HUD 50075.1 Annual Statement Performance and Evaluation Report

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0157
Expires 11/30/2023

“Public reporting burden for this collection of information is estimated to average 2.2 hours including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing

and reviewing the collection of information.. The information requested is required to obtain a benefit. This form is used to verify allowable and reasonableness of grant expenses. There are no assurances of confidentiality. HUD
may not conduct or sponsor, and an applicant is not required to respond to a collection of information unless it displays a currently valid OMB control number. Comments regarding the accuracy of this burden estimate and any
suggestions for reducing this burden can be sent to the Reports Management Officer, Office of Policy Development and Research, REE, Department of Housing and Urban Development, 451 7th St SW, Room 4176, Washington,
DC 20410-5000. When providing comments, please refer to OMB Approval No. 2577-0157.
FFY of Grant:
FFY of Grant Approval:

Grant Type and Number
Capital Fund Program Grant No:
Replacement Housing Factor Grant No:
Date of CFFP:

PHA Name

vision no:

Type of Grant

Reserve for Disasters/Emergencies
Original Annual Statement
Performance and Evaluation Report for Period Ending:

Line

Summary by Development Account
3

1

Totaal non-CFP Funnds

2

1
1406
Operations (may not exceed 20% of line 15)

3

1408 Management Improvem
ments

4

1410 Administration
Adm
(may not exceed 10% of line 15)

5

1480 General Capital Activity

6

1492 Moving to Work Dem
monstration

7

1

8

1503 RAD-CFP

9

1504 RAD Investment Activity

10

1505 RAD-CPT

11

9000 Debt Reserves

12

99001 Bond Debt Obligation pai
paid Via Syst m off Di c

13

Hard
9002 Loan Debt Obligation paid Via System of Direct Payment

14

9900 Post Audit Adjustment

Revised Annual Statement (re
Final Performance and Evaluation Report
Original

Total Estimated Cost
Revised2

Obligated

Totaal Actual Cost 1
Expended

Debt Service Paid by PHA

1505
1
To be completed for the Performance and Evaluation Report.
RAD-CPT
2
To be completed for the Performance and Evaluation Report or a Revised Annual Statement.
3
PHAs with under 250 units in management may use 100% of CFP Grants for operations.

Page 1

form HUD-50075.1 (07/2014)

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0157
Expires 11/30/2023

Part I: Summaary
PHA Name:

FFY of Grant:
FFY of Grant Approval:

Grant Type and Number
Capital Fund Program Grant Noo:
Replacem
ment Housing Factor Grant Noo:
Date of CF
C FP
P:

Typpe of Grannt

Original Annual Statemennt

Reserve for Disasterrs/Emergencies

Performance and Evaluation Report for Period Ending:
Line
Summary by
b Developm
ment Account
15

Revised Annual Statement (revision no:
Final Performance and Evaluation Report
Original

Total Estimated Cost

Revised 2

Obligated

Totaal Actual Co
C st 1

Expended

Am
mount of Annual Grant:: (sum of lines 2 - 14)

16

Amount of line 115 R
A
Related to LBP Activities

17

Amount of line 15 R
Related S
Sect. 504, ADA, and Fair Housing Act Activities.

18

Amount of line 115 R
A
Related to Security - Soft Costs

19

Amount of line 115 R
A
Related to Security - Hard Costs

20

Amount of line 15 Related to Energy Conservation Measures

Signature of Executive Director *

Date

Signature oof Publiic Hoousing D
Directoor

Date

* I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. WARNING: Anyone who knowingly submits a false claim or
makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287,
1001, 1010, 1012, 1014;
31 U.S.C. §3729, 3802).
1
2
3

Page 2

To be completed for the Performance and Evaluation Report.
To be completed for the Performance and Evaluation Report or a Revised Annual Statement.
PHAs with under 250 units in management may use 100% of CFP Grants for operations.

form HUD-50075.1 (07/2014)

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

Part II: Supporting Pages

PHA Name:

Development Number
Name/PHA-Wide
Activities

1
2

Page 3

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0157
Expires 11/30/2023

Grant Type and Number
Capital Fund Program Grant
No: CFFP (Yes/ No):
Replacement Housing
Factor Grant No:

General Description of Major Work
Categories

Development
Account No.

Federal FFY of Grant:

Quantity

Total Estimated Cost

Total Actual Cost

Original

Funds
Obligated2

Revised 1

Status of Work

Funds
Expended2

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

form HUD-50075.1 (07/2014)

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

Part II: Supporting Pages

PHA Name:

Development Number
Name/PHA-Wide
Activities

1
2

Page 4

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0157
Expires 11/30/2023

Grant Type and Number
Capital Fund Program Grant
No: CFFP (Yes/ No):
Replacement Housing
Factor Grant No:

General Description of Major Work
Categories

Development
Account No.

Federal FFY of Grant:

Quantity

Total Estimated Cost

Total Actual Cost

Original

Funds
Obligated2

Revised 1

Status of Work

Funds
Expended2

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

form HUD-50075.1 (07/2014)

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0157
Expires 11/30/2023

Part III: Implementation Schedule for Capital Fund Financing Program

PHA Name:

Federal FFY of Grant:

Development Number
Name/PHA-Wide
Activities

1

Page 5

All Fund Obligated
(Quarter Ending Date)
Original
Obligation End
Date

Actual Obligation
End Date

All Funds Expended
(Quarter Ending Date)
Original Expenditure
End Date

Reasons for Revised Target Dates 1

Actual Expenditure End
Date

Obligation and expenditure end dated can only be revised with HUD approval pursuant to Section 9j of the U.S. Housing Act of 1937, as amended.

form HUD-50075.1 (07/2014)

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0157
Expires 11/30/2023

Part III: Implementation Schedule for Capital Fund Financing Program

PHA Name:

Federal FFY of Grant:

Development Number
Name/PHA-Wide
Activities

1

Page 6

All Fund Obligated
(Quarter Ending Date)
Original
Obligation End
Date

Actual Obligation
End Date

All Funds Expended
(Quarter Ending Date)
Original Expenditure
End Date

Reasons for Revised Target Dates 1

Actual Expenditure End
Date

Obligation and expenditure end dated can only be revised with HUD approval pursuant to Section 9j of the U.S. Housing Act of 1937, as amended.

form HUD-50075.1 (07/2014)