1505-0266-REQUEST-VOLUNTARILY-REALLOCATED-FUNDS--AZDES.PDF

OMB Approved No.:1505-0266 
Expiration date: 04/30/2022 
EMERGENCY RENTAL ASSISTANCE PROGRAM 
U.S. DEPARTMENT OF THE TREASURY 
Request for Reallocated Funds 
ERA Grantee
its full allocation of funds for the delivery 
of emergency rental assistance ( ERA ) in accordance with section 501 of division N of the 
. The ERA Grantee hereby requests an 
additional $ 
of ERA funds from any amounts the U.S. Department of the 
Treasury 
makes available for reallocation under section 501(d) of the Act.  
Treasury has published guidance, available on its website, setting forth the procedures for the 
reallocation of ERA funds under the Act.  In accordance with the guidance, the ERA Grantee 
hereby certifies that: 
1. it has obligated at least 65% of its total ERA award funds 
as of the date below; and 
2. its jurisdiction has a demonstrated need for the ERA funds requested above and the 
capacity to use those funds pursuant to applicable requirements by September 30, 
2022. 
The ERA Grantee acknowledges that any funds remaining from its ERA1 Award must be 
obligated by September 30, 2022, and such funds not obligated or expended at that time must 
be returned to Treasury as part of the award closeout process pursuant to 2 C.F.R. 200.344(d). 
As permitted by the Act, the ERA Grantee hereby requests that Treasury extend the deadline 
for obligating any reallocated funds received pursuant to this request to December 29, 2022. 
This form includes and incorporates the attached Exhibits A (Obligation Report); B (Evidence of 
Demonstrated Need; and C (Voluntarily Reallocated Funds). 
[ERA GRANTEE] 
By: 
Date: 
, 202 
[
] 
[
] 
PAPERWORK REDUCTION ACT NOTICE:  The information collected will be used for the U.S. Government to determine the 
reallocation of emergency rental assistance funds. The estimated burden associated with this collection of information is 75 
minutes per response.  Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden 
should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., 
N.W., Washington, D.C. 20220. DO NOT send the form to this address.  An agency may not conduct or sponsor, and a person is 
not required to respond to, a collection of information unless it displays a valid control number assigned by OMB. 
PRIVACY ACT STATEMENT 
AUTHORITY:  Solicitation of this information is authorized by section 501 of division N of the Consolidated Appropriations Act,

PURPOSE: The Act requires Treasury to allocate funds to eligible grantees for the delivery of emergency rental assistance to 
eligible households.  Eligible grantees include State, Local governments, U.S. Territories, Tribes, or Tribally Designated Housing 
Entities (TDHEs), as applicable, and the Department of Hawaiian Home Lands.  Treasury maintains contact information for 
authorized representatives and contact persons of the ERA grantees for the purpose of communicating with ERA grantees 
regarding the administration of their award under the Act.  
ROUTINE USES: The information you furnish may be shared in accordance with the routine uses 
system of records notice, Treasury .017 Correspondence and Contact Information, which can be found at 81 FR 78266 (Nov. 7, 
2016). 
DISCLOSURE:  Disclosure of this information is voluntary.  However, grantees/recipients that do not disclose contact 
information will be unable to communicate with Treasury on issues related to their obligations under the Act which may affect 
the status of their award. 
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EXHIBIT A 
Obligation Report 
Treasury has published guidance, available on its website, setting forth the procedures for the 
reallocation of ERA funds under the Act.  As described in the guidance, Treasury considers ERA 
funds to be obligated if (i) the funds have actually been spent providing financial assistance and 
housing stability services for eligible households; (ii) the funds are needed to pay for assistance 
promised in a commitment letter issued to induce a landlord to enter a rental agreement with 
conditions, the 
agreement or funding commitment requiring the grantee to disburse the funds to a third party 
for eligible purposes. In addition, Treasury will 
expenditures, commitments, or obligations. 
Please provide information on this Exhibit A 
s use of funds 
from the ERA1 Award authorized by the Act not regarding its use of funds under an ERA 
award authorized by the American Rescue Plan Act of 2021 
. 
and 
certifies to Treasury that: 
As of 
[insert date], the ERA Grantee has obligated its ERA1 Award funds as 
follows:  
Enter 10% of total ERA1 Award amount for 
administrative costs: 
$ 
Enter total of all other amounts obligated by ERA 
Grantee as of the date hereof: 
$ 
Total amount obligated:  $ 
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EXHIBIT B 
Evidence of Demonstrated Need 
To receive reallocated ERA funds, an ERA grantee must confirm there is a demonstrated need 
for the assistance within its jurisdiction. In support of its request, the ERA Grantee must submit 
the following monthly projections. 
These projections should include expenditures and activities under both section 501 of the 
section 3201 of the American Rescue Plan Act of 
When 
projecting the amount of assistance to be provided to eligible households, assume the funds 
requested in the opening paragraph of this form will be available beginning February 1, 2022. 
February 2022 
Number of unique households that will be assisted 
Amount of assistance to eligible households 
expended 
$ 
Number of applications submitted 
March 2022 
Number of unique households that will be assisted 
Amount of assistance to eligible households 
expended 
$ 
Number of applications submitted 
April 2022 
Number of unique households that will be assisted 
Amount of assistance to eligible households 
expended 
$ 
Number of applications submitted 
May 2022 
Number of unique households that will be assisted 
Amount of assistance to eligible households 
expended 
$ 
Number of applications submitted 
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EXHIBIT C 
Voluntarily Reallocated Funds 
reallocate some or all of their remaining ERA1 award funds to another ERA1 grantee that (i) 
administers an ERA1 program in the same state, territory, or Tribal area; (ii) has obligated at 
least 65% of its own ERA1 award by the time of such transfer; and (iii) confirms a demonstrated 
. 
If known, please identify below any ERA1 grantee(s) who have recommended or are expected 
to recommend the voluntary reallocation of ERA1 funds to the ERA Grantee.  
Transferring Grantee 
Expected Amount 
$ 
$ 
$ 
If awarded voluntarily reallocated funds, the ERA Grantee agrees to comply with all 
administrative and operational requirements applicable to the transfer of ERA1 funds between 
and among ERA1 grantees.  These requirements may include the provision of any standard 
form documents needed to confirm 
deposit account, wire instructions, or other funds transfer information.  The ERA Grantee 
understands that failure to comply with these requirements may result in Treasury awarding 
any funds recommended for reallocation to the ERA Grantee to other grantees. 
As a condition to receiving voluntarily reallocated funds, the ERA Grantee certifies that it has 
complied with all ERA1 requirements under applicable law, the ERA1 guidance published by 
Treasury, and its ERA1 Award Terms. The ERA Grantee agrees that it will use its remaining ERA1 
funds, including any additional funds received through reallocation, in compliance with all such 
authorities. 
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