Emergency Recipient Payment Information Form

Emergency Rental Assistance Program (ERA1)

ERA Recipient Payment Information Form (Final 1-04-2021)

OMB: 1505-0266

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OMB Approved No. 1505-0266

Expiration Date: MM/DD/YYYY


RECIPIENT PAYMENT INFORMATION FORM

Eligible grantees—states (including the District of Columbia), U.S. Territories (Puerto Rico, the United States Virgin Islands, Guam, the Commonwealth of the Northern Mariana Islands, and American Samoa), local governments with more than 200,000 residents, the Department of Hawaiian Homelands, and Indian tribes (defined to include Alaska native corporations) or the tribally designated housing entity of an Indian tribe, as applicable—must provide payment information and an executed copy of the award terms not later than 11:59 p.m. EDT on January 12, 2021.


An exception is provided in the statute for Indian tribes that opted out of receiving a grant allocation under the Native American Housing Block Grants program formula in fiscal year 2020. Those Indian tribes must provide payment information and sign the acceptance of award terms form not later than 11:59 p.m. on January 26, 2021.

An authorized representative of the eligible grantee with legal authority to bind the eligible grantee must sign the acceptance of award terms forms. In the case of a local government, the chief executive officer of the local government must sign the acceptance of award terms form.

RECIPIENT INFORMATIONShape3

Recipient Name Shape4

Recipient’s Taxpayer ID NumberShape5

Recipient's DUNS NumberShape6

Recipient’s Address

StreetShape7


CityShape8

State Shape9

Postal CodeShape10

Authorized Representative NameShape11

Authorized Representative TitleShape12

Contact Person NameShape13

Contact Person TitleShape14

Contact Person PhoneShape15

Contact Person E-mail


RECIPIENT TYPE

Shape16

Type of recipient (choose one):

  • State/DC

  • Territorial Government

Shape17 Local Government

  • Indian Tribe or Tribally Designated Housing Entity

  • Department of Hawaiian Homelands


FINANCIAL INSTITUTION INFORMATION

Shape18

Routing Transit Number (Wire) Shape19

Routing Transit Number (ACH) Shape20

Recipient’s Account Number Shape21

Financial Institution Name Shape22

Financial Institution Address Shape23

Financial Institution Telephone Number



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.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorKowalski, Daniel
File Modified0000-00-00
File Created2022-05-23

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