96011

Public reporting burden for this collection of information is estimated to average 6 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

This form is used for third party applicants as required for applications submissions and other materials that are not normally available as electronic files, e.g. leverage letters, documentation from books, reports or other such items. This 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.

Instructions
IMPORTANT NOTE: If you have completed the SF 424 Request for Federal Assistance form, data fields will be pre-populated within this form.
Item	Entry
1. a-d Applicant Information	Enter legal name of applicant, name of primary organization unit (including division, if applicable), which will undertake the assistance activity. Enter the complete address, Street, City, County, State and Zip Code. Enter the country, i.e. USA. Enter the DUNS number (received from DUN and Bradstreet).
2. a-c. Catalog of Federal Domestic Assistance number and title of the program and program component.	Enter the Catalog of Federal Domestic Assistance number of the program you are apply for federal assistance. Enter the title of the program which assistance is requested. Enter program component under which assistance is requested. If there are no sub categories within a program you may leave “program component” blank. (For example: CFDA: 14.123)
3. a-b. Facsimile Contact Information	a. Enter the name of the Department and/or b. Division in which this facsimile is being transmitted.
4. Name and telephone number	Enter name, email and telephone number (remember to include area code) of person to be contacted on matters involving the transmitting fax.
5. Email	Enter email address of person to contact regarding facsimile.
6. b-d What are you transmitting/number of pages?	What are you transmitting? Check the appropriate box indicating what type of document you are transmitting, b. certification, c. document, d. letter, or e. other. For example, if you are transmitting a Memorandum of Understanding (MOU) this would be considered a document so you would check d ocument.. Please note: for each document you are transmitting a separate cover page is needed.
7. How many pages are being faxed?	Indicate how many pages including the cover are being faxed.

Name of Document Transmitted:

     

1. Applicant Information

a. Legal Name:

     

b. Address

Street:      	City:      
County:      		State:      	Zip Code:      

c. Country:

     

d. DUNS number:

     

2. Catalog of Federal Domestic Assistance Number:

a. CFDA No.

     

b. Title (Name of Program)

     

c. Program Component

     

3. Facsimile Contact Information

a. Department:      

b. Division      

4. Name and telephone number of person to be contacted on matters involving this facsimile:

Prefix:      	First Name:      	Middle Initial:      		Last Name:      
Phone number (include area code)      			Fax number (include area code)      

5. Email:

     

6. What is your transmittal? (Check one box per fax)		7. How many pages (including cover) are being faxed?
	b. Certification c. Document d. Match/Leverage Letter e. Other	     

Page 2 of 2 form HUD-96011

(8/2005)