Obligation Certification

EMERGENCY RENTAL ASSISTANCE PROGRAM

U.S. DEPARTMENT OF THE TREASURY

Obligated Funds Certification

[insert name of entity] (the “ERA Grantee”) received its full allocation of funds (the “ERA1 Award”) for the delivery of emergency rental assistance in accordance with section 501 of division N of the Consolidated Appropriations Act, 2021 (the “Act”). Section 501(d) of the Act requires the U.S. Department of the Treasury (“Treasury”) to recapture excess funds not obligated by grantees that may be reallocated to grantees that have a demonstrated need.

Treasury has published guidance, available on its website, setting forth the procedures for the reallocation of ERA funds under the Act. As described in the guidance, Treasury considers ERA funds to be obligated if (i) the funds have actually been spent providing financial assistance and housing stability services for eligible households; (ii) the funds are needed to pay for assistance promised in a commitment letter issued to induce a landlord to enter a rental agreement with an eligible household under Treasury’s ERA FAQ #35; or (iii) subject to certain conditions, the grantee has, as part of the grantee’s ERA program administration, entered into a binding agreement or funding commitment requiring the grantee to disburse the funds to a third party for eligible purposes. In addition, Treasury will consider 10% of each grantee’s total award amount as having been obligated for administrative costs regardless of the grantee’s actual expenditures, commitments, or obligations.

Please provide information on this form only regarding the ERA Grantee’s use of funds from the ERA1 Award authorized by the Act – not regarding its use of funds under an ERA award authorized by the American Rescue Plan Act of 2021 (“ERA2”).

Consistent with Treasury’s reallocation guidance, the undersigned hereby represents and certifies to Treasury that:

1. As of [insert date], the ERA Grantee has obligated its ERA1 Award funds as follows:

Enter 10% of total ERA1 Award amount for administrative costs:	$
Enter total of all other amounts obligated by ERA Grantee as of the date hereof:	$
Total amount obligated:	$

2. The undersigned is an official with the authority to provide this certification on behalf of the ERA Grantee.

[ERA GRANTEE] By: [Official’s Name] [Official’s Title]

Date: , 20

PAPERWORK REDUCTION ACT NOTICE: The information collected will be used for the U.S. Government to determine the reallocation of emergency rental assistance funds. The estimated burden associated with this collection of information is 30 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 section 501 of division N of the Consolidated Appropriations Act, 2021 (the “Act”)

PURPOSE: The Act requires Treasury to allocate funds to eligible grantees for the delivery of emergency rental assistance to eligible households. Eligible grantees include states, local governments, U.S. territories, Tribes or Tribally Designated Housing Entities (TDHEs), as applicable, and the Department of Hawaiian Home Lands. Treasury maintains contact information for authorized representatives and contact persons of the ERA grantees for the purpose of communicating with ERA grantees regarding the administration of their award under 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 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 which may affect the status of their award.

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OMB Approved No.: 1505-0266

Exp.: 11/30/2021