Form Hud-2880 - Applicant/recipient Disclosure/update Report

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Applicant/Recipient

OMB Approval No. 2510-0011 (exp. 12/31/2015)

U.S. Department of Housing

and Urban Development

Disclosure/Update Report

Instructions

See Public Reporting Statement and Privacy Act Statement and detailed instructions on page 2.)

(

Applicant/Recipient Information

Indicate whether this is an Initial Report

or an Update Report

1. Applicant/Recipient Name, Address, and Phone (include area code):

2. Social Security Number or

Employer ID Number:

4. Amount of HUD Assistance

3. HUD Program Name

Requested/Received

5. State the name and location (street address, City and State) of the project or activity:

Part I Threshold Determinations

1. Are you applying for assistance for a specific project or activity? These

2. Have you received or do you expect to receive assistance within the

terms do not include formula grants, such as public housing operating

jurisdiction of the Department (HUD) , involving the project or activity in

subsidy or CDBG block grants. (For further information see 24 CFR Sec.

this application, in excess of $200,000 during this fiscal year (Oct. 1 -

4.3).

Sep. 30)? For further information, see 24 CFR Sec. 4.9

Yes

No.

If you answered “No” to either question 1 or 2, Stop! You do not need to complete the remainder of this form.

However, you must sign the certification at the end of the report.

Part II Other Government Assistance Provided or Requested / Expected Sources and Use of Funds.

Such assistance includes, but is not limited to, any grant, loan, subsidy, guarantee, insurance, payment, credit, or tax benefit.

Department/State/Local Agency Name and Address

Type of Assistance

Amount

Expected Uses of the Funds

Requested/Provided

(Note: Use Additional pages if necessary.)

Part III Interested Parties.

You must disclose:

All developers, contractors, or consultants involved in the application for the assistance or in the planning, development, or implementation of the

project or activity and

2. any other person who has a financial interest in the project or activity for which the assistance is sought that exceeds $50,000 or 10 percent of the

assistance (whichever is lower).

Alphabetical list of all persons with a reportable financial interest

Social Security No.

Type of Participation in

Financial Interest in

in the project or activity (For individuals, give the last name first)

or Employee ID No.

Project/Activity

Project/Activity ($ and %)

(Note: Use Additional pages if necessary.)

Certification

Warning: If you knowingly make a false statement on this form, you may be subject to civil or criminal penalties under Section 1001 of Title 18 of the

United States Code. In addition, any person who knowingly and materially violates any required disclosures of information, including intentional non-

disclosure, is subject to civil money penalty not to exceed $10,000 for each violation.

I certify that this information is true and complete.

Signature:

Date:

(mm/dd/yyyy)

Form HUD-2880 (3/13)