HUD-52768 ROSS Service Coordinator Funding

Resident Opportunity & Self-Sufficiency (ROSS) Service Coordinator Funding

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

OMB Approval No. 2577-0229 Expiration Date 01-31-2024

Public reporting burden for the collection of information is estimated to average 4 hours 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 Resident Opportunity and Self-Sufficiency (ROSS) Service Coordinator (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.
PART I: General Information. ***Please read the ROSS NOFO carefully for instructions for the completion of this form and minimum requirements. ***
Applicant Type (please check) Public Housing Authority (PHA) Region-Wide PHA Statewide PHA Tribe/Tribally Designated Housing Entity (TDHE) Resident Association (RA) Site Based RA Non-Site Based RA Multifamily Owner 501(c)(3) Nonprofit applicant (Not a RA) PHA nonprofit affiliate/instrumentality B. Applicant Legal Name (For joint applicants, lead Applicant name):       Address:       City:       County:       State:       Zip Code:       UEI Number       PHA Code (s) affiliated with the applicant’s project (s) to be served (not applicable to Tribes/ TDHEs and Multifamily Owners).       C. Legal Name of Joint Applicant (If applicable):       PHA Code of Applicant (if applicable):       Legal Name of Joint Applicant (If applicable):       PHA Code of Applicant (If applicable):       D. Name of PHA, Tribe/TDHE(s), Multifamily Owner, and/or RA affiliated with the applicant’s project(s) to be served.       E. Are you (the applicant) a renewal applicant according to the terms of the NOFO to which you’re applying? Yes No *If you are a new applicant, and you are a nonprofit organization, you must attach documentation with this application form verifying your nonprofit status.* F. For renewal applicants that are nonprofit organizations: I      , certify the nonprofit status for       is current and in good standing. 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 Authorized Representative       Title Not Applicable

SC positions requested	Project name(s) to be served and project number or unique project identifier		Number of units to be served (See NOFO for minimum number of units)	Type of unit to be served (See NOFO for type of unit definition.)	For RAD-PBRA and RAD-PBV, enter the former project name(s) and number(s) from PIC for each project served	For Multifamily Owners, enter the Multifamily Contract Number (PBRA HAP contract number)	Area(s) of Need for your ROSS Program	Year	Salary/ Fringe Request (See NOFO for limits.)	Admin Request (See NOFO for limits.)	Training/ Travel Request (See NOFO for limits.)
1	     			Public Housing RAD-PBRA RAD-PBV NAHASDA Rental Assistance Other			Digital Inclusion Education Financial Literacy Health & Wellness Employment Elderly/Disabled Reentry Substance Use	1	$     	$     	$     
								2	$     	$     	$     
								3	$     	$     	$     
2	     			Public Housing RAD-PBRA RAD-PBV NAHASDA Rental Assistance Other			Digital Inclusion Education Financial Literacy Health & Wellness Employment Elderly/Disabled Reentry Substance Use	1	$     	$     	$     
								2	$     	$     	$     
								3	$     	$     	$     
3	     			Public Housing RAD-PBRA RAD-PBV NAHASDA Rental Assistance Other			Digital Inclusion Education Financial Literacy Health & Wellness Employment Elderly/Disabled Reentry Substance Use	1	$     	$     	$     
								2	$     	$     	$     
								3	$     	$     	$     
									$     	$     	$     

PART II: Service Coordinator Information (Budget Form)

PART III. Salary Comparability

Applicants’ salary requests are subject to salary comparability requirements as prescribed in the most recent ROSS NOFO. Salary requests must be based on local comparability information and support the amount requested for salary and fringe to similar positions in the local jurisdiction. Please review the most recent ROSS NOFO carefully for further instructions on completing the information below.

Salary Comparability

	Occupation Title	Annual Salary	Annual Fringe Benefits	Total Amount (Annual Salary +Fringe Benefits)	Source/ Employer Name	Name of Agency Point of Contact (POC)	POC Email Address	POC Telephone Number
1.	     	     	     	     	     	     	     	     
2.	     	     	     	     	     	     	     	     
3.	     	     	     	     	     	     	     	     

PART IV: Match

Match for the ROSS program should represent the needs assessed. Provide the need that you are proposing to meet, the source and value of the match. All applicants are required to have in place a firmly committed match contribution equivalent to 25 percent of the total grant amount being requested in order to be considered for ROSS funding. Match is a NOFO threshold requirement.

*Please read the ROSS NOFO carefully for instructions and minimum requirements. *

Area of Need that Match Will Address	Service to Be Provided	Source of Match	Value of Match
     	     	     	$     
     	     	     	$     
     	     	     	$      
     	     	     	$     
     	     	     	$     
		Total Match	$     

B. Match is      percent of grant requested (must be at least 25 percent to qualify)

C. I      , certify that the match recorded here is supported by letters on file from community or other partners which certify to this amount of match funding (cash or in-kind) and that this represents the total match for the term of the grant.

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 five years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802).

     

Signature of Authorized Representative

     

Title

Please attach with this form:

Renewal Applicants:

Narrative Statement

New Applicants:

Narrative Statement Nonprofit Status (if applicable)

Nonprofit Organizations:

Letter of Support from the PHA, tribe/TDHE, or RA

Joint Applicant(s):

Letter of Support from Joint Applicant(s)

PHAS Troubled:

Contract Administrator Partnership Agreement

Resident Associations:

Contract Administrator Partnership Agreement

Multifamily Owners

Housing Assistant Payment (HAP) Contract

Tribes Designated High-Risk:

Narrative Statement

Applicants requesting an additional Service Coordinator (see NOFO for eligibility):

Map

Equity Narratives (see NOFO for instructions):

Advancing Racial Equity Narrative

Affirmative Marketing Narrative

Affirmatively Furthering Fair Housing Narrative

*Please see NOFO for all other forms your complete application must include*

I     , certify that the information provided on this form and in any accompanying documentation is true and accurate.  I acknowledge that making, presenting, or submitting a false, fictitious, or fraudulent statement, representation, or certification may result in criminal, civil, and/or administrative sanctions, including fines, penalties, and imprisonment.

     

Signature of Authorized Representative

     

Title

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