Additional Funding Request Form

OMB Control Number: 1505-0270

OMB Expiration Date: 10/31/2021

[Date]

U.S. Department of the Treasury

[email protected]

Emergency Rental Assistance (ERA2) Request for Additional Funding

The undersigned submits this request on behalf of [Eligible Grantee] (the “Grantee”) to the U.S. Department of the Treasury (“Treasury”) for a disbursement of additional funds as authorized by Section 3201(c)(2) of the American Rescue Plan Act of 2021, Pub. L. No. 11-702 (March 11, 2021) (the “ARP”). Under Section 3201(b) of the ARP, Treasury allocated $ (the “Allocation”) to the Grantee for the funding of emergency rental assistance (“ERA”). As of the date of this request, the Grantee has received $ from the Allocation (the “Prior Disbursements”), equal to 40% of the Allocation, in accordance with Section 3201(c)(1) of the ARP, [plus subsequent disbursement(s) in the aggregate amount of $ ].

The Grantee hereby requests $ from the remaining amount of the Allocation to provide additional financial assistance in accordance with Section 3201(d) of the ARP. The Grantee acknowledges Treasury may require the Grantee to submit additional information and supporting documentation before approving this request.

The Grantee and the undersigned, on the Grantee’s behalf and to the best of the undersigned’s knowledge and belief, each make the following certifications in support of this request:

1. The Grantee has complied with, and is currently in compliance with, the Emergency Rental Assistance Award Terms and Conditions under FAIN # (the “Award Agreement”), all requirements applicable to ERA under the ARP, and Treasury’s interpretive guidance regarding such requirements (the “Program Requirements”).

2. A total of $ in funds received by the Grantee from the Allocation, representing % of the Prior Disbursements, has been (i) expended for financial assistance or housing stability services under Section 3201(d)(A) and 3201(d)(B) of the ARP, or obligated for such expenditure under legally binding agreements entered into by the Grantee; (ii) spent, or budgeted and held in a reserve account by the Grantee, to cover administrative costs under Section 3201(d)(1)(C) of the ARP in an amount that does not exceed 15% of the Prior Disbursements; or (iii) reserved by the Grantee for assistance contemplated by any outstanding commitment letters issued by the Grantee under Treasury’s ERA Frequently Asked Question 35.

3. The undersigned is duly authorized to submit this request on the Grantee’s behalf.

4. The Grantee acknowledges and agrees that the funds requested hereby will be subject to the terms and conditions of the Award Agreement.

The Grantee and the undersigned acknowledge that any materially false, fictitious, or fraudulent statement or representation (or concealment or omission of material fact) in this submission may be the subject of criminal prosecution under the False Statements Accountability Act of 1996, as amended (18 U.S.C. § 1001), and also may subject the Grantee and the undersigned to civil penalties and/or administrative remedies for false claims or otherwise.

GRANTEE [Eligible Grantee—State agency, locality, etc.] By: Name: Title: Date: , 20

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