HUD_52768_4_3-V4.3.pdf

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Resident Opportunity and Self-Sufficiency Service Coordinator (ROSS-SC) Program - Fiscal Year 2025
Opportunity number
FR-6900-N-05
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HUD-52768

HUD-52768

HUD-52768

D:20061130151358- 05'00' D:20061130151358- 05'00' OMB Number: 2577-0229 Expiration Date: 08/31/2026 Resident Opportunity & Self-Sufficiency (ROSS) Service Coordinator Funding U.S. Department of Housingand Urban DevelopmentOffice of Public and Indian Housing A. Applicant Type (please check) PART I: General Information ***Please read the ROSS NOFO carefully for instructions for the completion of this form and minimum requirements. *** B. Applicant Legal Name According to UEI (For joint applicants, lead Applicant name):

Street1:

Street2:

City:

County/Parish:

State:

Province:

Country:

Zip / Postal Code:

Address:

UEI Number:

PHA Code(s) affiliated with the applicant’s project(s) to be served (not applicable to Tribes/ TDHEs and Multifamily Owners):

Legal Name of Joint Applicant According to UEI (If applicable):

PHA Code of Joint Applicant:

D. Name of PHA, Tribe/TDHE(s), Multifamily Owner, and/or RA affiliated with the applicant’s project(s) to be served:

E. Are you (the applicant) a renewal applicant according to the terms of the NOFO to which you’re applying?

*If you are a new applicant, and you are a nonprofit organization, you must attach documentation with this application form verifying your nonprofit status.* F. For renewal applicants that are nonprofit organizations:

Title Signature of Authorized Representative I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. 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 five years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802).

PART II: Service Coordinator Information (Budget Form) A. Information Submission for ROSS Service Coordinator Determination HUD will use the information provided in this section to determine the number of ROSS Service Coordinators. To ensure an accurate assessment, all submitted information must be complete and correct.

Instructions:

• Project Number or Unique Project Identifier: Enter the identifier using the required format—two letters followed by nine digits (e.g., SCXXXXXXXXX). Each project number or unique identifier must be fully written out and follow this format.

• Number of Units Served: Confirm that the number of units entered corresponds accurately to the project number or unique identifier.

• RAD-PBRA and RAD-PBV Projects: Enter the former project name(s) and number(s) for each project served.

• Multifamily Owners: Enter the Multifamily Contract Number (PBRA HAP Contract #). Verify that this information is accurate.

SC positions requested Project number or unique project identifier to be served (2 alpha and 9 digits entry. Example: SCXXXXXXXXX) Number of units to be served(See NOFO for minimum number of units.)

Type of unit to be served (See NOFO for type of unit definition.)

For RAD-PBRA and RAD-PBV, enter the former project name(s) and number(s) from PIC for each project served For Multifamily Owners, enter the Multifamily Contract Number (PBRA HAP contract number) Area(s) of Need for your ROSS Program Year Salary/Fringe Request(See NOFO for limits.)

Admin Request(See NOFO for limits.)

Training/Travel Request(See NOFO for limits.)

PART III: Salary Comparability Applicants' salary requests are subject to salary comparability requirements as prescribed in the most recent ROSS NOFO. Salary requests must be based on local comparability information and support the amount requested for salary and fringe to similar positions in the local jurisdiction. Please review the most recent ROSS NOFO carefully for further instructions on completing the information below.

Salary Comparability Occupation Title Annual Salary Fringe Benefits Total Amount (Annual + Fringe Benefits) Source/ Employer Name Name of Agency Point of Contact (POC) Prefix First Middle Last Suffix POC Email Address POC Telephone Number PART IV: Match Match for the ROSS program should represent the needs assessed. Provide the need that you are proposing to meet, the source and value of the match. All applicants are required to have in place a firmly committed match contribution equivalent to 25 percent of the total grant amount being requested in order to be considered for ROSS funding. Match is a NOFO threshold requirement.

***Please read the ROSS NOFO carefully for instructions and minimum requirements.*** Area of Need that Match Will Address Service to be Provided Source of Match Value of Match A.

B. Match is % of grant requested (must be at least 25% to qualify) Total Match C. I certify that the match recorded here is supported by letters on file from community or other partners which certify to this amount of match funding (cash or in-kind) and that this represents the total match for the term of the grant.

I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. 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 five years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802).

Signature of Authorized Representative Title Please attach with this form:

Renewal Applicants:

• Narrative Statement New Applicants:

• Narrative Statement

• Nonprofit Status (if applicable) Nonprofit Organizations:

• Letter of Support from the PHA, tribe/TDHE, or RA Joint Applicant(s):

• Letter of Support from Joint Applicant(s) PHAS Troubled:

• Contract Administrator Partnership Agreement Resident Associations:

• Contract Administrator Partnership Agreement Multifamily Owners:

• Housing Assistant Payment (HAP) Contract Tribes Designated High-Risk:

• Narrative Statement Applicants requesting an additional Service Coordinator (see NOFO for eligibility):

• Map ***Please see NOFO for all other forms your complete application must include.*** Signature of Authorized Representative Title Applicant Legal Name (For joint applicants, lead Applicant name): Enter the Applicant Legal Name. For joint applicants, lead Applicant name. This field is required.

Street1: Enter the first line of the street address. This field is required.

Street2: Enter the second line of the street address.

City: Enter the city. This field is required.

County/Parish: Enter the County/Parish.

State: Select the State. This field is required if Country is the United States.

Province: Enter the Province.

Country: Select the Country. This field is required.

Zip / Postal Code: Enter the Zip / Postal Code. This field is required if Country is the United States.

Invalid UEI Number: Enter the UEI.

UEI Number: Enter the UEI. This field is required.

PHA Code (s) to be served (not applicable to Tribes/ TDHEs): Enter the PHA Code (s).

Title: Enter the position title. This field is required.

I certify the nonprofit status for is in current and in good standing.

1.

2.

3.

Title: Enter the position title. This field is required.

XDPFirstField:
Mandatory:
Burden Statement:

Public reporting burden for the collection of information is estimated to average 4 hours per response. This includes the time for collecting, reviewing, and reporting the data. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden the Reports Management Officer, REE, Department of Housing and Urban Development, 451 7th Street SW, Room 8210, Washington, DC 20410–5000. When providing comments, please refer to OMB Control No. 2577-0229. The information will be used to determine eligibility for the Resident Opportunity and Self-Sufficiency (ROSS) Service Coordinator (SC) grant. Response to this request for information is required in order to receive the benefits to be derived. 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 information does not lend itself to confidentiality.:

BSt:
Applicant Type is required.:
Applicant Type: A selection is required.

Public Housing Authority (PHA): Click to select this option.:

PHA Type is required.:
PHA Type: A selection is required.

Region-Wide PHA: Click to select this option.:

State: Pre-populated from the Application cover sheet. This field is required if Country is the United States.:
Applicant Type: A selection is required.

Tribe/ Tribally Designated Housing Entity (TDHE): Click to select this option.:

Applicant Type: A selection is required.

Resident Association (RA): Click to select this option.:

Applicant Type: A selection is required.

Multifamily Owner : Click to select this option.:

Applicant Type: A selection is required.

501(c)(3) Nonprofit applicant (Not a RA): Click to select this option.:

RA Type is required.:
RA Type: A selection is required.

Site Based RA: Click to select this option.:

RA Type: A selection is required.

Non- Site Based RA: Click to select this option.:

PHA nonprofit affiliate/instrumentality: Click to select this option.:
Legal Name of Joint Applicant According to UEI (If applicable): Enter information only if you are applying jointly.:
Street1: Pre-populated from the Application cover sheet. This field is required.:
Street2: Pre-populated from the Application cover sheet.:
City: Pre-populated from the Application cover sheet. This field is required.:
County/Parish: Pre-populated from the Application cover sheet. :
Province: Pre-populated from the Application cover sheet. :
Country: Pre-populated from the Application cover sheet. This field is required.: USA: UNITED STATES
Zip / Postal Code: Pre-populated from the Application cover sheet. This field is required if Country is the United States. :
UEI Number: Pre-populated from the Application cover sheet. This field is required.:
PHA Code(s) affiliated with the applicant’s project(s) to be served

(not applicable to Tribes/ TDHEs and Multifamily Owners): Forward populated from Federal Entity Identifier on the SF424.:

DataEntered:
Delete: Click to delete this entry.:
PHA Code of Joint Applicant: Enter the PHA Code of the joint applicant.:
C:
Add Joint Applicant:
Enter name of PHA, Tribe/TDHE(s), Multifamily Owner, and/or RA affiliated with the applicant’s project(s) to be served. This field is required.:
Are you (the applicant) a renewal applicant according to the terms of the NOFO to which you’re applying is required: Select yes or no.:
Are you (the applicant) a renewal applicant according to the terms of the NOFO to which you’re applying - Yes: A selection is required. Select yes or no.:
Are you (the applicant) a renewal applicant according to the terms of the NOFO to which you’re applying - No: A selection is required. Select yes or no.:
Authorized Representative Title: Enter the title. This field is required.:
ApplicantLegalName1:
Signature of Authorized Representative: Enter the applicant's signature. This field is required.:
ApplicantLegalName:
Are you (the applicant) a renewal applicant according to the terms of the NOFO to which you’re applying - Yes: A selection is required. Select yes or no.:
T394:
Project(s) to be served: Enter the identifier using the required format—two letters followed by nine digits (e.g., SCXXXXXXXXX). Each project number or unique identifier must be fully written out and follow this format. See NOFO for more details. This field is required for each entry.:
Number of units to be served: Enter the number of units. See NOFO for minimum number of units. This field is required for each entry.:
Type of unit to be served: A selection is required.:
Former Project: For RAD-PBRA and RAD-PBV, enter the former project name(s) and number(s) from PIC for each project served.:
Multifamily Contract Number: For Multifamily Owners, enter the Multifamily Contract Number (PBRA HAP contract number) :
Add Additional Need:
Area(s) of Need for your ROSS Program is required.:
Area(s) of Need for your ROSS Program: A selection is required.

Digital Opportunity: Click to select this option.:

Area(s) of Need for your ROSS Program: A selection is required.

Education: Click to select this option.:

Area(s) of Need for your ROSS Program: A selection is required.

Financial Literacy: Click to select this option.:

Area(s) of Need for your ROSS Program: A selection is required.

Health & Wellness: Click to select this option.:

Area(s) of Need for your ROSS Program: A selection is required.

Employment: Click to select this option.:

Area(s) of Need for your ROSS Program: A selection is required.

Elderly/Disabled: Click to select this option.:

Area(s) of Need for your ROSS Program: A selection is required.

Reentry: Click to select this option.:

Area(s) of Need for your ROSS Program: A selection is required.

Substance Abuse: Click to select this option.:

Year: This is a calculated field.:
Salary/Fringe Request: Enter the salary/fringe request. See NOFO for limits. This field is required for each entry.:
Admin Request: Enter the admin request. See NOFO for limits. This field is required for each entry.:
Training/Travel Request: Enter the training/travel request. See NOFO for limits. This field is required for each entry.:
Total Grant Requested: Total Grant Requested should be the same as 18a from SF 424. This is a calculated field.:
Total Salary/Fringe Request: This is a calculated field.:
Total Admin Request: This is a calculated field.:
Total Training/Travel Request: This is a calculated field.:
Occupation Title: Enter the occupation title.:
Annual Salary: Enter the salary.:
Fringe Benefits: Enter the fringe benefits.:
Total Amount (Annual +Fringe Benefits): This is a calculated field.:
Source/ Employer Name: Enter the source.:
Prefix: Enter the prefix (e.g., Mr., Mrs., Rev.) for the name of the Agency Point of Contact (POC).:
First Name: Enter the first name of the Agency Point of Contact (POC).:
Middle Name: Enter the middle name of the Agency Point of Contact (POC).:
Last Name: Enter the last (family) name of the Agency Point of Contact (POC).:
Suffix: Enter the suffix (e.g., Jr., Sr., Ph.D) for the name of the Agency Point of Contact (POC).:
POC Email Address: Enter a valid email address.:
POC Telephone Number: Enter the telephone number.:
Area of Need that Match Will Address: Select the area of need that match will address. This field is required for each entry.:
Service to be Provided: Enter the service to be provided. This field is required for each entry.:
Source of Match: Enter the source of the match. This field is required for each entry.:
Value of Match: Enter the value of the match. This field is required for each entry.:
Total Match: This is a calculated field.:
Invalid Match Percent: Percentage of grant requested. Must be 25% to qualify. This is a calculated field.:
Match Percent: Percentage of grant requested. Must be 25% to qualify. This is a calculated field.: 0
Signature:
Narrative Statement - View Attachment:
Narrative Statement - Delete Attachment:
Narrative Statement - Add Attachment: Click to add an attachment.:
Narrative Statement: Attach a file using the appropriate buttons.:
FileName:
MimeType:
href:
hashAlgorithm:
HashValue_data:
Narrative Statement - View Attachment:
Narrative Statement - Delete Attachment:
Narrative Statement - Add Attachment: Click to add an attachment.:
Narrative Statement: Attach a file using the appropriate buttons.:
Nonprofit Status (if applicable) - View Attachment:
Nonprofit Status (if applicable) - Delete Attachment:
Nonprofit Status (if applicable) - Add Attachment: Click to add an attachment.:
Nonprofit Status (if applicable): Attach a file using the appropriate buttons.:
Letter of Support from the PHA, tribe/TDHE, or RA - View Attachment:
Letter of Support from the PHA, tribe/TDHE, or RA - Delete Attachment:
Letter of Support from the PHA, tribe/TDHE, or RA - Add Attachment: Click to add an attachment.:
Letter of Support from the PHA, tribe/TDHE, or RA: Attach a file using the appropriate buttons.:
Letter of Support from Joint Applicant(s) - View Attachment:
Letter of Support from Joint Applicant(s) - Delete Attachment:
Letter of Support from Joint Applicant(s) - Add Attachment: Click to add an attachment.:
Letter of Support from Joint Applicant(s): Attach a file using the appropriate buttons.:
Contract Administrator Partnership Agreement - View Attachment:
Contract Administrator Partnership Agreement - Delete Attachment:
Contract Administrator Partnership Agreement - Add Attachment: Click to add an attachment.:
Contract Administrator Partnership Agreement: Attach a file using the appropriate buttons.:
Contract Administrator Partnership Agreement - View Attachment:
Contract Administrator Partnership Agreement - Delete Attachment:
Contract Administrator Partnership Agreement - Add Attachment: Click to add an attachment.:
Contract Administrator Partnership Agreement: Attach a file using the appropriate buttons.:
Housing Assistant Payment (HAP) Contract - View Attachment:
Housing Assistant Payment (HAP) Contract - Delete Attachment:
Housing Assistant Payment (HAP) Contract - Add Attachment: Click to add an attachment.:
Housing Assistant Payment (HAP) Contract: Attach a file using the appropriate buttons.:
Narrative Statement - View Attachment:
Narrative Statement - Delete Attachment:
Narrative Statement - Add Attachment: Click to add an attachment.:
Narrative Statement: Attach a file using the appropriate buttons.:
Map - View Attachment:
Map - Delete Attachment:
Map - Add Attachment: Click to add an attachment.:
Map: Attach a file using the appropriate buttons.:
LastField:

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