HUD-50095 Shortfall Application Redline

OMB Approval No. 2577-0300
(Exp. 03/31/2025)

HUD-50095: Shortfall Application
OMB Approval No. 2577-003 (exp. 03/31/2025)

CY 20___ Operating Fund Grant Program – Application for Funds from the Shortfall Funding Set-Aside 

Public Housing Agency (PHA) Application for Shortfall Funds and PHA Certification of Accuracy and Completeness of Financial Data. 

PHA Name: _____________________________________________ 
 
PHA Number: _____________________________________________ 
 
Executive Director: _____________________________________________ 

The above referenced agency is applying for Shortfall funds and has submitted accurate and complete financial data to the U.S. Department of Housing and Urban Development (HUD). 

First, please check the portion of Shortfall Funding for which your PHA is applying. Second, please check the category “Shortfall Tier 1” or “Shortfall Tier 2” for which your PHA is applying. The application must be signed by the appropriate PHA official. 

_____ PHA is requesting full Shortfall Funding eligibility as published by HUD. 
 
_____ PHA is requesting a lower amount than the Shortfall Funding eligibility as published by HUD. 

PHA Requested Lower Amount: ___________

If requesting a lower amount, please indicate reason below. (Please note that if requesting a lower amount due to an error in the FDS or PIC data, an Appeal must be submitted per the Shortfall notice.) 

Type/write reason here: 

___________________________________________________________________________ 

___________________________________________________________________________ 

___________________________________________________________________________ 

 
_____Shortfall Tier 1: For PHAs with a Months of Operating Reserves (MOR) ratio less than zero. 
 
I, ________________________  , hereby certify to the following: 

1. Information submitted to HUD systems including, but not limited to, the Financial Assessment Subsystem (FASS), Financial Data Schedule (FDS), and Public Housing Information Center (PIC), used in the computation of the Months of Operating Reserves and Shortfall Eligibility found in the Shortfall notice is complete and accurate. Further, the information provided via these systems supports the conclusion that the PHA is in a shortfall position and eligible for Shortfall funding in accordance with the Shortfall notice.  

2. If submitting an appeal, that the financial documentation and calculations provided by the PHA to support the basis of the appeal are accurate, complete, and truthful. 

3. The PHA acknowledges that any funds not drawn down and expended within the period of performance will be recaptured by HUD. 

4. The PHA understands that Shortfall funding can only be used to pay for immediate needs. 

5. The PHA agrees to collaborate with HUD in the development of an improvement plan , to submit a Shortfall budget , andto undertake reasonable cost saving or revenue increasing measure to improve its financial condition in accordance with the Shortfall notice.

 
 
_______Shortfall Tier 2: For PHAs with a Months of Operating Reserves (MOR) ratio greater than or equal to zero.  

  

I, ________________________, here by certify to the following: 

1. That I will comply with all the requirements listed in Shortfall Scenario 1. 

2. If that PHA is receiving Shortfall funding to raise their MOR above zero, the PHA must maintain an MOR as specified in the current year’s Shortfall Notice. Note that, for the last-funded Tier 2 PHA, if that PHA receives only partial funding an alternative requirement will apply. The last funded PHA will have to demonstrate an MOR that is equal to the MOR achieved when adding Tier 1 and the first increment of Tier 2 funding. 
   
   

Certification: “I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802)” 

 

Signature of Executive Director   Date 

__________________________________ ___________________ 

PHA Contact Name Phone Number 

__________________________________ ___________________ 

Paperwork Reduction Act burden statement:
Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.

HUD collects this information in accordance with 24 CFR Part 990 and annual Appropriations laws, including FY 2021 Consolidated Appropriations Act (Public Law 116-260). PHAs applying for the Shortfall Funding Program are required to complete this form. This Shortfall Application Form will be used by PHAs to self-certify the accuracy and completeness of financial data submitted, and for HUD to review that self-certification. HUD will use this application form in reviewing applications and to ensure that PHAs have submitted accurate and complete financial data. No assurances of confidentiality are provided for this information collection.