Directions for 2015 Bond Compliance Submissions
As an issuer of bonds awarded allocations from the California Debt Limit Allocation
Committee, the City of San José must be sent following information yearly by the owners of all
City bond-financed projects.
Please complete the following information, sign the forms, and send the following individually
scanned forms for each project to Brenda Charles, Brenda.charles@sanjoseca.gov, no later
than Friday, January 29, 2016. Thank you for your cooperation.
Required submissions:
1. Certification of Delivery of Public Benefits (attached) with validating back-up
information on services provided
2. Most recent Exhibit A to the CDLAC resolution (to verify our version is the same)
3. Annual QRRP Certification of Compliance form for 2015 on project sponsor letterhead
(form attached)
4. Certificate of Continuing Program Compliance for 2015
5. IRS Form 8703 Annual Certification of a Residential Rental Project for 2015
6. If the project ownership has changed since the bonds were first issued, please also
provide the following:
a. a Legal Status Questionnaire
b. W-1 Attachment
c. Partnership organizational chart with principals and officers of each entity of the new
partnership identified (see sample forms attached).
Should you have any questions regarding this request, please do not hesitate to call Brenda
Charles at (408) 975-4471, Leif Regvall at (408) 535-8232, or Kristen Clements at (408) 5358236.
City of San José Department of Housing | 200 East Santa Clara Street, San José, CA 95113 |
tel (408) 535-3860 | fax (408) 998-3183 | www.sjhousing.org
Certification of Delivery of Public Benefits
Issuer Name
Project Name
Program Type
CDLAC Resolution Number(s)
Application Number(s)
Property Address
Project Completion Date*
City of San José
QRRP
*Note: If the depreciable assets and/or project is “under rehabilitation or “under construction”, please
note this and then respond to questions 1 and 2.
SECTION A:
1. Have there been any changes to the ownership entity, principles or property management of
the project since the bonds were issued, or since the last certification was provided? (If YES,
please explain the change below and attach a request to revise the resolution along with
Attachment W-1, the legal status questionnaire (Attachment Y) from the standard CDLAC
application along with an organizational chart of the organizational structure noting all
pertinent information regarding the change of ownership. For changes to the property
management company, please explain the change, attach a request to revise the resolution (if
necessary), and include Attachment X from the standard CDLAC application.)
2. Has there been a change of use for the project? If so, please describe.
3. Has the project satisfied all of the requirements memorialized in the Exhibit A of the
Committee Resolution (i.e. qualifying project completion, qualifying depreciable asset
purchase, qualifying loan originations, the use of public funds, QRRP manager units, QRRP
income rent restrictions, QRRP sustainable building methods, etc.; as applicable), and thus
achieving all public benefit requirements (excluding QRRP service amenities) as presented to
the Committee? (If there is more than one resolution for this project, the most recent
resolution will supersede all previous resolutions).
City of San José Department of Housing | 200 East Santa Clara Street, San José, CA 95113 |
tel (408) 535-3860 | fax (408) 998-3183 | www.sjhousing.org
SECTION B:
1. As captured in Exhibit A of the resolution (attached), the QRRP project has committed to and is
currently providing the following service amenities for a minimum often years, on a regular
and ongoing basis, which are provided free of charge (with the exception of day care services):
Please check the services that apply or write N/A where appropriate:
Provided? Services
After-school Programs
Educational, health and wellness, or skill building classes
Health and Wellness services and programs (not group classes)
Licensed Childcare provided for a minimum of 20 hours per week (Monday-Friday)
Bona-Fide Service Coordinator/ Social Worker
Other (please describe)
For this reporting period, please provide evidence (i.e. MOU's, contracts, schedules, calendars, flyers,
sign-up sheets, etc.) to confirm that the above listed services are being provided and have met the
requirements of Exhibit A of the Resolution. Please label the documents provided to indicate clearly
which services are being evidenced by the supporting information.
I hereby attest that the information provided is truthful, accurate and complete, and that I am authorized to
sign this certification on behalf of the property owner.
Signature of Officer
Date
______
Printed Name of Officer
________________
Phone Number
Title
Organization
City of San José Department of Housing | 200 East Santa Clara Street, San José, CA 95113 |
tel (408) 535-3860 | fax (408) 998-3183 | www.sjhousing.org
Project Name
CDLAC Resolution Number(s)
Property Address
As of Date
If a separate sheet is used to respond to the following questions, the sheet shall be labeled Attachment
Y.
Disclosures should include civil or criminal cases filed in state or federal court; civil or criminal
investigations by local, state, or federal law enforcement authorities; and enforcement proceedings
or investigations by local, state or federal regulatory agencies. The information provided must include
relevant dates, the nature of the allegation(s), chatters, complaint or filing, and the outcome. For a
publicly-traded company, the relevant sections of the company's 10K, 8K, and 10Q most recently filed
with the Securities and Exchange Commission may be attached in response to question #1. With
respect to a response for question #2, previous 10K, 8K, and 10Q filings of the company may be
attached if applicable.
Disclose material information relating to any legal or regulatory proceeding or investigation in
which the project sponsor is or has been a party and which might have a material impact on the
financial viability of the project or the project sponsor. Such disclosures should include any parent,
subsidiary, or affiliate of the project sponsor that is involved in the management, operation, or
development of the project.
1.
Disclose any civil, criminal, or regulatory action in which the project sponsor, or any current board
members (not including volunteer board members of non-profit entities), partners, limited liability
corporation members, senior officers, or senior management personnel has been named a defendant
in such action in the past ten years involving fraud or corruption, matters involving health and safety
where there are allegations of serious harm to employees, the public, or the environment.
2.
City of San José Department of Housing | 200 East Santa Clara Street, San José, CA 95113 |
tel (408) 535-3860 | fax (408) 998-3183 | www.sjhousing.org
Project Name
CDLAC Resolution Number(s)
Property Address
As of Date
California Debt Limit Allocation Committee
ATTACHMENT W-1
INFORMATION ON PROJECT SPONSOR
The information provided in this form must relate to the Project Sponsor entity.
Date & place formed:
Partners comprising project sponsor:
Partner
Corporate Name
Corporate Address
Role
%Ownership
Partner #1
%
Partner #2
%
Partner #3
%
Partner #4
%
Check if
Nonprofit
Entity
Names and titles of the individuals who are the principals or officers of Partner #1: Please provide an
organizational chart of the entity.
Names and titles of the individuals who are the principals or officers of Partner #2: Please provide an
organizational chart of the entity.
Names and titles of the individuals who are the principals or officers of Partner #3: Please provide an
organizational chart of the entity.
Names and titles of the individuals who are the principals or officers of Partner #4: Please provide an
organizational chart of the entity.
If applicable, please provide additional information that may be pertinent to this Application:
City of San José Department of Housing | 200 East Santa Clara Street, San José, CA 95113 |
tel (408) 535-3860 | fax (408) 998-3183 | www.sjhousing.org
200 East Santa Clara Street, San José, CA 95113 tel (408) 535-3860 fax (408) 998-3183 www.sjhousing.org