HUD 2991 Acknowledgment of Application Receipt

Certification of Consistency with the
Consolidated Plan

OMB Number. 2501-XXXX
Expiration Date: pending

U.S. Department of Housing and
Urban Development

Public Reporting Burden Statement: This collection of information is estimated to average 3 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 the
requested information. Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to: U.S.
Department of Housing and Urban Development, Office of the Chief Data Officer, R, 451 7th St SW, Room 8210, Washington, DC 20410-5000. Do
not send completed forms to this address. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless the collection displays a valid OMB control number. This agency is authorized to collect this information under Section 102 of the
Department of Housing and Urban Development Reform Act of 1989. The information you provide will enable HUD to carry out its responsibilities
under this Act and ensure greater accountability and integrity in the provision of certain types of assistance administered by HUD. This information
is required to obtain the benefit sought in the grant program. Failure to provide any required information may delay the processing of your
application and may result in sanctions and penalties including of the administrative and civil money penalties specified under 24 CFR §4.38. This
information will not be held confidential and may be made available to the public in accordance with the Freedom of Information Act (5 U.S.C.
§552). The information contained on the form is not retrieved by a personal identifier, therefore it does not meet the threshold for a Privacy Act
Statement.

I/We, the undersigned, also certify under penalty of perjury that the information provided below is true, correct, and accurate.
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). 24 CFR § 28.10(b)(iii)
I/We, the undersigned, certify that the proposed activities/projects in the application are consistent with the jurisdiction’s current,
approved Consolidated Plan. (Complete the fields below.)
Applicant Name:
Project Name:
Location of the Project:
Name of the Federal Program to which the applicant is applying:

Name of Certifying Jurisdiction:
Certifying Official of the Jurisdiction
Name:
Title:
Signature:

Date:

form HUD-2991