Rev 10/2016

PROJECT PERFORMANCE AND

ACCOMPLISHMENT REPORT

Complete the “All Projects” section, including the accomplishment narrative, leveraging, project location and subrecipient sections. Complete all boxes in this section. Thereafter, complete only those sections under “Project Type Specific Measures” and “National Objective Specific Measures” that apply, respectively, to the type of project undertaken and the national objective for the activities undertaken. Complete all boxes that apply and check the “Does Not Apply” column for any other boxes. Please call your grants manager for additional assistance.

Grantee: Date Awarded:

Project Title:

Grant Number: Grant Amount:

Agency Use Only:

IDIS Activity Number: IDIS Matrix Code:

National Objective:

Objective: Outcome:

ALL PROJECTS

Accomplishment Narrative (to be filled out at closeout only)

At closeout, describe the accomplishments and impacts of the project (be specific and quantitative). Include any anecdotal information from beneficiaries.


ALL PROJECTS

Leveraging
/
Proposed /
Actual
CDBG Grant Amount / $ / $
Other HUD Funds
HOME Funds
ESG Funds
HOPWA Funds
Appalachian Regional Commission (ARC) Funds
Total CDBG/Other HUD/ARC Funds
OTHER FEDERAL FUNDS
Source 1
Source 2
Source 3
Source 4
Total Other Federal Funds
STATE AND LOCAL FUNDS
Source 1
Source 2
Source 3
Source 4
Total State and Local Funds
PRIVATE/NON-PROFIT FUNDS
Source 1
Source 2
Source 3
Source 4
Total Private/Non-Profit Funds
Project Location
/
Yes /
No
Located in a Local Target Area (provide name of Target Area below)
Located in a Historic Preservation Area
Located in a Presidential Disaster Area

Subrecipient o No subrecipient

Check all columns that apply
Name of Subrecipient / Non-Profit / Another Public Agency / Another ULG / Faith- Based Org / Inst. Higher Learning / For-Profit

Continue to National Objective Specific Measures, next page.


NATIONAL OBJECTIVE SPECIFIC MEASURES

Projects Qualifying Under Low Mod Area National Objective o Does not apply

o Census o Survey County: ______

#LMI in census/survey: ______Total # in census/survey: ______

Column 1 - Census Tract
(Maximum 1 census tract per line) / Column 2 – Block Group
(Enter all Block Groups for Census Tract indicated in Column 1)

Census & block group required for BOTH census and survey projects!

Slum Blight Area Benefit Projects o Does not apply
Boundaries of area
Year of Slum/Blight designation
Percentage deteriorated buildings/qualified properties / %
Public Improvement Type/Condition
Proposed / Actual / Does Not Apply
Number of buildings demolished
Number of buildings rehabilitated
Limited Clientele Projects o Does not apply
Yes / No
Qualifying under presumed LMI (abused children, elderly, battered spouses, homeless, disabled illiterate adults, persons with HIV, migrant workers)
Requiring information on family size and income to demonstrate 51% of clientele are LMI
Income eligibility requirements limit beneficiaries to 100% LMI
Qualifying Under Nature/Location (example: job training facility within a public housing complex)
Description of Nature/Location


PROJECT TYPE SPECIFIC MEASURES

Public Facility and Public Service Projects /
Proposed /
Actual / Does Not Apply
Public Infrastructure & Facilities / o
Number of persons assisted with new access to a facility or infrastructure
Number of persons assisted with improved access to a facility or infrastructure
Number of persons assisted where facility or infrastructure quality was improved
LMI units newly connected to public facilities
Number of units connected to water
Number of units connected to sewer
Public Service Projects / o
Number of persons with new access to service
Number of persons with improved access to service
Number of persons where service quality was improved
Clearance/Demolition Projects /
Proposed /
Actual / Does Not Apply
Demolition Projects / o
Number of buildings/structures demolished
Clearance Projects / o
Number of lots cleared
Housing Projects /
Proposed /
Actual / Does Not Apply
New housing construction / o
More than 2 units in any structure constructed? / o Yes ** o No
Owner Units / o Yes o No
Total number of owner units created
Number of units qualified as Energy Star*
Number of units Section 504 accessible
Number of households previously living in subsidized housing
Number of affordable units occupied by elderly (62 years of age or above)
Rental Units / o Yes ** o No
Total number of rental units created
Number of units affordable
Number of years affordability guaranteed
Number of units Section 504 accessible
Number of qualified as Energy Star*
Number of affordable units occupied by elderly (62 years of age or above)
Number of affordable units subsidized with project-based rental assistance by another
federal, state or local program


PROJECT TYPE SPECIFIC MEASURES

Housing Projects (continued) /
Proposed /
Actual / Does Not Apply
Rehabilitation (excluding water/sewer connections) / o
More than 2 units in any structure rehabilitated? / o Yes ** o No
Total number of units rehabilitated, replaced or repaired
Total number of units demolished
Owner-Occupied Units / o Yes o No
Total number of owner-occupied units rehabilitated, repaired or replaced
Number of units occupied by elderly (62 years of age or above)
Number of units brought from substandard to standard condition (HQS)
Number of units qualified as Energy Star*
Number of units Section 504 accessible
Number of units brought into compliance with the lead safe housing rule (24 CFR part 35)
Renter-Occupied Units / o Yes ** o No
Total number of renter-occupied units rehabilitated, repaired or replaced
Number of units affordable
Number of units occupied by elderly (62 years of age or above)
Number of units Section 504 accessible
Number of units brought from substandard to standard condition (HQS)
Number of units qualified as Energy Star*
Number of units brought into compliance with the lead safe housing rule (24 CFR part 35)
Number of units created through conversion of nonresidential building to residential
Project Location / o
** Project address is required if you checked yes above to:
a) more than 2 units in any structure constructed/rehabilitated and
b) renter-occupied units.
Provide one address corresponding to the location of the greatest number of units.
Street Address
City
State
Zip
Type of Rehabilitation or Other Housing Assistance /
Quantity /
Average $ Amount /
Average Interest Rate /
Average Term (months)
Grants
Standard Loans
Deferred Forgivable Loans
Supply additional sheet listing individual grant/loan terms and amounts.

* Energy efficiency rating provided by the U.S. Environmental Protection Agency (EPA).


PROJECT TYPE SPECIFIC MEASURES

Economic Development Projects /
Proposed /
Actual / Does Not Apply
All Projects Assisting Businesses (including job creation/retention and commercial facades) / o
New Businesses Assisted
Number assisted
Existing Businesses Assisted
Total number assisted
Number expanding
Number relocating
All Businesses Assisted
Number assisted with business building rehabilitation
Number of businesses assisted providing local goods or services
DUNS numbers (required for each businesses assisted - attach additional pages as needed)
Business #1
Business #2
Business #3
Business #4
Projects Resulting in Job Creation / o
Number of full-time jobs created
Number of part-time jobs created
Number of jobs created with employer sponsored health care benefits
Number of new jobs held by individuals previously unemployed
Type of Jobs Created
Officials and Managers
Professional
Technicians
Sales
Office and Clerical
Craft Workers (skilled)
Operatives (semi-skilled)
Laborers (unskilled)
Service Workers
Projects Resulting in Job Retention / o
Total number of jobs retained
Number of full-time jobs retained
Number of part-time jobs retained
Number of jobs retained with employer sponsored health care benefits


PROJECT TYPE SPECIFIC MEASURES

Economic Development Projects (continued) /
Proposed /
Actual / Does Not Apply
Projects Resulting in Job Retention (continued) / o
Type of Jobs Retained
Officials and Managers
Professional
Technicians
Sales
Office and Clerical
Craft Workers (skilled)
Operatives (semi-skilled)
Laborers (unskilled)
Service Workers
Projects Involving Direct Assistance / o
Quantity / Average
$ Amount / Average
Interest Rate / Average
Term (months)
Assistance Type
Grants
Standard Loans
Deferred Forgivable Loans
Supply additional sheet listing individual grant/loan terms and amounts.
Brownfield Projects /
Proposed /
Actual / Does Not Apply
Number of square acres of brownfields remediated
Result of the project (ie. housing, econ. development, public facility…)

Project Performance and Accomplishment Report Page 2