HUD 2996.pdf

form HUD 2996 (5/2025)

Public Reporting Burden Statement: This collection of information is estimated to average 0.20 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 this Agency to carry out its responsibilities under this Act and ensure greater accountability and integrity in the provision of certain types of assistance administered by this

Agency. The information collected via this form 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 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 collected via this form is not retrieved by a personal identifier, therefore it does not meet the threshold for a Privacy Act Statement.

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):

The proposed activities/projects will occur solely within the Opportunity Zone Census Tract(s) listed above.

The proposed activities/projects will occur within the Opportunity Zone Census Tract(s) listed above and other communities.

The proposed activities/projects will occur outside Opportunity Zone Census Tracts, but substantial and direct benefits will accrue within the Opportunity Zone Census Tracts listed above.

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 federal funding awarded that would result in a direct benefit within the Opportunity

Zone Census Tracts listed above:

76% - 100%

51% - 75%

26% - 50%

11% - 25%

1%- 10%

Certification for Opportunity Zones Preference Points

U.S. Department of Housing and Urban Development

OMB Number. 2501-0044 Expiration Date: 2/28/2027 https://opportunityzones.hud.gov/resources form HUD 2996 (5/2025)

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:

Access to Capital

Asset Building

Business Assistance

Community Capacity Building

Economic Development

Education

Healthy Food Access

Health

Housing

Human Services and Family Support

Community Infrastructure

Public Safety

Workforce Development

Low Income Housing Tax Credit (LIHTC) or other rent restricted housing

Market rate housing

Industrial development

Commercial or retail development

Other business development

"Above ground" infrastructure — streets, sidewalks, lighting

"Below ground" infrastructure — water, sewer, gas, electric

Schools or other educational facilities

Hospitals or other health care facilities

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 Initial: Last Name: Suffix:

Title: Organization:

Signature: _________________________________________ Date: