52767 PHA FSS Request Form

Public Housing Family
U.S. Department of Housing
Self-Sufficiency Funding
and Urban Development
Request Form
Office of Indian and Public Housing

OMB Approval No 2577-0229
(Expires: 02/28/2007)

Public reporting burden for the collection of information is estimated to average 4 hours per response. This
includes the time for collecting, reviewing, and reporting the data. The information will be used for the ROSS
grant. Response to this request for information is required in order to receive the benefits to be derived. 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.
1. PHA Information:

Name: ____________________________________ PHA Number: ____________________
Address: ____________________________________________________________________
____________________________________________________________________________
Joint Application: Yes _____ No _____ If yes, please provide name(s), PHA number(s), and address
information of joint applicant(s) (If more than one joint applicant, please attach addition sheets as
necessary):
Name: ____________________________________ PHA Number: ____________________
Address: ____________________________________________________________________
____________________________________________________________________________

2. Contact Information for the Person Most Familiar with This Application:
Name:______________________________Telephone:________________________________
e-mail address: _____________________________

3. Application Type: New ________

Renewal ________

4. All Applicants – Total Approved Slots: Please indicate the number of approved slots in your Public
Housing FSS Action Plan. There is a 25-slot minimum in order to be eligible for this program. Joint
applicants should indicate the combined total of FSS program slots in their HUD-approved Public Housing
FSS Action Plans.
Total number of approved slots: ________
5. Most Recent PHAS Rating:

High Performer ____________
Standard Performer _____________
Troubled _____________

6. Funding Category for this Application: 1

2 3 4

RENEWAL APPLICANTS PLEASE ANSWER QUESTIONS 7 - 9
7. FSS Coordinator Information:
a) FY under which your FSS Coordinator position was last funded: ________
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form HUD-52767
(12/2005)

b) Number of positions funded: ________
c) Number of positions requested under this NOFA: ________
d) Annual salary requested for each FSS Coordinator(s) (Please list all.): $ _________________________
(Note: The salary requested should include fringe benefits, if applicable. Salaries must be comparable to
salaries for similar positions in the local jurisdiction and must not exceed the cap referred to in the NOFA.)
e) Total funding requested for program coordinator salary(ies): $ ________
f) Evidence demonstrating salary comparability to similar positions in the local jurisdiction for each of the
positions you are applying for is on file at the PHA: _____ Yes _____ No
8. Reporting to HUD
The PHA has submitted reports on participating families to HUD via the HUD 50058 Family SelfSufficiency/Welfare-to-Work Voucher Addendum. _____ Yes _____ No
9. Program Accomplishments –
a.____ Number of years your program has been in existence.
b.____ The total number of PH FSS participants (The total number of families shown in HUD’s PIC data
system as enrolled in the applicant’s PH FSS program on the publication date of this NOFA, plus the
number of families that successfully completed their PH FSS contracts in the applicant’s program
between October 1, 2000, and the publication date of this NOFA.)
c._____The number of Public Housing FSS program participants with an FSS escrow account balance
greater than zero.
d.____ The percent of Public Housing FSS program participants with an FSS escrow account balance
greater than zero (Positive Escrow Percentage – see NOFA for definition) (calculate by dividing
c/b).
e.______The average escrow account distribution paid to Public Housing families that have graduated since
October 1, 2000.
f.____ The number of Public Housing FSS families that have successfully completed their FSS contracts
since October 1, 2000.
g.____ The percent of Public Housing FSS families that have successfully completed their FSS contracts
(Graduation Percentage – see NOFA for definition) (calculate by dividing f/b).
h.____ The number of Public Housing FSS graduates since October 1, 2000 that moved out of public
housing.
i.____ The number of Public Housing FSS graduates since October 1, 2000 who moved to homeownership
through a ROSS-funded homeownership program.
j.____ The number of Public Housing FSS graduates since October 1, 2000 who moved to homeownership
through other homeownership programs.
NEW APPLICANTS PLEASE ANSWER QUESTIONS 10 - 11
10. FSS Coordinator Information:
a) Annual salary requested for the FSS Coordinator position: $ ________
(Note: The salary requested should include fringe benefits, if applicable. Salaries must be comparable to
salaries for similar positions in the local jurisdiction and must not exceed the cap referred to in the NOFA)
b) Evidence demonstrating salary comparability to similar positions in the local jurisdiction for each of the
positions you are applying for is on file at the PHA: _____ Yes _____ No
11. Information About Potential Participants
Percent of target population that is unemployed ________
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form HUD-52767
(12/2005)