CM-09-10-221Request for Release of Funds
and Certification
U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development
OMB No. 2506-0087
(exp. 3/31/2011)
This form is to be used by Responsible Entities and Recipients (as defined in 24 CFR 58.2) when requesting the release of funds, and
requesting the authority to use such funds, for HIJD programs identified by statutes that provide for the assumption of the environmental
review responsibility by units of general local government and States. Public reporting burden for this collection of information is
estimated to average 36 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless that collection displays a valid OMB control number.
Part 1. Program Description and Request for Release of Funds (to be completed by Responsible Entity)
1. Program Titte(s)
City of Round Rock CDBG
4. OMB Catalog Number(s)
6. For information about this request, contact (name & phone number)
Elizabeth Alvarado, CD Asst.
(512) 341-3328
8. HUD or State Agency and office unit to receive request
One Alamo Center Fort Worth Regional Office
106 South St. Mary's Street, Ste 405 801 Cherry St. Unit 345 Ste 2500
San Antonio, TX 78205 Fort Worth, TX 76102
2. HUD/State Identification Number
(HUD GRANT NUMBER)
3. Recipient Identification Number
(optional)
B -08 -MC -48-0514 DUNS#10-274-0792
5. Name and address of responsible entity
James Nuse, City Manager
221 East Main Street
Round Rock, TX 78664
The recipient(s) of assistance under the program(s) listed above t equests the release of funds and removal of environmental
grant conditions governing the use of the assistance for the following
9. Program Activity(ies)/Project Name(s)
YMCA Restroom Facilities
10. Location (Street address, city, county, State)
1500 North Mays Street
Round Rock, Williamson, TX 78664
11. Program Activity/Project Description (including grant amount)
Construction of restroom facilities: $75,000.00 CDBG Funds to construct restrooms with ADA improvements at the YMCA
Sports Field Complex,
Previous editions are obsolete
CM -09 -1O -22I
Page 1 Of 2 form HUD -7015.15 (1199)
Part 2. Environmental Certification (to be completed by responsible entity)
With reference to the above Program Activity(ies)/Project(s), I, the undersigned officer of the responsible entity, certify that:
1. The responsible entity has fully carried out its responsibilities for environmental review, decision-making and action
pertaining to the project(s) named above.
2. The responsible entity has assumed responsibility for and complied with and will continue to comply with, the National
Environmental Policy Act of 1969, as amended, and the environmental procedures, permit requirements and statutory
obligations of the laws cited in 24 CFR 58.5; and also agrees to comply with the authorities in 24 CFR 58.6 and
applicable State and local laws.
3. After considering the type and degree of environmental effects identified by the environmental review completed for the
proposed project described in Part 1 of this request, I have found that the proposal did! I did not [X require the
preparation and dissemination of an environmental impact statement.
4. The responsible entity has disseminated and/or published in the manner prescribed by 24 CFR 58.43 and 58.55 a notice
to the public in accordance with 24 CFR 58.70 and as evidenced by the attached copy (copies) or evidence of posting and
mailing procedure.
5. The dates for all statutory and regulatory time periods for review, comment or other action are in compliance with
procedures and requirements of 24 CFR Part 58.
6. In accordance with 24 CFR 58.71(b), the responsible entity will advise the recipient (if different from the responsible
entity) of any special environmental conditions that must be adhered to in carrying out the project.
As the duly designated certifying official of the responsible entity, I also certify that:
7. I am authorized to and do consent to assume the status of Federal official under the National Environmental Policy Act
of 1969 and each provision of law designated in the 24 CFR 58.5 list of NEPA-related authorities insofar as the
provisions of these laws apply to the IIUD responsibilities for environmental review, decision-making and action that
have been assumed by the responsible entity.
8. I am authorized to and do accept, on behalf of the recipient personally, the jurisdiction of the Federal courts for the
enforcement of all these responsibilities, in my capacity as certifying officer of the responsible entity.
Signature of Certifying Officer of the Responsible Entity
X
Address of Certif, ing ' fficer
221 East Main •et
Round Rock, TX 78664
Name & Title of Certifying Officer
James R. Nuse, City Manager
Date signed
I D - 30- 2009
Part 3. To be completed when the Recipient is not the Responsible Entity
The recipient requests the release of finds for the programs and activities identified in Part 1 and agrees to abide by the special
conditions, procedures and requirements of the environmental review and to advise the responsible entity of any proposed change in
the scope of the project or any change in environmental conditions in accordance with 24 CFR 58.71(b).
Signature of Authorized Officer of the Recipient
X
Name & Title of Authorized Officer
Date signed
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)
Previous editions are obsolete
Page 2 Ot 2 form HUD -7015.15 (1/99)
DATE: October 26, 2009
SUBJECT: City Manager Staff Meeting - October 30, 2009
ITEM: Consider executing a Request for Release of Funds and Certification for the
YMCA Restroom Facilities Project.
Department: Planning and Community Development Department
Staff Person: Jim Stendebach, Planning and Community Development Director
Elizabeth Alvarado, Community Development Assistant
Justification: This Request for Release of Funds is required by the Department of Housing
and Urban Development (HUD) in order to receive authority to use grant
funds for any projects that are not exempt or categorically excluded from
environmental requirements.
Strategic Plan Relevance:
Funding:
Cost: N/A
Source of funds: N/A
Outside Resources (if applicable): N/A
Public Comment (if applicable): The public comment period (16 days minimum) began
on October 17, 2009 and ends on Nov. 2, 2009).
UPDATED APRIL 2008
5/122009
Request for City Council/City Manager Action
E] City Council a> City Manage/
Submit completed form for all City Manager and City Council approvals.
Department Name: Planning and Community Development
Contact Person: Veronica Chandler / Vickie Moreno
Project Mgr/Resource: Elizabeth Alvarado
Project Coordinator: Jim Stendebach
Assigned Attorney: Steve Sheets
City Council or City Manager Approval Date:
Agenda Wording
Received:
For AftighEitaverpLy
OCT 2870
Tag #: C(YI- O` -10-22
Original Documents Received:
Project Name: YMCA Restroom Facilities
ContractorNendor: N/A
Funding Source:
Additional funding Source:
Amount: $0.00
City Manager -
October 30, 2009
Account Number: N/A
Consider executing a Request for Release of Funds and Certification for the YMCA Restroom Facilities Project.
Finance Information
Is Funding Required?
Initial Construction Contract
Construction Contract Amendment
Change Order
Change in Quantity
Initial Professional Services Agreement
Supplemental Professional Service Agreement
Purchasing/Service Agreement
Purchase Order
Item(s) to be purchased
Yes 10 ► No
8
a
Unforeseen Circumstances
Other (Please clearly identify action on lines below)
Amount
Required for Submission of Adfro ity Council and City
Project Mgr. Signa
Dept. Director Signature:
'City Attorney Signature:
City Manager Signature:
anaqer Items
ate:
Date:
Date:
Olaf/0g
1D-30 -c i
10-30-0c1
City Attomey signature is required for all items.
REVISED 10/28/2009
LEGAL DEPARTMENT APPROVAL FOR CITY COUNCIL/CITY MANAGER ACTION
Required for Submission of ALL City Council and City Manager Items
Department Name: Planning/CDBG Project Name: YMCA Restroom Facilities
Protect Mgr/Resource: Jim Stendebach/Elizabeth Alvarado ContractorNendor: None
Council Action:
LJ ORDINANCE Q RESOLUTION
Agenda Wording
1
City Manager Approval
CMA Wording
Consider executing a Request for Release of Funds and Certification for the YMCA Restroom Facilities Project.
Attorney Approval
132fo-rney
Notes/Comments
Date 161„24Jac)
O:lwdox1SCCtn ts10179109031M I SC100174177
Updated 6/3/08