HUD-52769 - Origin ROSS Service Coordinators - NEEDS and SERVICE PARTNERS

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 – NEEDS and SERVICE PARTNERS
________________________________________________________________________
Public reporting burden for the collection of information is estimated to average 4 hours 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 ________________________
PHA/Tribe/TDHE(s) to be Served _______________________________________

NEEDS

NEED?
(check all that
apply – see
NOFA for
requirements)

SERVICE
PROVIDER/PARTNER(s)
(list all)

Value of
Match*

Life Skills Training
Financial Literacy/Credit
Counseling/Credit Repair
Literacy Training
ESL
GED/High School Equiv.
Mentoring
Job Soft Skills Training
Job Hard Skills
Training/Certification
Job Search and Placement
Job Retention/Promotion
ISAs/IDAs
Homeownership
Counseling
Computer Classes
Drug/Alcohol Treatment
Mental Health Treatment
Health/Dental Care
Home Maintenance
classes
Parenting classes
Form HUD-52769 (3/2009)

OMB Approval No. 2577-0229
Expiration Date 05/31/2011

Nutrition classes
Youth Programming –
tutoring/mentoring/after
school/summer
Child Care
Transportation
Tax Preparation
Assistance
Community Safety
Resident
Empowerment/Capacity
Building
Resident Business
Development
Assistance with Activities
of Daily Living
Meals to meet nutritional
need for Elderly
Disability Services
Counseling
Personal Emergency
Response Resources
Wellness Programs
Other (please describe)
Other
Other
Other
Other
TOTAL

$

*I _______________________________, certify that the match recorded here is
supported by letters on file from community or other partners which certify to this
amount of match funding (cash or in-kind) and that this represents the total match for the
term of the grant.
Total Grant Requested $___________
Total Match Documented $____________
Match is _________ % of Grant Requested (must be at least 25% to qualify)
___________________________________
Signature of Authorized Representative
___________________________________
Title

Form HUD-52769 (3/2009)