83C Attachment-1(NOFA)

Local Housing Counseling Agency (LHCA)
Application

OMB Number: 2502-0261
Expiration Date: 07/31/2019

Burden Statement:
Public reporting burden for this collection of information is estimated to average 40 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. The information is being collected for a housing counseling agency to participate in HUD’s Housing
Counseling program. The information will be used by HUD to ensure that Counselors provide guidance and advice to help families
and individuals improve their housing conditions and meet the responsibilities of tenancy and homeownership. Counselors also help
borrowers avoid predatory lending practices, such as inflated appraisals, unreasonably high interest rates, unaffordable repayment
terms, and other conditions that can result in a loss of equity, increased debt, default, and foreclosure. This agency may not collect
this information, and you are not required to complete this form, unless it displays a valid OMB control number.

form HUD-9906-L (10/2016)

CHART A1 -- LHCA CHARACTERISTICS
RATING FACTORS 1, 2, 3 AND 5
NOTE: Entering an "x" indicates a "Yes" response.
Rating Factor 1
B) Name of Applicant
C) Location City

State

D) Agency's HUD Housing Counseling System (HCS) Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
or Disaster Recovery
E) Promise
Promise Zones
Zones /. Housing
. . . . . . . .Counselors
. . . . . . . . . Received
. . . . . . . . Emergency
. . . . . . . . . .Preparedness
.
Training
J) Number of Housing Counselor Full-Time Equivalents (FTE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
K) Number of HUD HECM ROSTER
Roster Counselors
(if applicable)
. . . . . . .(if. .applicable)
.........................
Reverse Mortgage
Counselors
L) Average Counseling Hours per FY 2017
2016 HECM Client (if applicable) . . . . . . . . . . . . . . . . . . . . . . . . .
M) Formal Housing Counseling Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
N) HUD-certified
Require Testing/Certification
for Counselors
Housing Counselors
On Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
O) Alternate Mode(s) of Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
P) Adopted National Industry Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Q) Counseling Services available in Multiple Languages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
R) Alternate Formats Accessible to Persons with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
S) Client Exit Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
T) Follow-up Client Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rating Factor 2
U) Serves Rural Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
V) Serving Area with No Internet Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sole Agency Providing
W) Geographically
IsolatedHousing
Agency Counseling
. . . . . . . . . .Services
. . . . . . . in
. . Target
. . . . . .Area
.............................
Rating Factor 3
Y) Name(s) of Housing Counseling Related Partnerships/Collaboratives, if Applicable

Rating Factor 5
Z) Uses Reviews by Senior Management Staff with Results Reported to Organization's Board . . . . . . .
AA) Publishes Performance Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AB) Link to Published Performance Data, if Available Online

AC) Name of CMS

AD) Uses CMS to Generate Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AE) Use CMS to Record Notes, Action Plan, Financial Analysis and Follow-up . . . . . . . . . . . . . . . . . . .
AF) Uses CMS to Track Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AG) Performs Quality Control Review of CMS Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AH) Pulled Credit Reports 6 or More Months after Counseling was Completed . . . . . . . . . . . . . . . . . . . .
AI) Uses Other Methods of Evaluating Program Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Describe:

form HUD-9906-L (10/2016)

CHART B1
B ----SERVICES
CHART
SERVICESAND
ANDMODES
MODES
RATING FACTOR 3 (2A)
Applicant Name:

EXAMPLE

NOTE: Applicants proposing to fund sub-grantees and/or branches* must indicate the number of proposed sub-grantees and branches which will provide the proposed services.
*Do NOT include branches of sub-grantees.

Example: Housing Counseling
Service to be Provided 10/1/2017-3/31/2019
EXAMPLE: Housing Counseling Service

A

EXAMPLE

B

Indicate if One-on-One
Counseling Provided by
Applicant

C

# of Sub-grantees and/or
Branches* that Provided Oneon-One Counseling

D

Indicate if Group Education
Provided by Applicant

E

# of Sub-grantees and/or
Branches* that Provided Group
Education

F

Service Will be Provided In
Person

G

# of Sub-grantees and/or
Branches* that Will Provide
Service In Person

H

Service Will be Provided Via
Telephone

I

# of Sub-grantees and/or
Branches* that Will Provide
Service Via Telephone

J

Service will be provided Over
the Internet?

K

# of Sub-grantees and/or
Branches* that Will Provide
Service Over the Internet

L

Service Will Be Available in
Multiple Languages?

M

# of Sub-grantees and/or
Branches* that Will Provide
Service in Multiple Languages

Pre-purchase/
Home buying

Resolving/Preventing
Mortgage Delinquency
or Default

Home Maintenance and
Financial Management for
Homeowners (NonDelinquency Post-Purchase)

Rental
Topics

Homeless
Assistance

Reverse
Mortgage

TOTAL

2

5

5

10

1

4

4

2

5

5

10

1

5

5

1

2

2

1

2

2
form HUD-9906-L (10/2016)

OMB Number: 2502-0261
Expiration Date: 04/30/2016

CHART B1
B ----SERVICES
CHART
SERVICESAND
ANDMODES
MODES
RATING FACTOR 3 (2A)
Applicant Name:

NOTE: Applicants proposing to fund sub-grantees and/or branches* must indicate the number of proposed sub-grantees and branches which will provide the proposed services.
*Do NOT include branches of sub-grantees.

Housing Counseling Service to be Provided 10/1/2017-3/31/2019
Housing Counseling Service

Pre-purchase/
Home buying

A

Resolving/Preventing
Mortgage Delinquency
or Default

Home Maintenance and
Financial Management for
Homeowners (NonDelinquency Post-Purchase)

Rental
Topics

Homeless
Assistance

Reverse
Mortgage

TOTAL

B

Indicate if One-on-One
Counseling Provided by
Applicant

0

C

# of Sub-grantees and/or
Branches* that Provided Oneon-One Counseling

0

D

Indicate if Group Education
Provided by Applicant

0

E

# of Sub-grantees and/or
Branches* that Provided Group
Education

0

F

Service Will be Provided In
Person

0

G

# of Sub-grantees and/or
Branches* that Will Provide
Service In Person

0

H

Service Will be Provided Via
Telephone

I

# of Sub-grantees and/or
Branches* that Will Provide
Service Via Telephone

0

J

Service will be provided Over
the Internet?

0

K

# of Sub-grantees and/or
Branches* that Will Provide
Service Over the Internet

0

L

Service Will Be Available in
Multiple Languages?

0

M

# of Sub-grantees and/or
Branches* that Will Provide
Service in Multiple Languages

0

0

CHART C1
OTHERHUD
HUDPROGRAMS
PROGRAMS
C ----OTHER
RATING FACTOR 3 (3B)
Applicant Name:
NOTE: Applicants proposing to fund sub-grantees and/or branches must indicate the number of proposed sub-grantees and branches (Column D below) which provided (during 10/1/15 - 9/30/16)
housing counseling services in conjunction with other HUD programs that are marked in Column C below.
A

HUD Program

B

C

Administering Office

Second Mortgage Assistance for First-Time Homebuyers

Community Planning and
Development

Rural Housing Stability Grant Program

Community Planning and
Development

Public Housing Operating Fund

Public and Indian Housing

Housing Choice Voucher (Section 8) Tenant-Based Rental
Assistance Homeownership Option

Public and Indian Housing

Demolition and Disposition of Public Housing

Public and Indian Housing

Family Self-Sufficiency

Public and Indian Housing

Public Housing Resident Homeownership Programs

Public and Indian Housing

Conversion of Distressed Public Housing to Tenant-Based
Assistance

Public and Indian Housing

Low Income Housing Preservation and Resident
Homeownership Act Prepayment Options

Public and Indian Housing

Native American Housing Assistance Self Determination
Act Housing Block Grants

Public and Indian Housing

Native Hawaiian Housing Block Grants

Public and Indian Housing

Housing Choice Voucher (Section 8) Rental Assistance

Public and Indian Housing

D

Indicate if Applicant
For Intermediaries, SHFAs and MSOs
Provided Housing Counseling
Number of Sub-grantees and/or
Branches That Provided Service(s) in
Services in Conjunction with
Conjunction with HUD Programs,
HUD Programs, during
10/1/2017 - 3/31/2019
during 10/1/15 - 9/30/16
10/1/15 - 9/30/16

HUD-Sponsored Housing Counseling-Related Research or Pilot Program:
Must specify
Other:
Must specify

TOTAL

0

0

form HUD-9906-L (10/2016)

CHART D
D1----LEVERAGING
LEVERAGING
RATING
FACTOR
4 4
RATING
FACTORS
3 AND

OMB Number: 2502-0261
Expiration Date: 07/31/2019

Leveraged Resource 1 of 1
A. Applicant/Sub-grantee/Branch
B. Name of Applicant, Sub-grantee/Branch Office
Proposed to be Funded

C. Organization Providing Leveraged Funds/In-kind
Contributions
Point of Contact at Organization
Providing Leveraged Funds/In-kind
Contributions

Prefix

First Name

Last Name

Middle Name

Suffix

D. Type of Contribution (Cash, Fees, In-kind, Program
Income)
E. Funds Must be Available During the Grant Period

10/01/17 - 3/31/2019

F. Use of Funds -- Only Include Funds that are Exclusively
Allocated for Housing Counseling Program

G. Only Include the Amount of Funds that are Available
$
from October 1, 2017
2016 to March 31, 2019
2018
TOTAL

$

form HUD-9906-L (10/2016)

E.1 -- LHCA
CHART CHART
E.1 -- ACTUAL
EXPENSES
RATING FACTORS 1, 2, 3 AND 5
1 Applicant Name:
Maximum Grant Request (Optional): This amount, if provided, will be considered in the funding
methodology as a cap in establishing the maximum grant amount for the Applicant. In other words,
successful Applicants that specify a maximum grant request will receive a grant that is no higher
than the specified amount. If you do not want to specify a maximum grant request, leave this box
2 blank.

$

3

(A)

(B)

4

Expenses

Applicant's Total FY 2016
2017
Expenses, All Sources

5 Salaries
6

Housing Counselors

7

Housing Counseling Program Managers

8

All Other Housing Counseling Program Staff

9 Fringe Benefits
10

Housing Counselors

11

Housing Counseling Program Managers

12

All Other Housing Counseling Program Staff

13 Total Other Direct Costs
14 Other (Must Provide Explanation of Other Expenses in Narrative)
15

Total Direct Costs $

16 Indirect Cost Allocation Amount (if applicable)
17

TOTAL EXPENSES $

form HUD-9906-L (10/2016)

CHART FF1-- --AFFIRMATIVELY
AFFIRMATIVELYFURTHERING
FURTHERINGFAIR
FAIRHOUSING
HOUSING
CHART
RATING
FACTORS
2 AND
3
RATING
FACTOR
3

OMB Number: 2502-0261
Expiration Date: 07/31/2019

Applicant Name

Instructions: All Applicants must complete Fields A through E of the chart below to demonstrate how the Applicant will
fulfill its obligation to affirmatively further fair housing in the use of Housing Counseling grant funds.
Rating Factor 2, Sub-Factor 1(c)
(A) Jurisdiction/Service Area

(B) Brief description of impediments to fair housing choice in the jurisdiction/service area identified in Field A

(C) Information Source for Impediments identified in Field B (e.g. applicable state or local Consolidated Plan, Analysis of
Impediments, or Assessment of Fair Housing)

Rating Factor 3, Sub-Factor 2(c)
(D) Brief description of an activity that addresses an impediment to fair housing choice identified in Field B

(E) Brief description of how Applicant will measure outcomes related to the activity proposed in Field D

form HUD-9906-L (10/2016)

CHART G1 -- OVERSIGHT ACTIVITIES
CHART
G --FACTOR
OVERSIGHT
RATING
3 (1CACTIVITIES
AND 2B)
RATING FACTOR 3 SUB-FACTORS 1 (c) and 2 (b)
CHART G.1: LHCAs ONLY
Applicant Name:
For Rating Factor 3, Sub-factor 1(c), LHCAs must complete Chart G.1, by checking a box in Column B for the actual oversight activities conducted during FY 2016.
2017 Items selected in this
chart may be verified by HUD staff during a performance review.
For Rating Factor 3, Sub-factor 2(b), LHCAs must complete Chart G.1, by checking a box in Column C for oversight and quality control activities that will be performed as part of the
proposed FY 2017 work plan. Items selected in this chart may be verified by HUD staff during a performance review.
A

Oversight Activity

i.

Maintain disbursement supporting documentation, including personnel activity reports [or other
personnel expense documentation that satisfies 2 CFR 200.430(i) requirements], invoices, client file
lists, or similar forms of documentation.

ii.

Conduct and document quality control of disbursement process consistent with OMB and HUD
grant requirements.

iii.

Conduct supervisory monitoring by reviewing client and education files for compliance with HUD
recordkeeping requirements.

iv.

Conduct supervisory monitoring of counseling service activities to ensure Delivery of Services
requirements outlined in HUD Handbook 7610.1, Paragraph 3-5 are met.

v.

Conduct random supervisory monitoring of an interactive counseling session.

Rating Factor 3, Sub-factor 1 (c)

Rating Factor 3, Sub-factor 2 (b)

B

C

Actual Activities Performed
in FY 2016
2017

Proposed Activities to be Performed
in FY 2017
2018

form HUD-9906-L (10/2016)