HUD-4117 Appendices A-D

Indian Housing Block Grants (IHBG) Program Reporting

Final - HUD Form 4117 FRF Appendices A-D

Indian Housing Block Grants (IHBG) Program Reporting

OMB: 2577-0218

Add Other Geographies to Formula Area Based on Provision of Substantial Housing Services

Specific Geographic Area Requested

Number of Tribal Members Living in Requested Area

Affordable Housing Program/Program Purpose

Program Income Eligibility Provisions

Source of Funds

Year(s)

Total Dollar Amount of Program Investment by Year (If multiple sources of funding, please separate IHBG from other)

Document [docx]

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OMB Control No: 2577-0218

OMB Expiration Date: X/XX/20XX

Indian Housing Block Grant Formula Response Form Appendix A1:

Conveyance Eligibility and Conveyance of Formula Current Assisted Stock (FCAS) Units

Public Reporting Burden Statement: This collection of information is estimated to average 2 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.

Conveyance Regulation:

According to 24 CFR 1000.318,

"(a) Mutual Help and Turnkey III units shall no longer be considered Formula Current Assisted Stock (FCAS) when the Indian Tribe, TDHE, or IHA no longer has the legal right to own, operate, or maintain the units, whether such right is lost by conveyances, demolition, or otherwise, provided that:

(1) Conveyance of each Mutual Help or Turnkey III unit occurs as soon as practicable after a unit becomes eligible for conveyance by the terms of the Mutual Help and Occupancy Agreement (MHOA); and

(2) The Indian tribe, TDHE, or IHA actively enforce strict compliance by the homebuyer with the terms and conditions of the MHOA, including the requirements for full and timely payment.

(b)(1) A Mutual Help or Turnkey III unit not conveyed after the unit becomes eligible for conveyance by the terms of the MHOA may continue to be considered Formula Current Assisted Stock only if a legal impediment prevented conveyance; the legal impediment continues to exist; the tribe, TDHE, or IHA has taken all other steps necessary for conveyance and all that remains for conveyance is a resolution of the legal impediment; and the tribe, TDHE, or IHA made the following reasonable efforts to overcome the impediments:

(i) No later than four months after the unit becomes eligible for conveyance, the tribe, TDHE, or IHA creates a written plan of action, which includes a description of specific legal impediments as well as specific, ongoing, and appropriate actions for each applicable unit that have been taken and will be taken to resolve the legal impediments within a 24-month period; and

(ii) The tribe, TDHE, or IHA has carried out or is carrying out the written plan of action; and

(iii) The tribe, TDHE, or IHA has documented undertaking the plan of action.

(2) No Mutual Help or Turnkey III unit will be considered FCAS 24 months after the date the unit became eligible for conveyance, unless the tribe, TDHE, or IHA provides evidence from a third party, such as a court or state or federal government agency, documenting that a legal impediment continues to prevent conveyance. FCAS units that have not been conveyed due to legal impediments on December 22, 2016 shall be treated as having become eligible for conveyance on December 22, 2016.”

The tribe/TDHE shall not include units that have been paid-off but not conveyed unless the tribe/TDHE can demonstrate that the unit has not be conveyed for reasons beyond the tribe/TDHE’s control.

The deadline for responding with changes to the data on the Formula Response Form is August 1. Any changes reported after the August 1 deadline are not timely under §1000.315 and §1000.319. Accordingly, no back funding will be provided based on changes reported after August 1.

To maintain fairness to all tribes, if tribes receive funding for ineligible units, repayment will be required.

On Table A1-1 below Report:

All units that have been conveyed that did not have legal impediments preventing conveyance.
All units that are conveyance eligible but not conveyed.

TABLE A1-1: Conveyed units and conveyance-eligible units that did not/do not have legal impediments preventing conveyance
Project Number	Unit Number	Conveyance Eligibility date*	Conveyance date

*The conveyance eligibility date is the date that the unit’s purchase price was paid-off, whether through lump sum payment, accrual in equity accounts, self-amortization of the purchase price, or any combination of these. Because the MHOA has a self-amortizing purchase price, pay-off necessarily occurs no later than the end of the term of the MHOA.

On Table A1-2 below Report:

All units that are paid-off that have legal impediments preventing conveyance.
All units that were previously removed as conveyance eligible that had legal impediments and that have since conveyed.
For each unit meeting the criteria in bullets 1 and 2 above, provide reasons that conveyance was beyond the tribe’s control and steps the tribe has taken to resolve the problem. For further information see PIH Notice 2017-15.

TABLE A1-2: Units that are eligible for conveyance with legal impediments preventing conveyance
Project Number	Unit Number	Conveyance Eligibility date*	Conveyance date	Explanation of legal impediments preventing timely conveyance**

**Explanation of legal impediments preventing timely conveyance of each unit can be provided on supplemental pages if more space is needed.

Indian Housing Block Grant Formula Response Form Appendix A2:

Date of Full Availability (DOFA) of

Formula Current Assisted Stock (FCAS) Units

DOFA Regulation:

According to 24 CFR 1000.312 and 1000.314, FCAS "consists of housing units owned or operated pursuant to an ACC. This includes all Low Rent, Mutual Help, and Turnkey III housing units under management as of September 30, 1997, and all 1937 Act units in the development pipeline when they become owned or operated by recipients and are under management as indicated in the Formula Response Form."

Report:

Low Rent, Mutual Help, and Turnkey III units funded under 1937 Housing Act

(i.e., units that were subject to an Annual Contributions Contract (ACC)).

Do Not Report:

Units built with NAHASDA, HOME, or ICDBG funds.
Units built with Bureau of Indian Affairs, State, or tribal funds.
Units built over the number specified in the original ACC for Projects with DOFA after

October 1, 1997.

Please provide the information below for each new reported project DOFA. Please provide a copy of the ACC for each reported project indicating the number and type of units allowed.

In accordance with §1000.319(c), a recipient will not be provided back-funding for any units that the recipient failed to report on the Formula Response Form in a timely manner.

Project Number	Number of Units	Type of Units	DOFA

Indian Housing Block Grant Formula Response Form Appendix A3:

Conversion of Formula Current Assisted Stock (FCAS) Units

Public Reporting Burden Statement: This collection of information is estimated to average 2 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.

Conversion Regulation:

According to 24 CFR 1000.316 (c), “If units were converted before October 1, 1997, as evidenced by an amended ACC, then those units will be counted for formula funding and eligibility purposes as the type of unit to which they were converted. If units were converted on or after October 1, 1997, the following applies:

Units that converted after October 1, 1997 will be counted as the type of unit specified on the original ACC in effect on September 30, 1997.
Whether or not it is the first conversion, a unit converted after October 1, 1997, will be considered as the type converted to when determining continuing FCAS eligibility. A unit that is converted to low-rent will be treated as a low-rent unit for purposes of determining continuing FCAS eligibility. A unit that is converted to homeownership will be treated as a homeownership unit for purposes of determining continuing FCAS eligibility.
The Indian tribe, TDHE, or IHA shall report conversions on the Formula Response Form.”

Report:

Newly converted units.

Do Not Report:

Units that have been previously reported as converted unless there has been a change.

Please provide the information below for each unit converted. Please provide a copy of the Amended ACC for each unit converted prior to October 1, 1997.

Project Number	Unit Number	Unit Type as listed on Formula Response Form (LR, MH, TKY III)	Unit Type after Conversion (LR, MH, TKY III)	Date of Conversion

Indian Housing Block Grant Formula Response Form Appendix A4:

Demolition and Rebuilding of Formula Current Assisted Stock (FCAS) Units

Demolition Regulation:

According to 24 CFR 1000.318(e), "A unit that is demolished pursuant to a planned demolition may be considered eligible as a FCAS unit if, after demolition is completed, the unit is rebuilt within one year. Demolition is completed when the site of the demolished unit is ready for rebuilding. If the unit cannot be rebuilt within one year because of relative administrative capacities and other challenges faced by the recipient, including but not limited to geographic distribution within the Indian area and technical capacity, the Indian tribe, TDHE or IHA may request approval for a one-time, one-year extension. Requests must be submitted in writing and include a justification for the request.”

Report:

All demolished units when demolition is complete.
All units that were rebuilt. If applicable, provide justification of why the units cannot be rebuilt within one year of demolition.

Please note that requests for a one-time, one-year extension must be made within 24 months of completed demolition.

Project Number	Unit Number	Date Demolition Completed	Date Unit Rebuilt	Explanation of why unit was not rebuilt within one year of demolition date

Indian Housing Block Grant Formula Response Form Appendix A5:

All Other Corrections to Formula Current Assisted Stock (FCAS)

FCAS Correction Regulation:

According to 24 CFR 1000.312 and 1000.314, Formula Current Assisted Stock (FCAS) consists of housing units owned or operated pursuant to an ACC. This includes all Low Rent, Mutual Help, and Turnkey III units under management as of September 30, 1997, and all 1937 Act units in the development pipeline when they become owned or operated by recipients and are under management as indicated in the Formula Response Form.

On Table A5-1 Report:

Units not used as low-income housing dwelling units.
- Include units used for non-dwelling purposes.
- Include vacant units, unless they are being made available for occupancy through, for example, active repair or rehabilitation, advertising, or processing from a wait list.
- Include units that are not occupied by a NAHASDA eligible family.

On Table A5-2 Report:

Units previously removed based upon the project's DOFA that are still eligible for FCAS because of a subsequent homebuyer.

On Table A5-3 Report:

Differences between FCAS reported on the Formula Response Form and your Tribe’s records that are not due to conveyances, Date of Full Availability and/or conversion.

TABLE A5-1: Units not used as low-income dwelling units
Project Number	Unit Number	Date unit was last occupied by eligible recipient	Reason for change

TABLE A5-2: Units with Subsequent Homebuyers
Project Number	Unit Number			New Agreement Signed Date		Term of the Agreement (in years)





TABLE A5-3: All other corrections to FCAS
Project Number		Formula Response Form Unit Counts & Unit Type	Correct Number of Units & Unit Type		Reason/Explanation for Change

Indian Housing Block Grant Formula Response Form Appendix B1:

Request to Add Other Geographies to Formula Area Based on Formula Area Definition

Formula Area Regulation:

According to 24 CFR 1000.302 Formula Area, (1) Formula areas are: (i) Reservations for federally recognized Indian tribes, as defined by the U.S. Census; (ii) Trust lands; (iii) Department of the Interior Near-Reservation Service Areas; (iv) Former Indian Reservation Areas in Oklahoma Indian Areas, as defined by the U.S. Census as Oklahoma Tribal Statistical Areas (OTSAs); (v) Congressionally Mandated Service Areas; (vi) State Tribal Areas as defined by the U.S. Census as State Designated American Indian Statistical Areas (SDAISAs); (vii) Tribal Designated Statistical Areas (TDSAs); (viii) California Tribal Jurisdictional Areas established or reestablished by Federal court judgment; and (ix) Alaska formula areas described in paragraph (4) of this definition.

Please show the boundaries of the area being requested on a map** and provide a copy of legal documents (e.g., Federal Register Notice, publication of designation of Near-Reservation Service Area, Public Law documents legislating Congressionally Mandated Service Areas) for each geographic area you want to add to your Tribe’s Formula Area.

To request additional areas beyond those identified in the above list of nine, see Appendix B2.

**Maps are available from the US Census Bureau. https://www.census.gov/geo/maps-data/

Geographic Area requested	Category Requested (i.e. reservation, OTSA, SDAISAs, etc.)	Legal Document provided (description)	Map provided (Yes or No)?

Indian Housing Block Grant Formula Response Form Appendix B2:

Request to Add Other Geographies to Formula Area Based on Provision of Substantial Housing Services

Substantial Housing Services Regulation:

According to 24 CFR 1000.302 Formula Area: (2)(i) For a geographic area not identified in paragraph (1) of this definition, and for expansion or re-definition of a geographic area from the prior year, including those identified in paragraph (1) of this definition, the Indian tribe must submit, on a form agreed to by HUD, information about the geographic area it wishes to include in its Formula Area, including proof that the Indian tribe, where applicable, has agreed to provide housing services pursuant to a Memorandum of Agreement (MOA) with the tribal and public governing entity or entities of the area, or has attempted to establish such an MOA; and is providing substantial housing services and will continue to expend or obligate funds for substantial housing services as reflected in the form agreed to by HUD for this purpose.

According to §1000.302, Substantial Housing Services: (1) Affordable housing activities funded from any source provided to American Indian and Alaska Native (AIAN) households with incomes 80 percent of the median income as defined in the Native American Housing Assistance and Self-Determination Act (NAHASDA) (25 U.S.C. 4103 (14)) or lower, equivalent to 100 percent or more of the increase in the IHBG formula allocation that the Indian tribe would receive as a result of adding the proposed geography; or (2) Affordable housing activities funded with IHBG funds provided to AIAN households with incomes 80 percent of the median income as defined in NAHASDA or lower, equivalent to 51 percent or more of the Indian tribe’s current total IHBG grant; and either: (i) 51 percent or more of the Indian tribe’s official enrollment resides within the geographic area; or (ii) The Indian tribe’s official enrollment constitutes 51 percent or more of the total AIAN persons within the geography. (3) HUD shall require that the Indian tribe annually provide written verification…that the affordable housing activities it is providing meet the definition of substantial housing services.

If you wish to request additional areas based on the above regulations, please provide a map showing the boundaries if the area being requested**, an MOA or documentation of the Tribe’s efforts to secure one, and fill in the two tables below for each area that you want to add to your Tribe’s Formula Area. In addition, please provide a brief narrative describing each program and any income eligibility provisions that apply. Use a separate table for each geographic area requested.

Total dollar amount of program investment by year must appear in the Indian Housing Plan (IHP) and actual accomplishments must appear in the Annual Performance Report (APR) separately for each area requested. HUD will monitor Formula Area additions to ensure that the tribe continues investment at levels that are consistent with the definition of Substantial Housing Services.

**Maps are available from the US Census Bureau at https://www.census.gov/data

Indian Housing Block Grant Formula Response Form Appendix C: Enrollment in Overlapping Areas

Overlapping Area Regulation:

According to 24 CFR 1000.326, “(a) If an Indian tribe’s formula area overlaps with the formula area of one or more other Indian tribes, the funds allocated to that Indian tribe for the geographic area in which the formula areas overlap will be based on: (1) The Indian tribe’s proportional share of the population in the overlapping geographic area; and (2) The Indian tribe’s commitment to serve that proportional share of the population in such geographic area. (3) In cases where a State recognized tribe’s formula area overlaps with the formula area of a Federally recognized Indian tribe, the Federally recognized Indian tribe receives the allocation for the formula area up to its population cap, and the State recognized tribe receives the balance of the overlapping area (if any) up to its population cap.

(b) Tribal membership in the geographic area (not to include dually enrolled tribal members) will be based on data that all Indian tribes involved agree to use. Suggested data sources include tribal enrollment lists, the U.S. Census, Indian Health Service User Data, and Bureau of Indian Affairs data. (c) If the Indian tribes involved cannot agree on what data source to use, HUD will make the decision on what data will be used to divide the funds between the Indian tribes by August 1*.”

Please provide the information below for each overlapping geographic area of your Tribe’s Formula Area as listed in the Formula Response Form. This information will only be used if ALL tribes in the overlapping area submit data.

Geographic Area Name	Tribal Enrollment

*Please note that with respect to overlapping areas, while HUD requires requests for formula changes to be submitted byAugust 1^st, HUD may consider subsequent requests related to overlapping areas from tribes that have been directly affected by changes resulting from requests

submitted by another tribe or tribes in the overlapping area that were submitted prior to the August 1 deadline. Subsequent requests received in prior FYs may be carried into future FYs if processing of such requests is not finalized in the current FY.

Indian Housing Block Grant Formula Response Form Appendix D:

Tribal Enrollment & Population Cap

Tribal Enrollment and Population Cap Regulation:

According to 24 CFR 1000.302, “(5) In some cases the population data for an Indian tribe within its Formula Area is greater than its tribal enrollment. In general, to maintain fairness for all Indian tribes, the tribe’s population data will not be allowed to exceed twice an Indian tribe’s enrolled population. However, an Indian tribe subject to this cap may receive an allocation based on more than twice its total enrollment if it can show that it is providing housing assistance to substantially more non-member Indians and Alaska Natives who are members of another federally recognized Indian tribe than it is to members. For state-recognized Indian tribes, the population data and formula allocation shall be limited to their Tribal Enrollment figures as determined under enrollment criteria in effect in 1996. (6) In cases where an Indian tribe is seeking to receive an allocation more than twice its total enrollment, the tribal enrollment multiplier will be determined by the total number of Indians and Alaska Natives the Indian tribe is providing housing assistance (on July 30 of the year before funding is sought) divided by the number of members the Indian tribe is providing housing assistance. For example, an Indian tribe which provides housing to 300 Indians and Alaska Natives, of whom 100 are members, would then be able to receive an allocation for up to three times its tribal enrollment if the Indian and Alaska Native population in the area is three or more times the tribal enrollment.”

Appendix D1: Corrections to and Certification of Tribal Enrollment:

If you wish to correct your Tribe’s enrollment, you must complete the appropriate certification below and submit it to the IHBG Formula Customer Service Center by the correction deadline.

If there is a "*" next to "AIAN persons" in the Needs section of the Formula Response Form, your Tribe's data have been "capped." Whether or not you wish to correct your Tribe’s enrollment, if the population data within your Tribe’s Formula Area exceeds twice your Tribe’s enrollment (i.e., your Tribe is subject to the population cap described above), you must complete the appropriate certification below and submit it to the IHBG Formula Customer Service Center by the correction deadline.

Check and complete the applicable certification:

I certify, to the best of my knowledge, the Tribe’s enrollment number contained in this document is the most accurate number available at the time of certification.**

I certify, to the best of my knowledge, the Tribe’s enrollment number contained in this document is inaccurate.

The Tribe’s most accurate enrollment number available at the time of the certification is: .**

Shape9 Shape8 Shape7

Shape10

Signature of Tribal Representative authorized to make this certification

Print Name: Title: Date:

If the population data within your Tribe’s Formula Area exceeds twice your Tribe’s enrollment and you fail to complete the above certification and submit it to the IHBG Formula Customer Service Center by the correction deadline, you will be deemed to have certified the Tribe’s enrollment number contained in this document is the most accurate number available at the time of certification, which will be the correction deadline.**

Warning: I/We, the undersigned, certify under penalty of perjury that the information provided on this form is true, accurate 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 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012, 1014; 31 U.S.C. §3729, 3802).

Indian Housing Block Grant Formula Response Form Appendix D2:

Corrections to Population Cap

According to the Native American Housing Assistance and Self-Determination Act Guidance 98-12, “A tribe must demonstrate that it is serving substantially more non-member Indians and Alaska Natives who are members of another federally recognized tribe than members. For Population Cap purposes, Housing Assistance refers to grants or subsidies provided within the year before funding is sought to make housing more affordable for low-income Indians and Alaska Natives who are member of Federally recognized Indian tribes including but not limited to: HOME programs; energy assistance; home improvement assistance; mortgage or downpayment assistance; homeless or emergency shelter assistance; and, programs similar to the programs formerly known as Mutual Help, Low Rent, Turnkey 3, and Section 8.”

If you wish to adjust your Tribe’s population cap to a level greater than twice your Tribe’s enrollment, please provide the information below and a brief narrative describing the programs.*

A	B	C	D
Tribal Enrollment	Total Number of AIAN Persons Served	Total Number of Tribal Members Served	Total Number of Members of Other Federally Recognized Tribes Served	Population Factor (C+D)/C (submit if Factor>2.0)

Previous editions are obsolete Page 3 of 21 Form HUD-4117-Appendices A-D

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