HUD-92043 Certification for Provision of Supportive Services

CERTIFICATION FOR
PROVISION OF
SUPPORTIVE SERVICES
(Section 811 Only)

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

OMB Approval No. 2502-0462
(exp. 06/30/2002)

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. 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 Supportive Housing for Persons with Disabilities under Section 811. The information is
necessary to assist HUD in determining applicant eligibility and ability to develop housing for persons with disabilities within statutory and
program criteria. 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.

The undersigned certifies that this Agency has reviewed the Sponsor’s supportive services plan and finds that:
1.

The provision of supportive services is:
Well designed

Not well designed

to serve the individual needs of persons with disabilities the housing is expected to serve.
2.

The provision of supportive services will enhance independent living success and promote the dignity of
those who will access the proposed project.
Will enhance

3.

The supportive services will be available on a consistent, long-term basis.
Yes

4.

Will not enhance

No

The proposed housing is:
Consistent

Inconsistent

with State or local plans and policies addressing the housing needs of people with disabilities.

___________________________

____________________________________

Sponsor

Project Location

___________________________________
(Print Name of Authorized Official)

________________________________ __________
(Signature)

(Date)

____________________________________________
(Title)

____________________________________________
(Agency Name)

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form HUD-92043 (3/2002)