Rental Completion Report
Updated April 2024
Instructions
Complete this report for each project assisted with HOME and/or National Housing Trust Fund (NHTF) funds. Read the instructions below for each item carefully before completing the form. Retain a copy of the form(s) for your records. 
This report must be submitted prior to your final disbursement request of HOME and/or NHTF funds for the activity. This is required in order for your funds request to be processed. When designating the HOME-assisted and/or NHTF-assisted units, do not include any vacant units. 
When submitting this report, attach a copy of the original HOME and/or NHTF Unit Type Designation form(s) attached to the Written Agreement(s). The final unit designations must match what was originally designated.

Part A: Activity Information
1.	Name of the project:       
2.	Name of the owner:      
3.	Community Housing Development Organization (CHDO) Tax (Employer) Identification Number:       
Note: Complete only for activities assisted with HOME funds reserved for CHDOs.
4.	Check one box to indicate the type of property assisted:
 Condominium
 Cooperative
 Single Room Occupancy
 None of the Above
5.	Is the activity a Federal Housing Administration (FHA) insured activity?
 Yes
 No
6.	Is the activity a mixed-income activity?
 Yes; less than 100% of the activity’s housing units qualify as affordable housing as defined in section 92.252 of the HOME regulations.
 No; the activity is not mixed-income use.
7.	Is the activity a mixed-use activity?
 Yes; the activity is designated in part for uses other than residential but where residential living space must constitute at least 51% of the activity space
 No; the activity is not mixed-use.
8.	Mark only one of the five boxes to indicate the type of HOME-assisted activity financed. 
 Rehabilitation Only: A HOME/NHTF-assisted rehabilitation activity that did not include acquisition of real property. Such activities may have involved (a) repairs or improvement of residential unit(s) to bring the unit(s) up to the property standards required by 24 CFR 92.252, (b) the reconfiguration of a structure to reduce the total units in order to increase the number of large family units, (c) the addition of a room or rooms (e.g., bedroom or bathroom) outside the existing walls for purposes of meeting occupancy or code standards and/or (d) the adding of a unit or units within the existing structure.
 New Construction Only: Any activity that involved (a) the addition of units outside the existing walls of the structure and/or (b) the construction of a new residential unit(s). Note: When activities have combined new construction in one or more buildings on one parcel of land the projects, by type of activity (for example, rehabilitation or new construction), must be administratively set up as separate activities in the Integrated Disbursement and Information System (IDIS).
 Acquisition Only: Acquisition of a structure that received a certificate of occupancy at least 13 months before acquisition, which did not require rehabilitation and is being used to provide affordable rental housing.
 Acquisition and Rehabilitation: A HOME/NHTF-assisted rehabilitation activity, which included the acquisition of real property.
 Acquisition and New Construction: A HOME/NHTF-assisted new construction activity, which included the acquisition of real property. This includes acquisition of a structure that has received an initial certificate of occupancy within a one-year period prior to acquisition.
9.	What is the activity location? Mark all boxes that apply to this activity.
 Community Development Block Grant (CDBG) strategy area: A HUD-approved Neighborhood or Community Revitalization Strategy Area (NRSA or CRSA).
 Local target area: A locally designated non-CDBG strategy area targeted for assistance.
 Presidentially declared major disaster area: An area declared a major disaster under subchapter IV of the Robert T. Stafford Disaster Relief and Emergency Assistance Act.
 Conversion from non-residential to residential use: A conversion activity from non-residential to residential use.
 Brownfield redevelopment area: An abandoned, idled or underused property where expansion or redevelopment is complicated by real or potential environmental contamination.
 Historic preservation area: An area designated for historic preservation by local, state or federal officials.
10.	Will this activity be carried out by a faith-based organization?  
 Yes
 No
11.	Total number of units completed for this activity:      
12.	Total number of Minnesota Housing HOME-assisted units designated for this activity:      
13.	Total number of NHTF-assisted units designated for this activity:      
14.	Total number of units that meet Energy Star standards:      
•	Total number of HOME/NHTF-assisted units meeting energy star standards:      
15.	Total number of units that are 504-accessible:      
16.	Total number of units that are designated for persons with HIV/AIDS:      
•	Total number of HOME-assisted units that are designated for persons with HIV/AIDS:      
•	Of those units designated for persons with HIV/AIDS, enter the total number for those who are chronically homeless:      
•	Of those units designated for persons with HIV/AIDS, enter the total number of HOME/NHTF-assisted units for those who are chronically homeless:      
17.	Total number of units that are designated for people and families who are homeless:      
•	Total number of HOME/NHTF-assisted units that are designated for people and families who are homeless:       
•	Of those units designated for people and families experiencing homelessness, enter the total number for those who are chronically homeless:      
•	Of those units designated for persons and families experiencing homelessness, enter the total number of HOME/NHTF-assisted units for those who are chronically homeless:      

Part B: Financial Structure and Activity Costs
Include all HOME/NHTF funds used for the activity and all other funds public and private, but do not double count. If private funds are used for construction financing and those funds are later replaced by permanent financing, do not report both. Report all HOME/NHTF funds expended on the activity. Federal regulations specifically prohibit paying back HOME funds with HOME funds. 
For funds other than HOME, to the extent a choice must be made to avoid double counting, report permanent financing rather than construction financing. The total amount reported on line F of Part B should be the total cost of the activity and must equal the total amount disbursed through IDIS for this activity.
Activity Address:      
A.	HOME/NHTF Funds
Do not include HOME/NHTF program income anywhere in Section A. HOME/NHTF program income should be included in Line E instead.
1.	Deferred Payment Loan (DPL)
Enter the amount of HOME/NHTF funds provided through loans where payment of principal and interest is deferred until a future time and enter the interest rate and amortization period, if any. A DPL is sometimes called a conditional grant (for example, repayment is required when the property is sold, or is forgiven if the owner does not sell the property for a specified number of years or repayment of principal and interest starts after the bank loan is repaid).
a.	HOME annual interest rate:      %
b.	HOME amortization period:       years
c.	HOME loan amount: $     
d.	NHTF annual interest rate:      %
e.	NHTF amortization period:       years
f.	NHTF loan amount: $     
2.	Community Housing Development Organization (CHDO) Loan
a.	HOME funds provided as a CHDO technical assistance (TA) loan for the activity: $     
b.	HOME funds provided as a CHDO seed money loan: $       
Total CHDO Loan (enter the total of the amounts entered on 2a and 2b): $     
3.	Other
Total amount of HOME/NHTF funds provided for subsidy funding that is other than the type of loan/grant assistance identified in the above items: $     
4.	Total
Total HOME/NHTF funds (enter the total of items A1-A3 as the amount of HOME/NHTF funds expended): $     
B.	Public Funds
1.	Other Federal Funds 
Other federal funds (specify):      
Amount of other federal funds expended (exclude any HOME/NHTF funds: $     
2.	State/Local Appropriated Funds
State/local appropriated funds (specify):      
State/local appropriated funds expended: $     
3.	State/Local Tax-Exempt Bond Proceeds
State/local tax-exempt bond proceeds expended: $     
4.	Total
Total public funds (enter the total of items B1-B3 as the amount of public funds expended): $     
C.	Private Funds
1.	Private Loan Funds
Enter the amount of all of the costs that have been paid with funds obtained from private financial institutions, such as banks, savings and loans and credit unions, and enter the interest rate and amortization period of the loan. If there are multiple loans, enter the interest rate and term of the largest loan. Do not double count.
a.	Private loan annual interest rate:      %
b.	Private loan amortization period:       years
c.	Private loan amount: $     
2.	Owner Cash Contributions
Amount of all cash contributions provided by the project owner: $     
3.	Net Syndication Proceeds
Net amount of syndication proceeds, excluding Low-Income Housing Tax Credits, provided in financing this activity: $     
4.	Private Grants
Amount of cash contributions provided by private organizations, foundations, donors, etc.: $     
5.	Total
Total private funds (enter the total of items C1-C4 as the amount of Private Funds expended): $     
D.	Low Income Tax Credit Syndication Proceeds
Total amount of syndicated Low-Income Housing Tax Credits provided: $     
E.	HOME/NHTF Program Income
Total amount of funds provided from HOME/NHTF repayment income: $     
F.	Total Activity Cost
Sum of totals for HOME/NHTF Funds, Public Funds, Private Funds, Low Income Tax Credit Syndication Proceeds and HOME/NHTF Program Income (items A-E): $     

Part C: Household Characteristics
Using the Housing Characteristics and initial Tenant Occupancy Information tables beginning on page 12, complete one line for each unit assisted with HOME/NHTF funds and enter only one code per space. For activities that include multiple addresses, complete a separate Household Characteristics page for each address.
Unit Number. Enter the unit number of each unit assisted with HOME/NHTF funds.
Square Footage. Enter the square footage of the unit.
Number of Bedrooms. 
0 - Single room occupancy (SRO) unit or efficiency unit
1 - 1 bedroom
2 - 2 bedrooms
3 - 3 bedrooms
4 - 4 bedrooms
5 - 5 or more bedrooms
Occupancy Code. 
1 - The unit is occupied by a tenant
2 - The unit is occupied by a HOME/NHTF owner
Percent of Area Median. For each occupied residential unit enter one code only based on the following definitions:
1 - 0–30% of Area Median means a household whose adjusted income is at or below 30% of the median family income for the area, as determined by HUD with adjustments for smaller and larger families.
2 - 31–50% of Area Median means a household whose adjusted income exceeds 30% and does not exceed 50% of the median family income for the area, as determined by HUD with adjustments for smaller and larger families.
3 - 51–60% of Area Median means a household whose adjusted income exceeds 50% and does not exceed 60% of the median family income for the area, as determined by HUD with adjustments for smaller and larger families.
4 - 61–80% of Area Median means a household whose adjusted income exceeds 60% and does not exceed 80% of the median family income for the area, as determined by HUD with adjustments for smaller and larger families.
Annual Household Income. Enter the gross amount of income of all adult household members that is anticipated to be received during the coming 12-month period.
Race – Head of Household. For each occupied residential unit enter one code only based on the following definitions:
11 - White. A person having origins in any of the original peoples of Europe, North Africa or the Middle East.
12 - Black or African American. A person having origins in any of the black racial groups of Africa. 
13 - Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
14 - American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains affiliation or community attachment.
15 - Native Hawaiian or Other Pacific Islander. A person having origins in any of the original people of Hawaii, Guam, Samoa or other Pacific Islands.
16 - American Indian or Alaska Native and White. A person having these multiple race heritages as defined above.
17 - Asian and White. A person having these multiple race heritages as defined above.
18 - Black or African American and White. A person having these multiple race heritages as defined above.
19 - American Indian or Alaska Native and Black or African American. A person having these multiple race heritages as defined above. 
20 - Other Multi Racial. For reporting individual responses that are not included in any of the other categories listed above.
Hispanic Y/N. For each occupied residential unit enter the ethnicity for the head of household as either “Y” for Hispanic or Latino or “N” for Not Hispanic or Latino. Hispanic or Latino race is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic of Latino.”
Size of Household. Enter the appropriate number of persons in the household: 1, 2, 3, 4, 5, 6, 7 or 8 or more persons. For households or more than 8, enter 8. 
Head of Household Gender. For each occupied residential unit enter the gender for the head of household as either “M” for Male or “F” for Female.
Head of Household Type. For each occupied residential unit, enter one code only based on the following definitions:
1 - Single/Non-Elderly. One-person household in which the person is not elderly.
2 - Elderly. One- or two-person household with a person at least 62 years of age.
3 - Single Parent. Single parent household with a dependent child or children (18 years old or younger).
4 - Two Parents. Two-parent household with a dependent child or children (18 years old or younger).
5 - Other. Any household not included in the above 4 definitions, including two or more unrelated individuals.
Homeless Household. For each occupied residential unit enter “Y” if the household was previously without permanent shelter or “N” if the household previously had permanent shelter.
Handicapped Household. For each occupied residential unit enter “Y” if the household is occupied by a tenant with a disability or disabilities, or enter “N” if the household is not occupied by a tenant with a disability or disabilities.
Tenant Contribution. Enter the actual rent to the nearest dollar, including utilities, paid by the tenant at the time of activity completion. If the rent includes utilities, or if the rent includes partial utilities (for example, heat, but not electricity) these utility costs must be added to the rent. Compute utility costs for the area (compute costs for utilities excluded from the rent in the case of partial utilities), by using the utility allowance schedule by the local Public Housing Authority (PHA) or Housing Redevelopment Authority (HRA) in accordance with form HUD-52667, Allowance for Tenant Furnished Utilities and Other Services.
Subsidy Amount. Enter the amount that the tenant receives as a rent subsidy payment (including any utility allowances paid directly to the tenant) to the nearest dollar. If the tenant does not receive a tenant subsidy payment enter zero.
Total Rent. Enter the total monthly rent (tenant contribution plus subsidy amount).
Rental Assistance. Enter one code only to indicate the type of assistance, if any, being provided to the tenant.
1 – Project-Based Section 8. Tenant receives project-based section 8 rental assistance (for example, Housing Assistance Payment (HAP) contract or project-based housing choice voucher).
2 – Tenant-Based Section 8. Tenant is utilizing a portable, tenant-based housing choice voucher from an HRA or PHA.
3 - HOME/NHTF Tenant Based Rental Assistance. Tenant receives HOME tenant-based rental assistance.
4 - Other Project-Based Assistance. Tenant receives project-based federal, state or local rental assistance other than section 8 (for example, Housing Support (formerly Group Residential Housing (GRH)) if the property has a contract).
5 – Other Tenant-Based Assistance. Tenant receives federal, state or local rental assistance other than a portable section 8 voucher.
6 - No Assistance. Tenant does not receive any rental assistance.
Household Relocated. For each occupied residential unit, enter “Y” if the household was temporarily relocated due the HOME/NHTF activity or “N” if the household was not temporarily relocated due to the HOME/NHTF activity.
Cost to Relocate. For each occupied residential unit that was temporarily relocated due to the HOME/NHTF activity, enter the cost associated with the temporary relocation.

Household Characteristics and Initial Tenant Occupancy Information
Activity Address (Complete a separate sheet for each address):      
Complete one line for each unit assisted with HOME/NHTF funds. Use the codes in the instructions and enter only one code per space.
Unit *	Sq. Ft	Fixed or Floating Unit	HOME/ NHTF/ Both	# of Bedrooms Code	Occupant Code	# of Occupants in Household	% of Area Median Code	Low or High HOME Rent	30% or FPG NHTF Rent	Annual Household Income	Race of Head of Household Code	Hisp	Size of Household	Head of Household Gender	Head of Household Type Code	Homeless Household?	Handicapped Household?	Tenant Contribution	Subsidy Amount	Utility Allowance	Total Rent	Rental Assistance Type Code	Household Relocated?	Cost to Relocate	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	

No. of Bedrooms Code
1 – 1 Bedroom
2 – 2 Bedrooms
3 – 3 Bedrooms
4 – 4 Bedrooms
5 – 5 or more Bedrooms
Occupant Code
1 – Tenant
2 – Owner
9 – Vacant

% of Area Median Code
1 – 0 – 30%
2 – 31 – 50%
3 – 51 – 60%
4 – 61 – 80%
Hispanic
Y – Yes
N – No

Race of Head of Household Code
11 – White
12 – Black or African American
13 – Asian
14 – American Indian or Alaska Native
15 – Native Hawaiian or Other Pacific Islander
16 – American Indian or Alaska Native & White
17 – Asian & White
18 – Black or African American & White
19 – American Indian or Alaska Native & Black or African American
20 – Other Multi Racial
Head of Household Type Code
1 – Single/non-Elderly
2 – Elderly
3 – Single Parent
4 – Two Parents
5 – Other

Rental Assistance Type Code
1 – Project-Based Section 8
2 – Tenant-Based Section 8
3 – HOME TBRA
4 – Other Project-Based Assistance
5 – Other Tenant-Based Assistance
6 – No Assistance
Head of Household Gender
M – Male 
F – Female

Homeless Household
Y – Yes 
N – No 
Handicapped Household
Y – Yes 
N – No 
Household Relocated
Y – Yes 
N – No

Household Characteristics and Initial Tenant Occupancy Information
Activity Address (Complete a separate sheet for each address):      
Complete one line for each unit assisted with HOME/NHTF funds. Use the codes in the instructions and enter only one code per space.
Unit *	Sq. Ft	Fixed or Floating Unit	HOME/ NHTF/ Both	# of Bedrooms Code	Occupant Code	# of Occupants in Household	% of Area Median Code	Low or High HOME Rent	30% or FPG NHTF Rent	Annual Household Income	Race of Head of Household Code	Hisp	Size of Household	Head of Household Gender	Head of Household Type Code	Homeless Household?	Handicapped Household?	Tenant Contribution	Subsidy Amount	Utility Allowance	Total Rent	Rental Assistance Type Code	Household Relocated?	Cost to Relocate	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	

No. of Bedrooms Code
1 – 1 Bedroom
2 – 2 Bedrooms
3 – 3 Bedrooms
4 – 4 Bedrooms
5 – 5 or more Bedrooms
Occupant Code
1 – Tenant
2 – Owner
9 – Vacant
% of Area Median Code
1 – 0 – 30%
2 – 31 – 50%
3 – 51 – 60%
4 – 61 – 80%
Hispanic
Y – Yes
N – No

Race of Head of Household Code
11 – White
12 – Black or African American
13 – Asian
14 – American Indian or Alaska Native
15 – Native Hawaiian or Other Pacific Islander
16 – American Indian or Alaska Native & White
17 – Asian & White
18 – Black or African American & White
19 – American Indian or Alaska Native & Black or African American
20 – Other Multi Racial
Head of Household Type Code
1 – Single/non-Elderly
2 – Elderly
3 – Single Parent
4 – Two Parents
5 – Other

Rental Assistance Type Code
1 – Project-Based Section 8
2 – Tenant-Based Section 8
3 – HOME TBRA
4 – Other Project-Based Assistance
5 – Other Tenant-Based Assistance
6 – No Assistance
Head of Household Gender
M – Male 
F – Female
Homeless Household
Y – Yes 
N – No 
Handicapped Household
Y – Yes 
N – No 
Household Relocated
Y – Yes 
N – No

Household Characteristics and Initial Tenant Occupancy Information
Activity Address (Complete a separate sheet for each address):      
Complete one line for each unit assisted with HOME/NHTF funds. Use the codes in the instructions and enter only one code per space.
Unit *	Sq. Ft	Fixed or Floating Unit	HOME/ NHTF/ Both	# of Bedrooms Code	Occupant Code	# of Occupants in Household	% of Area Median Code	Low or High HOME Rent	30% or FPG NHTF Rent	Annual Household Income	Race of Head of Household Code	Hisp	Size of Household	Head of Household Gender	Head of Household Type Code	Homeless Household?	Handicapped Household?	Tenant Contribution	Subsidy Amount	Utility Allowance	Total Rent	Rental Assistance Type Code	Household Relocated?	Cost to Relocate	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	

No. of Bedrooms Code
1 – 1 Bedroom
2 – 2 Bedrooms
3 – 3 Bedrooms
4 – 4 Bedrooms
5 – 5 or more Bedrooms
Occupant Code
1 – Tenant
2 – Owner
9 – Vacant
% of Area Median Code
1 – 0 – 30%
2 – 31 – 50%
3 – 51 – 60%
4 – 61 – 80%
Hispanic
Y – Yes
N – No

Race of Head of Household Code
11 – White
12 – Black or African American
13 – Asian
14 – American Indian or Alaska Native
15 – Native Hawaiian or Other Pacific Islander
16 – American Indian or Alaska Native & White
17 – Asian & White
18 – Black or African American & White
19 – American Indian or Alaska Native & Black or African American
20 – Other Multi Racial
Head of Household Type Code
1 – Single/non-Elderly
2 – Elderly
3 – Single Parent
4 – Two Parents
5 – Other

Rental Assistance Type Code
1 – Project-Based Section 8
2 – Tenant-Based Section 8
3 – HOME TBRA
4 – Other Project-Based Assistance
5 – Other Tenant-Based Assistance
6 – No Assistance
Head of Household Gender
M – Male 
F – Female
Homeless Household
Y – Yes 
N – No 
Handicapped Household
Y – Yes 
N – No 
Household Relocated
Y – Yes 
N – No

Household Characteristics and Initial Tenant Occupancy Information
Activity Address (Complete a separate sheet for each address):      
Complete one line for each unit assisted with HOME/NHTF funds. Use the codes in the instructions and enter only one code per space.
Unit *	Sq. Ft	Fixed or Floating Unit	HOME/ NHTF/ Both	# of Bedrooms Code	Occupant Code	# of Occupants in Household	% of Area Median Code	Low or High HOME Rent	30% or FPG NHTF Rent	Annual Household Income	Race of Head of Household Code	Hisp	Size of Household	Head of Household Gender	Head of Household Type Code	Homeless Household?	Handicapped Household?	Tenant Contribution	Subsidy Amount	Utility Allowance	Total Rent	Rental Assistance Type Code	Household Relocated?	Cost to Relocate	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	

No. of Bedrooms Code
1 – 1 Bedroom
2 – 2 Bedrooms
3 – 3 Bedrooms
4 – 4 Bedrooms
5 – 5 or more Bedrooms
Occupant Code
1 – Tenant
2 – Owner
9 – Vacant
% of Area Median Code
1 – 0 – 30%
2 – 31 – 50%
3 – 51 – 60%
4 – 61 – 80%
Hispanic
Y – Yes
N – No

Race of Head of Household Code
11 – White
12 – Black or African American
13 – Asian
14 – American Indian or Alaska Native
15 – Native Hawaiian or Other Pacific Islander
16 – American Indian or Alaska Native & White
17 – Asian & White
18 – Black or African American & White
19 – American Indian or Alaska Native & Black or African American
20 – Other Multi Racial
Head of Household Type Code
1 – Single/non-Elderly
2 – Elderly
3 – Single Parent
4 – Two Parents
5 – Other

Rental Assistance Type Code
1 – Project-Based Section 8
2 – Tenant-Based Section 8
3 – HOME TBRA
4 – Other Project-Based Assistance
5 – Other Tenant-Based Assistance
6 – No Assistance
Head of Household Gender
M – Male 
F – Female
Homeless Household
Y – Yes 
N – No 
Handicapped Household
Y – Yes 
N – No 
Household Relocated
Y – Yes 
N – No

Household Characteristics and Initial Tenant Occupancy Information
Activity Address (Complete a separate sheet for each address):      
Complete one line for each unit assisted with HOME/NHTF funds. Use the codes in the instructions and enter only one code per space.
Unit *	Sq. Ft	Fixed or Floating Unit	HOME/ NHTF/ Both	# of Bedrooms Code	Occupant Code	# of Occupants in Household	% of Area Median Code	Low or High HOME Rent	30% or FPG NHTF Rent	Annual Household Income	Race of Head of Household Code	Hisp	Size of Household	Head of Household Gender	Head of Household Type Code	Homeless Household?	Handicapped Household?	Tenant Contribution	Subsidy Amount	Utility Allowance	Total Rent	Rental Assistance Type Code	Household Relocated?	Cost to Relocate	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	

No. of Bedrooms Code
1 – 1 Bedroom
2 – 2 Bedrooms
3 – 3 Bedrooms
4 – 4 Bedrooms
5 – 5 or more Bedrooms
Occupant Code
1 – Tenant
2 – Owner
9 – Vacant
% of Area Median Code
1 – 0 – 30%
2 – 31 – 50%
3 – 51 – 60%
4 – 61 – 80%
Hispanic
Y – Yes
N – No

Race of Head of Household Code
11 – White
12 – Black or African American
13 – Asian
14 – American Indian or Alaska Native
15 – Native Hawaiian or Other Pacific Islander
16 – American Indian or Alaska Native & White
17 – Asian & White
18 – Black or African American & White
19 – American Indian or Alaska Native & Black or African American
20 – Other Multi Racial
Head of Household Type Code
1 – Single/non-Elderly
2 – Elderly
3 – Single Parent
4 – Two Parents
5 – Other

Rental Assistance Type Code
1 – Project-Based Section 8
2 – Tenant-Based Section 8
3 – HOME TBRA
4 – Other Project-Based Assistance
5 – Other Tenant-Based Assistance
6 – No Assistance
Head of Household Gender
M – Male 
F – Female
Homeless Household
Y – Yes 
N – No 
Handicapped Household
Y – Yes 
N – No 
Household Relocated
Y – Yes 
N – No

Household Characteristics and Initial Tenant Occupancy Information
Activity Address (Complete a separate sheet for each address):      
Complete one line for each unit assisted with HOME/NHTF funds. Use the codes in the instructions and enter only one code per space.
Unit *	Sq. Ft	Fixed or Floating Unit	HOME/ NHTF/ Both	# of Bedrooms Code	Occupant Code	# of Occupants in Household	% of Area Median Code	Low or High HOME Rent	30% or FPG NHTF Rent	Annual Household Income	Race of Head of Household Code	Hisp	Size of Household	Head of Household Gender	Head of Household Type Code	Homeless Household?	Handicapped Household?	Tenant Contribution	Subsidy Amount	Utility Allowance	Total Rent	Rental Assistance Type Code	Household Relocated?	Cost to Relocate	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	
    	    	     	     	     	     	     	     	     	    	$     	     	   	     	     	     	     	     	$     	$     	$     	$     	     	     	$     	

No. of Bedrooms Code
1 – 1 Bedroom
2 – 2 Bedrooms
3 – 3 Bedrooms
4 – 4 Bedrooms
5 – 5 or more Bedrooms
Occupant Code
1 – Tenant
2 – Owner
9 – Vacant
% of Area Median Code
1 – 0 – 30%
2 – 31 – 50%
3 – 51 – 60%
4 – 61 – 80%
Hispanic
Y – Yes
N – No

Race of Head of Household Code
11 – White
12 – Black or African American
13 – Asian
14 – American Indian or Alaska Native
15 – Native Hawaiian or Other Pacific Islander
16 – American Indian or Alaska Native & White
17 – Asian & White
18 – Black or African American & White
19 – American Indian or Alaska Native & Black or African American
20 – Other Multi Racial
Head of Household Type Code
1 – Single/non-Elderly
2 – Elderly
3 – Single Parent
4 – Two Parents
5 – Other

Rental Assistance Type Code
1 – Project-Based Section 8
2 – Tenant-Based Section 8
3 – HOME TBRA
4 – Other Project-Based Assistance
5 – Other Tenant-Based Assistance
6 – No Assistance
Head of Household Gender
M – Male 
F – Female
Homeless Household
Y – Yes 
N – No 
Handicapped Household
Y – Yes 
N – No 
Household Relocated
Y – Yes 
N – No

Certification
I certify that, to the best of my knowledge, the information I have provided is true and accurate.
I certify that the assisted units are designated as above. I agree that, if fixed, these unit designations will not change during the Affordability Period. I agree that, if floating, the proportion of assisted units designated to each unit type will not change from the original mix of designated units. If units are floating, then I will record any reassignments of assisted units, including the new unit number, tenant income and rents, and continue to monitor the assisted unit for the remainder of the Affordability Period.
     	     
Owner Signature	Date
     	     
Printed Name	Title