4571.2

APPENDIX 11

SECTION 811 APPLICATION PACKAGE

Supportive Housing for Persons with Disabilities

INTRODUCTION: You have indicated an interest in constructing or

rehabilitating housing for persons with disabilities to be

financed under the Section 811 capital advance program as

authorized by the National Affordable Housing (NAH) Act, and to

be assisted by project rental assistance payments. This package

and enclosure constitute the Section 811 Application Package.

An original and six (6) copies of an Application for a Section

811 Fund Reservation must be submitted in response to the

Invitation published by this Office, in conformance with Section

II-Submission Requirements for a Section 811 Fund Reservation, of

this Application Package. Copies of the completed Application

must be submitted to this Office, either by hand, delivery

service or by certified mail, by the deadline date and time set

forth in the Invitation. APPLICATIONS RECEIVED AFTER THAT DATE

WILL NOT BE ACCEPTED, EVEN IF POSTMARKED BY THE DEADLINE DATE.

Applications submitted by facsimile will not be accepted.

Before preparing your Application, you should carefully review

the requirements of the Regulations (24 CFR Part 890) and general

program instructions set forth in Handbook 4571.2, Section 811

Capital Advance Program for Housing for Persons with

Disabilities, Chapter 3, and the current year\'s Housing Notice.

Note: Section 1001 of Title 18 of the United States Code

(Criminal Code and Criminal Procedure, 72 Stat. 967 shall apply

to all information supplied in the application submission. (18

U.S.C. 1001, among other things, provides that whoever knowingly

and willfully makes or uses a document or writing containing any

false, fictitious, fraudulent statement or entry, in any matter

within the jurisdiction of any department or agency of the United

States, shall be fined not more than \$10,000 or imprisoned for

not more than five years, or both.)

This Application Package consists of three Sections and an

Application Checklist which are summarized below:

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4571.2

APPENDIX 11

Section I: Project Development Requirements

The HUD Field Office will complete this Part

which sets forth information pertaining to

applicable operating cost standards,

Comprehensive Housing Affordability Strategies

(beginning with applications submitted after

October 1, 1991), Uniform Relocation Act, and

other special requirements the Field Office deems

necessary.

Section II: Submission Requirements for a Section 811

Fund Reservation

The Application for a Section 811 Fund

Reservation consists Of seven parts, and must be

accompanied by the materials, forms and exhibits

listed herein (see pages 3 thru 9 below, for a

description of the exhibits). Acceptable racial

and ethnic categories are defined in the

instructions for completing Form HUD-92013

on page 21). The submission must have a table of

contents and be indexed and tabbed accordingly.

Section III: General Program Requirements and Attachments

Self-explanatory.

Application A Checklist to assist in ensuring that the

Checklist: Sponsor\'s application submission is complete.

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4571.2

APPENDIX 11

SECTION 811 APPLICATION - SUPPORTIVE HOUSING FOR PERSONS WITH
DISABILITIES

Addendum to Form HUD-92013 and Certification

1\. Intended Residents 5. Development Method

Physically Disabled New Constr.

Developmentally Disabled Rehab.

Chronically Mentally Ill Acq.(group

Persons Disabled w/HIV\* homes or RTC)

2\. Fac. Type/# of Residents/Units 6. HUD Hdqtrs. Approval

Group home/\_\_\_\_(residents) Hsg. will serve

ILF/\_\_\_(units)\_\_\_(residents) persons w/HIV

3\. No. of Sites\_\_\_\_ Restricted

No. of residents per Site\_\_\_\_ occupancy

4\. Application contains: (check one) Group home to be

licensed as ICF

Evidence of site control

Identification of site Mixed Occupancy

THE SPONSOR CERTIFIES THAT ALL EXHIBITS ARE TRUE AND CORRECT.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Type in corporate name of Sponsor)

By:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Signature of Authorized Office of Sponsor)/Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Type in Name and Title)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Address)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(City) (State) (Zip Code) (Telephone)

\*If you are requesting units out of the 500 unit set-aside for

persons disabled w/HIV, check this category and the first

category under 6. above. Disabled w/HIV does not constitute a

fourth category of disability.

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4571.2

APPENDIX 11

FORMAT FOR SECTION I - PROJECT DEVELOPMENT REQUIREMENTS

1\. Allocation Area:

2\. Number 1/ and size of Units:

3\. Operating Cost Standards:

4\. The local/State Comprehensive Housing Affordability Strategy

(CHAS) requires:

5\. The local/State CHAS sets forth the following preference with

respect to the location:2/

6\. Inquiries related to the local/State CHAS should be addressed

to:2/

7\. Special requirements for location, density and site planning

are:

8\. Other requirements:

Acceptable Amenities:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9\. Name/address of State/local agency to which application

should be submitted for review of supportive services plan:

Physically Disabled
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Developmentally Disabled
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chronically Mentally Ill
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Persons Disabled w/HIV
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1/ NOTE: The total units requested must cover any nonrevenue

producing units as well as revenue units. For example,

if an independent living facility is 20 units, and if a

nonrevenue unit (i.e., resident manager\'s unit) is

planned, the configuration is 19 units, plus one

nonrevenue unit. Additions of nonrevenue units at

later stages of processing will not be accepted.

2/ NOTE: The CHAS certification is not required for applications

submitted for Fiscal Year 1991 funding.

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4571.2

APPENDIX 11

SECTION II - SUBMISSION REQUIREMENTS FOR A SECTION 811

FUND RESERVATION FOR HOUSING FOR PERSONS WITH DISABILITIES

PART 1 - GENERAL

Exhibit 1: Form HUD-92013, Application for Multifamily

Housing Project (attached). Complete only

specific portions of this form as outlined on

pages 11 and 12 of these requirements. No item on

page 2 of Form HUD-92013 is required.

Exhibit 2: A Housing Consultant\'s Resume, Contract (Form HUD

92531A-EH) and an Identity of Interest and

Disclosure Certification.

Exhibit 3: Evidence of each Sponsor\'s legal status as a

nonprofit entity, including:

a\. Articles of Incorporation, constitution or

other organizational documents;

b\. By-laws;

c\. A typed incumbency certificate, listing all

officers and directors, title, beginning date

of each person\'s term and when that term

expires. It must be certified by an officer

of the Sponsor that it constitutes all duly

qualified and sitting officers and directors

as of the date the application is filed with

HUD;

d\. IRS tax exemption ruling (required for all

Sponsors including CHURCHES) NOTE: If

applying for units out of the FY 1991

set-aside for persons disabled with the human

acquired immunodeficiency virus (HIV), the

Sponsor(s) must have a Section 501(c)(3) tax

exemption from the Internal Revenue Service;

e\. Resolution of the board, duly certified by an

officer, that no officer or director has or

will have any contract with the Owner or in

any firm or corporation which has or will

have a contract with the Owner.

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4571.2

APPENDIX 11

Exhibit 4: Satisfactory evidence that the Sponsor:

a\. Has the necessary legal authority to sponsor

the project and to assist the Owner to

finance, acquire, construct, or rehabilitate

and maintain the project, and

b\. Will form an Owner after the issuance of the

fund reservation, cause the Owner to file a

request for a capital advance, and provide

sufficient resources to the Owner to ensure

the development and long-term operation of

the project.

PART 2 - EVIDENCE OF ABILITY TO DEVELOP AND OPERATE THE

HOUSING ON A LONG-TERM BASIS

Exhibit 5: Description of the Sponsor\'s ties to the

community, including the minority community, and

any statements of support for the project by

members of the local community in which the

project is to be located and State and local

organizations familiar with the needs of persons

with disabilities proposed to be housed.

Exhibit 6: Evidence of any previous participation in HUD

programs by the Sponsor, its officers or

directors, on Form HUD-2530. If none, form must

be submitted indicating \"No previous experience\".

Exhibit 7: A description of any financial default,

modification of terms and conditions of financing,

or legal action taken or pending against the

Sponsor or its officers, directors or trustees in

their corporate capacity.

Exhibit 8: A description of any rental housing projects

and/or medical facilities sponsored, owned and

operated by the Sponsor including a description of

experience in providing housing to persons with

disabilities and/or families. If applying for

units out of the FY1991 set-aside for housing for

persons disabled with the human acquired

immunodeficiency virus (HIV), a description of

experience as a health care provider, if

applicable, as well as a copy of a working or

services agreement with a hospital.

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4571.2

APPENDIX 11

Exhibit 9: A description of the Sponsor\'s past or current

involvement in any programs other than housing

(including its provision of services) that

demonstrates the Sponsor\'s management capabilities

and experience in serving persons with

disabilities and/or families.

Exhibit 10: A certified Board Resolution, acknowledging

responsibilities of sponsorship, long-term support

of the project(s), willingness to sponsor, to

assist the Owner to develop, own, manage and

ensure the provision of appropriate services in

connection with the proposed project, and that it

reflects the will of its membership.

Exhibit 11: A description of the Sponsor\'s experience in

providing housing, medical or other facilities

and/or services to minority persons and in

contracting with minority- and women-owned

business enterprises.

PART 3 - FINANCIAL CAPACITY AND ABILITY TO DEVELOP A PROJECT

Exhibit 12: A list of the applications, if any, the Sponsor

has submitted or is planning to submit to any

other Field Office in response to the current

Invitations. Indicate by Field Office, the

proposed location by city and State, the number of

units requested and financial commitments related

to each application.

Exhibit 13: An estimate of start-up expenses and the source of

funds to meet these expenses. If the Sponsor

plans to use a Section 106(b) seed money loan, an

application (Form HUD-92290) for such loan must be

submitted with required attachments.

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4571.2

APPENDIX 11

Exhibit 14: Evidence, in the form of a certified Board

Resolution, of the Sponsor\'s willingness to fund

the Minimum Capital Investment, estimated start-up

expenses, and any associated development or

operating costs related to items not covered by

the capital advance and to ensure the development

and long-term operation of the project. Also, as

evidence of the Sponsor\'s financial ability to

cover these costs, include:

a\. a brief narrative description of financial

history;

b\. copies of balance sheets and statements of

income and expenses for each of the past

three years that the Sponsor has operated.

(The financial statements at a minimum must

include the information contained in Form

HUD-92417 and a certification pursuant to the

criminal warning provided in U.S. Criminal

Code, Section 1001, Title 18 U.S.C.);

c\. a Form HUD-2013 Supplement, Application for

Project Mortgage Insurance, listing current

bank and trade references; and,

d\. a list of all Fiscal Year 1990 and prior year

projects to which the Sponsor(s) is a party,

identified by project number, Field Office,

funding year, month and year of initial

closing, current status (if finally closed,

indicate month and year) and financial

requirements for closing.

PART 4 - NEED FOR SUPPORTIVE HOUSING IN THE AREA TO BE SERVED

Exhibit 15: Evidence of need for supportive housing for

persons with disabilities in the area to be served

such as:

a\. State or local needs assessments indicating

the extent of need in the locality for the

type of project proposed.

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4571.2

APPENDIX 11

b\. Letters from local agencies (i.e. housing,

services) indicating the extent of need for

supportive housing for the proposed

population in the area to be served.

c\. Referral arrangements proposed with

institutions, service providers or State and

local government agencies, and the placement

records of these organizations in other

community-based housing.

PART 5 - PRELIMINARY PROJECT SITE AND DESIGN INFORMATION

Exhibit 16: The Sponsor must submit either I. Evidence of Site

Control OR II. Identification of a Site, as

follows:

I. Evidence of Site Control

a\. Evidence that the Sponsor has entered into a

legally binding option agreement to buy or

lease the proposed site; or has a copy of the

contract of sale for the site, a deed, long-term

leasehold or other evidence of ownership

for the site (including properties to be

acquired from the Resolution Trust

Corporation). The option agreement period

should extend through the end of the month in

which funding decisions will be announced and

contain a renewal provision to guarantee site

availability through the subsequent stage of

processing. The Sponsor must also identify

any restrictive covenants. In the case of a

site to be acquired from a public body,

evidence that the public body possesses clear

title to the site, has entered into a legally

binding agreement to lease or convey the site

to the Sponsor after it receives and accepts

a notification of Section 811 fund

reservation and identified any restrictive

covenants. However, in localities where HUD

determines the time constraints of the

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4571.2

APPENDIX 11

funding round will not permit all of the

required official actions (e.g., approval of

Community Planning Boards as required by New

York City) necessary to convey publicly-owned

sites, a letter in the application from

the Mayor or Director of the appropriate

local agency indicating approval of

conveyance of the site, contingent upon the

necessary approval action, is acceptable and

may be approved by the Field Office if it has

had satisfactory experience with timely

conveyance of sites from that public body.

In such cases, documentation shall also

include a copy of the public body\'s evidence

of ownership and identification of any

restrictive covenants.

b\. A map showing the location of the site. The

map must identify the existence and proximity

of the following: single family homes,

apartments, condominiums, shopping centers,

educational, recreational, religious and

medical facilities, and the racial

composition of the neighborhood, with any

area of racial concentration delineated.

c\. Photographs of the site (four directional

views, i.e., north, south, east, west).

Xeroxed copies of photographs are acceptable

if the clarity has not been diminished

significantly.

d\. Evidence that the project as proposed is

permissible under applicable zoning

ordinances or regulations, or a statement of

the proposed action to make the proposed

project permissible and the basis for belief

that the proposed action will be completed

successfully before the receipt of the

conditional application (e.g., a summary of

the results of any recent requests for

rezoning on land in similar zoning

classifications and the time required for

such rezoning, preliminary indications of

acceptability from zoning bodies, etc.).

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4571.2

APPENDIX 11

e\. If acquisition is proposed as the development

method (other than RTC properties), evidence

that the structure has been constructed or

occupied for at least three years prior to

the date of the application and that it was

not previously owned by the Sponsor.

f\. An indication of the Sponsor\'s willingness to

seek a different site if the preferred site

is unapprovable, and if so, a reasonable

assurance (e.g., an alternate site already

identified) that site control will be

obtained within 6 months of notification of

fund reservation.

OR

II\. Identification of a Site

a\. A description of the location of the site,

neighborhood/community characteristics

(include racial and ethnic data) and

amenities, and adjacent housing or

facilities;

b\. A description of the activities undertaken to

identify the site as well as what actions

must be taken and the time needed to obtain

control of the site, if approved for funding;

c\. An indication as to whether the site is

properly zoned and, if it is not, an

indication of the actions/time necessary for

proper zoning; and

d\. A status of the sale of the site (i.e., is it

for sale, are there other contracts pending

on the site).

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4571.2

APPENDIX 11

Exhibit 17: If submitted evidence of site control in Exhibit

16 above, a statement that:

a\. Identifies all persons (families,

individuals, businesses and nonprofit

organizations (identified by race/minority

group and status as owners or tenants))

occupying the property on the

date of submission of the application for a

Section 811 fund reservation (or date of

initial site control, if later);

b\. Indicates the estimated cost of relocation

payments and other services; and

c\. Identifies the staff organization that will

carry out the relocation activities.

NOTE: If any of the relocation costs will be funded

from sources other than the Section 811

capital advance, the Sponsor must provide

evidence of a firm commitment of these funds.

DUE TO POTENTIALLY HIGH RELOCATION COSTS,

SPONSORS ARE ENCOURAGED TO UTILIZE SITES

WHICH INVOLVE MINIMAL OR NO RELOCATION COSTS.

Sponsors may use the Guide Form, Data on

Project Occupancy, Displacement and Real

Property (Appendix 26 of Handbook 4571.2) to

facilitate submission of the recruited

information.

OR

If submitted an identification of a site in

Exhibit 16 above, an indication as to whether the

site would involve relocation.

Exhibit 18: A narrative description of the proposed housing

consistent with Section 890.265(b)(3), including:

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4571.2

APPENDIX 11

a\. The development method (new construction,

rehabilitation, acquisition). If the project

will be developed using innovative

construction or rehabilitation methods or

technologies, identify them and describe how

they will promote energy efficiency or

efficient construction.

b\. Identification of the number and type of

projects (i.e., group home, independent

living facility), the number of units (by

bedroom size) and the number of residents per

independent living facility or the number of

bedrooms and the number of residents per

group home, and the number of residential

staff, if any.

c\. Identification of all community spaces,

special amenities or features planned for the

housing. A description of how the spaces

will be used also must be included. If these

amenities, features or community spaces

would not comply with the design and cost

standards, demonstrate your ability and

willingness to contribute both the

incremental development cost and continuing

operating cost associated with the community

spaces, features or amenities.

d\. A description of the design of the proposed

housing including any special design features

and community space necessary to accommodate

the physical needs of the proposed residents

and the provision of supportive services.

e\. If the Sponsor proposes a group home that

exceeds 8 persons with disabilities or an

independent living facility for persons with

physical disabilities or developmental

disabilities that exceeds 24 residents with

disabilities, it must demonstrate the

following:

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4571.2

APPENDIX 11

\(1\) the increased number of people is

necessary for the economic feasibility

of the project;

\(2\) the project is compatible with the

surrounding residential development and

with the population density of the area

in which it will be located;

\(3\) the project can be integrated

successfully into the neighborhood and

community; and

\(4\) the project is marketable.

Exhibit 19: A schematic drawing of each floor of the project

noting the location of any special design features

and community space as well as a typical bedroom

in a group home or a typical unit in an

independent living facility noting approximate

dimensions of each.

PART 6 - PROVISION OF SUPPORTIVE SERVICES

Exhibit 20: A supportive services plan that includes:

a\. A detailed description of proposed occupants

(i.e., physically disabled, developmentally

disabled, chronically mentally ill).

1\. If proposing to restrict occupancy to

persons with similar disabilities who

will require similar supportive

services, indicate the subcategory of

disability as well as the reasons why

the proposed occupants will require a

particular set of supportive services

unique to their disability. Include a

statement as to whether the Sponsor is

willing to provide unrestricted

occupancy should HUD not approve the

request for restricted occupancy.

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4571.2

APPENDIX 11

2\. If proposing to serve a mix of two or

more of the major disability categories

described in paragraph 1-5 B. of

Handbook 4571.2 in one project, indicate

the disability categories and provide

justification for mixing occupancy

types. Also include a statement as to

whether the Sponsor is willing to limit

occupancy to one disability category

should HUD not approve the request for

mixed occupancy.

Include information on how and from where

potential residents will be referred to the

project and project admission policies.

b\. A detailed description of the needs of

persons with disabilities that the housing is

expected to serve.

c\. A detailed description of the supportive

services proposed to be provided to the

anticipated occupancy, including:

\(i\) The name(s) of the agency(s) which will

be responsible for providing supportive

services and evidence of the service

provider\'s capability and experience in

providing such supportive services;

\(ii\) The manner in which such services will

be provided (i.e., how, when and how

often, where (on/off-site)), including

an assurance that the proposed residents

will receive supportive services based

on their individual needs.

\(iii\) The staffing plan, including a

description of the qualifications of

residential staff, if any, and other

staff necessary to provide the proposed

services.

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4571.2

APPENDIX 11

d\. Identification of the extent of State and

local funds available to assist in the

provision of supportive services.

e\. A letter of intent from each agency that will

provide funding for supportive services

indicating the source of funding and the

extent of commitment.

f\. A letter of support from each agency that

will provide supportive services for

compensation (if other than the Sponsor or

funding source in e. above) and from each

agency that will provide volunteer services,

if any, indicating the service to be provided

and the agency\'s commitment.

g\. If any State or local government funds will

be provided, a description of the State/local

agency\'s philosophy/policy concerning

residential facilities for the population to

be served as well as a demonstration by the

Sponsor that the application is consistent

with State or local plans and policies

governing the development and operation of

facilities to serve individuals of the

proposed occupancy category.

h\. An identification of the name and address of

the State agency to which the Sponsor

submitted one copy of its application for

review of the supportive services plan.

i\. Form HUD-92013-E, Supplemental Application

and Processing Form.

PART 7 - CERTIFICATIONS AND SPECIAL SUBMISSION REQUIREMENTS

Exhibit 21: Signed certifications of the Sponsor(s)\' intent to

comply with Title VI of the Civil Rights Act of

1964, the Fair Housing Act, Section 504 of the

Rehabilitation Act of 1973, the Age Discrimination

Act of 1975, Executive Orders 11063 and 11246,

Section 3 of the Housing and Urban Development Act

of 1968 and affirmative fair housing marketing

requirements at 24 CFR Part 200, subpart M.

6/91 Page 16

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4571.2

APPENDIX 11

Exhibit 22: In accordance with Section 105 of the NAH Act, a

certification from the public official responsible

for submitting a housing strategy, for the

jurisdiction to be served; that, the proposed

activities are consistent with the approved

Comprehensive Affordable Housing Strategy (CHAS)

of the State or unit of general local government

within which the site is located. NOTE: The

requirement for the CHAS certification will not be

effective until Fiscal Year 1992. For Fiscal Year

1991, the response to this Exhibit should be:

NOT APPLICABLE.

Exhibit 23: A certification from the appropriate State or

local agency that it has reviewed the supportive

services plan in the Sponsor\'s application and

that the provision of services identified in the

application is well designed to serve the special

needs of persons with disabilities the housing is

intended to serve, and whether the proposed

facility is/is not consistent with State or local

plans and policies governing the development and

operation of facilities to serve individuals of

the proposed occupancy category. NOTE: The

certification will not be included in the

Sponsor\'s application submission to the Field

Office. The State or local agency shall

complete the certification found in the Sponsor\'s

submission to the agency and forward it to the

Field Office within 30 days of the application

deadline date.

Exhibit 24: A certification by the Sponsor(s) that the

appropriate State agency (single point of

contact), under Executive Order 12372,

Intergovernmental Review, has been contacted to

determine if the Section 811 program is covered

under that State\'s review process, and, if

applicable, the date the application was submitted

to the State.

Exhibit 25: A certification on SF-424, Application for Federal

Assistance, that the Sponsor(s) is not delinquent

on the repayment of any Federal debt.

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4571.2

APPENDIX 11

Exhibit 26: A certification by the Sponsor(s) that the Section

811 and Project Rental Assistance funds will not

be used to lobby the Executive or Legislative

branches of the Federal government.

Exhibit 27: A certification by the Sponsor(s) that it will

comply with the requirements of the Drug-Free

Workplace Act.

Exhibit 28: A certification that the project will comply with

HUD\'s design and cost standards, the Uniform

Federal Accessibility Standards and HUD\'s

implementing regulations at 24 CFR Part 40,

Section 504 of the Rehabilitation Act of 1973 and

implementing regulations at 24 CFR Part 8 (See 24

CFR Part 8.22 for new construction requirements),

and for new construction projects (independent

living facilities only), the design and

construction requirements of the Fair Housing Act

and HUD\'s implementing regulations at 24 CFR Part

100\.

Exhibit 29: A certification by the Sponsor(s) that it will

comply (or has complied) with the acquisition and

relocation requirements of the Uniform Relocation

Assistance and Real Property Acquisition Policies

Act of 1970 (URA), as amended, and implementing

regulations at 49 CFR Part 24 and HUD Handbook

1378, Tenant Assistance, Relocation and Real

Property Acquisition.

Exhibit 30: If proposing a group home to be licensed as an

intermediate care facility for people with

developmental disabilities:

a\. Evidence demonstrating that the proposed

project will provide primarily housing rather

than medical facilities and that the facility

is or will be licensed by appropriate State

agencies.

b\. Description of the medical training of the

staff of the proposed facility and any

nursing services that will be required by the

residents on-site.

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4571.2

APPENDIX 11

c\. Description of the services that will be

funded by Medicaid for residents of the

proposed project, including their nature,

frequency and where the services are to be

provided.

d\. Description of any special design features in

the application that would not be common to

other Section 811 group homes for this

population and the Sponsor\'s rationale for

including them.

e\. Statement certifying that the Individual

Program Plan for each resident will include

participation in an out-of-the-home activity

program for at least six hours each weekday.

f\. The Sponsor\'s written evidence that the State

Medicaid Office recognizes the need for a

tenant contribution to rent and has agreed to

pay the cost of the tenant contribution in

the Medicaid payment to the Sponsor.

In an ICF, the tenant contribution is

determined on the basis of the income the

residents would have received if they were in

any other Section 811 group home. This

income is usually Supplemental Security

Income (SSI). The tenant contribution is 30

percent of that amount.

Occasionally, Sponsors proposing ICFs have

had difficulty in obtaining written evidence

from their State\'s Medicaid Office that it

recognizes the need for a tenant contribution

to rent and agrees to include the cost of the

tenant contribution to rent in the Medicaid

payment to the Owner. To be acceptable, the

written evidence must be signed and dated and

not merely in draft form. It is possible

that an agency other than a State\'s Medicaid

Agency would agree to make contributions to

rent on behalf of ICF tenants. This, too,

would be an acceptable arrangement, if

documented, but also would require that

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4571.2

APPENDIX 11

either the same agency, the Medicaid Agency

or some other public or private source take

on the responsibility for funding the needed

services which also would require

documentation. If private sources are to be

used, the source and the financial capability

of the private contributor must be explained

explicitly.

An example of approvable language from a

State Medicaid Agency (State Office of Mental

Retardation or other State Agency):

\"The (name of State Medicaid Agency)

recognizes the need for a tenant payment and

agrees to pay that cost, based on the SSI

income residents would receive if they were

living in a non-ICF/MR group home, in the

Medicaid payment to the Owner.\"

g\. A statement as to whether the Sponsor is

willing to have the application processed as

a regular Section 811 group home should HUD

not approve the ICF request.

SECTION III - GENERAL PROGRAM REQUIREMENTS AND FORMS

1\. All projects/sites are subject to HUD environmental

regulations 24 CFR Part 50, Protection and Enhancement of

Environmental Quality, implementing Section 102(2) of the

National Environmental Policy Act. These regulations also

include, in 24 CFR 50.4, other applicable environmental

statutes, Executive Orders and HUD regulations (e.g.,

National Historic Preservation Act, Executive Order 11988 on

Floodplain Management, etc.). NOTE: The Environmental

Clearance Officer in the HUD Field Office will provide

guidance with these requirements.

2\. Title VI of the Civil Rights Act of 1964, Fair Housing Act,

Section 504 of the Rehabilitation Act of 1973, the Age

Discrimination Act of 1975, Executive Orders 11063 and

11246, Section 3 of the Housing and Urban Development Act of

1968 and Affirmative Fair Housing Marketing Requirements at

24 CFR Part 200, Subpart M and all implementing rules,

regulations and requirements pertaining to these laws and

Executive Orders.

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4571.2

APPENDIX 11

Residency preferences will be permitted only to the extent

the preference is not inconsistent with the objectives of

the Affirmative Fair Housing Marketing (AFHM) Regulations

and the provisions of the AFHM Plan. NOTE: The Equal

Opportunity staff in the HUD Field Office will assist in

resolving any questions concerning the rules, regulations

and requirements pertaining to the laws and Executive Orders

described above.

3\. The Davis-Bacon Requirements and the Contract Work Hours and

Safety Standards Act. NOTE: The Labor Relations staff in

HUD Field Office will provide guidance in this area.

4\. Comprehensive Housing Affordability Strategies and

Relocation Requirements. NOTE: Community Planning and

Development staff in the HUD Field Office will provide

guidance in these areas.

5\. HUD Minimum Property Standards, local building codes,

Uniform Federal Accessibility Standards (UFAS) (A117.1) and

HUD\'s implementing regulations at 24 CFR Part 40, Section

504 of the Rehabilitation Act of 1973 and implementing

regulations at 24 CFR Part 8 (See 24 CFR Part 8.22 for new

construction requirements), and for new construction

projects (independent living facilities), the design and

construction requirements of the Fair Housing Act and HUD\'s

implementing regulations at 24 CFR Part 100.

6\. Forms. Certifications for lobbying, drug-free workplace,

supportive services, Executive Order 12372, relocation,

HUD\'s design and cost standards and Standard Form-LLL are

Attachments of the Housing Allocation Notice. The following

forms as required by Part II of this Package are attached

for your convenience in preparing the application:

\- Form HUD-92013 (Instructions are discussed below.)

\- Form HUD-92013E

\- Form SF-424 (4/88 revision must be used)

\- Form HUD-92531A-EH

\- Form HUD-2530

\- Form HUD-92290

\- Form HUD-92417

\- Form HUD-2013 Supplement

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4571.2

APPENDIX 11

INSTRUCTIONS FOR COMPLETING FORM HUD-92013

For purposes of submitting an application for a Section 811 Fund

Reservation, pages 1 and 3 as noted below shall be completed by

all applicants. It should be noted that two items (i.e.,

metropolitan/nonmetropolitan classification and minority

classification) are not contained on the form. The instructions

indicate the applicable places to identify this information on

the Form HUD-92013.

Section A - Project Identification: Complete Item 1. Items

2 and 3 will be completed by the HUD Field Office.

Section B - Purpose of Application: Check Block 3, as well

as the Block for Mortgage Insurance. However, mark through

\"Mortgage Insurance\" and write in Section 811 Capital

Advance Program. In addition to identifying the Capital

Advance amount, applicants must identify if funds are to be

used in a metro or nonmetro area.

Section C - Location and Description of Property: Complete

in its entirety. In completing Item 7., specify whether the

project is a group home (GH) or independent living facility

(ILF) on the line immediately following the number of

revenue units (i.e., 6GH). In a group home, the number of

revenue units will equal the number of residents with

disabilities (not the number of bedrooms). On the TOTAL

line, also enter the number of residents with disabilities,

even if there will be an additional bedroom for residential

staff since the development cost limits for group homes

incorporate the cost of an additional bedroom for

residential staff. Thus, leave the non-revenue unit line

blank. In an independent living facility, enter the number

of units for residents with disabilities on the revenue

line, the number of units for residential staff on the

non-revenue line, and enter the total of the two on the TOTAL

line.

Section D - Information Concerning Land or Property:

Complete, except for Item 8 which is satisfied by the

response to Exhibit 15.

Section E - Estimate of Income: All items, except 2, 6 and

7\.

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4571.2

APPENDIX 11

Section F - Equipment and Services and Section F-1:

Complete, as applicable.

Section K - Names, Addresses and Telephone Numbers:

Complete in its entirety. In addition, identify if SPONSOR

is minority or nonminority. A minority organization is one

in which more than 50 percent of the board members are

minority (i.e., Black, Hispanic, Native American, Asian

Pacific, Asian Indian, or Hasidic Jewish). The \"other\"

category is not acceptable.

If development team members (i.e., architect, attorney,

contractor) are identified, complete where applicable.

Section L - Application (SAMA and Feasibility Letter): Not

applicable.

Section M: All applicants check Block 3 and an authorized

officer of the SPONSOR must sign and date. The following

certification must be submitted with the application and

signed by an authorized officer of the applicant:

The SPONSOR certifies that the Form HUD-92013 and Exhibits

in this Application Request are true and correct:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Legal Name of Sponsor)

By: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Authorized Officer of Sponsor)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Title)

Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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4571.2

APPENDIX 11

SPONSOR\'S FUND RESERVATION APPLICATION CHECKLIST

The following checklist is a summary of the steps and

exhibits involved in the application process for a Section 811

Capital Advance for housing for persons with disabilities. The

checklist is a guide for determining whether your application is

completed and properly submitted. All exhibits must be completed

according to instructions in the application package.

Application Process:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Steps in the

Application Process Completed

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1\. Obtained copy of application package \_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Attended Field Office Workshop \_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. Completed all exhibits of application \_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. Submitted application to Field Office by

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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Application Requirements:

Exhibit Included in

Number Description Application

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1 Form HUD-92013 \_\_\_\_\_\_\_\_\_\_\_\_\_\_

2 Form HUD-92531A \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Consultant\'s Resume \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Identity of Interest &

Disclosure Certification \_\_\_\_\_\_\_\_\_\_\_\_\_\_

3 Articles of Incorporation,

Constitution, etc. \_\_\_\_\_\_\_\_\_\_\_\_\_\_

By-laws \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Incumbency Certificate \_\_\_\_\_\_\_\_\_\_\_\_\_\_

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4571.2

APPENDIX 11

IRS Tax Exemption Ruling \_\_\_\_\_\_\_\_\_\_

Conflict of Interest Resolution \_\_\_\_\_\_\_\_\_\_

4 Narrative - Legal authority

to sponsor project & assist Owner \_\_\_\_\_\_\_\_\_\_

Narrative - Will form Owner \_\_\_\_\_\_\_\_\_\_

5 Narrative - Community ties \_\_\_\_\_\_\_\_\_\_

6 Form HUD-2530 \_\_\_\_\_\_\_\_\_\_

7 Narrative - Financial & legal

actions taken or pending \_\_\_\_\_\_\_\_\_\_

8 Narrative - Description of

previous housing experience \_\_\_\_\_\_\_\_\_\_

9 Narrative - Description of

management experience \_\_\_\_\_\_\_\_\_\_

10 Board Resolution of support \_\_\_\_\_\_\_\_\_\_

11 Narrative - Experience serving

minorities & with minority business \_\_\_\_\_\_\_\_\_\_

12 List of other applications submitted \_\_\_\_\_\_\_\_\_\_

13 Estimate of start-up expenses \_\_\_\_\_\_\_\_\_\_

Form-HUD 92290 (If 106(b) applicable) \_\_\_\_\_\_\_\_\_\_

14 Certified Board Resolution committing

funds \_\_\_\_\_\_\_\_\_\_

Narrative - Financial history \_\_\_\_\_\_\_\_\_\_

Financial statements for past

three years

Form HUD-2013 Supplement \_\_\_\_\_\_\_\_\_\_

List of prior year projects \_\_\_\_\_\_\_\_\_\_

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457.2

APPENDIX 11

15 Narrative - Need for supportive

housing \_\_\_\_\_\_\_\_\_\_

16 Evidence of site control \_\_\_\_\_\_\_\_\_\_

Map showing site location \_\_\_\_\_\_\_\_\_\_

Photographs of site \_\_\_\_\_\_\_\_\_\_

Evidence of permissive zoning \_\_\_\_\_\_\_\_\_\_

Willingness to seek alternate site \_\_\_\_\_\_\_\_\_\_

Identification of site \_\_\_\_\_\_\_\_\_\_

Description of site location \_\_\_\_\_\_\_\_\_\_

Description of activities to identify

site/steps needed for site control \_\_\_\_\_\_\_\_\_\_

Indication of proper zoning \_\_\_\_\_\_\_\_\_\_

Status of sale of site \_\_\_\_\_\_\_\_\_\_

17 Data on Project Occupancy,

Displacement and Real Property

Acquisition \_\_\_\_\_\_\_\_\_\_

If site control:

Narrative - Persons to be relocated \_\_\_\_\_\_\_\_\_\_

Estimated cost of relocation \_\_\_\_\_\_\_\_\_\_

Narrative - Relocation staff \_\_\_\_\_\_\_\_\_\_

If site identified:

Indication of relocation \_\_\_\_\_\_\_\_\_\_

18 Narrative - Description of proposed

housing \_\_\_\_\_\_\_\_\_\_

19 Schematic drawings \_\_\_\_\_\_\_\_\_\_

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4571.2

APPENDIX 11

20 Narrative - Description of disabled

persons to be served \_\_\_\_\_\_\_\_\_\_

Narrative - Needs of disabled

residents \_\_\_\_\_\_\_\_\_\_

Description of services:

Name/capability/experience of

service provider \_\_\_\_\_\_\_\_\_\_

Narrative - service provision \_\_\_\_\_\_\_\_\_\_

Staffing plan \_\_\_\_\_\_\_\_\_\_

Identification of State/local funds \_\_\_\_\_\_\_\_\_\_

Letters of intent from service

providers \_\_\_\_\_\_\_\_\_\_

Form HUD-92013E \_\_\_\_\_\_\_\_\_\_

21 Civil Rights, Equal Opportunity,

etc. certifications \_\_\_\_\_\_\_\_\_\_

22 CHAS certification (Not Applicable

for FY 1991) \_\_\_\_\_\_\_\_\_\_

23 Submitted application to State/local

agency for certification \_\_\_\_\_\_\_\_\_\_

24 Certification of conformance

with EO 12372 \_\_\_\_\_\_\_\_\_\_

25 SF-424 \_\_\_\_\_\_\_\_\_\_

26 Lobbying Certification \_\_\_\_\_\_\_\_\_\_

27 Drug-free Workplace Certification \_\_\_\_\_\_\_\_\_\_

28 Design & Cost Standards

Certification \_\_\_\_\_\_\_\_\_\_

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4571.2

APPENDIX 11

29 Certification of Compliance with

Relocation and Acquisition

Requirements \_\_\_\_\_\_\_\_\_\_

30 If proposing intermediate care

facility:

Evidence that facility will be

housing not medical \_\_\_\_\_\_\_\_\_\_

Description of staff medical

training/any on-site nursing svcs. \_\_\_\_\_\_\_\_\_\_

Description of Medicaid-funded svcs. \_\_\_\_\_\_\_\_\_\_

Description of special design

features \_\_\_\_\_\_\_\_\_\_

Statement re: residents\'

out-of-home activities \_\_\_\_\_\_\_\_\_\_

Evidence that State Medicaid Agency

will include tenant payment in

Medicaid payment to Sponsor \_\_\_\_\_\_\_\_\_\_

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