Form 4123 a 4123 a Cost Summary

Cost Summary

Native American Housing Block Grant
(NAHBG)

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

OMB Approval No.
(exp. )

See Instructions and Public Reporting Statement on back.
1. Name of Applicant (as shown in Item 5, Standard Form 424)

3.

4.

Original

(check here if this is the
first submission to HUD)

Revision

(check here if submitted
with implementation schedule
as part of pre-award requirements

2. Application/Grant Number (to be assigned by HUD upon submission)

Amendment

(check here if submitted
after HUD approval of grant)

Project Name & Project Category
(see instructions on back)

a

Program Funds (in thousands of $ )

NAHBG

Amount Requested
for each activity

b

$

5.

Date (mm/dd/yyyy)

Other

Other Source Amount
for each activity

Source of Other Funds
for each activity

c

d

$

Administration and Planning
a. General Management and Oversight
b. Indirect Costs: Enter indirect costs to be charged to the
program pursuant to a cost allocation plan.
c. Audit: Enter estimated cost of Program share of A-133 audits.

Administration Total *

6. Sub Total Enter totals of columns b. and c.

0.00

$

0.00

0.00

$

0.00
$

7. Grand Total Enter sum of column b. plus column c.

0.00

* The total of item 5 cannot exceed 20% of the total NAHBG funds requested.

Previous editions are obsolete

Page 1 of 2

form HUD-4123A

Public reporting burden for this collection of information is estimated to average 40 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 collection of information requires that each eligible applicant submit information to enable HUD to select the best projects for funding during the
Recovery Act competitions for the NAHBG Program. The information will be used by HUD to determine whether applications meet minimum screening
eligibility requirements and application submission requirements. Applicants provide general information about the project which is preliminary to the
review of the applicant’s response to the criteria for rating the application. The information is essential for HUD in monitoring grants to ensure that
grantees are making proper use of Federal dollars. Responses to the collection are required by Section 105 of the Department of Housing and Urban
Development Reform Act (P.L. 101-235) as amended by the Cranston-Gonzales National Affordable Housing Act of l990.
The information requested does not lend tself to confidentiality.

Instructions for Item 4.
Project Name and Project Type
Participants enter the project name and the name of one of the
following two categories of activities:
• Housing Construction
• Housing Rehabilitation
Also enter the component name if applicable. Use a separate
Cost Summary sheet (form HUD-4123A) for each project
included in the application.

Infrastructure Component for Rehabilitation
or Construction for Affordable Housing

•
•
•
•

Water
Sewer
Roads and Streets
Storm Sewers

Examples of categories and/or components included, but are not
limited to, the examples of eligible activities listed below.
Housing Construction Component

• New Construction
• Acquisition
Housing Rehabilitation Component

• Rehabilitation
• Demolition
• Energy Efficiency and Conservation

Previous editions are obsolete

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form HUD-4123A