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Applicant Certification

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					                              Applicant Certification
Agency
Name:

Address:             __________________________________________________________
                     Denver, Colorado 80______

Telephone            (________) _________________________
Number:
Facsimile
Number:              ( _______) _________________________


Application          Name:   _______________________      Telephone:___________________
contact person:      Email Address:




Federal Tax
Identification
Number:
Amount               Total Amount Requested:
Requested:




I certify that I have read the terms of this Request for Application and understand
application and contracting procedures. If awarded, I agree to provide services and
documentation as specified in the application or as negotiated prior to final contact
approval.

__________________________________________               _______________________________
Signature of an Official Authorized to bind this offer   Title         Date

__________________________________________               ________________________________

Print Name of Authorized Official                               Print Title
                                                                                                  Attachment 2

Denver Department of Human Services
    Application to Provide Services for the 2009-2010 Community Services Block Grant Program
                                            Application Checklist
Your application will not be considered complete unless all of the documents are included. Please make
certain that you include all of the following:
____ Applicant Certification
____ Application Checklist
____ Application Narrative (Scope of Work)
____ Application HPRP Budget with narrative
____ Non-Discrimination Statement and Policy
____ One CD with a copy of your Application and ROMA in MS Word and budget in MS Excel
____ One original plus six (6) Copies of Application (no facsimiles (FAX) will be accepted)

Two (2) Copies of the following materials must be attached to the “original” application
(DO NOT PROVIDE 6 COPIES)
____ Proposer Disclosure Form
____ Certification Regarding Debarment, Suspension
____Copy Of IRS 501 (C) (3), Certification Of Good Standing With Colorado Secretary Of State

Please place an X next to the item requested above to indicate that it is included in your submission. This
sheet must accompany your application. You are advised to review your materials to ensure it is
comprehensive before you submit it.

I have reviewed this application and have included all the required information:



Print Name of Person completing Application

Signature of Person completing Application            Title                                Date



Print Name of Agency or Corporation Executive

Signature of Agency or Corporation Executive          Title
                                                                              ATTACHMENT 3
                           APPLICATION FOR
                HOUSING PREVENTION & RAPID RE-HOUSING

Applicants for the Homeless Prevention and Rapid Re-Housing Program must identify
whether they are applying as the Lead Agency or as a Supporting Agency.

The Denver Department of Human Services will select a Lead Agency for this grant. The
Lead Agency will be the Contractor for this grant and oversee and coordinate the
Homeless Prevention services that stabilize individuals and families that are at-risk of
becoming homeless; and the Rapid Re-Housing services that offer housing assistance to
individuals and families currently homeless. The Contractor will submit, with this
Application, Memorandum of Understanding (MOU) with each Supporting Agency. The
MOU’s should identify the HPRP functions and services of the Supporting Agency. The
Contractor is also responsible for compliance with the financial and programmatic
requirements of the Homeless Prevention and Rapid Re-Housing program and the data
collection and reporting. A Letter of Intent can be submitted if an MOU has not been
executed.

The Contractor will also be responsible for the overall management of the contract,
including executing subcontracts with Supporting Agency and for HPRP training,
compliance, Homeless Management Information System and the drawdown and
distribution of funding to subcontractors. Please identify the Lead Agency.


LEAD AGENCY (________________________________________________________)
                      Name of Contractor

PRINCIPAL CONTRACT PERSON (________________________________________)
                                      Name of Person

The Lead Agency must utilize an inclusive process that brings together partners from
state and local government agencies, housing authorities, non-profit homeless providers.
The Homeless Prevention and Rapid Re-Housing program is designed to provide
temporary financial assistance and housing relocation and stabilization services to
individuals and families who are homeless or would be homeless but for this assistance.
Lead Agency will be responsible for assessing each individual or family to make this
determination. The Lead Agency would also administer the “At-Risk Assessment” to
determine the level and need for receiving HPRP assistance or other support and
resources.

After completing the At-Risk Assessment the Lead Agency would be responsible to
identify the appropriate referral to a Supporting Agency, the subcontractor for financial
assistance or housing relocation and stabilization.
The Supporting Agency would provide preventive services, housing, supportive service
or case management. Below, please identify each of the Supportive Agencies. MOU’s or
Letters of Intent must be submitted for each of these Agencies with this Application.

Services proposed by the applicant to be subcontracted must be pre-approved by
DHS in advance. All subcontractors selected to provide services must also receive
prior approval by DHS in advance.

SUPPORTING AGENCY (________________________________________________)
                                 Name of Subcontractor


SUPPORTING AGENCY (________________________________________________)
                                 Name of Subcontractor


SUPPORTING AGENCY (________________________________________________)
                                 Name of Subcontractor


SUPPORTING AGENCY (________________________________________________)
                                 Name of Subcontractor



SUPPORTING AGENCY (________________________________________________)
                                 Name of Subcontractor



SUPPORTING AGENCY (________________________________________________)
                                 Name of Subcontractor



SUPPORTING AGENCY (________________________________________________)
                                 Name of Subcontractor


SUPPORTING AGENCY (________________________________________________)
                                 Name of Subcontractor
                                                                         Attachment 4
HUD has approved the following budget for Denver Department of Human Services and
the HPRP program. Please complete the attached budget that equals the Total Amount
Budgeted, $3,400,796. The budget line items should be used for guidance in completing
the itemized budget below. The Department of Human Services is retaining funding for
HPRP administrative and program responsibilities. Also complete the estimated number
of households served through your proposed HPRP program.

HPRP Estimated Budget Summary
                                     Homelessness         Rapid Re-         Total Amount
                                      Prevention           housing            Budgeted
Financial Assistance1                     $1,014,238         $1,521,358          $2,535,596
Housing Relocation and                      $266,080           $399,120            $665,200
Stabilization Services2
Data Collection and                                                                $200,000
Evaluation3
TOTAL                                    $1,280,318           $1,920,478           $3,400,796
1
  Financial assistance includes the following activities: short-term rental assistance,
  medium-term rental assistance, security deposits, utility deposits, utility payments,
  moving cost assistance, and motel or hotel vouchers.
2
    Housing relocation and stabilization services include the following activities: case
    management, outreach, housing search and placement, legal services, mediation, and
    credit repair.
3
    Data collection and evaluation includes costs associated with operating HUD-approved
    homeless management information systems for purposes of collecting unduplicated
    counts of homeless persons and analyzing patterns of use of HPRP funds.

On a separate page, please use this budget format for reporting a total program
budget and costs associated to specific supporting agencies. Include a budget
narrative that gives a detailed description of each budgeted category and the
breakdown for each described cost.

HPRP Budget Summary
                                                               Rapid         # of
                                       # of households                                     Budget
                            Prevention                          Re-       households
                                            served                                         Totals
                                                              Housing       served
Financial Assistance
Housing Relocation/
Stabilization Services
Data Collection and
Evaluation
TOTAL


                                                                          ATTACHMENT 5


INSTRUCTIONS FOR COMPLETING
        BIDDER/CONTRACTOR/VENDOR/PROPOSER DISCLOSURE


It is the responsibility of every non-governmental organization wishing to do
business with Denver Human Services to complete the attached Disclosure form.

In order to ensure consistent and uniform use of the form, each
bidder/contractor/vendor/ proposer should do the following regardless of whether
the organization is a for-profit or not-for-profit entity:

   1. Complete the first six (6) blank lines at the top of the form with the
      requested information.

   2. List the names of every Officer, Director, Principal, Owner, and/or
      Controller of 5% or more of the stock in the entity. In the case of not-for-
      profit entities, all officers and directors must be listed. In the first column
      of parenthetic boxes use the alpha coding for each name listed per the
      instructions given on the form so that each individual’s role in the
      organization is indicated.

   3. List the names of any spouse and/or children under the age of 18 years
      who have made a political contribution during the past five (5) years. Any
      spouses and/or children under the age of 18 years that have not made
      any political contributions need not be listed. Any names listed should
      reflect the appropriate alpha coding in the second column of parenthetic
      boxes to identify the relationships of each individual.

   4. Mark an asterisk to the left of each name for each individual who has
      made a political contribution during the past five (5) years. It is not
      necessary to disclose how much or to whom any contribution was made.

   5. Sign the line at the very bottom of the form to certify that the information
      listed is true and accurate as of the date entered at the top of the page.

   6. If more than sixteen (16) names need to be entered use additional copies
      of the form and, in any case, be sure to manually enter page numbers at
      the top right of each sheet. If you are only submitting a single sheet then
      you should enter “p. 1 of 1 submitted”.
                                                                                                ATTACHMENT 5
BIDDER/CONTRACTOR/VENDOR/PROPOSER DISCLOSURE

Bidding Entity's/Proposer's Name                                 Date this form was completed

                                                                  (     )
Address                                                          Telephone Number


City, State, Zip Code                                            Signature of Officer/Owner


Section 20-69, D.R.M.C. requires the disclosure of the name of each officer, director, shareholder who owns
or controls 5% or more of the business entity, principal, and owner of each bidding or proposing entity, and
either the names of the spouses of those individuals and the names of their children under the age of
eighteen (18), or a statement in lieu of the disclosure of the names of such spouses and children as set forth
below in the "Certified Statement in Lieu of Disclosure". The names of officers, directors, 5%
shareholders, principals and owners must be disclosed in either event. Required disclosures also
include the names of any subcontractor/supplier receiving more than $100,000.00 of work and the names of
any unions with which the bidder/proposer has a collective bargaining agreement. Not-for-profit entities are
also required to identify individuals in executive positions and disclose their relationship within such entity.

This page may be photocopied if additional space is required.

The individuals listed below are disclosed as having the noted relationship with the business
entity/proposer
listed above. Show appropriate letter in the box to the left. Use center box for relationship to
another line
number: A=Officer, B=Director, C=Principal, D=Owner, E=Controller of 5% or more of the stock,
F=Spouse, G=Child under age 18, H=Subcontractor, I=Supplier, J=Union. Identify with an
asterisk (*) all
listed persons who have made a contribution or contribution in-kind, as defined by Section 15-32
D.R.M.C.,
within the last five years.

1. [   ][   ]                                                   9. [   ][   ]
2. [   ][   ] ______________________                           10. [   ][   ]
3. [   ][   ] ______________________                           11. [   ][   ]
4. [   ][   ] ______________________                           12. [   ][   ]
5. [   ][   ] ______________________                           13. [   ][   ]
6. [   ][   ] ______________________                           14. [   ][   ]
7. [   ][   ] ______________________                           15. [   ][   ]
8. [   ][   ] ______________________                           16. [   ][   ]

BIDDER/CONTRACTOR/VENDOR/PROPOSER CERTIFIED STATEMENT IN LIEU OF
DISCLOSURE

I hereby certify that, except as identified by an asterisk above, no officer, director, shareholder
who owns or
controls 5% or more of the business entity, principal, or owner or his or her spouse or child under
eighteen
years of age has made a contribution, as defined at Section 15-32 D.R.M.C., or a contribution in
kind, as
defined at Section 15-32 D.R.M.C., to a candidate, as defined at Section 15-32 D.R.M.C., during
the last
five years.




Signature of Officer/Owner of Bidding/Proposing entity


Bids/discl
Rev. 5-19-95
                                                                               ATTACHMENT 5


                                                                                        To
        Procedures for Compliance with DRMC 20-69, Political Contributions
DRMC 20-69 “Political Contributions” has been amended, effective March 10, 1995.
This ordinance requires that certain City purchase orders and contracts shall on a separate
detachable page include information regarding political contributions by the contractor-
second party.
The information to be provided by the proposer for the above-described City contracts
includes the following:
               (1)    The name of any officer, director, owner or
               principal of the proposer business entity and his or her
               spouse, and children, if any, under eighteen (18) years of
               age or the name of any officer, director, owner or principal
               of the business entity, and a statement that he or she or his
               or her spouse, or children, if any, under eighteen (18) years
               of age have or have not made a contribution, as defined at
               Section 15-32, D.R.M.C., or a contribution in-kind as
               defined at Section 15-32, D.R.M.C. to a candidate, as
               defined at Section 15-32, D.R.M.C. during the five (5) year
               period preceding the date of such statement and identifying
               by name himself or herself or any spouse or child under the
               age of eighteen (18) who has made such a contribution or
               contribution in-kind to a candidate; and
               (2)    The identity of any shareholder who owns or
               controls five (5) percent or more of the proposer business
               entity and his or her spouse, and children, if any, under
               eighteen (18) years of age or the identity of any shareholder
               who owns or controls five (5) percent or more of the
               business entity and a statement that he or she or his or her
               spouse, or children, if any, under eighteen (18) years of age
               have or have not made a contribution, as defined at Section
               15-32, D.R.M.C. or a contribution in-kind as defined at
               Section 15-32, D.R.M.C., to a candidate as defined at
              Section 15-32, D.R.M.C. during the five (5) year period
              preceding the date of such statement and identifying by
              name any spouse or child under the age of eighteen (18)
              who has made such a contribution or contribution in-kind
              to a candidate; and
              (3)    The name of any subcontractor, subconsultant or
              supplier whose share of the application or contract exceeds
              One Hundred Thousand Dollars ($100,000.00) of the
              contract or application amount; and
              (4)    The names of any unions with which the proposer
              has a collective bargaining agreement.

Proposers should use the attached forms to provide this information. The forms are self-
explanatory and should be filled out as directed.
                                                                                               ATTACHMENT 6


Certification Regarding Debarment, Suspension, and Other
Responsibility Matters
                                   Primary Covered Transactions

Instructions for Certification
    1.   By signing and submitting this proposal, the prospective primary participant is providing the
         certification set out below.
    2.   The inability of a person to provide the certification required below will not necessarily result in
         denial of participation in this covered transaction. The prospective participant shall submit an
         explanation of why it cannot provide the certification set out below. The certification or
         explanation will be considered in connection with the department or agency’s determination
         whether to enter into this transaction. However, failure of the prospective primary participant to
         furnish a certification or an explanation shall disqualify such person from participation in this
         transaction.
    3.   The certification in this clause is a material representation of fact upon which reliance was placed
         when the department or agency determined to enter into this transaction. If it is later determined
         that the prospective primary participant knowingly rendered an erroneous certification, in addition
         to other remedies available to the Federal Government, the department or agency may terminated
         this transaction for cause or default.
    4.   The prospective primary participant shall provide immediate written notice to the department or
         agency to which this proposal is submitted if at any time the prospective primary participant learns
         that its certification was erroneous when submitted or has become erroneous by reason of changed
         circumstances.
    5.   The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction,
         participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as
         used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules
         implementing Executive Order 12549. You may contact the department or agency to which this
         proposal is being submitted for assistance in obtaining a copy of those regulations.

Certification
    1.   The prospective primary participant certifies to the best of knowledge and belief, that it and its
         principals:

         (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
         voluntarily excluded by any Federal department;
         (b) Have not within a three-year period preceding this proposal been convicted of or had a civil
         judgment rendered against them for commission of fraud or a criminal offense in connection with
         obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or
         contract under a public transaction; violation of Federal or State antitrust statutes or commission
         of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
         statements, or receiving stolen property;
         (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental
         entity (Federally, State or local) with a commission of any of the offenses enumerated in
         paragraph (1) (b) or this certification; and
         (d) Have not within a three-year period preceding this application proposal had one or more
         public transactions (Federal, State or local) terminated for cause or default.
   2. Where the Prospective primary participant is unable to certify to any of the
   statements in this certification, such prospective participant shall attach an
   explanation to this proposal.

_________________________________________
      _______________________________
      Signature Principal Officer         Title

__________________________________________
      ________________________________
      Name of Agency                                        Date
__________________________________________
      ________________________________

				
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