Closeout Forms by wantyou

VIEWS: 0 PAGES: 5

									                                   NORTH CAROLINA DEPARTMENT OF COMMERCE
                                          COMMERCE FINANCE CENTER




                                     Industrial Development Fund
                                  (Including Utility Account and Clean Water Bonds proceeds)


                                   CLOSEOUT PERFORMANCE REPORT

 Grantee:                                                                      Address:


 Grant Number:


          Check if the grant included a commitment by a specific company to create jobs?
          Project Company:

 Project Name:

 The grantee's authorized official representative must certify the following:

          a.      Project activities have been completed as proposed in the approved/amended application for
                  IDF/CWB funding of this project;
          b.      There are no unsettled third-party claims for activities funded in whole or in part with IDF/CWB
                  funds; and
          c.      To the best of his/her knowledge and belief, data in this report is true and correct.




                     Signature of Authorized Representative                                    Title




                   Typed Name of Authorized Representative                                     Date



 Preparer Information

 Name of person that prepared this report:

          Telephone Number:
          E-Mail Address:




35cf954a-f09e-4de5-83f0-38735bb917851Closeout Forms (8/01)   IDF Closeout Performance Report                   Page 1 of 4
                                                CERTIFICATE OF COMPLETION

 1. Grantee:                                                                                      2. Grant Number:


 3. Project Name:                                                                                 4. Grant Amount:



                                                                5. Final Statement of Costs


                                      To be completed by Grantee     For CFC use         To be completed by Grantee

 Use of Project Funds                    IDF/CWB funds                  ONLY            Local Funds (Match)
                                      Budgeted         ACTUAL         Approved           Budgeted       ACTUAL
                                                                       Costs
                                     Expenditures     Expenditures                      Expenditures   Expenditures
 Water
 Sewer
 Gas
 Electric
 Rail
 Engineering
 Contingency
 Loan
 Other
                     TOTALS


                                            6. Computation of Grant Balance and Grant Amount Payable

 (1) Grant amount per Grant Agreement                                                                                 $   -
 (2) Actual IDF/CWB expenditures (from section 5 above)                                                               $   -
 (3) Unutilized grant to be canceled (line 1 minus line 2)                                                                    $          -
 (4) Total IDF/CWB grant funds received from CFC
 (5) Actual IDF/CWB expenditures (from section 5 above)                                                               $   -
 (6) Unexpended IDF/CWB funds received                                                                                        $          -
 (7) Local funds committed to the project                                                                             $   -
 (8) Actual local expenditures (from section 5 above)                                                                 $   -
 (9) Unexpended Local Funds (line 7 minus line 8)                                                                             $          -
 (10) Balance of grant payable (line 6 + line 9)                                                                              $          -

                                                    7. Unpaid Costs and Unsettled Third Party Claims
 Are there any unpaid costs or unsettled third party claims against the recipient’s grant. Type "yes" or "no"
   If yes, describe the circumstances and amounts involved.




35cf954a-f09e-4de5-83f0-38735bb917851Closeout Forms (8/01)   IDF Closeout Performance Report                                      Page 2 of 4
                                                             8. Certification of Private Investment
       At the time of application,                                                         projected that it would invest
      as a result of this project.
                                                       has certified that it invested                           as a result of this project.*
 *The grantee must attach the letter of certification from the company and the company's most current NCUI 101form to this report.


                                                                  9. Certification of Recipient
 It is hereby certified that all activities undertaken by the Recipient with funds provided under the grant agreement identified on page 2
 hereof, have, to the best of my knowledge, been carried out in accordance with the grant agreement; that proper provisions have been
 made by the Recipient for the payment of all unpaid costs and unsettled third party claims identified on page 2 hereof; that the State of
 North Carolina is under no obligation to make any further payment to the Recipient under the grant agreement; and that every other
 statement and amount set forth in this instrument is, to the best of my knowledge, true and correct as of this date.


           Date                            Typed Name and Title of Recipient’s                                Signature of Recipient's
                                               Authorized Representative                                     Authorized Representative


                                                               (Name)


                                                                                                      √
                                                               (Title)



                                                               10. Remarks (For CFC Use Only)




                                                 11. CFC Approval (For CFC Use Only)
 This Certification of Completion is hereby approved. Therefore, I authorize cancellation of the unutilized contract commitment and
 related funds reservation and obligation of $________________, less $________________ previously authorized for cancellation
 (from Section 6, line 6, page 1).

           Date                            Typed Name and Title of Recipient’s                                Signature of Recipient's
                                               Authorized Representative                                     Authorized Representative


                                                               (Name)


                                                        Finance Officer                               √
                                                               (Title)




35cf954a-f09e-4de5-83f0-38735bb917851Closeout Forms (8/01)    IDF Closeout Performance Report                                            Page 3 of 4
                                                  ACTIVITY SUMMARY REPORT

 GRANT NUMBER                                                       PROJECT NAME

 AWARD DATE                                                         DATE ACTIVITIES WERE COMPLETED


                                 Budget                      Amount
        Activity                 Amount                      Expended      Proposed Accomplishments   Actual Accomplishments



             1




             1




             1




             1




             1




             1




35cf954a-f09e-4de5-83f0-38735bb917851Closeout Forms (8/01)    IDF Closeout Performance Report                         Page 4 of 4
Water
Sewer
Gas
Electric
Rail
Engineering
Loan
Other

								
To top