HUD-53233 Choice Neighborhoods Implementation Grants Application I

Choice Neighborhoods
IMPLEMENTATION GRANTS
Key Eligibility Data Form

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

OMB Approval No. 2577-0269
(exp. 4/30/2018)

CHOICE NEIGHBORHOODS IMPLEMENTATION GRANTS APPLICATION INFORMATION
ELIGIBLE NEIGHBORHOOD
Name of Neighborhood

ELIGIBLE APPLICANT
You must provide the following information for the Lead Applicant and, if applicable, the Co-Applicant
Lead Applicant:
Type of Eligible Applicant
(check one)

Public Housing Agency
PHA Code:

Local Government

Tribal Entity

Nonprofit

For profit developer applying jointly with a public entity

Mailing Address:
Executive Officer Name & Title:
Telephone:

Fax:

Email:

Fax:

Email:

Primary Contact Name & Title:
Telephone:

Co-Applicant (if any):
Type of Eligible Applicant
(check one)

Public Housing Agency
PHA Code:

Local Government

Tribal Entity

Nonprofit

For profit developer applying jointly with a public entity

Mailing Address:
Executive Officer Name & Title:
Telephone:

Fax:

Email:

Fax:

Email:

Primary Contact Name & Title:
Telephone:

HUD Form 53233 (3/2011)

PRINCIPAL TEAM MEMBERS
Housing Implementation Entity:
Mailing Address:
Executive Officer Name & Title:
Telephone:

Fax:

Email:

Fax:

Email:

Fax:

Email:

Fax:

Email:

Fax:

Email:

Fax:

Email:

Fax:

Email:

Fax:

Email:

Primary Contact Name & Title:
Telephone:

People Implementation Entity:
Mailing Address:
Executive Officer Name & Title:
Telephone:
Primary Contact Name & Title:
Telephone:
Neighborhood Implementation
Entity:
Mailing Address:
Executive Officer Name & Title:
Telephone:
Primary Contact Name & Title:
Telephone:

Education Implementation Entity:
Mailing Address:
Executive Officer Name & Title:
Telephone:
Primary Contact Name & Title:
Telephone:

HUD Form 53233 (3/2011)

CHOICE NEIGHBORHOODS- Key Eligibility Data Form

ELIGIBLE TARGET HOUSING
Your application must focus on severely distressed public and/or HUD-assisted housing. See section I.C for
defintions of "public housing," "assisted housing," and "severely distressed housing."
Provide the following information for each target housing project. List each site separately.

Project #1
Project Name:
Type of Eligible Housing
(check one)
Public Housing (section 9)
Project-based section 8
Project-based vouchers
If Public Housing

PIC AMP Number:
"old" Project Number:

If Assisted Housing

Contract Number:
REMS Number:
If FHA Insured, FHA #:

section 202
section 811
section 221(d)(3)

section 236
Indian Housing

Physical Street Address
(include city, state and ZIP)

Unit Information as of Application Date
Total Number of Units in Project
Number of Public and/or Assisted Units in Project
Project #2 (if applicable)
Project Name:
Type of Eligible Housing
(check one)
Public Housing (section 9)
Project-based section 8
Project-based vouchers
If Public Housing

PIC AMP Number:
"old" Project Number:

If Assisted Housing

Contract Number:
REMS Number:
If FHA Insured, FHA #:

Number Occupied
Number Vacant

section 202
section 811
section 221(d)(3)

section 236
Indian Housing

Physical Street Address
(include city, state and ZIP)

Unit Information as of Application Date
Total Number of Units in Project
Number of Public and/or Assisted Units in Project

Number Occupied
Number Vacant

HUD Form 53233 (3/2011)

Project #3 (if aplicable)
Project Name:
Type of Eligible Housing
Type of Eligible Housing
(check one)
Public Housing (section 9)
Project-based section 8
Project-based vouchers
If Public Housing
PIC AMP Number:
"old" Project Number:
If Assisted Housing

section 202
section 811
section 221(d)(3)

section 236
Indian Housing

Contract Number:
REMS Number:
If FHA Insured, FHA #:

Physical Street Address
(include city, state and ZIP)

Unit Information as of Application Date
Total Number of Units in Project
Number of Public and/or Assisted Units in Project
Project #4 (if applicable)
Project Name:
Type of Eligible Housing
Type of Eligible Housing
(check one)
Public Housing (section 9)
Project-based section 8
Project-based vouchers
If Public Housing
PIC AMP Number:
"old" Project Number:
If Assisted Housing

Number Occupied
Number Vacant

section 202
section 811
section 221(d)(3)

section 236
Indian Housing

Contract Number:
REMS Number:
If FHA Insured, FHA #:

Physical Street Address
(include city, state and ZIP)

Unit Information as of Application Date
Total Number of Units in Project
Number of Public and/or Assisted Units in Project

Number Occupied
Number Vacant

HUD Form 53233 (3/2011)