Form Eta 9143 – Fill Out and Use This PDF

	Work Site Description
	(A WorkSite Description is required for each property)
	YouthBuild (YB) GRANT
ATTACHMENT 1	OMB No. 1205-0464
ETA - 9143	Expires: 10/31/2010

APPLICANT IDENTIFYING INFORMATION (Complete All Sections)

Applicant Name:

Program/Project Name & Address:

1.Work Site Identification (Address/Parcel #))

2.Number of Housing Units Planned to be Produced:

3.Type of housing to be produced (Check all that apply)

Residential/rental  Homeownership  Transitional housing for the homeless

4Individual Housing Project Site Estimate and Documentation of Resources: Complete the Attachment 1A for each housing project site to be used in conjunction with the YouthBuild implementation program. Attach documentation of resources behind each Attachment 1A.

5.Homeless Housing: For housing that will be transitional housing for the homeless, attach a description of the plan for outreach and placement of homeless families or individuals (1 page). Please label this Attachment 1B

6.Will all housing produced be provided for homeless, low-income, or very-low income persons?

Yes  No

6.a. If no for question 5, please explain what other populations will be targeted and why?

7. The on-site training site consists of (Check all that apply) :  New Construction  Rehabilitation

8.Are any of the units currently occupied?  Yes  No (If yes, attach a relocation narrative that identifies the number of persons, the business or others occupying the property on the date of submission of this application, the number of displaced, the number to be temporarily relocated but not displaced, the estimated cost of relocation services payments and services, the source of funds for relocation, and the organization that will provide relocation assistance to occupants and the contact person's name and phone number. Label this Attachment 1C.)

9.Name of the current owner:

10.Documentation of Access: Attach required evidence of site access (Letter from the owner identified in No. 9). Label this Attachment 1D.

11.Describe the applicant role and responsibilities for the on-site housing construction or rehabilitation work. Label this Attachment 1E.

12.Name of entity which will own and manage the property after the construction or rehabilitation work is completed:

13. A Model Lease is Attached Yes No

OMB No.: 1205-0464 OMB Expiration Date: 10/31/2010 Average Response Time: 30 minutes

This reporting requirement is approved under the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of information includes time for reviewing instructions, searching existing data sources, gathering and reviewing the collection of information. Respondent’s obligation to reply to this collection of information, which is for general program oversight, evaluation, and performance assessment, is required to maintain benefits [PL 109-281 Sec 173(A)(c)(3)]. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden, to the U. S. Department of Labor, Employment and Training Administration, Youth Office, Room N4459, 200 Constitution Avenue, NW, Washington, D.C. 20210.

Signature of Authorized Certifying Official of: _______ Applicant _____ Rightful Owner

Printed Name:Signature:

Title: __________________________________________________ Date: _____________

Organization: ______________________________________________________________

		Individual Housing Project Site Estimate
			YouthBuild (YB) GRANT
ATTACHMENT 1B							OMB No.
ETA - XXXX							Expires:
APPLICANT IDENTIFYING INFORMATION
Applicant Name:
Address of the Property (include city, state, and zip code):
	Grant Activities			Resources
		YouthBuild	Other Federal	State	Local		Private	Total
1.	Acquisition
2.	Architecture &
Engineering
3.	Housing Construction
4. Housing Rehabilitation
5.	Total Housing Project
Costs for Site

Note 1: Include both cash and in-kind contributions.

Note 2: When paid, in whole or in part, with YouthBuild program funds, the activities will trigger applicable YouthBuild project-related restrictions contained in regulations XXXXXXX. Applicants who propose to use YouthBuild funds for one or more of these activities are required to complete the appropriate certifications.

Documentation of Housing Resources

Attach a letter of commitment from each source of funding. These letters will not count towards your total page count

Name of Provider (Donor)	Cash or In-Kind	Dollar Value Provided	Page # of Letter

OMB No.: xxxx-xxxx OMB Expiration Date: xx/xx/xxxx OMB Burden Hours: 30 minutes OMB Burdent Statement: These reporting instructions have been approved under the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Information is collected from eligible applicants for a competition to determine which entities will receive grant funds. Public reporting burden for this collection of information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Submission is mandatory and is authorized under YouthBuild Transfer Act Public Law 109-2810. The information will be used for the YouthBuild grant and response to this request for information is required in order to receive the benefits to be derived. The information requested does not lend itself to confidentiality. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce Security, Room S-4231, 200 Constitution Ave., NW, Washington, DC, 20210.