Form HUD-52768 Resident Opportunity & Self-Sufficiency (ROSS) Service C

Public reporting burden for the collection of information is estimated to average 4 hours per response. This includes the time for collecting, reviewing, and reporting the data. The information will be used for the ROSS grant. Response to this request for information is required in order to receive the benefits to be derived. 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. This information will allow HUD to determine eligibility for the ROSS SC Program. This information does not lend itself to confidentiality.

PART I: General Information.

***Please read the ROSS NOFA carefully for instructions for the completion of this form and minimum requirements. ***

1. Applicant Type (please check)

Public Housing Authority (PHA)

Tribe/ Tribally Designated Housing Entity (TDHE)

Resident Association (RA)

Site Based RA

Non- Site Based RA

501(c)(3) Nonprofit applicant (Not a RA)

• 501(c)(3) applicants must be supported by a PHA, Tribe/TDHE, or RA

B. Applicant Legal Name (For joint applicants, lead Applicant name):      

Address:      

City:       County:      

State:       Zip Code:      

DUNS Number       EIN Number     

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

PHA Number of Applicant:      

Legal Name of Joint Applicant. (If applicable.)      

PHA Number of Applicant:      

D. Name of PHA, Tribe/TDHE(s), and/or RA to be served.      

E. PHA Code (s) to be served (not applicable to Tribes/ TDHEs).      

F. Number of ACC Units/ Formula Currently Assisted Stock in PHA/Tribe:      

7. Do you (the applicant) have a current ROSS-SC grant (i.e., a grant that was awarded within two years from the date of this application)?

Yes No

*If you do not have a current ROSS-SC grant, you must attach documentation with this application form attesting to your nonprofit status. *

7. For Renewal Applicants:

I      , certify the nonprofit status for       is in current and in good standing.

     

Signature of Authorized Representative

     

Title

PART II: Service Coordinator Information (Budget Form)

SC positions requested	Project(s) to be served (See NOFA for limits. If different PHAs, list all.)	Number of units to be served (See NOFA for minimum number of units)	Clients to be served - families - elderly - both	Year	Salary/Fringe (See NOFA for limits.)	Admin (See NOFA for limits.)	Training (See NOFA for limits.)
1	     	     	Family Elderly Both	1	$     	$     	$     
				2	$     	$     	$     
				3	$     	$     	$     
2	     	     	Family Elderly Both	1	$     	$     	$     
				2	$     	$     	$     
				3	$     	$     	$     
3	     	     	Family Elderly Both	1	$     	$     	$     
				2	$     	$     	$     
				3	$     	$     	$     
				Total	$     	$     	$     
Total of Number of units       Total Grant Requested $      

Note: If you are currently eligible to receive funding for one or more Elderly/Disabled Service Coordinators (EDSC) Grant and you request Elderly through this NOFA, you will forgo any future EDSC renewal funding.

PART III. Salary Comparability

Applicants’ salary requests are subject to salary comparability requirements as prescribed in the most recent ROSS NOFA. Salary requests must be based on local comparability information, and support the amount requested for salary and fringe to similar positions in the local jurisdiction. Salary comparability must be kept on file in the offices of the PHA or tribe/TDHE. Please review the most recent ROSS NOFA carefully for further instructions on completing the information below.

Salary Comparability

	Occupation Title	Annual Salary	Fringe Benefits	Total Amount (Annual +Fringe Benefits)	Source/ Employer Name	Name of Agency Point of Contact (POC)	POC Email Address	POC Telephone Number
1.	     	     	     	     	     	     	     	     
2.	     	     	     	     	     	     	     	     
3.	     	     	     	     	     	     	     	     

PART IV: Match

The match for the ROSS program should represent the needs assessed and the mandatory metrics on the logic model. Provide the need that you are proposing to meet, the source of the match and the value of the match. All applicants are required to have in place a firmly committed match contribution equivalent to 25% of the total grant amount in order to be considered for funding.

*Please read the ROSS NOFA carefully for instructions and minimum requirements. *

Need of Residents	Service to be provided	Source of Match	Value of Match
     	     	     	$     
     	     	     	$     
     	     	     	$      
     	     	     	$     
     	     	     	$     
		Total Match	$     

B. Match is      % of grant requested (must be at least 25% to qualify)

C.

I      , certify that the match recorded here is supported by letters on file from community or other partners which certify to this amount of match funding (cash or in-kind) and that this represents the total match for the term of the grant.

     

Signature of Authorized Representative

     

Title

Please attach with this form:

New Applicants:

Narrative Statement

Nonprofit Status (if applicable)

Nonprofit Organizations:

Letter of Support from the PHA, tribe/TDHE, or RA

Joint Applicant(s):

Letter of Support from Joint Applicant(s)

PHAS Troubled:

Contract Administrator Partnership Agreement

Resident Associations:

Contract Administrator Partnership Agreement

Tribes Designated High-Risk:

Narrative Statement

*Please see NOFA for all other forms your complete application must include*

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