Form Hud-40094 - Rental/homebuyer/homeowner Rehab Set-Up Report
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5HUD-40094
U.S. Department of Housing
OMB Approval No. 2506-0171
Rental/Homebuyer/Homeowner
(Exp. 8/31/2009)
and Urban Development
Rehab Set-Up Report
Office of Community Planning
and Development
HOME Program
The HOME statute imposes a significant number of data collection and reporting requirements. This includes information on assisted properties, on the
owners or tenants of the properties, and on other programmatic areas. The information will be used: 1) to assist HOME participants in managing their
programs; 2) to track performance of participants in meeting fund commitment and expenditure deadlines; 3) to permit HUD to determine whether each
participant meets the HOME statutory income targeting and affordability requirements; and 4) to permit HUD to determine compliance with other
statutory and regulatory program requirements. This data collection is authorized under Title II of the Cranston-Gonzalez National Affordable Housing
Act or related authorities. Access to Federal grant funds is contingent on the reporting of certain project-specific data elements. Records of information
collected will be maintained by the recipients of the assistance. Information on activities and expenditures of grant funds is public information and is
generally available for disclosure. Recipients are responsible for ensuring confidentiality when public disclosure is not required.
Note: Complete for all Rental/Homebuyer/Homeowner Rehab Activities to
Check the Appropriate Box:
be set-up.
Original Submission
Change Owner’s Address
Ownership Transfer
Revision
Part A:
1. Activity Number
2. Name of Participant
6. HOME Funds for Activity
a. Total Funds Requested + $
3. Participant Tax ID Number
4. CHDO Tax ID Number
b. Participant Number
c. Dollar Amount of Funds
$
5. Type of Activity
(1)
Rehab
(3)
Acquisition Only
(5)
Acquisition New Construction
$
(2)
New Construction
(4)
Acquisition Rehab
8. Name &Phone Number of person completing form
9. CHDO Loan
(1)
Yes
$
(2)
No
7. Total Estimated Cost of Activity (HOME-assisted units,
including other public/private funds)
$
Part B: Activity Information
1. Street Address of Activity
1a. City
1b. State
1c. Zip Code
2. Name of Owner
2a. Last Name
2b. First Name
Mr.
Mrs.
Ms.
3. Mailing Address of Owner
3a. City
3b. State
3c. Zip Code
3d. Phone Number
4. Name of Firm (if applicable)
5. Total Units in Activity
6. Estimated Units
7. Total HOME-Assisted
Prior to Assistance
Upon Completion
Units Upon Completion
8. Type of Ownership (Check one box)
9. Tenure Type (Check one box only)
10. Complete for
11. County Code (to
CHDO Activities
be completed by
(1)
Individual
(4)
Not-for-Profit
(1)
Rental
(Check one box only)
Centralized States
(2)
Partnership
(5)
Publicly Owned
(2)
Homebuyer
only)
(3)
Corporation
(9)
Other
(3)
Homeowner Rehab
(1)
Owned
(2)
Sponsored
(3)
Developed
Page 1 of 5
form HUD-40094 (02/2003)
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