Quarterly Interim Report Form

OMB Control Number: 1505-0266

U.S. Department of the Treasury

Emergency Rental Assistance Program Q1 Interim Quarterly Report

Pursuant to Section 501 of Division N of the Consolidated Appropriations Act, 2021, Pub. L. No. 116-260 (Dec. 27, 2020)

Instructions: Each data element applicable below should be entered into Treasury's online form directly at the link below or uploaded to Treasury's secure portal. Treasury is unable to accept responses provided by email at this time. Where recipients demonstrate hardship uploading information to the portal, contact Treasury at [email protected].

Thank you for your participation in the Department of the Treasury’s Emergency Rental Assistance Program. The template details information that all ERA grantees receiving a direct payment from Treasury are required to submit for the new Q1 2021 Interim Quarterly Report, covering activity from January 1, 2021 – March 31, 2021, and Monthly Reports, covering activity from April 1, 2021

– April 30, 2021 and May 1, 2021 – May 31, 2021. These templates should only be used in connection with ERA funding made available under the first round of funding provided under the Consolidated Appropriations Act, 2021, Pub. L. No. 116-260 (the “Act”).

The Q1 Interim Quarterly Report covers fourteen data elements. For each element, grantees paid directly by Treasury are required to report on their aggregate data over the previous quarter. For data elements #2 and #9, grantees are also required to provide aggregated totals for all zip codes within their coverage area in which there is data to report.

Grantees have until Friday, May 7, 2021 to submit their Q1 Interim Quarterly Reports to Treasury. Reports must be submitted at the following link [LINK].

The Monthly Reports cover only two of the data elements from the interim quarterly report, #2 and #9. Using the above link, grantees have until May 14, 2021 to submit their monthly report covering activity from April 1, 2021 – April 30, 2021 and until June 15, 2021 to submit

their monthly report covering activity from May 1, 2021 – May 31, 2021.

Treasury will be supplementing these instructions in the coming weeks with other data elements required by section 501(g) of the Act and section 15011 of the CARES Act, Pub. L. No. 116-136, as amended by Division O, Title VIII, Section 801(b) of the Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, on December 27, 2020.

As a reminder, the Department of the Treasury (Treasury) Office of Inspector General (OIG) is responsible for monitoring and oversight of the receipt, disbursement, and use of Emergency Rental Assistance Program funds. Treasury will use the reported information from grantees to determine grantee compliance with program requirements. Grantees should maintain all documents and financial records sufficient to support the data request and establish compliance with program requirements.

Grantee Name:

Grantee City:

Grantee, State, or Territory:

Dun & Bradstreet Number (DUNS):

Contact Name:

Contact Title:

Contact Email:

Contact Phone:

Number	Data Element	Total (# or $)
1	Number of unique households that completed and submitted an application for ERA program assistance.
2	Number of unique households that received ERA assistance of any kind.
3	Number of unique households that received the following types of ERA assistance (where applicable):
	Rent (#)
	Rental arrears (#)
	Utilities/home energy bills (#)
	Utilities/home energy costs arrears (#)
	Other expenses related to housing (#)
	Housing stability services (#)
4	Number of unique households that received ERA assistance with household incomes of less than or equal to 30% of the area median income (AMI).
5	Number of unique households that received ERA assistance with household incomes greater than 30% but less than or equal to 50% of the area median income (AMI).
6	Number of unique households that received ERA assistance in the reporting period that are greater than 50% but less than or equal to 80% of the area median income (AMI).
7	Total number of rental payments paid by the ERA grantee (not counting rental arrears).
8	Total number of utility/home energy bill payments paid by the ERA grantee (not including arrears payments).
9	Total dollar amount of ERA grant funds paid by the ERA grantee to or for participating households.
10	Total dollar value of approved ERA applications that have not yet been paid.
11	Total dollar amount expended by the ERA grantee for administrative expenses.
12	Total dollar value of approved ERA administrative expenses that have not yet been expended.
13	Total dollar amount expended by the ERA grantee for housing stability services.
14	Total dollar value of approved ERA housing stability services that have not yet been expended.

Zip Code (00000-0000 or 00000)	Number of unique households that received ERA assistance (#)	Total dollar amount of ERA assistance provided to households ($)
00000-0000	5458	$0.00

Certification

I certify that the information provided is accurate and complete after reasonable inquiry of people, systems, and other information available to the ERA Grantee.  The undersigned acknowledges that a materially false, fictitious, or fraudulent statement (or concealment or omission of material fact) in this submission may be the subject of criminal prosecution and also may subject the ERA Grantee to civil penalties and/or administrative remedies for false claims or otherwise. The undersigned is an authorized representative of the ERA Grantee with authority to make the above certifications and representations on behalf of the ERA Grantee.

Authorized Representative: [Type name/signature equivalent]