Acceptance of Award Terms Form

OMB Approved No.: [ ]
Expiration Date: [ ]

HOMEOWNER ASSISTANCE FUND

U.S. Department of the Treasury

Financial Assistance Agreement

Recipient Name and Address: [Recipient to provide]

DUNS Number: [Recipient to provide] Taxpayer Identification Number: [Recipient to provide]

Section 3206 of the American Rescue Plan Act of 2021 authorizes the U.S. Department of the Treasury (Treasury) to mitigate financial hardships associated with the coronavirus pandemic by providing funds to eligible entities for the purpose of preventing homeowner mortgage delinquencies, defaults, foreclosures, loss of utilities or home energy services, and displacements of homeowners experiencing financial hardship after January 21, 2020, through qualified expenses related to mortgages and housing.

Recipient hereby agrees, as a condition to receiving such funds from Treasury, to the terms attached hereto.

Recipient:

__________________________________________________

Name of Authorized Representative:

Title:

Date:

U.S. Department of the Treasury:

__________________________________________________

Name of 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 III, Pub. L. 117-2.

PURPOSE:  Treasury is required by the American Rescue Plan Act of 2021 to identify eligible entities to provide homeowners assistance to individuals who qualify for relief under the Act.  Eligible entities are state, territorial, and tribal governments, which will identify homeowners eligible for relief based on requirements under the Act.  Treasury maintains contact information for authorized representatives and contact persons for the purpose of communicating with eligible entities 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.