HUD-52753 Resident Opportunity and Self Sufficiency Service Coordi

Applicant Name:

Certification of Election of Resident Council Board

I CERTIFY

(name of organization)

located in

has duly elected all

(city & state)

of our Resident Council Officers as required by the U.S. Department of Housing and Urban Development, 24 Code of Federal Regulations (CFR), Part 964.

Date of Most Recent Resident Council Board Election:

Name and Position of Resident Council officers:

U.S. Department of Housing

and Urban Development

Office of Public and Indian Housing

Approval No. 2577-0229 Expiration Date: XX-XX-XXXX

Certification of Election of Resident Council Board

Resident Opportunity & Self-Sufficiency (ROSS)

Service Coordinator Funding

Public reporting burden for the collection of information is estimated to average one hour per response. This includes the time for collecting, reviewing, and reporting the data. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden the Reports Management Officer, REE, Department of Housing and Urban Development, 451 7th Street SW, Room 8210, Washington, DC 20410–5000. When providing comments, please refer to OMB Control No. 2577-0229. The information will be used to determine eligibility for the ROSS SC 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 does not lend itself to confidentiality.

Instructions for completing this form: Resident associations applying to the ROSS program must certify that the Board of their Resident Council has been duly elected as required by HUD (24 CFR Part 964). All resident associations applying to the ROSS program must complete this form and have it signed by an authorized official from the local PHA.

Grant to which you are applying:____________________________________________

I, 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 penalties.  (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802)

Signed this

day of

,

By:

Housing Authority Executive Director or Other Authorized Representative

For:

(Housing Authority Name, Address, and Telephone)

Form HUD-52753 (06/2015)