HUD-52768 Ross Service Coordinators- Funding Request

OMB Approval No. 2577-0229

Expiration Date 3/31/11

U.S. DEPARTMENT OF HOUSING

AND URBAN DEVELOPMENT

OFFICE OF PUBLIC AND INDIAN HOUSING

ROSS SERVICE COORDINATORS – FUNDING REQUEST

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Public reporting burden for the collection of information is estimated to average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The information will be used for the ROSS grant. 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 will allow HUD to determine eligibility for the ROSS SC Program. This information does not lend itself to confidentiality.

***Please read NOFA carefully for directions and minimum requirements.***

Name of Applicant ________________________

Joint Applicant (if applicable) _________________________________

Name of PHA/Tribe/TDHE(s) to be Served _________________________________________________

PHA Code(s) to be served (Not applicable to tribes/TDHEs) _________________________________________________

Total Number of ACC Units/Formula Currently Assisted Stock in PHA/Tribe ______________

EDSC

PHA applicants: Are you currently eligible to receive funding for one or more Elderly/Disabled Service Coordinators (EDSC) through the Operating Subsidy? (NOT ROSS-Elderly/Persons with Disabilities) YES ___ NO ___

If YES and you request and are granted an SC to serve Elderly Residents through this NOFA, you will forgo any future EDSC Renewal funding.

RA Applicant? YES ___NO ___ (State and National Resident Associations applying as non-profits should check YES)

Non-Profit Applicant? YES ____ NO _______

If Yes, check all that apply:

Faith-based ____

Community-based ____  

Other _____

Do you (the applicant) have a current ROSS-SC grant? YES ____ NO ____

Are you applying to serve ONLY projects that are NOT served by current ROSS-SC grant(s)? YES ___ NO ___

Service Coordinators (SCs) Requested

SC Position Requested	Project(s) to be served (See NOFA for instructions) (if different PHAs, list PHA as well)	Number of Units to be Served by this SC (See NOFA for minimum)	SC will serve Family, Elderly or Both?	Year	Salary/Fringe (See NOFA for limits)	Admin (See NOFA for limits)	Training (See NOFA for limits)
1				1	$	$	$
				2	$	$	$
				3	$	$	$
2				1	$	$	$
				2	$	$	$
				3	$	$	$
3				1	$	$	$
				2	$	$	$
				3	$	$	$
				TOTAL	$	$	$
TOTAL GRANT REQUESTED $ _________________

For each SC position requested, fill in one large row.

Form HUD-52768 (3/2009)