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. Tlie terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "participant", "person", "primary covered transaction", "principal", "proposal", and "vokmtarily 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 tliat, 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 paiticipation in this covered transaction, unless authorized by the department or agency with which this transaction originated.
6. Tlie prospective lower tier participant furtlier agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debamient, 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.
7. A paiticipant 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 otlier remedies available to the Federal Government, tlie deparhnent or agency with whicli this transaction originated may pursue available remedies, including suspension and/or debaiment.
Attachment 5
City of Buena Park
2026-2027 Community Development Block Grant (CDBG)
Funding Proposal Summary Sheet
Organization Name: Fair Housing Foundation
Program Name: Fair Housing Services
Estimated Goal: 145 Households
Funding Request: $16,000
Organization Purpose:
Fair Housing Foundation has successfully provided fair housing services to Buena Park residents for over ten (10) years. The program’s purpose is to monitor unlawful housing discrimination to protect tenants and landlords from potential State and Federal Civil Rights Law violations. Fair Housing Foundation also provides a variety of other services including landlord/tenant counseling, education, and outreach activities.
Description of Request:
CDBG funds will be used for staff salaries, facility rent, communications, travel, consultant fees, insurance costs, and office supplies.
Analysis of Request:
The project meets the national objective of benefiting low- and moderate- income individuals. Fair Housing Foundation documents client data through call sheets, and maintains a database containing client’s income and demographic information.
Fair Housing Foundation staff have the training and experience to assist Buena Park tenants and landlords regardless of race, gender, language, etc. They provide in-person workshops as well as online assistance to meet residents’ fair housing needs.
HUD requires each entitlement city to implement a Fair Housing Program; therefore, it is cost effective to fund Fair Housing Foundation to provide these services.
Funding Recommendation:
Staff recommends funding in the amount of $15,000.
City of Buena Park
FY 2026-2027 Community Development Block Grant (CDBG) Program Application Checklist
Please complete, sign, and include this ehecklist with your appffiicatiott Required For All Applicants:
IZI Completed FY 2026-2027 CDBG Grant Application
[1 Copy of current client intake form for proposed activity [] N/A (only if adivity is LMA)
[21 Signed Acknowledgement Regarding Bidder SAM Registration form (Attachment 4) [21 Signed Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions form (Attachment 5)
Required For Nonprofit/Outside Organizations.
[21 Proof of active nonprofit status (IRS determination letter) Z List of Board of Directors (board member names and tales) [21 Copy of current organizational chart
[21 Copy of current lease (if CDBG funding request involves rental expenses) [a Completed Zoning/Land Use Approval Form (Attachment 6), if located in the City of Buena Park Organization/City Department Name: Fair Housinq Foundation Submiffed By: Stella Vanporppal, Executive Director
(Print Name, Title) (Date)
Attachment 2
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 (July 1, 2026 - June 30, 2027)
CDBG FUNDING APPLICATION
Q!Ig,,,,aYDE(,EMQ,Eal8, 20-26AT 5:00 P,M
Organization/City Department Name Fair Housing Foundation Activity/Program Name Fair Housing Services
Address 3605 Long Beach Bvd. Ste 302, Long Beach, CA 90807 Contact Person/T itle Stella Vanporppal / Executive Director Email Address
[email protected]
Plione Number 562-989-1206
AcUvity Type (select one) € Public Service Activity [:l Other CDBG Eligible Activity Organization Type (select one)
[] City Department
' [2] Nonprofit 501(c) (3) organization
' € Other (i.e. pub!ic agency)
Amount of CDBG Funds Requested $16,000
1. Estimatedunduplicatedindividuals or iiouseholdsto be served by proposedactivity during FY 2026-2027 (including a// persons regardless of residence):
Estimated Goal: 5,870 (ZI Individuals € Households
2. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including ONLY Buena Park residents):
Estimated Goal: 145 [21Individuals € Households
/ certify under penalty of perjury tliat the information provided in this CDBG funding application is true to the best of my knowledge.
o7:l'-'flA (,/-;?/?-'
(Sigruthorizedrepresentative) "
12/17/25
Date
Stella Vanporppal, Executive Director
(Print name and title of authorized representative)
Orgamzation Name' Fa'Housl"gFounda"o" p,,,].aln Nairie.' FairHousingServices Please answer each of the following questions. If any questions are leff unanswered, your application will not be considered. You may attach additional sheets and/or supporting materials as needed.
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I [24 CFR 57AOc.2TOIOV(laT)Y, 5o7EO.s2cOR"l-15P7TO.'020N8, 570.503] Describe the proposed activity, including services to be provided and goals to be accomplished. a) Why is there a need for this activity in the City of Buena Park? b) Identify the location of the activity and the service area boundaries. i c) Describe specifica!!y the intended use of the CDBG funds.
The Fair Housing Foundation (FHF), a non-profit corporation, continuously providing fair housing services to multiple municipalities for 61 years. FHF is dedicated to eliminating discrimination in housing and promoting equal access to housing choices for everyone.
FHF's Fair Housing Program includes: 1 ) Fair Housing Discrimination Intake, Investigations, and Resolutions; 2) Education and Outreach Activities and Services; 3) Landlord and Tenant Counseling; and 4) Activities to Affirmatively Further Fair Housing.
All Education and Outreach Activities all conducted within the city limits and are promoted to ensure maximum participation including distribution 6,000 pieces of literature, 2 Fair Housing booths, 4 Fair Housing workshops, 2 community agency contacts, 8 community meetings, 3 community presentations, and social networking.
FHF utilizes CDBG funds to accomplish the objectives and goals of the Fair Housing Program including:
salaries, benefits, rent, communications, mileage, insurance, consultants, staff development, testing, general office supplies, printing, outreach expenses, and advertising. 2 I
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TARGET POPULATiON
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population/demographic for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2026 through June 30, 2027. a) How was the estimated number of clients determined?
b) How will you reach your target population?
c) Explain why this activity is needed for this target population.
FHF specifically targets, promotes, and addresses the needs of specific groups including:
1. Extremely low-and low-income households - 91 % of YTD clients
2. Those with physical, mental, and emotional disabilities - 1 9% of YTD clients
3. Non-English Speaking individuals - 16% of YTD clients
4. Female Headed Households - 45% of YTD Clients
5. Seniors - 20% of YTD Clients
FHF will not limit the number of clients served although the goal is to provide a minimum of 145 unduplicated clients with direct services and another 500 individuals assisted through the outreach activities. [)irect services include: 4) Fair Housing Discrimination Intake, Investigations, and Resolutions; 2) Education and Outreach Activities and Services; 3) Landlord and Tenant Counseling; and 4) Activities to Affirmatively Further Fair Housing.
The 2026/2027 goals were estimates based on the averages of FY2022-23 through FY2024-25.
Application Page 2
Orgaiiization Nai'iie: Fa'H"a'ng Fo"d"o' Program Naine' Fa"HouslngSeNlces 3 l
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.
Se!ect one then explain in the space below:
(ZI 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.
FHF's Fair Housing Program meets the u.s. Department of Housing and Urban Development (HUD requirement that CDBG recipients must Affirmatively Further Fair Housing. The following outlines this requirement:
a Title Vlll of the Civil Rights Act of 1968
a Section 808(e)(5) of the Fair Housing Act
a Section 1 04(b)(2) of the Housing and Community Development Act of 1974, as amended aSection 105(b%3)of the National Affordable Housing Action of 1990 FHF's Fair Housing Program meets the National Objective to benefit low and moderate-income persons, area wide, throughout the entire city limits. The program specifically provides for the provision of public and community services for very low and moderate-income persons and persons with special needs. The program provides services that benefit families and individuals by addressing general housing and fair housing issues in their living environment.
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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] Provide the total administrative and/or operational costs for the proposed activity. Cost Category may include: staff salaries and benefits, rent/lease, supplies, utilities, etc.
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Cost Category CDBG Funding
Request
Other Funding
Sources
Totai Cost
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Personnel & Fringe ,
$ 11,312 $ 409,081 $ 420,393
Rent I
$ 1,957 $ 70,757 $ 72,714
Communications $ 396 $ 14,319 $ 14,715
Mileage & Travel $ 275 $ 9,959 $ 10,234
Consultants $ 483 $ 17,465 $ 17,948
Insurance $ 508 $ 18,376 $ 18,884
Supplies $ 1,069 $ 38,662 $ 39,732
$ $ $
$ $ $
$ $ $
Total $ 16,000 $ 578,620 $ 594,620
Application Page 3
Organization Name: FairHouslngFoundaflon pl()BIBlp 11 FairHouslrig Services 5 I
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I ELIGIBILITYDOCUMENTATION
Describe the fom'i or documentation that is collected to demonstrate that at least 70% of persons Psearrvkerdesalrdeenlotws- andmoderate-income, asrequired byHUD, andaminimum of20%areBuena , All services provided within the Fair Housing Program are available to all residents, home-seekers, and housing providers in the City of Buena Park.
However, FHF does receive and verify income as required. For Landlord/Tenant direct client services, this information is required and maintained in our Case Management database, including household size, income amount, and income level. The annual HUD income standards are changed on the back end of the database every year. For every bonafide fair housing case opened, a narrative of the income information provided by the client is included in the Complaint Narrative. The Complaint Narrative is a declaration of the alleged discrimination as well as the income information provided. The client is required to review and sign the Compiaint Narrative as complete and accurate. If required, FHF will request and provide supporting documents.
The data provided to the City for FY 24-25 represents 98% of those provided with direct client services were extremely-low, very-low, and low-income household.
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- - "-6ijTCOMEPERFORMANCEM-EASUREMENTSYSiaEM
[24 CFR 570.200(a), 570.201-570.208, 570.503J
Please indicate the adiv:ty's and that will be used to measure and track the activity's performance. Refer to the definitions on Page 6 of the RFP.
A. Select one :
[2] Suitabie Living Environment
€ Decent Affordable Housing
[1] Economic Opporturiities
B. Select one Outcome:
€ Availability/Accessibility
€ Affordability
[21 Sustainability
Application Page A
ACKNOWLEDGEMENT REGARDING
BIDDER SAM REGISTRATION
Pursuant to 2 CFR Section 5.1004 and the requirement of the u.s. Department of Housing and Urban Deve!opment (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 Awartj Management (SAM). This docurrient 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.
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 ari 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 tin'ie the Participant learns that this certification was erroneous when submitted or has become erroneoi.is 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 Certificatioi'i or Subcontractor Regarding Debarment, Suspension, Ineligibility arid 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 bidder's SAM registration:
[(liiiy %Bl'yl(,; Fair HOuS!11g Foundai!on
Address: 3605 Long Beach Blvd. Ste 302
City: Long Beach
Unique Entity ID (UEI): UPWKXNY53BL5
ActiveExclusions (SelectOne):gYes [ZINO
State: CA Zil): 90807
Expiration Date: 2/26/26
Attachment 4
CERTIFICATION REGARDING DEBAffiNT, SUSPENSION,
TTSJELTGTBTT,{TY AND VOLUNT ARY EXCLUSTON LOWER TIER COVERED TRANSAC'nONS This ccrtificaticin is required by late regulations iniplemen(ing Exccritive Ordcrs 12549 and 12689, DebaimenC and Suspension, and 2 CFR Par( 200, Paiticipait(s' responsibilities. (BEFORE C()IIP IETING CER TIF1C4 T(OA': RE.4D INSTR UCTTONS BELOrV) (1) Tl'ie lirospective lower tier particiliant certifies, by subi'nissioi'i of' this proliosal, tliat neitliei- it noi' its principles are presently debarred, suspended, proposed for tlebarnient, declared ineligible, or vciluntarily exc]uded 7aromparticipation in t!iis trai'isactioi'i by any Fedei-al departn'ient oi- agency. (") Wliere tlie prospectrve lower tier paitictpant is unable to certify to any of the stateiuents in tliis certification, st:iclilirospective pailicipanl sliaJlaltacli iu'iexplanation to t)iis pi'oposa.l.
Organization Nanie: Fair Housinq Foundation
AddreSS: 3605 Long Beach Blvd. Ste 302, Long Beach, CA 908p7 Stella Vanporppal, Executive Director (4 / h/7>
NameandTtfleofAutliorizedRepresentative / Signature /"" 12/17/25
Date
t. By sigi'iing and sxibinittiiig tliis proposal, tlie pi'ospective iowei' tier participam is )iroviding the certificaion set out belowi.
2. The certification in tliis clause is a niaterial i'el'iresentation of firct upon wliidi reliance was placed wben his transaction WaS entered imo. Tf it is )aier determined t?iat tlie prospective lowei' ier participant ki'iowingly rendered an erroneous ceitification, in addition to otl'ier rennedies available to Lhe Federal Government, tlie department or agency witli wliic!'i tliis ti'ansaction originated inay pursue available reiuedies, including suspension and/or debarn'ient.
3. The prospective lower tier pai'ticipan( sliall proyide iii'u'iiediate written notice to the person to wliidi tliis proposal is subn'iitted if"a( any tiine the prospective iower tier participant learns lliat its certification was erroneous wliei'i submitted or lias beconie erroneous by reason of clianged circumst;inces.
4. Tlie terins "covered transaction", "debarred", =stispei'ided", "ineligible", 'iower tier covered transaction", "participant", "person", =primaiy covei'ed transactioir', "principal", "proposal", aim "voluntarily excluded", as used in tliis clau.sc, liaie the nieanings set out iii tlic Definitions antl Coverage sections of iules ioiplcmentiiig Executive Orders l 2549 and 12689.
5. Tlie prospective lower tier participant agreesby submitting tliis liroposal tbat, s)iould die proliosed covereil triinsaction be entered into, it shall not knowingly enter into any lower ier covered rransaciion with a person wlio is debari-ed,suspended,declared ineligible, or voluntarily excluded iaron'iliarticipalion ii'i tliis cosiered rransaction. unless authorized by tlie departi'iient or agency witli which iliis triuisaction originated. it. Tlie prospecttve toer tier participant tui'tliei' agrees by subinittii'ig tliis pi'oposal tliat it will include tlie clause titled "Cettification Regai'ding Debaiment, Suspension, Jneligibility and Voluntary Exdusion-Lower Tier Covered Transactions", witl'iout modif-icatioi'i, in all lower tier c.ovei'ed transactions and in all so)icilmions for iower tier covered Lrai'isactions.
7. A particiliant in a covered transacion may rely cipona certificatiori of a prosl:iective liarticiliant ii'i a lower tier covered transaction tliat is i'io( debarred, suspended, ii'ieligible, or voluntarily excluded from tlie covered trattsaction, unless it kllOl)VS that tl'ie certification is eiyoneous. A participant nia)i decide tlie iuethotl anci fi'equency by wliicli it deterinines t)ie eligibility of its princilials. Eacl'i par(iciliai'it inay check tlie Systein for Award Mai'iagement (SAM).
8. NoGiingcontaiiaiedintlietoregoingsl'itillbeco.i'istruedtorequireestablislunentoJaasystemol"recordsinorderto rei'idei' in good fiiitli the certificatioi'i required by this clause. Tlie knowledge ai'id ii'il'ormatioi'i ol'a pariicipai'it is not reqriired to exceed tlia wliicli is normally possessect by a prudent person in tlie ordinary course of business deali'%'-"asi
9. Except foi' transactions arillioi'ized under pai-iigrali)i 5 o-r these ii'istructions, ir a pai'iicipam ii'i a covei'ed transaction la'iowingly enters into a lower tier covered transaction witli a person uilio is suspended, debarred, ineligible, or vo!untarily excluded fron'i participation ii'i this ti'ansac(ioi'i, in additioi'i to ot1ier reinedies available to the Federal Governinent, t)ie deparLinent or agency uiith wliicli Cliis LransitcCion originated may pursue available remedies,including susliension and/or debai'n'ient.
Attachment 5
FHF Client Intake Form
Date: Time: A.M. P.M. Tnterviewer:
FirstName: LastName:
Gender: []Female OMale OUnknown [iContract City Name:
Race: 0Am Ind/ Alsk OAm Ind/Alsk & Black gem Ind/Alsk & White gAsian gAsian & White gBlk/ Afr Am OBlk/Arr Am & White []Pacific Islander gwhite 00ther Ethnicity: [1 Latino 0 Non Latino National Origin:
Home Phone: ( ) Alternate Phone: ( )
Language Spoken: [lArmenian [lCambodian []English [lIndonesian []Khmer [lMandarin [lRussian [lSpanish OVtetnamese € Other
Type ofVisit: OEmail 00fiice OTelephone 0Website 00ther Type of Caller: OHomebuyer OIn-place Tenant OLandlord/Manager []Management Company [21Realtor OProperty Owner € Rental Home-seeker € Other Referral: Ocity Hall € CBO € FH Council € FHF Activity 0Friend []Newsprint []Radio []Television gather
Council District: Source of Income: IncomeLevel: []High OMedium OLow OVeryLow Income Amnt: No. of people in household
StreetAddress: City: ZipCode:
Comments:
Female Head: € Yes € No Rent Control: € Yes € No Disabled: € Yes € No Senior Citizen: € Yes € No General Housing Issue
€ Eviction € c.n. Issue OHarassment []Tl1egal Entry OLate Fees 0Notices OParking []Pets ORef. to Rent ORef. to Sell
OSection s 0Sec. Deposit []Habitability OUtilities []Other:
General Housing Action
0Ref. to Attorney @Building and Safety OCode Enforcement OCorrespondence OCounty Assessor ODiscrimination Department OHous €ng Authority []Legal Atd []Mediation
€ Resolved € Rent Stabiltzation € Small Clatms Court
OHabitabilttyCoordinator 00ther:
Tnterviewer: Time Spent:
Discrimination
gLease Terms gLockout
€ Rent Control []Rent Increase
€ Consumer Affairs
OHealth Department
00tlier FH Group
€ U.D. Assistance
[]Age
€ Harassment
gRace
OAncestry
€ Marital Status
0Religion
€ Color
OMental Disabiltty
€ Sexual Orientation
gFamiHal Status
€ National Origin
€ Source of Income
€ Gender
OPhysical Dtsability
[]Arbitrary:
€ Resolved
Discrimination Action
00ther (Pending an action) @Case Opened: Case #
Interviewer: Tinie Spent:
oaP35xl t5 H '<o"i-5'
U. S. TREASURY DEPARTMENT
INTERNAI REVENUE SERVIC!:
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Lal ANatlJ!1, CALIFOflHIA 90013
D*aember 15, 1965
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INR@Lfifflfl5t'm
Fxm L-178
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7 On the basis of your.stat*d purposes and the understanding that yout operatiana will mntinua as evide+need to date or wlll oonform to those proposed in your minq appliaitlon, m have ooncluded that you m *xsmpthom Federal income tax as an arganizatlon desaibed ln s*euon 501(cX3) ed the Int*tnaI Revenue Cods. Any cmng*a to opemtion from those discrlbed, or ln your ahamekm or purposes, must be reported immediately to your Dmtrict Director for eonsidemtion of their effect upon your exempt atatuas You must also raport any ehange ln your name at addmig.
You are not requimd to file Fedeml lnoome tax returns go long as you retain an exempt status, un- less you are subjeat to the tax on umelatedbuslness income imposed by seliori 511 of the Code, in which everit you are requked to file Form 990-T. Our determinatiein as to %routaliabillty for fffing tm anriuaJ information return, Form 990-A, is set forth above. That return, if required, must be flled on or before the 15th day of the fifth month after the close ot your annual accounting period indicated above.
PO
ConttibuUons made to you are deductible by donors.as provided in section 170 of the Code. Be- quests, le@oaten, devises, transfers or gifts to or for your use are deductible foxFederaJ estate and gift tax putponea under the provialons of section 2055, 2106 and 2522 of the Code.
You are not liabm fm the taxes imposed under ihe Fedetal Insurand Contributioris Act (social snoetc'ljalklXe'afXoresth) :'tlaxe'sjmyposou efldl'unad'er ltvh@erFdedeeXreaml pUknioenmpcleorym'lecnatkeTaa: X":ot."diendqu1niriaeuscahbaoeukt tWowuaalrvee r " of *xemptioh attttlcate for social security tmes should be addressed to tm offlce, as should any - questions concerning *xdse, employment or other Federal taxes.
This is a determinatlon letter.
,,,'ja.<(at i';
Very truly yours,
Fl. A. ffiddell
Distrid Director
* I!li li I J ?JI Ia * *l
Departmentofthe Treiasury
Internal Revenue Servioa
Ogden LIT 84409
In reply refer to: 2916808252
Oct. 31, 2000 LTR 252C
95-6122678 000000 00 000
00657
FAIR HOUSING FOUNDATION
200 PINE AVE STE 240
LONG BEACH CA 90802-3037008
Taxpayar Identification Numbers 95-6122678
Dear Taxpayers
Thank you for' the inquiry dated Sap. 06i 2000.
de have changed the name on your account as requested. The number shown above is valid for use on all tax documents.
If you have any questions* please call us toil free at 1-8tlO-829-1040 If you preferi you may write to us at the address shown at the top of the first pagai of this latter'
C'I')Wheneveryou write, please include this letter and, in the spaces belowy give us your' telephone number with the hours we can reach you AISI you may vant to keep a copy of this letter for your records Telspbone Nuniber (
Thank you for yaur cooperation.
Hours
Sincerely yoursi
Chief, Research & Perfectio.n Branch
Internal Revenue Service Department of the Treasury
Date: December 20, 2000
Fair Housing Foundation
200 Pine Ave Ste 240
Long Beach, CA 90802-3037
P. 0. Box 2508
Cincinnati, OH 45201
Person to Contact:
Michael Dutcher 3'l -0742'1
Customer Service Specialist
Toll Free Telephone Number:
8:00 a.m. to 9:30 p.m. EST
877-829-5500
Fax Number,
513-263-3756
Dear Sir or Madam:
Enclosedis the informationyou requestedin your letter4atedOctober20, 2000.
Please accept our apology for the delay in responding to your request and for any inconvenience this may have caused you or your organization.
C'I".)
Sincerely,
Michael Dutcher 31-0742'l
Customer Service Specia(ist
Enclosure: Letter affirming exempt status, name change and Amended Articles of Incorporation I'
Interr)al Revenue Service Department of the Treasury
P. 0. Box 2508
Cincinnati, OH 45201
Date: December 20, 2000
Fair Housing Foundation
200 Pine Ave Ste 240
Long Beach, CA 90802-3037
Person to Contact:
Michael Dutcher 31-07421
Customer Service Speciaiist
Toll Free Telephone Number:
8:00 a.m. to 9:30 p.m. E8T
877-829-5500
Fax Number:
513-263-3756
Federal Identification Number:
gs-e'izzeze
Dear Sir or Madam:
This is in response to the amendment to your organization's Articles of Incorporation fixedwith the state on June 22, 2000. We have updated our records to reflect those changes and revised your name as indicated above.
Our records indicate that a determination letter issued in December 1965 granted your organization exemption from federal income tax under section 501(c)(3) of the Internal Revenue Code. That letter is stitl in effect.
)Based on information subsequently submitted, we classified your organizationas one that is not a private foundation within the meaning of section 509(a) of the Code because it is an organizataton described in section 509(a)(2)
This classification was based on the assumption that your organization's operationswould continue as stated in the application. If your organization's sources of support, or its character, methodof operations, or purposes have changed, please let us know so we can consider the effect of the change on the exempt status and foundation status of your organization
Your organization is required to file Form 990, Return of Organization Exempt from Income Tax, only if its grOSS receipts eaCh \ear are normaiiY more than $25,000. If a return iS required, it inuStbe fited by the i5th day of the fifth month after the end of the organization's annual accounting period. The law imposes a penalty of $20 a day, up to a maximum of $10,000, when a return is filed late, unless there is reasonable cause for the delay.
All exempt organizations (unless specifically excluded) are liable for taxes under the Federal Insurance Contributions Act (social security taxes) on remuneration of $100 or more paid to each employee during a calendar year. Your organization is not liable for the tax imposed under the Federal Unemployment Tax Act (FUT A).
Organizations that are not private foundations are not subject to the excise taxes under Chapter 42 of the Code. However, these organizations are not automatically exempt from other federal excise taxes. )'Donors may deduct contributions to your organization as provided in section 170 of the Code. Bequests, legacies, devises, transfers, or gifts to your organization or for its use are deductiblefor federal estate and giffl tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. -2-
Fair Housing Foundation
95-6122678
Your organization is not required to fiie federal income tax returns unless it is subject to the tax on unrelated business income under section 5"?1 of the Code. If your organization is subject to this tax, it must file an income tax return on the Form 990-T, Exempt Organization Business Income Tax Return. In this letter, we are not determining whether any of your organization's present or proposed activities are unrelated trade or business as defined in section 5'l3 of the Code.
The law requires you to make your organization's annual return available for public inspection without 6harge for three years after the due date of the return. If your organization had a copy of its application for recognition of exemption on July 15, 1987, it is also required to make available for public inspection a copy of the exemption application, any supporting documents and the exemption letter to any individual who requests such documents in person or in writing. You can charge only a reasonable fee for reproduction and actual postage costs for the copied materials. The law does not require you to provide copies of public inspection documents that are wide)y available, such as by posting them on the Internet (World Wide Web). You may be liable for a penalty of $20 a day for each day you do not make these documents available for public -')nspection (up to a maximum of $10,000 in the case of an annual retum).
Because this letter could help resolve any questions about your organization's exempt status and foundation status, you should keep it with the organization's permanent records.
If you have any questions, please call us at the telephone number shown in the heading of this letterThis letter affirms your organization's exempt status.
Sincerely,
John E. Ricketts, Director, TE/GE
Customer Account Services
STATE OF CALIFOFINIA
F-FtANCHlSE T AX BOAFID
.'=')ACMM.ENTO, CALIFORN1.A.95867
aApzll -16i 1983 -
Fair Housing 7oiindation Of :[iong Baaah
($/O Robyn Polinaz " .
2023 Paoifio Avenua .
Long Baaaha eA 90806
Puzposa # CMtitabla
Form of Otganization s eozpozation
Aoooun+ing %ziod Endingt June 30
I
On the basis o:E the in:E6tiation submltted and pzovldad your pzesent op*tati.ons aontinue unahangsd ox ooxi:Eozm to those pzoyosad .tn youz appliaationi you aza exempt :Etom sa'!:ata ftanahite ox inooma tag undsz Saotion 23701di Revenue and '!axatiiin Code. Any ohang* in opaza4,ion, ohazaot*t ox puzpoge o:E the ozganiiiation must be tepoz+,ad immediately to +,his .of::Eiae go that We may data:tmine tM e:E:Eeo+, On 7011! ixaiipt status. Any ahanga o! name 03: aadr*ss also xaust ba z*poz-tad.
You axe zaqui:ced +,* file Fozm 199 (Exempt Ozganizakion Annual . -:tn:Eozmation Retutn) ox Fozm 199B (Exempt Ozganization Annual o-..)nfozmation Statement) on o:c bsjoze the 15th day o:E the Sth month (Q 1/2 months) a-jit*x tM close of yout aooounting pa:tiod. See annual instziio4ions with io;cms :Eoz raqtiiz*msn+,s.
You eU:e not z*quiz*d to -jila state ftanohisi ox income tax zatuzns unlai'sg you have inoome subject +,o the unzala+.sd business inooma.tax und*z Seotion 23731 o:! the Code. In +,hls eventi you axe taquixad to :Eil* Iota 109 (Kxamyt Otganization Businass Inoomi '!ax Re+:utn) by tha 15th day of the S4:h ion+,h,(Q jt2 months) a:Etaz the alosa of youz a annual aooounting pez:iod.
I:E agate ozganizati6n is ;tnooxpox.a+:ingy +,his appzoval vill axpiza unless ineozpozatton isi oompI*tad u.i4h *ha Sectetaty, of State within 60 days.
Kxamp € ion from :E*dO!01 illaOm* or Oth4u: taX*S and OtMt 8tata +,&X*a taquizag sapazata applications,
Thilax*mpaLlon affea+:iva as Of Daaemb*z 3oa 1964.
eentza.t Audit S*o*ion
S?Affl OF CAtlffilNIA
FRANCHISE TAX BOARD
1023 P STREET
!AC!IJJAENTO, CALIFORNIA ?$814
December 28, 1964
Fair Houain@ Foundation of Long Beach
903 Securf.ty Buildf.ng
110 Pine Avenue
Long Beach 2, California
Re: Exemption from franchise tax
Gentlemen;
It Es the opinlon of 'this offrce, based upon the eviderice presented, that you are exempt from State franchise tax under the provisions of Section 23701f of the Revenue and Taxation Code.
According1y, you wil1 not be required to file franchise tax returns unless you change the character of your organization, the purposes for which you were organized, or your method of operation. You are required to report any such changes immediately to this oFftce in order that their effect upon your exempt status may be determir'ied.
If in any year your gross'incor'e exceeds 925,000, you are required to f?le an information return on rorm T99 on or before the 15th day of the,5th month following the close of your ftscal year. These forms wi11 be mai fed to you i f you provide us with your current postal address.
if the or9anization 75 riot yet ?ncorporated or has not yet qualified to ao busTness in California, thTs approval wiH expire unless incorporation or qualification is comp1eced within thirty days,
James T. Philbfn
Associate Tax Courisel
JTP: ef
cc: Secretary of State
(f)
FTB 4216 00-6!+)
Fair Housing Foundation
Board Roster
2025-2027
Executive Director
Stena Verdeja, ex-officio
Officers
Connie Haynes, Chair
Richard Hernandez, Vice-Chair
Julia Moore, Secretary
Ken Hasting, Treasurer
Members
Julien Willard
Beatriz Wade
Fair Housing Foundation OrganziationaJ Chart
Stacy Viramontes I
Lashawna Hughesi
{i I
] Elizabeth Calderon j
FY 25-26
Docusign Envelope ID. 3BA42B73-379F-40BD-9856-73B528571F4C
FIFTH AMENDMENT TO LEASE
THIS FIFTH AMENDMENT TO LEASE, dated December 10, 2024
is attached to and becomes pai't of the Lease dated August 27, 2004, by and between 3605 Long Beach Blvd, LLC ("Lessor")
and
Fair Housing Foundation ("Lessee")
for the Premises located at 3605 Long Beacli Blvd, Suite 302, Long Beacli Ca QO807, consistiiig of approximately 1,461 i'entable sq'iiare feet.
Tt is mutually agreect by aiid between Lessor & Lessee that:
1. Lease Term - P:iragrapli 1.3, tbe lease temi shall be for sixty (60') months cffcctive January 1, 2025 ai'id cxpiring December 31, 2029.
2. Base .Monthly Rent - Paragrapli 1.5, notwithstanding anytl'iing to thc contrary containcd l'ierein, the montlily basc rent shall be as follows:
January i, 2025 tlu'ougl'i Decei'iiber 31, 2025 shail be S2,995.00 per montli.
January 1, 2026 througli December 31, 2026 shall be S3,085.00 per montl'i.
January1, 2027 tlxoug]i Decembcr 3], 2027 shall be S3,178.00 licr montli.
Jaiiuary 1, 2028 througli Decciriber 31, 2028 sliall be S3,273.00lier rriontl'i.
Jatiuary 1, 2029 tl'irougli Dcccmber 31, 2029 shall be S3,371.00 per montli.
3. Security Deposit - Lessor acknovvledges security deposit on }ia.nd of $3,300.00. T}ie security deposit shall be increascd to $3,371.00. Lessee sball dcposit an additional $71.00.
4. Tenant Improvexnents - Lcssor, at LeSSol-'s sole cost axid cxpcnse, shall provide the following in'iprovements to (he premiscs.
* Tnstallation of IICW ca+yet throughorit Suitc. Caipct coloi-, design aiyd installation shall be of buiidiixg standard quality.
* Provide new paint on tlie walls tlirougl'iout the Suite. Lessce has a choice of l paint color.
Painting and application sliall be of builcting standard qriality arid design. Lessec will be required to move all items at leastthree (3) feet away from wall piior to liainting.
Otliei' tlian tbc aforementioned improven'ients, Lessor slial] not be obligated to consti-uct or install any improvements or facilities of any kind in tbe Premises aiid Lcssce accepts the Premises in it's prescnt, AS-IS condition. Lessee shall be solely responsible for t)ie installation, rekeying, and/or maintenance of any interior door 10CkS and dcadbolts, witli Lessor's prior approval. Lcssec sball be solely responsible for the repair and maintenance of aity non-standard fixtures, materials ai'id finishes inclidiiig, but not liinited to, interior 'uindows, interior window coverings and tloorii'ig. Upoxi ineve- -osout,Lessee sliall return all suite aiid restroom keys to Lessor.
Ea'
Docusign Envelope ID' 3BA42B73-379F-40BD-9856-73B528671F4C
5. Right of Entry - A request for repairs, written or verbal, subinittcd by Lessee will be considered pcrniission for management or their agents to eyiter the premises during noimal business hours to make the requested repairs, at a time convenient to the managcment with no fiuther communication required.
Any emergency gives Lcssor thc riglit-of-entry.
6. Parking: For Sccririty pirposes, no ovemight parking is pcimitted without prior wi'itten authorization from tl'ie Lessor. Ifprior written autliorization is given, parking overniglit sl'iall be at tlie Lessee Veliicle Owners risk. Lessce shall not park veliicles in other Tenant's reserved parkii'ig stalls. Lessee sl'iall xiot store vc?iicles in any part of the parking lot. Any violation of the parking niles may result in iti t}'ie Lessee's vehicle being towed at the ve}iicle Owner's sole expcrise. Parkitig spaces shall be reduced from 6 parking spaces to 3 assigned parkiiig spaces, 1 single space and l tandcm space.
7. CASp - Pursucuit to California Civil Code Section 1 ')38, the Propeity and Premises have not undergone an inspection by a CASp.
8. Further Modifications: Except as set foitl'i in ttiis Fourth Airiendmcnt, all of the terms ai'id provisions of the Lease shall apply to tlxe Premises and shall remain unn'iodif-icd and in full force and effect.
Effective as of the date hereof, all references to the "Leasc" shall refer to tlic Lease as amended by tl'iis Tliird Anicndment.
EXCEPT AS OTHERWISE AGREED TO HERETN, ALL TERMS AND CONDITIONS OF SATD LEASE SHALL BE IN FULL FORCE AND EFFECT.
LESSOR:
3605 Long Beach Blvd, LLC
LESSBE:
Fair Housing Foundation
BY: I n I A
2DC9B84Agi2F 4EID
Donald Lam, Maiiaging Member
BY: [II5bUa47A.lAs'g""byoy#34F
Stella Verdeja, Executive Director
1/31/2025
Dated: Dated:
12 /'10/202 4
ItNtial
LESSOR LNITIAI,S TESSEE. INITIALS
AlRCRa.
STANDARD MULTI-TENANT OFFICE LEASE-GROSS
Basle Provlslons ("Basic Provisions"
1.1 Parties. This Lease("Lease"), datedforreference purposesonly March 19, 2021 ,lsmade byand between Cirsea o.c.,Inc. a California z ("Lessor")and Fair Housinz Focindation a NOD Profit Corporation l"Lessee"),[collectivelythe"Parties",orindividuaHya"Part
1.2(a) Premises: That certain Portion ofthe Project (as defined below), commonly known aS (street address, suite, city, state): 1855 w. Katella Ave.
Suie 355, Oranze. CA 92867 ("Premises"). The Premises are located in the County of andconsistofapproximateiy ,1685 rentablesquarefeetand approximatelyj)13 useablesquarefeet. In additiontoLessee'srightsto useandoccupy the Premises aS hereinatter specified, Lessee Shall haVe non-exclusive riglltS tO the Common Areas (aS defined in Paragraph 2.7 belOW) aS herelnaffer specified, but shall not have any rights to tlie roof, the exterior walls, the area above the dropped ceilings, or the utillty raceways of the building containing the Premises ("Building" or to any other buildings In the Project. The Premises, the Building, the Common Areas, the land upon which they are located, along with all other buildings and imprOVementS thereon, are herein collectively referred tO aS the "Protect" The PrOjeCt COnSIStSOf BpprOXimately rentable Square ftet. (See alSO Paragraph2) i.2(b) Parking: 2 unreserved and Q reserved velilcle parklrigspacesatamonthly costof 7 perunreservedspaceand . per reserved space. (See Paragraph 2.6)
1.4 Early Possession: lfthe Premises are available Lessee may have non-exclusive possession ofthe Premises commencinp, April 20, 2021 INITIALS {NIT}ALS
@ 2019 AIR CRE. All Rights Reserved.
OFG-21.20, Revised 01-On-2019
LastEdited:3/18/2021 12:47 PM
Page I of 18
staridards pursuant to California Civil Code §55.51 et seq. Lessee acknowledges that it received a copy of the Inspection report at least 48 hours prior to executing this Lease and agrees to keep such report confidential.
l-.= have undergone an inspection by a Certified Access Specialist (CASp) and It was determined that the Premises did not meet all applicable construction-related accessibility standards pursuant to California Civil Code §55.51 et seq. Lessee acknowledges that it received a copy of the inspection report atleast 48 hours prior to execut'n@ this Lease and agrees to keep such report confident'al except as necessary to complete repairs and correctionsof violations of constructionrelated accessibility standards.
In the event that the Premises have been issued an inspection report by a CASp the Lessorshall provide a copy of the disability access Inspection certificate to Lessee within 7 days of the execution of this Lease.
(b) Since compliance with the Americans with Dlsabllltfes Act (ADA) and other state and local accessibility statutes are dependent upon Lessee's speclfic use of the Premises, Lessor makes no warranty or representation as to whether or not the Premises comply with ADA or any similarlegislation. In the event that Lessee's use of the Premises requires modifications or additions to the Premises in order to be In compliance with ADA or other accessibility statutes, Lessee agrees to make any such necessary modifications and/or additions at Lessee's expense.
LESSOR AND IESSEE HAVE CAREFULLY READ AND REVIEWED THIS LEASE AND EACH TERM AND PROVISION CONTAiNED HEREIN, AND BY THE EXECUTION OF THIS IEASESHOW THEIR INFORMED AND VOLUNTARY CONSENT THERETO. THE PARTIES HEREBY AGREETHAT, ATTHE TIMETHIS LEASE IS EXECUTED, THETERMS OF THISLEASEARECC)MMERClALLYREASONABlEANDEFFECTUATETHEINTENT ANDPURPOSEOFLESSORANDLESSEEWITHRESPECTTOTHEPREMISES.
ATTENTION: NO REPRESENTATION OR RECOMMENDATION IS MADE BY AIR CRE OR BY ANY BROKER AS TO THE LEGAL SUFFICIENCY, LEGAL EFFECT, OR TAX CONSEQUENCES OF THIS LEASE OR THE TRANSACTION TO WHICH IT RELATES. THE PARTIES ARE URGED TO:
1. SEEKADVICEOFCOuNSELASTOTHELEGALANDTAXCONSEQuENCESOFTHISLEASE.
2. RETAIN APPROPRIATE CONSULTANTS TO REVIEW AND INVESTIGATE THE COND}TION OF THE PREMISES. SAID INVESTIGATION SHOULD INCLUDE BUT NOT BE LIMITED TO: THE POSSIBLE PRESENCEOF HAZARDOUS SUBSTANCES,THE ZONING AND SIZE OFTHE PREMISES, THE STRUCTURAL INTEGRITY, THE CONDITION OF
THE ROOF AND OPERATING SYSTEMS, COMPLIANCE WITH THE AMERICANS WITH DISABIIITIES ACT AND THE SUITABILITI OF THE PREMISES FOR LESSEE'S INTENDED USE.
WARNING: IFTHEPREMISESARELOCATEDINASTATEOTHERTHANCALIFORNIA,CERTAINPROVISIONSOFTHELEASEMAYNEEDTOBEREVISEDTOCOMPLYWITH THE IAWS OF THE STATE IN WHICH THE PREMISES ARE LOCATED.
The parties hereto have executed this Lease at the place and on the dates specified above their resptttiw '7/ )'f{' /
On:
By LESSOR:
NamePrinted: StepFlei'l Fefl'ari
Title: Presiderxt
Phone: 805-612-3510
Email: steveferrari(a)outlook.com
Name pri(H/"'Stella Verdeja
Title: Executjve Dfrecor
Phone: 562-989-1206 eXt 1100
Fax:
Em.,iih .sverdeja@fMcaorg
Name Printed:
Title:
Phone:
tmalli
Address: 2045 Magpte Ct
Newbhiry Park, CA 9Ii320
Federal 10 No.:
By:
Name Printed:
Title:
Phone:
Email:
Address: 3605 LOng BeaCh Blvd., Suite 302
Long Beach, CA 90807
Federal 10 No.:
BROKER
Lee & Associates - Orange, Inc
iNlTIAlS
(C 2019 AIR CRE. All Rights Reserved.
OFG-21.20, Revised 01-01-2019
BROKER
INITIALS
Last Edited: 3/18/2021 12:47 PM
AIRCRG!
ADDENDUM
Date: March 19, 2021
By and Between
Lessor: Cirsea o.c., Inc. a California qqrporation
lessee: Fair Housipz Fgundation a Non Profit Corporation Property Address: 1855 W. Katella Ave., Suite 355, Orange, CA 92867 (street address,city, state, zip)
Para((raph:
1. Base Rent Scliedule on a Full service gross basis.
May 1, 2021 tlirough April 30, 2022 $2,400.00 per montii Mayi,:=o:=:tlirougl'iApril3o,zo:3 $:z,55o,oopern"ionth
IVIay1, 2023 tliroughApril 30, 2024 $x,6,ro.oo permontli IVIayi,:zoz4througliApril3o,xox5 $x,8oo.oopermonth
Mayi,:-ox5tliroughApril3o,:-oz6 $p,g5o.oopermonth
2. : Lessor, at Lessor's sole cost and expense, sl'iall provitle Lessee witli standard suite entry signage and directory board signage
3. Tenant Improsieinents: Landlord, at Landlord's sole cost and expense,shall perform tlie folloisring minor tenaxit improvet'i'ients.
a) Repair all dan'iaged, missing or stained ceiling tiles, ceiling T-)yar, stained ceiling vents, liglits, ceiling grid, blincls, electrical/clata cosiersand perform a general office clean-up. b) Install new lyuilding carpet, color to be cl'iosen by Lessee and approved by Landlortl. c) Repaint entire suite, color to be cliosen !yy Lessee and approved by Landlord. d) Replace conference rooin wixidow xvith a door to matcli existing door. e) Add a Dutch split tloor from reception to back offices. t) Clean tile flooring in reception area.
4-aaaSo long as Lessee is not in default, beyoncl any period for cure, allCl subject to tlie rules and regulations attaclied l'iereto, cmd asestablisl'ied 1)V Lessor fron'i tiine to tin'ie, Lesseesliall be entitled to use seven (7) parking spaces in tl'ie office-builcling pro,ject. Seven (7) parking spaces are non-exchisive and on a first-come, first-servetl basis. Parking passes will be issued to Lessee ciccordingly. I'f any additiona) parking spaces are required, I,essor reserves tl'ie right to charge a n'ionthly feefor eact'icar, at a connnencemei'it datc of $22 per n'ionth per car, sucl'i to be directed to a designated parking area. By mentioning Lotlie Ixirking attendant, Lessee,its en'iployees and visitors are exempt fron'i paying for parking during such times as tl"ie parking concessionaire cliarges for parking.
INITIALS NITIALS
(c 2017 AIR CRE. All Rights Reserved. Last Edited: 3/18/2021 12:47 PM ADD-1.02, Revised 01-01-2019 Page1 of 2
City of Buena Park
2026-2027 Community Development Block Grant (CDBG)
Funding Proposal Summary Sheet
Organization Name: City of Buena Park Community & Economic Development Department
Program Name: Residential Rehabilitation Program Administration/Senior Outreach and Loans
Estimated Goal: 10 Households/2,000 Seniors
Funding Request: $255,955 – Program Administration (includes the amount requested by the Senior Outreach Program)
$260,000 – Residential Rehabilitation Loans
Organization Purpose:
The 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. The proposal includes program administration, senior outreach, and funding 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.
Description of Request:
CDBG funds will be used for Program administration and deferred loans. Program administration includes staff salaries and benefits, contractual services fees, operation costs, and supplies.
Funds 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.
Analysis of Request:
The 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 improvements 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:
Staff recommends funding in the amount of $255,955 for Program Administration/Senior Outreach and $260,000 for Residential Rehabilitation Loans.
City of Buena Park
FY 2026-2027 Community Development Block Grant (CDBG) Program Application Checklist
Please complete, sign, and include this checklist with your application Required For All Applicants:
[2] Completed FY 2026-2027 CDBG Grant Application
[ZI Copy of current client intake form for proposed activity € N/A (only if activity is LMA)
[21 Signed Acknowledgement Regarding Bidder SAM Registration form (Attachment 4) [2] Signed Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions form (Attachment 5)
Required For Nonprofit/Outside Orqanizations:
€ Proof of active nonprofit status (IRS determination letter) 0 List of Board of Directors (board member names and titles) € Copy of current organizational chart
€ Copy of current lease (if CDBG funding request involves rental expenses) € Completed Zoning/Land Use Approval Form (Attachment 6), if located in the City of Buena Park Organization/City Department Name: Community & Economic Development Department Submitted By: Sarabeth Suarez, Housing & CDBG Analyst
(Print Name, Title) (Sign)
I i>[nl,;-r
(Date)
RECEIVED
DE(, 17 2025
ECONOMICDEVaOPMENT
Attachment 2
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 (July 1, 2026 - June 30, 2027)
CDBG FUNDING APPLICATION
DUE BY DECEMBER 18, 2025 AT 5:00 PM
Organization/City Department Name Community & Economic Development Department Activity/Program Name Residential Rehabilitation Program Administration/Senior Outreach and Loans Address 6650 Beach Blvd., Buena Park. CA 90621
Contact Person/Title Sarabeth Suarez
Email Address [email protected]
Phone Number (714) 562-3591
Activity Type (select one) € Public Service Activity [2] Other CDBG Eligible Activity Organization Type (select one)
[ZI City Department
€ Nonprofit 501 (c) (3) organization
€ Other (i.e. public agency)
Amount of CDBG Funds Requested $515,955
1. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including all persons regardless of residence):
Estimated Goal: 10 € Individuals [21 Households
2. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including ONLY Buena Park residents):
Estimated Goal: 10 € Individuals [21 Households
Icertify under penalty of perjury that the information provided in this CDBG funding application is true to the best of my knowledge.
(Signature of authorized representative)
')vJsq/If
Date
Matt Foulkes, Community & Economic Development Director (Print name and title of authorized representative)
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 after 30 years or upon transfer of title, sale, or cash-out refinance of the property.
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. In order to qualify for this loan, households must have a total gross annual income that does not exceed eighty percent (80%) of the Orange County Area Median Income (AMI). Attached are the current income limits (Attachment A), which are updated by The Department of Housing and Urban Development (HUD) on an annual basis.
Senior residents (Age 55 and over) may also be eligible 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. In order to qualify, they must be referred to the program by Code Enforcement due to one or more outstanding code violations. Additionally, their annual gross income must not exceed fifty percent (50%) of the AMI.
The funds being requested will be used to provide 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 wait-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.
These programs are essential to the City of Buena Park because they make home improvement safe and affordable for low-income residents. The City facilitates the loan and construction process at every step so the homeowner can rest assured that their project will be completed to their satisfaction and HUD standards. The program not only helps low-income families in need but beautifies the city one project at a time.
The program goal is to assist ten (10) eligible low-income households in need of residential rehabilitation with deferred or forgivable loans. Program staff determined this goal by considering the average number of families the City has assisted in previous program years and the estimated funding available for Fiscal Year 2026-2027.
The target population for this program are low-income owner-occupied households in Buena Park. In order to reach this target population, staff will continue to assess applicants that are on the program wait-list; advertise the program on the City website, social media accounts, and City events; collaborate with Code Enforcement to refer seniors to the program when they have outstanding code violations; and display program lawn signs on completed projects to advertise to the surrounding neighborhoods.
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 as well as the value of their surrounding neighborhoods. The loans are affordable compared to traditional loans due to the 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.
Community & Economic Development Department
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. Applicants that are over the income limit are denied assistance but may reapply if their financial situation changes in the future.
Residential Rehabilitation Loans
Staff salaries and benefits
Maintenance & Operation/Prof. Services
260,000.00 0
218,100.00
37,855.00
0 218,100.00
0 37,855.00
260,000.00
515,955.00 0 515,955.00
Program staff conduct preliminary screenings of interested applicants using the program pre-application (Attachment B). The pre-application asks for the applicant's home address and estimated gross annual income along with other important details. If the pre-application shows that the property is not located in the City of Buena Park or that the household income is well above HUD's income limit, the City will not move forward with this application. These procedures allow program staff to ensure that 100% of the people receiving assistance are low-income Buena Park residents.
Applicants who pass the pre-application screening must submit a completed program application along with supplemental documents such as federal income tax returns, bank statements, pay-stubs, social security award letters, employment verification, property deeds, homeowner's insurance, etc. By collecting these documents, program staff can fully determine an applicant's eligibility.
Fiscal Year 2025 HUD Income Limits
Household Size 1 2 3 4 5 6 7 8
Extremely Low Income
(0%-30% AMI) $35,550 $40,600 $45,700 $50,750 $54,850 $58,900 $62,950 $67,000 Very Low Income
(30%-50% AMI) $59,250 $67,700 $76,150 $84,600 $91,400 $98,150 $104,950 $111,700 Low income
(50%-80% AMI) $94,750 $108,300 $121,850 $135,350 $146,200 $157,050 $167,850 $178,700 HUD Income Limits effective as of April 1, 2025 for Orange County, CA Attachment A
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 Attachment B
City of Buena Park
Home Improvement Program – “Pre-Application”
THE CITY OF BUENA PARK IS OFFERING LOW INTEREST LOANS TO OWNER OCCUPIED RESIDENCES FOR THE PURPOSE OF REPAIRING AND IMPROVING THEIR PROPERTIES. YOU
MUST BE APPROVED BY HOME IMPROVEMENT PROGRAM STAFF BEFORE PERFORMING ANY WORK.
ELIGIBLE IMPROVEMENTS MAY CONSIST OF BUT NOT LIMITED TO:
INTERIOR/EXTERIOR PAINTING, SANDBLASTING AND RESTUCCO, WINDOW AND DOOR
REPLACEMENT, ROOFING, PLUMBING, HEATING, ELECTRICAL UPGRADE, WEATHERIZATION,
KITCHEN AND BATHROOM RENOVATIONS, FLOORS, ADA ACCESSIBILITY IMPROVEMENTS, ETC.
TO QUALIFY YOU MUST OWN AND OCCUPY A SINGLE FAMILY RESIDENCE AND NOT EXCEED THE ESTABLISHED HUD INCOME LIMITS AND HAVE AVAILABLE EQUITY IN YOUR HOME.
DEFINITION OF ASSETS: ASSETS DO NOT INCLUDE THE VALUE OF THE HOME TO BE IMPROVED OR ANY PERSONAL PROPERTY. TYPICALLY, ASSETS COUNTED TOWARDS THE
INCOME CALCULATION INCLUDE STOCKS, BONDS, SAVINGS ACCOUNTS, CHECKING
ACCOUNTS, CERTIFICATES OF DEPOSIT, RETIREMENT ACCOUNTS, AND RENTAL OR VACATION PROPERTIES.
TO APPLY COMPLETE THE REVERSE SIDE OF THIS FORM AND MAIL IT IN. IF YOU HAVE ANY QUESTIONS PLEASE CALL (714) 562-3586.
APPLICANTS WILL BE ASSISTED ON A FIRST-COME, FIRST-SERVED BASIS
HABLAMOS ESPANOL
한국어 서비스 가능합니다
HIP (Rev. 10.22.24)
------------------------------------------------------------------------------------------------------------------------------------ Return Address:
_______________________
_______________________
_______________________
CITY OF BUENA PARK
HOME IMPROVEMENT PROGRAM
6650 BEACH BLVD.
BUENA PARK, CA 90621
Attachment B
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.
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.
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 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 bidder's SAM registration:
Entity Name: City of BuenaPark
AddreSS: 6650 Beach Blvd
City: Buena Park
Unique Entity ID (UEI): NuK2QVHWF623
ActiveExclusions (SelectOne):[]Yes [2]No
State: g Zip: 90621
Expiration Date: 3/19/26
Attachment 4
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBn,ITY AND VOLUNTARY EXCLUSION LOWER TIER COVERED TRANSACTIONS This certification is reqriired by the regulations implementing Executive Orders 12549 and 12689, Debarment and Suspension, and 2 CFR Part 200. Participants' responsibilities. (BEFORF. COA@LETING CERTIFICATION, READ INSTRUCTIONS 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 debarnnent, 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 tliis proposal.
1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.
2. Tlie certification in tliis clause is a material representation of fact upon wliicli reliance was placed when tliis 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 Govenirnent, 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. Tlie terms "covered transaction", "debarred", "suspended", "iiieligible", "lower tier covered transaction", "participant", "person", "primary covered transaction", "principal", "proposal", and "volrintarily 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 tlie 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 depaitment or agency with which this transaction originated.
6. Tlie prospectiye lower tier paiticipant fuither agrees by submitting this proposal tliat it will include the clause titled "Certification Regarding Debaiment, 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 tlie Federal Govemrnent, tlie department or agency with wliich this transaction originated may pursue available remedies, including suspension and/or debamient.
Attachment 5
City of Buena Park
FY 2026-2027 Community Development Block Grant (CDBG) Program Application Checklist
Please complete, sign, and include this checklist with your application Required For All Applicants:
[2] Completed FY 2026-2027 CDBG Grant Application
[2] Copy of current client intake form for proposed activity € N/A (only if activity is LMA)
[a Signed Acknowledgement Regarding Bidder SAM Registration form (Attachment 4) [U Signed Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions form (Attachment 5)
Required For Nonprofit/Outside Orqanizations:
€ Proof of active nonprofit status (IRS determination letter) € List of Board of Directors (board member names and titles) € Copy of current organizational chart
[] Copy of current lease (if CDBG funding request involves rental expenses) € Completed Zoning/Land Use Approval Form (Attachment 6), if located in the City of Buena Park Organization/City Department Name: City of Buena Park - Community Services Submitted By: Rosemary Nielsen
(Print Name, Title) a<sign>rntwpm'Y\ i(Datq:)iq-iiz
RECE/\/ED
DEc1820;45
ECOHBs DEvELOPMENT
Attachment 2
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 (July 1, 2026 - June 30, 2027)
CDBG FUNDING APPLICATION
DUE BY DECEMBER 18, 2026 AT 5:00 PM
Organization/City Department Name City of Buena Park - Community Services Activity/Program Name Senior Outreach Program
Address 8150 Knott Ave.. Buena Park. CA 90620
Contact Person/Title Rosemary Nielsen, Community Services Supervisor Email Address
[email protected]
Phone Number 714-236-3877
Activity Type (select one) [/ Public Service Activity € Other CDBG Eligible Activity Organization Type (select one)
[21 City Department
€ Nonprofit 501 (c) (3) organization
€ Other (i.e. public agency)
Amount of CDBG Funds Requested $15,566
1. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including all persons regardless of residence):
Estimated Goal: I ,300 [2]Individuals € Households
2. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including ONLY Buena Park residents):
Estimated Goal: 1 ,300 € Individuals € Households
Icertify under penalty of perjury that the information provided in this CDBG funding application is true to the best of my kr'iowledge.
Dalte'f)?)Z'
Oi' gap ization NB1II (3 CityoTBuenaPark- CommurulyServices Pl-() gi-Hlll N HIII (4; S(In:CFOulreacFProgram Please answer each of the following questions. 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. a) Why is there a need for this activity in the City of Buena Park? b) Identify the location of the activity and the service area boundaries. c) 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 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/demographic for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2026 through June 30, 2027. a) How was the estimated number of clients determined?
b) How will you reach your target population?
c) 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
Application Page 2
Organization Naine: CityofBuenaPark- CommunityServices p1-0gl-Blll QHlll(a; SeniorOulreachProgram 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 then explain in the space below:
[ZI 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.
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.a'l O; 24 CFR Parts 84 or 85, and OMB CircularA-87, A-122, Treasury Circular No. 1075] Provide the total administrative and/or operational costs for the proposed activity. Cost Category may include: staff salaries and benefits, renUlease, supplies, utilities, etc.
Cost Category CDBG Funding
Request
Other Funding
Sources
Total Cost
$ 15,566 $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
FT Salary + Benefits $ $ 58,490 $
$ $ $
Total $ 15,566 $ 58,490 $ 74,056
Application Page 3
01.ga niz atio n N am e ,City atBuenaPark- COmmUnilyServlCeS progr3lll N HIH (3; SeniorOulreachProgram 5 ELIGIBILITY DOCUMENT ATION
Describe the form of documentation that is 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.
The majority of clients served are over 60 years of age who meet the low/moderate income requirements.
Most of the clients are Buena Park residents.
Documentation consists of daily client contact tally sheets that define what type of services seniors are seeking
(i.e. housing, legal assistance, etc.). Staff references the tally sheets when completing monthly reports for HUD.
6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity's and that will be used to measure and track the activity's performance. Refer to the definitions on Page 6 of the RFP.
A. Select one :
[21 Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one :
€ Availability/Accessibility
€ Affordability
[2! Sustainability
Application Page 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.
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.
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.
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 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 bidder's SAM registration:
Entity Nal-7B: City of Buena Park- Community Services, Senior Center Address; 8150 KnottAve
City: Buena Park State: Ca Zip: 90620
Unique Entity ID (UEI): NUK2QVHWF623
ActiveExclusions (SelectOne):0Yes [2]No
Expiration Date: 3/17/26
Attachment 4
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELI(JBILITY AND VOLUNT ARY EXCLUSION LOWER TIER COVERED I"RANSACTIONS Tliis certification is required by tlie regulations iinpleinenting Executive Orders 12549 and 12689, Debarinent and Suspension, and 2 CFR Part 200, Participants' responsibilities. (BEFORECOMPLETING CERTIFICATjON, READ MSTRUCTJONS BELOW) (1) Tlie prospective lower tier paiticipant ceitifies, by submission of tliis proposal, that neither it nor its principles are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from paiticipation in tliis transaction by any Federal depaitment or agency. (2) Wliere t)ie prospective lower tier paiticipant is unable to ceitify to any of the statements in this ceitification, sucli prospective paiticipant shall attacli an explanation to tliis proposal.
Organization Name: City of Buena Park - Community Services AddreSS: 8150 Knott Ave., Buena Park, CA 90620
Jim Box, Director of Community Services
Name iiiid Title oi' Aut)iorized Representative tut'e /
1. By signing and submitting tliis proposal, t)ie prospectiv I er tier paiticipant is providing tlie ceitification set out below.
2. Tlie certification in this clause is a material representation of fact upon wliicli reliance was placed wlien tliis transaction was entered into. If it is later determined tliat tlie prospective lower tier participant knowingly rendered an erroneous ceitification, in addition to other reinedies available to the Federal Government, the depattment or agency witli wliich tliis transaction originated i'nay pursrie available remedies, including suspension and/or debari'ncnt.
3. The prospective lower tier paiticipant shall provide imi'nediate written notice to the person to whicli tliis proposal is subinitted if at any tiine the prospective lower tier pailicipant learns that its certification was erroneous wlicn subinitted or lias 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 implei'nenting Execritive Orders 12549 and 12689.
5. Tlie prospective lower tier paiticipant agrees by sribi'nitting this proposal that, sliould the proposed covered transaction be entered into, it s)iall not knowingly enter into any lower tier covered transaction witli a person who is debarred, suspended, declared ineligible, or voluntarily excluded from paiticipation in tliis covered transaction, unless aut)iorized by tlie depaitment or agency with whicl'i tl'iis transaction originated.
6. Tlie prospective lower tier pailicipant fuit)ier agrees by submitting tl'iis proposal that it will inc)ride tlie clarise titled "Cettification 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 paiticipant in a covered transaction inay rely upon a ceitification of a prospective participant in a lower tier covered transaction that is not debarred, stispended, ineligible, or voluntarily excluded from the covered transaction, unless it knows tliat the ceitification is erroneous. A participant n'iay decide the metliod and frequency by wliicli it detemiincs the eligibility of its principals. Eacli pailicipant may clieck the System for Award Management (SAM).
8. Nothing contained in t)ie foregoing shall be construed to require establisl'unent of a system of records in order to render in good faith t)'ie certification required by tliis clause. Tlie knowledge and inforination of a participant is not required to exceed tliat wliich is nomially possessed by a prudent person in the ordinary course of business dealings.
9. Except for transactions autliorized under paragraph 5 of tliese 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 paiticipation in tliis transaction, in addition to other rei'iiedies available to the Federal Government, tlie depaitment or agency wit)i w)iich this transaction originated may pursue available reinedies, including suspension and/or debarinent.
Attachment 5
Intake Form
First Name:
Address:
Email:
In- Person[] Over the Phone0
In-come Level:
Services Neederla
Resources Given:
Last Namea
7ip codp:
Phnne:
ABe: Disabled Yes0 NOD
Datea
Intake Form
First Name:
Address:
Email:
In- Person 0 0ver the Phone0
In-come I Pi/PI a
Services Neededa
Resources Given:
Last Name:
7ip codp:
Phone:
ABe: Disabled Yesg No[l
Date:
Tally In-take Form
DATE: LOCATION /EVENT:
WHITE
AFRICAN AMERICAN
ASIAN
AMERICAN INDIAN
NATIVE HAWAIIAN
AMERICAN INDIAN
ASIAN
OTHER
EXTREMELY LOW-INCOME
VERY LOW- INCOME
LOW- INCOME
ABOVE MODERATE- INCOME
City of Buena Park
2026-2027 Community Development Block Grant (CDBG)
Funding Proposal Summary Sheet
Organization Name: City of Buena Park
Community & Economic Development Department
Program Name: Neighborhood Improvement/Code Enforcement Estimated Goal: 575 Households
Funding Request: $279,490
Organization Purpose:
The 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.
Description of Request:
CDBG 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.
Analysis of Request:
The project meets the national objectives of benefiting low- and moderate- income areas and aiding in the prevention or elimination of slums or blight. The program’s funding is limited to staff time spent on code enforcement cases within the City’s low- and moderate-income census tracts.
Code enforcement investigates 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:
Staff recommends funding in the amount of $230,000.
City of Buena Park
FY 2026-2027 Community Development Block Grant (CDBG) Program Application Checklist
Please complete, siqn, and include this checklist with your application Required For All Applicants
[jCompletedFY 2026-2027 CDBG Grant Application
€ Copy of current client intake form for proposed activity [!N/A (only if activity is LMA)
W Acknowledgement Regarding Bidder SAM Registration form (Attachment 4) Xggnnee:certiricationsegamingoebarment,suspension,ineiigi Lower Tier Covered Transactions form (Attachment 5)
Required For Nonprofit/Outside Orqanizations:
€ Proof of active nonprofit status (IRS determination letter) € List of Board of Directors (board member names and titles) € Copy of current organizational chart
€ Copy of current lease (if CDBG funding request involves rental expenses) € Completed Zoning/Land Use Approval Form (Attachment 6), if located in the City of Buena Park Organization/City Department Name: City of Buena Park, Community and Economic Development Depart Submitted By: Matt Foulkes, Community and Economic Dev / (PrintName,Title) ( (Date)
"ECE/VED
o'Cl 8 2025
"offlM/Cnr"ELOJJ5air
Attachment 2
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 (July 1, 2026 - June 30, 2027)
CDBG FUNDING APPLICATION
DUE BY DECEMBER 18, 2025 AT 6:00 PM
Organization/City Department Name City of Buena Park, Community and Economic Development Depart Activity/Program Name Neighborhood Improvement/Code Enforcement Address 6650 Beach Blvd. Buena Park. CA 90621
Contact Person/Title Robert Cravens, Code Enforcement Supervisor Email Address [email protected]
Phone Number 714-562-3642
Activity Type (select one) [] Public Service Activity [ZI Other CDBG Eligible Activity Organization Type (select one)
[21 City Department
€ Nonprofit 501(c) (3) organization
€ Other (i.e. public agency)
Amount of CDBG Funds Requested $ 279,489.67
1. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including a// persons regardless of residence):
Estimated Goal: 65,000 [21 Individuals [21 Households
2. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including ONLY Buena Park residents):
Estimated Goal: 575 € Individuals [21 Households
Icertify under penalty of perjury that the information provided in this CDBG funding application is true to the best of my knowledge.
12/1 8/25
(Signature of authgrized representative) Date
Matt Foulkes - Community Development Director
(Print name and title of authorized representative)
Organization Name: CilyoTBuenaPark.CommunityandEconomicDevelopmeiProgram Namea Neighborhood Improvement/Code Enforcement Please answer each of the following questions. If any questions are lefi 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. a) Why is there a need for this activity in the City of Buena Park? b) Identify the location of the activity and the service area boundaries. c) 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 HUD, 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/demographic for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2026 through June 30, 2027. a) How was the estimated number of clients determined?
b) How will you reach your target population?
c) Explain why this activity is needed for this target population.
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 fifty 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.
Application Page 2
0lg 81li2Bii0 Il %81-H (:i: CityOfBuenaPerk,CommunityandECOnOmiCDevelopmt pj0 gyBl N 8(H 6 - NeighbOThOOd ImproVement / COde EnfotCemenl 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 then explain in the space below:
121 Benefit low- and moderate-income persons in Buena Park; [2] 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 ImprovemenUCode 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 and assist property owners with applications for home improvement. The program also provides referral for tenants to fair housing and legal aid. 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] Provide the total administrative and/or operational costs for the proposed activity. Cost Category may include: staff salaries and benefits, renUlease, supplies, utilities, etc.
Cost Category
CDBG Funding
Request
Other Funding
Sources Total Cost
Code Enforcement Supervisor $ 16,850.66 $ 181,392.34 $ 198,243 Code Enforcement Officer $ 92,953.47 $ 56,249.53 $ 149,203 Code Enforcement Officer $ 44,770.43 $ 124,174.57 $ 168,945 Code Enforcement Officer $ 50,761.05 $ 103,903.95 $ 154,665 Code Enforcement Officer P/T $ 10,089.04 $ 28,714.96 $ 38,804 Code Enforcement Officer P/T $ 12,374.96 $ 35,221.04 $ 47,596 Administrative Assistant $ 23,859.06 $ 101,714.94 $ 125,574 Office Assistant P/T $ 27,831 $ 0 $ 27,831
$ $ $
$ $ $
Total $ 279,489.67 $ 631,371.33 $ 910,861.00
Application Page 3
01'g,lH)az3jla()11 N31 pll' CityoTBuenaPark.Commun:j7andECOnOm:CDevelopmt Pl'()gyH NHyy) (a.' NeighborhoodImprovemenlI COdeEnforcemenf 5 ELIGIBILITY DOCUMENT ATION
Describe the form of documentation that is 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.
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's and that will be used to measure and track the activity's performance. Refer to the definitions on Page 6 of the RFP.
A. Select one :
[21 Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one :
€ Availability/Accessibility
€ Affordability
[a Sustainabi!ity
Application Page 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.
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.
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 bidder's SAM registration:
Entity Name: City of Buena Park, Community and Economic Development Department Address: 6650 Beach Blvd.
City: Buena Park, CA 90621
Unique Entity ID (UEI): NUK2QVHWF623
ActiveExclusions (SelectOne):0 Yes [21No
State: CA Zip: 90621
Expiration Date: 3/19/26
Attachment 4
CERTIFICATION REGARmNG DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNTARY EXCLUSION LOWER TIER COVERED TRANSACTIONS Tliis certification is required by the regulations implementing Executive Orders 12549 and 12689, Debai'ment and Suspension, and 2 CFR Part 200, Participants' responsibilities. (BEFORF. C(MvfPLETjNG CERTIFICATION. READ INSTRUCTIONS BEL(HQ (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, Community and Economic Development Department AddreSS: 6650 Beach Blvd. Buena Park, CA 90621
Matt Foulkes, Community and Econ Dev I 2/1 8/25
Name and Title of Authorized Representative Date
1. By signing and submitting this proposal, the prospective lower tier paiticipant is providing the certification set out below.
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 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 tiine 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 m.eanings 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 deteimines 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 department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.
Attachment 5
City of Buena Park
2026-2027 Community Development Block Grant (CDBG)
Funding Proposal Summary Sheet
Organization Name: City of Buena Park Public Works Department Program Name: Graffiti Removal Program
Estimated Goal: 57,785 Individuals within low-income census tracts/ 2,000 Graffiti Instances
Funding Request: $24,750
Organization Purpose:
Graffiti Removal Program staff proactively and reactively responds to graffiti incidents within the City’s CDBG eligible census tracts. The program’s purpose is to provide a suitable living environment for Buena Park residents by removing graffiti in residential and commercial areas.
Description of Request:
CDBG 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.
Analysis of Request:
The project meets the national objective of benefiting low- and moderate- income areas and aiding in the elimination of slums or blight within the City. Program staff estimate that 57,785 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 instances removed rather than individuals and households assisted.
Funding Recommendation:
Staff recommends funding in the amount of $16,000.
City of Buena Park
FY 2026-2027 Community Development Block Grant (CDBG) Program Application Checklist
Please complete, siqn, and include this checklist with your application Required For All Applicants:
[ZI Completed FY 2026-2027 CDBG Grant Application
[] Copy of current client intake form for proposed activity [2] N/A (only if activity is LMA)
[ZI Signed Acknowledgement Regarding Bidder SAM Registration form (Attachment 4) [21 Signed Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions form (Attachment 5)
Required For Nonprofit/Outside Orqanizations:
[1] Proof of active nonprofit status (IRS determination letter) € List of Board of Directors (board member names and titles) € Copy of current organizational chart
€ Copy of current lease (if CDBG funding request involves rental expenses) € Completed Zoning/Land Use Approval Form (Attachment 6), if located in the City of Buena Park Organization/City Department Name: Buena Park Public Works Department 8p5Bj00Bd 8y;Mina Mikhael,P.E.,Directorof PublicWorks/CityEngineer/ (PrintName,Title) (Sign)
/ 12/18/25
(Date)
RECEIVED
DEC18 2025
ECflNOMICflEVELOPMENT
Attachment 2
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 (July 1, 2026 - June 30, 2027)
CDBG FUNDING APPLICATION
DUE BY DECEMBER 18, 2025 AT 5:00 PM
Organization/City Department Name Buena Park Public Works Department Activity/Program Name Graffiti Removal Program
Address 6650 Beach Boulevard, Buena Park, CA 90620
Contact Person/Title Nino Libunao, Facilities and Parks Superintendent Email Address
[email protected]
Phone Number 714-562-3661
Activity Type (select one) [ZI Public Service Activity € Other CDBG Eligible Activity Organization Type (select one)
[21 City Department
€ Nonprofit 501 (c) (3) organization
€ Other (i.e. public agency)
Amount of CDBG Funds Requested $24,750
1. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including all persons regardless of residence):
Estimated Goal: 57,785 [2]Individuals € Households
2. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including ONLY Buena Park residents):
Estimated Goal: 57,785 [ZI Individuals € Households
Icertify under penalty of perjury that the information provided in this CDBG funding application is true to the best of my knowledge.
(Signature of authorized representative)
I2/1 8/25
Date
Mina Mikhael, P.E., Director of Public Works/City Enqineer (Print name and title of authorized representative)
01'gB1l laz3ila()11 N BIII (y; Bu€ntlPatkPublicWOLkS€epaTlmem P1()gl-H1llNBII')(- GraffiliRemoval Program Please answer each of the following questions. 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. a) Why is there a need for this activity in the City of Buena Park? b) Identify the location of the activity and the service area boundaries. c) 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 (714) 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/demographic for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2026 through June 30, 2027. a) How was the estimated number of clients determined?
b) How will you reach your target population?
c) Explain why this activity is needed for this target population.
All residents in tract 001801, 088601, 110110, 110201, 110202, 110302, 110303, 110401, 110402, 110500, 110603, 110604, 110606 and 110607 totaling 57,785 will be served. See attached project location map.
Application Page 2
Oi'ga1llzatioii N BIII (-; BuenaParkPublicWorksDepartment p1'0glaHlll )4H111(4aGraffitiRemovalProgram 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 then explain in the space below:
[21 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 Graffiti Removal Program meets the CDBG National Objective of Benefit to Low- and Moderate-Income Persons by providing graffiti removal services in areas where a majority of residents are low- and moderate-income. The program improves neighborhood conditions, enhances safety and quality of life, and helps maintain stable housing environments for LMI
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] Provide the total administrative and/or operational costs for the proposed activity. Cost Category may include: staff salaries and benefits, renUlease, supplies, utilities, etc.
Cost Category
CDBG Funding
Request
Other Funding
Sources
Total Cost
Staff salaries and benefits $ 24,750 $ $ 24,750
Maintenance and ooerations $ $ 40,100 $40,100
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
TOtal $ 24,750 $ 40,100 $ 64,850
Application Page 3
()rganiZa;all Naine.:BuenaParkPublicWoiks Department pp0glBlll %lly GraffitiRemovalProgram 5 ELIGIBILITY DOCUMENT ATION
Describe the form of documentation that is 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.
All residents in tract 001801, 088601, 110110, 110201, 110202, 110302, 110303, 110401, 110402, '110500, 110603, 110604, 110606 and 110607 totaling 57,785 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 and that will be used to measure and track the activity's performance. Refer to the definitions on Page 6 of the RFP.
A. Select one Objective:
[a Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one Outcome:
€ Availability/Accessibility
€ Affordability
[2] Sustainability
Application Page 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.
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.
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 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 bidder's SAM registration:
Entity Name: Buena Park Public Works Department
Address: 6650 Beach Boulevard
City: Buena Park State: CA Zip: 90621
Unique Entity ID (UEI): NUK2QVHWF62
Active Exclusions (Select One): gYes [2]No
Expiration Date: 4/16/26
Attachment 4
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNT ARY EXCLUSION LOWER TIER COVERED TRANSACTIONS Tliis certification is required by tlie regulations impleinenting Executive Orders 12549 and 12689, Debarn'ient and Suspension, and 2 CFR Part 200, Participants' responsibilities. (EEFORE COMP LETlMa CERTjFjCATjON, REA D INSTRUCTIONS 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 90621
Mina Mikhael, P E, Director of Public Works/City Engineer Name and Title of Authorized Representative
}-+J,-
Signature
12/1 8/25
Date
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 depaitment or agency with wliich 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 tiine the prospective lower tier participant leams that its certification was erroneous wlien 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 t)iis proposal that, should the proposed covered transaction be entered into, it sliall 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 t)iis transaction originated.
6. The prospective lower tier participant furtlier 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 inethod and frequency by which it determines the eligibility of its principals. Each paiticipant 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. Tlie knowledge and information of a participant is not required to exceed that which is norinally 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 wlio is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other reinedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.
Attachment 5
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City of Buena Park
2026-2027 Community Development Block Grant (CDBG)
Funding Proposal Summary Sheet
Organization Name: City of Buena Park Community Services Department Program Name: Senior Transportation Program
Estimated Goal: 350 Individuals
Funding Request: $33,690
Organization Purpose:
The Senior Transportation Program provides senior Buena Park residents with transportation to non-emergency medical appointments, pharmacies, grocery stores, and the Buena Park Senior Center.
Description of Request:
CDBG funds will be used for three part-time drivers’ salaries and benefits and cell phone expenses.
Analysis of Request:
The 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.
Funding Recommendation:
Staff recommends funding in the amount of $26,000.
City of Buena Park
FY 2026-2027 Community Development Block Grant (CDBG) Program Application Checklist
Please complete, siqn, and include this checklist with your application Required For All Applicants:
[U Completed FY 2026-2027 CDBG Grant Application
[21 Copy of current client intake form for proposed activity € N/A (only if activity is LMA)
[21 Signed Acknowledgement Regarding Bidder SAM Registration form (Attachment 4) 121 Signed Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions form (Attachment 5)
Required For Nonprofit/Outside Orqanizations:
€ Proof of active nonprofit status (IRS determination letter) € List of Board of Directors (board member names and titles) € Copy of current organizational chart
€ Copy of current lease (if CDBG funding request involves rental expenses) € Completed Zoning/Land Use Approval Form (Attachment 6), if located in the City of Buena Park Organizaion/City Departmem Name: City of Buena Park/Community Services Submitted By:Wilfredo Lozano, Drvier/Scheduler
(Print Name, Title) (Sign)
/ 12/1/20
(Date)
RECEIVED
DEC18 2025
ECONOMICDEVELOPMENT
Attachment 2
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 (July 1, 2026 - June 30, 2027)
CDBG FUNDING APPLICATION
DUE BY DECEMBER 18, 2025 AT 5:00 PM
Organization/City Department Name City of Buena Park/Community Services Activity/Program Name Senior and Non emergency medical transportation Address
8150 Knott Ave. Buena Park. Ca 90620
Contact Person/Title Wilfredo Lozano, Driver/Scheduler
Email Address
[email protected]
Phone Number 714-236-3874
Activity Type (select one) [D Public Service Activity € Other CDBG Eligible Activity Organization Type (select one)
[21 City Department
€ Nonprofit 501(c) (3) organization
€ Other (i.e. public agency)
Amount of CDBG Funds Requested $33,690.00
1. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including all persons regardless of residence):
Estimated Goal: 350 [21 Individuals € Households
2. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including ONLY Buena Park residents):
Estimated Goal: 350 [3 Individuals € Households
Icertify under penalty of perjury that the information provided in this CDBG funding application is true to the best of my knowledge.
(Signature of a edktative)
(Print-,, name Z and title of agthorYed 'T)irechr representative) v'; Cpmnmi%3"ce-s 12/1/20
Date
Ol'gBH izatio1l N 3111(4; CityoTBuenaParklCommunil'yServices p1'()glaB1-ll N Hy1l (s;SeniorandNonemergencymedicaltransportation Please answer each of the following questions. 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. a) Why is there a need for this activity in the City of Buena Park? b) Identify the location of the activity and the service area boundaries. c) Describe specifically the intended use of the CDBG funds.
The Senior and Non-Emergency Medical Transportation Program provides a driver and vehicle to transport Buena Park senior citizens from their home to the Buena Park Senior Center. The program also provides round-trip transportation to medical appointments and/or pharmacy for a fee of $1 each way; however, no one is denied transportation for inability to pay. The program is free to Buena Park residents 60 years of age and older. The location of the appointments (doctor, dentist, hospital or pharmacy) will be limited up to our miles outside of Buena Park.
2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population/demographic for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2026 through June 30, 2027. a) How was the estimated number of clients determined?
b) How will you reach your target population?
c) 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 s!iopping with a targeted goal of 350 seniors within the fiscal year. The estimated number of clients was 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 int he 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. The program operates with full accessibility to Buena Park seniors with trained courteous staff.
Application Page 2
Organization Nan'ie: CityofBuenaPark/Community Services p10glHlll QB1ll(i; SeniorandNonemergencymedicaltransportation 3 NATIONAL OBJECTIVES
[24 CFR 570.200(a), 570.201-570.208, 570.5031
Describe in detail how the activity meets at least one of the three CDBG Program national objectives.
Select one then explain in the space below:
I2] 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 Senior and Non-Emergency Medical Transportation Program provides a low cost, convenient and safe way for Buena Park senior citizens to receive medical care and treatment promoting their continued independence and well-being. As a result of a senior's inability or difficulty in obtaining transportation, seniors often delay or neglect to make necessary and critical appointments with their healthcare provider.
This often results in turning a 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 ultimately enhances their quality of life, fosters 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 and support counseling with outreach or support groups. The vast majority of participants are low to moderate income senior citizens. Many frail elderly residents are unable to access public transportation services, 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, 570.61 0; 24 CFR Parts 84 or 85, and OMB Circular A-87, A-122, Treasury Circular No. 1075] Provide the total administrative and/or operational costs for the proposed activity. Cost Category may include: staff salaries and benefits, renUlease, supplies, utilities, etc.
Cost Category CDBG Funding
Request
Other Funding
Sources Total Cost
'1 part time driver salary $ 32,516 $ 0 $ 32,516
Benefits $ 2,276 $ 0 $ 2,276
Cell phone allowance $ 900 $ 0 $ 900
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Total $ 35,692 $ $ 35,692
Application Page 3
0l'gHyllazBil'()11NH111(;;C:f7(]TBuenaPaTk/COmmlln:17SeN:Ce!i pl-0gl-Blll %lll(a; SeniorandNonemergencymedicaltransportation 5 ELIGIBILITY DOCUMENT ATION
Describe the form of documentation that is 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.
The majority of clients served are over 60 years of age, who meet the 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 requirement. Additionally a daily client contact tally sheets that define type of transportation (i.e. prescription pickup, doctors appointment, etc.)
6 I
OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity's and that will be used to measure and track the activity's performance. Refer to the definitions on Page 6 of the RFP.
A. Select one :
[21 Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one Outcome:
[21 Availability/Accessibility
[] Affordability
€ Sustainability
Application Page 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.
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.
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 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 bidder's SAM registration:
Entity Narl-iB; City of Buena Park
Address: 8150 Knott Ave
City: Buena Park
Unique Entity ID (UEI): NUK2QVHWF623
ActiveExclusions(SelectOne):0 Yes [] No
State: CA Zip: 90620
Expiration Date: 3/17/26
Attachment 4
CERI"IFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNT ARY EXCLUSION LOWER TIER COVERED TRANSACTIONS Tl'iis certification is required by tlie regulations ii'iipleinenting Execritive Orders 12549 and 12689, Debari'nent and Suspension, and 2 CFR Part 200, Participants' responsibilities. (BEFORECOA4PLETING CERTjFlCATION, READ INSTRUCT[ONS BELOW) (l) Tlie prospective )ower tier participant ceitifies, by submission of this proposal, that neither it nor its principles are presently debarred, suspended, proposed for debaririent, declared ineligible, or volrintarily excluded froi'n paiticipation in tliis transaction by any Federal departi'nent or agency. (2) Wliere tlie prospective lower tier paiticipant is unable to certify to any of tlie statements in this ceitification, sucli prospective paiticipant sliall attach ai'i explanation to tliis proposal.
Organization Name: City of Buena Park
AddreSS: 8150 Knott Ave, Buena Park, CA 90620
Jim Box Director of Community Services
Name and Title of Autliorized Representiitive
1. By signing and subinitting tliis proposal, the prospectiv out below.
Date
wer tier participant is providing the ceitification set
2. Tlic cei'lification in tliis clausc is a inaterial representation of fact ripon wliicli reliance was placed wlien tliis transaction was entered into. If it is later dctcri'nined tliat tlie prospective lower tier paiticipant knowingly rendered an erroneous ceitification, in addition to other remedies available to the Federal Governinent, tlie depaitinent or agency witli wliicli tliis transaction originated may pursue available reinedies, including suspension and/or debarment.
3. The prospective lower tier participant sliall provide iminediate written notice to tlie person to w)iich t)iis proposal is submitted if at any liine tlie prospective lower tier participant learns tliat its ceitification was erroneous wlien subinittcd or lias become erroneoris by reason of changed circumstances.
4. The terms "covered transaction", "debarred", "suspended", "ineligible", '!ower tier covered transaction", "participant", "person", "priinary covered transaction", "principal", "proposal", and "voluntarily excluded", as used in tliis clause, liave tlie incanings set out in tlie Definitions and Coverage sections of rules implementing Executive Orders 12549 and 12689.
5. The prospective lower tier paiticipant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it sliall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded froin participation in tliis covered transaction, unless autliorized by tlie depaitment or agency with which t)iis transaction originated.
6. Tlie prospective lower tier participant fuitlier agrees by submitting tliis proposal that it will include the clause titled "Ccitification Regarding Debarinent, Srispension, Ineligibility and Voluntai'y Exclusion-Lower TieiCovered Transactions", witliorit i'nodification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
7. A paiticipant in a covered transaction inay rely upon a ceitification of a prospective paiticipant in a lower tier covered transaction tliat is not debarred, suspended, ineligible, or voluntarily excluded froin the covered transaction, unless it kllOWS tliat tlie ceitification is ei'roneous. A participant may decide the metliod and frequency by whicli it deterinines tlie eligibility of its principals. Each participant i'nay check the System for Award Manageinent (SAM).
8. Nothing contained in tlie foregoing sliall be construed to require establislunent of a system of records in order to render in good faitli tlie certification required by tliis clause. The knowledge and information of a pai'ticipant is not required to exceed tl'iat wliic)i is normally possessed by a prudent person in the ordinary course of business dealings.
9. Except for transactions autliorized under paragraph 5 of these instructions, if a paiticipant in a covered transaction knowingly enters into a lower tier covered transaction witli a person wlio is suspended, debarred, ineligible, or voluntarily excluded fi'oi'n paiticipation in tliis transaction, in addition to ot)ier remedies available to the Federal Governinent, tlie depaitment or agency wit)i wliicli this transaction originated i'nay pursue available rei'nedies, including suspension and/or debarment.
Attachment 5
City of Buena Park
FY 2026-2027 Community Development Block Grant (CDBG) Program Application Checklist
Please complete, sign, and include this checklist with your application Required For All Applicants:
[ZI Completed FY 2026-2027 CDBG Grant Application
[21 Copy of current client intake form for proposed activity € N/A (only if activity is LMA)
[a Signed Acknowledgement Regarding Bidder SAM Registration form (Attachment 4) [ZI Signed Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions form (Attachment 5)
Required For Nonprofit/Outside Orqanizations:
€ Proof of active nonprofit status (IRS determination letter) € List of Board of Directors (board member names and titles) € Copy of current organizational chart
€ Copy of current lease (if CDBG funding request involves rental expenses) € Completed Zoning/Land Use Approval Form (Attachment 6), if located in the City of Buena Park Organization/City Department Name: City of Buena Park/Community Services Submitted By:Wilfredo Lozano, Drvier/Scheduler
(Print Name, Title) (Sign)
/ 12/1/20
(Date)
RECEIVED
DEC18 2025
ECONOMICDEVELOPMENT
Attachment 2
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 (July 1, 2026 - June 30, 2027)
CDBG FUNDING APPLICATION
DUE BY DECEMBER 18, 2025 AT 5:00 PM
Organization/City Department Name City of Buena Park/Community Services Activity/Program Name Senior and Non emergency medical transportation Address
8150 Knott Ave. Buena Park. Ca 90620
Contact Person/Title Wilfredo Lozano, Driver/Scheduler
Email Address
[email protected]
Phone Number 714-236-3874
Activity Type (select one) [U Public Service Activity € Other CDBG Eligible Activity Organization Type (select one)
[/ City Department
€ Nonprofit 501 (c) (3) organization
€ Other (i.e. public agency)
Amount of CDBG Funds Requested $33,690.00
1. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including all persons regardless of residence):
Estimated Goal: 350 E] Individuals € Households
2. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including ONLY Buena Park residents):
Estimated Goal: 350 [ZI Individuals [] Households
Icertify under penalty of perjury that the information provided in this CDBG funding application is true to tlie best of my knowledge.
(Signature of a edktative)
(Print name and title of authorEed representative)
12/1 /20
Date
Organization MIII (; ; CityoTBuenaPark/Community Services p)'()glaB1l-lQBl'y)(-a;Seniorand Nonemergencymedicaltransportation Please answer each of the following questions. If any questions are leff unanswered, your application will not be considered. You may attach additional sheets and/or supporting materials as needed.
I
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. a) Why is there a need for this activity in the City of Buena Park? b) Identify the location of the activity and the service area boundaries. c) Describe specifically the intended use of the CDBG funds.
The Senior and Non-Emergency Medical Transportation Program provides a driver and vehicle to transport Buena Park senior citizens from their home to the Buena Park Senior Center. The program also provides round-trip transportation to medical appointments and/or pharmacy for a fee of $1 each way; however, no one is denied transportation for inability to pay. The program is free to Buena Park residents 60 years of age and older. The location of the appointments (doctor, dentist, hospital or pharmacy) will be limited up to our miles outside of Buena Park.
2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population/demographic for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2026 through June 30, 2027. a) How was the estimated number of clients determined?
b) How will you reach your target population?
c) 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 was 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 int he 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. The program operates with full accessibility to Buena Park seniors with trained courteous staff.
Application Page 2
01-gHHlzB1l()ll N HIII C: CityOfBuenaPark/CommunilYServices pp0glHlll %HIII(H; SeniorandNonemergencymedicaltransportation 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 then explain in the space below:
[/ Benefit low- and moderate-income persons in Buena Park; € Aid in the prevention or elimination of slums or blight in Buena Park; € Meej a need having a particular urgency in Buena Park.
The Senior and Non-Emergency Medical Transportation Program provides a low cost, convenient and safe way for Buena Park senior citizens to receive medical care and treatment promoting their continued independence and well-being. As a result of a senior's inability or difficulty in obtaining transportation, seniors often delay or neglect to make necessary and critical appointments with their healthcare provider.
This often results in turning a 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 ultimately enhances their quality of life, fosters 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 and support counseling with outreach or support groups. The vast majority of participants are low to moderate income senior citizens. Many frail elderly residents are unable to access public transportation services, 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 or 85, and OMB Circular A-87, A-122, Treasury Circular No. 1075] Provide the total administrative and/or operational costs for the proposed activity. Cost Category may include: staff salaries and benefits, renUlease, supplies, utilities, etc.
Cost Category CDBG Funding
Request
Other Funding
Sources
Total Cost
1 part time driver salary $ 32,516 $ 0 $ 32,516
Benefits $ 2,276 $ 0 $ 2,276
Cell phone allowance $ 900 $ 0 $ 900
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Total $ 35,692 $ $ 35,692
Application Pagc 3
Organizati 011 Haallle,City ofBuenaPark/CommunityServices p)0gl-Blll %HIII(; SetuorandNonemergencymedical transportation 5 ELIGIBILITY DOCUMENT ATION
Describe the form of documentation that is 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.
The majority of clients served are over 60 years of age, who meet the 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 requirement. Additionally a daily client contact tally sheets that define type of transportation (i.e. prescription pickup, doctors appointment, etc.)
6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity's and that will be used to measure and track the activity's performance. Refer to the definitions on Page 6 of the RFP.
A. Select one :
[21 Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one Outcome:
[/ Availability/Accessibility
€ Affordability
€ Sustainability
Application Page 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.
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.
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 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 bidder's SAM registration:
Entity Name: City of Buena Park
Address: 8150 KnOtt AVe
City: Buena Park
Unique Entity ID (UEI): NUK2QVHWF623
ActiveExclusions(SelectOne):gYes [2]No
State: CA Zip: 90620
Expiration Date: 3/17/26
Attachment 4
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY ANDVOLUNTARYEXCLUSION LOWERTIERCOVEREDTRANSACTIONS Tliis ceilification is required by tlie regulations iinpleinenting Executive Orders 12549 and 12689, Debarinent and Suspension, and 2 Cl'R Part 200, Participants' responsibilities. (BEFORE COA,fPLETJNG CERTiFICATjON, READ INSTRUCTiONS EELOW) (l) T)ie prospective lower tier paiticipant ceitifies, by subinission of this proposal, that neither it nor its principles are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded froi'n paiticipation in tliis transaction by any Federal depaitirient or agency. (2) Wliere tlie prospective lower tier paiticipant is unable to ceitify to any of tlie stateinents in tliis cettification, sucli prospective paiticipant sliall attach an explanation to this proposal.
Organization Name: Ci[7 0f Buena Park
AddreSS: 8150 Knott Ave, Buena Park, CA 90620
Jim Box Director of Community Services
Name and Title ofAutliorized Representative
l. By signing and submitting tliis proposal, tlie prospectiv out below.
tiire /
Date
wer tier participant is providing the ceitification set
2. The ceitification in tliis clausc is a inaterial rcpresentation of fact ripon wliicli reliance was placed wlien this transaction was entered into. If it is later determined tliat the prospective lower tier paiticipant knowingly rendered an erroncous ceitification, in addition to other remedies available to the Federal Government, tlie depaitinent or agency witli wliicli tliis transaction originated may pursue available remedies, including srispension and/or debari'ncnt.
3. The prospective lower tier pailicipant sliall provide immediate written notice to tlie person to which this proposal is subinitted if at any tiine t)ie prospective lower tier paiticipant leams tliat its ceitification was ci-roneous wlien subinittcd or lias bccoine erroneous by reason of changed circuinstances.
4. arlic terms "covered transaction", "dcbarred", "suspended", "ineligible", "lower tier covered transaction", "participant", "person", "priinary covered transaction", "principal", "proposal", and "voluntarily excltided", as used in t)iis clause, liave tlie mcanings set orit in t)ie Definitions and Coverage sections of rules ii'nplementing Executiye Orders 12549 and 12689.
5. The prospective lower tier paiticipant agrees by sribmitting this proposal tliat, should tlie proposed covered transaction be entered into, it sliall not knowingly enter into any lower tier covered transaction witli a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in tliis covered transaction, unless aritliorizcd by tlie depaitment or agency with which tl'iis transaction originated.
6. The prospective lower tier pailicipant fuither agrees by submitting this proposal tliat it will include the clause titled "Ceitification Rcgarding Debarinent, Srispension, Ineligibility and Voluntaiy Exclusion-Lower TieiCovered alaransactions", witliout inodification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
7. A paiticipant in a covcred transaction i'nay rely upon a ceitification of a prospective paiticipant in a lower tier covered transaction tliat is not debarred, srispended, ineligible, or voluntarily excluded from the covered transaction, unless it knows tliat the ceitification is eri'oneous. A participant may decide the metliod and fi'equency by wliicli it deterinines tlie eligibility of its principals. Eacli paiticipant may check the System for Award Manageinent (SAM).
8. Notliing contained in tlie foregoing sliall be construed to reqtiire establishment of a systein of records in order to render in good faitli tlie certification required by tl'iis clause. The lcnowledge and information of a participant is not reqriired to exceed tliat wliicli is norinally possessed by a prudent person in tlie ordinary course of btisiness dealings.
9. Except for transactions autliorized under paragrapli 5 of these instructions, if a paiticipant in a covered transaction knowingly enters into a lower tier covered transaction witli a person who is suspended, debarred, ineligible, or voluntarily excluded froi'n paiticipation in this transaction, in addition to otlier remedies available to the Federal Goveminent, tlie depaitinent or agency wit)i w)iich tliis transaction originated inay pursue available reinedies, including suspension and/or debarinent.
Attachment 5
BuenaPark SeniorActivityCenter
SeniorTransportation(ST*R)ProgramApplieation
All sensitive information provided is confidential
The Buena Park Senior Transportation and Runabout (ST*R) Program offers both a non-emergency medical van for doctor visits and a Bus service that transports seniors to and from their residences to the Buena Park Senior Center. Tliis program is available to seniors 60 and older.
Tliis program is fiu'ided by the following:
* Orange County Transportation Authority (OCTA)
* Office on Aging (OoA)
@ Community Development Block Grant (CDBG)
* City of Buena Park.
Rider Information
Full Name:
Address:
City: Zip Code:
Cross Streets: and
Home Phone: Cell Plione:
Do you have access to transpoitation? (i.e. Family, Friends, Relatives)
Mobility Status (circle one):
Ambulatoiy Manual Wheelcliair Power Wheelcliair
Scooter Service Animal O'herD"a"y
(Please list):
Can tlie rider be left home alone? (Circle one): Yes No Birth Date:
Yes
Cane Walker
Apt:
No
Oxygen Tank
ID and Proof of Address will be required at the time of application submittal. [1] Age € Address
Verified Bv:
Staff Signature
Date
BuenaPark SeniorActivityCenter
Mark the days you wish to be picked-up for transportation ST*R Program
(To Senior Center) 8am-3pm
Non-Emergency *VIust call in advance
(Appointments Needed) 8am-12pm
€ Monday € Tuesday
€ Tuesday € Wednesday
€ Wednesday € Thursday
€ Thursday
Coininents:
Emergency Contact Information
Name: Relationship:
Contact #1
Phone: City:
Name: Relationship:
Contact #2
Phone: City:
Primary Physician Information
Pl'iysicianName: PliysicianPlione#:
PhysicianAddress: City: Zip:
Basic Medical Information
Additional important medical infori'nation (Allergies, medical info, existing conditions):
To be filled out by Staff:
BuenaPark SeniorActivityCenter
Senior Transportation and Runabout
Tlie program is fiinded by many supportive agencies. Tlie following questions are required to participate iii tlie progratn, answers will be held confidential. Your name will not be associated with this infonnation. Please fill out to the best of yorir ability.
Are you the Head of Horisehold (circle one): YES NO
Total Gross Horisehold Aiu'iual Income (Print Here):
Number of People in the Houseliold:
Pleaseanswerthe following basedLIPOII wliat you consider yourself to be. It may be difficult to clioose a single identity if yori have a multicultural heritage; nevertheless, to comply with Federal law yori must choose only one.
For the purposes of this survey, check only one of the following race/ethnic categories you identify with:
€ White (not of Hispanic origin): All persons having oi'igins in any of tlie original peoples of Europe, Nortli Africa, or the Middle East.
€ Black/African American (not of Hispanic origin): All persons liaving origins in any of the Black racial groups of Africa.
€ Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or otlier Spanisli culture or origin, regardless of race.
€ Asian: All persons having origins in any of tl'ie original peoples of tlie Far East, Southeast Asia, tl'ie Indian Subcontinent, or tlie Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Pliilippine Islands, and Samoa.
€ American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and WIIO maintain cultural identification tlirougli tribal affiliation or community recognition. € Native Hawaiian/Pacific Islander: All persons liaving origins in any of tlie original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
€ American Indian/Alaskan Native & White: All persons having origins in any of tlie original peoples of Nortli Ainerica, and who maintain cultural identification throrigh tribal affiliation or comnuuiity recognition and origins in any of tlie original peoples of Europe, Noitli Africa, or the Middle East. € Asian & White: All persons liaving origixis in any of tlie original peoples of tlie Far East, Soritlieast Asia, the Indian Subcontinent, or tlie Pacific Islands axid origins in any of tlie original peoples of Europe, Nortli Africa, or tlie Middle East.
€ Black/African American & White: All persons having origins in any of the Black racial groups of Africa and origins in any of tlie original peoples of Europe, Noitli Africa, or tlie Middle East. € American Indian/Alaskan Native & Black: All persons l'iaving origins in any of the original peoples of Nortli America, and who maintain cultural identification tlirough tribal affiliation or community recognitioii and oi'igins in any of tlie Black racial groups of Africa.
€ Other: Indicate specific ethnic group or national origin with which you identify.
Please Specify:
CERTIFICATION: I l'iereby ceitify tliat, to tlie best of my knowledge, tlie provided information is true ai'id accru-ate.
x
Signature Here
BuenaPark SeniorActivityCenter
Release and Waiver of Liability and Indemnity Agreement In consideration of my voluntary participation in the Buena Park Senior Center Transportation Program, tl'ie undersigned hereby agrees to the following:
The undersigned hereby releases, waives, discharges and covenants not to use the City of Buena Park, its officers and employees (hereinafter referred to as "releases") from all liability to the undersigned for any loss or damage, and any claim or demands therefore on account of injury to tlie person or property or resulting in death of the undersigned, caused by the negligence of the releases or a condition of City property, including City vehicles while the undersigned is using the Program.
The undersigned hereby assumes 'Lull responsibility and save and hold l'iannless the releases and each of them from any loss, liability, damage or cost they may incur due to the voluntary participation of the rindersigned in the Program.
The undersigned hereby assumes Ml responsibility for the risk of bodily injury, death or property damage due to the negligence of the releases or condition of City property, including City vehicles while using the Program.
Tl'ie undersigned fiuther expressly agrees that the foregoing release and waiver of liability and indemnity agreement is intended to be as broad and inclusive as is pen'nitted by the law of the State of Califomia and that if any portion tliereof is held invalid, it is agreed tliat tlie balance sl'iall, notwitlistanding, continue in full legal force and effect.
Tbe undersigned has read and voluntarily signs the release and waiver of liability and indemnity agreement, and furtlier agrees that no oral representation, statements or inducement apart from the foregoing written agreement liave been made.
Signahire of Participant:
BuenaPark SeniorActivityCenter
I,
the progran'i.
, agree to the following guidelines in order to be an active participant in Below is a review of the basic rules of utilizing the Transportation Program, initial each statement:
I will call The Senior Center to schedule an appointment for my pick up days to and from The Senior Center and/or medical/non-medical appointments 2 weeks in advance. I understand all pickups and returns are on a first come, first served basis and availability.
I understand that when using The Transportation Program for Medical purposes, and need ongoing treatment tl'iat Transportation Program will "attempt" but not guarantee to accommodate my appointments for a 6-week period. After that period of time, I will need to make otlier arrangements for transportation.
I understand that any cancellation with tl'ie ST*R trai'isportation is my responsibility, and I will contact the Senior Activity Center in a 241ir notice. The Senior Activity Center is open Monday -Friday from 7:30 a.m. - 5:30 p.m.
I will provide the transportation Coordinator witli name, addressandphone mtmber of IIIY doctor, dentist, pharmacy, and emergency contact information. I understand if this information is not provided, my ride will not be accommodated.
I understand that the program assists Buena Park residents over the age of 60 who want to come to tl'ie senior activity center or for grocery sliopping witliin tlie city limits, or for non-emergency medical transportation within three road miles (driving) of the city limits, and have no other means of transportation.
I rinderstand tlie non-compliance with these guide lines may jeopardize my continued participation in this program
It is my responsibility to be ready for pick up at the arranged time. Three strike rule - if the driver shows up three times and I am not ready or forgot to inform the senior activity center that I would not be coming - I will be put on probation. A fourth time and I will be off the program for four weeks. If it liappens again, I will be out of the program.
There is a large waiting list to utilize the ST*R program to ride to and from the senior activity center and to doctor appointments. I will be prompt and on time for my pickups. The driver is not allowed to come back "later", if I am not ready at tlie time agreed.
Tl'iank you for your interest in the Senior Mobility Program. It may take 2 weeks for new riders to be placed on the list.
City of Buena Park
2026-2027 Community Development Block Grant (CDBG)
Funding Proposal Summary Sheet
Organization Name: City of Buena Park Community Services Department Program Name: Homeless Outreach Program
Estimated Goal: 200 Individuals
Funding Request: $20,000
Organization Purpose:
The City’s Homeless Outreach Program provides services to homeless individuals living in Buena Park. They collaborate with Mercy House at the Navigation Center, the Buena Park Police Department, and other homeless services providers to assist individuals experiencing homelessness. They provide emergency housing solutions, supplies such as food and clothing, assistance with applying for federal and state benefits, medical treatment referrals, and other services to cater to individual’s needs. The Homeless Outreach Team also administers medication in emergency substance abuse cases.
Description of Request:
CDBG funds will be used for temporary shelter costs, relocation expenses, transitional housing fees, emergency/safety supplies, transportation, DMV/vital documentation fees, and program staff training.
Analysis of Request:
The 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. CDBG funds are used to provide direct services to clients. Overall, this program helps meet the City’s goal and HUD’s requirement for continuum of care to assist the homeless population.
Funding Recommendation:
Staff recommends funding in the amount of $19,500.
City of Buena Park
FY 2026-2027 Community Development Block Grant (CDBG) Program Application Checklist
Please complete, sign, and include this checklist with your application Required For All Applicants:
[ZI Completed FY 2026-2027 CDBG Grant Application
Ef'Copy of current client intake form for proposed activity € N/A (only if activity is LMA)
[ZI Signed Acknowledgement Regarding Bidder SAM Registration form (Attachment 4) [ZI Signed Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions form (Attachment 5)
Required For Nonprofit/Outside Orqanizations:
€ Proof of active nonprofit status (IRS determination letter) € List of Board of Directors (board member names and titles) € Copy of current organizational chart
€ Copy of current lease (if CDBG funding request involves rental expenses) [] Completed Zoning/Land Use Approval Form (Attachment 6), if located in the City of Buena Park Organization/City Department Name: Community Services, Homeless Outreach Services Submitted By: Rosemary Nielsen
(Print Name, Title) 1(SRlgn)r!1A/)'l!:)r'nJA0 1(Date)/'/"?/'15 RECEiVED
DEC18 2025
ECONOMIC DEVEIOPMENT
Attachment 2
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 (July 1, 2026 - June 30, 2027)
CDBG FUNDING APPLICATION
DUE BY DECEMBER 18, 2025 AT 5:00 PM
Organization/City Department Name Community Services, Homeless Outreach Services Activity/Program Name Homeless Outreach Services
Address
8150 Knott Ave, Buena Park. Ca 90620
Contact Person/Title Rosemary Nielsen/Community Services Supervisor Email Address
[email protected]
Phone Number (714) 236-3876
Activity Type (select one) [ZI Public Service Activity € Other CDBG Eligible Activity Organization Type (select one)
[3 City Department
€ Nonprofit 501 (c) (3) organization
€ Other (i.e. public agency)
Amount of CDBG Funds Requested $ 20,000
1. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including all persons regardless of residence):
Estimated Goal: 200 [] Individuals € Households
2. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including ONLY Buena Park residents):
Estimated Goal: 200 G Individuals € Households
Icertify under penalty of petjuiy that the information provided in this CDBG funding application is true to the best of my knowledge.
12/1 € /25-
Date
0rganizajl()n%Hl1le:COmmun:17SeNICeg,HOmeleSSOLllTeaCHS(irVlt-eS Pl-()g(Hlll %HIII(; HomelessOutreachServiCeS Please answer each of the following questions. 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), 570.2C)1-570.208, 570.503]
Describe the proposed activity, including services to be provided and goals to be accomplished. a) Why is there a need for this activity in the City of Buena Park? b) Identify the location of the activity and the service area boundaries. c) Describe specifically the intended use of the CDBG funds.
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 and Emergency Supplies, Local Transportation/DMV Fee's, Documentation/ID fee's and Staff Training.
2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population/demographic for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2026 through June 30, 2027. a) How was the estimated number of clients determined?
b) How will you reach your target population?
c) Explain why this activity is needed for this target population.
The proposed program is designed to serve individuals who face significant social, economic, and structural barriers to achieving stability and long-term success. Our primary target population is those experiencing homelessness or at risk of homelessness. This population is disproportionately impacted by limited access to quality educational, economic, and health-supportive resources. Many participants encounter multiple intersecting challenges, including; homelessness, underemployment, food insecurity, chronic health disparities, no transportation and feeling of helplessness. The program will prioritize outreach to individuals who identify as unhoused. to ensure equitable access to services. By addressing unmet needs and connecting participants with targeted support, the initiative aims to reduce homelessness and improve quality of life, and strengthen long-term community outcomes.
The Program will target individual who live or work in the City or Buena Park. Historically 200 individuals have been assisted per year.
Application Page 2
Organization N rune· Community Services, Homeless Outreach Services Program Name: Homeless Outreach Services 3 NATIONAL OBJECTIVES
f24 CFR 570.200/al, 570.201-570.208, 570.5031
Describe in detail how the activity meets at least one of the three CDBG Program national objectives.
Select one then explain in the space below:
0 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.
Benefits to the Community Investing in services for individuals experiencing homelessness strengthens the entire community by promoting stability, safety, and long-term sustainability. When the needs of the homeless population are effectively addressed, the community experiences measurable social and economic benefits, including:
1. Improved Public Health Access to shelter, improves overall community
2. Increased Public Safety Stable housing and supportive services reduce the likelihood of survival-based activities such as trespassing or loitering
3. Reduced Strain on Emergency Services Homelessness is closely linked to high utilization of emergency rooms, crisis intervention, and first-responder services.
4. Economic Savings and Efficient Use of Public Funds Evidence consistently shows that supportive housing and wraparound services are more cost-effective than repeated emergency interventions. Communities save money through reduced hospital visits, incarceration costs, and shelter turnover.
5. Enhanced Community Cohesion and Equity Addressing homeless demonstrates a commitment to compassion, fairness, and inclusion.
4 BUDGET
[24 CFR 570.502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and 0MB Circular A-87, A-122, Treasurv Circular No. 10751 Provide the total administrative and/or operational costs for the proposed activity. Cost Category may include: staff salaries and benefits, rent/lease, supplies, utilities, etc. k ),;; Cost CategOty
'. CDBG Fundiri!:f •·.·· .. • ,c OthElr .Funding .. . :., I<· T\ifalC9st · .. · ... Reauest ' -, ·,.; •.. Sources•? ' '··. . · .. · Motels/Room Rentals $ 5,000 $ $
Relocation/Storane Exnenses $ 2,000 $ $
Tra'"'sitional Housinn Fet=>s $ 2,000 $ $
Emernenc"/Safet" Supplies $ 2,500 $ $
Transnortation $ 5,500 $ $
OMV/Vital Documentation $ 1,000 $ $
StaffTraininn Conference/Edu/Su"'lies $ 2,000 $ $
Salaries/Benefits $ $ 390,800.00 $
Educational Incentive $ $ 4,200.00 $
Office Su""lies/Snecial $ $ 1,000 $
Total $ $ 396,000.00 $
Application Page 3
Organization Name: CommunityServices,HomelessOulreachServices prOgralll Name: HomelessOulreachServices 5 ELIGIBILITY DOCUMENT ATION
Describe the form of documentation that is 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.
'Clients served by the Homeless Outreach Program must 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 which include:
renting or owning a home, going to school or working within the city.
Documentation consists of intake sheets, hot line logs, drop-in logs and HMIS and Outreach Grid data. 6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity's and that will be used to measure and track the activity's performance. Refer to the definitions on Page 6 of the RFP.
A. Select one :
[] Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one Outcome:
[a Availability/Accessibility
€ Affordability
€ Sustainability
Application Page 4
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.
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.
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 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 bidder's SAM registration:
Entity Name: Homeless Outreach Services
AddreSS: 8150 Knott Ave
City: Buena Park
Unique Entity ID (UEI): NUK2QVHWF623
ActiveExclusions(SelectOne): OYes []No
State: Ca Zip: 90620
Expiration Date: 3/17/26
Attachment 4
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNT ARY EXCLUSION LOWER TIER COVERED TRANSACTIONS Tliis certif'ication is required by tlie regulations iinpleinenting Executive Orders 12549 and 12689, Debarment and Suspension, and 2 CFR Pait 200, Participants' responsibilities. (BEFORE COA4PLETING CERTiFiCA TjON, READ iNSTRUCTjONS BELOW) (1) The prospective lower tier paiticipant ceitifies, by submission of t)iis proposal, that neither it nor its principles are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded froin paiticipation in tliis transaction by any Federal depaitment or agency. (2) Wliere the prospective lower tier paiticipant is unable to ceitify to any of the statements in this certification, such prospective paiticipant s)iall attacli an explanation to tliis proposal.
Organization Name: Buena Park Homeless Services
AddreSS: 8150 Knott Ave Buena Park Ca 90620
Jim Box, Director of Community Services
Name and Title of Autliorized Representative
By signing and subinitting tliis proposal, tlie prospectiv l er tier paiticipant is providing tlie ceitification set out below.
2. Tlie ceitification in tliis clarise is a material representation of fact upon wliich reliance was placed wlien this transaction was entered into. If it is later determined that tlie prospective lower tier participant knowingly rendered an erroneous certiflcation, in addition to otlier reinedies available to the Federal Government, tlie depaitinent or agency witli wliicli t)iis transaction originated inay pursue available remedies, including suspension and/or debarinenl.
3. Tlie prospective lower tier pailicipant shall provide iminediate written notice to the person to wliich tliis proposal is sribinitted if at any tiinc tlie prospective lower tier paiticipant learns that its ceitification was erroneous wlien subinitted or lias becon'ie erroneous by reason of clianged circui'nstances.
4. The terins "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "patticipant", "person", "priinary covered transaction", "principal", "proposal", and "voluntarily excluded", as used in tliis clause, liave tlie ineanings set out in t)ie Definitions and Coverage sections of rules iiriplementing Executiye Orders 12549 and 12689.
5. Tlie prospective lower tier pai'ticipant agrees by subinitting tliis proposal t)iat, should tlie proposed covered transaction be entered into, it sliall not knowingly enter into any lower tier covered transaction wit)i a person who is debarred, suspended, declared ineligible, or voluntarily excluded from paiticipation in tl'iis covered transaction, rinless aut)iorized by the depaitinent or agency with which t)iis transaction originated.
6. The prospective lower tier paiticipant fuither agrees by submitting tliis proposal that it will include the clause titled "Ceilification Regarding Debarment, Suspension, Ineligibility and Voluntai'y Exclusion-Lower Tier Covercd Transactions", witliorit inodification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
7. A paiticipant in a covered transaction may rely Lll)Oil a ceitification of a prospective paiticipant in a lower tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded froin tlie covered transaction, unless it knows that tlie ceitification is erroneous. A paiticipant may decide tlie method and frequency by wliicli it deterinines t)ie eligibility of its principals. Each participant may clieck tlie System for Award Manageinent (SAM).
8. Nothing contained in tlie foregoing shall be construed to require establisliment of a systei'n of records in order to render in good faitli tlie certification required by this clause. T)ie knowledge and information of a paiticipant is not required to exceed tliat wliich is normally possessed by a prudent person in t)ie ordinary course of business dealings.
9. Except for transactions autliorized under paragrap)i 5 of tliese instructions, if a paiticipant in a covered transaction knowingly enters into a lower tier covered transaction witli a person wlio is suspended, debarred, ineligible, or voluntarily excluded froin paiticipation in tliis transaction, in addition to otlier rei'nedies available to the Federal Governn'ient, tlie depaitment or agency witli wliicli this transaction originated inay pursue available remedies, including suspension and/or debarinent.
Attachment 5
Community Services Department
HOMELESS OUTREACH PROGRAM
Access ID No.
Interviewed By
*Full Name
*Birthdate
*Race
*lncome Level
Place ofOrigin
Hame / Mailing Address
NEW CLIENT INT AKE FORM
Outreach Worker
Date
G=nd=r
*Hispanic
*Type (Homeless or Other)
QVhat broughi them [0 Bci=na Part-.'
Priano Narna=:
ID 'Y' / N
Wha[ Stage"
Sociai Sq,:uri:y Card Y / N
lvna- SiaCe
Do ag) oN:heie condi[ian; C) Disabi:ity € M.=ntal lilriess Pro,iirl,=r apply Co yoa" Pl=as= che,:J. € HIV/AIDs € Sitbstanixe Abiis= lIJi Chron= H-oalrh Coridi[iari -BP Resident *Verified by
Be Ce n r ReS'Clerl C't ('-'i-8 , IZiJ S Ie3Se ot 8 ,i Cl'l S Ll':ll '[1/ Ser';iCe V{'rlt,Ten Cl)-l"l" I-I 3'l S:-l t3' i ,E151lj,,; t'JJ} SJt'i.J)@, p,j,: l) 4',yi5) Proofof Srrong Ti=s PD / :ire R=feri a' / Cod= Enforcerr=n+ Medically Compromised / Age 60- years
Veteran BrarichoFService
[] High Vuln € Moderate Vuln
Nam: of cltyl' Offiaa'
DD2 14
[] Lovi Vuln.
BP Resident Verification
II amcertifying thatthecltent hasbeenhomeless, andlhaveveriftedthattheclient isaBuenaPrkResi Date
City of Buena Park
2026-2027 Community Development Block Grant (CDBG)
Funding Proposal Summary Sheet
Organization Name: Mercy House Living Centers
Program Name: Buena Park Navigation Center
Estimated Goal: 130 Individuals
Funding Request: $30,000
Organization Purpose:
Mercy 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.
Description of Request:
The program offers a safe environment for homeless individuals accessing emergency housing at the Buena Park Navigation Center. Services include housing navigation, enrichment activities, health care resources, drug and alcohol treatment referrals, employment placement referrals, and much more.
CDBG 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 dinner. The meals are prepared by an outside vendor and distributed by staff and volunteers at their on-site kitchen.
Analysis of Request:
This 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:
Staff recommends funding in the amount of $26,000.
City of Buena Park
FY 2026-2027 Community Development Block Grant (CDBG) Program Application Checklist
Please complete. sign, and include this checklist with your application Required For All Applicants:
u Completed FY 2026-2027 CDBG Grant Application
[fi Copy of current client intake form for proposed activity 0 N/A (only if activity is LMA)
52fSigned Acknowledgement Regarding Bidder SAM Registration form (Attachment 4) u Signed Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions form (Attachment 5)
Required For Nonprofit/Outside Orqanizations:
O Proof of active nonprofit status (IRS determination letter) UJ List of Board of Directors (board member names and titles) d Copy of current organizational chart
€ Copy of current lease (if CDBG funding request involves rental expenses) u Completed Zoning/Land Use Approval Form (Attachment 6), if located in the City of Buena Park Organization/City Department Name: Mercy House Living Centers Subm!tted BY: Cayman Beeman, Grants Specialist
(Print Name, Title)
/ "'7trzati &e'tpztz
(Sign)
/11 /26/2025
(Date)
RECEIVED
DEC15 2025
ECONOMIC DEVEIOPMENT
Attachment 2
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 (July 1, 2026 - June 30, 2027)
CDBG FUNDING APPLICATION
DUE BY DECEMBER 18, 2026 AT 6:00 PM
Organization/City Department Name Mercy House Living Centers Activity/Program Name Buena Park Navigation Center
Address p.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
Activity Type (select one) FL Public Service Activity [1 0ther CDBG Eligible Activity Organization Type (select one)
€ City Department
€ Nonprofit 501(c) (3) organization
€ Other (i.e. public agency)
Amount of CDBG Funds Requested $30,000
1. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including a// persons regardless of residence):
Estimated Goal: 300 En Individuals € Households
2. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including ONLY Buena Park residents):
Estimated Goal: 130 ThIndividuals g Households
Icertify under penalty of perjury that the information provided in this CDBG funding application is true to the best of my knowledge.
(Signature !L representative)
1l /26/2025
Date
Larry Haynes, Chief Executive Officer
(Print name and title of authorized representative)
Organization Name: Mercy House Living Centers Program Name: Buena Park Navigation Center Please answer each of the following questions. 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. a) Why is there a need for this activity in the City of Buena Park? b) Identify the location of the activity and the service area boundaries. c) 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 1l 8% 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 of 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:
I 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.
J Crisis Evaluation/Mental Health Resources - Shelter guests are connected to on and off-site health resources through KCS Health Center and various departments of the County of Orange.
Application Page 2
Application Page 3
2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target popuiation/demographic for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2026 through June 30, 2027. a) How was the estimated number of clients determined?
b) How will you reach your target population?
c) Explain why this activity 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.
Application Page 4
Organization Name: Mercy House Living Centers Program Name: Buena Park Navigation Center 3 I
I
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 then explain in the space below:
rS!iBenefit low- and moderate-income persons in Buena Park; € Aid in the prevention or elimination of slums or blight in Buena Park; Ul Meet 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 E: 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 2025 Consolidated Plan. The Buena Park Navigation Center is an integral investment that the City has been to support its goals in this area.
Application Page 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] Provide the total administrative and/or operational costs for the proposed activity. Cost Category may include: staff salaries and benefits, rent/lease, supplies, utilities, etc.
Cost Category
CDBG Funding
Request
Other Funding
Sources
Total Cost
Salaries + Benefits $ $1 ,560,224 $1,560,224
HR Expenses $ $8,000 $8,000
IT Systems and Services - Indirect $ $13,000 $13,000
Payroll Services $ $9,649 $9,649
Communications $ $3,000 $3,000
Audit Fees $ $5,000 $5,000
Office Rent $ $7,500 $7,500
Storage $ $2,000 $2,000
Staff Training $ $2,000 $2,000
Mileage $ $1,000 $1,000
Volunteer Expenses $ $1,000 $1,000
Office Supplies $ $9,000 $9,000
IT Systems and Services - Direct $ $10,000 $10,000
HMIS $ $500 $500
Communications - Direct $ $1,500 $1 ,500
Insurance Policies $ $30,605 $30,605
Equipment Leases & Rentals $ $2,000 $2,000
Utilities/ Disposal $ $102,000 $102,000
Repairs / Maintenance/
Landscaping
$ $30,000 $30,000
Laundry Rental $ $2,976 $2,976
Facility Fixtures, Equipment and
Furniture
$ $5,000 $5,000
Animals/Veterinary $ $18,000 $18,000
Supplies $ $87,940 $87,940
Security (Guards) $ $197,444 $197,444
Client Food and Snacks $30,000 $204,203 $234,203
Transportation ASSiSt $ $2,000 $2,000
Client services/Barrier Fund $ $8,000 $8,000
Shuttle, Fuel and Maintenance $ $45,600 $45,600
Total $30,000 $2,369,140 $2,399,140
Application Page 6
Organization Name: MercyHouseLivingCenters Program Name: BuenaParkNavigationCenter 5 ELIGIBILITY DOCUMENT ATION
Describe the form of documentation that is 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.
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 that verifies where the client was living (place not meant for human habitation, park, shelter, etc.) prior to referral. Additionally, a Declaration of Homelessness is completed and placed in the client's case file attesting 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 also collected on the intake form. Homeless individuals who are considered "residents of Buena Park" include those who self-report prior residency in the City of Buena Park or who spent the last night prior to shelter entry in the City of Buena Park.
Data from these intake forms (as well as forms completed at exit from the program) is inputted by a dedicated 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 quarterly CDBG reports as well as additional outcome reports.
Please reference Attachment E: Intake Form and Intake Documents to review documents described in this section.
6 OUTCOME PERFORMANCE MEASUREMENT SYSTEM
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Please indicate the activity's and O that will be used to measure and track the activity's performance. Refer to the definitions on Page 6 of the RFP.
A. Select one:
'a Suitable Living Environment
€ Decent Affordable Housing
€ Economic 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:
u Availability/Accessibility
0 Affordability
€ Sustainability
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.
Application Page 7
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.
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 oragency.
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 transactionoriginated.
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 without modification, in all lower-tier covered transactions and in all solicitations for lowertier coveredtransactions.
Provide the following information as detailed in the prospective bidder's SAM registration:
Entity Name: Mercy House Livinq Centers
Address: 6494 Caballero Blvd.
City: Buena Park
Unique Entity ID (UEI): DVJ5XQ7BMQ88
ActiveExclusions(SelectOne):[1 Yes IglNo
State: CA Zip: 90620
Expiration Date: 9/25/2026
Attachment 4
MERCY*HOUSE
ATTACHMENT A
NONPROFIT STATUS
P.0. Box 2508
Cjan(-ln!1a'CJ- OH 452()I
I n r ep I y r e fer t o : 0 2
jS,(1 g , 18, 2 011 I T R 416
.s:s-a:sxssbq oooooo oo
BODC
16430
MERC'v" it[J(ISE LIVING CENTERS
Pa BOX 1905
SANTA ANA CA 92702-1905
Employer Idei'itification Number : 33-0315864
Person to Contact ! Toriya Morris
l-oll Free Telephone Number: 1-877-829-5500
Dear Taxpayers
This is in response to your Aug. 09, 2011, recBiest for in'fornia regarding your tax-exenipt statcis.
Our records indicate that you were recognized as exempt under section 501.(c) (3) of the Internal Revenue Code in a deterniinat letter issued iri Apri.]. 1989.
Our records al.so indicate tliat you are not a private 'focmdatio the meaning of section 509(a) of the Code becacise you are desc s e c 't i o ri ( s ) 5 0 9 ( a ) (1 ) a n d 17 0 € b ) (1 ) ( A ) ( v i ) Donors inay deduct con'tributions to you as provided in section t)ie Code. Bacluests, legacies, devises, transfers, or gifts to for yonir i.ise are deductible for Federal estate and gift tax pt. if they ineet tl'te applicable provisions of sections 2055i 2106p 2 5 2 2 o f t h e C o d e.
our website www.irs.gov/eo
Specifically, section
failure to
Please refer to our website www.irs.gov/eo for inforniation reg filing requiraements. Specifically, section 6033(j) of the Code provides that failure to file ai'i annual inforination return for consecutive years results in revocation of tax-exempt statcis E t h e f ili n 9 Clu e d a 't e o f t h e t h i r d r e t ci r n f o r o r g a n i z a t i o n s r e q ( file, We tsiill pi.i!ili.sh a ].ist of organizations whose tax-exempt status vas revoked under sectior'i 6033(j) of the Code on our we beginning in early 2011.
Acig. 18i 2011 LTR ?
33 - 0 31586 4 0 0 0 0 0 0
MERCY HOUSE LIVING CENTERS
Pa BOX 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 yoursy
S. A. Martin s Operations
ACCO LlnfS Manag eflT en t Operaf
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
06/29/1 988
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
SAMS REGISTRATION
Ltrsrupdaredb,v.41hsonDasienpm tii Sep25. '025 ai 06'38 PAr[ MERCYIIOUSE Ljll[NG CENTERS ,uJSAM*GO\/'
MERCY HOUSE LMNG CENTERS
Unique Entity ID
DV J5XQ7BMQ88
Registration Status
Active Registration
Physical Address
807 N Gafield ST
Santa Ana, California 92701-3821
Llnited States
CAGE / NCAGE
49VY8
Expiration Date
Sep 25, 2026
Mailing Address
p.o. Box '1905
Santa Ana, California 92702-1905
Llnited States
Purpose of Registration
All Awards
Doing Business as
(blank)
Division Name
(blank)
Division Number
(blank)
Congressional District State/Country of Incorporation LIRL California 46 California/Llnited States www.mercyhouse.net Registration Dates
Activation Date Submission Date Initial Registration Date Sep 29, 2025 Sep 25, 2025 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 H), 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 cooperative 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 1 3(a) or 1 5(d) of the Securities Exchange Act of 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 $10,000,0007 Not Selected
Whin the last five years, had the business or organization (represented by the Unique Entity ID 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 faulI (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 $100,000, or other acknowledgment of fault?
Not Selected
(C
m
I[isi
kWj
It
J y -,
if
= d- - * W"m 0 + * - 0 0 'l Lj m l
INrps //siai.i gowenrrry/Dloj5YQ7BA4Q88/coreDara?s[alus-mdl Page / ii/ 3 LasL updaled b)i.41Hwn Dasienporl on Sep '5. '025 al 06 38 PM MERCYIIOUSE L[VlNG CENTERS Active Exclusions Records'
No
I authorize my entity's non-sensitive information to be displayed in SAM public search results.
Yes
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 52.2al2-3 or FAR 52.219-'1 to determine if the entity is an SBA-certified HLIBZone small business concern. Additional small business information may be found in the SBA's [)ynamic Small Business Search if the entity completed the SBA supplemental pages during registration.
Accepts Credit Card Payments
Yes
EFT Indicator
0000
Electronic Funds Transfer
Account Type
Checking
Financial Institution
WELLS FARGO BANK NA
Automated Clearing House
Phone (U S )
94975677 49
Fax
(blank)
Remittance Address
MERCY HOUSE
p.o. Box 1905
Santa Ana, California 92702
Llnited States
Debt Subject To Offset
No
CAGE Code
49VY8
Routing Number
*******47
Account Number
*******g 4
Email
(blank)
Lock Box Number
(blank)
Phone (non-U S )
(blank)
EIN
"""5864
Tax Year (Most Recent Tax Year)
2024
Address
807 N. Garfield ST.
Santa Ana, California 92701
Type of Tax
Applicable Federal Tax
Name/Title oflndividual Executing Consent
Chief Impact Officer
Signature
Allison Davenport
Taxpayer Name
MERCY HOUSE LMNG CENTERS
TIN Consent Date
Sep 25, 2025
Accounts Receivable POC
Mary Ellen Gross, Ms.
[email protected]
7148367188
Sep 29. "025 In /4 42 PA4 GirfT
liLLps//S(till Hov/pnft@/DI U5YQ7BA4Q88/coreDa[a%lnlus-null Page2of3 Ltrsl upda(ed by.41lisori Dasienpori on Sep '5, '!025 ar 06 38 PM A4ERCY110USE LIIIINGCENTERS Electronic Business
Patti Long, Mrs.
[email protected]
7148367188
Allison Davenport, Mrs.
Allisond@Mercyhouse. net
7148367188
Government Business
P.
Larry Haynes, Mr.
[email protected]
7148367188
Patti Long, Mrs.
[email protected]
7148367188
Past Performance
Allison Davenport, Mrs.
[email protected]
714836T188
Paiti Long, Mrs
[email protected]
7148367188
p.o. Box 1905
Santa Ana, California 92702
Llnited States
P O. Box '1905
Santa Ana, Califomia 92702
United States
p.o. Box 1905
Santa Ana, California 92702
Llnited States
p.o. Box 1905
Santa Ana, Califomia 92702
United States
Pa Box 1905
Santa Ana, California 92702
United States
Pa Box 1905
Santa Ana, Califomia 92702
united States
NAICS Codes
Primary
Yes
NAICS Codes
813410
NAICS Title
Civic And Social Organizations
IGT Size Metrics
Annual Revenue (from all IGTs)
(blank)
Worldwide
Annual Receipts (in accordance with 13 CFR 121 )
$64,000,000.00
Location
Annual Receipts (in accordance with 13 CFR 121 )
(blank)
Industry-Specific
Barrels Capacity
(blank)
Number of Employees (in accordance with 13 CFR 121)
705
Number of Employees (in accordance with 13 CFR 121)
(blank)
Megawatt Hours
(blank)
Total Assets
(blank)
This entity did not enter the EDI information
This entity does not appear in the disaster response registry.
Sep29. 2025 H) 14 42 PA4G-rl7'
hirps //soni gov/enrit)/DI :i5.YQ7Eil4Q88/coreDara?sralus-mdl Page 3 of 3 MERCY*HOUSE
ATT ACHMENT C
CERTIFICATION REGARDING
DEBARMENT AND SUSPENSION
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNT ARY EXCLUSION LOWER TIER COVERED TRANSACTIONS Tliis certification is required by the regulations implementing Executive Orders 12549 and 12689, Debari'nent and Suspension, and 2 CFR Part 200, Participantsa responsibilities. (BEFORECOAifPLETINGCERTjFICATiON, RjEAD [NSTRUCTIONS BELOW) (l) 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: Mercy House Living Centers
Address: 6494 Caballero BJvd., Buena Park, CA 90620
Larry Haynes, Chief Executive Officer
Name and Title ofAuthorized Representative
11 /26/2025
Date
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 tii'ne 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", "debaned", "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 andl2689.
5. The prospective lower tier paiticipant 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 voltintarily excluded from participation in this covered transaction, unless authorized by tlie department or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this proposal that it will include tlie 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 deten'nines 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 ceitification required by this clause. The knowledge and information of a participant is not required to exceed that wliich 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 department or agency with which this transaction originated may pursue available rei'nedies, including suspension and/or debarment.
Attachment 5
MERCY*HOUSE
ATTACHMENT D
ZONING/LAND USE APPROVAL
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 CDBG FUNDING APPLICATION
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.
Mercy House Living Centers
Name of organization
P.0. Box 1905, Santa Ana, CA 92702
Address of organization
Larry Haynes, Chief Executive Officer
Applicant name and title
714-736-7188 ext. 101, [email protected]
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)
Mercy House Living Centers operates CDBG-eligible Public Service activities (emergency shelters for homeless individuals) at the Buena Park Navigation Center located at 6494 Caballero Blvd in the City of Buena Park. The shelter site is owned by the city of Buena Park, Mercy House Living Centers is a contracted operator of the City.
Applica!:re
11 /26/2025
Date
To be completed by the City of Buena Park Planninq Department Use classification
Zoning
g Permitted Use
0 Conditional Use Permit Required
Comments:
Signature of Planning Department Representative Date
Attachment 6
MERCY*HOUSE
ATT ACHMENT E
INT AKE FORM
INTAKE DOCUMENTS
MERCY*HOUSE
Guest Casefile Summary
Intake
Date of Intakpa
Program Namt" Buena Park Navigation Center
Guest's Nampa
Referred Bya
Navigator
Date of first Strength Assessment/Housing Plan:
CEHNA
Date CEHNA Completed:
Doc Ready Datp:
Match Date:
Matched Agency:
Match Typp:
(For Programs Using Vl-SPDAT)
Vl-SPDAT Score:
Exit Information
Exit Date: Client Housed (Circle One): Yes No
Data Entry
HMIS Identifier:
HMIS Enrollment Completed on date:
HMIS Exit Completed on date:
MHSGuestCasefileSummary Revised03/14/2025
MERCY*HOUSE
Guest Casefile Check List : Section 1
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Client Piiota
Referral Forms
Proof of Eligibility (NSOPW & Warrants)
Diversion Questionnaire
HMIS Consent Form & ROI
HMIS Intake Packet
HMIS Current Living Situation
HMIS Status Update/Annual Assessments
CES Authorization Form
CDBG Form
Authorization for ROI and Participation
Mercy House Release of Info Disclosure
VA Release of Information Form (if applicable)
Guest Expectations
Guest Rights & Responsibilities
ADL Agreement
Bed Assignment Agreement
Guest Storage Agreement
Medical Equipment Agreement Form
Grievance Policy
Guest Exit Policy
Outreach Grid Consent Form
Copies of ID/Driver's License
10 Voucher/10 Reciept
Copies of Social Security Cards
Copy of Birth Certificate
Birth Certificate Application
BPNC.CasefileSectionChecklist Section I Revised03/18/2025 MERCY*HOUSE
DIVERSION QUESTIONNAIRE
Guest"sName: Staff"sName:
Program Name: Buena Park Navigation Center
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 shelterfor 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 housin(3 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. Ifyouwerestayingwithsomeoneisitpossibleorsafeforyoutocontinuestayingthere? Yes No
If yes, how long can you stay? Days Weeks Months
3. Whatotherhousingoptionsdoyouhaveforthenextfewdays/weeks? MHS DiversionQuestionnaire Revised6/23/2025
4. What are some issues that exist in your current housing situation that we can try to help you resolve?
€ Family/friends asked to leave
€ No family/friends to stay with
€ No/lack of employment orincome
€ No potential for increased income
€ Drug/alcohol problem
€ Disabled
€ Fleeing from domestic violence/abuse
€ Victim of human trafficking
€ Just moved to the area
€ Other-Pleaseexplain:
For Mercy House Staff Use only:
This person is ELIGIBLE to stay at this shelter while working toward their housing plan.
This person is INELIGIBLE for diversion assistance (note reason below).
Staff Notes:
Guest's Signature Staffs Signature
MHS DiversionQuestionnaire Revised6/23/2025
Revised10/2025
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 Management Information System (HMIS). HMIS is the secure database used to collect and store information about clients 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, service providers/organizations that participate in HMIS share data with each other to coordinate care and improve program outcomes. If you sign this consent form, you agree to allow information gathered by a participating service provider/organization to be shared in HMIS with other service providers/organizations that have access to HMIS. This allows 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 you have received in the past in Orange County. Signing this consent form also means that your data may be included in data requests approved by the CoC Board for academic research purposes, analysis of the homeless system of care, or other purposes as deemed appropriate by the Board.
A complete list of all service providers/organizations that participate in the HMIS is maintained at http://ochmis.or@/abouthmis/contributing-agencies/. You can also ask the service provider/organization you are receiving services from for a list of HMIS participating service providers/organizations. Please note that the list of service providers/organizations with access 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:
* lndividualclientdataisonlyviewablebytrainedstaffateachparticipatingserviceprovider/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 during your intake, assessment, and enrollment in the program. This may include, without limitation, the following:
* Your name and your contact information
* Your social security number and date of birth
* Your basic demographic information such as gender, race and ethnicity * Your history of homelessness and housing (including your current housing status, and where and when you have accessed services)
* Your medical history and disabling conditions, including 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 * Information about other members of your household
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)
By signing this form, you understand the following:
If you feel any of your rights outlined in this document have been violated, please contact (714) 589-2360.
Revised10/2025
You have the right to receive servlces 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 rizht to receive a copy of this consent form for your records.
Your consent permits your data to be shared in HMIS and allows participating service providers/organizations to view your history of homelessness and service utilization. Service providers/organizations can also add to or update yourinformation in HMIS without asking you to sign another consent form. Your consent also permits your data to be included in data requests approved by the CoC Board for academic research purposes, analysis of the homeless system of care, or other purposes deemed appropriate by the Board.
This consent form expires seven (7) years after the signature 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 chanted. However, data stored in HMIS will no longer be shared in HMIS or data requests upon the expiration of your consent, or if you revoke your consent.
* You may revoke your consent to share your information with other HMIS participatinH service providers/orzanizations at 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; it should be readily available to you and conspicuously posted at all participating service provider/organization locations. Upon receipt of your revocation, the HMIS Lead will ensure your record is no longer shared with service providers/organizations in the HMIS database. However, the PPIand 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.
There are some situations where your data may be shared without consent. Participatin@ agencies are required to post a Privacy Notice at each location where intakes are completed. The Privacy Notice contains more detailed information about how your information may be used and disclosed; it 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 ofinformation. This information is to be provided to you within five (5) business days of your request.
o A correction ofinaccurate or incomplete PPI and/or PHI o Acopyofyourconsentform
o A copy of your HMIS record (visit the Client Record Request page https://ochmis.orH/hmis-client-record-requests/ for more information about this process)
Aggregate or statistical data that is released from the HMIS database will not disclose any of yourPPl or PHI * You are not waiving any rights protected under Federal and/or California law.
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 your information with other participating organizations as described in this consent form.
Client Name: Date Of Birth (DOB): /
Signature: Date Signed: / /
Minor Children (if applicable and/or if you choose to include them):
Name:
Name: DOB: / /
DOB:l
Name: DOB: / / Name: DOB://
Agency Staff Signature:
Agency Staff Name: %ency Staff Signature:
Agency Name: Date: / /
If you feel any of your rights outlined in this document have been violated, please contact (714) 589-2360.
Revised 1 €1/2025
Orange County Continuum of Care
Homeless Management Information System Participating Service Providers/Organizations Please note that the list of service providers/organizations with access to HMIS can change frequently and without notice, and therefore the website should be consulted for the most recent list - http://ochmis.orz/about-hmis/contributinzagencies/.
The following service providers/organizations are participating in the Homeless Management Information System (HMIS).
These service providers/organizations have the ability to enter data into HMIS and/or view the client's information previously entered by other HMIS participating service providers/organizations, including utilization of homeless services in Orange County.
1736 Family Crisis Center
2110C
A Community of Friends
Abrazar, Inc.
Advanced Healthcare
Administration
AltaMed Health Services
American Family Housing
Anaheim Housing Authority
Anaheim Supportive Housing
APAIT
April Parker Foundation
Asian American Senior Citizens
Service Center
Be Well QC
CalOptima
Casa Teresa
Casa Youth Shelter
Celebrating Life Community
Health Center
CEO Outreach and Engagement
City Net
City of Buena Park
City of Costa Mesa
City of Dana Point
City of Fullerton
City of Garden Grove
City of Huntington Beach
City of Irvine
City of La Habra
City of Laguna Niguel
City of Lake Forest
City of Mission Viejo
City of San Clemente
City of San Juan Capistreino
City of Stanton
City of Westminster
Colette's Children's Home
Community Action Partnership of
Orange County
County of Orange/Office of Care
Coordination
Covenant House California
Encompass Housing
Families Forward
Families Together of Orange
County
Family Assistance Ministries
Family Health Matters - North
Orange County Regional
Health Foundation
Family Promise of Orange County
Family Solutions Collaborative
Friendship Shelter
Grandma's House of Hope
Health Care Agency - Housing and
Supportive Services
Healthcare In Action
Helping HandLlps
HIS-QC
Hope Center of Orange County
Housing for Health California
Hub Resource Center
Illumination Foundation
Jamboree
JMh - Anaheim Foundation
Korean Community Services, Inc.
Last Is First Philanthropies
Lutheran Social Services of
Southern California
Mariposa Women & Family Center
Mental Health Association
Mercy House
Mindful Living Center
Moving Forward Psychological
Institute, Inc.
New Directions for Veterans
Nurturing Care LLC
QC Rescue Mission
Orange County Asian and Pacific
Islander Community Alliance
Orange County Housing Authority
Orange County Llnited Way
People Assisting the Homeless
(PATH)
Pathways of Hope
Project Kinship
Radiant Health Centers
Salvation Army
Santa Ana Housing Authority
Share Our Selves
South County Outreach
Serving People In Need (SPIN)
StandUp for Kids
The Orangewood Foundation
Thomas House
US Veterans Initiative
VA Long Beach Healthcare System
Volunteers of America Los Angeles
(VOALA)
Waymakers
We Care Los Alamitos
WISEPlace
The following service providers/organizations have restricted access in HMIS. This means that the service providers/organizations are limited to only entering data into HMIS are not able to view client's history, files, project enrollments, etc.
Santa Ana Police Department
If you feel any of your rights outlined in this document have been violated, please contact (714) 589-2360.
BUENA PARK NAVIGATION CENTER
HMIS SUPPLEMENTAL ENTRY FORM
Effective Date: October 22, 2024
City participant lived in prior to becoming homeless (PRIOR CITY) o
o
o
o
o
o
o
o
o
Brea
Buena Park
Cypress
Fullerton
Garden Grove
La Habra
La Palma
Los Alamitos
Orange
o
o
o
o
o
o
o
o
o
Placentia
Stanton
Villa Park
Yorba Linda
Anaheim
Orange County-outside the NSPA
Other County in California
Outside the State of California
Outside the United States
Type of setting participant lived in before becoming homeless? o
o
o
o
o
o
Homeowner
Renting
Livingwith Family
Livingwith Friends
Mobile Home
Foster Home
o Hotel
o Incarcerated
o SubstanceAbuseTreatment
Facilityor Detox Center
o Other
Between the ages of 5-18, what city did the partictpant live the longest? o
o
o
o
o
o
o
o
o
Brea
Buena Park
Cypress
Fullerton
Garden Grove
La Habra
La Palma
Los Alamitos
Orange
o
o
o
o
o
o
o
o
o
o
Placentia
Stanton
Villa Park
Yorba Linda
Anaheim
Orange County-outside the NSPA
Other County in California
Outside the State of California
Outside the United States
Client prefers not to answer
Citywhere participantattended high school:
o Brea o Placentia
o Buena Park
o Cypress
o Fullerton
o Garden Grove
o La Habra
o LaPalma
o Los Alamitos
o Orange
o Stanton
o Villa Park
o Yorba Linda
o Anaheim
o Orange County-outside the NSPA
o Other County in California
o OutsidetheStateofCalifornia
o Outside the United States
o Clientprefersnottoanswer
FY 2024 QC HMIS: PROJECT INTAKE FORM GENERAL & CoC/ESG ICES
CLIENT PROFILE
SOCIAL SECURITY NUMBER (SSN) I I I l-l I l-l 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
= Approximate or partial
SSN reported
J Client doesn't know
= Client prefers not to
answer
z Data not collected
CLIENT'S NAME N/A
Last
First
Middle
Suffix
QUALITY OF NAME
z Full name
reported
Z Partial, street name, or code
name reported
z Client doesn't know
I Client prefers
not to answer
z Data not collected
DATE OF BIRTH I I I-l I I-I I I I 11Ag-= I
Month Day Year
QUALITY OF DOB
z Full DOB reported
- Approximate or
partial DOB reported
z Client doesn't know
z Client prefers not to
answer
Z Data not collected
GENDER (Select all that apply)
€ Woman (Girl if child)
[] Man (Boy if child)
€ Non-Binary
€ 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 thai aooly)
[ American Indian, Alaska Native, or
Indigenous
€ Asian or Asian American
€ Black, African American, or African
€ Hispanic/Latina/e/o
€ Middle Eastern or North African
€ Native Hawaiian or Pacific Islander
€ White
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
VETERAN STATUS
Z No
h Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
If 'YES' to Veteran Status
Year entered militarv service (vear)
1 Revised 12/2024
FY 2024 QC HMIS: PROJECT INTAKE FORM GENERAL & CoC/ESG ICES Year seoarated from militarv service (vear)
Theater of Operations: World Warll
[ NO
a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Theater of Operations: Korean War
€ No
a Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Theater of Operations: Vietnam War
€ No
€ Yes
€ Client doesn't know
€ Client prefers not to answer
a 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
e Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Theater of Operations: Other peace-keeping operations or military 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
a Data not collected
Discharge Status
€ Honorable
€ General under honorable conditions
a Other than honorable conditions (OTH)
€ Bad Conduct
€ Dishonorable
€ Uncharacterized
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
QC OPTIONAL O,UESTIONS
Alias
Pronouns(s)
€ She/Her/Hers
€ He/Him/His
€ They/T hem/Theirs
€ Other:
2 Revised 12/2024
FY 2024 QC HMIS: PROJECT INTAKE FORM GENERAL & CoC/ESG ICES
PROJECT ENROLLMENT
TRANSLATION ASSISTANCE NEEDED
z No
I Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Preferred Language
€ Spanish
[ Vietnamese
€ 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)
a Head of household's child
€ Head of household's spouse or partner
a Head of household's other relation member
€ Other: non-relation member
PROJECT NAME Buena Park Navigation Center
PROJECT START DATE I I l-I I l-I I I I I
HOUSING MOVE-IN DATE
/(_ .% t. f)@ Ll rill 1..:41. .h. Ai. .k :n4. . -. .i.... .... .. .4 - - A r5rJLl %rU{ r an, rn Wll/l IIU ulSdUlluy nitpilrbrfldfl5 drru r<nn Drniars*ca Qbrnrrl #ho Ado !I) tslibrd nr hrsiu_bhhlA mrs*ivc+ I I l-l I l-l I I I I I I UJliLtlO. I ICil.tljl u 11ICi uCllCi a l.illCil It IJI I Itjui)01 IUIIJ 1111JVCr:l into a permanent housing unit)
PRIORLIVINGSITUATIONfor Street Outreach, Emergency Shelter, orSafe Haven project types Type of Residence 3.9174 (Type of living arrangementon thenightbefore entering this project)
HOMELESS SITUATION
= Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside) z Emergency shelter, including hotel or motel paid for with emergency shelter voucher, or RHY-funded Host Home shelter -zSafe Haven
INSTITUTIONAL SITUATION
= Foster care home or foster care group home = Long-term care facility or nursing home _-:Hospitalorotherresidentialnon-psychiatricmedicalfacility _-Psychiatrichospitalorotherpsychiatricfacility s Jail, prison or juvenile detention facility _"Substance abuse treatment facility or detox center
TRANSITIONAL HOUSING SITUATION
3 Revised 12/2024
FY 2024 QC HMIS: PROJECT INTAKE FORM GENERAL & CoC/ESG ICES € Transitionalhousing for homeless persons (including € Staying or living in a friend's room, apartment, or house homelessyouth) [ 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 € Rentalby 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 otherongoing 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) [1 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 Z Client doesn't know € Two to six nights € 90 days or more, but less than one year Z ClientPrefers nOi iO € One week or more, but less than one month € One year or longer answer I Data not collected
If Client's Type of Residence is any of the lnstitutionalSituation options:
Length of Stay Less than 90 days?
(Indicate ifthe stayin the institutionalsetting they lived in immediatelypriorto project entry was less than 90 days)
z No z Yes
If 'Length of Stay Less than 90 days' is YES
On the night before - stayed on streets, ES or Safe Haven? (On the night before the dienfs stay of less than 90 days in an institutional setting were they on the streets, in an Emergenqy Shelter, orin a Safe Haven?) J_ No __Yes
Approximate Date Homelessness Started (Approximate date the client's currentepisode of homelessness began) _ / /
Number of times the client has been on the streets, in ES, or Save Haven in the pastthree years including today (Regardless ofwhere theystayedlastnight)
a One time a Three times = Client doesn't know
€ Two times z 501H07 1B07B OjlllB5 Z Clientprefersnet!O answer z 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) a Six Months a Eleven Months € Two Months € Seven Months € Twelve Months
II] Three Months € Eight Months € More than 12 months
€ Four Months a Nine Months = Client doesn't know
€ Five Months € Ten Months z Clientprefersnotto answer
z. Data not collected
4 Revised 12/2024
FY 2024 QC HMIS: PROJECT INTAKE FORM - GENERAL & CoC/ESG ICES PRIOR LMNG SITUATION for project types other than Street Outreach, Emergency Shelter, or Safe Haven
'FypeofResidence3.9l7B(rypeortivingarrangementonthenightberoretheentryintothepro4ect) / 'S, HOMELESSSITUATION /
, meshaentlteforr.lhnacbluitdaltniognh(oetRstHaYtiofnu/nad - Pla%not
-Emer%cy
= SafeHa%
} INSTITUTIONALSITUATION /
zFostercareh%orfostercaregrouphome =Long-termcarefacilityornursinghome/ zHospitalorother%identialnon-psychiatricmedicalfacility h.Psychiatrichospitalorotherpsychiatricfa4ty = Jail,prisonorjuvenJdetentionfacility s Substanceabusetreatment facilityordySxcenter
S TRANSITIONALHOUSINGSITUATION /
€ Transitionalhousing for persons (including € Staying or living in a friend's apartment, or house homeleSS 70uth) € Staying or living in a family s room, apartment, or € Residential project or halfway with no homeless criteria house € Hotel or motel paid forwithout shelter voucher
€ Host Home (non-crisis)
'yPERMANENTHOUSINGSITUATION/
€ Rental by client, no ongoing housing subsidy € Client € Rental by client, with ongoing housing subsidy € Client not to answer € Owned by client, with ongoing housing subsidy € Data collected € Owned by client, no ongoing housing subsidy
RentalSubsidyTypeif Rentalbydient,withongoinghousing%;dy € GPD TIP housing subsidy Rental by client, with other ongoing housing subsidy € VASH housing subsidy € ' Stability Voucher
€ RRH or equivalent subsidy € Unification Program Voucher (FUP) € HCVvoucher(tenantorprojectbased)(not € outhtolndependencelnitiative(FYI) € Publichousingunit € SupportiveHousing
€ Other housing dedicated for formerly homeless
persons
LengthofStayinPriorLivingSituationO&iwlongagodidtheclientstartstayingi%atTypeofResidence) aonen:ghtoriess / aonemonthormore,butiesstha%ooays zClientdoesn'tknow €Twotosixnights / a90daysormore,butlessthanone%r zClientprefersnotto aOneweekormore,butlessthanJemonth € Oneyearorlonger } anSWer / l Z Datanotcollected
IfClient's Type ofjasidence is anyofthe HomelessSituation options:
ApproximateDateHomeJ/isnessStarted(Approximatedatetheclient'scurrentepisode ofhomeles%ssbegan) ----/ S
(NRuemgabredr/eoSfStiomfrereetchleieynsttahyaesdbleaSetnno/gnhtt)he streets,in ES, orSave Haven inthepastthree years includin'%:ay a One time € Three times z Client doesn't
€ TWO € Four or more times I Clientprefersnot
z Data not collected
Jtal numberof monthshomelessonthestreets,inES,orSHinthepastthreeyears S 5 Revised 12/2024
FY 2024 QC HMIS: PROJECT INTAKE FORM - GENERAL & CoC/ESG - ICES One month (this time is the first month)
€ Months
€ ths
€ Four
[] Five Months
€ Six Months
€ Seven Months
€ Eight Months
€ Nine Months
€ Ten Months
€ Eleven Months
€ Twelve Months
€ More than 12
z Client doesn't k
Client pre to answer
Data not
IfClient'sT ofResidenceisanyofthe/nstitut7ona/Situotfonoptions:
LengthofStayLessthal days?
(inaicateirthestayintheinst%naisettingtheyiiveoinimmeoiateiypriorto prjectentrywas iessthangoaays) '( /
A_ z Yes
If Client's Tvoe of Resideffi is anv of the Transitional and Permanent)'fousira Situation ootions:
LengthofStayLessthan7nights?'y -- - - -- --7/ -
(Indicateifthestayinthetransitional orperm%thousingsewingtheylivedinimr@iiatelyprior toprojectentrywaslessthan7nights) '%, [
z No Z Yes
lf'LengthofstayLessthan90days'is)g-oR - lf'LenofStayLessthar 7nights'isYES Onthenightbefore-stayedonstreets,ESorSafeHad
(On thenightbefore the client's stayof less than 90 days in aonalsetting, orless than 7 nightsin atransitional/permanenthousingseffing, were theyoreets, in an Emergency Shelter,orinaSafeHaven?) /"'%y
Z No Z Yes
If 'Onthe nightbefore-stayed on streiES, orSafe%en'is YEs ApproximateDateHomelessness Started(App%atedatetheclient'sc%tepisode ofhomelessnessbegan) --/S
x(RuemqBbredrleoSrstiOmfeWshethreetchieieynSttahyaesdb/eaThlght, estreets,in ES, orSave Haven inthepasyears including today aOnetime / a Threetimes '! J Clientdoesn'tknow
€ TWOi:meS / €Fourormoretimes "C_lientprefersnottoanswer / z[J'$notcollected
Totalnumberofmos homelessonthestreets,inES,orSHinthepastthreeyears S € Onemonth ' isthefirstmonth) € SixMonths € Eleven
€ Two € SevenMonths [I]Twelve
€ Three € Eight Months € More than 12
€ € NineMonths IClientdoesn'tknow
€ MOnthS a Ten Months Z Clientprefersnotto
J_Data not collected
DISABLING CONDITIONS AND BARRIERS
Do you have a disabling condition?
= No
I Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Do you have a physical disability?
= No
_-Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Ifyes forPhysicalDisability, z No
6 Revised 12/2024
FY 2024 QC HMIS: PROJECT INTAKE FORM - GENERAL & CoC/ESG ICES Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?
z Yes
Do you have a developmental disability?
Z No
I Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Do you have a chronic health condition?
= No
_-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?
_ No
z 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? z No
z Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Do you have a mental health problem?
No
z Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
If yes for Mental Health Problem,
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?
= No
Z Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Do you have a substance abuse problem?
= No
Alcohol Abuse
z Drug Abuse
z Both Alcohol and Drug
€ Client doesn't know
€ Client prefers not to answer
€ 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?
z No
z 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
H No
z Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
IfYes forsurvivorof domestic orintimate partnerviolence When did this experience
occur?
€ Within the past three months
€ Three to six months ago (excluding six months exactly) € From six to twelve months ago (excluding one year exactly) € More than a year ago
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Are you currently fleeing?
ffl No
= Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
7 Revised 12/2024
FY 2024 QC HMIS: PROJECT INTAKE FORM GENERAL & CoC/ESG ICES
MONTHLY INCOME AND SOURCES
Income from Any Source
€ Client doesn't know
HNo € Client prefers not to
HYes 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
€ Private Disability Insurance
€ VA Service-Connected Disability Compensation
€ Social Security Disability Income (SSDI)
€ Supplemental Security Income (SSI)
a Retirement Income from Social Security
€ VA Non-Service-Connected Disability Pension
a Pension or retirement income from a former job
€ Temporary Assistance for Needy Families (TANF)
€ General Assistance (GA)
€ Alimony or other spousal support
€ Child Support
€ Other Cash Income (Specifv: )
NON-CASH BENEFITS
Receiving Non-Cash Benefits? H No a Clientdoesn'tknow
€ Client prefers not to answer
' Yes € Data not collected
IF"YES" TO RECEIVING NON.CASH BENEFITS- INDICATE ALL SOURCES THAT APPLY € Supplemental Nutrition Assistance Program (SNAP) a TANF Transportation Services € Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC)
€ Other TANF-funded services
€ TANF Childcare Services
[] Other Non-Cash Benefits
(Specify Source):
HEALTH INSURANCE
Covered by Health Insurance?
€ Client doesn't know
I No € Client prefers not to
,Yes anSWer
€ Data not collected
IF"YES" TO COVERED BY HEALTH INSURANCE- INDICATE ALL SOURCES THAT APPLY € MEDICAID € Insurance Obtained through COBRA
€ MEDICARE € Private Pay Health Insurance
a State Children's Health Insurance Program € State Health Insurance for Adults a Veteran's Health Administration (VHA) € Indian Health Services Program € Employer-provided Health Insurance
€ Other Health Insurance
(Specify Source):
8 Revised 12/2024
FY 2024 QC HMIS: PROJECT INTAKE FORM - GENERAL & CoC/ESG - ICES
LAST PERMANENT ADDRESS
Prior City
The last citv in which the client was oermanentlv housed orior " ' - ' - - - - ' -i " ' - " " - " - " - - " - " - " - - r - " " - " - " -' i " - - - - - r " - ' to entry into this project
ADDITIONAL INFORMATION
Sexual Orientation
I Heterosexual
= Gay
= Lesbian
z Bisexual
h 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 priorto entry into this project? The city in which the client spent the night priorto entryinto this project € Aliso Viejo € Huntington Beach € Newport Beach € Westminster € Anaheim € lrvine € Orange € YorbaLinda
€ Brea aLaHabra aPlacentia € Unincorporated Orange
€ Buena Park a La Palma € Rancho Santa Margarita County € Costa Mesa a Laguna Beach a San Clemente € Outside Orange County, € Cypress € Laguna Hills € San Juan Capistrano but:nCal!forn!a € Dana Point € Laguna Niguel II] Santa Ana € OutS:de OfCal:forn!a € EI Modena € Laguna Woods € Seal Beach € Cl:entdOeSn'i knOW € Fountain Valley € Lake Forest € Stanton € Cl:emPrefers nOiiO answer € Fullerton € LosAlamitos € Tustin € Da(anOtCOlleCted
€ Garden Grove € Mission Viejo € Villa Park
Phone Number (Optional)
Email Address (Optional)
Are you or your household member currently employed or go to school in the city of Anaheim, Garden Grove, and/or Santa Ana? Select all that apply. z Anaheim z Santa Ana
I Garden Grove
Household member with city tie (select all that apply)
€ Head of Household's
spouse or partner
] Se'f(HeadofHouSeho'd)a Head of Household's other
a_Head of Household's child re'a'onmember
€ Other: non-relation
member
9 Revised 12/2024
FY 2024 QC HMIS: PROJECT INTAKE FORM - GENERAL & CoC/ESG ICES Which individual access point is serving this household? Have you or someone in your family ever been legally
evicted?
€ Client doesn't know
HNo € Client prefers not to
2Yes anSWer
€ Data not collected
How manv leaal evictions?
What state were you born in?
€ AL-Alabama € GA-Georgia aMA-Massachusetts € NM-NewMexico € TN-Tennessee € AL-Alaska € Hl-Hawaii € Ml-Michigan € NY-NewYork € TX-Texas € AZ-Arizona [lD-ldaho aMN-Minnesota € NC-NorthCarolina OUT-Utah OAR-Arkansas € lL-lllinois € MS-Mississippi € ND-NorthDakota € VT-Vermont € CA-California € lN-lndiana € MO-Missouri € OH-Ohio € VA-Virginia € CO-Colorado € lA-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 aSC-SouthCarolina aClientdoesn'tknow € FL- FIOrida € MD- Maryland € NJ- NeW JerseV € SD - SOuth DakOta € Clientprefers net O answer
a Other
If'Other' for State 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?
Z No
z Yes
CFCOC Bed Night Start Date
ff. - -I i - - J l- !: - J L - _I _ ! _ 1_J !. . _ j _ _l l_ . . /j r /"l /% fi _ / / ure cuenr s rgsr r:iea rugnr rumea oy vrvxr
CFCOC Bed Night End Date
TL. - -l i- - 41- l- - J l- - j- i-I- J j. . _ j _ _l l_. . /% r /'l /'i /% _ / / me r.;rieinrs iasr r:ier.inignr runaea ay brvvv
10 Revised 12/2024
FY 2024 QC HMIS: PROJECT INTAKE FORM - GENERAL & CoC/ESG - ICES I certify that the information above is correct to the best of my knowledge.
Client Signature Date
Agency Staff Signature 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 Entry):
11 Revised 12/2024
FY2024 QC HMIS: CURRENT LIVING SITUATION ASSESSMENT FORM
CURRENT LMNG 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: Recordevery contact made with each client by recordingtheir Current Living Situation, including when the Project Start Date, Prior LivingSituationor Dateor 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 personneland the client goes beyond the basic provision of shelter services.A Current LivingSituation for emergency shelter does not includeactivities of daily sheltering (e.g. bed registration,request for personal care items, dinner sign-up, meals, etc.) PROJECT NAME Buena Park Navigation Center
CLIENT NAME
CURRENT LIVING SITUATION DATE I I l-l I l-l I I I I
Current Living Situation
(PATH funded pmjects are limited to the response options with an asterisk ")
HOMELESS SITUATION
I Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)" X_Emergency shelter, including hotel or motel paid for with emergency shelter voucher, or RHY-funded Host Home shelter" = Safe Haven"
INSTITUTIONAL SITUATION
J Foster care home or foster care group home h Long-term care facility or nursing home z Hospital or other residential non-psychiatric medical z Psychiatric hospital or other psychiatric facility facility s Substance abuse treatment facility or detox center z Jail, prison or juvenile detention facility
TRANSITIONAL HOUSING SITUATION
€ Transitional housing for homeless persons (including [ Host Home (non-crisis) Homeless Youth) a Staying orliving in a family member's room, apartment, or € Residential project or halfway house with no homeless house criteria € Staying or living in a friend's room, apartment or house € Hotel or motel paid for without emergency shelter voucher
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
€ Worker unable to determine"
€ Other" :
Rental Subsidy Type if Rental by client, with ongoing housing subsidy is selected Revised 2024 1
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 verified living situation information) client's Current Living Situation is any of-the non-homeless Is client going to leave their current living situation within 14 days?
Z No
= Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Hlfathseallieunbtsh:qsuteonlteraele.Idthemncebeen
2 No
= Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Iftheclienthas toleavetheircurrentlivingsitWin 14days:
Does individual or family have resources or supporks
to obtainotherpermanenthousing? '%%,
__No
Z Yes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
lftheclienthastoleavetheircurrentlivingsituationwithin14days, - Has the client had a lease or ownership interest in a permanent housing unit in the last 60 days? xYes
€ Client doesn't know
€ Client prefers not to answer
€ Data not collected
Ifthe client has to leave their current living situation within j4 days, Has the client moved 2 or more times in the last 60 days? = No "
= Yes
%Q Client doesn't know
ۤ prefers not to answer
€ Data 'lected
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
COORDINATED ENTRY SYSTEM (CES)
',uTHORIZATION TO USE & DISCLOSE PROTECTED HEALTH INFORMATION rheCoordinatedEntry System (CES) isdesignedtoconnectpeopleat-riskoforexperiencinghomelessnesswithhousingandsupportive services. Yourauthorization 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/coordinatedentry-system.
PART 1: CLIENT/PATIENTINFORMATION
ClienUPatlent Last Name ClientlPatient First Name Middle Initial Date of Birth Email CIN# MRN Telephone Number with Area Code
Add'ess 6494 Caballero Blvd C" Buena Park
State
Z'p90620
PART 2: PARTICIPATING ENTITIES WHO WILL DISCLOSE THIS INFORMATION Participating Entities within Coordinated Entry System (CES) Adtltess 601 N. Ross st., 5thFloor
City
Santa Ana
State
CA
Zip
92701
Telephone Number with area code
(714) 834-5000
PART 3: PARTICIPATING ENTITIES WHO W,LL RECEiVE THIS INFORMATION Participating Entities within Coordinated Entry System (CES) Address 601 N. Ross st., 5'h Floor
State
CA
Zip
92701
Telephone Number wiih area code
(714) 834-5000
Coordination ofcare with and between the Coordinated Entry System participating entities.
PART 5: INFORMATION THAT CAN BE RELEASED
A. The minimumamountofinformation to mrdinate carebetweenthe CoordinatedEntrySystemparticipatingentities.This includesbutis not limitedtoyourhistoryofhomelessness, disablingconditions, housingpreferencesandotherel5ibilitycriteria.
PART 6: DATE YOUR AUTHORIZATION EXPIRES
Unlessotherwiserevokedin writing,this authorizationexpiresuponterminationofprogram, OrangeCountyCoordinatedEntiy System.
FOR YOUR REVIEW
I have readthecontents ofthis form.l understand,agree,andallowthe CoordinatedEntrySystem(CES)to use and releasemy informationas I have statedabove. I havethe rightto revokethis authorizationat any time in writing by sending a notice to the CES ProgramAdministrator.
The revocationwillnotaffectdisclosuresthe CES participatingentitieshavealreadymade in relianceon the authorization.Informationdisclosed pursuantto this authorization may be re-disclosed by the recipient and no longer be protectedby federalprivacylaw (HIPAA). Applicable State or other federallaw may requirethe recipientto obtainyourwritten authorization before misclosure unlessotherwisepermittedby such laws. I am entitled to a copyofthis fomi. Feesmay applyto certain requests.A copyofthe originalauthorizationis valid.
PART 7: SIGNATURE - PARTICIPANT OR DESIGNATED PERSONAL
REPRESENTATIVE/GUARDIAN
PART 8: DATE
x
Personal Rep+esentaUve(Pnnt full name) Personal Relationship to Client /Patient (e.g. conservator, patent, etc ) City State Zip
Disclosures pursuarrtto 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 FY25-26 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 Last Name Date
Address(residence) 6494 CaballeroBLVD City Rl1PnR pBI-p ZipCode 90620 TelephoneNumber( ) E-mailAddress
DateofBirth Aqe Gender:QMaleQFemaleDidyouparticipateintheprogramlastyear:QYESQNO Ethnicity (must check one):
Q Hispanic Q Non-Hispanic
Race (must check one):
uWhite
C)Black/African American
QAsian
uAmerican Indian/AlaskanNative
FAMILY INCOME:
Disabled (must check one):
Q Yes Q No
QNat. Hawaiian/OtherPacificlslander
OAmerican Indian/Alaskan Nat &White
€ Asian & White
QBlack/African American &White
[JAmer. Ind./Alaskan Nat. & Black
anther Multi-Racial
Income includes wages, salaries, tips; self-employment or business income, unemployment & disability income, retirement &insurance income, public assistance,interest & dividend income, alimony, child support, gift income, armed forces income forall family members 18 years of age and older.
FAMILY INCOME TABLE' (BELOW):
1. FIRSTcirclethenumberofpersonsinyourhousehold
2. THENgoacrossandcircleyourhouseholdannuallncomeCategory Household
Size
Very Low Income
30% of Median Income
Low Income
50% of Median Income
1 Person $35,550 $59,250 $94,750
2 Persons $40,600 $67,700 $108,300
3 Persons $45,700 $76,150 $121,850
4 Persons $50,750 $84,600 $135,350
5 Persons $54,850 $91,400 $146,200
6 Persons $58,900 $98,150 $157,050
7 Persons $62,950 $104,950 $167,850
8 or More $67,000 $ffl,700 $178,700
"Income limb sffective 471125
Female Head of Household: uYES Q NO
Family Size Total: Children (0-17 years ofage): + 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 felony for any person to knowingly and willingly make false orfraudulent statementto anydepartment ofthe United States Govemment. By signingthis Document,l certify under penalty of perjury, that all the infomiation 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 my failure to provide necessary documents within a reasonable period oftime orfalsification ofthisinformation shall be grounds for mytermination from the program.l authorizethe release of said information to local, State and/or Federal agencies within five years of this date.
PrintName(applicant)
PrintName(parent/guardianif applicantis a minor)
Signature
Signature
Date
Date
Statt Reviewer StaffSignature L)ate
MERCY*HOUSE
AUTHORIZATION FOR RELEASE OF CONFIDENTIAI INFORMATION
AND PARTICIPATION IN NAVIGATION CENTER SERVICES
Name: DOB: Date:
Aliases, Nicknames and Street Names:
Initial orX in each box on the left to demonstrate your consent to participate in services and or share information:
jam requesting a bed and housing assistance services and agree to work toward the housing plan that will be created with me by my housing navigator. / also understand thot this is not a permanent living situation, and that the purpose of this shelter is to help me become stably housed, and / will work both independently and with staff in achieving this outcome as rapidly aslam capable.
/ agree to abide by all Shelter Expectations as they exist today and any amended expectations to come.
lagree that all staff may be involved in the shelter, housing and support process, andl understand that all staff may have access to information about mefor this purpose. / have had the Grievance Policy explained to me, and / understand that / am free to express my concerns about shelter, housing, and support services without negative impacts relating to my participation. / know that the Grievance Procedures and forms arefreely 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 / feel / have been wrongfully terminated from the program and thatlcan appeal my exit by completing a Grievance Form. / understand that participation in all shelter, housing, and supportive services is voluntary, andlmay revoke my agreement to participate at any time of my choosing, in writing. Ifurther understand and agree that any revocation will not O/)/)/)/ to information that has already been released in response to this authorization.
Iknow that information about me and my shelter, housing and support history gathered by Mercy House may be shared with any other entity with the intent to help end my homelessness and ensurelam able to remain in stable housing. Ihereby authorize the exchange of information between Mercy House and other agencies (public and nonprofit agencies) such os shelters, medical providers, schools, landlords and Rapid ReHousing Programs or other service providers, etc.
MHS AuthofRelease Page 1 of 2 Revised 06/23/2025
lunderstand and agree that Mercy House seeking or disclosing my information is solely for my benefit and will be kept confidential. / also understand that once Ileave the program, this disclosure consent becomes invalid.
/ certify under the penalty of perjury that all information / provide 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.
Guest: Staff Witness:
Signature Srgwture
0Guest Refused 0 Unableto Sign StaffWitness (Print):
MHS AuthofRelease Page 2 of 2 Revised 06/23/2025
MERCY*HOUSE
Release of Information Disclosure
Name of Guest: Date of Birth:
It may be necessary for Mercy House to collect or share your personal information in order to provide you with needed services. It is our goal to be as transparent in this process as possible. If consent is given, it shall remain in effect for the duration of services with Mercy House or until the consent is revoked in writing. You will receive a copy of this form once signed.
Please initial and indicate the Agency with whom an information exchange is being authorized. lauthorize Mercy House to exchange my personal information with ay agency or partner that they deem appropriate or necessary for the successful coordination of my care and housing plan.
lauthorize the exchange of information between Mercy House and the following agencies, partners, or individuals, for the successful coordination of my care and housing plan:
The entities listed above have my permission to disclose amongst themselves and with each other my personal information, both verbally and through written documentation, as pertinent to my case needs.
Types of information that may be shared include, but are not be limited to:
* General Identifying/Demographic Information
* Medical Health Information
* Rental History/Eviction History
* Mental Health Information
* Immigration Status Information
* Substance Abuse/Treatment History
* Criminal History/Information
* Personal Contact Information
* Employment History/Information
* Personal Finance Information
By signing below, you acknowledge that you understand why this information is being shared, and that you authorize Mercy House to exchange your information os outlined in this disclosure. Further, you understand you have the right to revoke future sharing of any time but acknowledge that some information may be shared already by the time such revocation has been made.
Guest:
Signature
Parent or Representative (if required):
Signature
Printed Name
Date
Date
MHS ReleaseOflnformationDisclosure Revised01/02/2025
MERCY*HOUSE
ATT ACHMENT F
ORG CHART
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Accounttng Manager
Connie K
Accounts Payable
Thomas E
Accounts Payable
Kanto K
Accounts Payable
Natalie R
Accounts Payable
Vanessa G
Accounts Payable
Vanessa R
Accounts Payable
Accounts Payable
Veronica L
(liiefFinancial Officer
Mary Ellen G
Accounts Receivable Manager
Accounts Payable Supei'visor
Accounts Receivable Specialist
Vivianna M
Accounts Receivable Specialist
Memory P
Accounts Receivable Specialist
David Le
Accounts Receiviible Specialist
Alex T
Accounts Receiviible Specialist
Anthony L
Accounts Receivable Specialist
George R
Accounts Receivable Specialist
Isaac H
Accounks Payable PT
Cassie A
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MERCY*HOUSE
ATT ACHMENT G
BOARD OF DIRECTORS
MERCY*HOUSE
BOard Of Djrec[crs
Tim Clyde, Chair
Katzkin Automotive Leather
2 Hermosa
Irvine, CA 92620
714-544-7371 Home
714-813-9119 Mobile
timclyde63@g mail.com
Affiliation: CEO
Term: 15 Years
William E. Baker, Jr., Assistant Secretary
18301 Hillcrest Avenue
Villa Park, CA 92861
714-998-1232 Home
wba [email protected]
Affiliation: Attorney
Term: 36 Years
Cary Q. Belz
11 Mallard
Irvine, CA 92604
949-551-2783 Home
714-978-1300 0ffice
gbelz53@g mail.com
Affiliation: Certified Public Accountant
Term: 36 Years
Mia Bergman
28211 Foxwood
Mission Viejo, CA 92692
708-870-6475 Cell
Maria.m.berg ma n@g mail.com
Affiliation: CPA
Term:3 Years
James Brooks
PO Box1905
Santa Ana, CA 92702
714-836-7188 x107 0ffice
ja [email protected]
Affiliation: Homeless Advocate and
Formerly Homeless Individua
Term:9 Years
Johnny Bryant
ASL Electric
21791 Sweetgrass Circle
Lake Forest, CA 92630
Affiliation: Owner
949-343-3018 Cell
[email protected]
Term:3 Years
Ariana Burris
Burris Law
19291 Maynard Way
Santa Ana, CA 92705
71 4-348-8457
ariana [email protected]
Affiliation: Co-Founder/Principa
Term:1 Year
Qaymond M. Bukaty
1 Corona
Irvine, CA. 92603
949-854-4241 Home
949-636-0939 Ce
[email protected]
Affiliation: Petired Attorney
Term: 21 Years
Mladen Buntich
Mladen Buntich Const. Co., INC
18831 Pockinghorse Lane
Huntington Beach, CA 92648
818-370-2583 Ce
M bj r@bu ntich.com
Affiliation: CEO
Term:8 Years
Daryl A. Cole, CFP
Cole & Company Wealth Management, Inc.
1420 E Chapman Ave
Orange, CA 92866
714-750-3090 x101 0ffice
714-743-2220 Ce
[email protected]
Affiliation: Business Owner
Term:16 Years
Mercy House Board Book 11
MERCY*HOUSE
BOard Of DireCtors
Sean Chaffins
First Citizens Bank
29818 Santa Margarita Pkwy
Pancho Santa Margarita, CA 92688
949-750-1502 Direct
sea [email protected]
Affiliation: VP Financial Sales Manager
Term:lYear
Jeremy Elkins
Camino Health Center
30300 Camino Capistrano
San Juan Capistrano, CA 92675
949-240-2030 Cell
jeremy.d.elkins@g mail.com
Jeremy.El [email protected]
Affiliation: CEO
Term:5 Years
Paul Julian
Advanced Peal Estate Services, Inc.
15320 Barranca Pkwy, Ste100
Irvine, CA 92618
949-294-8110 Ce
pjulia n@adva nced realestate.com
Affiliation: President
Term:1Year
Phillip P. Kaplan
Umberg Zipser, LLP
1920 Main St #750
rvine, CA 92614
949-679-0052 Cell
Pka plan@u m bergzipser.com
Affiliation: Attorney
Term:12 Years
Marianne R. Koshar
The Boeing Company
3491 Aquarius Dr.
Huntington Beach, CA 92649
2201 Sea Beach Blvd.
MC 110-SB25
Seal Beach, CA 90740-1515
562-225-4780 Cell
maria n ne.l.koshar@ boeing.com
Affiliation: HP Director
Term: 3Years
Dana Kovach
Kovach Marketing
456 Gaviota
Newport Beach, CA 92660
714-757-2870 Cell
dana kovach@kovachmarketi ng.com
Affiliation: Founder & CEO
Term:lYear
Richard Lopez
The Boeing Company
7159 Pidgecrest Ct Ventura, CA 93003
(714) 262-8811 Cel
Picha [email protected]
Affiliation: Attorney
Term:8 Years
Richard K. Masterson
2 Corona
rvi ne, CA 92603
949-394-9916 Ce
949-679-4122 Home
rkmasterson759@g mail.com
Affiliation: Petired
Term: 11 Years
Bryan Pavalko
PBA Builders
16490 Harbor Blvd
Fountain Valley, CA 92708
714-321-7606 Cell
brya n@rba bllc.com
Affiliation: President
Term:lYear
Jessica Petrillo
County of Ventura
435 South D Street
Oxnard CA, 93030
jessica.i.petrillo@g mail.com
805-385-8044 0ffice
Affiliation: Public Sector - Homeless
Assistance Program Coordinator
Term:2 Years
Mercy House Board Book 12
MERCY*HOUSE
Board of Directors
Jim Righeimer
Arbor Capital Partners
4040 MacArthur Blvd, Suite 250
Newport Beach, CA 92660
714-404-7567 Home
Jim@ PFComsites.co m
Affiliation: CEO / Developer
Term:3 Years
Michael Solo
Diversified Investment Services
3665 S. Bear St.
Santa Ana, CA 92704
714-390-0957 Ce
[email protected]
Affiliation: CFP
Term: 2Years
Julie Stark
CDC Designs
2915 Red Hill Avenue Costa Mesa,
CA 92626-5923
[email protected]
Affiliation: President
Term:1Year
Mercy House Board Book 03
City of Buena Park
2026-2027 Community Development Block Grant (CDBG)
Funding Proposal Summary Sheet
Organization Name: Friendly Center, Inc.
Program Name: Buena Park Friendly Mart
Estimated Goal: 500 Individuals
Funding Request: $87,000
Organization Purpose:
The Friendly Center offers stability programs, food distribution, case management, mental health counseling, utility and rental assistance, and other referral services to low income families in Buena Park. Additionally, they offer skill-building programs such as after-school tutoring, job development assistance, and financial literacy workshops.
Friendly Center has recently opened a new food distribution center called Friendly Mart located at William Peak Park in an effort to expand their food distribution services. Recent changes to federal food related benefits have led to a heightened need for community-based food services. By providing food distribution in this larger “market” setting, they strive to offer more clients the liberty to choose the foods that best meet their needs. The new location is also equipped with refrigerators, freezers, and a wider variety of foods that were not offered in their original food pantry location.
Description of Request:
CDBG funds will support a portion of Friendly Center’s staff salaries, benefits, and insurance costs for personnel assigned to Friendly Mart. This includes one full-time staff member and one part-time staff member who will ensure services are available two to three days per week, a significant increase from the twice-monthly service schedule at the previous pantry location.
Analysis of Request:
The activity meets the national objective of benefiting low- and moderate- income individuals. The Friendly Center offers assistance that improves many residents’ quality of life and promotes food security for low-income households. 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 organizations, which demonstrates their experience and ability to provide these services to the community.
Funding Recommendation:
Staff recommends funding in the amount of $15,000.
City of Buena Park
FY 2026-2027 Community Development Block Grant (CDBG) Program Application Checklist
Please complete, sign, and include this checklist with your application Required For All Applicants:
[21 Completed FY 2026-2027 CDBG Grant Application
[ffCopy of current client intake form for proposed activity € N/A (only if activity is LMA)
fSigned Acknowledgement Regarding Bidder SAM Registration form (Attachment 4) Signed Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions form (Attachment 5)
Required For Nonprofit/Outside Orqanizations:
[JProof of active nonprofit status (IRS determination letter) [2fList of Board of Directors (board member names and titles) [:]Copy of current organizational chart
€ Copy of current lease (if CDBG funding request involves rental expenses) [2j Completed Zoning/Land Use Approval Form (Attachment 6), if located in the City of Buena Park Organization/City Department Name: Friendly Center, Inc.
Submitted By: Kenia Cueto, Ph.D., President/CEO
(Print Name, Title) (Sign)
/ 12/15/25
(Date)
RECEIVED
DEC18 2025
ECONOMICDEVELOPMENT
Attachment 2
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 (July 1, 2026 - June 30, 2027)
CDBG FUNDING APPLICATION
DUE BY DECEMBER 18, 2025 AT 5:00 PM
Organization/City Department Name Friendly Center, Inc.
Activity/Program Name Buena Park Friendly Mart
Address
7225 El Dorado Dr., Buena Park, CA 90620
Contact Person/Title Jessica Ruelas
Email Address 2200 W. Orangewood Ave St 240 0range Ca 92868 Phone Number 714-771-5300 ext 136
Activity Type (select one) 0 Public Service Activity El Other CDBG Eligible Activity Organization Type (select one)
0 City Department
EI Nonprofit 501 (c) (3) organization
€ Other (i.e. public agency)
Amount of CDBG Funds Requested $87,000
1. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including a// persons regardless of residence):
Estimated Goal: 1 ,000 EI Individuals € Households
2. Estimated unduplicated individuals or households to be served by proposed activity during FY 2026-2027 (including ONLY Buena Park residents):
Estimated Goal: 500 EI Individuals g Households
Icertify under penalty of perjury that the information provided in this CDBG funding application is true to the best of my knowledge.
9p
(S4aPf authorized representative)
12/15/25
Date
Jessica Ruelas, Director of Community & Family Services (Print name and title of authorized representative)
Organization Name: F"endlVca"a' ""' Program Name: B"-'a Pa" F"a"d"/Ma' Please answer each of the following questions. 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. a) Why is there a need for this activity in the City of Buena Park? b) Identify the location of the activity and the service area boundaries. c) Describe specifically the intended use of the CDBG funds.
Friendly Center recently opened a Friendly Mart in the City of Buena Park, located at William Peak Park (7225 EI Dorado Dr., Buena Park, CA 90620). On September 24, 2025, we proudly opened our doors to our second market.
Our markets are designed to preserve client dignity while offering choice, allowing individuals and families to select foods that best meet their needs. The City of Buena Park is home to many families experiencing food insecurity, and access to basic necessities, particularly nutritious food.
The Friendly Mart is open to all Buena Park residents as well as individuals throughout Orange County.
Through this market, we provide bi-monthly food distributions that help families maintain consistent access to healthy meals.
If awarded this grant, funds would be used to support staffing, including the salaries of one full-time staff member and one part-time staff member. These positions are necessary to operate the market on a weekly basis and to provide services two to three days per week, ensuring consistent and reliable access to food for the community.
2 TARGET POPULATION
[24 CFR 570.200(a), 570.201-570.208, 570.503]
Describe the target population/demographic for this activity and the number of estimated unduplicated Buena Park residents to be served from July 1, 2026 through June 30, 2027. a) How was the estimated number of clients determined?
b) How will you reach your target population?
c) Explain why this activity is needed for this target population.
The Friendly Center Friendly Mart serves low-income families and individuals throughout Orange County, with a primary focus on Buena Park residents. While most clients live in Buena Park, services are available to any Orange County resident in need. For FY 2026-2027, Friendly Center anticipates serving 700 unduplicated individuals in Buena Park, with an estimated 10% increase based on year-over-year growth and expanded outreach efforts. Friendly Center collects ongoing client service data for grant reporting, program planning, and tracking unduplicated clients. Clients learn about the Friendly Mart through word-of-mouth, referrals from Orange County Social Services, schools, 2-1-1, and nonprofit partners. As a trusted organization, Friendly Center maintains strong collaborative partnerships across Orange County and continues to expand outreach through coordinated efforts by program leadership.The need for this program is confirmed by daily calls to Friendly Center's Community Resource Center, where food assistance is consistently the most requested service. This data underscores food insecurity as a critical need for residents of Buena Park and communities throughout Orange County, specifically after the government shut down and SNAP changes.
Application Page 2
Orgaruzation Name: FriendlyCenter,Inc. Program Namea BuenaPa'kF"a"d'YMa' 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 i objectives.
Select one then explain in the space below:
[a 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.
Friendly Center's Friendly Mart in Buena Park meets the "benefit low- and moderate-income persons in Buena Park" CDBG program national objective by providing free programs designed to meet the specific needs of low- and moderate-income households. These programs, and their specific benefits for low- and moderate-income individuals, are outlined below:
- Community Resource Center programs that alleviate food insecurity: bimonthly large-scale food distributions and emergency basic needs support.
- Community Resource Center programs that offer intervention in times of crisis: emergency basic needs support, diaper support, domestic violence intervention, case management, utility assistance, rental assistance, information and referral services, and legal services. - Community Resource Center programs that offer access to vital healthcare services: mental health counseling, mobile medical, and dental care services.
-Community Resource Center programs that provide education resources that may otherwise be out of reach due to cost or other barriers: year-round after-school tutoring, financial literacy, parenting classes, and job development workshops.
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] Provide the total administrative and/or operational costs for the proposed activity. Cost Category may include: staff salaries and benefits, rent/lease, supplies, utilities, etc.
Cost Category
CDBG Funding
Request
Other Funding
Sources
Total Cost
Staff Salaries and Benefits $ 85,500 $ 341 ,773 $ 42.1, z'yb Program Expenses $ $ 45,000 $ 45,000
Operation Exoenses $ $ 23,000 $ 23,000
Insurance $ 1500 $ 11 ,500 $13,000
In-Kind Exoense Value $ $ 535,000 $ 535,000
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Total $ 87,000 $ 4'salt:2-13 $ tle4'3 i!73
Application Page 3
Organization Namea F'a'd'V Center,Inc. py()gyB ,, %BBl(i. BuenaParkFnendlyMart 5 ELIGIBILITY DOCUMENT ATION
Describe the form of documentation that is 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.
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 and that will be used to measure and track the activity's performance. Refer to the definitions on Page 6 of the RFP.
A. Select one :
[/ Suitable Living Environment
€ Decent Affordable Housing
€ Economic Opportunities
B. Select one :
2 Availability/Accessibility
€ Affordability
€ Sustainability
Application Page 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 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.
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 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 bidder's SAM registration:
Entity Name: Friendly Center Inc.
Address: 2200 Beach Blvd
Cite: Buena Park State: CA Zip: 90621
UniqueEntityID (uei5It,'l'Si' NT('71TaW}4 ExpirationDate: 202'D ActiveExclusions(SelectOne):[3 Yes 0No
Attachment 4
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 Srispension, and 2 CFR Part 200, Participants' responsibilities. (BEFOF?ECOMPLET[NGCERTIFICATION, READ[NSTRUCTIONS BELOTV) (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: Friendly Center
1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.
2. The certification in tliis 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 la'iowingly rendered an erroneous certification, in addition to other remedies available to tlie Federal Government, the department or agency witli wliich this transaction originated may pursue available remedies, including suspension and/or debartnent.
3. The prospective lower tier participant shall provide immediate written notice to the person to whicli tliis proposal is submitted if at any time the prospective lower tier participant learns tliat its certification was erroneous wlien 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 "vohintarily excluded", as used in this clause, have the meanings set out in the Definitions and Coverage sections of niles 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 la'iowingly 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 tliat 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 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 infornnation of a participant is not required to exceed that which is normally possessed by a pnident person in the ordinary course of business dealings.
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, irieligible, 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 debamient.
Attachment 5
CITY OF BUENA PARK
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) PROGRAM
FY 2026-2027 CDBG FUNDING APPLICATION
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.
Friendly Center
Name of organization
2200 W. Oranqewood Suite 240 0ranqe Ca 92868
Address of organization
Je3sica Ruela3- Director of Community Bnd Family
Applicant name and title
714-771-5300 Jessica@friendlycenter,org
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)
Friendly Center has a license aqreement with the City of Buena Park to operate at 7225 EI Dorado Dr., Buena Park, CA 90621.
12/1 5/25
Date
To be completed by the City of Buena Park Planninq Department Use classification
Zoning
g Permitted Use
0 Conditional Use Permit Required
Comments:
Signature of Planning Department Representative Date
Attachment 6
City of Buena Park
Community Development Block Grant Program
Certificaci6n del Cliente
Subrecipiente: Friendly Center, Inc.
Afio Fiscal: FY 2025-2026 Pmyecta Community Food
Beneficiarioa
Direcci6n
Ciudad: CA
C6digo
Postal
1. Jefe de Familia € Mascrilino € Femenino 2. Desamparado € Si € NO
3. Marque uno.
(Si arilica)
Tercera Edad (62+)
Deshabilitado
4. Primero verifique el namero de personas en su hogar. Luego lea y rnarque la casffla en la misma fila que se aplica al ingreso anual bruto de su hogar. (El ingreso bruto anual es el ingreso de todas las fuemes antes de impuestos.)
Iimites de Jraesos
Numero de
Personas
Categoria l Categoria 2 Categoria 3 Categoria 4
01 [] $30,150 o menos € $50,250 o menos € $80,400 o menos € $80,400 y mAs € 2 € $34,450 o menos € $57,400 o menos [] $91,850 o menos € $91,850 y rubs 03 € $38,750 o menos € $64,600 o menos € $103,350 o menos € $103,350 y tnAs € 4 € $43,050 o menos [] $71,750 o menos € $114,800 o menos € $114,800 y m,is 05 € $46,500 o menos € $77,500 o menos [] $124,000o menos € $124,000 y mAs € 6 [] $49,950 o menos € $83,250 o menos 0 $133,200 o menos € $133,200 y m,is 07 [J $53,400 o menos € $89,000 o menos € $142,400 o menos € $142,400 y mAs 08 € $56,850 o menos € $94,750 o menos € $151,550 o menos € $151,550 y mAs Nota: Los [ngresos lfmites entraron en vkgemja ell5 de mayo de 2023 y est6m sujetos a cameos.
5. Etnicidad y Raza
€ Si [] NO
(Mavque uno por cada miembro de su familia.)
RAZA
Categorias de Raza tTnica o Categiirias de Raza Multiplc TOTAL
Blanco
Negro o
AfroameriCallOAsiAhco
Indio
americano
o Nativo
de Alaska
Nativo
Hawaiano
o Islaio
del
PacifiCO
Indio
Americam
o Nativo y
Blanco de
Alaska
AsiAtico
y
Blanco
Negro o
Afroamericaixi
y Blanco
Indio
Americano o
Nativo de
Alaskay
Negro o
Afroamericano
Otra
Raza
Maltiple
Residente de
Buena Park
No Residente
de Buena Park
De acuerdo con el Ti ulo 18, 5ecci6n 10 )1 de los Estados Unidos C6iligo, es un delito grave para cualquier persona a sabiendas y voluntariamente hacer declaraciones falsas o fraudulentas a cualqiier departarnento del Gobierno de los Estados Unidos. Yo, el abajo firtnante, cert'fico 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 estA sujeta a verificaci6n, y acepto proporcionar la docuinentaci6n necesaria si asi se solicita.
Firma del Solicitante Fecha
Aprobaci6n de la Agencia Fecha
City of Buena Park
Community Development Block Grant Program - Client Eligibility Certification Subrecipient Name: Friendly Center, Inc. Fiscal Year: 2025-2026 Project/Program Name: Community Food Orange
Beneficiary's Name:
Address:
City CA Zip Code
1. Head of Household: [1 Male € Female 2. Homeless: € Yes € No
3. Check only one. (If Applicable) € Elderly (62+) € Disabled
4. First check your household size. Then read across and check the box on the same row that applies to your househcld's gross annual income. (Gross annual incorr.e is income from all sources before taxes.) Household
Size Category l Category 2 Category 3
Category 4
01 € $33.150 or less € $55, 250 or less € $88,400 or less € $90,300 and above € 2 € $37,900 or less € $63, 100 or less € $101,000 or less 1J$103,200 and above € 3 € $42,650 or less € $71,050 or less [] $113,650 or less € $116,100 and above 04 € $47,350 or less [] $78,900 or less € $126,250 or less € $129,000 and above 05 € $51,150 or less € $85,250 or less [1 $136,350 or less € $139,300 and above 06 [] $54,950 or less € $91,550 or less € $146,450 or less € $149,650 and above 07 € $58,750 or less € $97,850 or less € $156,550 or less € $159,950 and above € 8 € $62,550 or less € $104,150 or less € $166, 650 or less [] $170,300 and above Note: Iricome Limits as published on August 15, 2024, and are subject to change.
S. Ethnicity and Race
€ Yes € No
White
Black or
African
American
Asian
American
Indian or
Ala5pB
Native
Native
Hawaiian
or Other
Pacific
Islander
:.Amer"can
A4iddlei Indianor
Eastern : Alaska
or ', Native
North ' and
African : White
I
Asian
___and
White
Black or
African
American
and
White
American
Indian or
Alaska
Native
__and
Black or
Afr"can
American
Other
Multiple
Race
Orange
Resident
NonOrange
Resident
According to Title 18, Section 1001 of the U.S. Code, it is a felony for any person to knowingly u'id willingly make false cr 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 m 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