Fraud Complaint Sample by dbp17580

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									              DEPARTMENT OF HOUSING AND
               COMMUNITY DEVELOPMENT



                INFILL INFRASTRUCTURE GRANT
                           PROGRAM



            GRANT APPLICATION PART E
                           FY 2008 – 2009 NOFA


                                    State of California
                    Department of Housing and Community Development
                             Division of Financial Assistance


                               1800 Third Street, MS 460-2
                                 Sacramento, CA 95811


                                Telephone: (916) 324-1555
                                Facsimile: (916) 324-1461
                              Website: http://www.hcd.ca.gov/fa/iig/
                                    Email: infill@hcd.ca.gov




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                            INFILL INFRASTRUCTURE GRANT
                                PROGRAM APPLICATION
1. Governing Board Resolution (SAMPLE)
                                           RESOLUTION No.
                                             __________


HEREBY AUTHORIZES THE SUBMITTAL OF AN APPLICATION TO THE CALIFORNIA STATE
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT FOR FUNDING UNDER THE
INFILL INFRASTRUCTURE GRANT PROGRAM; THE EXECUTION OF A STANDARD
AGREEMENT IF SELECTED FOR SUCH FUNDING AND ANY AMENDMENTS THERETO; AND
ANY RELATED DOCUMENTS NECESSARY TO PARTICIPATE IN THE INFILL
INFRASTRUCTURE GRANT PROGRAM.
WHEREAS:
A.                       0                         ,a
   wishes to apply for and receive an allocation of funds through the Infill Infrastructure Grant
   Program; and
B. The California Department of Housing and Community Development (hereinafter referred to as
   “HCD”) has issued a Notice of Funding Availability (“NOFA”) for the Infill Infrastructure Grant
   Program established under the Housing and Emergency Shelter Trust Fund Act of 2006
   (Proposition 1C) pursuant to the Infill Infrastructure Grant Program established Part 12 of
   Division 31 of the Health and Safety Code, commencing with Section 53545.12. Pursuant to the
   statute, HCD is authorized to approve funding allocations utilizing monies made available by the
   State Legislature, subject to the terms and conditions of the statute and the Infill Infrastructure
   Grant Program Guidelines implemented JANUARY 30, 2009; and

C.                       0                          wishes to submit an application to obtain
     from HCD an allocation of the Infill Infrastructure Grant Program funds in the amount of
                             .
IT IS NOW THEREFORE RESOLVED THAT:
1.                           0                        shall submit to HCD an application to
     participate in the Infill Infrastructure Grant Program in response to the NOFA issued on
    JANUARY 30, 2009 which will request a funding allocation in the amount of
      $                         - for the following activities:
    (Briefly describe the proposed Capital Improvement Project)




2.     If the application for funding is approved, the                          0
     hereby agrees to use the Infill Infrastructure Grant Program funds for eligible activities in the
     manner presented in the application as approved by HCD and in accordance with program
     Guidelines cites above. It also may execute any and all other instruments necessary or
     required by HCD for participation in the Infill Infrastructure Grant Program.


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                          INFILL INFRASTRUCTURE GRANT
                              PROGRAM APPLICATION
1. Governing Board Resolution (SAMPLE)
3.                               0
                          authorizes
     [office or position titles of authorized person(s)]
               to execute in the name of the
                                 0
    the application, the Standard Agreement, and all other documents required by HCD for
    participation in the Infill Infrastructure Grant Program, and any amendments thereto.

PASSED AND ADOPTED THIS                  (Day)    of    (Month)     ,   (Year)   by the following vote:

   AYES      (#)       NAYS      (#)      ABSTAIN         (#)       ABSENT          (#)

  The undersigned         (title of officer)     of the                         0
    there before names does hereby attest and certify that the foregoing is a true and full copy of a
   resolution of the Governing Board adopted at a duly convened meeting on the date above-
   mentioned, which has not been altered, amended or repealed.


                          Signature                                     Date

NOTES:
1. This is intended to be a sample resolution authorizing submittal of an application to HCD.
   Applicants may use their own format it if contains all of the authorizations contained in this
   sample
2. The person attesting to the signing of the resolution cannot be the same person who is
   authorized to execute documents in the name of the applicant.
3. Original resolution or a live certified copy of the resolution must be submitted with the
   application.




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                           INFILL INFRASTRUCTURE GRANT
                               PROGRAM APPLICATION
2. Legal Status Questionnaire
For purposes of the following questions, and with the exceptions noted below, the term “applicant”
shall include the applicant and joint applicant, and any subsidiary of the applicant or joint applicant
if the subsidiary is involved in (for example, as a guarantor) or will be benefited by the application
or the project.
In addition to each of these entities themselves, the term “applicant” shall also include the direct
and indirect holders of more than ten percent (10%) of the ownership interests in the entity, as
well as the officers, directors, principals and senior executives of the entity if the entity is a
corporation, the general and limited partners of the entity if the entity is a partnership, and the
members or managers of the entity if the entity is a limited liability company. For projects using
tax-exempt bonds, it shall also include the individual who will be executing the bond purchase
agreement.
The following questions must be responded to for each entity and person qualifying as an
"applicant," or "joint applicant" as defined above.
Explain all positive responses on a separate sheet and include with this questionnaire in
the application.
                                              Exceptions:
Public entity applicants without an ownership interest in the proposed project, including but not
limited to cities, counties, and joint powers authorities with 100 or more members, are not required
to respond to this questionnaire.
Members of the boards of directors of non-profit corporations, including officers of the boards, are
also not required to respond. However, chief executive officers (Executive Directors, Chief
Executive Officers, Presidents or their equivalent) must respond, as must chief financial officers
(Treasurers, Chief Financial Officers, or their equivalent).
Civil Matters
1. Has the applicant filed a bankruptcy or receivership case or had a bankruptcy or
receivership action commenced against it, defaulted on a loan, or been foreclosed
against in the past ten years ?
2. Is the applicant currently a party to, or been notified that it may become a party to, any
civil litigation that may materially and adversely affect (a) the financial condition of the
applicant’s business, or (b) the project that is the subject of the application?
3. Have there been any administrative or civil settlements, decisions, or judgments
against the applicant within the past ten years that materially and adversely affected (a)
the financial condition of the applicant’s business, or (b) the project that is the subject of
the application?
4. Is the applicant currently subject to, or been notified that it may become subject to,
any civil or administrative proceeding, examination, or investigation by a local, state or
federal licensing or accreditation agency, a local, state or federal taxing authority, or a
local, state or federal regulatory or enforcement agency?
5. In the past ten years, has the applicant been subject to any civil or administrative
proceeding, examination, or investigation by a local, state or federal licensing or
accreditation agency, a local, state or federal taxing authority, or a local, state or federal
regulatory or enforcement agency that resulted in a settlement, decision, or judgment?

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                          INFILL INFRASTRUCTURE GRANT
                              PROGRAM APPLICATION
2. Legal Matters Questionnaire
Criminal Status
6. Is the applicant currently a party to, or the subject of, or been notified that it may
become a party to or the subject of, any criminal litigation, proceeding, charge,
complaint, examination or investigation, of any kind, involving, or that could result in,
felony charges against the applicant?
7. Is the applicant currently a party to, or the subject of, or been notified that it may
become a party to or the subject of, any criminal litigation, proceeding, charge,
complaint, examination or investigation, of any kind, involving, or that could result in,
misdemeanor charges against the applicant for matters relating to the conduct of the
applicant’s business?
8. Is the applicant currently a party to, or the subject of, or been notified that it may
become a party to or the subject of, any criminal litigation, proceeding, charge,
complaint, examination or investigation, of any kind, involving, or that could result in,
criminal charges (whether felony or misdemeanor) against the applicant for any financial
or fraud related crime?
9. Is the applicant currently a party to, or the subject of, or been notified that it may
become a party to or the subject of, any criminal litigation, proceeding, charge,
complaint, examination or investigation, of any kind, that could materially affect the
financial condition of the applicant’s business?
10. Within the past ten years, has the applicant been convicted of any felony?
11. Within the past ten years, has the applicant been convicted of any misdemeanor
related to the conduct of the applicant’s business?
12. Within the past ten years, has the applicant been convicted of any misdemeanor for
any financial or fraud related crime?
   Please provide a letter of explaination if you responded "Yes" to any of the questions


           Printed Name of Applicant or Joint Applicant



              Signature of Applicant or Joint Applicant                                Date

                    Printed Name of Signatory


                     Printed Title of Signatory




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                            INFILL INFRASTRUCTURE GRANT
                                PROGRAM APPLICATION
3. Certifications and Identity of Interest Disclosure
                                         State of California
                              Infill Infrastructure Grant Program

On behalf of the entity identified in the signature block below, I certify that:
1. The information, statements and attachments included in this application are, to the best
of my knowledge and belief, true and correct.
2. I possess the legal authority to submit this application on behalf of the entity identified in
the signature block.
3. The following is a complete disclosure of all identities of interest – of all persons or entities,
including affiliates, that will provide goods or services to the project wither (1) in one or more
capacity or (b) that qualify as a “related Party” to any person or entity that will provide goods
or services to the project. “Related Party” is defined in Section 10302 of the California Code
of regulations (TCAC Regulations):




In addition, I acknowledge that all information in this application and attachments is public,
and may be disclosed by the State.


                              Signature                                            Date


                     Printed Name of Signatory                           Entity Represented


                      Printed Title of Signatory




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