Form Hud-40100-C - State Designation Of Other Entities - U.s. Department Of Housing And Urban Developmen

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State Designation of Other Entities
U.S. Department of Housing
OMB Approval No. 2506-0171
(Exp.11/30/2001)
and Urban Development
HOME Program
Office of Community Planning
Cash and Management Information (CMI) System
and Development
Return this form to:
To be completed by the Chief
Home Program,
Executive Officer or the
P.O. Box 23997, L'Enfant Plaza Station,
Designated Representative.
Washington, D.C. 20026
Name & Address of State
Type of Submission
State Participant Number
Original
Duplicate
State Participant Tax ID Number
Revision
Name & Address of Other Entity
Other Entity Number: (assigned by State)
Other Entity Tax ID Number
Amount of Funds Allocated to Other Entity
Functions Delegated to Other Entity
(mark appropriate box(es))
Previous Allocation
This Action (+)(-)
Revised Allocation
Total Allocation
$
$
$
Project Set-up
Disbursement
(Project Funds)
Project Funds
Disbursement
(Admin. Funds)
Administrative Funds
None
CHDO Operating Expenses
CHDO Reallocation
Name & Address of Other Entity
Other Entity Number: (assigned by State)
Other Entity Tax ID Number
Amount of Funds Allocated to Other Entity
Functions Delegated to Other Entity
(mark appropriate box(es))
Previous Allocation
This Action (+)(-)
Revised Allocation
Total Allocation
$
$
$
Project Set-up
Disbursement
Project Funds
(Project Funds)
Disbursement
(Admin. Funds)
Administrative Funds
None
CHDO Operating Expenses
CHDO Reallocation
Name & Address of Other Entity
Other Entity Number: (assigned by State)
Other Entity Tax ID Number
Amount of Funds Allocated to Other Entity
Functions Delegated to Other Entity
(mark appropriate box(es))
Previous Allocation
This Action (+)(-)
Revised Allocation
Total Allocation
$
$
$
Project Set-up
Disbursement
(Project Funds)
Project Funds
Disbursement
(Admin. Funds)
Administrative Funds
None
CHDO Operating Expenses
CHDO Reallocation
Approved by (Name, title and phone including area code)
Notary (Signature, date & seal)
Signature & Date
X
form HUD-40100-C (9/94)
Page 1 of
Previous edition is
____
obsolete.

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