OMB Approved No.: 1505-0269

Expiration Date: 10/31/2021

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United States Department of the Treasury

Homeowner Assistance Fund Plan 

Introduction and Purpose

Welcome to the U.S. Treasury Department’s submission portal for the Homeowner Assistance Fund (HAF) Plan. 

In the HAF, an eligible entity (the “Participant”) is (1) a state, the District of Columbia, or U.S. territory; (2) the 

Department of Hawaiian Home Lands; (3) each Indian tribe (or, if applicable, the tribally designated housing entity of 

an Indian tribe) that was eligible for a grant under Title I of the Native American Housing Assistance and SelfDetermination Act of 1996 (25 U.S.C. 4111 et seq.) for fiscal year 2020; and (4) any Indian tribe that opted out of 

receiving a grant allocation under the Native American Housing Block Grants program formula in fiscal year 2020.

A HAF Participant must submit its HAF Plan using this portal if it has been allocated $5 million or more in the HAF. If 

a HAF Participant has been allocated less than $5 million, it should not use this form; a different form has been 

made available for smaller allocations.

In the fields below, you will submit your HAF Plan, organized around the following plan elements:

• Homeowner Needs and Community Engagement

• Program Design 

• Performance Goals

• Readiness 

• Budget

After completing the form, please click on the DocuSign button to sign and submit the HAF Plan. 

Once the HAF Plan is submitted, Treasury will review the plan. Treasury may approve a HAF Plan in whole or in part. 

If Treasury identifies weaknesses in any elements of your HAF Plan, the Participant will be provided an opportunity to 

revise and resubmit those elements. Upon Treasury’s approval of the HAF Plan, Treasury will initiate steps to 

transmit the requested allocation amount. Treasury will evaluate HAF Plans as described in the HAF guidance, 

available at https://home.treasury.gov/system/files/136/HAF-Guidance.pdf. Please refer to the HAF guidance for 

definitions of terms used in this portal and additional information regarding the HAF.

Homeowner Needs and Community Engagement

What Quantitative Data Has Informed the Participant’s Planning?

Treasury will assess the extent to which a Participant has, in the course of its HAF planning process, relied on 

quantitative data, including from community-based organizations or organizations that serve potentially eligible 

homeowners. 
OMB Approved No.: 1505-0269

Expiration Date: 10/31/2021

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In its HAF planning process, has the Participant obtained quantitative data from mortgage servicers, private data 

providers, government entities, community-based organizations or other sources to inform its planning about how 

to target and best serve eligible homeowners with mortgage delinquencies, defaults, foreclosures?

 Yes

 No

If yes, please list and briefly describe each source of quantitative data.

In its HAF planning process, has the Participant obtained quantitative data from utility providers or entities charged 

with assessing and collecting property taxes or relied on quantitative data or studies to inform its planning about how 

to target and best serve eligible homeowners at risk of displacement due to utility arrearage or tax foreclosure? 

 Yes

 No

If yes, please list and briefly describe each source of this type of quantitative data.

In its HAF planning process, has the Participant obtained and reviewed quantitative data or studies regarding which 

demographic segments in its jurisdiction have historically experienced discrimination in the housing or housing 

finance market? 

 Yes

 No

If yes, list and briefly describe each study or source of quantitative data.

Examples: 

• Data provided by Treasury – Treasury provided data, contributed by a number of federal agencies, including 

information on mortgage delinquencies and forbearances, breakdowns by demographic factors, and 

concentration among mortgage servicers.

• Data from on Mortgage Servicing – The Participant has entered into a data sharing agreement with 

Mortgage Data Company to obtain regularly updated data on mortgage delinquency among private-held 

mortgages.

Examples: 

• Data collected from county tax assessors – Data was requested from every county tax assessor about the 

number, location (by census tract) and average amount of overdue property taxes on owner occupied 

residences. 60% of the tax assessors responded with data.

• Data collected from utility providers – Data was requested from utility providers about the number, location 

(by census tract) and average amount of past due or delinquent utility accounts. 60% of the utility providers 

responded with data

Example: 

• Johnson, S. (2020), Housing Discrimination, University Press. This book documents quantitative data on the 

experience and impacts of housing discrimination for African-American and Hispanic populations, including in 

our jurisdiction.
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In the following text box, please list any source not listed above of quantitative information, including sources of data 

on the performance of any of the Participant’s previously implemented programs, that the Participant used to inform 

its HAF planning process, briefly describe how the data informed the Participant’s planning.

Did the Participant communicate with mortgage servicers regarding the development of its program design?

 Yes

 No

Did the Participant communicate with other HAF participants regarding the development of its program design?

 Yes

 No

How Has Community Engagement and Public Participation Informed the Participant’s Planning?

Treasury will assess the extent to which a Participant’s assessment of homeowner needs has been informed by and 

reflects input from organizations and individuals representing eligible homeowners, including any opportunities for 

public participation in the development of the Participant’s plan. Treasury will pay particular attention to the extent 

of the Participant’s engagement with populations that are the subject of statutory targeting requirements. 

Has the Participant requested and received input on its HAF planning process from providers of housing counseling

services or providers of legal assistance to homeowners facing foreclosure or displacement? 

 Yes

 No

If yes, please list such providers, including the providers’ address and website. Please indicate by checking the 

appropriate box below if the provider’s primary purpose is to serve low- and moderate-income households or to 

address the impacts of housing discrimination on one or more demographic groups in the Participant’s jurisdiction. 

Provider 

Name

Provider 

Address

Provider Website Provider Primarily 

Serves LMI

Households

Provider 

Addresses 

Impacts of 

Housing 

Discrimination

Example: ABC 

Housing 

Counseling 

Organization 

123 Housing 

Counseling 

Way, Town, 

State Zip Code

www.abccounselingorganization.org CHECK BOX CHECK BOX

Examples: 

• Garcia, Adrian. “Homeownership Preservation”, ABC Journal, vol. 1, no.1, 2020, pp. 100-110. This journal 

article provides information on best practices for homeownership preservation. 

• Hardest Hit Fund Performance data: Participant operated a HHF program and used data from this program to 

inform its program design. 
OMB Approved No.: 1505-0269

Expiration Date: 10/31/2021

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Has the Participant requested and received input regarding its HAF planning process from community-based 

organizations or organizations that serve potentially eligible homeowners? 

 Yes

 No

If yes, please list such organizations, including the providers’ address and website if available. Please indicate by 

checking the appropriate box below if the provider’s primary purpose is to serve low- and moderate-income 

households or to address the impacts of housing discrimination on one or more demographic groups in the 

Participant’s jurisdiction. 

Organization 

Name

Organization 

Address

Organization Website Organization 

Primarily Serves 

LMI Households

Provider 

Addresses 

Impacts of 

Housing 

Discrimination

Example: ABC 

Community 

Organization, 

123 

Community 

Organization 

Way, Town, 

State Zip Code

www.abccommunityorganization.org CHECK BOX CHECK BOX

Has the Participant consulted with localities or tribal governments (cities, counties, or rural communities) in its 

jurisdiction regarding the needs of eligible homeowners in its jurisdiction? 

 Yes

 No

Has the Participant provided an opportunity for public input regarding its HAF Plan through public hearings or 

published materials? 

 Yes

 No

If yes, please indicate whether a proposed or draft plan was published, please describe where details about the 

comment solicitation were posted, for how long, in what languages, and whether any efforts were made to make the 

posting accessible to persons with disabilities or individuals without reliable internet access. 

Example: This HAF Plan was informed by three virtual public hearings (with phone access) held June 5, June 22 

and July 23 regarding emergency housing needs. Draft Plan was published on July 25, 2021, public comments 

accepted through July 31, 2021- by e-mail and web submission. Draft plan published in English, Spanish, 

Mandarin, and Vietnamese, and numerous community-based organizations were informed of this publication so 

that they could inform the communities they serve.
OMB Approved No.: 1505-0269

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How Will the Participant Continue to Assess the Needs of Eligible Homeowners?

Treasury anticipates that an ongoing process of assessing the needs of eligible homeowners will help address the 

needs of potentially eligible homeowners as economic conditions change over time. 

Does the Participant plan to update its assessment of community needs within the next year to determine whether 

its HAF program design should be updated to address changing needs of potentially eligible homeowners?

 Yes

 No

What additional data would be helpful to the Participant as it seeks to assess homeowner needs over time?

Program Design

What are the Program Design Elements Through Which the Participant Will Deliver HAF Assistance to Eligible 

Homeowners?

A program design element is a specific activity or program, which is consistent with a qualified expense category,

under which a Participant will disburse HAF funds in accordance with the HAF Plan. Please note that multiple program 

design elements may fit under a single qualified expense category; for example, a mortgage assistance program that 

has different terms for federally backed mortgages and manufactured-home mortgages may constitute two separate 

program design elements, for which case the Participant provides a separate term sheet or other description for each 

program design element. 

HAF participants must have at least one program design element intended to reduce mortgage delinquency among 

targeted populations. Treasury encourages HAF participants to consider program design elements that address 

homeownership preservation for targeted populations in areas where there is a sustained trend of increasing property 

taxes or utility costs, including for households that do not have mortgages. 

Please identify each qualified expense category in which the Participant will offer a program design element by 

checking the boxes below.

 mortgage payment assistance;

 financial assistance to allow a homeowner to reinstate a mortgage or to pay other housing-related costs related to 

a period of forbearance, delinquency, or default;

 mortgage principal reduction, including with respect to a second mortgage provided by a nonprofit or government 

entity;

 facilitating mortgage interest rate reductions;

 payment assistance for homeowner’s utilities, including electric, gas, home energy, and water;

 payment assistance for homeowner’s internet service, including broadband internet access service, as defined in 

47 CFR 8.1(b);

 payment assistance for homeowner’s insurance, flood insurance, and mortgage insurance; 

 payment assistance for homeowner’s association fees or liens, condominium association fees, or common 

charges;

 payment assistance for down payment assistance loans provided by nonprofit or government entities;

Examples: 

- Data on manufactured housing loans 

- Monthly data from servicers on loan delinquency 
OMB Approved No.: 1505-0269

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 payment assistance for delinquent property taxes to prevent homeowner tax foreclosures;

 measures to prevent homeowner displacement, such as home repairs to maintain the habitability of a home or 

assistance to enable households to receive clear title to their properties.

For each program design element that the Participant will offer, the Participant is required to upload a term sheet or 

other description that, at a minimum, provides the following information regarding that program design element. 

Term sheets for all of Participant’s HAF programs may be uploaded together as one document.

• Brief description – Explain how the funds will be used (e.g., what type of homeowner expense the funds will 

be used for). If applicable, describe how the funds may be used in combination with other assistance 

programs (e.g., loan servicer loss-mitigation programs). 

• Maximum amount of assistance per homeowner - Specify the maximum amount of assistance that each 

homeowner will be eligible to receive under the program design element.

• Eligibility criteria and documentation requirements – Explain all homeowner, mortgage, property, or other

eligibility criteria for the program design element (other than the mandatory eligibility requirements set forth 

in the HAF guidance). In addition, list any documentation that will be required from homeownersto establish 

such eligibility. Provide a justification for each additional eligibility or documentation requirement beyond 

those required under the HAF guidance, including an explanation of how the Participant determined that 

such requirement will not create barriers to participation for eligible households. 

• Form of assistance – Indicate whether the funds will be provided in the form of grants, forgivable loans, or 

other assistance. If the funds will be provided through forgivable loans, specify the terms for forgiveness. If 

the Participant proposes to provide the assistance in a form other than grants or forgivable loans, provide 

the reasoning for the proposed terms. If the Participant proposes to establish a home repair program, explain 

all criteria that will be used to determine whether a homeowner is eligible for the program (e.g., contractor 

licensing, repair contract requirements, zoning).

• Payment requirements – Indicate to whom payments will be made (e.g., to homeowners or to a third party) 

and any additional requirements there may be to complete a payment (e.g., bulk payment requirements for 

payees, method of determining amount of payment).

A HAF participant may elect to revise its HAF Plan over time to add or subtract program design elements. Does the 

Participant anticipate adding additional program design elements to this HAF Plan within one year of this submission? 

 Yes

 No

Treasury has provided sample term sheets to assist HAF participants in developing their HAF plans. Participants may 

use these sample term sheets, in whole or in part, as part of their submission. To the extent the Participant intends 

to structure the program differently with respect to significant program terms described in the Sample Term Sheets, 

Treasury will, in the course of its review of the HAF Plan, request a justification for how the alternate approach will 

further the objectives of the HAF, including targeting and prioritization requirements. In the chart below, the HAF 

Participant may provide a justification for significant deviations from the terms described in the sample term sheets 

upon initial submittal. 

(optional for initial submission)

Program Design Element Deviation from sample terms Justification
OMB Approved No.: 1505-0269

Expiration Date: 10/31/2021

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Documentation of Homeowner Income

Homeowners are eligible to receive amounts allocated to a HAF participant under the HAF only if they have incomes 

equal to or less than 150% of the area median income or 100% of the median income for the United States, whichever 

is greater. In addition, not less than 60% of amounts made available to each HAF participant must be used for qualified 

expenses that assist homeowners having incomes equal to or less than 100% of the area median income or equal to 

or less than 100% of the median income for the United States, whichever is greater. The HAF guidance describes 

permissible ways for HAF participants to determine homeowner income.

Under the HAF guidance, one permissible approach for determining income is for (1) the household to provide a 

written attestation as to household income and (2) the HAF participant to use a reasonable fact-specific proxy for 

household income, such as reliance on data regarding average incomes in the household’s geographic area. Will the 

Participant allow income to be determined in this way? 

 Yes

 No

If yes, please describe the fact-specific proxy or proxies to be used for the income determination.

TEXT BOX

Under the HAF guidance, HAF participants may provide waivers or exceptions to this documentation requirement as 

reasonably necessary to accommodate extenuating circumstances, such as disabilities, practical challenges related to 

the pandemic, or a lack of technological access by homeowners; in these cases, the HAF participant is still responsible 

for making the required determination regarding household income and documenting that determination. Will the

Participant allow applicants to request such waivers or exceptions? 

 Yes

 No

Eligible Mortgage Types

Please indicate which of the following mortgage types are eligible to be assisted under one or more of the 

Participant’s program design elements 

First Mortgages

Second Mortgages 

Reverse Mortgages (Home Equity Conversion Mortgages, Single-Purposes Reverse Mortgages, or Proprietary 

Reverse Mortgages)

Loans Secured by Manufactured Housing (secured by real estate or a dwelling)

Contracts for Deed or Land Contract (if it is a credit transaction secured by a consensual security interest in the 

dwelling)
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If the Participant excludes any of the forgoing mortgage types from one or more program design elements, explain 

the exclusion.

How Will the Participant Target HAF Resources Consistent with Statutory Requirements?

The Participant must describe how it will target HAF resources in accordance with the HAF guidance. Targeting 

strategies are affirmative efforts to inform, encourage the participation of, and facilitate access to resources for 

targeted households, including by offering multiple intake formats, engaging with nonprofit organizations (e.g., 

housing counselors or legal services organizations) to provide additional pathways into the program, and providing 

community outreach, partnerships with housing counseling agencies or legal aid organizations, or other educational 

services that are aligned with the HAF participant’s program design, in a manner that is culturally and linguistically 

relevant to the targeted communities. 

Defining Socially Disadvantaged Individual

Please describe the process the Participant will use to determine whether a homeowner is a “socially disadvantaged 

individual” as defined in the HAF guidance.

Public Communications

Will the Participant engage in a public communications campaign to raise awareness among targeted populations 

about the availability of HAF resources, in media such as television, newspapers, online media, or social media?

 Yes

 No

If yes, please indicate whether the public communications campaign will include communications that primarily target 

the following populations:

 Homeowners earning less than 100% of area median income

 member of a group that has been subjected to racial or ethnic prejudice or cultural bias within American society;

 resident of a majority-minority Census tract;

 resident of a U.S. territory, Indian reservation, or Hawaiian Home Land;

 homeowners that reside in persistent poverty counties;

 individual with limited English proficiency.

Please indicate in which languages, in addition to English, public communications to targeted populations will be 

undertaken:

 Spanish

 Chinese

 Vietnamese
OMB Approved No.: 1505-0269

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 Korean

 Tagalog

 Russian

 Arabic

 Haitian Creole

 other _______________________

Outreach

Will the Participant engage in outreach through partnerships with organizations that focus primarily on serving 

homeowners earning incomes below 100% of area median income or socially disadvantaged individuals and that have 

the capacity to engage targeted communities in a culturally and linguistically relevant manner to encourage the 

submission of applications for HAF resources from targeted populations?

 Yes

 No

If yes, please indicate whether the community outreach efforts will include partnerships with organizations that 

primarily target the following populations:

 member of a group that has been subjected to racial or ethnic prejudice or cultural bias within American society;

 resident of a majority-minority Census tract; 

 resident of a U.S. territory, Indian reservation, or Hawaiian Home Land;

 homeowners that reside in persistent poverty counties;

 individual with limited English proficiency.

Please indicate in which languages, in addition to English, community outreach efforts to targeted populations will 

be undertaken:

 Spanish

 Chinese

 Vietnamese

 Korean

 Tagalog

 Russian

 Arabic

 Haitian Creole

 other _______________________

Housing Counseling and Legal Services

Will the Participant facilitate access for eligible households to housing counseling or legal services?

 Yes

 No

If yes, please identify below the providers of housing counseling or legal services that have indicated to the Participant 

that they are willing and able to support homeowners receiving assistance under the Participant’s HAF programs.

Provider 

Name

Provider 

Address

Provider Website Provider Primarily 

Serves LMI

Households

Provider 

Addresses 

Impacts of 
OMB Approved No.: 1505-0269

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Housing 

Discrimination

Example: ABC 

Housing 

Counseling 

Organization 

123 Housing 

Counseling 

Way, Town, 

State Zip 

Code

www.abccounselingorganization.org CHECK BOX CHECK BOX

Targeting specific groups of homeowners

Will the Participant conduct outreach specifically tailored to target potentially eligible households that:

 have mortgages or mortgage assistance contracts held or backed by the Participant? 

 have mortgages backed by any of the following agencies: Federal Housing Administration; Department of Veterans 

Affairs; U.S. Department of Agriculture?

 have privately held mortgages?

What Efforts will be Made to Address Barriers to HAF Program Participation for Potentially Eligible Homeowners, 

Including Those with Limited English Proficiency or Who are Disabled?

Targeted outreach may be needed to reach homeowners who are likely to experience barriers to access, including 

persons with limited English proficiency and those with disabilities.

Indicate all of the languages, in addition to English, in which the Participant’s HAF application and other program 

documents will be made available:

 Spanish

 Chinese

 Vietnamese

 Korean

 Tagalog

 Russian

 Arabic

 Haitian Creole

 other _______________________

Will the Participant’s HAF applications and other program documents be provided in forms that are accessible to 

persons with disabilities?

 Yes

 No

Performance Goals

Treasury will consider the goals and benchmarks the Participant proposes to use to measure the effectiveness of its 

programs, including whether those goals address the homeowner needs identified by the Participant, the extent to 

which the goals are disaggregated by key homeowner characteristics as appropriate for the jurisdiction, and whether 

they include a goal focused on reducing mortgage delinquency.
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Please describe Participant’s goals and benchmarks for each of its programs with the following program design 

elements.

Program Design Element Metrics of Success Goal

Mortgage payment assistance

Allow homeowners to reinstate 

mortgages or pay other housingrelated costs

Mortgage principal reduction

Facilitating mortgage interest rate 

reductions

Payment assistance for 

homeowner’s utilities (e.g., 

electric, gas, home energy, and 

water)

Payment assistance for 

homeowner’s internet service (e.g., 

broadband)

Payment assistance for 

homeowner’s, flood, and mortgage 

insurance

Payment assistance for 

homeowner’s association fees or 

liens, condominium association 

fees, or common charges

Payment assistance for down 

payment assistance loans provided 

by nonprofit or government entities

Payment assistance for delinquent 

property taxes to prevent 

homeowner tax foreclosures

Measures to prevent homeowner 

displacement

Examples of metrics of success:

• Number of home losses avoided due to HAF funds.

• Number of tax-related delinquencies paid off.

Examples of goals:

• Prevent 500 home losses within 24 months

• Prevent the replacement of 100 homeowners by paying off delinquent property taxes

Readiness

Staffing, Systems and Contractors

Treasury seeks information regarding the Participant’s organizational capacity to implement its HAF Plan.
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Does the Participant anticipate needing to hire additional staff to implement this HAF Plan? 

 Yes

 No

Does the Participant anticipate significant information technology system upgrades to implement this HAF Plan? 

 Yes

 No

Does the Participant have policies or procedures that govern the implementation of each HAF program design 

element described in this HAF Plan? 

 Yes

 No

If no, is a policy and procedure in development for each HAF program design element described in this HAF 

Plan?

 Yes

 No

Will the Participant use HAF funds to assist eligible households through a program that was operational before the 

Participant first received HAF funds?

 Yes

 No

If yes, has the documentation for that pre-existing program been adapted to HAF requirements (please 

answer yes if the pre-existing program already complied with HAF program requirements)? 

 Yes

 No

Will the Participant use any third-party contractor or partner to conduct program administration (such as reviewing 

applications, determining eligibility, processing payments, conducting reporting, and reviewing compliance) forsome 

or all of the Participant’s HAF programs?

 Yes

 No

If yes, has the Participant entered into all necessary arrangements with all of the third-party contractors or 

partners that will conduct program administration? 

 Yes

 No

Use of Initial Payment

If the Participant has already received any HAF funds from Treasury, provide the following information about the use 

of such funds as of June 30, 2021.

What amount of the HAF funds that the Participant has received been disbursed to eligible homeowners?
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How much of the HAF funds that the Participant has reviewed been obligated?

Has the Participant begun accepting applications from homeowners for any HAF-funded programs?

 Yes

 No

If yes: 

How many households have applied for HAF assistance?

How many households has the Participant provided with assistance using HAF funds? 

How many households has the Participant provided with housing counseling or legal services using HAF 

funds?

Provide a brief description of how the Participant has used the HAF funds it has received.

Budget

Budgeting of HAF Funds by Program Design Element

Specify the amounts of HAF funds that the Participant proposes to allocate to each of the following program design 

elements, if offered: 

Amount ($0.00)

Mortgage Payment Assistance 

Mortgage Reinstatement

Mortgage Principal Reduction 

Facilitate Mortgage Interest Rate Reduction

Payment Assistance for Homeowners Utilities 

Payment Assistance for Homeowner’s Internet Service 

Payment Assistance for Homeowner’s Insurance

Payment Assistance for HOA fees or liens

Payment Assistance for Down Payment Assist. Loans

Please explain how the Initial HAF allocation has been utilized.
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Payment Assistance for Delinquent Property Taxes

 

Other measures to prevent homeowner displacement 

Sub-total: 

(Enter sum of amounts entered) 

Counseling or Legal Services

The Participant may allocate up to 5% of its HAF funds for counseling or educational efforts by housing counseling 

agencies approved by the Department of Housing and Urban Development or a tribal government, or legal services, 

target to households eligible to be served with funding from the HAF related to foreclosure prevention or 

displacement.

Specify the Participant’s allocations for the following:

 Amount ($0.00)

 Counseling or Educational Services 

 Legal Services

Sub-total: 

(Enter sum of amounts entered) 

Reimbursement of Funds Expended After January 21, 2020

As described in the HAF guidance, HAF funds may be used for reimbursement of certain expenses between January 

21, 2020 and the date when the first HAF funds are disbursed by the HAF participant under the HAF for a qualified 

expense (with certain limitations, as set forth in the HAF guidance).

If the Participant is seeking reimbursement for any previous expenses, please specify the expenses and amounts 

below, providing sufficient detail for Treasury to determine whether the expense is within the definition of “qualified 

expenses” in the HAF guidance:

 Amount ($0.00)

Expense Type

Sub-total: 

(Enter sum of amounts entered) 

Allocation of Administrative Expenses

As described in the HAF guidance, up to 15% of a HAF participant’s allocation may be used for administrative 

expenses. If the participant proposes to use HAF funds for administrative expenses, please specify the proposed 

expenses and amounts below, providing sufficient detail for Treasury to determine whether the expense is within the 

definition of “qualified expenses” in the HAF guidance:
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Expense Type Amount ($0.00)

Sub-total: 

(Enter sum of amounts entered) 

Points of Contact

Please identify up to three contacts for the Participant- a primary contact, a designated point of contact for 

reporting, and an additional contact. 

Primary Contact 

Name: ____________________________________________________ 

Agency/Office: _____________________________________________

E-mail: ____________________________________________________

Phone Number: ____________________________________________ 

Reporting Contact 

Name: ____________________________________________________ 

Agency/Office: _____________________________________________

E-mail: ____________________________________________________

Phone Number: _____________________________________________

Additional Contact 

Name: ____________________________________________________ 

Agency/Office: _____________________________________________

E-mail: ____________________________________________________

Phone Number: _____________________________________________ 

Authorized Official Information

Authorized Official Name: ____________________________________________________ 

Authorized Official’s Email Address: ____________________________________________

Authorized Official’s Title: ____________________________________________________
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Application Certification

I (the undersigned) certify that the information provided in the HAF submission is accurate and complete after 

reasonable inquiry of people, systems, and other information available to the HAF Participant. The HAF participant 

and I acknowledge that any materially false, fictitious, or fraudulent statement or representation (or concealment or 

omission of material fact) in this submission may be the subject of criminal prosecution under the False Statements 

Accountability Act of 1996, as amended, 18 U.S.C. § 1001 and also may subject me and HAF Participant to civil 

penalties and/or administrative remedies for false claims or otherwise, (including 31 U.S.C. §3729 et seq.). I am an 

authorized representative of HAF Participant with authority to make the above certifications and representations on 

behalf of the HAF Participant.

Name of HAF Participant 

Name and Title of Certifying Official 

Name Telephone

 

Title Email

 

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