83C Attachment-2 (NOFA)

Intermediary, State Housing Finance Agency,
Chart
A -- AgencyOrganization
Characteristics
and Multi-State
RATING FACTORS
1, 2, 3 AND 5
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.

Select whether your agency is applying as an LHCA, or as an Intermediary/SHFA/MSO
LHCA
Intermediary, SHFA, or MSO

form HUD-9906-P (10/2016)

CHART
INTERMEDIARY,
SHFA,
MSO
CHARACTERISTICS
CHART
A.2.A2
-- -INTERMEDIARY,
SHFA
OROR
MSO
CHARACTERISTICS
RATING FACTORS 1, 2, 3 AND 5
INSTRUCTIONS: The first page of this form is for the Applicant. Each branch and/or sub-grantee must be added individually below, using
the “Add a Branch/Sub-grantee” button. Totals are included at the bottom of the form and should be reviewed for accuracy. If totals are
incorrect, revise theThe
“Applicant”
or “Branch
and/orisSub-grantee”
that contains
the error. main office provides direct housing
INSTRUCTIONS:
first page
of this form
for the applicant.
If the Applicant's

counseling
Applicant activities, the main office must be included in the list of sub-grantees and branches in the Chart A2 attachment. All
Intermediary, SHFA, and MSO applicants must fill out and submit the Chart A2 attachment with their branch and/or subNOTE: Ifinformation.
the Applicant's main office provides direct housing counseling activities, the main office must be included in the list of subgrantee
grantees and branches.

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E) Preferred Sustainable Communities / Promise Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
J) Number of Housing Counselor Full-Time Equivalents (FTE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
K) Number of HUD HECM Roster Counselors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
L) Average Counseling Hours per FY 2016 HECM Client (if applicable) . . . . . . . . . . . . . . . . . . . . . . . . .
M) Formal Housing Counseling Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
N) Require Testing/Certification for Counselors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

*Chart
A2 Attachment
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
W) Geographically Isolated Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rating Factor 3
X) % of Award Applicant Intends to Allocate to Itself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
form HUD-9906-P (10/2016)

TOTAL
Totals

from Chart A2 Attachment

NOTE: If the Applicant's main office provides direct housing counseling activities, the main office
must be included in the list of sub-grantees and branches,. and thus will be included twice in these
totals.
Rating Factor 1
E

Promise
Zones
/ HousingCommunities
Counselors Received
Preferred
Sustainable
/ PromiseEmergency
Zones Preparedness or Disaster Recovery Training

0

F

Branch of an Intermediary, MSO or SHFA

0

G

Sub-grantee that is NOT HUD-Approved LHCA

0

H

Sub-grantee that is HUD-approved LHCA

I

Number of Sub-grantee's Branches

0.0

J

Number of Housing Counselor Full-Time Equivalents (FTE)

0.0

K

Number of HUD HECM Roster Reverse
Counselors
Mortgage Counselors (if applicable)

0.0

L

Average Counseling Hours per FY 2017
2016 HECM Client (if applicable)

M

Formal Housing Counseling Training

0

N

Require Testing/Certification
for Counselors
HUD-certified
Housing Counselors
On Staff

0

O

Alternate Mode(s) of Counseling

0

P

Adopted National Industry Standards

0

Q

Counseling Services available in Multiple Languages

0

R

Alternate Formats Accessible to Persons with Disabilities

0

S

Client Exit Surveys

0

T

Follow-up Client Surveys

0

0

Rating Factor 2
U

Serves Rural Community

0

V

Serving Area with No Internet Access

0

W

Geographically
IsolatedHousing
Agency Counseling Services in Target Area
Sole
Agency Providing

0

Rating Factor 3
X

% of Award Applicant Intends to Allocate to Itself or Each Branch or Sub-grantee

0

Y

Name(s) of Housing Counseling Related Partnerships/Collaboratives, if Applicable

0

Rating Factor 5
Z

Uses Reviews by Senior Management Staff with Results Reported to Organization's Board

0

AA

Publishes Performance Data

0

AB

Link to Published Performance Data, if Available Online

AC

Name of CMS

AD

Uses CMS to Generate Reports

0

AE

Use CMS to Record Notes, Action Plan, Financial Analysis and Follow-up

0

AF

Uses CMS to Track Grants

0

AG

Performs Quality Control Review of CMS Data

0

AH

Pulled Credit Reports 6 or More Months after Counseling was Completed

0

AI

Uses Other Methods of Evaluating Program Services

0

CHART
SERVICESAND
ANDMODES
MODES
CHARTB2
B ----SERVICES
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
Example: Housing Counseling
Service to
be Provided
10/1/2017 - 3/31/2019

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-P (10/2016)

CHART
SERVICESAND
ANDMODES
MODES
CHARTB2
B ----SERVICES
RATING FACTOR 3 (2A)

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

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

CHARTCC2
OTHER
HUD
PROGRAMS
CHART
-- -OTHER
HUD
PROGRAMS
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 10/1/2017-3/1/2019)
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

D

Administering Office

Indicate if Applicant
Provided Housing Counseling
Services in Conjunction with
HUD Programs, during
10/1/15 - 9/30/16
10/1/2017-3/1/2019

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

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

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

TOTAL

0

0

form HUD-9906-P (10/2016)

CHART
LEVERAGING
CHARTD2
D ----LEVERAGING
RATING
FACTORS
3 AND
RATING FACTOR
4 4

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

Leveraged Resource 1 of 1

INSTRUCTIONS: All applicants must fill out and submit the Chart D attachment and enter the total amount of leveraged funds
available from 10/1/2017-3/31/2019 here.

A. Applicant/Sub-grantee/Branch

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

*Chart D2
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

10/01/16 -- 3/31/2018

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, 2016 to March 31, 2018

Total of Leveraged Funds Available
TOTAL $
10/1/2017-3/31/2019

form HUD-9906-P (10/2016)

E2 -- ACTUAL EXPENSES
CHARTCHART
E.2 -- INTERMEDIARY,
SHFA, OR MSO
RATING FACTORS 1, 2, 3, AND 5

1 Applicant Name:

2

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 blank.

$

2017 Grant Period Percentage of HUD Funds Sub-allocated to Sub-grantees and Branches
3 FY 2016

4

5

%

(A)

(B)

(C)

(D)

Expenses

Applicant's Total FY 2017
2016
Administrative Expenses,
All Sources (Do Not Include
Funds Sub-allocated to
Sub-grantees/Branches)

Total FY 2017
2016 Expenses of
all Sub-Grantees/Branches,
All Sources (Include Main
Office that Provides Direct
Counseling)

(B + C) Networkwide Total FY 2016
2017
Expenses, All Sources

6 Salaries
7

Housing Counselors

$

8

Housing Counseling Program Managers

$

9

All Other Housing Counseling Program Staff

$

10 Fringe Benefits
11

Housing Counselors

$

12

Housing Counseling Program Managers

$

13

All Other Housing Counseling Program Staff

$

14 Total Other Direct Costs
Other (Must Provide Explanation of Other
15 Expenses in Narrative)
16

Total Direct Costs $

$
$
$

17 Indirect Cost Allocation Amount (if applicable)
18

TOTAL EXPENSES $

$
$

$

$

form HUD-9906-P (10/2016)

CHART
AFFIRMATIVELYFURTHERING
FURTHERINGFAIR
FAIRHOUSING
HOUSING
CHART F2
F ----AFFIRMATIVELY
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-P (10/2016)

CHART
-- -OVERSIGHT
ACTIVITIES
CHARTGG2
OVERSIGHT
ACTIVITIES
RATING FACTOR
SUB-FACTORS
1 (c)
and 2 (b)
RATING 3FACTOR
3 (1C AND
2B)
CHART G.2: INTERMEDIARIES, MSOs AND SHFAs ONLY
Applicant Name:
For Rating Factor 3, Sub-factor 1(c), Intermediaries, MSOs and SHFAs must complete Chart G.2, by checking a box in Column B and entering the number of affiliates/sub-grantees/
branches for which oversight and quality control activities were performed as part of the actual FY 2017
2016 work plan in Column C. Items selected in this chart may be verified by HUD staff during
a performance review.
For Rating Factor 3, Sub-factor 2(b), Intermediaries, MSOs and SHFAs must complete Chart G.2, by checking a box in Column D and entering the number of affiliates/sub-grantees/
branches for which oversight and quality control activities that will be performed as part of the proposed FY 2017
2018 work plan in Column E. Items selected in this chart may be verified by HUD
staff during a performance review.
Enter
total
number
of of
affiliates/sub-grantees/branches
in in
thethe
Applicant's
FYFY
2016
network
asas
of of
10/1/2015.
1.
Enter
total
number
affiliates/sub-grantees/branches
Applicant's
2017
network
10/1/2016
Enter
thethe
number
of performance
reviewsreviews
conducted
in FY 2016.
2.
Enter
total number
of performance
conducted
in FY 2017
3.
Enter
number
affiliates/sub-grantees/branches
(from
0 to
a maximum
which
Applicant
conduct a performance
Enter
thethe
number
of of
affiliates/sub-grantees/branches
(from
0 to
a maximum
of of
5) 5)
forfor
which
thethe
Applicant
willwill
conduct
review in FY review
2018 using
HUD-9910
Applicants
share the
results
these
reviews
with reviews
HUD. with HUD.
a performance
in FYthe
2017
using theform.
HUD-9910
form.must
Applicants
must
shareofthe
results
of these

Rating Factor 3, Sub-factor 1 (c)
A

Oversight Activity
i.

Train and provide technical assistance to affiliates/sub-grantees/branches.

ii.

Monitor, evaluate and verify quality of services provided by affiliates/sub-grantees/branches:

B

C

# of Affiliates/Subgrantees/Branches
Actual Activities for which Activity
Performed
was Performed in
in FY 2017
2016
FY 2017
2016

Rating Factor 3, Sub-factor 2 (b)
D

E

Proposed
Activities to be
Performed
in FY 2018
2017

Proposed # of
Affiliates/Subgrantees/Branches
for which Activity
will be Performed
in FY 2018
2017

Verify affiliates/sub-grantees/branches are conducting supervisory monitoring work of housing
counseling staff.
Verify affiliates/sub-grantees that are not directly approved by HUD meet HUD's approval
standards.
Monitor the grant funded work of sub-grantees/ branches to verify compliance with HUD grant
agreement requirements and progress in meeting projections.
Identify and rectify service delivery deficiencies and non-compliance issues.
iii.

Process sub-grantees' and branches' disbursements under the grant:
Review 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.
Conduct and document quality control of disbursement process consistent with OMB and HUD
grant requirements.

form HUD-9906-P (10/2016)