Form 4052 Instructions for Completing the CDBG Small Cities Perfor

Instructions for Completing the CDBG Small Cities Performance Assessment Report (PAR)

U.S. Department of Housing and Urban Development Office of Community Planning and Development

OMB Approval No. 2506-0020

(exp. 06/30/2016)

Public reporting burden for this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.

The information is needed for the HUD-Administered Small Cities competition in New York. The program is operating on a competitive basis and the information is essential for the rating and ranking process. The Performance Assessment Report (PAR) provides information on the financial and physical development status of each activity funded. Section 113(b) of the Housing and Community Development Act of 1974, as amended, requires the Secretary to require recipients of CDBG assistance to submit such reports to determine grantee performance and for HUD’s Annual Report to Congress on accomplishments. Information is used to rate and rank applications and determine performance under the grant agreement. There are no sensitive questions. Further, this collection does not include information on individuals and is considered public information. Collection of data to demonstrate compliance with CDBG program requirements is already covered by provisions of the Privacy Act.

The purpose of the Performance Assessment Report is to provide HUD with information on the financial and physical development status of each activity which has not been previously reported as completed in a performance report it must also provide information for HUD to make an initial determination about how the program has complied with certain civil rights requirements.

For example:

16 total

9-d,f

3-d

This report is due no later than 12 months following grant award, and annually thereafter on the date of the award until completion of all CDBG-funded activities. A report is also due no later than 90 days following completion of all CDBG-funded activities, unless waived by the HUD Manager. The HUD Manager may waive this final report if, in his/her judgment, the previous report adequately describes the project results.

4-c

Additionally, if there has been displacement, direct or indirect, as a result of CDBG-funded activities, indicate the number of households relocated by racial/ethnic group using the appropriate definition from the list of definitions below, and the census tract or enumeration district to which relocated.

The report consists of Form HUD 4052 and a set of required narratives:

1. Grantee. Enter the name as shown on the cover sheet of the report.

2. Grant number. Enter the grant number assigned by HUD.

For example:

20 total

6-a 1234.12

3. Date. Enter the submission date of the report.

5-b 3456.34

2-b 4567.46

4. Reporting period. Indicate the period covered by the report.

5. Activity number. Enter the number you assigned to the activity in your application.

7-e 8900.78

6. Name and location. For each activity numbered in Column 5, list the name used in the application. Below each activity, provide the actual location of each physical development activity either carried out or being carried out in whole or in part with CDBG funds. The location should be described in specific terms by street address and by census tract, enumeration district, or by quadrant of the city where there is only one enumeration district.

It should be noted that all displacement should be reported here whether or not the household qualified for relocation benefits. Displacement means the involuntary movement (excluding temporary relocation) of a household from a dwelling unit resulting from its acquisition, rehabilitation, or demolition when: funded in whole or in part with CDBG funds, or (2) funded with non-CDBG funds where the acquisition, rehabilitation, or demolition is a prerequisite for an activity carried out with CDBG funds, e.g., acquisition of a dwelling unit with local funds to provide a site for a neighborhood facility to be constructed with CDBG funds. Displacement also means the involuntary movement (excluding temporary reloca-tion) of a household from a dwelling unit necessitated by CDBG assisted code enforcement. The racial and ethnic categories required to be reported on are listed below. The category which most closely reflects and individual’s recognition in his/her community should be used for purposes of reporting on persons of mixed racial/ethnic origins.

7. Accomplishments. Describe the results of the expenditure of CDBG funds by providing clear measures such as: number of houses rehabilitated; length and diameter of new or improved water and sewer lines, including number of tap-ons and hook-up assistance: number of acres of parkland acquired: number of persons served by neighborhood health facilities; length of streets and sidewalks repaired; number of jobs created, etc. If there is any change from the application in terms of beneficiaries, scope or location of activities, be sure to indicate.

Definitions

8. Direct Benefit. Fill in this column for direct benefit only. A direct benefit activity is one which requires the beneficiary to submit and application or complete a personal record as an integral part of receiving the benefit of the activity. Examples of direct benefit activities are: rehabilitation loan or grant, sewer tap-ons; relocation; public services, indicate the number of person benefitting by racial/ethnic group, and whether female headed house-hold. For public services, indicate the number of persons benefitting, as above. Indicate the benefitting racial/ethnic group by using the letter for the appropriate definition from the list of definitions below.

a. Black/African American. A person having origins in any of the black racial groups

of Africa.

b. White. A person having origins in any of the original peoples of Europe, the Middle

East, or North Africa.

c. Asian. A person having origins in any of the original peoples of the Far East, South-

east Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. d. Native Hawaiian/Other Pacific Islander. A person having origins in any of the origi­nal peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Previous editions are obsolete.

form HUD-4052 (5/16)

e. American Indian/Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

and other payees. Reporting should be on an accrual basis. If the grantee’s accounting records are not kept on an accrual basis, the grantee should develop such information through an analysis of the documentation on hand.

f. American Indian/Alaskan Native and White

13. Unliquidated obligations. Enter the current amount of unliquidated obligations (in thousands of CDBG dollars) as of the end of this reporting period. Unliquidated obligations represent the amount of obligations incurred by the grantee for which an expenditure has not been recorded. Obligations are the amounts of orders placed, contract and grants awarded, services received and similar transactions during the reporting period that will require payment by the grantee during the same or a future period.

7. American Indian/Alaskan Native and Black/African American

8. Black/African American and White

9. Asian and White

j. Other

11. Female headed households

12. Ethnicity: Hispanic/Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

14. Unobligated balance. Enter the current unobligated balance (in thousands of CDBG dollars) as of the end of this reporting period. The unobligated balance is the amount of funds remaining after all expenditures and all unliquidated obligations have been sub-tracted from the total estimated cost of an activity.

9. National objectives. Each activity must address at least one national objective, if the

activity addresses the objective of benefit to low and moderate income persons, give the anticipated/actual percent of benefit to persons of low and moderate income. The final report must list the actual percent of benefit to persons of low and moderate income. For grants awarded in FY 84 and thereafter, not less than 51 percent of funds received must be used for activities that benefit low and moderate income persons.

15. Program income. If there is any program income earned or planned to be earned, check the box and attached a separate sheet describing:

1. the source of program incomes;

2. schedule of expected receipts; and

3. the amount of funds.

For the remaining two objectives, indicate the national objective addressed by the activity. The following symbols may be used:

L/M Low and moderate income

16. Narrative requirements. On a separate sheet

% persons

S/B Slums and blight U/N Urgent Need

a. Affirmative Fair Housing. Describe in narrative, the actions taken to affirmatively

further fair housing. See 24 CFR 5870.904(c).

10. Schedule status. Indicate by “yes”

specific milestone is more than two months ahead or behind schedule, or if the anticipated completion date more than two months ahead or behind schedule, submit a revised Program Schedule Form HUD 4126.6. This requirement may be waived at the discretion of the HUD office, provided the HUD office believes that the change in schedule will have no adverse effect on the timely completion of the project.

or “no” whether each activity on schedule. If a

b. Citizen comments. Summarize the comments, if any, received on the proposed

PAR.

c. Program assessment.

i. Amendments. Give the approval date of any program amendments that required HUD approval. If you made any program changes that did not require HUD approval, describe the changes, and give the date the changes were implemented.

11. Budgeted amount. Enter the current total budgeted amount of each activity numbered in Column 5. The total for this column should reflect the grant amount plus any program income.

ii. Program assessment. In narrative form, assess the relationship of your pro-gram accomplishments to the objectives identified in your application. Include your evaluation of the extent to which funds were used for activities that benefitted low and moderate income persons.

12. Funds expended. For each activity, enter the total amount of funds actually expended as of the date of this report. Expenditures include the sum of actual cash disbursements, the amount of indirect expense incurred and the net amount owed by the grantee for goods and other property received or for services performed by employees, contractor, subgrantees,

iii. Future changes. Given your experience with this program, indicate what changes, if any, you would make in any future program.

Name and Address of Grantee

Grant Number

The Grantee's authorized representative certifies that:

a. To the best of his/her knowledge and belief the data in this report was true and accurate as of the date of the report.

b. The records described in 24 CFR 570.506 are being maintained and will be made available upon request.

c. Activities have been carried out in compliance with the certifications submitted with the application, and future activities, will be carried out in compliance with the certifications.

Typed Name and Title of authorized representative

Telephone Number

Signature of authorized representative

Date

form HUD-4052 (5/16)

Previous editions are obsolete.

CDBG Small Cities

Performance Assessment Report (PAR)

U.S. Department of Housing and Urban Development Office of Community Planning and Development

OMB Approval No. 2506-0020

(exp.6/30/2016)

1. Grantee

2. Grant Number

3. Date

From:

To:

4. Reporting Period

5. Activity

Number

6. Name and Location

7. Accomplishments

8. Direct Benefit

9. National

Objective

10. Schedule

Status

11. Budgeted

Amount

12. Funds

Expended

13. Unliquidated

Obligations

14. Unobligated

Balance

(Thousands)

(Thousands)

(Thousands)

(Thousands)

Cumulative Program Income (See attached sheet)

Totals

$

$

$

$

Previous editions are obsolete.

Page

of

form HUD-4052 (5/16)