Form 4125 Implementation Schedule

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

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

Implementation Schedule
Indian Community Development Block Grant (ICDBG)
See Instructions and Public Reporting Statement on back.
Submit a separate implementation schedule for each project category.
1. Name of Applicant (as shown in Item 5, Standard Form 424)

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

4. Name of Project (as shown on form HUD-4123, item 4)
6. Environmental Review Status
Exempt (As described in 24 CFR 58.34)
EIS Required (Finding that project may
significantly affect environment or
EIS automatically required by 24 CFR 58.37)

5. Effective Date (mm/dd/yyyy)

Original (First submission to HUD)
Date (mm/dd/yyyy)
Pre-Award Submission
Amendment (submitted after grant approval)

3.

Expected Completion Date (mm/dd/yyyy) Expected Closeout Date (mm/dd/yyyy)

Under Review (Review underway;
findings not yet made)

Finding of No Significant Impact (Finding made that request for release of
funds for project is not an action which may significantly affect the environment.)

Not Started
(Review not yet begun)

Certification (Environmental review completed;
certification and request for release of funds
being prepared for submission.)

7. Tribal Fiscal Year (mm/dd/yyyy)

Categorically Excluded
(as described in 24 CFR 58.35)

9. Schedule.
(List tasks such as environmental assessment, acquisition, etc.) Use Calendar Year (CY) quarters. Fill-in the CY below. See detailed instructions on back.

8. Task List

1st Qtr.

2nd Qtr.

CY _____
3rd Qtr.

4th Qtr.

5th Qtr.

6th Qtr.

CY _____
7th Qtr.

Date (mm/dd/yyyy)
(If exceeds 8th Q tr

8th Qtr.

10. Planned Drawdowns by Quarter
(Enter amounts non-cumulatively)

$

$

$

$

$

$

$

$

$Total

11. Cumulative Drawdown
(If more than one page, enter total on last page only)

$

$

$

$

$

$

$

$

$Total

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form HUD-4125 (12/97)

Public reporting burden for this collection of information is estimated to average 40 hours per response, including the or
time
reviewing
f
instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate yorother
an aspect of this collection of information, including suggestions for reducing
this burden, to the Reports Management Officer, Paperwork Reduction Project (2577-0191), Office of Information Technology, U.S.
Department of Housing and Urban Development, Washington, D.C. 204103600. This agency may not collect this information, and you are not required to complete this form, unless it displays a curre
ntly valid OMB control number.
This collection of information requires that each eligible applicant submit information to enable HUD to select the best projec
ts for funding during annual competitions for the ICDBG Program. The information
will be used by HUD to determine whether applications meet minimum screening eligibility requirements and application submissio
n requirements. Applicants provide general information about the project which
is preliminary to the review of the applicant’s response to the criteria for rating the application. The information is essent
ial for HUD in monitoring grants to ensure 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(P.L.
Act 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 9 Schedule: Use Calendar Year (CY) quarters. Fill-in the CY below. If the project begins in May, for example, enter under "1st Qtr.",
A(April), M(May), J(June). Indicate time period required
to complete each activity, e.g., acquisition, by entering "X" under the months it will begin and end. Draw a horizontalrom
line the
f first to the second "X". If the completion date will extend beyond the 8th quarter, enter
date in the far right column and attach an explanation.

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form HUD-4125 (12/97)