ETA 9143 Worksite Description and Annual Housing Census Form

WORK SITE DESCRIPTION YouthBuild (YB) GRANT

PAGE 1 OMB No. 1205-0464

ETA – 9143 Expires: 11/30/2021

APPLICANT IDENTIFYING INFORMATION (Complete All Sections – see instructions below)

A SEPARATE ETA-9143 WITH ALL RELEVANT ATTACHMENTS* IS REQUIRED FOR EACH YOUTHBUILD WORK SITE

1. Applicant / Grantee Organization Name & Address:

2. Work Site Property Identification (Address and/or Geographic Parcel Identification Number (GPIN)):

3. Number of housing units planned to be constructed or renovated on this work site property:

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? □ Yes □ No

6. The on-site training consists of (Check all that apply): □ New Construction □ Renovation

7. Name of the current owner of work site property:

8. Name of entity that will own / manage the property after the construction or renovation work is completed (if unit will be sold to low-income individual or family after completion put current owner here):

9. In accordance with 20 CFR 688.730, the owner agrees to the five-year Restrictive Covenant at the time of the issuance of the occupancy permit:

□ Yes □ No If “No,” please explain:

*If the property is being renovated and will not require an occupancy permit, the grantee must confirm the home owner/resident is or will be a low-income individual or family.

*REQUIRED ATTACHMENTS: At a minimum, each work site property must include ETA-9143 pages 1 & 2 and Attachments A & B. See instructions below.

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. See the attached suggested template labeled Attachment A: Attestation of Ownership and Access. The attachment must be dated less than six months before submission to DOL.

ATTACHMENT B: Description of the specific construction / renovation activities in which YouthBuild participants will be actively engaged. See the attached suggested template, labeled ATTACHMENT B.

ATTACHMENT C: Are any YouthBuild grant funds being used for construction materials?

□ Yes □ No IF YES, complete and submit ATTACHMENT C, using the attached suggested template.

ATTACHMENT D: Are any of the units currently occupied? □ Yes □ No

IF YES, complete and submit ATTACHMENT D, using the attached suggested template.

Information required from Applicant / Grantee Organization Signatory:

Printed Name: ____________________________________ Signature: ________________________________________

Title: ____________________________________________________________ Date: ___________________________

Organization: _______________________________________________________________________________________

OMB No.: 1205-0464 OMB Expiration Date: 11/30/2021 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.

INDIVIDUAL HOUSING PROJECT SITE ESTIMATE YouthBuild (YB) GRANT

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ETA – 9143 Expires: 11/30/2021

Applicant / Grantee Organization Name:
Address and/or GPIN of Work Site Property (Include city, state, and zip code):
 Housing Project Costs1 for Site
Grant Activities	Resources – Do not include costs of staff salaries participant stipends and wages						Report leveraged resources that are NON-FEDERAL in origin here and on the ETA-9130. Report FEDERAL leveraged resources on this form only.
	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. • Note that the total value of the COSTS table (above) should match the total value of the DOCUMENTATION table (below).
Name of Provider / Donor				Cash or In-Kind?	Dollar Value Provided
TOTAL
OMB No.: 1205-0464 OMB Expiration Date: 11/30/2021 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. ATTACHMENT A: Attestation of Ownership and Access YouthBuild (YB) GRANTt ETA – 9143 OMB No. 1205-0464 Expires: XXXXXXXX I certify the following (check applicable box) regarding the work site property identified below: I am the legal owner of the work site property; I am the legal signatory for the organization that owns the work site property; I am the legal signatory for the organization that has a signed contract for, or option to purchase, the work site property (Future Owner). I affirm that the YouthBuild program and its participants will have access to the work site property for the duration of the program or until the agreed upon construction activities are completed by the program, whichever comes first. Work Site Property Address (Address and/or GPIN.*)   OWNER or FUTURE OWNER of Work Site Property¥   Name of Individual with the legal authority to make this attestation¥   TITLE   SIGNATURE   DATE SIGNED:   * The address specified must match the address listed in box 2 on page 1 and on page 2 of ETA-9143. ¥ The owner specified must be the same as that listed in box 7 on page 1 of ETA-9143. NOTE: If the property owner prefers to submit a letter, it must contain all information listed on this template and be signed and dated as required. ATTACHMENT B: Description of Activities YouthBuild (YB) GRANT ETA – 9143 OMB No. 1205-0464 Expires: 11/30/2021 1. Applicant / Grantee Organization Name & Address: 2. Work Site Property Identification (Address and/or GPIN): 3. Number of participants proposed to work on work site: 4. Anticipated time it will take to complete construction or renovation project: 5. Description of specific construction (new build or renovation) activities in which participants will be engaged (i.e. modules of training, such as framing, carpentry, drywall, installation, etc.). This section should describe exactly what work is being done on the housing unit, whether a brand-new build or a renovation, and in which parts of that work YouthBuild participants will receive hands-on training:

ATTACHMENT C: DOCUMENTATION OF YOUTHBUILD GRANT AND MATCH FUNDS FOR CONSTRUCTION MATERIALS YouthBuild (YB) GRANT

ETA – 9143 OMB No. 1205-0464

Expires: 11/30/2021

1. Applicant / Grantee Organization Name & Address:

2. Work Site Property Identification (Address and/or GPIN):

3. Describe applicable materials and costs below.

Note: refer to TEGL 05-10, Change 1, “Match and Allowable Construction and Other Capital Asset Costs for the YouthBuild Program” for allowable and unallowable costs.

ATTACHMENT D: RELOCATION NARRATIVE YouthBuild (YB) GRANT

ETA – 9143 OMB No. 1205-0464

Expires: 11/30/2021

1. Applicant / Grantee Organization Name & Address:

2. Work Site Property Identification (Address and/or GPIN):

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:

10. Use the space below to provide the full explanation of relocation process:

Instructions for COMPLETING ETA–9143 Pages 1 and 2 and Attachments A-D

EACH qualified work site (as identified by address or parcel number) must have its own ETA-9143 with all required attachments.

Page 1 – Applicant Identifying Information

1. Applicant Name – Name of the applicant/grantee and physical mailing address of the applicant/grantee as listed on the SF-424

2. The physical address and/or the Geographic Parcel Identification Number (GPIN) of a single work site property.

3. The number of housing units to be produced or renovated at that single property.

4. Select the type(s) of housing to be produced.

5. Indicate whether or not the housing is for homeless, low-income, or very-low income persons.

6. Indicate if the site is new construction and/or rehabilitation.

7. Name of the current owner or organization that owns the property.

8. Who will own/manage the property after work is completed.

9. Agrees to the five-year Restrictive Covenant Clause.

Additional Requirements:

• Individual Housing Project Site Estimate and Documentation of Resource must be filled out. Page 2 is a continuation of Page 1.

• Proof of access must be provided for all work sites. Please complete the Attachment A template or provide a letter containing all required information from the template.

• A description of specific and allowable construction/renovation activities must be provided. Please complete the Attachment B template.

• A description of specific and allowable construction/renovation activities must be provided. Please complete the Attachment C template.

• If any of the units are currently occupied, select yes and provide a relocation narrative. Please complete the Attachment D template.

• Applicant Signature on page 1 - Filled out, dated, and signed by the Applicant/Grantee Signatory or Authorized Representative with their title and organization name.

PAGE 2 – Individual Housing Project Site Estimate

1. List the Applicant Name – Name of the applicant/organization that is listed on the SF-424.

2. Address of the Work Site Property – The work site physical address and/or GPIN.

3. Grant Activities/Resources – Provide the resource amounts and where they are coming from as it pertains to this site. If YouthBuild grant funds are being expended on direct construction activities or materials (not including staff wages or participant stipends/wages, a separate attachment must be included to document the uses of YouthBuild grant funds.

4. Documentation of Housing Resources – List all providers, whether they are providing cash or in-kind, the dollar value, and a letter of commitment for each funding source.

5. The commitment letter(s) should be on organizational letterhead with a signature and date. Within the letter, it should state what it is they are committing, whether it is cash or in-kind, and the dollar value of the commitment. The letter should also include the physical address of the work site property(s) where those contributions are being applied.

6. Both charts on this form should add up to the same total.

Attachment A (Separate form required for each work site)

Attestation of Ownership and Access – Submit the following:

1. Applicants/Grantees should use the Attachment A template to confirm access and ownership. Alternately, if submitting a letter it must include all of the information asked for in the Attachment A template: (a) the name of the owner, explicitly stating that they own the property, (b) complete address of the property, (c) verification of access to the property, (d) signature of owner, and (e) date (using current date).

Attachment B (Separate form required for each work site)

Description of Activities – Submit the following:

1. Applicants/Grantees should use the Attachment B template to submit a detailed description of the roles and responsibilities and specific construction training activities that youth will perform as participants on the specified work site. If submitting a letter, label as Attachment B.

Attachment C (only required if YouthBuild grant funds are being used for construction materials – separate form required for each work site using YouthBuild grant funds)

Documentation of YouthBuild Grant and Match Funds for Construction Materials – Submit the following:

1. Applicants/Grantees should use the Attachment C template to submit a narrative that describes applicable materials and costs.

(Note: refer to TEGL 05-10, Change 1, “Match and Allowable Construction and Other Capital Asset Costs for the YouthBuild Program” for further information on allowable and unallowable costs.)

Attachment D (only required if a work site property is currently occupied – separate form required for each occupied property)

Relocation Narrative – Submit the following:

1. Applicants/Grantees should use the Attachment D template to submit a narrative that includes the identity of the individual(s) or organization occupying the property on the date of submission of this application

2. Whether relocation of occupants is necessary and the rationale for determination. If relocation is necessary, provide the following:

   1. Number of temporary and/or permanently displaced individuals

   2. Estimated cost of relocation

   3. Funding Source for relocation

   4. Organization providing the relocation assistance, along with the contact person’s name and phone number

*The ETA-9143 form can be found at https://www.dol.gov/agencies/eta/youth/youthbuild/ under the Forms section.

ANNUAL HOUSING CENSUS YouthBuild (YB) GRANT

INSTRUCTIONS OMB No. 1205-0464

ETA – 9143 Expires: 11/30/2021

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 may 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 grant 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 (e.g. The Housing Authority of Anytown).

Reporting Period: Please fill in the year that ends the reporting cycle for this housing census submission.

Final Report: Check this box if this is the final report for this grant’s period of performance.

SECTION 2

Completed On: Enter the date that the unit was completed and/or available for occupancy. Please note that the unit does not need to be occupied if it was previously vacant; it just needs to be available for occupancy.

Type of Unit: Check whether the development was a house, apartment, or town home/duplex. If marking “yes” for multi-unit, describe the total number of units at the property and the total units completed by YouthBuild participants but list the building as one unit in terms of the count.

Address: Enter the address of the property built or renovated.

Type of Work Completed: Check the type of work that the students completed.

Other: Check this box if your project is not new construction, or renovation (i.e. 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 ON THE SECOND PAGE ARE 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 YouthBuild (YB) GRANT

PAGE 1 OMB No. 1205-0464

ETA – 9143 Detailed instructions for completion are included on previous page of this document. Expires: 11/30/2021

Please note: If no unit is completed within the reporting period, an Annual Housing Census Form must still be completed. *Do not include any public or community facility projects.
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. The standard annual reporting period for the Annual Housing Census is August 1 through July 31. Please Note: You need to submit an Annual Housing Census form for any reporting period which overlaps with any portion of your grant’s period of performance.
SECTION 1	Grantee / Organization Signatory (please print): Date of Submission:
	Program and Organization Name, Address, Phone & Email:
	Grant Number: Reporting Period: August 1 – July 31, _______
	Check if this is the final report for the grant: □
SECTION 2	Unit #1 Completed in [MM/YY]: House □ Apartment □ Town Home/Duplex □
	Multi-Unit [Y/N]: If Yes, describe:
	Address:
	Type of work completed (check only one): New construction □ Renovation □ Other □
	Describe (if other):
	Unit #2 Completed in [MM/YY]: House □ Apartment □ Town Home/Duplex □
	Multi-Unit [Y/N]: If Yes, describe:
	Address:
	Type of work completed (check only one): New construction □ Renovation □ Other □
	Describe (if other):
	Unit #3 Completed in [MM/YY]: House □ Apartment □ Town Home/Duplex □
	Multi-Unit [Y/N]: If Yes, describe:
	Address:
	Type of work completed (check only one): New construction □ Renovation □ Other □
	Describe (if other):
	Unit #4 Completed in [MM/YY]: House □ Apartment □ Town Home/Duplex □
	Multi-Unit [Y/N]: If Yes, describe:
	Address:
	Type of work completed (check only one): New construction □ Renovation □ Other □
	Describe (if other):

continued on Page 2

ANNUAL HOUSING CENSUS YouthBuild (YB) GRANT

PAGE 2 OMB No. 1205-0464

ETA – 9143 Expires: 11/30/2021

Program Name: Grant Number: Reporting Period: August 1 – July 31, _______
SECTION 2	Unit #5 Completed in [MM/YY]: House □ Apartment □ Town Home/Duplex □
	Multi-Unit [Y/N]: If Yes, describe:
	Address:
	Type of work completed (check only one): New construction □ Renovation □ Other □
	Describe (if other):
	Unit #6 Completed in [MM/YY]: House □ Apartment □ Town Home/Duplex □
	Multi-Unit [Y/N]: If Yes, describe:
	Address:
	Type of work completed (check only one): New construction □ Renovation □ Other □
	Describe (if other):
	Unit #7 Completed in [MM/YY]: House □ Apartment □ Town Home/Duplex □
	Multi-Unit [Y/N]: If Yes, describe:
	Address:
	Type of work completed (check only one): New construction □ Renovation □ Other □
	Describe (if other):
	Unit #8 Completed in [MM/YY]: House □ Apartment □ Town Home/Duplex □
	Multi-Unit [Y/N]: If Yes, describe:
	Address:
	Type of work completed (check only one): New construction □ Renovation □ Other □
	Describe (if other):
SECTION 3	Total number of units completed during the annual housing census reporting period: ____________ Signature of Grantee / Organization Signatory: __________________________________________________________ Printed Name: ______________________________________________________ Date:_________________________ Title: ______________________________________________________________
OMB No.: 1205-0464 OMB Expiration Date: 11/30/2021 OMB Burden Hours: 30 minutes throughout the life of the grant 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. This collection of information is required for grant application and work site approval. 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.