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Memo of Understanding Mt. Sinai Medical Centerv~~U~° ~ ~ 7 y / Memorandum of Understanding Between City of Miami Beach, Florida And Mount Sinai Medical Center of Florida, Inc. -~, THIS MEMORAMDUM OF UNDERSTANDING is made this ~~ day of January, 2008 by and between the undersigned representative the City of Miami Beach ("CMB"), a Florida municipal corporation located at 1700 Convention Center Drive, Miami Beach, Florida 33139 and Mount Sinai Medical Center of Florida, Inc. ("MOUNT SINAI"), anot-for-profit corporation organized and existing under the laws of the State of Florida, located at 4300 Alton Road, Miami beach, Florida 33140. WHEREAS, CMB recognizes the importance of MOUNT SINAI's role in providing health care to the citizens of CMB; and WHEREAS, MOUNT SINAI is the largest single employer located within Miami Beach; and WHEREAS, CMB has identified improving access to labor, increasing affordable housing, and attracting and maintaining a quality workforce as Key Intended Outcomes of the CMB's Five-Year Vision and Strategic Plan; and WHEREAS, as an entitlement jurisdiction and recipient of State Housing Initiatives Partnership (SHIP), Community Development Block Grant (CDBG), and HOME Investment Partnership (HOME) funding, CMB has significant experience in the development of affordable housing and in complying with numerous multi-jurisdictional guidelines and regulations; and WHEREAS, CMB has defined income qualifying employees of the healthcare industry as Essential Services Personnel (ESP) in its State Housing Initiatives Partnership (SHIP) program and Local Housing Assistance Plan (CHAP); and WHEREAS, CMB has codified a master plan process to guide the future development and growth of MOUNT SINAI, including innovative initiatives such as density bonuses for the provision of such items as affordable housing and child care services by MOUNT SINAI; and WHEREAS, CMB and MOUNT SINAI desire to make a formal commitment to address workforce housing for healthcare ESP's by proposing a workforce housing project to the Florida Housing Finance Corporation's ("FHFC") Page 1 of 6 Community Workforce Housing Innovation Program ("CWHIP"), that leverages public and private resources. NOW, THEREFORE, in consideration of the mutual agreements and covenants contained herein and for other good and valuable consideration, the receipt of which is hereby acknowledged, it is mutually agreed and covenanted, under seal, by and between the parties to this Agreement, as follows: 1. Representations of MOUNT SINAI a. Upon award of the CWHIP grant, MOUNT SINAI commits to rehabilitate the second and third floors of the Lowenstein Building, consisting of seventy-six (76) apartments, to create affordable workforce housing for ESP's employed at Mount Sinai. These units will be used as workforce housing for income-eligible individuals for fifty (50) years (the Affordability Period), commencing from the date FHFC awards CWHIP funding to the MOUNT SINAI-CMB public-private partnership. Mount Sinai will manage the Lowenstein Building and ensure that FHFC rental rates, ESP, and affordability period requirements under CWHIP are met throughout the fifty (50) year Affordability Period. b. MOUNT SINAI shall submit to CMB for approval the proposed rents for the CWHIP units. CMB shall approve submitted rents if such rents comply with applicable FHFC and CWHIP Program standards. c. MOUNT SINAI shall provide CMB with the initial tenant list, and any and all subsequent updates, amendments and modifications thereto, with documentation for all tenants in the CWHIP units confirming income and job description. d. Annually, MOUNT SINAI shall deliver to CMB's Housing Division, by October 31St of each calendar year, during the Affordability Period, a list that includes names of tenants, income and job description, rents charged, and the occupancy/vacancy factor of each unit for the prior fiscal year (October 1St through September 30tH) e. MOUNT SINAI shall indemnify and hold harmless CMB from any and all claims, liabilities, losses, and causes of action which arise out of any act, omission, negligence or misconduct on the part of MOUNT SINAI or any of its agents, servants, employees, contractors, patrons, guests, patients, or invitees. MOUNT SINAI further shall indemnify and hold harmless CMB from any and all claims or repayment requirements imposed by FHFC or any other State agency related to MOUNT SINAI's failure and/or inability to comply with any and all requirements and guidelines of the CHWIP Program. The indemnifications contained herein are intended by the parties to survive termination of this MOU. Page 2 of 6 2. Representations of CMB a. Upon grant approval, and provided further that (i) the CMB Health Facilities Authority approves a declaration of a surplus and funding recommendation, and (ii) the funding award, CMB shall contribute $250,000 toward the total costs of rehabilitation of the Lowenstein Building's second and third floors. b. As a participant in this project, CMB Administration shall appear before the Health Facilities Authority to present the project with MOUNT SINAI and recommend in favor of funding this project, in the amount of $120,000 in 2008; $120,000 in 2009; and $10,000 in 2010. c. CMB Administration shall develop a Workforce Housing Funding Partnership Agreement with MOUNT SINAI for the use of HFA funding (if recommended by the HFA). Notwithstanding the preceding sentence, said Workforce Housing Funding Partnership Agreement shall be subject to and contingent upon final approval by the CMB Commission. d. CMB shall review in a timely manner all documents submitted by MOUNT SINAI pursuant to this Agreement including the proposed rents, the initial tenant list, and the annual report. City shall respond to MOUNT SINAI with the necessary approval or denial of said documents, within a reasonable time period. e. CMB shall review and approve the proposed rents for the CWHIP units, said approval shall not be unreasonably withheld upon determination by CMB that the proposed rents comply with the applicable FHFC and CWHIP Program standards. f. Consistent with the LHAP approved by the Miami Beach City Commission for the expenditure of SHIP funds, CMB shall apply certain affordable housing incentives as it deems reasonably necessary, to this workforce housing project, including expedited processing of permits. g. CMB shall work with MOUNT SINAI to conduct concurrent, rather than sequential, review of all City review and approval of building plans related to this project. 3. Term and Termination a. The term of the MOU shall commence following approval by the Mayor and City Commission and execution by the parties hereto, and shall be on the date first written above and shall continue for a term of fifty (50) years or until such time that it is replaced by the Workforce Housing Funding Partnership Page 3 of 6 Agreement, in the event that such agreement is approved by the CMB Commission. b. This MOU may be terminated by MOUNT SINAI with not less than one hundred twenty (120) days prior written notice of intent to discontinue CHWIP eligible activity at the project site and compliance with all related FHFC and CHWIP regulations and Section 1.e of this MOU. In the event that this MOU is terminated by MOUNT SINAI prior to completion of eligible activity at the project site, or in violation of or non-compliance with all related FHFC and CWHIP regulations, and/or non-compliance with any term and/or provision of this Agreement, MOUNT SINAI acknowledges and agrees that the City shall have no liability, whether to MOUNT SINAI, FHFC, and or any other State agency and/or any other third parties, and MOUNT SINAI shall fully indemnify and hold harmless the CMB for any claims and/or causes of actions (individually without limitation, repayment of any monies imposed by FHFC and/or any other State Agency). c. This MOU may be terminated by CMB with not less than one hundred twenty (120) days prior written notice of MOUNT SINAI's failure to cure a determination by CMB or any other authorized entity such as FHFC that the project is not in compliance with all related FHFC and CHWIP regulations or the terms of this MOU. Additionally, in the event of termination by the CMB, MOUNT SINAI shall continue to indemnify and hold the City harmless, and the City's rights and remedies shall be the same as set forth in Section i(e) and 3(b), respectively, of the Agreement. 4. Notifications All notifications shall be in writing: If to MSMC: Mount Sinai Medical Center of Florida, Inc. Warner Building, 5th Floor 4300 Alton Road Miami Beach, FL 33140 Attention: Mirene Charles, Director of Government Relations Copy to: Mount Sinai Medical Center of Florida, Inc. Warner Building, 5th Floor 4300 Alton Road Miami Beach, FL 33140 Attention: General Counsel Page 4 of 6 If to CMB: City of Miami Beach Attention: Kevin Crowder, Economic Development Director 1700 Convention Center Drive Miami Beach, FL 33139 Copy to: City of Miami Beach 1700 Convention Center Drive Miami Beach, FL 33139 Attn: Housing & Community Development Division 5. Governing Law This MOU shall be governed and construed in accordance with the laws of the State of Florida. This Agreement shall be enforceable in Miami-Dade County, Florida, and if legal action is necessary by either party with respect to the enforcement of any and all the terms or conditions herein, exclusive venue for the enforcement of same shall lie in Miami-Dade County, Florida. CMB and MOUNT SINAI hereby knowingly and intentionally waive the right to trial by jury in any action or proceeding that CMB and MOUNT SINAI may herein after institute against each other with respect to any matter arising out of or related to this Agreement. [REMAINDER OF THIS PAGE LEFT INTENTIONALLY BLANK] Page 5 of 6 IN WITNESS WHEREOF, MOUNT SINAI and CMB have executed this Agreement as of the day and year first written above by their duly authorized representatives. Mount Sinai Medical Center of Florida, Inc. B : _~l'~ v Name: Steven D, Sonenreich Title: President & CEQ ////~~~ //o 1, Attest: ~t/¢,~t~.~i.- ~ilt.eC~~~. ~" Signature ~ t TR~YZ-~/ Print Name/Title ~_ _`' City of Miami Beach ~r~ Na e: Matti .Bower Title: Mayor ~-t ~ ~~.~~~.,~,~_ Attest: Name: Robert Percher Title: City Clerk MY COMMISSION # DD 543864 EXPIRES: August 23, 2010 Bonded Thru Notary Publb Underwriters APPROVED A3 TO FORM $ LANGUAGE tk FOR EXECUTION i ~-f - I I - 0~ l ~Y ~ Date Page6of6 Mount Sinai M E D I C A L C E N T E R January 29, 2008 ATTN: Contracts Administrator Florida Housing Finance Corporation 227 North Bronough Street Suite 5000 Tallahassee, FL 32301 RE: 2007 COMMUNITY WORKFORCE HOUSING 1NNOVATION PILOT (CWHIP) PROGRAM -Mount Sinai Medical Center Lowenstein Building Rehabilitation Commitment to Waive General Contractor Fee Dear Administrator: Mount Sinai Medical Center (Mount Sinai) employs a highly qualified, full-time Director of Construction Services who has overseen the development and implementation of the overwhelming majority of construction and rehabilitation projects on the hospital Main Campus and two satellite campuses. Along with dedicated professional and support staff, Mount Sinai's Construction Services department regularly works with both City of Miami Beach and Miami- Dade County officials. The Mount Sinai staff has established along-standing favorable relationship with these key administrators. The department is of sufficient size to properly develop, execute, and monitor the 1•ehabilitation project proposed by the partnership of Mount Sinai and the City of Miami Beach. Therefore, Mount Sinai will act on its own behalf as Project General Contractor and will waive those associated fees for the benefit of the project cost in the estimated amount of $495,300. This commitment is conditioned upon Mount Sinai being awarded funding from this opportunity; however it will not expire before June 30, 2008. The amount of the contribution is comprised of the combined salaries and fringe benefits of all Mount Sinai personnel involved in the proposed project and their respective percentage of time dedicated throughout the project period. Based on current staff salaries, this is estimated to be $6,517 per unit. The total General Contractor's Fee amount being contributed is equal to 12% of the total estimated project construction costs. This is within the allowed limits of the CWHIP funding guidance set at a maximum of 14%. It is anticipated that using staff and resources that are already established and located on site will help execute the proposed project with optimal cost effectiveness. Please accept this letter on behalf of Mount Sinai as our firm commitment to this project contribution. Thank you for this important opportunity to obtain workforce housing funding. Sincerely, ~9`~ Steven D. Sonenreich President & CEO Mount Sinai Campus Miami f leart Campus Mount Sinai Avenhrra 4300 Alton Road 4701 N. Meridian Avenue 2845 Aventura Boulevard Miami Beach, FI 33140 Miami Beach, FL x3140 Avenlurt, FL 3:3180 Phone:305-674-2121 Phone_305-672-1111 Phonc~:305-932-2099 www.msmc.com • • ou n i nay January 29, 2008 M E D I C A L C E N T E R ATTN: Contracts Administrator Florida Housing Finance Corporation 227 North Bronough Street Suite 5000 Tallahassee, FL 32301 RE: 2007 COMMUNITY WORKFORCE HOUSING INNOVATION PILOT (CWHIP) PROGRAM -Mount Sinai Medical Center Lowenstein Building Rehabilitation Commitment to Waive Developer Fee Dear Administrator: Mount Sinai Medical Center (Mount Sinai) employs a highly qualified, full-time Director of Construction Services who has overseen the development and implementation of the overwhelming majority of construction and rehabilitation projects on the hospital Main Campus and two satellite campuses. Along with dedicated professional and support staff, Mount Sinai's Construction Services department regularly works with both City of Miami Beach and Miami- Dade County officials. The Mount Sinai staff has established a long-standing favorable relationship with these key administrators. The department is of sufficient size to properly develop, execute, and monitor the rehabilitation project proposed by the partnership of~ Mount Sinai and the City of Miami Beach. Therefore, Mount Sinai will act on its ovum behalf as Project Developer and will waive those associated fees for the benefit of the project cost in the estimated amount of $495,300. This commitment is conditioned upon Mount Sinai being awarded funding from this opportunity; however it will not expire before June 30, 2008. The amount of the contribution is comprised of the combined salaries and fringe benefits of all Mount Sinai persomiel involved in the proposed project and their respective percentage of time dedicated throughout the project period. Based on current staff salaries, this is estimated to be $6,517 per unit. The total Developer's Fee amount being contributed is equal to 12% of the total estimated project construction costs. This is within the allowed limits of the CWHIP funding guidance set at a maximum of 16%. It is anticipated that using staff and resources that are already established and located on site will help execute the proposed project with optimal cost effectiveness. Please accept this letter on behalf of Mount Sinai as our firm commitment to this project contribution. Thank you for this important opportunity to obtain workforce housing funds. Sincerely, G Steven . Sonenreich President & CEO Mount Sinai Campus Miami Heart Campus Mount Sinai Avenlura 4300 Alion Road 4707 N. Meridian Avenue ZR45 Avenlura Boulevard Miami Beach, FL "33140 Miami Beach, FL 33140 Avc~ntura, FL 33l£30 Nhonc:305-674-2121 Phone: 305-672-1111 Phone: .305032-2099 www.msmc.com 2007 COMMUNITY WORKFORCE HOUSING INNOVATION PILOT PROGRAM (CWHIP} CERTIFICATION STATEMENT By signing the Certification Statement, the Applicant agrees to the following For homeownership units, that the sales price of a detached unit, town home, or condominium unit is limited to not more than 90 percent (90%) of the higher of the median sales price for that type of unit in that county, or the statewide -nedian sales price for that type of unit. Applicants must require that al] eligible purchasers of homeownership units occupy the homes as their primary residence. For rental units, that rents will be restricted for all Workforce Housing serving those with incomes at or below 120 percent (120%) of the AMI at the appropriate income level using the restricted rents for the federal low-income housing tax credit program. For Workforce Housing units serving those with incomes above 120 percent (120%) of AMI, applicants must restrict rents to those established by Florida Housing, not to exceed 30 percent (30%) of the maximum household income adjusted to unit size. The Applicant certifies that the proposed Project can be completed and operating within the development schedule and budget submitted to the Corporation. The Applicant acknowledges that the Corporation may conduct its own independent review, analysis and verification of all information contained in this Application and that any funding preliminarily secured by the Applicant is expressly conditioned upon such verification, the successful completion of credit underwriting, all necessary approvals by the Board of Directors, Corporation legal counsel, Bond Counsel, if applicable, the Credit Underwriter, and Corporation Staff. If preliminary funding is approved, the Applicant will promptly furnish such other supporting information, documents, and fees as may be requested or required. The Applicant understands and agrees that the Corporation is not responsible for actions taken by the undersigned in reliance on a preliminary commitment by the Corporation. The Applicant commits that no qualified residents will be refused occupancy because they have Section 8 vouchers or certificates. The Applicant further commits to actively seek tenants from public housing waiting fists. If preliminal•y funding is approved, the Applicant commits to participate in the statewide housing locator system as required by Florida Housing. The Applicant and all Financial Beneficiaries have read all applicable Corporation rules governing this Application and have read the ]nstructions for completing this Application and will abide by the applicable Florida Statutes and administrative rules, including, but not limited to, Rule Chapter 67-58, Florida Administrative Code. Application - CVV[IIP-S1G (11/26/07) - Cc~lification 67-58.003(1)(x) In consideration for the Corporation processing and scoring this Application. the Applicant and all Financial Beneficiaries understand and agree that the Corporation shall hear appeals only pursuant to Rule 67-58.004, F.A.C. The undersigned is authorized to bind all Financial Beneficiaries to this certification and warranty of truthfulness and completeness of the Application. Under the penalties of pel jury, I declare and cel-tify that I have read the foregoing and that the information is true, correct and complete. j `s _--- -T- Signature of Applican Uate (n,n,la~lyyyy> -~ S e Vet. r~ ~~ , ~ ~ i 1 E f\ r _C_ , ~. }~ Name (typed or printed) Tltle (typed or printed) Failure to provide the completed form, reflecting original signatures by the appropriate parties, in the Application labeled "Original Copy" at Application Deadline will result in automatic rejection of the Application without the opportunity to cure. Signatures in blue tole are preferred. if this certification contains corrections or `white- out', or if it is scanned, imaged, altered, or retyped, the Application will fail to meet threshold. The certification may be photocopied. Threshold Item Application - CW'IIIP-S1G (11/2Gl07) -Certification G7-58.003(1)(x) X007 CoMNIt~~I~rl~~'~'Vc~IZhr~~RC>~ Ho[~S~~r; I~vuv~~rloti 3'riJoT ((:'~VNIP~ Plzoc.rza~~ VERIFICATION Oh AV,~ILARiI,I'i'Y" OF' INPR.ASTRL`CTLiRE SEWER CAPACI'T'Y, PAC~~ACE; ~1'REr~~G~'~E;N1', OR SEPTIC TANK Name of Prajeci~ Mount Sinai Lowenstein Building VVork.force Housing Rehabilitation Project Location: H4StJital-fu1ain Campus: 4300 Altpn_F~oad._Miami Beach FL 331.4©, •_ F ridenee o>' avaitabiliiJ' must be provided fur xll sites if the proposrd Project consists of scattered silts. 'I`17e undersigned s47~~ice provider confirt77s il~t ou ur before (~~,~^.~ ~,,.~~-~ r ,. I. ewer Capacity- Paekage'I'reatu7ent, or Septic Tank is available to the proposcci Project. 2. `hh~re .are no impediments to thti Imposed Project for obtaining thr specified ~~~aste treatment service other d7an payment oi- hook-u}> or installation ices, line extensions to be paid for by the Applicant in conttcet~on with the constructiotl c,f the Project, or other such routine adt~7inistratice procedure. 3. To the hest r?f aitr knowledge, uo variance or local hcarit7g is re:yuired to n7akc this service uvailahle to the proposed Prt~lect, 4. ~~T~o the best oti our knov~-ledge, there are no lnoratorimn; pertaining to dais st;rvice, which are applicable to the proposed Project. CFR'CIhIC'A"l'lOV I certi~tt tl fo uing inf'oru7ation is true and con-ect. ~ ~ _! 2 D8 __~ i `1 p ~- ~_t 1 • a t.~ ,`_ r,~Y`ct c•.- G. • ~____ _ __ -. ~.__.y _ Siluature [ ate ~~,,,~,i~r>>•>~~ \amc of I?~'roviding Service---- ~r~ Ft• l"3~c It.rvt-a.rln... v '~ -:' ~) ~~, ~ fit? y'i •~~nc~ ~..~.a.•t-t'r" D t- . Print or Type ~atrac :~cldress ~~ b 1-~c ~~J J f 1t~ `.~ t t?c f-1•~ ( ~ ~.~~~ i rz~ c ~7 ~,= L _~ ~~ i'3`i A ~-~_ ~-~._____~_,~_.__._.~~._._-___ ___ Print or 'hype 'hitle -~--['~le}7hoiie \wrtber tincluding area code.) Signatures fron3 local elected of~fic,als arc not. acceptable. If-the ccrtificatioia is apt~ficub€e to this ~d'rojeci and it is inappropriately signed, the Application ~.vill fail tl~,reshuld. If-this certification cunt:sins corrections nr `whirs-out', ur if it is scanned, ima~,ed, ,altered, or retypctt, the Application will fail to meet threshold. 'flit: ccrtificanon may be photocopicii. 'T~IRESHOL:D ITEM-7 ,application -C\\'FIIt'-816 {1 lf2G/07)- 4a6ibit Forms 67-5&A03{ I )~ a ) 2007 C'o~~;~~niwrrv ~'vc~r~hrouch 1Io~~Sln~c: t'`>yo~~.~~,r~~~T 1>,L,c~'r (cWt~(r') I'KC~c:K.a><•~ VH;ItII=IC:A'TlE)N OI+ :~V,~I1.A13I1..1'I'1' OF INFIt:~S"CItIJC'I'i:1zE f20A[)S Name of Project: Mount Sinai Lowenstein Building_Workforce Housing Rehabilitation Project Location: K~ain_~arnR.u.~43~4 &1tQn~.Road,hdiami_~~~oh._FL.3~1~0..__..-.---~ ~:vidence cif ~cailalriJih~ must he pro~'icled 1'or sill sites if the proposed prraject consists of scattered sites. Thy tutdersi~~rred local government representative crn~firms tl~ai on or laefi>rc _~~,,, „~,,~„~~,.z~ f ~atc (mm~dcL'yyyy -~~1 l . L-aisting paved reads provide access to Elie proposeii I'roj; cr or paved roads will be constructed as part. of tlae L~roposed Project. 2. There are no impediments fo the proposed Project using the roads other Chan payment o1 impact fees or providing curb cuts, nu•n lanes, or signal~zation. 3. "ho the best oi' our knowledge, no uariancc or local he.arin~ is rcyuired for thesis roads to be available to~fb~ proposed f'r~~ject. -}. 7b the best oi' our knova~ledge, there are tto moratoriums pertaining to road usage which arc applicable tc~ the proposed Project. crI2TI E'IC~;~.'rlo;v [ certify that the ib •,~oin'g in#'onnation is true a~;d correct. Z ~ a iti,~' Signature Cate {r~,~n S~i.}~~~ 1~Illte ol't.:ntit~' Proviiiirtg Ser1•iCe LL~~t'C >!~i'Vi it ~'1d'f ~ ~ ~ UL' `~."i,.LV.~ y~.'~t.' `-1 ~,,.~2/1'....1-~ 1~ 1.3 T J 1~~ Print or `I'ypc J~~ame ,Address I _~ ~., _.. c. ~~. c _ _~:..~ ~._._ r~ c t~ ~ f~ r Print or Type Title _ . .~~ v5 - W°~ ~3 . ,~ cl `i~r> - Telcph~>ue Nuutber (including area code) Signatures lirom local elected oi~ciais are riot acceptable. ff the certification is applicable tU this Project and it is inap;3ropriately signed, the. r~pplica~ion will fail threshold. Ifttris certification contains corrections or 'white-out', or i{~ it is scanned, imaged, ,~herccf, or retyped, the Applicanon will fail to meet threshold. 'The certification may he !>hotocohied. ~rflltN slrc~I,I~ ITE~'1 ~~pplicatfuu -E'~VIiIP-H1etl1l2G/[17)-Exhilritt~nrms 67-58.003(1)(:0 2007 Coa7.~><c~~rrv «1ou><cf~<~~zc>H; Hc~i.~si~c «ivo~••:~~~IC)_ti Yt[..c~•r (C'«~'H[ P) YROG RA?~~I `~'EKIPIC'A"I'IO\~ t)h' AVAIi..AIiILI"I'Y Or' I1FR:~4'['RUC'TUl2E WR'I'ER Name of Prajecl: Mount Sinai i_owenslein Building ~Norkforce Housing Rehabilitation Project Location: Hospital Pvlain Campus: 4300 Alton Road, t~4iam- Beach, FL 33140 Fa•idence ~~I'sivaitnbilitc must he provided For all sites if the proposed frojcrt consists ot'serltcrcd sites. The uudersi~ncd sct~ricc provider confiniis that on or befi~re ~ ~C~-1 t)ate (mnt'dd!yyyy} 1. Potable ~ti~ater is availahle to the proposed Project. 2. T}tere are no impediments io the pr.~oposed Project f~c~r ubtaitunv potable water service other than payment of hook-up «-• installation fees, line extensions to be paid for by the Applicant iu connection with the construction of the Project. or other such routine atinainistrativ4 procedure. 3. 1'o thr: best of our knowledbe, no variance or local hearing is required tc~ make potable water available to thu preyposcd Project. 4. `To t17e best at~our knowledge. there are uo moratoriums pcrtainin~; to potable water which are applicable to the prnposed Project. C:~RTIFICATIOV I cetYity t • l l-c// rT~'~'~~~ infort~talion is true a-id corre<a Signature Date tn,n,-d;i >y.-~> dame cat F:;ritity P-or~iciurr tierv-cc 'Fr-tG~ . N-_ ~' ~ c _ k y--m a w~------ L~ U Cf C~ ~~ v ~~ r, ~i ~ ' c' w~~~ : ~~ r r "v~ Print or1'~~pr'v~-me ;'address tsb 1 i L 1~~-~: Mks ,~ i_t~~' c_+~~ .r __. ~ ,x. a , i~ ~'~ L.- ~• _ Print or T1'pe Title -- "Celephone Number (including area code) Siknanucs from loco! elected officials arc nqt acceptable. If the certification is applicably to this I'rojeet and ii is inappropriately sit;ncd, the Application will fail threshold. If this certification contains corrections or 'wtute-out°, a- if if is ~canncd, u~aa~ed, ahcred, or rei}rpcct, [he Application wilt fail to meet Chreshold. The certificatio~i map be photocopied. 'THRESHOLD ITEM :lpplicaqun - C14'UI!'-kl6 (1 1126~b7) - F,xhibit Forms G~-eg.0a3tlxa>