HUD-50096 Shortfall Appeal

OMB Approval # 2577-0300
(Exp. 3/31/2025)

HUD-50096: Shortfall Appeal

CY 20__ Operating Fund Grant Program – Appeal

Public Housing Agency (PHA) Form to Appeal Published Shortfall Eligibility Amount

PHA Name: _____________________________________________

PHA Number: _____________________________________________

Executive Director: _____________________________________________

The above referenced agency is applying for Shortfall funds and has submitted accurate and complete financial data to the U.S. Department of Housing and Urban Development (HUD).

As specified in the Shortfall Notice, please submit the following items to submit your appeal:

Upload	a re-calculation of Operating Reserves assuming the amount of the requested appeal is approved.
Upload	a copy of the approved FDS that contains the error
Upload	an indication of the corrected entries and financial information
Upload	for PHAs that will submit a revised financial statement to HUD, a written concurrence from the PHA’s auditor
Upload	a signed statement (signed pdf is acceptable) by the PHA’s Executive Director certifying that the submitted information is accurate
Upload	other documentation to support appeal outside of the above categories

Justification for appeal:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

PHA Contact Name Date

__________________________________ ___________________

Paperwork Reduction Act burden statement:

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.

HUD collects this information in accordance with24 CFR Part 990 annual Appropriations laws, including FY 2021 Consolidated Appropriations Act (Public Law 116-260). PHAs appealing their Shortfall Funding eligibility are required to complete this form. PHAs will use this form to appeal the published Shortfall eligibility amount they were awarded. HUD will use this application form in making a determination on the appeal and to ensure that PHAs have submitted accurate and complete financial data. No assurances of confidentiality are provided for this information collection.