OMB Approved No. 1505-0266

Expiration Date: 07/31/21

Submission Required for Receipt of Emergency Rental Assistance Payments

January 5, 2021

Eligible grantees—states (including the District of Columbia), U.S. Territories (Puerto Rico, the United States Virgin Islands, Guam, the Commonwealth of the Northern Mariana Islands, and American Samoa), local governments with more than 200,000 residents, the Department of Hawaiian Homelands, and Indian tribes (defined to include Alaska native corporations) or the tribally designated housing entity of an Indian tribe, as applicable—must provide payment information and an executed copy of the award terms not later than 11:59 p.m. EDT on January 12, 2021.

An exception is provided in the statute for Indian tribes that opted out of receiving a grant allocation under the Native American Housing Block Grants program formula in fiscal year 2020. Those Indian tribes must provide payment information and an executed copy of the award terms not later than 11:59 p.m. on January 26, 2021.

An authorized representative of the eligible grantee with legal authority to bind the eligible grantee must sign the first page of the award terms form. In the case of a local government, the chief executive officer of the local government must sign the award terms form.

AWARD TERMS

Eligible grantees MUST also complete and execute the award terms form to receive payment from Treasury. Please click on the download link below to generate a filled pdf of the award terms form.

An authorized representative of the eligible grantee with legal authority to bind the eligible grantee must sign the first page of the award terms form. In the case of a local government, the chief executive officer of the local government must sign the award terms form. Attach a copy of the signed and scanned document below.

Download award terms

Files Provided

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PAPERWORK REDUCTION ACT NOTICE
The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of information is thirty minutes per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number assigned by OMB.