HUD 96012 Capacity of the Applicant and Relevant Organizational Ex

Healthy Homes and
Lead Hazard Programs

U.S. Department of Housing
and Urban Development

OMB Approval No. 2539-0015
(expires 11/30/2008)

Office of Lead Hazard Control
Factor 1

Capacity Of The Applicant And Relevant Organizational Experience

Public reporting burden for this collection of information is estimated to average 17 hours. This includes the time for collecting, reviewing, and reporting the data.
This information collection is collected during the application process and is used to select grantees under a competitive selection process. Section 1011 of Title
X of the Housing and Community Development Act of 1992 authorizes this collection. 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.

A. Key Personnel
Name and Position Title (please include the organization position
titles in addition to those shown). Resumes or position descriptions
are to be included in appendix.

Percent of Time
Proposed for this
Grant
(HUD Funded or InKind)

Percent of Time to
be spent on other
LHC HUD grants

Percent of Time to be
spent on other Activities

Note: These three columns should total 100%
A.1 Overall Project Director
Name:
Organization Position Title:
Phone Number:
Fax Number:
Email:
A.2 Day-to-Day Program Manager
Name:
Organization Position Title:
Phone Number:
Fax Number:
Email:
A.3 Other
Name:
Organization Position Title:
Phone Number:
Fax Number:
Email:

To be hired

On staff

To be hired

On staff

B. Partners
Name of the organization or entity that partners or will partner with
applicant and if partner will be subgrantee/subrecipient

Description of
Commitment
and Status

Proposed Activities To Be
Conducted by Partner

Amount of
HUD Grant
Funds
(If Subgrant)

B.1 Name:
Type of Organization
Subgrantee/Subrecipient:
Current Partner
B.2 Name:
Type of Organization
Subgrantee/Subrecipient:
Current Partner
B.3 Name:
Type of Organization
Subgrantee/Subrecipient:
Current Partner
B.4 Name:
Type of Organization
Subgrantee/Subrecipient:
Current Partner
B.5 Name:
Type of Organization
Subgrantee/Subrecipient:
Current Partner
B.6 Name:
Type of Organization
Subgrantee/Subrecipient:
Current Partner
B.7 Name:
Type of Organization
Subgrantee/Subrecipient:
Current Partner

Yes
No
Partnership to be developed

Yes
No
Partnership to be developed

Yes
No
Partnership to be developed

Yes
No
Partnership to be developed

Yes
No
Partnership to be developed

Yes
No
Partnership to be developed

Yes
No
Partnership to be developed

Definitions:
Partner Name: Name of organization or entity that will partner with applicant in conducting program activities.
Type of Organization or Program: Health, Housing, Environmental, Community Development Department, Planning Department,
Grassroots Faith-Based or Community-Based Organization, Childhood Lead Poisoning Prevention Program, Financial Institution, Job
Training and Economic Opportunity Organization, etc.
Description of Commitment: Memorandum of Understanding/Agreement, Contract, Subgrantees, Letter, etc.
Proposed Activities to be Conducted by Partner: The type of activities that will be conducted by the grant partner in support of program
efforts (i.e. rehabilitation, testing, training, education and outreach, specification writing, relocation, etc.)
Amount of HUD Grant Funds if Subgrantee/Subrecipient: The dollar amount subgrantee/subrecipient will be receiving for the services
they will provide.

Clear All

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form HUD-96012
(2/2005)