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2017RURAL WORKFORCE HOUSING FUND

(RWHF)

Application Guidelines

TABLE OF CONTENTS

Chapter 1: Introduction to the Nebraska Rural Workforce Housing Fund1.1 Purpose...............................................................................................................................................................11.2 Definitions..........................................................................................................................................................11.3 Rural Workforce Housing Fund...........................................................................................................................21.4 Eligibility.............................................................................................................................................................41.5 Timelines............................................................................................................................................................61.6 Scoring and Selection..........................................................................................................................................7

Chapter 2: RWHF Forms, Application Instructions, and Application2.1 Essential Documentation and Submittal Instructions.......................................................................................102.2 Application Forms and Instructions..................................................................................................................12Part I. General Information.....................................................................................................................................15Part II. Funding Summary.......................................................................................................................................16Part III. Investment Fund Budget and Fund Summary............................................................................................16Part IV. Non-Profit Development Organization Approval Form..............................................................................16Part V. Application Questions – Fund Design and Impact.......................................................................................20Appendix A – Required Exhibits..............................................................................................................................24Appendix B – Additional Exhibits............................................................................................................................24Appendix C – Required Attachments - Non-Profit Development Organization Approval Form..............................24

Chapter 3: ExhibitsExhibit A.................................................................................................................................................................26Sample Individual Donor Commitment Form.........................................................................................................27Sample Entity Commitment Form..........................................................................................................................28

CHAPTER 1: INTRODUCTION TO THE NEBRASKA RURAL WORKFORCE HOUSING FUND

1.1 PURPOSE

The Nebraska Rural Workforce Housing Investment Act was approved by the Governor on April 27, 2017. The Act went into effect on August 26, 2017 and allowed for the one time transfer of funds from the Nebraska Affordable Housing Trust Fund to the Rural Workforce Housing Investment Fund, administered by the Department of Economic Development (DED). The Act provides resources to support the creation of rural workforce housing investment funds to encourage development of workforce housing in Nebraska’s rural and underserved regions. “Rural” for this program excludes the counties of Douglas, Lancaster and Sarpy. The Act is in effect until June 30, 2022.

The Act recognizes that current economic conditions, and limited availability of modern housing units, impacts the ability of rural communities to recruit and retain a world-class workforce. A lack of workforce housing affects the ability to maintain and develop viable, stable, and thriving communities. A housing shortage in rural areas also impacts the ability of local private, nonprofit, and public employers to grow and prosper.

DED has established the Rural Workforce Housing Fund (RWHF) to foster and support the development of workforce housing in rural communities. Prioritization for the funds is based on a demonstrated and ongoing housing need, low unemployment rate, difficulty filling employment positions, demonstrated commitment to growing housing stock, projects reasonably ready for occupancy in a period of twenty-four months, and the capacity to manage a workforce housing investment fund. The intent of the program is to spur the development of workforce housing in rural Nebraska. Regional workforce housing investment funds are intended to revolve and allow for reinvestment in workforce housing projects into the future.

DED shall use its best efforts to assure that grant funds are awarded to non-profit development organizations are targeted to the geographic communities or regions with the most pressing economic and employment needs and that the allocation of grant funds provide equitable access to all eligible geographic areas. DED’s role in the RWHF is as an investor and a partner. As an investor, DED is seeking quality applications for grants to rural workforce housing investment funds, resulting in rural workforce housing projects that will provide the best investments of state resources to promote the development of workforce housing. As a partner, DED is interested in providing input as early as possible in fund development or project design. The Department will work closely with the awarded applicants to address any obstacles encountered during fund development, project development, or implementation.

1.2 DEFINITIONS

HOUSING STUDY: An assessment of the housing needs of a community or region is required; third party housing studies, as well as self-assessments are acceptable. The assessment should include the existing housing conditions within the community and the goals and initiatives addressing the community’s housing concerns. Identification of workforce housing needs must be included in the assessment, as well as a summary of housing projects and initiatives completed in the community over the last five (5) years (i.e. new single and multi-family housing construction, owner and rental housing rehabilitation, demolition activity, new subdivision development, etc.). The study may not be more than five years old. However, an update may be made to studies older than five years, as long as the required current information is included and provides for current conditions. In the case of regional applications, all existing community or county studies should be included along with a self-assessment and summary of the remaining areas in the region.

MATCHING FUNDS:As stated in the Legislation, RWHF investments must be matched 1:1 with cash contributions from individuals, businesses, foundations, local and regional political subdivisions, or other non-profit organizations to a

2017 RWHF Application Guidelines 1 January 3, 2018

workforce housing investment fund administered by a nonprofit development organization. These matching cash contributions are donations to the workforce housing investment fund with the intent of the fund perpetually financing workforce housing projects.

NON-PROFIT DEVELOPMENT ORGANIZATION:For the purposes of the RWHF program, an eligible applicant non-profit development organization must meet at least one of the following:

Non-profit 501(c)(3), 501(c)(4), or 501(c)(6) housing or related service organizations with a service area of at least one community in an eligible county, one eligible county, multiple eligible communities or counties, or statewide;

NDO – as previously designated by DED, under HUD regulations CHDO – previously state-designated Community Housing Development Organizations, under HUD

regulations

REGIONAL: As stated in the Legislation, the RWHF funds must be granted to an eligible statewide or regional non-profit development organization. For the purposes of the RWHF program, regional is defined as having a designated service area of at least one community in an eligible county, one eligible county, multiple eligible counties or statewide. Douglas, Lancaster and Sarpy counties are ineligible. This allows for more diverse consideration of population, numbers of employers, unfilled jobs, local economies, existing housing development capacity and further distribution of funds in light of the $1,000,000 maximum grant award per applicant.

RURAL COMMUNITY: Any municipality in a county with a population of fewer than one hundred thousand inhabitants as determined by the most recent federal decennial census. Currently, this excludes communities in the counties of Douglas, Lancaster and Sarpy. Projects funded with investment funds from the RWHF program must take place within the extraterritorial zoning jurisdiction of a municipality located within one of the ninety (90) eligible counties.

WORKFORCE HOUSING:Housing that meets the needs of today’s working families; housing that is attractive to new residents considering relocation to a rural community; owner-occupied housing units that cost not more than two hundred seventy-five thousand dollars ($275,000) (land and infrastructure costs included), or rental housing units that cost not more than two hundred thousand dollars ($200,000) per unit (land and infrastructure costs included); owner occupied and rental housing units for which the cost to substantially rehabilitate exceeds fifty percent (50%) of a unit’s assessed value; upper story housing; and housing that does not receive National Housing Trust Funds, Federal Low Income Housing Tax Credits, State Low Income Housing Tax Credits, Community Development Block Grants, HOME funds, or funds from the Nebraska Affordable Housing Trust Fund.

1.3 RURAL WORKFORCE HOUSING FUND

Under the Rural Workforce Housing Investment Act, the amount of funds allocated to the RWHF is $7,000,000, which will be granted through a competitive application process to eligible applicants. Grants will be made by DED to eligible applicants that administer or intend to administer, a rural workforce housing investment fund in at least one eligible county, multiple eligible counties, or statewide. All Nebraska counties are eligible with the exception of Lancaster, Douglas and Sarpy counties. Grantees must demonstrate their capacity to administer an investment fund and expertise in housing development.


Grants shall be awarded to successful competitive applicants based upon a demonstrated and ongoing housing need as identified by a recent housing study; a community or region that has a low unemployment rate and is having difficulty attracting workers and filling employment positions and exhibits a demonstrated commitment to growing its housing stock; projects that can reasonably be ready for occupancy in a period of twenty-four (24) months; a demonstrated ability to grow and manage a workforce housing investment fund.

The amount of grant funds awarded under the Rural Workforce Housing Fund will be determined on a case-by-case basis, through a competitive application process, with consideration given to the number of applications, geographic distribution, scoring and ranking criteria. The minimum award will be $100,000 and maximum award will be $1,000,000.

RWHF applications require a minimum dollar for dollar, 1:1 cash match. Applicants are not required to have the matching funds on hand at the time of application. The applicant must provide documentation of the date, amount, and source of the matching funds on hand and/or committed at the time of application. Sample Individual Donor Commitment forms can be found in Chapter 3: Exhibits. Organizations may use their own pledge and donor forms with DED approval. Allowable match is cash; dollars contributed by individuals, businesses, foundations, political subdivisions, or other non-profit organizations to a workforce housing investment fund, administered by the applicant. Allowable match also includes funds committed by the Nebraska Investment Finance Authority (NIFA) to an applicant from NIFA’s LB 518 Match Program Account. If the application is approved for funding, the match funds committed at the time of application must be deposited and certified by the bank (or in the case of a match from NIFA, certified by NIFA that funds in the LB 518 Match Funds Account have been designated by NIFA as available to the applicant), at the time of Drawdown to receive the matching RWHF award. The awarded non-profit development organization will have sixty (60) days to get committed funds deposited or the funding award will be reduced accordingly.

Non-profit development organizations are limited to submit one application in an application cycle, are limited to a maximum cumulative grant amount of $1,000,000 in a two-year period, and maximum of $2,000,000 through fiscal year 2020-2021.

There will be an initial application cycle, and if funds remain a second application cycle following the same competitive process. Applications will be reviewed for eligibility, threshold requirements, and then scored competitively. Successful applicants will be selected and contracts will be for a term of thirty-six (36) months. Projects receiving funding through the awarded RWHF funds, must be reasonably ready for occupancy in a period of twenty-four (24) months from the date of Release of Funds. If an awarded RWHF applicant fails to engage in the initial qualified activity within twenty-four (24) months of the date of Release of Funds, the applicant shall return the grant funds to the Department for credit to the Rural Workforce Housing Fund.

REPORTING:Workforce housing investment funds, funded through the RWHF, are subject to reporting requirements.


Each awardee shall submit an annual report to the Department, to be included as part of the Department’s annual status report required under section 81-1201.11. The report shall certify that the non-profit development organization meets the requirements of the Rural Workforce Housing Investment Act and shall include a breakdown of funded program activities. The annual report shall include, but not limited to:

1. The name, location, and geographical region served by the reporting non-profit development organization;

2. The number, amount, and type of workforce housing investment funds invested in qualified activities; 3. The number, geographical location, type and amount of investments made; 4. A summary of matching funds and where such matching funds were generated; and5. The results of the required annual audit.

If an awardee fails to file a complete annual report by February 15 of the following year, the Department may, at the discretion of its director, impose a civil penalty of not more than five thousand dollars for such violation. All money collected by the Department pursuant to this subsection shall be remitted to the State Treasurer for distribution in accordance with Article VII, section 5, of the Constitution of Nebraska.

If an awardee ceases administration of a workforce housing investment fund, it shall file an annual report with the Department in a form and manner required by the Department director. Before July 1, 2022, any unallocated grant funds shall be returned to the Department for credit to the Rural Workforce Housing Fund. On and after July 1, 2022, any unallocated grant funds shall be returned to the Department for credit to the Affordable Housing Trust Fund.

1.4 ELIGIBILITY

A. ELIGIBLE APPLICANTS:RWHF eligible applicants are non-profit development organizations that meet at least one of the following:

1. 501(c)(3), 501(c)(4), or 501(c)(6) housing or related service organization; with a designated service area of at least one community in a RWHF eligible county, one eligible

county, multiple eligible counties, or statewide; shall invest, or intend to invest, in workforce housing eligible activities; shall use any fees, interest loan repayments, or other funds it received as a result of the

administration of the grant to support qualified activities; have an active board of directors with expertise in development, construction, and finance that

meets at least quarterly to approve all qualified investments made by the non-profit development organization;

have a formal investment plan and proven expertise to invest unused workforce housing investment fund balances; and

have an annual audit of all financial records conducted by an independent certified public accountant.

2. NDO – as previously designated by DED, under HUD regulations, including: Central Nebraska Economic Development, Inc. Dawson County Area Economic Development Council Economic Development Corporation of Buffalo County, Inc. Grand Island Area Economic Development Corporation Hastings Economic Development Corporation Invest Nebraska Corporation MAPA Foundation Northeast Economic Development, Inc. Panhandle Regional Development, Inc. Siouxland Economic Development Corporation


South Central Economic Development District, Inc. Southeast Nebraska Development, Inc. West Central Nebraska Development District, Inc.

3. CHDO – previously state designated by DED, under HUD regulations, including: NeighborWorks Northeast Nebraska Housing Development Corporation

B. ELIGIBLE ACTIVITIES:The Department will award RWHF funds, through a competitive process, for the purpose of the development of workforce housing investment funds that will in turn facilitate the development of workforce housing projects in rural communities in the ninety (90) eligible counties of the state. The intent of the workforce housing investment funds is long range, continual investment in workforce housing projects. The funds are intended to perpetuate. The eligible activities of a non-profit development organization include:

1. New construction of owner-occupied or rental housing in a community with demonstrated workforce housing needs;

2. Substantial repair or rehabilitation of dilapidated housing stock, for which the cost to rehabilitate exceeds fifty percent (50%) of the unit’s assessed value;

3. Upper story housing development;4. Rehabilitation that includes the conversion of an existing building into housing.

Infrastructure development associated with workforce housing is an eligible use of RWHF in association with the above eligible activities, proportionate to the number of workforce housing units and subject to the RWHF price limits. DED will rely on the non-profit development organization’s fund investment plan to identify proportionality. For owner occupied housing units, costs cannot exceed $275,000 per unit. For rental units, costs cannot exceed $200,000 per unit. These limits for owner occupied and rental units include land and infrastructure costs.

Projects must take place within the extraterritorial zoning jurisdiction of a community and located in an eligible county. The RWHF housing may not receive National Housing Trust Funds, Federal Low Income Housing Tax Credits, State Low Income Housing Tax Credits, Community Development Block Grants, HOME funds, or funds from the Nebraska Affordable Housing Trust Fund.

C. QUALIFIED ACTIVITIES:RWHF qualified activities include: purchase and rental guarantees, loan guarantees, loan participations, and other credit enhancements or any form of assistance designed to reduce the cost of workforce housing related to the eligible activities of the non-profit development organization. Forgivable loans and grants are allowed with RWHF; however, financing structures that provide for RWHF to revolve in the rural workforce investment funds are preferred.

D. INELIGIBLE ACTIVITIES: Any activity not specifically authorized under Eligible & Qualified Activities is ineligible to be carried out with RWHF funds. This section further identifies ineligible activities:

1. Furnishings and personal property not an integral structural fixture including the purchase of equipment, fixtures, and motor vehicles;

2. Mobile homes, as defined by the Department; Mobile homes means a movable or portable dwelling constructed to be towed on its own chassis, connected to utilities, and designed with or without a permanent foundation for year-round living. It may consist of one or more units that can be telescoped when towed and


expanded later for additional capacity, or of two or more units, separately towable but designed to be joined into one integral unit.

3. Housing that receives National Housing Trust Funds, Federal Low Income Housing Tax Credits, State Low Income Housing Tax Credits, Community Development Block Grants, or funds from the Nebraska Affordable Housing Trust Fund.

4. Housing administration costs.5. Grant administration costs.

Grant Administration and Housing Administration costs for the RWHF at the project level can be supported with local matching funds, fees, loan repayments, interest and other funds and will need to be determined by the applicant and included within the Fund Investment Plan as eligible or ineligible costs.


1.5 TIMELINES

INITIAL APPLICATION CYCLE TIMELINEDate Action Location Responsible

Parties11/28/2017 DRAFT Application Guidelines are

posted and available for 15 day public comment period.

http://opportunity.nebraska.gov/ DED

1/3/2018 Final Application Guidelines are posted.

http://opportunity.nebraska.gov/ DED

3/30/2018 Original, Signed Hardcopy of Full Application must be postmarked by, or delivered to the Nebraska State Office Bldg, 4th Floor, with signed receipt from DED staff by 5:00 PM CDT.

Scanned Copy of Full Application must also be uploaded by 5:00 PM CDT.

Lincoln DED Office:

State Office BuildingDept. of Economic Development4th Floor301 Centennial Mall SouthLincoln, NE

Upload to:https://negov.sharefile.com/r-r4d847cb025d4423a

Applicant

4/16/2018 Application Review DED

4/30/2018 Award Letters distributed DED

TBD Contract Review DED, Applicant, and Application Preparer

SECOND ROUND APPLICATION CYCLE (IF NEEDED)Date Action Location Responsible

PartiesTBD Original, Signed Hardcopy of Full

Application must be postmarked by, or delivered to the Nebraska State Office Bldg, 4th Floor, with signed receipt from DED staff by 5:00 PM CDT.

Scanned Copy of Full Application must also be uploaded by 5:00 PM CDT.

Lincoln DED Office:

State Office BuildingDept. of Economic Development4th Floor301 Centennial Mall SouthLincoln, NE

Upload to:https://negov.sharefile.com/r-r4d847cb025d4423a

Applicant

TBD Application Review DEDTBD Award Letters distributed DED

TBD Contract Review DED, Applicant, and Application Preparer

Note: All applications are prepared at the Applicant’s expense.


https://negov.sharefile.com/r-r4d847cb025d4423a




1.6 SCORING AND SELECTION

During the RWHF initial application cycle, applicants will be required to submit a Non-Profit Development Organization Approval Form and a Funding Application to apply for the RWHF grant funds. At the conclusion of the RWHF initial application cycle, the Department will review the Non-Profit Development Organization Approval Form. The Funding Applications for any applicant that meets the Non-Profit Development Organization eligibility requirements, and were received by the required due date, will then be scored. Applications must meet the threshold requirements to be considered for a recommended award. The threshold requirements are noted in the Selection Criteria Matrix below.

The applications meeting threshold will be scored and ranked statewide, with the highest scoring projects being recommended in the order that they are ranked with consideration for geographic distribution. For purposes of determining geographical distribution, at the time of application submittal each applicant must designate the community, county or counties to be served under the fund.

Once the application review and scoring process has been completed, the Department will notify and schedule contract review with those applicants who have been preliminarily selected for funding. During the contract review, the applicants and the Department will clarify information in the application, and applicants may be required to submit items to DED by an agreed upon due date. If items requested during the contract review are not received by the Department by the agreed upon due date, the applicant will no longer be eligible to receive the RWHF funds.

In the event that the RWHF funds are not all awarded in the Initial Cycle, the Department will initiate a Second Round Application Cycle. If initiated, the Second Round Application Cycle will follow the application, review and award process as implemented within the Initial Application Cycle within the limitations established by the legislation.

DED reserves the right to fund or not fund applications based on the Director’s discretion.

SELECTION CRITERIA MATRIX:The following Selection Criteria Matrix provides information on the Characteristics, Criteria, and Total Possible Points for each application. All applications meeting basic threshold requirements and received by the due date, will be reviewed by DED on a competitive basis according to the Selection Criteria Matrix.

Is the Applicant an eligible applicant as defined in the Application Guidelines which includes: Regional non-profit 501(c)(3), 501(c)(4) or 501 (c)(6) housing or related service organizations; NDO; or CHDO?

Yes No

Applicant has provided a summary of housing needs in the region including workforce housing needs. Specific community or county housing studies are included.

Yes No

Applicant has provided unemployment rate, key employers, numbers of employees, open employment opportunities for the region.

Yes No

Was the full application submitted to DED by the required due date (including: required exhibits, attachments, and page numbers and sections indicated on each page)?

Yes No

Minimum 1:1 match as evidenced by pledge forms, letters of commitment, or fund balance.

Yes No

*Failure of the Application to meet all of the threshold requirements (Threshold Questions) will result in the Application not being funded during the 2017 RWHF Initial Application Cycle.


Full Application

Characteristic Criteria Points Possible

Points Awarded

I. Demonstrated Need

Summary of workforce housing needs of the region, including housing study(ies) specific to community(ies) or county(ies) where RWHF will be invested. Major employers with number of employeesOpen positions within the regionUnemployment ratePossible Points 100

II. CapacityCapacity to administer a workforce investment fund, including board expertiseHousing development experience, including board expertise Collaboration with housing development organizations, employers, economic development in the regionFundraising and fund developmentMatch committed and on handMatch exceeding 1:1Fund investment planFund administrator qualificationsPossible Points 150

III. ImpactImpact Workforce Housing Investment Fund will have on needDocumented other workforce housing development efforts Plans to address remaining workforce housing needsPossible Points 50

IV. ReadinessPotential projects to be financed under the Workforce Housing Investment FundWorkforce housing project selection processImplementation scheduleMatching funds on hand in the fundPossible Points 200Total Possible Points 500

Failure of the Application to meet all of the threshold requirements (Threshold Questions) will result in the Application not being funded during the 2017 RWHF Initial Cycle.

All ORIGINAL, SIGNED HARD-COPIES OF FULL APPLICATIONS must be postmarked by, or delivered to the Nebraska State Office Building, 4th Floor, with signed receipt by DED staff by 5:00 pm (CDT) by the application due date for the Initial Cycle, or Second Round Cycle, if warranted. A scanned copy should be uploaded and received by DED by 5:00 pm (CDT) by the same applicable application due date to https://negov.sharefile.com/r-r4d847cb025d4423a.


https://negov.sharefile.com/r-r5c7b158ea224fbc9

Individuals who are hearing and/or speech impaired and have a TTY, may contact the Department through the Statewide Relay System by calling (711) INSTATE (800) 833-7352 (TTY) or (800) 833-0920 (voice). The relay operator should be asked to call DED at (800) 426-6505 or (402) 471-3111. Additional information is at the Nebraska Relay website http://www.nebraskarelay.com/.

Nebraska Relay offers Spanish relay service for our Spanish-speaking customers. Spanish-to-Spanish (711) or 1-888-272-5528/ Spanish-to-English (711) or 1-877-564-3503. Nebraska le ofrece el servicio de relevo a nuestros clientes en español. Los consumidores de TTY pueden escribir por máquina en español y las conversaciones serán retransmitidas en español y inglés.

ADDITIONAL INFORMATION:For specific questions regarding the RWHF application process, please contact Leslie Coleman, Housing Manager, by email at [email protected] or phone 402-471-4169.


CHAPTER 2: RWHF FORMS, APPLICATION INSTRUCTIONS, AND APPLICATIONThese Forms and Instructions are designed for applicants applying for Non-Profit Development Organization Approval and RWHF Funding in the Initial Application Cycle.

2.1 ESSENTIAL DOCUMENTATION & SUBMITTAL INSTRUCTIONS

This section contains all forms and exhibits required for submission. Application narratives should be thorough and concise. The Department reserves the right to verify all information, and to consult with other agencies on the proposed fund and potential projects.

Required Documentation The following checklist is to help ensure you have included all required information:

Part I General Information Yes NoIs the applicant identification section complete?Is the application preparer’s section complete?Is the appropriate service area indicated? Is the certifying official section complete?Is the original copy appropriately bound and submitted?Is the digital copy uploaded in two separate files; as outlined below?Part II Funding SummaryIs the Funding Summary complete, clear, and correct?Part III Investment Plan Budget and Fund SummaryIs the Investment Plan Budget complete, clear, and correct? Is the Fund Description Included?Table of ContentsIs an updated Table of Contents with page numbers and titles of sections included?Part IV Non-Profit Development Organization Approval FormIs the approval form complete?Is the appropriate box in each section marked?Is each appropriate attachment identified with page number, included and labeled correctly?Is each exhibit and supporting documentation cited with page numbers?Part V Application Questions – Fund Design and ImpactIs each question answered?Is each page number and section cited?

Appendix A Required ExhibitsExhibit Description Yes NoExhibit A Authorizing Resolution

Appendix B Additional Exhibits Exhibit Description Yes NoExhibit 101 Housing Study(ies)Exhibit 102 Individual Donor Commitment Form and/or Entity Commitment Form (Samples

provided)Exhibit 103 Verification of Match on HandExhibit 104 Fund Investment PlanExhibit 105 Implementation Plan


Appendix C Required Attachments Non-Profit Development Organization Approval FormAttachment Description Yes No

Attachment A Certificate of Good StandingAttachment B Charter/Articles of Incorporation/By-Laws/Board ResolutionAttachment C Letter from IRS for 501(c) designationAttachment D Board Members and Areas of ExpertiseAttachment E Board Approved Investment PlanAttachment F Annual Audit, or reviewed year-end Financial Statement Attachment G Key Staff Resumes/Consultant Contract/StatementAttachment H Financial Accountability Notarized Statement/CPA CertificationAttachment I Bank Information Letter

The following criteria will be verified by DED: Yes No1. Applicant is eligible (non-profit: proof of non-profit status and Certificate of Good Standing)

Submittal Instructions

*Altering the Application questions in any way will automatically disqualify the application and result in the Applicant not being funded.

*Failure of the Application to meet all of the threshold requirements (Threshold Questions) will result in the Application not being funded during the 2017 RWHF Initial Cycle.

*In submitting your application, these instructions must be followed:

Submit the original signed hardcopy application and upload scanned copy of the original; Number all pages, exhibits inclusive, sequentially in the bottom right-hand corner, include the exhibit number above the page number. Handwritten numbers are acceptable;Upload scanned copy as two PDF files; one file will contain Part I-Part V and the second file will contain Required Exhibits, Additional Exhibits, and Required Attachments. (DED suggests printing and numbering the entire original hardcopy first, then scanning the files and uploading to the link provided. This will ensure the page numbers of the digital copy match those of the original.) Be sure to print and keep a copy of the original, including necessary signatures for the Applicant file.

Include page and section numbers for the exhibits for each question. Two-hole punch the original application in the center top; and Include a Table of Contents for both, the original hard copy and the scanned copy.

*Below is an outline and sample table of contents of what your RWHF Application should look like:

Part I. General Information (use required form) Part II. Funding Summary (use required form) Part III. Investment Fund Budget and Fund Summary (follow instructions) Table of Contents (include page numbers and title of sections) Part IV. Non-Profit Development Organization Approval Form (follow instructions) Part V. Application Questions (include form and narrative, page and section numbers) Required Exhibits

A Authorizing Resolution Additional Exhibits

101 Housing Study(ies)102 Donor Pledge Form and/or Commitment Form103 Verification of Match on Hand


104 Fund Investment Plan105 Implementation Plan

Appendix C Required Attachments Non-Profit Development Organization Approval FormA Certificate of Good StandingB Charter/Articles of Incorporation/By-Laws/Board ResolutionC Letter from IRS for 501(c) designationD Board Members and Areas of ExpertiseE Board Approved Investment PlanF Annual Audit, or reviewed year-end Financial Statement G Key Staff Resumes/Consultant Contract/StatementH Financial Accountability Notarized Statement/CPA CertificationI Bank Information Letter

2.2 APPLICATION FORMS AND INSTRUCTIONS

PART I. GENERAL INFORMATION INSTRUCTIONS:Type all information except where signatures are required.

Box 1: Provide the requested information.

Box 2: Provide the requested information. Check the appropriate application preparer box.

Box 3: Check the appropriate box for the RWHF activity for which the Applicant is applying.

Box 4: Check the appropriate applicant type box under which funds are being requested.

Box 5: Indicate the service area of the regional workforce housing investment fund. Enter the community, county, or counties served by the workforce housing investment fund.

Box 6: Type the name and title of the Certifying Official and date. Sign in blue ink. The Certifying Official for a non-profit applicant is the official authorized by the governing body to sign applications for state and federal funding. If the Certifying Official for a non-profit is not the Board President or Board Chair, attach the authorizing documentation of the governing body that allows the designated certifying official to sign the application.

Box 7: SUBMIT THE FULL APPLICATION – Original Hard Copy and Scanned Copy

SUBMIT ORIGINAL HARDCOPY BY MAIL OR IN PERSON TO:Nebraska Department of Economic DevelopmentHousing Manager301 Centennial Mall South - PO Box 94666Lincoln, NE 68509-4666

ALSO UPLOAD A SCANNED COPY TO: https://negov.sharefile.com/r-r4d847cb025d4423a

PART II. FUNDING SUMMARY INSTRUCTIONS:Enter dollar amounts into the appropriate boxes in the funding summary table. Include the requested RWHF Funds and Matching Funds to be included in the Award Contract. Please describe the source of all Matching Funds. Note: Funds already expended or committed to projects cannot be used as match.

The Department reserves the right to non-select an application at any point during the review process if the applicant does not have the full funding commitment of all matching funds prior to application due date.



PART III. FUND INVESTMENT PLAN BUDGET INSTRUCTIONS:Provide a detailed budget for the rural workforce housing investment fund, including sources of funds on hand, detailed commitments, fund operating costs and matching funds. Include a projected budget for the proposed, or potential, workforce housing projects to be funded from the workforce housing investment fund.

TABLE OF CONTENTS INSTRUCTIONS: Include a Table of Contents in both the original hardcopy application and in the scanned digital copy. Number every single page, include exhibit information above page number (handwritten page numbers are appropriate). Page numbers for the scanned digital copy should reflect the page numbers on the original hard copy Application submitted, and correspond to the Table of Contents.

DED suggests printing and numbering the entire original hardcopy first, then scanning each portion into its own file for upload to the DED link. This will ensure the page numbers of the digital copy match those of the original. Be sure to print and keep a copy of the original, including necessary signatures for the Applicant file.

PART IV: APPROVAL FORM INSTRUCTIONS:Answer the Part IV questions by checking the appropriate boxes and explaining your answer in the space provided below the question.

For sections that ask for more information in the form of an exhibit, please include the exhibit in the application.

For sections that require further documentation beyond requested exhibits, please include the documentation as an Applicant Specific Attachment, labeling it appropriately. Also, include the page and/or section number in the far right column.

PART V: APPLICATION QUESTIONS - FUND DESIGN AND IMPACT INSTRUCTIONS:

Threshold Questions:Answer the Threshold Questions by checking the appropriate boxes.

Demonstrated Need: Summary of workforce housing of the region, including housing study(ies) specific to community(ies) of

county(ies) where RWHF will be invested Major employers with number of employees Open positions within the region Unemployment rate

Capacity: Capacity to administer a workforce housing investment fund, include board expertise Housing development experience, include board expertise Collaboration with housing development organizations, employers, economic development in the region Fundraising and fund development Match committed and on hand Match exceeding 1:1 Fund investment plan Fund administrator qualification

Impact: Impact Workforce Housing Investment Fund will have on need Documented other workforce housing development efforts Plans to address remaining workforce housing needs


Readiness: Potential projects to be financed under the Workforce Housing Investment Fund Workforce housing project selection process Implementation plan Match on hand in the fund

Answer the Application Questions by checking the appropriate boxes and explaining your answer in the space provided below the questions. Use additional sheets of paper as needed; please include the questions along with all applicable answers.

For sections that ask for more information in the form of an exhibit, please include the exhibit in the application. For sections that require further documentation beyond requested exhibits, please include the documentation as an Applicant Specific Attachment, labeling it appropriately. Also, include the page and/or section number in the far right column.


2017 APPLICATION FOR THE NEBRASKADED USE ONLY

NEBRASKA AFRURAL WORKFORCE HOUSING FUNDNebraska Department of Economic Development (DED) Date Stamp Below Application Number

PART I. GENERAL INFORMATION17-RWHF-

TYPE OR PRINT ALL INFORMATION

1. APPLICANT IDENTIFICATION 2. APPLICATION PREPARER INFORMATION

Name: Name:

Contact person: Contact person:

Address: Address:

City/State/Zip: City/State/Zip:

Phone: Phone:

Fax: Fax:

Email: Email: Tax ID: Application Preparer (check one)

Duns #: Local Staff Out-of-State ConsultantIn-State Consultant Non-Profit OrganizationEconomic Development District

Other 3. RWHF ACTIVITIES

Rural Workforce Housing Investment Fund4. TYPE OF APPLICANT

Non-profit 501 (c)(3) Non-profit 501(c)(4) Non-profit 501(c)(6)

NDO CHDO

5. ORGANIZATIONAL SERVICE AREARegion to be served – List Community, Communities, County, Counties or Statewide.

6. CERTIFYING OFFICIAL:To the best of my knowledge and belief, data and information in this application is true and correct, including any commitment of local or other resources. The governing body of the applicant has duly authorized this application. This applicant will comply with all federal and state requirements governing the use of RWHF funds.

Signature in blue ink:

Typed Name and Title: Date Signed:

Address/City/State/Zip:

7. SUBMIT THE ORIGINAL FULL APPLICATION TO: UPLOAD THE SCANNED COPY of FULL APPLICATION TO:Nebraska Department of Economic DevelopmentHousing Manager301 Centennial Mall South - PO Box 94666Lincoln, NE 68509-4666


Leslie Coleman, [email protected]

Individuals, who are hearing and/or speech impaired and have a TTY, may contact the Department through the Statewide Relay System by calling (800) 833-7352 (TTY) or (800) 833-0920 (voice). The relay operator should be asked to call DED at (800) 426-6505 or (402) 471-3111.


mailto:[email protected]


PART II. FUNDING SUMMARY

Fund Financing Code

Activity RWHF Funds Matching Funds Total Funds Sources of Matching Funds

0583 RWHF Investment Fund

1000 TOTAL PROGRAM COSTS

Clarification for the above activities should be directed to Leslie Coleman, Housing Manager, 402-471-4169 or [email protected]

PART III. INVESTMENT FUND BUDGET SUMMARY

Provide a detailed budget for the rural workforce housing investment fund, including sources of funds on hand, detailed commitments, fund operating costs and matching funds. Include a projected budget for the proposed, or potential, workforce housing projects to be funded from the workforce housing investment fund.

PART IV. NON-PROFIT DEVELOPMENT ORGANIZATION APPROVAL FORM

Requirements for approval by the DED Director as an eligible non-profit development organization to apply for RWHF funding.

Complete the form by checking the boxes and indicating the specific page numbers that the documentation can be found in the application to demonstrate that the organization does meet all the requirements as outlined.

Attach all required documentation as outlined previously.

Previously DED designated NDO and CHDO applicants, may check the appropriate box for NDO or CHDO and are not required to submit the documentation, as the Department already has those documents on file.

Requirements are in five areas: 1) legal status, 2) organizational structure, 3) capacity and experience, 4) financial standards, and 5) investment plan.

1. LEGAL STATUS:A. The organization must be chartered or registered to do business in Nebraska and is maintaining its

status.

Attach the Certificate of Good Standing from the Secretary of State’s website at: http://www.sos.ne.gov/dyindex.html. Attach and label it as Attachment A.

B. The organization must be one of the following organizations:

Non-profit 501(c)(3) housing or related service organization with a service area of at least one community in an eligible county, eligible county, multiple eligible counties, or statewideNon-profit 501(c)(4) housing or related service organization with a service area of at least one community in an eligible county, eligible county, multiple eligible counties, or statewideNon-profit 501(c)(6) housing or related service organization with a service area of at least one community in an eligible county, eligible county, multiple eligible counties, or statewideDED designated NDO - previously designated by DED, under HUD regulationDED designated CHDO – Community Housing Development Organization, previously designated by DED, under HUD regulation


mailto:[email protected]

C. The organization must serve a clearly defined geographic region within the State of Nebraska. One eligible community in an eligible county is the minimum geographic service region for an organization. One eligible county, multiple eligible counties and statewide service areas are also allowed. The RWHF program cannot be used in Douglas, Lancaster and Sarpy counties.

Please mark and attach the appropriate organizational service area documentation:

Charter (Page Number )AND/ORArticles of Incorporation. (Page Number )AND/ORBy-Laws (Page Number )AND/ORResolution of the Organization’s Board of Directors (Page Number )

Organization is currently DED designated Nebraska NDO (as defined by HUD) and the service area has not changed. OROrganization is currently DED designated Nebraska CHDO (as defined by HUD) and the service area has not changed.

D. One of the purposes of the organization must be housing or related services.

Please mark and attach the appropriate organizational documentation:

Charter (Page Number )AND/ORArticles of Incorporation (Page Number )AND/ORBy-Laws (Page Number )AND/ORResolution of the Organization’s Board of Directors (Page Number )

Organization is currently DED designated Nebraska NDO (as defined by HUD) and the purpose has not changed. OROrganization is currently DED designated Nebraska CHDO (as defined by HUD) and the purpose has not changed.

E. No part of the organization’s earnings may benefit any members, founders, contributors or individuals.

Charter (Page Number )AND/ORArticles of Incorporation. (Page Number )AND/ORBy-Laws (Page Number )AND/ORResolution of the Organization’s Board of Directors (Page Number )Organization is currently DED designated Nebraska NDO (as defined by HUD)OR


Organization is currently DED designated Nebraska CHDO (as defined by HUD)F. The organization must have applied for, or received a tax-exempt ruling from the Internal Revenue

Service (IRS) under Section 501(c) of the Internal Revenue Code of 1986. The 501(c) designations permissible are 501(c)(3), 501(c)(4), and 501(c)(6).

Letter from the IRS for 501(c) designation (Page Number )Organization is currently DED designated Nebraska NDO (as defined by HUD) and the status has not changed.OROrganization is currently DED designated Nebraska CHDO (as defined by HUD) and the status has not changed.

2. ORGANIZATIONAL STRUCTURE:The non-profit development organization must meet the following criteria:

Have an active board of directors with expertise in development, construction and finance Have a formal plan and proven expertise to invest unused workforce housing investment fund

balances. Have a board that meets at least quarterly to approve all qualified investments made by the non-

profit development organization.

List of board members and their areas of expertise (Page Number )

By-Laws (Page Number )AND/OR

Charter (Page Number ) AND/OR

Articles of Incorporation (Page Number )AND

Copy of most recent annual audit or reviewed year end Financial Statement (Page Number )

3. CAPACITY AND EXPERIENCE:The non-profit development organization demonstrates the capacity and experience to operate a loan or investment fund. This means the organization must have at least one of the following:

Experienced key staff that have successfully managed a loan fund and/or investment fund. Staff with limited, or no experience, will work with an experienced consultant under a plan in place to

train the new or inexperienced staff. The organization will hire staff with the required experience. The organization will contract with a qualified fund administrator.

Submit resume’s and/or statements that describe the experience of key staff members; copies of any contract with consultants to train inexperienced or new staff; statement, job description with requirements and formal training plan for staff that is to be hired; or copy of fund administrator contract. (Page Number )

4. FINANCIAL:The organization must have financial accountability standards that have


Records that identify adequately the source and application of funds. These records shall contain information pertaining to awards, authorizations, obligations, unobligated balances, assets, outlays, income and interest.

Effective control over and accountability for all funds, property and other assets. Recipients shall adequately safeguard all such assets and assure they are used solely for authorized purposes.

Comparison of outlays with budget amounts for each award. Whenever appropriate, financial information should be related to performance and unit cost data.

Submit a notarized statement by the President or Chief Financial Officer of the organization (Page Number );ORSubmit a certification from a Certified Public Accountant (Page Number );OROrganization is currently DED designated Nebraska NDO (as defined by HUD)OROrganization is currently DED designated Nebraska CHDO (as defined by HUD)

5. Fund Investment PlanDescribe the process used to develop the Fund Investment Plan (Exhibit 104). The Fund Investment Plan must be Board approved and include the following, at a minimum:

• Geographic service area, including primary targeted communities• Eligible/Qualified workforce housing activities to be funded• Ineligible activities• Eligible applicant entities• Types, amounts (minimum and maximum) and terms of assistance to be provided • Approval process, including scoring or selection criteria• Application process• Administration

Loan Review Process and Procedures Loan Closing Process and Procedures Loan Servicing and Monitoring Program Compliance

• Risk mitigation Fund Project

• Conflict of Interest Clause • Future use plan

Submit a copy of the board approved Fund Investment Plan, including proof of board approval. (Exhibit 104) (Page Number );

BANK INFORMATION:For RWHF awards, the non-profit development organization must designate the bank(s) and/or NIFA that will be certifying the matching funds on hand in the non-profit’s accounts, prior to the drawdown of the RWHF funds.

Submit a letter indicating the certifying banks and/or NIFA, signed by the non-profit development organization certifying official. (Page Number );


PART V. APPLICATION QUESTIONS - FUND DESIGN AND IMPACT THRESHOLD QUESTIONS

1. Is the Applicant an eligible applicant as defined in the Application Guidelines which includes: Regional non-profit 501(c)(3), 501(c)(4) or 501 (c)(6) housing or related service organizations; NDO; or CHDO?

Yes No

2. Applicant has provided a summary of housing needs in the region including workforce housing needs. Specific community or county housing studies are included.

Yes No

3. Applicant has provided unemployment rate, key employers, numbers of employees, open employment opportunities for the region.

Yes No

4. Was the full application submitted to DED by the required due date (including: required exhibit, attachments, and page numbers and sections indicated on each page)?

Yes No

5. Minimum 1:1 match as evidenced by letters of commitment, or fund balance. Yes No*Failure of the Application to meet all of the threshold requirements (Threshold Questions) will result in the Application not being funded during the 2017 RWHF Initial Application Cycle.

FULL APPLICATION

Demonstrated Need Page # & Section Cite Below

6. Describe the workforce housing need of the region. Include statistical data (cited), independent sources (cited) and relevant information that supports the workforce housing need of the region and specific communities or counties where the RWHF will be invested. In the case of a regional applicant organization, summarize the needs within the region and include local housing studies for targeted communities or counties. For local non-profit applicants, include a local housing study. Housing studies should be current, not less than five years old.

• Include the major employers within the region and the number of employees. • List the open positions within the region.• Summarize the overall employment opportunities available within the region.• Include the unemployment rate

Exhibit 101 Housing Study(ies)

Demonstrated Need Points Possible – 100Capacity7. Describe the Applicant’s capacity and commitment to administer a workforce

housing investment fund, including Board expertise. Include a description of any other investment or loan funds administered by the fund administrator.

8. Describe the Applicant’s housing development experience, including Board expertise. List housing projects or activities that the Applicant has been involved in.

9. Describe the collaboration with housing development organizations, lenders,


employers, economic development organizations and other housing partners within the region in the development of the fund. Identify the individuals and/or entities that have participated in fund

development and planning.

10. Describe the fundraising and planning efforts.

11. All RWHF activities require a 1:1 cash match of the total award. Matching funds are cash donations into the fund and are included in the contract budget. Matching funds are cash contributions committed, or on hand, at the time of application. Describe the actual financial commitment of matching funds that will be invested in the fund. Identify matching funds on hand, including source. Commitments at the time of application are acceptable. Match must be available at the time of drawdown. Bank and/or NIFA certification will be required as documentation prior to drawdown of RWHF. The matching funds will be shown in the Sources and Uses of Funds in the contract. Commitment letters are required for any funds not already on hand in the fund, and must be documented on the Part II in the Matching Funds column. Successful applicants will have sixty (60) days to convert commitments to funds on deposit. Documentation of the match should include the amounts and sources of the matching funds. Quantify the dollar value of the funds and identify match exceeding 1:1 minimum requirement.

Exhibit 102 Sample Individual Donor Commitment Form and/or Sample Entity Commitment Form or organization’s forms as approved by DED. Exhibit 103 Verification of Match on Hand

12. Provide detailed documentation of the fund administrator’s qualifications and expertise to manage an investment fund. List the individuals that will be administering the fund and a description of each individual’s role in fund management (including: who will be primarily responsible for the investments of the fund; who will handle the day to day operations of the fund; who will handle the reporting requirements of the fund; who will inspect, evaluate, and review the progress of the funded projects; and any other individuals that will participate within the project).

13. Describe the process used to develop the Fund Investment Plan (Exhibit 104). The Fund Investment Plan must be Board approved and include the following, at a minimum:

• Geographic service area, including primary targeted communities• Qualified workforce housing activities to be funded• Ineligible activities• Eligible applicant entities• Types, amounts (minimum and maximum) and terms of assistance to be

provided


• Approval process, including scoring or selection criteria• Application process• Administration

Loan Review Process and Procedures Loan Closing Process and Procedures Loan Servicing and Monitoring Program Compliance

• Risk mitigation Fund Project

• Conflict of Interest Clause • Future use plan

Exhibit 104 Fund Investment Plan

Capacity Points Possible – 150Impact Page # & Section

Cite Below 14. How does the proposed workforce housing investment fund provide a solution to

the immediate workforce housing needs of the region? Be specific as to the type of projects proposed to be funded under the workforce housing investment fund and the impact of those projects. Describe how the proposed fund accomplishments will reduce or eliminate the need in the region

15. Is the fund serving a region that is working on other workforce development activities, both public and private? Provide specific examples.

16. Describe plans to address any remaining housing needs.

Impact Points Possible – 50Readiness17. Describe potential workforce housing projects to be funded from the fund.

Include letters of intent from workforce housing development projects that describe proposed projects potentially being funded under the applicant fund.

18. Describe the selection process to be used to determine which projects will be funded with the fund.

19. Provide a timeline for projects and implementation plan.

Exhibit 105 Implementation Plan


20. Explain any matching funds on hand in the investment fund.

Readiness Points Possible – 200TOTAL POSSIBLE POINTS – 500


APPENDIX A – REQUIRED EXHIBITS

EXHIBIT A Authorizing Resolution (sample format provided)

APPENDIX B – ADDITIONAL EXHIBITS

Please include the following exhibits noted below. Clearly identify each exhibit number in bottom right of each page of the exhibit.

Exhibit 101 Housing Study(ies)

Exhibit 102 Individual Donor Commitment Form and/or Entity Commitment Fund (Samples provided)

Exhibit 103 Verification of Match on Hand

Exhibit 104 Fund Investment Plan

Exhibit 105 Implementation Plan

APPENDIX C – REQUIRED ATTACHMENTS NON-PROFIT DEVELOPMENT ORGANIZATION APPROVAL FORM

If applicable, please include any attachments not previously included. Clearly identify each attachment name in bottom right of each page. On the scanned copy, please label each attachment name to correspond with the original submitted copy. Please include as many additional attachments as is necessary to support the Part IV application answers.

Attachment A: Certificate of Good Standing

Attachment B: Charter/Articles of Incorporation/By-Laws/Board Resolution

Attachment C: Letter from IRS for 501(c) designation, or CPA/Attorney Statement

Attachment D: Board Members and Areas of Expertise

Attachment E: Board Approved Investment Plan

Attachment F: Annual Audit, or reviewed year-end Financial Statement

Attachment G: Key Staff Resumes/Consultant Contract/Statement

Attachment H: Financial Accountability Notarized Statement/CPA Certification

Attachment I: Bank Information Letter


2017

RURAL WORKFORCE HOUSING FUND(RWHF)

CHAPTER 3:

EXHIBITS


Sample Resolution

AUTHORIZING RESOLUTION(NAME OF ORGANIZATION)

RESOLUTION NO

A resolution of the (AUTHORIZING BOARD) of (NAME OF ORGANIZATION) authorizing the submission of an application for 2017 Nebraska Rural Workforce Housing Funds, certifying that said application meets the community’s workforce housing and community development needs and the requirements of the Nebraska Rural Workforce Housing Fund, and authorizing all actions necessary to implement and complete the activities outlined in said application.

WHEREAS, the (AUTHORIZING BOARD) of (NAME OF ORGANIZATION) is desirous of undertaking workforce housing development activities; and

WHEREAS, the State of Nebraska is administering the Nebraska Rural Workforce Housing Investment Fund; and

WHEREAS, a recipient of Nebraska Rural Workforce Housing Fund is required to comply with the program guidelines and State regulations; and

WHEREAS, the (NAME OF ORGANIZATION) has not been disbarred from receiving federal funding; and

WHEREAS, the (NAME OF ORGANIZATION) has no significant unresolved audit findings relating to any prior grant award from the federal or state government which would adversely affect administration of this grant; and

WHEREAS, no legal actions are underway or being contemplated that would significantly impact (NAME OF ORGANIZATION) capacity to effectively administer the program and to fulfill the RWHF activities. .

NOW, THEREFORE BE IT RESOLVED THAT the (AUTHORIZING BOARD) of (ORGANIZATION OR AGENCY) authorize application to be made to the State of Nebraska, Department of Economic Development for 2017 Nebraska Rural Workforce Housing Fund, and authorize (NAME AND POSITION OF INDIVIDUAL) to sign application and contract or grant documents for receipt and use of these funds, and authorize the (NAME AND POSITION OF INDIVIDUAL) to take all actions necessary to implement and complete the activities submitted in said application(s); and

THAT, the (AUTHORIZING BOARD) of (ORGANIZATION OR AGENCY) will comply with all State regulations and Nebraska Rural Workforce Housing Fund policies.

Passed and adopted by the (AUTHORIZING BOARD) of (ORGANIZATION OR AGENCY) this

day of , 20 .

Chairperson, President or Authorized Person of Organization Date Signed

Use the language in this sample resolution and provide an original signature or a certified copy of the resolution.


EXHIBIT A

SAMPLERURAL WORKFORCE HOUSING INVESTMENT FUND

INDIVIDUAL DONOR COMMITMENT FORM

Applicant Organization Information

Organization Name:

Street Address:

City: State: Zip:

Contact Person:

Phone: Email:

Donor Information

Name:

Street Address:

City: State: Zip:

Contact Person:

Phone: Email:

I/We are committed to donating $ for the Rural Workforce Housing Investment Fund.

Printed Name:

Signature:_____________________________________________________________________

Date:


SAMPLE

(PLACE ON LETTERHEAD)

RURAL WORKFORCE HOUSING INVESTMENT FUNDENTITY COMMITMENT FORM

The Rural Workforce Housing Investment Fund Commitment Form must be completed by an official to confirm that funds are available. A letter on the entity’s letterhead is required. It must include the following information. All documents must be original and bear the signature and title of the entity’s official.

Applicant Organization Information

Organization Name:

Street Address:

City: State: Zip:

Contact Person:

Phone: Email:

Commitment Entity Information

Entity Name:

Street Address:

City: State: Zip:

Contact Person:

Phone: Email:

Entity Name: is committed to donating $ for the Rural Workforce Housing Investment Fund.

Entity Name:

Signature:_____________________________________________________________________

Date:


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