| Housing Site Decription |
| (A Housing Site Description is required for each property) |
| YouthBuild (YB) GRANT |
| ATTACHMENT 1A |
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OMB No. |
1205-0464 |
| ETA-9143 |
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Expires: |
10/31/2010 |
| APPLICANT IDENTIFYING INFORMATION (Complete All Sections) |
| Applicant Name: |
| Program/Project Name & Address: |
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| 1. Housing Site Identification (Address/Parcel #)) |
| 2. Number of Housing Units Planned to be Produced: |
| 3. Type of housing to be produced (Check all that apply) |
| ¨ Residential/rental ¨ Homeownership ¨ Transitional housing for the homeless |
| 4. Homeless Housing: For housing that will be transitional housing for the homeless, attach a description of the plan for outreach and placement of homeless families or individuals (1 page). Please label this narrative Exhibit 1B |
| 5. Will all housing produced be provided for homeless, low-income, or very-low income persons? |
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| ¨ Yes ¨ No |
| 5. a. If no for question 5, please explain what other populations will be targeted and why? |
| 6. The on-site training site consists of (Check all that apply) : ¨ New Construction ¨ Rehabilitation |
| 7. Are any of the units currently occupied? ¨ Yes ¨ No (If yes, attach a relocation narrative that identifies the number of persons, the business or others occupying the property on the date of submission of this application, the number of displaced, the number to be temporarily relocated but not displaced, the estimated cost of relocation services payments and services, the source of funds for relocation, and the organization that will provide relocation assistance to occupants and the contact person's name and phone number. Label this attachment as Exhibit 1C.) |
| 8. Name of the current owner: |
| 9. Documentation of Access: Attach required evidence of site access (Letter from the owner identified in No. 8). Label this attachment Exhibit 1D. |
| 10. Individual Housing Project Site Estimate and Documentation of Resources: Complete the attached Exhibit 1E for each housing project site to be used in conjunction with the YouthBuild implementation program. Attach documentation of resources behind each Exhibit 1E. |
| 11. Describe the applicant role and responsibilities for the on-site housing construction or rehabilitation work. Label this description Exhibit 1F. |
| 12. Name of entity which will own and manage the property after the construction or rehabilitation work is completed: |
| 13. A Model Lease is Attached ¨ Yes ¨ No |
OMB No.: xxxx-xxxx OMB Expiration Date: xx/xx/xxxx OMB Burden Hours: 30 minutes OMB Burden Statement: This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0455. Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of information is estimated to average xx hours per _______ per grantee, including time for reviewing instructions, searching existing data sources, gathering and reviewing the collection of information. Respondent’s obligation to reply to this collection of information, which is for general program oversight, evaluation, and performance assessment, is required to maintain benefits [PL 109-281 Sec 173(A)(c)(3)]. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden, to the U. S. Department of Labor, Employment and Training Administration, Youth Office, Room N4459, 200 Constitution Avenue, NW, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0455).
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| Signature of Authorized Certifying Official of: _______ Applicant _____ Rightful Owner |
| Title: __________________________________________________ Date: _____________ |
| Organization: ______________________________________________________________ |