Hud 965 Regional Partnership Certification Statement

OMB Approval No. 2529-0050

Expiration Date:

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

OFFICE OF FAIR HOUSING AND EQUAL OPPORTUNITY

SECTION 3 COORDINATION AND IMPLEMENTATION NOFA

REGIONAL PARTNERSHIP CERTIFICATION STATEMENT

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Public reporting burden for the collection of information is estimated to average two hours per response. This includes the time for collecting, reviewing, and reporting the data. The information will be used for determining eligibility for the Section 3 Coordination and Implementation NOFA. Response to this request for information is required in order to receive the benefits to be derived. 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 information does not lend itself to confidentiality.

Instructions: Part I: The primary applicant for funds must provide contact information for their agency and identify the specific geographic area/community that the Section 3 Coordinator will serve, if selected for funding under the Section 3 Coordination and Implementation NOFA. The primary applicant’s authorized representative must sign the certification statement. Part II.: The applicant’s regional partner(s) must provide contact information for their agency and the authorized representative must sign and date the certification statement. Additional copies of this page may be added depending on the number of regional partners. Part III.: Department of Labor Workforce Investment Boards or One-Stop Career Centers that are entering into partnerships with the primary applicant must provide contact information for their agency and the authorized representative must sign and date the certification statement.

1. PRIMARY APPLICANT CERTIFICATION STATEMENT

Primary Applicant/Agency Name: __________________________________________________________

Primary Applicant/Agency Address: ________________________________________________________

City/State: ___________________________________________________________________________

Zip Code + 4: ____ ____ ____ ____ ____ + ____ ____ ____ ____

Geographic Area/Community to be Served: ___________________________________________

I ________________________________________, certify as the primary applicant of funds under this NOFA, that my agency will enter into a regional partnership with the agency(ies) listed in Part II. and III. of this form, to ensure that the Section 3 Coordinator funded under this NOFA will carry out activities to meet the regulatory requirements of Section 3 of the Housing and Urban Development Act of 1968 within the entire geographic area/community where the applicant and regional partner(s) are located. If selected for funding under this NOFA, my agency will provide evidence to support this statement, as requested.

________________________________________________ ___________________________

Signature of Authorized Representative Date

_______________________________________________________________________________________

Title

2. REGIONAL PARTNER(S) CERTIFICATION STATEMENT^*

1. Regional Partner

(Agency Name):________________________________________________________________

Mailing Address: ________________________________________________________

City/State: ____________________________________________________________________

Zip Code + 4: ____ ____ ____ ____ ____ + ____ ____ ____ ____

I ________________________________________, certify as a regional partner of an applicant for funds under this NOFA that my agency will enter into a partnership with the applicant, listed in Part I of this form, to ensure that the Section 3 Coordinator funded under this NOFA will carry out regional activities to meet the regulatory requirements of Section 3 of the Housing and Urban Development Act of 1968 within the entire geographic area/community where our agencies are located. If the primary applicant is selected for funding under this NOFA, my agency will provide evidence to support this statement, as requested by HUD.

_______________________________________________ ___________________________

Signature of Authorized Representative Date

_________________________________________________________________________________

Print/Type Name and Title of Authorized Representative

2. Regional Partner

(Agency Name):________________________________________________________________

Mailing Address: ________________________________________________________

City/State: ____________________________________________________________________

Zip Code + 4: ____ ____ ____ ____ ____ + ____ ____ ____ ____

I ________________________________________, certify as a regional partner of an applicant for funds under this NOFA that my agency will enter into a partnership with the applicant, listed in Part I of this form, to ensure that the Section 3 Coordinator funded under this NOFA will carry out regional activities to meet the regulatory requirements of Section 3 of the Housing and Urban Development Act of 1968 within the entire geographic area/community where our agencies are located. If the primary applicant is selected for funding under this NOFA, my agency will provide evidence to support this statement, as requested by HUD.

_______________________________________________ ___________________________

Signature of Authorized Representative Date

___________________________________________________________________________________

Print/Type Name and Title of Authorized Representative

3. WORKFORCE INVESTMENT BOARD/ONE-STOP CAREER CENTER PARTNERSHIP CERTIFICATION

Workforce Investment Board

One-Stop Career Center Name: _______________________________________________________

Mailing Address: ________________________________________________________________________

City/State: ___________________________________________________________________________

Zip Code + 4: ____ ____ ____ ____ ____ + ____ ____ ____ ____

I ________________________________________, certify that the Department of Labor Workforce Investment Board/One-Stop Career Center will enter into a partnership with the primary applicant and/or regional applicant(s) for funds under the Section 3 Implementation and Coordination NOFA, to ensure that employment and training opportunities are provided to low- and very low-income residents of the geographic area/community where our agencies are located, and to the businesses that are either owned by or substantially employed by these persons. If the primary applicant agency is selected for funding under this NOFA, my agency will be required to submit evidence to support this statement.

_______________________________________________ ___________________________

Signature of Authorized Representative Date

_________________________________________________________________________________

Print/Type Name and Title of Authorized Representative

** Additional copies of this page may be inserted depending on the number of regional applicants.

Form HUD-965