Form Hud-92045 Multifamily Housing Assisted Living Conversion Program Application Summary Sheet

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OMB Approval No. 2502-0542

U.S. Department of Housing

Multifamily Housing Assisted

(exp. 11/30/2016)

and Urban Development

Living Conversion Program

Office of Housing

Federal Housing Commissioner

APPLICATION SUMMARY SHEET

Public reporting burden for 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 information. HUD may not collect this information, and you are not required to

complete this form, unless it displays a currently valid OMB control number.

This collection of information is required for HUD’s Assisted Living Conversion Program (ALCP). This program is

authorized under Section 522(c) of the Appropr iations Act of 2000. The information is necessary to assist HUD in

determining applicant eligibility and ability to con vert multifamily housing projects designated for the elderly (in whole or

in part) into assisted living facilities. A thorough evaluation of an applicant’s qualifications and capabilities is cr itical to

protect the Government’s financial interest and to mitigate an y possibility of fraud, waste, or mismanagement of public

funds. This collection of information does not collect any sensitive information. HUD does not ensure confidentiality.

Owner (Funds Recipient) Name ___________________________________________________

Address ____________________________________________________________________________

__________________________________________________________________________

City _____________________________ State ____________________ Zip ____________

Phone (Include Area Code) _______________________

Grant Contact Person (Name) ________________________________________

Phone (Include Area Code) _______________________

E-mail address _______________________________________________

List the specific development(s) targeted for assistance under this grant. Use additional sheets as needed.

Development Name ____________________________________________________________

Address ________________________________________________________________________

_______________________________________________________________________

City _____________________________ State ____________________ Zip ____________

FHA/Project Number _______________________________ Sec.8 Number _______________

Project Type (e.g., 236) ______________________________ No . of Units ______________

Location (Urban, suburban, or rural) ______________________________________________

Number of Residents __________ Estimated Number of F rail Elderly __________

Estimated Number of Non-elderly People with Disabilities ___________

Estimated Number of At-risk Elderly __________

Are you applying for a Service Coordinator Grant? _____ Yes

_____ No

Will this development share a service coordinator with other developments? _____ Yes

_____ No

If yes, please give name and address of the development(s) if different.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Senators 1. ________________________________ 2. _______________________

Congressional Representative(s) Name(s) 1. _______________________ District(s) 1. _________________

2. _______________________

2. _________________

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form HUD-92045 (3/2002)