OMB Approved No.: 1505-0269

Expiration Date: 10/31/2021

HOMEOWNER ASSISTANCE FUND

U.S. DEPARTMENT OF THE TREASURY

Notice of Funds Request

On behalf of ____________________________ [insert name of entity] (the Eligible Entity),1 I 

hereby notify the U.S. Department of the Treasury (Treasury) that the Eligible Entity requests 

funds allocated to it by Treasury under the Homeowner Assistance Fund (HAF) established 

under section 3206 of the American Rescue Plan Act of 2021.

If the Eligible Entity is a state, the District of Columbia, or a U.S. territory, this Notice 

must be submitted to Treasury by April 25, 2021, or the Eligible Entity will not be eligible 

to receive funds under the HAF. The deadline for any other Eligible Entity to submit this 

Notice is November 15, 2021.

The undersigned representative affirms that the undersigned has the authority to submit this 

Notice to Treasury on behalf of the Eligible Entity. This form should be submitted by an 

authorized agency or office of the Eligible Entity.

Signed:_______________________________________ Date:__________________________

Name

Title

Agency or Office

Street

City, State, Zip

Phone

E-mail

Contact Person for Eligible Entity:

Name

Title

Agency or Office

Street

City, State, Zip

Phone

E-mail

1 “Eligible entity” means a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, 

Guam, American Samoa, the United States Virgin Islands, the Commonwealth of the Northern Mariana Islands, the 

Department of Hawaiian Home Lands, and certain Indian Tribes or Tribally designated housing entities eligible for 

payment under section 3206(f) of the American Rescue Plan Act of 2021.
OMB Approved No.: 1505-0269

Expiration Date: 10/31/2021

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 15 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 the American Rescue Plan Act of 2021, 

Title III, Pub. L. 117-2.

PURPOSE: Treasury is required by the American Rescue Plan Act of 2021 to identify eligible entities to 

provide homeowners assistance to individuals who qualify for relief under the Act. Eligible entities are 

state, territorial, and tribal governments, which will identify homeowners eligible for relief based on 

requirements under the Act. Treasury maintains contact information for authorized representatives and 

contact persons for the purpose of communicating with eligible entities regarding issues related to 

implementation of 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 to Treasury is required in order to comply with the 

requirements the American Rescue Plan Act of 2021. 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 and this may affect the status of their grant.