Form HUD xxxx HUD xxxx Actual Choice Neighborhoods Cost Certificate

Actual Choice Neighborhoods Cost Certificate

U.S. Department of Housing

OMB Approval No. 2577-0269

(exp. xx/xx/xxxx)

and Urban Development

Office of Public and Indian Housing

Public reporting burden for this collection of information is estimated to average 1 hour 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. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number.

This collection of information requires that each Grantee submit information to enable HUD to initiate the fiscal closeout process. The information will be used by HUD to determine whether the Choice Neighborhoods grant is ready to be audited and closed out. The information is essential for audit verification and fiscal close out. Responses to the collection are required by the Choice Neighborhoods Grant Agreement. The information requested does not lend itself to confidentiality.

Lead Grantee Name

Grant Number

The Grantee hereby certifies to the Department of Housing and Urban Development as follows:

1. That the Actual Program Cost of the Choice Neighborhoods Grant is as shown below:

E. Excess of Funds Disbursed (B-C)

$

2. That all work in connection with the Choice Neighborhoods Grant has been completed;

3. That the entire Actual Program Cost or liabilities therefor incurred by the Grantee have been fully paid;

4. That there are no undischarged mechanics', laborers', contractors', or materialmen's liens against such Program work on file in any public office where the same should be filed in order to be valid against such Program work; and

5. That the time in which such liens could be filed has expired.

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. 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)

Signature of Executive Officer

Date (mm/dd/yyyy)

For HUD

The Cost Certificate is approved for audit (signature of approving official)

Use Only

Date (mm/dd/yyyy)

The audited costs agree with the costs shown above Verified (signature)

Date (mm/dd/yyyy)

Approved (signature)

Date (mm/dd/yyyy)

Previous editions are obsolete

form HUD-xxxxx (xx/xxxx)

Original Funds Approved					$
Funds Disbursed					$
Funds Expended (Actual Program Cost)					$
Amount to be Recaptured (A–C)					$

Instructions for Preparation of the Actual Choice Neighborhoods Cost Certificate

Prepare and submit to HUD an original Actual Choice Neighborhoods Cost Certificate for the completed Choice Neighborhoods grant.

Line 1D, Amount To Be Recaptured (A minus C) - Enter the amount to be recaptured by subtracting line 1C from line 1A.

Line Instructions:

Line 1E, Excess of Funds Disbursed (B minus C) - Subtract line 1C from line 1B. If more than zero, remit this amount to HUD.

Line 1A, Original Funds Approved - Enter the total Choice Neighborhoods funds originally approved by HUD through a Choice Neighborhoods Grant Agreement and any amendments.

Line 1B, Funds Disbursed - Enter the total amount of Choice Neighborhoods Grant funds disbursed by HUD.

Line 1C, Funds Expended - Enter the total amount of Choice Neighborhoods Grant funds expended by the Grantee. This amount may never exceed the amount on line 1A.

Previous editions are obsolete

form HUD-xxxxx (xx/xxxx)