HUD 53233 CN Implementation Grants Application Information

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Overview

Applicant and Team Info
Housing Project Info

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Sheet 1: Applicant and Team Info

Choice Neighborhoods

U.S. Department of Housing

OMB Approval No. 2577-0269

IMPLEMENTATION GRANTS

and Urban Development

(exp. 1/31/2015)

Key Eligibility Data Form

Office of Public and Indian Housing

CHOICE NEIGHBORHOODS IMPLEMENTATION GRANTS APPLICATION INFORMATION

ELIGIBLE NEIGHBORHOOD

Name of Neighborhood

ELIGIBLE APPLICANT

You must provide the following information for the Lead Applicant and, if applicable, the Co-Applicant

Lead Applicant:

Type of Eligible Applicant

Public Housing Agency

Local Government

Tribal Entity

(check one)

PHA Code:

Nonprofit

For profit developer applying jointly with a public entity

Mailing Address:

Executive Officer Name & Title:

Telephone:

Fax:

Email:

Primary Contact Name & Title:

Telephone:

Fax:

Email:

Co-Applicant (if any):

Type of Eligible Applicant

Public Housing Agency

Local Government

Tribal Entity

(check one)

PHA Code:

Nonprofit

For profit developer applying jointly with a public entity

Mailing Address:

Executive Officer Name & Title:

Telephone:

Fax:

Email:

Primary Contact Name & Title:

Telephone:

Fax:

Email:

PRINCIPAL TEAM MEMBERS

Housing Implementation Entity:

Mailing Address:

Executive Officer Name & Title:

Telephone:

Fax:

Email:

Primary Contact Name & Title:

Telephone:

Fax:

Email:

People Implementation Entity:

Mailing Address:

Executive Officer Name & Title:

Telephone:

Fax:

Email:

Primary Contact Name & Title:

Telephone:

Fax:

Email:

Neighborhood Implementation Entity:

Mailing Address:

Executive Officer Name & Title:

Telephone:

Fax:

Email:

Primary Contact Name & Title:

Telephone:

Fax:

Email:

Education Implementation Entity:

Mailing Address:

Executive Officer Name & Title:

Telephone:

Fax:

Email:

Primary Contact Name & Title:

Telephone:

Fax:

Email:

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Sheet 2: Housing Project Info

CHOICE NEIGHBORHOODS- Key Eligibility Data Form
ELIGIBLE TARGET HOUSING
Your application must focus on severely distressed public and/or HUD-assisted housing. See section I.C for defintions of "public housing," "assisted housing," and "severely distressed housing."
Provide the following information for each target housing project. List each site separately.
Project #1
Project Name:
Type of Eligible Housing
(check one)		Public Housing (section 9)			section 202					section 236
		Project-based section 8			section 811					Indian Housing
		Project-based vouchers			section 221(d)(3)
	If Public Housing		PIC AMP Number:
			"old" Project Number:
	If Assisted Housing		Contract Number:
			REMS Number:
			If FHA Insured, FHA #:
Physical Street Address
(include city, state and ZIP)
Unit Information as of Application Date
			Total Number of Units in Project					Number Occupied
			Number of Public and/or Assisted Units in Project					Number Vacant
Project #2 (if applicable)
Project Name:
Type of Eligible Housing
(check one)		Public Housing (section 9)			section 202					section 236
		Project-based section 8			section 811					Indian Housing
		Project-based vouchers			section 221(d)(3)
	If Public Housing		PIC AMP Number:
			"old" Project Number:
	If Assisted Housing		Contract Number:
			REMS Number:
			If FHA Insured, FHA #:
Physical Street Address
(include city, state and ZIP)
Unit Information as of Application Date
			Total Number of Units in Project					Number Occupied
			Number of Public and/or Assisted Units in Project					Number Vacant
Project #3 (if aplicable)
Project Name:
Type of Eligible Housing
Type of Eligible Housing
(check one)		Public Housing (section 9)			section 202					section 236
		Project-based section 8			section 811					Indian Housing
		Project-based vouchers			section 221(d)(3)
	If Public Housing		PIC AMP Number:
			"old" Project Number:
	If Assisted Housing		Contract Number:
			REMS Number:
			If FHA Insured, FHA #:
Physical Street Address
(include city, state and ZIP)
Unit Information as of Application Date
			Total Number of Units in Project					Number Occupied
			Number of Public and/or Assisted Units in Project					Number Vacant
Project #4 (if applicable)
Project Name:
Type of Eligible Housing
Type of Eligible Housing
(check one)		Public Housing (section 9)			section 202					section 236
		Project-based section 8			section 811					Indian Housing
		Project-based vouchers			section 221(d)(3)
	If Public Housing		PIC AMP Number:
			"old" Project Number:
	If Assisted Housing		Contract Number:
			REMS Number:
			If FHA Insured, FHA #:
Physical Street Address
(include city, state and ZIP)
Unit Information as of Application Date
			Total Number of Units in Project					Number Occupied
			Number of Public and/or Assisted Units in Project					Number Vacant