ATTACHMENT A

CRIMINAL BACKGROUND AND DISCLOSURE FORM – HOUSING

In connection with the 2006 Multi-Family Housing Application submitted to the Arkansas Development Finance Authority by ___ requesting a reservation of 2006 Low-Income Housing Tax Credits or 2006 Private Activity Volume Cap or HOME Investment Partnership Program (HOME) funds for the development of ___, I, ___, ___, on behalf of ___, being duly sworn, hereby certify that I or any principal¹ of ___: (Name of Development Team Member)

1. ☐ have not been convicted by any state or federal jurisdiction of any felony.

or

☐ have been convicted by a state or federal jurisdiction of a felony and the following details are provided:

Jurisdiction	Date	Offense	Punishment	Details

2. ☐ have not been fined, suspended, or debarred as a result of any financial, performance or housing activity by any state or federal agency.

or

☐ have been fined, suspended, or debarred as a result of any financial, performance or housing activity by a state or federal agency and the following details are provided:

Agency	Date	Details

3. ☐ have not filed for bankruptcy or reorganization.

or

☐ have filed for bankruptcy or reorganization and the following details are provided:

Jurisdiction	Date	Details

¹ If the development team member is a partnership, association, limited liability company, or corporation, “principal” shall include: it general partner(s), managing member(s), or any person who has at least a ten percent (10%) ownership interest in any ownership entity of such partnership, association, limited liability company or corporation.

ATTACHMENT A

CRIMINAL BACKGROUND DISCLOSURE FORM – HOUSING (continued)

4. ☐ do not have any outstanding, uncorrected noncompliance issues with any state or federal housing program or agency. or ☐ do have outstanding, uncorrected noncompliance issues with a state or federal housing program or agency and the following details are provided:

Agency	Date	Details

5. ☐ do not have any existing contracts or indebtednesses with the Arkansas Development Finance Authority. or ☐ do have the following existing contracts or indebtednesses with the Arkansas Development Finance Authority:

Date	Borrower	Details

6. ☐ do not have any prior delinquent, defaulted or foreclosed upon contract, loan or indebtedness with the Arkansas Development Finance Authority: or ☐ do have the following existing contracts or indebtednesses with the Arkansas Development Finance Authority:

Date	Borrower	Details

I, ____, in my capacity as ____, (Name) (Title/Position with Development Team Member) further certify that I have the authority and knowledge to make the representations contained herein and agree to the terms of ADFA's Criminal Background Check Policy.

Date: _______

(Signature)

(Printed/Typed Name)

(Title/Position with Development Team Member)

ATTACHMENT A

CRIMINAL BACKGROUND DISCLOSURE FORM – HOUSING (continued)

STATE OF ______)

______)

COUNTY OF ______)

Before me, ___, a Notary Public of the state and county stated above, personally appeared ___, with whom I have personal knowledge, and who, upon oath, acknowledged that _he executed the forgoing instrument for the purposes stated therein.

Witness my hand and seal this _ day of ___, 20__.

My Commission Expires:

Notary Public