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EXHIBIT 2 <br />55 <br />AppendixJ <br />CY2021HousingChoiceVoucherProgram RequestforDisasterSet-aside <br />NameofPHA: <br />PHANumber: <br />ExecutiveDirector: <br />The PHA may request both the additional leasing adjustment and the per unit cost adjustment <br />ormay request only oneadjustment. Pleasechecktheboxes that apply. <br />PresidentiallyDeclaredDisasterthatimpactedyourPHA: <br />LossofUnits <br />Unitsloss,needingfunding: <br />ThenumberofCY2021monthsimpactedby theloss ofunits: <br />IncreasedCosts <br />RequestedPUCAmount: <br />ThenumberofCY2021monthsimpactedby theloss ofunits: <br />Certification:Ihereby certifythatalltheinformationstatedherein,aswellasanyinformation <br />provided in the accompaniment herewith, is true and accurate. Warning: Anyone who knowingly submits a <br />false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up <br />to5years,fines,and civilandadministrativepenalties(18 U.S.C.§§287,1001, 1010,1012;31U.S.C.§3729, <br />3802). <br />SignatureofExecutiveDirectorand Date <br />ContactNameandPhoneNumber <br /> <br />