Attachment 2:

Field Office (FO) Representative: Fill-out the below requested information and include this completed Attachment with all the required documents listed in Attachment 1 with your request for transfer. Note that this document includes drop down menus for some of the responses.

Divesting PHA #: Divesting PHA Name:

Receiving PHA #: Receiving PHA Name:

Requested Effective Date of Transfer or Consolidation: Click here to enter a date.

Jurisdictional Approval: Certification from FO’s Legal Counsel that the receiving PHA has the legal authority to administer the program in their jurisdiction? Choose an item.

Why does the divesting agency want to transfer their program? (example:. Unable to Administer HCV Program because of reduced administrative fees, litigation, other market conditions, etc.)

Details on what is transferring:

How many vouchers will transfer from the divesting to the receiving agency?

Of the vouchers transferring, how many are currently in use?

Is this a full transfer of the HCV program? Choose an item.

Are special purpose vouchers a factor in this transfer, such as, FUP, VASH and/or NED? Choose an item.

If special purpose vouchers are transferring, how many of each kind?

FUP

VASH

NED

Other

If special purpose vouchers are a part of the transfer, is the receiving PHA capable of administering them?	Choose an item.

Is an FSS Program being transferred?	Choose an item.

If FSS is applicable, is the receiving PHA capable of administering the program? Choose an item.

If applicable, are any HCV programs, such as, MOD Rehab or Mainstream 5 included with the transfer?	Choose an item.

If HCV program(s) are included please specify which below:

Specific agency/performance related information:

The receiving or consolidating PHAs’ most recent SEMAP performance designation;

Underutilization based on the receiving or consolidating PHAs’ SEMAP leasing indicator regardless of performance;

Outstanding debts to HUD and the status of the divesting, receiving or consolidating PHA’s repayment; and

Estimated NRP and UNP balances as of the latest audited Financial Assessment Subsystem (FASS) submission, and restricted cash and investments for all divesting or consolidating PHAs as determined by the field office.

This form must be signed by the requesting field office’s Public Housing Director for submission along with all the required documents for the transfer request.

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Public Housing Director’s Signature and Date

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Contact Name and Date