4123 Cost Summary

Cost Summary
Indian Community Development Block
Grant (ICDBG)

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

OMB Approval No. 2577-0191
(exp. 2/29/2012)

See Instructions and Public Reporting Statement on back.
1. Name of Applicant (as shown in Item 5, Standard Form 424)

3.

Original

(check here if this is the
first submission to HUD)

Revision

(check here if submitted
with implementation schedule
as part of pre-award requirements

2. Application/Grant Number (to be assigned by HUD upon submission)

Amendment

(check here if submitted
after HUD approval of grant)

Program Funds (in thousands of $ )

4.

Project Name & Project Category

ICDBG

(see instructions on back)

Amount Requested
for each activity

a

Other

b

$

5.

Date (mm/dd/yyyy)

Other Source Amount
for each activity

Source of Other Funds
for each activity

c

d

$

Administration
a. General Management and Oversight
b. Indirect Costs: Enter indirect costs to be charged to the
program pursuant to a cost allocation plan.
c. Audit: Enter estimated cost of Program share of A-133 audits.

Administration Total *

0.00

0.00

6. Planning The Project description must address the proposed use
of these funds.
7. Technical Assistance Enter total amount of ICDBG funds
requested for technical assistance. **
8. Sub Total Enter totals of columns b. and c.

$

0.00

$

0.00
$

9. Grand Total Enter sum of column b. plus column c.

0.00

* The total of items 5 and 6 cannot exceed 20% of the total ICDBG funds requested.
** No more than 10% of ICDBG funds requested may be used for technical assistance. If funds are requested under this line item,
separate
a
project description
must accompany the application to describe the technical assistance the application intends to obtain. Only technical assistan
ce costs associated with the
development of a capacity to undertake a specific funded program activity are eligible (24 CFR 1003.206).

Previous editions are obsolete

Page 1 of 2

form HUD-4123 (12/98)

Public reporting burden for this collection of information is estimated to average 40 hours per response, including the time f or reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of info
rmation. 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 collection of information requires that each eligible applicant submit information to enable HUD to select the best projects for funding during annual
competitions for the ICDBG Program. The information will be used by HUD to determine whether applications meet minimum screeni
ng eligibility
requirements and application submission requirements. Applicants provide general information about the project which is prelim
inary to the review of the
applicant’s response to the criteria for rating the application. The information is essential for HUD in monitoring grants ensure
to
that grantees are making
proper use of Federal dollars. Responses to the collection are required by Section 105 of the Department of Housing and Urban
Development Reform Act (P.L.
101-235) as amended by the Cranston-Gonzales National Affordable Housing Act of l990. The information requested does not lend itself to confidentiality.

Instructions for Item 4.
Project Name and Project Type
Participants enter the project name and the name of one of the
following three categories of activities:
• Housing
• Community Facilities
• Economic Development
Also enter the component name if applicable. Use a separate
Cost Summary sheet (form HUD-4123) for each project included in the application.
Examples of categories and/or components including examples of eligible activities are listed below.

Community Facilitites
Infrastructure Component

•
•
•
•

Water
Sewer
Roads and Streets
Storm Sewers

Buildings Component

•
•
•
•

Health Clinic
Daycare Center
Community Center
Multi-purpose Center

Housing
Rehabilitation Component

Economic Development

•
•
•
•
•

• Rehabilitation
• Demolition

Land to Support New Housing Component
New Housing Construction Component

Previous editions are obsolete

Page 2 of 2

Commercial (wholesale, retail)
Industrial
Motel/Hotel
Restaurant
Agricultural Development

form HUD-4123 (12/98)