HUD 52768 Redline

Resident Opportunity &
Self-Sufficiency (ROSS)
Service Coordinator
Funding

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

OMB Approval No. 2577-0229
Expiration Date 01-31-20242026

Public reporting burden for the collection of information is estimated to average 4 hours per response. This includes the time for collecting,
reviewing, and reporting the data. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions to reduce this burden the Reports Management Officer, REE, Department of Housing and Urban Development, 451 7th
Street SW, Room 8210, Washington, DC 20410–5000. When providing comments, please refer to OMB Control No. 2577-0229. The
information will be used to determine eligibility for the Resident Opportunity and Self-Sufficiency (ROSS) Service Coordinator (SC) 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 does
not lend itself to confidentiality.

Commented [JO1]: @Simmons, Michael T What do we put
down for expiration date in the header?

PART I: General Information.
***Please read the ROSS NOFO carefully for instructions for the completion of this form and minimum requirements. ***
A.

Applicant Type (please check)
Public Housing Authority (PHA)

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Region-Wide PHA
Statewide PHA
Commented [JO2]: Added the additional underline to make
grouping more distinct. Any other suggestions welcomed for
usability.

Tribe/Tribally Designated Housing Entity (TDHE)
Resident Association (RA)
Site Based RA
Non-Site Based RA
Multifamily Owner
501(c)(3) Nonprofit applicant (Not a RA)
PHA nonprofit affiliate/instrumentality
B.

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Applicant Legal Name According to UEI (For joint applicants, lead Applicant name):
Address:
City:
County:
State:
Zip Code:
UEI Number
PHA Code (s) affiliated with the applicant’s project (s) to be served (not applicable to Tribes/ TDHEs and Multifamily Owners).

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Entity According to UEI”
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C. Legal Name of Joint Applicant According to UEI (If applicable):
PHA Code of Applicant (if applicable):
Legal Name of Joint Applicant (If applicable):
PHA Code of Applicant (If applicable):

Commented [MS4]: Add information language: According to
UEI

D. Name of PHA, Tribe/TDHE(s), Multifamily Owner, and/or RA affiliated with the applicant’s project(s) to be served.

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E. Are you (the applicant) a renewal applicant according to the terms of the NOFO to which you’re applying?
Yes
No
*If you are a new applicant, and you are a nonprofit organization, you must attach documentation with this application form verifying your
nonprofit status.*
F. For renewal applicants that are nonprofit organizations:
I
, certify the nonprofit status for
is current and in good standing.
I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. 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).
Signature of Authorized Representative
Title
Not Applicable

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HUD-52768

Commented [JO5]: @Mitchell, Lauren C Did you still want add
instructions like the other sections? What would they be?

PART II: Service Coordinator Information (Budget Form)

A.

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Part II: Information Submission for ROSS Service Coordinator Determination

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HUD will use the information provided in this section to determine the number of ROSS Service Coordinators. To ensure an accurate assessment,
all submitted information must be complete and correct.

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Instructions:





SC
positions
requested

1

Project Number or Unique Project Identifier: Enter the identifier using the required format—two letters followed by nine digits (e.g.,
SCXXXXXXXXX). Each project number or unique identifier must be fully written out and follow this format.
Number of Units Served: Confirm that the number of units entered corresponds accurately to the project number or unique identifier.
RAD-PBRA and RAD-PBV Projects: Enter the former project name(s) and number(s) for each project served.
Multifamily Owners: Enter the Multifamily Contract Number (PBRA HAP Contract #). Verify that this information is accurate.

Project number or unique project
identifier to be served
(2alpha and 9 digits entry.
Example: SCXXXXXXXXX)

Number
of units
to be
served
(See
NOFO for
minimum
number of
units)

Type of unit
to be served
(See NOFO
for type of
unit
definition.)

Public
Housing
RADPBRA
RADPBV
NAHASD
A Rental
Assistance
Other

For RAD-PBRA
and RAD-PBV,
enter the former
project name(s)
and number(s)
from PIC for each
project served

For Multifamily
Owners,
enter the
Multifamily
Contract Number
(PBRA HAP
contract number)

Area(s) of Need for your
ROSS Program

Digital Opportunity
Education
Financial Literacy
Health & Wellness
Employment
Elderly/Disabled
Reentry
Substance Use

Salary/
Fringe
Request
(See NOFO
for limits.)

Year

1

$

Admin
Request
(See NOFO
for limits.)

$

Training
/ Travel
Request
(See
NOFO
for
limits.)

$

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Commented [MS6]: (2alpha and 9 digits entry. Example:
SCXXXXXXXXX)
Commented [JO7]: Added sections formatting and landscape
page setup for usability.
Commented [MS8]: Change the functionality to only accept
2alpha and 9 digits), with an example (i.e.: SCXXXXXXXXX).
Will get an error message if format is incorrect
Commented [JO9]: Digital Inclusion changed to “Digital
Opportunity”; Please confirm what you would like to call this.
@Simmons, Michael T

2

$

$

$

3

$

$

$

Commented [BJ10R9]: May want to consider Digital
Workforce, to capture the administration's priority on "work."
Embedded in "workforce" means that skills need to be developed
and/or improved.
Commented [OJ11R9]: I like that! I also did a quick Google
and some people are using "readiness" as well for a replacement.
Shrug.
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HUD-52768

Public
Housing

2

3

RADPBRA
RADPBV

Digital Opportunity
Education
Financial Literacy
Health & Wellness
Employment
Elderly/Disabled

NAHASD
A Rental
Assistance
Other

Reentry
Substance Use

Public
Housing
RADPBRA
RADPBV

Digital Opportunity
Education
Financial Literacy
Health & Wellness

NAHASD
A Rental
Assistance
Other

Employment
Elderly/Disabled
Reentry
Substance Use

1

$

$

$

2

$

$

$

3

$

$

$

1

$

$

$

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2

$

$

$

3

$

$

$

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HUD-52768

PART III. Salary Comparability

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Applicants’ salary requests are subject to salary comparability requ
rements as prescribed in the most recent ROSS NOFO. Salary requests must be based on local comparability information and support the amount requested
for salary and fringe to similar positions in the local jurisdiction. Please review the most recent ROSS NOFO carefully for further instructions on
completing the information below. Applicants’ salary requests are subject to salary comparability requirements as prescribed in the most recent ROSS
NOFO. Salary requests must be based on local comparability information and support the amount requested for salary and fringe to similar positions in the
local jurisdiction. Please review the most recent ROSS NOFO carefully for further instructions on completing the information below.

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Salary Comparability
Occupation
Title

Annual
Salary

Annual
Fringe
Benefits

Total Amount
(Annual Salary
+Fringe
Benefits)

Source/
Employer
Name

Name of
Agency Point
of Contact
(POC)

Commented [MS12]: We previously requested the functionality
here to be change to make entry optional
POC
Email
Address

POC
Telephone
Number

1.

2.

3.

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HUD-52768

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Formatted Table

PART IV: Match

Match for the ROSS program should represent the needs assessed. Provide the need that you are proposing to meet, the source and value of the match. All applicants
are required to have in place a firmly committed match contribution equivalent to 25 percent of the total grant amount being requested in order to be considered for
ROSS funding. Match is a NOFO threshold requirement.
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***Please read the ROSS NOFO carefully for instructions and minimum requirements.***

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A.

Commented [JO13]: Did some formatting for clarity.

Area of Need that Match Will Address

Service to Be Provided

Total Match
B. Match is
C. I

Value of Match

Source of Match
$
$
$
$
$
$

Commented [MS14]: Request: Have a dropdown in the area of
need section? The dropdown would include the eight area of need
categories are: Education, Employment, Health & Wellness,
Financial Literacy, Reentry, Elderly & Disable, Substance Abuse,
Digital Inclusion

percent of grant requested (must be at least 25 percent to qualify)

, certify that the match recorded here is supported by letters on file from community or other partners which certify to this

amount of match funding (cash or in-kind) and that this represents the total match for the term of the grant.
I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. 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 five years,
fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802).
Signature of Authorized Representative
Title

Please attach with this form:
Renewal Applicants:
Narrative Statement
New Applicants:
Narrative Statement

Nonprofit Status (if applicable)

Nonprofit Organizations:
Letter of Support from the PHA, tribe/TDHE, or RA
Joint Applicant(s):
Letter of Support from Joint Applicant(s)
PHAS Troubled:
Contract Administrator Partnership Agreement
Resident Associations:
Contract Administrator Partnership Agreement
Multifamily Owners
Housing Assistant Payment (HAP) Contract
Tribes Designated High-Risk:
Narrative Statement
Applicants requesting an additional Service Coordinator (see NOFO for eligibility):
Commented [JO15]: I removed the narrative submissions
according to new EOs.

Map

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HUD-52768

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Equity Narratives (see NOFO for instructions):

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Advancing Racial Equity Narrative
Affirmative Marketing Narrative
Affirmatively Furthering Fair Housing Narrative

Commented [JO16]: I removed the narrative submissions
according to new EOs.
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***Please see NOFO for all other forms your complete application must include.***

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I
, certify that the information provided on this form and in any accompanying documentation is true and
accurate. I acknowledge that making, presenting, or submitting a false, fictitious, or fraudulent statement,
representation, or certification may result in criminal, civil, and/or administrative sanctions, including fines,
penalties, and imprisonment.

Signature of Authorized Representative
Title

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HUD-52768

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