Form Hud-92016-Ca-Application For Capital Advance Summary Information February 2001 Page 2

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12. Unusual Site Features

11. Check utilities and services not included in

the rent and to be paid directly by the tenant

None

Poor Drainage

Other (specify)

Electric

Cuts

Retaining Walls

Water

Fill

Rock Foundations

Heat

Erosion

High Water Table

Gas

13. Off-Site Facilities:

14. Community Spaces to be Included inProject: (identified by site no. indicated in 10 above):

Public

At Site

Ft. from Site

Water

Sewer

Paving

Gas

Electric

15. If Sponsor is applying for more than one HUD program from the SuperNOFA, indicate which application(s) contain the forms with original signatures.

Program Name

Form

16. Name, Address and Telephone Number of

(mark one box)

Consultant

Agent

Authorized Representative

17. Sponsor's Attorney (name, address and telephone number)

(signature of sponsor's authorized representative)

Type in Name

Title

Date(mm/dd/yyyy)

Public reporting burden for this collection of information is estimated to average 46 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. This agency

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 in support of HUD's efforts to expand the supply of Supportive Housing for Persons with Disabilities under Section 811.

The information is necessary to assist HUD to determine applicant eligibility and ability to develop housing for disabled with statutory and program criteria.

A thorough evaluation of an applicant's qualifications and capabilities is critical to protect the Government's financial interest and to mitigate any possibility

of fraud, waste or mismanagement of public funds. This application does not collect any sensitive information. HUD does not ensure confidentiality.

form HUD-92016-CA (02/2001)

ref Handbook 4571.2

Previous editions are obsolete

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