Form HUD-52768 Ross Service Coordinators - Funding Request

OMB Approval No. 2577-0229
Expiration Date 6/30/2018

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):
a. Public Housing Authority (PHA)

b. Tribe/Tribally Designated Housing Entity (TDHE) 
c. Resident Association (RA)

- RAs must also answer questions 8 and 9
d. 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:
a. Local/Site Based Resident Association



Form HUD-52768 (06/2015)

OMB Approval No. 2577-0229
Expiration Date 6/30/2018

b.
c.
d.
e.
f.
g.
h.
i.

Local/Site-Based Resident Council
City-Wide Resident Association
Jurisdiction-Wide Resident Association
Intermediary Resident Association
Regional Resident Association
Resident Management Corporation
Statewide Resident Association
National Resident Association










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



Please specify nonprofit type:
-

501(c)(3)
State-recognized/incorporated nonprofit
Other



 Please specify: _________________

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

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 

Form HUD-52768 (06/2015)

OMB Approval No. 2577-0229
Expiration Date 6/30/2018

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

Year

Salary/Fringe

Admin

Training

(See NOFA for
limits.)

(See NOFA for
limits.)

(See NOFA for
limits.)

$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$

- families
- elderly
- both

1
2
3
1
2
3
1
2
3
Total

1

2

3

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

Form HUD-52768 (06/2015)