Rental Housing Development HOME Program Payment Request Contract#: Request #: Amount Requested $ Period covered by this request: from to (mm/dd/yy) (mm/dd/yy) CHDO OPERATING ACTIVITY DOLLARS Agency/Activity Name: Address: email Contact Person: phone STATUS OF HOME FUNDS Activity Funds CHDO Operating Funds Authorized per Contract $ $ Requests Paid To Date $ $ LESS: Amount Per This Request $ $ LESS: Remaining Balance To Date $ $ ACTIVITY DOLLARS Type of Payment Activity Address Activity Number Amount of Request Reviewed 1=Progress 2=Final $ CHDO OPERATING Type of Payment Amount of Request Reviewed 1=Progress 2=Final $ CERTIFICATION By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objects set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812). ______________________________________________ ___________________________ Signature (original signature required) Date Print Name and Title: ATTACHMENT B
Rental Housing Development HOME Program Payment Request Request #: Amount Requested $ Contract#: Period covered by this request: from (mm/dd/yy) to (mm/dd/yy) CHDO OPERATING ACTIVITY DOLLARS Agency/Activity Name: Address: email Contact Person: phone STATUS OF HOME FUNDS Activity Funds CHDO Operating Funds Authorized per Contract $ $ LESS: Requests Paid To Date $ $ LESS: Amount Per This Request $ $ Remaining Balance To Date $ $ ACTIVITY DOLLARS Activity Number Activity Address Amount of Request Type of Payment 1=Progress 2=Final Reviewed $ CHDO OPERATING Amount of Request Type of Payment 1=Progress 2=Final Reviewed $ CERTIFICATION By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objects set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812). ______________________________________________ ___________________________ Signature (original signature required) Date Print Name and Title: ATTACHMENT B
HOME_RHD_Guide%202017-Final%20Draft.docx