pending Rural Partners Network Certification Form

Certification of Consistency with Rural
Partners Network Community Network
Goals and Implementation

U.S. Department of Housing and
Urban Development

OMB Number. 2501-XXXX
Expiration Date: pending

Public Reporting Burden Statement: This collection of information is estimated to average 0.50 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
the requested information. Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to:
U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, R, 451 7th St SW, Room 8210, Washington, DC 204105000. Do not send completed forms to this address. This agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless the collection displays a valid OMB control number. This agency is authorized to collect this information under Section 102 of
the Department of Housing and Urban Development Reform Act of 1989. The information you provide will enable HUD to carry out its
responsibilities under this Act and ensure greater accountability and integrity in the provision of certain types of assistance administered by HUD.
This information is required to obtain the benefit sought in the grant program. Failure to provide any required information may delay the processing
of your application and may result in sanctions and penalties including of the administrative and civil money penalties specified under 24 CFR §4.38.
This information will not be held confidential and may be made available to the public in accordance with the Freedom of Information Act (5 U.S.C.
§552). The information contained on the form is not retrieved by a personal identifier, therefore it does not meet the threshold for a Privacy Act
Statement.

I/We, the undersigned, certify under penalty of perjury that the information provided below is true, correct, and accurate. 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, 1014; 31 U.S.C. §§
3729, 3802; 24 CFR § 28.10(b)(iii)). (Complete the fields below.)
Applicant Name:
Name of the Federal Program to which the applicant is applying:

Rural Partners Network Community Network(s) which the proposed activities/projects will benefit:
Include below the full name of Rural Partner Network Community Network(s) from the All Community Networks list on rural.gov.

The application meets which of the following criteria (please select one):
The proposed activities/projects will occur solely within the boundaries of the Rural Partners Network Community Network(s)
listed above.
The proposed activities/projects will occur within the boundaries of the Rural Partners Network Community Network(s) listed
above and other communities.
The proposed activities/projects will occur outside the boundaries of the Rural Partners Network Community Network(s) listed
above, but substantial and direct benefits will accrue within the Rural Partners Network Community Network(s) listed above.
Note: Projects that substantially and directly benefit Rural Partners Network Community Network(s) residents, but which do not consist of activities
delivered within Rural Partners Network Community Network boundaries may be considered for competitive preference. If applicable, the respective
Federal Agency will clearly define "substantially and directly" in the relevant funding announcement.

Estimated Funding Allocations
Estimate a percentage of the expected total HUD award amount that would result in a direct benefit within the Rural Partners Network
Community Network(s) listed above:
76% - 100%
51% - 75%
26% - 50%
11% - 25%
1%- 10%

form HUD XXXXX (1/2024)

Provide a narrative and/or reference the section in the application that explains how the project will support public and
private investment in rural communities, specifically the designated Rural Partners Network Community Network(s) (1,000word limit):

Check the following boxes that accurately reflect the nature or purpose of the proposed project:
Access to Capital
Community Infrastructure
Asset Building
"Above ground" infrastructure — streets, sidewalks, lighting
Business Assistance
"Below ground" infrastructure — water, sewer, gas, electric
Community Capacity Building
Commercial or Retail Development
Economic Development
Hospitals or other Health Care Facilities Housing
Education
Low Income Housing Tax Credit (LIHTC) or other rent
Healthy Food Access
restricted housing
Health
Market rate housing
Human Services and Family Support
Industrial development
Other Business Development
Schools or other educational facilities
Public Safety
Workforce Development

Check this box if the applicant is the Rural Partners Network Community Network. Leave this box unchecked if the
applicant is not the Rural Partners Network Community Network Authorized Official.
Authorized Official signature, if the applicant is not the Rural Partners Network Community Network Authorized Official:
I/We certify that:
(1) We have completed the “Certification of Consistency with Rural Partners Network Community Network Goals and
Implementation” with consultation and approval from the Rural Partners Network (RPN) Community Network Authorized
Official
(2) We are engaged in activities, that in consultation with the RPN Community Network host entity, further the purposes of the
RPN initiative; and
(3) Our proposed activities either directly reflect the goals of the RPN initiative or will result in the delivery of services that are
consistent with the goals of the RPN initiative; and
(4) We have committed to maintaining an ongoing relationship with the RPN Community Network the RPN Community
Network Authorized Official, and the RPN Community Network Authorized Officials organization.”
Provide this completed form and request that the RPN Community Network Authorized Official provides a signed and dated letter that
references the name of the Federal program and, if available, the number of the Federal program which the applicant is applying for,
with the following Certification statement:
I/We certify that _____________________________________________________________ (Applicant name):
(1) Has completed the “Certification of Consistency with Rural Partners Network Community Network Goals and
Implementation” and I/we approve the content of the form; and
(2) The organization is/will be engaged in activities that further the purposes of the Rural Partners Network (RPN) initiative;
and
(3) The organization’s proposed activities either directly reflect the goals of the RPN initiative or will result in the delivery of
services that are consistent with the goals of the RPN initiative.
RPN Official signing the letter:
First Name: ______________________________________ Last Name: _______________________________________________
Title: ___________________________________________ Organization: ______________________________________________
Signature: ____________________________________________________________________Date: __________________________
Authorized Official signature, if the applicant is the Rural Partners Network Community Network:
I/We certify that:
(1) I have completed the “Certification of Consistency with Rural Partners Network Community Network Goals and
Implementation” and approve the content of the form;
(2) My organization is engaged in activities that further the purposes of the Rural Partners Network (RPN) initiative; and
(3) Our proposed activities either directly reflect the goals of the RPN initiative or will result in the delivery of services that are
consistent with the goals of the RPN initiative.
form HUD XXXXX (1/2024)

Note: If you are unable to have this form digitally signed by the Authorized Official via Grants.gov, then, fill in the information above
excluding the signature and attach to the application a signed letter that includes the certification statement above, references the
name of the Federal program, and if available, references the number of the Federal program.

Name (First Name, Middle Initial, Last Name):
Title:

Organization:

Signature: _________________________________________ Date:

form HUD XXXXX (1/2024)