ETA 9143, Part C - Work Site Description Form with Annual Housing Census -

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Overview

Part A - Worksite Description
Part B - Work Site Project Est.
Part C - HOUSING CENSUS
Tab 4 -House Census - Attmnt 2A

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Sheet 1: Part A - Worksite Description

Work Site Description
(A WorkSite Description is required for each property)
YouthBuild (YB) GRANT
PART A							OMB No.	1205-0464
ETA - 9143							Expires:	05/31/2015
APPLICANT IDENTIFYING INFORMATION (Complete All Sections)
Applicant Name:
Program/Project Name & Address:
1. Work Site Identification (Address/Parcel #))
2. Number of Housing Units Planned to be Produced or Renovated:
3. Type of housing to be produced (Check all that apply)
¨ Residential/rental ¨ Homeownership ¨ Transitional housing for the homeless
4. Will all housing produced be provided for homeless, low-income, or very-low income persons?
¨ Yes ¨ No
4. Individual Housing Project Site Estimate and Documentation of Resources: Complete Attachment 1A for each work site to be used in conjunction with the YouthBuild program. Attach documentation of resources behind each Attachment 1A.
5. The on-site training site consists of (Check all that apply) : ¨ New Construction ¨ Rehabilitation
6. Are any of the units currently occupied? ¨ Yes ¨ No (If yes, attach a relocation narrative that identifies the number of persons, the business or others occupying the property on the date of submission of this application, the number of displaced, the number to be temporarily relocated but not displaced, the estimated cost of relocation services payments and services, the source of funds for relocation, and the organization that will provide relocation assistance to occupants and the contact person's name and phone number. Label this Attachment 1B.)
7. Name of the current owner:
8. Documentation of Access: Attach required evidence of work site access (Letter from the owner identified in No. 7). Label this Attachment 1C.
9. Describe the applicant role and responsibilities for the work site housing construction or rehabilitation work. Label this Attachment 1D.
10. Name of entity which will own and manage the property after the construction or rehabilitation work is completed:
OMB No.: 1205-0464 OMB Expiration Date: 05/31/2015 Average Response Time: 30 minutes This reporting requirement is approved under the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of information includes time for reviewing instructions, searching existing data sources, gathering and reviewing the collection of information. Respondent’s obligation to reply to this collection of information, which is for general program oversight, evaluation, and performance assessment, is required to maintain benefits [PL 109-281 Sec 173(A)(c)(3)]. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden, to the U. S. Department of Labor, Employment and Training Administration, Division of Youth Services, Room N4508, 200 Constitution Avenue, NW, Washington, D.C. 20210.
Applicant Signature:
Printed Name:				Signature:
Title: __________________________________________________ Date: _____________
Organization: ______________________________________________________________

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Sheet 2: Part B - Work Site Project Est.

Individual Work Site Project Estimate
YouthBuild (YB) GRANT
PART B						OMB No.	1205-0464
ETA - 9143						Expires:	5/31/2015
APPLICANT IDENTIFYING INFORMATION
Applicant Name:
Address of the Property (include city, state, and zip code):
Grant Activities		Resources
		YouthBuild	Other Federal	State	Local	Private	Total
1. Acquisition
2. Architecture & Engineering
3. Housing Construction
4. Housing Rehabilitation
5. Total Housing Project Costs for Site
Note 1: Include both cash and in-kind contributions.
stom.anne: We need to look at this language very carefully Note 2: When paid, in whole or in part, with YouthBuild program funds, the activities will trigger applicable YouthBuild project-related restrictions contained in YouthBuild Final Rule, 20 CFR, part 672. Applicants who propose to use YouthBuild funds for one or more of these activities are required to complete the appropriate certifications.
Documentation of Housing Resources
Attach a letter of commitment from each source of funding. These letters will not count towards your total page count.
Name of Provider (Donor)			Cash or In-Kind		Dollar Value Provided		Page # of Letter
OMB No.: 1205-0464 OMB Expiration Date: 05/31/2015 OMB Burden Hours: 30 minutes OMB Burden Statement: These reporting instructions have been approved under the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection information unless it displays a currently valid OMB control number. Information is collected from eligible applicants for a competition to determine which entities will receive grant funds. Public reporting burden for this collection of information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Submission is mandatory and is authorized under YouthBuild Transfer Act Public Law 109-2810. The information will be used for the YouthBuild grant and response to this request for information is required in order to receive the benefits to be derived. The information requested does not lend itself to confidentiality.
Send comments regarding this burdent estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce Investment, Division of Youth Services, N-4508, Washington, DC 20210.

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Sheet 3: Part C - HOUSING CENSUS

YouthBuild Grant ANNUAL HOUSING CENSUS
PART C							OMB No.	1205-0464
ETA - 9143							Expires:	05/31/2015
The Department of Labor (DOL) will report to Congress and other stakeholders the number of affordable housing units built or renovated by YouthBuild participants. All grantees will be asked to complete and submit this form annually to provide DOL with this information. Your organization will receive a notification from DOL near the annual anniversary of your period of performance For example, if your grant has a period of performance from March 15, 2011 through March 14, 2013, you will receive a notice in March 2012 asking you to submit this form within 45 days.
Section 1:
1. Contact Person:
2. Program and Organization Name, Address, Phone & E-Mail :
3. Date of Submission:				Check if this is the final report for the grant: ¨
4. Please enter the total number of units that were completed during the period of performance year: ________
Detailed instructions for completion are included on the next tab this worksheet
Section 2:
Unit #1	Completed on [MM/YY]:			House ¨		Apartment ¨		Public or Community Facility: ¨
Multi-Unit [Y/N]:		If Yes, Describe:
Address:
Type of work completed [check only one]:		New construction ¨		Renovation ¨		Weatherization Only ¨
Other ¨	Describe:
Unit #2	Completed on [MM/YY]:			House ¨		Apartment ¨	Public or Community Facility: ¨
Multi-Unit [Y/N]:		If Yes, Describe:
Address:
Type of work completed [check only one]:		New construction ¨		Renovation ¨		Weatherization Only ¨
Other ¨	Describe:
Unit #3	Completed on [MM/YY]:			House ¨		Apartment ¨	Public or Community Facility: ¨
Multi-Unit [Y/N]:		If Yes, Describe:
Address:
Type of work completed [check only one]:		New construction ¨		Renovation ¨		Weatherization Only ¨
Other ¨	Describe:
For Additional Units Use Housing Census Continuation Form 2A
Section 3:
Signature of Contact Person: _______________________________________________________________________
Printed Name:
Title: __________________________________________________ Date: _____________
OMB No.: 1205-0464 OMB Expiration Date: 05/31/2015. Average Response Time: 30 minutes. This reporting requirement is approved under the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of information includes time for reviewing instructions, searching existing data sources, gathering and reviewing the collection of information. Respondent’s obligation to reply to this collection of information, which is for general program oversight, evaluation, and performance assessment, is required to maintain benefits [PL 109-281 Sec 173(A)(c)(3)]. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden, to the U. S. Department of Labor, Employment and Training Administration, Division of Youth Services, Room N-4508, 200 Constitution Avenue, NW, Washington, D.C. 20210.

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Sheet 4: Tab 4 -House Census - Attmnt 2A

YouthBuild Grant ANNUAL HOUSING CENSUS
PART C - Continuation Form
PART C						OMB No.	1205-0464
ETA - 9143						Expires:	05/31/2015
1. Contact Person:
2. Program and Organization Name, Address, Phone & E-Mail :
Unit # 4	Completed on [MM/YY]:			House ¨	Apartment ¨		Public or Community Facility: ¨
Multi-Unit [Y/N]:		If Yes, Describe:
Address:
Type of work completed [check only one]:		New construction ¨		Renovation ¨		Weatherization Only ¨
Other ¨	Describe:
Unit # 5	Completed on [MM/YY]:			House ¨	Apartment ¨		Public or Community Facility: ¨
Multi-Unit [Y/N]:		If Yes, Describe:
Address:
Type of work completed [check only one]:		New construction ¨		Renovation ¨		Weatherization Only ¨
Other ¨	Describe:
Unit # 6	Completed on [MM/YY]:			House ¨	Apartment ¨		Public or Community Facility: ¨
Multi-Unit [Y/N]:		If Yes, Describe:
Address:
Type of work completed [check only one]:		New construction ¨		Renovation ¨		Weatherization Only ¨
Other ¨	Describe:
Unit # 7	Completed on [MM/YY]:			House ¨	Apartment ¨		Public or Community Facility: ¨
Multi-Unit [Y/N]:		If Yes, Describe:
Address:
Type of work completed [check only one]:		New construction ¨		Renovation ¨		Weatherization Only ¨
Other ¨	Describe:
Unit # 8	Completed on [MM/YY]:			House ¨	Apartment ¨		Public or Community Facility: ¨
Multi-Unit [Y/N]:		If Yes, Describe:
Address:
Type of work completed [check only one]:		New construction ¨		Renovation ¨		Weatherization Only ¨
Other ¨	Describe: