Full Circle Communities - Request for Urban Revitalization Copyright 2014
City of Dubuque Action Items # 6.
ITEM TITLE: Full Circle Communities - Request for Urban Revitalization
Verification
SUMMARY: City Manager recommending approval of a request for local
support from Full Circle Communities for the proposed re-
development of the former Four Oaks building at 180 W.
15th Street into 36 residential units targeted to people with
disabilities and veterans.
RESOLUTION Finding that the designation of the Fifteenth
Street Apartments is in the Jackson Park Urban
Revitalization District and therefore eligible for Urban
Revitalization Tax Abatement for the redevelopment of 180
W. 15th Street, Dubuque, IA providing safe, affordable
housing for the residents of the City of Dubuque
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Adopt
Resolution(s)
ATTACHMENTS:
Description Type
Full Circle Communities-Request for Urban City Manager Memo
Revitalization Support-MVM Memo
Staff Memo Staff Memo
Figure 2, Map Supporting Documentation
Staff Memo - Planning Services Manager Supporting Documentation
Meeting Notice Supporting Documentation
Exhibit 5S Supporting Documentation
Resolution Resolutions
THE CM OF Dubuque
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DUB E 11 1r
Masterpiece on the Mississippi -2012I
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TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT: Fifteenth Street Apartments (Former Four Oaks Building) Request for
Urban Revitalization Support from Full Circle Communities
DATE: October 31, 2016
Housing & Community Development Department Director Alvin Nash is recommending
City support for the proposed re-development of the former Four Oaks building at 180
West 15th Street to 36 residential units targeted to people with disabilities and veterans.
The project, Fifteenth Street Apartments, is located in the Jackson Park Urban
Revitalization District and is eligible for a 10-year abatement to the value added by
improvements.
The Jackson Park Urban Revitalization District was established on December 22, 1980.
Improvements made to residential properties in the district are eligible for a 10-year
100% abatement on the value added by the improvements.
Full Circles Communities plan for the exterior rehabilitation of the former St. Patrick's
School was reviewed by the Historic Preservation Commission. The Commission voted
8-0 to grant the Certificate of Appropriateness for the Jackson Park Historic District with
one condition, the cross at the north entrance remain. Full Circles filed an application
with the Zoning Board of Adjustments for a Special Exception from zoning regulations to
develop the 36 residential units on a 17,000 square foot lot. An application was also
filed for a parking variance because there is a deficit of 39 off-street parking spaces in
an OR District. After a Public Hearing on October 27, both the Special Exception and
parking variance were approved.
The development plan provides for the construction of a 36 unit multi-family housing
targeted towards veterans and persons with disabilities. Full Circle Communities will
provide a mix of one bedroom and two bedroom units that will be highly accessible,
including roll in showers, accessible kitchens, grab bars and wider turn radii. Full
Circles sets aside 75% of project economics to provide services to residents. Services
include on-site case management, tenant advocacy, health awareness, reasonable
modifications and accommodations, benefits assistance, meal service, primary care
attendants and transportation assistance. The model to deliver services is to contract
with local service providers to ensure resident needs are met.
The Developer intends to apply for Low Income Housing Tax Credits as the primary
source of funding for the housing project and Full Circle has pledged $300,000 towards
the project. Local Government participation is very important to the success of the
project. The application for state tax credits is competitive. The Urban Revitalization
Tax exemption will provide an estimated $291 ,756 over 10 years in tax abatement for
the project showing local support for the project, which will strengthen Full Circle
Community's Tax Credit application to the Iowa Finance Authority.
Full Circles Communities met with neighbors to provide information and receive public
comments during the Downtown Neighborhood Association meeting on October 25,
2016. The project was well received by the residents in attendance. Residents asked
several questions of the Developer about parking, security for the building, lighting,
property management, construction timeline, tenant selection criteria, services and
amenities available for residents. A local service provider offering Rapid Rehousing
assistance for veterans stated there was a need for affordable housing for veterans who
are working with local agencies to receive support services and attain self-sufficiency.
Full Circles Communities cited data from the 2014 American Community Survey Five
Year estimates that shows approximately 4,400 veterans and 7,900 persons with a
disability reside in Dubuque. Of the 4,400 veterans, 3.9% live below the poverty level,
49% are over the age of 65, and 29% live with a disability. The need for affordable
housing has also been identified in the City of Dubuque Consolidated Plan.
The Consolidated Plan is a five-year plan for the use of Community Development Block
Grant funds in the community. The plan examines housing needs for low and moderate
income populations, earning up to 80% area median income. The City Consolidated
Plan, updated for Fiscal Years 2016-2020, identifies a need for housing for elderly
populations, homeless, and persons with disabilities. These populations often have
limited income and housing choices.
The Consolidated plan identified housing cost burden as the primary housing problem
faced by low and moderate income renters in Dubuque. The American Community
Survey five year estimates for Selected Housing Characteristics provides information on
the number of households experiencing cost burden. Economists call a household "cost
burden" when housing costs exceed 30% of the household income. 2014 American
Community Survey estimates show 52% of renter households are cost burdened,
compared with 21% owner occupied with a mortgage.
With over half of the renters in Dubuque experiencing cost burden, the addition of tax
credit rental units will provide opportunity for renters to live in housing they can afford.
When households pay 30% or less of their income for housing, a number of benefits
occur. Households are able to save for real wealth building assets, like down payment
on a home and continuing education.
2
The Fifteenth Street Apartments will be located at 180 W. 15th Street, directly across
from Jackson Park. It is the former St. Patrick's School Building. The location is in the
heart of downtown Dubuque, a historic area with historic housing. Due to the historic
nature of the housing stock, few of the historic buildings downtown are ADA accessible.
The Fifteenth Street apartments will be fully accessible to persons with a disability and
will assist to affirmatively further fair housing by offering more housing choices for low
and moderate income renters.
The project location is outside of the area of concentrated poverty, but still within a
neighborhood were many low and moderate income residents reside. This will allow
area residents to take advantage of quality, affordable housing options in their
neighborhood and is consistent with the City's goals to de-concentrate poverty as
identified in the Analysis of Impediments. The Analysis of Impediments examines the
barriers to fair housing and identifies strategies to eliminate these barriers. The location
of this project will assist to affirmatively further fair housing by creating affordable,
accessible housing options in areas of low poverty concentration.
The property value, based upon 2016 Beacon data, the land is valued at $50,150
Buildings are valued at $226,150. The property has a total assessed value of$276,300.
This property is currently tax exempt. The estimated abatement for the project after
improvements for a 10 year period is $291 ,756. After the abatement period expires, the
property will be taxed based on the assessed value for taxation as determined by the
assessor.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
z 6&4.4�
Mic ael C. Van Milligen
MCVM:jh
Attachment
cc: Crenna Brumwell, City Attorney
Cindy Steinhauser, Assistant City Manager
Teri Goodmann, Assistant City Manager
Alvin Nash, Housing & Community Development Department Director
3
THE CITY OF Dubuque
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All-America City
DUB t 1 r
Masterpiece on the Mississippi 2007.2012.2013
TO: Michael Van Milligen, City Manager
FROM: Alvin Nash, Housing & Community Development Director
DATE: October 31, 2016
RE: Fifteenth Street Apartments (Former Four Oaks Building) request for
Urban Revitalization support from Full Circle Communities
Introduction
This memorandum presents for City Council a request for local support from Full Circle
Communities, the Developer, for the proposed re-development of the former Four Oaks
building at 180 West 15th Street to 36 residential units targeted to people with
disabilities and veterans. The project, Fifteenth Street Apartments, is located in the
Jackson Park Urban Revitalization District and is eligible for a 10-year abatement to the
value added by improvements.
Background
Urban Revitalization Chapter 404 of the Iowa Code (Urban Revitalization Act)
authorizes cities to designate areas as urban revitalization areas. Improvements to
qualified real estate within these designated areas may receive a total or partial
exemption from property taxes for a specified number of years. The exemptions are
intended to stimulate private investment by reducing tax increases that usually
accompany property improvements. This additional private investment provides a
long-term increase or stabilization in the area's tax base, enhances the visibility of
revitalization areas and/or supports important city objectives such as historic
preservation, economic development and affordable housing development.
In order to implement the provisions of Chapter 404, the City determine the area is
eligible for exemption, prepare a revitalization plan for each designated area, and hold
at least one public hearing after proper notice. The law mandates specific criteria and
procedures must be followed.
The Jackson Park Urban Revitalization District was established on December 22, 1980
Improvements made to residential properties in the district are eligible for a 10-year
100% abatement on the value added by the improvement.
Full Circles Communities plan for the exterior rehabilitation was reviewed by the
Historic Preservation Commission. The Commission voted 8-0 to grant the Certificate
of Appropriateness for the Jackson Park Historic District with one condition. Full
Circles filed an application with the Zoning Board of Adjustments for a Special
Exception from zoning regulations to develop the 36 residential units on a 17,000
square foot lot. An application was also filed for a parking variance because there is a
deficit of 39 off-street parking spaces in an OR District. After a Public Hearing on
October 27, both the Special Exception and parking variance were approved (see
attached memo from Planning Services Manager, Laura Carstens).
Discussion
The development plan provides for the construction of a 36 unit multi-family housing
targeted towards veterans and persons with disabilities. Full Circle Communities will
provide a mix of one bedroom and two bedroom units that will be highly accessible,
including roll in showers, accessible kitchens, grab bars and wider turn radii. Full
Circles sets aside 75% of project economics to provide services to residents. Services
include on-site case management, tenant advocacy, health awareness, reasonable
modifications and accommodations, benefits assistance, meal service, primary care
attendants and transportation assistance. The model to deliver services is to contract
with local service providers to ensure resident needs are met.
The Developer intends to apply for Low Income Housing Tax Credits as the primary
source of funding for the housing project and Full Circle has pledged $300,000 towards
the project. Local Government participation is very important to the success of the
project. The application for state tax credits is competitive. The Urban Revitalization
Tax exemption will provide an estimated $291 ,756 in tax abatement for the project
showing local support for the project, which will strengthen Full Circle Community's Tax
Credit application to the Iowa Finance Authority.
Full Circles Communities met with residents to provide information and receive public
comments during the Downtown Neighborhood Association meeting on October 25, 2016.
The project was well received by the residents in attendance. Residents asked several
questions of the Developer about parking, security for the building, lighting, property
management, construction timeline, tenant selection criteria, services and amenities
available for residents. A local service provider offering Rapid Rehousing assistance for
veterans stated there was a need for affordable housing for veterans who are working with
local agencies to receive support services and attain self-sufficiency.
Full Circles Communities cited data from the 2014 American Community Survey (ACS)
Five Year estimates that shows approximately 4,400 veterans and 7,900 persons with a
disability reside in Dubuque. Of the 4,400 veterans, 3.9% live below the poverty level,
49% are over the age of 65, and 29% live with a disability. The need for affordable
housing has also been identified in the City of Dubuque Consolidated Plan.
The Consolidated Plan is a five-year plan for the use of Community Development Block
Grant funds in the community. The plan examines housing needs for low and moderate
income populations, earning up to 80% area median income. The City Consolidated Plan,
updated for Fiscal Years 2016-2020, identifies a need for housing for elderly populations,
homeless, and persons with disabilities. These populations often have limited income and
housing choices.
The Consolidated plan identified housing cost burden as the primary housing problem
faced by low and moderate income renters in Dubuque. The ACS five year estimates for
Selected Housing Characteristics provides information on the number of households
experiencing cost burden. Economists call a household cost burden when housing
costs exceed 30% of the household income. 2014 ACS estimates show 52% of renter
households are cost burdened, compared with 21% owner occupied with a mortgage
(Figure 1).
Housing Cort Burden
Dubuque, IA
Five Year ACS Estimates
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With over half of the renters in Dubuque experiencing cost burden, the addition of tax
credit rental units will provide opportunity for renters to live in housing they can afford.
When households pay 30% or less of their income for housing, a number of benefits
occur. Households are able to save for real wealth building assets, like down payment on
a home and continuing education.
The Fifteenth Street Apartments will be located at 180 W. 1$° Street, directly across from
Jackson Park (see figure 2, attached map). It is the former St Patrick School Building.
The location is in the heart of downtown Dubuque, a historic area with historic housing.
Due to the historic nature of the housing stock, few of the historic buildings downtown are
ADA accessible. The Fifteenth Street apartments will be fully accessible to persons with a
disability and will assist to affirmatively HaTerfair housing by offering more housing
choices for low and moderate income renters. The project location is outside of the area
of concentrated poverty, but still within a neighborhood were many low and moderate
income residents reside. This will allow area residents to take advantage of quality,
affordable housing options in their neighborhood and is consistent with the City goals to
de concentrate poverty as identified in the Analysis of Impediments. The Analysis of
Impediments examines the barriers to fair housing and identifies strategies to eliminate
these barriers. The location of this project will assist to affirmatively further fair housing by
creating affordable, accessible housing options in areas of low poverty concentration.
Budgetary Impact
The property value, based upon 2016 Beacon data, the land is valued at $50,150
Buildings are valued at $226,150. The property has a total assessed value of
$276,300. This property is currently tax exempt. The estimated abatement for the
project after improvements for a 10 year period is $291 ,756. After the abatement
period expires the property will be taxed based on the assessed value for taxation as
determined by the assessor.
Recommendation
I recommend that the City Council approve the attached resolution directing City Staff to
work with the City Assessor to complete exhibit 5S showing local support for the Full
Circle Community application for Low Income Housing Tax Credits to rehabilitate the
former Four Oaks building.
Action Requested
The Action Step is for the City Council to adopt the attached resolution.
Prepared by: Erica Haugen, Community Development Specialist
cc. Maurice Jones
Laura Carstens
F:\USERS\CDBG\Urban Revite\Petitions for Districts\Full Circle\Memo to Council.docx
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THE CITY OF Dubuque
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MEMORANDUM
TO: Alvin Nash, Housing & Community Development Director
FROM: Laura Carstens, Planning Services Manager
SUBJECT: UDC Compliance— Full Circle Communities Proposal for Fifteenth Street
Apartments at 180 West Street
DATE: October 31, 2016
Introduction
The purpose of this memorandum is to confirm that the Fifteenth Street Apartments proposal
filed by Full Circles Communities for the re-use of the former Four Oaks building at 180 West
Street as 36 residential units targeted to people with disabilities and veterans is in compliance
with Dubuque City Code Title 16 - Unified Development Code (UDC) as described below. The
property is located in the Jackson Park Historic District and zoned OR Office Residential.
Certificate of Appropriateness
Full Circles Communities filed an application with the Historic Preservation Commission for a
Certificate of Appropriateness in the Jackson Park Historic District to install new windows on the
building and to remove the concrete cross built into the entrance on the north elevation. After a
Public Meeting on October 20, 2016, the Commission voted 8-0 to grant the Certificate of
Appropriateness for the request, in accordance with UDC Section 10-6, with the condition that
the concrete cross must remain.
Special Exception
Full Circles Communities filed an application with the Zoning Board of Adjustment for a Special
Exception from zoning regulations to develop 36 residential units on a 17,000 square foot lot,
43,200 square feet minimum required in an OR District. After a Public Hearing on October 27,
2016, the Board voted 5-0 to grant the Special Exception in accordance with UDC Section 8-
7.3.
Variance
Full Circles Communities filed an application with the City's Zoning Board of Adjustment for a
Variance from zoning regulations to develop 36 residential units with a deficit of 39 off-street
parking spaces in an OR District. After a Public Hearing on October 27, 2016, the Board voted
4-1 to grant the Variance in accordance with UDC Section 8-6.3.
Please contact me if you have questions or need additional information. Thank you.
cc: Michael Van Milligen, City Manager
Erica Haugen, Community Development Specialist
F:\Users\LCARSTEN\WP\Housing Projects\Full Circle Communities\Memo Alvin Nash UDC Compliance.doc
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October 18, 2016
Dear Property Owner:
Please be advised that a presentation will be given regarding a proposed development at 180
West 15th Street. The presentation will happen at the Downtown Neighborhood Association
meeting at 6:30pm on Tuesday October 25, 2016 at St. Mark's located at 1201 Locust Street.
The proposed Fifteenth Street Apartments will be owned, developed, and managed by Full
Circle Communities, Inc. a non-profit dedicated to providing quality housing and services to
residents. The development will include 36 apartments and amenity space including a library,
computer room, and community and service space. The units will have accessible features and
be targeted to people with disabilities and veterans. There will be on-site property
management, maintenance, and service staff.
At this meeting you will be able to view the plans and discuss this new proposed development.
We look forward to seeing you there.
S' ereLy
Joshua Wilmoth r-� C";
President c3
Full Circle Communities, Inc. c.- C:,
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310 south peoria street • suite 500 • chicago, 1160607 * 847.849.5300 • www.fccommunities.org
housing is the foundation
RESOLUTION NO. 385-16
RESOLUTION FINDING,THAT THE FIFTEENTH STREET APARTMENTS IS IN THE
JACKSON PARK URBAN REVITALIZATION DISTRICT AND THEREFORE ELIGIBLE
FOR URBAN REVITALIZATION TAX ABATEMENT FOR THE REDEVELOPMENT OF
180 W 15TH STREET, DUBUQUE, IA PROVIDING SAFE, AFFORDABLE HOUSING
FOR THE RESIDENTS OF THE CITY OF DUBUQUE.
Whereas, the City of Dubuque supports the development and construction of housing
and residential properties which provide quality, affordable housing; and
Whereas, Fifteenth Street Apartments Limited Partnership, an Iowa limited
partnership (the "Owner"), and Full Circle Communities, Inc., and Illinois not-for-profit
corporation authorized to do business in Iowa (the "Developer") has proposed to develop
the property at 180 W. 15th St., Dubuque IA (the "Property") and to create 36 units of
multi -family housing at the Property targeted towards veterans and people with
disabilities; a
Whereas, the Property is located in an area eligible for the Urban Revitalization Tax
Exemption program; and
Whereas, through the Urban Revitalization Program, the Property is eligible to
receive a one hundred percent exemption from taxation on the actual value added by
the improvements for a period of ten years so long as it is assessed as residential
property, multi -family residential, or assessed as commercial property, if the commercial
property consists of three or more separate living quarters with at least seventy-five
percent of the space used for residential purposes;
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF
DUBUQUE, IOWA:
Section 1. That the construction of the hereinafter described Property legally
described as:
The North 3/5 of City Lot 463 in the City of Dubuque, Iowa, according to the
recorded Plat thereof;
is deemed necessary in the interest the residents of the City.
Section 2. That the City Council supports the Owner's and the Developer's Urban
Revitalization Application and the Owner's and Developer's efforts to receive a tax credit
award from the Iowa Finance Authority and the Iowa Economic Development Authority
for the development of the Property.
Section 3. That the City Council approve the resolution supporting the project and
authorize staff to work with the City Assessor to complete the form 5S for submission by
Developer prior to the November 17, 2016 deadline for consideration. The estimated
amount of the tax exemption is $291,755.63.
Section 4. That the proposed development of the Property is consistent with the City
of Dubuque's affordable housing strategies and its goal to implement its comprehensive
plan.
Passed, approved and adopted this 7th day of November, 2016.
Attest:
Kevi F. Firnstahl, Ci _ erk
,o
oy D. Buol, Mayor
EXHIBIT 5S
IOWA FINANCE
AUTHORITY
LOCAL GOVERNMENT CONTRIBUTION
Form(s) shall be completed by the qualified Government Entity or Political Subdivision along with any
additional supporting documents as required in QAP Section 6.2.4.1.
Project Name
Project Address
Ownership Entity Name
Fifteenth Street Apartments
180 W. 15th St, Dubuque, IA 52001
Fifteenth Street Apartments Limited Partnership
Iowa Finance Authority (IFA) encourages developers to coordinate with Iowa communities regarding
community revitalization plans, where applicable. A Local Government Contribution creates a
presumption that the project is not in conflict with the local government's community revitalization plan, if
any.
This form will verify the Local Government Contribution effort referenced in the Qualified Allocation Plan
(QAP). A Local Government Contribution can be provided by a qualified Government Entity or Political
Subdivision. QAP Section 6.2.4.1 states the following items will constitute a Local Government
Contribution:
Form of Contribution
Additional Supporting Documents
Cash Contribution
Commitment letter
Gift of Land or Building
Third party MAI certified appraisal
Tax Abatement (not tax exemption)
Scoring exhibit only
Tax Increment Financing
Project specific city council resolution
Urban Revitalization Tax Exemption (URTE)
Project specific city council resolution
Enterprise Zone Credits
Scoring exhibit only
Enterprise Zone Sales Tax Rebate
Scoring exhibit only
Waiver of Fees
Scoring exhibit only
City HOME
Scoring exhibit only
Below Market Interest Rate Loan
Calculation showing value of imputed savings using
a market rate of six percent (6%) with a maximum
20 year loan term and a maximum 30 year
amortization
QAP Section 6.2.4.1 states the agency making the Local Government Contribution shall indicate the
value of its contribution. The value of the Local Government Contribution is the value of the contribution
made by the qualified Government Entity or Political Subdivision minus the value of any consideration or
accommodation received by the qualified Government Entity or Political Subdivision in return for the
contribution.
The Governmental Entity or Political Subdivision completing this form understands that IFA will rely on
these valuations to determine whether the Applicant has met the requirements of the QAP to receive
points for Local Government Contribution.
IFA reserves the right to limit the amount of fees waived by any Government Entity or Political Subdivision
to one percent (1 %) of the Total Project Costs.
For scoring purposes under this category, a Government Entity or Political Subdivision contribution to a
Project provided through a certified Local Housing Trust Fund (LHTF) will be considered a qualified Local
Government Contribution only if the Applicant provides documentation from the LHTF showing the
Government Entity or Political Subdivision has made contributions to the LHTF during the current fiscal
year totaling at least the amount of the proposed Local Government Contribution to the Project.
2017 Round
EXHIBIT 5S
IOWA FINANCE
AUTP10:RiTY
Qualified Governmental Entity or Political Subdivision Contribution(s) (8 points maximum)
❑ CASH CONTRIBUTION — Commitment letter attached
Amount
Source of Cash
Name of Entity Making
Contribution
❑ GIFT OF LAND — Third party MAI certified appraisal attached
Appraised
AmountNalue
Name of Entity Making Contribution
Location/Address of property:
Is land held free and clear of encumbrances? ❑ YES El NO
If NO, disclose all known liens and encumbrances and explain how and when these will be satisfied.
❑ GIFT OF BUILDING — Third party MAI certified appraisal attached
Appraised
AmountNalue
Name of Entity Making Contribution
Address of building(s):
Is land held free and clear of encumbrances? ❑ YES ❑ NO
If NO, disclose all known liens and encumbrances and explain how and when these will be satisfied.
❑ TAX ABATEMENT (not exemption) — No attachment r
AmountNalue
Term of
Abatement
Describe How Amount Was
Determined
Name of Entity Making
Contribution
$291,756
10 year
Income calculation
verified by City
Assessor
City of Dubuque
❑ TAX INCREMENT FINANCING — Project specific city council resolution attached
Amount/Value
Name of Entity Making
Contribution
® URBAN REVITALIZATION TAX EXEMPTION — Pro
AmountNalue
Term of Exemption
Describe How Amount
Was Determined
Name of Entity Making
Contribution
$291,756
10 year
Income calculation
verified by City
Assessor
City of Dubuque
❑ ENTERPRISE ZONE CREDIT (equity value) — No attachment required
AmountNalue
Name of Entity Making
Contribution
2017 Round
EXHIBIT 5S
IOWA FINANCE
AUTHORITY
❑ ENTERPRISE ZONE SALES TAX REBATE — No attachment required.
AmountNalue
Name of Entity Making
Contribution
❑ WAIVER OF FEES — Limited to onepercent (1
AmountNalue
Type of Fees
Describe How Amount
Was Determined
Name of Entity Making
Contribution
Name of Entity Making
Contribution
6%
❑ CITY HOME LOAN — No attachment required
AmountNalue
Name of Entity Making Contribution
❑ BELOW-MARKET INTEREST RATE LOAN - Calculation showing value of imputed savings using a
market rate of six percent (6%) with a maximum 20 year loan term and a maximum 30 year amortization
attached. IFA shall use the imputed savings value or the principal amount of the loan whichever is the
lesser. IFA will allow the interest to be calculated only on a simple basis (not compounded) when
calculating.
Amount/Value
Market
Interest
Rate
Below-
Market
Interest
Rate
Describe How Calculated
Savings Was Determined
Name of Entity Making
Contribution
6%
City of Dubuque
Agency Name (Typed)
Roy D. Buol
Name of Agency Representative (Typed)
Mayor
Title of Agency, epresentative (Typed)
SIA
Signature of ,agency Representative
2017 Round
November 7, 2016
Date