JID 52837 Annual Statement/Performance Plan and Evaluation Report

HA Name

Comprehensive Grant Number

Original Annual Statement
Reserve for Disasters/Emergencies
Performance and Evaluation Report for Program Year Ending ________
Line No.

Summary by Development Account

1

Total Non-CGP Funds

2

1406

Operations (May not exceed 10% of line 20)

3

1408

Management Improvements

4

1410

Administration

5

1411

Audit

6

1415

Liquidated Damages

7

1430

Fees and Costs

8

1440

Site Acquisition

9

1450

Site Improvement

10

1460

Dwelling Structures

11

1465.1 Dwelling Equipment—Non-expendable

12

1470

Non-dwelling Structures

13

1475

Non-dwelling Equipment

14

1485

Demolition

15

1490

Replacement Reserve

16

1492

Moving to Work Demonstration

17

1495.1 Relocation Costs

18

1498

Mod Used for Development

19

1502

Contingency (may not exceed 8% of line 20)

20

Amount of Annual Grant (Sum of lines 2-19)

21

Amount of line 20 Related to LBP Activities

22

Amount of line 20 Related to Section 504 Compliance

23

Amount of line 20 Related to Security

24

Amount of line 20 Related to Energy Conservation Measures

Signature of Executive Director

1
2

OMB Approval No. 2577-0157
(exp. 11/30/2008)

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

Annual Statement / Performance and Evaluation Report
Comprehensive Grant Program (CGP) Part I: Summary

Revised Annual Statement/Revision Number _______
Final Performance and Evaluation Report
Original

Date

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

FFY of Grant Approval

Total Estimated Cost
Revised

1

Total Actual Cost
Obligated

Signature of Public Housing Director

Page ___ of ___

2

Expended

Date

Previous edition is obsolete

form HUD-52837 (9/98)
ref Handbook 7485.3

Annual Statement / Performance and Evaluation Report
Comprehensive Grant Program (CGP) Part II: Supporting
Development
Number/Name
HA-Wide
Activities

Pages

Total Estimated Cost
General Description of Major
Work Categories

Signature of Executive Director

1
2

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

Development
Account
Number

Total Actual Cost

Quantity

Date

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

Status of Proposed Work
Original

Revised

1

Funds
Obligated

2

Funds
Expended

2

Signature of Public Housing Director

Page ___ of ___

2

Date

Previous edition is obsolete

form HUD-52837 (9/98)
ref Handbook 7485.3

Annual Statement / Performance and Evaluation Report
Comprehensive Grant Program (CGP) Part III: Implementation
Development
Number/Name
HA-Wide
Activities

All Funds Obligated (Quarter Ending Date)
Original

Signature of Executive Director

1
2

Revised

1

Actual

Schedule

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

All Funds Expended (Quarter Ending Date)
2

Original

Date

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

Revised

1

Actual

Reasons for Revised Target Dates
2

Signature of Public Housing Director

Page ___ of ___

2

Date

Previous edition is obsolete

form HUD-52837 (9/98)
ref Handbook 7485.3

Public reporting burden for this collection of information is estimated to average 8 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 conduct or sponsor, and a person is not required to respond to, a collection of information
unless that collection displays a valid OMB control number.
This collection of information requires that each eligible applicant submit information to HUD in order to receive its annual formula grant. This information will be used by HUD to determine whether the
annual submission meets statutory and regulatory requirements for the annual formula grant and during implementation. Responses to the collection are required by Section 14(e)(3) and (4) of the U.S.
Housing Act of 1937, as amended. The information requested does not lend itself to confidentiality.

Instructions for Preparation of Form HUD-52837, Annual Statement/Performance and Evaluation Report, Report Submission For the Annual Statement
Prepare a separate Form HUD-52837 (Parts I, II and III) for each annual formula grant,
describing the activities which are planned to be undertaken with the current year’s
Comprehensive Grant Program (CGP) funds. Submit this form to HUD as part of each
annual submission. On an as-needed basis, submit a revised form when prior HUD
approval is required to amend the Annual Statement. When submitting a complete Form
HUD-52837 (Parts I, II and III), only Part I shall be signed and dated. For revisions affecting
individual pages, only the pages affected shall be signed, dated and submitted to HUD.

VA05P03670294. Any funding from the $75 million reserve for natural and other disasters
and emergencies shall be given a separate Comprehensive Grant number. Grant Numbers
shall be sequential, e.g., the annual formula grant is funded first and numbered
VA05P03670395; a grant from the $75 million reserve is funded next in the same FFY and
numbered VA05P03670495.
FFY of Grant Approval. Enter the FFY in which the grant is being approved/was approved.

Prepare a separate Form HUD-52837 (Parts I, II and III) for each emergency funding
request under the annual formula grant where there is no approved Comprehensive Plan.

Type of Submission. Check the appropriate box and indicate whether the submission is
the Original Annual Statement for the annual formula grant, the $75 million Reserve for
Disasters and Emergencies, the Revised Annual Statement (and revision number), the
Performance and Evaluation Report for Program Year Ending (enter date, e.g., 6/30/96), or
the Final Performance and Evaluation Report.

Report Submission For the Performance and Evaluation Report

Original Total Estimated Cost

At the end of the program year (6/30), complete the sections of Parts I, II and III as noted
in footnotes 1 and 2 on a copy of the original or revised Annual Statement and mark the box,
Performance and Evaluation Report for Program Year Ending ____________________.
Submit the form(s) to HUD, together with the narrative report on resident and local/tribal
government participation and other required items, by 9/30. Continue reporting at the end
of each program year, until the program is completed or all funds are expended.

Line 1. Enter the Original Total Estimated Cost for all work that will be undertaken from nonCGP funds, including CIAP funds being reprogrammed for CGP purposes. Enter zero if no
work will be undertaken from non-CGP funds.

Prepare a separate Form HUD-52837 (Parts I, II and III) for each funding request from
the $75 million reserve for natural and other disasters and emergencies.

Revisions to the Annual Statement which do not require prior HUD approval, (e.g.
expenditures for emergency work, revisions resulting from the HA’s application of fungibility) shall be reported in the Performance and Evaluation Report. Revisions requiring prior
HUD approval shall be submitted in a revised Annual Statement, on an as-needed basis,
prior to submission of the Performance and Evaluation Report.
Upon completion or termination of the activities funded in a specific grant year, complete
the sections of Parts I, II and III as noted in footnotes 1 and 2 on a copy of the original or
revised Annual Statement and mark the box, Final Performance and Evaluation Report.
Submit a Final Performance and Evaluation Report as soon as the program is completed or all
funds are expended.

Lines 2 through 19. For each line, enter the Original Total Estimated Cost, for all work that
will be undertaken from the annual formula grant or the $75 million reserve. Enter zero if
no work will be undertaken in a particular development account. The sum total of lines 2
through 19 must equal the amount of the annual grant on line 20.
Note: Line 2 may not exceed 10 percent of line 20.
Line 3 may not exceed 20 percent of line 20 except where approved by HUD or the
PHA is both an overall high performer and a Mod-high performer under the PHMAP.
Line 4 may not exceed 10 percent of line 20, excluding certain costs, except where
approved by HUD.
Line 16 is available only to HAs participating in the Moving to Work demonstration
program. The amount of funding that may be entered on this line is subject to the
terms of the HA's executed Moving to Work Agreement with HUD.
Line 20. Amount of Annual Grant. Enter the sum of lines 2 through 19 in the Original Total
Estimated Cost column.

Part I: Summary
Heading Instructions
HA Name. Enter the HA name.
Comprehensive Grant Number. Enter the unique Comprehensive Grant number designated for the annual grant. This number is a 13-digit alpha numeric code as follows: twodigit State code (alpha); two-digit Field Office code (numeric); P for Public Housing; threedigit HA number; three-digit Grant number; and two-digit Federal Fiscal Year identifier. The
first Comprehensive Grant approved under the CGP shall be 701; e.g., VA05P03670193.
The second Comprehensive Grant approved under the CGP shall be 702; e.g.,

Page i

Line 21. Amount of line 20 Related to Lead-Based Paint (LBP) Activities. Enter the amount
of line 20 related to LBP activities (hard and soft costs) in the Original Total Estimated Cost
column, as applicable. For example, if windows are being replaced, estimate the portion
of the funding which is directly related to LBP abatement.
Line 22. Amount of line 20 Related to Section 504 Compliance. Enter the amount of line
20 related to Section 504 compliance (hard and soft costs) in the Original Total Estimated
Cost column, as applicable.

Previous edition is obsolete

form HUD-52837 (9/98)
ref Handbook 7485.3

Line 23. Amount of line 20 Related to Security. Enter the amount of line 20 related to
Security (hard and soft costs) in the Original Total Estimated Cost column, as applicable.

Line 20. Enter the sum of lines 2 through 18 for obligated and expended. The sum of lines
2 through 18 may not exceed line 20 in the Original Total Estimated Cost column.

Line 24. Amount of line 20 Related to Energy Conservation Measures. Enter the amount
of line 20 related to Energy Conservation Measures (hard and soft costs) in the Original
Total Estimated Cost column, as applicable.

Part II: Supporting Pages

Revised Total Estimated Cost
Lines 1 through 19. After initial approval by HUD, the HA shall track cost increases and
decreases in lines 1 through 18 and cost decreases in line 19 of the Original Total Estimated
Cost and report these revisions in the Revised Total Estimated Cost column at the end of
each program year on the Performance and Evaluation Report. If revisions are reported in
the Revised Total Estimated Cost column when a Performance and Evaluation Report is
submitted, the revisions shall be reflected in the Original Total Estimated Cost column when
the next Performance and Evaluation Report is submitted.
Where prior HUD approval is required to revise the Annual Statement (i.e., where a major
work category is being added to the Annual Statement which was not included in the latest
HUD-approved Five-Year Action Plan or a prior approved budget), enter the revisions to
development accounts that are affected by the change in the Revised Total Estimated Cost
column and submit only the pages of the form affected by the revision to HUD. Each page
submitted for prior HUD approval of a revision shall be signed and dated by the HA and,
where approved by HUD, a signed copy shall be returned to the HA.
Line 20. After initial approval by HUD, the sum of lines 2 through 19 in the Revised Total
Estimated Cost column may not exceed the annual grant amount (line 20 in the Original
Total Estimated Cost column).
Lines 21 through 24. After initial approval by HUD, the HA shall track cost increases and
decreases in lines 21 through 24 of the Original Total Estimated Cost and report these
revisions in the Revised Total Estimated Cost column when the Performance and Evaluation Report is submitted. If revisions are reported in the Revised Total Estimated Cost
column when a Performance and Evaluation Report is submitted, the revisions shall be
reflected in the Original Total Estimated Cost column when the next Performance and
Evaluation Report is submitted.
Total Actual Cost

Development Number/Name. Enter the abbreviated number (e.g., VA-36-1) and the
name, if any, of each development where a major work category will be undertaken. Enter
“HA-wide” for a major work category that relates to a HA-wide activity (e.g., management
improvements; administration; physical improvements that are unpredictable, such as leadbased paint abatement, asbestos abatement, modernization of vacant units).
General Description of Major Work Categories. For each development listed, enter a
general description of the major work categories, including those that will be funded with
non-CGP funds and no cost items. Work categories should be described in broad terms,
such as kitchens, bathrooms, electrical, site, etc. A work category may encompass various
components; e.g., the major work category of kitchens may include ranges, refrigerators,
cabinets, floors, etc. Do not specify the per unit cost or the quality of materials. Identify
major work categories that will be accomplished by Force Account labor by entering (FA)
in parenthesis next to the major work category. PHAs that are designated as both overall
high performers and Mod-high performers under the PHMAP and IHAs do not have to
identify major work categories that will be accomplished by FA. After listing all major work
categories for all developments being funded, enter a general description of HA-wide
activities such as; management improvements; administrative costs; non-dwelling equipment; physical improvements that are unpredictable such as lead-based paint abatement,
asbestos abatement, modernization of vacant units. When major work categories are
subsequently deleted, draw a line through the General Description of Major Work Categories, Development Account Number, Quantity, and Estimated Cost. When major work
categories are subsequently added, enter the General Description of Major Work Categories, Development Account Number, Quantity and Estimated Cost under the appropriate
development number/name. Note: Describe administrative and management improvement costs in sufficient detail for HUD to make a determination of eligibility. Identify items
excluded from the 10 percent limitation on administrative cost, such as in-house LBP
testing; identify management improvements and how they relate to identified physical or
management improvement needs.

At the end of the CGP program year (6/30) for each grant with a separate Comprehensive
Grant Number for which funds are still being expended, complete the section on Actual Cost
on a copy of the original or revised Annual Statement, mark the box Performance and
Evaluation Report for Program Year Ending _________ and submit to HUD by 9/30.

Development Account Number. For each major work category and HA-wide activity, enter the
appropriate development account which corresponds to the major work categories described
under the General Description of Major Work Categories column. For appropriate development
accounts, refer to the CGP Handbook 7485.3. Where funding will be provided from non-CGP
sources, or the work is a no-cost item, enter “N/A” for not applicable.

Upon completion or termination of the activities funded for each grant with a separate
Comprehensive Grant Number, complete the section on Actual Cost as part of the
submission of the Final Performance and Evaluation Report.

Quantity. Enter the quantity of each major work category, and HA-wide activity, to be
undertaken as a percentage or whole number; e.g., 50 percent of the units, 125 units, train
25 residents, etc.

Lines 1 through 24. For each line, enter the Actual Cost of Funds Obligated and Expended
at the end of the CGP program year (6/30) or upon completion or termination of the activities
funded for each grant with a separate Comprehensive Grant Number. Note: Do not enter
a dollar amount for obligated and expended for line 19 (Contingency). Funds from this
account shall be shown as obligated and expended in another development account when
funds from this account are used for cost overruns, contract modifications, or other work.

Total Estimated Cost

Page ii

Original. For each major work category and HA-wide activity, enter the Original Estimated
Cost. Asterisk the estimated cost of each major work category that will be funded with nonCGP funds, including reprogrammed CIAP funds. After listing the estimated cost for all
major work categories at a particular development, enter a subtotal of the estimated
cost of only the major work categories that will be funded from the current year’s CGP
grant. (Note: Do not count costs that have been asterisked in this subtotal). Enter a
subtotal for each HA-wide activity. Enter a grand total for Part II of only the major work
Previous edition is obsolete

form HUD-52837 (9/98)
ref Handbook 7485.3

categories and HA-wide activities that will be funded with the current year’s CGP grant. The
Grand Total may not exceed line 19 of the Original Total Estimated Cost column in Part I.
Revised. After initial approval by HUD, the HA shall track cost decreases or increases in
the Original Total Estimated Cost and report these revisions in the Revised Total Estimated
Cost column at the end of each program year on the Performance and Evaluation Report.
If revisions are reported in the Revised Total Estimated Cost column when a Performance
and Evaluation Report is submitted, the revisions shall be reflected in the Original Total
Estimated Cost column when the next Performance and Evaluation Report is submitted.
Where prior HUD approval is required to revise the Annual Statement (i.e., where a major
work category is being added to the Annual Statement which was not included in the latest
HUD-approved Five-Year Action Plan or a prior approved budget), enter the revisions to
development accounts that are affected by the change in the Revised Total Estimated Cost
column and submit only the pages of the form affected by the revision to HUD.
Total Actual Cost. At the end of the CGP program year for each grant with a separate
Comprehensive Grant Number for which funds are still being expended, complete the section
on Actual Cost for the Performance and Evaluation Report. Upon completion or termination of
the activities funded for each grant with a separate Comprehensive Grant Number, complete the
section on Actual Cost for the Final Performance and Evaluation Report.
Funds Obligated. In this column, for each development listed, enter the cumulative dollar
amount of all funds obligated for that development opposite the Original Estimated Cost
subtotal. For each HA-wide activity listed, enter the cumulative dollar amount of all funds
obligated opposite the Original Estimated Cost subtotal. Enter the cumulative dollar amount
of all funds obligated opposite the Grand Total. The Grand Total may not exceed line 19
in the Original Total Estimated Cost column in Part I. This includes funds obligated by the
HA for work to be performed by contract labor (i.e., contract award) and force account labor
(i.e., work actually started). Funds that are recorded as being obligated shall remain
obligated so that total funds obligated are always greater than or equal to total funds
expended. Total funds obligated shall not exceed the amount of the annual grant. Note:
Do not enter a dollar amount for obligated for line 18 (Contingency). Funds from this account
will be shown as obligated in the appropriate development account when funds from this
account are used for cost overruns, contract modifications or other work.
Funds Expended. In this column, for each development listed, enter the cumulative dollar
amount of all funds expended for that development opposite the Original Estimated Cost
subtotal. For each HA-wide activity listed, enter the cumulative dollar amount of all funds
expended opposite the Original Estimated Cost subtotal. Enter the cumulative dollar
amount of all funds expended opposite the Grand Total. The Grand Total may not exceed
line 19 in the Original Total Estimated Cost column in Part I. Total funds expended means
cash actually disbursed and does not include retainage. Note: Do not enter a dollar amount
for expended for line 18 (Contingency). Funds from this account will be shown as expended
in the appropriate development account when funds from this account are used for cost
overruns, contract modifications or other work.
Status of Proposed Work. At the end of the CGP program year, complete this section for the
Performance and Evaluation Report. For each major work category and HA-wide physical
improvement listed, prepare a brief description of the status of the item, e.g., work completed
or contract awarded on May 5, 1996. Explain the addition, deletion or modification of any major
work category, such as the addition of any emergency work, or changes to the Annual

Statement, by substituting major work categories from the Five-Year Action Plan or other
approved modernization budgets. Where funds were budgeted for HA-wide physical improvements, indicate the actual developments/number of units where the funds were expended.
Part III: Implementation Schedule
Development Number/Name. Enter the abbreviated number (e.g., VA 36-1) and the
name, if any, of each development listed on Part II. Enter “HA-wide” for major work
categories that relate to HA-wide physical or management improvements.
Original - All Funds Obligated. Opposite each development and for each HA-wide
physical or management activity, enter the estimated quarter ending date for obligation of all
funds under the Original column. Note: Provide an implementation schedule only for HA-wide
physical or management improvements, not for other HA-wide activities (e.g., administration).
Revised - All Funds Obligated. The HA may revise the target dates for fund obligation for
delays outside of the HA’s control. The revised dates shall be reported in this column at the
end of the program year on the Performance and Evaluation Report. If revisions are
reported in the Revised - All Funds Obligated column, the revised dates shall be reflected
in the Original - All Funds Obligated column when the next Performance and Evaluation
Report is submitted. When it is necessary for the HA to revise a target date for reasons
within its control, the HA shall immediately submit a written request to the Field Office
requesting approval of the new date. If the Field Office approves the revision, the revised
dates shall be reflected in the Original - All Funds Obligated column when the next
Performance and Evaluation Report is submitted.
Actual - All Funds Obligated. When all funds are obligated for a development or HA-wide
activity, enter the quarter ending date that this occurred in the Actual column.
Original - All Funds Expended. Opposite each development and for each HA-wide physical
or management activity, enter the estimated quarter ending date for expenditure of all funds
under the Original column. Note: Provide an implementation schedule only for HA-wide
physical or management improvements, not for other HA-wide activities, (e.g., administration).
Revised - All Funds Expended. The HA may revise the target dates for funds expenditure
for delays outside of the HA’s control. The revised dates shall be reported in this column
at the end of the program year on the Performance and Evaluation Report. If revisions are
reported in the Revised - All Funds Expended column, the revised dates shall be reflected
in the Original - All Funds Expended column when the next Performance and Evaluation
Report is submitted. When it is necessary for the HA to revise a target date for reasons
within its control, the HA shall immediately submit a written request to the Field Office
requesting approval of the new date. If the Field Offices approves the revision, the revised
dates shall be reflected in the Original - All Funds Obligated column when the next
Performance and Evaluation Report is submitted.
Actual - All Funds Expended. When all funds are expended for a development or HA-wide
activity, enter the quarter ending date that this occurred in the Actual column. When all
funds have been expended for a specific grant, the HA shall complete Parts I, II, and III, mark
the box, Final Performance and Evaluation Report, and submit to the Field Office.
Reasons for Revised Target Dates. Explain any revisions to the target dates for fund
obligation or expenditure by specifying the delay outside of the HA’s control, where the HA
has self-issued a time extension, or the date on which HUD approved a revised target due
to delays within the HA’s control.

Page iii

Previous edition is obsolete

form HUD-52837 (9/98)
ref Handbook 7485.3