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EXHIBIT 2 <br />43 <br />AppendixC <br />CY2021HousingChoiceVoucherProgram <br />SpecialFees <br />Application for $30 Million Set-Aside for some Categories of Special Fees 1 HUD-VASH; <br />2FUP;3Disaster;and/or4 <br />NameofPHA: <br />PHANumber: <br />ExecutiveDirector: <br />CHECKALLBOXESTHATAPPLY <br />HUD-VASH <br />FUP <br />Disaster-Related <br />SpecialFeesUnderTheDiscretion <br />Documentation requirements and Deadlines for each of the above categories are contained <br />withinthedocumentthis pageis attached. <br />ThiscertificationmustbesignedbytheappropriatePHAofficialandreturned. <br />Certification:Iherebycertifythatallthe informationstatedherein,aswellasanyinformation <br />providedintheaccompanimentherewith,istrueandaccurate.Ialsocertifythatshouldfunding <br />beawardedunderanyoftheselectedspecialfeecategoriesperthispage,thatIwillkeepclear <br />andorganizedrecordsonhowallawardedthefundswerespentshouldHUDrequesttoreview <br />theoutcomesofthisfeefunding.Warning:Anyonewhoknowinglysubmitsafalseclaimor <br />makesafalsestatementissubjecttocriminaland/orcivilpenalties,includingconfinementforup <br />to5years,fines,andcivilandadministrativepenalties(18U.S.C.§§287,1001,1010,1012;31 <br />U.S.C.§3729,3802). <br />SignatureofExecutiveDirectorand Date <br />ContactNameandPhoneNumber <br /> <br />