2. Public Funds $ (1) Federal Funds $ (2) State/Local Funds $ (3) Tax Exempt Bond Proceeds $ Total Public Funds (1 + 2 + 3) 3. Private $ (1) Private Funds $ (2) Owner Cash Contribution $ (3) Private Grants $ Total Private Funds (1 + 2 + 3) $ 4. Activity Total (or Total this address) K. Household Characteristics (Refer to code below where applicable) Household Unit # # of Bdrms Occupant % Med Hispanic? Race Size Type Assistance Total Y/N Type Monthly Rent 1. Homebuyer Counseling 2. FHA Insured? 3. homebuyer? Homebuyer received (enter code): (For multi address activities) (1) No counseling (3) Post counseling Yes No Yes No (2) Pre-counseling (4) Both 5. Purchase? If yes, date of agreement 4. Coming from subsidized housing? Yes No (For address activities) # of Bdrms Occupant Household % of Med Household Race 0 SRO/Efficiency 1 - Tenant 1 0 to 30% 11 - – – 1 1 bedroom 2 - Owner 2 30+ to 50% 12 or African American – – – 2 2 bedrooms 3 Vacant Unit 3 50+ to 60% 13 - Asian – – – 3 3 bedrooms 4 60+ to 80% 14 American Indian or Alaska Native – – – 4 4 bedrooms Household Size 15 Native Hawaiian or Pacific Islander – – 5 -5 or more bedrooms 1 1 person Household Type 16 American Indian or Alaska Native & White – – 2 2 persons 1 Single, non elderly 17 Asian & White – – – Assistance Type 3 3 persons 2 - Elderly 18 Black or African American & White – – 19 American Indian or Alaska Native & Black or African – 1 Section 8 4 4 persons 3 Single Parent American – – – 2 HOME TBRA 5 5 persons 4 Two Parents 20 Other Multi racial – – – – 3 Other Federal, State of 6 6 persons 5 - Other – – local assistance 7 7 persons – 4 No assistance 8 8 or more persons – – Page 3 of 6 Revised (8/06)
2. Public Funds (1) Federal Funds $ (2) State/Local Funds $ (3) Tax Exempt Bond Proceeds $ Total Public Funds (1 + 2 + 3) $ 3. Private (1) Private Funds $ (2) Owner Cash Contribution $ (3) Private Grants $ Total Private Funds (1 + 2 + 3) $ 4. Activity Total (or Total this address) $ K. Household Characteristics (Refer to code below where applicable) Household Unit # # of Bdrms Occupant % Med Hispanic? Y/N Race Size Type Assistance Type Total Monthly Rent 1. Homebuyer Counseling Homebuyer received (enter code): (1) No counseling (3) Post counseling (2) Pre-counseling (4) Both 2. FHA Insured? (For multi address activities) Yes No 3. homebuyer? Yes No 4. Coming from subsidized housing? Yes No 5. Purchase? (For address activities) If yes, date of agreement # of Bdrms Occupant Household % of Med Household Race 0 – SRO/Efficiency 1 - Tenant 1 – 0 to 30% 11 - 1 – 1 bedroom 2 - Owner 2 – 30+ to 50% 12 – or African American 2 – 2 bedrooms 3 – Vacant Unit 3 – 50+ to 60% 13 - Asian 3 – 3 bedrooms 4 – 60+ to 80% 14 – American Indian or Alaska Native 4 – 4 bedrooms Household Size 15 – Native Hawaiian or Pacific Islander 5 -5 or more bedrooms 1 – 1 person Household Type 16 – American Indian or Alaska Native & White 2 – 2 persons 1 – Single, non elderly 17 – Asian & White Assistance Type 3 – 3 persons 2 - Elderly 18 – Black or African American & White 1 – Section 8 4 – 4 persons 3 – Single Parent 19 – American Indian or Alaska Native & Black or African American 2 – HOME TBRA 5 – 5 persons 4 – Two Parents 20 – Other Multi racial 3 – Other Federal, State of local assistance 6 – 6 persons 7 – 7 persons 5 - Other 4 – No assistance 8 – 8 or more persons Page 3 of 6 Revised (8/06)
DPA-Setup-Completion-Form.docx