HUD 92045 ALCP Application Summary Sheet

Multifamily Housing Assisted
Living Conversion Program
APPLICATION SUMMARY SHEET

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-0542
(exp. 8/31/2008)

Public reporting burden for this collection of information is estimated to average 2 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. HUD 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 is required for HUD’s Assisted Living Conversion Program (ALCP). This program is
authorized under Section 522(c) of the Appropriations Act of 2000. The information is necessary to assist HUD in
determining applicant eligibility and ability to convert multifamily housing projects designated for the elderly (in whole or
in part) into assisted living facilities. A thorough evaluation of an applicant’s qualifications and capabilities is critical to
protect the Government’s financial interest and to mitigate any possibility of fraud, waste, or mismanagement of public
funds. This collection of information does not collect any sensitive information. HUD does not ensure confidentiality.

Owner (Funds Recipient) Name ___________________________________________________
Address ____________________________________________________________________________
__________________________________________________________________________
City _____________________________ State ____________________ Zip ____________
Phone (Include Area Code) _______________________
Grant Contact Person (Name) ________________________________________
Phone (Include Area Code) _______________________
E-mail address _______________________________________________
List the specific development(s) targeted for assistance under this grant. Use additional sheets as needed.
Development Name ____________________________________________________________
Address ________________________________________________________________________
_______________________________________________________________________
City _____________________________ State ____________________ Zip ____________
FHA/Project Number _______________________________ Sec.8 Number _______________
Project Type (e.g., 236) ______________________________ No. of Units ______________
Location (Urban, suburban, or rural) ______________________________________________
Number of Residents __________ Estimated Number of Frail Elderly __________
Estimated Number of Non-elderly People with Disabilities ___________
Estimated Number of At-risk Elderly __________
Are you applying for a Service Coordinator Grant? _____ Yes
_____ No
Will this development share a service coordinator with other developments? _____ Yes
If yes, please give name and address of the development(s) if different.

_____ No

________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
Senators 1. ________________________________ 2. _______________________
Congressional Representative(s) Name(s) 1. _______________________ District(s) 1. _________________
2. _______________________
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2. _________________
form HUD-92045 (3/2002)