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|---|---|---|---|---|---|---|---|
1000 | Nested | {
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"$defs": {
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"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the concurrence/approval person"
},
"date": {
"type": "string",
"description": "Date of the concurrence/approval"
}
}
},
"FinalDecision": {
"type": "object",
"properties": {
"date": {
"type": "string",
"description": "Date of the final decision"
}
}
},
"ReceivingOfficial": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the receiving official"
}
}
},
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"properties": {
"name": {
"type": "string",
"description": "Name of the person making the request"
},
"position": {
"type": "string",
"description": "Position of the person making the request"
}
}
}
},
"properties": {
"control_number": {
"type": "string",
"description": "Control number assigned by the Disability Program Manager"
},
"date": {
"type": "string",
"description": "Date of the request"
},
"requester": {
"$ref": "#/$defs/Requester",
"description": "Nested Requester object(s)"
},
"receiving_official": {
"$ref": "#/$defs/ReceivingOfficial",
"description": "Nested ReceivingOfficial object(s)"
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"concurrence_approval": {
"$ref": "#/$defs/ConcurrenceApproval",
"description": "Nested ConcurrenceApproval object(s)"
},
"final_decision": {
"$ref": "#/$defs/FinalDecision",
"description": "Nested FinalDecision object(s)"
}
}
} | {
"control_number": "RA-2024-20217",
"date": "03/15/2024",
"requester": {
"name": "Pompeo Seifert",
"position": "Agricultural Engineer"
},
"receiving_official": {
"name": "Chelsea Aparecida"
},
"concurrence_approval": {
"name": "Livia Smits",
"date": "03/18/2024"
},
"final_decision": {
"date": "03/22/2024"
}
} | Accommodation
Request
For Persons With
Disabilities
U.S. Department of Housing and Urban Development
Office of Administration
Disability Program
Manager ➢
Control Number:
RA- -
Date:
Control Number (RA-Fiscal Year (e.g. 2002)-Sequential # Assigned by Disability Program Manager)
Administrative Instructions
Before completing this form, read the reverse.
Entries: May be either handwritten or typewritten. Forms Supply: Use local office copier for initial supply
and supply and providing completed copies. Copies Retained By: (1) Employee’s Program Office; (2)
Disability Program Manager; (3) Employee.
Requester
Other, such as Immediate
Supervisor, Employee
Assistance Staff, Disability
Program Manager, and
Selective Placement
Coordinator may help
employee complete this
section
Name
Signature
Date
Organization
Position Title
Series
Grade
Requester Comments
May be completed if others
initiate form. Otherwise,
entry not required
Receiving Official
(e.g., Immediate supervisor,
manager, Principal
Organization Head, Disability
Program Manager, Human
Resources Staff, Employee
Assistance Program Staff, or
Employee/ Labor Relations
Staff)
Date Received
*Disapproved
Approved
In Full
Approved
In Part
Name
Signature
Date
Comments
Concurrence/Approval
Employee Assistance Staff,
Immediate Supervisor,
Principal Organization Head,
Disability Program Manager,
etc.
Date Received
*Disapproved
Approved
In Full
Approved
In Part
Name
Signature
Date
Comments
Final Decision
Immediate Supervisor,
Principal Organization Head,
Disability Program Manager
(based on Reasonable
Accommodation Committee)
Date Received
Approved with changes
Approved
*Disapproved
Name
Signature
Date
Comments
Funds Availability
Office of the Chief Financial
Officer
Date Received
Not Available
Available
Name
Signature
Date
Comments
If disapproved, complete HUD Form 11600.
Form HUD1000
RA-2024-20217
03/15/2024
Pompeo Seifert
Agricultural Engineer
Chelsea Aparecida
Livia Smits
03/18/2024
03/22/2024
SIGN
SIGN
SIGN
SIGN
SIGN
| Accommodation U.S. Department of Housing and Urban Development
Request Office of Administration
For Persons With
Disabilities
Disability Program Control Number: RA-2024-20217 03/15/2024
RA- - Date:
Manager ➢
Control Number (RA-Fiscal Year (e.g. 2002)-Sequential # Assigned by Disability Program Manager)
Administrative Instructions Before completing this form, read the reverse.
Entries: May be either handwritten or typewritten. Forms Supply: Use local office copier for initial supply
and supply and providing completed copies. Copies Retained By: (1) Employee’s Program Office; (2)
Disability Program Manager; (3) Employee.
Requester
Other, such as Immediate Name Signature SIGN
Supervisor, Employee Pompeo Seifert
Assistance Staff, Disability Date Organization
Program Manager, and
Selective Placement
Position Title Series Grade
Coordinator may help Agricultural Engineer
employee complete this
section
Requester Comments
May be completed if others
initiate form. Otherwise,
entry not required
Receiving Official Date Received *Disapproved Approved Approved
(e.g., Immediate supervisor, In Full In Part
manager, Principal Name Signature Date
Organization Head, Disability Chelsea Aparecida SIGN
Program Manager, Human
Resources Staff, Employee Comments
Assistance Program Staff, or
Employee/ Labor Relations
Staff)
Concurrence/Approval Date Received *Disapproved Approved Approved
Employee Assistance Staff, In Full In Part
Immediate Supervisor, Name Signature Date
Principal Organization Head, Livia Smits SIGN 03/18/2024
Disability Program Manager, Comments
etc.
Final Decision Date Received Approved with changes Approved
Immediate Supervisor, *Disapproved
Principal Organization Head,
Disability Program Manager Name Signature Date
(based on Reasonable SIGN 03/22/2024
Accommodation Committee) Comments
Funds Availability Date Received Not Available Available
Office of the Chief Financial
Name Signature Date
Officer SIGN
Comments
If disapproved, complete HUD Form 11600. Form HUD1000 | ||
101 | Nested | {
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"name": {
"type": "string",
"description": "Name of the authorized label administrator"
},
"phone": {
"type": "string",
"description": "Contact phone number"
}
}
},
"LabelRequest": {
"type": "object",
"properties": {
"requested_labels_quantity": {
"type": "number",
"description": "Quantity of certification labels requested"
},
"inventory_duration_weeks": {
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}
}
},
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"description": "Name of the Inspection Primary Inspection Agency"
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},
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"type": "string",
"description": "Date the order was placed"
},
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"type": "number",
"description": "Quantity of certification labels ordered"
},
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"type": "string",
"description": "Name of the person who authorized the quantity change"
},
"receipt_date": {
"type": "string",
"description": "Date the order was received"
},
"received_labels_quantity": {
"type": "string",
"description": "Quantity of certification labels received"
},
"primary_inspection_agency": {
"$ref": "#/$defs/PrimaryInspectionAgency",
"description": "Nested PrimaryInspectionAgency object(s)"
},
"label_request": {
"$ref": "#/$defs/LabelRequest",
"description": "Nested LabelRequest object(s)"
},
"authorized_label_administrator": {
"$ref": "#/$defs/AuthorizedLabelAdministrator",
"description": "Nested AuthorizedLabelAdministrator object(s)"
}
}
} | {
"request_date": "04/15/2024",
"order_placed_by": "Julia V. Lall",
"order_placed_date": "04/15/2024",
"ordered_labels_quantity": 5000.0,
"authorization_name": "Raul Gay",
"receipt_date": "04/20/2024",
"received_labels_quantity": "4950",
"primary_inspection_agency": {
"name": "Grimes Inspection Agency",
"address": "27244 Bailey Keys, North Heatherberg, AZ 25356"
},
"label_request": {
"requested_labels_quantity": 5000.0,
"inventory_duration_weeks": "8"
},
"authorized_label_administrator": {
"name": "Phillip T. Davis",
"phone": "(344) 822-0447"
}
} | IPIA Request for Labels
(order control)
U.S. Department of Housing and Urban Development
OMB Approval No. 2502-0233
Office of Manufactured Housing Programs
(expires 5/31/2026)
The Manufactured Housing Procedural and Enforcement Regulations 24 C.F.R. Chapter XX Part 3280 Section 11 and Part 3282 Sections 204 and 205
requires manufacturers to affix a certification label. Manufacturers report affixed labels through reports required by 24 C.F.R. Chapter XX Part 3282 Sections
209 and 552, providing usage data on a monthly basis. In turn the Inspection Primary Inspection Agencies (IPIAs) are required to monitor and provide
Manufacturers a supply of certification label and request them from HUD in accordance with 24 C.F.R. Chapter XX Part 3282 Section 362(b). The information
collected here will be used to monitor home distribution, collect fees, and reimburse parties as appropriate under these Regulations. Public reporting burden
for this collection of information is estimated to average 0.5 hours per response including the time for reviewing instructions, searching existing data sources,
gathering, and maintaining the data needed, and completing and reviewing the collection of information. Response to this information collection is mandatory
under 42 U.S.C. 5413(c)(3). This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid
OMB control number.
Privacy Notice:
HUD collects information in accordance with 42 U.S.C. 5413(c)(3) of the National Manufactured Housing Construction and Safety Standards Act of 1974 which
requires manufacturers, under 42 U.S.C. 5413(f), to maintain records, make reports and provide such information as HUD requires to determine whether the
manufacturer is in compliance with the standards established under 42 U.S.C. 5403.
Purpose of this collection is necessary for accurate dispensation of program benefits and credits. Failure to comply with these regulations may subject the party
in question to the civil and criminal penalties provided for in section 611 of the Act, 42 U.S.C. 5410. While HUD generally only discloses this data in response to
a Freedom of Information or audit request, any information collected pursuant to 42 U.S.C. 5413(b), (c), (f), or (g) which contains or relates to a trade secret that
would result in a substantial competitive disadvantage if disclosed shall be considered confidential and shall not be further disclosed except as required or
permitted under 42 U.S.C. 5413(h).
IPIA Name
IPIA Address
Authorized IPIA Label/Administrator
Phone
Date (mm/dd/yyyy)
Request for Labels
(to be completed by IPIA)
We hereby request
certification labels for our on-hand inventory. Currently, our inventory is
(Quantity)
certification labels on-hand. Based on our current rate of certification labels issued, the on-hand
(Quantity)
inventory will last for approximately
weeks.
Order Processing
(to be completed by HUD or HUD’s monitoring agent)
Date request received
.
The request for certification labels was placed with the label manufacturer
(mm/dd/yyyy)
by
on
in the quantity of
certification labels.
(mm/dd/yyyy)
Note: If the quantity ordered is different than requested, the change was authorized by
.
(name)
This order should be received within the next three weeks.
Confirmation of Receipt
(to be completed by IPIA)
We have received the quantity of certification labels authorized by HUD or HUD’s monitoring agent.
Yes
No
If No, contact HUD or HUD’s monitoring agent immediately.
This order was received on
and contained:
(mm/dd/yyyy)
Certification labels
-
through & including
-
=
(Quantity)
Grimes Inspection Agency 27244 Bailey Keys, North Heatherberg, AZ 25356
Phillip T. Davis
(344) 822-0447
5000
8
04/15/2024
Julia V. Lall
04/15/2024
5000
Raul Gay
04/20/2024
4950
| IPIA Request for Labels U.S. Department of Housing and Urban Development OMB Approval No. 2502-0233
Office of Manufactured Housing Programs (expires 5/31/2026)
(order control)
The Manufactured Housing Procedural and Enforcement Regulations 24 C.F.R. Chapter XX Part 3280 Section 11 and Part 3282 Sections 204 and 205
requires manufacturers to affix a certification label. Manufacturers report affixed labels through reports required by 24 C.F.R. Chapter XX Part 3282 Sections
209 and 552, providing usage data on a monthly basis. In turn the Inspection Primary Inspection Agencies (IPIAs) are required to monitor and provide
Manufacturers a supply of certification label and request them from HUD in accordance with 24 C.F.R. Chapter XX Part 3282 Section 362(b). The information
collected here will be used to monitor home distribution, collect fees, and reimburse parties as appropriate under these Regulations. Public reporting burden
for this collection of information is estimated to average 0.5 hours per response including the time for reviewing instructions, searching existing data sources,
gathering, and maintaining the data needed, and completing and reviewing the collection of information. Response to this information collection is mandatory
under 42 U.S.C. 5413(c)(3). This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid
OMB control number.
Privacy Notice:
HUD collects information in accordance with 42 U.S.C. 5413(c)(3) of the National Manufactured Housing Construction and Safety Standards Act of 1974 which
requires manufacturers, under 42 U.S.C. 5413(f), to maintain records, make reports and provide such information as HUD requires to determine whether the
manufacturer is in compliance with the standards established under 42 U.S.C. 5403.
Purpose of this collection is necessary for accurate dispensation of program benefits and credits. Failure to comply with these regulations may subject the party
in question to the civil and criminal penalties provided for in section 611 of the Act, 42 U.S.C. 5410. While HUD generally only discloses this data in response to
a Freedom of Information or audit request, any information collected pursuant to 42 U.S.C. 5413(b), (c), (f), or (g) which contains or relates to a trade secret that
would result in a substantial competitive disadvantage if disclosed shall be considered confidential and shall not be further disclosed except as required or
permitted under 42 U.S.C. 5413(h).
IPIA Name IPIA Address
Grimes Inspection Agency 27244 Bailey Keys, North Heatherberg, AZ 25356
Phillip Authorized IPIA Label/Administrator T. Davis (344) Phone 822-0447 Date (mm/dd/yyyy)
Request for Labels
(to be completed by IPIA)
We hereby request certification labels for our on-hand inventory. Currently, our inventory is
(Quantity)
5000 certification labels on-hand. Based on our current rate of certification labels issued, the on-hand
(Quantity)
inventory will last for approximately 8 weeks.
Order Processing
(to be completed by HUD or HUD’s monitoring agent)
Date request received 04/15/2024 . The request for certification labels was placed with the label manufacturer
(mm/dd/yyyy)
by Julia V. Lall on 04/15/2024 in the quantity of 5000 certification labels.
(mm/dd/yyyy)
Note: If the quantity ordered is different than requested, the change was authorized by Raul Gay .
(name)
This order should be received within the next three weeks.
Confirmation of Receipt
(to be completed by IPIA)
We have received the quantity of certification labels authorized by HUD or HUD’s monitoring agent. Yes No
If No, contact HUD or HUD’s monitoring agent immediately.
This order was received on 04/20/2024 and contained:
(mm/dd/yyyy)
Certification labels - through & including - = 4950 (Quantity) | ||
1012 | Flat | {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the employee"
},
"employee_id": {
"type": "string",
"description": "Employee identification number"
},
"travel_authorization_number": {
"type": "string",
"description": "Travel authorization number"
},
"travel_purpose_code": {
"type": "string",
"description": "Code representing the purpose of travel"
},
"appropriation": {
"type": "string",
"description": "Appropriation code"
},
"budget_organization": {
"type": "string",
"description": "Budget organization code"
}
}
} | {
"name": "Pacheco, Sonya Y.",
"employee_id": "HUD-EMP-2022-0876",
"travel_authorization_number": "TA-2023-09876",
"travel_purpose_code": "TRAIN-2023-001",
"appropriation": "APPR-2023-001",
"budget_organization": "BUDG-ORG-001"
} | Travel Voucher
Attachment
U.S. Department of Housing
and Urban Development
Office of Chief Financial Officer
form HUD-1012 (3/95)
Privacy Act Statement: Public Law 97-255, Financial Integrity Act, 31 U.S.C. 3512, authorizes the Department of Housing and Urban Development (HUD)
to collect all the information. The data is used to determine the amount to reimburse an employee for expenses incurred in connection with temporary duty travel.
Provision of the EMP ID is mandatory. Failure to provide the information requested may delay the processing of your travel claim. This information will not be
otherwise disclosed or released outside of HUD, except as permitted or required by law.
Name (Last, first, middle initial) Employee ID
Travel Authorization Number
Travel Purpose Code
Appropriation
Budget Organization
( For Purpose of Travel Codes see HUD-25, Block 11d)
Code Number
Description
Amount
2101
Lodging
2102
Meals and Miscellaneous Expenses
2103
GSA Vehicles
2104
Rental Vehicles
2105
Privately Owned Vehicles
2106
Airfare
2107
Bus
2108
Train
2109
Taxi
2110
Airfare, Chartered
2111
Other
2199
Late Payment Charge Travel
Total
Pacheco, Sonya Y.
HUD-EMP-2022-0876
TA-2023-09876
TRAIN-2023-001
APPR-2023-001
BUDG-ORG-001
| Travel Voucher U.S. and Urban Department Development of Housing
Attachment Office of Chief Financial Officer
Privacy Act Statement: Public Law 97-255, Financial Integrity Act, 31 U.S.C. 3512, authorizes the Department of Housing and Urban Development (HUD)
to collect all the information. The data is used to determine the amount to reimburse an employee for expenses incurred in connection with temporary duty travel.
Provision of the EMP ID is mandatory. Failure to provide the information requested may delay the processing of your travel claim. This information will not be
otherwise disclosed or released outside of HUD, except as permitted or required by law.
Name (Last, first, middle initial) Employee ID Travel Authorization Number
Pacheco, Sonya Y. HUD-EMP-2022-0876 TA-2023-09876
Travel Purpose Code Appropriation Budget Organization
( For Purpose of Travel Codes see HUD-25, Block 11d)
TRAIN-2023-001 APPR-2023-001 BUDG-ORG-001
Code Number Description Amount
2101 Lodging
2102 Meals and Miscellaneous Expenses
2103 GSA Vehicles
2104 Rental Vehicles
2105 Privately Owned Vehicles
2106 Airfare
2107 Bus
2108 Train
2109 Taxi
2110 Airfare, Chartered
2111 Other
2199 Late Payment Charge Travel
Total
form HUD-1012 (3/95) | ||
1013 | Nested | {
"type": "object",
"$defs": {
"WorkAddress": {
"type": "object",
"properties": {
"street": {
"type": "string",
"description": "Street address of the work location"
},
"city": {
"type": "string",
"description": "City of the work location"
},
"state": {
"type": "string",
"description": "State of the work location"
},
"zip_code": {
"type": "string",
"description": "ZIP code of the work location"
}
}
}
},
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},
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"type": "string",
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"type": "string"
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"supervisor_signature_date": {
"type": "string",
"description": "Date of the supervisor's signature"
},
"work_address": {
"$ref": "#/$defs/WorkAddress",
"description": "Nested WorkAddress object(s)"
}
}
} | {
"applicant_name": "Yang, Kathy X.",
"work_telephone_number": "(898) 279-6869",
"email_address": "kyang@castrowiley.com",
"office_division_branch": "Human Resources Division",
"official_position_title": "Human Resources Specialist",
"pay_plan_series_grade": "GS-0203-09",
"time_limit_agreement_type": "One-year pilot program",
"agreement_statements": [
"I understand that my participation in the phased retirement program is limited to one year.",
"I agree to mentor a designated employee during my participation in the phased retirement program.",
"I acknowledge that my time limit may be extended for additional one-year periods if the program is fully implemented."
],
"employee_signature_date": "05/15/2023",
"supervisor_signature_date": "05/15/2023",
"work_address": {
"street": "8389 Swanson Hollow",
"city": "West Aaronfort",
"state": "PA",
"zip_code": "05687"
}
} | Time Limit and Mentoring Agreement U.S. Department of Housing
(Supplemental form required with Phased Retirement Application) and Urban Development
Last revision 8/18/15
1
HUD Form 1013
Part 1 – Applicant Information
1. Applicant Name
Last
First
Middle Initial
2. Work Address
Street
City
State
Zip
3. Work Telephone Number
( ) -
4. E-mail Address
Office/Division/Branch (Do not abbreviate or use acronyms)
5. Official Position Title (e.g. Management Analyst)
6. Pay Plan- Series – Grade (e.g. GS-343-09)
Part II – Time Limit Agreement
Time Limit – An established period of time that an employee may participate in phased retirement, by mutual agreement between the supervisor and
participating employee. Time limits are to be established for periods up to, but not exceeding one (1) year, in line with the expiration date of the pilot
program. If the program is fully implemented, extensions may be granted for periods of up to one year at a time, not to exceed three (3) years,
aggregately.
Select ONE of the following options:
_____ Initial Time Limit Agreement - This is applicant’s first time limit agreement. Employees electing to enter phased retirement will be subject
to a maximum period up to one (1) year for the pilot program.
_____ Time Limit Extension – Select this option if you are under an active time limit agreement and are requesting an extension. The employee is
to submit a request at least 30 days prior to expiration with written justification from the supervisor.
Applicant must read and initial each of the following statements. I understand that:
1)
_____ I may, with the permission of the approving official, return to regular employment status (prior to the expiration of this agreement),
subject to 5 CFR § 831.1721, 5 U.S.C. 8336a(g), and by following the procedures outlined in HUD’s Phased Retirement Policy and
Procedures Handbook.
2)
_____ I have the right to elect to fully retire at any time (as provided in 5 CFR § 831.1731) or upon expiration of the time limit agreement.
3)
_____ I may accept a new appointment at another agency, with or without the new agency’s approval for me to continue in phased
employment, at any time before the expiration of this agreement or within 3 days of the expiration of the agreement.
4)
_____ If I return to regular employment status, I will be prohibited from reelecting phased retirement status.
5)
_____ When the agreed term of phased employment ends, I will be separated from employment and that such separation will be considered
voluntary based on this agreement, unless I am approved to return to regular employment or accept a new appointment at another agency
prior to expiration of this agreement.
6)
_____ If I am separated from phased employment and not employed within 3 days (i.e., a break in service of greater than 3 days), that I will be
deemed to have elected full retirement.
7)
_____ A HUD authorized approving official may rescind an existing agreement, or approve the employee to enter into a new agreement to
extend or reduce the term of phased employment agreed to in an existing agreement, by entering into a new written agreement before the
expiration of the agreement currently in effect.
8)
_____ I understand that a HUD approving official may remove me from phased retirement prior to the end of the time limit agreement due to
budget restrictions, performance, or conduct and will use existing workforce authorities such as removal for performance or conduct; transfer
of function or reduction in force; as appropriate.
Employee’s Signature Date (mm/dd/yyyy)
Supervisor’s Signature Date (mm/dd/yyyy)
Yang, Kathy X.
8389 Swanson Hollow
West Aaronfort PA
05687
kyang@castrowiley.com
(898) 279-6869
Human Resources Division
Human Resources Specialist
GS-0203-09
One-year pilot program
I understand that my participation in the phased retirement program is limited to one year.
I agree to mentor a designated employee during my participation in the phased retirement program.
I acknowledge that my time limit may be extended for additional one-year periods if the program is fully implemented.
Kathy X. Yang
05/15/2023
Brian Zimmerman
05/15/2023
| Time Limit and Mentoring Agreement U.S. Department of Housing
(Supplemental form required with Phased Retirement Application) and Urban Development
Part 1 – Applicant Information
1. Applicant Name
Yang, Kathy X.
Last First Middle Initial
2. Work Address
8389 Swanson Hollow West Aaronfort PA 05687
Street City State Zip
3. Work Telephone Number 4. E-mail Address
( (898) 279-6869 ) - kyang@castrowiley.com
Office/Division/Branch (Do not abbreviate or use acronyms)
Human Resources Division
5. Official Position Title (e.g. Management Analyst) 6. Pay Plan- Series – Grade (e.g. GS-343-09)
Human Resources Specialist GS-0203-09
Part II – Time Limit Agreement
Time Limit – An established period of time that an employee may participate in phased retirement, by mutual agreement between the supervisor and
participating employee. Time limits are to be established for periods up to, but not exceeding one (1) year, in line with the expiration date of the pilot
program. If the program is fully implemented, extensions may be granted for periods of up to one year at a time, not to exceed three (3) years,
aggregately.
Select ONE of the following options:
_____ One-year pilot program Initial Time Limit Agreement - This is applicant’s first time limit agreement. Employees electing to enter phased retirement will be subject
to a maximum period up to one (1) year for the pilot program.
_____ Time Limit Extension – Select this option if you are under an active time limit agreement and are requesting an extension. The employee is
to submit a request at least 30 days prior to expiration with written justification from the supervisor.
Applicant must read and initial each of the following statements. I understand that:
1) _____ I understand that my participation in the phased retirement program is limited to one year. I may, with the permission of the approving official, return to regular employment status (prior to the expiration of this agreement),
subject to 5 CFR § 831.1721, 5 U.S.C. 8336a(g), and by following the procedures outlined in HUD’s Phased Retirement Policy and
Procedures Handbook.
2) _____ I agree to mentor a designated employee during my participation in the phased retirement program. I have the right to elect to fully retire at any time (as provided in 5 CFR § 831.1731) or upon expiration of the time limit agreement.
3) _____ I acknowledge that my time limit may be extended for additional one-year periods if the program is fully implemented. I may accept a new appointment at another agency, with or without the new agency’s approval for me to continue in phased
employment, at any time before the expiration of this agreement or within 3 days of the expiration of the agreement.
4) _____ If I return to regular employment status, I will be prohibited from reelecting phased retirement status.
5) _____ When the agreed term of phased employment ends, I will be separated from employment and that such separation will be considered
voluntary based on this agreement, unless I am approved to return to regular employment or accept a new appointment at another agency
prior to expiration of this agreement.
6) _____ If I am separated from phased employment and not employed within 3 days (i.e., a break in service of greater than 3 days), that I will be
deemed to have elected full retirement.
7) _____ A HUD authorized approving official may rescind an existing agreement, or approve the employee to enter into a new agreement to
extend or reduce the term of phased employment agreed to in an existing agreement, by entering into a new written agreement before the
expiration of the agreement currently in effect.
8) _____ I understand that a HUD approving official may remove me from phased retirement prior to the end of the time limit agreement due to
budget restrictions, performance, or conduct and will use existing workforce authorities such as removal for performance or conduct; transfer
of function or reduction in force; as appropriate.
Employee’s Signature Date (mm/dd/yyyy)
Kathy X. Yang 05/15/2023
Supervisor’s Signature Date (mm/dd/yyyy)
Brian Zimmerman 05/15/2023
Last revision 8/18/15 1 HUD Form 1013 | ||
1026 | Nested | {
"type": "object",
"$defs": {
"ApprovalDetails": {
"type": "object",
"properties": {
"administrative_officer": {
"type": "string",
"description": "Approval from the administrative officer or equivalent"
},
"administrative_officer_date": {
"type": "string",
"description": "Date of approval from the administrative officer"
},
"finance_director": {
"type": "string",
"description": "Approval from the Director, Office of Finance & Accounting or designee"
},
"finance_director_date": {
"type": "string",
"description": "Date of approval from the Director, Office of Finance & Accounting"
},
"personnel_director": {
"type": "string",
"description": "Approval from the Director, Office of Personnel & Training or designee"
},
"personnel_director_date": {
"type": "string",
"description": "Date of approval from the Director, Office of Personnel & Training"
}
}
},
"EmployeeDetails": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "The name of the employee requesting the payment"
},
"social_security_number": {
"type": "string",
"description": "The social security number of the employee"
},
"organization_code": {
"type": "string",
"description": "The organization code of the employee"
}
}
},
"ReimbursementDetails": {
"type": "object",
"properties": {
"due_date": {
"type": "string",
"description": "The date by which the employee is expected to reimburse the department"
},
"location": {
"type": "string",
"description": "Location where the employee will make the reimbursement"
},
"room": {
"type": "string",
"description": "Room number where the employee will make the reimbursement"
},
"received_date": {
"type": "string",
"description": "Date when the reimbursement amount was received"
},
"certification_date": {
"type": "string",
"description": "Date of the reimbursement certification signature"
}
}
}
},
"properties": {
"requesting_office": {
"type": "string",
"description": "The administrative office or equivalent requesting the payment"
},
"request_date": {
"type": "string",
"description": "The date when the payment request is made"
},
"form_of_payment": {
"type": "string",
"description": "Form of payment (cash, check, etc.)"
},
"employee": {
"$ref": "#/$defs/EmployeeDetails",
"description": "Nested EmployeeDetails object(s)"
},
"approvals": {
"$ref": "#/$defs/ApprovalDetails",
"description": "Nested ApprovalDetails object(s)"
},
"reimbursement_details": {
"$ref": "#/$defs/ReimbursementDetails",
"description": "Nested ReimbursementDetails object(s)"
}
}
} | {
"requesting_office": "Office of Personnel and Training",
"request_date": "02/15/2024",
"form_of_payment": "Check",
"employee": {
"name": "Andrea Preston",
"social_security_number": "686-77-8331",
"organization_code": "DPM-2024-40025"
},
"approvals": {
"administrative_officer": "Andrea Preston",
"administrative_officer_date": "02/15/2024",
"finance_director": "Nicholas Y. Moore",
"finance_director_date": "02/16/2024",
"personnel_director": "Cameron D. Guerra",
"personnel_director_date": "02/17/2024"
},
"reimbursement_details": {
"due_date": "03/15/2024",
"location": "Davidville, NC",
"room": "285",
"received_date": "03/14/2024",
"certification_date": "03/14/2024"
}
} | Office of Personnel and Training
Andrea Preston
686-77-8331 DPM-2024-
02/15/2024
Andrea Preston
02/15/2024
Nicholas Y. Moore
02/16/2024
Cameron D. Guerra
02/17/2024
03/15/2024
Davidville, NC
285
03/14/2024
Andrea Preston
03/14/2024
Check
| Office of Personnel and Training
Andrea Preston 686-77-8331 DPM-2024- 02/15/2024
Andrea Preston 02/15/2024
Nicholas Y. Moore 02/16/2024
Cameron D. Guerra 02/17/2024
03/15/2024
Davidville, NC 285
03/14/2024
Andrea Preston
03/14/2024
Check | ||
1044 | Nested | {
"type": "object",
"$defs": {
"RecipientInfo": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the recipient"
},
"address": {
"type": "string",
"description": "Address of the recipient"
}
}
},
"Signatures": {
"type": "object",
"properties": {
"recipient_signature_date": {
"type": "string",
"description": "Date of the recipient's signature"
},
"hud_signature_date": {
"type": "string",
"description": "Date of the HUD representative's signature"
}
}
}
},
"properties": {
"instrument_number": {
"type": "string",
"description": "Number of the assistance instrument"
},
"amendment_number": {
"type": "string",
"description": "Number of the amendment"
},
"effective_date": {
"type": "string",
"description": "Effective date of the action"
},
"control_number": {
"type": "string",
"description": "Control number for the document"
},
"hud_administering_office": {
"type": "string",
"description": "HUD administering office"
},
"name_of_administrator": {
"type": "string",
"description": "Name of the administrator"
},
"telephone_number": {
"type": "string",
"description": "Telephone number of the administrator"
},
"recipient_project_manager": {
"type": "string",
"description": "Name of the recipient project manager"
},
"hud_government_technical_representative": {
"type": "string",
"description": "Name of the HUD government technical representative"
},
"hud_payment_office": {
"type": "string",
"description": "HUD payment office"
},
"appropriation_number": {
"type": "string",
"description": "Appropriation number"
},
"reservation_number": {
"type": "string",
"description": "Reservation number"
},
"description": {
"type": "string",
"description": "Description of the assistance award/amendment"
},
"recipient_info": {
"$ref": "#/$defs/RecipientInfo",
"description": "Nested RecipientInfo object(s)"
},
"signatures": {
"$ref": "#/$defs/Signatures",
"description": "Nested Signatures object(s)"
}
}
} | {
"instrument_number": "GR-2025-12345",
"amendment_number": "AM-2025-001",
"effective_date": "01/15/2025",
"control_number": "CTRL-2025-42803-001",
"hud_administering_office": "Office of Community Planning and Development",
"name_of_administrator": "Sara B. Warner",
"telephone_number": "(369) 265-99",
"recipient_project_manager": "Emile H. Bottaro",
"hud_government_technical_representative": "Courtney E. Giannini",
"hud_payment_office": "Department of Housing and Urban Development Payment Office",
"appropriation_number": "APPR-2025-8200-377",
"reservation_number": "RSRV-2025-4059-820",
"description": "Amendment to the grant for community development project in North Danielletown, CA",
"recipient_info": {
"name": "Watson-Jenkins",
"address": "9378 White Flat, North Danielletown, CA 77023"
},
"signatures": {
"recipient_signature_date": "01/15/2025",
"hud_signature_date": "01/15/2025"
}
} | 1. Assistance Instrument
2. Type of Action
Cooperative Agreement
Grant
Award
Amendment
3. Instrument Number
4. Amendment Number
5. Effective Date of this Action
6. Control Number
7. Name and Address of Recipient
8. HUD Administering Office
8a. Name of Administrator
8b. Telephone Number
10. Recipient Project Manager
9. HUD Government Technical Representative
11. Assistance Arrangement
12. Payment Method
13. HUD Payment Office
Cost Reimbursement
Treasury Check Reimbursement
Cost Sharing
Advance Check
Fixed Price
Automated Clearinghouse
14. Assistance Amount
15. HUD Accounting and Appropriation Data
Previous HUD Amount
$
15a. Appropriation Number
15b. Reservation Number
HUD Amount this action
$
Total HUD Amount
$
Amount Previously Obligated
$
Recipient Amount
$
Obligation by this action
$
Total Instrument Amount
$
Total Obligation
$
16. Description
Assistance Award/Amendment
U.S. Department of Housing
and Urban Development
Office of Administration
17.
Recipient is required to sign and return three (3) copies
18.
Recipient is not required to sign this document.
of this document to the HUD Administering Office
19. Recipient (By Name)
20. HUD (By Name)
Signature & Title Date (mm/dd/yyyy)
Signature & Title Date (mm/dd/yyyy)
form HUD-1044 (8/90)
ref. Handbook 2210.17
Previous editions are obsolete.
GR-2025-12345
AM-2025-001
01/15/2025
CTRL-2025-42803-001
9378 White Flat, North Danielletown, CA 77023
Office of Community Planning and Development
Sara B. Warner
(369) 265-99
Emile H. Bottaro
Courtney E. Giannini
Department of Housing and Urban Development Payment Office
APPR-2025-8200-377
RSRV-2025-4059-820
Amendment to the grant for community development project in North Danielletown, CA
Watson-Jenkins
Emile H. Bottaro
01/15/2025
Sara B. Warner
01/15/2025
| Assistance Award/Amendment U.S. and Urban Department Development of Housing
Office of Administration
1. Assistance Instrument 2. Type of Action
Cooperative Agreement Grant Award Amendment
3. Instrument Number 4. Amendment Number 5. Effective Date of this Action 6. Control Number
GR-2025-12345 AM-2025-001 01/15/2025 CTRL-2025-42803-001
7. Name and Address of Recipient 8. HUD Administering Office
9378 White Flat, North Danielletown, CA 77023 Office of Community Planning and Development
8a. Name of Administrator 8b. Telephone Number
Sara B. Warner (369) 265-99
10. Recipient Project Manager 9. HUD Government Technical Representative
Emile H. Bottaro Courtney E. Giannini
11. Assistance Arrangement 12. Payment Method 13. HUD Payment Office
Cost Reimbursement Treasury Check Reimbursement Department of Housing and Urban Development Payment Office
Cost Sharing Advance Check
Fixed Price Automated Clearinghouse
14. Assistance Amount 15. HUD Accounting and Appropriation Data
Previous HUD Amount $ 15a. Appropriation Number 15b. Reservation Number
HUD Amount this action $ APPR-2025-8200-377 RSRV-2025-4059-820
Total HUD Amount $ Amount Previously Obligated $
Recipient Amount $ Obligation by this action $
Total Instrument Amount $ Total Obligation $
16. Description
Amendment to the grant for community development project in North Danielletown, CA
17. Recipient is required to sign and return three (3) copies 18. Recipient is not required to sign this document.
of this document to the HUD Administering Office
19. Recipient (By Name) 20. HUD (By Name)
Watson-Jenkins
Signature & Title Date (mm/dd/yyyy) Signature & Title Date (mm/dd/yyyy)
Emile H. Bottaro 01/15/2025 Sara B. Warner 01/15/2025
form HUD-1044 (8/90)
Previous editions are obsolete. ref. Handbook 2210.17 | ||
1044-D | Nested | {
"type": "object",
"$defs": {
"CorrespondentFinancialInstitution": {
"type": "object",
"properties": {
"type": {
"type": "string",
"description": "Type of the correspondent financial institution"
},
"address": {
"type": "string",
"description": "Full address of the correspondent financial institution"
},
"aba_number": {
"type": "string",
"description": "ABA number of the correspondent financial institution"
},
"telegraphic_abbreviation": {
"type": "string",
"description": "Telegraphic abbreviation of the correspondent financial institution"
}
}
},
"FinancialInstitution": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the financial institution"
},
"address": {
"type": "string",
"description": "Full address of the financial institution"
},
"aba_number": {
"type": "string",
"description": "ABA number of the financial institution"
},
"telegraphic_abbreviation": {
"type": "string",
"description": "Telegraphic abbreviation of the financial institution"
},
"account_number": {
"type": "string",
"description": "Account number at the financial institution"
}
}
},
"Mortgagee": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the mortgagee"
},
"address": {
"type": "string",
"description": "Full address of the mortgagee"
},
"contact_person": {
"type": "string",
"description": "Contact person for the mortgagee"
},
"phone_number": {
"type": "string",
"description": "Phone number of the mortgagee"
}
}
}
},
"properties": {
"fha_project_number": {
"type": "string",
"description": "FHA Project Number"
},
"comments": {
"type": "string",
"description": "Comments related to the claim"
},
"mailto": {
"type": "string",
"description": "Email address for mailing"
},
"title_of_person_completing_form": {
"type": "string",
"description": "Title of the person completing the form"
},
"date": {
"type": "string",
"description": "Date the form was completed"
},
"mortgagee": {
"$ref": "#/$defs/Mortgagee",
"description": "Nested Mortgagee object(s)"
},
"financial_institution": {
"$ref": "#/$defs/FinancialInstitution",
"description": "Nested FinancialInstitution object(s)"
},
"correspondent_financial_institution": {
"$ref": "#/$defs/CorrespondentFinancialInstitution",
"description": "Nested CorrespondentFinancialInstitution object(s)"
}
}
} | {
"fha_project_number": "FHA-2023-87654",
"comments": "Claim submitted for insurance benefits due to property damage. Please process as soon as possible.",
"mailto": "swagner@webstersmith.com",
"title_of_person_completing_form": "Community Education Officer",
"date": "05/15/2023",
"mortgagee": {
"name": "Webster-Smith",
"address": "0513 Christopher Port Suite 030, East Julietown, FL 24731",
"contact_person": "Susan J. Wagner",
"phone_number": "(645) 385-9321"
},
"financial_institution": {
"name": "Bank of America",
"address": "123 Main Street, New York, NY 10001",
"aba_number": "026009593",
"telegraphic_abbreviation": "BOFAUS3N",
"account_number": "4588-9330-9792"
},
"correspondent_financial_institution": {
"type": "Correspondent Bank",
"address": "321 Pine Street, Miami, FL 33101",
"aba_number": "067000014",
"telegraphic_abbreviation": "RBCBUS66"
}
} | Multifamily Insurance Benefit Claim
U.S. Department of Housing
Payment Information in Support of Claim
and Urban Development
OMB Approval No. 2502-0418
(Exp. 7/31/2025)
Treasury Financial Communication System
Office of Mortgage Insurance Accounting and Servicing
for Mortgage Wiring Instructions
Multifamily Insurance Benefit Claims
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this
information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
The information is collected to obtain required fiscal data for the Department to pay insurance benefits. The information provides the Department with the necessary
fiscal data to audit the claim submission and accurately compute insurance benefits owed to the lender. Payment of such benefits is cited in Statue 12 USC 1713(g) of
the National Housing Act. The information requested does not lend itself to confidentiality.
The information requested concerning the mortgagee's financial institution should be available through the mortgagee's Treasurer. If the mortgagee's financial institution
has access to the Federal Reserve Communication System, please complete only items 1 through 9 and item 14. If the mortgagee's financial institution does not have
access to the Federal Reserve Communication System, please complete all items except item 7.
This document may be executed using electronic signatures that shall be considered as original signature for all purposes and shall have the same force and effect as
original signatures. “Electronic signatures” shall include manual signatures scanned to an electronic format for transmission (e.g. via portable document format); digital
signatures created with the use of electronic authentication software; or such other means or electronic execution as may be sufficient to authenticate the document
under governing law.
1. Name of Mortgagee
2. Full Address
3. Contact Person
4. Phone Number
5. Name of Financial Institution
6. Full Address of Financial Institution
7. Financial Institution ABA Number (Only 1 digit per box) (Complete only if the mortgagee's financial institution has access to the Federal Reserve Communication System)
8. Telegraphic abbreviation of Financial Institution
9. Account Number at the Mortgagee's Financial Institution to be credited with the Funds
10. Type of Correspondent Financial Institution to receive Electronic Funds Transfer
(if the mortgagee does not have access to the Federal Reserve Communication System)
11. Full Address of Correspondent Financial Institution
12. Correspondent Financial Institution ABA Number (Only 1 digit per box) (For routing transfer of funds)
13. Telegraphic abbreviation of Correspondent Financial Institution
Comments:
Mail to:
14. Title of Person completing this Form
Signature
Date
Send original and 1 copy to the: U.S. Department of Housing and Urban Development
Multifamily Claims Branch, HWAFRC, Room 6252
451 7th Street, S.W., Washington, DC 20410-8000
Mortgagee/Servicer should retain 1 copy.
form HUD 1044-D (9/2009)
Previous editions are obsolete.
Page 1 of 1
ref Handbook 4110.2
FHA Project Number
FHA-2023-87654
Webster-Smith
0513 Christopher Port Suite 030, East Julietown, FL 24731
Susan J. Wagner
(645) 385-9321
Bank of America
123 Main Street, New York, NY 10001
BOFAUS3N
4588-9330-9792
Correspondent Bank
321 Pine Street, Miami, FL 33101
067000014
Claim submitted for insurance benefits due to property
damage. Please process as soon as possible.
swagner@webstersmith.com
Community Education Officer
Susan J. Wagner
05/15/2023
SIGN
026009593
RBCBUS66
| Multifamily Insurance Benefit Claim U.S. Department of Housing OMB Approval No. 2502-0418
Payment Information in Support of Claim and Urban Development (Exp. 7/31/2025)
Treasury Financial Communication System Office of Mortgage Insurance Accounting and Servicing
for Mortgage Wiring Instructions Multifamily Insurance Benefit Claims
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this
information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
The information is collected to obtain required fiscal data for the Department to pay insurance benefits. The information provides the Department with the necessary
fiscal data to audit the claim submission and accurately compute insurance benefits owed to the lender. Payment of such benefits is cited in Statue 12 USC 1713(g) of
the National Housing Act. The information requested does not lend itself to confidentiality.
FHA Project Number FHA-2023-87654
The information requested concerning the mortgagee's financial institution should be available through the mortgagee's Treasurer. If the mortgagee's financial institution
has access to the Federal Reserve Communication System, please complete only items 1 through 9 and item 14. If the mortgagee's financial institution does not have
access to the Federal Reserve Communication System, please complete all items except item 7.
This document may be executed using electronic signatures that shall be considered as original signature for all purposes and shall have the same force and effect as
original signatures. “Electronic signatures” shall include manual signatures scanned to an electronic format for transmission (e.g. via portable document format); digital
signatures created with the use of electronic authentication software; or such other means or electronic execution as may be sufficient to authenticate the document
under governing law.
1. Name of Mortgagee 2. Full Address
Webster-Smith 0513 Christopher Port Suite 030, East Julietown, FL 24731
3. Contact Person 4. Phone Number
Susan J. Wagner (645) 385-9321
5. Name of Financial Institution 6. Full Address of Financial Institution
Bank of America 123 Main Street, New York, NY 10001
7. 026009593 Financial Institution ABA Number (Only 1 digit per box) (Complete only if the mortgagee's financial institution has access to the Federal Reserve Communication System)
8. Telegraphic abbreviation of Financial Institution 9. Account Number at the Mortgagee's Financial Institution to be credited with the Funds
BOFAUS3N 4588-9330-9792
10. Type of Correspondent Financial Institution to receive Electronic Funds Transfer 11. Full Address of Correspondent Financial Institution
(if the mortgagee does not have access to the Federal Reserve Communication System) 321 Pine Street, Miami, FL 33101
Correspondent Bank
12. Correspondent Financial Institution ABA Number (Only 1 digit per box) (For routing transfer of funds)
067000014
13. Telegraphic abbreviation of Correspondent Financial Institution
RBCBUS66
Comments: Mail to:
Claim submitted for insurance benefits due to property swagner@webstersmith.com
damage. Please process as soon as possible.
14. Title of Person completing this Form Signature Susan SIGN J. Wagner Date 05/15/2023
Community Education Officer
Send original and 1 copy to the: U.S. Department of Housing and Urban Development
Multifamily Claims Branch, HWAFRC, Room 6252
451 7th Street, S.W., Washington, DC 20410-8000
Mortgagee/Servicer should retain 1 copy. form HUD 1044-D (9/2009)
Previous editions are obsolete. ref Handbook 4110.2
Page 1 of 1 | ||
1044-c | Nested | {
"type": "object",
"$defs": {
"CurrentAuthorizedOfficial": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the current authorized official"
},
"title": {
"type": "string",
"description": "Title of the current authorized official"
},
"date": {
"type": "string",
"description": "Date of the current authorized official's signature"
}
}
},
"CurrentGrantee": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the current grantee"
},
"tax_id": {
"type": "string",
"description": "Tax ID number of the current grantee"
},
"grant_agreement_number": {
"type": "string",
"description": "Grant agreement number of the current grantee"
},
"effective_date": {
"type": "string",
"description": "Effective date of the current grant"
},
"ending_date": {
"type": "string",
"description": "Ending date of the current grant"
}
}
},
"CurrentProjectManager": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the current project manager"
},
"title": {
"type": "string",
"description": "Title of the current project manager"
},
"phone": {
"type": "string",
"description": "Phone number of the current project manager"
}
}
},
"NewAuthorizedOfficial": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the new authorized official"
}
}
},
"NewGrantee": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the new grantee"
},
"tax_id": {
"type": "string",
"description": "Tax ID number of the new grantee"
},
"grant_agreement_number": {
"type": "string",
"description": "Grant agreement number of the new grantee"
},
"effective_date": {
"type": "string",
"description": "Effective date of the new grant"
},
"ending_date": {
"type": "string",
"description": "Ending date of the new grant"
}
}
},
"NewProjectManager": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the new project manager"
},
"title": {
"type": "string",
"description": "Title of the new project manager"
},
"phone": {
"type": "string",
"description": "Phone number of the new project manager"
}
}
}
},
"properties": {
"current_grantee": {
"$ref": "#/$defs/CurrentGrantee",
"description": "Nested CurrentGrantee object(s)"
},
"current_project_manager": {
"$ref": "#/$defs/CurrentProjectManager",
"description": "Nested CurrentProjectManager object(s)"
},
"current_authorized_official": {
"$ref": "#/$defs/CurrentAuthorizedOfficial",
"description": "Nested CurrentAuthorizedOfficial object(s)"
},
"new_grantee": {
"$ref": "#/$defs/NewGrantee",
"description": "Nested NewGrantee object(s)"
},
"new_project_manager": {
"$ref": "#/$defs/NewProjectManager",
"description": "Nested NewProjectManager object(s)"
},
"new_authorized_official": {
"$ref": "#/$defs/NewAuthorizedOfficial",
"description": "Nested NewAuthorizedOfficial object(s)"
}
}
} | {
"current_grantee": {
"name": "Hernandez PLC",
"tax_id": "74-1234567",
"grant_agreement_number": "HUD-AG-2019-001",
"effective_date": "01/15/2019",
"ending_date": "12/31/2023"
},
"current_project_manager": {
"name": "Julia Bryant",
"title": "Pensions Consultant",
"phone": "(055) 743-4852"
},
"current_authorized_official": {
"name": "Julia Bryant, Pensions Consultant",
"title": "Authorized Official",
"date": "10012023"
},
"new_grantee": {
"name": "New Horizon Development Corp",
"tax_id": "23-1237890",
"grant_agreement_number": "HUD-AG-2023-004",
"effective_date": "01/01/2024",
"ending_date": "12/31/2027"
},
"new_project_manager": {
"name": "Julia Bryant",
"title": "Project Director",
"phone": "(055) 743-4852"
},
"new_authorized_official": {
"name": "Julia Bryant, Project Director"
}
} | U.S. Department of Housing
and Urban Development
Assignment/Assumption
Agreement
16. Additional Terms (check one)
17.
Special Conditions (check one)
None
Attached
None
Attached
Current Grantee
New Grantee
18a. Name of Authorized Official (printed)
19a. Name of Authorized Official (printed)
18b. Title
19b. Title
18c. Signature
18d. Date (mm/dd/yyyy)
19.c Signature
19d. Date (mm/dd/yyyy)
Consent by HUD Authorized Official
20a. Name of Authorized Official (printed)
20b. Title
20c. Signature
20d. Date (mm/dd/yyyy)
form HUD-1044-C (3/2001)
Current Grantee
New Grantee
1.
Grantee's complete Name and Address
7.
Grantee's complete Name and Address
2.
Current Grantee Tax ID Number
8.
New Grantee Tax ID Number
3.
Current Grant Agreement Number
9.
New Grant Agreement Number (if any)
4.
Current Effective Date (mm/dd/yyyy)
10. New Effective Date (mm/dd/yyyy)
5.
Current Ending Date (mm/dd/yyyy)
11. New Ending Date (mm/dd/yyyy)
6.
Current Recipient Project Manager (Name)
12. New Recipient Project Manager (Name)
6a. Title
12a.Title
6b. Phone Number (Include Area Code)
12b.Phone Number (Include Area Code)
13.
Amount Previously Obligated
$ ___________________________
14.
Assistance Arrangement
Obligated by this action
$ ___________________________
Cost Reimbursement
Total Obligation
$ ___________________________
Fixed Price
Grantee Matching
$ ___________________________
15.
Description
Hernandez PLC
74-1234567
HUD-AG-2019-001
01/15/2019
12/31/2023
Julia Bryant
Pensions Consultant
(055) 743-4852
New Horizon Development Corp
23-1237890
HUD-AG-2023-004
01/01/2024
12/31/2027
Julia Bryant
Project Director
(055) 743-4852
Julia Bryant, Pensions Consultant
Authorized Official
10012023
Julia Bryant, Project Director
| Assignment/Assumption U.S. Department of Housing
and Urban Development
Agreement
Current Grantee New Grantee
1. Grantee's complete Name and Address 7. Grantee's complete Name and Address
Hernandez PLC New Horizon Development Corp
2. Current Grantee Tax ID Number 8. New Grantee Tax ID Number
74-1234567 23-1237890
3. Current Grant Agreement Number 9. New Grant Agreement Number (if any)
HUD-AG-2019-001 HUD-AG-2023-004
4. Current Effective Date (mm/dd/yyyy) 10. New Effective Date (mm/dd/yyyy)
01/15/2019 01/01/2024
5. Current Ending Date (mm/dd/yyyy) 11. New Ending Date (mm/dd/yyyy)
12/31/2023 12/31/2027
6. Current Recipient Project Manager (Name) 12. New Recipient Project Manager (Name)
Julia Bryant Julia Bryant
6a. Title 12a.Title
Pensions Consultant Project Director
6b. Phone Number (Include Area Code) 12b.Phone Number (Include Area Code)
(055) 743-4852 (055) 743-4852
13. Amount Previously Obligated $ ___________________________ 14. Assistance Arrangement
Obligated by this action $ ___________________________ Cost Reimbursement
Total Obligation $ ___________________________ Fixed Price
Grantee Matching $ ___________________________
15. Description
16. Additional Terms (check one) 17. Special Conditions (check one)
None Attached None Attached
Current Grantee New Grantee
18a. Name of Authorized Official (printed) 19a. Name of Authorized Official (printed)
Julia Bryant, Pensions Consultant Julia Bryant, Project Director
18b. Title 19b. Title
Authorized Official
18c. Signature 18d. Date (mm/dd/yyyy) 19.c Signature 19d. Date (mm/dd/yyyy)
10012023
Consent by HUD Authorized Official
20a. Name of Authorized Official (printed) 20b. Title
20c. Signature 20d. Date (mm/dd/yyyy)
form HUD-1044-C (3/2001) | ||
1044-g | Nested | {
"type": "object",
"$defs": {
"Signatures": {
"type": "object",
"properties": {
"recipient_signature_date": {
"type": "string",
"description": "Date of the recipient's signature"
},
"hud_signature_date": {
"type": "string",
"description": "Date of the HUD representative's signature"
}
}
}
},
"properties": {
"instrument_number": {
"type": "string",
"description": "Unique identifier for the assistance instrument"
},
"amendment_number": {
"type": "string",
"description": "Number of the amendment"
},
"effective_date": {
"type": "string",
"description": "Effective date of the action"
},
"tax_identification_number": {
"type": "string",
"description": "Tax identification number of the recipient"
},
"recipient_name": {
"type": "string",
"description": "Name of the recipient"
},
"hud_administering_office": {
"type": "string",
"description": "HUD office administering the grant"
},
"administrator_name": {
"type": "string",
"description": "Name of the administrator"
},
"administrator_telephone_number": {
"type": "string",
"description": "Telephone number of the administrator"
},
"recipient_project_manager": {
"type": "string",
"description": "Name of the recipient's project manager"
},
"hud_field_representative": {
"type": "string",
"description": "Name of the HUD field representative"
},
"hud_field_office": {
"type": "string",
"description": "HUD field office"
},
"hud_appropriation_number": {
"type": "string",
"description": "HUD appropriation number"
},
"description": {
"type": "string",
"description": "Description of the grant award/amendment"
},
"signatures": {
"$ref": "#/$defs/Signatures",
"description": "Nested Signatures object(s)"
}
}
} | {
"instrument_number": "INST-2023-00045",
"amendment_number": "AMEND-2023-00012",
"effective_date": "10/15/2023",
"tax_identification_number": "129-27-1067",
"recipient_name": "Cantrell, Le and Michael",
"hud_administering_office": "Office of Community Planning & Development",
"administrator_name": "Steven N. Manne",
"administrator_telephone_number": "(643) 296-9640",
"recipient_project_manager": "Jacqueline H. Koch",
"hud_field_representative": "Corey M. Dugar",
"hud_field_office": "Florida Regional Office",
"hud_appropriation_number": "HUD-APP-2023-00045",
"description": "Amendment to the existing grant for community development project in Port Dawn, FL",
"signatures": {
"recipient_signature_date": "10/15/2023",
"hud_signature_date": "10/15/2023"
}
} | 1. Assistance Instrument
2. Type of Action
Cooperative Agreement
Grant
Award
Amendment
3. Instrument Number
4. Amendment Number
5. Effective Date of this Action
6. Tax Identification Number
7. Name and Address of Recipient
8. HUD Administering Office
8a. Name of Administrator
8b. Telephone Number
10. Recipient Project Manager
9. HUD Field Representative
11. Assistance Arrangement
12. Payment Method
13. HUD Field Office
Cost Reimbursement
Treasury Reimbursement
Cost Sharing
Treasury Advance
Automated Clearinghouse
14. Assistance Amount
15. HUD Appropriation Number
HUD Amount this action
$
Recipient Amount
$
Other
$
Amount Previously Obligated
$
Total Instrument Amount
$
Obligation by this action
$
Total Obligation
$
16. Description
Grant Award/Amendment
U.S. Department of Housing
and Urban Development
Office of Community Planning & Development
17.
Recipient is required to sign and return four (4) copies
18.
Recipient is not required to sign this document.
of this document to the HUD Administering Office
19. Recipient (By Name)
20. HUD (By Name)
Signature & Title
Date
Signature & Title
Date
form HUD-1044-G (7/2001)
Previous editions are obsolete.
INST-2023-00045
AMEND-2023-00012
10/15/2023
129-27-1067
Cantrell, Le and Michael
Office of Community Planning & Development
Steven N. Manne
(643) 296-9640
Jacqueline H. Koch
Corey M. Dugar
Florida Regional Office
HUD-APP-2023-00045
Amendment to the existing grant for community development project in Port Dawn, FL
Jacqueline H. Koch
Steven N. Manne
Jacqueline H. Koch
10/15/2023
Steven N. Manne
10/15/2023
| Grant Award/Amendment U.S. and Urban Department Development of Housing
Office of Community Planning & Development
1. Assistance Instrument 2. Type of Action
Cooperative Agreement Grant Award Amendment
3. Instrument Number 4. Amendment Number 5. Effective Date of this Action 6. Tax Identification Number
INST-2023-00045 AMEND-2023-00012 10/15/2023 129-27-1067
7. Name and Address of Recipient 8. HUD Administering Office
Cantrell, Le and Michael Office of Community Planning & Development
8a. Name of Administrator 8b. Telephone Number
Steven N. Manne (643) 296-9640
10. Recipient Project Manager 9. HUD Field Representative
Jacqueline H. Koch Corey M. Dugar
11. Assistance Arrangement 12. Payment Method 13. HUD Field Office
Cost Reimbursement Treasury Reimbursement Florida Regional Office
Cost Sharing Treasury Advance
Automated Clearinghouse
14. Assistance Amount 15. HUD Appropriation Number
HUD Amount this action $ HUD-APP-2023-00045
Recipient Amount $
Other $ Amount Previously Obligated $
Total Instrument Amount $ Obligation by this action $
Total Obligation $
16. Description
Amendment to the existing grant for community development project in Port Dawn, FL
17. Recipient is required to sign and return four (4) copies 18. Recipient is not required to sign this document.
of this document to the HUD Administering Office
19. Recipient (By Name) 20. HUD (By Name)
Jacqueline H. Koch Steven N. Manne
Signature & Title Date Signature & Title Date
Jacqueline H. Koch 10/15/2023 Steven N. Manne 10/15/2023
form HUD-1044-G (7/2001)
Previous editions are obsolete. | ||
1067 | Flat | {
"type": "object",
"properties": {
"date_reported": {
"type": "string",
"description": "The date when the report is submitted"
},
"name_of_reporting_office": {
"type": "string",
"description": "The name of the office reporting the records for destruction"
},
"records_custodian": {
"type": "string",
"description": "The name, title, and phone number of the records custodian"
},
"records_management_coordinator": {
"type": "string",
"description": "The name of the records management coordinator"
},
"file_plan_name": {
"type": "string",
"description": "The name of the file plan if applicable"
},
"record_series_title": {
"type": "string",
"description": "The title or electronic application name of the record series"
},
"record_series_schedule": {
"type": "string",
"description": "The schedule for the record series"
},
"record_series_item_number": {
"type": "string",
"description": "The item number for the record series"
},
"records_retention_instructions": {
"type": "string",
"description": "Instructions for records retention"
},
"disposition_authority": {
"type": "string",
"description": "The authority for disposition of records"
},
"date_range_of_records": {
"type": "string",
"description": "The date range of the records to be destroyed"
},
"record_type": {
"type": "string",
"description": "Whether the record is paper or electronic"
},
"volume_of_records": {
"type": "string",
"description": "The volume or number of records to be destroyed"
},
"inventory_of_records": {
"type": "string",
"description": "Inventory of records to be destroyed and additional details or comments"
}
}
} | {
"date_reported": "06/15/2023",
"name_of_reporting_office": "Office of Administration, Lindsey-Case Hospital",
"records_custodian": "Aldonza X. Thomas, Hospital Records Custodian, (321) 358-8269",
"records_management_coordinator": "Lawrence Mielcarek",
"file_plan_name": "Lindsey-Case Hospital Records Plan",
"record_series_title": "Patient Medical Records",
"record_series_schedule": "HUD-2020-03",
"record_series_item_number": "Item #42",
"records_retention_instructions": "Retain for 7 years after patient discharge or death",
"disposition_authority": "HUD Records Management Division",
"date_range_of_records": "01/01/2013 - 12/31/2015",
"record_type": "Paper",
"volume_of_records": "150 boxes",
"inventory_of_records": "Medical records of patients discharged between 2013 and 2015. Includes patient charts, lab results, and discharge summaries."
} | HUD Records Destruction Form
U.S. Department of Housing and Urban Development
Form 1067
Office of Administration
_________________________________________________________________________________________
Date Reported
Name of Reporting Office
(Including primary organization, division, branch)
Records Custodian (name, title, phone #) Your Records Management Coordinator (name)
__________________________________________________________________________________________
We request authorization to destroy the below listed records which have reached their retention period per the
following noted Records Schedule:
File Plan Name (if applicable)
Record Row # Record Series Title or Electronic Application Name
Date Range of Records to be Destroyed Paper or Electronic Record? Volume/Number of Records to be Destroyed
Inventory of Records to be Destroyed (and additional details or comments) Check Here If Separate Inventory Is Attached
INSTRUCTIONS- Record Custodian must complete the first page using your approved Office File Plan or Record
Schedule, then forward the form to your Program Area Manager.
- Records may not be destroyed/ deleted until you receive authorization-
_________________________________________________________________________________________________
I authorize you to destroy these records in accordance with
all applicable HUD requirements & Federal regulations.
Record Series Schedule Record Series Item #
Records Retention Instructions Disposition Authority
HUD form 1067
06/15/2023
Office of Administration, Lindsey-Case Hospital
Aldonza X. Thomas, Hospital Records Custodian, (321) 358-8269
Lawrence Mielcarek
Lindsey-Case Hospital Records Plan
Patient Medical Records
Retain for 7 years after patient discharge or death
HUD Records
Management
Division
01/01/2013 - 12/31/2015
Paper
150 boxes
Medical records of patients discharged between 2013 and 2015. Includes patient charts, lab results,
and discharge summaries.
SIGN
HUD-2020-03
Item #42
| HUD Records Destruction Form U.S. Department of Housing and Urban Development
Form 1067 Office of Administration
_________________________________________________________________________________________
Date Reported Name of Reporting Office (Including primary organization, division, branch)
06/15/2023 Office of Administration, Lindsey-Case Hospital
Records Custodian (name, title, phone #) Your Records Management Coordinator (name)
Aldonza X. Thomas, Hospital Records Custodian, (321) 358-8269 Lawrence Mielcarek
__________________________________________________________________________________________
We request authorization to destroy the below listed records which have reached their retention period per the
following noted Records Schedule:
File Plan Name (if applicable) Record Row # Record Series Title or Electronic Application Name
Lindsey-Case Hospital Records Plan Patient Medical Records
Record Series Schedule Record Series Item #
Item #42
HUD-2020-03
Records Retention Instructions Disposition Authority
Retain for 7 years after patient discharge or death HUD Records
Management
Division
Date Range of Records to be Destroyed Paper or Electronic Record? Volume/Number of Records to be Destroyed
01/01/2013 - 12/31/2015 Paper 150 boxes
Inventory of Records to be Destroyed (and additional details or comments) Check Here If Separate Inventory Is Attached
Medical records of patients discharged between 2013 and 2015. Includes patient charts, lab results,
and discharge summaries.
INSTRUCTIONS- Record Custodian must complete the first page using your approved Office File Plan or Record
Schedule, then forward the form to your Program Area Manager.
- Records may not be destroyed/ deleted until you receive authorization-
_________________________________________________________________________________________________
I authorize you to destroy these records in accordance with SIGN
all applicable HUD requirements & Federal regulations.
HUD form 1067 | ||
1067.1 | Flat | {
"type": "object",
"properties": {
"date_reported": {
"type": "string",
"description": "The date when the report is submitted"
},
"name_of_reporting_office": {
"type": "string",
"description": "The name of the reporting office including primary organization, division, branch"
},
"records_custodian": {
"type": "string",
"description": "The name, title, and phone number of the records custodian"
},
"records_management_coordinator": {
"type": "string",
"description": "The name of the Records Management Coordinator"
},
"file_plan_name": {
"type": "string",
"description": "The name of the file plan if applicable"
},
"records_retention_instructions": {
"type": "string",
"description": "Instructions for records retention"
},
"disposition_authority": {
"type": "string",
"description": "The authority for disposition of records"
},
"date_range_of_records": {
"type": "string",
"description": "The date range of records to be destroyed"
},
"record_type": {
"type": "string",
"description": "Whether the record is paper or electronic"
},
"inventory_of_records": {
"type": "string",
"description": "Inventory of records to be destroyed and additional details or comments"
}
}
} | {
"date_reported": "03/15/2023",
"name_of_reporting_office": "Bailey-Martinez, Accounting Division",
"records_custodian": "Liam H. Nichols, Accountant, chartered certified, (997) 816-4619",
"records_management_coordinator": "Stephanie J. Sengupta",
"file_plan_name": "Annual Financial Records 2022",
"records_retention_instructions": "Destroy all records after 7 years of inactivity as per HUD guidelines.",
"disposition_authority": "HUD Records Management Division",
"date_range_of_records": "01/01/2016 - 12/31/2016",
"record_type": "Paper",
"inventory_of_records": "Financial statements, invoices, and receipts from the year 2016."
} | HUD Records Destruction Form
U.S. Department of Housing and Urban Development
Form 1067.1
Office of Housing Administration
_________________________________________________________________________________________
Date Reported Name of Reporting Office (Including primary organization, division, branch)
Records Custodian (name, title, phone #) Your Records Management Coordinator (name)
__________________________________________________________________________________________
We request authorization to destroy the below listed records which have reached their retention period per
the following noted Records Schedule:
File Plan Name (if applicable)
Record Row # Record Series Title or Electronic Application Name
Record Series Schedule Record Series Item #
Records Retention Instructions Disposition Authority
Date Range of Records to be Destroyed Paper or Electronic Record? Volume/Number of Records to be Destroyed
Inventory of Records to be Destroyed (and additional details or comments) Check Here If Separate Inventory Is Attached
INSTRUCTIONS- Record Custodian should complete the first page using your approved Office File Plan, then forward
the form to your Program Area Records Management Coordinator (RMC) for concurrence Routing.
- Records may not be destroyed/ deleted until you receive authorization-
-Paste and copy complete Records Schedule details from your File Plan or the Records Schedule.
-RMCs must confirm that any Transitory Records have passed the Housing Quality Control SOP and QA Checklist.
-Records Inventory should be as detailed as needed to identify all records, based on the record type.
-Electronic Records must be deleted according to your office IT SOP.
-Paper Records must be destroyed by cross shredding.
-The RMC must provide a Certificate of Destruction/ Sanitation if the Records are destroyed by a Contractor.
03/15/2023
Bailey-Martinez, Accounting Division
Liam H. Nichols, Accountant, chartered certified, (997) 816-4619
Stephanie J. Sengupta
Annual Financial Records 2022
Destroy all records after 7 years of inactivity as per HUD guidelines.
HUD Records
Management
Division
01/01/2016 - 12/31/2016
Paper
Financial statements, invoices, and receipts from the year 2016.
| HUD Records Destruction Form U.S. Department of Housing and Urban Development
Form 1067.1 Office of Housing Administration
_________________________________________________________________________________________
Date Reported Name of Reporting Office (Including primary organization, division, branch)
03/15/2023 Bailey-Martinez, Accounting Division
Records Custodian (name, title, phone #) Your Records Management Coordinator (name)
Liam H. Nichols, Accountant, chartered certified, (997) 816-4619 Stephanie J. Sengupta
__________________________________________________________________________________________
We request authorization to destroy the below listed records which have reached their retention period per
the following noted Records Schedule:
File Plan Name (if applicable) Record Row # Record Series Title or Electronic Application Name
Annual Financial Records 2022
Record Series Schedule Record Series Item #
Records Retention Instructions Disposition Authority
Destroy all records after 7 years of inactivity as per HUD guidelines. HUD Records
Management
Division
Date Range of Records to be Destroyed Paper or Electronic Record? Volume/Number of Records to be Destroyed
01/01/2016 - 12/31/2016 Paper
Inventory of Records to be Destroyed (and additional details or comments) Check Here If Separate Inventory Is Attached
Financial statements, invoices, and receipts from the year 2016.
INSTRUCTIONS- Record Custodian should complete the first page using your approved Office File Plan, then forward
the form to your Program Area Records Management Coordinator (RMC) for concurrence Routing.
- Records may not be destroyed/ deleted until you receive authorization-
-Paste and copy complete Records Schedule details from your File Plan or the Records Schedule.
-RMCs must confirm that any Transitory Records have passed the Housing Quality Control SOP and QA Checklist.
-Records Inventory should be as detailed as needed to identify all records, based on the record type.
-Electronic Records must be deleted according to your office IT SOP.
-Paper Records must be destroyed by cross shredding.
-The RMC must provide a Certificate of Destruction/ Sanitation if the Records are destroyed by a Contractor. | ||
1067A | Nested | {
"type": "object",
"$defs": {
"Manager": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the manager responsible for maintaining records"
},
"title": {
"type": "string",
"description": "Title of the manager responsible for maintaining records"
},
"organization": {
"type": "string",
"description": "Organization of the manager responsible for maintaining records"
},
"location": {
"type": "string",
"description": "Location of the manager responsible for maintaining records"
},
"email": {
"type": "string",
"description": "Email of the manager responsible for maintaining records"
}
}
},
"MediaDetails": {
"type": "object",
"properties": {
"make_vendor": {
"type": "string",
"description": "Make or vendor of the media"
},
"model_number": {
"type": "string",
"description": "Model number of the media"
},
"serial_number": {
"type": "string",
"description": "Serial number of the media"
},
"property_number": {
"type": "string",
"description": "Property number of the media"
},
"type": {
"type": "string",
"description": "Type of the media"
},
"classification": {
"type": "string",
"description": "Classification of the media"
}
}
},
"SanitizationDetails": {
"type": "object",
"properties": {
"backup_location": {
"type": "string",
"description": "Location where data is backed up"
},
"method_details": {
"type": "string",
"description": "Details about the sanitization method used"
},
"tool_used": {
"type": "string",
"description": "Tool used for sanitization (include version)"
},
"post_sanitization_classification": {
"type": "string",
"description": "Classification of media after sanitization"
},
"notes": {
"type": "string",
"description": "Additional notes about the sanitization process"
}
}
}
},
"properties": {
"program_office": {
"type": "string",
"description": "The program office responsible for the records"
},
"office_division_branch": {
"type": "string",
"description": "The specific office, division, or branch"
},
"location_of_records_url": {
"type": "string",
"description": "The location or URL where the records are maintained"
},
"media_destination_details": {
"type": "string",
"description": "Details about the media destination"
},
"manager": {
"$ref": "#/$defs/Manager",
"description": "Nested Manager object(s)"
},
"media_details": {
"$ref": "#/$defs/MediaDetails",
"description": "Nested MediaDetails object(s)"
},
"sanitization_details": {
"$ref": "#/$defs/SanitizationDetails",
"description": "Nested SanitizationDetails object(s)"
}
}
} | {
"program_office": "Department of Housing and Urban Development",
"office_division_branch": "Office of Public and Indian Housing",
"location_of_records_url": "https://records.hud.gov/pih",
"media_destination_details": "Media will be reused within the department for non-sensitive data storage",
"manager": {
"name": "Alexandra Jones",
"title": "Health Physicist",
"organization": "Martin-Rivera",
"location": "Josephshire, PA",
"email": "ajones@martinrivera.com"
},
"media_details": {
"make_vendor": "Seagate",
"model_number": "ST4000DM004",
"serial_number": "Z8408XJ8",
"property_number": "HUD-IT-2023-001",
"type": "Hard Drive",
"classification": "Confidential"
},
"sanitization_details": {
"backup_location": "HUD Data Center, Washington D.C.",
"method_details": "7-pass overwrite using DBAN",
"tool_used": "DBAN 2.3.0",
"post_sanitization_classification": "Public",
"notes": "Data was verified to be completely overwritten"
}
} | form HUD-1067A
(04/2021)
CERTIFICATE OF SANITIZATION
Department of Housing and Urban Development
1. Program Office
2. Office/Division/Branch
3. LOCATION OF RECORDS/URL
4. NAME AND TITLE OF MANAGER RESPONSIBLE FOR MAINTAINING RECORDS
CERTIFICATE OF SANITIZATION
PERSON PERFORMING SANITIZATION
Name:
Title:
Organization:
Location:
Email:
MEDIA INFORMATION
Make/ Vendor:
Model Number:
Serial Number:
Media Property Number:
Media Type:
Source (ie user name or PC property number):
Classification:
Data Backed Up: Yes No Unkown
Backup Location:
SANITIZATION DETAILS
Method Type: Clear Purge Damage Destruct
Method Used: Degauss Overwrite Block Erase Crypto Erase Other:
Method Details:
Tool Used (include version):
Verification Method:
Full
Quick Sampling Other:
Post Sanitization Classification:
Notes:
MEDIA DESTINATION
Internal Reuse External Reuse Recycling Facility Manufacturer Other (specify in details area)
Details:
SIGNATURE (System Owner)
I attest that the information provided on this statement is accurate to the best of my knowledge.
Signature:
VALIDATION
Name:
Title: Records Officer
Signature:
Name:
Title: Privacy Officer (or other)
Signature:
Alexandra Jones
Alexandra Jones
Alexandra Jones
Alexandra Jones
Alexandra Jones
Media will be reused within the department for non-sensitive data storage
Data was verified to be completely overwritten
Public
DBAN 2.3.0
7-pass overwrite using DBAN
HUD Data Center, Washington D.C.
Confidential
Hard Drive
HUD-IT-2023-001
Z8408XJ8
ST4000DM004
Seagate
Alexandra Jones
Health Physicist
Martin-Rivera
Josephshire, PA
ajones@martinrivera.com
Department of Housing and Urban Development
https://records.hud.gov/pih
Office of Public and Indian Housing
SIGN
SIGN
SIGN
| CERTIFICATE OF SANITIZATION
Department of Housing and Urban Development
1. Program Office Department of Housing and Urban Development
2. Office/Division/Branch 3. LOCATION OF RECORDS/URL
Office of Public and Indian Housing https://records.hud.gov/pih
4. NAME AND TITLE OF MANAGER RESPONSIBLE FOR MAINTAINING RECORDS
CERTIFICATE OF SANITIZATION
PERSON PERFORMING SANITIZATION
Name: Alexandra Jones Title: Health Physicist
Organization: Martin-Rivera Location: Josephshire, PA Email: ajones@martinrivera.com
MEDIA INFORMATION
Make/ Vendor: Seagate Model Number: ST4000DM004
Serial Number: Z8408XJ8
Media Property Number: HUD-IT-2023-001
Media Type: Hard Drive Source (ie user name or PC property number):
Classification: Confidential Data Backed Up: Yes No Unkown
Backup Location: HUD Data Center, Washington D.C.
SANITIZATION DETAILS
Method Type: Clear Purge Damage Destruct
Method Used: Degauss Overwrite Block Erase Crypto Erase Other:
Method Details: 7-pass overwrite using DBAN
Tool Used (include version): DBAN 2.3.0
Verification Method: Full Quick Sampling Other:
Post Sanitization Classification: Public
Notes: Data was verified to be completely overwritten
MEDIA DESTINATION
Internal Reuse External Reuse Recycling Facility Manufacturer Other (specify in details area)
Details: Media will be reused within the department for non-sensitive data storage
SIGNATURE (System Owner)
I attest that the information provided on this statement is accurate to the best of my knowledge.
Signature: Alexandra SIGN Jones
VALIDATION
Name: Alexandra Jones Title: Records Officer
Signature: Alexandra SIGN Jones
Name: Alexandra Jones Title: Privacy Officer (or other)
Signature: Alexandra SIGN Jones
form HUD-1067A
(04/2021) | ||
1068 | Flat | {
"type": "object",
"properties": {
"oig_control_number": {
"type": "string",
"description": "Control number assigned by the Office of Inspector General"
},
"status_date": {
"type": "string",
"description": "Date as of which the status is reported"
},
"report_title": {
"type": "string",
"description": "Title of the GAO report"
},
"recommendations": {
"type": "array",
"items": {
"type": "string"
},
"description": "List of GAO report recommendations"
}
}
} | {
"oig_control_number": "CTL-2024-11575",
"status_date": "06/15/2024",
"report_title": "Evaluation of HUD's Implementation of Disaster Recovery Programs",
"recommendations": [
"Improve monitoring of grantee compliance",
"Enhance training for program staff",
"Develop clearer guidance documents",
"Implement better data tracking systems",
"Strengthen oversight of subrecipients",
"Conduct regular audits of high-risk grantees",
"Establish performance metrics for programs",
"Ensure timely distribution of funds"
]
} | form HUD-1068 (5/79)
Status Report on Actions Promised
on GAO Report Recommendations
U.S. Department of Housing
and Urban Development
Office of Inspector General
OIG Control Number
Status as of (Date)
Report Title, Number, and Date:
Reply to the Congress
GAO Report Recommendation
Corrective Action Promised
Status
(Date and S-Ticket Number)
(Due Date)
CTL-2024-11575
06/15/2024
Evaluation of HUD's Implementation of Disaster Recovery Programs
Improve monitoring of grantee compliance
Enhance training for program staff
Develop clearer guidance documents
Implement better data tracking systems
Strengthen oversight of subrecipients
Conduct regular audits of high-risk grantees
Establish performance metrics for programs
Ensure timely distribution of funds
| Status Report on Actions Promised U.S. Department of Housing OIG Control Number
and Urban Development CTL-2024-11575
on GAO Report Recommendations Office of Inspector General
Status as of (Date)
06/15/2024
Report Title, Number, and Date:
Evaluation of HUD's Implementation of Disaster Recovery Programs
Reply to the Congress GAO Report Recommendation Corrective Action Promised Status
(Date and S-Ticket Number) (Due Date)
Improve monitoring of grantee compliance
Enhance training for program staff
Develop clearer guidance documents
Implement better data tracking systems
Strengthen oversight of subrecipients
Conduct regular audits of high-risk grantees
Establish performance metrics for programs
Ensure timely distribution of funds
form HUD-1068 (5/79) | ||
11600 | Flat | {
"type": "object",
"properties": {
"requester_name": {
"type": "string",
"description": "Name of the employee or applicant who requested the reasonable accommodations"
},
"office": {
"type": "string",
"description": "Office of the requester"
},
"location": {
"type": "string",
"description": "Location of the requester's office"
},
"control_number": {
"type": "string",
"description": "Control number assigned from Form #HUD-0000"
},
"date_of_request": {
"type": "string",
"description": "Date when the reasonable accommodation request was made"
},
"date_of_denial": {
"type": "string",
"description": "Date when the reasonable accommodation request was denied"
},
"type_of_accommodation_requested": {
"type": "string",
"description": "Type(s) of reasonable accommodation requested"
},
"reason_for_denial": {
"type": "string",
"description": "Reason for the denial of the accommodation request"
},
"detailed_reason_for_denial": {
"type": "string",
"description": "Detailed reason(s) for the denial of reasonable accommodation"
},
"alternative_accommodation_explanation": {
"type": "string",
"description": "Explanation if the individual proposed one type of reasonable accommodation which is being denied, but rejected an offer of a different type of accommodation"
}
}
} | {
"requester_name": "Davis, Daniel N.",
"office": "Claims Department",
"location": "Walterport, CA",
"control_number": "HUD-0000-RA-2021-90199",
"date_of_request": "03/15/2021",
"date_of_denial": "04/05/2021",
"type_of_accommodation_requested": "Modified work schedule, Ergonomic workspace",
"reason_for_denial": "Accommodation Would Cause Undue Hardship",
"detailed_reason_for_denial": "The requested modified work schedule would require significant restructuring of the claims department's operations, leading to undue hardship. The ergonomic workspace modifications would also be costly and disruptive to the office layout.",
"alternative_accommodation_explanation": "An alternative ergonomic chair was offered, but the requester declined as it did not meet their specific needs. A flexible work from home option was also proposed, but the requester preferred the modified work schedule."
} |
form HUD-11600 (03/2003)
U.S. Department of Housing and Urban Development
Office of Administration
DENIAL OF REASONABLE ACCOMMODATION REQUEST
The Disability Program Manager or other decision making official must complete questions 1 through 4
(and, if applicable, question 5), and must sign and date this form. The original must be forwarded to the
employee or applicant that requested the reasonable accommodation and a copy to the Disability
Program Manager, if not the decision maker. The Disability Program Manager shall retain a copy for
reporting purposes.
1.
Enter the following information about the employee or applicant who requested the reasonable
accommodations:
Requester’s Name:
Office:
Location:
Control Number Assigned (From Form #HUD-0000):
RA-
-
Date of Request:
(From Form #HUD-0000)
Date of Denial:
(From Form #HUD-0000)
2.
Type(s) of Reasonable Accommodation requested:
3.
Reason for Denial of Accommodation Request (check the appropriate boxes below):
Accommodation Ineffective
Accommodation Would Cause Undue Hardship
Medical Documentation Inadequate
Accommodation Would Require Removal of an Essential Function
Accommodation Would Require Lowering of Performance or Production Standards
Other (Please specify):
4.
Detailed reason(s) for the denial of reasonable accommodation (Must be specific, e.g., why the
accommodation is ineffective or causes undue hardship):
5.
If the individual proposed one type of reasonable accommodation which is being denied, but
rejected an offer of a different type of accommodation, explain both reasons for denial of the
requested accommodation and why you believe that chosen accommodation would be effective:
Davis, Daniel N.
Claims Department
Walterport, CA
HUD-0000-RA-2021-90199
03/15/2021
04/05/2021
Modified work schedule, Ergonomic workspace
The requested modified work schedule would require significant restructuring of the claims department's operations, leading to undue hardship. The ergonomic workspace modifications would also be costly and disruptive to the office layout.
An alternative ergonomic chair was offered, but the requester declined as it did not meet their specific needs. A flexible work from home option was also proposed, but the requester preferred the modified work schedule.
Accommodation Would Cause Undue Hardship
| U.S. Department of Housing and Urban Development
Office of Administration
DENIAL OF REASONABLE ACCOMMODATION REQUEST
The Disability Program Manager or other decision making official must complete questions 1 through 4
(and, if applicable, question 5), and must sign and date this form. The original must be forwarded to the
employee or applicant that requested the reasonable accommodation and a copy to the Disability
Program Manager, if not the decision maker. The Disability Program Manager shall retain a copy for
reporting purposes.
1. Enter the following information about the employee or applicant who requested the reasonable
accommodations:
Requester’s Name: Davis, Daniel N.
Office: Claims Department Location: Walterport, CA
Control Number Assigned (From Form #HUD-0000): RA- HUD-0000-RA-2021-90199 -
Date of Request: 03/15/2021 Date of Denial: 04/05/2021
(From Form #HUD-0000) (From Form #HUD-0000)
2. Type(s) of Reasonable Accommodation requested:
Modified work schedule, Ergonomic workspace
3. Reason for Denial of Accommodation Request (check the appropriate boxes below):
Accommodation Ineffective
Accommodation Would Cause Undue Hardship
Medical Documentation Inadequate
Accommodation Would Require Removal of an Essential Function
Accommodation Would Require Lowering of Performance or Production Standards
Other (Please specify):
Accommodation Would Cause Undue Hardship
4. Detailed reason(s) for the denial of reasonable accommodation (Must be specific, e.g., why the
accommodation is ineffective or causes undue hardship):
The requested modified work schedule would require significant restructuring of the claims department's operations, leading to undue hardship. The ergonomic workspace modifications would also be costly and disruptive to the office layout.
5. If the individual proposed one type of reasonable accommodation which is being denied, but
rejected an offer of a different type of accommodation, explain both reasons for denial of the
requested accommodation and why you believe that chosen accommodation would be effective:
An alternative ergonomic chair was offered, but the requester declined as it did not meet their specific needs. A flexible work from home option was also proposed, but the requester preferred the modified work schedule.
form HUD-11600 (03/2003) | ||
11601 | Nested | {
"type": "object",
"$defs": {
"DecisionMaker": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the decision maker"
},
"title": {
"type": "string",
"description": "Title of the decision maker"
}
}
},
"InitialRequestReceiver": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the person who received the initial request"
}
}
}
},
"properties": {
"requester_name": {
"type": "string",
"description": "Name of the employee or applicant who requested the reasonable accommodation"
},
"office_location": {
"type": "string",
"description": "Office and location of the requester"
},
"control_number": {
"type": "string",
"description": "Control number assigned to the request"
},
"request_date": {
"type": "string",
"description": "Date when the reasonable accommodation was requested"
},
"referral_date": {
"type": "string",
"description": "Date when the request was referred to the decision maker"
},
"decision_date": {
"type": "string",
"description": "Date when the reasonable accommodation was approved or denied"
},
"provision_date": {
"type": "string",
"description": "Date when the reasonable accommodation was provided"
},
"time_frame_explanation": {
"type": "string",
"description": "Explanation if the time frames outlined in the procedures were not met"
},
"position_information": {
"type": "string",
"description": "Current or desired position of the individual requesting the accommodation"
},
"initial_request_receiver": {
"$ref": "#/$defs/InitialRequestReceiver",
"description": "Nested InitialRequestReceiver object(s)"
},
"decision_maker": {
"$ref": "#/$defs/DecisionMaker",
"description": "Nested DecisionMaker object(s)"
}
}
} | {
"requester_name": "Debra B. Metel",
"office_location": "Martin, Smith and Jones, New Marc, TX",
"control_number": "RA-2023-8901",
"request_date": "10/15/2023",
"referral_date": "10/18/2023",
"decision_date": "10/25/2023",
"provision_date": "11/01/2023",
"time_frame_explanation": "The delay in provision was due to the need for additional equipment, which was sourced and installed by November 1st.",
"position_information": "Mining engineer at Martin, Smith and Jones",
"initial_request_receiver": {
"name": "Keith T. Costa"
},
"decision_maker": {
"name": "Holly Alexander",
"title": "Disability Program Manager"
}
} |
Form HUD-11601
U.S. Department of Housing and Urban Development
Office of Administration
REASONABLE ACCOMMODATION INFORMATION
REPORTING FORM
Enter the following information about the employee or applicant who requested the reasonable
accommodation:
Requester’s Name:
Office & Location:
Control Number Assigned:
RA-
1. Reasonable Accommodation: (Check one)
Approved
Denied (if denied, attach copy of the Denial of Reasonable
Accommodation Request Form HUD-11600).)
2. Date Reasonable Accommodation requested:
(Enter Date of Receipt)
Name and Title of person who received initial request:
3. Date Reasonable Accommodation request referred to Decision Maker (i.e., Supervisor, Disability
Program Manager, Principal Organization Head):
(Enter Date of Receipt)
Name and Title of Decision Maker:
4. Date Reasonable Accommodation approved or denied:
(Enter Date of Decision)
5. Date Reasonable Accommodation provided:
(Enter, if different from date approved)
6. If time frames outlined in the Reasonable Accommodation Procedures were not met, please explain
Why:
7. Current position or, if an applicant, desired position of the individual requesting Reasonable
Accommodation (including position title, series, grade level, and office):
Debra B. Metel
RA-2023-8901
10/15/2023
Keith T. Costa
10/18/2023
Holly Alexander
10/25/2023
11/01/2023
The delay in provision was due to the need for additional equipment, which was
sourced and installed by November 1st.
Mining engineer at Martin, Smith and Jones
Martin, Smith and Jones, New Marc, TX
Disability Program Manager
| U.S. Department of Housing and Urban Development
Office of Administration
REASONABLE ACCOMMODATION INFORMATION
REPORTING FORM
Enter the following information about the employee or applicant who requested the reasonable
accommodation:
Requester’s Name: Debra B. Metel
Office & Location: Martin, Smith and Jones, New Marc, TX
Control Number Assigned: RA- RA-2023-8901
1. Reasonable Accommodation: (Check one)
Approved Denied (if denied, attach copy of the Denial of Reasonable
Accommodation Request Form HUD-11600).)
2. Date Reasonable Accommodation requested: 10/15/2023
(Enter Date of Receipt)
Name and Title of person who received initial request: Keith T. Costa
3. Date Reasonable Accommodation request referred to Decision Maker (i.e., Supervisor, Disability
Program Manager, Principal Organization Head): 10/18/2023
(Enter Date of Receipt)
Name and Title of Decision Maker: Holly Alexander
Disability Program Manager
4. Date Reasonable Accommodation approved or denied: 10/25/2023
(Enter Date of Decision)
5. Date Reasonable Accommodation provided: 11/01/2023
(Enter, if different from date approved)
6. If time frames outlined in the Reasonable Accommodation Procedures were not met, please explain
Why:
The delay in provision was due to the need for additional equipment, which was
sourced and installed by November 1st.
7. Current position or, if an applicant, desired position of the individual requesting Reasonable
Accommodation (including position title, series, grade level, and office):
Mining engineer at Martin, Smith and Jones
Form HUD-11601 | ||
11708 | Nested | {
"type": "object",
"$defs": {
"IssuerInfo": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the issuer"
},
"id_number": {
"type": "number",
"description": "Identifier number of the issuer"
}
}
},
"MortgagorInfo": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the mortgagor"
}
}
}
},
"properties": {
"to_document_custodian": {
"type": "string",
"description": "Recipient of the document request"
},
"date_prepared_by_issuer": {
"type": "string",
"description": "Date when the issuer prepared the document"
},
"pool_number": {
"type": "number",
"description": "Number of the mortgage pool"
},
"fhavarhs_number": {
"type": "string",
"description": "FHA/VA/RHS number"
},
"issuer_loan_number": {
"type": "number",
"description": "Loan number assigned by the issuer"
},
"reason_for_requesting_documents": {
"type": "string",
"description": "Reason for requesting the documents"
},
"settlement_expected_return_date": {
"type": "string",
"description": "Expected date for settlement or return of documents"
},
"authorized_signature_document_custodian": {
"type": "string",
"description": "Signature of the authorized document custodian"
},
"document_custodian_number": {
"type": "number",
"description": "Number assigned to the document custodian"
},
"document_release_date": {
"type": "string",
"description": "Date when the documents are released"
},
"date_document_was_returned": {
"type": "string",
"description": "Date when the documents were returned"
},
"mortgagor_info": {
"$ref": "#/$defs/MortgagorInfo",
"description": "Nested MortgagorInfo object(s)"
},
"issuer_info": {
"$ref": "#/$defs/IssuerInfo",
"description": "Nested IssuerInfo object(s)"
}
}
} | {
"to_document_custodian": "Ginnie Mae Document Custodian",
"date_prepared_by_issuer": "06/15/2023",
"pool_number": 9876543210.0,
"fhavarhs_number": "FHA-2023-54321",
"issuer_loan_number": 4567891230.0,
"reason_for_requesting_documents": "To facilitate the refinancing of the mortgages in the specified pool.",
"settlement_expected_return_date": "06/22/2023",
"authorized_signature_document_custodian": "Laura J. Romero",
"document_custodian_number": 3216549870.0,
"document_release_date": "06/18/2023",
"date_document_was_returned": "06/20/2023",
"mortgagor_info": {
"name": "Stephanie F. Solorzano"
},
"issuer_info": {
"name": "Brady-Cox",
"id_number": 5432109870.0
}
} | Request for Release of
Documents
U.S. Department of Housing
and Urban Development
Government National Mortgage Association
OMB Approval No. 2503-0033(Exp. 04/30/2023)
Public reporting burden for this information collection is estimated to average 3 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Ginnie Mae may
not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. The information is
required by Sec. 306(g) of the National Housing Act or by Ginnie Mae Handbook 5500.3, Rev. 1. The purpose of this document is to provide issuers the
opportunity to request the release of mortgage documents held by the document custodian. The information collected will not be disclosed outside the
Department without consent, except as required by law.
To Document Custodian
Date Prepared by Issuer
In connection with the administration of the pool or loan package of mortgages held by you in custody for the Government National Mortgage Association,
the undersigned Issuer requests the release of the mortgage documents described below for the reason indicated. All documents to be released to the
Issuer shall be held in trust by the Issuer for the benefit of Ginnie Mae and the applicable securities holders, and the Issuer's possession of such documents
shall be at the will of Ginnie Mae and such securities holders solely for the purpose indicated below. The Issuer shall return the documents to the document
custodian when the Issuer's need thereof no longer exists, except where the mortgage is paid in full or otherwise disposed of in accordance with the Ginnie
Mae Mortgage-Backed Securities Guide, Rev. 1.
Mortgagor’s Name, Address and Zip Code
Pool Number
FHA/VA/RHS/§184 Number
Issuer Loan Number
Reason For Requesting Documents:
Enter Reason Number _______________
Settlement/Expected Return Date
1. Mortgagor Payoff
2. Buyouts of Delinquent Loan
3. Foreclosure – with or without Claim Payment
4. Loss Mitigation
5. Substitution
6. Other
7. Special Assistance
Issuer Signature
Issuer Name
Issuer ID Number
_
To Document Custodian: Please acknowledge by your signature the execution of the above request. You must retain this form for your
file in accordance with the terms of the Master Custodial Agreement. A copy of this form, signed and dated by you, shall be given to the
Issuer.
Authorized Signature of Document Custodian
Document Custodian Number
Document Release Date
Return of Released Document(s)
All Documents Released have been Returned.
Authorized signature of Document Custodian
Date Document was Returned
form HUD-11708 (01/2006)
Previous editions are obsolete
Page 1 of 1
ref. Ginnie Mae Handbook 5500.3, Rev. 1
Ginnie Mae Document Custodian
06/15/2023
Stephanie F. Solorzano
9876543210
FHA-2023-54321
4567891230
06/22/2023
Stephanie F. Solorzano
5432109870
Laura J. Romero
3216549870
06/18/2023
06/20/2023
To facilitate the refinancing of the mortgages in the specified pool.
Brady-Cox
| Request for Release of U.S. Department of Housing OMB Approval No. 2503-0033(Exp. 04/30/2023)
Documents and Government Urban Development National Mortgage Association
Public reporting burden for this information collection is estimated to average 3 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Ginnie Mae may
not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. The information is
required by Sec. 306(g) of the National Housing Act or by Ginnie Mae Handbook 5500.3, Rev. 1. The purpose of this document is to provide issuers the
opportunity to request the release of mortgage documents held by the document custodian. The information collected will not be disclosed outside the
Department without consent, except as required by law.
To Document Custodian Ginnie Mae Document Custodian Date Prepared by Issuer 06/15/2023
In connection with the administration of the pool or loan package of mortgages held by you in custody for the Government National Mortgage Association,
the undersigned Issuer requests the release of the mortgage documents described below for the reason indicated. All documents to be released to the
Issuer shall be held in trust by the Issuer for the benefit of Ginnie Mae and the applicable securities holders, and the Issuer's possession of such documents
shall be at the will of Ginnie Mae and such securities holders solely for the purpose indicated below. The Issuer shall return the documents to the document
custodian when the Issuer's need thereof no longer exists, except where the mortgage is paid in full or otherwise disposed of in accordance with the Ginnie
Mae Mortgage-Backed Securities Guide, Rev. 1.
Mortgagor’s Name, Address and Zip Code Pool Number 9876543210
Stephanie F. Solorzano
FHA/VA/RHS/§184 Number FHA-2023-54321
Issuer Loan Number
4567891230
Reason For Requesting Documents: 06/22/2023
Enter Reason Number _______________ To facilitate the refinancing of the mortgages in the specified pool. Settlement/Expected Return Date
1. Mortgagor Payoff
2. Buyouts of Delinquent Loan
3. Foreclosure – with or without Claim Payment
4. Loss Mitigation
5. Substitution
6. Other
7. Special Assistance
Issuer Signature Stephanie F. Solorzano Issuer Name Brady-Cox 5432109870 Issuer ID Number
_
To Document Custodian: Please acknowledge by your signature the execution of the above request. You must retain this form for your
file in accordance with the terms of the Master Custodial Agreement. A copy of this form, signed and dated by you, shall be given to the
Issuer.
Authorized Signature of Document Custodian Document Custodian Number Document Release Date
Laura J. Romero 3216549870 06/18/2023
Return of Released Document(s)
All Documents Released have been Returned.
Authorized signature of Document Custodian Date Document was Returned
06/20/2023
form HUD-11708 (01/2006)
Previous editions are obsolete Page 1 of 1 ref. Ginnie Mae Handbook 5500.3, Rev. 1 | ||
1407 | Nested | {
"type": "object",
"$defs": {
"Declarant": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "The name of the person making the statement"
},
"title": {
"type": "string",
"description": "The title or role of the person making the statement"
},
"organization": {
"type": "string",
"description": "The organization the declarant is associated with"
}
}
}
},
"properties": {
"date": {
"type": "string",
"description": "The date of the statement"
},
"city_and_state": {
"type": "string",
"description": "The city and state where the statement is made"
},
"recipient_name": {
"type": "string",
"description": "The name of the person or entity to whom the statement is made"
},
"statement_text": {
"type": "string",
"description": "The content of the statement"
},
"declarant": {
"$ref": "#/$defs/Declarant",
"description": "Nested Declarant object(s)"
}
}
} | {
"date": "10/15/2023",
"city_and_state": "Port Valerieborough, TN",
"recipient_name": "Huber Inc",
"statement_text": "This statement is made to confirm the details of the services provided by Jose V. Goodwin as an Art",
"declarant": {
"name": "Jose V. Goodwin",
"title": "Art Therapist",
"organization": "Huber Inc"
}
} | 10/15/2023
Port Valerieborough, TN
Jose V. Goodwin
Huber Inc
Art Therapist
Huber Inc
This statement is made to confirm the details of the services provided by Jose V. Goodwin as an Art
| 10/15/2023 Port Valerieborough, TN
Jose V. Goodwin Huber Inc
Art Therapist
Huber Inc
This statement is made to confirm the details of the services provided by Jose V. Goodwin as an Art | ||
1408 | Flat | {
"type": "object",
"properties": {
"status": {
"type": "string",
"description": "Status of the report"
},
"file_number": {
"type": "string",
"description": "File number associated with the report"
},
"date_of_report": {
"type": "string",
"description": "Date when the report was created"
},
"reported_by": {
"type": "string",
"description": "Name of the person who made the report"
},
"mice": {
"type": "string",
"description": "Mice field (context not clear from document)"
},
"typed_by": {
"type": "string",
"description": "Name of the person who typed the report"
},
"title": {
"type": "string",
"description": "Title of the report"
},
"narrative": {
"type": "string",
"description": "Detailed narrative content of the report"
},
"distribution": {
"type": "string",
"description": "Distribution details for the report"
},
"approved_by": {
"type": "string",
"description": "Name of the person who approved the report"
},
"approval_date": {
"type": "string",
"description": "Date when the report was approved"
}
}
} | {
"status": "Completed",
"file_number": "INV-2023-41789",
"date_of_report": "05/20/2023",
"reported_by": "Bolnbach, Carl F.",
"mice": "Field inspection",
"typed_by": "Kubaczyk, Tara K.",
"title": "Investigation Report on Transportation Incident",
"narrative": "On 05/20/2023, an incident occurred involving a transport vehicle. Preliminary investigation suggests mechanical failure.",
"distribution": "To: Pacheco-Garcia Management Team, Gill-Martin Safety",
"approved_by": "Heath, Berta H.",
"approval_date": "05/25/2023"
} | Completed
INV-2023-41789
05/20/2023
Bolnbach, Carl F.
Field inspection
Kubaczyk, Tara K.
Investigation Report on Transportation Incident
On 05/20/2023, an incident occurred involving a transport vehicle. Preliminary investigation suggests mechanical failure.
To: Pacheco-Garcia Management Team, Gill-Martin Safety
Heath, Berta H.
05/25/2023
| Completed INV-2023-41789 05/20/2023
Bolnbach, Carl F. Field inspection Kubaczyk, Tara K.
Investigation Report on Transportation Incident
On 05/20/2023, an incident occurred involving a transport vehicle. Preliminary investigation suggests mechanical failure.
To: Pacheco-Garcia Management Team, Gill-Martin Safety
Heath, Berta H. 05/25/2023 | ||
1440 | Nested | {
"type": "object",
"$defs": {
"Declarant": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "The name of the person making the statement"
},
"title": {
"type": "string",
"description": "The title or role of the person making the statement"
},
"identifier": {
"type": "string",
"description": "An identifier for the declarant, possibly an employee ID or similar"
}
}
}
},
"properties": {
"statement_date": {
"type": "string",
"description": "The date when the statement was made"
},
"investigation_subject": {
"type": "string",
"description": "The subject or matter under investigation"
},
"statement_content": {
"type": "string",
"description": "The content of the statement made by the declarant"
},
"declarant": {
"$ref": "#/$defs/Declarant",
"description": "Nested Declarant object(s)"
},
"location": {
"type": "string",
"description": "The city and state where the statement was made"
}
}
} | {
"statement_date": "11/15/2023",
"investigation_subject": "Alleged financial discrepancies in the accounting department",
"statement_content": "I, the undersigned, provide this statement regarding the financial irregularities observed.",
"declarant": {
"name": "Lara P. Roldan",
"title": "Manufacturing Engineer",
"identifier": "WIL-EMP-2023-0987"
},
"location": "Springfield, IL"
} | 11/15/2023
Springfield, IL
Lara P. Roldan
Manufacturing Engineer
WIL-EMP-2023-0987
Alleged financial discrepancies in the accounting department
I, the undersigned, provide this statement regarding the financial irregularities observed.
| 11/15/2023 Springfield, IL
Lara P. Roldan Manufacturing Engineer
WIL-EMP-2023-0987
Alleged financial discrepancies in the accounting department
I, the undersigned, provide this statement regarding the financial irregularities observed. | ||
1447 | Table | {
"type": "object",
"$defs": {
"Signature": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "Name of the person who signed"
},
"date": {
"type": "string",
"description": "Date of the signature"
}
}
}
},
"properties": {
"control_number": {
"type": "string",
"description": "Unique identifier for the document"
},
"date": {
"type": "string",
"description": "Date of the document"
},
"description": {
"type": "string",
"description": "Description of the document content"
},
"final_disposition": {
"type": "string",
"description": "Final disposition or handling instructions"
},
"signatures": {
"type": "array",
"items": {
"$ref": "#/$defs/Signature"
},
"description": "Nested Signature object(s)"
},
"recipient": {
"type": "string",
"description": "Recipient of the document"
},
"sender": {
"type": "string",
"description": "Sender of the document"
}
}
} | {
"control_number": "HUD-2023-56789",
"date": "11/15/2023",
"description": "Confidential medical records for patient review and analysis as per case",
"final_disposition": "Return to sender after review",
"signatures": [
{
"name": "Jessica X. Patton",
"date": "11/15/2023"
},
{
"name": "Emilian F. Parsons",
"date": "11/15/2023"
},
{
"name": "Emilie Montez",
"date": "11/16/2023"
}
],
"recipient": "Jessica X. Patton, Reed, Ray and Haney",
"sender": "Emiliano F. Parsons, Gonzales and Sons"
} | Classified
Document
Receipt
Control Number:
Date:
To:
From:
Description:
Number of Copies/Enclosures:
Final Disposition:
form HUD-1447 (11/79)
ref. Handbook 1750.1
Internal Routing
Name:
Name:
Name:
Signatue & Date:
Signatue & Date:
Signatue & Date:
Classified
Document
Receipt
Control Number:
Date:
To:
From:
Description:
Number of Copies/Enclosures:
Final Disposition:
form HUD-1447 (11/79)
ref. Handbook 1750.1
Internal Routing
Name:
Name:
Name:
Signatue & Date:
Signatue & Date:
Signatue & Date:
U.S. Department of Housing
and Urban Development
Note:
Immediately return the original of this receipt to the sender.
Caution: Avoid identifying the document in any manner which might
necessitate classification of the receipt.
U.S. Department of Housing
and Urban Development
Note:
Immediately return the original of this receipt to the sender.
Caution: Avoid identifying the document in any manner which might
necessitate classification of the receipt.
HUD-2023-56789
11/15/2023
Jessica X. Patton, Reed, Ray and Haney
Emiliano F. Parsons, Gonzales and Sons
Confidential medical records for patient review and analysis as per case
Return to sender after review
Jessica X. Patton
Emilian F. Parsons
Emilie Montez
11/15/2023
11/15/2023
11/16/2023
| Classified U.S. Department of Housing Control Number:
and Urban Development
Document HUD-2023-56789
Receipt Note: Immediately return the original of this receipt to the sender. Date:
Caution: Avoid identifying the document in any manner which might
necessitate classification of the receipt. 11/15/2023
To: From:
Jessica X. Patton, Reed, Ray and Haney Emiliano F. Parsons, Gonzales and Sons
Description: Number of Copies/Enclosures:
Confidential medical records for patient review and analysis as per case
Final Disposition:
Return to sender after review
Name: Name: Name:
Routing Jessica X. Patton Emilian F. Parsons Emilie Montez
Signatue & Date: Signatue & Date: Signatue & Date:
Internal 11/15/2023 11/15/2023 11/16/2023
form HUD-1447 (11/79)
ref. Handbook 1750.1
Classified U.S. Department of Housing Control Number:
and Urban Development
Document
Receipt Note: Immediately return the original of this receipt to the sender. Date:
Caution: Avoid identifying the document in any manner which might
necessitate classification of the receipt.
To: From:
Description: Number of Copies/Enclosures:
Final Disposition:
Name: Name: Name:
Routing
Signatue & Date: Signatue & Date: Signatue & Date:
Internal
form HUD-1447 (11/79)
ref. Handbook 1750.1 | ||
1459 | Nested | {
"type": "object",
"$defs": {
"Address": {
"type": "object",
"properties": {
"street": {
"type": "string",
"description": "Street address"
},
"city": {
"type": "string",
"description": "City"
},
"state": {
"type": "string",
"description": "State"
}
}
}
},
"properties": {
"signature_full_name": {
"type": "string",
"description": "Full name of the person signing the document"
},
"full_name_printed": {
"type": "string",
"description": "Printed full name of the person"
},
"other_names_used": {
"type": "string",
"description": "Other names used by the person"
},
"date": {
"type": "string",
"description": "Date of the authorization"
},
"telephone_number": {
"type": "string",
"description": "Telephone number of the person"
},
"current_address": {
"$ref": "#/$defs/Address",
"description": "Nested Address object(s)"
}
}
} | {
"signature_full_name": "Akshay V. Saini",
"full_name_printed": "Saini, Akshay V.",
"other_names_used": "A. V. Saini",
"date": "08/01/2023",
"telephone_number": "(718) 214-4971",
"current_address": {
"street": "753 Stephanie Bridge",
"city": "Port Williamshire",
"state": "MI"
}
} | Akshay V. Saini
Saini, Akshay V.
A. V. Saini
08/01/2023
753 Stephanie Bridge
Port Williamshire
MI
(718) 214-4971
| Akshay V. Saini
Saini, Akshay V.
A. V. Saini
08/01/2023
753 Stephanie Bridge
Port Williamshire
MI
(718) 214-4971 | ||
158 | Table | {
"type": "object",
"$defs": {
"AllotmentItem": {
"type": "object",
"properties": {
"description": {
"type": "string",
"description": "Description of the allotment item"
}
}
}
},
"properties": {
"allotment_to": {
"type": "string",
"description": "Name and location of the allotment recipient"
},
"advice_number": {
"type": "string",
"description": "Unique identifier for the advice of allotment"
},
"date": {
"type": "string",
"description": "Date of the advice of allotment"
},
"period_covered": {
"type": "array",
"items": {
"type": "string"
},
"description": "Start and end dates of the period covered by the allotment"
},
"remarks": {
"type": "string",
"description": "Additional remarks or notes"
},
"approved_by_title": {
"type": "string",
"description": "Title of the approving authority"
},
"approved_date": {
"type": "string",
"description": "Date of approval"
},
"allotment_items": {
"type": "array",
"items": {
"$ref": "#/$defs/AllotmentItem"
},
"description": "Nested AllotmentItem object(s)"
}
}
} | {
"allotment_to": "Serena S. Collins, Landscape Architect, Audreyside, TX",
"advice_number": "HUD-ALL-2023-00123",
"date": "03/15/2023",
"period_covered": [
"03/01/2023",
"to",
"03/31/2023"
],
"remarks": "Allotment approved for the month of March 2023 based on project requirements.",
"approved_by_title": "Engineer, Drilling",
"approved_date": "03/15/2023",
"allotment_items": [
{
"description": "Project Management and Coordination"
},
{
"description": "Material Procurement and Delivery"
},
{
"description": "Labor Costs for Skilled Workforce"
},
{
"description": "Equipment Rental and Maintenance"
},
{
"description": "Site Preparation and Clearing"
},
{
"description": "Contingency Fund for Unforeseen Expenses"
}
]
} | Allotment to (Name and Location)
Advice Number
Date (mm/dd/yyyy)
Period Covered (give dates as mm/dd/yyyy)
Advice of Allotment
form HUD-158 (9/82)
ref. Handbook 1830.3
U.S. Department of Housing
and Urban Development
Office of the Chief Human Capital Officer
Approved by (Signature)
Title
Date (mm/dd/yyyy)
Current
Change
New
Description
Allotment
Authorized
Allotment
Remarks
Serena S. Collins, Landscape Architect, Audreyside, TX
HUD-ALL-2023-00123
03/15/2023
03/01/2023
to
03/31/2023
Project Management and Coordination
Material Procurement and Delivery
Labor Costs for Skilled Workforce
Equipment Rental and Maintenance
Site Preparation and Clearing
Contingency Fund for Unforeseen Expenses
Allotment approved for the month of March 2023 based on project requirements.
Willibert Alexander
Engineer, Drilling
03/15/2023
| Advice of Allotment U.S. and Urban Department Development of Housing
Office of the Chief Human Capital Officer
Allotment to (Name and Location) Advice Number
Serena S. Collins, Landscape Architect, Audreyside, TX HUD-ALL-2023-00123
Date (mm/dd/yyyy)
03/15/2023
Period Covered (give dates as mm/dd/yyyy)
03/01/2023 to 03/31/2023
Current Change New
Description Allotment Authorized Allotment
Project Management and Coordination
Material Procurement and Delivery
Labor Costs for Skilled Workforce
Equipment Rental and Maintenance
Site Preparation and Clearing
Contingency Fund for Unforeseen Expenses
Remarks
Allotment approved for the month of March 2023 based on project requirements.
Approved by (Signature) Title Date (mm/dd/yyyy)
Willibert Alexander Engineer, Drilling 03/15/2023
form HUD-158 (9/82)
ref. Handbook 1830.3 | ||
171 | Flat | {
"type": "object",
"properties": {
"initiation_date": {
"type": "string",
"description": "The date when the clearance process was initiated"
},
"job_control_no": {
"type": "string",
"description": "The job control number assigned to this clearance log"
},
"component": {
"type": "string",
"description": "The component or department involved in the clearance"
},
"classification_no": {
"type": "string",
"description": "The classification number of the document"
}
}
} | {
"initiation_date": "03/15/2023",
"job_control_no": "HUD-CL-2023-00478",
"component": "Office of Public Housing",
"classification_no": "HUD-8101.01-2023"
} | ADM
ADSFM
CFO
CIR
CPD
FHEO
GC
GNMA
HSG
IG
PD&R
PIH
Public Affairs
Secy/Departmental EEO
Secy/Labor Rels.
Secy/Lead Hazard Control
Secy/SDBU
CIO
Enforcement
U.S. Department of Housing
and Urban Development
Clearance Log
Previous Edition May Be Used
HUD-171 (7/19/2000)
(HB 000.2)
Handbook
Regulation
New
Notice
Change
Special Issuance
Revision
Executive Order
Other
Date Returned to Originator
Final Action Dates
DMO Received:
Sent to POH:
POH Signed:
DMO Received:
To Visual Arts:
Visual Arts Received
To Printer:
Printed Issuance Received:
Remarks on Reverse:
1
2
3
4
Title
Initiation Date
Reviewing Components
1
2
3
DMO
In
Responses
Received
Clearance
Due
No
Comment
Non-Concur
Comment
DMO
In
Responses
Received
Clearance
Due
No
Comment
Non-Concur
Comment
DMO
In
Responses
Received
Clearance
Due
No
Comment
Non-Concur
Comment
Job Control No.
Component
Classification No.
03/15/2023
HUD-CL-2023-00478
Office of Public Housing
HUD-8101.01-2023
| Clearance Log U.S. Department of Housing
and Urban Development
Title Initiation Date 03/15/2023
1 2 3 Job Control No.
DMO In Responses DMO In Responses DMO In Responses HUD-CL-2023-00478
Received Clearance Due Received Clearance Due Received Clearance Due
Reviewing Components Component
No Comment Non-Concur No Comment Non-Concur No Comment Non-Concur Office of Public Housing
Comment Comment Comment
Classification No.
HUD-8101.01-2023
ADM
ADSFM Handbook Regulation
New Notice
CFO Change Special Issuance
CIR Revision Executive Order
Other
CPD Date Returned to Originator
FHEO 1
GC
2
GNMA
3
HSG
IG 4
PD&R
Final Action Dates
PIH DMO Received:
Public Affairs Sent to POH:
Secy/Departmental EEO
POH Signed:
Secy/Labor Rels.
DMO Received:
Secy/Lead Hazard Control
Secy/SDBU
To Visual Arts:
CIO
Visual Arts Received
Enforcement
To Printer:
Printed Issuance Received:
Remarks on Reverse:
Previous Edition May Be Used HUD-171 (7/19/2000)
(HB 000.2) | ||
1760 | Table | {
"type": "object",
"$defs": {
"LineItem": {
"type": "object",
"properties": {
"description": {
"type": "string",
"description": "Description of the line item"
},
"amount": {
"type": "number",
"description": "Amount of the line item"
}
}
}
},
"properties": {
"payee_name": {
"type": "string",
"description": "Name of the payee"
},
"voucher_number": {
"type": "string",
"description": "Unique identifier for the voucher"
},
"proposed_by": {
"type": "string",
"description": "Person who proposed the voucher"
},
"total_amount": {
"type": "number",
"description": "Total amount of the voucher"
},
"line_items": {
"type": "array",
"items": {
"$ref": "#/$defs/LineItem"
},
"description": "Nested LineItem object(s)"
}
}
} | {
"payee_name": "Amanda V. Sosa",
"voucher_number": "VD-2020-86964",
"proposed_by": "Mary W. Fronczyk, Tax Inspector, Li-Schneider",
"total_amount": 329289.66,
"line_items": [
{
"description": "Consulting services for IT infrastructure optimization and maintenance",
"amount": 150000.0
},
{
"description": "Hardware upgrades including servers and networking equipment",
"amount": 100000.0
},
{
"description": "Software licenses for enterprise applications and security tools",
"amount": 50000.0
},
{
"description": "Cloud services and hosting fees for the fiscal quarter",
"amount": 20000.0
},
{
"description": "Training and certification for IT staff on new technologies",
"amount": 5000.0
},
{
"description": "Travel expenses for on-site technical support and meetings",
"amount": 2500.0
},
{
"description": "Miscellaneous IT supplies and consumables",
"amount": 1000.0
},
{
"description": "Professional development and conference attendance fees",
"amount": 800.0
},
{
"description": "Subscription fees for industry publications and resources",
"amount": 200.0
},
{
"description": "Contingency fund for unforeseen IT-related expenses",
"amount": 500.0
}
]
} | Amanda V. Sosa
VD-2020-86964
Consulting services for IT infrastructure optimization and maintenance
150000
Hardware upgrades including servers and networking equipment
100000
Software licenses for enterprise applications and security tools
50000
Cloud services and hosting fees for the fiscal quarter
20000
Training and certification for IT staff on new technologies
5000
Travel expenses for on-site technical support and meetings
2500
Miscellaneous IT supplies and consumables
1000
Professional development and conference attendance fees
800
Subscription fees for industry publications and resources
200
Contingency fund for unforeseen IT-related expenses
500
Mary W. Fronczyk, Tax Inspector, Li-Schneider
329289.66
| Amanda V. Sosa
VD-2020-86964
Consulting services for IT infrastructure optimization and maintenance 150000
Hardware upgrades including servers and networking equipment 100000
Software licenses for enterprise applications and security tools 50000
Cloud services and hosting fees for the fiscal quarter 20000
Training and certification for IT staff on new technologies 5000
Travel expenses for on-site technical support and meetings 2500
Miscellaneous IT supplies and consumables 1000
Professional development and conference attendance fees 800
Subscription fees for industry publications and resources 200
Contingency fund for unforeseen IT-related expenses 500
Mary W. Fronczyk, Tax Inspector, Li-Schneider 329289.66 |
End of preview. Expand
in Data Studio
VAREX: A Benchmark for Multi-Modal Structured Extraction from Documents
VAREX (VARied-schema EXtraction) is a benchmark for evaluating multimodal foundation models on structured data extraction from government forms. It comprises 1,777 documents with 1,771 unique schemas across three structural categories, each provided in four input modalities. Ground truth is deterministic — generated via a Reverse Annotation pipeline that programmatically fills PDF templates with synthetic values, validated through three-phase quality assurance achieving ~98.5% field-level accuracy.
Paper: [arxiv link TBD] Evaluation code & scoring: github.com/udibarzi/varex-bench
Quick Start
from datasets import load_dataset
import json
ds = load_dataset("ibm-research/VAREX", split="benchmark")
doc = ds[0]
print(doc["doc_id"]) # e.g., "1044"
print(doc["split"]) # "Flat", "Nested", or "Table"
schema = json.loads(doc["schema"])
gt = json.loads(doc["ground_truth"])
image = doc["image"] # PIL Image, 200 DPI
text = doc["text_layout"] # Spatial text with layout
Columns
| Column | Type | Description |
|---|---|---|
doc_id |
string | Unique document identifier |
split |
string | Structural category: Flat, Nested, or Table |
image |
Image | Document page rendered at 200 DPI (primary evaluation modality) |
image_50dpi |
Image | Document page rendered at 50 DPI (resolution robustness evaluation) |
schema |
string | JSON Schema defining the extraction target |
ground_truth |
string | JSON ground truth values |
text_flow |
string | Plain text in reading order |
text_layout |
string | Spatial text with whitespace-preserved layout |
Input Modalities
| Modality | Paper code | Column(s) to use |
|---|---|---|
| Plain Text | P | text_flow |
| Spatial Text | S | text_layout |
| Image | V | image (or image_50dpi for robustness) |
| Spatial Text + Image | S+V | text_layout + image |
Document Splits
| Split | Documents | Description |
|---|---|---|
| Flat | 299 | Simple key-value schemas, no nesting |
| Nested | 1,146 | Schemas with nested objects |
| Table | 332 | Schemas with arrays of objects |
PDF Files
Original filled PDFs are available in the pdfs/ directory of this repository. Each filename corresponds to the doc_id column (e.g., doc_id "1044" → pdfs/1044.pdf). These allow researchers to apply their own text extraction or parsing pipelines.
Scoring
Evaluation code, scoring scripts, and field exclusion lists are maintained at: github.com/udibarzi/varex-bench
The benchmark uses Exact Match (EM) as the primary metric with order-invariant array matching via the Hungarian algorithm. 610 field-level exclusions are applied at scoring time for fields with known ground truth issues.
Citation
@inproceedings{varex2026,
title = {VAREX: A Benchmark for Multi-Modal Structured Extraction from Documents},
author = {Barzelay, Udi and Azulai, Ophir and Shapira, Inbar and Friedman, Idan and Abo Dahood, Foad and Lee, Madison and Daniels, Abraham},
year = {2026}
}
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Community Data License Agreement – Permissive, Version 2.0
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