Louisiana Office of Community Development
Disaster Recovery Unit
Application Forms and Instructions for the
Long Term Community Recovery Program
(December 2007, Revised November 2011 )
Office of Community Development, Disaster Recovery Unit
Post Office Box 94095
Baton Rouge, Louisiana 70804-9095
Phone (225) 219-9600 Fax (225) 219-9605
http://www.doa.louisiana.gov/cdbg/drhome.htm
Louisiana Relay Service
Information (800)333-0605
Voice User (800)947-5277
TDD User (800)846-5277
Eligible and Ineligible Activities for the Long Term Community Recovery Program
All activities funded by the Long Term Community Recovery Program must be hurricane
recovery related projects. Basic eligible activities under the CDBG program are
identified in Title 24, Sections 570.201 and 570.482 of the Code of Federal Regulations.
In accordance with Action Plan Amendment No. 12, eligible activities for this program
include, but are not limited to the following, to the extent that those activities are
recovery related and part of the recovery plan for a grantee:
acquisition of real property
public facilities and improvements
clearance, rehabilitation, reconstruction, and construction of buildings
removal of architectural barriers to access by the elderly and handicapped
disposition of real property, including costs associated with maintenance and
transfer of acquired properties
provision of public services, such as job training
payment of the non-federal share of other federal matching grant programs
relocation associated with projects that utilize one or more of the other eligible
activities listed here
activities carried out through nonprofits
assistance to neighborhood-based organizations, local development corps, and
nonprofits serving the developing needs of communities
energy efficiency/conservation programs
Ineligible activities are identified in Section 570.207. These may be viewed online at
http://www.access.gpo.gov/nara/cfr/waisidx_04/24cfr570_04.html .
Standard Application Forms
Only applications submitted on the standard forms included herein will be accepted.
Additional application forms are available from the Division of Administration, Office
of Community Development, Disaster Recovery Unit, Post Office Box 94095, Baton
Rouge, Louisiana 70804-9095. Telephone number (225) 219-9600 or 866-272-3587,
(800) 846-5277 (TTY Users), (800) 947-5277 (Voice Users). The application package is
also available on the Internet at http://www.doa.louisiana.gov/cdbg/DRInfra.htm .
Eligible Applicants to the Long Term Community Recovery Program
Eligible applicants are municipalities and parish governments located in the most
severely impacted areas of the State. Those areas have been determined to be located
in the following parishes: Acadia, Allen, Beauregard, Calcasieu, Cameron, East Baton
Rouge, Iberia, Jefferson, Jefferson Davis, Lafayette, Lafourche, Livingston, Orleans,
Plaquemines, St. Bernard, St. Charles, St. John the Baptist, St. Mary, St. Tammany,
Tangipahoa, Terrebonne, Vermilion, and Washington.
Federal and State Statutes and Regulations That Apply to the Long Term
Community Recovery Program
The following regulations apply to the Long Term Community Recovery Program and
should be considered in the preparation of applications.
Uniform Act (Acquisition and Relocation) – Requires appraisals for all acquisition
(valued over $10,000) undertaken in connection with activities included in the
application, including easements/servitudes for public facilities. The local governing
body is required to pay at least fair market value for all properties acquired. Acquisition
must be completed before construction begins. Acquisition and relocation can be very
time consuming; the program time schedule should be developed accordingly.
Davis-Bacon and Contract Work Hours and Safety Standards – Requires that Federal
prevailing wage rates are paid to all employees working under a construction contract of
$2,000 or more. Also, all employees must be paid at least time and a half for any time
they work more than forty hours per week. The Federal Labor Standards Provisions
and the applicable federal wage decision(s) must be included in bid packages and
contract documents as well as referenced in all bid advertisements. Prevailing wage
rates are higher than regular wages in many rural areas and may affect the project
budget.
Audit Requirements – OMB Circular A-133 requires single audits of all grantees that
have total annual federal expenditures in excess of $500,000. Financial audits and/or
certifications are required in accordance with State law when the grantee has annual
federal expenditures totaling less than $500,000. Single audit costs may be eligible for
reimbursement in part as an administrative expense.
Architectural Barriers Act – Requires that all non-residential structures and public
facilities constructed, renovated, or rehabilitated with federal funds be accessible to the
handicapped. Entrances must be ramped, bathrooms must accommodate wheelchairs,
etc.
Each project funded must meet the Benefit to Low and Moderate Income Persons,
Elimination of Slum and Blight, or Urgent Need national objective.
To be eligible for these funds, each project must be in compliance with all CDBG
regulations. Areas that require specific attention by the applicant include those
regarding HUD environmental clearance regulations, those related to labor standards
compliance (especially the Davis-Bacon requirements), and adherence to state and
federal procurement regulations.
One original and one copy of the completed application must be submitted to the
address below. Submittal of an incomplete application may result in the application
being rejected and/or a delay in the funding of the project.
Mail to:
Deliver to:
Division of Administration
Division of Administration
Office of Community Development
Office of Community Development
Post Office Box 94095
150 North Third Street, 5th Floor
Baton Rouge, LA 70804-9095
Baton Rouge, LA 70801
All funds to be used in conjunction with each project must be identified.
Disaster Recovery Unit
Disaster Recovery Unit
Checklist for Long Term Community Recovery Applications
This checklist is to be used during the preparation of the application; however it should
not be included in the submitted application. All forms listed are required for Long Term
Community Recovery Applications.
FORM
Page No.
Completed
General Description Form
Budget/Cost Summary Form
Supplemental Information Form
CDBG Program Schedule
Activity Beneficiary Form
Target Area Map(s)
Project Description
Architect/Engineer’s Cost Estimate
Project Maps
Other Funds Supplemental Documentation
Proofs of Publication
Statement of Assurances
Disclosure Report
 
OCD/DRU DISASTER RECOVERY APPLICATION
FOR Long Term Community Recovery
General Description Form
Place a check mark in the appropriate box:
Original Application
Amended Application
A pplicant Name, Address, Phone and Fax Numbers:
Project Name:
Applicant’s Contact Person Name, Address, Phone
Number and Email Address:
Name, Address, Phone Number and Email Address of
Administrative Consultant: (if applicable)
Name, Address, Phone Number and Email Address
of Architectural/Engineering Firm:
National Objective to be addressed (check one).
_____ Activities Benefiting Low/Moderate
Income Persons
_____ Prevention/Elimination of Slums or Blight
_____ Urgent Needs
Project Funds
Amount
Source and Status of Funds
CDBG
$
Local Funds
$
Private Funds
$
Other State Funds
$
Federal Funds
$
Other Funds
$
TOTAL FUNDS
$
Signature (Chief Elected Official) and Date Signed
Typed Name/Title (Chief Elected Official)
 
General Description Form Instructions
Mark the appropriate box at the top of the form to indicate whether this is the original
application or an amended application. An amended application must be submitted
each time there is a change to the project.
In the Applicant Name box indicate the name, address, phone and fax numbers of the
entity requesting funds (ex: City of Lake Charles).
In the Project Name box indicate the name of the project (ex: Improvements to Fire
Station No. 4).
In the Applicant’s Contact Person box indicate the name, address, phone number and
e-mail address of the person in the applicant’s office to be contacted regarding this
application.
In the Administrative Consultant box indicate the name, address, phone number and
e-mail address of the Administrative Consultant for this project if one was hired by the
applicant.
In the Architectural/Engineering Firm box indicate the name, address, phone number
and e-mail address of the architectural/engineering firm for this project if one was hired
by the applicant.
In the National Objective box indicate which national objective will be addressed by the
project.
Indicate the total dollar amount of Project Funds expected from each funding source.
Round all amounts to the nearest dollar. The TOTAL FUNDS amount should equal the
total project cost. Identify the funding source and the status of each of those funds
(committed, applied for, etc.).
The applicant’s Chief Elected Official must sign and date the form. Type the Chief
Elected Official’s name and title in the appropriate box.
BUDGET/COST SUMMARY FORM
PROJECT NAME:
(A) Costs by Activity
(B) CDBG
(C) Other
(D) Total
(E) Source
1. Acquisition of Real Property
2. Public Facilities and Improvements
3. Rehabilitation Loans and Grants (Hook-ups)
4. Clearance Activities
5. Public Services
6. Other (identify)
7. Administration
TOTAL
Architectural/Engineering (A/E) costs must be included in one of the activity costs above.
Budget/Cost Summary Form Instructions
Include the Project Name above the table.
Column A: Eligible activities are listed in the section entitled, “Eligible and Ineligible
Activities for the Long Term Community Recovery Program” shown at the beginning
of this document. Definitions of these activities may be found in 24 CFR 570.201.
The link to these definitions is:
http://www.access.gpo.gov/nara/cfr/waisidx_04/24cfr570_04.html.
Columns B-E: For each activity, complete each applicable cost column. Be sure
to include all costs related to an activity in the cost columns. For example, if the
proposed activity involves construction improvements to a building, the A/E design
costs, construction costs, construction observation costs, etc. must be included in
the in the “Public Facilities and Improvements” column .
SUPPLEMENTAL INFORMATION
PRJECT E
1. Identify the name, telephone and district # of the State Senator(s) representing your jurisdiction.
Name
Senate istrict #
2. Identify the name, telephone and district # of the State Representative(s) representing your jurisdiction.
Name
Representative istrict #
3. Identify the U.S. Congressman representing your jurisdiction and congressional district number.
Name
Congressional District #
4. Target Area Census Tract(s): ________________________________________________________
5. Indicate by means of an “x” as to whether the proposed project will involve a community-wide project
or a target area(s) and enter the zip code of the project. If a target area is involved, enter the name(s)
and zip code of the target area(s).
Community-wide (zip code ___________________ ) Target area(s)
name & zip of target area
name & zip of target area
name & zip of target area
6. Provide Lat/Long for the project location at or near geographical center:
Latitude: _______________ Longitude: _______________
Community-wide projects should use the zip code of the location of city hall. Target-area projects should use
the zip code of the target area where the majority of the construction funds will be spent (for each target area).
If the target area(s) does not have a name, please provide a brief geographical description of the area such as
“western portion of the city”. The following websites can assist in searching for this information:
http://www.louisiana.gov/wps/wcm/connect/Louisiana.gov/Government/Legislative+Branch/ ,
http://www.census.gov/ , and http://factfinder.census.gov/home/saff/main.html .
name & zip of target area
Supplemental Information Instructions
Item 1: Enter the name, telephone number, and district number of each State Senator
representing the local governing body for community-wide projects. If the project
involves a target area(s), enter the names of only those State Senators
representing the target area(s).
Item 2: Enter the name, telephone number, and district number of each State
Representative representing the local governing body for community-wide projects.
If the project involves a target area(s), enter the names of only those State
Representatives representing the target area(s).
Item 3: Enter the name and district number of each Congressman representing the local
governing body. The information required above can be found at
http://www.legis.state.la.us/ .
Item 4: Enter the Census Tract number(s) of the physical location of the project (Target
Area). This information can be found by entering your street address at the
following web site: http://www.census.gov/main/www/cen2000.html
Item 5: Indicate by means of an “x” whether the proposed project will involve a community-
wide project or a target area(s) and enter the zip code of the project. If a target
area is involved, enter the name(s) and zip code of the target area(s). Community-
wide projects should use the zip code of the location of city hall. Target-area
projects should use the zip code of the target area where the majority of the
construction funds will be spent (for each target area). If the target area(s) does
not have a name, please provide a brief geographical description of the area such
as “western portion of the city”.
The following websites can also be helpful in searching for the some of the above
information: http://www.census.gov/ and
http://factfinder.census.gov/home/saff/main.html .
CDBG PROGRAM TIME SCHEDULE APPLICANT NAME:
ACTIVITIES
Quarter
1
Quarter
2
Quarter
3
Quarter
4
Quarter
5
Quarter
6
Quarter
7
Quarter
8
Quarter
9
Quarter
10
Quarter
11
Quarter
12
Activity #1
Milestones
a.
b.
c.
d.
e.
Activity #2
Milestones
a.
b.
c.
d.
e.
Activity #3
Milestones
a.
b.
c.
d.
e.
Activity #4
Milestones
a.
b.
c.
d.
e.
CDBG Time Schedule Instructions
The CDBG program may have a duration period up to three year (twelve
quarters). On this schedule, for each major activity, indicate when completion
of major project milestones is expected. For example, milestones could be
acquisition of easements, engineering, bid advertisement/award, construction,
acceptance of work, and release of liens.
Consider the activities and decide what major tasks must be accomplished to
complete them. List these tasks as milestones under each activity. Then
indicate by lines on the twelve quarter schedule showing when these tasks will
occur. For each activity also estimate projected expenditures by dollar
amount for each quarter. The expenditures should reflect all funds
(CDBG and other) being used to complete the activity. Distinguish
between the funds by source and amount.
If more space is needed, attach additional sheets.
When completing this form, identify each activity as it corresponds to the line
items shown on the Budget/Cost Summary Form. For example, the
completion of a sewer project could involve the activities of acquisition (#1,
Acquisition of Real Property), sewer system construction (#2, Public Facilities
and Improvements), and the construction of sewer service lines on private
property (#5, Rehabilitation Loans and Grants (Hook-ups)).
ACTIVITY BENEFICARY FORM
Community-Wide Target Area Combined
P roject:
List name of each activity excluding Admin & Acquisition:
1)
2 )
3 )
#
%
#
%
#
%
Families (total):
Elderly Head of Family:
Female Head of Family:
Handicapped Head of Family:
Persons (total):
Total Mod/Low/ExLow Income:
Moderate Income:
Owner ( for Rehab activity only , i.e. hookups ):
Renter (for Rehab activity only , i.e. hookups):
Low Income:
Owner ( for Rehab activity only , i.e. hookups ):
Renter (for Rehab activity only , i.e. hookups):
Extremely Low Income:
Owner ( for Rehab activity only , i.e. hookups ):
Renter (for Rehab activity only , i.e. hookups):
Elderly:
Handicapped:
Race and Ethnicity
Of Total #, Of Total #, Of Total #,
Race Indicate # Race Indicate # Race Indicate #
Total # Hispanic* Total # Hispanic* Total # Hispanic*
American Indian or Alaskan Native:
Asian:
Black or African American:
Native Hawaiian or Other Pacific Islander :
White:
Am. Indian or Alaskan Native and White:
Asian and White:
Black or African American and White:
Am. Indian or Alaskan Native and Black:
Other Multi-racial:
* Hispanic or Latino
Activity Beneficiary Form Instructions
This form must be completed for all proposed activities. Each activity must be listed
separately. For example, sewer projects involving hook-ups must identify the
beneficiaries of sewer, and rehabilitation loans and grants (hook-ups) by each separate
activity. Attach additional forms if needed.
If there is more than one target area, then the low and moderate income information must be
determined for each target area independently of the others. An Activity Beneficiary form for
each target area and an additional form with combined totals from the target areas must be
submitted.
The information needed for this form will be taken from census data. The applicant must
utilize census data. Census data by parish for the logical record numbers has been made
available on spreadsheets compiled by the Office of Community Development. The
information on the spreadsheets are sorted by (1) census tract and block group order, (2) by
incorporated areas (and census defined places) and unincorporated areas, and (3) by
census tracts. Also included are the logical record numbers for these areas. The
spreadsheets can be accessed on the office website, or can be emailed. The spreadsheets
contain a copy of the Activity Beneficiary Form and it can be completed by copying
information from the spreadsheets. A tutorial is also provided at
http://www.doa.state.la.us/cdbg/LOGRECNO_index.htm . Please contact the Office of
Community Development, Disaster Recovery Unit, Infrastructure Section for assistance.
When a project area does not coincide with census tracts, block groups, or logical record
numbered areas, the applicant must perform a best match estimate to determine
beneficiaries.
The appropriate box in the top left corner of the Activity Beneficiary form that corresponds to
the data included on each form submitted, i.e. Community-Wide Target Area
Combined must be properly marked. In the space provided following “Target Area”, indicate
target area (1, 2, etc.) to which the data on the form corresponds.
The following definitions must be used when completing this form.
Household – a dwelling unit and all persons who reside therein. The occupants may
be a single family, one person living alone, unrelated individuals, two families, etc.
Family – all persons living in the same household who are related by blood or contract
(birth, marriage, adoption). In some instances, two families could reside in one
household. Therefore, a household could involve one or more families.
Low/ModerateIncome – persons, families, or households whose combined annual
income does not exceed eighty percent of the parish median income.
ModerateIncome – persons, families, or households whose combined annual income
exceeds fifty percent but does not exceed eighty percent of the parish median income.
LowIncome – persons, families, or households whose combined annual income
exceeds thirty percent but does not exceed fifty percent of the parish median income.
ExtremelyLowIncome – persons, families, or households whose combined annual
income does not exceed thirty percent of the parish median income.
Elderly – persons or head of family aged 62 or above.
Handicapped – persons or head of family receiving disability payments or having an
obvious handicap.
American Indian or Alaskan Native – A person having origins in any of the original
peoples of North and South America (including Central America), and who maintains
tribal affiliation or community attachment.
Asian – A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China,
India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.
Black or African American – A person having origins in any of the black racial groups
of Africa.
Native Hawaiian or Other Pacific Islander – A person having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White – A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin, regardless of race.
Please be aware that if you are using logical record numbers to retrieve your data, the
following categories are not available: American Indian or Alaskan Native and White; Asian
and White; Black or African American and White; and American Indian or Alaskan Native and
Black. In this case, these persons should be included under “Other Multi-racial”.
Please refer to the definitions above concerning the racial/ethnic categories listed in this
section. Enter the number of persons in the appropriate racial category under the “Total”
column. Of the number in the “Total” column, enter the number of persons that are of
Hispanic or Latino ethnicity in the “Hispanic” column.
When identifying the number of persons by income category, each person should be
included in only one category. For example, the number of extremely low income persons
should not be counted in the number of low income persons. Each income category is self-
contained and is not inclusive of other income categories. The number of persons identified
as within moderate income limits, within low income limits, and within extremely low income
limits should equal the total the number of low/moderate income persons.
All activities that have a different number of beneficiaries must be identified separately. For
example, a sewer project with hookups will have beneficiary information for the sewer activity
and for the rehabilitation loans and grants (hookups) activity.
Target Area Maps
A map (or maps) that delineate the following items for each target area must be
included in the application package:
1. census tracts and/or block groups (by number) and/or logical record
numbers;
2. location of concentrations of minorities, showing number and percent by
census tracts and/or block groups, and/or logical record numbers;
3. location of concentrations of low and moderate income persons, showing
number and percent by census tracts and/or block groups and/or logical
record number;
4. boundaries of areas in which the activities will be concentrated; and
5. the specific location of each activity.
PROJECT NAME:
PROJECT DESCRIPTION:
(Use only one sheet per target area)
Project Description Form Instructions
Provide a concise description of the public facilities improvements project for which you
are requesting funds. The description should include the following:
Describe how the proposed improvements are related to disaster recovery.
Show that the project considers and/or proposes a mitigation plan to minimize damage
in the event of future floods or hurricanes.
Identify the proposed improvements, location of the proposed improvements, current
size/capacity of and area served by the system, etc.
Indicate whether the project will require acquisition of property, easements, or rights-of-
way and the approximate number of parcels to be acquired.
Briefly explain the needs to be addressed with the proposed improvements.
Describe how the project relates to existing infrastructure. For example, if you plan to
install new sewage collection lines, then can the treatment plant handle the increase?
Describe how people will benefit from the project and indicate whether the benefits will
be direct and/or indirect. Direct benefits are defined as those that will take place on
private property such as hookups. Provide an estimated number of hookups, if
applicable.
Identify who will retain ownership of the system after the completion of the project.
Describe the method by which the applicant can ensure that adequate revenues will be
available to operate and maintain the proposed project. The description must identify
the source and the estimated amount of funds that will be generated for this purpose.
Describe the physical boundaries of the target area(s) in relation to the beneficiaries of
the project.
ARCHITECT/ENGINEER’S (Refer to the instructions for the specific information that must
COST ESTIMATE be included herein. Attach additional sheets if necessary).
Estimated number of parcels to be acquired:
Anticipated approvals/permits to be acquired:
___________________________________ ____________________
Signature of Date
Licensed Architect/Engineer
 
Architect/Engineer’s Cost Estimate Instructions
All proposed project activities shall be accompanied by a detailed cost estimate
prepared and signed by a Licensed Architect or Professional Engineer licensed in the
State of Louisiana. The cost estimate shall contain the cost of construction,
architectural/engineering fees, and related costs. The construction estimate shall be a
listing of construction items (as a bid proposal), estimated quantity, unit of measure, unit
price, and amount.
Architectural/Engineering fees shall be identified by type in a line item format. Typical
items include basic services, resident project representative, topographic surveying,
property surveying, geotechnical investigation, and testing. Written justification must be
provided for all engineering services other than basic services and resident project
representative. The justification shall contain an explanation of why the service is
needed and how the proposed fee was derived. Please refer to the document entitled,
“Architectural/Engineering Design and Construction Manual for Disaster Recovery
Programs” for more information concerning eligible fees.
If your proposed project involves hookups (water/sewer house connections), then the
costs associated with hookups should be identified separately on your cost estimate.
If any other funds (federal, local, etc.) will be used to complete the project, then the cost
estimate must identify the amount of those funds as well as the specific use of those
funds. For example, if $200,000 in local funds will be used to assist in the construction
of a treatment facility for a new sewerage collection and treatment system, a specific
identification of such must be shown on the cost estimate.
Provide an estimate of the number of parcels that will be needed to be acquired to
construct the proposed improvements.
Provide a listing of anticipated permits and government approvals that may be
necessary.
Examples of cost estimates for a sewer collection system improvements project and a
street improvement project can be found on the following pages.
Example of Cost Estimate – Street Improvements
ARCHITECT/ENGINEER’S (Refer to the instructions for the specific information that must
COST ESTIMATE be included herein. Attach additional sheets if necessary).
CONSTRUCTION:
AMOUNT
Mobilization Lump Lump Sum $ 25,000.00 $ 25,000
Asphaltic Concrete Wearing Course 3,700 Ton $ 80.00 $ 296,000
8-1/2” In-Place Cement Stab. Base Course 35,000 Sq. Yd. $ 6.00 $ 210,000
Water Valve Adjustments 5 Each $ 200.00 $ 1,000
Sewer Manhole Adjustments 10 Each $ 250.00 $ 2,500
Aggregate Surface Course 1,500 Cu. Yd. $ 45.00 $ 67,500
18” Corrugated Metal Pipe 100 Lin. Ft. $ 30.00 $ 3,000
24” Corrugated Metal Pipe 100 Lin. Ft. $ 38.00 $ 3,800
30” Corrugated Metal Pipe 80 Lin. Ft. $ 45.00 $ 3,600
Signs and Barricades Lump Lump Sum $ 8,500.00 $ 8,500
Project Sign 1 Each $ 1,000.00 $ 1,000
Subtotal: $621,900
Contingencies: $62,100
Total Estimated Construction Cost: $684,000
QUANTITY
UNIT OF
MEASURE
UNIT
PRICE
ENGINEERING: Basic Services: $59,100
Resident Project Representative: $25,500
Geotechnical Investigation: $3,000
Testing: $3,750
TOTAL PROJECT COST: $775,350
Estimated number of parcels to be acquired: 0
Anticipated approvals/permits to be acquired: DOTD permit
___________________________________ ____________________
Signature of Date
Licensed Architect/Engineer
DESCRIPTION
JUSTIFICATION FOR ADDITIONAL ENGINEERING FEES
Geotechnical Investigation:
To provide pre-design base testing for lime and cement determination. A
geotechnical engineering firm will provide investigation, recommendations, and
report. The cost is estimated at $3,000.
Testing :
To provide soil proctor tests and in-place density tests for the completed base
course and corings of completed asphaltic concrete pavement.
30 density tests @ $100 each =
$3,000
Total =
$3,750
25 corings @ $30 each =
$ 750
Example of Cost Estimate – Sewer Collection System Improvements
ARCHITECT/ENGINEER’S (Refer to the instructions for the specific information that must
COST ESTIMATE be included herein. Attach additional sheets if necessary).
CONSTRUCTION:
AMOUNT
Mobilization Lump Lump Sum $ 15,000.00 $ 15,000
8” PVC Sewer Main 4,800 Lin. Ft. $ 25.00 $ 120,000
Manholes 20 Each $ 2,000.00 $ 40,000
8” x 8” x 4” Wye 100 Each $ 50.00 $ 5,000
4” Cleanouts and bends 100 Each $ 120.00 $ 12,000
4” Service Line 500 Lin. Ft. $ 10.00 $ 5,000
Jack or Bore 4” Service Line 700 Lin. Ft. $ 22.00 $ 15,400
Lift Station Lump Lump Sum $ 75,000.00 $ 75,000
4” PVC Force Main 2,800 Lin. Ft. $ 7.00 $ 19,600
Maintenance Aggregate 100 Cu. Yd. $ 45.00 $ 4,500
Project Sign 1 Each $ 1,000.00 $ 1,000
Subtotal: $312,500
Contingencies: $31,000
Estimated Cost (Construction): $343,500
QUANTITY
UNIT OF
MEASURE
UNIT
PRICE
AMOUNT
4” Service Line 5,600 Lin. Ft. $ 10.00 $ 56,000
4” Cleanouts and bends 140 Each $ 120.00 $ 16,800
4” Connections 70 Each $ 120.00 $ 8,400
Subtotal: $81,200
Contingencies: $8,000
Estimated Cost (Rehabilitation Loans and Grants): $89,200
QUANTITY
UNIT OF
MEASURE
UNIT
PRICE
TOTAL ESTIMATED CONSTRUCTION COST: $432,700
DESCRIPTION
REHABILITATION LOANS AND GRANTS
DESCRIPTION
Example of Cost Estimate – Sewer Collection System Improvements Cont’d.
ARCHITECT/ENGINEER’S (Refer to the instructions for the specific information that must
COST ESTIMATE be included herein. Attach additional sheets if necessary).
TOTAL ESTIMATED CONSTRUCTION COST: $432,700
ENGINEERING:
Basic Services: $41,700
Resident Project Representative: $19,800
Topographic Surveying: $5,500
TOTAL ENGINEERING: $67,000
ACQUISITION:
Property Acquisition: $4,000
Property Surveying: $2,500
TOTAL ACQUISITION: $6,500
TOTAL PROJECT COST: $506,200
COST-SHARING:
CDBG Funds
Local Funds
Construction
$400,000
$32,700
Engineering
$67,000
-- 0 --
Acquisition
-- 0 --
$6,500
TOTAL
$467,000
$39,200
Estimated number of parcels to be acquired: 1
Anticipated approvals/permits to be acquired: DHH
___________________________________ ____________________
Signature of Date
Licensed Architect/Engineer
JUSTIFICATION FOR ADDITIONAL ENGINEERING FEES
Topographic Surveying :
This project includes the installation of new sewer mains, manholes, and a force
main. A survey is needed to establish benchmarks and to locate topographic
features including utilities in the vicinity of the proposed sewer main alignment.
Survey crew: 5 days @ $1,100 per day = $5,500.
Property Surveying :
Property surveying is needed for the acquisition of a site to construct the new lift
station.
Survey crew: 10 hours @ $110 per hour = $1,000
Draftsman: 10 hours @ $45 per hour = $ 450
Courthouse research: 10 hours @ $50 per hour = $ 500
Land Surveyor: 6 hours @ $75 per hour =
$ 450
Total =
$2,500
Project Map(s)
1.
Existing Conditions Map: Provide a detailed map of the existing improvements.
The map should delineate such items as the location and size of waterlines,
elevated water tanks, sewer lines, manholes, location of treatment plants, etc.
2.
Proposed Improvements Map : Provide a detailed map showing the location,
sizes, etc. of the proposed improvements.
Note : The Existing Conditions map and the Proposed Improvements map may be
combined into one map if all the information shown can be depicted in such a way as to
easily determine the difference between the existing and proposed.
Other Funds Supplemental Documentation
Some projects may cost more than is available under the Long Term Community
Recovery Program. The applicant may propose to use other funds in conjunction with
the CDBG funds. These other funds must be identified and must be available and
ready to spend. If these funds involve loans or grants from other state, federal, or
private sources, the monies must have already been awarded or be in the bank. To
substantiate the immediate availability of the other funds, one of the following items of
supporting documentation will be required: a letter and adopted resolution from the
local governing body stating the specific source, amount, and location of local cash, a
line of credit letter from a financial institution such as a bank stating the amount
available as a loan, specific evidence of funds to be received from a tax or bond election
that has already passed, or a letter from another funding agency stating that the funds
have been awarded and are currently available for expenditure.
Attach the supporting documentation to this application.
Proofs of Publication
A copy of the two public notices and proofs of publication must be included in the
application package. The required content of these notices is explained Section II,
Program Administration, Citizen Participation Requirements.
REVISED APPENDIX A
GRANTEE STATEMENT OF ASSURANCES
This Applicant/Grantee/Subrecipient hereby assures and certifies that:
1. It possesses legal authority to apply for a Community Development Block Grant (“CDBG”)
and to execute the proposed CDBG program.
2. Its governing body has duly adopted, or passed as an official act, a resolution, motion, or
similar action authorizing the filing of the CDBG application and directing and authorizing
the person identified as the official representative of the Applicant/Grantee/Subrecipient to act
in connection with the application, sign all understandings and assurances contained therein,
and to provide such additional information as may be required.
3. It has facilitated citizen participation by providing adequate notices containing the
information specified in the program instructions and by providing citizens an opportunity to
review and submit comments on the proposed application.
4. Its chief executive officer, or other officer or representative of Applicant/Grantee/Subrecipient
approved by the State:
a. Consents to assume the status of a responsible federal official under the National
Environmental Policy Act of 1969 ( 42 U.S.C.A. §4331, et seq.) insofar as the
provisions of such Act apply to the proposed CDBG Program; and
b. Is authorized and consents, on behalf of the Applicant/Grantee/Subrecipient and
himself, to submit to the jurisdiction of the federal courts for the purpose of
enforcement of Applicant/Grantee/Subrecipient’s responsibilities and his or her
responsibilities as an official.
5. It will develop the CDBG program and use CDBG funds so as to give maximum feasible
priority to activities that will benefit low and moderate income families, aid in the prevention
or elimination of slums or blight, or meet other community development needs having a
particular urgency.
6. It will comply with the following applicable federal grant management regulations, policies,
guidelines, and/or requirements as they relate to the application, acceptance, and use of
federal funds: OMB Circular A-87 (Cost Principles for State, Local and Indian Tribal
Governments) as amended and made part of State regulations; A-102 (Grants and Cooperative
Agreements with State and Local Governments), as amended and made part of State
regulations; OMB Circular A-133 (Audits of States, Local Governments, and Non-Profit
Organizations), revised; OMB Circular A-21 (Cost Principles for Educational Institutions); A-
122 (Cost Principles for Non-Profit Organizations); 24 CFR Part 85 (Administrative
Requirements for Grants and Cooperative Agreements to State, Local and Federally
Recognized Indian Tribal Governments) and 24 CFR Part 84 (Uniform Administrative
Requirements For Grants and Agreements With Institutions of Higher Education, Hospitals,
and Other Non-Profit Organizations).
7. It will administer and enforce the labor standards requirements set forth in 24 CFR § 570.603
and any other regulations issued to implement such requirements.
8. It will comply with the provisions of Executive Order 11988, as amended by Executive Order
12148, relating to evaluation of flood hazards, and Executive Order 12088, as amended by
Executive Order 12580, relating to the prevention, control and abatement of water pollution.
9. It will require every building or facility (other than a privately owned residential structure)
designed, constructed, or altered with funds provided to Applicant/Grantee/Subrecipient to
comply with any accessibility requirements, as required by Title III of the Americans with
Disabilities Act of 1990 (42 U.S.C.A. § 12101 et seq.). The Applicant/Grantee/Subrecipient
will be responsible for conducting inspections to ensure compliance with these specifications
by the contractor.
10.
It will comply with:
a. Title VI of the Civil Rights Acts of 1964, 42 U.S.C. § 2000d et seq., as amended,
and the regulations issued pursuant thereto (24 CFR Part 1), which provide that no
person in the United States shall on the grounds of race, color, or national origin,
be excluded from participation in, be denied the benefits of, or be otherwise
subjected to discrimination under any program or activity for which the
Applicant/Grantee/Subrecipient receives federal financial assistance and will
immediately take any measures necessary to effectuate this assurance. If any real
property or structure thereon is provided or improved with the aid of federal
financial assistance extended to the Applicant/Grantee/Subrecipient, this
assurance shall obligate the Applicant/Grantee/Subrecipient, or in the case of any
transfer of such property, any transferee, for the period during which the property
or structure is used for another purpose involving the provision of similar services
or benefits.
b. Section 104 (b) (2) of Title VIII of the Civil Rights Act of 1968 ( 42 U.S.C.A.
§3601, et seq. ), as amended, which requires administering all programs and
activities relating to housing and community development in a manner to
affirmatively further fair housing. Title VIII further prohibits discrimination
against any person in the sale or rental of housing, or the provision of brokerage
services, including in any way making unavailable or denying a dwelling to any
person, because of race, color, religion, sex, national origin, handicap or familial
status.
c. Section 109 of Title I of the Housing and Community Development Act of 1974
(42 U.S.C. § 5309), and the regulations issued pursuant thereto (24 CFR Part
§ 570.602), which provides that no person in the United States shall, on the
grounds of race, color, national origin, or sex, be excluded from participation in,
be denied the benefits of, or be subjected to discrimination under, any program or
activity funded in whole or in part with funds provided under that Part. Section
109 further prohibits discrimination to an otherwise qualified individual with a
handicap, as provided under Section 504 of the Rehabilitation Act of 1973, as
amended, and prohibits discrimination based on age as provided under the Age
Discrimination Act of 1975. The policies and procedures necessary to ensure
enforcement of section 109 are codified in 24 CFR part 6.
d. Executive Order 11063, as amended by Executive Order 12259, and the
regulations issued pursuant thereto, which pertains to equal opportunity in
housing and non-discrimination in the sale or rental of housing built with federal
assistance.
e. Executive Order 11246, as amended by Executive Orders 11375 and 12086, and
the regulations issued pursuant thereto, which provide that no person shall be
discriminated against on the basis of race, color, religion, sex or national origin in
all phases of employment during the performance of federal or federally assisted
construction contracts. Further, contractors and subcontractors on federal and
federally assisted construction contracts shall take affirmative action to insure fair
treatment in employment, upgrading, demotion, or transfer, recruitment or
recruitment advertising, layoff or termination, rates of pay or other forms of
compensation, and selection for training and apprenticeship.
f. Section 504 of the Rehabilitation Act of 1973, as amended, which provides that
no otherwise qualified individual shall, solely, by reason of his or her handicap be
excluded from participation, denied program benefits or subjected to
discrimination on the basis of age under any program or activity receiving federal
funding assistance.
11. The work to be performed by Grantee is subject to the requirements of section 3 of the
Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701u (section 3).
The purpose of section 3 is to ensure that employment and other economic opportunities
generated by HUD assistance or HUD-assisted projects covered by section 3, shall, to the
greatest extent feasible, be directed to low- and very low-income persons, particularly
persons who are recipients of HUD assistance for housing.
Grantee agrees to comply with HUD's regulations in 24 CFR part 135, which implement
section 3. Grantee also certifies that there are under no contractual or other impediment
that would prevent it from complying with the part 135 regulations.
Grantee agrees to send to each labor organization or representative of workers with which
the Grantee has a collective bargaining agreement or other understanding, if any, a notice
advising the labor organization or workers' representative of the Grantee's commitments
under this section 3 clause, and will post copies of the notice in conspicuous places at the
work site where both employees and applicants for training and employment positions can
see the notice. The notice shall describe the section 3 preference, shall set forth minimum
number and job titles subject to hire, availability of apprenticeship and training positions,
the qualifications for each; and the name and location of the person(s) taking applications
for each of the positions; and the anticipated date the work shall begin.
Grantee agrees to include this section 3 clause in every subrecipient agreement and
contract subject to compliance with regulations in 24 CFR part 135, and agrees to take
appropriate action, as provided in an applicable provision of such contract or in this section
3 clause, upon a finding that the subrecipient or contractor is in violation of the regulations
in 24 CFR part 135. Grantee will not contract with any subrecipient or contractor where
the contractor has notice or knowledge that the subrecipient or contractor has been found
in violation of the regulations in 24 CFR part 135.
The Grantee will certify that any vacant employment positions, including training
positions, that are filled (1) after the Grantee is selected but before the contract is executed,
and (2) with persons other than those to whom the regulations of 24 CFR part 135 require
employment opportunities to be directed, were not filled to circumvent the Grantee's
obligations under 24 CFR part 135.
Noncompliance with HUD's regulations in 24 CFR part 135 may result in sanctions,
termination of this Agreement for default, and debarment or suspension from future HUD
assisted contracts.
12. It will minimize displacement of persons as a result of activities assisted with CDBG funds.
In addition, it will:
a. Comply with Title II (Uniform Relocation Assistance) and Sections 301-304 of
Title III (Uniform Real Property Acquisition Policy) of the Uniform Relocation
Assistance and Real Property Acquisition Policies Act of 1970 (42 U.S.C.
Chapter 61), and HUD implementing instructions at 24 CFR Part 42 and 24 CFR
§ 570.606; and
b. Inform affected persons of their rights and of the acquisition policies and
procedures set forth in the regulations at 24 CFR Part 42; and
c. Provide relocation payments and offer relocation assistance as described in
Section 205 of the Uniform Relocation Assistance Act to all persons displaced as
a result of acquisition of real property for an activity assisted under the CDBG
Program. Such payments and assistance shall be provided in a fair, consistent and
equitable manner that ensures that the relocation process does not result in
different or separate treatment of such persons on account of race, color, religion,
national origin, sex or source of income; and
d. Assure that, within a reasonable period of time prior to displacement, comparable
decent, safe and sanitary replacement dwellings will be available to all displaced
families and individuals and that the range of choices available to such persons
will not vary on account of their race, color, religion, national origin, sex, or
source of income; and
With respect to work performed in connection with section 3 covered Indian housing
assistance, section 7(b) of the Indian Self-Determination and Education Assistance Act (25
U.S.C. 450e) also applies to the work to be performed under this Agreement. Section 7(b)
requires that to the greatest extent feasible (i) preference and opportunities for training and
employment shall be given to Indians, and (ii) preference in the award of contracts and
subcontracts shall be given to Indian organizations and Indian-owned Economic
Enterprises. Parties to this Agreement that are subject to the provisions of section 3 and
section 7(b) agree to comply with section 3 to the maximum extent feasible, but not in
derogation of compliance with section 7(b).
e. Assure that if displacement is precipitated by CDBG funded activities that require
the acquisition (either in whole or in part) of real property, all appropriate benefits
required by the Uniform Relocation Assistance and Real Property Acquisition
Policies Act of 1970 (42 U.S.C. 4601 et seq . , Pub. L. 91-646) and amendments
thereto shall be provided to the displaced person(s). Persons displaced by
rehabilitation of “Non-Uniform Act” acquisition financed (in whole or in part)
with CDBG funds shall be provided relocation assistance in accordance with one
of the following: (1) the acquisition and relocation requirements of the Uniform
Relocation Assistance and Real Property Acquisition Policies Act of 1970, as
required under 24 CFR Section 570.606 (a) and HUD implementing regulations at
24 CFR Part 42; (2) the requirements in 24 CFR Section 570.606 (b) governing
the Residential Antidisplacement and Relocation Assistance Plan under Section
104 (d) of the Housing and Community Development Act of 1974; (3) the
relocation requirements of Section 104 (k) of the Act; (4) the relocation
requirements of 24 CFR Section 570.606 (d) governing optional relocation
assistance under Section 105 (a) (11) of the Act; and (5) the provisions of 24 CFR
Part 511.10 (h) (2) (iii) rental Rehabilitation Program.
13. It will establish safeguards to prohibit employees from using positions for a purpose that is or
gives the appearance of being motivated by a desire for private gain for themselves or others,
particularly those with whom they have family, business, or other ties, in accordance with
CDBG regulations.
14. It will comply with the provisions of the Hatch Act that limit the political activity of
employees and the HUD regulations governing political activity at 24 CFR § 570.207.
15. It will give the State and HUD, and any of their representatives or agents, access to and the
right to examine all records, books, papers, or documents related to the grant.
16. It will ensure that the facilities under Applicant/Grantee/Subrecipient’s ownership, lease or
supervision utilized in the accomplishment of the CDBG Program are not listed on the
Environmental Protection Agency's (EPA) list of violating facilities and that it will notify
HUD of the receipt of any communication from the EPA Office of Federal Activities
indicating that a facility to be used in the CDBG Program is being considered for listing by
the EPA as a violating facility.
17. With regard to environmental impact, it will comply with the National Environmental Policy
Act of 1969 (42 U.S.C. § 4321-4347), and Section 104(f) of the Housing and Community
Development Act of 1974 ( 42 U.S.C. § 5304(d)).
18. It will comply with Section 106 of the National Historic Preservation Act of 1966 (16 U.S.C.
470 et seq.), as amended, Executive Order 11593, and the Preservation of Archaeological and
Historical Data Act of 1966 (16 U.S.C. § 469a-1 et. seq.), as amended, by:
a. Consulting with the State Historic Preservation Office to identify properties listed
in or eligible for inclusion in the National Register of Historic Places that are
subject to adverse effects (see 36 CFR Part 800) by the proposed activity; and
b. Complying with all requirements established by the State to avoid or mitigate
adverse effects upon such properties.
19. It will comply with the provisions in 24 CFR § 570.200(c) regarding special assessments to
recover capital costs.
20. It will adopt and enforce a policy prohibiting the use of excessive force by law enforcement
agencies within its jurisdiction against any individual engaged in non-violent Civil Rights
demonstrations and will enforce applicable state and local laws against physically barring
entrance to or exit from a facility or location which is the subject of such nonviolent civil
rights demonstrations within its jurisdiction.
21. It certifies that no federally appropriated funds will be used for any lobbying purposes
regardless of the level of government.
22 It will abide by and enforce the conflict of interest requirement set forth in 24 CFR § 570.611,
24 CFR § 85.36 and 24 CFR § 84.42.
23. It will comply with HUD rules prohibiting the use of CDBG funds for inherently religious
activities, as set forth in 24 CFR § 570.200(j).
24. Activities involving new building construction, alterations, or rehabilitation will comply with
the Louisiana State Building Code.
25. In relation to labor standards, it will comply with:
a. Section 110 of the Housing and Community Development Act of 1974, as
amended and as set forth in 24 CFR § 570.603.
b. Davis-Bacon Act, as amended (40 U.S.C. § 3141 et seq.).
c. Contract Work Hours and Safety Standards Act (40 U.S.C. § 327 et seq.).
d. Federal Fair Labor Standards Act (29 U.S.C. § 201 et seq.)
26. It will comply with the flood insurance purchase requirement of Section 102(a) of the Flood
Disaster Protection Act of 1973, 42 U.S.C. § 4001 et seq., which requires the purchase of
flood insurance in communities where such insurance is available as a condition for the
receipt of any federal financial assistance for construction or acquisition purposes for use in
any area that has been identified by the Secretary of the Department of HUD as an area
having special flood hazards. The phrase “federal financial assistance” includes any form of
loan, grant, guaranty, insurance payment, rebate, subsidy, disaster assistance loan or grant, or
any other form of direct or indirect federal funding.
27. It will comply with the Farmland Protection Policy Act, 7 U.S.C.A. §4201 et seq., which
requires recipients of federal assistance to minimize the extent to which their projects
contribute to the unnecessary and irreversible commitment of farmland to nonagricultural
uses.
28. It will comply with Sections 1012 and 1013 of Title X of the Housing and Community
Development Act of 1992 (Public Law 102–550, as amended). The regulation appears within
Title 24 of the Code of Federal Regulations as part 35 (codified in 24 CFR 35). The purpose
of this regulation is to protect young children from lead-based paint hazards in housing that is
financially assisted by the Federal government or sold by the government. This regulation
applies only to structures built prior to 1978.
29. It will comply with the Solid Waste Disposal Act, as amended by the Resource Conservation
and Recovery Act of 1976 (42 U.S.C. § 6901, et seq.).
30. It will comply with the Clean Air Act (42 U.S.C. § 7401, et seq.), which prohibits engaging
in, supporting in any way, or providing financial assistance for, licensing or permitting, or
approving any activity which does not conform to the State implementation plan for national
primary and secondary ambient air quality standards.
31. In relation to water quality, it will comply with:
a. The Safe Drinking Water Act of 1974 (42 U.S.C. §§ 201, 300(f) et seq. and
U.S.C. § 349), as amended, particularly Section 1424(e) (42 U.S.C. §§ 300h-
303(e)), which is intended to protect underground sources of water. No
commitment for federal financial assistance can be entered into for any project
which the U.S. Environmental Protection Agency determines may contaminate an
aquifer which is the sole or principal draining water source for an area; and
b. The Federal Water Pollution Control Act of 1972, as amended, including the
Clear Water Act of 1977, Public Law 92-212 (33 U.S.C. § 1251, et seq.) which
provides for the restoration and maintenance of the chemical, physical and
biological integrity of the nation’s water.
32. It will comply with HUD Environmental Standards (24 CFR, Part 51 and 44 F.R. 40860-
40866).
33. With regard to wildlife, it will comply with:
a. The Endangered Species Act of 1973, as amended (16 U.S.C. § 1531 et seq.).
Federally authorized and funded projects must not jeopardize the continued
existence of endangered and threatened species or result in the destruction of or
modification of habitat of such species which is determined by the U.S.
Department of the Interior, after consultation with the state, to be critical; and
b. The Fish and Wildlife Coordination Act of 1958, as amended, (16 U.S.C. § 661 et
seq.) which requires that wildlife conservation receives equal consideration and is
coordinated with other features of water resource development programs.
Signing these assurances means that Applicant/Grantee/Sub recipient agrees to implement its
program in accordance with these provisions. Failure to comply can result in serious audit
and/or monitoring findings that require repayment of funds to the State or expending
Applicant/Grantee/Sub recipient funds to correct deficiencies.
GRANTEE
By: ________________________________
Title: ________________________________
This ____day of _____________________, 20_____.
Applicant/Recipient
Disclosure/Update Report
U.S. Department of Housing
and Urban Development
OMB Approval No. 2510-0011 (exp. 10/31/2014)
Instructions . ( See Public Reporting Statement and Privacy Act Statement and detailed instructions on page 2.)
Applicant/Recipient Information
Indicate whether this is an Initial Report
or an Update Report
1. Applicant/Recipient Name, Address, and Phone (include area code):
2. Social Security Number or
Employer ID Number:
3. HUD Program Name
4. Amount of HUD Assistance
Requested/Received
5. State the name and location (street address, City and State) of the project or activity:
Part I Threshold Determinations
1. Are you applying for assistance for a specific project or activity? These
terms do not include formula grants, such as public housing operating
subsidy or CDBG block grants. (For further information see 24 CFR Sec.
4.3).
Yes
No
2. Have you received or do you expect to receive assistance within the
jurisdiction of the Department (HUD) , involving the project or activity in
this application, in excess of $200,000 during this fiscal year (Oct. 1 -
Sep. 30)? For further information, see 24 CFR Sec. 4.9
Yes
No .
If you answered “ No ” to either question 1 or 2, Stop ! You do not need to complete the remainder of this form.
However , you must sign the certification at the end of the report.
Part II Other Government Assistance Provided or Requested / Expected Sources and Use of Funds.
Such assistance includes, but is not limited to, any grant, loan, subsidy, guarantee, insurance, payment, credit, or tax benefit.
Department/State/Local Agency Name and Address
Type of Assistance
Amount
Requested/Provided
Expected Uses of the Funds
( Note : Use Additional pages if necessary.)
Part III Interested Parties. You must disclose:
1. All developers, contractors, or consultants involved in the application for the assistance or in the planning, development, or implementation of the
project or activity and
2. any other person who has a financial interest in the project or activity for which the assistance is sought that exceeds $50,000 or 10 percent of the
assistance (whichever is lower).
Alphabetical list of all persons with a reportable financial interest
in the project or activity (For individuals, give the last name first)
Social Security No.
or Employee ID No.
Type of Participation in
Project/Activity
Financial Interest in
Project/Activity ($ and %)
( Note : Use Additional pages if necessary.)
Certification
Warning : If you knowingly make a false statement on this form, you may be subject to civil or criminal penalties under Section 1001 of Title 18 of the
United States Code. In addition, any person who knowingly and materially violates any required disclosures of information, including intentional non-
disclosure, is subject to civil money penalty not to exceed $10,000 for each violation.
I certify that this information is true and complete.
Signature:
Date: (mm/dd/yyyy)
X
Form HUD-2880 (3/99)
Public reporting burden for this collection of information is estimated to average 2.0 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 information. This agency
may not conduct or sponsor, and a person is not required to respond to, a collection information unless that collection displays a valid OMB control
number.
Privacy Act Statement . Except for Social Security Numbers (SSNs) and Employer Identification Numbers (EINs), the Department of Housing and Urban
Development (HUD) is authorized to collect all the information required by this form under section 102 of the Department of Housing and Urban
Development Reform Act of 1989, 42 U.S.C. 3531. Disclosure of SSNs and EINs is voluntary. HUD is authorized to collect this information under the
Housing and Community Development Act of 1987 42 U.S.C.3543 (a). The SSN or EIN is used as a unique identifier. The information you provide will
enable HUD to carry out its responsibilities under Sections 102(b), (c), and (d) of the Department of Housing and Urban Development Reform Act of 1989,
Pub. L. 101-235, approved December 15, 1989. These provisions will help ensure greater accountability and integrity in the provision of certain types of
assistance administered by HUD. They will also help ensure that HUD assistance for a specific housing project under Section 102(d) is not more than is
necessary to make the project feasible after taking account of other government assistance. HUD will make available to the public all applicant disclosure
reports for five years in the case of applications for competitive assistance, and for generally three years in the case of other applications. Update reports
will be made available along with the disclosure reports, but in no case for a period generally less than three years. All reports, both initial reports and update
reports, will be made available in accordance with the Freedom of Information Act (5 U.S.C. §552) and HUD's implementing regulations at 24 CFR Part 15.
HUD will use the information in evaluating individual assistance applications and in performing internal administrative analyses to assist in the management
of specific HUD programs. The information will also be used in making the determination under Section 102(d) whether HUD assistance for a specific housing
project is more than is necessary to make the project feasible after taking account of other government assistance. You must provide all the required
information. Failure to provide any required information may delay the processing of your application, and may result in sanctions and penalties, including
imposition of the administrative and civil money penalties specified under 24 CFR §4.38.
Note : This form only covers assistance made available by the Department. States and units of general local government that carry out responsibilities
under Sections 102(b) and (c) of the Reform Act must develop their own procedures for complying with the Act.
Instructions
Overview .
A . Coverage. You must complete this report if:
(1) You are applying for assistance from HUD for a specific project or
activity and you have received, or expect to receive, assistance
from HUD in excess of $200,000 during the during the fiscal year;
(2) You are updating a prior report as discussed below; or
(3) You are submitting an application for assistance to an entity other
than HUD, a State or local government if the application is required
by statute or regulation to be submitted to HUD for approval or for
any other purpose.
B. Update reports (filed by “Recipients” of HUD Assistance):
General . All recipients of covered assistance must submit update
reports to the Department to reflect substantial changes to the initial
applicant disclosure reports.
Part I contains information to help the applicant determine whether the
remainder of the form must be completed. Recipients filing Update
Reports should not complete this Part.
If the answer to either questions 1 or 2 is No, the applicant need not
complete Parts II and III of the report, but must sign the certification at the
end of the form.
Part II. Other Government Assistance and Expected Sources and
Uses of Funds.
A. Other Government Assistance. This Part is to be completed by both
applicants and recipients for assistance and recipients filing update
reports. Applicants and recipients must report any other government
assistance involved in the project or activity for which assistance is
sought. Applicants and recipients must report any other government
assistance involved in the project or activity. Other government
assistance is defined in note 4 on the last page. For purposes of this
definition, other government assistance is expected to be made
available if, based on an assessment of all the circumstances involved,
there are reasonable grounds to anticipate that the assistance will be
forthcoming.
Both applicant and recipient disclosures must include all other
government assistance involved with the HUD assistance, as well as
any other government assistance that was made available before the
request, but that has continuing vitality at the time of the request.
Examples of this latter category include tax credits that provide for a
number of years of tax benefits, and grant assistance that continues to
benefit the project at the time of the assistance request.
The following information must be provided:
1. Enter the name and address, city, State, and zip code of the
government agency making the assistance available.
2. State the type of other government assistance (e.g., loan, grant,
loan insurance).
3. Enter the dollar amount of the other government assistance that is,
or is expected to be, made available with respect to the project or
activities for which the HUD assistance is sought (applicants) or
has been provided (recipients).
4. Uses of funds. Each reportable use of funds must clearly identify
the purpose to which they are to be put. Reasonable aggregations
may be used, such as "total structure" to include a number of
structural costs, such as roof, elevators, exterior masonry, etc.
Line-by-Line Instructions.
Applicant/Recipient Information.
All applicants for HUD competitive assistance, must complete the
information required in blocks 1-5 of form HUD-2880:
1. Enter the full name, address, city, State, zip code, and telephone
number (including area code) of the applicant/recipient. Where the
applicant/recipient is an individual, the last name, first name, and
middle initial must be entered.
2. Entry of the applicant/recipient's SSN or EIN, as appropriate, is
optional.
3. Applicants enter the HUD program name under which the assistance is
being requested.
4. Applicants enter the amount of HUD assistance that is being
requested. Recipients enter the amount of HUD assistance that has
been provided and to which the update report relates. The amounts
are those stated in the application or award documentation. NOTE: In
the case of assistance that is provided pursuant to contract over a
period of time (such as project-based assistance under section 8 of the
United States Housing Act of 1937), the amount of assistance to be
reported includes all amounts that are to be provided over the term of
the contract, irrespective of when they are to be received.
5. Applicants enter the name and full address of the project or activity for
which the HUD assistance is sought. Recipients enter the name and
full address of the HUD-assisted project or activity to which the update
report relates. The most appropriate government identifying number
must be used (e.g., RFP No.; IFB No.; grant announcement No.; or
contract, grant, or loan No.) Include prefixes.
B. Non-Government Assistance. Note that the applicant and recipient
disclosure report must specify all expected sources and uses of funds -
both from HUD and any other source - that have been or are to be,
made available for the project or activity. Non-government sources of
Part I. Threshold Determinations - Applicants Only
Form HUD-2880 (3/99)
 
funds typically include (but are not limited to) foundations and private
contributors.
not repeat the information, but need only refer to the form and location to
incorporate it into this report. (It is likely that some of the information
required by this report has been provided on SF 424A, and on various
budget forms accompanying the application.) If this report requires
information beyond that provided elsewhere in the application package,
the applicant must include in this report all the additional information
required.
Recipients must submit an update report for any change in previously
disclosed sources and uses of funds as provided in Section I.D.5., above.
Notes:
1. All citations are to 24 CFR Part 4, which was published in the Federal
Register. [April 1, 1996, at 63 Fed. Reg. 14448.]
2. Assistance means any contract, grant, loan, cooperative agreement, or
other form of assistance, including the insurance or guarantee of a loan
or mortgage, that is provided with respect to a specific project or
activity under a program administered by the Department. The term
does not include contracts, such as procurements contracts, that are
subject to the Fed. Acquisition Regulation (FAR) (48 CFR Chapter 1).
3. See 24 CFR §4.9 for detailed guidance on how the threshold is
calculated.
4. "Other government assistance" is defined to include any loan, grant,
guarantee, insurance, payment, rebate, subsidy, credit, tax benefit, or
any other form of direct or indirect assistance from the Federal
government (other than that requested from HUD in the application), a
State, or a unit of general local government, or any agency or
instrumentality thereof, that is, or is expected to be made, available
with respect to the project or activities for which the assistance is
sought.
5. For the purpose of this form and 24 CFR Part 4, “person” means an
individual (including a consultant, lobbyist, or lawyer); corporation;
company; association; authority; firm; partnership; society; State, unit
of general local government, or other government entity, or agency
thereof (including a public housing agency); Indian tribe; and any other
organization or group of people.
Part III. Interested Parties.
This Part is to be completed by both applicants and recipients filing update
reports. Applicants must provide information on:
1. All developers, contractors, or consultants involved in the application
for the assistance or in the planning, development, or implementation
of the project or activity and
2. any other person who has a financial interest in the project or activity
for which the assistance is sought that exceeds $50,000 or 10 percent
of the assistance (whichever is lower).
Note: A financial interest means any financial involvement in the
project or activity, including (but not limited to) situations in which an
individual or entity has an equity interest in the project or activity,
shares in any profit on resale or any distribution of surplus cash or
other assets of the project or activity, or receives compensation for any
goods or services provided in connection with the project or activity.
Residency of an individual in housing for which assistance is being
sought is not, by itself, considered a covered financial interest.
The information required below must be provided.
1. Enter the full names and addresses. If the person is an entity, the
listing must include the full name and address of the entity as well as
the CEO. Please list all names alphabetically.
2. Entry of the Social Security Number (SSN) or Employee Identification
Number (EIN), as appropriate, for each person listed is optional.
3. Enter the type of participation in the project or activity for each person
listed: i.e., the person's specific role in the project (e.g., contractor,
consultant, planner, investor).
4. Enter the financial interest in the project or activity for each person
listed. The interest must be expressed both as a dollar amount and as
a percentage of the amount of the HUD assistance involved.
Note that if any of the source/use information required by this report has
been provided elsewhere in this application package, the applicant need
Form HUD-2880 (3/99)