Hud 52768 Ross Service Coordinators � Funding Request

OMB Approval No. 2577-0229

Expiration Date pending

U.S. DEPARTMENT OF HOUSING

AND URBAN DEVELOPMENT

OFFICE OF PUBLIC AND INDIAN HOUSING

ROSS SERVICE COORDINATORS – FUNDING REQUEST

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Public reporting burden for the collection of information is estimated to average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The information will be used for the ROSS 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 will allow HUD to determine eligibility for the ROSS SC Program. This information does not lend itself to confidentiality.

***Please read NOFA carefully for directions and minimum requirements.*. ***

Name of Applicant ________________________

Joint Applicant (if applicable) _________________________________

PHA/Tribe/TDHE(s) to be Served (Name and PHA/IHA/TDHE or Tribal Locality Code) _________________________________________________

_________________________________________________

Total Number of ACC Units/Formula Currently Assisted Stock in PHA/Tribe ______________

EDSC

PHA applicants: Are you currently eligible to receive funding for one or more Elderly/Disabled Service Coordinators (EDSC) through the Operating Subsidy? (NOT ROSS-Elderly/Persons with Disabilities) YES ___ NO ___

If YES and you request and are granted an Elderly SC to serve Elderly Residents through this NOFA, you will forgo any future EDSC Renewal funding.

RA Applicant? YES ___NO ___ (State and National Resident Associations applying as non-profits should check YES)

Service Coordinators (SCs) Requested

SC Position Requested	Development(s)/AMP(S) to be served served (list name and/or number as applicable) (if different PHAs, list PHA as well)	Number of Units to be Served by this SC (See NOFA for minimum)	SC will serve Family, Elderly or MixedBoth?	Year	Salary/Fringe (See NOFA for limits)per year	Admin (See NOFA for limits)per year	Training (See NOFA for limits)per year
1				1	$	$	$
				2	$	$	$
				3	$	$	$
2				1	$	$	$
				2	$	$	$
				3	$	$	$
3				1	$	$	$
				2	$	$	$
				3	$	$	$
			TOTALS	TOTAL $	$	$	$
TOTAL GRANT REQUESTED $ _________________

For each SC position requested, fill in one row.

Form HUD-52768 (12/2007)