52671-e_Round III_3-8-21

COVID-19 Supplemental
Payment (CSP) Request

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

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Property/Management Company Phone Number
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FHA Project No. Assistance Contract(s) #

Contract Type (HAP, PRAC, SPRAC, PAC)


CSP Request Type (Tier I or II)

Property/Management Company Email Address

Operating Period for Which Reimbursement is Requested:
Combined Request (Tier 1 only):

OMB Approval No. 2502-0619
(Exp. X/XX/XXX)

Complete Parts I to III to determine

#1: 3/27/2020 to 7/31/2020
Periods #1 and #2

Tier I

#2: 8/1/2020 to 11/30/2020

Periods #2 and #3

Part I. Amounts Requested for Eligible COVID-19 Operating Expense Increases

PAC

✔ #3: 12/1/2020 to 3/31/2021

Periods #1 and #3

Periods #1, #2, and #3

Requested Amount

1. Payroll Costs: Custodial or Other Operational Staff (OT or other staff increase) (6510)
2. Contract Services: Cleaning/Sanitizing or Security Services (6520/6530)
3. Payroll Costs: Administrative Functions (OT or increase in hours if part-time) (6310)
4. Contract Services: Administrative Functions (6390)
5. Cleaning/Sanitizing Supplies and PPE (6515/6590)
6 Office Equipment/ IT (6311)
7. Other Allowable Costs (Specify Budget Line________ )
8 . Total Request Part I (calculated field)

$0

Part II. Multifamily Service Coordination for the Elderly and Disabled
(Eligible Section 8 and Section 202 Properties Only; see Notice H 2021-X, Section V)
9. Payroll Costs (OT or Increase in hours if Part-Time) (MFSC) (6900)
10. Coordinator Contract Services (MFSC) (6900)
11. Office Equipment/IT (MFSC) (6900)
12. PPE (MFSC) (6900)
13. Total Request Part II (calculated field)

$0

14. TOTAL COVID-19 Supplemental Payment Requested (calculated field; sum of lines 8 and 13)

$0

Part III. Calculation of Tier I Standard Payment Cap
15. Number of Assisted Units Under Contract
16. Unit-Based Allowance (calculated field; $60 per unit )

$- 0

17. Additional Property Allowance ($1k) Where Designated to Serve the Elderly (see Notice H 2021-X, Footnote 5)
18. Standard Property Allocation
19. Allowance for Ongoing Service Coordination ( Eligible Budget-Based Coordinators Only)

$ 2,000

$0

(calculated field; lesser of $3,000 or line 13 total)
20. Maximum Tier 1 Standard Payment* (calculated field)

$ 2,000

* Payments are only available to the extent required for eligible project cost increases and will not exceed the total on line 14.

Part IV. Tier II Request Information (if applicable)
Properties requesting funding at or below the Tier 1 Standard Payment Cap (line 20) do not need to complete Part IV and should skip to Part V. CSP requests
for amounts above the Tier 1 Cap (line 20) require completion of Section V and submission of documentation for expenses. Please see Section VIII of Notice H
2021-X for additional details on threshold eligibility requirements and documentation requirements for Tier II requests.
21. Requested Tier II Funding Increment (calculated field; amount above line 21 Standard Payment Cap)

$0

22. Which of the following apply for the requesting property? (check all that apply)
Multiple resident cases of COVID-19;
Documented on-site exposure threatening a high-risk population;
An infection rate in the surrounding county exceeding 1,000 confirmed cases per 100,000 people.

HUD-52671-E (3/2021)
ref. Notice H-2021

23. Justification Narrative for Tier II Payment Request (See Notice H 2021-X, Section VIII)
Attach supplemental pages as needed.

24. Financial Need Justification for Tier II (Only Required for Properties with Recent Surplus Cash; See Notice H 2021-X, Section VIII)
Attach supplemental pages as needed.

Part V. Other Supplemental Information (Both Tier I and Tier II Requests)
25. Has this property received funding from other assistance programs authorized by the CARES Act (P.L. Public Law 116-136)? (Y/N)
26. If yes, which program?

Yes

How much was awarded/provided?

Yes

27. Do you currently have a budget-based rent increase pending with HUD/PBCA? (Y/N)

28. Have you withdrawn or requested withdrawal of balances from residual receipts in 2021 for COVID-19 Expenses? (Y/N) Yes If yes, how much?

HUD-52671-E (3/2021)
ref. Notice H-2021

Part V. Certification and Acceptance of Terms
Owner's Certification: I certify that (1) the requested payment was computed in accordance with HUD’s Housing Notice H2021-X. It reflects only expenses incurred during the operating period(s) specified for eligible activities and purposes. (2)
No amount included on this funding request has been paid from other forms of governmental or philanthropic assistance
provided to address the impact of COVID-19. (3) I have considered current project funds and anticipated revenues over the
next nine months and require this funding in order to address project operating costs. (4) If receiving CSP assistance for a
Section 8 HAP contract, I agree to deposit an amount equal to the amount of the CSP in the residual receipt account, prior
to taking any cash distributions before 3/31/2022. Or, if the Section 8 contract and governing regulations do not require
the project owner to maintain a residual receipt account, I agree that upon taking distributions at any point from the issue
date of this notice through 3/31/2022, an amount at least equal to the amount of the CSP must be retained in the
operating account to address future project costs that is over-and-above the resources needed for current operating
requirements. (5) The property and ownership are in good standing with HUD, as defined in Section VII of Housing
Notice 2021-X. (6) If receiving CSP assistance for a Section 8 HAP contract that expires within 120 days, I anticipate
renewal of the contract and have not communicated intent to opt-out. (7) Upon request by the Department of Housing and
Urban Development, its duly authorized representative, or the Comptroller General of the United States, I will make
available for audit all books, records and documents related to this assistance payment. Warning: HUD will prosecute
false claims & statements, which may result in criminal conviction and/or the imposition of criminal fines and/or civil
penalties, to the full extent allowed by law.
Owner/Signatory Name (Printed)
29. Owner Signature

30. Date Owner Signature

Part VI. HUD/CA Use Only
31. Date Received by HUD/CA
32. Total Amount Eligible for Payment (enter $0 for incomplete of otherwise ineligible requests)
33. Notes on Any Disallowed Costs
34. Approved By (Print Name)
36. Date Approved

35. Approver Signature

This form must be completed by owners to request payment of supplemental assistance to offset operating cost increases related to COVID-19.
Amounts are available to properties with project-based rental assistance contracts under Section 8, Section 202, and Section 811. Please consult
Housing Notice H-2021-X for additional information on eligibility requirements.
The Department of Housing & Urban Development is authorized to collect this information by the Coronavirus Aid, Relief, and Economic Security Act
(CARES Act) (Pub. L. 116-136). The CARES Act provided an additional $1 billion under the heading Project-Based Rental Assistance (PBRA) for
Section 8 properties, $50 million under the heading Housing for the Elderly (Section 202), and $15 million under the heading Housing for Persons with
Disabilities (Section 811) to “prevent, prepare for, and respond to coronavirus, including to provide additional funds to maintain normal operations and
take other necessary actions during the period that the program is impacted by coronavirus.”
The owner/agent must provide all information in order to be considered for a COVID-19 Supplemental Payment. The information provided will be
used by HUD to determine if a request may be funded and the appropriate level of funding to provide.
HUD may disclose this information to Federal, state, and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions.
Otherwise, it will not be disclosed or released outside of HUD, except as permitted or required by law. HUD does not promise confidentiality but will
not disclose data on specific tenants. No questions of a sensitive nature are asked in this form.
Public reporting burden for this collection of information is estimated to average 1.1 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. This agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control
number.

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HUD-52671-E (3/2021)
ref. Notice H-2021