2013-148 - Laserfiche WebLink

Home Browse Search

Tenant Based Rental Assistance U.S . Department of Housing OMB Approval No. 2506-0171 and Urban Development (Exp . 05/31 /2007) Set- up Report Office of Community Planning HOME Program and Development Note : Complete for all Tenant Based Rental Assistance Activities, Mark Appropriate Box: ❑ Original Submission ❑ Revision Part A: 1 , Name Participant 5 , HOME Funds for Activity a . Total Funds Requested $ 2 . Activity Number 3. Participant Tax ID Number b. Participant Number c. Dollar Amount of Funds $ 4 . Name & Phone Number of person completing form $ $ Part B: Activity Information. 1 . Term of Contract 2 . County Code 3. Number of Tenants Assisted Part C : Household Characteristics. Enter one code ly in each block. No. Tenant's Last No, Tenant Subsidy Total Rent % of Hisp Race of Head Size of Head of Type of Is HOME As- Name or First 5 of Payment Amount (a + b) Area of Household House House Contract listed Tenant Letters of Last BRs (a) (b) Median hold hold O=Owner in HOME As- Name Income T=Tenant sisted Project 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 No. of Bedrooms Code Hispanic Race of Head of Household Code Size of Household Code Head of Household Code 1 - 1 Bedroom y - yes 11 - White 1 - 1 Person 1 - Single/Non Elderly 2 - 2 Bedrooms n - no 12 - Black or African American 2 - 2 Persons 2 - Elderly 3 - 3 Bedrooms 13 - Asian 3 - 3 Persons 3 - Related/Single Parent 4 - 4 Bedrooms 14 - American Indian or Alaska Native 4 - 4 Persons 4 - Relatedrrwo Parent 5 - 5 or more Bedrooms 15 - Native Hawaiian or Other Pacific Islander 5 - 5 Persons 5 - Other 16 - American Indian or Alaska Native & White 6 - 8 Persons % of Area Median Code 17 - Asian & White 7 - 7 Persons 1 - 0 - 30% 18 - Black or African American & White 8 - 8 or more Persons 2 - 3O - 50% 1 g - American Indian or Alaska Native & 3 - 50 - 60% Black or African American 4 - 6O - 80% 20 - Other Multi Racial Page 1 of 4 form HUD40095 (02/2003)