Demonstration Program for Elderly Housing for Intergenerational Families

Third Party Documentation
Facsimile Transmittal

U. S. Department of Housing
and Urban Development
Office of Department Grants Management
and Oversight

OMB Approval No. 2535-0118 (exp. 5/31/2008)

Public reporting burden for this collection of information is estimated to average 6 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information.
This form is used for third party applicants as required for applications submissions and other materials that are not normally
available as electronic files, e.g. leverage letters, documentation from books, reports or other such items. This 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
IMPORTANT NOTE: If you have completed the SF 424 Request for Federal Assistance form, data fields will be prepopulated within this form.
Item

1. a-d Applicant Information

2. a-c. Catalog of Federal Domestic
Assistance number and title of the
program and program component.

3. a-b. Facsimile Contact Information
4. Name and telephone number
5. Email
6. b-d What are you
transmitting/number of pages?

7. How many pages are being faxed?

Entry

a. Enter legal name of applicant, name of primary organization unit
(including division, if applicable), which will undertake the assistance
activity.
b. Enter the complete address, Street, City, County, State and Zip Code.
c. Enter the country, i.e. USA.
d. Enter the DUNS number (received from DUN and Bradstreet).
a. Enter the Catalog of Federal Domestic Assistance number of the
program you are apply for federal assistance.
b. Enter the title of the program which assistance is requested.
c. Enter program component under which assistance is requested. If
there are no sub categories within a program you may leave “program
component” blank.
(For example: CFDA: 14.123)
a. Enter the name of the Department and/or b. Division in which this
facsimile is being transmitted.
Enter name, email and telephone number (remember to include area code)
of person to be contacted on matters involving the transmitting fax.
Enter email address of person to contact regarding facsimile.
a. What are you transmitting? Check the appropriate box indicating what
type of document you are transmitting, b. certification, c. document, d.
letter, or e. other. For example, if you are transmitting a Memorandum
of Understanding (MOU) this would be considered a document so you
would check
document..
Please note: for each document you are transmitting a separate cover
page is needed.
Indicate how many pages including the cover are being faxed.

Page 1 of 2

form HUD-96011
(8/2005)

Name of Document Transmitted:

1. Applicant Information
a. Legal Name:

b. Address
Street:

City:

County:

State:

Zip Code:

c. Country:

d. DUNS number:

2. Catalog of Federal Domestic Assistance Number:
a. CFDA No.

b. Title (Name of Program)

c. Program Component

3. Facsimile Contact Information
a. Department:

b. Division

4. Name and telephone number of person to be contacted on matters involving this facsimile:
Prefix:

First Name:

Middle Initial:

Phone number (include area code)

Last Name:

Fax number (include area code)

5. Email:

6. What is your transmittal? (Check one box per fax)

7. How many pages (including cover) are being faxed?

b. Certification
c. Document
d. Match/Leverage Letter
e. Other

Clear All

Page 2 of 2

Print

form HUD-96011
(8/2005)