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HomeMy WebLinkAboutCORRESPONDENCE - RFP - P1026 NONPROFIT LEASE 906 E STUART (2)Administrative Services Purchasing Divison 215 North Mason Street y 2nd Floor y P.O. Box 580 y Fort Collins, CO 80522-0580 y (970) 221-6775 y Fax (970) 221-6707 www.fcgov.com REQUEST FOR PROPOSAL P1026 Nonprofit Lease: 906 E. Stuart Street The City of Fort Collins is seeking proposals from qualifying nonprofit organizations. Written proposals, six (6) will be received at the City of Fort Collins' Purchasing Division, 215 North Mason St., 2nd floor, Fort Collins, Colorado 80524. Proposals will be received before 3:00 p.m. (our clock), July 10, 2006. Proposal No. P1026. If delivered, they are to be sent to 215 North Mason Street, 2nd Floor, Fort Collins, Colorado 80524. If mailed, the address is P.O. Box 580, Fort Collins, 80522-0580. Questions concerning the scope of the project should be directed to Project Manager Helen Matson (970) 221-6276. Questions regarding proposals submittal or process should be directed to James B. O'Neill, II, CPPO, FNIGP (970) 221-6775. A Pre-Proposal meeting will be held at 9:00 a.m. on June 23, 2006 at 117 N. Mason St. Facilities Building Conference Room. There will be a tour of the facility following the meeting for those who are interested. A copy of the Proposal may be obtained as follows: 1. Download the Proposal/Bid from the Purchasing Webpage, www.fcgov.com/purchasinq. 2. Come by Purchasing at 215 North Mason St., 2nd floor, Fort Collins, and request a copy of the Bid. Sales Prohibited/Conflict of Interest: No officer, employee, or member of City Council, shall have a financial interest in the sale to the City of any real or personal property, equipment, material, supplies or services where such officer or employee exercises directly or indirectly any decision- making authority concerning such sale or any supervisory authority over the services to be rendered. This rule also applies to subcontracts with the City. Soliciting or accepting any gift, gratuity favor, entertainment, kickback or any items of monetary value from any person who has or is seeking to do business with the City of Fort Collins is prohibited. Collusive or sham proposals: Any proposal deemed to be collusive or a sham proposal will be rejected and reported to authorities as such. Your authorized signature of this proposal assures that such proposal is genuine and is not a collusive or sham proposal. The City of Fort Collins reserves the right to reject any and all proposals and to waive any irregularities or informalities. Sincerely, James B. O'Neill II, CPPO, FNIGP Director of Purchasing & Risk Management P1026 Nonprofit Lease: 906 E. Stuart Street Background: The City of Fort Collins is the owner of the property at 906 E. Stuart Street, Fort Collins, CO 80524. This property had been the home of Sunshine School for many years. Sunshine School provided child care for low income families and is no longer in business. The City is seeking a non-profit tenant who would be interested in this property. The property is currently empty and will be available immediately to the successful bidder. Pre-Proposal Meeting: A Pre-Proposal meeting will be held at 9:00 a.m. on June 23, 2006 at 117 N. Mason Street, Facilities Building Conference Room. There will be a tour of the facility following the meeting for those who are interested. Tenants must meet the following requirements: Proposal Submission Requirements: 1. Agency must submit documentation showing an established history of local community service. 2. Agency must submit the most recent agency audit or equivalent financial records (2005 or more recent). 3. Agency must provide documentation that the agency is in good financial standing, with the financial capacity to handle maintenance costs at 906 E. Stuart Street. 4. Agency must provide state licensing number (if applicable). 5. Agency must have current state licensure (if applicable) in good standing. 6. Must have staffing and financial capacity for operations at 906 E. Stuart Street. 7 Must have current 501(3)c status as a Colorado non-profit corporation (show documentation) 8. Must meet a CDBG National objective by serving a majority (51 % or more) of low-moderate income clients below 80% of Area Median Income {AMI} (provide documentation). 9. Service must be a CDBG-eligible activity. 10. By January 31st of each year, the agency must submit a yearly report to the CDBG Program, Advance Planning Department, City of Fort Collins. The report should detail the prior calendar year’s client statistics, demonstrating service to a majority of (51% or more) of low-moderate income clients below 80% of Area Median Income, and following household income documentation reporting standards as required by the U.S. Department of Housing and Urban Development (HUD). Zoning: In addition to meeting CDBG-eligible activity requirements, the proposal must be for a permitted use in the LMN Zoning District, must comply with all building code regulations and must meet the new Land Use Code Standards. This site has historically been used as a child care center. If the successful proposer intends to operate a child care center and their operations commence prior to September 9, 2006, there will not be a requirement to bring the property into compliance with new Land Use Code. These requirements would include platting the lot. Building and Site Specifics: • Lot size: .3 Acres • Design: Ranch style – main floor is main area of use for the building. There is a second floor that is only accessible from an outside stairway entrance. Building Square Footage: First floor 1,687 square feet Second Floor 384 square feet Total 2,071 square feet Review and Assessment: Tenant’s will be evaluated on the following criteria. These criteria will be the basis for review of the written proposals and any interview session. The rating scale shall be from 1 to 6, with 1 being a poor rating, 3 being an average rating, and 6 being an outstanding rating. WEIGHTING FACTOR QUALIFICATION STANDARD 5.0 Proposed Use Does the proposal show an understanding of the project objective, meet the CDBG and Zoning requirements, and result in a positive use of the property? 5.0 Personnel Qualifications Do the persons who will be working on the project have the necessary skills? Are sufficient people of the requisite skills assigned to the proposed use of the property? 2.0 Availability When can the Tenant begin to use the property? 2.0 What is the yearly lease rate? Is this within acceptable guidelines for non-profit use of the facility? 6.0 Tenant Capability How has the Tenant been meeting its mission? Does the Tenant have the support capabilities the assigned personnel required to continue to be viable? What is the reputation of the Tenant in the community? Reference evaluation (Top Ranked Tenant) The project Manager will check references. The evaluation rankings will be labeled Satisfactory/Unsatisfactory. Administrative Services Purchasing Divison 215 North Mason Street y 2nd Floor y P.O. Box 580 y Fort Collins, CO 80522-0580 y (970) 221-6775 y Fax (970) 221-6707 www.fcgov.com ADDENDUM No. 1 SPECIFICATIONS AND CONTRACT DOCUMENTS Description of RFP: P1026 Non-Profit Lease: 906 E Stuart Street OPENING DATE: 3:00 P.M. (Our Clock) July 10, 2006 To all prospective bidders under the specifications and contract documents described above, the following changes are hereby made. ADDITIONS: Prospective applicants should note the following in particular: • Please read the lease agreement carefully. • It should be emphasized that the tenant is responsible for ALL maintenance and necessary upgrades, including, but not limited to, all landscaping maintenance and upkeep (including trees), snow removal, painting, appliances, building systems upkeep, etc. The City of Fort Collins will not be responsible for the cost of any maintenance or upgrades. • Please note paragraph 4 of the Lease Agreement. The City is charging a $500 Security Deposit, to be paid at the time the lease is executed. This deposit for utilities and rent will be held by the City for the entire lease term. • Since the new tenant will be responsible for all maintenance, it is advisable to include building inspection in your due diligence. To arrange for a time for this inspection, please call Kayla Ballard, City Real Estate Services at 416-2276. Kayla will meet you and your inspector at the property. • The property does not have an underground sprinkling system. • The property is City-owned and any upgrades/repairs made by the tenant will become the property of the City at time of lease termination. These improvements contribute to the owner’s equity investment, and will not result in a financial return at any time for the tenant. • Please review the standards that outline documentation needed for income verification to meet CDBG regulations for client services • Lease Rate has been removed from the Evaluation Criteria ATTACHMENTS: • Lease Agreement attached. Please read the lease agreement carefully. • Please review the standards that outline documentation needed for income verification to meet CDBG regulations for client services. (attached) • Prebid Attendees List attached RECEIPT OF THIS ADDENDUM MUST BE ACKNOWLEDGED BY A WRITTEN STATEMENT ENCLOSED WITH THE BID/QUOTE STATING THAT THIS ADDENDUM HAS BEEN RECEIVED. LEASE AGREEMENT THIS LEASE AGREEMENT, made and entered into this day of , 2006, by and between THE CITY OF FORT COLLINS, COLORADO, a Municipal Corporation, hereinafter referred to as the ("City"), and , hereinafter referred to as ("Tenant"). WITNESSETH: WHEREAS, the City is the owner of certain Premises in the City of Fort Collins located at 906 E. Stuart Street, Fort Collins, Colorado 80524 (“Premises”); and WHEREAS, the Tenant desires to lease said Premises for the purpose of ; WHEREAS, the use by Tenant of the Premises for its would further an important public purpose of the City of Fort Collins. NOW THEREFORE, for and in consideration of the mutual covenants and obligations herein expressed, the monetary payment hereinbelow recited and the public benefit to be derived from the service provided by the Tenant, the receipt and adequacy of which is hereby acknowledged, it is hereby mutually covenanted and agreed by and between the parties as follows: 1. Premises. The City hereby leases to the Tenant and the Tenant hereby leases from the City, the Premises located at 906 E. Stuart Street in the City of Fort Collins, Colorado, said property more fully described as follows: A tract of land situate in the Northeast 1/4 of the Northeast 1/4 of Section 24, Township 7 North, Range 69 West of the 6th P.M., and being a part of Tract 7, of the East Acres Subdivision, a subdivision of record in the County of Larimer, State of Colorado, and being more particularly described as follows: Considering the South line of said Tract 7 as bearing S 89º56' 00" West and with all bearings contained herein relative thereto: Commencing at the Southeast corner of said Tract 7, thence S 89º56'00" West along the said South line a distance of 846.15 feet to the point of beginning; thence along the East line of the Spring Meadows on Spring Creek Subdivision N 00º42' East, a distance of 140.77 feet; thence along a South line of said subdivision N 89º50' West, a distance of 99.97 feet; thence S 00º03'39" West, a distance of 141.16 feet more or less to the South line of said Tract 7; thence N 89º56'00" East, a distance of 98.40 feet to the true point of beginning. 2. Term: A. Base Term. The base term of this Lease shall be for a five (5) year period commencing on , 20 , unless sooner terminated by either party pursuant to paragraph 14 hereof. B. Extensions. Unless the City determines, at its sole discretion, that such renewal is not in the City’s interest, the Tenant shall have the right and option to extend the base term of this lease for two additional five-year terms. However, such extension is expressly contingent upon the Tenant not being in default hereunder. Tenant shall provide sixty (60) day’s notice prior to the end of any given lease term of its intent to extend or to terminate the lease. 3. Rent. Tenant shall pay to the City, in advance, the sum of Five Dollars ($5.00) per year as and for rent for the above described Premises, such payment to be made at City's Right-of-Way Office, 117 North Mason Street, Fort Collins, Colorado, or at such other place as the City may from time to time designate. 4. Security Deposit. The Tenant shall pay to the City the amount of Five Hundred Dollars ($500.00) to be held as a security deposit on which the City is not required to pay interest to the Tenant. The City shall have the right to apply all or part of said deposit to any delinquent rent or utility charges to the Premises, but is not obligated to do so. Said deposit or balance thereof, after deduction for damages or past due rent or utility charges shall be refunded only on termination of this Lease Agreement after inspection by the City and after all personal property of Tenant has been removed. If Tenant is not found to be in default of the performance of the covenants or conditions herein at the sole discretion of the Landlord, the deposit will be returned within 60 days of vacancy, provided Tenant has provided the City with a forwarding address to which the deposit can be mailed. This deposit shall be not applied to the last rental payment. 5. Permissible Uses of Premises. Tenant agrees to use and occupy the Premises only for the purpose of and associated uses and for no other purpose whatsoever without the prior written consent of the City. 6. Condition of Premises, Maintenance and Damage. Tenant accepts the Premises in their present condition “as is". Tenant acknowledges that the Premises, in their present condition, comply fully with the City’s covenants and obligations hereunder. Tenant stipulates that the Premises have been examined, including the grounds, buildings and all improvements, and that they are, at the time of this lease, in good order and repair, safe, clean and in tenantable condition. Tenant shall be responsible for all routine maintenance associated with the use of the Premises. 7. Alterations, Improvements and Signs. A. All alterations, additions, improvements or changes to the Premises by Tenant subsequent to the commencement of the Lease term shall be subject to the written approval of the City and shall be done in a good and workmanlike manner without impairing the structural soundness of the building and in compliance with the building and zoning laws and with all other laws, ordinances, orders, rules, regulations and requirements of all federal state or municipal governments and the appropriate departments, commissions, boards and officers thereof; and the Tenant shall procure certificates of occupancy, if required by law. Furthermore, such alterations, additions and improvements shall not be commenced until any contractor or subcontractor engaged for such purpose shall deliver to the Tenant (with a copy to the City) a certificate evidencing that proper workmen's compensation insurance is in full force and effect, covering any persons performing such work, and that the same may not be canceled without at least ten (10) days prior written notice to the City. Furthermore, no such alterations, additions or improvements shall be commenced until the Tenant shall have procured and paid for all required municipal and other governmental permits and authorizations of the various municipal departments and governmental subdivisions having jurisdiction over the matter. B. All alterations, changes and improvements built, constructed, or placed on the Premises by Tenant, with the exception of the fixtures removable without damage to the Premises and movable personal property shall, unless otherwise provided by written agreement between the parties hereto, be the property of the City and remain on the Premises at the termination of this Lease. C. The Tenant shall not affix, erect or maintain on the Premises any sign or advertisement without first obtaining the City’s approval as to the sign or advertisement to be erected on the Premises. All such signs must comply with all applicable laws. The cost of erection and maintenance of such sign or advertisement shall be the responsibility of the Tenant. 8. Assignment and Subletting The Tenant shall not assign, sublet or grant any concession or license for use of the Premises or any part thereof without the prior written consent of the City. The City's consent to any given assignment, subletting, concession or license shall not be deemed to be a consent to any future assignment, subletting, concession or license. An assignment, subletting, concession or license obtained without the prior written consent of the City, or an assignment or subletting by operation of law, shall be void and shall, at the City's option, terminate this Lease. 9. Dangerous Materials Tenant shall not keep or have on the Premises any article, item or thing of a dangerous, inflammable or explosive character that might unreasonably increase the danger of fire to the Premises or that might be considered hazardous or extra hazardous by any responsible insurance company. 10. Utilities. Tenant shall be responsible for arranging for and paying for all utility services required on the Premises. 11. Maintenance and Repair. Tenant shall keep and maintain the Premises, grounds, appurtenances, improvements and fixtures in a safe and sanitary condition and in good repair during the term of this Lease and any renewal thereof at the sole expense of the Tenant. Such maintenance shall include, but not be limited to, all required repairs to the plumbing, heating apparatus, electric and gas fixtures, snow removal and grounds maintenance. In addition, major maintenance and repair of the Premises, whether or not due to the Tenant's misuse, waste or neglect or that of its employees, agents, or visitors, shall be the sole responsibility of the Tenant at Tenant's expense. 12. Mechanic’s Liens. The Tenant agrees to pay or cause to be paid promptly all bills and charges for material, labor or otherwise in connection with or arising out of any alterations, additions or changes made by the Tenant or its agents or subtenants to the Premises; and the Tenant agrees to hold the City free and harmless against all liens and claims of liens for such labor and materials, or either of them, filed against the Premises or any part thereof and from and against any expense and liability in connection therewith. The Tenant further agrees to discharge (either by payment or by filing the necessary bond or otherwise) any mechanic's, materialman's or other liens against the Premises arising out of any payment due or alleged to be due for any work, labor, services, materials or supplies claimed to have been furnished at the Tenant's request in, on or about the Premises and to indemnify the City against any lien or claim of lien attached to or upon the Premises or any part thereof by reason of any act or omission on the Tenant's part. The Tenant shall, however, have the right to contest any mechanic's liens or claims filed against the Premises, provided the Tenant shall diligently prosecute any such contest and at all times effectively stay or prevent any sale of the Premises under execution or otherwise and pay or otherwise satisfy any final judgment adjudging or enforcing such contested lien and thereafter procure record satisfaction or release thereof. The Tenant also agrees in any such contest, at the Tenant's cost and expense, to defend the same on behalf of theCity. 13. Right of Inspection. The City shall have the right at all reasonable times, during the term of this Lease and any renewal thereof, to enter the Premises for the purpose of inspecting the Premises and all buildings, grounds and improvements thereof, provided the City shall contact the Tenant at least twenty-four (24) hours prior to such visit. In the event of an emergency, to protect or minimize the risk of harm to life or property when Tenant shall not be personally present to open and permit an entry into the Premises, City or City’s agents may enter the same by a master key or may forcibly enter the same, without rendering the City or such agents liable therefore, and without in any manner affecting the obligations and covenants of this Lease. 14. Surrender of Premises At the expiration of this Lease term or any renewal thereof, the Tenant agrees to quit and surrender the Premises in as good a state and condition as they were at the time of commencement of this Lease, reasonable wear and tear and damages by the elements excepted. The Tenant agrees to be responsible and to reimburse the City for any repairs to the Premises required due to the Tenant's occupancy of the Premises. 15. Default. If any default is made in the payment of rent, or any part thereof, at the times hereinbefore specified, or if any default is made in the performance of or compliance with any term, provision or condition hereof, or if the Tenant fails to meet the Community Development Block Grant (CDBG) client service requirements, this Lease, at the option of the City, shall be terminated and forfeited, and the City may reenter the Premises and remove all persons therefrom. The Tenant shall be given written notice of any default or breach of the provisions of this Agreement and termination or forfeiture of the Lease shall not result if, within twenty (20) days after receipt of such notice, the Tenant has corrected the default or breach or has taken action reasonably likely to affect such correction within a reasonable time. 16. Insurance. A. The Tenant, at its sole cost and expense, shall, during the term of this Lease, procure, pay for and keep in full force and effect a comprehensive policy of commercial general liability insurance covering the improvements and the Premises insuring the Tenant in an amount not less than Five Hundred Thousand Dollars ($500,000.00) covering bodily injury, including death to persons, personal injury and property damage liability arising out of a single occurrence. Such coverage shall include, without limitation, legal liability of the insureds for property damage, bodily injuries and deaths of persons in connection with the operation, maintenance or use of the Premises (including acts or omissions of the Tenant), legal liability arising out of lawsuits related to employment contracts of the Tenant and protection against the liability for non-owned and hired automobiles. Such coverage shall also include, if applicable, comprehensive automobile liability insurance, garage keepers' liability, liability for property of others, host liquor liability, water damage liability, contractual liability, workmen's compensation insurance for employees of the Tenant and such other risks as shall customarily be required by private institutional mortgage investors with respect to property similar in construction, location and use. B. The Tenant, at its sole cost and expense, shall, during the term of this Lease, procure, pay for and keep in full force and effect a policy of property insurance covering all leasehold improvements to the Premises and all of the Tenant’s equipment, trade fixtures, appliances, furniture, furnishings and personal property from time to time in, on or upon the Premises. This insurance shall be in an amount not less than the full replacement cost without deducting for depreciation. Such insurance shall afford protection against at least the following: (i) loss or damage from fire and perils normally covered by the standard extended coverage endorsement; and (ii) such risk as shall customarily be covered with respect to property similar in construction, location and use, including all perils normally covered by the standard “all risk” endorsement when such is available. C. If the Tenant employs any person in connection with the operation and use of the Premises as contemplated under this Lease Agreement, the Tenant shall, at its own sole cost and expense, during the term of this Lease, procure, pay and keep in full force and effect workers’ compensation insurance, in an amount not less than Six Hundred Thousand Dollars ($600,000.00) for each occurrence, for all of its employees to be engaged in work on the Premises under this Lease Agreement. D. All policies of insurance carried by the Tenant shall name the Tenant as insured and shall name the City as additional insureds and loss payees for the policy. The policy or policies shall contain a provision that the policy or policies cannot be canceled or materially altered either by the insureds or the insurance company until thirty (30) days prior written notice thereof is given to the Tenant and the City. Upon issuance or renewal of any such insurance policy, the Tenant shall furnish a certified copy or duplicate original of such policy or renewal thereof with proof of premium payment to the City. Any such policies shall contain waivers of subrogation and waivers of any defense based on invalidity arising from any act or neglect of any assignees or sublessees of the Tenant. 17. Indemnification. Tenant agrees to indemnify and hold harmless the City against all damages, claims, liabilities for injury or damage to person, property or whenever and by whomever brought and causes of action arising from or in anyway relating to the Tenant's possession or use of the Premises. 18. Americans with Disabilities Act. The Tenant shall comply with all Federal, State and local laws, including the requirements of the Americans with Disabilities Act (ADA). The City does not represent that the Premises meet the requirements of the ADA for the purposes of Tenant’s intended use of the Premises. 19. Conditions of the Agreement. It is further agreed by and between the City and Tenant as follows: A. That this Agreement may not be enlarged, modified, or altered, except as in writing, signed by the parties as an amendment hereto. B. That no waiver of any breach of this Agreement shall be held or construed to be a waiver or any subsequent breach thereof. C. That it is expressly understood and agreed by the parties hereto that in the performance of the obligations provided for in this Agreement, time is of the essence. D. The covenants and conditions herein contained shall apply to and bind the heirs, legal representatives, and assigns of the parties hereto and all covenants are to be construed as conditions of this Lease. E. If either party must resort to legal action to enforce the terms of this Agreement, the non- prevailing party shall reimburse the prevailing party for the prevailing partys reasonable legal fees, including attorney’s fees. IN WITNESS WHEREOF, the parties hereto have signed this Agreement the day and year first written above. CITY: THE CITY OF FORT COLLINS, COLORADO, a Municipal Corporation By: Darin A. Atteberry, City Manager ATTEST: City Clerk APPROVED AS TO FORM: Assistant City Attorney TENANT: By: Title: ATTEST: Title: ATTACHMENT: 1. Lead-Based Paint Disclosure CDBG Client Income Documentation for Tenants at 906 E. Stuart HUD Guidelines regarding income documentation are VERY strict, and there is NO flexibility. They are serious about serving people and families in true need. The requirement for the CDBG program is that at least 51% of clients served during any given calendar year must be low and moderate income, according to HUD’s current income guidelines. Any tenant providing a CDBG-eligible activity at 906 E. Stuart Street who enters into a lease agreement with the City of Fort Collins will have to provide the following to the Advance Planning Department’s CDBG program: 1) Initial census (total number of clients being served) and income verification of clients at occupancy. 2) Within 30 days of each subsequent month, additional income verification must be submitted for any new, eligible clients. 3) If ratios of income levels served fall below 45% eligible clients vs. 55% non-eligible clients at any time during the calendar year, the tenant will be put on probationary status regarding the lease. However, cumulative compliant percentages within a calendar year will be taken into consideration. 4) A summary report and certification must be submitted by January 31st, outlining the total census for clients and income verification for eligible clients served during the prior calendar year. 5) If the tenant fails to meet the yearly majority percentage (51%) required for low and moderate income clients served, the lease with the City will be immediately terminated. 6) Contact Information: CDBG Program City of Fort Collins PO Box 580 Fort Collins, CO 80522 (281 N. College Ave., 2nd Floor) Phone: 970-221-6758 CDBG INCOME VERIFICATION STANDARDS CITY OF FORT COLLINS (rev. 6/06) 1. 51% of clients served during any given calendar year must fall within HUD Area Median Income (AMI) guidelines for the current calendar year. 2. Income must be included for adults 19 years old or older in residence, even if those adults are not immediate family members. That includes: roommates, significant others, relatives, etc. Additionally, even if an adult, immediate family member (e.g., spouse) is NOT in residence, that income must be declared. Examples would be those in active military service, or those who are incarcerated. Income must also be declared for all adult family members, unless the client is legally divorced (not just legally separated), whether or not the spouse is in residence. 3. Income Verification Documents: At a minimum: • months worth of the most recent paycheck stubs for ALL adult members of the client household who are 19 years old or older • the most recent household federal tax return may also be required • any other forms of supplemental/alternative income must also be declared, documented, and will be considered as part of the annual household income: Unemployment Compensation Retirement Fund Pay-outs Social Security Alimony Workers Compensation Income from Assets Child Support Pensions Education Grants/Work-Study General Assistance Self-Employment Other Forms of Disability Assistance TANF Union Benefits SSI Family Support SSDI Annuity Payments * Income received for foster parent responsibilities does NOT have to be declared. 4. Clients must be informed that false statements or omissions are grounds for prosecution under the full extent of Colorado law. 5. Information submitted to our office is considered confidential, and is used only for the purpose of monitoring regulatory compliance. DECLARATION OF NO INCOME The program for which you or a person in your household is applying is funded in part one or more of the following sources: the federal HOME Investment Partnership program, the federal Community Development Block Grant (CDBG) program, the City of Fort Collins Human Services Program, and/or the City of Fort Collins Affordable Housing Fund. The City is required to verify all income of anyone receiving assistance under these programs. To comply with this requirement, we ask your cooperation in supplying the information requested in the Certification below. This information will be held in strict confidence and used only for the purpose of establishing your household eligibility. CERTIFICATION I, ___________________________________, do hereby certify that I do NOT receive income from ANY source. I understand sources of income include, but are not limited to, the following: Employment by Others Retirement Funds Unemployment Compensation Alimony Social Security Income from Assets Workers Compensation Pensions Child Support General Assistance Education Grants/Work-Study Disability Self-Employment Union Benefits TANF Family Support SSI Annuities I certify that the foregoing is true, complete and correct. Inquiries may be made to verify statements herein. I also understand that false statements or omissions are grounds for disqualification and/or prosecution under the full extent of Colorado law. Name (PRINT): __________________________________ Relationship to Applicant: _________________________ Signature; ____________________________ Date: ________________________ Witness Signature: _________________________ Date: ______________________ Rev. 1/06