Annual Statement Performance and Evaluation Report HUD 50075.1.pdf

PDF 742 KB Posted May 9, 2022

Attached to: Capital Fund At Risk/Receivership/ Substandard/ Troubled Program
Opportunity number: FR-6500-N-81
Issued by: Department of Housing and Urban Development

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Annual Statement/Performance and Evaluation Report U.S. Department of Housing and Urban Development Office of Public and Indian Housing

Expires 11/30/2023

Capital Fund Program, Capital Fund Program Replacement Housing Factor and Capital Fund Financing Program OMB No. 2577-0157

“Public reporting burden for this collection of information is estimated to average 2.2 hours. This includes the time for collecting, reviewing, and reporting the data. The information requested is required to obtain a benefit. This form is used to verify allowable and reasonableness of grant expenses. There are no assurances of confidentiality. HUD may not conduct or sponsor, and an applicant is not required to respond to a collection of information unless it displays a currently valid OMB control number.

Type of Grant Original Annual Statement Reserve for Disasters/Emergencies Revised Annual Statement (revision no:

PHA Name

Performance and Evaluation Report for Period Ending: Final Performance and Evaluation Report

1 To be completed for the Performance and Evaluation Report.

2 To be completed for the Performance and Evaluation Report or a Revised Annual Statement.

3 PHAs with under 250 units in management may use 100% of CFP Grants for operations.

Page 1 form HUD-50075.1 (07/2014)

Grant Type and Number Capital Fund Program Grant No:

Replacement Housing Factor Grant No:

Date of CFFP:

FFY of Grant:

FFY of Grant Approval:

Line Summary by Development Account Total Estimated Cost Total Actual Cost 1

Original Revised2 Obligated Expended 1 Total non-CFP Funds

2 1406 Operations (may not exceed 20% of line 15) 3

3 1408 Management Improvements

4 1410 Administration (may not exceed 10% of line 15)

5 1480 General Capital Activity

6 1492 Moving to Work Demonstration

7 1501 Collaterization Expense / Debt Service Paid by PHA

8 1503 RAD-CFP

9 1504 RAD Investment Activity

Hard

RAD-CPT

Debt Reserves

Bond Debt Obligation

Loan Debt Obligation

Post Audit Adjustment

10 1505 RAD-CPT

11 9000 Debt Reserves

12 9001 Bond Debt Obligation paid Via System of Direct Payment 13 9002 Loan Debt Obligation paid Via System of Direct Payment

14 9900 Post Audit Adjustment

Annual Statement/Performance and Evaluation Report U.S. Department of Housing and Urban Development Capital Fund Program, Capital Fund Program Replacement Housing Factor and Office of Public and Indian Housing Capital Fund Financing Program OMB No. 2577-0157

Expires 11/30/2023

* I certify that the information provided on this form and in any accompanying documentation is true and accurate. I acknowledge that making, presenting, or submitting a false, fictitious, or fraudulent statement, representation, or certification may result in criminal, civil, and/or administrative sanctions, including fines, penalties, and imprisonment.

1 To be completed for the Performance and Evaluation Report.

2 To be completed for the Performance and Evaluation Report or a Revised Annual Statement.

3 PHAs with under 250 units in management may use 100% of CFP Grants for operations.

Page 2 form HUD-50075.1 (07/2014)

Final Performance and Evaluation Report

Part I: Summary PHA Name: Grant Type and Number

Capital Fund Program Grant No:

Replacement Housing Factor Grant No:

Date of CFFP:

FFY of Grant:

FFY of Grant Approval:

Type of Grant Original Annual Statement Reserve for Disasters/Emergencies Revised Annual Statement (revision no:

Performance and Evaluation Report for Period Ending:

Line Summary by Development Account Total Estimated Cost Total Actual Cost 1

Original Revised 2 Obligated Expended

15 Amount of Annual Grant:: (sum of lines 2 - 14)

16 Amount of line 15 Related to LBP Activities

17 Amount of line 15 Related Sect. 504, ADA, and Fair Housing Act Activities.

18 Amount of line 15 Related to Security - Soft Costs

19 Amount of line 15 Related to Security - Hard Costs

20 Amount of line 15 Related to Energy Conservation Measures

Signature of Executive Director * Date Signature of Public Housing Director Date

Development Number General Description of Major Work Development Quantity Total Estimated Cost Total Actual Cost Status of Work Name/PHA-Wide Categories Account No.

Activities

Original Revised 1 Funds Funds Obligated2 Expended2

1 To be completed for the Performance and Evaluation Report or a Revised Annual Statement.

2 To be completed for the Performance and Evaluation Report.

Page 3 form HUD-50075.1 (07/2014)

Part II: Supporting Pages PHA Name: Grant Type and Number

Capital Fund Program Grant No: CFFP (Yes/ No):

Replacement Housing Factor Grant No:

Federal FFY of Grant:

H19159 Cross-out R

Development Number General Description of Major Work Development Quantity Total Estimated Cost Total Actual Cost Status of Work Name/PHA-Wide Categories Account No.

Activities

Original Revised 1 Funds Funds Obligated2 Expended2

1 To be completed for the Performance and Evaluation Report or a Revised Annual Statement.

2 To be completed for the Performance and Evaluation Report.

Page 4 form HUD-50075.1 (07/2014)

Part II: Supporting Pages PHA Name: Grant Type and Number

Capital Fund Program Grant No: CFFP (Yes/ No):

Replacement Housing Factor Grant No:

Federal FFY of Grant:

1 Obligation and expenditure end dated can only be revised with HUD approval pursuant to Section 9j of the U.S. Housing Act of 1937, as amended.

Page 5 form HUD-50075.1 (07/2014)

Part III: Implementation Schedule for Capital Fund Financing Program PHA Name: Federal FFY of Grant:

Development Number Name/PHA-Wide

Activities

All Fund Obligated (Quarter Ending Date)

All Funds Expended (Quarter Ending Date)

Reasons for Revised Target Dates 1

Original Obligation End

Date

Actual Obligation End Date

Original Expenditure End Date

Actual Expenditure End Date

1 Obligation and expenditure end dated can only be revised with HUD approval pursuant to Section 9j of the U.S. Housing Act of 1937, as amended.

Page 6 form HUD-50075.1 (07/2014)

Part III: Implementation Schedule for Capital Fund Financing Program PHA Name: Federal FFY of Grant:

Development Number Name/PHA-Wide

Activities

All Fund Obligated (Quarter Ending Date)

All Funds Expended (Quarter Ending Date)

Reasons for Revised Target Dates 1

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Date

Actual Obligation End Date

Original Expenditure End Date

Actual Expenditure End Date

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Final Performance and Evaluation Report: Off

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File details come from the government source that posted it. Updated May 11, 2022.