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Attachment 2: Example of Expression of Interest Form <br />The following information is an example of the information that will need to be <br />submitted to the Department of Housing and Community Development by February 12, <br />2021. The final form will be made available after the Expression of Intent Survey closes <br />on February 3. For questions, please write to: housing@bcsh.ca.gov. <br />City or County? A) City <br />B) County <br />If a City, what County <br />does your City Reside in? <br /> <br />Name of City/County <br />Contact (Name, Phone, <br />Email) <br />Name) <br />Phone) <br />Email) <br />Secondary Contact Name) <br />Phone) <br />Email) <br />What is the size of the <br />Population you Serve? <br />A) Over 500,000 <br />B) Between 200,000 and 499,999 <br />C) Under 200,000 <br />If your population is over <br />500,000: <br /> <br /> <br />A) Opt-In to State Rental Assistance Program <br />(Direct Federal Allocation + State Reservation Amount) <br />-or- <br />B) Request State Reservation Amount via Block Grant and <br />attest local implementation of Direct Federal Allocation <br />will conform to State Requirements. <br />-or- <br />C) Will not be conforming Direct Federal Allocation to <br />State Program; Acknowledge that the State will still Serve <br />Jurisdictions’ Population through the State Program but <br />Jurisdiction assumes responsibility for Duplication of <br />Benefits <br /> <br />If your population is over <br />500,000 and you are <br />Requesting a Block <br />Grant, do you currently <br />have an existing rental <br />assistance program? <br /> <br />If your population is over <br />500,000, you opted into <br />the State Program and <br />you already requested a <br />UST distribution, what was <br />the value received? <br />A) Yes, the county/city I represent has an existing rental <br />assistance program <br />B) No <br /> <br /> <br /> <br /> <br />$ <br />EXHIBIT 7EXHIBIT 1