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OMB Approval No. 2577-0157 (Exp. 11/30/2023)
U.S. Department of Housing
Certification of Payments
and Urban Development
to Influence Federal Transactions
Office of Public and Indian Housing
Applicant Name
Program/Activity Receiving Federal Grant Funding
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be
(3) The undersigned shall require that the language of this
paid, by or on behalf of the undersigned, to any person for
certification be included in the award documents for all subawards
influencing or attempting to influence an officer or employee of
at all tiers (including subcontracts, subgrants, and contracts
an agency, a Member of Congress, an officer or employee of
under grants, loans, and cooperative agreements) and that all
Congress, or an employee of a Member of Congress in connec-
sub recipients shall certify and disclose accordingly.
tion with the awarding of any Federal contract, the making of any
This certification is a material representation of fact upon which
Federal grant, the making of any Federal loan, the entering into
reliance was placed when this transaction was made or entered
of any cooperative agreement, and the extension, continuation,
into. Submission of this certification is a prerequisite for making
renewal, amendment, or modification of any Federal contract,
or entering into this transaction imposed by Section 1352, Title
grant, loan, or cooperative agreement.
31, U.S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than
(2) If any funds other than Federal appropriated funds have
$10,000 and not more than $100,000 for each such failure.
been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of an agency, a
Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with this
Federal contract, grant, loan, or cooperative agreement, the
undersigned shall complete and submit Standard Form-LLL,
Disclosure Form to Report Lobbying, in accordance with its
instructions.
I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010,
1012; 31 U.S.C. 3729, 3802)
Name of Authorized Official
Title
Signature
Date (mm/dd/yyyy)
Previous edition is obsolete
form HUD 50071 (01/14)
Public reporting burden for this information collection is estimated to average 30 minutes. This includes the time for collecting, reviewing, and reporting data. The information
requested is required to obtain a benefit. This form is used to ensure federal funds are not used to influence members of Congress. There are no assurances of confidentiality.
HUD may not conduct or sponsor, and an applicant is not required to respond to a collection of information unless it displays a currently valid OMB control number.
CITY OF CHANDLER HOUSING AND REDEVELOPMENT
LOW-RENT PUBLIC HOUSING
Mayor Kevin Hartke
Public Housing Commission Chairman
________________________________________________________________________________________________________________________
Previous version is obsolete
Page 1 of 1 form HUD-50077-CR (3/31/2024)
Civil Rights Certification
(Qualified PHAs)
U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB Approval No. 2577-0226
Expires 3/31/2024
Civil Rights Certification
Annual Certification and Board Resolution
Acting on behalf of the Board of Commissioners of the Public Housing Agency (PHA) listed below, as its Chairperson or other
authorized PHA official if there is no Board of Commissioners, I approve the submission of the 5-Year PHA Plan , hereinafter
referred to as” the Plan”, of which this document is a part, and make the following certification and agreements with the Department
of Housing and Urban Development (HUD) for the fiscal year beginning July 1, 2023 in which the PHA receives assistance under 42
U.S.C. 1437f and/or 1437g in connection with the mission, goals, and objectives of the public housing agency and implementation
thereof:
The PHA certifies that it will carry out the public housing program of the agency in conformity with title VI of
the Civil Rights Act of 1964 (42 U.S.C. 2000d-2000d—4), the Fair Housing Act (42 U.S.C. 3601-19), Section
504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), title II of the Americans with Disabilities Act (42 U.S.C.
12101 et seq.), and other applicable civil rights requirements and that it will affirmatively further fair housing in
the administration of the program. In addition, if it administers a Housing Choice Voucher Program, the PHA
certifies that it will administer the program in conformity with the Fair Housing Act, title VI of the Civil Rights
Act of 1964, Section 504 of the Rehabilitation Act of 1973, title II of the Americans with Disabilities Act, and
other applicable civil rights requirements, and that it will affirmatively further fair housing in the administration
of the program. The PHA will affirmatively further fair housing, which means that it will take meaningful
actions to further the goals identified in the Assessment of Fair Housing (AFH) conducted in accordance with
the requirements of 24 CFR § 5.150 through 5.180, that it will take no action that is materially inconsistent with
its obligation to affirmatively further fair housing, and that it will address fair housing issues and contributing
factors in its programs, in accordance with 24 CFR § 903.7(o)(3). The PHA will fulfill the requirements at 24
CFR § 903.7(o) and 24 CFR § 903.15(d). Until such time as the PHA is required to submit an AFH, the PHA
will fulfill the requirements at 24 CFR § 903.7(o) promulgated prior to August 17, 2015, which means that it
examines its programs or proposed programs; identifies any impediments to fair housing choice within those
programs; addresses those impediments in a reasonable fashion in view of the resources available; works with
local jurisdictions to implement any of the jurisdiction’s initiatives to affirmatively further fair housing that
require the PHA’s involvement; and maintains records reflecting these analyses and actions.
City of Chandler Housing and Redevelopment
AZ028
_________________________________________
__________________________________________
PHA Name
PHA Number/HA Code
I hereby certify that all the statement above, as well as any information provided in the accompaniment herewith, is true and accurate. Warning: HUD will prosecute
false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
Name of Executive Director: Leah Powell
Name of Board Chairperson: Mayor Kevin Hartke
Signature
Date
Signature
Date
The United States Department of Housing and Urban Development is authorized to collect the information requested in this form by virtue of Title 12, U.S. Code, Section 1701 et seq.,
and regulations promulgated thereunder at Title 12, Code of Federal Regulations. Responses to the collection of information are required to obtain a benefit or to retain a benefit.
The information requested does not lend itself to confidentiality. The information is collected to ensure that PHAs carry out applicable civil rights requirements.
Public reporting burden for this information collection is estimated to average 0.16 hours per response, including the time for reviewing instructions, searching existing data
sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. HUD may not collect this information, and respondents are not
required to complete this form, unless it displays a currently valid OMB Control Number.
Page 1 of 1 form HUD-50077-SL (3/31/2024)
Certification by State or Local
U. S Department of Housing and Urban Development
Official of PHA Plans Consistency
Office of Public and Indian Housing
with the Consolidated Plan or OMB No. 2577-0226
State Consolidated Plan
Expires 3/31/2024
(All PHAs)
Certification by State or Local Official of PHA Plans
Consistency with the Consolidated Plan or State Consolidated Plan
I, ___________Leah Powell________, the Neighborhood Resources Director______
Official’s Name Official’s Title
certify that the 5-Year PHA Plan for fiscal years 2020-2024 and/or Annual PHA Plan for fiscal
year 2023 of the City of Chandler Housing and Redevelopment Division is consistent with the
PHA Name
Consolidated Plan or State Consolidated Plan including the Analysis of Impediments (AI) to Fair
Housing Choice or Assessment of Fair Housing (AFH) as applicable to the
City of Chandler
______________________________________________________________________________
Local Jurisdiction Name
pursuant to 24 CFR Part 91 and 24 CFR §§ 903.7(o)(3) and 903.15.
Provide a description of how the PHA Plan’s contents are consistent with the Consolidated Plan or
State Consolidated Plan.
The PHA Plan affirmatively furthers fair housing by examining the landscape and addressing
impediments to fair housing with a reasonable approach and adds resources to increase the supply
of affordable housing. The PHA Plan is consistent with the Consolidated Plan based on this
approach.
I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. Warning: HUD will
prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
Name of Authorized Official:
Title:
Leah Powell
Neighborhood Resources Director
Signature:
Date:
The United States Department of Housing and Urban Development is authorized to solicit the information requested in this form by virtue of Title 12, U.S.
Code, Section 1701 et seq., and regulations promulgated thereunder at Title 12, Code of Federal Regulations. Responses to the collection of information
are required to obtain a benefit or to retain a benefit. The information requested does not lend itself to confidentiality. This information is collected to
ensure consistency with the consolidated plan or state consolidated plan.
Public reporting burden for this information collection is estimated to average 0.16 hours per year per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. HUD
may not collect this information, and respondents are not required to complete this form, unless it displays a currently valid OMB Control Number.
Page 1 of 3
formHUD-50077-ST-HCV-HP (3/31/2024)
Certifications of Compliance
with PHA Plan and Related
Regulations
(Standard, Troubled, HCV-Only, and
High Performer PHAs)
U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0226
Expires 3/31/2024
PHA Certifications of Compliance with PHA Plan, Civil Rights, and Related Laws and Regulations
including PHA Plan Elements that Have Changed
Acting on behalf of the Board of Commissioners of the Public Housing Agency (PHA) listed below, as its Chairperson or other
authorized PHA official if there is no Board of Commissioners, I approve the submission of the___ 5-Year and/or X Annual PHA
Plan, hereinafter referred to as” the Plan”, of which this document is a part, and make the following certification and agreements
with the Department of Housing and Urban Development (HUD) for the PHA fiscal year beginning July 1, 2023, in connection with
the submission of the Plan and implementation thereof:
1. The Plan is consistent with the applicable comprehensive housing affordability strategy (or any plan incorporating such
strategy) for the jurisdiction in which the PHA is located (24 CFR § 91.2).
2. The Plan contains a certification by the appropriate State or local officials that the Plan is consistent with the applicable
Consolidated Plan, which includes a certification that requires the preparation of an Analysis of Impediments (AI) to Fair
Housing Choice, or Assessment of Fair Housing (AFH) when applicable, for the PHA's jurisdiction and a description of the
manner in which the PHA Plan is consistent with the applicable Consolidated Plan (24 CFR §§ 91.2, 91.225, 91.325, and
91.425).
3. The PHA has established a Resident Advisory Board or Boards, the membership of which represents the residents assisted by
the PHA, consulted with this Resident Advisory Board or Boards in developing the Plan, including any changes or revisions
to the policies and programs identified in the Plan before they were implemented, and considered the recommendations of the
RAB (24 CFR 903.13). The PHA has included in the Plan submission a copy of the recommendations made by the Resident
Advisory Board or Boards and a description of the manner in which the Plan addresses these recommendations.
4. The PHA provides assurance as part of this certification that:
(i) The Resident Advisory Board had an opportunity to review and comment on the changes to the policies and programs
before implementation by the PHA;
(ii) The changes were duly approved by the PHA Board of Directors (or similar governing body); and
(iii) The revised policies and programs are available for review and inspection, at the principal office of the PHA during
normal business hours.
5. The PHA made the proposed Plan and all information relevant to the public hearing available for public inspection at least 45
days before the hearing, published a notice that a hearing would be held and conducted a hearing to discuss the Plan and
invited public comment.
6. The PHA certifies that it will carry out the public housing program of the agency in conformity with title VI of the Civil
Rights Act of 1964 (42 U.S.C. 2000d-2000d—4), the Fair Housing Act (42 U.S.C. 3601-19), Section 504 of the
Rehabilitation Act of 1973 (29 U.S.C. 794), title II of the Americans with Disabilities Act (42 U.S.C. 12101 et seq.), and
other applicable civil rights requirements and that it will affirmatively further fair housing in the administration of the
program. In addition, if it administers a Housing Choice Voucher Program, the PHA certifies that it will administer the
program in conformity with the Fair Housing Act, title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation
Act of 1973, title II of the Americans with Disabilities Act, and other applicable civil rights requirements, and that it will
affirmatively further fair housing in the administration of the program.
7. The PHA will affirmatively further fair housing, which means that it will take meaningful actions to further the goals
identified in the Assessment of Fair Housing (AFH) conducted in accordance with the requirements of 24 CFR § 5.150
through 5.180, that it will take no action that is materially inconsistent with its obligation to affirmatively further fair housing,
and that it will address fair housing issues and contributing factors in its programs, in accordance with 24 CFR § 903.7(o)(3).
The PHA will fulfill the requirements at 24 CFR § 903.7(o) and 24 CFR § 903.15(d). Until such time as the PHA is required
to submit an AFH, the PHA will fulfill the requirements at 24 CFR § 903.7(o) promulgated prior to August 17, 2015, which
means that it examines its programs or proposed programs; identifies any impediments to fair housing choice within those
programs; addresses those impediments in a reasonable fashion in view of the resources available; works with local
jurisdictions to implement any of the jurisdiction’s initiatives to affirmatively further fair housing that require the PHA’s
involvement; and maintains records reflecting these analyses and actions.
8. For PHA Plans that include a policy for site-based waiting lists:
___________________________________________________________________________________________________________
Page 2 of 3 form HUD-50077-ST-HCV-HP (3/31/2024)
•
The PHA regularly submits required data to HUD's 50058 PIC/IMS Module in an accurate, complete and timely manner
(as specified in PIH Notice 2011-65);
•
The system of site-based waiting lists provides for full disclosure to each applicant in the selection of the development in
which to reside, including basic information about available sites; and an estimate of the period of time the applicant
would likely have to wait to be admitted to units of different sizes and types at each site;
•
Adoption of a site-based waiting list would not violate any court order or settlement agreement or be inconsistent with a
pending complaint brought by HUD;
•
The PHA shall take reasonable measures to assure that such a waiting list is consistent with affirmatively furthering fair
housing; and
•
The PHA provides for review of its site-based waiting list policy to determine if it is consistent with civil rights laws and
certifications, as specified in 24 CFR 903.7(o)(1).
9. The PHA will comply with the prohibitions against discrimination on the basis of age pursuant to the Age Discrimination Act
of 1975.
10. In accordance with 24 CFR § 5.105(a)(2), HUD’s Equal Access Rule, the PHA will not make a determination of eligibility
for housing based on sexual orientation, gender identify, or marital status and will make no inquiries concerning the gender
identification or sexual orientation of an applicant for or occupant of HUD-assisted housing.
11. The PHA will comply with the Architectural Barriers Act of 1968 and 24 CFR Part 41, Policies and Procedures for the
Enforcement of Standards and Requirements for Accessibility by the Physically Handicapped.
12. The PHA will comply with the requirements of Section 3 of the Housing and Urban Development Act of 1968, Employment
Opportunities for Low-or Very-Low Income Persons, and with its implementing regulation at 24 CFR Part 135.
13. The PHA will comply with acquisition and relocation requirements of the Uniform Relocation Assistance and Real Property
Acquisition Policies Act of 1970 and implementing regulations at 49 CFR Part 24 as applicable.
14. The PHA will take appropriate affirmative action to award contracts to minority and women's business enterprises under 24
CFR 5.105(a).
15. The PHA will provide the responsible entity or HUD any documentation that the responsible entity or HUD needs to carry
out its review under the National Environmental Policy Act and other related authorities in accordance with 24 CFR Part 58
or Part 50, respectively.
16. With respect to public housing the PHA will comply with Davis-Bacon or HUD determined wage rate requirements under
Section 12 of the United States Housing Act of 1937 and the Contract Work Hours and Safety Standards Act.
17. The PHA will keep records in accordance with 2 CFR 200.333 and facilitate an effective audit to determine compliance with
program requirements.
18. The PHA will comply with the Lead-Based Paint Poisoning Prevention Act, the Residential Lead-Based Paint Hazard
Reduction Act of 1992, and 24 CFR Part 35.
19. The PHA will comply with the policies, guidelines, and requirements of 2 CFR Part 200, Uniform Administrative
Requirements, Cost Principles, and Audit Requirements for Federal Financial Assistance, including but not limited to
submitting the assurances required under 24 CFR §§ 1.5, 3.115, 8.50, and 107.25 by submitting an SF-424, including the
required assurances in SF-424B or D, as applicable.
20. The PHA will undertake only activities and programs covered by the Plan in a manner consistent with its Plan and will utilize
covered grant funds only for activities that are approvable under the regulations and included in its Plan.
21. All attachments to the Plan have been and will continue to be available at all times and all locations that the PHA Plan is
available for public inspection. All required supporting documents have been made available for public inspection along with
the Plan and additional requirements at the primary business office of the PHA and at all other times and locations identified
by the PHA in its PHA Plan and will continue to be made available at least at the primary business office of the PHA.
22. The PHA certifies that it is in compliance with applicable Federal statutory and regulatory requirements, including the
Declaration of Trust(s).
City of Chandler Housing and Redevelopment
AZ028
PHA Name
PHA Number/HA Code
X Annual PHA Plan for Fiscal Year 2023
_____ 5-Year PHA Plan for Fiscal Years 20____ - 20____
I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. Warning: HUD will
prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802).
___________________________________________________________________________________________________________
Page 3 of 3 form HUD-50077-ST-HCV-HP (3/31/2024)
Name of Executive Director: Leah Powell
Name Board Chairman: Mayor Kevin Hartke
Signature
Date
Signature
Date
The United States Department of Housing and Urban Development is authorized to solicit the information requested in this form by virtue of Title 12, U.S. Code, Section 1701
et seq., and regulations promulgated thereunder at Title 12, Code of Federal Regulations. Responses to the collection of information are required to obtain a benefit or to
retain a benefit. The information requested does not lend itself to confidentiality. This information is collected to ensure compliance with PHA Plan, Civil Rights, and related
laws and regulations including PHA plan elements that have changed.
Public reporting burden for this information collection is estimated to average 0.16 hours per year per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. HUD may not collect this information, and
respondents are not required to complete this form, unless it displays a currently valid OMB Control Number.
(exp. 06/30/2022)
PHA Board Resolution
U.S. Department of Housing OMB No. 2577-0026
Approving Operating Budget
and Urban Development
Office of Public and Indian Housing -
Real Estate Assessment Center (PIH-REAC)
form HUD-52574 (06/2019)
Previous editions are obsolete
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this information, and you are not required to
complete this form, unless it displays a currently valid OMB control number.
This information is required by Section 6(c)(4) of the U.S. Housing Act of 1937. The information is the operating budget for the low-income public housing program and provides a
summary of the proposed/budgeted receipts and expenditures, approval of budgeted receipts and expenditures, and justification of certain specified amounts. HUD reviews the
information to determine if the operating plan adopted by the public housing agency (PHA) and the amounts are reasonable, and that the PHA is in compliance with procedures
prescribed by HUD. Responses are required to obtain benefits. This information does not lend itself to confidentiality.
PHA Name: PHA Code:
Board Resolution Number:
Acting on behalf of the Board of Commissioners of the above-named PHA as its Chairperson, I make the following
certifications and agreement to the Department of Housing and Urban Development (HUD) regarding the Board’s
approval of (check one or more as applicable):
DATE
Operating Budget approved by Board resolution on:
Operating Budget submitted to HUD, if applicable, on:
Operating Budget revision approved by Board resolution on:
Operating Budget revision submitted to HUD, if applicable, on:
I certify on behalf of the above-named PHA that:
1. All statutory and regulatory requirements have been met;
2. The PHA has sufficient operating reserves to meet the working capital needs of its developments;
3. Proposed budget expenditure are necessary in the efficient and economical operation of the housing for the purpose of
serving low-income residents;
4. The budget indicates a source of funds adequate to cover all proposed expenditures;
5. The PHA will comply with the wage rate requirement under 24 CFR 968.110(c) and (f); and
6. The PHA will comply with the requirements for access to records and audits under 24 CFR 968.110(i).
I hereby certify that all the information stated within, as well as any information provided in the accompaniment herewith,
if applicable, is true and accurate.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18
U.S.C. 1001, 1010, 1012.31, U.S.C. 3729 and 3802)
Print Board Chairperson’s Name:
Signature:
Date:
PHA Fiscal Year Beginning:
City of Chandler Housing and Redevelopment
AZ028
July 1, 2023
HO173
04/10/2023
04/10/2023
Mayor Kevin Hartke
Fund 233
Fund 234
Fund 236
Fund 101
Fund 224
Fund 227
Fund 230
Fund 232
Section 8
Capital Fund
PR/ Senior
Fund 240
Youth Program
Family Sites
Elderly/Scattered
PH Management
Family Self
Sufficiency
Voucher Choice
Program
Housing
Contingency
Total
Estimated
Revenue Sources
Rental Income
858,000
785,000
150,000
1,793,000
Management Fee Revenue
490,000
490,000
Other Income
99,476
80,000
4,000
42,000
19,000
244,476
Grant Funding
850,000
472,000
172,000
7,626,000
2,525,486
11,645,486
City Funded
120,511
135,000
150,000
405,511
Other Grant Opportunities
10,221,000
3,000,000
13,221,000
Use of Reserves
-
-
76,073
10,368
387,846
877
475,164
Total Budgeted Revenues
120,511
1,807,476
1,337,000
705,073
182,368
8,205,846
2,525,486
10,390,877
3,000,000
28,274,637
Expenditure Budget
Administrative Salaries
62,447
212,424
143,711
511,629
135,888
280,085
-
1,346,184
Other Administrative Exp.
630
53,800
38,500
6,000
43,000
3,000
144,930
Resident Participation
500
500
1,000
Utilities
150,000
20,000
-
500
170,500
Maintenance Labor
223,587
93,448
21,711
338,746
Maintenance Materials
120,000
97,011
50,000
25,000
292,011
Professional / Contract
400
462,358
394,842
1,500
68,896
675,000
148,877
1,751,873
Insurance
27,000
21,000
3,750
51,750
Employee Benefits
46,734
183,607
94,020
173,044
46,480
100,306
3,775
-
647,966
Bad Debt Expense
20,000
20,000
40,000
Other General Expense
10,300
103,200
53,400
12,900
12,100
5,000
196,900
Property Betterments / Additions
-
1,680,000
1,680,000
Housing Rental Assistance Pmts.
6,764,000
7,900,000
14,664,000
Management Fees (transfer to fund 230)
151,000
129,000
123,000
90,000
22,000
515,000
Contingency
100,000
150,000
100,000
-
2,287,750
3,000,000
5,637,750
Total Budgeted Expense
120,511
1,807,476
1,255,432
705,073
182,368
7,491,387
2,525,486
10,390,877
3,000,000
27,478,610
Housing Division Budget for Fiscal Year 22-23
Public Housing
2/15/2023
DISCLOSURE OF LOBBYING ACTIVITIES
Approved by OMB
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
0348-0046
(See reverse for public burden disclosure.)
1. Type of Federal Action:
2. Status of Federal Action:
3. Report Type:
a. contract
a. bid/offer/application
a. initial filing
b. grant
b. initial award
b. material change
c. cooperative agreement
c. post-award
For Material Change Only:
d. loan
year _________ quarter _________
e. loan guarantee
date of last report ______________
f. loan insurance
4. Name and Address of Reporting Entity:
5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
and Address of Prime:
Tier ______, if known :
Congressional District, if known :
Congressional District, if known :
6. Federal Department/Agency:
7. Federal Program Name/Description:
CFDA Number, if applicable: _____________
8. Federal Action Number, if known :
9. Award Amount, if known :
$
10. a. Name and Address of Lobbying Registrant
b. Individuals Performing Services (including address if
(if individual, last name, first name, MI):
different from No. 10a)
(last name, first name, MI):
11.
Signature:
Print Name:
Title:
Telephone No.: _______________________
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)
Information requested through this form is authorized by title 31 U.S.C. section
1352. This disclosure of lobbying activities is a material representation of fact
upon which reliance was placed by the tier above when this transaction was made
or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This
information will be available for public inspection.
required disclosure shall be subject to a
not more than $100,000 for each such failure.
Prime
Subawardee
Federal Use Only:
Date:
who fails to file the
Any person
$10,000 and
than
civil penalty of not less
B
B
A
5
4c 5
Office of Public and Indian Housing (PH)
14.872
Not known
None
None
Mayor Kevin Harke
Public Housing Authority Commission Chairman
480-782-3207
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal
action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreementto make
payment to any lobbying entity for influencing or attempting to influence an officer or employeeof any agency, a Member of Congress, an officer or employeeof
Congress, or an employeeof a Member of Congress in connectionwith a coveredFederalaction. Completeall items that apply for both the initial filing and material
change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriateclassification of this report. If this is a followup report caused by a material change to the information previously reported, enter
the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal
action.
4. Enter the full name, address, city, State and zip code of the reportingentity. Include CongressionalDistrict, if known. Check the appropriateclassification
of the reportingentity that designatesif it is, or expects to be, a prime or subawardrecipient. Identify the tier of the subawardee,e.g., the first subawardee
of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and zip code of the prime Federal
recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizationallevel below agency name, if known. For
example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance
(CFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number;
Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number
assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan
commitment for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting
entity identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and
Middle Initial (MI).
11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control
Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is
estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington,
DC 20503.