HUD 4136 Community Compass - Property Statement

OMB Approval No. 2506-0197

(Exp. 03/31/2023)

Community Compass - Property Statement

Cooperative Agreement Number
Organization Name

Part I. Based on the records and as required by the property management standards set forth in the award agreement, the following reflects the status of real and personnel property paid for in whole, or in part, by funds from this award:

1a. Was real property acquired?

☐Yes (continue) ☐No (skip to #2)

1b If yes, list the real property in Part II.

1c. Will the property continue to be used for the purpose authorized in the agreement?

☐Yes ☐No

If no, is approval being requested from HUD to use the property in other projects?

☐Yes ☐No

If yes, specify which projects:

If no, provide disposition instructions to HUD in Part II.

2. Was non-expendable personal property acquired?	☐Yes (continue) ☐No (skip to #3)
2a. If yes, list the non-expendable person property in Part II.
2b. Will the property continue to be used for the purpose authorized in the agreement?	☐Yes ☐No
If no, is approval being requested from HUD to use the property in other projects?
If yes, specify which projects:
If no, what is the proposed disposition of this property? (Check one or both)	☐ Approval is requested to retain the property in whole or in part. ☐ Disposition instructions from HUD are requested.
If both boxes are checked, please explain in detail in Part II of this Statement.

3. Was expendable personal property with an aggregate value of over $5,000 (for State and local Governments) or $1,000 (for non-profit organizations) acquired?

☐Yes ☐No

3a. If yes, refer to your agreement and request disposition forms from your GTR.

PART II. Information requested in Part I may be provided in the format that follows.

Date Purchased	 	 	 	 
Description
Serial Number
Unit Cost
% HUD funds
Location Address
Condition
Service Contracts
Inventory Reconciled

Authorized Official Name

Authorized Official Title

Date

Certification:

NOTE: I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012, 1014; 31 U.S.C. §3729, 3802).

Public reporting burden for this collection of information is estimated to average 0.5 hours. This includes the time for collecting, reviewing, and reporting the data. The information is being collected for Community Compass Technical Assistance and Capacity Building Program Notice of Funding Availability (NOFA) and will be used for NOFA application review. Response to this request for information is required in order to receive the benefits to be derived. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number. No confidentiality is assured.”

Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to the Reports Management Officer, Office of Policy Development and Research, REE, Department of Housing and Urban Development, 451 7th St SW, Room 4176, Washington, DC 20410-5000.  When providing comments, please refer to OMB Approval No. 2506-0197.

form HUD-4136 (3/23)