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4 - 60 - 80% 20 — Other Multi Racial Public reporting burden for this collection of information is estimated to average 15 minutes 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 conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number. The HOME statute imposes a significant number of data collection and reporting requirements. This includes information on assisted properties , on the owner or tenants of the properties , and on other programmatic areas. The information will be used: 1 ) to assist HOME participants in managing their programs; 2) to track performance of participants in meeting fund commitment and disbursement deadlines; 3 ) to permit HUD to determine whether each participant meets the HOME statutory income targeting and affordability requirements ; and 4) to permit HUD to determine compliance with other statutory and regulatory program requirements . This data collection is authorized under Title 11 of the Cranston-Gonzalez National Affordable Housing Act or related authorities. Access to Federal grant funds is contingent on the reporting of certain activity- specific elements. Records of information collected will be maintained by the recipients of the assistance . Information on activities and disbursements of grant funds is public information and is generally available for disclosure . Recipients are responsible for ensuring confidentially when public disclosure is not required . Sensitive Information: Some of the information collected on this form is considered sensitive and is protected by the Privacy Act. The Privacy Act requires that these records be maintained with appropriate administrative , technical , and physical safeguards to ensure their security and confidentiality. In addition, these records should be protected against any anticipated threats or hazards to their security or integrity which could result in substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom the information if maintained . Recipients are responsible for ensuring confidentiality when public disclosure is not required. Instructions for Completing the Tenant-Based Rental Assistance Set- Up Report HOME Program Read the instructions for each item carefully before completing Part C . Household Characteristics . the form . Use a typewriter or print carefully with a ballpoint pen . Complete one line for each tenant receiving HOME tenant-based Prepare an original and one copy . Retain the copy. rental assistance from HOME funds . Applicability. This report is to be completed for each rental Tenant' s Last Name or First 5 Letters of Last Name . Enter the activity assisted with HOME funds . A single set-up report form tenant's last name if the name is 5 letters or less . Enter the first may include up to 99 tenants so long as the term of the contract is five letters of the last name if the name is more than five letters . the same for all of the tenants in the report form . For centralized State projects , the tenants must be in the same country. Number of Bedrooms . Enter "0" for a single room occupancy (SRO ) unit or for an efficiency unit, 1 for 1 bedroom , 2 for 2 Timing . Data is to be entered into IDIS before funds may be bedrooms , 3 for 3 bedrooms , 4 for 4 bedrooms , and 5 for 5 or drawn down for an activity. An amended set-up report form more bedrooms . should be submitted to increase or decrease HOME funding for the activity . Monthly Rent ( Including Utilities ) . Tenant Payment. Enter the actual rent to the nearest dollar, Part A: Activity Information including utilities , paid by the tenant at the time of activity completion . If the rent includes utilities , or if the rent includes 1 . Name of Participant. Enter the name of the jurisdiction . partial utilities , e. g. , heat, but not electricity, these utility costs 2 . Project Number. Enter the activity number assigned by must be added to the rent. Compute utility costs for the area (and IDIS . in the case of partial utilities , compute costs for utilities excluded 3 . Participant' s Tax ID Number. Enter the Tax from the rent ) , by using the utility allowance schedule by the local ( Employer) Identification Number for the participant. Public Housing Authority ( PHA) in accordance with form HUD- 4 . Name & Phone Number of Person Completing Form . 52667 , Allowance for Tenant Furnished Utilities and Other Enter the name and phone number, including area code , Services . of the person to contact for further information regarding this project . HOME Subsidy Amount . Enter the amount from HOME funds 5. HOME Funds for Activity. that will be paid to the tenant or owner as a rent subsidy payment a . Enter the total amount of HOME ( including any utility allowances ) to the nearest dollar. funds requested for the activity . b . Enter the participant number (from Total Rent . Enter the total monthly rent (tenant payment plus item 2 of the HOME Investment HOME subsidy amount) . Note : This amount may exceed the rent Partnership Agreement for Project paid to the owner if it includes tenant-paid utilities . Areas ) for each fiscal year source of HOME project funds committed for Income Data . the activity. Percent of Area Median . For each occupied residential unit, c . Enter the amount of HOME funds enter one code only based on the following definitions : from each fiscal year by participant 1 . 0-30 Percent of Area Median means a household whose number. adjusted income is at or below 30 percent of the median family income for the area , as determined by HUD with Part B : Activity Information adjustments for smaller and larger families . Items 1 and 2 must be the same for all tenants included in a 2 . 30-50 Percent of Area Median means a household single activity set-up . whose adjusted income exceeds 30 percent and does 1 . Term of Contract. Enter the term in months of tenant- not exceed 50 percent of the median family income for based rental assistance activity . the area , as determined by HUD with adjustments for 2 . County Code . To be completed only by States that are smaller and larger families . being administered in a centralized State HOME 3 . 50-60 Percent of Area Median means a household Program . Enter the 3-digit county code for the county in whose adjusted income exceeds 50 percent and does which the project is located . not exceed 60 percent of the median family income for 3 . Number of Tenants Assisted . Enter the total number the area , as determined by HUD with adjustments for of tenants to be assisted by this activity. smaller and larger families . Page 3 of 4 form HUD40095 (02/2003 )