Community Development Block Grant Report

Instructions:

All Grantees (“Subrecipients”) with fully signed grant contracts are required to submit regular reports to the County. As needed, County staff may also request a report for projects with approved funding that are not yet under contract.

Please fill out this form twice yearly:

1. Before January 31st (covering the first half of the grant year, July 1 - December 31); and
2. Before July 31st (covering the entire grant year, July 1 - June 30).

You are required to submit reporting up until the end of the fiscal year in which you completely expend grant funds, or as determined by County staff.

If you have any questions about this form, please email FederalGrants@MarinCounty.gov.

Organization Name*

Contact Name*

Contact Email*

example@example.com

Project Name*

Project Address*

Street Address

Street Address Line 2

CityState

Zip Code

Reporting Period*

First half of grant year (July through December)Entire grant year (July through June)

Project Type*

Public ServicesCapital/Infrastructure ImprovementHousing

Summarize project progress and any activities carried out during the reporting period.*

Explain any challenges you faced in project implementation.*

Describe plans and strategies to improve or enhance project implementation. *

To report demographic information, please include both 1) the number of people your organization serves in total, and 2) the number of people being served directly by the CDBG funds. Depending on your project/organization, these numbers may be different.

The numbers you report must reflect the people served during the cumulative grant year, to date. (Please refer to the Reporting Period you selected above.)

The “Total” column must include the number of Hispanic/Latino beneficiaries as part of the sum. Due to federal reporting requirements, we ask that you specify the number of Hispanic/Latino beneficiaries in its stand-alone column.

Demographic Information*

	Organization-Wide Total	Organization-Wide Hispanic/Latino (out of Total)	CDBG-Specific Beneficiaries Total	CDBG-Specific Beneficiaries Hispanic/Latino (out of Total)
White
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & White
Asian & White
Black/African American & White
American Indian/Alaskan Native & Black/African American
Other Multi-Racial
Other/Not Disclosed
Total Individuals (Unduplicated)

CDBG Total Demographics

If you have any notes or clarifying information on the demographic numbers above, please include here:

Please refer to the Current Marin County Income Limits to help you fill out the table below.

Income Level*

	CDBG-Specific Beneficiaries
Extremely Low (0-30% of Area Median Income)
Very Low (30-50% AMI)
Low (50-80% AMI)
Moderate (80-120% AMI)
Non-Low/Moderate (120%+ AMI)
Total Individuals (Must equal the CDBG Total in the previous table)

Income Level CDBG Total

If you have any notes or clarifying information on the income numbers above, please include here:

Project Impact (or Expected Impact)*

	Total Persons Assisted
With new or continuing access to a service or benefit
With improved access to a service or benefit
Receiving a service or benefit that is no longer substandard
Total Individuals (Must equal the CDBG Total in the previous table)

Project Impact CDBG Total

If you have any notes or clarifying information on the impact numbers above, please include here:

The total number of CDBG Beneficiaries must match in all three tables: Demographic Information, Income Level, and Project Impact (or Expected Impact).

Fill in a number for each of the household fields below. If there are no applicable households, or you are unsure, please put 0.

Total Number of Households Served*

Female-headed households (Definition: An adult female is the sole or main income producer. Includes women living alone.) *

Households that include seniors (aged 65+)*

Households that include person(s) with a disability*

Other Funding Spent on Project*

	Amount Spent (Cumulative grant year, to date)
Other Federal Funds
Other Non-Federal Funds
Total Funds Expended

Please describe any other Federal and Non-Federal Funds, if applicable.

Have you awarded a construction contract?*

YesNo

Contractor's Name*

Contract Amount*

Contractor License #*

Construction Period*

Fill in date range

Notes

Please consult the Davis-Bacon Guidelines to see if your project is subject to the Davis Bacon Act.

Is your project subject to the Davis Bacon Act? Please consult County staff if you are unsure.

YesNo

Prevailing Wage Decision Number

Example: CA2003001/Mod35,12/01/06, Building

Wage Decision Lock-in Date

MonthDayYear

Notes

Please consult Section 3 Rule (24 CFR Part 75) to see if your project is subject to the Section 3 Rule (24 CFR Part 75).

Is your project subject to the Section 3 Rule (24 CFR Part 75)? Please consult County staff if you are unsure.*

YesNo

You must submit a Section 3 Data Collection Form. Please download it from the “Reporting Forms” section of the Federal Grants webpage. You may submit this CDBG report and then edit your submission at a later date to attach the Section 3 Form. However, please ensure you submit all reporting before the deadline.

Do you have current or expected residents?*

YesNo

If the housing project has current or expected residents, you are required to download and fill out a Resident Information Spreadsheet and attach it below. Refer to the Current Marin County Income Limits to determine income category.

Please upload your Resident Information spreadsheet*

Please fill out the information below for each unit with current or expected residents. Refer to the Current Marin County Income Limits to determine income category.

Resident Information*

Notes on resident information:

Are the housing units owner-occupied, renter-occupied or mixed?*

Owner-occupiedRenter-occupiedMixed

Total Number of Housing Units*

Homeowner Rehabilitation Units

	Owner-Occupied Units
Units Moved from Substandard to Standard (HQS or Local Code)
Section 504 Accessible Units
Units Qualified as Energy Star
Units Brought into Compliance with Lead Safety Rules (24 CFR Part 35)

Renter Rehabilitation Units

	Renter-Occupied Units
Units Moved from Substandard to Standard (HQS or Local Code)
Section 504 Accessible Units
Units Qualified as Energy Star
Units Brought into Compliance with Lead Safety Rules (24 CFR Part 35)

Rehabilitation Units

	Owner-Occupied Units	Renter-Occupied Units
Units Moved from Substandard to Standard (HQS or Local Code)
Section 504 Accessible Units
Units Qualified as Energy Star
Units Brought into Compliance with Lead Safety Rules (24 CFR Part 35)

Affordable Renter Units

	Total
Affordable Units
Years of Affordability
Units Occupied by Elderly Person(s)
Subsidized with Project-Based Rental Assistance by Another Federal, State or Local Program
Designated for Persons with HIV/AIDS, Including Units Receiving Funds for Operations
Designated for Chronically Homeless Persons with HIV/AIDS
Permanent Units Designated for Homeless Persons and Families
Permanent Units Designated for Chronically Homeless Persons

Notes on unit information:

Lead-Based Paint: Unit History

	Owner-Occupied Units
Housing constructed before 1978
Housing constructed 1978 or later
No paint disturbed during project activities
Otherwise exempt (Unit has 0 bedrooms, elderly /disabled resident with no children under 6, no lead-based paint, occupied no more than 100 days per year)

Lead-Based Paint: Unit History

	Renter-Occupied Units
Housing constructed before 1978
Housing constructed 1978 or later
No paint disturbed during project activities
Otherwise exempt (Unit has 0 bedrooms, elderly /disabled resident with no children under 6, no lead-based paint, occupied no more than 100 days per year)

Lead-Based Paint: Unit History

	Owner-Occupied Units	Renter-Occupied Units
Housing constructed before 1978
Housing constructed 1978 or later
No paint disturbed during project activities
Otherwise exempt (Unit has 0 bedrooms, elderly /disabled resident with no children under 6, no lead-based paint, occupied no more than 100 days per year)

Lead Hazard Remediation Actions (For units constructed before 1978)

	Owner-Occupied Units
Lead Safe Work Practices (24 CFR 35.930(b)) (Hard costs ≤ $5,000)
Interim Controls or Standard Practices (24 CFR 35.930(c)) (Hard costs $5,000 - $25,000)
Abatement (24 CFR 35.930(d)) (Hard costs > $25,000)

Lead Hazard Remediation Actions (For units constructed before 1978)

	Renter-Occupied Units
Lead Safe Work Practices (24 CFR 35.930(b)) (Hard costs ≤ $5,000)
Interim Controls or Standard Practices (24 CFR 35.930(c)) (Hard costs $5,000 - $25,000)
Abatement (24 CFR 35.930(d)) (Hard costs > $25,000)

Lead Hazard Remediation Actions (For units constructed before 1978)

	Owner-Occupied Units	Renter-Occupied Units
Lead Safe Work Practices (24 CFR 35.930(b)) (Hard costs ≤ $5,000)
Interim Controls or Standard Practices (24 CFR 35.930(c)) (Hard costs $5,000 - $25,000)
Abatement (24 CFR 35.930(d)) (Hard costs > $25,000)

Notes on lead-based paint information:

If you need to include any documents with your report, please attach them here.

Allowable file types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif

By checking this box,*

I hereby certify that this information is true and accurate to the best of my knowledge.

Community Development Block Grant (CDBG) Report

Subrecipient Information

Project Status

Beneficiary Information

Capital Projects

Housing Projects

Unit Information

Verification