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• <br /> Disclosure Report for Federally Assisted Projects <br /> Small Cities Community Development Block Grant Program <br /> HOME Investment Partnerships Program <br /> 1. Applicant/Recipient, 2. Check one: xx Initial Report <br /> Name, Address, and Phone: Update Report <br /> Orange County 3. Social Security Number or <br /> P.O. Box 8181 Employer ID Number: <br /> Hillsborough, N.C. 27278 <br /> 56-6000327 <br /> 4. Project Name and Location: <br /> Magnolia Place; Hillsborough, NC <br /> 5. Total Amount requested/received <br /> (including anticipated program income): $ <br /> 6. Other government assistance. Check one: <br /> No other government assistance is, or is expected to be, provided for this project; <br /> xx All other government assistance provided for this project is listed on the attached <br /> pages(s). <br /> 7. Interested Parties. Check one: <br /> • <br /> • xx No parties have a reportable financial interest in this project. Interested parties • <br /> include developers, contractors, consultants, individuals, entities including units of <br /> government with a financial interest greater than $50,000 or 10 percent of the <br /> assistance (whichever is lower; being a party to a contract procured under Federal <br /> procurement regulations at 24 CFR Part 85 does not, by itself, constitute:a reportable <br /> financial interest). <br /> All parties with a reportable Financial interest are listed on the attached pages(s). <br /> 8. All expected sources of funds available or expected to be available for the project or activity and all <br /> reportable uses of funds are included in the application for finds and on attached forms (check all that <br /> apply): . <br /> CDBG-5A LOCAL COMMITMENT FORM, Page 1 (CR Application) <br /> x CDBG 88-(6) PROJECT BUDGET (CR or HD Application)• <br /> X CDBG 87-4 PROJECT SOURCE AND USE FORM (HD Application) <br /> x SINGLE FAMILY COST AND FINANCING FORM (HD Application) <br /> MULTI-UNIT COST AND FINANCING FORM (HD Application) <br /> HOME Budget Form • <br /> HOME Developer Cost Form <br /> HOME Proforma Assumptions <br /> Other attachment(s). Describe • <br /> 9. Certification: I he t certify that aI formation in this report and its attachment is true and complete: <br /> Signature: l � / Date: <br />