Form HUD 4052 HUD 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 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 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.
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.
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.
3. Date. Enter the submission date of the report.
4. Reporting period. Indicate the period covered by the report.
5. Activity number. Enter the number you assigned to the activity in your application.
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.
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.
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 household. 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.

Previous editions are obsolete.

For example:
16 total
9-d,f
3-d
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.
For example:
20 total
6-a 1234.12
5-b 3456.34
2-b 4567.46
7-e 8900.78
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 relocation) 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.
Definitions
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, Southeast 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.
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.
f. American Indian/Alaskan Native and White
g. American Indian/Alaskan Native and Black/African American
h. Black/African American and White
i. Asian and White
j. Other
k. Female headed households
l. Ethnicity: Hispanic/Latino. A person of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, regardless of race.
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.
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
% persons
S/B Slums and blight
U/N Urgent Need
10. Schedule status. Indicate by “yes”or “no” whether each activity on schedule. If a
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.
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.
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,
Name and Address of Grantee

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.
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.
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 subtracted from the total estimated cost of an activity.
15. Program income. If there is any program income earned or planned to be earned,
check the box and attached a separate sheet describing:
a. the source of program incomes;
b. schedule of expected receipts; and
c. the amount of funds.
16. Narrative requirements. On a separate sheet
a. Affirmative Fair Housing. Describe in narrative, the actions taken to affirmatively
further fair housing. See 24 CFR 5870.904(c).
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.
ii. Program assessment. In narrative form, assess the relationship of your program 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.
iii. Future changes. Given your experience with this program, indicate what
changes, if any, you would make in any future program.
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

Previous editions are obsolete.

form HUD-4052 (5/16)

CDBG Small Cities
Performance Assessment Report (PAR)
1. Grantee

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

OMB Approval No. 2506-0020
(exp.6/30/2016)

3. Date

4. Reporting Period

From:
5. Activity 6. Name and Location
Number

7. Accomplishments

8. Direct Benefit

9. National
Objective

Cumulative Program Income (See attached sheet)
Previous editions are obsolete.

10. Schedule
Status

11. Budgeted
Amount
(Thousands)

Totals $
Page ____ of ____

To:

12. Funds
Expended
(Thousands)

13. Unliquidated 14. Unobligated
Obligations
Balance
(Thousands)
(Thousands)

$

$

$
form HUD-4052 (5/16)