HUD-52768 - Revise ROSS Service Coordinators - Funding Request

OMB Approval No. 2577-0229

Expiration Date 4/30/2015

U.S. DEPARTMENT OF HOUSING

AND URBAN DEVELOPMENT

OFFICE OF PUBLIC AND INDIAN HOUSING

ROSS SERVICE COORDINATORS – FUNDING REQUEST

­­­­­­­­­­­­­­­­________________________________________________________________________

The 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 for your application to be reviewed and/or receive ROSS SC funds. HUD 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 does not lend itself to confidentiality.

***Please read THE ROSS SC NOFA carefully for directions and minimum requirements***

1. Name of Applicant: ________________________________________________________

2. Applicant Type (please check):

1. Public Housing Authority (PHA) 

2. Tribe/Tribally Designated Housing Entity (TDHE) 

3. Resident Association (RA) 

• RAs must also answer questions 8 and 9

4. 501(c)(3) Nonprofit applicant 

• 501(c)(3) applicants must be supported by a PHA, tribe/TDHE, or RA.

• 501(c)(3) applicants must also answer question 10

3. Joint Applicant Name (if applicable): _________________________________________

4. Name of PHA/Tribe/TDHE(s) to be Served:

__________________________________________________________________________

5. PHA Code(s) to be served (Not applicable to tribes/TDHEs): __________________________________________________________________________

6. Number of ACC Units/Formula Currently Assisted Stock in PHA/Tribe: ___________

7. PHA Applicants – Elderly/Disabled Service Coordinators (EDSC) Grant:

Are you currently eligible to receive funding for one or more EDSCs through the Operating Subsidy (not ROSS-Elderly/Persons with Disabilities)?

Yes  No 

NOTE: If yes, and you request and are granted funding for an SC to serve Elderly/Disabled Residents through this NOFA, you will forgo any future EDSC Renewal funding.

8. RA Applicants - please indicate your RA type by checking the corresponding box:

1. Local/Site Based Resident Association 

2. Local/Site-Based Resident Council 

3. City-Wide Resident Association 

4. Jurisdiction-Wide Resident Association 

5. Intermediary Resident Association 

6. Regional Resident Association 

7. Resident Management Corporation 

8. Statewide Resident Association 

9. National Resident Association 

9. RA applicants – to be eligible you must indicate your nonprofit/incorporated status:

1. Nonprofit 

Please specify nonprofit type:

• 501(c)(3) 

• 501(c)(4) 

• State-recognized nonprofit 

• Other  Please specify: _________________

You must submit documentation with your application attesting to your nonprofit status.

2. Incorporated organization 

10. 501(c)(3) Non-Profit Applicants - indicate whether you are submitting your application on behalf of a PHA, tribe/TDHE, or RA:

• PHA 

• Tribe/TDHE 

• RA 

11. Do you (the applicant) have a current ROSS-SC grant (i.e., a grant that was awarded within 2 years from the date of this application)?

Yes  No 

If yes, please provide your ROSS grant #: ____________________

12. If yes to question 11, are you applying to serve only projects that are not served by your current ROSS-SC grant?

Yes  No 

Service Coordinator (SC) Information

SC positions requested	Project(s) to be served (See NOFA for limits. If different PHAs, list all.)	Number of units to be served (See NOFA for minimum number of units)	Clients to be served - families - elderly - both	Year	Salary/Fringe (See NOFA for limits.)	Admin (See NOFA for limits.)	Training (See NOFA for limits.)
1				1	$	$	$
				2	$	$	$
				3	$	$	$
2				1	$	$	$
				2	$	$	$
				3	$	$	$
3				1	$	$	$
				2	$	$	$
				3	$	$	$
				Total	$	$	$
TOTAL GRANT REQUESTED $ _________________________________________________________________

For each SC position requested, fill in one large row.

Form HUD-52768 (12/2011)