HUD-52651 Family Self-Sufficiency (FSS) Program Coordinator Fundin

Family Self-Sufficiency (FSS) Program Coordinator Funding

U.S. Department of Housing and Urban Development Office of Public and Indian Housing

OMB Number: 2577-0178 Expiration Date: xx/xx/20xx

This collection of information is estimated to average .5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of the requested information. Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to: U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, R, 451 7th St SW, Room 8210, Washington, DC 20410-5000. Do not send completed forms to this address. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid OMB control number. This agency is authorized to collect this information under Section 102 of the Department of Housing and Urban Development Reform Act of 1989. The information you provide will enable HUD to carry out its responsibilities under this Act and ensure greater accountability and integrity in the provision of certain types of assistance administered by HUD. This information is required to obtain the benefit sought in the grant program. Failure to provide any required information may delay the processing of your application and may result in sanctions and penalties including the administrative and civil money penalties specified under 24 CFR §4.38. This information will not be held confidential and may be made available to the public in accordance with the Freedom of Information Act (5 U.S.C. §552). The information contained on the form is not retrieved by a personal identifier, therefore it does not meet the threshold for a Privacy Act Statement.

1. Are you a Public Housing Agency (PHA) or Multifamily Owner (MF)? PHA ___ MF ___

Multifamily Owner is the legal entity that owns a Project-Based Rental Assistance (PBRA) Property.

NOTE: Multifamily Owner does NOT include Management Agents or General / Limited Partners.

2. Are you applying as a Renewal Applicant or New Applicant? Renewal ­­­___ New ___

Renewal Applicant: If you are currently or were funded in at least one of the TWO years before now.

New Applicant: If you were last funded THREE or more years ago, or were never funded before.

3. If you are a Renewal Applicant, number of Total Positions requested (All New Applicants = 1) ___

3b. Is this MORE than the number of Renewal Positions you were LAST funded for? No ___ Yes ___

3c. If YES, the number of Additional Positions requested (ONLY if eligible and NOT guaranteed)? ___

4. Please list YOUR information as the Lead Applicant on Line 1.

On Lines 2–10+, please identify ALL Joint Applicants (PHA & MF) that you will serve.

#	PHA or MF?	PHA or MF Owner Name	Unique Entity Identifier (UEI)	PHA # or MF Contract #	PHA Main or MF Property Zip Code	MF Property Name (PHA leave blank)
1
2
3
4
5
6
7
8
9
10+	Please use #5 below for additional entries

5. Please use this space to enter any additional information requested in the FSS Funding Notice.

NOTE: The FSS Notice supplements this set of instructions. Please read the FSS Notice carefully to ensure that you are following all instructions in completing this form.

HUD Form-52651