Annual Statement / Performance and Evaluation Report
Part I: Summary Capital Funds Program (CFP)
HA Name
U.S. Department of Housing and Urban Development Office of Public and Indian Housing
OMB Approval 2577-0157 (Exp. 3/31/2002)
Capital Funds Project Number
FFY of Approval
SAMPLE HOUSING AUTHORITY
[X] Original Annual Statement [ ] Reserve for Disasters/Emergencies [ ] Final Performance and Evaluation Report Line No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Total Non-CFP Funds 1406 1408 1410 1411 1415 1430 1440 1450 1460 1465.1 1470 1475 1485 1490 1492 1495.1 1499 1501 1502 Operations (May not exceed 20% of line 20 for PHAs with 250 or more Units) Management Improvements (May not exceed 20% of line 20) Administration (May not exceed 10% of line 20) Audit Liquidated Damages Fees and Costs Site Acquisition Site Improvement Dwelling Structures Dwelling Equipment - Nonexpendable Nondwelling Structures Nondwelling Equipment Demolition Replacement Reserve Moving to Work Demonstration Relocation Costs Mod Used for Development Activities Collaterization or Debt Service Contingency (may not exceed 8% of line 20) Summary by Development Account
CFFP Financing Proceeds
[ ] Revised Annual Statement/Revision Number # [ ] Performance and Evaluation Report for Program Year Ending---------
Total Estimated Cost Original Revision # Revised (2)
Total Actual Cost (2) Obligated Expended
$0 $0 $0 $0 $0 $150,000 $0 $0 $1,206,319 $0 $0 $0 $0 $0 $0 $0 $0 $238,109 $1,594,428.00
Amount of CFFP Proceeds (Sum of lines 2 - 19) Amount of line 20 Related to LBP Activities Amount of line 20 Related to Section 504 Compliance Amount of line 20 Related to Security Amount of line 20 Related to Energy Conservation Measures
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00
(1) To be completed for the Performance and Evaluation Report or a Revised Annual Statement. Signature of Executive Director and Date
(2) To be completed for the Performance and Evaluation Report. Signature of Public Housing Director/Office of Native American Programs Administrator and Date
Draft - Version 2.0 Subject to Change without Notice
Annual Statement / Performance and Evaluation Report Part II: Supporting Pages Capital Funds Program: Proposed Loan Funds
Development Number / Name HA - Wide Activities General Description of Major Work Categories Development Account Number Quantity
U.S. Department of Housing and Urban Development Office of Public and Indian Housing
OMB Approval 2577-0157 (Exp. 3/31/2002)
Total Estimated Cost Original Revised (1)
Total Actual Cost Status of Proposed Work (2) Funds Obligated (2) Funds Expended (2)
PHA Wide PHA Wide PHA Wide PHA Wide PHA Wide PHA Wide
1406 Operations 1408 Management Improvements 1410 Administration 1411 Audits 1415 Liquidated Damages 1430 Fees and Cost CLERK OF WORKS A & E Fees Financing Fees Total 1430
1406 1408 1410 1411 1415 1430
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00
$0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$30,000.00 $100,000.00 $20,000.00 $150,000.00 1440 1490 1499 1501 $207,938.00 $30,171.00 $238,109.00 $388,109 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00
PHA Wide PHA Wide PHA Wide PHA Wide
1440 SITE ACQUISITION 1490 REPLACEMENT RESERVE 1499 MOD USED FOR DEVELOPMENT 1501 Collaterization or Debt Service Capitalized Interest Debt Service Reserve Total 1501
SUBTOTAL
$0.00 $0
$0.00 $0
$0.00 $0
FL29P016-001
Development #1
1450 Site Improvements 1460 Dwelling Structure ADDITIONAL MASTERED LOCKS INSTALL NEW VINYL FLOOR TILE TERMITE TREATMENT REPLACE ROOF REPLACE OR INSTALL NEW SCREEN DOORS REPAIR TERMITE WOOD DAMAGE EXTERIOR PAINTING Total 1460 1465 Dwelling Equipment 1470 Non-Dwelling Structures
1450 1460 48 Units 48 Units 48 Units 12 Buildings 48 Units 48 Units 12 Buildings
$0.00
$0.00
$0.00
$0.00
$5,000.00 $112,500.00 $36,000.00 $246,300.00 $75,000.00 $19,200.00 $43,112.00 $537,112.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00
1465 1470
$0.00 $0.00
Page 2 of 5
Draft - Version 2.0 Subject to Change without Notice
Annual Statement / Performance and Evaluation Report Part II: Supporting Pages Capital Funds Program: Proposed Loan Funds
Development Number / Name HA - Wide Activities General Description of Major Work Categories Development Account Number Quantity
U.S. Department of Housing and Urban Development Office of Public and Indian Housing
OMB Approval 2577-0157 (Exp. 3/31/2002)
Total Estimated Cost Original Revised (1)
Total Actual Cost Status of Proposed Work (2) Funds Obligated (2) Funds Expended (2)
1475 Non-Dwelling Equipment 1485 DEMOLITION COSTS 1495 RELOCATION COST Total Cost for Development #1
FL29P016-002 Development #2
1475 1485 1495
$0.00 $0.00 $0.00 $537,112.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
1450 Site Improvements 1460 Dwelling Structure ADDITIONAL MASTERED LOCKS REPLACE ROOF REMOVE ATTIC FANS EXTERIOR PAINTING/STUCCO Total 1460 1465 Dwelling Equipment 1470 Non-Dwelling Structures 1475 Non-Dwelling Equipment 1485 DEMOLITION COSTS 1495 RELOCATION COST Total Cost for Development #2
FL29P016-003 Development #3
1450 1460 100 Units 8 Buildings 8 Buildings 8 Buildings
$0.00
$13,600.00 $180,000.00 $10,625.00 $160,000.00 $364,225.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
1465 1470 1475 1485 1495
$0.00 $0.00 $0.00 $0.00 $0.00 $364,225.00
$0.00
$0.00
1450 Site Improvements 1460 Dwelling Structure ADDITIONAL MASTERED LOCKS INSTALL NEW VINYL FLOOR TILE BATHROOM RENOVATION REPLACE ROOF REPLACE INTERIOR DOORS W/WO FRAMES REPLACE EXTERIOR DOORS W/WO FRAMES REPLACE OR INSTALL NEW SCREEN DOORS
1450 1460 60 Units 60 Units 60 Units 60 Units 60 Units 60 Units 60 Units
$0.00
$0.00
$0.00
$0.00
$8,000.00 $57,500.00 $20,000.00 $77,250.00 $18,200.00 $28,000.00 $24,000.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Page 3 of 5
Draft - Version 2.0 Subject to Change without Notice
Annual Statement / Performance and Evaluation Report Part II: Supporting Pages Capital Funds Program: Proposed Loan Funds
Development Number / Name HA - Wide Activities General Description of Major Work Categories Development Account Number Quantity
U.S. Department of Housing and Urban Development Office of Public and Indian Housing
OMB Approval 2577-0157 (Exp. 3/31/2002)
Total Estimated Cost Original Revised (1)
Total Actual Cost Status of Proposed Work (2) Funds Obligated (2) Funds Expended (2)
EXTERIOR PAINTING/STUCCO PROVIDE NEW UNIT SIGNS Total 1460 1465 Dwelling Equipment 1470 Non-Dwelling Structures 1475 Non-Dwelling Equipment 1485 DEMOLITION COSTS 1495 RELOCATION COST Total Cost for Development #3 1465 1470 1475 1485 1495
15 Buildings 60 Units
$70,832.00 $1,200.00 $304,982.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304,982.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
Page 4 of 5
Draft - Version 2.0 Subject to Change without Notice
Annual Statement / Performance and Evaluation Report Part III: Implementation Schedule Capital Fund Program: Proposed Loan Funds
Development Number / Name HA - Wide Activities All Funds Obligated (Quarter Ending Date) Original Revised (1) Actual (2)
U.S. Department of Housing and Urban Development Office of Public and Indian Housing
OMB Approval No. 2577-0157 (Exp. 3/31/2002) All Funds Expended (Quarter Ending Date) Original Revised (1) Actual (2) Reasons for Revised Target Dates (2)
PHA-Wide Development #1 Development #2 Development #3
05/31/04 09/16/05 04/30/05 04/30/05
09/16/04 09/16/06 08/31/06 08/31/06
To be completed for the Performance and Evaluation Report or a Revised Annual Statement. Signature of Executive Director and Date
(2) To be completed for the Performance and Evaluation Report. Signature of Public Housing Director/Office of Native American Programs Administrator and Date
Draft - Version 2.0 Subject to Change without Notice