Agenda packet, regular meeting — Buena Park City Council, March 11, 2025 (part 2 of 3)

Page 43 of 197 ends

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0483197

FAIR HOUSING FOUNDATION
✔
✔
d.

2025-2026 Community Development Block Grant (CDBG)
F
unding Proposal Summary Sheet
O
rganization Name: City of Buena Park
Community & Economic Development Department
Pr
ogram Name: Residential Rehabilitation Program
Administration/Senior Outreach and Loans
E
stimated Goal: 10 Households/2,000 Seniors
F
unding Request: $249,000 – Program Administration/Senior Outreach $250,000 – Residential Rehabilitation Loans
O
rganization Purpose:

T
he City of Buena Park Residential Rehabilitation Program (Program) offers low interest loans to low - and moderate - income residents to rehabilitate their home and make necessary repairs to comply with local and State health and safety regulations. T he proposal includes program a dministration, senior outreach, and f unding for loans . City staff administers the program to ensure that projects adhere to City guidelines and the requirements set by the U.S. Department of Housing & Urban Development (HUD) , provide loan servicing for outstanding loans, and provide senior outreach to facilitate the application process for participating seniors.

D
escription of Request:

C
DBG funds wil l be used for Program administration and deferred loan s. Program administration includes staff salaries and benefits, contractual services fees, operation costs, and supplies.

F
unds will also be used to provide deferred home improvement loans of $60,000 at one percent (1%) to qualified residents. A forgivable loan up to $15,000 is also available to very low income seniors to abate outstanding code enforcement violations.

A
nalysis of Request:

T
he project meets the national objective of benefiting low - and moderate - income households. The majority of residential structures in Buena Park are over 50 years old and require new plumbing, electrical systems, roofs and other essential components of a structure that require maintenance and/or replacement to provide a safe and healthy living environment for its occupants. Many low- and moderate-income individuals are unable to fund these improvement s and repairs without financial assistance . This program is effective in improving the quality of the City’s housing stock and increasing its aesthetic appeal as a whole.

Funding Recommendation:

S
taff recommends funding in the amount of $245,000 for Program Administration/Senior Outreach and $250,000 for Residential Rehabilitation Loans.

CITY OF BUENA PARK

COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2025-2026 CDBG GRANT APPLICATION
DUE BY DECEMBER 19, 2024 AT 5:00 PM
Approximate total funds available for public services: $116,110 Organization Name City of Buena Park
Activity/Program Name Residential Rehabilitation Program Loans & Administration Address 6650 Beach Blvd., Buena Park, CA 90621
Contact Person/Title Sarabeth Suarez / Housing & CDBG Analyst Email Address [email protected] Phone Number (714) 562-3591 Estimated individuals or households to be served by proposed activity during FY 2025-2026 (including Buena Park residents and non-Buena Park residents):

Estimated Goal: 10 € Individuals [x Households
Estimated Buena Park residents or households to be served by proposed activity during FY 2025-2026:

Estimated Goal: 10 € Individuals [X Households
Please indicate the amount of CDBG funds being requested:

Public Service Activities
Other Eligible Activities 499,000.00
ff/
(Signature of authorized representative) Date
Matt Foulkes, Community & Economic Development Director (Name and Title of authorized representative)
Organization Name: C:! Of Buena Park Progra m N a m e: Residential hehabililalion Program Loans & Administration Please answer the following questions completely. If any questions are left unanswered, your application will not be considered. You may attach additional sheets and/or supporting materials as needed.
1 ACTMTY DESCRIPTION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the proposed activity, including services to be provided and goals to be accomplished. * Why is there a need for this activity in the City of Buena Park? * Identify the location of the activity and the service area boundaries. * Describe specifically the intended use of the CDBG funds.

The City's Residential Rehabilitation Program offers deferred loans of $60,000 at one percent (1%) interest to qualified low-income Buena Park homeowners for eligible home improvements. The loan becomes due and payable affer 30 years or upon transfer of title, sale, or cash-out refinance of the properhl. Eligible improvements may include replacing a dilapidated roof, installing new windows, lead paint abatement. ADA accessibility modifications, new flooring, plumbing repair, interior and exterior painting, and other health and safety upgrades to the home. Eligible households must have a total gross annual income that does not exceed eighhy percent (80%) of the Orange County Area Median Income (AMI), a limit that is annually published by HUD.

Additionally, senior residents (Age 55+) may be referred by the Neighborhood ImprovemenUCode Enforcement Program to apply for a forgivable loan up to $15,000 through the Senior Code Enforcement Relief Program (SCERP) to rectify existing health and safety code violations in their home. For the SCERP, seniors' annual gross income must not exceed fifty percent (50%) AMI. This program is essential to the City of Buena Park because it makes home improvement possible for low-income residents and beautifies the City one project at a time.

The funds being requested will be used to supply deferred and forgivable loans and finance program administration costs such as staff salaries and benefits, contractual services, office supplies, and other expenses directly related to the program. Program staff work closely with the homeowners to gather required documents and complete the program application, conduct site visits of the properties, develop their desired scope of work, prepare environmental reports, consult with the State Historic Preservation Office, coordinate with contractors for bids. prepare contracts and loan documents, maintain the program waiting list, provide loan servicing, attend trainings held by the Department of Housing & Urban Development (HUD), manage the program budget, and advertise the program through social media and outdoor signage.
2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2025 through June 30, 2026. * How was the estimated number of clients determined? * How will you reach your target population?
* Explain why this activity is needed for this target population.

The program goal is to assist ten (10) eligible households in need of residential rehabilitation through deferred or forgivable loans. This goal is determined by considering the average number of families the City has assisted in previous program years and the funding available for fiscal year 2025-2026.

The target population for this program are low-income owner-occupied households in Buena Park. In order to reach this target population, staff will advertise the program on the City website, the City's social media accounts, work with Code Enforcement to refer the program to seniors that have outstanding code violations, and post program lawn signs on completed projects to advertise to the surrounding neighborhood. Additionally, program staff are available to answer questions about the program in a variety of languages as needed.

The Residential Rehabilitation Program is essential to the Buena Park community because it enables low-income families to make necessary interior and exterior modifications to their home, which improves their living conditions while increasing the value of their surrounding neighborhoods.

Application Page 2
Organization Name: C'iV Of Buena Park py() gl-(ly1l %3I1 (i. ; Residential %habilitatiOn Program LOanS & Administration 3 NATIONAL OBJECTIVES
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe in detail how the activity meets at least one of the three CDBG Program national objectives.

Select one:
[X Benefit low- and moderate-income persons in Buena Park; € Aid in the prevention or elimination of slums or blight in Buena Park; € Meet a need having a particular urgency in Buena Park.

The Residential Rehabilitation Program meets the CDBG national objective of benefiting low-income persons in Buena Park. In order to qualify for a loan, homeowners must submit a completed program application and income documents such as bank statements, pay-stubs, and taxes, to demonstrate that their total gross household income is under 80% of HUD's area median income (AMI) for Orange County. Program staff ensure that program beneficiaries are income qualified by thoroughly reviewing each application and supporting documents before approving a project.

The loan is affordable due to its 1 % annual interest rate and deferred payments for 30 years.

These loan terms aim to encourage low-income homeowners to apply for a loan, which they may not be able to obtain from other lenders.
4 BUDGET
[24 CFR 570.502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circular A-87, A-122, Treasury Circular No. 1075] Itemize administrative and operational costs for the proposed activity. Cost Category may include:
staff salaries and benefits, rent, utilities, etc.

Cost Category CDBG Funding
Request
Other Funding
Sources Total Cost
Residential Rehabilitation Loans $ 250,000.00 $ 0 $ 250,000.00 Staff salaries and benefits $ 196,000.00 $ 0 $ 196,000.00 Maintenance & Operation/Professional Services $ 53,000.00 $ 0 $ 53,000.00 $ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Total $ 499,000.00 $ $ 499,000.00
Application Page 3
Organization Name: c"l Of Buena Park programHame:ResidentialRehabililalionProgamLoans&Administralion 5 ELIGIBILITY DOCUMENT ATION
If the proposed activity is a public service, describe what form of documentation will be collected to demonstrate that at least 70% of persons served are low- and moderate-income, as required by HUD, and a minimum of 20% are Buena Park residents. (Please attach a copy of the activity's client intake/application/registration form)
The Residential Rehabilitation Program is not a public service activity. The program is a housing preservation activity designed to assist low-income households within Buena Park with affordable home improvement loans. Applicants must provide a completed program application along with several income documents such as federal income tax returns, bank statements, pay-stubs, social security award letters, employment verification, property deeds, etc., for staff to determine their eligibility. Program staff ensure that 100% of the homeowners assisted are low-income Buena Park residents.
6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.20"l-570.208, 570.503]
Please indicate the activity's Objective, Outcome, Outcome Statement, Purpose, and indicators that will be used to measure, track and report performance. Refer to the instructions on Page 5 through Page 7 of the RFP.

A. Select one :
€ Suitable Living Environment
lx Decent Affordable Housing
€ Economic Opportunities
B. Select one :
€ Availability/Accessibility
[x Affordability
€ Sustainability
C. Llsing the following formula, provide the activity's Purpose:

Purpose = Output + Outcome Statement + Activity
10 households + Affordability for the purpose of creating Decent Housing + Residential Rehabilitation Program = Purpose
The City of Buena Park Residential Rehabilitation Program will make it affordable for 10 households to rehabilitate their home through deferred and forgivable loans for the purpose of creating decent housing.

Application Page 4
Organization Name: C:tY Of Buena Park Program Name.: Residential Rehabilitation Program Loans & D. Identify the common, specific, and/or other indicators for the activity a. Common Indicators
- Ten (10) low-income households are assisted with residential rehabilitation loans. - Ten (10) units are brought from substandard to standard living conditions. - Ten (10) units are brought into compliance with residential lead safety regulations. b. Specific Indicators
- One hundred percent (100%) of households assisted are in compliance with local code/safety standards. '
- Ten (10) households are assisted and at least five (5) of them are senior residents. c. Other Indicators
- The program waitlist has decreased by at least ten (10) people.

Application Page 5

CITY OF BUENA PARK

COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY, 2025-2026 CDBG GRANT APPLICATION
DUE BY DECEMBER 19, 2024 AT 5:00 PM
Approximate total funds available for public services: $'l'l6,110 Organization Name City of Buena Park- Community Services Activity/Program Name Senior Outreach Program
Address 8150 Knott Ave., Beach Blvd., CA 90620
Contact Person/Title Justice Mompeller, Community Outreach Coordinator Email Address [email protected] Phone Number 1714-236-3871 Estimated individuals or households to be served by proposed activity during FY 2025-2026 (including Buena Park residents and non-Buena Park residents):

Estimated Goal: 1 ,200 [X Individuals € Households
Estimated Buena Park residents or households to be served by proposed activity during FY 2025-2026:

Estimated Goal: 1 ,200 [X Individuals [1 Households
Please indicate the amount of CDBG funds being requested:

Public Service Activities
Other Eligible Activities
(Signature of au;:li representative)
Jim Box, Directcfr of Community Services
(Name and Title of authorized representative)
$ i4;(A3
Date 12//? 24
Organization Name: City of Buena Park- Community ServiCeS p(()gpHlH %31BB; Senior Outreach Program Please answer the following questions completely. If any questions are leff unanswered, your application will not be considered. You may attach additional sheets and/or supporting materials as needed,
1 ACTMTY DESCRIPTION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the proposed activity, including services to be provided and goals to be accomplished. * Why is there a need for this activity in the City of Buena Park? * Identify the location of the activity and the service area boundaries. * Describe specifically the intended use of the CDBG funds.

The Senior Outreach program in Buena Park seeks continued funding to maintain and expand its vital community services to older adults. This comprehensive program serves as an essential lifeline for the senior population, with particular emphasis on supporting low-income older adults..

The Senior Outreach program is specifically tailored to meet the needs of seniors, many of whom are low-income individuals seeking valuable programs and services that improve their quality of i life. We offer a comprehensive range of human services, including assistance with Medicare/Medical insurance, housing, mental health, hoarding, social interaction, education, and isolation prevention. Our mission is to build a bridge of education and resources, connecting the residents of Buena Park with the support they need to thrive. 2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population for this act,ivity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2025 through June 30, 2026. * How was the estimated number of clients determined? a How will you reach your target population?
* Explain why this activity is needed for this target population.

The Senior Outreach Program serves as a vital lifeline for Buena Park residents aged 60 and above, providing essential guidance through the complex network of service agencies at county, state, and federal levels. Based on historical data analysis within our senior center, we project serving 1,200 Buena Park residents through outreach efforts and community events. This service has become increasingly critical as government agencies transition to online platforms, creating significant barriers for seniors attempting to access essential services. Many older adults find these digital systems challenging to navigate independently, making our program's personalized assistance invaluable. Beyond technical support, our program serves as a crucial safety net for vulnerable seniors, particularly those who have experienced the loss of a spouse or partner. We provide comprehensive support to help these individuals maintain stable housing and protect them from predatory scams that offen target the elderly population.

Application Page 2
Organization Name: City of Buena Park- Community Services py()gpBBl %B(11(H Sen:or Outreach Program 3 NATIONAL OBJECTIVES
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe in detail how the activity meets at least one of the three CDBG Program national objectives.

Select one:
[I Benefit low- and moderate-income pers5-ns in Buena Park; € Aid in the prevention cr elimination of slums or blight in Boena Park; € Meet a need having a particular urgency in Buena Park.

Our target population consists of residents aged 60 and older who need assistance in navigating the numerous services available through Orange County, the state, and federal programs. The Senior Outreach program aims to serve 1200 Buena Park seniors within our community. This target number is based on data collected from participation in exercise classes, lunch programs, transportation, and activities offered at the center. This program Is of great importance, as many seniors are unaware of the wide array of services they are eligible for. We are committed to ensuring that every senior feels heard, valued, and seen, and that they have the support they need to access these essential resources.
4 BUDGET
[24 CFR 570.502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circular A-87, A-122, Treasury Circular No. 1075] Itemize administrative and operational costs for the proposed activity. Cost Category may include:
staff salaries and benefits, rent, utilities, etc.

Cost Category CDBG Funding
Request
Other Funding
Sources Total Cost
FT Salary + Benefits '$$14,643 $ $48,056 $ 62,699
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Total $ 14,643 $ 48,056 $ 62,699
Application Page 3
0(gBHiz3jl()H %BII'I(H'. CI$ Of Buena P ark- COmmun!t'/ SeNfces py()g1'B %ByH(;; Sen:or Ouirea(tl P rogram 5 ELIGIBILITY DOCUMENT ATION
If the proposed activity is a public service, describe what form of documentation will be collected to demonstrate that at least 70% of persons served are low- and moderate-income, as required by HUD, and a minimum of 20% are Buena Park residents. (Please attach a copy of the activity's client intake/application/registration form)
With an intake form that is tailored to the seniors we serve. We are able to accuratly identify the seniors needs. The majority of clients serve are 60+ of age and meet the low/moderate income requirments, most of which are Buena Park residents.

Documentation consists of daily client contact tally sheets that define type of services seniors are seeking (i.e. housing, legal assistance, etc.). Staff references the tally sheets when completing monthly reports for HUD. In addition these tally sheets denote residenUnon resident status which tracks the resident percentage.
6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity's , Outcome, Outcome Statement,- Purpose, and indicators that will be used to measure7trackand report performance. Refer to the instructions on Page 5 through Page 7 of the RFP.

A. Select one :
[x Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one :
[] Availability/Accessibility
[1] Affordability
IX Sustainability
C. Using the following formula, provide the activity's Purpose:

Purpose = Output + Outcome Statement + Activity
Approximately 1,200 Buena Park elderly persons in the program are provided with access to senior social services/assistance which would allow them to promote a sense of independence which in turn would allow them to sustain their way of life. These seniors may not be able to access these services without this program.

Application Page 4
Organization Name: City of Buena Park- Community Services program Name: Senior Outreach P rogram D. Identify the common, specific, and/or other indicators for the activity a. Common Indicators
Common indicators of the success of the Senior Outreach program iriclude the number of individuals we have served and the high volume of calls we receive daily from seniors seeking services. The increasing demand for assistance reflects the program's effectiveness in meeting the needs of our community.
b. Specific Indicators
On any day, we can assist seniors with housing, mental health, food services, Medical questions and more.
c. Other Indicators
Individuals are now coming forward with questions. Some seniors are unaware of services that is at their disposal.

Application Page 5
CERTiFICATION REGARDING DEBARMENT, SUSPENSION,
INELJGIBILITY AND VOLUNTARY EXCLUS!ON LOWER TIER COVERED TRANSACTIONS Tliis ceitification is reqriired by the regulations implei'nenting Executive Orders 12549 and 12689, Debarment and Suspension, and 2 CFR Part 200, Paiticipants' responsibilities. (BEFORJE CO)vfl'LEThVG CERTIFICATION, READ JNSTRUCTIONS BELOkV) (1) The prospective lower tier participant ceitifies, by submission of this proposal, that neither it nor its principles are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier paiticipant is unable to certify to any of the statements in this certification, sricli prospective paiticipant shall attach an explanation to this proposal.

OrganizationName: C!i7 0f Buena Park
Address: 8150 Knott Ave. Buena Park, CA 9061 ,;)

1. By signing and submitting this proposal, the prospective low i tier participant is providing the cettification set out below

2. The certification in tliis clarise is a material representation of fact upon whicli rcliance was placed when this transaction was entered into. If it is later determined that tlie prospective lower tier participant knowingly rendered an erroneoris ceitification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available ret'nedies, inclriding suspension and/or debai'ment.

3. The prospective lower tier participant shall provide iinmediate written notice to tlie person to which this proposal is submitted if at any time tlie prospective lower tier paiticipant learns that its cettification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "participant", "person", "primary covered transaction", "principal", 'proposal", and "voluntarily excluded", as used in this clause, have the meanings set orit in the Definitions and Coverage sections of rules implementing Executive Orders 12549 and 12689.

5. The prospective lower tier paiticipant agrees by subinitting this proposal that, sliould the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by tlie depaitment or agency with which this transaction originated.

6. The prospective lower tier paiticipant fuither agrees by submitting this proposal that it will include the clause titled "Ceitification Regarding Debarment, Stispension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transactions", without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

7. A participant in a covered transaction may rely upon a ceitification of a prospective participant in a lower tier covered transaction tliat is not debarred, stispended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the ceitification is erroneous. A paiticipant may decide the method and fi'equency by which it determines the eligibility of its principals. Each participant may check the System for Award Management (SAM).

8. Nothing contained in the foregoing shall be construed to reqriire establishment of a system of records in order to render in good faith the ceitification required by this clause. The knowledge and information of a paiticipant is not required to exceed tliat which is normally possessed by a prudent person in the ordinary course of business dealings.

9. Except for transactions authorized rinder paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a perso'n who is suspended, debarred, ineligible, or voluntarily excluded from paiticipation in this transaction, in addition to other remedies available to the Federal Govei'nment, the depaitment or agency with which this transaction originated may pursue available remedies, including suspension and/or debarinent.

Attachment 4

ACKNOWLEDGEMENT REGARDING

BIDDER SAM REGISTRATION
Pursuant to 2 CFR Section 5.1004 and the requirement of the u.s. Department of Housing and Urban Development (HUD), contractors procured directly by grantees, sub-grantees, and/or sub-recipients of HUD funds, including CDBG are required to have an active registration in the System of Award Management (SAM). This document shall be completed and submitted as part of the proposal.

L By submitting this proposal, the prospective sub-recipient certifies that it has an active registration is SAM that is not set to expire within the next 90 days.

2. By submitting this proposal, the prospective sub-recipient certifies neither it, its principals nor affiliates, is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

3. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that an erroneous certification was rendered, in addition to other remedies available to the Federal Government, the Department or agency with which this transaction originated may pursue available remedies.

4. Further, the prospective sub-recipient shall provide immediate written notice to the person to which this proposal is submitted if at any time the Participant learns that this certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

5. By submitting this proposal, it is agreed that should the proposed covered transaction be entered into, the prospective sub-recipient will not knowingly enter into any lower-tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction unless authorized by the agency with which this transaction originated.

6. It is further agreed that by submitting this proposal, the prospective sub-recipient will include Certification ofSubcontractor Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion withoutmodification, in all lower-tier covered transactions and in all solicitations for lower-tier covered transactions.

Provide the following information as detailed in the prospective sub-recipient's SAM registration:

Entity Name: City of Buena Park
Address: 8150 KnOt AVe.

City: Buena Park
Unique Entity ID (UEI): NUK2QVHWF623
Active Exclusions (Select One): 0Yes [XNo
State: CA Zip: 90620
Expiration Date: 04/17/2025
Attachment 3

ACKNOWLEDGEMENT REGARDING

BIDDER SAM REGISTRATION
Pursuant to 2 CFR Section 5.1004 and the requirement of the L1.S. Department of Housing and Urban Development (HUD), contractors procured directly by grantees, sub-grantees, and/or sub-recipients of HUD funds, including CDBG are required to have an active registration in the System of Award Management (SAM). This document shall be completed and submitted as part of the proposal.

1. By submitting this proposal, the prospective sub-recipient certifies that it has an active registration is SAM that is not set to expire within the next 90 days.

2. By submitting this proposal, the prospective sub-recipient certifies neither it,,its principals nor affiliates, is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

4. Further, the prospective sub-recipient shall provide immediate w,ritten notice to the person to which this proposal is submitted if at any time the Participant learns that this certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

6. It is further agreed that by submitting this proposal, the prospective sub-recipient will include Certification of Subcontractor Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion withoutmodification, in all lower-tier covered transactions and in all solicitations for lower-tier covered transactions.

Provide the following information as detailed in the prospective sub-recipient's SAM registration:

Entity Name: City of Buena Park
Address: 6650 Beach Blvd
City: Buena Park
Unique Entity ID (UEI): NUK2QVHWF623
Active Exclusions (Select One): 0Yes [xNo
State: CA Zip: 90621
Expiration Date: 04/17/2025
Attachment 3

CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

INELIGIBILITY AND VOLUNT ARY EXCLUSION LOWER TIER COVERED TRANSACTIONS This certification is required by the regulations implementing Executive Orders 12549 and 12689, Debaiment and Suspension, and 2 CFR Part 200, Participants' responsibilities. (EEFORE COA4PLETING CERTIFICA TION. READ INSTRUCT[ONS BELOVV) (1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principles are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.

2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "participant", "person", "primary covered transaction", "principal", "proposal", and "voluntarily excluded", as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Orders 12549 and 12689.

5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.

6. The prospective lower tier participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transactions", without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may check the System for Award Management (SAM).

8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the depariment or agency with which this transaction originated may pursue available remedies, including suspension and/or deban'nent.

Attachment 4
City of Buena Park
Home Improvement Program – “Pre-Application”

How did you hear about this program? Water Bill Newspaper Website Other ___________

Name: Are you under Code Enforcement: Yes No
First Name Middle Initial Last Name Address:

Number Street Zip Code Home Phone: Cell Phone: Email:

Marital Status: Married Divorced Separated Widowed Single Race: White Asian & White Black/African American & White Black/African American Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native & Black/African American Asian American Indian or Alaskan Native & White Other Multiracial (Specify):________________ American Indian or Alaskan Native
Ethnicity: Hispanic Non-Hispanic
Household Composition
Household
Member Full Name Relationship Disabled Veteran Age Sex
Applicant Self
2 3
4 5
6 7
8 PROPERTY INFORMATION

Are you sole owner of this property? Yes No How long? Less than 1 year 1 to 5 years Over 5 years

EQUITY: Your property must have available equity to qualify for the program. Including the City loan , your property cannot have more than 95% Loan to Value ratio (LTV).

Do you have a Living Trust? Yes No Total loan balance (all mortgages): $______________

Do you have a 2nd mortgage? Yes No Do you have a 3rd mortgage? Yes No

Type of repairs needed:

INCOME INFORMATION

ASSETS: Total amount of your household assets: $___________________. Please see the reverse side for the definition of assets.

INCOME: Total annual GROSS income (before taxes) for ALL persons in your household over the age of 18: $ Income includes (not limited to): Employment, Interest Earned, Aid to Totally Disabled, Child Support, Pension, AFDC, Alimony, Social Security, Rental Income, Foster Care, Social Security SSI, Room and Board, Aid to the Blind.

To the best of my knowledge, the above information is correct and accurate.

Date: ______________________ Signature: _________________________________________________

PLEASE FILL OUT COMPLETELY, FOLD, SEAL THE EDGES AND MAIL

City of Buena Park
2025-2026 Community Development Block Grant (CDBG)
F
unding Proposal Summary Sheet
O
rganization Name: City of Buena Park
Community & Economic Development Department
P
rogram Name: Neighborhood Improvement/Code Enforcement
E
stimated Goal: 875 Households
F
unding Request: $229,722
O
rganization Purpose:

T
he Neighborhood Improvement/Code Enforcement Program identifies and responds to building and safety issues in residential and commercial areas to protect residents from living in substandard and unsafe conditions. Code Enforcement Officers work with residents to rectify code violations through verbal and written communication, site visits, and by referring them to the City’s Residential Rehabilitation Program and Senior Code Enforcement Relief Program.

D
escription of Request:

C
DBG funds will be used for a portion of staff salaries and benefits for the Neighborhood Improvement/Code Enforcement Program, which includes the Code Enforcement Supervisor, four Code Enforcement Officers, an administrative assistant, and a part time office assistant . The amount of funding requested will maintain the current level of service needed to improve living conditions for those residing within the CDBG eligible census tracts.

A
nalysis of Request:

T
he project meets the national objective s of benefiting low- and moderate- income areas and aiding in the prevention or elimination of slums or blight. The program’s funding is limited t o staff time spent on code enforcement cases within the City’s low- and moderate-income census tracts.

C
ode enforcement investigat es cases involving garage conversions, overcrowding, substandard housing, hazardous buildings, illegal dumping, illegal structures, etc. The Neighborhood Improvement/Code Enforcement Program has been highly successful by proactively and reactively identifying and cleaning -up many blighted buildings in the low- and moderate -income areas. It is also an effective method of reducing and preventing the overall deterioration of Buena Park’s neighborhoods.

Funding Recommendation:

S
taff recommends funding in the amount of $225,000.

CITY OF BUENA PARK

Activity/Program Name Neighborhood Improvement/Code Enforcement Address 6650 Beach Blvd., Buena Park, CA 90621
Contact Person/Title Matt Foulkes, Community and Economic Development Director Email Address [email protected] Phone Number 714-562-3610 Estimated individuals or households to be served by proposed activity during FY 2025-2026 (including Buena Park residents and non-Buena Park residents):

Estimated Goal: 65,000 § Individuals g Households
Estimated Buena Park residents or households to be served by proposed activity during FY 2025-2026:

Estimated Goal: 875 € Individuals % Households
Please indicate the amount of CDBG funds being requested:

Public Service Activities
Other Eligible Activities 229,722.00
(Signature or authorized representative)
Matt Foulkes, Community and Economic Dev. Dir.
(Name and Title of authorized representative)
Date
12/18/2024
Organization Name: Community and Economic Development Program Name: Code Enforcement Please answer the following questions completely. If any questions are lefi unanswered, your application will not be considered. You may attach additional sheets and/or supporting materials as needed.
1 PROJECT DESCRIPTION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the proposed project, including services to be provided and goals to be accomplished. * Why is there a need for this program in the City of Buena Park? * Identify the location of the project and the service area boundaries. * Describe specifically the intended use of the CDBG funds.

The Code Enforcement Division concentrates its efforts in the low-to-moderate income census tracts established by HOD, to protect residents from living in substandard and/or unsafe conditions.

These substandard and/or unsafe conditions include improper occupancy (garage living), overcrowding, substandard housing, hazardous buildings, unsecured vacant or abandon buildings, vacant lots, illegal dumping, inoperative vehicles, and the accumulation of trash and debris. The existence of these conditions contributes to blight and slum like conditions and negatively affects the property and surrounding neighborhood. Staff is also responsible for abating violations at properties that are declared a public nuisance.

Code Enforcement also participates in the city's multi-jurisdictional Neighborhood Improvement Task Force (NITF) along with the Police Department, Public Works, Community Services and external organizations (Health Department, Fire Authority and homeless outreach). The NITF is responsible for improving the appearance of the community, improving the quality of life for residents and reducing crime through cooperative efforts between property owners, tenants, business owners and city staff.

Community and Economic Development is requesting CDBG funds to support a portion of the salaries and benefits for Code Enforcement staff to maintain the current quality of service in eligible CDBG areas.
2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population for this program and the number of estimated unduplicated Buena Park residents to be served from July 1, 2024 through June 30, 2025. * How was the estimated number of clients determined? * How will you reach your target population?
* Explain why this program is needed for this target population. 2 Organization Name: Community and Economic Development Program Name: Code Enforcement The proposed program will target properties that have been designated to be low to moderate- income areas and are within the Community Development Block Grant areas designated by the Department of Housing and Urban Development.

The number of clients to be served is based on the 2020 Census and a proactive approach to eliminate blight, prevent substandard and slum like conditions within the CDBG area. Code Enforcement and the NITF will respond to calls for service and provide proactive inspections and services.

Buena Park has a growing number of low to moderate-income areas with homeowner occupancy just above fiffy percent. The increased number of rental properties along with a growing senior population and increased unemployment has resulted in an expansion of blight conditions within many residential neighborhoods. The proposed code enforcement efforts including proactive enforcement and assistance with code compliance will be crucial to preventing the growth of blight and slum-like conditions
3 NATIONAL OBJECTIVES
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe in detail how the project meets at least one of the three CDBG program national objectives.

Select at least one:
[X Benefit low- and moderate-income persons in Buena Park; [X Aid in the prevention or elimination of slums or blight in Buena Park; € Meet a need having a particular urgency in Buena Park.

1. Benefit Low- and Moderate-Income Persons in Buena Park Neighborhood Improvement/Code Enforcement serves approximately 65,000 residents who live in the low-to-moderate income areas. Code Enforcement staff also coordinates with the city's Senior Outreach Worker on cases involving seniors who are facing code violations but cannot abate them due to their low-income level. The Outreach Worker assists the clientele with completing the grant applications that ultimately provide the necessary funds to correct the violations.

Owners and residents rely on the Neighborhood Improvement/Code Enforcement to improve the appearance, health, and safety of the CDBG areas within the community.

2. Aid in the prevention or elimination of slums or blight in Buena Park The Neighborhood Improvement/Code Enforcement Program is structured to be proactive in addressing the cause and effect of blight. This is accomplished by identifying issues affecting the area, and working with owners to maintain their property, reduce crime, screen tenants, and submit various city applications for home improvement. The program also provides a referral system for tenants in need of legal aid and/or housing assistance to the Fair Housing Foundation. 4 BUDGET
[24 CFR 570.502-570.504, 570.506, 570.507, 570.61 0; 24 CFR Parts 84 or 85, and OMB Circular A-87, A-122, Treasury Circular No. 1075] Itemize administrative and operational costs for the proposed project. Cost Category may include:
staff salaries and benefits, rent, utilities, advertising, office supplies, etc. 3 Organization Name: Community and Economic Development Program Name: Code Enforcement Cost Category CDBG Funding
Request
Other Funding
Sources
Total Cost
Code Enforcement Supervisor $20,296 $164,303 $184,599 Code Enforcement Officer $36,651 $101,672 $138,323
Code Enforcement Officer $81 ,660 $49,245 $130,905
Code Enforcement Officer $43,110 $88,240 $131,350
Code Enforcement Officer P/T $ $27,170 $27,170
Administrative Assistant $21 ,496 $88,741 $110,237
Office ASSiStant P/T $26,509 $0 $26,509
$ $ $
$ $ $
$ $ $
Totar $229,722 $519,371 $749,093
5 ELIGIBILITY DOCUMENT ATION
If the proposed project is a public service activity, describe what form of documentation will be provided to demonstrate that at least 70% of persons served are low- and moderate-income, as required by HUD, and a minimum of 20% are Buena Park residents.

Code Enforcement will provide a quarterly report that lists the addresses identified within the Community Development Block Grant census tracts that include the low to moderate-income population. The number of properties inspected and the number of open and closed cases within the designated areas will be reported.
6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity objective, outcome/s, outcome statement/s and indicators that will be used to measure, track and report performance. Refer to the instructions in the RFP.

A. Select one Objective
[X Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one Outcome
€ Availability/Accessibility
€ Affordability
[X Sustainability
C. Using the following formula, provide the program specific purpose/objective:
4 Organization Name: Community and Economic Development Program Name: Code Enforcement Output + Outcome Statement + Activity = Purpose/Objective 850 households + Sustainability for the purpose of creating suitable living environment + Code Enforcement program/ Neighborhood Improvement = Purpose/Objective Purpose & Objective:

The Neighborhood Improvement/Code Enforcement Program's purpose is to serve low-to- moderate income residents, including senior citizens by regulating property maintenance, housing, building, and zoning codes, for enhancing a suitable living environment within the census tracts designated by HUD. The program will provide sustainability for creating a suitable living environment for 65000 residents within the CDBG-eligible census tracts.

D. Identify the common, specific, and/or other indicators for the program a. Common Indicators:

ASSisting the families, businesses, and the community while enhancing the quality of life and providing safe housing throughout the CDBG areas. Eliminating blight, crime and preventing slum- like conditions.
b. Specific Indicators:

The most specific indicator is the number of opened and closed cases per program year. In program year 23/24, Neighborhood Improvement/Code Enforcement resolved five hundred and ninety-four (594) of the six hundred & fifty-four (654) cases. The NITF Investigated and closed two (2) of the six (6) cases. All remaining cases were rolled over to program year 24/25 to achieve full compliance with code violations.
c. Other Indicators:

The City of Buena Park is a sought-after community by both homeowners and businesses, the Neighborhood/Code Enforcement and Neighborhood Improvement Task Force takes pride in providing an invaluable service to the community by improving quality of life issues. 5 ACKNOWLEDGEMENT REGARDING

L By submitting this proposal, the prospective sub-recipient certifies that it has an active registration is SAM that is not set to expire within the next 90 days.

6. It is further agreed that by submitting this proposal, the prospective sub-recipient will include Certification of Subcontractor Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion withoutmodification, in all lower-tier covered transactions and in all solicitations for lower-tier covered transactions.

Provide the following information as detailed in the prospective sub-recipient's SAM registration:

Entity Name: City of Buena Park
Address: 6650 Beach Blvd
City: Buena Park
Unique Entity ID (UEI): NUK2QVHWF623
Active Exclusions (Select One): 0Yes [XNo
State: CA Zip: 90621
Expiration Date: 04/17/2025
Attacliment 3

CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

INELIGIBILITY AND VOLUNT ARY EXCLUSION LOWER TIER COVERED TRANSACTIONS This certification is required by the regulations implementing Executive Orders 12549 and 12689, Debamient and Suspension, and 2 CFR Part 200, Participants' responsibilities. (EEFORECOA4PLETINGCERT[FiCATION, READ [NSTRUCTIONS BELOW) (I) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principles are presently debaired, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

Organization Name: C!i7 0f Buena Park
Address: 6650 Beach Blvd., Buena Park, CA 90621

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.

3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant leams that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "participant", "person", "primary covered transaction", "principal", "proposal", and "voluntarily excluded", as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Orders 12549 and 12689.

6. The prospective lower tier participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transactions", witliout modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each paiticipant may check the System for Award Management (SAM).

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

Attachment 4
City of Buena Park
2025-2026 Community Development Block Grant (CDBG)
F
unding Proposal Summary Sheet
O
rganization Name: City of Buena Park Public Works Department P
rogram Name: Graffiti Removal Program
E
stimated Goal: 60,740 Individuals within low-income census tracts/ 2,000 Graffiti Instances
F
unding Request: $22,930
O
rganization Purpose:

G
raffiti Removal Program staff proactively and reactively responds to graffiti incidents within the City’s CDB G eligible census tracts. The program’s purpose is to provi de a suitable living environment for Buena Park residents by removing graffiti in residential and commercial areas.

D
escription of Request:

C
DBG funds will be used for program staff salaries and benefits . CDBG funding is limited to staff responding to graffiti incidents within the City’s CDBG eligible census tracts.

A
nalysis of Request:

T
he project meets the national objective of benefiting low - and moderate- income areas and aiding in the elimination of slums or blight with in the City. Program staff estimate that 60,740 individuals living within the City’s low -income census tracts will benefit from this service. Due to the anonymity of graffiti removal requests, program staff track their goal by the number of graffiti instan ces removed rather than individuals and households assisted.

Funding Recommendation:

S
taff recommends funding in the amount of $17,200.

CITY OF BUENA PARK

COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2025-2026 CDBG GRANT APPLICATION
DUE BY DECEMBER 19, 2024 AT 5:00 PM
Approximate total funds available for public services: $116,110 Organization Name Buena Park Public Works Department Activity/Program Name Graffiti Removal Program
Address 6650 Beach Boulevard, Buena Park, CA 90620 Contact Person/Title Joe Hunt, Public Works Manager Email Address [email protected] Phone Number 714-562-3652 Estimated individuals or households to be served by proposed activity during FY 2025-2026 (including Buena Park residents and non-Buena Park residents):

Estimated Goal: 60,740 [X Individuals € Households
Estimated Buena Park residents or households to be served by proposed activity during FY 2025-2026:

Estimated Goal: 60,470 [X Individuals € Households
Please indicate the amount of CDBG funds being requested:

Public Service Activities $ 22/ Oi 2>0 - 00
Other Eligible Activities
12/1 9/2024
(Signature of authorized representative) Date
Mina Mikhael, P.E., Director of Public Work
(Name and Title of authorized representative)
Organization Name: Buena Park Public Works Department pla()glaB(ll %BB(; Graffl(t Removal P rogram Please answer the following questions completely. If any questions are left unanswered, your application will not be considered. You may attach additional sheets and/or supporting materials as needed.
1 ACTMTY DESCRIPTION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the proposed activity, including services to be provided and goals to be accomplished. * Why is there a need for this activity in the City of Buena Park? * Identify the location of the activity and the service area boundaries. * Describe specifically the intended use of the CDBG funds.

The funds will be utilized to remove graffiti in low and moderate income areas as specified in the attached project location map. Funds will cover time and material spent for the project, such as staff salaries, in order to combat the vast majority of graffiti problems within the City of Buena Park. Residents can report graffiti via many ways, including our 24-hour graffiti removal hotline at (7"l4) 821-8658; City's website; by e-mail ([email protected]); or by calling the Public Works Department during normal business hours at (714) 562-3755. The graffiti crew's goal is to respond and remove graffiti within 48 hours following receipt of the complaint. Our goal is to remove approximately 2,000 pieces of graffiti over the fiscal year. 2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2025 through June 30, 2026. @ How was the estimated number of clients determined? * How will you reach your target population?
* Explain why this activity is needed for this target population.

All residents in tract 110606, 110607, 110603, 110605, 110302, 410801, 11 0402,and 110201 totaling 60,740 will be served. See attached project location map.

Application Page 2
Organization Name: Buena P ark P ublic Works Department Program Name: Grafflti Removal Program 3 NATIONAL OBJECTIVES
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe in detail how the activity meets at least one of the three CDBG Program national objectives.

Select one:
[] Benefit low- and moderate-income persons in Buena Park; € Aid in the prevention or elimination of slums or blight in Buena Park; € Meet a need having a particular urgency in Buena Park.

1. To benefit low-and moderate-income persons:
a. Limited clientele (eligibility based on person's income) b. Area wide (see map of CDBG eligible areas)

2. To aid in the prevention or elimination of slums and blight (non-public projects only).

3. Graffiti must be removed immediately in order to discourage graffiti vandals and to prevent the spread of blight.
4 BUDGET
[24 CFR 570.502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB CircularA-87, A-122, Treasury Circular No. 1075] Itemize administrative and operational costs for the proposed activity. Cost Category may include:
staff salaries and benefits, rent, utilities, etc.

Cost Category CDBG Funding
Request
Other Funding
Sources Total Cost
Staff salaries and benefits $ $22,930 $ $ $22,930
Maintenance and operations $ $ $37,840 $ $37,840
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Total $ $22,930 $ $37,840 $ $60,770
Application Page 3
x
x
Organization Name: Buena Park Public Works Department py@glBBl %By5B; Graffitt Removal Program 5 ELIGIBILITY DOCUMENT ATION
If the proposed activity is a public service, describe what form of documentation will be collected to demonstrate that at least 70% of persons served are low- and moderate-income, as required by HUD, and a minimum of 20% are Buena Park residents. (Please attach a copy of the activity's client intake/application/registration form)
All residents in tract 110606, 410607, 110603,lf 0605, 110302, 1l 080af, 1l 0402,and 'l 5 0201 totaling 60,740 will be served. See attached project location map. 6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity's Objective, Outcome, Outcome Statement,- Purpose, and indicators that will be used to measure, track and report performance. Refer to the instructions on Page 5 through Page 7 of the RFP.

A. Select one :
[x Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one :
€ Availability/Accessibility
€ Affordability
[X Sustainability
C. Using the following formula, provide the activity's Purpose:

Purpose = Output + Outcome Statement + Activity
Eight (8) neighborhoods/communities will have improved living environments.

Application Page 4
0ygB(ljz3ii@y) %BIIIB; Buena Park Publ:C WOrkS Department Pro gram Name: Graffiti Removal Program D. Identify the common, specific, and/or other indicators for the activity a. Common Indicators
4 Common Indicators: Reporting on the following indicators, depending on how the program qualified, would still apply:
- Funds leveraged
- Number of persons, households, businesses, units or beds assisted - Income levels Of persons Or households by 30%, 50%, 60% Or 80% Of area med!an income, per applicable program requirements
- Current racial/ethnic and disability categories for households b. Specific Indicators
c. Other Indicators
Outcome: The graffiti program will bring about a more livable, safer, and sustainable environment.

Eight (8) neighborhoods/communities within low and moderate income areas will benefit from the graffiti removal program.

Application Page 5

ACKNOWLEDGEMENT REGARDING

1. By submitting this proposal, the prospective sub-recipient certifies that it has an active registration is SAM that is not set to expire within the next 90 days.

6. It is further agreed that by submitting this proposal, the prospective sub-recipient will include Certification of Subcontractor Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion withoutmodification, in all lower-tier covered transactions and in all solicitations for lower-tier covered transactions.

Provide the following information as detailed in the prospective sub-recipient's SAM registration:

Entity Name: Buena Park Public Works Department
Address: 6650 Beach Boulevard
City: Buena Park State: CA Zip: 90620
Unique Entity it) (UEI): NUK2QVHWF62i
Active Exclusions (Select One): 0Yes [XNo
Expiration Date: 04/ 1 7/2025
Attachment 3

CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

INELIGIBILITY AND VOLUNTARY EXCLUSION LOWER TIER COVERED TRANSACTIONS This certification is required by the regulations implementing Executive Orders 12549 and 12689, Debamient and Suspension, and 2 CFR Part 200, Participants' responsibilities. (BEFORE COA4PLETjNG CERTIFjCA TiON, REA D [NSTRUCTIONS BELOW) (1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principles are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

Organization Name: Buena Park Public Works Department Address: 6650 Beach Blvd, Buena Park, CA 90620
Mina Mikhael, Director of Public V
Name and Title of Authorized Representative Signature 1 2/1 9/2024
Date

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.

3. The prospective lower tier paiticipant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "paiticipant", "person", "primary covered transaction", "principal", "proposal", and "voluntarily excluded", as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Orders 12549 and 12689.

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

Attachment 4
CDBG E[lGIBlE ZONES
]
:J I t
.t
% . .1 ,l,
Fl a:

TO REPORT GRAFFITI ON PUBLIC PROPERTY (Including Metrolink Station) Graffiti Email: [email protected]
Graffiti Hotline: (714) 821-8658
Please include exact location and description of graffiti.

Please note that graffiti reported Friday-Sunday will be documented the following Monday.

REMOVAL PROGRAM
OUR MISSION:

The Public Works Department provides a complete Graffiti Removal Program to eradicate graffiti within the city using all available resources and reasonable efforts.

CALL 9-1-1 FOR GRAFFITI IN PROGRESS
Buena Park Public Works Department

TO REPORT GRAFFITI AT ALL OTHER LOCATIONS
Freeways CalTrans: (949) 724-2500 or www.dot.ca.gov
Flood Channels O.C. Flood Control Division: (714) 955-0200 or www.ocflood.com Railroad Tracks
BNSF Railway: (909) 386-4140 or www.bnsf.com
*For tracks between Beach Blvd. and Dale St., north of Artesia Blvd.

Union Pacific: (888) 877-7267 or www.up.com
*For tracks between Knott Ave. & Dale St., south of Auto Center Dr.

For more information, please call (714) 562-3655 or visit our website at www.BuenaPark.com
City of Buena Park
2025-2026 Community Development Block Grant (CDBG)
F
unding Proposal Summary Sheet
O
rganization Name: City of Buena Park Community Services Department P
rogram Name: Senior Transportation Program
E
stimated Goal: 350 Individuals
F
unding Request: $40,037
O
rganization Purpose:

T
he Senior Transportation Program provides senior Buena Park residents with transportation to non-emergency medical appointments, pharmacies, grocery stores, and the Buena Park Senior Center.

D
escription of Request:

C
DBG funds will be used for three part -time drivers’ salaries and benefits and cell phone expenses.

A
nalysis of Request:

T
he project meets the national objective of benefiting low - and moderate - income individuals, specifically low-income seniors. The program meets an underserved need within the City because many seniors are unable to access other public transportation, do not qualify for Orange County Transportation Authority ( OCTA) access service, or drive their own vehicle.

F
unding Recommendation:

S
taff recommends funding in the amount of $27,600.

CITY OF BUENA PARK

COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2025-2026 CDBG GRANT APPLICATION
DUE BY DECEMBER 19, 2024 AT 5:00 PM
Approximate total funds available for public services: $116,110 Organization Name City of Buena Park - Community Services Activity/Program Name Senior and Non Emergency Transportation Address 8150 Knott Ave,. Buena Park CA, 90620
Contact Person/Title Connie Hurtado, Community Services Supervisor Email Address [email protected] Phone Number 714-562-3878 Estimated individuals or households to be served by proposed activity during FY 2025-2026 (including Buena Park residents and non-Buena Park residents):

Estimated Goal: 350 iX Individuals € Households
Estimated Buena Park residents or households to be served by proposed activity during FY 2025-2026:

Estimated Goal: 350 [X Individuals € Households
Please indicate the amount of CDBG funds being requested:

Public Service Activities s tl0,lo37
Other Eligible Activities
(Signature a orized representative)
Jim Box,
(Name an
ector of Community Services
Title of authorized representative)
Dat22/ic/ 24
Organization Name:C:W of Buena Park - Community Services py()g1'31ll %3111(;; Senior and Non Emergency TransporFaton Please answer the following questions completely. If any questions are left unanswered, your application will not be considered. You may attach additional sheets and/or supporting materials as needed.
1 ACTMTY DESCRIPTION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the proposed activity, including services to be provided and goals to be accomplished. * Why is there a need for this activity in the City of Buena Park? * Identify the location of the activity and the service area boundaries. * Describe specifically the intended use of the CDBG funds.

The Senior and Non-Emergency Medical Transportation Program offers vital mobility services to Buena Park's senior community through a comprehensive transportation solution. This essential service provides a dedicated driver and a vehicle to transport senior citizens aged 60 and older from their residences to the Buena Park Senior Center at no cost to eligible residents. Additionally, the program extends its services to include round-trip transportation for medical needs, including doctor appointments, dental visits, hospital services, and pharmacy stops, all within a three-mile radius of Buena Park's boundaries. While these medical transportation services carry a nominal fee of USD 1.00 each way, the program maintains its commitment to accessibility by ensuring that no senior is denied service due to financial constraints. This transportation initiative serves as a crucial support system, enabling Buena Park's senior residents to maintain their independence and access to essential healthcare services while remaining connected to their community through the Senior Center.
2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2025 through June 30, 2026. * How was the estimated number of clients determined? * How will you reach your target population?
* Explain why this activity is needed for this target population.

The target population is Buena Park Residents 60 years of age or older who need assistance with transportation to and from doctors' appointments, pharmacy, and essential grocery shopping with a targeted goal of 350 seniors within the fiscal year. The estimated number of clients were determined by averaging the number of ridership applications we receive weekly. We will reach our target by continuously advertising to promote the program. In addition, we will be delivered to senior living facilities, senior apartments and medical offices. Furthermore, the program is also advertised in the City's Quarterly publication and a monthly newsletter. Many seniors do not have reliable transportation or the ability to drive and public transportation may not be appropriate as it can be confusing. This program operates with full accessibility to Buena Park seniors with trained courteous staff.

Application Page 2
Organization Name: City of Buena Park - Community Services pl'0gl'3('H Name: Sen:or and NOn Emergency Transporfai:on 3 NATIONALOBJECTIVES '
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe in detail how the activity meets at least one of the three CDBG Program national objectives.

Select one:
[X Benefit low- and moderate-income persons in Buena Park; € Aid in the prevention or elimination of slums or !_light in Buena Park; € Meet a need having a particular urgency in Buena Park.

The Senior and Non Emergency Medical Transportation Program provides low cost, convientient and safe way for Buena Park senior citizens to recieve medical care and treatment promoting their continued idependence and well-being. As a result of a seniors's inability or difficulty obtaining transportation, seniors often delay or negelct to make necessary and critital appointments with their health care provider. This offen results in turning minor health problems into major costly ones. Transportation will also be provided for seniors to pick up prescriptions, attend dental appointments and receive flu shots.

Providing transportation for seniors to the Senior Activity Center ultimatley enhances their quality or life, foster social interaction, independence and self-determination for Buena Park residents over the age of 60. This includes trips to the grocery store, transportation to the senior center for special appointments such as Medicare counseling and support counseling with outreach groups.

Many frail elderly residents are unable to access public transportation services, they don't qualify for OCTA ACCESS service, and they do not drive or own a vehicle. 4 BUDGET
[24 CFR 570.502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or85, and OMB Circular A-87, A-122, Treasury Circular No. 10751 Itemize administrative and operational costs for the proposed activity. Cost Category may include:
staff salaries and benefits, rent, utilities, etc.

Cost Category CDBG Funding
Request
Other Funding
Sources Total Cost
PT Driver Salary $ 34,860 $ 0 $ 34,860
Benefits $ 4,277 $ 0 $ 4,277
Cell Phones Allowance $ 900 $ 0 $ 900
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Total $ 40,037 $ 0 $ 40,037
Application Page 3
01'gH1liz3ji('1 %BB(5; C:$ Of Buena Park - Communfiy SerVtCeS Program Name: Senior and Non Emergency Transportation 5 ELIGIBILITY DOCUMENT ATION
If the proposed activity is a public service, describe what form of documentation will be collected to demonstrate that at least 70% of persons served are low- and moderate-income, as required by HUD, and a minimum of 20% are Buena Park residents. (Please attach a copy of the activity's client intake/application/registration form)
The majority of clients served are over 60 years of age who meet low/moderate income requirements. Most of the clients are Buena Park residents.

Documentation consists of filling out the transportation application which requires the applicant to fill out their income. We only provide transportation to Buena Park residents which meets the 20% minimum residency requirment. Additionally, a daily client contact tally sheets that define type of transportation (i.e precription pick up, doctors appointments, ect.) 6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity's e, Outcome, Outcome Statement, Purpose, and indicators that will be used to measure7trackand report performance. Refer to the instructions on Page 5 through Page 7 of the RFP.

A. Select one :
[x Suitable Living Environment
[] Decent Affordable Housing
[] Economic Opportunities
B. Select one :
[x Availability/Accessibility
[] Affordability
€ Sustainability
C. Using the following formula, provide the activity's Purpose:

Purpose = Output + Outcome Statement + Activity
Approximately 350 elder residents in the program are provided with affordable transportation/service assistance. These seniors may not be able to access these services if the program is not available.

Application Page 4
0yg31liz3iiH Name: Cih/ Of Buena Park - Commun:%' SerV:CeS pl'()gyBlH Name: Senior and NOn Emergency Transpodatlon D. Identify the common, specific, and/or other indicators for the activity a. Common Indicators
The program will increase of ridership for the senior transportation program and the non emergency medical transporation rides.
b. Specific Indicators
One hundred perecent of olderly persons in the prorgam are provided with affordable transportation to their medical appointments and/or transportation to meet their living necessities.

This allows a senior to live independly with dignity as long as possible. c. Other Indicators
Application Page 5

ACKNOWLEDGEMENT REGARDING

L By submitting this proposal, the prospective sub-recipient certifies that it has an active registration is SAM that is not set to expire within the next 90 days.

Provide the following information as detailed in the prospective sub-recipient's SAM registration:

Entity Name' City of Buena Park
Address: 8150 Knott Ave.

City: Buena Park State: CA Zip: 90620
Unique Entity ID (UEI): t4t)kl(J?VHuFW2-3 Expiration Date: o4/i'7 /2025 Active Exclusions (Select One): 0Yes [o
Attacent 3

CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

INELIGIBILITY AND VOLUNT ARY EXCLUSION LOWER TIER COVERED TRANSACTIONS Tliis ceitification is reqriired by the regulations implementing Exetutive Orders 12549 and 12689, Debannent and Srispension, and 2 CFR Pait 200, Participants' responsibilities.

1. 2. The ceitification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determiiied that the prospective lower tier participant knowingly rendered an erroneous ceitification, in addition to other remedies available to the Federal Government, the department or agency witli which this transaction originated may pursue available remedies, including suspension and/or debarment.

3. The prospective lower tier paiticipant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier paiticipant learns that its cettification was erroneous when submitted or has become erroneous by reason of changed circumstances

4. The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "participant", "person", "primary covered transaction", "principal", "proposal", and "voluntarily excluded", as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Orders 12549 and 12689.

5. Tlie prospective lower tier participant agrees by submitting tliis proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from patticipation in this covered transaction, unless authorized by the department or agency witli which this transaction originated.

6. The prospective lower tier paiticipant ftuther agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transactions", withorit modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

7. A participant in a covered transaction may rely ripon a ceitification of a prospective participant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded fi'om the covered transaction, unless it knows that the ceitification is erroneous. A patticipant may decide the method and frequency by wl'iich it determines the eligibility of its principals. Each participant may check the System for Award Management (SAM).

8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prrident person in the ordinary course of business dealings.

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available rei'nedies, incltiding suspension and/or debarment.

Attachment 4

City of Buena Park
2025-2026 Community Development Block Grant (CDBG)
F
unding Proposal Summary Sheet
O
rganization Name: City of Buena Park Community Services Department P
rogram Name: Homeless Outreach Program
E
stimated Goal: 200 Individuals
F
unding Request: $20,000
O
rganization Purpose:

T
he Homeless Outreach program provides services to homeless individuals living in the City of Buena Park. They collaborate with Mercy House, Police Department, and other homeless service providers t o assist individuals experiencing homelessness with temporary housing and emergency supplies.

D
escription of Request:

C
DBG funds will be used for temporary shelter costs, relocation expenses, transitional housing fees, emergency supplies, local transportation, DMV documentation fees, and program staff training.

A
nalysis of Request:

T
he Homeless Outreach Program meets the objective of benefitting low - and moderate- income residents in Buena Park. Homelessness continues to be a major concern in the City and this program will help decrease the issue by providing services that will propel homeless individuals into better living situations. This program helps meet the City’s goal of continuum of care to assist the homeless population.

Funding Recommendation:

S
taff recommends funding in the amount of $20,000.

CITY OF BUENA PARK

COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2025-2026 CDBG GRANT APPLICATION
DUE BY DECEMBER 19, 2024 AT 5:00 PM
Approximate total funds available for public services: $1161 1 0 Organization Name City of Buena Park - Community Services Activity/Program Name Homeless Outreach Services
Address 8150 Knott Ave, Buena Park Ca 90620
Contact Person/Title Rosemary Nielsen/ Homeless Services Supervisor Email Address [email protected] Phone Number (714) 236-3876 Estimated individuals or households to be served by proposed activity during FY 2025-2026 (including Buena Park residents and non-Buena Park residents):

Estimated Goal: 200 [X Individuals € Households
Estimated Buena Park residents or households to be served by proposed activity during FY 2025-2026:

Estimated Goal: 200 [X Individuals € Households
Please indicate the amount of CDBG funds being requested:

Public Service Activities $ 20,000.00
Other Eligible Activities
(Signature of autho ed presentative)
Jim Box Communa Services Director
(Name and Title of uthorized representative)
Dt)2/J Rl 2'f
Organization Name: Program Name:

Application Page 2
Please answer the following questions completely. If any questions are left unanswered, your application will not be considered. You may attach additional sheets and/or supporting materials as needed.
1 ACTIVITY DESCRIPTION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the proposed activity, including services to be provided and goals to be accomplished.

Why is there a need for this activity in the City of Buena Park? Identify the location of the activity and the service area boundaries.

Describe specifically the intended use of the CDBG funds. 2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2025 through June 30, 2026.

How was the estimated number of clients determined?
How will you reach your target population?
Explain why this activity is needed for this target population.

City of Buena Park - Community Services Homeless Outreach Services As of the Point in Time count January, 2024 it is estimated that the City of Buena Park has a total of 379 people experiencing homelessness. The Homeless Outreach Team provides services to those who are experiencing homelessness and those at risk of becoming homeless. All CDBG funds will be used to assist clients in connecting to emergency shelter, transitional living, transportation and other critical services. The goal is to eliminate homelessness to functional zero.

Homeless Outreach Services are located at Ehlers Event Center, 8150 Knott Ave, Buena Park, Ca 90620. We provide services to those experiencing homelessness from the City of Buena Park.

These CDBG funds will be used for the following: Housing Emergency Shelter, Relocation Expenses/Storage Emergency Supplies, Local Transportation/DMV Fee's, Documentation / lD fee's and staff training.

The target population will be 200 unduplicated Buena Park residents to be serves. The number was estimated upon the fieldwork of the homeless outreach team and the current Point In Time Count. The homeless outreach team has part time case managers who are accessible in the field Monday through Friday or via phone (714) 236-3877 or email at [email protected]. Residents may also visit the Homeless Outreach at Ehlers Event Center to seek homeless services.

Organization Name: Ctty of Buena Park - CommunitY ServiCeS pp@g1,l1'1l %3111(H; HomeleSS Outreach SerViCeS 3 NATIONAL OBJECTIVES
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe in detail how the activity meets at least one of the three CDBG Program national objectives.

Select one:
[x Benefit low- and moderate-income persons in Buena Park; € Aid in the prevention or elimination of slums or blight in Buena Park; [] Meet a need having a particular urgency in Buena Park.

This program meets the objective to benefit low and moderate income levels. All funds will be used to assist those experiencing homelessness or at risk of experiencing homelessness. 4 BUDGET
[24 CFR 570.502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circular A-87, A-122, Treasury Circular No. 1075] Itemize administrative and operational costs for the proposed activity. Cost Category may include:
staff salaries and benefits, rent, utilities, etc.

Cost Category CDBG Funding
Request
Other Funding
Sources Total Cost
Motels/Room Rentals $ 5000 $ $ 5000
Relocation/Storage Expenses $ 2000 $ $ 2000
Transitional Housing Fees $ 2000 $ $ 2000
Emergency Supplies/Safety Equipment $ 2500 $ $ 2500
Transportation $ 5500 $ $ 5500
DMV/Documentation $ 1000 $ $ 1000
Staff Training Conference/Edu/Outreach Supplies $ 2000 $ $ 2000 Salaries/Benefits $ $ 388790.66 $ 388790.66
Educational Incentive $ $ 4200 $ 4200
Office Supplies/Special $ $ 1000 $ 1000
Total $ 20000 $ 393990.66 $ 413990.66
Application Page 3
Organization Name: Program Name:

Application Page 4
5 ELIGIBILITY DOCUMENTATION
If the proposed activity is a public service, describe what form of documentation will be collectedto demonstrate that at least 70% of persons served are low- and moderate-income, as required by HUD, and a minimum of 20% are Buena Park residents. (Please attach a copy of the activity’s client intake/application/registration form)
6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity’s Objective, Outcome, Outcome Statement, Purpose,and indicators that will be used to measure, track and report performance. Refer to the instructions on Page 5 through Page 7 of the RFP.

A. Select one Objective:

Suitable Living Environment
Decent Affordable Housing
Economic Opportunities
B. Select one Outcome:

Availability/Accessibility
Affordability
Sustainability
C. Using the following formula, provide the activity’s Purpose:

Purpose = Output + Outcome Statement + Activity
City of Buena Park - Community Services Homeless Outreach Services Clients served by the Homeless Outreach Program will be extremely low income and unhoused or at risk of losing their housing. The participants will have significant ties to the City of Buena Park.

Documentation consists of intake sheets, hotline logs, drop-in logs and HMIS and Outreach Grid. 200 individuals will have access to services that can include emergency shelter, transitional shelter, rapid rehousing and permanent supportive housing if this grant with CDBG is funded. 0jgBQ;zBii0n %31B(5: City Of Buena Park - CommunitY ServiCeS pj0gl-8111 %816: Homeless Outreach ServiCeS D. Identify the common, specific, and/or other indicators for the activity a. Common Indicators
200 individual experiencing homelessness will have access to Outreach Services which can include: case management, detox, rehabilitation, shelter, rapid rehousing and permanent supportive housing.
b. Specific Indicators
b. 200 individuals will have access to services that can include: bus passes and Lyft rides. DMV documents, vital records. motel vouchers, room rentals. fee's for detox and rehabilitation c. Other Indicators
Application Page 5

ACKNOWLEDGEMENT REGARDING

BIDDER SAM REGISTRATION
Pursuant to 2 CFR Section 5.1004 and the requirement of the u.s. Department of Housing and Urban Development (HUD), contractors procured directly by grantees, sub-grantees, and/or sub-recipients of HUD funds, including CDBG are required to have an active registration in the System oF Award Management (SAM). This document shall be comp!eted and submitted as part of the proposal.

4. By submitting this proposal, the prospective sub-recipient certifies that it has an active registration is SAM that is not set to expire within the next 90 days.

6. It is further agreed that by submitting this proposal, the prospective sub-recipient will include Certification of Subcontractor Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion withoutmodification, in all lower-tier covered transactions and in all solicitations for lower-tier covered transactions.

Provide the following information as detailed in the prospective sub-recipient's SAM registration:

Entity yBpB: C!$ Of Buena Park
Address: 8150 Knott Ave
City: Buena Park
Unique Entity ID (UEI): nuk2qvhwf623
Active Exclusions (Select One): 0Yes [xNo
State: CA Zip: 90620
Expiration Date: 04/17/2025
Attachment 3

CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILtTY AND VOLUNTARY EXCLUSION LOWER TIER COVERED TRANSACTIONS This certification is required by the regulations implementing Executive Orders 12549 and 12689, Debannent and Suspension, and 2 CFR Part 200, Participants' responsibilities. (BEFORJE CCRvfPLETjNG CERTIFICATION, READ [NSTRUCTIONS BELOW) (1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principles are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

Organization Name: City of Buena Park - Homeless Outreach Program Address: 8150 Knott Ave., Buena Park, CA
Jim Box, Community Services Dir.

Name and Title of Authortzed Representative

1. By signing and submitting this proposal, the prospective lo er ti participant is providing the certification set out below.

2. The certification in this clause is a material representation of upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the deparhnent or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

3. The prospective lower tier participant sliall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "participant", "person", "primary covered trarisaction", "principal", "proposal", and "voluntarily excluded", as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Orders 12549 and 12689.

6. The prospective lower tier participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debaiment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transactions", witliout modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each paiticipant may check the System for Award Management (SAM).

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Goveniment, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

Attachment 4

City of Buena Park
2025-2026 Community Development Block Grant (CDBG)
F
unding Proposal Summary Sheet
O
rganization Name:

Pr
ogram Name:

E
stimated Goal:

Funding Request:

Boys & Girls Club of Buena Park
BGCBP
3,200 Individuals
$47,397
O
rganization Purpose:

T
he purpose of the Boys & Girls Club is to improve the quality of life of Buena Park’s youth through a variety of social and recreational programs addressing character and leadership development, arts, education, and career development, h ealth and life skills, sports, and fitness and recreation. In addition to these services, the program also provides low cost dental treatment to children who qualify.

D
escription of Request:

C
DBG funds wil l be used to reimburse utility costs including electricity, telephone, and internet services at their facility, 7758 Knott Ave., Buena Park, CA 90620.

A
nalysis of Request:

T
he project meets the national objective of benefiting low - and moderate - income individuals. Club members are required to submit a membership form, which includes their ethnicity, household size, household income, and other demographic information.

The Boys and Girls Club serves over 1,000 children , ages 4-18, at their on -site facility and participating school campuses.

F
unding Recommendation:

S
taff recommends funding in the amount of $10,000.

CITY OF BUENA PARK

COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2025-2026 CDBG GRANT APPLICATION
DUE BY DECEMBER 19, 2024 AT 5:00 PM
Approximate total funds available for public services: $116,110 Organizat €ori Name Boys & Girls Club of Buena Park Activity/Program Name BGCBP
Address 7758 Knott Ave. Buena Park CA 90620
Contact Person/Title Todd Trout CEO
EmaH Address tdtrout@theplaceforki Phone Number 714-522-7259 Estimated individuals or households to be served by proposed actlvity during FY 2025-2026 (including Buena Park residents and non-Buena Park residents):

Estimated Goal: 4,000 Individuals [1 Households
Estimated Buena Park residents or liouseholds to be served by proposed activity during FY 2025-2026:

Estimated Goal: 3,200 % Individuals € Households
Please indicate the amount of CDBG funds beirig requested:

Public Service Activities
Other Eligible Activlties
(Signature of authorizXrepr'esentatlve)
11, l ll /,8 Z
Date
71' op oTX!-> s;r () (f:9
(Name and Title of authorized representative)
OrganizationName:Boys&GirlsClubofBuenaPark programnan'ie: 8('i(:8P Please answer the following questions completely. If any questions are left unanswered, your application wlll not be considered. You may attach addltional sheets and/or supporting materials as needed.

I ACTIVITY DESCRIPTION
[24 CFR 570.200(a), 570.201-570.208, 570.5031
Describe the proposed activity, including services to be provided and goals to be accomplished. * Why is there a need for this activity in the City of Buena Park? * Identify the location of the activity and the service area boundaries. * Describe specifically the intended use of the CDBG funds.

The Boys & Girls Club of Buena Park is the only facility-based agency in the entire City of Buena Park providing after-school educational and recreational programs for youth ages 4-18. Boys & Girls Club's program focus is broken down Into five key Core Areas: The Ar(s; Character and Leadership Development; Education and Career Development; Health and Life Skills; Sports, Fitness and Recreation.

In cooperation with the Boys & GirlsClub, 8t. Jude Medical Center manages the St. Jude Medical Center Dental Clink, as well asyouth sports programs and other yearly activities. An estimated 1,000 youth and teens participate annually.

The inds being reques(ed will be used for a portion of the utility costs for the Boys 8, Girls Club main facility, and (he St. Jude Medical Center Dental Clinic (located on the Boys & Girls Club property). 2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target populatlon for this activity and the number of estimated unduplicated Buena Park residents to be served from July "1, 2025 through June 30, 2026. * How was the estimated number of clients determined? * How will you reach your target population?
* Explain why this activity is needed for this target population.

Our Target population is youth and teens ages 4-'1 8 years odd. With the youth served through the dental clinic onsite along with our monthly/yearly membership and community outreach activities leagues/tournaments, service clubs/projects) we continue to serve a steady number of familief cernjng out of previous pandemic restrictions. Through the pandemic we have transitioned to ir'iclude sen7i6esto families and not just limited to youth and teens. We recognize our members are better served when their family's needs are met In ways the Club can be of assistance.

App}icntioxi Page 2
Organization Name: BOYS & GtrlS Ckl5 0f Buena Park Pi'ogram Nainc: R('ICRP 13 ' NATIONALOBJECTIVES
[24 CFR 570.200(a), 570.20al-570.208, 570.503]
Describe in detail how the activity meets at least one of the three CDBG Program national objectives.

Select one:
0 Benefit low- and moderate-income persons in Buena Park; [:l Aid in the prevention or elimination of slums or blight in Buena Park; [1 Meet a need having a particular urgency in Buena Park.

The Boys & Girls Club of Buena Park continues to provide services to youth from low-and-moderate income households. Over 80% of the meinbers live in households that fall within that targeted economic range and are in need of after school services, summer program services, mental and physical health services (provided through comn'iunity partnerships i:e: ST. Jude, BP Police Department). Our Education, Health and Fitness, Leadership and Community Service, as well as Fine Arts along with the mentorship our Staff provide in the crucial years of development, play a huge role in bettering individual and families lives. We help prepare youth and teens for the challenges which lead to so many pitfalls these days in so many iives. We help guide youth and teens to successful pathways that help navigate the pitfalls and )ielp create strong citizens that create a positive force in our communities.
4 I
BUDGET
[24 CFR 570.502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circular A-87, A-122, Treasury Circular No. 1075] Itemize administrative and operational costs for the proposed activity. Cost Category may include:
staff salaries and benefits, rent, utilities, etc.

Cost Category CDBG Funding
Request
Other Funding
Sources Total Cost
Phones $ 7299 $ $ 7299
Internet $ 4427 $ $ 4427
Electricity $ 25000 $ $ 25000
Alarm $ 2534 $ $ 2534I
Vision & Neon Tracking Systeri $ 7093 $ $ 7093
IT Services $ 8137 $ $ 8137
l / : x a- -ffl O . h. I . l'l !!. _!__. . . j. :. ... ('. .. . l- - 'g - a..alQ !g_ f _ fflrvth ,71:.yl(,In a INt,'LIT - Thlt'ilHll1 W /U9J W - " - - % - w UIJ I
)
$ $ $
$ $ $
$ $ $ I
Total $ $ $7 'l
'ntM'%'
A1i)ilicalion Piige 3
orgniiizationname:Boys&GirlsClubofBuenaPark pinBrhinn+'iineaF3('CRP 5 ELIGIBILITYDOCUMENTATION
Ifthe proposed actMty Is a publlc service, describe what form or documentation will be collected todemonstrate that at least 70% of persons served are low- and moderate-income, as required byHUD, and a minimum of20% are Buena Park residents. (Please attach a copy of the activity's clientintake/application/registration form) Each mernberofthe Boys & Girds Club is required to complete a membership form which includes thefollowing information: Ethnicity; Household Size and Annual Income; Place of Residence and Employment; and Head ofHousehold, The membership Application has been designed to reflectthe required informationdesired by HUD.

The financial breakdown ofthe Household Income is taken directlyfrom the "CDBG Income Limits"documents distributed by the City of Buena Park. 6 0UTCOME PERFORMANCE MEASUREMENT 8Y8TEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
PJease indicate the activity's , e, Oiltcorr)e 8taJlqnt, pgrp'o';e-,-'and indicators that will be used to measure, track and report performance. Refer to the instructions on Page 5through Page 7 of the RFP.

A. Select one :
[] Suitable Living Environment
[1 Decent Affordable Housing
[1 Economic Opportunities
B. Select one :
[1 Availability/Accessibility
€ Affordabillty
a Sustainability
C. Using the following formula, provide the activity's Purpose:

Purpose = Output -i- Outcome Statement + Activ(ty
We estimate over 3,000 youth and teens have access to positive mentorship, educational guidance and tutoring, In a daily program enriched in leadership and character development program that operates year-round, as well as other forms of participation throughout the year. These youth and teens have access to !ow-cost dental services and other mental and physical wellness programs, ' sporting activities as well as social mentorship activities.

Application Page 4
OrganizationNanrc:Boys&GirlsClubofBuenaPark ProgramNaine: RGCRP D. IdenUfy the common, speciflc, and/or other indk.ators for the activity a. Common Indicators
Over 500families benefitand receiveweekly mentorship in our in person programs, The Club is a "second home" to many ofourfamilies in need. With the expansion ofyouth development programs (sporting acffvities,leagues, teen leadership programs BIG 6, Tri City Pod Cast, Dream itbe it, Junior StafQ the youth and teens served have multiple layers ofsupport by dedicated adultinteraction in positive self esteem enhancementand otherforms ofcare.
b. 8pectfk, Indlcators
Over 75% have gained knowledge in our pre/post testing through our Leadership programs (SMART Moves, SMART Girls, MAN Cave, Togh Club, Keystone Club). 85% have shown improvement In reading/wrlting and math skills in our Power Hour Program. c. Other Indicators
Over 50% have shown Improvement in physical fitness assessments and particlpation in daily exercise and movement activities along with the growing belief and positive self-esteem enhancement in oneself.

Apliliciition Page5

ACI(NOWI,EDGEMENT REGARDING

BIDDER SAM REGISTRATION
Pursuant to 2 CFR Section 5,1004 and the requirement of the u.s. Department of Housing and Urban Development (HUD), contractors procured directly by grantees, sub-grantees, and/or sub-recipients of HUD funds, includlng CDBG are requlred to have an actlve registration in the System of Award Management (SAM), This document shall be completed and submitted as part of the proposal.

1. By submitting thls proposal, the prospective sub-recipient certifies that it has an active registration is SAM that is not set to expire wlthin the next 90 days. 2, By submitting this proposal, the prospectlve sub-recipient certlfles neither it, Its prlnclpals nor affiliates, is presently debarred, suspended, proposed for debarment, declared Ineligible, or voluntarlly excluded from participation In this transaction by any Federal department or agency.

3. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered Into. If it is later determined that an enoneous certification was rendered, in addition to other remedies available to the Federal Government, the Department or agency with which this transaction originated may pursue available remedies.

5. By submitting this proposal, it is agreed that should the proposed covered transaction be entered into, the prospective sub-recipient will not knowingly ei'iter Into any lower-tier covered transaction with a person who Is debarred, suspended, declared Inellglble, or voluntarlly excluded from partlclpatlon In this covered transaction unless authorized by the agency with which this transaction originated.

6. It is further agreed that by submitting this proposal' the prospectaive sub-reclpient will Include Certification of Subcontractor Regarding Debarment, Suspension, Inellglbillty and Voluntaiy Exclusion wlthoutmodification, in all lower-tier covered transactions and in all solicitations for lower-tier covered transactlons.

Provide the following information as detailed in the prospective sub-recipient's SAM registration:

Entity Name: Boys & G1rlS Club Buena Park
Address: 7758 Knott AVe.

City: Buena Park State: Zip: 90620
UnlqueEntltylD(UEI): npqlrmnbzvk9
Active Exclusions (Select One): [lYes ZNo
Expiration Date: 02/25/2025
Attucl'imenl 3

CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INElJG[BILITY AND VOLUNTARY EXCLUSiON I,OWER TIER COVF.RED TRANSACTIONS Tbis ccitincntion is rcqtiiictl by tlic reguliitions iinplcmcntiiig Exccutivc Onlers 12549 nnd 12689, T)dinrincnt nnd Susl)011SiOn, arid 2 CFR Part 200, Paiticiptiins' rcsl)OnSibillliOS. (BIEFOIIE COMPLr.TMG CERTl74CATfOM RIEAD INSIRUCTJON,S BlrLOH/) (1) Tlie prospcctive lower tier participnm ccitifics, by sulimission of tl'iis proposnl, that neither it nor its principles tire liresenlly deL+nrred, suspeixled, liroliosed for debmment, declared ineligible, or vokintiuaily axe)udttl from piiiticipation in t)iis transaction by any I?cdcral dcpai'tmcnt or agency. (2) Wlierc lhe prospective lower tier piuticipanl is unablc to ceitify (o ariy of llie stalcments in tliis certifica(ion, sucli lirosliective puilicipant shnl) atlacli (Ill explanation to Iliis liroliosal.

Organizntion Nnnie: BO')/8 & GtrlS Clu5 Buena Park
Address: 7758 Knott Ave. Buena Park CA 90620
Todd Trout CEO
Niiine nod l'ltle of Aiitlioi4zed Represeiitiitlvc 12/17/2024
Diit(i

1. By sigiiing aiid suL+initUng this proposal, tlie prospeclivc lower liar piirticipant is providing llie certificalioii scl out below.

2. Tlie certification in tliis clause is a inaterial representation of fact upon wliich reliance was placed wlien tliis transiiction was entered into. If it is liitcr detennined tlint tlic pmsliectivc lower tier linrlicilxmt knoivingly rcndcrctl iui erroneous ccrliflcation, in iiddttion to oiliar remedies availiiblc to Ilie Fcdcrnl Govcrnmcm, die tlcparlment or agency witli wliid lliis transaction originated uiay puimic iivailiiblc remedies, including suspension rine1/or dcbnrmcnt.

3. TIIO prospective lower Liar pailicipanl shall provide iminediatc writlei'i nottcc to llie parson to wliicli this P1'OPO8111 is subinitted ifnt any tiinc tlic prospective lower ticr liarticiliiint learns tlint its ceitif?cntion was erroneous wiien submitted or liiis becoine erroneotis by reason or clianged cirmimslances.

4. The lcrms "covcred rtxnsiiction", "dcliaircd", "suspcimcd", "ineligible", '%wer tier covered transaction", "particiliant", "person", "primiiry coveretl transaction", "principal", "proliosal", and "vokmtarily cxdtitltxl", iis 1180(I in tliis clmisc, IIIIV(+ the mcanings scl out in tlie DcJinitioi'is and Covcragc sections of rtilcs imlilci'i'icnting Executi'vo Ortlcix }2549 and 12689.

5. Tlie prospective lower tier parliclliaiit agrees by subinitting tliis proposal lliat, sliould tlie proposed covered trai'tsaction be cnterad into, it s1iall not knouiingly enter into iuiy lowei' tier covercd transaction wit)i n person wlio is debarred, suspended, declared ineligilile, or voltinlariiy excltided front liarticipation !n this covered trnnsttction, unk'ss riutliorized by tlie depaitinent or iigency witli wliicli tliis traiisaction originated.

6. Tlic prospectivc lower tier participant furLlicr agrees by sribiuit(ing (bis proposal tlial iL will includc 1110 clause filled "Certification Ikegardiiig Debarinent, Sus)iension, Ineltgil'iility and Voluntary Bxcltision-Lower Tier Covcrcd Transactions", without niodificatioi'i, in all lower tier covcred ti'imsactions and in all solicitations for loivcr ticr coycred iri'insnctions.

7. A participant in a covered trnnsiiction may rely upon n ccrtiticntion of n prospective piirticipnnt iii h lower tier covered transaction Tom is not debarred, suspended, ineligible, or voluntaiily exchmed [iaom tlie covered transaction, unless it knows tlmt the certification is erroneous. A linrticipant miiy decide tlic inetliod sum (requency by wliicli it dotcrmitxis tbc eligibility of its lirincipals. Eocb pnrlicipanl inay clx,ck late S:YSlOm for Award Management (SAA4).

8. Nothing coiitained in ttu' foregoing shall bc coi'istittcd to reqtiirc establishment of a system of rccortls in ordcr to render in good railli tlie ceitificalion required by this clause. Tlie knowledge mid inlaorination of n pai'tictpant is not rcquircd to cxcced that wihicb is normiil1y posscsst,tl by a pn'idcnt Ix'rson ii'i the ordinaiy coursc of blisincss dealings.

9. JEXC(!l)t far tl?l1lStletlOllS HlltbOrl7C(1 under pnragiaaph 5 0f tl1eS(' InStl'llCtlOllS, if It parttcipant in 11 COVOrCd Iransaction knowingly enters ii'ito a lower tier covcrcd triinsaction with a parson who is stispcndcd, debarred, incligilile, or vokinffirily cxcludcd froin linrticiliiition in tliis triinsnction, in addition to otlicr rcincdics avnilitblc to ffic Fcderal Governincnt, tlie da(:iarLment Or agency wit)i wliicli Iliis transaclion originnk,d 1l1a3r IXlrSt}O availalile rcmedies, iticltiding suslxinsion and/or delxiririem.

Attncliment 4

CITY OF BUENA PARK

COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
2025-2025 REQUEST FOR PROPOSAU8 (RFP)

ZONING/LAND USE APPROVAL
This form shall only be used in City determination of eligibility for CDBG Grants and shall not constitute separate review for any other purpose.

Name of organization
Address of organization
Applicant name and title Phone Number/Email
Describe business operation, including services provided and activities performed in sufficient detail to allow determination of eligibility to operate at property (use a separate page for additional information)
Applicant's Slgnature Date
To be completed by the City of Buena Park Planning Department Use classification
Zoning
[] Permitted Use
[] Conditional Use Permit Required
Comments:

Signature of Planning Department Representative Date Attnchincnt 5
2024 BOYS & GIRLS CLUB OF BUENA PARK MEMBERSHIP
* II II * * * * * II * * * * * * * * * * II II * * * III * II * * * * * * * * * * * * * II * ** * * **** * * * * **

MEMBER INFORMATION

4. Member's Name First: Middle:

Gender: M/F Birth Date:/l Age: School:

Address: City:

Health Issues/Allergies: YES/NO If yes, List
Last:

Grade: NEWMEMBER Y/N
State: Zip:

Medications:

2. Member's Name First: Middle:

Gender: M/F Birth Date: ll Age: School:

Address: City:

Health Issues/Allergies: YES/ NO If yes, List
Last:

Grade:

State:

Medications:

NEW MEMBER Y / N

3. Member's Name First: Middle:

Gender: M/F Birth Date:// Age: School:

Address: City:

Health Issues/Allergies: YES/ NO If yes, List
ETHNICITY (need to mark yes or no)
Last:

Grade:

State:

Medications:

NEW MEMBER Y / N
Hispanic/ Latino: YES, ( if marked yes please circle one of the following) Mexican / Chicano, Puerto Rican, Cuban, Other Hispanic/Latino (need to circle one)
(WhitelCaucasian) (Black/African American) (Blackl African American & White) (Asian) (Asian & White) (American Indian/Alaskan Native) (American Indian/Alaskan Native & Black/African American) (Americanlndian/A1askanNative&White) (NativeHawafian/OtherPacificlslander) (OtherMulticultural) Mother/Guardian Information:

Name:

Father/Guardian Information:

Name:

Address: Address:

Emolover: Employer:

Home # Home #
Cell # Cell #
Work # Work #
E-Mail Address E-Mail Address
Emergency Contact (other than parent/guardian):

Name:

Emergency Contact (other than parent/guardian):

Name:

Cell # Cell #
Work # Work #
Relationship to Member: Relationship to Member:

The information that follows is necessary for our records and the funds that our organization receives. Information given to us is confidentiaf. Cooperation in giving us this information is appreciated and necessary.

Annual Household Income (including any child support): $ Occupants in Household:

Housing status: Own Renting Homeless Other:

Does this member live with their: Mom Dad Step Dad Grandparent Other:

Current Head of Household: Male/Female/Both
Number of Brothers: Ages: Number of Sisters: Ages:

MEMBERSHIP WILL NOT BE PROCESSED UNTIL PARENT/GUARDIAN HAS SIGNED THIS PORTION:

1. I have read the completed application, understand the rules of the Boys & Girls Club of Buena Park and request that my child be admitted into membership.

2. I understand my child's membership standing is based on their ability to obey the rules of the Club. Membership may be suspended or canceled at any time for safety concerns or failure to follow the Club's rules, policies, and procedures.

3. The Boys & Girls Club of Buena Park is for youth ages 6-18. A birth certificate must be provided for all new members that are age 6. Members that are 18 years of age must be currently enrolled in high school to attend the Club.

4. I understand that the Boys & Girls Club of Buena Park has a weekly fee during the school year for all members not in the Transportation Program. The Summer Program is a different rate, please refer to summer paperwork. Unpaid balances will result in a suspension of membership until balance has been paid in full.

5. I understand that the Boys & Girls Clubs of Buena Park has an "OPEN DOOR POLICY." This means that members are Tree to enter and leave the club. It is the parent's or legal guardian's responsibility to note on membership application whether or not their child can leave the Club.

6. Custody issues/payment responsibilities: The Club holds the parent that enrolls their child in our program responsible for any and all fees, regardless of "split or shared" costs involving custody issues.

7. I understand that my child must be picked up on or before closing time. The Boys & Girls Club of Buena Park closes at 6 p.m. Being late will not be tolerated and will result in membership being canceled.

8. The Boys & Girls Club of Buena Park has my consent to administer any treatment (including but not limited to: x-ray, examination, anesthetic, medical, surgical or dental diagnosis and any hospital care) that are considered necessary in the best judgment of the attending medical or emergency personnel. This consent is given prior to any such medical treatment, but is given to provide authority and power on the part of the Boys & Girls Club of Buena Park in the exercise of their best judgment upon the advice of any such medical or emergency personnel. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Boys & Girls Club of Buena Park to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any x-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.

9. I knowingly waive any claim against, or right to sue, the Boys & Girls Club of Buena Park, its agents, officers, employees, and Boys & Girls Clubs of America for any injury, accident, illness, or death occurring during or by reason of your child's participation in our program, and further waive any possible allegation or daim of liability of the Boys & Girls Club of Buena Park. I have carefully read this form and fully understand its contents, and by signing below, agree to this full and complete release of liability.

Parent's, Signature:

Staff: Date:

PARENT AGREEMENT
Please read the following and initial each one when finished. l) The Boys & Girls Club of Buena Park closes at 6pm. Being late will not be tolerated and will be cause for removal from the program without a refiind. 2) All balances must be paid in full at the beginning of the week in order for your child's membership to remain active. In addition, there is a $25 fee for all returned checks/ late Transportation fees, $10 late fee for weekly payments that can't be processed on due date *"'Fees are subject tO change at any time**
3) Parents must come into the Club to sign out their children. Members may not wait in the parking lot. When picking up members, parents must check in at the front desk. For safety reasons parents are not allowed into the program areas to look for their child. 4) Toys & electronic devices of any kind are not allowed at the Club. The Boys & Girls Club of Buena Park is not responsible for lost, stolen, or damaged items brought to the Club. 5) The Boys & Girls Club of Buena Park has a ZERO TOLERANCE policy concerning any form of fighting or any verbal "Bullying". This includes all forms of physical contact. These actions will result in an immediate suspension along with possible removal from the program. 6) Any equipment found to be damaged or broken through negligence of a Club member must be paid for by the parent before the child can return to the program. 7) Any changes to your membership/payment information falls on the parents responsibility and must be updated as soon as possible.
8) There is a separate registration fee when signing up for our Summer Program.

PARENT'S
{NITIALS
II

IGIVE MY CHILD PERMISSION TO LEAVE THE BOYS & GIRLS CLUB OF BUENA PARK ON THEIR OWN FOR LUNCH

OR ANY OTHER REAS(N KNOIWNG THAT THE CLUB IS NO LONGER RESPONSIBLE FOR THEM ONCE THEY HAVE LEFT THE BUILDING.

YES/NO
€ C.IVE &IY CHILD PERMISSION TO USE THE INTERNET AT THE BOYS & GIRLS CLUB OF BUENA PARK. CLUB STAFF USE STRICT GUmELINES REGARDING WHAT SITES CAN BE V{EWED.

YES/NO
Ihereby grant to the Boys & Girls Club of Buena Park the right to photograph my dependent and use the photo and or other digital reproduction of himher for publication processes, whether by prtnt or electronic publishing via the Internet.

YES/NO
Parents are expected to set a positive and professional example in their behavior while at the Club. The following rules of conduct need to be adhered to while in the building or on Club property:

1. Parents will show respect and courtesy to Staff, members, and other parents at all times.

2. Parents are not to approach or address any child other than their own. If there is an issue involving another child, the parent needs to bring the matter to the Unit Director's attention to be handled appropriately.

3. Parents will not create any type of negative disturbance in front of members. All matters of concern will be taken care of behind closed doors.

4. There will be no foul or derogatory language of any kind.

5. Parents will use caution when entering and exiting the parking lot.

Any behavior unbecoming of a Parent will result in the permanent removal from the Club's property and if need be, reported to the Buena Park Police Department.

Please make sure you have read the above in detail. Sign and date below stating you understand the above rules and policies.

Parent's Name Parent's Signature Date

BOYS & GNRLS CLUB

OF BUENA PARK
COViD-19 Warning and Assumption of Risk
-WARN!NG-
The novel coronavirus, COV[D-T9, has been declared a worldwide pandemic by the WorldHealth Organization. COVID-i9 % extremelywntagfous and fs believed to spread mainly fromperson-to-person contact. As a result, federal, state, and local governments and federal andstate health agencies recommend social distancfnd, and have, in rnany locations, prohibitedthe congregation of groups of people.

The Boys & Girls Club of Buena Park has put in place preventative measures to reduce thespi'ead oj COVID-19. However, the Club cannot guarantee you or your child viill not becomeinfected with COVID-19. Further, attending ths Club could increase your risk and your child'srisk of contracting COVID-19.

US
@ Member and Staff safety is our top priority, Under no circumstances shall any of ourprograrn requirements and best practices-be compromised. @ Sajety is non-negotiable regardless of any laxed legal requirements, personal/politicalviews, or liability exemptions. s FaiiuretoadheretoCiuband/orSat'etypolicieswillresultinremovalfromtheprogram.

Parent Signature Date
BOYS & GIRI!3 CLtm
OF BuENA PARK
Dear Parent/Guardian,
We have taken part in several SAFETY and BEST PRACTICE trainings over the past year as we continue to build one of the top programs in Orange County. ln accordance to best practices in child safety, we want to be clearin our rules and expectations for our members and families participating in our program.

Please take'a few minutes to review with your child/teen to ensure their highest level of success and what is expected, while attending the Club:
o The Boys & Girls Club of Buena Park (BGCBP) has a ZERO TOLERANCE policy when it comes to and Verba! or Written Threats of any kind. This behavior can be cause for removal from our program arid possible disqualification of membership privileges. 0 TheBGCBPhasZEROTOLERANCEtoanyformofRa6a//nto/erance.Derogatoryand/or demeaning forms or prejudicial lat'iguage will not be tolerated. a Physical Contact- Hitting, Pushing/Shoving, Kicking, Biting are not acceptable behavior and can result in an instant suspension regardless of a members age or relationship status i.e. brothers can nothit each other.
< Inappropriate language is not acceptable. This includes cursing, offensive language as weit as put downs i.e. "You suck, you're a loser, your mom is a so and so, etc." Respect and courtesy are expected at all times.. You may riot be friends with everyone, you may not like someorie, but you need to be nice to everyone. 4 ListenmgtosimpleStaffinstructionisamust.ForStafftosafelyandadequatelyrun hourly programs, members must be able to listen and follow basic instruction. For safety reasons, members who ccnsistentiy fail to do so can be disqualified from membership privileges.
@ Suspensionand/orDisqualificationofMembership-Ourgoalistoavoidremoving members from the program. However, if a members behavior warrants a suspension or forFeiture of membership, that decision will be made on an iridividciaf basis.

Suspensions can range from 1-14 days, possibly more if warranted, dependirig on the severity of the situation.

With so many great programs happening daily, we continue to stress a positive approach tc behavior and Club rules/expectations. We know respotisibility and growth include consequences whether positiye or negative to one's adioris. We hope you wili partner with cis and sit dovn and review these simple rules and expedations with yourloved ones.

If you are in need of discussing a sittiation or concern, please feel free to reach oat to our Unit Director Majia Hays @ 714-522-7259. Thank you for your corrtinued beliefin cur Mission and heiping make our program one of the top programs in Orange County.

St. Jude Neighborhood
Health Ceriteis JJL'. Ya)P
Buena Park
Pediatric Dental Clinic
Monday, Wednesday & Friday
8:00 AM - 4:30 PM
Tuesday & Thursday
10:30 AM - 7:00 PM
For appointments and information
please can:
714-522-8723
7758 KnottAve.

Buena Park, CA 90620
Services provided for children with Medi-Cal
or without Dental Insurance.

St. JudeNeighborhood
Health Centers 'JL'""NF
low-CostDe-n,tar Care
PARENTS: Did you know that your childrert may qualify for Low-CostDental Care? We accept:

Medi-Cal
If your children live in our senrice areas, tbey may qualify to be treated at ourfacility. Eligibility is based on income and fees are based on a sliding scale.

Our service areas include:

Anaheim zip codes 92801-92806
Buena Park
Cypress
Fullerton
La Habra
La Palma
Services Include:

Exam
X-rays
Fiuoride treatment
Fillings
Sealants
Extractions
Cleanings
Crowns
Space maintainers
Orai hygiene education
Root canal treatment
Los Alamitos
Placentia
Stanton
Brea
Fota 4yvtforxa'tatfon and
a..ppofintments ca,u:
7 24-522-8723
St. Jude DentaX Center
7758 Kn.ott Ave
Buerta Park, CA 90620
Hours: Tuesday - Friday
8:00 a.m. - 4:30 p.m.

St. JudeNeighborhood
Health Centers JJL'"l[r
Atenciondental a ha' - to-JO COS
PADRES DE FAMILIA: Sabian ustedes que ahora sus hijos puederi calificarpara recibir atmcio'n. dental a bajo costo? Aeeptamos:

Medi-cal
Si su nifio /nifia viven en una de las ciudades indicadas en este folleto, puedencaiificar para semcios dental. La eligibilidad se determina de acuerdo alingreso y el eosto de los servicios se establesen de acuerdo a una escala deingresos de la familia.

Las areas de seicio incluyen:

Anaheim zona postal 92801-92806
Buena Park
Cypress
Fullerton
La Habra
Los senricios incluidos son:
* Examen dental
* Radiografias
* Limpieza de dientes
* Tratamiento de Floruro
* Rellenos
* Coronas
* Tratamiento de nervio
* Educacion de Higiene Oral
* Mantenedor de espacio
* Selladores
* Bxtracciones
La Palma
Los AJamitos
Placentia
Stanton
Brea
Para informacion y citas, por
favor Ilarne:
(714) 522-8723
St. Jude Dental Center
7758 Knott Ave
Buena Park, CA 90620
Martes a Viernes
8:00 a.m. - 4:30 p.m.

Internai Revenue Senrice Department of the Treasury
District
Director
'%ll
, BOYS CLUB OF BUENA PARX
7758 KNOTT AVENUE
BUENA PARK, CA 90620-2420
EIN: 95-1808525
P.0. Box 2350 Los Angeles, Calif. 90053
Person to Contact:

L BARRAGAN
Teiephone Number:
(213) 894-2336
Refer Reply to:

EO(0803)95
Date:

AUGUST u, 1995
Dear Taxpayar:
-This letter is in response to your
determination letter for the above named
request for a copy of the
organization.

Our records indicate that this organization was recognized to be exempt from Federal income tax in MARCH 15)55 as described in Internal Revenue Code Section 501(0) (3). It is further classified as an organization that is not a private foundation as defined in Section 509(a) o,f the Code, because it is an organization described in Section 170(b) (1) (A) (vi). a a
The exempt status for the determination letter issued in MARCH 1955 continues to be in effect.

If you need further assistance, please contact our office at the above address or telephone nurriber,
Sincerely,
J, Y"2)=-'b"-'-
Disclosure ASSiStant
GREAT FUTLN?ES START HERE.
&OYS & G:[RLS Cl!JB
4! CIF BLleNA PARK
2024-2025 School Year
TRANSPORTATION Program
MonthlyFee
Dysinger, Raymond Temple, Buena Terra
* $175 per member
* $90 second sibling
* $45 third sibiing
Please note siblingdiscount on[yappties to same household, mustbe brother or sister, does not app(y to cousins etc.

Walker Junior High, Kennedy High School
* $60 per member
Payments are due on the lO'h of each month and mustbe made in advance. Payments must be paid in full to ensure prOgrElm partiCipatiOn.

Please see Front Counter for paperwork.

M-W, F:

THUR:

MASTER:

BOYS & GIRLS CLUB

OF BUENA PARK
2024-2025 SCHOOL YEAR TRANSPORTATION PROGRAM

PERMISSION SLIP
I give my child peimission to ride the Youth Bus to the Boys & Girls Clrib of Buena Park from school. I understand this is a one-way shuttle and I will pick up my child at the Boys & Girls Club of Buena Park by 6:00p.m. I hereby authorize the Club to carry out any measure deemed necessary should an emergency occur, including seeuring, at tlie expense of the undersigned, appropriate medical care for the participant. I hereby release the Boys & Girls Club of Buena Park, its employees, officers, agents, and board members from any and all liability claims arising out of the member's participation in this program.

Please note: This contract is valid for the 2024-2025 school year and will expire June 2025. Due to the insurance regulations this contract does not automatically renew and spots do not carry over to the following school year.

Member's Name: Age: Grade:

Member5s Name: Age: Grade:

Member's Name: Age: Grade:

Member5s School:

Days for Pick Up from School: M T W Th F
Parent5s Name:

Parent's Signature: Date:

BOYS & GIrlLS CLUB

OF-BUENA-PARK
Transportation Payment lnformation
A credit card must be kept on file to complete your child's transportation registration. Your account will automatically be charged the 1 0th of every month. Your first payment will be processed upon completing registration. Your final payment for 2024 will be processed on Friday, May 9th, 2025.

Transportation payments declined on their due date will automatically acquire a $151ate fee.

Unfortunately, fees not paid in full by 6pm will result in transportation services being suspended until accounts are made current.

Please note, if your credit card information has changed it is your responsibility to update your information before payments are processed I grant the Boys & Girls Club of Buena Park permission to chargemycreditcardendinginnumbers every10thofthemonth.

Name on Card: Card Number:

Expiration Date: CW:

Name: Siqnature:

Amount: Staff:

Receipt Type: Email, Text, Print?
Member(s)

City of Buena Park
2025-2026 Community Development Block Grant (CDBG)
F
unding Proposal Summary Sheet
O
rganization Name: Mercy House Living Centers
P
rogram Name: Buena Park Navigation Center
E
stimated Goal: 130 Individuals
F
unding Request: $30,000
O
rganization Purpose:

M
ercy House Living Centers administers the homeless services provided at the Buena Park Navigation Center. The program provides year -round shelter, hygiene facilities, meals, and intensive supportive services to homeless adults.

D
escription of Request:

T
he program offers a safe environment for homeless individuals access ing emergency housing at the Buena Park Navigation Center . Services include housing navigation, enrichment activities, health care resources, drug and alcoh ol treatment referrals, employment placement referrals, and much more.

C
DBG funds will be used to cover a portion of the cost to provide meals to individuals living in the shelter. The shelter provides three meals per day including breakfast, lunch and di nner. The meals are prepared by an outside vendor and distributed by staff and volunteers at their on-site kitchen.

A
nalysis of Request:

T
his program is designed to benefit low -and moderate -income persons by providing shelter and supportive services to the most vulnerable homeless men and women living within City limits . Homelessness is a major concern in the City and this program provides services needed to assist in addressing these issues.

Funding Recommendation:

S
taff recommends funding in the amount of $27,600.
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CITY OF BUENA PARK

COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2025-2026 CDBG GRANT APPLICATION
DUE BY DECEMBER 19, 2024 AT 5:00 PM
Approximate total funds available for public services: $116,110 Organization Name Mercy House Living Centers
Program Name Buena Park Navigation Center
Address t=i.o. Box 1905, Santa Ana, CA 92702
Contact Person/Title Cayman Beeman, Grants Specialist Email Address [email protected] Phone Number 714-836-7188 ext 364 Estimated individuals or households to be served by proposed program during fiscal year 2025-2026 (including Buena Park residents and non-Buena Park residents):

Estimated Goal: 300 []lndividuals 0 Households
Estimated Buena Park residents or households to be served by proposed program during fiscal year 2025-2026:

Estimated Goal: 130 [I Individuals g Households
Please indicate the amount of CDBG funds being requested:

Public Service Activities $ 30,000.00
er Eligible Activities
(Signature of authorized representative) Date
Larry Haynes, Chief Executive Officer
(Name and Title of authorized representative)
Organization Name: Mercy House Living Centers Program Name: Buena Park Navigation Center Please answer the following questions completely. If any questions are left unanswered, your application will not be considered. You may attach additional sheets and/or supporting materials as needed.
1 PROJECT DESCRIPTION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the proposed project, including services to be provided and goals to be accomplished. * Why is there a need for this program in the City of Buena Park? * Identify the location of the project and the service area boundaries. * Describe specifically the intended use of the CDBG funds.

The 2024 Homeless Point in Time Count found that as many as 7,322 people are homeless in Orange County. 3,227 of the homeless are in the North Service Planning Area, which includes the City of Buena Park. The City of Buena Park has an estimated 379 homeless people within the city, 186 are unsheltered and on the streets. The city saw a more than 42% increase in homelessness between 2022 and 2024. Furthermore, in comparing the 2022 PIT to 2024, the North Service Planning Area saw more than a 1 18% increase in the unsheltered homeless population and an increase of more than 6% in the sheltered population. As more people on the streets turn to our emergency shelters and navigation centers as reliable support networks on their way back to housing, initiatives like the Buena Park Navigation Center have played a crucial role in this additional support for the increased homeless population.

The Buena Park Navigation Center, located at 6494 Caballero Boulevard in Buena Park, provides homeless adults and couples with 149-beds of year-round shelter, access to showers and hygiene facilities, warm nutritious meals, and intensive supportive services focusing on housing search and placement to literally homeless adults living on the streets or and/or connected to Orange County's North Service Planning Area, including those on the streets of Buena Park. Clients of the Navigation Center have 24-hour access to shelter and ongoing supportive services. To reduce the impact on the surrounding communities, the Buena Park Navigation Center only allows entry into the program through a reservation system. The North Orange County Public Safety Task Force's Outreach Grid, an app that matches the efforts of designated street outreach teams and police departments in the North Orange County region to real-time bed vacancies at the shelter, is used to secure all reservations.

Mercy House addresses the needs and goals identified in the housing plan through the provision of the following services:
v' Housing Navigation - Housing Navigators conduct CES assessments to connect shelter guests to housing resources available through the Orange County Coordinated Entry System (CES); Shelter guests are helped obtain necessary documents. Crisis intervention services focus on enhancing the guests' ability to independently problem solve, utilize effective coping skills, and manage and self -coordinate own care.

I Enrichment Activities - Life Skills classes and workshops as well as indoor and outdoor recreational activities are provided to shelter guests to improve their quality of life and encourage them to remain onsite during the day to take advantage of all services available to them.

I Health Care Resources - Shelter guests are connected to on and off-site health resources through KCS Health Center and various departments of the County of Orange.

I Crisis Evaluation/Mental Health Resources - Shelter guests are connected to on and off-site 2 3
2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population for this program and the number of estimated unduplicated Buena Park residents to be served from July 1, 2025, through June 30, 2026. * How was the estimated number of clients determined? * How will you reach your target population?
* Explain why this program is needed for this target population.

The project serves homeless adults and it is estimated that 300 individuals will be served during the contract period, with 130 having ties to the City of Buena Park either through prior residency in the city or homeless in the City prior to entry into the shelter. The number of clients anticipated to be served is based on historical data since beginning operations in July 2020.

Referrals to the program are provided by partner agencies including the Buena Park City Outreach Team, all North SPA police departments and the County of Orange's Outreach and Engagement Team.

The project is necessary to protect the homeless of our community from morbidity on the streets.

Emergency shelters, including those such as the Buena Park Navigation Center that allow for the provision of on-site health services contribute to an overall reduction in both emergency room visits and hospital readmissions by homeless people.

Furthermore, emergency shelters offer advantages over other housing navigation service models that are solely based on street outreach or mobile services for homeless individuals. With the basic needs of shelter, food and hygiene met, homeless individuals can more easily focus on the goals identified in their housing support plans. Engagement in Care Coordination can more readily take place when transient populations are able to maintain consistency in their location. Regular availability and visibility of on-site health and supportive service providers reduces the barriers of connecting to services and reduces lengthy delays connecting to services.

Local and national data suggest that outreach programs on their own leave homeless people on the streets longer and have a lower rate of positive housing outcomes than programs that have a shelter component. Outside of the benefits for program participants, the community at large benefits from this program model. Businesses, parks, recreational and residential spaces are less impacted by homeless encampments.
4 Organization Name: Mercy House Program Name: Buena Park Navigation Center 3 NATIONAL OBJECTIVES
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe in detail how the project meets at least one of the three CDBG program national objectives.

Select at least one:
§Benefit low- and moderate-income persons in Buena Park; 0Aid in the prevention or elimination of slums or blight in Buena Park; 3Meet a need having a particular urgency in Buena Park.

Benefit low- and moderate-income persons in Buena Park:

The Buena Park Navigation Center program is designed to benefit extremely low to moderate- income persons by providing shelter and supportive services to the most vulnerable homeless men and women living on the streets of the Northern Service Planning Area (SPA), which includes the City of Buena Park. No walk-ups to the shelter are permitted. Referrals to the shelter will be made by the homeless liaison officers in the Police Department or the street outreach team led by personnel with City and the County of Orange's Outreach and Engagement Team. Outreach workers will verify homeless status at entry using a referral form that is kept in the client case file. (Please reference Attachment A: Intake Documentation to review referral form).

Meet a need having a particular urgency in Buena Park:
"Providing a continuum of supportive and housing services for the homeless and households at risk of homeless" continues to be a top 5 identified goal for the City of Buena Park in its 2020-2025 Consolidated Plan. The Buena Park Navigation Center is an integral investment that the City has been to support its goals in this area.
5 4 BUDGET
[24 CFR 570.502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85,
and OMB Circular A-87, A-122, Treasury Circular No. 1075] Itemize administrative and operational costs for the proposed project. Cost Categoiy may include: staff salaries and benefits, rent, utilities, advertising, office supplies, etc.

Cost Category CDBG Funding
Request
Other Funding
Sources Total Cost
Staffing - - - - - - - - - -
Salaries + Benefits $ I $2,336,897.00 , $2,336,897.00
I
I
I
_Adhiin --- - - - - aa - - - - - " - - - - - a - J' = - =- - --- -- o '--a - - - - - - - - - = = ---- - - - - - - - - -.----=-- --.-- - - ,-,.-. _ _ _ _ _ _ _._ - - 11 Audit Fees $ $5,500.00 $5,500.00
IT Agency Expenses/ Computer
Consultants $ $1,ooo.oo $1 ,ooo.oo
Payroll Services $ $17,000.00 $17,000.00
Communications $ $5,300.00 $5,300.00
Office rent $ $4,500.00 $4,500.00
:_rd;n!n-f"'rog;m- ' - "-- - ' -"-'-' "----" = ' "'=- -" o" """"'a" a -"-' =" " a ----"'-- -1 Mileage $ $1,ooo.oo $l,ooo.oo
Insurance Policies $ $60,000.00 $60,000.00
Computer Supplies & IT & Internet $ $10,000.00 $10,000.00 Office Supplies $ $5,000.00 $5,000.00
Equipment Leases & rentals $ $1,500.00 $1 ,500.00
P % z-'_.t -v*'-aa< - y - +a -B(4 .4 _.m _+ 4-1 - va_ -. } % a ++ > -,_ -+ - _a < - %_ % h t 0 +-y a-+ } + a _ _a% -, -) _ _ _ + _ z W_-. - l -# r , I, Fa.c.ip.t_y.Exp5_n.ses._ Jaa __ ii _____._. _i %il _....__,_ __ _ _____ , + _.._ _ ai *iiiia* _, . . _ _-_ __ _, Security (Guards) $ $473,040.00 $473,040.00
Utilities/Disposal $ $102,000.00 $102,000.00
Repairs/maintenance $ $30,000.00 $30,000.00
Laundry Rental $ $2,976.00 $2,976.00
!"Program 6perati'o'n73-ervic;s - " - a - ------= ' " '- '- '-"-' -"a a- - = a a '- ="' - a - ""- - l Client services/Barrier Fund $ $8,000.00 $8,000.00
Animals/\/eterinary $ $24,000.00 $24,000.00
Fuel and Maintenance $ $84,900.00 $84,900.00
Client Food and Snacks $30,000.00 $278,172.00 $308,172.00 Supplies $ $95,000.00 $95,000.00
Transportation ASSiSt $ $84,900.00 $2,000.00
HMIS $ $500.00 $500.00
Volunteer Expenses $ $1,ooo.oo $1,000.00
:,a *aa" aJ'-?aThjl!-" ' A!." ltau+ .."a-.' > tTh"aat< }'- az"y - '- --+a ' a' a a @ a,- :' ,l 7,9 iTOTAl J$30,000.00_-__.. -.__
"A:+thrth+<>_'rtta. .=-_- -==-.=-vi-
..!p.i!7!-.?!s . a:, $:l579.i:2q5_..-_
6 Organization Name: Mercy House Program Name: Buena Park Navigation Center 5 I
I
I
I
I
I
I
I
I
I
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ELIGIBILITY DOCUMENT ATION
If the proposed project is a public service, describe what form of documentation will be collected to demonstrate that at least 70% of persons served are low- and moderate-income, as required byHUD, and a minimum of 20% are Buena Park residents. (Please attach a copy of the activity's client intake/application/registration form)
The clients served at the Buena Park Navigation Center are considered a CDBG "presumed beneficiary"due to their homeless status. At entry a referral form is completed by the referring partner agency thatverifies where the client was living (place not meant for human habitation, park, shelter, etc.) prior toreferral. Additionally, a Declaration of Homelessness is completed and placed in the client's case fileattesting to their homelessness.

Mercy House uses a standardized intake form that captures all CDBG required demographic information,homelessness information as well as self-certified income information. Residency information is alsocollected on the intake form. Homeless individuals who are considered "residents of Buena Park" includethose who self-report prior residency in the City of Buena Park or who spent the last night prior to shelterentry in the City of Buena Park.

Data from these intake forms (as well as forms completed at exit from the program) is inputted by adedicated Data Specialist into a secure Homeless Management Information System (HMIS) database.Standard and ad hoc reporting capabilities from the system enable us to complete all required quarterlyCDBG reports as well as additional outcome reports.

Please reference Attachment E: Intake Form and Intake Documents to review documents describedin this section. 7 l-I [24 CFR 570.200(a), 570.201-570.208, 570.503]

OUTCOME PERFORMANCE MEASUREMENT SYSTEM
iPlease indicate the activity's Objective, Outcome, Outcome Statement, Pu, and indicators I
I
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Itthhraotuwgihll bPeaguese7dotfothmeeRasFuPre, track and report performance. Refer to the instructions on Page 5A. Select one Objective QSuitable Living Environment
0Decent Affordable Housing
0Economic Opportunities
Mercy House is seeking CDBG funding from the City of Buena Park to provide a suitable living environment to the homeless men and women living on the streets of Buena Park or having connections to cities in the Northern Service Planning Areas.

B. Select one Outcome
§Availability/Accessibility
0Affordability
0Sustainability
I Through this funding, the Buena Park Navigation Center will increase availability and accessibility , to shelter and housing for homeless adults living on the streets of or having connections to cities in the North Service Planning Areas. Participants will have access to showers and hygiene facilities, meals, laundry facilities, medical clinic, multi-service center and Housing Navigation services to connect them to housing through the coordinated entry system. , I
C. Using the following formula, provide the program specific purpose/objective:

Purpose = Output + Outcome Statement + Activity
At least 300 people will have increased access to emergency shelter and services at the Buena ,Park Navigation Center for the purpose of providing decent housing.

I
I
8 Organization Name: Mercy House Program Name: Buena Park Navigation Center I
I
I
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D. Identify the common, specific, and/or other indicators for the activity a. Common Indicators
At least 300 homeless individuals will be assisted with emergency shelter and services. At least 130 of these individuals will have former residency or were on the streets of Buena Park prior to entry.
b. Specific Indicators
30% of clients who exit to a known destination will exit to housing destinations. c. Other Indicators
90% of clients who stay in the shelter for 30 days or more will be assisted to connect to the Orange County Coordinated Entry System to gain access to housing resources they may qualify for.
9 ACKNOWLEDGEMENT REGARDING

1. By submitting this proposal, the prospective sub-recipient certifies that it has an active registration is SAM that is not set to expire within the next 90 days.

3. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. lf it is later determined that an erroneous certification was rendered, in addition to other remedies available to the Federal Government, the Department or agency with which this transaction originated may pursue available remedies.

Provide the following information as detailed in the prospective sub-recipient's SAM registration:

Entity Name: Mercy House Living Centers
Address: 6494 Caballero BIVd.

City: Buena Park
Unique Entity ID (UEI): DVJ5XQ7BMQ88
Active Exclusions (Select One): [lYes (glNo
State: CA Zip: 90620
Expiration Date: 1 0/24/2025
Attachment 3
MERCY*HOUSE

ATT ACHMENT A

NONPROFIT STATUS
!IRS TDi:'tpenrrn:ml"in;lcioaelA)u'eeTS'eer'i':'llc'r;' P.0. Box 2508
Cj.ncinnati OH 4520I
In reply refer to : 02
Au g 18, 2 all L TR 4 16
3 3 - a 3 I586 4 0 0 0 0 0 0 0 0
BODC

MERC'/ HOUSE LIVING CENTERS
Pa BOX !905
SANTA AHA CA 92702-1905
30 Employer Ideritification Number : 33-0315864
Person to Contact: Tonya Morris
Toll Free Telephone Number: 1-877-829-5500
Dear Taxpayer:

This is in response to your Aug. 09t 2011 > request for in forrna regarding yoi.ir tax-exempt status.

Our records indica'te 'that you were recognized as exempt under section 50Rc) (3) of the Internal Revenue Code in a determinat letter issued iri April 1989.
0 Ll r r e c o r d s a I s o i ri d i c a t e t h a t y o u a r e n o t a p r i v a t e f o u n d a t i o t h e m e a n i n g o f s e c t i o n 5 0 9 ( a ) o f t h e Co de b e c a u s e yo u a r e d e s c s e c t i o ri ( s ) 5 0 9 ( a ) (l ) =i ri d 17 0 ( b ) (1) ( A ) ( v i ) Donors may deduct contributions to you as provided in section the Code. Bequests, legaciesi devises, transfers, or gifts to f C) r y o u r i.i s e a r e d e d (l C t i b I e f o r F e d e r a l e s t a t e a n d g if t t a x p L if t h e y m e e 't t l"i e a p p li c a b 1 e p r o v i s i o ri s o f s e c t i o n s 2 0 5 5, 210 6 s 2 5 2 2 o f t h e Co d e.

Please refer 'to our vebsite www.irs.gov/eo for information reg filing requireiiierits. Specifically, section 6033(j) of the Code provides that failure to file an anncial information return for consecutive years results in revocation of tax-exempt status E t h e f ili n g d u e d a t e o f t h e t h i r d r e t u r n f o r o r g a n i z a t i o n s r e q t fi.le. We vill pi.iblj.sh a list of organizations whose tax-exempt status was revo!ced cinder sectiori 6033(j) of the Code on aur we b e g i n n i n g i n ea r ly 2 all.

Aug. 18, 2011 LTR (i
33-0315864 000000

MERCY HOUSE LIVING CENTERS
Pa BC)X 1905
SANTA ANA CA 92702-1905
If you have any questions, please call us at the telephone r shown in the heading of this letter.

Sincerely yourst
S. A. Martin, Operations l
A c c O Ll n t s M a n a g e m e n t 0 p e r a t
Secretary of State
Certificate of Status
I, SHIRLEY N. WEBER, PH.D., California Secretary of State, hereby certify:

Entity Name:

Entity No.:

Registration Date:

Entity Type:

Formed In:

Status:

MERCY HOUSE LMNG CENTERS
1439992
06/29/1988
Nonprofit Corporation - CA - Public Benefit

CALIFORNIA
Active
The above referenced entity is active on the Secretary of State's records and is authorized to exercise all its powers, rights and privileges in California.

This certificate relates to the status of the entity on the Secretary of State's records as of the date of this certificate and does not reflect documents that are pending review or other events that may impact status.

No information is available from this office regarding the financial condition, status of licenses, if any, business activities or practices of the entity.

IN WITNESS WHEREOF, I execute this certificate and affix the Great Seal of the State of California this day of June 27, 2024.

SHIRLEY N. WEBER, PH.D.

Secretary of State
Certificate No.: 224054023
To verify the issuance of this Certificate, use the Certificate No. above with the Secretary of State Certification Verification Search available at bizfileOnline.sos.ca.gov.

MERCY*HOUSE

ATT ACHMENT B
Sje!U\/15 REGISTRATION
J?lg'j*L7UV

MERCY HOUSE LMNG CENTERS
Unique Entity ID CAGE / NCAGE Purpose of Registration DV J5XQ7BMQ88
Registration Status
Active Registration
Physical Address
807 N Garfield ST
Santa Ana, California 927CIl-3821
49VY8
Expiration Date
act 24, 2025
Mailing Address
p.o. Box 1905
Santa Ana, California 92702-1905
All Awards
Llnited States United States
Doing Business as
(blank)
Division Name
(blank)
Division Number
(blank)
Congressional District State/Country oflncorpotation uRL California 46 California/United States (blank)
Registration Dates
Activation Date Submission Date Initial Registration Date act 28, 2024 act 24, 2024 Jan 26, 2006
Entity Dates
Entity Start Date Fiscal Year End Close Date
Jun 29, 1988 Jun 30
Immediate Owner
CAGE
(blank)
Legal Business Name
(blank)
Highest Level Owner
CAGE
(blank)
Legal Business Name
(blank)
Executive Compensation
In your business or organization's preceding completed fiscal year, did your business or organization (the legal entity to which this specific SAM record, represented by a Unique Entity ID, belongs) receive both of the following: 1. 80 percent or more of your annual gross revenues in u.s. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperafive agreements and 2. $25,000,000 or more in annual gross revenues from u.s. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements? No
Does the public have access to information about the compensation of the senior executives in your business or organization (the legal entity to which this specific SAM record, represented by a Unique Entity ID, belongs) through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act or 1934 (15 u.s.c. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986? Not Selected
Proceedings Questions
Is your business or organization, as represented by the Unique Entity ID on this entity registration, responding to a Federal procurement opportunity that contains the provision at FAR 52.209-7, subject to the clause in FAR 52.209-9 in a current Federal contract, or applying for a Federal grant opportunity which contains the award term and condition described in 2 C.F.R. 200 Appendix Xll? No
Does your business or organization, as represented by the Unique Entity ID on this specific SAM record, have current active Federal contracts and/or grants with total value (including any exercised/unexercised options) greater than $1 0,000,000? Not Selected
Within the last five years, had the business or organization (represented by the Unique Entity 10 on this specific SAM record) and/or any of its principals, in connection with the award to or performance by the business or organization of a Federal contract or grant, been the subject of a Federal or State (1 ) criminal proceeding resulting in a conviction or other acknowledgment of fault (2) civil proceeding resulting in a finding of fault with a monetary fine, penalty, reimbursement, restitution, and/or damages greater than $5,000, or other acknowledgment of fault and/or (3) administrative proceeding resulting in a finding of fault with either a monetary fine or penalty greater than $5,000 or reimbursement, restitution, or damages greater than $1 oo,ooo, Or other acknowledgment of fault?
Not Selected
No
I authorize my entity's non-sensitive information to be displayed in SAM public search results:

Yes
II ) m9 ',e'
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Business Types
Entity Structure
Corporate Entity (Tax Exempt)
Profit Structure
Non-Profit Organization
Socio-Economic Types
Entity Type
Business or Organization
Organization Factors
(blank)
Check the registrant's Reps & Certs, if present, under FAR 52.212-3 or FAR 52.2"l9-1 to determine if the entity is an SBA-certified HUBZone small business concern. Additional small business information may be found in the SBA's Dynamic Small Business Search if the entity completed the SBA supplemental pages during registration.

E4al q ;p o -- 1 o _ --- -lo = i in -- pii a : - lo ' - . -___ ______ _o __a -1 Accepts Credit Card Payments
Yes
EFT Indicator
0000
Electronic Funds Transfer
Accoum Type
Checking
Financial Institution

WELLS FARGO BANK NA
Automated Clearing House
Phone (u.s.)
9497567749
Fax
(blank)
Remittance Address

MERCY HOUSE
p.o. Box 1905
Santa Ana, California 92702
united States
Debt Subject To Offset
No
CAGE Code
49VY8
Routing Number
*******47
Account Number
*******04
Email
(blank)
Lock Box Number
(blank)
Phone (non-U.S.)
(blank)
9 ii-FIB iit il 5i
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tLmx--'N4 r I ..-_ o a*_ -C Z_____ xr- n u it tmwr4' EIN
"""5864
Tax Year (Most Recent Tax Year)
2023
Address
807 N. Gafield ST.

Santa Ana, California 92701
Type of Tax
Applicable Federal Tax
Name/Title oflndividual Executing Consent
Chief Strategy And Compliance Officer
Signature
Allison Davenport
Taxpayer Name

MERCY HOUSE LMNG CENTERS
TIN Consent Date
act 24, 2024
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Mary Ellen Gross, Ms.
[email protected]
7148367188
Patti Long, Mrs.

[email protected]
7148367188
Allison Davenport, Mrs.

[email protected]
7148367188
Government Business
Larry Haynes, Mr.

[email protected]
71483671 88
Patti Long, Mrs.

[email protected]
7148367188
Past Performance
?*
Allison Davenport, Mrs.
[email protected]
7148367188
Patti Long, Mrs.
[email protected]
7-148367188
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Primary
Yes
NAICS Codes
813410
p.o. BoX 1905
Santa Ana, California 92702
llnited States
p.o. Box 1905
Santa Ana, California 92702
Llnited States
p.o. Box 1905
Santa Ana, California 92702
United States
p.o. Box 1905
Santa Ana, California 92702
united States
Pa Box 1905
Santa Ana, California 92702
United States
Pa Box 1905
Santa Ana, California 92702
United States
NAICS Title
Civic And Social Organizations
IGT Size Metrics
Annual Revenue (from all IGTs)
(blank)
Worldwide
Annual Receipts (in accordance with 13 CFR 121) Number or Employees (in accordance with 13 CFR 121) $64,000,000.00 705
Location
Annual Receipts (in accordance with 13 CFR 121)
(blank)
Industry-Specific
Barrels Capacity
(blank)
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MERCY*HOUSE

ATT ACHMENT C

CERTIFICATION REGARDING

DEBARMENT AND SUSPENSION

CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

INELIGIBILITY AND VOLUNTARY EXCLUSION LOWER TIER COVERED TRANSACTIONS This certification is required by the regulations implementing Executive Orders 12549 and 12689, Debarment and Suspension, and 2 CFR Part 200, Participants' responsibilities. (BEFORE COMPLETING CERTIF[CAT[OAI READ INSTRUCT[ONS BELOW) (1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principles are presently debarred, suspended, proposed for debanent, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier paiticipant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

Organization Name: Mercy House Living Centers
Address: 6494 Caballero Blvd., Buena Pa , (,A 9,062C" Chief Executive Officer /
Name and Title of Authorized Representative 3 / / Signature /!- / ';2 '/
Date

1. By signing and submitting this proposal, the prospective lower tier paiticipant is providing the certification set out below.

2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the deparhnent or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant leams that its certification was erroneous when submitted or has become enoneous by reason of changed circumstances.

4. The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "participant", "person", "primary covered transaction", "principal", "proposal", and "voluntarily excluded", as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Orders 12549 and 12689.

6. The prospective lower tier participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntaiy Exclusion-Lower Tier Covered Transactions", without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

8. Nothing contained in the foregoing shall be constnied to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and infon'nation of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Govemment, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

Attachment 4
MERCY*HOUSE

ATTACHMENTE

INTAKEFORM

INT AKE DOCUMENTS
MERCY*HOUSE

DIVERSION QUESTIONNAIRE
Participants Name:

Program Name: Buena Park Nav!gai!on Center
Staff's Name:

Entry Date:

The goal at this point of your stay is to learn more about your specific current situation and what you need so that together we can identify the best possible way to find you safe permanent housing. This might mean staying in this shelter for a few days or longer, but we want to connect you with housing resources as quickly as possible. We will work with you to find a more stable alternative if we can. €
€
€
€
€
€
€
€
€
€
€
€
€
€
€

1. Where did you sleep last night? Name of City? Place not meant for habitation (e.g., cars, park, bus station) Emergency shelter or safe haven
Transitional housing program for homeless persons
Permanent housing program for formerly homeless persons Hospital (non-psychiatric)
Psychiatric hospital or other psychiatric facility
Substance abuse treatment facility or detox center Jail, prison, or juvenile detention facility
Foster care home or foster care group home
Hotel or motel paid for without emergency shelter voucher Staying or living in a friend's room, apartment, or house Staying or living in a family member's room, apartment, or house Room, apartment, or house that you rent
Apartment or house that you own
Other - Please explain:

2. If you were staying with someone is it possible or safe for you to continue staying there? Yes No
If yes, how long can you stay? Days Weeks Months

3. What other housing options do you have for the next few days/weeks? MHSDiversionQuestionnaire
Revised 5/04/2020

4. Whataresomeissuesthatexistinyourcurrenthousingsituationthatwecantrytohelpyou resolve?
€
€
€
€
€
€
€
€
€
€
Family/friends asked to leave
No family/friends to stay with
No/lack of employment or income
No potential for increased income
Drug/alcohol problem
Disabled
Fleeing from domestic violence/abuse
Victim of human trafficking
Just moved to the area
Other - Please explain:

For Mercy House Staff Use only:

The participant is ELIGIBLE to stay at this shelter while working toward housing plan.

The participant is INELIGIBLE for diversion assistance (note reason below).

Staff Notes:

Participant's Signature Staff"s Signature
MHS DiversionQuestionnaire Revised 5/04/2020
Wffil t:oor) iria ec

ENTRYSYSTEM

COORDINATED ENTRY SYSTEM (CES)

AUTHORIZATION TO USE & DISCLOSE PROTECTED HEALTH INFORMATION TheCoordinated EntrySystem(CES)isdesignedtoconnectpeopleat-riskoforexperiencinghomelessnesswithhousingandsupportive services. Your authorization will allow CES participating entities to have access to you and your care. Your authorization is required to enroll into CES. For more information about CES, please visit: ceo.ocgov.com/care-coordination/homeless-services/coordinated- entry-system.

PART 1: CLIENT/PATIENT INFORMATION
Client/Patient Last Name Client/Patient First Name Middle Initial Date of Birth Email CIN# MRN Telephone Numberwith Mea Code
Address City State Zip
PART 2: PARTICIPATING ENTITIES WHO WILL DISCLOSE THIS INFORMATION Participating Entities within Coordinated Entry System (CES) Address 601 N. Ross st., 5th Floor
City
Santa Ana
Stale
CA
Zip
92701
Telephone Number wi}h area code
(714) 834-5000
PART 3: PARTICIPATING ENTITIES WHO W,LL RECE VE THIS INFORMATION Participating Entities within Coordinated Entry System (CES) Address 601 N. Ross st., 5'h Floor
Cily
Santa Ana
State
CA
Zip
92701
Telephone Number with area code
(714) 834-5000
PART 4: PURPOSE OF THIS AUTHORIZATION
Coordination of care with and between the Coordinated Entry System participating entities.

PART 5: INFORMATION THAT CAN BE RELEASED
A, The minimum amount of information to coordinate care between the Coordinated Enhy System participating entities. This includes but is not limited to yourhistoiyofhomelessness, disabling conditions, housing preferences and othereligibility criteria.

PART 6: DATE YOUR AUTHORIZATION EXPIRES
Unless otherwise revoked in writing, this authorization expires upon termination of program, Orange County Coordinated Entry System.

FOR YOUR REVIEW
I have read the contents ofthis form.l understand, agree, and allowthe Coordinated Entry System (CES) to use and release my information as ThhaeVreevso1ac'a'tioan"wVilelnothaaffvece1thdeisr!hs'u'rOesrethVoekCeEThSSpaau:c0ipraZtian'gOennatiftieasn\ia1vmeealnrewajry'n!ab!esinenredljna'ncea noon"thCeea10ut1hhoerCizaEtSion.Pr'>orarmmaAtidomndnisScl1roas':dr pursuant to this authorization may be re-disclosed by the recipient and no longer be protected by federal privacy law (HIPAA). Applicable State or other federal law may require the recipient to obtain yourwritten authorization before re-disclosure unless otherwise permmed by such laws. I am entitled to a copyofthis form. Fees may apply to certain requests. A opyof the original authorization is valid.

PART 7: SIGNATURE-PARTICIPANT OR DESIGNATED PERSONAL

REPRESENT ATIVE/GUARDIAN
PART 8: DATE
x
Personal Representative (Pnnt full name) Personal Relationship to Client/Patient (e.g. conservafor, parent, etc ) Personal Representative Street Address City State Zip
Disclosures pursuant to this authorization are allowable only among Coordii ated Entry System participating entities All numbered items must be completed for authorization to be valid FORM - CES (Rev 01/09/2023) For Coordinated Entry System (CES) ONLY ffiffi%UTREACHaai
sffisORID
North Orange County Outreach Grid Network:

Release of Information Waiver
This agency participates in the NOC Outreach Grid Network. Because this Network may be made up of many service providers across the city, by signing this release of information waiver, you can share your information with other service providers from which you might be seeking services. This may reduce the time spent answering basic questions regarding your situation, and allow that agency to focus on meeting your service needs. The computer program used for this purpose has industry standard security protocols, and is updated regularly to meet these security standards. The information you provide will be shared with this agency and any other agency in the network you designate.

Information collected is housed in a secure serverlocated in Oregon. Limited staff persons of Appledore, Inc. have access to this server and the data housed there - for performing analysis, generating reports, customer and network support and maintenance purposes.Please note: If you do decide to share information at this time and later change your mind, you can revoke this permission in writing at any time and security protections to prevent your information from being viewed by any other service provider will be put into place. Participating agencies and theirinformation privileges may also change without notice. My name and signature indicate my permission to have my service information shared with the current agencies in the network, according to the information privileges listed. North Orange County Public Safety Task Force is a group of cities and nonprofit agencies who work to end street- level homelessness in a city or region through the coordination of community efforts and activities. In order to better serve you, we may need to share information with several other agencies working together to assist your move toward self- sufficiency. This will be done through conferencing and/or via database sharing. Your signature on this form allows information to be shared only for the purpose of helping you in the following areas:

Assisting individuals and families to complete their targeted goals successfully * Providing supportive services to the individuals of Outreach Grid and/or agencies involved in the NOC Outreach Grid Network
Release of photographs for internal and external agency use Collaborating with other support and assistance agencies to better serve Providing referrals to other service providers who may better serve the needs Information may be shared only with Outreach Grid staff and/or representatives of the following agencies who may be providing services and support to you.

North Orange County Public Safety Task Force
* Illumination Foundation
Mercy House
* The Midnight Mission
* Mckinney Vento Liaisons
* Orange County Social Services Agency
Serving People in Need (SPIN)
Project Hope Alliance
* Pathways of Hope
His House
Grandma/Grandpa's House of Hope
Potential Landlords
Public Law Center
Legal Aid
Family Promise of Orange County
Volunteers of America (VOA)
* F2egional Center
Social Security Administration
Other
The sharing of some information is important to the success to obtain the necessary services from participating agencies, avoid duplication of services, as well as help develop a comprehensive program that will better support you.

By signing, I give authorization for mine and my dependents listed above Protected Personal and relevant information to be entered into Outreach Grid.

Name:

Date:

Signature:

Revised 10/2024
Orange County Continuum of Care
Homeless Management Information System Client Consent form Welcome to the Orange County Continuum of Care (CoC).

You are currently accessing services from a service provider/organization participating in the Orange County Homeless Mana@ementlnformation System (HMIS). HMIS is the secure database used to collect and store information aboutclients served through this service provider/organization. It also allows the sharing of information among HMIS participating service providers/organizations to streamline access to services and help them understand a client's history of homelessness or housing instability. HMIS is managed and operated by Orange County United Way's 2-1-1 0range County (2110C).

In Orange County, all service providers/organizations that participate in HMIS share data with each other to coordinate care and improve program outcomes. If you agree to participate in HMIS, this means you allow information gathered by a participating service provider/organization to be entered into HMIS and allow all other participating service providers/organizations to view and use your data to provide services to you. Additionally, the service provider/organization will also be able to see what kind of services in Orange County you have received in the past.

A complete list of all service providers/organizations that participate in the HMIS is maintained at http://ochmis.org/about- hmis/contributinz-agencies/. You can also ask the service provider/organization you are receiving services from for a list of HMIS participating service provider/organization. Please note that the list of service providers/organizations contributing data to HMIS can change frequently and without notice, and therefore the website should be consulted for the most recent list.

HMIS contains sensitive health and personal data. The Orange County CoC and HMIS participating service providers/organizations take your privacy very seriously and have implemented the following protections to safeguard your data:
* Individual client data is only viewable by trained staff at each participatingservice provider/organization. * In order to participate in the HMIS, leaders at each agency must sign an Agency Agreement that includes a commitment to protecting client data and maintaining confidentiality. * In order to use HMIS, service provider/organization staff must complete multiple trainings that examines privacy laws and the importance of client privacy.
* The HMIS is hosted on a secure server and data is encrypted.

What information is shared in the HMIS database?
We share Protected Personal Information (PPI), Protected Health Information (PHI), and general information obtained durin@ yourintake, assessment, and enrollment in the program. This may include, without limitation, the following:
* Your name and your contact information
* Yoursocialsecuritynumberanddateofbirth
* Your basic demographic information such as gender, race and ethnicity * Your history of homelessness and housing (includin@ your current housing status, and where and when you have accessed services)
* Your medical history and disabling conditions, includin@ mental and physical health concerns, substance abuse history, and HIV/AIDS status
@ Your case notes and services
* Your income sources and amounts
@ Your non-cash benefits
* Your veteran status, service history and discharge status * lnformationaboutothermembersofyourhousehold
* Your self-reported history of domestic violence
* Verification of history of homelessness and/or disabling conditions (including third-party verifications and/or self- attestations)
* Your photo (optional)
If you feel any of your rights outlined in this document have been violated, please contact (714) 589-2360.

Revised 10/2024
By signing this form, you understand the following:
* You have the right to receive services even if you do not sign this consent form. Providers may not refuse to provide you with services based on your refusal to sign this form. * You have the right to receive a copy of this consent form for your records. * YourconsentpermitsyourdatabeenteredinHMISandallowsanyparticipatingserviceproviders/organizationstoview your history of homelessness and service utilization, add to or update your information in HMIS without asking you to sign another consent form. This consent form expires seven (7) years after the signatu re or at any time you choose to revoke your consent. Please note, the Orange County CoC is required to retain all data stored in HMIS for seven (7) years after the data was created or last changed. However, stored data will not be further shared upon the expiration of your consent.
* You may revoke your consent to share your information with other HMIS participating service providers/organizations at any time. Your revocation must be provided either in writing or by completing the Revocation of Consent form. The service provider/organization you are receiving services from must make this form available to you if you ask, and it should be out and available for you to take from the office or facility you receive services from. Upon receipt of your revocation, 2110C will remove your PPI and PHI from the shared HMIS database and prevent further PPI and PHI from being added. However, the PPI and PHI that you previously authorized to be shared cannot be entirely removed from the HMIS database. This information, as described previously, will remain accessible to the service providers/organizations that provided you with direct services. * Participating agencies are required to post a Privacy Notice at each location where intakes are completed. The Privacy Notice contains more detailed information about how yourinformation may be used and disclosed and should be readily available to you and conspicuously posted at all participating service provider/organization locations. You have the right to receive a copy of this notice for your records. * You have the right to request, in writing, the following pieces of information. This information is to be provided to you within five (5) business days of your request.
o A correction ofinaccurate orincomplete PPI and/or PHI o A copy of your consent form
o A copy of your HMIS record (agency staff must review this information with you if you request such a review so that you can fully understand theinformation presented to you and how it is used) * AggregateorstatisticaldatathatisreleasedfromtheHMISdatabasewillnotdiscloseanyofyourPPIorPHI * YouarenotwaivinganyrightsprotectedunderFederaland/orCalifornialaw.

SIGNATURE AND ACKNOWLEDGEMENT
Your signature indicates that you have read (or been read) this consent form, have received answers to your questions, and you freely consent to have your information, and that of your minor children (if applicable and/or if you choose to include them), entered into the HMIS database. You also consent to share yourinformation with other participating organizations as described in this consent form.

Client Name: Date Of Birth (DOB): /
Signature: DateSigned: J
Minor Children (if applicable and/or if you choose to include them):

Name:Name: DOB: / / DOB:/j-
Name: DOB: / / Name: DOB:.//
Agency Staff Signature:

Agency Staff Name: %ency Staff Signature:

Agency Name:

If you feel any of your rights outlined in this document have been violated, please contact (714) 589-2360.

BUENA PARK NAVIGATION CENTER

HMIS SUPPLEMENT AL ENTRY FORM
Effective Date: October 22, 2024
City participant lived in prior to becoming homeless (PRIOR CITY) o Brea
o Buena Park
o Cypress
o Fullerton
o Garden Grove
o LaHabra
o La Palma
o Los Alamitos
o Orange
o Placentia
o Stanton
o Villa Park
o Yorba Linda
o Anaheim
o Orange County-outside the NSPA
o Other County in California
o Outside the State of California
o Outside the United States
Type of setting participant lived in before becoming homeless? o Homeowner
o Renting
o Livingwith FamiLy
o LivingwithFriends
o Mobile Home
o Foster Home
o Hotel
o Incarcerated
o SubstanceAbuseTreatment
Faci(ityor Detox Center
o Other
Between the ages of 5-18, what city did the participant live the longest? o Brea
o Buena Park
o Cypress
o Fullerton
o Garden Grove
o La Habra
o LaPalma
o Los Alamitos
o Orange
o Placentia
o Stanton
o Villa Park
o Yorba Linda
o Anaheim
o Orange County-outside the NSPA
o Other County in California
o Outside the State of California
o Outside the United States
o Client prefers not to answer

Page 1 of 2 ends

Citywhere participantattended high school:
o Brea
o Buena Park
o Cypress
o Fullerton
o Garden Grove
o La Habra
o La Palma
o Los Alamitos
o Orange
o Placentia
o Stanton
o VilLa Park
o Yorba Linda
o Anaheim
o Orange County-outside the NSPA
o Other County in California
o Outside the State of California
o Outside the United States
o Client prefers not to answer

Page 2 of 2 ends

FY 2024 QC HMIS: PROJECT INTAKE FORM GENERAL & CoC/ESG

CLIENT PROFILE
SOCIAL SECURITY NUMBER (SSN) I I I l-l I l-I I I I I QUALITY OF SSN - Only required to collect the las: four digits of the SSN, though are not prohibited from collecting all nine digits for new client records.
z Full SSN reported a Approximate or partial
SSN reported a Client doesn't know a Client prefers not to answer
a Data not collected

CLIENT'S NAME N/A
Last
€
First
Middle €
Suffix €

QUALITY OF NAME
a Full name
reported
€ Partial, street name, or code
name reported a Client doesn't know a Client prefers
not to answer a Data not collected

DATE OF BIRTH
I I I-l I I l- I I I II Age: I
Month Day Year

QUALITY OF DOB
a Full DOB reported a Approximate or
partial DOB reported a Client doesn't know a Client prefers not to answer
a Data not collected
GENDER (Select all that apply)
€ Woman (Girl if child)
€ Man (Boy if child) Ia Non-Binary
I
€ Transgender
€ Questioning
€ Culturally Specific Identity (e.g., Two-Spirit)
€ Different Identity
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
If 'Different Identity' Please Specify
RACE AND ETHNICITY (Select all tha') apply)
€ American Indian, Alaska Native, or
Indigenous
€ Asian or Asian American
€ Black, African American, or African
€ Hispanic/Latina/e/o
€ Middle Eastern or North African
a Native Hawaiian or Pacific Islander
€ White
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected

VETERAN ST ATUS
a No
a Yes
€ Client doesn't know
€ Client prefers not to answer
[1 Data not collected
If 'YES' to Veteran Status
Year entered militarv service (year')
1 Revised 10/01/2023
FY 2024 QC HMIS: PROJECT INTAKE FORM GENERAL & CoC/ESG Year seoarated from militarv service (vear)
Theater of Operations: World War II
€ No
€ Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Theater of Operations: Korean War
€ No
€ Yes
€ Client doesn't know
€ Client prefers not to answer
€ [)ata not collected
Theater of Operations: Vietnam War
€ No
€ Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Theater of Operations: Persian Gulf War
€ No
€ Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Theater of Operations: Afghanistan
€ No
€ Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Theater of Operations: Iraq (Operation Iraqi Freedom) € No
€ Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Theater of Operations: Iraq (Operation New Dawn)
€ No
, a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Theater of Operations: Other peace-keeping operations or militaiy interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo)
€ No
€ Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Branch of the Military
€ Army
€ Air Force
€ Navy
€ Marines
€ Coast Guard
€ Space Force
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Discharge Status
€ Honorable
€ General under honorable conditions
€ Other than honorable conditions (OTH)
€ Bad Conduct
€ Dishonorable
€ Uncharacterized
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected

QC OPTIONAL QUESTIONS
Alias
Pronouns(s) € She/Her/Hers
€ He/Him/His
€ They/Them/Theirs
a Other:
2 Revised 10/01/2023
FY 2024 QC HMIS: PROJECT INTAKE FORM - GENERAL & CoC/ESG

PROJECT ENROLLMENT

TRANSLATION ASSISTANCE NEEDED
a No
a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Preferred Language
[1 Spanish
€ Vietnamese
a Chinese
€ Cantonese
€ Mandarin
€ Korean
€ Persian
€ Farsi
€ Arabic
€ Russian
€ French
€ Ukrainian
€ Different Preferred Language
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
If Different Preferred Language
Please Soecifv

RELATIONSHIP TO HEAD OF HOUSEHOLD
€ Self (head of household)
[] Head of household's child
€ Head of household's spouse or partner
€ Head of household's other relation member
€ Other: non-relation member
PROJECT NAME Buena Park Navigation Center
PROJECT ST ART DATE I I I-l I l-l I I I I
HOUSING MOVE.IN DATE
/f_x P f)C'LI Dlr ---#& - - A-a - -k :I:A - --- -;-- - - -4 ---I r)r'} Ll (rU/ r an, rn VVII{I {IU ulSidlj/1117 tbqumj{flu{lk, d{NJ rU'Yn Dmiotsla a Darsnrrl *hb t4do a tslrr:sn* tsr hru roahrslrl mruzov I I l-I I l-I I I I I I 11JJ(Aria. I SCrulJllJ {Ill:i IjglC+ a l.illCilll UI IILllJi)C+lll.{ltJ 1111JVCrN into a permanent housing unit)
PRIOR LMNG SITUATION for Street Outreach, EmerqencyShelter, orSafe Haven project types Type of Residence 3.9174 (Type of living arrangementon the night before entering this project)

HOMELESS SITUATION
a Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside) € Emergency shelter, including hotel or motel paid for with emergency shelter voucher, or RHY-funded Host Home shelter a Safe Haven

INSTITUTIONAL SITUATION
a Foster care home or foster care group home a Long-term care facility or nursing home a Hospital or other residential non-psychiatric medical facility a Psychiatric hospital or other psychiatric facility a Jail, prison or juvenile detention facility a Substance abuse treatment facility or detox center

TRANSITIONAL HOUSING SITUATION
3 Revised 10/01/2023
FY 2024 QC HMIS: PROJECT INTAKE FORM GENERAL & CoC/ESG € Transitional housing for homeless persons (including € Staying or living in a friend's room, apartment, or house homeless youth) € Staying or living in a family member's room, apartment, or [] Residential project or halfway house with no homeless criteria house € Hotel or motel paid for without emergency shelter voucher a Host Home (non-crisis)

PERMANENT HOUSING SITUATION
€ Rental by client, no ongoing housing subsidy € Client doesn't know € Rental by client, with ongoing housing subsidy € Client prefers not to answer € Owned by client, with ongoing housing subsidy € Data not collected € Owned by client, no ongoing housing subsidy
Rental Subsidy Type if Rental by client, with ongoing housing subsidy € GPD TIP housing subsidy € Rental by client, with other ongoing housing subsidy € VASH housing subsidy € Housing Stability Voucher
€ RRH or equivalent subsidy € Family Unification Program Voucher (FUP) € HCV voucher (tenant or project based) (not dedicated) € Foster Youth to Independence Initiative (FYI) € Public housing unit € Permanent Supportive Housing
€ Other permanent housing dedicated for formerly homeless persons
LengthofStayinPriorLivingSituation (HowlongagodidtheclientstartstayinginthatTypeofResidence) € One night or less € One month or more, but less than 90 days € Client doesn't know € Two to six nights € 90 days or more, but less than one year € Client Prefers nOi (O € One week or more, but less than one month € One year or longer answer a Data not collected
If Client's Type of Residence is any ofthe lnstitutionalSituation options:

Length of Stay Less than 90 days?
(Indicate if the stayin the institutional setting theylived in immediatelypriorto project entry was less than 90 days)
a No a Yes
If 'Length of Stay Less than 90 days' is YES
On the night before - stayed on streets, ES or Safe Haven? (On the nightbefore the clients stayof less than 90 days in an institutionalselting were theyon the streets, in an Emer,qencyShelter, orin a Safe Haven?) a No a Yes
Approximate Date Homelessness Started (Approximate date the client's current episode of homelessness began) //
Number of times the client has been on the streets, in ES, or Save Haven in the past three years including today (Regardless of where they stayed last night)
€ One time a Three times a Client doesn't know
€ Twotimes [] Four or more times € Client prefers notto answer a Data not collected
Total number of months homeless on the streets, in ES, or SH in the past three years € One month (this time is the first month) € Six Months € Eleven Months € Two Months € Seven Months € Twelve Months
€ Three Months € Eight Months € More than 12 months
€ Four Months € Nine Months a Client doesn't know
0 piyB J@z(113 0 7B7 J01')(55 € Cl!ent prefers nOi iO answer a Data not collected
4 Revised 10/01/2023
FY 2024 QC HMIS: PROJECT INTAKE FORM - GENERAL & CoC/ESG PRIOR LIVING SITUATION for project types other than Street Outreach, Emergency Shelter, or Safe Haven
Type of Residence 3,917B (Type of livingarrangement on the nightbefore the entryinto the project)

HOMELESS SITUATION
a Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside) a Emergency shelter, including hotel or motel paid for with emergency shelter voucher, or RHY-funded Host Home shelter a Safe Haven

INSTITUTIONAL SITUATION
[] Foster care home or foster care group home a Long-term care facility or nursing home a Hospital or other residential non-psychiatric medical facility a Psychiatric hospital or other psychiatric facility a Jail, prison or juvenile detention facility a Substance abuse treatment facility or detox center

TRANSITIONAL HOUSING SITUATION
€ Transitional housing for homeless persons (including € Staying or living in a friend's room, apartment, or house homeless youth) a Staying or living in a family member's room, apartment, or € Residential project or halfway house with no homeless criteria house € Hotel or motel paid for without emergency shelter voucher € Host Home (non-crisis)

PERMANENT HOUSING SITUATION
€ Rental by client, no ongoing housing subsidy € Client doesn't know € Rental by client, with ongoing housing subsidy € Client prefers not to answer € Owned by client, with ongoing housing subsidy € Data not collected € Owned by client, no ongoing housing subsidy
Rental Subsidy Type if Rental by client, with ongoing housing subsidy € GPD TIP housing subsidy € Rental by client, with other ongoing housing subsidy € VASH housing subsidy € Housing Stability Voucher
€ RRH or equivalent subsidy € Family Unification Program Voucher (FUP) € HCV voucher (tenant or project based) (not dedicated) € Foster Youth to Independence Initiative (FYI) € Public housing unit € Permanent Supportive Housing
€ Other permanent housing dedicated for formerly homeless persons i
LengthofStayinPriorLivingSituation (HowlongagodidtheclientstartstayinginthatTypeofResidence) € One night or less € One month or more, but less than 90 days € Client doesn't know € Two to six nights € 90 days or more, but less than one year € Client Prefers nOi !O € One week or more, but less than one month € One year or longer answer a Data not collected
If Client's Type of Residence is any of the Homeless Situation options:

Approximate Date Homelessness Started (Approximate date the client's current episode of homelessness began) _ / /
Number of times the client has been on the streets, in ES, or Save Haven in the past three years including today (Regardless of where theystayed lastnight)
€ One time a Three times a Client doesn't know
€ Two times a Four or more times € Client prefers not to answer a Data not collected
Total number of months homeless on the streets, in ES, or SH in the past three years 5 Revised 10/01/2023
FY 2024 QC HMIS: PROJECT INTAKE FORM -
€ One month (this time is the first month) € Six Months € Two Months € Seven Months
€ Three Months [ Eight Months
€ Four Months € Nine Months
H Five Months € Ten Months
€ Eleven Months
€ Twelve Months
€ More than 12 months
a Client doesn't know
a Client prefers not to answer
a Data not collected
GENERAL & CoC/ESG
If Client's Type of Residence is any of the Institutional Situation options:

Length of Stay Less than 90 days?
(Indicate if the stay in the institutionalsetting theylived in immediately priorto projed entry was less than 90 days)
a No a Yes (
If Client's Tvoe of Residence is anv of the Transitional and Permanent Housino Situation ootions:

Length of Stay Less than 7 nights?
(Indicate if the stay in the transitional orpermanent housing setting they lived in immediately prior to projectentrywas less than 7 nights)
a No a Yes
If 'Length of Stay Less than 90 days' is YES-OR - If 'Length of Stay Less than 7 nights' is YES On the night before - stayed on streets, ES or Safe Haven? (On thenjghtbefore the clienfsstayofless than 90 days in an jnstitutionalsetting, orless than 7 nights in a transitionalperrnanent housing setting, were they on the streets, in an Emergency Shelter, orin a Safe Haven?)
a No a Yes
If 'On the night before - stayed on streets, ES, or Safe Haven' is YES Approximate Date Homelessness Started (Approximate date ther,lient's current episode of homelessness began) //
Number of times the client has been on the streets, in ES, or Save Haven in the past three years including today (Regardless ofwhere theystayedlastnight)
€ One ime € Three times a Client doesn't know
€ Twotimes a Fouror more times a Client prefers notto answer a Data not collected
Total number of months homeless on the streets, in ES, or SH in the past three years € One month (this time is the first month) € Six Months € Eleven Months € Two Months € Seven Months € Twelve Months
€ Three Months € More than 12 months€ Eight Months
€ FOur MOnthS € Nine MOnthS € Client dOeSn't knOW
@ Five Months @ Ten Months a Client prefers not to answer a Data not collected

DISABLING CONDITIONS AND BARRIERS
Do you have a disabling condition?
a No
a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Do you have a physical disability?
a No
a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
If yes forPhysical Disabilifi, a No
6 Revised 10/01/2023
FY 2024 QC HMIS: PROJECT INTAKE FORM - GENERAL & CoC/ESG Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? a Yes
Do you have a developmental disability?
laNo
a Yes
I
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Do you have a chronic health condition?
a No
a Yes
[ Client doesn't know
€ Client prefers not to answer
€ Data not collected
If yes for Chronic Health Condition,
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? a No
a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Have you been diagnosed with AIDS or have you tested positive for HIV? a No
a Yes
[ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Do you have a mental health problem?
a No
a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
If yes forMentaj Health Problem,
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? a No
a Yes
€ Client doesn't know
[] Client prefers not to answer
€ Data not collected
Do you have a substance abuse problem?
a No
a Alcohol Abuse
a Drug Abuse
a Both Alcohol and Drug
[ Client doesn't know
€ Client prefers not to answer
a Data not collected
If you have any Substance Abuse Problem,
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? a No
a Yes
[] Client doesn't know
€ Client prefers not to answer
€ Data not collected
Are you a survivor of domestic or intimate partner violence? € Data not collected
a No
a Yes
[I Client doesn't know
€ Client prefers not to answer
a Data not collected
If Yes forsutvivorof domestic orintimate partner violence When did this experience
occur?
€ Within the past three months
€ Three to six months ago (excluding six months exactly) II] From six to twelve months ago (excluding one year exactly) € More than a year ago
[ Client doesn't know
€ Client prefers not to answer
a Data not collected
Are you currently fleeing?
a No
a Yes
€ Client doesn't know
[) Client prefers not to answer
€ Data not collected
7 Revised 10/01/2023
FY 2024 QC HMIS: PROJECT INTAKE FORM GENERAL & CoC/ESG

MONTHLY INCOME AND SOURCES
Income from Any Source
€ Client doesn't know
a No € Client prefers not to
aYes anSWer
€ Data not collected
IF "YES" TO INCOME FROM ANY SOURCE - INDICATE ALL SOURCES THAT APPLY Income Source (Check all that apply) Monthly Amount
[] Earned Income
[ Unemployment Insurance
€ Worker's Compensation
[1] Private Disability Insurance
€ VA Service-Connected Disability Compensation
€ Social Security Disability Income (SSDI)
€ Supplemental Security Income (SSI)
[) Retirement Income from Social Security ,
[] VA Non-Service-Connected Disability Pension
€ Pension or retirement income from a former job
€ Temporary Assistance for Needy Families (TANF)
€ General Assistance (GA)
€ Alimony or other spousal support
€ Child Support
a Other Cash Income (Specify: )

NON-CASH BENEFITS
Receiving Non-Cash Benefits? @ NO € Client doesn't know € Client prefers not to answer
a Yes € Data not collected
IF "YES" TO RECEIVING NON.CASH BENEFITS- INDICATE ALL SOURCES THAT APPLY € Supplemental Nutrition Assistance Program (SNAP) € TANF Transportation Services € Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC) € Other TANF-funded services a TANF Childcare Services
€ Other Non-Cash Benefits
(Specify Source):

HEALTH INSURANCE
Covered by Health Insurance?
€ Client doesn't know
a No [) Client prefers not to
aYes anSWer
€ Data not collected
IF "YES" TO COVERED BY HEALTH INSURANCE- INDICATE ALL SOURCES THAT APPLY € MEDICAID a Insurance Obtained through COBRA
€ MEDICARE € Private Pay Health Insurance
€ State Children's Health Insurance Program € State Health Insurance for Adults € Veteran's Health Administration (VHA) € Indian Health Services Program € Employer-provided Health Insurance
a Other Health Insurance
(Specify Source):
8 Revised 10/01/2023
FY 2024 QC HMIS: PROJECT INTAKE FORM GENERAL & CoC/ESG

LAST PERMANENT ADDRESS
Prior City
The last citv in which the client was nermanentlvhoused orior to entry into this project

ADDITIONAL INFORMATION
Sexual Orientation
aHeterosexual ia Gay
a Lesbian
aBisexual I
a Questioning/Unsure
€ Other
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
If Other
Please Soecifv

QC CUSTOM QUESTIONS
What city were you in immediately prior to entry into this project? The cifi in which ff761 dientspent the night priorto entry into this project € Aliso Viejo € Huntington Beach € Newport Beach € Westminster € Anaheim € lrvine € Orange € YorbaLinda
€ Brea € LaHabra € Placentia € Unincorporated Orange € Buena Park € La Palma € Rancho Santa Margarita County € COSta MeSa € Laguna BeaCh € San Clemente € OutSide Orange COunty, € Cypress € Laguna Hills II] San Juan Capistrano but !n Cal!fom!a € Dana Point [] Laguna Niguel € Santa Ana € OutS!de Of Cal:forn:a € EI Modena € Laguna Woods € Seal Beach € Client dOeSn'i knOW € Fountain Valley [ Lake Forest € Stanton € Client !)refers net !O answer € Fullerton a LosAlamitos a Tustin X Datanotcollected
€ Garden Grove € Mission Viejo € Villa Park
Phone Number (Optional)
Email Address (Optional)
What statewere you born in?
€ AL - Alabama € GA - Georgia € MA - Massachusetts € NM - New Mexico € TN - Tennessee € AL-Alaska € Hl-Hawaii € Ml-Michigan € NY-NewYork € TX-Texas € AZ - Arizona € ID - Idaho € MN - Minnesota € NC - North Carolina € UT - Utah [1] AR- Arkansas [] IL - Illinois € MS - Mississippi € ND - North Dakota € VT - Vermont € CA - California II] IN - Indiana € MO - Missouri € OH - Ohio € VA - Virginia € CO - Colorado € IA - lowa € MT - Montana € OK - Oklahoma € WA - Washington € CT-Connecticut € KS-Kansas ONE-Nebraska € OR-Oregon € WV-WestVirginia € DE - Delaware € KY - Kentucky € NV - Nevada € PA - Pennsylvania € Wl - Wisconsin € DC - District of € LA - Louisiana a NH - New € Rl - Rhode Island € WY - Wyoming Columbia € ME - Maine Hampshire € SC - South Carolina € Client doesn't know 9 Revised 10/01/2023
FY 2024 QC HMIS: PROJECT INTAKE FORM - GENERAL & CoC/ESG [i FL - Florida [ MD - Maryland € NJ - New Jersey € SD - South Dakota € Client prefers not to answer
€ Other
If'Other' forState you were born,
Which country were you born in?
Employment Status [ Full-Time € Unemployed € Client doesn't know € Part-Time € Disabled € Client prefers not to answer
€ Seasonal/Temporary € Retired € Data not collected
Work

CFCOC ENTRY QUESTIONS
Is this client receiving services funded by the Children and Families Commission Orange County?
a No
a Yes
CFCOC Bed Night Start Date
TL.- -I:..-Jl- !:-J l--J -:-IJ L.....l.J L.. /%r/l/"ua% //ITlb UlldT1k S IIISI Ddu I1lgrH Turl{M(J D'l I,irLUL CFCOC Bed Night End Date
rt - ..r= - Jl- 1. .- J h - g - :-L. J t. .- g - g t.. rs r rs rs rs //IrHj Ulldrlk S Idol UdU rllgrl{ lunkJd€J 07 kirkgkJlg I certify that the information above is correct to the best of my knowledge.

Client Signature
Agency Staff Signature
Date
Date
DO NOT ANSWER QUESTIONS BELOW - DATA ENTRY PERSONNEL ONLY (Optional):

Date entered into HMIS: / /
Question Answer Comments
Was the hard copyintake form
completely filled out correctly?
€ No
€ Yes
Staff Name (verifying completion of Data Entiy):
10 Revised 10/01/2023
FY2024 QC HMIS: CURRENT LIVING SITUATION ASSESSMENT FORM

CURRENT LIVING SITUATION
For Head of Households and Adults in CoC, ESG, RHY, or PATH funded Street Outreach; PATH funded Services Only, ESG funded Night-by-Night Emergency Shelters, and Coordinated Entry Projects.

Street Outreach, Services Only, and Coordinated Entry: Record every contact made with each client by recording their Current Living Situation, including when the Project Start Date, Prior Living Situation or Date of Engagement is recorded on the same day. There may or may not be a contact made at project exit.

Night-by-Night Shelters: Only record a Current Living Situation if the interaction between the shelter personnel and the client goes beyond the basic provision of shelter services. A Current Living Situation for emergency shelter does not include activities of daily sheltering (e.g. bed registration, request for personal care items, dinner sign-up, meals, etc.)

PROJECT NAME

CLIENT NAME
CURRENT LIVING SITUATION DATE I I I-l I I-l I I I I Current Living Situation
i (PATH funded projects are limited to the response options with an asterisk ")

HOMELESS SITUATION
a Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)" € Emergency shelter, including hotel or motel paid for with emergency shelter voucher, or RHY-funded Host Home shelter" a Safe Haven"

INSTITUTIONAL SITUATION
, a Foster care home or foster care group home a Long-term care facility or nursing home a Hospital or other residential non-psychiatric medical a Psychiatric hospital or other psychiatric facility facility a Substance abuse treatment facility or detox center a Jail, prison or juvenile detention facility

TRANSITIONAL HOUSING SITUATION
€ Transitional housing for homeless persons (including € Host Home (non-crisis) Homeless Youth) a Staying or living in a family member's room, apartment, or € Residential project or halfway house with no homeless house Crier!a € Staying or living in a friend's room, apartment or house € Hotel or motel paid forwithout emergency shelter voucher

Rental Subsidy Type if Rental by client, with ongoing housing subsidy is selected Revised 2024 I
FY2024 QC HMIS: CURRENT LIVING SITUATION ASSESSMENT FORM € GPD TIP housing subsidy € Housing Stability Voucher
€ VASH housing subsidy € Family Unification Program Voucher (FUP) € RRH or equivalent subsidy € Foster Youth to Independence Initiative (FYI) [ HCV voucher (tenant or project based) (not dedicated) € Permanent Supportive Housing € Public housing unit € Other permanent housing dedicated for formerly homeless € Rental by client, with other ongoing housing subsidy persons (Only for Coordinated Entry System Projects)
Living Situation Verified by:
(Agency/Project that verifted living suuation information) If the client's Current Living Situation is any of he non-homeless situation responses:

Is client going to have to leave their current living situation within 14 days?
a No
a Yes
€ Client doesn't know
* Client prefers not to answer
€ Data not collected
If the clienthas to leave theircurrentliving situation within j4 days:

Has a subsequent residence been identifled?
a No
a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
If the clienthas toleave theircurrentlivingsituation within 14 days:

Does individual or family have resources or support networks to obtain other permanent housing?
a No
a Yes
[ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Ifthe dienthas to leave theircurrent-Iivingsituation within 14 days, Has the client had a lease or ownership interest in a permanent housing unit in the last 60 days?
a No
a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
If the client has to leave their current living situation withinl4 days, Has the client moved 2 or more times in the last 60 days? a No
a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Location Details
I certify that the information above is correct to the best of my knowledge.

Client Signature Date
Agency Staff Signature Date
DO NOT WRITE IN BOX BELOW - DATA ENTRY PERSONNEL ONLY (Optional):

Date entered into HMIS: / /
Question Answer Comments
Was the current living situation assessment
form completely and correctly filled out
€ No
€ Yes
Staff Name (verifying completion of Data Entry):

Revised 2024 2
FY24-25 CDBG Program Statistical Information
and Income Self-Certification Form
Federally funded Community Development Block Program (CDBG) participants must disclose statistical information in order to participate. The information on this application is necessary for federal reporting purposes. Please print and answer all questions completely.

First Name
Address (residence)
Telephone Number (
Date of Birth Age
Ethnicity (must check one):

Q Hispanic € Non-Hispanic
Race (must check one):

QWhite
QBlack/African American
[JAsian
QAmerican Indian/Alaskan Native
FAMILY INCOME:

Last Name Date
City Zip Code
E-mailAddress
Gender: uMale QFemale Did you participate in the program last year: QYES QNO Disabled (must check one):

Q Yes Q No
QNat. Hawaiian/Other Pacific Islander
QAmerican Indian/Alaskan Nat &White
€ Asian & White
QBlack/African American & White
CIAmer. Ind./Alaskan Nat. & Black
QOther Multi-Racial
Income includes wages, salaries, tips; self-employment orbusiness income, unemployment & disability income, retirement &insurance income, publicassistance,interest& dividend income, alimony, child support, gift income, armed forces incomeforall familymembers 18 years of age and older.

FAMILY INCOME TABLE" (BELOW):

1. FIRSTcirclethenumberofpersonsinyourhousehold
2, THEN go across and circle your household annual Income Category Household
Size 30V%eorf'MlOeWdiannclOnmcoeme
Low Income
50% of Median Income
Moderate Income
80% of Median Income
1 Person $33,150 $55,250 $88,400
2 Persons $37,900 $63,100 $101 ,000
3 Persons $42,650 $72,050 $113,650
4 Persons $47,350 $78,900 $126,250
5 Persons $51 ,150 $85,250 $136,350
6 Persons $54,950 $91 ,550 $146,450
7 Persons $58,750 $97,850 $156,550
8 or More $62,550 $104,150 $166,650
' /ncome limits vffective 4/1/24
Female Head of Household: uYES [2 NO
Family Size Total: Children (0-17 yearsofage): + Adults (18+ years ofage):

CERTIFICATION: (Please read before signing)
This organization is supported with Federal funding. According to Title 18, Section 1001 ofthe u.s. Code,it is a Telonyfor any person to knowinglyand willingly makefalse orfraudulent statementto anydepartmentofthe United States Government. By signingthis Document,l certify under penalty of perjury, that all the information on this application is correct to the best of my knowledge and belief, and I acknowledge that such information is subjectto verification. I also acknowledge that myfailure to provide necessary documents within a reasonable period oftime orfalsification ofthis information shall be grounds for mytermination from the program.l authorizethe release of said information to local, State and/or Federal agencies within five years ofthis date.

Print Name (applicant)
Print Name (parenUguardian if applicant is a minor)
Signature
Signature
Date
Date
Staff Reviewer Staff Signature Date

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

AND PARTICIPATION IN SHEITER, HOUSING & RELATED SUPPORT Name: DOB: Date:

Aliases, Nicknames and Street Names:

Initial orXin each box on the left to demonstrate yourconsent to participate in services and orshare information:
jam requesting a bed and housing assistance services, and agree to work the housing plan that will be created with me by my housing navigator. Ialso understand that this is not a permanent living situation, and that the purpose of this shelter is to help me become stably housed, andlwill work both independently and with staff in achieving this outcome as rapidly aslam capable.

Ir:tgree to abide by all shelter expectations as they exist today and any amended expectations to come.

Iagree that all staff may be involved in the shelter, housing and support process, andlunderstand that all staff may have access to information about me for this purpose.

Ihave had the grievance policy explained to me, andlunderstand thatlam free to express my concerns about shelter, housing, and support services without negative impacts relating to my participation. Iknow that the Grievance Procedures and forms are freely available to me and are Located in a binder at the service desk.
lunderstand the reasons why my participation in the shelter may be terminated, and that these reasons may be voluntary or involuntary. Iunderstand thatlhave a right to appeal a termination decision if I feell have been wrongfully terminated from the program and that Ican find the appeal forms in the grievance binder.
/ understand that participation in all shelter, housing, and supportive services is voluntary, and / may revoke my agreement to participate at any time of my choosing, in writing. I further understand that any revocation will not apply to information that has already been released in response to this authorization.

Iknow that information about me and my shelter, housing and support history may be shared and gathered by Mercy House with any other entity with the intent to help end my homelessness and ensurel am able to remain in stable housing. Ihereby authorize the exchange of information between Mercy House and other agencies (public and non-profit agencies) such as shelters, medical providers, schools, landlords and Rapid Re-Housing Programs or other service providers, etc. lunderstand that Mercy House seeking or disclosing my information is solely for my benefit and will be kept confidential. Ialso understand that oncelleave the program, this disclosure consent becomes invalid.

Icertify under the penalty of perjury that all informationlprovide will be true and correct, andlhave given my permission for verification.

By signing on the line below, I am authorizing Mercy House to collect, store, and share information related to shelter, housing and support services, and to participate in housing and support services.

G uest: Staff Witness:

Signature Srgwture
Revised 7/24/2019
MERCY*HOUSE
Guest Expectations
Welcome to our shelter program. We hope your stay with us allows you to begin your path to ending your homelessness. To ensure that all guests are able to comfortably work toward that goal, the following expectations need to be followed while on the shelter property, on any program shuttle, as well as the immediate vicinity of the shelter or drop-offlocation.

All guests are asked to read and initial each of the following sections as an acknowledgement that they understand what is expected of them while enrolled in the program:

1. Demonstrateresponsibilityforyourself,youractions,andyourhousingplan.

2. Guestsareexpectedtoactivelyworkontheirhousingplan.Bysigningtheseexpectations, you understand that you are not guaranteed housing by enrolling in this program. The goal is to get you connected to housing resources as quickly as possible. You will be scheduled to meet regularly with your Housing Navigator to discuss your housing plans.

Part of your Housing Plan will be for you to identify tasks that you need to complete in order to achieve your goal of securing housing. Your progress will be reviewed at 30-day increments, with formal extension requests required after 6 months.

3. Follow all health and safety policies. These policies include, but are not limited to:
* When a new guest enters the program,
clothing/bedding items to be laundered
they are required to shower and submit any
or heat treated.
* Guests are expected to maintain their hygiene (including changing into clean clothes when possible), laundry once a week and showering at least twice a week. * All guests are expected to wear masks if observed as having any symptoms ofillness and must agree to temperature checks if asked. Social distancing protocols may also be enforced that all guests must follow.
* Every guest will be assigned a laundry day. Guests will be expected to bag their dirty clothes and bundle their bedding on this day to help streamline laundry services.

Laundry should be submitted to staff for cleaning by 9:00 AM on this day. * Guestsareexpectedtomaintainthesafetyofthesleepingareabystraighteningtheir beds when not in use. Personal items at the bed must be able to fit in the supplied indoor storage. In addition, each guest will be permitted to keep 1-2 pairs of shoes underthe bed. No additional personal items may be kept behind, under or in the aisles next to your bed. No barriers of any kind may be raised without explicit permission from the management team. Wateris allowed in the dorms, but no open or perishable food or other liquid drinks may be brought to the bed area at any time.

M HSGuestExpectations Page 1 of S Revised 2/03/2023
* All prescription medication must be recorded with Staff at Intake and stored in your indoor bin in its original labeled container. Pills or medication NOT matching the original labeled container may be confiscated. No marijuana will be allowed beyond the security check point at any time. Medical marijuana may only be stored in your outdoor bin with a valid Medicinal Use Card and must be 8 oz. or less. * Everyguestissuppliedwith2indoorunder-the-bedbins(orequivalent)andloutdoor bin. Outdoor bins are accessible during the posted times. Trash and recycling may not be brought onto the property. Guests may only use the bins that were assigned to them by staff. All bins must be able to properly close and latch, and indoor bins must be placed on top of the beds when the bed is not in use, with all bedding made neatly without touching the ground, so staff can properly sweep and mop underneath each day.

4. Current guests of the program may use this location as a mailing address. Please note, however, that after a guest exits, it becomes their responsibility to fill out a change of address form with the post office. Any mail that is delivered to the site after a guest has left the program will be sent back to the post office as "Return to Sender." Mail will be kept at the front desk, along with important program notices or messages from staff.

Upon signingin each day, the guest's name will have a mark next to it signifying that there is unclaimed mail or messages.

5. For your comfort and safety, all guests are expected to abstain from behavior that is disruptive and unacceptable to others. Examples include verbal harassment, physical harassment, excessive profanity, possessing weapons or sharp items, possession of drugs or alcohol, theft, etc. More critical offenses may include possession of weapons or hard narcotics, use of racial slurs, sexual harassment including nudity or obscene/sexual behavior, setting fires, threats or violent behavior, and any other inappropriate physical contact. Serious violations may result in an immediate exit from the shelter. If you are asked to leave, you must leave without incident in order to be eligible for a return to the program in the future. If a driveris available, you may be transported to an approved drop off location if it is deemed safe to do so.

6. lfaguest'sbehaviorisextremelydisruptiveandstafforsecurityasksyoutostepoutside or remove yourself from an area so you may calm down, you are expected to comply with this request. This is for your benefit, and you may be able to rejoin the group when your behavior is no longer a disruption to the other shelter guests. If you are unable to deescalate peacefully when addressed, staff may need to exit you from the program for the safety of all other participants.

7. Guests are expected to return each night before the posted curfew unless allowed special consideration by management (e.g., late entry to accommodate work, school, disability- related considerations, or other reasonably extenuating circumstances). Guests are not allowed to miss two consecutive nights or 3 nights in any calendar month without clearing the absence with their Housing Navigator. Guests are expected to sign-in daily and may M HSG uestExpectations R=t@e 2 0f S Revised 2/03/2023
not sign or hold beds for others. The program manager may grant excused nights out of the shelter upon request if deemed necessary and appropriate.

8. Photo IDs are required of all registered guests for safety purposes. If you do not have a California State ID, staff will assist you in acquiring an ID within the first few days after enrollment. Mercy House may take photos and thumbprints to produce program IDs for guests if necessary, and staff may also take photos of vehicles, bicycles, and other property for safety purposes. By entering this program, you give your consent to this. A photo ID of some sort is also required to receive a bath towel and is also used when waitingin the dinner line (a loanerlD may be created for you in the interim ifyou do not yet have one).

9. Out of respect for, and to protect the privacy of our staff and guests, no audio/videorecording or taking of photos is permitted on premises, except by the expressed permission from Management

10. For your safety, this site may incorporate closed-circuit surveillance cameras as part ofits security system. No cameras are installed in any restrooms or showers. Any footage captured is used only for safety purposes and may be shared with law enforcement as part of an active investigation. No footage will be shared with the general public.

11. Smoking and vaping are permitted in the designated outdoor smoking area only. No drugs, paraphernalia, alcohol, or marijuana (recreational or medicinal) will be permitted in or around the shelter. Anything containing THC (with or without a prescription) will not be allowed.

12. Guests are expected to attend resident meetings and contribute to the community. This includes mandatory participation in all fire and safety drills.

13. All guests are expected to be Good Neighbors of the communityin which they are served and have an obligation to comply with all state and local laws and ordinances and always behave in a courteous manner, including while traveling to and from the property. Complaints from residents, business owners, or public officials may result in expulsion from Mercy House Programs.

14. In order to remain Good Neighbors, all guests are expected to use the provided shuttles for transportation on to and from the property, unless they have a personal vehicle or utilize a rideshare/taxi service. We practice a strict no-walk-up/no-bike-up policy. Guests are expected to remain on the property at all times unless when leaving for the day.

Violation ofthis expectation may result in an immediate exit.

15. Guest vehicles may be parked on shelter property at the owner's risk and liability, onlyin designated areas once the vehicle is registered with the program. A valid license, registration, and insurance are required in the name of the guest. RVs (Recreational Vehicles) are not permitted on-site. Guests with bicycles must use the bicycle racks on the shuttle buses and allow Mercy House drivers to secure them on the rack. Guests are only allowed one bike per person and are not allowed to store spare bike parts unless M HSG uesiExpectaUons Page 3 0f 5 Reyi;ed 2,103/2023 they fit in the outdoor bin or personal vehicle. All bicycles brought onto the property must be registered and photographed. All vehicles, including bicycles, must be operable.

Abandoned or inoperable vehicles will be subject to tow at the owner's expense.

16. Several areas on site are restricted to staff and security only. Guests are not allowed to enter any areas other than the common areas, dorms, and restrooms without an appointment or explicit permission from the management team. If signage is posted designating an area as "Staff Only," guests are expected to respect the boundary.

17. There may be areas specific to men, women, non-binary guests, couples, or families with children. Please respect the privacy of others. Children must be attended to by an adult family member at all times. Guests are not allowed to enter any dorm other than the one they were assigned at intake.

18. Guests are expected to respect the rest and sleep of their neighbors. When lights are off, indoor voices should be used to limit distractions and not disturb their rest. Likewise, guests are not allowed to use bright lights or play music/watch videos with sound in the dorms after lights out.

19. Although we respect everyone's right to privacy, we reserve the right to pat down and search all persons as a precaution against any potential security risks. In addition, staff may search outdoor bins, with or without the owner's presence. Guests will be informed of items not allowed at the shelter. If those items are found on site, they may be confiscated and destroyed. Guests must agree to be searched any time they access their outside bins, bikes, vehicles, or any area deemed "unsearched." Refusing a search will amount to forfeiting your enrollment.

20. Approved pets, Service Animals and ESAs must be registered and cleared ahead of time with program management. Clients are limited to no-more-than one animal (with the possible exception of service animals), and the animal must be present with the client at the time ofintake. All pet owners must agree to and follow the guidelines provided in the Animal Expectations, which is a separate document that will be given upon entry of the animal into the shelter.

21. Neither Mercy House nor any of its vendors are in any way responsible or liable for lost, stolen, or damaged items that guests bring onto the premises. Guests are encouraged to keep valuable items close and guarded and are asked to turn in any found items to the front desk. We recommend that those who use the supplied charging stations have their electronics clearly marked or customized for easy identification.

22. Cash is never to be given to Staff, Volunteers, or Interns at ANY time.

23. It is our desire to never deny shelter or services to our guests, however, in the case that behavior becomes a health or safety risk, Shelter Management can expel or prevent any guests from staying at the shelter. Any conflicts between guests should be brought to the attention of the staff immediately.

M HSG uestExpectations Page 4 0f 5 Reyied 2/03/2023

24. At the time of your exit from the program, all shelter property (such as bedding, towels, pillows, laundry bags, locks, bins etc.) must be returned. As a courtesy, staff wilf temporarily hold your personal belongings for up to a maximum of 90 days. Any property not retrieved by then will be disposed of. No additional items can be brought back to the site to be stored. Guests must call in to schedule a pickup.

25. We wish to keep open communication between Mercy House and ourguests. Each shelter has a grievance binder at the front desk which contains our Grievance Policies and forms.

We ask that any issues be brought to our attention first through informal processes, so that we can address them quickly as they occur. For this reason, every site also has a suggestions box for you to leave comments or complaints. If any part ofthe program, staff or services is lacking, please do not hesitate to notify management immediately by speaking to the on-duty site leader or manager. If appropriate, you may also choose to complete a "Request for Consideration" form, to describe issues that you would like to see resolved. If after speaking to staff and completing a "Request for Consideration" form, you feel the matter has not been resolved, you will find a copy of the formal Grievance Form in this binder.

26. Any guest that does not follow these expectations is jeopardizing their ability to accomplish their housing plan and may be exited from the shelter. Because everyone can make a mistake, when an expectation is not met the staff will clarify any misunderstanding ofthe expectation and discuss ways that each guest can avoid further violations. If the violations continue, staff will meet with the guest to create an Action Plan in support of the client getting back on-track with their housing goals and meeting the program expectations. If management offers the guest an opportunity to enter into a Behavioral Contract, the guest will be required to abide by the terms of the contract to continue their enrollment.

As a result ofinitialing these expectations and signing this form, I understand that expectations, health, and safety policies may change as necessary and that I will be informed ofthese changes, and I am required to abide by any amended policies.

I have read the above and agree to follow the Shelter Expectations.

Name (please print):

Signature: Date:

M HSG ciestExpectations Pags 5 0f 5 Revised 2/03/20:!3 MERCY*HOUSE (cASEFILEcOPY)
Acknowledgment of Understanding
Understanding of Riqhts and Responsibilities
As a willing program participant, I understand that I have the following rights:
* The right to be treated with dignity and respect * The right to be treated with cultural responsiveness * The right to privacy within the constrictions of the shelter environment * The right to self-determination in identifying and setting goals * TherighttoreasonableaccommodationandmodificationsbasedonadisabilityorlimitedEnglish proficiency
* Therighttoconfidentialityandinformationaboutwhenconfidentialinformationwillbedisclosed, to whom and for what purpose, as well as the right to deny disclosure, unless disclosure is required by law
@ The right to reasonable access to any shared or provided records concerning my involvement in the program (ex: does not include access to case notes or incident reports).

In addition, I understand that each guest is responsible for the outcome of their program enrollment.

To help ensure a positive program outcome, I understand that my responsibilities include:
@ Supporting an environment that promotes safety, toward staff, the community, and other guests * The adherence to all expectations provided and reviewed at my intake, as well as any amendments or addendums formalized after my date of enrollment * Participation and being active in my own care, to the degree possible,in developing and achieving mutually agreed upon housing goals
* Providing, to the extent possible, accurate information that may be needed by Mercy House staff providing services to ensure thorough assessment, service planning, appropriate linkages, and referrals
* Maintaining confidentiality and privacy of others" circumstances and situations, just as my own privacy must be maintained.
lacknowledge that a copy of my Rights and Responsibilities has been provided to me for my own records.

Furthermore, Iknow that staff will inform me, in language Ican understand, about the purpose of the services being delivered to me. Lastly, lagree that services will be provided to me only in the context of a professional service provider-client relationship based on valid, informed, and mutual consent.

Guest (Printed): Date:

Guest (Signed): Program:
g Guest Refused or Unable to Sign Staff Witness (Printed ):

M HSGuestsRightsResponsibilities Revised 8/10/2021
MERCY*HOUSE
Activities of Daily Living (ADL) Agreement
p7@g73y; BuenCI Park NC)v!ga+!on Cemer (lj(q"lj;
A person measures their ability to function independently by looking at how well they manage their ADLs, or Activities of Daily Living. All persons requesting a bed at this facility are required to be able to handle their ADLs, which include (but may not be limited to) the activities listed below.

By writing my initials next to each line below, I am indicating that I understand these activities and am confirming my ability to perform them unassisted:

Personal hygiene
A person's ability to bathe and groom themselves (including oral, nail and hair care)
Toileting
A person's mental and physical ability to properly use the bathroom and clean themselves after
Dressing
A person's ability to select, get into and wear the proper clothes for different occasions
Feeding
A person's ability to appropriately feed themselves food and drink Transferring
A person's ability to change from one position to the other (especially from bed to chair or vice versa)
Ambulating
A person's ability to change from one position to the other and to walk or wheelchair independently
M HSADLAgreement Page 1 of 2 Revised 08/07/2023
Breathing
A person's ability to breathe on their own without major life-assistance machines.
(Exceptions would include Portable Oxygen Tanks or CPAP Machines) By signing belowlacknowledge these ADLs were reviewed with me andlagree thatlcan manage my own, unassisted. / further acknowledge that in eventlam unable to meet the terms of this agreement; my enrollment in this program may be ended for safety reasons.

Client
Client Signature Date
Staff
Staff Signature Date
MHSADLAgreement Page 2 of 2 Revised 08/07/2023

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date:

ESL ID:

Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID:

Entity Name:

1. The entity is in good standing with the Franchise Tax Board.

2. The entity is not in good standing with the Franchise Tax Board.

3. The entity is currently exempt from
tax under Revenue and Taxation Code (R&TC) Section 23701

4. We do not have current information about the entity.

5. The
entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

Connect With Us
Web:

MERCY HOUSE LIVING CENTERS
✔
✔
d.

City of Buena Park
2025-2026 Community Development Block Grant (CDBG)
F
unding Proposal Summary Sheet
O
rganization Name: Friendly Center, Inc.

P
rogram Name: Community Resource Center
E
stimated Goal: 812 Individuals
F
unding Request: $23,000
O
rganization Purpose:

T
he Friendly C enter offers free resources and support to low -income residents. They offer stability programs, food distribution, case management, mental health counseling, utility and rental assistance, and other referral services. Additi onally, they offer skill - building programs such as after -school tutoring, job development assistance, and financial literacy workshops.

D
escription of Request:

C
DBG funds will be used to fund a portion of Friendly Center’s staff salaries and benefits, culturally relevant food supplies, and other program related operational costs for their Buena Park location.

A
nalysis of Request:

T
he project meets the national objective of benefiting low - and moderate - income individuals. The Friendly Center offers assistance that improve s many residents’ quality of life. Friendly Center is a well -recognized resource center receiving many low -income resident referrals from Orange County Social Services, local schools, 2-1-1 Orange County, and other non- profit organi zations, which demonstrates their experience and ability to provide the needed services to the community.

Funding Recommendation:

S
taff recommends funding in the amount of $13,700.

CITY OF BUENA PARK

Activity/Program Name Community Resource Center
Address 6688 Beach Blvd, Buena Park, CA 90621
Contact Person/Title Kenia Cueto, PhD, President/CEO
Email Address [email protected] I Phone Number l 714-771-5300x133 Estimated individuals or households to be served by proposed activity during FY 2025-2026 (including Buena Park residents and non-Buena Park residents):

Estimated Goal:. ___ 1�6=2=5�-- 181 Individuals □ Households Estimated Buena Park residents or households to be served by proposed activity during FY 2025-2026:

Estimated Goal:. __ ----=-8-"12=----- □ Individuals 181 Households Please indicate the amount of CDBG funds being requested:

Public Service Activities
Other Eligible Activities
(Signature of authorized representative)
President/CEO
(Name and Title of authorized representative)
$ _______ _
$. ______ ----'-
12/16/2024
Date
23,000
Organization Name: Friendl7 Center. InC. py()gyBIH %BBIB; Commun:fV Resource Center Please answer the Following questions completely. If any questions are left unanswered, your application will not be considered. You may attach additional sheets and/or supporting materials as needed.
1 ACTMTY DESCRIPTION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the proposed activity, including services to be provided and goals to be accomplished. * Why is there a need for this activity in the City of Buena Park? @ Identify the location of the activity and the service area boundaries. * Describe specifically the intended use or the CDBG Funds.

Please see attached document.
2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2025 through June 30, 2026. * How was the estimated number of clients determined? * How will you reach your target population?
* Explain why this activity is needed for this target population.

Please see attached document.

Application Page 2
Organization Name: Fr'end'Y Cen'er- Inc' py@gyByIl %3B(;; Communfiy Resource Center 3 NATIONAL OBJECTIVES
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe in detail how the activity meets at least one of the three CDBG Program national objectives.

Select one:
(X Benefit low- and moderate-income persons in Buena Park; € Aid in the prevention or elimination of slums or blight in Buena Park; [:l Meet a need having a particular urgency in Buena Park.

Please see attached document.
4 BUDGET
[24 CFR 570.502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circular A-87, A-122, Treasury Circular No. 1075] Itemize administrative and operational costs for the proposed activity. Cost Category may include:
staff salaries and benefits, rent, utilities, etc.

Cost Category CDBG Funding
Request
Other Funding
Sources Total Cost
Program ASSiSt Spec. (salary) $ 15,000.00 $ 15,000.00 $ 30,000.00 Food ASSistant (salary) $ 5,000.00 $ 18,000.00 $ 23,000.00 Benefits (salary) $ 1,000.00 $ 4,300.00 $ 5,300.00
Program Exp. (non-salary) $ i500.00 $ 20,000.00 $ 21,500.00 Operating Exp. (non-salary) $ 500.00 $ 20,000.00 $ 20,500.00 $ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Total $ 23,000. $ 77,300.00 $ 100,300.00
Application Page 3
Organization Name: Fr'end'Y Cen1er- 'nc pl'ograrn %3e: CommuntiY Resource Cen{er 5 ELIGIBILITY DOCUMENT ATION
If the proposed activity is a public service, describe what form of documentation will be collected to demonstrate that at least 70% of persons served are low- and moderate-income, as required by HUD, and a minimum of 20% are Buena Park residents. (Please attach a copy of the activity's client intake/application/registration form)
Included with this submission is the required registration form that is completed by any client participating in programs at Friendly Center's Community Resource Center in Buena Park. On this form, clients state their name, address, household size, gross annual income, and ethnicity/race.

Cumulative data from this form can be used to report the unduplicated number served during a specific time period and prove that at least 70% of persons served are low- and moderate-income and a minimum of 20% are Buena Park residents.
6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity's Objective, Outcome, Outcome Statement, Purpose, and indicators that will be used to measure, track and report performance. Refer to the instructions on Page 5 through Page 7 of the RFP.

A. Select one :
[x Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one :
8 Availability/Accessibility
€ Affordability
€ Sustainability
C. Using the following formula, provide the activity's Purpose:

Purpose = Output + Outcome Statement + Activity
The Community Resource Center in Buena Park will provide free, high-impact supportive programs for 8121ow- and moderate-income Buena Park residents for the purpose of creating a safe and suitable living environment.

Application Page 4
Organization Name: Friendly Center, Inc. Pi'ograrri N arne: Community Resource Center D. Identify the common, specific, and/or other indicators for the activity a. Common Indicators
a 1,625 unduplicated low- and moderate income individuals assisted, 812 (50%) of whom are Buena Park residents.
a Up to 66% of households served by the Community Resource Center have an annual household income that is less than 30% of Area Median Income. b. Specific Indicators
812 unduplicated Buena Park residents assisted with new access to Community Resource Center programs.
c. Other Indicators
Application Page 5

ACKNOWLEDGEMENT REGARDING

BIDDER SAM REGISTRATION
Pursuant to 2 CFR Section 5.1004 and the requirement or the u.s. Department of Housing and Urban Development (HUD), contractors procured directly by grantees, sub-grantees, and/or sub-recipients of HLID funds, including CDBG are required to have an active registration in the System of Award Management (SAM). This document shall be completed and submitted as part of the proposal.

L By submitting this proposal, the prospective sub-recipient certifies that it has an active registration is SAM that is not set to expire within the next 90 days.

6. It is further agreed that by submitting this proposal, the prospective sub-recipient will include Certification of Subcontractor Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion withoutmodification, in all lower-tier covered transactions and in all solicitations for lower-tier covered transactions.

Provide the following information as detailed in the prospective sub-recipient's SAM registration:

Entity Name: Friendly Center, Inc.

Address: 2200 W. Orangewood Ave., Ste 240
City: Orange State: CA Zip: 92868
Unique Entity ID (UEI): J7UWNTG1TW1
Active Exclusions (Select One): []Yes [XNO
Expiration Date: 07/25/2025
Attachment 3

CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

INELIGIBILITY AND VOLUNTARY EXCLUSION LOWER TIER COVERED TRANSACTIONS This certification is required by the regulations implementing Executive Orders 12549 and 12689, Debamient and Suspension, and 2 CFR Part 200, Participants' responsibilities. (BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS BELOIF) (l) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principles are presently debai'red, suspended, proposed for debarment, declared ineligible, or votuntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier participant is rinable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

OrganizationName: Fr!endl)/ Center, Inc
Address: 2200 W. Orangewood Ave, Ste 240, Orange, CA 92868 Name and Title of Authorized Representative Signature 1 211 4/2024
Date

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.

2. The certification in tl'iis clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that tlie prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, tlie department or agency witli wliich tliis transaction originated may pursue available remedies, including suspension and/or debarment.

3. The prospective lower tier participant sliall provide iinmediate written notice to tl'ie person to wliicli this proposal is submitted if at any time tlie prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "participant", "person", "primaiy covered transaction", "pi'incipal", "proposal", and "vohintarily excluded", as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Orders 12549 and 12689.

6. The prospective lower tier participant furtlier agrees by submitting tl'iis proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Vohmtary Exclusion-Lower Tier Covered Transactions", witliorit modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

7. A participant in a covered transaction may rely ripon a certification of a prospective participant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is eironeoris. A participant may decide the method and frequency by which it detemiines the eligibility of its principals. Each participant may check the System for Award Matiagement (SAM).

9. Except for transactions authorized under paragraph 5 of these instnictions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in tliis transaction, in addition to other remedies available to the Federal Goveniment, the department or agency with which tliis transaction originated may pursue available remedies, including suspension and/or debarment.

Attachment 4
City of Buena Park
Community Development Blog Grant (CDBG) Program
FY 2025-2026 CDBG GrantApplication (attachment)

FRIENDLY CENTER, INC

1. Describe the proposed activity, including services to be provided and goals to be accomplished.
@ Why is there a need for this activity in the City of Buena Park? * Identify the location of the activity and the service area boundaries. * Describe specifically the intended use of the CDBG funds.

Friendly Center seeks to expand its food distribution program to address growing food insecurity in Buena Park. The program will provide added nutritious food to underserved families, particularly low-income residei'its and K-12 students dung and after class. Over 10.6% of children are living below poverty level in Buena Park. By addressing immediate hunger needs the program aims to support long-term stability, enabling families to focus on education, work, and self-sufficiency.

The program will be managed at the Buena Park Community Resource Center, utilizing Friendly Center's one-stop-shop model to deliver free, comprehensive support under two pillars: Food & Basic Needs and Education & Workforce Development. Services include large-scale food distributions, emergency basic needs assistance, and wrap-around programs to build resilience.

Need for This Activity in Buena Park:

Food insecurity is a critical issue in Buena Park, where many low-income families struggle to afford nutritious meals. Without proper nourishment, children's education and development are hindered, and adults face challenges in maintaining employment or progressing toward self- sufficiency. The growing demand for food, especially among families participating in Friendly Center programs, underscores the urgent need for expanded distribution efforts to stabilize households and improve community outcomes.

Location and Service Area Boundaries:

The activity will be conducted at Friendly Center's Buena Park Community Resorirce Center, which serves as a central hub for low-income residents of Buena Park and surrounding North Orange County communities.

Intended Use of CDBG Funds:

Duig the 2025-2026 CDBG program year, Friendly Center Estimates its Community Resource Center in Buena park will serve 1625 unduplicated Buena Park Residents providing them with accessible, wraparound requested $23,000 in Buena Park CDBG funding would support a portion of the cost to operate Friendly Center's Cornrnunity Resource Center in Buena Park, which is located at 6688 Beach Blvd and serves any resident seeking assistance.

The funds will help expand Friendly Center's bi-monthly food distribution efforts in Buena Park, specifically supporting the procurement of nutritious, culturally relevant food supplies, and salary of a part-time Food Distribution Coordinator. This role will oversee program logistics, coordinate food deliveries for underserved families, and ensure the students participating in educational programs also have access to meals duig and or after class. By addressing immediate hunger needs, and providing them with accessible, wraparound support this funding will lay the foundation for broader community stability, growth, and long-term self-sufficiency.

2. Describe the target population for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2025, through June 30, 2026. * How was the estimated number of clients determined? ii How wffl you reach your target population?
* Explain why this activity is needed for this target population.

Target Population and Estimated Clients Served:

The target population for the Buena Park Community Resource Center includes low-income families and individuals in Orange County, with a pary focus on Buena Park residents.

Services are open to all Orange County residents in need, regardless of age. From July 1, 2025, to June 30, 2026, we estimate serving 1625 unduplicated Buena Park residents, based on histoiical service data from our long-standing Community Resource Center in Orange and adjusted projections reflecting program growth.

How the Estimate Was Determined:

The estimated number of clients is derived from ongoing, detailed service data collected for grant reporting and program plaru'iing. With the implementation of new programs, such as our Emergency Rental Assistance Program funded by District 4, and strengthened connections with local schools, we anticipate an iiicrease iii the number of families seeking support at the Buena Park location.

Reaching the Target Population:

Friendly Center engages its target population through referrals from schools, 2-1-1, Orange Corinty Social Services, and partnerships witl'i nonprofit organizations. Word-of-morith and ongoing outreach by our Director of Programs and Site Coordinators also play a key role in connecting families to services.

Why This Activity is Needed:

Friendly Center addresses the complex needs of underserved families, offering not only irnrnediate stability but also pathways to self-sufficiency. As demand for resources like food, housing assistance, and educational support continues to grow, our programs are essential for reducing poverty, fosteig resilience, and building a more equitable community in Buena Park.

With expanded services, we aim to meet the increasing flow of families seeking support.

3. Describe in detail how the activity meets at least one of the three CDBG Program national objectives.

Select one:

X Benefit low- and moderate-income persons in Buena Park. [] Aid in the prevention or elimination of slums or blight in Buena Park.

Cl Meet a need having a particular urgency in Buena Park.

How the Activity Meets the CDBG National Objective:

Friendly Center's Community Resource Center in Buena Park directly meets the CDBG program national objective to "benefit low- and moderate-income persons in Buena Park" by offe*g targeted, free programs that address the critical needs of underserved households. These services are designed to alleviate barriers that disproportionately affect low- and moderate-income individuals and families, improving their qriality of life and fosteig long-term self-sufficiency.

The specific benefits provided include:

Alleviating Food Insecurity: Through bimonthly large-scale food distributions and emergency basic needs support, the Center ensures that families have access to essential nutrition, addressii'ig one of the most immediate barriers to stability.

How the Activity Meets the CDBG National Objective:

Friendly Center's Community Resource Center in Buena Park directly meets the CDBG program national objective to "benefit low- and moderate-income persons in Buena Park" by offeig targeted, free programs that address the critical needs of underserved households. These services are designed to alleviate barriers that disproportionately affect low- and moderate-income individuals and families, improving their quality of life and fostering long-term self-sufficiency.

The specific benefits provided include:

Alleviating Food Insecurity: Through bi-monthly large-scale food disttibutions and emergency basic needs support, the Center ensures that families have access to essential nutrition, addressing one of the most immediate barriers to stability.

Access to Healthcare: Programs offe*g mental health counseling and mobile medical and dental services ensure that low-income residents receive the care they need to maintain overall well-being.

Education and Workforce Development: Year-round after-school tutoig, financial literacy, parenting classes, and job development workshops empower individuals to overcome systemic barriers, increasing their oppoiinities for self-sufficiency and long- term success.

By providing these essential services, Friendly Center reduces economic disparities and improves outcomes for low- and moderate-income residents, aligning directly with the core goals of the CDBG program.

4. Budget
The Budget is Included in the PDF Documentation.

5. Eligibility Documentation
The Eligibility Documentation is included in the PDF Documentation

6. Outcome Performance Measurement System
The Outcome Performance Measurement System information is included in the PDF Documentation.

ACKNOWLEDGEMENT REGARDmG BIDDER SAM REGISTRATION
Entity Name: Friendly Center, Inc.

Address: 2200 W OrangewoodAve Ste 240
City: Orange State: CA Zip: 92868-1945
Unique Entity ID (UEI): J7UWNTG1TW14 Expiration Date: 07/25/2025 Active Exclusions (Select One): No
4 g'g*(7U V
THE FRIENDLY CENTER, INC.

Unique Entity ID
J7uWNTG1TWl4
Registration Status
Active Registration
Physical Address
2200 W. Orangewood Avenue
Suite 240
Orange, California 92868-2645
united States

CAGE / NCAGE
5QQS3
Expiration Date
Jul 25, 2025
Mailing Address
Pa Box 706
Orange, California 92856-6706
United States
Purpose of Registration
Federal Assistance Awards Only
@
:i
s!J-:J Thflo,r:ffl
m I ffi")'f\'!;m'Wphia-ai;is-il**aaaama---=--- ---"'-i-mW-""-=-""tJ" Doing Business as

FRIENDLY CENTER INC
Congressional District
California 46
Registration Dates
Activation Date
Jul 29, 2024
Entity Dates
Entity Start Date
Feb 28, 1967
Immediate Owner
CAGE
(blank)
Highest Level Owner
CAGE
(blank)
Executive Compensation
Division Name
The Friendly Center, Inc.

State / Country of Incorporation
California / United States
Submission Date
Jul 25, 2024
Fiscal Year End Close Date
Dec 31
Legal Business Name
(blank)
Legal Business Name
(blank)
Division Number
(blank)
URL
(blank)
Initial Registration Date
Oat 1, 2009
Registrants in the System for Award Management (SAM) respond to the Executive Compensation questions in accordance with Section 6202 of P.L. 110-252, amending the Federal Funding Accountability and Transparency Act (P.L. 109-282). This information is not displayed in SAM. It is sent to USAspending.gov for display in association with an eligible award. Maintaining an active registration in SAM demonstrates the registrant responded to the questions.

Proceedings Questions
Registrants in the System for Award Management (SAM.gov) respond to proceedings questions in accordance with FAR 52.209-7, FAR 52.209-9, or 2. C.F.R. 200 Appendix Xll. Their responses are displayed in the responsibility/qualification section of SAM.gov. Maintaining an active registration in SAM.gov demonstrates the registrant responded to the proceedings questions.

Active Exclusions Records?
No
I authorize my entity's non-sensitive information to be displayed in SAM public search results:

Yes
€-- i!!i-"""----" iiw+iwLiiiisIIZ-Y-'------o"'a:mW-"a""'.-Il Business Types
Entity Structure
Corporate Entity (T ax Exempt)
Profit Structure
Entity Type
Business or Organization
Organization Factors
(blank)
Check the registrant's Reps & Certs, if present, under FAR 52.212-3 or FAR 52.219-1 to determine if the entity is an SBA-certified HUBZone small business concern. Additional small business information may be found in the SBA's Dynamic Small Business Search if the entity completed the SBA supplemental pages during registration.

Electronic Business
Kenia Cueto
Pa Box 706
Orange, California 92867
united States
Steve Getman PO Box 706
Orange, California 92856
United States
Government Business
!,
Kenia Cueto, President/CEO
Pa Box 706
Orange, California 92867
United States
Th'av-icQj[6ia!..W
E-a'
-€na :"'aa" a ' - l4aa+aeaaaa**--*--"a ' mml "'--
NAICS Codes
Primary NAICS Codes NAICS Title
This entity does not appear in the disaster response registry.

City of Buena Park
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Subrecipient Name: Friendly Center, Inc.

Fiscal Year: FY 2025-2026 Project/Program Name: Community Program Beneficiary's Name:

Address:

City , CA Zip Code

1. Head of Household: Male Female 2. Homeless Yes No

3. Check only one. Elderly (62+)
(If Applicable) Disabled

4. First check your household size. Then read across and check the box on the same row that applies to your household’s gross annual income. (Gross annual income is income from all sources before taxes.)

Income Limits
Household
Size Category 1 Category 2 Category 3 Category 4
1 $33,150 or less $55,250 or less $88,400 or less $88,400 & above 2 $37,900 or less $63,100 or less $101,000 or less $101,000 & above 3 $42,650 or less $71,050 or less $113,650 or less $113,650 & above 4 $47,350 or less $78,900 or less $126,250 or less $126,250 & above 5 $51,150 or less $85,250 or less $136,350 or less $136,250 & above 6 $54,950 or less $91,550 or less $146,450 or less $146,450 & above 7 $58,750 or less $97,850 or less $156,550 or less $156,550 & above 8 $62,550 or less $104,150 or less $166,650 or less $166,650 & above

Note: Income Limits were effective April 1, 2024, and are subject to change.

5. Ethnicity and Race

Ethnicity (Check one.)

Hispanic or Latino Yes No

Race (Check one from below.)

RACE

Single Race Categories or Multiple Race Categories TOTAL
White
Black or
African
American
Asian
American
Indian or
Alaska
Native
Native
Hawaiian
or Other
Pacific
Islander
American
Indian or
Alaska
Native
and
White
Asian
and
White
Black or
African
American
and
White
American
Indian or
Alaska
Native
and
Black or
African
American
Other
Multiple
Race
Buena Park Resident
Non-Buena
ParkResident

According to Title 18, Section 1001 of the U.S. Code, it is a felony for any person to knowingly and willingly make false or fraudulent statements to any department of the United States Government. I, the undersigned, hereby certify that all statements contained herein, are true and correct to the best of my knowledge and belief. I understand the information I provide in this certification is subject to verification, and I agree to provide necessary documentation if requested to do so.

Project/Program Participant’s Signature Date

Subrecipient Agency's Approval Date

City of Buena Park
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Subrecipiente: Friendly Center, Inc.

Año Fiscal: FY 2025-2026 Proyecto: Community Program
Beneficiaries:

Dirección:

Ciudad: , CA
Código
Postal

1. Jefe de Familia: Masculino Femenino 2. Desamparado Yes No

3. Marque uno. Tercera Edad (62+)
(Si aplica) Deshabilitado

4. Primero verifique el número de personas en su hogar. Luego lea y marque la casilla en la misma fila que se aplica al ingreso anual bruto de su hogar. (El ingreso bruto anual es e l ingreso de todas las fuentes antes de impuestos.)

Límites de Ingresos
Número de
Personas Categoría 1 Categoría 2 Categoría 3 Categoría 4 1 $33,150 or less $55,250 or less $88,400 or less $88,400 & above 2 $37,900 or less $63,100 or less $101,000 or less $101,000 & above 3 $42,650 or less $71,050 or less $113,650 or less $113,650 & above 4 $47,350 or less $78,900 or less $126,250 or less $126,250 & above 5 $51,150 or less $85,250 or less $136,350 or less $136,250 & above 6 $54,950 or less $91,550 or less $146,450 or less $146,450 & above 7 $58,750 or less $97,850 or less $156,550 or less $156,550 & above 8 $62,550 or less $104,150 or less $166,650 or less $166,650 & above

Note: Los ingresos limites entraron en vigencia el 1 de abril de 2024 y están sujetos a cambios.

5. Etnicidad y Raza

Etnicidad (Marque uno.)

Hispano o Latino Si No

Raza (Marque uno por cada miembro de su familia.)

RAZA

Categoría de Raza Única o Categoría de Raza Múltiple
TOTAL
Blanco
Negro0
Afro-
americano
Asiático
Indio
Americano
o Nativo
de Alaska
Nativo
Hawaiano
o Isleño
del
Pacifico
Indio
Americano
o Nativo y
Blanco de
Alaska
Asiático
y
Blanco
Negro o
Afroamericano
y Blanco
Indio
Americano o
Nativo de
Alaska y
Negro o
Afroamericano
Otra
Raza
múltiple
Residente de
Buena Park

No Residente
de Buena Park

De acuerdo con el Titulo 18, Secci6n 1001 de los Estados Unidos C6digo, es un deli to grave para cualquier persona a sabiendas y voluntariamente hacer declaraciones falsas o fraudulentas a cualquier departamento del Gobierno de los Estados Unidos. Yo, el abajo firmante, certifico por la presente que todas las declaraciones contenidas en este documento son verdaderas y correctas a mi mejor conocimiento y creencia. Entiendo que la informaci6n que proporciono en esta certificaci6n está sujeta a verificaci6n, y acepto proporcionar la documentaci6n necesaria si así se solicita.

Firma del Solicitante Fecha

Aprobación de la Agencia Fecha

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date:

ESL ID:

Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID:

Entity Name:

1. The entity is in good standing with the Franchise Tax Board.

2. The entity is not in good standing with the Franchise Tax Board.

3. The entity is currently exempt from
tax under Revenue and Taxation Code (R&TC) Section 23701

4. We do not have current information about the entity.

5. The
entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

Connect With Us
Web:

THE FRIENDLY CENTER INC
✔
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Buena Park City CouncilMarch 11, 2025

Buena Park City Council
March 11, 2025