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["Required Pre-Disbursement Documents:"]
["1.     If your Standard Agreement has any special pre-disbursement conditions those must be met before funds can be disbursed.  These can be found in Exhibit E."]
["2.     A Relocation Plan that has been reviewed and approved by HCD’s Legal Division"]
["3.     Current Insurance Certificate, in accordance with the NOFA §800."]
["4.     Signed Statement of Assurances for State Prevailing Wages. \nMust include Contractor signature if requesting funds for Rehabilitation"]
["5.     A Current Preliminary Title Report dated within 15 days of the first request for funds"]
["6.     Request for Funds form (the final submission must be dated on or after the date of the Standard Agreement execution, but you may submit unsigned drafts of this form in advance to receive technical assistance from SGM staff). "]
["7. Draft Use Restriction (Covenant or Regulatory Agreement) "]
["If you intend to have acquisition award funds wired directly to an escrow company, as part of closing escrow and acquiring the property, the following is needed: "]
["7.  HCD Wire Transfer Request Form "]
["8.  Separate Request for Funds Form – This request should only include funds awarded for acquisition. "]
["9.  Wiring instructions from your title company in addition to the aforementioned listed items. "]
["These forms and more detailed instructions are available on our Monitoring and Disbursement webpage under Disbursement."]

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[]
[null,"DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT "]
[null,"DIVISION OF STATE FINANCIAL ASSISTANCE"]
[null,"STATE GRANT MANAGEMENT"]
[null,"2020 West El Camino, 4th Floor"]
[null,"Sacramento, CA  95833"]
[null,"HOMEKEY3SGM@HCD.CA.GOV "]
[]
[null,"HOMEKEY 3.0 PROGRAM \nREQUEST FOR FUNDS (RFF) FORM"]
[]
[null,"Last Revised 9/25/2023"]
[null,"Instructions: Fill out yellow cells as instructed. Ensure that names of Grantee and Payee match names listed in the Standard Agreement and on the TIN or STD 204 form. If requesting a Wire for Acquisition, please submit separate RFF forms for the wire amount and the remaining portion of the award (detailed instructions here: https://www.hcd.ca.gov/sites/default/files/docs/grants-and-funding/homekey/hk-requesting-a-wire.pdf). If requesting reimbursement for previous expenditures, please attach invoices and proof of expenditure."]
[null,"HCD Contract Number:",null,null," RFF Number:",null,null,"Date of Request:"]
[null,"Project Lead Applicant:",null,null,null,"Project Name: "]
[null,"Preparer Name",null,null,null,"Preparer Title:",null,null,null,null,null,null,null,null,null,null,null,null,null,1,2,3,4,5,6,7,8,9,10]
[null,"Payee per Standard Agreement Exhibit E:",null,null,null,"Payee Full Address:"]
[null,"Payee Contact Person:",null,null,"Payee Email:",null,null,"Payee Phone Number:"]
[null,"Is this an Acquisition-Only project? (No Rehabilitation or Construction needed after acquisition)","Select One",null,"Construction Start Date\nEnter \"N/A\" if acquisition-only",null,null,"If not Homekey, what funding source(s) will be used for rehabilitation/construction? "]
[null,"REIMBURSEMENT \nIf you are submitting a request for reimbursement of any eligible expenses incurred on or after March 3, 2021 and before the execution of the Standard Agreement, please fill out this section. Proof of expenditures must be attached to this document when submitted. If no funds were expended on Homekey-eligible activities prior to Standard Agreement execution, please skip this section."]
[null,"Are you submitting any eligible expenses incurred on or after March 3, 2021 and before the execution of the Standard Agreement? ","Select One",null,"Has Grantee attached proof of prior expenditures made after March 3, 2021?\nAcceptable forms of supporting documentation: Acquisition - Escrow Settlement Statement.  \nAll other Capital or COSR expenses must be suported by a General Ledger (GL) that specifically outlines the amounts that are being reimbursed.",null,null,null,"Select One"]
[null,"WIRES\nFor Acquisition funds only. All other funds must be requested on a separate RFF form. \nIf not requesting a wire transfer, please skip this section"]
[null,"Are you requesting a Wire to Escrow for Acquisition award funds in this form?\nOnly Homekey acquisition funds may be issued directly to an approved escrow company per NOFA §402","Select One",null,"Closing Date:",null,null,"Escrow Number "]
[null,"Escrow Company Name:",null,null,null,"Escrow Officer:"]
[null,"Escrow Officer E-mail:",null,null,"Escrow Officer Phone #:",null,null,"Title Company Full Address:"]
[null,"EXPENDITURE BREAKDOWN"]
[null,"Eligible Use\nPer NOFA §201 i-vii",null,"Total Award Amount\nInclude all amounts for activities in Exhibit E even if not requesting","Total Draw Amounts Previously Approved","Draw Amount Requested This Period","Total Drawn To Date ","Percent of Award Drawn","Amount of Award Remaining","HCD Approved Draw Amount This Period"]
[null,"Acquisition of motels, hotels, or hostels, or other sites and assets",null,null,null,null,{"$f":"SUM(E27+F27)","v":0},{"$f":"IF(D27,G27/D27,0)","v":0},{"$f":"SUM(D27-G27)","v":0}]
[null,"Rehabilitation of motels, hotels, or hostels, or other sites and assets",null,null,null,null,0,0,0]
[null,"Master leasing of properties for non-congregate housing",null,null,null,null,0,0,0]
[null,"Conversion of units from nonresidential to residential",null,null,null,null,0,0,0]
[null,"New Construction of Dwelling Units",null,null,null,null,0,0,0]
[null,"Purchase of affordability covenants and restrictions for units",null,null,null,null,0,0,0]
[null,"Relocation costs for individuals who are being displaced as a result of the Homekey project",null,null,null,null,0,0,0]
[null,"All other Eligible Uses: Remaining Total Award Amount (include all eligible use categories except Acquisition)",null,null,0,null,0,{"$f":"IF(D34,G34/D34,0)","v":0},{"$f":"SUM(D34-G34)","v":0}]
[null,"TOTAL CAPITAL",null,{"$f":"SUM(D27:D33)","v":0},{"$f":"SUM(E27:E33)","v":0},{"$f":"SUM(F27:F33)","v":0},0,0,0,{"$f":"SUM(J27:N33)","v":0}]
[null,"Capitalized operating subsidies for units purchased, converted, constructed or altered",null,null,null,null,0,0,0]
[null,{"$f":"IF(C22=\"Yes\",\"Please only include Acquisition funds on this RFF Form. If you intend to request award funds for other eligible uses, you must submit a separate RFF form.\",\"\")","v":""}]
[null,"TOTAL:\n",null,{"$f":"SUM(D27:D34,D36)","v":0},{"$f":"SUM(E27:E34,E36)","v":0},{"$f":"SUM(F27:F33,F36)","v":0},{"$f":"SUM(G27:G33,G36)","v":0},{"$f":"IF(D38,G38/D38,0)","v":0},{"$f":"SUM(I34,I35,I36)","v":0},{"$f":"SUM(J35,J36)","v":0}]
[null," CERTIFICATION"]
[null,"***By signing this request, I certify to the best of my knowledge and belief that the request is true, complete, and accurate, and the expenditures, disbursements and cash receipts will be  for the purposes and objectives set forth in the terms and conditions of the State award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)"]
[null,"Name of Authorized Representative per authorizing resolution",null,"Title of Authorized Representative ",null,null,null,"Date"]
[]
[null,"Signature of Authorized Representative"]
[]
[null,"HCD USE ONLY"]
[null,"Instructions: Review and fill out the pre-disbursement checklist to confirm compliance prior to routing this form for approval"]
[null,"Reimbursement Request Amount:",null,null,"Advance Request Amount:",null,null,"Total Request:",{"$f":"C47+F47","v":0}]
[null,"     SGM Representative Signature                                                                ",null,null,null,"     Date"]
[]
[null,"     SGM Manager Signature                                                                ",null,null,null,"     Date"]