HomeMy WebLinkAboutCOR-1999-Request for Release of Funds - R'equest for Release of Fla JF - U.S.Department of Housing — OMB No.2506-0087(exp.6G 20ot)
and Certification and Urban Development
This form is to be used by Responsibte Entities and Recipients(as defined in 24 CFR part 58.2)when requesf(ng the release of funds,and requesting the authority
to use such Tunis, for HUD programs idant eel by statul�that provide far the assumption of She erninmmerdal review responsibility by units of general local
government and States. Public reporting burden for this collection of information is estimated to average 0.8 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 infonnagon.This agency
may not conduct or sponsorihis collection of informaiot,and a person is not required to respond to questions about this requirement,unless the collection request
displays a valid OMB control number.
Part I. program Description and Request for Release of Funds (to be completed by Responsible Entity)
f.Program Titte(s): 2 HUD/Mate Identification Number. 3.Recipient Identification Number
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8.HU6 or state Agency a Office Unit lo Receive Request•
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recipient(s)of assistance under the p s)listed above requests the release of funds and removal of emironmental glen[conditions
governing the use of the assistance for the following:
g.Program ActiAty/Project Narna—, 10.gallon:(street,address,dfy,courdy.8 slate)
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Part 2: Environmental Certification (to t m^--ted by responsible entity)
With reference to the above Program Activity(ies, .oject(s),I,the undersigned officer of the respon_. .e entity, certify that:
1. The responsible entity has assumed responsibility for and complied with, or will continue to comply with,the National Environmental policy
Act of 1969, as amended; the environmental procedures, permit requirements and statutory obligations of the laws cited in 24 CFR 58.5 and
24 CFR 58.6;and the applicable State and Local laws.
2. After consideringthe type and degree of environmental effects identified b the environmental r completed Yp g y review compl d for the proposed project
described in Part 1 of this request, I have found that the project did did not require the preparation and dissemination of an
of an environmental impact statement.
3. The responsible entity has disseminated and/or published in the manner prescribed by 24 CFR 58.43 and 58.60 a notice to the public in
accordance with 24 CFR 58.70 and as evidenced by the attached copy(copies) or provide evidence of posting and mailing procedure.
4. The dates for all statutory and regulatory time periods for review, comment or other action are in compliance with procedures and
requirements of 24 CFR Part 58.
5. In accordance with 24 CFR Part 58.71(b) the responsible entity will advise the recipient (if different from the responsible entity) of any
special environmental conditions that must be adhered to in carrying out the project.
As the duly designated certifying official of the responsible entity,I also certify that:
6. I am authorized to and do consent to assume the status of federal official under the National Environmental Policy Act of 1969 and each
provision of law designated in the 24 CFR Part 58.5 and 24 CFR Part 58.6 list of NEPA-related authorities insofar as the provisions of these
laws apply to the HUD responsibilities for environmental review, decisionmaking and actions that have been assumed by the responsible
entity.
7. I am authorized to and do accept, on behalf of the recipient personally, the jurisdiction of the federal courts for the enforcement of all these
responsibilities,in my capacity as certifying officer of the responsible entity.
Signature of Certifying Officer of the Responsible Entity: Tdle of Certifying Officer:
Date Signed t
x NAVamber 22, 19.99
Address of Certifying Officer:
-Box;- 47, Anaeortes, WA 98221
Part 3. To be completed when the Recipient is not the Responsible Entity
The recipient agrees to abide by the special conditions,procedures and requirements of the environmental review and to advise the responsible
entity of any proposed change in the scope of the project or any change in environmental conditions in accordance with 24 CFR 58.71(b).
Signature of Authorized Officer of the Recipient: Title of Authorized Officer:
Date Signed: pp
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Warring:HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties(18 USC 1001, 1010,1012;31 USC 3729,3802).
form HUD-7015.15 (2/98)