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.