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Kentucky Department for Local Government

CDBG Handbook Attachments

Chapter 1: Project Administration

Attachment 1-1: Performance Measures Forms

Att 1-1a PM Forms PF

Attachment 1-1b PM Forms Public Service

Att 1-1c PM Forms ED

Att 1-1d PM forms housing

ATTACHMENT 1-2: REQUEST FOR RELEASE OF FUNDS

Attachment 1-3: Sample Public Hearing Notice

Chapter 2: Environmental Review

ATTACHMENT 2-1: SAMPLE FINDING OF EXEMPTION

ATTACHMENT 2-2: SAMPLE FINDING OF CATEGORICAL EXCLUSION NOT SUBJECT TO 24 CFR PART

ATTACHMENT 2-3: SAMPLE FINDING OF CATEGORICAL EXCLUSION SUBJECT TO 24 CFR PART 58.5

ATTACHMENT 2-4: STATUTORY CHECKLIST FOR CATEGORICALLY EXCLUDED ACTIVITIES/PROJECTS

Attachment 2-5 Sample HISTORIC PRESERVATION NOTICE

Attachment 2-6: Sample Notice of Intent To Request a Release of Funds

Attachment 2-7 Sample Public NOTICE Distribution List

ATTACHMENT 2-8: SAMPLE ENVIRONMENTAL CERTIFICATION

ATTACHMENT 2-9: SAMPLE ENVIRONMENTAL REVIEW STATUS

Attachment 2-10 Sample Floodplain and Wetland Early Public Notice

Attachment 2-11 Sample Floodplain and Wetland Notice of Explanation

ATTACHMENT 2-12: SAMPLE DOCUMENTATION MEMORANDUM FOR FLOODPLAIN/WETLANDS EIGHT

ATTACHMENT 2-13: SAMPLE FORMAT II: ENVIRONMENTAL ASSESSMENT

ATTACHMENT 2-14: FORMAT II: ENVIRONMENTAL ASSESSMENT - USERS GUIDE

ATTACHMENT 2-15: SAMPLE ENVIRONMENTAL ASSESSMENT CHECKLIST

Attachment 2-16 Sample COMBINED-Concurrent NOTICE to Public

ATTACHMENT 2-17: SAMPLE ENVIRONMENTAL REVIEW RECORD CHECKLIST

ATTACHMENT 2-18: SAMPLE RE-EVALUATION DETERMINATION

Chapter 3: Financial Management

ATTACHMENT 3-1: SAMPLE FINANCIAL MANAGEMENT CHECKLIST

ATTACHMENT 3-2: SAMPLE REQUEST FOR PAYMENT FORM

ATTACHMENT 3-3: SAMPLE AUTHORIZED SIGNATURE FORM

ATTACHMENT 3-4: SAMPLE DIRECT ELECTRONIC TRANSFER OF FUNDS FORM

Attachment 3-5 Approval for Use Request

Attachment 3-5a Approval for Use Request

Attachment 3-5 b Approval for Use Request - Cost Summary

ATTACHMENT 3-6: REPAYMENT REPORT- PROGRAM INCOME/ MISCELLANEOUS REVENUE REPORT

ATTACHMENT 3-7: SAMPLE HOUSING REVOLVING FUND GUIDELINES

Attachment 3-8 Sample ED Revolving Fund Guidelines

Chapter 4: Procurement

Attachment 4-1: Sample Procurement Standards

Attachment 4-2: Sample Grantee Section 3 Action Plan

Attachment 4-3 Section 3 Report HUD Form

Attachment 4-4 Sample RFQ

Attachment 4-5 Professional Services Evaluation

Attachment 4-6 Review Panel Selection Summary

ATTACHMENT 4-7: SAMPLE REQUEST FOR PROPOSALS

ATTACHMENT 4-8: SAMPLE ADVERTISEMENT FOR BIDS

Chapter 5: Contracting

ATTACHMENT 5-1:SAMPLE CONTRACT FOR PROFESSIONAL SERVICES – PART I

ATTACHMENT 5-2: SAMPLE CONTRACT FOR PROFESSIONAL SERVICES – PART II

Attachment 5-3: Contract Documents Guide

ATTACHMENT 5-4: SAMPLE SUBCONTRACT FORM

Attachment 5-5: Sample Legally Binding Agreement

Attachment 5-5a Certification of Legally Binding Agreement

Attachment 5-5b Legally Binding Agreement

Attachment 5-5c Legally Binding Agreement Standard Provisions

ATTACHMENT 5-6: http://www.hud.gov/offices/adm/hudclips/forms/files/2516.pdf

Chapter 6: Labor Standards and Construction Management

Attachment 6-1 Request for Determination of Wage Rate

Attachment 6-2 Notification of Public Works Project -State Prevailing Wage Request

Attachment 6-3 Goals for Female and Minority Participation

Attachment 6-4 Outline of preconstruction conference

Attachment 6-5 Commonly Asked Questions Concerning Equal Opportunity

Attachment 6-6 Contractor Employee Breakdown

Attachment 6-7 - EEO Poster - English

Attachment 6-7 Part 1 - WH 1321 Davis Bacon Poster

Attachment 6-7 Part 2 Safety Poster New - English

Attachment 6-8 PreConstruction Report Format

Attachment 6-9 Notice to Proceed

Attachment 6-10 Payroll Falsification Indicators

Attachment 6-11 Payroll Form WH347

Attachment 6-12 Statement of Compliance Form

Attachment 6-13 Record of Employee Interview form - HUD 11

Attachment 6-14 Federal Labor Standards Complaint Intake Form HUD Form 4731

Attachment 6-15 Construction Oversight Checklist

Chapter 7: Acquisition

All acquisitions should include:

Attachment 7-1: Sample Acquisition Log of Contacts

Voluntary acquisition should include:

Attachment 7.2 Disclosure to Sellers with Voluntary Arms Length Transaction

Attachment 7-3: Sample Acknowledgement Waiver of Acquisition and Relocation Rights and Benefits under URA

Involuntary acquisitions should include:

Attachment 7-4: Sample Notice to Owner

Attachment 7-5: "When a Public Agency Acquires Your Property" brochure

Attachment 7-6: Sample Notice of Intent to Acquire

Attachment 7-7: Sample Statement of the Basis for the Determination of Just Compensation

Attachment 7-8: Sample Notice of Intent Not to Acquire (as appropriate)

Attachment 7-9: Sample Site Acquisition Chart

Attachment 7-10: Short Form Appraisal Report for Easement Takings (Sample)

Attachment 7-11: Guide for Preparing Appraisal Scope of Work

Attachment 7-12: Sample Agreement for Appraisal Services

Attachment 7-13: Sample Invitation to Accompany an Appraiser

Attachment 7-14: Sample Review of Appraisal

Attachment 7-15: Sample Written Offer to Purchase

Attachment 7-16: Sample Statement of Settlement Costs

Attachment 7-17: Real Property Acquisition Checklist (Sample)

Chapter 8: Relocation, Displacement and One-for-One Replacement

ATTACHMENT 8-1: SAMPLE GUIDEFORM NOTICE TO PROSPECTIVE TENANTS

ATTACHMENT 8-2: URA RELOCATION FLOW CHART WITH TRIGGER DATES

ATTACHMENT 8-3: SAMPLE GUIDEFORM RESIDENTIAL ANTIDISPLACEMENT AND RELOCATION PLAN

ATTACHMENT 8-4: SAMPLE GUIDEFORM GENERAL INFORMATION NOTICE – RESIDENTIAL TENANT THAT WILL NOT BE DISPLACED

ATTACHMENT 8-5: SAMPLE GUIDEFORM GENERAL INFORMATION NOTICE – RESIDENTIAL TENANT TO BE DISPLACED

ATTACHMENT 8-6: SAMPLE HOUSEHOLD CASE RECORD

ATTACHMENT 8-7: SAMPLE GUIDEFORM NOTICE OF ELIGIBILITY FOR RELOCATION ASSISTANCE – RESIDENTIAL TENANT

ATTACHMENT 8-8: SAMPLE GUIDEFORM NOTICE OF NONDISPLACEMENT TO RESIDENTIAL TENANT

ATTACHMENT 8-9: RELOCATION ASSISTANCE TO DISPLACED HOMEOWNERS (HUD BROCHURE)

ATTACHMENT 8-10: RELOCATION ASSISTANCE TO DISPLACED TENANTS FROM THEIR HOMES (HUD BROCHURE)

ATTACHMENT 8-11: ELDERLY WAIVER FOR RELOCATION-SAMPLE FORM

ATTACHMENT 8-12: HUD FORM 52580 SECTION 8 EXISTING HOUSING PROGRAM INSPECTION CHECKLIST

ATTACHMENT 8-13: HUD FORM 40061 – SELECTION OF MOST REPRESENTATIVE COMPARABLE REPLACEMENT DWELLING FOR PURPOSES OF COMPUTING A REPLACEMENT HOUSING PAYMENT

ATTACHMENT 8-14: SAMPLE LETTER TO RELOCATEES IN A SUBSTANDARD UNIT

ATTACHMENT 8-15: CLAIM FOR RENTAL ASSISTANCE OR DOWN PAYMENT ASSISTANCE

ATTACHMENT 8-16: SAMPLE GUIDEFORM NOTICE OF ELIGIBILITY FOR SECTION 104(D) RELOCATION ASSISTANCE – LOWER INCOME RESIDENTIAL TENANT, SECTION 8 ASSISTANCE AVAILABLE

ATTACHMENT 8-17: SAMPLE GUIDEFORM NOTICE OF ELIGIBILITY FOR SECTION 104(D) RELOCATION ASSISTANCE – LOWER INCOME RESIDENTIAL TENANT, SECTION 8 ASSISTANCE NOT AVAILABLE

ATTACHMENT 8-18: SUMMARY OF MAJOR DIFFERENCES BETWEEN 104(D) AND URA RELOCATION ASSISTANCE

ATTACHMENT 8-19: SAMPLE 90-DAY AND 30-DAY NOTICE TO VACATE

ATTACHMENT 8-20: TENANT ASSISTANCE/RELOCATION PROCESS FLOW CHART

ATTACHMENT 8-21: RESIDENTIAL MOVING EXPENSE AND DISLOCATION ALLOWANCE PAYMENT SCHEDULE

ATTACHMENT 8-22: CLAIM FOR MOVING COSTS AND RELATED EXPENSES

ATTACHMENT 8-23: CLAIM FOR RENTAL OR PURCHASE ASSISTANCE UNDER SECTION 104(D)

ATTACHMENT 8-24: SAMPLE TEMPORARY RELOCATION NOTICE

ATTACHMENT 8-25(A): SAMPLE GENERAL INFORMATION NOTICE (NON-RESIDENTIAL)

ATTACHMENT 8-25(B): SAMPLE GUIDEFORM NOTICE OF ELIGIBILITY FOR RELOCATION ASSISTANCE – BUSINESSES

Attachment 8-26 CPD HUD Info Booklet Relocation Assistance to Business HUD Form 1043

ATTACHMENT 8-27: CLAIM FOR ACTUAL REASONABLE MOVING AND RELATED EXPENSES – BUSINESSES

ATTACHMENT 8-28: CLAIM FOR FIXED PAYMENT IN LIEU OF PAYMENT FOR ACTUAL MOVING AND RELATED EXPENSES – BUSINESSES, NONPROFIT ORGANIZATIONS AND FARM OPERATIONS

ATTACHMENT 8-29: SAMPLE GRIEVANCE PROCEDURES

Attachment 8-30: One-for-One Replacement Summary Grantee Performance Report

8.30a One for One Replacement Form

8.30b One for One Replacement Instructions

ATTACHMENT 8-31: SAMPLE RELOCATION FILE CHECKLIST

Attachment 8-32 Claim Form for 180 day Homeowner

Chapter 9: Fair Housing and Equal Opportunity

ATTACHMENT 9-1: SAMPLE FAIR HOUSING RESOLUTION

ATTACHMENT 9-2: INSTRUCTIONS FOR COMPLIANCE WITH CIVIL RIGHTS TITLE VI

Attachment 9-3 Equal Opportunity Checklist

ATTACHMENT 9-4: SAMPLE SECTION 504 CHECKLIST

Attachment 9-5 Section 504 Self-Evaluation

ATTACHMENT 9-6: SAMPLE SECTION 504 TRANSITION PLAN

ATTACHMENT 9-7: SAMPLE GRIEVANCE PROCEDURES FOR COMPLAINTS

Attachment 9-8 Fair Housing Complaint Information

ATTACHMENT 9-9: SAMPLE POLICY OF NON-DISCRIMINATION ON THE BASIS OF DISABILITY STATUS

ATTACHMENT 9-10: PROJECT BENEFICIARY PROFILE FORM

Attachment 9-11 Project Benefit Profile Instructions

ATTACHMENT 9-12: LOCAL GOVERNMENT EMPLOYMENT WORK FORCE ANALYSIS

Chapter 10: Housing

ATTACHMENT 10-1: COUNSELING REPORT, HOMEOWNER MAINTENANCE/LIFE SKILLS EDUCATION

ATTACHMENT 10-2: SAMPLE RATING AND RANKING CRITERIA ADVERTISEMENT AND SAMPLE RATING AND RANKING CRITERIA FOR VOLUNTARY PROGRAMS

ATTACHMENT 10-3: SAMPLE PROGRAM GUIDELINES

ATTACHMENT 10-4: SAMPLE REAL ESTATE MORTGAGE

ATTACHMENT 10-5: SAMPLE PROMISSORY NOTE

ATTACHMENT 10-6: SAMPLE APPLICANT RELEASE TO OBTAIN VERIFICATION OF INCOME

ATTACHMENT 10-7: PART 5 (SECTION 8) ANNUAL HOUSEHOLD INCOME CALCULATION FORM

ATTACHMENT 10-8: SAMPLE HOMEOWNER AUTHORIZATION FOR AGENCY TO ACT AS AGENT FOR HOMEOWNER

ATTACHMENT 10-9: SAMPLE GRIEVANCE PROCEDURES

ATTACHMENT 10-10: SAMPLE CDBG REHABILITATION ASSISTANCE APPLICATION

ATTACHMENT 10-11: “PROTECT YOUR FAMILY FROM LEAD IN YOUR HOME” PAMPHLET

Attachment 10-12 Verification of Receiving Lead Based Paint Pamphlet

Attachment 10-13 Work Write-Up and Cost Estimate Format

Attachment 10-14 KHC Specs for New Homes

ATTACHMENT 10-15: LEAD SAFE HOUSING RULE BRIEFING PACKET

ATTACHMENT 10-16: LEAD SAFE HOUSING REQUIREMENTS SCREENING WORKSHEET PARTS 1 4

Attachment 10-17: HUD EPA Notice and Guidance

Attachment 10-17a Guidance on HUD-EPA Abatement Letter

ATTACHMENT 10-18: SAMPLE NOTICE OF LEAD HAZARD EVALUATION

ATTACHMENT 10-19: SAMPLE NOTICE OF PRESUMPTION

ATTACHMENT 10-20: SAMPLE REHABILITATION GRANTING AGREEMENT

ATTACHMENT 10-21: SAMPLE CONTRACT PACKAGE FOR REHABILITATION

ATTACHMENT 10-22: SAMPLE NOTICE TO PROCEED

ATTACHMENT 10-23: SAMPLE PRE-CONSTRUCTION CONFERENCE CHECKLIST

ATTACHMENT 10-24: SAMPLE NOTICE OF ACCEPTANCE OF WORK

ATTACHMENT 10-25: SAMPLE CERTIFICATION OF INSPECTION

ATTACHMENT 10-26: SAMPLE CHANGE ORDER REQUEST

ATTACHMENT 10-27: SAMPLE NOTICE OF LEAD HAZARD REDUCTION ACTIVITIES

ATTACHMENT 10-28: SAMPLE CONTRACT TERMINATION AND RELEASE OF LIEN FORM

ATTACHMENT 10-29: PROJECT BENEFIT PROFILE BY PERSON AND BY HOUSEHOLD

ATTACHMENT 10-30: SAMPLE CERTIFICATION OF 60 DAY FOLLOW-UP INSPECTION

ATTACHMENT 10-31: SAMPLE REHABILITATION PROGRAM FILE CHECKLIST

Attachment 10-32: Sample Development Plan

Attachment 10-32a Urban Renewal Plan

Attachment 10-32b Urban Renewal Plan

Attachment 10-32c Urban Renewal Plan

Attachment 10-32d Urban Renwal Plan

ATTACHMENT 10-33: SAMPLE SHORT FORM DEVELOPMENT PLAN FOR VOLUNTARY REHABILITATION/RECONSTRUCTION

Chapter 11: Economic Development

ATTACHMENT 11-1: SAMPLE EMPLOYEE SURVEY FORM

ATTACHMENT 11-2: SAMPLE EMPLOYEE CHARACTERISTICS SUMMARIZATION

ATTACHMENT 11-3 LEGALLY BINDING AGREEMENT

ATTACHMENT 11-4: SAMPLE RESOLUTION OF AUTHORITY

ATTACHMENT 11-5: SAMPLE CERTIFICATION OF LEGALLY BINDING AGREEMENTS AND LOAN/LEASE DOCUMENTATION

ATTACHMENT 11-6: JOB CLASSIFICATIONS FOR PERFORMANCE MEASURES)

Chapter 12: Amendments and Monitoring

ATTACHMENT 12-1: REQUEST FOR PROJECT/BUDGET AMENDMENT FORM

Chapter 13: Project Close Out

ATTACHMENT 13-1: SAMPLE PROJECT CLOSE OUT PUBLIC HEARING ADVERTISEMENT

Attachment 13-2: KCDBG Program Project Completion Report (PCR) and Instructions

Attachment 13-2a Project Completion Report Instructions

Attachment 13-2b Project Completion Report

Attachment 13-3 Benefit Profile

 

 

Last Updated 4/3/2012
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