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Neighborhood Stabilization Program (NSP)
Program Income (PI) Report
Please complete the shaded areas.
Section I - NSP Grantee Information
1. Grantee Name NSP Grant Number Date Report Ending Qtr.
General Information
2. 3. 4.
City of San Juan Capistrano 12-NSP-0002 12/12/2009 6/30/2010
5. Grantee Address 6. Preparer Name and Address
Town of Richard Cranis'
123 Binky's Hideout Circle
Richard Crani, CA 00001
Email: dphillips@co.yuba.ca.us Email:
Phone Number: 900-749-5460 x777 Phone Number:
Section II - NSP Program Income Earned This Quarter
9. NSP Bank Interest 10. NSP PI Income
7. Activity Location / Site 8. NSP PI Income
Earned Earned
Income Earned
1 1800 3rd St, Sac, CA $25,000
2 1801 3rd St, Sac, CA $25,001
3 1802 3rd St, Sac, CA $25,002
4 1803 3rd St, Sac, CA $25,003 $10,000 $110,006
5
6
7
Section III - Status / Disposition of NSP PI Funds
13. PI Used/ Obligated
14. NSP PI
11. NSP Activitiy 12. Activity Location / Site for NSP This Quarter
Used/ Obligated
Activity Delivery
(03.D) Activity Delivery - Public Facilities and Improvement
$58,000 $5,000 $63,000
Activity - Used/ Obligated
1 1800 3rd St, Sac, CA
(General)
(05PD) Activity Delivery - Screening for Lead Based
2
Paint/Lead Hazards
1801 3rd St, Sac, CA $5 $4,500 $4,505
3 $0
(03HD) Activity Delivery - Solid Waste Disposal
4
Improvements
1802 3rd St, Sac, CA $566 $566
(05JD) Activity Delivery - Fair Housing Activities (Subject
5
to Pub. Serv. Cap)
$500,000 $500 $500,500
6 (05GD) Activity Delivery - Battered and Abused Spouses 1803 3rd St, Sac, CA $0
7 (21A.) General Program Administration $10,000 $10,000
Totals $568,571 $10,000 $578,571
Section IV - Balance Calculation of NSP PI Funds
Balance
15. Previous Net NSP 16. NSP PI Earned This 17. NSP PI Used/ 18. Remitto 19. Net NSP PI Balance
PI Balance Quarter Obligated This Quarter HCD this Quarter
$624,250 $110,006 $578,571 $45,679 $110,006
20. Comment asdfasdfasfdasdfa
As an Authorized Signator of the grantee, I certify to the best of my knowledge and belief the accuracy of this document as well as
21. Certification: all attachments were prepared according to the terms and conditions of all standard agreement exhibits.
Signature
Name: Date: 7/1/2009
Signature: Title:
11/22/2011
Instructions:
Section I - NSP Grantee Information
1. Grantee Name: Input the name of your entity (City of, County of, Town of, etc...).
2. NSP Grant Number: Input the NSP grant/ contract number.
3. Date Prepared: Input the date this report was prepared in MM/DD/YYYY format.
4. Report Ending Qtr.: Please select this report's ending quarter date from the drop-down menu.
5. Grantee Address: Input the name of your: entity, address, email address, and phone number.
6. Preparer Name and Address: Input the preparer's: name, address, email address, and phone number.
Section II - NSP Program Income Earned THIS Quarter.
7. Activity Location/ Site: Input specific location (address, floor, room #, etc…) where this activity occurred.
8. NSP PI Income: Input the amount of Program Income earned from this location during the quarter being reported.
9. NSP Bank Interest Earned: Input the total amount of NSP-related interest earned during the quarter being reported.
10. Auto-fill.
Section III - Status/ Disposition of NSP PI Funds.
11. NSP Activity: Select the NSP activity from the drop-down menu.
12. Activity Location/ Site: Input specific location (address, floor, room #, etc…) where this activity occured.
14. Auto-fill.
Section IV - Balance Calculation of NSP PI Funds.
15. Previous Net NSP PI Balance: Input the dollar amount from box 19 of the previous NSP Program Income Report.
16 & 17. Auto-fill.
18. Remit to HCD (Auto-fill): This is the amount of NSP Program Income funds to be returned to the HCD CDBG Program.
19. Auto-fill.
20. Comment: Enter any comments/ notes here.
10.01.09
Neighborhood Stabilization Program (NSP)
Program Income (PI) Report
Instructions:
Section I - NSP Grantee Information
1. Grantee Name: Input the name of your entity (City of, County of, Town of, etc...).
2. NSP Grant Number: Input the NSP grant/ contract number.
3. Date Prepared: Input the date this report was prepared in MM/DD/YYYY format.
4. Report Ending Qtr.: Please select this report's ending quarter date from the drop-down menu.
5. Grantee Address: Input the name of your: entity, address, email address, and phone number.
6. Preparer Name and Address: Input the preparer's: name, address, email address, and phone number.
Section II - NSP Program Income Earned THIS Quarter.
7. Activity Location/ Site: Input specific location (address, floor, room #, etc…) where this activity occurred.
8. NSP PI Income: Input the amount of Program Income earned from this location during the quarter being reported.
9. NSP Bank Interest Earned: Input the total amount of NSP-related interest earned during the quarter being reported.
10. Auto-fill.
Section III - Status/ Disposition of NSP PI Funds.
11. NSP Activity: Select the NSP activity from the drop-down menu.
12. Activity Location/ Site: Input specific location (address, floor, room #, etc…) where this activity occured.
13. PI Used/ Obligated for NSP This Quarter - Activity: Input the amount of NSP Program Income funds used/ obligated towards the cost
of this activity during the quarter being reported.
13. PI Used/ Obligated for NSP This Quarter - Activity Delivery: Input the amount of NSP Program Income funds used/ obligated towards
the cost of this activity during the quarter being reported.
13. PI Used/ Obligated for NSP This Quarter - General Admin: Input the amount of NSP Program Income funds used/ obligated towards
the cost of this activity during the quarter being reported.
14. Auto-fill.
Section IV - Balance Calculation of NSP PI Funds.
15. Previous Net NSP PI Balance: Input the dollar amount from box 19 of the previous NSP Program Income Report.
16 & 17. Auto-fill.
18. Remit to HCD (Auto-fill): This is the amount of NSP Program Income funds to be returned to the HCD CDBG Program.
19. Auto-fill.
20. Comment: Enter any comments/ notes here.
21. Certification: After verifying all information contained in this report is correct, the Authorized Signer must fill out this section and sign
before submitting to the State CDBG - NSP team.
10.01.09
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