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<br />X. PROPOSED BUDGET
<br />
<br />A Provide the proposed program/project budget utilizing Attachment #4(a) for social services
<br />programs or Attachment #6 for capital improvement projects. If your proposed budget includes
<br />CDBG funds for administration or program salaries or contractuaVprofessional services you must
<br />also complete Attachment #5,
<br />
<br />B. If the proposed program/project is currently funded by the City of Santa Ana with CDBG funds,
<br />complete budget information Attachment #4(b)
<br />
<br />C. If the proposed program/project was funded by the City of Santa Ana with CDBG funds in 200~
<br />2006, complete Attachment #4(c).
<br />
<br />XI. CERTIFICATIONS
<br />
<br />A. Applicant certifies that it will not discriminate against any employee or applicant for employment
<br />because of race, religious creed, color, national origin, ancestry, physical disability, mental
<br />disability, medical condition, marital status, sex or age, in compliance with Government Code
<br />12900, et seq. Applicant agrees to take affirmative action to insure that applicants are employed,
<br />and that employees are treated during employment, without regard to their race, religious creed,
<br />color, national origin, ancestry, physical disability, mental disability, medical condition, marital
<br />status, sex or age.
<br />
<br />B. Applicant certifies that it does not discriminate against any person wishing to benefit from their
<br />services/program on the basis of race, religious creed, color, national origin, ancestry, physical
<br />disability, mental disability, medical condition, marital status, sex or age.
<br />
<br />C, Does any officer, employee or board member have an ownership interest, either directly or
<br />through a partnership ~p,orate entity, in any facilities owned, leased, or rented by the applicant
<br />organization? Dyes ~o (NOTE: Federal regulations prohibit this type of conflict of interest,)
<br />
<br />If Yes, please explain.
<br />
<br />If No, please list the owner(s) of record.
<br />
<br />Please provide a list of your Board of Directors, by-laINS, and articles of incorporation as Attachment #8,
<br />
<br />0,
<br />
<br />Do your b~ ,m. embers receive a salary or other stipend for serving on this board?
<br />DYes .Q!{I~O (If yes, include amount next to each board member's name)
<br />
<br />What was the date of the last meeting of your board of directors?
<br />
<br />E.
<br />
<br />XII.
<br />
<br />SIGNATURE
<br />
<br />I hereby certify that, to the best of my knowledge, all statements made in this application are true and
<br />correct If funds are granted to our organization, they will be used for a CDBG-eligibJe purpose. I
<br />understand that liability and workers compensation insurance will be required for our group, and that our
<br />formal agreement with the City will specify other reporting and programmatic provislOnS~ .
<br />
<br />Name~~~THIe /r/S-r h~ ~ v,d//r?-
<br />""nature - Date 7 .rib/a:: ·
<br />( '
<br />
<br />....
<br />II
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