CITY OF BELOIT, WISCONSIN

COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM

SUBGRANTEE QUARTERLY PERFORMANCE REPORT

ECONOMIC DEVELOPMENT ACTIVITIES

  1. Name of Subgrantee:
  2. Name of Project:
  3. Project Year:
  4. Address of Subgrantee:
  5. Name of Contact Person:
  6. Phone Number of Contact Person:
  7. Period Covered. Please check the quarter this form covers and submit to the Department of Community Development.

For Period Ending:

March 31Quarterly Report is Due No Later than April 15, 2011

June 30Quarterly Report is Due No Later than July 15, 2011

September 30Quarterly Report is Due No Later than October 15, 2011

December 31Quarterly Report is Due No Later than January 15, 2011

  1. The Subgrantee’s authorized official representative certifies that:

(a)This report contains all items identified above.

(b)To the best of his/her knowledge and belief, the data in this report is true and correct as of the date in item.

  1. WARNING: Section 1001 of Title 18 of the United States Code (Criminal Code and Criminal Procedure) shall apply to the foregoing certification. Title 18 provides, among other things, that whoever, knowingly and willfully makes or uses a document or writing containing false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000 or imprisoned not more than five years or both.
  1. Type the name and title of the authorized official subgrantee representative:
  1. Signature:
  1. Date:

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2011 SUBGRANTEE QUARTERLY PERFORMANCE REPORT

JOBS CREATED/RETAINED IN 2011

TABLE 1

Income of Entire Household / 1st Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / Total Persons
Households, 81-100% CMI
Households, 51–80% CMI
Households, 31-50% CMI
Households, 0-30% CMI
Total Persons
Total Persons in Table 1 should equal the Total Persons in Table 2.
TABLE 2
Race of Person Served by the Program / 1st Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / Total Persons
White (Hispanic)
White (Non-Hispanic)
Black/African American (Hispanic)
Black/African American (Non-Hispanic)
Asian (Hispanic)
Asian (Non-Hispanic)
American Indian/Alaska Native (Hispanic)
Am. Indian/Alaska Native (Non-Hispanic)
Native Hawaiian/Other Pacific Islander (Hispanic)
Native Hawaiian/Other Pacific Islander (Non-Hispanic)
American Indian/Alaska Native and White (Hispanic)
American Indian/Alaska Native and White (Non-Hispanic)
Asian and White (Hispanic)
Asian and White (Non-Hispanic)
Black/African American and White (Hispanic)
Black/African American and White (Non-Hispanic)
American Indian/Alaska Native & Black/African American (Hispanic)
American Indian/Alaska Native & Black/African American (Non-Hispanic)
All Other Races Not Listed Above (Hispanic)
All Other Races Not Listed Above (Non-Hispanic)
TOTAL ALL RACES & ETHNICITY

CMI=CountyMedian Income Adjusted for Household Size (See Attached Chart on Next Page)

MAXIMUM HOUSEHOLD INCOME LIMITS

Eligibility Limits (as of May 14, 2010)

Size of Household / 0 – 30% CMI
Extremely Low Income / 31 – 50% CMI
Very Low Income / 51 – 80% CMI
Low Income
1-Person Household / $13,650 / $22,750 / $36,400
2-Person Household / $15,600 / $26,000 / $41,600
3-Person Household / $17,550 / $29,250 / $46,800
4-Person Household / $19,500 / $32,500 / $52,000
5-Person Household / $21,100 / $35,100 / $56,200
6-Person Household / $22,650 / $37,700 / $60,350
7-Person Household / $24,200 / $40,300 / $64,500
8-Person Household / $25,750 / $42,900 / $68,650

Eligibility Limits (as of May 31, 2011)

Size of Household / 0 – 30% CMI
Extremely Low Income / 31 – 50% CMI
Very Low Income / 51 – 80% CMI
Low Income
1-Person Household / $13,550 / $22,600 / $36,150
2-Person Household / $15,500 / $25,800 / $41,300
3-Person Household / $17,450 / $29,050 / $46,450
4-Person Household / $19,350 / $32,250 / $51,600
5-Person Household / $20,900 / $34,850 / $55,750
6-Person Household / $22,450 / $37,450 / $59,900
7-Person Household / $24,000 / $40,000 / $64,000
8-Person Household / $25,550 / $42,600 / $68,150

CMI – County Median Income Adjusted for Household Size

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2011 Subgrantee Quarterly Performance Report

Job Creation and/or Retention Data

Jobs Directly Supported with CDBG Funds
/ Full-time Jobs / Full-time Jobs – Low-Mod / Part-time Jobs / Part-time Jobs – Low-Mod
Name of Company
DUNS #
# Expected to Create
# Expected to Retain
Name of Company
DUNS #
# Expected to Create
# Expected to Retain
Name of Company
DUNS #
# Expected to Create
# Expected to Retain

Type of Jobs Created/Retained

Type of Job / Name of Company / Name of Company
# Created / # Retained / # Created / # Retained
Officials and Managers
Professional
Technicians
Sales
Office and Clerical
Craft Workers (Skilled)
Operatives ( Semi-Skilled)
Laborers (Unskilled)
Service Workers

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2011 Subgrantee Quarterly Performance Report

Job Creation and/or Retention Data

Jobs Directly Supported with CDBG funds / Number of Jobs
Name of Company
Of the jobs created, the number with employer-sponsored health care
Of the jobs created, the number of persons unemployed prior to taking the job
Of the jobs retained, the number with employer-sponsored health care
Name of Company
Of the jobs created, the number with employer-sponsored health care
Of the jobs created, the number of persons unemployed prior to taking the job
Of the jobs retained, the number with employer-sponsored health care

Number of Assisted Businesses

Businesses Assisted / Number / # Expanding / # Relocating
New Businesses Assisted
Existing Businesses Assisted
Total Businesses Assisted
Business Facades or Buildings Rehabbed
Businesses Assisted that Provide Goods and Services to Meet the Needs of the Service Area

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SUBGRANTEE QUARTERLY PERFORMANCE REPORT

BUDGET OVERVIEW

Budget Category(as listed in CDBG Contract) / Contracted to
Expend /
Requested
This Quarter /
Requested
To Date / Remaining
Balance
Total Budget

CDBG Program Income Summary

Activity Year / 2011
Program Income Balance, January 1, 2011 / $
Program Income Received This Quarter / $
Program Income Expended This Quarter / $
Program Income Received in 2009 / $
Program Income Expended in 2009 / $
Asset Inventory

Please list assets (worth at least $500) acquired with CDBG funds during this quarter.

Asset/Item / Value/Cost
$
$

Minority and Women-Owned Businesses

If CDBG funds were used this quarter to award subcontracts to minority and/or women-owned businesses, or if these businesses were used as a vendor, please list below.

Business/Vendor (include address) / CDBG Funds
$
$

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FINANCIAL SUMMARY REPORT

The Department of Housing and Urban Development is trying to identify the amount and type of dollars leveraged by CDBG dollars. Below indicate the total amount and type of funds used to provide your particular program.

TOTAL FUNDS EXPENDED FOR THE PROGRAM BY TYPE

Funding Sources / 1st Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / Total
CDBG Program Funds
HOME Program Funds
Other Federal Program Funds
State Funds
Private Funds
Other Funds – Please indicate the type of funds below.
Total Funds Expended

If you indicated any “Other Funds” above, please specify on the line below what the other funds are (ex. United Way, Stateline Foundation, etc.) – the line will expand to accommodate the amount of information you need to enter in this section.

ACTIVITY SUMMARY

Scheduled Activity Identified in Your Scope of Services / Status of Activity
1.
2.
3.
4.
5.
6.
7.

NARRATIVE SUMMARY

Please use this space to describe activities and/or information not documented elsewhere in this report. Please attach additional pages as needed.

  1. Coordination with Other Agencies and/or Programs:

Describe coordination efforts, include names of agencies and/or programs.

  1. Problems or Obstacles Encountered This Quarter:

Describe any problems staff and/or participants encountered, include any remedies or solutions devised.

  1. Accomplishments This Quarter:

Describe positive accomplishments by staff, program, and/or participants, highlight program and/or beneficiaries.

  1. Results This Quarter:

Describe any results (benefits) that were achieved this quarter.

OBJECTIVES AND OUTCOMES

This page should only be filled out at the end of the year. This information should reflect your entire program during the grant program year.

  1. Program Objective – Check which program objective applies to your program.

Only one program objective can be selected.

Create a suitable living environment

Provide decent affordable housing

Create economic opportunities

  1. Program Outcome – Check which program outcome applies to your program.

Only one program outcome can be selected.

Improve the availability and/or accessibility of a service to the public

Increase the affordability of a program or service

Assist with the sustainability of a program or service

  1. Check the statements below which apply to your program.

Helps prevent homelessness

Helps the homeless

Helps those with HIV/AIDS

Primarily helps persons with disabilities

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