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Recipient Profile Expenditure Summary Revenue Replacement Certification
Interim Report
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Verify Recipient Profile Complete Expenditure Complete Revenue Complete Certification
Summary Replacement
Recipient Profile
Instructions
Please verify that you are an authorized user of the prime recipient and confirm
the accuracy of your organization's program profile.
Recipient Information
Recipient DUNSO 021798863
Recipient DUNS (+4)
8
Recipient TINO 956000707
Recipient Legal Entity Lake Elsinore city,
Names California
Recipient Types
FAINO
CFDA No./Assistance
Listings
Recipient Address 0 130 S. Main St.
Recipient Address 20
Recipient Address 38
Recipient CitYO Lake Elsinore
Recipient CA
State/TerritorYe
Recipient Zip50 92530
Recipient Zip+4o
Recipient Reporting
Tiers
Please report discrepancies (if any) on the above
information
Point of Contact List
Name .. Title .. Phone .. Email
1 BRENDAN RAFFER... Fiscal Officer 951-674-3124 x298 ... brafferty_@lake-elsinore.org_(i
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Recipient Profile Expenditure Summary Revenue Replacement Certification
Interim Report
S ►
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Verify Recipient Profile Complete Expenditure Complete Revenue Complete Certification
Summary Replacement
EXPENDITURE SUMMARY LEVEL INFORMATION
Instructions
States, U.S. Territories, Metropolitan cities, Counties, and Tribes are required to
submit a one-time interim report with expenditures by category at the
summary level from the date of award to July 31, 2021. The recipient will be
required to enter obligations and expenditures for each expenditure category.
Category Funding Information
1. Expenditure Category: Public Health
Category Cumulative Cumulative
Obligations to date Expenditures to date
1.1 COVID-19 Vaccination
1.2 COVID-19 Testing
1.3 COVID-19 Contact Tracing J
1.4 Prevention in Congregate Settings
(Nursing Homes, Prisons/Jails, Dense Work
Sites, Schools, etc.)
1.5 Personal Protective Equipment
1.6 Medical Expenses (including Alternative
Care Facilities)
1.7 Capital Investments or Physical Plant
Changes to Public Facilities that respond to
the COVID-19 public health emergency
1.8 Other COVID-19 Public Health Expenses
(including Communications, Enforcement,
Isolation/Quarantine)
1.9 Payroll Costs for Public Health, Safety,
and Other Public Sector Staff Responding to
COVI D-19
1.10 Mental Health Services
1.11 Substance Use Services
1.12 Other Public Health Services
2. Expenditure Category: Negative Economic Impacts
Category Cumulative Cumulative
Obligations to date Expenditures to date
2.1 Household Assistance: Food Programs
2.2 Household Assistance: Rent, Mortgage, r
and Utility Aid
2.3 Household Assistance: Cash Transfers
2.4 Household Assistance: Internet Access
Programs
2.5 Household Assistance: Eviction
L
Prevention
2.6 Unemployment Benefits or Cash
Assistance to Unemployed Workers
2.7 Job Training Assistance (e.g., Sectoral job-
training, Subsidized Employment,
Employment Supports or Incentives)
2.8 Contributions to UI Trust Funds
2.9 Small Business Economic Assistance
(General)
2.10 Aid to nonprofit organizations
2.11 Aid to Tourism, Travel, or Hospitality
2.12 Aid to Other Impacted Industries
2.13 Other Economic Support
2.14 Rehiring Public Sector Staff
3. Expenditure Category: Services to Disproportionately Impacted Communities
Category Cumulative Cumulative
Obligations to date Expenditures to date
3.1 Education Assistance: Early Learning
3.2 Education Assistance: Aid to High-
Poverty Districts
3.3 Education Assistance: Academic Services
3.4 Education Assistance: Social, Emotional,
and Mental Health Services
3.5 Education Assistance: Other
3.6 Healthy Childhood Environments: Child
Care
3.7 Healthy Childhood Environments: Home
Visiting
3.8 Healthy Childhood Environments: J
Services to Foster Youth or Families Involved
in Child Welfare System
3.9 Healthy Childhood Environments: Other
3.10 Housing Support: Affordable Housing L
3.11 Housing Support: Services for Unhoused $61,916.25 $61,916.25
persons
3.12 Housing Support: Other Housing
Assistance
3.13 Social Determinants of Health: Other
3.14 Social Determinants of Health: I F
Community Health Workers or Benefits
Navigators
3.15 Social Determinants of Health: Lead
Remediation
3.16 Social Determinants of Health:
Community Violence Interventions
4. Expenditure Category: Premium Pay
Category Cumulative Cumulative
Obligations to date Expenditures to date
4.1 Public Sector Employees
4.2 Private Sector: Grants to other employers
5. Expenditure Category: Infrastructure
Category Cumulative Cumulative
Obligations to date Expenditures to date
5.1 Clean Water: Centralized wastewater
treatment
5.2 Clean Water: Centralized wastewater
collection and conveyance
5.3 Clean Water: Decentralized wastewater
5.4 Clean Water: Combined sewer overflows F
5.5 Clean Water: Other sewer infrastructure
5.6 Clean Water: Stormwater $458,364.00 $458,364.00
5.7 Clean Water: Energy conservation
5.8 Clean Water: Water conservation
5.9 Clean Water: Nonpoint source
5.10 Drinking water: Treatment
5.11 Drinking water: Transmission &
distribution
5.12 Drinking water: Transmission &
distribution: lead remediation
5.13 Drinking water: Source
5.14 Drinking water: Storage
5.15 Drinking water: Other water
infrastructure
5.16 Broadband: "Last Mile" projects
5.17 Broadband: Other projects
6. Expenditure Category: Revenue Replacement
Category Cumulative Cumulative
Obligations to date Expenditures to date
6.1 Provision of Government Services I L
7. Expenditure Category: Administrative and Other
Category Cumulative Cumulative
Obligations to date Expenditures to date
7.1 Administrative Expenses
7.2 Evaluation and data analysis
7.3 Transfers to Other Units of Government
Clear Form
Cumulative Amounts to Date, excluding NEU
and Non-UGLG transfers.
Total Cumulative Total Cumulative
Obligations to Date Expenditures to
Date
$520,280.25 $520,280.25
7. Expenditure Category: Recipient Allocation
Category Cumulative Cumulative
Obligations to date Expenditures to date
7.5 Transfers to Non-UGLGs I L
Cumulative Amounts to Date, for NEU and
Non-UGLG transfers only.
Total Cumulative Total Cumulative
Obligations to Date Expenditures to
Date
$0.00 $0.00
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Recipient Profile Expenditure Summary Revenue Replacement Certification
Interim Report
S
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Verify Recipient Profile Complete Expenditure Complete Revenue Complete Certification
Summary Replacement
REVENUE REPLACEMENT
Instructions
Please provide identifying information for revenue replacement funding.
Recipients must calculate the reduction in their general revenue using
information as-of December 31, 2020 for loss due to the Covid-19 public health
emergency. The formula for calculation is found in the Interim Final Rule as of
May 17, 2021.
Revenue Replacement Key Inputs
* (required) Base Year Revenues * (required) Fiscal Year End Dates
Fs8o,229,463.00 Jun 30, 2019
* (required)Growth Adjustment Used * (required)Actual General Revenue as of 12
27.50% months ended December 31, 2020
$62,391,529.00
* (required) Estimated Revenue Loss Due to
Covid-19 Public Health Emergency as of
December 31, 2020
$53,092,745.00
* (required)Were Fiscal Recovery Funds used to
make a deposit into a pension fund?
No
* (required) Please provide an explanation of how revenue replacement funds were allocated to
government services
Explanation
Salesforce Sans 12 B r u = 2= �1= �1= = _ _ �' I
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The process of allocating those funds is still in process.
Clear Form
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Recipient Profile Expenditure Summary Revenue Replacement Certification
Interim Report
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Step 1 Step 2 Step 3 Step 4
Verify Recipient Profile Complete Expenditure Complete Revenue Complete Certification
Summary Replacement
Official Certification
certify that the information provided is accurate and complete after reasonable inquiry of people,
systems, and other information available to the SLFRF recipient. The undersigned acknowledges
that any materially false, fictitious, fraudulent statement, or representation (or concealment or
omission of a material fact) in this submission may be the subject of criminal prosecution under the
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False Statements AccountabilityrA"otd&9e6 asdamended, 18 USC 1001, and also may subject me
and the SLFRF Recipient to civil penalties, damages, and administrative remedies for false claims or
otherwise (including under 31 USC 3729 et seq.) The undersigned is an authorized representative
of the SLFRF Recipient with authority to make the above certifications and representations on
behalf of the SLFRF Recipient.
By signing this report, the Authorized Representative for Reporting acknowledges in accordance
with 31 CFR 35.4(c) that recipients shall provide to the Secretary periodic reports providing
detailed accounting of the uses of funds, as applicable, all modifications to a State's or Territory's
tax revenue sources, and such other information as the Secretary may require for the
administration of this program. In addition to regular reporting requirements, the Secretary may
request other additional information as may be necessary or appropriate, including as may be
necessary to prevent evasions of the requirements of this program. False statements or claims
made to the Secretary may result in criminal, civil, or administrative sanctions, including fines,
imprisonment, civil damages and penalties, debarment from participating in Federal awards or
contracts, and/or any other remedy available by law.
Name of Current Login User
The information for the currently signed in user will populate as the Authorizer of this submittal.
Only those in Role of Authorized Representative for Reporting or Authorized Representative on
the Submission record will have access to Certify and Submit.
Name: Telephone:
BRENDAN RAFFERTY 951-674-3124 x298 (tel:951-674-3124 x298).
Title: Email:
Fiscal Officer m brafferty_@lake-elsinore.org_(maiIto:brafferty_@lake-
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Date Submitted
9/10/2021 11:45 AM
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