2015-267G

COPY

Pagel o/4 Exhibit B to RFA 2015-105 -Applicant Certification and Acknowledgement

1. The Applicant acknowledges and certifies that withm90-Cate-nciar1)a.ys-Qfthe-date-of- - -the Corporation letter of preliminary award, the Applicant must submit:

(a) All site control documentation as stated in Part I. Item A of Exhibit D*; and

(b) All Ability to Proceed documentation as stated in Part I. Item B of Exhibit D. THIS PROCESS OFTEN TAKES LONGER THAN ANTICIPATED. APPLICANTS ARE STRONGLY ADVISED TO BEGIN THIS PROCESS AS EARLY AS POSSIBLE.

An invitation to credit underwriting will not be issued until these requirements are met.

*As stated in Part I. Item A of Exhibit 0, failure to demonstrate site control by the stated deadline shall result in the withdrawal of the Corporation letter of preliminary award.

2. The Applicant acknowledges and certifies that the following information will be provided by the due date outlined below, or as otherwise outlined in the invitation to enter credit underwriting. Failure to provide the required information by the stated deadline shall result in the withdrawal of the invitation to enter credit underwritine.

a. Within seven {7) Calendar Days of the date of the invitation to enter credit underwritina, the Applicant must respond to the invitation. The Corporation will then submit the credit underwriting fee and deduct the expense from the Maximum Eliaible Funding Award Amount as outlined in Section Four, J. above.

b. Within 14 Calendar Days of the date of the invitation to enter credit underwritine, Applicants shall submit IRS Tax Information Authorization Form 8821 for all Financial Beneficiaries to the Corporation.

c. By April 29, 2016 the Applicant must provide a Transaction Screen Process (TSP) report in accordance with ASTM Practice E 1528 standards for the entire Development site as further explained in Part I, Item C.3 of Exhibit 0.

d. The credit underwriting report must be approved by the Board by the first Board meeting on or after August 31, 2016, unless a written extension of time has bffn approved by the Corporation as explained in Part I. Item C.4. of Exhibit D. In the event that the extension is granted, extension fees will be assessed as outlined in the fee section of Section Four, J.

e. All uant funding must close by November 30, 2016. Applicants may request one (1} extension of up to 3 months as explained in Part I. Item C.5. of Exhibit 0. In the event that the extension is ,,.anted, extension fees will be assessed as outlined in the fee section of Section Four, J.

Smaller Developments for Persons with ~ta/ Disabitm.s - RFA 2015-105

Pagelo/4 Exhibit B to RFA 2015-105 - Applicant Certification and Acknowledgement

f. All grant fundina must be expended by November 30, 2017. Applicants may request one (1) extension of up to 3 months, as expblined in Part I. Item C.6. of Exhibit 0. In the event that the extension is granted, extension fees will be assessed as outlined in the fee section of Section Four, J.

g. Other items that must be submitted during the credit underwriting process are set forth in Part I, Item 0 of Exhibit 0.

3. By submitting this RFA, the Applicant acknowledges and certifies that all requirements of the Rf A and commitments made by the Applicant will be provided for the proposed Development and its Residents. failure to do so shall result in the withdrawal of the invitation to enter credit underwriting:

a. All requirements set forth in the Rf A and all commitments made by the Applicant will be met;

b. The information set forth in Exhibit 0 will be provided within the timeframes prescribed by the Corporation and/or the Credit Underwriter;

c. The Applicant acknowledees that any funding preliminarily secured by the Applicant is conditioned upon any independent review, analysis, and verification that may be conducted by the Corporation of all information contained in the Application and/or subsequently provided, the successful completion of credit underwriting, and all necessary approvals by the Board of Directors, Corporation or other legal counsel, the Credit Underwriter, and Corporation Staff;

d. If preliminary funding is approved, the Applicant will promptly furnish such other supporting information, documents, and fees requested or required by the Corporation or Credit Underwriter;

e. AH awardees must provide a properly completed and executed Accessibility form at the end of construction certifying that the completed Development includes the applicable accessibility, adaptability, Visitability and universal design features required by the Corporation and proposed by the Applicant;

f. As a condition of the acceptance of funding, all awardees may be required to cooperate with the Corporation or any contractors affiliated with the Corporation in the evaluation of the effectiveness of Permanent Supportive Housing provided throuah this Rf A. The Corporation is interested in collecting evidence to demonstrate the extent to which these Developments meet expected outcomes;

g. All awardees may be subject to compliance monitorine visits durin& the affordability period;

Smaller Developments for Persons with Developmental Disabilities - RFA 2015-105

Page3 o/4 Exhibit B to RFA 2015-105 - Applicant Certification and Acknowledgement

h. The Applicant developing Community Residential Homes shall commit to license the Community Residential Home for 6 or fewer Residents for the entire affordability period. The Applicant shall submit a hard copy of the facility's license to the Corporation within 30 calendar days from the date the license is issued by the licensine agency. The Applicant shall also submit all subsequent renewal Community Residential Homes fadJity licenses to the Corporation with each annual Continuing Program Compliance self-certification submitted. A current license shall be available on-site for compliance monitoring visits during the affordability period;

i. The Applicant has read all applicable Corporation rules and provisions governing this RFA and has read the instructions for completing this RFA and wilt abide by the applicable Florida Statutes and the credit underwriting and program provisions outlined in the RFA;

j. When eliciting information from third parties required by this RFA and/or included in this Application, the Applicant has provided such parties' information that accurately describes the Development. The Applicant has reviewed the third party information included in this Application and, to the best of the Applicant's knowledge, the information provided by any such party is based upon, and is accurate with respect to, the Development as proposed in this Application;

k. The Applicant's commitments will be included in the Restrictive Covenant and Grant Agreement and must be maintained in order for the Development to remain in compliance, unless the Board approves a change; and

I. No more than two (2) Applications from the same Applicant entity can be submitted by the same Applicant entity. The Applicant understands that if more than two (2) Applications are submitted from the same Applicant entity, all Applications submitted from the AppHcant entity will be considered withdrawn, even if the Application(s) had been selected for funding and has entered into credit underwriting.

Smaller Dfrvelopments for Persons with Developmental Disabifmes - RFA 2015-105

Pagfl4 o/4 Exhibit 8 to RFA 2015-105 - Applicant Certification and Acknowledgement

m. The undersigned is authorized to bind all Financial Beneficiaries to this certification and warranty of truthfulness and completeness of the Application.

Under the penalties of perjury, I declare and certify that I have read the foregoing and that the information is true, correct and complete.

Chief Executive Officer

Title (Typed or Printed}

~

Charlotte Mather • Taylor

Name (Typed or Printed}

NOTE: The Original Hard Copy of the Application must contain the original signature of

the Applicant {blue ink is preferred). Other copies must be photocopies of the Original

Hard Copy.

Smaller Developments for Persons with Developmental Disabilities - RFA 2015-1.05

/ Internal Revenue Service

Date: January 9, 2007

ANN STORCK CENTER INC 1790 SW 43RD WAY FT LAUDERDALE FL 33317-5701

Dear Sir or Madam:

Department of the Treasury P.O. Box 2508 · Cincinnati, OH 45201

Person to Contact: Ms. Mills 31·08706 Customer Service Representative

Toll Free Telephone Number: 877 ·829-5500

Federal Identification Number: ' 59-2171081

This is in response to your request of January 9, 2007, regarding-your organization's tax­exempt status.

In May 1982 we issued a determination letter that recognized your organization as exempt from federal income tax. Our records indicate that your organization is currently exempt under section 501 (c)(3) of the Internal Revenue Code.

Our records indicate that your organization is also classified as a public charity under section 509{a)(2) of the Internal Reve·nue Code.

Our records indicate that contributions to your organization are deductible under section 170 of tha Code, and that you are qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the lntern~I Revenue Code.

· " ··1ryou have a.'ny questions," pf ease tall lJ's at th'~ teiephone numbershowrrirt thEfh&a:din·g ·of this letter.

Sincerely,

~\~ Michele M. Sullivan, Oper. Mgr. Accounts Management Operations 1

990 Return of Organization Exempt From Income Tax NMINn ,...._~_....,.7

Form

• Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung Oepartntem af the Tre .. ury benefit trust or private foundation) ,,,,

Ill> The organization may have to use a copy of lhis return to satisfy state reporting requirements. lnltmel Revenue Service ;;) __ · . For the 2012 cat.ndar vear or tax vear beolnnlna 10/01/12 andendlno 09/30/13

Check ~applicable: c N•me of organl2111on D Emplay1r ld1nUnc1ttan 1111mbtr

O Addre&S change Ann Storck Center Inc.

0 Name change Doing 8u1iness As 59-2171081

,, Number and 111 .. 1 (or P.O box K mail is not del1verld to atreet eddresa) Room/suite E Telephone number LJ lniti;lmtum

1790 s.w. 43rd Wav 954-584-8000 L Terminated City, town or pool olr1C9, 11818, and ZIP code

0 Amendlld retum f:ort Lauderdale FL 33317 G QQ5$"""1nlt$ 14.376 070

[J Applicalion pending F N- llr'<l adcrrea al prlncipoil officer.

C Yet [Rj No Jon Bandes H(o) Is (his a group mtum for affiliales?

c/o ASC, 1790 s.w. 43rd Way H(b) Ive ell effihale• incJuded? 0 Yes !--; No

Fort Lauderdale FL 33317 ff "No," attach a h•I. (see ..,.lrucllon•)

rex .. lClllWll llllfua IX! 501!cll3l 1. I 501!cl ( l ~ lontert no.l I r 49'17!•1!1 l or r i 527 I

J WMl!t: ... www.annstorckcenter.ora Hl~I l'.muo ..-uon number ...

K Formol~izalicll; iXI r.nmtlrlllinn I TNll( I I Association I Other .... IL Year ol'formalion: 1980 M staled IMal ~- FL :::;,1riifEF Summarv

1 Briefly describe the organization's mission or most signifteant actlvitie&: ,

8 The Ann Storck Center is d~di_cati=<?. _t~ . . ~.!"!-! ~c_h,i119 the lives of children and .......... ...... ' ... ··········

~ adults \-Ji t_h . deve_lop~~f!tal disabilities. ..

Check !hi~ bo~ .,.. 0 if t~ orilan~ti~~ dis~ni1~~d Its <>Pe~ail~~ ~~disposed of m~e tha~ ·25~/o of its net ~ss~t~. > 2 8 Ill 3 Number of voting members of the governing body (Part VI, line 1a) 3 14 .. II ' Number of independent voting members of the governing bocfy (Part VI, line 1b) ' 14 ;:; ..

473 > 5 Total number of individuals employed in calendar year 2012 (Part V, line 2a) 5 ii 6 Total number of volunteers (estimate if necessary) e 55 ..: .. .. . ... ..

7• Total unrelated business revenue from Part VIII, column (C), line 12 7a 0 b Net unrelated business taX11ble Income from Form 990-T lil'le 34 . .. 7b 0

PriorYMr Cutl'llltY•r

~ 8 Contributions and grants (Part VIII, line 1 h) ... 771,850 1,528,593

c 9 Program service revenue (Part VIII, line 2g) 12,976,044 11, 899, 216 j 10 Investment income (Part VIII, column (A), lines 3, "4, and 7d) 36 17

11 other revenue (Part VIII, column (A), lines 5, 6d, Sc, 9c, 1 Oc, and 11e) 345.363 935.528 12 Total revenue-lldd lines 8 lhroUQh 11 (muat eaual Part VIII column (Al line 12) 14,093,293 14 363 354 13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) 0 14 Benefits paid to or for members (Part IX, column (A), line oil) 0

i 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 10.133.113 10 154.005 1&aProfesslonal fundralsing fees (Part IX, column (A), line 11e) 0 ...

... ~_37 ! ~.4} -·::· :i·:r~t:?~~*i;$i/:':~:~;-~\1~~~·~~/~~~ : ·,:::f">&Js:·;'~ ;<:::-:·· "<:':······ b Total fundraislng expenses (Part IX, column (D), line 25) Ill> ~ 17 Other expenset (Part IX, column (A), lines 11a-11d, 11f-24e) 4.029 344 3.788.816 ..

18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) 14,162.457 13 942.821 19 Revenue lets e•-nses. Subtract Hne 18 from line 12 -69 164 420.533

1J llMllMlllll of Current Y 11r End OfYUI'

20 Total assets (Part X, line 16) 3.966.813 4.236.920 t 21 Total liabilities (Part X, line 26) 1.874,467 1.703.249 22 Net Hsaia or fund balances. Subtract llne 21 from line 20 2,092,346 2,533,671

·:1.artlf.M Slanlture Block Under penalties of perjury, I decla19 thet I have examined thia relum, including accompanying schedules and statements. and to the best of my knowledge end behef, it is true, o:mwct, end complete. , other o on all information of which preparer has any knowledge

Sign Here

Paid

~ Iii. Charlotte r Type 0( print Mine Ind l~le

PrinlfT ypoi pr•,,.,...• nome

Dale

Executive Director

l ~ PTIN

Prepmrer Firm's...,,,. • Hinkle Richter & Rhin LLP 59-1949459 , .. Only r'""~~-..;..._---2~6-=-o"=o~N'""E__.1,...4"""t=h~""'s..;:;t_r-'e;;_e--'t~C=..;:a..;;;,u ... s-e .... w""'a=y;..__ _______ -+~'"""'"'--~--=~;;....:;...~=--

Flno!'• addr9u • Pom ano 'Beach FL 33062-8224 May the IRS discuss this return with the preparer shown above? (see instructions) For hperwork R9ductlon Act Notice, lff the 1epal'lll• ln1tructlon1. OM

954-941-2312 IX: Yes No

Form (2012)

State of Florida Department of State

I certify from the records of this office that ANN STORCK CENTER, INC. is a corporation organized under the laws of the State of Florida, filed on December 23, 1981.

The document number of this corporation is 761254.

I further certify that said corporation has paid all fees due this office through December 31, 2014, that its most recent annual report/uniform business report was filed on April 25, 2014, and its status is active.

I further certify that said corporation has not filed Articles of Dissolution.

Given under my hand and the Great Seal of the State of Florida at Tallahassee, the Capital, this the Third day of November, 2014

~o~ Secretary of State

Authentication ID: CU9912993868

To authenticate this certificate,visit the following site,enter this ID, and then follow the instructions displayed.

https://efile.sunbiz.org/certauthver.html

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Attachment 11. Description of Intended Construction

01. Site 02. Process 03. Illustrative Plan 04. Renders 05. Drawings 06. Technical Data

RFA 2015-105 Ann Storck Center

SITE

Site Address: Property Owner:

SW 43 Way, Unincorporated Ann Storck Center, Inc.

Mailing Address: 1790 SW 43 Way Fort Lauderdale, FL 33317-5701

1

PROCESS

.. ~tentions

- create both stimulating sensorial spaces and secure comfortable spaces

- encourage a social atmosphere through the organization of the house

- design a home that will enable residents to discover more independence

- ensure every room is fully accessible to every resident

Form the social multi-sensory volume - different window shapes & sizes - a large dynamic shape - programmed for flexible activities

the "normal volume" - comfortable human scale - predictable usage

the private. living volume - practical and functional - modulated for accessible use

2

PROCESS

•he Circulation Loop ... is the backbone to the house's organization.

makes you think; there are always two paths to take.

surrounds the staff, helping them work more efficiently.

can strengthen the community by increasing accessibility to all areas of the house.

Communal (S) Think Learn Relax

+ Exterior

Public

Entrance (W)

+

Staff

; Bed/Bathrooms (E)

Communal (N) Interact

Play Dine Cook Listen Watch Create

+ Exterior

Private

3

ILLUSTRATIVE PLAN

Outdoor Space

AC &Storage

Dining Area

Single Bedroom (6)

Living I Activity Area

Shared Bathroom (3)

Entrance Kitchen

Staff Area Utility Room & Storage

Living I Relaxing Area

Storage

Outdoor Space

4

ILLUSTRATIVE PLAN

Active Outdoor Space comfort: southern shade from the tall volume & awning.

security: physical framing of space (N/S). serentity: natural exposure (ENV).

activity· leisure equipment.

Personal Areas .... ·+· ~· ~"'°' equality: rooms and bathrooms are identical and fully accessible. privacy: separated from common spaces by circulation corridor.

individual: a simple design with potential for personalization .. circadian. eastern orientation to wake with the sunrise.

Social & Sensorial Space . social: convergence of all common spaces ..

spatial: exceptional volume with high and sloped ceiling. ; visual: windows of different shapes and sizes frame

exterior scenes and create interesting shadows. audio: cooking, eating. activities, tv

aroma: food preparation

"Circulation Loop" unity: joins the home in an endless loop.

community: decreases isolation through its circular nature.

Service Spaces organization: most service tasks are concentrated in this zone.

Comfortable Common Space coz.y: traditional space for quiet activities

Semi-Private Outdoor Space personal: small open space suited to calm activities.

safe: protected from car & parking area.

5

RENDERS - BIRD'S EVES

6

RENDERS -EXTERIOR

7

RENDERS - INTERIOR

8

DRAWINGS

---------------D

9

DRAWINGS

Q

0 '

10

DRAWINGS

11

TECHNICAL DATA

Room Details

Room Dimensions Area Entrance 12' 3" x 9' 6 11 117 ft2

Kitchen 16' 1 O" x 11 ' 7" 196 ft2

Living (North) 26' 7" x 12' 8" 336 ft2

Staff 9' 2" x 6' 11 fl 63 ft2

Powder Room 9' 2" x3' 28 ft2

Utility 9' 2" x 8' 3" 76 ft2

Living (South) 24' 1" x 17' 1' 411 ft2

Bedrooms (6) 14' x 9' 2" 770 ft2 ( 128 ft2)

Bathrooms (3) 9'x7'6" 202 ft2 ( 67 ft2)

Storage (2) 9' 2" x4' 73 ft2 (37 ft2)

Circulation 409 ft2

Usable Area 2681 ft2

Total Area 3157 fl2

12

CONCEPTUAL ESTIMATES

Verzura Construction. Inc. Miami. FL

General Conditions Sitework Concrete CMU Metals Woods & Plastics Thermal & Moisture Prevention Doors & Windows Finishes Specialties Mechanical Electrical

TOTAL

Cost

28,000 18,500 100,704 25, 176 3,500 41,676 28,250 15,600 58,650 16,000 42,441 18,882

$ 397,379

13