2502-0619 - CSP Supplemental Certification (DocuSign)

OMB Control Number: 2502-0619

Expiration Date: 5/31/2022

Subject : Certification of Completion for [Property Name]

CSP Round IV Payments

Contract #: [Primary Contract]

CSP Category B Amount: [Funded Amt]

Request Type: [Standard CSP/Exceeds Standard CSP]

The subject property has been conditionally approved to receive reimbursement for Category B: Eligible Capital Expenses, as defined in Notice H 2021-05, Section V. B., [or subsequent Notice] in the amount of [Funded Amount] . In order for HUD to disburse payment to the property, owners must certify to HUD that all items for which reimbursement is being provided were delivered and installed at the property not later than [insert Standard Due Date]. If funds were approved as part of a CSP Request that exceeded the Standard CSP amount, the certification of completion must be supported by documentation of a completed expenditure for the approved amounts, e.g., paid invoices.

Payment will be equal to the actual costs incurred by the property, not to exceed the amount originally requested. Failure to submit a certification of completion by [Insert Standard Deadline], may result in the cancellation of the CSP approval for Eligible Capital Expenses and a recapture of associated funds from the property’s rental assistance contract.

Owners experiencing exceptional circumstances that are now anticipated to prevent installation by [Insert Due Date] may use the response fields below to indicate the desire for additional time. Given the recent extension of the installation deadline for all properties, approvals of any additional extensions are expected to be extremely limited. If an extension is granted, HUD will provide an additional DocuSign file in which the owner can subsequently certify completion.

Changes to the scope of work included under the purchase agreement submitted with the HUD 52671-E will generally not be permitted for CSP-reimbursable equipment and installation. Delivery/installation dates may be modified where these are mutually agreed upon between the owner and vendor and are within the installation period authorized by HUD.

Owners with Category B equipment purchases that are partially delivered and/or installed as of [Insert Standard Due Date], can request an extension to allow for project completion OR may opt to certify completion at a reduced cost and forfeit CSP amounts associated with any uninstalled equipment.

Please contact the HUD Field Office Reviewer indicated on Page 3 of this document to discuss any special circumstances or other project-specific questions.

Technical questions about the use of DocuSign may be sent to [email protected].

Please select ONE of the following three certification statements:

☐ Completion of the Project as Requested: As the owner of the subject property or their legally designated representative, I hereby certify that all equipment identified under Category B: Eligible Capital Expenses for which reimbursement was requested on the HUD 52671-E for Operating Period [X], submitted to HUD in [insert application due date], has been delivered and installed consistent with the submitted request. I have attached any required documentation of expenses incurred.

☐ Completion of the Project at a Reduced Cost: As the owner of the subject property or their legally designated representative, I hereby certify that all equipment identified under Category B: Eligible Capital Expenses for which reimbursement was requested on the HUD 52671-E for Operating Period [X], submitted to HUD in [insert application due date], has been delivered and installed at a lower total cost than was included in the CSP request. Actual eligible costs totaled $[number Entry field].

The reduction in costs was due to: [new multiline text field].

I understand that HUD will cancel CSP funds obligated to the contract for Eligible Capital Expenses that exceed the actual costs to the property. I have attached any required documentation of expenses incurred.

☐ Project Incomplete: As owner of the subject property or their legally designated representative, I am advising HUD that equipment identified under Category B: Eligible Capital Expenses for which reimbursement was requested on the HUD 52671-E for Operating Period [X], submitted to HUD in [insert application due date], will not/was not be completed by [insert deadline]. I understand that unless an extension is granted, HUD will cancel CSP funds obligated to the contract for Eligible Capital Expenses.

I would like to be considered for an extension to complete installation of the requested equipment:

☐ No ☐ Yes

If yes, proposed completion date: [Date Entry Field]

If requesting an extension to complete installation after [insert Standard Deadline], please provide a narrative justification detailing the cause of the delay. Approval of any extensions will be limited to exceptional circumstances occurring through no fault of the owner. Owners requesting an extension should have a firm, revised completion date agreed to by the vendor.

[Text Entry Box]

Owner Name:

Owner Signature:

Warning: HUD will prosecute false claims & statements, which may result in criminal conviction and/or the imposition of criminal fines and/or civil penalties, to the full extent allowed by law. Collection of supplemental owner certifications to complete processing of certain COVID-19 Supplemental Payments is authorized under OMB Collection 2502-0619, in conjunction with submission of a HUD 52671-E COVID-19 Supplemental Payment Request form. Please refer to the HUD 52671-E for additional information.

Processing Outcome (For HUD Use only):

Servicing Multifamily Regional/Satellite Office: [Field Office]

☐ Approve for Full Amount

☐ Approve with Reduction. Amount: $[Amount Entry]

☐ Extension Granted until [Date Entry Field]_______

☐ Purchase Incomplete/Cancel Funds

HUD Reviewer Name: [Data Field - editable]

HUD Reviewer Signature:

Comments:

[text entry field]