CDBG PLANNING GRANT
PROGRAM
APPLICATION MANUAL
CONTENTS
I.
II.
III.
IV.
V.
VI.
What is CDBG?
CDBG Planning Program Overview
Eligibility and Program Requirements
Application and Selection Process
Application Packet
Required Forms and Sample Documents
CDBG PROGRAM CONTACT INFORMATION
Wisconsin Division of Administration
Division of Housing – Bureau of Community Development
101 E. Wilson St., 5th Floor
Madison, WI 53703
Lisa Marks, Administrator
Wisconsin Department of Administration – Division of Housing (DOH)
(608) 267-0660
Tom Clippert, Bureau Director
Wisconsin Department of Administration – Division of Housing, Bureau of Community Development
(608) 261-7538
I.
What is CDBG?
The Community Development Block Grant (CDBG) program is a federal formula-allocated grant program
administered by the U.S. Department of Housing and Urban Development (HUD). The program was
created when Congress passed the Housing and Community Development Act, Title 1 in 1974 and it is
governed by the rules set forth in the Code of Federal Regulations (24 CFR Part 570).
The primary purpose of the CDBG program is the development of viable communities through the
provision of decent housing, a suitable living environment, and the expansion of economic opportunities,
principally for the benefit of persons of low and moderate income.
The CDBG program consists of two components: an “entitlement program” under which HUD provides
funding directly to urban counties with populations of at least 200,000; cities with populations of at least
50,000; and principal cities of Metropolitan Statistical Areas and a “state-administered program” under
which HUD provides CDBG funds to the State to distribute to non-entitlement communities. The
Department of Administration’s Bureau of Community Development is responsible for administering
Wisconsin’s State-Administered CDBG Program.
II. CDBG Planning Program – Overview
The Community Development Block Grant (CDBG) Planning Program provides funding to CDBG-eligible
local governments that have clearly identified a community or economic development concern, or
opportunity, and lack the resources needed to plan an appropriate response.
Planning Grants of up to $25,000 are available for community-wide planning and strategic development
activities that:
 emphasize collaboration among community stakeholders;
 address economic conditions such as assisting small business and responding to plant
closings;
 identify strategies to increase access to affordable housing;
 improve community vitality by addressing slum and physical blight; or
 address other issues that will improve the well-being of low and moderate income individuals.
Planning Grants can also be used to undertake the above listed planning and strategic development
activities for a specific neighborhood or district within a community or to help plan for the use or reuse of
a specific site, for example, the adaptive reuse of a former hospital or school building, or potential use of
a parcel of land. The Department will provide grants of up to $15,000 to fund plans and strategic
development activities that are neighborhood, district, or site specific.
III. Eligibility & Program Requirements
Eligible applicants are units of general local government eligible for the CDBG Small Cities Program in
Wisconsin. Entitlement communities are not eligible. In addition, to being an eligible unit of general local
government, applicants must meet the following eligibility and programmatic requirements:
National Objective Compliance
To qualify for assistance, a planning proposal must address an activity which, if implemented, meets at
least one of two national objectives under the CDBG Program. That is, it must be shown that either 1) at
least 51 percent of the persons who would benefit from implementation of the plan are low or moderate
income persons, or 2) implementation of the plan would eliminate slum or blight in the community.
Benefit to Low- to Moderate-Income Persons
Area Benefit
A project can meet the low- and moderate-income (LMI) national objective by serving an area in which at
least 51 percent of the residents are LMI persons (area basis) or by providing services to a group of
persons principally made up of LMI individuals (limited clientele).
An activity may qualify as benefitting low- and moderate income (LMI) persons on an area basis if at
least 51 percent of the persons residing in the area served by the activity are of low to moderate income.
Determining whether an activity qualifies as benefitting LMI individuals on an area basis requires the
applicant to determine both the area served by the activity and the percentage of low and moderate
income persons residing in the area. Service areas may or may not be coterminous with census tracts or
other officially designated boundaries.
When a service area is coterminous with census tracts or other officially designated boundaries, census
data should be used to the extent feasible to determine the percentage of low and moderate incomes
residents within the area. Data on low to moderate income residents in Wisconsin census tracts and
municipalities is available on HUD’s website.
If an activity’s service area in not contiguous with census data or an applicant has reason to believe that
available census data do not accurately reflect income levels in the area, an applicant may elect to
conduct a survey instead. If a survey is used to document compliance with the LMI national objective on
an area basis, an applicant must demonstrate that the survey is methodologically sound and submit
documentation of the survey instrument, responses, and results to DOA as part of the application.
Please contact Tom Clippert by email at [email protected] or by phone at 608/266-7538 for
additional information regarding the use of community surveys.
Limited Clientele
An activity that provides benefits to a particular group of persons rather than residents within a specified
service area may qualify as benefitting LMI individuals based on serving limited clientele. Activities that
exclusively benefit one of the following groups are presumed by HUD to be made up of principally low
and moderate income persons:








abused children;
elderly persons;
battered spouses;
homeless persons;
severely disabled adults;
illiterate adults;
persons living with AIDS; and
migrant farm workers.
Prevention or Elimination of Slum and Blight
Activities that qualify under the national objective of preventing or eliminating slum and blight deteriorated
infrastructure and living conditions which have long-lasting effects on community viability. Slum and
Blight can be addressed on an area wide basis or a spot basis.
Area Basis
An activity can qualify as addressing slum and blight on an area basis if it can be documented that:
A) the local government has passed a formal resolution declaring the area as a blight as defined by
Wisconsin Law;
AND
B) the local government has stated in writing that at least 25% of properties throughout the area
experience one or more of the following conditions:
 physical deterioration of buildings or improvements;
 abandonment of properties;
 chronic high occupancy turnover rates or chronic high vacancy rates in commercial or
industrial building;
 significant declines in property values or abnormally low property values relative to other
areas in the community;
 known or suspected environmental contamination; or
 the public improvements throughout the area are in a general state of deterioration.
Spot Basis
An activity can qualify as addressing slum and blight on a spot basis when the activity is not located in a
designated slum or blighted area. Spot basis can be met if the community specifically identifies and
treats one or more of the following conditions:
 acquisition
 clearance
 relocation
 historic preservation
 remediation of environmentally contaminated properties
 rehabilitation of buildings or improvements (limited to eliminating conditions detrimental to public
health and safety)
Eligible Activities
Proposed planning activities must relate to projects that are CDBG eligible. CDBG eligible activities are
enumerated in section 105(a) of Title 1 of the Housing and Community Development Act of 1974.
Typical eligible planning activities involve feasibility studies; project plans; redevelopment plans;
infrastructure/needs assessments in support of housing, efficient land use, economic development;
downtown revitalization; and historic preservation. Engineering, architectural and design costs related to
specific projects are not eligible.
Additionally, proposed planning activities must be consistent with the State’s CDBG program goals for
2013, which are included in the Annual Action Plan, and include:
 ensuring the affordability of basic services that enhance community vitality;
 promoting improved housing and economic opportunities for low- and moderate-income
households;
 supporting revitalization of established neighborhoods, downtown business districts and
blighted sites;
 assisting with capital improvement projects that support previous planning efforts and are part
of broader community development strategies;
 facilitating access to public facilities;
 encouraging the use of energy efficient design, retrofitting, and equipment, as well as projects
the benefit bicyclists and pedestrians; and

responding to natural and man-made disasters or catastrophic events.
Wisconsin’s 2013 Annual Action Plan is available on DOA’s website and can be accessed at:
http://doa.wi.gov/docview.asp?docid=10052&locid=173.
Match Requirements
Successful applicants must provide a match of at least 50 percent of the total grant award from sources
other than grants provided by the federal or state government. Local Units of Government must provide
at least 25 percent of the 50 percent match requirement. Private or public funding can be used for the
required match.
Completion of Plan
A completed plan must be produced and submitted to the Department of Administration within 12 months
of the contract execution date. The plan must include an analysis of the issue and the alternatives or
courses of action considered; the selected alternative and basis for its selection; and the specific
implementation steps to achieve the desired outcome, including proposed timelines, preliminary cost
estimates and potential sources of financing.
Citizen Participation
Federal regulations require that local governments provide citizens with advance notice of and
opportunity to comment on proposed activities in an application to the State. All Planning Grant
applicants must demonstrate compliance with federal citizen participation requirements at the time of
application.
Citizen Participation documents to be submitted by applicants include:
 a copy of the applicant’s citizen participation plan;
 public hearing notice(s) as published in the newspaper;
 public hearing meeting minutes; and
 copies of sign-in sheet(s) from public hearings.
In addition to documentation of citizen participation, Planning Grant applicants must submit a resolution
signed by the chief elected official of the unit of general local government requesting the funds
authorizing the submission of the Community Development Block Grant Application. The Authorizing
Resolution form is included in Section VI of this instruction manual.
Environmental Review
The National Environmental Policy Act of 1969 (NEPA) applies to every CDBG project. Regulations
governing Environmental Review Procedures for Entities Assuming HUD Environmental Responsibilities
can be found in 24 CFR Part 58, which is available via the following link: http://www.ecfr.gov/cgi-bin/textidx?c=ecfr&SID=d4966c17222ec9dc63a434ad9599aa6c&rgn=div5&view=text&node=24:1.1.1.1.33&idno
=24.
While applicants are not required to have completed the environmental review process by the application
deadline, the status of the review and amount of work required to complete it may impact DOA’s
assessment of a project’s feasibility.
At the completion of the environmental review process, DOA will issue an environmental clearance letter.
In addition, please note that:


A grantee may not commit any HUD assistance funds or non-HUD funds until an award has been
made and the environmental review has been completed. Exceptions may be granted for preaward costs if approved by DOA in advance; and
The Department of Administration cannot release funds until the environmental review process is
complete and an award and contract are in place.
Fair Housing
Per 24 CFR 570.487(b), recipients of CDBG funds must take some action to affirmatively further fair
housing during the contract period. DOA’s “Potential Fair Housing Action” form is included in Section VI
Please complete this form by indicating the actions that will be taken to affirmatively further fair housing
and submit it with your application materials. If your project is funded, the selected actions will be
included in your contract timetable and you will be required to implement them during that period.
Other Requirements
CDBG Planning applications will not be considered if there are any outstanding or unresolved instances
of non-compliance associated with prior CBDG awards, including non-compliance related to
administrative, underwriting, recordkeeping, reporting, auditing, closeout, payment, reimbursement or
other requirements.
Successful applicants will be required to document compliance with all applicable federal regulations and
will be required to submit semi-annual project performance reports to the Department as part of the
project contract.
IV. Application & Selection Process
It is the Department’s intention to fund specific economic or community development plans that are likely
to be implemented and that will improve the quality of life in Wisconsin communities. Applications for
CDBG – Planning Grants will be accepted on a continual basis.
DOA will review CDBG Planning Program applications on an annual basis. Applications for assistance
will be reviewed by DOA upon receipt of a complete application packet and all required supporting
documentation as described in this manual. The application review process will take approximately 45
days from receipt of all required information.
To be considered for annual competitive CBDG-Planning funding, complete application packets must be
submitted no later than 5:00 p.m. on November 5, 2013
Submit two (2) copies of your application to:
Wisconsin Department of Administration
Attn. Division of Housing – Bureau of Community Development
101 E. Wilson St., 5th Floor
Madison, WI 53703
One (1) copy must contain the original signature of the chief elected official of the municipality.
Funding decisions will be based upon the following criteria. The award of a planning grant does not
commit the Department to provide funds to implement the plan.
 The extent to which the plan will benefit low- and moderate-income individuals
 Consistency with the State of Wisconsin’s 2013 Annual Action Plan
 The need for a plan
 The ability to undertake all activities associated with the plan and meet the match requirements
 The demonstration that the proposed planning activity follows or reinforces local smart growth
plans
 The likelihood that the applicant is prepared to implement the plan in a timely manner.
 Plan proposals that reflect collaboration between public and private sector stakeholders will
receive preference
Applicants for CDBG-PF program assistance may appeal if their application is denied. The appeal must
be made in writing within ten (10) days of receiving notification of the denial. All appeals will be directed
to the Secretary of the State Department of Administration for a final decision.
The State of Wisconsin is responsible for ensuring that the CDBG-PF program is implemented in
compliance with State and Federal regulations and in accordance with proper program guidelines.
V. PLANNING GRANT PROGRAM APPLICATION – COVER PAGE
APPLICANT (unit of government):_______________________________________________________
APPLICANT TYPE (check one):
JOINT APPLICATION:
City 
Village 
Town 
County 
No  Yes 
If yes, list other unit(s) of government: ____________________________________________________
PROJECT TITLE: ____________________________________________________________________
PROJECT SCOPE:
Community Wide 
TOTAL PLAN COST: $_________________
Neighborhood, District or Site Specific 
CDBG FUNDS REQUESTED: $________________
CHIEF ELECTED OFFICIAL: ______________________________TITLE: _______________________
OFFICAL MUNICIPAL ADDRESS: _______________________________________________________
CITY: _________________________ COUNTY: _________________________ ZIP CODE: _________
PROJECT CONTACT: _____________________________________ TITLE: _____________________
PHONE: ___________________________________ FAX: ____________________________________
EMAIL: _____________________________________________________________________________
FEIN: ____________________________________ DUNS NUMBER: ___________________________
____________________________________________________
Signature of Chief Elected Official
_________________________
Date
If anyone other than the applicant assisted in preparing this application, please provide the following
information:
NAME OF PREPARER: ___________________________________ TITLE: ______________________
COMPANY: _____________________________ ADDRESS: __________________________________
CITY: __________________________________ STATE: ________________ ZIP CODE: ___________
PHONE: ___________________________________ EMAIL: __________________________________
____________________________________________________
Signature of Preparer
_________________________
Date
PART 1 – ELIGIBILITY
1. To qualify for assistance, a planning proposal must address an activity which, if implemented,
meets one of two national objectives under the CDBG Program. That is, it must be shown that
either 1) at least 51 percent of the persons who would benefit from implementation of the plan are
low or moderate income persons, or 2) the plan addresses a slum or blighted area in the
community.
Indicate which National Objective the plan, if implemented, would meet, and the category under
which it would qualify.
 Benefit to low and moderate income persons
Area Benefit
Limited Clientele
Housing
 Prevention or elimination of slum and blight
Area Basis
Spot Basis
Briefly summarize why implementation of the plan would meet the selected National Objective
and how it would qualify. Attach relevant supporting documentation as necessary.
Attach the following documents and forms to the application packet:
1) a copy of the community’s citizen participation plan
2) documentation of the public hearing notice as published in newspaper
3) meeting minutes from the public hearing
4) meeting sign-in sheet(s)
5) the community’s authorizing resolution
6) statement of assurances
7) lobbying certification
8) potential fair housing actions form
Note: A sample citizen participation plan, public hearing notice, and authorizing resolution can be found
in Section # of this manual, along with the required forms, which must be signed by the community’s
Chief Elected Official.
PART 2 – NARRATIVE RESPONSES
1. Provide a written narrative of no more than ½ single spaced page (1 inch margins, 12 pt. Times
New Roman font) describing why the proposed plan is needed. Address the following, as
appropriate:
 community distress factors that will be addressed by the plan;
 evidence of support for the plan by community stakeholders;
 how the plan is consistent with goals and objectives of recently completed community or
economic development plans or initiatives;
 any other relevant factors.
2. Provide a written narrative of no more than ½ single spaced page (1 inch margins, 12 pt. Times
New Roman font) describing the community’s capacity and readiness to implement the results of
the proposed plan. Address the following, as appropriate:
 financial capacity;
 organizational and staff availability;
 anticipated timelines;
 any other relevant factors.
Note: For each required narrative, cross-reference and clearly label all attachments. Responses that
exceed the above specified limits will not be reviewed.
PART 3 – PLAN FUNDING & COMPLETION
1. Estimated Plan Cost: $ ____________________________ (attach supporting documentation)
2. Indicate the sources and amounts of matching funds for the plan, including whether the funds
have been formally committed.
Source: _____________________________ Amount: $_________ Status: Pending 
Committed 
Source: _____________________________ Amount: $_________ Status: Pending 
Committed 
Source: _____________________________ Amount: $_________ Status: Pending 
Committed 
3. Attach a proposed budget for the plan that outlines how the requested CDBG funds and match
funds will be used.
4. Have you established a process for identifying the organization, firm or individual that will
complete the plan?
Yes 
No 
If you answered yes to Question #4, attach documentation demonstrating how your selected
process will comply with State and local procurement rules.
PART 4 – PRIOR CDBG ASSISTANCE
1. Indicate whether the applicant has previously been the recipient of CDBG funds from the State of
Wisconsin.
Yes 
No 
If yes, list the project(s) and dates(s) of prior awards:
Project: ____________________________________________
Date: ____________________
Project: ____________________________________________
Date: ____________________
Project: ____________________________________________
Date: ____________________
2. If you answered yes to question #1:
Were the CDBG funds awarded spent in a timely manner?
Were project performance goals met?
Were compliance and reporting requirements met?
Did the project come in on time and on budget?
Yes
Yes
Yes
Yes



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No
No
No
No
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
VI. CDBG Planning Application Forms and Sample Documents
1)
2)
3)
4)
5)
6)
Citizen participation plan template
Sample public hearing notice
Sample authorizing resolution
Lobbying certification
Statement of assurances
Fair housing actions form
Citizen Participation Plan
Community Development Block Grant Program
____________________________________
(Name of Municipality)
PURPOSE
In order for the Community Development Program to operate effectively, and to address the
needs of the citizens of the ______________________ (county, city, village, town), the entire
population must be kept informed. The decision-making process must be open and consistent
with State and Federal regulations. To accomplish this, the following plan will be followed:
PROGRAM OVERSIGHT
1.
The ____________________ (county, city, village, town) shall create a Citizen
Participation Committee, members of which shall be appointed by the Chief Elected
Official and confirmed by the ______________ (county, city, village, town) Board/Council.
This Committee shall be responsible for implementation of the Citizen Participation Plan,
as well as offering guidance in the preparation of the grant application.
The ___________________ (county, city, village, town) shall oversee the preparation of
the Community Development Block Grant – Planning Program grant application.
2.
To insure responsiveness to the needs of its citizens, the ______________________
(county, city, village, town) shall provide for and encourage citizen participation.
Particular emphasis shall be given to participation by persons of low and moderate
income (LMI).
CITIZEN PARTICIPATION
1.
The ___________________ (county, city, village, town) shall establish a committee
composed of persons representative of the _________________ (county, city, village,
town) demographics. This committee must include at least one LMI person.
The committee members should also include representatives from the local government,
real estate, banking and labor communities whenever possible. This committee will
assume responsibility for coordinating all required elements of the citizen participation
plan. All committee members must be residents of the ________________________
(county, city, village, town).
NOTICE OF HEARINGS
1.
Official notice of hearings will be by public notice in the __________________________
(Name of local newspaper) at least two weeks prior to the hearing. In addition, the public
notice shall be posted at the __________________ (county, city, village, town) municipal
building. These notices will include time, place and date of meetings, as well as a brief
agenda.
2.
All notifications of meetings and available assistance must be worded in such a way as to
encourage LMI participation. In addition, all meeting announcements shall include, where
and during what time information and records relating to the proposed and actual use of
funds may be found.
REQUIRED PUBLIC HEARINGS
Public hearings shall be held to obtain citizen views and to enable them to respond to proposals
at all stages of the Community Development Program, including the development of needs, the
review of proposed activities and the review of program performance. Hearings shall be held
after adequate notice, at times and locations convenient to potential or actual beneficiaries and
with accommodations for the handicapped, and, if needed, for non-English speaking persons.
1.
The first hearing will receive citizens’ views and provide an explanation of:
a.
Community development needs, objectives, and strategies.
b.
The Community Development Block Grant – Planning program including goals,
objectives, application process, amount of funds available, timetable, eligible
activities, etc.
2.
The second hearing will receive citizens’ views and provide a review of the performance
of the funded activities.
3.
The first public hearing shall be held during the development of the application for funds.
The second public hearing shall be held during the implementation of the program. The
______________________ (county, city, village, town) will attempt to have at least one
of the public hearings in the target area (if applicable).
PROGRAM INFORMATION/FILES/ASSISTANCE
1.
Technical assistance will be provided to any citizen who requests information about
program requirements. Assistance with the application process will be provided by
________________ (county, city, village, town) staff in the Community Development
Department. A ________________ (county, city, village, town) staff member will meet
with citizens on request.
2.
The _____________________ (county, city, village, town) will maintain, in the
______________________ (location), a record of all citizen participation efforts including
minutes of meetings, newspaper clippings, and copies of notices and brochures.
3.
Citizens will be invited to make proposals regarding the application. If suitable proposals
are submitted in writing, a written response will be provided within 15 days. Every effort
will be made to respond to all proposals prior to the final action on the subject.
4.
Citizens may petition or request in writing assistance or changes.
The__________________ (county, city, village, town) staff will respond to all such
requests within 15 days after the ___________________ (county, city, village, town)
__________________ (committee name) has met to discuss the request.
COMPLAINTS
The ______________________ (county, city, village, town) will handle citizen complaints about
the program in a timely manner. The _______________________ (county, city, village, town)
will respond in writing to all written letters of complaint within 15 days after receipt of the
complaint. The nature and disposition of verbal complaints will be reported in a complaint log.
The first contact for complaints should be made to the _______________________.
In addition to the above procedure, any citizen wishing to object may complain directly to the
following address:
Department of Administration
Division of Housing
P. O. Box 7970
Madison, WI 53707-7970
NON-ENGLISH SPEAKING PERSONS
The ____________________ (county, city, village, town) will regularly survey the municipality to
identify non-English speaking persons and will make all special efforts to assure them equal
opportunity in the citizen’s participation process.
PUBLIC HEARING NOTICE
APPLICANT NAME
PLACE
DATE
TIME
The
______of
will conduct a public hearing regarding its
proposed application for Community Development Block Grant – Planning funds. The public is
invited to attend to learn about the CDBG program, to help identify additional community
development needs, and to comment on the activities proposed to be included in the CDBG
application.
The agenda for the public hearing is:
1.
Identification of total potential funds
2.
Eligible CDBG activities
3.
Presentation of identified community development needs
4.
Identification of any community development needs by public
5.
Presentation of activities proposed for CDBG application
6.
Citizen input regarding proposed and other CDBG activities
Residents of the ____
____ of
attend, especially residents with low to moderate incomes.
The meeting room is handicapped accessible.
Persons needing additional accommodations should contact
at________________
_________.
are encouraged to
AUTHORIZING RESOLUTION
Authorizing Submission of a Community Development Block Grant Application
Relating to the _________________________ of __________________ participation in the
(County, City, Village, or Town)
(Name)
Community Development Block Grant program.
WHEREAS, Federal monies are available under the Community Development Block Grant
program, administered by the Wisconsin Department of Administration (DOA) for the
purpose of community planning activities; and
WHEREAS, after public meeting and due consideration, the
_______________________________
(Name of Appropriate Committee)
has recommended that an application be submitted to DOA for the following project(s):
__________________________________and;
WHEREAS, it is necessary for the__________________________________________ to
(County Board, City Council, Village Board, Town Board)
approve the preparation and filing of an application for the ________________________ to
receive funds from this program; and
(County, City, Town, Village)
WHEREAS, the _______________________________________________ has reviewed
the need
(County Board, City Council, Village Board, Town Board)
for the proposed project(s) and the benefit(s) to be gained there from;
NOW, THEREFORE, BE IT RESOLVED, that the ________________________________
(City Council, County Board, Village Board, Town Board)
does hereby approve and authorize the preparation and filing of an application for the
above-named project(s); and that ________________________________is hereby
(Council Pres., Mayor, Board Chair, Village Pres.)
authorized to sign all necessary documents on behalf of the __________________; and
(County, City, Village, Town)
that authority is hereby granted to__________________________ to take the necessary
steps to prepare and file the
(Name of Appropriate Committee)
application for funds under this program in accordance with this resolution.
ADOPTED on this ___ day of _________ , 20 ___. ATTEST: ______________________
(Signature of Clerk)
The governing body of ______________________________has authorized the above
(County, City, Village, Town)
resolution by Resolution No. ___________, dated _____________________
_____________________________________________________
(Signature of Chief Elected Official)
LOBBYING CERTIFICATION FROM THE MUNICIPALITY
The undersigned certifies, to the best of his/her knowledge and belief, that:
1.
No federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, 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 the awarding of any federal contract, the making of
any federal grant, the making of any federal loan, the entering into of any cooperative
agreement, and the extension, continuation, renewal, amendment, or modification of any
federal contract, grant, loan, or cooperative agreement.
2.
If any funds other than federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any 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 Standard Form-LLL, “Disclosure Form to Report Lobbying,” in
accordance with its instructions.
3.
The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts
under grants, loans, and cooperative agreements) and that all subrecipients shall certify and
disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to
file the required certification shall be subject to a civil penalty of not less than $10,000 and not more
than $100,000 for each such failure.
______________________________________________
(Name of Local Government)
____________________________________________________ ______________________
(Signature of Chief Elected Official)
(Date)
____________________________________________________ ______________________
(Signature of Clerk)
(Date)
STATEMENT OF ASSURANCES
I,
,
(Name of chief elected official)
in
__, of
(Title)
County certify that the
_______________
(Community name)
__________
(Community name)
[Initial each item]
1.____ Has authorized its Chief Elected Official or Administrator (City, Village, Town, or
County) to submit the application, sign contracts, and conduct other business related
to the proposed activity if funded.
2.____ Has identified its housing and community development needs, including those of
low- and moderate-income persons and the activities to be undertaken meet such
needs.
3.____Will conduct and administer its program in conformance with the Civil Rights Act of
1964 and the Fair Housing Act, and affirmatively further fair housing.
4.____ Will minimize displacement as a result of activities associated with CDBG funds, and
will follow an adopted residential anti-displacement and relocation assistance plan.
5.____ Will not use special assessments to recover the capital costs of CDBG funded public
improvements from low- and moderate-income owner occupants.
6.____ Will comply with 24 CFR 570.608 regarding notification, inspection, testing, and
abatement procedures concerning lead-based paint.
7.____ Has adopted and will enforce a policy prohibiting use of excessive force by law
enforcement agencies within its jurisdiction against any individuals engaged in
nonviolent civil rights demonstrations in accordance with Section 519 of Public Law
101144.
8.____ Has a policy of enforcing applicable state and local laws against physically barring
entrance to or exit from a facility or location which is the subject of nonviolent and
civil rights demonstrations.
9.____ Will not enter into a contract with any entity that is debarred, suspended, proposed
for debarment, declared ineligible, or voluntarily excluded from participation.
10.____ Is currently in compliance with terms and conditions of all past and/or active CDBG
awards and/or contracts.
11.____ Acknowledges that the project cannot commence prior to the grant award and
certain procedures must first be taken, including but not limited to the following:
complete the environmental review process, request federal wage rates if
applicable, establish base employment levels for job related projects, enter into a
development agreement with the participating business, and develop a system for
tracking job retention and/or creation for LMI persons if applicable to the project.
12.____Will comply with all the provisions of the Community Development Block Grant
Program and will maintain documentation of compliance with the above
certifications.
13.____ Certifies that to the best of his/her knowledge and belief, the information being
submitted to DOA is true and correct.
___
Signature of Chief Elected Official
Signature of Clerk
Date
______________
Date
POTENTIAL FAIR HOUSING ACTIONS
According to 24 CFR 570.487(b), the Grantee must take some action to affirmatively further fair
housing during the contract period. Circle the number of at least two (2) of the actions below. If
your project is funded, the action circled will be included in your contract timetable and you will
implement it during that period.
Fair housing actions may include, but are not limited to the following:
1. Enact, strengthen, or advertise a local fair housing law;
2. Make area-wide zoning revisions to facilitate the dispersal of multi-family housing outside of
minority-concentrated areas;
3. Initiate or fund any studies examining current housing opportunities for minority persons,
handicapped persons, and families with children and have these studies form the basis of an
affirmative action program providing greater housing opportunities for minorities, handicapped
persons and families with children;
4. Send letters from the chief elected official of the local government to those in the business of
selling, renting, or financing housing, encouraging them to adhere fully to the fair housing law;
5. Have the local governing body or chief elected official publicly endorse the principle of fair
housing and of adherence to the fair housing law in the form of a proclamation, resolution, or
similar publicized statement of importance;
6. Improve community facilities and public services in racially integrated neighborhoods to help
preserve their mixed character;
7. Display a fair housing poster or provide fair housing information at an appropriate public place;
8. Initiate a public education program on fair housing, involving, for example, representatives of fair
housing groups, human relations’ bodies, minority organizations, the real estate industry, and
government, through the local media. This could include talks on the community's housing
opportunities;
9. Fund a fair housing organization (such as a local housing authority) to conduct studies and/or to
aggressively investigate rental and/or realtor practices;
10. Suggest the use of affirmative marketing and advertising practices by private developers as a
condition for obtaining local licenses and permits; and
11. Enlist the participation of local associations (realtors, real estate brokers, home builders, and
mortgage lenders) in approved voluntary programs to promote affirmative fair housing marketing
and to review mortgage credit and underwriting criteria that may have an adverse impact on
minorities, women, handicapped persons, and families with children.
Grantee Name: ___________________________ Date action to be completed: ________________
Office of Fair Housing and Equal Opportunity: http://www.hud.gov/offices/fheo/
Fair Housing ads and other materials: http://www.fairhousinglaw.org/
Appendix 1
Federal Department of Housing and Urban Development (HUD)
Community Development Block Grant (CDBG) Entitlement Communities
(Entities receiving annual CDBG formula allocations)
City of Appleton
City of Beloit
Dane County (All communities except the Villages of Belleville, Brooklyn, Cottage Grove, Dane,
Deforest, Maple Bluff, Mazomanie, and Rockdale and the City of Edgerton)
City of Eau Claire
City of Fond du Lac
City of Green Bay
City of Janesville
City of Kenosha
City of La Crosse
City of Madison
City of Milwaukee
Milwaukee County (All communities)
City of Neenah
City of Oshkosh
City of Racine
City of Sheboygan
City of Superior
Waukesha County (All communities except the Villages of Chenequa and Oconomowoc Lake)
City of Wausau
City of Wauwatosa
City of West Allis