Form HUD-40110-B HOPWA Competitive Application & Renewal of Permanent Sup

OMB Approval No. 2506-0133

exp. XX/XX/XXXX

HOPWA

Competitive Application &

Renewal of Permanent Supportive Housing Project

Budget Summary

U.S. Department of Housing and Urban Development

Office of Community Planning and Development

Office of HIV/AIDS Housing

The information collection requirements pertain to grant application submission requirements which will be used to rate applications, determine eligibility, and establish grant amounts. Selections of applications for funding under the HOPWA Program are based on the criteria established in the published Notice of Funding Availability (NOFA) for new competitions or annual HOPWA renewal notice for grantees seeking renewal funding for eligible permanent supportive housing projects. HUD’s information collection requirements are supported by 42 U.S.C. § 12903(d) and HUD’s regulations at 24 CFR § 574.240.

The public reporting burden for the collection of information for a HOPWA Renewal Application (including this form, narratives, and other requirements listed in the renewal notice) is estimated at 15 hours. The public reporting burden for the collection of information for a new HOPWA Competitive Application (including this form, narratives, and other requirements listed in the applicable NOFA) is estimated at 45 hours. The information collected on this form is required to obtain a benefit. This agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless that collection displays a currently valid OMB control number. While confidentiality is not assured, HUD generally only releases this information as required or permitted by law. OMB Approval No. 2506-0133 (Expiration Date: XX/XX/XXXX)

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)

Application Budget Summary (all applicants)

Applicant Name

     

Number of Project Sponsors

     

Plan dates for grant agreement and activities

      (mo./yr.)

A.	Eligible Activity	HOPWA Request				Leveraged Funds
		A. Year 1	B. Year 2	C. Year 3	D. Total
Facility Development (new applications only)	1. Acquisition	     	     	     	     	     
	2. Rehabilitation, Repair & Conversion	     	     	     	     	     
	3. New Construction (for Community Residences and SRO dwellings only)	     	     	     	     	     
Facility Operations	4. Operating Costs for Housing Facility	     	     	     	     	     
	5. Leasing	     	     	     	     	     
TBRA	6. Tenant-based Rental Assistance	     	     	     	     	     
STRMU	7. Short-term Rent, Mortgage, & Utility Payments to Prevent Homelessness	     	     	     	     	     
Support Services	8. Supportive Services	     	     	     	     	     
Other Program Expenses	9. Housing Information Services	     	     	     	     	     
	10. Permanent Housing Placement	     	     	     	     	     
	11. Resource Identification to Establish, Coordinate & Develop Housing Assistance	     	     	     	     	     
	12. Other Housing Activity (Approved by HUD)	     	     	     	     	     
	13. Total Program Costs: (total of lines 1-12)				     
Administrative Expenses	14. Grantee’s Administrative				     
	15. Project Sponsor’s Administrative Costs				     
	16. Total HOPWA Request (total of lines 13-15)				     

Detailed Project Budget & Housing Outputs (each organization)

Name of organization:	     
Type:	Grantee: ☐; Project Sponsor: ☐	If applicable:	Faith based: ☐	Grassroots: ☐

B.	Eligible Activity		HOPWA Request
			Yr. 1	Yr. 2	Yr. 3	Totals:
Facility Development (new applications only)	1. Acquisition Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
	2. Rehabilitation/Repair/Conversion Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
	3. New Construction (Community Residences & SRO dwellings only) Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
	Type of Facility: Short-term shelter ☐; Transitional housing ☐; Community residence ☐; SRO dwelling ☐; or other permanent supportive housing ☐
Facility Operations	4. Operating Costs for Housing Facility Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
	5. Leasing Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
TBRA	6. Tenant-Based Rental Assistance Payments Description:      	Budget	     	     	     	     
		# of Households	     	     	     	     
STRMU	7. Short-Term Rent, Mortgage & Utility Payments to Prevent Homelessness Description:      	Budget	     	     	     	     
		# of Households	     	     	     	     
Support Services	8. Supportive Services Costs Description:      	Budget	     	     	     	     
		# of Households	     	     	     	     
Other Program Expenses	9. Housing Information Services Description:      	Budget	     	     	     	     
		# of Households	     	     	     	     
	10. Permanent Housing Placement Services Description:      	Budget	     	     	     	     
		# of Households	     	     	     	     
	11. Resource Identification to Establish, Coordinate, & Develop Housing Assistance Description:      	Budget
	12. Other Housing Activity (Approved by HUD) Description:      	Budget	     	     	     	     
		# of Units	     	     	     	     
Administrative Expenses	13. Grantee's Administrative Costs Description:      	Budget	     	     	     	     
	14. Project Sponsor's Administrative Costs Description:      	Budget	     	     	     	     
	15. Total HOPWA Request for this Organization					     

Note: Activity/Service delivery costs such as salary and overhead costs directly relating to carrying out a particular eligible activity in a budget line item should be represented in the funding amount requested for that particular budget line item.

15

Insert application package page number ____ Form HUD-40110-B (Expiration Date XX/XX/XXXX)