HUD-91180-A Summary Budget Grantee

Summary Budget
Grantee

OMB Approval No. 2502-0485 (exp.04/30/2018)

U. S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner
Please read the Public Reporting Statement before completing this form

Grantee Name

Expense/Service

HG

1. Total Cost
Cash
A

I.

Case Management

II.

Meals

Value of Services
or Staff
B

Project Name (If different)

2. Total Income
In-Kind
Volunteer
Resources
Services
C
D

E

Participant
Fees
F

(at least 50%)

(at least 10%)

Total Applicant Match
(sum of Cols. A thru D)

3. CHSP Funds
Requested

III. Personal Assistance
IV. Housekeeper/Chore
V.

Other (specify)

VI. Administration
VII. Grand Total (Annual)
VIII. Percent of Grand Total
(% of line VII.)

IX. a.
b.

(100%)

123456789012345678901234567890121234567890123456789012345678
123456789012345678901234567890121234567890123456789012345678
123456789012345678901234567890121234567890123456789012345678
123456789012345678901234567890121234567890123456789012345678
123456789012345678901234567890121234567890123456789012345678
123456789012345678901234567890121234567890123456789012345678
123456789012345678901234567890121234567890123456789012345678

(Maximum 40%)

In-Kind Resources _____________% of Match (total Col. E) (Maximum 10%)
Administration _____________ % of Total Cost (Maximum 10 %)

c. Local Government Contribution _____________ % of Match (total Col. E) (Maximum 10%)
Footnotes: (continue on back if necessary)

form HUD-91180-A (12/94)
ref. Handbook 4640.1

Public reporting burden for this collection of information is estimated to average 14 hours 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. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless that collecton displays a valid OMB control number.
The information is basic to the operations of the Congregate Housing Services Program. It supports statutory requirements and program and management controls that prevent fraud, waste and
mismanagement. The controls must be maintained as long as current grants are in operation. Section 802 of the National Affordable Housing Act authorizes/requires matching funds and participant
fee collections that are reported onthese forms. The rule at 24 CFR 700.155(d) requires grantees to submit these forms. The information will be used by State/Area offices to ensure that grant funds
are being used properly. This includes grantees’ expense of appropriate grant monies during each annual grant period and the use of grant funds to provide eligible activities to eligible residents, and
to ensure that statutory requirements are being met. Program staff use the information to compile annual program data. Grantees must complete forms and report grant activity in order to continue receiving
grant funds. Each grantee is required to maintain confidentiality of information related to any individual, per the Privacy Act of 1974.

form HUD-91180-A (12/94)
ref. Handbook 4640.1