HUD-53233_Key-Eligibility-Data.pdf

Choice Neighborhoods Implementation Grants U.S. Department of Housing and Urban Development OMB Approval No. 2501-0044

Key Eligibility Data Form (exp. 2/28/2027)

I. ELIGIBLE NEIGHBORHOOD

Name of Neighborhood

II. ELIGIBLE APPLICANT

You must provide the following information for the Lead Applicant and, if applicable, the Co-Applicant

Lead Applicant:

Type of Eligible Applicant Public Housing Agency Local Government

(check one) PHA Code:

Mailing Address:

Executive Officer Name & Title:

Telephone: Email:

Primary Contact Name & Title:

Telephone: Email:

Co-Applicant (if any):

Type of Eligible Applicant Public Housing Agency Local Government

(check one) PHA Code:

Mailing Address:

Executive Officer Name & Title:

Telephone: Email:

Primary Contact Name & Title:

Telephone: Email:

Co-Applicant UEI: EIN/TIN:

CHOICE NEIGHBORHOODS IMPLEMENTATION GRANTS APPLICATION INFORMATION

Office of Public and Indian Housing

Public Reporting Burden Statement: This collection of information is estimated to average 0.75 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 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.

HUD Form 53233 (5/2025)

PRINCIPAL TEAM MEMBERS

Housing Implementation Entity:

Mailing Address:

Executive Officer Name & Title:

Telephone: Email:

Primary Contact Name & Title:

Telephone: Email:

People Implementation Entity:

Mailing Address:

Executive Officer Name & Title:

Telephone: Email:

Primary Contact Name & Title:

Telephone: Email:

Neighborhood Implementation Entity:

Mailing Address:

Executive Officer Name & Title:

Telephone: Email:

Primary Contact Name & Title:

Telephone: Email:

III. ELIGIBLE TARGET HOUSING

Project #1

Project Name:

PIC AMP Number:

Physical Street Address

(include city, state and ZIP)

Unit Information as of Application Date

Total Number of Units in Project Number Occupied

Number of Public Housing Units in Project Number Vacant

Project #2 (if applicable)

Project Name:

PIC AMP Number:

Physical Street Address (include city, state and ZIP)

Unit Information as of Application Date Total Number of Units in Project Number Occupied

Number of Public and/or Assisted Units in Project Number Vacant

Project #3 (if aplicable)

Project Name:

PIC AMP Number:

Physical Street Address

(include city, state and ZIP)

Unit Information as of Application Date

Total Number of Units in Project Number Occupied

Number of Public and/or Assisted Units in Project Number Vacant

Your application must focus on severely distressed public housing. See Appendix for defintions of "public housing" and "severely distressed housing."

Provide the following information for each target housing project. List each site separately.