Emergency Recipient Payment Information Form

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 INFORMATION

Recipient Name

Recipient’s Taxpayer ID Number

Recipient's DUNS Number

Recipient’s Address

Street

City

State

Postal Code

Authorized Representative Name

Authorized Representative Title

Contact Person Name

Contact Person Title

Contact Person Phone

Contact Person E-mail

RECIPIENT TYPE

Type of recipient (choose one):

• State/DC

• Territorial Government

Local Government

• Indian Tribe or Tribally Designated Housing Entity

• Department of Hawaiian Homelands

FINANCIAL INSTITUTION INFORMATION

Routing Transit Number (Wire)

Routing Transit Number (ACH)

Recipient’s Account Number

Financial Institution Name

Financial Institution Address

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.