ETA 9143 Worksite Description and Annual Housing Census Form

Annual Housing Census: Instruc�ons

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

NOTE: This form is also available to submit online at [URL].
This informa�on is not a gauge of program performance; DOL uses it to report to Congress and other stakeholders the
valuable contribu�ons made by the young people in your programs for your community. It is understood that it may take
longer to build or renovate property when using these sites for training.
GENERAL
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The Repor�ng Period for each Annual Housing Census (AHC) is August 1 through July 31.
Grantees submit an AHC form for each Repor�ng Period that overlaps with their grant Period of Performance.
Each grantee will submit at least three AHC forms, regardless of the number of housing units completed.
Enter only those units that are complete and ready for occupancy. Unless this is your final AHC for the grant
period of performance, do not enter unfinished units on this form; enter them on the AHC form for the
Repor�ng Period in which they are completed.
Do not enter any units that have been submited in previous AHCs.
Complete Sec�ons 1, 2 (if any units completed), and 3, and send via email to [email protected].

SECTION 1: Complete this sec�on regardless of the number of housing units completed during the Repor�ng Period.
1. Print the grantee organiza�on name and address.
2. Print the grant number. Note: If your organiza�on had more than one DOL YouthBuild grant ac�ve during the
Repor�ng Period, you must submit one AHC form for each grant.
3. Print the year in which the Repor�ng Period ended, e.g., for the period August 2024 through July 2025, print 25.
SECTION 2: If par�cipants completed 0 housing units during the Repor�ng Period, leave this sec�on blank. If par�cipants
completed one unit, leave Units 2-6 blank. If par�cipants completed more than 6 units, submit addi�onal AHC forms.
1. Print the Month and Year (e.g., September 2024) that the unit was completed, and mark whether the unit was a
house, apartment, or townhome/duplex.
2. Print the address of the completed unit.
3. If par�cipants completed one unit at the address, mark No. If they completed more than one unit, mark Yes and
describe.
4. Mark the type of work par�cipants completed. If marking Other, describe the work.
SECTION 3: Complete this sec�on regardless of the number of housing units completed during the Repor�ng Period.
1.
2.
3.
4.

Print the total number of units completed during the Repor�ng Period. If the total is 0, print 0.
Print the name, �tle, and email address of the organiza�on signatory (e.g., Jane Smith, CEO, [email protected]).
Sign the document.
Print the date of submission to DOL.

OMB No.: 1205-0464 OMB Expiration Date: 11/30/2027 OMB Burden Hours: 30 minutes throughout the life of the grant OMB Burden Statement: These reporting
instructions have been approved under the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a
currently valid OMB control number. This collection of information is required for grant application and work site approval. Information is collected from eligible
applicants for a competition to determine which entities will receive grant funds. Public reporting burden for this collection of information includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Submission is
mandatory and is authorized under the Workforce Innovation and Opportunity Act Public Law 113-128 Sec. 171. The information will be used for the YouthBuild grant
and response to this request for information is required in order to receive the benefits to be derived. The information requested does not lend itself to confidentiality.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U. S.
Department of Labor, Employment and Training Administration, Office of Workforce Investment, Division of Youth Services, Room N4508, 200 Constitution Avenue, NW,
Washington, D.C. 20210.

Annual Housing Census: Page 1 YouthBuild Grant | OMB no. 1205-0464 | Exp. 11/30/2027
SECTION 1
Grantee Organiza�on Name & Address:
Grant Number:
Repor�ng Period:

August 1 – July 31, 20_____
Check if this is the final report for the grant:

SECTION 2
Unit #1

Address:

□

Completed in: _________________ Month _________ Year

□ House □ Apartment □ Townhome/Duplex

Did par�cipants complete mul�ple units
at this address?

□ No □ Yes (describe):

What type of work did par�cipants
complete?

□ New construc�on □ Renova�on □ Other (describe):

Unit #2

Address:

Completed in: _________________ Month _________ Year

□ House □ Apartment □ Townhome/Duplex

Did par�cipants complete mul�ple units
at this address?

□ No □ Yes (describe):

What type of work did par�cipants
complete?

□ New construc�on □ Renova�on □ Other (describe):

Unit #3

Address:

Completed in: _________________ Month _________ Year

□ House □ Apartment □ Townhome/Duplex

Did par�cipants complete mul�ple units
at this address?

□ No □ Yes (describe):

What type of work did par�cipants
complete?

□ New construc�on □ Renova�on □ Other (describe):

Annual Housing Census: Page 2
Unit #4

Address:

YouthBuild Grant | OMB no. 1205-0464 | Exp. 11/30/2027
Completed in: _________________ Month _________ Year

□ House □ Apartment □ Townhome/Duplex

Did par�cipants complete mul�ple units
at this address?

□ No □ Yes (describe):

What type of work did par�cipants
complete?

□ New construc�on □ Renova�on □ Other (describe):

Unit #5

Address:

Completed in: _________________ Month _________ Year

□ House □ Apartment □ Townhome/Duplex

Did par�cipants complete mul�ple units
at this address?

□ No □ Yes (describe):

What type of work did par�cipants
complete?

□ New construc�on □ Renova�on □ Other (describe):

Unit #6

Address:

Completed in: _________________ Month _________ Year

□ House □ Apartment □ Townhome/Duplex

Did par�cipants complete mul�ple units
at this address?

□ No □ Yes (describe):

What type of work did par�cipants
complete?

□ New construc�on □ Renova�on □ Other (describe):

SECTION 3
Total number of units completed during
Repor�ng Period:
Organiza�on Signatory:
* print name, �tle, & email address
Signature:
Date of submission: