Acceptance of Award Terms Form

OMB Approved No. 1505-0270

Expiration Date: 10/31/2021

U.S. Department of the Treasury
EMERGENCY RENTAL ASSISTANCE

Eligible grantee name and address:

DUNS Number: Taxpayer Identification Number:

Section 3201(a) of the American Rescue Plan Act of 2021, Pub. L. No. 117-2 (March 11, 2021) authorizes the Department of the Treasury (“Treasury”) to make payments to certain eligible grantees to be used to provide emergency rental assistance.

The eligible grantee hereby agrees, as a condition to receiving such payment from Treasury, to the terms attached hereto.

__________________________________________________

Authorized Representative Signature (above)

[To be signed by chief executive officer if recipient is a local government.]

Authorized Representative Name: ___________________________________

Authorized Representative Title: ____________________________________

Date signed: _________________________

U.S. Department of the Treasury:

__________________________________________________

Authorized Representative:

Title:

Date:

PAPERWORK REDUCTION ACT NOTICE

The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of information is 15 minutes per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number assigned by OMB.

PRIVACY ACT STATEMENT

AUTHORITY:  Solicitation of this information is authorized by the American Rescue Plan Act of 2021, Title V, Pub. L. 117-2.

PURPOSE:  The Department of the Treasury (Treasury) is required by the American Rescue Plan Act of 2021 to identify eligible grantees/recipients to provide emergency rental assistance to individuals who qualify for relief under the Act.  Eligible grantees/recipients are state, local, tribal and territorial governments which identify households requiring relief according to requirements contained in the Act.  Treasury maintains contact information for authorized representatives and contact persons for the purpose of communicating with eligible grantees regarding issues related to implementation of the Act.

ROUTINE USES: The information you furnish may be shared in accordance with the routine uses outlined in the Treasury’s system of records notice, Treasury .017 - Correspondence and Contact Information, which can be found at 81 FR 78266 (Nov. 7, 2016).

DISCLOSURE: Disclosure of this information to Treasury is required in order to comply with the requirements the American Rescue Plan Act of 2021.  Disclosure of this information is voluntary, however, grantees/recipients that do not disclose contact information will be unable to communicate with Treasury on issues related to their obligations under the Act and this may affect the status of their grant.