Form HUD-40123 Brownfields Economic Development Application

OMB Approval No. 2506-0153 (exp. 10/31/2007)

U.S. Department of Housing
and Urban Development

Brownfields Economic
Development Initiative
(BEDI) Application Form

Office of Community Planning and Development

The information collection requirements contained in this application have been submitted to the Office of Management
and Budget (OMB) for review under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). 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.
Information is submitted in accordance with the regulatory authority contained in each program rule. The information will
be used to rate applications, determine eligibility, and establish grant amounts.
Selection of applications for funding under the Brownfield Economic Development Initiative are based on rating factors
listed in the Notice of Fund Availability (NOFA), which is published each year to announce the Brownfield Economic
Development Initiative (BEDI) funding round. The information collected in the application form will only be collected for
specific funding competitions.
Public reporting burden for this collection of information is estimated to average 40 hours per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information.
To the extent that any information collected is of a confidential nature, there will be compliance with Privacy Act
requirements.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil
penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)

1

HUD-40123 (10/2004)

Exhibit A
Rating Factor 2: Distress/Extent of Problem
Applicant:______________________________________________________________
Project Name/Title:___________________________________________________
Instructions: The applicant is required to provide information related to the poverty rate for the Target
Neighborhood (the area in which the BEDI assistance will be used) and the larger jurisdiction. In addition,
the applicant may include optional indicators such as unemployment rate, median income of persons living
in the area, or other indicators of the applicant’s choosing. A data source and date are required for each
indicator. Use of data from the applicant’s Consolidated Plan and/or its Analysis of Impediments to Fair
Housing Choice (AI) is encouraged.

Required Indicator

Target
Neighborhood

Jurisdiction

Data Source and Date

Target
Neighborhood

Jurisdiction

Data Source and Date

1 Poverty Rate

Optional Indicators
2 Unemployment
3 Median Income
4
5
6
7
8

Definitions: Describe how the areas are defined (i.e., city boundaries, census tracts, zip codes, etc.)
Target Neighborhood: _________________________________________________
_____________________________________________________________________
Jurisdiction: __________________________________________________________

2

form HUD-40123 (10/2004)

Exhibit B
Rating Factor 3: Soundness of Approach/Financial Feasibility
Applicant:______________________________________________________________
Project Name/Title:___________________________________________________
Instructions: Use this table to show all sources and uses of funds for the proposed project through the time
when the project goes into service for its intended purpose. Add additional uses in the blank spaces at the
end of the column labeled Uses of Funds.
SOURCES OF FUNDS
USES OF FUNDS

BEDI

SECTION
108

CDBG

OTHER
PUBLIC

PRIVATE
EQUITY

PRIVATE
DEBT

TOTAL

SITE ACQUISITION
RELOCATION
SITE-PREP /
INFRASTRUCTURE
ENVIRONMENTAL
CLEAN-UP
M&E
CONSTRUCTION /
REHAB
NONRESIDENTIAL
RESIDENTIAL
WORKING CAPITAL
PROJECT DELIVERY
COSTS
CONTINGENCY
RESERVES *
LAND WRITEDOWN
INTEREST
WRITEDOWN

TOTAL
•

e.g., Loan Loss, Debt Service, Letter of Credit, etc.

Exhibit C
Rating Factor 3: Soundness of Approach/Project Timeline

3

form HUD-40123 (10/2004)

Applicant:______________________________________________________________
Project Name/Title:___________________________________________________
Instructions: Identify and list each major task/activity associated with the project. Darken appropriate
boxes for quarter(s) when task/activity will occur. Fill in the amount of “BEDI/108 Funds for Task.” Fill in
the amount of other sources of funding associated with each task in the column labeled “Other Funds.” If
the project extends beyond the timeframe on the form, please attach a justification or description of the
project term. Use as many attachments as necessary to show beginning - - end timeframes for all phases.
1Q

YEAR 1
2Q 3Q

4Q

1Q

YEAR 2
2Q 3Q

4Q

1Q

YEAR 3
2Q 3Q

Task/Activities
EXAMPLE:
Construction

4Q

BEDI/108
Funds for
Task

Other
Funds for
Task

$1,500,000

$2,500,000

1
2
3
4
5
6
7
8
9
10
11
12
TOTAL

Exhibit D
BEDI/Section 108/CDBG Funding Eligibility Statement
Page 1 of 2
Applicant:______________________________________________________________
4

form HUD-40123 (10/2004)

Project Name/Title:___________________________________________________
Instructions: The applicant should first enter the total project cost (line 16). Then, working backwards, the
applicant should enter the total costs paid with CDBG (line 14) and non CDBG-related funds (line 15).
These two amounts should equal the total listed in line 16. Next, the applicant should enter dollar amounts
on lines 1-13 in order to demonstrate among which eligible activities the BEDI, Section 108 or CDBG
funds are to be allocated.
Eligible Activities1
1 Acquisition of Real Property
24 CFR 570.703(a)
2 Rehabilitation of Publicly Owned Real Property
24 CFR 570.703(b)
3 Payment of Interest
24 CFR 570.703(c)
4 Relocation Payments
24 CFR 570.703(d)
5 Clearance, Demolition, Removal
24 CFR 570.703(e)
6 Site Preparation
24 CFR 570.703(f)
7 Payment of Issuance Fees
24 CFR 570.703(g)
8 Housing Rehabilitation
24 CFR 570.703(h)
9 Economic Development Activities
24 CFR 570.703 (i) (and 570.203/204)
10 Construction of Housing
24 CFR 570.703(j)
11 Debt Service Reserve
24 CFR 570.703(k)
12 Public Facilities
24 CFR 570.703(l)
13 Public Facilities – Colonias
24 CFR 570.703(m)

BEDI

Section
108

CDBG2

Total

14 Subtotal
15 Costs Paid with Non CDBG-Related Funds
16 Total Project Costs3

1

The eligible Section 108 activities are defined in detail at 24 CFR 570.703.
CDBG grants and program income other than BEDI or Section 108.
3
This figure should match the total provided on the Sources and Uses Statement.
2

5

form HUD-40123 (10/2004)

Exhibit D
BEDI/Section 108/CDBG Funding Eligibility Statement
Page 2 of 2
Applicant:______________________________________________________________
Project Name/Title:______________________________________________________
National Objective1
Single Project (check one only)

Loan Fund (check all that apply)

‫ ٱ‬Low-Mod Area Benefit

24 CFR 570.208(a)(1)

‫ ٱ‬Low-Mod Area Benefit

24 CFR 570.208(a)(1)

‫ ٱ‬Low-Mod Limited Clientele

24 CFR 570.208(a)(2)

‫ ٱ‬Low-Mod Limited Clientele

24 CFR 570.208(a)(2)

‫ ٱ‬Low-Mod Area Housing

24 CFR 570.208(a)(3)

‫ ٱ‬Low-Mod Area Housing

24 CFR 570.208(a)(3)

‫ ٱ‬Low-Mod Job Creation/
Retention

24 CFR 570.208(a)(4)

‫ ٱ‬Low-Mod Job Creation/
Retention

24 CFR 570.208(a)(4)

‫ ٱ‬Slum/Blight Area Basis

24 CFR 570.208(b)(1)

‫ ٱ‬Slum/Blight Area Basis

24 CFR 570.208(b)(1)

‫ ٱ‬Slum/Blight Spot Basis

24 CFR 570.208(b)(2)

‫ ٱ‬Slum/Blight Spot Basis

24 CFR 570.208(b)(2)

‫ ٱ‬Slum/Blight Urban Renewal

24 CFR 570.208(b)(3)

‫ ٱ‬Slum/Blight Urban Renewal

24 CFR 570.208(b)(3)

‫ ٱ‬Urgent Need/Imminent Threat 24 CFR 570.208(c)

‫ ٱ‬Urgent Need/Imminent Threat 24 CFR 570.208(c)

Public Benefit
PLEASE NOTE: This section is applicable only to projects which plan to spend funds on eligible
economic development activities as defined by 24 CFR 570.703(i).
A. If this project will meet the public benefit standard based upon the number of jobs created [see 24
CFR 570.209(b)(3)(i)(A)] enter the total number of jobs:

B. If this project will meet the public benefit standard based upon the number of low- and moderateincome persons served in the project area [see 24 CFR 570.209(3)(i)(B)], enter the number of lowand moderate-income persons living in the project area:

1

The CDBG national objectives are defined in detail at 24 CFR 570.208.

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form HUD-40123 (10/2004)