HUD 4123-4125 Combined Cost Summary

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Overview

Instructions
Form 4123
Form 4125

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Sheet 1: Instructions

Instructions for Completing 4123 and 4125
FORM HUD-4123
Section
1	Input Applicant name.
2	Input the ICDBG or IHBG-COMP grant number if it has been assigned by HUD. Leave blank if unknown at time of application.
3	Enter "X" for original submission or amended Cost Summary and Enter the date you completed this form.
4	Enter the project name. On the rows below, enter project costs. Use columns (b), (c) and (d) to indicate the applicable source for each line item. Use column (f) to describe the source of funds in column (d).
5	Enter planned administrative expenses, including (if applicable) indirect costs and audit costs. Administrative costs must not exceed 20% of the grant.
6	ICDBG only: Enter amount of ICDBG funds requested for technical assistance, if applicable. No more than 10% of ICDBG funds requested may be used for technical assistance. If funds are requested under this line item, a separate project description must accompany the application to describe the technical assistance the application intends to obtain. Only technical assistance costs associated with the development of a capacity to undertake a specific funded program activity are eligible (24 CFR 1003.206).
7	ICDBG only: Enter amount of ICDBG funds requested for Public Services. Public Service costs must not exceed 15% of the total ICDBG grant.
FORM HUD-4125
Section
1	Applicant Name: Auto populates from Form HUD-4123.
2	Input the ICDBG or IHBG-COMP grant number if it has been assigned by HUD. Leave blank if unknown at time of application.
3	Enter "X" for original submission with application or amended Implementation Schedule.
4	Enter the date you completed this form.
5	Project Name: Auto populates from Form 4123.
6	Period of Performance: Insert Start Date and End Date.
7	Expected Close Out Date: auto-populates 90 days from period of performance end date in from Box 6.
8	Insert an "X" in the box that best describes current Environmental Review status.
9	Insert description of task.
10	Insert anticipated start and end month/year of task.

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Sheet 2: Form 4123

Cost Summary HUD-4123							U.S. Department of Housing					OMB Approval No.2501-0044
Indian Community Development Block							and Urban Development					(exp. 2/28/2027)
Grant (ICDBG) and Indian Housing Block							Office of Public and Indian Housing
Grant Competitive (IHBG-COMP)
See Instructions and Public Reporting Statement
1. Name of Applicant (as shown on Standard Form 424)									2. Grant Number (assigned by HUD)
3.		Original (initial application)			Amendment (submitted after initial application)							Date (mm/dd/yyyy)
4.	Program Name:					Planned ICDBG Expenditures (b)	Planned IHBG-COMP Expenditures (c)	Other Federal and Non-Federal Expenditures (d)			Total Planned Expenditures (e)	Source of Other Funds in Column d (f)
Project Costs (a)
											$-
											$-
											$-
											$-
											$-
											$-
											$-
											$-
											$-
											$-
5.	Administration
	a	Planning and Administration Cost:									$-
	b	Indirect Costs: Enter indirect costs to be charged to the Program pursuant to a cost allocation plan.									$-
	c	Audit: Enter estimated cost of Program share of financial audits.									$-
	Administrative Total					$-	$-	$-			$-
6.	Technical Assistance: Enter amount requested for technical assistance. (up to 10% of total ICDBG Grant)										$-
7.	Public Service Component: up to 15% of ICDBG grant.										$-
8.	TOTAL EXPENDITURES					$-	$-	$-			$-
This collection of information is estimated to average 40 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 of 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.

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Sheet 3: Form 4125

Implementation Schedule HUD-4125

U.S. Department of Housing

OMB Approval No.2501-0044

Indian Community Development Block Grant (ICDBG)

and Urban Development

(exp. 2/28/2027)

and Indian Housing Block Grant Competitive (IHBG-COMP)

Office of Public and Indian Housing

See Instruction Tab and Public Reporting Statement.

Submit a separate implementation schedule for each project category.

1. Name of Applicant (as shown on Standard Form 424)

2. Grant Number (assigned by HUD)

3.

Original (First Submission to HUD)

4. Date (mm/dd/yy)

Auto Populates from Form 4123

Amendment (submitted after initial application)

5. Name of Project (as shown on form HUD-4123)

6. Period of Performance

7. Expected Close Out

Start Date (mm/dd/yy)

End Date (mm/dd/yy)

Date (mm/dd/yy)

Auto Populates from Form 4123

auto populates

8. Environmental Review Status

Exempt (as described in 24 CFR 58.34)

Under Review (review underway;

Finding of No Significant Impact (Finding made that request for release of

Categorically Excluded

findings not yet made)

funds for project is not an action which may significantly affect the environment)

(as described in 24 CFR 58.35)

EIS Required (Finding that project may

Not Started

Certification (Environmental review completed;

significantly affect environment or

(Review not yet begun)

certification and request for release of funds

EIS automatically required by 24 CFR 58.37)

being prepared for submission.)

9. Task List (List tasks such as environmental review, acquisition, etc.)

10. Schedule (anticipated start and end date of task) mm/yy

(Insert lines as needed. Home tab, cells, insert sheet row)

Start Date

End Date

This collection of information is estimated to average 40 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 of 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.