HUD 92016 CA Application for Capital Advance Summary Information

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

Supportive Housing for Persons with Disabilities
Section 811

Application for Capital Advance
Summary Information
For HUD HUD Project Number
Use Only

OMB Approval No. 2502-0462
(exp.09/30/2013)

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.
Yes
Is this sponsor a minority applicant?

1a. Sponsor is a "grassroots" organization

Yes

If "Yes," identify by numeric code as shown below ................
Codes: 2 - Black;
3 - Native American
4 - Hispanic;
5 - Asian Pacific
6 - Asian Indian

No

3a. Location of Site (city & State)

No

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.)

Yes
4a. Congressional District

5. Capital Advance
Amount Requested

4b. Census Tract

No

If "Yes," please indicate appropriate number as shown above.

$

6. Project Rental Assistance Contract Amount Requested

7. Application Contains

9a. Occupancy Type

Evidence of Site Control
Identification of Site

$

Note: For a group home(s)in 10. below, include the
number of disabled residents in both the "Total 8. Type of Construction
Units" and the "Total Disabled Residents" categoNew Construction
ries. For an independent living project(s), include
Rehabilitation
Resident Manager unit, if applicable, in the "Total
Acquisition
Units" category.

Physically Disabled
Developmentally Disabled
Chronically Mentally Ill
Mixed Occupancy
Identify Categories
________________________

9b.Restricted Occupancy Requested

Yes
No
If "Yes," identify subcategory
_______________________
_______________________

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
0
1
2 3

Total Disabled
Resident Mgr.
Units
Residents
Unit (Y/N)

Total
Units

Address

Total Disabled
Resident Mgr.
Units
Residents
Unit (Y/N)

Total
Units

Address

#1
#2
#3
#4
c. Condominium
Site

Units by No.
of Bedrooms
0
1
2 3

#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
Sites
Previous editions are obsolete

Mixed Finance or Mixed Use Project for Additional Units
Yes

No
Page 1 of 2

# of Add'l Units _______
form HUD-92016-CA (04/2002)
ref Handbook 4571.2

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

12. Unusual Site Features

None
Cuts
Fill
Erosion

Electric
Water
Heat
Gas
13. Off-Site Facilities:

Public

Poor Drainage
Retaining Walls
Rock Foundations
High Water Table

Other (specify)

14. Community Spaces to be Included inProject: (identified by site no. indicated in 10 above):

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.

Previous editions are obsolete

Page 2 of 2

form HUD-92016-CA (04/2002)
ref Handbook 4571.2