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. 2577-0157
Expires 11/30/2023

“Public reporting burden for this collection of information is estimated to average 2.2 hours. This includes the time for collecting, reviewing, and reporting the data. The information
requested is required to obtain a benefit. This form is used to verify allowable and reasonableness of grant expenses. There are no assurances of confidentiality. HUD may not
conduct or sponsor, and an applicant is not required to respond to a collection of information unless it displays a currently valid OMB control number.
FFY of Grant:
FFY of Grant Approval:

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

PHA Name

Type of Grant

Revised Annual Statement (revision no:

Reserve for Disasters/Emergencies
Original Annual Statement
Performance and Evaluation Report for Period Ending:
Line

Summary by Development Account

1

Total non-CFP Funds

2

1406 Operations (may not exceed 20% of line 15) 3

3

1408 Management Improvements

4

1410 Administration (may not exceed 10% of line 15)

5

1480 General Capital Activity

6

1492 Moving to Work Demonstration

7

1501 Collaterization Expense / Debt Service Paid by PHA

8

1503 RAD-CFP

9

1504 RAD Investment Activity

10

1505 RAD-CPT

11

9000 Debt Reserves

12

9001 Bond Debt Obligation paid Via System of Direct Payment

13

Hard Loan Debt Obligation paid Via System of Direct Payment
9002

14

9900 Post Audit Adjustment

Final Performance and Evaluation Report
Original

Total Estimated Cost
Revised2

Obligated

Total Actual Cost 1
Expended

1505
1
To be completed for the Performance and Evaluation Report.
RAD-CPT
2
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.

Page 1

form HUD-50075.1 (07/2014)

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. 2577-0157
Expires 11/30/2023

Part I: Summary
PHA Name:

FFY of Grant:
FFY of Grant Approval:

Grant Type and Number
Capital Fund Program Grant No:
Replacement Housing Factor 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
15

Revised Annual Statement (revision no:
Final Performance and Evaluation Report
Original

Total Estimated Cost

Revised 2

Obligated

Total Actual Cost 1

Expended

Amount of Annual Grant:: (sum of lines 2 - 14)

16

Amount of line 15 Related to LBP Activities

17

Amount of line 15 Related Sect. 504, ADA, and Fair Housing Act Activities.

18

Amount of line 15 Related to Security - Soft Costs

19

Amount of line 15 Related to Security - Hard Costs

20

Amount of line 15 Related to Energy Conservation Measures

Signature of Executive Director *

Date

Signature of Public Housing Director

Date

* I certify that the information provided on this form and in any accompanying documentation is true and accurate. I acknowledge that making, presenting, or submitting a false,
fictitious, or fraudulent statement, representation, or certification may result in criminal, civil, and/or administrative sanctions, including fines, penalties, and imprisonment.
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.
1
2

Page 2

form HUD-50075.1 (07/2014)

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

Part II: Supporting Pages

PHA Name:

Development Number
Name/PHA-Wide
Activities

1
2

Page 3

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0157
Expires 11/30/2023

Grant Type and Number
Capital Fund Program Grant
No: CFFP (Yes/ No):
Replacement Housing
Factor Grant No:

General Description of Major Work
Categories

Development
Account No.

Federal FFY of Grant:

Quantity

Total Estimated Cost

Total Actual Cost

Original

Funds
Obligated2

Revised 1

Status of Work

Funds
Expended2

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

form HUD-50075.1 (07/2014)

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

Part II: Supporting Pages

PHA Name:

Development Number
Name/PHA-Wide
Activities

1
2

Page 4

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0157
Expires 11/30/2023

Grant Type and Number
Capital Fund Program Grant
No: CFFP (Yes/ No):
Replacement Housing
Factor Grant No:

General Description of Major Work
Categories

Development
Account No.

Federal FFY of Grant:

Quantity

Total Estimated Cost

Total Actual Cost

Original

Funds
Obligated2

Revised 1

Status of Work

Funds
Expended2

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

form HUD-50075.1 (07/2014)

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. 2577-0157
Expires 11/30/2023

Part III: Implementation Schedule for Capital Fund Financing Program

PHA Name:

Federal FFY of Grant:

Development Number
Name/PHA-Wide
Activities

1

Page 5

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

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.

form HUD-50075.1 (07/2014)

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. 2577-0157
Expires 11/30/2023

Part III: Implementation Schedule for Capital Fund Financing Program

PHA Name:

Federal FFY of Grant:

Development Number
Name/PHA-Wide
Activities

1

Page 6

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

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.

form HUD-50075.1 (07/2014)