HUD 92016 CA Application for Capital Advance Summary Information

Supportive Housing for Persons with Disabilities Section 811 Application for Capital Advance Summary Information

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

OMB Approval No. 2502-0462 (exp.12/31/2003)

For HUD Use Only

HUD Project Number

PRAC Number

1. Name(s) Address(es), Contact Person, and Telephone Number(s) of Sponsor(s)

2.

Minority Sponsor Designation: A minority sponsor is one in which at least

51 percent of the board members are minority.

Is this sponsor a minority applicant?

Yes

No

Ethnicity (select only one)

Hispanic or Latino

Not Hispanic or Latino

Race (select one or more)

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

1a. Sponsor is a “grassroots” organization

Yes

No

White

3a. Location of site (city and state)

3b.

Will project be located within the boundaries of a Federally-designated: (1) Empowerment Zone, (2) Enterprise Community, (3) Urban Enhanced Enterprise Community, (4) Strategic Planning Community, or (5) Renewal Community? (Contact local HUD Office for information on these designated areas.)

4a. Congressional District

5.

Capital Advance Amount Requested

Yes

No

If “Yes,” please indicate appropriate number as shown above.

4b. Census Tract

$

6. Project Rental Assistance Contract Amount Requested

7.

Application Contains

9a.

Occupancy Type

9b.

Restricted Occupancy Requested

$

Evidence of Site Control

Physically Disabled

Yes

Note: For a group home(s) in 10. below, include the number of disabled residents in both the “Total Units” and the “Total Disabled Residents” categories. For an independent living project(s), include Resident Manager unit, if applicable, in the “Total Units” category.

Identification of Site

Developmentally Disabled

No

8.

Type of Construction

Chronically Mentally Ill

If “Yes,” identify subcategory.

New Construction

Mixed Occupancy

Rehabilitation

Identify Categories

Acquisition

10. Project Type & Number of Units/Residents Proposed

a. Group Home

Site

No. of Disabled Residents

Resident Mgr. Unit (Y/N)

Address

#1

#2

#3

#4

b. Independent Living Project

Site

Units by No. of Bedrooms

Total Disabled

Address

0

1

2

3

Units

Residents

#1

#2

#3

#4

c. Condominium

Site

Units by No. of Bedrooms

Total Disabled

Address

0

1

2

3

Units

Residents

#1

#2

#3

#4

Note: If an elevator structure in b or c above, indicate by placing an "E" next to the total number of units for each applicable site.

Totals

Units (Section 811)

Disabled Residents

Mixed Finance or Mixed Use Project for Additional Units

Sites

Yes

No

# of Add’l Units

11.

Check utilities and services not included in the rent and to be paid directly by the tenant

12.

Unusual Site Features

None

Poor Drainage

Other (specify)

Electric

Cuts

Retaining Walls

Water

Fill

Rock Foundations

Heat

Erosion

High Water Table

Gas

13.

Off-Site Facilities:

14.

Community Spaces to be included in Project: (identified by site no. indicated I 10 above):

Public

At Site

Ft. from Site

Water

Sewer

Paving

Gas

Electric

15.

If Sponsor is applying for more than one HUD program from the SuperNOFA, indicate which application(s) contain the forms with original signatures.

Program Name

Form

16.

Name, Address and Telephone Number of (mark one box)

Consultant

Agent

Authorized Representative

17.

Sponsor’s Attorney (name, address and telephone number)

By

(signature of sponsor’s authorized representative)

Type in Name

Title

Public reporting burden for this collection of information is estimated to average 46 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 is in support of HUD's efforts to expand the supply of Supportive Housing for Persons with Disabilities under Section 811. The information is necessary to assist HUD to determine applicant eligibility and ability to develop housing for disabled with 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 application does not collect any sensitive information. HUD does not ensure confidentiality.

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