ROSS FY 2004 FUNDING
Certification of Election of Resident Council Board 

Public reporting burden for the collection of information is estimated to average one hour 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. 

Instructions for completing this form:  Resident organizations applying to the ROSS program must certify that the Board of their Resident Council has been duly elected as required by HUD (24 CFR Part 964. All resident organizations applying to the ROSS program must complete this form and have it signed by an authorized official from the local PHA.

Applicant: __________________________			

Certification of Election of Resident Council Board 

I CERTIFY  											
			(name of organization)

located in 								  has duly elected all
			(city & state)

of our Resident Council Officers as required by the U.S. Department  of Housing and Urban Development, 24 Code of Federal Regulations (CFR), Part 964.

Date of Most Recent Resident Council Board Election: 						

Name and Position of Resident Council officers:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

The above information is true and correct to the best of my knowledge.  

Signed this ____________________ day of ______________________, 2004.

By: ____________________________________________________________
	Housing Auhority Executive Director or Other Authorized Representative

For: ____________________________________________________________
	(Housing Authority Name, Address, and Telephone)