HUD Form 40175 Attachment B Community Development Block Grant - (CDBG)

U.S. Department of Housing and Urban Development

Community Planning and Development

Community Development Block Grant – (CDBG) Entitlement Program

Attachment B

Grantee Closeout Certification

Grantee Name:

Grant Number:

The Grantee hereby certifies that: (1) the grant as described in the approved application has been performed in accordance with the terms and conditions of the executed Grant Agreement and that there are no known outstanding programmatic or financial issues; and (2) all data provided below fairly reflects costs and sources of funds of the CDBG grant and are taken from HUD-approved reports and other project-related documents.

1. Grant amount $ ___________

2. Cumulative grant funds disbursed $ ___________

(Grantee should draw down amounts for any final audit costs

or unsettled third-party claims. Any such amounts not subsequently disbursed

must be immediately reimbursed to HUD.)

3 Previously-recaptured grant funds $ ___________

4. Balance of grant funds. $ ___________

(These funds will be recaptured by HUD.)

______________________________________ _________________________________

Grantee Authorized Representative’s Signature CPD Division Director’s Signature

____________________________________ ________________________________

Typed Name of Signatory Typed Name of Signatory

____________________________________ _________________________________

Title Title

____________________________________ _________________________________

Date Date

The above signature by HUD signifies approval of grant closeout.

Note: Any false statements knowingly or deliberately made are subject to civil or criminal penalties under Section 1001 of Title 18 of the U.S. Code.

HUD Form 40175