HUD-2880 HUD Applicant/recipient Disclosure/Update Report

Applicant/Recipient
Disclosure/Update Report

Applicant/Recipient Information

OMB Number: 2510-0011
Expiration Date: 10/31/2012

U.S. Department of Housing
and Urban Development

* Duns Number:

* Report Type:

INITIAL

1. Applicant/Recipient Name, Address, and Phone (include area code):
* Applicant Name:

* Street1:
Street2:
* City:
County:
* State:
* Zip Code:
* Country:
* Phone:
2. Social Security Number or Employer ID Number:
* 3. HUD Program Name:

* 4. Amount of HUD Assistance Requested/Received: $
5. State the name and location (street address, City and State) of the project or activity:
* Project Name:
* Street1:
Street2:
* City:
County:
* State:
* Zip Code:
* Country:

USA: UNITED STATES

Part I Threshold Determinations
* 1. Are you applying for assistance for a specific project or activity? These
terms do not include formula grants, such as public housing operating
subsidy or CDBG block grants. (For further information see 24 CFR
Sec. 4.3).
Yes

No

* 2. Have you received or do you expect to receive assistance within the
jurisdiction of the Department (HUD) , involving the project or activity
in this application, in excess of $200,000 during this fiscal year (Oct. 1Sep. 30)? For further information, see 24 CFR Sec. 4.9
Yes

No

If you answered " No " to either question 1 or 2, Stop! You do not need to complete the remainder of this form.

However, you must sign the certification at the end of the report.

Form HUD-2880 (3/99)

Part II Other Government Assistance Provided or Requested / Expected Sources and Use of Funds.
Such assistance includes, but is not limited to, any grant, loan, subsidy, guarantee, insurance, payment, credit, or tax benefit.
Department/State/Local Agency Name:
* Government Agency Name:

Government Agency Address:
* Street1:
Street2:
* City:
County:
* State:
* Zip Code:
* Country:
* Type of Assistance:

* Amount Requested/Provided:

$

* Expected Uses of the Funds:

Department/State/Local Agency Name:
* Government Agency Name:

Government Agency Address:
* Street1:
Street2:
* City:
County:
* State:
* Zip Code:
* Country:
* Type of Assistance:

* Amount Requested/Provided:

$

* Expected Uses of the Funds:

(Note: Use Additional pages if necessary.)

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Form HUD-2880 (3/99)

Part III Interested Parties. You must decide.
1. All developers, contractors, or consultants involved in the application for the assistance or in the planning, development, or
implementation of the project or activity and
2. Any other person who has a financial interest in the project or activity for which the assistance is sought that exceeds $50,000 or 10 percent of
the assistance (whichever is lower).
* Alphabetical list of all persons with a
reportable financial interest in the project or
activity (For individuals, give the last name first)

* Social Security No.
or Employee ID No.

* Type of Participation in
Project/Activity

* Financial Interest in
Project/Activity ($ and %)
%

$

(Note: Use Additional pages if necessary.)

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$

%

$

%

$

%

$

%

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Certification
Warning: If you knowingly make a false statement on this form, you may be subject to civil or criminal penalties under Section 1001 of Title 18 of the
United States Code. In addition, any person who knowingly and materially violates any required disclosures of information, including intentional
non-disclosure, is subject to civil money penalty not to exceed $10,000 for each violation.
I certify that this information is true and complete.
* Signature:

* Date: (mm/dd/yyyy)

Completed Upon Submission to Grants.gov

Form HUD-2880 (3/99)