4123.pdf

Previous editions are obsolete form 4123 Page 1 of 2

Cost Summary Indian Community Development Block Grant (ICDBG)

See Instructions and Public Reporting Statement on back.

5. Administration

a. General Management and Oversight

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 A-133 audits.

Administration Total *

6. Planning The Project description must address the proposed use of these funds.

7. Technical Assistance Enter total amount of ICDBG funds requested for technical assistance. **

8. Sub Total Enter totals of columns b. and c.

9. Grand Total Enter sum of column b. plus column c.

1. Name of Applicant (as shown in Item 5, Standard Form 424) 2. Application/Grant Number (to be assigned by HUD upon submission)

3. Original Revision Amendment Date (mm/dd/yyyy) (check here if this is the (check here if submitted (check here if submitted first submission to HUD) with implementation schedule after HUD approval of grant) as part of pre-award requirements

4. Program Funds (in thousands of $ ) Project Name & Project Category ICDBG Other

(see instructions on back) Amount Requested Other Source Amount Source of Other Funds for each activity for each activity for each activity a b c d

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

OMB Approval No. 2577-0191

xp. 1/30/2015)

* The total of items 5 and 6 cannot exceed 20% of the total ICDBG funds requested.

** 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 assistan ce costs associated with the development of a capacity to undertake a specific funded program activity are eligible (24 CFR 1003.206).

h46246 Text Box Planned ICDBG Expenditures b h46246 Text Box Project Name & Project Category (see instructions on reverse) a h46246 Line h46246 Line h46246 Text Box h46246 Text Box Planned Other Federal Funds Expenditures h46246 Text Box c h46246 Line

Text Box Planned Non-Federal Funds Expenditures h46246 Text Box d h46246 Text Box h46246 Text Box Total Planned Expenditures h46246 Text Box Source of Other Funds for each Activity h46246 Text Box e h46246 Text Box f

Enter totals of columns b, c, and d.

h46246 Text Box Enter sum of columns b, c, and d.

h46246 Rectangle h46246 Text Box

b. Indirect Costs: Enter indirect costs to be charged to the program pursuant to a cost allocation plan.

h46246 Text Box

a. General Management and Oversight.

h46246 Text Box

c. Audit: Enter estimated cost of Program share of financial audits.

h46246 Text Box The Project description must address the h46246 Text Box Enter total amount of h46246 Text Box proposed use of these funds.

ICDBG funds requested for technical assistance. ** h46246 Cross-out h46246 Text Box (exp. 12/31/2024)

H46246

(4/2018)

Previous editions are obsolete form 4123 Page 2 of 2

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 info rmation. 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 the ICDBG Program. 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 prelim inary 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.

Instructions for Item 4.

Project Name and Project Type

Participants enter the project name and the name of one of the following three categories of activities:

• Housing

• Community Facilities

• Economic Development

Also enter the component name if applicable. Use a separate Cost Summary sheet (form HUD-4123) for each project in-cluded in the application.

Examples of categories and/or components including ex-amples of eligible activities are listed below.

Housing

Rehabilitation Component

• Rehabilitation

• Demolition

Land to Support New Housing Component

New Housing Construction Component

Community Facilitites

Infrastructure Component

• Water

• Sewer

• Roads and Streets

• Storm Sewers Buildings Component

• Health Clinic

• Daycare Center

• Community Center

• Multi-purpose Center

Economic Development

• Commercial (wholesale, retail)

• Industrial

• Motel/Hotel

• Restaurant

• Agricultural Development h46246 Text Box Category h46246 Text Box Column 4.a :

h46246 Text Box Column 4.b :

h46246 Text Box Column 4.c :

h46246 Text Box Column 4.d :

h46246 Text Box Enter the amount of ICDBG funds planned for the project.

h46246 Text Box Enter the amount of other Federal funds planned for the project.

h46246 Text Box Enter the amount of non-Federal funds planned for the project.

H46246

(4/2018)