Form HUD 9910 HUD 9910 Performance Review

Housing Counseling Program - Biennial Agency Performance Review

HUD 9910.xlsx

Housing Counseling Program - Biennial Agency Performance Review

OMB: 2502-0574

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OMB APPROVAL No.2502-0574 (Exp.11/30/2014)







U.S. Department of Housing and Urban Development







Office of Housing Counseling
















Performance Review







Of a HUD-Approved Housing Counseling Agency or Participating Agency
















Public reporting burden for this collection of information is estimated to average 9.5 hours per initial response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number.







The following information is used to assist HUD in evaluating the managerial and financial capacity of organizations to sustain operations sufficient to implement HUD approved housing counseling programs. The collection of information assists HUD to reduce its own risk from fraudulent activities or supporting inefficient or ineffective housing counseling programs. HUD publishes a web list of HUD approved Housing Counseling Agencies and maintains a toll free housing counseling hotline. Performance reviews help HUD ensure that individuals seeking assistance from these participating agencies can have confidence in the quality of services that they will receive. This information is collected in connection with HUD Housing Counseling Program and will be used by HUD to evaluate participating agencies’ compliance with programmatic requirements. The information is considered sensitive and is protected by the Privacy Act of 1974, which required the records to be maintained with appropriate administrative, technical and physical safeguards to ensure their security and confidentiality. NOTE: Part A will be completed by the HUD Reviewer, based on housing counseling agency performance, and Part B and C (if applicable) will be completed by the housing counseling agency. The agency will self-certify the responses and are subject to verification. HUD may, at its discretion, request clarification or additional information from an agency. The agency may consult with HUD to determine the specific actions needed to complete the form.







Agency Name: HCS ID Number:

















Address:

























Name of Parent Agency, if Applicable: Parent ID Number, if Applicable:

















Reviewer(s): Review Date:



































INSTRUCTIONS: Use this form to record the results of the Performance Review. Check the “Yes,” “No” or “N/A” box for each applicable question.







TO SUPPORT ANSWERS, PROVIDE DETAILED COMMENTS AND DOCUMENTATION, IF APPLICABLE. Housing Counseling Agencies are responsible for the requirements outlined in Parts A and B, and C, if applicable. Housing Counseling Agencies and HUD Reviewers are recommended to review Handbook 7610.1 REV 5, 24 CFR Part 214, and information on HUD's Website at: http://portal.hud.gov/hudportal/HUD?src=/program_offices/housing/sfh/hcc/hcc_home, in support of the most current legislative and programmatic requirements for the Department's Housing Counseling Program.







PART A – Complete by HUD Reviewer(s)







PART B – Complete by Housing Counseling Agency, self-certified by Representative of the Housing Counseling Agency







PART C – Complete by Housing Counseling Agency, self-certified by Representative of the Housing Counseling Agency, (if applicable).






Part A – Complete by HUD Reviewer















GRANT MANAGEMENT COMMENTS







1 Did the agency receive HUD Housing Counseling grants or sub-grants since the last performance review? If yes, answer the questions in this section.
Yes
No
N/A







2 Does the agency have adequate billing procedures in place so that it only bills HUD under a grant agreement for the cost of services in excess of the costs billed to other funding sources or fees charged to the client?
Yes
No
N/A







3 Is the agency maintaining personnel activity reports in compliance with OMB Circular 122? Provide supporting documentation.
Yes
No
N/A







4 Does the grantee or sub-grantee, if applicable, have source documentation of costs (invoices, cancelled checks, salary reports, etc.) to support all request for reimbursements under the HUD Housing Counseling grant?
Yes
No
N/A







5 Are indirect costs assessed to the grant(s)? Obtain copy of approval.
 Yes No N/A







a. If yes, was the indirect cost rate approved by a federal agency?
 Yes No N/A







b. If indirect costs are included in the voucher request(s), are they different
from what was approved?
Yes
No
N/A







6 Is there evidence that the total housing counseling budget reported is accurate and consistent with leveraged funds and program income documented in the grant application, if applicable? Provide support of all leveraged funds.
Yes
No
N/A







7 Do CMS client notes or other client documentation support counselor hours billed and/or reported to the HUD Housing Counseling grant?
Yes
No
N/A







8 Does client and group education client documentation support the average hours for counseling and education activities stated in the grant application work plan?
Yes
No
N/A







9 Is the agency charging the HUD grant only for activities/expenses included in its proposed grant work plan and budget?
Yes
No
N/A







10 Does the agency have documentation to support receipt of leveraged resources cited in the grant application?
Yes
No
N/A







11 Is the agency complying with reporting requirements of the grant agreement?
 Yes No N/A







12 Is the agency complying with its proposed or revised work plan(s) submitted for the grant award(s)?
Yes
No
N/A







MAINTAINING APPROVAL CRITERIA COMMENTS







13 Is the agency functioning as a private or public nonprofit organization or a unit of local, county or state government?
Yes
No
N/A







14 Does the agency have evidence of nonprofit status and tax-exempt status under Section 501(a) pursuant to Section 501(c) of the Internal Revenue Code of 1996 (26 U.S.C. 501(a) and (c))?
Yes
No
N/A







15 If the agency subcontracts for housing counseling services, has the agreement been approved by HUD? Obtain copies.
Yes
No
N/A







16 Is the agency being reviewed an Intermediary, Multi-State Organization or a State Housing Finance Agency? Indicate agency type in comment box at right.
Yes
No
N/A
Agency Type:





















a. If yes, is there a formal agreement between this agency and any affiliates
that delineates the respective Housing Counseling Program
responsibilities between these agencies? Obtain copies.
Yes
No
N/A







b. Does this agency also directly offer counseling services?
 Yes No N/A







17 Does the agency provide debt management services?
 Yes No N/A







a. If yes, did the agency provide HUD with certification that it complies with
all state and local laws?
Yes
No
N/A







b. If yes, does the agency provide counseling recipients with alternatives?
 Yes No N/A







REPORTING TO HUD COMMENTS







18 Did the agency transmit housing counseling activity data on form HUD 9902 on a timely basis?
Yes
No
N/A







19 Was the housing counseling activity data on form HUD 9902 completed correctly?
 Yes No N/A







20 Does the HCS reflect the agency’s current profile information including, but not limited to, name, address, telephone number and email address?
Yes
No
N/A







21 Does the agency validate its agency profile in HCS at least quarterly?
 Yes No N/A







CLIENT AND GROUP EDUCATION FILES COMMENTS







22 Does the agency maintain a separate confidential file; use a unique number for each client, documenting each unique, distinct provision of housing counseling services provided to the client?
Yes
No
N/A







23 Is the agency entering into its CMS all data elements required by HUD?
 Yes No N/A







24 Is there evidence in the files that the counselor(s) performed a financial analysis of the clients’ financial and credit circumstances?
If yes, answer the following questions:
Yes
No
N/A







a. Do the counselor(s) review the clients’ income, expenses, spending habits,
home value and use of credit?
Yes
No
N/A







b. Do the counselor(s) and client establish a household budget that the client
can afford?
Yes
No
N/A







c. For pre-purchase clients, do the counselor(s) perform a comparative
analysis of the client’s spending habits to determine if the client’s habits
are more suitable for renting or owning?
Yes
No
N/A







25 Does the agency record the date, time, duration and description of each interaction or activity performed on behalf of, and by, the client in the activity log?
Yes
No
N/A







26 Does the agency establish an action plan for each client except HECM clients?

 Yes No N/A







a. Do the action plans clearly identify the clients’ need or problem?
 Yes No N/A







b. Do the action plans outline what the agency and clients will do in order
to meet clients’ housing goal(s)?
Yes
No
N/A







27 Is there a copy of the disclosure statement in each client’s counseling file or documentation of the date that the disclosure statement was verbally provided during telephone counseling? Provide copy of disclosure(s).
Yes
No
N/A







28 Does the agency make referrals to other resources, if applicable?
 Yes No N/A







29 For pre-purchase clients, does the agency document client and homebuyer education files distribution of HUD publications on Home Inspection, if applicable?
Yes
No
N/A







30 If the counselor(s) provided information about a specific service, program, feature or product, do the counselor(s) document that he/she provided information on at least three alternatives if available, including FHA products, features or programs?
Yes
No
N/A







31 Do the counselor(s) monitor the client’s progress in meeting the housing need or correcting the housing problem?
Yes
No
N/A







32 Do the counselor(s) document each client file with the date and cause/explanation of termination when housing counseling services were terminated?
Yes
No
N/A







33 Is there evidence of follow-up as required by HUD in each client file?
 Yes No N/A







34 Do the counselor(s) document the results of counseling?
 Yes No N/A







35 Is the agency accessing fees for client services?
If yes, answer the following questions:
Yes
No
N/A







a. Does the agency document in each client file with the amount and the
source of fees paid by other parties, including HUD?
Yes
No
N/A






`
b. Does each file reflect the amount paid through client fees?
 Yes No N/A








If yes, does each file contain a copy of the receipt provided to
the client?
 Yes No N/A







c. Does the agency document in each client file that the cost did not create a
'financial hardship?
Yes
No
N/A







36 If the agency uses credit reports as a tool for counseling, does each applicable client file contain an authorization to obtain a credit report?
Yes
No
N/A







37 Does each client file contain the client authorization to share information with HUD and other third parties, if applicable?
Yes
No
N/A







38 Does the agency provide group education? If yes:
 Yes No N/A







a. Does the agency maintain a separate confidential file for each course?
 Yes No N/A







b. Are all required items documented and is the agency entering into its
CMS all data elements required by HUD?
Yes
No
N/A







c. Are there copies of the client disclosures in each education file?
 Yes No N/A





















PART B







Complete by Housing Counseling Agency. To be returned by the agency 15 working days prior to review. For each question below, submit verification/documentation to support the agency's response.







This self-certification is to be signed by a Representative of the Housing Counseling Agency authorized by the Agency Executive Board, or equivalent, to make such representations and certifications on behalf of the Agency.







FACILITIES INCLUDING ACCESSIBILITY COMMENTS







39 Is the agency easily identified by permanent signage?
 Yes No N/A







40 Provide the agency's normal business hours in the comments box at right.


Agency's normal business hours:





















41 Does the agency offer extended hours when necessary?
 Yes No N/A







42 Do the facilities provide for one-to-one counseling?
 Yes No N/A







43 Do the facilities have accessibility features in accordance with ADA requirements or does the agency offer alternative accommodations for person with disabilities?
Yes
No
N/A







DELIVERY OF HOUSING COUNSELING SERVICES COMMENTS







44 Types of Counseling Method: Check all that apply:








Face to Face Counseling Video Conference Phone Counseling








Internet Counseling (email) Skype or equivalent Group Counseling








Other (specify in box at right):








45 Does the agency counsel clients whose native language is not English? Explain in the comments box at right.
Yes
No
N/A
Explain:





















46 Does the agency counsel clients who are hearing impaired using interpreters, if necessary? Explain in the comments box at right.
Yes
No
N/A
Explain:





















47 Does the agency use TDD, TTY or 211 services? Explain in the comments box at right.
Yes
No
N/A
Explain:





















48 Does the agency indicate on written correspondence materials, provided to clients and prospective clients how to access information through alternative means if they have an impairment, disability or language barrier, etc.?
Yes
No
N/A







49 Does the agency comply with all applicable fair housing and civil rights requirements in 24 CFR 5.105a?
Yes
No
N/A







50 Has the agency:











a. Been charged with an ongoing systemic violation of the Fair Housing Act?
 Yes No N/A







b. Become a defendant in a Fair Housing Act lawsuit filed by the
Department of Justice alleging an on-going pattern or practice of
discrimination?
Yes
No
N/A







c. Received a letter of findings identifying ongoing systemic noncompliance
under Fair Housing and Civil Rights laws?
Yes
No
N/A







51 Does the agency provide outreach to persons least likely to apply for housing counseling services?
Yes
No
N/A







52 Does the agency maintain records of its activities to affirmatively further fair housing?
If "Yes," do these records:
Yes
No
N/A







a. Identify the impediments to fair housing addressed by the planned
activities?
 Yes No N/A







b. Describe the activities that took place, and to the extent possible, describe
the impact of the activities?
Yes
No
N/A







53 Do housing counselors advise clients of the fair housing law and their rights to file a housing discrimination complaint with HUD?
Yes
No
N/A







54 If the agency is an intermediary, affiliate, or sub-grantee, does the contract or agreement between the intermediary and its affiliate(s) or sub-grantee(s) address non-discrimination and equality opportunity responsibility per Handbook 7610.1 REV 5?
Yes
No
N/A







AGENCY RECORDKEEPING SYSTEM COMMENTS







55 Does the agency maintain a recordkeeping system so that HUD can access and review client files, electronic, or a combination of electronic and paper, and annual activity data can be verified, reported and analyzed?
Yes
No
N/A







56 Is the agency using a Client Management System (CMS) that is a HUD-certified CMS product or identified by HUD?
Yes
No
N/A







57 Does the agency retain the case file, both electronic and paper, for a period of three (3) years from the date the case file was terminated?
Yes
No
N/A







58 If the agency is a HUD housing counseling grant recipient or sub-grantee, does the agency retain the client files attributed to the grant for three (3) years from the date of the final grant invoice paid by HUD?
Yes
No
N/A







59 Does the agency safeguard and maintain the confidentiality paper and/or electronic files, including credit reports, etc.?
Yes
No
N/A







LENDER-FUNDED COUNSELING SERVICES COMMENTS







60 Does the agency receive any funding from lenders for counseling services? If yes, answer the following questions and attach copy of agreements:
Yes
No
N/A







a. Does the agreement indicate what services the agency will be
compensated for?
 Yes No N/A







b. Is the compensation commensurate with services provided?
 Yes No N/A







c. Does the agreement compensate the agency for referring clients to
the lender?
 Yes No N/A







d. Does the agreement compensate the agency for closing loans with a
specific lender?
Yes
No
N/A







e. Does the agreement state fee income is based on services rendered,
not on amount of loan?
Yes
No
N/A







f. Does the agreement state the agency will provide information on
comparable products from at least 3 different lenders?
Yes
No
N/A







FEES FOR HOUSING COUNSELING AND RELATED SERVICES COMMENTS







61 Does the agency charge fees for its counseling, education or debt management services? If yes, answer the following questions:
Yes
No
N/A







a. Does the agency charge fees for mortgage default or homeless housing
counseling or education services?
Yes
No
N/A







b. Does the agency waive fees for clients who cannot afford the fees or offer a
sliding fee scale?
Yes
No
N/A







c. Are the fees commensurate with the level of services provided and
reasonable and customary for the area?
Yes
No
N/A







d. Is the fee schedule prominently displayed?
 Yes No N/A


`



e. Are the clients informed of the fees prior to the provision of services?
 Yes No N/A







f. Is the initial client intake performed without charge?
 Yes No N/A







g. Does the agency charge the client for credit reports?
 Yes No N/A








If yes, does the agency charge only the actual cost of the report?
 Yes No N/A







FINANCIAL AUDIT AND CAPACITY COMMENTS







62 Did the agency/grant recipient/sub-grant recipient expend $500,000 or more in federal funds a year?
Yes
No
N/A







a. If yes, did the agency have an A-133 audit performed within the last
12 months?
 Yes No N/A







b. If no, did the agency have an independent audit every two years?
 Yes No N/A







63 Did the agency provide HUD a copy of all audit reports within 30 days of completion? Provide date of most recent audit in comment box at right.
Yes
No
N/A
Date of most recent audit:





















64 Did the auditor’s notes identify any significant deficiencies or material weaknesses relating to the agency’s housing counseling program or other programs that might impact the housing counseling program?
Yes
No
N/A







a. If yes, did the agency correct the problem(s)?
 Yes No N/A







65 Does the agency’s budget and financial statements demonstrate the necessary level of funds that enables the agency to perform the minimum workload required by HUD for the next year?
Yes
No
N/A







66 Do budget and financial statements reflect program income including fees charged to clients?
Yes
No
N/A







PERFORMANCE CRITERIA COMMENTS







Types of Counseling Services: Check the boxes for all housing counseling services the agency currently offers.







FBC - Financial Management/Budget Counseling PLW - Predatory Lending Education Workshops







FHW - Fair Housing Pre-Purchase Education Workshops RHC - Rental Housing Counseling







HIC - Home Improvement and Rehabilitation Counseling PPW - Pre-purchase Homebuyer Education Workshops







FBW - Financial, Budgeting and Credit Repair Workshops RMC - Reverse Mortgage Counseling







DFC - Mortgage Delinquency and Default Resolution Counseling RHW - Rental Housing Workshops







NDW - Non-Delinquency Post Purchase Workshops/Counseling HMC - Services for Homeless Counseling







PPC - Pre-purchase Counseling DFW - Resolving/Preventing Mortgage Delinquency







67 Does the agency offer individual counseling for the same topics covered in the group education sessions?
Yes
No
N/A







68 Does the agency limit its housing counseling activities to the geographic area specified in the agency’s approved housing counseling work plan?
Yes
No
N/A







69 Were there changes to the agency’s work plan? Provide date of most recent work plan in comment box at right.
Yes
No
N/A
Date of most recent work plan:





















a. If yes, were the changes submitted to HUD for approval before
implementation?
Yes
No
N/A







70 During the past fiscal year, for agencies that provided more services than just reverse mortgage counseling, were at least 30 clients provided counseling?
Yes
No
N/A







71 Do at least half of the counselors have a least six months experience in the job they are performing? Provide current list of counseling staff.
Yes
No
N/A







72 Have the agency’s housing counselor(s) received housing counseling training or education? List topics and dates, for each counselor, over the last 2 years.
Yes
No
N/A







73 Do the supervisors of housing counselors monitor their work and document these monitoring activities?
Yes
No
N/A







CONFLICT OF INTEREST COMMENTS







74 Does the agency provide any services besides housing counseling? If yes, list those services in comment box at right.
Yes
No
N/A
Services other than housing counseling:





















75 Does any person associated with the agency in a position of trust (as defined in Handbook 7610.1 REV 5) perform any additional services for the agency or outside of the agency that a housing counseling client would utilize?
Yes
No
N/A







a. If yes, does the person in a position of trust receive anything of value
including compensation on a commission basis for the services listed
above? (This excludes compensation in the form of a reasonable salary
from the participating agency.)
Yes
No
N/A







76 Does any person associated with the agency in a position of trust as defined by HUD engage in any activities that might result in or create the appearance of administering the housing counseling operation for personal or private gain or provide preferential treatment to any organization or person?

Yes
No
N/A







77 Does any person associated with the agency in a position of trust as defined by HUD undertake any action that might compromise the agency’s ability to ensure compliance with the requirements of HUD’s conflict of interest regulations and to serve the best interest of its clients?
Yes
No
N/A







78 Are all persons in a position of trust as defined by HUD in compliance with programmatic requirements that prohibit the acquisition of a client’s property from the trustee in bankruptcy?
Yes
No
N/A







79 Did the agency notify HUD of conflicts of interest no later than 15 days after the conflict was discovered and report to HUD on the corrective action taken to cure the immediate conflict and avoid future conflicts?
Yes
No
N/A







80 If applicable, did the agency notify HUD of its policy or changes to policy regarding the following:











a. Other housing services offered by the agency in addition to housing
counseling services?
Yes
No
N/A







b. Business practices and/or partnerships that would constitute a conflict of
interest pursuant to HUD regulations?
Yes
No
N/A







c. Description of the organizational structure and business practices that
protect the client from inappropriate steering or influence?
Yes
No
N/A







d. Agency’s written standard of ethics?
 Yes No N/A







e. Agency’s quality control plan for identifying, addressing or mitigating any
conflicts of interest and complying with HUD requirements?
Yes
No
N/A







81 Does the agency’s disclosure meet the following HUD requirements:
 Yes No N/A







a. Does the disclosure explicitly describe the various services provided by
the agency?
Yes
No
N/A







b. Does the disclosure identify any financial arrangements or partnerships
between the agency and any other industry partners that are relevant to the
client?
Yes
No
N/A







c. Does the disclosure clearly indicate that the client is not obligated to
receive any other services offered by the organization or its partners?
Yes
No
N/A







REPORTING TO HUD - HOUSING COUNSELING AGENCY COMMENTS







82 Did the agency experience any of the following changes?
 Yes No N/A







a. Change in address(es) of the agency’s main office and the address(es) of
its branches and affiliates.
Yes
No
N/A







b. Changes to staff personnel responsible for the Housing Counseling
Program, such as counselors, ineligible partners, and management staff.
Yes
No
N/A







c. Changes to the telephone numbers and website of the main office, affiliates
and branches.
Yes
No
N/A







d. Changes to any other aspect of the agency’s purpose or functions that may
impair its ability to comply with the programmatic requirements, applicable
regulations or applicable grant agreement(s) (e.g., lack of qualified housing
counselors).
Yes
No
N/A







83 Were the above changes reported to HUD within 15 days of the change?
 Yes No N/A







PART C







Complete by Housing Counseling Agency, if applicable. To be returned by the agency 15 working days prior to review. For each question below, submit verification/document to support the agency's response.







This self-certification is to be signed by a Representative of the Housing Counseling Agency authorized by the Agency Executive Board, or equivalent, to make such representations and certifications on behalf of the Agency.







REVERSE MORTGAGE COUNSELING COMMENTS







84 Does the client intake process collect all the required information per the HECM protocol?
Yes
No
N/A







85 During the intake process, did the counselor make an initial evaluation of the clients’ capability to understand the complexities of the HECM program?
Yes
No
N/A







86 Do the counselor(s) encourage participation by family, friends and/or professional advisors who could assist the client?
Yes
No
N/A







87 Is the agency in compliance with clients lacking legal competence?
 Yes No N/A







88 Do the counselor(s) document the session review with the client(s) and ask appropriate questions per Attachment B.10, Appendix 4, Handbook 7610.1 REV 5?
Yes
No
N/A







89 Do the files contain the required information noted below (if applicable)?
Yes No N/A







a. Client Data
 Yes No N/A







b. Client Concerns/Interest in Reverse Mortgage
 Yes No N/A







c. Client Needs and Circumstances
 Yes No N/A







d. Client and Property Eligibility
 Yes No N/A







e. Reverse Mortgage Features
 Yes No N/A







f. Reverse Mortgage Loan Cost
 Yes No N/A







g. Borrower Obligation/Implication after Closing
 Yes No N/A







h. Information about Financial Alternatives
 Yes No N/A







i. HECM Refinance Information
 Yes No N/A







j. HECM for Purchase Information
 Yes No N/A







k. HECM Saver Option and Information
 Yes No N/A







l. HECM Proceeds to Purchase Annuity
 Yes No N/A







90 Do the counselor(s) provide the required additional information as listed in Appendix B.1 and B.2, Appendix 4, Handbook 7610.1 REV-5?
Yes
No
N/A







91 Does the agency maintain complete client files that meet the requirements of the HECM protocol?
Yes
No
N/A







92 Does the agency issue a HECM counseling certificate through the FHA Connection System and keep an executed copy in the client file?
Yes
No
N/A







93 Do the counselor(s) perform the required client follow-up to include:
 Yes No N/A







a. Follow-up Phone Call
 Yes No N/A







b. Follow-up Emergency Counseling
 Yes No N/A







c. Close-out or Outcome Letter
 Yes No N/A







94 Are the Application Coordinator and/or counselor updating the HECM training information in FHA Connection (Information only)?
Yes
No
N/A







95 If a HECM Roster counselor is no longer with the agency, did the agency reflect the termination in FHA Connection?
Yes
No
N/A







96 Are only HECM roster counselors conducting the reverse mortgage counseling sessions?
Yes
No
N/A







97 Does the agency’s fee structure for HECM counseling meet the current HUD requirements including a policy for waiver of fees?
Yes
No
N/A







98 How do the clients become aware of the counseling agency? Check all that apply.












HUD Website State Office on Aging AARP or other RM Website








Lender Provided Counselor List Realtor Referrals Friend Referral








Direct Mailing Area Office on Aging Other (List in box below):





















GENERAL COMMENTS SECTION:
















Note: The self-certifications in Parts B and C (if applicable) are to be signed by a Representative of the Housing Counseling Agency authorized by the Agency executive board, or equivalent, to make such representations and certifications on behalf the Agency. By signing below, the Agency’s authorized representative hereby certifies that all responses and information provided, and submissions made for Parts B and C (if applicable) are true and correct. HUD may elect to change the status of a HUD-approved or Participating Agency’s status to inactive. HUD may exercise its discretion to change an agency’s status as a result of information obtained by HUD, or at the agency’s request.







Name: Representative of the Housing Counseling Agency
Please Print		 Title: Representative of the Housing Counseling Agency
Please Print

















Telephone Number: XXX-XXX-XXXX Email:

















Date: Month/day/year

























REVIEW RESULTS




























Date: Month/day/year

































Date: Month/day/year

































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