HUD-52651 Housing Choice Voucher (HCV)/Public Housing (PH) Family

Public reporting burden for this collection of information is estimated to average 0.75 hours. This includes the time for collecting, reviewing, and
reporting the data. Information provided is to determine the eligibility of the applicant for funding for the salary of a program coordinator. HUD
uses the information to determine eligibility of the applicant to receive funding. Information is required to obtain benefit under 24 CFR
982.302(b). The information is subject to the confidentiality requirements of the HUD Reform Legislation. 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.

PART I: General Information.

(To be completed by all applicants.)

Applicant Category:
PHAs Not Currently administering FSS
PHAs Currently administering FSS

Moving-to-Work
PHA?
Yes
No

DUNS Number of Applicant:

Funding Request
for Fiscal Year:

State or Regional
PHA?
Yes
No
A.

PHA Legal Name (For joint applicants, lead PHA name):
Address:
City:
County:
State:
Zip Code:
PHA Number of Applicant:

B.

Legal Name of Joint Applicant PHA. (If applicable.)
Address:
City:
County:
State:
Zip Code:
PHA Number of Applicant:

Legal Name of Joint Applicant PHA. (If applicable.)
Address:
City:
County:
State:
Zip Code:
PHA Number of Applicant:

Legal Name of Joint Applicant PHA. (If applicable.)
Address:
City:
County:
State:
Zip Code:
PHA Number of Applicant:
PHA Number of Applicant:

List any additional co-applicants on page 4
C.

Evidence demonstrating salary comparability to similar positions in the local jurisdiction for each
position requested is on file at the PHA.

D.

Contact information person most familiar with application:
Name:

Yes

Telephone Number;

Email Address:

Page 1 of 4

form HUD-52651
(12/2011)

No

PART II: Funding/Positions Requested by PHAs that are Currently Administering
HCV/FSS Programs
A.

Previously Funded Positions
FY Last Funded

B.

Salary Amount
Last Funded

Salary Requested
Per Position **
under this NOFA

Number of
Positions at salary
level

Is applicants
request above
percentage allowed
in the NOFA?
‘Y’ or ‘N’ ***

New Positions –Total salary requested per position including fringe benefits, if applicable. If more than one
position, list each separately:
Salary Requested,
including Fringe Benefits**

C.

Total Requested
1.
2.

Total number of positions requested in Part II
Total $ requested in Part II

** Salary awards will not exceed the cap per position stated in the most recent HCV/FSS NOFA.
*** For any position, where the applicant is requesting a percentage increase above the
amount provided for in the current HCV/FSS NOFA, the applicant must comply with justification
requirements in the current HCV/FSS NOFA.
Additional space for Part II A and B on page 4

Page 2 of 4

form HUD-52651
(12/2011)

PART III: Requests for PHAs that are NOT currently administering HCV/FSS Programs
A.

FSS Action Plan Information:
The number of HCV/FSS program slots in the HUD-approved Action Plan. (For Joint
applications, provide total approved slots for all joint applicant PHAs.)

B.

Position/Salary Requested:
Number of
Positions

Salary Requested,
including Fringe Benefits if applicable**

Additional space for Part III B on page 4
C.

Total Requested.
1.
Total number of positions requested in Part III B
2.
Total $ requested in Part III B
** Salary awards will not exceed the cap per position stated in the most recent HCV/FSS NOFA.

Page 3 of 4

form HUD-52651
(12/2011)

Continuation of Part I. B, Legal Name of Joint Applicant PHAs
Legal Name of Joint Applicant PHA. (If applicable.)
Address:
City:
State:
PHA Number of Applicant:

Legal Name of Joint Applicant PHA. (If applicable.)
Address:
City:
State:
PHA Number of Applicant:
PHA Number of Applicant:

County:
Zip Code:

County:
Zip Code:

Continuation of Part II. A, Previously Funded Positions:
FY Last Funded

Salary Amount
Last Funded

Continuation of Part II. B,

Salary Requested
Per Position **
under this NOFA

Number of
Positions at salary
level

Is applicants
request above
percentage allowed
in the NOFA?
‘Y’ or ‘N’ ***

New Positions:

Salary Requested,
including Fringe Benefits**

Continuation of Part III. B, Position/Salary Requested:
Number of
Positions

Salary Requested,
including Fringe Benefits if applicable**

Page 4 of 4

form HUD-52651
(12/2011)