Form HUD-2996.pdf

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form HUD 2996 (5/2025) OZ Certification Form D:20061108133256- 05'00' D:20061108133839- 05'00' OMB Number: 2501-0044 Expiration Date: 02/28/2027 Certification for Opportunity Zones Preference Points U.S. Department of Housing and Urban Development

Type or clearly print the following information.

**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)(1)(iii)).

Applicant Organization:

Assistance Listing number and Federal Program name to which the Applicant is applying:

Include the funding opportunity number and name exactly as it appears in the applicable funding opportunity announcement (example: 14.896, Family Self-Sufficiency Program).

Opportunity Zone Census Tract(s), which the proposed activities/projects will benefit:

Include below the full 11-digit census tract number (example: 06067001101). Designated Opportunity Zone Census Tracts can be found at: https://opportunityzones.hud.gov/resources. Select the “CDFI Fund Opportunity Zones Resources” link and then select the “List of designated Qualified Opportunity Zones.”

The application meets which of the following criteria (please select one):

Note: Projects which substantially and directly benefit Opportunity Zone Census Tracts, but which do not consist of activities delivered within Opportunity Zone Census Tracts may be considered for competitive preference. If applicable, the respective Federal Agency will clearly define “substantially and directly” in the relevant funding announcement.

Estimated Funding Allocations Estimate a percentage of the total dollar amount of awarded federal funding that would result in a direct benefit within the Opportunity Zone Census Tracts listed above:

Provide a narrative explaining and/or reference the section in the application that explains how the project will support public and private investment in urban and economically distressed areas, specifically qualified Opportunity Zones (300-word limit):

Example: “The Main Street project described in this application will stimulate economic opportunity and mobility, encourage entrepreneurship, expand quality educational opportunities, and promote workforce development for those families residing within the XYZ Opportunity Zone.”

Check the following boxes that accurately reflect the nature or purpose of the proposed project:

Certification of Authorized Representative for the Applicant:

**Under penalty of perjury, I certify on behalf of the Applicant that

(1) all information provided on this form is true, complete, and accurate, and

(2) the Applicant will notify the Agency immediately upon learning of any change in the information provided on this form, and

(3) I am authorized to speak for the Applicant regarding all information provided on this form.

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:

Organization:

Signature:

Date:

Applicant Organization: Enter the organization name. This field is required.

Federal Program: Enter the name of the federal program to which the applicant is applying.

Prefix: Select the prefix of the authorized representative from the provided list or enter a new prefix not provided on the list.

First Name: Enter the authorized representative first name. This field is required.

Middle Name: Enter the authorized representative middle name.

Last Name: Enter the authorized representative last name. This field is required.

Suffix: Select the suffix of the authorized representative from the provided list or enter a new suffix not provided on the list.

Title: Enter the authorized representative title. This field is required.

Organization: Enter the organization name. This field is required.

76% - 100%: Check to select.:

Estimated Funding Allocations: Estimate a percentage of the total dollar amount of awarded federal funding that would result in a direct benefit within the Opportunity Zone Census Tracts listed above. One selection is required.

51% - 75%: Check to select.:

Estimated Funding Allocations: Estimate a percentage of the total dollar amount of awarded federal funding that would result in a direct benefit within the Opportunity Zone Census Tracts listed above. One selection is required.

26% - 50%: Check to select.:

11% - 25%: Check to select.:

Estimated Funding Allocations: Estimate a percentage of the total dollar amount of awarded federal funding that would result in a direct benefit within the Opportunity Zone Census Tracts listed above. One selection is required.

1% - 10%: Check to select.: