HUD 50075.1 Annual Statement/Performance and Evaluation Report

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0226
Expires 4/30/2011

Part I: Summary
PHA Name:

Grant Type and Number
Capital Fund Program Grant No:
Date of CFFP: ________________________

Type of Grant
Original Annual Statement
Reserve for Disasters/Emergencies
Performance and Evaluation Report for Period Ending:
Line
Summary by Development Account
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18a
18ba

Replacement Housing Factor Grant No:

FFY of Grant:
_____________________
FFY of Grant Approval:

Revised Annual Statement (revision no:
)
Final Performance and Evaluation Report
Total Estimated Cost
Total Actual Cost
Obligated
Original
Revised 2

1

Expended

Total non-CFP Funds
1406 Operations (may not exceed 20% of line 21) 3
1408 Management Improvements
1410 Administration (may not exceed 10% of line 21)
1411 Audit
1415 Liquidated Damages
1430 Fees and Costs
1440 Site Acquisition
1450 Site Improvement
1460 Dwelling Structures
1465.1 Dwelling Equipment—Nonexpendable
1470 Non-dwelling Structures
1475 Non-dwelling Equipment
1485 Demolition
1492 Moving to Work Demonstration
1495.1 Relocation Costs
1499 Development Activities 4
1501 Collateralization or Debt Service paid by the PHA
9000 Collateralization or Debt Service paid Via System of Direct
Payment
1502 Contingency (may not exceed 8% of line 20)
Amount of Annual Grant: (sum of lines 2 – 19)
Amount of line 20 Related to LBP Activities
Amount of line 20 Related to Section 504 Activities
Amount of line 20 Related to Security – Soft Costs
Amount of line 20 Related to Security – Hard Costs
Amount of line 20 Related to Energy Conservation Measures

19
20
21
22
23
24
25

1

To be completed for the Performance and Evaluation Report.
To be completed for the Performance and Evaluation Report or a Revised Annual Statement.
3
PHAs with under 250 units in management may use 100% of CFP Grants for operations.
4
RHF funds shall be included here.
2

Page 1 of 6

form HUD-50075.1 (4/2008)

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
Expires 4/30/2011

Part I: Summary
PHA Name:

Grant Type and Number
Capital Fund Program Grant No:
Date of CFFP: ________________________

Type of Grant
Original Annual Statement
Reserve for Disasters/Emergencies
Performance and Evaluation Report for Period Ending:
Line
Summary by Development Account

Signature of Executive Director

Date

Replacement Housing Factor Grant No:

FFY of Grant:
_____________________
FFY of Grant Approval:

Revised Annual Statement (revision no:
)
Final Performance and Evaluation Report
Total Estimated Cost
Total Actual Cost
Obligated
Original
Revised 2

Signature of Public Housing Director

Page 2 of 6

1

Expended

Date

form HUD-50075.1 (4/2008)

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
Expires 4/30/2011

Part II: Supporting Pages

PHA Name:
Development
Number
Name/PHA-Wide
Activities

Grant Type and Number
Capital Fund Program Grant No:
Replacement Housing Factor Grant No:

General Description of Major Work
Categories

Development
Account No.

Federal FFY of Grant:
CFFP (Yes/ No):

Quantity

Total Estimated Cost

Original

1
2

Revised

Total Actual Cost

1

Funds
Obligated

2

Funds
Expended

Status of Work

2

To be completed for the Performance and Evaluation Report or a Revised Annual Statement.
To be completed for the Performance and Evaluation Report.

Page 3 of 6

form HUD-50075.1 (4/2008)

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
Expires 4/30/2011

Part II: Supporting Pages

PHA Name:
Development
Number
Name/PHA-Wide
Activities

Grant Type and Number
Capital Fund Program Grant No:
Replacement Housing Factor Grant No:

General Description of Major Work
Categories

Development
Account No.

Federal FFY of Grant:
CFFP (Yes/ No):

Quantity

Total Estimated Cost

Original

Revised

Total Actual Cost

1

Funds Obligated
2

1
2

Funds
Expended

Status of Work

2

To be completed for the Performance and Evaluation Report or a Revised Annual Statement.
To be completed for the Performance and Evaluation Report.

Page 4 of 6

form HUD-50075.1 (4/2008)

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
Expires 4/30/2011

Part III: Implementation Schedule for Capital Fund Financing Program
Federal FFY of Grant:

PHA Name:
Development Number
Name/PHA-Wide
Activities

All Fund Obligated
(Quarter Ending Date)
Original Obligation
End Date

1

Actual Obligation
End Date

All Funds Expended
(Quarter Ending Date)
Original Expenditure
End Date

Reasons for Revised Target Dates

1

Actual Expenditure
End Date

Obligation and expenditure end dated can only be revised with HUD approval pursuant to Section 9j of the U.S. Housing Act of 1937, as amended.

Page 5 of 6

form HUD-50075.1 (4/2008)

Annual Statement/Performance and Evaluation Report
Capital Fund Program, Capital Fund Program Replacement Housing Factor and
Capital Fund Financing Program

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
Expires 4/30/2011

Part III: Implementation Schedule for Capital Fund Financing Program
Federal FFY of Grant:

PHA Name:
Development Number
Name/PHA-Wide
Activities

All Fund Obligated
(Quarter Ending Date)
Original Obligation
End Date

1

Actual Obligation
End Date

All Funds Expended
(Quarter Ending Date)
Original Expenditure
End Date

Reasons for Revised Target Dates

1

Actual Expenditure
End Date

Obligation and expenditure end dated can only be revised with HUD approval pursuant to Section 9j of the U.S. Housing Act of 1937, as amended.

Page 6 of 6

form HUD-50075.1 (4/2008)