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Attachment A
Annual Program Income Statement
Reporting Period: July 1, 2010 Through June 30, 2011
1. Provide Information for all Program Income and Recaptured Funds:
State Recipients are required to differentiate between Program Income (PI) and Recaptured Funds due to the fact that 10% of Program Income can be used for
administrative costs, whereas recaptured funds cannot be used for admin. Additionally, the accounting of PI and Recaptured Funds should be separate from Admin
PI Funds. HOME requires that you expend all your PI/Recaptured Funds before drawing down active contract funds. This is true for Admin PI Funds also: HOME
requires that you expend all your Admin PI Funds before drawing down active contract Admin Funds.
Name of HOME Recipient:
Preparer's Name Date Phone
Program Income/Recaptured Financial Summary
Program Income Recaptured Funds Total
1) Beginning balance: $0
2) Amount received during Fiscal Year July 1, 2010 through June 30, 2011: $0
Program Income Recaptured Funds Total
3) Amount Disbursed for units also funded with HOME funds drawn down from HCD
(Do not list projects in page 2): $0
4) Amount Disbursed for units assisted with HOME Program Income or Recaptured
Funds, but not with HOME funds drawn down from HCD (list each project on
page 2): $0
5) Amount Retained for Administrative Funds:
6) Total Program Income/Recaptured Funds expended by the end of the reporting period: $0
7) Balance of Program Income/Recaptured Funds in local account at the end of the reporting period:
$0
Program Income Administrative Funds Summary
Amount of PI Administrative Funds Beginning Balance
Amount of PI Administrative Funds Received this Fiscal Year $0 Go to pages 4 and 5 for
Amount of PI Administrative Funds Expended this Fiscal Year instructions for completing
this form
Balance of PI Administrative Funds Available $0
2010/2011 Attachment A 1 of 5 HOME - 2A (06/07/2011)
Attachment A
Annual Program Income Statement
Reporting Period: July 1, 2010 Through June 30, 2011
Chart 1: Projects funded with HOME Program Income/Recaptured Funds (Do not include projects with HOME funds drawn down from HCD)
Amount Activity
Amount of ADC
Funds
(PI/Recaptured) Total # of
Owner/Project Name Address Activity (PI/Recaptured) Completed
Expended this Expenditures Units
Expended this
Fiscal Year
Fiscal Year
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Total Expenditures (should equal line 4, Total, from page 1): $0
$0
2010/2011 Attachment A 2 of 5 HOME - 2A (06/07/2011)
Attachment A
Annual Program Income Statement
Reporting Period: July 1, 2010 Through June 30, 2011
Chart 2: Program Income Reporting By Household Characteristics
List individually each assisted unit funded with state HOME Program Income/Recaptured Funds but not with HOME funds drawn down from HCD from Chart 1 that
was marked "Complete". Each project marked complete will have the address automatically populated to this page. Indicate the Total HOME Funds in the project
(this may not be the same as the funds expended on this Fiscal Year being reported as additional funds may have been expended in prior Fiscal Years).
For multi-family projects and TBRA, complete a line for each household. For TBRA only, complete the "Monthly Rent" and "Subsidy Amount" columns, again a
house per line.
Monthly Rent (Include Tenant Paid Utilities) Household Data
Number of Monthly % of area Head of Household Household
Address PI Amount Occupancy Tenant Subsidy Rental
Bedrooms Total Rent Gross Median
Contributions Amount Assistance
Income Income Ethnicity Race Size Type
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
% of Area Median Ethnicity Code Size of Household Rental
Number of Bedrooms Code Occupancy Code Race Code (Head of Household) Type of Household Code
Income Code (Head of Household) Code Assistance Code
0 - 0 Bedroom 1 - Tenant 1 - 0-30% Y - Yes HOH is 09 - Vacant Unit 1 - 1 Person 1 - Single/non-Elderly 1 - Section 8
1 - 1 Bedrooms 2 - Owner 2 - 30-50% Hispanic Origin 10 - Manager's Unit 2 - 2 Persons 2 - Elderly 2 - HOME
2 - 2 Bedrooms 3 - Vacant 3 - 50-60% N - No HOH is not 11 - White 3 - 3 Persons 3 - Related/Sngl Parent 3 - Other
3 - 3 Bedrooms 4 - 60-80% Hispanic Origin 12 - Black/African American 4 - 4 Persons 4 - Related/Two Parent 4 - No
4 - 4 Bedrooms 9 - Vacant 13 - Asian 5 - 5 Persons 5 - Other 5 - Vacant Unit
5 - 5 or more Bedrooms 14 - Amrcn Indn/Alskn Ntve 6 - 6 Persons 9 - Vacant Unit
15 - Ntve Hawaiian/Other Pac Islnder 7 - 7 Persons
16 - Amrcn Indn/Alskn Ntve & White 8 - 8 or more Persons
17 - Asian & White
18 - Black/African American 7 White
19 - Amrcn Indn/Alskn Ntve & Black/Afrcn Amr.
20 - Other
2010/2011 Attachment A 3 of 5 HOME - 2A (06/07/2011)
Attachment A
Annual Program Income Statement
Reporting Period: July 1, 2010 Through June 30, 2011
INSTRUCTIONS
Notes:
• All areas marked in blue are fields that will automatically populate based on the data you enter in other fields.
• Name of HOME Recipient: Insert your city or county’s name here.
Program Income/Recaptured Funds Summary
1. Put beginning balance of Program Income and Recaptured funds in each column. The amount in each column should reflect the
ending balance from the prior Fiscal Year.
2. Identify the amount of funds received during the Fiscal Year in both Program Income and Recaptured funds.
3. Enter the amount of Program Income and/or Recaptured funds used with funds from HOME contract.
4. Identify the amount of funds for units assisted with Program Income or Recaptured funds but not with HOME funds drawn down from
HCD.
5. Do not enter. 10% of Program Income received this quarter will automatically populate.
6. Do not enter. Total Program Income/Recaptured funds expended will automatically populate.
Program Income Administrative Funds Summary
• Enter beginning balance of Program Income Administrative Funds. This will be the ending balance from the previous Annual P.I.
Report.
• Program Income Administrative Funds received this Fiscal Year. Do not enter. It will automatically populate from Page 1.
• Enter amount of Program Income Administrative Funds expended in the reported Fiscal Year.
• Balance of Program Income/Recaptured Funds available. Do not enter. It will automatically populate from Page 1.
Chart 1: Projects funded with HOME Program Income/Recaptured Funds but not with HOME funds drawn down from HCD
Provide project information in each column.
Owner/Project Name: Enter name of owner(s) or project name.
Address: Enter address of project location.
Activity: From the drop down menu, enter the project activity.
Activity Funds Expended: Enter amount of expended Program Income/Recaptured Funds from this Fiscal Year.
ADC Funds Expended: Enter amount of Activity Delivery Costs expended. (Leave blank if TBRA.)
Total Expenditure: Do not enter total expenditures will automatically populate.
Number of Units: Enter the number of units.
Completed: is the project complete? Use the drop-down window to indicate "yes" or "no".
2010/2011 Attachment A 4 of 5 HOME - 2A (06/07/2011)
Attachment A
Annual Program Income Statement
Reporting Period: July 1, 2010 Through June 30, 2011
Chart 2: Program Income Reporting by Household Characteristics (Completed Programs)
Address: Do not enter. If the project is complete and you marked it "complete" in Chart 1 the address will automatically populate.
PI Amount: Enter total amount of Program Income. Note: this amount may not be the same as Chart 1 total as additional funds may
have been used in the prior Fiscal Year.
Number of Bedrooms: Enter total number of bedrooms.
Occupancy: Enter the code for occupancy from the chart.
Monthly Rent (Include Tenant Paid Utilities): For TBRA, enter tenant contributions and HOME subsidy amount. The Total Rent column
will automatically populate from the combined totals.
Household Data:
Monthly Gross Income: Enter the monthly gross income
Percent of Area Median Income (AMI). Enter one of corresponding codes listed on the chart.
Head of Household-Ethnicity/Race: Enter one of the codes listed on the chart.
Size of household: Enter one of the codes listed on the chart.
Type of household: Enter one of the codes listed on the chart.
Rental Assistance: Enter of the codes listed in the chart.
END OF DOCUMENT
2010/2011 Attachment A 5 of 5 HOME - 2A (06/07/2011)
Attachment A
Annual Program Income Statement
Reporting Period: July 1, 2010 Through June 30, 2011
2003
2004
2005
2006
2007
P 2008
2009
A 2013
2014
2015
G
E Yes
No
1
0
$0
$0
2010/2011 Attachment A 6 of 5 HOME - 2A (06/07/2011)
Attachment A
Annual Program Income Statement
Reporting Period: July 1, 2010 Through June 30, 2011
First Time Home Buyer Acquistion Only
First Time Home Buyer Subdivision
Owner Occupied Rehabilitation
Rental Rehab Projects
Tenant Based Rental Assistance
Rental Rehab w/o Acquisition
New Construction
Rental New Contruction
P
A
G
E
2
2010/2011 Attachment A 7 of 5 HOME - 2A (06/07/2011)
Attachment A
Annual Program Income Statement
Reporting Period: July 1, 2010 Through June 30, 2011
P
A
G
E
3
2010/2011 Attachment A 8 of 5 HOME - 2A (06/07/2011)
Attachment A
Annual Program Income Statement
Reporting Period: July 1, 2010 Through June 30, 2011
P
A
G
E
4
2010/2011 Attachment A 9 of 5 HOME - 2A (06/07/2011)
Attachment A
Annual Program Income Statement
Reporting Period: July 1, 2010 Through June 30, 2011
P
A
G
E
5
2010/2011 Attachment A 10 of 5 HOME - 2A (06/07/2011)
