HUD 40110b

OMB Approval No. 2506-0133

H OPWA

Competitive Application &

Renewal of Permanent Supportive Housing Project

Budget Summary

Sponsored by the

U.S. Department of Housing and Urban Development

Office of Community Planning and Development

Office of HIV/AIDS Housing

The information collection requirements pertain to grant application submission requirements which will be used to rate applications, determine eligibility, and establish grant amounts.

Selections of applications for funding under the HOPWA Program are based on the rating factors set forth in the SuperNOFA for Housing and Community Development Programs and the criteria established in the annual HOPWA renewal notice for those permanent supportive housing grantee’s seeking renewal funding.

The public reporting burden for the collection of information for the HOPWA Competitive Application & Renewal of Permanent Supportive Housing Projects Budget Summary is estimated to average 12 hours. This agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless that collection displays a currently valid OMB control number. OMB Approval No. 2506-0133 (Expiration Date: XX/XX/XXXX)

Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties.

(18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)

Application Budget Summary (all applicants)

Applicant Name

     

Number of Project Sponsors

     

Plan dates for grant agreement and activities

      (mo./yr.)

A.	Eligible Activity	HOPWA Request				Leveraged Funds
		A. Year 1	B. Year 2	C. Year 3	D. Total
Facility Development (new applications only)	1. Acquisition	     	     	     	     	     
	2. Rehabilitation, Repair & Conversion	     	     	     	     	     
	3. New Construction (for Community Residences and SRO dwellings only)	     	     	     	     	     
Facility Operations	4. Operating Costs for Housing Facility	     	     	     	     	     
	5. Leasing	     	     	     	     	     
TBRA	6. Tenant-based Rental Assistance	     	     	     	     	     
STRMU	7. Short-term Rent, Mortgage, & Utility Payments to Prevent Homelessness	     	     	     	     	     
Support Services	8. Supportive Services	     	     	     	     	     
Other Program Expenses	9. Housing Information Services	     	     	     	     	     
	10. Permanent Housing Placement	     	     	     	     	     
	11. Resource Identification to Establish, Coordinate & Develop Housing Assistance	     	     	     	     	     
	12. Other Housing Costs (please specify in narrative; requires HUD approval)	     	     	     	     	     
	13. Total Program Costs: (total of lines 1-12)				     
Administrative Expenses	14. Grantee’s Administrative				     
	15. Project Sponsor’s Administrative Costs				     
	16. Total HOPWA Request (total of lines 13-15)				     

Detailed Project Budget & Housing Outputs (each organization)

Name of organization:	     
Type:	Grantee: ; Project Sponsor:	If applicable:	Faith based:	Grassroots:

B.	Eligible Activity		HOPWA Request
			Yr. 1	Yr. 2	Yr. 3	Totals:
Facility Development (new applications only)	1. Acquisition Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
	2. Rehabilitation/Repair/Conversion Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
	3. New Construction (Community Residences & SRO dwellings only) Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
	Type of Facility: Short-term shelter ; transitional housing ; Community residence ; SRO dwelling ; or other permanent supportive housing
Facility Operations	4. Operating Costs for Housing Facility Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
	5. Leasing Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
TBRA STRMU	6. Tenant-Based Rental Assistance Payments Description:      	Budget	     	     	     	     
		# of Households	     	     	     	     
	7. Short-Term Rent, Mortgage & Utility Payments to Prevent Homelessness Description:      	Budget	     	     	     	     
		# of Households	     	     	     	     
Support Services	8. Supportive Services Costs Description:      	Budget	     	     	     	     
		# of Households	     	     	     	     
Other Program Expenses	9. Housing Information Services Description:      	Budget	     	     	     	     
		# of Households	     	     	     	     
	10. Permanent Housing Placement Services Description:      	Budget	     	     	     	     
		# of Households	     	     	     	     
	11. Resource Identification to Establish, Coordinate, & Develop Housing Assistance Description:      	Budget
	12. Other Housing Costs (approved by HUD) Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
Administrative Expenses	13. Grantee's Administrative Costs Description:      	Budget	     	     	     	     
	14. Project Sponsor's Administrative Costs Description:      	Budget	     	     	     	     
	15. Total HOPWA Request for this Organization					     

Note: Service delivery costs such as salary and overhead costs to deliver a particular budget line item should be represented in the funding amount requested for that particular budget line item.

Transparency Act Compliance

Instructions: Charts 1 and Chart 2 below should be completed for the grantee and each project sponsor. Chart 1 should be completed with the general information requested. Chart 2 should be completed for each sub-contractor (other than your project sponsor/s) who receives over $25,000.00 per the Transparency Act of 2006 (Public Law 109-282). If the sub-contractor information requested for Chart 2 is not known at the time of application submission, check the unknown check box. If the project is approved, this information will be collected and reported in the Annual Performance Report (APR).

Grantee: ; Project Sponsor:

Chart 1: General Information
Name and Address of Organization      
City      	State      		Zip      	County      
Congressional District of Organization      			EIN/TIN of Organization*      	Organization’s Website Address      
Parent Company Name and Address (If Applicable)      
Service Area (community, Metropolitan Statistical Area (MSA) or State in which this program is operating)      
City and County of Primary Service Area(s)            		Zip Code of Primary Service Area(s)      			Congressional District of Primary Service Area(s)      

Chart 2: Sub-contractors receiving $25,000 or more (Unknown )
Contract Recipient Business Name Address      
City      	State      		Zip      	County      
Congressional District of Contract Recipient      	NAICS Code*      		EIN/TIN of Organization*      	Organization’s Website Address      
Parent Company Name and Address (If Applicable)      
Service Area (community, Metropolitan Statistical Area (MSA) or State in which this program is operating)      
City and County of Primary Service Area(s)            		Zip Code of Primary Service Area(s)      			Congressional District of Primary Service Area(s)      

*Employer Identification Number or Tax Identification Number

*North American Industry Classification System code

HOPWA Applicant Certifications

The following certified statements are required by law.

The Applicant hereby assures and certifies that:

1. Fair Housing. It will comply with Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d and implementing regulations at 24 CFR part 1; Fair Housing Act, 42 U.S.C. 3601-3619, which state that no person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the applicant receives federal financial assistance. Applicant will immediately take any measures necessary to effectuate this agreement. With reference to the real property and structure(s) thereon which are provided or improved with the aid of federal financial assistance extended to the applicant, this assurance shall obligate the applicant, or in the case of any transfer, the transferee, for the period during which the real property and structure(s) are used for a purpose for which the federal financial assistance is extended or for another purpose involving the provision of similar services or benefits.

(b) It will comply with the Fair Housing Act (42 U.S.C. 3601-19), as amended, and implementing regulations at 24 CFR part 100, which prohibit discrimination in housing on the basis of race, color, religion, sex, handicap, familial status or national origin, and administer its programs and activities relating to housing in a manner to affirmatively further fair housing. For Indian tribes, it will comply with the Indian Civil Rights Act (25 U.S.C. 1301 et seq.), instead of Title VI and the Fair Housing Act and implementing regulations.

(c) It will comply with the Americans with Disabilities Act, 42 U.S.C. 12101 et.seq., and Title IX of the Education Amendments Act of 1972 (20 U.S.C. 1681 et.seq.).

(d) It will comply with Executive Order 11063 on Equal Opportunity in Housing and with implementing regulations at 24 CFR Part 107 which prohibit discrimination because of race, color, creed, sex or national origin in housing and related facilities provided with federal financial assistance.

(e) It will comply with Executive Order 11246 and all regulations pursuant thereto (41 CFR Chapter 60-1), which state that no person shall be discriminated against on the basis of race, color, religion, sex or national origin in all phases of employment during the performance of federal contracts and shall take affirmative action to ensure equal employment opportunity. The applicant will incorporate, or cause to be incorporated, into any contract for construction work as defined in Section 130.5 of HUD regulations the equal opportunity clause required by Section 135.11(e).

(f) It will comply with Section 3 of the Housing and Urban Development Act of 1968, (12 U.S.C. 1701(u)), as amended, and implementing regulations at 24 CFR part 135, which require that to the greatest extent feasible opportunities for training and employment be given to lower-income residents of the project and contracts for work in connection with the project be awarded in substantial part to per-sons residing in the area of the project.

(g) It will comply with Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), as amended, and implementing regulations at 24 CFR part 8, which prohibit discrimination based on handicap in federally-assisted programs and activities.

(h) It will comply with the accessibility requirements of Section 504 of the Rehabilitation Act of 1973, and where applicable, the design and construction requirements of the Fair Housing Act.

(i) It will comply with the Age Discrimination Act of 1975 (42 U.S.C. 6101-6107), as amended, and implementing regulations at 24 CFR part 146, which prohibit discrimination because of age in projects and activities receiving federal financial assistance.

(j) It will comply with Executive Orders 11625, 12432, and 12138, which state that program participants shall take affirmative action to encourage participation by businesses owned and operated by members of minority groups and women.

(k) If potentially eligible persons of particular race, color religion, sex, age, national origin, familial status, or handicap are unlikely to be reached, it will establish additional procedures to ensure that interested per-sons can obtain information concerning the assistance.

2. Environmental Requirements. The grantee, its project sponsors and their contractors may not acquire, rehabilitate, convert, lease, repair, dispose of, demolish, or construct property for a project, or commit or expend HUD or local funds for eligible activities, until the responsible entity (as defined in §58.2) has completed the environmental review procedures required by 24 CFR part 58 and the environmental certification and HUD approval of form HUD-7015.15, “Request for Release of Funds and Certification” (RROF) of compliance with the National Environmental Policy Act and implementing regulations at 24 CFR part 58 (Environmental Review Procedures for Entities Assuming HUD Environmental Responsibilities). HUD will not release grant funds if the recipient or any other party commits grant funds (i.e., incurs any costs or expenditures to be paid or reimbursed with such funds) before the recipient submits and HUD approves its RROF (where such submission is required).

3. HOPWA Facility Use Period Requirement. Any building or structure assisted with amounts under this part will be maintained as a facility to provide assistance for eligible persons: (i) for not less than 10 years in the case of assistance involving new construction, substantial rehabilitation or acquisition of a building or structure; and (ii) for not less than three years in cases involving non-substantial rehabilitation or repair of a building or structure.

4. Client Confidentiality. The grantee and project sponsor must comply with the confidentiality requirements, as mandated by Section 856 of the AIDS Housing Opportunity Act and implemented in HOPWA regulation at 574.440: “The Grantee shall agree, and shall ensure that each project sponsor agrees, to ensure the confidentiality of the name of any assisted under this part and any other information regarding individuals receiving assistance”.

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.
Warning: HUD will refer for prosecution false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012, 31 U.S.C. 3729, 3802)

HOPWA Applicant Certifications

Name with Signature of Authorized Certifying Official & Date

     

Title

     

Name of Applicant

     

20

Insert application package page number ____ Form HUD-40110-B (Expiration Date XX/XX/XXXX)