HUD Form 40156 Attachment C Community Development Block Grant - Recover

U.S. Department of Housing and Urban Development
Community Planning and Development
OMB Approval No. 2506-0193 (exp 1/31/2015)

Attachment: C

Community Development Block Grant – Recovery (CDBG-R) Program
Grantee Closeout Certification

Grantee Name:

Grant Number:

The Grantee hereby certifies that: (1) the grant as described in the approved application has been performed in
accordance with the terms and conditions of the executed Grant Agreement and applicable CDBG-R Grant Award and
that there are no known outstanding programmatic or financial issues; and (2) all data provided below fairly reflects
costs and sources of funds of the CDBG-R grant and are taken from HUD-approved reports and other project-related
documents.
1. Grant amount authorized.

$ ___________

2. Cumulative grant funds disbursed.

$ ___________

(Grantee should draw down amounts for any final audit costs
or unsettled third party claims. Any such amounts not subsequently disbursed
must be immediately reimbursed to HUD.)

3. Grant funds recaptured previously

$ ___________

4. Balance of grant funds to be recaptured.

$ ___________

(These funds will be recaptured by HUD in order for the funds to be returned to the U.S. Treasury.)

_____________________________________________
Grantee Authorized Representative’s Signature and Date

_________________________________
CPD Division Director Signature and Date

____________________________________
Typed Name of Signatory

________________________________
Typed Name of Signatory

____________________________________
Title

_________________________________
Title

The above signature by HUD signifies approval of grant closeout.

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HUD Form 40156 (1/2012)