STATE OF CALIFORNIA -BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY EDMUND G. BROWN JR., GOVERNOR

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT

DIVISION OF FINANCIAL ASSISTANCE

Emergency Housing and Assistance Program Capital Development

2020 W. El Camino Avenue, Suite 400, 95833

P. O. Box 952054

Sacramento, CA 94252-2054

(916) 263-2771 / FAX (916) 263-3391

PROJECT CLOSE-OUT CERTIFICATION FORM

EMERGENCY HOUSING AND ASSISTANCE PROGRAM

CAPITAL DEVELOMENT (EHAPCD)

EHAPCD Contract Loan No.:______-EHAPCD- ______

BorrowerName: ______

Authorized Representative Telephone Number: ______

Authorized Representative Email Address: ______

INSTRUCTIONS: Submit this completed form with your finalRequest for Disbursement (RFD) or within 60 days after your Contract expires. The “Certification of Borrower” section below must besigned by the Authorized Representative, as named in the Authorizing Resolution.

Note: Please confirmbelow that Semi-Annual Reports (SAR) for this Loan’s Standard Agreementterm have been submitted to EHAPCD staff. The EHAPCD Project Close-Out Certification Formcannotbe processed until allSAR’shave been received.

  • *Architect’s/EngineerCompletion Certificate sent to EHAPCD:□ Yes □ No
  • *Certificate of Completion Owner/General Contractor sent to EHAPCD: □ Yes □ No
  • Number of SAR’s sent to EHAPCD: ______
  • Number of Beds createdwith EHAPCD funds: New ______Preserved ______
  • Total number of Beds at the shelter facility: ______

*If you answered “No” above, please submit the required document(s) with this form.

CERTIFICATION OF BORROWER

It is hereby certified that all activities undertaken by the Borrower with funds provided under the Deferred Loan Agreement, have, to the best of my knowledge, been carried out in accordance with the Loan Agreement; that proper provisions have been made by the Borrower for the payment of all unpaid costs and unsettled third-party claims; that the State of California is under no obligation to make any further payment to the Borrower under the Loan Agreement in excess of the amount identified on the Standard Agreement; in the event there are any costs which are disallowed by any audit those costs shall be returned to the Department of Housing and Community Development; and that every statement and amount set forth in this instrument is, to the best of my knowledge, true and correct as of this date.

DATE / PRINTED NAME AND TITLE / SIGNATURE

THIS CAPITAL DEVELOPMENT PROJECT CLOSE-OUT IS HEREBY APPROVED BY HCD

DATE / PRINTED NAME AND TITLE / SIGNATURE

EHAPCD Project Close-Out Certification Form

(Rev. 5/14)