Housing Counseling Program

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Overview

Public Reporting Burden
LHCA Characteristics
INT SHFA MSO Characteristics
Sub-Grantee Branches
Services and Modes
Other HUD Programs
Leveraging
Budget
AFFH
Oversight Activities
Checklist

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Sheet 1: Public Reporting Burden

OMB Approval #2502-0261

Exp Date 04/30/2016

Public reporting burden for this collection of information is estimated to average 40 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.  The information is being collected for a housing counseling agency to participate in HUD’s Housing Counseling program.  The information will be used by HUD to ensure that Counselors provide guidance and advice to help families and individuals improve their housing conditions and meet the responsibilities of tenancy and homeownership.  Counselors also help borrowers avoid predatory lending practices, such as inflated appraisals, unreasonably high interest rates, unaffordable repayment terms, and other conditions that can result in a loss of equity, increased debt, default, and foreclosure.  This agency may not collect this information, and you are not required to complete this form, unless it displays a valid OMB control number.

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Sheet 2: LHCA Characteristics

Rating Factor 1

Rating Factor 2

Rating Factor 3

Rating Factor 5

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

AA

AB

AC

AD

AE

AF

AG

AH

Name of Applicant

Location City/State

Agency's HUD Housing Counseling System (HCS) Number

Preferred Sustainable Communities - HUD 2995 Certified

I

Number of Housing Counselor Full-Time Equivalents (FTE)

Number of HUD HECM Roster Counselors (if applicable)

Formal Housing Counseling Training

Require Testing/Certification for Counselors

Alternate Mode(s) of Counseling

Adopted National Industry Standards

Counseling Services available in Multiple Languages

Alternate Formats Accessible to Persons with Disabilities

Client Exit Surveys

Follow-up Client Surveys

Serves Rural Community

Serving Area with No Internet Access

Physically Located in Geographically Isolated Agency

% of Award Applicant Intends to Sub-allocate

Name(s) of Housing Counseling Related Networks/Collaboratives, if Applicable

Uses Reviews by Senior Management Staff with Results Reported to Organization's Board

Publishes Performance Data

Link to Published Performance Data, if Available Online

Name of CMS

Uses CMS to Generate Reports

Use CMS to Record Notes, Action Plan, Financial Analysis and Follow-up

Uses CMS to Track Grants

Performs Quality Control Review of CMS Data

Pulled Credit Reports 6 or More Months after Counseling was Completed

Uses Other Methods ofEvaluating Program Services

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Sheet 3: INT SHFA MSO Characteristics

NOTE: If the Applicant's main office provides direct housing counseling activities, the main office must be included in the list of sub-grantees and branches. Below is a completed example of Chart A. Complete the blank Chart on Page 2. NOTE: Entering an "x" indicates a "Yes" response.
Rating Factor 1																			Rating Factor 2			Rating Factor 3		Rating Factor 5
A	B	C	D	E	F	G	H	I	J	K	L	M	N	O	P	Q	R	S	T	U	V	W	X	Y	Z	AA	AB	AC	AD	AE	AF	AG	AH
					Funded Branch of an Intermediary	Sub-grantee that is NOT HUD-Approved LHCA	Sub-grantee that is HUD-approved LHCA	Number of Sub-grantee Branches. Provide Sub-grantee Branches on Chart A2a	Number of Housing Counselor Full-Time Equivalents (FTE)	Number of HUD HECM Roster Counselors	Formal Housing Counseling Training	Require Testing/Certification for Counselors	Alternate Mode(s) of Counseling	Adopted National Industry Standards	Counseling Services available in Multiple Languages	Alternate Formats Accessible to Persons with Disabilities	Client Exit Surveys	Follow-up Client Surveys	Serves Rural Community	Serving Area with No Internet Access	Physically Located in Geographically Isolated Agency	% of Award Applicant Intends to Sub-allocate	Name(s) of Housing Counseling Related Networks/Collaboratives, if Applicable	Uses Reviews by Senior Management Staff with Results Reported to Organization's Board	Publishes Performance Data	Link to Published Performance Data, if Available Online	Name of CMS	Uses CMS to Generate Reports	Use CMS to Record Notes, Action Plan, Financial Analysis and Follow-up	Uses CMS to Track Grants	Performs Quality Control Review of CMS Data	Pulled Credit Reports 6 or More Months after Counseling was Completed	Uses Other Methods ofEvaluating Program Services
Applicant	ABC Intermediary NOTE: If Applicant is providing counseling directly, enter information below with the approxpriate boxes marked.	Alexandria, VA	12345	x																		10			x	www.abcint.org/public	HCO	x
Funded Branches and/or Sub-grantees	ABC Intermediary	Alexandria, VA	12346	x	x				2		x		x	x	x	x	x					30		x			HCO	x		x		x
	Housing Resources	Alamosa, CO	56789				x		3	1	x	x			x	x	x	x	x	x		30			x	www.housingresources.org/data	CMAX	x	x	x	x		x
	Housing Affiliate	Erie, PA	98765	x		x		2	8		x		x	x	x	x	x					30	Erie Housing Counseling Agencies Collaborative	x			HCO	x		x		x
TOTAL				3	1	1	1	2	13	1	3	1	2	2	3	3	3	1	1	1	0	100	1	2	2			4	1	3	1	2	1
NOTE: If the Applicant's main office provides direct housing counseling activities, the main office must be included in the list of sub-grantees and branches. NOTE: Entering an "x" indicates a "Yes" response.
Rating Factor 1																			Rating Factor 2			Rating Factor 3		Rating Factor 5
A	B	C	D	E	F	G	H	I	J	K	L	M	N	O	P	Q	R	S	T	U	V	W	X	Y	Z	AA	AB	AC	AD	AE	AF	AG	AH
	Name of Applicant, Funded Branches and Sub-grantees Applicant proposes to Fund With this NOFA	Location City/State	Agency's HUD Housing Counseling System (HCS) Number	Preferred Sustainable Communities - HUD 2995 Certified	Funded Branch of an Intermediary	Sub-grantee that is NOT HUD-Approved LHCA	Sub-grantee that is HUD-approved LHCA	Number of Sub-grantee Branches. Provide Sub-grantee Branches on Chart A2a	Number of Housing Counselor Full-Time Equivalents (FTE)	Number of HUD HECM Roster Counselors	Formal Housing Counseling Training	Require Testing/Certification for Counselors	Alternate Mode(s) of Counseling	Adopted National Industry Standards	Counseling Services available in Multiple Languages	Alternate Formats Accessible to Persons with Disabilities	Client Exit Surveys	Follow-up Client Surveys	Serves Rural Community	Serving Area with No Internet Access	Physically Located in Geographically Isolated Agency	% of Award Applicant Intends to Sub-allocate	Name(s) of Housing Counseling Related Networks/Collaboratives, if Applicable	Uses Reviews by Senior Management Staff with Results Reported to Organization's Board	Publishes Performance Data	Link to Published Performance Data, if Available Online	Name of CMS	Uses CMS to Generate Reports	Use CMS to Record Notes, Action Plan, Financial Analysis and Follow-up	Uses CMS to Track Grants	Performs Quality Control Review of CMS Data	Pulled Credit Reports 6 or More Months after Counseling was Completed	Uses Other Methods ofEvaluating Program Services
Applicant
Funded Branches and/or Sub-grantees
TOTAL				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0	0	0	0	0	0
Funded Branches and/or Sub-grantees
TOTAL				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0	0	0	0	0	0
Funded Branches and/or Sub-grantees
TOTAL				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0	0	0	0	0	0
Funded Branches and/or Sub-grantees
TOTAL				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0	0	0	0	0	0
Funded Branches and/or Sub-grantees
TOTAL				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0	0	0	0	0	0

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Sheet 4: Sub-Grantee Branches

	Agency's HUD Housing Counseling System (HCS) Number (if assigned)	Name of Sub-Grantee		Name of Sub-Grantee's Funded Branch		Location City/State
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132

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Sheet 5: Services and Modes

Applicant Name:

NOTE: Below is a completed example of Chart B. Complete the blank Chart on Page 2. Applicants proposing to fund sub-grantees and/or funded branches must indicate the number of proposed sub-grantees and branches which will provide the proposed services. *Funded branches include funded branches of sub-grantees.

A

B

C

D

E

F

G

H

I

J

K

L

M

EXAMPLE: Housing Counseling Service

# of Sub-grantees and/or *Funded Branches that Provide One-on-One Counseling

Indicate if Group Education Provided  by Applicant

# of Sub-grantees and/or *Funded Branches that Will Provide Group Education

Service Will be Provided In Person

# of Sub-grantees and/or *Funded Branches that Will Provide Service In Person

Service Will be Provided Via Telephone

# of Sub-grantees and/or *Funded Branches that Will Provide Service Over the Telephone

Service will be provided Over the Internet?

# of Sub-grantees and/or *Funded Branches that Will Provide Service Over the Internet

Service Will Be Available in Multiple Languages?

# of Sub-grantees and/or *Funded Branches that Will Have Services Available in Multiple Languages

Pre-purchase/Home buying

x

5

x

4

x

5

x

2

Resolving/Preventing Mortgage Delinquency or Default

x

5

x

5

x

5

x

2

Home Maintenance and Financial Management for Homeowners (Non-Delinquency Post-Purchase)

Rental Topics

Shelter/Services for the Homeless Assistance

Reverse Mortgage

TOTAL

2

10

1

4

2

10

1

5

1

2

1

2

Applicant Name:

NOTE: Applicants proposing to fund sub-grantees and/or funded branches must indicate the number of proposed sub-grantees and branches which will provide the proposed services. *Funded branches include funded branches of sub-grantees.

A

B

C

D

E

F

G

H

I

J

K

L

M

Housing Counseling Service

Indicate if One-on One Counseling Provided by Applicant

# of Sub-grantees and/or *Funded Branches that Provide One-on-One Counseling

Indicate if Group Education Provided  by Applicant

# of Sub-grantees and/or *Funded Branches that Will Provide Group Education

Service Will be Provided In Person

# of Sub-grantees and/or *Funded Branches that Will Provide Service In Person

Service Will be Provided Via Telephone

# of Sub-grantees and/or *Funded Branches that Will Provide Service Over the Telephone

Service will be provided Over the Internet?

# of Sub-grantees and/or *Funded Branches that Will Provide Service Over the Internet

Service Will Be Available in Multiple Languages?

# of Sub-grantees and/or *Funded Branches that Will Have Services Available in Multiple Languages

Pre-purchase/Home buying

Resolving/Preventing Mortgage Delinquency or Default

Home Maintenance and Financial Management for Homeowners (Non-Delinquency Post-Purchase)

Rental Topics

Shelter/Services for the Homeless Assistance

Reverse Mortgage

TOTAL

0

0

0

0

0

0

0

0

0

0

0

0

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Sheet 6: Other HUD Programs

Applicant Name:
NOTE: Applicants proposing to fund sub-grantees and/or branches must indicate the number of proposed sub-grantees and branches (Column D below) which will provide housing counseling services in conjunction with other HUD programs that are marked in Column C below.
A	B	C	D
HUD Program	Administering Office	Enter an "X" if Applicant Provides Housing Counseling Services in Conjunction with HUD Programs	For Intermediaries, SHFAs and MSOs Number of Sub-grantees and/or Branches That Provide Service(s) in Conjunction with HUD Programs
Second Mortgage Assistance for First-Time Homebuyers	Community Planning and Development
Rural Housing Stability Grant Program	Community Planning and Development
Public Housing Operating Fund	Public and Indian Housing
Section 8 Tenant-Based Rental Assistance Homeownership Option	Public and Indian Housing
Demolition and Disposition of Public Housing	Public and Indian Housing
Family Self-Sufficiency	Public and Indian Housing
Public Housing Resident Homeownership Programs	Public and Indian Housing
Conversion of Distressed Public Housing to Tenant-Based Assistance	Public and Indian Housing
Low Income Housing Preservation and Resident Homeownership Act Prepayment Options	Public and Indian Housing
Native American Housing Assistance Self Determination Act Housing Block Grants	Public and Indian Housing
Native Hawaiian Housing Block Grants	Public and Indian Housing
Section 8 Rental Assistance	Public and Indian Housing
HUD-Sponsored Housing Counseling-Related Research or Pilot Program: Must specify
Other: Must specify
TOTAL		0	0

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Sheet 7: Leveraging

	A	B	C	D	E			F	G
	Applicant/ Sub-grantee/ Funded Branch	Names of Applicant, Sub-grantees/Branch Offices Proposed to be Funded	Organization Providing Leveraged Funds/In-kind Contributions and Point of Contact	Type of Contribution (Cash, Fees, In-kind, Program Income)	Funds Must be Available During the Grant Period			Use of Funds -- Only Include Funds that are Exclusively Allocated for Housing Counseling Program	Only Include the Amount Funds that are Available from October 1, 2013 2014 to March 31, 2015 2016
1	Applicant	Example: ABC Intermediary	ABC Intermediary	Program Income	10/1/2013 10/1/2014	--	3/31/2015 3/31/2016	Foreclosure Prevention Counseling	$100,000.00
2	Sub-grantee	Housing Affiliate	Jane Dough Foundation/ John Dough (719) 222-3232	Cash	10/1/2013 10/1/2014	--	3/31/2015 3/31/2016	Foreclosure Prevention Counseling	$10,000.00
3	Sub-grantee	Housing Affiliate	Chase Bank Foundation/ Sally Clams (719) 224-7676	Cash	10/1/2013 10/1/2014	--	3/31/2015 3/31/2016	Pre-purchase Counseling	$7,500.00
4	Sub-grantee	Housing Resources	City of Siever/ Pat Culver (719) 236-4565	Cash	10/1/2013 10/1/2014	--	3/31/2015 3/31/2016	Pre-purchase Counseling	$12,000.00
5	Sub-grantee	Housing Resources	ABC Legal Services/Suzy Council (719) 236-4444	In-kind	10/1/2013 10/1/2014	--	3/31/2015 3/31/2016	Foreclosure Prevention Counseling	$5,000.00
6					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
7					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
8					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
9					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
10					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
11					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
12					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
SUBTOTAL/TOTAL									$134,500.00
	A	B	C	D	E			F	G
	Applicant/ Sub-grantee/ Funded Branch	Names of Applicant, Sub-grantees/Branch Offices Proposed to be Funded	Organization Providing Leveraged Funds/In-kind Contributions and Point of Contact	Type of Contribution (Cash, Fees, In-kind, Program Income)	Funds Must be Available During the Grant Period			Use of Funds -- Only Include Funds that are Exclusively Allocated for Housing Counseling Program	Only Include the Amount Funds that are Available from October 1, 2013 2014 to March 31, 2015 2016
1					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
2					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
3					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
4					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
5					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
6					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
7					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
8					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
9					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
10					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
11					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
12					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
13					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
14					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
15					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
16					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
17					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
Err:504					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
18					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
19					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
20					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
21					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
22					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
23					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
24					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
SUBTOTAL/TOTAL									$0.00
25					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
26					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
27					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
28					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
29					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
30					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
31					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
32					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
33					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
34					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
35					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
36					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
37					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
38					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
39					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
40					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
41					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
42					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
43					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
44					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
45					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
46					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
47					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
48					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
49					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
SUBTOTAL/TOTAL									$0.00
50					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
51					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
52					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
53					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
54					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
55					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
56					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
57					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
58					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
59					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
60					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
61					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
62					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
63					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
64					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
65					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
66					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
67					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
68					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
69					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
70					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
71					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
72					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
73					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
74					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
SUBTOTAL/TOTAL									$0.00
75					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
76					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
77					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
78					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
79					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
80					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
81					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
82					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
83					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
84					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
85					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
86					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
87					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
88					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
89					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
90					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
91					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
92					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
93					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
94					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
95					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
96					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
97					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
98					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
99					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
SUBTOTAL/TOTAL									$0.00
100					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
101					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
102					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
103					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
104					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
105					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
106					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
107					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
108					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
109					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
110					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
111					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
112					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
113					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
114					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
115					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
116					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
117					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
118					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
119					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
120					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
121					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
122					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
123					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
124					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
SUBTOTAL/TOTAL									$0.00
125					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
126					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
127					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
128					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
129					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
130					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
131					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
132					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
133					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
134					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
135					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
136					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
137					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
138					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
139					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
140					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
141					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
142					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
143					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
144					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
145					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
146					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
147					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
148					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
149					10/1/2013 10/1/2014	--	3/31/2015 3/31/2016
SUBTOTAL/TOTAL									$0.00

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Sheet 8: Budget

1	Applicant Name:
2	FY 2013 2014 Grant Period Applicant's Total Budget, All Sources of Funding
3	FY 2013 2014 Grant Period HUD Housing Counseling Grant Fund Amount
4	FY 2013 2014 Grant Period Percentage of HUD Funds Sub-allocated to Sub-grantees and Funded Branches
5	(A)					(B)	(C)	(D)
6	Expenses					Applicant's Total Administrative Budget, All Sources (Do Not Include Funds Sub-allocated to Sub-grantees/ Funded Branches)	Total Budget of all Sub-Grantees/ Funded Branches, All Sources (Include Main Office that Provides Direct Counseling)	(B + C) Network-wide Total Budget, All Sources
7	Salaries
8	Housing Counselors
9	Housing Counseling Program Managers
10	All Other Housing Counseling Program Staff
11	Fringe Benefits
12	Housing Counselors
13	Housing Counseling Program Managers
14	All Other Housing Counseling Program Staff
15	Total Other Direct Costs
16	Other (Must Provide Explanation of Other Expenses in Narrative)
17	Total Direct Costs					$-	$-	$-
18	Indirect Cost Allocation Amount (if applicable)
19	TOTAL BUDGET					$-	$-	$-
CHART E.2. LHCAs
1	Applicant Name:
2	(A)						(B)
3	Expenses						Applicant's Total Budget, All Sources
4	Salaries
5	Housing Counselors
6	Housing Counseling Program Managers
7	All Other Housing Counseling Program Staff
8	Fringe Benefits
9	Housing Counselors
10	Housing Counseling Program Managers
11	All Other Housing Counseling Program Staff
12	Total Other Direct Costs
13	Other (Must Provide Explanation of Other Expenses in Narrative)
14	Total Direct Costs						$-
15	Indirect Cost Allocation Amount (if applicable)
16	TOTAL BUDGET						$-

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Sheet 9: AFFH

Applicant Name:
Instructions: Columns A - E: All Applicants must complete Columns A through E of the chart below to demonstrate how the Applicant will fulfill its obligation to affirmatively further fair housing in the use of Housing Counseling grant funds.
Rating Factor 2, Sub-Factor 1(c)			Rating Factor 3, Sub-Factor 2(c)
(A)	(B)	(C)	(D)	(E)
Jurisdiction/ Service Area	Brief description of impediments to fair housing choice in the jurisdiction/service area identified in Column A	Information Source for Impediments identified in Column B (e.g. applicable state or local Consolidated Plan and Analysis of Impediments to Fair Housing Choice)	Brief description of an activity that addresses an impediment to fair housing choice identified in Column B	Brief description of how Applicant will measure outcomes related to the activity proposed in Column D

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Sheet 10: Oversight Activities

Applicant Name:

CHART G.1: INTERMEDIARIES, MSOs AND SHFAs ONLY

For Rating Factor 3, Sub-factor 1(c), in addition to providing a narrative describing network management activities performed as part of the actual FY 2013 2014 work plan, Intermediaries, MSOs and SFHAs must complete Chart G.1, by placing an X in Column B and the number of sub-grantees/funded branches in which oversight and quality control activities were performed as part of the actual FY 2013 2014 work plan in Column C .

For Rating Factor 3, Sub-factor 2(b), in addition to providing a narrative describing network management activities that will be performed as part of the actual FY 2013 2014 work plan, Intermediaries, MSOs and SFHAs must complete Chart G.1, by placing an X in Column D and the number of sub-grantees/funded branches in which oversight and quality control activities that will be performed as part of the proposed FY 2014 2015 work plan in Column E.

A

Rating Factor 3, Sub-factor 1 (c)

Rating Factor 3, Sub-factor 2 (b)

B

C

D

E

Type of Oversight

Actual FY 2013 2014 Work Plan Conducted Oversight Activities

Number of Sub-grantees/Funded Branches Oversight was Performed for FY 2013 2014

FY 2014 2015 Proposed Oversight Activities

Proposed Number of Sub-grantees/ Funded Branches Oversight will be Performed for FY 2014 2015

i.

Train and provide technical assistance to sub-grantees/funded branches.

ii.

Monitoring, evaluating and ensuring quality of services provided by sub-grantees/funded branches including:

Verifying sub-grantees that are not HUD-approved and funded branches meet or exceed HUD's approval standards.

Monitoring the grant funded work of sub-grantees/funded branches on an ongoing basis throughout the grant year.

Identifying and rectifying service delivery deficiencies and non-compliance issues in its network.

iii.

Process sub-grantees and funded branches disbursements under the grant including:

Requiring and reviewing supporting documentation, including personnel activity reports.

Conducting quality control of disbursement process.

Recording how disbursement decisions are made.

iv.

Other (Applicant must list other activities to receive credit)

Applicant Name:

CHART G.2: LHCAs ONLY

For Rating Factor 3, Sub-factor 1(c), in addition to providing a narrative describing the process through which the applicant requested and justified disbursements under the grant, LHCAs must complete Chart G.2, by placing an X in Column B for the actual oversight activities conducted during FY 2013 2014.

For Rating Factor 3, Sub-factor 2(b), in addition to providing a narrative describing the process through which the applicant will request and justify disbursements under the grant, LHCAs must complete Chart G.2, by placing an X in Column C for oversight and quality control activities that will be performed as part of the proposed FY 2014 2015.

A

Rating Factor 3, Sub-factor 1 (c)

Rating Factor 3, Sub-factor 2 (b)

B

C

Type of Oversight

Actual FY 2013 2014 Work Plan Conducted Oversight Activities

FY 2014 2015 Proposed Oversight Activities

i.

Maintaining disbursement supporting documentation, including personnel activity reports.

ii.

Recording how disbursement decisions are made.

iii.

Conducting Quality Control of disbursement process.

iv.

Identifying and rectifying service delinquencies and noncompliance issues.

v.

Other (Applicant must list other activities to receive credit)

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Sheet 11: Checklist

SECTION III. ELIGIBILITY INFORMATION. C.2.THRESHOLDS REQUIREMENTS		YES	NO
a.	FY 2014 General Section Thresholds. Applicants and/or sub-grantees meet(s) the Threshold Requirements in Section III.C.2 of the FY2014 General Section.
b.	Applicant Eligibility. Applicant meets the eligibility requirements in Section III.A.
c.	Housing Counseling. Applicant proposes a work plan that includes the provision of housing counseling.
SECTION IV. B.2. APPLICATION CHECKLIST		YES	NO
a.	SF424, Application for Federal Assistance. NOTE: Applicant's 9 digit zip code (zip plus 4) is required.
	Applicant's DUNS number is listed on SAM with an active registration and the person submitting the application has an ID and password and has been authorized to submit the application on behalf of the applicant organization named in box 8a. of the SF424.
b.	SFLLL, Disclosure of Lobbying Activities (if applicable)
c.	HUD2995, Certification of Consistency with Sustainable Communities Planning and Implementation signed by the Designated Point of Contact for designated Preferred Sustainability Status Community or the HUD Regional Administrator
d.	HUD9902, Housing Counseling Agency Fiscal Year Activity Report, for the Period October 1, 2012 2013 through September 30, 2013 2014 (if not electronically submitted to HUD -- for example, applicants that received approval after September 30, 2013 2014)
e.	SHFA Statutory Authority (if applying as a SHFA)
f.	Organization Description
g.	External Audits and Investigations
h.	Narrative Statements as required in this NOFA
i.	HUD 9906 Housing Counseling Charts as required in this NOFA