HUD-52651 Family Self-Sufficiency (FSS) Program Coordinator Fundin

Public reporting burden for this collection of information is estimated to average 1 hour. This includes the time for collecting, reviewing, and reporting the data. Information provided is to determine the eligibility of the applicant for funding for the salary of a program coordinator. HUD uses the information to determine eligibility of the applicant to receive funding. Information is required to obtain benefit under 24 CFR 984.302. The information is subject to the confidentiality requirements of the HUD Reform Legislation. 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.

PART I: General Information. (To be completed by all applicants.)

1. State or Regional PHA?

Yes No

B. PHA Legal Name (For joint applicants, lead PHA name):      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

C. Legal Name of Joint Applicant PHA. (If applicable.)      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

PHA Number of Applicant:      

Note: Please use the table on page 7, Appendix A below to list any additional co-applicants.

PART II: Funding/Positions Requested by PHAs that are Currently Administering

FSS Programs

A. Previously Funded Positions

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)	Indicate whether Full-Time or Part-Time
1.	     	     
2.	     	     
3.	     	     
4.	     	     
5.	     	     
6.	     	     
7.	     	     
8.	     	     
9.	     	     
10.	     	     
Total Salary Requested:	     

2. New Positions – Positions not funded previously under a NOFA.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)	Indicate whether Full-Time or Part-Time
1.	     	     
2.	     	     
3.	     	     
4.	     	     
5.	     	     
6.	     	     
7.	     	     
8.	     	     
Total Salary Requested:	     

Note: Please use the tables on page 8, Appendix A below if you need additional space for previously

funded and/or new positions.

2. Total Requested

1.	    	Total number of positions requested in Part II (enter 0.5 for part-time positions)
2.	     	Total salary requested in Part II (add totals from Part II.A and Part II.B)

D. Total number of families under FSS contract during the NOFA target period.

PART III: Requests for PHAs that are NOT currently administering FSS Programs

1. FSS Action Plan Information:

    

The number of FSS program slots in the HUD-approved Action Plan. (For Joint applications, provide total approved slots for all joint applicant PHAs.)

2. Position/Salary Requested:

Position Number:	Salary Requested under this NOFA (Including Fringe Benefits) **	Indicate whether Full-Time or Part-Time
1.	     	     
2.	     	     
3.	     	     
4.	     	     
5.	     	     
6.	     	     
7.	     	     
8.	     	     
9.	     	     
10.	     	     
Total Salary Requested:	     

2. Total Requested.

1.	    	Total number of positions requested in Part III (enter 0.5 for part-time positions)
2.	     	Total salary requested in Part III

Instructions:

1. The FSS NOFA supplements this set of instructions. Please read the NOFA carefully to ensure that you are following all instructions in completing this form.

2. Previously Funded Positions (Part II.A.): The examples below help illustrate how to enter the information on this table.

Example 1: PHA is requesting 2 full-time renewal positions at $55,000 each.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time
1.	$55,000	Full-time
2.	$55,000	Full-time
3.
Total Salary Requested:	$110,000

Example 2: PHA is requesting 1 full-time renewal position at $45,000 and 1 full-time renewal position at $50,000.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time
1.	$45,000	Full-time
2.	$50,000	Full-time
3.
Total Salary Requested:	$95,000

Example 3: PHA is requesting 1 part-time renewal position at $30,000..

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time
1.	$30,000	Part-time
2.
3.
Total Salary Requested:	$30,000

3. New Positions (Part II.B.): Positions not funded previously under a NOFA.

• See the NOFA for more information on whether new positions (positions not funded previously under a NOFA) are allowed and whether applicants may qualify for part-time positions beyond the initial position (for example, whether an applicant can qualify for 1.5 positions).

• The examples below help illustrate how to enter the information on this table.

Example 1: PHA is requesting 2 new full-time positions at $55,000 each:

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time
1.	$55,000	Full-time
2.	$55,000	Full-time
3.
Total Salary Requested:	$110,000

Example 2: PHA is requesting 1 new full-time position at $45,000 and 1 new full-time position at $50,000:

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time
1.	$45,000	Full-time
2.	$50,000	Full-time
3.
Total Salary Requested:	$95,000

4. Requests for PHAs that are NOT currently administering FSS Programs (Part III.):

• See the NOFA for more information on whether Part III is applicable (i.e. whether PHAs not currently administering an FSS program are eligible to apply).

• Position/Salary Requested (Part III.B.):The examples below help illustrate how to enter the information on this table.

Example 1: PHA is requesting 1 new full-time position at $55,000:

Position Number:	Salary Requested under this NOFA (Including Fringe Benefits) **	Indicate whether Full-Time or Part-Time
1.	$55,000	Full-time
2.
3.
Total Salary Requested:	$55,000

Example 2: PHA is requesting 1 new part-time position at $30,000:

Position Number:	Salary Requested under this NOFA (Including Fringe Benefits) **	Indicate whether Full-Time or Part-Time
1.	$30,000	Part-time
2.
3.
Total Salary Requested:	$30,000

Appendix A: use only if additional space is needed

Part I.B. Legal Name of Joint Applicant PHAs.

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

APPENDIX A (continued)

Part II.A. Previously Funded Positions.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time		FY Last Funded	Salary Amount Last Funded	Is Applicant’s Request Above Percentage Allowed in the NOFA (if applicable)? ‘Y’ or ‘N’
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.	     	     		     	     	 
Total Salary Requested:	     

Part II.B. Additional Positions.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time
9.	     	     
10.	     	     
11.	     	     
12.	     	     
13.	     	     
14.	     	     
15.	     	     
16.	     	     
Total Salary Requested:	     

Page 9 of 9 HUD-52651