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EMERGENCY RENTAL ASSISTANCE PROGRAM U.S. DEPARTMENT OF THE (Department of the Treasury - OCIO)

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OMB Approved No.:1505-0266
Expiration date: 04/30/2022
EMERGENCY RENTAL ASSISTANCE PROGRAM
U.S. DEPARTMENT OF THE TREASURY
Request for Reallocated Funds
The undersigned entity (the “ERA Grantee”) received its full allocation of funds for the delivery
of emergency rental assistance (“ERA”) in accordance with section 501 of division N of the
Consolidated Appropriations Act, 2021 (the “Act”). The ERA Grantee hereby requests an
additional $ of ERA funds from any amounts the U.S. Department of the
Treasury (“Treasury”) makes available for reallocation under section 501(d) of the Act.
Treasury has published guidance, available on its website, setting forth the procedures for the
reallocation of ERA funds under the Act. In accordance with the guidance, the ERA Grantee
hereby certifies that:
1. it has obligated at least 65% of its total ERA award funds under the Act (the “ERA1
Award”) as of the date below; and
2. its jurisdiction has a demonstrated need for the ERA funds requested above and the
capacity to use those funds pursuant to applicable requirements by September 30,
2022.
The ERA Grantee acknowledges that any funds remaining from its ERA1 Award must be
obligated by September 30, 2022, and such funds not obligated or expended at that time must
be returned to Treasury as part of the award closeout process pursuant to 2 C.F.R. 200.344(d).
As permitted by the Act, the ERA Grantee hereby requests that Treasury extend the deadline
for obligating any reallocated funds received pursuant to this request to December 29, 2022.
This form includes and incorporates the attached Exhibits A (Obligation Report); B (Evidence of
Demonstrated Need; and C (Voluntarily Reallocated Funds).
[ERA GRANTEE]
By:
[Official’s Name]
[Official’s Title]
Date: , 202
PAPERWORK REDUCTION ACT NOTICE: The information collected will be used for the U.S. Government to determine the
reallocation of emergency rental assistance funds. The estimated burden associated with this collection of information is 75
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.
PRIVACY ACT STATEMENT
AUTHORITY: Solicitation of this information is authorized by section 501 of division N of the Consolidated Appropriations Act,
2021 (the “Act”)
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2
PURPOSE: The Act requires Treasury to allocate funds to eligible grantees for the delivery of emergency rental assistance to
eligible households. Eligible grantees include State, Local governments, U.S. Territories, Tribes, or Tribally Designated Housing
Entities (TDHEs), as applicable, and the Department of Hawaiian Home Lands. Treasury maintains contact information for
authorized representatives and contact persons of the ERA grantees for the purpose of communicating with ERA grantees
regarding the administration of their award under the Act.
ROUTINE USES: The information you furnish may be shared in accordance with the routine uses outlined in the Treasury’s
system of records notice, Treasury .017 – Correspondence and Contact Information, which can be found at 81 FR 78266 (Nov. 7,
2016).
DISCLOSURE: Disclosure of this information is voluntary. However, grantees/recipients that do not disclose contact
information will be unable to communicate with Treasury on issues related to their obligations under the Act which may affect
the status of their award.
3
EXHIBIT A
Obligation Report
Treasury has published guidance, available on its website, setting forth the procedures for the
reallocation of ERA funds under the Act. As described in the guidance, Treasury considers ERA
funds to be obligated if (i) the funds have actually been spent providing financial assistance and
housing stability services for eligible households; (ii) the funds are needed to pay for assistance
promised in a commitment letter issued to induce a landlord to enter a rental agreement with
an eligible household under Treasury’s ERA FAQ #35; or (iii) subject to certain conditions, the
grantee has, as part of the grantee’s ERA program administration, entered into a binding
agreement or funding commitment requiring the grantee to disburse the funds to a third party
for eligible purposes. In addition, Treasury will consider 10% of each grantee’s total award
amount as having been obligated for administrative costs regardless of the grantee’s actual
expenditures, commitments, or obligations.
Please provide information on this Exhibit A only regarding the ERA Grantee’s use of funds
from the ERA1 Award authorized by the Act – not regarding its use of funds under an ERA
award authorized by the American Rescue Plan Act of 2021 (“ERA2”).
Consistent with Treasury’s reallocation guidance, the undersigned hereby represents and
certifies to Treasury that:
As of [insert date], the ERA Grantee has obligated its ERA1 Award funds as
follows:
Enter 10% of total ERA1 Award amount for
administrative costs:
$
Enter total of all other amounts obligated by ERA
Grantee as of the date hereof:
$
Total amount obligated:
$
4
EXHIBIT B
Evidence of Demonstrated Need
To receive reallocated ERA funds, an ERA grantee must confirm there is a demonstrated need
for the assistance within its jurisdiction. In support of its request, the ERA Grantee must submit
the following monthly projections.
These projections should include expenditures and activities under both section 501 of the
Act (“ERA1”) and section 3201 of the American Rescue Plan Act of 2021 (“ERA2”). When
projecting the amount of assistance to be provided to eligible households, assume the funds
requested in the opening paragraph of this form will be available beginning May 1, 2022.
Number of unique households that will be assisted
Amount of assistance to eligible households
expended
$
Number of applications submitted
Number of unique households that will be assisted
Amount of assistance to eligible households
expended
$
Number of applications submitted
Number of unique households that will be assisted
Amount of assistance to eligible households
expended
$
Number of applications submitted
Number of unique households that will be assisted
Amount of assistance to eligible households
expended
$
Number of applications submitted
5
EXHIBIT C
Voluntarily Reallocated Funds
In accordance with Treasury’s ERA1 Reallocation Guidance, grantees may request to voluntarily
reallocate some or all of their remaining ERA1 award funds to another ERA1 grantee that (i)
administers an ERA1 program in the same state, territory, or Tribal area; (ii) has obligated at
least 65% of its own ERA1 award by the time of such transfer; and (iii) confirms a demonstrated
need for additional assistance in the grantee’s jurisdiction.
If known, please identify below any ERA1 grantee(s) who have recommended or are expected
to recommend the voluntary reallocation of ERA1 funds to the ERA Grantee.
Transferring Grantee
Expected Amount
$
$
$
If awarded voluntarily reallocated funds, the ERA Grantee agrees to comply with all
administrative and operational requirements applicable to the transfer of ERA1 funds between
and among ERA1 grantees. These requirements may include the provision of any standard
form documents needed to confirm a grantee’s data universal number system (DUNS) number,
deposit account, wire instructions, or other funds transfer information. The ERA Grantee
understands that failure to comply with these requirements may result in Treasury awarding
any funds recommended for reallocation to the ERA Grantee to other grantees.
As a condition to receiving voluntarily reallocated funds, the ERA Grantee certifies that it has
complied with all ERA1 requirements under applicable law, the ERA1 guidance published by
Treasury, and its ERA1 Award Terms. The ERA Grantee agrees that it will use its remaining ERA1
funds, including any additional funds received through reallocation, in compliance with all such
authorities.
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Completed 13 April 2022

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