HUD-52752 Certification of Consistency with the Indian Housing Pla

CERTIFICATION OF
CONSISTENCY WITH THE
INDIAN HOUSING PLAN

U.S. DEPARTMENT OF HOUSING
AND URBAN DEVELOPMENT
OFFICE OF PUBLIC AND INDIAN HOUSING

OMB Approval No. 2577-0229
Expiration Date: 04/30/2015

Instructions for completing this form: All tribes/TDHEs must submit this form in conjunction with their
ROSS application.
I certify that the proposed activities/projects in the application are consistent with the jurisdiction’s
current, approved Indian Housing Plan.

Applicant Name:

_________________________________________________

Project Name:

_________________________________________________

Location of the Project:

_________________________________________________
_________________________________________________
_________________________________________________

Name of the Federal Program(s) to
which the applicant is applying:

_________________________________________________

Name of Certifying Jurisdiction:

_________________________________________________

Title:

_________________________________________________

Signature:

_________________________________________________

Date:

_________________________________________________

Public reporting burden for the collection of information is estimated to average fifteen minutes per response.
This includes the time for collecting, reviewing, and reporting the data. The information will be used for the
ROSS grant. 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.

form HUD-52752 (12/2011)