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pdfWORK SITE DESCRIPTION
YouthBuild (YB) GRANT
OMB No. 1205-0464
Expires: 08/31/2018
PAGE 1
ETA – 9143
APPLICANT IDENTIFYING INFORMATION (Complete All Sections)
A SEPARATE ETA-9143 WITH ALL RELEVANT ATTACHMENTS* IS REQUIRED FOR EACH YOUTHBUILD WORK SITE
1. Applicant / Grantee Organization Name & Address:
2. Work Site Identification (Address / Parcel #):
3. Number of housing units planned to be constructed or renovated on this work site:
4. Type of housing to be produced (Check all that apply):
□ Residential / rental
□ Homeownership
□ Transitional housing for the homeless
5. Will all housing produced be provided for homeless, low-income, or very-low income persons?
□ Renovation
7. For new construction, the owner agrees to have the five-year Restrictive Covenant:
□ Yes
6. The on-site training consists of (Check all that apply):
□ New Construction
8. Name of the current owner of work site property:
□ Yes
□ No
□ No
9. Name of entity that will own / manage the property after the construction or renovation work is completed:
*REQUIRED ATTACHMENTS: At a minimum, each work site must include ETA-9143 pages 1 & 2 and Attachments A & B.
PAGE 2: Individual Housing Project Site Estimate and Documentation of Resources.
Complete PAGE 2 and attach documentation of resources behind PAGE 2.
ATTACHMENT A: Documentation of Access.
Attach required evidence of work site access (Letter from owner identified in item 8 above). Letter must be dated less than
six months before submission to DOL. Label this ATTACHMENT A.
ATTACHMENT B: Description of the specific construction / renovation activities that YouthBuild participants will be engaged
in. Label this ATTACHMENT B.
□
□
ATTACHMENT C: Are any of the units currently occupied?
Yes
No
IF YES, complete and submit ATTACHMENT C, included as page three of this document.
ATTACHMENT D: Are any YouthBuild grant funds being used for construction materials?
IF YES, complete and submit ATTACHMENT D, included as page four of this document.
□ Yes
□ No
OMB No.: 1205-0464 OMB Expiration Date: 08/31/2018 OMB Burden Hours: 30 minutes OMB Burden Statement: These reporting instructions have been approved under
the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
Information is collected from eligible applicants for a competition to determine which entities will receive grant funds. Public reporting burden for this collection of
information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Submission is mandatory and is authorized under the Workforce Innovation and Opportunity Act Public Law 113-128 Sec. 171. The information
will be used for the YouthBuild grant and response to this request for information is required in order to receive the benefits to be derived. The information requested
does not lend itself to confidentiality. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the U. S. Department of Labor, Employment and Training Administration, Office of Workforce Investment, Division of Youth Services, Room
N4508, 200 Constitution Avenue, NW, Washington, D.C. 20210.
Information required from Applicant / Grantee Organization Signatory:
Printed Name: ______________________________________ Signature: _____________________________________
Title: ____________________________________________________________ Date: ___________________________
Organization: _______________________________________________________________________________________
INDIVIDUAL HOUSING PROJECT SITE ESTIMATE
YouthBuild (YB) GRANT
OMB No. 1205-0464
Expires: 08/31/2018
PAGE 2
ETA – 9143
Applicant / Grantee Organization Name:
Address of Property (Include city, state, and zip code):
Housing Project Costs1 for Site
Resources
YouthBuild
Other
Federal
State
Local
Private
TOTAL
Acquisition
Architecture &
Engineering
Housing
Construction
Housing Renovation
TOTAL
Note 1: Include both cash and in-kind contributions.
Documentation of Housing Resources
• Attach a letter of commitment from each provider / donor that provides the specific match amount dedicated to
the construction project and the source of the funding. Letter should be dated no more than six months prior to the
date of submission to DOL. If using YouthBuild grant funds, include this in the chart below and in Attachment D.
• Report leveraged resources that are NON-FEDERAL in origin here and on the ETA-9130. Report FEDERAL leveraged
resources on this form only.
Cash or
Name of Provider / Donor
In-Kind?
Dollar Value Provided
Note that the total value of the COSTS table should match the total value of the DOCUMENTATION table.
Grant Activities
TOTAL
OMB No.: 1205-0464 OMB Expiration Date: 08/31/2018 OMB Burden Hours: 30 minutes OMB Burden Statement: These reporting instructions have been approved under
the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
Information is collected from eligible applicants for a competition to determine which entities will receive grant funds. Public reporting burden for this collection of
information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Submission is mandatory and is authorized under the Workforce Innovation and Opportunity Act Public Law 113-128 Sec. 171. The information
will be used for the YouthBuild grant and response to this request for information is required in order to receive the benefits to be derived. The information requested
does not lend itself to confidentiality. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the U. S. Department of Labor, Employment and Training Administration, Office of Workforce Investment, Division of Youth Services, Room
N4508, 200 Constitution Avenue, NW, Washington, D.C. 20210.
RELOCATION NARRATIVE
ATTACHMENT C
ETA – 9143
1. Applicant / Grantee Organization Name & Address:
2. Work Site Identification (Address / Parcel #):
3. Total number of persons currently occupying the unit(s):
4. Number to be permanently displaced during renovation:
5. Number to be temporarily relocated but not displaced during renovation:
6. Estimated cost of relocation services:
7. Source of funds for relocation:
8. Organization that will provide relocation assistance to occupants (if applicable):
9. Relocation assistance contact person's name and phone number:
Use the space below to provide the full explanation of relocation process:
YouthBuild (YB) GRANT
OMB No. 1205-0464
Expires: 08/31/2018
DOCUMENTATION OF YB FUNDS FOR CONSTRUCTION MATERIALS
ATTACHMENT D
ETA – 9143
YouthBuild (YB) GRANT
OMB No. 1205-0464
Expires: 08/31/2018
1. Applicant / Grantee Organization Name & Address:
2. Work Site Identification (Address / Parcel #):
3. Describe applicable materials and costs below.
Note: refer to TEGL 05-10, change one “Match and Allowable Construction and Other Capital Asset Costs for the YouthBuild
Program” for allowable and unallowable costs.
ANNUAL HOUSING CENSUS
INSTRUCTIONS
ETA – 9143
YouthBuild (YB) GRANT
OMB No. 1205-0464
Expires: 08/31/2018
This information is NOT being collected to gauge program performance; this information is requested to report to Congress
and other stakeholders the valuable contributions made by the young people in your programs for your community. It is
understood that it will take longer to build or renovate property when using these sites as training sites.
GENERAL INSTRUCTIONS
1. Enter only those units that are complete and ready for occupancy. Unless this is your final census for the
period of performance, do not enter unfinished units on this form; enter it on the next year's census.
2. Do not enter any units that have been submitted previously.
SECTION 1
Grantee / Organization Signatory: Please print the name of the person that we can contact if we need any
additional information.
Program and Organization Name: Please provide both the name of your program (e.g. Anytown YouthBuild) and
the name of the sponsoring organization (The Housing Authority of Anytown).
Final Report: Check this box if this is the final report for your grant.
SECTION 2
Completed On: Enter the date that the unit was completed and available for occupancy. Please note that the unit
does not need to be occupied; it just needs to be available for occupancy.
Type of Unit: Check the type of unit. If the building is multi-unit, describe the total and type of total units
completed in the building but just list the building as one unit.
Address: Enter the address of the property built, renovated, or weatherized.
Type of Work Completed: Check the type of work that the students completed.
Other: Check this box if your project is not new construction, renovation, or weatherization OR if it is a multi-unit
project. Please describe the activity and finished project.
SECTION 3
MUST BE COMPLETED AND SIGNED, EVEN IF UNITS 5 - 8 LEFT BLANK
Total Number of Units: Provide the total number of units completed and described in the census.
Signature: Please sign, print your name, and date.
ANNUAL HOUSING CENSUS
PAGE 1
ETA – 9143
YouthBuild (YB) GRANT
Detailed instructions for completion are included on previous page of this document
OMB No. 1205-0464
Expires: 08/31/2018
The Department of Labor (DOL) will report to Congress and other stakeholders the number of affordable housing units built or renovated by YouthBuild participants. All
grantees will be asked to complete and submit this form annually to provide DOL with this information. Your organization will receive a notification from DOL
approximately 30 days prior to the annual anniversary of your period of performance. For example, if your grant has a period of performance from August 1, 2019
through July 30, 2021, you will receive a notice in July 2020 asking you to submit this form no later than August 1, 2020.
SECTION 1
Grantee / Organization Signatory (please print):
Program and Organization Name, Address, Phone & Email:
Date of Submission:
Unit #1
Completed in [MM/YY]:
Multi-Unit [Y/N]:
If Yes, describe:
□
Public or Community Facility □
Check if this is the final report for the grant:
House
□
Apartment
□
Address:
Type of work completed (check only one):
Other
□
New construction
□
Renovation
□
Describe:
Unit #2
Completed in [MM/YY]:
Multi-Unit [Y/N]:
If Yes, describe:
House
□
Apartment
□
Public or Community Facility
□
Address:
SECTION 2
Type of work completed (check only one):
Other
□
New construction
□
Renovation
□
Describe:
Unit #3
Completed in [MM/YY]:
Multi-Unit [Y/N]:
If Yes, describe:
House
□
Apartment
□
Public or Community Facility
□
Address:
Type of work completed (check only one):
Other
□
New construction
□
Renovation
□
Describe:
Unit #4
Completed in [MM/YY]:
Multi-Unit [Y/N]:
If Yes, describe:
House
□
Apartment
□
Public or Community Facility
□
Address:
Type of work completed (check only one):
Other
□
New construction
□
Renovation
□
Describe:
continued on Page 2
ANNUAL HOUSING CENSUS
YouthBuild (YB) GRANT
OMB No. 1205-0464
Expires: 08/31/2018
PAGE 2
ETA – 9143
Program Name:
Unit #5
Completed in [MM/YY]:
Multi-Unit [Y/N]:
If Yes, describe:
House
□
Apartment
□
Public or Community Facility
□
Address:
Type of work completed (check only one):
Other
□
New construction
□
Renovation
□
Describe:
Unit #6
Completed in [MM/YY]:
Multi-Unit [Y/N]:
If Yes, describe:
House
□
Apartment
□
Public or Community Facility
□
SECTION 2
Address:
Type of work completed (check only one):
Other
□
New construction
□
Renovation
□
Describe:
Unit #7
Completed in [MM/YY]:
Multi-Unit [Y/N]:
If Yes, describe:
House
□
Apartment
□
Public or Community Facility
□
Address:
Type of work completed (check only one):
Other
□
New construction
□
Renovation
□
Describe:
Unit #8
Completed in [MM/YY]:
Multi-Unit [Y/N]:
If Yes, describe:
House
□
Apartment
□
Public or Community Facility
□
Address:
Type of work completed (check only one):
Other
□
New construction
□
Renovation
□
Describe:
SECTION 3
Total number of units completed during the housing census reporting period: ________
Signature of Grantee / Organization Signatory: __________________________________________________________
Printed Name: ____________________________________________________________________________________
Title: __________________________________________________
Date: _____________________________
OMB No.: 1205-0464 OMB Expiration Date: 08/31/2018 OMB Burden Hours: 30 minutes OMB Burden Statement: These reporting instructions have been approved under
the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
Information is collected from eligible applicants for a competition to determine which entities will receive grant funds. Public reporting burden for this collection of
information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Submission is mandatory and is authorized under the Workforce Innovation and Opportunity Act Public Law 113-128 Sec. 171. The information
will be used for the YouthBuild grant and response to this request for information is required in order to receive the benefits to be derived. The information requested
does not lend itself to confidentiality. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the U. S. Department of Labor, Employment and Training Administration, Office of Workforce Investment, Division of Youth Services, Room
N4508, 200 Constitution Avenue, NW, Washington, D.C. 20210.
| File Type | application/pdf |
| Author | Hunt, Jeff M - ETA |
| File Modified | 2018-07-20 |
| File Created | 2018-07-20 |