Form 92015-CA HUD-92015-CA

OMB Approval No. 2502-0267
(exp. 11/30/2004)

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

Supportive Housing for the Elderly Section 202

Application for Capital Advance
Summary Information

Public reporting burden for this collection of information is estimated to average 30 minutes 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 information. This agency may
not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
This information collection is necessary to assist HUD in determining applicant eligibility and ability to develop housing for the elderly within statutory and
program criteria. A thorough evaluation of an applicant’s qualifications and capabilities is critical to protect the Government’s financial interest and to mitigate any possibility of fraud, waste, or mismanagement of public funds. This information collection is considered non-sensitive and no assurance of confidentiality is provided.
HUD
202 Project Number
PRAC Number
Use Only
2. Minority Sponsor Designation. A minority sponsor is one in which at least
51 percent of the board members are minority.
Is this sponsor a minority applicant?
Yes
No

1. Sponsor's Name(s), Address(es) & Telephone Number (s)

1a. Sponsor is a "grassroots" organization

Yes

If "Yes," place the numeric code as shown below in this box
Codes: 2 - Black; 3 - Native American; 4 - Hispanic;
5 - Asian Pacific; 6 - Asian Indian

No

Please refer to the General Section of the SuperNOFA, as published in the
Federal Register for the current fiscal year
3a. Address of Site
3b.Will project be located within the boundaries of a Federally-designated: (1) Empowerment
Zone, (2) Enterprise Community, (3) Urban Enhanced Enterprise Community, (4) Strategic
Planning Community, or (5) Renewal Community?
(Contact local HUD Office for information on these designated areas.)
Yes

No

If "Yes," please place the appropriate number as shown above in this box
4a. Congressional District

5. Type of Area

6. Capital Advance Amount Requested

Metropolitan
Non-metropolitan

4b. Census Tract
8. Total No. of

8a. Number & Type of Resident Units Proposed

Efficiency

202 Units

$

$

8b. Resident Manager's Unit (check appropriate type)

One bedroom

9. Number of Buildings 10. Type of Project

Efficiency

Year Built (yyyy)

13. Number of Parking Spaces

Row/Townhouse
Walk-up
Elevator

Public

Water

Heat

16a. Community Spaces to be included in Project

At Site

Feet from Site

Water
Sewer
Paving
Gas
Electric

Semi-detached
Detached

Gas
16b. Mixed-Finance or Mixed-Use Project
For Additional Units
Yes

No

No. of Additional Units __________

17. Unusual Site Features

None
Cuts
Fill
Erosion
Other (specify)

Two bedroom

14. Check utilities and services not included in the rent and to be paid directly by the tenant.

Electric
15. Off-Site Facilities

One bedroom

11. Type of Building(s)

New Construction
Rehabilitation
Acquisition
12. Number of Stories

7. Project Rental Assistance Contract
Amount Requested

18. Mark one box

Poor Drainage
Retaining Walls
Rock Foundations
High Water Table

Name, Address & Telephone Number

Consultant
Agent
Authorized
Representative

19. If Sponsor is applying for more than one HUD program from the SuperNOFA, indicate which application(s) contain the forms with original signatures.
Program Name
Form
___________________________________________________________________________________________
___________________________
___________________________________________________________________________________________
___________________________
___________________________________________________________________________________________
___________________________
20. Sponsor's Attorney (name, address & telephone number)

By (Signature of Sponsor's Authorized Representative)

Type in Name

Date (mm/dd/yyyy)

Type in Title

Previous editions are obsolete

form HUD-92015-CA (06/2004)
ref: Handbook 4571.3 Rev-1