ForOffice Use FY:

CDD Rental Unit Completion Data & Annual Report

Agency/Owner: / Report Submitted By: / Project Managed By: / Agency/Owner / Property Mgmt Co.
Executive Director: / Email: / Date Submitted: / Completion OR / Annual / Revised
Contact RE: Tenant Files / Email: / Property Inspections: / Email:
Project Name: / Project #:
(e.g., DQ 020 2011) / CHDO Project: / Yes / No / CHDO Certification Date:
Project Address: / Source of CDD Funds:
(Check all that apply) / HOME/ Match CDBG NSP AHTF AHF Other:
Total # of Units in Project: / # of CDD-Assisted Units: / Total # of Buildings:
(with CDD-assisted units) / # Low HOME Rent Units: / # High HOME Rent Units:
Household Characteristics. Complete one line for each unit assisted with CDD funds. Enter one code only in each blank, except column (9).
Rental Unit Information / Monthly Rent
(Including Tenant Paid Utilities) / Household
Income Data / Household Demographic Data / Proposed Rents
(1) / (2) / (3) / (4) / (5) / (6)* / (7) / (8) / (9) / (10) / (11) / (12) / (13) / (14)* / (15) / (16) / (17) / (18) / (19) / (20) / (21) / (22) / (23) / (24)
Unit No. / No. of Bedrooms / Occupancy / Is there a live-in aide? / Fixed or Floating Unit? / Tenant Rent Contribution
(a) / Monthly
Utilities Allowance
(b) / Rental Assistance
(c) / Total Monthly Rent
(a) + (b) + (c) / HOME Rent Designation / Annual Gross Income / % of Area Median / Date of Most Recent Income Cert. / Hispanic / Race of
Head of HH / Size of HH / Type of
HH / Female Head
of HH / No. of Disabled Individuals / 2017 Proposed Rent / 2017Estimated Utility Allowance / 2017Total Monthly Rent / Effective Date / Unit in Compliance
SRO- Single Room Occ.
0- EFF
1 , 2, 3, etc. / T-Tenant
V-Vacant / (Y/N) / HOME
& NSP ONLY / Indicate amount.
OR if paid by agency = “included” / $ Amt / Code / Low (L) or High (H) / Round to nearest $ / 0-0-30%
3-31-50%
5-51-60%
6-61-80% / (Recert
only required for current HOME) / (Y/N) / See codes below / (1-8) / See codes below / (Y/N) / Office Use Only
Ex. 101 / 2 / T / N / Fixed / $250 / $75 / $500 / S / $825 / H / $12,500 / 0 / 5/15/15 / N / W / 2 / S2 / Y / 1 / $755 / $75 / $830 / 5/15/16
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
Codes: / Race of Head of Household (HH)
W – White
B1 – Black or African American
A1 – Asian
A2 – American Indian or Alaskan Native
N – Native Hawaiian or Other Pacific Islander / A3 – American Indian/Alaskan Native & White
A4 – Asian & White
B2 – Black or African American & White
A5 – American Indian or Alaskan Native & Black or African American
O – Other Multi-Racial / Type of Household (HH)
S1 – Single, Non-Elderly
S2– Single Parent
T – Two Parents
E – Elderly
O – Other / Rent Assistance
S= Section 8
H= HOME TBRA
O= Other (e.g. S+C, PBV)
N= No assistance / Demographic Summary / # of CDD-Assisted Units / % of CDD-Assisted Units
W
B1
A1
A2
All other
Hispanic
Female HH
Disabled
/ FOR OFFICE USE
(Init/Date)
Access / Compl
Review
CC’d to: / Annual
Review:
NOTE: Column (5) only applies to HOME and NSP units.
Units are subsidized with project-based rental assistance by another federal, state or local program:
(e.g., Section 811, 202, PBV) / No / Yes / Type

NOTE: By s submitting this report, the owner/manager of this property certifies that each building and all HOME-assisted units in the project are suitable for occupancy per CFR 92.251 and that all other CDD-assisted units are likewise suitable for occupancy.Please initial:

Rental Unit Completion Annual Report 2016.doc THIS FORM IS AVAILABLE ONLINE AT: