CERTIFICATION OF CONSISTENCY WITH THE INDIAN HOUSING PLAN

U.S. DEPARTMENT OF HOUSING
AND URBAN DEVELOPMENT
OFFICE OF PUBLIC AND INDIAN HOUSING

Instructions for completing this form: All tribes/TDHEs must submit this form in conjunction with their ROSS application.

I certify that the proposed activities/projects in the application are consistent with the jurisdiction’s current, approved Indian Housing Plan.

Applicant Name:

Project Name:

Location of the Project:

Name of the Federal Program(s) to which the applicant is applying:

Name of Certifying Jurisdiction:

Title:

Signature:

Date:

Public reporting burden for the collection of information is estimated to average fifteen minutes per response. This includes the time for collecting, reviewing, and reporting the data. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden the Reports Management Officer, REE, Department of Housing and Urban Development, 451 7th Street SW, Room 8210, Washington, DC 20410–5000. When providing comments, please refer to OMB Control No. 2577-0229. The information will be used to determine eligibility for the ROSS SC grant. 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.  This information does not lend itself to confidentiality.

I, 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 penalties.  (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802)

form HUD-52752 (12/2011)

     OMB Approval No. 2577-0229 Expiration Date: XX-XX-XXXX