HUD 52769 ROSS SERVICE COORDINATORS � NEEDS and SERVICE PARTNERS

OMB Approval No. 2577-0229

Expiration Date pending

U.S. DEPARTMENT OF HOUSING

AND URBAN DEVELOPMENT

OFFICE OF PUBLIC AND INDIAN HOUSING

ROSS SERVICE COORDINATORS – NEEDS and SERVICE PARTNERS

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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. This information will allow HUD to determine eligibility for the ROSS SC Program. This information does not lend itself to confidentiality.

***Please read NOFA carefully for directions and minimum requirements.***

Name of Applicant ________________________

PHA/Tribe/TDHE(s) to be Served (Name and PHA/IHA/TDHE or Tribal Locality Code) _______________________________________

NEEDS	NEED? YES/NO	SERVICE PROVIDER/PARTNER(s) (list all)	$$ In-Kind for life of grant (if committed)
Life Skills Training
Financial Literacy/Credit Counseling/Credit Repair
Literacy Training
ESL
GED/High School Equiv.
Mentoring
Job Soft Skills Training
Job Hard Skills Training/Certification
Job Search and Placement
Job Retention/Promotion
ISAs
Homeownership Counseling
Computer Classes
Drug/Alcohol Treatment
Mental Health Treatment
Health/Dental Care
Home Maintenance classes
Parenting classes
Nutrition classes
Youth Programming – tutoring/mentoring/after school/summer
Child Care
Transportation
Tax Preparation Assistance
Community Safety
Resident Empowerment/Capacity Building
Resident Business Development
Assistance with Activities of Daily Living
Meals to meet nutritional need for Elderly
Disability Services Counseling
Personal Emergency Response Resources
Wellness Programs
Other (please describe)
Other
Other
Other
Other
		TOTAL	$

I _______________________________, attest that the in-kind match recorded here is supported by letters from community or other partners and that the letters attesting to this amount of match funding (cash or in-kind) are on file.

Total Grant Requested $___________

Total Match Documented $____________

Match is _________ % of Grant Requested (must be at least 25% to qualify)

___________________________________ Authorized Signer

___________________________________ Title

Form HUD-52769 (12/2007)