1. Profile Type - LAHSA Documents

1. Profile Type

Instructions:Applicant Profile Type: (required) select one type of applicant based on the application to becompleted and submitted to HUD. For organizations that operate as both a CoC applicant and aproject applicant, a separate profile must be completed for each role.

- Collaborative applicant - the applicant designated by the CoC lead agency that will submit theCoC application (formerly known as Exhibit 1) on behalf of the CoC.

- Project applicant - an organization submitting one or more project applications (formerlyknown as Exhibit 2) to request homeless assistance funding under the CoC Program.

Applicant Profile Type: Project Applicant

Applicant: Harbor Interfaith Services, Inc. 618378053

Applicant Profile Page 1 12/30/2013

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Sticky Note

Attach updated and current Disclosure of Lobbying Activitites (SF-LLL) document Attach current Code of Conduct document Attach current and updated HUD form 50070 - Drug-free workplace Cert. Attach updated Survey on EEO for Applicants document

2. Organization Information

Instructions:Applicant Information: Enter the following related to the applicant organization/lead agency.

Legal Name: (required) enter the legal name of applicant that will submit the CoC applicationor project application, as appropriate.

Organizational Unit: (optional) enter the name of the primary organizational unit, department, ordivision for the applicant's legal entity, as applicable.

Organization Type: (required) select the appropriate organization type that identifies theapplicant. Nonprofit organization (both public and private) are required to submit to HUD one ofthe following sources documenting the nonprofit status: (1) IRS letter or ruling showing 501(c)(3)status; (2) Documentation showing certified United Way agency status; (3) Certification fromlicensed CPA (see NOFA for conditions); or (4) Letter from authorized state official showingapplicant as organized and in good standing as a public nonprofit organization.

Employer/Taxpayer Number (EIN/TIN): (required) enter the employer or taxpayer identificationnumber (EIN or TIN) as assigned by the Internal Revenue Service. If the legal applicantorganization is not in the US or is not legally organized, enter 44-4444444.

Organizational DUNS: (required) enter the applicant's DUNS or DUNS+4 number receivedfrom Dun and Bradstreet. Information on obtaining a DUNS number may be obtained athttp://www.dnb.com. If the legal applicant organization is not in the US or is not legallyorganized, enter 444444444.

- Collaborative applicant or project applicant - the DUNS number for the applicant organizationis required, in order to complete the Profile and apply for funding. HUD does not award fundingto applicants unless a DUNS number has been assigned.

Address: (required) enter the collaborative or project applicant's physical street address 1,street address 2, city, state, and zip code; (optional) also enter the county, province, andcountry, as applicable. Enter the mailing address, if different from the physical address entered.

Legal Name of Organization: Harbor Interfaith Services, Inc.

Organizational Unit

Department Name:

Division Name: "You Can Have It A.L.L."

Organization Type: M. Nonprofit with 501(c)(3) IRS Status (Otherthan Institution of Higher Education)

If Other, please specify:

Employer or Tax Identification Number: 33-0031099

Organization DUNS Number: 618378053 DUNSExtension:



Address

Street 1: 670 W. Ninth Street

Street 2:

City: San Pedro (City of Los Angeles)

State: California

Zip/Postal Code: 90731

County: Los Angeles

Country: United States

Is the organization's mailing address thesame as the address above?

Yes

If no, click 'Save' and enter the mailing address in the fields presented below.



Authorized Representative Contact Information

Instructions:Authorized Representative: (required) enter the prefix, first name, last name, title, telephonenumber, and email address of the person authorized to sign legal documents and legally obligatethe applicant organization; (required) enter the authorized representative's organizationalaffiliation, if affiliated with an organization other than the applicant organization; and (optional)enter the middle name, suffix, alternate number, extension, and fax number of the authorizedrepresentative.

Prefix: Ms.

First Name: Tahia

Middle Name:

Last Name: Hayslet

Suffix:

Title: Executive Director

Organizational Affiliation: Harbor Interfaith Services, Inc.

Phone Number:Format: 123-456-7890

(310) 831-0603

Extension:

Alternate Phone Number:Format: 123-456-7890

Extension:

Fax Number:Format: 123-456-7890

(310) 831-0791

E-mail Address: [email protected]

Confirm E-mail Address: [email protected]



Alternate Contact Information

Instructions:Alternate Contact: (required) enter the prefix, first name, last name, title, telephone number, andemail address of the applicant's alternate contact person; (required) enter the alternate contact'sorganizational affiliation, if affiliated with an organization other than the applicant organization;and (optional) enter the middle name, suffix, alternate number, telephone number extension, andfax number of the alternate contact.

Prefix: Ms.

First Name: Tahia

Middle Name:

Last Name: Hayslet

Suffix:


Organizational Affiliation: Harbor Interfaith Services, Inc.

Phone Number:Format: 123-456-7890

(310) 831-0603

Extension:

Alternate Phone Number:Format: 123-456-7890

Extension:

Fax Number:Format: 123-456-7890

(310) 831-0791

E-mail Address: [email protected]

Confirm E-mail Address: [email protected]



4. Additional Information

Instructions:1. Collaborative applicant's or project applicant's congressional district(s): indicate thecongressional district(s) in which the applicant organization operates:

- Collaborative applicants - (optional) identifying the congressional districts is optional;however, HUD encourages collaborative applicants to identify the congressional districts locatedwithin the CoC geography.

- Project applicants - (required) identify all congressional districts in which the applicant housesor serves homeless persons funded with McKinney-Vento dollars. The district(s) selected willpopulate all project applications, and will be used to send funding notification to the appropriateCongressional representatives.

2. Is the applicant a faith-based organization?: (required) select the appropriate answer thatidentifies the applicant organization.

3. Has the applicant ever received a federal grant?: (required) select the appropriate answersthat applies to the applicant organization.

4. Is the applicant's code of conduct already on file with HUD?: (required for nonprofitapplicants) select the appropriate source to document the applicant's nonprofit status. Thisdocument must be attached in e-snaps. This question does not apply to applicants who are notnonprofit organizations.

1. Indicate applicant's congressionaldistrict(s):

(for multiple selections hold CTRL and key)

CA-036

2. Is the applicant a faith-based organization? No

3. Has the applicant ever received a federalgrant?

Yes

4. Is the applicant's code of conduct alreadyon file with HUD?

Yes



Applicant/Recipient Disclosure/Update Report(HUD form 2880)

Document Type Required? Document Description Date Attached

Applicant/RecipientDisclosure/Update Report

Yes Form 2880 12/18/2013



Applicant/Recipient Disclosure/Update Report(HUD 2880) Attachment Detail

Document Description: Form 2880



Disclosure of Lobbying Activities (SF-LLL)


Disclosure of Lobbying Activities(SF-LLL)

No Form SF-LLL Discl... 10/06/2011



Disclosure of Lobbying Activities (SF-LLL)Attachment Detail

Document Description: Form SF-LLL Disclosure of Lobbying



Applicant Code of Conduct


Applicant Code of Conduct No



Applicant's Code of Conduct Attachment Detail

Document Description:



Drug-Free Workplace Certification (HUD form50070)


Drug-free WorkplaceCertification (HUD form 50070)

Yes Drug-free Workpla... 12/04/2012



Attachment Details

Document Description: Drug-free Workplace Cert. (HUD form 50070)



Nonprofit Documentation Attachment

Document Type Required? Document Description File Name Date Attached

Nonprofit Document Yes IRS 501(c)(3) letter Harbor_Interfaith... 10/19/2009



Attachment Details

Document Description: IRS 501(c)(3) letter



Faith-Based EEO Survey (SF424 Supplement,Survey on Ensuring Equal Opportunities for

Applicants)


Survey on Ensuring EqualOpportunities for Applicants

Yes Survey on Equal O... 10/08/2010



Survey on Ensuring Equal Opportunities forApplicants (SF-424 Supplement) - Attachment

Detail

Document Description: Survey on Equal Opportunities



Other Attachment


Other Attachment No



Attachment Details

Document Description:



6. Submission Summary

Page Last Updated

1. Profile Type 12/04/2012

2. Organization Information 12/04/2012

Authorized Representative 12/18/2013

Alternate Contact 12/18/2013

4. Additional Information 12/04/2012

HUD form 2880 12/18/2013

SF-LLL 08/30/2012

Code of Conduct No Input Required

HUD form 50070 12/04/2012

Nonprofit Document 08/30/2012

Survey on EEO 08/30/2012

Other Attachment No Input Required



DISCLOSURE OF LOBBYING ACTIVITIES Approved by O M B

Comple te this form to d isc lose lobbying activit ies pursuant to 31 U . S . C . 135 2 0348-0046 (See reverse for publ ic burden disc losure.)

1. Type of Federal Action: g a. contract

' ' b. grant c. cooperat ive agreement d. loan e. loan guarantee f. loan insurance

2. Status of Federal Action: A a. bid/offer/application

' b. initial award c. post-award

3. Report Type: 1 1 a . initial filing ' ——' b. material change

For Material Change Only: year quarter date of last report

4. Name and Address of Reporting Entity: I"/] Prime Q Subawardee

Tier , if known :

Harbor Interfaith Services, Inc. 663 W. Tenth Street - San Pedro, C A 90731 (310) 831-0603

Congressional District, if k n o w n : 36th

5. If Reporting Entity in No. 4 is a Subawardee, Enter Name and Address of Prime:

Congressional District, if k n o w n : 6. Federal Department/Agency:

U.S. Department of Housing and Urban Development (HUD)

7. Federal Program Name/Description:

C F D A Number , if app l icab le : 14.235

8. Federal Action Number, if k n o w n : 9. Award Amount, if k n o w n :

$ 127,673.00

10. a. Name and Address of Lobbying Registrant (if individual, last name, first name, M l ) :

N O T A P P L I C A B L E . This agency does not engage lobbyists.

b. Individuals Performing Services ( including address if different from No. 10a) (last name, first name, M l ) :

N O T A P P L I C A B L E .

( \ I f A A Information requested through this form is authorized by title 31 U.S.C. section

" 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less that $10,000 and not more than $100,000 for each such failure.

Sianature: ' lf,L 1 OMsJi i/^ A A Information requested through this form is authorized by title 31 U.S.C. section " 1352. This disclosure of lobbying activities is a material representation of fact

upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less that $10,000 and not more than $100,000 for each such failure.

Print N a r r W ^ T a h i a Harslet »

A A Information requested through this form is authorized by title 31 U.S.C. section " 1352. This disclosure of lobbying activities is a material representation of fact

upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less that $10,000 and not more than $100,000 for each such failure.


A A Information requested through this form is authorized by title 31 U.S.C. section " 1352. This disclosure of lobbying activities is a material representation of fact

upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less that $10,000 and not more than $100,000 for each such failure. Te lephone No. : (310) 831-0603 Date: 10/4/2011

_ . Authorized for Local Reproduction Federal Use Only: ^ _

Standard Form LLL (Rev. 7-97

form HUD-50070 (3/98)ref. Handbooks 7417.1, 7475.13, 7485.1 & .3

U.S. Department of Housingand Urban Development

Certification fora Drug-Free Workplace

Applicant Name

Program/Activity Receiving Federal Grant Funding

I certify that the above named Applicant will or will continueto provide a drug-free workplace by:

a. Publishing a statement notifying employees that the un-lawful manufacture, distribution, dispensing, possession, or useof a controlled substance is prohibited in the Applicant's work-place and specifying the actions that will be taken againstemployees for violation of such prohibition.

b. Establishing an on-going drug-free awareness program toinform employees ---

(1) The dangers of drug abuse in the workplace;

(2) The Applicant's policy of maintaining a drug-freeworkplace;

(3) Any available drug counseling, rehabilitation, andemployee assistance programs; and

(4) The penalties that may be imposed upon employeesfor drug abuse violations occurring in the workplace.

c. Making it a requirement that each employee to be engagedin the performance of the grant be given a copy of the statementrequired by paragraph a.;

d. Notifying the employee in the statement required by para-graph a. that, as a condition of employment under the grant, theemployee will ---

Acting on behalf of the above named Applicant as its Authorized Official, I make the following certifications and agreements tothe Department of Housing and Urban Development (HUD) regarding the sites listed below:

(1) Abide by the terms of the statement; and

(2) Notify the employer in writing of his or her convic-tion for a violation of a criminal drug statute occurring in theworkplace no later than five calendar days after such conviction;

e. Notifying the agency in writing, within ten calendar daysafter receiving notice under subparagraph d.(2) from an em-ployee or otherwise receiving actual notice of such conviction.Employers of convicted employees must provide notice, includ-ing position title, to every grant officer or other designee onwhose grant activity the convicted employee was working,unless the Federalagency has designated a central point for thereceipt of such notices. Notice shall include the identificationnumber(s) of each affected grant;

f. Taking one of the following actions, within 30 calendardays of receiving notice under subparagraph d.(2), with respectto any employee who is so convicted ---

(1) Taking appropriate personnel action against such anemployee, up to and including termination, consistent with therequirements of the Rehabilitation Act of 1973, as amended; or

(2) Requiring such employee to participate satisfacto-rily in a drug abuse assistance or rehabilitation program ap-proved for such purposes by a Federal, State, or local health, lawenforcement, or other appropriate agency;

g. Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs a. thru f.

2. Sites for Work Performance. The Applicant shall list (on separate pages) the site(s) for the performance of work done in connection with theHUD funding of the program/activity shown above: Place of Performance shall include the street address, city, county, State, and zip code.Identify each sheet with the Applicant name and address and the program/activity receiving grant funding.)

Check here if there are workplaces on file that are not identified on the attached sheets.

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties.

(18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)

Name of Authorized Official Title

Signature Date

X

Harbor Interfaith Services, Inc.

"You Can Have It A.L.L."

Work performance is conducted exclusively at: 550 W. 16th Street San Pedro, CA 90731

Tahia Hayslet Executive Director

December 4, 2012 Tahia Hayslet

SURVEY ON ENSURINGEQuAL OPPORTUNI rvFOR APPLICANTS

u.s. DEPARTMENT OF HOUSINGAND URBAN DEVELOPMENT (EXP 2/28/2009)

OMB NO. 1890-0014

Purpose: The Federal goverm [lent is committed to ensuring that all qualified applicants, small or large, non-religious or faith-based, have an equal opportuni ty to compete for Federal funding. In order for us to better understand the population of applicantsfor Federal funds, we are askin nonprofit private organizations (not including private universities) to fill out this survey.

Upon receipt, the survey will b~ separated from the application. Information provided on the survey will not be considered in anyway in making funding decisions and will not be included in the Federal grants database. While your belp in this data collectionprocess is greatly appreciated, ompletion of this survey is voluntary.

Instructions for Submitting thl' Survey: If you are applying using a hard copy application, please place the completed survey in anenvelope labeled "Applicant stey." Seal the envelope and include it along with your application package. If you are applyingelectronically, please submit thi

1survey along with your application.

Applicant's (Organizatilm) Name: Harbor Interfaith Services, Inc.

Applicant's DUNS Nu er: 618378053

Grant Name: You Can tave It A.L.L.,

Supportive Housing i rogram, Continuum of Care Homeless Assist. CFDA Number: 14.235

l. Does the applicant have 501(c)(3) status? 4. Is the applicant a faith-based/religiousorganization?

~ YesYes I8li No

o No

2. How many full-time eq ivalent employees doesthe applicant have? (Check only one box). 5. Is the applicant a non-religious community-based

organization?o 3 or Fewero 4-5

6-146. Is the applicant an intermediary that will manage

the grant on behalf of other organizations?

1&11 15-50

051-100

Dover 100

~ Yes ONo

3. What is the size of the plicant's annual budget?

(Check only one box.)DYes ~NO

Less Than $150,OY

o $150,000 - $299,9r

~ :::::::::::~:lZJJ $1,000,000 - $4,9Y,999

o $5,000,000 or more

7. Has the applicant ever received a governmentgrant or contract (Federal, State, or local)?

J8JJ Yes

8. Is the applicant a local affiliate of a nationalorganization?

Yes EJ No

SF 424-SUPP (412004)