HUD Form xxxx Rural and Tribal Abstract Form

SUBMIT

Rural/Tribal Communities 2013 Promise Zone Abstract Form

OMB Control
#: 2577-xxxx
Number:
(expires
xx/xx/2014)

When completed please press the submit button in the upper left hand corner of the document.
Posting Application Information. After the selection process, HUD may post on-line certain summary and contact information
from Promise Zone applications (e.g., the Executive Summary, community map, Lead Applicant contact information, etc.) in
order to provide information to interested non-federal organizations and members of the public.

Part A:
Rural or Tribal Target Community Name
Tribal or Rural Community Name:
Rural or Tribal Organizational Information
Organization Serving as Lead Applicant:
Street Address:

City:

State:

Zip Code:

Website:
Type of Organization: ...

Designated Official from Lead Applicant Organization

Please provide contact information for the person designated to execute documents on behalf of the lead
applicant organization, generally the local or tribal government official, Executive Director, President, CEO or
similar position.

Name:

Title:

Phone:

Email:

Street Address:

City:

State:

Zip Code:

Staff Point of Contact

Please provide contact information for an individual within the organization that Federal staff may contact
with any questions about the Promise Zones application.

Name:

Title:

Phone:

Email:

Street Address:

City:

State:

Zip Code:

Tribal and Rural Communities 2013 Promise Zone Abstract Form
Part B:

Leadership Support: Local Official

As noted in Section II of the Application Guide, please list the local officials that are submitting letters of
support. For applications across jurisdictional lines, a clear lead applicant must be identified, and
commitment must be demonstrated by leadership of all jurisdictions involved. For additional officials,
please list their information in the “Additional Local Official” box at the end of the form.

Authorized Representative
Name:
Title:
Jurisdiction:
Check Box if Letter of
Commitment Attached:

Congressional District(s)

Please list any Congressional District(s) your Promise Zone would encompass.

Implementation Partners

In the space below, please list partnering organizations that will be collaborating in the implementation
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of the Promise Zone .

Part C:
Qualifying Program Whose Boundaries are Included in the Proposed Promise Zone
Please list one or more qualifying programs. The complete list of qualifying programs is
at www.hud.gov/promisezones.

Select Qualifying Program:

Eligible Community Name:

...
...

...
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Refer to the last page of the Application guide for the definition of Implementation Partners.

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Tribal and Rural Communities 2013 Promise Zone Abstract Form
Part D: Boundaries of Zone
a. Check Box if Maps and Optional Mapping
Tool data sheet are attached:
b. Narrative Description of Proposed Promise Zone and its Boundaries (1,500 Character Limit):

County/counties:

Tribe(s):

State(s):

Part E: Qualifying Criteria and Need Criteria Data

Please provide information pertaining to Section II and III of the Rural/Tribal Promise Zone Application Guide. The
optional mapping tool provides this information except the crime statistics. In Section III of the Application Guide,
applicants can provide a narrative more fully describing the need-related data points.

Overall Poverty Rate:
Highest Poverty Census Tract Rate: 2
Population: 3
Employment Rate:
Rate of Part 1, serious and violent
crimes for 2002-2012 within the
proposed target area: 4

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Proposed Rural Promise Zones must have one census tract with a poverty rate above 30%. This is not applicable for tribal
applicants.
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Proposed Promise Zone boundaries must encompass a population of at least 6,000 but no more than 200,000 residents. For
Tribal Applicants a minimum population is not applicable.
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Use the most recent 10-year period, to the extent that data is available.

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Tribal and Rural Communities 2013 Promise Zone Abstract Form
Part F: Promise Zone Evidence Base (500 Characters Limit):

Please provide a brief statement of the community’s goals and stratregies related to each of the Promise Zone goals.

Creating Jobs:

Increasing Economic Activity:

Improving Career Educational
Opportunities:

Reducing (or Maintaining a Low
Rate of) Serious and Violent Crime:

Other Key Outcomes (If Applicable):
Including reduction of Promise Zone
poverty rate.

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Tribal and Rural Communities 2013 Promise Zone Abstract Form
Executive Summary (5,000 Character Limit) :

The Executive Summary should include a statement of local priorities and describe how the Promise Zones
designation would accelerate and strengthen efforts at comprehensive community revitalization.

Additional Local Officials (Optional) :

Please list any additional officials in the space below by name, title, jurisdiction, and if a letter of commitment is
attached to the final application.

Note: Public reporting burden for the entire collection of information is estimated to average 48 hours. This
includes the time for collecting, reviewing, and reporting the data. The information is being collected for OMB
#2577-xxx and will be used for xxx. 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. No confidentiality is assured.

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