Orange County Continuum of Care– 2017Request for Qualifications

EXHIBIT 1: Lead Agency Information Form

Agency Name:

Agency Type[1]:

Physical Address

Street 1:
Street 2:
City: / State: / Zip Code:

General Contact Information

Phone Number:
Fax:
Email:
Website:

Primary Point of Contact for Request for Qualifications

Name:
Title:
Phone:
Email:

Chief Executive Officer / Executive Director Contact

Name:
Title:
Phone:
Email:

Please include the following documents:

  • Attachment 1: Organizational Chart – include Board of Director’s body as it relates to the entire organization, and organization’s staff names and titles/positions.
  • Attachment 2: Board of Directors’ Roster[2] and Resolution
  • Attachment 3: State Certificate of Status
  • Attachment 4:Agency’s Code of Conduct
  • Attachment 5: 501(c)3 Certification, if applicable.
  • Attachment 6: Most recent[3] HUD Monitoring letter and close out letter for all HUD Projects, if applicable.
  • Attachment 7: A list identifying your organization’s past 5 years of experience receiving Federal and/or State assistance, highlighting any HUD experience.

Name, Title and Signature of Person who will complete the application:

Name/TitleSignatureDate

Name and Signature of Person authorized to sign the HUD application:

Name/TitleSignatureDate

I certify, on behalf of my agency that all information contained in this application is accurate and true, and based on our current records. I understand that falsifying information or failing to provide accurate information will have a negative impact on my overall review and may result in removal from the Continuum of Care Application to HUD.

Executive Director/CEO/PresidentDate

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[1] Examples of Agency Type: Not-for-Profit Organization, Faith-Based Organization, Public Housing Authority, or other unit of local government.

[2] Under the HEARTH Act, each recipient or project sponsor is required to provide for the participation of not less than one homeless individual on the board of directors or other equivalent policymaking entity of the recipient or project sponsor, to the extent that such entity considers and makes policy decisions regarding any project, supportive services, or assistance provided.

[3] Most recent meaning, in the last six years. Only submit documents if dated 2011 or later.