HUD 4136 Community Compass Closeout Property Form

OMB Approval No. 2506-0197

(Exp. 03/31/2023)

Community Compass - Property Statement

Cooperative Agreement Number	Click here to enter number.
Organization Name	Click here to enter name.

Part I. Based on the records and as required by the property management standards set forth in the award agreement, the following reflects the status of real and personnel property paid for in whole, or in part, by funds from this award:

1a. Was real property acquired?	☐Yes (continue) ☐No (skip to #2)
1b If yes, list the real property in Part II.
1c. Will the property continue to be used for the purpose authorized in the agreement?		☐Yes ☐No
If no, is approval being requested from HUD to use the property in other projects?		☐Yes ☐No
If yes, specify which projects:		Click here to enter text.
If no, provide disposition instructions to HUD in Part II.

2. Was non-expendable personal property acquired?	☐Yes (continue) ☐No (skip to #3)
2a. If yes, list the non-expendable person property in Part II.
2b. Will the property continue to be used for the purpose authorized in the agreement?		☐Yes ☐No
If no, is approval being requested from HUD to use the property in other projects?
If yes, specify which projects:		Click here to enter text.
If no, what is the proposed disposition of this property? (Check one or both)		☐ Approval is requested to retain the property in whole or in part. ☐ Disposition instructions from HUD are requested.
If both boxes are checked, please explain in detail in Part II of this Statement.

3. Was expendable personal property with an aggregate value of over $5,000 (for State and local Governments) or $1,000 (for non-profit organizations) acquired?	☐Yes ☐No
3a. If yes, refer to your agreement and request disposition forms from your GTR.

PART II. Information requested in Part I may be provided in the format that follows.

	Enter item name.	Enter item name.	Enter item name.	Enter item name.
Date Purchased	Enter a date.	Enter a date.	Enter a date.	Enter a date.
Description	Enter description.	Enter description.	Enter description.	Enter description.
Serial Number	Enter number.	Enter number.	Enter number.	Enter number.
Unit Cost	Enter cost.	Enter cost.	Enter cost.	Enter cost.
% HUD funds	Enter %.	Enter %.	Enter %.	Enter %.
Location Address	Enter text.	Enter text.	Enter text.	Enter text.
Condition	Enter text.	Enter text.	Enter text.	Enter text.
Service Contracts	Enter text.	Enter text.	Enter text.	Enter text.
Inventory Reconciled	Enter text.	Enter text.	Enter text.	Enter text.

Authorized Official Name

Authorized Official Title

Date

Public reporting burden for this collection of information is estimated to average 0.5 hours. This includes the time for collecting, reviewing, and reporting the data. The information is being collected for Community Compass Technical Assistance and Capacity Building Program Notice of Funding Availability (NOFA) and will be used for NOFA application review. 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. No confidentiality is assured.”

form HUD-4136 (3/23)