50153.pdf

form HUD 50153 (09/2014)

Public Reporting Burden Statement: This collection of information is estimated to average 0.25 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 the requested information. Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to:

U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, R, 451 7th St SW, Room 8210, Washington, DC 20410-

5000. Do not send completed forms to this address. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid OMB control number. This agency is authorized to collect this information under Section 102 of the Department of Housing and Urban Development Reform Act of 1989. The information you provide will enable HUD to carry out its responsibilities under this Act and ensure greater accountability and integrity in the provision of certain types of assistance administered by HUD.

This information is required to obtain the benefit sought in the grant program. Failure to provide any required information may delay the processing of your application and may result in sanctions and penalties including of the administrative and civil money penalties specified under 24 CFR §4.38.

This information will not be held confidential and may be made available to the public in accordance with the Freedom of Information Act (5 U.S.C.

§552). The information contained on the form is not retrieved by a personal identifier, therefore it does not meet the threshold for a Privacy Act

Statement.

I/We, the undersigned, certify under penalty of perjury that the information provided below is true, correct, and accurate. 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, 1014; 31 U.S.C. §

3729, 3802; 24 CFR § 28.10(b)(iii)).

I/We, the undersigned, certify that the proposed activities/projects in the application are consistent with the goals of the Promise Zones and the revitalization strategies detailed in my Promise Zone application. (Complete the fields below.)

Applicant Name: ___________________________________________________________________________________

Name of the Federal Program to which the applicant is applying:

Name of the Promise Zone Designated Community:

The proposed project meets the following geographic criteria (please select one):

The proposed project is solely within Promise Zone boundaries.

The proposed project includes the entire Promise Zone boundary and other communities.

The proposed project includes a portion of the Promise Zone boundary.

The proposed project is outside of the Promise Zone boundaries, but specific and definable services or benefits will be delivered within the Promise Zone or to Promise Zone residents.

Please note that projects which substantially and directly benefit Promise Zone residents but which are not within the boundaries of the Promise Zone may be considered. Agencies will make clear the acceptable definition of substantially and directly beneficial in the program’s award and funding announcement.

I further certify that:

(1) The applicant is engaged in activities, that in consultation with the Promise Zone designee, further the purposes of the

Promise Zones initiative; and

(2) The applicant’s proposed activities either directly reflect the goals of the Promise Zone or will result in the delivery of services that are consistent with the goals of the Promise Zones initiative; and

(3) The applicant has committed to maintain an on-going relationship with the Promise Zone designee for the purposes of being part of the implementation processes in the designated area.

Promise Zone Official authorized to certify the project meets the above criteria to receive bonus points:

Name: _________________________________________________ Title: _______________________________________________

Organization: ________________________________________________________________________________________________

Signature: ____________________________________________________________________Date: __________________________

Certification of Consistency with Promise Zone Goals and Implementation

U.S. Department of Housing and Urban Development

OMB Number. 2501-0044 Expiration Date: 2/28/2027