DRAFT 52671-e_Round IV_10-8_for Posting_Accessible

COVID-19 Supplemental
Payment (CSP) Request

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-0619
(Exp. MM/DD/YYYY)

DRAFT

FHA Project No.

Project Name

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Property/Management Company Phone Number
+ 105

Assistance Contract(s) #

Contract Type (HAP, PRAC, SPRAC, PAC)

PAC

CSP Operating Period for which
Period 4: 4/1/2021 to 10/31/2021
Reimbursement is Requested

Property/Management Company Email Address

✔ No
Is this request an amendment to a previously approved CSP for the selected Operating Period?:
Yes
If yes, what amount was previously paid for the Operating Period for which additional funds are now being requested?

Part I. Amounts Requested for Eligible COVID-19 Operational Expenses

0

Requested Amounts (use whole $)

1. Payroll Costs: Custodial or Other Operational Staff (OT or other staff increase) (6510)
2. Contract Services: Cleaning/Sanitizing or Security Services (6520/6530)
3. Payroll Costs: Administrative Functions (OT or increase in hours if part-time) (6310)
4. Contract Services: Administrative Functions (6390)
5. Cleaning/Sanitizing Supplies and PPE (6515/6590)
6. Office Equipment/ IT (6311)
7. Air Purification Equipment (Not Capitalized) and Supplies (6536)
8. Other Allowable Costs (Specify Budget Line________ )
Part I, SUBTOTAL 1

$0

Part I, SUBTOTAL 2

$0

Multifamily Service Coordination Program Expenses
(Eligible Section 8 and Section 202 Properties Only; see Notice H 2021-05, Section VI)
9. MFSC Payroll Costs (OT or Increase in hours if Part-Time) (6900)
10. MFSC Coordinator Contract Services (6900)
11. MFSC Office Equipment/IT (6900)
12. MFSC PPE (6900)

13. PART 1 TOTAL: CATEGORY A OPERATING EXPENSES (calculated field; sum of lines 1 to 12)

$0

Part II. Amounts Requested for Eligible Capital Expenses
14. Wifi Internet Infrastructure and Installation Costs
15. HVAC Improvements and Installation Costs
16. Emergency Generators and Installation Costs
17. PART II TOTAL: CATEGORY B ELIGIBLE CAPITAL EXPENSES (calculated field; sum of lines 14 to 16)
Have all equipment purchases included on lines 14-16 been delivered and installed?

Yes

$0

No

All Category B equipment purchases must be delivered and installed no later than March 31,2022. If either delivery and/or
installation is currently pending, additional certification of completion is required prior to disbursement of CSP funds.

18. TOTAL CSP REQUEST (calculated field; sum of lines 13 and 17)

$0

Part III. Calculation of Standard CSP Amount
19. Number of Assisted Units Under Contract
20. Unit-Based Allowance (calculated field; $75 per unit )

$0

21. Additional Property Allowance for Designated Elderly Housing (see Notice H 2021-05, Footnote 8) (Enter $1k or $0)
22. Standard Property Allocation
23. Allowance for Ongoing Service Coordination ( Eligible Budget-Based Coordinators Only)
(calculated field; lesser of $1,250 or Part I, Subtotal 2)
24. Standard CSP Amount (calculated field)
Note, CSP approved amount will not exceed the total amount requested for reimbursement (line 18).

$ 2,500

$0
$ 2,500

No
25. Does the Request (Line 18) Exceed the Standard CSP Amount (line 24) (calculated field)?.........................................................................................
N/A
If amending a prior CSP, does the increase reflected on line 18 plus the original CSP amount exceed the Standard CSP (line 24)? (select value)..................
If "yes" to either question, additional financial need qualifications and documentation requirements apply (see Sections VIII and X of Notice 2021-5)

Page 1 of 6

DRAFT - Do not use draft form for submission of requests to HUD

HUD-52671-E (10/2021)
ref. Notice H-2021-05

Part IV. Additional Justification for Requests Exceeding the Standard CSP Amount
Properties requesting funding at or below the Standard CSP amount (line 24) do not need to complete Part IV and should skip to Part V. CSP requests that
exceed the Standard CSP amount require completion of Section IV and submission of documentation for expenses. This includes amendments to CSPs
approved in prior Operating Periods where the combined total of the original payment and amendment amount exceeds the Standard CSP amount.
26. Justification Narrative for Payment Requests Exceeding the Standard Payment Amount. See Notice H 2021-05, Section X for more information on
the expected content of the narrative. This justification is required for all requests that exceed the Standard CSP amount (line 24).

Page 2 of 6

DRAFT - Do not use draft form for submission of requests to HUD

HUD-52671-E (10/2021)
ref. Notice H-2021-05

27. Description of Capital Investments for which Reimbursement is Requested. See Section X of Housing Notice 2021-05 for more information on
expected content of this description. The description is only required where the total request exceeds the Standard CSP amount and the
request includes Eligible Capital Expenses (line 17).

28. Financial Need Justification for requests exceeding the Standard CSP Payment amount. See Section X of Housing Notice H 2021-05 for more
information on expected content of this narrative. A response is only required for properties that recognized surplus cash at the end of their most
recently completed project fiscal year.

29. Have you withdrawn or requested withdrawal of residual receipt balances in 2020 or 2021 for COVID-19 Expenses? (Y/N)

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DRAFT - Do not use draft form for submission of requests to HUD

No

If yes, how much?

HUD-52671-E (10/2021)
ref. Notice H-2021-05

Part V. Certification and Acceptance of Terms
Owner's Certification and Acceptance of Terms: I certify that:
(1) The requested payment was computed in accordance with HUD’s Housing Notice H-2021-05. It reflects
only expenses incurred during the operating period(s) specified for eligible activities and purposes.
(2) The property and ownership are in good standing with HUD, as defined in Section IX of Housing Notice 2021-05.
(3) No amount included on this funding request has been paid from other forms of governmental or philanthropic
assistance provided to address the impacts of COVID-19 or previously reimbursed from a HUD residual receipts
account governed by a Section 8 HAP, or an FHA or Capital Advance regulatory agreement.
(4) If requesting funds that exceed the Standard CSP amount for the property (line 24) AND/OR requesting amounts
for expenses incurred before April 1, 2021, I have considered current project funds and anticipated revenues for the
next nine months and determined a larger CSP reimbursement is needed to address project operating needs. I
understand that properties projecting surplus cash at the close of their current project fiscal year and any Section 8
project for which the owner anticipates taking distributions at any point within the next 12 months are not eligible for a
CSP that exceeds the Standard CSP amount.
(5) If receiving funds for a Section 8 property that exceed the Standard CSP amount, I agree to limit distributions of
surplus cash in the following manner through 9/30/2022, notwithstanding the terms of the Housing Assistance
Payment contract: Should variances in projected financial performance result in surplus cash, I agree to deposit an
amount equal to the amount of the CSP in the project residual receipt account, prior to taking any cash distributions
distributions at any point from the issue date of the notice through 9/30/2022. Or, if the Section 8 contract and
governing regulations do not require the project owner to maintain a residual receipt account, I agree that upon taking
distributions at any point from the issue date of this notice through 9/30/2022, an amount at least equal to the amount
of the CSP must be retained in the operating account to address future project costs that is over-and-above the
resources needed for operating requirements known at that time.
(6) Where required by Section IX of Notice 2021-05, I agree to deposit amounts received as reimbursement for Eligible
Capital Expense items in the project’s Reserve for Replacement account.
(7) If requesting funds for Eligible Capital Expenses (line 17) all equipment for which CSP is requested has been
delivered and installed or is under contract to be delivered and installed no later than March 31, 2022.
(8) If receiving CSP assistance for a Section 8 HAP contract that expires within 120 days, I anticipate renewal of
the contract and have not communicated intent to opt-out.
(9) Upon request by the Department of Housing and Urban Development, its duly authorized representative, or the
Comptroller General of the United States, I will make available for audit all books, records and documents related to
this assistance payment. I, the undersigned, certify under penalty of perjury that the information provided in this form is
true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to
criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18
U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802)
Owner/Signatory Name (Printed)
30. Owner Signature

31. Date Owner Signature

Part VI. HUD/CA Use Only
32. Date Received by HUD/CA
33. Amount Eligible for Payment (enter $0 for incomplete of otherwise ineligible requests)
CATEGORY A Operating Costs
CATEGORY B Capital Expenses

TOTAL ELIGIBLE

34. Notes on Any Disallowed Costs
35. Approved By (Print Name)
36. Approver Signature

Page 4 of 6

37. Date Approved

DRAFT - Do not use draft form for submission of requests to HUD

HUD-52671-E (10/2021)
ref. Notice H-2021-05

Calculation Worksheet for Minimum Expected Funding and Priority Categories for Requests
Exceeding the Standard CSP Payment Level (Optional to Complete)
The worksheet below will provide information about the Minimum Expected Funding level for your request should the property and all expenses meet eligibility
requirements in Notice 2021-05.
Most totals below have been automatically calculated based on your entries in Lines 1-25 of this form. However, if you are submitting more than one HUD 52671E request form under Round IV due to having eligible costs in multiple Operating Periods, then you must manually populate expense data from those other forms
in order to receive accurate results.
IMPORTANT: The minimum funding allocation is per property for CSP Round IV and does not increase when submitting requests for multiple Operating
Periods.

Step 1: Apply the appropriate scaling factor to the Standard CSP amount for the property. To do this, multiply the amount on
line 24 by ".7" if a property has a PRAC,PAC, or SPRAC OR multiply by "1" for Section 8 HAP contracts.

$ 1,750

Step 2: Compare the result in Step 1 to the Total Round IV CSP Request to determine Minimum Expected Payment. The
smaller of the two numbers is your Minimum Expected Funding level. If submitting more than one HUD 52671-E, you must
transfer the totals from the other forms into the expense data fields below before making the comparison.
Total Expenses for this HUD 52671-E Request

$0

n

Category A Operating Cost subtotal (line 13)

$0

n

Category B Eligible Capital Expense subtotal (line 17)

$0

Complete the below section only if you are submitting more than one HUD 52671-E form under Round IV:
Totals Expenses from 2nd HUD 52671-E
n

Category A Operating Cost subtotal (line 13) (manual entry)

n

Category B Eligible Capital Expense subtotal (line 17) (manual entry)

$0

Total Expenses from for 3rd HUD 52671-E
n

Category A Operating Cost subtotal (line 13) (manual entry)

n

Category B Eligible Capital Expense subtotal (line 17) (manual entry)

$0

Total Expenses from 4th HUD 52671-E
n

Category A Operating Cost subtotal (line 13) (manual entry)

n

Category B Eligible Capital Expense subtotal (line 17) (manual entry)

$0

Grand Total of Expenses on All HUD 52671-E forms being submitted under Round IV

$0

n

Grand Total: Category A Operating Cost subtotal (line 13)

$0

n

Grand Total: Category B Eligible Capital Expense subtotal (line 17)

$0
$0

Round IV Minimum Expected Funding Level for the Requesting Property*
Step 3: For larger requests only, review the portion of the request that may be partially funded if CARES Act funds are not
sufficient to fully fund all eligible CSP requests. Only the portion of a request that exceeds the Minimum Expected Funding
amount identified in Step 2 is subject to partial funding. Amounts under Category A will be given higher priority than
amounts under Category B. See Section VII of Notice 2021-05 for more information.
Portion of Total Requested Amount that Exceeds the Minimum Expected Funding level (calculated field)

$0

a.

Amount of Request under "CATEGORY A: Operating Costs" that Exceeds the Minimum Expected Payment (calculated field)

$0

b.

Amount of Request under "CATEGORY B : Capital Expenses" that Exceeds the Minimum Expected Payment (calculated field)

$0

*Worksheet calculations are provided for informational purposes only and do not reflect an obligation by HUD to fund the property at the level indicated.
All payment approvals are subject to property and expense eligibility reviews and continuing availability of appropriations.

Page 5 of 6

DRAFT - Do not use draft form for submission of requests to HUD

HUD-52671-E (10/2021)
ref. Notice H-2021-05

This form must be completed by owners to request payment of supplemental assistance to offset operating cost increases related to COVID-19.
Amounts are available to properties with project-based rental assistance contracts under Section 8, Section 202, and Section 811. Please consult
Housing Notice H-2021-05 for additional information on eligibility requirements.
The Department of Housing & Urban Development is authorized to collect this information by the Coronavirus Aid, Relief, and Economic Security Act
(CARES Act) (Pub. L. 116-136, approved March 27, 2020). The CARES Act provided an additional $1 billion under the heading Project-Based Rental
Assistance (PBRA) for Section 8 properties, $50 million under the heading Housing for the Elderly (Section 202), and $15 million under the heading
Housing for Persons with Disabilities (Section 811) to “prevent, prepare for, and respond to coronavirus, including to provide additional funds to
maintain normal operations and take other necessary actions during the period that the program is impacted by coronavirus.”
The owner/agent must provide all information in order to be considered for a COVID-19 Supplemental Payment from CARES Act funding.
The information provided will be used by HUD to determine if a request may be funded and the appropriate level of funding to provide.
HUD may disclose this information to Federal, state, and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions.
Otherwise, it will not be disclosed or released outside of HUD, except as permitted or required by law. HUD does not promise confidentiality but will
not disclose data on specific tenants. No questions of a sensitive nature are asked in this form.
Public reporting burden for this collection of information is estimated to average 1.1 hours per response, 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 agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this
burden, to the Reports Management Officer, QDAM, Department of Housing and Urban Development, 451 7th Street, SW, Room 4176, Washington,
DC 20410-5000. When providing comments, please refer to OMB Approval No. 2502-0619.

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Page 6 of 6

HUD-52671-E (10/2021)
ref. Notice H-2021-05