HUD 52680-A Hope VI Application Data Form

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Overview

Att 1
Att 2
Att 3
Att 4
Att 5
Att 6
Att 6 p.2
Att 7
Att 7 p.2

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Sheet 1: Att 1

HOPE VI Revitalization

U.S. Department of Housing

OMB Approval No. 2577-0208

Application Data Form

and Urban Development

(exp. 4/30/2008)

and Urban Development

(exp. 12/31/2003)

Office of Public and Indian Housing

Attachment 1: Application Data Form: Cover Sheet

Existing Development Name(s):

Applicant Information

PHA Number:

PHA Name:

PHA Mailing Address:

Main Telephone:

PHA Executive Director:

Telephone:

Fax:

Email Address:

HOPE VI Coordinator:

Telephone:

Fax:

Email Address:

HOPE VI Developer (if any):

Telephone:

Fax:

HOPE VI Developer Contact:

Email Address:

Program Manager (if any):

Telephone:

Fax:

Email Address:

Additional Partner:

Functional Title:

Additional Partner:

Functional Title:

Street Address, City, State, Zip:

Existing Project Number(s):

Neighborhood/ Area of town:

New Development Name (if any):

Mixed Income Proposed?

Yes/No

Mixed Finance Proposed?

Yes/No

Data Summary

Existing

Post-Revitalization

0

0

Number of market-rate units (no income restrictions)

0

Number of other units

0

TOTAL NUMBER OF POST-DEVELOPMENT UNITS

0

Number of units to be rehabilitated (excluding acquisition with rehab)

0

Number of newly constructed on-site units (including acquisition with rehab)

0

Number of newly constructed off-site units (including acquisition with rehab)

0

Number of occupied units (at time of application)

0

Number of vacant units (at time of application)

0

form HUD-52860-A (08/2002)

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Sheet 2: Att 2

	Existing Housing Units at Time of Grant Application
Building Type	Size	Number Occupied	Number Vacant	Total Units	Converted to Non-Dwelling	Demo Planned
Row	0 BR			0
	1 BR			0
	2 BR			0
	3 BR			0
	4 BR			0
	5 BR			0
	6 BR			0
	Total	0	0	0	0	0
Detached/	0 BR			0
Semi-Detached	1 BR			0
	2 BR			0
	3 BR			0
	4 BR			0
	5 BR			0
	6 BR			0
	Total	0	0	0	0	0
Walkup	0 BR			0
	1 BR			0
	2 BR			0
	3 BR			0
	4 BR			0
	5 BR			0
	6 BR			0
	Total	0	0	0	0	0
Elevator	0 BR			0
	1 BR			0
	2 BR			0
	3 BR			0
	4 BR			0
	5 BR			0
	6 BR			0
	Total	0	0	0	0	0
Grand Total		0	0	0	0	0
						form HUD-52860-A (08/2002)

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Sheet 3: Att 3

Relocation/Occupancy
	Relocation Strategy						Planned
	Original households to be provided Section 8 certificates/vouchers
	Original households to be moved within public housing (on and off-site)
	Original households to move to non-assisted housing/unknown
						Total	0
	Number of Section 8 certificates/vouchers requested/received						Requested	Received
	from HUD for this project:
	Number of occupied units at time of grant application:
	Returning Households						Planned
	Number of original households estimated to return to revitalized HOPE VI units
	(both on-site and off-site):
	Number of these households to be housed in new construction
Household Income								Existing	Post Development
Average income (as percentage of Median) of public housing residents in development
Average income (as percentage of Median) of otherwise subsidized residents in neighborhood
Average income (as percentage of Median) of market-rate residents in the neighborhood
Resident Profile (not mutually exclusive)
Total number of residents
Number of children 6-18 years of age
Number of senior citizens
Number of individuals with disabilities
Non-Dwelling Structure Summary
Proposed non-dwelling structures (please describe, including type of
facility and whether proposing new construction or rehabilitation)						New or Rehab	Square Footage	Total Cost	Cost per Sq. Ft.
									form HUD-52860-A (08/2002)

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Sheet 4: Att 4

New Construction (include any acquisition w/rehab)						Rehabilitation
Row: New						Row: Rehabilitation
Size	Sq. Ft.	ACC Units*	Non-ACC Units**	HOPE VI and/or PH funded HO	Other Home-Ownership	Size	Sq. Ft.	ACC Units*	Non-ACC Units**	HOPE VI and/or PH funded HO	Other Home-Ownership
0 BR					0	0 BR
1 BR						1 BR
2 BR						2 BR
3 BR						3 BR
4 BR						4 BR
5 BR						5 BR
6 BR						6 BR
Total		0	0	0	0	Total		0	0	0	0
Detached/Semi-detached: New						Detached/Semi-detached: Rehabilitation
Size	Sq. Ft.	ACC Units*	Non-ACC Units**	HOPE VI and/or PH funded HO	Other Home-Ownership	Size	Sq. Ft.	ACC Units*	Non-ACC Units**	HOPE VI and/or PH funded HO	Other Home-Ownership
0 BR						0 BR
1 BR						1 BR
2 BR						2 BR
3 BR						3 BR
4 BR						4 BR
5 BR						5 BR
6 BR						6 BR
Total		0	0	0	0	Total		0	0	0	0
Walkups: New						Walkups: Rehabilitation
Size	Sq. Ft.	ACC Units*	Non-ACC Units**	HOPE VI and/or PH funded HO	Other Home-Ownership	Size	Sq. Ft.	ACC Units*	Non-ACC Units**	HOPE VI and/or PH funded HO	Other Home-Ownership
0 BR						0 BR
1 BR						1 BR
2 BR						2 BR
3 BR						3 BR
4 BR						4 BR
5 BR						5 BR
6 BR						6 BR
Total		0	0	0	0	Total		0	0	0	0
Elevator: New						Elevator: Rehabilitation
Size	Sq. Ft.	ACC Units*	Non-ACC Units**	HOPE VI and/or PH funded HO	Other Home-Ownership	Size	Sq. Ft.	ACC Units*	Non-ACC Units**	HOPE VI and/or PH funded HO	Other Home-Ownership
0 BR						0 BR
1 BR						1 BR
2 BR						2 BR
3 BR						3 BR
4 BR						4 BR
5 BR						5 BR
6 BR						6 BR
Total		0	0	0	0	Total		0	0	0	0
Grand Total		0	0	0	0	Grand Total		0	0	0	0
* ACC units include PH rental, PH/LIHTC, and Affordable Lease/Purchase with HOPE VI and/or PH funds.
** Non-ACC units have no PH or HOPE VI funds and will not be under ACC.
											form HUD-52860-A (08/2002)

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Sheet 5: Att 5

				Rental Units: ACC
		Planned		PH Only		PH/LIHTC		PH/Other		Total ACC
		Units		On-Site	Off-Site	On-Site	Off-Site	On-Site	Off-Site	On-Site	Off-Site
										0	0
				Rental Units: Non-ACC
				LIHTC		CDBG, HOME, or other subsidy		No Income Restrictions		Total Non-ACC
				On-Site	Off-Site	On-Site	Off-Site	On-Site	Off-Site	On-Site	Off-Site
										0	0
								Total Homeownership
On-Site	Off-Site	On-Site	Off-Site	On-Site	Off-Site	On-Site	Off-Site	On-Site	Off-Site	On-Site	Off-Site
										0	0
				Other Units (operating subsidy only, etc)
				Type:		Type:		Type:		Total Other Units
				On-Site	Off-Site	On-Site	Off-Site	On-Site	Off-Site	On-Site	Off-Site
										0	0
									Grand Total
									On-Site	Off-Site
									0	0
									Grand Total - All Units	0
		Accessibility
						Rental Units (including Lease/Purchase)		Homeownership Units		Total
				New Construction		% of Category		% of Category		% of Category
				Mobility-Impaired (wheelchair)
				Hearing-Impaired
				Sight-Impaired
				Visitability
						Rental Units (including Lease/Purchase)		Homeownership Units		Total
				Rehabilitation		% of Category		% of Category		% of Category
				Mobility-Impaired (wheelchair)
				Hearing-Impaired
				Sight-Impaired
				Visitability
		Concentration
								Pre-Development		Post-Development
		Density of on-site development (units per acre)
		Percent of very low income households in the development (30% of median or below)
											form HUD-52860-A (08/2002)

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Sheet 6: Att 6

NOTE: If property is vacant, describe previous residents.

During Last 12 Months

At Time of Application

At Grant Award

Projected One Year after Grant Award

Projected Two Years after Grant Award

Projected at Close of Grant

A. Graduation from Public Assistance

Number of households whose primary monthly source of income is:

Wages/Salary

TANF

Other

B. Employment/Obstacles to Employment

Number of TANF participants enrolled in job training programs

Number of non-TANF participants enrolled in job training programs

Number of unemployed residents placed in:

Section 3 jobs

Non-Section 3 jobs

C. Economic Development

Number of resident-owned businesses

D. Section 3

Dollar amount of HOPE VI contracts going to Section 3 firms

E. Education

Number of residents without a high school diploma or G.E.D.

Number of residents with a high school diploma, G.E.D.,

or higher degree

F. Homeownership

Number of residents in homeownership counseling

G. Case Management

If you have a Family Supportive Services program:

Number of residents enrolled in FSS program

Dollar amount in escrow accounts

H. Youth Programs

Number of youth participating in youth programs

Number of children participating in day care programs

I. Health

Number of partnerships with healthcare agencies

(e.g., clinics, hospitals, universities)

J. Transportation

Number of residents who use public transportation

to get to work or services

form HUD-52860-A (08/2002)

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Sheet 7: Att 6 p.2

K. Self-Sufficiency Projected Spending
Planned Spending	HOPE VI Funds	Other Funds		Total
Day Care				0
Health Care				0
Education				0
Job Training				0
Business Development Training				0
Case Management				0
Other (specify)				0
Other (specify)				0
Other (specify)				0
Other (specify)				0
Other (specify)				0
Other (specify)				0
TOTAL	0	0		0
L. Self-Sufficiency: Programs and Partners
			List of Self-Sufficiency Partners
				form HUD-52860-A (08/2002)

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Sheet 8: Att 7

Uses ($)*		HOPE VI		Non-HOPE VI
		Uses ($)	+	Uses ($)	=	Total
Administration
Administration						0.00
Management Improvements
Management Improvements - Dev						0.00
Management Improvements - CSS						0.00
Acquisition
Site Acquisition						0.00
Building Acquisition, Turnkey						0.00
Building Acquisition, Rehabilitation						0.00
Building Acquisition, Non-Dwelling						0.00
Building Remediation/Demolition
Remediation, Dwelling Units						0.00
Demolition, Dwelling Units						0.00
Remediation, Non-Dwelling Units						0.00
Demolition, Non-Dwelling Units						0.00
Demolition, Other						0.00
Site Improvements
Site Remediation						0.00
Site Infrastructure						0.00
Off-site Improvements						0.00
Construction
Dwelling Structures - Hard Costs						0.00
Non-Dwelling - Hard Costs						0.00
General Requirements						0.00
Builder’s Profit						0.00
Builder’s Overhead						0.00
Bond Premium						0.00
Hard Cost Contingency						0.00
Equipment
Dwelling Equipment						0.00
Non-Dwelling Equipment						0.00
Professional Fees/Consultant Services
Program Management Services						0.00
Architectural						0.00
Engineering						0.00
Construction Management Services						0.00
Appraisal						0.00
Environmental						0.00
Market Study						0.00
Historic Preservation Documentation						0.00
Other						0.00
Legal
Organizational						0.00
Syndication						0.00
PHA Outside Counsel						0.00
Other						0.00
Tax Credit
Accounting						0.00
Tax Credit Application						0.00
Tax Credit Monitoring Fee						0.00
Consultant						0.00
Other						0.00
Page 1 Total	$	0.00	$	0.00	$	0.00
								form HUD-52860-A (08/2002)

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Sheet 9: Att 7 p.2

Uses ($)*		HOPE VI		Non-HOPE VI				Sources ($)
		Uses ($)	+	Uses ($)	=	Total
Other Development Costs								HUD Funds
(Soft Costs)
Accounting Fees						0.00		HOPE VI Revitalization
Financing Fees						0.00		PH Capital Fund
Permit Fees						0.00		Modernization
Title/Recording/Settlement Fees						0.00		PH Development
Real Estate Taxes During								MROP
Construction						0.00		HOPE VI Demolition
Insurance During Construction						0.00		Grant
Interest During Construction						0.00		Other HUD Funds
Bridge Loan Interest						0.00		HOME
Marking/Rent-up Expenses						0.00		CDBG
Initial Operating Deficit						0.00		Other
Soft Cost Contingency						0.00
Other						0.00		Total HUD Funds	$	0.00
Relocation
Relocation Costs						0.00		Non-HUD Public Funds
Developer Fee								State Funds
Developer Fee						0.00		Local Funds (Non PHA)
Reserves								PHA Funds
Operating Reserve						0.00		Other Funds
Other Reserves						0.00		Describe Other
								Total Non-HUD
Page 2 Total						0.00		Public Funds	$	0.00
						0.00
GRAND TOTAL USES:								Private Funds
						0.00		Tax Exempt Bonds
								Taxable Bonds
	$	0.00	$	0.00	$	0.00		Private LIHTC
								Other Equity
	$	0.00	$	0.00	$	0.00		Homebuyer Down Payment
								Donations/Grants
								Private Lender
								Other
								Describe Other:
								Total Private Funds	$	0.00
				Total Uses	$	0.00		Total Sources	$	0.00
										form HUD-52860-A (08/2002)