certifications must be sent with the completed RFP application to the cisaac@brocktonredevelopmentauthority.com email address at the same time as the completed RFP application.)

☐ Articles of Incorporation☐ Current List of Board of Directors☐ Certified Organization Audit/Financial Statements of most recent year

a. Copy of 2 CFR Part 200, Subpart F Audit (Required if $750,000 in aggregate Federal funds expended), or

b. Financial statements audited by a CPA (only if not qualified for 2 CFR Part 200, Subpart F), or

c. Profit and Loss Statement for most recently completed fiscal year and General Ledger printout (only first-time applicants or those who do not meet above criteria may submit)

☐ IRS 501(c)(3) Designation Letter (Pending letters will not be accepted)☐ Evidence of current filing of IRS 990☐ Current Fiscal Year Agency Budget, including all funding sources☐ Job Descriptions☐ DUNS Number☐ A completed Conflict of Interest Form☐ A completed Certificate of Payment of State Taxes Form ☐ A completed Certificate of Non-Collusion Form

☐ An Executed Internal Controls Checklist Form.☐ An Executed Statement of Applicant Form.☐ An Executed Signature Authorization Form.☐ Has the Signature Authorization Form been signed by an authorized officer of the Board?

(President or Secretary) as registered with the Secretary of Commonwealth, Corporations Division. (http://corp.sec.state.ma.us/corpweb/CorpSearch/CorpSearch.aspx)

I hereby confirm that this packet contains all materials required.

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Signature of Authorized Signer Printed Name

ATTACHMENT BSTATEMENT OF APPLICATION

The undersigned acknowledges the following:

1. That, to the best of its knowledge and belief, all factual information provided is true and correct and all estimates are reasonable.

2. That no revised proposals/applications may be made in connection with this application once the deadline for applications has passed.

3. That the City of Brockton may request or require changes in the information submitted, and may substitute its own figures, which it deems reasonable for any or all figures provided. That the applicant will participate in required interview for project assessment and cooperatively assist in the review process.

4. That, if the project(s) is recommended and approved by the Mayor and City Council, the city reserves the right to reduce and/or cancel the allocation if federal entitlements are cancelled, reduced, or rescinded.

5. The City of Brockton reserves the right not to fund any submittals received.

6. By submission of this application, the organization agrees to abide by the federal regulations applicable to this program.

7. That, if the project(s) is funded, the organization agrees to abide by the city’s locally established policies and guidelines.

8. That past program and financial performance will be considered in reviewing this application.

9. That services are to be provided at no cost to citizens during the grant period. All program income (i.e. fees, repayments, foreclosures, etc.) must be remitted to the city.

10. That, if the project(s) is funded, the city or a designated agency may conduct an accounting system inspection to review internal controls, including procurement and uniform administrative procedures, prior to issuance of payments for projected expenditures.

11. That, if project(s) is funded, the city will perform an environmental review prior to the obligation of funds.

12. That, if a project is funded, a written agreement that includes a statement of work, records retention and reporting, program income procedures, local and federal requirements, circumstances that would trigger grant suspensions and terminations, and reversions of assets would be required between the organization and the city.

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Statement of Applicant continued on following page.

13. That, if the project(s) is funded, the agency shall be required to provide a Certificate of Liability Insurance with the City of Brockton as additionally insured. Also, the agency shall provide evidence of Workers Compensation and Employee Liability insurance.

14. That a project’s funding does not guarantee its continuation in subsequent action plans.

15. Provide written signatory authority from the organization’s governing body indicating who can execute contracts and amendments on its behalf.

16. Agrees to abide by the City of Brockton’s Conflict of Interest policy. Items of concern would include staff members serving on the Board of Directors, staff members’ families serving on the Board of Directors, and other matters that may give the appearance of a conflict of interest.

PENALTY FOR FALSE OR FRAUDULENT STATEMENT

U.S. Code Title 18, Section 1001, provides that a fine of up to $10,000 or imprisonment for a period not to exceed five years, or both, shall be the penalty for willful misrepresentation and the making of false, fictitious statements, knowing same to be false.

By signature below, the applicant acknowledges the above in its name on this __ day of ___________ , 2021.

Name of Organization By: __________________________________ Signature of Authorized Signer

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ATTACHMENT CCONFLICT OF INTEREST DISCLOSURE

The standards in 2 CFR Part 200.112, provide that no employee, officer, or agent shall participate in the selection, award, or administration of a contract supported by Federal funds if a real or apparent conflict of interest would be involved. Such a conflict would arise when an employee, officer, or agent, any member of his or her immediate family, his or her partner, or an organization which employs or is about to employ any of the parties indicated herein, has a financial or other interest in the firm selected for an award. The CDBG regulations at 24 CFR 570.611 and HOME regulations at 24 CFR 92.356 provide that no person who is an employee, agent, consultant, officer, or elected official or appointed official of the recipient or subrecipient that are receiving CDBG or HOME funds and (1) who exercises or has exercised any functions or responsibilities with respect to activities assisted with CDBG funds; or (2) who is in a position to participate in a decision making process or gain inside information with regard to these activities, may obtain a financial interest from a CDBG-assisted or HOME-assisted activity, or have any interest in any contract, subcontract, or agreement with respect thereto, or the proceeds thereunder, either for themselves or those with whom they have family or business ties, during their tenure or for one (1) year thereafter. A disclosure of the nature of any perceived or actual conflict must be made prior to the execution of agreements utilizing CDBG or HOME. IF NO CONFLICT EXISTS, COMPLETE THE FOLLOWING:

☐ I certify that no conflict of interest exists between the City of Brockton and (name of organization).

☐ I certify that no conflict of interest exists between the subcontractors of and (name of organization).

IF A POTENTIAL CONFLICT EXISTS, COMPLETE THE FOLLOWING:

☐ I certify that a potential conflict of interest may exist between the City of Brockton and (name of organization) _____________________.

☐ I certify that a potential conflict of interest may exist between (name of subcontractor) _____________________ and (name of organization) _____________________.

Describe the nature of the conflict of interest below. Identify the individual, employment and the conflict or potential conflict, and their affiliation with your organization. _________________________________________________________________________________. _________________________________________ _______________________________________Signature of Authorized Signer Date

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_________________________________________Typed Name, Title

ATTACHMENT DCITY OF BROCKTON, MASSACHUSETTS TAX COMPLIANCE CERTIFICATION

Pursuant to M.G.L. c. 62C, 49A, I/we certify under the penalties of perjury that, to the best of my knowledge and belief, I/we are in compliance with all laws of the Commonwealth relating to taxes, reporting of employees and contractors, and withholding and remitting child support.

Federal Identification Number or SS# _____________________

Date _____________________

Name of Business/Organization _____________________

Street Address _____________________

City, State, Zip Code _____________________

Name of Company Officer (Printed) _____________________

_____________________________________________Signature of Authorized Signer

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ATTACHMENT ECITY OF BROCKTON, MASSACHUSETTS CERTIFICATE OF NON-COLLUSION

The undersigned certifies under penalties of perjury that this bid or proposal has been made and submitted in good faith and without collusion or fraud with any other person. As used in this certification, the word “person” shall mean any natural person, business, partnership, corporation, union, committee, club, or other organization, entity or group of individuals.

Date _____________________

Name of Business/Organization _____________________

Street Address _____________________

City, State, Zip Code _____________________

Name of Company Officer (Printed) _____________________

_____________________________________________Signature of Authorized Signer

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ATTACHMENT F SIGNATURE AUTHORIZATION FORM

The Board of Directors of _________________ does hereby resolve that on the ___ day of _________, 2021, the Board reviewed the Application for Community Development Block Grant Funds to be submitted to the City of Brockton Office of Housing and Community Development for funding consideration for the fiscal year 2021 and in a proper motion and vote approved this application for submission.

The Board further certifies that the organization making this application has complied with all applicable laws and regulations pertaining to the application and is a non-profit organization, tax-exempt and incorporated in the State of Massachusetts.

___________________________________ (Name of organization requesting CDBG funds) hereby proposes to provide the services or project identified in the Scope of Services in accordance with this application for Community Development Block Grant Funds. If this application is approved and this organization receives CDBG funding from the City of Brockton, this organization agrees to adhere to all relevant Federal, State and local regulations and other assurances as required by the city. Furthermore, as the duly authorized representative of the organization, I certify that the organization is fully capable of fulfilling its obligation under this application as stated herein.

I further certify that this application and the information contained herein are true, correct and complete.

I also authorize the following person(s) to act as the Authorized Signer to this grant:

__________________________________ __________________________________Name Title__________________________________ __________________________________Name Title

_____________________________________________________________________________________

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Clerk/Secretary/Treasurer of Board (or other Designated Authority)

__________________________________ __________________________________Name Title

__________________________________ __________________________________Signature Date

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PENALTY FOR FALSE OR FRAUDULENT STATEMENT

U.S. Code Title 18, Section 1001, provides that a fine of up to $10,000 or imprisonment for a period not to exceed five years, or both, shall be the penalty for willful misrepresentation and the making of false, fictitious statements, knowing same to be false.