HomeMy WebLinkAbout02.28.13 Special EDA Packet ACz
A
AGENDA
SPECIAL ECONOMIC DEVELOPMENT AUTHORITY MEETING
FEBRUARY 28, 2013
6:30 P.M.
CITY COUNCIL CHAMBERS
Todd Larson, Chair; Geraldine Jolley,Vice-Chair
Douglas Bonar, Steve Wilson, Kirk Zeaman
Action Taken
1. Call Meeting to Order
2. Pledge of Allegiance
3. Roll Call
4. Approve Agenda
5. New Business
a) Approve CDBG Business Development Grant Agreement
Baldys BBQ
b) Open to Business Program Presentation—Laurie Crow
6. City Staff Reports/Open Forum/Discussion
a) City Council Visits
7. Adjourn
ao``�` i���► City of Farmington
430 Third Street
Farmington,Minnesota
651.280.6800•Fax 651.280.6899
www.cifarmington.mn.us
TO: EDA Members
FROM: Lee Smick,AICP CNU-A
City Planner/Economic Development
SUBJECT: Baldy's BBQ—Business Grant Agreement
DATE: February 28,2013
INTRODUCTION
Brian Wheeler and Natasha Coursole, owners of Baldy's BBQ, are requesting the EDA approve their Business
Development Grant agreement(Ex. A)for$15,000 (the maximum amount allowed for the Business Development Grant)
offered by the Federal Government's CDBG program. In approving the funding, the EDA would also approve the grant
agreement. The available balance in the Business Development Grant program fund is$22,377.50.
DISCUSSION
Mr.Wheeler(overseeing the project)has owned and operated the Baldy's BBQ restaurant in Lakeville for a number of
years and he is now pursuing the opening of a second restaurant in Farmington at 122 Elm Street,the former Burger King
location. They hope to open April 1,2013. Mr.Wheeler approached City staff and asked if there were any funding
incentives to assist with his start up costs. Staff and the Dakota County CDA worked with Mr.Wheeler on reviewing the
CDBG Business Development Grant. There is a provision in the grant for Business Expansion assistance for existing,
relocating,and expanding businesses within the City. On February 4,2013,the City Council approved a revision to the
Business Development Grant to allow"new"business to be funded through this program,qualifying Mr.Wheeler to
pursue the grant. The grant allows for a new or expanding business to purchase equipment if the additional equipment
results in additional product or service offerings by the company. Staff and the CDA agrees that kitchen equipment,
signage,and a computer system meet these equipment defmitions.
The Business Development Grant requirements have been met by Mr.Wheeler. Underlined below,are specific
requirements pertaining to the Baldy's BBQ application and they are as follows:
Business Expansion Assistance. One time grant funding for a new or existing Farmington business that is
establishing a new business,expanding their current facility,relocating to,or constructing a facility elsewhere
within the city limits. Relocation outside of the City of Farmington within three years of receipt of grant funding,
or sale of equipment purchased with grant funding within three years will trigger repayment of grant funding in
full. The Applicant would have to meet the criteria for the national objective of benefiting low to moderate
income persons as defined by the Federal Department of Housing and Urban Development through job creation.
Job Creation Requirements and Wage and Income Reporting. Applicants must meet the CDBG national objective
of benefiting low to moderate income persons,the Applicant will be required to verify that 51%of permanent
jobs created or retained on a full time equivalent basis are low to moderate income. These jobs must be
documented as either being held by or available to low to moderate income persons(per 24 CFR Part 570.208(a)
(4)). Verification must be submitted annually to the Project Coordinator for a period of five years.
Notice to Proceed.A preconstruction conference will be held with the Program Coordinator,the Building
Official,the Applicant and contractors and subcontractors to ensure awareness and compliance with Davis-Bacon
requirements and any other requirements necessary to begin the project. A notice to proceed will be issued after
the preconstruction conference. The contractor will normally have one(1)year in which to complete the awarded
contract.If construction work does not begin within 90 days of the award of contract the Grant Agreement is null
and void;however,the Applicant may apply for one extension if necessary. The length of the extension will be
determined on a case-by-case basis.
CDBG Payment. All CDBG funds will be disbursed by the Dakota County CDA upon authorization by the
Applicant and the City of Farmington. Payments will be made only after all project work has been completed
according to the authorized scope of work,and has been accepted by the Applicant. Funds will be released once
all improvements are complete to the satisfaction of the City Building_Official and once title ownership,Davis-
Bacon wage payments and other requirements are satisfied with the CDA and the City, The Building Official and
City staff will inspect the final project,and a Certificate of Occupancy(CO)or a Temporary Certificate of
Occupancy(TCO)will be issued by the Building Inspections Division. The CO or TCO as well as lien waivers
are required before the CDA releases funds.
Staff has attached forms for the EDA's review showing the procedure by staff and the CDA in order to meet HUD
requirements(Ex. B). The forms are completed after the EDA has approved the Application and Grant Agreement and
labor or employees are calculated. Self Certification Form will need to be submitted after the hiring of Mr.Wheeler's
employees.
Bids for Equipment
Per the grant,a minimum of three(3)competitive bids must be solicited and two(2)competitive bids must be obtained
for each improvement project the Applicant proposes for Program funding.The contract will be awarded to the lowest bid
unless the applicant can show reason why no additional bids were pursued. In this case,Mr.Wheeler has submitted a
letter stating that the Farmington restaurant requires a universal computer system to be able to interface with the Lakeville
restaurant(Ex.B)because it is considered part of the business establishment/expansion and the additional equipment
results in additional product or service offerings by the company. Staff and the CDA have agreed to this reasoning of
creating a universal system for interfacing the restaurant in Lakeville with his new restaurant in Farmington. Because the
computer system by Dynamic Products Midwest is operating at the Lakeville restaurant,the computer system bid
submitted is approved as part of the funding request.
Computer System
Focus POS Software from Dynamic Products Midwest-$8,266.00-Preferred,please see explanation
The remaining equipment purchases have met the 3-bid requirement and the lowest bid has been preferred by Mr.
Wheeler. The bids are as follows:
Smoker
Bid#1 -Convecture Tri Oven Multi-Use Smoker: $5,400-Preferred
Bid#2-Smart Smoker Model SM200: $6,615.00
Bid#3 -Smart Smoker Model SM360: $9,655.00
2
Range
Bid#1—Comstock Castle Model No.FK430- 1.5RB: $4,496.50-Preferred
Bid#2—Southbend Model No.P32A-XC: $7,809.59.
Bid#3—Southbend Model No.Pi8N-X: $7,617.87
Fryer
Bid#1 —Vulcan Model No.LG400: $2,311.50-Preferred
Bid#2—Comstock Castle Model No.P32A-XC: $2,819.30.
Bid#3—Southbend Model No.Pi8N-X: $3,071.06
Convection Oven
Bid#1 —Southbend Model No.BGS/22SC: $5,519.41 -Preferred
Bid#2—Vulcan Model No.VC44GD: $6,812.62
Bid#3—Blodgett Oven Model No.ZEPH240GPLUSDBL: $7.910.35
The total for the items above calculates to$25,993.41. Mr.Wheeler is requesting funds of$15,000 to cover his kitchen,
computer system,and signage to the fullest funding amount available,he is required to spend$30,000 to meet the 1:1
match providing the full$15,000 he has requested. The remaining sign costs are$4,006.59. As shown below,his
preferred bid is$9,364.87,covering the$4,006.59,adding to$30,000. Two bids were submitted because the covering
cost of$4,006.59 would be the same for all bids. The sign has recently been purchased and installed by the preferred sign
company,Capstone Creative,LLC. At the time of installation,staff and the CDA met with Mr.Wheeler and approved the
signage funding in order for the sign to be installed and immediately be recognized by the community. The bids for the
sign are shown below.
Restaurant Sign
Bid#1 -Action Plus Sign Company Pylon cabinet sign and custom channel letter sign—9,260.00
Bid#2-Capstone Creative,LLC—Cabinet sign and custom channel letter sign(wall sign)-$9,364.87 Preferred,
Farmington owned business
A large portion of the sign installation is labor Capstone Creative, LLC needs to submit Davis Bacon prevailing wage
paperwork. I have attached the wage determination and it has a sign installer for a job description,found on page 6 of the
attachment. The person must be paid at least $25.37 per hour (combo of fringe and benefits). The City Attorney has
reviewed the application and grant agreement.
ACTION REQUESTED
Award a Business Development Grant of$15,000 to Coursole and Wheeler Inc. (Baldy's BBQ) and execute the attached
grant agreement of Community Development Block Grant money.
Respectfully submitte
•
Lee mick,AICP CNU-A
City Planner/Economic Development
Cc: Brian Wheeler and Natasha Coursole
3
Business Development Grant Program
kAilt
Grant Application
APPLICANT INFORMATION MP
•A PRO"'
NAME OF APPLICANT(S) 04/V �/ e6
ADDRESS a01) 1L , )1
CITY,STATE, ZIP LA- (0t )1?., in1 V � v / /
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PHONE ✓ NC %C% 7c_9
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SOCIAL SECURITY# 1-1
BUSINESS INFORMATION
LEGAL NAME OF BUSINESS CLOUT snlI' A 1'
ADDRESS 7 )() J f 274 'J14
CITY, STATE,ZIP 104 ;6 M"1 f' ø
BUSINESS PHONE 75)/' 7/7. 7 f?! FAX
FEDERAL TAX ID# "g.-[ " 5 '' '70 DATE ESTABLISHED //2o(2o1 3
SOLE PROPRIETORSHIP CORPORATION )6 PARTNERSHIP
CONTRACT FOR DEED MORTGAGE PRINCIPAL /VA-
LESSEE TERMS OF LEASE
OWNERSHIP INTEREST OF ALL PARTIES NAMED ON TITLE: C
NAME /t%/a4' ' 614(50// INTEREST 5-6 `�
b
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NAME �t//t/U AicL' INTEREST �O
NAME INTEREST
PROPERTY INFORMATION
ESTIMATED DATE OF BUILDING CONSTRUCTION
ESTIMATED CURRENT TAX MARKET VALUE
NUMBER OF STORIES NUMBER OF BUSINESSES
NUMBER OF BUILDINGS NUMBER OF APARTMENTS
HAS THIS BUILDING BEEN HISTORICALLY REGISTERED?
PROJECT INFORMATION
BRIEF DESCRIPTION OF PROPOSED PROJECT:
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11
-
j14 ael fOafegi etYll traIl 00(1g 15-214.
• ESTIMATED PROJECT COSTS
EXTERIOR/FAcADE ESTIMATED COST
INTERIOR • ESTIMATED COST
ELECTRICAL ESTIMATED COST
PLUMBING ESTIMATED COST
MECHANICAL • ESTIMATED COST
FIRE SUPPRESSION ESTIMATED COST •
MONTHLY LEASE PAYMENT(MICROENTERPRISE APPLICANTS ONLY) ESTIMATED COST
TOTAL ESTIMATED COST
FUNDING INFORMATION
TOTAL GRANT AMOUNT REQUESTED $ ` ri )
APPLICANT FUNDS $ 025-ova
ADDITIONAL SOURCES OF FUNDING $
M�
NAME OF FINANCIAL INSTITUTION AA 417 f t. S
ADDRESS /755_5 1YVQoJ gaff__
CITY,STATE,ZIP ,; //izz'L-- ,tZ V .55 o
r Yi-1
CONTACT PERSON PHONE# (3 / 3/2- 976> /
REQUIRED ATTACHMENTS
1. Financial statements-Provide balance sheets and income statements for the past two years
2. Personal financial statements of all principals
3. Current satisfactory credit report of owners/partners
4. Corporate resolution (if applicable)
5. Completed W-9 form
6. Most current property tax statement
7. Letter from the county clerk/treasurer verifying that there are no outstanding judgments or tax liens against the
property
8. Letter from the City of Farmington Finance Department indicating any outstanding balance for prior financial
assistance or business incentives if applicable.
9. Business Plan (for microenterprise applicants only)
I/We declare that the information provided on this application and the accompanying attachments is true and complete
to the best of my/our knowledge. I/We understand that any intentional misstatements will be grounds for
disqualification and that the City of Farmington has the right to verify this information. I/We agree to provide the
project coordinator reasonable access to information and reasonable access to the construction project site so that they
may monitor project implementation.
APPLICA (S)
DATE 40///3
..1�. _ DATE r3 l
City of Farmington
Business Development Grant
Baldy's BBQ
Grant Agreement
This agreement is made and entered into this day of ,2013,by and between Coursole&
Wheeler,Inc.,a Minnesota corporation,having its principal offices at 21219 Ilavista Way,Lakeville,MN 55044,
d/b/a Baldy's BBQ, (hereinafter referred to as"Grantee")and the Economic Development Authority in and for
the City of Farmington,a public body corporate and politic,having its principal offices at 430 Third Street,
Farmington,Minnesota(hereinafter referred to as"Grantor").
WHEREAS,the Grantor is a Subrecipient of Dakota County Community Development Agency in the County's
Community Development Block Grant("CDBG")Program;and
WHEREAS,the Grantor has established a Business Development Grant funded by its entitlement of CDBG
funds;and
WHEREAS,the Grantee has proposed a business development project to include business expansion or
relocation assistance for the restaurant it operates as Baldy's BBQ located at 122 Elm St.,Farmington,Minnesota;
and
WHEREAS,one hundred percent(100%)of the shares of Grantee are held by Brian Wheeler and Natasha
Coursolle("Business Owners");and
NOW THEREFORE,in consideration of the Grant and the mutual covenants contained herein,the parties agree
as follows:
1. The Grantor agrees to provide a maximum of$15,000.00(fifteen thousand dollars and no cents)in CDBG
funds ("Grant Funds")to the Grantee for the acquisition of new equipment including,signage,computer
operating system,smoker and range,fryer and convection oven to expand the business at its new location
in Farmington,thereby offering additional products and services.
2. Grant Funds will be paid on a reimbursement basis upon evidence of payments made for acquisition of
the equipment approved under this Agreement.
3. The Grantee will provide the Grantor copies of all bid documents(if applicable),appraisals and
verification of payments for equipment in the form of receipts and copies of checks or payment issued.
4. The Grantee will be required to verify that 51%of permanent jobs created or retained on a full time
equivalent basis are low to moderate income. These jobs must be documented as either being held by or
available to low to moderate income persons(per 24 CFR Part 570.208 (a)(4)).
5. The Grantee agrees to submit verification of employee income annually to the Project Coordinator for a
period of five years.
6. The Grantee agrees not to relocate outside of the City of Farmington for a period of three years after the
date of this grant agreement.
7. The Grantee shall defend,indemnify,and hold harmless the officers and employees of the Grantor and the
Dakota County CDA from all liability and claims for damages arising from bodily injury,death,property
damage,sickness,disease,or loss and expense resulting from or alleged to result from Grantee's
operations under this Agreement.
1
8. The Grantee agrees to keep in force at all times during the term of this Agreement a comprehensive
general liability insurance policy in the amount of$1,000,000.00 per occurrence,covering any injury
and/or property damage, including damage caused by any negligent act or omission on the part of the
Grantee,its agents,or employees in the performance of or with relation to the work or services to be
performed or furnished by the Grantee under the terms of this Agreement.The Grantee further agrees to
maintain worker's compensation coverage in accordance with state law. Evidence of such insurance
policies shall be provided to the Grantor prior to initiation of clearance activities covered by this
Agreement.
9. The Grantee agrees to comply with all local,state,and federal equal employment opportunity laws and
ordinances as they pertain to unlawful discrimination on account of race,color,creed,religion,national
origin,sex,marital status, status with regard to public assistance, familial status,disability or age.
10. The Grantee agrees to comply with other Federal CDBG contract provisions as detailed in Attachment A.
11. Grantee agrees that if there occurs any breach in the terms of this agreement after payment of CDBG
funds that is not cured within 30 days or such longer period as may be necessary after written notice from
the Grantor to the Grantee of such breach, the Grantor may take whatever action, including legal,
equitable or administrative action, which may appear necessary or desirable to the Grantor, to enforce
performance and observance of any obligation, agreement, or covenant of the Grantee under this
Agreement. In addition, upon said breach and the failure to cure said breach within 30 days or such
longer period as may be necessary after written notice from the Grantor to the Grantee of such breach,the
Grantor shall have the option to require the Grantee to reimburse the Grantor CDBG funds, plus any
expenses incurred by the Grantor to include, but not necessarily be limited to, administrative and legal
expenses and any investment of CDBG funds.
IN WITNESS WHEREOF,the parties hereto have hereby executed this Agreement as of the year and date written
above.
GRANTOR: GRANTEE:
CITY OF FARMINGTON COURSOLE&WHEELER,INC.
ECONOMIC DEVELOPMENT . Y.' :ORITY
40111011.!Pr:
BY.,�_ BY: ni d;),L, L. c- fiL1/J1 l( ,
//Ale-
ITS: ITS:
2
Attachment A-PROVISIONS FOR CDBG FUNDED CONTRACTS
L SPECIAL EQUAL OPPORTUNITY PROVISIONS
A. Activities and Contracts Not Subject to Executive Order 11246,as Amended
(Applicable to Federally assisted construction contracts and related subcontracts of$10,000 and under.)
During the performance of this contract,the contractor agrees as follows:
1. The Contractor shall not discriminate against any employee or applicant for employment because of race,color,
religion, sex, or national origin. The Contractor shall take affirmative action to ensure that applicants for
employment are employed, and that employees are treated during employment, without regard to their race,
color, religion, sex, or national origin. Such action shall include, but not be limited to, the following:
employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination;
rates of pay or other forms of compensation;and selection for training,including apprenticeship.
2. The Contractor shall post in conspicuous places,available to employees and applicants for employment,notices
setting forth the provisions of this non-discrimination clause. The Contractor shall state that all qualified
applicants will receive consideration for employment without regard to race, color, religion, sex, or national
origin.
3. Contractors shall incorporate the foregoing requirements in all subcontracts.
B. Executive Order 11245
(Applicable to Federally assisted contracts and related subcontracts of$10,000 and over.)
1. Section 202 Equal Opportunity Clause
During the performance of this contract,the contractor agrees as follows:
(A) The contractor will not discriminate against any employee or applicant for employment because of race,
color,religion,sex, or national origin. The contractor will take affirmative action to ensure that applicants
are employed, and that employees are treated during employment, without regard to their race, color,
religion,sex,or national origin. Such action shall include,but not be limited to the following:employment,
upgrading,demotion,or transfer;recruitment,or recruitment advertising;layoff or termination,rates of pay
or other forms of compensation;and selection for training,including apprenticeship. The contractor agrees
to post in conspicuous places, available to employees and applicants for employment, notices to be
provided setting forth the provisions of this non-discrimination clause.
(B) The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the
contractor, state that all qualified applicants will receive consideration without regard to race, color,
religion,sex,or national origin.
(C) The contractor will send to each labor union or representative of workers with which he has a collective
bargaining agreement or other contract or understanding, a notice advising the said labor union or workers'
representatives of the contractor's commitment under this section, and shall post copies of the notice in
conspicuous places available to employees and applicants for employment.
(D) The contractor will comply with all provisions of Executive Order 11246 of September 24, 1965,and of the
rules,regulations,and relevant orders of the Secretary of Labor.
(E) The contractor will furnish all information and reports required by Executive Order 11246 of September
24, 1965, and by rules, regulations, and orders of the Secretary of Labor, or pursuant thereto, and will
permit access to his books, records, and accounts by the Department and the Secretary of Labor for
purposes of investigation to ascertain compliance with such rules,regulations,and others.
(F) In the event of the contractor's non-compliance with the non-discrimination clauses of this contract or with
any of the said rules, regulations, or orders, this contract may be cancelled, terminated, or suspended in
whole or in part and the contractor may be declared ineligible in part and the contractor may be declared
ineligible for further Government contracts in accordance with procedures authorized in Executive Order
11246 of September 24, 1965, or by rule, regulation, or order of the Secretary of Labor, or as otherwise
provided by law.
(G) The contractor will include the provisions of the sentence immediately preceding paragraph (A)and the
provisions of paragraphs(A)through(G)in every subcontract or purchase order unless exempted by rules,
regulations,or orders of the Secretary of Labor issued pursuant to section 204 of Executive Order 11246 of
1
September 24, 1965, so that such provisions will be binding upon each subcontractor or vendor. The
contractor will take such action with respect to any subcontract or purchase order as the Department may
direct as a means of enforcing such provisions, including sanctions for non-compliance. Provided,
however, that in the event a contractor becomes involved in, or is threatened with, litigation with a
subcontractor or vendor as a result of such direction by the Department, the contractor may request the
United States to enter into such litigation to protect the interest of the United States.
2. Notice of Requirement for Affirmative Action to Ensure Equal Employment Opportunity (Executive Order
11246).
(A) The Offer's or Bidder's attention is called to the `Equal Opportunity Clause" and the "Standard Federal
Equal Employment Opportunity Construction Contract Specifications"set forth herein.
(B) The goals and timetables for minority and female participation, expressed in percentage terms for the
Contractor's aggregate workforce in each trade on all construction work in the covered area,are as follows:
Goals for Women/Minority Participation 5%Overall
Timetables: N/A
These goals are applicable to all the Contractor's construction work (whether or not it is Federal or
federally assisted)performed in the covered area. The Contractor's compliance with the Executive Order
and the regulations in 41 CFR Part 60-4 shall be based on its implementation of the Equal Opportunity
Clause, specific affirmative action obligations required by the specifications set forth in 41- CFR 60-4.3
(a), and its efforts to meet the goals established for the geographical area where the contract resulting from
this solicitation is to be performed. The hours of minority and female employment and training must be
substantially uniform throughout the length of the contract,and in each trade,and the contractor shall make
a good faith effort to employ minorities and women evenly on each of its projects. The transfer of minority
or female employees or trainees from Contractor to Contractor or from project to project for the sole
purpose of meeting the Contractor's goals shall be a violation of the contract,the Executive Order and the
regulations in 41 CFR Part 60-4. Compliance with the goals will be measured against the total work hours
performed.
(C) The Contractor shall provide written notification to the Director of the Office of Federal Contract
Compliance Programs within 10 working days of the award of any construction subcontract in excess of$
10,000 at any tier for construction work under the contract resulting from this solicitation. The notification
shall list the name, address and telephone number of the subcontractor; employer identification number;
estimated dollar amount of the identification number;estimated dollar amount of the subcontract;estimated
starting and completion dates of the subcontract; and the geographical area in which the contract is to be
performed.
(D) As used in this Notice, and in the contract resulting form this solicitation, the "Covered Area" is Dakota
County,Minnesota.
3. Standard Federal Equal Employment Opportunity Construction Contract Specifications (Executive Order
11246)
(A) As used in these specifications:
(1) "Covered area" means the geographical area described in the solicitation from which this contract
resulted;
(2) "Director" means Director, Office of Federal Contract Compliance Programs, United States
Department of Labor,or any person to whom the Director delegates authority;
(3) "Employer identification number"means the Federal Social Security number used on the Employer's
Quarterly Federal Tax Return,U.S.Treasury Department Form 941.
(4) "Minority"includes:
(a) Black(all persons having origins in any of the Black African racial groups not of Hispanic origin);
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(b) Hispanic (all persons of Mexican, Puerto Rican, Cuban, Central or South American or other
Spanish Culture or origin,regardless of race);
(c) Asian and Pacific Islander (all persons having origins in any of the original peoples of the Far
East,Southeast Asia,the Indian Subcontinent,or the Pacific Islands):and
(d) American Indian or Alaskan Native (all persons having origins in any of the original peoples of
North American and maintaining identifiable tribal affiliations through membership and
participation or community identification).
(B) Whenever the Contractor,or any subcontractor at any tier,subcontracts a portion of the work involving any
construction trade, it shall physically include in each subcontract in excess of$10,000 the provisions of
these specifications and the Notice which contains the applicable goals for minority and female
participation and which is set forth in the solicitations from which this contract resulted.
(C) If the Contractor is participating (pursuant to 41 CFR 60-4.5) in a Hometown Plan approved by the U.S.
Department of Labor in the covered area either individually or through an association,its affirmative action
obligations on all work in the Plan area(including goals and timetables)shall be in accordance with that for
those trades which have unions participating in the Plan. Contractors must be able to demonstrate their
participation in and compliance with the provisions of any such Hometown Plan. Each Contractor or
subcontractor participating in an approved Plan is individually required to comply with its obligations
under the EEO clause, and to make good faith effort to achieve each goal under the Plan in each trade in
which it has employees. The overall good faith performance by other Contractors or Subcontractors toward
a goal in an approved Plan does not excuse any covered Contractor's or Subcontractor's failure to take
good faith efforts to achieve the Plan goals and timetables.
(D) The Contractor shall implement the specific affirmative action standards provided in paragraphs (G)(1)
through(16)of these specifications.The goals set forth in the solicitation from which this contract resulted
are expressed as percentages of the total hours of employment and training of minority and female
employees the Contractor should reasonably be able to achieve in each construction trade in which it has
employees in the covered area. The Contractor is expected to make substantially uniform progress toward
its goals in each craft during the period specified.
(E) Neither the provisions of any collective bargaining agreement, nor the failure by a union with whom the
Contractor has a collective bargaining agreement, to refer either minorities or women shall excuse the
Contractor's obligations under these specifications, Executive Order 11246, nor the regulations
promulgated pursuant thereto.
(F) In order for the non-working training hours of apprentices and trainees to be counted in meeting the goals,
such apprentices and trainees must be counted in meeting the goals, such apprentices and trainees must be
employed by the Contractor during the training period, and the Contractor must have made a commitment
to employ the apprentices and trainees at the completion of their training, subject to the availability of
employment opportunities. Trainees must be trained pursuant to training programs approved by the U.S.
Department of Labor.
(G) The Contractor shall take specific affirmative actions to ensure equal employment opportunity. The
evaluation of the Contractor's compliance with these specifications shall be based upon its efforts to
achieve maximum results from its actions. The Contractor shall document these efforts fully, and shall
implement affirmative action steps at least as extensive as the following;
(1) Ensure and maintain a working environment free of harassment,intimidation,and coercion at all sites,
and in all facilities at which the Contractor's employees are assigned to work. The Contractor shall
specifically ensure that all foremen,superintendents,and other on-site supervisory personnel are aware
of and carry out the Contractor's obligation to maintain such a working environment, with specific
attention to minority or female individuals working at such sites or in such facilities.
(2) Establish and maintain a current list of minority and female recruitment sources, provide written
notification to minority and female recruitment sources and to community organizations when the
Contractor or its unions have employment opportunities available, and maintain a record of the
organizations'responses.
(3) Maintain a current file of the names, addresses and telephone numbers of each minority and female
off-the-street applicant and minority or female referral from a union, a recruitment source or
community organization and of what action was taken with respect to each such individual. If such
individual was sent to the union hiring hall for referral and was not referred back to the Contractor by
the union or,if referred,not employed by the Contractor,this shall be documented in the file with the
reason therefore,along with whatever additional actions the Contractor may have taken.
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(4) Provide immediate notification to the Director when the union or unions with which the Contractor has
a collective bargaining agreement has not referred to the Contractor a minority person or woman sent
by the Contractor, or when the Contractor has other information that the union referral process has
impeded the Contractor's efforts to meet its obligations.
(5) Develop on-the-job training opportunities and/or participate in training programs for the area which
expressly include minorities and women, including upgrading programs and apprenticeship needs,
especially those programs funded or approved by the Department of Labor. The Contractor shall
provide notice of these programs to the sources compiled under(G)(2)above.
(6) Disseminate the Contractor's EEO policy by providing notice of the policy to unions and training
programs and requesting their cooperation in assisting the Contractor in meeting its EEO obligations;
by including it in any policy manual and collective bargaining agreement; by publicizing it in the
company newspaper, annual report, etc.; by specific review of the policy with all management
personnel and with all minority and female employees at lease once a year; and by posting the
company EEO policy on bulletin boards accessible to all employees at each location where
construction work is performed.
(7) Review, at least annually, the company's EEO policy and affirmative action obligations under these
specifications with all employees having any responsibility for hiring, assignment, layoff,termination
or other employment decisions including specific review of these items with onsite supervisory
personnel such as Superintendents, General Foremen,etc.,prior to the initiation of construction work
at any job site. A written record shall be made and maintained identifying the time and place of these
meetings,persons attending,subject matter discussed,and disposition of the subject matter.
(8) Disseminate the contractor's EEO policy externally be including it any advertising in the news media,
specifically including minority and female news media, and providing written notification to and
discussing the Contractor's EEO policy with other Contractors and Subcontractors with whom the
Contractor does or anticipates doing business.
(9) Direct its recruitment efforts,both oral and written,to minority, female and community organizations,
to schools with minority and female students and to minority and female recruitment and training
organizations serving the Contractor's recruitment area and employment needs. Not later than one
month prior to the date for the acceptance of applications for apprenticeship or other training by any
recruitment source, the Contractor shall send written notification to organizations such as the above,
describing the openings,screening procedures,and tests to be used in the selection process.
(10)Encourage present minority and female employees to recruit other minority persons and women and,
where reasonable, provide after school, summer and vacation employment to minority and female
youths both on the site and in other areas of a Contractor's work force.
(11)Validate all tests and other selection requirements where there is an obligation to do so under 41 CFR
part 60-3.
(12)Conduct,at least annually,an inventory and evaluation at least of all minority and female personnel for
promotional opportunities and encourage these employees to seek or to prepare for, through
appropriate training,etc.,such opportunities.
(13)Ensure that seniority practices,job classifications,work assignments and other personnel practices,do
not have a discriminatory effect by continually monitoring all personnel and employment related
activities to ensure that the EEO policy and the Contractor's obligations under these specifications are
being carried out.
(14)Ensure that all facilities and company activities are non-segregated except that separate or single-user
toilet and necessary changing facilities shall be provided to assure privacy between the sexes.
(15)Document and maintain a record of all solicitations of offers for subcontracts from minority and
female construction contractors and suppliers, including circulation of solicitations to minority and
female contractor associations and other business associations.
(16)Conduct a review, at least annually, of all supervisors' adherence to and performance under the
Contractor's EEO policies and affirmative action obligations.
(H) Contractors are encouraged to participate in voluntary associations which assist in fulfilling one or more of
their affirmative action obligations [(G)(1) through (16)]. The efforts of a contractor association,joint
contractor-union, contractor-community, or other similar groups of which the contractor is a member and
participant,may be asserted as fulfilling any one or more of its obligations as enumerated above provided
that the Contractor actively participates in the group, makes every effort to assure that the group has a
positive impact on the employment of minorities and women in the industry, ensures that the concrete
4
benefits of the program are reflected in the Contractor's minority and female workforce participation,
makes a good faith effort to meet its individual goals and timetables, and can provide access to
documentation which demonstrates the effectiveness of actions taken on behalf of the Contractor.
(I) A single goal for minorities and a separate single goal for women have been established. The Contractor,
however, is required to provide equal employment opportunity and to take affirmative action for all
minority groups,both male and female,and all women,both minority and non-minority. Consequently,the
Contractor may be in violation of the Executive Order if a particular group is employed in a substantially
disparate manner(for example,even though the Contractor has achieved its goals for women generally,the
Contractor may be in violation of the Executive Order if a specific minority group of women is
underutilized).
(J) The Contractor shall not use the goals and timetables or affirmative action standards to discriminate against
any person because of race,color,religion,sex,or national origin.
(K) The Contractor shall not enter into any subcontract with any person or firm debarred from Government
contracts pursuant to Executive Order 11246.
(L) The Contractor shall carry out such sanctions and penalties for violation of these specifications and of the
Equal Opportunity Clause, including suspension, termination and cancellation of existing subcontracts as
may be imposed or ordered pursuant to Executive Order 11246, as amended, and its implementing
regulations, by the Office of Federal Contract Compliance Programs. Any Contractor who fails to carry
out such sanctions and penalties shall be in violation of these specifications and Executive Order 11246,as
amended.
(M)The Contractor,in fulfilling its obligations under these specifications,shall implement specific affirmative
action steps,at least as extensive as those standards prescribed in paragraph(G)of these specifications, so
as to achieve maximum results from its efforts to ensure equal employment opportunity. If the Contractor
fails to comply with the requirements of the Executive Order, the implementing regulations, or these
specifications,the Director shall proceed in accordance with 41 CFR 60-4.8.
(N) The Contractor shall designate a responsible official to monitor all employment related activity to ensure
that the company EEO policy is being carried out,to submit reports relating to the provisions hereof as may
be required by the Government and to keep records. Records shall at least include for each employee the
name, address, telephone numbers, construction trade, union affiliation if any, employee identification
number assigned, social security number, race, sex, status (e.g., mechanic, apprentice trainee, helper, or
laborer),dates of changes in status,hours worked per week in the indicated trade,rate of pay,and locations
at which the work was performed. Records shall be maintained in an easily understandable and retrievable
form;however,to the degree that existing records satisfy this requirement,contractors shall not be required
to maintain separate records.
(0) Nothing herein provided shall be constructed as a limitation upon the application of other laws which
establish different standards of compliance or upon the application of requirements for the hiring of local or
other area residents (e.g., those under the Public Works Employment Act of 1977 and the Community
Development Block Grant Program).
4. Segregated Facilities
The Contractor or Subcontractor will not maintain any facility which is provided for their employees in a
segregated manner or permit their employees to perform their services at any location under their control where
segregated facilities are maintained except that separate or single user toilet and necessary changing facilities
shall be provided to assure privacy between the sexes.
C. Section 503 Handicapped—Affirmative Action for Handicapped Workers
(Applicable to Federally assisted contracts and related subcontracts if$2,500 or over.)
1. The Contractor will not discriminate against any employee or applicant for employment because of physical or
mental handicap in regard to any position for which the employee or applicant for employment is qualified.
The Contractor agrees to take affirmative action to employ, advance in employment and otherwise treat
qualified handicapped individuals without discrimination based upon their physical or mental handicap in all
employment practices such as the following: employment, upgrading, demotion or transfer, recruitment,
advertising, layoff or termination, rates of pay or other forms of compensation, and selection for training,
including apprenticeship.
2. The Contractor agrees to comply with the rules, regulations, and relevant orders of the Secretary of Labor
issued pursuant to the Act.
5
3. In the event of the Contractor's noncompliance with the requirements of this clause,actions for noncompliance
may be taken in accordance with the rules, regulations, and relevant orders of the Secretary of Labor issued
pursuant to the Act.
4. The Contractor agrees to post in conspicuous places, available to employees and applicants for employment,
notices in a form to be prescribed by the Director,provided by or through the contracting officer. Such notices
shall state the Contractor's obligation under the law to take affirmative action to employ and advance in
employment qualified handicapped employees and applicants for employment, and the rights of applicants and
employees.
5. The Contractor shall notify each labor union or representative of workers with which it has a collective
bargaining agreement or other contract understanding,that the Contractor is bound by the terms of Section 503
of the Rehabilitation Act of 1973, and is committed to take affirmative action to employ and advance in
employment physically and mentally handicapped individuals.
6. The Contractor will include the provisions of this clause in every subcontract or purchase order of$2,500 or
more unless exempted by rules,regulations,or orders of the Secretary issued pursuant to Section 503 of the Act,
so that such provisions will be binding upon each subcontractor or vendor. The Contractor will take such action
with respect to any subcontract or purchase order as the Director of the Office of Federal Contract Compliance
Programs may direct to enforce such provisions,including action for non-compliance.
D. Section 402 Veterans of the Vietnam Era
(Applicable to Federally assisted contracts and related subcontracts of$10,000 or over.)
1. Affirmative Action for Disabled for Disabled Veterans and Veterans of the Vietnam Era
(A) The Contractor will not discriminate against any employee or applicant for employment because he or she
is a disabled veteran or veteran of the Vietnam Era in regard to any position for which the employee or
applicant for employment is qualified. The Contractor agrees to take affirmative action to employ,advance
in employment and otherwise treat qualified disabled veterans and veterans of the Vietnam Era without
discrimination based upon their disability or veteran status in all employment practices such as the
following: employment upgrading, demotion or transfer, recruitment, advertising, layoff or termination,
rates of pay or other forms of compensation,and selection for training,including apprenticeship.
(B) The Contractor agrees that all suitable employment openings of the Contractor which exist at the time of
the execution of this contract and those which occur during the performance of this contract, including
those not generated by this contract and including those occurring at an establishment of the Contractor
other than the one wherein the contract is being performed but excluding those of independently operated
corporate affiliates, shall be listed at an appropriate local office of the State employment service system
wherein the opening occurs. The Contractor further agrees to provide such reports to such local office
regarding employment openings and hires as may be required. State and local government agencies
holding Federal contracts of$10,000 or more shall also list all their suitable openings with the appropriate
office of the State employment service,but are not required to provide those reports set forth in paragraphs
(D)and(E).
(C) Listing of employment openings with the employment service system pursuant to this clause shall be made
at least concurrently with the use of any other recruitment source or effort and shall involve the normal
obligations which attach to the placing of a bona fide job order, including the acceptance of referrals for
veterans and lion-veterans. This listing of employment openings does not require the hiring of any
particular job applicant or from any particular group of job applicants, and nothing herein is intended to
relieve the Contractor from any requirements in Executive Orders or regulations regarding non-
discrimination in employment.
(D) The reports required by paragraph(B) of this clause shall include, but not be limited to, periodic reports
which shall be filed at lease quarterly with the appropriate local office or, where the Contractor has more
than on hiring location in a State, with the central office of the State employment service. Such reports
shall indicate for each hiring location(1)the number of individuals hired during the reporting period, (2)
the number of non-disabled veterans of the Vietnam era hired, (3)the number of disabled veterans of the
Vietnam era hired,and(4)the total number of disabled veterans hired. The reports should include covered
veterans hired for on-the-job training under 38 U.S.C. 1787. The Contractor shall submit a report within 30
days after the end of each reporting period wherein any performance is made on this contract identifying
data for each hiring location. The Contractor shall maintain at each hiring location copies of the reports
submitted until the expiration of one year after final payment under the contract,during which these reports
6
and related documentation shall be made available, upon request, for examination by any authorized
representatives of the contracting officer or of the Secretary of Labor. Documentation would include
personnel records respecting job openings,recruitment and placement.
(E) Whenever the Contractor becomes contractually bound to the listing provisions of this clause, it shall
advise the employment service system in each State where it has establishments of the name and location of
each hiring location in the State. As long as the Contractor is contractually bound to these provisions and
has so advised the State system,there is no need to advise the State system when it is no longer bound by
this contract clause.
(F) This clause does not apply to the listing of employment openings which occur and are filled outside the 50
states,the District of Columbia,Puerto Rico,Guam and the Virgin Islands.
(G) The provision of paragraphs (B), (C), (D), and (E) of this clause do not apply to openings which the
Contractor proposes to fill from within his own organization or to fill pursuant to a customary and
traditional employer-union hiring arrangement. This exclusion does not apply to a particular opening once
an employer decides to consider applicants outside of his own organization or employer-union arrangement
for that opening.
(H) As used in this clause:
(1) "All suitable employment openings" includes, but is not limited to openings which occur in the
following job categories: Production and non-production; plan and office; laborers and mechanics;
supervisory and non-supervisory; technical; and executive administrative, and professional openings
that are compensated on a salary basis of less than $ 25,000 per year. This term includes full time
employment,temporary employment of more than 3 days duration,and part-time employment. It does
not include openings which the contractor proposes to fill from within his own organization or to fill
pursuant to a customary and traditional employer-union hiring arrangement or openings in an
educational institution which are restricted to students of that institution. Under the most compelling
circumstances an employment opening may not be suitable for listing,including such situations where
the needs of the Government cannot reasonably be otherwise supplied,where listing would be contrary
to national security, or where the requirement of listing would otherwise not be in the best interest of
the Government.
(2) "Appropriate office of the State employment service system" means the local office of the Federal-
State national system of public employment offices with assigned responsibility for serving the areas
where the employment opening is to be filled,including the District of Columbia,Guam,Puerto Rico,
and the Virgin Islands.
(3) "Openings which the Contractor proposes to fill from within his own organization"means employment
openings for which no consideration will be given to persons outside the Contractor's organization
(including any affiliates,subsidiaries, and the parent companies)and includes any openings which the
Contractor proposes to fill from regularly established"recall"lists.
(4) "Openings which the Contractor proposes to fill pursuant to a customary and traditional employer-
union hiring arrangement" means employment openings which the Contractor proposes to fill from
union halls,which is part of the customary and traditional hiring relationship which exists between the
Contractor and representatives of his employees.
(I) The Contractor agrees to comply with the rules,regulations, and relevant orders of the Secretary of Labor
issued pursuant to the act.
(J) In the event of the Contractor's non-compliance with the requirements of this clause, actions for non-
compliance may be taken in accordance with the rules,regulations, and relevant orders of the Secretary of
Labor issued pursuant to the act.
(K) The Contractor agrees to post in conspicuous places, available to employees and applicants for
employment, notices in a form to be prescribed by the Director, provided by or through the contracting
officer. Such notice shall state the Contractor's obligation under the law to take affirmative action to
employ and advance in employment qualified disabled veterans and veterans of the Vietnam era, and the
rights of applicants and employees.
(L) The Contractor will notify each labor union or representative of workers with which it has a collective
bargaining agreement or other contract understanding, that the contractor is bound by the terms of the
Vietnam Era Veterans Readjustment Assistance Act,and is committed to take affirmative action to employ
and advance in employment qualified disabled veterans and veterans of the Vietnam Era.
(M)The Contractor will include the provisions of this clause in every subcontract or purchase order of$ 10,000
or more unless exempted by rules,regulation,or orders of the Secretary issued pursuant to the Act,so that
7
such provisions will be binding upon each subcontractor or vendor. The Contractor will take such action
with respect to any subcontract or purchase order as the Director of the Office of Federal Contract
Compliance Programs may direct to enforce such provisions,including action for noncompliance.
E. Section 109 of the Housing and Community Development Act of 1974.
No person in the United States shall on the grounds of race, color, national origin, or sex be excluded from
participation in,be denied the benefits of,or be subjected to discrimination under any program or activity funded in
whole or in part with funds made available under this title.
F. "Section 3"Compliance in the Provision of Training,Employment and Business Opportunities
1. The work to be performed under this contract is on a project assisted under a program providing direct Federal
financial assistance from the Department of Housing and Urban Development and is subject to the requirements
of Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701u. Section 3
requires that to the greatest extent feasible opportunities for training and employment be given lower income
residents of the project area and contracts for work in connection with the project be awarded to business
concerns which are located in,or owned in substantial part by persons residing in the area of the project.
2. The parties to this contract will comply with the provisions of said Section 3 and the regulations issued pursuant
thereto by the Secretary of Housing and Urban Development set forth in 24 CFR,Part 135 and all applicable
rules and orders of the Department issued there under prior to the execution of this contract. The parties to this
contract certify and agree that they are under no contractual or other disability which would prevent them from
complying with these requirements.
3. The Contractor will send to each labor organization or representative of workers with which he has a collective
bargaining agreement or other contract or understanding,if any,a notice advising the said labor organization of
workers representative of his commitments under this Section 3 clause and shall post copies of the notice in
conspicuous places available to employees and applicants for employment or training.
4. The Contractor will include this Section 3 clause in every subcontract for work in connection with the project
and will,at the direction of the applicant for or recipient of Federal financial assistance,take appropriate action
pursuant to the subcontract upon a finding that the subcontractor is in a violation of regulations issued by the
Secretary of Housing and Urban Development,24 CFR Part 135. The Contractor will not subcontract with any
subcontractor where it has notice or knowledge that the latter has been found in violation of regulations under
24 CFR Part 135 and will not let any subcontract unless the subcontractor has first provided it with a
preliminary statement of ability to comply with the requirements of these regulations.
5. Compliance with the provisions of Section 3, the regulations set forth in 24 CFR Part 135, and all applicable
rules and orders of the Department issued hereunder prior to the execution of the contract,shall be a condition
of the Federal financial assistance provided to the project, binding upon the applicant or recipient for such
assistance, its successors and assigns. Failure to fulfill these requirements shall subject the applicant or
recipient, its contractors and subcontractors, its successors and assigns to those sanctions specified by the grant
or loan agreement or contract through which Federal assistance is provided, and to such sanctions as are
specified by 24 CFR Part 135.
II. CERTIFICATION OF COMPLIANCE WITH AIR AND WATER ACTS
(Applicable to Federally assisted construction contracts and related subcontracts exceeding$100,000)
A. During the performance of this contract,the Contractor and all subcontractors shall comply with the requirements of
the Clean Air Act,as amended,42 USC 1251 et seq.,and the regulations of the Environmental Protection Agency
with respect thereto,at 40 CFR Part 15,as amended.
B. In addition to the foregoing requirements,all non-exempt contractors and subcontractors shall furnish to the owner,
the following:
1. A stipulation by the Contractor or subcontractors,that any facility to be utilized in the performance of any non-
exempt contract or subcontract, is not listed on the list of Violating Facilities issued by the Environmental
Protection Agency(EPA)pursuant to 40 CFR 15.20.
2. Agreement by the Contractor to comply with all the requirements of Section 114 of the Clean Air Act, as
amended(42 USC 1857c-8)and Section 308 of the Federal Water Pollution Control Act,as amended,(33 USC
1318) relating to inspection, monitoring, entry, reports and information, as well as all other requirements
specified in said Section 114 and Section 308,and all regulations and guidelines issued thereunder.
8
3. A stipulation that as a condition for the award of the contract, prompt notice will be given of any notification
received from the Director, Office of Federal Activities,EPA,indicating that a facility utilized,or to be utilized
for the contract,is under consideration to be listed on the EPA List of Violating Facilities.
4. Agreement by the Contractor that he will include, or cause to be included, the criteria and requirements in
paragraph(1)through(4)of this section in every non-exempt subcontract and requiring that the Contractor will
take such action as the Government may direct as a means of enforcing such provisions.
III. CERTIFICATION FOR CONTRACTS,GRANTS,LOANS,AND COOPERATIVE AGREEMENTS
The undersigned certifies to the best of his or her knowledge and belief,that:
A. No Federally appropriated funds have been paid or will be paid, by or on behalf of the undersigned,to any person
for influencing or attempting to influence an officer or employee of any agency,a Member of Congress, an officer
or employee of Congress in connection with the awarding of any Federal Contract,the making of any Federal grant,
the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal,amendment,or modification of any Federal contract,grant,loan,or cooperative agreement.
B. If any funds other than Federally appropriated funds have been paid or will be paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant,
loan,or cooperative agreement,the undersigned shall complete and submit Standard Form—LLL,"Disclosure Form
to Report Lobbying,"in accordance with its instructions.
C. The undersigned shall require that the language of this certification be included in the award documents for all sub-
awards at all tiers(including subcontract,sub-grant,and contracts under grants, loans, and cooperative agreements)
and that all sub-recipients shall certify and disclose accordingly.
D. This certification is a material representation of fact upon which reliance was placed when this transaction was made
or entered into. Submission of this certification is a pre-requisite for making or entering into this transaction
imposed by Section 1332, Title 31, U.S. Code. Any person who fails to file the required certification shall be
subject to a civil penalty of not less than$10,000 and not more than$100,000 for each such failure.
9
To whom it may concern,
The reason behind not getting another quote for the computer system is that we
are trying to become a franchise and we need a universal computer sytem that
everyone in the company uses. This system is the same system that we use in the
Lakeville store. Which is where we do all of our training.
I hope this explains enough. If not, feel free to contact me at anytime for more
information.
Brian Wheeler
Self Certification Form - 2013 (effective 12/11/12)
Dakota County CDBG Program
Information on annual household income and race is required to determine eligibility for public services
funded with federal Community Development Block Grant(CDBG)funds. Each participant must indicate
the number of persons in their household, and then CHECK THE BOX that contains the amount of
annual income. INCOME is defined as the total annual gross income of all family and non-family
members 18+years old living within the household, including a percent of assets. All sources of income
must be counted from all persons in the household based on anticipated income within 12 months.
Please check your Income Range based on your Family Size (for example if there are 5 people in
your household, go to Household of 5):
Household of 1: ❑ $0 - $17,300 ❑ $17,301 -$28,850 ❑ $28,851 - $45,100 ❑ $45,101+
Household of 2: ❑ $0 - $19,800 ❑ $19,801 -$32,950 ❑ $32,951 - $51,550 ❑ $51,551+
Household of 3: ❑ $0 - $22,250 ❑ $22,251 -$37,050 ❑ $37,051 - $58,00 ❑ $58,001+
Household of 4: ❑ $0 - $24,700 ❑ $24,701 -$41,150 ❑ $41,151 - $64,400 ❑ $64,401+
Household of 5: ❑ $0 -$26,700 ❑ $26,701 -$44,450 ❑ $44,451 -$69,600 ❑ $69,601+
Household of 6: ❑ $0-$28,700 ❑ $28,701 -$47,750 ❑ $47,751 - $74,750 ❑ $74,751+
Household of 7: ❑ $0 -$30,650 ❑ $30,651 -$51,050 ❑ $51,051 - $79,900 ❑ $79,901+
Household of 8: ❑ $0-$32,650 ❑ $32,651 -$54,350 ❑ $54,351 - $85,050 ❑ $85,051+
Please calculate your total assets, including (a) checking, savings and other account balances; (b)tax
assessed value of real estate owned other than your home; (c) cash value/equity of any Life Insurance
Policy; and (d) any other assets. NOTE: a percentage of assets will be calculated by staff as part of
income (example: $100,000 assets x 2.0% = $2,000). Total Assets = $
Please check your Ethnicity(pick 1 of 2): ❑ Hispanic or ❑ Non-Hispanic
Please check your Race (pick 1 of 10 choices):
❑ White ❑ Black or African American
❑ Asian &White ❑American Indian or Alaskan Native
❑ Native Hawaiian or Other Pacific Islander ❑ Other
❑ Black/African American &White ❑American Indian/Alaskan Native &White
❑Asian ❑American Indian/Alaskan Native & Black
Does your family have a FEMALE HEAD OF HOUSEHOLD? ❑ Yes ❑ No
Program or Activity Dates of Participation
Birth Date of Participant
APPLICANT STATEMENT: I hereby certify that the information on this form is accurate and complete. I
understand that this self-certification may be subject to further verification by the agency providing services, the
City, the Dakota County CDA, or the U.S. Department of Housing&Urban Development. I, therefore,authorize
such verification, and I will provide supporting documents, if necessary. WARNING: Title 18, Section 1001 of the
U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements
to any department of the U.S. Government.
Participant or Beneficiary Name (Please Print)
Signature (Parent or Guardian, if participant is under 18 years old) Date
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Dakota County CDBG Request for Reimbursement Form
From: City/Township of Date:
Please complete the appropriate sections. The Dakota County CDA will fill in the shaded areas. Please use
separate request forms for each activity or service period.
Reimbursement for the following activities is being requested from the CDBG Program:
Name of Project/Activity Program Amount Dates of Service CDA Account Number
(Fiscal) Yr. Requested (start/end) -
Do you have program income (i.e., revolving account) to draw first for this activity? Yes No
If yes, please indicate how much program income you are drawing for this activity: $
Do you have other funding sources that are being combined with the CDBG funds? Yes No
If yes, please indicate the source(s) and amount(s):
Documentation to support Request for Reimbursement: You must attach all appropriate documentation
to support this request(i.e. staff hours and rate of pay, invoices for work completed, copies of plans, etc.)
❑ Timesheets ❑ Invoices/ Proof of Payment ❑ Completed product
(# of hours, rate of pay, etc.) (copies of checks, receipts, etc. ) (i.e. plan, study, survey)
The following chart is for DIRECT BENENFIT ACTIVITIES (housing or public service activities). Please report
the demographic information of those served during the dates of service listed above. If you are reporting a
HOUSING activity, please report in number of HOUSING UNITS. If you are reporting a PUBLIC SERVICE
activity, please report in number of PEOPLE.
DO NOT COMBINE DATA FROM MORE THAN ONE ACTI V ITY OR SERVICE DATES
DEMOGRAPHICS Ethnicity Income Level
Race His panic Non- Very Low Low Moderate Above L/M
p Hispanic (0-30%) (31-50%) (51-80%) (81% +)
White
Black/African American
Black/African American&White
Asian
Asian &White
American Indian or Alaskan Native
American Indian/Alaskan &White
American Indian/Alaskan &Black
Native Hawaiian/Other Pacific Islander
Other
----- -- ----- - --------------
TOTALS(Ethnicity= Income Level)
Number of Female-headed Households = Percent as Low/Mod Income =
Number of clients new to program= Number of clients with improved access =
Prepared by: Approved by:
Program Administrator City or Township Finance Officer