Form Hud-52371 - Tenant Opportunities Program - U.s. Department Of Housing And Urban Development
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1
2U.S. Department of Housing
Tenant Opportunities Program
OMB Approval No. 2577-0229
(exp.11/30/2003)
and Urban Development
Consultant/Trainer Checklist
Office of Public and Indian Housing
Public Housing Tenant Opportunities Program (TOP) Technical Assistance
Public reporting burden for this collection of information is estimated to average 16 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.
Completion of this form is voluntary, but if you wish to provide technical assistance, it will ensure that your primary areas of interest/expertise are recorded
. Data collected is publicly available. The collection of this information is authorized by Sections 23(c) and (g) of the U.S. Housing Act of 1937 as amended
by Section 554 of the Cranston-Gonzales National Affordable Housing Act, P.L. 101-625. HUD may not collect this information, and you are not required
to complete this form, unless it displays a currently valid OMB control number.
The U.S. Housing Act of 1937, as amended, authorizes the Department of Housing & Urban Development (HUD) to collect all the information on this form.
The Housing & Community Development Act of 1987, 42 U.S.C 3543 authorizes HUD to collect Social Security Numbers (SSN). The information will used
to help manage the number and quality of consultants participating in the program. Specifically, the information will allow HUD to categorize consultants
by field of expertise, geographic location, check references, and determine daily fees. The SSN is used as a unique identifier. HUD may disclose this
information to Federal, State and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise
disclosed or released outside of HUD, except as required and permitted by law. Failure to provide the information could result in HUD’s denial of proposed
management or fees or cancellation of management contracts for noncompliance with HUD procedures. Providing the SSN is mandatory, and failure to
provide it could affect your participation in HUD programs.
Please answer all the following questions. Part 1 asks for your name and other personal information and your business mailing address. Part
2 requests you identify from a list your specific capabilities and skills. Part 3 requests information about your references and background.
Part 1. Personal Information
Your Last Name
Your First Name
Your Social Security Number
Your Home Phone (Include area code)
Your Mailing Address (Department)
Office
Street Address
Business Phone (Include area code)
City, State & Zip Code
Business Fax (Include area code)
Part 2. Skills Inventory
Please identify the types of projects you feel you would be most effective in providing technical assistance. Refer the the categories on the
back of this form. These categories are refined further into specific Skill Areas. Please review the categories listed, and then list the specific
Skill Areas (eg.A204, C303) which best fits your capabilities and interests in the spaces provided below. You may list up to 15 Skill Areas. Please
attach a narrative capability statement and approach to giving technical assistance in the Skill Areas you list.
Other
Skill 1
Skill 2
Skill 3
Skill 4
Skill 5
Skill 6
Skill 7
(specify)
Skill 8
Skill 9
Skill 10
Skill 11
Skill 12
Skill 13
Skill 14
Part 3. Work References (Please list at least three references. At least one should be a Housing Agency, Resident Management Corp.,
or Resident Council you have provided services for.)
Name & Address of Reference
Contact Person
Phone Number (Include Area Code)
1.
2.
3.
Background
Have you completed all parts of this form?
Yes
No
Do you have experience working with persons who:
speak only Spanish?
Yes
No
Have you attached a narrative capability statement
that explains your experience in the Skill Areas you
are Native Americans?
Yes
No
listed in Part 2?
Yes
No
Have you attached your resume?
Yes
No
Do you have a criminal record?
Yes
No
Having a criminal record may not prevent you from participating in the
Have you attached your rate of pay justification?
Yes
No
program.
If you checked "Yes,"
please explain: (attach additional
This could include a previous invoice for similar
information if necessary.)
work, a recent W-2 form, or an accountant's statement.
Incomplete applications will be returned
form HUD-52371 (7/96)
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