HUD 91178A Annual Program Budget Grantee

Annual Program Budget
Grantee

OMB Approval No. 2502-0485
(exp.01/31/2015)

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

Please read the Public Reporting Statement before completing this form.
Grantee Name

HG

Project Name (If different)

Program Year

Budget Category (check one and specify type)

Service
Item Name
1.
Direct Labor (List staff positions, hours worked, rate of pay per hour and year)

Administration
Total Amount

Total $
2.

Fringe Benefits (Provide percentage and calculations for direct labor positions)

3.

Materials and Equipment (Identify items and costs used in providing above Service/Administration)

4.

Subcontracts (Identify service, number of participants, unit cost, and amount of service provided)

5.

Other (Specify)

6.

Total Cost

Total $

Total $

Total $

7.

Total $
$

Applicant Match
a. Cash
b. Imputed value of other agency or third-party provided direct services or staff
c. In-kind resources

$
$
$

d. Volunteer services (at $5.00 per hour)

$

Total Match $
8.

Participant Fees

9.

Net CHSP Funds Requested (line 6 minus lines 7 + 8)

$
$

10. Footnotes (continue on back if necessary)

1

form HUD-91178-a (12/94)
ref. Handbook 4640.1

Annual Program Budget
Grantee

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

OMB Approval No. 2502-0485
(exp.XX/XX/XXXX)

Public reporting burden for this collection of information is estimated to average 2 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 conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection
displays a valid OMB control number.
The information is basic to the operations of the Congregate Housing Services Program. It supports statutory requirements and program and
management controls that prevent fraud, waste and mismanagement. The controls must be maintained as long as current grants are in operation.
Section 802 of the National Affordable Housing Act authorizes/requires matching funds and participant fee collections that are reported on these
forms. The rule at 24 CFR 700.155(d) requires grantees to submit these forms. The information will be used by State/Area offices to ensure that
grant funds are being used properly. This includes grantees’ expense of appropriate grant monies during each annual grant period and the use of
grant funds to provide eligible activities to eligible residents, and to ensure that statutory requirements are being met. Program staff use the
information to compile annual program data. Grantees must complete forms and report grant activity in order to continue receiving grant funds.
Each grantee is required to maintain confidentiality of information related to any individual, per the Privacy Act of 1974.

2

form HUD-91178-a (12/94)
ref. Handbook 4640.1