Form ETA 9143 ETA 9143 Work Site Description and Annual Housing Census Forms

ETA-9143 Instruc�ons

YouthBuild Grant | OMB no. 1205-0464 | Exp. 11/30/2027

See Training and Employment Guidance Leter (TEGL) 06-15, which provides guidance on the types of work sites that are
acceptable for construc�on training for YouthBuild par�cipants and describes the minimum construc�on ac�vi�es
allowed for work site training.
A separate ETA-9143 with all relevant atachments is required for each YouthBuild work site. A work site may include
mul�ple housing units, but not mul�ple addresses.
For each work site, complete the following:
• all sec�ons of ETA-9143 pages 1 and 2, and atach leters of commitment documen�ng all resources listed on
page 2
• all sec�ons of Atachments A and B
Page 1, all leters atached to page 2, and Atachment A must be dated less than six months before submission to DOL.
If YouthBuild grant or match funds will be used for construc�on materials, complete Atachment C. If not, omit.
If any of the work site units are currently occupied, complete Atachment D. If not, omit.
OMB no.: 1205-0464 OMB Expira�on Date: 11/30/2027 OMB Burden Hours: 30 minutes OMB Burden Statement: These repor�ng instruc�ons have been approved
under the Paperwork Reduc�on Act of 1995. Persons are not required to respond to this collec�on of informa�on unless it displays a currently valid OMB control
number. Informa�on is collected from eligible applicants for a compe��on to determine which en��es will receive grant funds. Public repor�ng burden for this
collec�on of informa�on includes the �me for reviewing instruc�ons, searching exis�ng data sources, gathering and maintaining the data needed, and comple�ng and
reviewing the collec�on of informa�on. Submission is mandatory and is authorized under the Workforce Innova�on and Opportunity Act Public Law 113-128 Sec. 171.
The informa�on will be used for the YouthBuild grant and response to this request for informa�on is required in order to receive the benefits to be derived. The
informa�on requested does not lend itself to confiden�ality. Send comments regarding this burden es�mate or any other aspect of this collec�on of informa�on,
including sugges�ons for reducing this burden, to the U. S. Department of Labor, Employment and Training Administra�on, Office of Workforce Investment, Division of
Youth Services, Room N4508, 200 Cons�tu�on Avenue, NW, Washington, D.C. 20210.

ETA-9143 Page 1: Work Site Descrip�on
1. Applicant/Grantee Organiza�on Name:

YouthBuild Grant | OMB no. 1205-0464 | Exp. 11/30/2027

2. Applicant/Grantee Organiza�on Address:
3. Work Site Property Iden�fica�on:
(Address and/or Geographic Parcel Identification Number)
4. Number of housing units that YB par�cipants will
construct or renovate on this work site property:
5. Type of housing to be produced:
(Check all that apply)
6. Does the owner agree to the five-year Restric�ve
Covenant* that ensures all housing produced be provided
for homeless, low-income, or very low-income persons?
7. The on-site training consists of:
(Check all that apply)
8. Name of the current owner of work site property:

□ Rental/Residential □ Homeownership □ Transi�onal
□ Yes □ No, explana�on atached
□ New Construc�on □ Renova�on

9. Name of en�ty that will own/manage the property
a�er the construc�on or renova�on work is completed:
10. Are any YouthBuild grant funds or match being used
for construc�on materials?
11. Are any of the units currently occupied?

□ Yes, Atachment C includes details □ No
□ Yes, Atachment D includes details □ No

* See 20 CFR 688.730, which requires that the owner agree to the five-year Restric�ve Covenant at the �me of the
issuance of the occupancy permit. If the property is being renovated and will not require an occupancy permit, the
grantee must confirm the homeowner/resident is or will be a low-income individual or family.
12. Applicant / Grantee Organiza�on Signatory
Printed Name and Title: ____________________________________________________________________________

Organiza�on: _____________________________________________________________________________________

Signature: __________________________________________________ Date: ________________________________

ETA-9143 Page 2: Work Site Project Es�mate
1. Applicant/Grantee Organiza�on Name:

YouthBuild Grant | OMB no. 1205-0464 | Exp. 11/30/2027

2. Work Site Property Iden�fica�on:
(Address and/or Geographic Parcel Identification Number)
3. Housing Project Costs for Site
• Include both cash and in-kind contribu�ons. See TEGL 05-10, change 1 for allowable construc�on costs.
• Include any YouthBuild grant funds, match funds, and leveraged funds dedicated to the construc�on project in both
charts below.
• Do not include costs of staff salaries or par�cipant s�pends/wages.
Grant
YouthBuild
Other
Ac�vi�es
grant funds
Federal
State
Local
Private

TOTAL

Acquisi�on
Architecture &
Engineering
Housing
Construc�on
Housing
Renova�on

TOTAL
4. Documenta�on of Housing Resources
• If using YouthBuild grant funds or match funds, include in the chart below and in Atachment C.
• Atach a leter of commitment from each provider/donor that provides the specific match amount dedicated to the
construc�on project and the source of the funding. Leters must include the work site address or GPIN and be dated
no more than six months prior to the date of submission to DOL.
• Report leveraged resources that are non-federal in origin here AND on the ETA-9130 financial report. Report federal
leveraged resources on this form only.
Cash OR In-Kind? Dollar Value
Name of Provider/Donor

TOTAL resources must match the total costs in the table above 

ETA-9143 Atachment A: Ownership/Access Atesta�on

YouthBuild Grant | OMB no. 1205-0464 | Exp. 11/30/2027

An individual with legal authority to make this atesta�on must complete the following. If this individual prefers to
submit a leter, it must contain all informa�on listed on this template and be signed and dated as required.
1. Work Site Property Iden�fica�on:
(Address and/or Geographic Parcel Identification Number)
2. Name of the current owner of work site property:
3. Name of en�ty that will own/manage the property
a�er the construc�on or renova�on work is completed:
4. I cer�fy the following regarding the work site property iden�fied above (check all that apply):

□
□
□

I am the legal owner of the work site property.
I am the legal signatory for the organiza�on that owns the work site property.
I am the legal signatory for the organiza�on that has a signed contract for, or op�on to purchase, the work site
property (future owner).

5. I affirm that the YouthBuild program operated by (organiza�on)
____________________________________________ and its par�cipants will have access to the work site property
for the dura�on of the program or un�l the agreed upon construc�on ac�vi�es are completed by the program,
whichever comes first.
Printed Name and Title: ______________________________________________________________________________
Organiza�on: _______________________________________________________________________________________
Signature: __________________________________________________

Date: ________________________________

ETA-9143 Atachment B: Descrip�on of Ac�vi�es
1. Applicant/Grantee Organiza�on Name:

YouthBuild Grant | OMB no. 1205-0464 | Exp. 11/30/2027

2. Work Site Property Iden�fica�on:
(Address and/or Geographic Parcel Identification Number)
3. Number of par�cipants proposed to work on work site:
4. An�cipated �me it will take to complete construc�on
or renova�on:
5. Descrip�on of specific construc�on (new build or renova�on) ac�vi�es in which par�cipants will be engaged (i.e.,
modules of training, such as framing, carpentry, drywall, installa�on, etc.). See TEGL 06-15 for level of construc�on work
that qualifies a work site for YouthBuild. This sec�on should describe exactly what work is being done on the housing
unit, and in which parts of that work YouthBuild par�cipants will receive hands-on training:

ETA-9143 Atachment C: Grant/Match Funds for Construc�on YouthBuild Grant | OMB no. 1205-0464 | Exp. 11/30/2027
1. Applicant/Grantee Organiza�on Name:
2. Work Site Property Iden�fica�on:
(Address and/or Geographic Parcel Identification Number)
3. List applicable materials and costs below. See TEGL 05-10, change 1 for allowable construc�on costs.

ETA-9143 Atachment D: Reloca�on Narra�ve
1. Applicant/Grantee Organiza�on Name:

YouthBuild Grant | OMB no. 1205-0464 | Exp. 11/30/2027

2. Work Site Property Iden�fica�on:
(Address and/or Geographic Parcel Identification Number)
3. Total number of persons currently occupying the
unit(s):
4. Number to be permanently displaced during
renova�on:
5. Number to be temporarily relocated but not displaced
during renova�on:
6. Es�mated cost of reloca�on services:
7. Source of funds for reloca�on:
8. Organiza�on that will provide reloca�on assistance to
occupants (if applicable):
9: Reloca�on assistance contact person’s name and
phone number:
10. Use the space below to fully describe the reloca�on process: