Form HUD-4123 and HUD-4 HUD-4123 and HUD-4 Cost Summary (4123) and Implementation Schedule (4125)

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Overview

Instructions
Form 4123
Form 4125

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Sheet 1: Instructions

Instructions for Completing 4123 and 4125
FORM 4123
Section
1	Input Applicant name.
2	Insert the grant number if it has been assigned by HUD. Use the grant number(s) applicable to the program(s) you are reporting on (ICDBG or IHBG Competitive, or both). Leave blank if unknown at time of application.
3	Check the appropriate box associated with the form submission. Enter the date you completed this form.
4	Enter the project name. On the rows below, enter project costs. Use columns (b), (c) and (d) to indicate the applicable source for each line item. Use column (f) to describe the source of funds in column (d).
5	Enter planned administrative expenses, including (if applicable) indirect costs and audit costs. Administrative costs must not exceed 20% of the grant.
6	Enter amount of ICDBG funds requested for technical assistance, if applicable. No more than 10% of ICDBG funds requested may be used for technical assistance. If funds are requested under this line item, a separate project description must accompany the application to describe the technical assistance the application intends to obtain. Only technical assistance costs associated with the development of a capacity to undertake a specific funded program activity are eligible (24 CFR 1003.206).
7	Enter amount of ICDBG funds requested for Public Services. Public Service costs must not exceed 15% of the total ICDBG grant.
FORM 4125
Section
1	Applicant Name: Auto populates from Form 4123.
2	Insert the grant number if it has been assigned by HUD. Use the grant number(s) applicable to the program(s) you are reporting on (ICDBG or IHBG Competitive, or both). Leave blank if unknown at time of application.
3	Input an "X" in the appropriate box associated with the form submission.
4	Enter the date you completed this form.
5	Project Name: Auto populates from Form 4123.
6	Period of Performance: Insert Start Date and End Date.
7	Expected Close Out Date: auto-populates 90 days from period of performance end date in from Box 6.
8	Insert an "X" in the box that best describes current Environmental Review status.
9	Insert description of task.
10	Insert anticipated start and end month/year of task.

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Sheet 2: Form 4123

Cost Summary							U.S. Department of Housing					OMB Approval No.0000-0000
Indian Community Development Block							and Urban Development					(exp. 00/00/0000)
Grant (ICDBG) and Indian Housing Block							Office of Public and Indian Housing
Grant Competitive (IHBG)
See Instructions and Public Reporting Statement
1. Name of Applicant (as shown on Standard Form 424)									2. Grant Number (assigned by HUD)
3		Original (Check here if this			Amendment							Date (mm/dd/yyyy)
		is the first submission to HUD)			(Check here if submitted after initial application)
4.	Project Name & Category (see instructions tab) (a)					Planned ICDBG Expenditures (b)	Planned IHBG Competitive Funds Expenditures (c)	Planned Other Federal and Non-Federal Funds Expenditures (d)			Total Planned Expenditures (e)	Source of Other Funds (Column d) for each Activity (f)
Project Name:
											$-
											$-
											$-
											$-
											$-
											$-
											$-
											$-
											$-
											$-
											$-
5.	Administration
	a	Planning and Administration Cost									$-
	b	Indirect Costs: Enter indirect costs to be charged to the Program pursuant to a cost allocation plan.									$-
	c	Audit: Enter estimated cost of Program share of financial audits.									$-
	Administrative Total					$-	$-	$-			$-
6.	Technical Assistance Enter amount requested for technical assistance. (up to 10% of total ICDBG Grant)										$-
7.	Public Service Component: up to 15% of ICDBG grant.										$-
8.	TOTAL EXPENDITURES					$-	$-	$-			$-
Public reporting burden for this collection of information is estimated to average 40 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 information. 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 collection of information requires that each eligible applicant submit information to enable HUD to select the best projects for funding during annual competitions for these Grant Programs. The information will be used by HUD to determine whether applications meet minimum screening eligibility requirements and application submission requirements. Applicants provide general information about the project which is preliminary to the review of the applicant’s response to the criteria for rating the application. The information is essential for HUD in monitoring grants to ensure that grantees are making proper use of Federal dollars. Responses to the collection are required by Section 105 of the Department of Housing and Urban Development Reform Act (P.L. 101-235) as amended by the Cranston-Gonzales National Affordable Housing Act of l990. The information requested does not lend itself to confidentiality.

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Sheet 3: Form 4125

Implementation Schedule

U.S. Department of Housing

OMB Approval No.0000-0000

Indian Community Development Block Grant (ICDBG)

and Urban Development

(exp. 00/00/0000)

and Indian Housing Block Grant Competitive (IHBG)

Office of Public and Indian Housing

See Instruction Tab and Public Reporting Statement.

Submit a separate implementation schedule for each project category.

1. Name of Applicant (as shown on Standard Form 424)

2. Grant Number (assigned by HUD)

3.

Original (First Submission to HUD)

4. Date (mm/dd/yy)

Auto Populates from Form 4123

Amendment (submitted after initial application)

5. Name of Project (as shown on form HUD-4123)

6. Period of Performance

7. Expected Close Out

Auto Populates from Form 4123

Start Date (mm/dd/yy)

End Date (mm/dd/yy)

Date (mm/dd/yy)

auto populates

8. Environmental Review Status

Exempt (as described in 24 CFR 58.34)

Under Review (review underway;

Finding of No Significant Impact (Finding made that request for release of

Categorically Excluded

findings not yet made)

funds for project is not an action which may significantly affect the environment)

(as described in 24 CFR 58.35)

EIS Required (Finding that project may

Not Started

Certification (Environmental review completed;

significantly affect environment or

(Review not yet begun)

certification and request for release of funds

EIS automatically required by 24 CFR 58.37)

being prepared for submission.)

9. Task List (List tasks such as environmental assessment, acquisition, etc.)

10. Schedule (anticipated start and end date of task) mm/yy

(Insert lines as needed. Home tab, cells, insert sheet row)

Start Date

End Date

Public reporting burden for this collection of information is estimated to average 40 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 information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestion for reducing this burden, to the Reports Management Officer, Paperwork Reduction Project (2577-0191), Office of Information Technology, U.S. Department of Housing and Urban Development, Washington D.C. 20410-3600. 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 collection of information requires that each eligible applicant submit information to enable HUD to select the best projects for funding during annual competitions for these Grant Programs. The information will be used by HUD to determine whether applications meet minimum screening eligibility requirements and application submission requirements. Applicants provide general information about the project which is preliminary to the review of the applicant’s response to the criteria for rating the application. The information is essential for HUD in monitoring grants to ensure that grantees are making proper use of Federal dollars. Responses to the collection are required by Section 105 of the Department of Housing and Urban Development Reform Act ( P . L . 101-235) as amended by the Cranston-Gonzales National Affordable Housing Act of l990. The information requested does not lend itself to confidentiality.