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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 ark Part B : Activity Information . 1 . Term of Contract 2 . County Code 3 . Number of Tenants Assisted Part C : Household Characteristics . Enter one code only 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 sisted 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 — 6 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 - 30 - 50% 19 — American Indian or Alaska Native & 3 - 50 - 60% Black or African American 4 - 60 - 80% 20 — Other Multi Racial Page 1 of form HUD-40095 (02/2003 )