HUD-52651 (Previou Family Self-Sufficiency (FSS) Program Coordinator Fundin

Public reporting burden for this collection of information is estimated to average 1 hour. This includes the time for collecting, reviewing, and reporting the data. Information provided is to determine the eligibility of the applicant for funding for the salary of a program coordinator. HUD uses the information to determine eligibility of the applicant to receive funding. Information is required to obtain benefit under 24 CFR 982.302(b). The information is subject to the confidentiality requirements of the HUD Reform Legislation. 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.

PART I: General Information. (To be completed by all applicants.)

Applicant Category:  PHAs Not Currently administering FSS PHAs Currently administering FSS Type of FSS Program: HCV FSS PH FSS	Moving-to-Work PHA?  Yes No State or Regional PHA? Yes No	DUNS Number of Applicant:      	Funding Request for Fiscal Year:      
PHA Legal Name (For joint applicants, lead PHA name):      
Address:      
City:       County:      
State:       Zip Code:      
PHA Number of Applicant:      
Legal Name of Joint Applicant PHA. (If applicable.)      
Address:      
City:       County:      
State:       Zip Code:      
PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

PHA Number of Applicant:      

Note: Please use the table on page 7, Appendix A below to list any additional co-applicants.

Evidence demonstrating salary comparability to similar positions in the local jurisdiction for each position requested is on file at the PHA.

 Yes No

4. Contact information for person most familiar with the application:

Name:       Telephone Number:      

Email Address:      

PART II: Funding/Positions Requested by PHAs that are Currently Administering

FSS Programs

A. Previously Funded Positions

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time		FY Last Funded	Salary Amount Last Funded	Is Applicant’s Request Above Percentage Allowed in the NOFA (if applicable)? ‘Y’ or ‘N’
1.	     	     		     	     	 
2.	     	     		     	     	 
3.	     	     		     	     	 
4.	     	     		     	     	 
5.	     	     		     	     	 
6.	     	     		     	     	 
7.	     	     		     	     	 
8.	     	     		     	     	 
9.	     	     		     	     	 
10.	     	     		     	     	 
Total Salary Requested:	     

2. New Positions – Positions not funded previously under a NOFA.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time
1.	     	     
2.	     	     
3.	     	     
4.	     	     
5.	     	     
6.	     	     
7.	     	     
8.	     	     
Total Salary Requested:	     

Note: Please use the tables on page 8, Appendix A below if you need additional space for previously

funded and/or new positions.

2. Total Requested

1.	    	Total number of positions requested in Part II (enter 0.5 for part-time positions)
2.	     	Total salary requested in Part II (add totals from Part II.A and Part II.B)

** Salary awards will not exceed the cap per position stated in the most recent NOFA.

D. Total number of families under FSS contract during the NOFA target period.

PART III: Requests for PHAs that are NOT currently administering FSS Programs

1. FSS Action Plan Information:

    

The number of FSS program slots in the HUD-approved Action Plan. (For Joint applications, provide total approved slots for all joint applicant PHAs.)

2. Position/Salary Requested:

Position Number:	Salary Requested under this NOFA (Including Fringe Benefits) **	Indicate whether Full-Time or Part-Time
1.	     	     
2.	     	     
3.	     	     
4.	     	     
5.	     	     
6.	     	     
7.	     	     
8.	     	     
9.	     	     
10.	     	     
Total Salary Requested:	     

2. Total Requested.

1.	    	Total number of positions requested in Part III (enter 0.5 for part-time positions)
2.	     	Total salary requested in Part III (add totals from Part III.A and Part III.B)

** Salary awards will not exceed the cap per position stated in the most recent NOFA.

Instructions:

Part I. Funding Request for Fiscal Year:

Enter the Fiscal Year (FY) that corresponds to the NOFA you are applying under. For example, if you are applying for funds under the FY 2013 HCV FSS NOFA, enter 2013 on the “Funding Request for Fiscal Year” box.

Part II.A. Previously Funded Positions:

• Please see the NOFA for more information on whether column 6 “Is Applicant’s Request Above Percentage Allowed in the NOFA” is applicable (i.e. whether the NOFA allows for funding increases). If requesting an increase above the percentage allowed in the NOFA, please include a justification and other requirements as instructed in the NOFA.

• See the NOFA for more information on whether applicants may qualify for part-time positions beyond the initial position (for example, whether applicants may qualify for 1.5 positions).

• See the examples below which help illustrate how to enter the information on this table.

Example 1: PHA is requesting 2 full-time positions at $55,000 each that were last funded in FY2011 for $55,000 each. The requested amount is the same as the amount last funded because the NOFA does not allow for funding increases.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time		FY Last Funded	Salary Amount Last Funded	Is Applicant’s Request Above Percentage Allowed in the NOFA (if applicable)? ‘Y’ or ‘N’
1.	$55,000	Full-time		2011	$55,000	 
2.	$55,000	Full-time		2011	$55,000	 
3.	     			     	     	 
Total Salary Requested:	$110,000

Example 2: PHA is requesting 1 full-time position at $45,000 and 1 full-time position at $50,000. Each position was last funded in FY 2012 for these same amounts. The requested amount is the same as the amounts last funded because the NOFA does not allow for funding increases.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time		FY Last Funded	Salary Amount Last Funded	Is Applicant’s Request Above Percentage Allowed in the NOFA (if applicable)? ‘Y’ or ‘N’
1.	$45,000	Full-time		2012	$45,000	 
2.	$50,000	Full-time		2012	$50,000	 
3.	     			     	     	 
Total Salary Requested:	$95,000

INSTRUCTIONS (CONTINUED)

Example 3: PHA is requesting 1 part-time position at $30,000 for a position that was last funded in FY 2012 for the same amount. The requested amount is the same as the amount last funded because the NOFA does not allow for funding increases.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time		FY Last Funded	Salary Amount Last Funded	Is Applicant’s Request Above Percentage Allowed in the NOFA (if applicable)? ‘Y’ or ‘N’
1.	$30,000	Part-time		2012	$30,000	 
2.	     			     	     	 
3.	     			     	     	 
Total Salary Requested:	$30,000

Part II.B. New Positions: Positions not funded previously under a NOFA.

• See the NOFA for more information on whether new positions (positions not funded previously under a NOFA) are allowed and whether applicants may qualify for part-time positions beyond the initial position (for example, whether an applicant can qualify for 1.5 positions).

• Please see the examples below which help illustrate how to enter the information on this table.

Example 1: PHA is requesting 2 new full-time positions at $55,000 each:

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time
1.	$55,000	Full-time
2.	$55,000	Full-time
3.
Total Salary Requested:	$110,000

Example 2: PHA is requesting 1 new full-time position at $45,000 and 1 new full-time position at $50,000:

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time
1.	$45,000	Full-time
2.	$50,000	Full-time
3.	     
Total Salary Requested:	$95,000

INSTRUCTIONS (CONTINUED)

Part III. Requests for PHAs that are NOT currently administering FSS Programs:

See the NOFA for more information on whether Part III is applicable (i.e. whether PHAs not currently administering an FSS program are eligible to apply).

Part III.B. Position/Salary Requested:

Please see the examples below which help illustrate how to enter the information on this table.

Example 1: PHA is requesting 1 new full-time position at $55,000:

Position Number:	Salary Requested under this NOFA (Including Fringe Benefits) **	Indicate whether Full-Time or Part-Time
1.	$55,000	Full-time
2.	     	     
3.	     	     
Total Salary Requested:	$55,000

Example 2: PHA is requesting 1 new part-time position at $30,000:

Position Number:	Salary Requested under this NOFA (Including Fringe Benefits) **	Indicate whether Full-Time or Part-Time
1.	$30,000	Part-time
2.	     
3.	     
Total Salary Requested:	$30,000

Appendix A: use only if additional space is needed

Part I.B. Legal Name of Joint Applicant PHAs.

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

Legal Name of Joint Applicant PHA. (If applicable.)      

Address:      

City:       County:      

State:       Zip Code:      

PHA Number of Applicant:      

APPENDIX A (continued)

Part II.A. Previously Funded Positions.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time		FY Last Funded	Salary Amount Last Funded	Is Applicant’s Request Above Percentage Allowed in the NOFA (if applicable)? ‘Y’ or ‘N’ ***
11.	     	     		     	     	 
12.	     	     		     	     	 
13.	     	     		     	     	 
14.	     	     		     	     	 
15.	     	     		     	     	 
16.	     	     		     	     	 
17.	     	     		     	     	 
18.	     	     		     	     	 
19.	     	     		     	     	 
20.	     	     		     	     	 
21.	     	     		     	     	 
22.	     	     		     	     	 
23.	     	     		     	     	 
24.	     	     		     	     	 
25.	     	     		     	     	 
26.	     	     		     	     	 
27.	     	     		     	     	 
28.	     	     		     	     	 
29.	     	     		     	     	 
30.	     	     		     	     	 
31.	     	     		     	     	 
32.	     	     		     	     	 
33.	     	     		     	     	 
34.	     	     		     	     	 
35.	     	     		     	     	 
36.	     	     		     	     	 
Total Salary Requested:	     

Part II.B. Additional Positions.

Position Number	Salary Requested Per Position under this NOFA (Including Fringe Benefits)**	Indicate whether Full-Time or Part-Time
9.	     	     
10.	     	     
11.	     	     
12.	     	     
13.	     	     
14.	     	     
15.	     	     
16.	     	     
Total Salary Requested:	     

Page 10 of 10 form HUD-52651

(01/2014)