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Section 3 Business Certification Updated February 2011 1 Dear Applicant: Thank you for your interest in the Anoka County Section 3 Certification Program. The Program makes it easier for businesses like yours to become involved as Section 3 business concerns and facilitates your ability to take advantage of the business opportunities that are generated by certain types of Department Housing and Urban Development (HUD) funding. The ultimate goal of Section 3 is to generate economic development by improving the local economy, the neighborhood economy, developing self sufficiency, and promoting home ownership. Certified businesses are included in a Section 3 directory that Anoka County provides to contractors and other entities. These certified businesses are also eligible to participate in various activities and trainings that may be sponsored by Anoka County. Completed application forms should be submitted to the following address: Anoka County Community Development Attn: Barb McKusick, Section 3 Coordinator 2100 3rd Ave., Suite 700 Anoka, MN 55303 If you have any questions regarding the certification process, need assistance with completing the application, or would like more information regarding the Section 3 Certification Program, please contact Barb McKusick at (763) 323-5722 or by email at [EMAIL REDACTED]. ---PAGE BREAK--- Section 3 Business Certification Updated February 2011 2 SECTION 3 CERTIFICATION PROGRAM ELIGIBILITY CRITERIA Section 3 business concern means a business as defined in this section. That is 51 percent or more owned by Section 3 residents; or Whose permanent, full-time employees include persons, at least 30 percent of whom are currently Section 3 residents, or within three years of the date of first employment with the business concern were Section 3 residents, or That provides evidence of a commitment to contract in excess of 25 percent of the total dollar award of all subcontracts to be awarded to business concerns that meet the qualifications set forth in paragraphs or in this definition of “Section 3 business concern”. Section 3 resident means, for the purposes of Anoka County,: An Anoka County public housing resident; or An individual who resides in Anoka County*, and who is: A low-income person, as this term is defined in section 3(b)(2) of the 1937 Act (42 U.S.C. 1437a(b)(2). Section 3(b)(2) of the 1937 Act defines this term to mean families (including single persons) whose incomes do not exceed 80 per centum of the median income for the area, as determined by the Secretary, with adjustments for smaller and larger families, except that the Secretary may establish income ceilings higher or lower than 80 per centum of the median for the area on the basis of the Secretary's findings that such variations are necessary because of prevailing levels of construction costs or unusually high or low-income families; or (ii) A very low-income person, as this term is defined in section 3(b)(2) of the 1937 Act (42 U.S.C. 1437a(b)(2)). Section 3(b)(2) of the 1937 Act (42 U.S.C. 1437a(b)(2)) defines this term to mean families (including single persons) whose incomes do not exceed 50 per centum of the median family income for the area, as determined by the Secretary with adjustments for smaller and larger families, except that the Secretary may establish income ceilings higher or lower than 50 per centum of the median for the area on the basis of the Secretary's findings that such variations are necessary because of unusually high or low family incomes. * For Section 3 Businesses, if owner(s) do not reside in Anoka County, the business is still eligible for certification. However, it will have lower preference when competing against an Anoka County Section 3 Business. Section 3 covered assistance means Assistance provided under any Anoka County housing or community development program that is expended for work arising in connection with: Housing rehabilitation (including reduction and abatement of lead-based paint hazards, but excluding routine maintenance, repair and replacement); (ii) Housing construction; or (iii) Other public construction projects (which includes other buildings or improvements, regardless of ownership). ---PAGE BREAK--- Updated February 2013 3 Application Checklist for Completeness Applicants must provide ALL of the attachments indicated for their respective Section 3 application: DOCUMENT Application Type 51% Ownership 30 % Employment 25 % Commitment Application Form – Part 1. Company Information Application Form – Part 2, A. Ownership Information Application Form – Part 2, B. Company Employee Information Application Form – Part 2, C. Subcontracting Commitment Application Form –Attestation Application Form – Section 3 Resident Application: AND Section 3 Resident Application Copy of Documents Verifying Eligibility Certifications by other government agencies (if applicable) Certificate of Assumed Business Name (if applicable) Partnership Agreement (if applicable) Articles of Incorporation/Organization Purchase Agreements (if needed to demonstrate ownership) Stock Certificates (if needed to demonstrate ownership) List of All Employees List of Sub-contracts (for reference purposes) ---PAGE BREAK--- Section 3 Business Certification Updated February 2011 4 Application Part 1. Company Information Company Name: Doing Business As (DBA): Street Address: City: County: State: Zip: Mailing Address (if different than above): City: State: Zip: Primary Title: Phone: Fax: Web Site Address: Email Address: Description of Product(s) and/or Service(s) (use additional sheet if necessary): Federal Tax ID State Tax ID Legal Structure: Individual/Sole Proprietorship Partnership C-Corporation S-Corporation Limited Liability Company Part 2. Select Section 3 Certification Type A. Category 1 - Section 3 Ownership (At least 51% Ownership by Section 3 Resident) IMPORTANT: If there is more than one owner, attach the following information for each additional owner on a separate sheet. First Name: Middle Initial: Last Name: Title: Social Security Number: Phone: Residence Address: City: State: Zip: Have there been any changes in ownership in the last year? Yes* No *If yes, please provide details on a separate sheet. % of Ownership: Owner Since (mm/yyyy): Hours Devoted to Business per Each owner has completed a Section 3 Resident Application (blank copy is provided in this application) Each owner has made copies of family income verification and proof of residency and attached to this application ---PAGE BREAK--- Updated February 2013 5 B. Category 2 - Section 3 Employees (30% Employment of Section 3 residents) Each employee requesting Section 3 preferences must submit a Section 3 Resident Form. List all the company’s employees on a separate form. Provide a copy of your company’s payroll records. Indicate the total number of full and part time employees: FT C. Category 3 - Subcontracting Commitment Information - 25% Subcontracts will be awarded to certified Section 3 business(es)* *This Section 3 certification is completed on a per-project basis. Project address: List all the company’s subcontractors to be utilized on a separate sheet. Include company name and contact information. Indicate the total dollar amount to be subcontracted: Indicate the dollar amount awarded to Section 3 businesses: Attestation This section must be completed by an authorized representative of the business that is applying for certification. I certify that the statements provided in this application are true and correct. Furthermore, I understand that the information provided herein is subject to classification under the Minnesota Government Data Practices Act or other applicable law, that it would likely be classified as public, and that it is the responsibility of the Applicant Firm to claim and defend any other classification. I understand that the certifying entities reserve the right to request additional information and to perform on-site checks as necessary. I also understand that intentionally supplying false information for the purpose of obtaining certification will be sufficient reason for rejection of this application and/or removal from the Section 3 Certification Program. Signature Date Print Name Title I have attached the documents listed on the Checklist for Completeness. ---PAGE BREAK--- Updated February 2013 6 Section 3 Resident Application Legal Last Name Legal First Name Middle Initial Street Address Apt. # Home # City Zip Cell Phone # Social Security Number - - Age Email Address: Gender: Male Female Ethnicity: Hispanic or Latino Non-Hispanic or Non-Latino Race (check all that apply): American Indian/Alaskan Native Asian Black/African American Hawaiian Native/Pacific Islander White FAMILY MEMBERS Name (First, Last) Age Relationship to you 1. SELF 2. 3. 4. 5. 6. 7. INCOME SOURCES (CONTINUED ON NEXT PAGE) To determine your family’s income, check all of the following and calculate the gross income that any family member 18 years and older received, or is expected to receive in the next 12 months: Wages, salaries, overtime pay, commissions, fees, tips, bonuses, or other compensation Income or gain from CD’s, money market accounts, brokerage accounts, stocks, bonds, or Treasury Bills Periodic payments from Social Security, disability/death benefits, pensions, retirement funds, annuities, insurance policies, or similar types of periodic benefits payments Payments in lieu of earnings, such as unemployment and disability compensation, workers compensation or severance pay Welfare assistance or TANF benefits Child support, spousal support/alimony, or regular contribution or gifts from persons not residing in the household including scholarships, parental gifts for tuition, etc. Revocable trust Lump sum payment or receipt of inheritances, capital gains, lottery winnings, victims’ restitution or insurance settlements Real estate other than the primary residence or other capital investments Yes No Do you receive housing assistance (Section 8, Subsidized)? (amount) ---PAGE BREAK--- Updated February 2013 7 Income Information: Find your family size (total number in family including foster children) then, without changing rows, circle the amount listed to the right of the “family size” column that includes your gross family income including the income sources described above. Family Size 2013 Income Categories (Effective December 2012) Category 1 Category 2 Category 3 Category 4 1 $17,300 or below $17,301 - $28,850 $28,851 - $45,100 $45,101 or above 2 $19,800 or below $19,801 - $32,950 $32,951 - $51,550 $51,551 or above 3 $22,250 or below $22,251 - $37,050 $37,051 - $58,000 $58,001 or above 4 $24,700 or below $24,701 - $41,150 $41,151 - $64,400 $64,401 or above 5 $26,700 or below $26,701 - $44,450 $44,451 - $69,600 $69,601 or above 6 $28,700 or below $28,701 - $47,750 $47,751 - $74,750 $74,751 or above 7 $30,650 or below $30,651 - $51,050 $51,051 - $79,900 $79,901 or above 8 $32,650 or below $32,651 - $54,350 $54,350 - $85,050 $85,051 or above More than 8 Talk to agency staff for help in determining income category for your household. I certify that the information on this application is accurate and complete. I authorize Anoka County to verify the information provided if necessary. Print Name of Applicant Signature of Applicant Date Warning: Section 1001 of Title 18 of US. Code makes it a criminal offense to make false statements or misrepresentations to any Department or Agency of the U.S. as to matters within its jurisdiction. ---PAGE BREAK--- Updated February 2013 8 Section 3 Employee Income Verification Company: Legal Last Name Legal First Name Middle Initial Street Address Apt. # Home # City Zip Cell Phone # Social Security Number - - Age Email Address: Gender: Male Female Ethnicity: Hispanic or Latino Non-Hispanic or Non-Latino Race (check all that apply): American Indian/Alaskan Native Asian Black/African American Hawaiian Native/Pacific Islander White CURRENT FAMILY MEMBERS Name (First, Last) Age Relationship to you 1. SELF 2. 3. 4. 5. 6. 7. INCOME SOURCES To determine your family’s income, check all of the following and calculate the gross income that any family member 18 years and older received, or is expected to receive in the next 12 months: Wages, salaries, overtime pay, commissions, fees, tips, bonuses, or other compensation Income or gain from CD’s, money market accounts, brokerage accounts, stocks, bonds, or Treasury Bills Periodic payments from Social Security, disability/death benefits, pensions, retirement funds, annuities, insurance policies, or similar types of periodic benefits payments Payments in lieu of earnings, such as unemployment and disability compensation, workers compensation or severance pay Welfare assistance or TANF benefits Child support, spousal support/alimony, or regular contribution or gifts from persons not residing in the household including scholarships, parental gifts for tuition, etc. Revocable trust Lump sum payment or receipt of inheritances, capital gains, lottery winnings, victims’ restitution or insurance settlements Real estate other than the primary residence or other capital investments Yes No Do you receive housing assistance (Section 8, Subsidized)? (amount) ---PAGE BREAK--- Updated February 2013 9 Income Information: Find your family size (total number in family including foster children) then, without changing rows, circle the amount listed to the right of the “family size” column that includes your gross family income including the income sources described above. Family Size 2013 Income Categories (Effective December 2012) Category 1 Category 2 Category 3 Category 4 1 $17,300 or below $17,301 - $28,850 $28,851 - $45,100 $45,101 or above 2 $19,800 or below $19,801 - $32,950 $32,951 - $51,550 $51,551 or above 3 $22,250 or below $22,251 - $37,050 $37,051 - $58,000 $58,001 or above 4 $24,700 or below $24,701 - $41,150 $41,151 - $64,400 $64,401 or above 5 $26,700 or below $26,701 - $44,450 $44,451 - $69,600 $69,601 or above 6 $28,700 or below $28,701 - $47,750 $47,751 - $74,750 $74,751 or above 7 $30,650 or below $30,651 - $51,050 $51,051 - $79,900 $79,901 or above 8 $32,650 or below $32,651 - $54,350 $54,350 - $85,050 $85,051 or above More than 8 Talk to agency staff for help in determining income category for your household. Another way to qualify for the program is if, within the 3 years after your initial employment with the company, you qualified under that year’s income levels. Please provide the following information: Year of Hire: Year Annual Income Family Size Example 2001 $28,000 3 Year of Hire Year of Hire +1 Year Year of Hire +2 Years I certify that the information on this application is accurate and complete. I authorize Anoka County to verify the information provided if necessary. Print Name of Applicant Signature of Applicant Date Warning: Section 1001 of Title 18 of US. Code makes it a criminal offense to make false statements or misrepresentations to any Department or Agency of the U.S. as to matters within its jurisdiction.