HUD-52651 Housing Choice V oucher (HCV) Family Self-Sufficiency (F

Public reporting burden for this collection of information is estimated to average 0.75 hours. This includes the time for collecting, reviewing, and reporting the data. Information provided is to determine the eligibility of the applicant for funding for the salary of a program coordinator. HUD uses the information to determine eligibility of the applicant to receive funding. Information is required to obtain benefit under 24 CFR 982.302(b). The information is subject to the confidentiality requirements of the HUD Reform Legislation. 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.

PART I: General Information. (To be completed by all applicants.)

Applicant Category:  Renewal New	Moving-to-Work PHA?  Yes No	DUNS Number of Applicant:      	Funding Request for Fiscal Year:      
PHA Legal Name (For joint applicants, lead PHA name):      PHA Name, Mailing Address & PHA Number of applicant: (For joint PHA applicants, PHA Name, Mailing Address & PHA Number of lead PHA applicant):
Address:      
City:       County:      
State:       Zip Code:      
PHA Number of Applicant:      

2. PHA Legal Name for Each Joint Applicant (if Applicable). Note: Use Additional pages if necessary.:      

Address:            

City:       County:            

State:       Zip Code:      

PHA Number of Applicant:      

Evidence demonstrating salary comparability to similar positions in the local jurisdiction for each position requested is on file at the PHA.

 Yes No

4. The applicant requests consideration for the following preference categories under this NOFA:

Homeownership Colonias: Other - Specify Category (If applicable under this NOFA):

 Yes No  Yes No      

5. Name and telephone number of person most familiar with application:

Name       Telephone Number      

PART II: Homeownership Information. (To be completed by all applicants.)

The PHA applicant currently administers or participants in a HCV Homeownership program or another homeownership program

that serves HCV FSS families.  Yes No

If yes, provide information requested in A – C below:

1. Name of qualifying homeownership program or programs:

     

     

     

2. The total number of HCV FSS families enrolled in homeownership preparation activities in the qualifying homeownership program/programs identified above as of the publication date of the current NOFA:

1.	    	HCV homeownership program
2.	    	Other qualifying homeownership programs

C. Number of HCV FSS program participants and graduates that purchased homes

between October 1, 2000 and the publication date of the current NOFA:

1.	    	HCV homeownership program
2.	    	Other qualifying homeownership programs

PART III: PHA Applicant Program Status and Accomplishments. (Renewal PHAs Only)

1. Program Status:

1. The applicant qualifies as an eligible renewal PHA under the NOFA. Yes No

2. The PHA has filled each position for which it is seeking renewal funding. Yes No

3. The applicant has submitted reports on participating families to HUD via Yes No

the form HUD-50058, Family Self-Sufficiency/Welfare-to-Work Voucher Addendum.

2. Program accomplishments as of the publication date of the current NOFA:

1.	    	Total HCV FSS families under FSS Contract.
2.	    	The number of HCV FSS program participants with an escrow account balance greater than zero.

3. Program accomplishments for the period from October 1, 2003 through the publication date of the current NOFA:

1.	    	The number of HCV families that successfully completed their FSS contracts.
2.	    	The number of those graduates that no longer needed rental subsidy.
3.	     	The average escrow account distribution paid to families.

PART IV: Funding/Positions Requested. (Renewal PHAs Applicants Only)

For both renewal of currently funded positions and requests for new positions, provide the

Information below for each position requested. Use additional pages as needed.

A. Renewal Positions - Funding requested to continue currently funded positions: (List FSS homeownership

coordinators and regular FSS coordinators separately.)

FY Last Funded	Salary Amount Last Funded	Position Type ‘H’ or ‘R’ *	Salary Requested Per Position **	Number of Positions	Requesting an increase above percent allowed in the NOFA? ‘Y’ or ‘N’ ***
     	     	 	     	  	 
     	     	 	     	  	 
     	     	 	     	  	 
     	     	 	     	  	 
     	     	 	     	  	 
     	     	 	     	  	 
     	     	 	     	  	 
     	     	 	     	  	 
     	     	 	     	  	 

2. New Positions - Funding requested by coordinator type and salary level (If applicable. Refer to most recent

FSS NOFA for maximum new positions that can be funded in the current year.) If more than one position,

list each separately.

Position Type ‘H’ or ‘R’ *	Salary Requested, including Fringe Benefits**
 	     
 	     
 	     
 	     
 	     
 	     
 	     
 	     
 	     

2. Total Requested

1.	    	Total number of new and renewal positions requested in this application.
2.	     	Total $ requested.

* Type: R= Regular, H=Homeownership

** Salary awards will not exceed the cap per position stated in the most recent NOFA.

*** For any renewal position, where the applicant is requesting a percentage increase above the

amount provided for in the current NOFA, the applicant must comply with justification

requirements in the current FSS NOFA.

PART V: Application Information. (New PHA Applicants Only.)

A. FSS Action Plan Information:

    

HCV FSS program size in the HUD-approved Action Plan. (For Joint applications, provide total approved slots for all participating PHAs.)

2. Position/Salary Requested:

Number of Positions	Salary Requested, including Fringe Benefits**
  	     
  	     
  	     

2. Total Requested.

1.	    	Total number of positions requested.
2.	     	Total $ requested.

** Salary awards will not exceed the cap per position stated in the most recent NOFA.

Page 5 of 5 form HUD-52651

(10/2006)