HUD-52768 - Origin ROSS Service Coordinators - Funding Request

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

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

ROSS SERVICE COORDINATORS – FUNDING REQUEST
________________________________________________________________________
Public reporting burden for the collection of information is estimated to average 1 hour 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. This information will allow HUD to determine
eligibility for the ROSS SC Program. This information does not lend itself to confidentiality.

***PLEASE READ NOFA CAREFULLY FOR DIRECTIONS AND MINIMUM
REQUIREMENTS.***
Name of Applicant ________________________
Joint Applicant (if applicable) _________________________________
Name of PHA/Tribe/TDHE(s) to be Served
_________________________________________________
PHA Code(s) to be served (Not applicable to tribes/TDHEs)
_________________________________________________
Total Number of ACC Units/Formula Currently Assisted Stock in PHA/Tribe
______________
EDSC
PHA applicants: Are you currently eligible to receive funding for one or more Elderly/Disabled
Service Coordinators (EDSC) through the Operating Subsidy? (NOT ROSS-Elderly/Persons with
Disabilities) YES ___ NO ___
If YES and you request and are granted an SC to serve Elderly Residents through this NOFA, you
will forgo any future EDSC Renewal funding.
RA Applicant? YES ___NO ___ (State and National Resident Associations applying as nonprofits should check YES)
Non-Profit Applicant? YES ____ NO _______
If Yes, check all that apply:
Faith-based ____
Community-based ____
Other _____
Do you (the applicant) have a current ROSS-SC grant? YES ____ NO ____
Are you applying to serve ONLY projects that are NOT served by current ROSS-SC grant(s)?
YES ___ NO ___

Form HUD-52768 (12/2011)

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

Service Coordinators (SCs) Requested
SC
Project(s) to be Number
of Units
Position
served (See
to be
Requested NOFA for
Served
instructions)
(if different PHAs,
by this
list PHA as well)
SC (See

SC will
serve
Family,
Elderly
or Both?

Year

Salary/Fringe

Admin

Training

(See NOFA for
limits)

(See NOFA for
limits)

(See NOFA for
limits)

$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$

NOFA for
minimum)

1

2

3

1
2
3
1
2
3
1
2
3
TOTAL

TOTAL GRANT REQUESTED $ _________________
For each SC position requested, fill in one large row.

Form HUD-52768 (12/2011)