HUD-96011 Facsimile Transmittal

Facsimile Transmittal

U. S. Department of Housing
and Urban Development

1399995037 - 6043

OMB Number: 2535-0118
Expiration Date: 12/01/2016

Office of Department Grants
Management and Oversight

Name of Document Transmitting:

1. Applicant Information:
Legal Name:
Address:
Street1:
Street2:
City:
County:
State:
Zip Code:

Country:

USA: UNITED STATES

2. Catalog of Federal Domestic Assistance Number:
Organizational DUNS:

CFDA No.:

Title:
Program Component:

3. Facsimile Contact Information:
Department:
Division:
4. Name and telephone number of person to be contacted on matters involving this facsimile.
Prefix:

First Name:

Middle Name:
Last Name:
Suffix:
Phone Number:
Fax Number:
5. Email:
6. What is your Transmittal? (Check one box per fax)
a. Certification

b. Document

c. Match/Leverage Letter

d. Other

7. How many pages (including cover) are being faxed?

Form HUD-96011 (10/12/2004)