HUD-52515 Funding Application - Housing Choice Voucher Program

OMB Approval No. 2577-0169

U.S Department of Housing and Urban Development

Office of Public and Indian Housing

Funding Application

Housing Choice Voucher Program

The public reporting burden for this information collection is estimated to be up to 5 hours, 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 Department of Housing and Urban Development (HUD) is authorized to collect the information on this form by Section 8 of the U.S. Housing Act (42 U.S.C. 1437f). Form is only valid if it includes an OMB Control Number.

Name and Mailing Address of the Public Housing Agency (PHA)			PHA Code
Number of Vouchers Requested	Geographic Area/Jurisdiction (describe the area in which assisted may live)
If directed in the NOFA or Funding Notice, complete additional fields on the next page of this form. HUD is committed to protecting the privacy of individual’s information stored electronically or in paper form in accordance with federal privacy laws, guidance and best practices. HUD expects its third-party business partners including public housing authorities who collect, use, maintain, or disseminate HUD information to protect the privacy of that information in accordance with applicable law. PHA Signature
Signature of PHA Representative		Print or Type Name of Signatory
Email Address		Phone Number		Date
Capacity of the Organization
Need/Extent of the Problem
Soundness of Approach
Leveraging Resources
Achieving Results and Program Evaluation
Memorandum of Understanding
Other Information Required in the NOFA or Funding Notice
Program Specific Certifications (enter here any certification required in the NOFA or Funding Notice)

Previous editions are obsolete 1 HUD-52515