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STATE OF CALIFORNIA SECTION 811 PROJECT RENTAL ASSISTANCE DEMONSTRATION PROGRAM APPLICATION FORM Section 811 Project Rental Assistance Application Form –Rev August 2017

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Page 1:  · Web viewWater Conservation Fixtures - Installation of water-conserving fixtures is i.e. resource efficient plumbing and appliances such as low flow showerheads and faucet and

STATE OF CALIFORNIA

SECTION 811 PROJECT RENTAL ASSISTANCE DEMONSTRATION PROGRAM

APPLICATION FORM

Section 811 Project Rental Assistance Application Form –Rev August 2017

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TABLE OF CONTENTS

I. LIST OF ATTACHMENTS............................................................................................3

II. APPLICATION SUMMARY FORM..............................................................................4

III. SAMPLE GOVERNING BOARD RESOLUTION.........................................................5

IV. PROPOSED OCCUPANCY SCHEDULE...................................................................7

V. FEDERAL OVERLAY COMPLIANCE..........................................................................8

A. HOUSING STANDARDS AND ACCESSIBILITY........................................................................................8

B. AFFIRMATIVELY FURTHERING FAIR HOUSING..................................................................................11

C. FULL DISLOSURE OF AVAILABLE HOUSING.......................................................................................14

D. LIMITED-ENGLISH PROFICIENCY (LEP)..............................................................................................15

E. ENERGY AND WATER CONSERVATION..............................................................................................16

F. ENVIRONMENTAL REQUIREMENTS...................................................................................................17

G. LEAD-BASED PAINT...........................................................................................................................24

VI. APPLICANT OR PROPERTY MANAGER EXPERIENCE........................................25

VII. NEED.......................................................................................................................29

VIII. PROJECT SUITABILITY........................................................................................31

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I. LIST OF ATTACHMENTS

Attachment Description See for More Details

Check if provided or N/A if you believe this item is Not Applicable to your application. If N/A, briefly explain

why.A Applicant and

Tenant Referral Organization Written

Agreement

NOFA Section VIII

B Notice of Completion and

Davis-Bacon Wage Determination

NOFA Section XIII.F and Excel File

C Governing Board Resolution

Application Section III

D Tenant Selection Plan

NOFA Section XIII.C

E

Label each environmental document separately as E1, 2, 3, etc., in the order in which documents are

requested in the application, If submitting environmental documents for multiple properties

within the same application, Property #2 Environmental documents are Attachment F, 1, 2, 3,

etc; Property #3 environmental documents are Attachment G, 1,2,3, etc…

Environmental Compliance

Documentation

NOFA Section XIII.H and Application Section V.F

* Add rows if necessary for additional attachments.

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II. APPLICATION SUMMARY FORM 1

Applicant Name: 2

Address: City: State: Zip:

Applicant Contact Person:

Phone:

E-mail address:

Project Sponsor DUNS #

CCT Provider:

Address: City: State: Zip:

Contact Person(s):

Phone:

E-mail address:

Service Area(s):

Regional Center Organization:

Address: City: State: Zip:

Contact Person(s):

Phone:

E-mail address:

Service Area(s):

Application Type: ___ Single Project Application; ___ Multi-Project Application

Total PRA Funds Requested 3 $: Total Projected Number of Units to receive PRA 4

1 Add more lines as necessary to accommodate contact information for more than two Tenant Referral Organizations.

2The entity submitting the PRA application to the State must be the Project Sponsor. For the purpose of application submission and evaluation, the Project Sponsor is the developer of the project(s) proposed for PRA assistance.

3 Figure should be calculated from Excel File “Funds Requested” Table(s) for each project that is part of this Application, “Total Rental Subsidy Per Project” line(s).

4 Figure should be calculated from Excel File “Funds Requested” Table(s) for each project that is part of this Application, “Total Units Requested Per Project” line(s).

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III. SAMPLE GOVERNING BOARD RESOLUTION

RESOLUTION NO. _______________

THE GOVERNING BOARD OF

[Name of Applicant]

HEREBY AUTHORIZES: Submittal of an application to the California Housing Finance Agency for funding under the Project Rental Assistance Demonstration (PRA) Program; and if selected, the execution of any related documents necessary to participate in the PRA Program.

WHEREAS:A. The California Housing Finance Agency (CalHFA) is authorized to allocate Project Rental

Assistance Demonstration Program (PRA) funds made available from the U.S. Department of Housing and Urban Development (“HUD”). PRA funds are to be used for the purposes set forth in Section 811 of the Cranston-Gonzalez National Affordable Housing Act, as amended by the Frank Melville Supportive Housing Investment Act of 2010 (Pub. L. 111-374.

B. On August 1, 2014 CalHFA issued a Notice of Funding Availability announcing the availability of funds under the PRA program (the “NOFA”).

C. In response to the NOFA, ______________________ [insert name of applicant] a ____________________ [insert the legal form of entity, e.g., municipal corporation, subdivision of the State of California, nonprofit corporation] (the “Applicant”), wishes to apply to CalHFA for, and receive an allocation of, PRA funds.

IT IS NOW THEREFORE RESOLVED THAT:

1. In response to the NOFA, the Applicant shall submit an application to CalHFA to participate in the PRA program and for an allocation of funds not to exceed ______________________ Dollars ($_______________) for project-based rental assistance to be located in _________________________________ [activity/program location(s)].

2. If the application for funding is approved, then the Applicant hereby agrees to use the PRA funds for eligible activities in the manner presented in its application as approved

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by CalHFA in accordance with the statutes cited above and program requirements. The Applicant may also execute any and all other documents or instruments necessary or required by CalHFA or HUD for participation in the PRA program (collectively, the required documents).

3. The applicant authorizes _________________ [position title(s) of person(s) authorized] or his/her designee(s) to execute, in the name of the applicant, the required documents.

PASSED AND ADOPTED THIS ________ DAY OF __________ 20__, BY THE FOLLOWING VOTE:

AYES:_____ NAYS:_________ ABSTAIN:________ ABSENT:________

The undersigned ____________________________ [title of officer] of the applicant does hereby attest and certify that the foregoing is a true and full copy of a resolution of the governing board of the applicant passed and adopted at a duly convened meeting on the date set forth above, and said resolution has not been altered, amended, or repealed.

_________________________________ ________________Signature Date

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IV. PROPOSED OCCUPANCY SCHEDULE

All PRA units must be occupied by September 30, 2020

Please provide a schedule below for rent-up of the requested number of PRA units by this deadline. If the projects for which you are requesting PRA funds include both new and existing projects, discuss the anticipated timeframes for both. Include the following implementation issues:

1. Execution of the written agreement between the housing Sponsor and the tenant-referral organizations

2. Start date for PRA referrals3. Expected average time from tenant identification to housing placement4. Expected number of placements per month5. Expected completion date of placements

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V. FEDERAL OVERLAY COMPLIANCE

A. HOUSING STANDARDS AND ACCESSIBILITY (NOFA Sections XIII. A & B.)

1. CERTIFICATION

To be completed by the project architect or other qualified third-party inspector for each project proposed for PRA assistance.

Project Name:

Address:

a) All PRA-assisted units meet local and State housing codes, ordinances, zoning requirements and minimum Uniform Physical Condition Standards and

b) The above-named project meets all of the applicable accessibility standards in place at the time of project construction or rehabilitation under the following provisions:

i. HUD Uniform Physical Condition Standards at 24 CFR 5.703, ii. The Uniform Federal Accessibility Standards at 24 CFR 40.7, iii. Section 504 of the Rehabilitation Act of 1973 as implemented by 24 C.F.R. Part 8;iv. The design and construction requirements of the Fair Housing Act as implemented by 24 CFR

Part 100; v. State of California accessibility standards for publically funded projects (Chapter 11A).

Name:

Title:

Organization:

Street Address:

Phone

E-mail:

Date:

Signature:

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2. Eligible Applicants and PRA Tenant Referral Organizations (TROs), please describe your Reasonable Accommodation process in accordance with Section 504, the Fair Housing Act, and the Americans with Disabilities Act, and applicable program requirements.

Applicant:

TROs:

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3. Eligible Applicants and PRA TROs, describe your methods of communication to persons with hearing, visual, or other communications-related disabilities consistent with Section 504 of the Rehabilitation Act of 1973 and, as applicable, the Americans with Disabilities Act.

Applicant:

TROs:

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B. AFFIRMATIVELY FURTHERING FAIR HOUSING (NOFA Section XIII.C.)

1. Please describe the specific actions that will be taken by the TROs associated with this application to meet the objectives of the State’s PRA Affirmative Marketing Requirements for each project associated with this application. (See Appendix B for the PRA Marketing Requirements.)

The TROs must sign and date below to certify that such actions will be taken. (Add more identification blocks if more than two TROs are associated with this application.)

Name:

Title:

Organization:

Street Address:

Phone

E-mail:

Date:

Signature:

Name:

Title:

Organization:

Street Address:

Phone

E-mail:

Date:

Signature:

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2. All methods of outreach and referral and management of TROs waiting list(s) must be consistent with fair housing and civil rights laws and regulations, and affirmative marketing requirements. (See Section XIII C. of the NOFA for additional information.)

a) Please describe how the TROs will manage their waiting list(s) for PRA-assisted projects consistent with the requirements of Section XIII C. of the NOFA.

b) Attach a copy of the project’s completed PRA Tenant Selection Plan as Attachment D. (One plan may be submitted for multiple properties within the same Application.)

Note: Sponsors of TCAC, HCD, or CalHFA-financed projects have permission to deviate from the Tenant Selection Plan approved in connection with this financing in order to meet PRA requirements.

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3. PRA-assisted units must be dispersed and integrated within the property.

Please describe how PRA units will be disbursed an integrated within each proposed PRA-assisted property:

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C. FULL DISLOSURE OF AVAILABLE HOUSING (NOFA Section XIII.D.)

Please describe your process for providing, in collaboration with your TROs, full disclosure to each applicant for a PRA-assisted unit of all options available to the applicant in the selection of the property in which to reside. Include a description of your process for providing:

(1) basic information about available sites (e.g., location, number and size of accessible units, access to transportation and commercial facilities);

(2) information on your process for requesting and determining if a Reasonable Accommodation is necessary, and

(3) an estimate of the period of time the applicant would likely have to wait to be admitted to units of different sizes and types (e.g., regular or accessible) at each site.

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D. LIMITED-ENGLISH PROFICIENCY (LEP) (NOFA Section XIII.E.)

Persons who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English can be Limited English Proficient, or ‘‘LEP,’’ Recipients of federal financial assistance have an obligation to reduce language barriers that can preclude meaningful access by LEP persons to its programs and services.

Eligible Applicants and their TROs, describe your:

a. outreach and marketing strategies to potential and existing LEP project tenants;b. policies to accommodate the oral and written language assistance needs of potential

and existing LEP project tenants.

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E. ENERGY AND WATER CONSERVATION (NOFA Section XIII. G.)

New Construction and Substantial Rehabilitation Projects must meet the following requirements at time of application for PRA assistance:

(1) Energy Efficiency - Low-rise (up to 3 stories): PRA-assisted properties must meet the requirements of EPA’s ENERGY STAR Qualified Homes. Mid-Rise & High Rise developments (4 or more stories) must meet the requirements of the ENERGY STAR Qualified Multifamily High Rise Buildings.

(2) Water Conservation Fixtures - Installation of water-conserving fixtures is i.e. resource efficient plumbing and appliances such as low flow showerheads and faucet and high efficiency toilets). The materials used should be the most current WaterSense or a greater water efficiency product.

Discuss how the project(s) proposed for PRA assistance complies with the above requirements.

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F. ENVIRONMENTAL REQUIREMENTS

(NOFA Section XIII.H.)

Complete this section as instructed below for each property that is part of this application. Include copies of all required documents below with the application. Unless otherwise indicated, the requirements below apply to all project types.

.

Project Type:

1. __ Existing Project that is HUD-funded or HUD-insured that will not engage in activities with physical impacts or changes beyond routine maintenance activities or minimal repairs.

If the above project type: (1) submit evidence of the project’s federal environmental clearance and project completion, such as a copy of their Authority to Use Grant funds and Notice of Completion. (2) Skip the rest of this section; no further action is required.

2. __ Existing Project without HUD funds or HUD insurance that will not engage in activities with physical impacts or changes beyond routine maintenance activities or minimal repairs.

3. __ New Construction Project

4. __ Rehabilitation Project (activities beyond routine maintenance and repair)

PRA funds cannot be awarded, until all necessary environmental clearance has been obtained.

Note: Projects for which construction or rehabilitation activity is underway at the time of PRA Application submission that have not already received their required federal environmental clearance through other federal funding sources cannot apply for PRA funds until construction is complete.

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Environmental Evaluation

1. Assess whether the site: (i) is listed on an EPA Superfund National Priorities or CERCLA list or equivalent State list; (ii) is located within 3,000 feet of a toxic or solid waste landfill site; (iii) has an underground storage tank other than a residential fuel tank; or (iv) is known or suspected to be contaminated by toxic chemicals or radioactive materials.

a. If none of these conditions exist , provide a letter of finding from Project Owner or Phase I preparer certifying that none of these conditions exist

ATTACHED CERTIFICATION LETTER

___ YES ___ NO

b. If any of these conditions exist, provide an ASTM Phase I Environmental Site Assessment (ESA) for the project prepared in accordance with ASTM E 1527-05 or the most recent edition. (If your current Phase I does not meet ASTM E 1527-05, you must submit a Phase I meeting ASTM E 1527-13.) If not already available, the Phase I/II Report can be provided upon notification that your PRA award is pending.

__CURRENT PHASE I ATTACHED__CURRENT PHASE I NOT YET AVAILABLE

___ NOT APPLICABLE

2. HISTORIC CONSULTATION –Please provide the following support documentation regarding historic properties.

a. Results of a historical properties records search from the California Historical Resources Information System (CHRIS).

b. Contact with a local government agency regarding historical properties that may be affected by the project.

c. Record of any public notice concerning historic or tribal consultation.

___ATTACHED

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3. NOISE (24 CFR part 51, subpart B) - New Construction Projects only

Provide documentation of either of the following:

a. A map documenting that the property is not located within:

i. 1,000 feet of a major noise source, road, or highway;ii. 3,000 ft of a railroad; or, iii. 5 miles of a civil airport or 15 miles of a military airfield;

___ATTACHED

OR

b. if the property is located within range of a major road, highway or railroad as indicated above, complete the HUD Site DNL calculator at: http://portal.hud.gov/hudportal/HUD?src=/program_offices/comm_planning/environment/dnlcalculatortool.

The local planning agency (traffic engineer), CalTrans, and the airport agency (for airport contour maps) are typical sources of noise information. Metropolitan Planning Organizations have regional transportation data that can be used to calculate the future noise level in order to document the following:

i. interior noise level of the project is 45 decibels (dB) or less; OR

ii. using the day-night average sound level (Ldn), the site does not exceed 65 dB of environmental noise; OR

iii. sites above 65 dB have sound attenuation in the building shell to 45 dB; OR

iv. sites above 75 dB do not have noise sensitive outdoor uses (e.g. picnic areas, tot lots, balconies or patios) situated in areas exposed to such noise levels.

___ATTACHED

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4. AIRPORT CLEAR ZONES (24 CFR part 51, subpart D)

Attach documentation that the project is not located within the “clear zones” or the “accident potential zones” of military airfields, or the “runway protection zones” of civilian airports. Clear Zone maps are not required if the property is clearly more than 2,500 feet from a civilian airport or more than 15,000 feet from a military airport.

___ATTACHED

5. COASTAL ZONE MANAGEMENT ACT (16 USC 1451 et seq.) Attach documentation that the project is consistent with the appropriate state coastal zone management plan:

a. A map showing that the project is not located in a Coastal Zone (CZ)

OR

b. Approval from the CZ Commission or delegated local planning commission that your project is consistent with the applicable CZ Plan,

OR

c. the project has a coastal zone permit

___ATTACHED

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6. FLOODPLAINS (Executive Order 11988; Flood Disaster Protection Act).

New Construction Projects: Provide the following documenting that the project is not located in a 100-year or 500-year floodplain:

a. a current FEMA Flood Hazard Determination Form, OMB # 1660 - 0040 (or later form number) issued by a flood certification service, or other appropriate independent third party.

___ATTACHED

b. the most current available Flood Insurance Rate Map (FIRM) showing that the project is not located in the mapped 500-year floodplain, or in the 100-year floodplain

___ATTACHEDExisting Projects:

a. Provide a current FEMA Flood Hazard Determination Form, OMB # 1660 - 0040 (or later form number) issued by a flood certification service, or other appropriate independent third party documenting the project’s floodplain status.

___ATTACHED

b. Provide the most current available Flood Insurance Rate Map (FIRM) showing the location of the project. Existing projects cannot be located in coastal high hazard areas (V Zones) or regulatory floodways.

___ATTACHED

c. If the project is in a 100-year floodplain, documentation of all of the following must be provided:

i. The existing structures are flood-proofed or have the lowest habitable floor and utilities elevated above both the 500-year floodplain when such elevations have been determined by FEMA, or if not available, the 100-year floodplain.

___ATTACHED

ii. The project has an early warning system and evacuation plan that includes evacuation routing to areas outside of the applicable floodplain.

___ATTACHED

iii. The project has flood insurance up to the maximum amount available under the National Flood Insurance Program, or the value of the structures, whichever is less, for the life of the structures. No activities or projects located within the 100-

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year floodplain may be assisted in a community that is not participating in or has been suspended from the National Flood Insurance Program.

___ATTACHED

7. WETLANDS (Executive Order 11990).

New Construction Projects - Attach documentation showing that the project is not located in wetlands. New construction projects in wetlands cannot be assisted. (Note: activities such as draining, dredging, channelizing, filling, diking, impounding, and related grading activities are considered new construction activities, which are not permitted in wetlands.)

Rehabilitation Projects – Attach documentation showing that the project’s footprint did not expand as a result of the rehabilitation, or if it did expand that such expansion did not involve destruction of wetlands.

___ATTACHED

8. Sitting of Projects Activities Near Hazardous Operations Handling Conventional Fuels or Chemicals of an Explosive or Flammable Nature (24 CFR part 51, Subpart C) New Construction Projects Only

Unshielded or unprotected new construction sites must attach documentation (e.g. from the most recent Phase I) that they meet the standards of blast overpressure (0.5psi-buildings and outdoor unprotected facilities) and thermal radiation (450 BTU/ft2 -hr – people, 10,000 BTU/ft2 - hr – buildings) from facilities that store, handle, or process substances of explosive or fire prone nature in stationary, above ground tanks/containers.

___ATTACHED___NOT APPLICABLE

If NOT APPLICABLE, explain why:

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9. ENDANGERED SPICIES (16 U.S.C.1531 et seq.) New Construction Projects Only

New construction must attach documentation based on contact (informal consultation) made with the U.S. Fish and Wildlife Service or with State Department of Fish and Wildlife, or by special study completed by a professional biologist or botanist that the new construction activities shall not result in a taking of endangered plant or animal species as listed under the Endangered Species Act of 1973. Taking includes not only direct harm and killing but also modification of habitat.

A determination of “no effect” is based on the well-documented absence of listed species.

Guidance: http://www.hud.gov/offices/cpd/environment/review/endangeredspecies.cfm

___ATTACHED

10.FARMLAND PROTECTION (7 USC 4201 et seq. and 7 CFR part 658) - New Construction Projects Only

Attach documentation that the project shall not result in the conversion of unique, prime, or otherwise productive agricultural properties to urban uses. The location of prime agricultural land may be determined using maps available from the Natural Resources Conservation Service, as well as U.S. Census Urbanized Area maps and US Geological Survey topographic maps.

___ATTACHED

11.SOLE SOURCE ACQUIFERS (Section 1424(e) of the Safe Drinking Water Act of 1974 (42 U.S.C. 201, 300 et. seq., and 21 U.S.C. 349)).

Any new construction activities and projects located in federally designated sole source aquifer areas (SSAs) provide a copy of EPA approval of these activities.

___ APPLICABLE, EPA APPROVAL ATTACHED___ NOT APPLICABLE

If NOT APPLICABLE, explain why:

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G. LEAD-BASED PAINT

(NOFA Section XIII. I.)

For assisted units and common areas in properties constructed prior to January 1, 1978, is a child of less than 6 years of age expected to reside in the PRA-unit?

___ YES

___ NO

___ UNKNOWN AT THIS TIME

___ STRUCTURES BUILT AFTER JANUARY 1, 1978

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VI. APPLICANT OR PROPERTY MANAGER EXPERIENCE

1. Eligible Applicants or their proposed PRA Project property manager(s) must have a minimum of one project which includes services to a special needs population. (Note: this project does not have to be a project that is requesting PRA funds, a project that currently serves the PRA Target Population, or a project that exclusively serves special needs tenants.)

Please complete the table below to provide information on current projects of the PRA Project Applicant or Property Manager(s) that provide services to a special needs population. Insert additional tables for additional experience you would like to highlight.

APPLICANT EXPERIENCE:

Project InformationProject Name:

Address:Special Needs

Population(s) Served:Total Affordable Units:

Total Special Needs Units:Identification Number

for TCAC, HCD, CalHFA:Type(s) of Services

Provided:Date Participation Began:Date Participation Ended:

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2. PROPERTY MANAGER(S’) EXPERIENCE Insert additional tables for additional experience you would like to highlight.

Project InformationProject Name:

Address:Special Needs

Population(s) Served:Total Affordable Units:

Total Special Needs Units:Identification Number

for TCAC, HCD, CalHFA:Type(s) of Services

Provided:Date Participation Began:Date Participation Ended:

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3. The HUD 811 PRA subsidy will be administered through a contract similar to project-based Section 8 contracts. Eligible Applicants or their management agent must have experience with project based Section 8 subsidy processing, including the use of the Tenant Rental Assistance Certification System (TRACS) and Enterprise Income Verification (EIV). HUD requires Eligible Applicants to have the capability to transmit tenant information using HUD 50059 (certification and recertification form) and HUD 52670 (voucher data). Eligible Applicants must also have experience calculating tenant rents in accordance with HUD occupancy guidelines (HUD Handbook 4350.3 REV-1).  Insert additional tables for additional experience you would like to highlight.

APPLICANT EXPERIENCE WITH SECTION 8 RENTAL SUBSIDY:

Project InformationProject Name

Address

Total UnitsTotal Project-based

Section 8 Units:Identification Number

TRACSMail ID, EIV User IDDate S8 participation beganDate S8 participation ended

Tenant Rents Calculated by(HUD Handbook 4350.3 REV-1)

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2. PROPERTY MANAGER(S’) EXPERIENCE WITH SECTION 8 RENTAL SUBSIDY: Insert additional tables for additional experience you would like to highlight.

Project InformationProject Name

Address

Total UnitsTotal Project-based

Section 8 Units:Identification Number

TRACSMail ID, EIV User IDDate S8 participation beganDate S8 participation ended

Tenant Rents Calculated by(HUD Handbook 4350.3 REV-1)

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VII. NEED

Each TRO assisting proposed PRA projects under this application must complete the following section in order to determine the number of units in a project that would be realistic to make referrals to in the available time period for renting-up PRA units. Add more rows to the table below if needed. TROs of Regional Center clients must complete Question 5 below. The total number of units that may be requested is the total from Question 4, Column C and Question 6.

1. TROs:

2. TRO Service Area(s):

3. Transitions made by the TROs: a) CCT #: b) Regional Center Organization #:

4. CCT Providers complete the chart below:

Column A:

Inpatient MediCal Facility from which PRA Referrals/Transitions will be Made (CCT Provider Completes)

Column B:

# of MediCal patients ages18-61 in this facility. (See PRA website for this information.)

Column C:

Column B times 10%

TOTAL #:

5. Base Calculation Need Number (the total of all numbers in column C) =

6. Additional units requested (include expected Regional Center referrals) =

7. Total Units That May Be Requested =

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8. If you are including completed transitions in your responses above that were not funded through CCT or Regional Center, indicate what percentage of the individuals who benefited from these transitions are in an existing home arrangement, or into a new apartment.

9. If the calculation of Need includes facilities from which the TRO has not made transitions since 2007, please explain why the TRO has not had transitions from these facilities since 2007.

10. Additional units greater than the calculation in Column C may be requested. If doing so, TROs must adequately explain how/why this additional number of transitions can be made by the occupancy deadlines set forth in Section XII.

11.TROs must also describe how they currently provide or plan to provide outreach and education about the PRA program to inpatient facility staff, recruit eligible patients into the program, and educate families about community living and home and community-based care options.

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VIII. PROJECT SUITABILITY

PRA Applicants and their partner TROs must select projects for participation that offer access to appropriate services, accessible transportation and commercial facilities to ensure greater integration of persons with disabilities in the broader community.

1. Describe how each proposed project for PRA assistance meets these criteria.

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2. Complete the tables below regarding each project proposed for PRA assistance. The information will be evaluated in light of what is typical for other housing in the community in which the project is located. (Copy the table as necessary for each project.)

Project Name: Address: City: Zip Code:

Community Feature

Miles from Project

Community Feature

Miles from Project

“Paratransit” service Available (Yes/No)

XXXXX Entertainment Venues

Public Trans. Stop LibraryFull-Service Grocery

Bank/Credit Union

Convenience Store Community CenterShopping Centers Post OfficePublic Parks Fire/PoliceMajor Health Care Providers

Other: (Specify)

Hospital Other: (Specify)Pharmacy Other: (Specify)

Additional Explanation: (Optional)

Section 811 Project Rental Assistance Application Form –Rev August 2017