Disbursement Request Form by ColleenEynon


									                                                                           Disbursement Request Form
                                                              (Please include a detailed invoice and any required forms/documentation)

                                                                                Anoka County Use Only
        Date Received:                                      AC Project Number:                     HUD Activity Number:                        HUD Voucher Number:

City/Agency:                                                                                                                   Payment Requested for:

Payment Address:                                                                   Project Title:
                                                                                   Funding Year:

Contact Information:                                                                      Original                       Total
Name:                                                                                   Grant Amount               Previous Requests            Amount This Draw                New Balance

                                                                               Accomplishment Data:
                                          (Total persons, beneficiaries and/or units served by this project* - THIS SECTION MUST BE COMPLETED)

     Total                                             Income                                          Female Head of            Seniors            Severely      Performance Measurements
  Beneficiaries       Extremely Low            Low              Moderate               Over              Household            (62 and older)        Disabled           New              Improved

                                   Single Race                                                                                Multi-Race                                             Other
                                                 Total                   Total                  Total                 Total                Total               Total
                  Total                     American Indian        Native Hawaiian          American Indian           Asian          African American    American Indian
Total            Black /         Total            or                      or                     and                   and                  and                 and                   Total
White      African American      Asian       Alaska Native         Pacific Islander            White                  White                White         African American       Other Multi-Race

Note below: Total Hispanic in each race category

                        *NOTE: Actual participant surveys must be retained in your office for a minimum of 5 years. Please do not submit surveys with this request.
Mail completed and signed requests to:                  Questions, please call:                     Date:                                          Signature:
 Anoka County Community Development, STE 700                 Kristina Hayes
 2100 3rd Avenue                                             763-323-5707
 Anoka, MN 55303-5024
                                                                                                                                                                 AC Disbursement Request Form – 10/11/07
                                                   Disbursement Request Form Directions
             (Please be sure to complete the entire form including accomplishment data as well as signing/dating when done.)

“Anoka County Use Only” box: Community Development staff will insert the information needed.

Insert:    -City/Agency (name of entity who applied for and received CDBG funding);
           -Payment Address (current address where reimbursement is to be mailed); and,
           -Contact Information: (name, title and phone number of person completing the reimbursement request).

Insert:    -Project Title (as listed on project application); and,
           -Funding Year (see application - the program year for which funds were allocated).

Insert:    -Original Grant Amount (total CDBG funds awarded at start of project),
           -Total of Previous Requests (total of funds already reimbursed to the agency for this project)
           -Amount this Draw (gross amount for this reimbursement request); and,
           -New Balance (the Original Grant Amount minus Total Previous Requests minus Amount This Draw).

The “Accomplishment Data” section must be completed in order for a reimbursement to be made. Your intake form/s or Participant Survey/s, if
properly filled out, should provide this data. Remember, per HUD regulations, the data reported must be for the period covered and is required to be
completed at the time of the draw. Actual Participant Survey’s must be retained by your organization for a minimum of 5 years after the end of the
program year. Please do NOT submit participant surveys with this Disbursement Request.

-Total Beneficiaries: total of those households that benefited from the CDBG portion of funding for this project;
-Income: “Very Low” – participant is at or below 30% of median income as adjusted for size of household;
           “Low” – participant is between 31% and 50% of median income as adjusted for size of household;
           “Moderate” – participant is between 51% and 80% of median income as adjusted for size of household.
          “Over” – participant whose income is above Section 8 low income limits.
-Female Head of Household: a married or unmarried female who maintains a household for a dependent, or non-dependent relative, and provides
                                more than half of the dependent’s financial support.
-Total Seniors: total number of beneficiaries who are seniors. A senior, per HUD’s definition, is a person 62 years or older.
-Total Severely Disabled: total number of beneficiaries who are severely disabled. Severely disabled, per HUD’s definition, is a participant who:
                         1) uses a wheel chair or another special aid for 6 months or longer; or
                         2) is unable to perform one or more functional activities (such as seeing, hearing, having one’s speech understood, lifting
                             and carrying, walking up a flight of stairs, and walking); or needs assistance with activities of daily living (such as getting
                             around inside the home, getting in or out of bed or a chair, bathing, dressing, eating or toileting); or is unable to perform
                             instrumental activities of daily living (such as going outside the home, keeping track of money or bills, preparing meals,
                             doing light housework and using the telephone); or
                         3) is prevented from working at a job or doing housework; or
                         4) has a selected condition including autism, cerebral palsy, Alzheimer’s disease, senility, dementia or mental retardation; or
                         5) is under 65 years of age and is covered by Medicare or receives Supplemental Security Income (SSI).
-Performance Measurements: total number of clients that were new to your agency OR the total that received improved access or services. This
   number should equal the total beneficiaries.
-Single Race/Multi-Race/Other: the beneficiaries should be placed into appropriate race categories according to the info they supplied on their
                                   intake forms/participant surveys. The sum total of all race categories should match the total number of beneficiaries.
-Total Hispanic: HUD considers Hispanic to be an ethnicity not a race so a Hispanic beneficiary should, on their intake/survey, also select a race
                  category. You, in turn, need to insert on the reimbursement request the total number of Hispanics in each race category.

Be sure to date and sign the request prior to submitting it for payment, and attach a detailed invoice and all required forms/documentation (i.e.,
Performance Measurement, Davis Bacon reporting forms, etc.) with each Disbursement Request. Incomplete forms and forms missing required
information will not be processed until all requested information is received.

  Supporting documentation must be retained and maintained by your office for a minimum of 5 years following the close of the project.
          Failure to keep accurate and appropriate documentation may result in the repayment of project funds to HUD.

Send the completed, signed request and any required forms/documentation to: Anoka County Community Development, STE 700
                                                                            ATTN: Kristina Hayes, CDBG Assistant
                                                                            2100 3rd Avenue
                                                                            Anoka, MN 55303-5024

          If you have questions or want an electronic version of this form, contact Kristina at 763-323-5707 or kristina.hayes@co.anoka.mn.us
                                                                         Thank you!

                                                                                                                  AC Disbursement Request Form Directions - 4/09

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