HUD 4136 Community Compass Closeout Property Form

Community Compass TA and Capacity Building Program NOFA

updated form 4136 CLOSEOUT PRA approved Property Form HUD 4136.proposed change (003)

OMB: 2506-0197

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OMB Approval No. 2506-0197

(Exp. 03/31/2023)

Community Compass - Property Statement


Cooperative Agreement Number

Click here to enter number.

Organization Name

Click here to enter name.


Part I. Based on the records and as required by the property management standards set forth in the award agreement, the following reflects the status of real and personnel property paid for in whole, or in part, by funds from this award:

1a. Was real property acquired?

Yes (continue) No (skip to #2)

1b If yes, list the real property in Part II.

1c. Will the property continue to be used for the purpose authorized in the agreement?

Yes No

If no, is approval being requested from HUD to use the property in other projects?

Yes No

If yes, specify which projects:

Click here to enter text.

If no, provide disposition instructions to HUD in Part II.



2. Was non-expendable personal property acquired?

Yes (continue) No (skip to #3)

2a. If yes, list the non-expendable person property in Part II.


2b. Will the property continue to be used for the purpose authorized in the agreement?

Yes No

If no, is approval being requested from HUD to use the property in other projects?


If yes, specify which projects:

Click here to enter text.

If no, what is the proposed disposition of this property? (Check one or both)

Approval is requested to retain the property in whole or in part.

Disposition instructions from HUD are requested.

If both boxes are checked, please explain in detail in Part II of this Statement.




3. Was expendable personal property with an aggregate value of over $5,000 (for State and local Governments) or $1,000 (for non-profit organizations) acquired?

Yes No

3a. If yes, refer to your agreement and request disposition forms from your GTR.


PART II. Information requested in Part I may be provided in the format that follows.


Enter item name.

Enter item name.

Enter item name.

Enter item name.

Date Purchased

Enter a date.

Enter a date.

Enter a date.

Enter a date.

Description

Enter description.

Enter description.

Enter description.

Enter description.

Serial Number

Enter number.

Enter number.

Enter number.

Enter number.

Unit Cost

Enter cost.

Enter cost.

Enter cost.

Enter cost.

% HUD funds

Enter %.

Enter %.

Enter %.

Enter %.

Location Address

Enter text.

Enter text.

Enter text.

Enter text.

Condition

Enter text.

Enter text.

Enter text.

Enter text.

Service Contracts

Enter text.

Enter text.

Enter text.

Enter text.

Inventory Reconciled

Enter text.

Enter text.

Enter text.

Enter text.




Authorized Official Name



Authorized Official Title



Date




Public reporting burden for this collection of information is estimated to average 0.5 hours. This includes the time for collecting, reviewing, and reporting the data. The information is being collected for Community Compass Technical Assistance and Capacity Building Program Notice of Funding Availability (NOFA) and will be used for NOFA application review. Response to this request for information is required in order to receive the benefits to be derived. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number. No confidentiality is assured.”

form HUD-4136 (3/23)

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorChrissy
File Modified0000-00-00
File Created2022-10-14

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