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Certification & Legal Disclosure 110/2/2f <br />On behalf of the entity Identified in the signature block below 1 certify that <br />1 The information statements and attachments included in this application are to the best of my knowledge and belief true and correct. <br />2. I possess the legal authority to submit this application on behalf of the entity identified in the signature block <br />3. The following is a complete disclosure of all identities of interest of all persons or entities including affiliates that will provide goods or services to the Project either (a) in one or <br />more capacity or (b) that qualify as a Related Party" to any person or entity that will provide goods or services to the Protect. "Related Party" is defined In Section 10302 of the <br />California Code of Regulations (CTCAC Regulations) <br />1) San Bernardino County, Department of Behavioral Health <br />2.) Shangri-La Industries <br />3.) Step Up on Second Street Inc <br />4. As of the date of application, the Project, or the real property on which the Project is proposed (Property) is not party to or the subject of any claim or action at the State or <br />Federal appellate level <br />5 I have disclosed and described below any claim or action undertaken which affects or potentially aff sibility of the Project <br />In addition I acknowledge that all information <br />in <br />this application and attachments is public, <br />and <br />y be disclosed b the State. <br />Paul T Barich <br />Mayor <br />Printed Name <br />Title of Signatory <br />Signature <br />Date <br />Legal Disclosure <br />For purposes of the following questions and with the exceptions noted below the term applicant" shall include the applicant and joint applicant, and any subsidiary of the applicant <br />or joint applicant if the subsidiary is involved in (for example as a guarantor) or will be benefited by the application or the project. <br />In addition to each of these entities themselves the term applicant" shall also include the direct and indirect holders of more than ten percent (10%) of the ownership interests in <br />Ole entity as well as the officers directors principals and senior executives of the entity if the entity is a corporation the general and limited partners of the entity if the entity is a <br />partnership, and the members or managers of the entity if the entity is a limited liability company For projects using tax-exempt bonds it shall also include the individual who will be <br />executing the bond purchase agreement. <br />The following questions must be responded to for each entity and person qualifying as an applicant, or joint applicant" as defined above <br />Explain all positive responses on a separate sheet and Include with this questionnaire In the application <br />Exceptions: <br />Public entity applicants without an ownership interest in the proposed project, including but not limited to cities counties and joint powers authorities with 100 or <br />more members are not required to respond to this questionnaire <br />Members of the boards of directors of non-profit corporations, including officers of the boards are also not required to respond. However chief executive officers (Executive <br />Directors Chief Executive Officers Presidents or their equivalent) must respond as must chief financial officers (Treasurers, Chief Financial Officers or their equivalent) <br />Civil Matters <br />1 Has the applicant filed a bankruptcy or receivership case or had a bankruptcy or receivership action commenced against it, defaulted on a loan or been foreclosed <br />against in past ten years? <br />N/A <br />2 Is the applicant currently a party to or been noted that it may become a party to any civil litigation that may materially and adversely affect (a) the financial condition of <br />the applicant's business, or (b) the project that is the subject of the application? <br />N/A <br />3. Have there been any administrative or civil settlements, decisions or judgments against the applicant within the past ten years that materially and adversely affected (a) <br />the financial condition of the applicant's business, or (b) the project that is the subject of the application? <br />N/A <br />4 Is the applicant currently subject to, or been notified that it may become subject to any civil or administrative proceeding examination or Investigation by a local, state <br />or federal licensing or accreditation agency a local state or federal taxing authority or a local state or federal regulatory or enforcement agency? <br />N/A <br />5 In the past ten years has the applicant been subject to any civil or administrative proceeding, examination, or investigation by a local state or federal licensing or <br />accreditation agency, a local, state or federal taxing authority or a local state or federal regulatory or enforcement agency that resulted in a settlement, decision or <br />judgment? <br />N/A <br />Criminal Matters <br />6 Is the applicant currently a party to or the subject of or been notified that it may become a party to or the subject of any criminal litigation proceeding, charge, <br />complaint examination or investigation of any kind involving or that could result in, felony charges against the applicant? <br />N/A <br />7 Is the applicant currently a party to or the subject of or been notified that it may become a party to or the subject of any criminal litigation proceeding charge, <br />complaint examination or investigation of any kind involving or that could result in misdemeanor charges against the applicant for matters relating to the conduct of the <br />applicant's business? <br />N/A <br />8 Is the applicant currently a party to or the subject of or been notified that It may become a party to or the subject of any criminal litigation, proceeding, charge, <br />complaint, examination or investigation, of any kind, involving, or that could result in, criminal charges (whether felony or misdemeanor) against the applicant for any <br />financial or fraud related crime? <br />N/A <br />9 Is the applicant currently a party to or the subject of or been notified that it may become a party to or the subject of any criminal litigation proceeding charge <br />complaint, examination or investigation of any kind that could materially affect the financial condition of the applicant's business? <br />N/A <br />10 Within the past ten years has the applicant been convicted of any felony? <br />N/A <br />11 Within the past ten years has the applicant been convicted of any misdemeanor related to the conduct of the applicant's business? <br />N/A <br />12 Within the past ten years has the applicant been convicted of any misdemeanor for any financi or fraud re aced crime? <br />N/A <br />Provide a letter of explanation If you responded Yes to any of the questions above <br />File Name 'Cart & Legal Explanation (Letter of explanation for any "Yes" answe <br />or red shaded items above. - _ Uploaded to HCD? N/A <br />Paul T Barich <br />Mayor <br />✓� <br />Printed Name <br />Title of Signatory <br />g re <br />Date <br />