Hud 966 Needs Assessment Form

OMB Approval No. 2529-0050

Expiration Date:

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

OFFICE OF FAIR HOUSING AND EQUAL OPPORTUNITY

SECTION 3 COORDINATION AND IMPLEMENTATION NOFA

NEEDS ASSESSMENT FORM

­­­­­­­­­­­­­­­­_____________________________________________________________________________________

Public reporting burden for the collection of information is estimated to average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The information will be used to determine eligibility for the Section 3 Coordination and Implementation NOFA. Response to this request for information is required in order to receive the benefits to be derived. 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 information does not lend itself to confidentiality.

Primary Applicant/Agency Name: __________________________________________________

Mailing Address: _______________________________________________________________

City/State: _____________________________________________________________________

Zip Code + 4: ____ ____ ____ ____ ____ + ____ ____ ____ ____

1. GEOGRAPHIC AREA/COMMUNITY TO BE SERVED

Instructions: Identify the geographic area/community (i.e., the city, county, state, or metropolitan area) that the Section 3 Coordinator will serve below. In choosing the geographic area/community to be served by the Section 3 Coordinator, please identify the most appropriate city, county, state, or metropolitan area which best describes the community that will be served by the Section 3 Coordinator. Applicants that are proposing to enter into regional partnerships for the purpose of applying for funds under this NOFA should consult the Section 3 Coordination and Implementation NOFA for additional information.

1. Geographic Area/Community to be Served:

_________________________________________________________________

2. SECTION 3 COORDINATOR

Instructions: Please enter the name of the authorized representative for the primary applicant/agency in the space provided below. Check the appropriate statement indicating whether the primary applicant/agency currently employs a Section 3 Coordinator. The authorized representative is required to sign and date this form.

As the primary applicant/agency for funds under the Section 3 Coordination and Implementation NOFA, I

______________________________________________________ [enter name], certify that:

	The Primary Applicant/Agency Currently Does Employ a Section 3 Coordinator
	The Primary Applicant/Agency Currently Does Not Employ a Section 3 Coordinator

3. LOCAL UNEMPLOYMENT DATA

Instructions: Part a.: Enter the unemployment data for the specific geographic area/community that the Section 3 Coordinator will serve as published by the DOL Bureau of Labor Statistics. This data can be found at the DOL BLS Data Site at: http://data.bls.gov/cgi-bin/dsrv?la. Part b.: List the current civilian labor force of the geographic area/community to be served. For your convenience, this information can be found on the Section 3 website at: www.hud.gov/section 3. Applicants that are proposing to enter into regional partnerships for the purpose of applying for funds under this NOFA should consult the Section 3 Coordination and Implementation NOFA for additional information.

1. Current Unemployment Rate for Geographic Area/Community to be Served:

______________ % as of __________, 2011

Unemployment Rate Month

2. Civilian Labor Force of the Geographic Area/Community to be Served:

_________________ persons

Check this box if the primary applicant is proposing to enter into a regional partnership, and has provided an average unemployment and civilian labor force data above to reflect multiple jurisdictions that will be served by the Section 3 Coordinator.

________________________________________________ ___________________________

Signature of Authorized Representative Date

_____________________________________________________________________________________________

Print/Type the Name and Title of the Authorized Representative

Form HUD-966