Fair Housing Initiatives Program Grant

Survey on Ensuring U.S. Department of Housing OMB No. 1890-0014

Equal Opportunity and Urban Development (Exp. 1/31/2006)

for Applicants

Purpose: The Federal government is committed to ensuring that all qualified applicants, small or large, non-religious or faith-based, have an equal opportunity to compete for Federal funding. In order for us to better understand the population of applicants for Federal funds, we are asking nonprofit private organizations (not including private universities) to fill out this survey.

Upon receipt, the survey will be separated from the application. Information provided on the survey will not be considered in any way in making funding decisions and will not be included in the Federal grants database. While your help in this data collection process is greatly appreciated, completion of this survey is voluntary.

Instructions for Submitting the Survey: If you are applying using a hard copy application, please place the completed survey in an envelope labeled “Applicant Survey.” Seal the envelope and include it along with your application package. If you are applying electronically, please submit this survey along with your application.

Applicant’s (Organization) Name: ______________________________________________________________

Applicant’s DUNS Number: ___________________________________________________________________

Grant Name: ____________________________________________________CFDA Number: _____________

1. Does the applicant have 501(c)(3) status?

Yes No

2. How many full-time equivalent employees does the applicant have? (Check only one box).

3 or Fewer 15-50

4 -5 51-100

6-14 over 100

3. What is the size of the applicant’s annual budget? (Check only one box.)

Less Than $150,000

$150,000 - $299,999

$300,000 - $499,999

$500,000 - $999,999

$1,000,000 - $4,999,999

$5,000,000 or more

4. Is the applicant a faith-based/religious
organization?

Yes No

5. Is the applicant a non-religious community-based organization?

Yes No

6. Is the applicant an intermediary that will manage the grant on behalf of other organizations?

Yes No

7. Has the applicant ever received a government grant or contract (Federal, State, or local )?

Yes No

8. Is the applicant a local affiliate of a national
organization?

Yes No

SF 424-SUPP (4/2004)

Survey Instructions on Ensuring Equal Opportunity for Applicants

Provide the applicant’s (organization) name and DUNS number and the grant name and CFDA number.

1. 501(c)(3) status is a legal designation provided on application to the Internal Revenue Service by eligible organizations. Some grant programs may require nonprofit applicants to have 501(c)(3) status. Other grant programs do not.

2. For example, two part-time employees who each work half-time equal one full-time equivalent employee. If the applicant is a local affiliate of a national organization, the responses to survey questions 2 and 3 should reflect the staff and budget size of the local affiliate.

3. Annual budget means the amount of money your organization spends each year on all of its activities.

4. Self-identify.

5. An organization is considered a community-based organization if its headquarters/service location shares the same zip code as the clients you serve.

6. An “intermediary” is an organization that enables a group of small organizations to receive and manage government funds by administering the grant on their behalf.

7. Self-explanatory.

7. Self-explanatory.

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1890-0014. The time required to complete this information collection is estimated to average five (5) minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Housing and Urban Development, Office of Departmental Grants Management and Oversight, Room 3156, Washington, D.C. 20410.

If you have comments or concerns regarding the status of your individual submission of this form, write directly to the address above.

SF 424-SUPP (4/2004)